JANUARY 1, 2008 BY CHIROTRUST Neck sprains that result from a whiplash injury are not simple problems like a sprained ankle because the neck is involved in a lot of important duties other than simple movement. One such function of the neck is to keep you upright and balanced. Balance is complex and involves coordination between your brain and sensations in your inner ear, your eye movements, and neurological signaling from your neck, spine, and legs. If any of these areas is affected, then balance is disturbed. You may stumble around more or not really have a sense of where your feet are. In severe cases, you may develop vertigo (a spinning sensation). These symptoms can have a devastating effect on your quality of life. A 2007 study funded by an insurance company (Coll Antropol 2007;31:823) looked at how individuals sense the position of the head following a whiplash injury when compared with normal healthy controls. The results were alarming. Patients with a cervical spine injury showed significant impairment of proprioception (sense of position). Chiropractic care for the whiplash patient can involve treatments aimed to normalize joint function in the neck. Adjustments are designed to restore normal mobility and improve the posture of the neck so that it is more balanced and can move and heal properly. In addition to spinal manipulation, some patients may need specific exercises, even balance therapy, to help improve their sense of position and keep them from feeling dizzy. So, if you’re feeling unsteady, or are not really sure on your feet, this could be a consequence of a whiplash injury. Because both the brain and neck can be injured in whiplash, the symptoms can be quite substantial. Hoping it will go away on its own with bed rest or not moving the neck can lead to muscle weakness and possibly even more problems.
MAY 27, 2012 BY CHIROTRUST Fibromyalgia (FM) is a very common cause of chronic pain and fatigue. It’s plagued with the combination of not knowing what causes it (in many cases) and, the fact that very few treatments seem to work. Also, patients often relay information about a “bad experience” with a doctor who down plays the diagnosis or worse, outwardly denies that it even exists! This makes it all the more challenging for the patient who is simply just trying to find answers as to how to manage living with this condition. Chiropractic offers the patient a “quarterback” or, someone who can coordinate care (when needed) from different health care providers, as well as offer the patient a very effect treatment option. In one study, chiropractic spinal manipulation was used in conjunction with ischemic compression with results measured by tracking pain, fatigue levels and sleep quality by the use of validated questionnaires completed by the patient. In this 24 FM patient trial (members were recruited from a regional Fibromyalgia Association group), the subjects had symptoms for >3 months, and a total of 30 treatment were performed. After the first 15 treatments, about 2/3rds of the subjects reported significant improvement (questionnaire score improvements of at least 50%) in the pain, fatigue and sleep quality! Even better, after 30 treatments, there was a 77% reduction in pain intensity, 64% improvement in sleep quality, and 75% reduction in fatigue level scores. Moreover, these improvements were maintained even a month after treatment ended. Also, they found that subjects with less than 35% improvement after 15 treatments did not have a satisfactory response after the 30 treatments. A trend (though not statistically significant) suggested that older subjects with more severe symptoms and chronic pain tended to do have a greater number of tender points, and responded more poorly to treatment. The conclusion reported this favorable response deserves a larger scaled study. So, what you can expect when you arrive for treatment? The first “order of business” is to obtain your health history, paying particular attention to your specific treatment goals. This is also the time when we review your daily activities and quantify your activity tolerance so we can properly compare your current (baseline) level of function to future re-evaluations. Part of the assessment may include measuring your physical performance, although that entirely depends on your level of function at the time of the initial examination. Usually, after 2-3 treatments and after reviewing your response to the treatments, we will begin incorporating home-based exercises or if you’re already exercising, augment your current program. These exercises may include stretching, core stabilizing strengthening exercises, balance training, aerobic exercises, and others. Depending on your confidence with exercise and, of course, your goals, other forms of exercise may also be recommended such as yoga, Palates, water exercises, health club programs, and/or others. We may recommend various modalities such as electric stimulation, ultrasound, pulsed magnetic stimulation, low level laser therapy, class IV laser therapy, and/or others. A massage therapist may also be considered as part of your “management team.” Coordination of care with your primary care physician is also important. Nutritional counseling can also be highly effective and may include an anti-inflammatory diet such as a low gluten diet, and specific vitamin recommendations may include a multiple vitamin mineral, magnesium, calcium, omega 3 fatty acids, vitamin D, and/or CoQ10 (anti-oxidant). Most important is that we can facilitate as a “quarterback” with your other personal management strategies.
