Dr. Deepak Ravindran is one of the UK is leading pain specialists. He is one of the few medical consultants who possesses triple certification in lifestyle medicine, musculoskeletal medicine and pain medicine, using all of this knowledge together to give his patients a truly integrative and holistic approach. He is the author of the book, the pain free mindset, which outlines Seven Steps to taking control and overcoming chronic pain, which I'm certainly excited to be discussing with him today. Welcome Dr. Of enderun.
Thank you, dude so much for inviting me onto your podcast samosa. Enjoy. I've listened to a few of the episodes, and we've got some really good lineup of guests. So I'm really pleased to be now part of that lineup. Thank you.
Thank you so much. And I really wanted to invite you onto the podcast today, because chronic pain is such a complex and tricky problem for so many of the patients I see in a&e. And yet I think that doctors on the frontline like myself, and GPS in primary care can feel quite helpless with the tools that they have available to them, which are often, you know, the analgesia pain ladder, which I'm sure many people are familiar with, which leaves many people on strong pain medications with multiple side effects, or referred to surgery, which does doesn't always help, which leaves us referring them to pain clinics, which are very inaccessible. So people can be waiting for months, and sometimes years to see a specialist in this field. And I'm really interested in knowing what I can suggest to these patients so that they can give themselves the best chance of helping them help themselves while they're waiting for such specialist management.
I think, a great start and a great question. During fact, there's so much to unpack in there. Because fundamentally, you highlight a very major challenge that probably every service primary or secondary care service faces, not just I think in the UK, but this is a theme that I'm now aware is an issue in most European countries. And definitely in the US and Latin America as well. I suspect it probably is a global issue of how we are to manage chronic pain, because if you take it in sheer numbers itself, most of the countries where this data has come, you got a 20% prevalence of chronic pain in the population. So if you are taking a global view, we are talking about roughly one and a half to 2 billion people roughly struggling with chronic pain. That is a huge proportion of the population that is having an issue that in theory is lasting more than three months. And that's the artificial distinction we make between acute and chronic pain. And the biggest problem I think we have is the way our systems are all set up. Or in trying to treat pain as a symptom of something that's going wrong. Therefore, it needs a medical model, which means you have to investigate where the pain is coming from, which means you already decided that the pain is coming from a structure in the body. And therefore it needs investigations and tests and frequent scans. And that I think is really the challenge we are doing because the last 10 to 20 years of the neuroscience of how our brain, our nervous system, our immune system are all wired and working together in a network fashion is teaching us that that fundamental premise that pain always comes from a structure is probably a flawed construct to start with. And I think that if we can, first of all, as a society has a system has a medical, primary or secondary care. Accept that actually, not every pain needs to come from a structure and that there can be a more holistic and integrated way to understand pain, then automatically our choices on what we can do to help our patients immediately improve right now as you highlighted, because we think it comes from a structure we've Set up 10 minute primary care, consultations 15 to 20 minute appointments or at the most 25 minute appointments in secondary care, because everything is about an examination and investigation and an intervention, or a set of interventions in order to find the right cause or the right structure where it's coming from. And the meanwhile, just keep dishing out medications until the cost is found. And if the medications don't work, go for a surgery. That's the mantra under which we've operated. And that I think, is the challenge. I think the last 1020 years, as I said, if that knowledge of what I have found out, a lot of my colleagues in this field are talking about, if that were to be more commonly accepted, and more spread, we will be able to have a better conversation because right now, we sort of still think, okay, if the patients are told what to do, they will do it, almost forgetting that we as healthcare professionals also have a lot of upskilling to do in how we feel comfortable about managing pain. And I think both sides have to be improved in equal measures, so that we start giving patients the confidence that what they are doing holistically in an integrated manner is the right way forward.
Yes, I actually think this goes beyond actually pain, you know, it, we're speaking actually to a wider problem in general, by setting up our healthcare systems, to look for organic causes, and often send patients from one specialist to another to exclude said organic cause. All the while the patient is experiencing symptoms, and is not necessarily given directions on how to manage their symptoms, how to manage their experience. Because the focus is just always on that organic cause. And whether we have to have a system which has no system set up in tandem, or whether we have to rethink the whole way in which we consider the body is a separate conversation, I guess. But yeah, I think we're talking about what what I hear you say around pain, it's not just actually around how we deal with pain, but how we deal with so many medical problems, our focus does tend to be on excluding organic causes. And once we've done that, we can then sort of reassure the patient and move them on, but these patients have symptoms. And I wonder, and I am on a mission, to be able to equip patients with the knowledge that they need to, to really optimise their their health and their experience of their illness. So I know you work in an integrative way. And I know that you use holistic approaches, can you outline some of the approaches that you find most effective in the pain sphere?
