Aromatherapy for Pain Relief

Introduction

Managing pain remains one of the biggest challenges in medical care today, with chronic disabling pain in particular affecting millions of people around the world. Our experience has shown us that in many cases aromatherapy can offer a significant way forward as either a complementary or alternative form of pain relief for a large number of people. There are several possible reasons why this may be so and this article aims to examine possible ways by which essential oils and the global aromatherapy experience may help the person in pain.

Pain as a Unique Experience

To begin with, we need to remind ourselves that pain is a multidimensional experience. Until relatively recently, pain was defined largely from a physiological/sensory viewpoint. One of the biggest contributions of Melzack and Wall in 1965[1] was to widen the understanding of pain to include somatic, cognitive and affective aspects that are all integral and essential to the pain experience. This acknowledgment that psychological and emotional factors also play a key role in how pain is perceived, appraised and effectively treated is a clear step forward.

Pain can be difficult to assess and classify. This is because the experience of pain is unique, subjective and highly personal. It also has complex psychological, social and spiritual aspects. As aromatherapists, we have to rely on the client to express their experience of the pain and to respect their impressions.

One of the most important steps a therapist can make in their initial assessment of the person in pain is to take a detailed case history. Within this context, there may be questions pertinent to the person's pain experience. Typical questions concerning the pain experience itself are included in Figure 1.

Figure 1. Typical pain questions Where is the pain? Is it localised or generalised? When did the pain begin? Is there a past history? Is it related to work, injury or activity? Are there aggravating or precipitating factors? Is there a pattern to the pain? Does it interfere with normal activities? Is it constant, intermittent or episodic? What is the pain like? What is its severity? Is there associated stiffness, swelling or inflammation? What helps to ease it? Are there associated neurological symptoms?

The words the person in pain uses to describe their pain can reveal their experiences from a sensory, cognitive and affective perspective. Words such as 'sickening', 'blinding', 'frightful', 'miserable' and 'unbearable' are commonly used descriptors. These words have significant affective or cognitive weighting. Words such as 'sharp', 'burning', 'shooting', 'pounding' and 'throbbing' have a more somatic emphasis. Thus effective listening skills are essential for the therapist in order to hear truly what the person is saying about himself or herself.

As a holistic approach is the most effective model for working with pain management, let us take a moment to explore further aspects of a person's unique experience of pain.

The Person in Pain

A general observation of the person in pain is that they are often 'trapped in the moment'. As time goes by and pain continues, the concept of a future without pain is harder to grasp and to focus on. Pain becomes the focus of their attention. Many people feel that they are controlled by pain; it dominates every aspect of their life.

There are many variables with regard to the perception of pain by an individual. However, the most common factor is that of anxiety, in particular the fear of pain or the fear of more pain. This has an impact not only on the experience of pain but also on the person's coping strategy that is highly individual and may be influenced by cultural and social factors as well as past experiences. A vicious cycle (Figure 2) may quickly develop whereupon fear leads to anxiety, which in turn increases attention and focus on the pain.

If pain persists, then instead of fear and anxiety, a sense of failure, frustration, anger and depression may be experienced. Depression is a feature of most chronic painful conditions. Often in this stage, the person is likely to adopt passive coping mechanisms or avoidance behaviour which in the short term can give some relief but in the long term can perpetuate the problem.

There are intrinsic relationships between injury, pain and stress (physical or psychological). Pain always initiates the stress response/alarm state. Any type of stress has a profound impact on the immune system. Chronic stress is particularly disabling. It can actually perpetuate and contribute to ongoing chronic pain via peripheral and central nervous system mechanisms.

Sleep deprivation is another common feature of the person in pain. This is partly due to the fact that pain creates an alarm state and thus affects arousal and wakefulness. A lack of sleep potentiates pain.

The sensation of pain also leads to postural, behavioural and social changes. If the person locks into a 'pain posture' and maintains this for any prolonged period of time, biodynamic stress is placed on the musculoskeletal system, leading to compensatory changes that may include endocrine and nervous system changes and lead to further imbalance. Furthermore, the 'sick role' that the person may adopt may include further behavioural and social changes that perpetuate the problem. If a person's experience has taught them that a particular action (e.g. a massage or a cup of tea) brings relief, their expectation is likely to affect the end result positively.

