Using Wellness Approaches to Manage Pain
Online Health Chat with Cleveland Clinic physician and William Welches, DO, PhD
June 24, 2013
Whether you have persistent back pain, joint pain, headaches or another type of chronic pain, you’re not alone. Chronic pain costs the U.S. economy an estimated $100 billion annually, including healthcare expenses, lost income and lost productivity.
While many patients feel better with conventional pain management treatment, others continue to struggle to live their normal lives. That’s when it can be helpful to combine mainstream therapies with complementary or alternative therapies for which there is scientific evidence of safety and effectiveness.
Some examples of complementary therapy include anti-inflammatory diets, exercise and stress management that can be used to help lessen pain. Other alternative therapies for chronic pain and stress include:
- Acupuncture—inserting hair-thin needles into points of the body to stimulate healing and pain relief
- Chiropractic or osteopathic manipulation—which can help relieve neck pain, headaches, spinal pain and more
- Cranial sacral therapy—a gentle, hands-on technique that releases compression in the bones of the head, spine and lower back
- Massage—which can be used with exercise and education to treat non-specific lower back pain. It can improve blood and lymph flow, relax muscles, and reduce anxiety and depression.
- Mind-body therapies—such as hypnosis, guided imagery, cognitive-behavioral therapy, support groups, meditation and breath work.
- Reiki—which has shown positive results in healing wounds and treating pain, anxiety, arthritis and various orthopaedic conditions.
About the Speaker
William Welches, DO, PhD is an associate staff physician in Cleveland Clinic’s Department of Pain Management and is board certified in family practice medicine. He sees patients at South Pointe Hospital and Euclid Hospital. Dr. Welches uses osteopathic manipulation, along with diet therapy, counseling and other programs, to provide patients with comprehensive treatment for their pain. His specialty interests include acupuncture, cranial sacral therapy, visceral manipulation, interventional pain management, back and neck pain, pelvic pain, migraines, and chronic and neuropathic pain management.
Dr. Welches received acupuncture training at University of California-Los Angeles School of Medicine after completing his family practice residency and internship at South Pointe Hospital, in Warrensville Heights, Ohio. Dr. Welches completed medical school at Ohio University College of Osteopathic Medicine, in Athens, Ohio, and received his doctorate degree in biochemistry from University of Illinois Hospital at Urbana-Champaign, in Urbana, Ill.
Let’s Chat About Using Wellness Approaches to Manage Pain
Stress and Pain
lacerta227: How does stress contribute to increased pain?
William_Welches,_DO,_PhD: Stress activates the sympathetic nervous system among other things. It charges us up for ‘flight or fight’. This was useful when our concerns were saber cats and cave bears. Such situations were rapidly resolved. Today's stress—like the pain it often causes—is chronic. Your boss doesn't eat you and you can't run away. The physiological conditions that the stress creates don't go away. The muscular tension created by stress often settles in the pelvis or the shoulder girdle. Don't get me started on stress and inflammation.
Alternative Treatment for Headaches
molly: I get frequent and often severe headaches. What are recommended alternative treatments to help with headache pain? I am not sure what causes the headaches, if that makes a difference.
William_Welches,_DO,_PhD: For headache, I would start with osteopathic manipulation therapy specifically cranial-sacral therapy. Some of my patients are surprised when I start with their pelvic and legs before moving my way up. Alignment starts with how I stand on planet Earth. Alignment is critical to my body mechanics and how my cranium interacts with my neck. How my head and neck align will influence not just the fascial and muscular layer, but can affect the flow of blood, lymph and cerebrospinal fluid. After the patient is aligned with special emphasis on the cranium and if there is persistent pain, then I would add in acupuncture. This ordering of treatment is my bias. You also can go straight to acupuncture, which has a proven record with headaches of all sorts.
Alternative Therapy for Chronic Back Pain
jonah: My mother has chronic back pain, works a very stressful job and has a stressful life. She was recently prescribed Xanax® (alprazolam) for the stress. She said that it has taken away most of her pain as well and she has cut down on her pain medications considerably. Is it O.K. for her to combine the two therapies and is the pain relief from the Xanax® normal?
