ENVIRONMENT

Chemical products in our homes, other internal environments and in the external environment have been shown to be directly or indirectly responsible for causing or exacerbating pain symptoms.

They include room sprays, perfumes, cleaners, household chemicals, soap, some carpets, air and water pollutants, commercial laundry detergents and fabric conditioners, household cleaners, air fresheners, fragrant candles and personal toiletries

Environmental factors or gene-environment interactions are likely to play a pivotal role in disease pathogenesis (how disease develops). (‘Unifying Mechanisms of Neurological Disorders: Scientific, Translational, and Cli’, University of Arkansas Med scis - Lttle Rock)

plastic food containers and water bottles

Polychlorinated biphenyls (PCB)

Man-made chemicals that never existed in nature until the 1900's when they started to be released into the environment by manufacturing companies and consumers. First manufactured by Monsanto (the only American company to manufacture PCBs) in 1929, PCB's were quickly acclaimed as an industrial breakthrough.

PCBs were used for many different industrial purposes, including electronic components, hydraulic fluids; casting wax; carbonless carbon paper; compressors; heat transfer systems; plasticizers; pigments; adhesives; liquid cooled electric motors; fluorescent light ballasts

The manufacture of PCBs has been banned since 1977 in the USA and the highest human exposures to these compounds occur via the consumption of contaminated fish and in certain occupational setting via contact with pre-1977 equipment.

• Joint pain occurs in 11% of workers exposed to PCB-containing mixtures (ATSDR 2000a). This rate is similar to the 10% incidence of unspecified joint pain reported in farm families who consumed beef and dairy products contaminated with PCBs (ATSDR and EPA 1998).

(U.S. Department of Health and Human Services Environmental Alert)

• Signs of PCB exposure can include weight loss, anorexia, nausea, vomiting, jaundice, and abdominal pain. Headache, dizziness, and edema have also been reported

(U.S. Department of Health and Human Services Environmental Alert)

Pesticides

• People became ill when their home or place of employment was treated with a pesticide (Dursban). Symptoms included chronic complaints of fatigue, headaches, dizziness, loss of memory, upper and lower respiratory symptoms, joint and muscle pain and gastrointestinal disturbances. (Archives of Environmental Health, 48(2):89-93, March/April 1993 - Department of Health Science at California State University)

Mould (household)

The scientific literature supports the possibility of neurotoxicity with extended exposure to repeated water intrusions and moldy household interior surfaces.  

• After relocation to a domicile subject to repeated water intrusions from a poorly designed roof and periodic ground flooding, she developed pain, difficulty with concentration and memory, headaches, light sensitivity, sleep disorder, depression, and weight gain.

Visible mold, and mold counts elevated more than three times the recommended limit at more than one site in the domicile were found,. . . Stachybotrys chartarum.

Mayo Clinic diagnosed her with fibromyalgia. Elevated mycotoxin antibodies were found.

(Forensic Evaluation of a Mold (Repeated Water Intrusions) Neurotoxicity Case. Archives of Clinical Neuropsychology, 2005,Volume 20, Issue 7,

pp. 808)

Environmental factors or gene-environment interactions are likely to play a pivotal role in disease pathogenesis (influence how disease develops).

ETHNICITY

People with red hair are more sensitive to pain and consequently need more anaesthetic during operations than other patients

• New Scientist - Red heads suffer more pain

People with naturally red hair are resistant to subcutaneous local anesthetics

• Genetic Variations Associated With Red Hair Color and Fear of Dental Pain, Anxiety Regarding Dental Care and Avoidance of Dental Care - Catherine J. Binkley, DDS, MSPH, PhD, Abbie Beacham, PhD, William Neace, PhD, Ronald G. Gregg, PhD, Edwin B. Liem, MD and Daniel I. Sessler, MD  - J Am Dent Assoc, Vol 140, No 7, 896-905

GENDER

Sleep continuity disturbance impairs endogenous pain-inhibitory function and increases spontaneous pain in women. This supports a possible pathophysiologic role of sleep disturbance in chronic pain, according to a study in the April 1 issue of the journal Sleep.

• Sleep Disturbance Increases Spontaneous Pain in Women
• (ADVANCE for Respiratory Care and Sleep Medicine)

• Romano JM, Turner JA, Clancy SL. Sex differences in the relationship of pain patient dysfunction to spouse adjustment. Pain 1989;39:289-95.

