Welcome back to the Healing Pain Podcast with Rowena Field, PhD, M. Physio

In this episode, we are discussing the latest evidence which supports the use of a ketogenic diet and its potential impact on pain and central nervous system sensitization. My guest is Dr. Rowena Field. She is a physiotherapist with many years of experience, primarily in chronic pain management. We discussed the results of her recent PhD dissertation, where she investigated the use of a ketogenic diet for the treatment of chronic pain and now incorporates this approach in her physiotherapy practice.

We will discuss how a ketogenic diet impacts pain, blood biomarkers, and quality of life for patients with chronic pain and other chronic health conditions. This is sponsored by the Functional Nutrition for Chronic Pain Practitioner Certification. In this training, you will learn how to apply diet and nutrition for multiple chronic pain syndromes, including how to use a ketogenic diet for the treatment of chronic pain. Without further ado, let’s begin. Let’s meet Dr. Rowena Field and learn about how a ketogenetic diet impacts chronic pain

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Ketogenic Diet: How It Improves Pain And Central Sensitization With Rowena Field, PhD, M. Physio

Dr. Rowena, thanks for joining me on the show. It’s great to be here.

Thank you for having me.

Nutrition is something we are very interested in on this show. There are all sorts of different dietary plans, dietary habits, healthy eating patterns, mechanisms, and inflammatory markers. All that is not necessarily new to people except for what you are going to talk about. That’s why I’m excited to chat with you because you’ve done a lot of research on the ketogenic diet and pain. For people who know me and my work, I’m excited to talk to you because when I wrote my first book back in 2014, I put a chapter on the ketogenic diet.

It was very new at that time. Although, the research was there. It has been done a long time ago but you brought this together through your PhD programs. That’s why I’m excited because your work is meaningful to the world of nutrition, to PT, and to people with pain. You have got a great intersection of lots of different things going on. I’m excited for you. Tell us how a PT becomes interested in nutrition first.

It’s a little bit like most things. It’s a lived experience thing. I always struggled with my weight as a teenager. I did every diet out there and exercised to a whole heap of trying to keep my weight under control and all the rest of it. Somewhere along the line, I came across low carbohydrate and ketogenic diets. I went down that rabbit hole a little bit and learned about them. I was fascinated with some of the talks around mechanisms and particularly around how epilepsy is managed with ketogenic diets and things like that. That’s what fascinated me from a mechanistic perspective.

I then started to scratch my head a little bit when I’m sitting in some pain conferences and things, hearing people talking about those same mechanisms that were targeting drugs or different things to try and alter. I’m sitting there thinking, “You should talk to each other because it’s an interesting crossover here. We could be working on a diet for people with pain instead of just giving them lots of medication. Let’s have a look at the literature and see what’s there.” Funny enough, there isn’t very much there at all about that. Hence, I’ve got involved in doing a PhD and finished that. That was great to do some trials around that topic and add to the literature in that area.

I’m excited that physio pursued that work because it fits perfectly with our approach to pain because we understand the mechanisms better than other professionals do. Even though people may understand the diet aspect more, physios understand a lot of the neurophysiology and what’s happening. It is interesting because you mentioned epilepsy. That’s where the strongest research base sits for a ketogenic diet but there are some similarities with regard to epilepsy and pain a little bit.

Epilepsy is obviously a situation where the nervous system has become so excitable that fatal or a seizure. If you think about what chronic pain is, in terms of it being a sensitization of the nervous system, it is somewhere along that spectrum. That was one of the things that piqued my interest back at the start. When I was looking at a lot of the clients that we have on all sorts of medications, a lot of them are anti-seizure and antiepileptic drugs. I think, “That’s an interesting sort of crossover as well.” It was trying to target that sensitivity component of the nervous system. Yet, again, we have got a diet that could be doing something quite effectively when you look at the literature for epilepsy and what’s the link there.

At the same time, I was watching a lot of different forums and things that I was involved with that were using low-carb and ketogenic diets. That would be all approaching the diet because they were wanting to manage their diabetes, lose weight or whatever it might be. There were always these offhand comments about, “This shoulder pain that I have had for nine months seems to have gone away.” That equals one reporting that interested me. There is something with time management here that we could be harnessing as part of our overall strategy for looking after people with chronic pain.

You are talking about the gabapentinoid-type of medications and Neurontin. People might know them. We have people taking these medications. Oftentimes, those are prescribed as the first line of care for patients. I have lots of patients who are on gabapentin and would love to get off it because it has become quite difficult to get off it. You are looking and saying, “There’s this dietary approach that has similar mechanisms. The way this pharmaceutical is working and potentially with less side effects.”

