Control Pain & Heal Faster with Your Brain
Andrew Huberman
0:00 - Welcome to the Huberman Lab Podcast,
0:01 where we discuss science
0:03 and science-based tools for everyday life.
0:09 I'm Andrew Huberman
0:10 and I'm a professor of neurobiology and ophthalmology
0:13 at Stanford School of Medicine.
0:15 This podcast is separate from my teaching
0:17 and research roles at Stanford.
0:19 It is, however, part of my desire and effort
0:21 to bring zero-cost-to-consumer information
0:23 about science and science-related tools
0:25 to the general public.
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4:57 Thank you.
4:58 Let's continue our discussion about neuroplasticity.
5:02 This incredible feature of our nervous system
5:04 that allows it to change itself in response to experience,
5:07 and even in ways that we consciously
5:10 and deliberately decide to change it.
5:13 That's an incredible feature.
5:14 No other organ in our body has that capability.
5:17 Our nervous system,
5:18 which governs everything about who we are,
5:20 how we feel and what we do,
5:22 does have that capability.
5:24 The issue is most people don't know
5:26 how to access neuroplasticity.
5:28 Children readily access neuroplasticity
5:30 and they don't even realize that they're doing it.
5:33 Adults want neuroplasticity
5:35 and so that's what this entire month
5:37 of the Huberman Lab Podcast has been about.
5:39 We've explored neuroplasticity
5:41 from a variety of different perspectives.
5:43 We talked about representational plasticity.
5:45 We talked about the importance of focus and reward.
5:48 We talked about this amazing and somewhat surprising aspect
5:52 of the vestibular system,
5:53 how altering our relationship to gravity,
5:57 and in addition to that,
5:59 making errors as we try and learn,
6:01 can open up windows to plasticity,
6:03 but we have not really talked so much about
6:06 directing the plasticity toward particular outcomes,
6:09 and thus far,
6:11 we really haven't talked yet
6:13 about how to undo things that we don't want.
6:18 I've talked about learning and I say
6:19 learn a language, learn free throws,
6:21 learn a particular motor skill, et cetera,
6:24 but what about what we would call unlearning
6:26 or about removing some aspect
6:29 of our experience that we don't want?
6:31 And so today,
6:32 we are going to explore that aspect of neuroplasticity
6:35 and we are going to do that in the context
6:38 of a very important and somewhat sensitive topic
6:42 which is pain regeneration,
6:45 and in some cases, injury to the nervous system.
6:48 For those of you that are fortunate enough
6:50 to not have or had a concussion
6:54 or not have or know someone
6:56 who is experiencing chronic or acute pain,
6:59 I encourage you to stay in here with us
7:01 because a lot of the information that we are going to cover
7:04 has direct relevance to neuroplasticity for other purposes.
7:10 We, as always here on this podcast,
7:13 are going to discuss some of the science,
7:14 we get into mechanism,
7:16 but we also really get at principles.
7:20 Principles are far more important than any one experiment
7:24 or one description of mechanism
7:26 and certainly far more important than any one protocol
7:29 because principles allow you
7:30 to think about your nervous system
7:32 and work with it in ways that best serve you.
7:35 They are very flexible batches of information.
7:39 We are going to talk about the principles of neuroplasticity
7:42 for removing pain and wound healing and injury.
7:46 We're going to talk about acupuncture, of all things.
7:49 We are going to talk about modern medicine's attempt
7:52 to try and restore youth to the aging
7:55 or injured or demented brain,
7:59 and we are going to definitely talk about tools.
8:02 Got a lot of tools.
8:04 I consulted a number of fantastic colleagues at Stanford,
8:08 at Harvard Medical School,
8:09 and in the greater community of tissue rehabilitation,
8:13 injury and pain management in preparation for this podcast.
8:17 I do want to be very clear and just remind you
8:20 that I'm not a medical doctor.
8:22 I'm a professor, so I don't prescribe anything.
8:24 I profess things.
8:26 I have my beliefs,
8:27 but the podcast is for information purposes.
8:29 I do hope that the tools that we discuss
8:32 will be of benefit to you, but as always,
8:34 you should talk to your doctor or healthcare provider
8:38 about any tools that you plan to add
8:41 or are looking to explore,
8:42 as well as anything that you might look to remove
8:45 from your daily protocols.
8:46 In other words, don't change anything
8:47 without consulting an expert first.
8:49 You are responsible for your health, not me,
8:52 and I say this not just to protect me
8:54 but also to protect you.
8:57 Please keep that in mind as we move forward
8:59 and I'm very excited to share with you this information
9:02 because I do feel that it can be of great benefit
9:05 to a number of people.
9:06 Let's start our discussion about pain and sensation
9:10 and regeneration and wound healing with a discussion about
9:14 a very important system in the nervous system,
9:16 which is the somatosensory system.
9:19 The somatosensory system is, as the name implies,
9:22 involved in understanding touch,
9:26 physical feeling on our body,
9:28 and the simplest way to think about the somatosensory system
9:31 is that we have little sensors
9:33 and those sensors come in the form of neurons, nerve cells,
9:37 that reside in our skin
9:38 and in the deeper layers below the skin,
9:40 and indeed, we do.
9:41 We have some that correspond to,
9:45 and we should say respond to, mechanical touch,
9:49 so pressure on the top of my hand or a pinpoint,
9:53 or other sensors, for instance, respond to heat, to cold.
9:58 Some respond to vibration.
10:00 We have a huge number of different receptors in our skin
10:04 and they take that information
10:07 and send it down these wires that we call axons
10:10 in the form of electrical signals to our spinal cord
10:13 and then up to the brain,
10:14 and within the spinal cord and brain,
10:16 we have centers that interpret that information,
10:19 that actually make sense of those electrical signals,
10:21 and this is amazing because none of those sensors
10:25 has a different unique form of information that it uses.
10:29 It just sends electrical potentials into the nervous system.
10:32 The nervous system,
10:33 you somehow decode what a given stimulus on your skin is.
10:38 Maybe it's the wind blowing gently
10:41 and deflecting some of the hairs on your arm
10:44 or maybe it's a sharp pinprick or a hot stove
10:48 or the warmth of a glowing fire.
10:51 That all arrives in your nervous system
10:53 in the form of these electrical things
10:55 we call action potentials, which is just amazing,
10:57 and then the brain computes them and make sense of them.
11:01 We have peripheral sensors
11:03 and we've got stations up in our brain
11:05 and within our spinal cord
11:07 that make sense of all the stuff coming in.
11:10 Pain and the sensation of pain is, believe it or not,
11:15 a controversial word in the neuroscience field.
11:18 People prefer to use the word nociception.
11:21 Nociceptors are the sensors in the skin
11:24 that detect particular types of stimuli.
11:27 It actually comes from the Latin word nocere
11:29 which means to harm,
11:30 and why would neuroscientists not want to talk about pain?
11:33 Well, it's very subjective.
11:35 It has a mental component and a physical component.
11:38 We cannot say that pain is simply an attempt
11:42 to avoid physical harm to the body,
11:45 and here's why.
11:47 They actually can be dissociated from one another.
11:49 A good example would be if, God forbid,
11:53 you were exposed to high levels of radiation,
11:57 such as working with some sort of material
11:59 that was radioactive
12:00 or you were near a former radioactive plant
12:04 or some some radiation,
12:05 excessive X-rays, et cetera,
12:07 you wouldn't feel any pain during the X-rays.
12:10 In fact, you don't.
12:10 If you've ever had X-rays, as I have,
12:12 you don't feel anything.
12:14 They put you under that lead blanket,
12:15 they run behind a wall and then they, in my case,
12:17 then they take these pictures of your teeth
12:19 and it's really scary because you go,
12:21 "Something really terrible must be happening here,"
12:23 but you don't feel anything,
12:25 but there can be a lot of tissue damage.
12:27 There can be mutations introduced to cells, et cetera.
12:31 I've had X-rays,
12:31 I'm not saying people shouldn't have X-rays,
12:33 but excessive X-rays certainly are not good
12:35 for human beings,
12:36 likewise with excessive exposure to any radiation.
12:39 There can be tissue damage without the physical perception
12:43 or mental perception of pain at all.
12:46 As well, there can be the belief of pain
12:50 or the feeling of pain without there being tissue damage,
12:52 and there's a famous case that was published
12:55 in the "British Journal of Medicine"
12:57 where a construction worker,
13:00 I think he fell is how the story went,
13:03 and a 14-inch nail
13:06 went through his boot and up through the boot
13:10 and he was in excruciating pain
13:13 just beyond anything he'd experienced.
13:15 He reported that he couldn't even move in any dimension,
13:18 even a tiny bit, without feeling excruciating pain.
13:21 They brought him into the clinic, into the hospital,
13:24 they were able to cut away the boot
13:26 and they realized that the nail had gone between two toes
13:29 and it had actually not impaled the skin at all.
13:33 His visual image of the nail going through his boot
13:37 gave him the feeling, the legitimate feeling,
13:41 that he was experiencing the pain
13:43 of a nail going through his foot,
13:44 which is incredible
13:46 because it speaks to the power of the mind
13:48 in this pain scenario
13:50 and it also speaks to the power of the specificity.
13:54 It's not like he thought that his foot was on fire.
13:56 He thought, because he saw a nail going through his foot,
13:59 well, it was going through his boot,
14:01 but he thought it was going through his foot,
14:02 that it was sharp pain of the sort
14:05 that a nail would produce,
14:07 and there are thousands
14:09 of these kinds of case reports out there.
14:11 That is not to say that all pain that we experience
14:14 is in our head,
14:15 but it really speaks to the incredible capacity
14:18 that these top-down,
14:19 these higher-level cognitive functions have
14:22 in interpreting what we're experiencing
14:25 out in the periphery,
14:26 even just on the basis of what we see,
14:28 and the example of radiation speaks to the fact
14:31 that pain and tissue damage
14:33 are dissociable from one another.
14:37 Why are we talking about pain
14:38 during a month on neuroplasticity?
14:41 Well, it turns out that the pain system offers us
14:44 a number of different principles that we can leverage to,
14:48 A, ensure that if we are ever injured,
14:51 we are able to understand the difference
14:52 between injury and pain because there is a difference,
14:55 that if we're ever in pain,
14:57 that we can understand the difference between
14:59 injury and pain,
15:00 that we will be able to interpret our pain,
15:02 and during the course of today's podcast,
15:04 I'm going to cover protocols that help eliminate pain
15:08 from both ends of the spectrum,
15:11 from the periphery, at the level of the injury,
15:14 and through these top-down mental mechanisms.
15:17 A lot of times on this podcast, in fact mostly,
15:20 I tend to center on the physiology,
15:22 on the really objective things
15:24 that you can describe and talk about,
15:26 diaphragmatic movement
15:27 or sunlight of a particular number of photons, et cetera,
15:30 but today's a really exciting opportunity
15:33 for us to discuss some of the more subjective things.
15:35 Believe it or not, we're going to talk about love.
15:37 A colleague of mine at Stanford,
15:39 who runs a major pain clinic,
15:43 is working on and has published quality peer-reviewed data
15:47 on the role of love in modulating the pain response,
15:52 only there's a twist to it
15:54 and I'm not going to reveal it just yet,
15:55 but it turns out that the specific type of connection
15:59 one has to a romantic partner
16:01 actually dictates whether or not their love for them
16:05 will alleviate physical pain
16:07 and the effects are really robust.
16:09 It's an amazing literature,
16:10 and so what we're talking about today
16:12 is plasticity of perception,
16:14 which has direct bearing on emotional pain
16:18 and has direct bearing on trauma
16:20 and other things that we discussed
16:22 in previous episodes a little bit
16:23 but that we're going to explore even more
16:25 in an entire month about those topics.
16:29 Let's get started in thinking about what happens with pain,
16:34 and I will describe some examples
16:36 of some kind of extreme cases.
16:39 For instance, I will tell you just now
16:41 that there is a mutation,
16:42 a genetic mutation in a particular sodium channel.
16:45 A sodium channel is one of these little holes in neurons
16:48 that allows them to fire action potentials.
16:50 It's important to the function of the neuron.
16:51 It's also important for the development of certain neurons,
16:54 and there's a particular mutation,
16:56 there are kids that are born
16:57 without this sodium channel 1.7,
16:59 if you want to look it up.
17:01 Those kids experience no pain, no pain whatsoever,
17:04 and it is a terrible situation.
