Exciting new research has recently emerged regarding the impact of mental imagery on reported pain levels, which could open new paths for research and treatment.

For patients living with chronic pain, it’s probably old news that pain can be different on different days, during different activities, or even when a patient is in different moods. This is because there are both physical and emotional components to pain, transforming a very intricate and precise firing of neurons into a varied and personal subjective experience. We know that these signals can be interrupted and diminished by drugs, physical therapies,  and new advances in technology

In a study conducted with 40 healthy volunteers, participants were stimulated on their arm with different temperatures and asked to rate their experience of pain on a scale of 1 to 100. For each temperature stimulus, a photo of a person’s face was shown to the participant on a screen. The research consisted of two parts: In the first part participants were shown the faces with the matching temperatures repeatedly, conditioning the group to associate the image with the level of pain reported. This part was essentially a classical test of the placebo effect, where the participants would expect and then report a level of pain that they associated with the image, even if the stimulus was changed. In the second part, the image was shown for 12 milliseconds and then masked, too fast to be perceived by the conscious mind. The researchers found similar results in the second experiment, indicating that the mechanisms in the brain responsible for the placebo effect can work without the person being consciously aware of the cues.

Mindfulness meditation is a process where calming the body, eliminating stress and recognizing pain signals as they occur allows patients to control how strong these impulses are interpreted by the brain. We mentioned use of mindfulness meditation techniques on the blog earlier this year.  This mental exercise technique uses guided visualization to bring awareness to all parts of the body. This is an active process, where the patient is imagining specific images that promote relaxation.

What sets this new research apart is that it questions whether or not the brain can respond to mental images without the person being conscious or aware of what they are seeing and ultimately determining if the unconscious mind can be trained to affect pain responses.

The conscious mind is sometimes described as the tip of an iceberg, with the larger unconscious mind lying beneath the surface of the water. What if treatments could target this submerged underworld?

If you are interested in reading more about the study the  full text  is available online.


Some recognizable examples of Nonsteroidal anti-inflammatory drugs (NSAIDs) include ibuprofen (Advil, Motrin), diclofenac, and  naproxen (Aleve).  They are frequently used as the first line of defence to reduce pain and inflammation.  Most NSAID medications are available without a prescription and are widely used to reduce fever and pain related to long- and short-term medical conditions such as headaches, arthritis, menstrual cramps, and flu symptoms. However, just because they are available without a prescription does not mean that they are 100% safe. New labeling requirements have raised awareness of potential risks for the estimated 30 million Americans taking nonsteroidal anti-inflammatory drugs each year.

The Food and Drug Administration has recently strengthened its warning on NSAIDs due to recent studies that shows even small amounts of NSAIDs present a risk of heart attack, heart failure, or stroke. The updated warning is a result of a growing body of research into these widely used over the counter (OTC) drugs. While it was always presented as a risk, the new strengthened warning clarifies that NSAIDs may increase the risk of heart attack or stroke in all patients, with or without heart disease or risk factors for heart disease as previously thought.  Those with risk factors of heart disease should be particularly cautious because they are already at a higher baseline for such complications. The FDA will require new labels to reflect this developing research.

Should you worry? Not if you are using these medications as directed. There seems to be a consensus from the medical community that more studies are needed before we empty out our medicine cabinets. Bruce Lambert, director of the Center for Communication and Health at Northwestern University, who specializes in drug safety communication shared his comments with the New York Times, “One of the underlying messages for this warning has to be there are no completely safe pain relievers, period.” Another article for NPR highlights the general rule of using caution with any medication.

Although the FDA’ s  new warnings need not cause alarm, the announcement is an important reminder to the millions of people that use NSAIDs on a daily basis that misuse or overuse of OTC drugs could result in severe health consequences. Patients that rely on these OTC painkillers long term should talk to their health care providers about reasonable alternatives.


The latest from the Apollo Blog outlines very interesting and encouraging interim research about chronic pain patients who are using opiates (pain killers) as their main way to manage their pain: a significant number of patients who are on addictive pain killers are reporting using less of those drugs while on the medical cannabis available through the Apollo program.

Also very interesting: a clinically significant number of their patients are offering lower numbers on pain scores, leading us to think that they are finding some relief for their pain when other types of treatments are failing.

According to a preliminary analysis of Apollo patient data, 27% lowered their use of opioid medications, which included Percocet, methadone and oxycodone. Across all patients, a significant average pain reduction score of 30% was reported.

Through the research, we are proud to present that 54% of patients showed a clinically significant reduction in pain score. Clinical significance is present when a pain score reduction of more than 30% is reached. Patients at or above this level saw an average reduction in pain score of 45%.

