The 7 Approaches To Pain Management
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More Than One Way To Kill Pain
This is Dr. Deepak Ravindran (MD, FRCA. FFPMRCA, EDRA. FIPP, DMSMed). He has decades of experience and is a specialist in acute and chronic pain management, anesthesia, musculoskeletal medicine, and lifestyle medicine.
A quick catch-up, first:
We’ve written about chronic pain management before:
Managing Chronic Pain (Realistically!)
As well as:
Science-Based Alternative Pain Relief
Dr. Ravindran’s approach
Dr. Ravindran takes a “trauma-informed care” approach to his professional practice, and recommends the same for others.
In a nutshell, this means starting from a position of not “what’s wrong with you?”, but rather “what happened to you?”.
This seemingly subtle shift is important, because it means actually dealing with a person’s issues, instead of “take one of these and call my secretary next month”. Read more:
Pain itself can be something of a many-headed hydra. Dr. Ravindran’s approach is equally many-headed; specifically, he has a 7-point plan:
Medications
Dr. Ravindran sees painkillers (and a collection of other drugs, like antidepressants and muscle relaxants) as a potential means to an end worth exploring, but he doesn’t expect them to be the best choice for everyone, and nor does he expect them to be a cure-all. Neither should we. He also advises being mindful of the drawbacks and potential complications of these drugs, too.
Interventions
Sometimes, surgery is the right choice. Sometimes it isn’t. Often, it will change a life—one way or the other. Similar to with medications, Dr. Ravindran is very averse to a “one size fits all” approach here. See also:
The Insider’s Guide To Making Hospital As Comfortable As Possible
Neuroscience and stress management
Often a lot of the distress of pain is not just the pain itself, but the fear associated with it. Will it get worse if I move wrong or eat the wrong thing? How long will it last? Will it ever get better? Will it get worse if I do nothing?. Dr. Ravindran advises tackling this, with the same level of importance as the pain itself. Here’s a good start:
Stress, And Building Psychological Resilience
Diet and the microbiome
Many chronic illnesses are heavily influenced by this, and Dr. Ravindran’s respect for lifestyle medicine comes into play here. While diet might not fix all our ills, it certainly can stop things from being a lot worse. Beyond the obvious “eat healthily” (Mediterranean diet being a good starting point for most people), he also advises doing elimination tests where appropriate, to screen out potential flare-up triggers. You also might consider:
Four Ways To Upgrade The Mediterranean Diet
Sleep
“Get good sleep” is easy advice for those who are not in agonizing pain that sometimes gets worse from staying in the same position for too long. Nevertheless, it is important, and foundational to good health. So it’s important to explore—whatever limitations one might realistically have—what can be done to improve it.
If you can only sleep for a short while at a time, you may get benefit from this previous main feature of ours:
How To Nap Like A Pro (No More “Sleep Hangovers”!)
Exercise and movement
The trick here is to move little and often; without overdoing it, but without permitting loss of mobility either. See also:
The Doctor Who Wants Us To Exercise Less, And Move More
Therapies of the mind and body
This is about taking a holistic approach to one’s wellness. In Dr. Ravindran’s words:
❝Mind-body therapies are often an extremely sensitive topic about which people hold very strong opinions and sometimes irrational beliefs.
Some, like reiki and spiritual therapy and homeopathy, have hardly any scientific evidence to back them up, while others like yoga, hypnosis, and meditation/mindfulness are mainstream techniques with many studies showing the benefits, but they all work for certain patients.❞
In other words: evidence-based is surely the best starting point, but if you feel inclined to try something else and it works for you, then it works for you. And that’s a win.
Want to know more?
You might like his book…
The Pain-Free Mindset: 7 Steps to Taking Control and Overcoming Chronic Pain
He also has a blog and a podcast.
Take care!
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When A Period Is Very Late (Post-Menopause)
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Knowledge Is
PowerSafety, Post-Menopause TooNote: this article will be most relevant for a subset of our subscribership, but it’s a very large subset, so we’re going to go ahead and address the reader as “you”.
