Alright, so let’s move along. Let’s think about what to do about osteoarthritis. Cause that is really what matters. This is where the metal hit is the road, or the rubber hit is the road. The pedal hit is the metal. I don’t know. The goals are to reduce pain, improve function, and slower stop the disease process. So we’re gonna do a big picture. And we’re gonna get a view of reducing pain and improving function or slowing the stopping the disease process. And my hope is to produce more content about the details so that you can understand it. So you can do the things that you can do for yourself. Cause it is so important to empower yourself with things that you can do to take care of yourself. I also, you know, a lot of us do this work one on one with people. And I’ll talk to you about that too.

So there’s the old school approach. And the new school approach. Old school is 20th-century medicine. New school is 21st-century medicine. Let’s go forward kadema. So what to do. The conventional approach. We’ve all heard about this. Probably things like analgesic medicines like Tylenol. NSAIDs nonsteroidal anti-inflammatory drugs. Advice to lose weight. And then injections like steroids and hyaluronic acid, which is kind of like joint fluid. And then there’s physical treatments, mainly exercise, but other modalities and acupuncture. These are things that are all getting lots of use in the past decades. And this is the way I train. This is what I learned to do for people with osteoarthritis. And what I’ve learned subsequently is there are serious issues with some of these things that they are not even putting out there in mainstream stuff. Because the view is like this is the best we’ve got. So we’ll touch on some of those issues in a few moments.

So the problem with conventional approaches. First of all, there’s no evidence that it actually changes the disease process. And there is evidence that it might worsen the disease process. So let’s just unpack that for a second. Okay, so medications. There’s toxicities, right? Everybody knows that Tylenol, if you take too much, can hurt your liver. And too much depends on the person. And if you have other issues that are stressing your liver, other toxication issues, less Tylenol can be toxic. And everyone is not the same. And the conventional assumption is that, well, you can take 2 to 3 grams of Tylenol a day. But I know people who have impaired liver function, I know people who have fatty liver disease, which is an inflammatory chronic low-grade inflammatory disease of the liver. They have less capacity to detoxify stuff. Some people have genetic or nutritional issues that prevent the liver from detoxifying. So sometimes Tylenol can be great but in the right measure. NSAIDs, nonsteroidal anti-inflammatory, ibuprofen, naproxen, and then all the prescription things like diclofenac and meloxicam. And you’ve probably heard of these things if you are dealing with chronic pain. And there’s the obvious things everybody knows about that they can cause gastrointestinal bleeding, that they can cause problems with the kidneys, that they can worsen cardiovascular disease and high blood pressure and even trigger heart attacks.

But there’s this other thing that not most people don’t know, which is that they can worsen joint inflammation. And you know this data. There’s a couple of things quoted at 2021 study, but there’s things going back longer than that showing that sometimes people who take NSAIDs get worse. One of the things that NSAIDs seem to do is actually drive leaky gut. They break down that gut barrier. So you don’t even have to get to the point of having a gastrointestinal bleed. NSAIDs start to break down the gut barrier. And what happens when the gut barrier breaks down? What happens when there’s lucky gut, leaky gut? What does it cause systemically? Inflammation! Right.

So it is this crazy thing. Nonsteroidal anti-inflammatory drugs cause leaky gut, which worsens inflammation. And so there’s a number of studies, and this is back from 1998, Intestinal permeability and inflammation in patients on NSAIDs. They reviewed a bunch of studies. There’s research since then for decades showing that NSAIDs contribute to leaky gut. But it is not showing up in the literature. I just recertified in my field. I had to do a bunch of CME and read all these papers and answer questions. And I read this. That year 2020, like review, one of the professional expert bodies were giving their recommendations, consensus about how to manage osteoarthritis. They talked about NSAIDs, and they didn’t even talk about leaky gut. They didn’t talk about NSAIDs causing systemic inflammation. The most kind of compelling stuff about worsening joint inflammation may have been after they stopped collecting resources for that study, for that meta-analysis. But basically, there’s a few different research studies where they gave NSAIDs to people and then looked at their joints two years later and found worse inflammation and joint space narrowing. The people who had NSAIDs were worse than the people who didn’t. So real issues there.

Okay, so we also have topical NSAIDs, and this is an important thing because there are creams and ointments and gels that are made out of NSAIDs. And we actually know that those are better tolerated. And so if you have bad osteoarthritis and you don’t know what else to do and you are worried about taking something like ibuprofen or naproxen, you can take topical NSAIDs. There’s diclofenac, there’s a bunch of different ones that are topical that don’t get absorbed as much. They don’t seem to bother the gut, and that was shown in a couple of different meta-analyses. The jury is out on whether they contribute to heart disease from what I can tell.

Okay, and then injections and steroids, right. Short term benefit is you give a person who’s got a hot, irritated, swollen osteoarthritic joint, you give them cortisone, they feel better. If they don’t have a hot swollen joint, then they often don’t feel better. And it can actually worsen the joint and it could create more joint space. We’re seeing more research showing that cortical steroid injections, cortisone injections can worsen the process of osteoarthritis. So, I tend to avoid them unless it is an emergency.

