Despite the high frequency of spinal related pain disorders, few patients or physicians understand or even acknowledge the role nutrition plays in pain perception. This presentation will explain the anatomy of the most common spinal structures responsible for being sources of pain. The lecture will also examine the robust role diet plays in increasing or decreasing the perception of pain.

1. DIET AND
CHRONIC SPINAL
PAIN
DR. PAUL RALSTON
HEALTHWISE CHIROPRACTIC

2. NOT-PALEOPALEO

3. CHRONIC PAIN
“HE HAS SEEN BUT HALF THE
WORLD WHO HAS NOT
BEEN SHOWN THE HOUSE
OF PAIN”
RALPH WALDO EMERSON

5. PAINFUL STATS
• A RECENT INSTITUTE OF MEDICINE REPORT FINDS CHRONIC PAIN
AFFECTS MORE THAN 100 MILLION PATIENTS
• THE ESTIMATED COSTS OF TREATING PAIN IS BETWEEN $560-$635
BILLION ANNUALLY, OR $2000 PER PERSON PERYEAR
• IN A RECENT STUDY BY THE GLOBAL BURDEN DISEASE 2010
PROJECT, LOW-BACK PAIN HAS BECOME THE NUMBER ONE CAUSE
OF DISABILITY WORLDWIDE
• LOWER BACK PAIN IS ALSO THE NUMBER TWO CAUSE OF MISSED
DAYS AT WORK
• EVEN FIRST LINE PHARMACOLOGICAL INTERVENTION FOR PAIN IS
NOT WITHOUT RISK
• ACCORDING TO A STUDY OF 1990’S STATISTICS IN THE UNITED
STATES, 32,000 HOSPITALIZATIONS AND 3,200 DEATHS OCCUR EACH
YEAR AS A RESULT OF NSAID-RELATED GI BLEEDING

6. INFLAMMATION
• ANY DISCUSSION OF PAIN WILL INVOLVE A DESCRIPTION OF
INFLAMMATION
• IN GENERAL, INFLAMMATION IS DESCRIBED AS EITHER ACUTE OR
CHRONIC AND HAS BEEN CLASSIFIED INTO THREE PHASES,THE
ACUTE INFLAMMATORY PHASE,THE REPAIR PHASE,AND THE
REMODELING PHASE
• HOWEVER, IN REAL LIFE,THE INFLAMMATORY PROCESS HAS NO
REAL BOUNDARIES
• IN MANY CASES, ACUTE INFLAMMATION DOES NOT RESOLVE AND
BECOMES CHRONIC; HOWEVER, CHRONIC INFLAMMATION CAN
DEVELOP FROM THE START WITHOUT ACUTE INJURY
• IN BOTH CASES, INFLAMMATION IS A CHEMICAL EVENT, SO IT IS
IMPORTANT TO HAVE A FAVORABLE BIOCHEMISTRY IN THE EVENT
OF INJURY,WHETHER IT IS AN INFECTION OR SOFT TISSUE INJURY

7. INFLAMMATORY
MESSENGERS
• MANY INFLAMMATORY AND ANTI-INFLAMMATORY MESSENGERS
EXIST IN THE BODY
• PRO-INFLAMMATORY EICOSANOIDS ARE DERIVED FROM FATTY
ACIDS AND INCLUDE PGE-2,TXA-2, LTB-4
• PRO-INFLAMMATORY AMINO ACID/PEPTIDE MEDIATORS KNOWN AS
CYTOKINES INCLUDE HISTAMINE, IL-1, IL-6,TNF, SUBSTANCE P
• HOWEVER, EICOSANOIDS AS WELL AS CYTOKINES CAN ALSO BE
ANTI-INFLAMMATORY (PGE-I, PGE-3, LTB-5, IL-4, IL-10)
• UNDERSTANDING AND IDENTIFYING THE ROLE AND BALANCE OF
THEVARIOUS CHEMICAL MEDIATORS OF THE BODY CAN AID US IN
OUR MANAGEMENT OF CHRONIC PAIN AND INFLAMMATION
• IT’S BECAUSE OF THESE INFLAMMATORY CYTOKINES THAT OBESITY
BECOMES MORE OF A CHEMICAL PROBLEM THAN A MECHANICAL

9. NOCICEPTON
• NOCICEPTION IS THE TERM FOR THE NERVOUS SYSTEM
COMMUNICATING NOXIOUS STIMULATION
• THE RECEPTORS FOR NOXIOUS STIMULI ARE CALLED
NOCICEPTORS, PAIN IS HOWYOUR BODY PERCEIVES THESE STIMULI
• ONCE STIMULATED, NOCICEPTORS SEND THIS INFORMATION TO
THE BRAIN AND THE END RESULT CAN BE THE SUBJECTIVE
EXPERIENCE OF PAIN
• THE THRESHOLD OF NOCICEPTORS IS KNOWN AS SENSITIZATION
AND THIS THRESHOLD CAN BE LOWERED; CALLED NOCICEPTIVE
SENSITIZATION
• DUE TO THE NEUROPLASTICITY OF THE NERVOUS SYSTEM,
NOCICEPTIVE SENSITIZATION CAN OCCUR, RESULTING IN
HYPERALGESIA,AN INCREASED SENSITIVITY TO PAIN
• AGAIN,WE’RE GETTING CHEMICAL RESPONSES IN THE BODY WITH
EVERY MOVEMENT, SO IT’S IMPORTANT TO HAVE A FAVORABLE
CHEMISTRY IN THE EVENT OF INJURY

