Chronic Pain & BP: Unveiling The Link

Scott Stoll, MD, FABPMR

I’m great, Laurie. Thank you so much. It’s just a delight to be with you again.

Laurie Marbas, MD, MBA

In this part of our conversation, I wanted to focus on chronic pain in hypertension and chronic disease in general. Could you give us a little background on what your specialty is as a physician and why chronic pain would be something that we should be concerned about with hypertension?

Scott Stoll, MD, FABPMR

My specialty is something I stumbled into in my fourth year of medical school, thinking about what I wanted to do. I love the musculoskeletal system. Someone said to me, Have you ever heard about physiotherapy, physical medicine, or rehabilitation? I had no idea what that was. However, I discovered that physical medicine is just working with the body, the musculoskeletal system, and the neurologic system to help restore function. One of the reasons that I loved my residency is that they always talked about adding life to people’s years. I think even my introduction to lifestyle medicine philosophically started in residency with that idea of looking out of the box to try and help bring resources around people to solve problems and improve the quality of their lives, unlike so much of medicine, which is just treating and managing symptoms. Physiotherapy is much more focused on enhancing the quality of life. Part of our residency is working with spinal cord injury patients, amputees, and brain injuries. The other part of the residency is sports medicine, musculoskeletal medicine, and spine, which is where I specialize. But when I got into practice, I learned that even the basics that I had learned in my residency of trying to help people with their pain were still just trying to mitigate a lot of symptoms. Treating inflammation and pain, but again, not going down to the roots of the problem. I started asking questions early in my career about what’s the origin of pain, how I treat it, and how I can help regenerate whatever damage to the pain is resolved because the tissue is healed.

Laurie Marbas, MD, MBA

Now that’s perfect. Let’s just dive down into the roots. Can you tell us what is the root cause of chronic pain in particular? There’s acute pain from injury, but there’s also chronic pain, and there are so many things that I think the mind-body connection is important to you. But can you share with us what your thoughts are and what you feel?

Scott Stoll, MD, FABPMR

Chronic pain. That’s a huge topic. But we’ll try to boil it down and just peel back some of the layers. But as you mentioned, there are several ways to look at pain. We’ll first start with injured tissue because you can have damaged tissue that occurs through all kinds of accidents and circumstances in life. We can have slips and falls or injuries to the tissue where it gets partially torn. Because of circumstances, we continue to work with that injured area that doesn’t heal, or because our system—the way that we’re eating and living our lives—is not sufficient, our body doesn’t heal. We end up with chronically damaged areas that are a source of chronic inflammation and pain. That’s one layer. There’s another layer of just chronic inflammation because of our lifestyle choices. As everybody is learning in this amazing summertime, we’ve tipped the scales in favor of chronic inflammation. When we look at inflammation in our body, it uses inflammation to heal tissue.  Normally, if somebody twists and their ankle area becomes inflamed because their body is sending cells into the area to chew up the damaged tissue, followed by growth factors to repair the tissue, we’re chronically damaging our system. our body has a chronic, high inflammatory load, which can be not only a source of pain but also a source of limited healing. We also have the mind-body component of pain, which is very interesting—not going to go into too much depth—but there’s this interface between pain and suffering. The other component is that our tissue has a memory. so we can avoid accidents and injuries. The tissue itself remembers the injury, the accident, or the trauma, and it can be a source of pain. Treating somebody holistically to help them mentally release the pain, as well as treating the tissue itself, can help to eliminate those painful situations as well as treating somebody for chronic pain requires a little bit of investigative work. It’s going beyond just an MRI. It’s a good physical examination to identify the tissues. It’s a good examination of body alignment to see if things are out of alignment and that misalignment is over, stressing certain tissues and causing pain. It’s also an evaluation, spiritually and psychologically, to try and understand if there is trauma or suffering that’s also involved that needs to be alleviated and released to bring total healing to the body.

Laurie Marbas, MD, MBA

One of my favorite books is The Body Keeps The Score.

Scott Stoll, MD, FABPMR

That’s a great book, isn’t it?

Laurie Marbas, MD, MBA

It’s like an eye-opener. But getting back to hypertension and chronic inflammation, do you feel like this could be tied to hypertension, people who are struggling or would have dips and flows in their blood pressure, or other chronic diseases?