Cleveland Clinic Physician: Chronic stress has been associated with pain, depression and anxiety. Using Xanax®may be helpful in the short term because it will allow the patient to have less anxiety during stressful situations. It doesn't, however, address the underlying issue and it will usually lead to tolerance (requiring increasing doses to have the same effect) and can lead to addiction. So, I would recommend against using long-term Xanax®for your mother's pain. I strongly recommend using a combination of magnesium (500 to 1000 at bed time) along with sipping chamomile tea throughout the day to assist with anxiety. Your mother would likely benefit from seeing a holistic psychotherapist to deal with stress management. She may also consider ways to reduce her external sources of stress. Lastly, acupuncture has also been shown to be very helpful for both anxiety and pain.
Alternative Therapy for Rheumatoid Arthritis and Fibromyalgia
mamas12: I have been on Enbrel® (etanercept) for rheumatoid arthritis (RA) and Savella® (milnacipran hydrochloride), Flexeril® (cyclobenzaprine hydrochloride) and Naprosyn® (naproxen sodium) for pain related to fibromyalgia. Although the RA is under control, the fibromyalgia-related pain continues despite these medicines. What alternatives should I be discussing with my doctor?
Cleveland Clinic Physician: In my experience fibromyalgia-related pain can be significantly improved with the combination of acupuncture and magnesium. Many patients with fibromyalgia have inadequate sleep, which may lead to fatigue, pain and depression. These can also be symptoms of low total body magnesium status. Taking a magnesium supplement of 500 to 1000 mg at bed time can be very useful in helping with the underlying cause of the symptoms as opposed to covering up symptoms of low magnesium with drugs. High doses of magnesium may cause diarrhea. I recommend beginning with 500 mg at bed time and adjust the dosage upward to 1000 mg, stopping at perfect daily bowel movements. Some studies have shown that food intolerances can cause symptoms associated with fibromyalgia as well as RA. If your symptoms are not significantly controlled with acupuncture and magnesium, I would recommend taking wheat completely out of the diet for two to four weeks. The next culprit is usually dairy. try the same with dairy if needed. If there is still significant pain, consider being evaluated by a physician in the Center for Integrative Medicine for intestinal permeability issues (leaky gut syndrome).
William_Welches,_DO,_PhD: There can also be a role for manual medicine with some patients, but this can be contraindicated for others. You can try and see if manipulation benefits you, but I agree with the medications and general use of acupuncture that our Cleveland Clinic physician suggests.
Multiple Sclerosis Pain
Cat666: Can you suggest how to manage painful neuropathy due to multiple sclerosis (MS) throughout the body without the use of medications?
Cleveland Clinic Physician: My first choice making sure that a MS patient's vitamin D level is between 50 and 80. A low vitamin D status has been associated both with MS and chronic pain. Next, I would highly recommend using acupuncture, which has been shown to be very helpful for neuropathy caused by multiple conditions. Two other supplements may be very helpful, including Omega 3 fatty acids (fish oil) at doses 2000 to 6000 mg per day as well as alpha lipoic acid 600 mg twice daily. As always, avoiding inflammatory foods (as specified in an anti-inflammatory diet) should be part of any plan for chronic pain.
William_Welches,_DO,_PhD: Acupuncture can play a role in the treatment of neuropathic pain.
Treatment for Cervical Spondylosis Pain
andreead: What kind of treatment do you recommend for the pain associated with cervical spondylosis?
William_Welches,_DO,_PhD: I am assuming that the problem is neck pain. You need to be evaluated for musculo-skeletal problems associated with the spondylosis. The term cervical spondylosis is somewhat general and I would need a more specific diagnosis to begin to treat you, but manual medicine and acupuncture are good places to start.
Treatment for Amyotrophic Lateral Sclerosis (ALS) Pain
nutzy: Is there any new medications or maybe an NSAID that is advisable for amyotrophic lateral sclerosis patients who take Coumadin® (warfarin sodium) daily?
Cleveland Clinic Physician: My preference is to avoid NSAIDs for daily use if possible. Therefore, for patients with chronic pain who are using Coumadin®, they may want to consider integrating complementary therapies to minimize the use of NSAIDs. Such therapies would include acupuncture, massage, osteopathic or chiropractic manipulation, physical therapy, anti-inflammatory diet, relaxation therapies and omega-3 fatty acids.
