The Connections Between Chronic Pain And Dementia ​

Joshua Levitt, N.D​.

Well, thank you, it’s so great to be here. This is a real treat, and that intro was, gosh, I could have written that myself, you know. I was blushing throughout it. Yeah, so I’m excited. I’m excited to be in the hot seat here. I have indeed been in the position that you are in, and it’s a pleasure to be on the other side of the room here, so to speak.

Heather Sandison, N.D.

Yeah, so I was just asking you what you learned from doing all of those interviews, and if there was kind of a takeaway that you got from it?

Joshua Levitt, N.D​.

Yeah, that’s a great question. I mean, what a treat it is first of all, to get to interface with experts, right? I mean, I’ve found that such a great way to learn. It felt like, yes, it was work for me, but it was also, like, a joy to get to meet and engage with smart and interesting people who have this world of experience, who then get to convey that to me. I’m sure you probably feel the same way. I think there’s no better way to learn than from people who have been doing it in the trenches for decades themselves. 

Gosh, it’s a big question ’cause I interviewed a lot of people, and there was a lot of takeaways, some rather technical and some of the more broad ones. I think the broad ones are maybe most appropriate here to talk about in this context. And that is that there is reason to be hopeful. I mean, Alzheimer’s disease is really scary, right? Like, everybody lives in fear of it. We have these kind of very compelling, almost poetic, but tragically poetic terms to describe it. One in particular is the disease that kills you twice. We’ve heard that, right? It takes away your memory who you are, and then takes away the biology, your physical systems. And that is frightening indeed. And so, yes, we have medical literature that’s fraught with failures in the magic bullet looking for drugs department, but what I’m learning from all of these experts, and I suspect you’re learning it too, is that there is reason to be hopeful, especially, if we can intervene earlier, right? 

If we can intervene at younger ages before the disease becomes really advanced, there is an opportunity to change the course, to turn the tide so to speak. And a lot of the things that I’m sure your other guests are talking about, that we’ll talk about here today, diet, lifestyle, nutrition, sleep, stress management, toxic exposures, all of that sort of stuff are very real risk factors. And there is a very real opportunity to reverse the course of this illness, to change course as long as we act early, so. I think hopefulness and optimism was probably the biggest takeaway for me, which is a pretty good takeaway.

Heather Sandison, N.D.

Yeah, that’s wonderful. And part of that what you were describing is like this lifestyle intervention, so. Today, talking with you it’s a little bit different, like you mentioned from other talks that I’ve done where we’re both naturopathic doctors, and so that certainly influences sort of this human perspective around pain, and its connection to dementia. So can you just go ahead and sort of launch into your thoughts on that?

Joshua Levitt, N.D​.

Yeah, absolutely. And feel free to cut me off at any point, or interrupt. I am here running a clinical practice right in the shadows of Yale University, which is just right down the road. And Yale is a wonderful high-level medical care center. And they have an extreme focus on specialties, and subspecialties, which sort of define, I think, modern medical practice, mainstream medical practice, as we think about it. I can send people, I actually have sent people to thumb doctors, okay? Not hand doctors, thumb doctors, there’s a thumb specialist at Yale, and so on, right? Like, so every disease, every body part has a specialist. 

Now, that’s remarkable, and I think quite a wonderful thing if you have a thumb problem, or a right eye, or a left eye problem, that’s not, there’s not actually right eye and left eye specialists, but you get the idea that subspecialization, super specialization is this big trend. And there’s some beauty to that, right? People who have Alzheimer’s disease see specialists in Alzheimer’s. 

People who have Parkinson’s disease, see Parkinson’s, or movement disorder specialists, so my perspective, and I think that you share this as a naturopathic doctor, is to treat people rather than to treat illnesses, right? So, so far, at least in my 20 plus years of practice, every person that’s come through my door is a person. They might have cancer, they might have Alzheimer’s, they might have heart disease, but I have to think about them as the person that they are, not the disease that they have. And that perspective really is a game changer. And I think it’s related to what we’re gonna talk about here today, right? It’s very easy to go down the road of, oh, a person has Alzheimer’s disease. 

So that becomes the definition of sort of who they are, and all of their care, all of their medicines, all of their attention goes to that narrow thing, but as I’m sure many of your viewers can attest, these people with Alzheimer’s disease also have other problems, low back pain, their knees hurt. They have heart disease. They have other issues, skin problems, whatever the case may be. And it’s very easy for all of those other problems to get lost in the shadow of their big ticket illness, which Alzheimer’s disease is for what it’s worth a big ticket illness. So is cancer and some other big ones, but when you have that you get narrowed. And I think that’s problematic. It’s really good to have the specialists, but it’s also really important to keep that pulled back 30,000 foot view, and that’s the approach that I try to take.

Heather Sandison, N.D.

Wow, and then when this interfaces with pain, there can be some other things that are actually quite cruel in terms of the dementia verse, right? Like when someone with dementia is complaining of pain, there’s a risk that they might forget it, and so that the clinician, or the caregiver, might not be as apt to treat right away, so as I see to sort of discuss this landscape.

Joshua Levitt, N.D​.

