Topical Analgesics

David Leprich, DC
December 19, 2011
Written by David Leprich, DC
Most chiropractors would agree that our main goal is to help people live healthier lives. This is not always easy. Our definition of health may differ from the patient’s. They may not comply with our recommendations. There may be disagreement about how to maintain the benefits achieved through chiropractic care. The results are well worth the effort, but it would be nice to have some help.
It might make the job easier if we start with a definition of health. Good health is more than simply an absence of disease or pain. The World Health Organization defines it as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Dr. Halbert Dunn is acknowledged as the first to coin the term “wellness.” In his 1961 book High Level Wellness, he describes wellness as “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable of functioning within the environment.”

The McKinley Health Center, University of Illinois, defines wellness as “a state of optimal well-being that is oriented toward maximizing an individual’s potential. This is a life-long process of moving towards enhancing your physical, intellectual, emotional, social, spiritual, and environmental well-being.”

The role of pain
If you are a bit confused at this point, imagine how patients must feel! In many cases, all they wanted – the thing that made them come to you – was relief from back pain. Their perception that pain is the problem and not just a symptom is often a barrier to following through with appropriate care. However, I think we make a mistake by not acknowledging its importance in the process.

As an example, low back pain is one of the most common and costly health problems in North America. This complaint, along with neck pain and headache, motivates many to seek chiropractic care. However, a good initial chiropractic experience can help them decide on wellness as an approach to good health, so it is important that as practitioners, we don’t ignore the pain.

A growing body of research into the nature of pain provides information that is very useful in helping our patients. The International Association for the Study of Pain defines it as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” A quick look at the association’s website reveals 18 distinct pain classifications.
For chiropractors, and for those experiencing pain, the situation is much simpler. We both want the pain to disappear. The difference is that as healers, we seek to fix the problem that is causing the pain, while those in pain just want it to go away.

Strategies for providing pain relief
One of our duties is to teach patients how to be healthier. This may mean continuing care beyond the initial pain relief phase. This is easier to do if we are able to provide a light at the end of the tunnel through some immediate relief.

There are a number of tools at our disposal to help with this. A home stretch program may help reduce muscle spasm and ease pressure on inflamed joints. The proper use of cushions, braces and supports can speed recovery. Icing is recommended to reduce the pain and swelling of an acute injury. None of these tools replaces the treatment we provide as chiropractors, but they all enhance recovery and provide temporary relief for the patient.

Even better, they help to avoid, or minimize, the use of oral analgesics and anti-inflammatories. Far too often, we see people who are consuming alarming quantities and combinations of ibuprofen, acetaminophen and Naproxen. Admittedly, there are times these can be helpful in achieving the goal of a healthier patient but, unfortunately, many people use them as a substitute for proper care.
Fortunately, there is another tool that has very few side-effects, is much safer to use than oral analgesics and can be more effective.

Topical analgesics
Topical analgesics have been widely used for many years. In ancient Athens, the paidotribai (athletic therapists) used various oils to supplement massage treatments on athletes. Menthol, used in Japan more than 2000 years ago, was isolated from peppermint oil in 1771 by German physician Hieronymus Gaubius. At the turn of the 19th century in America, the first athletic trainers employed the combination of massage and a counterirritant to treat athletes.

One of the oldest producers of menthol and other topical applications, the Mentholatum Company, can trace its roots to Wichita, Kansas, where Albert Alexander Hyde founded the Yucca Company in 1889. After four years of research he introduced his very first Mentholatum Ointment, which is still available today as are other Mentholatum products.

When topicals were initially marketed, it was believed that cooling gels (those containing menthol) and the heating applications (those with capsaicin and methyl salicylate) mimicked the effects of ice and various heat sources, but the mechanism of action was poorly understood. More recent research has provided much better insight into what is happening at a cellular and molecular level.    
   
