You get hurt, and your instinct is to blame the injury itself, right? For Dr. Elizabeth Yurth, it’s a much broader picture than just the injury. 

While Dr. Yurth got her start in orthopedics and sports medicine, she took a pivot about 15 years into her career. She started looking at ways to keep patients out of her office, rather than coming back in. 

“I was patching people back together, throwing them back in the fire, and they're back a month later,” she says of her patients. “So I started to ask, could we do better? Could we make people healthier? That way, they could actually heal more completely and they wouldn't keep coming back into my office.”

Rather than looking at just the injury, Dr. Yurth looks at the whole inflammation framework. And fortunately, she’s found that you don’t need expensive lab tests to figure out if your hormones are the source of your inflammation. Basic lab work, like CBC, metabolic panels, and glucose tests, can indicate whether hormones are off balance — and at a low cost. 

Her best advice to maintain health before you even hit the doctor’s office? Keep moving. It’s tempting to stop exercising when you’re injured, but something is better than nothing. Find the movement that works for you and stick to it. Why? Because your muscle acts like an organ, and building and stimulating muscle can help reduce pain. 

“Stop moving and you will die,” she says. “You’ve got to do something … you've got to move your muscles.”

On this episode of Back Talk Doc, hear some of Dr. Yurth’s top tips for staying out of the doctor’s office, such as identifying and minimizing sources of inflammation and treating your muscle as an organ.

💡 Featured Expert 💡

Name: Elizabeth (Betsy) Yurth, MD

What she does: An expert in orthopedics and spine care, Dr. Yurth is the co-founder and Chief Medical Officer of the Boulder Longevity Institute. She’s fellowship trained in anti-aging medicine, regenerative medicine, and cellular medicine, with over 500 hours of continued education in longevity, nutrition, epigenetics, bioidentical hormone replacement therapy, and regenerative orthopedic procedures. 

Company: Boulder Longevity Institute

Words of wisdom: “We have absolute certainty and absolute proof now that the cause of the degenerative disease is not the trauma. It’s the immune response to the trauma. If you can change that immune response, then you shouldn't see the trauma go on.”

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Welcome. You are listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery & Spine Associates, where cutting edge, nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.

Hello, everyone. I hope you're all out there having a great summer, enjoying time with friends and family, living your best life. Again, as the intro said, my name is Sanjiv Lakhia and I'm a DO and osteopathic physician, board certified in physical medicine, rehab and integrative medicine. And if you're new to the show, I like to bounce around between modernized approaches to spine and orthopedic conditions where we talk about discectomies with my colleagues. Again, we're the largest neurosurgical practice in the country.

But then, I always pivot to my true love, which is health and wellness. And today is one of those days, folks. I'm delighted to have a national authority on the topic of health, wellness, longevity, orthopedics, and spine care in Dr. Betsy Yurth. Betsy, welcome to the show.

Thank you, Sanjiv.

It's a real delight to have you. Folks, let me introduce her to you all. She's a co-founder and chief medical officer of Boulder Longevity Institute where she's been providing tomorrow's medicine today. I love that tagline. That's so awesome. She's been doing it since 2006. And obtained her medical degree from the University of California Keck School of Medicine and residency at University of California, Irvine. And she's also done a fellowship in sports and spine medicine. In short, she's really an expert on orthopedics and spine care.

And on top of that, then she's fellowship-trained in anti-aging medicine, regenerative medicine, cellular medicine, over 500-plus hours of continued education in these areas of longevity, nutrition, epigenetics, bioidentical hormone replacement therapy, peptides and regenerative orthopedic procedures.

And she's going to help me break down today's topic, which is integrative approaches to back pain. Before we jump into that, I really have just enjoyed listening to some of the interviews you've given on some of the other podcasts out there. And I think Betsy, your story about how you got yourself into running your own clinic and focusing on health in this manner, I think it's very interesting. I'd love for you to share that with people if you don't mind.

Sure. And it sounds like we kind of have a little bit of a similar background from how we got into this world, that we both went from the more orthopedic or in your case, neurosurgical, but really, from that more musculoskeletal medicine approach. So we both got our degrees more in a musculoskeletal medicine field. And then, kind of learned along the way that maybe there was more to the story.

And so, I was in practice with a big orthopedic group for 30 years, but about 17 years ago, I started to get a little bit frustrated because I would sort of see I was kind of patching people back together and then, they'd fall apart again. Or you probably see this in spines where somebody hurts a disc, they have surgery on that, and then they're back again with the next level, or they have a fusion and then, the next level. So I started to get a little frustrated with feeling like, "Gosh, I'm just sort of patching people back together, throwing them back in the fire in their back a month later." The sort of realm that you never really felt like you got people truly better. It was always like another niche in the artwork.

So I started to look at could we do better? Could we actually make people healthier? And in that way, they could actually heal better, heal more completely, and they wouldn't keep coming back into my office. So 17 years ago I started to really explore that and I explored how hormones and nutrients and stress and all the other pieces of our lives were playing a role in orthopedics, not just back pain, but your knee pain, your shoulder pain, all these things. And I started to realize that there was a lot of overlap and unless we actually fixed people, got their hormones better, got their nutrients better, got their diets better, got their glucose managed, they were not going to actually help their arthritis or even heal from a simple thing like an ACL tear.

So I started going back and relearning and fellowship in anti-aging, longevity methods of 17 years ago. We started back down that road. And then, opened, kind of overlapped the two. I would see my orthopedic patients and I'd try and talk to them a little bit about hormones and nutrients, but you know how it is, you've got 15 minutes. And so, it was a little bit like, "Okay, I'm really not going to get very far in this." We opened Boulder Longevity Institute. And I actually wore both hats. All day, I'd work in orthopedics and I would see patients here all evening. So I'd come over here at five o'clock and work here till nine.

And then, really, only just two years ago now, finally, I need to just combine these two because it was, number one, both killing me, but I was getting a little bit increasingly frustrated in trying to treat people the way I thought they should be treated with some orthopedic partners who were very conventional. And in fact, straw that kind of broke the camel's back was one of my partners saying to me, "You've got to stop ordering labs on people. We don't do medicine here, we do orthopedics." And I was like, "Oh, that's not really my paradigm." I thought I'd better move on.

So we really brought the orthopedics over to the regenerative clinic or to my longevity clinic. And mostly, what I do in the orthopedic realm now is getting people healthier, but also looking at regenerative techniques that we can actually help to sort of reverse things and the damage done too. So about half my practice now is just orthopedics and about half is now every other disease in the book or really just people who want to age really healthily or I have a lot of athletes who just don't want to get old. And as we talk, you'll see that those all overlap, that there is no difference between the athlete who doesn't want to get old, or the athlete who wants to perform at their best and your patients with back pain. The same disease processes are going on, the same prevention has to go on. So that's kind of how I got into this field.

I love that story. Maybe when we get offline, I can pick your brain a little bit more about that transition. I'm fortunate, I do work in a practice that really values kind of how I approach patients.

That's great.

But there's always room to grow and evolve. And the other thing I would say, folks, is that in kind of hearing her story, I want to point out how difficult it is as a practicing physician to pivot your career. Number one, getting the training and the knowledge, that takes tremendous amount of time and expense and effort and energy. So it's just fantastic that you're so passionate about helping people out.

