So there we go; what is arthritis? What’s the 21st-century science? The notion that osteoarthritis is not inflammatory is changing. It is a new paradigm, and we’re gonna talk a little bit of a kind of overview of how do we treat pain, how do we treat and help function improve, and how do we get the actual disease process of osteoarthritis, and so those are the main points we will get at so you know arthritis is basically pain, or that doesn’t go away or comes back in a joint warmth redness, swelling this is probably pretty basic stuff I know some of you who are out there, and I know you are dealing with this on a regular basis so you don’t need me to tell you about warmth and swelling and stiffness and pain that doesn’t go away. 

Then, sometimes, trouble moving joints is the general definition of arthritis, and arthritis can affect many different joints. When we talk about osteoarthritis, is main knee and, hip, and hands are the main ones, but arthritis can affect the spine, the hands, the elbows, the ankles,  every joint in the body; the temporal mandibular joint can have can have arthritis in it, so you know here is from the Cleveland Clinic and here they give that definition of osteoarthritis which is wear and tear, but we’re gonna focus on that right we’re gonna focus on osteoarthritis you may have heard of rheumatoid arthritis which is more of an autoimmune disease against the joint tissues gout which is where the body creates these kind of crystals that precipitate into the joint and create inflammation  ankylosing spondylitis and psoriatic arthritis which mainly affect the spine but can affect the other joints too.

 And then there’s juvenile rheumatoid arthritis, so we’re gonna focus on osteoarthritis in this conversation today, and so you know the classic signs of inflammation. This is an important distinction because, you know, until 20 years ago, you asked the average doctor, or maybe you still say, but what’s inflammation? They will say redness, pain, swelling, and heat are the four cardinal signs of inflammation. Rubore, calor, dolore, and tergore are the latin things we learned in medical school, and that is what we used to understand was inflammation. Sometimes there’s an elevated white blood count, or these clinical markers like an esr or a crp, and in rheumatoid arthritis, you can get a rapid breakdown of the joint, and then osteoarthritis was understood to be, well, there’s no inflammation there; it is just wear, and tear and but we what we know now is there is low-grade inflammation it is a subtle process where you don’t get this necessarily red hot thing going on but what you do get is this biochemical inflammation that is in the background that drives processes that create degenerative changes in the joint and those same processes like we’ll talk about in a bit affect potentially all of the chronic diseases that people deal with which is part of why people with osteoarthritis get chronic illness.

So it is  really important to understand these things occasionally someone with osteoarthritis has a warm swollen joint cause you can get what’s called an effusion where fluid flows into it and sometimes the clinical biomarkers go up but usually they don’t on the other hand there are research markers that they measure in labs that are elevated and changed in osteoarthritis and so what’s really going on is like this is a view of a healthy joint on the left side and  so that is  what’s happening in in a healthy joint that the cartilage is smooth you got these menisci and you get that nice rolling joint where the joint works just fine and it is  sliding and grooving that is  all great you got a nice wide joint space there and what happens in osteoarthritis is that that joint breaks down the cartilage breaks down over time the cartilage can completely go away and you can get this bone on bone thing right you get bone spurs which can be a source of pain cause they are like pokey things in the joint and you get narrowing of the joint which can cause these changes in the biomechanics and on a biomechanical level it can be like a vicious cycle where you lose cartilage and that nice smooth surface is no longer there and you get these bony things and pointy things that are creating more pressure which creates more breakdown and

So it is  a degenerative process that happens over the course of a long time it is  typically not a quick process like rheumatoid arthritis but like many of you might know  okay my knee started hurting a little bit a few years ago and then it got worse and then it got worse and then it got worse and they said I have osteoarthritis well that is the way it goes sometimes for sure so in any event this degenerative process happens with a joint breaks down and it hurts that is  the worst thing most people describe but some people get loss of joint function hard to bend stiffness the stiffness is frequently worse in the morning or when you’ve been immobile for a while there’s this process in osteoarthritis called gelling it is  one of those classic things when the person says yeah you know I’m really stiff and uncomfortable when I first get up but then once I walk around for a while it gets better it is  sort of a classic osteoarthritis thing as opposed to a like hot inflammatory arthritis like rheumatoid arthritis or gout flare up or something like that the really important thing to know is that okay yeah there’s so there’s this loss of function of the joints being stiff there’s frequently kind of a behavioral response to it which is like it hurts so I don’t want to move.

