Episode 12: How Chronic Pain Is Connected To The Gut Microbiome

Hello, and welcome to the Better Biome Podcast where we explore the universe within.

We're your hosts, Dr. Nicole Beurkens,

And Kiran Krishnan.

And on today's show, we're talking with Dr. Joe Tatta about chronic pain and its connection to the gut microbiome. Dr. Tatta is a leading expert in lifestyle interventions for treating persistent pain. A unique combination of physical therapist and nutritionist, he has 25 years of experience creating integrative models of pain management and clinical systems for private practice innovation. He holds a doctorate in physical therapy, is a board certified nutrition specialist, and has trained extensively in cognitive and behavioral techniques for the treatment of pain. Dr. Tatta is the founder of the Integrative Pain Science Institute, a company dedicated to reinventing pain care through education, research and professional training. He also volunteers his time on the New York Physical Therapy Association's Opioid Alternative Task Force. Dr. Tatta is author of the best selling book Heal Your Pain now, and host of The Healing Pain podcast featuring interviews and free training from respected clinicians and researchers. Welcome to the show, Dr. Tatta.

Thanks for having me here. Thanks for inviting me.

It's so great to have you here. This is such an important topic. So many people are struggling with chronic pain and don't know what to do about it. So we're really excited to delve into this. But I'd love to start by having you share a bit about your career journey. How did you come to be doing this really specialized kind of work?

Yeah, it's a great question to start with. I have a clinical doctorate in physical therapy. So when you think of a physical therapist, you at first think of someone who's interested in maybe sports medicine, orthopedics, or maybe works in a nursing home with people who are maybe more frail. And for the first part of my journey in my profession, I worked in outpatient physical therapy, and I did all the things that physical therapists do, manual therapy and therapeutic exercise, and lots of patient education. And I actually started this really small personal training business on the side. So after the therapy patients were gone for the day, we had people who personal train come in for regular exercise programs. Nice, healthy, well, people who want to optimize their health. Along with those exercise programs, they started asking me questions about nutrition, what should I eat? What's the best diet? I want to lose some weight? I want to lose this muffin top. All very common questions that many healthcare professionals get. So I just started to dip my toes into, well, let's take out sugar first. Let's take out the appetizer and just have an entree. And I noticed people, of course, losing weight. But there were really other interesting things happening like swelling was getting better, people's pain was being alleviated. They were sleeping better. So once I saw that happen, I was like, "There's got to be something more here that I'm not seeing. There's got to be research behind this." I started of course, like all of us in PubMed first, doing my own research, then I said let me take some courses and classes, that led me to getting board certified in nutrition. And then now we really have started to weave all of this together to help people with pain, which is important, because we know that for treating people with pain, more than one modality or more than one treatment is what's really the best and safest way to treat them.

Yeah, so one global question maybe to follow up with that is, why are people in the Western world in so much pain? I mean, pain is a neurological signal to elicit a reaction, if you will, to remove your finger or hand or whatever it is, from a source that could harm you if you're touching something hot, for example. Why are we in so much chronic pain? What's going on?

Yeah, it's a great question that we can explore this on an individual level all the way up to a society level. The biggest thing is that we have, first, a lack of education about pain. Probably over the last 50 years, our primary approach to pain was either a pharmaceutical or an intervention such as injection or a surgery. Through the opioid epidemic, we have brilliant research and of course real life experience that that's not the way to go for pain. Many of the interventions, the surgical interventions, most of them were injections that people are having now for pain. Again, they don't alleviate chronic pain. They have their place for acute pain, yeah, but for chronic pain, no. So that's where we've been. We're kind of now in this transitional period, trying to figure out okay, what really works and what combination works best for different populations of people?

And to me that's really interesting when we started looking at that transition because the treatment has been, okay you have pain, let's stop the signal, right? That's what the surgical or the pharmaceutical interventions are doing. Here's your nerve telling you something is wrong, let's quiet that nerve or shut that nerve down. We're not really looking at why the pain is there, right? So I'm guessing that the work you do kind of takes a bigger holistic approach to why is the pain there in the first place.

Yeah, so with that pharmaceutical, as you mentioned, they're trying to, in essence, shut that pain signal off. It sounds really good. Like there's a switch that goes on and off. But in reality, pain is really, really complex. It involves aspects of your musculoskeletal system, aspects of your nervous system, aspects of your immune system and your endocrine system. There are cognitive behavioral changes that happen. So you have this matrix, almost like this web, where pain is in the center of that web, and then the practitioner has to figure out, okay, what part of this web do I focus on first? What's most important for this particular patient? And when I say "that particular patient", pain is contextual. So for one patient, it may be the cognitive behavioral aspect that's really important. For the next patient, it may be the nutritional aspect that is most important. Oftentimes is usually a combination of about three or four that we need to focus on. But from a practitioner perspective, it's interesting, because it really calls on you to use all of your skills, all of your education. And that's why I train practitioners on how to do these things, because they need a lot of different tools to help people.