And for today, obviously, we deal with back pain a lot, and that's my whole podcast is centered around back pain. When I started this in 2019, I said, "I'll never have enough to talk about," and boy, was I wrong? Because I totally agree. One of my mentors used to tell me, "The same blood goes everywhere, so if you have sickness in one body part, that metabolic process is affecting every other place."

Exactly.

And I've learned through my integrative health training and recent training, taking the peptide modules and things like that, how to affect everything at once in some way, shape or form.

So let's go ahead and pick your brain about back pain. And I'd just love to get your thoughts, 30,000-foot view, why you think it's so prevalent. I mean, it's one of the number one or two causes of disability and lost work time in this country.

Ye. And I think there's very few people you talk to who have not, at some point in their life, suffer from back pain, but not with the chronic, disabling pain that so many people have.

But the scary thing is, you're right, it is really, I think, in younger people, the number one cause of disability. And this is work related years too, these are the years you should be working, making money, that's the group that seems to be very, very affected by this.

If you look back to like 1990s, it was probably like 300 million people, now you're up to 500 million people who are affected by back pain, actually, more than that now. COVID did a big huge jump in back pain. So when you think, it was 2017, there was 500 million people, within COVID alone, it's increased almost 20, 30 million just from those years that COVID existed. So you have to say, "Well, why did everybody get back pain during COVID? Nobody was even out doing anything." Right? So if you're saying everybody's out skiing and hurting themselves and beating themselves up, and that's why we're ruining our backs, it would make sense, because during COVID, most people were sitting in their house watching TV and drinking too much and eating crappy.

So when you think about that and you think about, okay, well, that's an interesting [inaudible 00:08:33], that it wasn't when people were active and doing things that their back pain worsened, it was when they were sitting doing nothing.

And so, I think the big issue here is the same reason we're seeing an increase in every disease. Because as you said, same blood goes everywhere and every disease is linked to really a very specific because, and that's just what we call inflammation. It's an abnormal inflammation process going on in the body. So our immune system gets defunct, and that can happen for a lot of reasons. It can happen genetically. You don't have as robust immune system, you have different genetics than I do. Or environmental influences, you eat nothing but sugar. Or there are wear and tear type phenomenas that may play a secondary role. Like my first ACL tear was when I was 16. I went on and tore my ACLs four more times after that. But the key was why didn't I ever heal? I should have healed. The same thing with backs. You're going to have these active athletes who hurt their backs, they should just heal, when they don't, is there a reason they just don't heal?

So I think it's a little unclear why we're seeing worsening in all of these immune or inflammatory diseases. I don't care if you're talking about obesity, diabetes, cancer, they're all increasing. So we have to sort of say, are we not taking care of people the way we should, which is actually working on people's overall health, metabolic health, how do you exercise, how do you eat, and then, other pieces that we will get into on this? But I think that that's why all these diseases are increasing. And don't play lightly that this is a big, huge problem that we're going to see worsen over time. It's not just an aging population, it's a less healthy population than our ancestors were.

Yeah, I mean, I often kid I should change my license plate to L5-S1 because there is no shortage of lumbar disc disease. It's never going away, it would appear. So my job security is great. But I'm being truthful, if tomorrow it all went away, I would gladly go do something else because of the degree of suffering that we have to observe as practitioners. It's really hard.

Horrible.

One of the things you mentioned there was this phenomenon of wear and tear. I practice in Rock Hill, South Carolina, which is about a few miles over the border from Charlotte. And that is the pervasive mentality in this region is that, "Well, my back hurts because I spent 30 years on cement floors" or something of that nature. And I never discount that because I don't think you ever should discount a patient's story that they believe about themselves. But I know you think a little bit differently when it comes to why we develop disc disease and kind of the process behind it. So I'd love for you to share your thought process on that.

Really, it's the same thing you hear with osteoarthritis in joints. One of my old partners who was a hip replacement doctor used to say, "Well, the fact that you wore out your hip, it's just a sign of a life well lived." And I would argue, that's not the case, that all degenerative joint disease and degenerative disc disease is an altered inflammatory process. We're not designed to wear our backs, we're not designed to wear our knees, we're not designed to wear our hips any more than the concept that I used my brain too much so it got worn out. So does your dementia patient go, "Well, I was a really high level astrophysicist, so that's why my brain doesn't work so well anymore"? Or you have a heart attack and you're like, "Oh, well, that's because I really just used up my heart." It doesn't happen and it shouldn't happen with joints and it shouldn't happen with discs.

So there's more and more data now supporting the fact that if you have a healthy environment, if everything is perfect and you're standing on cement floors and you twist too much, bend too much play football, I don't care what it is, you do not see more degeneration than other people. And this has been now looked at in the past couple of years in probably about 10 different, really well done studies. But most recently, the study is actually not even published yet, it came out of Russia, but it's not even published, just came out a few months ago, but it should be published next month I think.

So they looked at degenerative discs and they biopsied out the nucleus of the disc, the guts of the disc, and they looked at the pro-inflammatory cytokines inside that degenerative disc. Now remember, cytokines are inflammatory proteins that our body produces, and they're necessary. We have anti-inflammatory and pro-inflammatory cytokines. So whenever you hurt yourself, like you stood on your cement floor too long, or you bent over to pick up your shoes off the floor and you hurt yourself a little bit, was designed for our body to do is to create a little bit of inflammation, and that inflammatory response brings in these cells to help encourage healing. And then, the anti-inflammatory proteins come in and they say, "Oh, okay, you guys go away. Time to heal up. And all is well." So you want this balance of anti-inflammatory and pro-inflammatory cytokines. So keep that in mind.

So now, if I hurt myself, I bend over, I stand on cement floor too long and these pro-inflammatory cytokines come in and they stay up and the anti-inflammatory cytokines never come up to par to get rid of them, they just stay elevated, then I'm going to wear discs.

So when they looked inside the discs, these degenerative discs in people, they had very, very high levels of something called interleukin-1 beta, which is also found in synovial fluid degenerative joints. They found very high level of interleukin-6, interleukin-17, tumor necrosis factor-alpha and some very destructive proteases, the proteolytic enzymes. If you look at these proteolytic enzymes, they're actually chewing away at your cartilage, they're chewing away your disc, they're destroying your disc. They found very, very high levels. Said, "Okay, well, that's a traumatic response."

But then they went to the disc above and they actually took a little nucleus, a harder study to do in the US, but you can do these things in Russia and China much more easily. So then they took a little bit of the nucleus of the disc above, so this was not the disc that was injured, and they found that there was very high levels of inflammatory cytokines in that disc as well.

So why is that? Well, is it because there was this change in vascular response or is it because this person just has high inflammatory cytokines everywhere and so when they're injured, they're much more likely to go down this cascade? It's probably a little bit of both.

They also did a great study in mice, this was I think 2019, where they took mice that they upregulated the inflammatory cytokines. They took mice that were bred to have very, very high levels of these inflammatory cytokines, and they really stuck just a little needle hole into the disc. And the disc rapidly degraded just from a little puncture hole in the disc. It rapidly degraded. When they blocked these, when they used mice that had none of these inflammatory cytokines and they punctured the disc, nothing happened. The disc healed. That was fine.

