>> GOOD MORNING, EVERYONE. THANKS FOR COMING BACK. I THINK WE HAVE A REALLY EXCITING DAY COMING UP. I WOULD LIKE TO INTRODUCE TO YOU THIS MORNING DR. DAVID WILLIAMS. HE IS A PROFESSOR AT THE UNIVERSITY OF MICHIGAN IN ANESTHESIOLOGY MEDICINE, PSYCHIATRY AND PSYCHOLOGY. HE'S ONE OF OUR MAT INITIATIVES AT THE NIH. HE'S AN NIH-FUNDED INVESTIGATOR, AND ALSO DOES CLINICAL WORK. WE INVITED HIM HERE THIS MORNING AS THE PRESIDENT OF THE AMERICAN PAIN SOCIETY TO REPRESENT THE SOCIETY. EACH YEAR WE ASK THE APS TO SEND A REPRESENTATIVE TO GIVE US AN UPDATE, THEY SOMETIMES TALK ABOUT CONCERNS THAT THEY HAVE WITH NIH, THEY SOMETIMES TALK ABOUT COLLABORATIONS THAT WE HAVE WITH NIH, BUT IT'S BEEN A REALLY NICE COLLABORATION WITH THE AMERICAN PAIN SOCIETY, SO WE REALLY APPRECIATE HAVING DAVE HERE THIS MORNING. DAVE? >> THANK YOU AND GOOD MORNING. AT YESTERDAY'S SESSION, THERE WERE A NUMBER OF SPEAKERS WHO MADE REFERENCE TO THE AMERICAN PAIN SOCIETY. AND SO THIS MORNING WHAT I'D LIKE TO DO, FOR THOSE WHO ARE MEMBER, IS PROVIDE YOU WITH AN UPDATE OF WHAT THE SOCIETY HAS BEEN DOING THE PAST YEAR. AND FOR THOSE OF YOU WHO ARE NOT YET MEMBERS, I'D LIKE TO PROVIDE AN OVERVIEW OF HOW THE AMERICAN PAIN SOCIETY SUPPORTS PEOPLE WHO HAVE AN INTEREST IN THE SCIENCE OF PAIN. TO REMIND YOU OF THE MISSION, THE AMERICAN PAIN SOCIETY IS A MULTIDISCIPLINARY COMMUNITY THAT BRINGS TOGETHER A DIVERSE GROUP OF SCIENTISTS, CLINICIANS AND OTHER PROFESSIONALS TO INCREASE THE KNOWLEDGE OF PAIN AND TRANSFORM PUBLIC POLICY AND CLINICAL PRACTICE TO REDUCE PAIN-RELATED SUFFERING. IN THIS MISSION, I WOULD LIKE TO DRAW YOUR ATTENTION TO THE WORD MULTIDISCIPLINARY. THE AMERICAN PAIN SOCIETY TRULY IS A MULTIDISCIPLINARY SOCIETY. WE DO HAVE CLINICIANS, A NUMBER OF PSYCHOLOGISTS, SOCIAL WORKERS, PHYSICAL THERAPISTS, OCCUPATIONAL THERAPISTS, BUT WE ALSO HAVE A VERY LARGE SEGMENT OF OUR SOCIETY THAT ARE FROM BASIC SCIENCES AND FROM NEUROSCIENCES. WE ALSO HAVE A NUMBER OF EPIDEMIOLOGISTS, PEOPLE INVOLVED IN PUBLIC POLICY, WE HAVE JOURNALISTS, ATTORNEYS, ANTHROPOLOGISTS WHO ARE PART OF THE SOCIETY. SO IT TRULY IS BRINGING TOGETHER A NUMBER OF PROFESSIONALS WHO ARE INTERESTED IN THE SCIENCE OF PAIN. IN FACT, THE APS IS REALLY THE ONLY PROFESSIONAL SOCIETY WHOSE PRIMARY GOAL IS THE PROMOTION OF PAIN SCIENCE IN THE COUNTRY. THIS IS HOW APS IS STRUCTURED. THERE ARE FOUR PILLARS: RESEARCH, EDUCATION, TREATMENT AND ADVOCACY. IN OUR EDUCATION PILLAR, WHICH IS HEADED UP RIGHT NOW BY GARY WALCO AND BARB RAEKEL, WHO PRESENTED HERE YESTERDAY, THE FOCUS RELATES TO THE DISSEMINATION OF SCIENTIFICALLY BASED INFORMATION, AND JUST TWO WEEKS AGO, THE MESH PAIN SOCIETY HELD ITS ANNUAL SCIENTIFIC MEETING IN PITTSBURGH. MICHAEL GOLD WAS OUR PROGRAM CHAIR. THE MEETING WAS A VERY SUCCESSFUL MEETING, BUT IN ADDITION TO HOLDING THE SCIENTIFIC MEETING WHERE THERE WERE SIM POSE YA, POSTERS, WE POSE IN SPRI NG PAIN, THERE WERE FOUR PRESENTATIONS OF ORIGINAL NOT YET PUBLISHED RESEARCH BEING CONDUCTED IN THE BASIC CLINICAL SCIENCES. THIS IS VERY EXCITING, IT HAPPENS EVERY COUPLE OF YEARS, OPPORTUNITIES FOR SCIENTISTS TO PRESENT THEIR FINDINGS BEFORE THEY GO TO PRESS. THE AMERICAN PAIN SOCIETY ALSO HELD A PRECONFERENCE ON ANALGESIC TRIALS IN TERMS OF METHODOLOGIES, LATEST ADVANCES IN CONDUCTING CLINICAL TRIALS. FOR 16 YEARS, WE'VE BEEN PUTTING ON THE FUNDAMENTALS OF PAIN. THIS IS FOR PEOPLE WHO MAY BE NEW TO THE FIELD OR PEOPLE WHO WANT TO KIND OF GET THE BASICS OF WHAT WE KNOW ABOUT PAIN MECHANISM, PAIN PRACTICE, AND AGAIN WE HELD THAT THIS YEAR AND IT WAS VERY SUCCESSFUL. IN PARALLEL TO OUR ANNUAL SCIENTIFIC MEETING, THE AMERICAN PAIN SOCIETY ALSO CO-SPONSORED WITH THE AMERICAN CHRONIC PAIN ASSOCIATION A PATIENT CONFERENCE AND WE WERE ABLE TO SHARE FACULTY BETWEEN THE APS MEETING AND THIS PATIENT CONFERENCE OR CONFERENCE FOR INDIVIDUALS WITH PAIN. EVERY YEAR WE ALSO PROMOTE THE EARLY EARLY CAREER SCIENTIST PROGRAMS. THE EARLY CAREER FORUM ALLOWS AN EVENT WHERE PEOPLE EARLY IN THEIR CAREER CAN MEET UP WITH FACULTY MEMBERS WHO ARE MORE SENIOR AND SHARE INFORMATION ABOUT HOW TO BREAK IN TO THE FIELD OF SCIENCE. WE HOLD MOCK STUDY SESSIONS, NIH GRANT WORKSHOPS AS WELL AS A SOUNDING BOARD, WHICH IS AN OPPORTUNITY FOR YOUNG FOLKS TO -- OR PEOPLE NEW TO THE FIELD TO SHARE THEIR IDEAS WITH MORE SENIOR FOLKS AND GET AN IDEA OF HOW MAYBE TO IMPLEMENT. OF COURSE YOU'RE PROBABLY FAMILIAR WITH THE JOURNAL "PAIN," WHICH HAS BEEN A PART OF OUR SOCIETY FOR MANY YEARS. MARK JENSEN IS OUR EDITOR. IN OUR TREATMENT DOMAIN, THAT'S HEADED UP BY MARK WALLACE. WE HAVE PUBLISHED A NUMBER OF CLINICAL PRACTICE GUIDELINES. IN 2016, THE MANAGEMENT OF POSTOPERATIVE PAIN GUIDELINE WAS PUBLISHED. OF COURSE IN THE TREATMENT AREA, WE'RE INTERESTED IN THE NATIONAL PAIN STRATEGY. MANY OF THE MEMBERS OF APS PARTICIPATED IN THE CONSTRUCTION OF THE NATIONAL PAIN STRATEGY AND CERTAINLY DOES REFLECT OUR BELIEF ABOUT HOW PAIN SHOULD BE MANAGED CLINICALLY. NOT EVERYBODY HAS THE ADVANTAGE OF BEING ABLE TO WORK IN A LARGE SYSTEM SUCH AS THE V.A. OR IN LARGE TERTIARY CARE CENTERS. APS NOW, IN ADDITION TO OUR ANNUAL SCIENTIFIC MEETING, WE HAVE THE PAIN CARE FOR PRIMARY CARE PROGRAM, WHERE WE BRING THE EVIDENCE-BASED SCIENCE OF PAIN TO CLINICIANS WHO ARE OUT IN THE FIELD, AND MANY TIMES THESE ARE INDIVIDUALS IN SOLO PRACTICES OR VERY SMALL REGIONAL NETWORK PRACTICES. IN OUR RESEARCH PILLAR, THIS IS HEADED UP BY TED PRICE AND ROB EDWARDS. MUCH OF OUR RESEARCH PILLAR HAS BEEN DEVOTED TO GRANT SUPPORT FOR YOUNG INVESTIGATORS, PEOPLE GETTING THEIR PROJECTS STARTED IN THE FIELD. THE FIRST IS THE FUTURE LEADERS IN PAIN. SINCE 2005, WE'VE HAD 43 RECIPIENTS OF THE FUTURE LEADERS AND PAIN GRANTS, AND I THINK WE CHOSE WELL. THESE 43 INDIVIDUALS HAVE NOW PUBLISHED 897 ARTICLES AND BEEN THE RECIPIENT OF 82 GRANT AWARDS TOTALING $58 MILLION. THE NEXT CALL FOR APPLICATIONS FOR THE 2017 FUTURE LEADERS IN PAIN RESEARCH GRANT PROGRAM OPENS JUNE 12TH OF THIS YEAR. THE 2016 FUTURE LEADER AND PAIN RECIPIENT WAS ANNA TAYLOR FROM THE UNIVERSITY OF CALIFORNIA LOS ANGELES, AND MELANIE NOEL FROM THE UNIVERSITY OF CALGARY. THE APS WISHES TO ACKNOWLEDGE THE MAY DAY FUND FOR SUPPORTING THE FUTURE LEADERS AND GRANTS RESEARCH PROGRAM. THE MAYDAY FUND PROVIDES $25,000 IN FUNDING FOR GRANTS FOR THE 2016, 2017 AND 2018 YEARS. WE ALSO WANT TO ACKNOWLEDGE THE RITA ALLEN FOUNDATION FOR SUPPORTING THE FUTURE LEADERS AND GRANTS PROGRAM. THE RITA ALLEN FOUNDATION IS SUPPORTING FUTURE LEADERS IN PAIN RESEARCH GRANT IN HONOR OF DR. KATHLEEN FOLEY FOR 2016 AND 2017. THE RITA ALLEN FOUNDATION ALSO HAS AWARDS IN WTION PAIN "SINCE 2009, WEE PARTNERED WITH THEM, FUNDING TWO AWARDS, $50,000 GRANTS ANNUALLY FOR A PERIOD OF UP TO THREE YEARS. APPLICATION FOR THE 2018 FUNDING CYCLE OPEN IN SEPTEMBER. THE 2017 RITA ALLEN FOUNDATION AWARD RECIPIENTS WERE ARKDADY KHOUTORSKY AND KYLE BAUMBAUER. WE ALSO WANT TO ACKNOWLEDGE SUPPORT FROM NIH FROM THE NATIONAL CENTER OF COMPLEMENTARY AND INTEGRATIVE HEALTH, THE NATIONAL CANCER INSTITUTE AND THE NATIONAL INSTITUTE ON DRUG ABUSE FOR