CHRONIC PAIN, CHIROPRACTIC AND THE BRAIN, PART 4: HANDS-ON APPROACH

CHRONIC PAIN, CHIROPRACTIC AND THE BRAIN, PART 4: HANDS-ON APPROACH

In this final installment of the series on chronic pain, I want to cover some of the modifications of hands-on manual therapy that may best address the unique central nervous system dysfunction associated with chronic pain. What may work for a more immediate issue, or episodically relapsing, with more of a peripheral and less of the central nervous system involvement may really backfire in chronic pain.

Since one of the hallmarks of chronic pain is the fact that pain signal is becoming very "efficient" and amplified and multiple points along the relay from the site of injury and the periphery through the spinal cord, and the sensory cortex, including all of the other branching off to other parts of the brain, manual therapy should avoid amplifying and that efficient pain transmission any further.

A fairly natural and instinctive reflex of people with chronic pain is to "dig deep" into the areas affected. If the sensory transmission loops in the sensory cortex perception of sensory transmission are working normally, that approach is going to be successful. However if the central nervous system is hyper sensitized to any sort of pressure on the affected peripheral tissues, the result will be counterproductive, with increased C pain fiber transition lighting up the cortex and feeding into the chronic pain cycle, making it even more "efficient", likely to fire up with less pressure at the next opportunity. At that point, that approach becomes nonbeneficial.

The way to address this self perpetuating and self amplifying positive feedback loop of chronic pain is to look at sensory input that competes rather than amplifies it. There are several ways to achieve that:

– 1st, look away from the proverbial bull's-eye. It means that sometimes, you do some therapy on an area outside of the targeted chronic pain area. It makes no sense to patient but from a neurological perspective, you are giving competition to the chronically hyper sensitized area by inputting normal signal from adjacent areas into the sensory cortex, efficiently reducing the amount of chronic pain C fibers reaching the sensory cortex and eliciting a perception of pain.

– Certain sensory input do not feed into the chronic amplifying C fiber pathways: light high-frequency vibration, extremely light sensory touch and brushing, mild heat. Using those therapies on and around the affected pain producing areas can also give competition to the sensory cortex, by retraining the brain to perceive sensory input from those areas rather than pain. While we use them in the office, these are the types of therapies that should be part of a home program, including very light high-frequency vibratory home device (something as simple as a high-frequency vibrating kids toy, or a handheld massager held very lightly on the skin at a high-frequency), light sensory brushing, gentle heat from either direct pad or infrared/red light therapy.

– Position sensors, such as those in joints, sensing in which direction joint is moving and how far, are also extremely good at down regulating chronic C fiber pain transmission. This is why instinctively a lot of patients with chronic pain will continue to rock, continuously move and try to rearrange or stretch the affected area. We can leverage that from a therapeutic standpoint by having patient doing active range of motion of an affected area, with in a pain free range, frequently.

There are unique challenges to healthcare providers like chiropractors and how to manually treat an area affected by chronic pain sensitization. 32 years into this great mighty a venture of patient care, I've come to realize that in the situation, "less is more". It means that I have to be realistic that achieving your musculoskeletal structural correction will require more time, less force, more precision and specificity, and respecting the body's ability to respond to my input without triggering an amplified pain response at the level of the brain. It also means that sometimes we have to communicate what we're doing and why would doing it in the we were doing it to patients, who legitimately expect that more is going to be better in this situation. It's also important to educate patients about how they handle the area at home. Shifting them from using deep pain producing, chronic C fiber pain perpetuating therapies to themselves (such as vigorous rolling, self massaging etc.) to things that are much more gentle and down regulating of the chronic pain cycle, including light brushing and vibration therapy at home.

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

OSTEOARTHRITIS AND MYOFASCIAL PAIN SYNDROME

An increasing percentage of our population is living above 65, and often for another 2 or 3 decades. This bit of good news if you're approaching that milestone (I am!), Is that you have 2 or 3 more decades to experience and hopefully enjoy life. The bit of bad news is that you will get to live out those 3 decades in a body facing increasing wear and tear.

