Osteopathic Journals and Research by Darren Chandler


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  1. Anatomy of the thoracic dorsal and ventral ramus

    Spinal cord -->

    Dorsal nerve root (sensory) & ventral nerve root (motor) -->

    Spinal nerve (sensory & motor) -->

    • Dorsal ramus of the spinal nerve: joints, muscles and skin of the back.
    • Ventral ramus of the spinal nerve: anterolateral trunk & limbs (intercostal nerves & subcostal nerve).
    • Rami communicans: spinal nerve --> sympathetic trunk.

    Dorsal ramus of the spinal nerve

    The dorsal ramus passes through the narrow space between the bony structures and adjacent fibrous tissue (Ishizuka 2012) to innervate the joints, muscles and skin of the back.

    The dorsal ramus divides into the: 

    • Medial (articular) branch of the dorsal ramus: emerges between the joint and medial edge of the superior costotransverse ligament and intertransverse muscle (Standring 2015 pg 945) and then passes between the semispinalis and multifidus (Ishizuke 2012). Innervates the facet joints and multifidus. 
    • Lateral branch of the dorsal ramus: passes underneath the intertransverse ligament (Ishizuke et al 2012) in an interval between the costotransvse ligament and intertransvse muscle before inclining posteriorly on the medial side of the levator costae (Standring 2015 pg 945). The main lateral branch runs caudally, laterally, and dorsally underneath the longissimus muscles and descends approximately two vertebral segments caudally before it pierces the thoracolumbar fascia (Maatman et al 2019). It then divides into the medial (or intermediate) and lateral cutaneous branches:

      • Medial (or intermediate) cutaneous branch innervates the longissimus (Saito et al 2006). Penetrates both the thoracolumbar fascia and tendinous portion of the back muscles to innervate the skin (Ishizuka et al 2012).
      • Lateral cutaneous branch innervates the iliocostalis (Saito et al 2006). Penetrates only the thoracolumbar fascia to innervate the skin (Ishizuka et al 2012).

    Lateral branch of the dorsal ramus forms the posterior cutaneous nerve and superior cluneal nerve.

    Dorsal ramus of the spinal nerve: lateral branch

    Spinal nerve > dorsal ramus > lateral branch > medial cutaneous branch & lateral cutaneous branch

    Dorsal ramus > lateral branch > medial cutaneous branch

    T1-6 medial cutaneous branch: between multifidus and semispinalis --> pierces rhomboid  --> pierces trapezius --> pierce the thoracolumbar fascia. Supplies the skin by the SP of the same segmental number of the nerve (Aizawa & Kumaki 1996).

    T6-12 medial cutaneous branch distributed to the multfidus and longissimus and occasionally the skin near the midline

    Dorsal ramus > lateral branch > lateral cutaneous branch

    Aizawa & Kumaki (1996) found these nerves extended from T2-4 to T12.

    Passes through or beneath the longissimus dorsi to the interval between it and the iliocostales. At T2-3 pierces the rhomboid (Aizawa & Kumaki 1996).

    T5/6-12:  also give off cutaneous branches which pierce the serratus posterior inferior and latissimus dorsi in line with the angles of the ribs.

    Where the lateral cutaneous branch pierces the thoracolumbar fascia is generally at the gap between the longissimus and the iliocostal muscles in the intercostal space. This is one segment lower than the same segmental number of the nerve (Aizawa & Kumaki 1996). 

    Lateral cutaneous branches are bent at points where the nerve penetrates superficial muscles forming a "Z"-shape (Aizawa & Kumaki 1996):

    • Rhomboid: changes course from an infero-lateral to an infero-medial direction.
    • Trapezius muscle and latissimus dorsi: changes course from an infero-medial to a lateral direction.

    Sometimes the lateral cutaneous branch is sharply pulled in a medial direction by the trapezius muscle as it penetrates the muscle near the median plane (Aizawa & Kumaki 1996).

    The lateral cutaneous branches from T12-L3 communicates with one another to form a nerve plexus under the lumbodorsal aponeurosis. This plexus then penetrates the aponeurosis to form several nerve bundles. It then crosses over the iliac crest to supply the skin over the hip as the superior cluneal nerves (Aizawa & Kumaki 1996).

    Posterior cutaneous nerve entrapment syndrome (POCNES)

    Dorsal ramus > lateral branch > posterior cutaneous nerve

    POCNES is pain that can originate from the posterior cutaneous nerve (T7-12) (Maatman et al 2019).

    When effected lower down in the thoracoulumbar area this can cause a superior cluneal entrapment syndrome*.

    *: dorsal ramus > lateral branch > superior cluneal nerve.

    Diagnostically the point of maximum pain is located just lateral to the spinal process in the lower paravertebral region (Maatman et al 2019).

    Low back pain caused by an entrapped cutaneous branch of the posterior ramus of the thoracic spinal nerve most commonly originates from T11–12.

    Ventral ramus of the spinal nerve

    Anatomy of the intercostal muscles, serratus anterior and endothoracic fascia

    External intercostals

    Rib tubercles and posterior fibers of the superior costotransverse ligament --> almost costal cartilage: external intercostal membrane --> sternum.

    Internal intercostals

    Sternum & cartilage of true ribs & false ribs --> posterior costal angles: internal intercostal membrane --> anterior fibers of superior costotransverse ligament & fascia between the internal & external intercostals.

    Davies et al (1932) described an intracostal muscle that is largely co-extensive with the internal intercostal muscle (refer ‘Intercostal nerve’).

    Intercostals intimi

    Insignificant/absent in highest thoracic levels but more substantial lower down.

    It occupies the middle two quarters of the lower intercostals spaces fusing at its inferior insertion with fibres of the internal intercostal (Siddiqi & Mullick 1935).

    Posteriorly it may come into contact with the subcostales.

    Intercostals intimi are related internally to the endothoracic fascia, parietal pleura and intercostal nerves and vessels.

