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WDDTY WHAT DOCTORS DON’T TELL YOU Chronic pain Your guide to beating it naturally New discoveries 2 Pain: killing it safely Common conditions 7 Chronic back pain 10 Migraine misery 13 Fibromyalgia 15 Chronic fatigue syndrome 18 Irritable bowel syndrome Tested treatments 21 Healing magnets 22 Serrapeptase 24 Cetylated fatty acids 26 SCENAR 28 Exercise for a better back Your questions answered 29 Lumbago 30 Period pain 31 Endometriosis 32 Phantom-limb pain 33 Carpal tunnel syndrome 34 Ulcerative colitis 35 Osteoarthritis WWW.WDDTY.COM New discoveries Pain: killing it safely Statistics show that ...
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WDDTY WHAT DOCTORS DON’T TELL YOU Chronic pain

Your guide to beating it naturally New discoveries 2 Pain: killing it safely Common conditions 7 Chronic back pain 10 Migraine misery 13 Fibromyalgia 15 Chronic fatigue syndrome 18 Irritable bowel syndrome Tested treatments 21 Healing magnets 22 Serrapeptase 24 Cetylated fatty acids 26 SCENAR 28 Exercise for a better back Your questions answered 29 Lumbago 30 Period pain 31 Endometriosis 32 Phantom-limb pain 33 Carpal tunnel syndrome 34 Ulcerative colitis 35 Osteoarthritis

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New discoveries Pain: killing it safely Statistics show that more Opioids such as morphine, oxyco-

people than ever are done, buprenorphine and fentanyl living with chronic, have long been regarded as among the persistent pain, and the most effective drugs for the treatment usual treatments just of pain, but even these have proveduseless in many cases. In a review of aren’t working. Yet, the 15 trials of opioids for chronic non- latest research suggests a malignant pain (CNMP), the average wealth of effective reduction in pain intensity was only alternative options—from around 30 per cent, and the dropout mind–body techniques to rate was 56 per cent after two years. something as simple as Moreover, only three of eight studiesthat assessed functional disturbance vitamin D. (such as being unable to work because of pain) found any improvement with hronic pain is a devastating opioid agents (Pain, 2004; 112: 372–80). Chealth problem that affects A number of other reviews of themillions of people around use of opioids for chronic pain havethe world. In the UK alone, similarly reported only modest nearly eight million people are living evidence of efficacy with these drugs. with moderate-to-severe pain lasting What’s more, although the medical for more than six months—and the use of opioids has increased over the figures are on the rise. In his annual years, there is no evidence that this report published in March 2009, has resulted in a lower prevalence of Professor Sir Liam Donaldson, the UK chronic pain. government’s Chief Medical Officer, In Denmark, for example, the use revealed that chronic pain is two to of opioids for CNMP has risen by more three times more common now than than 600 per cent over the past two it was 40 years ago. Currently, over a decades. Yet, in a national survey, 90 third of UK households have someone sometimes no known cause at all—yet per cent of opioid users continued in pain at any given time. conventional medicine’s answer is to complain of moderate to very- Unlike acute pain, which warns us of generally the same: to treat it with severe pain compared with 46 per actual or potential harm to the body, pain-relieving drugs. cent of non-opioid users (Exp Clin chronic pain serves no useful purpose Paracetamol (acetaminophen) is Psychopharmacol, 2008; 16: 405–16). and, yet, has a major impact on thought to reduce pain by inter- Worse, in addition to being largely people’s lives. Indeed, 65 per cent of rupting or suppressing pain signals inadequate, another problem with sufferers report difficulty sleeping, and carried along the nerves, while conventional painkillers is their side- nearly 50 per cent report having opioids—which are much stronger effects (see box, page 3). Clearly, problems with social activities, walk- drugs—affect the way in which pain is these drugs are not the answer to the ing, driving or having a normal sex life. processed in the brain and spinal cord problem of pain. Depression is also common, affecting to reduce the sensation of pain. Anti- The good news for pain sufferers, about half of all chronic-pain patients. inflammatory drugs tackle pain by however, is that the failings of mod- For some sufferers, suicide appears to reducing inflammation. ern medicine have encouraged studies be the only solution. But while these drugs may work in into alternative methods for treating But it doesn’t have to be that way. theory, in practice, they’re failing to pain. Now, there’s a wide variety of New evidence suggests that chronic hit the spot. According to a study of non-drug therapies that offer new pain may simply be due to an un- UK nursing homes, cited in Sir Liam hope to sufferers. recognized nutritional deficiency or Donaldson’s annual report, most some other sort of imbalance in the residents experienced constant or The vitamin D approach body. An holistic approach that views frequent moderate-to-severe pain, So far, some of the most compelling pain in a very different way from despite the fact that 99 per cent were evidence suggests that the solution to conventional medicine may be the on pain medication. In another study chronic pain could be something as closest we’ve come to a cure. of chronic-pain patients of all ages, simple as vitamin D. over one-third reported inadequate In a nationwide UK study of nearly Conventional pain treatment pain control, and more than two- 7000 adults, scientists at the Institute Chronic pain is a complex condition thirds admitted that, at times, their of Child Health in London found a link with many different causes—and medication failed completely. between low levels of vitamin D and 2 WDDTY Chronic pain, chronic wide-spread pain (CWP). an important role for this vitamin in mia—low levels of circulating Although the findings were not pain control. Indeed, according to an calcium—which “sets in motion a significant in men, in women, CWP extensive review of the research so cascade of biochemical reactions prevalence varied according to far—published online at Pain Treat- negatively affecting bone metabolism vitamin D concentrations. Those with ment Topics (http://paintopics.org/ and health”. One of these reactions is levels of 75–99 nmol/L—the range pdf/vitamind-report.pdf)—having not an increase in parathyroid hormone deemed necessary for bone health— enough vitamin D is linked to a raft (PTH), which impairs bone mineraliz- had the lowest rates of CWP, which of painful maladies, including bone ation, causing a spongy bone matrix were just over 8 per cent. In contrast, and joint pain, muscle aches, fibro- to form. As this matrix absorbs fluid, in women with levels less than 25 myalgia, rheumatic disorders, osteo- the resultant expanding pressure nmol/L, CWP rates were nearly arthritis and other complaints. triggers pain in the tissues overlying doubled at 14.4 per cent (Ann Rheum Much of the research has focused the bones that are abundant in Dis, 2009; 68: 817–22). on chronic musculoskeletal-related sensory pain fibres. Similar results were reported last pain. Indeed, the report’s author, Dr In addition, vitamin D deficiency year in an American study. Mayo Stewart Leavitt, identified 22 clinical might contribute to pain in other Clinic researchers found a connection studies investigating vitamin D status ways. Several studies cited in Leavitt’s between inadequate vitamin D levels in patients with this sort of pain. report found that vitamin D may be and the amount of opioid medication Across these studies, an average of involved in non-musculoskeletal pain taken by patients suffering from around 70 per cent of patients with syndromes, including neuropathy, chronic pain. Those with low vitamin chronic musculoskeletal pain were migraine headaches and inflamma- D levels were taking much higher found to be deficient in vitamin D. tory autoimmune conditions such as doses of medication—nearly twice as The evidence also shows that inflammatory bowel disease. much—as those with adequate levels. supplementing with vitamin D can Whatever the mechanism involved, Moreover, the low-vitamin-D opioid dramatically improve pain. In 324 the data suggest that checking for users reported poorer physical women with chronic back pain, vitamin D deficiency—and correcting functioning and a worse overall vitamin D eased symptoms in 95 per it (see box, page 4)—may be a key perception of health (Pain Med, 2008; 9: cent—and in 100-per-cent of those factor in chronic-pain management. 979–84). with the most severe D deficiency Although these two studies aren’t (Spine [Phila Pa 1976], 2003; 28: 177–9). Mind–body techniques proof that a lack of vitamin D causes According to Leavitt, vitamin D Observing soldiers during World War chronic pain, they do contribute to a deficiency might lead to musculo- II proved that the mind plays a huge growing body of evidence suggesting skeletal pain by causing hypocalcae- part in the perception of pain. Among soldiers with equally devastating wounds, some asked for less morphine

Dangerous drug side-effects than others. Their perception of the

wound and what it meant in their lives Opioids are known to cause constipation, nausea and vomiting, sedation, appeared to be crucial. To one, the cognitive impairment and respiratory depression. Worse, patients can wound meant surviving the battle and develop a tolerance to the drug effects, resulting in physical dependence going home; to another, it meant and withdrawal symptoms on stopping the medication. Estimated addiction major surgery and a lower income, rates among patients with non-cancer-related pain range from 3 per cent to fewer activities and other negative almost 20 per cent (Drugs, 2003; 63: 17–32). consequences (Purves D et al., eds. Another class of drugs with a worrying safety profile are the non-steroidal Neuroscience, 2nd edn. Sunderland, MA: anti-inflammatory drugs, or NSAIDs, which are commonly prescribed for Sinauer Associates, 2001). arthritis, headache and other inflammatory conditions. In the US alone, Nowadays, when considering treat- some 60 million NSAID prescriptions are written each year. ment for chronic pain, it’s accepted The main concern is the risk of gastrointestinal (GI) complications such that the emotional reaction to pain is as ulceration, perforation and bleeding. Indeed, the US drugs regulator, the almost as important as the sensation Food and Drug Administration (FDA), has estimated that 2–4 per cent of itself in determining how well the the Americans who take these drugs for a year will develop one of these patient will cope. This means that complications, leading to 107,000 hospitalizations and at least 16,500 therapies that take this mind–body deaths annually among arthritis patients alone (Am J Med, 1998; 105: 31S–8S; connection into account are partic- Geriatr Nurs, 2001; 22: 118–9). ularly useful for managing pain. Recent evidence has also linked NSAIDs to serious cardiovascular One such therapy is hypnosis, a events, including heart attack, angina and transient ischaemic attacks (TIAs, technique that introduces instruc- or ‘mini-strokes’) (Am J Cardiol, 2009; 103: 1227–37; Clin Ther, 2006; 28: 1827–36). tions or suggestions to bring about Even good old aspirin—one of the less potent NSAIDs—has been changes in subjective experience, associated with major risks of bleeding such as haemorrhagic stroke, a type perception, sensation, emotion, of stroke caused by ruptured blood vessels leaking blood into the brain thoughts and behaviour. In the case (Lancet, 2009; 373: 1849–60) of chronic pain, hypnosis enables patients to control the intensity of

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the pain, to manage the pain and the Nutrients for chronic pain emotions accompanying it, and to find suitable resources to deal with it, u Vitamin D. Sunlight is the best source of this vitamin but, as most of us thereby allowing them to be involved don’t get enough of it this way, pain expert Stewart Leavitt recommends in their own treatment (Rev Med Suisse, (with the supervision of a qualified practitioner) a daily supplement of 2009; 5: 1380–2, 1384–5). 2000 IU of vitamin D3 (cholecalciferol), along with a daily multivitamin Scientific reviews—called ‘meta- that includes calcium and 400–800 IU of vitamin D. It may take up to nine analyses’, as they analyze all of the months to experience the maximum effects of this regimen. findings and assess them altogether— u Glucosamine and chrondroitin sulphate. This combination is known to have found hypnosis to be effective be effective for inflammatory conditions such as osteoarthritis of the knee for chronic pain. On combining 18 (J Rehabil Res Dev, 2007; 44: 195–222). studies of laboratory-induced and u Proteolytic enzymes, such as bromelain, have various pain-relieving patients’ pain, the findings were that properties that have proved useful in the treatment of rheumatic diseases hypnosis obtained greater pain relief (Wien Med Wochenschr, 1999; 149: 577–80). than in 75 per cent of those given u Amino acids, such as D-phenylalanine and L-tryptophan, appear to either the usual care or no treatment increase pain tolerance in animals as well as in humans (Prog Clin Biol Res, at all (Int J Clin Exp Hypn, 2000; 48: 138–53). 1985; 192: 363–70; J Psychiatr Res, 1982–1983; 17: 181–6). In yet another meta-analysis of the efficacy of hypnosis for headache, lower-back, temporomandibular joint tion that is causing the pain, and then the energy fields that are thought to (TMJ), cancer-related and sickle-cell- helps the patient to recognize when surround and penetrate the human disease pain, as well as the pain this dysfunction is occurring and to body (J Rehabil Res Dev, 2007; 44: 195–222). related to fibromyalgia, osteoarthritis correct it using various strategies. Both types of energy medicine have and disability, hypnotherapy resulted This means of getting to the root of proved to be beneficial for chronic in greater pain reduction than either the pain may be why a number of pain, but one of the most popular standard care or no treatment. The studies have found biofeedback to be therapies—which falls into the first authors concluded that “.hypnotic more effective than conventional energy-medicine category—is treatment for chronic pain results in treatments for chronic pain (J Rehabil transcutaneous electrical nerve significant reductions in perceived Res Dev, 2007; 44: 195–222). stimulation, or TENS. This technique pain that maintain for at least several Other techniques that integrate transmits electrical impulses into the months, and possibly longer” (J Rehabil the body and mind have also proved body through electrodes that are Res Dev, 2007; 44: 195–222). useful for chronic pain. Yoga and placed on or near the painful area. As well as working, a further bonus mindfulness meditation are especially Although it doesn’t address the of hypnosis is that it is almost always effective for treating chronic lower- underlying cause of pain, these a benign treatment with little risk of back pain (J Altern Complement Med, 2008; electrical impulses produce a tingling negative side-effects. Indeed, what 14: 637–44; J Pain, 2008; 9: 841–8), while sensation that reduces the pain itself. ‘side-effects’ do occur are overwhelm- guided imagery—which uses mental Indeed, numerous studies have shown ingly positive, including a greater images to imagine and ‘create’ the that TENS works for a range of sense of control over pain, greater desired physical outcome—has shown chronic-pain conditions—from overall feelings of wellbeing, and less promise in alleviating the pain of musculoskeletal pain, such as back tension, stress and anxiety (J Rehabil osteoarthritis and fibromyalgia (Fam and neck pain, to the persistent pain Res Dev, 2007; 44: 195–222). Community Health, 2008; 31: 204–12; Pain that often follows surgery (Pain, 2007; Another mind–body technique with Med, 2007; 8: 359–75). 130: 157–65; Curr Opin Anaesthesiol, 2009; Jul a good track record for pain control 9: Epub ahead of print). is biofeedback, a process of recording Energy medicine Of the other bioelectromagnetic- and feeding back real-time informa- Besides mind–body techniques, based therapies that are currently tion on how the body is functioning another drug-free approach that’s available, pulsed electromagnetic field to allow the patient to learn how to proved to be successful among pain (PEMF) generators and cranial actively control these functions. patients is the use of so-called ‘energy electrotherapy stimulation (CES) Numerous studies have established medicine’. hold particular promise for patients that biofeedback is an effective According to the US National Cen- who suffer from chronic pain. treatment for a wide range of chronic ter for Complementary and Alterna- PEMF generators—which include pain problems, including migraine tive Medicine (NCCAM), this comes in low-power, wearable devices designed and tension-type headaches, muscle- two types: the first includes bio- for virtually continuous use as well as related orofacial pain, lower-back electromagnetic-based therapies that high-power machines meant to be pain, phantom-limb pain and fibro- involve electromagnetic fields (EMFs) used several times a day—are able to myalgia. such as pulsed fields, magnetic fields help osteoarthritis sufferers, and can The technique generally works and alternating-/direct-current fields; reduce chronic migraine headache because it first identifies the patient’s while the second includes biofield activity by around 80 per cent (J own, individual physiological dysfunc- therapies that are intended to affect Rehabil Res Dev, 2007; 44: 195–222). 4 WDDTY Chronic pain, CES, which delivers a low-level research so far, as 2–3 out of 5, which bones and joints, soft tissues, and the electrical current through electrodes means that it’s ‘possibly’ to ‘probably’ circulatory and lymphatic systems. attached to the skin surface (usually effective for the treatment of chronic They can be particularly effective for on the ears), has proved to be better pain (J Rehabil Res Dev, 2007; 44: 195–222). chronic pain, as practitioners of these than a sham procedure for treating Like acupuncture, Qigong is a therapies generally tailor their fibromyalgia pain as well as the pain traditional technique for enhancing treatments to the specific needs of associated with spinal-cord injury (J the flow of qi in the body through each individual patient. Clin Rheumatol, 2001; 7: 72–8; J Rehabil Res combining movement, meditation Chiropractic manipulation—specif- Dev, 2006; 43: 461–74). and breath regulation. ically, spinal manipulation therapy Precisely how these two electrical For pain control, ‘Qi therapy’ was (SMT)—is the treatment of choice for treatments work is still not fully particularly successful in reducing many chronic back-pain patients. understood. PEMF generators appear negative psychological symptoms, Studies show that it has clinically and to increase blood flow to the areas while boosting melatonin and statistically significant benefits com- exposed to the EMFs, whereas CES is immune-system activity—at least in pared with either sham manipulations thought to bring about changes in younger subjects. Nevertheless, in a or treatments considered to be certain chemicals of the brain, study of 94 elderly patients, those ineffective or even harmful, such as including serotonin and norepineph- who received Qi therapy had less bed rest and traction (Cochrane Database rine. Both mechanisms appear to have pain—and less anxiety, depression and Syst Rev, 2004; 1: CD000447). a positive affect on pain (J Rehabil Res fatigue—compared with those given SMT has also been used in the Dev, 2007; 44: 195–222). sham therapy as a control (Complement treatment of a variety of other painful As for biofield therapies, the other Ther Med, 2003; 11: 159–64). conditions, including fibromyalgia, type of energy medicine, acupuncture In a systematic review of all carpal tunnel syndrome, migraine and is the one that is most extensively randomized clinical trials (up to dysmenorrhoea (menstrual pain), and studied. As with other biofield January 2007) assessing Qi therapy was found to be more effective than modalities, this traditional Chinese for chronic pain, Qigong produced conventional treatments in improving medical technique is based on the greater reductions in pain than did pain and disability (J Rehabil Res Dev, concept that all living things, the control treatments. Moreover, a 2007; 44: 195–222). including humans, are infused with a meta-analysis of two studies showed Massage therapy for chronic pain subtle form of energy (qi), and that a significant effect of Qi therapy also has plenty of supporting any disturbances to this energy result compared with general care for evidence. In a recent comprehensive in illness. This means that acupunc- treating chronic pain (J Pain, 2007; 8: review by the prestigious Cochrane ture treats pain and other conditions 827–31). Collaboration, massage proved to be by improving the quality, balance and superior to joint mobilization, flow of energy within the body. Manipulation-based medicine relaxation therapy, physical therapy, In fact, acupuncture appears to be Yet another approach to pain manage- acupuncture and self-care education especially effective for back pain. In ment is the use of manipulative and for the treatment of lower-back pain. a meta-analysis of 33 randomized, body-based techniques such as chiro- What’s more, the beneficial effects controlled trials, acupuncture was practic and massage therapy. These lasted for at least a year beyond the superior to sham acupuncture for methods focus on physiological end of the treatment (Cochrane Database relieving chronic lower-back pain. structures and systems, including the Syst Rev, 2008; 4: CD001929). However, one drawback is that the study was only looking at short-term results (Ann Intern Med, 2005; 142: 651–63). Herbal painkillers More recent studies suggest that acupuncture might also help those u Capsaicin, an extract of cayenne pepper, can ease many types of who have shoulder pain, headaches, chronic pain when regularly applied to the skin. In one study, a capsaicin TMJ dysfunction, fibromyalgia, osteo- plaster was significantly better than a placebo in patients with chronic arthritis of the knee, tennis/golfer’s back pain (Arzneimittelforschung, 2001; 51: 896–903). elbow and other painful conditions (J u Ginger appears to have both analgesic and anti-inflammatory effects Altern Complement Med, 2009; 15: 613–8; (J Ethnopharmacol, 2005; 96: 207–10). In a trial of women with menstrual pain, MMW Fortschr Med, 2007; 149: 37–9). ginger supplements were just as effective as the NSAIDs mefenamic acid Nevertheless, more studies are needed and ibuprofen in providing relief (J Altern Complement Med, 2009; Feb 13: Epub to determine whether the pain relief ahead of print). with acupuncture is long-lasting u Devil’s claw (Harpagophytum procumbens) may be useful against (Anesth Analg, 2008; 106: 611–21). arthritic and lower-back pain. According to one study, for the herb to be Other biofield therapies, including effective, the daily dose needs to provide at least 50 mg of the active Qigong, Reiki and Therapeutic Touch, ingredient harpagoside (Orthopade, 2004; 33: 804–8). have been used to treat pain. The u Willow bark (Salix alba), which is chemically related to aspirin, appears evidence for Qigong is the most to provide acute, short-term relief for patients with lower-back pain encouraging, with one study rating (Cochrane Database Syst Rev, 2006; 2: CD004504). its level of efficacy, on the basis of the