Alternative Therapy for Inflammatory Demyelinating Polyneuropathy
Madonna: My husband , who diagnosed with chronic inflammatory demyelinating polyneuropathy six months ago, cannot walk or stand and has extreme pain in his legs and feet. He also has daily nausea. He is receiving intravenous immunoglobulin (IVIG) monthly and takes quick, long-acting morphine daily. He will be started on high-dose prednisone. He started three months ago with ‘moxa’ (moxibustion) acupuncture two times per week. Where should we go from here? Will he be comfortable with alternative pain treatment? What can he do to promote nerve regeneration and stop the autoimmune response causing this disease?
William_Welches,_DO,_PhD: You didn't mention whether the moxa (moxibustion) acupuncture was providing relief. Every therapy comes with some kind of time limit, i.e., ‘How soon will I see some kind of result?’ No one can answer whether he will be comfortable with alternative therapies; he needs to try it to find out. I would recommend lifestyle changes first, including diet and exercise. I believe that these are the most important things in any pain management program. If you don't know how to get started, I think that you need to find a therapist or doctor you can work with to help you develop a program of diet and exercise. Also, such an individual can help with guiding you to appropriate therapies.
Cleveland Clinic Physician: I would say similarly to those with multiple sclerosis, I would recommend utilizing alpha lipoic acids, fish oil, acupuncture and making sure that his vitamin D levels are between 50 to 80. Given the autoimmune component, if his symptoms continue to be significant after implementing the above, consider being evaluated for intestinal impermeability.
Alternative Therapy for Ménière Disease
loveitaly: I have had Ménière disease since I was in my teens, but at the time of its occurrence I was never diagnosed with it. They treated it with prednisone, antihistamines, etc. It disappeared for more than 30 years. In 2008 ,it reappeared, with severe tinnitus, hearing loss, pressure in the ears and severe vertigo. I received three injections of cortisone in the ear and eventually it subsided, In 2009 I had the same situation, three more cortisone injections, oral prednisone, diazepam, and vestibular rehabilitation. Again, it went and came back in 2010. I underwent the same process again, until September 2010 when they put me in betahistine dihydrochloride (Serc®)—a non-FDA approved medication here in the U.S., but a medication that has been used over 40 years in Europe, South America, Canada and Mexico. It was a blessing. I was vertigo free until March 3 of this year. It came back stronger—many times in the same day. I underwent cortisone injections again, etc. I have to finalize vestibular testings to then decide what are we going to do, but the next step surely will be the injection of gentamicin to kill my vestibular system. I am not pleased with this idea, and many sources have been telling me to try acupuncture, cranial-sacral therapy, manual lymphatic drainage massage, etc. saying it does work. Can you please provide your input? It has been very disabling for me. I have not been driving in the past four months. I am only 58 years and the main caregiver of a family member with severe disabilities.
William_Welches,_DO,_PhD: I agree with your friends who suggested you try acupuncture or cranial sacral therapy before you agree to gentamicin treatment. I am a certified acupuncturist and use cranial-sacral therapy as part of my osteopathic practice. However, Cleveland Clinic has many fine acupuncturists on staff, so you should have no trouble finding help in that area. Craniosacral therapists are a bit harder to find, since I am only aware of a handful of practitioners. I am not familiar with manual lymphatic drainage, but I also would be very interested in that technique as an alternative to ‘killing’ my vestibular system. You bring up a problem I have with medications. Patients almost always develop a tolerance to medications and with time they stop working. Medications can be useful and essential, but almost always work best in a context of multiple therapies—including what we call ‘alternative’.
Therapy for Syringomyelia
ssnerwood: I have syringomyelia. The pain begins in my lower right neck area, goes through my shoulder area and continues down my right arm. I have already experienced a loss of temperature sensation in my right side. I am currently taking Ultram® (tramadol) and Neurontin® (gabapentin). Do you have any suggestions on different courses of action?
William_Welches,_DO,_PhD: Both Dr. Edwards and I recommend acupuncture for a wide range of conditions. It is likely that with 4,000 years of history the Chinese physicians had to treat everything we see today.
Treatment of Pain After Knee Surgery
Valeria: Why do I continue to have knee pain even though I had surgery one year ago? Since then I had my knee drained three times and had three cortisone shots, but the pain is still there. Why, and what should I do about this?
