From biking and jogging to playing golf, tennis and weekend basketball, millions of us regularly enjoy athletics. As we all know, there are many benefits to participating in sports. To do it safely, it’s important to take precautions, otherwise we run the risk of incurring injuries that not only cause us pain and inconvenience, but also cost us financially in terms of medical expenses and lost productivity.
At the Kaplan Center, we encourage all our patients to engage in some level of regular physical exercise to improve their health. Time and time again, however, we’ve found that most people can benefit from learning more about how to exercise properly — the goal being to gain strength and flexibility while avoiding injury.
Whether you are a competitive athlete or just starting a new exercise routine, here are 5 tips that everyone who is physically active should consider adopting:
1) Customize your workout to achieve your personal fitness goals.
Whether your goal is to improve your cardiovascular health, body composition (including the ratio of muscle to fat), strength, endurance, or your position and motion awareness, not all exercise is the same, and more is definitely not necessarily better!
To improve your cardiovascular health: You will need to get your heart rate up to 70-85% of its maximal rate for at least 30 minutes per day, three days a week. To determine your maximal heart rate, subtract your age from 220. (e.g. The maximal heart rate for a 50-year-old is 170 (220 – 50 years = 170), so his or her target heart rate will be 70 to 85 percent of 170, or between 120 and 145.)
To improve your body composition (ratio of fat to muscle) and to optimize your body’s fat-burning capacity: You will want to exercise in a way that gets your heart rate up to 40-60% of your maximum heart rate.
To increase your muscle power and endurance: To maximize muscle power, you should engage in a lower number of total exercise repetitions at a higher level of weight/resistance, whereas to improve muscle endurance, you’ll need a higher number of repetitions at a lower weight/resistance. For example, athletes wanting to develop power might design a program where they perform 2-3 sets of 10 repetitions, with each lift set at 70% of their single-repetition, maximum weight. On the other hand, to develop endurance, the same athlete should perform 2-3 sets of 20-30 repetitions, with each lift set at 30-50% of their single-repetition, maximum weight. Your single-repetition, maximum weight is how much weight you can lift one time using the maximum effort that you can safely exert. Be very careful not to push past your maximum limit when you test yourself – you don’t want to get injured before you get started!
When strengthening: Work with a qualified and experienced physical therapist, personal trainer, or athletic trainer so that you can develop proper form and safe sports-motion habits early on. Give yourself a day between exercise sessions to allow for muscle cell repair and growth, for example, doing upper body strengthening on Mondays, Wednesdays, and Fridays, and lower body strengthening on the other days. When increasing your exercise intensity, a generally safe approach is to increase your weight/resistance level by no more than 10% every 2 weeks.
To improve your motion awareness and bone strength: Consider cross-training with yoga, soccer, basketball, tennis, or other activities that encourage side-to-side movement and speed changes. Research has shown that pure long-distance runners, particularly women, can actually be more at risk for stress fractures because the straight-line movement of running only strengthens bones in one plane, whereas cross-training strengthens bones in a more complete, multi-directional fashion.
2) Ditch the myth about stretching prior to exercise to prevent injury.
Contrary to popular belief, scientific reviews indicate that stretching only before and after intense exercise does little to prevent injury. What does matter is your baseline level of flexibility. In other words, if you are already flexible, you have some reduced risk of muscle injury even if you do not stretch much before you exercise. But if you are not very flexible, doing a bunch of stretching just before exercise is unlikely to prevent muscle injury. Therefore, you need to stretch regularly over a period of time, and not just as a method of warming up before exercise.
To stretch correctly: Hold each position for a minimum of 30 seconds. If the stretch is not held long enough, then the muscle fibers will simply return to their pre-stretch length after you stop, and your stretching will be of minimal benefit. Once a muscle is properly stretched, the effect lasts for about six hours. Therefore, to improve flexibility most efficiently, one should stretch three times per day, for at least 30 seconds per muscle stretched.
Be aware that having too much flexibility can be as much of a problem as having too little. For example, with increased flexibility, the ligaments holding our joints together can become more vulnerable to being overstretched and sprained. How flexible is too flexible? The Beighton Hypermobility Score, which is easily located on the Internet, provides a quick method to rate joint hyperflexibility. If you are already very flexible, then stretching may not be in your best interest. Instead, focus on strengthening and balancing your muscles, which will help stabilize and protect your joints and ligaments.
3) Consider integrative treatment options if you sustain an injury.
Musculoskeletal injuries are extremely common; in fact, it is estimated that over 100 million injuries occur every year worldwide. Of these, 30-50% involve ligament and tendon injuries. Fortunately, there are several effective options available to treat these conditions, including osteopathic manual therapy (OMT), platelet-rich plasma (PRP) therapy and prolotherapy, which enhance the body’s own healing capability to repair damaged tissue. A growing body of medical research has demonstrated the effectiveness of these therapies in treating various painful conditions of the neck, shoulder, elbow, hand, low back, hip, knee, and ankle.
OMT is a non-invasive therapy that applies gentle pressure and movement to stretch muscles, soft tissue and joints for proper alignment.
PRP therapyinvolves taking a patient’s blood, centrifuging it to concentrate the platelets — which contain numerous growth factors responsible for tissue healing as well as blood-clotting factors — and then injecting it into the injured area to promote healing. Professional athletes often use PRP to help them recover and return to their sport more quickly.
Prolotherapy is another injection method which uses simple fluid solutions other than blood for treating injured tendons, ligaments, and joints.
