What is an evidence-based way to address chronic musculoskeletal pain without medications?
Short answer: A Multi-Pronged Approach Including Movement, Stress Management, Low Carbohydrate Diet, Optimal Weight, and Optimal Sleep
Table of Contents
Introduction: What is the Burden of Chronic Pain?
We carry through life the sum-total of trauma to our brains and bodies. As we age, there is an increased experience of pain associated with the dysfunction of joint wear and tear – osteoarthritis. Other conditions can affect the brain, peripheral nervous system, and connective tissues and lead to chronic pain syndromes. As we grapple with these changes, we attempt to adjust to a new normal of increasing background pain. And, in some cases, the pain can be disabling.
The CDC estimates 20 to 30% of adults live with chronic pain, and the likelihood increases with advancing age- affecting more than 70 million Americans (Zelaya, 2019). Arthritis contributes to the most cases of disability, amounting to 1.2% of U.S. gross domestic product (MMWR, 2007). The likelihood of chronic pain goes up with age. In those 65 and older, almost one in three people (30.8%) report chronic pain and high-impact chronic pain, meaning a report of pain “most days” or “every day.”
Many studies support the role of physical activity on psychological health, overall aging, and life expectancy, including in people with chronic health conditions (Durstine, 2012.) Few therapies can offer such a panacea on health conditions as physical activity (Manini, 2006). In the study of high-functioning, community-dwelling older adults aged 70-82 years, increased daily energy expenditure halved the risk of death when the highest activity tertile compared with the lowest.
The Pain Pathway
A child who touches a hot oven quickly realizes that acute pain has a beneficial function to protect the body from further harm. It communicates that the body is in distress; it is one of the five cardinal signs of inflammation.
However, each person experiences the signals uniquely. As with any neural network, the receiving end can become sensitized to the distress signals and increase the experience. Compounding the attempts to make pain “the fifth vital sign” is that pain is not objective; there are placebo effects, emotional interaction, and attentional factors (Breivik, 2008; Brooks, 2002). Pain assessment becomes especially complicated in chronic pain.
The pathway responsible for pain perception and relief is the endogenous opioid system: the opioids responsible are beta-endorphin, the met- and leu- enkephalins, and the dynorphins. These neurotransmitters function at opioid receptors to produce analgesia. In chronic pain conditions such as fibromyalgia, imaging findings suggest that dysregulation of the endogenous opioid system accounts for increased pain in these patients (Schrepf, 2016). Interestingly, dysregulations in pain pathways may contribute to the increased association of opiate use in people with PTSD, suggesting that chronic pain and chronic stress are interrelated (Abdallah, 2017).
Opiate drugs share the same receptors (Holden, 2005). Chronic pain medications and the opiate epidemic exposed the harms and limitations of opiates in treating chronic musculoskeletal pain. The CDC estimates that nearly 500,000 people have died between 1999 and 2019 from opioid drug overdose, including illicit and prescription meds. Drug overreliance and overprescribing to treat chronic pain were the “root causes” of the epidemic (Ballantyne, 2017).
What is the Evidence of Movement and Exercise and Chronic Pain?
Facing the threat of worsening pain or reinjury, some people with chronic pain find themselves drastically adjusting their movement, a condition known as kinesiophobia. The behavior can exacerbate a person’s disability, pain, and reduce quality of life. It can lead to an increased risk of health problems and death (Sawatzky, 2007).
There are opposing issues that come up for osteoarthritis and other pain syndromes. On the one hand, it is not infrequent that when a doctor sends a patient for physical therapy, their joint pain worsens afterward. On the other hand, movement exercises and treatment can improve pain and range of motion.
Movement and exercises programs benefit individuals with chronic arthritis and other pain syndromes. Although specific exercise guidelines for chronic pain are lacking, people with chronic pain can expect significant improvement in pain, flexibility, depression, and sleep (Ambrose, 2015).
Here are some additional studies:
- A study comparing sham mobilization with movement (MWM) and actual MWM therapy for knee arthritis observed improved pain, function, flexion, extension, and muscle strength after two days of MWM therapy (Alkawajah, 2019).
