WDDTY

WHAT DOCTORS DONT TELL YOU

Chronic pain
Your guide to beating it naturally
New discoveries
2 Pain: killing it safely

Common conditions
7 Chronic back pain
10 Migraine misery
13 Fibromyalgia
15 Chronic fatigue syndrome
18 Irritable bowel syndrome

Tested treatments
21 Healing magnets
22 Serrapeptase
24 Cetylated fatty acids
26 SCENAR
28 Exercise for a better back

Your questions answered

29 Lumbago
30 Period pain
31 Endometriosis
32 Phantom-limb pain
33 Carpal tunnel syndrome
34 Ulcerative colitis
35 Osteoarthritis

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New discoveries
Pain: killing it safely
Statistics show that more
people than ever are
living with chronic,
persistent pain, and the
usual treatments just
arent working. Yet, the
latest research suggests a
wealth of effective
alternative optionsfrom
mindbody techniques to
something as simple as
vitamin D.
hronic pain is a devastating
C health problem that affects
millions of people around
the world. In the UK alone,
nearly eight million people are living
with moderate-to-severe pain lasting
for more than six monthsand the
figures are on the rise. In his annual
report published in March 2009,
Professor Sir Liam Donaldson, the UK
governments Chief Medical Officer,
revealed that chronic pain is two to
three times more common now than
it was 40 years ago. Currently, over a
third of UK households have someone
in pain at any given time.
Unlike acute pain, which warns us of
actual or potential harm to the body,
chronic pain serves no useful purpose
and, yet, has a major impact on
peoples lives. Indeed, 65 per cent of
sufferers report difficulty sleeping, and
nearly 50 per cent report having
problems with social activities, walk-
ing, driving or having a normal sex life.
Depression is also common, affecting
about half of all chronic-pain patients.
For some sufferers, suicide appears to
be the only solution.
But it doesnt have to be that way.
New evidence suggests that chronic
pain may simply be due to an un-
recognized nutritional deficiency or
some other sort of imbalance in the
body. An holistic approach that views
pain in a very different way from
conventional medicine may be the
closest weve come to a cure.
Conventional pain treatment
Chronic pain is a complex condition
with many different causesand
2 WDDTY Chronic pain
sometimes no known cause at allyet
conventional medicines answer is
generally the same: to treat it with
pain-relieving drugs.
Paracetamol (acetaminophen) is
thought to reduce pain by inter-
rupting or suppressing pain signals
carried along the nerves, while
opioidswhich are much stronger
drugsaffect the way in which pain is
processed in the brain and spinal cord
to reduce the sensation of pain. Anti-
inflammatory drugs tackle pain by
reducing inflammation.
But while these drugs may work in
theory, in practice, theyre failing to
hit the spot. According to a study of
UK nursing homes, cited in Sir Liam
Donaldsons annual report, most
residents experienced constant or
frequent moderate-to-severe pain,
despite the fact that 99 per cent were
on pain medication. In another study
of chronic-pain patients of all ages,
over one-third reported inadequate
pain control, and more than two-
thirds admitted that, at times, their
medication failed completely.
Opioids such as morphine, oxyco-
done, buprenorphine and fentanyl
have long been regarded as among the
most effective drugs for the treatment
of pain, but even these have proved
useless in many cases. In a review of
15 trials of opioids for chronic non-
malignant pain (CNMP), the average
reduction in pain intensity was only
around 30 per cent, and the dropout
rate was 56 per cent after two years.
Moreover, only three of eight studies
that assessed functional disturbance
(such as being unable to work because
of pain) found any improvement with
opioid agents (Pain, 2004; 112: 37280).
A number of other reviews of the
use of opioids for chronic pain have
similarly reported only modest
evidence of efficacy with these drugs.
Whats more, although the medical
use of opioids has increased over the
years, there is no evidence that this
has resulted in a lower prevalence of
chronic pain.
In Denmark, for example, the use
of opioids for CNMP has risen by more
than 600 per cent over the past two
decades. Yet, in a national survey, 90
per cent of opioid users continued
to complain of moderate to very-
severe pain compared with 46 per
cent of non-opioid users (Exp Clin
Psychopharmacol, 2008; 16: 40516).
Worse, in addition to being largely
inadequate, another problem with
conventional painkillers is their side-
effects (see box, page 3). Clearly,
these drugs are not the answer to the
problem of pain.
The good news for pain sufferers,
however, is that the failings of mod-
ern medicine have encouraged studies
into alternative methods for treating
pain. Now, theres a wide variety of
non-drug therapies that offer new
hope to sufferers.
The vitamin D approach
So far, some of the most compelling
evidence suggests that the solution to
chronic pain could be something as
simple as vitamin D.
In a nationwide UK study of nearly
7000 adults, scientists at the Institute
of Child Health in London found a link
between low levels of vitamin D and
chronic wide-spread pain (CWP). an important role for this vitamin in mialow levels of circulating
Although the findings were not pain control. Indeed, according to an calciumwhich sets in motion a
significant in men, in women, CWP extensive review of the research so cascade of biochemical reactions
prevalence varied according to farpublished online at Pain Treat- negatively affecting bone metabolism
vitamin D concentrations. Those with ment Topics (http://paintopics.org/ and health. One of these reactions is
levels of 7599 nmol/Lthe range pdf/vitamind-report.pdf)having not an increase in parathyroid hormone
deemed necessary for bone health enough vitamin D is linked to a raft (PTH), which impairs bone mineraliz-
had the lowest rates of CWP, which of painful maladies, including bone ation, causing a spongy bone matrix
were just over 8 per cent. In contrast, and joint pain, muscle aches, fibro- to form. As this matrix absorbs fluid,
in women with levels less than 25 myalgia, rheumatic disorders, osteo- the resultant expanding pressure
nmol/L, CWP rates were nearly arthritis and other complaints. triggers pain in the tissues overlying
doubled at 14.4 per cent (Ann Rheum Much of the research has focused the bones that are abundant in
Dis, 2009; 68: 81722). on chronic musculoskeletal-related sensory pain fibres.
Similar results were reported last pain. Indeed, the reports author, Dr In addition, vitamin D deficiency
year in an American study. Mayo Stewart Leavitt, identified 22 clinical might contribute to pain in other
Clinic researchers found a connection studies investigating vitamin D status ways. Several studies cited in Leavitts
between inadequate vitamin D levels in patients with this sort of pain. report found that vitamin D may be
and the amount of opioid medication Across these studies, an average of involved in non-musculoskeletal pain
taken by patients suffering from around 70 per cent of patients with syndromes, including neuropathy,
chronic pain. Those with low vitamin chronic musculoskeletal pain were migraine headaches and inflamma-
D levels were taking much higher found to be deficient in vitamin D. tory autoimmune conditions such as
doses of medicationnearly twice as The evidence also shows that inflammatory bowel disease.
muchas those with adequate levels. supplementing with vitamin D can Whatever the mechanism involved,
Moreover, the low-vitamin-D opioid dramatically improve pain. In 324 the data suggest that checking for
users reported poorer physical women with chronic back pain, vitamin D deficiencyand correcting
functioning and a worse overall vitamin D eased symptoms in 95 per it (see box, page 4)may be a key
perception of health (Pain Med, 2008; 9: centand in 100-per-cent of those factor in chronic-pain management.
97984). with the most severe D deficiency
Although these two studies arent (Spine [Phila Pa 1976], 2003; 28: 1779). Mindbody techniques
proof that a lack of vitamin D causes According to Leavitt, vitamin D Observing soldiers during World War
chronic pain, they do contribute to a deficiency might lead to musculo- II proved that the mind plays a huge
growing body of evidence suggesting skeletal pain by causing hypocalcae- part in the perception of pain. Among
soldiers with equally devastating
wounds, some asked for less morphine
Dangerous drug side-effects than others. Their perception of the
wound and what it meant in their lives
Opioids are known to cause constipation, nausea and vomiting, sedation, appeared to be crucial. To one, the
cognitive impairment and respiratory depression. Worse, patients can wound meant surviving the battle and
develop a tolerance to the drug effects, resulting in physical dependence going home; to another, it meant
and withdrawal symptoms on stopping the medication. Estimated addiction major surgery and a lower income,
rates among patients with non-cancer-related pain range from 3 per cent to fewer activities and other negative
almost 20 per cent (Drugs, 2003; 63: 1732). consequences (Purves D et al., eds.
Neuroscience, 2nd edn. Sunderland, MA:
Another class of drugs with a worrying safety profile are the non-steroidal
Sinauer Associates, 2001).
anti-inflammatory drugs, or NSAIDs, which are commonly prescribed for
arthritis, headache and other inflammatory conditions. In the US alone, Nowadays, when considering treat-
some 60 million NSAID prescriptions are written each year. ment for chronic pain, its accepted
The main concern is the risk of gastrointestinal (GI) complications such that the emotional reaction to pain is
as ulceration, perforation and bleeding. Indeed, the US drugs regulator, the almost as important as the sensation
Food and Drug Administration (FDA), has estimated that 24 per cent of itself in determining how well the
the Americans who take these drugs for a year will develop one of these patient will cope. This means that
complications, leading to 107,000 hospitalizations and at least 16,500 therapies that take this mindbody
deaths annually among arthritis patients alone (Am J Med, 1998; 105: 31S8S; connection into account are partic-
Geriatr Nurs, 2001; 22: 1189).
ularly useful for managing pain.
Recent evidence has also linked NSAIDs to serious cardiovascular One such therapy is hypnosis, a
events, including heart attack, angina and transient ischaemic attacks (TIAs, technique that introduces instruc-
or mini-strokes) (Am J Cardiol, 2009; 103: 122737; Clin Ther, 2006; 28: 182736). tions or suggestions to bring about
Even good old aspirinone of the less potent NSAIDshas been changes in subjective experience,
associated with major risks of bleeding such as haemorrhagic stroke, a type perception, sensation, emotion,
of stroke caused by ruptured blood vessels leaking blood into the brain thoughts and behaviour. In the case
(Lancet, 2009; 373: 184960) of chronic pain, hypnosis enables
patients to control the intensity of

