San Diego Pain Summit – post summit thoughts

After what can only be described as an excellent few days of meeting and greeting, rubbing shoulders and entertainment the San Diego Pain Summit lived up to my expectations! So I share with you some short post summit thoughts on my favourite talks, finishing with my thoughts of my presentation – clinicians get creative.

The first day of talks started with Professor Sapolsky, someone that I was very excited about to hear talk. The basis of his presentation was on stress and the short and long term effects that it has on humans. Furthermore how animals and humans differ when it comes to stress.  Sapolsky deconstructed the body explaining the effects stress has on each of the body systems.

I found Sapolsky to be entertaining, however I feel if you had listened to his podcasts and/or read his book why Zebra’s don’t get ulcers you may feel you came up somewhat short. Until he got to the Q & A section, which highlighted for me that although we now understand that the adult brain is plastic aspects of our childhood still are entrenched in the adult brain. They can’t be changed but they can be moderated.

Next up was Fabrizio Benedetti discussing placebo and nocebo, an aspect of healthcare that is understood and acknowledged but not fully accepted. Benedetti’s work has shown or contributed to the effects of placebo / nocebo on performance, recovery, pain control etc (reference, reference, reference). What struck me was the effect that placebo has on brain and mind neural pathways. I discussed the placebo effect on Parkinsons with Dr Benedetti following his presentation. According to Dr Benedetti with administration of a placebo (such as positive reinforcement) causes dopamine to be released from the frontal cortex as opposed to the substantia nigra, which is the pathway that is commonly involved in Parkinsons. This provides a short term improvement in co-ordinated tasks which is commonly associated with Parkinson. The same can also be said of pain pathways.  In my opinion this shows the significant effects that the mind has on the brain (not to sound dichotomous).  Unfortunately Dr Benedetti was unable to comment on the transient effects of the placebo in long term re-inforcement but certainly an avenue for further research!

Bronnie Thompson also stood out for me as we share a common interest in communication, language and also work with complex patients. What first struck me was Bronnie’s admiration of Bruce Lee! I had no idea! I was also disappointed not to see some role-play!

Bronnie discussed how we can use change talk to increase confidence and motivation in our patients. A strong focus was on the use of motivational interviewing and also collaboration and discussion amongst attendees. This resonated with me. Bronnie’s presentation may have focussed on educating us how to use motivational interviewing to guide our patients, but she encouraged us to engage in discussion to prevent a didactic teaching style which is so common in CPD courses and conferences. I wonder if people picked up on a further aspect of her talk through showing us how we should be collaborating with our patients by encouraging us to engage in small discussions with each other about what we want to achieve with our patients providing a brief opportunity for reflection. Furthermore Bronnie demonstrated the need to provide an opportunity for dialogue, listening skills and collaboration with our patients.

Kevin Vowles started his presentation with a poignant message of a patient suffering with chronic pain and highlighted the need for a change in direction regarding treating pain “It’s not really about treating pain, it’s about treating life”. The basis of his talk was the efficacy of Acceptance and Commitment Therapy (ACT). He discussed the ongoing use of opioids in treating chronic pain by highlighting the incredible difficulty to get clean and reliable pain reduction and that there was no evidence to support opioid use for longer than 4/12 in the treatment of pain.

Kevin discussed the effects of ACT, that fighting against pain caused more suffering and shifting the focus to function, activity and performance is a more appropriate approach (reference, reference). Furthermore Kevin supported the use of ACT with statements such as “I’d be proud to put a 1 of 2 success rate in ACT against any other intervention” and “to have acceptance is to have a bit more looseness towards your pain freeing up the behaviour you want”.  I was fortunate enough to catch up with Kevin after the summit and invited him to talk on the the naked physio natters podcast later in the year.

Greg Lehman was certainly entertaining, jumping around the stage and sharing flippant remarks of certain clinicians over emphasising biomechanics and what they would look like if biologically merged. (Confused? search twitter for what I’m talking about).

I was completely drawn in to Greg’s talk. He is better known for questioning when biomechanics matter and the relationship pain science has with biomechanics. Specific aspects of the talk that stood out were spine biomechanics. Greg highlighted the difficulties he has in reconciling his respect for the research that shows repeated lumbar flexion can create disc herniation in certain models. Specifically the research by Callaghan and McGill (2001), questioning the movements that we do throughout our daily lives (such as ADLs and sporting activities) is beyond the 35% of the flexion movement that the research claimed is a predictor of disc herniation. Interestingly the study measured flexion from a neutral spine. 35% from “neutral” is not a lot of lumbar flexion. As Greg highlighted this is when the biomechanics questions the biomechanics.

Greg’s opening and closing slide was also very direct and certainly struck a cord with the audience. you can check out his site for more details.

There were many other excellent talks and I want to acknowledge the work of Alison Sim. She has shown real promise in the use of CBT in her research and clinical work.

Finally I want to finish with clinicians get creative. The idea was to showcase clinicians work in a presentation about how clinicians explain pain to their patients through use of various mediums.  This included poems, art, images, metaphors, blogs, diagrams etc.

Interestingly, prior to my presentation (the night before) I co-hosted a podcast with Karen Litzy. 5 of the speakers were invited to share their thoughts on specific questions. One of the responses to the questions was the suggestion of developing a repository of ways to explain and motivate patients to engage with activity and to understand pain. How appropriate that response was in relation to my presentation!

The engagement and feedback was excellent from the audience and so I was asked to return to present at the conference next year.

The clinicians get creative idea has opened an opportunity to conduct some research and with permission of those that submitted their work the hope is that come next years San Diego Pain Summit there will be some preliminary data to share with attendees.

Watch this space!

Thanks for having a read.

TNP