PAIN MANAGEMENT

PAIN + STRUGGLE = SUFFERING

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Dietary ingredients to relieve musculoskeletal painMany over-the-counter products are available for relief of musculoskeletal pain. Some are based on “dietary ingredients”—substances the Food and Drug Administration (FDA) has accepted for use in foods or dietary supplements. Such products are available in the form of capsules, tablets, powders, liquids, topical creams, and patches. The first 4 potentially qualify as dietary supplements, which (by definition) must be taken by mouth; the last 2 do not. How well do they work? Researchers at the Consortium for Health and Military Performance (CHAMP) at the Uniformed Services University recently conducted an in-depth search of the scientific literature to gather all the reliable evidence together into a resource to help you make informed choices when considering non-drug products for musculoskeletal pain. Below are lists of ingredients grouped according to whether they have sufficient reliable evidence of possible effectiveness, lack such evidence, or have evidence showing that undesirable effects outweigh any possible benefit with regard to relieving musculoskeletal pain. Some of these ingredients do have potential benefits for other uses, so it’s important to keep in mind that this discussion is limited to the effects on musculoskeletal pain. What’s the evidence? A diverse group of experts, both military and civilian, with expertise in human performance, dietary supplements, nutrition, and pain reviewed the results of CHAMP’s evaluation of the literature and developed evidence-based recommendations for the Special Operations community. The results, summarized here, are also useful for Warfighters in general. The study was sponsored by the U.S. Special Operations Command’s Preservation of the Force and Family Behavioral Health Program (POTFF). Possibly effective dietary ingredients The following dietary ingredients might help alleviate musculoskeletal pain with little to no risk of any harmful side effects (adverse events). Some can be taken as part of a balanced diet, others as a dietary supplement, and some as a topical (cream, patch) application. Note: They should be used only after consulting a healthcare provider. Avocado soybean unsaponifiables (ASU) are made from one-third avocado oil and two-thirds soybean oil. ASU might reduce pain and improve function for some users. Studies have used 300–600 mg per day of ASU for 3 months to 3 years, although this is based on research with a single commercial product. Reported side effects include minor gastrointestinal complaints. Capsaicin is a primary constituent of the Capsicum species of chili peppers. Capsicum is grown worldwide and adds color, pungency (“heat”), and aroma to food. Studies have reported significant pain reduction within 4 weeks from using a capsaicin cream applied to the skin. Most creams contain 0.025–0.075% capsaicin and can be applied 3 or 4 times a day. Some users report burning, itching, and irritation, especially when used at higher doses such as 0.25%. Initial use should begin at a lower dose. Curcuma, or turmeric, is a spice that comes from a plant grown throughout India, other parts of Asia, and Central America. Turmeric root and powder are available as grocery items for cooking. Research studies using doses of 700–2,000 mg per day over 6–12 weeks have shown significant pain reduction. The only reported side effects are minor gastrointestinal complaints. Insufficient evidence exists for its effectiveness as a dietary supplement, but 500 mg 2 or 3 times a day can be incorporated into cooking. Ginger is a tropical plant widely used as a flavoring or fragrance in foods, beverages, soaps, and cosmetics. Common forms include fresh or dried root, tablets, capsules, liquid extracts, and teas. As a dietary supplement, it doesn’t appear to be as effective as other ingredients listed here, but it poses no additional risk when used in food or tea to help with pain. Minor complaints of bad taste or stomach upset have been reported. In research, doses of 250–1,000 mg per day over 3–12 weeks have been used, with higher doses producing greater benefits. As with curcumin, it can be incorporated into cooking. Glucosamine is produced naturally in the human body, but it is also available in prescription and over-the-counter products. The most effective form to reduce pain seems to be crystalline glucosamine sulfate (pCGS) at a dose of 1500 mg per day. Little reliable evidence is available for over-the-counter versions, for which dosing and formulas vary. Side effects of 1,500 mg pCGS include nausea, heartburn, diarrhea, constipation, drowsiness, skin reaction, and headache. Effectiveness and tolerance are similar to 1200 mg per day Ibuprofen, but pCGS takes longer to be effective. (The effectiveness of pCGS combined with prescription chondroitin is still unknown. Controversy concerning the use of glucosamine sulfate and combination products containing glucosamine largely reflects the differing regulatory status, labeling, and availability of medications in different regions of the world.) Melatonin is produced by the pineal gland and plays a role in sleep, with production and release related to time of day (that is, rising in the evening and falling in the morning). It is available as both prescription and over-the-counter sleep aids. However, the research into its use to relieve musculoskeletal pain is very limited. Studies have used 3–10 mg per day over 4–8 weeks, but lower doses of 3–5 mg per day are preferred until better evidence is available. Side effects are uncommon but include drowsiness, nausea, and headache. Polyunsaturated fatty acids (PUFA): Fish oil comes from a variety of fish that provide PUFAs known as omega-3 fatty acids, (alpha-linolenic acid [ALA], eicosapentaenoic acid [EPA], and docosahexaenoic acid [DHA]). Fish oil supplements contain varying amounts of EPA and DHA (18–51% and 12–32%, respectively). ALA is mainly found in green vegetables, canola oil, and soybeans. EPA and DHA almost exclusively come from fish oil and other seafoods. Omega-3 fatty acids might help relieve pain. Studies have used various combinations and doses of PUFAs (300–9,600 mg per day over 4–48 weeks). Reported side effects include fishy aftertaste, gastrointestinal complaints, and rash. Since PUFAs are already available in food, it should be considered as a dietary source. As a supplement, one should not to exceed 1200 mg per day until we have a better understanding of the various formulations. Vitamin D is a fat-soluble vitamin that can be obtained from sun exposure, food, and dietary supplements. Vitamin D promotes calcium absorption, is necessary for bone growth, and appears to affect skeletal muscle, immune regulation, cardiovascular health, and metabolic activities. However, some limited evidence suggests it can help reduce musculoskeletal pain when used in doses of 2,000 IU per day (but not over 4,000 IU per day). Higher doses should be used only as prescribed by a healthcare provider, since excess use can lead to vitamin D toxicity. In research studies, it has been used safely up to 2 years. Buyer beware! Other dietary ingredients have been marketed to reduce musculoskeletal pain, but some lack sufficient reliable evidence of effectiveness or information enabling us to weigh the desirable against undesirable effects. Among these are: Boswellia Collagen Creatine Devil’s claw L-carnitine Methylsulfonylmethane (MSM) Pycnogenol Rose hip S-adenoysl-L-methionine Vitamin E Willow bark extract Keep in mind that the above applies only to the use of these ingredients to relieve musculoskeletal pain. At least some of them are possibly effective for other uses. When you’re considering products or ingredients to help relieve your musculoskeletal pain, remember: Consult a healthcare provider or registered dietitian before you take any dietary supplement. Use the resources at Operation Supplement Safety (OPSS), including the “red flag” article and the interactive supplement scorecard tool. Send a question to OPSS using the Ask the Expert feature. |Dietary ingredients to relieve musculoskeletal pain

