Holistic Help For Chronic Pain

What is Chronic Pain

Chronic pain is the presence of persistent pain which has lasted for more than 6 months.

According to Pain Australia, chronic pain affects 1 in 5 Australians aged over 45 but also affects younger people too.

In 2018, it was estimated that 3.24 million Australians had chronic pain with 44.6% of this population also living with depression and anxiety.

Because chronic pain is invisible and poorly understood, many who experience it are not taken seriously and may also face discrimination adding to financial and emotional burdens.

More than 20% of all visits to GPs involved chronic pain.

Most people who live with chronic pain require frequent healthcare support with patients typically visiting a health care practitioner weekly.

The financial cost of chronic pain as a result of medications, treatments and lost work was estimated at $139.3 billion dollars. . 

Given the complex and individual nature of chronic pain, it is useful to consider how the pain originated.

For many, chronic pain may be the result of “wear and tear” such as in the case of osteoarthritis.

Apart from osteoarthritis, back pain is the second most common chronic condition.

This may present with chronic pain that is worse in the mornings, or with overuse.

Chronic pain may also be the result of acute injuries being poorly managed or the result of mental health disorders that are linked with increased inflammation.

Risk factors for developing chronic pain include:

  • Being female
  • Being diagnosed with a long term condition such as diabetes
  • Longer hospital stays
  • Limitations on daily activities
  • Having poor nutrition
  • Having a sedentary lifestyle
  • Experiencing high levels of stress
  • Problems with sleep
  • Mental health problems

Treatments for chronic pain are often varied and frequently concomitant.

Popular treatments for chronic pain include pain medication, nerve blocks, active physical therapy, behavioural interventions, assistance with vocational training and psychological help.

Despite these interventions showing improvements in pain scores, cures for chronic pain remain elusive.

This creates a conundrum – how best to treat individuals with chronic pain and how to reduce financial and emotional burden?

There is growing awareness of the importance of creating a person-centered approach in healthcare that includes multidisciplinary support.

By using this model, one study noted there was a 35% reduction on the healthcare system but even more importantly, patients noted a significant improvement in their depression (57%), anxiety (41%), and reduction in opioid use (50%).

This suggests that natural therapies may play a key role in managing pain and addressing concomitant issues that present with chronic pain. 

References:

  • Apkarian, A. V., Baliki, M. N., & Geha, P. Y. (2009). Towards a theory of chronic pain. Progress in neurobiology, 87(2), 81-97.
  • Michael A Ashburn, Peter S Staats (1999). Management of chronic pain,

The Lancet,Volume 353, Issue 9167,

https://doi.org/10.1016/S0140-6736(99)04088-X.

The Impact of Diet on Chronic Pain

Emerging research is clearly demonstrating the link between diet and chronic pain.

This is because chronic pain often presents with increased levels of oxidative stress and inflammation which are commonly accepted mechanisms for pain.

Dietary factors including proteins, carbohydrates, fats, fibre, vitamins, minerals and probiotics are important for normal health, function and repair. 

The presence of chronic pain and associated inflammation suggests that nutritional needs are higher.

This is supported by evidence that suggests dietary changes may impact oxidative and stress levels.

For example, low dietary intake of micronutrients including omega-3 fatty acids, B4, magnesium and zinc combined with high intakes of glutamate and aspartate (found in meat, soy sauce and aged cheeses) increased the risk of fibromyalgia.

Similarly, the use of magnesium, B12 and zinc have been shown to improve neuropathic pain. 

Consuming a wide and varied diet with minimal processed foods with low salt and sugar is associated with multiple health benefits, a decrease in chronic pain is just one aspect.

As chronic pain  presents  with co-morbidities including decreased mental health, it is imperative that systemic damage and symptoms are managed well and safely.

A good starting point would be the digestive system as it is responsible for all nutrient breakdown and absorption.

Home to trillions of bacteria known as the microbiome, this diverse system can affect our health in a variety of ways.

In an ideal environment, our microbiome would remain diverse and balanced through our diet.

In this state it is able to modulate the immune system, reduce symptoms of allergies, improve mental health and decrease systemic inflammation making it a safe and effective treatment for chronic pain.