The science of topicals
The sensation of pain originates with stimulation of nerve endings. Myelinated A-delta fibres transmit pain signals faster and carry sharp pain. The slower, unmyelinated C fibres carry pressure and touch. Both fibres stimulate transmission and inhibition cells at the dorsal horn of the spinal cord. While there is some uncertainty as to how pain is modulated at the cord level, the gate theory, introduced by Melzack and Wall in 1965, is currently favoured. The A-delta fibres impede the inhibitory cells, leaving the gate of pain transmission up to the brain open. The slower C fibres excite the inhibitory cells, thus closing the gate. This is why we rub a sore or injured area. The pressure of the rub closes the gate and inhibits transmission of the pain signal to the thalamus.

This also helps explain the function and value of topical analgesics. Among the most common active ingredients found in topical analgesics are menthol, methyl salicylate, capsicum and trolamine salicylate. The effect of menthol is primarily due to its counterirritant properties. Menthol stimulates the C fibres (type 2) and this triggers stimulation of the inhibitory cells and the release of substance P. Once this substance is depleted, the pain signals are temporarily blocked. Capsicum works in a similar manner. When a pain signal is received within the brain, endorphins are released to the nerve endings. Trolamine salicylates are believed to relieve pain by inhibiting prostaglandins at a local level, much as ASA does systemically. A study published in Medicine and Science in Sports and Exercise (vol. 20(2)) found that trolamine salicylate penetrated well into underlying muscle tissue. It slowed the onset of soreness; reduced levels of soreness; and reduced duration of soreness.

There is another very good reason to consider the use of trolamine over oral analgesics. Researchers at the VA Medical Center in Philadelphia applied trolamine salicylate to the knees of dogs. They found that the dogs had 20 times as much salicylate in the underlying muscles as those who were given ASA orally. The oral salicylates resulted in higher blood levels, but dogs given a topical application received much more of the salicylate in their tendons, ligaments, cartilage, and joint cavities, where it would be far more effective in relieving pain and inflammation.

In clinical applications, a study published in the Open Orthopedics Journal in 2008 found that menthol was effective in the treatment of the muscle pain associated with tempero-mandibular joint (TMJ) disorders. The Journal of Chiropractic Medicine published a study in 2008 reporting that topical menthol combined with chiropractic adjustment showed significant reduction in low back pain.

All of these studies indicate that topical analgesics have an important role to play in the control of pain and a return to health.

Practical considerations
There are also a number of practical benefits to using these products.

Chiropractors often recommend applications of cold or heat to help control pain or to affect a response in the injured area. In the home, the patient can do this with ice, freezer packs, heating pads and hot water bottles. But, this is not practical for many occupational situations. For the long-distance trucker or office worker who often can’t follow this recommendation for long periods of time, a topical gel can be ideal.

If repeated applications of the selected product can help reduce or eliminate the use of oral analgesics and anti-inflammatories including non-steroidal anti-inflammatory drugs, the benefits are compounded. This can be vital in situations where oral analgesics are contraindicated such as when treating female patients who are pregnant or nursing.

Topical analgesic products have additional practical applications in the clinic as well. The Journal of Athletic Training published a study in 2001 that found that topical menthol gels combined with typical ultrasound gel can be effective as a coupling agent when applying therapeutic ultrasound.

Many chiropractors are using kinesio-taping techniques to aid in the treatment of soft-tissue injuries. Spray products, with an alcohol content of up to 90 per cent, can be effective as skin cleansing agents prior to applying the tape. In addition, the menthol included in most sprays helps reduce the discomfort that might accompany the application of the tape. 

Topical analgesics offer a safe and effective adjunct to chiropractic treatment. The pain relief they provide can give the patient a good reason to maintain care until the problem is resolved. They can prevent the often harmful side-effects of oral analgesics. They are convenient to use in a number of occupational and recreational situations and they are extremely cost effective. In my experience, the patients who have followed my advice to use a specific topical product have been very thankful and have maintained their health through chiropractic care.

Dr. David Leprich has practised in St. Catharines since graduating from CMCC in 1977. He is a member of the Board of Directors of the Canadian Chiropractic Research Foundation and has previously served as president of the Niagara Chiropractic Society, director of the Ontario Chiropractic Association and president and chairman of the board of the Canadian Chiropractic Association. He is the theatre chiropractor for the Shaw Festival Theatre in Niagara-on-the-Lake and a chiropractic consultant to the Niagara Health System and Mentholatum Canada.


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