Telemedicine – Another Way to Access the Doc

At the Kaplan Center we pride ourselves on the hands on, high-touch, close relationships that we cultivate with our patients. There is nothing like the comfort that patients feel when they are in the company of a health care provider who, at that moment, is only there for them.
But office visits are not always possible. Work, travel, having young children at home, and countless other situations, can prevent a patient from getting the care they need. Other situations, such as reviewing data with your doctor, checking in on a treatment protocol, or refilling prescriptions, simply do not require an in-person visit.
Telemedicine, or “e-visits” with a doctor, is an easy and convenient alternative when physically being in the same room with your doctor is not possible or necessary.
Several Kaplan providers* are now using an online service called SecureVideo to schedule appointments with their existing patients that we call cloudvisits. Providers and patients connect with each other electronically, and have clear, face-to-face conversations. A visit can be scheduled so that our patients, who cannot take time off work or cannot leave their home, can maintain access to their provider which otherwise would not have been possible.
Our patients who have participated in cloudvisits have been impressed and thrilled with its simplicity and convenience. We still have our in-office visits, but the cloudvisits have been a wonderful additional service which has saved both time and money.
In the right circumstance, telemedicine can be an efficient, effective, and frictionless option for our patients, and can be done practically anywhere and anytime. Communication using SecureVideo is encrypted and HIPAA compliant.
Telemedicine is reimbursable by some insurance companies. If you have out-of-network benefits please check with your insurance company to see if telemedicine is reimbursable under your plan. The CPT codes (codes used to bill office procedures) are 99215 or 99214, depending on the length of your appointment.
*Participating providers:
Dr. Gary Kaplan
Dr. Lisa Lilienfield
Jodi Brayton, LCSW, MSW
Telemedicine appointments are only available for current patients of the Kaplan Center – and – who have previously been seen at our practice. Please ask your provider if a cloudvisit is appropriate for you.

Moving Forward with Back Pain

With an emphasis on decreasing the use of opioids in the United States, the American College of Physicians (ACP) updated its guidelines for treating back pain. The new guidelines, keeping in-line with the Centers for Disease Control’s (CDC) position on opioid medications, strongly encourage clinicians to consider prescribing narcotics for their patients only as a last resort.

Low back pain affects close to two-thirds of Americans. The new guidelines emphasize that patients with acute and sub-acute cases (pain that goes away within 3 months) may find their pain improve over time without treatment of any kind. But not everyone has the ability to simply wait it out. In these cases, and when pain becomes chronic (pain that persists beyond 3 months), the ACP strongly advises physicians to avoid unnecessary tests and prescribing costly and potentially harmful drugs, especially narcotics. When it comes to low back pain the ACP recommends that non-invasive and non-drug therapies like acupuncture, massage, yoga, and other mind-body therapies should be the first line of treatment, and we agree!

Remember, chronic pain, including low back pain, is a symptom of inflammation. Without targeting the root cause of the inflammation and treating it, a person’s pain symptoms will not improve. Mind-body therapies, like the ones recommended by the ACP, help calm the inflammatory process in the body, promote healing, and present little to no risk.

Acupuncture – This 2000-year-old practice is thought to work by blocking pain messages to the brain with competing stimuli that cause an increase of endorphins, the body’s natural painkillers, and the secretion of neurotransmitters, which affect one’s perception of pain.

In 2007 the results of a large study of over 1,100 patients with chronic back pain was published in the Archives of Internal Medicine. After 10 treatments, the group that received acupuncture had a 47% improvement in pain and functioning after six months.

Massage therapy – A 2011 study concluded that people who were treated with massage therapy, whether relaxation massage or structural massage (deep tissue massage), for their chronic back pain saw benefits that lasted at least 6 months.

Yoga therapy – The poses, controlled breathing, and meditation involved in the practice of yoga can not only improve symptoms of chronic low back pain but can lower instances of depression and use of medication.

The ACP also recommends nonsteroidal anti-inflammatory drugs (NSAIDs) if drug therapy is desired or if patients have seen little improvement with non-invasive treatments. Occasional use of NSAIDs can certainly be helpful, but a big misconception about these OTC (over-the-counter) painkillers is that they’re completely safe and harmless. Regular use of NSAIDs can lead to problems with gut ulcers, liver damage and kidney damage. Ironically NSAIDs can even heighten one’s sensitivity to pain. People who take them more than once a week should discuss this with their physician.

A study released by the CDC showed drug overdose deaths in the United States have more than doubled since 1999, confirming the need for continued emphasis on the opioid crisis. ACP’s guidelines take the right approach; opioids should only be prescribed with close monitoring by the diagnosing physician, for the purpose of relieving pain and improving quality of life when all other medical approaches have been exhausted.

