Welcome back to the Healing Pain Podcast with Professor Ömer Elma, PT

We are discussing nutrition and chronic musculoskeletal pain. This episode is an update because if you went into PubMed and looked for a systematic review or a meta-analysis on how diet and nutrition influence or impact chronic musculoskeletal pain, you would have only found one review. I’m excited to introduce you to a researcher who is also a physiotherapist who has completed the second systematic review. It was available in the March 2020 Journal of Clinical Medicine. It’s an open access paper. The title of that review is Do Nutritional Factors Interact with Chronic Musculoskeletal Pain? A Systematic Review.

My expert guest is Omer Elma. He has been a physiotherapist since 2014 and he is pursuing his PhD with the Pain In Motion research group with a focus on the link between chronic musculoskeletal pain and nutrition. We’ll discuss the findings of his systematic review that investigated the interaction between nutrition and chronic musculoskeletal pain. The mechanisms of action between nutrition and pain, how diet and nutrition interact with central pain processing mechanisms. The role of the gut microbiome and its interaction between nutrition and pain. Finally, how nutritional factors affect the sensitization of the central nervous system. Let’s meet Omer Elma and look at how nutrition factors influence musculoskeletal pain.

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An Update On Nutrition And Chronic Musculoskeletal Pain With Ömer Elma

Omer, thanks for joining me on the show.

Thank you for giving me an opportunity to participate and to have a conversation with you.

It’s a topic that everyone who follows the show is interested in. It’s a topic that more integrative practitioners and physical therapists are interested in. Before we start to talk about nutrition, tell us about your current work. Give us the broad overview of who you are and what you’re doing?

I’m a physiotherapist and I have a physiotherapy background. I’ll tell about the history of my coming to this PhD position. After my graduation, I mostly worked in orthopedic rehabilitation field. It was for two years and during these two years, although I was not structurally aware of biopsychosocial approach, I was trying to share about patients’ psychological education because my sister is a psychologist and we were always having talks about health psychology. I was reading her books of alternate contexts. I noticed that implementing psychology science in pain management type has these positive effects on treatment outcomes of patients. With this experience, I started my Master’s program at the University of Nottingham and it was on advanced neuromusculoskeletal practice.

In there, I had more opportunities to learn and expand my knowledge on various components of chronic pain, including social factors and lifestyle factors. During these times, I met with Pain In Motion international research group. With the help with my talks and discussions with Professor Jo Nijs, I realized how less attention has been given to the nutrition as a lifestyle factor. I have decided to study the link between nutrition and chronic musculoskeletal pain. This is why I’m here and I started to work here at Vrije Universiteit Brussel in Belgium. We have nutrition and pain research group here. We are doing our research on mainly two group of patients, chronic musculoskeletal pain patients and breast cancer survivors who has chronic pain. My field is chronic musculoskeletal pain. In the publications of our works, we were aiming to bring together and to give an overview of the available literature to raise awareness about this topic and to share our ideas with the scientific community and the clinicians.

As a physiotherapist in the United States, nutrition is more a part of our graduate training and the doctor of physical therapy programs, both as far as health, wellness and promotion. More and more, nutrition is becoming another modality we use like therapeutic exercise or pain science education. Nutrition is being elevated to that level in our profession. It’s great to see a physiotherapist and a researcher like yourself help us make the connections that we’re seeing in clinical practice, and help us prove what those connections are, so it becomes valid for our practice. You did a systematic review that investigated the interaction between nutrition and chronic muscle skeletal pain. Can you give us some of the highlights of what you found in that systematic review?

Our first step in our research line with pain and nutrition in this review, we were mainly aiming to see how dietary patterns of patients and components of their diet interact and link with their pain. Therefore, we include both observational and experimental studies. One important point here as a nutritional factor, we investigated overall diets and dietary patterns instead of focusing on single nutrient intakes because this is also in the literature. It’s suggested as a more natural way of searching nutritional factors. In this way, it was possible to take into account synergistic effect of nutrients that are consumed together. At the end of review process, we ended up with twelve studies and nine of them were experimental and three were observational.

Seven out of nine of these experimental studies reported improvements in chronic pain. They were saying like, “Dietary change can affect chronic pain.” These positive pain-reducing diets included vegan diets for fibromyalgia and rheumatoid arthritis patients, weight-loss calorie-restricted diet for osteoarthritis patients, vegetarian diet for general musculoskeletal pain, FODMAP diet for fibromyalgia, and peptide diet for rheumatoid arthritis. This type of diets has effects on these patients. From the observational studies, the evidence is weak because it’s not easy to research nutrition observationally and to have scientifically strong evidence.

