Tuesday, December 26, 2023

Zoe and Zak's Adventures to meet the PNW Trolls

With my niece, Zoe, at the Fremont Troll
A few months ago, I was scrolling my social media when I came across a post announcing completion of the installation of five Dambo Trolls in Washington. These trolls are large pieces made from recycled materials designed and constructed by Danish artist Thomas Dambo. An unrelated troll has resided in Seattle under the Fremont Bridge since 1990, originally intended to deter homeless people from living in the area, which was a few blocks from my apartment when I moved here. I took many visitors to mee the 18-foot tall Fremont Troll sculpture, but didn't know if trolls had any significance to the area. Washington is more associated with Sasquatch (AKA Big Foot), and my research has shown that trolls aren't really connected to the PNW, but these new masterpieces seemed interesting, so I decided to visit them. 

1990's Troll Toy
I also decided to learn more about the history of these fantasy creatures. I remember liking The BFG (The Big Friendly Giant) by Roald Dahl, who wrote my favorite book, Matilda, but have no recollection of reading tales of trolls. My brother used to have a collection of trolls when we were little, with the famous neon pointed hair and gemstone belly buttons.  Interestingly, those troll toys were invented by a Danish man named Thomas Dam, and these led to the creation of the Trolls movies that star Justin Timberlake and Anna Kendrick. I couldn't figure out if Thomas Dam was related to Thomas Dambo, but those names are way too much of a coincidence if they're not family.

According to Wikipedia, Trolls come from Nordic Folklore and Mythology and the word has a few different possible meanings including fiend, demon, or mythical magician. Trolls typically live in isolation, in forests, mountains, or caves, and Dambo shared that his installations use recycled materials to help the planet and bring people outside to visit nature. He's creating a "bridge between cultural and environmental stewardship." As I read more about trolls, I thought about childhood adventures and fantasy tales, but the isolation so frequently depicted also reminded me of some of my patients with chronic pain. I frequently work with teenagers experiencing chronic pain or illness, and it's common to see them isolate as their condition worsens, transitioning into a period of hibernation.

Zoe and Zak's Pain Hacks
I decided to write about the five trolls along with a review of a new children's book series written by Dr. Joshua Pate, an Australian physiotherapist, called "Zoe and Zak's Pain Hacks." (Link to buy in the US.) Dr. Pate has written a TED talk called "The Mysterious Science of Pain," that's a great five-minute video clip.  
I first learned about Dr. Pate and his work with kids experiencing pain in November 2021. While preparing to give a talk to coworkers at Seattle Children's about treating kids with chronic pain, I couldn't find research indicating what age kids start to understand the pain neuroscience concepts recommended by the Explain Pain Books so frequently shared with adults. I tweeted what I was searching for, and Dr. Rachel Zoffness came to my rescue. 

Not only did Dr. Pate send me a copy of his (soon to be published, now available in a book) chapter called "Developmental Influences on the Meanings of Pain in Children," he offered to meet for a Zoom chat. He was very kind to spend an hour chatting with me about the work he was doing and that he had this series of children's books coming out soon. His research, and there's loads of it!, determined that kids start to understand pain concepts around age 8, and he also explained how he conducted some of his research and some of the interesting things he had discovered. I found his reference to this paper where children were asked to draw whatever the word "pain" made them think of particularly memorable. Dr. Pate found that in his small sample of kids, those who were experiencing chronic pain drew emotional components like a broken heart or tears, which kids who did not have pain did not draw.  
Pia the Peacekeeper
The boxed set of books arrived at my home soon after our call and I read them right away. They're beautiful and fun to read, despite being about pain. I started to write a blog post about them way back then without the trolls, but the post felt like it was just me spitting out pain research and I prefer to write my posts connecting different thoughts, so I stored the books on my shelf, alongside my other fabulous pain nerd books, until the epiphany came to pair the books with the trolls. So here's Zoe and Zak Zoppins on their adventures with me as we met the PNW Dambo Trolls.

The first book in the series is called "Zoe Zoppins Nails It." It tells the story of "A Tale of Two Nails." Zoe's Uncle Ozzie steps on a nail and has intense pain, only to later find out that the nail went between his toes and didn't injure his foot at all. This story is commonly used to show that pain doesn't always equal tissue damage, and the illustrations and rhyming make it easily understood even at a young age.  The first troll we visited was located on Bainbridge Island, across the Puget Sound just a little bit west of Seattle, and is named Pia the Peacekeeper. Located on Salish territory, the Muckleshoot and Snoqualmie tribes collaborated on the development of Pia. These trolls are quite massive, and I had an immense appreciation for the size of their hands and feet. Having Pia hold the book was the best way to demonstrate the scale, but of course my nerd thoughts went to the homunculus and how much sensory input these trolls would have from their massive hands.
Frankie Feetsplinters

Second in the series is "Zoe Zoppins Lights It Up" which is based on this research from Lorimer Moseley, author of the previously mentioned Explain Pain Books and mentor to Dr. Pate. This study examines pain under different contextual circumstances. Zoe is tapped on her hand by a cold metal rod and rates her pain when there is either a blue or a red light shining in the room. When the blue light shines, the pain is less intense, but when the red is illuminated, the pain increases. I wonder if Dr. Pate chose this book to have a blue cover because of the storyline. Similarly, I recently participated in the 30-day course The Embodied Clinician with Sheren Gaulbert who I met at the San Diego Pain Summit. We also discussed the relationship between colors and emotions, so naturally I sought research on this topic and found this paper, which suggests this science is in its infancy, but that red has been studied and found to relate to increased attention and outward focus and potentially has an impact on performance. 