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In another study of patients with serotonin, which is thought to currently available for chronic pain, mixed chronic pain, massage therapy modulate the body’s pain-control and the search for alternative options was at least as effective as the system. Another possibility is that continues to flourish. A major step standard medical care. However, after massage promotes deep, restorative forward is the realization that pain is three months, only those in the sleep, which reduces levels of sub- not always the result of a mechanical massage group still showed significant stance P, a brain chemical associated breakdown or traumatic physical improvement (J Altern Complement Med, with pain (J Rehabil Res Dev, 2007; 44: injury, but may be the result of a bio- 2003; 9: 837–46). 195–222). chemical or energetic imbalance—or Interestingly, massage appears to even an emotional one. If so, then the have an impact on the brain that may Pain: a new paradigm cure for chronic pain is unlikely to be explain its painkilling effects. It may These therapies are merely a selection found by popping the usual pills. be that massage raises levels of of the vast array of non-drug options Joanna Evans 6 WDDTY Chronic pain,

Common conditions Chronic back pain There is now a multitude body mass index (BMI) was

of effective drug-free significantly associated with an alternative treatments for increased preva-lence of LBP, particularly in women (Spine [Phila Pa this common, often 1976], 2010; 35: 764–8). disabling, condition u Stop smoking. Cigarette-smoking appears to be linked to LBP, ore than 80 per cent of us according to several studies. In a Mwill suffer from disabling recent meta-analysis that pooledlow back pain (LBP) at the results of 40 separate studies,some point in our lives. current smokers were 80-per-cent Although most of us will recover more likely to suffer from chronic within a few months, some will go on LBP and also had more than twice to develop chronic LBP—pain that the risk of disabling LBP (Am J Med, persists for three months or longer. In 2010; 123: 87.e7–35). most cases, it’s not possible to identify More worrying, exposure to a specific cause of the pain, and the secondhand smoke during treatment usually involves course after childhood can increase the risk of course of dangerous drugs (BMC developing back problems later in Musculoskelet Disord, 2010; 11: 163). life. Researchers have postulated Happily, there’s a vast array of that this might be because tobacco complementary and alternative smoke has detrimental effects on therapies now available for chronic the developing spine (Eur J Public spongy bone matrix to form. This LBP, many of which are supported by Health, 2004; 14: 296–300). leads to fluid absorption, resulting good evidence of success (see box, u Get enough sunshine. Mounting in an expansive pressure that trig- page 8). But perhaps the best way to research suggests that a lack of gers the abundant pain fibres in the tackle LBP is to prevent it from vitamin D, produced naturally by tissues overlying the bones. becoming a problem in the first place. the body in response to sunlight, This suggests that anyone who could be contributing to chronic has non-specific LBP should be

Preventing back pain musculoskeletal pain, including tested for vitamin D deficiency.

According to the latest evidence, there LBP (BMJ, 2005; 331: 109). u Manage stress. Psychological fac- are a number of ways you can reduce In one study of patients with tors such as stress and depression your risk of LBP. chronic, non-specific (no obvious are also thought to play a role in u Stay active. Lower levels of physical cause) LBP attending spinal and LBP. In one UK study that followed activity are linked to LBP (Aust J internal medicine clinics in Saudi 4500 adults (aged 18 to 75 years) Physiother, 2009; 55: 53–8), while regular Arabia for six years, 83 per cent for 12 months, the likelihood of exercise appears to prevent the were found to have abnormally low having a new episode of LBP was condition (Joint Bone Spine, 2008; 75: levels of vitamin D. After supple- greater among those who scored in 533–9). This makes sense as having menting with the vitamin, however, the upper-third of a questionnaire strong, flexible muscles are symptomatic clinical improvement for psychological distress (Spine essential for a healthy back. was seen in all those who had low [Phila Pa 1976], 1995; 20: 2731–7). In However, overly strenuous or initial concentrations of the vitamin another study, psychological dis- excessive exercise can be bad for (Spine [Phila Pa 1976], 2003; 28: 177–9). tress was a better predictor of back the back (Pain, 2009; 143: 21–5), so be According to Dr Stewart Leavitt, pain than the standard diagnostic sure to choose the right form of a member of the American techniques (Spine [Phila Pa 1976], 2004; activity for you. Academy of Pain Management and 29: 1112–7). Psychological factors are According to Wisconsin-based editor-in-chief of the online journal also implicated in the transition spine expert Dr Peter Ullrich, an Pain Treatment Topics, vitamin D from acute to chronic LBP (Spine ideal back workout includes a deficiency can cause musculoskele- [Phila Pa 1976], 2002; 27: E109–20). combination of stretching, streng- tal pain by causing hypocalcae- u Avoid poor posture. In particular, thening and low-impact aerobic mia—abnormally low levels of sitting in a chair for long periods conditioning. circulating calcium—which “sets in of time creates imbalances in the u Watch your weight. Being over- motion a cascade of biochemical musculoskeletal system that can weight places an additional burden reactions negatively affecting bone increase the risk of pain and injury. on the spine and strain on the back metabolism and health”. One of According to one study, workers muscles. In one study of more than these reactions is increased para- who sit for more than half a day in 60,000 men and women, a high thyroid hormone (PTH), causing a awkward postures are significantly

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Common conditions Drug-free treatment for back pain

u Exercise. Not just good for preventing back pain, either back school or individual physiotherapy (Clin exercise can treat it, too. One review concluded that Rehabil, 2010; 24: 26–36). exercise can reduce pain and improve physical u Biofeedback. This mind–body technique was found to function in chronic or recurrent LBP (Joint Bone Spine, be more effective than behavioural therapy or 2008; 75: 533–9). The most effective strategy appears to conservative medical treatment for sufferers of chronic be an individually designed exercise programme that back pain. The researchers also reported that includes stretching and strengthening, and is carried biofeedback was the only method to significantly out under limited supervision—for example, home- reduce pain over the two-year follow-up (J Consult Clin based exercises with regular follow-ups by a therapist Psychol, 1993; 61: 653–8). (Ann Intern Med, 2005; 142: 776–85). However, group u Hypnotherapy. Numerous studies show that hypnosis exercise can also help, especially if you join a class is an effective treatment for a range of chronic pain that focuses on the mind as well as the body. conditions. In a small preliminary study to assess its v Yoga. A two-year study showed that an Iyengar yoga success in chronic LBP, a brief, four-session class twice a week can improve functional disability, standardized self-hypnosis protocol, combined with pain intensity and depression in adults with chronic psychoeducation, dramatically reduced pain intensity LBP, and also allowed the use of less pain medication and pain interference (Int J Clin Exp Hypn, 2010; 58: 53–68). (Spine [Phila Pa 1976], 2009; 34: 2066–76). u Supplements. In addition to a balanced diet, a number v Pilates Method. Increasingly used to treat chronic of supplements may be useful for beating back pain. LBP, this form of exercise can be effective for reducing v Vitamin D could be the key to curing LBP if you are pain and improving general physical function (J Bodyw deficient in this nutrient (see main story). In a study Mov Ther, 2008; 12: 364–70). of 360 patients with chronic LBP, vitamin D eased v Qigong. The main posture used in this form of symptoms in virtually all those with the most severe D exercise is similar to the posture recommended by deficiency (Spine [Phila Pa 1976], 2003; 28: 177–9). Although healthcare professionals dealing with back pain (Wien sunshine is our best source of this vitamin, most of us Med Wochenschr, 2004; 154: 564–7). Also, when used as an don't get enough of it that way. Pain expert Stewart adjunct to drug treatment, this meditative form of Leavitt recommends (with the supervision of a qualified movement and breathing techniques can successfully practitioner) a daily supplement of 2000 IU of vitamin relieve chronic pain (Am J Chin Med, 2010; 38: 695–703). D3 (cholecalciferol), along with a daily multivitamin u Acupuncture. In one major review, acupuncture was that includes calcium and 400–800 IU of vitamin D. Be found to be superior to the usual care for treating patient, as it may take up to nine months to experience chronic LBP, thereby justifying the recent recognition the maximum effects of this regimen. of this traditional Chinese medicine technique asavB-complex vitamins may also help. A combination therapeutic option for LBP by the UK’s National of vitamins B1, B6 and B12, taken twice a day at Institute for Health and Clinical Excellence (NICE) (Ann 50 mg, 50 mg and 1 mg, respectively, together with the R Coll Surg Engl, 2010 Jun 7; Epub ahead of print). popular non-steroidal anti-inflammatory drug (NSAID) u Massage. Several studies suggest that therapeutic diclofenac (50 mg twice daily), was better at relieving massage is useful against chronic LBP, especially when back pain than the NSAID alone (Curr Med Res Opin, 2009; combined with exercise and patients’ self-care 25: 2589–99). education (Spine [Phila Pa 1976], 2009; 34: 1669–84). In one v Proteolytic enzymes, such as trypsin and serra- trial, the benefits of massage were still evident 9–10 peptase, may be useful as they are known to have anti- months after the therapy had ended (Trials, 2009; 10: 96). inflammatory properties (Indian J Pharm Sci, 2008; 70: u Alexander Technique. This discipline, which 114–7). emphasizes the self-perception of body movement, u Herbs. The following may help to relieve back pain. was found to be more effective than conventional care v Capsaicin, found in all hot peppers, can ease many or massage as a treatment for chronic or recurrent types of chronic pain when applied regularly to the back pain. What’s more, just six lessons followed by skin. In one study, a capsaicin plaster was significantly prescribed exercises were nearly as successful as 24 better than a placebo in patients with chronic back pain lessons of Alexander Technique on its own (Br J Sports (Arzneimittelforschung, 2001; 51: 896–903). Med, 2008; 42: 965–8). v Devil's claw (Harpagophytum procumbens) is u Spinal manipulation. Performed by chiropractors as effective for LBP when the daily dose provides at least well as some osteopaths and physical therapists, 50 mg of the active ingredient harpagoside. One trial spinal manipulation was recently pitted against back found it to be just as effective as the NSAID rofecoxib school (consisting of group exercise and education) (Spine [Phila Pa 1976], 2007; 32: 82–92). and individual physiotherapy (exercise, passive v White willow bark (Salix alba) is chemically related to mobilization and soft-tissue therapy) for the treatment aspirin and appears to provide short-term relief of LBP. of chronic LBP. The results showed that spinal Studies used daily doses standardized to 120 mg or manipulation provided better short- and long-term 240 mg of salicin, which has anti-inflammatory actions functional improvements, and more pain relief, than (Spine [Phila Pa 1976], 2007; 32: 82–92). 8 WDDTY Chronic pain, more likely to suffer from LBP (Eur twisting simultaneously. an adult (Arch Pediatr Adolesc Med, 2009; Spine J, 2007; 16: 283–98). (See WDDTY u Treat childhood back pain. 163: 65–71). It is vital, therefore, that vol 20 no 3 for tips on keeping a Contrary to popular belief, non- the condition, when it arises, be healthy back while sitting.) specific LBP is a serious problem dealt with promptly. Poor lifting technique can also among children and teenagers. The possible causes of childhood be the cause of back pain. You Indeed, a review of the relevant LBP include intensive sports should always push, rather than studies suggests that rates are activities and carrying a too-heavy pull, when you need to move heavy almost as high as in adults (Ugeskr backpack, as well as the factors objects and, if you have to lift, let Laeger, 2002; 164: 755–8). mentioned above (Rev Chir Orthop your legs do the work by holding the There are also clear correlations Reparatrice Appar Mot, 2004; 90: 207–14). load close to your body, keeping between experiencing LBP as a For backpack safety tips, see your back straight and bending only child/adolescent and suffering from http://orthoinfo.aaos.org/topic.cf at the knees. Avoid lifting and LBP—especially chronic LBP—as m?topic= A00043. Joanna Evans