Scott Stoll, MD, FABPMR

When we look at what happens to the body when we’re in chronic pain, pain elicits a sympathetic nervous system response, a fight or flight system, when we’re in pain. If you have chronic pain, it’s a stressor on the body. Your body interprets that stress through the lens of an emergency. It activates this fight or flight response, which releases all of these hormones: epinephrine, cortisol, and adrenaline, which drive blood pressure up because of the high sympathetic discharge in the system. Chronic pain directly impacts your blood pressure in that way. It’s a high sympathetic, low parasympathetic tone. the blood vessels, which causes the blood vessels to narrow down and become restricted, which increases the blood pressure. Medicine often treats this with blood pressure medications but doesn’t go back again to say why the blood pressure is elevated. Lifestyle factors, but is there a chronic pain component that’s disrupting daily activities that are causing physical stress? Sleep disruption is also another stressor that can be impacted by chronic pain. then the emotional stress of pain; the emotional stress of having limitations; being fearful because you’re hurting; or being depressed because you can’t participate in life in the same way. It has a multiplier effect on our bodies. But all are diving down to the same level of driving the sympathetic discharge and driving chronic inflammation, which is again going to impact the blood vessel diameter and blood pressure.

Laurie Marbas, MD, MBA

When someone comes to see you because they can’t see you in person, via Zoom, or via whatever modality you’re caring for, how do you start the investigation, or do you look at pain, in general, the same through the same lens? Or, like, where does that investigation even begin? Maybe some ideas for people to start thinking about their pain in a different way?

Scott Stoll, MD, FABPMR

It goes back to what we learned in medical school. Take a good history and be a good listener. I think what I’ve learned through the years is that it’s easy to make the mistake as a physician to just assume that’s what’s going on. I’ve got knee pain. Well, let me take a look at you, and let’s examine why your knee hurts during your physical examination and discover that. But I’ve learned through the years that, as far as I know, you have to just sit back and ask good, curious questions to understand the totality of someone’s life, to understand when it started, if any other conditions existed before it started, how it’s impacted, whether their total body has compensatory issues on the other side of their body, and how it’s impacting sleep. Maybe they’re making different dietary choices because of the pain that’s causing persistent inflammation, making the condition worse, how it’s affected them emotionally, and holding stress in their body in those tissues. Once you have a good history and understanding of that patient, you can begin to write a more comprehensive plan to help them overcome the pain. It’s not just the reductionistic idea of medicine. We just treat the one thing: everything is connected in the body, from the big toe to the top of the head. Emotionally, physically, and spiritually, it’s all connected. when we begin to treat the totality of the person in the context of the pain, we will certainly treat the knee injury, but we’ll also treat the system. Then you have a beautiful resolution that allows people to move on in a way that brings vitality and abundance to their lives.

Laurie Marbas, MD, MBA

Vitality and abundance. I like that. Are there any across-the-board interventions, discussions, or things that you counsel patients to do that help the majority of your pain patients?

Scott Stoll, MD, FABPMR

Since you’d asked previously about things that people can do, you can just begin. I love asking myself curious questions, and that’s a great place. If you have chronic pain, just begin asking yourself, When did this start? How does it affect my life? How is it impacting my sleep when I choose different foods that may cause inflammation because of the pain? We eat foods because they help satiate pain temporarily. But on the backside, sugar, fat, salt, and processed foods may cause inflammation, which makes your condition worse. By eating foods that may be making my condition worse. I love the mirror test, which is also a good opportunity for people to just stand in front of a mirror, just in a pair of shorts, and look for imbalances in their bodies. Hip or shoulder to high as a shoulder rolled forward, causing an impingement. You have imbalances that you can see from side to side. Those are good clues about what you may need to do to start helping your body feel better. But there are basic things that people can do at home or just simply to begin stretching. Stretching can make such a big difference, and it’s something that we don’t do very often. I love to reclaim time in my life. If I turn on a movie, I sit on the floor and stretch for 30 minutes. If I’m on a phone call, I stretch while I’m talking. Just finding little ways to redeem the time in your life to begin adding more stretching and restoring some postural balance is a very beautiful way to begin helping your body relieve some of the stress and regaining postural balance. I also love that functional exercises, just to begin strengthening the body, don’t cost any money. You can do all of this at home, letting your body be in the gym, by simply doing isometric exercises like pushups. If you have to start with walk-ups or push-ups, you can do that. Pulling your shoulder blades back together will strengthen those postural muscles in the back. They get so tight. We were on computers all day, but just very simple things to begin helping your body to move more: go for walks and just get the body moving. That often makes a huge difference as well. Then the two last things I’ll mention are that, as we know, sleep is restorative and so important, and we need to get to bed between ten and 11 and wake up between five and six because there is a response in our restorative regenerative hormones that occurs between midnight and three a.m. If we miss that regenerative window of sleep, our body will not recover. Getting a good night’s sleep is essential for the regeneration of the body and gives your body a chance to mitigate some of the damage and reduce inflammation. Finally, as everybody is learning here on your summit, and I won’t go into too much detail, eating a wholesome, plant-based diet is the best way to not only reduce inflammation but also foods like broccoli and kale that are cruciferous vegetables activate the stem cells in your bone marrow to be released into your system to begin repairing tissue. Three or four servings of cruciferous vegetables every day can add to that regenerative lifestyle that you’re building and can help you alleviate some of that pain.