Absolutely, I think it'll be great to dive down that rabbit hole as it were, but in in reference to your point which you made, you know, what you seek to equip, not just your listeners, but your patients as well, when you look up to them. I think the I had, I still have the same mission as well. And it's great that we are now an increasing tribe of people right across this country and and probably globally, hopefully. However, this is where I think our integrated and more holistic outlooks clash, if there is a still a group of people who are focused on just the linear Cartesian model, you know, where they've already separated the mind and body. And they said, the body must be the first thing to be looked at, we won't think about the mind or the soul, we'll just focus on the body and do a series of linear investigations one after the other, to get to a reductive, single celled single organ reason for it. That becomes a for lack of a better word of cognitive dissonance because of the patient, then on one side might hear somebody like you and me saying, and preaching a message of holistic integrated outlook. But then they've also then run into someone who kind of says poopoo to all of that and says, it's only a joint or a bone or a disc or organ, which if you do A, B and C, we'll fix it. And that means that part of what what I set out to write the book for as well is realising that we alone cannot be the voices we need to be providing an ecosystem to the patients. We need to be wrapping our care around the patient in such a way that most of us are singing from a Common hymn sheet as it were, of a set of things that people can do to manage the pain. And in a way, that's been my mantra of how I preach and practice, my integrated approach. I call it like a trauma informed approach. And I think you may have heard this word in other contexts with your other speakers as well. This is something that we've realised that deep down at functional at neurological at a biological at a psychological and social level, our nervous and immune systems are completely intertwined together. And their main mission as a tour is to look out for us and to protect us from anything, the nervous and immune system together considers as potentially harmful or dangerous. And pain then becomes a manifestation of what the nervous and immune system together have decided is something to protect us against, and pain becomes a manifestation of that desire for protection. And chronic pain or persistent pain, therefore, is a symptom of the over protective nature of the nervous immune system together. So a common theme that comes is what can you do to calm the nervous and immune system down? But one upstream question to ask is, well, what might have exerted this nervous and immune system to go into a spiral in the first place. And that's where we realise factors like social determinants of health do make a part because as far as the immune system is concerned, poverty, or lack of access, or bullying or isolation or neglect, or abuse is going to be interpreted by the immune and nervous system as equally stressful as an actual injury where you have a fracture, or you have a cut, or you break a bone or you have a heart attack, or you have rheumatoid arthritis flare up, the activation of the nervous and immune system is the same. And so a lot of approaches the trauma informed approach takes into account that anything that potentially can excite the nervous and immune system into a spiral needs to be addressed as part of the overall pain experience. And so therefore, you can have somebody who has had an acute injury, but then also is going through a social system or a psychological system, wherein they would be feeling more anxious, they'd be at risk of a job loss, or they would be living in isolated circumstances or neglected. And we've got to therefore, keep in mind that why you can't address the acute injury with the help of certain mainstream treatments, we also need to keep the whole patient in view. And that will require a different set of treatments and my research into chronic pain into persistent pain management, the studies that have been done over the last 2030 years, what I've distilled into the book, kind of leads me to say that right now, the other integrative or holistic approaches that must be added, in addition to sort of medications and mainstream interventions, is the attention to sleep is nutrition, is the attention to movement is the role of other Mind Body techniques to calm the nervous and immune system down. I think if we can bring those aspects in and combine it with the mainstream interventions, that is my integrated approach or practice, and over the years, both within the NHS, as well as privately, I've tried to wrap myself up with those colleagues who can provide that expertise, so that as far as the patient comes, they are exposed to that ecosystem, at least to start with, because if they hear it from three, four members of my team, then they are likely to shift a little bit otherwise, if they just hear me and then they go see a surgeon or someone else who tells them a linear Cartesian message, then whatever I've said, doesn't really stick.