WDDTY Chronic pain 3

New discoveries
the pain, to manage the pain and the
emotions accompanying it, and to
find suitable resources to deal with it,
thereby allowing them to be involved
in their own treatment (Rev Med Suisse,
2009; 5: 13802, 13845).
Scientific reviewscalled meta-
analyses, as they analyze all of the
findings and assess them altogether
have found hypnosis to be effective
for chronic pain. On combining 18
studies of laboratory-induced and
patients pain, the findings were that
hypnosis obtained greater pain relief
than in 75 per cent of those given
either the usual care or no treatment
at all (Int J Clin Exp Hypn, 2000; 48: 13853).
In yet another meta-analysis of the
efficacy of hypnosis for headache,
lower-back, temporomandibular joint
(TMJ), cancer-related and sickle-cell-
disease pain, as well as the pain
related to fibromyalgia, osteoarthritis
and disability, hypnotherapy resulted
in greater pain reduction than either
standard care or no treatment. The
authors concluded that . . . hypnotic
treatment for chronic pain results in
significant reductions in perceived
pain that maintain for at least several
months, and possibly longer (J Rehabil
Res Dev, 2007; 44: 195222).
As well as working, a further bonus
of hypnosis is that it is almost always
a benign treatment with little risk of
negative side-effects. Indeed, what
side-effects do occur are overwhelm-
ingly positive, including a greater
sense of control over pain, greater
overall feelings of wellbeing, and less
tension, stress and anxiety (J Rehabil
Res Dev, 2007; 44: 195222).
Another mindbody technique with
a good track record for pain control
is biofeedback, a process of recording
and feeding back real-time informa-
tion on how the body is functioning
to allow the patient to learn how to
actively control these functions.
Numerous studies have established
that biofeedback is an effective
treatment for a wide range of chronic
pain problems, including migraine
and tension-type headaches, muscle-
related orofacial pain, lower-back
pain, phantom-limb pain and fibro-
myalgia.
The technique generally works
because it first identifies the patients
own, individual physiological dysfunc-
4 WDDTY Chronic pain
Nutrients for chronic pain
u Vitamin D. Sunlight is the best source of this vitamin but, as most of us
dont get enough of it this way, pain expert Stewart Leavitt recommends
(with the supervision of a qualified practitioner) a daily supplement of
2000 IU of vitamin D3 (cholecalciferol), along with a daily multivitamin
that includes calcium and 400800 IU of vitamin D. It may take up to nine
months to experience the maximum effects of this regimen.
u Glucosamine and chrondroitin sulphate. This combination is known to
be effective for inflammatory conditions such as osteoarthritis of the knee
(J Rehabil Res Dev, 2007; 44: 195222).
u Proteolytic enzymes, such as bromelain, have various pain-relieving
properties that have proved useful in the treatment of rheumatic diseases
(Wien Med Wochenschr, 1999; 149: 57780).
u Amino acids, such as D-phenylalanine and L-tryptophan, appear to
increase pain tolerance in animals as well as in humans (Prog Clin Biol Res,
1985; 192: 36370; J Psychiatr Res, 19821983; 17: 1816).
tion that is causing the pain, and then the energy fields that are thought to
helps the patient to recognize when surround and penetrate the human
this dysfunction is occurring and to body (J Rehabil Res Dev, 2007; 44: 195222).
correct it using various strategies. Both types of energy medicine have
This means of getting to the root of proved to be beneficial for chronic
the pain may be why a number of pain, but one of the most popular
studies have found biofeedback to be therapieswhich falls into the first
more effective than conventional energy-medicine categoryis
treatments for chronic pain (J Rehabil transcutaneous electrical nerve
Res Dev, 2007; 44: 195222). stimulation, or TENS. This technique
Other techniques that integrate transmits electrical impulses into the
the body and mind have also proved body through electrodes that are
useful for chronic pain. Yoga and placed on or near the painful area.
mindfulness meditation are especially Although it doesnt address the
effective for treating chronic lower- underlying cause of pain, these
back pain (J Altern Complement Med, 2008; electrical impulses produce a tingling
14: 63744; J Pain, 2008; 9: 8418), while sensation that reduces the pain itself.
guided imagerywhich uses mental Indeed, numerous studies have shown
images to imagine and create the that TENS works for a range of
desired physical outcomehas shown chronic-pain conditionsfrom
promise in alleviating the pain of musculoskeletal pain, such as back
osteoarthritis and fibromyalgia (Fam and neck pain, to the persistent pain
Community Health, 2008; 31: 20412; Pain that often follows surgery (Pain, 2007;
Med, 2007; 8: 35975). 130: 15765; Curr Opin Anaesthesiol, 2009; Jul
9: Epub ahead of print).
Energy medicine Of the other bioelectromagnetic-
Besides mindbody techniques, based therapies that are currently
another drug-free approach thats available, pulsed electromagnetic field
proved to be successful among pain (PEMF) generators and cranial
patients is the use of so-called energy electrotherapy stimulation (CES)
medicine. hold particular promise for patients
According to the US National Cen- who suffer from chronic pain.
ter for Complementary and Alterna- PEMF generatorswhich include
tive Medicine (NCCAM), this comes in low-power, wearable devices designed
two types: the first includes bio- for virtually continuous use as well as
electromagnetic-based therapies that high-power machines meant to be
involve electromagnetic fields (EMFs) used several times a dayare able to
such as pulsed fields, magnetic fields help osteoarthritis sufferers, and can
and alternating-/direct-current fields; reduce chronic migraine headache
while the second includes biofield activity by around 80 per cent (J
therapies that are intended to affect Rehabil Res Dev, 2007; 44: 195222).
 CES, which delivers a low-level
electrical current through electrodes
attached to the skin surface (usually
on the ears), has proved to be better
than a sham procedure for treating
fibromyalgia pain as well as the pain
associated with spinal-cord injury (J
Clin Rheumatol, 2001; 7: 728; J Rehabil Res
Dev, 2006; 43: 46174).
Precisely how these two electrical
treatments work is still not fully
understood. PEMF generators appear
to increase blood flow to the areas
exposed to the EMFs, whereas CES is
thought to bring about changes in
certain chemicals of the brain,
including serotonin and norepineph-
rine. Both mechanisms appear to have
a positive affect on pain (J Rehabil Res
Dev, 2007; 44: 195222).
As for biofield therapies, the other
type of energy medicine, acupuncture
is the one that is most extensively
studied. As with other biofield
modalities, this traditional Chinese
medical technique is based on the
concept that all living things,
including humans, are infused with a
subtle form of energy (qi), and that
any disturbances to this energy result
in illness. This means that acupunc-
ture treats pain and other conditions
by improving the quality, balance and
flow of energy within the body.
In fact, acupuncture appears to be
especially effective for back pain. In
a meta-analysis of 33 randomized,
controlled trials, acupuncture was
superior to sham acupuncture for
relieving chronic lower-back pain.
However, one drawback is that the
study was only looking at short-term
results (Ann Intern Med, 2005; 142: 65163).
More recent studies suggest that
acupuncture might also help those
who have shoulder pain, headaches,
TMJ dysfunction, fibromyalgia, osteo-
arthritis of the knee, tennis/golfers
elbow and other painful conditions (J
Altern Complement Med, 2009; 15: 6138;
MMW Fortschr Med, 2007; 149: 379).
Nevertheless, more studies are needed
to determine whether the pain relief
with acupuncture is long-lasting
(Anesth Analg, 2008; 106: 61121).
Other biofield therapies, including
Qigong, Reiki and Therapeutic Touch,
have been used to treat pain. The
evidence for Qigong is the most
encouraging, with one study rating
its level of efficacy, on the basis of the
research so far, as 23 out of 5, which bones and joints, soft tissues, and the
means that its possibly to probably circulatory and lymphatic systems.
effective for the treatment of chronic They can be particularly effective for
pain (J Rehabil Res Dev, 2007; 44: 195222). chronic pain, as practitioners of these
Like acupuncture, Qigong is a therapies generally tailor their
traditional technique for enhancing treatments to the specific needs of
the flow of qi in the body through each individual patient.
combining movement, meditation Chiropractic manipulationspecif-
and breath regulation. ically, spinal manipulation therapy
For pain control, Qi therapy was (SMT)is the treatment of choice for
particularly successful in reducing many chronic back-pain patients.
negative psychological symptoms, Studies show that it has clinically and
while boosting melatonin and statistically significant benefits com-
immune-system activityat least in pared with either sham manipulations
younger subjects. Nevertheless, in a or treatments considered to be
study of 94 elderly patients, those ineffective or even harmful, such as
who received Qi therapy had less bed rest and traction (Cochrane Database
painand less anxiety, depression and Syst Rev, 2004; 1: CD000447).
fatiguecompared with those given SMT has also been used in the
sham therapy as a control (Complement treatment of a variety of other painful
Ther Med, 2003; 11: 15964). conditions, including fibromyalgia,
In a systematic review of all carpal tunnel syndrome, migraine and
randomized clinical trials (up to dysmenorrhoea (menstrual pain), and
January 2007) assessing Qi therapy was found to be more effective than
for chronic pain, Qigong produced conventional treatments in improving
greater reductions in pain than did pain and disability (J Rehabil Res Dev,
the control treatments. Moreover, a 2007; 44: 195222).
meta-analysis of two studies showed Massage therapy for chronic pain
a significant effect of Qi therapy also has plenty of supporting
compared with general care for evidence. In a recent comprehensive
treating chronic pain (J Pain, 2007; 8: review by the prestigious Cochrane
82731). Collaboration, massage proved to be
superior to joint mobilization,
Manipulation-based medicine relaxation therapy, physical therapy,
Yet another approach to pain manage- acupuncture and self-care education
ment is the use of manipulative and for the treatment of lower-back pain.
body-based techniques such as chiro- Whats more, the beneficial effects
practic and massage therapy. These lasted for at least a year beyond the
methods focus on physiological end of the treatment (Cochrane Database
structures and systems, including the Syst Rev, 2008; 4: CD001929).
Herbal painkillers
u Capsaicin, an extract of cayenne pepper, can ease many types of
chronic pain when regularly applied to the skin. In one study, a capsaicin
plaster was significantly better than a placebo in patients with chronic
back pain (Arzneimittelforschung, 2001; 51: 896903).
u Ginger appears to have both analgesic and anti-inflammatory effects
(J Ethnopharmacol, 2005; 96: 20710). In a trial of women with menstrual pain,
ginger supplements were just as effective as the NSAIDs mefenamic acid
and ibuprofen in providing relief (J Altern Complement Med, 2009; Feb 13: Epub
ahead of print).
u Devils claw (Harpagophytum procumbens) may be useful against
arthritic and lower-back pain. According to one study, for the herb to be
effective, the daily dose needs to provide at least 50 mg of the active
ingredient harpagoside (Orthopade, 2004; 33: 8048).
u Willow bark (Salix alba), which is chemically related to aspirin, appears
to provide acute, short-term relief for patients with lower-back pain
(Cochrane Database Syst Rev, 2006; 2: CD004504).
WDDTY Chronic pain 5
New discoveries
In another study of patients with
mixed chronic pain, massage therapy
was at least as effective as the
standard medical care. However, after
three months, only those in the
massage group still showed significant
improvement (J Altern Complement Med,
2003; 9: 83746).
Interestingly, massage appears to
have an impact on the brain that may
explain its painkilling effects. It may
be that massage raises levels of
6 WDDTY Chronic pain
serotonin, which is thought to
modulate the bodys pain-control
system. Another possibility is that
massage promotes deep, restorative
sleep, which reduces levels of sub-
stance P, a brain chemical associated
with pain (J Rehabil Res Dev, 2007; 44:
195222).
Pain: a new paradigm
These therapies are merely a selection
of the vast array of non-drug options
currently available for chronic pain,
and the search for alternative options
continues to flourish. A major step
forward is the realization that pain is
not always the result of a mechanical
breakdown or traumatic physical
injury, but may be the result of a bio-
chemical or energetic imbalanceor
even an emotional one. If so, then the
cure for chronic pain is unlikely to be
found by popping the usual pills.
Joanna Evans
Common conditions
Chronic back pain
There is now a multitude
of effective drug-free
alternative treatments for
this common, often
disabling, condition
ore than 80 per cent of us
M will suffer from disabling
low back pain (LBP) at
some point in our lives.
Although most of us will recover
within a few months, some will go on
to develop chronic LBPpain that
persists for three months or longer. In
most cases, its not possible to identify
a specific cause of the pain, and the
treatment usually involves course after
course of dangerous drugs (BMC
Musculoskelet Disord, 2010; 11: 163).
Happily, theres a vast array of
complementary and alternative
therapies now available for chronic
LBP, many of which are supported by
good evidence of success (see box,
page 8). But perhaps the best way to
tackle LBP is to prevent it from
becoming a problem in the first place.
Preventing back pain
According to the latest evidence, there
are a number of ways you can reduce
your risk of LBP.
u Stay active. Lower levels of physical
activity are linked to LBP (Aust J
Physiother, 2009; 55: 538), while regular
exercise appears to prevent the
condition (Joint Bone Spine, 2008; 75:
5339). This makes sense as having
strong, flexible muscles are
essential for a healthy back.
However, overly strenuous or
excessive exercise can be bad for
the back (Pain, 2009; 143: 215), so be
sure to choose the right form of
activity for you.
According to Wisconsin-based
spine expert Dr Peter Ullrich, an
ideal back workout includes a
combination of stretching, streng-
thening and low-impact aerobic
conditioning.
u Watch your weight. Being over-
weight places an additional burden
on the spine and strain on the back
muscles. In one study of more than
60,000 men and women, a high
body mass index (BMI) was
significantly associated with an
increased preva-lence of LBP,
particularly in women (Spine [Phila Pa
1976], 2010; 35: 7648).
u Stop smoking. Cigarette-smoking
appears to be linked to LBP,
according to several studies. In a
recent meta-analysis that pooled
the results of 40 separate studies,
current smokers were 80-per-cent
more likely to suffer from chronic
LBP and also had more than twice
the risk of disabling LBP (Am J Med,
2010; 123: 87.e735).
More worrying, exposure to
secondhand smoke during
childhood can increase the risk of
developing back problems later in
life. Researchers have postulated
that this might be because tobacco
smoke has detrimental effects on
the developing spine (Eur J Public
Health, 2004; 14: 296300).
u Get enough sunshine. Mounting
research suggests that a lack of
vitamin D, produced naturally by
the body in response to sunlight,
could be contributing to chronic
musculoskeletal pain, including
LBP (BMJ, 2005; 331: 109).
In one study of patients with
chronic, non-specific (no obvious
cause) LBP attending spinal and
internal medicine clinics in Saudi
Arabia for six years, 83 per cent
were found to have abnormally low
levels of vitamin D. After supple-
menting with the vitamin, however,
symptomatic clinical improvement
was seen in all those who had low
initial concentrations of the vitamin
(Spine [Phila Pa 1976], 2003; 28: 1779).
According to Dr Stewart Leavitt,
a member of the American
Academy of Pain Management and
editor-in-chief of the online journal
Pain Treatment Topics, vitamin D
deficiency can cause musculoskele-
tal pain by causing hypocalcae-
miaabnormally low levels of
circulating calciumwhich sets in
motion a cascade of biochemical
reactions negatively affecting bone
metabolism and health. One of
these reactions is increased para-
thyroid hormone (PTH), causing a
spongy bone matrix to form. This
leads to fluid absorption, resulting
in an expansive pressure that trig-
gers the abundant pain fibres in the
tissues overlying the bones.
This suggests that anyone who
has non-specific LBP should be
tested for vitamin D deficiency.
u Manage stress. Psychological fac-
tors such as stress and depression
are also thought to play a role in
LBP. In one UK study that followed
4500 adults (aged 18 to 75 years)
for 12 months, the likelihood of
having a new episode of LBP was
greater among those who scored in
the upper-third of a questionnaire
for psychological distress (Spine
[Phila Pa 1976], 1995; 20: 27317). In
another study, psychological dis-
tress was a better predictor of back
pain than the standard diagnostic
techniques (Spine [Phila Pa 1976], 2004;
29: 11127). Psychological factors are
also implicated in the transition
from acute to chronic LBP (Spine
[Phila Pa 1976], 2002; 27: E10920).
u Avoid poor posture. In particular,
sitting in a chair for long periods
of time creates imbalances in the
musculoskeletal system that can
increase the risk of pain and injury.
According to one study, workers
who sit for more than half a day in
awkward postures are significantly
WDDTY Chronic pain 7
Common conditions
Drug-free treatment for back pain
u Exercise. Not just good for preventing back pain,
exercise can treat it, too. One review concluded that
exercise can reduce pain and improve physical
function in chronic or recurrent LBP (Joint Bone Spine,
2008; 75: 5339). The most effective strategy appears to
be an individually designed exercise programme that
includes stretching and strengthening, and is carried
out under limited supervisionfor example, home-
based exercises with regular follow-ups by a therapist
( Ann Intern Med, 2005; 142: 77685 ). However, group
exercise can also help, especially if you join a class
that focuses on the mind as well as the body.
v Yoga. A two-year study showed that an Iyengar yoga
class twice a week can improve functional disability,
pain intensity and depression in adults with chronic
LBP, and also allowed the use of less pain medication
(Spine [Phila Pa 1976], 2009; 34: 206676).
v Pilates Method. Increasingly used to treat chronic
LBP, this form of exercise can be effective for reducing
pain and improving general physical function (J Bodyw
Mov Ther, 2008; 12: 36470).
v Qigong. The main posture used in this form of
exercise is similar to the posture recommended by
healthcare professionals dealing with back pain (Wien
Med Wochenschr, 2004; 154: 5647). Also, when used as an
adjunct to drug treatment, this meditative form of
movement and breathing techniques can successfully
relieve chronic pain (Am J Chin Med, 2010; 38: 695703).
u Acupuncture. In one major review, acupuncture was
found to be superior to the usual care for treating
chronic LBP, thereby justifying the recent recognition
of this traditional Chinese medicine technique as a
therapeutic option for LBP by the UKs National
Institute for Health and Clinical Excellence (NICE) (Ann
R Coll Surg Engl, 2010 Jun 7; Epub ahead of print).
u Massage. Several studies suggest that therapeutic
massage is useful against chronic LBP, especially when
combined with exercise and patients self-care
education (Spine [Phila Pa 1976], 2009; 34: 166984). In one
trial, the benefits of massage were still evident 910
months after the therapy had ended (Trials, 2009; 10: 96).
u Alexander Technique. This discipline, which
emphasizes the self-perception of body movement,
was found to be more effective than conventional care
or massage as a treatment for chronic or recurrent
back pain. Whats more, just six lessons followed by
prescribed exercises were nearly as successful as 24
lessons of Alexander Technique on its own (Br J Sports
Med, 2008; 42: 9658).
u Spinal manipulation. Performed by chiropractors as
well as some osteopaths and physical therapists,
spinal manipulation was recently pitted against back
school (consisting of group exercise and education)
and individual physiotherapy (exercise, passive
mobilization and soft-tissue therapy) for the treatment
of chronic LBP. The results showed that spinal
manipulation provided better short- and long-term
functional improvements, and more pain relief, than
8 WDDTY Chronic pain
either back school or individual physiotherapy (Clin
Rehabil, 2010; 24: 2636).
u Biofeedback. This mindbody technique was found to
be more effective than behavioural therapy or
conservative medical treatment for sufferers of chronic
back pain. The researchers also reported that
biofeedback was the only method to significantly
reduce pain over the two-year follow-up (J Consult Clin
Psychol, 1993; 61: 6538).
u Hypnotherapy. Numerous studies show that hypnosis
is an effective treatment for a range of chronic pain
conditions. In a small preliminary study to assess its
success in chronic LBP, a brief, four-session
standardized self-hypnosis protocol, combined with
psychoeducation, dramatically reduced pain intensity
and pain interference (Int J Clin Exp Hypn, 2010; 58: 5368).
u Supplements. In addition to a balanced diet, a number
of supplements may be useful for beating back pain.
v Vitamin D could be the key to curing LBP if you are
deficient in this nutrient (see main story). In a study
of 360 patients with chronic LBP, vitamin D eased
symptoms in virtually all those with the most severe D
deficiency (Spine [Phila Pa 1976], 2003; 28: 1779). Although
sunshine is our best source of this vitamin, most of us
don't get enough of it that way. Pain expert Stewart
Leavitt recommends (with the supervision of a qualified
practitioner) a daily supplement of 2000 IU of vitamin
D3 (cholecalciferol), along with a daily multivitamin
that includes calcium and 400800 IU of vitamin D. Be
patient, as it may take up to nine months to experience
the maximum effects of this regimen.
v B-complex vitamins may also help. A combination
of vitamins B1, B6 and B12, taken twice a day at
50 mg, 50 mg and 1 mg, respectively, together with the
popular non-steroidal anti-inflammatory drug (NSAID)
diclofenac (50 mg twice daily), was better at relieving
back pain than the NSAID alone (Curr Med Res Opin, 2009;
25: 258999).
v Proteolytic enzymes, such as trypsin and serra-
peptase, may be useful as they are known to have anti-
inflammatory properties (Indian J Pharm Sci, 2008; 70:
1147).
u Herbs. The following may help to relieve back pain.
v Capsaicin, found in all hot peppers, can ease many
types of chronic pain when applied regularly to the
skin. In one study, a capsaicin plaster was significantly
better than a placebo in patients with chronic back pain
(Arzneimittelforschung, 2001; 51: 896903).
v Devil's claw (Harpagophytum procumbens) is
effective for LBP when the daily dose provides at least
50 mg of the active ingredient harpagoside. One trial
found it to be just as effective as the NSAID rofecoxib
(Spine [Phila Pa 1976], 2007; 32: 8292).
v White willow bark (Salix alba) is chemically related to
aspirin and appears to provide short-term relief of LBP.
Studies used daily doses standardized to 120 mg or
240 mg of salicin, which has anti-inflammatory actions
(Spine [Phila Pa 1976], 2007; 32: 8292).
more likely to suffer from LBP (Eur
Spine J, 2007; 16: 28398). (See WDDTY
vol 20 no 3 for tips on keeping a
healthy back while sitting.)
Poor lifting technique can also
be the cause of back pain. You
should always push, rather than
pull, when you need to move heavy
objects and, if you have to lift, let
your legs do the work by holding the
load close to your body, keeping
your back straight and bending only
at the knees. Avoid lifting and
twisting simultaneously.
u Treat childhood back pain.
Contrary to popular belief, non-
specific LBP is a serious problem
among children and teenagers.
Indeed, a review of the relevant
studies suggests that rates are
almost as high as in adults (Ugeskr
Laeger, 2002; 164: 7558).
There are also clear correlations
between experiencing LBP as a
child/adolescent and suffering from
LBPespecially chronic LBPas
an adult (Arch Pediatr Adolesc Med, 2009;
163: 6571). It is vital, therefore, that
the condition, when it arises, be
dealt with promptly.
The possible causes of childhood