Laurie Marbas, MD, MBA

Besides the broccoli and the kale, are there any other spices, supplements, or anything else that you’d recommend that might be very helpful for inflammation?

Scott Stoll, MD, FABPMR

As you mentioned, spices are very helpful. There have been so many studies on ginger and turmeric families and the ways that they can help stimulate the cartilage cells to begin regrowing cartilage and our joints and reduce inflammation throughout the system. There have been thousands of studies on those two spices, and an easy way that I like to get them every day is just a cup of tea. I make a cup of tea every morning with a teaspoon of turmeric powder, a teaspoon of matcha, a little bit of ginger, some cinnamon, oat milk, and hot water. It’s a beautiful way to start the day. Yes, spices and mushrooms also help to support the immune system, which is part of the healing cascade as well.

Laurie Marbas, MD, MBA

Are there any particular mushrooms?

Scott Stoll, MD, FABPMR

The white variety of mushrooms. I like eating varieties because they all do something different. I pick the mushrooms in as often as I possibly can.

Laurie Marbas, MD, MBA

You mentioned starting with some stretching. What are some of the more gentle stretches that you would do for someone? Is there decent mobility? If they’re not limited by the back or something, what would be some good stretches that someone could do while they’re in a chair, at work, or in other places? Any thoughts there to help people just get the ball rolling and be amazing? I mean, the questions that will get ones like, well, what are the specific strategies?

Scott Stoll, MD, FABPMR

We’re sitting, and we can just, even if you’re sitting at your desk, do some simple ones. I’m just sitting at your desk. A good one for the side is just up and over to stretch the side, and you can even grab the underside of your chair and fall to give yourself some more. On the other side, you can also just stretch for the neck, where you take one arm and grab it underneath your chair, and then you lean away from that side and stretch through the trapezius, which is a nice stretch up through those muscles to get some type of stress. Just taking your arms up and stretching your shoulders can be so helpful. Their shoulders get so tight up and over and around as you’re sitting, just squeezing the shoulder blades back together, pulling them, and holding them tight. 15 to 30 seconds strengthens all those muscles and stretches the pecs, which are important. As you said, you can just straighten one leg out, reach down towards your toe, and stretch your hamstring. We can do that on both sides. A good stretch for you. But it’s down to good. much for your hips to get. just to simply cross your hips and push down on your knee, and that stretches all that hip muscle we get. We’re always seated in this position. I also encourage people, when they’re sitting, to sit Indian-style or cross-legged because that opens up the hips. We found that in countries where people squat more and sit cross-legged, they have a very low incidence of hip arthritis because they’re opening their hips much more frequently. Perfect. A good one if you’re working at a desk is to just open and push your hand open, which opens the carpal tunnel and prevents the carpal tunnel from getting pinched. That’s a very simple one. You can go across, and you can go up and over. In that way, you can incorporate an amazing stretching program throughout your day while you’re sitting at your desk.

Laurie Marbas, MD, MBA

I just did that with you, and I feel better because we don’t do a lot of lifting over your arm.

Scott Stoll, MD, FABPMR

That’s right. On our shoulders. I mean, as we sit, they roll forward.

Laurie Marbas, MD, MBA

I love to hang from it; we have a pull-up bar in the garage that I love to just hang from. I got some calluses from working on that stuff, but it’s great, and it’s good for strengthening too. I guess. One quick question before we go for a little break here, is there anything else as far as things that maybe someone needs to think outside the box? Maybe I’ve been on pain medications for many years. I think back pain would be a growing thing. That’s probably the most done. The majority of people that you see, or at least a lot of people that I saw in primary care, are on pain medications and escalating doses over the years. they just have been total they’ve done everything, anything else that they should look at. I mean, there, we read dietary inflammation. But how did you feel when someone even started to crawl out of this massive hole of chronic pain? Because I feel like sometimes they’re like, That’s so simple. get better sleep. But how can I, when I’m always in pain, eat better? Well, I can’t even get up and stand to cook a healthy meal like I don’t. Even when someone even begins to crawl out, I ask maybe a bigger question.