So it's not the trauma, it's the altered inflammatory response. So this is why you see so many people, after you fuse one level of their spine, they come back, and now, the next level gets to be fused. Everybody's like, "Well, that's because there's altered forces on it." No, it's because you have not addressed the response that you did that surgery, it's just upregulated all these inflammatory cytokines which are in the circulation, affect the disc above, affect the next disc, affect the next disc. So you already are dealing with a person who has poor protoplasm in the first place. And it's really common to have altered interleukin-1 beta genetics where you make higher levels in people, higher levels of interleukin-6. That's why you can see familial histories of different arthritis and degenerative disc disease. And it can be related to dietary influences, medications you're taking, bad glucose control. So there's lots of reasons these inflammatory cytokines could be high.

But we have absolute certainty and absolute proof now that the cause of the degenerative disc is not the trauma, it's the immune response to the trauma. If you can change that immune response, then you shouldn't see the trauma go on.

Absolutely same thing happens in joints. So you have a young person like me, I tore my first ACL when I was 60, and then I tore another one, and then I had tore the other side and toward the other side and finally stopped fixing them and just lived without my ACLs, end up with stage 4 knee arthritis. So if you look at people who have ACL reconstructions, 80% of them, you fix the ACL all good, 80% of them develop knee arthritis. Why is that? Because you fix the ACL, everything should be good, right? Why do 80% go on and develop knee arthritis? It's because of this altered inflammation.

So what we really have to work on is instead of saying we want to stop this degradative process by, I don't know, fussing the disc or sticking steroids in the disc or sticking even platelets or stem cells into the disc, we've got to first work on this patient's overactive inflammatory response. So that's really, I think, the key and why this is not a wear and tear disease.

Look at knees, for instance, and again, knees and joints or joints and spine are very, very similar in terms of their pathology. And if you look at high level runners, have much less knee osteoarthritis than sedentary people who sat at their desk. So activity is actually good. Moving is good. The more you move, the better off you are.

Does trauma play a role? Yes, but if you did not have an altered inflammatory response to the trauma, you should not go down this cascade. Does that make sense?

Yeah. Thank you for sharing that. I'm just sitting here listening because this is a new way of thinking, to be honest, within traditional medical circles. But I feel like what you've described here is far more empowering than, "It's just wear and tear. There's nothing you can do about it." I think-

Right. "Yeah. I'm sorry you played too much, you did too much. I'm glad you had a good time." It's not.

Yeah, and I love the analogy about wearing out your heart or wearing out your brain. It's almost ludicrous.

I always get my patients who are having well-shown knee arthroscopy, so scoping a knee and cleaning it up, one of the main bread and butter surgeries here, you scope a knee and clean it up. And it's been banned every other country, it doesn't work, it makes things worse. And I always say, "Would you go take your mother who has Alzheimer's and look at the brain, it's all spotty and [inaudible 00:18:50], and then go, "Just go clean that up. You'll be fine""? I mean, the same thing is happening and we're just ignoring this as a process. So it really is silly. And again, unless you take those patients that your partners are doing surgery on, you treat them afterwards, you take over their care and say, "Okay, now we've got to stop this process or you're going to be back here. It's great for the business for my partners, but you're going to be back here next year with the next level being infused. So you've got to take that on and start working. Now we've got to make you healthy because this is not going to stop here."

Yeah. And that's so true. Look, there are cases where people just need surgery, right?

Right.

There's ruptured disc, nerve root pain, radiculopathy nerve pain-

Yeah, a big, old disc sitting on a nerve, you got to go get rid of it, right?

That's why we're the busiest practice in the country. But what you're saying is kind of next level because when you look at the data, adjacent level disc disease and stenosis, anywhere five to 12% depending on what you're reading, sometimes more. And people get fearful that it's just a lifetime of more and more surgery. And ultimately, we want people, the neurosurgeons, everyone wants people to get treated, get better and stay better. And this really opens up a lot of different tools to consider.

I think people, understanding that this is a disease process and it's not your fault, there's genetics involved in it, but this is a disease. It is similar to rheumatoid arthritis. These are disease processes. And so, there is a little bit of that some of this has been a little out of your control. It wasn't just that you beat yourself up or did things wrong or you're too fat, there's a lot of things that, honestly, are a little out of control based on some genetic pieces. Why you can do an MRI scan on a back and, even if people have no pain, you'll see 30-year-olds who have multilevel degenerative disc disease. So they started wearing that disc, sometimes, at the age of 14, 15. So we know that some of those people had high levels of interleukin-1 beta, very, very high levels, and they started wearing their discs very early.

I think there's a little piece of we can treat this as a disease and really help you a lot more. And that empowers people a little bit too to understand that there is... And obviously, you've got to take control of your health, exercise, food, we'll talk about those, they all play a huge role in treating the disease, but it is something that you're going to need some help with.

I'm more about looking for opportunities than making patients feel guilty.

Right.

I mean, inflammatory changes in the body. Look, there are a lot of things that aren't necessarily even in our control, environmental exposures is probably top of the list, chemical exposures and air we breathe and the chemicals and pesticides and the food and so forth. Then I'll educate people about that, and then, we can outline some alternatives as you start to really heal internally.

Before we move on to next question, I did an interview recently with Dr. Greg Lutz who is really known in the space of regenerative spine care, and he kind of spoke a little bit similarly about how his PRP injections, and we do some intradiscal PRP here in the practice, and what that does to the microenvironment. You're basically validating that with the cytokine issues and the imbalance and even more systemically.

I've always wondered about this. We look at autoimmune disease, rheumatoid arthritis, the classic one, and I say, "Is this disease autoimmune per se?" I think, at a minimum, it's immune and you can kind of take it from there.

You remember, years ago they were publishing articles about antibiotic usage to help with degenerative disease coming out of Europe, and then, it kind of didn't come to fruition. But I've always, always wondered because when you look in functional medicine, talk about the research between the gut and the brain, the gut and the heart, the gut and the joints. Well, does it stop with gut and spine? I mean, why? There's a classic, ankylosing spondylitis has some good data on it. I'm really encouraged to hear you kind of share that information about the immune mechanism that may be at play here.

All right, let's get deeper into kind of your lens of how you look at back pain. Let's say someone who comes in to see you, there's different groups of patients, my population is largely adults with chronic back pain, you probably see younger athletes or people who are more acutely injured. So maybe share a little bit with the listeners just your thought process, your lens for how you work up someone with back pain.

I certainly see both. I mean, we have certainly a lot of people who have failed everything and the surgeon's like, "Well, we just probably need to fuse you from T12 to S1." So we get a lot of those who have multilevel disc disease and not a lot of hope in terms of even surgical options for this. We have a lot of those too. I always like to see the acute injuries and obviously, if I have somebody who is a young person with an acute disc, I'm going to send them off [inaudible 00:23:21]. I know that an outpatient surgery getting rid of that disc can sometimes be the best thing, but we always follow them up afterwards to try and say, "Okay, now this."

So if I have somebody come in, kind of more chronic back pain patients, usually they're coming to you, they've already had all sorts of imaging, but I like to see imaging. There's a few reasons for that. Number one, if you see things like Modic endplate changes, so for your listeners, Modic endplate changes are when we look at a spine, you'll see the vertebrae, you've got this degenerative disc, and the vertebrae around it look bright white on an MRI scan, image of MRI scan. So there's actually inflammation in the endplate of the vertebrae. It's not the disc, in the endplate of the vertebrae, and that's very painful.

