CHIROPRACTIC, CHRONIC PAIN AND THE BRAIN PART 3: new strategies for the brain

In this section I would like to review some important concepts on how we treat chronic pain differently than acute pain, with the understanding that this is a vast complex and evolving field, and we will only be able to touch on the surface in this blog entry. In this section I will focus on how we understand the brain's reaction to chronic pain, while focusing on how we need to modify body care approaches in the following section.

In section 2 we discussed how chronic pain is transmitted differently and more "efficiently" to the brain, with much more signal ramification into other parts of the brain as well. Meaning that chronic pain can be triggered with minimal sensory input, and is more perpetuated and activated at the level of the brain itself by other functions and parts of the brain. As a result, you really need to think about how well all of your brain is functioning when you're trying to manage chronic pain.

Brain nutrition and biochemistry: this is often overlooked in chronic pain. Making sure that the "chemical soup" of the brain is optimized to minimize inflammation, nutritional insufficiencies. Some low hanging fruit to improve your brain's response to chronic pain would be making sure that you stay away from oxidized fats (pretty much all refined seed oils of modern processed foods like sunflower oil, safflower oil, canola oil, etc.), focusing on whole foods complex fat and essential fatty acid from the fish and seafood family. Making sure you have adequate amounts of protein, optimizing vitamin D levels, electrolytes such as potassium and magnesium especially (involved in brain energy production and sustenance), minimizing blood sugar fluctuations by staying away from refined carbohydrates, making sure you have adequate amount of whole foods antioxidants, and staying away from ultra processed food since most of these food additives are known to be excitatory and inflammatory to the brain.

Of special note is a nutrient that we often do not think of as such for the brain which is oxygen. Chronic pain can often be associated with down regulation of the autonomic vascular system, meaning that we tend to have decreased blood flow perfusion to all parts of our bodies but especially to the central nervous system. Mild regular cardiovascular aerobic activity that gets your heart rate above 100 is really important in that regard, as is basic breath works. Making sure you don't have chronic low-grade anemia, or reduced oxygen availability from smoking and vaping for example. Patients taking certain medications that are associated with decreased blood flow to the central nervous system will need to discuss the specifics on how best to mitigate those problem with the individual provider.

Stress: the physiological impact of stress on the brain is widespread and underestimated when it comes to chronic pain. But there's almost a 1:1 correlation between stress increase and chronic pain increase, so you really never are going to manage one without managing the other. It will look differently in individual people. Sometimes we need to 1st take a stock of the stress and look at practical strategies so that we can start making some cuts, while concurrently increasing patients coping resources towards the inevitable stress burden of real life.

Sleep: suboptimal sleep is also almost a 1:1 driver of poor chronic pain management and resolution. It's also a self-perpetuating vicious cycle since chronic pain tends to disrupt sleep, and poor sleep tends to worsen chronic pain. It's also important to realize that most people will easily reach for heavy-duty pharmacological interventions for sleep disruption, (not only medication but things like over-the-counter antihistamines, CBD/THC, melatonin etc.), which may backfire because of suppressing normal brain adaptative mechanism over time. It's surprising to me how many people still practice poor sleep hygiene in spite of widespread data available from Dr. Google, (simple things such reducing your screen exposure in the evening is still very hard to achieve for most people). So as a starting place, you may want to take a simple inventory of your sleep hygiene habits and start making some changes. Other changes such as sleeping positions, mattresses, temperature, supplementation may need to be individualized with your healthcare provider. I have found it helpful to look at tracking device for overall sleep quality when making changes, to make sure that you focusing your efforts on things that actually pay off for you.

CHRONIC PAIN, CHIROPRACTIC and THE BRAIN, PART 2: why and how

In this brief section I want to further expand on some of the mechanisms by which chronic pain develops from acute pain, and why it may do so.

– Acute pain is usually described as new onset pain that resolves within 6 weeks, while chronic pain is pain that is persistent 12 weeks after an initial insult or trauma. So chronic pain normally starts becoming chronic pain anywhere between 6 and 12 weeks.

– Acute pain transmission to the brain is pretty energy consuming, so if the brain senses the need to continually experience pain signaling for self protection, it will switch to a more efficient and less metabolically demanding way of doing so. The type of chronic pain fibers are often referred to as "C fibers", which has less myelin, transmit pain signal more slowly, but also more efficiently. C pain fibers are also known to sprout more side connecting branches to other parts of the nervous system in the spinal cord, and at the level of the brain.