Despite this promising evidence many people with chronic pain do not view dietary changes as a potential treatment option.

In one study, 76% of patients rated their diet between “good” and excellent, believing that it promoted wellbeing, however 74% of these people were overweight with multiple co-morbidities.

Another study suggested that individuals with diets high in whole grains, dairy, fruit and vegetables were 24% less likely to report chronic spinal pain.

Those who had increased sugar in their diet were associated with 49% increased odds of chronic spinal pain suggesting that sugar is a key driver for inflammation. 

In the Western World, the use of sugar in pre-packaged, processed and fast foods is everywhere.

It is found in juices, drinks, soups, breads, yoghurts – it is highly overused.

One study found that soft drinks and juices were responsible for the addition of 36% more sugar in a person’s diet, causing inflammation and offering no nutritional benefit in return.

For consumers who want to be more aware of diet, it is daunting to identify sugar as it can go by many names – glucose, high fructose corn syrup, sucrose, dextrin and dextrose are just a few of the names.

Our bodies are designed to function at a slightly alkaline pH balance between 7.35 and 7.45.

By altering our bodies’ pH (how acidic or alkaline our bodies are), sugar causes an increase in acid which then places more pressure on vital organs to try and maintain a this balance.

Apart from this spike in pH, sugar also drives inflammation by stimulating the flight-or-fight response (adrenalin and cortisol) which increases blood pressure and alertness.

A really fascinating area of research that is emerging is the use of medically supervised fasts (lasting from 7 – 21 days at 200 – 500kcal a day intake) to treat chronic pain.

This study by Michalsen in 2010, demonstrated that fasting was accompanied by improved alertness and mood as well as a reduction in pain as there was increased brain availability of serotonin and other endocannabinoids. 

Tips to alleviate chronic pain through diet:

  1. Dramatically reduce sugar intake (no processed sugars, limit fruit to 2 serves daily)
  2. Increase intake of water
  3. Increase intake of fresh vegetables
  4. Limit intake of red meats
  5. Avoid foods that are high in saturated fats, burned, fried or deep fried
  6. Limit dairy intake
  7. Limit alcohol consumption
  8. Limit portion sizes
  9. Consider keto diets or intermittent fasting. 

References:

  • Philpot, U., & Johnson, M. I. (2019). Diet therapy in the management of chronic pain: better diet less pain?
  • van Hecke, O., Torrance, N., & Smith, B. H. (2013). Chronic pain epidemiology–where do lifestyle factors fit in?.British journal of pain, 7(4), 209-217.
  • Okifuji, A., & Hare, B. D. (2015). The association between chronic pain and obesity.Journal of pain research, 8, 399.
  • Field, R. J., Pourkazemi, F., & Rooney, K. B. (2020). Participants with chronic pain do not perceive diet as a contributing factor to their pain: a survey-based study.Pain management, 10(3), 195-204.
  • Michalsen, A. (2010). Prolonged fasting as a method of mood enhancement in chronic pain syndromes: a review of clinical evidence and mechanisms.Current pain and headache reports, 14(2), 80-87.

The Link Between Exercise and Chronic Pain

Regular exercise has been identified as a primary prevention for more than 35 chronic conditions.

These include obesity, anxiety, depression and joint pain.

The use of exercise is ideal as it has multiple benefits, is low cost, may be done by the patient, is easily tailored to individuals and can work with (even lower) the amount of prescription medication.

Despite the clinical advocacy for exercise, often individuals with chronic pain are afraid of exacerbating their pain.

When an individual is in chronic pain, behavioural changes will often result in the person avoiding any extra movement in an attempt to further limit pain.

Unlike acute pain that comes on as the results of an injury, chronic pain is not confined to local tissues or structures and tends to impact the nervous system more.

By sensitising the nervous system to pain receptors, a vicious cycle is created which sees individuals:

  1. Limit exercise
  2. Which can impact weight 
  3. Weight issues may cause self confidence issues, compound physical pain and increase inflammation
  4. Increase the likelihood of poor diet due to comfort eating processed foods which also drives inflammation and increases sensitivity to pain
  5. Decrease movement even further, including social activities which can impact mental health and emotional health

Studies have shown that exercise, done slowly and gradually is an essential part of treating of chronic pain.

