Can technology transform the way we approach health and healing? In this episode, we explore the intersection of neuroscience, innovation, and the mind-body connection with Dr. Brennan Spiegel from Cedars-Sinai. Dr. Spiegel challenges the long-standing myth that the mind and body function separately, revealing how our thoughts, emotions, and physiological responses are deeply intertwined.
We take a deep dive into alternative therapies that go beyond conventional treatments, including vagus nerve stimulation (VNS) and its impact on relaxation, well-being, and potential applications in treating health conditions. From implanted devices to non-invasive, direct-to-consumer options, we break down how VNS works and its role in the parasympathetic nervous system (think: rest and digest). We also discuss percutaneous electrical nerve field stimulation (PENFS), a distinct yet related therapy offering new opportunities for managing gastrointestinal disorders.
But the innovation doesn’t stop there. We explore the growing role of virtual reality (VR) in healthcare, examining its influence on physiology, pain management, and patient outcomes. Backed by research from leading institutions like Cedars-Sinai and the Mayo Clinic, we uncover how VR is shaping modern medicine. Also, Dr. Spiegel shares fascinating insights on how gravity affects the body and how cutting-edge technology provides immersive healing experiences for patients in need.
Join us as we navigate this exciting frontier where technology and health converge, offering fresh perspectives on how VNS, VR, and the power of the mind-body connection may revolutionize medicine.
Tune in now and discover how these advancements could change the future of healthcare and well-being.
This podcast episode is sponsored by Ardelyx.
References:
Resources mentioned by Dr. Brennan Spiegel
SynerGI - IBS VR Program available through research studies
Xaia - VR support program available through Apple Vision Pro
Tripp VR - Immersive meditation program on mobile and VR devices
Vagustim - Vagus nerve stimulation product mentioned by Dr. Spiegel (contains marketing affiliate link). Get an extra 20% off by using coupon code: GutHealth20
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata (00:00):
This podcast has been sponsored by Ardelyx.
Maintaining a healthy gut iskey for overall physical and
mental well-being.
Whether you're ahealth-conscious advocate, an
individual navigating thecomplexities of living with GI
issues, or a healthcare provider, you are in the right place.
(00:23):
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello friends, and welcome toThe Gut Health Podcast, where we
talk about all things relatedto your gut and well-being.
(00:44):
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Dr. Megan Riehl (00:47):
And I'm Dr Megan Riehl, a GI health
psychologist, and we have areally fascinating episode for
you today as we dive into theincredible power of the vagus
nerve and some interestingtreatments.
As one of the 12 cranial nerves,the vagus nerve connects the
brain and the body and itstretches from the brainstem all
the way to the gut.
That's why we think about thevagus nerve when we're thinking
(01:09):
about some of our gut healthissues.
It plays a very crucial role inparasympathetic nervous system
activation.
So we're thinking relaxation,response, and what we think is
very exciting is that we'relearning more and more about the
ways that we can get at thatvagus nerve.
We see FDA-approved devicesthat can stimulate the nerve for
(01:31):
conditions like epilepsy andmajor depressive disorder, as
well as migraines.
But research is emerging andhow we're getting to the vagus
nerve might include handhelddevices that you can purchase on
the internet, or evenpotentially enhancing brain
function through deep breathing,meditation, massage or even
moments of wonder and awe, whichcan all activate our vagus
(01:54):
nerve to promote calmness andwell-being.
So we're thrilled to have anexpert with us today to step
outside the box and explore someof the science of this
neurostimulation, and you'llhear us using some terms like
vagus nerve stimulation,percutaneous electrical nerve
field stimulation, also known asPENFS, and the transformative
(02:18):
potential of virtual reality forour gut, health and beyond.
So we are very excited tointroduce you to our guest
expert today.
Kate Scarlata (02:29):
Yes, we are so excited.
Dr.
Brennan Spiegel is Director ofHealth Service Research for
Cedars-Sinai in Los Angeles anddirects the Cedars-Sinai Center
for Outcomes Research andEducation, a multidisciplinary
team that investigates howdigital health technology,
including wearable biosensors,smartphone applications, virtual
(02:51):
reality and social media, canstrengthen the patient-doctor
bond, improve outcomes and savemoney.
His team developed one of thelargest and most widely
documented medical virtualreality programs at Cedars-Sinai
, and his work has helped tosupport a new field of medicine
called Medical Extended Realityor MXR, in which doctors use
(03:15):
immersive technologies likevirtual reality to help treat
conditions ranging from pain toanxiety and depression and even
irritable bowel syndrome.
Dr Spiegel has publishednumerous best-selling medical
textbooks, editorials and hasmore than 270 articles in
peer-reviewed journals.
His digital health research hasbeen featured by major media
(03:37):
outlets, including the New YorkTimes, bloomberg, cbs News and
more.
Dr Spiegel published the bookBloomberg, cbs News and more.
Dr Spiegel published the bookVRX How Immersive Therapeutics
Will Revolutionize Medicine,which was named by Wired
Magazine as one of its top eightscience books of 2020.
We welcome you.
Dr. Megan Riehl (03:57):
Dr Spiegel.
Brennan Spiegel, MD (03:58):
Good to be here.
Thanks for having me.
Dr. Megan Riehl (04:00):
So, before we dive in, we like to start every
episode by asking our guestabout a myth they'd like to bust
.
So what myth would you like tobust pertaining to your area of
expertise or gut health?
Brennan Spiegel, MD (04:15):
Well, I think there's a myth that goes
all the way back to around the1600s probably well before that,
but at least the 1600s when thephilosopher, the famous
philosopher, Rene Descartesanyone who studied philosophy
has come across his work theFrench philosopher, and he came
(04:37):
up with this idea.
He called dualism.
And the idea behind dualism isthat the mind and the body are
separate and distinct, that themind is this immaterial
experience with a spiritualcomponent and the body is the
physical machinery that movesthat mind around in the world.
(05:01):
And they're separate, they'redistinct, they're dual.
And that's how we've thoughtabout modern medicine for years.
You think about psychiatristsyou know, manage the mind, and
GI doctors manage you know thepumps and tubes in the body.
There's plumbers that manage.
You know the heart and theblood vessels and all that.
And then there's people thatthink about the emotions that we
(05:24):
experience.
But that's a myth.
In reality, we know that it'sall one system.
This says nothing about whatyou think about religion or
spirituality.
I'm just talking about thephysical systems that connect
the mind and body and in fact,that sets up the vagus nerve in
part.
Sure does.
Because that is a clear and whatwe'll talk about today sign
(05:48):
that the mind and body are notseparate and distinct.
They very tightly are coupledand interact with one another.
So that's a big myth.
Dr. Megan Riehl (05:56):
It's a great myth to bust.
Kate Scarlata (05:57):
I like that, yes, and I think we're seeing just
this integration ofmultidisciplinary teams,
especially in gut disorders,being so much more beneficial.
So we're really just thisintegration of multidisciplinary
teams, especially in gutdisorders, being so much more
beneficial.
So we're really, you know,looking at the whole body
instead of separating things.
So we're going to talk aboutvagus nerve stimulation.
We're going to talk a littlebit about virtual reality, but
(06:19):
let's start with vagus nervestimulation.
I find the science reallyinteresting and feel like we're
not quite there yet, maybe withsome of these devices that are
out there, but they could have alot of health benefits, or
there's the signals that theymight have some health benefits
to a lot of different conditions.
So how does one stimulate theirvagus nerve?
(06:42):
What are some of the techniquesto do such?
Brennan Spiegel, MD (06:45):
Yeah, well, there's different ways to
stimulate the vagus and, as yousaid, the vagus nerve is one of
the cranial nerves.
Vagus shares the root forvagabond, which basically is a
wanderer.
And the vagus nerve is awanderer.
It is the longest nerve and itwanders all throughout the body.
(07:09):
It takes twists and turns, ithas branches and side branches.
It goes all throughout the GIsystem, the heart, it gets all
around.
So you can imagine there'sdifferent ways to stimulate it
because it goes in all sorts ofdifferent locations.
We can stimulate it in the ear,can stimulate it in the neck.
That's, the most common placeis on the neck, because the
(07:31):
vagus nerve runs right up theneck along the carotid arteries,
the main big arteries where youcan feel your pulse in the
front of your neck on eitherside.
And in the past it wasstimulated by implanting an
electrode underneath the skinthrough a procedure which is
rather invasive.
But now we have different waysto stimulate it through the skin
(07:52):
.
So, for example, I do have avagus nerve stimulator that I
have used and it stimulates itthrough the ear, and so it's
almost like wearing an earbud.
It releases a very lightelectrical pulse through the ear
and it stimulates a branch ofthe vagus nerve that goes all
the way up to the ear, and thenyou know it's a rather
(08:14):
non-invasive, pretty simple wayto stimulate the vagus nerve
without having to do a procedureor an operation or something
like that.
But yeah, there's differentways of doing it like that.
Dr. Megan Riehl (08:23):
But yeah, there's different ways of doing
it.
I think in my clinical practice, you know I've had patients
that have been told by somebodyyou know they have vagus nerve
dysregulation or dysfunction andyou know they're here to fix
that.
How do I fix my vagus nerve?
And you know, I think if youGoogle the vagus nerve you're
going to see all of thesedifferent, more invasive vagus
nerve stimulation which, to bevery honest, when somebody would
(08:45):
come to me, I used to be like Idon't do that, like I'm not
going to implant something inyour system, but I would talk
about lifestyle, that connectingthe mind and the body, and that
the things that we can do toactivate our parasympathetic
system are going to be good foryour vagus nerve.
But there's so much in betweenthat that people can find it is
(09:07):
kind of cool to see that thereare these devices that you can
purchase and experiment withthat, see what your experience
is with.
You know there are somecontraindications that you will
certainly want to talk to yourmedical providers about when
you're thinking about exploringthis on your own.
And I think you know it'sinteresting to just kind of when
(09:31):
you were looking at why youpurchased, without getting too
personal, but I'm curious likewhat were you looking for when
you made that purchase?
Brennan Spiegel, MD (09:36):
Well, mainly I wanted to understand
what it felt like and whether itmade an impact on my own body
and mind.
You know it's useful to have afirst person experience.
This is the reason why, by theway, when I had my first
colonoscopy, I did it withoutsedation, so I'm not
recommending that for everybody,but that's what I did so, you
know, got to understand whatyou're talking about if you've
(09:58):
been through it.
So vagus nerve stimulationappealed to me because it's so
non-invasive, generally quitesafe and there's evidence behind
it.
It's evolving, like you guyssaid at the beginning, this is
an area that we don't yet have alot of information on, but it's
growing and in some cases wehave FDA-cleared indications,
(10:18):
like for epilepsy.
It's gotten so far that it'sFDA-cleared.
In other areas like, let's say,inflammatory bowel disease or
irritable bowel syndrome orother GI conditions, are still
learning.
So I wanted to see what it waslike and I looked at a bunch of
different technologies.
I also talked to some expertsin the field see what they use,
and the intraauricular or theearbud version was recommended
(10:42):
as a good starting point.
So I've really enjoyed using it.
You know, talk more about ourexperiences, yeah.
Kate Scarlata (10:47):
Love it.
So what is like the biologicalmechanism behind stimulating the
vagus nerve and some of thesedownstream effects like motility
, maybe even inflammation, oryou know how would it help
epilepsy?
