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?

Kathleen Sluka: Neuron Rainbow

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! 

Applied Neuroscience & the Paining Person

This is the second post in a three-part series about the San Diego Pain Summit.  You can find part one here and part three here (coming soon). Part one was a look back at all the Pain Summits prior to 2023.  Part three will share highlights from the February 2023 Summit.  

This post summarizes what I learned from the two day pre-conference workshop with Dr. Morten Hoegh entitled "Applied Neuroscience & the Paining Person."  It combines Dr. Hoegh's teachings with the tangled web my brain weaves when I try to make connections between what I'm learning and things I've thought of before.  Dr. Hoegh's bio from the Pain Summit Website along with all the other 2023 Speakers' Bios highlights that he is a physiotherapist who specializes in musculoskeletal and sports physiotherapy, has a Master's of Science in Pain: Science & Society from King's College in London, and a PhD in Medicine/Pain from Aalborg University in Denmark. (Fun fact: in Denmark, they speak Danish.  Don't be the dummy - like I was - who incorrectly thought they speak Dutch... Dutch is spoken in the Netherlands). Dr. Hoegh is an Associate Professor at Aalborg University and lectures around the world.  He also provides patient care, which I think elevates his ability to teach to practitioners, because he understands how to apply it to the people we're working with.  If you're interested in seeing his publications and learning more about his pain research, his Aalborg University Bio includes links to those. He also offers a Course on PhysioNetwork called "Pain: A Guide for Clinicians."

Morten Hoegh: humanist, skeptic, pragmatist

Dr. Hoegh started off the course by introducing and describing himself as "humanist, skeptic, pragmatic."  Here come some definitions.  Humanism: "an outlook or system of thought attaching prime importance to human rather than divine or supernatural matters. Humanist beliefs stress the potential value and goodness of humans, emphasize common human needs, and seek solely rational ways of solving human problems."  As a somewhat religious person who is constantly overwhelmed by my emotional approach at solving patient issues and occasional beliefs that a higher being has directed life, this descriptor was novel to me.  I've previously written about the collide between science and religion, evolution and creation, here. Ironically, my own therapist often tells me I'm approaching my mental health too rationally rather than emotionally, so perhaps there are parts of this system I apply to myself, but not sufficiently to my patients. 

Skeptic: "a person inclined to question or doubt accepted opinions." How self aware to know you're like this. I want to question my own beliefs and critically analyze things I'm learning rather than believe on first hearing. Perhaps I am now a wannabe skeptic. I think skepticism makes for improved clinical reasoning and evidence-based practice, supporting the ability to critique and seek alternative solutions. It's interesting to see how Dr. Hoegh exhibits his skepticism throughout his talk... with statements that really make you question your own beliefs.  I wonder who else would proudly call themself a skeptic.

Pragmatic: "dealing with things sensibly and realistically in a way that is based on practical rather than theoretical considerations." Dr. Hoegh spent time discussing how most (all?) theories are wrong AND how they can also be useful, but if you're applying a theory, you need to recognize the limitations of where the theory can be appropriately applied. If you do something and it works, you're likely to keep doing it, even if it doesn't always work. In an effort to learn more about theories, I found this article that I found interesting discussing the difference between Scientific Theories and the use of the word theory in everyday practice. It states, "A scientific theory is accepted as a scientific truth, supported by evidence collected by many scientists. Lots of data has been collected to support theories, and no data has been identified to prove theories incorrect. That does not necessarily mean that evidence does not exist against a theory does not exist, it simply means that evidence has yet to be identified." I actually think Dr. Hoegh is a philosopher, but perhaps that's too theoretical for his liking.  

It would be wrong of me to share a play by play of Dr. Hoegh's course because I will not do it justice and he gives lectures around the world worth hearing directly from him.  Instead, I'll share the big picture take-away pieces about the biopsychosocial model, the classifications of pain, and peripheral and central sensitization.  I won't touch upon descending modulation because - even though it was part of the course - I still don't understand it well enough to describe to another person.  More for me to study at a later time!

