Ramblemuse Touch Points

A couple of weeks ago, I spent two days at the San Diego Pain Summit, to listen, tweet, and archive tweets from the conference and adjoining workshops. The purpose of the 2017 summit, as was the case for the prior two years, is to bridge pain research and manual therapy. I could say that it was a great conference, with much information conveyed in a lucid manner and with multiple opportunities to network and socialize. All of this is true, but not the focus of this post. Look instead to the 1811 tweets and the tweet vocabulary for the summit linked to my conference tweets index.

Bronnie Lennox Thompson noticed something in the the tweet vocabulary list that had previously caught my eye, bringing it back to mind; a hat-tip to her. The root word ‘thing‘, including thing and things, was flying high in the list at number eight. Now, thing and things are nouns of total vagueness, relying entirely on their referents to give them meaning. That also, however, means that ‘thing‘ can be a key to multiple concepts. A few minutes of cut and paste and Python scripting and I had a file containing just the text in context of all the summit tweets containing the words thing or things (Python’s the king, with which to catch the context of a thing). These tweets provide an interesting keyhole through which to view the summit’s concepts. Before looking at those, however, I’ll take a foray into background.

If there is a theory common to those who discuss “pain science” (i.e., scientific research on the neurological and psycho-social basis for the experience of (often chronic) pain), it is that the final synthesis of the experience of pain occurs in the brain. It appears to be multi-faceted, including the system’s current state (which depends on history), with inputs from psycho-social-emotional beliefs, the immune system, and current multi-sensory input.

The neurological input often associated with pain serves, at a reflexive level, to remove tissue from a situation producing damage. An experience of pain then serves as a notification that damage has occurred, and as a disincentive to fully use an area that needs time to heal. However, there is a group survival advantage for, under extreme need, not to feel pain but to be injured and still protect the group (or even oneself). This in itself conveys an evolutionary incentive for pain to be a mediated experience rather than a simple direct one.

There are adequate observations in the variety of the experience of pain and what modulates it to require synthesis in the brain as an inescapable conclusion, meaning that no simpler system of processing can explain the full scope of observations.  This scope includes: pain directly related to a tissue injury, pain continuing after an injury has healed, an injury without pain, pain without an injury, and pain in a part amputated or never grown. Only a state-dependent synthesis in the brain can cover this range. There are, of course, details about this process that are unknown, just as there are details of how we integrate a body-sense that are unknown. Specific to pain, Melzack (2001) and Malzack and Katz (2013) are commonly cited. Ramachandran and Blakeslee (1999) and Blakeslee and Blakeslee (2008) give readable and more general research connecting body perception with neurology.

From my background in computer science, I also conceptualize and simplify the experience of pain as a finite state machine, a system with multiple states in which the response to an input depends on the state. For pain, the problem then becomes figuring out an input that will prompt a transition from a painful state to one more benign. Nadim et al (2008) delve deeper into state-dependent output from networks of neurons.

Back to the tweets containing the words thing or things. In an informal qualitative analysis I separated them into six categories:

• Empowering patients and getting them back to the things they love
• Avoiding saying things that produce fear of activity
• Extending things we measure beyond posture and structure
• Things about the importance of movement
• Things showing psycho-social effects in animal models
• Things about provider flexibility in attitude and learning

The tweets within each category are listed below as an appendix. Please remember that this is not an overall summary of the pain summit, just a peek through a particular keyhole. That wraps ‘things‘ up. Thanks for reading.

 

References

Blakeslee, Sandra, B., & Blakeslee, Matthew, 2008. The Body Has a Mind of Its Own, Penguin Random House. Available at: http://www.penguinrandomhouse.com/books/14618/the-body-has-a-mind-of-its-own-by-sandra-blakeslee-and-matthew-blakeslee/9780812975277 [Accessed 23 Feb 2017], ISBN 9780812975277.

Melzack, R., 2001. Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), pp.1378–1382. Available at: http://www.jdentaled.org/content/65/12/1378.long [Accessed 24 Feb 2017]

Melzack, R. & Katz, J., 2013. Pain. Wiley Interdisciplinary Reviews: Cognitive Science, 4(1), pp.1–15. doi: 10.1002/wcs.1201

Nadim, F., Brezina, V., Destexhe, A, and Linster, C., 2008. State Dependence of Network Output: Modeling and Experiments. Journal of Neuroscience, 28(46), pp.11806–11813. doi: 10.1523/jneurosci.3796-08.2008

Ramachandran, V.S. & Blakeslee, Sandra, 1999. Phantoms in the Brain, William Morrow Paperbacks. Available at: https://www.harpercollins.com/9780688172176/phantoms-in-the-brain [Accessed 23 Feb 2017].