That’s the real benefit without the little nasty side effects that go along with it, other than, maybe they might lose a little bit of weight or improve their depression and things already. There are all good reasons why that should be offered to somebody as an option in pain management rather than prescribing more medications.

I know your PhD did not go into other types of conditions. You have already mentioned seizures. I know you’ve done a lot of reading on the literature because some of these mechanisms overlap with other conditions. Other than epilepsy, what other conditions are we interested in, let’s say, with regard to a ketogenic diet? There’s research building in other areas besides pain.

One of the pre-studies that I had to do as part of my PhD was doing a review. We did one looking at animal models for trying to tease out all the different mechanisms but we also did another whole huge scoping review looking at all of the different ketogenic and low-carb research that is out there. I went into this not trying to focus on the things that I was interested in in terms of neurological outcomes because I wanted to get a bit of an idea about what is the actual breadth of research that is out there. That’s one of the criticisms that often comes up. There’s no research about the ketogenic diet to back that up.

We went in and reviewed every reported trial that used a ketogenic diet, which we classed as below 130 grams of carbohydrate per day. We also compared that below 50 grams a day. We could talk about both low carb and ketogenic diets in there. There were 846 studies that were reported. It had to be longer than two weeks as well. It wasn’t just a couple of dieting. We are talking about an actual dietary change for a reasonable length of time. Out of those, there were 64 trials that were neurological outcomes and 63 trial settings that talked about inflammatory markers. There were 500 odd trials in all other areas, which include various metabolic health conditions, sport, cancer, general health with some of those, and gastrointestinal things.

There was quite a large body of literature there to look back at and that’s what we did as part of trying to have a look because we were interested in inflammation because inflammation is something that’s relevant from a chronic pain perspective. There might have been a study in the metabolic health arena that was looking at inflammation but we wouldn’t have captured it if we had only been looking at neurological outcomes.

We did these two screens. There’s a stack of research out there supporting the outcomes. For example, from the 64 human trials that we are looking at neurological outcomes, 83% of them showed improvement. For the 63 trials doing inflammatory markers, 71% showed reduced inflammation. Those are pretty good outcomes when you look at the body of research.

When you are online because I’m sure you probably spend a little bit of time online, as we all do, and people say, “This is a fad diet. There’s no research to back up going on a low-carbohydrate or a high-fat ketogenic diet.” What goes through your mind?

I would like to get in there and start talking but I’m a bit of a chicken. I don’t want to be too controversial with social media and get myself into any sort of trouble but it does frustrate me. That was one of the reasons why we did this review. It’s in its 2nd review now in 1 of the journals, so it looks like there weren’t any too many dramas with it. I’m hopeful that we will be shortly published with them as well. That will be out there showing all the different research. For the appendix of that article, I listed all of those trials so that nobody else has to go and look, “You can look at a great big long list of 850-odd ketogenic or low-carbohydrate trials in the various different areas that you might be interested in.”

Thank you for doing that work. I realized that work is deep work and it takes time. We appreciate that. Someone can now access and use that for the future. Fast forward to this important aspect of nutrition, there’s another thing that’s come up in the literature that has been building. That’s the idea of conceptualizing chronic pain almost like a neurodegenerative condition and running side by side. When we are talking about the ketogenic diet, there are some research and discussion around using ketosis for Alzheimer’s, dementia, and Parkinson’s. What perks up when I bring up those topics of neurogenic conditions?

One of the systematic reviews that we do is we looked at all of the neurological outcomes.

I believe there is a randomized controlled trial on Parkinson’s and the ketogenic diet.

There’s quite a bit of research out there in that area. The problem with a lot of those trials is it’s very difficult if you are looking at a Parkinson’s model or something to it. I have those people being able to or capable of managing diet and things like that. There’s a little bit more in the exogenous ketones space there as well but mechanistically, it’s the same concept. There’s a lot of supporting research starting to build in that area as well.

When we are talking about these low to lower carbohydrate ketogenic diets, you mentioned below 130 grams to 50 grams of carbohydrates or somewhere in that range. We lower the carbohydrates. It seems easy. We know that potentially that’s not because of some behavioral changes.

People love their bread.

What are the mechanisms that you have discovered, the more salient mechanisms when you are talking maybe to a physio and say, “I’m interested in this concept of ketosis and pain?” How does it impact someone’s chronic pain or the pain mechanisms?

