Tuesday, October 30, 2012

Air travel stories

October 29/12
Today I made it back home, safe and sound, from the final teaching adventure in Vancouver on the weekend, the last one for 2012. Whew. Traveling stresses me out. 

Poor me
This post is pure self-pity, so if you'd rather skip it, I understand. I am going to go on and on, probably, just to get it out of my system so I can move on.
Every trip is the Worst One Ever, usually, but I think my luck is starting to change. This last one wasn't nearly as stressful as the one just before, to England and back in five days flat, with two full days of teaching in between. More about that later.

I like meeting new people who are interested enough in my particular pet passion to invite me to come by and teach it, and I've become accustomed to teaching, sort of, even though I am definitely not a natural - introverted plus having a quiet speaking voice isn't a great combination. I have no natural inclination or any teacher training, so I had to reinvent the wheel, then try to make it round enough that it could roll. But at least I don't dread it so much anymore. 

Getting there, and getting home, is still pretty dreadful, though. Usually. One day I hope I can blog about how I've grown accustomed to travel, and how it used to bother me some, but now it's old hat. So far, that just isn't true.

What I hate about traveling
It's kind of a toss-up which I hate more, the airport or the airplane. If I were to take a piece of paper with the words "Things I Hate About Traveling" across the top, then put a line down the middle, with "Airport" at the top of one column, and "Airplane" at the top of the other, both columns would probably fill up about the same.

Just getting to the airport
For starters, I used to live a 30 minute drive through traffic, or else a $25 cab ride, to/from the airport. Now I live a 1-hour, 15-minute drive away, in a different city, which forces me, pretty much, to either drive my own car and park it for 4 or 5 days, at $11/day, or take the bus between cities and have to stay overnight with hotel costs, plus cab to and from airport to bus station, which costs way more.. so I usually drive. 

It's about 115 km, a fast highway, 2-way/single lane; many, many huge trucks connected to the booming oil field activity barrel along in caravans. They either pull out and pass timid car drivers doing the speed limit, or else are passed by aggressive 4x4 drivers taking chances with equally aggressive 4x4 oncoming traffic. The speed limit is 100km/hr, but usual traffic speed is about 120. 

Prairie highways are deceptive. You think they are nice and straight, but it's not so. They take odd bends and curves for no good reason, obscuring one's ability to see oncoming traffic, especially in snowstorms or rainstorms. Number #39 has this one place where it looks like the surveyor must have become inordinately fond of one particular pond; instead of building the highway straight through it, the same way all the other ponds in the way were crushed, he decided to build around it; people driving cars have the illusion that the highway is straight, because you can see headlights off in the distance, but if you don't know the highway very well, or are going too fast, you could miss the curve, that arbitrary sideways bulge in the road that exists for no apparent reason other than a whim on the part of the surveyor; you could hydroplane straight off, fly for a short while and land smack in the pond.

Anyway, long story short, I don't much enjoy the drive. There is nothing quite like having to get up at 3:30 AM to get ready and leave the house by 4AM to drive for a good hour to reach the airport in enough time to catch a 6AM flight, and realize that nature has given you an unexpected, sideways prairie downpour to have to drive through, surrounded by huge trucks connected to the oil wells splashing your windshield every 3 or 4 minutes into opacity, slowing you down to about 70km/hour. Your cortisol levels peak jaggedly, you speed as hard as you can, you get to the airport desk with only one minute to spare before they were going to close boarding altogether. In other words, you are very late, but they let you on the plane anyway, 5 seconds before they would have had to lock the door and take off without you. That happened in May, on the way to teach in Quebec. Oh yay, please diminish, cortisol levels. 

Or, after being stressed out and sleep-deprived and jet-lagged for five days straight, you land in your home airport at about midnight, and still have to drive home; you clear immigration, pay your parking in the machine inside the airport, forget to take your parking stub out of the pay machine, but remember to take your receipt, get to the car, can't find the stub, hunt everywhere for it wondering to yourself oh-what-fresh-hell-is-this, still can't find it, suspect that you must have lost it somewhere between the terminal and the car, are too tired to go all the way back to see if you can find it on the ground in the dark, decide to take your chances and beg the parking guy to let you out, show him the receipt, but he only will accept the stub, and you feel like bursting into tears because you are so tired and you so do not need any more delay (but you are over 60 years old and so not a teenager anymore that you can't/don't go there).  You sit there, car running. You ask, "What do you suggest?"
He shrugs, and calls his colleagues in the terminal. They take a look in the machine, and voila, find your stub still in there, right where you had forgot to take it out in the first place. "So," he says, "next time bring your stub," and all you can do is say, OK, I will, sorry, and he lifts the barrier and lets you through. 

And you drive... you nearly fall asleep and go off the highway about 20 times, but you hang in there and you make it to your own bed that night. But you decide, never again. If you ever ever have to go to Europe ever again, the night you come back you'll go straight to a hotel and go to bed and not try to drive home until the next day.  

But really, driving to and from the airport is the least awful part, usually. If courage is defined as being afraid and doing it anyway, I had nothing but courage 2 years ago when I travelled to Brazil and back via the Toronto airport. I have learned subsequently through word of mouth talking to other women my age who travel, that older females traveling alone are often targeted for body searches, because security goons at the Toronto airport think we would make perfect mules, so they decided in advance that we therefore must be mules, then "randomly" select us for public pat down. So, yay about that.. 

