Pain is a complex physical phenomenon that is intimately bound with emotions and mental states. When pain becomes chronic the consequences are far-reaching and profound. You don’t have to just mask pain though, as there are gentle yet powerful natural approaches that have proven positive effects in relieving chronic pain.

Pain is a fascinating topic as it covers so many parameters of living. Pain is not just an unpleasant physical sensation. It is intimately influenced by attitudes, beliefs, personality and social factors, and affects physical as well as mental and emotional wellbeing. Although two people may have exactly the same condition, their experience of the pain can be vastly different. Pain can be acute or chronic, and it poses many challenges for the researchers, the practitioners and the patients alike.

Acute vs chronic

Acute pain lasts for a short time and occurs following some trauma or a specific condition. It has survival value and serves as the body’s warning system for injury or disease. As survival value, pain encourages you to seek medical help and makes you rest in the process of recovery, and then informs you — by its absence — when you can resume normal activities. Acute pain is also a teacher reminding you of harmful situations, teaching you what to avoid in the future and what to do to prevent it. People born without the capacity to feel pain rarely live beyond childhood because they do not learn to protect themselves from injury or disease.

Chronic pain however is very different; it lasts beyond the time expected for healing, and sometimes it exists without a clear reason at all. It can also be a condition in its own right, characterised by changes in the central nervous system. Chronic pain appears to serve no adaptive purpose. It is often not responsive to treatments based on specific remedies. Chronic severe pain has many negative consequences including psychological distress, social isolation and job losses, and is strongly associated with depression and anxiety, and in severe cases even suicide.

Chronic severe pain has many negative consequences including psychological distress, social isolation and job losses, and is strongly associated with depression and anxiety, and in severe cases even suicide.

There are various definitions of chronic pain — with the distinction between acute and chronic pain often decided by an arbitrary period of time since onset, the most common markers being of three months or six months’ duration since onset, although some medical personnel determine the transition from acute to chronic pain to be 12 months. Generally, the symptoms are considered to be persistent pain anywhere in the body, associated with anxiety or depression, fatigue and sleep deprivation. Chronic pain that has no medical explanation is understood to involve an interplay between peripheral and central neurophysiological mechanisms that have malfunctioned.

Painful facts

Chronic pain is a global biopsychosocial problem and is a rapidly growing public health epidemic. In Australia in 2018, 3.24 million Australians were living with chronic pain; 53.8 per cent of these are women (1.74 million) and 46.2 per cent are men (1.50 million). People of working age make up 68.3 per cent (2.21 million).

Among older Australians (those 65 years and over), 1.03 million were living with chronic pain, with rates almost twice as high as the working age population; and 65.6 per cent of Australians with chronic pain live in urban areas compared to 34.4 per cent in regional areas. For the majority of Australians living with chronic pain (56 per cent), their pain restricts the activities they can undertake and can significantly reduce their quality of life.

The prevalence of chronic pain is increasing and is estimated to increase from 3.24 million Australians in 2018 to 5.23 million people by 2050.

The total financial cost of chronic pain in Australia in 2018 was estimated to be $139.3 billion for one year, comprising:

• $12.2 billion in health system costs
• $48.3 billion in productivity losses
• $66.1 billion in reduction of quality of life costs, and
• $12.7 billion in other financial costs, such as informal care, aids and modifications and deadweight losses.

Health system costs make up 16.7 per cent of financial costs, accounting for $12.2 billion. Of this expenditure, $2.7 billion was paid by Australians in out-of-pocket costs to manage their chronic pain. Governments paid for 66.7 per cent of total health expenditure ($7.9 billion), while individuals and other funding sources respectively contributed 22.1 per cent and 11.2 per cent to the total. Hospitalisations accounted for $3.7 billion of total health expenditure, followed by out-of-hospital expenses ($1.3 billion), and pharmaceuticals ($1.1 billion). In 2018 the cost of pain was estimated to be $22,790 per person per year.

