Bracing for the fall

One of my golf buddies is desperate to find a common-sense solution for his chronic pain. More than six months have passed since he suffered a shoulder injury after falling off a three-foot ladder.

“I braced the fall with my arm when I hit the ground,” he told me. “I got up, moved a little, and checked to see if I broke anything. Nothing broken, just a little pain. I thought to myself: ‘No big deal.’

“They were sympathetic and did a brief physical exam,” he continued. “The doctor advised an X-Ray, MRI, and even some blood tests, since it’s been several years since I had them. The tests revealed little, other than I have moderate arthritis and high cholesterol (but that’s another story).”

He was getting increasingly frustrated.

“Without a precise diagnosis for my pain, the doctor referred me to a physical therapist (PT) and prescribed more potent pain medication. The PT exam, while a little more extensive, showed nothing outstanding. I complied with the recommended month of bi-weekly rehab exercises in the clinic and learned some new stretches and warm-up exercises.

“My PT experience reduced the pain slightly, but the pain meds worked better. I was able to get one more refill, and I fear I’m now dependent on them. The medication is the only thing that seems to work, though. What else can I do to stop the pain? I’ll try anything!”

Does this sound familiar?

What is pain?

The International Association for the Study of Pain (ISAP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Chronic pain associates with reduced quality of life, increased personal medical expenditures, and significant societal/economic costs. (Image: iStock.)

Some researchers argue pain is nature’s way of getting one’s attention to change behaviors that promote tissue damage. Clinically, chronic pain presents as a “pain perception” that lasts more than several months, sometimes defined as 3-6 months, but longer than it would take to “normally heal.”

Chronic pain associates with reduced quality of life, increased personal medical expenditures, and significant societal/economic costs. It is among the most common chronic conditions in the U.S., although estimates vary widely regarding its precise prevalence. The most recent data from the National Health Interview Survey reported 50.2 million adults in the U.S. (20.5 percent) report pain on most days or every day.

The most common pain locations were the back, hip, knee, and foot (in that order). Chronic pain respondents reported limitations in regular functioning, including diminished activity around social activities and daily living. They also reported significantly more missed workdays compared to people without chronic pain. Overall, these findings indicate more than 1 in 5 adults in America experiences chronic pain.

What causes chronic pain?

Chronic pain has many origins. It often manifests due to injury, surgery, or some longstanding condition like cancer or arthritis. However, many people suffer chronic pain without any past injury or illness. Pain might be precipitated by episodes of prolonged sitting and/or standing, awkward movements, dyskinesis (fragmented or jerky motions, as in Parkinson’s disease), posture misalignment, malalignment, overuse, and direct trauma.

This image illustrates this “injury cycle.”

With chronic pain, the nerve-muscle infrastructure is deactivated, and the muscle subsequently becomes weak and immobilized. The injured person compensates by using muscles that can assist in the movement. (Imagine turning your head by turning the body instead of using your neck muscles.)

Pain perception starts in receptor nerve cells from the injured or deactivated muscles, joints, tendons, or other tissues — even skin. These receptor cells send neural messages along nerve pathways to the spinal cord, which transmits the message to the brain. The brain interprets these signals and responds by sending pain sensations of varying magnitude and often does not permit the muscle to activate normally (contract).

The pain triad

Chronic pain often interferes with the normal activities of daily living. Thus, it can cause irritability and depression, often leading to insomnia, which generates more irritability, depression, and pain. Experts refer to this cycle of pain-induced suffering, sleeplessness, and sadness as the pain triad. People caught in the triad may experience dependency on pain meds, undergo repeated surgeries, or pursue questionable treatments. (See my June 2022 Health Yourself article regarding health mis- and disinformation)

Understanding chronic pain’s origins

The notion of pain has changed considerably over human history. Pain, from its Latin etymological origin — poena — means penalty. During medieval times, people regarded suffering from pain as a penalty for sin. René Descartes (1596-1650) contributed to the study of pain after researching the phenomenon of “phantom limb” pain. He observed some people experienced pain in an amputated limb and thus deduced pain originates in the brain, not the flesh. He theorized that pain locates in the pineal gland, the small, pea-shaped gland in the brain that produces and regulates some hormones, including melatonin.