SUPPORTING 60 TRAINEES IN PRESENTING THEIR RESEARCH DURING DESIGNATED POSTER SESSIONS AT THE ANNUAL SCIENTIFIC MEETING. AMERICAN PAIN SOCIETY ALSO HAS A PAIN RESEARCH FUND. THIS IS SOMETHING YOU ALL CAN CONTRIBUTE TO IF YOU'D LIKE. AGAIN THIS IS A FUND THAT DOES GO TOWARD THE SUPPORT OF RESEARCH IN PAIN, TYPICALLY GIVEN TO A YOUNG INVESTIGATOR. THIS PAST YEAR, THE APS PARTNERED WITH PFIZER INDEPENDENT GRANTS FOR LEARNING AND CHANGE. THIS IS REALLY THE FIRST GRANT PROGRAM DEDICATED TO SUPPORTING THE TENETS OF THE NATIONAL PAIN STRATEGY. PFIZER PROVIDED $2 MILLION IN ORDER TO SUPPORT GRANTS THAT WERE ACKNOWLEDGING AND SUPPORTING THE TENETS OF THE NATIONAL PAIN STRATEGY. WE RECEIVED OVER 100 LETTERS OF INTENT. WE FORMED A STUDY SECTION, AND WE WERE ABLE TO MAKE THREE AWARDS WHICH WERE ANNOUNCED IN MAY OF 2017. THE AWARDING INSTITUTIONS WERE WEILL CORNEL MEDICINE, SEATTLE CHILDREN'S AND THE UNIVERSITY OF IOWA. IT'S IMPORTANT TO NOTE THAT ALL OF THESE THREE AWARDS WERE FOR THE IMPLEMENTATION OF NON-PHARMACOLOGICAL APPROACHES TO THE MANAGEMENT OF PAIN, AND REALLY ACROSS THE LIFESPAN FROM PEDIATRICS TO ADULTS AND THEN INTO GERIATRICS. THE OTHER PILLAR IS THE ADVOCACY PILLAR. THIS IS HEADED BY ED MICHNA AND ROB COGHILL. THE ADVOCACY DOMAIN IS LARGELY FOCUSED RIGHT NOW ON IMPLEMENTING THE NATIONAL PAIN STRATEGY, AND SOON THE FEDERAL PAIN RESEARCH STRATEGY. I WANT TO ALSO ACKNOWLEDGE CLAUDIA CAMPBELL AND BARB ST MARIE WHO WAS HERE YESTERDAY AND MAYBE TODAY. THESE ARE THE INDIVIDUALS WHO ARE IN CHARGE OF MEMBERSHIP, AND WE ALSO HAVE PAT DOUGHERTY AND JENNIFER HAYTHORNTHWAITE, THE TREASURER. NEXT YEAR IN ANAHEIM, THE THEME WILL BE UNDERSTANDING PAIN MECHANISMS AND TONYA PALERMO WILL BE THE SCIENTIFIC PROGRAM CHAIR FOR THAT MEETING. SO I WANT TO THANK YOU VERY MUCH FOR LISTENING, AND LEARNING ABOUT HOW THE AMERICAN PAIN SOCIETY IS REALLY A SOCIETY ALL ABOUT SUPPORTING INDIVIDUALS WHO ARE INTERESTED IN THE SCIENCE OF PAIN. THANK YOU VERY MUCH. [APPLAUSE] >> NEXT I'D LIKE TO INTRODUCE CINDY STEINBERG. CINDY STEINBERG IS AN ADVOCATE FOR PEOPLE WITH PAIN. SHE CONTINUALLY ACCEPTS ALL OF OUR REQUESTS TO HELP US OUT HERE WITH WORKSHOPS. SHE NOW SERVES IN THE INTERAGENCY PAIN RESEARCH COORDINATING COMMITTEE. SHE'S JUST BEEN AN AMAZING HELP TO US, AND SHE'S GOING TO TALK TODAY ABOUT HER PERSPECTIVE AS A PERSON WITH PAIN ON RESEARCH, AND I BELIEVE PROBABLY TELL A LITTLE BIT OF HER STORY OF WHAT IT'S LIKE TO LIVE WITH PAIN. BUT WE REALLY APPRECIATE ALL OF CINDY'S DEDICATION AND ENTHUSIASM TO THE EFFORT. CINDY. >> THANKS, LINDA. CAN YOU HEAR ME? OKAY. SO I'M GOING TO GIVE YOU A LITTLE GUIDE THROUGH MY TALK, I'M GOING TO TAKE A FEW TURNS TODAY THAT I DIDN'T EXPECT TO DO BUT I THINK IT WILL INTEGRATE ULTIMATELY. SO THEY ASKED ME TO TELL A LITTLE ABOUT MY STORY AND THEN I'M GOING TO TALK ABOUT MOST OF MY WORK WHICH IS IN PAIN POLICY AS A CHANGE AGENT IN AN ENTRENCHED SYSTEM. WE HEARD TODD TALK ABOUT THAT YESTERDAY. SO I'M PASSIONATE ABOUT THAT. THEN I'M GOING TO TALK A LITTLE BIT ABOUT MY VIEW AND A PATIENT'S VIEW OF YESTERDAY'S THEME, AND TODAY'S THEME, THE MULTIDISCIPLINARY STRATEGIES FOR PAIN MANAGEMENT, AND THEN SINCE I'M TALKING TO A RESEARCH AUDIENCE, I'M GOING TO PUT A FEW OF MY RESEARCH WISHES OUT ON THE TABLE, AND THEN SOME THANK YOUS. IS MORE THAN 15 YEARS AGO, WAYS A CORPORATE MANAGER IN A TECH COMPANY IN HARVARD SQUARE, I WENT OUT TO OPEN A DRAWER AND UNBEKNOWNSTED TO ME, THERE WERE STACKED CUBICLE WALLS BEHIND IT AND I COULDN'T SEE THEM. I OPENED THE DRAWER AND ALL OF A SUDDEN THE CABINETS STARTED COMING AT ME, ONE OF THOSE GREAT BIG LATERAL METAL FILE CABINETS. I WASN'T QUICK ENOUGH, I TURNED THEN BUT THE DRAWER STRUCK ME IN THE MIDDLE OF MY BACK AND KNOCKED ME OVER AND I WAS CRUSHED UNDERNEATH ABOUT 10 KEUP KEL WALLS OF THIS FILE CABINET. THAT CAUSED EXTENSIVE DAMAGE TO MY BACK, IT TORE LIGAMENTS AND NERVES, AND LEFT ME WITH THIS BAND OF GNAWING PAIN, BURNING PAIN EXACTLY WHERE THE DRAW STRUCK MY BACK IN MY THORACIC BACK, AND THEN MUSCLE SPASMS AS WELL. I HAVE HAD PAIN EVERY DAY OF MY LIFE SINCE THAT ACCIDENT. IT JUST NEVER WENT AWAY. SOMETIMES THE PAIN AND SPACHS CAN SPASMS CAN BE REALLY INTENSE. LITERALLY IF I'M UP RIGHT MORE THAN ABOUT AN HOUR AT A TIME, I CAN GO INTO A REALLY BAD SPASMS. SO I STARTED TO SEEK HELP WHILE HAVING A BUSY JOB. I MANAGED ABOUT 40 PEOPLE AND TRAVELED FREQUENTLY, HAD A BABY AT HOME AND I HAD A PRETTY FULL LIFE, AND HERE I WAS STRUGGLING WITH THIS EXCRUCIATING PAIN. SURGERY WASN'T AN OPTION, SO I WENT ON THE ROUTE THAT MOST PEOPLE WITH PAIN GO ON NOW. SO I WENT TO PAIN CLINICS AND I GOT A LOT OF INJECTIONS, AND NERVE BLOCKS AND UNFORTUNATELY THOSE DIDN'T HELP. I TRIED PT, OT, SOMETHING CALLED PROLOTHERAPY TO TRY TO RE-GROW LIGAMENT TISSUE WHICH IS PAINFUL, YOU HAVE LIKE 12 NEEDLES IN YOUR BACK EVERY FEW MONTHS, ALTERNATIVE CARE LIKE ACUPUNCTURE, MASSAGE, I TRIED ALMOST EVERYTHING. AT BEST, HEALTHCARE PROVIDERS TOLD ME WE CAN'T HEMIF HELP YOU, AND AT WORST, I QAS TREATED IN A DEMEANING, DI MI SIEVE MANNER LIKE ARE YOU REALLY SURE YOU HAVE THIS PAIN? I WORKED LIKE 80 HOURS A WEEK IN STARTUP, THE DAY I WENT INTO LABOR -- I DON'T THINK I TOOK A SICK DAY IN 20 YEARS AND HERE I WAS BEING ACCUSED OF MAKING THIS UP. IT WAS REALLY A FIVE-YEAR JOURNEY UNTIL I FOUND A DOCTOR WHO REALLY HELPED ME. I CALL IT THE ROLLER COASTER OF CHRONIC PAIN TREATMENT. YOU'RE ON THIS TORTUOUS ROUTE OF TRIAL AND ERROR, YOU PUT ALL YOUR HOPES INTO THE NEXT TREATMENT, SURELY THE NEXT THING IS GOING TO HELP ME. YOU GIVE IT YOUR ALL, YOU TRY IT FOR MONTHS, AND THEN YOUR HOPES ARE DASHED WHEN IT DOESN'T HELP YOU. YOU TRY TO STAY HOPEFUL, BUT IT'S REALLY TOUGH. AFTER A FEW YEARS OF THIS, I STARTED ENVISIONING EVERY HEALTHCARE PROVIDER'S OFFICE THAT I WENT INTO AS THEM BEING BLINDFOLDED AIMING AT A TARGET WHICH THEY COULDN'T SEE, AND JUST SHOOTING ARROWS AT IT AND HOPING THEY WOULD HIT. SO THERE WERE A LOT OF MISSES AND OCCASIONALLY SOMETHING MIGHT HELP A BIT, BUT IT WAS -- IT WAS A REALLY BIZARRE EXPERIENCE, I JUST COULDN'T BELIEVE THAT THIS PAIN COULDN'T BE TAKEN AWAY AT SOME POINT. SO I FELT REALLY ISOLATED. I THOUGH I COULDN'T BE THE ONLY ONE LIVING LIKE THIS, BUT I DIDN'T KNOW THERE WERE OTHER PEOPLE LIVING IN PAPER. I HUNG A SIGN AT PAIN. I HUPG A SIGN AT A LOCAL LIBRARY SAYING I WAS GOING TO START A SUPPORT GROUP AND PEOPLE STARTED SHOWING UP. THE FIRST MONTH, THERE WAS A WOMAN WITH DISK DISEASE AND A YOUNG ENGINEER THAT HAD THORACIC OUTLET SYNDROME AND THEN THEY CAME BACK THE NEXT MONTH, AND A FELLOW CAME IN WITH MIGRAINES EVERY DAY AS A RESULT OF CHEMOTHERAPY. HIS LEUKEMIA WAS CURED BUT HE WAS LEFT WITH TERRIBLE MIGRAINES. AND ON AND ON. RHEUMATOID ARTHRITIS, DISK DISEASE, NEUROPATHY, CONDITIONS I NEVER HEARD OF LIKE EDS, CRPS, MARFAN'S, PUDENDAL NEURALGIA, FIBROMYALGIA, TMJ, VUVADYNIA, IBS, PEOPLE WITH ALL KINDS OF CONDITIONS. THAT WAS 17 YEARS AGO AND I'M THAN 350 PEOPLE HAVE COME TO THIS LITTLE GROUP IN A SUBURB OF BOSTON. I DON'T DO PUBLICITY FOR THIS, PEOPLE HEAR BY WORD OF MOUTH, BUT I'M STILL DOING