17:07 They burn themselves.
17:09 They tend to rest on their limbs too long.
17:11 They don't make the microadjustments.
17:13 You might see me swiveling around in my chair,
17:14 moving around a lot.
17:15 Those microadjustments are actually
17:17 normal, healthy microadjustments
17:19 that prevent us from going into pain.
17:21 They don't make those adjustments.
17:22 They don't get the feedback
17:23 that they're in a particular position
17:25 and so they never make those adjustments
17:26 and their joints get destroyed, essentially.
17:30 They don't tend to live very long due to accidents.
17:33 It's a really terrible and unfortunate circumstance.
17:35 Some people have a mutation in the same channel
17:39 where they make too much of this channel
17:40 so they feel too much pain.
17:41 In fact, it's reasonable to speculate
17:45 that one of the reasons, not all,
17:46 but one of the reasons why people might differ
17:48 in their sensitivity to pain
17:50 is by way of genetic variation
17:52 in how many of these sorts of receptors that they express.
17:56 People who make too much of this receptor
17:59 experience extreme pain from even subtle stimuli.
18:03 The good news is there are good drug treatments
18:06 that can block specifically this sodium channel 1.7
18:10 and so those people get a lot of relief
18:12 from taking such drugs.
18:15 Pain and how much pain we are sensitive to
18:18 or insensitive to probably has some genetic basis,
18:21 and then of course, there are things that we can do
18:24 to make sure that we experience less pain,
18:26 although pain has this adaptive role.
18:29 Let's talk about some of the features of
18:32 how we're built physically and how that relates to pain
18:35 and how we can recover from injury.
18:38 First of all,
18:41 we have maps of our body surface in our brain.
18:44 It's called a homunculus.
18:45 In a rat, believe it or not, I'm not making this up,
18:48 it's called a ratunculus.
18:50 In Costello, my dog, who is snoring behind me,
18:53 it's a dogunculus.
18:55 I could get into the nomenclature and why it's called this,
18:57 but it's basically a representation of the body surface.
19:01 That representation is scaled
19:03 in a way that matches sensitivity,
19:06 so the areas of your body that are most sensitive
19:09 have a lot more brain real estate devoted to them.
19:12 Your back is an enormous piece of tissue
19:15 compared to your fingertip,
19:16 but your back has fewer receptors devoted to it
19:19 and the representation of your back in your brain
19:21 is actually pretty small,
19:23 whereas the representation of your finger is enormous.
19:28 How big a brain area is devoted to a given body part
19:32 is directly related
19:34 to the density of receptors in that body part,
19:36 not the size of the body part,
19:38 and that's why if we were to draw your homunculus
19:40 or Costello's dogunculus,
19:42 what we would find is that certain areas,
19:44 like the lips, like the fingertips,
19:47 like the genitalia,
19:48 like the eyes and the area around the face,
19:51 would have a huge representation,
19:53 whereas the back, the torso,
19:55 and areas of the body that are less sensitive
19:57 are going to have smaller representations.
20:00 It'd be a very distorted map.
20:01 You can actually know
20:03 how sensitive a given body part is
20:07 and how much brain area is devoted to it
20:10 through what's called two-point discrimination.
20:12 You can do this experiment if you want.
20:13 I think I've described this once or twice before,
20:15 but basically if you have someone put,
20:18 maybe take two pens
20:20 and put them maybe six inches apart on your back
20:24 and touch while you're facing away
20:26 and they'll ask you how many points they're touching you
20:29 and you say two,
20:31 but if they move those closer together, say three inches,
20:34 you're likely to experience it as one point of contact,
20:37 whereas on your finger,
20:39 you could play that game all day
20:41 and as long as there's a millimeter or so spacing,
20:44 you will know that it's two points as opposed to one
20:46 and that's because there's more pixels,
20:48 more density of receptors.
20:50 This has direct bearing to pain
20:52 because it says that areas of the body
20:54 that have denser receptors are going to be more sensitive
20:56 to pain than to others,
20:58 and where we have more receptors,
21:01 we tend to have more blood vessels and glia,
21:05 which are the support cells,
21:07 and other cells that lend to the inflammation response
21:10 and that's really important.
21:12 Just as a rule of thumb,
21:14 areas of your body that are injured
21:16 that are large areas that have low sensitivity before injury
21:19 likely are going to experience less pain
21:23 and the literature shows will heal more slowly
21:28 because they don't have as many cells around
21:31 to produce inflammation,
21:32 and you might say, "Wait, I thought inflammation is bad."
21:35 Well, one of the things I really want to get across today
21:37 is that inflammation is not bad.
21:40 Inflammation out of control is bad,
21:42 but inflammation is wonderful.
21:43 Inflammation is the tissue repair response
21:46 and we are going to talk about subjective and objective ways
21:49 to modulate inflammation after tissue injury,
21:53 even after just exercise that's been too intense.
21:57 You have this map of your body surface.
21:59 It's sensitive in different ways. Now you know why.
22:02 You've got your neurobiology of somatosensation 101
22:05 under your belt now.
22:07 We didn't cover everything,
22:08 but we'll touch on some of the other details
22:10 as we go forward.
22:12 I thought it might be a nice time to just think about
22:14 the relationship between the periphery and the central maps
22:17 in a way that many of you have probably heard about before,
22:19 which will frame the discussion a little bit better,
22:22 which is phantom limb pain.
22:24 Some of you are probably familiar with this,
22:26 but for people that have an arm or a leg
22:30 or a finger or some other portion of their body amputated,
22:35 it's not uncommon for those people
22:37 to feel as if they still have that limb or appendage
22:40 or piece of their body intact,
22:42 and typically, unfortunately,
22:45 the sensation of that limb is not one of the limb
22:48 being nice and relaxed and just there.
22:52 The sensation is that the limb is experiencing pain
22:56 or is contorted in the specific orientation
22:59 that it was around the time of the injury.
23:01 If someone has a blunt force to the hand
23:04 and they end up having their hand amputated,
23:06 typically they will continue to feel pain
23:08 in their phantom hand, which is pretty wild,
23:11 and that's because the representation of that hand
23:14 is still intact in the cortex, in the brain,
23:18 and it's trying to balance its levels of activity.
23:21 Normally it's getting what's called proprioceptive feedback.
23:24 Proprioception is just our knowledge
23:26 of where our limbs are in space.
23:27 It's an extremely important aspect
23:29 of our somatosensory system,
23:31 and there's no proprioceptive feedback
23:34 and so a lot of the circuits start to ramp up
23:36 their levels of activity
23:37 and they become very conscious of the phantom limb.
23:42 Before my lab was at Stanford,
23:43 I was at UC San Diego and one of my colleagues was a guy,
23:46 everyone just calls him by his last name, Ramachandran,
23:49 who is famous for understanding this phantom limb phenomenon
23:52 and developing a very simple
23:54 but very powerful solution to it
23:56 that speaks to the incredible capacity
23:59 of top-down modulation,
24:01 and top-down modulation,
24:02 the ability to use one's brain cognition and senses
24:06 to control pain in the body,
24:08 is something that everyone,
24:09 not just people missing limbs or in chronic pain,
24:12 can learn to benefit from because it is a way to tap into
24:15 our ability to use our mind
24:18 to control perceptions of what's happening in our body,
24:22 and this is not a mystical statement.
24:23 This is not about mind, I guess, as much as it is brain
24:27 to control our perceptions of our body.
24:29 What did Ramachandran do?
24:32 Ramachandran had people who were missing a limb
24:37 put their intact limb into a box
24:41 that had mirrors in it
24:42 such that when they looked in the box
24:44 and they moved their intact limb,
24:47 the opposite limb,
24:49 which was a reflection of the intact limb
24:51 'cause they're missing the opposite limb,
24:53 they would see it as if it was intact,
24:55 and as they would move their intact limb,
24:58 they would visualize with their eyes
25:01 the limb that's in the place of the absent limb,
25:05 so this is all by mirrors,
25:06 moving around and they would feel immediate relief
25:10 from the phantom pain,
25:13 and he would tell them and they would direct their hand
25:16 toward a orientation that felt comfortable to them.
25:20 Then they would exit the mirror box,
25:22 they would take their hand out,
25:24 and they would feel as if
25:26 the hand was now in its relaxed normal position.
25:29 You could get real time, in moments,
25:32 remapping of the representation of the hand.
25:35 Now, that's amazing.
25:36 This is the kind of thing that all of us
25:37 would like to be able to do if we are in pain.
25:39 If you stub your toe, if you break your ankle,
25:41 if you take a hard fall on your bike
25:43 or if you're in chronic pain.
25:45 Wouldn't it be amazing to be able to use
25:47 a mind trick,
25:50 but it's not a trick because it's real, visual imagery,
25:54 to remap your representation of your body surface
25:57 and where your body is.
25:59 That is something that we could all benefit from
26:02 because if you do anything for long enough, including live,
26:06 you're going to experience pain of some sort,
26:08 and this, again I just want to remind you,
26:10 isn't just about physical injuries and pain,
26:12 this has direct relevance to emotional pain as well,
26:16 which, of course, we'll talk about.
26:19 The Ramachandran studies were really profound
26:21 because they said a couple things.
26:22 One, plasticity can be very fast,
26:25 that it can be driven by the experience of something,
26:28 just the visual experience.
26:29 He had people do this mirror box thing
26:32 but not look into the mirror box
26:34 and they didn't get the remapping,
26:35 so it required visual imagery coming in.
26:39 We also know, for instance,
26:41 that in cases like where people are congenitally deaf,
26:46 the cochlear implant,
26:48 which is simply a way of putting, it's not simple,
26:51 but it's a way of putting in a device
26:53 that replaces the cochlea,
26:55 the device that we're normally born with in the ear
26:59 that has these little what are called hair cells
27:01 that deflect according to sound waves and allow us to hear.
27:04 By replacing the normal hearing apparatus
27:07 that's deficient in deaf people with this cochlear implant,
27:12 the brain can make sense of this artificial ear, basically,
27:15 it's not the outside ear, not the pinna, but the inner ear,
27:18 and they can start to hear sounds.
27:21 Some people really like the artificial cochlea.
27:26 They really benefit from it.
27:28 It restores their ability to hear and they like it.
27:31 Other people don't.
27:32 Some deaf people would prefer not to hear anything,
27:35 can be very disruptive to them,
27:37 and some of that might have to do with the need
27:39 for further better engineering of these artificial cochleas,
27:42 but all this really speaks to the fact
27:44 that the brain is an adaptive device.
27:47 It will respond to what you give it.
27:50 It is not a device that is fixed.
27:52 In fact, the essence of the brain,
27:53 especially the human brain,
27:54 is to take sensory inputs
27:56 and to make sense of those, meaning cognitive sense,
28:01 and then to interpret those signals,
28:02 and so this may come as a shock to some of you
28:05 and by no means am I trying to be insensitive,
28:07 but pain is a perceptual thing
28:10 as much as it's a physical thing.
28:11 It's a belief system about
28:13 what you're experiencing in your body
28:15 and that has important relevance
28:17 for healing different types of injury
28:19 and the pain associated with that injury.
28:21 In people's pursuit for neuroplasticity,
28:24 a question that comes up every once in a while
28:26 is people will say,
28:28 "If I just brush my teeth with the opposite hand
28:30 for a couple nights in a row,
28:32 will I get neuroplasticity?"
28:34 And the answer is probably yes. It's a deliberate action.
28:37 You're focusing on it. There's an end goal.
28:39 You're very likely to make errors,
28:40 like jamming up into your lips and gums at first
28:43 and then getting better at it,
28:44 and as you heard in last episode,
28:46 making errors is really important
28:48 'cause those errors are the signal
28:49 that plasticity needs to happen,
28:51 and then when you get the actions correct,
28:54 then those correct actions are programmed in.
28:58 I'm not sure that brushing one's teeth
29:00 with the opposite hand is the most
29:03 effective use of this incredible thing that we have,
29:05 which is plasticity.
29:06 It's not going to open up plasticity for many other things.
29:09 If that were really important to you, for whatever reason,
29:13 maybe you have a crowded bathroom
29:14 and it's easier to do on one side or the other, then fine,
29:17 but it's kind of hard to imagine why this would be
29:18 a highly adaptive behavior,
29:20 unless, of course, you have an injured limb
29:22 or you're missing a limb,
29:23 and that gets me to some really exciting
29:25 and important studies that were performed
29:28 mostly in the '90s as well as in the 2000s,
29:31 and that, for now, there is really a solid base of data.
