The truth about sports, nutrition and pain!

Posts tagged ‘Pain’

The Fear of Back pain !!

I have already done quite a few blogs on back pain (Part 1, 2 , 3) but the myths surrounding it still continue, so I decided to do one more.

80% of us will probably experience an episode of back pain at one point or another in our life (some studies say that it is even more) (1-3). So, if you think about it, back pain is very common. In fact, to not experience back pain at some point in our life would be quite abnormal. And it doesn´t matter if you have strong or weak abdominals, or if you have too much flexibility or too little, or if one leg is larger than the other, or if you walk in a funny way, none of these factors will influence you experiencing an episode of back pain (4-8). To tell you the truth, the biggest factor for developing back pain is a history of back pain!!! (9). Sounds crazy but it is true.

So, instead of focusing on prevention of back pain (which we have already done for the last 20 years and nothing has changed), maybe we should focus on ¨how do I prevent my back pain from lasting so long¨. You see, when they experience back pain people get really scared, and get fearful of movement, which are two things that can actually make the back pain worse (10-11). Remember, we know the body needs movement to heal. Disk and cartilage etc. need movement to get their blood supply. So in most cases we should try and keep movement. Only when the pain is really bad should we rest but that rest should never be longer than 2 days (12). Pain does not equal tissue damage and it can be influenced by stress, beliefs, fears, anxiety and a thousand other things (as I have stated in previous blogs click here). Our body, including our back, is a wonderful strong machine. We have to start changing our beliefs around the idea that our back can get damaged easily or that our back is vulnerable.

In conclusion, we will all probably experience an episode of back pain in the coming weeks, months, years or whenever, just like we will probably experience a headache or a stomach pain. It is part of life and we shouldn´t get too worried. Studies say that 85-90% percent of the time we have back pain it is due to ¨non specific mechanical factors¨. This basically means we have no IDEA why your back hurts but it does. Only 2% of the time the pain is caused by a tumor, infection or a fracture and 8% due to a nerve compression (13-15). So next time your back hurts don´t be so afraid and keep moving. 😉

References

  1. Biering-Soeren2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-6736(11)60610-7. Epub 2011 Oct 6.se F. A prospective study of low back pain in a general population. Occurence, recurrence, and etiology. Scand S Rehabilitation Med 1983;19:71.
  2.  Balague F, Mannion AF, Pellise F, Cedraschi. Non-specific low back pain2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-67
  3. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers compensation on low back pain claims. J Occup Environ Med 1998:40:261-66.
  4. Biering-Sorense F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 1984: 9:106-19.
  5. Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. The role of spinal flexibility in back pain complaints within industry: A prospective study. Spine 1.
  6. Axler CT, Mcgill SM. Choosing the best abdominal exercises based on knowledge of tissue loads. Medicine and Science in Sports and Exercise. 1997: 29:804-11.
  7. Hellsing AL. Tightness of hamstring and psoas major muscles. Upsala Journal of Medical Science 1988. 93:267-76.
  8. Sandler R, Xuemei Su, TImothy C, Fritz S, Beattie P, Blari S. Are flexibility and muscle-strengthening activities associated with a higher risk of developing low back pain. Journal of Sciend and Medicine in Sporte. 2013.
  9. Taylor JB, Goode AP, George SZ, & Cook CE. Incidence and risk factores for first-time incident low back pain: a systematic review and meta-analysis. Spine Journal 2014
  10. Gheldof EL, Crombez G, Van den Brussche E, et al. Pain related fear predicts disability, but not pain severity: a pathway analytic approach of the fear avoidance model. Eur J Pain.2010;14:870
  11. Awinkkels-Meewisse IE, Roelofs J, Schouten EG, Verbeek AL, Oostendorp RQ, Vlaeyen JW. Fear of movemen/ re injury predicting chronic disabling low back pain: a prospective inception cohort study. Spine( Phila Pa 1976) 2006;31:658-664.
  12. Deyo RA, Diehl Ak, Rosenthal M. How many days of bed rest for acute low back pain? New England Journal of Medicine 1986;315:1064.
  13. Agency for HEalth Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 19. Washington DC, US. Government Printing. 1994.
  14. Danish Health Technology Assessment (DIMTA). Manniche C, et al. Low back pain. Frequency Managemente and Prevention from an HAD. Perspective. 1991.
  15. Royal College of General Practioners (ACGP). Clinical Guideline for the management of Acute Low Back Pain. London Royal College of General Practicioner.1999

Why does pain move?

