DIET AND CHRONIC SPINAL

PAIN

DR. PAUL RALSTONHEALTHWISE CHIROPRACTIC

NOT-PALEOPALEO

CHRONIC PAIN

“HE HAS SEEN BUT HALF THE WORLD WHO HAS NOT

BEEN SHOWN THE HOUSE OF PAIN”

RALPH WALDO EMERSON

PAINFUL STATS• A RECENT INSTITUTE OF MEDICINE REPORT FINDS CHRONIC PAIN

AFFECTS MORE THAN 100 MILLION PATIENTS

• THE ESTIMATED COSTS OF TREATING PAIN IS BETWEEN $560-$635 BILLION ANNUALLY, OR $2000 PER PERSON PER YEAR

• IN A RECENT STUDY BY THE GLOBAL BURDEN DISEASE 2010 PROJECT, LOW-BACK PAIN HAS BECOME THE NUMBER ONE CAUSE OF DISABILITY WORLDWIDE

• LOWER BACK PAIN IS ALSO THE NUMBER TWO CAUSE OF MISSED DAYS AT WORK

• EVEN FIRST LINE PHARMACOLOGICAL INTERVENTION FOR PAIN IS NOT WITHOUT RISK

• ACCORDING TO A STUDY OF 1990’S STATISTICS IN THE UNITED STATES, 32,000 HOSPITALIZATIONS AND 3,200 DEATHS OCCUR EACH YEAR AS A RESULT OF NSAID-RELATED GI BLEEDING

INFLAMMATION• ANY DISCUSSION OF PAIN WILL INVOLVE A DESCRIPTION OF

INFLAMMATION

• IN GENERAL, INFLAMMATION IS DESCRIBED AS EITHER ACUTE OR CHRONIC AND HAS BEEN CLASSIFIED INTO THREE PHASES, THE ACUTE INFLAMMATORY PHASE, THE REPAIR PHASE, AND THE REMODELING PHASE

• HOWEVER, IN REAL LIFE, THE INFLAMMATORY PROCESS HAS NO REAL BOUNDARIES

• IN MANY CASES, ACUTE INFLAMMATION DOES NOT RESOLVE AND BECOMES CHRONIC; HOWEVER, CHRONIC INFLAMMATION CAN DEVELOP FROM THE START WITHOUT ACUTE INJURY

• IN BOTH CASES, INFLAMMATION IS A CHEMICAL EVENT, SO IT IS IMPORTANT TO HAVE A FAVORABLE BIOCHEMISTRY IN THE EVENT OF INJURY, WHETHER IT IS AN INFECTION OR SOFT TISSUE INJURY

INFLAMMATORY MESSENGERS

• MANY INFLAMMATORY AND ANTI-INFLAMMATORY MESSENGERS EXIST IN THE BODY

• PRO-INFLAMMATORY EICOSANOIDS ARE DERIVED FROM FATTY ACIDS AND INCLUDE PGE-2, TXA-2, LTB-4

• PRO-INFLAMMATORY AMINO ACID/PEPTIDE MEDIATORS KNOWN AS CYTOKINES INCLUDE HISTAMINE, IL-1, IL-6, TNF, SUBSTANCE P

• HOWEVER, EICOSANOIDS AS WELL AS CYTOKINES CAN ALSO BE ANTI-INFLAMMATORY (PGE-I, PGE-3, LTB-5, IL-4, IL-10)

• UNDERSTANDING AND IDENTIFYING THE ROLE AND BALANCE OF THE VARIOUS CHEMICAL MEDIATORS OF THE BODY CAN AID US IN OUR MANAGEMENT OF CHRONIC PAIN AND INFLAMMATION

• IT’S BECAUSE OF THESE INFLAMMATORY CYTOKINES THAT OBESITY BECOMES MORE OF A CHEMICAL PROBLEM THAN A MECHANICAL

NOCICEPTON• NOCICEPTION IS THE TERM FOR THE NERVOUS SYSTEM

COMMUNICATING NOXIOUS STIMULATION

• THE RECEPTORS FOR NOXIOUS STIMULI ARE CALLED NOCICEPTORS, PAIN IS HOW YOUR BODY PERCEIVES THESE STIMULI

• ONCE STIMULATED, NOCICEPTORS SEND THIS INFORMATION TO THE BRAIN AND THE END RESULT CAN BE THE SUBJECTIVE EXPERIENCE OF PAIN

• THE THRESHOLD OF NOCICEPTORS IS KNOWN AS SENSITIZATION AND THIS THRESHOLD CAN BE LOWERED; CALLED NOCICEPTIVE SENSITIZATION