We will talk more about that later and the real key thing to hear right now so really listen to this  is that there are a number of different other chronic illnesses that go along with osteoarthritis you see more frequently with people who have osteoarthritis and part of it is is the new understanding of what causes osteoarthritis cause we got these underlying biological imbalances that cause these other diseases too so that is  why I really want you to understand this stuff so cardiovascular disease depression, anxiety diabetes, stroke, dementia chronic pain syndrome fibromyalgia really tough difficult things going on so osteoarthritis is growing these are estimates from you know 2015 I think it was where they had this initial data with it growing like this is just in the united states from like 46 million people to 54 million people over the course of about a little bit less than that and this is their projection for it is  gonna go up into 2040 like maybe 80 million people with osteoarthritis in America and worldwide even huger numbers than that because it is  a big world we live in 

So it is  incredibly important that we find solutions to potentially change the course of osteoarthritis cause old school is really about just treating the pain and hoping you don’t have to get a joint replacement and so we’re starting to understand things about what causes it and seeing things that we can do that we will talk about that actually can slow that process so that is  what’s so exciting about thinking about this now in 2023 where we have got like a few decades of research that are showing us like wow it is  not what we thought at all there’s things we can do that are lifestyle things to intervene and make this problem better so let’s unpack what that is obesity and osteoarthritis it is  been known forever this is what I learned people who are obese are overweight and because it is  overweight then it is  too much wear and tear in the joints and that is  what doctors would say to the patient Mr jones  overweight people are more likely  to have osteoarthritis because if you are overweight you are heavy and that means increase wear and tear on your joints so you should lose some weight like that was the old understanding but that is  not the new understanding what we’re understanding now is that extra fat tissue actually is inflammatory and it drives a whole set of biochemical changes that drives osteoarthritis so being overweight and having extra fat it is  not just that you are heavier than your joints want you to be it is  that you have a systemic metabolic thing going on that is  inflammatory and drives the disease process of osteoarthritis as well as a disease process of other stuff that is  no fun to have 

So let’s keep moving forward here so yeah 21st century thinking is much different than 20th century thinking it is  not like that with Mr Jones and somehow it is  still in the mainstream sites right I went to Hopkins medicine, John Hopkins hospital and here’s what they say on their website about osteoarthritis osteoarthritis is caused by wear and tear of the joint over time because of overuse they are missing 20 years of research they are not talking about it this isn’t so surprising it is  actually well known that medical research doesn’t get into the clinic for a long time like 20 or 30 years and you know objectively scientifically there are reasons for that because our new understanding of osteoarthritis is new and science is still working at the details about what do we want to  do about this how do we turn this into treatments what do we recommend for people how do we know what’s safe and not safe it is  a really complex question so giving credit to the conservative nature of medicine because you know one of the things that they always taught me in medical school is first do no harm and they don’t want to promote uncertainty they want certainty first but as we know we’re living in a world that is  more and more uncertain there’s lots of complex influences that are affecting what information gets given to the public and what treatments are given to the public. 

I know a lot of your faces out there you are very tuned into this kind of thing it is it is  not the benevolent thing like we thought it was there’s a lot of financial interests and political interests and all sorts of things going on but there is also reasonably a scientific interest in whoa, hold the horses let’s make sure that these things are really true and we know what to do with it before you put it on this John Hopkins website but it could be that because you are here you are interested in a more progressive understanding my view is that especially with issues where lifestyle changes can make a difference we’re talking about safe things not drugs with horrible side effects we’re talking about things that are generally safe there’s much more latitude  to be progressive to get at the cutting edge of what we know in science and actually come up with intervention that can make a difference for people at low risk to them so let’s keep moving alright yes no that is  not the answer anymore cross it out so what is the answer the answer is that osteoarthritis is caused by a complex holistic process it is systems biology where all your systems are interacting with each other your immune system your joints your brain your gastrointestinal system your hormones your brilliantly complex system of little molecules that are communicating among all of your cells it is  astonishing what goes into it we’re gonna touch on that hopefully in a way that won’t explode your brain like it explodes mine.