Bottom line: Whether you have an acute, sub-acute, or chronic case of low back pain, the first line of treatment should be a therapy that can help calm the body’s inflammatory process naturally and safely.

Will these guidelines be practiced? This responsibility lies in the hands of both the physician and the patient. When low back pain interferes with quality of life, talk to a physician about these wonderful and science-based therapies that can benefit your mind, body, and soul.


The Hidden Risks of NSAIDs

Painkillers: The 14-Day Time-Bomb

What Doctors Don’t Tell You, September 2016
by Celeste McGovern

Although these over-the-counter and prescription pills are the modern standby for every ache and pain, what Big Pharma hasn’t told you about the risks of non-steroidal anti-inflammatory drugs could just kill you, as Celeste McGovern discovers.

When Aaron Marino opened his own gym for business, he thought the stress of running it was giving him tension headaches. Each morning on the way to work at about 5:00 am, and as the dull throb began at the base of his skull, he would reach for one of the world’s most popular over-the-counter (OTC) painkillers for arthritis, headaches, menstrual cramps and more, and wash down two ibuprofen pills with black coffee—and the pain soon melted away.

Popping a couple of Advil — or Motrin or Aleve or other, generic versions of non-steroidal anti-inflammatory drugs (NSAIDs) — was so effective that it became a habit for Marino, a simple reflex to pain and he did it three to five days a week without a thought for years.

“I knew there was a risk to taking them,” says Marino, who had scanned the label and thought the warning applied to people who were gobbling far more than two pills a day. As a ‘superfit’ gym owner in the prime of his mid-30s, he had little reason to worry about a painkiller he could purchase in bulk at Costco — and, besides that, it worked.

Three years into this routine, though, one Tuesday in 2010, Marino rose from the toilet and noticed that his stool was liquorice black. By Friday, he was feeling dizzy when he stood and friends commented on his pallor. A Google search told him his black ‘tarry’ stools were indications of an upper gastrointestinal (GI) bleed, and when he went to the doctor, he was sent for an emergency blood transfusion and surgery to close a perforation in his duodenum.

“I was about two days from actually kicking the bucket,” says Marino, owner of Alpha M men’s image consulting business in Atlanta, Georgia. He wasn’t exaggerating: every year in the US alone, more than 100,000 people are hospitalized for NSAID painkiller-related stomach ulcers and injuries, and thousands die from NSAID-induced GI bleeding.

Silent epidemic of GI bleeds

Way back in 1999, this NSAID-induced GI problem was described in the New England Journal of Medicine as a “silent epidemic” claiming at least 16,500 lives each year in the US alone — and those only among arthritis patients and those taking prescription NSAIDs — not the OTC pills. The report also said that almost 75 percent of those surveyed who ingested NSAIDs regularly were “either unaware of or unconcerned about possible gastrointestinal complications.”

And while nearly two-thirds of regular users indicated that they expected warning signs before the development of serious NSAID-induced complications, in reality, more than 80 percent of patients with serious GI complications experience no prior gut discomfort as a warning.

Current estimates have lowered the NSAID-induced GI-bleed mortality figure to somewhere between 7,000 and 10,000 each year in the US, according to the American College of

Gastroenterology. German researchers have calculated the risk too: just two months of using an NSAID puts your odds of dying from a GI bleed at one in 1,220, which may sound small but is actually, they say, more dangerous than bungee-jumping a few hundred times.1 Use them longer and the odds multiply.

NSAID heart attacks and strokes

GI ulcers and bleeding are only one part of the NSAIDs’ toll. The unwanted side-effect of inducing heart attacks and strokes is now relatively well known to doctors, but these potential dangers and and the drug’s maker Merck’s attempts to deliberately obscure the risk only came to light in courtrooms when the drug Vioxx (rofecoxib) was withdrawn from the market in 2004 after an estimated 120,000 people died taking it.

But the NSAID carnage has still not ended as, recently, the US Food and Drug Administration (FDA) upgraded its warning on these drugs yet again. After reviewing new data on the drugs using compounds like ibuprofen, naproxen, diclofenac, ketorolac, celecoxib and more, the US oversight agency required new drug labelling for both the OTC and prescription non-aspirin NSAIDs stating that they increase the risk of heart failure and stroke even within the first week of use, and that the risk may increase further with longer use and higher doses.