• DUE TO THE NEUROPLASTICITY OF THE NERVOUS SYSTEM, NOCICEPTIVE SENSITIZATION CAN OCCUR, RESULTING IN HYPERALGESIA, AN INCREASED SENSITIVITY TO PAIN

• AGAIN, WE’RE GETTING CHEMICAL RESPONSES IN THE BODY WITH EVERY MOVEMENT, SO IT’S IMPORTANT TO HAVE A FAVORABLE CHEMISTRY IN THE EVENT OF INJURY

DISC ANATOMY• THE INTERVERTEBRAL DISC CONSISTS OF THE INNER NUCLEUS

PULPOSUS, THE TOUGHER, OUTER ANNULUS FIBROSIS, AND THE VERTEBRAL END PLATES

• THE NUCLEUS IS A MORE WATER-RICH STRUCTURE IN THE CENTER OF THE DISC AND IS UNDER VERY HIGH PRESSURE, ESPECIALLY WHEN YOU ARE SITTING OR STANDING

• THE ANNULUS IS A MUCH TOUGHER COLLAGEN-RICH STRUCTURE WHICH IS RESPONSIBLE FOR RESISTING THE HIGHLY PRESSURIZED NUCLEUS

• THE VERTEBRAL END PLATES, DESPITE THEIR NAME, ARE ACTUALLY NOT ATTACHED TO THE VERTEBRAE BUT ARE INTERWOVEN INTO THE DISC AND CONSIDERED PART OF THE DISC

• THE SINUVERTEBRAL NERVES INNERVATE THE POSTERIOR THIRD OF THE ANNULUS AND CONTAIN AUTONOMIC AND SENSORY NERVE FIBER

NORMAL DISC ANATOMY

DISC DEGENERATION

• THE NORMAL DISC IS CONSIDERED THE LARGEST AVASCULAR STRUCTURE IN THE BODY

• IT HAS NO BLOOD SUPPLY AND RELIES ON NUTRITION THROUGH THE VASCULAR BEDS OF THE END PLATE AND GETS ITS LIMITED NUTRITION THROUGH PASSIVE DIFFUSION

• BECAUSE OF THE POOR BLOOD SUPPLY, THE DISC IS EXCEPTIONALLY PRONE TO DEGENERATIVE CHANGES AND IN FACT BEGINS TO LOSE BLOOD SUPPLY WITHIN THE FIRST DECADE OF LIFE

• THE PARTIAL LOSS OF BLOOD SUPPLY LEADS TO PREMATURE DEATH OF THE PROTEOGLYCANS RESPONSIBLE FOR MAINTAINING THE HYDROSTATIC PRESSURE WITHIN THE DISC

• THE ULTIMATE RESULT IS THE TRANSFER OF AXIAL FORCES TO THE OUTER ANNULUS AS WELL AS THE POSTERIOR FACET JOINTS

DISC DEGENERATION

• ONE OTHER PROCESS THAT LEADS TO PREMATURE DEGENERATION OF THE DISC IS GLYCATION

• GLYCATION OCCURS WHEN REDUCED SUGAR COMES INTO CONTACT WITH THE COLLAGEN FIBERS (PROTEIN) OF THE DISC, RESULTING IN CROSSLINKING

• THE END RESULT IS A THICKER, MORE BRITTLE SUBSTANCE MORE SUSCEPTIBLE TO DEGENERATION

DISCOGENIC PAIN• INTERNAL DISC DISRUPTION IS THE MOST COMMON CAUSE OF

LOWER BACK PAIN

• BOGDUK ESTIMATES 40% OF CHRONIC BACK PAIN IS CAUSED BY RADIAL ANNULAR TEARS

• RADIAL TEARS ARE OFTEN PRECEDED BY DISC DEGENERATION AND BEGIN IN THE INNER ANNULUS AND PROGRESS OUTWARD

• ONCE A RADIAL TEAR REACHES THE OUTER LIMITS OF THE ANNULUS IT CAN BREAK THROUGH

• THE RESULTING NUCLEAR MATERIAL IS HIGHLY INFLAMMATORY AND INFLAMMATORY CYTOKINES SOAK THE SINUVERTEBRAL NERVES RESULTING IN LOW BACK PAIN AND OFTEN LOWER EXTREMITY PAIN (SCIATICA)

• IN ADDITION, WITH DISC HERNIATION, THE HYDROSTATIC PRESSURE IS REDUCED, CAUSING MORE LOAD TO BE PLACED ON THE OUTER ANNULUS WHICH CONTAINS THE ALREADY INFLAMED NERVES

ANNULAR TEARS

TRANSVERSESAGITTAL

ANNULAR TEARS

YOUR BRAIN ON PAIN

• IS THE PAIN JUST IN YOUR HEAD?

