Positive Health Online

This is an amazing book, written by an amazing doctor. 

The book is complex, and a testament to Dr Kaplan’s willingness to regard his patients as complex problems to be solved, not just dismissed because the standard treatments don't work.  This means that this review must also be complex. We are sick of having 'total recovery' touted by charlatans, and of having the fact that our pain and illness may have some psychological traumas as precursors being treated as “therefore it's all in your head, and if you don't get better from CBT and GET, it's your fault”.  So Dr Kaplan’s perspective on these things needs careful explanation.

First of all, we are used to thinking that a claim for ‘total recovery’ is going to be followed by some magic pill, herbal remedy, or exercise regime that is supposed to provide immediate cure for our symptoms.

What Doctor Kaplan describes, with ultimate respect for his patients, is a persistent and wide-ranging search for the multiple and cumulative events in our lives - traumatic childhoods, infectious diseases, physical injuries - which can lead to a condition of chronic pain and chronic depression, which may be manifestations of a single illness.  Medical school teaches “if you hear the sound of hoof-beats, think horses, not zebras”.  Kaplan point out that by the time his patients have been diagnosed and treated, unsuccessfully, by eight to fifteen other doctors, all the horses have been ruled out.  He knows he is looking for zebras.

He also reiterates the unfortunate tendency of medical school to “engender a sense of us-against-them superiority that makes doctors quick to presume they are right and the patient is wrong – not just about the diagnoses, but about the symptoms themselves.  ….Just because a doctor doesn’t know how to cure the patient, relieve the pain or make sense of the clues, it doesn’t mean dismissing the patient is the most logical thing to do.  ….. In my experience, patients often tell us exactly what we need to know, if only we would listen.”  (pp. 29,30)

Although Total Recovery is full of technical information, the reader is carried along through a series of fascinating case studies, in a style which I suspect may owe a great deal to Donna Beech [Medical Writer and Collaborator].  If so we owe her a debt of gratitude in turning what is basically a medical text into a book that we ‘can’t put down’.  The information is vitally important, a revolutionary approach to some of the most intractable chronic health conditions (which involve extreme and long-term suffering to thousands, of patients), which confront medical science today.

Dr Kaplan’s cases are of mostly high-achievers who have gradually succumbed to a range of crippling symptoms, and have experienced an equal range of attempts by various medical specialists to treat them, without success.   The general medical view in the UK is that the more symptoms a patient reports, the more likely it is that his symptoms are “functional”, or “somatoform”, and the standard response is to suggest Cognitive Behaviour Therapy, to ‘cure’ the false belief that they have a real medical problem.   This divests the doctor of any further responsibility, and if the patients don’t get better, it’s their own fault.

Dr Kaplan’s response is the opposite - he regards the symptoms as important clues to the nature of the underlying, complex medical problem.  His diagnostic process begins with a lengthy interview, in which the first question to the patient is “tell me your whole medical history”.  Childhood illnesses and accidents, and every medical event since then up to the present - it is all significant, all part of the whole picture.  The second question is “tell me what has happened in your life”.  Because this will also include important clues to events that will have had consequences to health.

He will be interested in previous medical notes and reports, but will also conduct his own tests.  He works with a team, and draws on the skills and information available from a wide range of specialities, in conventional medicine, alternative practices, and psychotherapy.  He says it is the duty of the doctor to keep up with recent research, new ideas about treatment, the latest diagnostic tests – he says it takes time, but must be done. 

His own history is of a successful college graduate, determined to go to medical school to become a neurologist.  (In America, a doctor will typically get a university degree before entering the four year course to become a doctor.)  Before starting his medical training, he took a year to study acupuncture with one of the first physicians in the US to make use of it.  He thus began traditional medical training with the holistic approach of Chinese medicine still in his mind.  He found Western medical specialities very narrow, compared with the Chinese emphasis on treating the whole person.  Impressed with the precision of neurological diagnostic techniques, he was shocked to find that neurology had little to offer in the way of treatments.  One of the most renowned and beloved neurologists of the time became ill with ALS, a fatal neurodegenerative disease, and there was nothing that could be done.  Dr Kaplan “couldn’t bear the prospect of a lifetime of giving patients devastating diagnoses with no hope”.  As his medical education progressed, he concluded that while Western medicine was excellent at treating acute illnesses and injuries, “We were abysmal at treating chronic pain.  The way we treated patients suffering with chronic conditions, especially pain, was even worse.  It was as if these patients represented unknowns that were an affront to Western medical science.”  He found that family medicine offered the breadth of perspective he wanted in order to learn how to understand and treat chronic conditions.