29:34 There's really a center of mass around
29:37 a particular set of experiments
29:39 that point to particular protocols
29:41 for how to overcome motor injury,
29:44 and this may resonate with some of you
29:46 who've ever been injured to the point
29:48 where you couldn't walk well,
29:50 temporarily, I hope, or even longer.
29:53 Think about a sprained ankle scenario
29:56 or a broken arm scenario.
29:59 We're all familiar with the stories of people
30:01 having a cast on and then getting the cast off
30:04 and the particular limb that wasn't being used
30:06 that was casted is much smaller and atrophied.
30:10 Most of that atrophy, you might be surprised to learn,
30:13 is not because the muscles aren't being used.
30:16 It's because the nerves sending signals to those muscles
30:19 are not active and therefore the muscles aren't contracting.
30:24 Work done by a guy named Timothy Schallert
30:27 and his graduate students and postdocs,
30:30 Theresa Jones and others,
30:32 in the '90s and 2000s showed something really wonderful
30:36 that I think we can all benefit from
30:38 should we have an injury
30:39 and even if we simply want to balance out imbalances
30:43 in our motor activity,
30:44 and I think all of us tend to be stronger
30:47 on one side or the other side.
30:49 Usually a right-handed person
30:51 will be stronger in their left arm, not always,
30:55 for compensatory reasons.
30:57 Some other time we can talk about handwriting.
30:59 The lefties likely will be stronger in their right arm,
31:02 although it depends on whether or not
31:03 people are hook righties,
31:05 that's when you hook around and write from the top,
31:07 or hook lefties.
31:08 There are all sorts of theories about this
31:09 that we can talk about,
31:11 right brain, left brain, math proficiency, et cetera.
31:13 In any event,
31:14 what Schallert and colleagues showed
31:16 was that if we have damage to our brain
31:20 in the sensory motor pathways,
31:23 any number of different sensory motor pathways,
31:25 or we have damage to a limb,
31:29 could be a leg, could be an arm, could be a hand,
31:32 there's great benefit to restricting the use
31:36 of the opposite, better-performing, uninjured limb
31:42 or hand or other part of the body.
31:45 They had about a dozen papers showing
31:48 that if there was damage centrally in the brain
31:50 or there was damage to a limb,
31:52 so unilateral damage, as we say, one side,
31:55 the thing to do is not to cast up the damaged side,
32:00 although you need to do that to protect the limb,
32:02 of course, from further damage.
32:04 If it's a broken arm, you need to cast the arm
32:05 or you need to brace the arm,
32:07 but that the key thing was to restrict movement
32:11 of the intact, uninjured, opposite limb,
32:14 and when they did that,
32:16 it forced some movement in the injured limb
32:21 and remarkably,
32:23 through connections from the two sides of the brain,
32:26 through the corpus callosum,
32:27 this huge fiber pathway
32:28 that links the two sides of the brain,
32:30 they saw plasticity on both sides of the brain.
32:34 This makes sense when you hear it.
32:36 Let's say I injure my left ankle
32:39 and I'm limping along or I'm using crutches.
32:42 You would think, well, the last thing you want to do
32:45 is injure your opposite limb or not use your opposite limb.
32:48 My right ankle is perfectly fine,
32:50 but if I lean too hard on my right limb
32:53 and I take all the work out of the left limb,
32:55 the left ankle,
32:57 that's actually setting up a situation
32:59 where there's going to be runaway asymmetry
33:01 in the central pathways
33:02 and the nerve-to-muscle pathways on my left side,
33:06 and so what they suggested
33:07 and what they showed in a variety of experiments
33:10 was that by encouraging activity of the injured limb,
33:14 provided it could be done without pain,
33:17 and importantly,
33:18 not just exercising that limb or part of the body
33:22 but restricting the opposite healthy part of the body,
33:26 that the speed of recovery was significantly faster.
33:31 Now, I want to repeat,
33:32 you don't want to go injuring something further.
33:34 That's probably the worst thing you could do,
33:36 but in some cases where people have damage in their brain,
33:39 the limbs are perfectly fine,
33:40 but the motor signals aren't getting down to the limbs,
33:42 and in that case, the limb is fine,
33:45 so you actually are free to use
33:48 either limb as much as you want, and in that case,
33:50 you don't want to rely on the uninjured pathway too much.
33:53 In fact, you want to restrict the uninjured pathway.
33:56 I find these studies remarkable
33:58 and they've been followed up on at the molecular level,
34:00 at the cellar level many times,
34:02 and I think the physiotherapists out there
34:04 and the rest of you who are involved in sports medicine
34:06 and some of the physicians will say,
34:08 "Well, of course that makes perfect sense,"
34:10 but oftentimes this is not what happens.
34:12 Oftentimes what happens is it's all about resting
34:15 and limiting inflammation, et cetera,
34:17 of the injured limb
34:19 or the limbs corresponding to the injured part of the brain,
34:23 and these experiments and the collection of them
34:27 point to the fact that the balance between
34:30 the right and left side of our body is always dynamic.
34:33 It's always being updated at the level of neural circuitry,
34:36 the Ramachandran studies with the mirror box
34:37 support that too,
34:39 and that even slight imbalances in the two sides of the body
34:42 can get amplified,
34:44 and so when you're in a situation where one side is injured
34:46 or the brain is injured representing one side of the body,
34:49 the key thing to do is to really overwork
34:52 the side that needs the work
34:54 and to restrict the activity of the side
34:57 that doesn't need the work because it's healthy,
34:59 and this has great semblance to ocular dominance plasticity,
35:04 which I talked about a couple episodes ago.
35:06 I won't go into it in detail,
35:07 but where the Nobel Prize winning neurobiologists
35:10 Torsten Wiesel and David Hubel showed
35:12 that if one eye is closed early in development,
35:15 that the representation of the opposite eye in the brain
35:19 is completely overtaken by the intact eye.
35:23 This is important.
35:24 It means that all of our senses and our movements
35:27 are competing for space in our brain
35:30 and so the way to think about the principle is
35:33 anytime you're injured and you're hobbling along,
35:36 you don't want to injure yourself further,
35:38 but you want to try and compensate
35:41 in the ways that respect this competition
35:44 for neural real estate,
35:46 and what that usually means is not relying on
35:48 where you're still strong
35:50 because that's just going to create runaway plasticity
35:53 that's going to make it very hard
35:54 for you to recover the motor function,
35:57 and in some cases, the sensory function,
35:58 of the damaged limb.
36:00 Some of you may be wondering
36:02 how long and how often one should restrict the activity
36:05 of the intact or healthy limb,
36:09 or limbs in some cases,
36:11 and the answer is
36:12 you don't have to do that all day, every day.
36:14 These experiments centered on
36:16 doing one or two hours of dedicated work,
36:20 sensory motor work or,
36:22 so for instance, if you had a sprained ankle on the left,
36:25 you might spend part of the day where your left leg,
36:28 provided it's not too painful, can be exercised,
36:31 again, in a way that's not damaging to the injury,
36:34 and the right limb can't contribute to that exercise.
36:37 This might be peddling unilaterally
36:40 on a stationary bike if you can do that.
36:43 For a different type of limb injury, like an arm injury,
36:46 this might be reaching,
36:48 provided the shoulder is mobile, doing reaching.
36:51 It might be even writing with the damaged side
36:54 and then intentionally not writing
36:56 with the preferred or undamaged side.
37:00 This has been shown to accelerate the central plasticity
37:03 and the recovery of function,
37:05 which I think is what most people want
37:07 when people are injured.
37:08 They want to get back to doing
37:09 what they were doing previously
37:11 and they want to be able to do that without pain.
37:15 This brings up another topic,
37:16 which is definitely related to neuroplasticity and injury
37:20 but is a more general one that I hear about a lot,
37:23 which is traumatic brain injury.
37:25 Many injuries are not just about the limb
37:27 and the lack of use of the limb
37:29 but concussion and head injury,
37:31 and I want to emphasize I'm not a neurologist.
37:34 I have many colleagues that are.
37:35 At some point, we will do a whole month on TBI
37:38 because it's such a serious issue
37:40 and it's such a huge discussion,
37:43 but I want to talk a little bit about
37:44 what is known about recovery from concussion,
37:48 and this is very important because it has implications
37:52 for just normal aging as well
37:54 and offsetting some of the cognitive decline
37:58 and physical decline that occurs with normal aging.
38:02 We shouldn't think of TBI as just for the football players
38:04 or just for the kids that had an injury
38:06 or just for the person that was in the car accident.
38:07 We want to learn about TBI
38:09 and understand TBI for those folks,
38:11 but we're also going to talk about TBI
38:14 as it relates to general degradation of brain function
38:18 because there's a certain resemblance there
38:21 of TBI to general brain aging.
38:23 Typically after TBI,
38:25 there are a number of different things that happen
38:26 and there are a huge range of things that can create TBI.
38:31 Neurologists and the emergency room physicians
38:34 are going to want to know
38:37 was the skull itself injured
38:38 or did the brain rattle around in the skull?
38:42 Was there actually a breach through the skull?
38:45 Is there a physical object in there?
38:47 How many concussions has the person had?
38:49 Everyone's situation with TBI is incredibly different,
38:52 but there's a constellation of symptoms
38:54 that many people, if not all people with TBI,
38:56 report which is headache,
38:58 photophobia, that lights become aversive,
39:01 sleep disruption, trouble concentrating,
39:04 sometimes mood issues.
39:06 There's a huge range
39:07 and of course the severity will vary, et cetera.
39:11 In a previous episode, I mentioned the Kennard Principle.
39:15 The Kennard Principle,
39:16 named after the famous neurologist,
39:18 named by and after the famous neurologist Margaret Kennard,
39:22 said that if you're going to get a brain injury,
39:24 better to get it early in life than later in life
39:26 and that's because the brain has a much greater
39:28 or heightened capacity for repairing itself
39:30 early in life than later,
39:32 but of course, none of us want TBI
39:34 and you can't pick when you get your TBI.
39:36 You can avoid certain activities that would give you TBI,
39:39 but really, when it comes to TBI,
39:42 there are a couple of things that are
39:44 agreed upon across the board.
39:46 The first one is,
39:47 as much as possible you want to avoid
39:48 a second traumatic brain injury or concussion.
39:52 That's going to be a tough one for some of the athletes
39:54 and even recreational athletes to swallow
39:57 because they want to continue in their sport,
40:00 and I'm not here to tell you
40:01 that you should or you shouldn't,
40:02 but that's simply the way that it is.
40:07 For folks that are in military
40:08 or that are in certain professions,
40:11 construction is a place where we see a lot of TBI.
40:14 It's not always just football.
40:15 A lot of construction workers are dealing with heavy objects
40:18 swinging around in space.
40:19 They wear those hardhat helmets,
40:21 which unfortunately don't protect much
40:23 against a lot of those blunt forces
40:26 and certainly not against falls and things of that sort.
40:28 Many people, in order to survive and feed their families,
40:31 have to go back to work.
40:33 It's very clear that regardless of whether or not
40:36 there was a skull break
40:37 and regardless of when the TBI happened
40:39 and how many times it's happened,
40:41 that the system that repairs the brain, the adult brain,
40:46 is mainly centered around this lymphatic system
40:49 that we call, for the brain, the glymphatic system.
40:53 The brain wasn't thought to have a lymphatic system.
40:55 It wasn't thought to have circulating immune cells,
40:58 but about 10 years ago it was sort of rediscovered
41:01 because if you look in the literature
41:02 you realize this stuff was around longer,
41:04 that there's a glymphatic system.
41:06 It's sort of like a sewer system that clears out
41:09 the debris that surrounds neurons,
41:11 especially injured neurons,
41:13 and the glymphatic system is very active during sleep.
41:17 It's been imaged in functional magnetic resonance imaging
41:21 and the glymphatic system is something
41:23 that you want very active
41:25 because it's going to clear away the debris
41:26 that sits between the neurons,
41:28 and the cells that surround
41:31 the connections between the neurons, called the glia,
41:34 those cells are actively involved
41:36 in repairing the connections between neurons when damaged.