As a practice that is keen to see the world not just improve the way it manages pain, but better manage addictive medication, we see this as a major development for patients looking to manage pain without the challenges of high-dose narcotics.

Several Allevio physicians work closely with and are actively referring into the program.


Today we are happily sharing another whiteboard video by Dr. Mike Evans, Toronto based professor, doctor and health educator extraordinaire.

Dr. Evans outlines some very practical aspects of preparing for joint surgery which encourage the patient to be at the centre of the process. The key message: all of the surgeons, nurses and practitioners that participate in your care before and after your joint surgery will be doing everything they can to support you with their skill and expertise, but ultimately you will play the instrumental role in the healing and long term functionality of your new joint.

The video points out that, in Ontario, patients are generally in and out of hospital after 4 days… sometimes sooner. This gives us bit of perspective on this major procedure. The actual surgery is a the shortest event in the whole process. It is what you do before and after your time in the hospital that will influence your outcome dramatically.

Dr. Evans introduces the idea of the new normal: Your joint has been causing you pain and therefore limiting your activity. After surgery it might be difficult to imagine doing things you had avoided to prevent pain leading up to the replacement. However, it is important to develop the physical  and mental strength before  your procedure and keep up this momentum and attitude in the days and months after surgery. More specifically, simple tasks done in advance (organizing your home for your return and having a contact list of people to call on for help) can allow you to focus on your rehabilitation as soon as you leave the hospital.

We see a lot of people at Allevio who are considering joint replacement or are working with our specialists post-operatively.  We are in the process of developing a Total Knee Program and we currently offer several therapies that address pain following joint replacement surgery. If you are a patient considering or having a joint replacement, please take time to research the conditions and treatments below, or feel free to ask your clinical team about these options. It is always important to do homework and understand what treatments may be available, and what independent reserach has shown for any treatment you may consider.

Some potential treatments may include:

Pulse Radio Frequency

Platelet Rich Plasma (see previous post)

Osteopathy (see previous post)

Chiropractic strategies including various modalities

Custom designed support bracing and orthotics, available through certified and trained experts such as Chiropractors for bracing and Chiropractors or Chiropodists for orthotics.


Platelet Rich Plasma (PRP) injection is a therapeutic treatment using the patients’ own blood, put through a centrifuge to separate and concentrate the number of platelets, which is then re-injected to the injured site or pain area. Because platelets contain a variety of growth factors which are instrumental in the healing process of tissues, this concentrated dose is championed for its regenerative properties. Considered a conservative therapy (as opposed to surgery, for example), PRP injections are administered in an office setting and work fast to kickstart a number of biological processes.

Recently, Platelet Rich Plasma injection treatment has become popular among professional athletes as a solution to potentially career-slowing injuries. When Tiger Woods spoke to the media about his treatment in 2009, research on PRP was relatively new and considered more trend than science due to its high profile list of supporters.

However, the popularity of the treatment has pushed the scientific community to further examine the effects PRP. The evidence base continues to mount with exploration into how platelet-rich plasma may play a role in improving clinical outcomes in patients with early onset osteoarthritis. In a double-blind randomized trial published in 2013, patient groups who received PRP reported a relief in symptoms over the placebo group who received injections of saline.

Dennis Cardone, associate professor in the Department of Orthopedic Surgery at NYU’s Langone Medical Center explains in an interview with NPR, that although its effectiveness is still in the early stages of research, PRP is at least now something that he can safely offer to patients who might not have had conservative options before.


In a recent article in  Chatelaine, an assistant editor tested out osteopathy for her joint pain. Like many first time patients of osteopaths (also known as DOs or Doctors of Osteopathic Medicine) she was surprised by just how much information could be determined by observation and touch alone. The final verdict: not only was the physician able to aleve some of her discomfort, but she was also able to tell her about her digestive and respiratory problems after one session of hands-on therapy.

So what is osteopathy exactly?

In short, an osteopath is trained to treat the whole person instead of the symptoms or disease. The intricacy of all of the body’s systems (musculoskeletal, respiratory, cardiovascular, digestive, reproductive, or nervous system) are considered when trying to determine the source of imbalance causing sickness or discomfort. The overall idea is to restore function so the body can find its way toward healing itself naturally.

What sets osteopaths apart is their holistic approach, the osteopathic medicine structure influences function, and osteopaths are trained to touch and observe the body to determine the state of tissues, muscles, fluids, and bones.

There have been several studies which demonstrate that osteopathy is particularly effective in treating chronic pain. The holistic approach of an osteopath takes into account the patient’s full life situation (for example; stress, mental health, living conditions) and uses a combination of treatments to restore balance and function to all systems. As pain is a complex experience, many patients benefit from the the comprehensive approach of osteopathic techniques.