Can exercise relieve chronic pain?If you struggle with chronic pain, you might feel that exercise is futile: It hurts when you don't exercise, and it hurts when you do. However, a properly structured exercise routine might help reduce your pain level or keep it from getting worse. First, it’s important to know the difference between acute pain and chronic pain. Acute pain—pain lasting less than 6 weeks—can be managed with exercise to prevent your pain from becoming long-lasting. If your pain has been continuous without breaks for more than 3 months—that is, it has become chronic—exercise also might be helpful to manage or reduce your pain, although exercising might be more difficult than during the acute phase. Exercise can help reduce pain in several ways. Pain triggers the body’s “stress response,” which in turn reduces your body’s serotonin, a brain chemical partly responsible for mood and perception of pain. Exercise can boost serotonin, reducing your stress and improving your mood. For some people with depressed mood related to pain, exercising might help them feel better emotionally, as well as physically. Finally, exercise also increases endorphins—the body's natural painkillers—which help block pain, enabling you to relax. “…a properly structured exercise routine might help reduce your pain level…” If you’re thinking of adding exercise to your pain management plan, consider starting with low-intensity exercises and stretches such as those in HPRC’s Rx3 low-back pain program, but only after you discuss exercise with a healthcare provider.|Can exercise relieve chronic pain?