I can mention that rheumatoid arthritis patients show insufficient intake of some micronutrients such as calcium, folate, zinc, magnesium and vitamin B6. Fibromyalgia patients show lower intake of carbohydrates, proteins, lipids, vitamin A, E, K, and these kinds of micronutrients. The last thing I can say from the observational studies is relationship associated between pain severity and the intake of some nutrients. They reported that pain severity is positively associated with fat and sugar intake in chronic osteoarthritis patients’ pain. The pain threshold is associated with protein intake. These were the main things that I can mention here.

That right there is a lot for us to discuss and unpack. You mentioned that you looked at different types of overall diet changes. Taking someone who was on their standard everyday diet and then changing their dietary pattern toward a vegetarian diet or a vegan diet or FODMAP diet. They looked at different types of diets. One thing that you said, which was important and we haven’t gone into detail much on this show, I want to bring it to light here a little bit, is that nutrition and pain studies are difficult to conduct. They’re very difficult to do in a way that has a lot of power behind them. Can you explain to us why that is and potentially why we’re not seeing as many studies on nutrition and pain?

This is something I experienced when I start collecting data and when I start to read articles because human body by itself is complex. We are talking about the chronic pain. It is more complex than we know. Nutrition research is difficult because nutritional factors can have many interactions with many factors. We don’t know what the result exactly because of the nutritional intake or dietary change or something else, because we don’t know also the interaction mechanisms or what is happening in the human body. It’s not easy to figure out what is happening there. The diet itself, there are many factors that can affect your results and you cannot control this results in your laboratory or in your study. From my point of view, this is one of the most important things that we need to like deal when we conduct the research in nutrition.

When I looked through the literature on nutrition and chronic pain specifically, one of the things that always strikes me is that often, there’s the lack of a control group. If that right there was taken toward more diligently, we’d have some better information. Certain practitioners would feel more confident in using nutrition in their practice. You mentioned the idea of nutritional factors not affecting one process in our body, but affecting multiple at the same time. There can be pros and cons to that. The pro to it could be that it could influence pain positively, and it could also influence cardiovascular disease positively. There are two sides of the coin to that as well. Talk to us about the mechanisms behind what you discovered with regard to the interaction between nutrition and pain. Specifically, we’re looking at pain processing mechanisms. What did your research discover?

The one thing that I have learned doing my readings in nutrition research is it’s difficult to identify the exact mechanism of action. However, if we bring together relevant research and some dominance underlying mechanisms, it can maybe help us to explain the association interaction between pain and nutritional factors. In our systematic review, when we consider the findings and the way that their theories and among studies that we found positive effect, the main point is, and we can collect under a broad term, is healthy eating. Most of the effective diets like plant-based diets such as vegan and vegetarian diets compared to omnivorous diet have higher scores on Healthy Eating Index. In these kinds of indexes, we get how they are healthy or less healthy than the omnivorous style.

If we analyze the components of these plant-based diets, studies show more nutritional sufficiency and the amount of nutritional intake is more in line with recommended daily intake compared to omnivorous diet. If we go more specific and more in depth, one of the most important impact of dietary intakes is their effect on neuro-immune system or neuro-immune activation. Another index that we can use to see this association is Dietary Inflammatory Index. This index is used to measure the inflammatory potential of specific foods or dietary patterns. From this point of view, we see that plant-based diets are more pro-inflammatory. They have a relieving effect on systemic inflammation, which can lead to pain-relieving as well because chronic level inflammation is suggested one of the underlying because of chronic musculoskeletal pain conditions including lower back pain, fibromyalgia, etc.

Therefore, their effect on chronic musculoskeletal pain might arise from their pro-inflammatory characteristics. Lastly, calorie-restricted diets were also suggested as effective on osteoarthritis pain. I know there are also conflict on this type of diet. It’s not clear how this type of diet act on pain because all the patients show significant weight loss. Therefore, the impact of this type of diet can be explained by its effects on weight loss. On the other hand, the neuro-immune system can play a major role because it’s associated with increased several inflammatory biomarkers. Therefore, decreasing adipose tissue especially in fat mass can result in decreased systemic inflammatory biomarkers and inflammatory responses. This will lead to pain-relief in this type of patients. These are healthy eating, neuro-immune activation, and weight loss by itself. It depends with the patient because then the mechanism change.

The neuro-immune part speaks to practitioners who are interested in treating chronic pain. We know that pain is a function of the nervous system that makes the green lights blink on and off. You mentioned weight loss. We think about pressure on joints, especially the weight-bearing joints, although you’re taking a step further, which I appreciate. You are saying that if there’s a decrease specifically in visceral adipose tissue, that leads to a change in inflammatory biomarkers that can be measured in basic blood work. If we take that one step further and the microbiome is on the tip of everyone’s tongue, when we’re talking about nutrition, what did your research tell you about the gut microbiome with regard to certain chronic pain conditions like fibromyalgia or rheumatoid arthritis?

