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
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.
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
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
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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