    Functions of the intercostal muscles

    External intercostals < posterior portion of the cephalic interspaces contract during inspiration (Hudson et al 2010).

    Internal intercostals < caudal interspaces contract during expiration (Hudson et al 2010).

    Intercostal intimi contract during expiration.

    External intercostals in the lateral portion induces contralateral rotation (Whitelaw et al 1992).

    Internal intercostals in the lateral portion induces ipsilateral rotation (Whitelaw et al 1992). 

    The parasternal intercostals (the intercartilagenous portion of the internal intercostals) induces an ipsilateral rotation and sidebending. Even though they are internal intercostals they have an inspiratory, rather than an expiratory, function (Hudson et al 2010).

    The fibers of the transversus thoracis run cephalic and laterally from the posterior aspect of the sternum, xiphoid and costal cartilages r4-7 to the r2-6 costal cartilages.

    The fibers of the transversus thoracis contract during expiration, to draw down the costal cartilages (Jelev et al 2011) and contralateral rotation (Hudosn et al 2010). Therefore through reciprocal inhibition contraction of the transversus thoracis diminishes or prevents activation of the parasternal intercostals during contralateral rotation and expiration (Hudson et al 2010).

    Serratus Anterior

    Attachment: rib 1-8(-10) to the medial boarder of the scapula.

    The serratus anterior has three divisions (Webb et al 2018): 

    (1) Superior division: attaches to the superior angle of scapula (anterior and posteriorly) and rib 1 and 2.  These fibers are shorter, thicker, and separated from the rest of the muscle. They, can, in cases, attach on to the fascia covering the intercostal space. They form a bed for the neurovascular structures in the upper axilla (Smith et al 2003).

    (2) Middle division: attaches to the medial boarder of scapula and rib 2 and 3.

    (3) Inferior division: attaches to the inferior angle of scapula (anteriorly and posteriorly) and rib 4 to 8/10.

    The anterior attachments of the levator scapula, rhomboid minor and major overlap the costal surface of the serratus anterior fascia for about three centimeters. This causes the fascia of these muscles to merge with each other (Barihoke & Gupta 1986).

    The continuity of the upper fibers of the serratus anterior and rhomboid/levator scapulae has been described as a wide muscular sheet with a deep common fascia (Nguyen & Nguyen 1987).

    Action: all fibers protract, upwardly rotate* (Smith et al 2003) and fixes the scapula against the thorax (externally rotates** and posteriorly tips the scapula***). This posterior tipping is countered by an anterior tipping from the superior fibers of the serratus anterior (Smith et al 2003). Just as the serratus anterior rolls the scapula anterior on the rib cage (protracts) it also "lifts the ribs and trunk" up to a fixed scapula (Neumann & Camargo 2019). The serratus anterior is the primary stabilizer of the scapulothoracic articulation. This provides a stable axis for scapular rotation as it provides a solid base of support for upper extremity function (Smith et al 2003). The upward rotation combined with posterior tipping and, to a lesser extent, external rotation of the scapula, functions in increasing or maintain the volume of the subacromial space (Neumann & Camargo 2019).

    *: upward rotation of scapula: inferior angle of scapula swings superiorly and laterally around an A-P axis.

    **: external rotation of scapula: medial boarder of scapula moves anteriorly around a vertical axis at the AC joint.

    ***: posterior tipping of scapula: superior aspect of the the scapula moves posterior around a horizontal axis going through the spine of scapula.

    Upper fibers: suspend the scapula with the levator scapula and upper fibers of trapezius. They stabilize the scapula during humeral elevation and create an anterior tipping movement of the scapula around an axis parallel to the spine of scapula (Smith et al 2003).

    Lower fibers protact the scapula to assist the upper fibers of trapezius in raising the arm above the head.

    Endothoracic fascia 

    The endothoracic fascia is the outer lining of the thoracic cavity. It separates the intercostal spaces and ribs from the pleura. It becomes more fibrous over the lung apex as the suprapleural membrane.

    It is continuous:

    • Superiorly with the prevertebral fascia (Feigl 2015 & Natale et al 2015) via the scalene minimus.
    • Inferiorly with the endoabdominal fascia via traverseing the medial and lateral arcuate ligaments, aortic hiatus and oesophageal hiatus by forming the phrenico-esophageal ligament (Apaydin et al 2008).

    The endothoracic fascia splits to enclose the subcostales and intercostal muscles*. At the anterior border of the intercostal muscle the fascia covers the inner surface of the internal intercostal muscle and splits again to enclose the transversus thoracis muscle before fusing with the periosteum of the sternum (Siddiqi & Mullick 1935).

    *: this splitting of the endothoracic fascia is an alternative to the description of other authors who describe the endothoracic fascia as simply being continuous with the most internal component of the investing fascia of the intercostal muscles and the adjacent layer of periosteum (epimysium). The confusion as to whether the endothoracic is separate to, or splits to enclose the intercostal muscles (and transversesus thoracis and subcostales) maybe clarified by Stecco et al (2017) explanation. These authors found the visceral fascia of the thorax cannot be isolated from the muscular fascia of the intercostal muscle, as the two are fused, forming the endothoracic fascia. 

    Ventral rami of the spinal nerves

    Spinal cord > dorsal nerve root (sensory) & ventral nerve root (motor) > spinal nerve (sensory & motor) > dorsal ramus & ventral ramus

    There are twelve pairs of thoracic ventral rami:

    1-11: intercostal nerve.

    12: subcostal nerve.

    Each ventral rami is connected with the sympathetic trunk via the grey and white rami communicans.

    Intercostal nerves

    The intercostal nerves enter the corresponding intercostal space between the posterior intercostal membrane and the parietal pleura. The intercostal intimi does not exist at this point and only the parietal pleura is present on the inner side. As the intercostal nerve travels forward in the subcostal groove it travels between the intercostal intimi and internal intercostal muscles (Olamikan et al 2016). 