DIET / NUTRITION

Pesticides

You can lower your pesticide consumption by nearly four-fifths by avoiding the 12 most contaminated fruits and vegetables and instead eating the least contaminated produce, according to EWG calculations. When you eat the 12 most contaminated fruits and vegetables, you’ll be exposed to an average of 10 pesticides a day. When you choose fresh produce from the 15 least contaminated fruits and vegetables, you’ll consume fewer than 2 pesticides per day.

• Shoppers Guide to Pesticide by the Environmental Working Group
• Full List: (49 fruits and vegetables)
• Complete details of all pesticide measurements (USDA and FDA Data)

Food Intolerance

Gluten:

• Study Reveals Problem of Gluten Sensitivity (video by  the Wall Street Journal)

Wheat Germ Agglutinin (WGA): Found in wheat (even organic) at quantities of about one microgram per grain. Amongst many adverse effects, it promotes inflammation. “WGA binds to N-Acetylglucosamine which is believed to function as an atypical neurotransmitter functioning in nocioceptive (pain) pathways.” (Green Med)

WGA stimulates the synthesis of pro-inflammatory chemical messengers (cytokines) in intestinal and immune cells and be associated with inflammation in the intestines.

• Effects of wheat germ agglutinin on human gastrointestinal epithelium: insights from an experimental model of immune/epithelial cell interaction (Toxicol Appl Pharmacol. 2009 Jun 1;237(2):146-53. Epub 2009 Mar 28)
• Lectin glycosylation as a marker of thin gut inflammation (The FASEB Journal. 2008;22:898.3)
• 3 Ounces of This a Day May Be Harming Your Brain (Dr Mercola)

Food additives

Aspartame

• The Effect of Aspartame on Migraine Headache - Shirley M. Koehler M.S. Alan Glaros Ph.D. - Journal of Head and Face Pain 2005. DOI: 10.1111/j.1365-2524.1988.hed2801010.x
• Controlled, double-blind, randomized cross-over study (“The results of this study indicated that the ingestion of aspartame by migraineurs caused a significant increase in headache frequency for some subjects”)
• Direct and indirect cellular effects of aspartame on the brain -  Humphries P, Pretorius E, Naudé H. - Eur J Clin Nutr. 2008 Apr;62(4):451-62. Epub 2007 Aug 8. (“… the wood alcohol in aspartame is converted into formaldehyde and then to formic acid, which in turn causes metabolic acidosis. The methanol toxicity is thought to mimic the symptoms of multiple sclerosis … symptoms of fibromyalgia, spasms, shooting pains, numbness in the legs, cramps, vertigo, dizziness, headaches, tinnitus, joint pain, depression, anxiety, slurred speech, blurred vision or memory loss have been attributed to aspartame.” )
• Relief of Fibromyalgia Symptoms Following Discontinuation of Dietary Excitotoxins,The Annals of Pharmacotherapy: Vol. 35, No. 6, pp. 702-706.  Jerry D Smith, Chris M Terpening, Siegfried OF Schmidt, and John G Gums (“The elimination of MSG and other excitotoxins from the diets of patients with fibromyalgia offers a benign treatment option that has the potential for dramatic results in a subset of patients”).
• Aspartame-induced fibromyalgia, an unusual but curable cause of chronic pain - Ciappuccini R, Ansemant T, Maillefert JF, Tavernier C, Ornetti P. - Department of Rheumatology, Dijon University Hospital, Burgundy University, Faculty of Medicine, Dijon, France. (“...practitioners should ask patients suffering from fibromyalgia about their intake of aspartame. In some cases, this simple question might lead to the resolution of a disabling chronic disease”)
• Joint pain associated with aspartame use - H. J. Roberts, M.D - Results: Joint pain was a major complaint in 58 (10.5%) of 551 aspartame reactors. Its convincing association with aspartame is derived from the following clinical evidence.                        
•    * These patients suffered "severe joint pain" as a recent complaint, requiring analgesics in most instances.
•     * They also experienced many of the symptoms reported by other aspartame reactors.
•     * Both the join pain and nonrheumatic complaints subsided when aspartame-containing products were avoided...generally within several days or weeks. The most notable exceptions were severe visual and neuropshychiatric disturbances.
•     * These symptoms promptly and predictably recurred on rechallenge with aspartame, known or inadvertent.
•     The average age was 45 years. Females outnumbered males 3:1

Sulphites

Sulphites are widely used as preservatives in the food and pharmaceutical  industries.  They can be found in wines, dried fruits (as preservative), dried potato products, shrimp (sometimes treated with sulphites on fishing vessels but may not appear on the labels)

Sulphites are used in increasing amounts as a food preservative or enhancer. They may come in various forms, such as:[“Allergies: Sulfite Sensitivity". WebMD.]