This isn’t settled science with this sort of stuff. There is still a lot of extrapolation from the animal-based studies. We did a paper looking at all the mechanisms from mouse model studies. There are problems with some of that research but there’s quite a long list of potential mechanisms that are being affected by a ketogenic diet. If you think about what you are doing when you lower the carbohydrate, you are doing two things at once. You are not only reducing the dietary glucose that’s coming in. You potentially may or may not be increasing the dietary fat that’s going in. The one thing we haven’t talked about yet is when I’m talking about a low-carbohydrate or a ketogenic diet, I’m talking about a well-formulated one.

This is one that’s a nutrient-replete diet. We are not just talking about only eating bacon and eggs, which theoretically could be a ketogenic diet but it’s probably not going to cover all your nutrient basis that you need to be eating. Not only are we reducing the glucose and maybe changing the fat up a little bit but we are also providing nutrients, potentially reducing anti-nutrients and oxidative stress things that we are taking in through our food as well. If we look at what we are doing, when we are reducing the dietary glucose, what happens is the system then has to switch over and use fat as a fuel source instead. Once the fat is metabolized in the body, it’s broken down into free fatty acids and ketones, which is where we get the ketogenic diet from.

The beauty of ketones is not only are they a very efficient energy source for the body as the same as glucose is used by the cells, ketones are used by the cells the same way but it’s also a potent signaling molecule. It acts a little bit like a hormone that is floating around the body and it has a target action of various cells. They are the things that we pick up for years when we are trying to think about, “How’s this potentially affecting pain physiology?” One of the first things that it’s doing is that we know that ketones have an effect on nervous system sensitivity. We have already talked about that a little bit in the epilepsy side of things but if you think about how our nervous system works, we have to have a dynamic range of excitability.

That’s not only within the nerve but also between nerves and within networks. When we are thinking about what’s going on with chronic pain, there is some increasing neuronal excitability or sensitization in the nervous system. We have got this chronic situation where membrane potentials are potentially on the edges of where the normal homeostatic range would be. We have already talked about the drugs that try and target that in epilepsy to try and bring that down but we also know that ketones will do that as well because we have seen the epilepsy model that ketones will quite successfully mitigate seizures.

We think that’s potentially got something to do with the GABA, the glutamate ratio. Potentially, how the glutamate is taken back up into the vesicle that gets inhibited in some way or maybe there’s less released, or the GABA resynthesis has improved. They are all theoretical things coming from the animal models but we know something is going on in that respect. There are also potential changes in the G protein receptors and the ion channels.

Also, ATP production is potentially changed. If we’ve got better energy provision to the cell, that’s going to help the nervous system that is roving a little bit higher than it probably should be. When ATP is broken down to adenosine, it also affects cells in different ways and that tends to help with the regulation of membrane potential and lots to pre and postsynaptic stability. If we stand back and have a look at all that stuff as an overarching thing, we can say that ketones are in some way neuromodulatory or neuroprotective.

Their ability to be the signaling molecule is one of the things that we are interested in when we are looking at pain management. As well as signaling for membrane excitability stuff, they also seem to block the NLRP3 inflammasome. That’s the pairing upper body inflammatory molecule from which a whole heap of other different cascades comes. If you can block something upstream like that, then you have got the potential to change the whole heap of different inflammatory pathways that are running.

Also, this is trying to help reduce oxidative stress by improving mitochondrial function. They are also an epigenetic regulator, so they are HDAC inhibitors. They tend to inhibit genes that are related to both inflammatory processes and mitochondrial function, that part of the story where ketones are acting and all these signaling things are all different. The potential area is that it can be improving pain outcomes. The other flip side to that story does not only have we created ketones and done all of that stuff but we’ve also reduced blood glucose.

That in itself, even regardless of ketone production, is an important part of this story because if you reduce that volatility of glucose excursion in the blood, that also helps to manage inflammation. It also helps to negate the problem of too much glucose floating around in the bloodstream. That’s potentially a problem. We have seen that as a threat. When we are talking about threatened safety for pain management, if we have got extra glucose floating around in that system, that glucose is a bit of a naughty molecule and sticks itself to proteins and stops them from working properly.

We end up with a situation where we can have damaged or dysfunctional proteins in tendons, ligaments, cartilage, joints, and all those things. The poor old diabetics are a great case study for this. If you look at somebody with diabetes because they habitually have high glucose levels, they are also much more likely to get both neuropathies, tendonitis, and things in the shoulders for that reason because that extra glucose is now sticking itself to proteins in the nervous system or the tendon and the ligaments. Reducing the glucose in somebody’s diet has a great potential impact on pain outcomes as well.

