Pain, in all of its forms, (mental, emotional and physical) is one of medicine's greatest challenges. Rarely is pain the actual disease process; rather it is almost always a symptom of imbalance in the body. Pain in all of its presentations is often the patient's greatest motivator to seek care and recovery and because of this, pain often takes precedence in expediency of care. Too often pain is treated as just that; a symptom in and of itself and oftentimes the symptom picture becomes mired in treating the patient's pain rather than working simultaneously to resolve the cause. As one of the main tenets of naturopathic medicine is to 'identify and treat the cause,' locating the causative agent(s) in pain is a large part of treatment. Losing focus on the cause of pain can easily occur in patients with overwhelming symptoms.

Pain management from the naturopathic perspective focuses on several aspects of pain, including attempts to elicit physiologic change in a person's perspective of pain. Undoubtedly, many conventional pain medicines (the majority of which are derived from plant substances, originally) provide strong and rapid treatment. These medicines are quite useful in times of unbearable pain when pain relief transcends all other treatments. In the naturopathic model of disease, pain may result (at the end of a long line) from improper care of the body, overindulgence and excess, and poor diet. Interestingly, early naturopathic doctors prescribed what we still recognize today as healthful outlets; fresh air, sunshine, good diet, 'scientific relaxation' and a positive mental attitude, among other things. Seemingly simplistic recommendations, they provide the basic framework for health, perhaps more than ever today, as the simultaneous pursuit of health while maintaining poor lifestyle habits is counterproductive. Of course, the suggestions mentioned above are far removed from today's modern chemical pain relievers, yet when combined with additional treatments utilizing natural medicines, a much-improved state of health can be achieved.

Furthermore, a focus on relieving pain from a naturopathic perspective may assist a person in avoiding the addictive perils of pharmaceutical prescriptions, including their strong and toxic side effects. What is most important is that in removing the cause, physicians deliver their greatest service by altering one's course of health away from what may be lifelong protracted pain and disability.

Dietary Factors
A primary intervention in removing pain involves creating an environment in which the tissues (referring to physical pain) affected are provided with the best opportunity for health. Techniques for improving tissue health via dietary regulation include optimizing protein intake, limiting refined carbohydrates, and ensuring adequate micronutrient and fatty acid intake. An overabundance of refined carbohydrate intake negates effective insulin metabolism, leading to weight gain and promotion of the inflammatory cascade. Inadequate protein intake limits repair of injured tissue when consumed at less than 30% of the RDA (0.8 g of protein per kg body weight per day). Foods rich in omega 6 fatty acids are known to promote inflammatory processes, cancer, autoimmune conditions, and circulatory issues.¹ Adequate synthesis of protein (and thus tissue repair) may be limited by several conditions; insufficient intake of dietary protein has been associated with immune dysfunction, impaired muscle use, decreased bone mass, decreased cognitive function, delayed healing of wounds (surgical included) and increased morbidity.² Additionally, medical conditions such as malabsorption syndromes, gastrointestinal disease, and both chronic and acute infections can lead to deficiencies of micronutrients and increased requirements for protein and energy. Finally, pain patients who strongly rely on prescription pain medications may have further compromised nutrient absorption, loss of appetite and gastrointestinal conditions.

Proteolytic Enzymes
In addition to well-recognized anti-inflammatory and anti-endemic properties, proteolytic enzymes exert analgesic effects as well. Enzyme-induced analgesia is thought to arise by their ability to limit the inflammatory cascade and directly influence nociceptors, the body's pain-sensing apparatus.³ One such widely used enzyme is bromelain. Bromelain refers to a group of enzymes that are obtained from the fruit and stem of the pineapple (Ananas comosus).⁴ Bromelain's anti-inflammatory effects are mediated by its ability to slow leukocyte migration and activation to areas of tissue injury. Other mechanisms include protein degradation at points of inflammation, depletion of kininogen, and inhibition of inflammatory prostaglandins and induction of prostaglandin E1, a prostaglandin with anti-inflammatory properties. Side effects of bromelain are limited to gastrointestinal upset, sometimes with diarrhea. One source mentioned that Ig-E mediated allergic reactions are possible when using bromelain yet this has been rarely documented.5 As for clinical application, one study evaluated bromelain's analgesic and anti-inflammatory effects in osteo- and rheumatoid arthritis patients for 3 months.⁶ Bromelain was used at doses of 200 or 400 milligrams per day. Pain evaluation was based on patient symptom scores; these were reduced by 41% (200 milligram group) and by 59% (400 milligram group). Scores for stiffness and physical function decreased significantly in the 400-milligram dose group in comparison to the low dose group. A final note by the study authors revealed that in comparison to baseline, overall psychological well being improved (with a significant dose-response relationship) in both groups after their treatments.