There’s so much to know about this. It is outrageous, but basically, we still know that mechanical stress is important, right? It puts physical stress on the cartilage, but we know that there’s biochemical and metabolic stress, and we know that excess body fat is an inflammatory organ that produces all sorts of chemistry that drives that metabolic stress on the joint. We know that mental and emotional stress can affect inflammation and that there are immune changes that there are brain signaling changes. 

And even more, we will dive into the complex holistic process systems biology backed by ongoing scientific understanding of the gut brain immune interactions brain gut. Immune this is showing up in every field of specialty, whether it is arthritis, medicine, diabetes, neurodegenerative disease, cardiovascular disease, or psychiatry. All of the journals are starting to look at gut-brain immune interactions as being drivers of the chronic illnesses that conventional medicine doesn’t know what to do with, and osteoarthritis is no different, right so it is  interactions among these things that’ll unpack a little bit that create joint degeneration as we talked about before 

So one of the things that is  going on in the gut is this process called leaky gut you may have heard that language it also gets called intestinal permeability or intestinal hyperpermeability if you look on the left side of this slide you see these cells right this is the inside of your gut and this is the blood vessels running along it right and so here’s where your food moves through here’s where your biome lives all of the trillions of bacteria and viruses and fungi that are normal inhabitants of your gastrointestinal tract and on the left side we’ve got these healthy cells that have something called tight junctions I’m not sure if you can see it that holds the cells together and what it does is makes it so that their intestines are like an incredible filter and all they do is bring fluids and digested food across to the blood vessels where they feed the body where you absorb fluids you absorb nutrients but a variety of different things create this situation called leaky gut or intestinal hyperpermeability where those tight junctions break down and you get little particles from bacteria and partially digested food crossing over that cellular boundary and getting to the blood vessels so besides the blood vessels what have you got wrapped around your gut.

You’ve got a massive immune organ called your gut associated lymphoid tissue or galt doesn’t matter what the name is the point is that you know your gut is like an interface it is  like the border of a country and there’s soldiers on the border making sure that the bad guys don’t come across and so that is your immune system surveying your gut and when you get leaky gut you get all this stuff moving across the barrier and creating a systemic inflammatory response the other thing that happens is that you know bacteria in the gut produce this thing called lps or lipopolysaccharide and when that gets into the body well bad stuff happens if you’ve ever heard of someone who got a bloodstream infection where they got really sick that is  endotoxemia that is  lipopolysaccharide that can cause a massive massive systemic inflammation  and kill a person god forbid if it is  a really big time you know inoculation of that but when it is  just a drip over the course of time it doesn’t make a person super sick like that but what it does do is cause systemic inflammation.

And that is one of the things that leaky gut does, and that is how it contributes to so many different kinds of chronic illness, and so here’s another view of that and what this is doing it is the same thing here’s the inside of your gut here are those nice little cells protecting it as a barrier and here’s that brain-gut connection and this is the vagas nerve has anyone heard of the vagas nerve? It is  your big sort of gut affecting relaxation nerve but the vagus nerve can do all sorts of different stuff and when we’ll get into some more detail but basically the body’s responding to perceive danger whether it is  biochemical danger environmental danger there’s a war there’s a fire there’s a boss who’s a mean person there’s an ex husband who’s nasty who knows whatever the stressor is but you get changes in the way the brain and the chemicals from the brain work that that can break down and cause leaky gut that can change the ecology of the gut flora just having a chronic stress response and then there’s other things like you know antibiotics and medications and all of that that break down this barrier and it is  not just brain gut but there’s other systems that get involved like your hormones nerve function this process called oxidative stress which is like biochemical stress cellular energy the structure of your body detox systems it is  super complex biology it is  astonishing and it is  beautiful and it is  awesome when it works and I’m really into helping it work better for people so that is  what we’re talking about  