So what are the understandings which he has reached?  Via the case studies, the book takes us through his journey of increasing insight into the mysteries of conditions which here have been dismissively labelled MUS,  “medically unexplained symptoms”, as though this is an actual condition which warrants no further attempt at explanation!

Early in the book, he introduces the insights of Dr Janet Travell, concerning the fascia, the normally soft and stretchy material which holds our bodies together and allows us to move freely.  Having a tensile strength of 2,000 pounds, when it constricts, it can send pain signals throughout our body. Dr Travell was the first to recognize this, and was the only doctor able to help President John Kennedy overcome the constant back pain which had plagued him for years.  The fascia have sensitive spots with a long-term memory of previous injuries, which she called trigger points.  These are electrically active spindles of muscle; 75-95% of regional pain is myofascial.  There are various treatments for this: often the kind of massage called ‘deep tissue work’ can resolve it.

After description of several very complicated cases, and his efforts to find ways of treating them, using all the tools that were available to him and his team, including diagnosing current bacterial, viral and parasitic infections, nutritional deficits, muscular and neurological problems, and past and current emotional stresses, he leads us to the discovery of the link that ties it all together.  He has already noted that chronic pain and depression seem to be linked, not just in the ways we might expect (that having chronic pain would naturally lead to depression).  According to a paper by neurologist Michael J Robinson and colleagues, pain and depression shared much of the same neurophysiology, and these “were both neuroinflammatory diseases”.  Further research added anxiety and PTSD to the list of “neuroinflammatory diseases in the brain”.

The insight that inflammation in the central nervous system and brain could be the cause of both pain and depression led to a further ‘Eureka moment’.  This concerns “microglia”.  “Microglia act as the resident immune system of the central nervous system.”  They act in two ways:  “In order to protect the brain, the microglia secrete inflammatory chemicals to create swelling that acts as a buffer, as they work to destroy the invaders.”

Dr Kaplan found articles linking the upregulation of the microglia “to physical injury, psychological trauma, loss of oxygen to the brain, bacterial infections, viral infections, environmental toxins”.  When they are upregulated, “the person enduring it begins to feel sick with fatigue, headaches, fevers and achiness all over.”

And the microglia have a long memory - as each event is added to the others, the effect is cumulative, and eventually the microglia remain permanently upregulated, with the predictable effects on the health of the patient - up to and including chronic pain and depression.

The book continues with a section on the importance of the gut - now known to be a central part of our immune system, and in need of the right balance of bacteria to help maintain its health and good functioning, including our basic ability to absorb nutrients, and to differentiate between nutrients and substances which could do us harm.  This section is a full explanation of the term ‘leaky gut’, and all of its implications.

Dr Kaplan then discusses the importance of laboratory tests, the responsibility of doctors to be informed about their accuracy and reliability (and their limitations), and to continually check that the laboratories to which samples are sent are doing their job properly.  He also admonishes doctors to remember that their patients are the most reliable source of information, and not to be ruled exclusively by lab results.

So what does Dr Kaplan mean by “total recovery”?  And what does he offer the reader, who probably doesn’t have access to his centre, or to doctors like him, doctors with his wisdom and respect for patients.?

What he means is that the patient must be treated as a whole; all the aspects of their situation and life history must be taken into account in trying to understand their state of health.  Then treatment must address all of the issues - bacterial, viral or parasitic infections, nutritional deficiencies and intolerances, myofascial tensions, muscular problems, digestive tract problems, sleep disorders, emotional trauma.  The overall focus is to address the issues which lead to upregulation of the microglia.

