Green, Organic and Healthy Living Articles

Integrative Approaches to Chronic Pain Geoff Lecovin, D.C., N.D., L.Ac., CSCS

Pain is among the top reasons that patients visit their physician. Acute pain is less than six months duration and is biologically useful. It signifies that an area is injured and that the body is attempting to clean up tissue damage and begin the repair process. Chronic pain is generally greater than six months in duration and is biologically useless. It persists beyond the usual course of the acute insult or injury, can be affected by psychological factors and often has a relationship with the nervous system.

There is a tendency among physicians to assume that pain is a signal of “tissue damage.” This assumption had resulted in the overuse and misuse of medications such as Non Steroidal Anti Inflammatory Drugs (NSAIDs), analgesics, narcotics, antidepressants and anticonvulsants. These drugs have numerous side effects, some of which over time are irreversible. In addition, these drugs can inhibit cartilage formation and accelerate cartilage destruction, resulting in osteoarthritis and chronic pain.

Integrative approaches to pain differs from conventional therapies in that they are less invasive, have minimal side effects, focus on the cause, and are harmonious with the body’s bioelectric healing processes.

This article reviews the different phases of pain and describes effective treatment strategies from an integrative perspective.

There are three phases of pain:
1. Immediate (nociception) - information regarding damage to tissue is relayed by receptors via nerve tracts to the brain.
2. Acute (inflammation) - continued tissue damage stimulating the production of chemical agents. This phase of pain is characterized by swelling, redness, heat and altered function.
3. Chronic - may be due to ongoing tissue damage/inflammation, psychological problems or neuropathic/myofascial changes (functional and structural alterations within the nerves, muscles and joints).

Neuropathic/myofascial pain has the following features:
1. Pain is present without ongoing tissue damage.
2. There is a delayed onset after injury.
3. It is characterized by abnormal or unpleasant sensations.
4. Mild stimulation is aggravating.
5. There is loss of joint range of motion due to muscle shortening.

Neuropathic pain is typically accompanied by changes in sensation and strength in the areas affected by the involved nerves. This process is commonly referred to as “neuropathy.” There are many causes of neuropathy, but by far the most common is structural degeneration within the musculoskeletal system. These changes occur gradually over time usually as a result of accumulated trauma. Many of these traumas go unnoticed, until at some point nerves become injured, resulting in abnormal function.

The classic signs of neuropathic/myofascial pain include:
1. Muscle shortening.
2. Tender and painful focal areas in muscles (“trigger points”).
3. Changes in strength, sensation and nerve function in area supplied by the involved neuropathic nerves.

Muscle shortening is the hallmark of neuropathic pain. Local muscles along with their spinal counterparts (i.e. those muscles in the spine where the nerves are exiting to go to the damaged area) are involved. For example, in the case of shoulder or elbow pain, there is muscle shortening locally at the sites of dysfunction as well as at the associated spinal muscles, in this case C5 C6.
Shortening of muscles in the extremities (i.e. wrists, elbows, shoulders, hips, knees and ankles) places mechanical stress at their insertions and can cause tendonitis, bursitis, etc. Shortening of muscles acting across a joint can upset alignment causing arthralgia (arthritis-like pain) and eventually degenerative changes. Muscle shortening across the spine can compress discs, narrow the holes where nerves exit and eventually lead to nerve irritation.

A “vicious cycle” develops whereby shortened spinal muscles cause pressure on nerve roots (neuropathy), leading to irritation and shortening of the muscles supplied by those nerves, which reflexively sends back information causing more spinal muscle shortening (perpetuating the cycle).
Lastly, mechanical stress caused by muscle shortening results in inferior collagen, leading to weaker tendons, cartilage and bone, thereby predisposing these areas to further injury, pain and dysfunction.

Effective approaches to chronic neuropathic pain include intramuscular stimulation (IMS), myofascial release, neuromuscular reeducation and corrective stretching exercises.
IMS is a form of acupuncture based upon fundamental orthopedics and neurophysiology. Fine needles are inserted into shortened muscles, causing a gradual release of muscle spasm. Needling creates minute injuries, resulting in bioelectrical changes, which stimulate healing at the cellular level. Local inflammation stimulates growth factors, which provide stronger and more durable collagen, thereby strengthening damaged tissue. Pain in tendons, ligaments and joints is lessened as shortened muscles acting upon them gradually relax.

Neuromuscular reeducation and myofascial release involve deep tissue massage with active and passive motion, along with stretching of soft tissue structures. This helps to lengthen shortened muscles and stretch adhesions. Treatments are followed up at home with specialized stretching and self myofascial release exercises using tennis balls or foam rollers.

Conclusion
Chronic pain diminishes quality of life, impairs activities of daily living, decreases involvement in activities, causes lost workdays and can lead to depression or anxiety. Over 80 million people in the U.S. experience chronic pain, with back pain and headaches being the most frequent complaints. The annual total cost of chronic pain was estimated to be $150 billion in 1998.

Conventional approaches to chronic pain typically employ the use of medications aimed at covering up symptoms. One must weigh the benefits of short-term pain relief and the potential for irreversible side effects.

Integrative approaches to chronic pain address the cause, have minimal side- effects, and stimulate the body’s inherent ability to heal itself.

Dr. Lecovin is a naturopathic physician, chiropractor, acupuncturist and certified strength and conditioning specialist. He is in private practice in Kirkland, Washington, specializing in the treatment of chronic pain and sports injuries. He can be reached at (425) 825-5707 or through his web site at www.eimed.com.