I want to just even be clear for people who are listening. We're talking about chronic pain. You mentioned the term acute pain. There's a difference, and I think that's important as we start to delve into this further, to just break that down a little bit, what are the two sorts of categories of pain?

It's super important. So there's, as you mentioned, acute pain and chronic pain. So acute pain is the pain we all know. So you fall and let's say you break your leg, and you have a broken bone, bone takes anywhere between six to eight weeks to heal, bone heals. And as the healing is happening, the pain is going away and decreasing. A sprained ankle or maybe a cut on your wrist or a little booboo on your knee, like when you're a kid, heals very fast and rapidly. As that healing happens, as the tissue healing happens, your pain goes away. With chronic pain, there's actually little to no tissue healing in general within peripheral tissues, but there's actually what they call sensitization of the nervous system. So actually, in the nervous system, both the central nervous system and the peripheral nervous system, there's what's called neuroinflammation. So it's inflammation happening in that system.

So this is pain that persists.

Yeah.

And is it often the case that someone starts out with maybe some kind of acute pain and then sort of gets stuck in that, becomes chronic? Or how does that happen?

Yeah, some people have an injury, and even though the tissue heals, their brain, as you mentioned before, is still kind of paying attention to that pain. And once it gets beyond that three month period of time, it's identified as chronic pain. Some people have metabolic diseases which cause systemic inflammation. That can become chronic. And then there's kind of this in between part, which is called nociplastic pain, which basically means there are both contributors of peripheral tissues, as well as the central nervous system.

And it sounds like inflammation plays a role in all of this to some degree.

It does, especially when we start to talk about centralized pain. So pain that's actually in the central and the peripheral nervous system. We know that there's neuroinflammation that's caused by many different factors. A poor diet is one of them, though.

Yeah. And speaking of diet, then, does the gut microbiome get involved in this?

It does. What's interesting — So you mentioned the brain before it. So let's kind of talk a little bit about the brain first. So your brain, first and foremost, is concerned about safety. The way your brain kind of surveys the area, it takes in information. How does your brain take information? Through your eyes, through your nose, through taste, through hearing and then through touch. So those are the five senses. We all know our five senses. I actually look at chronic pain, I look at this actual sixth sense that's been left out, and that's the gut. And why is this a sixth sense? Because your gut has a direct connection to your brain. And actually, what's inside the gut technically, is actually outside the body. Because your digestive tract is a long tube that's opened on two ends. The other thing is, inside your gut, the nervous system has more nerves in it than your spinal cord does. So if I take that back to my clinical experience, I used to work in a spine clinic, we just saw spine patients. And back in the kind of early 2000s, spinal cord stimulators were really common. They were implanting them in people's spines to try to shut the signal off before it reached the brain. It didn't work very well, and had lots of bad side effects. But now that we know the research with regard to the gut microbiome and our second nervous, our second brain, actually in our gut, it makes sense that we look there to try to modulate that signal before actually going to the spinal cord.

Right. And that's because the enteric nervous system, the nervous system that basically coats the digestive tract is even more complex and your spinal cord itself, as you stated. And the microbes have direct access to your brain through the vagus nerve. And so they can play a role in how your brain interprets sensory input.

So we look at that peripheral sensitization that ultimately leads to that central sensitization. Poor nutrition is a doorway to that. So there's poor nutrition, obviously, being peripheral inflammation, there's oxidative stress in the periphery. And then finally, there are changes in the gut microbiome. And as you mentioned before, that gut microbiome connects and communicates with that enteric nervous system first and foremost.

This is such a different way of thinking about this, because really, as you alluded to earlier, people are so conditioned to think about "When I am having pain, this chronic pain, this pain that's now been ongoing for months and months, there must be something wrong in my body. The injury hasn't healed, there must be a surgery that's needed, there must be a medication that's needed." And that, from the medical professional, is the message that's been sent, right? As you said, with sort of the traditional modalities. But what you're talking about is that really chronic pain is not about a certain place of an injury, it's not about a certain place in the body. It's about a much more systemic process than that.

