Chronic Pain and Inflammation

Imagine talking to your doctor and finding out that chronic pain is actually an inflammatory disease. It’s an unconventional idea that surprises many people, but it’s slowly gaining traction thanks to the work of Gary Kaplan, DO, a clinical associate professor at Georgetown University in Washington, D.C.

For more than a decade, Kaplan has been a leading voice in efforts to solve the mystery of chronic pain and depression. Since so many individuals with pain have a history of emotional, physical, and infectious disease problems, he set out to discover the underlying source of pain. Finally, he had a eureka moment and came to the conclusion that pain and depression are inflammatory diseases — a major shift from traditional thinking.

Kaplan is the founder and medical director of the Kaplan Center for Integrative Medicine based in McLean, Virginia. He is board-certified in both family medicine and pain medicine and is a member of the federal Chronic Fatigue Syndrome Advisory Committee. He’s also the author of Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression (Rodale Press, 2014).

I interviewed Kaplan recently about his book, discoveries about the source of inflammation, and what people in pain can do to feel better.

Why did you write your book?

Kaplan: What led me to write the book is that we have about 100 million people struggling with chronic pain in America. Our attempts to treat it have been abysmal. For decades, we didn’t know what we were treating or how to effectively treat it. We overused medicines like opioids that cause more harm than good. We’ve been leaving patients in a great deal of pain and disability and not getting results. We asked, “Why is that happening and why do pain and depression co-occur so frequently?” There’s a huge overlap between pain and neuropsychiatric illnesses. As we were trying to understand the “why,” it led me to understand the symptoms of inflammation in the brain. That discovery changed my entire way of diagnosing and treating individuals suffering from chronic pain.

What information would our readers learn about in your book?

Kaplan: They are going to learn that chronic pain such as fibromyalgia, back pain, pain associated with osteoarthritis, daily headaches, and depression are not diseases but symptoms. These conditions are symptoms of inflammation in the brain. A brain on fire, if you will. The “fire” can start from a number of events that tend to be cumulative over time. Unless we identify and treat the causes of the inflammation, then our treatments will fail. Our current approach to treating chronic pain is like a fireman only clearing away the smoke and not putting out the fire.

What is the underlying cause of pain and inflammation?

Kaplan: The underlying cause of chronic pain is inflammation. The purpose of inflammation is to initiate the repair of damaged tissue. Problems occur when the cells responsible for initiating the inflammation, our immune system, get stuck in a chronic inflamed state. This results in ongoing damage to the brain. This led to the astonishing conclusion that pain, depression, anxiety, and PTSD are all symptoms of neuro-inflammatory diseases in the brain — a radical new concept and a huge shift away from conventional treatment approaches.

Inflammation occurs due to toxins such as molds and heavy metals, long-term stress, especially a traumatic childhood situation, infections such as tick-borne illnesses, and concussions. The result is symptoms such as chronic pain, depression, difficulties with sleep, and a whole host of other symptoms.

What’s at the core of the inflammation?

Kaplan: I kept asking myself that question for years. I pored through research studies and articles in search of answering the question: What was causing and sustaining that inflammation? Finally, while attending a seminar at the American Academy of Pain Management about inflammatory factors in the brain, I learned about the culprit: microglia.

What is microglia’s role in brain inflammation?

Kaplan: Microglia are little cells in the brain, and they act as the immune system of the central nervous system. Their job is to repair any damage to neurons in the brain and secrete inflammatory chemicals to create swelling while they destroy any invading cells. If there is damage, they start the repair process. They clean out the dead cells or bacteria and make room for the new cells to develop. The microglia send out signals to other parts of the brain to start the cellular repair process, and then they go back to sleep. In some cases, the microglia never stop the cleaning out process to allow for repairs, and that leads to chronic pain and damaged neurons.

What is the proof that microglia is the root cause of chronic pain and depression?