LBP include intensive sports
activities and carrying a too-heavy
backpack, as well as the factors
mentioned above (Rev Chir Orthop
Reparatrice Appar Mot, 2004; 90: 20714).
For backpack safety tips, see
http://orthoinfo.aaos.org/topic.cf
m?topic= A00043.
Joanna Evans
WDDTY Chronic pain 9
Common conditions
Migraine misery:
triggers and treatments
If you suffer from these
severe chronic headaches,
its useful to know that
theres a wide range of safe
alternative treatments you
can take
ore than just a headache,
M migraine is a chronic
condition that can have a
huge impact on peoples
lives. In fact, the World Health
Organization has rated migraine
amongst the top-20 most-disabling
chronic lifetime conditions.
Besides a severe headache, sufferers
may experience a range of other
symptoms that include nausea,
vomiting, abdominal pain, and an
increased sensitivity to light and noise.
Whats more, recent evidence suggests
that people with migraine have a
higher risk of stroke, particularly those
who suffer from migraine with aura
sensory, motor or visual disturbances
that can precede or accompany the
headache. Smoking, oral contraceptive
use and being a woman can increase
the risk even further (Neurol Sci, 2010; 31
Suppl 1: S1278).
Migraine is thought to occur when
the blood vessels in the brain constrict
and then suddenly widen. But precisely
what brings about this pattern of
vascular constriction and relaxation
remains a mystery.
Doctors usually blame it on heredity,
and treat the condition with prescrip-
tion drugs such as prochlorperazine,
sumatriptan and ergotamine. But
these agents do nothing to cure the
condition and, worse, come with a
myriad of side-effects. Some can even
cause rebound headachesthat is,
headaches brought on by the
medication itself.
Sufferers stand a much better
chance of long-term relief if they try
to work out whats causing their
migraines in the first place.
Although its not clear why some
people have migraines and others
dont, studies have identified a number
of factors that can precipitate such
10 WDDTY Chronic pain
headaches. These can vary from person
to person and, in most cases, the
sufferer is responding to multiple
triggers (Aust Fam Physician, 2005; 34:
64751).
Migraine triggers
u Food allergies/sensitivities. One
factor known to bring on migraines
particularly in children
teenagersis food. Usually, its the
chemicals within foods that are
thought to be the culprit. Chemicals
such as tyramine (found in cheese),
phenylethylamine (found
chocolate), tyrosine, monosodium
glutamate (MSG), aspartame, caffeine,
sulphites, nitrates (found in processed
meats) and histamine (found in wine
and beer) appear to trigger the
condition by altering the physiological
processes associated with migraine
attacks (Pediatr Neurol, 2003; 28: 915).
A study of 577 migraine sufferers
found that sensitivity to cheese,
chocolate, red wine and beer had the
most clear-cut associations with
attacks (Headache, 1995; 35: 3557).
Theres also some evidence that
gluten sensitivity may play a role in
migraines. Indeed, it appears that
migraine is a common feature in
patients with coeliac disease (CD) (Mov
Disord, 2009; 24: 235862), and one study
found that a gluten-free diet can help.
When four patients with migraine and
CD were put on a gluten-free diet for
six months, one patient subsequently
had no migraine attacks, while the
other three experienced improvements
in the frequency, duration and intensity
of their migraines (Am J Gastroenterol,
2003; 98: 6259).
Other types of anti-allergy diets have
also proved effective. In a double-blind
controlled trial of 88 children with
severe, frequent migraines, an elim-
ination diet led to full recovery in 93
per cent of them. Their symptoms
recurred when the suspected foods
were reintroduced into their diets
(Lancet, 1983; 2: 8659).
u Sleep problems. Several studies have
found an association between sleep
patterns and migraine. In a recent
Norwegian study, severe sleep
disturbances were five times more
common among migraine sufferers
than headache-free individuals (J
Headache Pain, 2010; 11: 197206). Another
study found that overnight headaches,
or headaches first thing in the
morning, reflected a sleep disturbance
and in 55 per cent of patients. Treatment
of the sleep disorder varied, but the
results showed an improvement in
headache symptoms in 100 per cent of
the participants, and complete resolu-
in tion in 65 per cent of cases (Aust Fam
Physician, 2005; 34: 64751).
u Infection. Helicobacter pylori (the
microorganism that causes peptic
ulcers) infection can predispose some
people to migraine. In one trial, 40 per
cent of migraine sufferers had H. pylori
infection, and the intensity, duration
and frequency of attacks of migraine
were significantly reduced in all
participants in whom the bacteria were
eradicated (Hepatogastroenterology, 1998;
45: 76570). More recently, researchers
discovered that H. pylori infection is
most common in people whose
migraines are not triggered by hor-
monal fluctuations (such as during
menstruation) and in those without a
family history of migraine (J Headache
Pain, 2007; 8: 32933).
u Magnesium deficiency. Compared
with non-sufferers, people with
migraines have lower blood and brain
levels of magnesium. However, taking
around 600 mg/day was found to
significantly reduce the frequency of
migraine attacks (Altern Med Rev, 1999; 4:
8695). But lower doses of magnesium
can also be effective. Another study
found that just 200 mg/day could
reduce the frequency of migraines in
80 per cent of those treated (Headache,
1990; 30: 168). Its thought that magnes-
ium plays a role by counteracting the
sudden contraction of blood vessels,
inhibiting platelet aggregation and
stabilizing cell membranesall of
which are involved in migraine.
u Stress. This is the factor listed most
often by migraine sufferers as a trigger
for their attacks. Theres also evidence
that stress may even help to initiate
migraine in those predisposed to the
disorder and that migraine attacks
themselves may be a stressor, thus
leading to a vicious cycle of chronic
migraines. This suggests that stress-
reduction techniquessuch as medita-
tion, yoga or regular massageor even
a relaxing hobby may help to prevent
and manage migraines (Headache, 2009;
49:137886).
u Environment. Bright sunlight, flick-
ering lights, air quality and odours are
known to trigger migraines (Headache,
2009; 49: 94152). Moreover, headache is
a common symptom of sick building
syndrome (SBS), a condition thought
to result from factors such as volatile
organic compounds (found in paint,
lacquer, plastic and glue), moulds,
electromagnetic radiation, lighting,
noise, air conditioning, excessive
heating and poor ventilation.
According to one review, SBS may
indeed be a plausible explanation for
chronic headache in some patients
(Aust Fam Physician, 2005; 34: 64751).
Alternative treatments
A variety of other factorsranging
from drugs to hormones to
dehydrationcan bring on migraines,
so the best course of action is to keep
a headache diary to help to determine
your potential triggers. Addressing
these triggerswith the help of an
experienced practitionermay reduce
the frequency of attacks or even
eradicate the problem entirely. How-
ever, if this approach doesnt work,
there are a number of tried-and-tested
Herbal helpers
u Feverfew (Tanacetum parthenium) is a popular herbal remedy for
preventing migraine. Trials show that remedies standardized to around
250 mcg of parthenolide can reduce the severity, duration and frequency
of migraines (Phytother Res, 1997; 11: 50811). When using feverfew, be
patient, as it can take four to six weeks to see results.
u Butterbur (Petasites hybridus) is another effective migraine
preventative. In one study, just 50 mg/day (standardized extract) for 12
weeks significantly reduced the frequency of migraines compared with
placebowith no adverse effects (Altern Med Rev, 2001; 6: 30310). However,
butterbur contains alkaloids that are toxic to the liver, so be sure to
choose alkaloid-free formulations.
u Ginger (Zingiber officinale) may help against migraineat least
according to anecdotal evidence (J Ethnopharmacol, 1990; 29: 26773).
Clinical trials are lacking, but an observational study suggests that
500600 mg/day of dried ginger can relieve migraine attacks as well as
reduce their frequency and severity (Altern Med Rev, 1999; 4: 8695).
u Ginkgo biloba inhibits the action of what is known as platelet-activating
factor, an agent that is believed to contribute to migraine headaches.
Indeed, two small trials suggest that Ginkgo extract may have benefits
for migraine patients. The recommended dosage, standardized to 24-per-
cent Ginkgo heterosides (its active ingredient), is 40 mg three times a day
(Altern Med Rev, 1999; 4: 8695).
natural ways to treat migraine. cent had reduced nausea and vomiting
u Supplements. The following nutri- (Cephalalgia, 1997; 17: 12730). In contrast,
tional supplements may be beneficial a randomized double-blind placebo-
for migraine. controlled trialconsidered the gold
v Riboflavin (vitamin B2). A German standard for scientific evaluation
study found that supplementing with found no significant differences
400 mg of riboflavin reduced the between treatment with omega-3
number of migraine attacks by half, supplements and placebo. However, the
although once an attack had occurred, placebo was olive oil, which is itself a
the vitamin had no effect on either its source of beneficial PUFAs (J Adolesc
severity or duration (Eur J Neurol, 2004; Health, 2002; 31: 15461).
11: 4757). Similar results have been v 5-Hydroxytryptophan (5-HTP) can
reported in earlier studies (Neurology, be just as effective as two commonly
1998; 50: 46670). Riboflavin is generally used migraine drugspropranolol and
safe, although some people taking high methysergide (Schweiz Med Wochenschr,
doses may develop diarrhoea. 1991; 121: 158590; Eur Neurol, 1986; 25:
v Coenzyme Q10. A significant propor- 3279). In general, dosages of 400600
tion of migraine sufferers may be mg/day are taken.
deficient in this vitamin-like antioxi- u Manual therapies. According to a
dant (Headache, 2007; 47: 7380). Placebo- review of the scientific literature,
controlled trials are lacking, but 150 spinal manipulation/mobilization is
mg/day of CoQ10 may cut migraine effective for migraine (Chiropr Osteopat,
frequency by more than 50 per cent 2010; 18: 3). One study found that spinal
without any side-effects (Cephalalgia, manipulation was on par with drugs
2002; 22: 13741). for reducing migraine sufferingand
v Polyunsaturated fatty acids (PUFAs) had fewer side-effects (J Manipulative
may also be useful. When 129 migraine Physiol Ther, 1998; 21: 5119).
sufferers were given gamma-linolenic u Transcranial magnetic stimulation
acid (an omega-6 PUFA) and alpha- (TMS). This non-invasive technique,
linolenic acid (an omega-3 PUFA), 86 which uses a fluctuating magnetic field
per cent saw reductions in the severity, to stimulate neurons in the brain,
frequency and duration of their shows promise as a migraine treatment
migraine attacks, 22 per cent became and preventative. Indeed, a portable
migraine-free, and more than 90 per device called Neuralieve was found to
WDDTY Chronic pain 11
Common conditions
be significantly better than placebo at
alleviating migraine attacks (Lancet
Neurol, 2010; 9: 37380).
u Exercise. Physical activity has been
reported to trigger headaches in some
people, yet recent evidence also
suggests that exercise may be bene-
ficial for migraines. When Swedish
researchers studied 26 patients at a
local headache clinic for 12 weeks, they
found that regular exercise (indoor
cycling three times a week) led to
significant improvements, including
fewer migraine attacks, less intense
symptoms and less use of medicines,
12 WDDTY Chronic pain
and better quality of life (Headache, 2009;
49: 56370).
u Acupuncture. This traditional
Chinese technique can treat a range of
different sorts of headaches, including
migraine. According to a review by the
Cochrane Collaboration, acupuncture
is at least as effective as, or possibly
more effective than, prophylactic drug
treatment, and has fewer adverse
effects (Cochrane Database Syst Rev, 2009;
1: CD001218).
u Biofeedback. This technique uses
special machines to feed back
information related to your specific
internal physiological states. In fact,
numerous studies have shown that
biofeedback is effective for reducing
the frequency and severity of head-
aches. However, such treatment can
be expensive and time-consuming (Pain
Physician, 2009; 12: 100511).
u Homeopathy. A two-year study
carried out in Germany suggests that
homeopathy may be useful against
migraine (J Altern Complement Med, 2010;
16: 34755). A qualified practitioner will
be able to prescribe personalized
treatment.
Joanna Evans
Fibromyalgia:
mind and body techniques
that help
Eight times more women
than men develop
fibromyalgia. Although
painkillers are the usual
treatment, exercise may be
a safe and effective
alternative.
robably the last thing you
P feel like doing. But the
evidence is stacking up to
show that keeping active
might be the best way to combat this
painful chronic condition.
Several studies published over the
last few years have found that regular
physical activityeven just
walkingmay help alleviate the
devastating symptoms of
fibromyalgia, which include wide-
spread pain, fatigue, disturbed sleep,
stiffness, reduced physical
functionality and depression.
In one of the latest studies,
published in February 2011 in an
international peer-reviewed journal,
Nordic walkinga fitness technique
that involves walking with specially
designed poleswas revealed to
improve the physical capacity of
women with fibromyalgia.
A total of 58 women completed
the study, which compared moderate-
to-high-intensity Nordic walking
(twice a week for 15 weeks) with
supervised, low-intensity walking (as
the control condition). The results
showed that both groups enjoyed
clinically meaningful reductions in
pain and fatigue. However,
compared with the control group,
the Nordic walkers experienced
significant fitness gains and had
significantly improved scores on a
fibromyalgia-specific questionnaire
assessing physical function.
Whats more, Nordic walking did
not trigger any flareups of
fibromyalgia symptoms, which can
happen with some other forms of
high-intensity exercise.
Nordic walking . . . offers patients
a safe and effective means of
regaining functionality and physical
fitness, the study authors concluded
(Arthritis Res Ther, 2011; 13: 103).
Another studypublished in the
same international journal, but in
2010demonstrated that even short
bursts of physical activity, such as
gardening or housework, can be
beneficial for fibromyalgia sufferers.
In this report, researchers at John
Hopkins University and the
University of Michigan in the US
investigated the effects of 30
minutes of lifestyle physical activity
(LPA), five to seven days a week, on
physical functionality, pain and other
measures of disability in 84 relatively
inactive fibromyalgia patients.
LPA involves doing moderate-
intensity physical activities (intense
enough to cause heavy breathing, but
not to the extent that you cant hold
a conversation) based around
everyday life, such as taking the
stairs instead of the lift or vacuuming
the house.
After 12 weeks, the findings
showed that, compared with controls
(who were only given information
and support), the LPA group
reported improved physical function
and reduced painand these results
were statistically significant (Arthritis
Res Ther, 2010; 12: R55).
As Kevin Fontaine, lead author of
the study, stated, The nature of
fibromyalgia's symptoms, the body
pain and fatigue, make it hard for
people with this malady to
participate in traditional exercise.
Weve shown that LPA can help them
to get at least a little more physically
active, and that this seems to help
improve their symptoms.
However, a follow-up study that
tracked the participants for 12
months suggests that the effects of
LPA are rather short-lived. Although
the LPA group reported greater
perceived improvement at six and at
12 months, they no longer differed
from the controls in terms of pain,
physical activity, body point
tenderness, fatigue and depression (J
Clin Rheumatol, 2011; 17: 648).
The researchers noted that
activity levels declined over the
course of the study, suggesting
that the participants had
difficulty adhering to the LPA
recommendations.
Mindbody techniques
Another type of activity that may
help fibromyalgia sufferers is exercise
that involves the mind as well as the
body.
Yoga, for example, relieved a
variety of fibromyalgia symptoms,
including pain, fatigue and
depression. In this study, 53 women
were randomized to receive either an
eight-week yoga programme
(involving gentle poses, meditation,
breathing exercises and group
discussions) or standard care. The
results with yoga were clinically
significant: pain was reduced by an
average of 24 per cent, fatigue by 30
per cent and depression by 42 per
cent (Pain, 2010; 151: 5309).
Crucially, participants showed a
strong commitment to the yoga.
Attendance at the classes was good
WDDTY Chronic pain 13
Common conditions
as was most participants willingness
to practice yoga while at home, said
study author James Carson. However,
further research is needed to see if
yoga is an effective therapy in the
long term.
Another promising mindbody
technique is tai chi, which combines
meditation with slow, gentle,
graceful movements, as well as deep
breathing and relaxation.
In this trial, 66 fibromyalgia
patients were assigned to either tai
chi classes (one-hour sessions twice a
week for 12 weeks) or a control
intervention of wellness education
and stretching. At the end of the
study, the tai chi group showed
clinically significant improvements
in symptoms, as measured by the
Fibromyalgia Impact Questionnaire.
In particular, tai chi was associated
with reduced pain and depression,
and better sleep and quality of life.
No adverse effects were reported and
the benefits were sustained for 24
weeks (N Engl J Med, 2010; 363: 74354).
But if faster-paced exercise is
preferred, it may be worthwhile
combining your favourite aerobic
exercise with simple relaxation
techniques such as deep breathing
and visualization (adding these to
the end of your workout). In a study
from Spain, fibromyalgia patients
who participated in an aerobic
exercise programme combined with
progressive relaxation techniques
experienced significant improve-
ment compared with the control
group, which received sham
magnetic therapy. After 10 weeks,
the exercise + relaxation group
reported better sleep, reduced
anxiety and improved quality of life
(Med Clin [Barc], 2011 Feb 21; Epub ahead of
print).
Clearly, drugs are not the only
answer to fibromyalgia, as studies are
now suggesting that aerobic exercise
and mindbody techniques are
effective. Nevertheless, more
research is needed to see how these
interventions fare in the long-term,
although it appears that if you can
stick with it, you will continue to
reap the benefits. For best results,
work with a physical therapist who
can devise an exercise programme
thats right for you.
Joanna Evans
14 WDDTY Chronic pain
Other approaches
u Try TCM.According to a recent review,Traditional Chinese Medicine (TCM) appears
to be effective against fibromyalgia. Studies show that acupuncture, Chinese herbs, and
a combination of acupuncture and cupping are more successful at reducing pain than
are conventional drug treatments (J Altern Complement Med, 2010; 16: 397409).
u Give homeopathy a go. In a double-blind, randomized controlled trial (RCT,
considered the gold standard for scientific evaluation), individualized homeopathy
proved to be significantly better than placebo in lessening tender point pain and
improving the quality of life and global health of persons with fibromyalgia (Rheumatology
[Oxford], 2004; 43: 57782).
More recently, a review of the findings of RCTs so far revealed that homeopathy is
consistently better than a placebo at alleviating the symptoms of fibromyalgia. However,
the researchers noted that more rigorous trials are needed (Clin Rheumatol, 2010; 29:
45764).
u Consider massage. A particular technique called myofascial release therapy was
found to improve pain, quality of sleep, anxiety levels and quality of life in a 20-week RCT
study of 74 fibromyalgia patients (Evid Based Complement Alternat Med, 2011; 2011: 561753).
u Go vegan. A vegan dietwhich includes no animal productsmight be helpful for
fibromyalgia, according to a study of 33 fibromyalgia patients who were split into two
groupsone following a strict, low-salt vegan diet consisting of only raw foods, and one
that continued with an omnivorous diet. After three months, the vegan dieters saw
significant improvements in their overall health, with less pain and stiffness, too (Scand J
Rheumatol, 2000; 29: 30813).
However, these beneficial effects could simply be down to the fact that the
participants lost weightmost were overweight at the beginning of the study, and
shifting to a vegan diet caused significant reductions in their body mass index (BMI).As
several studies have found a link between obesity and fibromyalgia (J Pain, 2010; 11:
132937), it may perhaps be that the weight loss rather than the vegan diet per se was
responsible for the improvements.
u Eliminate harmful food additives. There is evidence to suggest that the artificial
sweetener aspartame and the flavour enhancer monosodium glutamate (MSG)both
known to be excitotoxinsmay be involved in fibromyalgia. One study describes
four women with fibromyalgia who saw complete or nearly complete resolution of
their symptoms within months of eliminating MSG or MSG plus aspartame from
their diet. More important, symptoms recurred whenever they ingested the
chemicals again.
We propose that these four patients may represent a subset of fibromyalgia
syndrome that is induced or exacerbated by excitotoxins or, alternatively, may
comprise an excitotoxin syndrome that is similar to fibromyalgia, the researchers
said (Ann Pharmacother, 2001; 35: 7026).
In a case report including a woman with fibromyalgia, her symptoms completely
disappeared after she stopped consuming aspartame (Clin Exp Rheumatol, 2010; 28 [6
Suppl 63]: S1313).
u Try supplements. 5-Hydroxytryptophan (5-HTP; 100 mg three times a day) and
S-adenosylmethionine (SAMe; 800 mg per day) may be effective for fibromyalgia,
according to double-blind trials (J Int Med Res, 1990; 18: 2019; Scand J Rheumatol, 1991; 20:
294302). Other potentially useful supplements include vitamin D (Clin Rheumatol, 2007;
26: 5514), magnesium with malic acid (J Rheumatol, 1995; 22: 9538), and antioxidants such
as vitamins C and E (Redox Rep, 2006; 11: 1315). Many fibromyalgia sufferers are deficient
in these and other nutrients, so it may be worth getting tested to see what youre low
in.
u Check your thyroid. According to Dr John Lowe of the Fibromyalgia Research
Foundation in Boulder, CO, many of the features of fibromyalgia and hypothyroidism
(an underactive thyroid) are virtually identical, and thyroid hormone treatment trials
have reduced or eliminated fibromyalgia symptoms as well (Med Sci Monit, 2006; 12:
CR2829). For this reason, it may prove useful to investigate the possibility of having
hypothyroidism, and to seek out natural treatments if you do (see WDDTY vol 20 no10,
pages 189).
Chronic fatigue syndrome
CFSalso known as
myalgic encephalomyelitis
(ME) or post-viral fatigue
syndromeis a
debilitating condition that
affects an estimated 17
million people worldwide.
Luckily, theres now a wide
variety of promising
natural treatments,
ranging from acupuncture
to saunas and
supplements.
hronic fatigue syndrome
C (CFS) is a mysterious
illness with a long history of
controversy. Early on,
medical authorities were sceptical as
to whether or not it even existed.
Today, there are still disagreements
as to its diagnosis, cause(s),
treatment and prevalencenot to
mention what to call it.
Sadly, two new studies have come
up with nothing to help clear up the
confusion. The first, an investigation
by the US Food and Drug Adminis-
tration (FDA), reportedly confirmed
previous research that found a link
between CFS and the so-called xeno-
tropic murine leukaemia virus-
related virus (XMRV).
The study has yet to be published
but, in a presentation at a blood
safety meeting in the Croatian
capital of Zagreb, virologist Harvey
Alter, one of the study researchers,
reported a very strong CFSXMRV
connection, independently conf-
irming data that had been published
in the journal Science in 2009
(www.independent.co.uk/ news/science-
/study-that-solves-chronic-fatigue-syndrome-
blocked-2022195.html). Until now, other
teams have failed to replicate the
results (Science, 2009; 326: 5859).
However, any hopes that such an
association would offer a solid
explanationor lead to a potential
treatmentfor the puzzling
condition were soon dashed when
another US government study, this