Jakob Two Trees
The second troll I visited was Frankie Feetsplinters who lives in Ballard, a Seattle Neighborhood that houses the Nordic Museum. It makes sence that this would be the location for one of the trolls, as the Nordic countries include Denmark, home of the artist. Frankie was the last of the PNW trolls to be installed and was assembled in West Seattle and transported on a flatbed truck to Ballard. The blue-grey skies of Seattle and the more welcoming pose of this troll were certainly not scary. I've never actually gone into this museum, but I hear great things about it and have tickets to check it out in early 2024. (Seattle pals - you can get free tickets to many museums through your library card or directly through the museum! The Nordic Museum has free tickets on the first Thursday of every month).

"Zoe and Zak's Brainy Adventure" is the third book in the series.  I think the illustrations in this one might be my favorite from the set, though the art is really great for all of them. This story explains the numerous messages that are sent and received when an injury occurs and how quickly they're processed, all contributing to pain which is meant to protect us. In an acute pain situation, the protection from pain is helpful, but in a long-term situation when the pain persists, it can become over-protective. This story shares many Explain Pain concepts, like "Pain does not always mean tissue damage." It uses virtual reality to explore the brain, though it doesn't go into detail about how virtual reality can be used for pain - maybe that will be in the second series if Dr. Pate keeps writing these! The third troll I visited was Jakob Two Trees, located in Issaquah, who is simply magnificent at 14-feet tall. I think Jakob was my favorite troll - a short walk among the trees that protect you from the rain, just like pain is protecting our bodies - but there were SO many people visiting, that it was hard to get a close-up photo. It was really fun meeting others who were Troll Hunting on these adventures. 

Oskar the Bird King
Book number four is "Zak Zoppins Retrains His Brain." Zak is Zoe's cousin who shares that he has back pain while they're playing. They discuss how pain can change and isn't permanent using different strategies such as calm breathing and imagery to re-train the brain when it's used to having pain for too long. This is an important message to use with kids with chronic pain because a lot of the time they're fixated on their pain being permanent and that there isn't any hope for it to get better. They're not yet exposed to slow and steady progress for most things in life and are more immediate in their thought patterns, particularly the younger they are. This book, along with the previous and next ones don't refer to a specific research paper, but rather encompass many studies about pain. If you search for "Retrain Pain," you'll come up with several papers, including an online company, that offers a certification for rehab providers which looks interesting (though I'm not familiar with it, so I can't recomend the program).

The fourth troll was Oskar the Bird King, located on Vashon Island. Oskar was the farthest troll from my house and of course it wasn't raining when I departed, but by the time I arrived, it was POURING. Typical Seattle. Oskar is the most intimidating of the trolls in the PNW, pointing at you and with eyes that seem to follow you no matter where you're standing. He's just as awesome as the others, even with the rain, but I didn't want my book to get wet! It's hard to tell from this photo, but Oskar is wearing a crown of birdhouses and sitting on a throne. There are actually birdhouses near the other trolls and Thomas Dambo's earlier work was to install birdhouses all around Denmark. He uses scraps of material from making the trolls to create the birdhouses and at some of the locations, they are painted and posted to indicate the troll is nearby. 

Bruun Idun with the whole set
The fifth and final book is "Zoe Zoppins' Action-Packed Action Plan." In this story, Zoe shares her action plan to use if she's having pain and applies it to different scenarios, like her belly ache when she's nervous about giving a speech in school or when she gets hurt playing soccer.  It's got some similarities to the previous book in that it's sharing some strategies that might be helpful for a kid experiencing pain and how to try to treat it. I particularly liked the focus on all the different activities that Zoe CAN do, rather than on things she can't because of her pain.  This is an approach I frequently use, encouraging patients to participate in whatever they can, particularly if it's fun, as the activities might help reduce their pain in the long-term. 