Osteoarthritis refers to the process by which articular cartilage starts to deteriorate, leading to loss of joint space, and a constellation of associated structural findings and symptoms: instability, spurring, loss of normal motion, chronic pain and inflammation. It should be noted that osteoarthritis is not a linear finding correlating with simply aging. Some patients are more predisposed to osteoarthritis than others because of additional mechanical factors causing accelerated wear and tear on joints of the spine and extremities (which is why chiropractic research has shown some modulation of progressive osteoarthritis in many patient receiving care, reducing unnecessary mechanical stress). Other patients experience worse osteoarthritis because of metabolic factors that have to do with our poor nutrition, lack of blood flow from inadequate physical activity, and other complications from health issues such as medications, medical treatments etc.

One aspect of the constellation of osteoarthritis related findings and symptoms that is often missed or poorly understood is the secondary chronic myofascial pain syndrome and widespread trigger points. There are complex reasons for that that have to do with the local neurology of the deteriorating joint on muscular tone and control. Patients often are frustrated about what they believe to be a completely new problem, until we sit down and explain to them the correlation between myofascial pain syndrome and osteoarthritis, as being the manifestations of one common phenomenon. But there is something unnerving about patients suddenly feeling that every muscle tendon and ligament in their body is starting to hurt.

Myofascial pain syndrome and trigger pointsin the context of osteoarthritis should be treated both concurrently for the best results. Addressing the myofascial pain alone will have little to no lasting results since there's an upstream trigger. Joint adjustments, active range of motion exercise and strengthening, information control will hugely impact the severity of the myofascial pain. Conversely, only addressing the osteoarthritis will often fail to adequately resolve the myofascial pain since it often has become a self-perpetuating condition of its own.

Myofascial interventions in patients with moderate to severe osteoarthritis does need some modifications. Levels of pressure, frequency of treatment need to be adjusted down. Qualified soft tissue therapist know how to modify the treatment plan accordingly. Other supporting treatments that have found to be very effective are dry needling, traditional acupuncture needling with caution, as well as a variety of topical intervention such as infrared therapy and counter irritant topicals

https://pubmed.ncbi.nlm.nih.gov/36943163/

Topical treatment for pain and inflammation

It's a question that comes up frequently and I realized recently that I don't have a good written resource material to direct patients to and I find myself repeating the same thing over and over in the middle of a busy day. Unlike some of my colleagues, who tend to downplay their value in an overall treatment plan, I feel that topical's can have huge benefits to direct therapeutic activity to a local local area, and can overall minimize the patient's need for more toxic oral medications.

Understand that this is a generic list, and that you will probably need to figure out with your own individual healthcare provider which 1 of these may be the best, and understand that you may need different topical treatments at different times. Also understand that while mostly safe, a few of them do have some potential contraindication related to other medications and comorbidities that you should be aware of.

Topical treatments full in different broad categories matching their mode of action: counter irritant, vasodilators, anti-inflammatory, analgesics, and some of them crossover into more than one category.

COUNTER IRRITANTS: those agents tend to create a local receptor response that competes with pain receptors, thus tricking the body in perceiving sensation rather than pain. Menthol is probably the most common one. It's found as a base in the majority of topical treatments. It's usually quite safe, short acting and reversible. There's a huge variety of products available, and ultimately it boils down to preferring water-based versus oil-based, and how much of an overlying sent or not you want to have.

VASODILATORS: those agents tend to increase local blood flow by increasing vasodilation of smaller blood vessels. The main benefit is to improve circulation to a particular area, especially in the periphery of the body. The main ingredient is capsaicin, derived from hot peppers. On the tail end of the activity, they tend to have a mild analgesic effects. The benefits are to improve blood flow to deliver soft tissue repair nutrients, especially oxygen, in areas that are having a hard time healing or are somewhat avascular because of previous trauma or general health issue with blood circulation. You have to be quite careful with them, since they can create great irritation to the skin, and they are more medical contraindications to using them, especially with peripheral vascular disease and diabetes. It comes in different potencies, and you also have to be extremely careful not to rub your eyes after applying them.

ANTI-INFLAMMATORIES: it's a relatively broad category, with many agents having a secondary anti-inflammatory effect in addition to another primary effect. The effect pathways of information in peripheral tissue. This includes both pharmacological over-the-counter substances as well as naturally occurring substances.