Although inflammation has a bad reputation for causing many painful conditions, it’s essential to the process of healing. After an acute injury, healing occurs in three complex phases over a long period of time, during which new connective tissue is created that replaces and reinforces the injured tissue. The first of these phases is inflammation, which causes pain in order to restrict our range of movement to protect the area from further injury. Perhaps even more importantly, the inflammation triggers cellular activity that initiates healing of the damaged tissue. The inflammatory phase typically lasts 4-6 days.
Although clinical research has shown that taking an anti-inflammatory after an acute injury can speed one’s return to activity by decreasing pain, several studies also have demonstrated that using an anti-inflammatory immediately after being injured can reduce tendon and ligament strength during healing. In sum, taking anti-inflammatory medication can interrupt the inflammatory process and thereby reduce the potential, maximal healing of the injured area.
We tell patients to try to avoid using anti-inflammatories, such as Aspirin (unless you are taking it for heart protection), ibuprofen (a.k.a. Motrin, Advil, Nuprin) and naproxen (a.k.a. Aleve, Naprosyn) for at least the first few days after injury. Instead, I recommend taking acetaminophen (a.k.a. Tylenol) up to 4000 mg. per day, as long as you do not have any liver problems and are taking it for less than a two-week period. In cases of more severe pain, you should consider seeing your doctor for a check-up and, if appropriate, obtaining a prescription for a muscle relaxant or other pain medication that you can take for a few days until the pain from inflammation subsides.
5) Be diligent about getting regular physical exams to address significant or persistent injuries.
Routine physical exams are very important for identifying conditions that may affect your ability to exercise safely, such as certain heart and lung problems or uncontrolled high blood pressure. Let your provider know about any concerns you have regarding your exercise regimen. It’s also a good idea to see your provider if you are experiencing any of the following:
An inability to bear weight on an injured limb due to severe pain
Pain that persists for more than 3 or 4 weeks without improvement
New or progressive numbness, tingling or — especially — weakness in your arms or legs
Persistent dizziness or light-headedness during or after exercise
Head, neck or back injuries that are causing deterioration of your balance, problems with your mental faculties, or changes in your bladder and/or bowel function (any of these symptoms could indicate a rare but urgent medical emergency!)
When a medical problem is exercise-related, for the best results, you need a medical specialist who can not only comprehensively assess your musculoskeletal system, but also provide you with the widest range of treatment options, from the least to the more invasive procedures.
We are here for you, and we want to help.
Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2
This article was reviewed and updated in January, 2024.
Has living with chronic low back pain affected your productivity, mobility, and overall ability to enjoy life?
In the United States, it’s estimated that nearly 16 million adults experience chronic back pain, making it one of the most costly health expenses annually and one of the most common complaints heard in doctors’ offices. Causes can include injury, disease (i.e. arthritis, cancer), obesity, poor posture, a sedentary lifestyle, even infection.
Patients with acute and sub-acute cases (pain that goes away within 3 months) may find that their pain improves over time without treatment of any kind. But not everyone has the ability to simply wait it out. In these cases, and when the pain becomes chronic, the American College of Physicians (ACP) recommends that non-invasive and non-drug therapies like exercise, acupuncture, massage, yoga, and other mind-body therapies should be the first line of treatment over surgery and narcotics, and we agree!
Remember, chronic pain, including low back pain, is a symptom of inflammation. Without targeting the root cause of the inflammation and treating it, your pain symptoms will not improve. Mind-body therapies help calm the inflammatory process in the body, promote healing, and present little to no risk to the patient.
Here are a few common misconceptions about treating back pain that can contribute to a slower recovery.
Myth: Exercise makes back pain even worse
Putting the brakes on exercise may seem like a good idea when you’re feeling pain symptoms, but research shows that the opposite is true. Strengthening and stretching exercises combined with aerobic activity will improve back pain symptoms by increasing blood flow, improving range of motion and flexibility, and strengthening core muscles.
· Physical Therapy is a great place to start if you’re concerned about further injuring or straining your back. Physical therapists have outstanding manual skills with a comprehensive understanding of body mechanics. They can work with you to decrease pain, improve movement, and provide instruction on how to continue moving safely in your everyday life.
· Going for a walk is one of the easiest ways to stay active. Try taking a short walk every day to keep your heart pumping and blood flowing.
· The poses, controlled breathing, and meditation involved in the practice of yoga can not only improve symptoms of chronic low back pain but can lower instances of depression and use of medication. As reducing back pain requires improving core strength, yoga is great for increasing core stability and strength while increasing awareness of other areas that may need stretching and strengthening.
Occasional use of NSAIDs can certainly be helpful if patients have seen little improvement with non-invasive treatments. But a big misconception about these OTC (over the counter) painkillers is that they’re completely safe and harmless. Regular use of NSAIDs can lead to problems with gut ulcers, liver damage, and kidney damage. Ironically NSAIDs can even heighten one’s sensitivity to pain. People who take them more than once a week should discuss this with their physician.
Myth: Mind-body therapies are unscientific
Dismissing the benefits of mind-body therapies is at the least, misguided. There is a mountain of evidence that supports the use of alternative therapies for pain management.
· Acupuncture: This 2000-year-old practice is thought to work by blocking pain messages to the brain with competing stimuli that cause an increase of endorphins, the body’s natural painkillers, and the secretion of neurotransmitters, which affect one’s perception of pain.
In 2007 the results of a large study of over 1,100 patients with chronic back pain were published in the Archives of Internal Medicine. After 10 treatments, the group that received acupuncture had a 47% improvement in pain and functioning after six months.