William_Welches,_DO,_PhD: I am assuming that you have already spoken with the surgeon who did the replacement. You need to make sure that the replacement appears normal. The next thing to look at are musculoskeletal problems that arise as a result of the replacement. Total knee replacements are well understood and generally the surgeons do a good job, but a replaced knee is never the same as the original. When you exercise on the knee your stance may be a bit off. You may be applying asymmetric force down through the joint. Problems may reach up into the pelvis and the lumbar region. A manual medicine approach like osteopathic manipulation therapy or similar protocols may help. Further physical therapy may be indicated. I would recommend the anti-inflammatory diet to help control the some of the pathology in the knee.
andreead: Is there any scientific evidence behind acupuncture? Has it been proven to work or is it a hoax?
Cleveland Clinic Physician: There are over 500 published articles on acupuncture for pain. The conclusions for an overwhelming majority of the research studies show that acupuncture is very effective for pain relief.
William_Welches,_DO,_PhD: Acupuncture is an ancient, empirical Chinese technique. It has a history of enormous clinical experience, but only recently have the rules of Western science been applied to it. The language surrounding acupuncture is poetic and mythological because it was developed in a time before the scientific method was used.
andreead: Is pain relief the only use for acupuncture?
William_Welches,_DO,_PhD: Acupuncture can treat just about any condition you can think of. There are protocols for hypertension, diabetes, stress, urinary frequency and on and on. Acupuncture is holistic, and considers the entire individual in the treatment. So, there would be no single treatment for diabetes, for example, but there would be general patterns. Interestingly, the ancient Chinese physicians were forever going on about diet and exercise as well.
JJ1234: What is ‘moxa’ (moxibustion) acupuncture?
Cleveland Clinic Physician: Moxa acupuncture is utilizing the herb moxa, which is burned at the acupuncture site or placed on the acupuncture needle after is inserted. It has been shown in a few studies to improve the acupuncture outcome for certain conditions.
Chinese Herbal Medicine with Acupuncture
loveitaly: Do you use Chinese medicine in conjunction with the acupuncture? I consulted an acupuncturist and he complements his acupuncture with Chinese herbs. My internal medicine doctor agrees with me doing the acupuncture, but he is not O.K. with the Chinese herbs, since they can interact with some medications I currently take.
William_Welches,_DO,_PhD: Your physician is right. The use of Chinese herbals is a very complicated science in itself for the reason you give—not to mention toxicity. The Chinese study herbal medicine at universities there. Like acupuncture it requires a large commitment from the therapist. Being a physician I am very wary of herbals, not because they don't work—they do, but they also come with side effects and contraindications.
Alpha Lipoic Acid
WaveWolf: I am using R-alpha lipoic acid for neuropathic pain in my lower legs that is from neurosarcoidosis. I had been taking 100 mg daily, but found greater relief when I doubled this dose. In researching the recommended dosage, I found information at: http://www.ncbi.nlm.nih.gov/pubmed/20421656 Based on the currently available evidence, when given intravenously at a dosage of 600 mg once daily over a period of three weeks, alpha lipoic acid leads to a significant and clinically relevant reduction in neuropathic pain (grade of recommendation A). It is unclear if the significant improvements seen after three to five weeks of oral administration at a dosage of 600 mg or more daily are clinically relevant. Is an oral dose of value, and how much is recommended?
William_Welches,_DO,_PhD: This question is outside my expertise. However, I tend to be pragmatic and believe that the most important measure of a pain reliever is the response of the patient. My only concern with oral medications are side effects and unintended consequences.
Valeria: What is an anti-inflammatory diet?
Cleveland Clinic Physician:
An anti-inflammatory diet includes:
- Eliminating meat, dairy products, butter and even margarine because of their pro-inflammatory fats (saturated and trans). Most processed foods are also high in these fats. Protein sources should be fish, nuts, seeds and beans. Eggs from high omega-fed hens also are good (such as Eggland’s Best or Land-O-Lakes).
- Increase sources of Omega-3 fatty acids in the diet, which include flax seeds, walnuts and cold water fish (see chart). Omega-3 is also found in fish oil supplements 2,000-6,000 milligrams per day (must be refrigerated if in liquid form). GNC Triple Strength Fish Oil or Lovaza® are recommended.