It had previously been thought that only people at higher risk of cardiovascular events could possibly suffer vascular injury induced by NSAIDs. But the recent FDA warning makes it clear that the risk is also increased in those with no known heart issues and that injury can happen “without warning.” NSAIDs pose the greatest risk to patients following a first heart attack, with those treated with the drugs being, according to the FDA, “more likely to die in the first year after the heart attack” compared with patients who aren’t taking the drugs.

“For people who have coronary artery disease and have suffered a heart attack, the risk starts with the very first pill, and the risk does not get any better if you wait for a year or even five years after a heart attack,” says pain specialist Gary Kaplan, of Georgetown University School of Medicine and author of Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression.

The new FDA heart and stroke warning is now added atop its GI warning, which states that NSAIDs like ibuprofen may cause ulcers, bleeding or holes in the stomach or intestines which “may develop at any time during treatment, may happen without warning symptoms, and may cause death.” It then adds that the risk may be higher the longer you’ve taken the NSAID, if you are elderly, in poor health or drink three or more alcoholic drinks per day while taking ibuprofen.

Ignorance of the GI risks of NSAIDs is apparently just as widespread as the New England Journal of Medicine described in 1999 because in 2010, the FDA conducted surveys to determine if illiteracy among the elderly was the underlying reason for their lack of awareness of the risks associated with NSAID consumption. It was not.

In the UK, the reason for such ignorance may well be down to the lack of awareness of the National Health Service itself: its current information page on NSAIDs describes the side-effects as “troublesome,” and lists ulcers and GI bleeds below stomach aches and diarrhea, with heart attacks and strokes last of all as “rare” side-effects. The site offers no information on the suddenness with which symptoms can arise.

As for alcohol, while the increased risk of GI bleeding with its greater consumption has been documented in the medical literature since 1999, the NHS blithely states: “It’s usually safe to drink alcohol while taking NSAIDs, but drinking alcohol excessively during treatment may irritate your stomach.”

Other dangers

While heart and GI problems are well documented among NSAIDs’ unwanted effects, there’s more. In 2005, Pfizer pulled its NSAID valdecoxib (Bextra) from the US market because of its high heart risks, but also because it was linked to more than 150 cases of serious and sometimes fatal skin reactions.

Two years later, the UK and Australia abruptly pulled the NSAID lumiracoxib (Prexige) when they discovered that some patients taking it were suffering from severe liver damage as a result; indeed, some patients even required liver transplants. And last year, the drugs regulators reviewing diclofenac-based NSAIDs moved them from the OTC category to prescription-only.

NSAIDs’ risk to kidneys is also well known to regulators. A recent pooled analysis of five earlier studies confirmed that NSAID use significantly increases the risk of acute kidney injury.2 They’ve also been linked to hearing loss in both men and women.3 And while there are conflicting results for NSAID dangers in pregnancy, some researchers have concluded that several NSAIDs can induce “spontaneous abortion.”4 The painkillers can also induce or exacerbate sinusitis and hives, and studies have shown they can increase allergic responses by 10 to 30 percent in asthma sufferers.

NSAIDs can make pain worse

Ironically, for those dealing with pain, NSAIDs may actually interfere with the body’s own painkilling machinery, the long-term effect of which is to sustain pain rather than eliminate it. This is exactly what happened to image-consultant Marino. When his gut problems forced him to stop taking NSAIDs, he noticed that, in less than a week, the headaches he’d been taking
the drugs for in the first place, for years, simply vanished.

“NSAIDs are not truly addictive, but can make you dependent,” explains pain-expert Kaplan. “Regular use, three times or more a week of NSAIDs and Tylenol [not an NSAID, but acetaminophen/paracetamol] can suppress the body’s own natural pain-relieving system. The result can be rebound pain when you stop the medication because your own pain-relieving system has been suppressed. Over time, when you stop the medications, your own system kicks back in and the pain goes away. The problem has been well documented in people with chronic headaches. In some people with chronic headaches, all we need to do to fix the headache is to get them to stop taking NSAIDs and Tylenol for a few weeks, and the body will fix itself.”

In the case of arthritis pain, doctors know NSAIDs do nothing to help the underlying condition, although they can alleviate pain in the short term. But a new study suggests that taking a painkiller like an NSAID can actually make arthritis worse in the long run. Researchers at Johns Hopkins University compared people taking painkillers (two-thirds were taking an NSAID) for knee arthritis with those who weren’t taking any drugs for a matching condition, and followed them all for three years, X-raying their knees at intervals. Those taking the painkillers were more likely to have knee arthritis that had visibly got worse on X-rays and were also more likely to undergo knee replacement surgery compared with those not taking the drugs.5

The COX-2 scandals

COX-2-selective NSAIDs were developed as a way to target pain and inflammation while sparing COX-1 and the gut lining. Merck’s Vioxx (rofecoxib) and Pfizer’s Celebrex (celecoxib) were the first of these COX-2 inhibitors.

