There Is Much More to Pain Relief Than Painkillers
For many people, pain relief means painkillers. However, there are many more ways of obtaining pain relief, which is just as well, especially for those who suffer with chronic pain. After all, painkillers don’t always work, and they also have a number of unfortunate side effects. Opioid painkillers such as tramadol for instance, tend to inhibit deep REM sleep, the kind of sleep which is important for health in general and for managing pain in particular. NSAIDs like ibuprofen and dicolfenac taken long term are associated with a higher risk of heart disease and stroke, as well as potentially life-threatening gastro-intestinal complications, and there is also some research which suggests they slow down healing (which is not surprising if you remember that the inflammation that such drugs are inhibiting is part of the body’s natural healing process). Painkillers can also sometimes actually cause pain, as was made clear earlier this year in the new NICE guidelines for the treatment of headache. So, for reasons like these, we need to remember that there is lot more to pain relief than drugs. Anyone suffering from chronic pain, in particular, needs more than one string to their pain relieving bow.
Broadly speaking there are two different kinds of pain relief. The first kind blocks or kills the pain without doing anything to help the problem which is causing the pain; this is how painkillers work. We might call this symptomatic pain relief. Such an approach may be sufficient in the case of a minor injury which can be expected to resolve itself (although bear in mind the point made previously about NSAIDs slowing down healing.) In most cases, however, and especially in the case of chronic pain, symptomatic pain relief is no substitute for getting to the root of the problem, which is what the second type of pain relief aims to do, what we might call true pain relief. This kind of treatment aims to promote the body’s own healing responses and to resolve underlying disharmonies and tensions, so that the cause of the pain is removed, or at least attenuated.
Pain in essence is an alarm signal telling us that there is some damage to part of our body which needs attending to; maybe it simply needs protecting for a while, or maybe it needs some form of treatment. Getting into the habit of simply using painkillers to block the alarm signal is therefore a bad idea, a little like shutting down the fire alarm without finding out if there is a fire.
If we are not going to rely exclusively on painkillers for pain relief, what other options are there? Quite a few, as detailed below; some require a qualified clinician, others can be self-administered. Not all of these are suitable for everyone; it is a matter of putting together an individualised package of measures, perhaps with the help of a clinician, to create a personalised pain relief plan.
Acupuncture has been used in China and other parts of the Far East for literally millennia in the treatment of pain, and is now used extensively for that purpose all over the world, including by many conventional medical practitioners. These latter tend to use acupuncture primarily as a symptomatic painkiller without significant side effects; we might feel a bit ‘woozy’ after an acupuncture treatment, or maybe get a little bruise, but that is likely to be the sum of things side effects-wise. From this conventional point of view, acupuncture works by stimulating the release of the body’s own internal painkilling substances, such as endorphins, as well as by activating certain kinds of peripheral nerve endings which block the signals sent by pain detecting nerves at the spinal cord, so that the pain signals do not reach the brain. Acupuncture is also used by some conventional medical practitioners to treat pain caused by tight muscles; in this case treatment goes beyond symptomatic pain relief because it releases the trigger point in the muscle which is the cause of the pain (although we also need to be asking why the muscle was tight in the first place.)
Traditional Chinese acupuncture, on the other hand, focuses more on true pain relief, since it looks to find the source of the pain and resolve that. In Traditional Chinese Medicine (TCM) pain is essentially a blockage in the free flow of something called Qi; a traditional Chinese medical saying has it that “where there is no flow, there is pain.” Our clinician aims, through careful questioning and examination, to understand why the flow of the Qi is blocked. This may be a purely local blockage, or it may involve a more systemic imbalance. Acupuncture treatment then frees up the flow of the Qi and works to resolve the underlying disharmonies which are at the root of the blockage. This is a holistic approach to pain relief.