41:41 The glymphatic system is so important
41:44 that many people, if not all people who get TBI,
41:47 are told, "Get adequate rest, you need to sleep,"
41:50 and that's kind of twofold advice.
41:52 On the one hand, it's telling you to get sleep
41:54 because all these good things happen in sleep.
41:56 It's also about getting those people
41:59 to not continue to engage in their activity full time
42:01 or really try and hammer through it.
42:04 You might say, "Well, if you have trouble sleeping,
42:07 how are you supposed to get deep sleep?"
42:09 Most of the activity of the glymphatic system,
42:11 this wash out of the debris,
42:12 is occurring during slow-wave sleep.
42:15 Slow-wave sleep, as I mentioned in a previous episode,
42:18 is something that happens typically
42:19 in the early part of the evening.
42:21 Even for those of you that are falling,
42:23 or early part of the night, rather,
42:24 if you're falling asleep and then waking up
42:25 three, four hours later,
42:26 it's important that you continue to get sleep
42:30 but know that the slow-wave sleep
42:32 is mainly packed toward the early part of the night,
42:35 so that hopefully will alleviate some of the anxiety
42:39 of the 3:00 and 4:00 am wake up,
42:41 although you really should follow
42:42 some of the protocols that I've suggested
42:44 and your physician's protocols
42:45 in order to try and get regular, longer sleep
42:48 of seven, eight hours.
42:49 Later, we're going to talk about the eight-hour mark
42:51 as a prerequisite for repair.
42:54 The glymphatic system has been shown
42:56 to be activated further in two ways.
43:00 One is that sleeping on one side,
43:03 not on back or stomach,
43:05 seems to increase the amount of wash out,
43:09 or wash through, I should say,
43:11 of the glymphatic system.
43:12 There aren't a ton of data on this,
43:14 but the data that exist are pretty solid.
43:17 Again, sleeping on one side
43:19 or with feet slightly elevated, as well,
43:23 has been shown to increase the rate of clearance
43:26 of some of the debris
43:27 and that's because the way that the glymphatic system works
43:31 is it has a physical pressure fluid dynamic to it
43:35 that allow it to work more efficiently
43:38 when one is sleeping on their side
43:40 or with feet slightly elevated.
43:42 This means not falling asleep in a chair while watching TV.
43:46 This means, if possible,
43:48 not falling asleep on one's back or on one's stomach,
43:50 sleeping on one's side,
43:52 and if you can't do that,
43:53 I don't really like to sleep on my side.
43:55 I sleep with my feet slightly elevated.
43:56 I put a thin pillow under my ankles.
43:58 I don't have TBI, but I have had a few concussions before,
44:03 but right now I feel fine,
44:05 but I find that putting the pillow under my ankles
44:08 helps me sleep much more deeply
44:10 and I wake up feeling much more refreshed.
44:12 The other thing that has been shown
44:15 to improve the function of the glymphatic system,
44:18 and this is, again, is for sake of TBI
44:21 as well as for everyone, even without brain injury,
44:25 is a certain form of exercise,
44:27 and I want to be very, very clear here.
44:29 I will never and I am not suggesting
44:32 that people exercise in any way
44:35 that aggravates their injury
44:38 or that goes against their physician's advice.
44:41 Take your physician's advice
44:43 as to whether or not you should be exercising at all
44:45 and how much and then to what intensity.
44:48 However, there's some interesting data,
44:51 and we can provide a link to the review on this.
44:54 It shows that exercise of
44:56 what I guess people would nowadays call it Zone 2 cardio,
45:00 which is low-level cardio that one could do
45:03 while talking to somebody else.
45:04 You could maintain a conversation,
45:06 although you don't have to talk to somebody else.
45:08 It just gives you a sense of the intensity of the exercise.
45:11 That Zone 2 cardio
45:12 for 30 to 45 minutes 3 times a week
45:15 seems to improve the rates of clearance
45:19 of some of the debris after injury,
45:22 and in general, injury or no,
45:24 to accelerate and improve the rates of flow
45:28 for the glymphatic system.
45:31 I find this really interesting
45:32 because I think nowadays there's such an obsession
45:34 with high-intensity interval training
45:36 and people trying to pack in as much as they can
45:39 into a short workout,
45:40 which is great if it brings people to the table
45:42 who haven't been exercising before,
45:44 but I think it's really important that we know
45:47 that the data on exercise
45:48 and its relationship to brain health
45:51 speak to doing 30 to 45 minutes
45:54 of this what we call low-level cardio.
45:57 It could be fast walking.
45:59 It could be jogging
46:00 if you can do that with your injury safely.
46:03 It could be cycling.
46:04 This is not the kind of workout
46:06 that's designed to get your heart rate up to the point
46:09 where you're improving your fitness levels
46:10 at some sort of massive rate
46:14 or taking huge jumps in your VO2 max or anything like that.
46:18 This is exercise,
46:19 I do this and I know a number of other people,
46:22 especially people in communities
46:23 where there is a lot of TBI,
46:24 are now starting to adopt this,
46:27 that the 30 to 45 minutes 3 times a week or so,
46:30 could be more,
46:32 of this Zone 2 type cardio can be very beneficial
46:35 for washout of debris from the brain,
46:37 and this is really interesting outside of TBI
46:40 because what we know from aging
46:42 is that aging is a nonlinear process.
46:45 It's not like with every year of life
46:47 your brain gets a little older.
46:49 Sometimes it follows what's more like a step function
46:51 where you get these big jumps in markers of aging.
46:55 I guess that we could think of them as jumps down
46:57 because it's a negative thing for most everybody.
47:00 We'd like to live longer and be healthier in brain and body,
47:02 and so the types of exercise I'm referring to now
47:06 are really more about brain longevity
47:09 and about keeping the brain healthy
47:11 than they are about physical fitness.
47:14 There's no reason why you couldn't do this and also,
47:17 provided, again, it's safe for you
47:19 given your brain state and injury state, et cetera,
47:23 there's no reason why you couldn't also combine it
47:24 with weight training and other forms of cardio.
47:27 I think this is really interesting
47:28 and if some of you would like to know the mechanism
47:30 or at least the hypothesized mechanism,
47:33 there's a molecule called aquaporin-4.
47:36 It almost sounds like
47:38 the fourth in a sequel of movies or something like that,
47:40 but aquaporin-4 is a molecule
47:44 that is related to the glial system.
47:47 Glia are the, it means glue in Latin,
47:49 are these cells in the brain,
47:51 the most numerous cells in the brain, in fact,
47:53 that ensheathe synapses, but they're very dynamic cells.
47:56 They're like little ambulant cells.
47:57 The microglia will run in
47:59 and will gather up debris and soak it up
48:02 and then run out after an injury.
48:04 Aquaporin-4 is mainly expressed
48:06 by the glial cell called the astrocyte.
48:07 Astro, it looks like a little star.
48:10 Incredibly interesting cells
48:11 and the thing to remember is
48:14 that the astrocytes bridge the connection
48:17 between the neurons,
48:19 the synapse, the connections between them,
48:23 and the vasculature, the blood system,
48:25 and the glymphatic system.
48:27 They sit at the interface and they kind of,
48:29 imagine somebody on an emergency site, car crash site,
48:31 who's directing everybody around as to what to do.
48:33 Get that person on a stretcher, bandage them up,
48:36 call their mother, et cetera, et cetera,
48:38 get this out of the road, put down some flares.
48:41 The astrocytes work in that capacity
48:43 as well as doing some things more directly.
48:47 This glymphatic system and the glial astrocyte system
48:49 is a system that we want chronically active
48:52 throughout the day as much as possible,
48:54 so low-level walking, Zone 2 cardio,
48:57 and then at night, during slow-wave sleep,
48:59 is then really when this glymphatic system kicks in.
49:02 That should hopefully be an actionable takeaway,
49:04 provided that you can do that kind of cardio safely,
49:07 that I believe everybody should be doing
49:09 who cares about brain longevity,
49:11 not just people who are trying to get over TBI.
49:14 Now I'd like to return a little bit
49:16 to some of the subjective aspects of pain modulation
49:20 because I think it's so interesting and so actionable
49:24 that everyone should know about this,
49:26 and in this case,
49:29 we can also say that regardless of whether or not
49:31 you're experiencing pain, acute or chronic,
49:34 what I'm about to tell you
49:35 is as close as anything is to proof,
49:39 in science, we rarely talk about proof,
49:41 we talk about evidence in favor or against a hypothesis,
49:44 but as close as possible to proof
49:47 that our interpretation,
49:49 our subjective interpretation of a sensory event
49:52 is immensely powerful
49:53 for dictating our experience of the event.
49:58 Here are a couple examples.
49:59 First of all,
50:01 anyone who's ever done combat sports or martial arts
50:04 knows that it's incredible
50:07 how little a punch hurts during a fight
50:11 and it's incredible how much it hurts after a fight.
50:15 The molecule adrenaline,
50:16 when it's liberated into our body,
50:20 truly blunts our experience of pain.
50:23 We all know the stories of people
50:26 walking miles on stumped legs,
50:29 people doing all sorts of things
50:32 that were incredible feats
50:35 that allowed them to move through
50:36 what would otherwise be pain,
50:38 and afterward they do experience extreme pain,
50:40 but during the event oftentimes
50:42 they are not experiencing pain and that's because of
50:45 the pain-blunting effects of adrenaline.
50:48 I'll tell you exactly how this works in a few minutes
50:50 when we talk about acupuncture,
50:52 but norepinephrine binding to particular receptors,
50:55 adrenaline binding to particular receptors
50:57 actually shuts down pain pathways.
51:02 People who anticipate an injection of morphine
51:06 immediately report the feeling of loss of pain.
51:11 Their pain starts to diminish
51:12 because they know they're going to get pain relief
51:16 and it's a powerful effect.
51:17 All of you are probably saying placebo effect.
51:19 Placebo effects are very real.
51:21 Placebo effects and belief effects, as they're called,
51:24 have a profound effect on our experience
51:26 of noxious stimuli like pain
51:29 and they can also have a profound effect on positive stimuli
51:32 and things that we're looking forward to.
51:35 One study that I think is particularly interesting here,
51:37 it's from my colleague at Stanford, Sean Mackey.
51:39 They did a neuroimaging study.
51:41 They subjected people to pain.
51:43 In this case, it was a heat pain.
51:45 People have very specific thresholds to heat
51:47 at which they cannot tolerate any more heat,
51:50 but they explored the extent to which
51:52 looking at an image of somebody,
51:55 in this case, a romantic partner that the person loved,
51:58 would allow them to adjust their pain response,
52:03 and it turns out it does.
52:05 If people are looking at an image
52:07 or thinking about a person that they love,
52:11 or even a thing that they love, a pet that they love,
52:14 studies previous to the one that Mackey and colleagues did
52:17 showed that their experience of pain was reduced.
52:21 Their threshold for pain was higher.
52:23 They could tolerate more pain
52:25 and they reported it as not as painful,
52:28 but there's a twist there which is it turns out
52:31 that the extent to which love will modulate pain
52:36 has everything to do with how infatuated
52:39 and obsessed somebody is with the object of their love.
52:44 People that report thinking about somebody, or a pet,
52:49 for many hours of the day,
52:52 kind of having an obsessive nature,
52:54 almost like what people might call
52:56 quote, unquote, codependency.
52:57 For those of you that are listening,
52:58 I'm just providing air quotes
53:00 'cause codependency is kind of a clinical thing now
53:02 although it's thrown around a lot all the time.
53:04 It's sort of like gaslighting.
53:05 People talk about gaslighting all the time now.
53:07 Gaslighting is a real thing
53:08 but then people talked about gaslighting
53:10 for many things outside the clinical description.
53:15 If people are very obsessed with somebody,
53:18 they have a kind of obsessive love of somebody's face,
53:21 even if the other person doesn't know them,
53:22 which is a little weird,
53:25 that response, that feeling of love internally
53:29 can blunt the pain experience to a significant degree.
53:34 These are not small effects.
53:36 It's not just that love can protect us from pain.
53:38 It's that infatuation and obsession
53:41 can protect us from pain,
53:42 and not surprisingly,
53:44 how early a relationship is, how new a relationship is
53:48 directly correlates with people's ability, they showed,
53:51 to use this love, this internal representation of love,
53:55 to blunt the pain response.
53:58 For those of you that have been with your partners
54:00 for many years and you love them very much
54:02 and you're obsessed with them, terrific.