What's going on?
What do we know?
How?
Brennan Spiegel, MD (11:04):
Would it help epilepsy?
What's going on?
What do we know?
Well?
Kate Scarlata (11:07):
We don't know what we don't know.
Brennan Spiegel, MD (11:08):
Okay, so that's a good place to start,
that's always the case and weshould always try and stay
humble with science.
And I will say that in science,particularly in academics,
where we are in this sort offortress of orthodoxy, we
sometimes will just poo-pooideas that seem like
(11:28):
pseudoscience or we'll brandthem as voodoo or pseudoscience.
But they're not pseudoscience.
Pseudoscience means you cannotunder any circumstance even
study this idea.
It doesn't even make senseaccording to the laws of physics
or science or whatever.
That's not the case forsomething like vagus nerve
stimulation.
Although some people mightthink it's kind of silly, it's
(11:50):
like any other new innovation wehave to study it.
So the vagus nerve does lots ofthings and if we stimulate it,
you can imagine it's going tohave different effects on the
body.
Certainly in the gut it'sinvolved in promoting rhythmic
contractions.
Certainly in the gut it'sinvolved in promoting rhythmic
contractions.
So we call this the rest anddigest phase as opposed to the
fight or flight phase.
(12:11):
So these are the ways we thinkabout it in physiology is you
know, if you see a lion comingat you?
God forbid that happens to you.
But 10,000 years ago ourancestors were getting chased
down by all sorts of threats.
You got to either fight thatthing or run like crazy and get
away.
You don't have time to digestyour food right.
(12:31):
That's not a time to be puttingany blood flow into your gut.
The blood's got to go into yourmuscles, your lungs, your brain
, and you got to run like crazyand fight.
Your pupils have to dilateright.
You need to be ready to go.
That's how too many people livetheir lives, as if they're being
chased down by lions, and thatleads to stress and anxiety and,
(12:54):
at some point, just downrightdepression, because you can't
handle it anymore.
You just collapsed, and so thevagus nerve is a switch that
helps turn on that rest anddigest program.
That's the exact opposite.
This is where you're relaxing,you're digesting your food.
Your heart rate is slowing down, you know, and you have what we
(13:17):
call improved or more variableheart rate variability and this
is an important concept of thebeat to beat variation in the
heart, not just the heart rate,but how is the heart beating and
the vagus nerves involved inthat too.
And that's just the beginning.
You know you've touched on someof these already in terms of
inflammation and the microbiomeand serotonin.
(13:41):
We would definitely have totalk about serotonin today, and
I don't want to get too far outthere because I've just thrown
out so much already.
But all of these are potentialways that if we buzz this nerve,
good things could happen, youknow, if we're careful about it,
and some of those I've justtouched on there.
Dr. Megan Riehl (13:58):
And there's different ways to buzz it.
That's the key, and I think,when we think about some of the
GI literature out there, thereare vagus nerve stimulation
techniques that again are thingsthat any of us could do, like
diaphragmatic breathing or evengurgling to get at certain sound
(14:19):
wave sensations that can moveyour body.
And then there's a separate butdistinct type of therapy that I
mentioned earlier thepercutaneous electrical nerve
field stimulation, and this isthe type of intervention that
we're seeing in some of theliterature where, if you are
Googling, especially for thepeds population things like
(14:40):
functional abdominal painrelated to IBS we're seeing some
products out there that areavailable that have really great
data with reductions in painand disability, improving
well-being, some of thoseemotional outcomes that we're
looking for in the treatment ofthese symptoms.
So there are really cool thingsin the pipeline that are
(15:04):
happening that are going toshift the way we look at what a
treatment might look like forpeople, and so I'm wondering you
know I mentioned a study thatwe'll link and it was a 2023
study on these devices but whatis some of the latest research
and studies in theseneurostimulation therapy kind of
(15:24):
worlds related to the brain-gutaxis that are getting you
excited?
Brennan Spiegel, MD (15:29):
Yeah, I mean, you've hit it on the head.
There's so many differentapproaches and so many different
mechanisms and so manydifferent conditions, so you
almost think of it like a Venndiagram.
There's the actual modality,the actual electrical system.
There's what condition are wemanaging?
And then what mechanisms do wethink we're leveraging?
(15:49):
Leveraging, and it's still alittle bit murky.
But this idea of percutaneouselectrical nerve stimulation is
really fascinating to me,because what we do know is that
there are virtual gates thatallow pain to pass through and
up the spinal cord or not, andso you can imagine even just
(16:13):
something like TENS therapy youknow, transcutaneous electrical
nerve stimulation for chroniclower back pain.
Just take away abdominal painfor a second.
The idea here is, when you werea kid or even as an adult, you
hit your elbow and it hurts.
The first thing you start doingis you rub it.
You know, you like just rubyour elbow because you got a
boo-boo right and it hurts.
(16:33):
And somehow you know a parentrubbing their child's boo-boo
makes them feel better.
Well, what's that all about?
Is that just placebo?
Well, no, actually what wethink is happening is you're
overriding the pain sensationswith these additional
stimulations, these additionalsignals, stimulations, these
(16:57):
additional signals, and whatthat can do is overwhelm the
pain processing sites and evenclose down these so-called
virtual gates.
And these gates are aligned upand down the spine and they are
involved in kind of like a gatein a fence.
If it's open, then the horsewill go right out of the barn,
but if it's closed, the horsestays in there.
And by literally rubbing theskin, you are modulating or
(17:19):
changing whether the gates areopened or closed.
So with electrical stimulation,what's happening is it's a more
precise and modifiable way ofdoing that, and we think that
closing virtual gates is one ofthe ways that this works.
We also know that people withirritable bowel syndrome in
particular, and people ingeneral who have chronic pain,
(17:42):
often have difficulty closingthose gates, and it has to do
with the brain.
Now, now we're back up on thebrain side, because what the
brain does is it sends signalsdown the spinal cord.
The brain can fight back.
The brain doesn't just sitthere and take whatever it gets.
It can fight back.
And the way it fights back isby sending what are called
(18:07):
inhibitory signals.
The technical term is descendinginhibitory pathways where these
signals go down the spine andactively shut those gates so
that you can just relax.
So just imagine if you didn'thave that.
Every twist and turn your boweltakes, every stretch of the
intestine, every movement of thefood would be constantly
bombarding your brain withsignals and you would feel your
(18:29):
food going through your body.
I mean, just imagine howmaddening that would be if we
didn't have an ability to shutdown those sensations.
And that's how we do it.
But if you can't shut thosedown, then that's very tough.
So electrical stimulation oneway we think it works is by
shutting those gates down.
Dr. Megan Riehl (18:47):
Yeah, and you know, I think that's where, to
your point, we have to be opento exploring this.
Because you know, just like, ifyou would have told me I would
be doing gut-directedhypnotherapy every day in my
clinical practice a decade ago,I would have told you we're kind
of nuts.
But yet here I am and it's sopowerful and we have a fully
(19:07):
integrated acupuncturist in ourGI practice.
And same thing they're lookingat certain acupressure points,
acupoints in the body, that ifwe hit on those in the right way
, we can produce profoundchanges for patients.
So it's exciting.
Brennan Spiegel, MD (19:27):
And I will add one thing here, because we
have, you know, a dietician withus.
Kate Scarlata (19:31):
That's right.
Brennan Spiegel, MD (19:32):
But the idea there is.
It's all interrelated.
So the intestinal system.
If we think about this for asecond, it's a little bit like a
donut.
So what do I mean by that?
If you take a donut and youstick your finger straight
through the hole, you're neveractually inside of the donut,
you're not in the substance ofthe donut at all.
You've just put your fingerright through the hole and
(19:54):
you're touching nothing but air,right?
Well, that's basically how ourGI system works.
It's like a hole, but it's along one, right, and it's a long
tube, but it's an invertedpassageway and if you pass all
the way through into the otherend, you're actually never
really inside the body.
You know, it's like those waterwiggler toys.
If you've ever played withthose.
(20:14):
They inside the body.
You know it's like those waterwiggler toys.
If you've ever played withthose, they'll like invert on
themselves and you can't keepthem in your hands and they
slide right out.
Kate Scarlata (20:18):
Yes.
Brennan Spiegel, MD (20:18):
So what's happening in the gut is it is
the outside of our body,sampling the world around us and
allowing some of it to pass inand some of it not.
And so we know for sure thatthe microbiome which lines the
colon and in some cases worksits way up into the small
intestine is really vital formodulating that interface with
(20:41):
the world itself.
And of course, the food that weput in will modify the
microbiome and in some parts ofthe gut it may change how
so-called leaky the gut is, howpermeable the membranes are.
And this is where the vagusnerve comes back.
Again.
It may be, it's thought, thatstimulating the vagus nerve can
(21:04):
help us modulate how tight thegut membrane is, even by
changing the local immune systemthrough these pathways,
electrical pathways.
And now it starts to all cometogether in a way that if we
change the diet and we changethe microbiome and we modify the
local immune system and we cando some of that through the neck
(21:25):
or the ear, that's like wild tothink about that.
But now we have tools diet,electrical stimulation.
Of course psychotherapy,psychological therapies are
vital, whether it's hypnotherapy, cognitive behavioral therapy.
All of this gets back to myoriginal myth that the mind and
the body are not separate anddistinct.
They're tightly coupled witheach other and they talk to each
(21:45):
other.
And these are some of the waysthat they talk to each other.
Dr. Megan Riehl (21:48):
It's fascinating, you know.
I think it goes back to wedon't have to do it all at once,
you know.
I think it goes back to we don'thave to do it all at once Right
and subtle changes in ourlifestyle can be a good stepping
stone moving forward to makingchanges in your overall health
and your gut health.
And we don't want to overwhelmeverybody with, like you got to
(22:17):
do it all at once but over time,living this kind of mindful
approach to our health, knowingthat how we eat, how we move,
how we engage with ourenvironment, the air that we
breathe, all of these thingsimpact this incredible
microbiome that we have.
That's unique.
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Dr. Megan Riehl (23:42):
So what do you say?
We kind of dive into your otherareas of expertise.
We've got a couple of questionsabout virtual reality that our
listeners will definitely beinterested in, and I may even
share a little bit about myexperience with virtual reality.
Kate Scarlata (23:52):
Yes, I think I maybe had a little experience
with virtual reality as well.
There you go.
I know it's nice.
We know people in high placeslike Dr.
Spiegel, right?
So let's talk a little bitabout different VR products.
How do they work?
I know you've done a lot ofwork in virtual reality and IBS
(24:13):
and pain, so can you talk alittle bit about how they work
for those issues?
Brennan Spiegel, MD (24:19):
Yeah, absolutely, and this may seem
like a big pivot from our lastdiscussion, but not really.
It's another mechanism where wetry to modulate that
relationship between we'll callit mind and body, or brain and
gut, and VR, we have found is avery powerful way of positively
(24:39):
affecting the mind in a way thatcan change the body.
So most people when they thinkof VR, they think of a platform
for gaming and entertainment.
They might think about MarkZuckerberg and meta or whatever.
And yeah, it's been used forgaming and entertainment.
But long before it was used forthat, it was being tested in
(25:01):
psychology labs all around theworld, all the way back by the
Department of Defense, even the1950s, as a way to simulate
complex environments.