    Davies et al (1932) described the intercostal nerve being separated from the pleura by two soft tissue strata:

    • A thin layer of muscle these authors termed the intracostal muscle. This muscle is largely co-extensive with the internal intercostal, but becomes more membranous in its anterior part and superior attachment to the inner (upper) lip of the subcostal groove.
    • Extra-pleural stratum consisting of subcostal muscles posteriorly, transversus thoracis anteriorly and the connecting fascial plane between these two muscles.

    This may be the fibrous sheath described by Olamikan et al (2016) that contained the intercostal nervs and vessels.

    T3-6 intercostal nerves: run in the intercostal space between the internal intercostal and intercostal intimi.

    T7-11 intercostal nerves: run superficial to either the transversus thoracis or transversus abdominis muscles (Nguyen (2018).

    The intercostal nerves are distributed primarily to the thoracic and abdominal wall. However they also innervate the diaphragm and may also supply the pleura and the peritoneum.

    T1-6 intercostal nerves

    Intercostal nerves 1-2: upper limb and thorax.

    T1 ventral ramus, often receives a connecting branch from T2 ramus, and splits into two branches: 

    • Brachial plexus.
    • Intercostal nerve which terminates as the first anterior cutaneous nerve of the thorax.

    In approximately 60% of individuals, there is a linkage of the brachial plexus to the first and/or second intercostal nerve and stellate ganglion, known as Kuntz’s nerve. This nerve carries sympathetic fibers to the brachial plexus without passing through the sympathetic trunk (Zaidi & Ashraf 2010).

    Intercostal nerves 2-6: pass forwards in the intercostal spaces.

    Posteriorly: travels between the pleura and external intercostal membrane. Mainly runs between internal intercostal and subcostales/intercostal intimi. Anteriorly near the sternum they cross anterior to transversus thoracis, pierce internal intercostals, external intercostal membrane and pectoralis major to terminate as the anterior cutaneous nerve of the thorax.

    Second anterior cutaneous nerve may send branches of the supraclavicular nerves (cervical plexus).

    T1-6 branches:

    • Muscular branch: intercostals, serratus posterior superior, transversus thoracis.
    • Collateral branch.
    • Lateral cutaneous nerve. The lateral cutaneous branch of each nerve has a short course between the internal and external intercostal muscles before finally piercing the external intercostal (Davies et al 1932) and serratus anterior (Maatman et al 2017) to innervate the skin at the mid-axillary line. Maatman et al (2017) identified the nerve piercing the external intercostal and serratus anterior as a site of entrapment ('Lateral Cutaneous Nerve Entrapment Syndrome' 'LACNES').

    Except for first and second intercostal nerve (first intercostal nerve does not always give off a lateral cutaneous branch) each lateral cutaneous nerve divides into an anterior rami (skin over pectoralis major/upper external oblique) and posterior rami (skin over latissimus dorsi/scapula). 

    Lateral cutaneous nerve of second intercostal (intercostobrachial) nerve: pierces the external intercostal and serratus anterior (Chang et al 2018), travels through the axilla, joins the medial cutaneous nerve of the arm and pierces deep fascia of the arm to communicate with the posterior cutaneous branch of the radial nerve. Supplies skin of the upper posterior and medial parts of the arm. 

    Koizumi & Horiguchi (1992) described a branch of the second third or fourth lateral cutaneous nerve adhering to the fascia of the external intercostal muscle. It then pierces the origin of the pectoralis minor to communicate with a pectoral nerve which originates from the loop composed of the lateral and medial pectoral nerves. 

    T6-12 intercostal nerves

    Ventral rami T6-11 (intercostal nerve) and T12 (subcostal) with L1 (iliohypogastric and ilioinguinal nerves) supplies the muscles and skin of the anterior abdominal wall.

    Intercostal nerves 7-10: approaching the costal margin (7-10 costal cartilages) they course between the digitations of the diaphragm and transversus abdominis.

    Subcostal nerve (T12) passes along the inferior boarder of r12 behind the lateral arcuate ligament and kidney and anterior to the upper part of the quadratus lumborum.

    All these nerve run within thin layers of fascia formed between the transverse abdominis and internal oblique where they branch and interconnect with other nerves.

    They enter the rectus sheath at the lateral margin and pass posterior to the rectus abdominis, where they intercommunicate and then pierce the rectus abdominis from its posterior aspect.

    Muscular branches: transversus abdominis, internal oblique, external oblique, rectus abdominis and pyramidalis.

    Sensory branches: costal part of the diaphragm and the parietal peritoneum.

    Cutaneous branches: skin of the lateral and anterior abdominal wall. The subcostal nerve (T12) also supplies the skin of the anterior gluteal region and groin.

    Anterior cutaneous nerve entrapment syndrome (ACNES)

    The anterior abdominal wall is innervated by the ventral rami of the T6–L1 spinal nerves (Shian & Larson 2018). 

    The terminal branches of the T7–T12 ventral rami (intercostal nerves) enter the lateral posterior rectus abdominis at a 90-degree angle through a fibrous neurovascular channel, progressing anteriorly through the muscle and anterior rectus sheath to become the anterior cutaneous nerves of the abdomen. Once those nerves reach the overlying aponeurosis, the nerves again change course at a 90-degree angles beneath the skin (Sian & Larson 2018).

    L1 nerve bifurcates into the iliohypogastric and ilioinguinal nerves; the iliohypogastric nerve pierces the external oblique aponeurosis superior to the superficial inguinal ring, whereas the ilioinguinal nerve passes through the inguinal canal to emerge through the superficial inguinal ring (Sian & Larson 2018).

    These nerves are usually anchored at three sites (Maatman et al 2019):

    • Posteriorly where the posterior branches of the thoracic nerve originate at the back.
    • Laterally at the flank where the lateral branch originates.
    • Anteriorly at the anterior abdominal wall where the nerve enters the rectus abdominis muscle.