That's right. So we can use things like imaging study, so X-Rays and MRI to see what's happening in a joint. What you do with that information after you "diagnose" that injury or diagnose that condition is what's important. So if you see inflammation in a joint, if you're, let's say, a traditional allopathic orthopedic surgeon, you may decide to prescribe an anti-inflammatory or you may decide to perform an interventional surgery where those of us in the integrated field would say, "Okay, what's leading to that joint inflammation?" We know that there is a gut-joint connection, we know there's a gut-pain connection. So starting to look at someone's diet and optimizing their microbiome, in essence, is safer, potentially more effective, cheaper and easier for the patient. You don't have to go under anesthesia, you don't have to be overnight in the hospital. These are all the things that patients are looking for now. But you know what to kind of keep in mind? That people are getting smarter. They're reading things on the internet, they're listening to podcasts like this or educating themselves. And they're saying, "Okay, I could maybe change my diet, optimize my diet, start moving, start some physical activity," which actually optimizes the microbiome as well. "Or I could "go under the knife", go into anesthesia, and be laid up for potentially four weeks and be out of work. So these are things that people are weighing, and they're important for practitioners to start to talk about, because these are where we look at, okay, how am I going to create my clinical practice to help support this consumer need?

Yeah. And the resolutions you're talking about, the other solutions you're talking about for chronic pain, the diet modifications, lifestyle changes, paying attention to what you're putting in your body and all that, are actually very similar to a lot of people that we interviewed who are dealing with other chronic conditions, right? Depression, anxiety, obesity, heart disease, autoimmune disease, whatever it may be. So my guess, I would connect that as you're treating people for chronic pain by taking this approach, you're probably helping other conditions that they're also dealing with.

Yeah. So when you look at people with chronic pain, two things come to mind" They have multiple comorbidities. So all the things that you're seeing on both the physical and the mental health side, they oftentimes struggle with, and they have a decreased health span, as well as a decreased lifespan. So that healthspan and lifespan are really important when we're trying to help people with pain, because chronic pain is the number one cause of physical disability, pretty much globally. So people are physically disabled, and then they also live a shorter life. So we're seeing generations of people who are now living shorter lives than their parents, and chronic pain is one of the reasons for that.

There's a huge overlap as well, in people with chronic pain and mental illness issues, things like depression anxiety in particular, right?

Yeah. Big. I mean, depending on the study you read, if you look at people with osteoarthritis, it's about 50% to 75%. If you look at fibromyalgia, it jumps to 75% to 100%. Those people often have the most persistent pain, haven't been able to find a cure and those cognitive behavioral interventions help modulate the gut microbiome. They help modulate inflammation. So if you can have, let's say, a practitioner like Nicole, who's integrating those cognitive behavioral therapies with nutrition, they really become a win-win.

Yeah. When looking at nutrition and diet modifications, what are some of your go to staples when you're looking at what people are either eating too much or not enough of? Where do you start that work?

So it really depends on the chronic pain syndrome. So I try to break them up into categories as best as possible. So if we take, let's say, people who have some type of metabolic syndrome as well as osteoarthritis, that's kind of category number one.

So diabetes, obesity, those kinds of things.

Exactly. So that category combined with those who have osteoarthritis, they'll respond relatively well to a modified Mediterranean diet, or your baseline Mediterranean diet. Once you start moving outside of that category, then you have to start to look at other types of therapeutic diets that can help people. So autoimmune disease is probably about half of the 100 million Americans that have pain, then you have to move towards some type of autoimmune protocol. Then there's lots of good research that has come out of the studies based on headache with regard to nutrition. And those patients, when you look at the functional MRI of what happens with a headache, there's like this depolarization that moves throughout the brain, throughout the entire cortex. And that's a similar model to central sensitization. So those patients do really well with higher fat, lower carbohydrate diets. I'm not going to necessarily say ketogenic because for some people, you may not necessarily have to go that far, but just moving them to a lower carbohydrate, higher fat diet can be beneficial for them

Any particular type of fat that you have them focusing on?

The Omega Threes first, first and foremost. The studies on the anti-inflammatory effects of those are well proven, somewhere between 3000 and 10000 milligrams, depending on the study you're reading. I say if you can get people up to 5000 milligrams, that's a nice sweet spot for people. Done through, of course, cold water fish as well as supplements. There are some good studies, specifically with regard to chronic pain, that people need upwards of five servings of fish a week. The typical dietary approaches are somewhere between two and three. Then they need to go a little bit further to help them overcome what their other challenges are.

So people suffering from migraines are really suffering from very similar chronic pain as people that suffer from pain in the other parts of the body.

Yeah. And then of course, food sensitivities are important to the gut, pretty much with everybody.