And it just got to the pointwhere the technology got so good
and so inexpensive, relativelyspeaking, that we could start
testing it out in clinics.
So, for example, we justpublished a paper recently with
Mount Sinai, which was sofascinating, demonstrating how
(25:25):
VR can change physiologydirectly.
So what we did in this study iswe took people and we put them
in a really relaxing beach invirtual reality.
You can hear the reality, youcan hear the music, you can sort
of hang out on a beach or on alake or on a mountaintop and it
really feels very, very real.
The music's beautiful and wecan do guided breathing, which
starts to affect the heart rateand heart rate variability.
(25:48):
So it's actually affecting thevagus nerve directly and when we
actually measure heart ratevariability we can see that it
changes.
But we also can see that wechange cortisol levels in the
body.
We can see that we can changebody temperature.
We can cool the body down.
We're doing a study now at theMayo Clinic using VR for
vasomotor symptoms of menopause.
(26:09):
For example, can we literallycool the body down through
beautiful snowy environmentswhere you feel like you're
sitting in the snow?
We can even change white bloodcell count through virtual
reality.
We've now been able to show,and so we've been using this for
a bunch of conditions,especially pain, and not just
for the immediate experience,but over the course of eight
(26:31):
weeks.
We can deliver different formsof cognitive behavioral therapy
to supplement clinicians likeMegan right who do the hard work
of really tailoring therapy.
But then you go home and youmay not see your therapist for
another week or two or more, andso having something like VR
might help bridge that gap, andso we've created VR programs for
(26:54):
irritable bowel syndrome.
We're using it now in IBD andIBS.
We're using it for chroniclower back pain, for cancer pain
a whole variety of differentconditions.
Dr. Megan Riehl (27:05):
How do people receive this?
You know, when you walk in andyou say, in addition to your
inflammatory bowel diseasetreatment, we're going to
recommend this headset and thisexperience for you.
Brennan Spiegel, MD (27:16):
I'll tell you, most people really are
intrigued.
Yeah, because we're not sayingthis is a substitute for your
traditional medical care, it'sto help augment it.
And when we talk about thebrain-gut axis or the mind-body
axis and all the stuff we'vebeen talking about today, people
I think are very open to tryingthese things and all the stuff
we've been talking about today,people, I think, are very open
to trying these things.
I can think of an example justfrom the hospital a few weeks
(27:38):
ago, when I was on service andwe had a patient who had had
really significant abdominalpain after abdominal surgery and
it really never got better.
The pain just didn't get better.
We see that sometimes afterabdominal surgery better, the
pain just didn't get better.
We see that sometimes afterabdominal surgery and it got to
(27:58):
the point where this patientreally couldn't eat and ended up
being on TPN total parenteralnutrition, where all the
calories are put through theveins.
She couldn't eat anymore and wecouldn't really figure out what
was inhibiting her ability toeat.
And so, you know, I spoke tothis patient and really came to
realize like there was a lot ofanxiety, to the point where if
(28:21):
they even sipped some water itwould just cause immediate pain
in the belly, and so that's thepoint where I say God, that
doesn't even make physiologicalsense.
That is a form of anticipation,anxiety at that point where the
brain is primed, sensitized, tofeel pain, and I don't think
doing another surgery is goingto fix that Right.
(28:43):
So we tried virtual reality andwe try to form a virtual
reality that also usesartificial intelligence to help
talk to people, and we've gottenbetter and better at this over
the last couple of years,developing and you guys use an
early version of this- Good oldMaya.
Yeah, maya, and so she used itand I mean this doesn't always
(29:05):
happen, but it happens.
Within five days she was eatingI mean almost a full diet.
She had bacon and eggs fivedays later and she hadn't eaten
anything in months and months.
And she was eating I meanalmost a full diet.
She had bacon and eggs fivedays later and she hadn't eaten
anything in months and monthsand she was walking around the
ward, really just conversational.
Now we didn't secure anythingand maybe it'll come back, but
(29:26):
just to see that response, Irealized like we are only
working.
We're like we're working withone hand tied behind our back if
we don't use these kinds oftechniques.
Dr. Megan Riehl (29:37):
So you're mentioning something that's very
, again, very similar with ourbrain-gut behavioral therapies,
where openness to trying isreally a key characteristic.
Are there other characteristicsthat are going to contribute
potentially to a patient'ssuccess and outcomes?
Brennan Spiegel, MD (29:51):
Yeah, yeah for sure, openness is a big part
of it, but there's alsosomething called immersive
tendencies, and this is kind ofa technical term.
It's easy to understand.
Some of us get more easilyimmersed into fantasy worlds
than others, and not even justfantasy, I mean just watching a
football game.
Some people love sports.
(30:13):
They are so into that game thatyou can't talk to them, but
that game is happening on adigital screen somewhere far,
far away.
In a way, it's like a fantasyexperience.
It's not literally happening inyour, but you feel that it's
happening.
And or you're reading a booklike my son loves reading, and
(30:35):
I'll call his name out and hecan't hear me because he's in
the book or you're in a movie.
Whatever the example is, itturns out that there is a
natural variation among humans.
Some people are very easilyswept up into these narratives
and some not so much, and itseems like that affects how well
something like VR works.
You know, you might just think,oh, this is really interesting
(30:57):
and cool looking, but I'm notfeeling anything, whereas other
people they realize like I'm soimmersed in this world that I've
forgotten that I have pain, Idon't feel it.
My nervous system has releaseditself, and that's the moment
where we say listen, like you'venow learned that you have the
superpower.
Supernatural and I use the termsupernatural Literally.
I say super means above, likeSuperman flies overhead.
(31:18):
Super means you have found alevel of consciousness higher
than where you normally operate.
And natural, you did ityourself.
We didn't give you a medicationor inject something, so you've
just learned something about it.
It's the people who haveimmersive tendencies that are
most likely to have that kind ofsupernatural reaction.
Kate Scarlata (31:36):
That's me, you know it's funny.
When I did yeah, I was like I'mjust going to do this virtual
reality thing with Brennan forlike five minutes.
And then it was like how longhave I been doing this?
But I am so immersive.
My husband talks to me all thetime.
I'm like what you know, totallyfishy, and my father was the
same way too, like just lockedinto whatever you're doing.
(31:58):
Yeah, so that's interesting.
Dr. Megan Riehl (32:01):
And I don't tend to miss a thing.
So when I had the headset onnumber one, I wanted to see if
Maya was any good.
You know, like she is me right,she's the AI version of a
therapist and so it wasinteresting to put the headset
on and you're seeing thevisualization.
And again, if you're a listenerand you are an immersive person
and you have IBS, you know, Iwould encourage you to check out
(32:22):
Dr Spiegel's products and kindof work in this area, because
you do get evidence-basedtreatment in this virtual way
and she's using many of theskills and cognitive reframing
and psychoeducation that reallycould reinforce, especially if
(32:44):
somebody is working one-on-onewith a therapist or doing group
work.
No-transcript.
(33:25):
to the point of the beginningof our episode.
We're thinking outside the box.
Brennan Spiegel, MD (33:30):
Believe it or not, that was almost two
years ago, I know, and that wasa pretty early prototype.
It was still pretty impressive,I'd say.
Now we're at, I know, write anote out that's quite impressive
(33:54):
and put it in the chart.
We think of it kind of like aparatherapist that's a term I
just made up, you know, aparamedic is.
Para means beside, and in thiscase medic means doctor.
So the paramedic is beside thedoctor and as a liaison between
the doctors in the emergencyroom and the patients out in the
field and helps run back andforth between them.
(34:18):
And the way I think of aparatherapist again, I just made
this up, see what you think ofit is, you know, like when you
go to see a hairdresser, theycut your hair and then by the
time you get home it's like allmessed up, like how did they do
that?
How do I fix this hair?
It's like, as soon as you spendall this time and energy with a
client and they go home andthen life starts to happen,
they're like oh my God, how do Iremember what we talked about
(34:40):
and those skills that I learned?
How do I reinforce those?
And that's where, like, thereal learning is happening, and
so the idea of the paratherapistis have somebody who's got your
back, who knows your patientand has almost like a
prescription of exercises tofollow and can inform you about
what's been going on betweenvisits, writing notes and also
(35:01):
contacting you if something'snot going well, and doing all of
that to get it back to the VRwithin virtual reality, because
the whole point of the VR,rather than just talking to a
chatbot is we use AI to changethe world around you.
In virtual reality, we callthis GR generated reality, so
we're generating a realityaround you based upon what
(35:22):
you're talking about, and itwill pull up the right music or
the right visualizations or artbased upon what you're saying.
Like, if you're talking aboutstress, maybe it's going to put
you in a Japanese you know, zenrock garden.
If you're talking about yourgender identity, maybe it's
going to surround you withrainbow colored butterflies and
with images of acceptance.
Right, it's pretty wild withthe VR pulls off, but it's
(35:45):
really not a substitute for ahuman.
It's.
I think of it like aparatherapist.
Kate Scarlata (35:50):
Yeah.
Dr. Megan Riehl (35:51):
We could all benefit from that Right.
Kate Scarlata (35:53):
I mean I loved it when I left.
After doing that, I came homeand I'm like everyone should
have one of these headsets.
You're just kind of lost intranslation.
I was very in my own littlespace and you know, sometimes
you, we could all benefit fromthat, you know.
Just see you later, everyone,that's right.
Brennan Spiegel, MD (36:10):
People always ask like well, are people
going to get addicted to it?
Or what about real reality?
And we're very concerned aboutthat too.
We don't want people todisappear into screens.
We've seen enough of that.
Kate Scarlata (36:22):
Right.
Brennan Spiegel, MD (36:23):
We want people to learn something about
their mind and their body andtheir reality and their emotions
and whatever we can teach themthat they then bring back to
real reality.
I call that RR real reality yes.
And so we try to keep theexperiences short 10 to 20
minutes, even though you were inthere for quite a while.
Kate Scarlata (36:41):
I know, all right , just beat me up, beat me up.
Brennan Spiegel, MD (36:45):
And we also have an app that goes along
with our programs.
We have a new NIH study that,by the way, is about to start,
so if you have any listeners whohave been diagnosed with
irritable bowel syndrome, theymay be eligible for this study.
It's a remote study, so youdon't need to be in Los Angeles,
where I live.
It can be anywhere in thecountry and we can ship out the
equipment to you.
So that study is about to start, using our eight-week VR
(37:08):
treatment program that I've beendescribing here as an aside.
Kate Scarlata (37:11):
So can you give us a link to the study or
something in the show notes?
Perfect.
Brennan Spiegel, MD (37:16):
Yeah, absolutely so.
We'll post that information sothat people can find out more
about it.
Kate Scarlata (37:21):
Excellent.
How many people are you goingto recruit for this?
Brennan Spiegel, MD (37:32):
So it's a pretty small study.
This is an NIH small R01.
So it's a preliminary study.
Dr Chris Almario is theprincipal investigator, the PI
here at Cedars-Sinai, and theexact number is not that high.
It's less than 100.
I forget the exact number offthe top of my head.
I could be wrong about that,but it's not a big study, but
the key is that we can recruitpeople from anywhere who are
interested.
Dr. Megan Riehl (37:50):
It's important for generalizability and
learning more across the country.
Well, you have a trulythought-provoking perspective on
the human experience and healthand from your paper on
gravity's impact on the gut inIBS.