Another clinical trial compared a standard commercial preparation of bromelain (Phlogenzym-containing 90 milligrams bromelain) to the non-steroidal anti-inflammatory drug (NSAID) diclofenac in patients with osteoarthritis (OA).⁷ In both treatment groups, patients reported comparable reductions in joint tenderness, pain, swelling and a small improvement in range of motion 7 weeks after the conclusion of the study, while a greater improvement in joint tenderness reduction was reported in the Phlogenzym group. This study's investigators concluded that the bromelain preparation was as effective (and tolerated) for the treatment of OA. For treatment of post-surgical pain and tissue swelling, enzymes are effective as well. One interesting study divided post-surgical fracture patients into two different treatment groups; one was treated with standard anti-swelling medication and the other was treated with a proteolytic enzyme preparation.⁸

The treatment group that received the enzymes showed a continuous and significantly more rapid reduction in postoperative swelling in comparison to the control group. Additionally, the enzyme group had an average reduction in limb fluid volume of 8% while the controls actually had an increase of 100% fluid volume. Study investigators also documented an analgesic effect of the enzymes; the total amount of painkillers consumed by the enzyme treatment group was significantly lower compared to that of the control group.

Widely used for athletic injuries such as bruising and swelling and for decreasing healing time, bromelain is an effective medicine. Injuries exclusive to the musculoskeletal system (strains, sprains, ligament tears, and contusions) are well treated by bromelain's ability to decrease fibrin production, thereby allowing for improved local circulation and improved resorption of post-traumatic inflammatory components that cause pain. A study of orthopedic patients treated with bromelain demonstrated a significant decrease in swelling, tenderness, and pain at rest and movement at all followup visits when compared to baseline levels.⁹ In this particular study, patient tolerance was noted to be quite good as well, indicating a highly tolerable treatment. The previous studies are excellent examples of the demonstrable effects of enzymes at treating inflammation, edema, and resultant pain. Enzymes can also increase the speed at which tissues heal, providing a distinct advantage to short-circuiting chronic pain due to delayed injury recovery.

Botanical Medicines for Pain
A handful of herbal medicines are useful for treating pain. These medicines display analgesic, antiinflammatory, anxiolytic and sedative properties. When used in combination, they are best suited for certain conditions and are quite effective in a large part of the population. As with all pain medicines, their use must always be monitored and limited to a certain time period.

Piscidia erythrina (Jamaican dogwood)
Piscidia is derived from tropical America and the West Indies; the medicine is taken from the bark. Jamaican dogwood has several pain relieving effects; these include sedative, antiinflammatory, and an antispasmodic effect in smooth muscle.¹⁰ Historically, this herb has been used to treat neuralgia, migraine, toothache, insomnia and smooth muscle spasm, specifically in the gastrointestinal system and the uterus. Piscidia can be used for insomnia resulting from neuralgia or nervous tension as well. A medicine with powerful sedative action, relatively little research has been performed investigating this and other effects. Piscidia acts as an antitussive and antipyretic as well; little knowledge regarding these effects is known, either.

Piscidia has a reputation as a toxic herb, mainly due to its potent neuromuscular sedative effects. Piscidia has been used as a fish poison; the leaves were crushed and used to stun fish, allowing them to be easily caught. In fact, the name is derived from Latin meaning "fish killer." Additionally, extracts of this plant are effective natural pesticides. The main toxic constituent, rotenone is a mitochondrial toxin that interferes with oxygen consumption in cold-blooded animals. With this information in mind, limited amounts must be used and the risk to benefit ratio should always be assessed when using this herb. Perhaps best used for short, acute episodes of pain, and until further information is learned, Piscidia should be used for short periods of time with caution.