Plus, Air Canada likes to hold back checked luggage to later flights, which has inconvenienced me, twice in a row, which in turn taught me to never travel with any more luggage than I can take with me into the cabin. This has discouraged me from making any trips that are any longer than just a few days.

So, if you make your flight, you calmly scrunch yourself into the one square foot of real estate you are allotted, for the five or seven or nine hours there, and then back, with a tray table that sits way too close to the midriff, with just enough room for a small laptop computer to sit on top, and the danger that anytime, the huge dude sitting in the chair ahead of you might decide to catch a nap and throw his chair back the two inches it can recline. This isn't much, but it will either break the case on your computer into an accordion shape, or else will drive it like a very blunt machete into your midsection, and neither possibility is any fun. Please, cortisol level, will you go down already?  

In case you get complacent, there is always DependentAnkleSwelling (DAS) one develops when sitting for hours on a vibrating plane, dozing instead of staying awake and uptight all night, plus dehydration, plus meals (when they are served) that contain way more salt than you normally eat in a week, which add more water retention. 

Airline officials must think there is an inverse, not direct, ratio, between the obesity epidemic, on the one hand, and their job of gauging the size of seats, amount of leg room on planes they would need to provide to ensure travel comfort, on the other: At least it seems as though, when airlines hear news that the world's population is getting fatter and fatter, they interpret it as thinking they should cram even more seats into airplanes. 

I am a short person with short legs, but my knees are against the seat in front of me, usually. I do not know how long-legged people cope. I really do not. And I'm kind of roly-poly, but I don't weigh 300 lbs or anything - I do not know how large men fit in those seats. Or large-bottomed women. I fill the whole seat, in size ten pants. My elbows slide over into other peoples' space frequently, and I have to haul them back in and try to velcro them to my sides so as not to intrude into someone else's one square foot of real estate for that trip.

Still, all this kind of pales by comparison to the living nightmare that some of the world's largest airports have to offer: Toronto, I'm looking at you, and, Heathrow, you too.

I managed to navigate the huge airport at Sao Paulo by myself, and it was in a different language and everything. People there spoke enough English and were willing enough to help a bewildered foreigner that I found my next gate and connecting flight to Rio without much problem at all, inside about a half hour. Immigration was perfunctory, there were many uniforms all over the place whose sole job seemed to be to expedite traffic by moving the ribbon barriers to make movement between them intelligent and swift. If there weren't very many people in line, those ribbons were instantly moved into a perpendicular pathway to the desired counter, avoiding the arbitrary switchback manoeuvre. Brazilian airports (the three I was in) were still stressful, but they weren't frustrating.

So, I had to go to England, which was fine.. my carry-ons fit the cage in the Regina airport to the attendant's satisfaction, and she let me get on the plane to Toronto without any further ado.. there was a bit of a wait in Toronto, so I went to what I thought was my gate, and sat there for awhile, checking my computer, grabbing a bite.. My latent OCD niggled at me though, so I decided to check the gate, my boarding pass, just in case I missed something. I guess my brain knows me better than I do. Anyway, as it turned out, I had sat down at a gate that was the same number as my seat number (!Duh!), and the actual gate was nowhere to be found on my boarding pass. I now had 45 minutes to catch a plane and had NO IDEA what gate I was supposed to be at. 

So I started looking at those big hallway screens, asking people, found out I had to walk about a half mile back to E section, couldn't find E section, went all the way up D wing thinking maybe E was at the end of D, but it was a dead end, and the guy at the dead end said, go back - it's beside the info booth, I went all the way back, kept missing it because it was up an escalator with poor signage, tucked around a corner! I found it at last, went up, realized it was yet another half mile to get to the gate along another huge passage way past two more boarding pass checkers, at intervals, caught a little ride on a cart (although I could have run faster even dragging luggage). Anyway, I made it, caught the boarding line just as it was in process, and caught the plane with a good ten minutes to spare. Oh please, cortisol level, please go down, we still have so much ahead of us we have to get through.

The flight went OK, no sleep, 7 hours all night after being up all day, but we landed and bam, I was suddenly in England. It was 7:30 AM there and about 11 PM my time. Bed time. So, up for about 18 hours by now. I had 5 hours to kill in Heathrow. The crowd I was part of herded itself toward immigration. Immigration was in an enormous room about the size of a football field, divided into the usual two sides, one for locals and one for foreigners. I had walked and jogged, but still ended up at kind of the tail end of the crowd. Anyway, it was the usual RibbonedSwitchbackArrangement for controlling traffic flow. There were about thirty long lines moving past each other in opposite directions.. to an overhead camera it would have looked like slow-moving herringbone pattern. Each line was half the length of a football field. After about an hour, it was my turn.