I have already talked about pain numerous times, in fact three times (pain part 1,2,3), but this is a subject that people have a hard time understanding. So, I will do one more post to try to clarify things. The most important thing about pain that people should know is that pain is an output of the brain and that pain does NOT EQUAL TISSUE DAMAGE (1-5). It sounds almost crazy and scary but it is true. That is why sometimes you see people with lots of arthritis that have no pain and other people who have very little arthritis and have lots of pain. Pain depends on the situation, I will give an example: Imagine a soldier at war and a professional soccer player at a match, and they both experience the same devastating knee injury. For those two people the significance of their injury is going to mean two completely things. For the soldier it means he can get the hell out of there and go home, for the soccer player it means good-bye to his professional career and maybe even income. Take a wild guess and think who is going to experience more pain??

But anyway, let us get back to the topic at hand and try to clarify why pain moves. Pain is basically controlled by the nervous system, so imagine something happens to your back,  ¨nociceptors¨will send  this information to your spine and from there to the brain. Now, let us suppose this ¨injury¨ keeps bothering you for a while, and these ¨nociceptors¨ will be firing away 24/7 during this whole time. At the end, the pain becomes centralized. Now, this is where it gets interesting. Your spine is also receiving at the same time information from all the different parts of the body. Once the original pain has become ¨centralized¨, the spine can sometimes make an error and get confused with all the different types of information that it is receiving from its nerves (6). This confusion can lead to the pain moving from one place to another. Now, when this happens it doesn´t mean that you have injured yourself in a new area,  it just means that your central nervous system has made an error in its processing of the information.

 

Hope you liked it.

 

  1. Flor H, Nikolajse Li, Stachelin Jensen T. Phantom limb pain: a case of maladaptive CNS plasticity.Nat Rev Neuroscience 2006 Nov;7(11):873-81.
  2. Flor H, Braum C, Elber T, BIlbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience 1997: March 7.224(1)5-8.
  3. Ren K, Dubner R. Central nervous system plasticity and persistent pain. J Orofac. Pain.1999.Summer.13(3):155-63.
  4. Kim S, Lee Hoo T, Lim Mee S. Prevalence of Disc Degeneration in Asymptomatic Korean Subjects. Part 1: Lumbar Spine. Journal of Korean Neutrosurgical Society 2013 January;53(1): 31-8.
  5. Kendrick D, Fielding K, Bentler E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: Randomized controlled trial. BMJ 2001;322:400-05.
  6. Hargrove T. A guide to better movement.  Better movement 2014. pg 101-4.

 

THE BOSS -The Central Nervous System-

Most people know that the central nervous system (CNS) is the part of the nervous system consisting of the brain and spinal cord, and that is about it. But most people don´t know the importance of it and how it affects us in things like dealing with pain, strength, flexibility and a thousand other things (1-4). Let me explain.

 

Most of the information the body gets from our nerves arrives at our CNS and the CNS is going to decide what to do with that information. So for example, when you cut yourself in the hand, that is going to activate nociceptors that are going to reach your CNS. Your CNS will decide what to do with that information, so it could either ignore it or produce an ¨ouput¨ like pain (4). If you don´t believe me, just try to remember the times you have had a ¨black and blue¨and didn´t remember where that came from. You see, pain is an output of the brain to try to protect us, but if the brain decides for whatever reason (a lion chasing us down the street) that pain is not good, it is going to ignore that and concentrate itself on more important things. So, always remember that pain does not equal tissue damage and that pain is an output of the brain.

 

So, what about flexibility or stiffness? Well, recent studies have shown that that is probably controlled by the CNS also (2-3). You see, excess flexibility creates the threat of injury.  So to control this the CNS sends information to stiffen the muscle. When we stretch and gain flexibility we  aren´t stretching the muscle (although it feels like it), instead what we are doing is sending information to the brain, saying ¨hey, it is ok, the movement is under control and is not going to produce any harm, could you loosen up a little?¨

 

The same thing can be said about strength and fatigue. Also, when we go to the massage therapist or physical therapist and they say we have a ¨knot¨ and that is producing your pain and  that they are going to take it away. Well, they probably don´t take it away, what they are doing is sending information to the CNS and if the CNS decides that what they are doing is ¨nice¨ and ¨effective¨, it will send down commands  for the muscle to relax but if the CNS doesn´t like the ¨information¨ that it is receiving, the treatment will probably not work.

The brain  is the real boss in our body. We have to embrace it, protect it and take care of it. One way to do it is exercise. Even if it´s mindless! And when we warm-up to exercise, remember to warm up the CNS also. One easy way to do it is imagining  beforehand the movement you are going to practice, studies have shown that it will help (1).

 

Until next time.