54:04 You have a pre-installed,
54:06 well, I suppose it's not pre-installed.
54:07 You had to do the work because relationships are work,
54:09 but you've got a installed mechanism for blunting pain,
54:14 and again, these are not minor effects.
54:16 These are major effects
54:18 and it's all going to be through that top-down modulation
54:20 that we talked about,
54:21 not unlike the mirror box experiments with phantom limb
54:24 that relieve phantom pain
54:26 or some other top-down modulation,
54:29 and the opposite example was the nail through the boot,
54:31 which is a visual image that made the person think
54:33 it was painful when in fact
54:34 it was painful even though there was no tissue damage.
54:38 It was all perceptual.
54:40 The pain system is really subject
54:41 to these perceptual influences,
54:44 which is remarkable because, really,
54:47 when we think about the somatosensory system,
54:49 it has this cognitive component,
54:50 it's got this peripheral component,
54:52 but there's another component
54:54 which is the way in which our sensation,
54:56 our somatosensory system is woven in
54:58 with our autonomic nervous system,
55:00 and we're going to get to that next,
55:01 but I want to just raise the idea
55:04 that the reason that this kind of infatuation
55:07 and obsessive love can blunt the pain response
55:10 and increase one's threshold for pain
55:13 may have to do,
55:15 I would say almost certainly has to do,
55:16 but it hasn't been measured yet,
55:19 with dopamine release
55:20 because dopamine is absolutely the molecule
55:23 that's liberated in our brain and body
55:26 when there's a new kind of obsession or infatuation.
55:30 It's very distinct from the kind of love chemicals,
55:34 if you will,
55:36 I don't even like calling them love chemicals.
55:37 That just feels weird.
55:38 If this were text, I would delete that line,
55:40 but from the chemicals associated
55:43 with warmth and connection,
55:45 such as serotonin and oxytocin,
55:47 which tend to be for more stable,
55:49 long-lasting relationships.
55:50 Dopamine is what dilates the pupils,
55:53 which gets people really excited.
55:54 They can't stop thinking about somebody.
55:56 The text messages are even exciting.
55:58 They write to them and they can't wait
56:00 for the text message to come back,
56:02 the dot dot dot on the screen.
56:03 The text message is excruciating.
56:05 They don't respond for two minutes
56:07 and people are getting flipped out.
56:08 I'm not here to support that kind of whatever,
56:12 what I'm saying is that
56:14 that obsessive type of love,
56:16 which without question
56:18 is going to be associated with the dopamine pathway,
56:19 does seem to have a utility in the context of
56:24 reducing the unpleasantness of physical pain,
56:28 and probably has a lot to do
56:29 with reducing the unpleasantness of a lot of life,
56:31 like sitting in traffic, et cetera,
56:32 because when we talk about pain,
56:34 emotional pain and physical pain
56:36 start to become one in the same.
56:38 They are so closely intertwined
56:41 that the lines between them neurally become very blurry.
56:44 What do I mean by that?
56:45 Well, if love and infatuation
56:49 can reduce pain,
56:51 presumably through the release of dopamine,
56:53 well, then does dopamine release itself blunt pain?
56:56 Should we be chasing dopamine release
56:59 as a way to treat chronic and acute pain?
57:01 And that's exactly what we're going to talk about now.
57:03 Independent of love,
57:04 we're going to talk about something quite different
57:06 which is putting needles and electricity
57:08 in different parts of the body, so-called acupuncture.
57:11 Something that, for many people,
57:15 it's been viewed as a kind of alternative medicine,
57:19 but now there are excellent laboratories exploring
57:22 what's called electroacupuncture and acupuncture.
57:25 These are big university centers.
57:26 In fact, my source for everything I'm about to tell you next
57:30 is Professor Qiufu Ma at Harvard Medical School
57:33 and his papers.
57:34 I stand behind the information that I'm going to provide today,
57:36 but it's extracted largely from the Ma lab's papers
57:40 which use very rigorous variable-isolating experiments
57:46 to address just how does something like acupuncture work,
57:49 and I think what you'll be interested in
57:51 and surprised to learn is that it does work,
57:53 but sometimes it can exacerbate pain
57:57 and sometimes it can relieve pain
57:59 and it all does that through very discrete pathways
58:01 for which we can really say,
58:03 "This neuron connects to that neuron
58:05 connects to the adrenals,"
58:06 and we can tie this all back to dopamine
58:08 because in the end it's the chemicals and neural circuits
58:11 that are giving rise to these perceptions,
58:13 or these experiences, rather,
58:15 of things that we call pain, love, et cetera.
58:17 In a previous podcast episode,
58:19 I mentioned my experience of visiting an acupuncturist
58:23 and getting acupuncture.
58:25 The acupuncture itself
58:28 didn't really do that much for me,
58:30 but I wasn't there for any specific reason.
58:31 It was gifted to me by somebody and I wanted to try it.
58:35 I'm not passing judgment on acupuncture.
58:37 In fact, I know a number of people
58:39 that really derive tremendous benefit from acupuncture
58:42 for pain and for gastrointestinal issues.
58:45 There are actually a lot of
58:46 really good peer-reviewed studies
58:49 supporting the use of acupuncture for, in particular,
58:52 GI tract issues.
58:55 In recent years, there's been an emphasis on
58:57 trying to understand the mechanism
58:59 of things like acupuncture and acupuncture itself,
59:03 not to support acupuncture
59:05 or to try to get everybody to do acupuncture
59:07 but as a way to try and understand
59:08 how these sorts of practices
59:10 might actually benefit people who are experiencing pain
59:14 or for changing the nervous system
59:15 or brain-body relationship in general,
59:18 and actually,
59:19 the National Institutes of Health in the United States
59:22 now has a entire subdivision,
59:25 an institute within the National Institutes of Health,
59:29 which is complementary health,
59:32 and that institute is interested in things like acupuncture
59:36 and a variety of other practices that, I think,
59:39 10, 15 years ago people probably thought
59:41 were really alternative and maybe even counterculture,
59:45 at least in the States, and it's exciting.
59:47 I think people are starting to really take a look at
59:49 what's going on under the hood
59:51 for certain types of treatments that are very useful
59:53 and I think it's very likely to lead
59:55 to an expanded number of treatments
59:57 for a number of different conditions.
1:00:00 What I want to talk about in terms of acupuncture
1:00:02 is the incredible way in which acupuncture illuminates
1:00:07 the crosstalk between the somatosensory system,
1:00:10 our ability to feel stuff
1:00:12 externally, exteroception,
1:00:14 internally, interoception,
1:00:16 and how that somatosensory system
1:00:20 is wired in with and communicating
1:00:22 with our autonomic nervous system
1:00:24 that regulates our levels of alertness or calmness.
1:00:29 After that, I'm going to talk about
1:00:30 how the acupuncture that's being done right now
1:00:34 also points to relief for what's called referred pain.
1:00:39 This takes us all back to the homunculus. Let's start there.
1:00:42 We have this representation of our body surface
1:00:44 in our brain.
1:00:47 That representation is what we call somatotopic,
1:00:50 and what somatotopy is
1:00:53 is it just means that areas of your body
1:00:55 that are near one another,
1:00:56 so your thumb and your forefinger, for instance,
1:00:59 are represented by neurons that are nearby each other
1:01:02 in the brain.
1:01:04 You might say, "Well, duh,"
1:01:05 but actually, it didn't have to be that way.
1:01:07 The neurons that represent the tip of my forefinger
1:01:09 and the neurons that represent my thumb on the same hand
1:01:11 could have been distantly located
1:01:13 and therefore the map of my body surface, the homunculus,
1:01:16 would be really disordered, but it's not that way.
1:01:18 It's very ordered. It's very smooth.
1:01:20 As, let's say you were to image my brain,
1:01:22 if you were to stimulate my finger, my forefinger,
1:01:24 and then march that stimulation across my finger,
1:01:27 across the palm and to the nearby thumb,
1:01:29 you would see that neurons in the brain
1:01:31 would also make a sort of J shape
1:01:32 in their pattern of activation.
1:01:35 That means there's so-called somatotopy,
1:01:37 but the connections from those brain neurons
1:01:40 are sent into the body
1:01:42 and they are synchronized with,
1:01:45 meaning they cross-wire with
1:01:47 and form synapses with some of the input
1:01:52 from the viscera, from our guts,
1:01:54 from our diaphragm, from our stomach,
1:01:56 from our spleen, from our heart.
1:02:00 Our internal organs are sending information
1:02:02 up to this map in our brain of the body surface,
1:02:06 but it's about internal information,
1:02:07 what we call interoception,
1:02:09 our ability to look inside or imagine inside
1:02:11 and feel what we're feeling inside.
1:02:14 The way to think about this accurately
1:02:17 is that our representation of ourself
1:02:19 is a representation of our internal workings,
1:02:22 our viscera, our guts, everything inside our skin,
1:02:25 and the surface of our skin,
1:02:27 and the external world, what we're seeing.
1:02:30 Those three things are always being combined
1:02:31 in a very interesting, complex but very seamless way.
1:02:38 Acupuncture involves taking needles,
1:02:40 and sometimes electricity and or heat as well,
1:02:43 and stimulating particular locations on the body
1:02:47 and through these maps of stimulation
1:02:49 that have been developed over thousands of years,
1:02:52 mostly in Asia,
1:02:56 but now this is a practice that's being done
1:02:58 many places throughout the world,
1:03:00 they have these maps that speak to,
1:03:02 oh, well, if you stimulate this part of the body,
1:03:04 you get this response,
1:03:05 and if somebody has a gastrointestinal issue,
1:03:07 like their guts are moving too quick, they have diarrhea,
1:03:09 you stimulate this area
1:03:11 and it'll slow their gut motility down,
1:03:12 or if their gut motility is too slow, they're constipated,
1:03:15 you stimulate someplace else and it accelerates it,
1:03:17 and hearing about this stuff, it sounds kind of,
1:03:20 to a Westerner who's not thinking about
1:03:22 the underlying neural circuitry,
1:03:24 it could sound kind of wacky.
1:03:25 It really sounds like alternative
1:03:27 or even really out there stuff,
1:03:29 but when you look at the neural circuitry, the neuroanatomy,
1:03:32 it really starts to make sense,
1:03:33 and Qiufu Ma's lab at Harvard Medical School
1:03:36 is an excellent laboratory,
1:03:39 has been exploring how stimulation of different types,
1:03:43 intense or weak, with heat or without heat,
1:03:47 on different parts of the body
1:03:50 can modulate pain and inflammation,
1:03:53 and what they've shown in a particularly exciting study
1:03:57 is that stimulation of the abdomen,
1:04:01 anywhere on the midsection,
1:04:03 weakly does nothing.
1:04:06 "Well, that's not very interesting," you might say.
1:04:08 Intense stimulation of the abdomen, however,
1:04:11 with this electroacupuncture has a very strong effect
1:04:15 of increasing inflammation in the body,
1:04:19 and this is important to understand
1:04:21 because it's not just that stimulating the gut does this
1:04:25 because you're activating the gut area.
1:04:28 It activates a particular nerve pathway.
1:04:30 For the aficionados,
1:04:31 it's the splenic spinal sympathetic axis
1:04:34 if you really want to know,
1:04:35 and it's pro-inflammatory under most conditions.
1:04:40 However, there are other conditions where if, for instance,
1:04:43 the person is dealing with a particular bacterial infection,
1:04:46 that can be beneficial,
1:04:48 and this goes back to a much earlier discussion
1:04:51 that we had on a previous podcast
1:04:52 that we'll revisit again and again,
1:04:54 which is that the stress response
1:04:56 was designed to combat infection.
1:04:58 It turns out that there are certain patterns
1:05:00 of stimulation on the abdomen
1:05:01 that can actually liberate immune cells
1:05:04 from our immune organs, like our spleen,
1:05:07 and counter infection
1:05:08 through the release of things like adrenaline.
1:05:11 Qiufu's lab also showed
1:05:13 that stimulation of the feet and hands
1:05:18 can reduce inflammation,
1:05:21 and again, this was done mechanistically.
1:05:23 This was done by blocking certain pathways
1:05:26 with the appropriate control experiments.
1:05:28 This was done not in any kind of subjective way.