There's so much too, that I want to pick up on here. But I guess I think there's a growing number of physicians like you're talking about that are interested interested in in delivering holistic approach and a growing number of patients who really are shifting from from believing. Believing the mainstream medical model is the only way to consider their health and they're looking for integrative and holistic. approaches. So I think this is a great time to be sharing knowledge like you have in your book. And you've touched on a couple of, of the integrative approaches that you highlight in your book. And I'd love to take this opportunity just to go into those in more detail. So can you take us through the seven steps that you outlined in your book that really can help Help Help someone really modulate their experience of pain by as you say, targeting the immune system, the nervous system, so that the whole, the whole body can feel safer inside itself and not need to over alert over alert you to over alert us to to the danger signals that the pain is actually a part of?
Absolutely. I think primarily what I'd like to add the outset to your listeners is to actually say that our present best neuroscientific understanding is that pain is a marker of protection. We used to think that it is a marker of detection of abnormality, we have to now think of it as a marker of protection, which means that there is a reason why the nervous and immune system together have decided that pain is necessary, because it feels it needs to protect us against something. So that is the first thing I want your listeners to be aware of is that the question they need to ask themselves is what is my nervous and immune system trying to protect me against? That's a kind of opening statement, which will help open out an options there. My book in itself while I wrote it for the patient, who would come to my clinic there, I think a lot of healthcare professionals have found it useful, just because it kind of sets the stage for saying, what are the treatments possible? And how should we go about it? And the acronym so while it's called the pain free mindset, and there's a group of people who push back against the title, saying that, Oh, you're again saying, mindset? Is it something that's all in the head, which is a very common thing that people talk about when it comes to pain? I do want to reassure that the mindset is still an acronym. Yes, there is a way of thinking about the pain. As I said, if you change your mindset from thinking, pain is a sign of abnormality to saying pain is a sign of protection and ask the question, What is he trying to protect me against? That's the mindset shift. I'm hoping that will happen in the minds of the patient. But the acronym itself works out in such a way that I really want to indicate that I don't want to throw the baby out with the bathwater, while I accept that. Maybe not everyone needs medications. And not every surgery works, which is absolutely the right thing to be. But there is a role for medications and interventions, that is the M and Di. However, there is a huge role to understanding the neuroscience of pain. That's the end, there's a huge understanding of nutrition the microbiome, so that's the D, there is an increasing understanding that there is a very complicated and bi directional relationship between sleep and pain. So that's the s, there is no doubt about it, that physical exercise and movement is hugely important to neural circuit development and modulation. So that's the E. But it's also recognition that increasingly, we are getting evidence for a lot of what we used to think as a jump, they were complimentary therapies, we now know that they can have as much power and sometimes better efficiency, effectiveness, then even mainstream stuff. So things like yoga, mindfulness, or breathing techniques, or a variety of trauma supporting techniques are probably much much better than conventional medication. So therapy, so the mind and body that's the tea. So that's like the seven step approach that I talk about in the book and I write about as to how to go about it. However, at the foundation to it is to understand that even the biggest pain association so for example, the International Association for study of brain which is our flagship organisation in the world for talking about pain, researching about pain and presenting the findings about pain, they themselves have signalled a change in 2020 to reflect the understanding of the changing neuroscience. So all of us in medical school or any healthcare school, we will all read that there are two kinds of pain there's the kind of pain that occurs is when you have an acute injury, that's what they call as nociceptive pain. And there's the kind of injury or pain that you get when the nerves are actually damaged. So for example, things like diabetes, or multiple sclerosis, or Parkinsonism, or chemotherapy induced damage to the nerves, they're all called neuropathic pain, you might have nerves caught during surgery as well. So those are all kinds of neuropathic pain, examples of neuropathic pain, and then you have nociceptive pain, which is acute injury, fracture, heart attack, rheumatoid arthritis, inflammatory bowel disease. So these are the only two things that we were all taught about in the 80s 90s. And even now in many and most medical schools, but we all knew in the field, that there was this broad overlap between, you know, what about a migraine pain? What about a nonspecific low back pain? What about fibromyalgia? All of these kinds of syndromes and pains didn't really neatly fit into a normal receptive pain, where there's often an elevation in your white blood cells, or some kind of inflammatory changes, or neuropathic pain, where you can say, Yep, there's definite nerve damage. You have none of these happening, for example, in patients with fibromyalgia, yet, you can't deny that this patient was not in pain. So all of these kinds of symptoms and conditions, were just lumped into one big category called mixed pain. But now in 2020, the ISP finally said, we have to recognise that conditions like migraines, some forms of CRPS, lots of nonspecific low back pain. And most cases of low back pain or neck pain, are probably due to an over sensitization of the nervous system. And they have called this third category of pain, nor seat plastic pain. So now, you've got nociceptive, pain, neuropathic pain, and Nasik, plastic pain. And in Nasik, plastic pain, there is no signs of acute injury or inflammation, there is no signs of nerve damage, like the way you have with diabetes, but there is definite amplification of the nervous system. The reason I say all this is, it now automatically becomes clear. I hope that when you do have clear signs of inflammation, like acute injury, bring out the medications. When you have neuropathic pain, go for some nerve blocks, or go for some nerve medications. But when you do have this Nasi plastic pain, these two categories of medications and interventions and nerve blocks or surgeries, will not work because the research isn't there. That is when for Nasi plastic pain, you have to look at the neuroscience, you have to look at the nutrition, you have to reinforce exercise, sleep optimization, physical activity, and mind body techniques, because that's the best, more sustainable way of calming down the nervous and immune system for Nasik plastic pain. They also call it central sensitization. So that's how my book is oriented around saying, These are the seven steps. But this is how you want to think about bringing the seven steps together for the kind of pain that is in your patient who's sitting in front of you.