  * Sulfur dioxide,which is not a sulphite, but a closely related chemical oxide.

  * Potassium bisulfite or potassium metabisulfite

  * Sodium bisulfite, sodium metabisulfite or sodium sulfite

• “In the United States more than 250 cases of sulfite-releted  adverse reactions, including anaphylactic shock, asthmatic attacks, urticaria and angioedema, nausea, abdominal pain and diarrhea t seizures and death, have been reported, including 6 deaths allegedly associated with restaurant food containing sulfites.” (Adverse Reactions to Sulfites, Can Med Assoc J. 1985 November 1; 133(9): 865-867, 880)

DRUGS / MEDICATION

Bisphosphonates (class of drugs that prevent the loss of bone mass, used to treat osteoporosis, for treating hypercalcemia of malignancy and Paget's disease and similar diseases) eg Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), Atelvia (risedronate delayed release), Didronel (etidronate), and Skelid (tiludronate)

Temporary or permanent discontinuation of bisphosphonate therapy should be considered in patients who present with severe musculoskeletal pain

(Oral Osteoporosis Drugs (bisphosphonates) are also involved in Potential Increased Risk of Esophageal Cancer)

• Bisphosphonate Therapy Linked to Risk for Severe Musculoskeletal Pain - January 2008

Pain killers

Painkillers May Raise Risk of Dangerous Heart Flutter Drugs.com

• NSAIDs and atrial fibrillation:
• BMJ 2011;343:doi:10.1136/bmj.d2495 (Published 4 July 2011)

Healthy people who take NSAIDs to relieve minor aches and pains at risk of death from heart problems.

• Cause-Specific Cardiovascular Risk Associated With Nonsteroidal Antiinflammatory Drugs Among Healthy Individuals:
• Circulation: Cardiovascular Quality and Outcomes - Journal of the American Heart Association

Overuse of medication including those for treating headaches can actually lead to ‘Medication Overuse Headaches’ (MOH) and ‘Probable Medication Overuse Headaches’ (PMOH).

“Educational initiatives should emphasize that the newer specific acute migraine medications (triptans) may also be associated with PMOH.”

• Meskunas, C. A., Tepper, S. J., Rapoport, A. M., Sheftell, F. D. and Bigal, M. E. (2006),
• Medications Associated with Probable Medication Overuse Headache Reported in a Tertiary Care Headache Center Over a 15-Year Period.
• Headache: The Journal of Head and Face Pain, 46: 766–772. doi: 10.1111/j.1526-4610.2006.00442.x

Acetaminophen (Paracetamol)toxicity usually involves 4 phases: 1) anorexia, nausea, vomiting, malaise, and diaphoresis (which inappropriately may prompt administration of additional acetaminophen); 2) resolution of phase-1 manifestations and replacement with right upper quadrant pain or tenderness, liver enlargement, elevated bilirubin and hepatic enzyme concentrations, prolongation of prothrombin time, and occasionally oliguria;

• American Hospital Formulary Service. AHFS Drug Information. Human Toxicity Excerpts - American Society of Health-System Pharmacists, Bethesda, MD. 2007., p. 2182] **PEER REVIEWED**

EMOTIONS

Crying (with sadness)

A crying episode triggered by sadness or emotional distress may cause migraine headaches in some patients.

But crying triggered by happiness, peeling onions, or a sad movie does not necessarily have the same effect.

• Headache 1998;38:799-800.

LIFESTYLE

Sleep

Poor sleep quality correlated with higher levels of depressive symptoms, greater pain severity, increased fatigue, and greater functional disability in patients with Rheumatoid Arthritis (RA). The study suggests that addressing sleep problems have a critical impact on the health and lives of patients with Rheumatoid Arthritis.

• Improving Sleep Quality Eases Disability In Rheumatoid Arthritis Patients
• Sleep Quality and Functional Disability in Patients with Rheumatoid Arthritis, American Academy of Sleep Medicine , Feb 2011

Sleep deprivation is a common contributor to frequent headaches, and lack of sleep can lead to problems handling stress, which then generates more stress, and again interferes with sleep.

Many had sleep-related pathologies, including sleep apnea, periodic limb movements, psycho-physiological insomnia and fibromyalgia. They were more likely to have excessive daytime sleepiness severe enough to interfere with their work.