This is a very noteworthy paper, and you know there's that.
(38:11):
And then, spearheading anentirely new field of medicine.
Your insights do challengeconventional thinking, and so
you know what excites you themost about the future of AI and
medicine.
Brennan Spiegel, MD (38:23):
Oh, wow, so much.
I'm really excited to announcethat I've got a book coming out
this year on the gravityhypothesis.
Dr. Megan Riehl (38:31):
All right, awesome, give us your elevator
pitch.
Brennan Spiegel, MD (38:35):
Here's the title and the cover, but it's a
little.
You can't really see that onthe screen.
So the book is called PullP-U-L-L.
It's how gravity shapes yourbody, steadies the mind and
guides our health.
And this is maybe anotherpodcast for another day, but a
little brief intro.
The vagus nerve is a big partof it.
(38:55):
The vagus nerve, I believe, isa gravity management mechanism
actually, and you'll have toread the book to learn more.
Come back for a future podcast.
Kate Scarlata (39:04):
Yes.
Brennan Spiegel, MD (39:05):
And just standing up and staying up is
our goal in life, literally fromthe moment we're conceived to
the moment we die.
Gravity is acting upon everycell in our body, in our gut, in
our brain, in our gut, in ourbrain, in our nerves, in our
muscles, in our lungs,everything.
And our goal is to stand up andstay up as long as we can and
as well as we can, until finallywe're pulled back down and in
(39:26):
some cases we end up.
I hate to put it this way, butwe end up literally in a grave,
which is a word derived from theword gravity, that's, a gravity
box.
And so if we think of gravityin that way, we think that
fighting it through not onlystrength training, which is, by
the way, one of the mostimportant interventions for all
(39:47):
of medicine, and through diet,which can alter serotonin levels
, which is, I argue, a gravitymanagement substance that's what
serotonin does is it helps usfight gravity both physically
and mentally.
We can get to that some otherday, some other time yeah.
You know, we can modulate ourexperience of the world and live
(40:09):
better, stronger lives, findbalance and stand stronger and
really live longer, and sothat's what this whole book is
about and I'm really excitedabout that.
That's just a preview of awhole other discussion about
what I call biogravitationalmedicine, and it actually brings
the vagus nerve back in, itbrings virtual reality back in,
it brings diet back in,psychology back in, and that's
(40:30):
what I'm most excited about thisbook It'll be a wide release
book from St Martin's Press,coming out actually October 7th
of 2025.
I just learned today.
Kate Scarlata (40:38):
Excellent.
Oh, I'm very excited about that.
I love the way your brainthinks and you're definitely
coming back on.
So let's look at our schedulefor October because, that would
be awesome.
Where do people go if they'reinterested in learning about VR?
Are there sites?
Can you talk a little bit aboutthe IBS VR program?
(40:59):
That is available.
You know people are interested.
What do they do?
Brennan Spiegel, MD (41:04):
Yeah, so we have a website.
It's virtualmedicine.
org, so it's pretty easy toremember virtualmedicine one
word, org and on that site wehave a lot of information about
our VR programs here atCedars-Sinai, where I work, and
some of the grants that we havein the ongoing studies that you
(41:24):
can learn about.
We haven't posted the IBS linkyet, but that will come up soon
and I'll be sure that you candistribute that to your
listeners.
Definitely we also have aconference that we put on every
year and actually we have anumber of people that join who
are not doctors or notclinicians.
It's called the VirtualMedicine Conference.
This year it's March 27th and28th in Los Angeles, so there's
(41:46):
information on the website.
It's a lot of fun.
You can meet all thesedifferent people from around the
world creatively usingtechnology like VR to treat all
sorts of different conditions.
So we will have some GI topics.
This year.
We're going to talk abouteverything from menopause one of
the world's leaders inmenopause at the Mayo Clinic
using VR to GI applications,chronic pain.
(42:07):
So that's going to be againcoming up in March.
And then we have some softwareavailable.
So our software is calledSynerGI, spelled Syner-G-I
instead of G-Y.
It's kind of a play words.
It is available through theMetaQuest, but right now we're
keeping it within research, soyou'll need to be enrolled in
one of our trials.
(42:28):
We also have a software programcalled XAIA X-A-I-A.
That's available through theApple Vision Pro, which not many
people have at this point.
It's a very expensive virtualreality headset that Apple made,
but it is available.
It's that AI therapy, mentalhealth support bot, and so, yeah
, there's different ways tolearn about this stuff and you
(42:50):
can even just go on to the AppStore for Meta.
I really like this programcalled TrippVR T-R-I-P-P.
I'm not associated with it.
TrippVR is an amazing softwareprogram for incredible beautiful
worlds and guided imagerymeditations.
It's a very, very good program.
(43:11):
I really love that program.
So yeah, those are just a fewthoughts.
Kate Scarlata (43:15):
I love that.
And just for going back to thevagus nerve stimulation, who
would you see to talk about that?
I just don't think that it'svery mainstream.
So if you're just curious andyou wanted to talk to someone,
or is there a good resource?
Or can you share the productthat you tried if you feel
comfortable or you feel like itwas beneficial?
Brennan Spiegel, MD (43:36):
Yeah, so I don't have any relationship, and
I will also say, just as anaside, that I have fully
divested my financial interestsin the products that I've talked
about today, including SynerGIand Zaia, although I was
involved in their developmentand testing and even an initial
startup company.
I've fully divested so I canfeel comfortable about talking
(43:56):
about these things.
I just want to make so I canfeel comfortable about talking
about these things.
I just want to make sure youraudience is aware.
Dr. Megan Riehl (44:00):
That's really important.
Brennan Spiegel, MD (44:01):
Yeah, same thing with the vagus nerve
stimulator.
So the one that I use is calledVagustim, v-a-g-u-s-t-i-m, I
believe, and I had learned aboutit from a colleague who
recommended it because it's easyto put into the ear and
relatively inexpensive.
I think I got a discount like afew hundred bucks but you'll
have to look up and see whatthey're charging these days and
(44:24):
easy to use there's an app, soI've found it very helpful.
I like the way it works and youcan change a bunch of different
parameters so it doesn't buzztoo hard or just enough for your
liking.
Yeah, so who to see for vagusnerve stimulation is really
interesting question, becauseit's one of these technologies
that kind of falls in the cracks, kind of like VR.
(44:44):
There isn't a VR provider yet.
I would love to have a VRclinic and there are certain
people that just do VR,particularly in psychology, but
you won't find like a VRspecialist all that easily or a
vagus nerve stimulationspecialist.
Now, obviously, neurologistswould be a reasonable place to
(45:04):
start, because it is aneurological intervention and
that's what they study, andthere are certain neurologists
who have particular expertise invagus nerve stimulation.
But I've also metrheumatologists that use VNS
vagal nerve stimulation becausethey deal with so much chronic
pain arthritis for example andthere's some suggestion that
(45:27):
even autoimmune conditions mightbenefit through these
mechanisms of VNS.
So you can see a rheumatologistand there's some
gastroenterologists.
I will recommend it from timeto time as an augmentive, like
an accessory tool.
Sometimes I'll use it withvirtual reality, recommend
people use them together,although I don't have any data
(45:50):
that they're synergistic.
These are all wide open areasso it's not like there's one
person to go to.
I think you need to findsomebody in your community that
knows about it and has aclinical experience working with
it, who you know can reallyguide you through the safe and
appropriate use.
Now, obviously, epilepsy isdifferent.
That's a neurological conditionand neurologists would
(46:10):
recommend VNS for that.
Kate Scarlata (46:12):
Because that's surgical right, Don't they have
to implant?
Brennan Spiegel, MD (46:15):
They can implant it, yeah.
Dr. Megan Riehl (46:22):
That's right, and I think safety is really
something we have to be mindfulof when we're having these kinds
of conversations.
So to the point that, having animplanted device, you're going
to talk about your medicalhistory, you're going to talk
about your comorbidities, therisks, there tends to be a
preference for the left sideplacement of these devices, as
opposed to the right, based onlocation of the nerves and your
cardiac nerves.
(46:42):
So it's important, beforepurchasing one of these, I think
, to really read the fine printon the websites, or to, when
you're talking about some of thetranscutaneous types of devices
that are available too, meaningyou place them on your ear, on
your neck, just being mindfulthere are some contraindications
, and so being aware of whatyours may potentially be is a
(47:05):
conversation to have with yourstart, with your primary care,
and if they don't know, they'llrefer you onward to a
subspecialist.
Kate Scarlata (47:12):
Yeah, don't self-dianose.
Talk to your doctor.
I say that even with dietchanges or supplements, just
have a health professionalinvolved in some of this.
Brennan Spiegel, MD (47:20):
Absolutely I don't know if you ever watched
that show Yellowstone.
I've really gotten into thisNetflix show Yellowstone.
Kevin Costner's character islike never goes to the doctor
for anything and ends upspending too much of his time
worried about things heshouldn't be, or not being
worried about things that heshould.
So that just happens to be.
Anyone who's watchedYellowstone knows what I'm
(47:41):
talking about.
But yeah, the left versus rightthing is a big deal because the
right side has more directconnections to the heart and
particularly the sinoatrial node, which is the part of the heart
that is the pacemaker, and soone of the side effects would be
slow heart rate, and I see thateven on the left side.
I definitely see my heart slowdown when I use it, and so you
(48:03):
know these are things you needto really check with a doctor.
If you have low heart rate, youmay want to be kind of careful
about it, or arrhythmias orwhatever.
You need to work with somebodywho knows what they're talking
about.
Kate Scarlata (48:13):
Unbelievable.
Well, this was incredible.
No surprise, because you arealways just such an interesting
wealth of knowledge and somevery interesting topics that
aren't really spoken intraditional medical settings or
with other guests that we've had.
We have learned so much fromyou, so thank you.
We'd like to end our episodewith a wrap up question to our
(48:36):
guests, and that is what do youdo in your daily life for your
own wellness and health?
Brennan Spiegel, MD (48:43):
Well, as I'm talking to you right now, I
am wearing something that looksa bit unusual.
This is actually a weightedvest.
It's a 20-pound weighted vest.
It's got metal inside of it.
It's not a bulletproof vest,it's just a weighted vest and
around both of my ankles I have20-pound weights around my
(49:03):
ankles.
So I'm right now wearing 60pounds of weight just sitting
here talking to you, and all daylong I'm at a standing desk.
I have a balance board that Istand on and I passively wear
about 60 pounds on my body.
It goes back to that gravitystory.
Dr. Megan Riehl (49:17):
I was going to say working on some gravity.
Brennan Spiegel, MD (49:19):
Yeah, when you release yourself from this
weight, all of a sudden you feelso much stronger and there's
even evidence you can loseweight just by weighting your
body down and passively exertingyourself against this pull.
So this is stuff that I do juston a regular basis to maintain
balance on the balance board Ihave a desk stepper.
I'll sometimes just walk inplace.
(49:41):
I don't have a walkingtreadmill.
I want to get one of those, butthose are a little expensive.
But those are good too.
Just simple things you can do.
Drink a lot of water.
I have a big thing of waterhere right now.
This is about gravity too.
If you stand up too quickly,get lightheaded, that's gravity
intolerance.
That's called orthostasis.
You need to keep fluid in yourbody and I think we really under
(50:05):
hydrate ourselves.
So these are really simplethings to do that can actually
contribute to longevity.