Mental facts

Nearly 80 per cent of patients living with chronic pain also experience depression or anxiety, often associated specifically with their pain. Suicide is reported to be two to three times higher in those suffering chronic pain compared to the general population. In 2017–18, 823 Australians are believed to have lost their lives as a result of prescription opioid misuse.

Major depression in patients with chronic pain is associated with reduced functioning, poorer treatment response and increased health care costs. High rates of generalised anxiety disorder, post-traumatic stress disorder and substance misuse are also reported in up to 50 per cent of people with chronic pain. The preexisting presence of depression, anxiety and distress are strong predictors of the transition from acute to chronic pain, and both their psychological state and their pain are less likely to respond to pharmacological treatment.

In Australia in 2018, 3.24 million Australians were living with chronic pain …

These broad-reaching mental health issues significantly impact on the person’s quality of life involving impairment in both physical and emotional functioning and sleep problems. It is estimated that up to 88 per cent of people in pain report sleep disorders, and while the relationship goes both ways, there is increasing evidence that sleep disturbances the night before are a better predictor of subsequent pain the following day rather than the reverse. Sleep deprivation, even short-term, has been shown to increase pain sensitivity, and long-term sleep deprivation can cause spontaneous pain in some.

Chronic pain in older adults has further complications. Pharmaceutical treatment is only partially effective and frequently limited by severe side effects such as urinary retention, constipation, excess sedation, cognitive impairment and the greater risk of falls. Chronic pain in the elderly is also a risk factor for premature death, along with accelerated cognitive decline. This suggests a shared mechanism between persistent pain and/or its treatment and dementia. Cognitive decline and dementia also impact on the ability to report pain, further complicating the issue. Safer more effective treatment options need to developed, particularly for older adults.

Metabolic pathways of pain

Very briefly, when an injury occurs, the signals from the area travel through the spinal cord along nerve fibres to various parts of the brain (there is no single pain centre in the brain) where scientists are still unclear about how this information is processed.

However, it is known that the brain can significantly influence your perception of pain: if you are distracted, for example, and you don’t think about the pain, it bothers you less. Conversely, we experience more pain when we are stressed, fatigued or sleep-deprived.

Sharp pain is triggered by rapid-response A-type pain neurons and slower dull aches are conducted by the slower C-fibres. Using anaesthetics, scientists can block one type of neuron and separate the two types of pain.

A theory has been developed that there is also a “gating” mechanism in the spinal cord whereby the pain pathways from the brain are inhibited and the perception of pain is diminished. For example, if you hurt your finger and rub it, this closes the “gate” and the perception of pain is reduced.

Pain can also trigger autonomic nervous system pathways, causing increased heart rate and blood pressure, rapid breathing and sweating, depending on the intensity.

Neurotransmitters — serotonin and dopamine

The interaction between sleep and pain may involve overlapping mechanisms in the central nervous system. For example, dopamine pathways play a fundamental role in both sleep regulation and endogenous analgesia (ie the body’s own pain management system). Similarly, serotonin pathways are involved in pain modulation as well as in the regulation of circadian rhythms. Dysregulation of either of these interrelated pathways could explain both sleep disturbances and dysfunctional endogenous analgesia in people with chronic pain. These neurotransmitters (particularly dopamine) are also intimately involved in addiction and human pain perception. Regulating dopamine can improve the sensory, cognitive and physical aspects of the pain experience. Curcumin, quercetin, L-theanine (from green tea), resveratrol all taken nutritionally, as well as St John’s wort (Hypericum perforatum), kava (Piper methysticum), rhodiola (Rhodiola rosea) and lavender (Lavendula angustifolia) have been shown to regulate dopaminergic pathways and improve both the experience of pain as well as reducing the associated anxiety and depression.

The Chinese medicinal plant corydalis has a long history of use for pain relief. An active ingredient dehydrocorybulbine (DHCB) isolated from this plant has efficacy in acute pain, inflammatory pain and neuropathic pain, without side effects such as sedation. DHCB has a strong affinity to the dopamine receptors and is thought to work through these, particularly the D2 receptor which is reported to have strong analgesic properties.