And the last troll I visited was Bruun Idun, located in the most scenic setting of the PNW trolls in a coastal spot of Lincoln Park in West Seattle. If you plan to go visit, you could take an easy walk from the parking lot, or you could have no sense of direction like me and turn it into a nice two-mile hike through the woods, culminating in a gorgeous view. Bruun Idun is playing songs for the orca whales living in the nearby Puget Sound. Music is one of the things that I often use with my patients with chronic pain as something to help them move and sometimes even let out their feelings.  We talk about matching music to moods, yelling along with songs that help them let out frustrations or crying along with songs that might also be sad. We talk about trying to go for walks that last the length of their favorite song as a way to incorporate movement throughout their day, potentially including the distraction of pairing it to something more pleasant if the movement is uncomfortable. And sometimes, I give patients the homework of listening to their favorite songs and coming up with lyrics that are positive for them to post around their house as a reminder of better days to try to bring hope and momentary happiness. Everyone could use more joy in their day, but sometimes when kids are sick for so long, it's really hard to find that. 

All in all, it took me three months, four ferry rides, and one very wet outing to complete my visits to all the trolls. Zoe and Zak's tales helped me to think about pain from a different perspective and taking them on adventures helped me to enjoy the PNW in the early part of this year's rainy season. I'm hoping to make a trek down to the Portland, Oregon Troll, Ole Bolle, who is 19 feet tall at some point, but of now, thanks for the good reads, Dr. Pate, and thanks for the beautiful artwork, Mr. Dambo.

Monday, September 25, 2023

San Diego Pain Summit 2023

Kathleen Sluka: Unnerved
This is the last of a three-part series about the San Diego Pain Summit. You can find the first post here which reviewed the video recordings of the previous years' summits and the second part is here, which described my experience at the 2023 Pre-Conference "Applied Neuroscience" Course with Dr. Morten Hoegh. 

This final installment, long overdue, and perhaps too verbose in content, was an opportunity for me to re-watch all the 2023 presentations, dive into the cited resources, and review my notes from the conference several months after the fact. I didn't read every paper that was referenced and some talks more closely relate to my patient care, so I dove into that content a bit more than others. A two-day course filled with so many incredible speakers left me with more questions about pain mechanisms and management, tons of new resources, a broader network that I'm so grateful for, and numerous tidbits of knowledge and paths to follow for further growth. Overall, I highly recommend watching the YouTube videos that San Diego Pain Summit Founder/Owner Rajam Roose has generously posted online for everyone (2023 Summit to be made available in November 2023).

Keynote Speaker: Dr. Kathleen Sluka
Keynote Speaker Dr. Kathleen Sluka kicked off the weekend talking about "The Science of Exercise: Basic Mechanisms and Clinical Implications." She shared, “We have known about the value of exercise for over 100 years. This paper (Wainwright 1921) is said to be the first known paper published in Physical Therapy, and what you can see is that physical therapy showed 25% decrease in disability and saved the hospital $4000 a year which is a ton of money 100 years ago. Exercise is cost effective and reduces disability.” She continued, there are "numerous randomized controlled trial studies that show that exercise is effective for almost every pain condition."

Kathleen Sluka: Muscle Fibers

It was entirely by accident that I started part one of this blog series describing animal studies used to explore pain, as I didn't realize Dr. Sluka was going to share research from her lab about pain in rodents. Pain does increases during activity in people and animals - but over time, exercise helps reduce pain. This is often a battle we face in the clinic - where patients are hesitant to exercise because the acute bout of activity is uncomfortable and needs to be repeated for the cumulative impact of pain reduction. Consistent participation in activity is the key for pain management, and it is not a simple task to convince those who have suffered to push through the early days to achieve that long-term outcome. Dr. Sluka described experiments where they compared pain responses in sedentary and exercising rodents to demonstrate underlying mechanisms for how pain reduction occurs. 

As a physical therapist with a degree in exercise physiology, I've read about exercise and pain before, but I considered a macroscopic level for why it works. Concepts like exercise facilitates blood flow and circulation of nutrients or waste in the body, increases GI motility, reduces brain fog and increases concentration, stimulates appetite and improves sleep, and enhances psychological and sociological well-being. Dr. Sluka commented on many of these macro mechanisms, but she studies the microscopic level, and explained how exercise reduces pain at this deeper level.

source
Exercise is multi-modal, preventing and improving pain through multiple mechanisms, It impacts the central and peripheral nervous systems as well as having an impact on immune function. Exercise can increase endogenous opioids in the central nervous system, increase serotonin availability which reduces pain, reduce central excitability, increase the presence of receptors and block others known to impact pain, and more! Dr. Sluka and her team researched these physiological processes and she shared how they studied each mechanism. 

Dr. Sluka described an experiment studying the impact of resistance training on pain in rats in which weights were attached to their tails while climbing ladders. Typically, aerobic exercise is more commonly studied for pain reduction, but this study found strength training to be beneficial as well. The image of rats climbing ladders with weights on their tails made me laugh... it puts the concept of a gym rat into a whole new context, right? So what exercise is most effective? Almost everything works, so the choice should depend on patient references, therapist training, and cost effectiveness. If the patient doesn't do it consistently, it won't work. 