time by the Centers for Disease
Control and Prevention (CDC), and
two additional laboratories, reported
contradictory findings.
In that study, blood samples from
around 100 people with and without
CFS were tested, with the result that
the CDC researchers could find no
evidence of a link between CFS and
XMRV. This was in direct contrast to
the Science study, which reported the
presence of XMRV in 67 per cent of
the CFS patients compared with 3.7
per cent of the healthy controls (Retro
virology 2010, 7: 57; doi: 10.1186/1742-4690-7-
57).
In response, Judy Mikovits, director
of research at the Whittemore
Peterson Institute in Reno, NV, and
lead author of the Science study, stated
that the CDC report was flawed
because it failed to use patients that
had been officially diagnosed with
CFS, and it also lacked positive
controls in the form of blood from
people known to be diagnosed with
XMRV infection.
Weve now got more than 1000
individual patients from around the
world in whom weve detected and
isolated the virus . . . I havent changed
my mind on this, Dr Mikovits said.
But the FDA study that supposedly
supports Mikovits findings has also
come under criticism, and is currently
undergoing a rigorous scientific review
process. Clearly, well have to wait a bit
longer to find out whether XMRV plays
a role in CFS or not.
Multiple causes
Although theres been a preoccu-
pation with finding a single cause of
CFS in conventional circles, holistic
practitioners have long believed that
the condition has many potential
causes, each of which shares a
common endpointsevere immune
suppression.
Within such a construct, every one
of the proposed causes of CFS
including viruses, stress, depression,
impaired liver function, environmental
illness, medicine use, adrenal insuf-
ficiency, Candida albicans infection,
leaky gut, hypothyroid, hypoglycaem-
ia, anaemia, nutritional deficiencies,
food allergies, sleep disturbances,
emotional problems, poor posture and
lack of exerciseis credible.
Successful treatment requires
working with an experienced practi-
tioner who knows the importance of a
comprehensive diagnosis that takes
into consideration the patients
medical history as well as their
physical and emotional lives. The most
effective regime is likely to be the one
that assesses all these factors to arrive
at an individual plan tailored to the
given patients needs.
Proven natural treatments
Conventional medicine has little to
offer the CFS sufferer besides anti-
depressants or pain relievers that only
manage symptoms. Fortunately,
although the scientific evidence is
relatively weak, there are a number of
promising natural treatments for CFS.
u Supplements. Research suggests
that the following nutritional
supplements may be beneficial.
However, be sure to first consult a
qualified practitioner who can
check for any deficiencies and
advise you on dosages.
v Magnesium. Some CFS sufferers
have been found to have low levels
of magnesium in their blood.
Indeed, many of the symptoms of
CFS resemble those of magnesium
deficiency (Altern Med Rev, 2000; 5:
93108). Also, in one small ran-
domized controlled trial, patients
WDDTY Chronic pain 15
Common conditions
who had weekly injections of
magnesium sulphate were more
likely to feel better after six weeks
than those who had received
injections of a dummy treatment
(Lancet, 1991; 337: 75760). Oral mag-
nesium has also proved useful in
magnesium-deficient CFS sufferers,
according to a preliminary report
(Lancet, 1992; 340: 426).
v Carnitine is essential for the
production of energy in the power-
houses of cells (mitochondria). Not
enough of this nutrient can impair
mitochondrial function, leading to
symptoms of generalized fatigue,
along with musle pain (myalgia),
muscle weakness and malaise
following physical exertion (Altern
Med Rev, 2000; 5: 93108).
In addition, low carnitine levels
have been found in CFS patients,
and one study saw a statistically
significant clinical improvement
in those taking L-carnitine supple-
ments for two months (Neuro-
psychobiology, 1997; 35: 1623).
v Vitamin B12. Evidence suggests
that high-dose injections of this
vitamin may benefit people with
CFS. Injections of 25005000 mcg
of B12 given every two to three
days led to improvement in 50 to
80 per cent of patients (Altern Med
Rev, 2000; 5: 93108).
v NADH (nicotinamide adenine
dinucleotide) helps make adenosine
triphosphate (ATP), the source of
the energy that the body runs on. In
a small double-blind crossover
study, 26 CFS sufferers took either
10 mg of oral NADH or a placebo
every day for four weeks, then
switched to the other treatment
after a four-week interval. In the
NADH group, 31 per cent saw their
symptoms improve compared with
just 8 per cent in the placebo group
(Ann Allergy Asthma Immunol, 1999; 82:
18591).
v Essential fatty acids (EFAs). Low
levels of various EFAs could be
contributory to CFS (J Clin Pathol,
2007; 60: 1224; Neuro Endocrinol Lett,
2005; 26: 74551). However, whether
supplements help is unclear.
When 63 CFS sufferers took
either an EFA supplement (contain-
ing linoleic, gamma-linolenic,
eicosapentaenoic and docosahexa-
enoic acids) or a placebo every day
16 WDDTY Chronic pain
CFS symptoms
Sufferers with chronic fatigue syndrome (CFS) can experience a wide range
of signs and symptoms, but the main ones include:
u fatigue
u impaired memory or concentration
u sore throat
u painful and mildly enlarged lymph nodes in the neck or armpits
u unexplained muscle pain
u pain that moves from one joint to another with no swelling or redness
u headache of a new type, pattern or severity
u unrefreshing sleep
u extreme exhaustion that lasts for more than 24 hours after physical or
mental exercise.
Source: mayoclinic.com
for three months, those taking the drome (IBS)-like symptoms seen
EFAs saw significant improvement in all patients, a significant finding,
in their symptoms compared with as CFS patients have a high rate of
the placebo. Moreover, the EFA IBS (Altern Med Rev, 2001; 6: 4509).
supplementation corrected the Another study concluded that
abnormal fatty-acid levels noted at choosing organically grown fruit
the start of the study (Acta Neurol and vegetables is important for CFS
Scand, 1990; 82: 20916). In contrast, patients, as they are found to have
another trial using the same EFA elevated levels of pesticides in their
supplement found no significant blood (Med J Aust, 1995; 163: 2947).
differences between the active- Pesticide exposure may be a direct
treatment and placebo groups (Acta cause of CFS symptoms by affecting
Neurol Scand, 1999; 99: 1126). cell membranes or, indirectly, by
v Antioxidants may be beneficial, playing a role in the loss of natural
as oxidative stress is thought to play tolerance for chemicals, including
a role in CFS. Selenium, glutathi- those present in foods (Toxicol Ind
one, N-acetylcysteine, alpha-lipoic Health, 1999; 15: 38697).
acid, coenzyme Q10 and oligomeric u Exercise. Traditionally, there is
proanthocyanidins (OPCs), as well some concern that exercise may
as vitamins C and E, may prove to make symptoms of fatigue worse,
be invaluable in a CFS treatment but studies show that graded
protocol. Ginkgo biloba and bilberry exercisewhich builds up gradually
(Vaccinium myrtillus) are also from a gentle beginningcan
recommended (Altern Med Rev, 2001; 6: improve CFS symptoms.
4509). In a recent study of adolescent
u Diet. As there may be a connection CFS sufferers, both graded aerobic
between food intolerance and CFS, exercise and progressive resistance
identifying and addressing these training were able to significantly
intolerances should prove helpful. improve physical capacity and
When Australian CFS patients quality of life. However, only aerobic
eliminated wheat, milk, benzoates, exercise improved fatigue severity
nitrites, nitrates, and food and symptoms of depression (Clin
colourings and other additives from Rehabil, 2010 July 6; Epub ahead of print).
their diet, 90 per cent of those Nevertheless, its generally advis-
who were able to stick with the able that CFS sufferers only do the
diet reported improvement in the graded exercise that is prescribed
severity of a wide range of symp- and supervised by a trained thera-
toms, with significant reductions in pist, such as a physiotherapist.
fatigue, recurrent fever, sore throat, u Cognitive behavioural therapy
muscle pain, headache, joint pain (CBT). This form of talking
and cognitive dysfunction. treatment is often used to treat
Whats more, the elimination chronically ill patients, and its
diet resulted in a marked improve- effectiveness in CFS was recently
ment in the irritable bowel syn- the subject of a major review of the
 literature. It found that those who
received CBT were more likely to
feel less tired at the end of
treatment than patients who
received the usual care from their
doctor. Moreover, the review
concluded that it may be more
effective in reducing fatigue
symptoms compared with other
psychological therapies (Cochrane
Database Syst Rev, 2008; 3: CD001027).
u Massage has many proven benefits
relevant to CFS sufferers, including
better relief from pain, depression
and anxiety, and improved sleep
patterns.
A recent study from China found
that a technique called intelligent-
turtle massage not only alleviated
the physical symptoms of CFS, but
also boosted immune function (J
Tradit Chin Med, 2009; 29: 248).
u Acupuncture. A meta-analysis of
the pooled results of several studies
concluded that acupuncture is an
effective therapy for CFS. However,
it was also noted that more high-
quality studies are needed to
confirm this finding (Zhen Ci Yan Jiu,
2009; 34: 4218).
u Sauna therapy. Two case reports
from Japan have found that
repeated far-infrared (FIR) saunas,
a form of thermal therapy, may be
an invaluable treatment for CFS.
Symptoms such as fatigue, pain,
sleep disturbances and low-grade
fever were all dramatically improved
after 15 to 25 sessions (J Psychosom
Res, 2005; 58: 3837). In fact, saunas
may help by also encouraging the
elimination of pesticides and other
toxins from the body (which may
be involved in CFS). See WDDTY
vol 20 no 10 for other effective ways
to detox.
u Breathing retraining. A prelim-
inary study carried out in Belgium
identified specific breathing prob-
lems in patients with CFS. One
session of breathing retraining was
able to improve lung function in
these patients, suggesting that this
form of treatment may be useful in
some cases (Physiother Theory Pract,
2008; 24: 8394).
u Relaxation techniques. According
to one study from the Netherlands,
stress may well play an important
predisposing, precipitating and
perpetuating role in CFS (Tijdschr
Psychiatr, 2009; 51: 60310). This
suggests that stress-reduction
activities such as meditation, tai
chi or yoga may be beneficial.
Indeed, yoga appeared to help with
the characteristic symptoms of
fatigue in an observational study
(J Clin Psychiatry, 2005; 66: 62532).
u Pacing is a form of treatment that
is based on finding the optimal
balance between rest and activity
for the individual patient. Its
thought that, if those with CFS use
what limited energy they have
wisely, their energy levels will even-
tually and gradually increase.
Randomized controlled trials are
lacking, but an observational study
found that three weeks of self-
managed pacing led to a modest
improvement in symptom severity
and everyday functioning (J Rehabil
Res Dev, 2009; 46: 98596).
For this reason, a randomized
controlled comparative trial is
currently under-way to confirm the
effectiveness of pacing, as well as
CBT and graded exercise, in
addition to the usual specialist
medical care of CFS (BMC Neurol,
2007; 7: 6).
Joanna Evans
WDDTY Chronic pain 17
Common conditions
Irritable bowel syndrome
There are a number of
effective alternative
ways to manage IBS
rritable bowel syndrome (IBS)
I is among the most common
problems of the digestive
system, affecting up to 15 per
cent of people in the developed
countries. Although its not life-
threatening, the symptomswhich
include abdominal pain, bloating,
wind, constipation and diarrhoea
can severely affect the IBS
sufferers quality of life. Those with
IBS frequently report experiencing
loss of freedom, spontaneity and
social contacts, as well as feelings
of fearfulness, shame and
embarrassment (Dig Dis Sci, 2009; 54:
153241).
Adding to the problem,
conventional therapy is highly
inadequate. Many treatments (such
as antispasmodics, antidiarrhoeals,
bulking agents, tranquillizers and
sedatives) can harm more than
help, and none of them has proved
to be globally effective at treating
IBS symptoms (J Chin Med Assoc, 2009;
72: 294300).
Its no surprise, therefore, that a
growing number of IBS patients are
turning to complementar y and
alternative medicine ( Gastroenterol
Clin Biol, 2009; 33 Suppl 1: S7983).
The role of sugar
Part of the problem of treating IBS
is that no one knows what causes it.
The latest research, however,
suggests that certain foods might
play a role, an idea that alternative
practitioners have been expounding
upon for years. In particular, the
more recent studies have revealed
that around a third of IBS patients
may have problems with processing
fructose, the type of sugar that is
found in fruits, some vegetables,
honey and high-fructose corn
syrup. Fructose malabsorption, as
its officially knownwhich refers
to the bodys failure to completely
absorb fructose as it passes
through the small intestinecan
lead to many of the symptoms that
18 WDDTY Chronic pain
are typically seen in IBS (J Am Diet
Assoc, 2006; 106: 16319).
In one American study,
researchers at the Immanuel St
Josephs Hospital, part of the Mayo
Health System in Minnesota,
looked at 80 patients with IBS and
found that 31 (38 per cent) also
had fructose malabsorption. Of
these patients, 26 were then put on
a fructose-restricted diet, and
those who managed to stick with
the diet (only around half of them)
enjoyed significant improvements
in their symptoms, including
abdominal pain, belching, bloating,
feelings of fullness, indigestion and
diarrhoea. The patients who didnt
stick with the dietary restrictions,
on the other hand, generally saw no
change in their symptoms (J Clin
Gastroenterol, 2008; 42: 2338).
Similarly, in a study of 32
children with persistent un-
explained abdominal pain, 11 of
them were found to have fructose
malabsorption and, so, were
subsequently put on a low-fructose
diet. After two months, all but two
of these children showed rapid
improvement of their symptoms,
and all continued to report positive
changes thereafter. The res-
earchers, from the New York
Medical College in the US,
concluded that fructose
malabsorption may be a significant
problem in children and that
management of dietary intake can
be effective in reducing gastro-
intestinal symptoms ( J Pediatr
Gastroenterol Nutr, 2008; 47: 3038).
Although the researches into the
precise role and mechanism(s)
behind fructose malabsorption in
IBS are still in their early stages, in
cases where symptoms of gas,
bloating and diarrhoea appear to be
related to eating fruit, a fructose
elimination diet might be
something worth considering.
Other problem foods
Besides fruit sugars, other ferment-
able, poorly absorbed carb-
ohydratessuch as lactose (found
in milk), fructans (found in wheat
and onions) and sorbitol (a
common sweetener)are also able
to cause or exacerbate the usual
symptoms of IBS (J Am Diet Assoc,
2009; 109: 120414; Curr Gastroenterol Rep,
2009; 11: 36874).
Whats more, some of the foods
that are commonly recommended
to ease IBS may actually be making
the condition worse. Wheat bran,
for instance, often prescribed for
constipation due to its high fibre
content, only helped 10 per cent of
sufferers in one study. On the other
hand, more than half of the IBS
sufferers followed-up by researchers
at the University Hospital of South
Manchester, in the UK, reported
that bran made their symptoms
including bowel disturbances, and
abdominal distention and pain
worse, leading the researchers to
conclude that excessive con-
sumption of bran in the community
may actually be creating patients
with irritable bowel syndrome
(Lancet, 1994; 344: 3940).
Considering that wheat (along
with milk and eggs) is one of the
most common triggers of
symptoms in those with IBS, such
results are hardly surprising ( Am J
Gastroenterol, 1998; 93: 218490).
If any fibre is to be
recommended, then Plantago
seedsa source of soluble fibre
that is sold commercially as
psyllium or ispaghula fibre blurred vision (Phytomedicine, 2005; 12: 6016), whereas bulking agents and
appears to be a better option, but it
can still aggravate symptoms in
some IBS sufferers (Townsend Letter
Docs, 2004; 252: 159).
Probiotic yoghurt is another
popular recommendation for
people with IBS, but this, too, can
make symptoms worse. While
probiotics may be beneficial for the
condition in some, dairy products
have also been found to trigger
symptoms in a significant
proportion of IBS sufferers.
According to Dr Stephen O.
Wangen, Chief Medical Officer of
the IBS Treatment Center in
Seattle, WA, A large number of our
patients who experience IBS are
actually suffering from a dair y
allergy but dont realize it. Yogurt,
although it is fermented, is still a
dairy product and can be a potent
trigger of their digestive problems.
For these people, the consumption
of yogurt, even brands with high
probiotic bacteria content, is
inadvisable ( Townsend Letter, 2008;
June: 35).
Clearly, diet is a crucial factor in
IBS, but there is no one-size-fits-all
approach when it comes to
successful treatment. Experi-
menting with limiting or
completely eliminating certain
foods from your usual diet and/or
working with an experienced
nutritional practitioner may be the
best way to get the condition under
control.
Other treatment approaches
Along with a change of diet, there
are a number of other natural ways
to tackle IBS.
u Hypnotherapy. Emotional and
psychological factors appear to
be involved in IBS, which may
explain why hypnosis has proved
helpful for patients with the
condition. According to an
extensive review of the
medical/scientific literature
carried out by the prestigious
Dangerous IBS drugs
Most of the drugs prescribed for irritable bowel syndrome come with a
host of unwanted side-effects.
Anticholinergicsdrugs that block the effects of the neurotransmitter
acetylcholinesuch as Buscopan, for example, can cause dry mouth and
antispasmodic drugs such as Spasmonal (alverine citrate) can trigger
nausea, dizziness, itching, rash and headache, according to the Electronic
Medicines Compendium (see http://emc.medicines.org.uk/medicine/
15704/XPIL/Spasmonal+60mg/).
Whats more, one drug has even been linked to life-threatening adverse
effects. Alosetron (Lotronex), currently used in the US only for the
management of severe diarrhoea-predominant IBS in women, was
withdrawn from the market in 2000 following reports of five deaths and 70
cases of serious adverse reactions. These reactions included ischaemic
colitis (fever and gut pain caused by insufficient blood supply) and
obstructed or ruptured bowels as a complication of severe constipation.
Yet, the US Food and Drug Administration (FDA) advisory panels
recommended that the drug be reintroduced in 2002 (albeit with restricted
use and availability)the first case ever of a drug being brought back onto
the US market after being withdrawn for reasons of safety.
Dr Sidney Wolfe, director of the Public Citizens Health Research Group,
commented, With the exception of some drugs used to treat cancer, the
frequency and severity of a life-threatening adverse reactionin this case,
ischaemic colitis in patients using alosetronis among the highest I have
seen for any other drug (BMJ, 2002; 324: 1053).
Cochrane Collaboration, which functional relaxation or
resulted in a pooled meta- enhanced medical care
analysis of four studies involving (standard treatment plus two
147 patients altogether, counselling sessions) for five
hypnotherapy was superior to weeks, the results showed that
both the standard medical care functional relaxation was
and no treatment in relieving significantly more effective than
abdominal pain and other IBS the control treatment. Indeed,
symptomsat least for the short the positive effectsboth
term (Cochrane Database Syst Rev, physical and mentalwere still
2007; 4: CD005110 ). Clearly, present three months later (J
however, more high-quality Altern Complement Med, 2010; 16:
studies are needed before any 4752).
definitive conclusions can be A small-scale (21 IBS
drawn. patients), randomized controlled
u Relaxation. As numerous trials trial, carried out at Tohoku
have already identified the role University Graduate School of
of psychological and emotional Medicine in Japan, involved the
factors as triggers in patients use of autogenic training (AT),
with IBS, relaxation techniques a relaxation technique that
are often recommended. In teaches your body how
Germany, the technique called to respond to your verbal com-
functional relaxationa term mands through six standard
coined decades ago to describe a exercises. The technique appears
form of relaxation that is also to combine elements of both
known as self-hypnosisaims self-hypnosis and biofeedback.
to maintain equilibrium within The results of this study suggest
the nervous system and appears that AT can benefit IBS by
to be beneficial for IBS. In a enhancing self-control, as
randomized controlled trial of reflected by the patients
80 patients, who received either responses to a number of IBS-
WDDTY Chronic pain 19
Common conditions
related questionnaires ( Appl
Psychophysiol Biofeedback, Dec 8 2009;
Epub ahead of print).
u Exercise. There is also evidence
to suggest that exercise may be
an effective intervention for IBS.
When pitted against con-
ventional care in a 12-week trial,
the patients in the exercise
group reported significant
improvement in symptoms of
constipation (Int J Sports Med, 2008;
29: 77882 ). Another trial
concluded that even mild
physical activity can reduce gas
and abdominal bloating (Am J
Gastroenterol, 2006; 101: 25527).
u Peppermint oil. According to a
review of the literature, eight
out of 12 placebo-controlled
studies showed statistically
significant positive effects with
peppermint oil for the treatment
of IBS. The average response
rates, as a reflection of overall
success, were 58 per cent for
20 WDDTY Chronic pain
peppermint oil and 29 per cent
for placebo. However, even
though peppermint oil usually
comes in specially coated
capsules designed to protect the
stomach, these capsules may
still lead to side-effects such as
heartburn or rectal irritation
(Phytomedicine, 2005; 12: 6016).
u Chinese herbal medicine
(CHM). In a trial involving more
than 100 IBS patients, those
treated with CHM, using
formulas that were either
individualized or standardized,
saw significant improvements in
terms of bowel symptoms as well
as overall quality of life.
However, only the CHM group
taking herbals tailored to the
patient were able to maintain
the improvements 14 weeks
later.
Furthermore, only two
patients taking CHM reported
any adverse effects: one
complained of gastrointestinal
discomfort while the other
experienced headaches ( JAMA,
1998; 280: 15859).
u Acupuncture. The results of one
trial in the US found that
acupuncture combined with
moxibustion may be promising
for IBS management (Gastroenterol
Nurs, 2009; 32: 24355).
However, a major review of the
studies up to 2006 found only six
randomized controlled trials,
which were, in fact, inconclusive
due to poor quality or not
comparable because of too many
differences in the variables
studied.
Also, orthodox researchers
have concluded that it is still not
clear whether traditional
acupuncture is any better than
sham acupuncture at reducing
IBS symptoms (Cochrane Database
Syst Rev, 2006; 4: CD005111).
Joanna Evans
Tested treatments
Healing magnets
Do magnetic devices truly
heal, or are they just
hokum?
agnetic devicesfrom
M bands and bracelets to
leg wraps and shoe
insertsare used by
thousands of people worldwide,
thanks to a multimillion-pound
industry that claims they can cure a
laundry list of ailments, especially
pain. But do these products work?
What the science says
Despite their popularity, theres
little scientific evidence that
magnets are beneficial to health.
Although theyre often used to
manage pain in chronic
musculoskeletal disorders, one
study found that magnetic wrist
straps were no better than a
placebo.
A total of 45 osteoarthritis (OA)
sufferers were randomly allocated to
one of four treatments, all using the
same devicesa standard magnetic
wrist strap; a weakened magnetic
wrist strap; a demagnetized
(dummy) wrist strap; and a copper
(non-magnetic) braceletbut in
different sequences. Each device was
worn for at least eight hours a day
for four weeks, after which the
patients filled in questionnaires to
assess symptoms.
The results showed no significant
differences among the devices for
pain relief, with similar findings for
stiffness, physical function and
medication use. The overall
