Hélène Langevin, MD
Ramsey Badawi, from the University of California Davis, talked with Hélène Langevin, director of the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH; Bethesda, MD), about her career-long perspective on the ways in which medical treatment should address the whole patient. She is currently the chair of the Interagency Pain Research Coordinating Committee and has been a prime mover in engaging the NIH community in research in the whole-person health initiative.
Dr. Langevin received her medical degree from McGill University (Montreal, Canada). She completed a postdoctoral research fellowship in neurochemistry at the Medical Research Council Neurochemical Pharmacology Unit (Cambridge, U.K.) and a residency in internal medicine and fellowship in endocrinology and metabolism at the Johns Hopkins Hospital (Baltimore, MD). She was a professor of neurologic sciences at the University of Vermont Larner College of Medicine (Burlington) until 2012, when she became director of the Osher Center for Integrative Medicine (Boston, MA) and a professor of medicine in residence at Harvard Medical School (Boston, MA). She became director of NCCIH in 2018. As the principal investigator of several NIH-funded studies, Dr. Langevin has centered her research around the role of connective tissue in chronic musculoskeletal pain and the mechanisms of acupuncture, manual, and movement-based therapies. Her more recent work has focused on the effects of stretching on inflammation resolution mechanisms within connective tissue.
Dr. Badawi: You studied music as well as biology as a student. I was curious: what was your instrument of choice? Do you still play?
Dr. Langevin: Piano. I still play. I find it so relaxing. I love classical music—it takes you back to a different epoch. My favorite period is the turn of the 20th century, when things were getting deconstructed in art and music. That’s an interesting time.
Dr. Badawi: You spent quite some time as a practicing physician. How did that inform your choices of scientific inquiry?
Dr. Langevin: I was an endocrinologist, and I also practiced internal medicine. I ended up seeing a lot of people who had pain—chronic pain, specifically. You can’t be a doctor without encountering patients who are dealing with chronic pain. I felt so frustrated by how little I could offer. That’s what got me interested in nonpharmacologic methods for pain management, of which there were very few at the time.
Dr. Badawi: You have had a tremendously successful scientific career. What would you describe as your most significant contribution?
Dr. Langevin: I was part of a group of people who, around 20 years ago, started seriously thinking about the role of connective tissue in the body: how important it is, how understudied it is, how it interfaces with all of the other systems in the body, and how much more we need to understand. We needed to study the connection between biochemistry and biomechanics and the whole field of mechanical transduction. We developed a very simple model in my lab, which used acupuncture needles to deliver a force into the tissue. By simply stretching the tissue, we could look at the impact of this force on cells and cascades of signaling pathways. But much remains to be done. At the cellular level, we think about connective tissue as the extracellular matrix, but at the whole-organ and whole-body levels, huge gaps remain in our understanding of the role connective tissue plays.
Dr. Badawi: When we think of vigorous aerobic or resistance training, the metabolic pathways and the outcomes of the signaling are understood even by lay people, but significant benefits are associated with other exercise modalities, such as yoga. Is this related to what you are talking about?
Dr. Langevin: Absolutely. If you’re doing a less vigorously aerobic exercise, such as gentle yoga, your heart rate may not go up very much. But what may happen is that you move your body in directions that are not habitual. At the same time, you are relaxing your body and removing some of the connective tissue restrictions by gentle stretching. It’s a very different effect physiologically. Doing yoga for 30 min or running for 30 min can both be beneficial but in very different ways.
Dr. Badawi: May I ask about your own exercise habits?
Dr. Langevin: I do about 15 min of stretching every morning, because I know that if I don’t, I tend to stiffen, get more pain, and be more injury-prone. I also always try to do something aerobic. I don’t run any more, but I ride my bicycle to work. I’ll swim in the summer and do cross-country skiing in the winter. I also like canoeing—anything that’s outside. I like to challenge my body in different ways. I think aerobic exercise is important for your general health, but it’s not enough by itself. The stretching is necessary to maintain my capability to do the aerobic exercise.