Who else spoke? The lineup included researchers and clinicians from different backgrounds and countries with unique perspectives. Bios for all the speakers

Dr. Nathalia Costa
Dr. Nathalia Cordeiro da Costa talked about “The Ubiquity of Uncertainty: Learnings from the Low Back Pain Context.” Dr. Costa said, "Rather than resisting uncertainty, navigate it alongside your patient as if you’re on a journey together. Where clinicians do embrace uncertainties, they provide care in a way in which they can collaboratively and continually attempt to attune knowledge to complex lives, attending to emotions that emerge and exploring ways of shaping a good life in a non-linear manner." Dr. Costa cited one of her papers co-authored with fellow 2023 presenter Dr. Karime Mescouto, which I enjoyed reading because the paper shares how uncertainty in practice can contribute to clinician burnout.  The paper described interviews with 22 clinicians of varied backgrounds, all of which worked with patients with low back pain, summarizing various ways that uncertainty appears in low back pain management.  

I sit with uncertainty in my patient care pretty frequently and it's a topic of discussion with coworkers particularly with more complex medical conditions. We typically discuss the selection of interventions for the patient, but we don't discuss how we deal with the uncertainty ourselves or if we address it with the patients. Since hearing this talk, I have found myself sharing my uncertainty more directly with some patients and I've noticed that in those cases, patients are more willing to help choose their treatment pathways and also to speak up if they want to make a change to their approach.  "Uncertainty is a necessary stance that pushes clinicians to remain open to other possibilities rather than to paralyze or ossify their practices." 

Dr. Nathan Hutting
Dr. Nathan Hutting was next with "Person-focused self-management support in people with musculoskeletal pain conditions." Dr. Hutting discusses the importance of the biopsychosocial approach in patient-centered care in an effort to encourage patient self-management. He emphasized therapeutic alliance and an understanding of problem-solving skills and behavior change approaches in patient care, and then provides two definitions of self management:

“The ability to manage the symptoms, treatment, physical and psychosocial consequence and lifestyle changes inherent in living with a chronic condition.” Barlow 2010.

“Interventions that aim to equip patients with skills that allow them to actively participate in and take responsibility for managing their persistent condition so they can function optimally.”  Jonkmen 2016. 

Self-management is the idea that patients with chronic conditions need to take an active role in their treatment.  This isn't easy to do and it certainly goes against a lot of the usual patient care that we provide - but I think it's an essential practice that we should be encouraging patients to partake in, particularly when they are likely to need ongoing self-care. How did I apply this to clinical practice? A few months ago, I sat down with a new patient experiencing chronic pain who could hardly tolerate getting out of bed. Her pain had taken over her life. Self management for this patient included the patient deciding that the pain couldn't be in charge anymore. She started by deciding what activities she wanted to do even when she had pain. This approach isn't possible for everyone - but it was possible for that patient. I don't think her progress would have been the same if we had just started with a home exercise program like our usual approach. She needed some motivational interviewing and behavior change and some autonomy over her day to day activities. 

Dr. Morten Hoegh
Next was the return of Dr. Morten Hoegh, this time focused on "Low Back Pain and what to do about it in 2023." I already wrote about Morten in part two of this series, but this was a different talk, also very excellent, so I'll share one key take away from him here. "Just because you have pain, doesn't mean you need pain management." This directly aligns with two key papers and ideas he shared. First - the presence of pain is something that occurs because we're human. What if, instead of looking at low back pain as a problem, we looked at it as the normal occurrence that it is, since most people will have it at some point in their lives?  Does it always need treatment if it's normal?  

And second - imaging for pain often takes us down the wrong path and can be quite harmful for patients. In fact, many patients who have MRIs taken have worse outcomes than those who do not. This paper discusses the negative impact of having imaging conducted too soon. He shared this clinical practice guideline for non-specific low back pain from 2018 which has three key recommendations: 1) triage patients with low back pain and group them into subtypes, only pursuing imaging if serious pathology is suspected. 2) "In acute low back pain, patient education, reassurance about a favorable prognosis, advice on returning to normal activity, avoiding bed rest, and use of NSAIDS and use weak opioids for a short time period" are recommended treatment. 3) "In chronic low back pain, patient education, exercise therapy, psychological interventions, NSAIDS, and anti-depressants when necessary are the recommended treatment." Morten is speaking again soon (Oregon Pain Summit October, 2023), and it's a huge bummer that I can't attend that conference

Dr. Tran & Mistress of Ceremonies Dr. Sarah Haag

Dr. Mai Huong Ho-Tran talked about "Creating Patient Safety." This was a discussion including breath work and mindfulness strategies. She outlined the six core processes of ACT (Acceptance and Commitment Therapy, which uses mindfulness and acceptance along with commitment and behavior change processes to increase psychological flexibility. 

She cited BJ Fogg who studies behavior change at Stanford and wrote Tiny Habits, which explores the premise that if you tie a behavior to something that already exists in your routine, it can act as a cue for the patient. The example she used was to have a patient do a heel raise every time they go to the bathroom. I personally do my heel raises while I'm pumping gas. 