conclusion was that magnetic and
copper bracelets are generally
ineffective for managing pain,
stiffness and physical function in
osteoarthritis, and that any
reported therapeutic benefits were
most likely due to non-specific
placebo effects (Complement Ther Med,
2009; doi: 10.1016/j.ctim.2009. 07.002).
Other studies have arrived at
much the same conclusions. In a
placebo-controlled trial of 165
patients with postoperative pain,
the effects of magnet therapy on
pain intensity and opioid
requirements were similar to what
was seen in patients receiving fake
magnet therapy. In fact, the active- above, the patients knew they had
magnet group used 1.5 mg more real magnets as they often were
morphine than the fake-magnet stuck to their keys in their pockets
group (Anesth Analg, 2007; 104: 2904).
Similarly, magnets were no more
effective than a placebo for carpal-
tunnel syndrome and chronic lower-
back pain (J Fam Pract, 2002; 51: 3840;
(BMJ, 2006; 332: 4).
In fact, the authors of that study
were themselves aware of the
problem ( BMJ, 2004; 329: 14504).
Similarly, the authors of the study
JAMA, 2000; 283: 13225), and a meta- on magnet therapy for chronic
analysis of nine randomized, pelvic pain admitted that blinding
placebo-controlled trials of various efficacy was compromised (Am J
pain-related conditions reported Obstet Gynecol, 2002; 187: 15817).
that the evidence does not support However, its possible that the
the use of static magnets for pain conflicting results were due to the
relief (CMAJ, 2007; 177: 73642). strength of the magnets used, as
However, the pain of OA of the studies that failed to show any effect
hip and knee was decreased by on pain generally used weaker
wearing magnetic bracelets magnets (1950 mTesla), while
compared with a dummy bracelet in those that found an effect used
a study of 194 men and women (BMJ, stronger ones (47180 mTesla)
2004; 329: 14504). Also, in a (BMJ, 2004; 329: 14504). Nevertheless,
preliminary study of 29 patients its clear that more research is
with OA of the knee, magnets needed to determine whether this is
showed statistically significant indeed the answer.
efficacy compared with a placebo
(Altern Ther Health Med, 2004; 10: 3643). The bottom line
Others found magnets to be better Although many people swear by
than a placebo for chronic pelvic magnets, the bulk of the research so
pain and diabetic neuropathy (Am J far suggests that theyre no better
Obstet Gynecol, 2002; 187: 15817; Arch than a placebo for relieving pain.
Phys Med Rehabil, 2003; 84: 73646). Yet, looked at another way, magnets
Nevertheless, some scientists then do have an effect, albeit all in
question these findings, pointing the head.
out that many so-called controlled Ultimately, the studies show that
tests are unreliable, as participants the mind is a powerful healer, and if
can usually work out whether magnets can help it to perform that
theyre in the real or fake magnet function, then perhaps theyre
group, which can affect the results. useful after all.
Indeed, in the BMJ study mentioned Joanna Evans
Static vs pulsed magnetic fields
Magnets are claimed to cure a variety of ills besides pain, although scientific
proof is lacking; for example, although magnets supposedly increase
circulation, a well-designed study found this wasnt so (Sci Rev Alt Med, 2002;
6: 912). Other research shows that magnets are ineffective for snoring, sleep
apnoea, tinnitus, and reducing heart rate and blood pressure (Wis Med J,
1997; 96: 357; Clin Otolaryngol Allied Sci, 1991; 16: 3712; Clin Rehabil, 2002; 16:
66974).
However, static magnets (those marketed to consumers) shouldnt be
confused with pulsed electromagnetic-field therapy (PEMF), which involves
brief exposures to much stronger electromagnetic fields. PEMF is effective
for treating slow-healing fractures and shows promise for other conditions,
including arthritis (Wien Klin Wochenschr, 2002; 114: 67884; Injury, 2008; 39: 41929).
WDDTY Chronic pain 21
Tested treatments
Serrapeptase: a natural
anti-inflammatory
An enzyme found in
silkworms is touted as a
natural alternative to non-
steroidal anti-inflammatory
drugs (NSAIDs). But what
does the science say?
errapeptase, or serra-
S tiopeptidase, is a proteolytic
(protein-digesting) enzyme
with a long history of use in
Germany and Japan. Now known
worldwide for its anti-inflammatory
effects, its purported to treat
everything from arthritis to heart
disease and infections. But what
does the science say about
serrapeptase?
What the studies say
Serrapeptase has been the subject of
intense study in recent decades and,
although much of the research has
been in humans, larger-scale higher-
quality trials are needed.
Nevertheless, so far, the evidence
suggests that the enzyme may be
useful for a range of conditions.
u Postoperative pain and swelling.
In a study of 24 healthy subjects
undergoing tooth extraction, all
were given a treatment combina-
tion of either serrapeptase (5 mg)
or placebo tablets and parace-
tamol (acetaminophen) tablets
(1000 mg) at the time of the
operation. Those taking serrapep-
tase reported significantly less
pain and swelling after surgery
compared with the placebo-
control group (Int J Oral Maxillofac
Surg, 2008; 37: 2648).
In a much larger study, this
time in patients with chronic
empyema (where pus collects
around the lungs and in the chest
wall) undergoing surgery, the
patients were given either
serrapeptase or a placebo both
before and after their operation.
Here again, the degree of post-
operative swelling was signifi-
cantly less with serrapeptase than
22 WDDTY Chronic pain
with the placebo ( Pharmathera-
peutica, 1984; 3: 52630).
Yet another study showed that
serrapeptase is better than the
traditional post-surgery advice:
bed rest, elevation and the
application of ice. In patients
undergoing surgery of the ankle,
those treated with serrapeptase
had 50-per-cent less postopera-
tive swelling compared with those
who followed the traditional
advice. The serrapeptase group
also became pain-free sooner
than the control group did
(Fortschr Med, 1989; 107: 678, 712).
u ENT disorders. An Italian study
of 193 patients suffering from
ear, nose and throat disorders
(acute or chronic) found that
serrapeptase treatment led to a
significant reduction in symp-
toms compared with a placebo. In
addition, not only did the enzyme Compared with no treatment,
act rapidly on localized inflamma- 30 mg/day of the enzyme for four
tion, but it also led to less water weeks reduced both the amount
retention, while boosting clot- of phlegm (sputum) produced
busting effects (fibrinolysis), thus and the frequency of coughing
speeding up healing (J Int Med Res, (Respirology, 2003; 8: 31620).
1990; 18: 37988). u Carpal tunnel syndrome (CTS).
u Chronic obstructive pulmonary Twenty CTS patients were
disease (COPD). A small study enrolled in a clinical study to
carried out in Japan investigated investigate whether serrapeptase
the effects of serrapeptase in could help in the treatment of
patients with COPD, such as their symptoms. Following a short
emphysema and bronchitis. course of the non-steroidal anti-
What is serrapeptase?
Serrapeptase is an enzyme produced by the Serratia bacteria that live in
the intestines of silkworms. Once the silkworm has completed its
transformation into a moth, it uses this substance to melt a hole in its
confining cocoon, allowing it to escape. Unlike other biological enzymes,
serrapeptase affects only non-living tissue, such as the silk cocoon. In
humans, it breaks down the protein debris resulting from toxins and
inflammation while sparing healthy tissues and cells.
Serrapeptase is taken orally typically at a dosage of 1030 mg/day. To
ensure maximum absorption in the small intestine and to stop stomach acid
from destroying the enzyme, it usually comes in enteric-coated tablets.
Currently, research is underway to develop topical preparations of
serrapeptase in the form of ointments and gels (Indian J Pharm Sci, 2010; 72:
6571).
 inflammatory drug (NSAID)
nimesulide, the patients were
given 10 mg of serrapeptase twice
a day for six weeks. At the end of
the study, 65 per cent reported
significant improvements in their
symptoms, with no serious side-
effects (J Assoc Physicians India, 1999;
47: 11702). Larger, higher-quality
trials are now needed to confirm
these findings.
u Breast disease. Serrapeptase may
be beneficial for breast engorge-
ment, the painful overfilling of
the breasts with milk. When 70
women with the condition were
given either Danzen, a Japanese
serrapeptase preparation, or a
placebo for three days, Danzen
proved to be superior to placebo
for improving breast pain, breast
swelling and induration (harden-
ing). Indeed, while 86 per cent of
the Danzen patients achieved
moderate to marked improve-
ments, only 60 per cent of the
patients taking the placebo saw
similar improvements. Also, a
marked improvement was seen
in 23 per cent of the treatment
group vs just 3 per cent with the
placebo (Singapore Med J, 1989; 30:
4854).
u Infections. Serrapeptase was
effective for eradicating infection
caused by Staphylococcus epider-
midis bacteriaat least in rats,
so this may not apply to humans.
Nevertheless, these findings led
the researchers to conclude that
the enzyme might be able to
enhance antibiotic efficacy in
the treatment of staphylococcal
infections (J Bone Joint Surg Am,
2006; 88: 120814).
Heart disease and beyond
The potent anti-inflammatory
effects of the enzyme make it a good
candidate for treating a variety of
other disorders, including arthritis,
fibromyalgia, migraine, irritable
bowel syndrome and even heart
disease. Indeed, the late German
physician Dr Hans Nieper reported
that serrapeptase is an invaluable
agent for the safe removal of fibrous
clots from coronary arteries and, in
particular, from the carotid arteries
in the neck, which supply blood to
the brain (www.serrapeptase.info/content.
asp?page=Dr-H-A-Nieper).
However, more clinical studies
are needed to ascertain whether or
not serrapeptase is, in fact, effective
for any of these conditions.
Serrapeptase safety
In general, no significant side-
effects have been reported with the
use of this enzyme, although there
have been a few case reports of
eosinophilic pneumonia (usually
triggered by an allergic reaction,
often to a medication) in response
to serrapeptase (Nihon Kokyuki Gakkai
Zasshi, 2009; 47: 2548; 2000; 38: 5404).
Although the reaction is unusual,
it nevertheless highlights the fact
that natural is not always harmless.
Other potential adverse effects
include diarrhoea and gastro-
intestinal problems. However, these
effects are usually mild, especially in
comparison to the often severe side-
effects of NSAIDs. Yet, until we know
more, its up to users to monitor
their own health when using this
product.
Joanna Evans
WDDTY Chronic pain 23
Tested treatments
Cetylated fatty acids
Cetylated fatty acids are
among the latest natural
remedies for joint health,
and are said to be even
better than glucosamine.
But what does the science
say about these fats?
etylated fatty acids (CFAs)
C are a group of naturally
occurring fats that are
widely marketed as a treat-
ment for osteoarthritis. These fats
are thought to help lubricate joints
and muscles, soften tissues, reduce
inflammation and increase flexibility.
The question is, do they really work?
CFA studies so far
Several studies used a proprietary
blend of CFAs called Celadrin (70-
per-cent CFAs and 30-per-cent olive
oil) which comes as an oral supple-
ment or topical cream. In one study
using the capsules, 64 patients with
chronic knee osteoarthritis (OA)
were given either Celadrin (350 mg,
plus 50 mg of soy lecithin and 75 mg
of fish oil, taken six times daily) or a
placebo (vegetable oil) for 68 days.
At the end of the study, those in
the Celadrin group saw a significant
improvement in their knee range of
motion (flexibility) and overall joint
functioning compared with those in
the placebo group.
CFA may be an alternative to the
use of non-steroidal anti-inflam-
matory drugs for the treatment of
OA, the researchers concluded (J
Rheumatol, 2002; 29: 170812).
The topical version of Celadrin has
also been tested in three separate
studies by a team of researchers at
the University of Connecticut.
Again, the product was trialled in
patients with OA of the knee.
In the first of this series of studies,
40 older patients (mean age: 65
years) were randomly assigned to one
of two treatment groupsCeladrin
cream or a placeboand were
evaluated before application, 30
minutes after application and 30
days after treatment. Assessments
included how long it took the
24 WDDTY Chronic pain
patients to get up and go from a
chair, go up and down stairs, balance
and weight distribution across the
soles of the feet during quiet
and move their knees. standing (J Strength Cond Res, 2005; 19:
Celadrin was superior to placebo 11521), while the other reported that
and had fast-acting effects. Climbing it significantly reduced pain and
ability, for example, improved just improved functional performance in
30 minutes after initial treatment individuals with OA of the knee,
(J Rheumatol, 2004; 31: 76774). elbow and wrist (J Strength Cond Res,
The other two studies of this series 2005; 19: 47580).
also found Celadrin to be effective for
relieving the pain of OA. One found Beyond arthritis
that it improved postural stability Some websites claim that CFAs can
Other supplements for osteoarthritis
u
Glucosamine. Numerous studies have shown that this is a safe and
effective way to reduce symptoms of OA (Arthroscopy, 2009; 25: 8694). The
results of a three-year, double-blind trial suggest that the nutrient (1500
mg/day in one dose) may even slow the progression of the disease
(Lancet, 2001; 357: 2516).
u
Chondroitin. A recent review concluded that oral chondroitin sulphate is
a valuable and safe symptomatic treatment for OA disease. Interestingly,
800 mg/day had nearly the same effects as 1200 mg/day in one study
(Osteoarthritis Cartilage, 2008; 16 Suppl 3: S1921). Its often recommended that
chondroitin be taken in combination with glucosamine.
u
S-adenosylmethionine (SAMe). Double-blind trials show that SAMe
(1200 mg/day) reduces pain, stiffness and swelling better than a placebo,
and as well as painkilling drugs such as ibuprofen and naproxen in OA
sufferers (Am J Med, 1987; 83: 813; Am J Med, 1987; 83: 6671).
u
Pycnogenol (pine bark extract). This supplement (150 mg/day) was
tested against a placebo on 100 patients with mild-to-moderate OA of the
knee. After eight weeks, the Pycnogenol group reported a significant
reduction in pain, and the benefits were still evident three months later.
They also had less stiffness in the joints, and were able to carry out more
day-to-day activities and reduce their use of painkillers; in contrast, 10
per cent in the placebo group had to increase their dose of analgesics
(Phytother Res, 2008; 22: 108792).
u
Bromelain. Mounting evidence suggests that this extract, derived from
pineapple, may be a useful treatment for OA. The research so far shows
that it has powerful anti-inflammatory and painkilling properties, although
more studies are needed to determine the optimal dosage (Evid Based
Complement Alternat Med, 2004; 1: 2517).
be used to treat a range of condi-
tions other than OA, such as skin
problems, gum disease, gout and
lupus. However, theres little
research to support these claims.
One small-scale, preliminary study
suggested that Celadrin cream might
be helpful for people with psoriasis, a
chronic autoimmune skin disorder.
However, although it was a double-
blind, placebo-controlled study, the
results have yet to be published in a
peer-reviewed journal, but are
available at the following website:
http://celadrininfo.com/studies/
SafetyHumans.pdf.
Another small study found that
Celadrin together with glucosamine
might benefit the heart and blood-
circulation status by reducing
platelet aggregation (blood-clot
formation). The researchers, who
tested the combination on 24
healthy people, reported that it had
aspirin-like effects (Clin Lab Sci, 2010;
23: 326). Nevertheless, more research
is needed to confirm these results.
Consider this
CFAs appear to be a promising
treatment for OA, but the research
is far from conclusive, and some
claims go far beyond the current
evidence. Indeed, while some claim
that these fatty acids are more
effective than glucosamine and
chondroitintwo popular natural
treatments for arthritisno
comparative studies have been
conducted.
Another point to bear in mind is
that the studies have been carried
out with a specific brand of CFAs
(Celadrin), so we dont know if
other preparations will have the
same results.
As for safety, no adverse effects
have been reported with the use of
CFAsbut then, no one appears to
be looking. This suggests that, in
particular, there need to be studies
to determine the effects of their
long-term use.
Joanna Evans
WDDTY Chronic pain 25
Tested treatments
The next Russian revolution
SCENAR is a new way of
healing that challenges the
worlds cash-strapped
healthcare systems
he Russian problem
T used to mean the spread
of Communism to the
West. Today, the term
could just as easily be applied to
a new healing modality,
developed behind the Iron
Curtain during the Cold War and
which, its advocates claim, will
revolutionize Western medicine.
The SCENAR (Self-Controlled
Energo-Neuro-Adaptive Regulation)
device is the size of a TV remote, and
runs on a single 9-V battery.
Researchers and doctors in Russia
claim that it can reverse most diseases
without drugs or surgery. In the UK, its
licensed as a pain-relief device.
The problemlike so much of alter-
native medicine that doesnt enjoy the
sizeable profits of the drugs industry
is the lack of good scientific evidence
from a double-blind placebo-controlled
trial to support such ambitious claims.
There are, however, thousands of
case studies gathered from the 10,000
thera-pists and doctors in Russia who
routinely use SCENAR in their
practices. Dr Yuri Gorfinkel, who
became a SCENAR therapist after
working in the Chernobyl clean-up
operations, has collated 18,255 case
studies of SCENAR treatments for
almost every conceivable diseasefrom
gastritis, haemorrhoids and impotence
to bronchitis, hypertension and acute
heart failure. Of these patients, there
was no recurrence in 88.5 per cent of
cases, while 6 per cent reported signif-
icant improvement in symptoms, with
only 3 per cent reporting little or no
change for the better (SCENAR Therapy,
SCENARMedical Assessment and Expertise,
1998; 4).
In a later report compiled by Dr Irina
Kossovski, who tracked hundreds more
case reports involving a similarly wide
range of diseases, Russian SCENAR
practitioners were said to have achieved
a complete recovery rate of around 66
per cent, while the remaining third of
patients reported some improvement in
26 WDDTY Chronic pain
their condition (Kossovski I. An Overview of
the Basic Results of a SI Medicine Treatment
Complex. MediSCEN Inc., 2001).
The sole study published in a West-
ern medical journal pitted SCENAR
against TENS (transcutaneous electric-
al nerve stimulation). In this trial, 24
chronic neck-pain sufferers received
six months of treatment with either
SCENAR or TENS, or no treatment
(controls). The researchers reported
that the SCENAR group showed
significant reduction of neck pain
and disability compared with either the
TENS or control group. They also
pointed out that none of those in the
SCENAR group reported any adverse
reactions (Chiropractic & Osteopathy, 2007;
15: 9; doi: 10.1186/1746-1340-15-9).
The device has also been used by
athletes to speed recovery time after
injury. French football star Djibril Cisse
has prepared a YouTube testimonial,
claiming the SCENAR helped him to
recover more quickly from an ankle
injury. Also, SCENAR is currently being
used by the Greek professional football
team Panathinaikos, based in Athens.
How does it work?
SCENAR has been described as elec-
tronic acupuncture and space-age
medicine, the latter in reference to its
use in the late 1970s as a healing aid
for cosmonauts training in zero gravity.
Although Dr Alexander Karasev
invented the device in 1976, it was dev-
eloped by two electronics engineers,
who were awarded the Order of Lenin
for their work. The technology was
secret and classified until Perestroika
in the mid-1980s opened up the Soviet
Union. It was then that SCENAR was
made available to Russian doctors.
SCENAR is a simple hand-held
device controlled by four buttons. The
practitioner brushes the device along
the patients skin, looking for any
resistance or stickiness, as SCENAR
therapists call it. Such stickiness
indicates disease, inflammation or
injury, while different areas of the skin
correlate with different internal organs
and muscle groups, similar to the
acupuncture model.
Once a problem area has been
detected, the practitioner changes the
SCENAR frequency modulation and,
using biofeedback, begins a dialogue
with the patients central nervous
system. Eventually, SCENAR is said to
stimulate neuropeptides in damaged
cells to speed recovery by helping cells
to remember their healthy signature
state. The healing process continues
long after the session ends, although it
may take many sessions to achieve full
health, depending on how chronic the
condition is.
However, if the problem is acute,
such as a sports injury, SCENAR practi-
tioners say the device can heal the
problem even before bruising appears.
SCENAR in the West
SCENAR is becoming part of the
accepted medical therapy in Russia,
and is now being used in clinics and
hospitals. It is also gaining a foothold in
Germany, where there are around 3000
practitioners.
However, inroads into the UK market
have been more torturous. There have
been several attempts to introduce it
into Great Britain, but infighting and
squabbles between various competing
groups have impeded its progress.
Today, the SCENAR licence for the UK
and Ireland is held by 21st Century
Energy Medicine, and its CEO is former
IT consultant Richard Cumbers.
SCENAR is officially distributed in the
UK by its sister company Pain Genie.
Nevertheless, Cumbers has been
forced to fight a constant battle against
black-market versions of the device,
which are often sold on the Internet by
workers at the Russian factoryand at
a far lower price. However, the black-
market versions dont come with any
training or support.
Cumbers sells the Pain Genie Home
SCENAR for 469, which includes a
training manual and DVD. Although
some retailers believe that only properly
trained practitioners should use it,
Cumbers promotes its use among the
public, although he emphasizes the
importance of after-sales support.
In the three years that he has held
the SCENAR licence, Cumbers has
trained around 1200 practitioners in
the UK. His efforts have interested a
few doctors in the UK, including Dr
Jan Beute, from the Doncaster Royal
Infirmary Accident & Emergency
department. Beute, who uses his own
SCENAR on patients, has said: The
Pain Genie will save the NHS a
tremendous amount of money because
its so easy, cheap and effective to use.
There are only a handful of
practitioners in the US, where it has
light touch Food and Drug Adminis-
tration (FDA) approval as a relaxant and
muscle re-educator.
SCENAR and the future
In fact, there are more case studies
of SCENAR effectiveness than for any
other alternative device or technology.
As the technology is now more than
30 years old, this is perhaps not so
surprising. Nevertheless, its success
rate is impressiveand far higher than
that of any single drug or conventional
therapy.
But such success arouses suspicion
among doctorsit all seems too good
to be trueespecially as there have
been little independent research and
few clinical trials published in Western
medical journals.
For SCENAR practitioners and
advocates like Cumbers, this is
frustrating, as they see the technology
as an inexpensive and effective
alternative within the mainstream of
Western medicine, especially at a time
when the National Health System and
its counterparts around the world are
virtually bankrupt.
However, the issue runs far deeper
than just proving that the modality
works through the gold-standard
clinical trials. SCENAR attacks the very
heart of medicineits protocols and
theorieswhich is avidly guarded
directly by the pharmaceutical industry,
and indirectly by medical schools and
government-approved bodies, and even
the mainstream media.
Undaunted, Cumbers and others
nevertheless believe that the time is
now right for making a serious pitch to
governments, which are looking to cut
costs wherever they can, and whose
allegiances may lean more towards the
public purse and less towards protect-
ing the conventional medical paradigm.
They also point to the Russian health
system, where there is already wide
acceptance of SCENAR.
For Prime Minister Cameron,
President Obama and other world
leaders, it could be the start of the
Russian problem all over again.
Bryan Hubbard
WDDTY Chronic pain 27
Tested treatments