So why does that occur? So if you see Modic endplate changes, they're very, very, very inflammatory. And a lot of times, what the surgeon will say, well, that's because there's too much load on the bone because the disc has worn out so much, but it's not, it's an inflammatory response. Where's a change in the vascular flow? So you actually have disrupted vascular flow to those end plates.

And we know that these proteolytic enzymes I talked about, something called metallo matrix protease-3 and ADAM enzymes, these are like the Pacman. And so, whenever there's inflammation in your back, the proteases are trying to kind of clean that up. But the problem is if I keep cleaning, like you have a spot on your wall and you keep rubbing on that spot, finally, the plaster's gone off the wall. So I have this chronic inflammatory response going on in my disc, proteolytic enzymes just keep gnawing away at stuff until there's not even vertebrae left. So you start seeing these endplate changes. So when I see that, I know I'm in a very acute inflammatory state when I see Modic endplate changes. That may change my management a little bit because I have to more acutely get that patient inflammation down more rapidly because there's a pretty significant point on

Or if I see things like Schmorl's nodes. And so, for your listeners, sometimes you'll see the shape of the vertebrae, it's got this little indentation up into the vertebrae. So it's weird looking. Instead of the disc being just this little oval shape, it's got this weird little blip up into the vertebrae. So Schmorl's nodes, and we always say, oh, they don't usually cause pain, but what they are is a sign that that person actually started having some wear of their discs at a very young age because when we're young, the bone endplates are actually softer and so the disc herniates up into the bone. So I know, square one, this person really has a lot of genetic influence going on. So I'll modify my treatments a little bit that way too.

So I do like to get MRI scan imaging. I won't even tell people, when you read these MRI scan imaging, people get terrified, and the last thing you need is to be terrified. Sometimes the worst thing you can do is read your own MRI scan images and then you're like, "Oh, my god, I had no idea."

I recently was actually doing one of those total body MRI scans. And I actually don't really believe in them, but one of my patients had a unit he wanted me to check out. My back doesn't hurt, when I saw my back on this total body MRI scan, I was like, "Holy cow."

Started to hurt.

I had like scoliosis. I had like really worn out L3-4 disc, [inaudible 00:26:22]. It was frightening. I was like, "Maybe my back does hurt a little bit," right?

Right.

So I'm actually very careful about what I tell people in their MRI scan. I'll try and say, "Listen, this is what's causing your pain and I'm not going into every little detail about what's on your back." So you guys, when you read your MRI scans, remember, we know that MRI scans show us a lot of detail, that has nothing to do with your pain, it's nothing to worry about. So don't get that into your head too much because that can actually change how your back feels even from there. But I do like to get m MRI scan imaging, it just helps me a little bit with refining what I'm going to do next.

And then, I think, when we're talking about this sort of full body healing, so think about what's critical. So if I want to look a little bit more at immune function, a simple DBC, so simple, just complete blood count. If I have a high C-reactive protein or sedimentation rate, that tells me there's very active inflammation. But not everybody's going to have big, old active inflammation with chronic disc pain that skyrockets their CRP. But a lot of people will have little signs that their immune system is suffering.

For instance, you can look at a complete blood count. All you guys, every one of your doctors will order a complete blood count. You've got them probably year to year from your primary care doc. And they read them, they go, "Oh, it's normal." But you can look at little secrets that are in there. For instance, when you look at the white blood cell count, you'll see white blood cells are made up of all these different cells.

Right.

The ones that are the big infection fighting guys you need a lot of are the neutrophils and lymphocytes. As we age, the lymphocytes start to decline and the neutrophils start to go up. So this neutrophil/lymphocyte ratio tells us the immune system is starting to age, it's starting to get sluggish. Even in young people, it means the immune system is stressed a little bit. If I looked at a young, healthy 18-year-old male, their neutrophil/lymphocytes are going to be one-to-one. They're going to have one-to-one ratio. As they get older, neutrophils go up, lymphocytes go down. So you can look and see, "Your immune system's a little bit struggling there."

And then, you could look at things like the monocytes, the monocytes just right in your CBC. Monocytes are macrophages. High macrophages, we know that activated macrophages contribute to back pains. When I see a high monocyte count, those are all things that I can say to the patient, "Look, there is immune stuff going on we need to focus on."

So we can look at simple little things in a basic $6 lab test that give us information about the immune system without measuring everything single cytokine in a $300 test.

Right.

Right? So I always get a CBC and a metabolic profile to look at that, but you really cannot downplay, especially in your population of people who are getting to be more in that sort of 40-plus age, you can't downplay how much hormones play a role.

We know in and of itself that estrogen is a key player in disc degeneration, that testosterone is a key player in immune function. And we're seeing now young guys, guys in their 20s that have low testosterone levels. Remember, guys have estrogen too. So their testosterone converts into estrogen. And if testosterone levels drop too low, they stop making estrogen. Well, estrogen's really, really helpful for discs. So when that estrogen level drops, they start getting more back pain and more disc, not just pain, but disc degeneration. You've got to make sure hormones are optimized or you're not going to make headway, not just because they're paramount to helping the disc, but also because they're for the immune system. The immune system needs progesterone, it needs testosterone, it needs those all balanced, men and women. Men don't just have testosterone, they've got estrogen, they've got progesterone. Those all have to be balanced if you're going to help the immune system and I'm going to help the person age more gracefully and I'm going to help their pain.

In fact, there was a great study on progesterone, both in men and women, how much progesterone in and of itself helped back pain. And there's some theories about that, one is that there is actually progesterone receptors on the spine, but two is that progesterone is so useful for our immune system. So I'll measure progesterone levels in my men too and sometimes give them smidgen, men don't need a lot of progesterone, a little smidgen of progesterone if levels are low. And sometimes, that in itself helps their back pain. So I look at that.

And I look at cardiometabolic stuff because if you've got high insulin levels, if you have high glucose levels, if you have a lot of oxidative stress, so high myeloperoxidase or oxidized LDL, if you're in this oxidative stress state, you've got poor glucose metabolism and you've got high insulin levels, your inflammation is going to be higher.

So now, you've got this genetic predisposition maybe, so you had one little hit strike against you. And then, you've got a little injury, so the inflammation accelerated. Two little strikes against you. And now, you have an insulin level of 25, and this high insulin is very inflammatory. It really suppresses your immune system. That's why diabetics have infections, so it really suppresses their immune system. So basically, you've now three strikes, you're out, you're going to have back pain. Unless I fix all three of those pieces, I'm not going to get you better. So I think it's really important to look at metabolic control as well and I think it gets really neglected.

When you're in a practice like yours, where you're more of an insurance-based practice, I presume, and you have 20 minutes with a patient or 30 minutes with a patient, sometimes it's hard to sit there and now talk about how are we going to get your glucose managed.

Were you saying fasting insulin? That was on your list?

Yeah, fasting insulin.

Okay. And where do you like to see that?

I like to see a fasting insulin of six.

Okay. It's interesting, I'm in the south, and there is stigma for sure with checking hormones for men. And the other stigma I've observed is, "There's no need to check hormones, you're too old." So that is real, that is palpable, at least in the insurance-driven world of healthcare. And that's unfortunate because-

You are in a little different population. I'm in Boulder, Colorado.

Yeah, the fittest place in the country, I think.