Alright, this is a lot of information; I hope it is not overwhelming. Are people having fun? Some people are nodding it is  good okay so here’s that whole gut brain immune joint degeneration thing and I’m just sort of spelling out that all this other stuff is involved too we talked already about hormones inflammation oxidative stress but mood  behavior diet you know when someone’s under stress and feels crummy and they have pain they tend to eat comfort foods which feed into other problems maybe they are drinking too much alcohol or smoking which create a toxic load on the body maybe they are doing less physical activity and physical activity is so incredibly healthy and important social isolation because of feeling sick of feeling pain not being able to get out and about the stress of social isolation you know if we were to put all of these things in a relationship and they be in a circle and there be like a million arrows and we would lose our minds looking at it but like everything here is everything connected with everything else and that is  the brilliance and beauty and complexity of systems biology because we’re learning about all these interconnections with things we’re learning about all these different variables that are influencing our  health and our disease processes and that we can mobilize them to lead us towards health as well so, just touching on that here is another key point the gut brain immune interactions that cause osteoarthritis through these other variables like we just talked about are what drives so many different  chronic illnesses like chronic pain fibromyalgia abdominal pain fatigue depression anxiety  migraine neurodegenerative problems like  Alzheimer’s or Parkinson’s disease, Neuropathy, Dementia, Autoimmune disease, Chronic fatigue syndrome, Hashimoto’s, Thyroiditis, other autoimmune diseases and these are drivers of that and that is  what we’re seeing throughout the medical literature so this is part of why it is  so incredibly important if you have a significant amount of osteoarthritis to also be thinking about okay I need to work on these underlying drivers I need to get my gut healthy, my stress level healthy, my immune system healthy.

The other thing I wanted to add is this piece about autonomic imbalance. We will talk about it more in a second, but basically, that stress response leans towards oh my gosh! There’s danger whether it is perceived or real; the body thinks it is real, and that is one of the drivers that is one of the wheels that put juice behind this whole thing because it creates a danger signal, and that danger signal primes and shifts all of these other systems and it is part of what creates the illness and response that is why I do so much stuff with mind-body stuff because it is all about how do you create safety for your body and safety for yourselves okay so that is a ton of information you weren’t supposed to see this little yellow box just the sunflowers, but here it is just to sum up that there are all these processes of inflammation oxidative stress dysbiosis  leaky gut autoimmune imbalance autonomic imbalance and obesity-related inflammation and just to give you a quick understanding I’m gonna run through this a bit but like this is not just my idea okay? For example, if you do a medical on PubMed and you look up arthritis and the microbiome, and this is just 2016 to 2024, first of all, you see how those citations are going up. 

This is exploding research. I mean, research is exploding everywhere, but especially in microbiome relationships with so many diseases. It is a thousand papers about arthritis & the microbiome if you look at only osteoarthritis, which, as we talked about, I think got a slower uptake right because people understood well microbiome & inflammation and everyone was thinking, well, osteoarthritis is not inflammatory, right? So it took a while for that to catch up there’s a lot more research in things like psoriatic arthritis in the microbiome or rheumatoid arthritis in the microbiome but there’s a significant body that is  growing I found like 120 papers in the past three years on the microbiome and osteoarthritis this is another view of those relationships it is  another way to think about it this is from this this tremendous research group at rockefeller university doctor mcewen is a huge like mind body researcher he’s like been a really mover and shaker and these are these different accesses you’ll see in the middle there’s this chronic low grade inflammation and over here it is  like the joint brain connection and the inflammatory thing in the middle and he talks about the fatty tissue adipose tissue brain connection the way all those stress chemicals and fatty tissues inflammatory molecules relate to each other and then there’s the gut brain axis like we talked about and then the whole central nervous system you know there’s more and more research about how osteoarthritis is connected to our body clock some of the like the higher centers that like organize the body the daily rhythm the circadian rhythm something called the suprachiasmatic nucleus our sleep cycles all these things are interconnected with these low grade inflammatory processes adiposity and you know whether the body storing fat or mobilizing energy the way the gut works the brain all that kind of stuff so this is big stuff and really big people are looking at it and coming up with awesome science and again in my my view of it is that this is such a big driver of all of it what’s going on between your ears do you feel safe do you feel happy do you feel connected or do you feel disconnected and unsafe and unhappy and we live in a hard world it is  really important to pay attention and nurture yourself and care for yourself  okay so autonomic imbalance immune dysregulation boom massive amount of interaction cause it is  a danger signal right?

 The autonomic system is all about whether there is danger or not. The immune system is for defense and repair; when it perceives danger, it goes into attack mode like the autonomic nervous system danger! Danger! Danger! Means inflammation and and maybe you’ve heard about this just what is that autonomic nervous system most you probably know but we got these two branches we’ve got what we call the sympathetic branch which is your fight, flight, freeze  response your stress response your get up and go it is  what mobilizes you for action and here is the way the sympathetic branch of the actual nerves themselves innovate every organ in your body and the same thing for parasympathetic which is the relaxation response this is recovery repair and heal this is rest and digest and again through your vagus nerve but also your sacral nerves through a whole bunch of  different biochemical pathways it is innovating every bit of you so there’s this potential to have balance but for most of us living in our time and for those of us who’ve had difficult stressful experiences or illnesses or trauma that sympathetic response is overactive the fight flight freezes overactive and that is part of what drives so much of this process okay?