If, for example, you are a man and this doesn’t apply to you, we hope it will interest you anyway (we imagine there are women in your life).
PS: the appendicitis check near the end, works for anyone with an appendix
We’ve talked before about things that come with (and continue after) menopause:
- What You Should Have Been Told About The Menopause Beforehand
- What Menopause Does To The Heart
- Alzheimer’s Sex Differences May Not Be What They Appear
But what’s going on if certain menstrual symptoms reappear post-menopause (e.g. after more than a year with no menstruation)?
Bleeding
You should not, of course, be experiencing vaginal bleeding post-menopause. You may have seen “PSA” style posts floating around social media warning that this is a sign of cancer. And, it can be!
But it’s probably not.
Endometrial cancer (the kind that causes such bleeding) affects 2–3% of women, and of those reporting post-menopausal bleeding, the cause is endometrial cancer only 9% of those times.
So in other words, it’s not to be ignored, but for 9 people out of 10 it won’t be cancer:
Read more: Harvard Health | Postmenopausal bleeding: Don’t worry—but do call your doctor
Other more likely causes are uterine fibroids or polyps. These are unpleasant but benign, and can be corrected with surgery if necessary.
The most common cause, however is endometrial and/or vaginal atrophy resulting in tears and bleeding.
Tip: Menopausal HRT will often correct this.
Read more: The significance of “atrophic endometrium” in women with postmenopausal bleeding
(“atrophic endometrium” and “endometrial atrophy” are the same thing)
In summary: no need to panic, but do get it checked out at your earliest convenience. This is not one where we should go “oh that’s weird” and ignore.
Cramps
If you are on menopausal HRT, there is a good chance that these are just period cramps. They may feel different than they did before, because you didn’t ovulate and thus you’re not shedding a uterine lining now, but your body is going to do its best to follow the instructions given by the hormones anyway (hormones are just chemical messengers, after all).
If it is just this, then they will probably settle down to a monthly cycle and become quite predictable.
Tip: if it’s the above, then normal advice for period cramps will go here. We recommend ginger! It’s been found to be as effective as Novafen (a combination drug of acetaminophen (Tylenol), caffeine, and ibuprofen), in the task of relieving menstrual pain:
See: Effect of Ginger and Novafen on menstrual pain: A cross-over trial
It could also be endometriosis. Normally this affects those of childbearing age, but once again, exogenous hormones (as in menopausal HRT) can fool the body into doing it.
If you are not on menopausal HRT (or sometimes even if you are), uterine fibroids (as discussed previously) are once again a fair candidate, and endometriosis is also still possible, though less likely.
Special last note
Important self-check: if you are experiencing a sharp pain in that general area and are worrying if it is appendicitis (also a possibility), then pressing on the appropriately named McBurney’s point is a first-line test for appendicitis. If, after pressing, it hurts a lot more upon removal of pressure (rather than upon application of pressure), this is considered a likely sign of appendicitis. Get thee to a hospital, quickly.
And if it doesn’t? Still get it checked out at your earliest convenience, of course (better safe than sorry), but you might make an appointment instead of calling an ambulance.
Take care!
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Black Olives vs Green Olives – Which is Healthier
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Our Verdict
When comparing black olives to green olives, we picked the black olives.
Why?
First know this: they are the same plant, just at different stages of ripening (green olives are, as you might expect, less ripe).
Next: the nutritional values of both, from macros down to the phytochemicals, are mostly very similar, but there are a few things that stand out:
• Black olives usually have more calories per serving, average about 25% more. But these are from healthy fats, so unless you’re on a calorie-restricted diet, this is probably not a consideration.
• Green olives are almost always “cured” for longer, which results in a much higher sodium content often around 200% that of black olives. Black olives are often not “cured” at all.Hence, we chose the black olives!
You may be wondering: do green olives have anything going for them that black olives don’t?
And the answer has a clue in the taste: green olives generally have a stronger, more bitter/pungent taste. And remember what we said about things that have a stronger, more bitter/pungent taste:
Tasty Polyphenols: Enjoy Bitter Foods For Your Heart & Brain
That’s right, green olives are a little higher in polyphenols than black olives.
