We are all very familiar with pain. We learn about it very early in life, when perhaps we fall and bump our knees on the concrete or we walk barefoot on a hidden pin. Although such scenarios won’t be remembered as our most pleasant experiences, we should be thankful to the existence of the pain response as it is a self-preservation reaction to a potentially harmful circumstance. Pain begins at the tissue level where specific pain receptors (nociceptors) are triggered by a potential harmful stimulus in a process called transduction. In the following process of transmission the nociceptors send an electric signal through the axons of afferent (from tissue to brain) neurons reaching the higher centres in the brain (namely brain stem reticular formation, thalamus, somatosensory cortex, and limbic system.) via the dorsal horn of the spinal cord (24). In the brain, a series of electro-chemical processes modulate the signal which then is transmitted to the cortex and limbic brain for its final step, perception, which is the integration of many sensory messages into a coherent and meaningful whole. As these meticulously orchestrated processes take place, a structure of the midbrain called periaqueductal gray (PAG) triggers the descending pain pathways, which are responsible for antagonizing the pain signals. Once the pain stimulus is over, pain perception also halts. (38).
When the pain perception carries on after the tissue has regenerated and persists longer than three months is considered chronic (30). Chronic pain syndrome is the leading cause of disability worldwide and presents a major challenge to health-care providers because of its complex natural history, unclear aetiology and poor response to therapy (21). It is now recognised that chronic pain should be managed through a multidisciplinary approach, requiring an accurate consideration of the physiological, psychological, emotional, social and environmental dynamics affecting the individual (21). This article will focus on three strategies including a combination of nutritional advice, herbs and supplements that can be helpful in reducing the frequency and intensity of chronic pain
STRATEGY # 1: INFLAMMATION MANAGEMENT
One of the first steps to tackle chronic pain is to reduce the active inflammatory processes in the body to the bare minimum, the reason being that inflammation may lead to three major pain response derangements: hyperalgesia (exacerbated pain perception), allodynia (pain perception caused by a non-harmful stimulus) and sympathetic maintained pain (pain perception maintained by the fight-or-flight response) (38). It is logical to assume then that being chronically inflamed largely increases the risk to develop chronic pain (33). There exist many ways to address and cut chronic inflammation and whole books have been written about it; nevertheless, all authors agree that to reduce inflammation is to primarily make changes to what we eat. Firstly, all the widely recognised pro-inflammatory foods need to be largely reduced if not completely eliminated; the ones on the top of the list are: sugar and refined carbohydrates, seed oils, processed foods and alcohol. Refined sugars (the most common being sucrose, glucose and fructose) have a bad reputation. They cause insulin to spike, increase insulin resistance, to promote fat deposition around the liver and belly and increase inflammatory markers in the bloodstream. This is not only caused by sugars, but also by starchy foods with low fibre content such as white grains and cereals, cornflakes, white bread and potatoes (4, 16); Seed and vegetable oils, with exception of very few, are very high in omega-6 which are the building block of pro-inflammatory cytokines (to not mention that if they have been subject to heat-extraction processes, it is very likely that they end up already rancid on your shelves )(37, 8) . Finally, processed foods are not only high in refined sugars but also in trans-fatty acids, which are also an atomic bomb for your immune system (6); processed meats and low quality animal products are packed with nitrites and purines, which can elicit oxidative stress in the body and arachidonic acid, which is also a pro-inflammatory molecule (13,17); Alcohol notoriously damages the liver, which plays a vital role in inflammation (35).
The second step to counteract chronic inflammation is to introduce regular intake of foods which have anti-inflammatory properties; among these, we find oily fish and antioxidant-rich foods. Oily fish and high quality fish oil supplements are packed with omega-3 fatty acids, which provide the body with the building blocks to manufacture anti-inflammatory cytokines (29). Oxidation and reduction are chemical processes that have a profound implication in chronic inflammation: as the body becomes chronically inflamed, its reserves of antioxidant compounds (especially glutathione and superoxide dismutase) get depleted (2) ; supplements such as MSM (a form of dietary sulphur), cysteine (an amino acid) and herbs such as milk thistle seeds (Sylybum marianus) and schisandra berries (Schisandra sinensis) can support the regeneration these endogenous antioxidants (19, 5, 7). In addition, berries, grapes, green tea, and chocolate together with alpha-lipoic acid (ALA), vitamins A,C and E are excellent sources of exogenous antioxidants and can counteract the damage from free radicals (20,25). Finally, cooking with and juicing turmeric and ginger can also be helpful in managing inflammation (27)
The third and last step is to take deep care of the gut integrity and microbiome. The gut is your second brain where a lot of neurotransmitters and immune factors get produced and there is mounting evidence of its implication in the aetiology of chronic pain and inflammation (11). Increased intestinal permeability (Leaky gut syndrome) and imbalanced microbiome (dysbiosis) can in fact have a severe negative impact on the immune function (22) . Including in the diet fermented foods (yogurth, kefir, kimchi etc.) prebiotics (fermentable fibres) and collagen proteins (abundant in bone broth) can support a healthy microbiome and reduce gut permeability (32, 11).