Let’s move forward. We have so much to talk about that is actually more interesting. Alright. So then there’s this functional progressive approach. We talked about old school, and then let’s talk about what I’m calling new school because I tend to think progressively. I tend to think, okay, if we’ve got some research and we are doing things that are probably safe cause they are not as invasive, then I’m more willing to take that step and share with people the reality that okay, we might not have as much research as we do with NSAIDs, but we know that NSAIDs cause all these problems and you’ve got pain, you need to walk.

So here are some of the things that research is telling us. Heal the gut, supporting detox pathways, nutrients right. Let’s just touch on this. We know that low magnesium is associated with elevated inflammatory markers. Low magnesium is associated with worse osteoarthritis outcomes. Low vitamin D is associated with worse osteoarthritis outcomes. So, the nutrient status in your body is actually really important, and these things are incredibly inexpensive and easy to take. You need a little support with them. You know B12 and B6 and B1 are so involved in so many different chemical reactions but especially pain transmission and neurotransmitter synthesis. And these are things that are really important to pain.

There’s this big category of chemicals that are called polyphenols. And polyphenols come from plants. They are colorful molecules, the things that give blueberries and raspberries and celery and spinach and other living green things. The things that nature, God, evolution, whatever you want to call it, made for us to use and eat and enjoy are profoundly disease preventing and anti-disease. They are antioxidants, and they reduce inflammation, reduce pain. We will talk about that in more detail. There’s something called LDN or low dose naltrexone which I use a lot for people who have chronic pain. And exercise is really important. Movement is medicine. There’s something called microcurrent, and I’ve been consulting with a company that created a microcurrent device. Really tiny electrocurrent electrical currents that actually reduce inflammation in a profound way. They reduce cellular stress. They enhance mitochondrial production. So this thing, this stuff is up and coming. There’s gonna be physics-based devices, what are electromagnetic, that they are gonna do amazing things to your body. If you are of the age where you ever saw Star trek and like you know Bones McCoy would come along and go you know and do this little thing on people and they would get better. Like we’re heading in that direction. I think in the decades and 100 years to come we’re gonna look back and think, oh my gosh, we used chemistry that was so dumb. Like physics is so much better. Gentle electromagnetic fields. Light. You know these things actually have physiologic effects and changes.

So keep an eye on all that. We should know that, in the eyes of conventional medicine, all this stuff is experimental. Cause we’ve got either a little bit of research or no research. But again, it is a different rationale. I don’t have a slide of this, but one of my mentors decades ago painted the picture of a lever, right? Like with a fulcrum and a lever on it, right? And if you are pressing really close to the fulcrum and you are trying to lift a load, you have to press really hard. Like if you are on a seesaw and you get really close to the hinge, you have to be really heavy to lift the other person. And that is kind of what a lot of interventional invasive things are. They are not utilizing the complexity of the biological system. So they have to hit hard, and that is where you get side effects. And on the other hand, a lot of natural approaches and products are using the complexity and the intelligence of the organism. So it is less force, it is less intensity. You are working with the system and its inherent intelligence. And that is why maybe they are more safe, and we will hear about that when it comes to polyphenols in a moment. So stay tuned.

Hope you all are doing okay. People are asking great practical questions. How much B vitamins? What form? Oh my gosh, it is wonderful. It has got to be a whole other talk, Sandy. Thank you. I appreciate you asking. It is a great question. Alright!

So treating the gut neutral, we already did this. The same slide, okay? So what do I do in my practice? First of all, what I want to say is sometimes the conventional approach is faster and more appropriate. I don’t like to use oral NSAIDs, but if I’m working with a young person who’s got a really hot situation, sometimes a week or 10 days of NSAIDs is okay. You take precautions, you give them stuff that helps protect the gut. It is like using antibiotics. I like not to do that, but if I have to, okay. Then let’s replace the biome and support the body’s natural health. So again, I tend towards topical instead of systemic because the topical ones have less side effects, especially towards this whole biology of gut-brain axis and all of that.

Steroid injections, you know, somebody came to me about a year ago and she had really bad arthritis for the knee. And she was having a flare-up, and her daughter was getting married in three days. And she wanted to have a good time. And, like curcumin is not gonna help your joint, and neither is LDN in three days. So I gave her a steroid injection, and her joint was better in 12 hours. And she had a great time at her daughter’s wedding. I think that is a good use of the steroid injection, and so did she. You know, on a similar note, I used to work in rehab a lot. So, somebody has a fall or an injury, whatever it is, and it is pretty common that stressor flares up their arthritis. And they are in the hospital and they come to rehab, and they are in a subacute rehab facility, and their arthritis is flared up. And if they can’t demonstrate progress in their ambulation, the insurance company is gonna cut them off and send them to a nursing home, God forbid. So, in a situation like that, knee needs to be better now or tomorrow so that this person can actually get up and walk and strengthen themselves after the stroke and go home and not get stuck in a nursing home. So you know, it is contextual, it is situational. So I try to treat the patient and not be dogmatic about it. And I encourage you to think that way too, and you know, whatever in your conversations with your doctors.