    Mole et al (2017) found the anterior cutaneous nerve (T7-12 intercostal nerves) anchored at:

    • Spinal cord.
    • Dorsal branch of the spinal nerve.
    • Where the lateral cutaneous branch originates.
    • Entering the point of the anterior cutaneous branch into the posterior rectus sheath.
    • Skin (Mol et al 2017)

    Sian & Larson (2018) identified the most common location of entrapment being at the lateral border of the rectus abdominis.  Mol et al (2017) described various plexiform interconnections between anterior branches of intercostal nerves at this level possibly extending over multiple dermatomal zones.

    Mol et al (2017) described the most likely anatomical site of entrapment is the point where the neurovascular bundle enters the posterior rectus abdominis sheath and makes a nearly 90° turn, piercing through the rectus muscle, eventually reaching the skin.

    A branch of T9 travels beneath the internal oblique and runs within the posterior rectus sheath through a resistant fibrous foramen. At this level, the posterior rectus sheath is a fusion of the deep internal oblique abdominal aponeurosis and the transverse abdominal aponeurosis. These authors described that this structure might correspond with the description of a fibrous ring.

    These authors also found llioinguinal–iliohypogastric nerve (L1) entrapment as a common cause of lower abdominal pain in patients with a history of lower abdominal surgery (Sian & Larson 2018).

    Diagnostically depending on the site of entrapment depends on where the point of tenderness is (Maatmen et al 2019).

    Differential diagnosis of intercostal pain (Olamikan et al 2016)

    The most common causes of intercostal neuralgia:

    • Damage-related pain: postherpetic neuralgia, thoracic surgery and diabetic thoracic neuropathy.
    • Direct nerve injury (physical trauma or post surgery): stretching (e.g. expanding gravid uterus, entrapment) and inflammation.
    • Entrapment can be caused by neoplasm, sarcoidosis and pleural mesothelioma.


    Koizumi M, Horiguch M (1992). A study on the communication between the pectoral nerve and the extramural nerve branches of the intercostal nerves

    Saito T, Yoshimoto M, Yamamoto Y, Miyaki T, Itoh M, Shimizu S, Oi Y, Schmidt W, Steinke H (2006). The medial branch of the lateral branch of the posterior ramus of the spinal nerve

    Maatman R, Boelens O, Scheltinga M & Roumen R (2019). Chronic localized back pain due to entrapment of cutaneous branches of posterior rami of the thoracic nerves (POCNES): a case series on diagnosis and management

    Aizawa Y, Kumaki K (1996). [The courses and the segmental origins of the cutaneous branches of the thoracic dorsal rami

    SHIAN B, LARSON S (2018). Abdominal Wall Pain: Clinical Evaluation, Differential Diagnosis, and Treatment 

    Mol M, Lataster A, Scheltinga M, Roumen R (2017)Anatomy of abdominal anterior cutaneous intercostal nerves with respect to the pathophysiology of anterior cutaneous nerve entrapment syndrome (ACNES): A case study

    Ishizuka K, Sakai H, Tsuzuki N, Nagashima M (2012). Topographic anatomy of the posterior ramus of thoracic spinal nerve and surrounding structures.


    Stecco C, Sfriso M, Porzionato A, Rambaldo A, Albertin G, Macchi V, Caro R (2017). Microscopic anatomy of the visceral fasciae 

    Nguyen K, MD, Choudhri H, MD, and Macomson S (2018). The intercostal nerve as a target for diagnostic biopsy. 


    Maatman R, Papen-Botterhuis N, Scheltingaa M, Roumena R (2017). Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain

    Feigl G (2015). Fascia and spaces on the neck: myths and reality (2015).

    Natale G, Condino S, Stecco A, Soldani P, Belmonte MM, Gesi M (2015). Is the cervical fascia an anatomical proteus? 

    Apaydinal N, Uz A, Evirgen O, Loukas M, Tubbs RS, Elhan A (2008). The phrenic-esophageal ligament: an anatomical study.

    Whitelaw W, Ford G, Rimmer K, De Troyer A (1992). Intercostal muscles are used during rotation of the thorax in humans

    Hudson A, Butler J, Gandevia S, De Troyer A (2010). Interplay between the inspiratory and postural functions of the human parasternal intercostal muscles

    Zaidi Z & Ashraf A (2010). The Nerve of Kuntz: Incidence, Location and Variations

    Chang K-V, Mezian K, Naňka O, Wu W-T, Lou Y-M, Wang J-C, Martinoli C, Özçakar L (2018). Ultrasound Imaging for the Cutaneous Nerves of the Extremities and Relevant Entrapment Syndromes: From Anatomy to Clinical Implications

    Standring S (2015). Gray's Anatomy 41st Editon. The Anatomical Basis of Clinical Practice. 

    Webb AL, O'Sullivan E, Stokes M, Mottram S. (2018). A novel cadaveric study of the morphometry of the serratus anterior muscle: one part, two parts, three parts, four?

    Smith R, Nyquist-Battie C, Clark M, Rains J (2003). Anatomical Characteristics of the Upper Serratus Anterior: Cadaver Dissection  

    Nguyen HV, Nguyen H. (1987). Anatomical basis of modern thoracotomies: the latissimus dorsi and the "serratus anterior-rhomboid" complex

    Bharihoke V, Gupta M. (1986). Muscular attachments along the medial border of the scapula.

    Neumanna D, R. Camargob P (2019). Kinesiologic considerations for targeting activation of scapulothoracic muscles - part 1: serratus anterior

    Jelev L, Hristov S, Wladimir O (2011). Variety of transversus thoracis muscle in relation to the internal thoracic artery: an autopsy study of 120 subjects


  2. Introduction

    Given the choice most people would say winning the lottery would improve their happiness but a year later these people adapt and return to previous levels of happiness (Delamothe et al 2005).