In Traditional Chinese Medicine there is a saying that ‘all pain comes from the heart’. Whilst this might look like a bit of an exaggeration, it corresponds to what conventional medicine refers to as the affective component of pain. Pain is a very complex thing. If the weather is miserable and we have just lost our job, any physical pain will probably feel worse. If the sun is shining and someone smiles at us, it may not feel so bad. Basically, our mood has a significant effect on pain, whatever the primary cause of the pain. This is the affective component of pain – ‘affective’ means influenced by or resulting from the emotions. This means in turn that doing things which help raise our mood, in particular which help us to feel more relaxed, calmer, more at peace with ourselves, can be important in pain relief.
Finding ways that work for us, ways to help us to develop calmness, peacefulness, mindfulness, are in fact very important. Pain itself can be a cause of stress – we worry about how we are going to cope, whether the pain will ever go, whether we will be able to get any sleep. Pain can get us down in an overwhelming kind of way. This leads us into what is called the pain cycle: pain creates stress, which makes the pain worse, which makes us more stressed….a truly vicious circle. Learning some simple meditation techniques or perhaps practising something like T’ai Chi or Chi Kung if that is appropriate for our condition, or maybe using some good relaxation CDs can be a vital part of our learning to break the pain cycle.
Of course, if we are in a lot of pain it may be very difficult for us to begin to relax – our instinctive response may be to tighten up to protect ourselves. In this case, we will probably need some skilled help, from a Chi Kung or meditation teacher for instance.
iii) Appropriate Exercise and Rest.
It is important to rest up for a day or two after an acute injury, so that the body can start healing itself. After that initial rest, and certainly in the case of most chronic pain conditions, exercise is crucial in promoting healing and pain relief.
Sometimes specific exercises are appropriate for a given condition, and expert advice will probably be necessary from your clinician. For instance, many cases of sciatic-type pain are caused by tightness in the muscles of the buttock, particularly the piriformis muscle. Treatments such as acupuncture and deep massage can help release this tightness, but we can help ourselves by doing exercises to relax these muscles. (Although we also need to understand why the muscles are tight in the first place and take steps to stop them tightening up again).
More generally, even light exercise such as walking is often helpful in giving pain relief. Or if our pain is exacerbated by walking, as may be case with arthritis of the knee, for instance, swimming might be a better option. From the point of view of traditional Chinese Medicine, something as simple as brisk walking promotes the flow of Qi. Since pain is ultimately Qi which is not flowing, this will help. In conventional terms, exercise increases endorphin levels; endorphins are the body’s own painkillers. By the way, laughter also increases endorphin release, and in Chinese medicine terms it releases blocked Qi, which explains the pain control regime of the American journalist Norman Cousins for whom watching Marx brothers’ movies, and having a good belly laugh, formed an important part of a pain relief programme.
So in most cases, some gentle exercise is going to contribute to pain relief, but we will need to get advice from our clinician about what is right for us. Too much of the wrong kind of exercise is going to make things worse, of course. Remember that if we overdo it we are making it more difficult for the body to heal itself. Expert advice is important, but it is also worth learning to ‘listen’ to our body. If our body needs rest, or if it needs to move, it will let us know if we pay attention. Some of us are liable to reinjure ourselves by overdoing things too quickly; others of us are more likely to be too inactive and slow down the healing process; we need to know ourselves!
Sleep is often a big issue for people in pain, especially for those who are kept awake, or woken up, by their pain. Such sleep disturbance adds insult to injury, because sleep is crucial in any healing process. In particular deep REM sleep is important in tissue recovery. Therefore, if we can, we need to make sure we can get sufficient sleep, or at least as much as possible. There is some evidence that modern lifestyles are leading to people to miss out on sleep; burning the candle at both ends is not a good idea if we are someone who is in pain. Sometimes, with certain kinds of musculoskeletal pain for instance, it may be a matter of finding a position in which we can be more or less pain free; for instance, with some kinds of low back pain, sleeping on our side with a pillow or cushion between our knees may ease any discomfort.