One of the most common assumptions by the person in pain is that activity/exercise will exacerbate or aggravate the condition. In many cases this is a false assumption, at least in the case of chronic pain or when avoidance of activity and movement is prolonged. Periods of inactivity can lead to a vicious cycle (Figure 3) whereby pain creates fear and leads to avoidance behaviour that in fact increases disability and pain. Thus avoidance of activities that may create pain may help to reduce anxiety but in fact precipitates the pain itself!

If we consider the above points as situations we frequently encounter with persons in pain, it becomes obvious that essential oils may be able to give positive assistance in a number of ways that can directly or indirectly affect the pain experience.

How Aromatherapy Can Help

Generally speaking, aromatherapy has a positive role to play with regard to pain management, both in reducing existing pain and preventing/reducing anticipated pain. If we take the various aspects of pain (somatic, affective and cognitive) we can summarize as follows.

Working with the Somatic Aspects of the Pain Experience

Aromatherapy can work in real, direct and practical ways to help reduce pain perception. Figures 4 to 8 list typical essential oils used to exert the physical effects mentioned below.

The reader is referred to the bibliography at the end of the article for examples of research pertaining to these physical effects. Essential oils can be used to:

* reduce inflammation (Figure 4);
* give a local anaesthetic effect (Figure 5);
* create a counterirritant stimulus (Figure 6);
* establish analgesia (Figure 7);
* reduce spasm (Figure 8);
* create a sensation of cooling (essential oils such as peppermint and eucalyptus);
* create a sensation of warmth and increase local blood flow (rubefacient essential oils).

Figure 4. Anti-inflammatory essential oils
Achillea millefolium Chamaemelum nobile Matricaria chamomilla Helichrysum italicum Cedrus deodara Cymbopogon martinii Mentha arvensis Lavandula angustifolia Zingiber officinale Pinus sylvestris	yarrow Roman chamomile German chamomile immortelle Himalayan cedarwood palmarosa cornmint lavender ginger Scots pine

Figure 5. Local anaesthetic essential oils
Syzygium aromaticum* Ocimum gratissimum Cinnamomum verum fol.* Laurus nobilis Lavandula angustifolia Mentha piperita Mentha arvensis * to be used with professional advice only	clove bud tree basil cinnamon leaf bay laurel lavender peppermint cornmint

Figure 6. Counter-irritant essential oils
Laurus nobilis Rosmarinus officinalis Piper nigrum Thymus vulgaris ct thymol* Origanum vulgare* Syzygium aromaticum* Cinnamomum camphora Gaultheria procumbens* Betula lenta* Mentha piperita Eucalyptus globulus Melaleuca cajuputi * to be used with professional advice only	bay laurel rosemary black pepper thyme thymol chemotype oregano clove bud camphor wintergreen sweet birch peppermint eucalyptus cajeput

Figure 7. Analgesic essential oils
Cymbopogon citratus Lavandula angustifolia Lavandula latifolia Lavandula x intermedia Laurus nobilis Mentha piperitat Eucalyptus globulus Elettaria cardamomum Pinus sylvestris Coriandrum sativum Cedrus deodara Melissa officinalis Melaleuca cajuputi Gaultheria procumbens* Betula lenta* * to be used with professional advice only	lemongrass lavender spike lavender lavandin bay laurel peppermint eucalyptus cardamom Scots pine coriander seed Himalayan cedar melissa cajeput wintergreen sweet birch

Figure 8. Antispasmodic essential oils
Lavandula angustifolia Ocimum basilicum* Citrus aurantium Salvia sclarea Eucalyptus citriodora Origanum majorana Chamaemelum nobile Artemisia dracunculus* Elettaria cardamomum * to be used with professional advice only	lavender basil methyl chavicol and linalool chemotypes petitgrain clary sage lemon scented eucalyptus sweet marjoram Roman chamomile tarragon cardamom

In order to exert the aforementioned effects, the essential oils need to be applied to the skin, preferably in the locality or close to the site of the pain. Hot or cold compresses, ointments and creams or gels containing essential oils are the most common forms of application, with the dose and frequency of application dependent on the type and severity of the painful condition.

If combined with massage or other physical therapy, there are additional benefits:

* Restoration or improvement in mobility;
* Short-term relief by joint mobilization;
* Increase in endorphin production;
* Activation of descending pain control systems;
* Stimulation of healing in peripheral joints;
* Sensory distraction as a form of pain relief.

Obviously the usual contraindications to massage apply in painful conditions, such as over broken bone, severe inflammation or infection.