You know, we know that thesodium levels in your body I'm
getting way off topic now, butyou asked me will in some part
determine your longevity, andsodium is determined in large
part by how much fluid you drink.
You know, don't overdo it.
Too much fluid is bad too, Okay.
(50:26):
So I want to be careful aboutthat.
If you drink water all day.
That can literally kill you.
So I'm just talking aboutkeeping yourself well, hydrated,
strong, standing up.
These are things that I try todo every day, just to kind of
keep myself in some modicum ofshape.
Kate Scarlata (50:41):
I think we need to get that vest.
Dr. Megan Riehl (50:44):
You get the vest, Kate, I'm going to do some
strength training and fill upmy water.
There, you go, Dr.
Spiegel.
Thank you so much, and to allof our friends listening, we
hope that you subscribe like,follow The Gut Health Podcast.
Your support means the world tous.
See you later, friends.
Thank you for joining us as wegrow this gut health community.
(51:07):
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This podcast has been sponsored by Ardelyx.
Maintaining a healthy gut iskey for overall physical and
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Whether you're ahealth-conscious advocate, an
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(00:23):
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello friends, and welcome toThe Gut Health Podcast, where we
talk about all things relatedto your gut and well-being.
(00:44):
We are your hosts.
I'm Kate Scarlata, a GIdietitian.
Dr. Megan Riehl (00:47):
And I'm Dr Megan Riehl, a GI health
psychologist, and we have areally fascinating episode for
you today as we dive into theincredible power of the vagus
nerve and some interestingtreatments.
As one of the 12 cranial nerves,the vagus nerve connects the
brain and the body and itstretches from the brainstem all
the way to the gut.
That's why we think about thevagus nerve when we're thinking
(01:09):
about some of our gut healthissues.
It plays a very crucial role inparasympathetic nervous system
activation.
So we're thinking relaxation,response, and what we think is
very exciting is that we'relearning more and more about the
ways that we can get at thatvagus nerve.
We see FDA-approved devicesthat can stimulate the nerve for
(01:31):
conditions like epilepsy andmajor depressive disorder, as
well as migraines.
But research is emerging andhow we're getting to the vagus
nerve might include handhelddevices that you can purchase on
the internet, or evenpotentially enhancing brain
function through deep breathing,meditation, massage or even
moments of wonder and awe, whichcan all activate our vagus
(01:54):
nerve to promote calmness andwell-being.
So we're thrilled to have anexpert with us today to step
outside the box and explore someof the science of this
neurostimulation, and you'llhear us using some terms like
vagus nerve stimulation,percutaneous electrical nerve
field stimulation, also known asPENFS, and the transformative
(02:18):
potential of virtual reality forour gut, health and beyond.
So we are very excited tointroduce you to our guest
expert today.
Kate Scarlata (02:29):
Yes, we are so excited.
Dr.
Brennan Spiegel is Director ofHealth Service Research for
Cedars-Sinai in Los Angeles anddirects the Cedars-Sinai Center
for Outcomes Research andEducation, a multidisciplinary
team that investigates howdigital health technology,
including wearable biosensors,smartphone applications, virtual
(02:51):
reality and social media, canstrengthen the patient-doctor
bond, improve outcomes and savemoney.
His team developed one of thelargest and most widely
documented medical virtualreality programs at Cedars-Sinai
, and his work has helped tosupport a new field of medicine
called Medical Extended Realityor MXR, in which doctors use
(03:15):
immersive technologies likevirtual reality to help treat
conditions ranging from pain toanxiety and depression and even
irritable bowel syndrome.
Dr Spiegel has publishednumerous best-selling medical
textbooks, editorials and hasmore than 270 articles in
peer-reviewed journals.
His digital health research hasbeen featured by major media
(03:37):
outlets, including the New YorkTimes, bloomberg, cbs News and
more.
Dr Spiegel published the bookBloomberg, cbs News and more.
Dr Spiegel published the bookVRX How Immersive Therapeutics
Will Revolutionize Medicine,which was named by Wired
Magazine as one of its top eightscience books of 2020.
We welcome you.
Dr. Megan Riehl (03:57):
Dr Spiegel.
Brennan Spiegel, MD (03:58):
Good to be here.
Thanks for having me.
Dr. Megan Riehl (04:00):
So, before we dive in, we like to start every
episode by asking our guestabout a myth they'd like to bust
.
So what myth would you like tobust pertaining to your area of
expertise or gut health?
Brennan Spiegel, MD (04:15):
Well, I think there's a myth that goes
all the way back to around the1600s probably well before that,
but at least the 1600s when thephilosopher, the famous
philosopher, Rene Descartesanyone who studied philosophy
has come across his work theFrench philosopher, and he came
(04:37):
up with this idea.
He called dualism.
And the idea behind dualism isthat the mind and the body are
separate and distinct, that themind is this immaterial
experience with a spiritualcomponent and the body is the
physical machinery that movesthat mind around in the world.
(05:01):
And they're separate, they'redistinct, they're dual.
And that's how we've thoughtabout modern medicine for years.
You think about psychiatristsyou know, manage the mind, and
GI doctors manage you know thepumps and tubes in the body.
There's plumbers that manage.
You know the heart and theblood vessels and all that.
And then there's people thatthink about the emotions that we
(05:24):
experience.
But that's a myth.
In reality, we know that it'sall one system.
This says nothing about whatyou think about religion or
spirituality.
I'm just talking about thephysical systems that connect
the mind and body and in fact,that sets up the vagus nerve in
part.
Sure does.
Because that is a clear and whatwe'll talk about today sign
(05:48):
that the mind and body are notseparate and distinct.
They very tightly are coupledand interact with one another.
So that's a big myth.
Dr. Megan Riehl (05:56):
It's a great myth to bust.
Kate Scarlata (05:57):
I like that, yes, and I think we're seeing just
this integration ofmultidisciplinary teams,
especially in gut disorders,being so much more beneficial.
So we're really just thisintegration of multidisciplinary
teams, especially in gutdisorders, being so much more
beneficial.
So we're really, you know,looking at the whole body
instead of separating things.
So we're going to talk aboutvagus nerve stimulation.
We're going to talk a littlebit about virtual reality, but
(06:19):
let's start with vagus nervestimulation.
I find the science reallyinteresting and feel like we're
not quite there yet, maybe withsome of these devices that are
out there, but they could have alot of health benefits, or
there's the signals that theymight have some health benefits
to a lot of different conditions.
So how does one stimulate theirvagus nerve?
(06:42):
What are some of the techniquesto do such?
Brennan Spiegel, MD (06:45):
Yeah, well, there's different ways to
stimulate the vagus and, as yousaid, the vagus nerve is one of
the cranial nerves.
Vagus shares the root forvagabond, which basically is a
wanderer.
And the vagus nerve is awanderer.
It is the longest nerve and itwanders all throughout the body.
(07:09):
It takes twists and turns, ithas branches and side branches.
It goes all throughout the GIsystem, the heart, it gets all
around.
So you can imagine there'sdifferent ways to stimulate it
because it goes in all sorts ofdifferent locations.
We can stimulate it in the ear,can stimulate it in the neck.
That's, the most common placeis on the neck, because the
(07:31):
vagus nerve runs right up theneck along the carotid arteries,
the main big arteries where youcan feel your pulse in the
front of your neck on eitherside.
And in the past it wasstimulated by implanting an
electrode underneath the skinthrough a procedure which is
rather invasive.
But now we have different waysto stimulate it through the skin
(07:52):
.
So, for example, I do have avagus nerve stimulator that I
have used and it stimulates itthrough the ear, and so it's
almost like wearing an earbud.
It releases a very lightelectrical pulse through the ear
and it stimulates a branch ofthe vagus nerve that goes all
the way up to the ear, and thenyou know it's a rather
(08:14):
non-invasive, pretty simple wayto stimulate the vagus nerve
without having to do a procedureor an operation or something
like that.
But yeah, there's differentways of doing it like that.
Dr. Megan Riehl (08:23):
But yeah, there's different ways of doing
it.
I think in my clinical practice, you know I've had patients
that have been told by somebodyyou know they have vagus nerve
dysregulation or dysfunction andyou know they're here to fix
that.
How do I fix my vagus nerve?
And you know, I think if youGoogle the vagus nerve you're
going to see all of thesedifferent, more invasive vagus
nerve stimulation which, to bevery honest, when somebody would
(08:45):
come to me, I used to be like Idon't do that, like I'm not
going to implant something inyour system, but I would talk
about lifestyle, that connectingthe mind and the body, and that
the things that we can do toactivate our parasympathetic
system are going to be good foryour vagus nerve.
But there's so much in betweenthat that people can find it is
(09:07):
kind of cool to see that thereare these devices that you can
purchase and experiment withthat, see what your experience
is with.
You know there are somecontraindications that you will
certainly want to talk to yourmedical providers about when
you're thinking about exploringthis on your own.
And I think you know it'sinteresting to just kind of when
(09:31):
you were looking at why youpurchased, without getting too
personal, but I'm curious likewhat were you looking for when
you made that purchase?
Brennan Spiegel, MD (09:36):
Well, mainly I wanted to understand
what it felt like and whether itmade an impact on my own body
and mind.
You know it's useful to have afirst person experience.
This is the reason why, by theway, when I had my first
colonoscopy, I did it withoutsedation, so I'm not
recommending that for everybody,but that's what I did so, you
know, got to understand whatyou're talking about if you've
(09:58):
been through it.
So vagus nerve stimulationappealed to me because it's so
non-invasive, generally quitesafe and there's evidence behind
it.
It's evolving, like you guyssaid at the beginning, this is
an area that we don't yet have alot of information on, but it's
growing and in some cases wehave FDA-cleared indications,
(10:18):
like for epilepsy.
It's gotten so far that it'sFDA-cleared.
In other areas like, let's say,inflammatory bowel disease or
irritable bowel syndrome orother GI conditions, are still
learning.
So I wanted to see what it waslike and I looked at a bunch of
different technologies.
I also talked to some expertsin the field see what they use,
and the intraauricular or theearbud version was recommended
(10:42):
as a good starting point.
So I've really enjoyed using it.
You know, talk more about ourexperiences, yeah.
Kate Scarlata (10:47):
Love it.
So what is like the biologicalmechanism behind stimulating the
vagus nerve and some of thesedownstream effects like motility
, maybe even inflammation, oryou know how would it help
epilepsy?
What's going on?
What do we know?
How?
Brennan Spiegel, MD (11:04):
Would it help epilepsy?
What's going on?
What do we know?
Well?
Kate Scarlata (11:07):
We don't know what we don't know.
Brennan Spiegel, MD (11:08):
Okay, so that's a good place to start,
that's always the case and weshould always try and stay
humble with science.
And I will say that in science,particularly in academics,
where we are in this sort offortress of orthodoxy, we
sometimes will just poo-pooideas that seem like
(11:28):
pseudoscience or we'll brandthem as voodoo or pseudoscience.
But they're not pseudoscience.
Pseudoscience means you cannotunder any circumstance even
study this idea.
It doesn't even make senseaccording to the laws of physics
or science or whatever.
That's not the case forsomething like vagus nerve
stimulation.
Although some people mightthink it's kind of silly, it's
(11:50):
like any other new innovation wehave to study it.