Next we come
 to Dr. Devra Joy Sheldon's “Intruding on the Intruder.” Dr. Sheldon has graciously mentored me with complex patient cases and is a brilliant human and neurology specialist PT. We're presenting a talk about Complex Regional Pain Syndrome along with Dr. Karen Litzy at the Boston APTA Combined Sections Meeting in February 2024 together! Want to have your mind blown? Watch this presentation when it comes up on YouTube. Neurology is an area in which my knowledge is immensely limited. I heard her talk in person in San Diego and watched it twice more since then, reading several of the papers she cited as my neurons slowly exploded from being overwhelmed. I had never heard many of the words in her talk prior to the San Diego Pain Summit, and I can't imagine I'm doing them justice here, but alas...

Dr. Devra Joy Sheldon
Dr. Sheldon describes chronic pain as an intrusion on living life, an interruption of thought. Pain steals attention and impacts a human's ability to multi-task. People can train their ability to complete two tasks at the same time, unless pain is present. Distraction is a common approach in pain management for some patients, used in an effort to bring attention away from the pain. An opposite to the pain intrusion is a deeply absorbing mental state called the flow state. Flow is a state of complete focus. 

Think of a basketball player's ability to tune out the fans in the arena during a game while being acutely aware of what's happening on the court. That's a flow state. When in a flow state, there is high focus and concentration, driven towards a goal, concurrent with a loss of self-reflection and awareness of the environment. It brought me back to when I attended a course in 2017 where we talked about examples of an athlete breaking their leg on a final play of a big game - and if it would hurt the same depending on if their team won or lost. 

Kathleen Sluka: Tree of Life
Dr. Sheldon cited this paper, which describes three key networks in the brain which regulate the flow state. First, the default mode network (DMN), which prevails when a person isn't engaged in a cognitive task or working towards achieving a goal. It is an internal-directed network, active when a person is thinking about themself or the impact of their own words or actions, active in social scenarios or in reflection. 

Next is the central executive network (CEN), an external-directed network that facilitates concentration and focus. With limited resources to process all the thoughts in our brain at one time, it appears that one network must dominate over the other at any given time, as we are unable to concentrate on an external task while simultaneously focusing on ourselves. 

Finally, the salience network (SN) appears to serve as the switch between the other two networks (and more networks that exist), making the determination of where attention should be directed - internally to self or externally to a task. It is the brain location where we assess self awareness taking into consideration risk versus rewards, skill versus ability, parasympathetic versus sympathetic activity, and if we are willing to put forth the effort to pursue the goal in front of us.

me & Dr. Sarah Cruser
As a fun flow state activity, Dr. Sheldon had us partner up and draw together. I sat with my friend and colleague, Dr. Sarah Cruser, at the conference, so we drew together. These brain networks for attention for flow are also involved in chronic pain. For this reason, we cannot use reduction in pain in order to help patients to feel better. We need to use opposing processes like joy, novelty, fun, play, and curiosity in order to reduce pain. This reduces prior expectation and anticipation of pain. Novel activities demand attention and facilitates reflection - which shifts us to the default mode network, which we want! Art and self expression can help improve resiliency, self-efficacy, activation of reward circuits, and improve novelty, and are another way to work towards flow state and away from chronic pain. Dr. Sheldon's talk was really incredible and definitely provided new subjects that I hope to spend more time learning. 

Dr. Ryan Shelton
To wrap up the first day's talks was Dr. Ryan Shelton, my Twitter pal prior to the Summit. Meeting him IRL was like reuniting with an old friend.  "Reimagining the role of business in healthcare: aligning our work with the needs of the community to minimize health inequalities," was a deep dive into how he built his company, PhilanthroPT, dedicated to providing physical therapy services (and so much more) to those in his community, regardless of their ability to pay for care, while still making enough money to provide for his family and his employees. He's revolutionizing physical therapy, starting in Kentucky, and I hope he'll eventually be able to revolutionize healthcare as a whole. 

Dr. Shelton reminded everyone in attendance, particularly the American physical therapists, of the APTA Code of Ethics which includes social responsibility as a Core Value. It is our responsibility to help those in our community 
APTA Code of Ethics, Principle #8

In general, my employer, Seattle Children's Hospital, provides options for payment for medical care so that no kid goes without it. I previously worked in a private practice clinic where patients were turned away if they had certain types of insurance or couldn't pay for their care. Medical care in the United States is a business, and it's a poorly run business, in my opinion. Insurance companies act as gate-keepers, limiting what services are covered, profiting at the expense of people who are sick. I think physical therapy is an important service, but at an even bigger level, I find immense appreciation for the fact that kids who need vital medical treatments can get them at my hospital. Unfortunately, they might not be able to get them elsewhere, just because their family can't pay. (It is the law, however, that US hospitals provide life-saving treatment to people in an emergency room regardless of ability to pay.) 

me & Dr. Shelton
Dr. Shelton's talk was full of great kindness. He said, "If you don't make a conscious decision to do something, you've already made a conscious decision to do nothing... I know that where I live, nobody else is going to take care of the people that I take care of. If I don't get up and do the work, nobody does the work. Every one of us has a community that we care deeply about, and have enough determination to work for. The least we can do is 'no harm.' That's the least we can do. The best we can do is advocate for justice."