Scott Stoll, MD, FABPMR

It’s a big question, and I’ll start with a simple place to solve those issues. But if you’re having that much pain, you’re on chronic pain medications. I would encourage someone to find a physiotherapist like myself in your area who also practices regenerative medicine because addressing some of the underlying drivers of the pain and treating them can effectively break some of the pain cycle, which then can allow you to start exercising and strengthening some of the weak muscles, which will allow you to decrease and discontinue the pain medications because the pain medications have a multiplied negative effect in your body, including reducing testosterone and growth hormone, which are essential in the repair process anyway. We have to be able to discontinue those and move forward. I was just thinking, and I remember having a patient who was an engineer. so, we didn’t take care of patients who are engineers that come with lots of graphs and charts because they chart everything.

Laurie Marbas, MD, MBA

They are data-driven.

Scott Stoll, MD, FABPMR

It’s so great because you learn so much from them. He brought in a chart. I was working with them to discontinue a pain medication opioid that he was on, and so he had charted all of these things—his pain levels, his medications—and he came in, and he said, What have I discovered, Dr. Stoll? I discovered that my body was creating pain as a craving mechanism for my medication. He said that I was decreasing my medications and that my pain spikes were going down. When I got off my medication, my pain levels were much better off than on medications because I became aware of that. I saw that many times that it seemed like the body would almost spike pain as a mechanism for triggering the use of an opioid medication.

Laurie Marbas, MD, MBA

Do you think that was the body doing, or do you feel like the mind was like, I’m four hours out, you think I’m the brain, you expecting pain from the body’s like, here’s some pain?

Scott Stoll, MD, FABPMR

It’s a mind-body thing.

Laurie Marbas, MD, MBA

I’m reading a book called Mindfulness by Ellen Langer unless you’re familiar with her work, but we’re going to get her on the podcast as well. But it’s just fascinating to me to see the different things that she did with people, even when they were younger. There was one incident where they took someone and put them in the woods for a week. A group of older gentlemen put them like 25 years younger in an environment and told them, “You have to talk like you were back 25 years ago, act like you were 25 years ago. All the music, everything, the food—everything was just like it was 25 years ago.” They said by the end of the week, their biometrics were different like the blood pressure was better and the blood sugars were better. They looked younger. The two that were walking with canes were no longer ambulating with canes saying, “I’m going back to the seventies,” and as I get older, they call it counterclockwise. You wrote a book about it? I have yet to read it, but it’s on my list. But I think that’s so fascinating to me. If we start thinking about it, how did we think our way into this dilemma? I don’t know.

Scott Stoll, MD, FABPMR

There is more and more evidence coming out on the link between our thoughts and emotions and our pain looking at functional MRI, which measures the activity of the brain, and showing that as people begin changing the way they think about themselves and their pain and looking at the future more, hopefully, the activity in their brain changes and their pain levels go down. 

Laurie Marbas, MD, MBA

I think that’s an interesting place to pause for a moment, and then we’ll get back into that. But I want to thank everyone so much for joining us today, and I hope you found this conversation insightful and engaging. If you’re a summit purchaser, stay right here because we’re about to go even deeper into this awesome discussion. But if you’re not, you can click on the button below or somewhere around here, and you can have access to the rest of the conversation. 

Now, if you’re watching us, thank you for being a valuable member of our community. Let’s continue this conversation with Dr. Stoll. We are talking about the mind-body experience. What I would like to understand is: if you see anxiety, depression, or pain as the cause of pain, is it a result of pain or both, or how can we peel back the layers there? I think so many people are treated for depression or anxiety, but maybe it’s a cause of something. Where do you even start?

Scott Stoll, MD, FABPMR

It’s at both ends. Somebody has chronic pain from an injury that’s just not getting better, and they’ve lost quality of life. They may feel like they’ve been disconnected from things they love to do or participate in life or relationships can drive depression, but feeling depressed can also be a driver of chronic inflammation in the body and pain. It’s a both-end situation. But again, the solutions are the same for either, as we’re talking about. It’s approaching it from the totality of our bodies and our spirit, mind, and bodies, looking at the spiritual, psychological, and emotional components, and working typically through, as you mentioned, those mindful interventions that have been shown scientifically to not only reduce pain but change the functional state of our brain, and then addressing the underlying physical conditions that may be contributing to the pain, such as misalignment of the body, chronically damaged tissue or tissue injuries, and laxity of ligaments, which can be a source of pain. then, in treating someone as a whole, we get that complete resolution of pain and a full, functional, fulfilling life rather than just the compartmentalized treatment of pain today, which is to inject it, operate on it, live with it, and take medications. That certainly doesn’t solve anything, nor does it give people the opportunity to become whole.