Exercise for a better back

Many people who suffer Intern Med, 2005; 142: 77685).
from back pain fear that For those who dont have the time
physical activity will do or money for personal training,
however, joining a yoga class may be
more damage. But now, another useful option. In one study,
research shows that patients participating in a 12-week
staying active may yoga programme enjoyed significant
be the key to beating back improvement in back pain and
pain for good. function compared with those given
a self-care exercise book. Whats (AT) is beneficial for back pain. This
ost people know that more, the benefits persisted for discipline emphasizes the self-

M regular exercise will

improve their physique
and fitness levels, but few
realize that keeping active may also
be beneficial for low back pain, one
of the most common causes of
disability in the West.
According to Wisconsin-based
spine expert Dr Peter Ullrich, When
done in a controlled, gradual, and
progressive manner, active exercise
distributes nutrients into the disc
space and soft tissues in the back to
keep the discs, muscles, ligaments
and joints healthy. Consequently, a
regular exercise routine helps to
avoid stiffness and weakness, mini-
mize recurrences of low back pain,
and reduce the severity and duration
of possible future episodes of low
back pain (www.spine-health.com).
But you dont have to take his
word for it. There are numerous
studies supporting the benefits of
exercise for low back pain.
Indeed, just a few weeks ago, a
review by the Lausanne Institute of
Sports Science and Physical Educa-
tion concluded that exercise is
effective for both the prevention and
treatment of low back pain. As a
treatment, exercise reduced pain and
improved physical function in
patients whose condition was chronic
or recurrent (Joint Bone Spine, 2008 Sep
16; Epub ahead of print).
Other studies have looked at
several months (Ann Intern Med, 2005; 143:
84956).
In yet another study, just one week
of intensive yoga practiceincluding
postures, breathing practices, medi-
tation and philosophical concepts
reduced pain-related disability and
improved spinal flexibility signifi-
cantly better than a conventional
exercise regime (J Altern Complement
Med, 2008; 14: 63744).
Precisely why yoga is so effective for
back pain is not clear, but it appears
to be a combination of mindbody
factors. As one report noted: Yoga
may be beneficial for back pain
because it involves physical
movement, but it may also exert
benefits through its effects on mental
focus. Mental focus may help people
to relax tense muscles, relieve mental
stress, and increase their awareness of
how they are moving and positioning
their body (Ann Intern Med, 2005; 143:
84956).
This synthesis between physical
movement and mental focus might
also explain the results of a study
showing that the Alexander Technique
Stretch the pain away
According to Dr Peter Ullrich, daily stretching is an important part of any
back pain exercise routine. The most important muscles to target in any
back pain regimen are:
u hamstrings, which run along the back of the leg, help to correct posture
perception of movement, and was
recently found to be more effective
than the usual care or massage as a
treatment for chronic back pain. Also,
just six lessons followed by prescribed
exercises was nearly as successful as
24 lessons of AT on its own (BMJ, 2008;
337: a884; doi: 10.1136/ bmj.a884).
Pilates, another discipline with a
focus on posture, has also produced
impressive results (J Orthop Sports Phys
Ther, 2006; 36: 47284).
But what about aerobic activity? Do
the more vigorous forms of exercise
cause more harm than good? It
appears not. A study of patients aged
from 30 to 60 with low back pain
found that those who indulged in
aerobic exercisewalking or cycling
for 45 minutes four times a week
required significantly fewer pain-
medication prescriptions and were
given fewer physical-therapy referrals
than those who did not exercise. The
researchers also noted that exercise
improved the patients moodyet
another excellent reason to stay active
(Spine J, 2001; 1: 95101).
Joanna Evans

specific types of exercise to find out while sitting and standing; they also support the gluteus muscles in the
what works best. According to one, buttocks and the hip flexors, and minimize stress on the low back
the most effective exercise strategy u piriformis, which runs from the back of the femur (thigh bone) to the

is an individually designed exercise sacrum (the base of the spine); when tight, this muscle can cause
programme carried out under limited sciatica-like pain, and has been linked to sacroiliac joint dysfunction
supervisionfor example, home u psoas major, which is attached to the front portion of the lower spine and

exercises with regular follow-up by a can greatly limit lower back mobility if tight, making it difficult to stand for
therapist. Stretching and muscle- extended periods of time or to kneel on both knees
strengthening exercises proved best u gluteus muscles of the buttocks, which support hip flexibility as well as

for improving pain and function (Ann the pelvis.