Launched in 1999, they quickly became blockbusters; doctors wrote more than 100 million prescriptions for them in the first year and the manufacturers of each raked in billions in dollars. But tens of thousands of patients began dying from heart attacks and strokes.

All of the sordid details of how Merck and Pfizer doctored the data and deliberately concealed the drugs’ dangers eventually trickled out in a myriad court cases years after Vioxx was first pulled from the market in 2004.

“The scandal of the COX-2 inhibitors is really monumental,” says former drug insider and co-founder of the Danish Cochrane Collaboration Peter Gøtzsche in his book, Deadly Medicines and Organised Crime (CRC Press, 2013). “The drugs were approved based on small, short-term trials that didn’t look for cardiovascular harms, in patients with low risk for such events, although nearly half of real-world patients with arthritis have coexisting cardiovascular disease.”

Gøtzsche recounts how Merck employees deliberately manipulated data too, not just by exaggerating the benefits of Vioxx, but also by actually producing a fake peer-reviewed journal just to market pro-Vioxx reports.6 They also did not publish data available in 1999—which clearly showed the increased rates of heart attacks and strokes—until 2006, two years after the drug was pulled from the market. When they did publish data, they distorted the findings: for example, they failed to report three heart attacks during a critical clinical trial, listing one cause of death as “unknown” when it was clearly a heart attack.

But to most of the American public, the true extent of Merck’s ruthless concealment was hidden by the media’s Pharma-friendly reporting. News of the Vioxx ban, for instance, was followed by a 10-minute interview with a Pfizer-funded representative of an American arthritis foundation lamenting the loss of the painkiller for patients. Yet, there was little national reporting in 2007 when the jury in a Vioxx case found that Merck’s conduct was “malicious, oppressive and outrageous.”

And it wasn’t until 2009 in an Australian court that details emerged, such as Merck’s internal emails naming the influential doctors and researchers who were concerned about the drug’s risks. The emails described how company employees intended to “neutralize” and “discredit” these “problem” detractors. Neutralization was apparently achieved through the company’s lengthy list of “opportunities,” which included “Research,” “National Consultant Meetings,” “Program Faculty Training” and “Medical School Grants.” If these bribery tactics failed, schemes that were evidently not discussed via email were then employed to “discredit” the detractors.

Gøtzsche also describes how Celebrex (celecoxib) manufacturer Pfizer similarly contorted data to suit its drug-marketing strategy. Its biggest study, he says, was “fraudulent” and its authors were either employees or paid consultants to the company. When Vioxx was pulled from the market, Pfizer shamelessly seized the moment to promote its own drug.

The next day, the company wrote to Danish doctors that more than 50 million people worldwide used celecoxib and that the company had reviewed clinical trials of more than 400,000 patients. “That’s what they wrote; I suppose they meant 40,000,” says Gøtzsche, “and this had not yielded any sign that celecoxib increased the risk of cardiovascular events. The fine for this ruthless misinformation: $2,000.”

In reality, all COX-2-inhibiting NSAIDs increase the risk of heart attack and stroke. Celebrex, the only one left on the market, has similar cardiovascular risks to Vioxx. Pfizer has awarded millions of dollars in damages to patients who have suffered as a result and has even paid out $164 million to its own shareholders, who claimed the company misrepresented the drug’s safety data.
As Gøtzsche says, “The NSAID story illustrates that drug regulators are consistently willing to award the benefit of scientific doubt to manufacturers rather than patients.

Know your painkillers

As with every other drug, there’s no such thing as ‘safe’. The top five categories of painkillers are rated here for their relative dangers.



Why COX inhibitors affect your gut

The wide variety of NSAID side-effects has to do with how they work. Our bodies have an enzyme called ‘cyclooxygenase’ (COX), which produces prostaglandins that, in turn, promote inflammation, pain and fever in the body. NSAIDs are believed to block these COX enzymes and so reduce prostaglandin production, thus damping down inflammation, pain and fever.

There are two kinds of COX enzymes: COX-1 and COX-2. COX-1 is known as a ‘housekeeping’ enzyme, as it plays a critical role in regenerating and protecting organs like the kidneys, as well as the mucosal lining of our gut. In fact, this activity is part of the reason why we don’t digest our own stomach every time we eat anything. It is also the reason why ingesting COX-1-disrupting NSAIDs puts our gut lining at risk.