    Whilst money can buy you happiness, it can’t buy much, and above a modest threshold, more money does not mean more happiness. This is exemplified by the fact that individuals usually get richer during their lifetime but not necessarily happier (Delamothe et al 2005).

    Social capital is the ties that bind families, neighbourhoods, workplaces, communities and religious groups together. These social factors, as well as a state of authenticity (Lenton et al 2013), correlate strongly with subjective wellbeing (Delamothe 2005 & Lawrence et al 2015). In fact, the breadth and depth of an individuals' social connections are the best predictors of their happiness (Delamothe et al 2005).

    O’Take et al (2006) found an individual's social capital is influenced by the value they place on gratefulness, kindness and life's simple pleasures.

    Happy people place a high value on gratefulness and kindness. This is because happy people experience more happiness and therefore have more happy memories making them more grateful. To re-experience these memories and gratitude happy people not only desire to be kind and are more likely to be so, but are also more attuned to the recognition of kindnesses.

    This leads to a reciprocal relationship between gratitude, kindness, subjective happiness, and good social relationships. Therefore, compared with unhappy people, happy people have close and satisfying relationships and feel more gratitude in their lives (O'Take et al 2006).

    Consciously drawing people's attention to kind behaviour in daily life by 'counting kindnesses' makes their motivations, thoughts, and actions more positive. This can increase their wish to be kind to others, more strongly identify themselves as kind people and encourage kind behaviours toward others which will all increase happiness and promote enduring happier memories (O’Take et al 2006).

    But is there a danger of 'chasing happiness' or pathologically pursuing 'whatever makes you happy'? Should the emphasis be on a self defining action or mindset with happiness or sadness being a less relevant by-product? Having too higher expectation of happiness in one's past, present or imagined future, or placing too much importance on the self-narrative associated with happiness or sadness makes people more brittle as they negatively evaluate their progress (Mauss et al 2011) resulting in self-blame (Cataline et al 2014) and less tolerant views (An et al 2017). This would imply it's the relationship with being happy that defines its positive or negative impact on life as opposed to merely experiencing happiness; this relationship with being happy also defines both the positive and negative impacts of experiencing sadness.

    Happy people typically enjoy better health due to how it permeates through the different facets of their life (Laurence et a 2015). Therefore as well as adding years to your life happiness adds life to your years (Delamothe et al 2005). The health benefits attributed to happiness include:

    • Reduced stress and improved immune function (Strean 2009 & Bennett et al 2003)
    • More successful adaptation (Laurence et a 2015).
    • Better problem-solving skills and coping strategies (Laurence et a 2015).
    • More creative, imaginative, and integrative thinking (Laurence et a 2015).
    • Greater resilience (Laurence et a 2015).
    • Greater ability to deal with adversity (Laurence et a 2015).
    • Improved management of chronic pain through the use of humour (Pérez –Aranda et al 2019).

    These attributes are thought to improve health through socioeconomic and social resources as happy people have more friends (i.e. increased social capital) and increased earnings. However the effect of happiness on self-rated health is largely independent of marital status, education, income, and socioeconomic resources (Lawrence et al 2015).

    What is happiness? There are three different forms of happiness:

    • Hedonic happiness. Hedonic happiness is achieved through experiencing pleasure and enjoyment. It is more of a reflex pleasure that doesn’t require much cognitive appraisal (Medvedev & Landhuis 2018).
    • Eudemonic happiness. This is also called psychological well-being or positive functioning. It comprises six dimensions: purpose in life; personal growth; environmental mastery; autonomy; positive self-regard; and social connections. Note the eudemonic model does not include emotions and life satisfaction (Medvedev & Landhuis 2018).
    • Psychological flourishing. Psychological flourishing includes social relationships; purposeful life; engagement in activities; self-esteem; and optimism (Medvedev & Landhuis 2018).

    A purposeful life elicits positive emotions which positively shapes an individual's perception of their life satisfaction; this contributes to improved emotional well-being and happiness. Lenton et al (2013) argued this must be accompanied by a sense of authenticity without conforming to the expectations of others. This makes the individual feel they are fully self-aware in upholding their values.

    These positive emotions can involve mixed happy and sad emotions that are registered at a level centred around the individual flourishing. Therefore a transient sad emotion e.g. stress and fatigue may lead on to personal growth in a field that leads to a happy emotion e.g. satisfaction, fulfillment and self esteem.

    This is how positive emotions broadens an individual's confidence to build on their abilities to adapt to life's challenges (O’Take et al 2006) which defines their appraisal of themselves, their circumstances and function in society. This self appraisal should be positively balanced between one’s relationships with others and comparing oneself with others (Delamothe et al 2005).

    Obviously this process has to be performed in a genuine way. If at a moment in time an individual follows the path of least resistance for convenience but later on would rather reflect on it to draw a more premeditated desirable conclusion there will be a mismatch between an individual's perception of themselves, their circumstances and function in society and what really is.

    The pursuit of happiness

    “Life’s too short to pursue happiness”

    Whereas some view being happy as a nice thing to have every now and then, others see it as absolutely necessary to their existence (Mauss et al 2011). People with an obsession of pursuing happiness to excess tend to be more depressed, miserable, and unhappy (An et al 2017). Mauss et al (2011) also found the more people valued happiness, the lower were their hedonic balance, psychological well-being, life satisfaction and experience of happiness in situations that should give rise to it. 

    Relating to one’s happiness in an obsessive manner may chase happiness away (Cataline et al 2014) as people negatively evaluate their progress from setting too higher expectations that inadvertently result in them setting themselves up for disappointment (Mauss et al 2011). This can result in self-blame (Cataline et al 2014) and a more extreme less tolerant view of experiencing sadness (An et al 2017). Whilst this is true generally with life or when under low stress people react more positively to valuing happiness when feeling sad (Mauss et al 2011).

    People placing a high importance on pursuing happiness (An et al 2017) and who excessively value happiness as a gauge for determining how worthwhile life is (Cataline et al 2014) experience significantly more loneliness, selfishness and poorer well-being compared to those who are more neutral in pursuing happiness (An et al 2017).

