CHRONIC PAIN CAN HAVE A COMPLEX ETIOLOGY. It’s not usually as simple as a single injury causing the pain (ie. cutting your finger while chopping vegetables). Acute pain tends to be more simplistic with injury, inflammation and healing occurring over the span of days, weeks or in some more serious cases (ie. a broken bone), months.
With chronic pain (pain with psychosocial dysfunction, lasting >6 months), there is often a combination of mechanisms out of balance and it requires some detective work from your Naturopathic Doctor to get to the source of the issue.
It is ideal that a patient diagnosed or suffering from chronic pain have thorough laboratory testing completed to rule out concomitant conditions.
Why do I feel pain?
Pain is a perceived sensation from your nervous system relaying messages to your brain that an injury is occurring and to remove that stimulus to prevent further damage. The message can be sent from an injury to your body or organs (ie. peripheral nervous system) or an internal message from within your spinal cord and brain (ie. Central nervous system).
Peripheral and central are the 2 main systems that make up your nervous system. Within them, you have several sub-systems that regulate various sensations and actions. Here’s a generalized summary of the nervous system:
Acute Pain from External Injury
When an injury occurs from an outside source (ie. paper cut to the finger) the sensation causes a relay of messages to the brain (sensory afferent pathway) that registers the feeling as painful or harmful, which then sends a different signal to engage a physical response (motor efferent pathway), such as pulling your finger away
Afferent pathway (sensory signals such as pain, touch, temperature, itch, and stretch from the surfaces on the skin) –> to the brain to be processed as information –> efferent pathway takes the brain’s message and influences your motor neurons and muscles to limit damage appropriately.
Chronic Pain is Complex
With chronic pain, the pathways are much more complex and often require treatments on both the peripheral and central nervous system. Common causes for chronic pain include:
- Physical malformation and structural limitations – Repetitive injuries, nerve impingement (joint, muscular, bursae), structural deformities causing compensation, phantom limb pain.
- Endocrine imbalance -Hormone secreting glands including the adrenals, thyroid, pancreas, sex hormones and Hypothalamic-Pituitary Axis (HPA) can all interact with one another and disrupt the equilibrium, especially serotonin, norepinephrine, dopamine.
- Environmental toxins – Chemical exposures from smoking, pollution, household cleaning agents, skin care, foods, beverages, poor water quality, heavy metal exposure (mercury amalgums, aluminum), personal hygiene products, synthetic hair dyes, perfumes and creams , and poor air quality, ventilation and filtration (toxins, pollution, allergens, mold).
- Psychological and physical trauma or stress – Trauma and stress can be held in the body if proper support and counseling isn’t given. The body has an unconscious way of remembering and reacting to incidences that have caused significant emotional or physical injury. These triggers can re-expose a person to more pain if not resolved effectively.
- Malnutrition and malabsorption of critical nutrients – Nutrients required for healing injured tissues include dietary protein, vitamin C, vitamin A, vitamin E, vitamin B6, zinc, magnesium, lysine, proline, arginine, glutamine, and glucosamine. A poor or unvaried diet and poor GI absorption of nutrients (ie. leaky gut syndrome, low pancreatic enzymes) can cause malnutrition and delayed healing.
- Physical undiagnosed injuries or impeding masses – Unidentified lesions or masses can displace other tissue causing chronic pain. Getting proper lab and image testings will help to identify these undiagnosed conditions.
- Systemic inflammation – acute inflammation will reveal neutrophils in the tissue spaces, while lymphocytes are seen in chronic inflammation. The inflammation may be due to inflammatory foods and environmental factors, autoimmune disorders, chronic infection, repetitive injuries, allergic reactions or chronic stress. Read more here (“That’s Not Fat”).
- Hyper-sensitization – over-exposure to particular chemicals, foods, environmental factors, and stress can lead to exaggerated biochemical signal responses and potentially low pain tolerance. Inappropriate responses to Substance P is a common example of hyper-sensitization causing pain perceptions from the CNS.
- Genetic predisposition – Some people are born with structural anomalies, autoimmune diseases or brain chemical imbalances that are easily triggered to experience pain. Genetic etiology are not a life-sentencing, rather a reminder to take on specific preventative health and lifestyle measures.