· Massage Therapy: A 2011 study concluded that people who were treated with massage therapy, whether relaxation massage or structural massage (deep tissue massage), for their chronic back pain, saw benefits that lasted at least 6 months.
· Meditation: A study reported in the Journal of Neuroscience showed that patients who had received only a little more than 60 minutes of meditation training were able to dramatically reduce their experience of pain. Patients experienced a reduction in “pain intensity” of about 40 percent and a reduction in “pain unpleasantness” of 57 percent. According to the lead author of the study, Fadel Zeidan, “Meditation produced a greater reduction in pain than even morphine or other pain-relieving drugs, which typically reduce pain ratings by about 25 percent.”
Bottom line
Whether you have an acute, sub-acute, or chronic case of low back pain, the first line of treatment should be a therapy that can help calm the body’s inflammatory process naturally and safely. While there is unquestionably a time and a place for surgery or narcotics, medical evidence indicates that conservative treatment of low-back pain is often as effective.
When low back pain interferes with your quality of life, talk to a physician about these wonderful and science-based therapies that can benefit your mind, body, and soul.
We are here for you, and we want to help.
Our goal is to return you to optimal health as soon as possible. To schedule an appointment please call: 703-532-4892 x2
Although these over-the-counter and prescription pills are the modern standby for every ache and pain, what Big Pharma hasn’t told you about the risks of non-steroidal anti-inflammatory drugs could just kill you, as Celeste McGovern discovers.
When Aaron Marino opened his own gym for business, he thought the stress of running it was giving him tension headaches. Each morning on the way to work at about 5:00 am, and as the dull throb began at the base of his skull, he would reach for one of the world’s most popular over-the-counter (OTC) painkillers for arthritis, headaches, menstrual cramps and more, and wash down two ibuprofen pills with black coffee—and the pain soon melted away.
Popping a couple of Advil — or Motrin or Aleve or other, generic versions of non-steroidal anti-inflammatory drugs (NSAIDs) — was so effective that it became a habit for Marino, a simple reflex to pain and he did it three to five days a week without a thought for years.
“I knew there was a risk to taking them,” says Marino, who had scanned the label and thought the warning applied to people who were gobbling far more than two pills a day. As a ‘superfit’ gym owner in the prime of his mid-30s, he had little reason to worry about a painkiller he could purchase in bulk at Costco — and, besides that, it worked.
Three years into this routine, though, one Tuesday in 2010, Marino rose from the toilet and noticed that his stool was liquorice black. By Friday, he was feeling dizzy when he stood and friends commented on his pallor. A Google search told him his black ‘tarry’ stools were indications of an upper gastrointestinal (GI) bleed, and when he went to the doctor, he was sent for an emergency blood transfusion and surgery to close a perforation in his duodenum.
“I was about two days from actually kicking the bucket,” says Marino, owner of Alpha M men’s image consulting business in Atlanta, Georgia. He wasn’t exaggerating: every year in the US alone, more than 100,000 people are hospitalized for NSAID painkiller-related stomach ulcers and injuries, and thousands die from NSAID-induced GI bleeding.
Silent epidemic of GI bleeds
Way back in 1999, this NSAID-induced GI problem was described in the New England Journal of Medicine as a “silent epidemic” claiming at least 16,500 lives each year in the US alone — and those only among arthritis patients and those taking prescription NSAIDs — not the OTC pills. The report also said that almost 75 percent of those surveyed who ingested NSAIDs regularly were “either unaware of or unconcerned about possible gastrointestinal complications.”
And while nearly two-thirds of regular users indicated that they expected warning signs before the development of serious NSAID-induced complications, in reality, more than 80 percent of patients with serious GI complications experience no prior gut discomfort as a warning.
Current estimates have lowered the NSAID-induced GI-bleed mortality figure to somewhere between 7,000 and 10,000 each year in the US, according to the American College of
Gastroenterology. German researchers have calculated the risk too: just two months of using an NSAID puts your odds of dying from a GI bleed at one in 1,220, which may sound small but is actually, they say, more dangerous than bungee-jumping a few hundred times.1 Use them longer and the odds multiply.
NSAID heart attacks and strokes
GI ulcers and bleeding are only one part of the NSAIDs’ toll. The unwanted side-effect of inducing heart attacks and strokes is now relatively well known to doctors, but these potential dangers and and the drug’s maker Merck’s attempts to deliberately obscure the risk only came to light in courtrooms when the drug Vioxx (rofecoxib) was withdrawn from the market in 2004 after an estimated 120,000 people died taking it.
But the NSAID carnage has still not ended as, recently, the US Food and Drug Administration (FDA) upgraded its warning on these drugs yet again. After reviewing new data on the drugs using compounds like ibuprofen, naproxen, diclofenac, ketorolac, celecoxib and more, the US oversight agency required new drug labelling for both the OTC and prescription non-aspirin NSAIDs stating that they increase the risk of heart failure and stroke even within the first week of use, and that the risk may increase further with longer use and higher doses.
It had previously been thought that only people at higher risk of cardiovascular events could possibly suffer vascular injury induced by NSAIDs. But the recent FDA warning makes it clear that the risk is also increased in those with no known heart issues and that injury can happen “without warning.” NSAIDs pose the greatest risk to patients following a first heart attack, with those treated with the drugs being, according to the FDA, “more likely to die in the first year after the heart attack” compared with patients who aren’t taking the drugs.