That's so helpful. That's so helpful. And bit not being a pain specialist myself, I was not aware of the new class of pain that's being defined. And already I can see how that new label allows and invites a new way of thinking about dealing with a lot of people with persistent pain that doesn't fall into those two categories. So that's really helpful. I guess my first question is like, from the outset, it seems tricky to tell someone or who to work with patients who are in pain
to get better sleep, to be to move to
I guess those two are instantly sort of challenging to think like how,
how
pain keeps them up at night. They can't sleep because of pain. They can't move because of their pain. How do you work with patients who can find themselves in a vicious cycle and I can just imagine, look at me with rolled eyes. If I suggest to them, you know what you need to get some better sleep When they're really struggling with, with their pain, which is preventing them from from getting the sleep that they know, they may need, how do you approach that?
Great, really great question. And it's such an important part there because traditionally pain clinics have had a set of people with the skill. So you know, in my service, we've got physiotherapy specialist, paying physios and pain psychologists, and that's the traditional Arsenal that's always been available in the pain clinic. And what they would be doing is this thing called the pain management programme. So all these essential life skills around sleep optimization, movement and thinking CBT, those kinds of approaches, those were all delivered as part of a pain management programme. But already you can imagine, somebody goes through this journey like you've described, go to a&e go to your primary care, go to an orthopaedic surgeon, go initially down the linear Cartesian approach of investigation after investigation, one or two years down the line, the secondary gain is already set in the sleep is already lost, the jobs are at risk. And then three years or four years down the line, they would finally come and see a pain clinic. And then the pain consultant might do a further set of nerve blocks or, or medication trials before saying well, you know what, we've tried everything. Now we're going to teach you how to manage the pain. You can see how, when I talk to you and tell you about critical see how utterly flawed and upside down we have the system, that the very skills that we need to be telling patients on how to manage it is being considered as the last option, sometimes years down the line, when actually it should be flipped, or it should be done partially across. And that was the challenge that we never had anybody in primary care or secondary care to be able to offer those options which were being offered so far down the line by my colleagues. So one thing that has changed in the last four or five years is how primary care is really been going around looking at long term conditions itself these days, and has been saying, let's have health coaching, let's have social prescribing, let's have care coordinators, let's have behavioural therapist or physiotherapist or nutritionist in the primary care with GP practices with primary care networks. And we want to offer this for long term conditions. They've started with diabetes and obesity and those kinds of things. But I think those professionals have got enough of the skills to actually repurpose and start to support chronic pain or even pain patients right at the outset, because I agree with you trying to give the message in an a&e setting or in a secondary care setting about sleep, when they are struggling with pain or movement is quite tricky, because you've already lost six to eight to 10 months or one year, or they're in a massive flare when they present to the emergency department. It doesn't seem like the right time to actually offer those messages. What I do in my pain clinic as well, as I use a combination of essentially a little bit of motivational interviewing techniques. So am I. So first of all, I tried to judge where they are at and this comes from, there's a particular theory called the Stages of Change theory, which was talked about by Portchester, Neil. And essentially, they kind of say that all of us have some ambivalence in terms of how we want to change behaviour or what activities we want to do. And when somebody is in an acute pain flare, they pretty much are in a phase where they are not ready to take up some big change. So at that point, in a secondary care