WDDTY Chronic pain 9

,

Common conditions Migraine misery:

triggers and treatments

If you suffer from these When four patients with migraine and

severe chronic headaches, CD were put on a gluten-free diet for it’s useful to know that six months, one patient subsequently there’s a wide range of safe had no migraine attacks, while the alternative treatments you other three experienced improvements can take in the frequency, duration and intensity of their migraines (Am J Gastroenterol, ore than just a headache, 2003; 98: 625–9). Mmigraine is a chronic Other types of anti-allergy diets havecondition that can have a also proved effective. In a double-blindhuge impact on people’s controlled trial of 88 children with lives. In fact, the World Health severe, frequent migraines, an elim- Organization has rated migraine ination diet led to full recovery in 93 amongst the top-20 most-disabling per cent of them. Their symptoms chronic lifetime conditions. recurred when the suspected foods Besides a severe headache, sufferers were reintroduced into their diets may experience a range of other (Lancet, 1983; 2: 865–9). symptoms that include nausea, u Sleep problems. Several studies have vomiting, abdominal pain, and an found an association between sleep increased sensitivity to light and noise. headaches. These can vary from person patterns and migraine. In a recent What’s more, recent evidence suggests to person and, in most cases, the Norwegian study, severe sleep that people with migraine have a sufferer is responding to multiple disturbances were five times more higher risk of stroke, particularly those triggers (Aust Fam Physician, 2005; 34: common among migraine sufferers who suffer from migraine with aura— 647–51). than headache-free individuals (J sensory, motor or visual disturbances Headache Pain, 2010; 11: 197–206). Another that can precede or accompany the Migraine triggers study found that overnight headaches, headache. Smoking, oral contraceptive u Food allergies/sensitivities. One or headaches first thing in the use and being a woman can increase factor known to bring on migraines— morning, reflected a sleep disturbance the risk even further (Neurol Sci, 2010; 31 particularly in children and in 55 per cent of patients. Treatment Suppl 1: S127–8). teenagers—is food. Usually, it’s the of the sleep disorder varied, but the Migraine is thought to occur when chemicals within foods that are results showed an improvement in the blood vessels in the brain constrict thought to be the culprit. Chemicals headache symptoms in 100 per cent of and then suddenly widen. But precisely such as tyramine (found in cheese), the participants, and complete resolu- what brings about this pattern of phenylethylamine (found in tion in 65 per cent of cases (Aust Fam vascular constriction and relaxation chocolate), tyrosine, monosodium Physician, 2005; 34: 647–51). remains a mystery. glutamate (MSG), aspartame, caffeine, u Infection. Helicobacter pylori (the Doctors usually blame it on heredity, sulphites, nitrates (found in processed microorganism that causes peptic and treat the condition with prescrip- meats) and histamine (found in wine ulcers) infection can predispose some tion drugs such as prochlorperazine, and beer) appear to trigger the people to migraine. In one trial, 40 per sumatriptan and ergotamine. But condition by altering the physiological cent of migraine sufferers had H. pylori these agents do nothing to cure the processes associated with migraine infection, and the intensity, duration condition and, worse, come with a attacks (Pediatr Neurol, 2003; 28: 9–15). and frequency of attacks of migraine myriad of side-effects. Some can even A study of 577 migraine sufferers were significantly reduced in all cause rebound headaches—that is, found that sensitivity to cheese, participants in whom the bacteria were headaches brought on by the chocolate, red wine and beer had the eradicated (Hepatogastroenterology, 1998; medication itself. most clear-cut associations with 45: 765–70). More recently, researchers Sufferers stand a much better attacks (Headache, 1995; 35: 355–7). discovered that H. pylori infection is chance of long-term relief if they try There’s also some evidence that most common in people whose to work out what’s causing their gluten sensitivity may play a role in migraines are not triggered by hor- migraines in the first place. migraines. Indeed, it appears that monal fluctuations (such as during Although it’s not clear why some migraine is a common feature in menstruation) and in those without a people have migraines and others patients with coeliac disease (CD) (Mov family history of migraine (J Headache don’t, studies have identified a number Disord, 2009; 24: 2358–62), and one study Pain, 2007; 8: 329–33). of factors that can precipitate such found that a gluten-free diet can help. u Magnesium deficiency. Compared 10 WDDTY Chronic pain, with non-sufferers, people with migraines have lower blood and brain Herbal helpers levels of magnesium. However, taking around 600 mg/day was found to u Feverfew (Tanacetum parthenium) is a popular herbal remedy for significantly reduce the frequency of preventing migraine. Trials show that remedies standardized to around migraine attacks (Altern Med Rev, 1999; 4: 250 mcg of parthenolide can reduce the severity, duration and frequency 86–95). But lower doses of magnesium of migraines (Phytother Res, 1997; 11: 508–11). When using feverfew, be can also be effective. Another study patient, as it can take four to six weeks to see results. found that just 200 mg/day could u Butterbur (Petasites hybridus) is another effective migraine reduce the frequency of migraines in preventative. In one study, just 50 mg/day (standardized extract) for 12 80 per cent of those treated (Headache, weeks significantly reduced the frequency of migraines compared with 1990; 30: 168). It’s thought that magnes- placebo—with no adverse effects (Altern Med Rev, 2001; 6: 303–10). However, ium plays a role by counteracting the butterbur contains alkaloids that are toxic to the liver, so be sure to sudden contraction of blood vessels, choose alkaloid-free formulations. inhibiting platelet aggregation and u Ginger (Zingiber officinale) may help against migraine—at least stabilizing cell membranes—all of according to anecdotal evidence (J Ethnopharmacol, 1990; 29: 267–73). which are involved in migraine. Clinical trials are lacking, but an observational study suggests that u Stress. This is the factor listed most 500–600 mg/day of dried ginger can relieve migraine attacks as well as often by migraine sufferers as a trigger reduce their frequency and severity (Altern Med Rev, 1999; 4: 86–95). for their attacks. There’s also evidence u Ginkgo biloba inhibits the action of what is known as ‘platelet-activating that stress may even help to initiate factor’, an agent that is believed to contribute to migraine headaches. migraine in those predisposed to the Indeed, two small trials suggest that Ginkgo extract may have benefits disorder and that migraine attacks for migraine patients. The recommended dosage, standardized to 24-per- themselves may be a stressor, thus cent Ginkgo heterosides (its active ingredient), is 40 mg three times a day leading to a vicious cycle of chronic (Altern Med Rev, 1999; 4: 86–95). migraines. This suggests that stress- reduction techniques—such as medita- tion, yoga or regular massage—or even natural ways to treat migraine. cent had reduced nausea and vomiting a relaxing hobby may help to prevent u Supplements. The following nutri- (Cephalalgia, 1997; 17: 127–30). In contrast, and manage migraines (Headache, 2009; tional supplements may be beneficial a randomized double-blind placebo- 49:1378–86). for migraine. controlled trial—considered the ‘gold u Environment. Bright sunlight, flick- v Riboflavin (vitamin B2). A German standard’ for scientific evaluation— ering lights, air quality and odours are study found that supplementing with found no significant differences known to trigger migraines (Headache, 400 mg of riboflavin reduced the between treatment with omega-3 2009; 49: 941–52). Moreover, headache is number of migraine attacks by half, supplements and placebo. However, the a common symptom of ‘sick building although once an attack had occurred, placebo was olive oil, which is itself a syndrome’ (SBS), a condition thought the vitamin had no effect on either its source of beneficial PUFAs (J Adolesc to result from factors such as volatile severity or duration (Eur J Neurol, 2004; Health, 2002; 31: 154–61). organic compounds (found in paint, 11: 475–7). Similar results have been v 5-Hydroxytryptophan (5-HTP) can lacquer, plastic and glue), moulds, reported in earlier studies (Neurology, be just as effective as two commonly electromagnetic radiation, lighting, 1998; 50: 466–70). Riboflavin is generally used migraine drugs—propranolol and noise, air conditioning, excessive safe, although some people taking high methysergide (Schweiz Med Wochenschr, heating and poor ventilation. doses may develop diarrhoea. 1991; 121: 1585–90; Eur Neurol, 1986; 25: According to one review, SBS may v Coenzyme Q10. A significant propor- 327–9). In general, dosages of 400–600 indeed be a plausible explanation for tion of migraine sufferers may be mg/day are taken. chronic headache in some patients deficient in this vitamin-like antioxi- u Manual therapies. According to a (Aust Fam Physician, 2005; 34: 647–51). dant (Headache, 2007; 47: 73–80). Placebo- review of the scientific literature, controlled trials are lacking, but 150 spinal manipulation/mobilization is

Alternative treatments mg/day of CoQ10 may cut migraine effective for migraine (Chiropr Osteopat,

A variety of other factors—ranging frequency by more than 50 per cent— 2010; 18: 3). One study found that spinal from drugs to hormones to without any side-effects (Cephalalgia, manipulation was on par with drugs dehydration—can bring on migraines, 2002; 22: 137–41). for reducing migraine suffering—and so the best course of action is to keep v Polyunsaturated fatty acids (PUFAs) had fewer side-effects (J Manipulative a headache diary to help to determine may also be useful. When 129 migraine Physiol Ther, 1998; 21: 511–9). your potential triggers. Addressing sufferers were given gamma-linolenic u Transcranial magnetic stimulation these triggers—with the help of an acid (an omega-6 PUFA) and alpha- (TMS). This non-invasive technique, experienced practitioner—may reduce linolenic acid (an omega-3 PUFA), 86 which uses a fluctuating magnetic field the frequency of attacks or even per cent saw reductions in the severity, to stimulate neurons in the brain, eradicate the problem entirely. How- frequency and duration of their shows promise as a migraine treatment ever, if this approach doesn’t work, migraine attacks, 22 per cent became and preventative. Indeed, a portable there are a number of tried-and-tested migraine-free, and more than 90 per device called Neuralieve was found to

WDDTY Chronic pain 11

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Common conditions

be significantly better than placebo at and better quality of life (Headache, 2009; internal physiological states. In fact, alleviating migraine attacks (Lancet 49: 563–70). numerous studies have shown that Neurol, 2010; 9: 373–80). u Acupuncture. This traditional biofeedback is effective for reducing u Exercise. Physical activity has been Chinese technique can treat a range of the frequency and severity of head- reported to trigger headaches in some different sorts of headaches, including aches. However, such treatment can people, yet recent evidence also migraine. According to a review by the be expensive and time-consuming (Pain suggests that exercise may be bene- Cochrane Collaboration, acupuncture Physician, 2009; 12: 1005–11). ficial for migraines. When Swedish is “at least as effective as, or possibly u Homeopathy. A two-year study researchers studied 26 patients at a more effective than, prophylactic drug carried out in Germany suggests that local headache clinic for 12 weeks, they treatment, and has fewer adverse homeopathy may be useful against found that regular exercise (indoor effects” (Cochrane Database Syst Rev, 2009; migraine (J Altern Complement Med, 2010; cycling three times a week) led to 1: CD001218). 16: 347–55). A qualified practitioner will significant improvements, including u Biofeedback. This technique uses be able to prescribe personalized fewer migraine attacks, less intense special machines to feed back treatment. symptoms and less use of medicines, information related to your specific Joanna Evans 12 WDDTY Chronic pain,

Fibromyalgia:

mind and body techniques that help and support), the LPA groupreported improved physical function and reduced pain—and these results

Eight times more women were statistically significant (Arthritis

than men develop Res Ther, 2010; 12: R55). fibromyalgia. Although As Kevin Fontaine, lead author of the study, stated, “The nature of painkillers are the usual fibromyalgia's symptoms, the body treatment, exercise may be pain and fatigue, make it hard for a safe and effective people with this malady to alternative. participate in traditional exercise. We’ve shown that LPA can help them to get at least a little more physically robably the last thing you active, and that this seems to help Pfeel like doing. But the improve their symptoms.”evidence is stacking up to However, a follow-up study thatshow that keeping active tracked the participants for 12 might be the best way to combat this months suggests that the effects of painful chronic condition. LPA are rather short-lived. Although Several studies published over the the LPA group reported greater last few years have found that regular perceived improvement at six and at physical activity—even just 12 months, they no longer differed walking—may help alleviate the from the controls in terms of pain, devastating symptoms of high-intensity exercise. physical activity, body point fibromyalgia, which include wide- “Nordic walking .offers patients tenderness, fatigue and depression (J spread pain, fatigue, disturbed sleep, a safe and effective means of Clin Rheumatol, 2011; 17: 64–8). stiffness, reduced physical regaining functionality and physical The researchers noted that functionality and depression. fitness,” the study authors concluded activity levels declined over the In one of the latest studies, (Arthritis Res Ther, 2011; 13: 103). course of the study, suggesting published in February 2011 in an Another study—published in the that the participants had international peer-reviewed journal, same international journal, but in difficulty adhering to the LPA Nordic walking—a fitness technique 2010—demonstrated that even short recommendations. that involves walking with specially bursts of physical activity, such as designed poles—was revealed to gardening or housework, can be Mind–body techniques improve the physical capacity of beneficial for fibromyalgia sufferers. Another type of activity that may women with fibromyalgia. In this report, researchers at John help fibromyalgia sufferers is exercise A total of 58 women completed Hopkins University and the that involves the mind as well as the the study, which compared moderate- University of Michigan in the US body. to-high-intensity Nordic walking investigated the effects of 30 Yoga, for example, relieved a (twice a week for 15 weeks) with minutes of lifestyle physical activity variety of fibromyalgia symptoms, supervised, low-intensity walking (as (LPA), five to seven days a week, on including pain, fatigue and the control condition). The results physical functionality, pain and other depression. In this study, 53 women showed that both groups enjoyed measures of disability in 84 relatively were randomized to receive either an “clinically meaningful reductions in inactive fibromyalgia patients. eight-week yoga programme pain and fatigue”. However, LPA involves doing moderate- (involving gentle poses, meditation, compared with the control group, intensity physical activities (intense breathing exercises and group the Nordic walkers experienced enough to cause heavy breathing, but discussions) or standard care. The significant fitness gains and had not to the extent that you can’t hold results with yoga were clinically significantly improved scores onaaconversation) based around significant: pain was reduced by an fibromyalgia-specific questionnaire everyday life, such as taking the average of 24 per cent, fatigue by 30 assessing physical function. stairs instead of the lift or vacuuming per cent and depression by 42 per What’s more, Nordic walking did the house. cent (Pain, 2010; 151: 530–9). not trigger any flareups of After 12 weeks, the findings Crucially, participants showed a fibromyalgia symptoms, which can showed that, compared with controls strong commitment to the yoga. happen with some other forms of (who were only given information “Attendance at the classes was good

WDDTY Chronic pain 13

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Common conditions

as was most participants’ willingness to practice yoga while at home,” said Other approaches study author James Carson. However, further research is needed to see if u Try TCM.According to a recent review,Traditional Chinese Medicine (TCM) appears yoga is an effective therapy in the to be effective against fibromyalgia. Studies show that acupuncture, Chinese herbs, and long term. a combination of acupuncture and cupping are more successful at reducing pain than Another promising mind–body are conventional drug treatments (J Altern Complement Med, 2010; 16: 397–409). technique is tai chi, which combines u Give homeopathy a go. In a double-blind, randomized controlled trial (RCT, meditation with slow, gentle, considered the ‘gold standard’ for scientific evaluation), individualized homeopathy graceful movements, as well as deep proved to be “significantly better than placebo in lessening tender point pain and breathing and relaxation. improving the quality of life and global health of persons with fibromyalgia” (Rheumatology In this trial, 66 fibromyalgia [Oxford], 2004; 43: 577–82). patients were assigned to either tai More recently, a review of the findings of RCTs so far revealed that homeopathy is chi classes (one-hour sessions twice a consistently better than a placebo at alleviating the symptoms of fibromyalgia. However, week for 12 weeks) or a control the researchers noted that more rigorous trials are needed (Clin Rheumatol, 2010; 29: intervention of wellness education 457–64). and stretching. At the end of the u Consider massage. A particular technique called ‘myofascial release therapy’ was study, the tai chi group showed found to improve pain,quality of sleep,anxiety levels and quality of life in a 20-week RCT clinically significant improvements study of 74 fibromyalgia patients (Evid Based Complement Alternat Med, 2011; 2011: 561753). in symptoms, as measured by the u Go vegan. A vegan diet—which includes no animal products—might be helpful for Fibromyalgia Impact Questionnaire. fibromyalgia, according to a study of 33 fibromyalgia patients who were split into two In particular, tai chi was associated groups—one following a strict, low-salt vegan diet consisting of only raw foods, and one with reduced pain and depression, that continued with an omnivorous diet. After three months, the vegan dieters saw and better sleep and quality of life. significant improvements in their overall health, with less pain and stiffness, too (Scand J No adverse effects were reported and Rheumatol, 2000; 29: 308–13). the benefits were sustained for 24 However, these beneficial effects could simply be down to the fact that the weeks (N Engl J Med, 2010; 363: 743–54). participants lost weight—most were overweight at the beginning of the study, and But if faster-paced exercise is shifting to a vegan diet caused significant reductions in their body mass index (BMI).As preferred, it may be worthwhile several studies have found a link between obesity and fibromyalgia (J Pain, 2010; 11: combining your favourite aerobic 1329–37), it may perhaps be that the weight loss rather than the vegan diet per se was exercise with simple relaxation responsible for the improvements. techniques such as deep breathing u Eliminate harmful food additives. There is evidence to suggest that the artificial and visualization (adding these to sweetener aspartame and the flavour enhancer monosodium glutamate (MSG)—both the end of your workout). In a study known to be ‘excitotoxins’—may be involved in fibromyalgia. One study describes from Spain, fibromyalgia patients four women with fibromyalgia who saw complete or nearly complete resolution of who participated in an aerobic their symptoms within months of eliminating MSG or MSG plus aspartame from exercise programme combined with their diet. More important, symptoms recurred whenever they ingested the progressive relaxation techniques chemicals again. experienced significant improve- “We propose that these four patients may represent a subset of fibromyalgia ment compared with the control syndrome that is induced or exacerbated by excitotoxins or, alternatively, may group, which received sham comprise an excitotoxin syndrome that is similar to fibromyalgia,” the researchers magnetic therapy. After 10 weeks, said (Ann Pharmacother, 2001; 35: 702–6). the exercise + relaxation group In a case report including a woman with fibromyalgia, her symptoms completely reported better sleep, reduced disappeared after she stopped consuming aspartame (Clin Exp Rheumatol, 2010; 28 [6 anxiety and improved quality of life Suppl 63]: S131–3). (Med Clin [Barc], 2011 Feb 21; Epub ahead of u Try supplements. 5-Hydroxytryptophan (5-HTP; 100 mg three times a day) and print). S-adenosylmethionine (SAMe; 800 mg per day) may be effective for fibromyalgia, Clearly, drugs are not the only according to double-blind trials (J Int Med Res, 1990; 18: 201–9; Scand J Rheumatol, 1991; 20: answer to fibromyalgia, as studies are 294–302). Other potentially useful supplements include vitamin D (Clin Rheumatol, 2007; now suggesting that aerobic exercise 26: 551–4), magnesium with malic acid (J Rheumatol, 1995; 22: 953–8), and antioxidants such and mind–body techniques are as vitamins C and E (Redox Rep, 2006; 11: 131–5). Many fibromyalgia sufferers are deficient effective. Nevertheless, more in these and other nutrients, so it may be worth getting tested to see what you’re low research is needed to see how these in. interventions fare in the long-term, u Check your thyroid. According to Dr John Lowe of the Fibromyalgia Research although it appears that if you can Foundation in Boulder, CO, many of the features of fibromyalgia and hypothyroidism stick with it, you will continue to (an underactive thyroid) are virtually identical, and thyroid hormone treatment trials reap the benefits. For best results, have reduced or eliminated fibromyalgia symptoms as well (Med Sci Monit, 2006; 12: work with a physical therapist who CR282–9). For this reason, it may prove useful to investigate the possibility of having can devise an exercise programme hypothyroidism,and to seek out natural treatments if you do (see WDDTY vol 20 no10, that’s right for you. pages 18–9). Joanna Evans 14 WDDTY Chronic pain,