I love the term dementia verse, and it is indeed a kind of rapidly expanding universe itself, right? As it relates to pain, you used the word cruel, which is a powerful word, but I think it’s appropriate in this situation. Cruel assumptions about pain in the Alzheimer’s community is absolutely a real thing. There’s a trope that goes back many, many years that people with Alzheimer’s disease experience less pain. This has been something that many doctors, actually, still believe to this day, that the neurocognitive decline associated with Alzheimer’s also changes the perception of pain. And it’s long been thought inappropriately and inaccurately that people with Alzheimer’s disease experience less pain somehow. 

That turns out not to be true, but, of course, it is very difficult to assess pain in a person who can’t really articulate what they are experiencing. It’s hard enough to assess pain in a cognitively intact person, I can tell you that myself. In a person who’s not cognitively intact, or non-verbal, it’s extremely difficult to assess pain. And so that leaves room for all these cultural interpretations, and some of them have turned out to be rather cruel assumptions. So one of them, yes, people who have Alzheimer’s experience less pain, not true, that’s a problem. And that can lead to poor pain management practices. 

The other, and I think you alluded to this as well, is that when a person has an injury, or has some kind, let’s say they slip and fall down the stairs, or have a low lumbar disc herniation, or something like that, that because they have dementia they’ll forget the injury, which is often true. They may have forgotten falling down the stairs, or forgotten having a car accident, but the pain from that injury, that trauma, that surgery, whatever the case may be, whatever the initial stimulus was, may have been forgotten, but the pain, no doubt, persists. And I would challenge anybody, you, or any of your viewers to imagine what it’s like to have severe pain, and not know why you have it. Pain provokes a lot of fear by itself, even when you do know why you have it. And if you don’t know why you have it, I can only imagine how much more frightening, and anxiety provoking that must be. And that is the plight of many an Alzheimer’s patient who has a serious acute, or chronic pain syndrome.

Heather Sandison, N.D.

I can imagine waking up in the morning, or being woken up at night with this pain, not knowing why I had it, and am I dying, right? You jump to what is this trying to tell me? When you don’t have the answers to that question, then the mind would go down some crazy loops I would imagine.

Joshua Levitt, N.D​.

Absolutely, and even something as simple, but it could be rather painful as a fracture, someone falls and breaks their wrist. Well, you wake up in the morning after having broken your wrist it hurts it’s gonna hurt. I’ve done it I’ve broken a few bones in my time, and they hurt, but every time I wake up with that pain, or it hurts when I roll over, I remember why I broke that body part. And that gives me at least some comfort. Yeah, my foot hurts, my hand hurts because I rolled my ankle over playing basketball, so I can deal with that, but if I didn’t remember that, that could be really problematic. 

And that, again, is another cruel assumption. Oh, they’ll just forget about it. So it’s not really that big of a deal. I would argue that it’s actually a bigger deal in the patient who has pain, and doesn’t actively, or consciously understand why. And so we really need to be careful, and compassionate in our assessment of these folks with pain, despite the difficulties in assessing it, right? There’s no less than, like, 30 different assessment tools, pain rating scales, and whatnot, that have attempted to qualify, and quantify pain in people with dementia. Like I said, it’s extremely difficult. You can’t ask a person, especially, who has advanced disease how much does it hurt? Where does it hurt? Is it sharp or dull? Can you rate it on a scale of one to 10? You’re more looking for subtle kind of cues. And it’s a big challenge indeed.

Heather Sandison, N.D.

We’ve already seen at Marama, the residential care facility, how people who are in pain from one thing or another, that they also need to be reminded, okay, you’ve got to use your walker because your left knee is still swollen from, I’m remembering a woman who had a procedure. And so she had had a procedure on her left knee, and we had to remind her over and over, you’ve got to use your walker. If you put weight on that knee it’s going to hurt. And so even this is a little bit more obvious, I think then the nuances you were describing, but even that it’s like you said it’s a bigger deal. When there’s pain it’s a bigger deal that someone needs to be reminded to gingerly walk on a limb that’s ailing when we wouldn’t have to be reminded over and over, right? And so we would be less likely to re-injure. They’re almost at risk a bit more because of the lack of memory of an injury.

Joshua Levitt, N.D​.

Indeed, yeah, or a surgical procedure as it was in your patient there. Yeah, it is, it’s remarkably challenging, right? It’s a highly complex kind of clinical management in that situation. And, yeah, the musculoskeletal story, and there’s so much musculoskeletal pain, right? The knee procedure, and I’d love to get into the details of kind of some of the pitfalls of musculoskeletal pain management, but more broadly, but, yeah, you are absolutely right. It’s a challenging thing to assess. And in people, especially, with more advanced disease, you have this challenge of being able to articulate even the experience of the pain. 

So you’re looking for other cues, right? You might touch something and see if there’s a grimace, this sort of thing, more softer signs rather than the hard obvious signs where a person can articulate. And then there’s this added complexity, also, that I think is important, and so relatable, is that pain is at once a signal that something is wrong, right? In that woman’s knee, or wherever the body part may be, but it also incites a fear and an anxiety that really pain does serve a biological purpose. 