“What people think about with stomach upset for the NSAIDs is stomach ulcers, but the bigger issue is that regular use causes ulcerations in the small intestine in up to 75 percent of people,” explains Georgetown University’s Gary Kaplan, medical director of the Kaplan Center for Integrative Medicine.

“The small intestine is the final arbiter of what substances that we eat are allowed to enter our bodies and what will pass through to be eliminated in the stool. Damage to that filter by the NSAIDs allows substances to be adsorbed that would normally be kept out. This increases the risk of allergic reactions and worsening of food sensitivities.”

The other problem with NSAIDs is that they disrupt the gut microbiome, a mini-ecosystem of microflora that interacts with our nervous system, and helps to determine the health of our body and brain.

“Disrupting the garden of our gut can let weeds overgrow and potentially damage our health the same way weeds overgrowing a garden can damage the flowers and other plants we actually want to thrive,” says Kaplan.

What else can you do?

It’s a fact that more than 100 million Americans and 14 million Brits suffer from chronic pain—whether mild, sporadic, unremitting or excruciating. So the big question remains: what else can they do to deal with the pain?

For acute pain

For acute muscle strain, ice, elevation and rest, and perhaps a muscle relaxant, is recommended by Georgetown University’s Gary Kaplan, an integrative osteopath and one of only 19 US physicians specialized in both family and pain medicine.

After the first 24 hours of an acute injury, he says, apply heat.

The homeopathic combo preparation Traumeel, which comes as a pills, a cream or gel ( provides pain relief, as does bromelain (see right).

For chronic pain

As chronic pain is really about inflammation, according to Kaplan, the first place he starts with patients at his pain clinic is their diet.

Eliminate all fatty and fried foods as well as refined sugars and stimulants like coffee and tea.

Eat an anti-inflammatory diet, starting with brown rice, fish, chicken, fresh fruit and vegetables, and eliminate gluten, soy milk and milk products.

Some people suffering from osteoarthritis find that avoiding nightshades (tomatoes, eggplants/aubergines, bell peppers) is helpful. Try it for a month and see if your condition improves.

Take omega-3s for arthritis. These essential fatty acids are essential for your body to fight inflammation—including what’s associated with osteoarthritis and rheumatoid
arthritis (RA).

  • Suggested daily dosage: 200–1,000 mg as fish oil or 1 Tbsp flaxseed oil

Glucosamine has also been shown to help arthritis sufferers because it provides the raw material for rebuilding cartilage and synovial joint fluid. One study of patients with moderate-to-severe hip and knee osteoarthritis found that taking 1,500 mg of glucosamine sulphate plus 200 mg of omega-3 fatty acids had greater pain reduction and less morning stiffness and pain than those who took glucosamine alone.1

  • Suggested daily dosage: 2,500 mg

Take turmeric, the bright-yellow root in the ginger family most familiar as a spice in Indian curry. Hundreds of studies link its active ingredient curcumin to anti-inflammatory activity. It’s also been shown to act specifically as a COX-2 inhibitor—but without the side-effects of drugs like Vioxx and Celebrex.

  • Suggested daily dosage: 1–3 g/day as dried powdered root

A highly bioavailable form of curcumin was more effective in alleviating RA symptoms, including joint tenderness and swelling, than NSAIDs in one study. What’s more, those taking the curcumin without the NSAID diclofenac experienced the greatest improvements overall. Also, those taking turmeric had no side-effects at all, whereas 14 percent of those who dropped out of the study did so because of NSAID side-effects.2

  • Suggested daily dosage: 500–3,000 mg of bioavailable curcumin extract three or four times a day

N-Acetylcysteine (NAC), an amino acid, has anti-inflammatory properties that have been well described, yet only recently did researchers discover in a small preliminary study that its biochemical mechanism also relieves pain, so suggesting its potential in the treatment of chronic inflammatory pain.3

  • Suggested daily dosage: 600–1,200 mg or as directed

Bing cherries and raspberries are examples of Nature’s own COX inhibitors. According to one study, these fruit contain particular antioxidants and anthocyanins that make them capable of inhibiting COX-1 and COX-2 activities comparable to those of ibuprofen and naproxen.4

Pineapple contains an enzyme called ‘bromelain’, shown to reduce inflammation by apparently also blocking the COX-2 enzyme pathway naturally.5 You can take it as a supplement derived from the stems of pineapples, which contain the highest concentration of bromelain.