setting, I tried to gauge first of all with my initial conversations, whatever it is on where they are in the face of change, how do they respond to some questions of mine? And whether they are ready for a slightly open way to look at what else they want to do to manage the pain? Or are they very focused on getting pain relief first, if that is the case that they want pain relief first, then I do stick with saying okay, you know what, let's talk about medications. So my choice will be there. But what I tried to do in every consultation is to seed the beginning of saying this is a bit complex. What if the medications does not relieve all your pain? What could you do them? And that just shakes them a little bit to actually say I just introduced a bit more ambivalence, because then I don't give them the full thing oh, this drug will take out 100% of your brain because that would be a false statement to say But it gets them thinking, Well, if it doesn't work, what can I do? And some of them will actually say, well, I could do this, probably I could do that. And that's where I introduce a little bit of saying, well, what could you do that easy for you? Is it movement? Could you be doing about five or 10 minutes of a movement based strategy, something that you like, whether I so it's not necessarily walking or exercise, it could be something as much as a breathing technique with a little bit of a yoga or pilates style. I've got a few colleagues, I think I'm aware of a GP colleague in Wales, who's got a gentle sort of YouTube channel for teaching and talking about yoga techniques for back pain. There are some other popular YouTubers who do a five minute or a 10 minute, gentle start for people with back pain or neck pain or arm pain. So I then have those curated resources ready to sign post, just to give them a feel. So there is no pressure, there is no prescription. But if it I would ideally want that rapport and collaboration to say, I'm giving you a medication, but would you want to consider more technique? Would you want to consider maybe another point wherein I say about a nutrition because again, that feels like a tangible thing to them to do, rather than saying you need to sleep more. Because at that stage, patients often won't help. If they are in distress, and they have come to the IDI or they're in a clinic, asking for help. It means that their personal story of resilience and coping has been impacted to a certain extent. And I am respectful of that to actually say, that may not be the right time to actually say you should sleep more, or you should move definitely the shoot is what I avoid, I can just say, Well, what can you do to do and what is a tangible thing to do often is a movement based routine, or distraction based routine, a relaxation based routine, and a nutritional simple thing, an extra thing to add, so that that feels like a tangible thing to do. Because then all of those are things that they feel they have done before and can do. So it's a bit of confidence. And it doesn't put any added pressure on them to start something brand new in terms of a habit change. So those are my sort of techniques and tips to manage somebody who is coming with a very definite mind. And it's often a combination of motivational interviewing techniques with a little bit of ambivalence judgement and nudging them to consider a couple of options. And if they're not ready to kind of say, okay, you know what, take this medication, just look at a couple of these websites and resources, see what might be possible for you to do. And let's meet up in a couple of months time or two, three months time. Meanwhile, all I'm asking you to consider is can you do one of these two or three things a bit of a choice, and then I picked that topic up the next time.
That's so useful to understand, because it should never really be either, or, I mean, there's a place for both and, and there's a place for medication, I think what I have a bit of a bugbear around is that medication is given, it's just given and then left. And actually there's no choice offered, so that people can't really make an informed choice about their health. So I love the way that you're broaching this with recognising that there is an acute flare of pain normally at the at the at the time that help help is sought. And so sort of getting some instant relief for the patient, and best fully managed by by medication, but then offering alternatives that may feel manageable so that they can consider them and make an informed choice.