And so for many people who experience pain, you might see a grimace, or people moaning or groaning at night in their sleep, this sort of thing that looks like pain, but a lot of times those outward expressions of pain, or suffering can be relieved by human contact, right? This has been seen time and time again. A caregiver comes in, a granddaughter comes in and holds grandma’s hand, and then all of a sudden the moaning and groaning, and the grimacing decreases. So it’s an added challenge to wonder whether or not this outward expression that looks like suffering is actually pain, or like physical pain in my knee and my back, wherever, or is crying out for relief in some other department, like loneliness, whatever else it might be. And, yeah, there again, another layer of complexity in the sort of assessment, and management of pain in people with Alzheimer’s disease.

Heather Sandison, N.D.

Yeah, and what I’m inspired to do, right? Just having this conversation with you is to manage pain aggressively in our seniors, or in our dementia patients because we lack that ability to really fully communicate about it. And so you have a different sort of paradigm for thinking about pain, but before we go there, I want to understand a little bit more about this sort of poorly understood, but well-known toxic brew as you called it of pain and dementia, so this interface of things that cause pain typically lead people to live less healthy lives, or less the life that would reverse, or prevent dementia from happening. And then also as they potentially add things to treat pain, there’s an effect on the brain. So let’s dig into what we do know at least about that.

Joshua Levitt, N.D​.

Yeah, it’s a great question. And I support the idea of aggressively managing pain, right? There’s some pitfalls there as well, and we’ll get into those, right? We’ve seen that with opiates, and kind of the aggressive management of pain using opiates, has led to a whole new societal crisis, thinking of pain as a vital sign, which it probably deserves to be, but then we have to think more elegantly about the way we actually approach it. Yeah, so to unpack that a little bit. Pain and dementia, right? 

So, yes, it’s difficult to assess, but to the extent that this has been studied, and it has rather extensively, there’s a few things that are pretty clear. People who have chronic pain, which is often musculoskeletal, but not always, orthopedic arthritis that type of thing, can be expected to have a more rapid course, a more rapid progression of their Alzheimer’s disease. And the reasons for this are not totally well understood. There’s probably some that are related to the actual in medical speak pathophysiology, right? 

The biochemistry, the pain causes some biochemical changes in the brain, and the central nervous system that may enhance the progression of a neurocognitive degeneration. So pain can make the condition worse directly. You also alluded to that pain can influence your life. It can mess you up in all kinds of ways, right? It becomes a preoccupation. It becomes a big source of anxiety. It can become a big limitation on your lifestyle, and ability to exercise, your ability to sleep. The choices that you make when you’re preoccupied, I think we can all relate to this. Something hurts, doughnuts sound better, you know? Comfort foods and these sorts of things. So pain can have this effect of draping over a person, and impacting adversely their diet and their lifestyle, their stress management, their sleep. 

And all of those things, and I’m sure you have many experts that are talking about this are also associated with advanced more severe disease, more rapid progression, et cetera. So, yeah, that’s kind of what we know, I mean. And it speaks, I think, to your point, right? Which is that we should do what we can to keep the pain under control, to understand it because doing so will help people in all kinds of different ways, right? And when we just sort of neglect, or ignore pain in a person with dementia, we are doing them a great disservice, both in terms of their dementia, and in terms of their humanity, right? Their life itself, so.

Heather Sandison, N.D.

Then the other piece of this, I think we can all agree that an increase in stress leads to more dementia, and a reduction in sleep quality leads to more dementia, not sleeping, or excuse me, not eating as well. So more inflammation potentially from an unhealthy diet leads to more dementia. Now on the flip side of this, when we go to intervene, right? So when we think about using Tylenol, or NSAIDs, or opiates, like you mentioned, what are the effects of those interventions on cognitive function?

Joshua Levitt, N.D​.

Those drugs, and you mentioned a bunch of them, and they’re all sort of in different categories. Broadly speaking, there’s this big class of medications that includes so many different drugs called anticholinergics, which are known sort of triggers for increasing risk of Alzheimer’s disease, and increasing the rate of progression. Anticholinergics include common over the counter medications. Most notably, probably Benadryl, but also a whole bunch of other drugs that end in A-M-I-N-E. Benadryl is diphenhydramine, but there’s all these other drugs, many of them, not all, that end in A-M-I-N-E are anticholinergics, and associated with increased risk of dementia. 

So we want to try to minimize the use of those things whenever possible, Tylenol PM, Advil PM, these kinds of things. The PM is diphenhydramine and should attempt to be avoided. It also is soporific and it induces sleep. People take Benadryl that’s what the PM is about. And so many over the counter, and prescription medications contain these anticholinergic compounds, and that’s a problem. And then when we go up the chain, in terms of force of the intervention, if you will, you ultimately wind up at opiates, right? This is your OxyContin, Oxycodone, Percocet, Vicodin, Fentanyl, Dilaudid, all these drugs, which are a pandemic of their own, and are widely used for pain management including in the dementia population, and are fraught with all kinds of problems, including cognitive deficits. 