Chronic pain remedies

Patients look to OTC medications, prescription drugs, and “alternative” methodologies to alleviate chronic pain. Since single remedies often fail to produce total relief, people tend to follow a combination of treatment options.

Some individuals will respond positively, while others show no response, or even a negative response.

Predicting who will react positively to any one pain remedy has produced conflicting evidence. One recent study using chronic low-back pain patients identified personal characteristics for those who favorably responded to yoga, physical therapy, or self-care literature. Of the 299 patients studied, 39 percent showed a positive response, with more positive responders in the yoga or PT group (42 percent) than the self-care (23 percent) group. Positive success predictors included:

• Level of education
• Higher income
• Employment
• Few depressive symptoms
• Lower perceived stress
• High pain self-efficacy
• Being a nonsmoker

Drug therapy

Nonsteroidal anti-inflammatory drugs like ibuprofen (Advil, Motrin), naproxen (Aleve) and aspirin affect pain by blocking an enzyme called COX that plays a key role in a biochemical cascade that produces inflammatory chemicals.

Nonsteroidal anti-inflammatory drugs like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin block an enzyme called COX that plays a crucial role in a biochemical cascade that produces inflammatory chemicals and pain. Cascade blocking decreases the inflammatory chemicals and reduces pain signals sent to the brain. While acetaminophen (Tylenol) doesn’t reduce inflammation as NSAIDs do, it inhibits COX enzymes and has similar pain-reducing effects.

When OTC drugs do not provide relief, patients look to more potent medications, such as muscle relaxants, anti-anxiety drugs (Valium), antidepressants (Cymbalta), or prescription NSAIDs such as Celebrex. Sometimes a physician will prescribe a short course of stronger painkillers such as codeine, fentanyl patches, oxycodone/acetaminophen (Percocet, Roxicet, Tylox) or hydrocodone/acetaminophen (Lorcet, Lortab, and Vicodin).

Nerve block

Sometimes, a local injection of nerve-numbing drugs can block pain by targeting a group of nerves called a plexus or ganglion that cause pain to a specific organ or body region.

Sometimes, a local injection of nerve-numbing drugs can block pain by targeting a group of nerves called a plexus or ganglion that cause pain to a specific organ or body region.

Three types of nerve blocks include:

• Therapeutic nerve blocks, which contain local-targeted anesthetics.
• Diagnostic nerve blocks, which contain an anesthetic with a specific duration of relief.
• Preemptive nerve blocks, which prevent pain that follows a medical procedure, such as surgery.

Patient-controlled analgesia (PCA)

PCA is another method of pain control. By pushing a button on a computerized pump, a person can self-administer a premeasured dose of pain medicine, often infused with opioids. The pump connects to a small tube that injects intravenous drugs subcutaneously or into the spinal area. Hospitals use this method to treat post-traumatic or post-surgical pain, and terminal cancer pain.

Trigger point injections

Trigger point injections treat painful areas of muscle that contain trigger points or knots that form when muscles do not relax or become deactivated. A local anesthetic is introduced into the trigger point area using a small needle. Physicians use trigger point injections to treat fibromyalgia, tension headaches, and myofascial pain syndrome (pain originating in the tissue surrounding the muscle), which are resistant to other treatments.

TENS

Transcutaneous electrical nerve stimulation therapy, more commonly referred to as TENS, uses electrical stimulation to reduce pain.

Transcutaneous electrical nerve stimulation therapy, or TENS, uses electrical stimulation to reduce pain. During the procedure, a low-voltage electrical current travels through electrodes on the skin near the pain source. The charge stimulates the affected nerves and transmits signals to the brain that “scramble” the pain message.

Physical Therapy (PT)

Next to nonprescription and prescription drug therapy, PT represents the most common chronic-pain relief modality. PT helps relieve pain by using special movement techniques that can improve function. Stretching, strengthening, and pain-relieving movement techniques have proven successful in most cases.