You are talking about the Advanced Glycation End Products. We call it AGEs.

It’s because they then trigger those receptors that then produce an inflammatory response, it also triggers proteins and things that break down and degrade enzymes that degrade the cartilage surface. We think of things like arthritis as being very mechanical problems and as the joint being worn out because it has been used too much but there’s more to that story. There is got to do with how much glucose potential loading that person has had in their lifetime as well because that cartilage stuff is going to be degraded by how much AGEs production and how much degradation has resulted because of that high glucose levels.

As physios, even if we are not taking this deep dive and trying to get people into a keto diet that’s trying to get their ketone levels up and all the rest of it, if all we are doing is trying to reduce their glucose load a little bit and get a bit more of a stable blood glucose level, then that is still potentially going to have great pain outcomes for that person.

Although you have the ability to influence a peripheral mechanism, which is, let’s say, glucose regulation, insulin control, insulin regulation, and essential regulation because you were mentioning that you tell them bodies and neuromodulators, but then we know that all that overlaps.

It’s all this complex system.

It’s all one system, especially when you are talking about nutrition. You have done a pilot randomized controlled trial on the Effects of a Low-Carbohydrate Ketogenic Diet on Reported Pain, Blood Biomarkers, and Quality of Life. People first want to know what type of ketogenic diet we are talking about. Even when you go to a bookstore and look at what a ketogenic diet is, there are hundreds of different types of ketogenic approaches. What is the approach that you use in your randomized control trial?

Another little mini project that we did as preparation for this trial was that another person in my research group is a dietician. We sat down together and we did almost a systematic review of all of the Australian and New Zealand food databases. We worked out based on appropriate serving sizes, which was the best low-carbohydrate food for each of the different vitamins and minerals, which hasn’t been done. We are trying to get that through to be published at the moment. The journals don’t tend to look to publish low-carbohydrate diets in papers.

The beauty of that was it accounted for serving size. We went with the dietary guidelines stuff. That penalizes things like red meat because you can only have 65 grams of that were the sufficient be 110 grams and things like that. We tried to account for all of those things and account for things like what people say or something like Nori or the seaweed sheets that make up sushi. They have got great amounts of iodine and things in them but they are only 2.5 grams. You are going to have to eat three packets of all of that stuff to get the vitamin and minerals.

From that study, we came up with a nice list of all the different foods for all of those different categories. We made a Bingo sheet for our participants in the study. Over the course of the week, we were trying to get them to tick a box in all those different categories. There was enough flexibility in there that you could choose between, whether you wanted more plant things or more meat-based stuff. I must say the animal products were quite highly represented in that group when you have a look at it, but there were certainly obviously vegetarian things in there as well.

When we are talking about what type of diet the participants were on, they could choose the flavor of what their diet looked like, whether they wanted to have a more Mediterranean diet or vegetarian in there or whether they wanted to be more meat-based. Whatever it was, as long as they were ensuring that they were getting that nutrient sufficiency, which was one of the things that we mentioned. We want to make sure that you are putting all those good inputs into the system to try and help the nervous system recover as well. That was how we approached it. In terms of trying to work out, how much carbohydrates they were eating and all the rest of it, we didn’t count carbohydrates.

What we did was give them a blood fingerprick ketone monitor so that they were monitoring their ketone levels. We used that to get them to adjust what levels they were eating. We try and help set them up, targeting what we thought was about 50 grams of carbohydrate. If they weren’t getting into ketosis, then we were getting those people to pull it back a little bit or if they were going, “They could add a little bit more in.”

One of the things that we forget in this whole thing is it’s a very individual approach to these diets. What gets one person into ketosis and probably might necessarily get another person is depending on their metabolic status. Having that feedback objectively so that they can have a look at it and see whether that reduced their carbohydrates enough was one of the good things that we did in there to help them do that. Everybody had a different-looking diet in there but it was all trying to get the carbohydrate levels down to below 50 grams of carbohydrate.

I appreciate that because they are monitoring their own biomarkers and then they can adjust their diet as they see fit. The diabetes research with regards to measuring glucose has helped us in that area because when people monitor their blood sugar, they realize, “Brown rice may work for that person, which doesn’t work for me.”

I get clients who get a continuous glucose monitor or something for two ways because it is like this big a-ha moment for them to turn. They realized, “That rice does this to me but I can eat that egg for breakfast and I’m fine.” People make sense of what they are doing rather than it just being a list of foods and, “I can’t remember. Can I eat that? Can I not eat that?”

