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PPM Editorial Board Outlines Nutritional Advice for Chronic Pain Patients

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Eating Well—A Natural Aid In Pain Relief
John Claude Krusz, PhD, MD
Dallas, TX

I advise my patients with chronic pain and chronic headache that nutrition is tied to exercise; both are inextricable and very important, because anything that makes our overall health better or worse can make us less or more susceptible to migraine and other pain triggers.

I also stress to my patients the dangers of eating too much processed food. Approximately 17,000 new food products are introduced to the store shelves every year, and the vast majority of them are derived from two potentially poisonous sources: high-fructose corn syrup and soybeans. Both are highly genetically modified and produced with large amounts of pesticides, thus contributing to a toxin “load” that can impede overall health. In fact, soybean-based food products and high-fructose corn syrup are not “natural” foods and really should not be part of anyone’s diet. I suggest that patients read Omnivore’s Dilemma and In Defense of Food, both by Michael Pollan (Penguin Press, New York, NY), for a good overview of this important topic.

In terms of more specific ways that I address nutrition in my practice, I measure vitamin D levels in every patient, because the substance plays an important role in pain syndromes. This was underscored in a study we presented at the 2010 annual meeting of the American Headache Society in Los Angeles. We found that vitamin D levels were low in patients with migraine or headache, and those low levels are comparable to what we see in our patients with chronic pain. The results make sense, given the fact that vitamin D isn’t actually a vitamin at all; rather, it is a hormone with receptors in five or six brain areas that modulate pain transmission.

So a lack of adequate vitamin D levels is a significant problem, and we address it in our practice by recommending vitamin D supplements to our patients. We determine the optimal dose by sending patients’ blood samples to a lab, which will measure serum levels of the two major types of vitamin D—D2 and D3. If D2 is low, I recommend 50,000 units of oral vitamin D per week via prescription. Low D3 levels can be addressed with 5,000 units daily, which is available in over-the-counter products. I also recommend that patients take 
4 to 5 mg of essential fatty acids (EFAs) containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as they have potent anti-inflammatory effects. Additionally, I recommend zinc supplements (about 10-20 mg per day)because zinc can help counteract sugar dyscontrol, which in turn can affect headache and pain syndromes.

I also measure magnesium levels in the red blood cells of all of my patients because this assay provides a good index of intracellular stores of the metal. Magnesium supplements can be very restorative, as intracellular magnesium levels have been shown to be low in both headache and generalized pain patients. (Most clinicians do not measure intracellular stores but rather whole blood magnesium, which is fairly useless as a guide.) Magnesium has other health benefits as well: Similar to zinc, it can help regulate blood sugar levels. It also affects the metabolism of other essential nutrients like potassium, calcium, and vitamin D. I suggest about 400 to 500 mg per day of oral magnesium. When patients need IV therapy, I recommend between 1 and 2 g per infusion over 
1 to 2 hours.

I also suggest that patients ingest a variety of foods high in magnesium. High-magnesium foods include peas and beans (legumes), such as black beans, black-eyed peas, green beans, green peas, kidney beans, lentils, lima beans, navy beans, and pinto beans; whole grains, such as brown rice, buckwheat, millet, oats, quinoa, and wheat; whole-grain products, including whole-grain cereals, buckwheat flour, and rye flour; nuts, such as almonds, cashews, and peanuts; and pumpkin, sesame, sunflower, flax, and mustard seeds. Another great source of dietary magnesium is dark green, leafy vegetables such as spinach, Swiss chard, kale, mustard greens, turnip greens, broccoli, and collard greens.

I really don’t think that physicians are aware of these basic nutritional issues, even though in the case of vitamin D, studies have shown that up to 75% of people are deficient in the substance. However, I do think this is beginning to change and that we are in the initial stages of a new era of awareness. So stay tuned!

Diet and Exercise Can Tame Musculoskeletal Pain
Elmer Pinzon, MD
Knoxville, TN

Many patients with musculoskeletal pain syndromes have poor nutrition, typified by the heavy use of caffeine and alcohol and diets laden with fast food. These poor dietary habits create the foundation for an unhealthy musculoskeletal system and interfere with normal neurologic control of motor system function. Obesity—the natural outgrowth of these unhealthy habits—continues to be a serious societal problem that has reached epidemic proportions in the United States. Obesity can have a profound impact on patients with chronic musculoskeletal conditions because of the excess load placed on the joints and also the reduced activity level that further exacerbates their pain.

Smoking is another poor health choice that patients make, and it is one that contributes to a poor response to both the nonoperative and operative care of spinal conditions. Reduction in smoking, alcohol, and illicit drug use, plus a well-balanced diet that helps patients maintain an appropriate body weight, can be of major significance in the recovery of patients with musculoskeletal problems.

This overall approach is something that I stress very strongly when counseling patients with chronic pain conditions. I urge them to consider a nutritional plan that includes weight-reduction strategies such as a low-fat, low-carbohydrate diet and an aerobic, nonimpact exercise program that takes place in a controlled setting on a regular basis, similar to an approach advocated in American Heart Association guidelines. In some cases, the services of a skilled nutritionist can be of assistance in the rehabilitation process.

Patients with persistent pain also are turning to a wide variety of supplements, including chondroitin sulfate, glucosamine sulfate, S-adenosylmethionine (SAMe), vitamin B3, vitamin D3, methylsulfonylmethane (MSM), and various herbal medications such as cayenne pepper, nettle, boswellia, autumn crocus, and meadowsweet. These are especially popular with patients who have musculoskeletal pain. It is important to note that only glucosamine sulfate has shown positive clinical effects in some osteoarthritis studies; most of the other agents have not undergone controlled clinical trials. Thus, rigorous studies are needed to establish therapeutic efficacy. Because some nutraceuticals interact with over-the-counter and prescription drugs, knowledge of their use and effects is clinically important, and adverse effects thought to be related to nutritional supplements should be reviewed and reported to the FDA (

Nutrition Advice: Power Up for the Summer!
Tiziano Marovino, PT, DPT, MPH, DAAPM
Ypsilanti, MI

Last updated on: December 9, 2011
First published on: July 1, 2011