Wednesday, February 26, 2020

#SDPAIN2020 Final chapter

There were many good speakers throughout the weekend including my old friend Dave Walton, who presented his current research in a presentation with the intriguing title, Blood, Spit, Hair, and Poop: How Novel Biomarkers Are Shedding New Light On The Transition To Chronic Pain.
Dave Walton
Photo credit Julie Tudor

I met Dave long ago (2005) when we were starting up the PainScience Division in Canada. Here's the story in point form. 
  • David Butler (in Australia) moderated a physio discussion forum in the early 2000's, where I met Nick Matheson (from Nova Scotia). Nick contacted me in 2004 with the idea that we should ask CPA to let us make a new division, a pain division. He had to drop the project early though, for family urgent family reasons. So, at that point, I was it. 
  • I realized Neil Pearson, another discussion group member, was living in the lower mainland near Vancouver, where I lived at the time. I contacted him and ran the idea by him. He was in. 
  • I contacted Dave Walton. I remembered a letter to the editor of the ortho group's journal in which he mused about there being a special interest group someday in Canada for physios. He was in. A few others heard the news and wanted in. Soon we were a group of 6 or 7. 
  • CPA didn't want another division at first. So we made a group anyway. Dave built a webpage and we posted stuff on it. We suddenly had a profile. We made newsletters that I sent around to a mailing list that developed. We called ourselves the Canadian Physiotherapy Pain Science Group. 
  • Eventually, we became a division in 2009.  I served on it as a comm-liaison until 2013. Both Dave and Neil served two-year terms as chair. I retired after CPA locked down our stuff and I couldn't deal with the tech side of things on their complicated website. 
Anyway, this year at the summit Dave showed up!! It was good to catch up with him. He has published a book, had it there for sale, was signing it. 

Dave's book
I'm giving it a read. So far, so good.


The panel discussions were wonderful - and Rajam has made both of them available for all to watch. Challenging. Provocative. Graded exposure, health care people. Graded exposure. If the summit can give you anything beyond more facts and knowledge to digest and a wonderful safe relaxed space to meet interesting people, it can give you digestible graded exposure to the difficult psychosocial topics of life.  


Joletta Belton and Keith Meldrum co-presented The Lived Experience: A Conversation About Pain. Both of them had harrowing experiences, not just with their lived pain but with its exacerbation by well-intended but humanity-less medical "systems" of care.
I know those systems quite well, was part of them in younger newly-graduated days. 

They do tend to suck away the soul; my training as a physio did not equip me to handle other peoples' souls very well. I would advance the idea that we are all trained to be operators, working from concepts only, doing stuff to people, instead of interactors, knowing boundary skills on how to be with people. After a while, I realized that "systems" would be the death of my own humanity, so I went private, where I could salvage and deploy whatever was left of it. But when you are a helpless patient they are the mental meat grinders you are forced to go through, for better or worse - great for keeping you biologically alive but not great at helping you become un-shattered psychosocially; in fact, they can make those components of the lived pain experience much worse. 
I have concluded, after 50 years of being a physio, that these "systems" evolved to provide space and distance to protect helpers from the angst and pain of the people they are presumably trying to help, but they backfire bigtime for the person enduring a lived pain experience. 
Not always.
But mostly. 

You can watch their presentation (and presentations by others from previous years) here

Joletta Belton and Keith Meldrum discuss their experiences
being patients with chronic pain


This panel was with Sandy Hilton, Mark Milligan, Maxi Miciak, and Uchenna Ossai. They tackled topics of discrimination, white fragility, redlining, systemic barriers to health care, institutionalized racism, colourism; all the psychosocial stressors people in marginalized communities and identity groups put up with daily and take a huge health toll. This is hugely educational. You can watch it for free at this link

Audience (me in the red shirt)
Photo credit: Lisa Flores



All the presentations were great. Rajam has made ALL the summit presentations, to date, available by paying her only a few hundred dollars. Six summits worth of high-value education, for just a few hundred dollars. She wants the world to transform itself toward better health care. Not just talk about it, but DO IT! You can gain access to this amazing body of education at this link


This fall's SD Pain Summit East, in Charlotte, North Carolina, is at this link. Sign up now. 

Next year's San Diego Pain Summit in San Diego is at this link. Sign up now. 

