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As a chronic pain coach, one of the most common things I get asked by clients is How do I know whether my pain is REALLY due to a structural abnormality, or something else?
It’s a common issue, and one that isn’t always straightforward to discern.
For instance, it’s been proven that abnormalities on MRIs and x-rays aren’t always representative of pain. When in doubt, it’s always best to be checked out by a certified physician that is also trained in Tension Myositis Syndrome (TMS) / mindbody medicine who can rule out a structural abnormality.
However, pain from Tension Myositis Syndrome, a common condition that causes physical pain and other symptoms in the body in response to stress, trauma, anxiety, etc. differs from pain from structural structural abnormalities. Clues are discernible if you know what to look for.
Generally when your symptoms match any of the the F.I.T. Criteria, your pain is likely brain-generated in nature (i.e. Tension Myositis Syndrome).
I’ve shared this resource with numerous clients, and it’s amazing how it can help get to the truth behind symptoms, saving weeks of doubt, fear and frustration.
Dr. Howard Schubiner's FIT Criteria for Tension Myositis Syndrome
Developed by Dr. Howard Schubiner, the F.I.T. Criteria stand for Functional, Inconsistent and Triggered.
Dr. Schubiner’s decades of experience in the field of chronic pain make him an important authority in this space.
His criteria were used in a recent study in the prestigious Journal of Pain.
It was the first of its kind to provide a model for neuroplastic evaluation for chronic back pain in literature.
Using a cautious approach, they found that 98% of back and neck pain sufferers had abnormal MRIs - some sort of 'imperfection' that was visible. However, in only 5% of cases was that abnormality actually causing their pain. In a whopping 88% of cases, the pain had nothing to do with what they found on the MRI - it was neuroplastic.
Put simply, the F.I.T. Criteria is a checklist that can help you rule in brain-generated, or Tension Myositis Syndrome pain.
Here’s what the F.I.T. Criteria stand for:
Functional = Symptoms affect the function, not the structure of the area
Inconsistent = Symptoms are inconsistent in their appearance
Triggered = Symptoms are triggered by harmless stimuli
Each of these are different than how a structural issue, like a broken leg, pulled hamstring, or torn ACL would present. In the case of structural pain, the function AND structure of the area would be affected, the symptoms would be consistent, and pain wouldn't be triggered by innocuous events.
Let’s get into what these actually mean, and provide key ways that you can assess whether your symptoms are brain-generated.
Note - you do not need to match each of these points or subpoints in order to rule-in Tension Myositis Syndrome. In fact, many TMS chronic pain sufferers will not check each of these boxes. The presence of any one of these likely means your pain is neuroplastic, which means it is reversible. If you’d like a comprehensive questionnaire, which takes into account personal history and other factors, click here.
Functional
Functional means that the symptoms affect the function, not the structure of the area. This is the difference between a rapid heart rate due to the butterflies of giving a big presentation, versus a rapid heart rate due to a problem with a heart valve. In both cases, the heart rate is affected (i.e. the function), but in only the case of the damaged heart valve is a structural abnormality causing it.
Here are some key hallmarks of ‘Functional’ pain:
Pain lasts longer than six months.
Most injuries heal within a few weeks to months. Consider that the largest bones in the body will only a maximum of 12 weeks to heal. If you’ve been in pain for six months, especially if your doctor believes you’re not improving as expected, then it’s a sign that you’re dealing with neuroplastic pain.
No apparent injury precedes the symptoms.
If your pain comes out of nowhere, unrelated to an activity, doing a benign activity, or it gradually appears one day, there’s a good chance that it’s neuroplastic.
Symptoms spread to different body parts.
Symptoms can start in one area, and then spread to another, like over an entire limb or area of the body. Generally, this is representative of neuroplastic pain, as acute pain generally does not start in one area and spread over a wider area.
Symptoms are symmetrical.
For example, if you get pain in both your knees, ankles, shoulders, etc. at the same time. I’ve seen a number of clients (including myself with shin splints!) present with this. The odds of structural issues occurring in each body part in the same place at the same time is low.
Inconsistent
Think about a structural problem like a broken leg. You wouldn’t be able to walk on that leg without pain on some days, right? It would hurt every day you tried to walk on it. If you can, well, there’s likely something else going on. Here are some key things to look out for:
Symptoms shift from one location to another.
It’s not uncommon for neuroplastic pain to start in one area, and then spread to another over time - especially if you’re fearful of the symptoms. For example, if your pain starts in the lower back, and then moves to your upper back or down your leg. Or if it shifts from the right side to the left side. Any change of location is a clear indication of neuroplastic pain. If it were a structural issue causing the pain, it’s highly likely that the pain would be in a single location, not here one day, and there another!