THE GROUP. I SAY PAIN DOESN'T DISCRIMINATE. PEOPLE FROM TEENAGERS TO 90-YEAR-OLDS, MEN, WOMEN, DIFFERENT SOCIOECONOMIC BACKGROUNDS, DIFFERENT RACES. AMAZING HOW MANY PEOPLE ARE AFFECTED BY PAIN. SO THE GROUP REALLY PROVIDES LONG TERM SUPPORT. WE HEARD THAT YESTERDAY FROM DENNIS ABOUT HOW HE THOUGHT IT WAS REALLY IMPORTANT TO PROVIDE THIS FOR PEOPLE LIVING WITH A CHRONIC CONDITION. EDUCATION AND STRONG SOCIAL CONNECTION, MEETING OTHER PEOPLE THAT LIVE LIKE YOU DO. PEOPLE OFTEN CRY THE FIRST TIME THEY COME TO THE GROUP, THEY SOMETIMES BRING THEIR FAMILY MEMBERS BECAUSE THEY'RE SHY, BUT IT'S GREAT FOR THEM TO HEAR ABOUT IT. WE TEACH SKILLS, COPING SKILLS, HOW TO COMMUNICATE WITH THE HEALTHCARE PROVIDER, BEING ASSERTIVE, AND LOTS OF OTHER THINGS TRACKING YOUR PAIN WHICH IS SO IMPORTANT. WE EXPOSE MEMBERS TO EVERY POSSIBLE TREATMENT AND THERAPY, I HAVE GUEST SPEAKERS AND DO PROGRAMMING REALLY ALL YEAR-ROUND. WE TAKE SOME PRACTICAL TIPS FOR LIVING WITH PAIN, HAVE HOW DO YOU TRAVEL, HOW DO YOU NEGOTIATE FAMILY EVENTS AND OTHER THINGS AND DISCUSS A LOT OF THE PSYCHOSOCIAL UNDERPINNINGS GOING THROUGH THE STAGES OF GRIEF AND PAIN IN THE FAMILY, PAIN IN RELATIONSHIPS, PAIN IN SELF-ESTEEM. THERE'S NO END TO TOPICS YOU COULD TALK ABOUT THAT WOULD HELP PEOPLE. SO WHAT I CAME TO SEE; REGARDLESS OF THE ETIOLOGY OF THE PAIN, PAIN BECOMES THE DISEASE. AND PEOPLE'S EXPERIENCE OF IT, EVEN THOUGH I TOLD YOU ABOUT ALL THE DIFFERENT CONDITIONS PEOPLE HAVE, IS STRANGELY SIMILAR, RIGHT? WE ALL KNOW THAT IT'S A DISEASE, THAT IT AFFECTS THE NERVOUS SYSTEM AND THE SPINAL CORD, I DON'T HAVE TO TELL PEOPLE HERE THAT. EVERYONE IN MY GROUP, ALMOST EVERYONE, HAS HAD TO SEE AT LEAST FOUR OR FIVE PRAK TITION PRACTITIONE RS BEFORE THEY FIND ANY HELP. MEANWHILE, YOU LISTEN TO THEIR STORIES AND PAIN DEVASTATES LIVES, IT DESTROYS YOUR ABILITY TO WORK, TO EARN A LIVING, YOUR SELF-ESTEEM, WE HEARD ABOUT SLEEP DISTURBANCE, WE HEARD ABOUT DEPRESSION. YOUR ABILITY TO SOCIALIZE, TO PURSUE INTEREST, TO FIND ENJOYMENT IN LIFE. I OFTEN GIVE THE EXAMPLE OF A SERIOUS ILLNESS, LIKE CANCER, WHERE YOUR DISEASE CAN BE PUT INTO REMISSION AND PEOPLE CAN GO ON AND HAVE PRETTY MUCH A NORMAL LIFE IN MANY CASES. WITH PAIN, THAT DOESN'T HAPPEN. YOUR PREVIOUS LIFE IS OVER, AND YOU NEED TO START A NEW LIFE BECAUSE WE HAVE NO CURE FOR THIS THIS. PEOPLE'SFUNDAMENTAL EXPERIENCE, YOU HEAR DESCRIPTIONS THAT ARE SIMILAR, STABBING, GNAWING, BURNING, KNIFING, CRUSHING PRESSURE. YOU GET THE SENSE WHEN I'M IN MY EXTREME PAIN MOMENTS THAT YOU ARE A PRISONER IN YOUR OWN BODY. YOU CAN'T ESCAPE. YOU'RE IN YOUR BODY 24/7. AND YOU KNOW, IT'S WORSE THAN THAT BECAUSE YOU'RE A PRISONER WHO'S BEING TORTURED ALL OF THE TIME. I OFTEN SAY, WE DEBATE THE MORALITY OF TORTURING ONE PRISONER, WHICH AS WE SHOULD, BUT WHAT ARE WE DOING ABOUT ALL THE PEOPLE LIVING WITH PAIN? SO I STARTED TO WONDER, WHAT ARE THE ROOT CAUSES OF THIS, AFTER SEEING PERSON AFTER PERSON AFTER PERSON COME TO MY GROUP. WE KNOW ABOUT THE UNDERINVESTMENT IN RESEARCH RELATIVE TO THE BURDEN, RIGHT? YOU'VE HEARD THIS BEFORE, IT'S THE NUMBER ONE REASON WHY PEOPLE GO TO THE DOCTOR, PAIN IS THE LEADING CAUSE OF DISABILITY IN THE WORLD, AND YET THERE'S A SMALL INVESTMENT AT NIH RELATIVE TO THE BURDEN. WE STILL DON'T UNDERSTAND THE BASIC MECHANISM OF PAIN IN THE PO DE, WE KNOW IT'S A NEUROBIOLOGICAL DISEASE, A NEUROPHYSIOLOGICAL DISEASE, BUT WE'VE YET TO FULLY UNLOCK ITS MECHANISM. LACK OF TRAINED PHYSICIANS, SO LESS THAN 1% OF DOCTORS ARE SPECIALIZED IN PAIN MEDICINE. VERY LITTLE TIME SPENT EDUCATING DOCTORS AND OTHER HEALTHCARE PROVIDERS. YOU PROBABLY HEARD THE STATISTIC ABOUT 9 HOURS OF PAIN MANAGEMENT EDUCATION IN FOUR YEARS OF MED SCHOOL, 87 HOURS FOR VED NAIRIANS. OUR DOGS GET BETTER PAIN CARE THAN PEOPLE SOMETIMES. THE DEARTH OF EFFECTIVE TREATMENT OPTIONS, THERE'S REALLY NO CURE. YOU HAVE TO FIND THINGS THAT ARE GOING TO HELP YOU. THIS IS ONE BIG ONE FOR ME, THE LACK OF EPIDEMIOLOGICAL DATA ON PAIN. WE DON'T COLLECT REGULAR STATISTICS ON PAIN, LONGITUDINALLY HOW ARE WE GOING TO KNOW WHETHER WE'RE DOING BETTER OR NOT, WE DON'T KNOW TRENDS, WE DON'T KNOW ABOUT VARIOUS SYNDROMES AND HOW THEY AFFECT PEOPLE, WE DON'T KNOW ABOUT THE ECONOMIC BURDEN. WE DON'T HAVE PRECISE NUMBERS AND I REALLY FEEL THAT'S REALLY HAMPERING OUR PROGRESS. LACK OF PUBLIC AWARENESS ABOUT THE SCOPE AND THE SEVERITY AND THE IMPACT. WE TALK ABOUT IT BEING A HIDDEN EPIDEMIC, PEOPLE DON'T REALLY KNOW ABOUT ALL THESE PEOPLE THAT ARE ISOLATED LIVING AT HOME IN PAIN. AND STIGMA AND MISINFORMATION IS ALL OVER THE MEDIA. NOW WE'VE SORT OF AS WE SAY SWUNG THE PENDULUM THE OTHER WAY AND THERE'S EXTREME ACCESS RESTRICTIONS REGARDING OPIOIDS. OPIOIDS ARE CERTAINLY NOT FOR EVERYONE, BUT THEY CAN BE A LIFE LINE FOR SOME PAIN SUFFERERS, AND THE VAST MAJORITY OF PEOPLE WITH PAIN, AGAIN AS WE HEARD FROM PEGGY YESTERDAY, ARE LEGITIMATE PATIENTS THAT JUST WANT PAIN RELIEF. THEY'RE OFTEN NOW TREATED AS DRUG ABUSERS AND MARGINALIZED, PEOPLE AREN'T BEING BELIEVED, SOME PEOPLE ARE BEING DROPPED FROM CARE AND WE HEAR FROM THEM ALL THE TIME, WHICH IS REALLY UPSETTING. AND THEN THERE'S THE INSURER PRACTICES NOW WITH COSTS OF HEALTHCARE TRYING TO LIMIT TREATMENT, AND PHARMACY BENEFIT MANAGEMENT PRACTICES THAT CAUSE STEP THERAPY, MAKE IT DIFFICULT TO GET OTHER PHARMACOLOGICAL TREATMENTS OR NOT EVEN ALTERNATIVE TREATMENTS THAT WE KNOW ARE NOT COVERED. SO I'M A BIG FAN OF GREAT ADVOCACY LEADERS, "YOU MUST BE THE CHANGE YOU WISH TO SEE IN THE WORLD." I HAVE A STRONG BELIEF IF YOU DON'T LIKE SOMETHING, WORK TO CHANGE IT. AND AFTER MY OWN EXPERIENCE SEARCHING FOR HELP AND THOSE OF LISTENING TO MY PAIN GROUP MEMBERS' STORY, I DECIDED I'M GOING TO DEVOTE THE REST OF MY WORKING LIFE TO IMPROVING PAIN CARE IN THIS COUNTRY. AND I REALIZE THAT I REALLY NEEDED TO DO THAT ON A DIFFERENT LEVEL. I WAS HELPING PEOPLE AND STILL AM THAT ARE LIVING WITH PAIN EVERY DAY, WE DO A LOT OF WORK IN THE U.S. PAIN FOUNDATION ALL OVER THE COUNTRY, BUT I FELT LIKE I COULD AFFECT MANY MORE THINGS IF I WORKED AT THE POLICY LEVEL. SO POLICY HAS REALLY BEEN MY PASSION, AND I JUST FEEL IT HAS THE ABILITY TO CHANGE SO MANY MORE LIVES. SO I'M GOING TO TAKE A LITTLE DETOUR AND TELL YOU A COUPLE OF THINGS THAT I'VE WORKED ON BECAUSE OF PEOPLE YESTERDAY ALLUDING TO THE IMPORTANCE OF THIS. I CAN'T SAY ENOUGH ABOUT HOW IMPORTANT IT IS FOR PEOPLE TO, AS PRESIDENT OBAMA SAID, GET IN THE ARENA. DEMOCRACY IS NOT A SPECTATOR SPORT, RIGHT? SO I KNEW NOTHING ABOUT POLICY, AND I HEARD A LITTLE BIT ABOUT, WELL, THERE'S SOME THINGS THAT ARE GOING ON AT THE STATEHOUSE THAT MIGHT AFFECT PEOPLE WITH PAIN. AND YOU WENT TO THE STATEHOUSE AND START THE LOOKING AT BILLS AND THOUGHT, OH, MY GOD, THESE LAWMAKERS ARE WRITING THESE BILLS AND THEY DON'T KNOW ANYTHING ABOUT PAIN OR ABOUT THESE HEALTH CONDITIONS. AND NO ONE IS HERE WATCHING THEM. SO I STARTED GETTING SMART ABOUT IT AND I GOT INVOLVED IN AN ORGANIZATION CALLED THE MASSACHUSETTS PAIN INITIATIVE. PART OF THE PAIN INITIATIVES, MANY OF THEM DON'T EXIST ANYMORE, BUT MASS