Medical Models:

Looking through the history of medicine, illness has always been connected to a specific cause. This makes it much more difficult in current times when clinicians can't identify an underlying cause of a patient's illness or pain. The evolution of Medical Models helps us to understand where we've been - where we are now - and what's still missing.  

As far back as medicine can be studied, an evil spirit or demon was thought to cause pain or illness in some religions and cultures. There was a clear separation between the body and the soul (dualism) and healing was conducted through Shaman who drove away the evil spirits to restore the body. I read this article "Judeo-Christian Concepts Related to Psychiatry," for more details, opening my eyes to the potential influences of religion on medicine and health. So, in the Beginning, there was a cause - evil spirits or sin - underlying the effect of pain or illness. With development of improved science and medicine, beliefs that other things - like bacteria or cells caused illness or that tissue damage caused pain - continued to evolve.  This cause/effect relationship is a feature of the Biomedical Model and is pervasive for those who believe that physical health is separate from mental health. (I do not believe this and have previously written about that here.) 

The Biomedical Model is a theory in which biological issues (think back to biology classes: cells, anatomy and physiology) are the underlying cause of disease. But as we know now, pain is far too complex for this reductionist thinking: "the practice of analyzing and describing a complex phenomenon in terms of phenomena that are held to represent a simpler or more fundamental level, especially when this is said to provide a sufficient explanation." Is it possible that sometimes a tissue injury results in pain for a human?  I believe it is - however there are multiple factors that need to be considered in addition to the tissue injury that impact the individual's pain experience.  The same tissue injury in multiple people will not be experienced in the same way.  Pain - and illness - require broader thinking to understand, evaluate, and treat. In 1977, George Engel wrote his landmark paper challenging the Biomedical Model and naming the Biopsychosocial Model, a more integrated approach adding psychological and sociological considerations to the biological contributions. This updated model does not remove the importance of biological contributions to illness.  Rather it expands the potential contributors to a broader picture that more wholly encompasses the patient's environment, beliefs, emotions, behaviors, body, and mind.

The biopsychosocial model is not meant to outline the cause of pain, though. We need to step away from the cause/effect relationship and think more about a complex interwebbing of multiple characteristics of our patients where it's not helpful to our patients to identify specific causes.  We need to get more comfortable being uncomfortable and sitting with uncertainty.  More and more frequently, particularly in circumstances of chronic pain, the truth is that medical providers do not know what is causing the pain.  Why?  BECAUSE THERE IS NOT ONE CAUSE!  I think the concept that had the most impact on me from Dr. Hoegh's talk was "You have pain, period" compared to "You have pain, because..."  I've now shared this conversation with two coworkers in my clinic - here's how that played out.  My coworker, also a physical therapist, was evaluating a patient with a complex chronic pain diagnosis while I had documentation time so instead of writing notes, I sat in on his session.  He looked at her mobility and strength, the patient's parent commented on their poor posture, an exercise program was provided that looked like it was meant to directly impact the patient's posture. Afterwards, I said to my coworker - "Do you think that patient has pain because of their posture?" and he said no! But the parent's expectation was that we needed to "correct" posture to "fix" the pain. No... the exercise program he provided looked very similar to what I would have done. It's really hard to dispute patient's and family's beliefs at the first meeting, but the language I would have used would have been to challenge the beliefs about posture as the because, explain that pain is multifactorial in nature, and get the patient moving. (Don't get me started on how much it hurts my soul when parents look at their children as if they're broken because they're experiencing pain.  Your kid is not broken!  Unless they have a fracture, and then, still, a piece is broken, but they're still a whole child!). 

I think the development of the biopsychosocial model is a valiant attempt to reverse the reductionism of the biomedical model.  Many medical providers still live in the previous biomedical model world where something happens to anatomy and they believe this causes pain.  However, the biopsychosocial model encourages us to look at the human as a whole, taking into consider their biology along with their psychological and sociological environments.  There are still problems with this new approach, however, if medical providers blame the biopsychosocial findings as the cause of a patient's pain. That's not how the model is intended to be used, and all too often the model is broken into it's components with each considered separately.  The patient in front of you needs to be treated with consideration from all these perspectives holistically in an effort to individualize the best possible patient care. The biopsychosocial model has been broken down into separate parts for providers trying to determine if a person's pain comes from their bio, psycho, or social, when really the biopsychosocial model is not a model of pain - but rather a model of looking at illness and health for the human as a whole person who has a unique environment and history.  The biomedical model is already a big mess for medicine, can we try to avoid the same disaster with the biopsychosocial model? That was a lot of philosophy for a Neuroscience Talk, wasn't it?!