Chronic pain syndromes are often associated with abnormalities in circadian and biological rhythms, which also cause disturbances in the sleep–wake cycle. Melatonin, the hormone that balances circadian rhythms in humans, is also an effective analgesic and anxiolytic nutrient, working through the endorphins and the opioid and GABA receptor pathways. As such it can be effective for improving sleep as well as the management of chronic pain.

Inflammatory pathways

Inflammation is an immune response whereby various chemicals are produced such as histamine, prostaglandins and bradykinin, triggering a painful response. The basic symptoms of inflammation are heat, pain, redness and swelling. Inflammatory chemicals are produced due to injury, infection or any perceived damage to the body. Substance P can also be produced from nearby nerve fibres, triggering the pain response.

While inflammation is a critical protective component when our immune systems are challenged, if it is not resolved quickly it can develop into a chronic condition, and chronic unresolved inflammation is the basis of chronic pain as well as of our major illnesses.

Nearly 80 per cent of patients living with chronic pain also experience depression or anxiety, often associated specifically with their pain.

Regulating the inflammatory pathways is therefore a crucial component of the management of painful conditions. There are two major prostaglandin or inflammatory pathways: COX-1 and COX-2 pathways. Management of these starts with inhibiting the initial triggers (such as arachidonic acid) with nutrients such as quercetin, curcumin, vitamin E and selenium. To inhibit the COX-1 pathways, omega-3 fatty acids, ginger (Zingiber officinalis), turmeric (Curcuma longa) and willow bark (Salix alba) help, and to inhibit COX-2 pathways you will also need garlic and onion, feverfew (Tanacetum parthenium) and boswellia (Boswellia serrata).

The prostaglandin pathways of inflammation also play a role in modulating the serotonin-regulated response to pain aversion.
Research on low-grade inflammation of the central nervous system provides a potential link between sleep impairment and pain.

While healthy sleep facilitates immune function, impaired sleep quality or quantity can result in low-grade inflammatory responses. The responses include increased levels of pro-inflammatory cytokines and prostaglandins, which are likely mediated by glial cells in the brain. These in turn lead to increased sensitivity in people with chronic pain, known as central sensitisation.

Types of pain

Pain is an incredibly complex issue. There are many types and many experiences of it. It can be associated with trauma, injuries or surgery, or it can exist without any obvious pathology. Research has shown that pain is inseparable from emotion and can exist even in the absence of tissue injury. Pain can result from specific dietary and/or lifestyle choices (such as a hangover); it can be a symptom of another disease or not. Nociceptive pain, defined as pain caused by physical damage to the body, is only one type of pain.

Pain can occur anywhere in the body, in one spot or at multiple sites. It can also move from place to place, called shifting pain. A person can have a single type of pain or several forms of pain at the same time. Chronic pain can be a daily occurrence, or be recurring, such as headaches.

Neuropathic pain
Neuropathic pain (or nerve pain) can manifest in various forms such as post-herpetic pain (shingles), trigeminal pain in the jaw or neck, occipital pain in the base of the skull, pudendal pain (pelvic pain) and in other sites such as hands and feet.

Nerve pain can result from nerve damage following a disease such as diabetes or an injury, or as a side effect of pharmaceutical medications. The damage can cause the nerves to misfire and send pain signals to the brain. It can also be caused by nutrient deficiencies such as a vitamin B12 deficiency.

Scientific research indicates that natural substances can help relieve neuropathic pain.

Herbally, St John’s wort is specific for relieving nerve pain and inflammation. It is also useful for relieving depression and anxiety.