While Allevio Pain Management offers Osteopathy services as part of its integrated care model, Allevio always suggests patients find a provider that they are comfortable with, who can communicate and collaborate with their existing team for care, and of course who is a member in good standing with their local college or governing body.


”Burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.”

Psychology Today has a great summary of what burnout is, what symptoms are, and what you as a patient, caregiver or healthcare professional should look out for.  Not sure what burnout is?  Give this a read.

This article, recently published in the Atlantic magazine, openly discusses the challenge with burnout in young physicians today. Reading it shows   that many of the same challenges apply equally to patients, caregivers, and many others battling long-lasting and challenging conditions.  Allevio is a practice that tirelessly seeks to raise the bar of service, care, and what is available for both physicians and patients. We do this while the challenge for us is great, our opponents and people who celebrate mediocrity are many, and there are small challenges every day and at every turn.  The point, as this article explains quite well, is that for the future of medicine – and the very challenging area of pain management – nuances and small issues of the everyday realities can wear away at the vision and philosophical objective of the chosen path.

The long battle against a thousand small forces pushing against us is what we all collectively need to recognize and deal with. From Psychological support and group support at Allevio, to teamwork building, and even the blog you’re reading now and patient blogs as well – standing together makes all the difference.

It is the patient truly committed to control their condition and their life.  The caretaker truly focused on having their own life while supporting the person that needs them. The physician that enters their practice with an eagerness to work in their community to help all. The most challenging and not necessarily the most financially comfortable.  It is for these people that Allevio thrives.


There are so many good and important points in this video, it’s too much to completely summarize in one post. This 11 minute video is simply a must-watch for everyone to both advises on and manages their chronic pain.

A a few of the key points that are very important and are often overlooked relate to the recovery and management of pain as a chronic condition: the stress on multi-dicipinary care (having Osteopathy, Chiropractic, Massage and Physiotherapy) and staying active, coupled with Cognitive Behavioural Therapy on the psychological side, can all have a roll to play in patient management and recovery.

If you know anyone with Sciatica, Spinal Stenosis, or other causes of low back pain, this is one worth forwarding.


A new study recently led by Dr. Richard Deyo of the Oregon Health and Science University in Portland and published in the May 15, 2013 edition of Spine, set out to examine associations between use of medication for erectile dysfunction or testosterone replacement and use of opioid therapy, patient age, depression, and smoking status.

The study concluded that dose and duration of opioid use, combining with age, comorbidity, depression, and use of sedative-hypnotics, were associated with evidence of erectile dysfunction.

The Evidence (Taken from the Spine Abstract):

Summary of Background Data. Males with chronic pain may experience erectile dysfunction related to depression, smoking, age, or opioid-related hypogonadism. The prevalence of this problem in back pain populations and the relative importance of several risk factors are unknown.

Methods. We examined electronic pharmacy and medical records for males with back pain in a large group model health maintenance organization during 2004. Relevant prescriptions were considered for 6 months before and after the index visit.

Results. There were 11,327 males with a diagnosis of back pain. Males who received medications for erectile dysfunction or testosterone replacement (n = 909) were significantly older than those who did not and had greater comorbidity, depression, smoking, and use of sedative-hypnotics. In logistic regressions, the long-term use of opioids was associated with greater use of medications for erectile dysfunction or testosterone replacement compared with no opioid use (odds ratio, 1.45; 95% confidence interval, 1.12–1.87, P < 0.01). Age, comorbidity, depression, and use of sedative-hypnotics were also independently associated with the use of medications for erectile dysfunction or testosterone replacement. Patients prescribed daily opioid doses of 120 mg of morphine-equivalents or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (odds ratio, 1.58; 95% confidence interval, 1.03–2.43), even with adjustment for the duration of opioid therapy.

More information on the study, and comment from the research team, can be found in this article on MedPage Today.


This video not only explains how pain relievers work, it also gives a great account of how pain (for example neuropathic pain) occurs in the body and is interpreted by our minds. For many of us who experience headaches,acute injuries, and other aches and pains, medications like AsprinTylenol or Advil are staples for pain relief. However, few of us understand how these drugs interact with our neuro-immune system to offset our pain. What we suffer from can range from acute,  or sub acute  pain in some cases, to chronic total body pain in others. For all, understanding how neuropathic pain starts, develops and spreads  in our body is integral in understanding how to manage it best. This video will hopefully shed a little more light on how our favourite pain relievers work in our bodies to counteract pain so that we can manage our pain more effectively. All the best!


More than managing headaches and chronic pain, Allevio is here to help you get your life back. Our services are completely geared to offering you the best relief available.

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240 Duncan Mill Road Main Floor Suite 101 Toronto, Ontario M3B3S6

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