I mean, anybody who has ever had even the short-term experience of what it feels like to be under the influence of opiates knows that they are powerful agents on the central nervous system, and not exactly associated with, like, sharp cognitive function, right? So, yeah, if we can find a way to help people feel better with respect to their musculoskeletal pain, that doesn’t make their other problems, including their dementia worse, well, that’s a win.

Heather Sandison, N.D.

When you mentioned just something as simple as a granddaughter’s hand on a dementia patient, or touch from a caregiver, these are things that they take human time, they take some labor, but really do tend to reduce the intensity of pain. Our experience of pain goes down, and we know this also from assessing people who do not have dementia, right? So any sort of human touch, human interaction, again, good diet, all of these things, a healthy lifestyle can reduce not only dementia, but also can help with how intensely we might feel pain.

Joshua Levitt, N.D​.

Yeah, well, you’re right. Yeah, of course, we’re talking about people with dementia, but pain is a universal experience, well, nearly universal. There’s a few select people who are not fortunate to not be able to experience pain, it’s a rare condition, but for the rest of us, 99.9% it’s a universal experience, but it’s a complex one, right? It’s not as simple as measuring something like blood pressure. And that’s largely because, and I think you just alluded to this, pain is both about what you are feeling, and how you feel about it, right? And that’s a really important thing in pain management, right? 

And I think this is a nice segue into the next part of our discussion is that the stimulus that caused the pain in the first place is one thing, but then the way we feel about that pain, what it means to us, what fears it provokes, what stories we’ve told ourselves, what our past experiences have been, what we’ve seen, what our mother, or our father, or our grandparents went through, those inform the experience of the pain, and have a dramatic impact for better, or for worse on the amplitude of the experience, right? And so this is why some people can have a certain stimulus, maybe a fracture, or whatever the case may be, a surgery and kind of come through it just fine. 

And others, there may be genetic reasons, and other types of reasons, but much of what our experiences of pain, and how bad or impactful it is upon our lives has to do not with the trigger, but with our story, the story that we tell ourselves around it, often around fear, anxiety, those sorts of things. And so, yeah, so human touch, caring, compassionate care, music, these kinds of things can influence the story that can calm that inner fear and anxiety, which actually has a benefit on the experience of the pain. This is a well-known phenomenon in mindfulness research, and all sorts of other non-pharmaceutical ways to manage pain, and it’s a beautiful thing if we can employ those techniques in this population.

Heather Sandison, N.D.

Right, and I think that’s maybe the point I was trying to make was that we have a lot that we do know about pain from people who can fully articulate their experience.

Joshua Levitt, N.D​.

Yes.

Heather Sandison, N.D.

If we can aggressively apply that information to a dementia population, then we can get them sort of the best of both worlds, right? We can reduce the pain that might be driving the dementia, or maybe not driving, but certainly contributing to that rate of decline. And we can also get them pain management, which is just from a human perspective so important. And then not also be adding to the dementia-scape, like what’s going to further lead to progression. And so I want to jump into that. So if that’s the goal, and I think that that’s a worthy one, and certainly that’s what we aim to do at Marama, the goal is to get them the best of the medicine with a broad idea of what medicine is.

Joshua Levitt, N.D​.

Yeah, yeah, yeah, prescriptions in the broadest sense of the word, I’m with you, yeah.

Heather Sandison, N.D.

Yes, so if that’s the goal, then what does that look like? How do you think about pain management from your naturopathic perspective?

Joshua Levitt, N.D​.

Yeah, it’s such a great discussion here that we’re having. And I think it’s just so important, you’re so right, right? If we can apply aggressive pain management, and all these non-toxic safe things that are gonna help people in other ways, I mean, we’re relieving suffering, right? And that’s really, I think, one of the primary responsibilities of a doctor, naturopathic, or otherwise, is to help relieve suffering, and pain is such a fundamental cause of it. So, yeah, let’s look at this. 

I suspect and correct me if I’m wrong. There’s been a lot of discussion about diet, and the influence of diet on inflammation, neurocognitive decline. All of that same information applies to pain management too. Inflammation being one of the really fundamental sort of pieces that enhances the experience of pain in a person with a degenerative musculoskeletal condition. So, yeah, all the dietary approaches that I’m sure have been mentioned, diets that are minimally processed, that are rich in Omega-3 oils, that are low in industrial seed oils, and bad fats so to speak, that are coming from all minimally processed kind of plant-centric type of diets. 

Those are the kind of diets that I advocate for general health and for pain management as well. And then we also touched on lifestyle. So I’m sure there’s discussion here about sleep, anything and everything that we can do to enhance the quantity and the quality of sleep we should do. And that includes limiting exposure to light. We have all sorts of artificial toxic light in our lives, and that’s a problem. It impairs our melatonin secretion, and on and on the list goes of different ways to naturopathically, so to speak, intervene, to help people get more restful and restorative sleep, we’re doing them a favor for pain management, for Alzheimer’s progression, and for their general health. 

Stress management is another piece that I’m sure is being discussed here by other experts. And yeah, again, everything that we can do to help manage that stress in a non-toxic. There’s many ways to do this non-pharmaceutically, cognitive behavior therapy, mindfulness. And if a person is more advanced, and those tools aren’t accessible then just simple human compassionate care is a great way to help relieve people’s stress. It’s really scary to not have your memory, especially, if you’re in pain. And so the comfort of another human, we are a social species. 