Symptoms increase or decrease in intensity throughout the day.
Symptoms that tend to fluctuate throughout the day, perhaps better or worse in the morning or evening, can be a hallmark of brain-generated pain.
Symptoms are worse after exercise/activity.
Generally doing activity will set structural pain off, and resting will help it. (Just think of walking on that broken leg!) If you find the opposite - that you're able to exercise/be active with minimal symptoms, yet they get worse at rest, then you're in luck. It's a subtle yet tell-tale signal for brain-generated pain.
Symptoms decrease temporarily after therapies like massage or acupuncture.
There can be a few reasons for this. It could be that there’s a general activation of the rest and digest (parasympathetic ventral vagal system), which decreases stress, and therefore reduces pain signals from the brain. It could be due to increased bloodflow to the area decreasing the pain. Or, it could be a placebo effect at work. Any way you slice it, it’s a sign of neuroplastic pain.
Symptoms are reduced or nonexistent when positively distracted.
This is pretty cut and dry. If you go on vacation and your pain is reduced, then on Monday morning when you’re about to go to work your pain gets worse, then you likely have neuroplastic pain. Your pain doesn’t take a break while you’re on vacation! This can also be the case in more subtle ways - if you’re engrossed in a really good book, film, sporting event, or having an enjoyable time with friends. If you had a structural issue, the pain wouldn’t take a break because you’re distracted!
Triggered
A final hallmark in brain-generated pain is when symptoms are triggered by innocuous stimuli. This is representative of a conditioned response (think Pavlov’s dogs) and is a clear sign of neuroplastic pain. Here’s what to look out for:
Symptoms are triggered by weather, foods, smells, etc.
It can be common for people to get triggered by things like cold weather, certain foods, or even smells. However, numerous studies have come out decoupling phenomena like weather with flare-ups. While the symptoms of these triggers are very real, they are likely conditioned. Which means they can be deconditioned with the right brain-focused approach.
Symptoms are triggered by stress, or anticipation of a stressful event.
Got a big presentation coming up and noticing a flare-up? It’s probably not a coincidence. It’s a sign that your mental and emotional state is influencing your physiology. This flare-up is triggered by something in your life - not a structural issue!
Symptoms are triggered when thinking about a trigger.
Sometimes, just thinking about a trigger can generate a flare-up. If you think about a stressful person or situation in your life, and you experience a flare-up, it’s textbook proof that there’s a brain-generated component to your symptoms.
Putting the F.I.T. Criteria into Practice with The Evidence List
Look over the list. How many of the FIT Criteria do you match?
If you have more than 1-2 on that list, then there's a great chance that your symptoms are Tension Myositis Syndrome. This means they're reversible!
Here's a practical and brief exercise to continue to build confidence that your symptoms are TMS/brain-generated.
I call this the Evidence List:
Write down a list of times when your symptoms matched a FIT criterion. It could be the fact that you felt it had practically gone away one day. It could be that it intensified when you were anxious, or that when you were really busy with a project, it disappeared. If your pain has a pattern, list any exceptions to the pattern, or if it tends to change in intensity or location during the day.
All of these data points are ‘proof’ that the symptoms are likely Tension Myositis Syndrome. The more evidence you have, the stronger the case.
Keep the list handy, and note down any new exceptions or inconsistencies that arise throughout the day. Curiosity is key!
The F.I.T. criteria can be a powerful tool to help you build confidence in a mindbody diagnosis. And if you're keen to explore how to reverse your symptoms and get your life back, here are 3 free ways you can get help right now:
Take my comprehensive Pain Free Comeback Assessment. Designed to uncover mental, physical, and emotional blindspots keeping the chronic pain cycle going + provide you tools to address them
Join my FREE live Zoom workshop: Starting Your Pain Free Comeback. I’ll share the real cause of (most) chronic pain, unveil the neuroscience behind your symptoms, and give you strategies that offer lasting relief. There will also be Q&A - so come with questions!
Sign up for a free 1:1 coaching call with me. You'll come away with 'ah-ha's about your pain and more confidence that a full recovery can happen - more quickly than you can imagine. Those who attend say they feel reassured, inspired, and optimistic.
Alec Kassin is a former semi-pro cyclist, former chronic back pain sufferer, and certified Breakthrough Chronic Pain Coach. He's the Co-Founder of Pain Free Comeback, a proven brain-focused recovery method for athletes and active people with chronic pain. He empowers clients to become pain free without drugs, surgery, or physical treatment.
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