Loolwa Khazzoom: What are your general guidelines for treating a chronic pain condition?
David Simon: There are many different causes for chronic pain. Before anyone treats pain just for the sake of relieving it, you want to know what’s causing that pain. Assuming that someone has a disorder for which there’s no easy medical fix — like some kind of arthritis — then you begin a process of trying to relieve yourself of that pain, starting with the most non-invasive and then gradually working their way to more invasive approaches.
Nobody wants to live with pain, and people will do anything that’s required in order to get out of pain. So let’s take a common problem — chronic lower back pain. Over time, most people get back pain, because mechanically we’re not that well designed to stand up on two legs, against gravity, our whole lives. So it’s quite common that as people reach their 40s, 50s, 60s and beyond, they get degeneration in their discs and bones — resulting in chronic discomfort.
Usually people will first get an evaluation from their doctors — their family doctors or an orthopedist. More often than not, the response will come back that you have chronic degenerative arthritis, which will not benefit from a surgical approach. So from a medical perspective, that usually that means trying various types of anti-inflammatory medications or other types of anti-pain medications.
From a more holistic perspective, we know that a person’s perception of pain has as much to do with their overall sense of wellbeing as it does with any particular irritation in a joint or in a nerve root. So the first thing that we suggest for people with chronic pain is that they learn how to quiet their minds and relax their bodies — through a combination of meditation and relaxation techniques, stretching and yoga practices, and gentle, calming breathing exercises.
These classic techniques from the yoga tradition — meditation, breathing exercises, and postures — can often both raise a person’s pain threshold and also improve circulation, reduce muscle spasm, and improve flexibility in the area that’s causing the pain.
LK: Have scientific studies validated these approaches to natural pain relief?
DS: There is increasing scientific understanding that our interpretation of the sensations of pain is as important as whatever is causing the pain. For a condition like fibromyalgia, where people complain of pain throughout their muscles and joints, we now believe that the primary problem is actually in the brain: The pathways that modulate pain are, in a sense, letting too much traffic through those pathways, so it’s as much a brain problem as it is a muscle or a joint problem.
We also know that any technology that helps to increase the brain’s natural production of pain-relieving chemicals, called endorphins, will help to reduce a person’s perception of pain.
There are a fairly limited number of studies looking specifically at the role of meditation, yoga, and massage on pain. The reason they tend to be limited is that it’s difficult to control for these studies. It’s difficult to round up 100 people with the same type of pain, asking half the people to do nothing and the other half to only do yoga. The people who are willing to participate in these studies are generally not just going to sit around for six months doing nothing.
But the studies that have been done have suggested that people who take a more active role in their own pain management — through exercise, for example – end up increasing the body’s production of natural pain-relieving substances and lowering the perception of pain. Flexibility-enhancing, strength-enhancing, and cardiovascular-enhancing activities have been shown to improve a person’s mood, and mood and pain go hand in hand:
When someone is in a lot of pain, they’re more likely to feel depressed or anxious. Conversely, when someone is depressed or anxious, their pain threshold is lowered — so that the same level of pain is perceived as being more serious.
LK: What are the biomechanics of how meditation, exercise, and yoga work?
DS: We think that meditation works by changing the neural circuits in the brain. Whenever we put our attention on something, it becomes more prominent in our lives. So if all day long someone is thinking about their pain, their pain, their pain, then that becomes their life.
When people learn meditation, they learn how to shift their thought processes. MRI scans have shown that during meditation, different parts of the brain light up. The parts of the brain involved with pain become less active. So on a physiological level, we know that our attention influences what parts of the brain are dominating our awareness.
Regarding movement like yoga or exercise, pain begins with some neurological problem: Maybe someone lifted something too heavy, for example, causing some mild herniation of a disc that began to irritate a nerve route. So the first phase is direct irritation of the nerves.
Often what happens is because of that irritation, the nervous system sends signals to the muscles, to try and stabilize the area causing pain. The body then thinks, “If I stop moving so much, I won’t irritate that part of the body.” But there is a secondary source of the pain — chronic muscle spasm. When the muscles are in spasm, circulation to those muscles is impaired. The muscles then hold on to these toxic byproducts of metabolism, irritating the nerves.
So often, even though the muscle spasm is secondary, it becomes the primary source of the pain over time. The swelling of the disc — the nerve root irritation – subsides, but the muscles continue to be in spasm, causing ongoing pain. So the current theory is that through stretching, physical therapy, yoga, and massage, we’re able to reduce the muscle spasms and allow circulation to be restored. As such, we can reduce the secondary cause of pain.
LK: We’ve discussed meditation and movement. What is another effective means of natural pain relief?
DK: Sleep is another important component. It’s another one of those negative circuits, or vicious cycles: Pain keeps you from sleeping well, then poor sleep lowers your natural production of pain-reducing chemicals. We recommend starting with non-pharmacological approaches to helping a person sleep:
Before bed, treat yourself to a self-massage, a hot bath, relaxing music, aromatherapy, or mind-quieting herbs. The whole idea is to help a person get deep rest, following which the pain level is reduced. Focusing on the secondary effects of chronic pain and showing improvement in those areas can often reduce the perception of the primary pain problem.
LK: What about diet?
DS: There are direct and indirect effects of diet. People are overweight to begin with, or as a result of pain, they find it difficult to exercise. And so, unless they adjust their caloric intake, it’s easy to start gaining weight, which only worsens the underlying pain problem. So on the first level, it’s important that people eat properly. It’s also important that people are conscious that if they’re reducing their level of activity, because of the pain, they also have to reduce their caloric intake.
On the second level, there’s some evidence that certain foods are more pro-inflammatory and other foods are more anti-inflammatory. We recommend that when people are dealing with chronic pain, they become aware of the research on how different foods — particularly certain fatty acids — can either enhance the production of these pain-inflammatory producing chemicals or can reduce it.
The main evidence is for Omega-3 fatty acids, which are generally not as high an intake in the standard Western diet as in other cultures. The highest concentrations of Omega-3 are found in flaxseed, cold water fish, and to a lesser but still significant extent, in walnuts.
You want to make an effort to reduce the intake of foods that are higher in the Omega-6 fatty acids, which are the more pro-inflammatory fatty acids — predominately present in animal sources of fat. So if people are eating a lot of red meat, we encourage them to move towards a vegetarian or vegetarian-and-fish diet, then add flaxseed and nuts as a way of taking advantage of these anti-inflammatory, natural chemicals.
David Simon, M.D., is a board-certified neurologist and ayurvedic practioner; co-founder, CEO, and Medical Director of The Chopra Center for Wellbeing; and assistant clinical professor in the Department of Neurosciences at The University of California. Dr. Simon has authored popular wellness books including his newest book, Free to Love, Free to Heal: Heal Your Body by Healing Your Emotions and Grow Younger, Live Longer: 10 Steps to Reverse Aging (co-authored with Deepak Chopra, M.D.). Dr. Simon is a keynote speaker for the March of Dimes, American Cancer Society, California Medical Association, Harvard Medical School, and other prestigious institutions.