Some people do great with opioids for osteoarthritis. I’m not a big fan, but some people come to me and they say if I take one tramadol in the morning, I’m up and going and I feel great and I have been doing it for 10 years. Can you prescribe it for me? Sure, why not? It is working. In the meantime, let’s try some other things. Maybe we can get your system healthier and you won’t need it. And if they are open to that, great. But if not, I try to be a good gas station attendant. Somebody wants gas, I give them gas. If they want oil, I give them oil. I try to convince them and explain to them to use the right gas and right oil. Let’s keep going. What else is alright? This whole process of disease that we want to change? We talked about this before for the late arrivals. Welcome gut-brain immune axis joint, you know, sickness of osteoarthritis. That same process is driving a lot of other chronic illnesses and it is important to address that. A lot of people come to me cause they want that deeper underlying approach. And just so you know, I do this by telemedicine. I work through Rose Wellness which is why this whole thing is called Rose Wellness, right? It is a company in America that lets me practice in a number of different states where I’m licensed. And I also do it where I live in Israel. And so part of it can be like okay, I’ve got osteoarthritis, what do we do about pain and helping me deal with it so I can function? Great. But then there’s this underlying reality of the underlying biological imbalances that we’ve been talking about this whole time that are driving not only arthritis but potentially driving other chronic illnesses that can have horrible effects over time. So, I like to think about all of that. So I do a really comprehensive assessment. We spend like 60 to 90 minutes.

It is a functional medicine approach. It is time-intensive, right? I want to know how widespread are the joint issues. Somebody who’s got one joint that is bothered and hot might benefit from a very different approach than someone who’s got six or seven joints that are hot or back arthritis and in two knees. And it, you know, it really depends on the context and how bad things are and what’s needed in the short term to help them get going, to help them get physically active because physical activity shifts so much to this other milieu of complex systems biology. And then what’s the individual sort of a biological picture based on their history, their symptom inventory, and their conventional labs? What’s going on in the gut, mind, body, stress? Is there trauma, a lot of anxiety, immune stuff going on, oxidative stress? These things leave clues. They show up in the history, they show up in systems that, whether it is psychological cognitive symptoms versus skin symptoms versus, you know, gut stuff. Like I do a really broad look and that triangulates back and lets me know a little bit, but what’s going on here.

So my approach, what I’m aiming to do and what functional medicine is about, and this is why I work with Rose Wellness ’cause they are really into this stuff, but basically, this is another way of mapping out all the things I talked about, all these different variables: digestion, the immune system, energy production, detoxification, cardiovascular signaling molecules. But like disease is a stream rolling down stream. Things start upstream and they roll downstream over time. And what we want to do is try to start rolling the stream backward. We want to do the things that counteract and turn off the processes that create the illness experience.

Okay, so what do we do after we do that comprehensive assessment? First of all, we think about a functional workup because there are tests that we can do to really characterize what’s going on in the gut, right? There’s a test that I do, The Biome, that tells me is there a balance in the biome? Are there inflammatory nasty bacteria that tend to cause inflammation? Are there yeast that tend to cause inflammation? It gives variables about the actual immune system in the gut and something and some of the molecules that show up in the gut when there’s an overactive or out-of-balance immune system. It looks at pancreatic enzymes, and most importantly, it looks at something called zonulin in the stool. And zonulin is one of the markers that go up when someone has a leaky gut. And some people come to me, and their zonulin is pinned; it is red; it is like, whoa, big-time leaky gut.

Somebody came to me after 15 years of horrible pain, completely dysfunctional. She’s only 22 years old, miserable, unable to do almost anything. And all of the normal markers were fine, and we did this gut test. She had gluten testing by the blood, which we know isn’t sensitive. There are lots of different molecules that gluten can cross-react with and cause inflammation systemically and cause leaky gut besides the ones they test for, which were designed to look for celiac disease. And so in the testing we did in that stool, we saw this massive anti-gliadin antibody, which is one of the gluten antibodies, and massive inflammatory markers. And she’s miserable, and we just stopped gluten for three weeks, and she was like, “Oh my gosh, it is life-changing.” And that is from a stool test. But they don’t do it in conventional clinics, but they do do it. So not everybody wants to do that, not everyone can afford to do that. So sometimes we just do empiric treatments, things to address pain, inflammation, oxidative stress, gut health, nutrients, all the things we’ve been talking about. These are things that we can do to address them. So how do we heal the gut?