Well, I got me a keener, as it turned out. Woman, thirty-something, maybe looking to work her way up, my first actual encounter with British bureaucracy. She took my card, looked at my passport, saw I was only there for 4 days, must have decided that was Strange, saw that the line was very dwindled and decided to take the bit in her teeth, and Do Her Job To Her Very Best. Long story short, I was held for "questioning", because she was pretty sure I should have had a work permit to show her, but I didn't. She made it clear she could make me turn around and go back to Canada right there if she wanted. She took all the contact info I had on me, left me sitting for a good 20 minutes while she phoned the people who had organized the workshop, said she hadn't been able to get hold of them, asked me tons of questions about what I was teaching and how much I was being paid and what it was all about and did I have the invitation with me? I said yes! it's on my computer - it was in an email - was there wifi available? I could show her, but she said, no, no wifi. I had already cracked like an egg, had told her Everything I could under the circumstances, had given her my complete cooperation.
She crisply informed me that had I been from Europe, or from anywhere in the UK, it wouldn't be a problem, but because I was Canadian, it was a huge problem. She pondered the situation. I thought maybe she was going to start asking me for a medical history or something, next. But she didn't. 

I didn't know what more I could do. I was completely at her mercy. I had no locus of control in this situation, and had to take whatever Fresh Hell might come my way. I think I stayed patient. I think I asked her if she had any suggestions on what to do next. 
Eventually, she decided to make a one-time exception. I was to never ever come back to England to teach without a work permit, ever again. OkyDoky then. 
Now the poor guys who organized the workshop are permanently emblazoned on some sort of Official Brit Bad Boy list, along with both their phone numbers.

By now it was about 9:30 AM. I still had lots of time to find my way around Heathrow, or so I thought, and the organizers had even very kindly arranged an executive lounge pass where I might catch a nap if I wanted, which was tempting, but I had no idea where to find it, so I thought I would better use my time first finding the next gate, getting the domestic flight to Manchester's boarding pass, then I could relax and explore a bit, or else find the lounge and snooze for a little while, maybe.

However, all there was for me to explore was the next circle of Heathrow Hell. The e-ticket had on it which terminal to go to, to get the next boarding pass, so I defaulted to my usual strategy for finding my way, which is to ask successive people if I'm going in the right direction. Yes, I was going the right direction, it was right over there, just a short walk. 
The short walk was at least a kilometer, through all sorts of tunnels, some with moving sidewalks but mostly not, tunnels that were inclined up and declined down and contained bends and switchbacks.. anyway, I finally saw elevators, and went up. I came out on the ground level. It seemed quite small, and only had restaurants. I didn't see any airline counters. So I asked at a coffee shop how to find the airline counter I needed. The girl behind the counter said, airline counters are upstairs. So I went up to level two, stepped out.

The elevators in England are very careful to explain to you, in perfect English, when the doors are opening and closing. There must be a lot of blind people in England, who travel, because, while the talking elevators are nice, the signage is absolutely terrible. At least, in that terminal, the signage was terrible. 
In probably every other airport on the planet, when you walk into a terminal, there are huge logo signs all along the top of the walls, where you can easily scan for the one you want. You take a quick look, see where you want to head, then head over. Easy. Right? 
In this huge, vast terminal, there were big, generic yellow signs, row after row after row of them. The actual information was in black text. Sort of like price club, where no-name brands of food are in yellow plastic labelled in black helvetica. I had no idea where to start looking, and I was exhausted. It looked like it would take me at least an hour to drag my luggage around, looking at every sign to find the right sign. So, I defaulted to asking, as usual. A guy who looked quite together and organized, a middle-aged man, well-dressed, who seemed sane enough, walked by; so I asked him, excuse me, what direction should I head in order to find British Airways? And he replied, oh, BA isn't in here, hasn't been for years - you need to go to terminal 5. 
Oh... OK, where is that? 
And he said, go downstairs and take the tube, it's just a short walk. 
And I said, Oh, OK, thanks. And went down stairs. And the elevator told me when it was closing, and when it was opening. I looked for signs, found one that had an arrow on it pointing to where the train station would be, and off I went. 
The underground train was not far away, but the walk to get to the right place to get on it, was another kilometer or so, through a big underground passage, brightly lit, with a big arched ceiling, lots of coin-op machines in the center for this or that, and foot traffic on both sides. I found myself walking on the wrong side, against the traffic flow. Oh well, I was too tired to care. 
I found the right platform, waited eight minutes, got on the train, which was free, and reassured me in perfect English over and over that it was, indeed, going to terminal 5. It took about ten minutes to get there. 
So I got out, into the bottom of some huge fancy glass tower building, occupied completely by British Airways. I had to go up to the twelfth floor or something - memory is sort of hazy, but anyway, I remember feeling flooded with relief when I spotted a big British Airways logo sign only a quarter mile or so across the huge room, and hardly any people in the way. Long before I got to the ribboned pathways, a nice man in a uniform asked if he could help me, and I said, yes, was this the right place to be? I needed a boarding pass to go to Manchester. 
He said, I'm sorry but you'll have to get that in Terminal 2. (...WHAT??)
British Airways had just sold its domestic portion to another company, which was in Terminal 2, but there would still be a sign there that said British Airways, if I looked closely. 
I said, OMG, I just came from there. Now I have to go back? And he said, yes, afraid so. So I turned around to go back. Of course, I had not paid much attention to how I had got from the train up the elevator, got turned around, couldn't find the elevator I'd come up on, everything looked different, so I asked a flight attendant how to find the elevator to get to the train to find terminal 2. She said, come with me, I'll show you, I'm going there myself. So, yay.