This was also mechanism of action of diets that can affect pain. It was related within neuro-immune activation that’s why I didn’t mention it specifically. There’s evidence that there is a bi-directional relationship between a central nervous system and gut microbiota. The microbiome, which is called gut central nervous system axis. Patients with chronic musculoskeletal pain, for instance, fibromyalgia can have alteration in their microbiome. Alteration in the gut microbiome can cause systemic inflammation in the brain and inflammation in the central nervous system, which can contribute to pain chronification and amplification also. We know that dietary intake can affect gut health. Therefore, chronic pain patients’ gut microbiome can be a therapeutic target as well.

From this point of view, it is reported that compared to omnivorous or Western-style diet, plant-based diets such as vegetarian, vegan and vegetarian diets play an important role in protecting the stability and diversity of gut microbiome. The reason behind this interaction, when we also see the literature, between plant-based diets and the healthy gut microbiome is the high proportion of some specific nutrients that have positive effects on gut health such as high amounts of dietary fiber, polyunsaturated fatty acids, plant proteins, and polyphenols. Therefore, the application of more plant-based diet might alleviate chronic musculoskeletal pain by the positive effect on gut microbiome and eventually on systemic and central inflammation.

The microbiome has an immediate impact on the function of your nervous system because there’s a bi-directional relationship between your microbiome and your central nervous system?

From the readings, what we understand is there is a bi-directional relation. You can have negative effects with your poor diets or the other lifestyle factors. You can have positive effects and have more health with microbiome, and you can have a positive effect on your nervous system.

It’s important because we’re seeing a lot of changes in the literature with regard to looking at the microbiome with many different types of chronic diseases that are either primary or secondary to people living with chronic pain.

This is the new approach in the pain field. That’s why day-by-day with readings, we see microbiome is a second brain. I don’t know how correct it is but it’s considered as an important place to investigate and find out the more comprehensive approach to the chronic pain.

I appreciate that because as physical therapists, if we go back a couple of decades, we would say, “Our way to influence the nervous system with someone who’s living in chronic pain is through exercise or potentially manual therapy.” Over time, as we’ve noticed the psychosocial factors become more important, then we’re looking at things like top-down mechanisms where we have educational interventions, psychoeducation interventions or psychotherapeutic interventions. What you’re saying is the research is pointing strongly to a third way, this second brain that through diet changes, we can influence and modulating the nervous system.

When you say this, it reminds me of a story. Once a scientist attended at Congress. They asked the professor who is into brain field, “What is the proportion that you can say how much of the brain that we know?” He said 5% or 30%. The next year when he was asked the same question, he said, “We know 1%.” How it decreased? As much as we learn, we learn how we know less in this field. For me, it was the same. When I start doing research on pain, I was thinking, “I will memorize the physiology of neuro-anatomy of the pain and know some ways like manual therapy and some therapeutic agents, then it’s okay. I will do it and finish.” As much as I read, I learn how it is complex. We are not aware of the things that we don’t know. Day-by-day we will see how it is connected with other factors that even we don’t know. Science is like this tubular case.

As a physiotherapist, how has your investigation into nutrition changed your perspective on how we can help people with pain?

I don’t know in the US or in another country how physiotherapists did rise in the clinical practice. I’m from Turkey and there, we cannot touch patients for manual therapy without permission of the doctor. Patients ask for something like a drug to change their life. It’s not just show exercises and do some electric therapy and send them home. I find a way to touch their life. This is something important for me. Nutrition is not only the pain that you start with. It’s also the quality of their life. This is also two ways intervention. You will manage pain. It will be preventative rehabilitation for the next maybe problems that you run into. I find a therapeutic intervention that I can use in the clinic.

Nutrition is a powerful contextual change agent. That’s the way I look at it. If we want to change the context of someone’s life and move them toward a life of cultivating pain versus a life of moving beyond their pain, nutrition is a powerful way to cultivate and change that context for people. It nourishes your body, but a lot of ways it nourishes your soul. It affects your social connections. It affects many aspects of how we live as humans. I’m also wondering how has your diet changed since you’ve been studying nutrition? Have you explored more? Have you experimented more? Have you looked back and said, “I’ve been eating things I may not should have been eating,” and made some positive changes? Has it been helpful for your behavior change?