But! If you want to enjoy the polyphenol content of green olives without the sodium content, the best way to do that is not olives, but olive oil—which is usually made from green olives.
For more about olive oil, check out:
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The Hidden Risk of Stretching: Avoiding Hamstring Injuries in Yoga
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What is Yoga Butt
Have you ever experienced a mysterious pain while stretching, or perhaps during yoga? You might be dealing with “yoga butt,” a common—although rarely discussed—injury. In the below video, the Lovely Liv from Livinleggings shares her journey of discovering, and overcoming, “yoga butt”.
Dealing With Yoga Butt
Yoga butt, or proximal hamstring tendinopathy, occurs when the hamstrings are overstretched without adequate strengthening. Many yoga poses help stretch the hamstrings, but often don’t focus on strengthening said hamstrings; this imbalance is what can lead to damage over time.
To help prevent Yoga butt, it’s essential to balance stretching with strengthening. You can look into incorporating hamstring-strengthening exercises like Romanian deadlifts, hamstring curls, and modified yoga poses into your routine.
(If you’re new to strengthening exercises, we recommend reading Women’s Strength Training Anatomy Workouts or Strength Training for Seniors).
Watch the full video to learn more and hopefully protect yourself from long-term injuries:
Let us know your thoughts, and whether you have any other topics you’d like us to cover.
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Related Posts
A Correction, And A New, Natural Way To Boost Daily Energy Levels
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
First: a correction and expansion!
After yesterday’s issue of 10almonds covering breast cancer risks and checks, a subscriber wrote to say, with regard to our opening statement, which was:
“Anyone (who has not had a double mastectomy, anyway) can get breast cancer”
❝I have been enjoying your newsletter. This statement is misleading and should have a disclaimer that says even someone who has had a double mastectomy can get breast cancer, again. It is true and nothing…nothing is 100% including a mastectomy. I am a 12 year “thriver” (I don’t like to use the term survivor) who has had a double mastectomy. I work with a local hospital to help newly diagnosed patients deal with their cancer diagnosis and the many decisions that follow. A double mastectomy can help keep recurrence from happening but there are no guarantees. I tried to just delete this and let it go but it doesn’t feel right. Thank you!❞
Thank you for writing in about this! We wouldn’t want to mislead, and we’re always glad to hear from people who have been living with conditions for a long time, as (assuming they are a person inclined to learning) they will generally know topics far more deeply than someone who has researched it for a short period of time.
Regards a double mastectomy (we’re sure you know this already, but noting here for greater awareness, prompted by your message), a lot of circumstances can vary. For example, how far did a given cancer spread, and especially, did it spread to the lymph nodes at the armpits? And what tissue was (and wasn’t) removed?
Sometimes a bilateral prophylactic mastectomy will leave the lymph nodes partially or entirely intact, and a cancer could indeed come back, if not every last cancerous cell was removed.
A total double mastectomy, by definition, should have removed all tissue that could qualify as breast tissue for a breast cancer, including those lymph nodes. However, if the cancer spread unnoticed somewhere else in the body, then again, you’re quite correct, it could come back.
Some people have a double mastectomy without having got cancer first. Either because of a fear of cancer due to a genetic risk (like Angelina Jolie), or for other reasons (like Elliot Page).
This makes a difference, because doing it for reasons of cancer risk may mean surgeons remove the lymph nodes too, while if that wasn’t a factor, surgeons will tend to leave them in place.
In principle, if there is no breast tissue, including lymph nodes, and there was no cancer to spread, then it can be argued that the risk of breast cancer should now be the same “zero” as the risk of getting prostate cancer when one does not have a prostate.
But… Surgeries are not perfect, and everyone’s anatomy and physiology can differ enough from “textbook standard” that surprises can happen, and there’s almost always a non-zero chance of certain health outcomes.