Did you know that for every inch the head moves forward in posture, its weight on your neck and upper back muscles increases by 10 pounds? For example, a human head weighing 12 pounds held forward only 3 inches from the shoulders results in 42 pounds of pressure on the neck and upper back muscles. That’s the equivalent of almost three watermelons resting on your neck and back! When you neglect your posture, you invite chronic back pain. Rounding your low back while sitting for extended periods of time in front of a computer, standing for hours stooped over, sleeping improperly and lifting poorly can all lead to debilitating aches. Maintaining the natural lumbar curve in your low back is essential to preventing posture-related back pain. This natural curve works as a shock absorber, helping to distribute weight along the length of your spine. Adjusting postural distortions can help stop back pain. A basic remedy to sitting all day is to simply get up! Frequently getting up from a seated position and doing these six quick and easy realignment exercises can help you reeducate your muscles from getting stuck in a hunched over cave man position. 1. Chin Tuck The Chin Tuck can help reverse forward-head posture by strengthening the neck muscles. This exercise can be done sitting or standing. Start with your shoulders rolled back and down. While looking straight ahead, place two fingers on your chin, slightly tuck your chin and move your head back (image at left). Hold for 3-5 seconds and then release. Repeat 10 times. Tip: The more of a double chin you create, the better the results. If you’re in a parked car, try doing the Chin Tuck pressing the back of your head into the headrest for 3-5 seconds. Do 15-20 repetitions. 2. Wall Angel Stand with your back against a flat wall with your feet about four inches from the base. Maintain a slight bend in your knees. Your glutes, spine and head should all be against the wall. Bring your arms up with elbows bent so your upper arms are parallel to the floor and squeeze your shoulder blades together, forming a letter “W” (image at left). Hold for 3 seconds. Next, straighten your elbows to raise your arms up to form the letter “Y.” Make sure not to shrug your shoulders to your ears. Repeat this 10 times, starting at “W,” holding for 3 seconds and then raising your arms into a “Y.” Do 2-3 sets. 3. Doorway Stretch This exercise loosens those tight chest muscles! Standing in a doorway, lift your arm so it’s parallel to the floor and bend at the elbow so your fingers point toward the ceiling. Place your hand on the doorjamb. Slowly lean into your raised arm and push against the doorjamb for 7-10 seconds. Relax the pressure and then press your arm against the doorjamb again, this time coming into a slight lunge with your legs so your chest moves forward past the doorjamb for 7-10 seconds (image at left). Repeat this stretch two to three times on each side. 4. Hip Flexor Stretch Kneel onto your right knee with toes down, and place your left foot flat on the floor in front of you. Place both hands on your left thigh and press your hips forward until you feel a good stretch in the hip flexors. Contract your abdominals and slightly tilt your pelvis back while keeping your chin parallel to the floor (image at left). Hold this pose for 20-30 seconds, and then switch sides. The next two exercises require a resistance band: 5. The X-Move This exercise helps strengthen your upper back muscles, especially the ones between your shoulder blades (the rhomboids). Sit on the floor with your legs extended forward. Place the middle of the resistance band around the bottom of your feet and cross one side over the other to form an “X”. Grasp the ends of the band with your arms extended in front of you. Pull the ends of the band toward your hips, bending your elbows so they point backward (image at left). Hold and slowly return. Do 8-12 repetitions for three sets. 6. The V-Move According to a 2013 study by the Scandinavian Society of Clinical Physiology and Nuclear Medicine, performing this simple resistance band exercise 2 minutes a day, five times a week, will significantly decrease your neck and shoulder pain and improve your posture. While standing, stagger your feet so one is slightly behind the other. Grasp the handles, or the ends, of the resistance band and lift your arms upward and slightly outward away from your body about 30 degrees. Keep a slight bend in your elbows. Stop at shoulder level; hold and return. Make sure to keep your shoulder blades down and back straight. Repeat this exercise for 2 minutes each day, five days a week. Good work! http://www.mindbodygreen.com/0-15552/6-exercises-to-reverse-bad-posture.html