- Autoimmune conditions – Autoimmune conditions present themselves once they are triggered by an external factor: poor diet, sedentary lifestyle, hyper-sensitization, excessive and chronic stress, infection. Autoimmune conditions can target glandular tissues to disrupt hormonal balance, joints, muscles and neurological function.
- Chronic infection – viral, bacterial, fungal, and parasites can cause local and systemic pain. Sometimes a lingering infection can cause a low-grade infection that goes undetected. Supporting a healthy immune system will help to irradiate persistent infections and improve healing, although more intensive treatments may be necessary for certain infections.
- Poor sleep – Sleep is the crux of healing damaged tissue. Without adequate sleep, the body won’t be able to function at it’s optimal capacity. Sometimes sleep is impaired due to pain, in which sometimes pain killers or sleeping pills may be needed temporarily for the body to re-set.
Conditions to Rule Out
- Addison’s disease, Cushing’s syndrome, hypothyroidism/ hyperthyroidism, iron deficiency/ iron overload syndrome, anemia of various types, diabetes mellitus, cancer, treatable sleep disorders (ie. apnoea), neurological and auto-immune disorders (ie. multiple sclerosis, Parkinson’s disease, myasthenia gravis, B12 deficiency, rheumatoid arthritis), osteoarthritis, osteoporosis and fractures, nerve impingments (ie. disc herniation, sciatica, thoracic outlet syndrome, carpal tunnel syndrome), muscular tears and injury, surgical complications, infectious diseases (ie. AIDS, hepatitis, tuberculosis, Lyme disease, ), Celiac disease, primary psychiatric disorders and substance abuse
Etiology and Laboratory Testings
Blood tests: CBC, ESR, serum electrolytes, glucose, Calcium, RBC Mg, phosphorous, TSH, T3, protein electrophoresis screen, CRP, Ferritin, Creatinine, Rf, ANA, CPK, Liver function tests, Urinalysis.
Brain/ cervical imaging: SPECTS scan (blood flow, glucose uptake), MRI (white/ grey matter, Chiari Malformation, phospholipis, abnormal pain processing areas).
Neuroendocrine studies: HPA, CRH, ACTH, Cortisol 4 point salivary test.
Neuropsychological investigation and testing: cognition, brain fog, slowed processing speed, impaired working memory, inability to multitask, poor leaning of information, depression.
Other: Functional testing; food intolerances and allergies; oxidative stress; heavy metal toxicity, genetic testing, sleep studies.
Additional testing depending on personal and family history: STI, hepatitis B and C, tuberculosis, HIV, cancer.
Potential Treatment Strategies for Chronic Pain
Lifestyle, dietary nutrition, nutritional supplementation, parenteral therapies, physical medicine, traditional Chinese medicine, homeopathy, psychological counseling, limiting environmental toxins and pharmaceutical medications are all effective ways of managing chronic pain. It is important to keep in mind that these are NOT cures but ways to manage and lift symptoms. Thorough investigation to the underlying causes will aid in the path to healing.
Adequate rest periods and restorative practices such as yoga, meditation and moderate resistance training exercise and activities can help with pain management. Exercise is important in maintaining muscle strength and healthy circulation, however over-training can worsen symptoms. A study by Kingsbury et al. (1998) shows athletes with “Over-training Syndrome” to have decreased plasma glutamine which can increase susceptibility for infections and chronic fatigue.
Poor standing, sitting and sleeping postures can affect muscle imbalances and healing response. The optimal posture is maintaining a neutral spine and strengthening core muscles with postural exercises.