For any unfamiliar, here’s a good starting point for learning about the many types of mastectomy, that we didn’t go into in yesterday’s edition. It’s from the UK’s National Health Service:
NHS: Mastectomy | Types of Mastectomy
And for the more sciency-inclined, here’s a paper about the recurrence rate of cancer after a prophylactic double mastectomy, after a young cancer was found in one breast.
The short version is that the measured incidence rate of breast cancer after prophylactic bilateral mastectomy was zero, but the discussion (including notes about the limitations of the study) is well worth reading:
Breast Cancer after Prophylactic Bilateral Mastectomy in Women with a BRCA1 or BRCA2 Mutation
❝[Can you write about] the availability of geriatric doctors Sometimes I feel my primary isn’t really up on my 70 year old health issues. I would love to find a doctor that understands my issues and is able to explain them to me. Ie; my worsening arthritis in regards to food I eat; in regards to meds vs homeopathic solutions.! Thanks!❞
That’s a great topic, worthy of a main feature! Because in many cases, it’s not just about specialization of skills, but also about empathy, and the gap between studying a condition and living with a condition.
About arthritis, we’re going to do a main feature specifically on that quite soon, but meanwhile, you might like our previous article:
Keep Inflammation At Bay (arthritis being an inflammatory condition)
As for homeopathy, your question prompts our poll today!
(and then we’ll write about that tomorrow)
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Elderly loss of energy
10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.
It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝Please please give some information on elderly loss of energy and how it can be corrected. Please!❞
A lot of that is the metabolic slump described above! While we certainly wouldn’t describe 60 as elderly, and the health impacts from those changes at 45–55 get a gentler curve from 60 onwards… that curve is only going in one direction if we don’t take exceptionally good care of ourselves.
And of course, there’s also a degree of genetic lottery, and external factors we can’t entirely control (e.g. injuries etc).
One factor that gets overlooked a lot, though, is really easy to fix: B-vitamins.
In particular, vitamins B1, B5, B6, and B12. Of those, especially vitamins B1 and B12.
(Vitamins B5 and B6 are critical to health too, but relatively few people are deficient in those, while many are deficient in B1 and/or B12, especially as we get older)
Without going so detailed as to make this a main feature: these vitamins are essential for energy conversion from food, and they will make a big big difference.
You might especially want to consider taking sulbutiamine, which is a synthetic version of thiamin (vitamin B1), and instead of being water-soluble, it’s fat-soluble, and it easily crosses the blood-brain barrier, which is a big deal.
As ever, always check with your doctor because your needs/risks may be different. Also, there can be a lot of reasons for fatigue and you wouldn’t want to overlook something important.
You might also want to check out yesterday’s sponsor, as they offer personalized at-home health testing to check exactly this sort of thing.
❝What are natural ways to lose weight after 60? Taking into account bad knees or ankles, walking may be out as an exercise, running certainly is.❞
Losing weight is generally something that comes more from the kitchen than the gym, as most forms of exercise (except HIIT; see below) cause the metabolism to slow afterwards to compensate.
However, exercise is still very important, and swimming is a fine option if that’s available to you.
A word to the wise: people will often say “gentle activities, like tai chi or yoga”, and… These things are not the same.
Tai chi and yoga both focus on stability and suppleness, which are great, but:
- Yoga is based around mostly static self-support, often on the floor
- Tai chi will have you very often putting most of your weight on one slowly-increasingly bent knee at a time, and if you have bad knees, we’ll bet you winced while reading that.
So, maybe skip tai chi, or at least keep it to standing meditations and the like, not dynamic routines. Qigong, the same breathing exercises used in tai chi, is also an excellent way to improve your metabolism, by the way.
Ok, back onto HIIT:
You might like our previous article: How To Do HIIT* (Without Wrecking Your Body)
*High-Intensity Interval Training (the article also explains what this is and why you want to do it)
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Mythbusting The Mask Debate
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Mythbusting The Mask Debate
We asked you for your mask policy this respiratory virus season, and got the above-depicted, below-described, set of responses:
- A little under half of you said you will be masking when practical in indoor public places
- A little over a fifth of you said you will mask only if you have respiratory virus symptoms
- A little under a fifth of you said that you will not mask, because you don’t think it helps
- A much smaller minority of you (7%) said you will go with whatever people around you are doing
- An equally small minority of you said that you will not mask, because you’re not concerned about infections
So, what does the science say?