Thank you Rajam, for everything you do. See you next year!! 

Sunday, February 23, 2020

#SDPAIN 2020 Melanie Noel, keynote speaker

Melanie Noel is a pediatric pain researcher and psychologist at University of Calgary, a self-designated "Newfi" whose speech still contains slight traces of that particular accent, a slightly hard "R" in words like "hARd" and "embARk." She is interested in preventing children from becoming adults with chronic pain,  and has uncovered evidence-based ways to intervene. 

Melanie Noel #SDPAIN2020

She began with a horror story: in 1981, the year she was born, she could easily have been one of the infants who underwent surgery for a congenital heart problem with only paralytics but no pain management,  because infants were (and in some cases still are - perish the thought) regarded as having no capacity to form pain memory. She is adamantly opposed to this idea;

"Early painful experiences from the time of birth set the stage for the adult that lies in front of you if you're a massage therapist or the adult that you work with."


She discussed papers that back up her point of view.  One study (Taddio et al 2002) compared babies who received lots of post-birth heel pricks compared to babies who did not, and their fear memory reactions a few months later in a vaccination clinic. Thay would cry and demonstrate "fear, distress and pain expressions," as soon as a totally non-nociceptive cleansing swipe was applied to their thigh, prior to the actual needle.


In another study (Weisman et al 1998),  children with cancer who received painful medical procedures were divided into two groups, one of which received fentanyl prior to the procedure and one which did not. It turned out that children in the group which did not receive the fentanyl, but in a second round of painful procedures did, received less benefit from the analgesia than the "kids who had had their pain properly managed from the getgo, raising the suggestion that not only is pain remembered from the first days of life, but, if it's not well-managed, those memories can actually influence whether or not whether a child can benefit from pain management." 

In other words, as adults, these children have a greater chance of developing chronic pain issues. 


"These memories are powerful drivers of future pain experience."


Even aiming for "less unpleasantness" is a good idea. In a randomized trial (Redelmeier et al 2019), 682 subjects underwent colonoscopies. One group was treated as usual, while subjects in the other group were treated more gently, as in, the scope was removed more slowly, "less unpleasantly." It turned out their memories of the event measured as having been less unpleasant, leading the researchers to hope they would be more likely to be compliant with future medical visits and tests. 


Girls develop more negatively biased memories than boys. Seventy percent of our chronic pain patients are female. "Anxiety is the biggest culprit in everything." An anxious person is more likely to remember what they expected to happen than what actually happened. Negatively biased memory is increased in children with anxious negatively biased parents. Pain seems to come out of nowhere right around puberty. Scanning the brain of a kid with chronic pain vs. without, there are differences in size of hippocampus, and connectivity between hippocampus and frontal areas and hippocampus to amygda are different. 


Her own research is about finding ways to block pain memories from gaining any traction in children. Speaking as a mother of three, and a pain researcher, she says, children age 4 to 6 are very suggestible. She says, "catastrophization is a thinking style." How children frame pain will be learned from parents. So she wants parents to:

1. Not enhance or engage in any exaggerated pain talk with their children or within their earshot

2. Focus on related but positive distraction topics instead. E.g., Remember the nice nurse who gave you that popsicle after you had your tonsils out? She was nice, wasn't she? They will remember the event clearly but the pain of it will be remembered a lot less clearly. 


I had not really seen the connection between pediatric pain and adult chronic pain as clearly before listening to Noel's talk as I do now. She will be back next year to keynote the summit again, which I look forward to. 
SDPAIN2020 Part 1
SDPAIN2020 Part 2
SDPAIN2020 Part 4



1. Taddio A, Shah V, Gilbert-MacLeod C, Katz J., 2002, Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002 Aug 21;288(7):857-61


2. Weisman SJ, Bernstein B, Schechter NL, 1998, Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998 Feb;152(2):147-9.  

3. Help Eliminate Pain in Kids: The Hidden Cost of Immunization Nov 19, 2013 YouTube video 

4. Nancy White, 2012, Needle phobia in childhood linked to future health-care fears. The Star Feb 21, 2012.  "One in ten" adults have needle phobia. 

