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13 Articles in Volume 11, Issue #6
A Diet for Patients With Chronic Pain
A Practical Approach to the Management Of Diabetic Neuropathy
Book Review: Handbook of Pain Assessment, Third Edition
Diagnosis of Neck and Upper Extremity Pain
Diet and Nutrition For Patients With Pain—The Time Is Here
Dislocated Shoulder: Approaches to Lessen The Pain of Reduction Techniques
Guide to Dietary Supplements Most Commonly Used in Pain Management
New Device Combines Acupuncture With Four Other Technologies to Alleviate Pain
PPM Editorial Board Outlines Nutritional Advice for Chronic Pain Patients
Prospective Study of a Lumbar Back Brace In an Interventional Pain Practice
Q&A: The Legal Implications Of Medical Marijuana
Smoking and Pain
The Skeptical Radiology Nurse

PPM Editorial Board Outlines Nutritional Advice for Chronic Pain Patients

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 (www.fda.gov).

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

As a practicing orthopedic and sports physical therapist, I try to provide my patients with very broad and generally accepted nutrition parameters.My favorite nutrition “pearl” has to do with hydration principles and applies to athletic populations and patients with chronic pain equally. I have always supported the use of electrolyte drinks (not energy drinks), such as Gatorade or Powerade, for proper hydration. The benefits of using these drinks are numerous, including electrolyte (salts) replacement, water ingestion, and carbohydrates for refueling, but most importantly, the formulation of these drinks makes them optimal for hydration. Water alone may be insufficient, especially during high-intensity activities and/or micronutrient deficiency states not uncommon in chronic pain.

Remember, in third-world countries we use a salt and water mix to treat dehydration; simply giving water without salts is inadequate for proper fluid absorption in the gut. Patients with chronic pain benefit from the added salts (eg, sodium, potassium, magnesium) because they provide critical elements of muscle function, sometimes alleviating painful muscle cramping stemming from salt deficiencies.

Add a Nutritionist To the Healthcare Team
William M. Lamers Jr., MD
Malibu, CA

In the 1970s, when I was a hospice physician, most of the patients I treated had various malignancies and were in severe pain. It was my impression that these patients were not likely to have much of an appetite and often developed nutritional deficiencies. So we often suggested adding multivitamins to their diets. Because some researchers and clinicians argued that the supplements would only cause further cancer growth, we discussed this possible side effect with patients and their caregivers.

It is important to remember that nutrition is vital in the care of persons with end-stage illness, no matter what the cause. We saw instances of family caregivers “pushing” food on the patient with the implicit message “You’ve got to eat something!” We saw this attitude as a variant of the “chicken soup can cure anything” system of beliefs. One of the later stages of this phenomenon was the demand that the patient receive IV nutrition. In some instances, it was the family pushing for nutrition to be delivered by IV or some variation of a percutaneous endoscopic gastrostomy (PEG) tube. In other instances, the main pressure for hyperalimentation came from the medical staff. The mostly unspoken plea was something like “You just can’t let him/her die!”

The bottom line: Most physicians are not well versed in the complexities of nutrition. They know some general rules, some taboos, and some old wives’ tales. It is therefore advisable to have a nutritionist on the healthcare team either full time or as a part-time consultant.

My Nutritional Advice: Eat Real Foods
C. Norman Shealy, MD, PhD
Fairgrove, MO

Eat a wide variety of real food—that’s a great starting point. Avoid sugar, white flour, trans fatty acids, soda, fast food restaurants, MSG [monosodium glutamate], and aspartame. Unless you live 50 miles or more from a city and raise all of your food, take supplements:

  • Vitamin D3: 50,000 units once a week
  • Vitamin C: 2,000 mg or more daily
  • Beta carotene: 25,000 units daily
  • Vitamin E: 400 units daily
  • A good multivitamin with at least 
    25 mg of B complex
  • Omega 3: 3,000 mg daily
  • Coenzyme Q10: 100 to 200 mg daily
  • Use magnesium lotion daily
  • Probiotics

Super Foods = Super Results
Joseph Shurman, MD
La Jolla, CA

It is important to help patients focus on weight loss when appropriate. It is certainly a logical approach in patients with musculoskeletal pain, because every pound of body weight lost translates to about a 2- to 4-pound relative loss on the lumbar spine and knees. Reducing that weight load on the back and joints can help control pain and boost mobility.

I recommend a high-protein, low-glycemic diet, assuming lab studies are within normal ranges. Wild fish also is an important dietary component and can provide key proteins, along with omega-3 fatty acids. Assorted fresh vegetables (green when possible) are also a great addition, along with any of the “super foods” described in the book SuperFoods Rx: Fourteen Foods That Will Change Your Life (William Morrow, New York, NY), by my colleague and friend at the Scripps Clinic, Steven G. Pratt, MD.

To be fair, however, most of the studies on nutrition include small numbers of patients or are case reports, thus making it difficult to generalize nutrition advice to a wide range of patients with any degree of certainty. Also, I am not a big fan of dietary supplements.

One area of great interest—but again, hampered by a lack of definitive data—is the impact of low-calorie diets on aging and pain control. This is very relevant today given the growing aging population: More than 50% of individuals older than 50 years suffer from chronic pain. The only longevity study of which I am aware was done in mice, who were maintained on a bare number of calories. It is still controversial to apply the results to humans, but reduced-calorie diets will definitely help, as noted, in decreasing the load on joints, which in turn results in significant pain relief.

Finally, one relatively well-researched dietary intervention is to have patients with chronic migraine headaches avoid certain headache-inducing foods. There are well-accepted lists of foods—many containing tyramine—that can act as catalysts for bringing on migraines, so they should definitely be avoided. (For a list, visit http://www.webmd.com/migraines-headaches/guide/triggers-specific-foods.)

Show Me the Data: Part 1
Peter Moskovitz, MD
Washington, DC

I am not aware of any decent science on nutrition and the experience of pain. I make no recommendations beyond accepted guidelines for good dietary practice. Therefore, if patients ask me about various diets or supplements, and if the notion behind those diets is not manifestly outrageous, I tell them that although I have no reason to support or refute the alternative recommendation they’ve received, I have no objection to it.

Show Me the Data: Part 2
John F. Peppin, DO, FACP
Lexington, KY

As far as what role nutrition plays in pain management, my answer is a fairly short one: There is almost nothing in the scientific literature to support a strong connection between the two, so advice is hard to give. Having said that, I think this is a tremendously important topic and one that is overlooked. Still, more data are needed, so we recently hired a nutritionist who is working on a survey of our patients with chronic pain to determine their eating patterns. We feel that we can not begin to discuss nutrition and pain until we know some baseline information about these patients’ diets. Our hypothesis is that they eat much worse than the average person without chronic pain.

Should, but Don’t
Lynn R. Webster, MD
Salt Lake City, UT

I don’t provide any advice on nutrition. I should, but I don’t.

Last updated on: December 9, 2011
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