“For people who have coronary artery disease and have suffered a heart attack, the risk starts with the very first pill, and the risk does not get any better if you wait for a year or even five years after a heart attack,” says pain specialist Gary Kaplan, of Georgetown University School of Medicine and author of Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression.
The new FDA heart and stroke warning is now added atop its GI warning, which states that NSAIDs like ibuprofen may cause ulcers, bleeding or holes in the stomach or intestines which “may develop at any time during treatment, may happen without warning symptoms, and may cause death.” It then adds that the risk may be higher the longer you’ve taken the NSAID, if you are elderly, in poor health or drink three or more alcoholic drinks per day while taking ibuprofen.
Ignorance of the GI risks of NSAIDs is apparently just as widespread as the New England Journal of Medicine described in 1999 because in 2010, the FDA conducted surveys to determine if illiteracy among the elderly was the underlying reason for their lack of awareness of the risks associated with NSAID consumption. It was not.
In the UK, the reason for such ignorance may well be down to the lack of awareness of the National Health Service itself: its current information page on NSAIDs describes the side-effects as “troublesome,” and lists ulcers and GI bleeds below stomach aches and diarrhea, with heart attacks and strokes last of all as “rare” side-effects. The site offers no information on the suddenness with which symptoms can arise.
As for alcohol, while the increased risk of GI bleeding with its greater consumption has been documented in the medical literature since 1999, the NHS blithely states: “It’s usually safe to drink alcohol while taking NSAIDs, but drinking alcohol excessively during treatment may irritate your stomach.”
Other dangers
While heart and GI problems are well documented among NSAIDs’ unwanted effects, there’s more. In 2005, Pfizer pulled its NSAID valdecoxib (Bextra) from the US market because of its high heart risks, but also because it was linked to more than 150 cases of serious and sometimes fatal skin reactions.
Two years later, the UK and Australia abruptly pulled the NSAID lumiracoxib (Prexige) when they discovered that some patients taking it were suffering from severe liver damage as a result; indeed, some patients even required liver transplants. And last year, the drugs regulators reviewing diclofenac-based NSAIDs moved them from the OTC category to prescription-only.
NSAIDs’ risk to kidneys is also well known to regulators. A recent pooled analysis of five earlier studies confirmed that NSAID use significantly increases the risk of acute kidney injury.2 They’ve also been linked to hearing loss in both men and women.3 And while there are conflicting results for NSAID dangers in pregnancy, some researchers have concluded that several NSAIDs can induce “spontaneous abortion.”4 The painkillers can also induce or exacerbate sinusitis and hives, and studies have shown they can increase allergic responses by 10 to 30 percent in asthma sufferers.
NSAIDs can make pain worse
Ironically, for those dealing with pain, NSAIDs may actually interfere with the body’s own painkilling machinery, the long-term effect of which is to sustain pain rather than eliminate it. This is exactly what happened to image-consultant Marino. When his gut problems forced him to stop taking NSAIDs, he noticed that, in less than a week, the headaches he’d been taking
the drugs for in the first place, for years, simply vanished.
“NSAIDs are not truly addictive, but can make you dependent,” explains pain-expert Kaplan. “Regular use, three times or more a week of NSAIDs and Tylenol [not an NSAID, but acetaminophen/paracetamol] can suppress the body’s own natural pain-relieving system. The result can be rebound pain when you stop the medication because your own pain-relieving system has been suppressed. Over time, when you stop the medications, your own system kicks back in and the pain goes away. The problem has been well documented in people with chronic headaches. In some people with chronic headaches, all we need to do to fix the headache is to get them to stop taking NSAIDs and Tylenol for a few weeks, and the body will fix itself.”
In the case of arthritis pain, doctors know NSAIDs do nothing to help the underlying condition, although they can alleviate pain in the short term. But a new study suggests that taking a painkiller like an NSAID can actually make arthritis worse in the long run. Researchers at Johns Hopkins University compared people taking painkillers (two-thirds were taking an NSAID) for knee arthritis with those who weren’t taking any drugs for a matching condition, and followed them all for three years, X-raying their knees at intervals. Those taking the painkillers were more likely to have knee arthritis that had visibly got worse on X-rays and were also more likely to undergo knee replacement surgery compared with those not taking the drugs.5
The COX-2 scandals
COX-2-selective NSAIDs were developed as a way to target pain and inflammation while sparing COX-1 and the gut lining. Merck’s Vioxx (rofecoxib) and Pfizer’s Celebrex (celecoxib) were the first of these COX-2 inhibitors.
Launched in 1999, they quickly became blockbusters; doctors wrote more than 100 million prescriptions for them in the first year and the manufacturers of each raked in billions in dollars. But tens of thousands of patients began dying from heart attacks and strokes.
All of the sordid details of how Merck and Pfizer doctored the data and deliberately concealed the drugs’ dangers eventually trickled out in a myriad court cases years after Vioxx was first pulled from the market in 2004.
“The scandal of the COX-2 inhibitors is really monumental,” says former drug insider and co-founder of the Danish Cochrane Collaboration Peter Gøtzsche in his book, Deadly Medicines and Organised Crime (CRC Press, 2013). “The drugs were approved based on small, short-term trials that didn’t look for cardiovascular harms, in patients with low risk for such events, although nearly half of real-world patients with arthritis have coexisting cardiovascular disease.”