Five major compounds from foods have been extensively researched for neuropathic pain relief. From these groups:

• Capsaicin (from chilli) induces pain in a single dose but relieves nerve pain with repeated applications.
• PEA (palmitoylethabolamide) has been shown to reduce neuropathic pain through the cannabinoid receptors and has been shown to be effective regardless of age, sex and the pain trigger.
• Zerumbone from ginger and curcumin from turmeric alleviated neuropathic pain, modulated dopamine and reduced the inflammatory response through COX-2 pathways in rat studies.
• Omega-3 fatty acids have shown positive effects on mood and also analgesic effects. Omega-3 fatty acids are effective against inflammatory and neuropathic pain.

Headaches and migraines
There are many types of headaches, from the severe migraines to cluster headaches, hormonal headaches, headaches from dehydration, to headaches associated with hypoglycaemia to general stress-related neck muscle spasms, for example. They are all painful.

People with chronic headaches, chronic migraines in particular, have been shown to have higher oxidative stress and increased neuroinflammation compared with those controls without headache.

Despite their variety there are some essential nutrients that if deficient predispose those susceptible to the excruciating pain of a headache. Low magnesium levels are a common problem, as well as low micronutrients such as vitamins B2, B3 and B12, alpha-lipoic acid and co-enzyme Q10.

Research has shown that higher intakes of anti-inflammatory omega-3 fatty acids in fish oils (EPA/DHA) are associated with a lower incidence of all headaches, including migraines.

The anti-inflammatory herb feverfew has been shown to be effective for migraine prophylaxis, particularly when taken with co-enzyme Q10 and magnesium.

Musculoskeletal pain — arthritis
The most common source of musculoskeletal pain is arthritis, a term for more than 100 medical conditions, such as osteoarthritis, inflammatory arthritis (rheumatoid arthritis) and gout. One in six Australians have some form of arthritis. The symptoms include pain, stiffness, inflammation or swelling in a joint, fatigue and feeling unwell. Shifting pain is a common symptom in inflammatory arthritis.

Managing arthritis depends on the type and position of the body part affected, but exercise and weight loss are common approaches, along with acupuncture, massage and physiotherapy.

Glucosamine has been shown to be effective alone or in combination against osteoarthritis of the knee, the finger joints and the hip. One study showed that chondroitin was more effective in relieving pain and improving physical function in osteoarthritis and glucosamine improved stiffness.

Glucosamine research has shown that if taken orally it is more effective for musculoskeletal pain with chondroitin and methylsulfonylmethane (MSM). These nutrients need to be supplemented for several weeks for optimal effects, and it can be useful to take them long-term for their overall anti-inflammatory effects. Glucosamine and chondroitin are anti-inflammatory and strengthen cartilage.

Glucosamine and chondroitin have also been shown to alter the gut microbiome to produce anti-inflammatory metabolites.

Low back pain
Back pain is a very common condition, being the most common cause of disability and inability to work. Muscle spasm is a common problem, and long-term pain can be as a result of degeneration of the spinal discs. Glucosamine and chondroitin taken over a period of two years showed improvement in spinal disc degeneration.

Muscle cramps and spasms
Muscle cramps and spasms are the sudden and involuntarily contraction of one or more otherwise relaxed muscles, causing sudden sharp pain. Leg cramps typically occur at night and are more common as people age.

Cramps and spasms have various causes including dehydration, neuropathies, exercise (from increased lactic acid levels), poor circulation and nutrient deficiencies. Sodium (or salt) depletion and electrolyte imbalances (such as calcium and magnesium) can also contribute to this condition.

Nocturnal cramps in the legs can indicate a magnesium or calcium deficiency. Cramps in the toes only is often a sign of poor circulation and may respond to ginkgo or vitamin E. While these have shown positive outcomes clinically, more research needs to be done as improvements to date are inconsistent.

Stretching exercises can help and medically quinine has shown improvements over placebo, although there are some significant side effects with this treatment.

Fibromyalgia and chronic fatigue syndrome
There is substantial debate about the cause of these conditions, and while there are similarities and differences, both are characterised by widespread often severe pain, specific tender points, fatigue and sleep disturbances. Research has been investigating the biopsychosocial components, and the predominant underlying triggers seem to be infections such as viruses, with inflammatory and oxidative changes in the neurological and endocrine systems. Imbalances in neurotransmitters such as serotonin can also be a feature. Antidepressants are a common prescription medically but have mixed success.