P.I. DOES, IT'S AN ALL VOLUNTEER ORGANIZATION, AND I WAS ASKED TO TAKE OVER THE COUNCIL, I DIDN'T KNOW MUCH ABOUT IT BUT I DECIDED I'M GOING TO JUMP IN AND DO IT. SO ONE OF THE FIRST THINGS I WORKED ON WAS GETTING PAIN ADVISORY RULINGS THROUGH ALL THE ADVISORY BOARDS. BASICALLY WORKING, I GOT THE NURSING, PHARMACY, DENTAL AND PHYSICIANS TO ALL ADOPT POLICY RULINGS ALL TOGETHER ON THE SAME DAY. IT WAS A REAL REMARKABLE THING FOR DPH. AND THEN WORKED ON WITH A LAWMAKER IN 2009, BECAUSE I WAS CONCERNED ABOUT THE FACT THAT THERE WASN'T MUCH TRAINING IN PAIN, TO REQUIRE RECURRING PAIN MANAGEMENT EDUCATION OF PHYSICIANS. WE WERE ONE OF THE FIRST TO DO THIS KIND OF THING IN CALIFORNIA, ALREADY HAD LIKE A 12-HOUR FIRST TIME THAT I FELT LINING THIS HAS GOT TO BE RECURRING, I WORKED WITH A LAWMAKER WHO FELT AS STRONG AS I ABOUT THIS, I SAID THEY SAID WHAT CAN WE DO AND I SAID TIE IT TO THEIR MEDICAL LICENSE. SO THE MASS MEDICAL SOCIETY FOUGHT ME ON IT BUT I WAS NOT GOING TO BE STOPPED. IT'S LAW NOW, THAT WAS PASSED IN 2009. IN MASSACHUSETTS IT STARTED AS A PAIN -- NOW THEY WORK ON OPIOID PRESCRIBING AND ALL THE OTHER ASPECTS OF THE OPIOID ISSUE. SO THAT'S BEEN ADDED ON. BUT WE GOT THAT DONE. I DRAFTED A BILL THAT I'M INTRODUCING IN EVERY SESSION NOW REQUIRING PAIN ASSESSMENT AND MANAGEMENT IN ALL HEALTHCARE FACILITIES IN MASSACHUSETTS. I'M NOT GOING TO STOP UNTIL IT GETS PASSED. I WORKED WITH PAUL WHO WAS WORKING ON A STEP THERAPY BILL IN CONNECTICUT AND WE GOT THAT DONE IN CONNECTICUT, NOW ABOUT 20 STATES HAVE REQUIREMENTS USING SOME OF THAT LANGUAGE ACTUALLY FROM THAT ORIGINAL BILL TO NOT BE ALLOWED TO LIMIT THE PROCESS AND HAVE OVERRIDES FOR STEP THERAPY FIRST. I DON'T KNOW IF PEOPLE ARE FAMILIAR WITH MASSACHUSETTS, WE TYPICALLY ARE A LEADER IN THESE THINGS, BUT GOVERNOR BAKER HAD INTRODUCE ADD BILL LAST YEAR TO REQUIRE A THREE-DAY LIMIT ON YOUR FIRST INITIAL SCRIPT FOR OPIOIDS, AND THERE'S 25,000 PEOPLE A YEAR IN MASSACHUSETTS THAT GET SHOULDER REPLACEMENT SURGERY SO LET ME UNDERSTAND THIS. AFTER THREE DAYS OF MAJOR ORTHOPEDIC SURGERY, YOU'RE GOING TO DRAG YOURSELF IN TO THE PHYSICIAN TO GET A SCRIPT? HOW DO PEOPLE DO THAT? SO I WAS VERY ACTIVE IN SPEAKING AT THE HEARING, GETTING LOTS OF PEOPLE INVOLVED, AND ENDED UP DRAFTING AN EXCEPTION FOR CHRONIC PAIN, CANCER PAIN AND PALLIATIVE CARE AT THE PEOPLE AT DANA FARBER CANCER TO WORK WITH ME AT MASS MEDICAL SOCIETY, I FORMED A COALITION AND WE ACTUALLY GOT THAT LANGUAGE IN THE BILL. IT WAS TOUGH, IT WENT IN AND OUT, BUT IN THE END WE GOT THAT LANGUAGE THERE, AND NOW I'M READING BILLS IN OTHER STATES, THEY'RE USING THE EXACT SAME LANGUAGE IN THREE OTHER STATES RIGHT NOW. SO I'M GLAD WE WERE THE FIRST TO GET THAT DONE. I WORKED ON A SPECIAL COMMISSION COMMISSION -- SO IN THAT SAME BILL, THERE ARE TWO COMMISSIONS THAT LANGUAGE THAT WE WORKED ON. ONE IS TO STUDY THE REFERRAL SYSTEM FOR ACCESS TO PAIN MANAGEMENT SPECIALISTS. SO IT WOULD BE SORT OF AN ADVISORY GROUP OF PAIN SPECIALISTS THAT WOULD SPEAK TO DOCTORS ON THE PHONE, PRIMARY CARE, WHO HAD DIFFICULTY WITH A PATIENT AND NEED A CONSULT. AND SO WE'RE GOING TO DO A PILOT OF THAT ACTUALLY THAT CAME OUT OF THAT COMMISSION. ANOTHER THING, ANOTHER LANGUAGE I WORKED ON IN THAT COMMISSION IS FOR A STUDY OF WHAT INSURERS COVER AND HOW TO WRITE LEGISLATION TO MAKE THEM COVER MORE TREATMENTS FOR PAIN. AND NOW WE'RE ONE OF THE ORGANIZATIONS IN MASSACHUSETTS THAT DOES HEALTH POLICY ANALYSIS, IS DOING AN ANALYSIS FOR US OF WHAT INSURERS COVER. SIMILAR TO WHAT CHRISTION JONES TALKED ON WHEN THE NATIONAL LISTENING SESSION FOR PAIN STRATEGY. SO I'M GOING TO START SKIPPING THROUGH SOME OF THESE BECAUSE I WANT TO GET TO SOME MORE OF MY TALK, BUT WAS ON A WORKING GROUP GOVERNOR BAKER APPOINTED ME TO, ALSO A DRUG FORMULARY COMMISSION. OF COURSE IN FEDERAL WORK, YOU ALL KNOW ABOUT THE INTERAGENCY RESEARCH PAIN COORDINATING COMMITTEE, ALSO THE NATIONAL PAIN STRATEGY, AS MANY PEOPLE DID HERE. SO I'M GOING TO TALK ABOUT MULTIDISCIPLINARY CARE, THE PATIENTS' VIEW OF MY PERSPECTIVE ON HOW TO MANAGE PAIN. SO FIRST OF ALL, YOU NEED TO ACCEPT THAT THERE IS NO CURE. THERE IS NO MAGIC BULLET. YOU NEED TO LEARN TO COPE WITH A CHRONIC ILLNESS. I TELL PEOPLE THIS MAY NOT BE THE LIFE YOU PLANNED, BUT MOST PAIN CAN BE MANAGED AND YOU CAN STILL HAVE A GOOD QUALITY OF LIFE. RECOGNIZE THERE ARE GREAT INDIVIDUAL VARIABILITIES IN PAIN IN RESPONSE TO TREATMENT. I THINK IT'S ESSENTIAL TO EXPOSE PEOPLE TO ALMOST EVERY POSSIBLE THERAPY BECAUSE YOU NEVER KNOW WHAT IS GOING TO HELP PEOPLE. MULTIMODAL TREATMENT IS ESSENTIAL, RIGHT? YOU HAVE TO FIND THE RIGHT COMBINATION THAT REDUCES YOUR PAPER. THERE IS NOT PAIN. THERE IS NOT GOING TO BE ANY ONE THING THAT IS MOSTLY GOING TO TAKE PEOPLE'S PAIN, I BELIEVE, IN MOST CASES. IF YOU FIND SOMETHING THAT LET'S SAY REDUCES IT 15%, YOU ADD SOMETHING ELSE THAT REDUCES IT 20%, 30%, COMBINING THOSE THINGS, THAT'S A 65% REDUCTION, WHICH IS HUGE. WE'VE HEARD YESTERDAY MEDICATION ONLY GETS PEOPLE TO 40% REDUCTION IN PAIN. THE MOST SUCCESSFUL THERAPEUTIC OUTCOMES IS THE ONE I'VE HAD AND I'VE SEEN OTHER PEOPLE V IT'S RARE, WHERE YOU FIND A PHYSICIAN THAT SAYS, WE'RE GOING TO -- I'M GOING TO PARTNER WITH YOU. WE ARE GOING TO SOLVE THIS TOGETHER. YOU ARE NOT ALONE. THE DOCTOR REALLY SHOULD BE THE CAPTAIN OF THE TEAM AND RECOMMEND THERAPIES AND THEN CHECK BACK WITH THE PATIENT, HAVE THE PATIENT COME BACK AND TELL YOU WHAT'S WORKING AND NOT WORKING, AND MAKE ADJUSTMENTS, RIGHT? SO ALL THERAPEUTIC OPTIONS DON'T HAVE TO BE AVAILABLE WITHIN THAT PRACTICE, WE'LL TALK A LITTLE ABOUT THAT YESTERDAY ALSO, BUT THE DOCTOR NEEDS TO HAVE A NETWORK OF PROVIDERS THAT HE KNOWS HE CAN SEND PEOPLE TO. WHAT DID THE DOCTOR DO THAT FINALLY HELPED ME? SO IT WASN'T ANYTHING MIRACULOUS. HE WAS AN OSTEOPATH, SPECIALIZING IN PAIN MANAGEMENT, WHICH IS A GOOD START BECAUSE I THINK OSTEOPATHS HAVE A GOOD MUSCULOSKELETAL SYSTEM UNDERSTANDING. HE OFFERED ME LOTS OF DIFFERENT TREATMENTS. SOME OF THEM HELPED, SOME OF THEM DIDN'T, BUT HE WAS VERY EMPAT HIC, HE LISTEN TODAY ME, ONE OF HIS REQUIREMENTS WAS I HAD TO GIVE UP MY CAREER. IT WAS ONE OF THE HARDEST THINGS I'VE EVER DONE. I LOVED MY WORK BUT I KNEW HE WAS RIGHT AND I WALKED AWAY FROM A CAREER THAT I LOVED. SUCCESSFUL PAIN MANAGEMENT REQUIRES LONG TERM SUPPORT. THERE WAS A LITTLE DISCUSSION ABOUT THAT YESTERDAY, BUT THE KIND OF THING THAT MY PAIN GROUP DOES FOR PEOPLE, THIS IS A LIFELONG CONDITION, IT IS A LIFE LIMITING CHRONIC ILLNESS AS I'VE SAID BEORE, YOU'RE GOING TO HAVE UPS AND DOWNS, THERE'S GOING TO BE RELAPSES THAT NEED IMPROVEMENTS, THERE ARE GOING TO BE SETBACKS, HOW DO YOU DEAL WITH THAT? PEOPLE NEED SUPPORT AND HELP FOR DEALING WITH THAT. I OFTEN THINK, MY GOD, IT WOULD BE SO CHEAP, I VOLUNTEER MY TIME FOR THIS GROUP, THERE'S PROBABLY NOT A LOT OF PEOPLE THAT WOULD DO THAT, BUT IT WOULD NOT BE THAT COSTLY TO HAVE A NETWORK OF SUPPORT GROUPS. SO THINK THAT'S A REALLY IMPORTANT PIECE WE CAN'T FORGET. WE HEARD FROM A NUMBER OF PEOPLE YESTERDAY ABOUT HOW WE GET THIS IMPROVEMENT AND THEN IT