The education part around nutrient-dense food because that’s what we are talking about. Nutrient-dense food that provides your body with the essential nutrients it needs and helps you maintain a state of ketosis is probably powerful in general from an educational perspective.

One of the teaching tools we used to do that was the NOVA Classification System. I’m not sure whether you have seen that or not but it’s red, green, orange and yellow. It’s a four-category system where the red categories are all of your ultra-processed foods. All we said to people was, “You can have anything in the first three categories, which is basically your whole foods or minimally processed things. Anything in the ultra-processed category, that’s out.”

That’s all the fun things, the chips, biscuits, cakes, and all those things. We asked them to compile their diet from the other things and the Bingo sheet that we’ve given them as well has only got whole foods on it. We eliminated any category of whole foods as well. It was that real focus on nutrient quality and density in what they were eating.

You mentioned ketone bodies. What other biomarkers were you tracking?

We did a few questionnaires looking at the quality of life. We did anxiety and depression markers. We did some blood work. We tested for inflammatory markers and the general screening stuff that you get in there looking at cholesterol and all those metabolic markers that are generally done. We had a few other things that we were looking at. The way the trial ran was that everybody started for the first three weeks by pulling out those category red foods.

Their job for the first three weeks was to get their diet looking a little bit clean-up. At the three-week mark, we randomized people to either keep doing that for the rest of the remaining up to twelve weeks and the other group got randomized to go into the low-carb ketogenic group. We did the biomarkers for everybody at the beginning and the blood biomarkers only at the beginning at the end.

The interesting thing between the two groups was that whilst both groups got a significant improvement in their pain outcomes, which is an important outcome, the ketogenic group got significant improvements in their inflammatory markers, their depression, and anxiety scores, and both groups got improvement in their quality of life scores.

There were additional benefits that we are seeing in the ketogenic group. The other thing was that the ketogenic group also had lost a significant amount of weight, whereas the whole food and not process group didn’t have a reduction in their weight. There were some added benefits from doing the keto. The important thing that we took away from the trial was that even pulling those ultra-processed foods out of the diet for people, it got a significant pain improvement.

Physio is working with clients. Even if we don’t have time to try and set up some grabbing diet for people, helping them understand that pulling the ultra-processed foods out of their diet is going to get some pain improvement potentially from doing that, that’s not that harder leap to get people. This is something you can be talking to people while you are doing other sorts of treatment and things like that but it’s got a potential to change how that person is going from a pain client perspective.

The other interesting thing when we looked at the groups was that we also did analyze the carbohydrate levels and things of the food at various points through the diet. The group that was pulling out the ultra-processed food by default dropped their carbohydrate levels down. It is still above 130 grams. It was about 170 grams or something like that but it was from 250 grams, 300 grams or whatever it was at the start. Even though they didn’t fall down into what we categorized as a low carbohydrate diet, they had lowered their carbohydrate level. When we think about or what we were talking about with the glucose levels, that is possibly what helped in their outcomes as well.

The one thing you didn’t mention is in this randomized clinical trial, how many people were in each arm of the trial? Do you have that data handy?

It was only a pilot study. It’s because it was my PhD study, which was unfunded, we didn’t have any money. Nobody wants to fund nutrition research. We had to keep our numbers relatively small. We started with 27. We lost three before the randomization and then one out of each arm after that. We did end up with more people in the ketogenic arm than the whole food. We ended up getting situations where we would have somebody that wanted to be in the trial but their partner or child or something also had chronic pain and they wanted to be in it as well. It was going to be too hard to put one person on one diet and one person on the other, so we allocated them as groups.

The way it fell was we ended up with a few more. We ended up with 15 in the keto group and 9 in the whole food group. We have to be careful about the conclusions that we are drawing from any of this because we are talking pretty small numbers here. The whole point of the trial was to be able to look at, “What happens with this small group that we are going to have a look at, and what experience did they have?” That can then inform us if we are going to do a bigger trial if somebody wants to fund us in the future.

It is smaller but not insignificant. I want to touch on something that you said there. Some people know I published a paper on nutrition and chronic pain. I called the paper, A Global Call to Action for Physical Therapist Practice. Someone reached out to me on Facebook and said, “There are not enough randomized controlled trials on nutrition for pain specifically. Therefore, this is not valid.” I’m like, “There’s not enough. I agree with you. We always need more research.” To your point, the money that goes into nutrition research for randomized control trials is minuscule.

