More than a Feeling
More than a Feeling
by Timothy J. Maggs, DC
Pain management is a vital part of an active practice, and the modality or protocol a DC uses will often dictate his or her success as well as the success of the patient. With pain management, emotional, economical, and clinical factors must be considered. All three are important when working with patients in pain. Conventional marketing bombards the public with, "You haven't got time for the pain," and the public believes this message. As chiropractors, we work at a distinct disadvantage in the pain market because our treatments, although beneficial, don't necessarily reduce pain at the same consistent speed as pharmaceuticals. Therefore, we need to consider additional options.
Pain has many root causes: An 81-year-old woman with rheumatoid arthritis of the hands, a 22-year-old competitive male runner with severe achilles tendinitis, a 43-year-old male laborer with an acute low back injury. All have pain, and the DC who can confidently help this broad spectrum of patients emotionally, economically, and clinically will benefit most.
The active ingredient in topical analgesics such as Biofreeze produces an "irritation" to the skin, canceling the pain signal before it reaches the brain.
One topical analgesic available today is Biofreeze?. The active ingredients in Biofreeze are menthol, the cool substance found in peppermint oil, and Ilex, an herbal enhancing ingredient. When you apply Biofreeze to the skin, there is a rather immediate decrease in the sensation of pain. Menthol is also considered "cryotherapy," or cold therapy without the side effects of cold packs or ice. The topical application of menthol provides similar effects as ice, such as increased pain threshold and increased cutaneous circulation.
From an emotional point of view, the "sensation" of this product produces an immediate benefit to the patient, because the patient knows something is happening. "I could feel that treatment for 2 hours after I left your office" is a common statement. The cooling, then warming sensation is very appealing to most patients. People want to feel as though something has happened, and to feel a decrease of pain. The application of a topical analgesic satisfies that emotional need for the patient.
In the pain-management market, cost is a huge consideration. Pharma- ceuticals, surgeries, and extensive therapies can cost exorbitant dollars to the consumer. A good topical analgesic costs the practitioner pennies to use on each patient, and a home supply costs virtually no money relative to the other options mentioned above. As an adjunct therapy, combined with exercise, chiropractic adjustments, and cold laser therapy, it makes perfect economical sense to include a topical analgesic in every pain-management case.
Doctors and patients have known for years that topical analgesics are effective for pain relief. Initially, it was believed the benefits were due to the "counter-irritant" mechanism. The mechanism works like this: A message is sent from a part of the body to the brain, alerting the brain of some sensation of pain. The active ingredient in the topical analgesic produces an "irritation" to the skin, canceling the pain signal before it reaches the brain. The skin irritation would stimulate certain nerve fibers (larger-sized nerve fibers) that would send more information than the smaller-sized nerve fibers that carry the pain signals, essentially blocking the pain signals from reaching the brain. This is known as the gate control theory, and it is a commonly held view of pain relief.
Menthol acts as an "irritant" ingredient. In addition, it has been shown through research that menthol will also increase cutaneous blood flow and increase the pain threshold (tolerance to pain).
It is now believed that the "counter irritant" mechanism is only part of the reason for pain relief with menthol. Researchers have shown that menthol, in particular, may actually stimulate the smaller-diameter nerve fibers, rather than the large-diameter fibers.1 Clinicians have also noted that many patients with chronic pain also have temperature sensitivities, as these two perceptions share similar paths to the brain in the spinal cord. Therefore, when local pain becomes chronic (more than 1 month), the pain becomes "centralized" in the central nervous system, meaning the perception we have of pain is controlled more by the brain than the actual site of pain itself.
Scientists recently learned of specialized protein receptors in nerves that are sensitive to specific chemicals (ingredients). These receptors are called "transient receptor proteins," or "TRP" channels, as they help give us our sense of temperature.2,3 Only recently did researchers discover the specific receptor for menthol. This newly discovered receptor is called TRPM8. These receptors are being investigated for their role in chronic pain control.
TRP receptors are activated by chemicals such as menthol, and this response produces a potent beneficial effect on the achilles tendon patient, the rheumatoid arthritis patient, and the low back patient mentioned earlier in this article. These benefits are also seen in elbow, shoulder, neck, hip, ITBand, calf, and hamstring injuries.
Topical analgesics provide temporary relief. The level of relief is based upon the underlying condition, the length of the treatment, and the use of any additional modalities during the treatment. The use of a topical analgesic in the office by the practitioner has shown to be extremely beneficial in helping patients reduce pain, which is typically the No. 1 goal for a patient in pain. This latest discovery of the TRPM8 receptors will certainly enhance future knowledge on better ways to help patients reduce pain longer and with greater success.
Topical analgesics come in multiple forms: gels, creams, or sprays. They are applied at the point of pain. This approach acts more quickly without having to wait for medication to be absorbed internally before taking effect. Topical analgesics can be used with a much greater frequency in the office, increasing the patient's emotional satisfaction as well as clinical results. The use of topical analgesics is universally accepted as a safer treatment, especially over a lengthy period of time, than pharmaceuticals, whether prescription or over the counter. This treatment follows more closely the chiropractic model of care in the management of pain.
1. Proudfoot CJ, Garry EM, Cottrell DF, et al. Analgesia mediated by the TRPM8 cold receptor in chronic naturopathic pain. Curr Biol. 2006;16:1591Ò1605.
2. McKemy DD. How cold is it? TRPM8 and TRPA1 in the molecular logic of cold sensation. Mol Pain. 2005;1:16.
3. McKemy DD, Neuhausser WM, Julius D. Identification of a cold receptor reveals a general role for TRP channels in thermosensation. Nature. 2002;416:52Ò58.