Chronic fatigue syndrome CFS—also known as longer to find out whether XMRV plays

myalgic encephalomyelitis a role in CFS or not. (ME) or post-viral fatigue Multiple causes syndrome—is a Although there’s been a preoccu- debilitating condition that pation with finding a single cause of affects an estimated 17 CFS in conventional circles, holistic million people worldwide. practitioners have long believed that

Luckily, there’s now a wide the condition has many potential

causes, each of which shares a variety of promising common endpoint—severe immune natural treatments, suppression. ranging from acupuncture Within such a construct, every one to saunas and of the proposed causes of CFS— supplements. including viruses, stress, depression, impaired liver function, environmental illness, medicine use, adrenal insuf- hronic fatigue syndrome ficiency, Candida albicans infection, C(CFS) is a mysterious leaky gut, hypothyroid, hypoglycaem-illness with a long history of ia, anaemia, nutritional deficiencies,controversy. Early on, food allergies, sleep disturbances, medical authorities were sceptical as emotional problems, poor posture and to whether or not it even existed. lack of exercise—is credible. Today, there are still disagreements two additional laboratories, reported Successful treatment requires as to its diagnosis, cause(s), contradictory findings. working with an experienced practi- treatment and prevalence—not to In that study, blood samples from tioner who knows the importance of a mention what to call it. around 100 people with and without comprehensive diagnosis that takes Sadly, two new studies have come CFS were tested, with the result that into consideration the patients’ up with nothing to help clear up the the CDC researchers could find no medical history as well as their confusion. The first, an investigation evidence of a link between CFS and physical and emotional lives. The most by the US Food and Drug Adminis- XMRV. This was in direct contrast to effective regime is likely to be the one tration (FDA), reportedly confirmed the Science study, which reported the that assesses all these factors to arrive previous research that found a link presence of XMRV in 67 per cent of at an individual plan tailored to the between CFS and the so-called ‘xeno- the CFS patients compared with 3.7 given patient’s needs. tropic murine leukaemia virus- per cent of the healthy controls (Retro related virus’ (XMRV). virology 2010, 7: 57; doi: 10.1186/1742-4690-7- Proven natural treatments The study has yet to be published 57). Conventional medicine has little to but, in a presentation at a blood In response, Judy Mikovits, director offer the CFS sufferer besides anti- safety meeting in the Croatian of research at the Whittemore depressants or pain relievers that only capital of Zagreb, virologist Harvey Peterson Institute in Reno, NV, and manage symptoms. Fortunately, Alter, one of the study researchers, lead author of the Science study, stated although the scientific evidence is reported a “very strong” CFS–XMRV that the CDC report was flawed relatively weak, there are a number of connection, independently conf- because it failed to use patients that promising natural treatments for CFS. irming data that had been published had been officially diagnosed with u Supplements. Research suggests in the journal Science in 2009 CFS, and it also lacked “positive that the following nutritional (www.independent.co.uk/ news/science- controls” in the form of blood from supplements may be beneficial. /study-that-solves-chronic-fatigue-syndrome- people known to be diagnosed with However, be sure to first consult a blocked-2022195.html). Until now, other XMRV infection. qualified practitioner who can teams have failed to replicate the “We’ve now got more than 1000 check for any deficiencies and results (Science, 2009; 326: 585–9). individual patients from around the advise you on dosages. However, any hopes that such an world in whom we’ve detected and v Magnesium. Some CFS sufferers association would offer a solid isolated the virus .I haven’t changed have been found to have low levels explanation—or lead to a potential my mind on this,” Dr Mikovits said. of magnesium in their blood. treatment—for the puzzling But the FDA study that supposedly Indeed, many of the symptoms of condition were soon dashed when supports Mikovits’ findings has also CFS resemble those of magnesium another US government study, this come under criticism, and is currently deficiency (Altern Med Rev, 2000; 5: time by the Centers for Disease undergoing a rigorous scientific review 93–108). Also, in one small ran- Control and Prevention (CDC), and process. Clearly, we’ll have to wait a bit domized controlled trial, patients

WDDTY Chronic pain 15

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Common conditions

who had weekly injections of magnesium sulphate were more CFS symptoms likely to feel better after six weeks than those who had received Sufferers with chronic fatigue syndrome (CFS) can experience a wide range injections of a dummy treatment of signs and symptoms, but the main ones include: (Lancet, 1991; 337: 757–60). Oral mag- u fatigue nesium has also proved useful in u impaired memory or concentration magnesium-deficient CFS sufferers, u sore throat according to a preliminary report u painful and mildly enlarged lymph nodes in the neck or armpits (Lancet, 1992; 340: 426). u unexplained muscle pain v Carnitine is essential for the u pain that moves from one joint to another with no swelling or redness production of energy in the power- u headache of a new type, pattern or severity houses of cells (mitochondria). Not u unrefreshing sleep enough of this nutrient can impair u extreme exhaustion that lasts for more than 24 hours after physical or mitochondrial function, leading to mental exercise. symptoms of generalized fatigue, Source: mayoclinic.com along with musle pain (myalgia), muscle weakness and malaise for three months, those taking the drome (IBS)-like symptoms seen following physical exertion (Altern EFAs saw significant improvement in all patients, a significant finding, Med Rev, 2000; 5: 93–108). in their symptoms compared with as CFS patients have a high rate of In addition, low carnitine levels the placebo. Moreover, the EFA IBS (Altern Med Rev, 2001; 6: 450–9). have been found in CFS patients, supplementation corrected the Another study concluded that and one study saw a “statistically abnormal fatty-acid levels noted at choosing organically grown fruit significant clinical improvement” the start of the study (Acta Neurol and vegetables is important for CFS in those taking L-carnitine supple- Scand, 1990; 82: 209–16). In contrast, patients, as they are found to have ments for two months (Neuro- another trial using the same EFA elevated levels of pesticides in their psychobiology, 1997; 35: 16–23). supplement found no significant blood (Med J Aust, 1995; 163: 294–7). v Vitamin B12. Evidence suggests differences between the active- Pesticide exposure may be a direct that high-dose injections of this treatment and placebo groups (Acta cause of CFS symptoms by affecting vitamin may benefit people with Neurol Scand, 1999; 99: 112–6). cell membranes or, indirectly, by CFS. Injections of 2500–5000 mcg v Antioxidants may be beneficial, playing a role in the loss of natural of B12 given every two to three as oxidative stress is thought to play tolerance for chemicals, including days led to improvement in 50 to a role in CFS. Selenium, glutathi- those present in foods (Toxicol Ind 80 per cent of patients (Altern Med one, N-acetylcysteine, alpha-lipoic Health, 1999; 15: 386–97). Rev, 2000; 5: 93–108). acid, coenzyme Q10 and oligomeric u Exercise. Traditionally, there is v NADH (nicotinamide adenine proanthocyanidins (OPCs), as well some concern that exercise may dinucleotide) helps make adenosine as vitamins C and E, may prove to make symptoms of fatigue worse, triphosphate (ATP), the source of be invaluable in a CFS treatment but studies show that graded the energy that the body runs on. In protocol. Ginkgo biloba and bilberry exercise—which builds up gradually a small double-blind crossover (Vaccinium myrtillus) are also from a gentle beginning—can study, 26 CFS sufferers took either recommended (Altern Med Rev, 2001; 6: improve CFS symptoms. 10 mg of oral NADH or a placebo 450–9). In a recent study of adolescent every day for four weeks, then u Diet. As there may be a connection CFS sufferers, both graded aerobic switched to the other treatment between food intolerance and CFS, exercise and progressive resistance after a four-week interval. In the identifying and addressing these training were able to significantly NADH group, 31 per cent saw their intolerances should prove helpful. improve physical capacity and symptoms improve compared with When Australian CFS patients quality of life. However, only aerobic just 8 per cent in the placebo group eliminated wheat, milk, benzoates, exercise improved fatigue severity (Ann Allergy Asthma Immunol, 1999; 82: nitrites, nitrates, and food and symptoms of depression (Clin 185–91). colourings and other additives from Rehabil, 2010 July 6; Epub ahead of print). v Essential fatty acids (EFAs). Low their diet, 90 per cent of those Nevertheless, it’s generally advis- levels of various EFAs could be who were able to stick with the able that CFS sufferers only do the contributory to CFS (J Clin Pathol, diet reported improvement in the graded exercise that is prescribed 2007; 60: 122–4; Neuro Endocrinol Lett, severity of a wide range of symp- and supervised by a trained thera- 2005; 26: 745–51). However, whether toms, with significant reductions in pist, such as a physiotherapist. supplements help is unclear. fatigue, recurrent fever, sore throat, u Cognitive behavioural therapy When 63 CFS sufferers took muscle pain, headache, joint pain (CBT). This form of ‘talking either an EFA supplement (contain- and cognitive dysfunction. treatment’ is often used to treat ing linoleic, gamma-linolenic, What’s more, the elimination chronically ill patients, and its eicosapentaenoic and docosahexa- diet resulted in a marked improve- effectiveness in CFS was recently enoic acids) or a placebo every day ment in the irritable bowel syn- the subject of a major review of the 16 WDDTY Chronic pain, literature. It found that those who from Japan have found that suggests that stress-reduction received CBT were more likely to repeated far-infrared (FIR) saunas, activities such as meditation, tai feel less tired at the end of a form of thermal therapy, may be chi or yoga may be beneficial. treatment than patients who an invaluable treatment for CFS. Indeed, yoga appeared to help with received the usual care from their Symptoms such as fatigue, pain, the characteristic symptoms of doctor. Moreover, the review sleep disturbances and low-grade fatigue in an observational study concluded that “it may be more fever were all dramatically improved (J Clin Psychiatry, 2005; 66: 625–32). effective in reducing fatigue after 15 to 25 sessions (J Psychosom u Pacing is a form of treatment that symptoms compared with other Res, 2005; 58: 383–7). In fact, saunas is based on finding the optimal psychological therapies” (Cochrane may help by also encouraging the balance between rest and activity Database Syst Rev, 2008; 3: CD001027). elimination of pesticides and other for the individual patient. It’s u Massage has many proven benefits toxins from the body (which may thought that, if those with CFS use relevant to CFS sufferers, including be involved in CFS). See WDDTY what limited energy they have better relief from pain, depression vol 20 no 10 for other effective ways wisely, their energy levels will even- and anxiety, and improved sleep to detox. tually and gradually increase. patterns. u Breathing retraining. A prelim- Randomized controlled trials are A recent study from China found inary study carried out in Belgium lacking, but an observational study that a technique called ‘intelligent- identified specific breathing prob- found that three weeks of self- turtle massage’ not only alleviated lems in patients with CFS. One managed pacing led to a modest the physical symptoms of CFS, but session of breathing retraining was improvement in symptom severity also boosted immune function (J able to improve lung function in and everyday functioning (J Rehabil Tradit Chin Med, 2009; 29: 24–8). these patients, suggesting that this Res Dev, 2009; 46: 985–96). u Acupuncture. A meta-analysis of form of treatment may be useful in For this reason, a randomized the pooled results of several studies some cases (Physiother Theory Pract, controlled comparative trial is concluded that acupuncture is an 2008; 24: 83–94). currently under-way to confirm the effective therapy for CFS. However, u Relaxation techniques. According effectiveness of pacing, as well as it was also noted that more high- to one study from the Netherlands, CBT and graded exercise, in quality studies are needed to stress may well play “an important addition to the usual specialist confirm this finding (Zhen Ci Yan Jiu, predisposing, precipitating and medical care of CFS (BMC Neurol, 2009; 34: 421–8). perpetuating role in CFS” (Tijdschr 2007; 7: 6). u Sauna therapy. Two case reports Psychiatr, 2009; 51: 603–10). This Joanna Evans

WDDTY Chronic pain 17

,

Common conditions Irritable bowel syndrome There are a number of

effective alternative ways to manage IBS rritable bowel syndrome (IBS)

Iis among the most commonproblems of the digestivesystem, affecting up to 15 per

cent of people in the developed countries. Although it’s not life- threatening, the symptoms—which include abdominal pain, bloating, wind, constipation and diarrhoea— can severely affect the IBS are typically seen in IBS (J Am Diet behind fructose malabsorption in sufferer’s quality of life. Those with Assoc, 2006; 106: 1631–9). IBS are still in their early stages, in IBS frequently report experiencing In one American study, cases where symptoms of gas, loss of freedom, spontaneity and researchers at the Immanuel St bloating and diarrhoea appear to be social contacts, as well as feelings Joseph’s Hospital, part of the Mayo related to eating fruit, a fructose of fearfulness, shame and Health System in Minnesota, elimination diet might be embarrassment (Dig Dis Sci, 2009; 54: looked at 80 patients with IBS and something worth considering. 1532–41). found that 31 (38 per cent) also Adding to the problem, had fructose malabsorption. Of Other problem foods conventional therapy is highly these patients, 26 were then put on Besides fruit sugars, other ferment- inadequate. Many treatments (such a fructose-restricted diet, and able, poorly absorbed carb- as antispasmodics, antidiarrhoeals, those who managed to stick with ohydrates—such as lactose (found bulking agents, tranquillizers and the diet (only around half of them) in milk), fructans (found in wheat sedatives) can harm more than enjoyed significant improvements and onions) and sorbitol (a help, and none of them has proved in their symptoms, including common sweetener)—are also able to be globally effective at treating abdominal pain, belching, bloating, to cause or exacerbate the usual IBS symptoms (J Chin Med Assoc, 2009; feelings of fullness, indigestion and symptoms of IBS (J Am Diet Assoc, 72: 294–300). diarrhoea. The patients who didn’t 2009; 109: 1204–14; Curr Gastroenterol Rep, It’s no surprise, therefore, that a stick with the dietary restrictions, 2009; 11: 368–74). growing number of IBS patients are on the other hand, generally saw no What’s more, some of the foods turning to complementary and change in their symptoms (J Clin that are commonly recommended alternative medicine (Gastroenterol Gastroenterol, 2008; 42: 233–8). to ease IBS may actually be making Clin Biol, 2009; 33 Suppl 1: S79–83). Similarly, in a study of 32 the condition worse. Wheat bran, children with persistent un- for instance, often prescribed for The role of sugar explained abdominal pain, 11 of constipation due to its high fibre Part of the problem of treating IBS them were found to have fructose content, only helped 10 per cent of is that no one knows what causes it. malabsorption and, so, were sufferers in one study. On the other The latest research, however, subsequently put on a low-fructose hand, more than half of the IBS suggests that certain foods might diet. After two months, all but two sufferers followed-up by researchers play a role, an idea that alternative of these children showed rapid at the University Hospital of South practitioners have been expounding improvement of their symptoms, Manchester, in the UK, reported upon for years. In particular, the and all continued to report positive that bran made their symptoms— more recent studies have revealed changes thereafter. The res- including bowel disturbances, and that around a third of IBS patients earchers, from the New York abdominal distention and pain— may have problems with processing Medical College in the US, worse, leading the researchers to fructose, the type of sugar that is concluded that “fructose conclude that “excessive con- found in fruits, some vegetables, malabsorption may be a significant sumption of bran in the community honey and high-fructose corn problem in children and that may actually be creating patients syrup. ‘Fructose malabsorption’, as management of dietary intake can with irritable bowel syndrome” it’s officially known—which refers be effective in reducing gastro- (Lancet, 1994; 344: 39–40). to the body’s failure to completely intestinal symptoms” (J Pediatr Considering that wheat (along absorb fructose as it passes Gastroenterol Nutr, 2008; 47: 303–8). with milk and eggs) is one of the through the small intestine—can Although the researches into the most common triggers of lead to many of the symptoms that precise role and mechanism(s) symptoms in those with IBS, such 18 WDDTY Chronic pain, results are hardly surprising (Am J Dangerous IBS drugs Gastroenterol, 1998; 93: 2184–90). If any fibre is to be Most of the drugs prescribed for irritable bowel syndrome come with a recommended, then Plantago host of unwanted side-effects. seeds—a source of soluble fibre Anticholinergics—drugs that block the effects of the neurotransmitter that is sold commercially as acetylcholine—such as Buscopan, for example, can cause dry mouth and ‘psyllium’ or ‘ispaghula’ fibre— blurred vision (Phytomedicine, 2005; 12: 601–6), whereas bulking agents and appears to be a better option, but it antispasmodic drugs such as Spasmonal (alverine citrate) can trigger can still aggravate symptoms in nausea, dizziness, itching, rash and headache, according to the Electronic some IBS sufferers (Townsend Letter Medicines Compendium (see http://emc.medicines.org.uk/medicine/ Docs, 2004; 252: 159). 15704/XPIL/Spasmonal+60mg/). Probiotic yoghurt is another What’s more, one drug has even been linked to life-threatening adverse popular recommendation for effects. Alosetron (Lotronex), currently used in the US only for the people with IBS, but this, too, can management of severe diarrhoea-predominant IBS in women, was make symptoms worse. While withdrawn from the market in 2000 following reports of five deaths and 70 probiotics may be beneficial for the cases of serious adverse reactions. These reactions included ischaemic condition in some, dairy products colitis (fever and gut pain caused by insufficient blood supply) and have also been found to trigger obstructed or ruptured bowels as a complication of severe constipation. symptoms in a significant Yet, the US Food and Drug Administration (FDA) advisory panels proportion of IBS sufferers. recommended that the drug be reintroduced in 2002 (albeit with restricted According to Dr Stephen O. use and availability)—the first case ever of a drug being brought back onto Wangen, Chief Medical Officer of the US market after being withdrawn for reasons of safety. the IBS Treatment Center in Dr Sidney Wolfe, director of the Public Citizen’s Health Research Group, Seattle, WA, “A large number of our commented, “With the exception of some drugs used to treat cancer, the patients who experience IBS are frequency and severity of a life-threatening adverse reaction—in this case, actually suffering from a dairy ischaemic colitis in patients using alosetron—is among the highest I have allergy but don’t realize it. Yogurt, seen for any other drug” (BMJ, 2002; 324: 1053). although it is fermented, is still a dairy product and can be a potent trigger of their digestive problems. Cochrane Collaboration, which functional relaxation or For these people, the consumption resulted in a pooled meta- enhanced medical care of yogurt, even brands with high analysis of four studies involving (standard treatment plus two probiotic bacteria content, is 147 patients altogether, counselling sessions) for five inadvisable” (Townsend Letter, 2008; hypnotherapy was superior to weeks, the results showed that June: 35). both the standard medical care functional relaxation was Clearly, diet is a crucial factor in and no treatment in relieving significantly more effective than IBS, but there is no one-size-fits-all abdominal pain and other IBS the control treatment. Indeed, approach when it comes to symptoms—at least for the short the positive effects—both successful treatment. Experi- term (Cochrane Database Syst Rev, physical and mental—were still menting with limiting or 2007; 4: CD005110). Clearly, present three months later (J completely eliminating certain however, more high-quality Altern Complement Med, 2010; 16: foods from your usual diet and/or studies are needed before any 47–52). working with an experienced definitive conclusions can be A small-scale (21 IBS nutritional practitioner may be the drawn. patients), randomized controlled best way to get the condition under u Relaxation. As numerous trials trial, carried out at Tohoku control. have already identified the role University Graduate School of of psychological and emotional Medicine in Japan, involved the

