Living With Chronic Pain
Author: Karen Hart
February, 2017 Issue
Chronic pain is a cruel companion that attacks the body physically, mentally and emotionally. It can be mild or excruciating, but it’s always persistent and inconvenient—sometimes even incapacitating. “Chronic pain is a condition that impacts your ability to function normally in your daily life,” says Holly Kelly, M.D., a physical medicine and rehabilitation medicine practitioner. “The source of pain isn’t always easily identifiable, but we do know that some people seem more predisposed to painful conditions, and these conditions can take a long time to improve. Sometimes the pain never completely resolves.”
About 50 million Americans are living with chronic pain today, according to the American Chronic Pain Association (ACPA), which cites lower back problems, arthritis, shingles, headaches, cancer, fibromyalgia, repetitive stress injuries, and Reflex Sympathetic Dystrophy Syndrome (RSDS) as the most common sources.
Sports injuries are among the most frequent causes of pain for people in their 20s. “Football always comes to mind when thinking about injuries, because it’s a contact sport and places stress on all your joints,” says Kelly. “What happens is that repetitive micro-trauma can cause the propensity for early joint degeneration. Oftentimes, knee X-rays from avid football players look 10 to 20 years older than their chronological age.”
Other pain conditions are dangerous and require emergency treatment, according to Kelly. “Pain associated with weakness in an arm or leg, or with changes in balance or numbness in your arm or leg, and headaches need to be addressed by a physician,” she adds.
According to Kelly, most people over age 40 would admit they’re coping with some type of chronic pain. But if chronic pain is interfering with daily activities and you’re avoiding social interaction because of pain, it’s important to see a doctor to determine the source of pain.
“About one-third of all doctor office visits are for some type of pain,” adds Andrea Rubinstein, M.D., chief of pain medicine at Kaiser Permanente in Santa Rosa. “About 10 to 15 percent of adults are believed to suffer from some form of chronic pain. Low back pain is probably the most common.” Myofascial pain, fibromyalgia and degenerative spinal disease are also quite common. “These [conditions] probably make up the majority of patients we see.”
The cost of chronic pain
Chronic pain is the number one cause of adult disability in the United States, according to the ACPA. Today, chronic pain costs society more than $100 billion each year. Who’s paying the cost?
“Medications are covered under employee medical plans and in the coming year, there’s a push toward using more generic drugs,” says Terry De Decker, vice president of employee benefits at Vantreo Insurance in Santa Rosa. “One trend we’re seeing is that more [insurance] carriers are covering alternative treatments such as chiropractic care and acupuncture. More health plans are covering these treatments, and it’s built into the plan, it’s not a ‘rider’ that comes with an additional premium.”
In addition, more insurance companies such as Kaiser Permanente and Blue Cross Blue Shield offer classes and information on their websites to educate people about lifestyle changes they can make to manage and prevent chronic pain. Says De Decker, “There’s a push towards wellness. In the past, we mostly treated patients once they were sick, but now we’re aiming towards prevention and having patients interact with their physicians to get healthy.”
Here’s an overview of chronic pain, the treatments and programs available in the North Bay, and the alternative therapies that can significantly ease and help manage the pain.
What causes chronic pain?
Acute pain is a normal sensation triggered in the nervous system to alert you of a possible injury and the need to take care of yourself, but chronic pain persists, according to the American Academy of Pain Medicine (AAPM). Pain signals keep firing in the nervous system for weeks, months or even years. Chronic pain may originate in the body, brain or spinal cord; it can be difficult to treat and is often handled by a pain management team.
The pain usually starts when nerves send signals to your brain, telling it you have an injury or illness, according to information on Kaiser Permanente’s website. When you have chronic pain, your body might heal but your brain keeps getting these signals. Studies show that, over time, your brain may become so conditioned to getting pain signals, it can’t turn them off. In some cases, chronic pain isn’t caused by injury or illness at all, but by pain signals that aren’t working properly. Damaged nerves, or unexplained pain may cause this.
There are many variables involved in pain and many of them confuse the picture. Weight gain, for example, may make degenerative joint and back pain worse via mechanical stress. Poor sleep can lead to fatigue, which leads to less interest in moving, which in turn leads to de-conditioning and more pain, which confounds the sleep problem, according to Rubinstein.