So the loneliness as we’ve seen in this last year and a half or so really has advanced disease progression in this community, and that’s largely because of the dangers of loneliness, which is a risk factor. Physical activity, motion, getting people moving in a safe, controlled manner. So important for general health, cardiovascular health, dementia prevention, and pain management. So movement and physical activity is critical. Yeah, so that’s the kind of the broad overview. And then I’d like to narrow in if this is appropriate on musculoskeletal pain in general, and kind of a different way of thinking about that. Does that cover your answer to your question?

Heather Sandison, N.D.

Yeah, but I think the other thing I want to drive home here is the list that you just gave us is the same list whether we’re talking about dementia itself, or pain, whether we’re talking about cardiovascular disease, or dementia, right? Whether we’re talking about diabetes or heart disease. And so just to drive home that there is a healthy lifestyle, and there’s nuances to this, right? Like some people will say ketogenic is definitely the most important for cognitive function. And somebody else might say it’s plant-based if you really want to reduce inflammation. 

So there’s some nuance amongst that, but overall, the recommendations are the same. And this is, I think it’s great, and it’s a little bit challenging, right? Because we have to sort of give up our attachments to these things that really are not healthy if we want to heal. And if you want to heal, the answer is sort of the same across the board, right? So it simplifies things, but, also, sometimes people need a little kick to get started, right? And I hope that these conversations are part of that, that inspiration to go ahead and get started making these decisions, it’s chop wood, carry water, right? It’s what we do every day that really changes the trajectory of our health. So, yes, thank you for sharing that list kind of in this context of pain because it’s such a reminder, not only I think, to our listeners, but to me personally, that it’s these lifestyle decisions that really make the biggest differences.

Joshua Levitt, N.D​.

You’re absolutely right. And that was a very eloquent way to describe it, I think. I see a lot these days, and you’re right about the nuance too. Like you can sort of split hairs, but there is this overarching kind of patterns, right? Patterns that people who are healthy, who live long healthy lives without as much suffering from the chronic diseases that plague the Western world right now, they’re patterns that are pretty clear. We see a lot and it’s very trendy, and attractive to think about, like, what’s now being called biohacking, running all these laboratory tests, and assessing different parameters, and all this kind of stuff. 

And then eating in funky, weird, interesting ways, and exercising and using all kinds of different tools. I think a lot about the people who live in the Blue Zones, which are these famous areas, people have long healthy lives, and don’t suffer from the cardiovascular disease, the cancer, the neurodegenerative diseases that we see here, and there’s no biohackers in the Blue Zones. 

They just, like, live long healthy lives. They chop wood and carry water, right? Like they move their bodies a lot. They sleep well. They live in communal kind of high social interactions. There’s not a lot of loneliness. They eat well, whatever that means. It usually means minimally processed. In some places they eat meat. It’s usually kind of either wild or pastured. In some places they eat a lot of fish. In some places they eat none, no animal products. So you’re right, like, yes, there’s nuance, but that’s the details, right? The overarching pattern is what really matters the most. And if we can implement that kind of pattern in people starting younger, right? We can turn the tide I really am convinced that we can.

Heather Sandison, N.D.

And I also hope that these conversations what you just illustrated was that society plays a big role, too. Like how healthy is society? How many of the people around us are living this way? Do we feel like we’re swimming upstream? Are we making the decisions everyone around us isn’t, or do the people in the Blue Zones are we living in a place like that where everyone around you is social. Everyone around you is getting plenty of movement. Everyone around you is eating these really great foods. And so you’re not having to constantly make the harder decision all day long to stay healthy. And so I think it’s a little bit of both, the individual decision-making and the collective.

Joshua Levitt, N.D​.

You’re right. And you said before, and I love that, that you used the word medicine in the broadest possible sense, and you were referring to like, yeah, medicines can be prescriptions from a pharmacy, but it can also be your food, and your sleep, and your movement, and all these other things. I think, also, and I heard this recently, it really struck me that your diet, right? We think of diet as the things that we eat, right? Which is an appropriate definition for it, but your diet if you think of it really broadly is all that you consume. 

You can think about it that way, which is like the news media that you consume, the people that are around you, and all of their potential toxicity, your relationships, the chemicals that are out on your lawn, which you are consuming inadvertently. And so if we’re thinking of improving our diet, again, sort of like your medicine in the broadest possible terms, yeah, I think that’s what the people are doing in the Blue Zones and other places where people live these long healthy lives. And that’s what I hope that these kinds of conversations can inspire people to do.

Heather Sandison, N.D.

So, leaving aside the societal piece for a moment, as much as I love to have those conversations, I really want people to.

Joshua Levitt, N.D​.

Yeah, we might not fix those problems. We might not fix those problems here today, right? We might not, we tried.

Heather Sandison, N.D.

It will be a start. So, for someone who’s listening to this conversation in particular because maybe they have pain, or someone they’re caring for has some musculoskeletal pain, I want to understand more specifically, like what is the approach that you would take to help a patient like that?