The other thing I noticed about Heathrow is that there are not very many facilities of the "Ladies" kind there. Maybe about a fifth as many as anywhere else. Plus, they are old, and always up some stairs, up which you have to drag your luggage, and wait in a line. This was a bit disconcerting. But I dealt.

Anyway, at last I was back in Terminal 2 in the huge room with yellow signs. At least another hour was long gone, and I had put several kilometers on my inner pedometer, dragging my luggage. I felt pretty hopeless yet again as I gazed around, looking once again for a clue as to where to even start. Two guys walked nearby. They looked like they worked there, not nice, misleading passengers who would send me off on another wild goose chase. They had badges strung around their necks. I decided to ask. They were in some deep conversation about something and weren't all that thrilled to be interrupted by a lost Canadian, but one of them pointed in a specific direction, so I said thanks, and headed off.

This time, I made it. I got the boarding pass, and got pointed toward the gate. Good, there was only one gate, clearly marked. Except for, when I got to it, it wasn't a gate, but was yet another one of those endless tunnel things that changed direction and went up, then around a corner, then down for awhile, with no moving sidewalk, and felt just plain creepy. Another kilometer at least. Then another room full of ribboned pathways, with a counter at the far side. I was the only passenger in the place, and the guy behind the desk was as bored as bored could be, yawning and rubbing his eyes. But he sat there and watched me go back and forth and back and forth, through six widths of the room, until I had made my way through  the arbitrary maze. In Brazil, there would have been a guy who would have moved the ribbon aside. Clearly, in Britain, there is no such guy, and the guy behind the desk who does the retina scans doesn't consider moving ribbons as any part of his job..

But I still wasn't anywhere close to my gate. I walked for another kilometer at least - dragging that luggage, walking through progressively older parts of the airport, different flooring, different architecture, the usual shortage of bathrooms, and at last, I was at the gate. 
I had about twenty minutes to spare. I bought a coffee, and sat down, and opened my computer, but, because it's Heathrow, there is no free airport wifi. Of course.

Coming home was a bit easier.. I didn't have to navigate Heathrow again - I flew straight back from Manchester to Washington on a US carrier. But because it was a US carrier, and security is at least 12 times tighter than through any other city I've ever flown through, there were about 5 more retinal scans and as many showings of my passport and checking of my luggage and yes, I had to take my shoes off. So many more ribboned gates and large burly guys wearing navy blue suits and ear pieces. And I had to take tweezers and nail clippers out of my luggage. What a colossal pain. One of the guys who helped organize the class, and who had brought me to the airport on the train, and who had made sure I got to the right airline counter, offered to send them to me by post, which was above and beyond the call of duty and very kind of him; they arrived a couple weeks later, so no harm done. 
And the flight was OK, what I can remember of it. I guess I must have crashed. I do remember I played sudoku for awhile on the touch screen on the seat in front of me. That was kind of cool. In DC there was more immigration, but it was a whole lot faster and no one cared about the little old female Canadian. There was whole body scanning involved but no patting down at random. Eventually I got to Denver, then to Regina, and then had the parking attendant run-in, and the scary drive home.

This latest flight, to Vancouver and back, was fairly uneventful but for the blizzard I had to drive through on the way to the airport, and the Christmas carols or else bagpipe muzack that played, and here it was, not even Hallowe'en yet, plus the fact the plane was delayed by a good half hour in both directions because it needed to be de-iced. But no major problems, no cortisol inducing waking nightmares.

And yay - that's it for awhile. I can finally dig in and start building up this practice I'm supposed to be running.

Thursday, October 25, 2012

Digesting the Moose Jaw adventure: Part VIII, Wave hands like clouds

Older posts in this series:
Digesting the Moose Jaw adventure: Part I
Digesting the Moose Jaw adventure: Part II NERVES, baby
Digesting the Moose Jaw adventure: Part III Sensory testing for pain
Digesting the Moose Jaw adventure: Part IV Nature of Pain
Digesting the Moose Jaw adventure: Part V Mindfulness

Digesting the Moose Jaw adventure: Part VI Sensory testing 2

Digesting the Moose Jaw adventure: Part VII, Pain and Depression

There were other presentations in Moose Jaw, one on opioids (Lynette Kosar, pharmacist), one on injecting spines (Sujay Ishwarlall, anesthesiologist, Saskatoon, no public profile), one on online team building (Vernon Curran online from St.John's NL), one on medico-legal risk management (K. Reducka), a pretty interesting one by Susan Tupper on pain management across the lifespan, and another by her on interprofessional program planning for pain.

The brain can only absorb so much, though. I must say, mine wandered fairly extensively at times.

One presentation that brought it back into focus, into the present, was on Tai Chi. Shane Kachur from Regina (4th picture down) explained how Tai Chi could be used to help people with chronic pain. I was too busy eating to be able to take notes, unfortunately, and his presentation, slides and everything, isn't in the binder with the others. He has agreed to send me his presentation/references, and when he does, I'll add the references in a list at the bottom.

He presented the slideshow while we were all busy eating lunch on Day 2, and I must confess, I found the food a bit distracting. As I recall, some of it was about different kinds of pronunciation relating to positions or moves in Tai Chi, some of the deeper history of the form, its connection to martial arts. I think there were references to studies that had been done on Tai Chi and pain, but like I said, I'm waiting for those. 