People with chronic pain tend to also experience symptoms such as depression and anxiety, problems with exercising and moving around, mood swings and sleep disturbances. What’s more, chronic pain can also cause strained relationships with family and friends.
Understanding what triggers pain, gauging how bad the pain is and what makes it better is the first step to managing it.
The inflammation connection
Inflammation is the new buzzword and is noted by some health care practitioners to be the culprit to chronic pain. What exactly is inflammation? Says Rubinstein, “Inflammation is the body’s immune response to heal itself.” It works to heal wounds, but it can also play a role in some chronic diseases such as heart disease and strokes, diabetes, arthritis, Alzheimer’s disease and cancer.
“If we get a cut on our skin, messenger cells move to the area to promote healing,” explains Tawnya Dorn, outpatient dietitian at Queen of the Valley Wellness Center. “We might see the area become a little red and inflamed, which is good. We want the body to fight off viruses, bacteria and other invaders.” However, chronic inflammation can be bad. Says Dorn, “We don’t want an inflammatory response to be a constant internal process in the body.”
“[Inflammation] is a very hot area of research right now,” says Rubenstein. “It almost certainly plays a role in chronic pain, but exactly how it works to regulate pain hasn’t been well-elucidated. Nonetheless, we often tell patients that an anti-inflammatory diet can have a variety of positive effects.”
If you suffer from chronic pain, exercise and shifting to a plant-based diet can have a dramatic effect on tamping down inflammation. “Diet and exercise is critical to managing chronic pain,” says Matthew Bernd, D.C., a chiropractor in Santa Rosa. Incorporating plant-based foods can greatly improve systemic inflammatory levels, he says, and it’s best to eat locally grown produce and seasonal foods in the regions where we live.
“We tend to take food for granted, but [food] helps us survive and can change health outcomes,” Dorn adds. “It changes cells and can turn on and off precursors in DNA—it doesn’t change DNA, but it can turn the switches on and off that can lead to chronic inflammation. Overly processed food, added sugar and ‘bad’ fats act as invaders in our body, causing a chronic negative response, such as inflammation in our bodies.” According to Dorn, eating mindfully and adopting a Mediterranean-style diet can make an enormous difference. (See “The Anti-Inflammatory Diet”).
Research is now proving exercise is also important, says Kelly. “Patients who consistently exercise tend to do much better than those who don’t. If you maintain a moderate level of activity, you’re better off in the long run. You don’t want to lose muscle mass, coordination or balance. You need to use the neural connections. Otherwise, they become slower and less effective.”
While exercising is key to enhancing the anti-inflammatory effects in your body, modern day technology tends to reduce activity levels. “We’re designed to be in motion,” says Bernd. “As humans spend more time in front of computers, tablets and smartphones, activity decreases. Go outside: Ride a bike, walk and incorporate anything that challenges your balance. Your body will thank you for it.”
For the athletically inclined, the best way to prevent a lifetime of chronic pain is to make sure you’re cross training. “You want to condition the whole body, not just the muscles associated with a single sport,” says Kelly. “Train to balance all muscles, and don’t overuse one certain group of muscles.” According to Kelly, some North Bay physicians are now working with high school coaches and athletic trainers to educate them about the importance of cross-training student athletes.
Several classes of medications, including non-steroidal anti-inflammatories (NSAIDs), muscle relaxers, opioids, anticonvulsants and antidepressants, can be helpful for chronic pain management, especially when combined with other therapies such as heat, ice and gentle exercise, according to Kelly. A particular medication can be used alone or combined with other medications to address different parts of the pain pathway.
The most common medication class used is NSAIDs, which can be purchased over-the-counter and typically have the fewest side effects. These include ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin. While usually safe in small doses, Kelly advises patients be monitored by a physician if using NSAIDs on a regular basis, as stomach, kidney, and blood pressure changes may occur.
Opioids such as Vicodin and OxyContin are generally used for more severe pain. “Opioids fit into treatment early on when you’re first in pain,” explains Kelly. “They should be thought of as a short-term option while considering other treatments. Long term, opioids are not a great management tool, as they can possibly lead to tolerance or addiction.”