Sleep is crucial to healing the mind and body. The insomnia can further exacerbates fatigue, brain fog, migraines, and myalgia (muscular pain) symptoms. For optimal health and healing, proper sleep hygiene is critical:
- keep the bedroom as dark as possible
- utilizing the bedroom for sleep and sex only
- creating a quiet and clutter-free environment
- keeping to a regular bed time schedule (going to bed and waking up) every day of the week
- avoid going to bed too exhausted
- avoid stimuli at least 30 minutes prior to bedtime (ie. caffeine, exercise, TV, computer use)
- moderate daily physical activity
- avoiding large meals late at night
- utilizing relaxation techniques in the evenings (ie. meditation, deep breathing, baths, calming teas)
- using comfortable and supportive mattress and pillows
Nutritional modifications are often very beneficial to the overall well-being of people living with chronic pain. As with many conditions, improvements to a balanced diet high in vegetables and limited animal protein and simple carbohydrates supports healthy body function. A mostly raw vegetarian diet has been shown to have overall symptom improvements. Other helpful diet modifications can be:
- eating small frequent meals
- avoiding food sensitive and allergic foods
- having an anti-inflammatory diet
- avoiding foods that have been processed and preservatives
- avoiding chemical additives, such as glutamate (aka MSG)
- limiting refined sugars
- drinking 8-10 glasses of filtered and re-mineralized water
A trial period of a hypoallergenic or oligo-antigenic diet to identify food sensitivities and intolerances is often helpful in decreasing inflammation and dysfunction.
The top 5 offenders include: wheat, dairy, corn, soy, and eggs.
Note that some of the foods on the list are very nutritious, so if you are not sensitive to the food, bring them back into your diet (ie. eggs).
Try and stay away from packaged, canned, processed and deep fried foods. And be cautious of dehydrated and dried foods for they often contain added sugars and preservatives. Raw and fresh is often your best bet for optimal health.
To get your free comprehensive Hypo-Allergenic eManual including dietary guidelines, recipes for a 7-day meal plan, shopping lists, and food re-introduction schedule, sign-up HERE.
Periodic nutritional supplementation is typically indicated for patients with chronic pain to regain and maintain healthy cellular homeostasis. I typically don’t recommend analgesics because of their addictive nature and ability to rely solely on masking pain rather than getting to the source of the cause.
Please contact your Naturopathic Doctor if you are considering taking any of these supplements. There are potentially severe interactions and may not be best indicated for your particular situation. Dosing and duration of treatment is critical in healthy healing without complications or aggravation of your condition. If you need references for a Naturopathic Doctor in your area please visit www.DrAlisonChen.com/ND.
Turmeric (aka Curcumin) — Turmeric is the great anti-inflammatory spice that is also available in capsule form. Taking high doses on a daily basis can help with joint and inflammatory pains.
5-Hydroxytryptophan (5-HTP)– 5-HTP is a precursor to serotonin which can significantly improve symptoms of anxiety, pain intensity and distribution, sleep quality, and fatigue. Side effects are rare but can cause sleep disturbances and gastrointestinal discomfort. 5-HTP can also interact with certain medications that function on the CYP 3A4 pathway, especially in antidepressants medications (ie. SSRI, amitriptyline and monoamine oxidase inhibitors).
Digestive Enzymes— Digestive enzymes (ie. bromaine, peptidase, papaine) taken between meals has been shown to decrease systemic inflammation, along with foods high in ascorbic acid (vitamin C).
Joint Formulas (Eggshell membrane, glucosamine, chondroitin, MSM)— common joint formulas may be beneficial for cartilaginous issues and joint pain, however studies produce varied results.
Acetyl-L-Carnitine (ALC)– L-carnitine is a neurotransmitter that passes the blood-brain barrier to increase blood flow and enhance enzyme activations to help treat depression and musculoskeletal pain.
Alpha-Lipoic Acid (ALA)– Intracellular GSH (glutathione) is a potent anti-oxidant, which is found to be increased with supplementation of ALA and can delay muscular fatigue during exercise.
Cobalamine (Vitamin B12)– Vitamin B12 has a wide range of benefits in the human body. It is especially useful in the treatment of fatigue, muscle pain and neurological symptoms. It can aid in regulating red blood cell shape (RBC) and stiffness, which can impair capillary blood flow in tissues. Nutritional insufficiencies due to poor dietary intake or dysfunctional GI absorption (ie. leaky gut syndrome) can be corrected with sublingual, oral, or intramuscular injections of different forms of vitamin B12.
CoEnzyme Q10– CoQ10 is essential in energy production (ATP synthesis) in the mitochondria by being an electron carrier. It often supports proper muscle repair and function.