Other treatment approaches factors as triggers in patients use of ‘autogenic training’ (AT),

Along with a change of diet, there with IBS, relaxation techniques a relaxation technique that are a number of other natural ways are often recommended. In teaches your body how to tackle IBS. Germany, the technique called to respond to your verbal com- u Hypnotherapy. Emotional and ‘functional relaxation’—a term mands through six standard psychological factors appear to coined decades ago to describe a exercises. The technique appears be involved in IBS, which may form of relaxation that is also to combine elements of both explain why hypnosis has proved known as ‘self-hypnosis’—aims self-hypnosis and biofeedback. helpful for patients with the to maintain equilibrium within The results of this study suggest condition. According to an the nervous system and appears that AT can benefit IBS by extensive review of the to be beneficial for IBS. In a “enhancing self-control”, as medical/scientific literature randomized controlled trial of reflected by the patients’ carried out by the prestigious 80 patients, who received either responses to a number of IBS-

WDDTY Chronic pain 19

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Common conditions

related questionnaires (Appl peppermint oil and 29 per cent complained of gastrointestinal Psychophysiol Biofeedback, Dec 8 2009; for placebo. However, even discomfort while the other Epub ahead of print). though peppermint oil usually experienced headaches (JAMA, u Exercise. There is also evidence comes in specially coated 1998; 280: 1585–9). to suggest that exercise may be capsules designed to protect the u Acupuncture. The results of one an effective intervention for IBS. stomach, these capsules may trial in the US found that When pitted against con- still lead to side-effects such as acupuncture combined with ventional care in a 12-week trial, heartburn or rectal irritation moxibustion may be promising the patients in the exercise (Phytomedicine, 2005; 12: 601–6). for IBS management (Gastroenterol group reported significant u Chinese herbal medicine Nurs, 2009; 32: 243–55). improvement in symptoms of (CHM). In a trial involving more However, a major review of the constipation (Int J Sports Med, 2008; than 100 IBS patients, those studies up to 2006 found only six 29: 778–82). Another trial treated with CHM, using randomized controlled trials, concluded that even mild formulas that were either which were, in fact, inconclusive physical activity can reduce gas individualized or standardized, due to poor quality or not and abdominal bloating (Am J saw significant improvements in comparable because of too many Gastroenterol, 2006; 101: 2552–7). terms of bowel symptoms as well differences in the variables u Peppermint oil. According to a as overall quality of life. studied. review of the literature, eight However, only the CHM group Also, orthodox researchers out of 12 placebo-controlled taking herbals tailored to the have concluded that it is still not studies showed statistically patient were able to maintain clear whether traditional significant positive effects with the improvements 14 weeks acupuncture is any better than peppermint oil for the treatment later. sham acupuncture at reducing of IBS. The average response Furthermore, only two IBS symptoms (Cochrane Database rates, as a reflection of ‘overall patients taking CHM reported Syst Rev, 2006; 4: CD005111). success’, were 58 per cent for any adverse effects: one Joanna Evans 20 WDDTY Chronic pain,

Tested treatments Healing magnets Do magnetic devices truly

heal, or are they just was seen in patients receiving fake magnet therapy. In fact, the active- above, the patients knew they had hokum? magnet group used 1.5 mg more real magnets as they often were agnetic devices—from morphine than the fake-magnet stuck to their keys in their pockets Mbands and bracelets to group (Anesth Analg, 2007; 104: 290–4). (BMJ, 2006; 332: 4). leg wraps and shoe Similarly, magnets were no more In fact, the authors of that studyinserts—are used by effective than a placebo for carpal- were themselves aware of the thousands of people worldwide, tunnel syndrome and chronic lower- problem (BMJ, 2004; 329: 1450–4). thanks to a multimillion-pound back pain (J Fam Pract, 2002; 51: 38–40; Similarly, the authors of the study industry that claims they can cure a JAMA, 2000; 283: 1322–5), and a meta- on magnet therapy for chronic laundry list of ailments, especially analysis of nine randomized, pelvic pain admitted that “blinding pain. But do these products work? placebo-controlled trials of various efficacy” was “compromised” (Am J pain-related conditions reported Obstet Gynecol, 2002; 187: 1581–7).

What the science says that the “evidence does not support However, it’s possible that the

Despite their popularity, there’s the use of static magnets for pain conflicting results were due to the little scientific evidence that relief” (CMAJ, 2007; 177: 736–42). strength of the magnets used, as magnets are beneficial to health. However, the pain of OA of the studies that failed to show any effect Although they’re often used to hip and knee was decreased by on pain generally used weaker manage pain in chronic wearing magnetic bracelets magnets (19–50 mTesla), while musculoskeletal disorders, one compared with a dummy bracelet in those that found an effect used study found that magnetic wrist a study of 194 men and women (BMJ, stronger ones (47–180 mTesla) straps were no better than a 2004; 329: 1450–4). Also, in a (BMJ, 2004; 329: 1450–4). Nevertheless, placebo. preliminary study of 29 patients it’s clear that more research is A total of 45 osteoarthritis (OA) with OA of the knee, magnets needed to determine whether this is sufferers were randomly allocated to showed “statistically significant indeed the answer. one of four treatments, all using the efficacy” compared with a placebo same devices—a standard magnetic (Altern Ther Health Med, 2004; 10: 36–43). The bottom line wrist strap; a weakened magnetic Others found magnets to be better Although many people swear by wrist strap; a demagnetized than a placebo for chronic pelvic magnets, the bulk of the research so (dummy) wrist strap; and a copper pain and diabetic neuropathy (Am J far suggests that they’re no better (non-magnetic) bracelet—but in Obstet Gynecol, 2002; 187: 1581–7; Arch than a placebo for relieving pain. different sequences. Each device was Phys Med Rehabil, 2003; 84: 736–46). Yet, looked at another way, magnets worn for at least eight hours a day Nevertheless, some scientists then do have an effect, albeit ‘all in for four weeks, after which the question these findings, pointing the head’. patients filled in questionnaires to out that many so-called ‘controlled’ Ultimately, the studies show that assess symptoms. tests are unreliable, as participants the mind is a powerful healer, and if The results showed no significant can usually work out whether magnets can help it to perform that differences among the devices for they’re in the real or fake magnet function, then perhaps they’re pain relief, with similar findings for group, which can affect the results. useful after all. stiffness, physical function and Indeed, in the BMJ study mentioned Joanna Evans medication use. The overall conclusion was that “magnetic and copper bracelets are generally Static vs pulsed magnetic fields ineffective for managing pain, stiffness and physical function in Magnets are claimed to cure a variety of ills besides pain, although scientific osteoarthritis”, and that any proof is lacking; for example, although magnets supposedly increase reported therapeutic benefits were circulation, a well-designed study found this wasn’t so (Sci Rev Alt Med, 2002; most likely due to “non-specific 6: 9–12). Other research shows that magnets are ineffective for snoring, sleep placebo effects” (Complement Ther Med, apnoea, tinnitus, and reducing heart rate and blood pressure (Wis Med J, 2009; doi: 10.1016/j.ctim.2009. 07.002). 1997; 96: 35–7; Clin Otolaryngol Allied Sci, 1991; 16: 371–2; Clin Rehabil, 2002; 16: Other studies have arrived at 669–74). much the same conclusions. In a However, static magnets (those marketed to consumers) shouldn’t be placebo-controlled trial of 165 confused with pulsed electromagnetic-field therapy (PEMF), which involves patients with postoperative pain, brief exposures to much stronger electromagnetic fields. PEMF is effective the effects of magnet therapy on for treating slow-healing fractures and shows promise for other conditions, pain intensity and opioid including arthritis (Wien Klin Wochenschr, 2002; 114: 678–84; Injury, 2008; 39: 419–29). requirements were similar to what

WDDTY Chronic pain 21

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Tested treatments Serrapeptase: a natural

anti-inflammatory

An enzyme found in with the placebo (Pharmathera-

silkworms is touted as a peutica, 1984; 3: 526–30). natural alternative to non- Yet another study showed that steroidal anti-inflammatory serrapeptase is better than the traditional post-surgery advice: drugs (NSAIDs). But what bed rest, elevation and the does the science say? application of ice. In patients undergoing surgery of the ankle, errapeptase, or serra- those treated with serrapeptase Stiopeptidase, is a proteolytic had 50-per-cent less postopera-(protein-digesting) enzyme tive swelling compared with thosewith a long history of use in who followed the traditional Germany and Japan. Now known advice. The serrapeptase group worldwide for its anti-inflammatory also became pain-free sooner effects, it’s purported to treat than the control group did everything from arthritis to heart (Fortschr Med, 1989; 107: 67–8, 71–2). disease and infections. But what u ENT disorders. An Italian study does the science say about of 193 patients suffering from serrapeptase? ear, nose and throat disorders (acute or chronic) found that What the studies say serrapeptase treatment led to a Serrapeptase has been the subject of significant reduction in symp- intense study in recent decades and, toms compared with a placebo. In although much of the research has addition, not only did the enzyme Compared with no treatment, been in humans, larger-scale higher- act rapidly on localized inflamma- 30 mg/day of the enzyme for four quality trials are needed. tion, but it also led to less water weeks reduced both the amount Nevertheless, so far, the evidence retention, while boosting clot- of phlegm (sputum) produced suggests that the enzyme may be busting effects (fibrinolysis), thus and the frequency of coughing useful for a range of conditions. speeding up healing (J Int Med Res, (Respirology, 2003; 8: 316–20). u Postoperative pain and swelling. 1990; 18: 379–88). u Carpal tunnel syndrome (CTS). In a study of 24 healthy subjects u Chronic obstructive pulmonary Twenty CTS patients were undergoing tooth extraction, all disease (COPD). A small study enrolled in a clinical study to were given a treatment combina- carried out in Japan investigated investigate whether serrapeptase tion of either serrapeptase (5 mg) the effects of serrapeptase in could help in the treatment of or placebo tablets and parace- patients with COPD, such as their symptoms. Following a short tamol (acetaminophen) tablets emphysema and bronchitis. course of the non-steroidal anti- (1000 mg) at the time of the operation. Those taking serrapep- tase reported significantly less What is serrapeptase? pain and swelling after surgery compared with the placebo- Serrapeptase is an enzyme produced by the Serratia bacteria that live in control group (Int J Oral Maxillofac the intestines of silkworms. Once the silkworm has completed its Surg, 2008; 37: 264–8). transformation into a moth, it uses this substance to ‘melt’ a hole in its In a much larger study, this confining cocoon, allowing it to escape. Unlike other biological enzymes, time in patients with chronic serrapeptase affects only non-living tissue, such as the silk cocoon. In empyema (where pus collects humans, it breaks down the protein debris resulting from toxins and around the lungs and in the chest inflammation while sparing healthy tissues and cells. wall) undergoing surgery, the Serrapeptase is taken orally typically at a dosage of 10–30 mg/day. To patients were given either ensure maximum absorption in the small intestine and to stop stomach acid serrapeptase or a placebo both from destroying the enzyme, it usually comes in enteric-coated tablets. before and after their operation. Currently, research is underway to develop topical preparations of Here again, the degree of post- serrapeptase in the form of ointments and gels (Indian J Pharm Sci, 2010; 72: operative swelling was signifi- 65–71). cantly less with serrapeptase than 22 WDDTY Chronic pain, inflammatory drug (NSAID) group vs just 3 per cent with the the brain (www.serrapeptase.info/content. nimesulide, the patients were placebo (Singapore Med J, 1989; 30: asp?page=Dr-H-A-Nieper). given 10 mg of serrapeptase twice 48–54). However, more clinical studies a day for six weeks. At the end of u Infections. Serrapeptase was are needed to ascertain whether or the study, 65 per cent reported effective for eradicating infection not serrapeptase is, in fact, effective significant improvements in their caused by Staphylococcus epider- for any of these conditions. symptoms, with no serious side- midis bacteria—at least in rats, effects (J Assoc Physicians India, 1999; so this may not apply to humans. Serrapeptase safety 47: 1170–2). Larger, higher-quality Nevertheless, these findings led In general, no significant side- trials are now needed to confirm the researchers to conclude that effects have been reported with the these findings. the enzyme might be able to use of this enzyme, although there u Breast disease. Serrapeptase may “enhance antibiotic efficacy in have been a few case reports of be beneficial for breast engorge- the treatment of staphylococcal eosinophilic pneumonia (usually ment, the painful overfilling of infections” (J Bone Joint Surg Am, triggered by an allergic reaction, the breasts with milk. When 70 2006; 88: 1208–14). often to a medication) in response women with the condition were to serrapeptase (Nihon Kokyuki Gakkai given either Danzen, a Japanese Heart disease and beyond Zasshi, 2009; 47: 254–8; 2000; 38: 540–4). serrapeptase preparation, or a The potent anti-inflammatory Although the reaction is unusual, placebo for three days, Danzen effects of the enzyme make it a good it nevertheless highlights the fact proved to be superior to placebo candidate for treating a variety of that natural is not always harmless. for improving breast pain, breast other disorders, including arthritis, Other potential adverse effects swelling and induration (harden- fibromyalgia, migraine, irritable include diarrhoea and gastro- ing). Indeed, while 86 per cent of bowel syndrome and even heart intestinal problems. However, these the Danzen patients achieved disease. Indeed, the late German effects are usually mild, especially in “moderate to marked” improve- physician Dr Hans Nieper reported comparison to the often severe side- ments, only 60 per cent of the that serrapeptase is an invaluable effects of NSAIDs. Yet, until we know patients taking the placebo saw agent for the safe removal of fibrous more, it’s up to users to monitor similar improvements. Also, a clots from coronary arteries and, in their own health when using this “marked” improvement was seen particular, from the carotid arteries product. in 23 per cent of the treatment in the neck, which supply blood to Joanna Evans

WDDTY Chronic pain 23

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Tested treatments Cetylated fatty acids Cetylated fatty acids are

among the latest natural remedies for joint health, and are said to be even better than glucosamine.