First of all, alright, yeah, we want to heal the gut to get out all those diseases. And I use an approach that is called 5 R’s. These are the five things we want to remove – the bad stuff, meaning foods to which a person might be sensitive, meaning toxic bacteria or fungi or viruses. We want to replace missing stuff like nutrients that might be depleted. We want to reinoculate the biome and create a healthy biome. We want to repair the gut lining. And we want to rebalance the brain-gut immune system. Those are the big picture things, and there’s lots of details, and I’m gonna give a big picture idea of what those details are. But that is the general process we try to do, and that is how we heal the gut, and that is how we turn off that fire coming from the intestines, driving systemic inflammation and a lot of these other issues.

Okay, I hope you all still with me. So, healing the gut, dealing with all of these different biological imbalances that are part of that sick intestinal and brain-gut immune system. Okay, so let’s get into this. So here we are, and we want to heal the gut, we want to address the biome, we want to address the inflammation in the gut. We all know about probiotics, and we might not all know about prebiotics and postbiotics. Cause basically, what do all those healthy bacteria in the gut eat? They eat fiber. They eat digestible and non-digestible fiber. And that is why fiber supplements are so important.

There’s something like called beta-glucan, which is a fiber-like, but it is produced by various kinds of mushrooms and fungus. Profoundly anti-inflammatory. Healthy bacteria digest it. It builds the healthy bacteria. And then they produce post products biotics. The most well-known, well-mapped things are some things called short-chain fatty acids. And there’s something called Butyrate, or butanoic acid or butyric acid, which you can actually get as a supplement. It is really cheap. And not only does it reduce intestinal inflammation, but it helps rebuild the gut barrier. And so when I’m thinking about healing the gut, yeah, these things are biome-oriented, but they are also prebiotic postbiotic, like shifting overall biochemistry and shifting the products that the bacteria in the gut are producing, which are great for the gut, healing the gut, and healing the system as a whole.

I just want to step back for a second cause I wanted just to share a thing that I’ve heard a lot from a lot of people. And maybe this applies to you or somebody you knew, but I’ve listed five things – removing the bad stuff, replacing missing stuff, re-inoculating, repairing the gut lining, rebalancing the brain-gut immune system. I can’t tell you how many people have come to me and said, “I don’t think the problem is in my gut cause I stopped gluten and I still have the problem or I stop dairy or whatever it is.” That is a good move, right? Because many people are sensitive to gluten or dairy or refined sugar. And there’s certain things that I recommend people do initially, if they are sick, to do an elimination diet for like four weeks where you stop all of that stuff and see how you feel. And if you feel better, you gradually add those things back in, and you see what’s triggering you.

So it doesn’t mean being deprived for your whole life. But what it does mean is doing due diligence and initial effort to discover things that might be poisoning your gastrointestinal tract, driving inflammation and breakdown. And if you stop those things, and you can’t kind of stop them, you know like one of my patients came back after 5 weeks. “Oh, I did the gluten-free diet. It didn’t help.” “Oh, interesting. So you didn’t have any gluten?” “Well, I had a little gluten.” “What do you mean?” “Well, I had a piece of toast in the morning, but I didn’t have all the gluten I was eating all day long.” “Like great. That is less gluten, but that is not gluten-free. If you are sitting at a campfire with your friends and you stop putting wood on the fire, and the fire is burning down, but then someone puts a piece of wood on the fire, it comes back up, and then, like, it goes down, and then they put another. You are keeping the fire going.

 And you need to let the fire go out. And typically, we recommend doing that for four or five weeks. So that is really important. But that is not enough. All that is is exploring whether there are food substances that are triggering your gut, and that is huge. But that hasn’t told you whether or not you got dysbiosis, and it hasn’t done anything to address nutrients you might be missing cause of leaky gut and a broken-down gut lining. You haven’t reinoculated the biome. You haven’t taken the stuff to help repair the gut lining. There’s a rich literature about people with celiac disease who get conventional care, which says stop this, the gluten, and they do that. But so many of them continue to be sick, and so many of them continue to have endoscopic findings of a non-healthy gut for years cause they are not doing the rest of this stuff. Cause this is 21st-century medicine, and they are in 20th-century medicine. They are just stopping the gluten.

More and more stuff is coming out about the role of this stuff. More and more we’re learning about pre- and probiotic fibers and substances. We’re learning about nutrients that heal the leaky gut. L-glutamine is a nutrient for intestinal cells. It is an amino acid. It is cheap; it is in powders, and it is in capsules.

First of all, all right, yeah. We want to heal the gut to get out all those diseases. And I use an approach that is called 5 R’s. These are the five things we want to remove: the bad stuff, meaning foods to which a person might be sensitive; toxic bacteria, fungi, or viruses. We want to replace missing stuff like nutrients that might be depleted. We want to reinoculate the biome and create a healthy biome. We want to repair the gut lining. And we want to rebalance the brain-gut immune system. Those are the big picture things. And there’s lots of details, and I’m gonna give a big picture idea of what those details are. But that is the general process we try to do, and that is how we heal the gut. And that is how we turn off that fire coming from the intestines, driving systemic inflammation and a lot of these other issues. Okay, I hope you all still with me.