Right. It's a super healthy group of people, right? Now, that said, I'm licensed in 48 states and have patients all across the world, so I do get a taste of your patients as well.

I don't want to paint everyone with the same brush, but there's cultural aspects to areas where you work.

There's culture, I agree. There definitely is. And there's people who are like, "Why are you checking my hormones? It's my back." And again, I'm getting these patients, lots of times, who have already been down every other road, so they're happy to do anything because getting them a little bit earlier in the stage, sometimes a little bit harder to concept.

But I think that's where people have to see the literature, they have to see the articles that show how important this is and that it's not like, all of a sudden, I hit 50, I don't need hormones anymore, if I want to die, I don't. But in general, everybody will feel better with hormones, with testosterone levels optimized, with estrogen, progesterone optimized. And it is really key.

And why do people think that everything gets worse as we get older? Why does my joints hurt more as I'm older? And why does dementia get worse as I'm older? My heart gets worse. Why are all these aging processes going on? Because we don't have what we had when we were 20. We don't have the things to help our body repair. So one of my really big things to people is you've got to get the body back into that state it was when you were 20 so that it can heal like it is when you were 20, that includes hormones and the micronutrients you need.

So I also will check magnesium levels. I'll check vitamin D3 because we know D3 is really critical for the immune system. And then, again, go back to were you think all this is very related to the immune system. So you want to take vitamin D, you want to look at magnesium levels because magnesium is really also important for vascular flow, so you get normal vascular flow to the disc, which is really important. So I think that those are all things you've got to really look at if you're looking holistically at the patient to try and get the better.

And what I love about that is everything mentioned is readily available through LabCorp, Quest and very inexpensive without going down the rabbit hole of expensive functional lab tests that are often offered and talked about. You can get a lot of data from what you just suggested.

I know. I will come in all the time with these people who have, you probably see this, they literally have a stack, this much lab work that nobody has ever gone over with. And I go, "Yeah, honestly, you could have gotten that same information from looking at a simple CBC and saying this immune system's off. I didn't need every cytokine tested at a eight, $780 lab test to show that because it's obvious with my simple lab test."

Okay. I want to be respectful of your time and energy and I've got a lot of things on our list, but what I want to really get to and pivot to now, and as much as you're willing to share and dive into, are some of the treatment strategies you have. Let's say you've optimized, you've got your patient in front of you, you've done their metabolic workup, you've got the counseling and the pillars of health in place with their nutrition and such. What are some of your go-tos? I'm really interested to hear about your thoughts on exercise because I know you're big in exercise and fitness. And then, obviously, you're an expert in peptides. What are some things that you utilize routinely? Obviously, everyone's different, it has to be individualized care. But what are some things you think that people may not be aware of that can be helpful if they're suffering with back and joint pain?

Well, I think that exercise has to be number one, and not for the reason all you guys are thinking. It's not that exercise will make you thinner and make you more muscular, so you can support your back. That's all important maybe. But honestly, it's that exercise, your muscle is an organ just like your heart, just like your liver. We forget that. So when you exercise, that's when you stimulate your muscle to produce what are called myokines. Myokines are very interesting because they actually have far-reaching effects all over your body.

So let's say, for instance, I have really high levels of interleukin-1 beta, I do. I have very high levels, my knees wear out, I've got bad shoulders. So very high levels of interleukin-1 beta wear out my joints. And what happens when we exercise? Some of these inflammatory cytokines, so one of the things that happens when you exercise is it pulls these inflammatory cytokines out of your blood into the muscles. The muscles want inflammation, it's going to make them bigger, it's going to make them grow, they want inflammation. You actually pull these inflammatory cytokines out of the serum where they're hurting your back and doing everything bad into the muscle. So you lower the systemic level of these inflammatory cytokines simply by exercising, put into the muscle, which helps the muscle grow. So that's number one.

Number two, when the muscle releases things, it releases things like brain-derived neurotrophic factors. That's why it's so good for brain, but it's also good for nerve. So BDNF is really good for nerve function, so when you have neurogenic pain. And we know that a lot of back pain is neurogenic too, so when you exercise you can relieve that.

And so, the main thing to think about is, yes, it's important to be strong. You've got to have good core strength, you've got to support your spine. But the main reason to exercise is because the muscle, it's your medicine, it's going to provide all of these cytokines and these myokines, these proteins that go and fix things. They fix your brain, they fix your heart, they fix your spine, they fix your joints. So that's the number one reason. That is any kind of exercise, it doesn't matter if it's aerobic exercise or strength training, both of those will produce myokines. Myokines are a little bit different, it's why I think people need a little bit of both.

I'm a big proponent of strength training over aerobic exercise, but that's more because I think muscle is just critical to longevity. I think from a perspective of treating chronic pain, it doesn't matter, you just need to move. And one of the first things you see happen when people are in pain is they stop moving, right?

Yes, absolutely.

You're afraid to move. You're afraid it's going to hurt. Your doctor told you, "Okay, you just need to lay low. And you need to really take it easy." Even post-surgery, you've got to get people moving as fast as possible. You can't keep them in bed, you can't keep [inaudible 00:37:41], you've got to get moving. And it is uncomfortable, yeah, you've still got to move because that's, honestly, what's going to heal you. Really, make that point number one, you've got to exercise. And I don't care if it's... It's whatever you can do, it's walking, it's getting an exercise bike, it's working with a trainer that can work with you in the realm of getting you stronger. But don't just think it's because I want you to go lose weight, it's because the muscle is going to actually cure you.

So then, what else? Obviously, fixing the hormones, fixing the micronutrients, that all goes a long way, I was just talking about to help the inflammation.

But I'm going to talk about something that a lot of you guys don't know about, and Sanjiv, I don't know if you know much about it either, but you've probably heard some of my talk, it's a drug we use a lot, it's called pentosan polysulfate. So pentosan is what's called a repurposed drug and it got approved in Australia in 2019 for treating osteoarthritis and it's been actually considered a cure for osteoarthritis, to reduce their need for hip replacements by almost 80%.

Oh, wow.

It's coming to the US as a drug called Zilosul. So it's being rushed through phase III trials as a drug called Zilosul. And it will be approved. So when you bring drugs for FDA approval, you have to go with one cause, right? You say, "I'm going to use this drug to treat this," right? You can't say, "I'm going to bring this drug over and it's going to cure everything." FDA would never give you approval for that. So what they chose is knee osteoarthritis because the most prominent of the arthritis is here. So that was their big gun.

So they're bringing it over here in the US. It's actually rushing to phase III, almost phase IV trials. They just signed a big contract with some ex-NFL players to start using it. But we've been using it. I've been using it since 2019 when it got approved in Australia.

But pentosan polysulfate, it's glycosaminoglycan, it comes from a beech tree, very nice drug. But what it does is unlike any other medication that we have. Because remember those cytokines I just explained to you, interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, metallo matrix protease, ADAM enzymes, it actually reduces all of those. So I'm actually treating the inflammatory process.

So if I have a patient, for instance, who hurts themselves, I'm going to start them on pentosan quickly. If they have a surgery, I'm going to start them on pentosan quickly after the surgery to try and reduce that over-response of the inflammatory cytokines. The pentosan polysulfate, the reason we can use it here in the US, even though it's not approved yet, is that it is an approved drug in a different form. So again, this is what we call drug repurposing. So it is an oral drug called Elmiron. So Elmiron is a high dose of pentosan polysulfate, usually between 300 and 500 milligrams a day.