– Chronic pain signaling is happening increasingly less in the periphery, at the site of the original insult, and more so at the level of the central nervous system, especially starting to give side branches into other brain centers that manage sleep, mood, autonomic regulation, and thus becomes increasingly independent from the original injury, almost taking a circuitry and a life of its own over time. The chronic pain becomes more "efficient" in the sense that it takes less signaling for the body to experience the warning signal. It had an evolutionary benefit in making us aware more easily that a previously injured area is at risk of reinjury for the sake of self protection, but in our modern times, means that the pain is more easily triggered with a very minimal threshold, which is no longer an evolutionary advantage.

– The circuitry and neuronal hardware of chronic pain take some time to build up, and unfortunately can also take some time to takedown. Which is why chronic pain is often persistent when all the apparent active triggers may have been resolved.

– Chronic pain is also more likely to develop, and persist, in certain unfavorable conditions: a state of general inflammation, a state of general sleep deprivation, mental or physical stress, and certain nutritional deficiencies. It's also possible that certain medications will make chronic pain more likely to develop. This is why addressing chronic pain needs to be more comprehensive than addressing acute pain, and can be much more challenging.

CHRONIC PAIN, THE BRAIN AND CHIROPRACTIC ( part 1)

While our stated goal is to help people optimize the health potential through our chiropractic invention, the reality is that the majority of people will seek care with their primary focus on addressing pain. Pain is the human experience that is as old as human themselves, and it is a complex topic to put it mildly.

The series is intended to talk about the even more complex subset of chronic pain. Acute onset new trauma related pain is quite different than ongoing chronic pain, from a neurological and physiological perspective. As a result, we need to apply different concepts on addressing chronic pain and acute pain, and quite a bit of the frustration in dealing with chronic pain is that we are trying to apply concepts of acute pain management to a completely different clinical presentation.

1st you need to understand that pain is a brain phenomenon, whether acute or chronic. But the ways in which pain registers in the brain are quite different.

Acute pain: it is mediated through a set of nerves that are large, highly coated in myelin which makes them fast, they have few relay points between the periphery in the brain, and they do not send side branches. As a result, it's pretty much a 1:1 connection between the body insult and the landing place in the central part of the brain cortex. It fires out fast and it turns off equally fast if the periphery receptor is not being activated. To some extent, that's what most people think of as pain, and it's a bit more of an uncomplicated system.

Chronic pain: it looks different neurologically and biochemically. Chronic pain is mediated through a set of fibers that is smaller, slower, and has a lot more peripheral branches, side branches, and spreads to more areas of the brain. The areas of the brain where chronic pain is transmitted are more diffuse, not as well localized in the body, and tend to send connections to part of the brain that are not sensory but associated with autonomic regulations such as mood, sleep and involuntary functions for example digestion and blood flow. It's also highly noteworthy that chronic pain in the brain tends to continuously fire off and be active even if the peripheral tissue from which they originate and not actively being traumatized. As a result, chronic pain can be more uncoupled from the original injury, making it very confusing for the patient to understand why their pain is firing up. The chronic pain circuitry in the brain as well as the small chronic pain fibers are more susceptible to biochemical changes such as inflammation, electrolyte balance, temperature etc.

There is a little bit of a gray area as to when acute pain transitions into chronic pain and why. It's generally accepted that chronic pain pathways can establish as soon as 6 weeks post injury, but in some people it may take up to 3 months. The why question is much more nuanced and will be discussed in a subsequent section.

Tactical and practical about microplastics

Not immediately a topic of discussion within a chiropractic practice, the subject of environmental toxicity and more specifically micro plastics toxicity will often hover on the periphery, as all chemical burden on the body will increase systemic inflammation and at some point, spillover into the know musculoskeletal system, especially chronic pain. It is definitely a topic for many questions from patients with whom were working on hormone balancing, which in most cases, involves as much hormone detoxification support is it does hormone and enhancing support.

As with all things environmental, the proverbial "deer in the headlights look" seems to be the 1st reaction to the topic, as the idea of how, where, and when to start tackling reducing exposure can feel overwhelming. This 30 minute podcast is a great starting point to start understanding the issues, and more importantly, understanding some relatively straightforward 1st step you can take in starting to reduce your exposure.

https://www.youtube.com/watch?v=Gg6151sABPk

USING VOICE TYPING TECHNOLOGY TO MINIMIZE REPETITIVE INJURIES

It's another 1 of those overdue blogs that I've been meaning to write for a few months now. Every week I have the same conversation with patients whose seemingly never recovering neck shoulder and upper extremity injury is caused by excessive use of typing and mousing on the computer, up to 10 hours a day, 5 – 6 days a week. Ergonomics, although highly needed to make sure the patient's keyboard mouse and screen are correctly place, cannot fully resolve the basic problem: the human body simply not engineered to have this kind a repetitive continuous static loading in front of our computers and tablets.