Treatment and alternative therapies
When treating chronic pain, the goal is to reduce discomfort and improve function so you can resume day-to-day activities. Medication is sometimes necessary to manage acute pain, but longer-term, it’s best to follow a multidisciplinary approach.
“Evidence shows that, for the majority of patients, the best treatment for chronic pain is a multi-disciplinary bio-psycho-social approach,” says Rubinstein. “Kaiser-Permanente is unique because we offer this type of treatment throughout all facilities in Northern California.”
Kaiser Permanente offers a variety of classes and programs that combine exercise and rehabilitation, which is spearheaded by physical therapy. It also promotes additional therapies such as mindfulness, cognitive behavioral therapy, individual psychotherapy or counseling when needed and acupuncture. “Models like this are considered the gold standard in pain treatment, but aren’t available in the fee-for-service world of medicine, because insurance companies often won’t reimburse for this type of treatment,” says Rubinstein.
When it comes to living with chronic pain, the challenge is to keep it from being the entire focus of your life. Alternative therapies such as chiropractic care, meditation and acupuncture can help. “Chiropractic care is beneficial for acute strains in the neck and back, and should be one of the first-line treatments,” says Kelly.
“Chiropractic manipulation is critical for maintaining proper joint mechanics,” adds Bernd. “When a chiropractic manipulation is achieved it stimulates motion [sensor] receptors in the joint, which, in turn, inhibits pain receptors at the spinal cord level. It also enhances the circulatory effect and helps with metabolic flushing, such as lactic acid and other pain-producing chemicals that build up in tissue, causing chronic pain patterns and chronic inflammatory states. Generally, appropriate conservative therapies can help most people manage their lower back pain.” (See “Oh, My Aching Back!” )
Mindfulness meditation can also help people manage pain. “Numerous studies have found that meditation actually reverses chronic diseases at the genetic level when done at least 20 minutes daily,” says Melanie Kates, M.D., who’s affiliated with Sutter Santa Rosa Regional Hospital and specializes in internal medicine in Healdsburg. She’s been teaching mindfulness meditation to her patients for 30 years. “Meditation slows down the mind and therefore the breath. Slower, deeper breaths allow for greater oxygen flow and relaxation of the mind and body.”
According to Kates, current long-term studies show irrefutable evidence that stress causes disease. “We want to target the causes of stress so that we can alleviate pain and suffering.
“A disease process always involves the physical, emotional and spiritual layers of our being, and none of the layers can be separated,” she explains. “Chronic disease needs to be approached from the standpoint that all healing is an ‘inside job.’ We encourage people to become more aware of what’s creating an imbalance in their life that has led to a lack of ‘ease,’ or ‘dis-ease,’ in their physiology.”
How can people cultivate mindfulness meditation? Says Kates, “Spending time in meditation daily—in nature, contemplating positive thoughts, being involved in nurturing relationships—all promotes healing.”
Acupuncture is another way to manage chronic pain, according to Kates. “Acupuncture is a form of energy work with the subtle energy levels of the body, addressing the physical, emotional and spiritual levels of imbalance. I like using it in conjunction with Western medicine, as it goes to the root cause of illness.”
On the horizon
Today, lifestyle changes are recognized as a simple and key way to manage chronic pain. “As a society, we’re working towards health and wellness, but we’re not quite there yet,” says De Decker. “Ultimately, what keeps [health insurance] costs down is prevention strategies.”
And while a sports injury or a herniated disc requires surgical intervention. Science continues to study the cause and treatment of chronic pain. “There’s a lot of research going on, and it’s rapidly evolving,” says Kelly. “Hopefully, in the next five years, we’ll have advancements in regenerative medicine techniques. These minimally invasive procedures involve harvesting stem cells from your fat or bone marrow and injecting them into your damaged joints or spine. The hope is to stimulate your body to repair and regrow tissue on its own.
During the past several years, a preparation called platelet-rich plasma (PRP) and its potential effectiveness in the treatment of injuries that cause pain shows promise. “We’re doing this in our office now, and inject it in joints and spinal discs,” Kelly explains. Although it’s not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.