Gøtzsche recounts how Merck employees deliberately manipulated data too, not just by exaggerating the benefits of Vioxx, but also by actually producing a fake peer-reviewed journal just to market pro-Vioxx reports.6 They also did not publish data available in 1999—which clearly showed the increased rates of heart attacks and strokes—until 2006, two years after the drug was pulled from the market. When they did publish data, they distorted the findings: for example, they failed to report three heart attacks during a critical clinical trial, listing one cause of death as “unknown” when it was clearly a heart attack.
But to most of the American public, the true extent of Merck’s ruthless concealment was hidden by the media’s Pharma-friendly reporting. News of the Vioxx ban, for instance, was followed by a 10-minute interview with a Pfizer-funded representative of an American arthritis foundation lamenting the loss of the painkiller for patients. Yet, there was little national reporting in 2007 when the jury in a Vioxx case found that Merck’s conduct was “malicious, oppressive and outrageous.”
And it wasn’t until 2009 in an Australian court that details emerged, such as Merck’s internal emails naming the influential doctors and researchers who were concerned about the drug’s risks. The emails described how company employees intended to “neutralize” and “discredit” these “problem” detractors. Neutralization was apparently achieved through the company’s lengthy list of “opportunities,” which included “Research,” “National Consultant Meetings,” “Program Faculty Training” and “Medical School Grants.” If these bribery tactics failed, schemes that were evidently not discussed via email were then employed to “discredit” the detractors.
Gøtzsche also describes how Celebrex (celecoxib) manufacturer Pfizer similarly contorted data to suit its drug-marketing strategy. Its biggest study, he says, was “fraudulent” and its authors were either employees or paid consultants to the company. When Vioxx was pulled from the market, Pfizer shamelessly seized the moment to promote its own drug.
The next day, the company wrote to Danish doctors that more than 50 million people worldwide used celecoxib and that the company had reviewed clinical trials of more than 400,000 patients. “That’s what they wrote; I suppose they meant 40,000,” says Gøtzsche, “and this had not yielded any sign that celecoxib increased the risk of cardiovascular events. The fine for this ruthless misinformation: $2,000.”
In reality, all COX-2-inhibiting NSAIDs increase the risk of heart attack and stroke. Celebrex, the only one left on the market, has similar cardiovascular risks to Vioxx. Pfizer has awarded millions of dollars in damages to patients who have suffered as a result and has even paid out $164 million to its own shareholders, who claimed the company misrepresented the drug’s safety data.
As Gøtzsche says, “The NSAID story illustrates that drug regulators are consistently willing to award the benefit of scientific doubt to manufacturers rather than patients.
Know your painkillers
As with every other drug, there’s no such thing as ‘safe’. The top five categories of painkillers are rated here for their relative dangers.
The wide variety of NSAID side-effects has to do with how they work. Our bodies have an enzyme called ‘cyclooxygenase’ (COX), which produces prostaglandins that, in turn, promote inflammation, pain and fever in the body. NSAIDs are believed to block these COX enzymes and so reduce prostaglandin production, thus damping down inflammation, pain and fever.
There are two kinds of COX enzymes: COX-1 and COX-2. COX-1 is known as a ‘housekeeping’ enzyme, as it plays a critical role in regenerating and protecting organs like the kidneys, as well as the mucosal lining of our gut. In fact, this activity is part of the reason why we don’t digest our own stomach every time we eat anything. It is also the reason why ingesting COX-1-disrupting NSAIDs puts our gut lining at risk.
“What people think about with stomach upset for the NSAIDs is stomach ulcers, but the bigger issue is that regular use causes ulcerations in the small intestine in up to 75 percent of people,” explains Georgetown University’s Gary Kaplan, medical director of the Kaplan Center for Integrative Medicine.
“The small intestine is the final arbiter of what substances that we eat are allowed to enter our bodies and what will pass through to be eliminated in the stool. Damage to that filter by the NSAIDs allows substances to be adsorbed that would normally be kept out. This increases the risk of allergic reactions and worsening of food sensitivities.”
The other problem with NSAIDs is that they disrupt the gut microbiome, a mini-ecosystem of microflora that interacts with our nervous system, and helps to determine the health of our body and brain.
“Disrupting the garden of our gut can let weeds overgrow and potentially damage our health the same way weeds overgrowing a garden can damage the flowers and other plants we actually want to thrive,” says Kaplan.
What else can you do?
It’s a fact that more than 100 million Americans and 14 million Brits suffer from chronic pain—whether mild, sporadic, unremitting or excruciating. So the big question remains: what else can they do to deal with the pain?
For acute pain
For acute muscle strain, ice, elevation and rest, and perhaps a muscle relaxant, is recommended by Georgetown University’s Gary Kaplan, an integrative osteopath and one of only 19 US physicians specialized in both family and pain medicine.
After the first 24 hours of an acute injury, he says, apply heat.
The homeopathic combo preparation Traumeel, which comes as a pills, a cream or gel (www.traumeel.com) provides pain relief, as does bromelain (see right).
For chronic pain
As chronic pain is really about inflammation, according to Kaplan, the first place he starts with patients at his pain clinic is their diet.
Eliminate all fatty and fried foods as well as refined sugars and stimulants like coffee and tea.
Eat an anti-inflammatory diet, starting with brown rice, fish, chicken, fresh fruit and vegetables, and eliminate gluten, soy milk and milk products.
Some people suffering from osteoarthritis find that avoiding nightshades (tomatoes, eggplants/aubergines, bell peppers) is helpful. Try it for a month and see if your condition improves.
