Published in the California Journal of Oriental Medicine, Fall 2004
Non-steroidal anti-inflammatory drugs (NSAIDs) relieve pain most effectively the first time they are taken, however, when taken daily they lose their effectiveness. Increasing the dosage or changing to stronger pain pills may bring temporary relief, but soon even these strategies fail to be effective. In such cases even acupuncture fails to give lasting relief for this pain. Few sufferers realize that this formula for failure they are experiencing known as rebound pain, results from their use of NSAIDs (aspirin, ibuprofen, naproxen and acetaminophen). The cause of rebound pain will be explained in the following article.
In order to discuss rebound pain, a fundamental understanding of tissue repair is helpful. Western medicine identifies three healing stages for injuries great and small (note 1). When these three stages of healing proceed naturally, healing progresses quickly. However, when healing is disrupted, problems abound: specifically, poor circulation of blood and lymph, as well as chronic pain and its associated disability. During tissue repair, fresh blood brings nutrients and oxygen to provide material for healing and the lymph removes the byproducts of tissue repair. As pain becomes chronic, it is often accompanied by stiffness and reduced range of motion. The use of pain pills to relieve chronic pain often backfires. The resulting rebound pain causes or plays a role in several chronic pain syndromes such as fibromyalgia, chronic muscle pain syndrome, and chronic fatigue syndrome.
The Three Stages of Healing
The three stages of healing are:
- Cell proliferation
Scar tissue normally forms during the first two stages of healing.
1) During the initial inflammatory stage, which lasts three to five days, prostaglandins initiate multiple tasks: to stimulate the immune system, to buildup platelets around the lesion, and to attract white blood cells that protect against infections and clean up the damaged tissue. Specialized cells called fibroblasts produce disorganized fibrous (scar) tissue.
2) During the second stage, which lasts four to six weeks, cells proliferate to replace the damaged cells and scar tissue becomes organized. Physical activity eliminates unnecessary scar tissue that has inadvertently adhered to neighboring tissue.
3) During the remodeling stage, lasting about six months or more, the repaired tissue remodels itself. Interestingly forensic anthropologists and archeologists observe changes in bone structure, for example, to determine the types of work a person performed based on the fact that remodeling is an automatic process accompanying use. During the third stage of healing this process can restore damaged tissue so it is stronger than it was before the injury. If remodeling doesn’t occur, it leads to weakened tissue prone to reinjury.
Injuries are an opportunity to become stronger. When the three stages proceed normally, tissue becomes stronger and less prone to injury. This principle is used by performance athletes. Likewise, pain is rare if the damage heals quickly and thoroughly, without abnormal adhesions.
What Is Scar Tissue?
The fibrous connective tissue produced during the initial inflammatory stage serves to temporarily replace damaged tissue during the first stage of healing. Scar tissue lacks oil glands and elasticity. By contrast, healthy tissue is elastic and lubricated, which protects it against irritation. It is the nature of scar tissue to contract over time and become sensitive as pain nerves enter the aging scar tissue. (note 2) This sensitivity prolongs the period of inflammation and results in the formation of excessive scar tissue. Muscles become fibrous as a result of chronic inflammation. Scar tissue reduces and blocks the circulation of fresh blood, carrying nutrients and oxygen, and the flow of lymph, which carries away toxins. This vicious cycle of continued scar formation can thus increase pain, reduce circulation, and restrict movement.
As pain nerves penetrate scar tissue, it becomes hypersensitive to stimulation. This makes it easy to find during massage because the pain response indicates the scar tissue with its hypersensitive nerves. An acupuncturist can also feel the presence of recent and old scar tissue by feeling the resistance to the needle. Healthy tissue offers no resistance and feels like it is soft and lubricated.
Other Causes of Scar Tissue
From my clinical experience, there are many causes of fibrous, sclerotic tissue in the musculo-skeletal system. In-depth discussions with patients about the history of their pain have revealed treatments with trendy therapies such as icing, cortisone injections, and NSAIDs, all of which alter and inhibit healing by blocking prostaglandin production. Prostaglandins are produced during the first stage of healing to protect and repair the damaged tissue. They protect by delivering a pain message and by sensitizing the area or injury to keep from further injury. They initiate a host of repair activities that are required during the healing process.