Joshua Levitt, N.D​.

Yeah, it’s a great question. And like you said in the intro, this has been a big chunk of my career is helping people, or at least trying to help them who have musculoskeletal pain. And I think there’s a lot of pitfalls in the mainstream management of this. And this might be a little controversial for people to hear the next part of what I’m about to say, but so it goes. I’m gonna propose that for so many people who have pain, whether it’s in their knee, or their hip, or their back, or their neck, or whatever, who have had X-rays, or MRIs that have told them things, and said words in there like degeneration, or disc herniation, or bone-on-bone, or whatever the case may be these kind of very colorful, scary sounding degenerative terms that describe the syndrome on X-ray, or on MRI, that a lot times those descriptions are certainly fear-mongering and are wrong. 

They’re inaccurate, and we know this. This is actually not as controversial as it may sound. We know that many lumbar spine surgeries are unnecessary. We know that many knee arthroscopy surgeries, and that includes total knee replacements are not necessary, and this has been studied. We’ve seen sham surgery studies, where they do a group who actually gets the arthroscopic knee surgery versus a group who just gets a pretend surgery, and seeing that outcomes are the same after one year. 

So what I’m proposing here is this very simple idea, which is that the reason why you’ve been told you have pain is not the reason why you actually have pain. You’re being told that it’s the disc that’s herniated, or that it’s the cartilage that’s lost, or that it’s the osteophytes, the little bone spurs that are sticking down here and there, and that you can see it on the X-ray. So it’s like, ooh, I saw it on the MRI. It looked like this little white part, or this little black part, and it was super scary. And in many, many cases those diagnoses, and when I say diagnosis, I mean, the description that’s given on the X-ray, or the MRI that is associated with the pain is inaccurate. There’s other reasons why the people are hurting. And in order to explore this a little bit further, I’d like to share a quick story. Do you mind a quick story about a 85-year-old lady who was a patient of mine that I think explains this very well. 

So this woman came in to see me. I was actually in a teaching capacity at the time. So I was in an institutional setting. She was in a wheelchair. Her daughter was pushing her in the wheelchair. And she was in a wheelchair because her neck hurt. She couldn’t walk. Her neck was in excruciating pain. She had a soft collar on, and I was worried because she was in her 80s, and she seemed to be hunched over that she had osteoporosis. And I was worried that she probably had a fracture in her cervical spine. So I was in an institutional setting. I had students that were following me around. We got an X-ray that was the first thing we did. The exam was very difficult to conduct because she was in agony. We did an X-ray. 

This was in the days where you had a light box. Now it’s all on the computer, but it was like snap the X-ray up on the light box there with the radiologist. And he was telling me, and the students behind me what he saw, and what he saw was advanced cervical spine disease, stenosis, all kinds of degeneration. This was an X-ray, so you couldn’t see the discs, but foraminal stenosis, all kinds of problems, degenerative spine, you could call it arthritis. And his implication was that this was the reason why her neck was hurting. And I, at that point, challenged him and said, with all due respect, you haven’t met the woman, and I’m gonna respectfully disagree with your diagnosis here and this is why. So I just talked to this woman. It was a hard conversation ’cause she was in so much agony, but she told me that her neck had been hurting for three days right? She was something like 85 years old. And she had three days of neck pain. Thankfully it wasn’t fractured that was the good news. 

So we’re looking at this X-ray and her neck’s a mess. It looks terrible this is advanced cervical disc disease. And this doctor is telling me that her neck, what we see on the X-ray is the reason why she’s in pain. And I asked my students let’s do a thought experiment here. Let’s just say for a moment that we had the good fortune to be able to travel back in time to four days ago, when her neck felt fine because she told us it only hurt three days. So we go back four or five days, and we take an X-ray then. Well, what do you think the X-ray would look like? Well, you and I both know, we all know it would look the same as it does today. It would look terrible, right? All the discs collapsed and all kinds of bone spurs, and it’s a mess, but four days ago, her neck didn’t hurt. So how could it possibly be that what we’re seeing on the X-ray is explaining this woman’s pain? It can’t be, she had that same X-ray four days ago, or four years ago, right? So there must be something else. And so that’s my story. And that story, I think, illustrates this perspective. So forgive me if I rant here for a moment.

Heather Sandison, N.D.

Well, what was it? What was causing her neck pain?

Joshua Levitt, N.D​.

Right, well, that’s the good question, right? So the cause of her neck pain, and the cause of many people’s musculoskeletal pain is three things. Number one, inflammation. And we just talked about that, right? And the influence that it has on diet, not just regular inflammation, but excessive inflammation. Inflammation in excess of what the appropriate amount of inflammation is. When we have trauma or infection, inflammation is an appropriate healthy response, but many people who don’t eat well, who have poor diets, lifestyles, nutrition, et cetera, have more inflammation than they should, whether they have advanced cervical disc disease, or a mosquito bite, right? More inflammation because of underlying nutritional biochemical problems. 