Anyway, after we ate we were invited to stand up and learn how to stand, hold an imaginary ball, then move to the other foot and change hand position so that we held the imaginary ball in mirror position, hands reversed. I can see how this would challenge the motor output parts of the brain, in a novel way, slide nerves harmlessly around, and provide lovely interoception. 

We learned (or at least tried to) something called "Wave hands like clouds". It looks nice, feels relaxing.  
(The man in the video is not Shane, by the way. Thank you, instead, to Rich Marantz.)

Sunday, October 21, 2012

Digesting the Moose Jaw adventure: Part VII Pain and depression

Older posts in this series:
Digesting the Moose Jaw adventure: Part I
Digesting the Moose Jaw adventure: Part II NERVES, baby
Digesting the Moose Jaw adventure: Part III Sensory testing for pain
Digesting the Moose Jaw adventure: Part IV Nature of Pain
Digesting the Moose Jaw adventure: Part V Mindfulness

Digesting the Moose Jaw adventure: Part VI Sensory testing 2

Dr. O. Afolabi is a UK-trained psychiatrist, originally from Nigeria, with no profile on google, who participated on the planning committee for the neuropathic pain conference, and who presented some compelling information related to pain and depression comorbidity: 

1. meds reduce pain severity by about 30-40%, in about 50% of patients, but don't usually touch the suffering
2. patients who seek treatment at chronic pain centers have had pain for a mean duration of 7 years
3. their mean age is 44 years
4. prevalence of depression in the general population: 18%. In primary care, 27%. In psychiatric clinics, 38%. In pain clinics, 52%. In orthopaedic or rheumatology clinics, 56%. (Bair 2003)
5. Looked at the other way, % of patients with mood or depressive disorders that have chronic pain is; no chronic pain, 34%; non-disabling chronic pain, 25%; disabling chronic pain, 41%. (Psychsom medicine 2006)
6. Incidence of depression in patients with non-disabling CP, 3 times higher than in those without non-disabling CP
7. In patients with disabling CP, incidence of depression was 5.4 times higher than in those without.
8. One in 5 Canadians have daily chronic pain to contend with (Schopflocher et al 2009; Gibson 2003) 

9. Economic burden of 1 out of 5 canadians with chronic pain is bigger than that of cancer, heart disease, HIV combined
10. One in 6 Canadians will experience depression at some point in their lives.
11. Direct pain care costs estimated to exceed $6B/year. Productivity costs related to job loss, sick days, estimated at $37B/year (Schopflocher 2008)
12. In Canada cost of depression estimated to exceed $25B
13.  Much greater economic cost with co-morbid depression and pain, lost work and access of health care - Suicide rate higher in this co-morbid situation
14. Biomedical, psychosocial and behavioural factors must all be assessed. Determine the patients' stressors, find out about their lives. What could they do before and what can't they do now? How does the spouse feel about the patient and the patient's situation? 
15.  Pain and depression share common neuro pathways, and share links in many other domains, such as genetic, cellular, structural, functional, neurotransmitter, and neuroendocrine. Link
16. Using PHQ9 - "you can find out in 5 minutes the extent of co-morbidity of depression and chronic pain." Scores will reveal the depression underlying the pain. Patient will tend to focus on the pain, not the depression, but test will show it. 

1. Bair MJ,  Robinson RL,  Katon W,  Kroenke K.; Depression and pain comorbidity: a literature review. Arch Intern Med. 2003 Nov 10;163(20):2433-45.

2. Lackner JM, Gudleski GD, Zack MM, Katz LA, Powell C, Krasner S, Holmes E, Dorscheimer K.; Measuring health-related quality of life in patients with irritable bowel syndrome: can less be more? Psychosom Med. 2006 Mar-Apr;68(2):312-20.

3. Marcus D; Chronic Pain: A Primary Care Guide to Practical Management (Current Clinical Practice) Humana Press; 2nd ed. 2009 edition (December 10, 2008)

4. Maletic V, Raison CL.; Neurobiology of depression, fibromyalgia and neuropathic pain. Front Biosci. 2009 Jun 1;14:5291-338. (Full text)

5.Clauw DJ, Chrousos GP. Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation. 1997 May-Jun;4(3):134-53.

6. Lisa C Campbell, Daniel J Clauw, Francis J Keefe; Persistent pain and depression: a biopsychosocial perspective. Biological Psychiatry Volume 54, Issue 3, 1 August 2003, Pages 399–409

7. A K P Jones, B Kulkarni and S W G Derbyshire; Pain mechanisms and their disorders Imaging in clinical neuroscience. British Medical Bulletin Volume 65, Issue 1 83-93.

8. Stahl S, Briley M. Understanding pain in depression. Hum Psychopharmacol. 2004 Oct;19 Suppl 1:S9-S13.

9. Arnow BA, Blasey CM, Lee J, Fireman B, Hunkeler EM, Dea R, Robinson R, Hayward C.; Relationships among depression, chronic pain, chronic disabling pain, and medical costs. Psychiatr Serv. 2009 Mar;60(3):344-50.