5. Full list of papers authored/co-authored by Melanie Noel 

6. Redelmeier, Donald & Katz, Joel & Kahneman, Daniel. (2003). Memories of Colonoscopy: A Randomized Trial. Pain. 104. 187-94. 10.1016/S0304-3959(03)00003-4. 

7.  Melanie Noel, Jennifer A Rabbitts, Gabrielle G Tal, Tonya M Palemo,  2015, Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall.  Pain. 2015 May; 156(5): 800–808. 

Friday, February 21, 2020

Nervi nervorum and pain as perception

This post is a wee break from summit postings because as we know, we need to carry on with what's going on right under our noses and not just bathe in nostalgia for recent events. 

Two things came to my attention yesterday that I think perfectly sum up pain.

First, its treatment, at least of pain that stems from a crabby nerve, i.e., neuropathic pain. I won't go into the many kinds of neuropathic pain that exist, because there are several ways nerves can be crabby and reasons for it.
Let's just say that in my line of work, you never know. You can only guess from someone's story, which is why it's important to listen to the story.
Generally, manual therapy followed by some movement instruction is a good go-to for chronic pain that stays in one place and varies with position or rest. That implies that only one nerve or few are involved, and the nervous system has contained the problem, so is therefore healthy. In other words, the pain isn't anything to do with the central nervous system itself, it's doing its job just fine, keeping the problem localized to an area (e.g., low back) or limb (e.g., pain at the knee). This sort of pain has more to do with the behaviour of the person living inside the nervous system, probably. Easy peasy. Well, not at first - there's a learning curve. Or maybe I should say, there's an UN-learning curve. Because all the people who lean toward helping people clinically with their pain problems are first saddled with a TON of biomedicalese and Type 1 diagnostic errors and labels for pain that make it seem like mesodermal derivative causes their pain. But don't even get me started on that, and stop me from complaining about all the treatment models there are out there that focus on irrelevant minutiae like biomechanics and muscle and fascia and discs and whatnot.
Can we at least agree that pain is in the nervous system and stop all the BS about joints etc.?
Usually movement helps, so we should always remember that motion is lotion.

Here is one thing that caught my eye, put in front of me in fact by my facebook friend Alice: a 2016 review paper about nervi nervorum.
Papers like these are as scarce as hen's teeth but essential for manual therapy models in my humble opinion. I first heard about nervi nervorum probably about 40 years ago as I sat in Loren Rex's (Bear's) classes at the Ursa Foundation in Edmunds, Wa.
Since then I've seen perhaps three papers about them, this being one of them.
Why do we need to understand nervi nervorum to be a manual therapist?
Because, if we want to have a conceptually accurate (or at least less-wrong!) model for our work, we need to understand everything we can about nerves. 

Neurons are the most excitable "tissue" in the body, and come from ectoderm. I think ectodermal derivative, which makes up the entire nervous system, is pretty special that way. There are even papers out now about how excitable skin cells are, and, lest we forget, skin cells are also from ectoderm. And we literally (!) can't touch anything but skin. Which is why we should toss all operative illusions that we can have any kind of direct effect on anything lying beneath.
We touch people and that helps change their perception of pain. This is "dermo."
We pull skin sideways, and that tugs a bit on actual nerves, so we can add a layer of neurodynamics onto that. That's "neuro."
Things change for the patient. That's "modulating." 

And we aren't doing that - their brain does that.
And a nerve does not have to be injured for its nervi nervorum to be able to start complaining.
Which takes me to the next thing I saw which fits beautifully: This wonderful video from MindField, on touch. 
The narrator starts out peripherally with thermal grill illusion (illustrated by alternating cold and hot hot dogs!) and ends up showing how easily one can induce nocebo in a person such that they send "pain" out peripherally from their own perception, in a demo of fake laser.

Pain is perception!

Perception is so wily it can predict, then impersonate, "sensation." 