So, healing the gut, dealing with all of these different biological imbalances that are part of that sick intestinal and brain-gut immune system. Okay, so let’s get into this. So here we are, and we want to heal the gut. We want to address the biome. We want to address the inflammation in the gut. We all know about probiotics, and we might not all know about prebiotics and postbiotics. ‘Cause basically, what do all those healthy bacteria in the gut eat? They eat fiber. They eat digestible and non-digestible fiber. And that is why fiber supplements are so important. There’s something like called beta-glucan, which is a fiber-like but is produced by various kinds of mushrooms and fungus. Profoundly anti-inflammatory. Healthy bacteria digest it. It builds the healthy bacteria, and then they produce post-products biotics. The most well-known, well-mapped things are some things called short-chain fatty acids. And there’s something called butyrate or butanoic acid or butyric acid, which you can actually get as a supplement. It is really cheap. And not only does it reduce intestinal inflammation, but it helps rebuild the gut barrier. And so when I’m thinking about healing the gut, yeah, these things are biome-oriented, but they are also prebiotic postbiotic like shifting overall biochemistry and shifting the products that the bacteria in the gut are producing, which are great for the gut, healing the gut, and healing the system as a whole.

I just want to step back for a second because I wanted just to share a thing that I’ve heard a lot from a lot of people. And maybe this applies to you or somebody you knew, but I’ve listed five things: removing the bad stuff, replacing missing stuff, re-inoculating, repairing the gut lining, rebalancing the brain-gut immune system. I can’t tell you how many people have come to me and said, “I don’t think the problem is in my gut because I stopped gluten and I still have the problem.” Or I stop dairy or whatever it is. That is a good move, right? Because many people are sensitive to gluten or dairy or refined sugar. And there’s certain things that I recommend people do initially if they are sick: to do an elimination diet for like four weeks where you stop all of that stuff and see how you feel. And if you feel better, you gradually add those things back in and you see what’s triggering you. So it doesn’t mean being deprived for your whole life, but what it does mean is doing due diligence and initial effort to discover things that might be poisoning your gastrointestinal tract, driving inflammation and breakdown. And if you stop those things and you can’t kind of stop them.

You know, like one of my patients came back after 5 weeks. “Oh, I did the gluten-free diet. It didn’t help.” “Oh, interesting. So you didn’t have any gluten?” “Well, I had a little gluten.” “What do you mean?” “Well, I had a piece of toast in the morning, but I didn’t have all the gluten I was eating all day long.” “Like great. That is less gluten, but that is not gluten-free. If you are sitting at a campfire with your friends and you stop putting wood on the fire, and the fire is burning down, but then someone puts a piece of wood on the fire, it comes back up, and then, like, it goes down, and then they put another. You are keeping the fire going. And you need to let the fire go out. And typically, we recommend doing that for four or five weeks. So that is really important. But that is not enough. All that is is exploring whether there are food substances that are triggering your gut, and that is huge. But that hasn’t told you whether or not you got dysbiosis, and it hasn’t done anything to address nutrients you might be missing cause of leaky gut and a broken-down gut lining. You haven’t reinoculated the biome. You haven’t taken the stuff to help repair the gut lining.

There’s a rich literature about people with celiac disease who get conventional care, which says stop this, the gluten, and they do that. But so many of them continue to be sick, and so many of them continue to have endoscopic findings of a non-healthy gut for years cause they are not doing the rest of this stuff. Cause this is 21st-century medicine, and they are in 20th-century medicine. They are just stopping the gluten. More and more stuff is coming out about the role of this stuff. More and more we’re learning about pre- and probiotic fibers and substances. We’re learning about nutrients that heal the leaky gut. L-glutamine is a nutrient for intestinal cells. It is an amino acid. It is cheap; it is in powders, and it is in capsules.

There are other things I give along with that frequently, like aloe or marshmallow root and a few other things that help kind of the not just the cells, the lining of the cells, but the cells that produce the mucus layer. Butyrate is the other thing; vitamin D is really important. Omega-3 fatty acids are part of that gut lining membrane and really important. They are anti-inflammatory, and like the butyrate I spoke about, postbiotic fiber, which I didn’t put in here (and it is really a mistake), is anti-inflammatory polyphenols. I’m gonna talk more about them in a minute. But examples of that are things like curcumin, berberine, and quercetin. And depending on what’s going on for the person, depending on their clinical picture, one or more of those things might be more appropriate than others. There’s a lot of polyphenols we want to think about.