But what does the science

say about these fats? etylated fatty acids (CFAs)

Care a group of naturallyoccurring fats that arewidely marketed as a treat-

ment for osteoarthritis. These fats patients to get up and go from a and weight distribution across the are thought to help lubricate joints chair, go up and down stairs, balance soles of the feet during quiet and muscles, soften tissues, reduce and move their knees. standing (J Strength Cond Res, 2005; 19: inflammation and increase flexibility. Celadrin was superior to placebo 115–21), while the other reported that The question is, do they really work? and had fast-acting effects. Climbing it significantly reduced pain and ability, for example, improved just improved functional performance in CFA studies so far 30 minutes after initial treatment individuals with OA of the knee, Several studies used a proprietary (J Rheumatol, 2004; 31: 767–74). elbow and wrist (J Strength Cond Res, blend of CFAs called Celadrin (70- The other two studies of this series 2005; 19: 475–80). per-cent CFAs and 30-per-cent olive also found Celadrin to be effective for oil) which comes as an oral supple- relieving the pain of OA. One found Beyond arthritis ment or topical cream. In one study that it improved postural stability Some websites claim that CFAs can using the capsules, 64 patients with chronic knee osteoarthritis (OA) were given either Celadrin (350 mg, Other supplements for osteoarthritis plus 50 mg of soy lecithin and 75 mg of fish oil, taken six times daily) orauGlucosamine. Numerous studies have shown that this is a safe and placebo (vegetable oil) for 68 days. effective way to reduce symptoms of OA (Arthroscopy, 2009; 25: 86–94). The At the end of the study, those in results of a three-year, double-blind trial suggest that the nutrient (1500 the Celadrin group saw a significant mg/day in one dose) may even slow the progression of the disease improvement in their knee range of (Lancet, 2001; 357: 251–6). motion (flexibility) and overall joint u Chondroitin. A recent review concluded that oral chondroitin sulphate “is functioning compared with those in a valuable and safe symptomatic treatment for OA disease”. Interestingly, the placebo group. 800 mg/day had nearly the same effects as 1200 mg/day in one study “CFA may be an alternative to the (Osteoarthritis Cartilage, 2008; 16 Suppl 3: S19–21). It’s often recommended that use of non-steroidal anti-inflam- chondroitin be taken in combination with glucosamine. matory drugs for the treatment of u S-adenosylmethionine (SAMe). Double-blind trials show that SAMe OA”, the researchers concluded (J (1200 mg/day) reduces pain, stiffness and swelling better than a placebo, Rheumatol, 2002; 29: 1708–12). and as well as painkilling drugs such as ibuprofen and naproxen in OA The topical version of Celadrin has sufferers (Am J Med, 1987; 83: 81–3; Am J Med, 1987; 83: 66–71). also been tested in three separate u Pycnogenol (pine bark extract). This supplement (150 mg/day) was studies by a team of researchers at tested against a placebo on 100 patients with mild-to-moderate OA of the the University of Connecticut. knee. After eight weeks, the Pycnogenol group reported a significant Again, the product was trialled in reduction in pain, and the benefits were still evident three months later. patients with OA of the knee. They also had less stiffness in the joints, and were able to carry out more In the first of this series of studies, day-to-day activities and reduce their use of painkillers; in contrast, 10 40 older patients (mean age: 65 per cent in the placebo group had to increase their dose of analgesics years) were randomly assigned to one (Phytother Res, 2008; 22: 1087–92). of two treatment groups—Celadrin u Bromelain. Mounting evidence suggests that this extract, derived from cream or a placebo—and were pineapple, may be a useful treatment for OA. The research so far shows evaluated before application, 30 that it has powerful anti-inflammatory and painkilling properties, although minutes after application and 30 more studies are needed to determine the optimal dosage (Evid Based days after treatment. Assessments Complement Alternat Med, 2004; 1: 251–7). included how long it took the 24 WDDTY Chronic pain, be used to treat a range of condi- might benefit the heart and blood- chondroitin—two popular natural tions other than OA, such as skin circulation status by reducing treatments for arthritis—no problems, gum disease, gout and platelet aggregation (blood-clot comparative studies have been lupus. However, there’s little formation). The researchers, who conducted. research to support these claims. tested the combination on 24 Another point to bear in mind is One small-scale, preliminary study healthy people, reported that it had that the studies have been carried suggested that Celadrin cream might aspirin-like effects (Clin Lab Sci, 2010; out with a specific brand of CFAs be helpful for people with psoriasis, a 23: 32–6). Nevertheless, more research (Celadrin), so we don’t know if chronic autoimmune skin disorder. is needed to confirm these results. other preparations will have the However, although it was a double- same results. blind, placebo-controlled study, the Consider this As for safety, no adverse effects results have yet to be published in a CFAs appear to be a promising have been reported with the use of peer-reviewed journal, but are treatment for OA, but the research CFAs—but then, no one appears to available at the following website: is far from conclusive, and some be looking. This suggests that, in http://celadrininfo.com/studies/ claims go far beyond the current particular, there need to be studies SafetyHumans.pdf. evidence. Indeed, while some claim to determine the effects of their Another small study found that that these fatty acids are more long-term use. Celadrin together with glucosamine effective than glucosamine and Joanna Evans

WDDTY Chronic pain 25

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Tested treatments The next Russian revolution SCENAR is a new way of their condition (Kossovski I. ‘An Overview of

healing that challenges the the Basic Results of a SI Medicine Treatment world’s cash-strapped Complex.’ MediSCEN Inc., 2001). healthcare systems The sole study published in a West- he ‘Russian problem’ ern medical journal pitted SCENAR Tused to mean the spread against TENS (transcutaneous electric-of Communism to the al nerve stimulation). In this trial, 24West. Today, the term chronic neck-pain sufferers received could just as easily be applied to six months of treatment with either SCENAR frequency modulation and, a new healing modality, SCENAR or TENS, or no treatment using biofeedback, begins a ‘dialogue’ developed behind the Iron (controls). The researchers reported with the patient’s central nervous Curtain during the Cold War and that the SCENAR group showed system. Eventually, SCENAR is said to which, its advocates claim, will “significant reduction” of neck pain stimulate neuropeptides in damaged revolutionize Western medicine. and disability compared with either the cells to speed recovery by helping cells TENS or control group. They also to ‘remember’ their healthy signature The SCENAR (Self-Controlled pointed out that none of those in the state. The healing process continues Energo-Neuro-Adaptive Regulation) SCENAR group reported any adverse long after the session ends, although it device is the size of a TV remote, and reactions (Chiropractic & Osteopathy, 2007; may take many sessions to achieve full runs on a single 9-V battery. 15: 9; doi: 10.1186/1746-1340-15-9). health, depending on how chronic the Researchers and doctors in Russia The device has also been used by condition is. claim that it can reverse most diseases athletes to speed recovery time after However, if the problem is acute, without drugs or surgery. In the UK, it’s injury. French football star Djibril Cisse such as a sports injury, SCENAR practi- licensed as a pain-relief device. has prepared a YouTube testimonial, tioners say the device can heal the The problem—like so much of alter- claiming the SCENAR helped him to problem even before bruising appears. native medicine that doesn’t enjoy the recover more quickly from an ankle sizeable profits of the drugs industry— injury. Also, SCENAR is currently being SCENAR in the West is the lack of ‘good’ scientific evidence used by the Greek professional football SCENAR is becoming part of the from a double-blind placebo-controlled team Panathinaikos, based in Athens. accepted medical therapy in Russia, trial to support such ambitious claims. and is now being used in clinics and There are, however, thousands of How does it work? hospitals. It is also gaining a foothold in case studies gathered from the 10,000 SCENAR has been described as ‘elec- Germany, where there are around 3000 thera-pists and doctors in Russia who tronic acupuncture’ and ‘space-age practitioners. routinely use SCENAR in their medicine’, the latter in reference to its However, inroads into the UK market practices. Dr Yuri Gorfinkel, who use in the late 1970s as a healing aid have been more torturous. There have became a SCENAR therapist after for cosmonauts training in zero gravity. been several attempts to introduce it working in the Chernobyl clean-up Although Dr Alexander Karasev into Great Britain, but infighting and operations, has collated 18,255 case invented the device in 1976, it was dev- squabbles between various competing studies of SCENAR treatments for eloped by two electronics engineers, groups have impeded its progress. almost every conceivable disease—from who were awarded the Order of Lenin Today, the SCENAR licence for the UK gastritis, haemorrhoids and impotence for their work. The technology was and Ireland is held by 21st Century to bronchitis, hypertension and acute secret and ‘classified’ until Perestroika Energy Medicine, and its CEO is former heart failure. Of these patients, there in the mid-1980s opened up the Soviet IT consultant Richard Cumbers. was no recurrence in 88.5 per cent of Union. It was then that SCENAR was SCENAR is officially distributed in the cases, while 6 per cent reported “signif- made available to Russian doctors. UK by its sister company Pain Genie. icant improvement” in symptoms, with SCENAR is a simple hand-held Nevertheless, Cumbers has been only 3 per cent reporting little or no device controlled by four buttons. The forced to fight a constant battle against change for the better (SCENAR Therapy, practitioner brushes the device along black-market versions of the device, SCENAR—Medical Assessment and Expertise, the patient’s skin, looking for any which are often sold on the Internet by 1998; 4). resistance or ‘stickiness’, as SCENAR workers at the Russian factory—and at In a later report compiled by Dr Irina therapists call it. Such ‘stickiness’ a far lower price. However, the black- Kossovski, who tracked hundreds more indicates disease, inflammation or market versions don’t come with any case reports involving a similarly wide injury, while different areas of the skin training or support. range of diseases, Russian SCENAR correlate with different internal organs Cumbers sells the Pain Genie Home practitioners were said to have achieved and muscle groups, similar to the SCENAR for £469, which includesaacomplete recovery rate of around 66 acupuncture model. training manual and DVD. Although per cent, while the remaining third of Once a problem area has been some retailers believe that only properly patients reported some improvement in detected, the practitioner changes the trained practitioners should use it, 26 WDDTY Chronic pain, Cumbers promotes its use among the other ‘alternative’ device or technology. works through the ‘gold-standard’ public, although he emphasizes the As the technology is now more than clinical trials. SCENAR attacks the very importance of after-sales support. 30 years old, this is perhaps not so heart of medicine—its protocols and In the three years that he has held surprising. Nevertheless, its success theories—which is avidly guarded the SCENAR licence, Cumbers has rate is impressive—and far higher than directly by the pharmaceutical industry, trained around 1200 practitioners in that of any single drug or conventional and indirectly by medical schools and the UK. His efforts have interested a therapy. government-approved bodies, and even few doctors in the UK, including Dr But such success arouses suspicion the mainstream media. Jan Beute, from the Doncaster Royal among doctors—it all seems too good Undaunted, Cumbers and others Infirmary Accident & Emergency to be true—especially as there have nevertheless believe that the time is department. Beute, who uses his own been little independent research and now right for making a serious pitch to SCENAR on patients, has said: “The few clinical trials published in Western governments, which are looking to cut Pain Genie will save the NHS a medical journals. costs wherever they can, and whose tremendous amount of money because For SCENAR practitioners and allegiances may lean more towards the it’s so easy, cheap and effective to use.” advocates like Cumbers, this is public purse and less towards protect- There are only a handful of frustrating, as they see the technology ing the conventional medical paradigm. practitioners in the US, where it has as an inexpensive and effective They also point to the Russian health “light touch” Food and Drug Adminis- alternative within the mainstream of system, where there is already wide tration (FDA) approval as a relaxant and Western medicine, especially at a time acceptance of SCENAR. “muscle re-educator”. when the National Health System and For Prime Minister Cameron, its counterparts around the world are President Obama and other world

SCENAR and the future virtually bankrupt. leaders, it could be the start of the

In fact, there are more case studies However, the issue runs far deeper Russian problem all over again. of SCENAR effectiveness than for any than just proving that the modality Bryan Hubbard

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Tested treatments Exercise for a better back Many people who suffer Intern Med, 2005; 142: 776–85).

from back pain fear that For those who don’t have the time physical activity will do or money for personal training, more damage. But now, however, joining a yoga class may beanother useful option. In one study, research shows that patients participating in a 12-week staying active may yoga programme enjoyed significant be the key to beating back improvement in back pain and pain for good. function compared with those given a self-care exercise book. What’s (AT) is beneficial for back pain. This ost people know that more, the benefits persisted for discipline emphasizes the self- Mregular exercise will several months (Ann Intern Med, 2005; 143: perception of movement, and wasimprove their physique 849–56). recently found to be more effectiveand fitness levels, but few In yet another study, just one week than the usual care or massage as a realize that keeping active may also of intensive yoga practice—including treatment for chronic back pain. Also, be beneficial for low back pain, one postures, breathing practices, medi- just six lessons followed by prescribed of the most common causes of tation and philosophical concepts— exercises was nearly as successful as disability in the West. reduced pain-related disability and 24 lessons of AT on its own (BMJ, 2008; According to Wisconsin-based improved spinal flexibility signifi- 337: a884; doi: 10.1136/ bmj.a884). spine expert Dr Peter Ullrich, “When cantly better than a conventional Pilates, another discipline with a done in a controlled, gradual, and exercise regime (J Altern Complement focus on posture, has also produced progressive manner, active exercise Med, 2008; 14: 637–44). impressive results (J Orthop Sports Phys distributes nutrients into the disc Precisely why yoga is so effective for Ther, 2006; 36: 472–84). space and soft tissues in the back to back pain is not clear, but it appears But what about aerobic activity? Do keep the discs, muscles, ligaments to be a combination of mind–body the more vigorous forms of exercise and joints healthy. Consequently, a factors. As one report noted: “Yoga cause more harm than good? It regular exercise routine helps to may be beneficial for back pain appears not. A study of patients aged avoid stiffness and weakness, mini- because it involves physical from 30 to 60 with low back pain mize recurrences of low back pain, movement, but it may also exert found that those who indulged in and reduce the severity and duration benefits through its effects on mental aerobic exercise—walking or cycling of possible future episodes of low focus.” Mental focus may help people for 45 minutes four times a week— back pain” (www.spine-health.com). to relax tense muscles, relieve mental required significantly fewer pain- But you don’t have to take his stress, and increase their awareness of medication prescriptions and were word for it. There are numerous how they are moving and positioning given fewer physical-therapy referrals studies supporting the benefits of their body (Ann Intern Med, 2005; 143: than those who did not exercise. The exercise for low back pain. 849–56). researchers also noted that exercise Indeed, just a few weeks ago, a This synthesis between physical improved the patients’ mood—yet review by the Lausanne Institute of movement and mental focus might another excellent reason to stay active Sports Science and Physical Educa- also explain the results of a study (Spine J, 2001; 1: 95–101). tion concluded that exercise is showing that the Alexander Technique Joanna Evans effective for both the prevention and treatment of low back pain. As a treatment, exercise reduced pain and Stretch the pain away improved physical function in patients whose condition was chronic According to Dr Peter Ullrich, daily stretching is an important part of any or recurrent (Joint Bone Spine, 2008 Sep back pain exercise routine. The most important muscles to target in any 16; Epub ahead of print). back pain regimen are: Other studies have looked at u hamstrings, which run along the back of the leg, help to correct posture specific types of exercise to find out while sitting and standing; they also support the gluteus muscles in the what works best. According to one, buttocks and the hip flexors, and minimize stress on the low back the most effective exercise strategy u piriformis, which runs from the back of the femur (thigh bone) to the is an individually designed exercise sacrum (the base of the spine); when tight, this muscle can cause programme carried out under limited sciatica-like pain, and has been linked to sacroiliac joint dysfunction supervision—for example, home u psoas major, which is attached to the front portion of the lower spine and exercises with regular follow-up by a can greatly limit lower back mobility if tight, making it difficult to stand for therapist. Stretching and muscle- extended periods of time or to kneel on both knees strengthening exercises proved best u gluteus muscles of the buttocks, which support hip flexibility as well as for improving pain and function (Ann the pelvis. 28 WDDTY Chronic pain,

Your questions answered Lumbago (NICE. Interventional Procedure Overview ofLaser Lumbar Discectomy. 26 August 2003;

http://guidance.nice.org.uk/ download.aspx? o=ip075overview). A friend of mine has been As for other surgical options, the Q told he has a deter- most common operation is toiorating disc and needs a connect the two vertebrae sur-laser operation. What can rounding the problem disc (spinal be done, if anything? Are there any fusion). However, the spine inevitably alternative treatments?—C.B., via e- becomes more rigid which, in the mail long term, puts extra strain on the rest of the spine and may create pain Your friend’s problem elsewhere. Other ‘complications’ A sounds like a crumbling include eating disorders, wounddisc in the spine, called infection, urinary retention, ‘pseudo-lumbar degenerative disc arthritis’, blood clots in the lung and disease (DDD). Discs act as shock- paralysis. absorbers between the spinal One of the latest surgical vertebrae but, over time, they lose techniques is to replace the damaged their resilience. This happens to disc with an artificial one. There’s a virtually everyone over the age of 40 bionic disc that has been available for osteopathy/chiropractic and acu- but, for most of us, it isn’t a problem. about four years. Called Charité, it puncture. Unconventional man- However, it can cause chronic pain in consists of two metal plates that are ipulative techniques have been a sizeable minority. The most attached to adjacent vertebrae, notoriously underresearched, but common symptoms are low back between which is inserted an there is good evidence that pain, hip pain, or aches in the artificial disc made of polyethylene. osteopathy can help to ease lower buttocks or thighs. There may also be Its theoretical advantage is that it back pain (J Can Chiropr Assoc, 2005; 49: occasional tingling or weakness in mimics a natural disc, allowing 270–96). However, no studies appear the knees. normal spinal movement. However, to have been done on DDD per se. Nowadays, surgery is generally in practice, the bionic replacements Acupuncture can also work and is only offered as a last resort, as it’s turn out to be not nearly as tough as widely used—and not only in China. usually irreversible and invasive. Nature’s original. Serious wear, German researchers have done Nevertheless, there’s a bewildering deformations, cracks and fractures clinical trials on herniated (‘slipped’) array of surgical options, of which have forced many surgeons to rip discs, and found that acupuncture is laser treatment is just one. Laser them out and resort to simple an effective pain-reliever (Am J Chin discectomy uses a powerful laser to fusion—often causing further spinal Med, 2000; 28: 25–33). ‘vapourize’ the crumbling bits of disc damage in the process. A study from Shanghai University soft tissue. The laser is inserted In the UK, one NHS hospital group tested two types of electroac- through a small incision in the back. recently reported that the Charité upuncture, and demonstrated that The operation is claimed to be device barely improved spine ‘single-point’ acupuncture is minimally invasive, cost-effective and mobility or reduced pain, leading superior to the more usual ‘multi- free of postoperative pain, and can be them to abandon it (J Bone Joint Surg Br, point’ methods for prolapsed lumbar done in an outpatients setting. 2007; 89: 785–9). Yet, a long-term survey intervertebral discs (Zhongguo Zhen Jiu, However, the clinical evidence in a French hospital found an 82-per- 2006; 26: 319–21). isn’t all that favourable, with a recent cent success rate (Spine, 2007; 32: Finally, percutaneous electrical review concluding that there’s only 661–6). Success may depend on the nerve stimulation (PENS) uses fine “moderate” evidence of pain relief skill of the individual surgeon as needles, inserted up to 4 cm into the (Pain Physician, 2007; 10: 7–111). In fact, much as on the quality of the skin (not at acupoints), through the official UK health watchdog NICE implant. which a mild pulsed electrical (National Institute for Health and A new version of Charité has just current is passed. Clinical Excellence) is fairly been approved by the Food and Drug A placebo-controlled trial of DDD scathing, describing the procedure Administration, the US health showed that back pain was reduced as having “uncertain risks and watchdog. This uses two pieces of by 50 per cent, with major benefits”. NICE warns that it may hinged stainless steel without the improvements in mobility, sleep have serious complications, such as polyethylene cushion (FDA news, 19 July quality and general wellbeing. “damage to nerve roots, vertebral 2007). This may prove to be superior if Indeed, 81 per cent of the 60 endplates and neighbouring only because there are fewer parts to participating patients said they structures, and disc space infection”. fail. would fork out their own money to Because of the high failure rate, Ideally, though, it’s best to avoid pay for the treatment (Anesth Analg, many operations have had to be back surgery altogether. The classic 1999; 88: 841–6). Sadly, PENS is not, as repeated using conventional surgery treatment alternatives are yet, widely available.