Take omega-3s for arthritis. These essential fatty acids are essential for your body to fight inflammation—including what’s associated with osteoarthritis and rheumatoid
arthritis (RA).
Suggested daily dosage: 200–1,000 mg as fish oil or 1 Tbsp flaxseed oil
Glucosamine has also been shown to help arthritis sufferers because it provides the raw material for rebuilding cartilage and synovial joint fluid. One study of patients with moderate-to-severe hip and knee osteoarthritis found that taking 1,500 mg of glucosamine sulphate plus 200 mg of omega-3 fatty acids had greater pain reduction and less morning stiffness and pain than those who took glucosamine alone.1
Suggested daily dosage: 2,500 mg
Take turmeric, the bright-yellow root in the ginger family most familiar as a spice in Indian curry. Hundreds of studies link its active ingredient curcumin to anti-inflammatory activity. It’s also been shown to act specifically as a COX-2 inhibitor—but without the side-effects of drugs like Vioxx and Celebrex.
Suggested daily dosage: 1–3 g/day as dried powdered root
A highly bioavailable form of curcumin was more effective in alleviating RA symptoms, including joint tenderness and swelling, than NSAIDs in one study. What’s more, those taking the curcumin without the NSAID diclofenac experienced the greatest improvements overall. Also, those taking turmeric had no side-effects at all, whereas 14 percent of those who dropped out of the study did so because of NSAID side-effects.2
Suggested daily dosage: 500–3,000 mg of bioavailable curcumin extract three or four times a day
N-Acetylcysteine (NAC), an amino acid, has anti-inflammatory properties that have been well described, yet only recently did researchers discover in a small preliminary study that its biochemical mechanism also relieves pain, so suggesting its potential in the treatment of chronic inflammatory pain.3
Suggested daily dosage: 600–1,200 mg or as directed
Bing cherries and raspberries are examples of Nature’s own COX inhibitors. According to one study, these fruit contain particular antioxidants and anthocyanins that make them capable of inhibiting COX-1 and COX-2 activities comparable to those of ibuprofen and naproxen.4
Pineapple contains an enzyme called ‘bromelain’, shown to reduce inflammation by apparently also blocking the COX-2 enzyme pathway naturally.5 You can take it as a supplement derived from the stems of pineapples, which contain the highest concentration of bromelain.
Suggested daily dosage: 200–400 mg/day or 90 mg three times a day
Pine bark extract, or Pycnogenol (French maritime pine bark extract) is another natural COX inhibitor described in dozens of published research papers to have beneficial effects on a wide variety of inflammatory diseases and conditions, including the pain of osteoarthritis. In one study, 100 patients treated for three months with 150 mg/day of Pycnogenol with meals saw a “significant alleviation of pain” and reduced their NSAID consumption compared with those taking a placebo, who saw no improvements and increased their NSAID consumption instead.6
Suggested daily dosage: 150 mg/day or as directed
Supplement with magnesium, as muscle twitches, cramps, tension and aches are among the most common signs of a deficiency of this mineral. So it’s no wonder that pain doctors like Kaplan advise patients with chronic pain—from migraines to fibromyalgia—to supplement with magnesium, as it’s hard to eat your way out of a deficiency once it develops. Magnesium oil applied topically is also reported to dramatically relieve some cases of arthritis within minutes. In one study, patients receiving intravenous magnesium after heart surgery had similar pain levels, but self-medicated far less with morphine.7
Suggested daily dosage: 400–800 mg
Cayenne or capsaicin topical creams (containing at least 0.075 percent capsaicin), derived from hot peppers, are available over the counter, and alleviate pain by reducing levels of the pain transmitter ‘substance P’, such that the pain messages never reach the brain.8
Suggested daily dosage: Apply to painful areas, but never on broken skin; if there’s no improvement after two to four weeks, stop using it. It may also cause skin irritation. After use, avoid touching your eyes and wash your hands carefully.
Sleep is crucial for good pain control, according to pain doctor Kaplan, so anything that helps you get a good night’s sleep is also likely to benefit pain. This includes meditation, yoga, exercise and stretching, while massage, acupuncture and other physical therapies can help tremendously too.
1 BMJ, 2011; 343: d5142
2 Presentation by Dr Carl Orr at the Annual Congress of the European League Against Rheumatism, 14 June 2013, Madrid, Spain
What else can you do? References:
1 Adv Ther, 2009; 26: 858–71
2 Phytother Res, 2012; 26: 1719–25
3 Mol Pain, 2015; 11: 14
4 Phytomedicine, 2001; 8: 362–9
5 Cancer Lett, 2009; 282: 167–76
6 Phytother Res, 2008; 22: 1087–92
7 J Cardiothorac Vasc Anesth, 2007; 21: 827–31
8 http://umm.edu/health/medical/altmed/herb/cayenne
Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. – Hippocratic Oath
When it comes to the treatment of chronic pain, the medical profession may be in violation of what can be regarded as the first medical ethic: First do no harm.
Together, the prevalence of chronic pain and the increasing use of opioids have created a “silent epidemic” of distress, disability, and danger to a large percentage of Americans. The overriding question is: Are we, as a nation, approaching management of chronic pain in the best possible manner that maximizes effectiveness and minimizes harm?
More recently, the Centers for Disease Control in an attempt to address the massive public health crisis identified by the NIH issued a new set of twelve guidelines aimed at reducing the risk of opioid over-prescription and over-use. Although these recommendations are not yet mandated, they are a necessary first step in rethinking how we look at chronic pain treatment and how narcotics are prescribed.