International Association for the Study of Pain (IASP) Pain Classifications

Dr. Hoegh is really quite genius in teaching pain neuroscience.  He's currently in the process of releasing a series called "Pain Science in Practice" through the Journal of Sports Physical Therapy JOSPT, all parts so far are less than 3 pages of digestible pieces about pain neuroscience. They're great.  The course discussed the first five of these papers that have been released and more are coming soon.  I highly recommend them for the new PT and the Painiacs like me to better help understand pain mechanisms. 

Dr. Hoegh's Pain Classifications

Dr. O'Connor's Pain Classification Continuum

In part one of this blog series, I mentioned the IASP Pain Classifications as presented by Dr. Annie O'Connor. Dr. Hoegh used this image (above) to demonstrate the three classifications. Dr. O'Connor used several others, including this one (right). The three classifications are nociceptive pain, neuropathic pain, and nociplastic pain. The goal with patient care evaluations is to determine which classification the patient fits under and treat appropriately. Ready for more definitions?  

First we have nociceptive pain.  This type of pain is related to the body receiving stimuli which achieve a threshold that is experienced as pain. In Dr. O'Connor's image, nociceptive pain is on the top left of the continuum and is associated with ischemic (low oxygen) or inflammatory conditions.  In nociceptive pain, there is no damage to nerves.  Instead, receptors in the skin or inside the body are detecting signals from temperature, chemical substances, or mechanical pressure, and when that stimulus is removed, the symptoms should eventually reverse. This type of pain is typically shorter in duration, and many acute pain conditions would fit into this classification including broken bones, muscle/tendon/ligament injuries, a bladder infection, appendicitis, a heart attack, the list goes on.  

Tooth Fairy © Irina Akolzina

Next is neuropathic pain which occurs when the nerves are directly impacted. This can be tested in rats by injuring nerves in various ways and it can be measured. This commonly occurs with back and neck pain and also with peripheral neuropathies where the nerves are either being squished or they've been stretched or torn. We commonly see allodynia: when typically non-painful stimuli hurt and hyperalgesia: increased sensitivity to stimuli with these patients as the nerves are protecting the body from further nerve injury.  

The third classification, nociplastic pain, is where things get more complex. This classification isn't really a "thing." It's more like... "pain that's not the others and doesn't have a known underlying cause but we needed to have a name for it so that we could talk about it." Dr. Hoegh referred to this classification as the tooth fairy. It has a name in order for researchers and clinicians to label it and write about it and try to find underlying mechanisms and treatments and medications, but the underlying cause is unknown.  As you can see from Dr. Hoegh's Pain Classifications image, a question mark stimulus elicits a pain response. From Dr. O'Connor's image, nociplastic pain is likely to be more chronic in nature, there are behavioral (affective) considerations as we mentioned in part 1, the autonomic nervous system which regulates heart rate, respiration, and excitation may be involved.

Nociplastic pain is the category that most frequently matches the patients I see at the Seattle Children's Hospital Pain Clinic and who often require a multidisciplinary approach to their recovery - because the underlying cause is unknown. This is a great place to re-iterate, "you have pain, period, rather than you have pain, because..." It really doesn't help to provide patients with a "because" if it's wrong, if you can't prove it, if there's plenty of research saying that the "because" you're using isn't a cause of pain (like posture), or if there isn't a known treatment for that cause. There are many other images online describing the three classifications.  One other that I found and wanted to include, particularly because it resonated as some patients really present like they're in hell, I've included here. The patients know they're experiencing more than "just" pain - their lives are impacted and they're the ones who know best what's happening inside their bodies.  It goes so much deeper and we need to treat accordingly. 