Just like food, exercise is a valid treatment strategy that can be tailored to suit individual needs.

It is recommended that people with chronic pain explore different forms of exercise to increase flexibility, loosen stiff muscles, improve range of motion and maintain healthy muscle mass which will enable daily activities and support good posture.

This may have flow on effects to impact mood, ability to work and socialise while reducing the financial burden of treating chronic pain. 

Exercise therapy has been used on a variety of chronic pain disorders including people with fibromyalgia, chronic fatigue syndrome, arthritis, chronic whiplash associated disorders, migraines and low back pain.

In one study, aerobic exercise was shown to be the best option for the prevention of migraines whereas specific neck and shoulder exercises were better suited for treating chronic headaches arising form stress and tension.

For those who are already struggling with weight and chronic pain, the use of aerobic exercise and resistance exercise was able to reduce joint pain by up to 71.4%.

It is worth noting that while acute exercise was associated with temporary exacerbations in pain, this subsided and continued adherence led to decreased pain, greater range of movement and mood. 

Beginning an exercise regime when living with chronic pain does not need to be daunting.

It is better to do multiple short workouts than push and exacerbate inflammation and pain. 

Here are some tips to start:

  1. Begin with simply deep breathing
  2. Try to move your body in sequence – from the toes up scrunch, roll, extend, wave and just explore what your current motion is without pain
  3. Consider walking slowly for short periods of time but with good posture, it’s very easy to engage other muscles which will exacerbate bad form and increase pain due to poor posture
  4. Consider walking in water – anything that is water based will reduce pressure on joints. If you have access to a warm hydrotherapy pool or centre, maybe consider looking into classes
  5. Consider slow yoga (yin yoga) or pilates. Aim for short (10 minute) sessions that are slow and gentle
  6. Consider investing in some yoga resistance bands or light small weights to build muscle 
  7. Consider elliptical machines or other non-impact exercise equipment

If all else fails, please consult a trained exercise physiologist or physiotherapist for more specific exercises that may benefit you. 

References:

  • Sullivan, A.B., Scheman, J., Venesy, D.et al. The Role of Exercise and Types of Exercise in the Rehabilitation of Chronic Pain: Specific or Nonspecific Benefits. Curr Pain Headache Rep 16, 153–161 (2012). https://doi.org/10.1007/s11916-012-0245-3
  • Daenen, Liesbeth PhD, PT*,†; Varkey, Emma RPT, PhD; Kellmann, Michael PhD§,∥; Nijs, Jo PhD, PT Exercise, Not to Exercise, or How to Exercise in Patients With Chronic Pain? Applying Science to Practice, The Clinical Journal of Pain: February 2015 – Volume 31 – Issue 2 – p 108-114 doi: 10.1097/AJP.0000000000000099
  • Kroll, H. R. (2015). Exercise therapy for chronic pain.Physical Medicine and Rehabilitation Clinics, 26(2), 263-281.
  • Integrated Pain Science Institute How And Why To Exercise With Chronic Pain Accessed on  29/04/2021 from https://www.integrativepainscienceinstitute.com/exercise-chronic-pain/

Stress and Chronic Pain

The overlap of anxiety, depression and pain is excruciatingly clear.

It makes perfect sense that being in chronic pain increases levels of stress.

Along with being in pain, for many, there are additional emotional and financial burdens.

Having to cope with an invisible illness that many people can’t see can make many sufferers feel under pressure to “act normally” which can be a huge drain on their energy.

Furthermore, chronic pain may create stress on relationships as well job insecurity due to pain impeding work productivity.

All of this creates a perfect storm for a health disaster. 

In a study conducted in 2017, researchers investigated how persistent pain and stress resulted in brain remodelling – both physiologically and structurally.

They came to the conclusion that the changes observed in chronic pain, depression and post traumatic stress disorder were all linked and affected the limbic brain.

This area of the brain is crucial for learning and generating learning signals that are needed during the decision making process.

What this means, is that despite being identified as two separate disorders, both chronic pain and stress affect the brain in a similar way.