Research into nutrients has been equivocal, but the nutrients most likely to be deficient in people suffering from these conditions are vitamins C, D and E, calcium and magnesium. Mild exercise, massage and acupuncture can help, and adaptogenic herbs such as rhodiola, ashwaganda (Withania somnifera), ginseng (Panax ginseng) and hawthorn (Cratageus oxycantha) improve sleep and decrease fatigue.

Cancer pain
Cancer pain can occur in both the early and late stage of the disease. Pain is a common and debilitating side effect of both the cancer (when the tumour presses on pain receptors and/or invades surrounding tissues) and cancer treatments. Cancer patients have both acute and chronic pain, which can continue for years after completing treatment, and the pathways of these pains are not well understood. Complementary medicines can be very useful as adjunctive therapies to help reduce pain and to enhance or to reduce pharmacological management and to help improve quality of life.

… chronic unresolved inflammation is the basis of chronic pain as well as our major illnesses.

Acupuncture and massage can have analgesic effects and are helpful in reducing pain. Herbal medicines and supplements can have significant anti-inflammatory properties used either internally or topically. Hypnotherapy, meditation and behavioural therapies can reduce pain perception as well as the associated anxiety, depression and insomnia.

Medical treatments

Anticonvulsants, antidepressants, SSRIs and opioids such as morphine are commonly prescribed medically, the choice of pharmaceutical determined by the severity and the persistence of the pain; and while these may provide temporary pain relief (and in severe cases can be essential), there are multiple side effects and high risks of addiction.

Herbal medicines

Herbs for stress management — adaptogens such as ashwaganda (which also improves sleep), Siberian ginseng (Eleuthrococcus senticosis), rhodiola — provide some pain relief while reducing anxiety and depression. Adaptogenic herbs support the adrenal glands and the stress response. Herbs for nervous system support and calming are lavender and lemon balm (Melissa officinalis). Herbs with stronger sedative actions to improve sleep (and include antispasmodic activity) are valerian (Valeriana officinalis), hops (Humulus lupus) and passionflower (Passiflora incarnata).

Devils claw
Devils claw (Harpagophytum procumbens) has widespread uses for treating fever, malaria, indigestion and pain. Its anti-inflammatory activity helps with pain management in both musculoskeletal pain (arthritis), gut pain (IBS) and nerve injury pain.

Ginkgo
Mouse studies have shown that Ginkgo biloba has analgesic and anti-inflammatory properties and is effective for the relief of neuropathic pain. It is showing potential as a new analgesic for treating neuropathic pain, modulating inflammatory pathways and the opioid system. By regulating neurotransmitters and exerting both antioxidant and neuroprotective effects, ginkgo can have positive psychological and physiological benefits in the treatment of neuropathic pain and anxiety. By improving circulation it can also help relieve cramps caused by poor circulation.

Nutrients

Magnesium “calms” the nervous system and relieves pain, spasms, cramps and anxiety, and helps with sleep. It is the fourth most abundant mineral in the body and a cofactor for more than 300 enzyme reactions, including regulation of muscular contraction, neuromuscular conduction and nerve transmission among others. Low levels are associated with a variety of chronic illnesses including pain, headaches, muscle spasms, blood pressure and insomnia, as well as mood changes and anxiety particularly. The stress response is regulated by the adrenal glands, so nutrients to support the adrenals are zinc and vitamins C and B5. Magnesium also has a role in stress management.

To balance neurotransmitters such as serotonin and dopamine in the brain, zinc, B3, B6 and magnesium are important.
Anti-inflammatory compounds have multiple effects on pain management: quercetin, bromelain, resveratrol and PEA (a bioactive lipid with analgesic, anti-inflammatory and neuroprotective effects, a cannabimimetic compound) are all effective in regulating inflammation and pain.