Working with the Affective and Cognitive Aspects of the Pain Experience

It is in this sphere where a holistic aromatherapy treatment can be used to its fullest potential. As the affective and cognitive aspects of the pain experience are just as important as the physical/somatic aspects, aromatherapy goes far beyond the physical to give sound and lasting benefits. Here the selection of essential oils is more open to interpretation, as each client has individual needs and preferences and the therapist has their own experiences of how essential oils work on the mind and emotions. For example, essential oils and the overall treatment approach can be selected for:

* inducing relaxation to override abnormal prolonged stress;
* improving disrupted sleep patterns;
* increasing motivation;
* improving mood states;
* restoring confidence;
* engaging social skills;
* providing emotional and cognitive support and counselling;
* using non-judgemental listening skills;
* encouraging a sense of control over pain;
* using a whole-person focus rather than a pain focus;
* acknowledging anxiety and fear;
* encouraging active and positive coping strategies;
* encouraging greater mobility.

Much of the above-mentioned effects are achieved through inhalation of essential oils during treatment coupled with a more general holistic approach. The therapist-client relationship is fundamental to supporting the person in pain. Once the client has achieved a sense of control over their pain in conjunction with the use of essential oils, it is often the case that merely the aroma of the selected blend of essential oils is sufficient to instigate a cascade of responses that include relaxation, positive affect and improved confidence. Helping the person to live with chronic pain and encouraging them to use positive, active coping strategies are perhaps the greatest rewards of aromatherapy.

To further illustrate how aromatherapy can help, consider the following case history.

Case History - Jane - Severe Headache

Jane is a 32-year-old personal assistant who works in the city of London. She has come for aromatherapy treatments at the suggestion of her doctor who has been investigating her one-year history of tension-type headaches. These occur at least once per week, usually in the evenings after work and can last all night, disrupting sleep and leaving her tired and stressed the following day with feelings of being unable to cope. She dislikes taking prescription medication but does so reluctantly when the pain is severe. She describes the pain as "blinding, pounding and unbearable" and associated with nausea. Her other health history is unremarkable.

On questioning, she reveals that the severity of her headaches has increased in parallel with increased workload, office changes and stress at work. Her working hours are long and her diet and fluid intake are erratic. She takes no regular exercise, and her social life revolves around drinking with colleagues after working hours.

Treatment Approach

Jane's aromatherapy treatment plan was twofold. Firstly, twice-weekly evening massage sessions were arranged. These lasted one hour and were focused on her upper body (head, neck, shoulders, back, arms and hands) in an attempt to reduce the muscle tension in these areas that are likely to be contributing to her headaches. The advantage of this approach is that the selection of essential oils can include ones for her stress and anxiety as well as muscular relaxation as the massage is also exerting psychophysiological effects. Thus the oils were selected for their antispasmodic, analgesic, calming and uplifting actions (see Figure 9). As Jane was involved in the oil selection process, the overall blend was highly personalized and once blended had a pleasing fragrance. The sessions were planned to leave her deeply relaxed and the same blend of essential oils was deliberately used with each subsequent treatment to establish a conditioned response, helping Jane to link the blend with a feeling of relaxation, even when massage was not used. Jane was then encouraged to use this same blend of oils at home and at work whenever she felt stressed.

Figure 9. Blend 1 - giving a 2% concentration of essential oils
Citrus aurantium ssp aurantium fol. Chamaemelum nobile Origanum majorana Lavandula angustifolia Cedrus deodara Simmondsia chinensis	bitter orange petitgrain essential oil Roman chamomile essential oil sweet marjoram essential oil lavender essential oil Himalayan cedarwood essential oil jojoba oil	0.1ml 0.1ml 0.2ml 0.3ml 0.3ml 49ml

The second approach was to help Jane directly when headaches did occur (see Figure 10). This blend was predominantly created for its physical action in reducing pain[2] and given to Jane for use at home. Jane was advised to apply a small amount of the blend directly to the forehead, neck and pressure points just below the skull. The concentration of the formula was deliberately raised in order to exert the desired therapeutic effect. The use of gel as opposed to carrier oil was to enable easy penetration and not leave a greasy feel on the skin or hair.