When they are combined they have the ability to physically alter brain chemistry and structure which then results in altered behaviours. 

In one study that investigated women who had chronic pain, the researchers found that social support was tied to perceived social stress and this negative mood exacerbated their pain scores.

This experimented highlighted that just as chronic pain is individual, so too is stress.

For example, what one person may find stressful may be a source of enjoyment for another person.

Where social groups may normally be associated with decreased stress, for these women, it increased their anxiety. 

Researchers have also identified common external factors such as socioeconomic background and education levels which have been shown to alter the experience of stress.

Known as environmental stressors, one study found that educational level was a protective factor against Swedish patients with osteoarthritis in their knee.

Individuals who were financially well off also were associated with decreased pain levels suggesting that there can be a build-up of chronic stress that can exacerbate chronic pain.

It may seem hopeless, but there are a number of ways to break the cycle of stress and pain.

  1. Educate yourself on your condition
    Education is the key to understanding what your condition is, how it started, how it is likely to progress, what are the current treatment methods and what new research is emerging.
  2. Understand yourself
    Make a note of your daily habits and how you feel. 
    Do you notice any correlation between what you eat and your pain levels? 
    What about sleep?
    Are there joints or body parts that hurt more? 
    What have you tried to do to alleviate the pain and did it work?
    What do you do for fun?
    What do you do for work and does this impact your posture / pain?
  3. Set small goals
    Once you understand what makes you tick, see if you can work on small goals. 
    This might include 5 minutes of meditation or mindfulness practices a day, cutting back on sugar, making yourself go to bed earlier, doing yoga. 
  4. Reward yourself
    It is important to reward yourself for trying to achieve your goal – with stress and chronic pain fighting to re-wire your brain, it is important to fight back. Rewarding yourself with healthy pleasures (spa treatment, massage etc) will stimulate dopamine (the neurotransmitter responsible for “reward” pleasure in the brain). Massages and physical treatments also help to relieve muscular stress and tension, improve circulation and re-align postural muscles for increased stress and pain relief. 
  5. Live with yourself
    On the days when the pain gets a bit too much, just breathe through it and know that you are doing the best you can. Take medication if you need to, lie down if you need to – your pain is temporary and can be managed. So do not get caught up in negative emotions. 

References:

Chadi G Abdallah, Paul Geha

Published online 2017 Jun 8. doi: 10.1177/2470547017704763

  • Blackburn‐Munro, G., & Blackburn‐Munro, R. E. (2001). Chronic pain, chronic stress and depression: coincidence or consequence?.Journal of neuroendocrinology, 13(12), 1009-1023.
  • Hart, R. P., Wade, J. B., & Martelli, M. F. (2003). Cognitive impairment in patients with chronic pain: the significance of stress.Current pain and headache reports, 7(2), 116-126.
  • Banks, S. M., & Kerns, R. D. (1996). Explaining high rates of depression in chronic pain: A diathesis-stress framework.Psychological Bulletin, 119(1), 95–110. https://doi.org/10.1037/0033-2909.119.1.95
  • Steven Rosenzweig, Jeffrey M. Greeson, Diane K. Reibel, Joshua S. Green, Samar A. Jasser, Denise Beasley, (2010) Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice,

Journal of Psychosomatic Research, 68(1), https://doi.org/10.1016/j.jpsychores.2009.03.010.

Supplements for Chronic Pain

Unsurprisingly, a number of the supplements that are used to treat chronic pain are also used to treat mood disorders.

This is because many of these supplements are able to target pathways that promote inflammation.

The use of supplements for chronic pain is incredibly common but care needs to be taken as many people with chronic pain are also on multiple medications and suffer from other co-morbidities.

As always, it is important to get advice from a professional to ensure that supplements and medications work together and you don’t take excessive supplements. 

Some nutritional compounds that may be worth considering include l-theanine (from green tea), N-acetyl cysteine (NAC) and palmitoylethanolamide (PEA). L-theanine has been shown to help with moderate and severe generalised anxiety disorder and improve feelings of calm as well as sleep quality which can help people with chronic pain who have problems sleeping.