DROPS OFF. WHY? BECAUSE PEOPLE GO BACK TO THEIR LIFE. YOU KNOW, YOU REALLY NEED TO KEEP THIS UP. WHAT I'VE SEEN IS THAT SUCCESSFUL PAIN MANAGEMENT, NO MATTER WHAT TYPE OF PAIN YOU HAVE, ALWAYS REQUIRE SOME PACING AND SOME LIMITATION ON YOUR ACTIVITIES. THE LIMITS COULD BE ALL DIFFERENT, BUT YOU REALLY NEED TO ADAPT TO A NEW LIFE WITH LIMITS. SO I'M GOING TO GET CLOSE TO THE END AND GIVE YOU SOME OF MY RESEARCH WISHES AND SUGGESTIONS. SO I FEEL REALLY STRONGLY THERE NEEDS TO BE A CLOSER WORKING RELATIONSHIP BETWEEN RESEARCHERS AND PATIENTS. I THINK THERE'S A VALUE IN HEARING DIRECTLY FROM PATIENTS ABOUT THE CHARACTERISTIC OF THE DISEASE, WHAT MAKES IT BETTER, WHAT MAKES IT WORSE, WHAT SIDE EFFECTS ARE TOLERABLE AND WHAT ARE NOT BECAUSE OTHER PEOPLE HAVE IDEAS ABOUT WHAT THEY THINK IS TOLERABLE AND WHAT ISN'T, AND I DON'T THINK THAT'S ALWAYS THE CASE FOR THE PATIENT. SO I WOULD REALLY LIKE A BETTER PARTNERSHIP WITH PATIENTS AND PEOPLE WORKING IN THE FIELD. NOT ONLY WOULD IT ACCOMPLISH THOSE CONCRETE GOALS, BUT I FEEL LIKE THAT GIVES PEOPLE HOPE. I OFTEN HAVE RESEARCHERS TALK TO THE GROUP. THE EDITOR OF THE PAIN RESEARCH FORUM COMES IN FREQUENTLY TO TALK TO MY GROUP, AND IT GIVES PEOPLE HOPE AND ON THE RESEARCHERS SIDE, I FEEL LIKE IT WOULD GIVE RESEARCHERS THE FEELING OF REL VABS AND IMPORTANCE THAT THE WORK THAT THEY ARE DOING IS REALLY AFFECTING PEOPLE'S LIVES, AND SOMETIMES THAT IS SO DIVORCED FROM THEIR EXPERIENCE THAT I HOPE THAT CAN HAPPEN. A PLEA FOR MORE AND BETTER EPIDEMIOLOGICAL STUDY AND ANALYSIS AND REPORTING ON PAIN. THERE'S A HUGE GAP, WE NEED THOSE NUMBERS TO BE ABLE TO DO IT. WE NEED LONGITUDINAL COMPARISONS OF PAIN DATA TO IDENTIFY TRENDS AND SUBPOPULATIONS AT RISK, WE NEED THE HEALTH CONSEQUENCES IN TERMS OF MORBIDITY, MORTALITY AND DISABLIBILITY. WE CERTAINLY DO IT FOR OTHER ILLNESSES, WE DON'T DO IT FOR PAIN. WE DON'T UNDERSTAND THE INCIDENCE AND REL VAPS OF PAIN SYNDROMES, DIFFERENTIATED BY AGE, COMORBIDITIES, SOCIOECONOMIC DISPARITIES. AND RESOURCE UTILIZATION OF MEDICAL AND SOCIAL SERVICES, WE ARE SPENDING A LOT OF MONEY IN INEFFICIENT WAYS IN PAIN, FROM DIRECT HEALTHCARE COSTS THAT ARE WASTED. AND I THINK WE COULD DO A MUCH BETTER JOB, BUT WE NEED THE NUMBERS. I FEEL REALLY STRONGLY ABOUT THAT. STUDYING PEOPLE WITH DEBILITATING PAIN WHO HAVE HAD SUCCESSFUL OUTCOMES. SO WHAT DO THEY DO? CERTAINLY THERE'S PEOPLE AROUND THAT HAVE THINGS THAT HAVE WORKED FOR THEM. WHAT ARE THE PERSONAL SKILLS AND CHARACTERISTICS THAT HAVE HELPED THEM? I KNEW THIS 10 YEARS AGO, THESE TIPS THAT I TOLD YOU BUT NOBODY ASKED ME. IT WAS REMARKABLY SIMILAR TO MANY OF THE THINGS RESEARCHERS CONCLUDED YESTERDAY, BUT MAYBE I COULD HAVE SHORT-CIRCUITED A LOT OF THAT IF PEOPLE HAD COME TO ME AND KNEW THAT I KNEW THE STORIES OF MORE THAN 350 PEOPLE AND REALLY GET A SENSE OF WHAT LIFE IS LIKE WITH PAIN. I'M ALSO INTRIGUED WITH HOW PEOPLE ARE NOT USING AGGREGATE PATIENT EXPERIENCE DATA IN HELPING FIND TREATMENTS. SO WEBSITES LIKE "PATIENTS LIKE ME," I THINK WE CAN LEVERAGE BIG DATA TO FIND BETTER TREATMENTS AND WE NEED TO MAKE BETTER USE OF THAT INFORMAION THAT'S NOW OUT. AND IN CLOSING, I WANT TO SAY A FEW THANK YOUS. FIRST OF ALL, TO LINDA. FOR HER EXTRAORDINARY JOB IN BRINGING TWO MAJOR AND EXCELLENT PIECES OF WORK FORWARD: THE NATIONAL PAIN STRATEGY, WE'RE GOING TO HEAR MORE ABOUT THE FEDERAL PAIN RESEARCH STRATEGY, I'VE GOTTEN A PEOPLE PIQUE AT IT BUT IT IS A WONDERFUL PIECE OF WORK, AND IT IS THERE AND WAITING TO BE DONE. AND LINDA IS A TIRELESS ADVOCATE, I DON'T KNOW WHAT WE WOULD DO IF SHE WASN'T HERE AT THE NIH. SO I WANT TO THANK LINDA FOR HER TERRIFIC WORK. [APPLAUSE] AND THEN TO ALLEN, ALLEN, RAISE YOUR HAND. STAND UP. HE WON'T. SO ALLEN COE LED THE FEDERAL PAIN RESEARCH STRATEGY, AND IT'S A GREAT PIECE OF WORK, IT'S BEEN REALLY ANTICIPATED AND I FEEL LIKE WE'VE GOT TO BRING THAT TO FRUITION AND I ENCOURAGE PEOPLE IF THEY HAVEN'T HEARD ABOUT THE DETAILS TO STAY AROUND AND HEAR IT THIS AFTERNOON. SO ALL OF YOU PAIN RESEARCHERS HERE TODAY, THANK YOU FOR INVESTING YOUR TIME AND ENERGY AND YOUR WORKING ENVIRONMENT TO PAIN RESEARCH, AND PLEASE KNOW IT IS GREATLY APPRECIATED BY MILLIONS OF PEOPLE THAT ARE LIVING WITH DEBILITATING PAIN EVERY DAY. SO THANK YOU FOR LISTENING, AND QUESTIONS? OKAY, NO PROBLEM. THANKS. [APPLAUSE] >> GOOD MORNING. THANK YOU, CINDY, THAT WAS REALLY INFORMATIVE. I APPRECIATE IT. SO THIS MORNING'S DISCUSSION IS FOCUSED ON PREVENTING CHRONIC PAIN THROUGH MULTIDISCIPLINARY APPROACHES, AND BASICALLY THE MOST SALIENT -- I THINK ONE OF THE MOST SALIENT FEATURES OF CHRONIC PAIN IS THE DIFFICULTY IN TREATING IT ONCE IT'S BEEN ESTABLISHED. SO IT'S REALLY MY PLEASURE TO INTRODUCE OUR FOUR SPEAKERS THIS MORNING ON THIS PANEL, WHICH IS PREVENTING CHRONIC PAIN THROUGH MULTIDISCIPLINARY APPROACHES. OUR FIRST SPEAKER IS A PROFESSOR OF PHYSICAL THERAPY AT SAN DIEGO STATE UNIVERSITY, WHERE SHE DIRECT THE APPLIED SENSORY MOTOR LABORATORY, FOCUSING ON NEUROPHYSIOLOGY, TISSUE BIOMECHANICS AND REHABILITATION TO STUDY NOT ONLY MECHANISMS BUT ALSO PREVENTION STRATEGIES FOR STRESS-RELATED CHRONIC PAIN. IN ADDITION TO AN IMPRESSIVE AMOUNT OF SERVICE TO THE FIELD, DR. KATRINA MALUF HAS SERVED AS THE FOUNDING DIRECTOR OF THE REHABILITATION SCIENCE PH.D. PROGRAM AT THE UNIVERSITY OF COLORADO DENVER, AND HAS RECEIVED A NUMBER OF AWARDS AND RESEARCH GRANTS. SO PLEASE WELCOME DR. KATRINA MALUF. [APPLAUSE] >> GOOD MORNING. THANK YOU SO MUCH FOR HAVING ME. THIS IS MY FIRST TIME ATTENDING THE PAIN SYMPOSIUM AND I REALLY, REALLY ENJOYED HEARING THE VARIETY OF PERSPECTIVES UNDER THE BIGGER UMBRELLA OF MULTIDISCIPLINARY CARE FOR PAIN, WHICH I THINK IS AN INCREDIBLY IMPORTANT TOPIC. AS MY VERY CREATIVE TITLE IMPLIES, I WAS ASKED TO PROVIDE AN OVERVIEW OF PREVENTION OF CHRONIC PAIN USING MULTIDISCIPLINARY APPROACHES, AND WE HEARD YESTERDAY FROM DR. TURK A COMPELLING RATIONALE OF WHY MULTIDISCIPLINARY APPROACHES ARE NEEDED IN CHRONIC PAIN. AND I THINK A LOT OF THE ARGUMENTS FOR WHY WE NEED MULTIDISCIPLINARY APPROACHES IN PAIN MANAGEMENT ALSO APPLY TO PREVENTION OF PAIN. SO REALLY MY CHALLENGE THIS MORNING IS TO, WITHOUT BEING REDUNDANT, MAKE THE CASE AND ADD TO THE DISCUSSION THAT WE ALSO NEED MULTIDISCIPLINARY INTERVENTIONS, SO THAT'S WHAT I'LL TALK ABOUT TODAY. SO TO DO THAT, I'M GOING TO START OFF JUST BY GIVING HOPEFULLY A VERY BRIEF OVERVIEW OF HOW OUR BIOLOGICAL MODELS OF PAIN HAVE EVOLVED OVER TIME WITH INCREASING LEVELS OF COMPLEXITY. TO MAKE THE CASE THAT THERE'S NOT ONLY A CLINICAL ARGUMENT FOR APPROACHING PAIN FROM A BIOPSYCHOSOCIAL PERSPECTIVE, BUT ALSO A BIOLOGICAL ARGUMENT FOR DOING THAT AS WELL. AND THEN I'LL SPEND THE LAST HALF OF THE TALK TALKING ABOUT CHAL EPTION AND OPPORTUNITIES THAT I SEE IN USING MULTIDISCIPLINARY APPROACHES TO PREVENT PAIN. SO NO PAIN SYMPOSIUM, I THINK, WOULD BE COMPLETE WITHOUT THIS CLASSIC ILLUSTRATION FROM DECART WHICH REALLY ILLUSTRATES. SO SIMPLISTIC UNDERSTANDING OF PAIN AS A BOTTOM-UP APPROACH WHERE TISSUES ARE INJURED IN THE PERIPHERY AND SIGNALS ARE SENT UP THROUGH