Peripheral and Central Sensitization 

This is the meat and potatoes.  This is the part that I see in my patients, scratch my head, and wonder why it's happening for so long instead of going away. Both Peripheral and Central Sensitization are cases of the nervous system being sensitive. Things that wouldn't normally hurt, now might - or things that would hurt before, hurt more than they previously did. 

The Central Nervous System includes the brain and spinal cord - so the underlying mechanisms of Central Sensitization occur there. The Peripheral Nervous System is the rest of the nervous system, all the nerves that come out from the spinal cord and provide sensation and movement to the rest of the body.  

JOSPT Pain Science in Practice #3 Peripheral Sensitization

Peripheral Sensitization is sensitive to heat where central sensitization is not - so if a person was complaining of pain and you applied heat, worsening symptoms could indicate peripheral sensitization. At the time of an injury, sensitization is normal! You broke your leg - a sensitive leg reminds you not to put weight on it! The picture shows peripheral sensitization where an injury (far left) results in inflammation (all the little balls) and that inflammation is a bunch of chemicals that attach to different receptors on the nerve (blue part on the right).  If the inflammation continues to occur, the receptors on the nerve get more sensitive to them. So in a nociceptive pain situation, the injury occurs, inflammation happens, and then the tissue heals and inflammation stops.  In a nociplastic situation, the tissue heals, but for some reason, the sensitive receptors remain sensitive.  This may be related to the mast cells (purple blob) or the immune cells (brown blob) which also give out inflammatory chemicals. 

JOSPT Pain Science in Practice #5 - Central Sensitization

In Central Sensitization, the scenario is similar, but the location is different and the body impact is a bit different.  Now the changes occur in the spinal cord or brain. So in this schematic, the top left corner is similar to the peripheral sensitization photo described previously: injury to the body occurs and the nerve is set into action. Initially there would be inflammation at the periphery where the injury occurred, but over time and with normal healing processes, that inflammation resolves. Instead, the peripheral nerve conducts signals along it's pathway to the spinal cord nerves (right side, big blueish gray circle) and here inflammation (all the little balls) occurs, acting on receptors in the central nervous system.  When this has happened for a long time, the receptors could become more sensitive to the inflammation or more receptors could be made which makes a change in the system.  When that happens, if a feather touches the skin, which wouldn't normally hurt, the signal is passed along but since the spinal cord is more sensitive with these receptor changes, the body produces a pain experience (hyperalgesia and/or allodynia).  This is part of pain neuroscience.  I mentioned in part one that I don't teach this to patients.  It's so hard for me to understand, and I'm sure that if Dr. Hoegh ever reads this, he could point out all the areas where I've got it a bit wrong.  The big concepts about the body becoming more sensitive, however, sometimes help patients to cope.  Their bodies are actually doing what they're supposed to be doing - protecting from future damage - even though it doesn't feel good.  Both peripheral and central sensitization are features of chronic pain, but again, they're not the cause of it and they do not explain why it's happening.  

Me with Dr. Morten Hoegh

A final thought about therapeutic alliance. As always. I've written about therapeutic alliance in several blog posts, this one probably being my favorite. Dr. Hoegh wrapped up his two-day talk with great reminders about the importance of the patient-clinician relationship. It truly does not matter how much pain neuroscience you know if you can't connect with your patients.  Can you empower your patient, even when they're in pain, to finish a session with an "I did it!" feeling? Can you help create situations where they meet success after success after success and stop a potentially perpetual cycle of failures?  Can you find a topic to talk about so your patient who has depression and is sad has a moment of laughter or joy so that there is positivity breaking up the negativity?  Empowering your patients can be a powerful behavior change tool to get them moving in new ways to change their pain experience.  I once had a patient who was in treatment for CPRS and had spent months in his bed.  He was improving very slowly, but after a family discussion to get some new bedding and a new poster and rearrange the furniture in his room, things got dramatically better.  He had a new environment, a change of habits, and something that brought him excitement that previously was part of his negative state.  Would I say that this change caused his pain to improve?  No.  He had pain, period.  Not pain, because his room was part of the problem.  I'm really excited to move away from pain, because. I hope you'll join me. Thank you, Morten!