Chronic pain can lead to central sensitisation and hyper-excitability of neurons, resulting in increased sensitivity and pain perception. This can occur in any chronic pain condition and is common in musculoskeletal presentations. This can be further complicated by structural issues, requiring co-management with relevant musculoskeletal specialists. Injuries and structural abnormalities can limit the reach of naturopathic treatment and must be considered when providing patients with realistic outcomes. This case is an example of the large benefits that can be gained using relatively simple treatment along with effective co-management strategies.

Initial Consultation

A 27-year-old female presented with hypogammaglobulinaemia (a genetic chronic immune deficiency syndrome) and a 12-year history upper back pain following physical and emotional trauma that occurred in her teens. Having four broken vertebrae from this trauma (L1-L4), she had received a nerve block to manage her pain. The patient rated her upper back pain 8/10 and described it as a tight, knotty feeling in thoracic region and neck. She also had pain radiating down both legs. The back and leg pain were treated with anti-inflammatory medications as needed (see medications list below). She also suffered headaches, which occurred 3 times weekly, particularly when her neck and shoulders were feeling tight.  

A case history revealed:

• Energy levels varied between 2/10 and 7/10
• Frequent infections (respiratory) treated with antibiotics 2 times weekly for the past 2 years
• Asthma managed with medication (see medications list below)
• Depression and anxiety managed with medication, well managed at present
• Chronic bloating for years, almost daily, mostly located to the lower abdomen
• Chronic vaginal thrush, treated every 2 weeks with oral fluconazole
• Post-traumatic stress disorder (PTSD)
• Irregular menstrual cycle, treated with combined oral contraceptive pill (OCP)
• Sugar cravings
• Hay fever
• Occasional twitching and muscle cramping
• Teeth grinding at night, wears a splint to protect teeth
• Diet high in packaged and processed foods, including wheat and dairy

Medication included:

• Paracetamol osteo - 2 tablets, three times daily
• Oxycodone/naloxone - 5 mg/day (oxycodone) + 2.5 mg/day (naloxone), 1 tablet, twice daily
• Oxycodone - 5 mg as required
• Ibuprofen - 2 tablets, twice daily
• Budesonide/formoterol inhaler - twice daily
• Azithromycin - 250 mg, 3 times weekly
• Sertraline - 100 mg, twice daily
• Quetiapine - 175 mg/day
• Prazosin - 4 mg before bed
• Lorazepam - 500 mcg if difficulty sleeping
• Fluconazole - 150 mg as required
• Magnesium (chemist brand) - 1 scoop daily (dose unknown)
• Omega 3 fish oils - 2 capsules/day

Initial Prescription

The initial prescription was aimed at supporting her immune system, reducing musculoskeletal pain and inflammation, and improving gut health. Her prescription included:

• A herbal liquid containing (Dosage: 7.5 ml, twice daily before food):
  •  Echinacea spp. (echinacea)                               25 ml
  • Andrographis paniculata (andrographis)            20 ml
  • Glycyrrhiza glabra (licorice)                                 10 ml
  • Thymus vulgaris (thyme)                                      15 ml
  • Lavandula angustofolia (lavender)                       15 ml
  • Viburnum opulus (cramp bark)                             20 ml
• An anti-inflammatory herbal tablet containing Boswellia serrata (boswellia) 1.9 g, Curcuma longa (turmeric) 2 g, Apium graveolens (celery) 1 g, Zingiber officinale (ginger) 300 mg. Dosage: 2 tablets, twice daily;
• A probiotic containing lactobacillus acidophilus (NCFM), bifidobacterium lactis (Bi-07) and Lactobacillus rhamnosus (LGG). Dosage: 1 capsule twice daily
• A nutritional powder containing quercetin 448 mg, rutoside 500 mg, bromelains 100 mg, ascorbic acid 850 mg, vitamin A 2500 IU, and cofactors for mucous membrane and immune function. Dosage: 1 teaspoon twice daily,
• Continue own magnesium and fish oil supplements

Dietary and lifestyle advice included:

• Remove wheat and dairy from the diet
• Increase homemade food
• Make vegetables the basis of lunch and dinner meals

2-Week Follow-Up

The patient noted a significant improvement in muscle pain, which resulted in a decrease in pain medication use. She reduced paracetamol osteo to 1 tablet twice daily and was not using ibuprofen or oxycodone.  Her pain specialist was reducing the dose of oxycodone with naxolone by 25%. Her immune function had also improved, with workmates suffering from colds, but with her only feeling mild symptoms. She had one headache in the past 2 weeks after a visit to the physiotherapist. Sugar cravings were significantly reduced and bloating only occurred after a dairy-based dietary slip up on the weekend. She reported a slight amount of thrush, which was treated with oral fluconazole. She was adhering to the dietary advice 90% of the time. Her energy levels had steadied at 5-6/10.

Her prescription was continued with the following replacing her own magnesium powder:

• A nutritional powder providing 310 mg magnesium as a blend of phosphate, citrate and orotate along with vitamins and minerals to support energy production. Dosage: 1 teaspoon, twice daily

Diet and lifestyle advice:

• Include 1 to 2 pieces of fruit daily; preferably those with anti-inflammatory enzymes such as kiwifruit, papaya, pineapple, or good fibre such as apples and pears

She was referred to osteopath for co-management of her musculoskeletal pain and structural issues.

7-Week Follow-Up

The patient reported that she was feeling good. She had begun seeing an osteopath whose treatment had provided significant relief from shoulder tension. She no longer experienced any headaches since starting osteopathic treatment, except for one migraine prior, with vomiting, which required hospitalisation. Her immunity was improved, with no colds or other infections since the previous appointment, with no incidences of thrush. She was not experiencing any muscle cramping.

Her updated prescription included:

• A herbal formula containing (Dosage: 7.5 ml, twice daily with food):
  •  Hapagophytum procumbens (devil’s claw)              40 ml
  •  Andrographis paniculata (andrographis)                 30 ml
  • Echinacea spp. (echinacea)                                       30 ml
  • Zingiber officinale (ginger)                                           5 ml
• A nutritional powder containing ascorbic acid 2.4 g, zinc 12 mg, Fallopia japonica (giant knotweed) 7.5 g, providing resveratrol 15 mg, and co-factors for immune function. Dosage: 1 teaspoon/day
• Continue herbal anti-inflammatory herbal tablet, magnesium and co-factors powder, and probiotic from previous prescription

Dietary advice included:

• Use lots of fresh ginger and garlic to support immune function
• Include orange-coloured vegetables for beta-carotene and immune function
• Increase vitamin C-containing foods such as broccoli, capsicum, strawberries, kiwifruit, and pineapple to support immunity
• Include nuts and seeds such as sunflower, pumpkin, chia, almond, and brazil for improved mineral intake

11-Week Follow-Up

The patient continued to report good health. She had reduced her anti-inflammatory medication to 1 paracetamol osteo daily. Her doctor had also reduced the dose of quetiapine to 125 mg. She had experienced a few headaches since the previous visit, with reduced intensity reported. Her neck pain was currently 4/10, although she noticed an increase when she ran out of the magnesium powder. She ceased treatment due to financial hardship but was maintained on her previous prescription for 3 months.

Reducing nerve hyper excitability and inflammation are key to supporting patients with chronic pain. While herbs and nutrients grant substantial benefit, an anti-inflammatory diet provides the foundation from which these supplements work. Although this patient had complex health issues and an array of medications to consider, a relatively simple approach broke the pain cycle and restored her health.