- salicylate and dicofenac are topical versions of pharmacological oral equivalents, which are available over-the-counter. (Aspercream or generic equivalent is the most common version). They are quite effective, have a moderate acting range, but have to be used very carefully especially if it's used consistently in the long term because it does eventually reach your bloodstream. I think there is definitely a time and a place for short-term use during acute trauma recovery, to minimize the need for oral pain medication. There are some definite contraindications, so best to check with your provider before using.

-Essential oils like frankincense: should be used in small amounts in a carrier oil because of their potency, but can be a very nice long-term alternative because in smaller doses they really quite safe.

- Arnica: increasing in popularity in the US, I grew up with Arnica as a mainstay in our pharmacy box. It's a little bit of an atypical anti-inflammatory, which is used mostly for acute trauma and contusions. It has virtually no side effects so that one is safe for just about everyone to try.

- CBD: an oil-based extract from the hemp plant, CBD alone has no psychotropic effect and is relatively easy to use in the long term quite safely. I find that CBD takes a little bit to kick in, and I think it's best used for long-term management of chronic joint or soft tissue inflammation rather than as an acute aid.

- MSM: a sulfur based compound, it has a great safety profile when used topically. It has a mild anti-inflammatory effect, but is primarily used to support chronically injured collagen, such as osteoarthritis of joints, and chronic ligamentous or tendon injuries.

ANALGESICS: it's a little bit of a difficult category to pain, since analgesics means pain reducer. The mechanism of pain can vary in different patients, so all of the above can act as analgesics in a particular patient. However technically only very few compounds are considered true analgesics and they are relatively uncommon. The most commonly available over-the-counter is a pharmacological compound called lidocaine usually applied in transdermal patches. Lidocaine is powerful, short to moderate acting, but it has a fair amount of side effects and many medications adverse interactions for a lot of people so I would use that one was a lot of caution and with the green light of your provider. There are very few nonpharmacological true analgesics, such as California Poppy.

This is not an exhaustive list, with several other less commonly used compounds such as homeopathic's, and many bundled products. But this should at least be enough of a background for patients to start asking the right questions to select the right topical for their personal use.

How frequent is spinal pain in children?

https://www.sciencedirect.com/science/article/abs/pii/S1413355524000042

I continue to listen to a series of research podcasts, catching up from 2015 and on. All I can say is that we have some amazing colleagues doing serious research and enlightening our day to day practices.

This particular piece of research caught my attention because I've been thinking about children a lot recently. We have a crop of new babies coming in to the office, the children are back in school dragging heavy backpacks and happily crashing into each other in their fall sports.

Over the last 30 years of practice I feel that at times I have been fighting an uphill battle in the area of chiropractic pediatrics, trying to convince many parents and the community at large that children do develop spinal problems fairly early, fairly frequently, and that we are currently operating by a false narrative that back pain is not something that happens to children but rather to adults, and that if a child is complaining about pain, it is usually a psychological reason behind it. Up until recently we've not really had much research data to back this up.

This brand-new study (January 2024), from Brazil, indicates that a whopping 30% of adolescents may complain of spinal pain that could be at times disabling. What's most interesting looking through the fine print of the paper is that the pain pattern is really quite similar than adults already. (Objective factors, risk factors etc.) these numbers fly in the face of our current cultural understanding of spinal pain in children, much less our healthcare intervention resources. Having had the pleasure and privilege of working with individuals from birth to natural death over 30 years, I can say without a doubt that I have been shocked by the types of finding I've seen in rather young children over the year. But ultimately, as time goes by, I see the continuum of presentation between my adult patients and the history of their 1st trauma much more clearly now. When I see the children taking tumbles on the playground, falling down the stairs, and wrestling with the siblings I realize that none of us adults could do this and still get out of bed the next day. To be fair children's neuromusculoskeletal systems are more pliable and a little more resilient than ours, but they do not magically survive some of these injuries without some potential long-term residuals that will manifest episodically into adulthood.

I am most excited about another 10 year longitudinal initiative started in Denmark, currently underway. It will start screening a very large swath of schoolchildren starting in preschool and through high school, looking at a variety of metrics from pain to motor control to balance to visual efficiency. I think were going to get a wealth of data as to how children develop pain over time and what the risk factors are in their history, as well as what early signs in their other developmental milestones may be useful to flag them for early intervention. Those little people are genuinely our most precious resource and it's time we stop writing off their back pain as just something in their heads.