    This is especially true depending on the emotional context. In relatively negative situations people can attribute their unhappiness to the circumstances e.g people are unlikely to be disappointed if they fail to be happy after hearing of a personal loss. In contrast, in relatively positive situations, people have every reason to feel happy, and are likely to feel disappointed when they do not. For instance, people who value happiness may feel disappointed if they fail to feel happy at an event or in a situation where they deem themselves to be entitled. Therefore the more people value happiness, and have a higher expectation of it, the less likely they may be to obtain it (Mauss et al 2011).

    This result of this unhappiness, be it reasonable or from failing to reach an unrealistic expectation of how happy one thought they were entitled to be, is that people are inclined to rely on a negative social comparison. This negative comparison is because their self-concepts are less stable, less clear and less certain; they also perceive, interpret and think about events and circumstances in a more negative way than happy people (O'Take et al 2006).

    This is in contrast to positive emotions that predict higher quality relationships, improved physical health, and better work performance. However, much like excessively valuing and pursuing happiness, a pathological pursuit of positivity or trying to upregulate positivity during a pleasant experience make people feel worse (Cataline et al 2014).

    Prioritizing positivity

    "To improve the golden moment of opportunity, and catch the good that is within our reach, is the great art of life. Many wants are suffered, which might once have been supplied; and much time is lost in regretting the time which had been lost before." Samuel Johnson

    An individual’s self-perceived success, is an aspect of life satisfaction. It requires social relationships, a purposeful life, engagement in activities, self-esteem and optimism (Medvedez & Landhuis 2018).

    These positive emotions include a component of positive affect which prompts individuals to flourish and engage with their environments and partake in activities, many of which are adaptive for the individual, society or both (Fredrickson 2001).

    Positive situations involve mixed emotions of happiness and sadness. For instance, an individual may make a positive lifestyle choice to train for a marathon.

    In such a situation meeting milestones in their training to gauge improvement may boost self esteem and self confidence and make them happy and experience pleasant feelings.

    On the other hand, inconvenient training times, lack of motivation on certain days, injuries and other set backs may make them feel sad and experience unpleasant feelings.

    How an individual evaluates their current state, how introspective they are of short term momentary happy (pleasant) and sad (unpleasant) feelings and how they relate to the need to experience or avoid these feelings is a defining feature of their well-being. It determines if the original positive situation the individual planned i.e. running the marathon, leads to a more positive mind-set and well being or negative mind-set and ill health.

    Medvedev & Landhuis (2018) identified this as the difference between feeling happy as a momentary state of pleasure and being happy as an enduring condition that can come about from positive situations.

    Therefore positive emotions are not solely comprised of happy hedonic emotions eliciting reflex pleasant feelings. For instance, the benefits to experiencing emotions that typically elicit transient unpleasant feelings e.g. anger, can, when reflected upon productively, result in better performance in a confrontational task (An et al 2017). 

    In this example whether experiencing anger makes the individual feel momentarily happy or sad is not the defining feature or of primary importance, it is largely irrelevant; what is relevant, and should act as the primary self-narrative is the deliberate attempt to pre-plan and utilise whatever pleasant or unpleasemt emotions for a positive result. Mauss et al (2011) hypothesised that when people pursue non-emotion-regulatory goals, the limited emotional context means that the goals and how people feel about their progress toward their goals are not in conflict with one another and therefore the individual will experience more happiness.

    Therefore, unpleasant feelings and emotions that may elicit some fleeting level of apprehension, anxiety or sadness, can lead to the successful completion of a positively self defining task. The completion of this positively self defining task through mixed momentary emotions leads to increase life satisfaction (Medvedev & Landhuis 2018). Increased life satisfaction contributes to the self appraisal of the individual's skills and abilities; this broadens their range of thought-action repertories to strengthen their enduring personal resources to continually adapt and progress through life (O'Take et al 2006).

    Obviously not everything has to be about ‘prioritizng positivity’ enduring the ups and downs to experience life satisfaction and self-perceived success. In balance reflex momentary hedonic happiness such as pleasure and enjoyment should be savoured in people's life. Conversley not being in touch with some immediate sad emotions in certain scenarios can have unhealthy negative supressive effects.

    However, when taken to the extreme, an unhealthy linear thinking that craves momentary positive emotions and avoidance of momentary negative emotions creates an entrenched mindset that expects stability with extreme perspectives that are less tolerant to contradictions (An et al 2017).

    This acute introspective awareness of momentary emotions has a place in life-threatening situations. Here a linear thinking narrowed thought–action repertoire promotes quick and decisive action that carries an immediate benefit e.g. momentary emotion: extreme fear - action: run away (Fredrickson 2001). Any contradicting thoughts or actions in this scenario could be life threatening and therefore not tolerated. Day to day such an intense awareness of momentary emotions and a narrow-linear interpretation of these emotions is not needed. To be aware of ourselves engaging, adapting and flourishing in our environment we need a less introspective approach to our momentary emotions in order to elicit a broader more tolerant and lateral thinking though-action repertoire.

    This tolerant, lateral thinking more broader thought-action repertoire builds personal resources that broaden habitual ways of thinking or acting. This ranges from physical and intellectual resources to social and psychological resources; they allow the individual to play, explore, savor, integrate and envision future achievement (Fredrickson 2001) without getting bogged down with transient emotions.

    When thinking about, and valuing momentary happy and sad emotions is less extreme, as when prioritizing positivity, there is a greater expectation and acceptance of change for better or worse. This leads to a more malleable thought process allowing for a greater tolerance of contradictions (An et al 2017).

    Therefore prioritizing positivity is defined by how an individual seeks out positivity by making decisions in how to organize their day-to-day lives. It is associated with a host of beneficial well-being indicators such as (Cataline et al 2014):

    • Experiencing more frequent positive emotions and less depressive symptomology.
    • Access to greater resources such as self-compassion and ego-resilience.