STRATEGY # 2: STRESS MANAGEMENT AND MINDFULNESS
In the first paragraph it was discussed how the limbic system and the brainstem are fundamental cogs in the pain perception machinery. When these systems become overwhelmed or their function is somewhat altered, pain signals cease to be properly elaborated; the factor that accounts for most of this biochemical alteration is stress. The best examples to use for this scenario are chronic stress and post traumatic stress-disorder (PTSD): people affected by PTSD are more likely to report significantly higher levels of pain intensity, pain-related disability, depression, and anxiety compared to chronic pain patients without a trauma (28). Moreover, a systematic review found that in many clinic cohorts for chronic pain recovery there is a prevalence of PTSD affected patients (31). Stress causes secretion of cortisol, adrenaline and noradrenaline in response to a threat. In chronically stressed and traumatised individuals, the nervous system behaves as if there is an ongoing menace and prepares the body to fight or escape it causing a copious amount of these hormones to flood the bloodstream. This excessive amount of stress chemicals affect the homeostasis of the body and how the limbic brain and PAG modulate the pain signals, resulting in the exacerbation of pain perception (14, 3). Fortunately, there are many therapeutic tools that can promote calm and resilience such as mindfulness and adaptogenic herbs.
Mindfulness, as defined by John Kabat-Zinn, is the awareness that arises through paying attention, on purpose, in the present moment, nonjudgmentally (23). Daily mindfulness practices have provided evidence to be helpful to improve the biochemical consequence of stress response improving the life quality of people living with chronic pain (34). A study on more than a hundred patients affected by chronic pain showed that mindfulness is valuable for lowering general anxiety and depression, improving mental quality of life (psychological well-being), promoting feelings of control over the pain, and supporting higher pain acceptance (18). Furthermore, a systematic review from 2017 reviewed 38 randomized control trials and concluded that there is evidence that mindfulness meditation is effective at improving pain and depression symptoms (15).
Adaptogens are wonderful herbs that support the ability of the body to cope with stressors (36). Every adaptogen exerts a unique effect over the body-mind, but most of them lower serum cortisol, calm the mind and balance the immune system. Popular adaptogenic herbs are Ashwaganda root (Withania somnifera), Schisandra berries (Schisandra sinensis), Korean ginseng (Panax ginseng), Siberian ginseng (Eleutherococcus senticosus), Golden root (Rhodiola rosea), Reishi mushroom (Ganoderma lucidum), Cordyceps mushroom (Cordyceps sinensis) and Chinese foxglove (Rehmannia glutinosa) (36)
STRATEGY # 3: HERBAL ANALGESICS
Ultimately, there are herbs that have anodyne and analgesic effects on the body, meaning that they directly affect and ameliorate pain perception.
Corydalis yanhusuo is a popular painkiller in Chinese pharmacopoeia. It is a distant cousin of opium poppy and contains analgesic and anti-inflammatory compounds which have shown to reduce pain, inflammation and improve depression symptoms (39). It is thought that its properties are linked to a compound called dehydrocorybulbine, which probably improves pain modulation without the side effects of morphine (12)
Eschscholzia californica, also called californian poppy, is another member of the poppy family with analgesic properties. This herb contains a somewhat large amount of psychoactive alkaloids such as sanguinarine, dihydrosanguinarine chelirubine, macarpine which are thought to stimulate GABA receptors and thus promote sedation and analgesia (9,1)
Hypericum perforatum or st. John’s wort is a UK native herb with a strong affinity for the nervous system and commonly used for depression and anxiety. Some evidence supports the use of st. John’s wort as an effective mild analgesic (10)
Mitragyna speciosa, commonly known as kratom, is a plant native to SouthEast Asia and widely used for opiates withdrawal. Although there are some concerns about its long-term safety, it has shown promising analgesic effects similar to the ones exerted by opioid drugs (26)
Chronic pain is a complex phenomena influenced by many physiological and psychological factors. Educating and supporting chronic pain sufferers with proper dietary advice, mindfulness practices and medicinal herbs could result in a remarkable improvement in their quality of life. Seen its extreme burden on healthcare systems across the world and the lack of a silver bullet to cure it, it is of paramount importance to increase the awareness of the small but impactful changes that can be done to reduce the incidence of chronic pain disorders
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