Cardio exercise

Research shows regular exercise can diminish pain in the long term by improving muscle tone, strength, and flexibility. Movement may also cause a release of endorphins, the body’s natural painkillers. People experiencing pain may be tempted to rest in hopes of reducing discomfort. Resting for short periods may alleviate pain, but too much rest may increase pain and the risk of injury when movement initiates.

Alternative and complementary therapies

Mind-body therapies include acupuncture, nutritional and herbal supplements, massage, spinal manipulation, osteopathic (bone) manipulation therapies (chiropractic), therapeutic touch, meditation, Tai chi, and yoga, to name a few. Conflicting and sparse-to-moderate scientific evidence support these “alternative” therapies, yet many people find them helpful and recommend their use.

Let’s discuss what the research shows regarding a few popular alternative pain therapies.

Acupuncture

Results from a number of studies suggest that acupuncture can ease some chronic pain symptoms.

This traditional Chinese medicine technique uses thin needles placed through the skin at specific body points. Results from several studies suggest that acupuncture can ease chronic pain symptoms that associate with low-back pain, neck pain, and osteoarthritis/knee pain. In addition, it may help reduce the frequency of tension headaches and prevent migraine headaches, menstrual cramps, carpal tunnel syndrome, tennis elbow, and osteoarthritis in some individuals. Current evidence suggests many factors — like expectation and belief — unrelated to acupuncture needling itself, may play an important role in acupuncture’s success.

Cannabinoids

Cannabinoid receptors in the brain outnumber many other receptor types and act like traffic cops to control the levels

These naturally occurring compounds are found in the Cannabis sativa plant. Of the more than 480 compounds in the plant, about 66 are termed cannabinoids. The most well-known cannabinoid is the delta-9-tetrahydrocannabinol (Δ9-THC), the primary psychoactive ingredient. Cannabidiol (CBD), another cannabinoid but non-psychoactive, has been shown to enhance anti-inflammation properties and can positively influence pain perception across different conditions.

New research shows the human body has an endocannabinoid system (ECS) comprising a vast network of chemical signals and cellular receptors densely packed throughout the brain and body. Cannabinoid receptors in the brain outnumber many other receptor types and act like traffic cops to control the levels and activity of most of the other neurotransmitters and can directly affect pain perception.

Chiropractic treatment

Chiropractic treatment is another common nonsurgical treatment for chronic back and neck pain. The majority of clinical trials in the research literature suggest chiropractic’s overall treatment effectiveness is not uniform; outcomes seem to depend on the individual and their specific pain.

Massage therapy

Massage therapy involves physically manipulating muscle and soft tissue. Common in most cultures, the therapy includes deep tissue massage, sports massage, and clinical massage. Popular traditions derived from Eastern cultures include Shiatsu, which uses fingers, thumbs, and palms to apply pressure to various areas of the body’s surface, and Tuina, which uses oscillating and pressure techniques that differ in force and speed at specific body locations.

Research indicates massage can produce beneficial effects, decreasing chronic pain and anxiety in people with fibromyalgia and different forms of cancer. Massage can reduce stress and relieve tension by enhancing blood flow. Available data suggest massage therapy, like chiropractic manipulations, holds considerable promise for treating various types of chronic pain.

Final words

Finding ever-elusive relief from chronic pain can be challenging. Research indicates some measure of relief is possible via available treatment options, including inpatient and outpatient modalities. When performed by trained and licensed professionals, treatment options pose little risk.

I recommend individuals take an active role in their treatment by familiarizing themselves with the available options supported by real science, not just testimonials.
 
 
References

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Berman, B.M., et al. “Acupuncture for chronic low back pain.” New England Journal of Medicine. 2010;363(5):454–461.

Cherkin, D.C., et al. “A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.” Archives of Internal Medicine. 2009;169(9):858–866.

Chou, R., et al. “Nonpharmacologic therapies for low back pain: A systematic review for an American College of Physicians Clinical Practice Guideline.” Annals of Internal Medicine. 2017;166(7):493-505.

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