ABC (Source: mangpor_2004/iStockphoto) The commonly-prescribed drug paracetamol does nothing to help low back pain, and may affect the liver when used regularly, a large new international study has confirmed. Reporting in today’s issue of the British Medical Journal researchers also say the benefits of the drug are unlikely to be worth the risks when it comes to treating osteoarthritis in the hip or knee. “Paracetamol has been widely recommended as being a safe medication, but what we are saying now is that paracetamol doesn’t bring any benefit for patients with back pain, and it brings only trivial benefits to those with osteoarthritis,” says Gustavo Machado of The George Institute for Global Health and the University of Sydney. “In addition to that it might bring harm to those patients.” Most international clinical guidelines recommend paracetamol as the “first choice” of treatment for low back pain and osteoarthritis of the hip and knee. However, despite a trial last year questioning the use of paracetamol to treat low back pain, there has never been a systematic review of the evidence for this. Machado and colleagues analysed three clinical trials and confirmed that paracetamol is no better than placebo at treating low back pain. An analysis of 10 other clinical trials by the researchers quantified for the first time the effect paracetamol has on reducing pain from osteoarthritis in the knee and hip. “We concluded that it is too small to be clinically worthwhile,” says Machado. He says the effects of paracetamol on the human body are not well understood and just because it can stop headaches, it doesn’t mean the drug will work in all circumstances. “There is probably a difference in the pain mechanisms in low back pain and osteoarthritis, compared to headache,” says Machado. Liver effects Importantly, the new study was the first to show that patients using paracetamol for low back pain and osteoarthritis were nearly four times more likely than those taking placebo, to have abnormal results on liver function tests. Machado says it’s unclear whether this means paracetamol could cause liver damage in the long term. “But if you see elevation of enzymes in the short term, it’s a concern for the long term,” he says. Machado and colleagues point to another recent study suggesting paracetamol raises the risk of cardiovascular, gastrointestinal and renal disease. They argue doctors should reconsider their recommendation that patients use the drug for low back pain and osteoarthritis of the hip or knee. “A clinician should weigh benefits and harms when they prescribe any drug, and if that drug is not providing any benefit and it has the potential of doing harm it shouldn’t be recommended,” says Machado. Call to review guidelines “It’s time the clinical guidelines are reviewed,” says co-author of the new study Associate Professor Manuela Ferreira. “Paracetamol shouldn’t be included in the guidelines for back pain.” When it comes to treating osteoarthritis, Machado and Ferreira call on doctors to explain the actual risks and benefits. “If you ask me it’s not worthwhile,” says Ferreira. Ferreira says anti-inflammatories are the second choice of treatment for low back pain but they have greater side effects. The researchers say other non-drug treatments recommended in the clinical guidelines should be used instead. These include reassuring patients that low back pain is generally benign and that the best remedy is to keep active. Exercise, strength training and weight management have been shown to be effective in treating osteoarthritis of the hip and knee,” says Machado. “We should have a further look at the guidelines and use those safer approaches.” Related: Low back pain top cause of disability Related: Most patients ‘too optimistic’ about medicine http://www.abc.net.au/science/articles/2015/04/01/4208298.htm
B Vitamins Improve Memory, Prevent Brain Atrophy By James P. Meschino, DC, MS The 2010 OPTIMA [Oxford Project to Investigate Memory and Ageing] study showed that the accelerated rate of brain atrophy in elderly with mild cognitive impairment could be slowed via supplementation with homocysteine-lowering B vitamins, which included folic acid, vitamin B12 and vitamin B6. This is an important finding, as 16 percent of individuals older than age 70 have mild cognitive impairment (MCI), 50 percent of whom realize further progression to Alzheimer’s disease. It is well-documented that brain atrophy is a characteristic of subjects with mild cognitive impairment who progress to Alzheimer’s disease. The Biochemistry of Brain Aging Aging studies reveal that the brain shows progressive atrophy after the age of 60. Some atrophy occurs even in cognitively healthy subjects, but to a lesser extent than patients suffering from Alzheimer’s disease. An intermediate rate of atrophy is found in people with MCI, and brain atrophy is more rapid in subjects with MCI who progress to Alzheimer’s disease. One cause of brain atrophy has been reported to be elevated concentrations of plasma total homocysteine (tHcy), as moderately elevated concentrations of tHcy have been associated with an increased risk of dementia, notably Alzheimer’s disease, in many cross-sectional and prospective studies. Elevated plasma total homocysteine is also associated with both regional and whole-brain atrophy, both in patients with Alzheimer’s disease and in healthy elderly individuals. The tissue and plasma concentrations of homocysteine are largely