Nobody makes any money out of this. If you teach people to eat better and maybe not eat so much, then the drug companies don’t win and the fast-food people don’t win either, so there’s nobody wanting to fund it.

The message that I have become more comfortable with throughout a couple of years doing this is that we have brilliant people like yourself who are starting. The fact that you did a randomized clinical trial on this is huge because it is relatively new and it’s hard to have people enter into that. There’s no money flowing into this area. Do we need more studies? Always. That doesn’t mean that, as licensed clinical professionals, we can’t appraise what’s out there and start to use that in a meaningful way with the patient’s population we are working with.

To this day, there is still a segment of the population that I continually think about which your work talks intimately. Those are people with aging brains and degenerative conditions. Type 3 diabetes is a dementia-type condition. Their nervous system literally cannot uptake glucose any longer. Their nerves are starving, in essence.

Even if you regulate blood sugar, some people are past that point of being able to maintain a “healthy diet” with a blood glucose level of 90 or below. I know, based not only on looking at the research, reading your work, and working with patients myself that these are options for that segment of the population, which is growing in leaps and bounds. We have a lot of people who have aging brains who haven’t had the opportunity to interact with someone like yourself and have them change their die. Now they are in their 60s or 70s and are like, “What is my option? My glucose receptors are basically shot.”

We do a big disservice. There’s no thought around this going into what’s being fed in nursing homes and all those things or what programs are being run for our elderly populations in the community. There’s no talk about this at all where we couldn’t be making such a huge difference in their lives. There’s a difference between somebody being able to stay at home and manage or not if you can get their cognitive function improved. It is not happening.

There is some research in the area of using exogenous ketones. The reason for that would be that it’s sometimes difficult in those elderly populations to instigate a diet in a way that they understand what they are doing and are going to follow it. I would love to see how that research plays out. Certainly, improving the quality of the diet for that age group is essential.

That’s when I looked at that paper. You have these two arms and people always have some type of benefit. Typically, when you move them off of highly processed foods through a more whole food diet, which was the first run in part but the ketogenic group in your study had benefits on depression, and anxiety and the other group didn’t. We’re always interested in the intersection between pain and mental health.

We were only doing fairly basic measures, so it would be lovely to do a proper trial looking at the mental health side of things. There are some of those starting to pop up. How much are we giving people medication for all of this and when we could be improving their life a whole heap by changing their diet and helping to educate them on the mechanisms behind it. One of the things that are missing in these holes is teaching people to understand why they are doing something because it has to make sense for us to be able to implement it in our lives. To me, we do this already in pain management.

When we are trying to explain to people what they should or shouldn’t be doing, we are giving them a reason why they are doing it so their brain can go, “That makes sense why I will be doing that exercise.” We are trying to add the safety component to the brain’s evaluation rather than the dangerous side of things. We need to do the same thing when we are talking about diet as well. We need to give, not in great detail as we have talked about, the basic information that why this is going to help their physiology and have a good outcome so that they can go, “That’s something that I should be doing.”

If you just tell people that diet has an impact on pain, specifically through inflammation, “When we shift your diet to a more whole food diet, we can decrease inflammation and as your inflammation decreases, it is going to have a positive impact on your pain.”

Every physio should be saying that to everybody.

As professionals, we can read your research to understand, “Here are the deeper mechanisms that are at work here because we have to be able to play with both.” As part of your journey, you came in here as someone who had some challenges in weight loss, tried some diets, and discovered a lower carbohydrate diet that specifically works for you. You ran that for a while in your life, then you get a little curious about your career and you are like, “I want to pursue a PhD in this. I want to get to do the research.”

I believe in a systematic review out and you have a randomized control trial on this. I’m interested in how this has changed your clinical practice because, for some physios, nutrition is new to them, probably not new to the readers. Some people are still like, “How do I start to talk about diet.” How has this changed your professional scope of practice?

My private practice is a little bit different from the average physio private practice. I’m not a hands-on clinician. I work with a psychologist and we were on specifically a pain management program. That’s an education program based on explaining pain and helping people understand what they need to do to get out of the pain hole that they are in. I would always downward a little bit with the idea that we should be including nutrition into that. I’ve got interested in it at the same time as then starting my PhD.

Over the course of the last couple of years, it’s now become not quite a focal point in what we are doing. We are still doing all of the other stuff that we would usually do from an education perspective. Part of that is a big chunk is nutrition as well. I go into it on two different levels. I start with, “Let’s pull the ultra-processed food out of your diet because if we do that, it’s going to help to reduce your inflammation and that’s going to have a positive outcome.”