10. DISC ANATOMY
• THE INTERVERTEBRAL DISC CONSISTS OF THE INNER NUCLEUS
PULPOSUS,THE TOUGHER, OUTER ANNULUS FIBROSIS,AND THE
VERTEBRAL END PLATES
• THE NUCLEUS IS A MORE WATER-RICH STRUCTURE IN THE CENTER
OF THE DISC AND IS UNDERVERY HIGH PRESSURE, ESPECIALLY WHEN
YOU ARE SITTING OR STANDING
• THE ANNULUS IS A MUCH TOUGHER COLLAGEN-RICH STRUCTURE
WHICH IS RESPONSIBLE FOR RESISTING THE HIGHLY PRESSURIZED
NUCLEUS
• THEVERTEBRAL END PLATES, DESPITE THEIR NAME,ARE ACTUALLY
NOT ATTACHED TO THEVERTEBRAE BUT ARE INTERWOVEN INTO
THE DISC AND CONSIDERED PART OF THE DISC
• THE SINUVERTEBRAL NERVES INNERVATE THE POSTERIOR THIRD OF
THE ANNULUS AND CONTAIN AUTONOMIC AND SENSORY NERVE
FIBER

11. NORMAL DISC
ANATOMY

12. DISC
DEGENERATION
• THE NORMAL DISC IS CONSIDERED THE LARGEST AVASCULAR
STRUCTURE IN THE BODY
• IT HAS NO BLOOD SUPPLY AND RELIES ON NUTRITION THROUGH
THEVASCULAR BEDS OF THE END PLATE AND GETS ITS LIMITED
NUTRITION THROUGH PASSIVE DIFFUSION
• BECAUSE OF THE POOR BLOOD SUPPLY,THE DISC IS
EXCEPTIONALLY PRONE TO DEGENERATIVE CHANGES AND IN FACT
BEGINS TO LOSE BLOOD SUPPLY WITHIN THE FIRST DECADE OF LIFE
• THE PARTIAL LOSS OF BLOOD SUPPLY LEADS TO PREMATURE DEATH
OF THE PROTEOGLYCANS RESPONSIBLE FOR MAINTAINING THE
HYDROSTATIC PRESSURE WITHIN THE DISC
• THE ULTIMATE RESULT IS THE TRANSFER OF AXIAL FORCES TO THE
OUTER ANNULUS AS WELL AS THE POSTERIOR FACET JOINTS

13. DISC
DEGENERATION
• ONE OTHER PROCESS THAT LEADS TO PREMATURE DEGENERATION
OF THE DISC IS GLYCATION
• GLYCATION OCCURS WHEN REDUCED SUGAR COMES INTO
CONTACT WITH THE COLLAGEN FIBERS (PROTEIN) OF THE DISC,
RESULTING IN CROSSLINKING
• THE END RESULT IS A THICKER, MORE BRITTLE SUBSTANCE MORE
SUSCEPTIBLE TO DEGENERATION

14. DISCOGENIC PAIN
• INTERNAL DISC DISRUPTION IS THE MOST COMMON CAUSE OF
LOWER BACK PAIN
• BOGDUK ESTIMATES 40% OF CHRONIC BACK PAIN IS CAUSED BY
RADIAL ANNULAR TEARS
• RADIAL TEARS ARE OFTEN PRECEDED BY DISC DEGENERATION AND
BEGIN IN THE INNER ANNULUS AND PROGRESS OUTWARD
• ONCE A RADIAL TEAR REACHES THE OUTER LIMITS OF THE
ANNULUS IT CAN BREAK THROUGH
• THE RESULTING NUCLEAR MATERIAL IS HIGHLY INFLAMMATORY
AND INFLAMMATORY CYTOKINES SOAK THE SINUVERTEBRAL
NERVES RESULTING IN LOW BACK PAIN AND OFTEN LOWER
EXTREMITY PAIN (SCIATICA)
• IN ADDITION,WITH DISC HERNIATION,THE HYDROSTATIC
PRESSURE IS REDUCED, CAUSING MORE LOAD TO BE PLACED ON
THE OUTER ANNULUS WHICH CONTAINS THE ALREADY INFLAMED
NERVES