 

 

References:

 

  1. Ratey, Hagerman . Spark: The Revolutionary New Science of Exercise and the Brain. 2008
  2. Weppler et al. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther. 2010 Mar; 90(3):438-49
  3. Noakes. Fatique is a brain derived emotion that regulates the exercise behavior to ensure protection of whole body homeostasis. Front Physiol. 2012; 3: 82.
  4. Moseley and Butler. Explain pain. 2013
  5. Hodges P. Moving differently in pain: a new theory to explain the adaptation to pain. Pain. 2011 Mar; 152: S90-8

 

 

 

 

 

Placebo! How powerful can it be? part 2

So in the first part I gave some examples of what placebo is and how effective it can be.  In this second part I will  give one more example so that people really understand and see the power and the ¨magic¨ behind placebo.

I´ll start by mentioning a study that Dr. Tor Wager in Bolder Colorado did.  He wanted to see if ¨placebo¨ can influence the feeling of pain. I´ve already mentioned a couple of times that pain is a subjective feeling and it can vary depending and a lot of factors, like stress, anxiety, beliefs, and a thousand other things (pain part 1). Anyway, what he did that was new was that he scanned people as they were getting their placebo to see what the brain was doing, and the results were amazing. First, let me explain how the study went. He got some volunteers, and on one part of their arm he put a moisturizing cream and told them what it was, this would be the ¨control group¨. In another spot on their arm he put a local anesthetic and also told them what it was. Then on a different part of the arm he put the same moisturizing cream as before but told patients that this was also a local anesthetic. After this was done he put them under a scan and did a thermo pain test on them. The results, as you can imagine, were that the placebo cream was as effective (sometimes even more) than the local anesthetic. But what was really amazing is that the brain (they saw this on the scan), was releasing endogenous opioid  in the placebo group, meaning it was releasing its own morphine!!  Thanks to this study we can now begin to understand how a placebo works….. it works because placebo relies on chemicals, but those chemicals, unlike ¨real medicine¨, are being produced in the brain!!

This doesn´t mean that placebo works for everything, it sure won´t fix a broken leg or help to reduce a tumor, but in the area where it seems effective scientists are trying to figure out how to make the most of it. And what they have seen is that for a placebo to work we usually need to belief it´s real. In other words, it´s about expectations.  That is why the size and shape of a pill can influence how a placebo works. It´s also why a capsule is more effective than a tablet,  why a large capsule is more effective than a small tablet, why expensive medication is more effective than cheap medication, why color makes a difference; red pills are more effective for treating pain and blue pills are more effective for treating anxiety, unless of course you are a male italian (blue is the color of the national football team, and a symbol of immense excitement, passion and heart ache) (2-5).

So does this mean that if something is as good as placebo it should be allowed to be used as medicine? Well, in my opinion not really. In my opinion we should use medicine that has been proven to be more effective than placebo in clinical control studies. Meaning medication that no matter what the expectation of the patient is will work. But I do believe that once this medication has been proven to be effective, we should try to make use of the placebo effect, as it will help the real medication even more.

One last thing quick thing that a lot of people might not know. Any medication that comes out onto the market must have been proven to be more effective than placebo. If it is not more effective than placebo then that medication (pill, capsule), is not allowed to go onto the market.

Hoped you enjoyed!! Till next time

References

 

  1. http://wagerlab.colorado.edu/files/papers/Wager_Fields_Textbookofpain_toshare.pdf
  2. McRae C, Cherin E, Yamazaki TG, Diem G, Vo AH, Russell D, Ellgring JH, Fahn S, Greene P, Dillon S, Winfield H, Bjugstad KB, Freed CR (2004). “Effects of perceived treatment on quality of life and medical outcomes in a double-blind placebo surgery trial”. Arch Gen Psychiatry 61 (4): 412–20. 
  3. de Craen AJ, Roos PJ, Leonard de Vries A, Kleijnen J (1996). “Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ 313 (7072): 1624–6. .
  4. Buckalew LW, Ross S (1981). “Relationship of perceptual characteristics to efficacy of placebos”. Psychol. Rep. 49 (3): 955–61. doi:10.2466/pr0.1981.49.3.955. PMID 7330154.
  5.  Dolinska B (1999). “Empirical investigation into placebo effectiveness”. Ir J Psych Med 16 (2): 57–58.
  6. Blackwell B, Bloomfield SS, Buncher CR (1972). “Demonstration to medical students of placebo responses and non-drug factors”. Lancet 1 (7763): 1279–82. PMID 4113531.
  7.  Branthwaite A, Cooper P (1981). “Analgesic effects of branding in treatment of headaches”. Br Med J (Clin Res Ed) 282 (6276): 1576–8. doi:10.1136/bmj.282.6276.1576. PMC 1505530. PMID 6786566.

Placebo!! How can it be so powerful?

They are the miracle pills that shouldn’t really work at all. Placebos come in all shapes and sizes, but they contain no active ingredient. Now they are being shown to help treat pain, depression and even alleviate some of the symptoms of Parkinson’s disease. How is this possible?