1. Manoel Jacobsen Teixeira, Daniel Benzecry Almeida, Lin Tchia Yeng, 2016, Concept of acute neuropathic pain. The role of nervi nervorum in the distinction between acute nociceptive and neuropathic pain. Rev Dor. São Paulo, 2016;17(Suppl 1):S5-10 (translated from Portuguese)

2. Moehring, F., Cowie, A. M., Menzel, A. D., Weyer, A. D., Grzybowski, M., Arzua, T., . . . Stucky, C. L. (2018). Keratinocytes mediate innocuous and noxious touch via ATP-P2X4 signaling. 2018; 7: e31684

3. Touching: Skin cell to nerve cell communication uncovered. Jan 18, 2018

4. Touch - Mind Field (Ep 6), Feb 15,  2017, YouTube. 

Thursday, February 20, 2020

#SDPAIN2020 Part 2

Beth Darnell, teaching Empowered Relief
Photo credit, Nick Ng

Every year this summit is the highlight of my life. My peer group is here. I am older than most of them but that's OK. The youngsters will own the world one day. The ones my age are all retired and living their quiet well-ordered boomer lives somewhere far away from physiotherapy, and far away from my own natural inclinations about what to do with the rest of my life.

Me, I can't seem to quit. I'm reveling in feeling the sea change, the pull of the tide. Like I'm lying in the tidal zone, enjoying it, not wanting to move. 

I think I'll post about the workshops first, then speakers, and personal stuff later. Bear with me please, there will likely be several posts.

The first workshop this year was Empowered Relief, with Beth Darnell. Her bio on SDPainSummit website::
Beth Darnell is Clinical Associate Professor in the Division of Pain Medicine at Stanford University. She is a pain psychologist and scientist. She is a past President of the Pain Society of Oregon and is current Co-Chair of the Pain Psychology Task Force at the American Academy of Pain Medicine. Her NIH-funded research investigates mechanisms of pain catastrophizing and the effectiveness of a single-session pain catastrophizing treatment she developed. She is author of The Opioid-Free Pain Relief Kit © 2016 and Less Pain, Fewer Pills: Avoid the dangers of prescription opioids and gain control over chronic pain ©2014.  Beth also blogs for Psychology Today and the Huffington Post.

What I loved about her workshop:
1. Her work arises from her personal experience with chronic pain. She was a teen who had had chronic pain since childhood, at age 19 went to the hospital afraid of dying, was told there was nothing wrong and given a prescription for Vicodin. She climbed out of that rabbit hole successfully it would seem, and now teaches others to teach others how to become calm and remain that way.
2. Very much brings the relationship between stress and pain into focus. Intervene on the stress, the effect stress has on the autonomic NS, and the pain will decrease. Lots about breathing and relaxation and mindfulness. 
3. She gives everything away for free. She makes no money from it. I admire that! It's trademarked (Stanford owns it) but she makes the boundaries very clear: don't leave anything out or add anything to the content, use the slides (all the slides) and you can personalize them with your own bullet points and speaking style. 
4. She calls it "plug and play." And for sure, it is all very programmed. She has tried her utmost to make it deliverable by anyone who cares to teach it. And this was a teacher training for all of us to become accredited providers.
5. The "binaural" aspect of the relaxation sound file is cool: She explained that the RCT was done on surgical patients. All patients were under general anesthetic. Group one wore headphones during surgery that emitted tones, first into one ear, then the other, alternating. Group two wore headphones with classical music coming through them. Group three wore headphones with nothing, nada, no sound. It turned out that the "binaural" tone group received less anesthetic because their heart and respiration rate fluctuated less during surgery. (I found this fascinating and asked her if there had ever been any research combining binaural input with virtual reality in awake people, and she said she was on it. :) Just think: superior colliculi and inferior colliculi being stimulated at the exact same time. If only I had life to live all over again...)


Steven Berg Smith
"No fixin'!
Photo credit, Julie Tudor

The second workshop was with Steven Malcolm Berg-Smith. This is his bio from the SD pain summit website:
For over 30 years, Steven Malcolm Berg-Smith has worked as a behavior change counselor, health educator, drug & alcohol prevention specialist, and researcher.  He currently has a private practice in the San Francisco Bay Area as a motivational interviewing (MI) trainer, consultant, coach & mentor.
A member of the International Motivational Interviewing Network of Trainers (MINT) since 1994, Steve has conducted over 1000 motivational interviewing (MI) workshops and presentations throughout the US and internationally.  Considered a master trainer by his peers, Steve has served as a “trainer of trainers” for MINT, and collaborated in the design of MI-inspired behavior change intervention protocols for numerous national clinical research trials.  He has authored a manual on the “The Art of Teaching Motivational Interviewing,” along with several frequently cited articles on how to use motivation-enhancing tools and strategies to support adolescents and adults in making positive lifestyle changes.
Steven holds a MS in Community Health Education from the University of Oregon, and a BA in psychology from the University of Redlands.