What’s the best advice for managing chronic pain? Says Kelly, “Make sure you’ve seen your primary care doctor or a pain management doctor to determine the source. If it’s determined you may have chronic pain, get active and be aware of any changes in symptoms as a result.”
As science continues to make strides in new treatments and therapies, the best first strategy is to make lifestyle changes. Aside from ramping up the plants in your diet and exercising, you can enhance their anti-inflammatory effects through additional lifestyle changes. If you smoke, quit. Drop the excess pounds, because weight gain can bring on inflammation. Keep stress in check, and learn to meditate.
Oh, My Aching Back!
Back pain is the leading cause of disability in Americans under 45 years old, and more than 26 million Americans between the ages of 20 and 64 experience frequent back pain, according to the American Academy of Pain Medicine. “Acute lower back pain can be managed with mild motion or stretching, ice and cryotherapy usually within the first 48 to 72 hours,” says Matthew Bernd, D.C., a chiropractor in Santa Rosa. Here are two quick tips from Bernd to manage chronic back pain:
Target your core with proper core exercises while using a Swiss Ball (also known as a physio ball), BOSU ball or Indo Board, which focus on deep core and non-volitional spinal muscles (known as non-voluntarily muscles) for strength and stability.
Take up yoga and Pilates, which can significantly help manage lower back pain.
Says Bernd, “When people are consistent with these simple instructions, I might not see them in my office for a long while.” For more information, go to www.berndchiropractic.com.
The Mind-Body Connection
Using your mind can be a powerful way to cope with pain. Here are some practical strategies from Kaiser Permanente for coping with pain:
Think positively. Studies show that keeping a positive outlook can reduce day-to-day pain.
Get plenty of sleep. Pain can cause sleepless nights, which can add to pain.
Relax and breathe deeply. Stress has been shown to make pain worse. Listen to relaxing guided imagery podcasts to help manage stress.
Reach out to loved ones or professional therapists. Feelings of anger, fear, frustration or depression can increase pain.
The Anti-Inflammatory Diet
If you suffer from chronic pain, a diet makeover with a focus on vegetables can have a dramatic effect, according to Tawnya Dorn, outpatient dietitian at Queen of the Valley Medical Center in Napa. “The idea is to come up with a plan that works for you, and to try to make your diet 85 to 90 percent based on healthy food choices. Try to increase your fruit and vegetable intake. Two to three pieces of fruit and one to two cups of vegetables per day can be a good starting point,” she says.
Foods to Eat
Think rainbow for fruits and vegetables. The darker and more colorful the foods in your diet, the more antioxidants and polyphenols they carry to tamp inflammation. Try fruits such as oranges, cherries, blueberries and strawberries. Eat dark leafy greens such as spinach, kale and collards; purple cabbage, carrots, red onions and tomatoes.
Make it spicy and use herbs with wild abandon. Spices offer significant anti-inflammatory benefits. Tumeric leads the way with inflammation-fighting polyphonic compounds, so try adding it to stews and sauces. Ginger also reduces inflammation and can be used in curries and soups. Herbs such as parsley, cilantro, basil and thyme add flavor and have healing benefits.
Embrace Mediterranean style. Eat fish or lean proteins such as chicken two to three times per week; eat whole grains, legumes and nuts; limit red meat (and make it grass-fed); learn to love hummus; cook with extra virgin olive oil or avocado oil (make sure not to cook them above their smoke point, since this causes an inflammatory response); drink plenty of water and green tea (and make your own tea, avoid prepackaged teas with high fructose corn syrup); and enjoy an occasional glass of red wine, if you like.
Foods to Avoid
Red meat and processed meats such as hot dogs, bacon and sausages;
Fried foods, including French fries, fried chicken and chicken nuggets, which are processed (better to eat chicken roasted or baked);
White bread and pastries as well as other refined carbohydrates;
Soda and sugary drinks, including orange juice and apple juice;
Margarine, butter and lard; and
Alcoholic beverages should be enjoyed in moderation. That means one alcoholic beverage a day for women, and two for men.
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