10. Yiannakoulias, N, Svenson LW, Schopflocher DP. (2009). An integrated framework for the geographic surveillance of chronic disease. International Journal of Health Geographics, 8:69 (open access)

11. Patten, SB, Schopflocher, D. (2009). Longitudinal epidemiology of major depression as assessed by the Brief Patient Health Questionnaire (PHQ-9). Comprehensive Psychiatry, 50, 26-33.

12. Lynch ME, Schopflocher D, Taenzer P, Sinclair, C. (2009). Research funding for pain in Canada. Pain Research and Management, 14(2), 113-115.

13. Rashiq S, Schopflocher D, Taenzer, P (Editors) (2008) Chronic Pain: A Health Policy Perspective, In Jonsson, E. (Series Editor) Health Care And Disease Management Series, John Wiley, ISBN: 978-3-527-32382-1.

* There were two more references under the topic of comorbidities, but they were impossible to read from a tiny 6-slide to a page, B&W photocopy, even under magnification, so they are missing from this list.  Also I couldn't find Gibson 2003, nor am I certain I could find the correct Schopflocher reference, so I brought all from 2009.

Saturday, October 20, 2012

Digesting the Moose Jaw adventure: Part VI Sensory testing 2

Older posts in this series:
Digesting the Moose Jaw adventure: Part I
Digesting the Moose Jaw adventure: Part II NERVES, baby
Digesting the Moose Jaw adventure: Part III Sensory testing for pain
Digesting the Moose Jaw adventure: Part IV Nature of Pain
Digesting the Moose Jaw adventure: Part V Mindfulness

"What we know now that we didn't know 5 years ago" 
Pam Squire
This post belongs with Part II and Part III in this series. There didn't seem to be much "new" here I hadn't already seen and stumbled over multiple times; as a PT on the outskirts of medicine, completely familiar with working in the dark, with the shadows, with uncertainty [hampered by clunky unwieldy and largely irrelevant tissue-based explanatory models], and as an aging human in a HumanAntiGravitySuit, I figured out a long time ago that peoples' pain presentations are more about them, and their own nervous system glitches, than about some maddeningly elusive definitive diagnosis that may have been missed. It seems to me this title and the content it contained suggested that news of this unknowability has begun to dawn on the medical profession, that they are starting to learn how to be more comfortable with uncertainty, starting to learn how to grapple with the idea that pain is its own phenomenon, not just a symptom of something else they've not been able to get their finger quite on. Good on them. More interactive, less operative, maybe.

Criterion 1: "Pain with a distinct neuroanatomically plausible distribution" refers to "a region corresponding to a peripheral innervation territory or to the topographical representation of a body part in the CNS", Pam Squire said.  She said, have your patient draw a pain diagram. She suggested using the colour key as described in Part III.

Criterion 2: "A history of relevant lesion or disease affecting the peripheral or central somatosensory system", i.e., the "lesion or disease is reported to be associated with pain, including a temporal relationship typical for the condition." She said, medical history plus or minus neuropathic pain scales will help establish this criterion. Various scales include LANSS, Neuropathic Pain Diagnostic Questionnaire (DN4), Neuropathic Pain Scale (NPS), Neuropathic Pain Questionnaire (NPQ), Neuropathic Pain Symptom Inventory (NPSI, in French).

Criterion 3: "Demonstration of the distinct neuroanatomically plausible distribution by at least one confirmatory test"; "as part of the neurological exam, these tests confirm the presence of neurological signs concordant with the distribution of pain."
 E.g., quantitative sensory testing, using the "kit" as described in Part III. Other ways include electrophysiology (not very practical in the clinical setting) or a clinical neurological exam (I'm thinking, reflex hammers etc.). Testing for hot and cold sensation can be done with a metal object, which is going to feel cold to the touch, usually, unless it's been sitting in the sun or on a radiator. 
Back in PT school we used hot and cold water in test tubes.
Other tools: clinical neurological exam, electroneurography (sensory nerve conduction), evoked potentials (SEP, LEP)

Criterion 4: "Demonstration of relevant lesion or disease by at least one confirmatory test" These included more specific pathoanatomical tests such as biopsy, MRI, CSF analysis etc. Challenges to pinning down a diagnosis of neuropathic pain include the reality that "the pain system is dynamic and changes unpredictable", and that "signs and symptoms may change over time." 
Well, yeah... this has been a huge confound for PT all along. We have pretty much never been able to get beyond tooth fairy science, haven't been able to show our interventions to have much credibility beyond "non-specific effects." 
Not that there is anything wrong with non-specific effects of the relieving sort - they are better than nothing, and way better than nocebo. 

This included sensory testing and pain diagraming as in Part III. DN4 with its 7 sensory descriptors was recommended as the best questionnaire to use, validated, and free from http://dn4.ca/local/files/pdf/en/questionnaire.pdf . 
Questions to ask: OPQRST:
O = onset (Sudden? Gradual? Trauma? Surgery?)
P = provoking factors, palliative factors. What makes it worse or better? Spontaneous pain is a hallmark of NeP, also sensory avoidance symptoms like avoiding certain kinds of clothes, or lights, or toothbrushing.
Q = qualities of the pain, its intermittence or constancy
R = region, radiation
S = severity on visual analogue scale
T = time duration, especially how long it's been the way it is now. 
If CRPS is suspected, check for 5 "S"s: 
Skin colour change, swelling (intermittent or constant), sweating, spasms/dystonia, shaking/focal tremors/clonus/tics. 