That’s the starting point that our trial was trying to get people in on. We try and get them working on that along with everything else that we are doing. If they have shown some interest in doing the dietary stuff, “We have got another lever that we can pull in this we can own. We can also look at nutrition as an actual treatment strategy. Let’s talk about that because if we do something like reduce the carbohydrates, here are all the different things that it could potentially do.”

We know from the research that there is a good chance it is going to have a good outcome. Do we want to go down that route as well? Most people will say, “Yeah,” up at that point. They will have a go at anything. In our practice, we tend to see the people that are at the end of the road from a chronic pain perspective and everybody else’s thrown up their hands and given up said, “I will send them to pain management instead.”

They are at the point where they will try anything that is suggested to them. We get some amazing results from people. There are some people that don’t want to include diet in what they are doing and that’s fine. We work on the other stuff but we have had other people that have had dramatic 180s in terms of their pain.

They are the people that you go to, “This makes this all worthwhile if we can try and help them with this,” because they have had this chronic pain for 18 months or 2 years, however long it might be and they have gotten nowhere. That’s pulling that lever of diet and that whole thing was enough to shift the direction and start working on the right out of the sensitized hole that they were in. It can have dramatic improvements.

If you are talking about average physio practice, it’s probably a little bit harder to go into that level but it might mean that you can have some introductory discussions with people about that while you are doing something else with them. Maybe link in with some other providers, a dietician or something that understands some of this stuff. I do not want to be disrespectful to the dieticians but there are some that aren’t interested in those things.

There are some new ones coming out that are fabulous with low carbs. One of the dieticians I work in with is doing her PhD at the same time as well is running a clinical trial using ketogenic diets for Type 1 diabetics. That’s the area that she’s working in but she’s a great resource as well. We bounce patients between us as well. It’s having a network of people around you that can support the stuff that you are trying to do as well.

There’s a lot of hope in eating healthy food for your physical and emotional health. It tastes good too.

It’s great food. I don’t know what people complain about.

We are all eating three times a day, maybe having a little snack here and there. We might as well shift into a way that’s healthy for our long-term health and our pain. Where would you like to see our profession go? You are in PhD. People do PhDs for their own interests and curiosity. I wrote in my paper because I was like, “I have been doing nutrition for a while.” People are like, “Let’s move this into the profession in a more significant way.” What’s your dream of how the profession might use the data that you have mined here?

I would like to see it become part of the standard physio curriculum that they at least cover diet and the options that are there and the things that could potentially help somebody because I’m sure you need a diet. It wasn’t ever discussed in any lecture ever. We know GPs get pretty much none as well. There’s that whole lack of understanding for all these primary healthcare people that are treating people. They don’t know anything about the dietary stuff that we should be recommending either. The education system needs to change a little bit and it will be nice to include that.

I would love to see nutrition included in things like the explained pain stuff. We do a lot looking at our dangers, safeties, and all that stuff. Metabolic health falls very solidly into either a safety or threat bucket for most people. When we looked at one of the first studies that I did for my PhD, we did a block, a little bit of a cross-sectional survey of a whole group of people that had chronic pain to find out, what did they think about their diet and how good was their metabolic health?

The funny thing was that they all rated their health and diet as pretty good but they all had an average of three comorbidities. The average BMI was 31. This is a real disconnect between, “How well am I?” and this chronic pain. We tend to put you in chronic pain in a box over here and all these other things like your blood pressure, weight, and all the rest of it. It’s a different problem over there but it’s not. It’s all part of the same problem that we need to deal with.

If people can see that improving their diet would improve some of those things that are all related to their pain story, then you can start to work in other areas that have that good flow and effect back to the pain that the person is having. Sometimes when people, particularly when you are in a bad chronic pain situation, it all feels very hopeless. You are in this big black hole. It doesn’t matter what you do. Nothing seems to work.

Whereas giving somebody some doctor stuff to work on is like a different thing. I can have a little bit of ownership and traction. We can feel like they are getting some control back, then they get a bit of improvement in metabolic health. It all has a good flow and effect back to what we were trying to do in the first place. That teaching needs to be happening in our universities and things that people are coming out on with that knowledge.

I’m teaching nutrition in PT programs. I hope people in Australia reach out to you and do the same because you are a wealth of information. I want to touch on the DIM and SIM parts because that comes from the Explain work. It’s the Danger In Me and Safety In Me. For example, if I injured my back lifting a heavy box, then my brain now starts to perceive that bending forward and lifting is a danger potentially.