An example is a patient whose lab results showed: Extremely low vitamin D, Extremely low magnesium, Gluten intolerance, Amoebic dysentery, Bacterial overgrowth and Sleep disorder. 

The treatment included: Manual therapy, Live probiotics, Elimination diet, Magnesium IV, Prolotherapy (this is a form of providing a slight irritant to tendons and ligaments as a way of stimulating healing processes, now known as “regenerative medicine therapy”), Chinese herbs, Physical therapy, Cognitive behavioral therapy, Antibiotic and antiparasitic medications.

These, as well as acupuncture and low dose naltrexone were applied in a carefully considered order and timescale over more than a year.  The patient’s IBS was resolved within a month, her chronic headaches in four months, her pain reduced by 90 percent.  Her energy was 80 percent better, and she was back at work, back to enjoying her life.

The chapter on the importance of emotional trauma, especially in early life emphasizes that these experiences and the emotional responses involved upregulate the microglia in the same way that physical trauma or infections do.  A childhood characterised by any form of emotional or physical abuse primes the microglia to respond in extreme and long-term ways to any type of subsequent challenge, potentially causing permanent pain after events that most people would recover from very quickly.

But what about us, the readers?  Chapter 8, Stacking the Deck in Your Favor, What You Can Do is a considered and detailed account of actions that you can take, in taking charge of your own health.  It includes studying your own timeline, dealing with past emotional traumas, (and creating a timeline for recording positive events and the positive changes you are making!), trying a low-inflammation diet, and keeping a record of eating and after-effects, avoiding stimulants, evaluating your progress, adding new foods one at a time, while looking for signs of allergies, considering supplements such as magnesium and omega-3s, probiotics, as well as dark chocolate, green tea, regular exercise and meditation.  All of these are aimed at down-regulating the microglia.  He also suggests enquiring about low-dose naltrexone, minocycline and angiotensin II receptor blocker.  He says that you can’t do all this without a partner, so it will be important to seek out a medical practitioner who will be sympathetic and supportive as you work with this approach.  Try to find someone who has the same respect for you that Dr Kaplan has for his patients (good luck with that!)

So, no magic bullets, no expensive treatment protocols - disease is not a single event, but a process.  Taking responsibility for your own health is a process which you can undertake with the information in this book to guide you.  A complex set of events has led to your current state of health: a complex set of processes you can undertake can lead towards ‘total recovery’. 

I will end where I began:  This is a book which has the potential to take the whole practice of medicine forward. Chronic diseases are becoming more common, they are not well served, patients too often dismissed as ‘somatoform’ or ‘functional’ (meaning that the problem is purely a matter of letting emotions from the past cause physical symptoms: not in the sense that this means the doctor should find a way to treat it, but rather that if psychotherapy doesn’t help, it’s the patients’ fault.) 

If / when the information in this book reaches mainstream medical education and medical practice, doctors will be able to experience the rewards of seeing their patients regain good health, and patients with chronic illnesses can begin to experience total recovery.  We patients need to read it, and we need to get our doctors to read it.   It is an amazing book, written by an amazing doctor.

I should add a postscript that in this book, Dr Kaplan is dealing with exactly what he says he is:  chronic pain and depression.  He does not mention ME in the book - many patients who have ME do not experience pain as a symptom, and few are depressed.  Nevertheless I am convinced that his insights are very relevant to ME.  It is beginning to be recognized as a disease involving inflammation in the central nervous system and brain, and ‘leaky gut’ is beginning to be researched as well.  ME has complex etiological factors and no truly effective treatment exists, although there are a range of things which have helped certain patients in particular ways.  I feel sure we’ll learn that microglia, also ‘leaky gut’ are an important part of the picture, and I feel confident that an ME patient who followed the recommendations he makes would benefit greatly.

Further Information

Available at Amazon and at www.KaplanClinic.com

www.amazon.co.uk/Total-Recovery-Solving-Mystery-Depression/dp/162336275X

www.amazon.com/Total-Recovery-Solving-Mystery-Depression/dp/162336275X