Vitamin D
A deficiency of vitamin D is common these days, and while it is often asymptomatic, it is also known to cause bone and muscle pain. A deficiency of vitamin D has been associated with bone pain, migraine frequency and headaches, painful conditions such as fibromyalgia, lower back pain, leg pain and chronic neck pain. Potentially this results from its anti-inflammatory effect. Research has shown that low vitamin D levels are associated with increased pain and higher opioid doses.

Quercetin
There is increasing research on the powerful anti-inflammatory properties of the unique flavonoid quercetin. These actions are expressed in a variety of cell types and perform multiple activities, including improving the outcomes of many of our acute and chronic diseases including infections, cardiovascular disease, neurological conditions, immune disorders and cancer.

The anti-inflammatory properties of quercetin have been shown to relieve a wide variety of types of pain including neuropathic pain, the pain of osteoarthritis (animal studies showing it particularly effective when combined with PEA) and headaches. It also has gastroprotective effects, reducing gut pain and inflammation.

Quercetin may also act as a natural inhibitor of the 5-HT receptor blocking the acute inflammation generated by serotonin and regulating the analgesic effect of dopamine.

Quercetin is synergistic with curcumin, glutathione and vitamin C to form an intricate antioxidant and anti-inflammatory network to achieve an overall better outcome. Quercetin also needs to be taken with bromelain, the pineapple digesting enzyme, for maximum absorption and utilisation.

Essential fatty acids
Omega-3 fatty acids are vitally important in the body’s response to inflammation and pain at the basic cellular level. By regulating prostaglandin pathways they have been shown to provide relief for inflammatory arthritis, neuropathic pain, cancer pain, musculoskeletal pain and all types of pain based on inflammation.

Endocannabinoids are endogenously synthesised from the omega-3 and the omega-6 fatty acids, and the consumption of omega-3 fatty acids increases these therapeutic compounds. Omega-3 fatty acids also compound with the neurotransmitters serotonin and dopamine, improving psychological/neurological challenges as well as diseases such as pain, inflammation and cancer.

CBD oil (cannabis oil)
Research on pain relief and sleep improvement and reduction in anxiety has shown that cannabidiol (CBD oil) regulates the serotonin 5-HT receptor and relieves neuropathic pain as well as anxiety and helps with sleep. Cannabidiol works along similar pathways to opioid pharmaceuticals without the adverse effects and reduces the potential for addiction.

CBD oil has been used successfully to treat neuropathic pain with its ability to decrease both hyperalgesia (a process by which nerve endings are oversensitised to stimulation) and allodynia (the sensation of pain from minimal stimulation).

While much more research needs to be done, current research is promising, using cannabinoids for pain relief from various triggers to relieve neuropathic pain, numbness and tingling from chemotherapy, pain caused by inflammation and pain from injury, including spinal injuries.

Musculoskeletal therapies

The management of chronic pain needs to be comprehensive and include not only pain relief but also the associated mental health issues and the sleep problems.

Massage can relieve muscle spasms and relieve pain. Spinal manipulation, osteopathy or chiropractic techniques relieve nerve compression to relieve pain.

Hot applications increase blood flow and cold applications reduce inflammation, both of which relieve pain.

Acupuncture for chronic non-specific low back pain has been shown to be effective, with patients suffering significantly lower pain intensity for a short period of time after treatment, but is more cost effective than other treatments. The body can produce natural pain-relieving opiate neurotransmitters such as endorphins and enkephalins — one explanation of how acupuncture works is by triggering the release of these endorphins and providing pain relief.

For fibromyalgia, exercise, tai chi, qigong and myofascial release massage all helped for short- to medium-term pain relief. Continuing these therapies long-term should continue their benefits.