He advises that you think about the niche of your patients. As an example, there are physical therapists who treat patients following an ACL injury. They need to consider if they would treat the patient with an ACL injury if they couldn't pay for their services or if they didn't have insurance? This is the case for some of my patients. They can't get care elsewhere, so they come to my facility. This is the case for a lot of Dr. Shelton's patients. He has shown that he can own a profitable business without turning these patients away with creative payment methods, and he shares these methods with others to encourage the rest of us to find ways to help our communities so everyone can have access to medical care. 

Dr. Jessica Isom
The keynote speaker leading day two was Dr. Jessica Isom, a board-certified psychiatrist whose talk, "The Urgency of Now: Disrupting Racism in Pain Management," guided us to reflect on our biases and unpack medical discrimination. She shared video clips from The Whiteness Project, a collection of short interview clips with white people sharing their understanding of white privilege or race accompanied by statistics. There were some really interesting beliefs expressed, some show understanding of the problem, others openly denying that being white comes with privilege. I highly recommend checking out a few of these clips and considering the potential implications of the beliefs that are demonstrated. If the person in the interview was your healthcare provider, would they provide optimal care to you, regardless of the color of your skin? They might not ever say the same words in a clinical visit, but how would these underlying beliefs impact the way they behave? I found these clips eye-opening. 

Dr. Isom referred to research from this 2022 paper about racism in healthcare, "The majority of healthcare providers tend to dismiss racism as existing in healthcare interactions. Racism is seen as a matter of individual experiences rather than structural." She also cited this 2019 study that asked subjects to identify pain on photographs of people's faces, which found that white participants more readily recognized pain on white faces than on black faces, and that this facial recognition of pain also carried over to the treatment recommendations made for the patients. She also included this 2021 correspondence to the Lancet that she co-wrote with my college friend, Dr. Galina Portnoy, written as a response to Trump legislation that restricted diversity training in healthcare, later rescinded by the Biden administration, outlining the importance of DEI in medicine. 

Dr. Karime Mescouto & Dr. Haag
Dr. Karime Mescouto followed with "Let’s talk about power in pain management? Thinking beyond the biopsychosocial model." This was a talk about shared decision making which requires an exchange of expertise, ultimately requiring negotiation of the balance of power. Power can play out in numerous ways in a clinical interaction. 

In January 2023, about two weeks before attending the San Diego Pain Summit, I met with a lawyer to finalize my estate plan, the legal paperwork for what happens to all my stuff if I die. The process was emotionally difficult for me, initiated solely because of the torture my siblings and I went through when our parents died suddently from COVID and their wills were not recognized in Florida. The lawyer had been incredibly kind, thoughtful, supportive, and well-organized. Her conference room was beautifully decorated in all my favorite shades of blue, but the chairs at the table did not fit my body. Not even close. The arm rests dug into my sides as I sat through our meeting, sad and distracted, struggling in a physically uncomfortable way. After all the signatures were completed, I went home, grateful I wouldn't ever need to return to that office unless I want to make changes to my paperwork.

As I was listening to Dr. Mescouto talking about power in clinical spaces, I could appreciate that the way a clinic looks or feels might not be comfortable for every patient, but I couldn't build the bridge to understand how it impacted power. She asked, "What color are the walls in the clinical space? Is there artwork or posters on the walls?" If there are pictures of anatomy on the wall, those might impact how the clinicians practice physical therapy - directing our treatment at anatomical structures. "Do the posters include people on them and are those representative of everyone who will be present in your space?" Are there diverse representations - or just white people in the posters? And then she said it. "Are the chairs different sizes, able to accommodate different bodies? A small change to the physical environment may seem minor, but they can have a big impact on who feels the power in an interaction." 

Wait a second! I emailed that lawyer while I was still sitting at the Pain Summit, thanked her profusely for how she handled my particular estate-planning circumstances, and I shared that I needed to provide feedback that could make her company's services even better: the addition of more inclusive chair sizes in their conference room. The response I got was overwhelmingly positive - gratitude from someone who loves shopping and wants her clients to feel comfortable during their work together. I no longer need to dread an update to my will, and hopefully nobody else can now avoid an uncomfortable meeting. I looked around my clinical space when I returned from the conference to make sure there are chairs and treatment tables that can accommodate everyone - and was pleased with the options in both the PT gym and in the lobby. 

Dr. Mescouto includes reference to this video clip, made with Dr. Costa, called Power and the Clinic. In this clip, a dinosaur is the patient and there are interactions discussed between a provider and their supervisor reviewing how the patient experience went. It's very cute, while also impactful. 