28 WDDTY Chronic pain

Your questions answered
Lumbago
Q
A friend of mine has been
told he has a deter-
iorating disc and needs a
laser operation. What can
be done, if anything? Are there any
alternative treatments?C.B., via e-
mail
A
Your friends problem
sounds like a crumbling
disc in the spine, called
lumbar degenerative disc
disease (DDD). Discs act as shock-
absorbers between the spinal
vertebrae but, over time, they lose
their resilience. This happens to
virtually everyone over the age of 40
but, for most of us, it isnt a problem.
However, it can cause chronic pain in
a sizeable minority. The most
common symptoms are low back
pain, hip pain, or aches in the
buttocks or thighs. There may also be
occasional tingling or weakness in
the knees.
Nowadays, surgery is generally
only offered as a last resort, as its
usually irreversible and invasive.
Nevertheless, theres a bewildering
array of surgical options, of which
laser treatment is just one. Laser
discectomy uses a powerful laser to
vapourize the crumbling bits of disc
soft tissue. The laser is inserted
through a small incision in the back.
The operation is claimed to be
minimally invasive, cost-effective and
free of postoperative pain, and can be
done in an outpatients setting.
However, the clinical evidence
isnt all that favourable, with a recent
review concluding that theres only
moderate evidence of pain relief
(Pain Physician, 2007; 10: 7111). In fact,
the official UK health watchdog NICE
(National Institute for Health and
Clinical Excellence) is fairly
scathing, describing the procedure
as having uncertain risks and
benefits. NICE warns that it may
have serious complications, such as
damage to nerve roots, vertebral
endplates and neighbouring
structures, and disc space infection.
Because of the high failure rate,
many operations have had to be
repeated using conventional surgery
(NICE.
Interventional Procedure Overview of
Laser Lumbar Discectomy. 26 August 2003;
http://guidance.nice.org.uk/ download.aspx?
o=ip075overview).
As for other surgical options, the
most common operation is to
connect the two vertebrae sur-
rounding the problem disc (spinal
fusion). However, the spine inevitably
becomes more rigid which, in the
long term, puts extra strain on the
rest of the spine and may create pain
elsewhere. Other complications
include eating disorders, wound
infection, urinary retention, pseudo-
arthritis, blood clots in the lung and
paralysis.
One of the latest surgical
techniques is to replace the damaged
disc with an artificial one. Theres a
bionic disc that has been available for
about four years. Called Charit, it
consists of two metal plates that are
attached to adjacent vertebrae,
between which is inserted an
artificial disc made of polyethylene.
Its theoretical advantage is that it
mimics a natural disc, allowing
normal spinal movement. However,
in practice, the bionic replacements
turn out to be not nearly as tough as
Natures original. Serious wear,
deformations, cracks and fractures
have forced many surgeons to rip
them out and resort to simple
fusionoften causing further spinal
damage in the process.
In the UK, one NHS hospital group
recently reported that the Charit
device barely improved spine
mobility or reduced pain, leading
them to abandon it (J Bone Joint Surg Br,
2007; 89: 7859). Yet, a long-term survey
in a French hospital found an 82-per-
cent success rate (Spine, 2007; 32:
6616). Success may depend on the
skill of the individual surgeon as
much as on the quality of the
implant.
A new version of Charit has just
been approved by the Food and Drug
Administration, the US health
watchdog. This uses two pieces of
hinged stainless steel without the
polyethylene cushion (FDA news, 19 July
2007). This may prove to be superior if
only because there are fewer parts to
fail.
Ideally, though, its best to avoid
back surgery altogether. The classic
treatment alternatives are
osteopathy/chiropractic and acu-
puncture. Unconventional man-
ipulative techniques have been
notoriously underresearched, but
there is good evidence that
osteopathy can help to ease lower
back pain (J Can Chiropr Assoc, 2005; 49:
27096). However, no studies appear
to have been done on DDD per se.
Acupuncture can also work and is
widely usedand not only in China.
German researchers have done
clinical trials on herniated (slipped)
discs, and found that acupuncture is
an effective pain-reliever (Am J Chin
Med, 2000; 28: 2533).
A study from Shanghai University
tested two types of electroac-
upuncture, and demonstrated that
single-point acupuncture is
superior to the more usual multi-
point methods for prolapsed lumbar
intervertebral discs (Zhongguo Zhen Jiu,
2006; 26: 31921).
Finally, percutaneous electrical
nerve stimulation (PENS) uses fine
needles, inserted up to 4 cm into the
skin (not at acupoints), through
which a mild pulsed electrical
current is passed.
A placebo-controlled trial of DDD
showed that back pain was reduced
by 50 per cent, with major
improvements in mobility, sleep
quality and general wellbeing.
Indeed, 81 per cent of the 60
participating patients said they
would fork out their own money to
pay for the treatment (Anesth Analg,
1999; 88: 8416). Sadly, PENS is not, as
yet, widely available.
WDDTY Chronic pain 29
Your questions answered
Help for period pain
Q
I am aged 36, and am
increasingly experiencing a
very high level of pain and
discomfort with each
period. I have breast pain for a week
before, and then excruciating pain on
the day of my period, along with
vomiting and diarrhoea. I have no
children and Im also having difficultly
conceiving. I have tried quite a few
alternative therapies to no avail, so any
advice would be much appreciated.
D.S., via e-mail
A
Period painor dysme-
norrhoea, in medical-
speakaffects up to 95 per
cent of menstruating
women (Nurs Times, 2004; 100: 403).
Cramping lower abdominal pain is
common, but the pain can also extend
to the lower back and thighs, and lead
to nausea, vomiting, diarrhoea and
fatigue (Aust Fam Physician, 2006; 35: 8424,
8469).
But period pain doesnt have to be
simply endured, particularly if its
impacting on your lifestyle and daily
activities. But before starting any
treatment, you need to establish
whether you are suffering from primary
or secondary dysmenorrhoea. Primary
dysmenorrhoea is menstrual pain
without pelvic disease; secondary
dysmenorrhoea is pain associated with
an identifiable condition, usually
endometriosis, fibroids or pelvic
inflammatory disease (BMJ, 2006; 332:
11348).
As you are over 25 and having
trouble conceiving, secondary
dysmenorrhoea is a possibility, so you
may wish to see your doctor for a
diagnosis.
Treating the cause of the pain is
more effective than treating just the
pain itself. Conventional treatments
usually involve non-steroidal anti-
inflammatory drugs (NSAIDs) or oral
contraceptives, but these have various
adverse effects and may not work in up
to 25 per cent of sufferers (Cochrane
Database Syst Rev, 2004; 3: CD002119).
Fortunately for you, there is a variety
of alternative treatments, many with
good evidence of success.
u Dietary changes and supplements.
30 WDDTY Chronic pain
Taking 100 mg/ day of thiamine
(vitamin B1) may be effective: 87
per cent of patients were cured after
three months of treatment and
remained pain-free two months later
(Indian J Med Res, 1996; 103: 22731).
Other helpful supplements are
pyridoxine (vitamin B6), magnesi-
um, vitamin E and fish oil,
particularly Neptune Krill Oil (BMJ,
2006; 332: 11348; Altern Med Rev, 2003; 8:
1719).
Changing your diet may also
bring relief. Endometriosis and
dysmenorrhoea are known to be
related to a low intake of vegetables
and fruit, and a high intake of
vegetarian polyunsaturated fat,
ham, beef and other red meat (Eur J
Obstet Gynecol Reprod Biol, 2007; 132:
1407). Another study found a
significant improvement in
menstrual pain and PMS symptoms
with a low-fat vegetarian diet (Obstet
Gynecol, 2000; 95: 24550).
u Herbs. A Japanese herbal
formulation known as Toki-
shakuyakusana blend of six herbs,
including angelica and peony root
reduced menstrual pain (Am J Chin
Med, 1997; 25: 20512). Together with
another remedy called Shakuyaku-
kanzo-to (including peony and
liquorice), this combination may
also help women with secondary
dysmenorrhoea to conceive (Clin Exp
Obstet Gynecol, 2003; 30: 958).
u Acupuncture. When 649 women
with dysmenorrhoea received
acupuncture (15 sessions over three
months) in addition to their usual
medical care, they saw significant
improvements in pain and quality of
life compared with those receiving
only the usual care (Am J Obstet
Gynecol, 2008; 198: 166). Other trials
have also been positive, although
one trial found that acupuncture
worked well for primary
dysmenorrhoea but was only
satisfactory for cases of secondary
dysmenorrhoea (Akush Ginekol [Sofiia],
1996; 35: 245).
u Transcutaneous electrical nerve
stimulation (TENS). This involves
stimulation of the skin using
currents at various pulse
frequencies and intensities to
relieve pain. A number of small
studies found high-frequency TENS
to be effective for dysmenorrhoea
(Cochrane Database Syst Rev, 2002; 1:
CD002123).
In one trial, 4260 per cent of
patients achieved at least moderate
relief, and required the use of fewer
additional analgesics (BMJ, 2006; 332:
11348).
u Heat. A randomized, controlled trial
found that a heat patch (at 39 C)
used for 12 hours a day was as
effective as ibuprofen (400 mg three
times a day) and more effective than
placebo in reducing pain (Obstet
Gynecol, 2001; 97: 3439). Another study
found that a heat wrap was better
than paracetamol (acetaminophen)
for pain relief over an eight-hour
time period (J Reprod Med, 2004; 49:
73945).
u Magnets. A 2700-gauss static
magnet attached over the pelvic area
significantly reduced menstrual pain
and irritability compared with a
placebo (140-gauss) magnet (J Altern
Complement Med, 2005; 11: 6817).
u Aromatherapy and massage. In a
trial of 67 college students,
aromatherapy (topically applied
lavender, clary sage and rose) eased
the severity of menstrual cramps (J
Altern Complement Med, 2006; 12: 53541).
Combining aromatherapy with
massage is also a good idea, as a
Korean study found that women
receiving abdominal meridian
(Kyongrak) massage had
significantly less menstrual pain
than the control group (Taehan Kanho
Hakhoe Chi, 2005; 35: 132532).
u Biofeedback. A study of nine women
suggested that thermal biofeedback
may be effective for painful periods
(Biofeedback Self Regul, 1982; 7: 499520).
Another study reported that thermal
biofeedback may be a promising
treatment for menstrual pain and
other symptoms related to
endometriosis (Appl Psychophysiol
Biofeedback, 2003; 28: 27989).
u Relaxation techniques. High levels
of stress can greatly increase
dysmenorrhoea (BMJ, 2006; 332: 1134
8), but a review of the literature
suggests that relaxation techniques
may help to relieve symptoms
(Cochrane Database Syst Rev, 2007; 3:
CD002248).
Healing Foods
Endometriosis
Q
Ive just been diagnosed
with endometriosis, and
I am having difficulty
finding information on
effective alternative treatments.
Can you help?C.C., via e-mail
A
Endometriosis is a gynae-
cological condition where
cells of the mucous mem-
brane lining the womb
become deposited elsewhere in the
body. It affects around 10 per cent of
women of reproductive age, causing
symptoms such as painful, heavy or
irregular periods, bowel and bladder
problems, tiredness, insomnia and
depression. However, some cases have
no symptoms at all.
Endometrial deposits are most
commonly found on the ovaries,
fallopian tubes and peritoneum. But
other sites may be involvedeven, in
rare cases, the eye. The cells then
behave just as they do in the womb,
bleeding during menstruation, caus-
ing inflammation and often forming
fibrous adhesions that make organs
stick to each other. Inflammation or
scarring of the reproductive organs,
particularly the fallopian tubes, can
result in infertility.
No one knows exactly what causes
endometriosis or how to cure it, so
the goals of conventional medicine
are pain relief, slowing its progression
and relieving infertility, if present.
However, the treatments prescribed
painkillers, hormonal drugs and
surgeryall come with high rates of
recurrence and significant risks (Coch-
rane Database Syst Rev, 2009; 3: CD006568).
Gonadotropin-releasing hormone
(GnRH) agonists, for example, among
the most popular drugs for the
condition, can induce a pseudo-
menopause, complete with hot
flushes, vaginal atrophy, mood swings
and osteoporosis (Aust Fam Physician,
2006; 35: 8647). Happily, there are safer
ways to manage the condition.
Alternative approaches
Although more research is needed,
the evidence so far suggests that the
following may be helpful for women
with endometriosis.
u Avoid toxic chemicals. Certain
environmental pollutants, such as
dioxins and polychlorinated
biphenyls (PCBs), may play a role
in endometriosis (Environ Health
Perspect, 2009; 117: 10705). Experts
believe that over 90 per cent of
human exposures to these
chemicals comes from food, mainly
animal fat, so eating an organic,
wholefood diet low in animal fats
may be beneficial.
u Limit caffeine. Caffeine intake may
be related to endometriosis and
infertility. Women who consumed
more than 5 g/month of caffeine
(about 1.5 cups of coffee a day)
were nearly twice as likely to have
endometriosis and be infertile as a
result (Am J Epidemiol, 1993; 137:
135360).
u Eat more fruit & veg. In more than
1000 women in northern Italy,
those with low intakes of fresh fruit
and green vegetables had a signifi-
cantly higher risk of endometriosis.
Those who ate a lot of beef and red
meat were also more likely to have
the disease (Hum Reprod, 2004; 19:
17559).
u Exercise. This may influence the
risk of endometriosis. Women who
reported frequent, high-intensity,
physical activity had a 76-per-cent
lower risk than those who did not
engage in any such physical activity
(Am J Epidemiol, 2003; 158: 15664).
u Increase antioxidants. Endometri-
osis sufferers were found to have a
lower intake of antioxidants (vita-
mins A, C and E, zinc and copper)
than women without the disease.
Consuming more of these nutrients
through either diet or supplements
may help (Reprod Biol Endocrinol, 2009;
7: 54). Indeed, in women with pelvic
pain possibly due to endometriosis,
taking vitamins E (1200 IU/day)
and C (1000 mg/day) for two
months led to improvement in pain
in 43 per cent of cases. In contrast,
none of the women taking a place-
bo reported pain relief (Townsend
Lett, 2004; 253/254: 36).
u Boost omega-3 fats. Animal and
test-tube experiments show that
omega-3s can help by reducing
inflammation (Fertil
Steril, 2008; 90 [4
Suppl]: 1496502; Fertil Steril, 2001; 76:
71722), although whether supple-
ments will benefit women in real
life remains to be seen. However, a
daily dose of omega-3 (1080 mg of
eicosapentaenoic acid and 720 mg
of docosahexaenoic acid) plus
1.5 mg of vitamin E improved
symptoms of dysmenorrhoea (pain-
ful menstruation), which may be
related to endometriosis (Am J
Obstet Gynecol, 1996; 174: 13358).
u Take Chinese herbs. A review of all
randomized controlled trials found
that Chinese herbals were just as
effective as the hormone drugs
gestrinone and danazol for
symptom reliefwith fewer side-
effects (Cochrane Database Syst Rev,
2009; 3: CD006568). A variety of herbs
can be used, so be sure to consult a
qualified practitioner for advice.
u Consider curcumin. Derived from
the popular Indian spice turmeric,
curcumin has properties that
suggest benefit for endometriosis.
A study in mice showed significant
antiendometriosis effects, although
these results may not necessarily
apply to humans (Indian J Biochem
Biophys, 2009; 46: 5965).
u Try acupuncture. This well-known
pain treatment was both safe and
effective for endometriosis-related
pelvic pain in adolescents (J Pediatr
Adolesc Gynecol, 2008; 21: 24757), and
was just as effective, if not more so,
than the drug danazol in relieving
symptomsand again, with far
fewer side-effects (Zhongguo Zhen Jiu,
2006; 26: 8635).
u Use biofeedback. A small study of
five women reported that thermal
biofeedback helped to improve the
pain and other symptoms of endo-
metriosis (Appl Psychophysiol Biofeed-
back, 2003; 28: 27989). Other mind
body techniques, such as hypnosis
and meditation, may also help to
control endometriosis-related pain
(see Special Report, pp 69).
u Join a support group. Sharing with
other sufferers may also help in
coping with the condition. When
women had a chance to speak with
other endometriosis patients and
to meet with a counsellor, they all
reported being highly satisfied with
their overall care (J Psychosom Obstet
Gynaecol, 1997; 18: 2558).
WDDTY Chronic pain 31
Your questions answered
another trial, TENS took four weeks
Phantom-limb pain to work but, after four months, the
treated patients reported signifi-
cantly less PLP than the controls
analgesics and opioids to antidep- (J Bone Joint Surg Br, 1988; 70: 10912).

Q
Since my friend had a
below-knee amputation
five months ago, shes
been troubled by severe
phantom-limb pain and itching where
her lower leg once was. Doctors have
prescribed drugs, which help, but the
side-effects have stopped her from
using them. Are there any effective
alternative treatments available?
A.C., via e-mail
ressants and anticonvulsants, all of
which come with a truckload of side-
effectsand may be no better than
a placebo (Lancet Neurol, 2002; 1: 1829).
Surgery is another option but,
here again, results are generally
disappointing (Br J Anaesth, 2001; 87:
10716). However, a recent uncontrol-
led study found that surgical treat-
ment of the peripheral nerve was
successful in reducing PLP in 14 of
Another promising treatment is
acupuncture. Similar to TENS, elec-
trical stimulation of acupoints was
effective at reducing PLP by an
average of 66 per cent in controlled
studies (Pain, 1975; 1: 35773). Tradi-
tional needle acupuncture may also
be beneficial (Minerva Med, 1979; 70:
384351; Arch Phys Med Rehabil, 1981;
62: 22931). Needling of the residual
limb according to Western medical

A
First described more than
500 years ago, phantom-
limb pain (PLP) is the
strange phenomenon of
feeling pain in a limb that has been
amputated. Although the limb is
gone, the nerve endings at the site
of the amputation continue to send
signals to the brain that make it
think that the limb is still there.
Almost all amputees feel at least
some sort of sensation in the missing
limb such as tingling, itching and
heat or cold. But up to 80 per cent
suffer actual painfrom throbbing
and stabbing pain to cramping and
burningwhich can persist for years
after the surgery (Lancet Neurol, 2002;
1: 1829).
Although particularly common
after amputation of an arm or leg, it
can also occur with removal of other
body partsafter mastectomy or
tooth extraction, for example. Rarely,
PLP has been reported in people born
without limbs.
The precise cause of PLP remains
unclear and its notoriously difficult
to manage. As one study noted,
So far, none of the more than 40
treatment methods has proven to be
really effective (Zentralbl Chir, 2005; 130:
559). Even more shocking, a 2006
survey revealed that 53 per cent of
patients with PLP38 per cent of
whom had severe painreceived no
treatment whatsoever (Arch Phys Med
Rehabil, 2006; 87: 2707).
Treatment options
Pharmaceuticals are usually the first
course of action for PLP sufferers,
although there are no specific drugs
for the condition. Your friend could
have been prescribed anything from
the 15 patients involved (Plast Reconstr acupuncture resulted in complete
Surg, 2006; 118: 156272). Deep brain relief of PLP and other sensations in
stimulation also alleviated PLP two out of three patients (Acupunct
albeit in only three sufferers (J Clin Med, 2004; 22: 937).
Neurosci, 2005; 12: 399404). Neverthe- Another option to consider is
less, its clear that more research is Farabloc, a nylon and stainless-steel
needed. In the meantime, there are fabric that is meant to be worn over
far less-invasive treatments on offer. the site of amputation. The manu-
One of them is transcutaneous facturer claims that it filters out
electrical nerve stimulation (TENS), harmful electromagnetic waves that
a safe and painless technique that aggravate the severed nerve endings.
involves sending a weak electrical A study cited on their website
current to specific points on the skin (www.farabloc.com) has been pub-
overlying a nerve pathway. In a lished and, according to the results,
placebo-controlled study, TENS it may be effective in reducing PLP
applied to the outer ear reduced (Can J Rehab, 1993; 6: 15561).
PLP as well as non-painful phantom- Finally, theres evidence that
limb sensations in amputees (J Pain rewiring the brain can help to deal
Symptom Manage, 1991; 6: 7383). In with the pain (see box).
Brain over pain
There is evidence to support the use of biofeedback, hypnosis and relaxation
training in PLP (Appl Psychophysiol Biofeedback, 2005; 30: 8393; Clin Rehab, 2002;
16: 36877). One way these techniques may work is by reducing stress, thought
to be a factor in PLP (J Psychosom Res, 1990; 34: 717). In one study of 16 PLP
patientstwo recent amputees and 14 with chronic painmuscle-relaxation
exercises combined with biofeedback resulted in virtually complete pain relief in
more than half the participants. Moreover, these results were sustained for up to
three years (Pain, 1979; 6: 4755).
A particularly novel treatment for PLP is the use of a mirror box to produce
the illusion of two healthy limbs. Using such visual feedback, the patient is
able to move the phantom limb and release it from a potentially painful
position. Mirror-box therapy has proved useful for upper- and lower-limb
amputees (Disabil Rehabil, 2004; 26: 9014).
Similarly, virtual reality may combat PLP. UK scientists have reported that PLP
may be relieved by attaching the real limb to an interface that allowed
the sufferer to see two limbs moving in a computer-generated simulation (Disabil
Rehabil, 2007; 29: 14659).
These techniques may work by increasing a sense of control over the
phantom limb which, in turn, rewires the brain. Indeed, amputees who used a
fully functioning prosthesis on the affected limb showed significant reductions
in PLP whereas the controls, wearing a cosmetic prosthesis with little
functionality, showed no changes (Neurosci Lett, 1999; 272: 1314).