This guy was an original San Diego surfer dude back in the day. He teaches motivational interviewing like no one else I've ever seen teach it. He stuffed information into our collective brains through every channel he could using multiple props to get his points across; music, movement, objects, mirrors, rattles. Snapping fingers. Clapping hands. Slapping thighs. Drumming on tables. Big sighs. Story-telling. Roleplay. Roleplay was huge. He had us practice listening, reflecting, summarizing, and giving hopeful messages.
I thought back to physio school and how USEFUL it would have been to include training like this right from the start.

What I loved about his workshop:
1. Lively and fun and totally engaging, included movement
2. Practicing the stuff, not just learning about it
3. A bit of ritual. He invited us to each write on a piece of paper some sort of "fixin'" behaviour we might like to get rid of, walk up to the front, put it in a box: he promised he would take the papers down to the beach April 1 and burn them in some area where small bonfires are permitted.
4. Not only was the workshop very interactive, but the content was also all about interaction. The patient has locus of control. Watch for change talk (whenever we heard any of that, we drummed on the table). We were taught to support that in our reflections (he picked up a mirror to symbolize that). No way for a predictive brain to NOT absorb some of that.
5. It all made me think about DNM. For a longtime I've taught manual therapy as interaction between two nervous systems at a non-verbal level, designed to enhance the function of the receiving nervous system. MI seems like the verbal equivalent of that. Imagine: DNM as non-verbal MI. MI as verbal DNM.

Next post will be about the speakers.

Tuesday, February 18, 2020

#SDPAIN2020 Part 1

Rey Allen (hat, from Texas) and Erik Ouellet (from Montreal) in foreground

Soooooooooo much to unpack after this past week. I'm waiting for the eval forms to arrive by email, because there is much to say about this year's San Diego Pain Summit, and at the moment it's all a bit blurry. But I wanted to get started with this lovely evening out the first night of the 6-day summit. Jason Erickson (the guy behind Erik with his arm extended along the back of a chair) proposed the venue, Ortega's Cocina. It's a lovely place full of colourful folkloric kitch, great food, and giant pitchers full of margarita. I was transported back to 1987 when I lived in Mexico City for 4 months. Good times!
Right down the street was Belching Beaver with the most wonderful stout I've ever tasted.
Have I ever mentioned how much I love visiting San Diego?  In February? Yeah, it was a bit chilly (that's me with the orange scarf keeping my neck warm) but nothing like the hour-long drive home from the airport yesterday late afternoon through a ground blizzard.
Seriously, ground blizzards are hard to drive through. The highway appears covered in millions of writhing white snakes traveling at high speed from one side of the highway to the other. Your eyes are drawn to watch the snakes instead of the road. You have to interrupt your brain constantly and force your eyes to stay glued to the lane markings instead. Very tiring. And then, when a car goes by, the snakes blow up and visibility is completely lost for a few seconds. Huge focus is required, especially when most of you is still nostalgically lingering in the land of palm trees, your peer people, and intense mental stimulation. Ah Rajam, you have created quite a movement, with fierce momentum.
This was my sixth summit. I've been to every single one of them. They are such fun I just don't know how to quit. Now Rajam is offering a second one in the autumn, in Charlotte North Carolina. Clearly she doesn't know how to quit either! And I hope she never does. 

SDPAIN2020 Part 2
SDPAIN2020 Part 3
SDPAIN2020 Part 4

Monday, February 03, 2020

Historical references

Today Guillaume Thierry, a French physio using and teaching DNM, posted to the Facebook group about his discovery of two old references (see pictures).
It seems he loves to poke through really old books!

The first one:

He tells us:

From 1912! Nineteen TWELVE!!

But wait! There's more!
The second one: 

This one is from 1872!!!
He says...

So, it seems that others got there before I did.
And that's OK! It's wonderful!
All the people who don't believe something because it hasn't already existed for hundreds of years can rest easy now. There is indeed somewhere else to place trust without cognitively wandering around, forever trapped in the Dark Forest of Mesodoom.