1:05:32 This was also done by measuring particular molecules,
1:05:34 IL-6 and cytokines
1:05:36 and things that are related to the inflammation response,
1:05:39 and what they showed is that the stimulation of the,
1:05:41 in particular, the hind limbs at low intensity
1:05:47 led to increases in the activity of this vagal pathway.
1:05:51 The vagus nerve being this 10th cranial nerve
1:05:53 that serves the rest and digest and parasympathetic,
1:05:56 in other words, calming response.
1:05:58 What this means is that we are now at the front edge
1:06:00 of this research field that's,
1:06:03 it's early days still,
1:06:05 but it's discovering that depending on whether or not
1:06:07 the stimulation is intense or mild
1:06:10 and depending on where the stimulation is done on the body
1:06:13 you can get very different effects.
1:06:15 This points to the idea that you can't say acupuncture good
1:06:18 or acupuncture bad.
1:06:20 There has to be a systematic understanding of
1:06:23 what exactly the effect is that you're trying to achieve
1:06:26 and the underlying basis for this is really relevant
1:06:28 to the thing about adrenaline that I said before,
1:06:31 that in a fight,
1:06:32 it's rare that you ever feel pain when you get hit,
1:06:35 I've experienced that,
1:06:37 but later it hurts a lot.
1:06:38 It turns out that when you stimulate these pathways
1:06:40 that activate, in particular, the adrenals,
1:06:43 the adrenal gland liberates norepinephrine and epinephrine
1:06:47 and the brain does as well,
1:06:49 it binds to what are called
1:06:50 the beta noradrenergic receptors.
1:06:52 This is really getting down into the weeds,
1:06:54 but the beta noradrenergic receptors activate the spleen
1:06:58 which liberates cells that combat infection
1:07:01 and it's anti-inflammatory.
1:07:03 That's the short-term quick response.
1:07:06 The more intense stimulation of the abdomen and other areas
1:07:11 can be pro-inflammatory
1:07:14 because of the ways that they trigger certain loops
1:07:16 that go back to the brain and trigger the anxiety pathways
1:07:20 and that place people into a state of anxiety
1:07:22 that exacerbates pain.
1:07:24 One pathway stimulates norepinephrine and blunts pain,
1:07:26 the other one doesn't.
1:07:28 What does all this mean?
1:07:29 How are we supposed to put all of this together?
1:07:31 Well, there's a paper that was published
1:07:33 in "Nature Medicine" in 2014,
1:07:34 this is an excellent journal,
1:07:36 that describes how dopamine
1:07:40 can activate the vagus peripherally in the,
1:07:43 not dopamine in the brain, peripherally,
1:07:45 and norepinephrine can activate the vagus peripherally
1:07:49 and reduce inflammation,
1:07:50 and I'm not trying to throw a ton of facts at you.
1:07:52 You'll say, "Well, what am I supposed to do
1:07:54 with all this information?"
1:07:55 What this means is that
1:07:57 there are real maps of our body surface
1:07:59 that when stimulated
1:08:01 communicate with our autonomic nervous system,
1:08:04 the system that controls alertness or calmness,
1:08:06 and thereby releases either molecules
1:08:09 like norepinephrine and dopamine,
1:08:11 which make us more alert, as we would be in a fight,
1:08:15 and blunt our response to pain
1:08:17 and they reduce inflammation,
1:08:20 but there are yet other pathways that when stimulated
1:08:23 are pro-inflammatory,
1:08:25 and that brings us to the question of
1:08:26 what is all this inflammation stuff
1:08:28 that people are talking about?
1:08:29 One of the things that bothers me so much these days,
1:08:32 and I'm not easily irritated,
1:08:34 but what really bothers me is when people
1:08:36 are talking about inflammation like inflammation is bad.
1:08:38 Inflammation is terrific.
1:08:39 Inflammation is the reason why cells are called
1:08:42 to the site of injury to clear it out.
1:08:44 Inflammation is what's going to allow you
1:08:46 to heal from any injury.
1:08:47 Chronic inflammation is bad,
1:08:50 but acute inflammation is absolutely essential.
1:08:53 Remember those kids that we talked about earlier
1:08:54 that have mutations in these receptors for sensing pain?
1:08:57 They never get inflammation
1:08:59 and that's why their joints literally disintegrate.
1:09:03 It's really horrible
1:09:04 because they don't actually have the inflammation response
1:09:06 because it was never triggered by the pain response.
1:09:10 Inflammation can be very beneficial.
1:09:13 There's a lot of interest nowadays
1:09:15 in taking things and doing things to limit inflammation.
1:09:17 One of the ones that comes up a lot is turmeric.
1:09:19 I'm sure the moment anyone starts talking about
1:09:21 inflammation the question is, "What about turmeric?"
1:09:24 I have talked before about turmeric elsewhere.
1:09:28 I am very skeptical of turmeric
1:09:30 and I might lose a few friends,
1:09:32 although that'd be weird if my friend,
1:09:34 that would say something about my friendships
1:09:35 if I lost friends over a discussion about turmeric,
1:09:38 but in any case,
1:09:41 turmeric does have anti-inflammatory properties,
1:09:44 there's no question about that,
1:09:45 but as we've just described,
1:09:48 inflammation can be a very good thing,
1:09:49 at least in the short term.
1:09:50 The other thing about turmeric is
1:09:52 there was a study published out of Stanford
1:09:54 in collection with some work from other universities
1:09:56 showing that a lot of turmeric
1:09:58 is heavily contaminated with lead.
1:10:01 The lead is used to get
1:10:02 that really rich, dense, orange coloring to it
1:10:06 that everyone wants to see,
1:10:08 so you have to check your sources of turmeric.
1:10:10 The other thing is, for men in particular,
1:10:13 turmeric can be very antagonistic to dihydrotestosterone.
1:10:17 Dihydrotestosterone is the more dominant form
1:10:20 of androgen in human males
1:10:23 and it's involved in things like aggression and libido
1:10:27 and things of that sort.
1:10:28 Many people that I've talked to who have have taken turmeric
1:10:32 get a severe blunting of affect and libido.
1:10:36 For some people that might be a serious negative.
1:10:39 I certainly avoid turmeric.
1:10:40 I don't like turmeric for that reason.
1:10:43 I also think that the inflammation response
1:10:45 is a healthy response.
1:10:47 You have to keep it in check
1:10:48 and we're going to talk about specific practices
1:10:50 for wound healing and injury in a moment,
1:10:52 but this idea that just inflammation is bad
1:10:55 and you want to reduce inflammation across the board,
1:10:57 nothing could be further from the truth.
1:10:59 We have pathways that exist in our body
1:11:01 specifically to increase inflammation.
1:11:04 It's the inflammation that goes unchecked, just like stress,
1:11:07 which is problematic for repair, for brain injury,
1:11:11 and it can exacerbate certain forms of dementia, et cetera,
1:11:14 but I'd like to create a little bit more nuance
1:11:16 or a lot more nuance, if possible,
1:11:18 in the conversation around inflammation
1:11:20 because people have just taken
1:11:22 this discussion around inflammation to be this idea
1:11:26 that just inflammation is bad
1:11:27 and nothing could be further from the truth.
1:11:30 Before I continue,
1:11:31 I just thought I'd answer a question that I get a lot
1:11:35 which is what about Wim Hof breathing?
1:11:37 I get asked about this a lot.
1:11:38 Wim Hof, also called aka The Iceman,
1:11:41 has this breathing that's similar to Tummo breathing,
1:11:44 as it was originally called,
1:11:45 involves basically hyperventilating
1:11:47 and then doing some exhales and some breath holds.
1:11:49 A couple of things about that.
1:11:50 It should never be done near water.
1:11:52 People who have done it near water
1:11:53 unfortunately have drowned.
1:11:56 It's certainly not for everybody
1:11:58 and I'm not here to either promote it
1:12:01 nor discourage people from doing it,
1:12:03 but I think we should ask ourselves,
1:12:04 "What is the net effect of that?"
1:12:06 Because a number of people have asked me about it
1:12:08 in relation to pain management.
1:12:10 The effect of doing that kind of breathing,
1:12:13 it's not a mysterious effect.
1:12:14 It liberates adrenaline from the adrenals.
1:12:17 There is a paper published in
1:12:18 the "Proceedings of the National Academy of Sciences,"
1:12:20 which is a very fine journal,
1:12:21 showing that that breathing pattern
1:12:23 can counter infection from endotoxin
1:12:26 and that's because when you have adrenaline in your system
1:12:29 and when the spleen is very active,
1:12:32 that response is used to counter infection
1:12:36 and stress counters infection.
1:12:39 We'll talk about this more going forward,
1:12:41 but the idea that stress lends itself to infection is false.
1:12:44 Stress counters infection
1:12:46 by liberating killer cells in the body.
1:12:49 You don't want the stress response
1:12:50 to stay on indefinitely, however.
1:12:53 Things like Wim Hof breathing, like ice baths,
1:12:56 anything that releases adrenaline
1:12:57 will counter the infection,
1:13:01 but you want to regulate the duration
1:13:03 of that adrenaline response.
1:13:05 This should make perfect sense.
1:13:06 We, as a species,
1:13:07 had to evolve under conditions of famine and cold.
1:13:09 Actually, Texas right now
1:13:10 is an extreme case of cold and power outage.
1:13:13 I've seen the pictures and a lot of people out there
1:13:15 are really suffering.
1:13:17 Their systems are releasing a ton of adrenaline.
1:13:19 They're cold. Some of them are likely to be hungry.
1:13:22 They're probably stressed.
1:13:25 They're releasing a lot of adrenaline
1:13:26 which is keeping them safe from infection.
1:13:30 After they get their heat back on and they relax
1:13:32 and they can finally warm up again,
1:13:34 which we would like for them very soon,
1:13:37 hopefully by the time this podcast comes out,
1:13:38 that will have already happened,
1:13:40 that's typically when people get sick
1:13:42 because the immune response is blunted
1:13:44 as the stress response starts to subside.
1:13:48 Stress, inflammation, countering infection,
1:13:51 that comes from endotoxin,
1:13:52 that comes from any number of things.
1:13:54 It can be from cold. It can be from hyperventilation.
1:13:56 It can be from a physical threat.
1:13:58 It can be from the stress of an exam or an upcoming surgery.
1:14:02 This adrenaline thing
1:14:04 and the inflammation associated with it is adaptive.
1:14:07 It's highly adaptive.
1:14:08 It is a short-term plasticity
1:14:10 that is designed to make us better
1:14:12 for what we're experiencing and challenged with, not worse,
1:14:16 and so hopefully that will add an additional layer
1:14:19 to this whole idea that stress is bad,
1:14:21 inflammation is bad, et cetera.
1:14:23 Again, I'm not suggesting people do or don't do
1:14:26 something like Wim Hof, Tummo breathing,
1:14:28 I just want to point to the utility.
1:14:29 It's very similar to the utility from cold showers,
1:14:32 ice baths and other forms of anything
1:14:34 that increase adrenaline.
1:14:36 Every episode, I want to make sure
1:14:38 that every listener comes away
1:14:39 with as much knowledge as possible
1:14:42 but also actionable tools,
1:14:44 and today we've talked about a variety of tools,
1:14:46 but I want to center in on a particular sequence of tools
1:14:50 that hopefully you won't need,
1:14:52 but presumably if you're a human being and you're active,
1:14:55 you will need at some point.
1:14:57 It's about managing injury
1:14:58 and recovering and healing fast
1:15:02 or at least as fast as possible.
1:15:05 It includes removing the pain.
1:15:07 It includes getting mobility back
1:15:10 and getting back to a normal life,
1:15:12 whatever that means for you.
1:15:14 I want to emphasize that what I'm about to talk about next
1:15:17 was developed in close consultation with Kelly Starrett,
1:15:20 who many of you probably have heard of before.
1:15:24 Kelly can be found at The Ready State.
1:15:25 He's a formally trained,
1:15:27 so degreed and educated, exercise physiologist.
1:15:30 He's a world expert in movement
1:15:32 and tissue rehabilitation, et cetera.
1:15:35 They're not sponsors of the podcast.
1:15:36 Kelly is a friend and a colleague.
1:15:38 He's somebody that I personally trust
1:15:40 and his views on tissue rehabilitation and injury
1:15:45 I think are really grounded extremely well
1:15:47 in both medicine, physiology,
1:15:50 and the real cutting edge of what's new
1:15:53 and what you might not get in terms of advice
1:15:56 from the typical person.