 

Appendix: Categorized Tweets containing the words Thing or Things

Empowering patients and getting them back to the things they love

• Re: low mood, get people back to the things they love and that will lift mood.
• Get people back to the things they love – helps with identity.
• We spend too much time treating symptoms and not returning people to things they love.
• Focuses on movements and positions that are related to things she cares about most from the interview.
• Cognitive approach – focusing on unhelpful beliefs and behaviors. Take people back to the things they love.
• People get sad when they don’t do the things they love.
• What is it that you love to do? Has pain been stopping you doing them? These are the things we need to focus on.
• Stop doing dumb stuff: when I stopped doing dumb stuff, I started filling time with things important to the patient.
• Your goal setting should be things that the patient really cares about! You get this from listening to the patient.
• ‘Goal setting – Things that people really care about. In the US, can be tricky when pt goals aren’t covered by insurance.
• Empowering people to do things themselves is one of the best things we can do
• Validation is one of the most important things that you can give a patient.
• Validation is one of the most important things to give to patients, their pain is real. Relay their story back to them”.
• The things we study in clinical trials for pain are not the things people worry about. Can we make science human centered?
• What’s the #1 thing for prediction of recovery? Expectation of getting better.
• Engagement is the crucial thing. Doesn’t matter “what”.

Avoiding saying things that produce fear of activity

• Fear has the habit of feeding the very thing we’re frightened of.
• Disconnection between body parts, thinking things are “out of place”, is linked to increased stress and pain.
• Stop saying “Wear and Tear”. This implies that things will get worse with increased activity.  It increases fear and anxiety.
• Too many people come to me and have been told that the one thing that made them feel better is ‘bad’ for them and will make them worse.
• The biggest obstacle we have is getting people to start doing things they are afraid of – but it’s critical.
• Most back pain is managed by avoiding things – that pattern can start young, and persist (also doesn’t fix the pain!).
• Key thing is therapist’s confidence. YOU have to really believe movement won’t damage the patient

Extending things we measure beyond posture and structure

• Is back pain associated with slump sitting? Whole bunch of things were associated but mostly being male.
  We use the back as a model but all these things go for pain experienced anywhere.
• The unfortunate thing about directional preference (McKenzie) is that it was linked to anatomy and pathology. We need to shift that.
• Change label system around back pain “the cool thing is, it doesn’t look like your scan is your problem” vs “Non-specific back pain”.
• If you measure the wrong thing well, you still don’t know anything.
• Measures still look at physical things. But in patients, we have to go past that.
• Things related to patient  not regularly discussed in the literature: context, perception, emotion, self-efficacy, locus of control, education, reconceptualization.
• The physical measures we target don’t have to get better for people to have less pain  (measuring the wrong thing?).
• There is no such thing as perfect or ideal posture. Timing and variability of your posture matters more.
• We assume at the bio level things should translate pretty well and not at psychosocial level, but this is backward. Pain researchers may be measuring the wrong thing.

Things about the importance of movement

• Maladaptive or unhelpful movement patterns can often be in the direction of the very thing that triggers pain.
• Nobody gets excited about ‘prone on elbows.’ They talk about interactions, new things they can do, how they can move.
• The most difficult thing in being in pain is the commitment to activity, not activity itself”
• Patient interview — Lots of reps of retrained movements in between discussing things – a lot of volume of new movements w/new pattern
• Be strong – but only when you need it”. This is often the missing piece in the core stability thing.
• Only two things that are really rested – major trauma or broken bones”. Everything else should be worked.
• I’m biased about movement, which is a good thing. But exercise is not the answer.
• The #1 thing preventing individuals from complying with regular exercise was inability to include it as part of daily routine.
• Exercise really is pretty good. For general health it is a good thing. We need to educate patients about this.
• We don’t have concrete ideas about how exercise works for pain – tricky thing to measure.

Things showing psycho-social effects in animal models

• Rat grimace scale findings are skewed in presence of scent of male humans – simple things making reproduction of research difficult.
• Lab mice have a social life! They do things even in a cage that can be measured/manipulated. Real paucity of research.

Things about provider flexibility in attitude and learning

• Hearing all the awesome things going on at the 2017 Summit?
• [Prof says controversial but accurate thing] “Oh you’re going to tweet that aren’t you?” Me: oh yeah
• Two biggest things: patient education and behavioral experimentation.
• These are basic things that should be taught in PT schools…how to listen, how to talk to patients.
• The cool thing is that we get to learn, stop, move out of old beliefs as the evidence says to STOP.
• ‘Research creep’ – what happens when you’re looking for literature on a topic and you get distracted by the other things to learn!
• If we can change one thing, it might change everything. Thinking about the Why behind the What.
• No singular intervention is going to provide the answer for complex things.
• The best evidenced base thing is redundant if it never gets done.
• “Whilst our Hearts are violently set upon any thing, there is no convincing us that we shall ever be of another Mind.” – Mary Astell
• I’m not good at many things, but I’m great at procrastination.
• Helpful to learn things that aren’t good – helps you compare to better things
• Can be helpful to learn “not so good things” as student to appreciate those things that ARE good.
• Folks who are curious are going to be fine; worry about the ones who are certain about things.
• If you keep explaining things the same way and need to keep repeating yourself, you are doing it wrong [communicating].
• You can’t just push people to see things your way and to value things as you do.