Nutrition for Pain

Nutrition for Pain Article by Geoff M. Lecovin

Clinical Nutrition for Pain
Using diet and Supplements to control inflammation and promote healing

The Inflammatory Process
Inflammation is the biological response that occurs when tissues are injured (e.g. infections, trauma, chemicals, immune reactions).

Acute inflammation is part of the healing process. It is characterized by swelling, heat, altered function, redness and pain. The outcome of acute inflammation should be the repair and remodeling of injured tissue. If acute inflammation does not resolve, then a state of chronic inflammation develops.

Chronic inflammation is destructive to tissue and viewed as a disease process. When inflammation goes awry, the body produces chemicals that have been linked to:

Cardiovascular disease, Diabetes, Obesity, Alzheimer’s disease, Cancer, Arthritis, Migraines Allergies, Eczema and other skin disorders, Chronic pain, inflammatory bowel disease, Asthma, Food sensitivities, Chronic athletic injuries, Delayed healing from old injuries e.g. Whiplash, Dental inflammation, Gastritis and ulcers, Auto immune disease e.g. Lupus Multiple sclerosis.

Ideally, treatment of inflammation should focus on assisting the healing process, while limiting tissue damage caused by inflammatory metabolites.

The following outlines the biochemistry of inflammation followed by treatment with diet and nutritional supplements. Nutritional approaches to inflammation are aimed at enhancing the salutary effects while limiting the destructive sequelae.

The inflammatory process is a physiological continuum that can be divided into three phases:
1. Acute inflammation- The first 72 hours
2. Repair- 48 hours to 6 weeks
3. Remodeling

Acute Inflammation (the first 72 hours):
I. Vascular response
II. Cellular response

The Repair Phase (48 hours to 6 weeks):
1. Repair- Restoring continuity to interrupted tissues

2. Physiological debridement- “Cleaning of injured area”

3. Ebb and flow phases of healing- Alternating periods of hypo and hyper metabolism

4. Additional factors affecting tissue healing- Immobilization, re-injury of damaged tissue, poor blood supply, temperature, nutrient deficiency (e.g. vitamin C and A, zinc, protein, ), age, medications (e.g. steroids, NSAIDs, anticoagulants, antibiotics, female sex hormones, cancer drugs), certain illnesses, and genetics

5. Angiogenesis- New vessel formation

6. Fibroblasts- Cells responsible for collagen formation, connective tissue repair and scar tissue

Glycosaminoglycans and Tissue Healing:
In the repair phase, glycosaminoglycans (GAGS), proteoglycans and collagen are provided to repair injured tissues and form healthy connective tissue. Nutritional considerations include the need for adequate: B1, B2, B3, B5, B6, B12, folic acid, calcium, magnesium, zinc, manganese, cysteine, calcium, iron, vitamin C, vitamin E, Vitamin A, silicon and bioflavonoids. Additional supplementation with Glucosamine Sulphate and Chondroitin Sulphate can help to regenerate new tissue. This process is negatively impacted by a pro-inflammatory diet, glycemic dysregulation (High glycemic index foods) and NSAIDs.

The Remodeling Phase (6 weeks -3 months or longer):
During remodeling, tissues realign and normal motion is restored. An important part of preventing chronic problems when areas are injured and inflamed is to initiate rehabilitation along with nutritional intervention in order to ensure proper remodeling through movement and conditioning.

Rehabilitation should occur in four phases:
I. Modalities/nutrition to eliminate pain at rest, in conjunction with pain free range of motion exercises

II. Stretching and range of motion exercises with self-imposed resistance (once capacity to perform unstressed basic daily activities is achieved)

III. Isometric strengthening exercises (once capacity to perform normal activities with minimal restraints is achieved)

IV. Isokinetic/isotonic strengthening exercises (after ability to perform normal uncontrolled activities is reached)

Summary of Major Biochemical Causes of Pain:
1. Lactic Acid- increases Bradykinin, the most potent chemical mediator of inflammation

2 Potassiumions- caused by alterations in the sodium/potassium pump. Results from: magnesium deficiency, free radical activity, and essential fatty acid deficiency

3. PGE-2 (Prostaglandins)- promoted by increased arachadonic acid (e.g. trans fats, meat and dairy)

4. LTB-4 (Leukotrienes)- promoted by increased arachadonic acid (e.g. trans fats, meat and dairy)

5. TXA-2 (Thromboxane A-2)- promoted by increased arachadonic acid (e.g. trans fats, meat and dairy)

6. Histamine- causes increased vascular permeability and activates nociceptors (pain receptors)

7. 5-HT (5-Hydroxytryptamine-serotonin)- a nociceptive irritant and promoter of platelet aggregation leading to the production of other chemical irritants

8. Bradykinin- the most potent nociceptor irritant, responsible for the four cardinal signs of inflammation (dolor/pain, calor/fever, rubor/redness, and tumor/swelling)

9. Cytokine ( Interleukins and Tumor necrosis factor)- play a major role in promoting tissue damage and chronic inflammation

A Diet-Induced Pro-InflammatoryState (Excessive amounts of meat, sugar and refined carbohydrate intake along with deficient quantities of cold water fish, vegetables and fruits):

1. Increased tissue acidity- activates bradykinin a potent nociceptor (pain) irritant

2. Inadequate potassium intake- causes alkalosis, ischemia and hypoxia (reduced blood and oxygen supply)

3. Inadequate magnesium intake- causes increased lactic acid, platelet aggregation and free radicals

4. Free radical production- reactive, unstable molecules damaging to cellular structures

5. Fatty acid imbalances- all cell membranes contain phospholipids (fat). Depending upon the nature of fat intake, cells can be pro-inflammatory or anti-inflammatory:

PRO-INFLAMMATORY fats- meat, dairy and trans fats- hydrogenated vegetable oils (increases arachadonic acid causing the formation of pro-inflammatory metabolites PGE-2, LTB-4 and TXA-2)

ANTI-INFLAMMATORY fats- cold water fish and green leafy vegetables (increases eicosapentaenoic acid causing the formation of anti-inflammatory metabolites PGI-3, TXA-3, PGE-3 and LTB-5)

Monounsaturated fatty acids e.g. olive oil promotes the incorporation of omega 3 fatty acids into phospholipids membranes and reduces unwanted immune-driven inflammatory processes.