Dr. Badawi: Changing the topic, how did you make the transition from practicing scientist to leadership at NIH, and what drove that career choice?
Dr. Langevin: One of the nice things about being at NIH is that I’m able to have a lab in the NIH intramural space. I’m still able to do research, although I have less time for it. Having the opportunity to also be the director of NCCIH has opened up a whole other aspect of science for me. In this role, I can impact the kinds of questions that researchers can address in a much larger sense. For example, the NIH Helping to End Addiction Long-Term (HEAL) Initiative is aimed at addressing the opioid epidemic. This has 2 components: the opioid problem and the related crisis of pain. So many people live with chronic pain. A lot of it is musculoskeletal, and in many cases, we don’t understand the pathophysiology. Together with the HEAL Initiative, we launched an effort aimed at developing imaging and other methods to quantify abnormalities within the musculoskeletal tissues that may underlie myofascial pain. These are areas in which we have historically done very little research. As NCCIH director, I have a wonderful opportunity to help researchers make a tremendous impact.
Dr. Badawi: I once attended a lecture by a hand surgeon, John Agee. He mentioned the opioid epidemic and the pain crisis. He opined that a direct cause of a large fraction of the problem was not a deficit of medicine, it was a deficit of love—that many of these people who find themselves dependent on opioids for pain management actually have a lack of meaningful human connection in their lives. He said that human connection is enormously important in reducing the impact of pain. What is your thought about that statement?
Dr. Langevin: I think that you’re talking about the psychosocial component of what we call the biopsychosocial model of pain. The muscles, the connective tissue that I was talking about earlier in terms of the myofascial pain, are the bio part. That’s hugely important, but the psychosocial component is enormously important as well. Thirty years ago, if you had back pain, you went to see an orthopedic surgeon, who decided whether you needed surgery. If you didn’t need surgery, your back pain was called nonspecific and not much could be done for you, which led to huge frustration. However, the pendulum has now swung toward the psychologic components of pain. We have begun to understand the processes involving the central nervous system, emotional distress, stress responses, and behaviors that go along with having pain. We have begun to understand the negative consequences of, for example, loneliness in this context. But we have yet to fully connect the psychologic and social contexts of pain with what’s going on in the physiologic space and the tissues. I think that’s the big challenge now.
Dr. Badawi: That sounds like a tremendously exciting paradigm to explore.
Dr. Langevin: Indeed!
Dr. Badawi: Tell us a bit about your current role as director of NCCIH.
Dr. Langevin: When I came to NIH, one of the big things that I presided over was mapping out the new strategic plan for NCCIH. In the past, NCCIH had focused on a few very important areas, such as pain, mind-and-body practices (such as yoga and meditation), and natural products, which are in widespread use but not always supported with robust scientific evidence of utility. This is important work, and we still support this kind of research.
But as part of the new strategic plan, we decided to create a framework for studying these in the context of what we call whole-person health. We define this in a way that empowers individuals, families, communities, and whole populations to improve their health in multiple interconnected domains. We want to stop thinking about biologic, behavioral, social, and environmental factors as separate and instead look at them all together. Even within the biologic domain, we tend to compartmentalize: we look separately at the nervous system, cardiovascular system, and digestive system. The point of whole-person health is to think about the integration of the whole person.
My role involved not just developing the new strategic plan but also publicizing and implementing it and overseeing new funding opportunities. We’re starting to see people submitting grant applications in response to this, which is very gratifying. Part of my job is also to go out to speak with people from other NIH institutes that are more focused on specific body systems or diseases and advocate for collaboration on whole-person health. So far this has been very successful. We have an internal NIH working group on whole-person health in which many other institutes and centers participate.
We also participate in several trans-NIH initiatives. One of these is the Pragmatic Trials Collaboratory, which focuses on research in health-care settings. Conducting trials that are embedded within health-care systems can help disseminate knowledge and address obstacles in implementation of proven approaches that aren’t being used. We know, for example, that opiates should not be the first-line treatment for pain. Yet if you look at health-care systems, they’re often still used in this way. Nonpharmacologic methods, however, can be tricky to implement, because they require different expertise, different people. This initiative is aimed at changing that.