Intentional scarring therapy (sclerotherapy) is sometimes used to treat chronic pain. This involves local injections, especially of the steroid anti-inflammatory cortisone; the more cortisone administered, the more scarring of subcutaneous tissue. Patients who have received cortisone shots often report more painful acupuncture-needle insertions at the injury site. Relief for them will also require more acupuncture treatments than if cortisone was not used. Cortisone injections have also been shown to dematerialize bone and cause soft tissue to become fragile. (note 3)
One of the therapeutic actions of cortisone is tissue necrosis. Injections at the site of inflammation kills the inflamed tissue sending out pain signals. My interviews with surgeons indicate scar tissue present at the site of cortisone injections. Basically, washing inflamed tissue with cortisone kills it, and it is replaced by scar tissue. At first this brings quick relief, but in about three months pain nerves enter the aging scar tissue as it shrinks. This vicious cycle spreads to surrounding tissue, resulting in reduced mobility and the return of more intense and intractable pain.
Unintentional scarring can also result from the application of cold to relieve pain. My interviews with patients having a history of athletic injuries often revealed a pattern of stiff and painful tissue in areas where icing was used to relieve pain after athletic events. The more often icing was used, the more resulting tissue stiffness was discovered and the more subsequent treatments with needle moxa were required to restore the circulation of blood and lymph.
Although no statistics are available, a survey of the history of medicine from around the world suggests that traditionally, though pain was an uncomfortable problem, chronic pain was rare. (note 4) Prior to the 20th century, the method of treating pain was dramatically different. In the past, chronic pain was treated with counterirritants (irritation applied to the surface of the body to counteract pain and disease), such as mustard and medicinal plasters. Since the discovery of aspirin and the increased use of anti-inflammatories, there has been an increased incidence of chronic pain. Chronic pain is reported to be most common in countries where anti-inflammatories are used extensively. In Third World countries where time-honored means of treating pain are employed, chronic pain is rare. (note 5)
Many recent studies have associated NSAIDs with chronic pain, especially degeneration of joint cartilage. (note 6) Basically the inhibiting effect of NSAIDs that applies to muscle healing also applies to cartilage repair. The use of anti-inflammatories heightens the incidence of chronic pain. Treating pain while disrupting the healing process results in a build up of painful scar tissue, which can also interfere with the functioning of muscles by scarring proprioceptors.
Proprioception & Tension Receptors
The simple act of walking upright is actually not so simple; it is still a challenge for robot designers. When our body’s ability to sense its position and orientation – known as proprioception – becomes impaired, our ability to move quickly and accurately degrades and our athletic performance suffers. One facet of proprioception is the product of our muscles’ tension receptors, dysfunction of which can also cause chronic pain. Knowing how to locate and heal tension receptors using massage and acupuncture can quickly and permanently reverse years of chronic pain where other attempts to heal brought only temporary relief.
If the muscles become scarred and fibrous, tension receptors in the muscle belly do not readily change shape with the muscle, resulting in delayed or absent responses. When this happens, the brain fails to register the degree of muscle contraction. Consequently, the brain’s signal to contract is increased, causing spasms and/or continuous muscle tension.
When a muscle is either tense or constantly tight it may have fibrous, stiff, and frozen tension receptors. Even when the patient believes they are relaxed, the muscle is tight. It is tight when they go to sleep and tight when they wake up. Deep-tissue massage and acupressure on the origin, insertion, or belly of the muscle can forcefully change the shape of the tension receptor and the muscle will relax temporarily, but constant tightness will return because the tension receptor has not changed. Massage and meditation will fail to relax this type of muscle. Stretching can temporarily reset the tension level, but tension will return. Therefore, the use of massage, acupuncture and moxibustion can correct the chronic tension that often accompanies chronic pain.
Rebound pain is paradoxically caused by NSAIDs. NSAIDs stop the first stage of healing by blocking the production of prostaglandins. Bradykinin is one type of prostaglandin that increases pain sensitivity by ten times and speeds healing by five times. (note 7) In other words NSAIDs inhibit healing and the subsequent stages of healing are thus compromised. Rebound pain begins after 4-8 days of continual NSAID usage and slowly increases until it becomes the major component of chronic pain. It is a type of withdrawal pain and may be diagnosed as fibromyalgia (FMS), fibrositis, chronic muscle pain syndrome, psychogenic rheumatism, tension myalgias, and chronic fatigue syndrome (CFS). It is my belief that FMS is fibrosis of the soft tissue often complicated by rebound pain.
Rebound pain probably develops because NSAIDs mask small pain signals that cause us to squirm and wiggle or adjust how we sit and stand. These adjustments to our posture stop tissue damage from the pressure applied to joints and muscles when we sit or stand still. When people stop using pain pills, they temporarily feel their body trying to heal this damage in their joints and muscles. Some patients tell me they cannot stop using the drugs they take because their pain is so bad, but when they do stop, they often have a remarkable reduction in their pain.