In this situation, just to reinforce that point that I consider that if I alone, said do this, and consider these three options. It doesn't in a pan and that's part of what my mission is, and what your mission is, is to actually get everyone to be doing this and talking not just about medications, but also seeding it. There's some popular research I don't think there ever was a paper to actually say this. But I think coke had it as part of their marketing strategy. In order to get somebody to sort of shift their viewpoint and embrace something different. Or on average, it takes around seven touch points, which means that someone needs to listen to a message in probably seven different ways or seven different times before they considered change. So I accept that on that day, I might have used an EMI bass technique given a drug, and then said look, consider A, B and C. But I'm under no illusion to think that they would automatically take option A, B, and C, if it was not going to be reinforced by somebody in primary care, or one of their family members, or maybe someone else they need in the next one or two weeks. And that I realised actually is an ongoing challenge and an opportunity because that means that if we can influence everyone to actually say, these are the things you offer, then that means the whole system can move that that is, in a way makes the whole journey that I'm on interesting because you can think about it. Otherwise, if I'm going to see people four or five years down the line, and I just give them a drug, and they come back three months later, and they haven't made any change, which is what would be expected, then it just becomes an unsustainable amount of activity for me, which is a risk for burnout. And it means that the constant stream of patients would not never change because they have no place to go. Often pain clinics are considered as the kind of last resort for every other speciality. When they feel they haven't been able to fix the patient. They just say go to the pain clinic, they'll sought you out, which is unhelpful for the pain clinic professional but also for the patient because the patient is still left feeling with some kind of a hope of a fix, when actually the whole message across the board needs to be about whether it's a gynaecological problem or a neurological problem, or GI issue or a musculoskeletal issue. There are things that all our colleagues need to be talking about in a similar fashion, not their interventions and medications, that they offer those specialties. But they need to be bringing these kind of lifestyle elements, you know, I think sometimes lifestyle itself can be considered as a difficult word because patients take it personally. But what I mean it is in the spirit of what the British society of lifestyle medicine talks about, is the attention to those important elements of looking after ourselves, reducing harmful substances, doing good nutrition, all of those factors need to be something that probably all specialists to say. And so in that sense, I'm really pleased that you are at the front end of hospital practice, and you're taking it up because in a way, when they beat you, that is actually a great time for change, they might be willing to consider change, because they're coming in in a potentially distressed place. That's a great place to where they might take up their advice, much more than when they come to see me. So it's really useful to be able to talk to you like this, but also for you to be at the vanguard of propelling change that.
Thank you. Yes and Agreed. Agreed. I do I do hold hope that the medical students of later years will have a greater education about these things. And you've touched on, you've touched on this, the topic of nutrition with regards to managing pain now, mine in your generation was never talked about nutrition in across any discipline, which is is beyond shocking, really. I've never really heard about its importance in managing pain. Can you tell me what the sort of key stones of what would be considered good nutritional advice for someone in pain?
Absolutely. I think at the outset, the big picture is a Whole Foods predominantly Whole Foods. I'm not saying it's only that's predominantly Whole Foods, predominantly plant based, anti inflammatory diet is like the big picture five or six statement that I would make, that has been shown to be the best bang for the buck. As far as pain is concerned, and nutrition is concerned. I'm also mindful that I'm not going to pick on one particular diet or one particular dietary form, although there has been lots of studies looking at Mediterranean diet in the context of autoimmune conditions and other conditions as well. So probably the evidence leans a little bit towards that form of diet. But I think we must be very cognizant of cultural context. We can't really you know, the Mediterranean itself is a wide region. And there is so much variation we see in how people adapt the so called Mediterranean diet into their cultural norms, trying to offer that to our Asian population or to our other ethnic minorities that live amongst us in a diverse community that we are, I think, I that is still learning that I'm having to say, what is the right kind of culturally congruent cuisine that would be suitable for the patients in front of us when we want to offer for pain. Also, I'm cognizant of the fact that now Nutrition has been talked about in the context of diabetes, about long term kidney disease, about obesity, about hypertension. And also from a patient perspective, we need to think most patients with pain 50 to 70% of patients with pain, also have multiple comorbidities, they also have one or at least a minimum of three other long term conditions. So I'm mindful that I don't want to say this is the diet for pain. And the diabetic specialist says, this is your diet for diabetes. And the kidney person said, this is your diet for kidney. And somebody comes down to this is your diet for obesity, because that is the recipe for a patient saying to do poor cuisines. I'm not doing anything at all, I'm just going back to my pizza from one place, which costs one pound 59. And we've lost everything. So I really would say that if we can have one form of healthy diet that is being introduced for a patient, then I'd like to piggyback most of that. And most of it is likely to work for pain as well. And that's why it's the whole foods, predominantly plant based anti inflammatory diet, very little processed food, would be the big ticket statement, I'd say, why all this around pain, because as you rightly said, nobody has been talking about it. In our times when we were training, and specifically within pain itself. Nobody still talking about it, although there are a few leaflets floating around here and there. But I'm glad to say that there is change happening. So for example, the right now finishing up an article for the British Journal of anaesthesia to come in their educational resource of articles a review article on nutrition and pain.