Evening Primrose Oil (EPO)– EPO induces prostaglandin E1 and helps increase the fluidity of the lipid bilayer of red blood cells to improve it’s flexibility. EPO and vitamin B12 has shown to effectively work together to improve RBC health.
Glutathione (GSH)– low GSH is associated with increased permeability of the blood-brain barrier and oxidative damage. Intramuscular injections have shown improvements in fatigue, memory, concentration and pain tolerance.
Magnesium (Mg)– Magnesium is an essential cofactor in energy production to support the health of the parasympathetic nervous system and central nervous system. Mg malate has shown efficacy for musculoskeletal pain management in patients with chronic fatigue syndrome and fibromyalgia. Meanwhile, magnesium bisglycinate is preferred for post-exercise muscle soreness. You can also use topical Mg to reduce painful muscles.
Melatonin– Insomnia and sleep difficulties can contribute to further decline in the healing and pain management. Melatonin is a safe supplement to assist in regulating the normal circadian rhythms of the body and mind and is an anti-oxidant when taken at high dosages.
N-Acetylcysteine (NAC)– NAC indirectly increases GSH synthesis. It is also an anti-viral for post-viral fatigue and oxidative damage.
Omega-3 fatty acids– Omega-3 fatty acids especially high in EPA have been found to decrease inflammation, cardiovascular conditions and cognitive decline in various illnesses. Patients with chronic pain have seen a significant improvement in pain management, fatigue, sleep, mood, mobility, and depression.
Probiotics (Tuzen, Culturelle)– Irritable Bowel Syndrome (IBS) is a condition often experienced by people with hyper-sensitivities. Probiotics can help to regulate TH1 and TH2 immune function but can be often too intense for sensitive patients. Tuzen and Culturelle are 2 brands that are specifically beneficial and safe for this population.
Vitamin D– Vitamin D is often deficient in the chronic pain population. This deficiency is confounded by for people living in Canada (due to its geographical location in relation to the sun), advancing age, obesity, malabsorption, malnutrition or chronic renal failure. Musculoskeletal pain is a common manifestation of vitamin D deficiency.
Topical rubs– Topical rubs such as arnica, capsicum, magnesium, castor oil, and homeopathic Traumeel aid in improving circulation, decreased inflammation and speed up healing of minor trauma. Topical capsicum is especially helpful for peripheral neuropathies in people living with diabetics and HIV.
Parenteral IV therapies
Dr. Alan Gaby re-evaluated Dr. John Myers’ intravenous (IV) treatment of vitamins and minerals and found them to be very effective in treating migraines, chronic fatigue, fibromyalgia, depression, athletic performance and other conditions. His basic Myers’ Cocktail is shown in Table 1, however modifications are often made depending on the patient’s presentation and sensitivities.
Some side effects of the Myers’ Cocktail can be a sensation of heat and decreased blood pressure, especially if the solution is injected to rapidly, and is often resolved after 10-30 seconds once the treatment is discontinued. Patients with kidney dysfunction should not be given this treatment or closely monitored depending on their condition.
Patients taking potassium-depleting diuretics, beta-agonists, or glucocorticoids should have their potassium levels corrected before IV magnesium therapy is considered. In rare cases, anaphylactic reaction to IV thiamine is possible and if the patient has a known vitamin B1 sensitivity should be made aware to their health practitioner and lab technician. All allergies and sensitivities must be reported along with recent normal creatinine laboratory results prior to IV treatment.
Table 1: Nutrients in Myers’ Cocktail
Nutrient Amount (common protocol) Magnesium chloride hexahydrate 20% (magnesium) 2-5 ml (4ml) Calcium gluconate 10% (calcium) 1-3 ml (2ml) Hydroxocobalamin 1000mcg/ml (B12) 1 ml Pyridoxine hydrochloride 100mg/ml (B6) 1 ml Dexpanthenol 250mg/ml (B5) 1 ml B complex 100 1 ml Vitamin C 222mg/ml 4-20 ml (6ml) Sterile water (8 ml)
Traditional Chinese Medicine
Various Cochrane studies have looked at the benefits of using acupuncture (including electro-stimulation ) for pain management in low back pain, shoulder pain, pain from cancer, fibromyalgia, chronic fatigue syndrome, endometriosis, dysmenorrhea, back pain from pregnancy, spinal cord injury, rheumatoid arthritis, tension headaches, migraines, GI complaints, etc. Many of the studies showed inconclusive results due to poor trial designs, but were effective for pain relief and functional improvements without harmful adverse effects.
