Prevention is often cure.
Earlier we looked at just a brief overview of the process of normal inflammation – part of the body’s vital defense and rebuilding system and we compared it to the presence of the National Guard followed by relief workers after a natural disaster. We then switched gears and looked at how the system can get stuck in an endless loop, like poor Bill Murray in Groundhog Day, except with more destructive consequences – to muscles and fascia, joints, the nervous system, and even vital organs like the lungs and heart.
Without rehashing all the advanced biology, in this state of chronic inflammation, immune system cells begin manufacturing and circulating pro-inflammatory chemicals (cytokines) such as interleukin-1 beta and tumor necrosis factor alpha (under the direction of nuclear factor kappa-B.) These chemicals cause other downstream cells to release molecules such as histamine, bradykinin and reactive oxygen species (ROS) which are intended to facilitate destruction of invading microbes. Unfortunately there’s collateral damage to our own tissues, and as our own cells begin to break down, other pro-inflammatory molecules such as prostaglandins and leukotrienes are formed from their membranes. Among other things, this ‘inflammatory milieu’ alters both specialized pain nerve endings and also other ‘innocent bystander’ nerve endings to an enhanced state of pain sensitivity and transmission.
Sometimes these [modifiable risk factors] are circumstances, sometimes they're choices. But we always have the power to change some, if not all of them for the better, and to turn down – maybe even shut off - chronic inflammation.
So the million dollar questions (considering we purportedly spend over $600 billion a year on pain issues) are
what's causing the endless loop of chronic inflammation? and
how do we break the cycle?
What’s causing chronic inflammation?
There are some contributors, like genetics and our environment that are difficult (not impossible!) to change - even genetics can be overridden by epigenetic factors. [We’re not going to concentrate on those things; suffice it to say we all need to pitch in with our choices, time, money and votes if we hope to slow down let alone reverse the destruction we’ve wreaked on the planet over the past century, and leave a recognizable planet to the next generation.]
What we are going to concentrate on here is an introduction to what we call modifiable risk factors. Just like it sounds, these are contributors to a disease state – in this case chronic inflammation – that have to do primarily with lifestyle issues that are mistreating our minds and bodies. Sometimes these are circumstances, sometimes they're choices. But we always have the power to change some, if not all of them for the better, and to turn down – maybe even shut off - chronic inflammation.
Decades of medical textbooks and literature document the progressive unraveling of inflammation's mysteries including the role of the immune system and our connective tissues. We’re not going to cover any of that beyond what we’ve already alluded to above; if you’re interested, a great place to start is Guyton and Hall’s Textbook of Medical Physiology, or if you’re into audiovisual summaries, try the Khan Academy’s video series [e.g., https://www.youtube.com/watch?v=FXSuEIMrPQk]. What we are going to very briefly survey are two exciting frontiers in our understanding of chronic inflammation and chronic disease in general:
The role of nutrition/diet and the ‘microbiome’ in health and disease, including chronic inflammation and chronic pain, and
The role of the central nervous system and its interactions with the endocrine and immune systems in causing chronic inflammation and chronic pain
There's growing understanding and appreciation that what we put into our bodies (and of equal importance, how frequently we do so) has a huge impact on our health in general. We’ve known for decades that cancer and heart disease risks go up with poor diet. Surprisingly it’s taken us half a century to get the picture that so do risks of autoimmune diseases like rheumatoid arthritis and lupus, and even more mysterious conditions like depression and chronic fatigue syndrome. There’s a spectrum of ‘direct’ pro-inflammatory effects of food and beverages such as simple sugars, saturated and trans fats, alcohol, etc. Many modern preservatives in food have been linked to disease states, and increasingly concern about genetically-modified foods (e.g., gluten) has been raised as well in conjunction with multiple health problems.
There are indirect pro-inflammatory effects of poor nutrition as well, both from lack of key nutrients, especially vitamins and phytonutrients (decreasing in the Western diet as we move further and further from real to processed food) and also from obesity, which we now recognize as contributing to inflammation in a number of ways. Obesity also causes inflammation both directly (via adipokines) and also indirectly through deleterious effects upon sleep and activity profiles.
We are also just beginning to understand the critical importance of an intact and normal 'microbiome' or microbiota, also known as normal gut flora. This refers to the population of beneficial bacteria that live in our intestines, and that help maintain a healthy digestive system. Poor nutrition among other things can alter our microbiota, leading directly to inflammation from harmful bacteria and their products but also by damaging protective functions of the intestines that keep antigens we consume from stimulating our immune system into attacking our own tissues by mistake.
these are areas most of us can improve in, perhaps with more incentive and enthusiasm once we understand how much of our pain comes from inflammation brought on by failure to maintain and care for these processes as we should be doing
The brain and nervous system (including the enteric nervous system in the intestines) are also key players as it turns out in our inflammatory response, and important glial cells (comprising something like 75% of the brain) that support, protect, and shape our neurons and synapses can also become activated and lead to inflammation within the central nervous system itself, but beyond that, the whole body. It's now understood that several diffuse and global pain syndromes as diverse as fibromyalgia, migraines, and inflammatory bowel diseases such as Crohn's disease and ulcerative colitis are heavily influenced if not even caused by this phenomenon of neurogenic inflammation. (Perhaps we should be calling it glia-genic inflammation.)
How do we overcome chronic inflammation?
There are some things in life we can't easily change, perhaps such as a job or where we live, or our DNA. But for every one of those things there's probably at least one or two things we can make changes in for the better, and which will dramatically improve our overall health and also reduce inflammation - and with that, pain.
We'll look at the key areas of :
improving sleep quantity and quality
improving diet (better nutrients, fewer 'empty calories' and intermittent fasting)
improving mobility and conditioning
improving stress management
in greater detail by individual topic in later posts. For now let's just say these are areas most of us can improve in, perhaps with more incentive and enthusiasm once we understand how much of our pain comes from inflammation brought on by failure to maintain and care for these processes as we should be doing. Are you worth the investment? We think so!
-Heath McAnally, MD, MSPH
11 Jul 2019
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