We've been invited as part of the British Pain Society to do a webinar on nutrition and pain in the next few months. And then on top of it. For the British society of lifestyle medicine, we've got a special interest group around pain and lifestyle medicine. And I've done about two three talks with the BSC LM last year for nutrition and pain. And there's also a couple of websites for pain management in the UK, where I've done a few podcasts and some videos recordings around the overlap of nutrition and pain. So I think I'd like to say that we are creating that see well of change to say we need to focus this is a very tangible target. Why do I say all of this and what underlines the evidence. As I said, the biggest driver of central sensitization are Nasi plastic pain. The third category that are talked about, we understand that nervous and immune system are massively interconnected, if anything, every neuronal junction, so the synapses that we call the central nervous system, every junction, so considering that there are about a billion and a billion and a half neurons in the central nervous system, and then another billion probably in the second brain, which is the nervous system around the gut. You have got a representative of the immune system at each and every signups. So you got about billions of immune cells, constantly modulating the signalling that scurrying around across the junctions. And the second brain that is the nervous system in the gut, is constantly talking to the first brain, that's the nervous system within the skull and within the spinal cord. And they are talking all the time, possibly, and most likely to the vagus nerve, but also through the other nerves as well. So which means that one potential way to calm the nervous system down is to use the immune system as a target. And the biggest representation of the immune system is in and around the gut. So what you feed what you eat when you eat How you eat is all going to make a difference in how the immune system reacts. And as I said, the immune system is just looking out to protect us. If you take in a lot of processed food, or you're taking drugs like anti inflammatories or proton pump inhibitors, or opioids in more than excess quantity, or antibiotics, you are changing the ecosystem of the gut, such that the immune system in the gut which is monitoring it is going to say that feels like threat. And that means the immune system is going to act up, put out its signals its cytokines as messengers, which is going to travel through the vagus into the central nervous system in the first brain. And there if the system is already heightened, or vulnerable or sensitised food, and the wrong food is just going to be a way that the immune system says this is threat. This is threat, I'm just going to activation protection systems, full systems go and people will have a flare up of their pain. But it will be driven by actually what they ate, when they ate, what they didn't eat, or eat. And that's something that even all of us have realised over time, people will tell us that with migraine, there are some things foods that make their migraine worse or better. There are people who identify that some foods make their pelvic or abdominal pain better or worse. There are people who identify a variety of autoimmune conditions and room for arthritis, they can identify foods that make it worse, we can now put that all in perspective and say there's a very real reason why the changes, because that alters the cytokines, the messengers, and the immune system in the gut, which spills over into the nervous system in the brain, amplifying or dampening, the central sensitization of the Nasi plastic thing. So that's the reason for looking at nutrition in the context of pain. And that automatically, this explanation hopefully, sort of underscores, to say, as long as you can reduce your processed foods, because that is the one thing that the nervous system considers as pro inflammatory, as long as you can eat a diverse amount of foods, which will come through a plant based diet, but also there's going to be some forms of meat, which will definitely be healthy. And you can give some time for the gut to do its mot. So intermittent fasting or time restricted eating of some kind, which will allow for the ecosystem of the gut to sort of keep itself ticking along. If those three conditions are met, that itself is enough for a nutritionally sound approach to managing or helping with pain. I'm not saying that it's the be all and end all. And in my book, in fact, I do have a couple of patients and case stories where nutrition itself has made a fantastic difference to some people's pain histories. But I think it's a very easy, tangible, relatively simple target to try, because they will already be doing it probably for their other long term conditions. So it's a relatively easy and safe thing for people to slip into. Rather than asking them to make a massive change in that there are some challenges, I will have to say that we need to work more at the societal and system level to say, where do they get these foods? If we're saying plant base? How are we going to provide economically sustainable, cheap, but healthy foods to them? Where do they go and shop? Because if you're going to have a desert, your nutritional desert, in terms of how close their healthy foods are, and unhealthy foods are, I think that is still a challenge we have to address, but in principle, that are in my mind, influencing the microbiome, attempting to restore the ecosystem. Reducing the process foods is a huge anti inflammatory recipe in itself.
And even giving that sense of control and personal responsibility for someone who feels like desperate and very out of control is something that they can that they can at least try that's safe, that doesn't have any side effects that they could really see some tangible and experience some tangible results that will not only affect their degree of pain, but their health in the long term. So this is much yeah, it's such it's so useful for for this message to be II repeated by multiple healthcare professionals the importance of eating whole food, plant predominantly plant based, unprocessed, diverse, diverse diet. Which which there's a growing number of people out there sharing incredible recipes for Yeah, you know, really inspired, inspired by so. So yeah, that's, that's great. So if you just to round off Dr. Ravindran if you were speaking to someone who's listening here, who has been struggling within the healthcare system struggling to navigate the multiple specialists they've been shunted, shunted to, they're still in pain, they don't know what to do, they're feeling quite hopeless.