Glycemic Dysregulation and Its Pro-Inflammatory Potential:

Factors:
High carbohydrate diets increase insulin levels favoring biochemical pathways that lead to the formation of Arachidonic acid and increased pro-inflammatory Eicosanoids.
Insulin Resistance Syndrome:

1. Promotes a prothrombotic and hypofibrinolytic state favoring inflammation
2. Impairs proteoglycan synthesis
3. Causes hypercortisolemia leading to:
• Decreases protein stores, glucose utilization, REM sleep, and immunity.
• Increases kidney stress.
• Reduced proliferation of osteoblasts (bone builders) and reduced collagen and protein synthesis.
• Hypercortisolemia inhibits secretory IgA from the gut, causing increased absorption of food antigens and the release of pro-inflammatory prostaglandins.

Pharmacological Therapy of Pain:

Anti-Inflammatory Agents (NSAIDs):
1. Aspirin
2. NSAIDs- e.g.Ibuprofen, Feldene, Naprosyn, Anaprox, Indocin
3. Acetominophen- Tylenol (analgesic and anti-inflammatory)
4. Corticosteroids e.g. Prednisone

Mechanisms of Action:
Inhibition of Prostaglandins, Leukotrienes and Thromboxanes

Side-effects:
• Acceleration of bone destruction
• Interferes with cartilage and bone repair and can lead to weakened tendons and ligaments
• Loss of intestinal permeability
• Gastritis, ulcers, reflux and gastrointestinal tract injury
• Asthma, rhinitis, sinusitis and hives in sensitive individuals
• Liver damage
• Dizziness
• Avascular necrosis (tissue and joint destruction)
• Adverse effects on lipid metabolism
• Osteoporosis, arthritis, bursistis
• Decreased mental status
• Water retention, obesity, cushings syndrome

Muscle Relaxants:
1. Flexeril,
2. Soma
3. Skelaxin
4. Robaxin

Mechanisms of Action:
Depression of the central nervous system

Side-effects:
• Drowsiness and dizziness
• Nausea,
• Ataxia,
• Vertigo,
• Confusion
• Headaches

Opiate Analgesics:
1. Morphine
2. Demerol
3. Dilaudid
4. Codeine
5. Fentanyl

Mechanisms of Action:
• Act upon opiate receptors in the brain
• Release neurotransmitters (endorphins, enkephalin, GABA, dynorphin, seratonin)
• Inhibit nociceptive (pain) receptors

Side-effects:
• Mood changes, sedation, mental clouding
• Nausea, vomiting, decreased G.I. motility and increased bile duct pressure
• Respiratory depression and cough suppression
• Histamine release
• Pruritis
• Urinary retention

Nutritional Recommendations for Inflammation:
• Focus on vegetable, fruit, cold water fish and olive oil consumption
• Total carbohydrate consumption should be less than 50% of calories
• Maintain a 3:1 to 2:1 ratio of carbohydrates to protein
• Pursue a 1:1 ratio of omega 3 to omega 6 fatty acids
(Omega 3- flax, leafy greens, fish, walnuts; Omega 6- corn, sunflower, grains, borage, evening primrose)
• Limit meats, dairy fats and shellfish
• Limit/Avoid refined carbohydrates and sugar
• Ensure adequate fiber intake
• Eat small frequent intervals, to ensure proper glycemic regulation
• Ensure proper digestion
• Optimize bowel habits
• Phytochemicals: whole grains, nuts, , onions, carrots, green vegetables, broccoli, Brussels sprouts, cabbage, cauliflower, tomatoes, beets, avocado, peppers, soybeans, squash, cilantro, parsley, citrus, berries, cranberries, apples, melon, cherries, pomegranates, green tea, red wine, dark chocolate, turmeric, garlic, ginger, cinnamon, rosemary, sage, oregano, thyme
• Adequate water intake
• Multiple Vitamin/mineral
• Antioxidants : A, E, C, Selenium, Zinc, CoQ10
• B1, B6, B12, folic acid, Calcium, Iron, Potassium (Chronic Myofascial Pain)
• Bioflavonoids
• Magnesium
• Fish oil
• Bromelain
• Quercetin
• Boswellia
• Glucosamine Sulphate
• Chondroitin Sulphate

Mechanisms of Action:
• Decreases platelet aggregation
• Decreases lactic acid
• Balances Potassium ions
• Decreased Eicosanoids (prostaglandins, leukotrienes, thromboxanes, platelet derived growth factor)
• Decreases Histamine levels
• Decreases Serotonin, Bradykinin and Cytokines

Side-effects: None

Exercise
An exercise program consisting of cardiovascular and resistance training can:
• Increase metabolism and weight loss, thereby enhancing physical appearance and well being
• Decrease the risk for heart disease
• Reduce blood pressure and cholesterol
• Reduce certain cancers
• Promotes insulin sensitivity , thereby reducing insulin resistance
• Improve sleep
• Increase strength and bone density
• Enhance immune function

Lifestyle modification:
1. Quit smoking
2. Ensure adequate sleep hygiene
3. Stress management
4. Weight management

Nutrition for Pain Article by Geoff M. Lecovin