The urgency of this blog really hit me earlier today. As many of you know, my only living relative left lives overseas, and is well into his 80s. Being able to communicate on a regular basis is really crucial in our relationship and I had sadly noticed recently how little messages I was receiving beyond our weekly video call. A few days ago I found out the rather simple reason: hand tremors. They have been getting worse to the point of making it difficult to type anything on the computer or on a widescreen smart phone. Like many people in his generation, albeit more tech savvy at some point than some, he was not aware of the easily accessible new voice typing options that would allow him to bypass his physical limitations. We changed the setting on the phone to have the little microphone pop-up next to the what's up keyboard on the main screen,and voila ! The weekly litany of complaints, comments and mild badgering is back in full force ( with a few clorful French cuss words).

The democratization of readily available and free voice typing technology is moving at such a pace that you should take this blog information with a grain of salt - it could have changed a little bit even in a few weeks - but I want you to get away with one concept: it's pretty ridiculous to continue killing your body keying and typing when you could use your voice and keep your neck and shoulder in a relaxed position.

Below is a sample of some of the way to activate this feature on the most common technology platforms.

First, understand that getting good voice recognition when using voice typing requires you to learn to speak in a way that is going to be recognized by technology: steady voice volume, low moderate speed, full enunciation. You basically have to talk a little bit like a robot because essentially that's what your voice typing software is and you want to talk their love language.

Next, unless you're dictating on your smart phone, in which case you want to have your mouth within about 3 or 4 inches of your phone consistently, you want to use a good microphone that has a mouth extension. Your buds don't work very well when you seriously and continuously dictating. But even the average run-of-the-mill basic dictation microphone that you can get for under $50 is going to be able to do the job. Some of them are better than others so always read user reviews of ordering online. One important aspect is their ability to maintain the Bluetooth connection, unless you using a USB dongle.

On your phone: most of the time your keyboard when it pops up will have a little voice icon on the right upper corner. You just tap it, speak, make corrections if needed after the text has typed out, shut your microphone and hit send. If your voice typing is not yet activated on your gboard, follow the following instructions : Settings > System > Languages & input > Keyboards > Voice typing

In Windows based systems (Windows 11 and later, you may be able to activated through the system settings in earlier versions), you can bring up the microphone in any part of the system by simply doing Windows key + H it will pop up in the center bottom of your screen and you can start dictating. The dictating icon shows up automatically on most all documents of the Microsoft 365 suite, such as Word documents, as you can see on the screenshot attached.

In the Google suite, you can bring up voice typing from the Tools drop-down menu, as seen in the screenshot. You can also add a browser extension for voice typing but I haven't found those to be as user-friendly and they will often ask you to upgrade to a paid subscription.

https://support.google.com/docs/answer/4492226?hl=en

Special note for people using spreadsheets: it's very different to navigate you wave and edit the spreadsheet that it is to dictate a simple text. There is a dedicated free version of an excel voice dictation software that allows heavy Excel users to learn basic commands to move to different cells, edit cells, and rearrange the spreadsheet.

https://www.speech4excel.com/en/

As you find your way around voice dictation, also understand that nowadays, we use our mouse quite a bit. Learning the list of commands is going to help you leverage the best out of voice typing and will take a little bit of time. Myself included, as I know basic commands but I'm finding out that more commands have become available that I'm having to teach my old habitual self to use.

https://support.microsoft.com/en-us/topic/voice-access-command-list-dac0f091-87ce-454d-8d57-bef38d3d8563

Getting the nutrients out of your veggies

https://pubmed.ncbi.nlm.nih.gov/28814399/

Fat-soluble nutrients, including vitamins A, D, E, and K along with carotenoids like lutein, beta-carotene, and lycopene, require dietary fat to be absorbed, and without it, a meaningful portion of these compounds passes through the digestive system largely unused.

This latest bit of published research is interesting in that the measured 3 fat-soluble vitamin families (vitamin A, vitamin K, vitamin E) absorption rates in relationship to fat ingestion along vegetables. While there are individual differences, the results confirm what previous studies have already shown, namely that fat-soluble vitamins in particular are absorbed at a much higher rate when vegetables are combined with some amount of fat. It does not have to be a lot of fat to be exact, but the presence of fact seems to be pretty crucial for maximizing nutrient status of those essential fat-soluble vitamins. My only and strident criticism of the study is that soybean oil is by far not the oil of choice to add to your vegetable, due to its highly chemically processed nature and polyunsaturated unstable chemical structure. The good news is that most people really do prefer the taste of vegetable when there is alittle bit of added olive oil to their raw vegetables and a little bit of melted butter to their lightly cooked vegetables. This kind of nutritional research that confirms the natural inclination of our taste buds is always welcome.