When appropriately treated, headaches disappeared in the OSA patients and in 40 percent of periodic limb movements patients. The headaches were decreased in frequency in fibromyalgia and insomnia patients.

• Lamberg, L. (Feb. 24, 1999). Chronic pain linked with poor sleep; Exploration of cause and treatment. JAMA. 281(8): 691.

• James R. Weintraub, DO Sleep & Pain - ADVANCE for Nurses -

Treatment must focus on alleviation of both the pain and sleep disturbance.

• Sleep and pain: interaction of two vital functions - Semin Neurol. 2005 Mar;25(1):106-16

Sleep Disturbance Increases Spontaneous Pain in Women

Sleep continuity disturbance impairs endogenous pain-inhibitory function and increases spontaneous pain in women. This supports a possible pathophysiologic role of sleep disturbance in chronic pain.

•  According to a study in the April 1 issue of the journal Sleep.

• (ADVANCE for Respiratory Care and Sleep Medicine)

Relationships

Spouses of chronic pain patients are at risk for emotional and marital maladjustment.

• Romano JM, Turner JA, Clancy SL. Sex differences in the relationship of pain patient dysfunction to spouse adjustment. Pain 1989;39:289-95.

Cigarettes

Cigarette Smoking Impairs Ligament Healing

Cigarette smoking delays the healing process and increases morbidity associated with many common musculoskeletal disorders such as medial collateral ligament (MCL) injury.

• Gill CS, Sandell LJ, El-Zawawy HB, Wright RW. Effects of cigarette smoking on early medial collateral ligament healing in a mouse model. Journal of Orthopaedic Research, vol. 24, pp. 2141-2149. Dec. 2006.

Former and current heavy smokers are more likely to report more pain locations and more intense pain than never smokers.

Tobacco smoking in relation to pain in a national general population survey

• John U, Hanke M, Meyer C, Völzke H, Baumeister SE, Alte D. Prev Med. 2006 Dec;43(6):477-81. Epub 2006 Sep 1.

Regular smoking in adolescence was associated with Low Back Pain in young adults. Pack-years of smoking showed an exposure-response relationship among girls.

Is smoking a risk factor for low back pain in adolescents? A prospective cohort study

• Paula Mikkonen, Päivi Leino-Arjas, Jouko Remes, Paavo Zitting, Simo Taimela, Jaro Karppinen Spine (2008) Volume: 33, Issue: 5, Pages: 527-532 ,  PubMed: 18317198, DOI 10.1097/BRS.0b013e3181657d3c

Chronic Low Back Pain smokers appear to be at greater risk of thinking about suicide than nonsmoking CLBP patients. The risk of suicide ideation is even greater if the CLBP patient is a heavy smoker and has problems with alcohol.

Are chronic low back pain patients who smoke at greater risk for suicide ideation?

• Fishbain DA, Lewis JE, Gao J, Cole B, Steele Rosomoff R. Pain Med. 2009 Mar;10(2):340-6. Epub 2009 Feb 25, DOI 10.1111/j.1526-4637.2009.00570.x

People suffering from temporomandibular disorder (TMD) suffer more pain if they are smokers. A correlation was found between pain intensity and the number of cigarettes smoked in a day (ie the more cigarettes are smoked, the more intense the pain is)

Effect of cigarette smoking on pain intensity of TMD patients: a pilot study

• Melis M, Lobo SL, Ceneviz C, Ruparelia UN, Zawawi KH, Chandwani BP, Mehta NR. Cranio. 2010 Jul;28(3):187-92  (Craniomandibular Pain Center, Tufts University, USA) PMID: 20806737 [PubMed - indexed for MEDLINE]

OTHER

Look

Look At Your Body To Reduce Pain

Simply looking at your body reduces pain, according to new research by scientists from UCL (University College London) and the University of Milano-Bicocca, Italy.

• Flavia Mancini, Matthew R. Longo1, Marjolein P.M. Kammers and Patrick Haggard1
• ‘Visual distortion of body size modulates pain perception', Psychological Science, Feb 2011

Straining at stools

Straining at stools can precipitate migraine headaches.

Screwing the eyeballs tight-shut or keeping the mouth open or manual self-compression of the eyeballs (or any combination of these maneuvers) can prevent development of such headaches. Such pressure-related intraocular aberrations have no conceivable link to CSD. Migrainous SS is also likely linked to a pressure-related retinal aberration. As the use of statins becomes widespread, the link between constipation and migraine will become more apparent.

• Gupta V .
• Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review . WebmedCentral NEUROLOGY 2010;1(12):WMC001433