THE SPINAL CORD TO WHAT APPEARS TO BE A VERY SMALL BRAIN, WHERE THEY'RE INTERPRETED AS A SENSATION OF PAIN. BUT EVEN BEFORE DECART, THERE WAS AN APPRECIATION AND AN UNDERSTANDING THAT PAIN IS NOT SIMPLY A SENSORY EXPERIENCE, IT ALSO HAS A VERY STRONG EMOTIONAL COMPONENT. I REALLY BELIEVE THIS QUOTE FROM ARISTOTLE BECAUSE IT GIVES ME AN EXCUSE TO TELL MY FRIENDS AND FAMILY THAT I'VE DEVOTED MY LIFE TO STUDYING A PASSION OF THE SOUL. SO OVER THE PAST SEVERAL CENTURIES, OUR UNDERSTANDING OF PAIN HAS REALLY EVOLVED FROM WHAT STARTED AS A BOTTOM-UP PROCESSING OF SENSORY SIGNALS TO REALLY UNDERSTANDING THAT THERE'S A LOT OF TOP-DOWN MODULATION FROM THE BRAIN TO THE PERIPHERY AND WE CAN ACTUALLY GATE THE SENSORY INFORMATION THAT WE RECEIVE FROM THE BODY WITH COGNITIVE AND ALSO EMOTIONAL PROCESSING OF PAIN. SO AGAIN, NOW WE UNDERSTAND THAT PAIN IS A MUCH MORE COMPLEX EXPERIENCE, BOTH A SENSORY AND EMOTIONAL EXPERIENCE, WHICH CAN EXIST IN THE PRESENCE BUT ALSO IN THE ABSENCE OF ACTUAL TISSUE DAMAGE. SOME OF THE EARLIEST THEORIES, BIOLOGICAL THEORIES REALLY FOCUSED ON A SENSORY PROCESSING AT THE LEVEL OF SPINAL CORD. THE EARLIEST THEORY POSTULATED THAT DIFFERENT TYPES OF SENSORY INFORMATION WERE CARRIED IN DEDICATED NERVES, SO NERVES FOR TOUCH, PAIN, TEMPERATURE, FOR EXAMPLE, AND THAT THOSE NERVES FED INFORMATION TO DEDICATED CELLS IN THE SPINAL CORD, WHICH THEN TRANSMITTED THOSE SIGNALS UP TO THE DEDICATED REGIONS OF THE BRAIN, WHERE THEY WERE PERCEIVED AS PAIN, PRESSURE, TOUCH, ET CETERA. FLOSH THROUGH LOTS OF RESEARCH, PATTERN THEORIES STARTED TO EVOLVE, WHICH BASICALLY ARE ALL SOME VERSION OF AN INTEGRATION OF SENSORY INFORMATION AT THE LEVEL OF THE SPINAL CORD. SO NOW WE KNOW THAT INFORMATION FROM DIFFERENT PLACES IN THE BODY, INFORMATION FROM OVER TIME AND SENSORY INFORMATION FROM DIFFERENT SENSORY MODALITIES CAN ALL CONVERGE IN DORSAL HARD CELLS IN THE SPINAL CORD WHICH INTEGRATE THAT INFORMATION BEFORE TRANSMITTING IT UP TO THE BRAIN TO BE PERCEIVED AS PAIN. ADVANCED IMAGING TECHNIQUES HAVE ALSO ADDED ANOTHER LAYER OF COMPLEXITY TO OUR BIOLOGICAL UNDERSTANDING OF SENSORY PROCESSING. SO NOW WE KNOW THAT THE BRAIN PLAYS A VERY LARGE ROLE IN PROCESSING OF PAIN. SO FOR EXAMPLE, WE HAVE THE CLASSIC SPINAL THALAMIC PATHWAY WHERE WE HAVE INFORMATION TRAVELING FROM THE BODY UP TO THE SPINAL CORD AND THEN UP TO THE THALAMUS AND UP TO THE SOMATOSENSORY CORE TECH, SO THAT'S THE CORTEX, BUT WE ALSO HAVE BEEN ABLE TO IDENTIFY NETWORKS INVOLVED IN COGNITIVE AND EMOTIONAL PROCESSING OF PAIN. TWO OF THE MORE CLASSIC EXAMPLES INVOLVE MOTIVATIONAL PATHWAYS, WHICH YOU SEE IN BLUE HERE, AND ALSO DESCENDING PAIN MODULATORY PATHWAYS, WHICH ARE INDICATED IN GREEN. SO WHAT YOU'LL NOTICE IS THAT BOTH OF THOSE PATHWAYS INVOLVE CONNECTIONS BETWEEN THE PREFRONTAL CORTEX AND AREAS OF THE BRAINSTEM THAT ARE INVOLVED IN THINGS LIKE ADDICTION, EMOTION, AROUSAL, STRESS, DESCENDING ANALGESIC RESPONSES FROM THE PERI -- THE PARTM, FOR EXAMPLE. SO THIS GIVES US SORT OF A BIOLOGICAL UNDERSTANDING OF WHY PAIN MAY COEXIST WITH SOME OF THE COMORBIDITIES THAT WE COME TO SEE IN PATIENTS WITH CHRONIC PAIN, SUCH AS STRESS, SLEEP DISTURBANCES, ET CETERA. IF WE TAKE ANOTHER STEP BACK, WHAT WE HAVE TO REALIZE IS THAT NOT ONLY DO WE HAVE BIOLOGICAL COMPLEXITY AND OVERLAP IN UNDERLYING SYSTEMS BETWEEN PHYSIOLOGICAL PROCESSES AND PSYCHOLOGICAL PROCESSES, BUT THOSE PROCESSES WITHIN AN INDIVIDUAL FUNCTION WITHIN A LARGER CONTEXT, AND THAT CONTEXT IS HOW THE INDIVIDUAL INTERACTS WITH THEIR SOCIAL ENVIRONMENT. AND SO REALLY THIS FORMS THE BIOPSYCHOSOCIAL MODEL, WHICH SAYS THAT IT'S THE INTERACTION BETWEEN PHYSIOLOGY, PSYCHOLOGY, AND THE SOCIAL ENVIRONMENT WHICH DETERMINES THE INDIVIDUAL'S PAIN EXPERIENCE. WITHIN THAT MODEL, EACH OF THE DOMAINS HAS ITS OWN LEVEL OF COMPLEXITY. AND WHEN WE'RE TALKING ABOUT PREVENTION OF PAIN, I THINK IT'S CRITICALLY IMPORTANT TO IDENTIFY RISK FACTORS AND RISK PROFILES. THERE'S A VAST AMOUNT OF LITERATURE AND RESEARCH OUT THERE ON DIFFERENT RISK FACTORS FOR CHRONIC PAIN. WITHIN THE SOCIAL AND ENVIRONMENTAL DOMAIN, THOSE RISK FACTORS ARE ROUGHLY DIVIDED INTO THREE DIFFERENT AREAS, HOW CONNECTED THE INDIVIDUAL IS AND HOW THEY INTERACT IN THEIR HOME AND COMMUNITY, IN THE WORKPLACE, AND ALSO THE HEALTHCARE SYSTEM, AND WE SAW SOME REALLY COMPELLING TALKS YESTERDAY ABOUT BARRIERS THAT THE HEALTHCARE SYSTEM PRESENTS TO NOT ONLY MANAGEMENT BUT PREVENTION OF CHRONIC PAIN. I'M NOT GOING TO TALK ABOUT EACH OF THESE INDIVIDUALLY, BUT WHAT I HOPE YOU CAN APPRECIATE IS THAT GIVEN ALL OF THESE RISK FACTORS, AND THE COMPLEXITY OF THESE RISK FACTORS, IT'S INCREDIBLY DIFFICULT FOR ONE HEALTHCARE INDIVIDUAL TO HAVE THE EXPERTISE TO ADDRESS ALL THESE AND SO THIS GIVES US AN OPPORTUNITY TO GET INPUT FROM A NUMBER OF ALLIED HEALTHCARE PROFESSIONALS, SO FOR EXAMPLE, VOCATIONAL AND OCCUPATIONAL REHABILITATION SPECIALISTS. IN TERMS OF THE HEALTHCARE SYSTEM, PATIENT ADVOCATES, HELPING PATIENTS NAVIGATE A VERY COMPLEX HEALTHCARE SYSTEM IS CRITICALLY IMPORTANT. AND THEN I THINK A VERY UNDERAPPRECIATED RESOURCE IN TERMS OF AN INDIVIDUAL'S INTERACTION WITH THEIR HOME AND COMMUNITY IS A NETWORK OF HELP FROM FAMILY CAREGIVERS AND FRIENDS AND ALSO COMMUNITY LEADERS. PSYCHOLOGICAL RISK FACTORS FOR PAIN ARE SOME OF THE MOST ROBUST IN THE LITERATURE, AND THEY ROUGHLY -- IF WE FOLLOW THE COGNITIVE BEHAVIORAL MODEL, THEY ROUGHLY FALL INTO THREE DIFFERENT CATEGORIES. AND THOSE ARE FEELINGS OR EMOTIONAL RESPONSES TO PAIN OR OTHER LIFE STRESSORS, THOUGHTS, OUR COGNITIVE APPRAISAL OF THE CONSEQUENCES AND CAUSES OF PAIN, AND THEN THE BEHAVIORS, SO HOW DO WE RESPOND TO PAIN. SO THESE RISK FACTORS GIVE US AN OPPORTUNITY AGAIN TO TAKE ADVANTAGE OF MULTIDISCIPLINARY EXPERTISE IN PAIN PREVENTION, SO WE REALLY RELY ON THE EXPERTISE OF HEALTHCARE WORKERS, PSYCHOLOGISTS AND PSYCHIATRISTS, TO PRESCRIBE MOOD-ALTERING MEDICATIONS TO HELP WITH MOOD REGULATIONS, BUT ALSO COGNITIVE INTERVENTIONED SUCH AS COGNITIVE RESTRUCTURING, COGNITIVE BEHAVIORAL THERAPIES, TO REALLY HELP PEOPLE UNDERSTAND THAT YOU CAN RESTRUCTURE YOUR THOUGHTS TO HELP DECOUPLE BEHAVIORS FROM NEGATIVE THOUGHTS AND FEELINGS. THEN FINALLY THE PHYSIOLOGICAL DOMAIN. SO I'VE DIVIDED THIS INTO TWO CATEGORIES. SORT OF THE INNATE BIOLOGY OR PHYSIOLOGY THAT PATIENTS BRING TO THE TABLE. THESE WOULD BE HERITABLE THINGS THAT ARE DIFFICULT TO MODIFY, SUCH AS GENDER, ETHNICITY AND RACE, PROCESSES THAT OCCUR WITH THERE'S ALSO ACQUIRED PHYSIOLOGICAL PROCESSES, AND THAT'S REALLY WHERE I THINK WE HAVE THE MOST POTENTIAL TO INTERVENE AND I'LL TALK ABOUT THAT IN JUST A LITTLE BIT. BUT IN TERMS OF PHYSIOLOGY, THERE IS A WEALTH OF RESEARCH AND LITERATURE ON PHYSIOLOGICAL SYMPTOMS THAT CONTRIBUTE TO PAIN. I'VE TALKED MOSTLY ABOUT SENSORY MOTOR COGNITIVE AFFECTIVE PROCESSING, BUT THERE'S ALSO WHOLE FIELDS OF RESEARCH LOOKING AT HOW THE MUSCULOSKELETAL SYSTEM, THE CARDIORESPIRATORY SYSTEM, IMMUNOLOGIC, METABOLIC AND ENDOCRINE FUNCTIONS& CONTRIBUTE TO PAIN. SO ALL OF THESE PROCESSES REQUIRE EXPERTISE FROM DIFFERENT PRACTITIONERS AND