v) Hot and Cold
One of the questions a traditional acupuncturist will always ask us about a painful condition is how it responds to temperature changes. Does it get worse in cold weather? Is it better if we hold a hot water bottle against the area in question? If the answer to these questions is ‘yes’, then straight away we have a useful pain reducing treatment available – warmth. And we also know that we should avoid exposing the area to the cold. If on the other hand, the painful area feels hot and looks red, heat may not be such a good idea (although sometimes there might be exceptions to this, where we can fight fire with fire.) In TCM, acupuncture treatment is often accompanied by the use of moxibustion, the burning of the herb mugwort to warm acupuncture points and key areas of the body.
In the west, it is common to use ice to kill pain, especially in the case of inflammation. TCM is not hot on ice (pun intended!); one traditional Chinese doctor/martial artist is reported as saying that ‘ice is for dead people’. TCM uses other forms of treatment for inflammation, such as cupping and acupuncture. This is because whilst the ice may stop the pain in the short term, it can impair the flow of Qi through the area in the long run. If we do use ice, therefore, it is best to use it for short bursts, say 15 minutes at a time. Or we can alternate between ice and warmth.
Eating well is an important aspect of any pain management programme; and for a number of reasons. To begin with, being overweight is a big contributory factor to a number of painful conditions. For instance, if we have chronic knee or low back pain, any extra weight we are carrying increases the load on the knee or spinal joints. Losing weight is not always an easy matter, and we may need some kind of therapeutic assistance, but if we are carrying more weight than our body is ‘designed’ for, it is not surprising that we are suffering.
However, there is more to the connection between food and pain than that. TCM has a sophisticated understanding of how different foods and indeed different ways of cooking (and eating!) food impact upon our systems. For instance, if we have painful joints which are swollen and puffy, and which maybe feel worse in damp weather conditions, there are certain foodstuffs, including dairy and wheat products, which will reinforce the tendency to fluid congestion and make such pain worse – and there are certain other foods which can play a part in relieving that congestion. Thus a well-trained TCM clinician will be able to make personalised suggestions as to ways we can use food as part of a pain relief regime. This is very much a matter of finding a diet for ourselves which restores our natural balance and harmony.
Conventional medicine is also waking up to the way that diet impacts upon pain levels; in particular it is discovering how a poor diet lacking in fruit and vegetables and including too much sugar and processed foods promotes inflammation; which is to say that the body responds to such food as if it were a pathogen!
TENS stands for transcutaneous electrical nerve stimulation. It involves running a small electrical current between adhesive electrodes strategically placed at points on the skin related to the location of our pain. A pleasant tingling sensation is felt in the process. TENS machines can be purchased from major chemists and are quite safe providing we follow the manufacturer’s instructions. TENS works by blocking pain signals from the source of the pain as they enter the spinal cord, in something called the gate control theory of pain control. Basically it shuts the door, or closes the gate, on the pain message so that it does not reach the brain, and we therefore feel no pain. Like painkillers, therefore, TENS is a form of treatment that blocks pain but does nothing to address the cause of the pain, but it can be a useful method of combating pain whilst the cause is dealt with either by other forms of treatment or by the body’s own healing process.
The important thing with TENS is to position the electrodes appropriately so that they block pain signals from the right area. Our clinicians are be able to advise if necessary. There are a number of situations in which TENS should not be used, for example in the first trimester of pregnancy and if the patient has a pacemaker; click here for more details.
Massage is obviously particularly useful in the treatment of pain which has its origin in tight and knotted muscles and related tissue pathology. However, even when the initial origin of the pain is not muscular, muscle tightness may arise secondary to the problem and contribute significantly to the pain we feel. For instance, if we have osteoarthritis of the hip, it is likely that our buttock muscles will become tight and tense because of this, and sometimes this muscle tightness may cause much of the pain we feel, a fact that can be overlooked. On top of that, as mentioned before pain is inherently stressful, and stress leads us to tighten up in the shoulders and neck, in the abdomen, in many places; so a relaxing massage will nearly always be helpful in pain management.