Immune function, this is the place where LDN can be really incredibly powerful. LDN, in case you haven’t heard of it, is an orphan drug. The parent drug is an opioid blocker that is used for people who have substance abuse issues to block the action of the drugs they might take. When you use LDN in very low doses, like 20th or 50th of what’s used for addiction issues, what happens is it shuts down the opioid receptors for a few hours, and the body says, “Hey, I need more endorphins and enkephalins.” The body produces more of its naturally occurring pain-blocking, inflammation-blocking chemicals. So, you are triggering the body to have a more robust responsive endorphins and enkephalins. For many people, that does an incredible thing in terms of reducing digestive system symptoms, reducing pain, reducing inflammation. There’s a lot of preliminary research. LDN is one of those drugs that is never gonna get big research because it is generic, doesn’t cost anything. So there’s no company that is gonna spend $50 million to do a full set of trials and get FDA approval for LDN. It is not gonna happen anyhow. Works great for a lot of people.

Mind-body care, we talked about how danger signaling ubiquitously at the level of the cells, the level of the organism, perceived danger, stress, anxiety. You can do all this great biochemical stuff, but if you are walking around in a stress phenotype and an anxiety phenotype and a post-trauma phenotype, you are probably not gonna heal because that is probably driving your disease in a huge way, whether it is osteoarthritis or fibromyalgia or fatigue or any other number of chronic illnesses. Okay, so we want all that stuff to go away. What else?

Some practical details: we talked about the LDN a little bit. Again, this is an off-label use, a compounded drug that you get at compounded pharmacies. Very good safety profile. It has to be customized to the person so that the dose is right for the person. A lot of doctors out there just want to throw it at people and don’t titrate it properly, and that is no good. Curcumin comes from the turmeric; it is the spice of turmeric. But you really probably can’t get enough eating turmeric unless you are eating a huge amount of turmeric. But curcumin, 500mg to 1,000 mg twice daily, is a powerful anti-inflammatory. And I think I got some slides talking about it. Basically, curcumin, boswellia, some of these other polyphenols. Boswellia is also frankincense, and boswellia is another herb, another plant-based substance that comes from a root. And basically, not only does it aid in pain blocking, but it blocks a lot of those inflammatory pathways that we were talking about. They are looking at curcumin and, like, I think I’ll show it to you later in a minute.

There’s other things I’m not gonna get into dosing on this. What I should do is give a whole talk on these things and get into details because there’s particulars and details. You got ta use the right curcumin and the right boswellia ‘ because there’s a lot of junk out there. I don’t have a slide on this, but like, there have been studies for decades showing that unregulated nutritional supplements very often don’t have what’s in the bottle, don’t have what’s on the label. Actual capsules don’t have what’s on the label. There’s also evidence showing that they frequently are produced in ways that aren’t safe. So you really need to get things that have good manufacturing processes where a third party has reviewed it, and you want some evidence that what’s on the label is what’s in the capsule. So I want to talk about all that more detail on another talk because we can’t cover it all here.

But these are some of the things that I use depending on the person. A lot of people have heard about glucosamine. Glucosamine got some interesting press a bunch of years ago because of the GAIT study, which is this huge randomized control trial with lots of people. It was the biggest, supposedly best study of glucosamine. But they used a different kind of glucosamine than what had been used in all of the previous studies. They used glucosamine hydrochloride, which is not glucosamine sulfate. And it was just an assumption that, like, well, it doesn’t matter if it is sulfate or hydrochloride.

That paper that I mentioned, that review paper that I had to study and do answer all these questions to recertify recently, it actually commented in there, “We didn’t review glucosamine because the GAIT study gave such negative results. And based on a meta-analysis, we didn’t see. But you take a huge study and you put it together with a lot of smaller studies, and if the huge study is done wrong, it is gonna make all those smaller studies look like there’s nothing really happening there.” That is what happened with the initial meta-analysis after the GAIT study. More recent meta-analyses have shown, actually, no, there does seem to be some benefit, and there’s potential reasons why.

That paper that I mentioned, which is this expert panel that reviewed it, they actually said, “We can’t think of a reason why glucosamine hydrochloride wouldn’t work as well as glucosamine sulfate.” So we’re assuming that the issue is with glucosamine and not the kind of glucosamine. To hear that kind of twisted logic was very disappointing. I was very disappointed in my colleagues.

In any event, omega-3 fatty acids, fish oils, the most common source. Some people get it in green-lipped mussels, and some people get it in vegetarian sources that are grown from algae. Like, where do the fish get the omega-3s? It grows in algae. It gets eaten by little organisms, and the fish eat the organisms. That is why fish have omega-3 fatty acids. You need 1 to 2 grams a day. If you look at most fish oils, they’ll have like total omega-3s, and they’ll have EPA and DHA marked separately. What you want is 1 to 2 grams of EPA/DHA, not just the overall omega-3s because the body has to produce the ones that are really anti-inflammatory, and these are the ones that have the most data supporting their anti-inflammatory effects.

I was listening to some other research lately about how EPA and DHA help the person maintain muscle mass as they get older, and that is a really huge thing because muscle is metabolically active. There is a practice in Europe that is muscle-centric medicine. There’s a lot more research coming out about how physical exercise, using your muscles, reduces inflammation, shifts all this sort of oxidative stress stuff. It is a really huge thing. So maintaining muscle mass is incredibly important, and omega-3 is showing up as something that seems to help maintain muscle mass too.