Well, it all lies inside the brain and scientists are trying to figure out why, but I want to give you a couple of examples to show you how powerful a placebo can be.

In one test they had professional  bicycle riders do a time trial around a track as fast as they could. After that was done, they gave each cyclist a placebo pill. Now, the cyclist thought they were getting this ¨legal¨ caffeine pill that would improve their results but in reality there was NOTHING in the pill.  The normal thing would be that the second time trial they would go slower because they were already tired from the first. But all cyclist performed better and some even register their best record ever!! So how can a pill with nothing inside help someone cycle faster than ever before??

But a placebo doesn´t even have to be a pill, for instance lately there have been different studies where they have done ¨fake operations¨ and have gotten the same results as real operations (1). In one these ¨fake operations¨, patients thought they were getting a vertebroplasty. This means that ¨cement¨ is injected into a fracture spinal bone to provide extra strength to it. So what they did is they had thirty-six patients believing they were undergoing this procedure (while another group was actually getting the real surgery).  To mimic the effect of the operation, surgeons just tapped against the spine making the patients believe the needle containing medical cement was being inserted into the spinal bone. To make it even more authentic, they also made sure that the odour of the cement was present in the operating room. The results were that the patients who had the sham surgery reported that they experienced the same relief of pain as those who had the real operation (2)!!! This is not an isolated finding as they have done the same thing with knee arthroscopic surgery and found the same results!!! Incredible or what?

In another test, Professor Fabrizio Benedetti (University of Turin) is using low oxygen levels at high altitudes to conduct his investigations, to test whether placebos can cause real changes in the body. Subjects strapped with fake oxygen canisters were requested to hike for 30 minutes whilst their brain activity, heart rate and neurotransmitters were all monitored. You see, when we come to high altitudes the low oxygen levels cause our blood levels to fall, this makes our PGE2 (a neurotransmitter) levels to go up, and that leads us to feel some of the familiar symptoms of altitude sickness like pain, but extra oxygen can ease the problem. Well guess what, the fake oxygen cause those PGE2 levels go down.  A placebo, meaning nothing, has changed something physically in the body. How crazy is that?

I will leave it at that today so that you guys can digest all the information. But I will do a second part with more examples to try to explain a little more of what placebo is and how we can use it.

Hope you liked it!!

References:

1)J. Bruce Moseley, M.D., Kimberly O’Malley, Ph.D., Nancy J. Petersen, Ph.D., Terri J. Menke, Ph.D., Baruch A. Brody, Ph.D., David H. Kuykendall, Ph.D., John C. Hollingsworth, Dr.P.H., Carol M. Ashton, M.D., M.P.H., and Nelda P. Wray, M.D., M.P.H. A controlled trial of Arthroscopic Surgery for Osteoarthritis of the Knee.N Engl J Med 2002; 347:81-88

2)http://www.dailymail.co.uk/health/article-2558438/The-remarkable-power-PLACEBO-effect-Patients-FAKE-surgery-broken-recovered-just-documentary-reveals.html#sthash.6BeKXKul.dpuf

 

POST HOC ERGO PROPTER HOC

¨After this, therefore because of this¨ – It´s a logical fallacy that we tend to make more often than we would like to admit. I already talked about this in one of my previous posts but I would like to explain it one more time by giving 2 examples.

A lot of people don´t know what a wonderful machine our body and mind is. It is by far the best thing you will own in your lifetime. For example, did you know that roughly 50% of all illnesses for which people seek medical help are ¨self limited¨, meaning they are cured by the body´s own healing processes without assistance from medical science. Let´s see a Porsche trying to fix a flat tire or a broken suspension……haven´t seen it yet. So the body, we can safely say, is a truly amazing machine with remarkable powers to set itself right.

With the body so effective in healing itself, many who seek medical assistance will experience a positive outcome even if the therapist or doctor does nothing. In other words, even a worthless treatment can appear effective, I mean we have a 50% change that our body will fix itself. So when an intervention is followed by improvement, the intervention is said to be ¨effective¨ according to the person´s experience. Now, don´t try to convince that person that maybe it may not have been the treatment that restored his health because he will not even listen to you, you have no chance. His ¨personal experience¨ tells him otherwise.  But what about if he would have tried another treatment or even no treatment at all? Maybe he would have learned something else. This is a classic example of  Post hoc ergo propter hoc.

Regression to the mean-  Many diseases are cyclical, meaning they get worse or better temporarily, but always move back to an average severity(1). Back pain, arthritis, allergies, and multiple sclerosis are cyclical, meaning sometimes they get worse and sometimes they get better. Usually, we go to the therapist or doctor when we have the most pain, so it´s bound to get better no matter what the therapist does to you (2). So as you can see this would be another classic example of post hoc ergo propter hoc.