And if you look up pentosan polysulfate, the first thing that will scare you is a big black box warning about pentosan polysulfate causing a retinopathy. Now there's all these lawsuits going on. But what that was was a dose-dependent response. So people who have been on this drug about 15 years, once they get about two gram dose, they started to see rare cases, then about 11% of people, they started to see damage to the retina, and it was serious. So the drug does have a problem with that.

But we can use it subcutaneously. So it's used orally for bladder inflammation because it works really well in reducing the inflammation of the bladder. It doesn't work so well for the spine. But if you do as a little subcutaneous injection, you just kind of give yourself a little subcutaneous injection with an insulin syringe, it actually works systemically on osteoarthritis and degenerative disc disease. And there was a rapid study with pentosan that showed that, not only did they stop any further degradation of discs in rabbits that were bred for bad discs, they actually reversed the disc disease. They were actually able to regrow discs.

Oh, wow.

It also works on what are called neural growth factors. So one of the things that happens is you get these growth factor overgrowth that's what's causing some of the blood vessels that are changing, causing those Modic endplate changes. So you can see dramatic changes in the Modic endplate changes pretty rapidly with this drug.

Again, subcutaneous injection, we have to get it compounded because it's not available yet as a subcutaneous injection, Zilosul will be. So when it comes to market as Zilosul, I don't know if that will help you guys with back pain because it's probably only going to be insurance approved for knee pain, so it still might make it more expensive, I don't know. But right now we get this as a compounded drug. It is a game changer in the arthritis world and the back pain, honestly. You basically do a little twice a week injection.

Its biggest issue is it's a weak blood thinner about the same as a baby aspirin a day, and I feel you'll get some bruising from it and be a little uncomfortable with the injections. Some people, I don't know, I've been using this drug for three years. I have end-stage arthritis in my knees, I mean, bone on bone.

Oh wow.

Pretty bone on shoulder. And I have zero pain.

Plus, it has all of these other, when you look, an article just came out in March on this drug, anti-cancer, antiviral, if you take orally, really good for the gut.

So we're actually working now on coming up with a very, very micro dose of the oral to see if we can get the benefit of the gut effects on it without the detriment of the eyes. Now to put it in perspective, even if this drug subcutaneously causes the retinopathy, it would take you 70 years using it on a regular basis to ever hit the dose that caused retinopathy. So from that perspective, extremely safe.

So it is a go-to for any of my patients with disc disease, especially if I see those endplate changes because I got to fill those in, I got to get that bone to heal, and that's one of the few things that's going to do it.

People will tell you there's no way to get rid of Modic endplate changes except fusing the spine, not true, just like the bone edema you see in the knee joint too, not true. We can fix that.

So this drug, yeah, you'll have to look up the study on rabbits, which is pretty remarkable in terms of that. So the more and more research going on, we'll see this drug get bigger and bigger. I think it'll come to market as Zilosul in about two years, probably will be available. Again, I don't know if that's going to help people with back pain, but if you have knee pain and back pain, which a lot of people do, then you can probably get it covered by insurance. I don't know what the insurance coverage is going to be yet. I don't know. But what we do now is we basically get a compound and people cash pay it. And it can work wonders.

Now it does take time. It doesn't instantly heal people. But when you do something like surgery on people, where I know now I'm increasing that inflammatory cascade or I have an acute injury, then I do like to do a course of it then because that's when I'm going to start that process and I want to head it off at the chase.

Wow.

The other thing I like a lot, so if somebody comes to me with really acute pain, so you've got degenerative disc or degenerative facet joints and they've got pretty acute pain for some reason, something just flared up, sets that inflammation in it, and I will sometimes still do steroids, one shot of steroids to get them by. So sometimes I'll put steroids in there. But are you familiar with A2M or alpha-2-macroglobulin at all?

Yeah, I haven't used it, but I know it's an offering through some of the regenerative vendors for PRP to kind of inhibit proteases.

Yeah. You look at PRP and stem cells, and I can give you my opinion on why using our own stem cells may not be the best idea in back pain, but one of the problems is that we are, stem cells a little bit less, but we are creating a little inflammation to get the healing going, right?

Right.

And again, so that's why you'll see all these people after PRP, they flare up and they stay flared up. You're like, "Oh, I don't know what happened here." It's because their inflammation stayed escalated. So one of the things that when you have an acute inflammatory process, so Alpha-2-macroglobulin is this molecule that your body makes. Bodies are really smart. They're really designed to heal. That's why when you look at stuff go back to your body's design to heal, it's just that, as we age or genetics or whatever, we just have less of the things we need to heal.

So alpha-2-macroglobulin is this very cool molecule. It looks like Pacman, it's got sort of a weird little shape to it, and when there's an injury or something bad going on your body, your body takes A2M to that site and the A2M, sort of Pacman, eats up all those bad cytokines and gets rid of them and then they get excreted out. But it has a hard time getting to things like the disc because it's not very vascular there, or an arthritic knee where sometimes you have low vascular, or sometimes, people genetically just don't make as much alpha-2-macroglobulin, or they've had chronic pain and they've just have lower levels because they've used it up.

So what you can actually do is take your blood and filter out, using a very kind of detailed, pain in the ass system, to filter out the alpha-2-macroglobulin. It's a specific size of protein, so you have to go through this filtration process. It's not as easy as PRP. It takes a little while, it's about 40 minutes to filter out the A2M. And then, you've got this A2M, where now I can inject that back into the disc or around a nerve or into a facet joint to really reduce the inflammation, but also allow the healing to occur.

I haven't just blunted all the inflammation like a steroid does, where I'm good, bad, it doesn't matter. All I've done is bound out the inflammatory cytokines that are upregulated right now. Once I balance out, then I can do things like pentosan to try and get the patient healing a little bit or other things.

A lot of times, I'll do A2M, and then, once I get everything settled down, then I'll do some of the regenerative therapies. Once I get all that inflammation down, then I'll do the regenerative process after that.

And it's pretty cool. The problem is, it's a little tedious. Cytonics is a company that makes a filter for this. They're actually coming up with a synthetic A2M, which will be really nice when it's available, not yet, but-

Just from a vial, yeah. I'm curious, do you think the pentosan then could be part of a post-surgical rehab protocol?

Yeah, so pentosan is a weak blood thinner, so you can't do it pre-surgery. That week before surgery, they have to get off of it. But a lot of times, by time up until their surgery, so they're having surgery in a month, let's say, or six weeks, whatever, eight weeks, do pentosan for a while just to get their inflammation under control, and then, take them off of the week before surgery, and then, start them back on it right after surgery.

Wow. One of the things I've been using a little more since early spring when I was at the A4M peptide course is two of them, BPC-157 and oxytocin. I've trialed them different settings and I've seen some very interesting results with some patients who have chronic kind of single-level discogenic pain. And then also, frankly, even in the acute setting, I've had some interesting results with it. So I'd love to hear your thoughts on both of those.

So huge proponent. I always have. Those are all in kind sort of a surgical package or somebody has an acute injury. So just for your listeners, I don't know how familiar they're with peptides, but peptides are basically... Have you talked to them about peptides before, sir?