32 WDDTY Chronic pain

Carpal tunnel syndrome
Q
Ive recently been
diagnosed with carpal
tunnel syndrome in my
right hand, probably
related to my job, which involves using
a computer mouse for long hours. Can
you recommend any effective
treatments that dont involve drugs or
surgery?J.F., London
A
Carpal tunnel syndrome
(CTS) is caused by
compression of the median
nerve, which runs through a
U-shaped space in the wrist called the
carpal tunnel. Symptoms include
numbness, tingling, pain and weakness
in one or both wrists and hands. In
severe cases, the condition can lead to
a permanent loss of feeling in some
fingers.
Repetitive computer use is
commonly assumed to cause CTS, but
the scientific evidence is unclear. In
one US study, the frequency of CTS in
computer users was similar to that of
the general population (Neurology, 2001;
56: 156870). In a Danish one, however,
people who used a mouse device for
more than 20 hours a week had a
higher risk of developing CTS (JAMA,
2003; 289: 29639).
Other conditions can contribute to
CTS, including diabetes, inflammatory
arthritis, untreated thyroid disease and
pregnancy (J Gen Intern Med, 1999; 14:
3104). In your case, assuming an
underlying condition has been ruled
out, the following may help.
u Osteopathy. This has proven suc-
cess in treating CTS, especially
using the opponens roll man-
oeuvre. Used together with self-
stretching exercises, it resulted in
less restricted wrist movement and
improved nerve conduction in all
treated wrists (J Am Osteopath Assoc,
1994; 94: 647).
u Yoga. A study published in a pres-
tigious medical journal found that a
yoga-based regimen was more
effective than wrist splints or no
treatment in relieving the
symptoms and signs of CTS. The
study participantsmedian age 52
yearswho practised 11 yoga
postures that worked the joints
of the upper body, along with manifestation of a deficiency of this
relaxation twice a week for eight vitamin, as some sufferers do
weeks, significantly improved their experience pain relief with its
grip strength and pain reduction supplementation. However, so far,
compared with the controls (JAMA, studies have been poorly designed
1998; 280: 16013). and inconclusive (Nutr Rev, 2004; 62:
u Massage. The results of a recent 96104). Nevertheless, given the low
preliminary study suggest that both risk of toxicity at the suggested
targeted and general massage may doses, it may not hurt to try B6
be useful for CTS sufferers. Targeted supplements at dosages up
massage may be especially to 200 mg/day (J Am Acad Nurse Pract,
beneficial, as it resulted in greater 2003; 15: 1822).
gains in grip strength than general u C-TRAC. This new hand-traction
massage (J Altern Complement Med, 2008; device (see www. carpaldoctors.com
14: 25967). or www.carpaltunnelcure.co.uk) has
u Heat. Heat-wrap therapy can relieve proved to be both effective and well
various types of wrist pain, including tolerated when used for only 5
CTS, within one to three days. In minutes, three times a day, in a
addition, it improves grip strength, recent study of CTS patients, all of
joint stiffness and hand function whom had failed to respond to
(Arch Phys Med Rehabil, 2004; 85: conservative therapy. Overall, 79 per
140916), so try applying a warm cent of patients rated the treatment
compress to the wrist several times as excellent; however, the study had
a day. no control group for comparison (J
u Vitamin B6. CTS might be a Hand Ther, 2007; 20: 207).
Less strain, less pain
By far, the best way to treat carpal tunnel syndrome (CTS) is to deal with
whatevers causing it. Making the following changes may reduce repetitive
strain while you work.
u Improve your posture. Make sure that you are sitting properly, and that
your keyboard and monitor are positioned correctly:
v your back should be straight and not slouching, and you shouldnt
be stretching forward
v you should be looking down at your monitor, and it should be at least
an arms length away
v your chair and keyboard should be set so that the thighs and forearms
are horizontal and level
v your wrists should remain straight when typing, and not be bent down
or back, and they shouldnt be resting on anything when typing.
u Warm up. Before you begin work, warm up your muscle groups with a
few simple exercises, just as you would prepare your body before
beginning a workout at a gym.
u Take frequent breaks. Give your hands and wrists a break every 1520
minutes by gently stretching and bending them. Alternate with other
tasks whenever possible.
u Change your mouse. Choose a mouse design that fits your hand, but is
as flat as possible to reduce wrist extension. Consider a larger mouse
such as the Perfit or Whale mouse, or try a pen-shaped design for a more
comfortable grip. In one study, a mouse with a pivoting pen-shaped
handle significantly reduced muscle tension ( Int J Occup Saf
Ergon, 2003; 9: 46377).
For more tips on how to improve your computer workstation, visit the
Cornell University Ergonomics Web at www.ergo.human.cornell.edu.
WDDTY Chronic pain 33
Your questions answered
Ulcerative colitis
Q
Ive recently been
diagnosed with ulcera-
tive colitis. My doctor
wants to start me on
drug therapy as soon as possible,
but Id rather try natural treatments
first. What do you suggest?C.S.,
via e-mail
A
Ulcerative colitis (UC) is
a type of inflammatory
bowel disease (IBD) that
leads to frequent bowel
movements and diarrhoea accom-
panied by blood or mucus; other
symptoms include weight loss,
abdominal cramps, anaemia, fever
and fatigue. No one knows for sure
what triggers UC, but it appears to
be a combination of genetic and
environmental factors.
Conventional treatment usually
involves drug therapy or surgery.
However, both options are risky and
not always effective. Indeed, 4060
per cent of IBD patients will not
benefit from the available treatments
(J Clin Gastroenterol, 2007; 41: 799809).
Its not surprising, then, that so
many sufferers turn to alternative
ways to manage UC naturally.
Nutritional strategies
u Address deficiencies. Working
with a qualified health practitioner
to identify and correct nutritional
deficiencies may improve specific
symptoms as well as overall health.
Helpful supplements are vitamins A,
C, E and K as well as beta-carotene,
folic acid, calcium, magnesium,
selenium and zinc (Altern Med Rev, 2003;
8: 24783).
u Rule out allergy. Although
doctors continue to rebut any link
between food allergy and UC, this
may be one of the first things to
check. UC sufferers put on an elim-
ination diet excluding commonly
allergenic foods had significantly
fewer symptoms (primarily diarrhoea
and rectal bleeding) compared with
patients on a normal diet. Foods
likely to trigger symptoms include
dairy, pork, tomatoes, spicy foods,
citrus fruit, apples, grapes and
shellfish (S Afr Med J, 1995; 85: 11769).
34 WDDTY Chronic pain
Avoiding sulphur-containing amino
acids (such as eggs, cheese, whole
milk, ice cream, mayonnaise, soy
milk, wine, mineral water, nuts and
cruciferous vegetables) can also ease
symptoms and reduce relapse rates
(Altern Med Rev, 2003; 8: 24783).
u Increase fibre. Too little fibre
increases the risk of UC, so a high-
fibre diet might be protective
(Digestion, 1989; 44: 21721). Specifically,
psyllium husks (410 g twice a day)
and germinated barley foodstuff
(GBF; 10 g twice a day) may be
especially beneficial (Altern Med Rev,
2003; 8: 24783). During flare-ups, how-
ever, fibre may need to be reduced
until inflammation subsides.
u Limit sugar and fat. A high
intake of sugar and animal fat is
associated with an increased risk for
UC (Gut, 1997; 40: 75460).
u Take probiotics. In a double-
blind trial of 116 UC sufferers,
therapy with a non-pathogenic strain
of Escherichia coli was as effective
as low-dose mesalazine for control-
ling symptoms and maintaining
remission. Both achieved around 70-
per-cent remission, lasting for about
six months on average (Lancet, 1999;
354: 6359). A combination using four
strains of Lactobacillus, three strains
of Bifidobacterium and one strain of
Streptococcus has also proved to be
beneficial (Drugs, 2006; 66: 137187).
u Try EFAs. Fish-oil supplements,
rich in omega-3 fatty acids, can
reduce inflammation and lower the
need for anti-inflammatory drugs.
With few exceptions, studies show
its beneficial effects in UC patients
(Altern Med Rev, 2003; 8: 24783). The
recommended dosage is 12 g of
EPA/DHA three times a day.
u Other nutrients. Bromelain
(0.51 g twice a day), quercetin (500
mg two or three times a day) and
glutamine (1.53 g/day) may help to
improve symptoms of UC (Altern Med
Rev, 2003; 8: 24783).
Other natural treatments
u Herbs. The gum resin of Bos-
wellia serrata (Indian frankincense)
is a traditional Ayurvedic remedy for
inflammatory diseases. Clinical trials
in patients with UC and other
irritable bowel disorders (IBDs) have
proved promising (Wien Med Wochen-
schr, 2002; 152: 3738). In one study, 82
per cent of UC patients treated with
the resin (350 mg three times a day
for six weeks) achieved remission vs
75 per cent with the drug sulpha-
salazine (Eur J Med Res, 1997; 2: 3743).
Another natural anti-inflamma-
tory is aloe vera. In a double-blind
trial, oral aloe gel resulted in
remission or improved symptoms in
47 per cent compared with 14 per
cent with placebo (Aliment Pharmacol
Ther, 2004; 19: 73947). Other helpful
herbs are Ginkgo biloba, ginger, slip-
pery elm, fenugreek and devils claw
(Carcinogenesis, 2008 Jun 20, Epub ahead of
print; J Ethnopharmacol, 2008 May 15, Epub
ahead of print; Aliment Pharmacol Ther, 2002;
16: 197205).
u Melatonin. This natural hor-
mone may be useful in the treatment
of UC (Inflamm Bowel Dis, 2008 Jul 14,
Epub ahead of print). However, while
melatonin is freely available as a
supplement in the US, its difficult
to find in the UK and other European
countries. Also, further study is
needed on its side-effects and
potential drug interactions.
u Hypnotherapy. A recent UK
study had 17 patients with active
UC undergo a 50-minute session of
gut-focused hypnotherapy and com-
pared them with controls who
listened to music. Blood levels of
interleukin-6, a marker of inflamma-
tion in the body, fell by 53 per cent
in the hypnosis group, whereas the
music-listeners showed no changes
whatsoever (Am J Gastroenterol, 2008; 103:
14609).
For more information on UC and
IBDs, see The WDDTY Guide to Good
Digestion, which is available from our
website at www.wddty.com.
Osteoarthritis
Q
Is there an alternative
way of dealing with
osteoarthritis, specifically
spondylitis? As you are
no doubt aware, orthodox medicine
has no answer. In fact, following an X-
ray, which established that three of
my vertebrae of the neck were without
the cushioning discs, my doctor flatly
stated that there is no treatment.
P.B, Ipswich
A
Osteoarthritis (OA) has
always been considered an
inevitable feature of
ageing, only because it
affects so many people as they grow
older. Some surveys reckon that 80
per cent of those over 50, usually
women, have the disease. OA involves
the degeneration or destruction of
cartilage, after which the joint
hardens and the cartilage is replaced
by large bone spurs, called calcified
osteophytes, in the spaces between
the joints. However, unlike
rheumatoid arthritis, there is only
slight inflammation, if any.
Although osteoarthritis principally
affects the joints of the hand, knees
and hips, it can also involve the
spine. Spondylitis is an inflammation
of one or more vertebrae of the spine.
It is true that general wear and
tear on the joints is one cause of
osteoarthritis, causing a breakdown
in the network of the cartilage and
often the release of enzymes which
further destroy collagen. The reason
OA mostly affects people over 50
usually has to do with a lessening of
their bodys ability to synthesise
collagen.
Other causes of osteoarthritis
include hormonal changes, trauma,
rheumatoid arthritis or even surgery.
The usual medical solution is to
offer pain killers (nonsteroidal anti
inflammatory drugs NSAIDs) or to
wait until the joint is completely
destroyed and then to offer major
joint replacement surgery.
What is little known, according to
US naturopaths Joseph Pizzorno and
Michael Murray, is that modern
medicines treatment of OA usually
makes the problem worse. NSAID use
simply speeds the progress of the
disease (Lancet,
1985; ii: 11-3; Am J Mrf,
2987; 83: Suppl 5A: 29-34), largely
because NSAIDs inhibit cartilage
repair and speed up cartilage
destruction (J Rheumatol, 1982; 9: 3-5).
Although modern medicine argues
that osteoarthritis is a natural
consequence of growing older, it is
not true that cartilage loss is
inevitable. Poor nutritional status or
food intolerance may create the
deficiencies that lead to collagen
destruction.
Your first port of call should be to
determine whether your problem is
caused by allergy or intolerance to
certain foods. Although OA is often
associated with the presence of
certain antigens in the body, few
doctors associate OA with allergies.
But there is a connection with the
drugs usually dispensed for this
condition. NSAIDs make the gut
more permeable, increasing a
persons chances of becoming food
sensitive (Melvyn Werbach, Healing Through
Nutrition, Thorsons, 1995).
There are also many anecdotal
reports of patients whose
osteoarthritis improves once they
remove foods usually known to spark
off arthritis such as the nightshade
family (potatoes, tomato, bell
peppers, aubergine). The best way of
determining which foods may be
exacerbating your problem is to
undergo a controlled exclusion diet,
noting when certain foods make your
condition worse, or to use
neutralizing/desensitizing methods
to isolate the foods which may be
causing the problem (see the WDDTY
Allergy Handbook).
Antioxidants
Another possible culprit is low levels
of certain antioxidants. Vitamin C,
which is necessary for collagen
synthesis, is often deficient in the
elderly. In one study, comparing OA
patients given vitamin C, beta
carotene and vitamin E against
controls, those taking high doses of
vitamin C reduced the rate in which
cartilage was lost by 70 per cent
(Arthritis Rheum, 1996; 39: 648-56).
Vitamin E is also essential to
collagen repair. Studies have shown
that vitamin E inhibits the enzymes
which break down collagen; in one
clinical trial, OA patients given 600
IU of vitamin E significantly
improved (J Am Geriatrics Society, 1978; 26:
328-30). Both vitamins have certain
synergistic effects in slowing the
destruction of cartilage and so
should be taken together.
Large doses of niacinamide, or
vitamin B3 (900 mg 4 g taken in
divided doses), have been long
advocated as a treatment for OA. In
one study, 663 patients receiving
niacinamide had a greater range of
movement , compared with controls
(J Am Geriatric Society, 1955; 3: 927). One
patient of WDDTY panellist Melvyn
Werbachs was so crippled she could
barely get up out of her chair; three
months after taking 250 mg of
niacinamide every 11/2 hours (for a
maxmum of 10 doses per day) she
had regained her strength, could
walk on her own and get in and out of
chairs and bed. Setbacks only
occurred if she used her hands too
much in knitting, which would
temporarily reduce mobility.
One caveat: you should never
embark on this kind of regime
without careful medical supervision
as high levels of niacinamide can
cause liver damage and glucose
intolerance, among other side
effects.
Another good natural remedy is
boron. Naturopath Rex Newnham
reports positive results with boron
WDDTY Chronic pain 35
Your questions answered
supplementation. In one double
blind (admittedly small) trial, half
the boron patients improved,
compared to only one tenth on
placebo (J Nutri Med, 1990; 1: 127-32). Dr
Werbach suggests that since the
minimum daily allowance for boron
hasnt been established, patients
increase consumption of boron rich
foods: vegetables, such as soy,
cabbage, lettuce and peas; fruits,
such as apples, dates, raisins and
prunes; and nuts, especially almonds,
hazelnuts and peanuts.
B12 and folic acid may also play a
role in controlling joint pain. In one
study of 26 OA sufferers, these two B
vitamins were more effective than
drugs in controlling hand joint pain
(J Am College Nutrition, 1994; 13; 351-6).
Glucosamine
Some researchers have theorized
that arthritis is the result of
abnormal glucosamine metabolism.
Glucosamine is one of the chief
components of the proteoglycans, a
major building block of cartilage. It
seems to work by stopping the
proteoglycans from breaking down
and rebuilds damaged cartilage
(Orthop Praxis, 1970; 9: 225). Sulphate,
another naturally occurring
substance, appears to strengthen
glucosamines effect (Pharma-
therpeutica, 1981; 2: 504-8).
The research on glucosamine
sulphate demonstrates that it
36 WDDTY Chronic pain
relieves pain better than NSAIDs and,
unlike the drugs, apparently helps to
reverse the disease process,
stimulating the synthesis of
cartilage.
In a large scale study of more than
1000 Portuguese arthritis patients
given glucosamine sulphate for two
months, pain symptoms and
movement improved significantly in
59 per cent and sufficiently in
another 36 per cent (Int J Tissue Ract,
1992; 14: 243-51).
In another study, of 80 OA
patients given either 500 mg of
glucosamine sulphate three times a
day (a standard dose) or a placebo,
those taking glucosamine had a
significantly larger reduction in
overall symptoms, compared with the
placebo group (73 per cent vs 41 per
cent), after a month on the regime.
An electron microscopy sample of
cartilage from the treated patients
showed evidence of new growth (Clin
Ther, 1980; 3: 260-72).
In another double blind study,
where glucosamine sulphate was
compared with ibuprofen, a popular
NSAID, the ibuprofen group
recorded a better response initially.
However, the glucosamine group
experienced a steady improvement
with pain to the point where by the
second month, their improvement
outstripped that of the drug takers
(Curr Med Res Opin, 1982; 8: 145-9).
Glucosamine is often sold with
chondroitin sulphate, one of the
main glycosaminoglycans found in
cartilage, and so another of its
building blocks. CS is generally
made from bovine, whale and shark
cartilage. Glucosamine sulphate
and chondroitin sulphates supp-
osedly have synergistic effects.
Patients having a proprietary
form of chondroitin injections have
been shown to have joint changes
visible on X-ray (Semin Arth Rheum,
1987; 17: 2: Supple 1: 35-53 ) and a
reduced narrowing of joint spaces
(Rheumatol Med Int, 1986; 20: 24-8).
Although glucosamine seems to
have no side effects in standard
doses, intramuscular doses of
chondroitin have been linked with
severe kidney liver toxicity (Lancet,
1989; 1:1275).
Other potentially useful
alternative solutions include New
Zealand green lipped mussel extract
(Lancet, 1981; i: 439); the antioxidant
superoxide dismutase; omega-3
fatty acids, largely found in flaxseed
and fish oils; zinc; and sulphur,
taken as colloidal sulphur or
sulphur baths. Capsaicin cream
(made from chili peppers) has been
found to reduce pain and tenderness
by 40 per cent (J Rheumatology, 1992; 19:
604-7). As for herbs, extract of yucca
and devils claw (Harpagophytum
procumbens) have both been found
to reduce pain and increase mobility
(J Applied Nutrition, 1987; 27: 45-50).