There is a lot to be said, in fact, for the healing power of touch. We might remember our mother ‘rubbing it better’ when we fell over as a child. A physical exam by a trained clinician, even before they start using acupuncture or massage or whatever they are going to do, can be the start of the healing process. When we are in pain, of course, we need to be listened to properly by our clinician; we need to feel they understand something of what it is like for us. Maybe also we need their touch as part of this process. Our patients often comment that conventional medicine sometimes seems to marginalise this vital aspect of healing; how often does a GP put his or her hands on our lower back if we go to them complaining of low back pain? X-rays and Ultrasound scans are wonderful things, but it is a shame if they end up completely taking the place of diagnosis by touch.
Of course massage needs to be appropriate for the painful condition we have; like all forms of treatment it needs to be tailored to the individual. One person may need vigorous deep massage, another only the gentlest of touches.
Cupping is a traditional medical technique used in many different cultures across the world. It involves lowering the pressure inside a glass or plastic ‘cup’, either by using a naked flame or a simple suction device, and placing the cup on the skin. In TCM, cupping is often used alongside acupuncture to remove obstructions to the free flow of Qi, for instance on the knees or hips. The expansion of tissue under the skin where the cups are placed causes increased blood flow and drains toxins and stagnant blood, as well as stretching and releasing any rigid soft tissue. Sometimes the cups are simply left in place for several minutes, or sometimes, when used on the back for instance, they may be slid up and down to further invigorate the flow of Qi.
x) Posture and Ergonomics
Some kinds of pain can be caused, or made worse; by the way we hold and move ourselves. Repetitive strain injury, for instance, arises when damage builds up in muscles, tendons and other structures due to continued and repetitive movements such as our bodies were not evolved for. Clearly we can help alleviate such pain by either ceasing from the activity altogether, or if that is not possible, modifying the way we do it or undertaking some compensatory exercise or self-massage. For instance, using a computer mouse for several hours at a time is not something our hands, wrists, arms and shoulders were evolved to do. This can lead to tissue damage and pain. We can, however, train ourselves to use the mouse with our other hand some of the time, or perhaps invest in an ergonomic mouse. (Ergonomics is the study of the ‘fit’ between people and their work environments and involves adapting the work environment so that it does not cause problems for the worker’s health).We can take breaks from using the mouse and use the opportunity to loosen up our shoulder and elbow and maybe do some light massage on our wrist and forearm.
In general terms, we can make changes to how we position and use our body at work and at home (how do we stand when we are doing the washing up? How do we sit down to watch the telly? Ergonomics is not just about work!) so that we are not continually re-injuring ourselves, and so our body has a good chance to heal itself. We can help ourselves by bringing awareness to how we are holding, positioning and moving ourselves; indeed in some cases the pain we feel may be our body letting us know that we are habitually mistreating it. Although it might sound churlish to talk about something as unpleasant as pain having advantages, nevertheless it is true that some individuals with chronic pain problems become much more self-aware, in a number of ways, than they used to be.
xi) Topical Applications
A very traditional form of pain relief, of course, relies on creams and liniments which can be rubbed onto the affected area. Conventional applications use painkilling drugs such as NSAIDs, which are subject to some of the reservations mentioned above; in TCM, herbal applications such as Tiger Balm are used. Red Tiger Balm is made up of ingredients like camphor and menthol and mint oil; White Tiger Balm has more mint oil and is used where there is heat and inflammation.
Anyone in pain for more than a day or two, and particularly those with chronic pain conditions, need a pain relief programme incorporating some of the above, either in addition to or in place of painkillers. Working out such a programme with a qualified clinician is probably the best approach, as they will have expert advice on a number of methods such as exercise and diet.
Written by Vimalaprabha