We have not, no. Actually, I probably-

Okay, so what peptides are, they're just chains of amino acids. So basically, a protein is greater than 50 amino acids, and a peptide is less than 50 amino acids. Sometimes they're two amino acids. They're like an arginine:glycine together. So all they are is a chain of amino acids. They can be synthesized. Just like your body makes hormones, it makes tons of peptides. And again, some of those peptides are really good for healing.

So for instance, there's the peptides that your gut makes called body-protective compound 157 or BPC-157. When you're injured or when you have gut, this is a great thing too that you guys are taking anti-inflammatories, BPC-157 as an oral capsule, protects the gut from ulcers. But also, if I have an injury, I hurt my shoulder, I hurt my knee, whatever it is, it will go to that site to try and encourage some healing to occur.

So again, this is my body's... All I'm doing is just helping my body do what it's supposed to do anyway, right? So I give a little bit more BPC-157 because maybe I'm not making as much or maybe my gut's messed up and so I don't have as much. So BPC-157, a really useful peptide for both pain and healing and recovery post-surgery or just from an injury.

Usually you'll combine that with another peptide called thymosin beta 4. So when we're babies, we have this giant thymus glands in our chest. And that thymus gland makes thymic peptides, one of them, thymosin alpha 1, really important for the immune system. That can be useful, right? Immune system, we've talked about. Thymosin beta 4 is what encourages collagen, [inaudible 00:49:25], really encourages tissue healing. So really good for healing after an injury or after surgery.

And again, these are peptides your body makes, but you don't have a thymus gland. Once get to be old like me, you don't have thymus gland anymore. You've got a little tiny fatty lump of tissue, no thymus gland, so I'm not making thymic peptides anymore. So I give myself thymic peptides, right? I give them back. I'm giving back my body the hormones it's lacking, the thymic peptides, the BPC it's lacking. That way I can heal and recover. So BPC, thymosin beta four, the go-to.

We should talk about oxytocin. Oxytocin is very interesting, it's called a peptide hormone. So oxytocin is our love hormone, right? So when you guys fall in love, you make oxytocin, when you hold your baby, when you nurse your baby, you make tons of oxytocin. But oxytocin has some other really interesting properties and it's very, very helpful for pain and it's helpful for muscle growth, so muscle strengthening, and it can be really helpful to encourage tissue healing as well.

Unless somebody has acute pain, I'll use oxytocin for pain, but usually, I'll go for the BPC, thymosin beta 4, along with pentosan, that's my go-to kind of fuel stop inflammation packet. And then, oxytocin, I'll use more along lines to help somebody who has a lot of pain.

Wow, I think that's really comprehensive.

They're hugely helpful too. When you guys have an acute injury, go right to BPC, thymosin beta 4. My kid sprains an ankle, he is going to have BPC, thymosin beta 4 right away.

Are you having your clients inject BPC at the site of injury or does it really not matter?

Well, debatable, anecdotally. From a perspective of, does it make any sense to inject it near the joint matters? Probably not. From an anecdotal, almost every doc you talk to says, or people you talk to, it seems to work better when you inject close to the site. I mean, even [inaudible 00:51:11], who's probably, I think you've heard on peptides, he's like, "Nah, I think you should inject it next to the site, from my own experience."

So your spine, it's a little harder, right? So it's in your back, how do you do it? But I have people just kind inject it up and down there, the hip here, somewhere there. But if it's a knee, kind of grab a little tissue by the knee, a shoulder, you kind of grab a tissue like that and just kind inject it in. It seems to be that it does work a little bit better to do the BPC and thymosin beta 4 a little closer to the site. But if that's hard, you can't get to your back somewhere. It subcutaneously works.

Yeah. Okay. Awesome. Look, I want to back up a little bit, folks. First of all, she did start with the basics. You got to get that right, your metabolic health-

Right. Exercise.

Get that in play. Exercise, for sure. And the issue with the myokines, Betsy, I didn't learn about that in medical school. I mean, there was none of that, at least when I was in training. And to hear you refer to muscle as an organ is really like light bulbs going off in my brain about, well, that makes a lot of sense. Why is it that we tell people with osteoporosis they need to lift weights? Well-

Right, exactly. Right. Yeah, it's not just load to the bone.

In fact, muscle and bone play a really close interface and absolutely will not have bone growth unless you stimulate muscle. So it's not just the bone loading, it's actually stimulating the muscle, so moving the muscle.

And you're a lot younger than I am, but the only research is very recent on how important myokines are to our health. And now we know about 2000 different myokines. We haven't really isolated the purpose of all of them, but it's really incredible and that's why exercise is absolutely 100%... Stop moving and you will die. It's really so critical to encourage you guys that... I have never taken a day off of doing something, it's true, but for the most part. And even I tell all my patients, they're like, "Oh, my back hurts too much." I'm like, "You've got to do something. You get up and move." I'll get them working with somebody. You can find something you can do, but you've got to move your muscles.

Yeah. As much about our practice, but we have physical therapy centers at almost all our locations. It's different. When you come to PT at Carolina Neurosurgery, it's very exercise-based, it is strength-based and some people are disappointed because they want someone to rub their back and stem. And that doesn't do much of anything longterm.

They want the ultrasound and the massage, right?

But we get people much better and I'm wondering if that's a big part of it. For me, I am 48, so I'm certainly more aware of my health and my hormones and all that and I'm always modifying my lifestyle. So what's really been working well for me has been more frequent weight training. And then, I use the rowing machine in between my weight training sessions. And I just feel this big boost of energy and I just feel stronger. So I encourage people out there, really practice what she said. It doesn't quite matter exactly what you're doing, but get your body moving and get yourself healthy.

As we wrap up, I would love for you to share, if you're comfortable as well, some of your daily routine on how... Look, I'll give you a lot of credit. You share a lot of information just about your own health and some of the challenges you've had with shoulders and knees and all that. And I love that because sometimes as doctors, when you're a physician and you're having some issues that are similar to the ones you treat people with, when I hurt my back years ago and I was like, "Oh, my gosh, I'm a podcaster talking about back pain and I hurt my back, I'm a fraud. It's just embarrassing." But then, when you share that with people, actually, what I found is I connect better with them. Like when someone says they hurt their back and they felt like someone shot them in the back-

Right. I've been there. I know what it feels like. Right.

... I've been there, done that. And frankly, physicians are under the highest level of stress of almost any profession, especially since COVID. So I'd love to hear some of your thoughts on that as well, kind of your daily routine.

Yeah. So I prioritize exercise, and for me, that means I have to get it done first thing in the morning. To keep me committed to it, I have a workout buddy I meet at the gym at five in the morning every morning. Having somebody, be it your PT that you go work with or your trainer or a friend, somebody who commits, because it's really hard to get yourself, sometimes, to the gym every day. So having somebody that you're committed to. And if you get up in that morning, you're like, "I don't feel like working out today," then you walk, you do something. But that's just got to be a commitment. You have to say... For me, if I put till the end of my day, by the time I get home from the office, sometimes nine o'clock at night, I'm just not going to do it. So five in the morning, I get up, I exercise. Usually exercise fasted. There's a lot of controversy around fasting and non-fasting, I don't know if that's all that pertinent here, but you just got to move.