So the vagus nerve does lots ofthings and if we stimulate it,
you can imagine it's going tohave different effects on the
body.
Certainly in the gut it'sinvolved in promoting rhythmic
contractions.
Certainly in the gut it'sinvolved in promoting rhythmic
contractions.
So we call this the rest anddigest phase as opposed to the
fight or flight phase.
(12:11):
So these are the ways we thinkabout it in physiology is you
know, if you see a lion comingat you?
God forbid that happens to you.
But 10,000 years ago ourancestors were getting chased
down by all sorts of threats.
You got to either fight thatthing or run like crazy and get
away.
You don't have time to digestyour food right.
(12:31):
That's not a time to be puttingany blood flow into your gut.
The blood's got to go into yourmuscles, your lungs, your brain
, and you got to run like crazyand fight.
Your pupils have to dilateright.
You need to be ready to go.
That's how too many people livetheir lives, as if they're being
chased down by lions, and thatleads to stress and anxiety and,
(12:54):
at some point, just downrightdepression, because you can't
handle it anymore.
You just collapsed, and so thevagus nerve is a switch that
helps turn on that rest anddigest program.
That's the exact opposite.
This is where you're relaxing,you're digesting your food.
Your heart rate is slowing down, you know, and you have what we
(13:17):
call improved or more variableheart rate variability and this
is an important concept of thebeat to beat variation in the
heart, not just the heart rate,but how is the heart beating and
the vagus nerves involved inthat too.
And that's just the beginning.
You know you've touched on someof these already in terms of
inflammation and the microbiomeand serotonin.
(13:41):
We would definitely have totalk about serotonin today, and
I don't want to get too far outthere because I've just thrown
out so much already.
But all of these are potentialways that if we buzz this nerve,
good things could happen, youknow, if we're careful about it,
and some of those I've justtouched on there.
Dr. Megan Riehl (13:58):
And there's different ways to buzz it.
That's the key, and I think,when we think about some of the
GI literature out there, thereare vagus nerve stimulation
techniques that again are thingsthat any of us could do, like
diaphragmatic breathing or evengurgling to get at certain sound
(14:19):
wave sensations that can moveyour body.
And then there's a separate butdistinct type of therapy that I
mentioned earlier thepercutaneous electrical nerve
field stimulation, and this isthe type of intervention that
we're seeing in some of theliterature where, if you are
Googling, especially for thepeds population things like
(14:40):
functional abdominal painrelated to IBS we're seeing some
products out there that areavailable that have really great
data with reductions in painand disability, improving
well-being, some of thoseemotional outcomes that we're
looking for in the treatment ofthese symptoms.
So there are really cool thingsin the pipeline that are
(15:04):
happening that are going toshift the way we look at what a
treatment might look like forpeople, and so I'm wondering you
know I mentioned a study thatwe'll link and it was a 2023
study on these devices but whatis some of the latest research
and studies in theseneurostimulation therapy kind of
(15:24):
worlds related to the brain-gutaxis that are getting you
excited?
Brennan Spiegel, MD (15:29):
Yeah, I mean, you've hit it on the head.
There's so many differentapproaches and so many different
mechanisms and so manydifferent conditions, so you
almost think of it like a Venndiagram.
There's the actual modality,the actual electrical system.
There's what condition are wemanaging?
And then what mechanisms do wethink we're leveraging?
(15:49):
Leveraging, and it's still alittle bit murky.
But this idea of percutaneouselectrical nerve stimulation is
really fascinating to me,because what we do know is that
there are virtual gates thatallow pain to pass through and
up the spinal cord or not, andso you can imagine even just
(16:13):
something like TENS therapy youknow, transcutaneous electrical
nerve stimulation for chroniclower back pain.
Just take away abdominal painfor a second.
The idea here is, when you werea kid or even as an adult, you
hit your elbow and it hurts.
The first thing you start doingis you rub it.
You know, you like just rubyour elbow because you got a
boo-boo right and it hurts.
(16:33):
And somehow you know a parentrubbing their child's boo-boo
makes them feel better.
Well, what's that all about?
Is that just placebo?
Well, no, actually what wethink is happening is you're
overriding the pain sensationswith these additional
stimulations, these additionalsignals, stimulations, these
(16:57):
additional signals, and whatthat can do is overwhelm the
pain processing sites and evenclose down these so-called
virtual gates.
And these gates are aligned upand down the spine and they are
involved in kind of like a gatein a fence.
If it's open, then the horsewill go right out of the barn,
but if it's closed, the horsestays in there.
And by literally rubbing theskin, you are modulating or
(17:19):
changing whether the gates areopened or closed.
So with electrical stimulation,what's happening is it's a more
precise and modifiable way ofdoing that, and we think that
closing virtual gates is one ofthe ways that this works.
We also know that people withirritable bowel syndrome in
particular, and people ingeneral who have chronic pain,
(17:42):
often have difficulty closingthose gates, and it has to do
with the brain.
Now, now we're back up on thebrain side, because what the
brain does is it sends signalsdown the spinal cord.
The brain can fight back.
The brain doesn't just sitthere and take whatever it gets.
It can fight back.
And the way it fights back isby sending what are called
(18:07):
inhibitory signals.
The technical term is descendinginhibitory pathways where these
signals go down the spine andactively shut those gates so
that you can just relax.
So just imagine if you didn'thave that.
Every twist and turn your boweltakes, every stretch of the
intestine, every movement of thefood would be constantly
bombarding your brain withsignals and you would feel your
(18:29):
food going through your body.
I mean, just imagine howmaddening that would be if we
didn't have an ability to shutdown those sensations.
And that's how we do it.
But if you can't shut thosedown, then that's very tough.
So electrical stimulation oneway we think it works is by
shutting those gates down.
Dr. Megan Riehl (18:47):
Yeah, and you know, I think that's where, to
your point, we have to be opento exploring this.
Because you know, just like, ifyou would have told me I would
be doing gut-directedhypnotherapy every day in my
clinical practice a decade ago,I would have told you we're kind
of nuts.
But yet here I am and it's sopowerful and we have a fully
(19:07):
integrated acupuncturist in ourGI practice.
And same thing they're lookingat certain acupressure points,
acupoints in the body, that ifwe hit on those in the right way
, we can produce profoundchanges for patients.
So it's exciting.
Brennan Spiegel, MD (19:27):
And I will add one thing here, because we
have, you know, a dietician withus.
Kate Scarlata (19:31):
That's right.
Brennan Spiegel, MD (19:32):
But the idea there is.
It's all interrelated.
So the intestinal system.
If we think about this for asecond, it's a little bit like a
donut.
So what do I mean by that?
If you take a donut and youstick your finger straight
through the hole, you're neveractually inside of the donut,
you're not in the substance ofthe donut at all.
You've just put your fingerright through the hole and
(19:54):
you're touching nothing but air,right?
Well, that's basically how ourGI system works.
It's like a hole, but it's along one, right, and it's a long
tube, but it's an invertedpassageway and if you pass all
the way through into the otherend, you're actually never
really inside the body.
You know, it's like those waterwiggler toys.
If you've ever played withthose.
(20:14):
They inside the body.
You know it's like those waterwiggler toys.
If you've ever played withthose, they'll like invert on
themselves and you can't keepthem in your hands and they
slide right out.
Kate Scarlata (20:18):
Yes.
Brennan Spiegel, MD (20:18):
So what's happening in the gut is it is
the outside of our body,sampling the world around us and
allowing some of it to pass inand some of it not.
And so we know for sure thatthe microbiome which lines the
colon and in some cases worksits way up into the small
intestine is really vital formodulating that interface with
(20:41):
the world itself.
And of course, the food that weput in will modify the
microbiome and in some parts ofthe gut it may change how
so-called leaky the gut is, howpermeable the membranes are.
And this is where the vagusnerve comes back.
Again.
It may be, it's thought, thatstimulating the vagus nerve can
(21:04):
help us modulate how tight thegut membrane is, even by
changing the local immune systemthrough these pathways,
electrical pathways.
And now it starts to all cometogether in a way that if we
change the diet and we changethe microbiome and we modify the
local immune system and we cando some of that through the neck
(21:25):
or the ear, that's like wild tothink about that.
But now we have tools diet,electrical stimulation.
Of course psychotherapy,psychological therapies are
vital, whether it's hypnotherapy, cognitive behavioral therapy.
All of this gets back to myoriginal myth that the mind and
the body are not separate anddistinct.
They're tightly coupled witheach other and they talk to each
(21:45):
other.
And these are some of the waysthat they talk to each other.
Dr. Megan Riehl (21:48):
It's fascinating, you know.
I think it goes back to wedon't have to do it all at once,
you know.
I think it goes back to we don'thave to do it all at once Right
and subtle changes in ourlifestyle can be a good stepping
stone moving forward to makingchanges in your overall health
and your gut health.
And we don't want to overwhelmeverybody with, like you got to
(22:17):
do it all at once but over time,living this kind of mindful
approach to our health, knowingthat how we eat, how we move,
how we engage with ourenvironment, the air that we
breathe, all of these thingsimpact this incredible
microbiome that we have.
That's unique.
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Dr. Megan Riehl (23:42):
So what do you say?
We kind of dive into your otherareas of expertise.
We've got a couple of questionsabout virtual reality that our
listeners will definitely beinterested in, and I may even
share a little bit about myexperience with virtual reality.
Kate Scarlata (23:52):
Yes, I think I maybe had a little experience
with virtual reality as well.
There you go.
I know it's nice.
We know people in high placeslike Dr.
Spiegel, right?
So let's talk a little bitabout different VR products.
How do they work?
I know you've done a lot ofwork in virtual reality and IBS
(24:13):
and pain, so can you talk alittle bit about how they work
for those issues?
Brennan Spiegel, MD (24:19):
Yeah, absolutely, and this may seem
like a big pivot from our lastdiscussion, but not really.
It's another mechanism where wetry to modulate that
relationship between we'll callit mind and body, or brain and
gut, and VR, we have found is avery powerful way of positively
(24:39):
affecting the mind in a way thatcan change the body.
So most people when they thinkof VR, they think of a platform
for gaming and entertainment.
They might think about MarkZuckerberg and meta or whatever.
And yeah, it's been used forgaming and entertainment.
But long before it was used forthat, it was being tested in
(25:01):
psychology labs all around theworld, all the way back by the
Department of Defense, even the1950s, as a way to simulate
complex environments.
And it just got to the pointwhere the technology got so good
and so inexpensive, relativelyspeaking, that we could start
testing it out in clinics.
So, for example, we justpublished a paper recently with
Mount Sinai, which was sofascinating, demonstrating how
(25:25):
VR can change physiologydirectly.
So what we did in this study iswe took people and we put them
in a really relaxing beach invirtual reality.
You can hear the reality, youcan hear the music, you can sort
of hang out on a beach or on alake or on a mountaintop and it
really feels very, very real.
The music's beautiful and wecan do guided breathing, which
starts to affect the heart rateand heart rate variability.
(25:48):
So it's actually affecting thevagus nerve directly and when we
actually measure heart ratevariability we can see that it
changes.
But we also can see that wechange cortisol levels in the
body.
We can see that we can changebody temperature.
We can cool the body down.
We're doing a study now at theMayo Clinic using VR for
vasomotor symptoms of menopause.
(26:09):
For example, can we literallycool the body down through
beautiful snowy environmentswhere you feel like you're
sitting in the snow?