Things are sometimes not  as clear as they appear and looking at things from a different perspective can give us a better idea of what´s really going on.

References

  1. Streiner DL. Regression toward the mean: Its etiology, diagnosis, and treatment. Can J Psychiatry. 2001;46:72–76
  2. Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008
  3. Gilovich Thomas. How we know what isn´t so.The free press. 1991

Alternative medicine part 3

My last post has created some controversy and some people were not happy with what I had written. I even got a couple of e-mails asking why I was so harsh with ¨alternative medicine¨. The senders said that, in their case, they had tried ¨alternative therapy¨ and it had worked for them, whereas ¨real medicine¨ had failed. And if their problem was one that had to do with pain or some other disease that is ¨subjective¨, I believe them. Yes, that´s right I believe them, but not for the reasons they think that the alternative therapy worked. I´ll use the example of pain and I will try to explain it.

In my last post (click here) I gave an example of an experiment which demonstrated that, subjectively, everything works. There wasn´t really any difference between any of the treatments, right? Well, pain is a very subjective feeling. We can´t measure pain. Some people have a small injury and lots of pain, while other people can have a huge injury and no pain. Pain is influenced by stress, anxiety, your beliefs, attitude, and a thousand other things. That is why pain is very complex, after all, pain is in the brain (click here). Your belief in a therapy can even influence pain, so if you belief something is going to help you with your pain then it probably will! And that may be the reason why sometimes alternative therapy helps these patients.
Now, when you have a disease that can be measured, for example diabetes, asthma, high blood pressure, etc. alternative therapy simply doesn´t work.  Because different trials have shown that  alternative  therapy is no better than placebo. A pill is horrible and I wish doctors would stop prescribing so many of them. But a pill is only released onto the market when it has been proven that is has a BETTER effect than placebo, while with alternative therapy that doesn´t happen. 
But not only this, if we look at the logic behind these alternative therapies we realize that there is no logic. For example, acupuncture bases itself on the principles that a ¨life force called qi flows through bodies along 12 channels or ¨meridians¨, and that illness and pain occur when qi cannot flow freely. Science cannot do a lot of things but it can measure energy, and ¨QI¨has never been found.
Homeopathy dilutes one drop of the original substance  in a hundred, thirty times over, meaning  that less than one part per million of the original solution is in the final product, but this doen´t matter because homoeopathist believe that ¨water has memory¨.
I will say, though, that most alternative therapists usually listen better to their clients, they create a greater bond than a doctor does with his client. If you are lucky the doctor will maybe give you 5 minutes and prescribes you something. I think this is horrible and something that should change. The best thing would be to combine both treatments, things that have been demonstrated to work in clinical studies, with the care and effort that alternative therapists treat their patients.
So in conclusion: I believe those patients 100% when they say that the alternative therapy worked for them… but it´s not for the reasons why they think it worked.
References
  1. Singh S, Ernst E. Trick or Treatment? Alternative medicine on trial. Transworld Publishers.2009
  2. Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne JA, Pewsner D, Egger M. Are the clinical effect of homeopathy placebo effects? Comparative study of placebo-controlled trials of homoepathy and allopathy. Lancet.2005
  3. Ernst E. Homeopathy: what does the ¨best¨evidence tell us? Med J Aust. 2010 Apr 19;192(8):458-60.
  4. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011:152:755-64.
  5. Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne JA, Pewsner D, Egger M. Are the clinical effect of homeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet.2005
  6. David Colquhoun (UCL) and Steven Novella (Yale). acupuncture is a theatrical placebo. Anesthesia & Analgesia, June 2013 116:1360-63
  7. Asbjørn Hróbjartsson, M.D., and Peter C. Gøtzsche, M.D. Is the Placebo Powerless?-An analysis of clinical trials comparing Placebo with no Treatment.N Engl J Med 2001; 344:1594-1602.

Controlling inflammation and pain through NUTRITION

Happy New Year!! My first post of the year will be about nutrition and the importance of a good diet in dealing with pain and inflammation. But before that, I just want to mention that I have gotten some feedback saying that my post are too long, so from now on I will try to make them shorter. If there is something someone doesn´t understand or wants me to go into greater detail please don´t hesitate to comment or write me an email.