Chest pain and chiropractic

The common question posed during the patient encounter: "can chiropractic help pain in XYZ area?" can be applied to many many places but today I want to explore the chest. Pain in the chest obviously raises a lot of alarms about the potential of life-threatening cardiothoracic causes, and those obviously always need to be ruled out before I will look at a patient with acute chest and chest wall pain. But in many cases, I see patient come in who have had a battery of tests and being told with glee that the do not have a heart or lung problem, but not given a lot of options to resolve their pain.

Chest and chest wall pain can come from many know musculoskeletal structures that are treated by chiropractic. Below are my most common culprits.

– Mid cervical disc herniation, spinal nerve compression. The C5 and C6 nerve roots will radiate to the upper shoulder and clavicle. Submit cervical disc herniations for example, or chronic degenerative bony spurs, can trigger a sensation of vague pain in the upper chest. In most instances, patients will have noticed a correlation to neck movement and position.

– Brachial plexus above the clavicle in the scalene muscles. A remarkably common area of problem that's escaping detection. I sometimes joke that I could pay my mortgage alone by working on the anterior cervical spine muscular injuries. The brachial plexus exits between 2 branches of the scalenes, and is remarkably susceptible to irritation or compression between the exit from the spine and the entrance into the axilla. Another 1 of my overused jokes is that there is as much cervical spine in the front as there is in the back. Carefully palpating the neurological structures as they exit the anterior cervical spine can be a bull's-eye for mysterious pain in the shoulder chest and arm. Of all the conditions affecting the chest, this particular 1 is more immediately gratifying since you can often get release of symptoms within 1 or 2 treatments and sometimes right away on the spot.

– Anterior shoulder, especially deep intrinsic protractor muscles like the pectoralis minor and the pectoralis major. The pectoralis minor in particular is known to have trigger points referring to the area underneath the breast. It's a muscle that's often shortened due to postural anterior strain. It's also a muscle that can be pretty easily injured with pushing activities, and certain athletic activities like planks when people decide to become weekend warriors or for the 1st 2 weeks of their New Year's resolution after prolonged couch potato status.

– The costochondral junction: slightly lateral to the breastbone/sternum, the junction of the anterior ribs to the central sternum is through a complex cartilage called the costochondral cartilage. It can get inflamed from systemic inflammatory conditions, and be remarkably painful, even during normal breathing. It's also subject to trauma, especially with compressive rotational forces to the chest. It does respond pretty well to modified adjustments.

– 1 of my all-time favorite, the sternal clavicular joint. I never cease to be surprised how many times it's an issue and how much it's below everyone's radar. The junction of the distal clavicule to the breastbone is actually a fairly complicated join with the meniscal cartilage similar to your knee. The sternal clavicular joint is the last joint in the kinetic chain from the arm to the neck and is often involved in incidents of force transmitted from the arm to the body, such as catching yourself falling on your arm. I also had seen it a fair amount after motor vehicle accidents when people slam into both hands on the steering wheel. Almost as gratifying as the brachial plexus at the scalenes, attempts to respond pretty fast to manual adjustments.

The moral of the story: if you chest pain has been ruled out as not being cardiac or pulmonary in nature, it's worth a chiropractic evaluation.

CAUTION IN THE USE OF MELATONIN IN CHILDREN

I was glad to see this article because I feel that I have sometimes been the lone voice in raising concerns about the use of melatonin for routine sleep problems in children (and in adults as well). 

Melatonin, while available over the counter, is not the benign supplement that some people think it is. It is an actual short chain hormone that has profound actions on the brain and is involved in multiple delicate feedback loops. There are relatively few studies on its long-term safety use in adult and virtually none in children outside of the moderate to severe neurodivergent population like autism, where the risk tolerance may be different. 

Low dose short-term use of melatonin for special circumstances like acute situational stress or jet lag may be appropriate, but that's where I would personally draw the line. Beyond that, you run the risk of suppressing and altering feedback loops pertaining to hormone and neurotransmitter regulation in a rapidly developing pediatric brain. 

This is not to say that sleep difficulties in children should be brushed off. They can be significantly impacting a child and their parents. It's just to say that different interventions will be more effective and safer in the long-term but will require a little more detective work than simply giving a melatonin lozenge at bedtime.

https://link.springer.com/article/10.1007/s12519-025-00896-5?utm_source=klaviyo&utm_medium=email&utm_campaign=%28Friday+Email+-+Chris+Kresser+General+News%29+Chris%27s+Friday+Favorites&utm_term=World+Journal+of+Pediatrics&utm_content=World+Journal+of+Pediatrics&_kx=ZpXBDTeEF9QJhwDqQXXrImrT_HpFsBz1ZlYMbsx_Vq0.my75y6