WDDTY Chronic pain 29

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Your questions answered Help for period pain frequencies and intensities torelieve pain. A number of small

studies found high-frequency TENS to be effective for dysmenorrhoea I am aged 36, and am Taking 100 mg/ day of thiamine (Cochrane Database Syst Rev, 2002; 1: Q increasingly experiencing a (vitamin B1) may be effective: 87 CD002123). very high level of pain and per cent of patients were cured after In one trial, 42–60 per cent ofdiscomfort with each three months of treatment and patients achieved at least moderate period. I have breast pain for a week remained pain-free two months later relief, and required the use of fewer before, and then excruciating pain on (Indian J Med Res, 1996; 103: 227–31). additional analgesics (BMJ, 2006; 332: the day of my period, along with Other helpful supplements are 1134–8). vomiting and diarrhoea. I have no pyridoxine (vitamin B6), magnesi- u Heat. A randomized, controlled trial children and I’m also having difficultly um, vitamin E and fish oil, found that a heat patch (at 39° C) conceiving. I have tried quite a few particularly Neptune Krill Oil (BMJ, used for 12 hours a day was as alternative therapies to no avail, so any 2006; 332: 1134–8; Altern Med Rev, 2003; 8: effective as ibuprofen (400 mg three advice would be much appreciated.— 171–9). times a day) and more effective than D.S., via e-mail Changing your diet may also placebo in reducing pain (Obstet bring relief. Endometriosis and Gynecol, 2001; 97: 343–9). Another study Period pain—or dysme- dysmenorrhoea are known to be found that a heat wrap was better A norrhoea, in medical- related to a low intake of vegetables than paracetamol (acetaminophen)speak—affects up to 95 per and fruit, and a high intake of for pain relief over an eight-hourcent of menstruating vegetarian polyunsaturated fat, time period (J Reprod Med, 2004; 49: women (Nurs Times, 2004; 100: 40–3). ham, beef and other red meat (Eur J 739–45). Cramping lower abdominal pain is Obstet Gynecol Reprod Biol, 2007; 132: u Magnets. A 2700-gauss static common, but the pain can also extend 140–7). Another study found a magnet attached over the pelvic area to the lower back and thighs, and lead significant improvement in significantly reduced menstrual pain to nausea, vomiting, diarrhoea and menstrual pain and PMS symptoms and irritability compared with a fatigue (Aust Fam Physician, 2006; 35: 842–4, with a low-fat vegetarian diet (Obstet placebo (140-gauss) magnet (J Altern 846–9). Gynecol, 2000; 95: 245–50). Complement Med, 2005; 11: 681–7). But period pain doesn’t have to be u Herbs. A Japanese herbal u Aromatherapy and massage. In a simply endured, particularly if it’s formulation known as Toki- trial of 67 college students, impacting on your lifestyle and daily shakuyakusan—a blend of six herbs, aromatherapy (topically applied activities. But before starting any including angelica and peony root— lavender, clary sage and rose) eased treatment, you need to establish reduced menstrual pain (Am J Chin the severity of menstrual cramps (J whether you are suffering from primary Med, 1997; 25: 205–12). Together with Altern Complement Med, 2006; 12: 535–41). or secondary dysmenorrhoea. Primary another remedy called Shakuyaku- Combining aromatherapy with dysmenorrhoea is menstrual pain kanzo-to (including peony and massage is also a good idea, as a without pelvic disease; secondary liquorice), this combination may Korean study found that women dysmenorrhoea is pain associated with also help women with secondary receiving abdominal meridian an identifiable condition, usually dysmenorrhoea to conceive (Clin Exp (Kyongrak) massage had endometriosis, fibroids or pelvic Obstet Gynecol, 2003; 30: 95–8). significantly less menstrual pain inflammatory disease (BMJ, 2006; 332: u Acupuncture. When 649 women than the control group (Taehan Kanho 1134–8). with dysmenorrhoea received Hakhoe Chi, 2005; 35: 1325–32). As you are over 25 and having acupuncture (15 sessions over three u Biofeedback. A study of nine women trouble conceiving, secondary months) in addition to their usual suggested that thermal biofeedback dysmenorrhoea is a possibility, so you medical care, they saw significant may be effective for painful periods may wish to see your doctor for a improvements in pain and quality of (Biofeedback Self Regul, 1982; 7: 499–520). diagnosis. life compared with those receiving Another study reported that thermal Treating the cause of the pain is only the usual care (Am J Obstet biofeedback may be a promising more effective than treating just the Gynecol, 2008; 198: 166). Other trials treatment for menstrual pain and pain itself. Conventional treatments have also been positive, although other symptoms related to usually involve non-steroidal anti- one trial found that acupuncture endometriosis (Appl Psychophysiol inflammatory drugs (NSAIDs) or oral worked well for primary Biofeedback, 2003; 28: 279–89). contraceptives, but these have various dysmenorrhoea but was only u Relaxation techniques. High levels adverse effects and may not work in up “satisfactory” for cases of secondary of stress can greatly increase to 25 per cent of sufferers (Cochrane dysmenorrhoea (Akush Ginekol [Sofiia], dysmenorrhoea (BMJ, 2006; 332: 1134– Database Syst Rev, 2004; 3: CD002119). 1996; 35: 24–5). 8), but a review of the literature Fortunately for you, there is a variety u Transcutaneous electrical nerve suggests that relaxation techniques of alternative treatments, many with stimulation (TENS). This involves may help to relieve symptoms good evidence of success. stimulation of the skin using (Cochrane Database Syst Rev, 2007; 3: u Dietary changes and supplements. currents at various pulse CD002248). 30 WDDTY Chronic pain,

Healing Foods Endometriosis inflammation (Fertil Steril, 2008; 90 [4Suppl]: 1496–502; Fertil Steril, 2001; 76:

717–22), although whether supple- ments will benefit women in real I’ve just been diagnosed u Avoid toxic chemicals. Certain life remains to be seen. However, a Q with endometriosis, and environmental pollutants, such as daily dose of omega-3 (1080 mg ofI am having difficulty dioxins and polychlorinated eicosapentaenoic acid and 720 mgfinding information on biphenyls (PCBs), may play a role of docosahexaenoic acid) plus effective alternative treatments. in endometriosis (Environ Health 1.5 mg of vitamin E improved Can you help?—C.C., via e-mail Perspect, 2009; 117: 1070–5). Experts symptoms of dysmenorrhoea (pain- believe that over 90 per cent of ful menstruation), which may be Endometriosis is a gynae- human exposures to these related to endometriosis (AmJAcological condition where chemicals comes from food, mainly Obstet Gynecol, 1996; 174: 1335–8).cells of the mucous mem- animal fat, so eating an organic, u Take Chinese herbs. A review of allbrane lining the womb wholefood diet low in animal fats randomized controlled trials found become deposited elsewhere in the may be beneficial. that Chinese herbals were just as body. It affects around 10 per cent of u Limit caffeine. Caffeine intake may effective as the hormone drugs women of reproductive age, causing be related to endometriosis and gestrinone and danazol for symptoms such as painful, heavy or infertility. Women who consumed symptom relief—with fewer side- irregular periods, bowel and bladder more than 5 g/month of caffeine effects (Cochrane Database Syst Rev, problems, tiredness, insomnia and (about 1.5 cups of coffee a day) 2009; 3: CD006568). A variety of herbs depression. However, some cases have were nearly twice as likely to have can be used, so be sure to consult a no symptoms at all. endometriosis and be infertile as a qualified practitioner for advice. Endometrial deposits are most result (Am J Epidemiol, 1993; 137: u Consider curcumin. Derived from commonly found on the ovaries, 1353–60). the popular Indian spice turmeric, fallopian tubes and peritoneum. But u Eat more fruit & veg. In more than curcumin has properties that other sites may be involved—even, in 1000 women in northern Italy, suggest benefit for endometriosis. rare cases, the eye. The cells then those with low intakes of fresh fruit A study in mice showed significant behave just as they do in the womb, and green vegetables had a signifi- antiendometriosis effects, although bleeding during menstruation, caus- cantly higher risk of endometriosis. these results may not necessarily ing inflammation and often forming Those who ate a lot of beef and red apply to humans (Indian J Biochem fibrous adhesions that make organs meat were also more likely to have Biophys, 2009; 46: 59–65). stick to each other. Inflammation or the disease (Hum Reprod, 2004; 19: u Try acupuncture. This well-known scarring of the reproductive organs, 1755–9). pain treatment was both safe and particularly the fallopian tubes, can u Exercise. This may influence the effective for endometriosis-related result in infertility. risk of endometriosis. Women who pelvic pain in adolescents (J Pediatr No one knows exactly what causes reported frequent, high-intensity, Adolesc Gynecol, 2008; 21: 247–57), and endometriosis or how to cure it, so physical activity had a 76-per-cent was just as effective, if not more so, the goals of conventional medicine lower risk than those who did not than the drug danazol in relieving are pain relief, slowing its progression engage in any such physical activity symptoms—and again, with far and relieving infertility, if present. (Am J Epidemiol, 2003; 158: 156–64). fewer side-effects (Zhongguo Zhen Jiu, However, the treatments prescribed— u Increase antioxidants. Endometri- 2006; 26: 863–5). painkillers, hormonal drugs and osis sufferers were found to haveauUse biofeedback. A small study of surgery—all come with high rates of lower intake of antioxidants (vita- five women reported that thermal recurrence and significant risks (Coch- mins A, C and E, zinc and copper) biofeedback helped to improve the rane Database Syst Rev, 2009; 3: CD006568). than women without the disease. pain and other symptoms of endo- Gonadotropin-releasing hormone Consuming more of these nutrients metriosis (Appl Psychophysiol Biofeed- (GnRH) agonists, for example, among through either diet or supplements back, 2003; 28: 279–89). Other mind– the most popular drugs for the may help (Reprod Biol Endocrinol, 2009; body techniques, such as hypnosis condition, can induce a ‘pseudo- 7: 54). Indeed, in women with pelvic and meditation, may also help to menopause’, complete with hot pain possibly due to endometriosis, control endometriosis-related pain flushes, vaginal atrophy, mood swings taking vitamins E (1200 IU/day) (see Special Report, pp 6–9). and osteoporosis (Aust Fam Physician, and C (1000 mg/day) for two u Join a support group. Sharing with 2006; 35: 864–7). Happily, there are safer months led to improvement in pain other sufferers may also help in ways to manage the condition. in 43 per cent of cases. In contrast, coping with the condition. When none of the women taking a place- women had a chance to speak with

Alternative approaches bo reported pain relief (Townsend other endometriosis patients and

Although more research is needed, Lett, 2004; 253/254: 36). to meet with a counsellor, they all the evidence so far suggests that the u Boost omega-3 fats. Animal and reported being highly satisfied with following may be helpful for women test-tube experiments show that their overall care (J Psychosom Obstet with endometriosis. omega-3s can help by reducing Gynaecol, 1997; 18: 255–8).

WDDTY Chronic pain 31

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Your questions answered Phantom-limb pain another trial, TENS took four weeksto work but, after four months, the

treated patients reported signifi- cantly less PLP than the controls Since my friend had a analgesics and opioids to antidep- (J Bone Joint Surg Br, 1988; 70: 109–12). Q below-knee amputation ressants and anticonvulsants, all of Another promising treatment isfive months ago, she’s which come with a truckload of side- acupuncture. Similar to TENS, elec-been troubled by severe effects—and may be no better than trical stimulation of acupoints was phantom-limb pain and itching where a placebo (Lancet Neurol, 2002; 1: 182–9). effective at reducing PLP by an her lower leg once was. Doctors have Surgery is another option but, average of 66 per cent in controlled prescribed drugs, which help, but the here again, results are generally studies (Pain, 1975; 1: 357–73). Tradi- side-effects have stopped her from disappointing (Br J Anaesth, 2001; 87: tional needle acupuncture may also using them. Are there any effective 107–16). However, a recent uncontrol- be beneficial (Minerva Med, 1979; 70: alternative treatments available?— led study found that surgical treat- 3843–51; Arch Phys Med Rehabil, 1981; A.C., via e-mail ment of the peripheral nerve was 62: 229–31). Needling of the residual successful in reducing PLP in 14 of limb according to Western medical First described more than the 15 patients involved (Plast Reconstr acupuncture resulted in complete A 500 years ago, phantom- Surg, 2006; 118: 1562–72). Deep brain relief of PLP and other sensations inlimb pain (PLP) is the stimulation also alleviated PLP— two out of three patients (Acupunctstrange phenomenon of albeit in only three sufferers (J Clin Med, 2004; 22: 93–7). feeling pain in a limb that has been Neurosci, 2005; 12: 399–404). Neverthe- Another option to consider is amputated. Although the limb is less, it’s clear that more research is Farabloc, a nylon and stainless-steel gone, the nerve endings at the site needed. In the meantime, there are fabric that is meant to be worn over of the amputation continue to send far less-invasive treatments on offer. the site of amputation. The manu- signals to the brain that make it One of them is transcutaneous facturer claims that it filters out think that the limb is still there. electrical nerve stimulation (TENS), harmful electromagnetic waves that Almost all amputees feel at least a safe and painless technique that aggravate the severed nerve endings. some sort of sensation in the missing involves sending a weak electrical A study cited on their website limb such as tingling, itching and current to specific points on the skin (www.farabloc.com) has been pub- heat or cold. But up to 80 per cent overlying a nerve pathway. In a lished and, according to the results, suffer actual pain—from throbbing placebo-controlled study, TENS it may be effective in reducing PLP and stabbing pain to cramping and applied to the outer ear reduced (Can J Rehab, 1993; 6: 155–61). burning—which can persist for years PLP as well as non-painful phantom- Finally, there’s evidence that after the surgery (Lancet Neurol, 2002; limb sensations in amputees (J Pain ‘rewiring’ the brain can help to deal 1: 182–9). Symptom Manage, 1991; 6: 73–83). In with the pain (see box). Although particularly common after amputation of an arm or leg, it can also occur with removal of other Brain over pain body parts—after mastectomy or There is evidence to support the use of biofeedback, hypnosis and relaxation tooth extraction, for example. Rarely, training in PLP (Appl Psychophysiol Biofeedback, 2005; 30: 83–93; Clin Rehab, 2002; PLP has been reported in people born 16: 368–77). One way these techniques may work is by reducing stress, thought without limbs. to be a factor in PLP (J Psychosom Res, 1990; 34: 71–7). In one study of 16 PLP The precise cause of PLP remains patients—two recent amputees and 14 with chronic pain—muscle-relaxation unclear and it’s notoriously difficult exercises combined with biofeedback resulted in virtually complete pain relief in to manage. As one study noted, more than half the participants. Moreover, these results were sustained for up to “So far, none of the more than 40 three years (Pain, 1979; 6: 47–55). treatment methods has proven to be A particularly novel treatment for PLP is the use of a mirror box to produce really effective” (Zentralbl Chir, 2005; 130: the illusion of two healthy limbs. Using such visual feedback, the patient is 55–9). Even more shocking, a 2006 able to ‘move’ the phantom limb and release it from a potentially painful survey revealed that 53 per cent of position. Mirror-box therapy has proved useful for upper- and lower-limb patients with PLP—38 per cent of amputees (Disabil Rehabil, 2004; 26: 901–4). whom had severe pain—received no Similarly, virtual reality may combat PLP. UK scientists have reported that PLP treatment whatsoever (Arch Phys Med may be relieved by attaching the real limb to an interface that allowed Rehabil, 2006; 87: 270–7). the sufferer to see two limbs moving in a computer-generated simulation (Disabil

Treatment options Rehabil, 2007; 29: 1465–9).