How about things that people with chronic pain conditions are eating or have in their diet that are not helpful? So it's good to know specific types of diets that can be helpful, but how about just in general, things that most people are incorporating that just are probably not helping their pain or making it worse?

Yeah, simple. I always say if it comes in a box or a can or made by man, it probably doesn't have a place in your diet. So when you look at the American diet, they say 60% of Americans are eating mostly processed foods, or what I call junk food. It's probably higher depending on where you are in certain parts of the country. So first, just moving to that whole food diet is really important. Sugar, we're in New York City, there's a Starbucks on every corner that serves huge coffees that really are just milk shakes, that have upwards of 55 grams of sugar. Sugar is a fantastic way to create systemic inflammation in your body. it's a fantastic way to damage your nervous system, we need to move people off that. Even the American Heart recommendations for sugar, which for men can be 30 grams of sugar — too much. We have to really bring them down to something under 10, as far as I'm concerned.

So those pieces can be great starting points for people who just even want to play around with the idea of how the food that they're eating can impact their pain just to kind of see what they experience.

Yeah. And that's what's fun about food and nutrition, it's that everyone's eating, and so they're already doing something you want them to do. It's not like you have to work on changing their behavior. Yes, you have to modify their behavior a little bit, introduce them to some different types of foods, but ultimately, everyone's eating three times a day. So even as a physical therapist, I tell people that when you're doing your rehab exercises, do them once or twice a day. Yeah, but with nutrition, I have a way to optimize someone's health, to decrease inflammation, to optimize their microbiome three times a day, potentially more if you're looking at supplements and other types of interventions.

Yeah. With chronic pain, I'm guessing it's going to be hard for people to motivate themselves to get out and get moving because they are not in a comfortable state. How important is it on the physio side to get people actually moving to some degree?

Super important. I mean, when you look at the combination of nutrition and physical activity or nutrition and exercise, that's where the research sits the best. It is difficult for people to get moving. One is they need a lot of support without a doubt, a lot of encouragement. Some types of strategies to help with their behavior change, but once they start to move, they generally feel better. So when we go back to that kind of web I was talking about before, the musculoskeletal system, gentle movement is really a nice way to kind of modulate and down regulate your nervous system and to make you feel better.

Sure, are there devices that you have people use to help them get some movement in? Those vibrating plates and all kinds of things that are available these days to help people who can't naturally go out for a jog to move?

Yeah, lots of things. So one of the oldest and has some really good research behind it is a simple TENS unit, which stands for Transcutaneous Electrical Neuro Stimulation. And just putting it on the part or around the part where you're not feeling well, and maybe a little bit sore there, a little bit achy, it's a nice way to alleviate some pain there. People can actually wear it when they exercise, they can wear it to bed, they can wear it when they're at work, they can wear it when they're doing any of their typical ADLs. So it's a really nice way for people looking for a little bit of help. So they don't feel good. It doesn't feel good to wake up in the morning and have pain shooting down the back of your leg and in your back. It drains your energy. It impacts your social system and your friends and your family. So we want to meet people where they are and give them a little bit of help to help them overcome that.

You mentioned a little bit ago, obviously about the impact of nutrition on the microbiome. But I heard you say something too, about the research on movement exercise and the microbiome. Let's talk about that a bit more.

So it's interesting. So when I first started learning about movement in the microbiome with people who are involved in high intensity athletics, so if you look at CrossFitters, or even long distance marathon runners, they're likely to have intestinal permeability that happens if they're not well trained. If you're well trained, you're working your body up and it should be okay. But oftentimes, when you start those types of exercise programs, you see intestinal permeability. So that's the high end of the spectrum. On the low end of the spectrum, when you're not exercising, one of the important things that does not happen is your gut motility slows down. So exercise helps your gut motility. Exercise helps move food from your stomach all the way out through your colon. So it helps to increase motility, which is really important for people with change in their microbiome. It's also really important for people who are on opioids, because opioids cause constipation. So we're looking for natural ways to help people have a bowel movement without placing them on yet another pharmaceutical medication. So again, moderate activity, somewhere in the middle. Things that I like and recommend are a gentle yoga class, really great for stretching and strengthening, really great for stress reduction. There's a mindfulness component to gentle yoga, which is very helpful for people with chronic pain. And then some of those positions actually place different pressures along your gut, which is actually really good for your gut motility.

Sure, that makes sense. And then when it comes to the nutrition feeding side, do you do anything with fasting, intermittent fasting and so on?