Metabolic functions in our body are not always but oftentimes below our perception. At all times, as you and I are speaking, there are metabolic activities happening in every system in our body. It’s a whole system approach. That can be a contributor to the Danger In Me because the entire system is scanning for dangers, not just in the periphery.

My theory along the way is you never have anybody come in to see you with chronic pain. The picture of health and all I’ve got is this ripping along with chronic back pain. They come in. They are overweight and depressed, and there are all these other things that are going on that are being ignored essentially. The pain is the thing that they turn up for. When you look at that from a threat to safety model, then it’s not only just the fact that they have had this pain and the doctors have told them they are never going to get any better, the insurance companies harassing them, and all those things that are going into their threat bucket.

If their blood pressure is high and blood glucose is volatile all over the place, even though they are not consciously aware that that’s what’s going on because there are things that are very tightly regulated by the brain. The brain is going to perceive those as being something that’s dangerous that has to be dealt with. We don’t just have a back threat and safety bucket. We’ve got a whole person threat and safety bucket. All these things can fill up that threat bucket. I made the case that a lot of metabolic stuff is going in there as well and we can be doing something about that from a diet perspective.

Early on in that work, there was this conceptualization that there’s no inflammation involved in chronic pain. We are starting to move, specifically when you look at neuro, central sensitization is a neuroinflammatory response. It’s not the same inflammatory response as when you break a leg. It’s an acute inflammatory response. This is more of a chronic low-grade inflammatory response. That message is still out there somewhere that there’s no inflammation and chronic pain.

I’m thinking, as you said, because you are not getting this great big spike that you might see if you had an infection or something else that happened, the difference in the immune system response doing that’s like a big response that then creates the right pro-resolving molecules to turn the whole thing back off again. What you see in chronic pain is this little kindling slight increase of inflammatory soup, as David Butler would call it. There’s this slight little increase.

That increase is they are not creating the right things to turn it off. It’s becoming this chronic sustained defensive response that’s then going to be picked up by nociceptors that are now up-regulated because they are picking up on chemicals in the environment. There are all implications. If the person is overweight, then their adipose tissue puts out inflammatory cytokines. That then adds to the problem. I’m thinking about chronic pain as being a chronic inflammatory problem is something that we need to start thinking about along those lines.

It’s a whole health perspective. What’s important about it is you are looking at the whole person, not just a nervous system or neuroimmune system, but now, you are starting to look at obviously a gut-brain immune musculoskeletal. That’s when people obviously start to get better because you are treating the entire person versus just the nervous system. Rowena, it has been incredible chatting with you. I love your work. I know people who are reading this episode will love it as well. Let them know how they can learn more about you and follow everything you have going on.

I’m not big on social media. I do have a Twitter handle, which is @Rowena_Field. I don’t often put a lot on there. Occasionally, when we get something published, I will put that up but I’m not big on Twitter wars or anything like that. We have a website for our business, which is STEPP. It is Solutions, Tools & Education for Persistent Pain, Stepp.com.au. That’s an Australian-based program that we run here in New South Wales. You can contact me through there if you want to as well. I’m happy to chat with practitioners or anybody that wants any advice or direction towards any of the research.

You can find all the information that she’s up to and follow her research as well. Rowena may not be big on social media but we are going to make sure that she becomes big on social media because you are all going to share this because it is important to work. Please make sure to share this on Facebook, LinkedIn, Twitter, Instagram or wherever anyone is talking about ketogenic diets and chronic pain, especially in the physiotherapy or physical therapy community.

A lot of people in our community are going to benefit from this perspective and are now able to help their patients with it. I want to thank Rowena for being here and all of you for joining us. Take a screenshot of this episode and tag me on Instagram. My handle is @DrJoeTatta. Thank you so much. We will see you next episode.

Important Links

• Dr. Rowena Field
• Functional Nutrition for Chronic Pain Practitioner Certification
• Effects of a Low-Carbohydrate Ketogenic Diet on Reported Pain, Blood Biomarkers and Quality of Life
• A Global Call to Action for Physical Therapist Practice
• @Rowena_Field – Twitter
• Stepp.com.au
• @DrJoeTatta – Instagram

About Rowena Field, PhD, M. Physio

Rowena is a physiotherapist with 30 years’ experience in both private practice and as a work rehabilitation consultant. She specializes in chronic pain management and developed the STEPP (solutions, tools and education for persistent pain) program with a psychology colleague. Her PhD investigated the use of ketogenic nutritional therapy for chronic pain, so she now incorporates this with her physiotherapy expertise within the STEPP program.