Wearing a mask reduces the transmission of respiratory viruses: True or False?
True…with limitations. The limitations include:
- The type of mask
- A homemade polyester single-sheet is not the same as an N95 respirator, for instance
- How well it is fitted
- It needs to be a physical barrier, so a loose-fitting “going through the motions” fit won’t help
- The condition of the mask
- And if applicable, the replaceable filter in the mask
- What exactly it has to stop
- What kind of virus, what kind of viral load, what kind of environment, is someone coughing/sneezing, etc
More details on these things can be found in the link at the end of today’s main feature, as it’s more than we could fit here!
Note: We’re talking about respiratory viruses in general in this main feature, but most extant up-to-date research is on COVID, so that’s going to appear quite a lot. Remember though, even COVID is not one beast, but many different variants, each with their own properties.
Nevertheless, the scientific consensus is “it does help, but is not a magical amulet”:
- 2021: Effectiveness of Face Masks in Reducing the Spread of COVID-19: A Model-Based Analysis
- 2022: Why Masks are Important during COVID‐19 Pandemic
- 2023: The mitigating effect of masks on the spread of COVID-19
Wearing a mask is actually unhygienic: True or False?
False, assuming your mask is clean when you put it on.
This (the fear of breathing more of one’s own germs in a cyclic fashion) was a point raised by some of those who expressed mask-unfavorable views in response to our poll.
There have been studies testing this, and they mostly say the same thing, “if it’s clean when you put it on, great, if not, then well yes, that can be a problem”:
❝A longer mask usage significantly increased the fungal colony numbers but not the bacterial colony numbers.
Although most identified microbes were non-pathogenic in humans; Staphylococcus epidermidis, Staphylococcus aureus, and Cladosporium, we found several pathogenic microbes; Bacillus cereus, Staphylococcus saprophyticus, Aspergillus, and Microsporum.
We also found no associations of mask-attached microbes with the transportation methods or gargling.
We propose that immunocompromised people should avoid repeated use of masks to prevent microbial infection.❞
Source: Bacterial and fungal isolation from face masks under the COVID-19 pandemic
Wearing a mask can mean we don’t get enough oxygen: True or False?
False, for any masks made-for-purpose (i.e., are by default “breathable”), under normal conditions:
- COVID‐19 pandemic: do surgical masks impact respiratory nasal functions?
- Performance Comparison of Single and Double Masks: Filtration Efficiencies, Breathing Resistance and CO2 Content
However, wearing a mask while engaging in strenuous best-effort cardiovascular exercise, will reduce VO₂max. To be clear, you will still have more than enough oxygen to function; it’s not considered a health hazard. However, it will reduce peak athletic performance:
…so if you are worrying about whether the mask will impede you breathing, ask yourself: am I engaging in an activity that requires my peak athletic performance?
Also: don’t let it get soaked with water, because…
Writer’s anecdote as an additional caveat: in the earliest days of the COVID pandemic, I had a simple cloth mask on, the one-piece polyester kind that we later learned quite useless. The fit wasn’t perfect either, but one day I was caught in heavy rain (I had left it on while going from one store to another while shopping), and suddenly, it fitted perfectly, as being soaked through caused it to cling beautifully to my face.
However, I was now effectively being waterboarded. I will say, it was not pleasant, but also I did not die. I did buy a new mask in the next store, though.
tl;dr = an exception to “no it won’t impede your breathing” is that a mask may indeed impede your breathing if it is made of cloth and literally soaked with water; that is how waterboarding works!
Want up-to-date information?
Most of the studies we cited today were from 2022 or 2023, but you can get up-to-date information and guidance from the World Health Organization, who really do not have any agenda besides actual world health, here:
Coronavirus disease (COVID-19): Masks | Frequently Asked Questions
At the time of writing this newsletter, the above information was last updated yesterday.
Take care!
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