    The danger of jumping from positive situation to positive situation is that we loose sight of the fundamental purpose of enjoyment. Realising one set of aspirations, can immediately lead to more ambitious aspirations, to which we transfer our hopes for happiness. As Samuel Johnson observed human traits seem to dictate that “life is a progress from want to want, not from enjoyment to enjoyment”  (Delamothe et al 2005).

    Positive emotions can be promoted through the use of humour. Using humour to cognitively reappraise a situation helps to distance oneself from the negative emotions and promotes resilience. This helps the individual view the negative situation as a challenge rather than a threat and refocus and reappraise the situation using positive emotions (Pérez –Aranda et al 2019) that may, as a side effect, induce temporary feelings of happiness or sadness.

    Happiness through humour

    Appropriate humour creates an environment that promotes learning and is a vital communication tool. Palliative care experts believe that the value of humour should not be trivialized, even in the end-of-life setting (Samant et al 2020). The value of humour is:

    • Attracts and sustains attention (Savage et al 2017) and improves energy levels (Fu et al 2020).
    • Produces a more relaxed and productive learning environment (Savage et al 2017) by dispersing tension (Fu et al 2020).
    • Reduces stress and anxiety by improving coping mechanisms (Samant et al 2020), shifting perspectives (Fu et al 2020) allowing for cognitive reappraisal (Pérez –Aranda et al 2019) and dealing with misfortune (Wilkins et al 2009).
    • Enhances participation and increases motivation (Savage et al 2017)
    • Facilitates interpersonal communication and attraction (Pérez –Aranda et al 2019) whilst improving trusting relationships (Samant et al 2020).
    • Builds bonds with others (Wilkins et al 2009). Laughing can signal to others our intentions of using humor to play out and practice certain kinds of social interactions (Libera 2020). The strength of a student-teacher relationships has a greater impact on student success than socioeconomic status (Savage et al 2017).
    • Improves quality of life for patients (Samant et al 2020) by strengthening an individual’s physical, psychological, and spiritual abilities (Fu et al 2020).
    • Makes sense of rule violations (Wilkins et al 2009).

    Awareness of negative types of humour that are best avoided, include mocking, sarcasm, and criticism (Samant et al 2020).

    Some patients report humour to be the quality that they most valued in their cancer care to decrease anxiety to help cope and deal with their disease with 86% declarimg it "some what important” or “very important” (Samant et al 2020).

    One cancer patient described:

    “The other reactions; anger, depression, suppression, denial, took a little piece of me with them. Each made me feel just a little less human. Yet laughter made me more open to ideas, more inviting to others, and even a little stronger inside. It proved to me that, even as my body was devastated and my spirit challenged, I was still a vital human” (Strean 2009).

    Humour also has positive physiological effects, such as decreasing stress hormones like epinephrine and cortisol and increasing the activation of the mesolimbic dopaminergic reward system (Brandon et al 2017). This decrease in stress hormones may explain the connection between laughter and enhanced immune function (Strean 2009 & Lawrence et al 2015) including improving NK cell activity (Bennett et al 2003). This is proposed to increases morbidity in the population as a whole (Lawrence et al 2015) and in patients with cancer and HIV (Bennett et al 2003).

    Pérez –Aranda et al (2019) also associated humor with reductions in growth hormones.

    Happiness as a meeting of minds (Tenney et al 2009)

    Individuals with similar personality patterns like each other more than individuals with dissimilar patterns. However, this was more prevalent for similarities of undesirable traits rather than desirable traits.

    This can be in contrast to the fundamental principle of liking that states people like others to whom they attribute generically desirable personality traits (e.g. generosity, kindness) and dislike others to whom they attribute undesirable traits (e.g. arrogance, rudeness).

    This attraction of people who exhibit the same personality traits was thought to be because people automatically like whatever reminds them of themselves. This familiarity is easier to perceive and interpret and is experienced as pleasurable.

    The stronger association individuals have with others that share their negative, as opposed to positive personality traits are thought to be from:

    • Positive traits are often encountered and rarely hidden. They are clearly advertised so are easy for everyone to perceive and understand. Therefore, there is no personal intimate benefit to being familiar with someone’s positive traits because everyone would be familiar with them.
    • Negative traits are viewed in multiple degrees of negativity; positive traits are viewed as generically positive with less fluctuation therefore it is more difficult to ally yourself with a comparable score. This makes it more easy to accurately associate yourself with someone else’s negative personality traits as there’s a more accurate measure.
    • People with similar patterns of positive traits understand each other better and see their own positive traits in others in an especially positive light. This can breed a competitiveness as the individual is no longer unique and indispensable negating any added benefit to their encounter.

    Humour and chronic pain (Pérez –Aranda et al 2019)

    Humour is a behavioural endurance strategy described as one of the possible ways to react to pain. It can modify emotion related temperament i.e. cheerfulness, seriousness and bad mood and influence motivational states.

    In chronic pain, i.e. persisting for more than three months, this can be associated with mental and emotional problems or disabilities in daily functioning, as well as difficulties participating in social activities.

    In the fear avoidance model of chronic pain the meaning associated with the pain experience is a key aspect in the development of fear of pain and, therefore, avoidance behaviours. The process by which chronic pain leads to disability seems to be mediated by variables such as sensitivity to anxiety, depression, distress, fear of pain, catastrophism, and body vigilance.

    Humorous stimuli or tasks may impact on health due to distraction and cognitive reappraisal. However, the humorous stimuli needs to match the individual’s preferences and that being able to choose the humour is an important part of the phenomenon. Therefore ‘imposing’ an ego or comedy style upon a patient may not work. Using humour to manage chronic pain can work through two forms:

    • Distraction has been shown to be an effective strategy for dealing with pain. This is because the perception of pain is suppressed by consciously focusing attention on the nonpainful, humorous, stimulus.
    • Cognitive reappraisal of stressful events promotes resilience and well being. Using humour enables individuals to view stressful situations as challenges rather than threats to gain a sense of mastery over the situation. It also helps distance oneself from the emotional impact of an event and refocus on its positive aspect. This would help individuals reappraise pain in retrospect as less negative and stressful.