A Brief History of Opioid Medication Use/Misuse
In 1997, the American Academy of Pain Medicine, in an acknowledgment of 1) the severity of the suffering of patients with chronic pain, and 2) the medical profession’s inability to provide many of these patients with acceptable treatment solutions, issued a consensus paper endorsing the use of opioid medications for the treatment of chronic non-cancerous pain. The Academy openly acknowledged that one of the problems with the long-term use of opioids is addiction. In response, the medical profession began making the distinction between addiction and dependence. Addiction was defined as a craving for opioids with the intention of getting “high” consistent with drug-seeking behavior. Dependence, on the other hand, was defined as any situation in which an opioid medication was prescribed for medical reasons, with a dosage sufficient to control the pain, and a significant improvement in the quality of life of the patient. While the intention was noble, the consequences have been quite disastrous.
Since the release of the AAPM’s paper, the sales of prescription opioid medications measured in grams has skyrocketed. Between 1997 and 2007, sales rose by 866% for oxycodone, 525% for fentanyl, 280% for hydrocodone, and 222% for morphine. As reported in Pain Physician in July 2012, “Gram for gram, people in the United States now consume more narcotic medication than any other nation worldwide.” The report goes on to document that over 90% of patients taking opioid pain medications were prescribed these medications for the treatment of chronic pain.
In 2011, approximately 17,000 drug overdose deaths involved prescription opioid medications. The CDC also reported that “In 2007 there were more opioid analgesic deaths than overdoses involving heroin and cocaine combined.” While a significant number of these drug overdose deaths are associated with diversion of the medication to people who were not originally prescribed the medication, 60% of the deaths occurred in patients that were given prescriptions based on the prescription guidelines by medical boards.
Furthermore, significant side-effects from opioid medications include increased risk of birth defects, falls and fractures, addiction, constipation, heart attacks, a decrease in the production of testosterone, and in some cases, hyperalgesia, an actual worsening of the pain.
Deciphering the Problem
While the NIH report and recent CDC guidelines offer a number of important policy and institutional points to address, I believe that the fundamental basis of our problem comes from a lack of understanding of what we’re treating. Acute pain and chronic pain (not associated with ongoing tissue damage such as in cancer) are two very different phenomena in the body.
1. Chronic pain is not a thing but one manifestation of a complex physiological process that frequently impacts many body systems, including sleep, gastrointestinal, psychological, and endocrine. Thus, we must take a whole-person approach in our diagnosis and treatment, which requires looking at multidisciplinary treatment options.
2. Unquestionably the evidence supporting the use of long-term opioids in the treatment of chronic pain is insufficient. We need better studies to help us understand when long-term use is beneficial.
3. Physicians need to be better educated about the diagnosis and treatment of patients suffering from chronic pain. Ultimately the use of long-term opioid medications is an admission of treatment failure. The recent CDC guidelines are a step in the right direction in this regard.
As a pain specialist, I believe there is an important role for opioid medication, but that role should be limited. Opioids should only be prescribed with close monitoring by the diagnosing physician, for the purpose of relieving pain and improving quality of life when all other medical approaches have been exhausted.
First, do no harm. Opioids should be medications of last resort.
Dr. Kaplan explains how treating the symptoms of chronic pain is contributing to a system of mismanagement in this country. He discusses why we must shift the way chronic pain is treated by addressing its root cause – inflammation of the Central Nervous System.
How to figure out if food allergies are causing inflammation—and making you hurt
Sure you should eat that?
When it comes to chronic pain and depression, there’s no reason why you “just have to put up with it.” We now know that these states—and a host of conditions that accompany them—are caused by the inflammation of microglia in the brain. The microglia (your brain’s immune cells) turn on inflammation, and when they reach a tipping point, they become hyper-reactive, after which the slightest assault can set them off, triggering system-wide inflammation that can be difficult to stop.
This means that we have more reason than ever to eat well, exercise, meditate and make sure our bodies have the nutrients they need—avoiding the foods that are the likely culprits for allergies and sensitivities.
Here’s how to figure out if your diet is what’s causing your inflammation:
Try a low-inflammation diet
For 6 weeks eat only brown rice, fish, chicken, eggs, fresh fruits, and vegetables. This diet eliminates most of the foods people are allergic or sensitive to, such as wheat, soy, and milk products. Organic, grass-fed beef can be included in the diet as well.
Start an “eating and aftereffects” diary
When you’re trying a low-inflammation diet, it’s important to keep a food diary. In addition to writing down what you eat and when you eat it, you will also check back in with yourself throughout the day to see how the food made you feel. Allergies and food sensitivities may not show up for hours after you eat the offending food or spice, but if you are alert, you’ll increase the odds of making connections between the food and your response. Be sure to write down exactly how you feel at the beginning of the diet, so you can make an accurate comparison in 6 weeks.
Avoid stimulants
This means no caffeinated coffee, tea, or alcohol. It also means no NSAIDS to inflame your gut. If you typically drink more than 2 cups of coffee a day, it might be best to cut your consumption in half every few days until you are coffee-free. If you normally drink 6 cups, cut it down to 3 cups for a few days, then 1.5 cups for a few days. After a week or two easing off caffeine, you should be able to go without coffee and not get a headache.
Rate the following factors in your diary: Energy Level, Ability to Focus and Concentrate, General Pain Level, and Specific Pain Level. Complete the diary at the same time every day. Feel free to add comments about your sleep, digestion, and any other aspect of your health or mood. Make note of any unusual life events.