1:15:58 All that said, you always, always, always should consult
1:16:00 with your physician before adopting any protocols
1:16:03 or removing any protocols.
1:16:06 I asked Kelly, I made it really simple, I said,
1:16:08 "Okay, let's say I were to sprain my ankle
1:16:10 or break my arm or injure my knee
1:16:12 or ACL tear or something like that or shoulder injury,
1:16:16 what are the absolute necessary things
1:16:20 to do regardless of situation
1:16:21 and what science is this grounded in?"
1:16:25 And then I made it a point to go find the studies
1:16:27 that either supported or refuted what he was telling me
1:16:32 because that's why I'm here.
1:16:34 The first one is a very basic one,
1:16:37 that now you have a lot of information to act on,
1:16:39 which is in terms of
1:16:42 what we know about tissue rehabilitation,
1:16:43 both brain and body, we know that sleep is essential,
1:16:46 and so we both agreed that eight hours minimum
1:16:49 in bed per night is critical.
1:16:51 What was interesting, however,
1:16:52 is that it doesn't have to be eight hours of sleep.
1:16:55 We acknowledged that some of that time
1:16:58 might be challenging to get to sleep,
1:16:59 especially if one is in pain or mobility is limited.
1:17:03 We forget how often we roll over in bed
1:17:05 or how the conditions of our sleeping
1:17:09 can impact those injuries too.
1:17:13 Kelly acknowledged, and I agree,
1:17:14 that eight hours of sleep would be ideal,
1:17:17 but if not, at least eight hours immobile
1:17:19 and that speaks to the power of
1:17:20 these non-sleep deep rest protocols too.
1:17:22 If you can't sleep,
1:17:23 doing non-sleep deep rest protocols,
1:17:25 we've provided links to them before,
1:17:26 we're going to continue to provide links to the previous ones
1:17:29 and new ones are coming soon,
1:17:31 that is extremely beneficial.
1:17:32 That's a non-negotiable
1:17:35 in terms of getting the foundation for allowing
1:17:38 for glymphatic clearance and tissue clearance, et cetera.
1:17:41 The other is, if possible,
1:17:42 unless it's absolutely excruciating or you just can't do it,
1:17:46 a 10-minute walk per day,
1:17:47 of course you don't want to exacerbate the injury,
1:17:50 at least a 10-minute walk per day and probably longer.
1:17:53 This is where it gets interesting.
1:17:55 I was taught, I learned that when you injure yourself,
1:17:57 you're supposed to ice something.
1:17:58 You're supposed to put ice on it, but I didn't realize this,
1:18:01 but when speaking to exercise physiologists
1:18:03 and some physicians,
1:18:05 they said that the ice is really more of a placebo.
1:18:08 It numbs the environment of the injury,
1:18:12 which is not surprising,
1:18:13 and will eliminate the pain for a short while,
1:18:16 but it has some negative effects
1:18:18 that perhaps offset its use.
1:18:21 One, it sludges,
1:18:22 it creates sludging within the blood
1:18:24 and other lymphatic tissue,
1:18:25 so it actually can create some clotting and sludging
1:18:28 of the tissue and fluids,
1:18:31 the fascial interface with muscle,
1:18:34 and a number of the stuff
1:18:36 that's supposed to be flowing through there
1:18:37 can slow up and increase inflammation in the wrong way,
1:18:40 can actually restrict movement out of the injury site,
1:18:44 which is bad because you want the macrophages
1:18:47 and the other cell types phagocytosing, eating up,
1:18:51 the debris in an injury
1:18:53 and moving it out of there so that it can repair.
1:18:56 That was surprising to me which made me ask,
1:18:58 "Well, then what about heat?"
1:18:59 Well, it turns out heat is actually quite beneficial.
1:19:03 A lot of people talk about heat shock proteins
1:19:04 and all these genetic pathways and protein pathways
1:19:07 that can be activated by heat.
1:19:10 Very little data to support the idea
1:19:13 that heat shock proteins
1:19:14 are part of the wound healing process,
1:19:16 at least in terms of the sorts of conventional heat
1:19:19 that one could use like a hot water bottle
1:19:22 or a hot bath or a hot compress.
1:19:25 The major effects seem to be explained
1:19:27 by heat improving the viscosity of the tissues
1:19:31 and the clearance and the perfusion of fluid,
1:19:35 blood, lymph and other fluids,
1:19:37 out of the injury area.
1:19:38 That's really interesting. I didn't know this.
1:19:40 I thought, well, you're supposed to ice something.
1:19:42 I said, well, whenever I would see
1:19:43 a kid get injured in soccer,
1:19:45 never me, of course,
1:19:46 no, of course I got injured in soccer from time to time,
1:19:48 they give you an ice pack
1:19:49 and the ice pack removes some of the pain.
1:19:52 I think the consensus now, which was surprising to me,
1:19:55 is that the ice pack is actually
1:19:57 more of the top-down modulation.
1:19:58 You think you're doing something for the pain
1:20:01 and there's some interesting studies
1:20:02 that actually showed the placebo effect of the ice pack,
1:20:05 so ice packs are placebo, perhaps.
1:20:07 That's interesting.
1:20:08 I'll underline perhaps because who knows?
1:20:10 Maybe there's some people out there that are going to say
1:20:12 this is totally crazy
1:20:13 and the ice is actually very beneficial,
1:20:15 but it seems like heat, mobility,
1:20:18 sleep, keeping movement,
1:20:20 and it turns out that the movement itself
1:20:22 can act as a bit of an analgesic,
1:20:24 it can actually reduce the pain,
1:20:26 whereas the ice reduces the pain but sludges the tissue
1:20:29 and keeps the cells that need to be removed
1:20:33 from leaving the area.
1:20:35 What's also interesting is in neuroscience we know
1:20:39 that if we want to kill neurons or silence neurons,
1:20:42 we cool them.
1:20:43 This is a well-known tool in the laboratory.
1:20:46 Some of the early and most important studies in neuroscience
1:20:50 that formed the basis for the textbooks
1:20:52 were lowering a cooling probe
1:20:53 into a particular area of the brain or a peripheral nerve
1:20:56 in order to shut down that nerve,
1:20:57 so the cooling will shut down the nerve,
1:21:00 but another very well-known fact in neuroscience text books
1:21:04 is that when the activity of the nerve pathway
1:21:07 or neurons comes back,
1:21:08 there's what's called homeostatic plasticity,
1:21:11 that it rebounds with greater pain,
1:21:13 with a higher level of intensity,
1:21:14 which in the pain system would equate to greater pain.
1:21:17 Regardless of where these neurons are in the body,
1:21:19 if you stimulate a neuron, it's active.
1:21:22 If you cool it, it becomes inactive
1:21:24 and when the neuron heats back up after being cooled,
1:21:27 it becomes hyperactive,
1:21:28 and so this makes really good sense as to why heat,
1:21:32 provided it's not damaging levels of heat,
1:21:34 would be more beneficial for wound healing
1:21:37 and for reducing pain in the short and long run
1:21:40 than would be cold or ice,
1:21:43 which I find very interesting.
1:21:45 In terms of chronic pain,
1:21:48 the manuscripts on this,
1:21:49 my discussion with Kelly and with others,
1:21:52 point to the fact that chronic pain is basically
1:21:54 plasticity gone wrong.
1:21:56 It's sort of like PTSD for the emotional system
1:21:59 and the stress system,
1:22:00 and chronic pain is going to involve
1:22:02 a number of different protocols
1:22:04 to rewire both the brain centers
1:22:07 and the peripheral centers associated with chronic pain.
1:22:09 Certain things like fibromyalgia, for instance,
1:22:11 which is whole-body pain,
1:22:13 relate to too little inhibition.
1:22:16 In the brain, you have excitation and inhibition.
1:22:18 They come from different sources of neurons.
1:22:19 The inhibition is mainly from GABA
1:22:23 and glycine and things like that.
1:22:26 In fibromyalgia, there's too little central,
1:22:29 within the brain,
1:22:31 modulation of the pain responses
1:22:33 so that people experience whole-body pain.
1:22:36 In that case, the emerging therapies are really interesting.
1:22:39 I have a friend who works
1:22:40 for the National Institutes of Health
1:22:41 who unfortunately suffers from fibromyalgia
1:22:44 who asked me about this a lot
1:22:45 and his question and what he's now actually exploring
1:22:48 is red light therapy.
1:22:50 Something that I've talked about on various Instagram posts.
1:22:53 Red light therapy typically is talked about
1:22:55 in terms of mitochondria
1:22:56 and the data on that are not so terrific,
1:22:59 at least not really published
1:23:01 in blue ribbon journals in most cases,
1:23:03 except for one study that I'm aware of
1:23:04 from Glen Jeffery's lab at University College London
1:23:07 showing that red light stimulation to the eyes
1:23:09 in people 40 or older
1:23:11 can offset some of the effects of macular degeneration
1:23:13 by improving the health of the photo receptors.
1:23:16 People with fibromyalgia, which is this whole-body pain,
1:23:19 are now starting to use red light therapies.
1:23:23 When I asked Kelly and others and some experts in pain,
1:23:27 "What are your thoughts on this red light therapy
1:23:29 for things like fibromyalgia and pain,
1:23:32 especially red light local therapy?"
1:23:34 Their idea, and I don't think this is a field
1:23:38 that's progressed far enough now
1:23:39 to really place any firm conclusions on,
1:23:42 but the idea is that red light therapy locally
1:23:45 may have some effect,
1:23:47 but the systemic red light therapy,
1:23:49 this is like wearing protection to the eyes, in some cases,
1:23:52 so not for the treatment of macular degeneration
1:23:55 but wearing protection of the eyes
1:23:56 and getting very bright red light therapy
1:23:59 in many ways may be, and to use Kelly's words,
1:24:02 "Approximating the effects of nature."
1:24:04 These are like surrogate technologies
1:24:06 for getting outside in the sunshine.
1:24:07 When you're in the sun, it might not look red,
1:24:09 but there are a lot of red wavelengths coming toward you.
1:24:12 The red light therapies may have some utility,
1:24:14 but getting into sunlight may actually have
1:24:18 as much or more effect.
1:24:20 Of course, if these wounds are on a part of the body
1:24:21 that you can't expose,
1:24:23 then you could imagine why
1:24:24 the red light therapy might be good.
1:24:25 I don't know, depending on the neighborhood you live in,
1:24:27 that may or may not be a weird thing to go outside
1:24:29 and expose your body to sunlight.
1:24:32 Probably a number of factors that dictate
1:24:33 whether or not that'd be weird or not,
1:24:34 but that's up to you, not me,
1:24:36 and it seems that,
1:24:38 so movement, heat, not ice,
1:24:42 light, sleep,
1:24:44 and in some cases, the use,
1:24:47 and I'll talk about this in a moment,
1:24:48 that some cases the use of restricting
1:24:51 above and below the injury to then release
1:24:53 and then increase perfusion through the site
1:24:56 may actually accelerate the wound healing.
1:24:59 All of this might sound just like common sense knowledge,
1:25:02 but to me, at least as a 45-year-old,
1:25:04 I always just thought it's ice,
1:25:06 it's non-steroid anti-inflammatory drugs,
1:25:08 it's things that block prostaglandins,
1:25:10 so things like aspirin, ibuprofen, acetaminophen.
1:25:14 Those things generally work by blocking things,
1:25:17 they're called the COX prostaglandin blockers
1:25:21 and things of that sort, things in that pathway.
1:25:25 Those sorts of treatments which reduce inflammation
1:25:28 may not be so great at the beginning
1:25:29 when you want inflammation,
1:25:31 they may be important for limiting pain
1:25:33 so people can be functional at all,
1:25:35 but the things that I talked about today
1:25:37 really are anchored in three principles.
1:25:41 One is that the inflammation response is a good one.
1:25:44 This is what we're learning from Qiufu Ma's lab's
1:25:47 work on acupuncture.
1:25:48 The immediate acute inflammation response is good.
1:25:51 It calls to the site of injury
1:25:53 things that are going to clean up the injury and bad cells.
1:25:57 Then there are going to be things
1:25:58 that are going to improve perfusion,
1:26:00 like the glymphatic system, getting deep sleep,
1:26:03 feet elevated, sleeping on one side,
1:26:07 low-level Zone 2 cardio three times a week.