Let’s move further, treating pain and inflammation and oxidative stress. We mentioned magnesium, vitamin D, B complex – very important things. And here is a meta-analysis and a systematic review of curcumin. They looked at 1,621 people and did better with pain control. Did as well as NSAIDs without as much side effects. The key thing is you need to use curcumin for three months, but it seems like it works as well as NSAIDs if you get a good quality curcumin, if you take enough, and you take it for 3 months. So it is a reasonable substitute for persons who’ve got osteoarthritis or are dependent on whatever NSAID. It is a reasonable thing to switch, and I do this a lot with people.

Polyphenols, like we talked about, eating the rainbow, all the colorful foods. In nature, this is a reviewed article entitled “Dietary Interventions with Polyphenols in Osteoarthritis: A Systematic Review Directed from the Practical Data and Clinical Studies and Nutrients.” And I got to get closer to this to see it, and maybe you do too, so forgive me for my face getting out of it. But basically, what they find with polyphenols, lots of different colored foods first of all – anti-inflammatory effects like we talked about, anti-pain effects, blocking pain, reducing oxidative stress, and working on signal pathways and anti-aging catabolic pathways. Kind of hard to explain that, but the point is nature’s bounty, the colorful foods that are so important to consider in quantity and build into your diet. We’ve got all this research out there looking at plant-based diets and how much better they are than meat-based diets, and everyone’s assumption is meat is bad for you, and it can be. I’m not knocking that research as a whole, but when you look at something like that, you have to realize, well, eating more plant-based foods does all sorts of amazing stuff to reduce the things that are driving chronic illness, like I spoke about in the earlier part of this talk.

There’s a whole set of biological processes – inflammation, oxidative stress, signaling DNA changes, mutations – that are drivers of osteoarthritis and chronic illness. Polyphenols, colored plant and fruit-based substances, are turning those processes down and moving them towards a healthy direction. So, polyphenols are powerhouses of nutrient for so many reasons.

This is a huge amount of information, but this is another systematic review and meta-analysis of curcumin, basically supporting the idea about all the pharmacologic things that curcumin does – blocking molecules involved in driving inflammation inside of the cell, inhibiting oxidation by removing free radicals, promoting cartilage repair by affecting a whole bunch of different proteins living inside your joint. So, it is not just about inhibiting pain; it is about actually changing the process of disease. Like we talked at the beginning, there’s 20th-century medicine, which is all about palliation, and let’s block your pain and hope you don’t need a joint replacement. And now we’ve got these substances that we’re starting to measure in such an unbelievable way that are nature-based, available, being produced, being refined about how to deliver them, how to absorb them better. And not only do they block pain, but they block the process that drives the disease process. So that is really cool, and I’m really excited about that. And I don’t even own stock in curcumin; I just think it is great.

Okay, so blocking pain, we kind of talked about that, yeah. I’m gonna run through a few things. We’ve been at this for a little more than an hour, and I think somebody else needs to use the Zoom soon. So, I’m gonna just kind of deck, deck, deck, move through. Can you spell butyric acid? B-U-T-Y-R-I-C. Pain is not like a light switch. You’ve got an incredibly complex pain transmission pathway. It is full of these processing states in your spinal cord and your brain before it gets to the part of your brain that says “ow.” And there are amplifiers in your spine and your brain, and those amplifiers can get turned up. We call that process central sensitization, and we know that it happens in osteoarthritis, fibromyalgia, neuropathy, and a whole bunch of different things. We suspect that part of it has to do with those attack macrophages.

 We spoke about central sensitization, but it can come from stress, inflammation, and nutrient deficiencies. This is why it is really important if you have chronic pain to look at all those things carefully. That is a big part of what I do when I consult with people. It is like, let’s cover the bases. What are all the things that can cause central sensitization? Let’s see the things that we can change, check off, and shift. Let’s unpeel off the layers of things that can drive this central sensitization process. We talked about the autonomic nervous system, and just reviewing that is a big driver of central sensitization. So many people I know who have come to me miserable with chronic pain, and they dealt with their trauma, and their pain got a lot better. It is not to say that everybody who has pain is just from trauma, but if a lot of it is, and many of you may have heard of John Sarno’s work. Doctor Sarno’s approach, it is a systematic approach that a lot of docs do, and a lot of laypeople teach other people to really get at the emotional layers, writing exercises, identifying sharp, hard emotions, because that turns off that autonomic nervous system imbalance, and it also corrects a lot of brain chemistry and neuropeptides and signal molecules that may be holding an emotional response that is contributing to a pain response.