Take control over your painEffectively managing pain can be complicated. Some forms of pain can have emotional, mental, spiritual, and relationship consequences, but each of these elements also can help you manage your pain. The common process for dealing with pain is often too passive: You realize you are in pain. You tell your healthcare provider. He or she prescribes a medication and perhaps some things for you to do or not do. You, as the person in pain, simply follow the instructions. When you take an active role working with your healthcare provider to manage your pain, you can help protect against unwanted side effects such as dependence or potential misuse of prescribed pain medications. For example, opioid pain relievers such as oxycodone, codeine, and morphine are common medications prescribed to help individuals with moderate to severe pain, but addiction and overdose have become a national epidemic. The more involved you are in the process of managing your pain, the more likely you are to effectively use the treatments prescribed appropriately, and the more in control you will feel as you progress through your treatments. Feeling in control can be important for you to maintain hope and stay mentally strong as you manage your pain. One way you can take a more active role in your pain management is to learn about less common methods to ease your pain and, together with your healthcare provider, explore options to find a plan that will work for you. You also can use these strategies with loved ones to build your relationships, as well as maintain your spiritual, mental, and emotional health. Alternative pain-management strategies The Defense & Veterans Center for Integrative Pain Management (DVCIPM) and the Army Pain Management Task Force recommend a number of pain-management strategies that you can use alone or with other treatments to help you manage your pain. Discuss with your doctor which of these might be helpful for your situation. Yoga is gaining attention in the military as a strategy to enhance fitness and address physical pain. It often blends exercise and stretching with deliberate breathing and meditation. Yoga can sometimes help improve back pain, arthritis, fibromyalgia, and general pain. It also might help improve your mood and alleviate stress. Acupuncture is an ancient practice that can sometimes improve migraines, nausea, back pain, chronic pain, and more. Acupuncture involves the use of thin needles to prick the skin or tissue at specific points on the body. Battlefield acupuncture is a form of acupuncture using needles in just the ear, rather than in various parts of the body as with traditional acupuncture, that is easier to transport and administer in the field. Biofeedback involves sensors on your body to provide you with real-time medical data. This enables you to practice strategies such as muscle relaxation, deliberate breathing, or mental imagery to experience the immediate results on your body’s functions. Biofeedback can help you more effectively practice such strategies to reduce, for example, migraines and neck, shoulder, and back pain. Therapeutic medical massage is when a trained masseuse applies pressure to muscles or soft tissue to address a direct medical goal, such as relieving pain, compared to general relaxation. Massage can improve blood flow, calm the nervous system, and relax muscle tension to help relieve pain. Mind-body therapies also can help you relieve pain by helping shift your attention, calm your body, and relieve stress. HPRC’s “Mind-body strategies for pain” provides information on relaxation techniques, meditation, imagery, and redirection. Another mind-body strategy that can help address pain is Tai Chi, a traditional Chinese practice that involves controlled movements and breathing. Take control of your pain! Dealing with pain is not fun, but there are steps that you can put into action to take a more active role in the management of your pain. Once you’ve learned about the different strategies available, you can discuss them with your healthcare provider. It’s always important to prepare in advance for an appointment so you can ask direct questions to help your healthcare provider find the best pain management plan for you. One useful tool is the “Manage pain on your terms” handout from the Defense & Veterans Center for Integrative Pain Management. Another tool you can use to give your provider useful information is to complete the pain rating scale from the Veterans Health Administration. And explore the other articles and resources in HPRC’s Pain Management section for even more information. |Take control over your pain

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