Corydalis cava (Corydalis) and Eschscholzia californica (California poppy)
Both of these plants have a long history of use in pain management and are often used in combination. Corydalis is typically utilized for pain resulting from nerve damage, tremors, and skeletal muscle spasms. Other uses include hypertension and gastrointestinal spasms as well. Corydalis has powerful effects; it is mainly classified in the literature as a mild sedative while other sources label it as a tranquilizer. There are several purported active ingredients in Corydalis, most of which are classified as Protoberberine alkaloids, type 2. One of these constituents, tetrahydropalmatine (THP) is a neuroactive alkaloid with analgesic and hypnotic actions.¹¹

Much remains to be learned regarding the exact effects of this herb as well. Similarly, California poppy has historical use for general aches and pains, nervous conditions (stress), insomnia, sedation, and even bedwetting in children and other bladder disorders. The active constituents of California poppy (derived from the dried stem and leaves) are identified as isoquinoline alkaloids.¹² Sometimes confused with Papaver somniferum, the opium poppy, California poppy is only distantly related (same family, different genera) and does not produce opium.

The few existing studies on these plants utilized a proprietary combination of both herbs known as Phytonoxon N that is widely used in Germany. The alkaloids derived from Corydalis rhizome (protoberberine alkaloids) exhibited a positive binding affinity to gamma amino butyric acid (GABA) receptors in one experiment.¹³ GABA receptors in the human brain, when activated, promote a down regulatory function. Meaning, that when GABA receptors are activated, certain neural activities are slowed or decreased. The effect of calming and sedation can be correlated with these receptors in the human brain.

A group of peptide chemicals in the brain, endorphins and enkephalins, are widely regarded for their pain modulating effects in humans under a number of physical stressors. These chemicals bind opioid receptors in the pain-interpreting area of the brain and can therefore alter one's perception of pain. Interestingly, extracts of Corydalis and Eschscholzia were shown to slow the degradation process of some pain-regulating peptides in the brain. This effect serves to prolong the functional activity of these peptides, thereby increasing pain modulation.¹⁴ In this particular study, Corydalis was shown to exert a greater effect on preserving pain-related peptides than did Eschscholzia. Additionally, investigators demonstrated the additive effects of both herbs on maintaining elevated levels of catecholamines; this is thought to explain the hypnotic, sedative and antidepressive activity of these medicines. These studies highlight the fascinating effects of these herbs on neurotransmitter metabolism and provide definitive answers as to how these herbs work at pain modulation.

Zingiber officinale (Ginger)
Ginger is one of the more widely used herbal medicines; it has several effects acting as an antipyretic, antibiotic, antifungal, sedative, antiemetic, antitussive, cardiac inotropic, and analgesic.¹⁵ These effects are varied and are dependent on the particular herb preparation used. The active constituents of ginger (ginerols and ginerdione) are derived from the rhizome and root of the plant. Ginger is used in pain management for its analgesic and antidepressant effects; additionally it is an inhibitor of inflammatory prostaglandins, thromboxanes and leukotriene synthesis.¹⁵ In addition, the antiplatelet aggregation effects of ginger enhance healing from bruises and contusions.
The analgesic effect of ginger is thought to be related to one of its constituents known as shagoal; this substance has inhibitory effects on the release of substance P, a neurotransmitter that is used by the sensory neurons involved in the perception of intense pain.¹⁶

For osteoarthritis (OA) pain, ginger has been shown to have a mild effect on this type of pain. Patients with moderate to severe OA pain were treated in a placebo controlled, double blind study for 6 weeks.¹⁷ Researchers concluded that the ginger extract's effects on OA pain were statistically significant in reducing symptoms of knee pain, with a moderate effect when patients were supplemented twice a day. Those treated with ginger reported less pain on standing and following walking. Adverse effects included mild gastrointestinal upset in the treatment group. Ginger is a botanical medicine that can modulate pain via several effects; its efficacy in this regard has shown it to be an effective medicine in cases of mild pain.

This brief sampling of the medicines available for pain mitigation highlights their effectiveness in pain management. Treating the pain patient can be a formidable task, regardless of medicines used. As mentioned earlier, prescription pain medicines are effective yet have fairly severe consequences in the realm of addictive potential. Treating the pain patient entirely, using diet and natural medicines, can provide a bridge between stronger, more aggressive pharmaceutical treatment and eventual recovery and remittance of their pain symptoms. Utilizing natural medicines in people with pain provides an alternative for those who cannot tolerate or do not wish to gamble with some of prescription pain medicine's risks.

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