Check for body perception disorders - if present they might be evaluated using the Recognize App from NOI for hands and feet

Handouts included several pages of useful tips on sensory testing for and interpreting results of light brush, vibration, cool, warm, cold, hot, punctate, pin prick, deep pressure - getting it just right; what kind of fiber is tested in each case, what results mean re: which "pain" mechanism is being revealed. 
All that is still a bit too nerdy, even for me - useful though, for anyone setting up an actual study that incorporates sensory testing. 

1. Editorial; The Neuropathic Pain Scales Regional Anesthesia and Pain Medicine, Vol 30, No 5 (September–October), 2005: pp 417–421 (full access pdf)

2. Michael I. Bennett, Blair H. Smith, Nicola Torrance, and Jean Potter; The S-LANSS Score for Identifying Pain of Predominantly Neuropathic Origin: Validation for Use in Clinical and Postal Research. The Journal of Pain, Vol 6, No 3 (March), 2005: pp 149-158

3. Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire. Clin J Pain. 2003 Sep-Oct;19(5):306-14.

4. Troels S. Jensen and Ralf Baron; Translation of symptoms and signs into mechanisms in neuropathic pain. Pain 102 (2003) 1–8 (open access pdf)

5. Alban Latremoliere and Clifford J. Woolf; Central Sensitization: A Generator of Pain
Hypersensitivity by Central Neural Plasticity. J Pain. 2009 September; 10(9): 895–926.

6. Didier Bouhassira, Nadine Attal, Haiel Alchaar, François Boureau, Bruno Brochet, Jean Bruxelle, Gérard Cunin, Jacques Fermanian, Patrick Ginies, Aurélie Grun-Overdyking, Hélène Jafari-Schluep, Michel Lantéri-Minet, Bernard Laurent, Gérard Mick, Alain Serrie, Dominique Valade, Eric Vicaut; Comparison of painsyndromesassociated with nervous orsomaticlesions and development of anewneuropathicpaindiagnosticquestionnaire (DN4). Pain Volume 114, Issues 1–2, March 2005, Pages 29–36

7. Johan Marinus, G Lorimer Moseley, Frank Birklein, Ralf Baron, Christian Maihöfner, Wade S Kingery, Jacobus J van Hilten;  Clinical features and pathophysiology of complex regional
pain syndrome. Lancet Neurol. 2011 Jul;10(7):637-48. (Full pdf)

8. Backonja, Miroslav-Misha; Walk, David; Edwards, Robert R.; Sehgal, Nalini; Moeller-Bertram, Toby; Wasan, Ajay; Irving, Gordon; Argoff, Charles; Wallace, Mark; Quantitative Sensory Testing in Measurement of Neuropathic Pain Phenomena and Other Sensory Abnormalities. Clinical Journal of Pain: September 2009 - Volume 25 - Issue 7 - pp 641-647

9. Walk, David; Sehgal, Nalini; Moeller-Bertram, Tobias; Edwards, Robert R.; Wasan, Ajay; Wallace, Mark; Irving, Gordon; Argoff, Charles; Backonja, Misha-Miroslav; Quantitative Sensory Testing and Mapping: A Review of Nonautomated Quantitative Methods for Examination of the Patient With Neuropathic Pain. Clinical Journal of Pain: September 2009 - Volume 25 - Issue 7 - pp 632-640

10. Maija L. Haanpää, Misha-Miroslav Backonja, Michael I. Bennett, Didier Bouhassira, Giorgio Cruccu, Per T. Hansson, Troels Staehelin Jensen, Timo Kauppila, Andrew S.C. Rice, Blair H. Smith, Rolf-Detlef Treede, Ralf Baron; Assessment of NeuropathicPain in PrimaryCare. The American Journal of Medicine Volume 122, Issue 10, Supplement, October 2009, Pages S13–S21

11. Ann-Sofie Leffler, Per Hansson; Painful traumatic peripheral partial nerve injury-sensory dysfunction profiles comparing outcomes of bedside examination and quantitative sensory testing. European Journal of Pain Volume 12, Issue 4, pages 397–402, May 2008.

12. Peter Vestergaard Rasmussen, Søren Hein Sindrup, Troels Staehelin Jensen, Flemming Winther Bach; Symptoms and signs in patients with suspectedneuropathicpain.  Pain Volume 110, Issues 1–2, July 2004, Pages 461–469

13. Scott, David; Jull, Gwendolen; Sterling, Michele; Widespread Sensory Hypersensitivity Is a Feature of Chronic Whiplash-Associated Disorder but not Chronic Idiopathic Neck Pain. Clinical Journal of Pain: March/April 2005 - Volume 21 - Issue 2 - pp 175-181

Thursday, October 18, 2012

Digesting the Moose Jaw adventure: Part V, Mindfulness

Older posts in this series:
Digesting the Moose Jaw adventure: Part I
Digesting the Moose Jaw adventure: Part II NERVES, baby..
Digesting the Moose Jaw adventure: Part III, Sensory testing for neuropathic pain
Digesting the Moose Jaw adventure: Part IV, the nature of pain