We all know how important a good diet is for our health (althought most of us don´t practice it), but I´m pretty sure that a lot of us don´t know that what we eat can have an influence on pain and inflammation. That´s right, whenever, for example, we twist our ankle or have a tendinitis, what we eat is going to either help us get better sooner or delay our recovery. Also, many of the current diseases develop and exist as consequence of chronic inflammation, such as cancer, heart disease, hypertension, osteoarthritis, diabetes, osteoporosis, etc. (1-4) Let me explain:

Inflammation is part of the healing process; however, chronic inflammation represents a lack of tissue healing and actually promotes on-going tissue damage (5).  The way we are eating is causing dietary imbalances and this, in turn, is leading to inflammation. Some of those dietary imbalances are: excessive omega-6 fatty acid intake, inadequate potassium intake, inadequate magnesium intake, and inadequate phytonutrient.  Now, I hope no one is  getting the silly idea that all they have to do is take supplementation pills to correct those imbalances, because it´s not that easy. The easiest way to correct it is by eating properly. And what is eating properly? Well, this list might help you:

Pro-inflammatory foods : Refined grains, Whole grains, Grain/ flour products, most packaged foods, most processed foods, deep fried food, trans fats, grain fed meats/eggs.

Anti-inflammatory foods: Fruits, Vegetables, Nuts Fresh Fish, Wild game, Dark Chocolate, Omega-3 eggs, Organic extra virgin olive oil, organic coconut oil, organic butter, red wine (a glass, not a WHOLE BOTTLE), spices: ginger, turmeric, garlic, oregano, potatoes.

Type 2 diabetes, which is caused by insulin resistance (https://sports-diet-pain.com/2013/10/31/sugar-the-hidden-enemy-part-2/), is also an inflammatory disease (7). Monounsaturated fatty acids found in nuts, olive oil and animal product promote insulin sensitivity and have anti-inflammatory properties, which lowers insulin resistance.  Another thing that causes inflammation is when we have an imbalance between omega 6 intake and omega 3 intake. Ideally, we should consume an omega 6:omega 3 ratio of 4 :1; however most of us are consuming a ration of 20-30:1. Here is a list of some common foods and what their ratios are (more than one might be surprising):

Food                                                                               N-6: N -3 Ratio

Grains                                                                                 20 : 1

Seed and seed oils (corn, sunflower)                    70 : 1

Soybean oil                                                                       7 : 1

Chicken (white meat)                                                  15 : 1

Chicken (dark meat)                                                    17: 1

Salmon                                                                              1 : 1

Potato chips                                                                  60 : 1

Fruit                                                                                   3 : 1

Nuts                                                                                    5 :1

Wild game                                                                        2.5 : 1                 (8)

So to summarize, food can have a big impact on pain and inflammation.  So next time you hurt yourself and you see that the pain or the inflammation is not going away, try to eat properly. It will probably help with the inflammation and in the long run you will be doing yourself a favour.

References

  1. Balkwill F, Mantovani A. Inflammation and cancer back to Virchow? Lancert.2001;357:539-45.
  2. Ban WA, Man SF, Senthilselvan A, Sinn DD. Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and meta-analysis. Thorax 2004;59:574-80.
  3. Fernandez-Real JM, Ricart W. Insulin resitance and chronic cardiovascular inflammatory syndrome. Endo Rev 2003;24:278-301.
  4. Ross R. Atherosclerosis-an inflammatory disease. N Engl J Med 1999;340:115-26.
  5. Seaman DR. THe diet-induced proinflammatory state: a cause of chronic pain and other degenerative diseases? J Manipulative Physio Ther 2002;25:168-79.
  6. Liebenson C. Rehabilitation of the Spine. Lippincott Williams & Wilkins 2007. pg 730
  7. Pickup JC. Inflammation and activated innate immunity in the pathogenesis of type 2 diabetes. Diabetes Care 2004; 27:813-23.
  8. Ros E. Dietary cis-monounsaturated fatty acids and metabolic control in type 2 diabetes. Am J Clin Nutr 2003:78:61
  9. Liebenson C. Rehabilitation of the Spine. Lippincott Williams & Wilkins 2007. pg 733

Pain part 3

So we have talked already about how pain is produced in the brain, how posture really doesn´t affect pain and how pain can be divided into acute and chronic pain. Acute pain being pain that last 3 to 6 moths and chronic pain, pain that last more than 6 months. So how do you treat the different kinds of pain?

With acute pain it is usually quite easy, the pain is associated with the tissue injury that has been produced and, in many cases, pain medications do work reasonably well. For example, NSAIDs (Nosteroidal anti-inflammatory drugs) have been shown to be effective for injuries (like ankle sprain), and after surgery. But for chronic pain, medications are only slightly effective and this is due to the fact that pain can change your nervous system (1,2).

It has always been said that the brain and the nervous system couldn´t change. But since a decade ago we know that the brain is plastic and can indeed change, it´s called NEUROPLASTICITY. Scientists have seen from imaging and animal studies that persistent pain or pain which last for months and years can change the pain pathway, in other words we become more sensitive. This hypersensitivity causes the brain to interpret anything related to those tissues to be highly threatening. So basically the nervous system and the brain have become more efficient in producing and maintaining pain (3-5). You could say that in chronic pain, the pain has moved up to the nervous system and now has very little to do with the initial damage to the tissues that caused the pain.