1:26:11 Red light, perhaps, is going to be useful
1:26:13 although sunlight might be just as good
1:26:15 depending on who you talk to,
1:26:17 and we can talk about that probably more at length
1:26:20 in a future episode.
1:26:21 A number of people will ask me, I'm sure, about stem cells
1:26:24 and I don't want to take more of your time
1:26:27 by going into an hour-long discussion about stem cells.
1:26:29 Stem cells exist in all of us during development.
1:26:31 We were created from stem cells,
1:26:33 which are cells that can become essentially anything.
1:26:36 Later, cells get what's called restricted in their lineage,
1:26:39 so a skin cell,
1:26:40 unless you do some fancy molecular gymnastics to it,
1:26:44 you can't actually turn that cell into a neuron.
1:26:47 Yamanaka won the Nobel Prize
1:26:49 for finding these Yamanaka factors
1:26:51 which you could give a skin cell to turn into a neuron,
1:26:53 but that's not an approved therapy at this time,
1:26:55 but many people ask me about platelet-rich plasma,
1:26:59 so-called PRP.
1:27:00 They take blood, they enrich for platelets,
1:27:04 and they re-inject it back into people.
1:27:06 Here's the deal. This deserves an entire episode.
1:27:10 It has never been shown whether or not the injection itself
1:27:13 is what's actually creating the effect.
1:27:16 This is something that the acupuncture literature
1:27:17 suffered from for a long time,
1:27:19 that the sham control, as it's called,
1:27:22 sham, we don't mean it's a sham,
1:27:23 but in science you say a sham control
1:27:25 meaning you do everything exactly the same way you would.
1:27:28 So for acupuncture,
1:27:30 you would bring the needle right up to the skin,
1:27:33 but you wouldn't actually poke it
1:27:34 into the skin, for instance.
1:27:36 That would be a sham control.
1:27:37 With a drug treatment,
1:27:38 you would inject a drug into a person
1:27:41 and then the control, the sham control,
1:27:43 would be that you would bring the injection over,
1:27:45 you might do the injection or not do the injection
1:27:47 'cause you imagine that the injection itself
1:27:49 could have an effect.
1:27:50 It's never really been shown whether or not PRP
1:27:52 has effects that are separate
1:27:53 from injecting a volume of fluid into a tissue.
1:27:57 The claims that PRP actually contains stem cells
1:28:00 are very, very feeble,
1:28:02 and when you look at the literature
1:28:04 and you talk to anyone expert in the stem cell field,
1:28:08 they will tell you that it's,
1:28:10 the number of stem cells in PRP is infinitesimally small.
1:28:14 In fact, so much so that these places
1:28:17 that inject PRP for injuries are not allowed to advertise
1:28:21 through the use of the words stem cells.
1:28:23 It's actually illegal at this point,
1:28:24 at least as far as I know.
1:28:26 It was through the end of last year
1:28:28 and I'm guessing it still is now.
1:28:30 Stem cells are an exciting area of technology.
1:28:32 However, there's a clinic down in Florida
1:28:35 that was shut down a couple of years ago
1:28:37 for injecting stem cells harvested from patients
1:28:41 into the eye for macular degeneration.
1:28:43 These were people that were suffering from poor vision
1:28:46 and very shortly after injecting
1:28:48 the stem cells into the eyes,
1:28:50 they went completely blind.
1:28:52 I'm somebody who is very skeptical
1:28:56 of the stem cell treatment work that's out there.
1:28:59 It's actually very hard to get
1:29:01 in the United States for this reason.
1:29:02 It's not approved. The PRP treatments are very complicated.
1:29:06 The marketing around them is
1:29:09 shaky at best.
1:29:11 I'm sure a number of people will say that they had PRP
1:29:14 and benefited from it tremendously and I don't doubt that.
1:29:17 Whether or not it was placebo,
1:29:18 today we talked a lot about top-down control,
1:29:20 that's just a variant on the word placebo, belief effects,
1:29:24 whether or not it was placebo or not, I don't know.
1:29:27 I wasn't there.
1:29:28 That's for you to decide and I'm not here to tell you
1:29:31 that you should or shouldn't do something,
1:29:32 but I do think that anything involving stem cells,
1:29:34 one should be very cautious of.
1:29:36 You should also be very cautious of anyone that tells you
1:29:38 that PRP is injecting a lot of stem cells.
1:29:41 This is an evolving area that really needs
1:29:43 a lot more work and attention.
1:29:45 The major issue with stem cells that I think is concerning
1:29:49 is that stem cells are cells
1:29:52 that want to become lots of different things,
1:29:54 not just the tissue that you're interested in.
1:29:56 If you damage your knee
1:29:57 and you inject stem cells into your knee,
1:30:00 you need to molecularly restrict those stem cells
1:30:02 so that they don't become tumor cells.
1:30:05 A tumor is a collection of stem cells.
1:30:08 When you get something horrible
1:30:10 like glioblastoma in the brain,
1:30:11 which is a terrible thing to have,
1:30:14 it's glial cells that returned
1:30:17 to stemness, excessive stemness,
1:30:19 they've started to produce too many of themselves,
1:30:21 and glioblastoma is often deadly, not always.
1:30:25 Injecting stem cells, it sounds great,
1:30:27 and it sounds like something that one would want to do,
1:30:29 but one needs to approach this with extreme caution,
1:30:33 even if it's your own blood
1:30:35 or stem cells that you're re-injecting.
1:30:37 I think those technologies are coming. They're on the way.
1:30:41 If any of you are devotees of PRP,
1:30:44 tell me your experiences with them.
1:30:46 I'm curious. I want to see the papers.
1:30:48 I want to know the evidence,
1:30:49 and of course, there are always folks out there that say,
1:30:51 "I don't care what the scientists
1:30:52 and the physicians and the FDA say.
1:30:55 I just want to do this,"
1:30:56 and if that's your stance, that's your stance.
1:30:58 I'm not here to govern that,
1:31:00 but I do think that people should be informed,
1:31:02 and in thinking about tissue recovery and injury,
1:31:06 that's what I was able to glean.
1:31:08 Again, check out what Kelly
1:31:10 and his coworkers are doing at The Ready State.
1:31:13 It's phenomenal and they've worked with all the top people
1:31:16 in just about every domain of life, it seems.
1:31:18 Very high-integrity folks.
1:31:21 Some of you are probably saying, "Well, I'm not injured.
1:31:23 I'm not an athlete. I don't want stem cell injections.
1:31:25 I don't have," again,
1:31:26 I'm saying you shouldn't get stem cell injections for now.
1:31:29 Please hold off until the field learns more
1:31:31 about how to do that safely,
1:31:33 but I want to talk about
1:31:35 and end with a really interesting
1:31:38 and somewhat weird technology,
1:31:40 which is baby blood.
1:31:43 I have a colleague at Stanford,
1:31:44 his name is Tony Wyss-Coray,
1:31:46 and in 2014 his laboratory published a study
1:31:50 showing that the blood of young rodents,
1:31:54 mice and rats,
1:31:56 when transfused into old, demented rodents,
1:32:00 mice and rats,
1:32:01 made those old, demented rodents
1:32:04 recover much of their memory and seem much more
1:32:09 vital and energetic,
1:32:11 better recall of different spatial learning tasks.
1:32:16 Tissue and wound healing, they've since shown,
1:32:19 can be improved in these older animals.
1:32:22 It's pretty incredible.
1:32:24 They went on to show several years later
1:32:26 that blood from umbilical cords,
1:32:30 I'm not making this up,
1:32:31 blood from umbilical cords can do the same
1:32:35 and this is the basis of a biotech company.
1:32:37 Actually, one of my former postdocs
1:32:39 is now an employee there.
1:32:41 They've isolated the molecules from young blood
1:32:46 that seems to vitalize
1:32:48 or revitalize the old brain and body,
1:32:52 and one of those molecules goes by the name TIMP2.
1:32:55 T-I-M-P-2.
1:32:58 Where's all this going?
1:32:59 Well, I don't know how long it's going to be
1:33:03 before there are treatments based on
1:33:05 these blood transfusions.
1:33:07 I doubt that blood transfusions themselves
1:33:11 from young people into old people
1:33:13 is going to be used for the treatment of dementia,
1:33:16 although it might, as weird as it seems.
1:33:19 We know that transfusions of all sorts of stuff,
1:33:22 for instance, fecal transplants
1:33:24 are being used to treat obesity.
1:33:25 The gut microbiome of thin people is being,
1:33:30 not transfused, but is being transplanted
1:33:33 into the colons and guts of obese people
1:33:36 and leading to weight loss,
1:33:37 which sounds really wild
1:33:39 and is not a topic I particularly enjoy talking about,
1:33:42 but nonetheless, it points to the importance
1:33:45 of the gut microbiome in regulating things
1:33:47 like blood sugar and health
1:33:50 as it relates to obesity and diabetes
1:33:52 and all sorts of things.
1:33:55 It does appear that there are things,
1:33:57 factors in the blood of young members
1:34:00 of a given species that are lost over time
1:34:03 in the older members of that species.
1:34:06 I'm not going to give you a tool
1:34:08 on the basis of these findings today.
1:34:10 I am not going to tell you to consume any fluid
1:34:14 from any other member of your species,
1:34:18 our species, for any reason,
1:34:21 but I do think that it's important to mention
1:34:23 that the science is asking questions
1:34:27 such as what are the factors within the brain
1:34:31 that allow the young brain to recover so much better
1:34:34 than the older brain from injury,
1:34:37 from all sorts of things, events, et cetera,
1:34:40 and what are the factors in the older brain
1:34:43 that are limiting,
1:34:45 and thinking about identifying which factors
1:34:49 are going to allow people to restore cognitive function,
1:34:53 physical function, wound healing and so forth.
1:34:56 It's a really exciting area.
1:34:57 I mention it not to be sensationalist
1:35:00 but because it's happening
1:35:02 and because there's a lot of excitement about it
1:35:05 and because I think it's clear
1:35:08 that the young brain and body and blood
1:35:12 are very different from the old brain, body and blood,
1:35:16 and the goal of science is to identify
1:35:18 and isolate those factors that make that so,
1:35:23 such that people who would otherwise get dementia
1:35:27 or perhaps even have dementia will be allowed to recover.
1:35:31 Again, not an actionable item at this point,
1:35:34 but one to think about, perhaps not too long,
1:35:38 but one to think about.
1:35:41 I'm going to close there.
1:35:42 I've talked about a lot of tools today.
1:35:45 I've talked a lot about somatosensation,
1:35:48 about plasticity, about pain, about acupuncture,
1:35:51 some of the nuance of acupuncture, inflammation and stress.
1:35:55 We even talked a little bit about high-intensity breathing,
1:35:59 talked about restricting limb movement
1:36:01 to get compensatory regrowth of pathways,
1:36:05 or I should say reactivation of pathways
1:36:08 that have been injured or damaged.
1:36:09 As always,
1:36:10 we take a whirlwind tour through a given topic,
1:36:15 lay down some tools as we go.
1:36:18 Hopefully the principles that relate to pain and injury
1:36:22 but also neuroplasticity in general,
1:36:24 today in the context of the somatosensory system,
1:36:26 will be of use to all of you.
1:36:28 I don't wish injury on any of you,
1:36:31 but I do hope that you'll take this information to mind
1:36:34 and that you will think about it
1:36:35 if ever you find yourself in a situation
1:36:38 where you have to ask
1:36:39 what's the difference between my perception
1:36:41 and the actual tissue damage?
1:36:43 Is injury and pain, is it the same?
1:36:45 Well, no.
1:36:45 Do I have some control over my experience of pain?
1:36:48 Absolutely.
1:36:49 Does all of that involve taking drugs
1:36:51 or doing certain therapeutics?
1:36:53 No, not necessarily.
1:36:54 There's the incredible subjective component.
1:36:56 There also is a need sometimes
1:36:59 to treat the injury at the level of the pain receptors
1:37:03 at the site of the wound,
1:37:05 so please take the information, do with it what you will,
1:37:09 and in the meantime,
1:37:11 thank you so much for your time and attention.
1:37:13 Before we go, I just want to remind you
1:37:15 to please subscribe to the YouTube channel,
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1:37:29 and as well,
1:37:31 if you're interested in the supplements that I take
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1:37:47 Once again,
1:37:48 thanks so much for your time and attention today,
1:37:50 and as always, thank you for your interest in science.
1:37:54 [relaxing rock music]