DIFFERENT RESEARCHERS TO EXPLAIN CAUSES OF PAIN THAT CAN OCCUR FOR DIFFERENT PATIENTS. SO ONE OF THE RAPID FIELDS THAT I THINK IS REALLY, REALLY EXCITING IS THE FIELD OF EPIGENETICS, SPECIFICALLY PAIN EPIGENETICS, AND THE REASON THAT THIS IS REALLY INTERESTING IS THAT BECAUSE IT CONNECTS AN INDIVIDUAL'S BIOLOGY WITH THEIR INTERACTION WITH THE SOCIAL ENVIRONMENT. SO EPIGENETICS IS THE IDEA THAT THROUGH INTERACTION WITH THE ENVIRONMENT, THE GENOME, THE INNATE GENOME IS PACKAGED AND TRANSLATED IN DIFFERENT WAYS TO HELP THAT INDIVIDUAL ADAPT TO THE ENVIRONMENTAL STRESSORS THAT THEY'VE ENCOUNTERED, SO WE CAN PACKAGE AND MODIFY DNA TO CHANGE PROTEIN EXPRESSION, NOT OVER GENERATIONS BUT WITHIN THE SAME PERSON IN REALTIME TO GIVE A MOLECULAR MEMORY OF THOSE CHALLENGES TO PRIME THE SYSTEM TO BE BETTER ABLE TO ADAPT TO THOSE CHALLENGES. SO MODIFICATION OF THE GENETIC -- OR NOT MODIFICATION OF GENETICS BUT MODIFICATION OF HOW THOSE GENETICS ARE TRANSLATED INTO PROTEINS THAT AFFECT CELLULAR SIGNALING, THEN THOSE CHANGES IN SIGNALING REALLY AFFECT HOW NETWORKS ARE WIRED. AGAIN, THIS HAPPENS IN REALTIME IN RESPONSE TO REALTIME ENVIRONMENTAL STRESSORS. AND SO WHAT WE'RE LEARNING IS THAT THE BODY IS INCREDIBLY ADAPTIVE AND THESE ACQUIRED MECHANISMS ARE VERY IMPORTANT IN PREVENTION AND ALSO MANAGEMENT OF PAIN. SO HOPEFULLY I'VE CONVINCED YOU THAT IN ADDITION TO SORT OF THE CLINICAL RATIONALE FOR USING A BIOPSYCHOSOCIAL APPROACH, THAT THE INTERACTION OF THE INDIVIDUAL AND THEIR OWN PHYSICIAN KOLG AND PSYCHOLOGICAL MAKEUP WITH THE ENVIRONMENT, WHICH CAN BE MODIFIED IN REALTIME, GIVES US SORT OF A BIOLOGICAL BASIS FOR USING A BIOPSYCHOSOCIAL APPROACH TO PREVENTION AND MANAGEMENT. IN TERMS OF IMPLEMENTATION, I WAS REALLY GLAD TO HEAR ABOUT THE PROGRESS THAT'S BEEN MADE WITH THE STEPS PROGRAM AT THE V.A. YESTERDAY, BECAUSE TRADITIONALLY, PAIN MANAGEMENT AND PREVENTION IN THE U.S. HAS FOCUSED ON INTERDISCIPLINARY, MULTIDISCIPLINARY PROGRAMS AT THE TERTIARY LEVEL. SO ONCE PATIENTS HAVE ALREADY DEVELOPED A CHRONIC PAIN CONDITION WHICH WE KNOW IS VERY, VERY DIFFICULT TO MANAGE, AND MOST OF THE RESOURCES HAVE BEEN PUT INTO INTERDISCIPLINARY MANAGEMENT AT THAT LEVEL AT THE U.S. OTHER SYSTEMS OF SOCIALIZED MEDICINE WHERE THEY HAVE MORE INTEGRATED SYSTEMS OF CARE HAVE REALLY FOCUSED AND ARE STARTING MORE TO FOCUS ON PREVENTION AT THE LEVEL OF PRIMARY CARE SO WE CAN INTERVENE IN THE EARLY STAGES OF THE PAIN PROCESS TO PREVENT CONIS IT. NOW SOME OF THE METHODS THAT I'LL TALK ABOUT TODAY WHICH I THINK ARE MOST PROMISING ARE STRATIFYING PATIENTS BASED ON RISK PROFILES AND TAILORING THE MANAGEMENT TO THOSE RISK PROFILES. AND THAT'S BEING DONE INCREASINGLY, ESPECIALLY OVERSEA, BUT HOPEFULLY IN THE U.S. AS WELL IN THE FUTURE. OTHER ASPECTS OF SUCCESSFUL INTERDISCIPLINARY PREVENTION PROGRAMS ARE INTERDISCIPLINARY PAIN EDUCATION. SO I THINK WE'RE MAKING HUGE STRIDES IN PAIN EDUCATION, CROSSING DISCIPLINARY BOUNDARIES WITH PAIN COMPETENCIES THAT ARE COMMON ACROSS DISCIPLINES SO THAT EACH DISCIPLINE WHILE OPERATING IN THEIR OWN SILO UNDERSTANDS WHAT THE OTHER DISCIPLINES HAVE TO OFFER, SO WE'RE MAKING STRIDES THERE. MINIMUM DATASETS FOR COST BENEFIT ANALYSES, SO CINDY TALKED ABOUT THE IMPORTANCE OF PROVIDING ECONOMIC DATA TO DRIVE HEALTHCARE POLICY, AND I THINK THAT'S CRITICALLY IMPORTANT. SO IMPLEMENTATION OF MINIMUM DATASETS SO THAT WE CAN EVALUATE WHETHER THE MULTIDISCIPLINARY PROGRAMS THAT WE'RE PROVIDING ARE COST-EFFECTIVE. THERE ARE ALSO FORMAL MECHANISMS OF INTERPROFESSIONAL COLLABORATION BASED ON A BIOPSYCHOSOCIAL APPROACH, WHICH INCLUDE THINGS LIKE VIRTUAL INTERDISCIPLINARY NETWORKS, SO THESE ARE FORMAL WAYS OF CONNECTING DIFFERENT DISCIPLINES SO THAT WE'RE TALKING TO EACH OTHER, AND NOT ONLY HEALTHCARE PROVIDERS, BUT ALSO CONNECTING PATIENT COMMUNITIES. THESE PROGRAMS ALSO TEND TO FOCUS ON COMMUNITY-BASED EDUCATION PROGRAMS USING EVIDENCE-BASED RESOURCES AND EMERGING TECHNOLOGIES IN TELEHEALTH. AS WELL AS ELECTRONIC TECHNOLOGIES. I THINK WE'LL HEAR ABOUT USING THESE TECHNOLOGIES TO REALLY PROMOTE SELF MANAGEMENT. SO THESE DIFFERENT HEALTHCARE MODELS HAVE USED -- WE TALKED A LOT ABOUT MULTIDISCIPLINARY CARE, BUT IN ACTUALITY, THERE ARE MANY METHODS OF MULTIDISCIPLINARY CARE. MULTIDISCIPLINARY REALLY REFERS TO BEING SEEN BY MULTIPLE HEALTHCARE PROVIDERS WITHIN THEIR OWN DISCIPLINES. OFTEN TIMES AS IMPLEMENTED NOW, THERE'S NOT GREAT CONNECTION OR COLLABORATION BETWEEN THOSE HEALTHCARE PROVIDERS, SO A BETTER MODEL, I THINK, IS INTERDISCIPLINARY CARE, WHERE HEALTHCARE PROVIDERS HAVE KNOWLEDGE OF EACH OTHER'S PROFESSIONAL DOMAINS, THEY TALK, AND THEY WORK TOWARD COMMON GOALS FOR THE SAME PATIENT AS AN IND DISCIPLINARY TEAM. TRANSDISCIPLINARY. SO THIS IS A MODEL THAT'S INCREASINGLY BEING EXPLORED IN PHYSICAL THERAPY, AND DR. RIDDLE WILL GIVE US AN EXAMPLE OF THAT TODAY. TRANSDISCIPLINARY MODELS REALLY ALLOW HEALTHCARE PROFESSIONALS WITHIN ONE DISCIPLINE TO ADOPT SOME OF THE SKILLS FROM ANOTHER DISCIPLINE TO PROVIDE INTEGRATED CARE WITH ONE HEALTHCARE PROVIDER. AND I'LL GIVE YOU SOME EXAMPLES OF THAT. SO WHEN WE'RE TALKING ABOUT PREVENTION SPECIFICALLY, I REALLY THINK THAT IT'S USEFUL TO BORROW FROM THE PUBLIC HEALTH LITERATURE IN COMMUNICABLE DISEASES, INFECTIOUS DISEASES, FOR EXAMPLE, AND THINK ABOUT PREVENTING CHRONIC PAIN IN THAT CONTEXT. SO WE HAVE MULTIPLE OPPORTUNITIES TO INTERVENE. WE CAN INTERVENE IN PRIMARY PREVENTION, AND THIS IS WHERE THERE'S REALLY A FOCUS ON IDENTIFYING EXPOSURES, ENVIRONMENTAL EXPOSURES, MITIGATING THOSE EXPOSURES, AND ALSO IDENTIFYING SUSCEPTIBILITY. SO WHO'S MOST SUSCEPTIBLE TO BEING EXPOSED TO DISEASE-CAUSING CONDITIONS, IF WE BORROW FROM INFECTIOUS DISEASE, AN EXAMPLE OF THIS WOULD BE PROVIDING VACCINATIONS FOR TUBERCULOSIS, FOR EXAMPLE. SO PRIMARY PREVENTION IS REALLY FOCUSED ON PREVENTING A HEALTH CONDITION FROM OCCURRING IN THE FIRST PLACE. IF EXPOSURE DOES OCCUR, AND AN INDIVIDUAL DEVELOPS A HEALTH CONDITION, AN ACUTE HEALTH CONDITION, SECONDARY PREVENTION EFFORTS ARE REALLY FOCUSED ON PREVENTING A RECURRENCE OR CHRONICITY OF THAT ACUTE CONDITION, SO THE STRATEGIES HERE ARE EARLY SCREENING AND EFFECTIVE PREVENTION. AND SO I'LL TALK ABOUT SOME WAYS THAT WE CAN DO THAT IN CHRONIC PAIN. FROM THE INFECTIOUS LITERATURE, THE EXAMPLE WOULD BE SCREENING OF HEALTHCARE WORKERS WHO HAVE INCREASED EXPOSURE TO TUBERCULOSIS IN HEALTHCARE SETTINGS, FOR EXAMPLE, SO SCREENING AND AGGRESSIVE TREATMENT TO REVERSE THE ACUTE CONDITION AND PREVENT COULD NIS IT. THEN FINAL LITTER SHEAR PREVENTION IS PREVENTION OF SORT OF SECONDARY SEQUELLA AND DISABILITY RELATED TO A CHRONIC CONDITION. SO I'M GOING TO USE SPINE PAIN AS AN EXAMPLE BECAUSE SPINE PAIN HAS BEEN -- IS PROBABLY ONE OF THE MOST WELL STUDIED CONDITIONS USING A MULTIDISCIPLINARY PREVENTION METHODS AND IT ALSO ONE OF THE LEADING CAUSES OF DISABILITY GLOBALLY. SO IN TERMS OF PREVENTING CHRONIC PAIN, I THINK THE MAJORITY OF THE EFFORTS TO DATE HAVE BEEN IN THE AREA OF TERTIARY PREVENTION, SO PREVENTING DISABILITY IN PATIENTS WHO ALREADY HAVE DEVELOPED A CHRONIC