  • Suggested daily dosage: 200–400 mg/day or 90 mg three times a day

Pine bark extract, or Pycnogenol (French maritime pine bark extract) is another natural COX inhibitor described in dozens of published research papers to have beneficial effects on a wide variety of inflammatory diseases and conditions, including the pain of osteoarthritis. In one study, 100 patients treated for three months with 150 mg/day of Pycnogenol with meals saw a “significant alleviation of pain” and reduced their NSAID consumption compared with those taking a placebo, who saw no improvements and increased their NSAID consumption instead.6

  • Suggested daily dosage: 150 mg/day or as directed

Supplement with magnesium, as muscle twitches, cramps, tension and aches are among the most common signs of a deficiency of this mineral. So it’s no wonder that pain doctors like Kaplan advise patients with chronic pain—from migraines to fibromyalgia—to supplement with magnesium, as it’s hard to eat your way out of a deficiency once it develops. Magnesium oil applied topically is also reported to dramatically relieve some cases of arthritis within minutes. In one study, patients receiving intravenous magnesium after heart surgery had similar pain levels, but self-medicated far less with morphine.7

  • Suggested daily dosage: 400–800 mg

Cayenne or capsaicin topical creams (containing at least 0.075 percent capsaicin), derived from hot peppers, are available over the counter, and alleviate pain by reducing levels of the pain transmitter ‘substance P’, such that the pain messages never reach the brain.8

  • Suggested daily dosage: Apply to painful areas, but never on broken skin; if there’s no improvement after two to four weeks, stop using it. It may also cause skin irritation. After use, avoid touching your eyes and wash your hands carefully.

Sleep is crucial for good pain control, according to pain doctor Kaplan, so anything that helps you get a good night’s sleep is also likely to benefit pain. This includes meditation, yoga, exercise and stretching, while massage, acupuncture and other physical therapies can help tremendously too.


Main References:

1 Z Rheumatol, 2001; 60: 288
2 Eur J Intern Med, 2015; 26: 285–91
3 Am J Med, 2010; 123: 231–7; Am J Epidemiol, 2012; 176: 544–54
4 CMAJ, 2011; 183: 1713–20
5 Osteoarthritis Cartilage, 2016; 24: 597–604

Know your painkillers References:

1 BMJ, 2011; 343: d5142
2 Presentation by Dr Carl Orr at the Annual Congress of the European League Against Rheumatism, 14 June 2013, Madrid, Spain
What else can you do? References:
1 Adv Ther, 2009; 26: 858–71
2 Phytother Res, 2012; 26: 1719–25
3 Mol Pain, 2015; 11: 14
4 Phytomedicine, 2001; 8: 362–9
5 Cancer Lett, 2009; 282: 167–76
6 Phytother Res, 2008; 22: 1087–92
7 J Cardiothorac Vasc Anesth, 2007; 21: 827–31

10 Natural Ways to Reduce Your Exposure to Ticks.

A recent article in Reader’s Digest offered 10 natural ways to lower a person’s exposure to ticks. These are not suggestions on what types of repellent to use before you go outside, but rather how you can reduce the number of ticks in the environment around your home where you may be spending time gardening, socializing, or where kids may be playing. Some of these suggestions are fairly straightforward while others may require more research and testing on your end to see what works best for your particular situation.

Click here to read the article on the Reader’s Digest website. We have also made it available below to save or print at your convenience.

gut microbiome

Central Sensitization Syndrome Research Study

Is there a relationship between bacteria in the gut and chronic pain? This is what Dr. Gary Kaplan and his colleagues at the Kaplan Center for Integrative Medicine, in conjunction with the J. Craig Venter Institute are investigating through a research study this summer.
If you are struggling with chronic pain and depression/anxiety disorders, or are a healthy individual with no history of chronic pain but an interest in participating as part of a control group, you may be eligible to participate in this study.

What is Central Sensitization Syndrome?

The co-occurrence of chronic pain conditions such as Chronic Fatigue Syndrome, Fibromyalgia, and/or Myofascial pain, with a neuropsychiatric condition such as Major Depressive Disorder (MDD), Anxiety, and/or PTSD is known as Central Sensitization Syndrome (CSS). There is currently no known cure and doctors have so far only been able to treat the symptoms of the disease with pain medications and other alternative therapies such as acupuncture and massage. However, this may be changing.
There is growing speculation among the medical community that individuals suffering from CSS may have a bacterial composition in the GI tract that differs from that of healthy individuals. Instead of attributing this difference to the normal genetic variation seen from person to person, Dr. Kaplan and his research partners will examine the bacterial makeup of a study and control group with the goal of identifying possible risk factors for CSS. Results from this research study could lay the foundation for an entirely new outlook regarding the indicators and causes of CSS and MDD.
Over the last 25 years, Professor Thomas Borody, a renowned Australian physician, has made tremendous progress in the treatment of various gastrointestinal (GI) diseases through bacteriotherapy. As part of an investigation into a link between the composition of the gut microbiota and Chronic Fatigue Syndrome (CFS), he conducted an experimental study in which the manipulation of colonic microbiota improved the symptoms of CFS in a whopping 70% of subjects.