We can even change white bloodcell count through virtual
reality.
We've now been able to show,and so we've been using this for
a bunch of conditions,especially pain, and not just
for the immediate experience,but over the course of eight
(26:31):
weeks.
We can deliver different formsof cognitive behavioral therapy
to supplement clinicians likeMegan right who do the hard work
of really tailoring therapy.
But then you go home and youmay not see your therapist for
another week or two or more, andso having something like VR
might help bridge that gap, andso we've created VR programs for
(26:54):
irritable bowel syndrome.
We're using it now in IBD andIBS.
We're using it for chroniclower back pain, for cancer pain
a whole variety of differentconditions.
Dr. Megan Riehl (27:05):
How do people receive this?
You know, when you walk in andyou say, in addition to your
inflammatory bowel diseasetreatment, we're going to
recommend this headset and thisexperience for you.
Brennan Spiegel, MD (27:16):
I'll tell you, most people really are
intrigued.
Yeah, because we're not sayingthis is a substitute for your
traditional medical care, it'sto help augment it.
And when we talk about thebrain-gut axis or the mind-body
axis and all the stuff we'vebeen talking about today, people
I think are very open to tryingthese things and all the stuff
we've been talking about today,people, I think, are very open
to trying these things.
I can think of an example justfrom the hospital a few weeks
(27:38):
ago, when I was on service andwe had a patient who had had
really significant abdominalpain after abdominal surgery and
it really never got better.
The pain just didn't get better.
We see that sometimes afterabdominal surgery better, the
pain just didn't get better.
We see that sometimes afterabdominal surgery and it got to
(27:58):
the point where this patientreally couldn't eat and ended up
being on TPN total parenteralnutrition, where all the
calories are put through theveins.
She couldn't eat anymore and wecouldn't really figure out what
was inhibiting her ability toeat.
And so, you know, I spoke tothis patient and really came to
realize like there was a lot ofanxiety, to the point where if
(28:21):
they even sipped some water itwould just cause immediate pain
in the belly, and so that's thepoint where I say God, that
doesn't even make physiologicalsense.
That is a form of anticipation,anxiety at that point where the
brain is primed, sensitized, tofeel pain, and I don't think
doing another surgery is goingto fix that Right.
(28:43):
So we tried virtual reality andwe try to form a virtual
reality that also usesartificial intelligence to help
talk to people, and we've gottenbetter and better at this over
the last couple of years,developing and you guys use an
early version of this- Good oldMaya.
Yeah, maya, and so she used itand I mean this doesn't always
(29:05):
happen, but it happens.
Within five days she was eatingI mean almost a full diet.
She had bacon and eggs fivedays later and she hadn't eaten
anything in months and months.
And she was eating I meanalmost a full diet.
She had bacon and eggs fivedays later and she hadn't eaten
anything in months and monthsand she was walking around the
ward, really just conversational.
Now we didn't secure anythingand maybe it'll come back, but
(29:26):
just to see that response, Irealized like we are only
working.
We're like we're working withone hand tied behind our back if
we don't use these kinds oftechniques.
Dr. Megan Riehl (29:37):
So you're mentioning something that's very
, again, very similar with ourbrain-gut behavioral therapies,
where openness to trying isreally a key characteristic.
Are there other characteristicsthat are going to contribute
potentially to a patient'ssuccess and outcomes?
Brennan Spiegel, MD (29:51):
Yeah, yeah for sure, openness is a big part
of it, but there's alsosomething called immersive
tendencies, and this is kind ofa technical term.
It's easy to understand.
Some of us get more easilyimmersed into fantasy worlds
than others, and not even justfantasy, I mean just watching a
football game.
Some people love sports.
(30:13):
They are so into that game thatyou can't talk to them, but
that game is happening on adigital screen somewhere far,
far away.
In a way, it's like a fantasyexperience.
It's not literally happening inyour, but you feel that it's
happening.
And or you're reading a booklike my son loves reading, and
(30:35):
I'll call his name out and hecan't hear me because he's in
the book or you're in a movie.
Whatever the example is, itturns out that there is a
natural variation among humans.
Some people are very easilyswept up into these narratives
and some not so much, and itseems like that affects how well
something like VR works.
You know, you might just think,oh, this is really interesting
(30:57):
and cool looking, but I'm notfeeling anything, whereas other
people they realize like I'm soimmersed in this world that I've
forgotten that I have pain, Idon't feel it.
My nervous system has releaseditself, and that's the moment
where we say listen, like you'venow learned that you have the
superpower.
Supernatural and I use the termsupernatural Literally.
I say super means above, likeSuperman flies overhead.
(31:18):
Super means you have found alevel of consciousness higher
than where you normally operate.
And natural, you did ityourself.
We didn't give you a medicationor inject something, so you've
just learned something about it.
It's the people who haveimmersive tendencies that are
most likely to have that kind ofsupernatural reaction.
Kate Scarlata (31:36):
That's me, you know it's funny.
When I did yeah, I was like I'mjust going to do this virtual
reality thing with Brennan forlike five minutes.
And then it was like how longhave I been doing this?
But I am so immersive.
My husband talks to me all thetime.
I'm like what you know, totallyfishy, and my father was the
same way too, like just lockedinto whatever you're doing.
(31:58):
Yeah, so that's interesting.
Dr. Megan Riehl (32:01):
And I don't tend to miss a thing.
So when I had the headset onnumber one, I wanted to see if
Maya was any good.
You know, like she is me right,she's the AI version of a
therapist and so it wasinteresting to put the headset
on and you're seeing thevisualization.
And again, if you're a listenerand you are an immersive person
and you have IBS, you know, Iwould encourage you to check out
(32:22):
Dr Spiegel's products and kindof work in this area, because
you do get evidence-basedtreatment in this virtual way
and she's using many of theskills and cognitive reframing
and psychoeducation that reallycould reinforce, especially if
(32:44):
somebody is working one-on-onewith a therapist or doing group
work.
No-transcript.
(33:25):
to the point of the beginningof our episode.
We're thinking outside the box.
Brennan Spiegel, MD (33:30):
Believe it or not, that was almost two
years ago, I know, and that wasa pretty early prototype.
It was still pretty impressive,I'd say.
Now we're at, I know, write anote out that's quite impressive
(33:54):
and put it in the chart.
We think of it kind of like aparatherapist that's a term I
just made up, you know, aparamedic is.
Para means beside, and in thiscase medic means doctor.
So the paramedic is beside thedoctor and as a liaison between
the doctors in the emergencyroom and the patients out in the
field and helps run back andforth between them.
(34:18):
And the way I think of aparatherapist again, I just made
this up, see what you think ofit is, you know, like when you
go to see a hairdresser, theycut your hair and then by the
time you get home it's like allmessed up, like how did they do
that?
How do I fix this hair?
It's like, as soon as you spendall this time and energy with a
client and they go home andthen life starts to happen,
they're like oh my God, how do Iremember what we talked about
(34:40):
and those skills that I learned?
How do I reinforce those?
And that's where, like, thereal learning is happening, and
so the idea of the paratherapistis have somebody who's got your
back, who knows your patientand has almost like a
prescription of exercises tofollow and can inform you about
what's been going on betweenvisits, writing notes and also
(35:01):
contacting you if something'snot going well, and doing all of
that to get it back to the VRwithin virtual reality, because
the whole point of the VR,rather than just talking to a
chatbot is we use AI to changethe world around you.
In virtual reality, we callthis GR generated reality, so
we're generating a realityaround you based upon what
(35:22):
you're talking about, and itwill pull up the right music or
the right visualizations or artbased upon what you're saying.
Like, if you're talking aboutstress, maybe it's going to put
you in a Japanese you know, zenrock garden.
If you're talking about yourgender identity, maybe it's
going to surround you withrainbow colored butterflies and
with images of acceptance.
Right, it's pretty wild withthe VR pulls off, but it's
(35:45):
really not a substitute for ahuman.
It's.
I think of it like aparatherapist.
Kate Scarlata (35:50):
Yeah.
Dr. Megan Riehl (35:51):
We could all benefit from that Right.
Kate Scarlata (35:53):
I mean I loved it when I left.
After doing that, I came homeand I'm like everyone should
have one of these headsets.
You're just kind of lost intranslation.
I was very in my own littlespace and you know, sometimes
you, we could all benefit fromthat, you know.
Just see you later, everyone,that's right.
Brennan Spiegel, MD (36:10):
People always ask like well, are people
going to get addicted to it?
Or what about real reality?
And we're very concerned aboutthat too.
We don't want people todisappear into screens.
We've seen enough of that.
Kate Scarlata (36:22):
Right.
Brennan Spiegel, MD (36:23):
We want people to learn something about
their mind and their body andtheir reality and their emotions
and whatever we can teach themthat they then bring back to
real reality.
I call that RR real reality yes.
And so we try to keep theexperiences short 10 to 20
minutes, even though you were inthere for quite a while.
Kate Scarlata (36:41):
I know, all right , just beat me up, beat me up.
Brennan Spiegel, MD (36:45):
And we also have an app that goes along
with our programs.
We have a new NIH study that,by the way, is about to start,
so if you have any listeners whohave been diagnosed with
irritable bowel syndrome, theymay be eligible for this study.
It's a remote study, so youdon't need to be in Los Angeles,
where I live.
It can be anywhere in thecountry and we can ship out the
equipment to you.
So that study is about to start, using our eight-week VR
(37:08):
treatment program that I've beendescribing here as an aside.
Kate Scarlata (37:11):
So can you give us a link to the study or
something in the show notes?
Perfect.
Brennan Spiegel, MD (37:16):
Yeah, absolutely so.
We'll post that information sothat people can find out more
about it.
Kate Scarlata (37:21):
Excellent.
How many people are you goingto recruit for this?
Brennan Spiegel, MD (37:32):
So it's a pretty small study.
This is an NIH small R01.
So it's a preliminary study.
Dr Chris Almario is theprincipal investigator, the PI
here at Cedars-Sinai, and theexact number is not that high.
It's less than 100.
I forget the exact number offthe top of my head.
I could be wrong about that,but it's not a big study, but
the key is that we can recruitpeople from anywhere who are
interested.
Dr. Megan Riehl (37:50):
It's important for generalizability and
learning more across the country.
Well, you have a trulythought-provoking perspective on
the human experience and healthand from your paper on
gravity's impact on the gut inIBS.
This is a very noteworthy paper, and you know there's that.
(38:11):
And then, spearheading anentirely new field of medicine.
Your insights do challengeconventional thinking, and so
you know what excites you themost about the future of AI and
medicine.
Brennan Spiegel, MD (38:23):
Oh, wow, so much.
I'm really excited to announcethat I've got a book coming out
this year on the gravityhypothesis.
Dr. Megan Riehl (38:31):
All right, awesome, give us your elevator
pitch.
Brennan Spiegel, MD (38:35):
Here's the title and the cover, but it's a
little.
You can't really see that onthe screen.
So the book is called PullP-U-L-L.
It's how gravity shapes yourbody, steadies the mind and
guides our health.
And this is maybe anotherpodcast for another day, but a
little brief intro.
The vagus nerve is a big partof it.
(38:55):
The vagus nerve, I believe, isa gravity management mechanism
actually, and you'll have toread the book to learn more.
Come back for a future podcast.
Kate Scarlata (39:04):
Yes.