Dr. Ericka Merriwether's talk, "Personalized Pain Management for EveryBODY,"

Dr. Ericka Merriwether
presented a framework for conducting research for patients with chronic pain with consideration for the intersectionality of race and BMI. Weight and body type are assigned identities, constructs that were created by people. I've previously written about BMI, a construct I have a lot of issues with, here. One comment Dr. Merriwether made was that weight changes daily, but race does not. These labels may or may not be self-adopted, so while the world may view you as white or black, skinny or fat - you may not subscribe to those same labels. Some people are light-skinned, but have black ancestry, and thus identify as black. Just because others do not view them in that group, does not make it the case. They may benefit from the way others view them, but this goes in both directions. Identities and the interactions between them, along with who is perceiving them, all need to be considered in pain research.  

Dr. Merriwether shared Antiracism CoaliTION in Pain Research (ACTION): Guiding Principles for Equity in Reporting which described a group, formerly known as the Pain Justice League, and their work to identify racial disparities in pain research and combat them. They conducted pain research taking race into consideration, presented lectures and grand rounds to share their findings, and developed guidelines to improve EDI in publishing research specific to pain. The coalition also worked with the editorial staff of the Journal of Pain, including current Editor in Chief (and my colleague at Seattle Children's) Dr. Tonya Palermo, to implement new processes to increase EDI in research content, author and reviewer diversity, and methods for tracking EDI metrics.   

Dr. Jonathan Alexander
Dr. Jonathan Alexander spoke next in a talk titled "Queer & in Pain: the Challenges of being an LGBT Patient in the Contemporary Medical Establishment." He described The Cancer Journals, written by Audre Lorde, which describe her experience with breast cancer as a lesbian and feminist and how this work impacted his own writing journey after experiencing a mild stroke. Another resource Dr. Alexander shared was an article from The Medium that summarized US legislation emerging to restrict trans rights, including severe penalties for providing gender-affirming care in many states.  Then he provides four suggestions for how we can best serve those who are LGBT: 1) Use the name they provide and honor the pronouns they identify with. 2) Inquire kindly about your patients' sexual health needs and concerns. 3) Many LGBT patients have had family experiences that have been harmful to their physical and/or mental health. Their family may be chosen family instead of born family. 4) Keep in mind that most LGBT patients have been traumatized by past experiences with the medical establishment. My LGBT patients have certainly been suffering from the legislation and family traumas. This was a timely lecture and opened up conversation between attendees outside the conference hall.

"Persuading Change: Pointers from Conversational Cognitive Hypnotherapy" was the penultimate talk, presented by Sheren Gaulbert. Sheren's bio tells of her history with debilitating chronic pain for which she used cognitive hypnotherapy (in the US, this is called hypnosis), building a career on her lived experience. She described SnowWorld, an immersive video game during which participants throw snow balls at penguins, used with patients who have suffered from burns while they underwent bandage changes, and how this immersive experience decreased their pain experience by 35-50%. That pain reduction is comparable to the use of opiate medications! Whren I attended the 2022 NOI Group's Mastersessions, Dr. Daniel Harvey also presented data about the use of virtual reality systems in pain management, so I think we may be seeing more of this down the road in clinical practice. 
Sheren Gaulbert

A word I had never heard before came from Sheren's talk: aphantasia: the inability to create mental imagery, described in this paper. Aphantasia is a condition which impacts memory and perception, found in a very small percentage of people. About half of these people cannot dream. I don't dream and I also have no ability to imagine a map in my head, which has always frustrated me, so I found this new concept fascinating to read about. I'm stuck with two questions related to aphantasia and how it might impact pain. The first specifically relates to Graded Motor Imagery (GMI), a treatment approach where a patient visualizes their body doing an activity that they're currently having pain with. Some athletes visualize themselves performing their sport before doing it - that would be a similar comparison. A person with chronic pain of their foot who may not be able to tolerate walking might be able to tolerate visualizing themself walking as an exposure for the brain to the task. I've previously written about GMI here. Do humans use something analogous to GMI automatically for self-care? Are the neurological processes of a meditative body scan the same as those in GMI? The second question relates "The Gift of Pain," a book about patients who do not feel pain and how dangerous it was for them. Fantastic book, but in my mind, a patient who cannot feel pain is not the same as someone who cannot create mental imagery, but can these patients who don't feel pain mentally image their own body? I'm trying to discern the implications for a patient with aphantasia related to pain. Unfortunately, in my mind they're all bad, but since pain is an experience and includes memory components, I'm hopeful that perhaps there is some good that I just can't (yet) comprehend.