determined by the body’s status of certain B vitamins (folate, B6 and B12), which are cofactors or substrates for enzymes involved in homocysteine recycling to methionine (folic acid and B12) or serine (B6). As such, the discovery that supplementation with folic acid, vitamin B6 and vitamin B12 can reduce tHcy and slow brain atrophy has clinical significance in an aging population.1 More Research Support for B-Vitamin Supplementation Prior to the published results of the OPTIMA study, another B-vitamin supplementation study had shown improvement in memory function in a well-designed human clinical trial. In this study, supplementation was provided to 211 healthy younger, middle-aged and older women who took either 750 mcg of folic acid, 15 mcg of vitamin B12, 75 mg of vitamin B6 or a placebo daily for 35 days. Dietary intake of these vitamins and cognition and mood were also diarized. Usual dietary intake status was estimated using a retrospective, self-reported, quantified food-frequency questionnaire. Participants completed alternate forms of standardized tests of cognitive processing resources, memory, executive function, verbal ability and self-report mood measures before and after supplementation. Results showed that the group administered the B-vitamin supplementation protocol exhibited a significant positive effect in terms of certain measures of memory performance. Dietary intake status of the same B vitamins was associated with speed of processing, recall and recognition, and verbal ability.2 Subsequent to the OPTIMA study, a large 2011 prospective study showed that lower vitamin B12 blood levels were associated with decreased brain volumes and cognitive scores. The study involved 121 older residents of the south side of Chicago who are participants in the Chicago Health and Aging Project (CHAP), a large, ongoing prospective study of 10,000 subjects over the age of 65. All participants had their blood tested to determine levels of vitamin B12 and B12-related markers that can indicate deficiency. The subjects also underwent tests that evaluated their memory and other cognitive skills. After four-and-a-half years, on average, MRI scans of the participants’ brains were taken to measure total brain volume and look for other signs of brain damage. Results showed that having high levels of four of five markers for vitamin B12 deficiency was associated with lower scores on the cognitive tests and a smaller total brain volume. One of the markers for vitamin B12-related markers included total plasma homocysteine levels. Findings from this study showed that for each increase of 1 micromole per liter of homocysteine, the cognitive scores decreased by 0.03 standardized units or points, which the researchers indicated was a significant finding.3 Clinical Considerations In addition to keeping homocysteine in check, it should be noted that folic acid, B6 and B12play important roles in the brain, as cofactors for the synthesis of various neurotransmitters required for normal cognition. Vitamin B12 deficiency is a common finding as people age due to decreased absorption, and is secondary to declining stomach acid secretion. An acid environment enhances B12 absorption by up-regulating the secretion of intrinsic factor, which is necessary for vitamin B12 absorption in the small intestine. Compounding the problem is the fact that many older subjects take antacid drugs (over-the-counter or prescription) for digestive complaints, or to reduce the intestinal irritation from nonsteroidal anti-inflammatory drugs used to manage arthritis and/or chronic pain. It is also noteworthy that in spite of the folic acid food-fortification program implemented by the U.S. government in 1998, epidemiological studies have repeatedly shown that the average daily intake of folic acid from food is suboptimal for certain subgroups, and that ingestion of alcohol, having a poor diet and decreased stomach acidity can compromise folic acid absorption and folate nutritional status. Many older subjects exhibit some or all of these conditions, which may increase their propensity for suboptimal folate status. Given the emerging importance of these B vitamins on the rate of brain atrophy after age 60, memory, cognition, and risk of MCI and Alzheimer’s disease, health care practitioners should consider evaluating plasma folate (more ideally using the erythrocyte folate test), plasma B12 levels and total plasma homocysteine levels in patients over age 50 to identify those who would best benefit from supplementation with these three B vitamins. When warranted, a low dose of prevention may translate into many more years of normal cognitive function and preserved quality of life and dignity.4-5 References Smith AD, Smith SM, de Jager CA, et al. Homocysteine-lowering by B vitamins slows the rate of accelerated brain atrophy in mild cognitive impairment: a randomized controlled trial. PLOS One, Sept. 8, 2010;5(9):e12244. Bryan J, Calvaresi E, Hughes D. Short-term folate, vitamin B-12 or vitamin B-6 supplementation slightly affects memory performance but not mood in women of various ages. J Nutr, 2000;132(6):1345-56. Tangney C, Aggarwal NT, Li H, et al. Vitamin B12, cognition, and brain MRI measures: a cross-sectional examination. Neurology, 2011;77(13):1276-82. Dietary Supplement Fact Sheet: Folate. National Institutes of Health, Office of Dietary Supplements, Dec. 14, 2012. Skerrett PJ. “Vitamin B12 Deficiency Can Be Sneaky, Harmful.” Harvard Health Blog, Jan. 10, 2013. Post by Dr. Charlie S Chae. D.C Chiropractic Focus