• A RECENT DOUBLE BLIND, RANDOMIZED, CONTROLLED TRIAL SHOWED IMPROVED OUTCOME AFTER LUMBAR MICRODISCECTOMY IN PATIENTS WHO WERE SHOWN THEIR EXCISED DISC FRAGMENTS J Neurol Neurosurg Psychiatry. 2009 Sep;80(9):1044-6. doi: 10.1136/jnnp.2008.

• IN ANOTHER STUDY, 34 COLLEGE STUDENTS WERE TOLD AN ELECTRIC CURRENT WOULD PASS THROUGH THEIR HEADS AND HEADACHES ARE A COMMON SIDE EFFECT. DESPITE NO CURRENT BEING USED, MORE THAN 2/3 DEVELOPED HEADACHES Headache. 2003 Nov-Dec;43(10):1113-5.

• EXPECTATION EFFECTS DEPEND AS MUCH ON WHAT HAPPENS IN THE SPINE AS WHAT HAPPENS IN THE BRAIN, THIS HAS IMPORTANT IMPLICATIONS FOR CLINICAL PRACTICE Pain. 2007 Jul;130(1-2):137-43. Epub 2007 Jan 9.

PSYCHOGENIC PAIN• CAN OCCUR WHEN THE PSYCHOLOGIC STATE SUCH AS ANXIETY

OR DEPRESSION FACILITATES NOCICEPTIVE PATHWAYS

• RECENT RESEARCH HAS SHOWN INCREASED LEVELS OF CRP IN PATIENTS WITH PTSD AND INTERPERSONAL VIOLENCE

• LEVELS OF PRO-INFLAMMATORY CYTOKINES HAVE BEEN IMPLICATED IN DEPRESSION AND MOOD DISORDERS

• IN ADDITION, DUE TO THE NEUROPLASTICITY OF THE CENTRAL NERVOUS SYSTEM, SELF DEFEATING BELIEFS AND CATASTROPHIZATION CAN INTERACT WITH THE PAIN REDUCING NEURAL NETWORKS RESULTING IN CHRONIC PAIN

• OFTENTIMES THE ORIGINAL INJURY HAS HEALED, BUT CONTINUED BELIEFS, ANTICIPATION OF PAIN, FEAR, AND ANXIETY CAN CREATE CHRONIC PAIN AND INFLAMMATION

• PATIENTS CAN COME UNRAVELED ON YOU WHEN YOU TELL THEM THEY WILL NEVER BE ABLE TO DO (X) AGAIN

THE ANTI-INFLAMMATORY DIET• BASICALLY AN AUTO-IMMUNE PALEO PROTOCOL

• FISH, PASTURED MEAT, WILD GAME

• VEGETABLES AND FRUIT, WITH THE EXCEPTION OF THE NIGHTSHADE FAMILY

• SWEET POTATOES AND OTHER NON-NIGHTSHADE TUBERS

• RAW NUTS

• MOST SPICES, ESPECIALLY TURMERIC, GINGER AND GARLIC

• DARK CHOCOLATE (GREATER THAN 75% CACAO)

• DON’T LET THE PHARMACEUTICAL INDUSTRY FRUSTRATE YOU OR YOUR PATIENTS

ANTI-INFLAMMATORY SUPPLEMENTATION

• THE FOLLOWING NUTRIENTS CAN BE TAKEN DAILY TO SUPPLEMENT AN ANTI-INFLAMMATORY DIET

• VITAMIN D3

• PROBIOTICS (GI SYMPTOMS HAVE BEEN ASSOCIATED WITH BACK PAIN)

• EPA/DHA

• MAGNESIUM GLYCINATE (ANIMAL RESEARCH INDICATES LOW LEVELS OF MAG CREATE LONG TERM SENSITIZATION OF THE NOCICEPTIVE PATHWAYS)

• TURMERIC, GINGER

• PROTEOLYTIC ENZYMES SUCH AS TRYPSIN, CHYMOTRYPSIN, AND BROMELAIN CAN BE USED AS AN ANTI-INFLAMMATORY, BUT RESEARCH IS DIVIDED ON THEIR EFFICACY

CHRONIC PAIN PRESCRIPTION

• ANTI-INFLAMMATORY DIET

• ANTI-INFLAMMATORY SUPPLEMENTS

• AVOID LUMBAR FLEXION FOR AT LEAST 2 HOURS AFTER WAKING

• AVOID PROLONGED SITTING

• AVOID MECHANICAL POSTURES, MOTIONS, AND LOADS THAT CAUSE YOU PAIN

• IF YOU NEED TREATMENT, PROGRESS FROM CONSERVATIVE (CHIROPRACTIC, ACUPUNCTURE, PHYSICAL THERAPY, MASSAGE, ETC.) TO INVASIVE (DRUGS, INJECTIONS, SURGERY)