Common Tread

Alternatives to manage chronic pain and keep on riding

Sep 26, 2017

Earlier, we explored a variety of options for managing acute pain, the aftermath of “weekend warriorism.” The flip side of this coin is chronic pain.

Chronic pain often accompanies serious injury from which you recover, and in particular seems tied to bone and joint injury for many. Chronic pain is not limited to the old, but afflicts the young as well, from surviving combat veterans injured in Afghanistan or Iraq to the victims of violence cared for at trauma centers.

Chronic pain shares many features with other conditions, like arthritis, and those who had suffered joint injuries are often said to have “post-traumatic arthritis.” The joint hurts, does not move as well as it should, and is frequently swollen. Other chronic pain sufferers have had soft tissue and nerve injury. There is a vast spectrum of causes for chronic pain as well as a variety of chronic pain syndromes.  

Regardless of which variety you have, management often embraces one of the following approaches: physical therapy, anti-inflammatory agents, opioids, anticonvulsant agents (for which there are a host of potential side effects), sometimes steroids, or transcutaneous nerve stimulation. Yes, some people have chronic pain from auto-immune disorders (your body attacks itself) like rheumatoid arthritis. That discussion is more complex and may involve monoclonal antibodies like the one mentioned in my article on anticoagulant medications.

Instead, we will focus on those who have chronic pain after injury. Opioids are frequently prescribed for these patients to manage their disabling pain, and these patients are part of the U.S. “opioid epidemic” that has led to increased scrutiny of licensed prescribers and their practices.

A U.S. Air Force doctor uses acupuncture on an airman to treat chronic pain. U.S. Air Force photo.

Alternatives for treating chronic pain

You want to keep riding, but are concerned about how meds will affect your safety. What alternatives do you have? There are a number of non-traditional, non-opioid approaches available to help keep you safely and comfortably riding. Perhaps not an Iron Butt ride, but OK for a day ride. Your doctor can help you access the things above, so instead we will look at things not typical for your regular doctor to consider: acupressure, acupuncture, yoga, and video gaming. Two are derived from Traditional Chinese Medicine (TCM) practices, one is more globally Eastern, and one is just pure fun.

Accupressure and acupuncture both rely on TCM energy meridians. Both are associated with improved pain compared to control subjects who did not get the treatment. More research has been devoted to acupuncture and there is specific licensure for those who do it. Back and neck pain, osteoarthritis and headache all seem to benefit from acupuncture (more than 50 percent pain relief). Nonetheless, some organizations advocate against using acupuncture for osteoarthritis (UK National Institute for Health and Care Excellence [NICE], and the American Academy of Orthopedic Surgeons). NICE does, however, recommend acupuncture for headache that does not respond to medical management. So why not osteoarthritis? Well, we do have a variety of other therapies for osteoarthritis, including surgery. Also, at least in Western medicine, the precise mechanism of acupuncture remains elusive, according to a clinical synopsis published in the Journal of the American Medical Association.

The mechanism makes perfect sense in the Far East, I suspect, and reflects rebalancing a person’s energy or “qi” along specific energy lines. Indeed, the World Health Organization considers auricular (ear) therapy a form of acupuncture that can affect the entire body. Auricular therapy can include typical acupuncture needles or acupressure. Acupressure is more widely used in China than the United States. It would appear that more U.S. insurance plans are covering acupuncture than in previous years, especially for chronic pain. Most recommendations are to use acupressure or acupuncture as an adjunct to pain control, rather than a standalone therapy.

Yoga proponents claim that it works like acupuncture — by balancing and promoting flow through energy meridians. Alternatively, yoga’s ability to enhance flexibility, increase local blood flow, and improve core strength are all well documented. Many years past, my MSF instructor often barked at his much younger class that “as we age we all become crunchy, can’t turn our necks, and then have to ride Harleys.” That speaks to the lack of flexibility that accompanies aging, osteoarthritis and injury. Yoga — yes, you can do it in the privacy of your home using a video guide — also increases endorphins (natural pain killers), eases pain, and improves balance, posture, core strength, and most importantly, flexibility. To wit, modern home fitness courses often include yoga as part of the regimen (i.e. P 90X and others). Reduced range of motion is a frequent cause of stiffness after being seated and can even cause falls when navigating obstacles, like getting your leg over your bike.

Insurance companies do not cover video gaming, and certainly not virtual reality rigs. Evidence that video gaming may help with chronic pain comes from injured kids and injured soldiers who reported less pain when gaming and immediately thereafter. One notion is that players are “distracted” from their pain. A second is that the more intense the game, the more endorphins are released. Virtual reality seems to be a natural extension, where the experience is truly immersive and allows the player to explore “pleasant and engaging” experiences that translate into less pain after the experience. This therapy has been used for burn patients, those with incomplete spinal cord injury, pediatric chronic headache, as well as pain-related fear and chronic disability.

Why does this work? Is it just distraction? Likely not. It seems that the human brain can “unlearn” chronic pain (at least in part). Chronic pain seems to make some very specific changes in your brain’s wiring. Cognitive behavioral therapy (CBT), perhaps similar to VR distractions, appears to beneficially alter how different parts of your brain connect to one another, in effect, rewiring your circuitry. These can be tracked using special neurologic imaging techniques called “functional neuroimaging.” Regardless, CBT is much more than VR diversion and includes improving coping skills and changing activity patterns, including enhanced exercise, activity pacing, and keeping a pain diary. This multimodal approach seems to be able to change brain connections and reduce the intensity and disabling features of chronic pain. 

Acupressure, acupuncture, and yoga have all worked for me (not so crunchy, but I do ride a Harley). Yoga remains a regular part of my regimen, since it is easy to do on my own, is low cost, and can be done virtually anywhere.

What works for you?