I also do a lot of outreach and external talks. For example, I spoke at the September 2022 Total-Body PET Conference in Edinburgh, U.K. It was great fun to be able to interact with a completely different scientific community that I did not know before.
Dr. Badawi: Can you tell us a bit about how your whole-person health research effort came about?
Dr. Langevin: It goes back all the way to when I did my very first research fellowship after medical school. My area of study was the hypothalamus, which is a really interesting part of the body. It’s very small and difficult to image, but packed inside that little hypothalamus is control of the autonomic nervous system, the endocrine system, sleep, appetite, growth, reproductive function, and more. I always think it is like the orchestra conductor for the whole body. Subsequently, when I was practicing internal medicine, my subspecialty was endocrinology. The endocrine system is a whole-body system that impacts all the organs. Then I got interested in connective tissue, which in a completely different way also has its fingers over all these different organ systems. So, this idea of whole-body research was kind of in my head for a long time.
Then, when I came to NIH, I really wanted to start thinking about what we call whole-person health. Instead of focusing on diseases a single organ system at a time, we need to understand health better, which is a whole-body phenomenon. Imagine you’re not so healthy; perhaps you’ve had an unhealthy lifestyle for a couple of years, gained a few pounds, your blood pressure might be starting to creep up, your blood sugar might be a bit less controlled, your lipids a little high. This is the beginning of what we call the metabolic syndrome. It’s a very, very common problem, but it’s reversible up to a point. So if you do the right interventions (eating a good diet, getting some exercise, and especially managing stress), the entire thing can be reversed. All of these abnormalities can improve at the same time, because it’s a whole-body intervention. You can see that this is all connected: exercise ties into the musculoskeletal system, diet and nutrition tie into metabolism and endocrinology, and then stress and sleep tie into the nervous system and the hypothalamus. For me, this represents much of what I have been thinking about pretty much my whole career.
Dr. Badawi: We’ve been talking about the potential role of molecular imaging and, in particular, total-body PET in whole-person research. What do you think are the key areas in which total-body PET might be able to contribute?
Dr. Langevin: We talked a little bit already about the relationship between the structure of the body and its biochemistry. When we think about biochemistry, we tend to think about these molecules sort of floating around in liquid—but that’s not right. All biochemistry occurs in a structural environment. What PET imaging and total-body PET in particular allow you to do is to look at biochemistry in this greater context. So I’m very intrigued. I think there’s a lot of potential here. This is a really wonderful new way to look at how the different organs and systems communicate with one another. Some of the presentations that I saw at the Edinburgh conference last fall showed me that this new technique really encourages integrative thinking. Sometimes it takes the development of a new technology to allow the generation of a different kind of hypothesis or a different way to look at a problem.
Dr. Badawi: I think the field is beginning to see that the mathematic and analytic tools for molecular imaging that we’ve been using quite successfully for the last 40 years are not really adequate for addressing the whole-person health problem. As a result, people are starting to reach out to others who have expertise that can help us. I think that is very positive.
Dr. Langevin: I agree. And, if I may, I would like to mention the trans-NIH Methodologic Approaches for Whole Person Research Workshop that NCCIH hosted in summer 2021. Our goal was to identify expertise in all kinds of fields that could be brought to bear on studying whole-person health. The discussion was very encouraging. We have a new generation of researchers who are not afraid to tackle big data and complex questions. They have the necessary computational tools, the networks, and the analytic tools. They also have new technologies that can collect and analyze these kinds of data, and we have new thoughts on how to design studies properly to look at complex systems. We looked at how to study interconnected systems and how to study the impact of multicomponent interventions on these interconnected systems. I would encourage anyone who is interested to watch the conference [on-demand at https://www.nccih.nih.gov/news/events/methodological-approaches-for-whole-person-research]. It really showed us that the field is ready to tackle this.
Dr. Badawi: Dr. Langevin, thank you so much for a fascinating conversation!
Dr. Langevin: My pleasure. This has been very fun!