And then, number one, I eat, I keep my body in very strict metabolic control. And that's really important, you guys too, is prescribing a continuous glucose monitor for my patients so they can see what foods are spiking their glucose. Sometimes people think, "Oh, I eat really well. I'm really healthy." And I'll put a CGM on them and then it's great because I've got their data in front of me and I'm like, "Oh, look, you spiked your glucose up to 180, what'd you eat?" So it keeps people really honest sometimes in terms of glucose spikes. Every time you're spiking your glucose, you're spiking your insulin. Every time you spike insulin, you increase inflammation. So I think really strict.

So I eat primarily, it's a very high protein, lower carb diet. I struggle with optimizing my sleep. It's still critical, but I'm really not great. I stay up too late. I don't get enough sleep. I wake up early in the morning. But I will say that we know more and more and more that that circadian rhythm getting disturbed, the bowel gene and clock gene, those two genes really influence inflammatory processes too. So really, guys, it's important to sleep in the dark. It's important to use blue light blocking glasses at night, all those things that tell your brain it's nighttime, and get good rest because that is a healing, recovery, immune-restorative state. Right?

No, for sure.

I'll also say that one of the biggest things we know now is the importance of hydration, that we're mostly all dehydrated. And that plays a really big role in back pain too. So you've got to make sure that you're actually drinking enough. I mean, most people are actually running around this world dehydrated.

Oh, yeah, and they're drinking more coffee than water. And that also is a diuretic.

Exactly. Right.

That doesn't help.

Yeah, I mean, I try and get through a couple of big jugs of water every day. It's like you've got to make sure you're staying hydrated. That's so important for cellular health. Your cell really rely on being osmotically stable and that means good hydration. So I really try and prioritize hydration.

And you can take a pretty big, but not too many supplements. I'm not a big fan of always taking 70 supplements. I have people come in taking a list of 80 supplements. It's ridiculous. But I certainly have about 12 supplements I take on a regular basis. I do rotate peptides. So I take hormones and I rotate peptides. So I'm keeping everything, particularly the peptides, my body makes, BPC, thymosin beta four, thymosin alpha 1, and [inaudible 00:57:40] that your mitochondria makes. So I'll rotate through that cycle.

Again, my paradigm is replace everything I'm losing. I'm 62, I don't have estrogen, I don't have testosterone, I don't have progesterone. If I don't give them back myself, I don't have them. If I don't give myself back some of those thymic peptides, my immune system's going to fail. So I need to give back the thymic peptides. So I'll cycle those. And they're expensive, so I don't take them continuously. I'm cycling them on and off to make it a little more cost-effective. The growth hormones, [inaudible 00:58:08] to keep my growth hormone level higher.

I was tell people where do you need to start and what to fix first. We have a whole course with this academy called Human Optimization Academy that you guys can look into, but it's just courses on how do you actually, in one sense, become your own doctor? Because not everybody has a great doctor like you, right? And I snooped on you a little bit and I thought patients saying, "Well, yeah, just plan ahead because it takes a long time to get in to see him because he's so good." You just can't see everybody.

I'm trying folks. We're trying to get people in.

But everybody, yeah, it was like, "He's worth it." So the key is that you need to be able to take some control of your own health. So you can go in there and you can now have these sensible conversations with Sanjiv or whoever your doctor is. So this Human Optimization Academy, if you go to the What to Fix first course, and it talks about kind of saying, start here, go here, go here, go here so that people have a stepwise approach to how do I just take control of this without trying to do everything every Instagram influencer is telling me to do? That becomes ridiculous.

Yeah, no, I love that. We'll definitely link to that in the show notes. People, if you're listening, go ahead and check that out. That's amazing that you've taken the time to put that material together for people to learn how to take care of themselves.

Even things like reading your own labs a little bit, like knowing to understand that neutrophil/lymphocyte ratio, those kinds of things. So people can look at those labs and say, "Oh, I do have immune problems."

So what about the days when you're just like, you've had enough of guys like me peppering you with questions about back pain and patients asking about hormones and all these things, and I know you've got a family as well, what's your go-to kind of de-stress, mind-body tool?

I have five kids. They're mostly grown now. My youngest is 16, my oldest is 27. We love, every year, we prioritize traveling. So I love traveling. And we do trips kind of differently than most people, we just throw backpacks on, we figure out the starting destination, and then, what country we want go in. We just did Bain and Portugal. And then we just pretty much wing it. We are like, "Oh, this looks..." Kind of the day before we research and we say, "Let's go here."

We find somewhere to stay, usually in the hospitals and places like that. So we do these trips that are two, three weeks long that are literally just... We don't go to a resort, we just put on our backpacks where we're mobile. You hear people talking or you read something, you're like, "Oh, let's go here, let's go check this out." So nothing is really planned.

And then, the most fun thing, it's usually with my whole family, my five kids, and it's by far my favorite thing to do. But I live in Boulder. I love mountain biking and hiking here because it's so easy for me to get out and do that. Not a big road cyclist because everybody seems to get hit by cars.

That winging is the exact opposite of how we do it.

I know.

It wouldn't work for us.

So we started doing this even when my kids were young. And my youngest, I remember my youngest is a five-year-old actually carrying his little backpack. And it's funny because I have one kid who does not really do well with it. She doesn't like that sort of more winging it kind of thing. But everybody else has gotten into it. I think it just makes you a little bit more open. Life will hand you the good things and the bad things and you learn from them all.

Yeah, absolutely. All right, if people are listening and they want to get ahold of you, maybe even get a consultation set up with you, how can they do that, Betsy?

So boulderlongevity.com, if you go there and there's a sort of information sheet you can just put your name into and it will sort of guide you. So it's all pretty easy to do. Human Optimization Academy is BLI.academy. So BLI Academy, if you just put that in, then you will be able to kind of look at the Human Optimization Academy stuff and there's some free courses and there's some that... You become a member of that because we're really trying to grow that membership because we do these very fun Q&As.

One of my big passions, honestly, is staying one step ahead of, even when you learn on an A4M. So we have a whole group, the cellular medicine group, which you should come to, that is a little bit the forefront. Every time I go for A4M I'm like, "Oh, this is all old stuff now." And it's finding the stuff that's the next level. We're trying to bridge that gap between what's proven effective in research and get it to people earlier. So that's where we have these Q&As. A lot of doctors are involved in it, but it's very fun and interesting for you guys. So go to BLI Academy.

And then, if you just want to learn about things like pentosan, you go to BLI.glossary, it's our glossary. You can put in pentosan or whatever you want, some peptide's name, and it'll give you references and what it is. So it's a nice little source to go to when you hear these words, you're like, "I don't even know what that is." So you can go there and we've tried to put together a bunch of articles there for you and things. So those are just three sources. Boulderlongevity.com. Human Optimization is BLI.academy, and then, BLI.glossary.

This is awesome. I'm going to force all my partners to listen to this episode, and then, we're going to sit down and have a talk about it. It's definitely thought-provoking. Certainly, you're on the forefront of care. And you've really given me a lot to think about too. And that's one of the things I love about doing this is I learn as much as I give, and then, we can spread it to people to better their lives. So thank you again so much for your time. It was a real delight. I know you're super, super busy.

Thank you. I appreciate you and I appreciate to have another colleague in this realm.

Yes, yes, it's good to have friends, that's for sure.

Yeah.

All right, well, thank you again. And look forward to collaborating in the future. Thank you.

All right, bye.

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina.

If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.