Add back foods
After 6 weeks, gradually add back new categories of food, one at a time, one week at a time. A good food to start with is dairy. Pay close attention to whether bringing dairy back causes gas, bloating, or other reactions. The next week, add soy products, such as tofu, soybeans, miso, and soy sauce. The following week, add wheat, such as bread, cereal, pasta, and canned or frozen foods with wheat fillers.
You will be the best judge of whether or not these foods have a negative effect on your energy level, your mood, or your ability to concentrate.
Signs of allergies
If you lose as much as 5 pounds or more the first week, it may be a sign that you’ve been eating foods you’re allergic to and your tissues have been swollen. Other signs of allergies include migraines, numbness in the arms or legs, inability to focus, poor concentration, fatigue, depression, brain fog, headaches, mood fluctuations, itchiness, sneezing, gas, diarrhea, sinus congestion, and skin rashes.
Delayed reactions are not uncommon. You may get a headache in the morning from something you ate the night before. This is why it’s important to add foods back into your diet very slowly.
Prepare for the toughest part
It’s likely that the first 2 weeks will be the hardest. Old habits can be tough to change. The next difficult part comes at the end, after the 6 weeks, when you are feeling better but starting to add in new foods. It can be frustrating to learn that you are having a negative reaction to one of your favorite foods. Maybe you add gluten in for a few days, but soon realize you’re experiencing bloating, congestion, and brain fog. Many people will ask: “Does this mean I can’t eat wheat anymore?!” The truth is: You can eat whatever you want. It depends on whether or not you’re willing to accept the consequences.
Published date: Apr 10, 2014 / This article was first seen on Prevention.com. Read more about the new connection between inflammation and chronic pain — and what scientists are doing about it — with Is Depression Ever Just Depression?
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More Americans are suffering from chronic pain than have diabetes, according to a panel of researchers at the National Institutes of Health. While 29 million people are diagnosed with diabetes, the panel estimated that 100 million Americans live with chronic pain.
While the statistics are staggering, the scary truth is that, despite the apparent universality of pain, there isn’t nearly enough research on safe, effective treatments.
“We learned that sufficient clinical research doesn’t exist to show physicians how best to treat chronic pain in adults, many of whom suffer from multiple health problems,” said panel member and founding director of the Indiana University Center for Aging Research, Christopher Callahan, MD.
Instead, our medical system is heavily reliant on painkillers, both over-the-counter and prescription, despite the fact that, according to the panel, clinicians recognize that pain narcotics aren’t the solution for long-term pain treatment. (Here are 5 reasons over-the-counter painkillers are a bad idea.)
Gary Kaplan, DO, author of Total Recovery: Solving the Mystery of Chronic Pain and Depression, explains that medication—either for treating pains or treating other conditions—can be at the root of chronic pain. “Because of the powerful, short-term effectiveness of many drugs, we’re beginning to experience polypharmaceutical problems, where patients end up taking one drug to treat the side effects of other drugs,” he explains.
“The rough guideline I give my patients about taking medications is this: A drug has to work better than the side effects it creates,” he says. “If it doesn’t, get rid of it.” Of course, it’s important to do so under the supervision of your doctor, he adds.
While it’s easy to tune out the side-effect disclaimer on pharmaceutical ads, you may want to talk to your doctor if you’re experiencing chronic pain and are taking one of these prescriptions:
Statins
Statins are commonly used to lower cholesterol. “They can be the cause of cataracts and unexplained muscle pain. Some studies show they may increase your risk of developing diabetes,” says Dr. Kaplan.
Diet can have a big impact on cholesterol. Consider eating avocados, as research has shown that they’re a food that helps lower cholesterol.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
In the ultimate irony, your painkiller might be causing you more discomfort. “More than 70 percent of people chronically taking NSAIDs—such as ibuprofen (Advil, Motrin), naproxen (Naprosyn), diclofenac (Voltaren), and aspirin (Bayer, Bufferin)—will get ulcers in their small intestines, creating a permeability problem (aka leaky gut syndrome),” says Dr. Kaplan.
Leaky gut is associated with all kinds of painful issues, including food sensitivities, joint pain, headaches, and psoriasis.
Antibiotics
Speaking of your gut, taking antibiotics may be causing more painful inflammation than the infection itself. “Multiple treatments of antibiotics for any reason can profoundly change the gut flora,” says Dr. Kaplan. “Those changes can then damage the intestinal tract enough to create leaky gut syndrome, which will result in inflammation and activate the microglia.”
While he doesn’t dismiss the lifesaving importance of antibiotics, Dr. Kaplan recommends balancing their use with a probiotic supplement. And be sure to support a your gut bacteria with healthy foods.
Opioids
Another counterintuitive finding: Dr. Kaplan says that opioids can heighten your sensitivity to pain. “Additionally, these painkillers—such as codeine, hydrocodone (Vicodin), morphine (Avinza), and oxycodone (Percocet)—can lead to depression, constipation, and sexual dysfunction,” he says.
Instead of popping a pill for your pain, consider meditation as an effective treatment.
Sleeping Pills
Sleep is so important for your health, but popping a pill to get there isn’t the answer. “A chronic reliance on any type of sleeping pill—such as zolpidem (Ambien), eszopiclone (Lunesta), or zaleplon (Sonata)—can, in the short term, make it hard to focus and, in the long run, even shorten your life span,” says Dr. Kaplan. Plus, you might be missing key warning signs of sleep apnea. Article reprinted from www.RodaleNews.com, Jan/2015