Laurie Marbas, MD, MBA

Going with that same idea of treating someone whole. An integrative approach is so key. How do you help someone decipher? This is a mental health component, and where do you send your patients to get help with that piece? They feel like there’s such a stigma around mental health in seeking help and even knowing where to go and getting adequate help. How do you do that with someone with chronic pain? I do know I did interview Dr. David Spiegel, I believe, as his last name. He does self-hypnosis at Stanford. See the spiders needle this needle. However, he had some interesting research regarding how self-hypnosis can help decrease chronic pain. But how does someone even begin to look for someone to help with that piece of it?

Scott Stoll, MD, FABPMR

That’s a great question. There are just gaps in our medical system in finding people who can help in that way. Locally, I have some resources here in our clinic, where we work with people who can come alongside and assist people in dealing with freedom. But going into the medical system just to find that answer is difficult because the medical model, again, is so reductionistic. It is a diagnosis of depression, anxiety, and medication, but it does not assist people in gaining freedom. I can maybe send you a few resources or links for people so they can utilize a couple of great books that can help walk people through the process of mindfully addressing some of their pain symptoms. Which I think is maybe the best way to start first. It’s just not easy.

Laurie Marbas, MD, MBA

No, it’s just that it’s a very complex and difficult task because everyone’s so different, and it’s amazing. Final question: do you ever recommend meditation or something like that where people turn into pain and start investigating, and that in a mindful approach?

Scott Stoll, MD, FABPMR

I think mindfulness is always a good way to approach it. Mindfulness is just looking at yourself through a non-judgmental lens, just as an observer, to ask curious questions, and those curious questions help us dig a little bit deeper down into the subconscious to discover some of the roots that live underneath the surface of our daily lives and that are part of our operating system. We don’t know where they’re discovering some of those roots and bringing them back up to the surface. We can consciously work through some of the challenges, the stressors, the unresolved relational issues, or the emotional issues that are hindering healing or giving us insight into pain. Yes, I certainly do always help. I want to help people step into that because, in every way, it’s helpful. Mindfulness is always helpful; it gives us more control in our lives and gives us an opportunity through a non-judgmental lens to just curiously explore why we do what we do, ask those questions, and retain freedom through the process.

Laurie Marbas, MD, MBA

Could you also share where people want to connect with you or other things like the Plantation Project? Is there anything there that you’d like to share with our audience? Just to show all the breadth of work that you’ve done, depth, and breadth in our space.

Scott Stoll, MD, FABPMR

There are a couple of places you can connect with me. We educate healthcare providers and students around the world about the power of, hopefully, plant-based nutrition. Food is medicine, and food is more than medicine; it connects to every aspect of our lives. That’s prime tertiary product talk, and we have some resources that we’ve created for healthcare professionals and students, including an amazing journal, the International Journal of Disease Reversal and Prevention, that you, Laurie, helped us kick off. I was just thinking the other day about how you and I started, and we had no idea. I haven’t started a journal yet.

Laurie Marbas, MD, MBA

There are lots of sticky notes on my wall.

Scott Stoll, MD, FABPMR

Thanks to you, the Journal is alive and has 30,000 subscribers. Thank you. That’s your gift to so many people. That’s  IJDRP, internationaljournalofdiseasereversalandprevention.org. We have a platform for students and faculty members interested in the university that is free and has courses that are being offered every month, as well as neat forces that are not just food and medicine. We’re talking about three indications and using nonviolent communication to communicate more effectively with patients and others about the intersection of food, agriculture, and climate. It’s a dynamic, fun platform that we continue to grow at Prime Christian University, free for all students and faculty around the world, and free for conferences. You’ll find that we do it every year, which is a beautiful opportunity for us to get together as a community, learn from each other, and connect. You can also find more information about me here. This is MaxWell Clinic in Nashville, Tennessee, and that’s where I practice some regenerative musculoskeletal medicine to assist people in overcoming their pain and healing tissue using a variety of regenerative injections and holistic integrative care to give people their lives back as well.

Laurie Marbas, MD, MBA

That’s called the Maxwell Clinic.

Scott Stoll, MD, FABPMR

Maxwell, like Maximum Wellness. Maxwell Clinic. That’s right.

Laurie Marbas, MD, MBA

Maxwell Clinic in Nashville.

Scott Stoll, MD, FABPMR

In Nashville, that’s right.

Laurie Marbas, MD, MBA

It’s okay. Perfect. We will put that stuff there as well. That’s fantastic. Well, thank you, Dr. Stoll, for sharing your information. It’s just always delightful to talk to you. I appreciate your time today.

Scott Stoll, MD, FABPMR

Thank you, Laurie. It is so great to be with you. I wish you all the best. Thank you.