The truth about sports, nutrition and pain!

Posts tagged ‘Pain’

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.

Acupuncture

A quick side note before I start talking about acupuncture. I want to say that I did a Postgraduate degree on acupuncture 8 years ago, after finishing my Physical Therapist studies. I never got the hang of it, and I never really understood it, so I never used it with my clients, but during the time of my studies, I inserted needles and people inserted needles onto me.

OK, let´s begin by saying what acupuncture is: Acupuncture is a collection of procedures involving penetration of the skin with needles to stimulate certain points on the body. It is based on the notion that health and well-being relate to the flow of a life force through pathways (meridians) in the human body (1). In its classical form it is a characteristic component of traditional Chinese medicine. There are various schools of acupuncture but the majority support the notion of 12 meridians (there are 12 main rivers in China). Meridians supposedly are associated or connected to one of the mayor organs and there are hundreds of possible acupuncture points along the meridians. Before deciding on the acupuncture points, the acupuncturist must first diagnose the patient by inspection, auscultation, olfaction, palpation and inquiring. (1)

The thing that I always find funny is the way people defend acupuncture. They always say to me ¨it has existed for thousand of years so it has to be true¨, and this makes me believe they don´t know what they just said because right there, in that sentence, is part of the answer of why acupuncture doesn´t really work. First, I´ll start by saying that over 2000 years ago (the first mention of acupuncture was 2,600 BC), we didn´t really know how the human body worked, even now, with all the technology we still can´t explain certain things. So you think 2,000 thousand years ago in a culture that performed no DISSECTIONS, they knew what they were doing or where they were sticking their needles (1,2)? If you believe that, then you have to believe 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……….and if that´s the case then acupuncture is the right treatment for you.

Let´s just imagine that qi doen´t really exist, since it has never been proven by science (3), this doesn´t mean acupuncture doesn´t work. Maybe acupuncture works through a theory called ¨gate control theory of pain¨. The theory is based on the idea that the spinal cord contains a neural ¨gate¨ that can open and close to reduce or enhance pain messages passing to the brain. This theory seems more logical and maybe that´s why acupuncture does seem to work, or maybe it´s just all a placebo effect.

So to see if acunpuncture is a real treatment or a ¨trick¨, the scientific community has been doing trials, and a lot of trials have been done.

At the beginning these trials compared acupuncture with no treatment. These studies suffered from bias because as I mentioned in my last post (https://sports-diet-pain.com/2013/10/18/placebo/): patients having any procedure tend to feel better than those who have none. So a lot of positive clinical trials came out in the 1970s, 80s and even 90s. Also a lot of positive clinical trials were coming in from China. But if you compared the clinical trials coming from China from the ones coming in from other countries, the Chinese trials were always positive!! (Most people don´t know that during the Daoguang Emperor (1782-1850) acupuncture was in decline and that it only experienced a revival in 1949 as a direct result of Mao Zedong, who promoted Chines traditional medicine during the Cultural Revolution as a way to boost national identity and deliver cheap healthcare (1,2) .

So in 2003 the World Health Organization did a review and analysis of reports on controlled clinical trials and they said that the benefits of acupuncture were either proven or had been shown in the treatment of 91 conditions!!!! (4). But… they had included all those clinical trials that I have mentioned before that were badly conducted and the ones coming in from China.

Cochrane Collaboration is a global network of experts coordinated via its headquarters in Oxford. They adhere to the principles of evidence-based medicine and what they do, is examine clinical trials and other medical research in order to offer clear conclusions about which treatments are genuinely effective for which conditions. It´s basically the  ¨gold standard¨ inside the scientific community. They disregard any clinical trial that is not reliable and only look at those in which their quality is reliable. They published their conclusions and said that there is no significant evidence that acupuncture is an effective treatment for the following conditions:  Smoking addiction, cocaine dependence, induction of labour, Bell´s palsy, chronic asthma, stroke rehabilitation, breech presentation, depression, epilepsy, carpal tunnel syndrome, irritable bowel syndrome, schizophrenia, rheumatoid, arthritis, insomnia, non-specific back pain, lateral elbow pain, shoulder pain, soft tissue shoulder injury, morning sickness, eggcollection, glaucoma,vascular dementia, period pain, whiplash injury and acute stroke (5). They did however say that it ¨could¨ help in the cases of pelvic and back pain during pregnancy, low back pain, headaches, post-operative nausea and vomiting, neck disorders and bed wetting – the important word here is ´could´.

The problem with clinical trials with acupuncture is how do you create a ¨sham¨ group or control group? With pills it´s easy, one group takes the real pill and the ¨control group¨ takes the fake pill, the patients don´t know what they are taking. After that, you just compare results between one group and the other, to see if the real pill does really have an effect or if it´s just a placebo effect. With acupuncture is quite hard because you HAVE to use needles, if not the patient is going to know the difference. So a doctor by name of Edzar Ernst and Jongbae Park created a telescopic needle- that is, an acupuncture needle that looks as if it penetrates the skin, but which instead retracts into the upper handle part (1). The needle offers some resistance as it is retracted into the upper handle. This meant that it would cause some minor sensation during its apparent insertion, so patients would think they were getting real acupuncture but were actually not.

After this new invention came out, new trials started to be conducted and the results of these trial were not that good for acupuncture (6). It showed that acupuncture is just as good as ¨sham acupuncture¨, meaning its benefits are only derived from its placebo effect. A lot of people will say who cares if it´s a placebo effect or something else, if the patient is deriving benefit from the treatment, why not just go ahead with it. I have my opinion regarding to this, which I stated in my last post. Some agree with it, some disagree with it and that´s perfectly fine, as long as you know the real reason why you are doing acupuncture or getting acupuncture.

My next post will be about pain. Do we really know what pain is?  How come people who have arthritis in their knee have no pain and some do have pain? How come people with herniation have pain in their back, and some don´t? Is pain really in the knee, back, arm……… or is it all in the head? If so, then maybe we have to start changing the way we deal with injuries or treat our patients. Until next time enjoy the weekend!

P.S. I have added a video to my last post. I would highly recommend that you take a look at it. Sometimes videos express things more clearly than I do. So far I have posted 2 videos. One in the ¨placebo¨ article and the other one in ¨the myth about fast and slow metabolism¨. Really interesting both of them.

Bibliography

1.Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008.

2. Derbyshire D. Why acupuncture is giving sceptics the needle. The observer 2013.

3. Gorski D. A Trilogy of (Acupuncture) Terror. Science Based medicine 2013.

4.http://www.who.int/en/ . Word Health Organization.2003.

5.http://www.thecochranelibrary.com/view/0/AboutCochraneSystematicReviews.html

6. Ingraham P. Does acupuncture work for pain? http://saveyourself.ca/articles/acupuncture-for-pain.php 2009.

7. Moffet HH. Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. J Altern Complement Med. 2009 Mar;15(3):213-6.

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