Brennan Spiegel, MD (39:05):
And just standing up and staying up is
our goal in life, literally fromthe moment we're conceived to
the moment we die.
Gravity is acting upon everycell in our body, in our gut, in
our brain, in our gut, in ourbrain, in our nerves, in our
muscles, in our lungs,everything.
And our goal is to stand up andstay up as long as we can and
as well as we can, until finallywe're pulled back down and in
(39:26):
some cases we end up.
I hate to put it this way, butwe end up literally in a grave,
which is a word derived from theword gravity, that's, a gravity
box.
And so if we think of gravityin that way, we think that
fighting it through not onlystrength training, which is, by
the way, one of the mostimportant interventions for all
(39:47):
of medicine, and through diet,which can alter serotonin levels
, which is, I argue, a gravitymanagement substance that's what
serotonin does is it helps usfight gravity both physically
and mentally.
We can get to that some otherday, some other time yeah.
You know, we can modulate ourexperience of the world and live
(40:09):
better, stronger lives, findbalance and stand stronger and
really live longer, and sothat's what this whole book is
about and I'm really excitedabout that.
That's just a preview of awhole other discussion about
what I call biogravitationalmedicine, and it actually brings
the vagus nerve back in, itbrings virtual reality back in,
it brings diet back in,psychology back in, and that's
(40:30):
what I'm most excited about thisbook It'll be a wide release
book from St Martin's Press,coming out actually October 7th
of 2025.
I just learned today.
Kate Scarlata (40:38):
Excellent.
Oh, I'm very excited about that.
I love the way your brainthinks and you're definitely
coming back on.
So let's look at our schedulefor October because, that would
be awesome.
Where do people go if they'reinterested in learning about VR?
Are there sites?
Can you talk a little bit aboutthe IBS VR program?
(40:59):
That is available.
You know people are interested.
What do they do?
Brennan Spiegel, MD (41:04):
Yeah, so we have a website.
It's virtualmedicine.
org, so it's pretty easy toremember virtualmedicine one
word, org and on that site wehave a lot of information about
our VR programs here atCedars-Sinai, where I work, and
some of the grants that we havein the ongoing studies that you
(41:24):
can learn about.
We haven't posted the IBS linkyet, but that will come up soon
and I'll be sure that you candistribute that to your
listeners.
Definitely we also have aconference that we put on every
year and actually we have anumber of people that join who
are not doctors or notclinicians.
It's called the VirtualMedicine Conference.
This year it's March 27th and28th in Los Angeles, so there's
(41:46):
information on the website.
It's a lot of fun.
You can meet all thesedifferent people from around the
world creatively usingtechnology like VR to treat all
sorts of different conditions.
So we will have some GI topics.
This year.
We're going to talk abouteverything from menopause one of
the world's leaders inmenopause at the Mayo Clinic
using VR to GI applications,chronic pain.
(42:07):
So that's going to be againcoming up in March.
And then we have some softwareavailable.
So our software is calledSynerGI, spelled Syner-G-I
instead of G-Y.
It's kind of a play words.
It is available through theMetaQuest, but right now we're
keeping it within research, soyou'll need to be enrolled in
one of our trials.
(42:28):
We also have a software programcalled XAIA X-A-I-A.
That's available through theApple Vision Pro, which not many
people have at this point.
It's a very expensive virtualreality headset that Apple made,
but it is available.
It's that AI therapy, mentalhealth support bot, and so, yeah
, there's different ways tolearn about this stuff and you
(42:50):
can even just go on to the AppStore for Meta.
I really like this programcalled TrippVR T-R-I-P-P.
I'm not associated with it.
TrippVR is an amazing softwareprogram for incredible beautiful
worlds and guided imagerymeditations.
It's a very, very good program.
(43:11):
I really love that program.
So yeah, those are just a fewthoughts.
Kate Scarlata (43:15):
I love that.
And just for going back to thevagus nerve stimulation, who
would you see to talk about that?
I just don't think that it'svery mainstream.
So if you're just curious andyou wanted to talk to someone,
or is there a good resource?
Or can you share the productthat you tried if you feel
comfortable or you feel like itwas beneficial?
Brennan Spiegel, MD (43:36):
Yeah, so I don't have any relationship, and
I will also say, just as anaside, that I have fully
divested my financial interestsin the products that I've talked
about today, including SynerGIand Zaia, although I was
involved in their developmentand testing and even an initial
startup company.
I've fully divested so I canfeel comfortable about talking
(43:56):
about these things.
I just want to make so I canfeel comfortable about talking
about these things.
I just want to make sure youraudience is aware.
Dr. Megan Riehl (44:00):
That's really important.
Brennan Spiegel, MD (44:01):
Yeah, same thing with the vagus nerve
stimulator.
So the one that I use is calledVagustim, v-a-g-u-s-t-i-m, I
believe, and I had learned aboutit from a colleague who
recommended it because it's easyto put into the ear and
relatively inexpensive.
I think I got a discount like afew hundred bucks but you'll
have to look up and see whatthey're charging these days and
(44:24):
easy to use there's an app, soI've found it very helpful.
I like the way it works and youcan change a bunch of different
parameters so it doesn't buzztoo hard or just enough for your
liking.
Yeah, so who to see for vagusnerve stimulation is really
interesting question, becauseit's one of these technologies
that kind of falls in the cracks, kind of like VR.
(44:44):
There isn't a VR provider yet.
I would love to have a VRclinic and there are certain
people that just do VR,particularly in psychology, but
you won't find like a VRspecialist all that easily or a
vagus nerve stimulationspecialist.
Now, obviously, neurologistswould be a reasonable place to
(45:04):
start, because it is aneurological intervention and
that's what they study, andthere are certain neurologists
who have particular expertise invagus nerve stimulation.
But I've also metrheumatologists that use VNS
vagal nerve stimulation becausethey deal with so much chronic
pain arthritis for example andthere's some suggestion that
(45:27):
even autoimmune conditions mightbenefit through these
mechanisms of VNS.
So you can see a rheumatologistand there's some
gastroenterologists.
I will recommend it from timeto time as an augmentive, like
an accessory tool.
Sometimes I'll use it withvirtual reality, recommend
people use them together,although I don't have any data
(45:50):
that they're synergistic.
These are all wide open areasso it's not like there's one
person to go to.
I think you need to findsomebody in your community that
knows about it and has aclinical experience working with
it, who you know can reallyguide you through the safe and
appropriate use.
Now, obviously, epilepsy isdifferent.
That's a neurological conditionand neurologists would
(46:10):
recommend VNS for that.
Kate Scarlata (46:12):
Because that's surgical right, Don't they have
to implant?
Brennan Spiegel, MD (46:15):
They can implant it, yeah.
Dr. Megan Riehl (46:22):
That's right, and I think safety is really
something we have to be mindfulof when we're having these kinds
of conversations.
So to the point that, having animplanted device, you're going
to talk about your medicalhistory, you're going to talk
about your comorbidities, therisks, there tends to be a
preference for the left sideplacement of these devices, as
opposed to the right, based onlocation of the nerves and your
cardiac nerves.
(46:42):
So it's important, beforepurchasing one of these, I think
, to really read the fine printon the websites, or to, when
you're talking about some of thetranscutaneous types of devices
that are available too, meaningyou place them on your ear, on
your neck, just being mindfulthere are some contraindications
, and so being aware of whatyours may potentially be is a
(47:05):
conversation to have with yourstart, with your primary care,
and if they don't know, they'llrefer you onward to a
subspecialist.
Kate Scarlata (47:12):
Yeah, don't self-dianose.
Talk to your doctor.
I say that even with dietchanges or supplements, just
have a health professionalinvolved in some of this.
Brennan Spiegel, MD (47:20):
Absolutely I don't know if you ever watched
that show Yellowstone.
I've really gotten into thisNetflix show Yellowstone.
Kevin Costner's character islike never goes to the doctor
for anything and ends upspending too much of his time
worried about things heshouldn't be, or not being
worried about things that heshould.
So that just happens to be.
Anyone who's watchedYellowstone knows what I'm
(47:41):
talking about.
But yeah, the left versus rightthing is a big deal because the
right side has more directconnections to the heart and
particularly the sinoatrial node, which is the part of the heart
that is the pacemaker, and soone of the side effects would be
slow heart rate, and I see thateven on the left side.
I definitely see my heart slowdown when I use it, and so you
(48:03):
know these are things you needto really check with a doctor.
If you have low heart rate, youmay want to be kind of careful
about it, or arrhythmias orwhatever.
You need to work with somebodywho knows what they're talking
about.
Kate Scarlata (48:13):
Unbelievable.
Well, this was incredible.
No surprise, because you arealways just such an interesting
wealth of knowledge and somevery interesting topics that
aren't really spoken intraditional medical settings or
with other guests that we've had.
We have learned so much fromyou, so thank you.
We'd like to end our episodewith a wrap up question to our
(48:36):
guests, and that is what do youdo in your daily life for your
own wellness and health?
Brennan Spiegel, MD (48:43):
Well, as I'm talking to you right now, I
am wearing something that looksa bit unusual.
This is actually a weightedvest.
It's a 20-pound weighted vest.
It's got metal inside of it.
It's not a bulletproof vest,it's just a weighted vest and
around both of my ankles I have20-pound weights around my
(49:03):
ankles.
So I'm right now wearing 60pounds of weight just sitting
here talking to you, and all daylong I'm at a standing desk.
I have a balance board that Istand on and I passively wear
about 60 pounds on my body.
It goes back to that gravitystory.
Dr. Megan Riehl (49:17):
I was going to say working on some gravity.
Brennan Spiegel, MD (49:19):
Yeah, when you release yourself from this
weight, all of a sudden you feelso much stronger and there's
even evidence you can loseweight just by weighting your
body down and passively exertingyourself against this pull.
So this is stuff that I do juston a regular basis to maintain
balance on the balance board Ihave a desk stepper.
I'll sometimes just walk inplace.
(49:41):
I don't have a walkingtreadmill.
I want to get one of those, butthose are a little expensive.
But those are good too.
Just simple things you can do.
Drink a lot of water.
I have a big thing of waterhere right now.
This is about gravity too.
If you stand up too quickly,get lightheaded, that's gravity
intolerance.
That's called orthostasis.
You need to keep fluid in yourbody and I think we really under
(50:05):
hydrate ourselves.
So these are really simplethings to do that can actually
contribute to longevity.
You know, we know that thesodium levels in your body I'm
getting way off topic now, butyou asked me will in some part
determine your longevity, andsodium is determined in large
part by how much fluid you drink.
You know, don't overdo it.
Too much fluid is bad too, Okay.
(50:26):
So I want to be careful aboutthat.
If you drink water all day.
That can literally kill you.
So I'm just talking aboutkeeping yourself well, hydrated,
strong, standing up.
These are things that I try todo every day, just to kind of
keep myself in some modicum ofshape.
Kate Scarlata (50:41):
I think we need to get that vest.
Dr. Megan Riehl (50:44):
You get the vest, Kate, I'm going to do some
strength training and fill upmy water.
There, you go, Dr.
Spiegel.
Thank you so much, and to allof our friends listening, we
hope that you subscribe like,follow The Gut Health Podcast.
Your support means the world tous.
See you later, friends.
Thank you for joining us as wegrow this gut health community.
(51:07):
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at The Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
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