So inflammation is number one and she had that. Number two, muscular tension. So muscular tension is a major trigger for joint pain. You can’t see it on an X-ray, you can’t see it on an MRI, but when you have a bad cervical disc, or a bad knee, or a bad shoulder it’s very, very common. We’ve all experienced this for the muscles around, and adjacent to that joint to get tight. And they do that for a purpose to protect you, to protect you from further motion so that you don’t further injure the already problematic area. That muscle tension in the setting of nutritional problems, especially magnesium deficiency can be excessive, just like inflammation can be excessive. 

So now you have a person with an arthritic shoulder, but all the muscles in the shoulder girdle are just tight, and spasmodic putting further pressure on the already painful shoulder, and making it hurt even worse, right? So inflammation was number one, excessive muscle tension is number two. And then number three is something that’s called fibrosis. Fibrosis is scar tissue, right? The deposition of fibrin, which is this fibrous, gristly-like substance. It’s sort of when you get a piece of gristle if you eat meat that’s what you’re chewing there is that fibrous stuff that’s very chewy and tough. 

And if inflammation and muscle tension, and all the consequences of that persist for extended periods, we start to see the transition of normal, soft, supple, healthy soft tissue into something that’s more fibrotic, just like a more gristly piece of meat, or something, right? And so this combination of inflammation, muscle tension, and fibrosis is a pattern that I’ve observed in people with musculoskeletal pain over and over and over again in my practice, regardless of whether they have advanced disease on X-ray, regardless of whether they have bone on bone pain, evidence of bone on bone disease in their knee or their hip, very often, not always, but very often the effective management of inflammation, muscular tension and fibrosis can help alleviate pain, even in people with the most advanced imaging findings, and severe looking disease on imaging. So that’s my matrix, if you will. There’s a lot of tools, and we can talk about those, in the naturopathic doctors toolkit that can be useful in that department. So that’s the story.

Heather Sandison, N.D.

And so, yeah, what do you do next?

Joshua Levitt, N.D​.

I mean, a great question, so, obviously, I am a doctor, but I’m not your doctor, right? So each case needs to be managed individually, right? Because there’s all kinds of factors. What other medicines you’re on, what the nature of your problem is, what your diet is, but broadly speaking, right? I’m not treating anyone in particular. The kind of primary tools that I use, yes, dietary manipulation to try to enhance all the anti-inflammatory stuff, and decrease the pro-inflammatory stuff. I’m sure you’ve had speakers address that, we do that, but that’s not gonna get somebody out of pain today. 

What I’ve employed in my practice is a number of different things. Herbal and nutritional medicine tools, I’ll give you a list of my favorites. Turmeric, the herbal medicine curcuma longa, I usually use the high potency extracts of turmeric in some form or another where we can concentrate the curcuminoids. And I find it a very, very useful anti-inflammatory agent to address point number one. Another of my favorite herbal medicines in this department is Boswellia serrata, otherwise known as frankincense. And there’s a number of novel extracts of Boswellia that have very potent anti-inflammatory activity, and are much safer than their sort of prescription, and over the counter alternatives. 

And there’s a little evidence that some Boswellia extracts also can enhance the integrity of the cartilage surfaces, and joints as well, So curcumin and Boswellia are very useful. I also love to use bromelain, which is the extract from pineapple, the center core of pineapple because it’s anti-fibrotic. Here’s a little fun fact for you, by the way, you may know this, but I bet a lot of your viewers don’t. Meat tenderizer. I don’t use meat tenderizer too much ’cause I don’t eat very much meat, but meat tenderizer is this powder that you sprinkle on a tough piece of meat, and you can pound it with one of those meat tenderizing hammers, right? And it will make the meat less tough. So, do you know what the active ingredient in meat tenderizer is?

Heather Sandison, N.D.

No.

Joshua Levitt, N.D​.

It’s bromelain, yeah, that’s what meat tenderizer is made out of. And so that’s why it works because it breaks up fibrin. So bromelain is another tool that I love. Quercetin, which is this amazing bioflavonoid, widely distributed in the plant world, concentrated in onions and apples, and other plants, also have some anti-fibrotic and anti-inflammatory activity. I mentioned magnesium as well, magnesium really important, very common micronutrient deficiency. 

And when people are deficient in magnesium, they are much more likely to have muscle spasms at the site of joint injury, or trauma. So optimizing magnesium status is really important. Yeah, so that’s a handful of the kind of tools. And then I also, and this is very difficult to convey in a telemedicine kind of setting, but I mentioned briefly the meat tenderizing hammer, right? I don’t know if you know it’s like a mallet with the pokey bits on there, and you whack it into the meat to soften it up. So for 20 years of my practice, these were my meat tenderizing hammers. I used my hands, right? And sometimes some tools to work on people. 

So going back to that woman, the 85-year-old lady with the neck in agony, I gave her those tools, right? All of those herbal medicines in a formulation. And then I worked on her very gently with my meat tenderizers in the neck, in the upper back to try to soften up those muscles. And it didn’t take long. We had a few visits and she was back to feeling good again, neck, range of motion back, the agony was gone. Her neck still looked terrible on X-rays. Had we taken another picture it still would have looked awful, but her pain went away, and that’s really what it was all about. So that’s my story.