Painkillers able to target pain? No way by Cathy Johnson Claims that suggest you need a different painkiller for back pain, migraine, period pain or tension headache are simply untrue, health and consumer experts say. ISTOCKPHOTO | SEOTERRA Browse the painkiller aisle of your supermarket or pharmacy and there’s a bamboozling array of products on display. Many are marketed with one clear suggestion: depending on where you’re hurting, you’ll need to buy a different pill. Pain in your ‘back and neck’? Buy this one. But if it’s a tension headache, you’ll need this one. Oh, and a different one again if it’s a migraine you’re suffering. The same goes for period pain. But health experts and consumer groups have been arguing for years that this simply isn’t the case and that the marketing is misleading. A large proportion of over-the-counter painkillers contain one of two main active ingredients: paracetamol or ibuprofen. Branded forms of these such as Panadol, which contains paracetamol, and Nurofen, which contains ibuprofen, dominate the market. Panadol has a few pain-specific products, Nurofen has more. But there are other generics which are also being pitched to consumers as targeting specific types of pain. The issue has now escalated with the Australian Competition and Consumer Council launching legal action against Nurofen manufacturer Reckitt Benckiser over targeted pain relief claims on products, such as Nurofen Back Pain, Nurofen Period Pain, Nurofen Migraine Pain and Nurofen Tension Headache. “In this case, we allege that consumers have been misled into purchasing Nurofen specific pain products under the belief that each product is specifically designed for and effective in treating a particular type of pain, when this is not the case,” ACCC Chairman Rod Sims said. No magic at work Dr Michael Vagg, a pain specialist with Barwon Health in Victoria says both paracetamol and ibuprofen work as painkillers throughout the body, attacking whichever pain they come across. Or as consumer advocacy group CHOICE put it in the blurb for the “Shonky” award it made to Nurofen in 2010: “So does the back pain version somehow magically go straight to your back – and only your back – as soon as you’ve swallowed it? Could you, say, choose to treat only your back pain while keeping your headache? If you want to treat both, do you need to take a dose of each? The answers are no, no and definitely no.” The ACCC’s Mr Sims says the current legal action is only against the manufacturer of Nurofen, but if successful it would no doubt “send a warning” to other manufacturers making similar marketing claims. Last year CHOICE pointed out other products like those marketed under Coles’ MediChoice brand were also being pitched to consumers as targeting specific types of pain. Coles’ MediChoice Migraine Pain and its MediChoice Period Pain both contain exactly the same active ingredient as its regular ibuprofen gel capsules, but at more than 1.5 times the price, CHOICE said. “In reality, the only relief targeted marketing claims provide is to the weight of your wallet,” CHOICE spokesman Tom Godfrey says. “The most effective targeted relief you can get is to look at the active ingredients on the pack. 200 mg of ibuprofen is 200 mg of ibuprofen – reaching for the pack with a flashy name or a targeted claim will just leave you with a pain in your hip pocket.” Potential health danger Mr Sims said he believes the ACCC action is very important because the current marketing both wasted consumers’ money and potentially endangered their health. Buying more than one packet of what is essentially the same product, just under a different name, is unnecessary and probably wasteful if some of the pills pass their expiry date before they are used. And to add to the financial burden, the products marketed for specific pain are disproportionately more expensive than the regular forms containing the same ingredient, Sims said. But more importantly, someone who has pain in two different areas may be harmed by ‘doubling up’ on ibuprofen through taking pills from two different specific pain products because they happened to have pain in two body areas – say a headache and a period pain at the same time. “Until these specific pain products came on the market, you would have taken the same product for pain in the head and pain in the toe. And lo and behold, your experience was that it found the pain. “We think it’s hugely important when you’re advertising in relation to medical and health goods, that you do not mislead consumers. These matters we take very seriously.” Ken Harvey, adjunct Associate Professor of Public Health at