Ramblemuse Touch Points

For what’s likely to be my last summary of  the 1811 tweets from the San Diego Pain Summit 2017 using various metrics of tweet importance, I created a ranked word-pair vocabulary from the body of tweets, where each word-pair had to occur within single tweets. With this pair-vocabulary in place, I then summed up the word-pair score for each tweet and sorted them into an order of decreasing scores. I’ve listed the top 50 tweets under this measure of importance below, in the sorted order.

Note that this post is a follow-on to “Things” from the Pain Summit (Literally) and From the Pain Summit — Doubles from The One Hundred.

• We see small sample sizes, and small effect sizes, but why do we expect large effect sizes out of a singular treatment approach?
• Sleep hygiene, activity levels based on preference, set goals, graded activity (social), min of 4 times/wk for 30 min
• Set small realistic goals to set up our patient for success. Small achievable goals to activate rewards systems in the brain.
• The cautionary tale of morphidex: tested only on male rats where it made a difference; on women it made no difference.
• Tenderness of the pelvic floor caused more disability than weakness of the pelvic floor

• Farmer, MindBody: When addressing fear of movement it is critical to determine the specific core belief underlying the fear.
• Pelvic floor rehab is orthopedics in a cave. It is not only a female problem. Everyone has a pelvic floor.
• Lots more rats than mice used in animal research. Genetics: most research is used on 1 kind of mouse and 1 kind of rat.
• Cognitive factors, emotional, social, physical lifestyle factors all influence pain. All are modifiable factors.
• Why would we expect to see large effect sizes from a single intervention – lots of interventions have small effect size.

• Koban: social factors that modulate pain/relief: presence, social stress, cultural beliefs, therapeutic alliance, social norms.
• The issue of genetics: rats and mice are used in Pain research. And only on 1 kind of mouse or rat. Not a lot of diversity.
• It matters whether human presence is female or male! If human is male, mice grimace less.
• Lifesyle changes to work on: sleep hygiene, regular exercise to preference (activity), set goals, min 30m 4x wk.
• Physical factors – postural extension + cognitive factors – fear – tend to increase muscle contraction of lumbar muscles during movement.

• Barriers to exercise adherence: low self efficacy, envisaging lots of barriers to exercise.
• Cortisol levels in response to stress predict musculoskeletal pain: low response leads to increased inflammation response and pain.
• Lifting from a flexed position – back muscles work more efficiently. Lifting in lordosis increases work/load.
• Ben – Minds change slowly. Rarely do patients have an epiphany. Sometimes you are never going to change people’s mind.
• CFT [Cognitive Functional Therapy] Management Plan sample: making sense of pain, exposure with control, lifestyle changes, give control over pain.

• Do people approach or avoid pain? Women sit away from people pretending to be sick and close to people in pain. Men could care less either way.
• And to humans. Male mice are standing in for human women. And women are the “real clinical problem”.
• Engram: the physical changes in the brain that represent a specific memory (memory trace).
• Increase in dendrite spine dictates where info goes. Learning changes neuron structure, spine growth/pruning.
• Rat grimace scale findings are skewed in presence of scent of male humans – simple things making reproduction of research difficult.

• With female mice that know each other, mouse in middle will spend time with mice in pain, lowering pain.
• “Pelvic floor dysfunction treatment belongs in the Orthopedic Division, not Women’s Health. This is orthopedics.” C Vandyken
• Barriers to exercise: Pain and anxiety re worsening, low self-efficacy, envisaging barriers (time, pessimism, dislike)
• Exercise: means of imparting progresive physical and psychological stresses; dose depends on bio, psych, and soc factors.
• A bit of geek heaven. Microglia studies done on male mice are positive, on female mice they are negative.

• With strange mice, stress goes up, blocking empathy. Blocking stress, empathy appears.
• Exercise doesn’t have to suck for it to be effective – set activity goals based on patient preference.
• Focus on finding gaps in others knowledge, not ignorance of knowledge. Identify opportunities to build confidence and trust.
• You don’t want to have an orgasm while you pee, and you don’t want pee while having an orgasm. Pelvic floor pain often undermines.
• Making sense of pain is really important for patients. Exposure with control. Lifestyle change. It’s a journey.

• Patient “It doesn’t feel normal it just feels unnatural – slouchy to sit like this. But it feels better.”
• Refer out for major depressive disorder, anxiety disorder, major social stressors, work with other HCPs, don’t abandon.
• First muscles to contract in a threatening situation are muscles of the pelvic floor – makes sense for survival https://t.co/xB6n1Ohv9M
• Play the “long game”: Establish therapeutic alliance, find gaps in knowledge, Identify chances to build trust, lead gently.
• Never attempt to directly correct patients’ or ‘clients’ beliefs. Changing minds takes time. https://t.co/QA2p4F7EBP

• So you see clusters. Times of rapid change – emergence at adolescence, physical, emotional, physiological change.
• Prof Pete O’Sullivan PT uses iPhone photos of the patient to show that relaxed posture (no pain) is still “good posture” to the patient.
• Do: Goal setting (get your interview skills up!), outcome measures (patient specific functional scale!), preferences, expectations.
• Can we think of cognitive bias as sensitized beliefs? Treat communication like we treat movement. Graded communication?
• The goal, to create frequent high quality communication and strong relationships. Open avenues of opportunity to be accurate.

• Negative beliefs about back pain, fear of movement, and decreased self efficacy are predictive of disability.
• Reviewing biomechanics of lifting – no clear benefit to different lifting methods in terms of load/shear. Kingma 2010
• Spending time helping a person work out how they will plan for exercise is a worthwhile pursuit.  Address barriers.
• Henderson Reframing exercise. Imparts progress in physical and psych Stress. Dosing is dependent upon a variety of factors.
• C. Vandyken – Data indicates that a large percent of women with LBP had pelvic floor dysfunction. (63% of n=1636, 78% of n=200)