So there's wonderful studies on fasting that are very controlled. Usually people are fasting for somewhere between four and seven days, just a simple water fast. I have some concerns about that for clinicians that are placing people on aggressive fasting schedules, only because these are patients that typically have multiple nutrient deficiencies, but had problems with energy production. So placing them on severe or prolonged fasts, I have not found that to be a really good approach for people. If you want to work on fasting with people with chronic pain, then do that as they fast overnight. And so stretching out that 12, 14, 16, maybe even 18 hours over bedtime. But I have concerns, especially with women, when it comes time for long, prolonged fasts, for people with chronic pain, specifically.

So more of the intermittent fasting, the 12 to 16 hours a day kind of approach.

Yeah. And if you want to skip an occasional breakfast, that's fine, that can prolong a fast. If you want to have a very small or very light meal for dinner, or maybe just a simple protein shake. That's fine, too. But more than two day fasts for people with pain, it tends to deplete them really fast, both their energy stores as well as the nutrition stores. And their nervous system just starts to just kind of modulate down really fast.

And so from a nutrition standpoint, that's probably something to keep in mind too then, is the deficiencies that many of these people have. And do you feel like that results from sort of chronic nature of their body having to put so much into managing pain over time? Is that food? Is it the impact of medications that they're on?

It's definitely food first. So we look for food first. So that poor diet is nutrient deficient. The other one which no one talks about and you don't hear anything about it in the news, it's in the literature, but not really spoken about at conventions and places where professionals are talking about it, are opioids. Opioids deplete vitamin A, all the B vitamins, all your amino acids, so when you're placing someone even on a gentle exercise program, you're hoping that they're going to build new tissue, new muscle, new tendon. If you don't have your amino acids, that's not going to happen. Magnesium and chromium which are important for that neuromuscular endplate, for that communication between the nerve and the muscle to happen, the longer someone's on an opioid, the more likely they are to be deficient in all those nutrients. So testing, of course, becomes important in that case.

And so the opioid is really not a solution for pain. I mean, it's a temporary Band Aid, if you will, but then it really makes things worse.

Yeah. We want to approach pain compassionately. Pain hurts. So there's a place for opioids. I always tell people: The lowest dose possible for the shortest period of time. And then we need practitioners to manage people and to watch what's happening with regards to their symptoms. Are they getting better? Are they not getting better? Long term opioid use leads to what's called opioid-induced hyperalgesia, which means the nervous system actually becomes better at producing pain. We already talked about constipation. The flip side of that is now we see lots of tapering schedules happening, which are important, and we need to support people on those tapers. But when you taper someone too fast, they actually have diarrhea, massive loose stools for days at a time. So a nice, gentle taper is what we want, helping them with some mental health to help them with that taper. And then of course optimized nutrition is a part of that.

So another nutritional group of compounds that have become very popular when it comes to pain management are cannabinoids. CBD and all the various forms of cannabinoids. Do you use cannabinoids in your practice? What are your thoughts on that and the latest research on the impact of cannabinoids on pain?

I'm really supportive of the research, I'm looking forward to more research on it. Where I've seen the, I'd say, the best support for patients with regard to pain is with sleep. So when you look at chronic pain, almost every patient with chronic pain has challenges with sleep, and that's where I see where the CBD has really helped. Does it help with pain? It does, it helps with some pain. It's not going to bring people down to zero for that many people. But if you can help them improve their sleep, then overnight, when all their neurotransmitters and hormones are resetting, then you can really help someone. The one thing that's in the literature that's interesting — so we've talked about different types of plant compounds now: Saffron

Oh, interesting. Okay. Yeah.

So there's some really good — There's two randomized control trials on saffron. And they actually put it up against methadone. Oftentimes people on methadone are on these tapering schedules. So 30 milligrams of saffron once or twice a day actually did better than methadone with helping people taper off of opioids. So in a capsule, of course, you can take it as a supplement. And of course, saffron can go and all your food. Delicious.

Yeah. Well, I think the issue with the opioid piece, it seems like we've gone from one extreme to the other very quickly, and I think that's left a lot of patients really feeling frustrated. Because it's sort of been this idea that we dole out these prescriptions, this is fine. Take these, take these. We've gotten all of these people's systems dependent on these drugs. They are not easy for most people to come off of. And now the pendulum has swung back the other way, where it's like, "Oh, we see these studies now that actually, we've done a bad thing here, we've created more problems, we've created all this dependency. We're not going to let physicians prescribe them anymore, and you have to come off of them quickly." And that leaves patients, who are already, in my opinion, a very vulnerable patient population, even more vulnerable in the midst of this going "But I've been on this, and now I'm supposed to go off of it. And I can't", and I think that what's going on right now is that so many patients are feeling such a sense of desperation and hopelessness with that, which is why I think the work you're doing is so important, but what are your thoughts on just that evolution of things?