Study information:

A total of 30 participants will be selected and upon enrollment, required to provide stool and urine samples, as well as a small blood draw. There is no cost to participate and the Kaplan Center will provide a copy of results from the Genova stool analysis, and a nutritional assessment to participants, upon request. This is an observational study, so is not designed to provide treatment recommendations however participants are encouraged to discuss results with their primary care provider.
Over the course of this CSS study, Dr. Kaplan will examine and compare the metabolites, plasma, and gut microbiome of healthy (control) individuals to that of the CSS study group. Following a thorough analysis conducted by the J. Craig Venter Institute and Genova Diagnostics, Dr. Kaplan will look for shared patterns among results. Nutritional assessments from urine and plasma samples will help Dr. Kaplan to establish which essential nutrients are failing to be absorbed by the CSS group, while also identifying possible inflammatory factors caused by the presence of CSS.
As one of the first American physicians to ever look at imbalances in the gut microbiome as a possible risk factor for CSS, Dr. Kaplan hopes to set the foundation for future research, opening the door to new treatment possibilities for those suffering from chronic pain and/or major depressive disorder. It is his hope that observational results from this study will lead to a better understanding of CSS’ behavior – providing some much needed clues in the critical search for the long-awaited cure.
* We have now filled the volunteer roster for the study. Thanks to all who have contacted our office or told others!

Dr. Kaplan Discusses The Dangers of Over-The-Counter Habits

Dr. Kaplan was recently interviewed by FUSION, a new multi-platform media company for millennials, on the dangers of over-the-counter pain medications.

I take Tylenol or Advil every day. Am I killing myself?

by Taryn Hillin

I used to pop Tylenol and Advil like candy. Wake up with a headache? Wash that cereal down with some acetaminophen. Tough workout? Cool down with a Gatorade and some ibuprofen.

My daily over-the-counter habit didn’t concern me. After all, I bought my pills in bulk at Costco—how dangerous could they be?

I clearly wasn’t alone in this thinking. Americans love over-the-counter pain medication: From July 2014 to July 2015, we spent more than four billion dollars on the stuff. Continue reading>>

Dr. Kaplan Talks to CBSNews About the IOM’s Report on Chronic Fatigue Syndrome

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Dr. Gary Kaplan spoke with CBSNews on the recent IOM report, “Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Redefining an Illness,” and what it means for frustrated patients who still struggle to be taken seriously by both physicians and their peers. Read the article, here.

This video is an original publication of CBSNews.

Physical Therapist & Orthopedic Clinical Specialist Michele McLellan Joins the Kaplan Medical Team

A Letter to Patients From Michele McLellan, PT, OCS, CLT

My name is Michele McLellan, and I am delighted to introduce myself as the newest member of the Kaplan Center’s medical staff.
I completed my physical therapy degree at Northeastern University in 1983. Since then I have become a board certified Orthopedic Clinical Specialist – a distinction only 4% of licensed physical therapists in Virginia have achieved. As a Certified Lymphedema Therapist, I have expertise in decreasing edema and inflammation. I also specialize in analyzing the body for faulty movement patterns, mechanical restrictions, muscle imbalances of length and strength, and exercise prescription.
My passion has always been to treat the root cause of illness or injury and uncovering the factors that contribute to delayed healing. By being inquisitive, methodical and committed, my goal is to assist you to find answers for your pain and restore your ease of movement.
I am very excited to work with Dr. Kaplan and the other practitioners here at the Kaplan Center. Together we welcome the opportunity to develop a comprehensive treatment plan, which considers all aspects of healing – including your mind, body and spirit. A plan developed with your input allows for you to achieve your best possible health.
I look forward to working with you!
Michele McLellan, PT, OCS, CLT
To read Michele’s bio, click here.

What's Missing From the IOM Report About Chronic Fatigue Syndrome (SEID)

One doctor’s take on the Institute of Medicine’s new consensus report.