Could you just speak to speak, speak to this sort of person about what they could, you know, what their what the next best step that they could take, that they may be able to try today, to move the needle in one way in almost to give them maybe some hope that there, there are things that can be done, there are people who care, and there are people that you can approach, perhaps online, just to let them know that that that help is available to them?
Absolutely. So I guess this would be an appropriate and shameless time to plug the book, to actually say, that's part of the reason why I wrote the book. So my suggestion would be at least to say, explore in an open and curious mind, what my book has to say about why somebody might be having their pain, and what they can do in terms of having a chart. So there are there are options within the book, wherein they can write out a plan of what they have tried up to know what drugs they have tried up to now, what else have could they do or not to. And by the end, they should be able to have a set and say, These are the things that I would like to do, these are the things that I have not done. And that itself gives them an opportunity to take that to the to the physio or to the GP or to their specialist, if they are under one to actually say, How can I get this? Or can I get this locally in there. That's kind of what the purpose of the book is. The people who cannot absorb material that way, reading is not their option there. And then common websites that I suggest to all patients who come to see me in the clinic are one there's a website called live well with pain, or co.uk, which is a wonderful compilation done by, I think a GP and lots of lived experience patients, patients who have learned how to manage their pain, without necessarily resorting to higher and higher drug dosages. They've all got together around the pandemic time and put their collective heads together and created this resource, which gives a lot of simple things that other people have tried. And that might be something your listener could find useful, or at least definitely, even if it's a healthcare professional listening, then signpost to their patients to this resource there. Another resource that I recommend is the flippin pain.co.uk. So for people who really want to just understand their pain, understand specifically the neck cord musculoskeletal pain, to understand why that could be happening, then that is a fantastic set of lots of resources. There's stuff to read the stuff to visually look at. And there are lots of webinars or podcasts that have been done to kind of pick it apart and see on the particular app that I tend to recommend especially for people where there is an overlap of trauma or stress that has contributed to a worsening of that pain, a lot of conditions like fibromyalgia we recognise an autoimmune conditions we recognise that stress can impact on their mental health and physical health. Then I suggest the app called curable. It is an American based app. But there are there is a huge global following on their conflict of interest. I'm on the scientific board for that app there. Not much of input into the creation of it, but I've done a couple of webinars with them, but they are a fantastic resource in terms of gain, that kind of mind body techniques are the holistic approaches to thinking about trauma, stress and pain, and how to manage them. And what are the non drug techniques that can be effective. There's a lot of fantastic recovery stories in there. And I think lots of patients who have used that have told me how it has resonated with them, and that has given them the confidence to say, if I did this, I can make a difference to my pain, you know, exactly as you said, it gives some people the realisation that they are not alone, that there are others who have gone on this journey before them and made good progress. And that gives them that control that feeling that they can do something about it. So I think these are two three resources that I would suggest electronically for your listeners, and for patients who are listening to your podcast, as well as healthcare professionals who know how to signpost and I think, I'd like to think that in these days, in the last four, five years, every place has got social prescribers and care coordinators, and GPS in most practices were more enlightened than they have ever been with these lifestyle medicine approaches. So I suspect that if the patient did their first bid at least, and said, I'd like help with this, what's available in my GP practice, or in my GP practice, or in the primary care network, I think they themselves might have a set of resources that they can signpost, people to, and that itself would be a good start.
That's great. I will get those resources down from you. And they will be accessible in the show notes for anyone that does want to have a look at those websites. And consider using the app. I'll put a link to all of that. And Dr. Ravindranath book, in the show notes so that you can explore some of the evidence and the options that you may wish to try alongside or instead of medication, and whatever is right for you and right for the stage of your illness. Thank you so much for your expertise for your hard work for, I guess, really, I notice how you are almost like translating the more esoteric evidence and bringing it really into the mainstream writing journal articles writing review articles getting it known within the medical community, which is just so important. So thank you so much for your hard work and efforts in this area.
Thank you, Joe, thank you for having me on your podcast and wish you the very best of luck and to your listeners as well. Thank you. Thank you