I think we have an anxious situation. People are very anxious. Pain makes you naturally anxious. It's called pain-related anxiety. And like you mentioned, we have identified "a problem", then we pulled the rug out from under people. So we left them with no tools, no strategies at all, pretty much. Then we say, okay, let's not do this because people are hurting themselves because rapid tapers can damage people in lots of different ways. So now we're like, okay, how do we support people off the taper? Because when you really sit down with somebody who has been on an opioid for a long time and you talk to them, they will start to identify: "I don't feel good. I can't concentrate anymore. I can't sleep. I haven't had a bowel movement in over a week." So when you sit down with them and you spend time with them, one on one, they start to identify, "I really do want off this opioid." But many times, they've actually tried, and as they've been pulled off, as Nicole mentions, their pain actually gets worse because it's too fast. They can't sleep, they're having more sleep problems than they had. They have wide mood changes from depression to anxiety. So then we have to step up and say, okay, let's do a nice slow taper. And let's look at nutrition, which we know has a positive impact on sleep, we know has a positive impact on pain, we know has a positive impact on mood and various types of mood disorders. So if we can help support everything that's happening there, then that's the way we should do it. Now, the allopathic community has yet to kind of open up to this. So I would love to see tapering programs that combine many of the treatments that we're talking about here today. Will that happen? That remains to be seen. We have one multidisciplinary integrative pain program for every million people in the United States, which is scary. Yeah. So we know the insurance companies look at this and they say, "Okay, well, we know that nutrition works and physical therapy and psychology work. Those three practitioners are wonderful, but they're also expensive. So we're going to cover it for a very short period of time, or we're going to cover it very minimally", which leads people to pay for — A lot of these people have not worked for a long time, they're on disability and looking for options that are affordable. I think integrative practitioners are the way to address that problem.

And looking at that, then, looking at the whole approach of the integrative side of the practice, you can take an integrative practitioner, who is maybe just doing your conventional internal medicine type of care, and train them to be a pain specialist in a way, based on the the type of approach that you take.

I believe we can. I believe you can take most licensed health care professionals and teach them the foundation that's needed to provide integrative care to someone with pain.

Do you have resources on that? Do you do training courses? Do you have a book, anything like that, that you could…

I do. So I have a book that I wrote for the public, which the public have really enjoyed, but practitioners like it as well. It's called "Heal Your Pain Now, and it kind of models out an integrative approach to pain. And then from that, I started an institute called the Integrative Pain Science Institute, where I trained practitioners on integrative strategies to treat pain.

So if there's any practitioners listening to this, really, they should be looking into that because there's a significant amount of need for an integrative approach to pain management. and we don't have it on the allopathic side, obviously. And there are very few integrative practitioners doing it. And I'm guessing the prevalence of chronic pain just continues to increase. I don't have the statistics on it, but maybe you do, on the prevalence rate of this chronic pain.

Yeah, so it varies. But in general, we probably have about 90 million Americans who struggle with some type of chronic pain syndrome. That has not really changed much. It may have leveled off a little bit because we're getting better at identifying it. The one place that we are seeing chronic pain increase is in children and adolescents. So that's kind of where the new research is heading. So maybe we can stop some of this before it gets to the older population. But we have a couple of generations of people right now that have chronic pain. And once your nervous system becomes primed and sensitized, it takes a lot to start to turn it around. And that's why, at my institute, one of the first courses I teach is functional nutrition. That's the foundation of everything. So exercise is important. But you need the food and the fuel to move and be physically active. Cognitive behavioral therapy is important. But again, if your brain is not functioning correctly because it doesn't have the nutrients it needs, it's very difficult to move people through some of those phases.

Right. And ultimately, nutrition impacts the microbiome, and the microbiome plays such an important role in allowing us to function the way we're supposed to function.

Yeah. What I'm interested in watching with regard to the microbiome, specifically with regard to pain, is that it communicates with the microglia in the brain. So the microglia are these macrophages that really have two functions: One is it's anti-inflammatory. So it tries to create an anti-inflammatory environment. And then two, it gobbles up any type of neuron that is, in essence damaged, that's in a pro-inflammatory state. The other thing it does, it has these really cool arms that reach out and provide myelination. So those two things right there are so interesting. Your microbiome has a direct connection with the microglia in the brain, so with those immune cells, in essence in your brain.