- Increasing fruits and vegetables to eight to 10 servings per day. Choose low glycemic index (or load) items. Spices, such as turmeric, ginger, rosemary and basil, as well as tea (white, green and black) have anti-inflammatory effects.
- Grains, if eaten, should have the highest fiber and protein content possible. This lowers their glycemic index.
hdw669: Do you have any literature (including what to have or avoid) for the anti-inflammatory diet?
William_Welches,_DO,_PhD: There are numerous books in the popular culture that appear to be reasonable. I use the suggestions from Dr. David Rakel’s Integrative Medicine book as well as some reference papers from the scientific literature.
tom50: Are there recommended websites for anti-inflammatory diets?
William_Welches,_DO,_PhD: I have no recommended websites and if you find one let me know.
Meditation for Chronic Pain
lightning#: Do you see meditation as helpful with chronic pain? What do you think of ‘facing down’ the pain as in making the effort to feel into it? Is there a technique suggested for this, say hypnotherapy?
Cleveland Clinic Physician: There have been multiple control trials that reveal the pain relief effects of deep relaxation. Those trials include research on hypnosis, guided imagery, cognitive behavioral therapy, support groups, meditation and breath work. One of these approaches may be more beneficial to a particular patient, depending on that patient's unique preference.
William_Welches,_DO,_PhD: Meditation is one of the most underused effective therapies I am aware of. Meditation techniques vary, and so far I haven't run into a bad one.
Safety and Efficacy of Alternative Therapy
jetty: I have severe leg pain due , which I was told is due to my spine being out of alignment. I went to a chiropractor three times a week for one month, with little to no results. I gave up. Did I give up too soon, or are there some things that can't be helped with 'alternative treatments'?
William_Welches,_DO,_PhD: If the treatment, chiropractic or osteopathic doesn't show results after a reasonable period of time I would stop with that therapist. You might want to try at least one more manual medicine person before you give up. This holds true for acupuncture as well.
leap frog: Before taking over-the-counter herbal supplements for pain, etc., how do you know which ones are safe? How do you know which ones react with other medications? Is there a place where you can go to get this kind of information?
Cleveland Clinic Physician: A good place to begin may be www.nccam.nih.gov, www.herbmed.org , dietarysupplementdatabase.usda.nih.gov, www.fda.gov/AboutFDA/CentersOffices/OfficeofFoods/CFSAN/ and www.nlm.nih.gov/medlineplus/vitamins.html. These websites should provide you with the information you need on herbal supplements.
Coordination of Care with Integrative Medicine
callie: If I am interested in trying alternative therapies for pain management of my arthritis. Can this be done through my regular physician or do I need to see a specialist? Also, if I do need to see a specialist, do they work with my physician?
Cleveland Clinic Physician: More physicians these days are including alternative practices in their treatment of patients. Some, however, have no interest. I would recommend discussing this with your physician, to see what he or she would recommend. You may also consider utilizing many of the recommendations posted throughout this web chat. If your pain remains a significant issue, then seeing an integrative medicine physician at Cleveland Clinic may be very helpful. We work very closely with primary care physicians.
Cleveland Clinic Integrative Medicine
loveitaly: Are all these alternative treatments offered at Cleveland Clinic Florida, or only in Ohio?
William_Welches,_DO,_PhD: I am unaware of the therapies offered at Cleveland Clinic Florida. However, any primary care osteopathic physician should be able to either perform osteopathic manipulation therapy or tell you who to go to. Interestingly, family practice osteopathic physicians are also often aware of acupuncture or who to recommend.
Moderator: I'm sorry to say that our time with Cleveland Clinic expert William Welches, DO, PhD is now over. Thank you both for taking your time to answer our questions today about wellness approaches to managing pain.
Cleveland Clinic Physician: Thanks for chatting with us today. These were great questions!
William_Welches,_DO,_PhD: I've also enjoyed chatting with you today. Good luck in finding relief of your pain!
To make an appointment with the specialists in our Center for Integrative Medicine at Cleveland Clinic, please call 216.986.HEAL (4325). You can also visit us online at www.clevelandclinic.org/integrativemedicine.
To make an appointment with William Welches, MD or any of the other specialists in our Department of Pain Management at Cleveland Clinic, please call 216.444.PAIN(7246) or 800.392.3353. You can also visit us online at clevelandclinic.org/painmanagement
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