Figure 10. Blend 2 - giving a 15% concentration of essential oils
Mentha x piperita Eucalyptus globulus Aloe vera	Peppermint essential oil Eucalyptus essential oil Aloe vera gel	0.5ml 0.25ml 4.25ml

Outcome

Following a fortnight of twice-weekly massage sessions and regular use of the blends at home, Jane was able to reduce her appointments to weekly and then monthly massage treatments as her frequency of headaches diminished. After the first month of regular treatment, the blend of essential oils was altered to suit her changing needs. When she did experience pain, the concentrated gel blend helped to reduce its severity quickly to a manageable level, leaving her clear headed and relaxed and without the usual accompanying nausea. The benefits she experienced were not solely confined to her headaches; she found she also had more energy, her quality of sleep improved and her anxiety levels reduced. As she improved, she became more motivated to make lifestyle changes. These included:

* altering her office layout, especially with relation to her computer chair and computer screen;
* taking regular short breaks to get fresh air;
* making healthy packed lunches and snacks;
* consciously drinking more water during the day;
* using her leisure time more constructively;
* developing assertiveness and delegation skills.

Conclusion

From the above it can be seen that a holistic aromatherapy approach holds much potential for offering deep and lasting pain relief. It goes without saying that the responsibility of the aromatherapist to work always within their sphere of competence. When working with the person in pain, in many cases the person is under the simultaneous care of their doctor or other health-care practitioner (osteopath, chiropractor, etc). Close liaison between practitioners is essential.

References

1. Wall P D and Melzack R. Textbook of Pain. 4th ed. Churchill Livingstone Press. London. 1999.
2. Gobel H et al. Essential plant oils and headache mechanisms. Phytomed. 2(2): 93-102. 1995.

Bibliography

Afifi NA et al. Some pharmacological activities of essential oils of certain umbelliferous fruits. Vet Med J Giza. 42(3): 85-92. YEAR?
Buckle J. Use of aromatherapy as a complementary treatment for chronic pain. Alt Therapies. 5(5): 42-51. 1999.
Chandra D and Gupta SS. Anti-inflammatory and antiarthritic activity of volatile oil of Curcuma longa (Haldi). Indian J Med Res. 60(1): 138-42. 1972.
El Tahir KEH. Exploration of some pharmacological activities of cardamom seed (Elettaria cardamomum) volatile oil. Saudi Pharmaceut J. 5(2-3): 96-102. 1997.
Galeotti N et al. Local anaesthetic activity of (+)- and (-) - menthol. Planta Med. 67: 174-76. 2001.
Ghelardini C et al. Local anaesthetic activity of the essential oil of Lavandula angustifolia. Planta Med. 65: 700-03. 1999.
Gobel H et al. Effect of peppermint and eucalyptus oil preparations on neurophysiological and experimental algesimetric headache parameters. Cephalagia. 14: 228-34. 1994.
Harris B and Lewis R. Pain management: a hands-on approach. Parts 1 and 2. IJACM. 12(8) and 12(9). 1994.
Hong C-Z et al. Effects of a topically applied counterirritant (Eucalyptamint) on cutaneous blood flow and on skin and muscle temperatures. A placebo-controlled study. Am J Phys Med Rehabil. 70: 29-33. 1991.
Krall B et al. Efficacy and tolerance of Mentha arvensis aetheroleum. Program abstracts. 24th Symposium Essent Oils. 1993.
Krishnamoorty G et al. Anti-inflammatory activity of the essential oil of Cymbopogon martinii. Indian Journal of Pharmaceutical Sciences. pp114-16. 1998.
Lorenzetti BB et al. Myrcene mimics the peripheral analgesic activity of lemongrass tea. J Ethnopharmacol. 34(1): 43-48. 1991.
Santos FA and Rao VSN. Anti-inflammatory and antinociceptive effects of 1,8-cineole a terpenoid oxide present in many plant oils. Phytotherapy Research. 14: 240-44. 2000.
Schafer K et al. Effect of menthol on cold receptor activity. J Gen Physiol. 88: 757-76. 1986.
Seth G et al. Effect of essential oil of Cymbopogon citratus Stapf on the central nervous system. Indian J Exper Biol. 14(3): 370-71. 1976.
Sharma J et al. Suppressive effects of eugenol and ginger oil on arthritic rats. Pharmacology. 49: 314-18. 1994.
Viana GSB et al. Antinociceptive effect of the essential oil from Cymbopogon citratus in mice. J Ethnopharmacol. 70: 323-27. 2000.
Von Frolich E. A review of clinical, pharmacological and bacteriological research into Oleum spicae. Wein Med Wochenschr. 15: 345-50. 1968.
Wall P. Pain - The Science of Suffering. Phoenix Press. London. 1999.