Let´s try to clear this up and make it easier to understand with an example: John, age 45, has had lower back pain for the last 2 years. Everytime he bends down to pick up something he experiences pain, so he stops doing that. We know that tissues or bones usually heal in between 3 to 6 moths, so there is really nothing wrong with him from a anatomical point of view. And everytime he bends down it doesn´t mean that he got hurt again or that he re-injured himself. It is just that Johns brain and nervous system have become so good at constructing pain that the slightest of triggers – even those that don´t cause damage, cause pain. So how do we deal with this?

The most important thing would be to educate John about pain, to teach him the role of the brain in pain, and to explain to him that pain doesn´t always equal to damage. When education about pain physiology is included into physiotherapy treatment of patients with chronic pain, pain and disability are reduced (6,7). After this, the next thing would be to gradually expose John to the feared activity (bending down) without causing pain and thereby lowering the threat level in the brain. So we would teach him first how to bend down correctly and to only bend till the point before the pain starts. This process would start to decentralize his pain and eventually make his pain disappear.

To finish I want to hopefully think that people now understand a little bit more of how pain acts and how to deal with pain. These last 3 articles have been difficult and maybe hard to understand but I would be satisfied if people took at least these 3 points home:

  1. Damage does not equal pain; not all damage leads to pain, and not all pain is caused by damage. Example: a study in the journal Arthritis & Rheumatism looked at the relationship between knee osteoarthritis and pain (8). They found out that some people had little arthritis and high pain, and some people had severe arthritis but low pain. The researchers concluded that the level of knee pain was due to central sensitization, rather than the level of osteoarthritis. In other words, the level of pain had more to do with changes in their nervous system, not changes in their knee structure.
  2. You can have a bulged disc or degenerated spine, maybe even impinging on one of your nerves, and still not have pain. Or you could have none of these problems, and still have persistent pain (9-12).
  3. The International Association for the Study of Pain defines pain as an emotion. That is, pain is a perception rather than a sensation. Unless and until the brain senses danger or threat, nothing can cause pain.

To finish I will post 2 links.

In one of them Lorimer Moseley describes how to explain pain to patients and in the second one, which is quite long (44 minutes), he talks about the whole process of pain. Enjoy

http://www.youtube.com/watch?v=jIsF8CXouk8

http://www.youtube.com/watch?v=-3NmTE-fJSo

In my next blog we will change the topic drastically and talk about food. Is food a drug?? Can you get addicted to food? We will see and explain in my next blog. See you then.

Bibliography

1. Ekman EF, Ruoff G, Kuehl K, Ralph L, Hombrey P, Fiechtner J, Berger MF. THe COX-2 sècific inhibitor Valdecoxib versus tramadol in acute ankle sprain: a multicenter randomized, controlled trial. Am J Sports Med. 2006 JUn;34(6):945-55. Epub 2006 Feb 13. PubMed PMID: 16476920

2. Buvanendaran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of cuntion after knee replacement a randomized controlled trial. JAMA. 2003 Nov 12,290(18):2411-8. PubMEd PMID: 14612477.

3.Flor H, Nikolajse Li, Stachelin Jensen T. Phantom limb pain: a case of maladaptive CNS plasticity.

Nat Rev Neuroscience 2006 Nov;7(11):873-81.

4. Flor H, Braum C, Elber T, BIlbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience 1997: March 7.224(1)5-8.

5. Ren K, Dubner R. Central nervous system plasticity and persistent pain. J Orofac. Pain.1999.Summer.13(3):155-63.

6.Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J pain 2004. Sept 20(5): 324-30.

7. Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiotherapy 2005: 31(1):49-52.

8.Dallinga JM, Benjaminse A, Lemmink KA. Which screening tools can predict injury to the lower extremities in team sports?: a systematic review. Sports Med. 2012 Sep 1;42(9):791-815.

9. Johnson C. Modernized Chiropractic reconsidered: beyond foot-on-hose and bones-out-of-place. J Manipulative Physiol Ther. 2006 May;29(4):253-4. PubMed PMID:

10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008 May;35(5):544-62. Epub 2008 Feb 14. Review.

11. Homola S. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res. 2006 Mar;444:236-42.

12. Good CJ. The great subluxation debate: a centrist’s perspective. J Chiropr Humanit. 2010 Dec;17(1):33-9. Epub 2010 Sep 21.

Pain part 2 – Does bad posture cause pain?