Monash University, said the ACCC’s legal action had come more than three and a half years after the first complaint about promotion of the painkillers to the Therapeutic Products Advertising Complaints Resolution Panel. This was an unacceptable delay because the current system of resolving complaints did not have enough power to force companies to respond to judgements, he said. The products remain on sale. “The complaints just go from one body to another before the ACCC can act. Companies can keep laughing all the way to the bank because of the craziness of the system.” The manufacturer of Nurofen said in a statement today it “disputes any allegation of contravention of consumer law in relation to its pain-specific packaging”. It claimed its pain-specific products provided “easier navigation” of options in the grocery environment for consumers who are experiencing a particular type of pain. In 2103, Australians spent around $629 million on over-the-counter painkillers. CHOICE tips for choosing painkillers are: look at the active ingredient and dosage you need don’t be fooled by targeted pain relief claims note that most painkillers are absorbed within 15-30 minutes Which painkiller? Paracetamol vs ibuprofen – some facts In many cases, either can work to relieve pain. But ibuprofen has stronger anti-inflammatory effects, which make it better for injuries such as sprains or fractures. Period pain is an instance where there is some evidence to prefer ibuprofen or one of its anti-inflammatory cousins to paracetamol. Paracetamol is considered safer in most people, and ibuprofen should be avoided by people with stomach problems such as ulcers, high blood pressure, heart failure, asthma, pregnant women and children under three months. (Paracetamol should not be given to children under one month.) Compared to other over-the-counter pain relievers, paracetamol is significantly more toxic in overdose. Many studies suggest a combination of one paracetamol and one ibuprofen tablet is more effective for acute pain such as headaches, than either treatment alone (this doesn’t apply to persistent or chronic pain like arthritis). Sources: Dr Michael Vagg, pain specialist Barwon Health in Victoria, Choice. http://www.abc.net.au/health/thepulse/stories/2015/03/05/4192065.htm
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Chiropractic is a health care system that holds that the structure of the body, particularly the spine, affects the function of every part of the body. Chiropractors try to correct the body’s alignment to relieve pain and improve function and to help the body heal itself. While the mainstay of chiropractic is spinal manipulation, chiropractic care now includes a wide variety of other treatments, including manual or manipulative therapies, postural and exercise education, ergonomic training (how to walk, sit, and stand to limit back strain), nutritional consultation, and even ultrasound and laser therapies. In addition, chiropractors today often work in conjunction with primary care doctors, pain experts, and surgeons to treat patients with pain. Most research on chiropractic has focused on spinal manipulation for back pain. Chiropractic treatment for many other problems—including other musculoskeletal pain, headaches, asthma, carpal tunnel syndrome, and fibromyalgia—has also been studied. A recent review concluded that chiropractic spinal manipulation may be helpful for back pain, migraine, neck pain, and whiplash. There have been reports of serious complications, including stroke, following spinal manipulation of the neck, although this is very rare and some studies suggest this may not be directly caused by the treatment. “Spinal manipulation” is a generic term used for any kind of therapeutic movement of the spine, but used more precisely it is the application of quick but strong pressure on a joint between two vertebrae of the spine. That pressure twists or rotates the joint beyond its normal range of motion and causes a sharp cracking noise. That distinctive noise is believed to be caused by the breaking of a vacuum or the release of a bubble into the synovial fluid, the clear, thick fluid that lubricates the spinal and other joints. Spinal manipulation can be done either directly by pushing on the vertebrae or indirectly by twisting the neck or upper part of the body. It should be done to only one spinal joint at a time. Chiropractors and other practitioners accomplish this by positioning the body so the force they exert is focused on one joint while parts of the spine above and below it are held very still. Most spinal manipulation treatments take somewhere between 10 and 20 minutes and are scheduled two or three times a week initially. Look for improvements in your symptoms after a couple of weeks. In addition, a chiropractor may advise you about changing your biomechanics and posture and suggest other treatments and techniques. The ultimate goal of chiropractic is to help relieve pain and help patients better manage their condition at home. http://www.health.harvard.edu/pain/chiropractic-care-for-pain-relief