There is a saying, “Do what I say but don’t do what I do is.” I’m a Turkish and I like to eat food. Now I know how unhealthy I am feeding myself, but before I was not aware of it. Day by day, I’m trying to change also my diet because now maybe we don’t have any pain, we don’t have any problem, but it doesn’t mean that we will haven’t in the future. I’m trying to change but it’s not easy. This is a nice experience. We are saying using nutrition as a therapeutic target in the clinical practice, but we know it’s not easy to change habits of people. I will also keep this in mind to find more effective ways. When I learn a type of diet, I’m trying in my life to see the effects and to see what are the difficulties in this type of diet. For example, if I start to work with depressions, I achieve these whole experiences in my mind and then try to give from this line to make it more applicable and more doable for them. In my life, it’s not changing. I need to be honest here.

I always tell physical therapists who explore nutrition and ask me questions, “Think back to when you were in physical therapy school. You tried every exercise and you tried every joint mobilization on yourself as well as on other people. It’s the same with nutrition. When you learn a little bit about it, you have a foundation based on knowledge. Maybe you start making some small changes on your own, try different diets, try certain supplements, see how they work on yourself, and then you gain a little bit more confidence to use it with other people.” You mentioned plant-based diet a number of times. I want to come back to that because the word plant-based means a lot of different things to a lot of different people. Plant-based can encompass many different diets.

When we say plant-based, it is a group of diets. You can put many types of diets in this plant-based diet. I was trying to collect them on the broad term to make it easier to understand. If we go more specific like for example, if we say Mediterranean diet, it doesn’t mean one kind of that. Also, when I research vegan diets, there are always some changes. It’s not the same vegan diet in the research. For me also, after our systematic review, we were willing to conduct or meta-analyze but with the results, it was not possible because the nutrition is not the same for all. Even if it’s a vegan diet, it’s not the same vegan diet. There is more heterogeneity in the same term.

A plant-based diet means the base of your diet or the majority of your diet is plant food. For instance, there are many different types of Mediterranean diet ad there are many different types of Mediterranean cultures. Even in the US, our nutritional associations have tried to adopt the DASH diet, which is similar to a Mediterranean diet with less of a cultural context to it. That doesn’t necessarily mean that it’s a meat free diet.

How you cook it and the type of meat changed. It changes the healthy characteristics of your diet. It doesn’t mean it’s a meat-free diet.

I always encourage people as they are reading this episode, and this is for researchers, clinicians, as well as for people who are interested in helping soothe their pain with nutrition. It’s that nutrition changes throughout your life. Your nutritional needs may change as you exercise. Your nutritional needs may change as you develop a condition or as you overcome a condition. Your nutritional needs may change as you age as well. They’re all good topics to talk about it. They all point back to that plant-based diet. Within that plant-based diet, it’s not constrained. There’s flexibility there to make changes that are right for you in a form of personalized medicine for your body. It’s been wonderful chatting with you. Tell us what’s next in your line of work with regards to nutrition and research?

As much as I read, I learn how we have a long way on the road. This is just the first step that we revealed some articles and publications to bring together these ideas. First of all, we want to influence and give inspiration to the researchers to collaborate and to clinicians to think about implementing nutrition in their clinical practice. This is the main idea of doing research for me. Maybe, someone can say something different but for me, this is what we do. Once, I read a paper and it says, “It takes ten years for scientific knowledge to transmit into the practice.” This is a long time. Thanks to you and with these episodes, maybe we will give this time to start to practice in the clinical practice. What we do is we are preparing some experimental research that we are interested in. For example, blood glucose levels, prediabetics, diabetics and the glycemic response, and their relation with the pain. These are the ideas we have in mind and we are working on it. I hope that we will share with the community these findings soon.

We appreciate your work and you making these connections for us so we can understand how nutrition has an impact on the central nervous system, on the microbiome, on central processing mechanisms with regard to chronic pain. Omer, it’s been a pleasure chatting with you. Let us know how we can learn more information and follow your work.

You can follow the publication from ResearchGate. I’m a member Pain In Motion international research group. You can follow me from there.

I want to thank Omer for being on the show discussing nutrition and chronic musculoskeletal pain. You can learn more about him by searching on ResearchGate under his name, Omer Elma. You can go to the Pain in Motion group, and you can find him at www.PainInMotion.be.

Important Links:

• Omer Elma – LinkedIn
• ResearchGate
• Do Nutritional Factors Interact with Chronic Musculoskeletal Pain? A Systematic Review
• http://www.PainInMotion.be/
• https://www.NCBI.nlm.nih.gov/pmc/articles/PMC7141322/
• https://www.TAndFOnline.com/doi/abs/10.1080/14728222.2020.1784142?journalCode=iett20

About Ömer Elma, PT

Omer Elma is a Physiotherapist, graduated from Abant Izzet Baysal University, Turkey in 2014. He did his master at the University of Nottingham, England. He is a PhD researcher at the Vrije Universiteit Brussel since 2018. He is also a member of “Pain in Motion” international research group. His research focus is “the link between chronic musculoskeletal pain and nutrition”.