The other day we saw that pain is very complex and that in most cases it´s produced in the brain. So, if it´s really produced in the brain, does posture or movement really matter? We have all gone to the physical therapist or doctor and have heard that ¨your back pain comes because you have too much of a curve in your back¨, or ¨your back pain or shoulder pain comes because of your forward head posture¨ or ¨your knee pain comes because you have too much of a pronation on your foot¨. Hell, I´ve done it, I´ve been saying that to my patients for years because that is what was taught to me.

Up to last year I had a client, XG, who always came to me because he had back pain. I would always tell him that his back pain was coming because of his posture. He had a forward head (still does) and a big lordosis (inward curve) in the lower back .I tried to correct his posture, I gave him exercises to do at home, I stretched him, I did everything you could imagine but his posture hasn´t really changed but guess what, his pain has, it´s gone!!

So what I´m basically trying to say is that there is no consensus on supporting a biomechanical (and posture) model of pain (1-10). Because:

• Postural and structural asymmetries cannot predict back pain and are unlikely to be its cause (1).

• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain (1).

• A postural structural biomechanical model is not suitable for understanding the causes of back pain (1).

This is so because postural structural asymmetries and imperfections are normal!! The body has surplus capacity to tolerate such variation without loss of normal function. That is why there is little scientific evidence to show that posture will cause pain (2-5). If posture was a factor of pain how come you see thousands of people around with bad posture with no pain and thousands more with ideal posture in a lot of pain? That just shows that there is much more to pain than just posture.

This is not meant to deny that there is a correlation between pain and certain postures, but that this association is neither sufficient nor conclusive to justify our efforts to dictate people’s posture and movement. But what we do know for sure is that there is no ‘ideal’ posture, and any posture if maintained for too long will result in dysfunction, and maybe pain. The key is movement.

To end this article and the topic of posture and pain, and to confuse people even more, I will say that there actually is potential harm in  “addressing” the unsubstantiated claims of bad posture. Things just as: focus on “bad” movement or “bad” positioning have the potential to sensitize the individual into believing that a benign (wrong) positioning is in fact something that represents a threat. And as we saw yesterday in the video, pain is the response to threat, either real or perceived, and how we view our environment and ourselves within that environment can positively or negatively affect that threat response. So by addressing things that don’t have evidence to support them (bad posture), we are actually increasing the chance that an individual might have the very real experience of pain. We are creating a self-fulfilling prophecy. That is real harm – and it is evidenced (2-5).

I will finish by quoting some of Lorimer’s famous quotes and with a link to a video that demonstrates the tricks the mind can play on us.

Favorite Lorimer Quotes

  • “Pain is very complex.”
  • “We can’t treat every pain patient with a simple solution.”
  • “The best way to get rid of chronic pain is to chop the person’s head off.”
  • “As soon as you interact with the patient, you are in their brain.”
  • “Always do more today than you did yesterday.”

http://www.youtube.com/watch?v=sxwn1w7MJvk

P.S In my last post I said that you can have an injury without having pain. Some of you didn´t believe me, which is normal, so references 7-12 demonstrate just that.

Also, those that have been following me may be asking themselves why I still  haven´t talked about how to deal with pain. The simple answer is that I first wanted you guys to really understand what pain is and change the way you think about it. With these 2 posts maybe you haven´t really understood it yet, but I probably made you look at pain from a different perspective. Now that we have this different perspective, in my next post I will finally talk about how to ¨deal¨ with it. Hope you liked the article, until next time.

Bibliography

1. Lederman E. The fall of the postural-structural-biomechanical model in

manual and physical therapies: exemplified by lower back pain. J Bodyw Mov

Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011

2. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May
8;353(9164):1607-9.

3.Moseley, G. Lorimer. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews 2007; 12: 169–178.

4.G Lorimer Moseley. Teaching people about pain: why do we keep
beating around the bush? Pain Manage. (2012) 2(1), 1–3.

5.Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.

6. Moseley GL. Pain, brain imaging and physiotherapy–opportunity is
knocking. Man Ther. 2008 Dec;13(6):475-7.
7.Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people
without back pain. N Engl J Med.1994 Jul 14;331(2):69-73.

8. Sher JS et al. Abnormal findings on magnetic resonance images of
asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5.

9.Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset
and descriptor patterns related to different injuries. Pain. 1982
Sep;14(1):33-43.

10. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magneticresonance
scans of the lumbar spine in asymptomatic subjects. A prospective
investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.

11. Kleinstück F, Dvorak J, Mannion AF. Are “structural abnormalities” on
magnetic resonance imaging a contraindication to the successful conservative
treatment of chronic nonspecific low back pain? Spine (Phila Pa 1976). 2006
Sep 1;31(19):2250-7.

12. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S,
Einhorn TA, Felson DT. The clinical importance of meniscal tears
demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J
Bone Joint Surg Am. 2003 Jan;85-A(1):4-9.

Tag Cloud