    Developing social support through the use of appropriate humour may initiate and sustain friendships more easily enabling the patient to achieve more satisfying social relationships which can help cope with chronic pain.

    Happiness through situations and comedy

    “Until the scientists work out all the details, get in all the laughter that you can!” Robert Provine, Laugh Out Loud

    Pérez –Aranda et al (2019) identified four general types of humour style:

    • Affiliative humour uses humour to affirm oneself and others.
    • Aggressive humour is impulsive and derisive toward others such as sarcasm, teasing, and ridicule.
    • Self-enhancing humour maintains an optimistic outlook on life when stressful events arise, so it could also be considered as the coping type of humour.
    • Self-defeating humour which consists of allowing oneself to be the butt of jokes to gain others’ approval.

    Affiliative and self-enhancing humour are associated with positive outcomes such as cheerfulness, self-esteem, intimacy, relationship satisfaction and predominant positive moods. This may have analgesic effect.

    Aggressive and self-defeating humour have been associated with neuroticism, stress, anger, depression and anxiety, low self-esteem and negative moods.

    However even though self-defeating humour was associated with more pain with low level of daily stresses, both self-defeating humour and aggressive humour were found to play an adaptive role when daily stresses were high. Both self-enhancing and self defeating humour has been associated more with happiness than the other humour styles.

    How these different humour styles are vocalised and played out involves four theories of their delivery:

    • Incongruity theory.
    • Superiority theory.
    • Arousal theory.
    • Combination theory.

    Incongruity theory

    Incongruity theory states humour results when our brains perceive two things as coexisting in a manner that does not at first appear to make logical sense. Laughter or humour occurs when the discomfort caused by this incongruity is resolved in some way. A simple example of this is a pun (Libera 2020). 

    For this to occur people must be aware of appropriate or inappropriate behaviour in social situations (Savage et al 2017).

    Libera (2020) found variations in incongruity theory to include:

    • When social roles are reversed: the powerful are taken down or the powerless become powerful, as occurred during medieval carnivals when a peasant became a carnival king for the day.
    • When there is a simultaneously violation of norms seen as being benign

    Superiority theory

    Superiority theory dates back to the writings of Plato and Aristotle and suggests that the primary motivator for humour is triumph or pleasure at the pain, flaws, or indignities of others. It requires ridicule, disparaging or belittling others. This involves laugh “at” something or someone because that person is seen as being genuinely less than ourselves (Libera 2020).

    Arousal theory

    Defines humour as a complex interaction between emotion and cognition.

    Individuals will describe the humour as appropriate and possibly funny or inappropriate based on whether the targeted subject is associated with them personally or not.

    Combination theory

    Libera (2020) combined these three models as well as the tension-release theory. She broke this combined theory into three elements:

    • Recognition: describe something familiar. This shared observation supports or reflects the audience’s experiences of the world creating a bond through mutual understanding.
    • Pain: what would the world’s worst version of a particular occupations do or say? For example describing the worst first date.

    This generates tension, cognitive dissonance (contradictory thoughts, beliefs and values), and embarrassment or shame. For example: The Office.

    Releasing tension and recognizing awkwardness or discomfort without making any kind of formal joke can lead to laughter. Laughter is inherently social and shared laughter creates more points of connection.

    • Distance: this allows us to reflect on these experiences with some degree of objectivity, equanimity, or sense of safety, perhaps making them benign. Very painful or highly taboo subjects require a great deal of distance in order to feel funny.


    Wilkins J, Eisenbraun A (2009). Humor theories and the physiological benefits of laughter

    Fu X, Wu L, and Shan L (2020). Review of possible psychological impacts of COVID-19 on frontline medical staff and reduction strategies  

    Pérez-Aranda A, Hofmann J, Feliu-Soler A, Ramírez-Maestre C, Andrés-Rodríguez L , Ruch W, Luciano J  (2019). Laughing away the pain: A narrative review of humour, sense of humour and pain

    Bennett M, Zeller J, Rosenberg L, McCann J (2003). The effect of mirthful laughter on stress and natural killer cell activity

    An S, Ji L, Marks M and Zhang Z (2017).Two Sides of Emotion: Exploring Positivity and Negativity in Six Basic Emotions across Cultures

    Savage B, Lujan H, Thipparthi R, and DiCaHumor S (2017). Laughter, learning, and health! A brief review  

    Anne Libera A (2020). The Science of Comedy (Sort of)

    Samant R, Balchin K, Cisa-Paré E, Renaud J, Bunch L, McNeil A, Murray S, and Meng J (2020). The importance of humour in oncology: a survey of patients undergoing radiotherapy

    Tenney E, Turkheimer E, and Oltmanns T (2009). Being Liked is More than Having a Good Personality: The Role of Matching

    Catalino L, Algoe S, and Fredrickson B (2014). Prioritizing Positivity: An Effective Approach to Pursuing Happiness 

    Strean W (2009). Laughter prescription


    B. Mauss I, Tamir M, Anderson C, Savino N (2011). Can Seeking Happiness Make People Happy? Paradoxical Effects of Valuing Happiness

    Delamothe T (2005). Happiness. Get happy—it's good for you

    Medvedev O and Landhuis E (2018). Exploring constructs of well-being, happiness and quality of life

    Lawrence E, Rogers RWadsworth T (2015). Happiness and longevity in the United States

    Fredrickson B (2001). The Role of Positive Emotions in Positive Psychology. The Broaden-and-Build Theory of Positive Emotions

    Lenton ABruder MSlabu LSedikides C (2013). How does "being real" feel? The experience of state authenticity