I've looked at this topic quite a lot in the past: "Mindfulness Based Stress Reduction" - Jon Kabat-Zinn", Still meditating on meditation, and a 1 hr 12 min. video supplied in the comment section, Mindfulness with Jon Kabat-Zinn; other posts include Growing a steering wheel for one's brain, and "Everything you wanted to know about phobias and were afraid to ask" - Gordon Asmundson on fear avoidance

A lot of what pain seems to be about, at least according to me, is some sort of unfortunate standoff between the critter brain, or internal regulation system,  and human brain, whereby the human brain doesn't understand how to let the critter brain do its own thing. I'm going to deliberately call it Critter brain (I want it to have its own identity, personify it a bit, deliberately exaggerate its differentness from Human brain, aka, mind). It includes the insular cortex, involved in the spinal cord system Bud Craig says is 500 million years old (see Notes re: Interoception, point 5), in contrast to the human part, thought to be only a couple hundred thousand years old at most.

It seems to me that mindfulness is all about teaching Human brain to back off, watch, but not interfere with Critter brain: learn how to appreciate, and interact with rather than try to override, interrupt, control, dominate or punish Critter brain. It's only our lifeboat on the vast ocean of life, after all - once it gets a hole in it and deflates, we're done.

At the Moose Jaw conference, mindfulness came up more than once. Dr. Anita Chakravarti, a Saskatoon anesthesiologist, presented Mindfulness for Pain Management, in the second segment of Day I. 
She began by reading a reflection by a patient who has chronic pain, and another by a physician who looks after others who have chronic pain. Both reflections contained helpless exhaustion and frustration.
Then she said, "Both of these are me. I wrote them both."
And I was hooked. 

She reminded the audience of the WHO definition of health:
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
Her entire talk was about how mindfulness serves not only those who have chronic pain, but also caregivers who look after patients who have chronic pain. She led the group through a few experiential exercises, talked about others (like spending 45 minutes eating a single raisin). 

I live tweeted her talk, #SNPC. Live tweet streams degrade rapidly, and this stream already has, so I went into PSD's official (permanent) tweet list, and have reproduced the tweets here: 
* Mindfulness! Is a didactic concept but also experiential 
Mindfulness is efficacious for pain AND for caregiver stress 
Mindfulness is EB tool, has helped improve quality of life, find strengths, resilience. 
 Process of being completely in the moment = mindfulness 
* 21st century medicine. Different roles have evolved. Chronic disease has replaced acute as the most common. 9 million Canadians with chronic disease.  
"We don't see things as they are - we see them as WE are." 
 Self awareness is important for how we take in information from our patients. 
* High level of health care worker burnout. Quality of life and health and wellbeing most importnat for most people. What does this mean?  
 turning inward... any sort of sensation can be pleasant or unpleasant or neutral. Turning toward rather than away. 
Takes adaptation, graded exposure. Self reflection and self awareness, not just a cognitive idea. Takes work, practice.. 
Listen. Choices we make in the middle of life. Not just on holiday. Each moment has choices. 
Our sensations are not who we are, our worries are not who we are, our emotions are not who we are. 
In mindfulness you begin to realize what you are... NOT. Kabat-Zinn: Pay attention in a particular way, on purpose, no judgment. 
You don't try to stop the waves of "crap" - you learn to surf ON them. 
Principles: Pay attention to both internal and external processes, processing. 
Principles of mindfulness: be aware of mental, emotional, physical thoughts and feelings in the moment. Pause. Make mindful response 
 Mindfulness: CHOOSE response. Promotes awareness, balance, choice, acceptance of what is. Not about letting go, is about being with. 
Choose where attention goes. Acceptance and curiosity. Dip a toe in. Be with the pain. Turning inward means facing possible change. 
Attention awareness non-judging beginner's mind, critical curiosity, presence, letting go, acceptance, trust, non-attachment 
patience, attentive observation, vigilance, engagement, clear comprehension. 
Don't assign meaning too swiftly. Mindfulness teases things apart. Deconflates. 
Science is moving the goalposts. Mindfulness is constantly being redefined as is pain. 
Mindfulness training for troops pre and post deployment. Better resiliency. Also is being offered in prison systems. 
Has been shown to help with stress, Q of Life, pain, psoriasis, HIV, hot flashes - very very long list. 
Various kinds of pain, including fibromyalgia, measured with various pain tools; mindfulness has shown good results 
Good when combined with CBT. 
Mindfulness when taught in med school leads to medical error reduction and better patient outcomes. 
Decreased burnout! 
 Not just quality of care - quality of carING. 
 Decreased suicide in physicians etc., many other benefits for carers.. 
Taking 45 minutes to eat a raisin. Learning all about eating. Mindful eating. 
mindful walking. Transition times are great, important times to be mindful. Others: breathing, mindbody scan 
Transitioning between patients - mindfulness during the day: touching the next doorknob can be a reminder to refocus. Two mins, AM, PM
"Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom."- Victor E. Frankl

Absolutely good sensible advice. The word "spiritual" showed up on a few slides. Apart from always having a bit of allergic reaction to that word, such a human-centric adjective, a memeplex suggestive of potentially misleading woo, I thought her content was simply very good and practical advice on how to slow down one's mind and be a decent human being when dealing with one's own and others' critter brains, especially for busy doctors. 


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