Heather Sandison, N.D.

I love it, yeah, it’s such a great illustration of how to think more holistically about pain, not be jumping right away to do I need surgery, and how that cycle can sort of perpetuate pain. I can’t tell you how many patients I’ve seen. I’m sure you’ve seen them as well. I wish I’d never gotten that surgery because that led to the next thing that led to the next thing that led to the next thing. And I can’t find the subspecialist that is going to unwind whatever is causing the pain secondary to that procedure. 

So I just love having these conversations where we can expand our worldview around something, right? Instead of being so stuck on because I have this bone spur, because I have this herniated disc I must be in pain. I just want to sort of second your claim that imaging is sort of the end all be all, and just because you have abnormal imaging means that’s why you’re in pain. There are many, many, many of us walking around. I think the statistics are about 30% of us walk around with completely asymptomatic herniated discs. So there’s a reason why your particular herniated disc is causing pain if that is actually what’s doing it. And I think very often people will start to feel something, then go get the X-ray, or the MRI, and want to connect those dots because it makes it feel simpler. And then the surgeon wants to connect those dots because that’s their tool and it makes them feel helpful, but seeing someone like you, there may be a whole world of interventions that are going to be less aggressive, and just as effective if not more so.

Joshua Levitt, N.D​.

You’re absolutely right, it was eloquently stated. And just to piggyback on your comments about the 30% number, so that number increases with advancing age, right? So what you described is accurate. There are loads and loads of people walking around with disc herniations and arthritis, cartilage degeneration in their knees, or hips, who do not have any pain, right? There’s loads of people. And if you talk about the neck, the lumbar spine, the hip and the knee these kinds of diagnoses, radiological or imaging-based diagnoses are very, very common in asymptomatic people. And it almost follows the decade of life. 

So that 30% figure applies to people who are in their 30s, right? People who are in their 30s, there’s 30% of them with lumbar disc herniations who don’t have any pain. In their 40s, 40%. In their 50s, 50% and so on, right? So that means when you get up to 80, 80% of people, and this is asymptomatic people they don’t have any pain, have herniations in their neck, or in their back, or degenerative changes that are visible in their knees. And this is people who do not have pain, right? So it’s well-known. I started my rant by suggesting that I was saying something controversial. It’s actually not controversial we know this. 

We know that the imaging lies, right? I mean, you’re seeing what you’re seeing, but to connect the dot between the disc herniation, and the pain is unfair and inappropriate. And there’s many, many people who can have perfectly healthy pain-free lives with a disc herniation, with degeneration in their knee. And it’s a real shame when we intervene operatively on a person who could have otherwise benefited from some of the tools that I just mentioned. Now, and I’d like to conclude that by saying, surgery is amazing when it’s necessary, right? I’m not opposed to someone getting their knee scoped, or knee replaced, or their lumbar spine operated on it and stabilized if they need it, but not until they’ve exhausted those other options that are lower force, less expensive, safer, and often more effective. So, yeah, we’re on the same page, which I’m not surprised to find out.

Heather Sandison, N.D.

Dr. Levitt, thank you so much for being here. I want to make sure our listeners know where to find out more about you.

Joshua Levitt, N.D​.

Thank you for that. So, like you said, in the beginning, I have a clinical practice here in Hamden, Connecticut. My practice is rather exclusive these days. I’m kind of focusing my energies more on my writing, and consulting and other sorts of things, and having the younger doctors, I can’t believe I’m saying that now, kind of do the clinical work at my practice here in Connecticut. And I’m putting a lot of my energy these days into product formulation, into consulting for a company that I co-founded and own, and that is called UpWellness. So if people want to scope out UpWellness, and see the sorts of products that I’ve put together to address the kinds of issues here, musculoskeletal pain and otherwise, feel free to jump over to upwellness.com. U-P-W-E-L-L-N-E-S-S, upwellness.com. I have my mug here that shows the wave logo.

Heather Sandison, N.D.

I love it.

Joshua Levitt, N.D​.

I’m an old surfer from Southern California, so the wave logo speaks to me. And, yeah, a wave of, hopefully, a tidal wave of good health that we can bring to people over at UpWellness. So thank you for that.

Heather Sandison, N.D.

Fantastic. I’m so happy to hear that you are training doctors because I know that I certainly have patients in mind. We’re in San Diego, where you’re from, and I know you’re in Connecticut, and I’m thinking, gosh, I wish that my 85-year-old female patient who was complaining of pain could come see you. And I’m sure there are going to be lots and lots of people who might not be able to get in to see you, but just knowing that you are passing on this wisdom to future doctors, or newer doctors is reassuring.

Joshua Levitt, N.D​.

I’m doing my best, yeah, I am, I’m trying. I think it’s such important medicine at a really critical time, so, yeah, thank you for that.

Heather Sandison, N.D.

Well, thank you. Thank you again for sharing your time today. It’s been an absolute pleasure, very insightful, very helpful. And I know so many of our listeners are gonna get a ton out of this, thank you.

Joshua Levitt, N.D​.

No, that’s great. I hope so, that’s what we’re here for.