So I’m not really into vagal stimulation as a tech thing but just to share with you the importance of your vagus nerve and there’s importance to this autonomic balance thing there are research companies and tech companies that are putting millions and millions of dollars in creating high tech vagal stimulation devices where they implant by neurosurgery a little device in your neck and you wear a little thing like a little you know looks like a pager or cellphone on your belt and it triggers your vagus nerve to fire off and trigger a relaxation response throughout your intestines into your gut gut brain access it turns it on and the reason these companies are spending millions is because the early research of vagal stimulation is astounding what it does that people come in with horrible widespread inflammation throughout their body from rheumatoid arthritis vagal stimulation,  it stops them so you know this is a high tech technology that isn’t perfect yet has all sorts of issues but they are trying to work it out 

They are making cyborgs you know how it is? They want to do everything. The point is that there’s a pathway between your vagus nerve and certain ganglia and neurotransmitters that are all in your gut that release and block the inflammatory molecule right here with this is tnf-alpha (tumor necrosis factor). It is one of the end effectors, the chemical that drives inflammation and so many of these chronic illnesses, like we’ve been talking about, tumor necrosis factor, and when they do vagal stimulation, it just shuts that down; it turns it off; it turns off the inflammation, and so that is why I keep teaching people how to stimulate your vagus nerve through breathing through mindfulness through attention through spiritual practice because that also works to stimulate the vAgas and it is one of the most powerful things you can do and it is free, it creates a safety signal when you stimulate the vagus nerve and that changes the course of chronic illness okay so this is a crazy complex slide.

There are dozens of articles with researchers mapping out all these zillions of different biochemicals talking to each other and doing things. This is a schematic of the gut and all these things coming from the liver. I’m not going to go into the details of the bottom line: gut microbiome changes cause intestine permeability and breakdown of the barrier that changes the immune system throughout your body. There are dozens and dozens of articles with pictures which show the authors’ particular sort of biases. And a similar one from the same article, right?

It is again the same idea, but what he’s pointing out is that specific changes in the bio cause an increase in joint inflammation. At the same time, they activate immune cells, which are called macrophages, and macrophages, when they are activated, are the attack cells of the immune system, so dysbiosis is a leaky gut immune system attack. Are you hearing how important this is? You need to really get it. Because there’s so much that we can do to shift that okay this is a crazy dark drawing I don’t expect anyone to understand it but it is  just another way of organizing the same set of principles that I’ve already talked about it is  in an article that is  called an integrated view of stressors as causative agents in osteoarthritis pathogenesis from biomodical molecules in 2023 briefly it is  talking here about inflammation and cell signaling and oxidation as a core thing that is  affecting these other five domains and those five domains are mechanical stress on the joint mitochondrial stress where the mitochondria don’t work and create a sick cell basically DNA damage where the actual process of  cellular division get sick and protein stress where  proteins don’t work properly as well as metabolic stress from overweight and from too much fatty tissue so again we are reviewing osteoarthritis reviewing and just getting a big picture about the 21st century science which tells us that osteoarthritis is not a wear and tear disease osteoarthritis yeah wear matters and mechanical loading matters there’s a whole set of biochemical and metabolic and biological changes that we can influence with the choices we make about how to live they are out there developing drugs to do this too

But there are lifestyle things, and that is what we’re gonna talk about next, alright, so it is good to see the sea. It is very soothing, and so, just by way of summing all of that up, I’m not gonna read this. We’ve read it so many times, but this is just okay. That is what we talked about so far. If you just came in in the past few minutes, all we did was talk about what causes osteoarthritis, mechanical stress, dysbiosis, leaky gut, immune changes, inflammation, autonomic imbalance, oxidative stress, mitochondrial stress, and metabolic stress from blood sugar control issues and diabetes and metabolic syndrome so that is like a summary of what we’ve done so far and if you want to get the details, there will be a replay.