Moving forward, pain reactivity and disability. This is a huge thing for any chronic pain problem. Here is the cycle: the pain experience, for some people, creates what we call the pain avoidance cycle. Pain catastrophizing – “Oh my gosh, I’ve got pain, I can’t do anything, this is never gonna get better, it is a disaster, I’m gonna be a wreck, forget about it.” All those thought patterns that get triggered, that is part of that stress response, part of chronic anxiety. And this is not to shame or blame anybody but to recognize that that is a big driver of the cycle, and catastrophizing is one of the things that turns up the volume on pain transmission. This has been demonstrated in functional MRI scans – really important thing.

Okay, so pain-related fear, avoidance, and hypervigilance. A lot of people have pain, are guarding their joint, they don’t want to move. I see this in my practice every week with people who’ve had the injury, they’ve had the surgery, they are having pain that persists, and no one knows why. The orthopedic surgeon says everything’s fine. Part of what’s going on is they are holding their body, and it is not on purpose, it is a reflexive thing. You add some anxiety into it, it makes it worse. You add some biochemical imbalances – B12 deficiency, other different things that can make the neurologic system more irritable, magnesium deficiency – you get more of that, and that creates a secondary source of pain.

So it is really important to think about these things, including in osteoarthritis, and that process of not using the limb, not using the body part, leading to disuse, depression, disability, which feeds that whole catastrophizing pain experience. And the way out is to break through the fear, and you got to find whatever way you can find – whether it means getting psychological support, doing some Sarno work online, finding your best friend to scream at you if that works for you, getting up and moving, figuring out if it is pain that is dangerous or not. Most chronic pain is not dangerous, but the body doesn’t know that. The fear response to the body doesn’t know that, and when your fear response, your body thinks that your pain is dangerous, it feeds that vicious cycle of biology and neurochemistry and inflammation and all of that and feeds into the sickness of chronic pain. So breaking out of that, confronting it, moving forward, recovering – huge, huge thing. Sometimes you need support, sometimes you need a great physical therapist or a mental/emotional therapist.

This is just mapping it out again, we already kind of talked about it, so you know I’m not gonna talk this through because we don’t have so much time. But like that is how it works. I see this hundreds and hundreds of times where all these biochemical imbalances and metabolic balances we talked about sensitize the nervous system, create this whole distressing suffering experience, feeds it all, and feeds into fear avoidance. This is chronic pain syndrome, and getting it addressed is hugely important.

And this is what I’ve been doing for over 20 years. You need to see someone who really knows pain, who can help you out of it if you’ve fallen into this cycle. Stuff you do for yourself – strengthen coordination. I love gentle, mindful movement for chronic pain because it is gentle, and you are stimulating the relaxation response while you are strengthening the body. So tai chi, qigong, yoga, Pilates, whatever it is. There’s a lot of different approaches, there’s all sorts of great techniques for retraining the body to move freely. If you have chronic pain, osteoarthritis, I went to China many years ago when I was in medical school, and you go to any park early in the morning, you got all these elderly people moving and doing tai chi. It is like the national pastime, and part of it has to do with the effect on the joints and moving the joints to the full range of motion.

We got a bunch of people here who are in my movement towards health, tai chi, qigong-based class. You guys want to speak up and tell – no, I’m just kidding, but it is really good stuff. Aerobic exercise is good if you can do it. Strength training is really good if you can do it. The muscles of the joint need to be strong. That is the piece we haven’t really talked about, but one of the things is that in osteoarthritis, the loss of joint position sense and coordination happens before the joint breaks down. Crazy, right? That is one of the things doctors aren’t often thinking about.

So the basic idea is that the deconditioning and the loss of the neuromuscular intelligence of the joint are part of what contributes to the generative process. So it is really important to think about that movement is medicine. It generates hormones, reduces inflammation, signals molecules, helps you sleep, reduces pain, and releases neurotransmitters. Have I said this enough? So important to find a way. I’m gonna do another talk about osteoarthritis and movement training. I’m gonna do another talk about osteoarthritis and polyphenols. We’ll get into some more of the details here. I know this is a superficial overview, but I wanted to give you the big picture.

What else? Mind-body healing. So many different layers to that. Relaxation response, mindfulness. We don’t have time to really talk about this, but it is a whole area of self-healing through the mind-body system and the intelligence of your own consciousness. I’m not gonna go down this road and talk about these things in detail. I want to leave a little time for Q&A. These are some of the processes that people go through as they are healing inside, healing the deeper layers of your being. I know a lot of people who had trauma or difficult experiences and they get CBT, which is mainly about functioning, kind of behavioral therapy. But they are never working on that heart-centered or body-centered nervous system. The stress response is in the body, and you can get your thoughts in shape, and that can help you a lot. But until you meet the hyper-vigilant emotional responses and hyper-vigilant biological responses and transform them and rewire them, then they are gonna continue, and they’ll continue to drive disease. And there are safe, proven things to do that, and it is worth a whole talk. It is really worth it.

Okay, great. So, I think that is the end, folks. Thanks for staying so long. I had no idea how long this is gonna be. I hope it was fun for you.