Yeah. And those cells are implicated in neurodegenerative disorders as well like Parkinson's and so on, right?

Yeah. And that's where the chronic pain research actually started, by looking at models of Alzheimer's, Parkinson's dementia, to see what the similarities were, and they started to kind of piggyback off that.

Yeah. And then to bring it back to what we talked about earlier, the interesting first symptom of Parkinson's is constipation. So it starts in the gut.

That's right. Every day I have people, more and more people — because we see a lot of people with Parkinson's in physical therapy practice, so more and more people reach out to me and say, "Is it true what I'm hearing about the gut? This is where we need to look first.

You talked about, from a nutrition standpoint, food wise, different diets and things can be helpful. I'm curious from the standpoint of looking at supporting a healthy gut microbiome, specifically the things that people can do to increase the prevalence of good bacteria, to decrease the prevalence of the potentially harmful bacteria. Food is certainly one way to do that. Are there certain types of foods that you think are really important for patients with chronic pain, as it relates to properly feeding their microbiome? Or supplements or things like that you feel are important?

Yeah, it's interesting, looking at some of the research on FODMAPs, there's some really good research on FODMAP diets with regard to visceral pain. So a lot of patients with chronic pain also complained of visceral pain. So I don't think you actually have to put someone on a complete FODMAP diet, but trying to figure out which type of carbohydrates are beneficial for them and which type of not. And of course, we know that those carbohydrates are what the microbiome feeds off of. So that can be as simple as, for instance, avocado, which is very healthy, very anti-inflammatory, but people can overdo it with that, and they become very gassy. And those FODMAPs actually irritate their gut, which can of course, irritate everything else in your body, basically. So looking at some really kind of key categories of FODMAPs. So dairy being a big one. Fructose, which makes you think of fruit, I don't really go there first. I go to the high fructose corn syrup first, which is in all your products. Many people have fructose intolerances that they're not aware of. Yes, looking at things like mango and moving people towards more of the berries, that's fine. Lots of the fats, as we mentioned before, higher fiber diets for people, but those are the main…

So really, it sounds like for people to track, to be aware of and sort of keep track of "What are the things that I'm eating that are leading to more of these GI kinds of symptoms?", whether or not they think of their pain as being housed in their gut, but to just notice: Foods that make me gassier, more bloated, have pain, change my my bowel habits. So even noticing those things, then, people can start to cue into maybe what is healthier for them, for their microbiome.

That's right. So I usually like to look at food as far as — we're probably heading into elimination diets at this point. For people with chronic pain, they have a lot going on. So yes, you can put them on an entire autoimmune protocol. It's going to be a little challenging for them because it's hard for them to make that big change. So usually, like two or three foods is fine, like Nicole mentioned: Start with two or three foods and notice how that affects you. Notice how it affects your digestion. Notice if it affects your joints, your tightness, swelling your joints, notice if it affects your mood, your sleep. So two to three foods is really plenty for people to start out with.

And what about gluten? Is gluten a big driver of the inflammation and the issues?

Probably number two. Some people say "What should I eliminate from my diet?" Sugar first and then gluten is second. And the American Academy of Neurology actually supports a gluten free diet for people with neuropathic pain. So there's good research that you have support from a very allopathic community with that. So gluten would be number two.

And I think that's important for people to understand, is that these changes with food as they impact our gut microbiome, it doesn't take a tremendously long time to notice the difference. I mean, as somebody who struggles with some joint issues and things myself, you can make a change, and even within a couple of days, notice a tremendous difference with that. And I think it's important for people to know: You don't have to do this for weeks or months on end to determine how something might be impacting you.

That's right. So we know the microbiome changes within 24 hours, which is pretty amazing. And within 24 hours, you can change entire communities in your gut. Okay, so give that 24 to 48, probably around 72 hours, four days, people start to notice some kind of difference. And that's pretty amazing. Because it's safe, and it's effective. That's the amazing part about it. So, yes, you may be able to take Advil and feel better within a couple hours. But that's not a long term solution.

You'll be taking another dose in four hours, probably

From the standpoint of supplementation, whether we're talking about supplements related to the microbiome or just nutrients in general, you mentioned the essential fatty acids that can be helpful to do and supplement form mainly because people aren't eating enough fish and those kinds of things. Are there other key things supplementation wise that you find are helpful?

I'll tell you about a study that I recently read that is interesting, and it [inaudible 0:39:46.4 my gut microbiome is communicating with my enteric nervous system, and we have so much of it, maybe 50 is not enough. Maybe we actually need to go to 100, 200. So those are the things that I'm interested in watching because I actually think we need to give people actually a lot more than what we're prescribing, as far as probiotics for them and probiotics.