Homeopathy is able to help limit acute symptoms of pain, but is most effective with a constitutional diagnosis of the individualized patient. For example, a common acute remedy for body aches and pain is Arnica montana given at a lower potency more frequently.
Psychological counseling and Cognitive Behavioural Therapy
Catastrophism congnition can plague people living with chronic pain, in which they are exclusively focused on pain and the belief that the worst possible outcome is going to occur, concentrating on negative vision (magnification), continuous rumination, and helplessness. There is a consistent relationship between catastrophizing and distress reactions to painful stimulations. Potential consequences associated with pain catastrophizing are heightened pain behaviors, increased pain intensity, greater analgesic consumption, reduced daily activity involvement, occupational disability and suicidal ideation. Cognitive Behavioral Therapy helps patients cope with pain and catastrophising responses by aiming to alter a person’s attitude towards pain and self-management. Please also see my post on Fibromyalgia and CBT treatment for more details.
There are various environmental aggravates that typically worsen pain and hyper-sensitivity symptoms. Avoiding these triggers can support health and limit further functional decline:
- change in sleep schedule
- cold exposure
- overexertion (physical or mental)
- sensory and information overload
- excessive stress
- prolonged driving
- air travel
- specific food agents and sensitivities (ie. glutamate/ MSG, aspartame)
- heavy metal exposure (mercury amalgums, aluminum)
- household cleaning agents
- personal hygiene products (ie. Sodium Lauryl Sulfate containing ingredients)
- synthetic hair dyes
- perfumes and creams (especially people with multiple chemical sensitivities)
- poor air quality, ventilation and filtration (toxins, pollution, allergens, mold)
- water and food quality
As a Naturopathic Doctor in Ontario, prescribing the pharmaceuticals below are not YET in our jurisdiction (but we will soon be able to prescribe some of these drugs). However, we are very familiar with the actions, interactions and side effects of these medical drugs. Pharmaceuticals can be great aiders when used appropriately for the patient’s particular condition and for the proper dose and duration.
Most patients are unaware that they may potentially be able to come off some (if not all) of their medications under careful monitoring by their MD and ND. Please speak with your health practitioners when you are starting or stopping any medications and if you notice unwarranted side effects. Common pharmaceutical medications utilized by medical doctors for the treatment of chronic pain:
Sleep disturbances– Dimenhydrinate/ Gravol, Tryptophan/ Tryptan, Zopiclone/ Imovane, Clonazepan/ Rivotril, Doxepin/ Sinequan, Amitriptyline/ Elavil, Trazodone/ Desyrel, Cyclobenzaprine/ Flexeril, Mirtazapine/ Remeron, Bromazepam/ Lectopam, Zolpidem/ Ambien
Pain management– Aspirin, Tylenol, Advil, Lakota, non-steroidal anti-inflammatory drugs (ie. Ibuprofen, Naproxen), muscle relaxants (ie. Flexeril, Baclofen), analgesics (ie. acetaminophen), narcotics (ie. codeine, oxycodone, tramadol hydrochloride, morphine, fentanyl)
Anti–Epileptics– Neurontin/ Gabapentin, Lyrica/ Pregabalin
Antidepressants– Tricyclic antidepressants (ie. Amitriptyline, Doxepin), selective Serotonin reuptake inhibiors (ie. Paxil, Zoloft), dual reuptake inhibitors (ie. Effexor/ Venlafaxine)
Again, please contact your Naturopathic Doctor if you are considering taking any of these supplements. There are potentially severe interactions and may not be best indicated for your particular situation. Dosing and duration of treatment is very critical in healthy healing without complications or aggravation of your condition. If you need references for Naturopathic Doctors in your area please visit www.DrAlisonChen.com/ND.