NAC has been clinically proven to help treat anxiety, depression, obsessive compulsive disorder and bipolar disorder while PEA is an endogenously produced cannabinoid-like substance that has been shown to improve mood and pain states.

PEA is similar to cannabis but research suggests that it is much safer as it is better tolerated, has fewer side effects, is not associated with symptoms of withdrawal and is not subject to tolerance levels.

That said, for many cannabis is also a viable option for the relief of chronic pain and is also able to offer improved mood and sleep. 

Herbs have also been shown to be effective for treating chronic pain.

White willow bark is the original gut-friendly aspirin and is good for all kinds of general pain and to reduce fever.

It’s botanical name is Salix alba.

Jamaican Dogwood (or Piscidia erhythrina) is another herb that is effective for osteoarthritic pain, nerve pain, migraines, insomnia, anxiety and nervous tension.

The evocatively named Devil’s claw (also known as Harpagophytum procumbens) has been consistently shown to be effective for managing osteoarthritic pain.

Many studies have demonstrated it’s safety as well as its efficacy.

The unrelated herb Cat’s Claw (Uncaria tomentosa) has also been shown to reduce inflammation.

For nerve pain, Californian Poppy is traditionally used.

It would be impossible to not include both turmeric and saffron.

As potent anti-inflammatories, both have been shown to be highly effective and safe with medications. 

The use of probiotics as supplements may also help to alter the gut microbiome.

This can have a huge impact on mood and sensitivity to pain.

Probiotics have been associated with an increase brain derived neurotrophic factor and reduce inflammation, a broad strain probiotic may be worth considering.

Finally, the use of essential fatty acids for the treatment of inflammation is well known.

Fish oil has been shown to consistently improve mood states as well as physical pain by reducing pain and inflammation.

For sufferers of osteoarthritis and other joint degenerative conditions, the use of gelatin is gaining momentum as research is demonstrating that it is able to help repair joints with early signs of degeneration. 

Many of these supplements can be taken in the form of foods (increasing a daily intake of fish and green tea, for example) while others may be more exotic and hard to source.

When in doubt, go back to basics.

Chronic pain is a long term condition that can improve but takes time and patience.

Rather than one magic supplement fixing it, research has demonstrated that chronic pain will respond better to a multitude of different approaches done at the same time. 

References:

  • Barker, J. E., & Meletis, C. D. (2004). Naturopathic pain management.Alternative & Complementary Therapies, 10(4), 188-193.
  • Oregon State University. “Boosting levels of known antioxidant may help resist age-related decline.” ScienceDaily. ScienceDaily, 24 October 2016. <www.sciencedaily.com/releases/2016/10/161024132851.htm>
  • Prasanth, M. I., Sivamaruthi, B. S., Chaiyasut, C., & Tencomnao, T. (2019). A Review of the Role of Green Tea (Camellia sinensis) in Antiphotoaging, Stress Resistance, Neuroprotection, and Autophagy. Nutrients, 11(2), 474. https://doi.org/10.3390/nu11020474
  • De Gregorio, D., Manchia, M., Carpiniello, B., Valtorta, F., Nobile, M., Gobbi, G., & Comai, S. (2019). Role of palmitoylethanolamide (PEA) in depression: Translational evidence: Special Section on “Translational and Neuroscience Studies in Affective Disorders”. Journal of affective disorders, 255, S0165-0327(18)31599-4. https://doi.org/10.1016/j.jad.2018.10.117
  • de Magalhães, J. P., Müller, M., Rainger, G. E., & Steegenga, W. (2016). Fish oil supplements, longevity and aging.Aging, 8(8), 1578–1582. https://doi.org/10.18632/aging.101021
  • Piscoya, J., Rodriguez, Z., Bustamante, S. A., Okuhama, N. N., Miller, M. J. S., & Sandoval, M. (2001). Efficacy and safety of freeze-dried cat’s claw in osteoarthritis of the knee: mechanisms of action of the species Uncaria guianensis.Inflammation Research, 50(9), 442-448.
  • Moskowitz R. W. (2000). Role of collagen hydrolysate in bone and joint disease.Seminars in arthritis and rheumatism, 30(2), 87–99. https://doi.org/10.1053/sarh.2000.9622
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