These techniques may work by increasing a sense of control over the Pharmaceuticals are usually the first phantom limb which, in turn, rewires the brain. Indeed, amputees who used a course of action for PLP sufferers, fully functioning prosthesis on the affected limb showed significant reductions although there are no specific drugs in PLP whereas the controls, wearing a cosmetic prosthesis with little for the condition. Your friend could functionality, showed no changes (Neurosci Lett, 1999; 272: 131–4). have been prescribed anything from 32 WDDTY Chronic pain,

Carpal tunnel syndrome

I’ve recently been of the upper body, along with manifestation of a deficiency of this Q diagnosed with carpal relaxation twice a week for eight vitamin, as some sufferers dotunnel syndrome in my weeks, significantly improved their experience pain relief with itsright hand, probably grip strength and pain reduction supplementation. However, so far, related to my job, which involves using compared with the controls (JAMA, studies have been poorly designed a computer mouse for long hours. Can 1998; 280: 1601–3). and inconclusive (Nutr Rev, 2004; 62: you recommend any effective u Massage. The results of a recent 96–104). Nevertheless, given the low treatments that don’t involve drugs or preliminary study suggest that both risk of toxicity at the suggested surgery?—J.F., London targeted and general massage may doses, it may not hurt to try B6 be useful for CTS sufferers. Targeted supplements at dosages up Carpal tunnel syndrome massage may be especially to 200 mg/day (J Am Acad Nurse Pract, A (CTS) is caused by beneficial, as it resulted in greater 2003; 15: 18–22).compression of the median gains in grip strength than general u C-TRAC. This new hand-tractionnerve, which runs through a massage (J Altern Complement Med, 2008; device (see www. carpaldoctors.com U-shaped space in the wrist called the 14: 259–67). or www.carpaltunnelcure.co.uk) has ‘carpal tunnel’. Symptoms include u Heat. Heat-wrap therapy can relieve proved to be both effective and well numbness, tingling, pain and weakness various types of wrist pain, including tolerated when used for only 5 in one or both wrists and hands. In CTS, within one to three days. In minutes, three times a day, in a severe cases, the condition can lead to addition, it improves grip strength, recent study of CTS patients, all of a permanent loss of feeling in some joint stiffness and hand function whom had failed to respond to fingers. (Arch Phys Med Rehabil, 2004; 85: conservative therapy. Overall, 79 per Repetitive computer use is 1409–16), so try applying a warm cent of patients rated the treatment commonly assumed to cause CTS, but compress to the wrist several times as excellent; however, the study had the scientific evidence is unclear. In a day. no control group for comparison (J one US study, the frequency of CTS in u Vitamin B6. CTS might be a Hand Ther, 2007; 20: 20–7). computer users was similar to that of the general population (Neurology, 2001; 56: 1568–70). In a Danish one, however, Less strain, less pain people who used a mouse device for more than 20 hours a week had a By far, the best way to treat carpal tunnel syndrome (CTS) is to deal with higher risk of developing CTS (JAMA, whatever’s causing it. Making the following changes may reduce repetitive 2003; 289: 2963–9). strain while you work. Other conditions can contribute to u Improve your posture. Make sure that you are sitting properly, and that CTS, including diabetes, inflammatory your keyboard and monitor are positioned correctly: arthritis, untreated thyroid disease and v your back should be straight and not slouching, and you shouldn’t pregnancy (J Gen Intern Med, 1999; 14: be stretching forward 310–4). In your case, assuming an v you should be looking down at your monitor, and it should be at least underlying condition has been ruled an arm’s length away out, the following may help. v your chair and keyboard should be set so that the thighs and forearms u Osteopathy. This has proven suc- are horizontal and level cess in treating CTS, especially v your wrists should remain straight when typing, and not be bent down using the ‘opponens roll’ man- or back, and they shouldn’t be resting on anything when typing. oeuvre. Used together with self- u Warm up. Before you begin work, warm up your muscle groups with a stretching exercises, it resulted in few simple exercises, just as you would prepare your body before less restricted wrist movement and beginning a workout at a gym. improved nerve conduction in all u Take frequent breaks. Give your hands and wrists a break every 15–20 treated wrists (J Am Osteopath Assoc, minutes by gently stretching and bending them. Alternate with other 1994; 94: 647). tasks whenever possible. u Yoga. A study published in a pres- u Change your mouse. Choose a mouse design that fits your hand, but is tigious medical journal found that a as flat as possible to reduce wrist extension. Consider a larger mouse yoga-based regimen was more such as the Perfit or Whale mouse, or try a pen-shaped design for a more effective than wrist splints or no comfortable grip. In one study, a mouse with a pivoting pen-shaped treatment in relieving the handle significantly reduced muscle tension (Int J Occup Saf symptoms and signs of CTS. The Ergon, 2003; 9: 463–77). study participants—median age 52 For more tips on how to improve your computer workstation, visit the years—who practised 11 yoga Cornell University Ergonomics Web at www.ergo.human.cornell.edu. postures that worked the joints

WDDTY Chronic pain 33

,

Your questions answered Ulcerative colitis

I’ve recently been Avoiding sulphur-containing amino Q diagnosed with ulcera- acids (such as eggs, cheese, wholetive colitis. My doctor milk, ice cream, mayonnaise, soywants to start me on milk, wine, mineral water, nuts and drug therapy as soon as possible, cruciferous vegetables) can also ease but I’d rather try natural treatments symptoms and reduce relapse rates first. What do you suggest?—C.S., (Altern Med Rev, 2003; 8: 247–83). via e-mail u Increase fibre. Too little fibre increases the risk of UC, so a high- Ulcerative colitis (UC) is fibre diet might be protective in patients with UC and otherAatype of inflammatory (Digestion, 1989; 44: 217–21). Specifically, irritable bowel disorders (IBDs) havebowel disease (IBD) that psyllium husks (4–10 g twice a day) proved promising (Wien Med Wochen-leads to frequent bowel and germinated barley foodstuff schr, 2002; 152: 373–8). In one study, 82 movements and diarrhoea accom- (GBF; 10 g twice a day) may be per cent of UC patients treated with panied by blood or mucus; other especially beneficial (Altern Med Rev, the resin (350 mg three times a day symptoms include weight loss, 2003; 8: 247–83). During flare-ups, how- for six weeks) achieved remission vs abdominal cramps, anaemia, fever ever, fibre may need to be reduced 75 per cent with the drug sulpha- and fatigue. No one knows for sure until inflammation subsides. salazine (Eur J Med Res, 1997; 2: 37–43). what triggers UC, but it appears to u Limit sugar and fat. A high Another natural anti-inflamma- be a combination of genetic and intake of sugar and animal fat is tory is aloe vera. In a double-blind environmental factors. associated with an increased risk for trial, oral aloe gel resulted in Conventional treatment usually UC (Gut, 1997; 40: 754–60). remission or improved symptoms in involves drug therapy or surgery. u Take probiotics. In a double- 47 per cent compared with 14 per However, both options are risky and blind trial of 116 UC sufferers, cent with placebo (Aliment Pharmacol not always effective. Indeed, 40–60 therapy with a non-pathogenic strain Ther, 2004; 19: 739–47). Other helpful per cent of IBD patients will not of Escherichia coli was as effective herbs are Ginkgo biloba, ginger, slip- benefit from the available treatments as low-dose mesalazine for control- pery elm, fenugreek and devil’s claw (J Clin Gastroenterol, 2007; 41: 799–809). ling symptoms and maintaining (Carcinogenesis, 2008 Jun 20, Epub ahead of It’s not surprising, then, that so remission. Both achieved around 70- print; J Ethnopharmacol, 2008 May 15, Epub many sufferers turn to alternative per-cent remission, lasting for about ahead of print; Aliment Pharmacol Ther, 2002; ways to manage UC naturally. six months on average (Lancet, 1999; 16: 197–205). 354: 635–9). A combination using four u Melatonin. This natural hor-

Nutritional strategies strains of Lactobacillus, three strains mone may be useful in the treatment

u Address deficiencies. Working of Bifidobacterium and one strain of of UC (Inflamm Bowel Dis, 2008 Jul 14, with a qualified health practitioner Streptococcus has also proved to be Epub ahead of print). However, while to identify and correct nutritional beneficial (Drugs, 2006; 66: 1371–87). melatonin is freely available as a deficiencies may improve specific u Try EFAs. Fish-oil supplements, supplement in the US, it’s difficult symptoms as well as overall health. rich in omega-3 fatty acids, can to find in the UK and other European Helpful supplements are vitamins A, reduce inflammation and lower the countries. Also, further study is C, E and K as well as beta-carotene, need for anti-inflammatory drugs. needed on its side-effects and folic acid, calcium, magnesium, With few exceptions, studies show potential drug interactions. selenium and zinc (Altern Med Rev, 2003; its beneficial effects in UC patients u Hypnotherapy. A recent UK 8: 247–83). (Altern Med Rev, 2003; 8: 247–83). The study had 17 patients with active u Rule out allergy. Although recommended dosage is 1–2 g of UC undergo a 50-minute session of doctors continue to rebut any link EPA/DHA three times a day. ‘gut-focused’ hypnotherapy and com- between food allergy and UC, this u Other nutrients. Bromelain pared them with controls who may be one of the first things to (0.5–1 g twice a day), quercetin (500 listened to music. Blood levels of check. UC sufferers put on an elim- mg two or three times a day) and interleukin-6, a marker of inflamma- ination diet excluding commonly glutamine (1.5–3 g/day) may help to tion in the body, fell by 53 per cent allergenic foods had significantly improve symptoms of UC (Altern Med in the hypnosis group, whereas the fewer symptoms (primarily diarrhoea Rev, 2003; 8: 247–83). music-listeners showed no changes and rectal bleeding) compared with whatsoever (Am J Gastroenterol, 2008; 103: patients on a normal diet. Foods Other natural treatments 1460–9). likely to trigger symptoms include u Herbs. The gum resin of Bos- For more information on UC and dairy, pork, tomatoes, spicy foods, wellia serrata (Indian frankincense) IBDs, see The WDDTY Guide to Good citrus fruit, apples, grapes and is a traditional Ayurvedic remedy for Digestion, which is available from our shellfish (S Afr Med J, 1995; 85: 1176–9). inflammatory diseases. Clinical trials website at www.wddty.com. 34 WDDTY Chronic pain,

Osteoarthritis

Is there an alternative disease (Lancet, 1985; ii: 11-3; Am J Mrf, Qway of dealing with 2987; 83: Suppl 5A: 29-34), largelyosteoarthritis, specifically because NSAIDs inhibit cartilagespondylitis? As you are repair and speed up cartilage no doubt aware, orthodox medicine destruction (J Rheumatol, 1982; 9: 3-5). has no answer. In fact, following an X- Although modern medicine argues ray, which established that three of that osteoarthritis is a natural my vertebrae of the neck were without consequence of growing older, it is the cushioning discs, my doctor flatly not true that cartilage loss is stated that there is no treatment.— inevitable. Poor nutritional status or P.B, Ipswich food intolerance may create the deficiencies that lead to collagen Osteoarthritis (OA) has destruction. A always been considered an Your first port of call should be toinevitable feature of determine whether your problem isageing, only because it caused by allergy or intolerance to affects so many people as they grow certain foods. Although OA is often older. Some surveys reckon that 80 associated with the presence of per cent of those over 50, usually certain antigens in the body, few women, have the disease. OA involves doctors associate OA with allergies. that vitamin E inhibits the enzymes the degeneration or destruction of But there is a connection with the which break down collagen; in one cartilage, after which the joint drugs usually dispensed for this clinical trial, OA patients given 600 hardens and the cartilage is replaced condition. NSAIDs make the gut IU of vitamin E significantly by large bone spurs, called calcified more permeable, increasing a improved (J Am Geriatrics Society, 1978; 26: osteophytes, in the spaces between person’s chances of becoming food 328-30). Both vitamins have certain the joints. However, unlike sensitive (Melvyn Werbach, Healing Through synergistic effects in slowing the rheumatoid arthritis, there is only Nutrition, Thorsons, 1995). destruction of cartilage and so slight inflammation, if any. There are also many anecdotal should be taken together. Although osteoarthritis principally reports of patients whose Large doses of niacinamide, or affects the joints of the hand, knees osteoarthritis improves once they vitamin B3 (900 mg4gtaken in and hips, it can also involve the remove foods usually known to spark divided doses), have been long spine. Spondylitis is an inflammation off arthritis such as the nightshade advocated as a treatment for OA. In of one or more vertebrae of the spine. family (potatoes, tomato, bell one study, 663 patients receiving It is true that general wear and peppers, aubergine). The best way of niacinamide had a greater range of tear on the joints is one cause of determining which foods may be movement , compared with controls osteoarthritis, causing a breakdown exacerbating your problem is to (J Am Geriatric Society, 1955; 3: 927). One in the network of the cartilage and undergo a controlled exclusion diet, patient of WDDTY panellist Melvyn often the release of enzymes which noting when certain foods make your Werbach’s was so crippled she could further destroy collagen. The reason condition worse, or to use barely get up out of her chair; three OA mostly affects people over 50 neutralizing/desensitizing methods months after taking 250 mg of usually has to do with a lessening of to isolate the foods which may be niacinamide every 11/2 hours (for a their body’s ability to synthesise causing the problem (see the WDDTY maxmum of 10 doses per day) she collagen. Allergy Handbook). had regained her strength, could Other causes of osteoarthritis walk on her own and get in and out of include hormonal changes, trauma, Antioxidants chairs and bed. Setbacks only rheumatoid arthritis or even surgery. Another possible culprit is low levels occurred if she used her hands too The usual medical solution is to of certain antioxidants. Vitamin C, much in knitting, which would offer pain killers (nonsteroidal anti which is necessary for collagen temporarily reduce mobility. inflammatory drugs NSAIDs) or to synthesis, is often deficient in the One caveat: you should never wait until the joint is completely elderly. In one study, comparing OA embark on this kind of regime destroyed and then to offer major patients given vitamin C, beta without careful medical supervision joint replacement surgery. carotene and vitamin E against as high levels of niacinamide can What is little known, according to controls, those taking high doses of cause liver damage and glucose US naturopaths Joseph Pizzorno and vitamin C reduced the rate in which intolerance, among other side Michael Murray, is that modern cartilage was lost by 70 per cent effects. medicine’s treatment of OA usually (Arthritis Rheum, 1996; 39: 648-56). Another good natural remedy is makes the problem worse. NSAID use Vitamin E is also essential to boron. Naturopath Rex Newnham simply speeds the progress of the collagen repair. Studies have shown reports positive results with boron

WDDTY Chronic pain 35

,

Your questions answered

supplementation. In one double relieves pain better than NSAIDs and, chondroitin sulphate, one of the blind (admittedly small) trial, half unlike the drugs, apparently helps to main glycosaminoglycans found in the boron patients improved, reverse the disease process, cartilage, and so another of its compared to only one tenth on stimulating the synthesis of building blocks. CS is generally placebo (J Nutri Med, 1990; 1: 127-32). Dr cartilage. made from bovine, whale and shark Werbach suggests that since the In a large scale study of more than cartilage. Glucosamine sulphate minimum daily allowance for boron 1000 Portuguese arthritis patients and chondroitin sulphates supp- hasn’t been established, patients given glucosamine sulphate for two osedly have synergistic effects. increase consumption of boron rich months, pain symptoms and Patients having a proprietary foods: vegetables, such as soy, movement improved significantly in form of chondroitin injections have cabbage, lettuce and peas; fruits, 59 per cent and “sufficiently” in been shown to have joint changes such as apples, dates, raisins and another 36 per cent (Int J Tissue Ract, visible on X-ray (Semin Arth Rheum, prunes; and nuts, especially almonds, 1992; 14: 243-51). 1987; 17: 2: Supple 1: 35-53) and a hazelnuts and peanuts. In another study, of 80 OA reduced narrowing of joint spaces B12 and folic acid may also play a patients given either 500 mg of (Rheumatol Med Int, 1986; 20: 24-8). role in controlling joint pain. In one glucosamine sulphate three times a Although glucosamine seems to study of 26 OA sufferers, these two B day (a standard dose) or a placebo, have no side effects in standard vitamins were more effective than those taking glucosamine had a doses, intramuscular doses of drugs in controlling hand joint pain significantly larger reduction in chondroitin have been linked with (J Am College Nutrition, 1994; 13; 351-6). overall symptoms, compared with the severe kidney liver toxicity (Lancet, placebo group (73 per cent vs 41 per 1989; 1:1275).

Glucosamine cent), after a month on the regime. Other potentially useful

Some researchers have theorized An electron microscopy sample of alternative solutions include New that arthritis is the result of cartilage from the treated patients Zealand green lipped mussel extract abnormal glucosamine metabolism. showed evidence of new growth (Clin (Lancet, 1981; i: 439); the antioxidant Glucosamine is one of the chief Ther, 1980; 3: 260-72). superoxide dismutase; omega-3 components of the proteoglycans, a In another double blind study, fatty acids, largely found in flaxseed major building block of cartilage. It where glucosamine sulphate was and fish oils; zinc; and sulphur, seems to work by stopping the compared with ibuprofen, a popular taken as colloidal sulphur or proteoglycans from breaking down NSAID, the ibuprofen group sulphur baths. Capsaicin cream and rebuilds damaged cartilage recorded a better response initially. (made from chili peppers) has been (Orthop Praxis, 1970; 9: 225). Sulphate, However, the glucosamine group found to reduce pain and tenderness another naturally occurring experienced a steady improvement by 40 per cent (J Rheumatology, 1992; 19: substance, appears to strengthen with pain to the point where by the 604-7). As for herbs, extract of yucca glucosamine’s effect (Pharma- second month, their improvement and devil’s claw (Harpagophytum therpeutica, 1981; 2: 504-8). outstripped that of the drug takers procumbens) have both been found The research on glucosamine (Curr Med Res Opin, 1982; 8: 145-9). to reduce pain and increase mobility sulphate demonstrates that it Glucosamine is often sold with (J Applied Nutrition, 1987; 27: 45-50). 36 WDDTY Chronic pain]
15

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