15. ANNULAR TEARS

16. TRANSVERSESAGITTAL
ANNULAR TEARS

17. YOUR BRAIN ON
PAIN
• IS THE PAIN JUST INYOUR HEAD?
• A RECENT DOUBLE BLIND, RANDOMIZED, CONTROLLED TRIAL
SHOWED IMPROVED OUTCOME AFTER LUMBAR
MICRODISCECTOMY IN PATIENTS WHO WERE SHOWN THEIR
EXCISED DISC FRAGMENTS J Neurol Neurosurg Psychiatry. 2009 Sep;80(9):1044-6. doi: 10.1136/jnnp.2008.
• IN ANOTHER STUDY, 34 COLLEGE STUDENTS WERE TOLD AN
ELECTRIC CURRENT WOULD PASS THROUGH THEIR HEADS AND
HEADACHES ARE A COMMON SIDE EFFECT. DESPITE NO CURRENT
BEING USED, MORE THAN 2/3 DEVELOPED HEADACHES Headache. 2003 Nov-Dec;
43(10):1113-5.
• EXPECTATION EFFECTS DEPEND AS MUCH ON WHAT HAPPENS
IN THE SPINE AS WHAT HAPPENS IN THE BRAIN, THIS HAS
IMPORTANT IMPLICATIONS FOR CLINICAL PRACTICE Pain. 2007 Jul;130(1-2):
137-43. Epub 2007 Jan 9.

18. PSYCHOGENIC PAIN
• CAN OCCUR WHEN THE PSYCHOLOGIC STATE SUCH AS ANXIETY
OR DEPRESSION FACILITATES NOCICEPTIVE PATHWAYS
• RECENT RESEARCH HAS SHOWN INCREASED LEVELS OF CRP IN
PATIENTS WITH PTSD AND INTERPERSONALVIOLENCE
• LEVELS OF PRO-INFLAMMATORY CYTOKINES HAVE BEEN IMPLICATED
IN DEPRESSION AND MOOD DISORDERS
• IN ADDITION, DUE TO THE NEUROPLASTICITY OF THE CENTRAL
NERVOUS SYSTEM, SELF DEFEATING BELIEFS AND
CATASTROPHIZATION CAN INTERACT WITH THE PAIN REDUCING
NEURAL NETWORKS RESULTING IN CHRONIC PAIN
• OFTENTIMES THE ORIGINAL INJURY HAS HEALED, BUT CONTINUED
BELIEFS,ANTICIPATION OF PAIN, FEAR,AND ANXIETY CAN CREATE
CHRONIC PAIN AND INFLAMMATION
• PATIENTS CAN COME UNRAVELED ONYOU WHENYOU TELL THEM
THEY WILL NEVER BE ABLE TO DO (X) AGAIN

20. THE ANTI-
INFLAMMATORY DIET
• BASICALLY AN AUTO-IMMUNE PALEO PROTOCOL
• FISH, PASTURED MEAT,WILD GAME
• VEGETABLES AND FRUIT,WITH THE EXCEPTION OF THE
NIGHTSHADE FAMILY
• SWEET POTATOES AND OTHER NON-NIGHTSHADE TUBERS
• RAW NUTS
• MOST SPICES, ESPECIALLY TURMERIC, GINGER AND GARLIC
• DARK CHOCOLATE (GREATER THAN 75% CACAO)
• DON’T LET THE PHARMACEUTICAL INDUSTRY FRUSTRATEYOU OR
YOUR PATIENTS

21. ANTI-INFLAMMATORY
SUPPLEMENTATION
• THE FOLLOWING NUTRIENTS CAN BE TAKEN DAILY TO
SUPPLEMENT AN ANTI-INFLAMMATORY DIET
• VITAMIN D3
• PROBIOTICS (GI SYMPTOMS HAVE BEEN ASSOCIATED WITH BACK
PAIN)
• EPA/DHA
• MAGNESIUM GLYCINATE (ANIMAL RESEARCH INDICATES LOW
LEVELS OF MAG CREATE LONG TERM SENSITIZATION OF THE
NOCICEPTIVE PATHWAYS)
• TURMERIC, GINGER
• PROTEOLYTIC ENZYMES SUCH AS TRYPSIN, CHYMOTRYPSIN,AND
BROMELAIN CAN BE USED AS AN ANTI-INFLAMMATORY, BUT
RESEARCH IS DIVIDED ON THEIR EFFICACY

22. CHRONIC PAIN
PRESCRIPTION
• ANTI-INFLAMMATORY DIET
• ANTI-INFLAMMATORY SUPPLEMENTS
• AVOID LUMBAR FLEXION FOR AT LEAST 2 HOURS AFTER WAKING
• AVOID PROLONGED SITTING
• AVOID MECHANICAL POSTURES, MOTIONS,AND LOADS THAT
CAUSEYOU PAIN
• IFYOU NEED TREATMENT, PROGRESS FROM CONSERVATIVE
(CHIROPRACTIC,ACUPUNCTURE, PHYSICAL THERAPY, MASSAGE,
ETC.) TO INVASIVE (DRUGS, INJECTIONS, SURGERY)