A Formula for Success
Acupuncture can initiate a healing process with puncture wounds where healing had been incomplete or interrupted by NSAIDs, cortizone or icing. It is interesting to note that regeneration, the ability to regrow limbs for example, which happens in lower life forms is absent in higher life forms with one exception, the healing of puncture wounds. Local treatments at sites of sensitivity called ahshi points stimulate or restimulate healing as described in the three stages of healing. Therefore, when a patient suffers from chronic pain which doesn’t respond to acupuncture treatments, ask them to reduce and eventually stop pain pills.
Explain to your patients how NSAIDs, cortizone or icing all interfere with healing, which impede the effectiveness of therapeutic approaches such as acupuncture, acupressure, and massage. Acupuncture, however, can be used as a complementary method to quickly end rebound pain when NSAIDs are discontinued. Ear acupuncture is commonly used in detox programs and can restore the body’s natural pain relievers, endorphins. Local treatment with needle moxa therapy on scarred fibrous tissue eliminates the cause of chronic pain. (See “Treating Chronic Pain with Meridian Dredging“ by Michael Turk in CJOM 14.2, Summer 2003)
1a) Wells, D. “Injury: Three Stages of Healing” in CJOM 14.1 winter 2003
1c) The Encyclopedia Britannica CDROM refers to four stages of healing. The first stage is divided in two: one lasts for one day and the second part the typical 3-5 days.
2a) Singh, Vijay, MD “Pathophysiology of the Disc” in Interventional Pain Management
2b) Encyclopedia Britannica CDROM
3) Diwan, P., “Influence of Zinc Sulfate on Steroid Depressed Wound Healing,” Kulkarni, D. InsJPharmac., 11(4), 257-264 (1979)
4) The following statistics indicate the trend toward high rates of chronic pain in the USA
1973 “Although accurate statistics are not available, data from a variety of sources suggest that chronic pain states cost the American people between 10 and 25 billions of dollars annually” (The Puzzle of Pain by Ronald Melzack 1973).
1973 The first world conference on pain estimated 10 million Americans suffer from chronic pain. (The Conquest of Pain by Samuel Mines 1973).
1980 40 million Americans suffer; it is the third leading cause of disability (Pain Control, the Bethesda Program by Bruce Smoller, M.D. & Brian Schulman, M.D. 1980).
1983 “Authorities figures prepared for the year 1983 estimated that 90 million Americans suffered from chronic pain, that 60 million Americans were either partially or totally disabled… (The Culture of Pain by David Morris 1991).
5) Dr. Brand lived and worked in India for many years. He reports that chronic pain was rare p185-190. Brand, P. The Gift of Pain 1997 Zondervan
“Frantic attempts to silence pain signals may actually have a paradoxical effect.”
“My esteem for pain runs so counter to the common attitude that I sometimes feel like a subversive, especially in modern Western countries. On my travels I have observed an ironic law of reversal at work: as a society gains the ability to limit suffering, it loses the ability to cope with what suffering remains. (It is the philosophers, theologians, and writers of the affluent West, not the Third World, who worry obsessively about ‘the problem of pain,’ and point an accusing finger at God.)”
6a) Werbach, M. Nutritional Influences on Illness. Third Line Press, California, (468, 469, 590), 1987
6b) see bibliography at http://www.unitedmedicalnetwork.com/umnrationale_joint.asp
6c) Lopes Vaz AL. Double-blind, clinical evaluation of the relative efficacy of ibuprofen and glucosamine sulphate in the management of osteoarthrosis of the knee in out-patients. Curr Med Res Opin 1982;8:145-9.
6d) Dingle JT., Cartilage maintenance in osteoarthritis: interaction of cytokines, NSAID and prostaglandins in articular cartilage damage and repair. J Rheumatol Suppl. 1991 Mar;28:30-7.
7) From a private communication with Dr. Bruce Pomerantz who has been studying the role of Bradykinin in healing.
8) Turk, M. “Treating Chronic Pain with Meridian Dredging” in CJOM 14.2, Summer 2003
1) Chang, Yeung, Chung Through-and-through & Collective Loci Acupuncture 1976, Medical Interflow Publishing House
2) Chen Xingseng “Comparative Study on Acupuncture Needling Methods for Sciatica: Routine Needling Vs. Point-to-point and Deep Puncture” in American Journal of Acupuncture Vol. 26 No.1 1998.
3) Lowenkopf, Anne N. Osteopuncture 1976 Medical Arts Press
4) Brand, Paul, The Gift of Pain 1997 Zondervan
5) Turk, Michael Pain’s Healing Secret 2001 Chico, CA: Acu Press