Placebos

Over the years there has been repeated research indicating that placebos can be effective in reducing low back pain, if presented to the patient in a positive manner. A recent study supported this when a placebo was added to the patients’ usual treatment in 97 adults for three months. The results indicated that adding the placebo to the “normal” treatment for back pain showed greater pain reduction on all the points measured and there was also a significant reduction in disability scores. Psychological factors play a significant role in the pain experience and a persons’ reaction to it, along with the neurotransmitters dopamine and serotonin which are implicated in mood changes.

Cognitive behavioural therapy (CBT)

CBT is a type of psychotherapeutic treatment that assists the patient in understanding the thoughts and feelings that influence their behaviours. At the centre of it is an assumption that a person’s mood is directly related to their patterns of thought and that negative thoughts affects a person’s mood, their behaviours and even their physical state. Therefore, changing thought patterns can help change behaviours, reduce stress and relieve anxiety and depression. The aim of CBT is to teach people that while they cannot control every aspect of their world, they can control how they interpret and deal with their environment. A recent clinical trial showed that the use of CBT in 113 participants with both pain and insomnia with comorbid fibromyalgia improved pain by more than 30 per cent and sleep in about one third of the participants.

Biofeedback

Biofeedback is a mind–body technique developed many decades ago. It involves using visual or auditory feedback to learn control over involuntary bodily functions, including muscle tension, pain perception, tension and migraine headaches and heart rate, blood pressure and blood flow. It is a non-drug treatment so has no adverse side effects, and research has shown it can help in a range of conditions. It is often combined with relaxation training.

• There are three common types of biofeedback:
• Thermal biofeedback measures skin temperature.
• Electromyography measures muscle tension.
• Neurofeedback or EEG biofeedback focuses on electrical brain activity.

During a biofeedback session, electrodes are attached to the skin and information is sent to a monitoring device; this identifies a range of mental activities and relaxation techniques that can help regulate these processes. Eventually the person learns to control these processes without the need for monitoring.

While it is still unclear exactly how biofeedback works, it appears to benefit conditions related to the stress response. There are many studies indicating its effectiveness in the management of various types of pain.

Topical treatments

Magnesium cream
Magnesium applied topically as a cream, an oil or even in a bath is effective at relieving spasms and cramping, generating relaxation and improving sleep. It appears to be absorbed through human skin depending on the time administered and the concentration, and this absorption is facilitated by hair follicles.

Glucosamine cream
Topically, glucosamine creams with capsaicin (from chilli) provide quick pain relief and can be reapplied several times a day for osteoarthritic pain relief.

Others
The anti-inflammatory omega-3 oils — CBD oil, emu oil or hemp oil — can relieve pain when applied topically to the area. Used topically St John’s wort oil can be very effective in relieving nerve pain and inflammation.

A philosophy of pain relief

While pharmaceutical measures may be useful short-term (but have issues with side effects and potential for addiction), there are many alternatives that can help relieve pain. While most pain originates from a disease or some physical damage, chronic pain behaviours are learned and influenced by the environment and emotions. Beliefs and attitude, expectations, cognitive processes, emotions such as anger, anxiety, fear and depression and their control by the patient are the basic emotional and cognitive aspects in the interpretation of pain. Thoughts, cognitive evaluations and understanding about the events which form their perception of the environment shape the meaning of an individual’s experience.

The individual’s belief about the ability to overcome pain is a key factor for effective adaption with pain and directs the patient toward behaviours promoting recovery, while the existence of beliefs such as catastrophising and lack of pain control is associated with high level of depression, disability and pain.

Using adaptive coping strategies such as praying, hoping, meditation, positive affirmations and distractions all play an effective role in the reduction of pain severity and increase the ability to control pain.

Exercises, multidisciplinary rehabilitation, acupuncture, CBT, yoga and mind–body practices are consistently associated with improvements in function and pain for specific chronic pain conditions.

Dietary changes, herbs and nutrients can also assist in the relief of pain and inflammation, improving function and reducing insomnia and the mental symptoms of anxiety and depression associated with chronic pain.

Dealing with the paradox of pain requires a broad-spectrum multidisciplinary approach.