Paincloud Conference (Oslo)
A brief overview
Enrico Verdini is a Physiotherapist working as Private Practitioner in Rome. Also he is a Master Candidate at the University of Brighton (UK). In this short piece you can read his “stream of consciousness” regarding the key points and the topics discussed at the Paincloud Conference held in Oslo this year.
The Paincloud convention is an international conference based on Pain Science.
This idea was developed by some young professionals who wanted to bridge the gap between pain management and the latest scientific research.
Some of the leading clinicians within the pain science field were gathered together for two consecutive days in Oslo. The warm response and passionate interested received from over a hundred professionals, made the conference a complete success.
In fact, more than 120 healthcare professionals from different countries and background attended it.
The speakers: Sigurd Mikkelsen (NOR), Jason Silvernail (USA), Kjartan Vibe Fersum (NOR), Sandy Hilton (USA), Jørgen Jevne (NOR), Tory Madden (ZAF), Alison Sim (USA), Bronnie Lenox Thompson (NZL).
“The clinical implications of predictive processing” (a super biased account of nearly everything)
Clinical encounter is a fluid interaction. Our “beliefs” colours our perception. Discussion on predictive processing are challenging: beliefs and definition about it are not universal. Are we “manipulating” sensations?
The experience between interoception/exteroception and expectation is interesting. Giving information doesn’t have the impact of experiencing something different (for example, telling patients that they are safe or myth busting in its own is not enough to change internal sensations). It can be interesting to use illusions to provide evidence to patients that sensation can be manipulated (optical illusions to illustrate perception and sensation and to demonstrate how easily senses can get it wrong). If we can manipulate photoreceptors with illusions, we can manipulate mechanoreceptors to modify pain and movement. Visual input may over-ride auditory input, so how can we influence pain experience using these principles clinically?
The brain tries to predict the cause of sensory input. An example of how vision and previous experience manipulates mechanosensations (e.g. hearing) is the MgGurk effect. The brain is always making inferences form prior information, and it normally filters sensory input and it aims to reduce prediction errors. Changing sensory input may facilitate reduced prediction errors which may change perception: in other words, the painful area is prediction error, so, distraction and reduced focus on the area can reduce prediction area and consequently it can reduce discomfort. Violation of expectations are sometimes preferable to confirmations of expectations. Surprises (puzzling) violate expectations and help shaking a convinced brain. It is important to use exercise to violate expectations and transfer it into daily life. The best thing to do for patients with pain is to stand through the storm with them. It is worthwhile not to see body parts, but to see processes mechanism and trajectories.
“Flipping the pain curriculum”
The now-standard approach to pain education, which begins with and empathizes processes at the subcellular scale, poorly prepares trainees to assess and treat pain in everyday clinical practice. When people come in, why do we ask so many questions about the pain, and so few about the person? Helping people is more important than knowing stuff, we are practitioner centered not patient centered. It is really important to build a strong therapeutic alliance.
Three main steps:
-be credible and likable
-build resilience and internal locus of control
-agree on goals and approaches.
If we don’t know anything about our patients helping them becomes difficult. The patient is more important than the pain itself. It’s about creating a story where the patient is the hero, not the clinician.
Two things to achieve in the first visit: the first is to rule out red flags and the second is to develop a good therapeutic alliance. We should not allow the time we have with patients to dictate our strategy.
Kjartan Vibe Fersum
“Cognitive functional therapy”
The musculoskeletal problem is bigger than all of us, collaboration is the key. The first session is about turning all the puzzles the right way, figuring out what the problem is. Recording ourselves during a session can help us learn what we do when we are communicating. Patient goal setting and an important question: if you had no pain, what would you be doing? Good way of finding out what’s meaningful to the person. Are we, as health care professionals, creating more harm than good? It is really important to show care and to be sensible. Patient satisfaction has been shown to be higher in the CFT (Cognitive Function Therapy) group than in the manual therapy group (Fersum et al. 2013). How can we be truthful of the complexity of pain? We need to provide a narrative we are both agreeing on.
Sometimes we don’t have to declare the truth! Graded exposure principles can be applied to faulty beliefs, people who are told they shouldn’t flex spine can became “walking planks”. And if someone is a walking plank why on earth are you going to give him plank exercises? Don’t become a yellow flag for your patient!
“From #sexyscalpel to #sexyrehab – a case for making rehabilitation more exciting and less boring”
Making rehab more exciting than surgery to follow evidence. Exercise therapy is as good as surgery for many common conditions, but this isn’t widely known.
Enjoy exercise. Have fun with it. Practice what you preach. Be flexible. It extremely important to make exercise therapy fun and engaging to improve compliance. Nonspecific conditions (pain) abound and they can be managed with exercise therapy.
“Classical conditioning framework in pain”
Can pain be a classically conditioned response? It is clear that nociception is not sufficient for pain. Some clinicians were already using the idea of uncoupling pain from certain movements. People think pain can be a conditioned response. Findings about clinicians beliefs and classical conditioning in pain: 86% agree that pain can occur without nociception, a follow up question showed that 94% agree that pain can be a classically conditioned response and 91% believe that there is evidence to support that idea (Madden and Moseley 2016 – Manual Therapy). Some experimental data prove the principle that a pairing response occurs for hyperalgesia. Fear, rather than pain, has good evidence for classical conditioning in literature. Fear conditioning may have to do with failure to recognize a safe condition. Can literature on fear be a clue to generalization of pain across movements? Can we teach people to distinguish between cues? Hypothetically research could lead to treatments to reduce generalized pain (but it’s not ready for clinical use).
“Phsycological approaches for chronic pain and how manual and exercise therapist can integrate them into their practice”
We have to integrate psychological literature into clinical practice in the treatment of persistent pain. The triangle of CBT (Cognitive Behavioural Therapy) consists of emotions, thoughts, behaviour. CBT is ideal for pain management as collaborative approach. It identifies unhelpful thoughts/ beliefs and it looks for evidence to support or negate these. Research supports CBT approach for persistent pain but it may not represent our patients or context. CBT is usually delivered in groups, but more intense symptoms may need more intense and individual therapy. Catastrophizing is a reflection of disability, therefore a good measure of functioning. A Cochrane review 2013 on CBT did not show maintenance of results at follow-up. In primary care CBT shows reasonable results and cost effective. Acceptance and Commitment Therapy (ACT) may be harder to learn at first but easier to apply, so if CBT is not always reducing pain, does that matter? Many other variables may improve, i.e. disability and functioning. ACT, as third wave of CBT, focuses on valued behaviour and it may be easier to teach. Many people would reject psychological referral for pain, how can physiotherapists bridge the gap? Refer out when needed and think of communication as an intervention. Therapeutic alliance has strong evidence to change all outcomes positively.
Bronnie Lenox Thompson
“Motivational approaches to enhancing self-management”
Changing is hard and even harder when you’re not convinced it is worth doing. We often enforce our preferences and ideas on patients that is a wrong approach! “When in doubt, shout louder” doesn’t work well. What gets in the way of changing? Self-management is complex! Too much focus on managing the pain forces people to place their pain at the centre of their lives. So we need to change the focus! People only really do what they want to do, what they believe in. They tend to back away from what they don’t believe in. It is worthwhile to evoke answers and reflections from the patient, and not to rush to tell people or to lecture them.