Sheren talked about self efficacy and locus of control. An external locus of control is a person outside ourselves, an expert to guide us. An internal locus of control is guidance from within, such as with self efficacy. One of the keys I took from Sheren's talk was the concept of ironic process: when you try to avoid thinking about something, you're inevitably going to think about that thing you're trying to avoid. She advises the room "If I asked you NOT to think of a blue elephant, what happens? You're going to think of a blue elephant!" If the patient's goal is to be pain-free, but they're thinking about pain all the time, the attention to pain is prioritized. By "starting with the end in mind," you can restructure pain care by determining what is important to the patient, re-directing the focus away from the pain and towards the functions the patient wants to be participating in. This is the common approach we use at the Seattle Children's Pain Clinic, where we focus on function rather than trying to remove pain first. It's difficult to achieve, but for many patients, this approach has proven to be optimal.

Since the San Diego Pain Summit, Sheren is one of the few presenters whose work I've actively followed online and who I've also had some continued engagement with. Her company, The Ultimate You, is where she provides patient care as well as services to educate clinicians. I recently reviewed her Burnout resource for healthcare providers and it guided me to make some positive changes in my daily routine. Physios - we need more mental health providers in our arsenal when working with patients with chronic pain. Her website has some great resources on it.

Laura Rathbone
Which leads me to the last presenter from the 2023 San Diego Pain Summit, Laura Rathbone, who I've spent the most time interacting with since February because I joined her International Reading Community, Pain Geeks. Laura's talk, "Phenomenology: the body as a place of knowing," was a fantastic conclusion to the conference. Phenomenology is the philosophical study of objectivity. I generally find philosophy to be deeply maddening as my brain seems to malfunction at such deep levels of thought, filled with big words, but Laura managed to explain these pieces in a way that both light-hearted and accessible. It certainly helped that I was able to re-watch her talk several times, looking up terms I wasn't as familiar with as I went along, reading cited articles, and thinking about what she's demonstrating.

I'd imagine that any talk about philosophy would include many terms with definitions in order to apply to the concepts. Laura started her talk with the concept of experience, which is subjective in nature. Since pain is an experience that can only be described by the person having it, it is also subjective. But remember, Laura is talking about phenomenology, which is objective, acknowleding that objectivity is difficult to achieve, influenced by bias, experience, knowledge, and assumptions. Phenomenology, defined another way, is a philosophical movement that explores human experience without preconceptions or theories. We can measure changes in pain, so to some degree there is an objective component available to us. Basically the key is that we need both phenomenology and science to best understand pain. 

This talk was so good, and goes even deeper. The Hard Problem of consciousness is "How do you explain unconscious matter giving rise to conscious experience?" Humans are made of neurons and cells and hormones - and these thigns all interact with each other in order for consciousness to occur. The Easy Problem is explaining mechanisms using science, but the hard problem persists and we don't have the answer to it. We use a phenomenological approach to acknowledge that we can't answer the Hard Problem and to understand that we don't know how consciousness happens, despite knowing that the brain is made of of components that work together in order for consciousness to occur. I'm pretty sure there was an underlying suggestion of being comfortable with uncertainty, but I don't want to put words into Laura's mouth.

Laura defines homeostasis: the state of internal steady state maintained in a living system and allostasis: the processes which occur in the living creature in order to maintain homeostasis. She continues to describe embodied cognition, a phenomenological approach to studying the human experience that looks at the whole human: mind and body together.  

She asks the group to look at a chair and decide - "What makes it a chair?" The realization that the item becomes a chair because a person can sit on top of it demonstrates the importance of understanding the relationships between things. As clinicians, we come from a position of belief. We believe the item is a chair because it can be sat upon. Would it be a chair if you could not sit upon it?
There is a need to understand our own beliefs and the beliefs of our patients. If they see the item as a chair, but you do not, how will this impact your relationship? They see their pain, but we do not - so how will this impact our relationship? Only you know the truth about yourself, and only the patient knows the truth for themself, so we must believe the accounts that are shared with us. Laura shared the article, "An Embodied Predictive Processing Theory of Pain Experience," which goes into far more detail about embodied congition, phenomenology, and maintaining homeostasis. If this wasn't Laura's attempt to make sure my brain completely exploded by the conclusion of the conference, she was successful at it anyways. A great read that I'm glad I spent my time on and I'm very grateful to have made a new friend. 

And so I've reached the conclusion of this far-too-long, many-months-delayed summary. Re-watching all the talks was worth every minute and reviewing all the papers I've linked to throughout this post maximized my learning from the conference. All this knowledge has impacted my patient care already. I would be wrong to leave out that the best part of this conference was meeting so many people who care about helping those who are experiencing pain. These speakers are brilliant and caring for patients or researching so that clinicians can do better. Many of them have served as gracious mentors, opening my eyes to the vast world that pain inhabits. So - who wants to join me at the 2024 San Diego Pain Summit? Registration is already open. I'll be there. It's sure to be a great time and the speaker list is fantastic.

Special thanks to Dr. Sluka who agreed to let me include some of her artwork in this post. It's really incredible. Here's the link to her website to see more of her art - which is for sale. I can't decide which is my favorite. It's really cool to see that journals have used her art on their covers, too!