Updated: Jul 7, 2019
Why we ache.
Inflammation - like pain itself, no fun. But a necessary part of life. Like pain, it protects us, and to take it a step further it helps rebuild us. To a point...
Normal (Physiologic) Inflammation
We experience it constantly. Stub a toe or smash a finger in a door, grab that hot dish out of the oven without thinking, stop flossing for a while. Red, hot, swollen, and tender tissue (even nerves.)
The timeline above shows how the body responds to injury (it's a little different when it comes to infection, but the basic concepts still hold.) Within minutes a cascade of biochemical responses surges into action. Our immune system and its helpers in the blood vessels and connective tissues begin the complex job of containing any invaders and rebuilding damaged tissue.
It's not unlike how we respond to natural disasters, really. First on the scene is the National Guard to help defend and protect, and also bring emergency aid. (Immune system cells.) Once there's some semblance of order, relief workers with construction/restoration expertise, like Habitat for Humanity and Samaritan's Purse arrive to help rebuild. (Fibroblasts.)
Notice how in the timeline the process of inflammation occurs and lasts minutes to days, generally. This is important to keep in mind when we think about the normalcy of pain, swelling, heat, etc. after an injury. It's also important to realize that there should be a definite termination to the process. Remember - we're talking in this section about how the system is supposed to work.
Many experts believe that our original design (as active hunter-gatherers without refrigeration or preservatives, cigarettes and couches) just isn't up to the challenges/health bludgeoning of 20th/21st century living.
An exciting area of research right now, pioneered by Dr. Charles Serhan's group at Harvard-Brigham & Women's is expanding our understanding of the natural process for resolution of inflammation. It should come as no surprise that under conditions of good health, we're designed to contain and terminate the inflammatory process in short order as healing commences. Some of the key players in this process include lipoxins and resolvins, synthesized by blood cells to help stop inflammation (call off the Guard) and let the work of rebuilding and getting on with life proceed. There are lots of things we do in modern life that interfere with lipoxins and resolvins, as discussed below; interestingly, besides committing to a healthy lifestyle, one of the best ways to increase these helpful anti-inflammatory mediators is to take a baby aspirin every day! Aspirin but not other NSAIDs (such as ibuprofen, naprosyn, meloxicam, celecoxib) increase the formation of lipoxins. Maybe because aspirin is several steps closer to nature than the other drugs synthesized in a laboratory - aspirin comes from willow bark.
Chronic Inflammation: "Our Technology Has Exceeded Our Humanity."
I'm taking Einstein's supposed quotation a bit out of context, but whether your salivary glands are going nuts right now OR you're nauseated looking at the photo above, I'd argue your reaction supports the point. Personally I'm both drawn to AND turned off by the image. We're addicted to foods, beverages, toxins (like alcohol and tobacco), activities and lifestyles that are stoking the fires of chronic inflammation in our brains and the rest of our bodies. And it just ain't natural.
Habit alone will overcome chronic inflammation - and chronic pain.
We've entered the era of chronic, self-inflicted disease in the West. Major infectious diseases are under control for the time being. Our increasingly technological and automated culture has contained many injuries (while opening up the doors for a whole new set of them from motor vehicle accidents, 'text neck', sitting too much, etc.) And yet chronic inflammation is growing by leaps and bounds. Heart disease, diabetes, asthma, autoimmune diseases (like rheumatoid, lupus, Crohn's, etc.) and most chronic pain states all have in common an inflammatory response that won't shut down and continues to make us sick - and hurt.
[For those who care to learn about the pathophysiology, the Reader's Digest version as we understand it today is that a combination of pro-inflammatory chemical messengers such as interleukin-1 beta and tumor necrosis factor alpha are continuously produced in excess by our immune cells, with orchestration seeming to arise from dysregulation of a key DNA transcription factor called nuclear factor kappa-B that perpetuates the cycle. This process can be brought on by a number of underlying issues such as lack of proper nutrients (antioxidants, polyphenols), obesity, poor intestinal health, sleep deprivation, stress, and lack of exercise. At the same time, inflammatory-suppressing lipoxins and resolvins (and other anti-inflammatory prostaglandins, etc.), IL-10 and IL-1Ra just aren't being made in enough quantity to make a dent. This imbalance perpetuates the sensitivity of joints, fascia and other tissues in the body.
In addition, other critically important neuroimmune components of our central nervous system (CNS) like glial cells may become activated into a pro-inflammatory role and begin aggravating the CNS into a pathological state we know as central sensitization, which we'll discuss at some length in its own dedicated post. For now, suffice it to say that central sensitization is responsible for a huge swath of chronic pain problems including fibromyalgia, migraine, and possibly even arthritis and back and neck pain. The things that bring it on? Keep reading...]
Many experts believe that our original design (as active hunter-gatherers without refrigeration, preservatives, cigarettes and couches) just isn't up to the challenges/health bludgeoning of 20th/21st century living. Too many Omega-6 fatty acids and refined carbohydrates, sleep deprivation, stress and anxiety, lack of exercise and obesity (each independently), chronic opioid use, alcohol and tobacco, and childhood abuse ALL confer chronic inflammation and chronic pain. We'll address each of these independently in future posts, looking more into the mechanisms of each as well as strategies for overcoming them.
Soothing (and Re-Programming) the Savage Beast
The bear in the photo above hasn't strayed from its genetic and instinctive behavioral patterns. Unfortunately we aren't gifted with such a compass, and need to be re-trained. We have to first find the motivation (that's cognitive and emotional stuff, for those savvy to the realm of the psyche) and then 'Just Do It' (that's the formation of habit, or behavioral stuff.) The evidence is pretty watertight: making health behavior changes has to start with intention of course, but it only survives on programming. The only New Year's resolutions I've ever kept are the ones that made it to March or April.
The key isn't better drugs or more procedures (certainly these things have their time and place. But too much chronic anti-inflammatory therapy - except for aspirin, it turns out - and certainly too much opioid therapy just makes it worse.) It's no more soda pop/potato chips in the grocery cart and staying on the perimeter of the grocery store. It's substituting mixed nuts and a pre-bagged salad once a day, if that's what it takes. It's calling the QuitLine and wearing Nicoderm - and calling your QuitCoach 20 times a day if that's what it takes. That money from cigarettes will pay for a gym membership; even better - walk 30 minutes, 3 days a week (that's free!) Need a personal trainer to keep you accountable but can't afford it? Then get another friend to stop smoking and commit to exercising together. Put the fish oil bottle in front of your alarm clock so you remember to take it every night (much more pleasant recycling that at 1AM than 1PM) and put the turmeric bottle in your shoes every night if you have to, so you can't get out the door without taking it. It's getting that 8hrs of sleep(-ish). Habit alone will overcome chronic inflammation - and chronic pain.
There's no other way around it. I tell my patients several times a week that until we overcome all these issues (sleep deprivation, PTSD, tobacco, Doritos, too much TV or internet and not enough exercise) we'll never improve their pain. The ones who get it, and DO IT, get better. Those who don't, I am truly sorry to say, just keep getting worse.
-Heath McAnally, MD, MSPH
30 Aug 2018
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