Kaplan: We have MRI studies and human and animal studies that show that we’re looking at a neuro-inflammatory disease of the central nervous system. We had already figured out that neuropathic pain was associated with inflammation of the spinal cord that was maintained by the microglia. We now understand that the entire process goes much higher than the spinal cord and extends throughout the entire brain. And that’s what we now see — what is called central sensitization syndrome — a mix of chronic pain and depression. The studies have moved beyond just understanding microglia as the mediator of inflammation in the central nervous system. Now we are looking at other immune cells such as mast cells, which we previously thought were only associated with allergies and some rare forms of cancer. We now understand that at the basis of chronic pain, depression, and other conditions such as chronic fatigue syndrome is a dysfunctional immune system. When you actually take the time to listen to people suffering with chronic pain you realize this is a disabling, systemic illness that affects their ability to think, sleep, causes digestive problems, and fatigue.

Are there studies being done to manage microglia?

Kaplan: There is new research to look at how we can shut down the microglia. Those studies are moving along and it will be interesting to see what happens as the studies progress. As we learn more about the nature of microglia through research efforts, we will find new and better ways to regulate their response to trauma. That in turn will give us more direct ways to quiet the inflammation that never settles down.

Are there tests that could help identify inflammation in the brain?

Kaplan: From the proceeds of the book, I created a nonprofit called the Foundation for Total Recovery to find a cure for neuro-inflammatory disease. One of the goals of the foundation is to identify biomarker tests that would help us identify inflammation in the brain. Currently, there are no biomarkers identified for chronic pain or depression. That would guide us in diagnosis and help us create more successful treatments.

How does all this research help patients recover from pain?

Kaplan: I’ve treated countless patients and usually spend about two hours with each individual understanding their medical history to help identify what the underlying health issues are. Take, for instance, a 40-year-old woman who came to me with a history of migraines, problems with depression, and increasing fatigue. After a number of tests, we found that she had a mold toxicity disorder and she had problems with overgrowth of gut bacteria. She also had a lot of muscle spasms in her neck and shoulders. We treated the mold toxicity and repaired her digestive system. We also did some trigger point and musculoskeletal work with her. After treatment, the end result was that she had complete resolution of the migraines, depression, and fatigue [and was] off all medication.

I had a patient, a 17-year-old young man, who was suicidal and depressed. He was hospitalized on several occasions and was not responding to any antidepressant medications. We diagnosed him with celiac disease, an autoimmune disease in which the ingestion of gluten leads to damage in the small intestine. We put him on a gluten-free diet and fixed the celiac disease and that led to a full recovery.

My own son developed chronic pain and we realized that it was due to Lyme disease and infectious mononucleosis. It took us three years to treat him, but now he’s fully recovered.

What can individuals do?

Kaplan: Eliminate foods that may be contributing to your brain being on fire. I have my patients start with an elimination diet, eating only rice, fish, chicken, fresh fruits, and vegetables for a month. Meditation is anti-inflammatory, as is exercise. You have to be getting at least seven to eight hours of continuous sleep a night. At my center, I’ve brought together a team of doctors, therapists, acupuncturists, and psychological counselors to look at the patients holistically and develop a treatment plan that’s right for each individual. It is most important to partner with a doctor and get away from taking pills to fix things. (See the “Source of Pain Test” for questions to ask yourself.)

What tests should patients with chronic pain undergo?

Kaplan: When I see a patient, he or she has usually been to more than nine other doctors by the time he or she comes to me. There are certain tests that I recommend to potentially eliminate possible causes of several pain conditions. These tests include gluten intolerance/celiac disease, Lyme disease, chronic Epstein-Barr virus, biotoxins like mold and heavy metals, sleep disorders, and thyroid imbalance. Most of these tests can be done by your family physician or internist at their office or a nearby medical laboratory.

Are you working on a follow-up book?

Kaplan: I’ll be working on a new book in the coming months that will hopefully come out next year. It will be a how-to book for people because there are a lot of things that people can do for themselves. We know that meditation and exercise absolutely help regenerate the brain. Nutrition is so important because the gut is the second brain. Communication between the brain and the gut determines whether the brain is going to be healthy or not.

Want to learn more about inflammation? Read “Mindfulness Meditation Reduce Inflammation” and “The Anti-Inflammatory Diet Cookbook.”

Paul Wynn, a writer based in Garrison, NY, has covered health-care trends for the past 20 years.

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