By Gary Kaplan, D.O.
As first seen on U.S. News & World Report.
The Institute of Medicine released their consensus report on myalgic encephalomyelitis/chronic fatigue syndrome, “Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness,” on Feb. 10. This report was prepared by the Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in response to a request by multiple agencies, including the Department of Health and Human Services, to examine the evidence base for ME/CFS. This committee was to set new diagnostic criteria that would facilitate timely diagnosis and care, as well as enhance the understanding of this disease among health care providers and the public.
The IOM panel proposed several positive changes, but I believe they fell short on two key issues. Here is a general overview of IOM’s findings, along with my commentary:
1. IOM declares that this disease does exist and is a medical, not psychiatric, condition.
For years, people suffering with ME/CFS have been battling a stigma associated with this condition. Some physicians have even doubted it to even be a legitimate illness. The acknowledgement from the IOM that this is a medical, not psychiatric, condition, as well as a complex, multi-system disease, was an important and necessary acknowledgement that will enable us to move beyond its stigma and provide the necessary support for patients suffering from ME
2. ME/CFS is out, SEID is in – maybe.
The IOM proposed the name Systemic Exertion Intolerance Disease to replace CFS. While I completely agree that a name change is necessary, as many consider CFS to be both stigmatizing and/or trivializing, SEID is not appropriately descriptive. It does not speak to the underlying complex pathophysiology of the disease but remains descriptive only of what is now regarded as the hallmark symptom – post exertion malaise. The World Health Organization regards CFS as a neurologic disease, and the International Consensus Criteria regards it as an immunological mediated neuro-inflammatory disease with multi-system manifestations. The term Myalgic Encephalomyelitis speaks to the pathophysiology and is accepted worldwide. ME does not carry a negative connotation, and I believe it should have been accepted by the IOM.
3. IOM’s Diagnostic Criteria for SEID.
IOM states that diagnosis requires the following three symptoms:

  • A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social or personal activities that persists for more than six months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest;
  • Post-exertional malaise; and
  • Unrefreshing sleep.

At least one of the two following manifestations is also required: cognitive impairment or orthostatic intolerance.
IOM successfully defined the criteria for diagnosis, but I disagree with the mandatory time of six months to make a diagnosis. This is far too long. To insist that a person suffering with this condition wait six months for a diagnosis, especially if they have no other infectious or disease process, is wrong. The IOM acknowledges that nearly a quarter of the approximately 1 million people suffering with this disease are housebound or bedridden. To delay their opportunity to seek specialty help imposes unnecessary suffering. It also denies researchers the opportunity to study this disease in its earliest stages. We should follow the ICC’s example and not have a limit on the length of time someone needs to be suffering with these symptoms before getting a diagnosis.
4. Creation of a new ICD-10 code.
This is another positive step that will help doctors and researchers identify and track the percentage and demographic of the population affected by this disease, treatment success and failure rates, and other details associated with SEID.
So where do we go from here?
What we need now is the commitment of research dollars commensurate with the extent and severity of this disease to enable us to further its study and treatment. To give one a perspective on the current lack of research funding, multiple sclerosis, a devastating disease that affects less than half the estimated number of people suffering from ME/CFS/SEID, will receive approximately $100 million in NIH research dollars this year, while ME/CFS/SEID will receive a mere $5 million.
With the release of reports from NIH P2P and IOM acknowledging the extent and severity of this disease, we need to see a drastic increase in research funds that will not only assist in the creation of several centers of excellence to study and treat this disease, but also further educate the next generation of physicians and researchers. I believe a commitment from HHS/NIH of $150 million in research grants a year is essential to address and find a cure for this devastating disease.
In January I had the opportunity to share my view on the challenges of diagnosing and treating ME/CFS/SEID. I also discussed the recent findings of the NIH Pathways to Prevention conference “Advancing the Research on ME/CFS.”

Dr. Gary Kaplan on "How To Be Mentally & Physically Healthy for Life"

About 100 million Americans live with some form of chronic pain — more than the combined number of those with diabetes, heart disease, and cancer. In this interview with Joe Polish and Dean Jackson, Dr. Kaplan reveals his single-point-of-origin approach: seemingly unrelated symptoms of chronic pain and depression actually have a single, neurological basis.

Dr. Kaplan draws on patient stories and cutting-edge research to reveal that physical pain and emotional pain are manifestations of the same inflammation, brought on by tiny microglial cells found in the brain and spinal cord. And, in order to see greater success in treatment we must stop thinking of pain and depression as diseases, but rather symptoms of this inflammation.

Dr. Kaplan explains:

  • Why we should be looking at pain as a symptom, not a disease
  • The role of microglia in the central nervous system, and in chronic pain
  • How to treat (or down-regulate) the inflammatory process and move towards total recovery

Dr. Kaplan stresses that “while pain is not optional, your suffering is,” and offers 3 daily actions to be mentally and physically healthy for life.

To listen to Dr. Kaplan’s interview please click on the play button below.