- Exercise can be a valuable modality for individuals with fibromyalgia. Aerobic programs improve health-related quality of life, fitness and reduce pain, fatigue, and depression (Haeuser W, 2010.)
- Finally, a Cochrane review of 21 studies found that, while further research is needed, exercise and increased physical activity may improve pain severity, physical function, and quality of life (Geneen, 2017).
The Interrelationship of Brain and Body In Chronic Pain
The experience of pain is as much an experience in the brain as in the body. The brain provides feedback as it receives pain signals, leading to anticipation of pain and fear avoidance. Studies support that fear of pain is a learned response and may be partly responsible for the experience of chronic pain (Al-Obaidi, 2000). Models suggest that the fear of movement-related pain can drive the development of chronic musculoskeletal pain (Meulders, 2011).
Within the brain, the neurotransmitter dopamine may act in pain anticipation and the emotional experience of pain (Changsheng, 2019). It is helpful to think of dopamine as the anticipation neurotransmitter, regulating movement toward or away from a pleasurable or painful stimulus, respectively. The relative dopamine deficiency that occurs after increased dopamine release is a source of dependence and addiction. Studies implicate dopamine deficiency and increased pain sensitivity in conditions such as Parkinsonism (Thompson, 2017).
Just as we have voluntary control over our breathing and, for some, our pulse, we may also be able to control our perception of pain. The brain can amplify or dampen the peripheral pain signal. And we can learn or receive therapy for this behavior!
- Neuroscientists applied real-time functional MRI (rtfMRI) to provide feedback and train subjects to control a brain region associated with pain known as the rostral anterior cingulate cortex (rACC) (deCharms, 2005).
- A recently published study showed the benefit of cognitive behavior therapy interventions in reducing pain level and disability reports, corroborating the benefits of addressing the perception of pain (DeBar, 2021).
Moving Towards a Complementary Pain Management Model
Although some patients struggling with chronic pain do benefit from opiate therapy, continuous pain therapy challenges the analgesic effects of these medications with the body’s homeostatic response. In many people who maintain therapy, there is a waning effect of pain relief to eventual increased pain sensitivity, going from analgesia to hyperalgesia on therapy (Ballantyne, 2017). Tolerance relates to a waning benefit and becomes a reason to escalate therapy, which increases the risk of harm. Studies indicate that occasional use provides similar or better results because it likely avoids this adaptation (Merrill)
Multiple modalities can complement and limit the need for escalating opioid doses. Chronic stressors may lead to an oxidative stress state of neuro-inflammation and increased pain perception. In some cases, addressing some of the triggers to pain (and stress) may relieve the signal enough to maintain a productive life.
Here are five non-pharmacologic modalities that address chronic pain. Importantly, these are similar modalities that lead to a lengthened healthspan and longevity.
- Optimal diet. Consume food that is low in fat and sugar. One approach to take is a plant-based diet. Research reports a positive association with fat and sugar intake and osteoarthritis pain (Elma, 2020). Similarly, an “inflammatory diet,” associated with high intake of processed foods has been associated with exacerbations of chronic diseases (Bjorklund, 2019).
- Sleep. There is an interactive effect between chronic pain, opiate medications, and sleep. Pain can worsen sleep; sleep apnea can increase pain perception and lead to a stress response from non-restorative sleep.
- Physical Activity. Exercise and movement are useful modalities in preventing and relieving pain.
- Stress Management. Stress raises cortisol levels, which lead to inflammation. Effective stress management can reduce the maladaptive responses and the sensation of pain. The development of helpful coping strategies may reduce stress and the psychological response to pain (Hannibal, 2014)
- Maintain Optimal Weight. This will reduce the risk of inflammation from increased adipose tissue, hypertriglyceridemia, and sleep apnea.
Here are a few links for Amazon-related products that can help to improve pain issues that you might have:
This product may be useful in developing a routine for back stretching.
This book will be helpful in addressing chronic pain. Cognitive behavioral therapy has been found to be useful for pain.
Here is a book that is a good start for addressing chronic pain issues:
Here is a muscle rub that you can use when you are experiencing pain.
Other YHF Reading
Here is an article on Mindfulness with a neuroscience framework.
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