Sure, yeah. And I think a lot of it is because we really don't encounter bacteria as much as we should, naturally, like we used to. People living on farms or off the land, as we've done so through the vast majority of human evolution, we've now segmented ourselves away from most microbes and live in sterile environments. So the more we can get beneficial or non-harmful bacteria into our system, probably the better off we'll be.

That's right. And for these patients with comorbidities, oftentimes, they're sicker more often, they're more likely to be prescribed an antibiotic. So it makes sense that we start to say, okay, maybe we should actually increase how much probiotic is in their diet.

Yeah, do you have the patients that you work with change anything in their household that you think would contribute to their progression and improvement in their symptoms?

That's a big question. Lots of things: Their sleep environment first. Second, is to try to get them more mobile within their actual current environments, so many people are sedentary at home. So just trying to figure out simple ways to get them off the couch. If they're taking daytime naps, which sometimes people need, that doesn't happen on their living room couch. Naps are meant for bed only. So starting to accommodate, or having to be more accustomed to sleep and naps happening in the bedroom and not on their couch. And having them start to move more throughout the day. And then of course, their kitchen environment, looking at their kitchen and starting to have them bring in healthy foods. What winds up in their shopping cart is going wind up in the refrigerator, on their plate and of course in their body.

Yeah. And what about the family and the people that surround them? Are there things that they should be considering in order to be supportive and empathetic to the person that's dealing with this condition? So somebody who's listening may have a close family member or a spouse or somebody that's dealing with chronic pain. What are some of the things they can do to really support that?

Yeah, like many chronic diseases, this could be a family affair. So looking at your physical activity level, and maybe kind of buddying up with your partner or your family member and saying, "Hey, let's go for a little bit of a walk after dinner", or "Let's put on a yoga tape on the television. Let's try that on the weekends." Helping children as well is a big part of that. So there's lots of interaction between kids and parents with chronic pain. So helping them, facilitating that interaction. And then there are some good online platforms where people can interact with other people who have chronic pain from their home. Those are important. But ultimately, I'd like to see people start to do things outside their home.

Yeah, physically in the real world, and actually going somewhere and moving.

There's so much research coming out on all of these pieces of things, on nutrition, on the microbiome, on how that intersects with our health and even specific to chronic pain. As we wrap up, I'd love for you to share with listeners, what do you feel like is the message coming out of that? What message do you think people should take from this, especially if they're living with a debilitating type of chronic pain condition?

Yeah, the message is to know that there is support out there, that there is help. If you're not finding it with a practitioner that's just trying one approach, that's usually the first kind of red light for you. So if you're just seeing someone who's just doing exercise, or they're just prescribing a medication, or they're just doing cognitive behavioral therapy, that's kind of the red light for you. Start to look at other healthy things you can implement into your rehabilitation program, and of course, into your life. That takes a little bit of self exploration. Sometimes that can be done on their own. Sometimes they need help from a practitioner to do that. So creating an alliance, finding a practitioner who you trust who can take an integrative approach, oftentimes is the way they should go.

And just that there's tremendous hope that with all the tools we currently have, and more and more that are coming, that people can and should expect that they can improve.

Actually, that reminds me that I had a patient who worked her entire life, raised kids, and entire family, with fibromyalgia. She finally retired, she had some time, and she started looking for solutions. Now at this point, she was walking with a walker, only household distances.

At what age? How old was she?

She was probably about 63 years old. So she had started to play and experiment a little bit with diet before I started to work with her. So of course I see her and we kind of fast forward that a little bit. Within a matter of four months, she's doing pool therapy. So she'd go into the local YMCA, do some pool therapy. She's no longer using a walker, she went to a cane. Now she walks outside blocks and blocks and miles at a time. This is someone who you would think, you'd say, oh, someone who is a little bit older, in their late 60s, they've had a chronic disease, they probably can't turn that around. That's actually not true. We see many people turn around many different types of chronic diseases, especially chronic pain.

Yeah, our body's capacity to heal cannot be overstated, right?

And the resiliency we have is, I think, severely underestimated. And what's nice about chronic pain, the nice part about chronic pain is that when you start to weave in all these different therapies, you're actually making someone more resilient.

For sure. Such a great message. Thank you so much for the work that you're doing in this important area and for spending time with us today.

Thank you for having me.

Thank you.

And thanks to all of you for joining us for today's episode of The Better Biome Podcast. Tune in next week to continue with us as we journey through the universe within.