DISORDER. AND AS WE SPOKE YESTERDAY WITH DR. TURK, THESE CONDITIONS ARE VERY DIFFICULT IF NOT IMPOSSIBLE TO CURE AND THE FOCUS REALLY IS ON REHABILITATION AND PREVENTION OF DISABILITY, AND THE METHODS THAT WE HAVE TO DO THAT, MULTIDISCIPLINARY METHODS, ARE THE MOST PROMISING, BUT THEY OFFER RELATIVELY SMALL BENEFITS. SO THIS IS A RECENT META-ANALYSIS COMPARING MULTIDISCIPLINARY TERTIARY PREVENTION OF CHRONIC DISABILITY IN PATIENTS WITH CHRONIC LOW BACK PAIN, AND WHAT YOU SEE IS THAT MULTIDISCIPLINARY INTERVENTION IS SLIGHTLY BETTER THAN TRADITIONAL MEDICAL CARE, AND PHYSICAL INTERVENTIONS, IN TERMS OF REDUCING PAIN, REDUCING DISAIN'T AND DISABILITY AND RETURN TO WORK. TO PUT THIS INTO PERSPECTIVE, THE MAGNITUDE OF THESE SIZES TRANSLATE INTO ABOUT A HALF A POINT IMPROVEMENT ON A 10-POINT SCALE IN PAIN INTENSE AT THIS TIME WHERE CLINICALLY IMPORTANT DIFFERENCES ARE SEEN, AND ON A DISABILITY SCALE, THIS TRANSLATE INTO ABOUT 1 1/2 POINTS ON A 47-POINT SCALE, WHERE WE REALLY WANT TO SEE AT LEAST 5 POINTS FOR CLINICALLY MEANINGFUL CHANGE. SO THESE ARE RELATIVELY SMALL IMPROVEMENTS IN PREVENTION OF CHRONIC DISABILITY IN PATIENTS WHO HAVE CHRONIC LOW BACK PAIN. WHEN WE LOOK AT CHRONIC NECK PAIN, THERE HAS BEEN MUCH, MUCH LESS WORK DONE ON MULTIDISCIPLINARY INTERVENTIONS IN THIS POPULATION, SO THE MOST KURNLT META-ANALYSIS I WAS ABLE TO FIND WAS DONE IN 2003, AND ONLY TWO STUDIES HAD COMPARED MULTIDISCIPLINARY INTERVENTIONS FOR CHRONIC NECK PAIN TO TRADITIONAL PSYCHOLOGICAL TREATMENT AND TRADITIONAL PHYSICAL INTERVENTIONS AND FOUND NO EFFECTS FOR EITHER PAIN OR DISABILITY. BUT AS WE SAW YESTERDAY, THERE'S BEEN A RECENT RANDOMIZED CLINICAL TRIAL SHOWING MUCH MORE POSITIVE EFFECTS OF MULTIDISCIPLINARY INTERVENTION, PARTICULARLY ON NECK DISABILITY. WHERE THE AMOUNT OF IMPROVEMENT IN MULTIDISCIPLINARY STRATEGIES COMPARED TO TRADITIONAL PHYSICAL CARE REALLY ARE CLINICALLY MEANINGFUL. SO THERE IS HOPE FOR THIS APPROACH IN TERTIARY PREVENTION IN CHRONIC NECK PAIN, ALTHOUGH WE'RE NOT QUITE THERE YET. SECONDARY PREVENTION. SO GIVEN THE MODEST EFFECTS THAT WE'RE HAVING AT THE LEVEL OF TERTIARY PREVENTION, I WOULD ARGUE THAT WE REALLY NEED TO INVEST EFFORTS INTO SECONDARY PREVENTION OF THE TRANSITION FROM AN ACUTE PAIN CONDITION TO CHRONIC PAIN. SO THERE'S BEEN A LOT OF ACTIVITY IN THIS AREA RECENTLY, SO I'LL GO THROUGH SOME EXAMPLES IN THE AREA OF SPINE PAIN. SO ONE STRATEGY WHICH I THINK HAS A LOT OF POTENTIAL AS I SAID BEFORE IS SCREENING FOR RISK. SO WHAT WE KNOW FROM PREVIOUS STUDIES IS THAT DEPENDING ON THE SORT OF MECHANISM OF INJURY OR THE PRIMARY DIAGNOSIS, THE INCIDENCE OF PATIENTS DEVELOPING CHRONIC PAIN INJURY RANGE FROM ABOUT 10% TO 50%. SO IT'S A MINORITY OF PEOPLE WHO GO ON TO DEVELOP CHRONIC PAIN, BUT THERE ARE ENORMOUS CONSEQUENCES FOR THAT MINORITY. SO IF WE CAN PREDICT WHO ARE THE PEOPLE WHO ARE MOST SUSCEPTIBLE, THEN WE CAN DIVERT RESOURCES TOWARD INTERVENING EARLY. SO MOST OF YOU HAVE PROBABLY HEARD ABOUT DEVELOPMENT OF THE STARBACK TOOL. THIS IS ONE OF MANY TOOLS THAT HAVE BEEN INVENTED FOR PATIENTS WITH LOW BACK PAIN. SO WHAT I WANT TO POINT OUT ABOUT THIS START BACK SCREENING TOOL IS NUMBER ONE, IT'S QUICK, EASY TO IMPLEMENT IN A PRIMARY CARE SETTING WHERE WE CAN GET TO PATIENTS AFTER AN ACUTE INJURY, AND IT'S ALSO -- IT CONSIDERS RISK FACTORS FROM A BAY OWE PSYCHOSOCIAL APPROACH, SO IT LOOKS AT SYMPTOMS, IT LOOKS AT PHYSICAL FUNCTION, AND IMPORTANTLY, IT ALSO LOOKS AT THE PSYCHOLOGICAL FACTORS SUCH AS MOVEMENT, RUMINATION, KA TAS KNOWN RISK FACTORS FOR CHRONIC PAIN. BASED ON THE SCORES IN THIS RISK ASSESSMENT TOOL, PATIENTS CAN BE DIVIDED INTO LOW, MEDIUM AND HIGH RISK GROUPS AND THEN INTERVENTIONS CAN BE TAILORED TO THOSE INDIVIDUAL GROUPS. SO AS I SAID, THE START BACK TOOL SOMEONE OF SEVERAL THAT HAVE BEEN DEVELOPED FOR SCREENING FOR RISK OF CHRONIC PAIN. SOME OTHERS ARE THE BAC DISABILITY RISK SCORE, THE CHRONIC PAIN RISK SCORE AND THE HANCOCK CLINICAL PREDICTION RULE, AND A RECENT META-ANALYSIS OF THESE SCREENING INSTRUMENTS SHOWS THAT WE'RE ONLY MODERATELY GOOD AT PREDICTING PATIENTS WHO GO ON TO DEVELOP CHRONIC PAIN, BUT THE TOOLS ARE MUCH BETTER AT PREDICTING THE OCCURRENCE OF CHRONIC DISABLE, WHICH IS ARGUABLY THE MOST IMPACTFUL OUTCOME. SO USING THESE SCREENING TOOLS, CAN WE TAILOR TREATMET TO BETTER INTERVENE AND PREVENT THE DEVELOPMENT OF CHRONIC PAIN, AND THE START BACK TRIAL WAS DONE IN BRITAIN, THIS IS ONE OF THE STUDIES USING THAT APPROACH, AND I KNOW YOU CAN'T SEE AT ALL THE WRITING IN THIS FLOW DIAGRAM FOR THIS STUDY, BUT WHAT I'D LIKE TO POINT OUT IS DIFFERENCES IN REFERRAL PATTERN. THE TRIAGE OR SCREENING PROCEDURE RISK STRATIFICATION WAS DONE BY PHYSICAL THERAPISTS, WHO SCREENED PATIENTS AT AN INITIAL VISIT, USING EITHER THE START BACK SCREENING TOOL OR BASED ON THEIR CLINICAL JUDGMENT REFERRED THE PATIENTS FOR ADDITIONAL PHYSICAL THERAPY. REFERRAL PATTERNS BASED ON CLINICAL JUDGMENT ALONE RESULTED IN A ROUGHLY EQUAL NUMBER OF PEOPLE IN LOW, MEDIUM AND HIGH RISK GROUPS BEING REFERRED FOR PHYSICAL THERAPY, SO THIS MAY REPRESENT OVERREFERRALS FOR LOW RISK PATIENTS AND UNDERREFERRALS FOR HIGH RISK PATIENTS. USING THE START BACK TOOL, PATIENTS WERE ASSIGNED TO LOW, MEDIUM AND HIGH RISK INTERVENTION, WHERE THE LOW RISK GROUP RECEIVEED BASICALLY AN EDUCATION BASED INTERVENTION FROM A PHYSICAL THERAPIST, THE MEDIUM RISK GROUP RECEIVED TRADITIONAL PHYSICAL THERAPY CARE BASED ON PHYSICAL IMPAIRMENT AND PHYSICAL FUNCTION, AND THOSE IN THE HIGH RISK GROUP RECEIVED PSYCHOLOGICALLY INFORMED PHYSICAL THERAPY CARE. SO WHAT DOES THAT LOOK LIKE? SO THIS IS BASICALLY A TRANSDISCIPLINARY MODEL WHERE PHYSICAL THERAPISTS ARE TRAINED IN COGNITIVE BEHAVIORAL AND OTHER PSYCHOLOGICAL TECHNIQUES BORROWING FROM THE MENTAL HEALTH PROFESSION, THEY'RE TRAINED IN ELEMENTS OF THOSE STRATEGIES FOR KAI AND THEY CARE, AND THEY INCORPORATE THAT INTO THEIR OWN CLINICAL PRACTICE. SO IT'S A COMBINATION OF MINIMIZING, EVALUATING AND TREATING MUSCULOSKELETAL IMPAIRMENTS THAT MAY CONTRIBUTE TO PAIN BUT WITH THE ADDITION OF A MULTITUDE OF STRATEGIES THAT CAN BE USEED TO ADDRESS PAIN RELATED FEAR BEHAVIORS AND OTHER PSYCHOLOGICAL RISK FACTORS. AND THIS HAS BEEN DONE IN CHRONIC LOW BACK PAIN, IT'S ALSO BEEN DONE IN -- STARTING TO BE DONE IN OTHER MUSCULOSKELETAL CONDITIONS, AND AGAIN DR. RIDDLE WILL TALK IN MORE DETAIL ABOUT THIS TODAY. SO WHAT ARE THE OUTCOMES OF THIS APPROACH? FOR ALL PATIENTS TOGETHER? THE OUTCOMES -- THE STRATIFIED RISK MANAGEMENT OR RISK INTERVENTION PROGRAM WERE GOOD, SO PATIENTS WHO WERE IN THE INTERVENTION GROUP HAD A HIGHER GREATER CHANGES IN DISABILITY AT FOUR MONTHS, AGAIN AT 12 MONTHS. AGAIN THOSE DIFFERENCES AS WE'VE TALKED ABOUT BEFORE BECAME LESS OVER TIME SO THIS AGAIN ARGUES FOR THE NEED FOR ONGOING PROGRAMS. THE DIFFERENCES BETWEEN TREATMENT GROUPS WERE MOST PRONOUNCED IN THE MEDIUM AND HIGH RISK GROUPS, WHERE WE SEE BENEFITS ABOVE AND BEYOND USUAL CARE. SO A SIMILAR APPROACH HAS BEEN USED IN THE PREVENTION OF CHRONIC WHIPLASH ASSOCIATED DISORDERS AFTER AN ACUTE NECK INJURY DUE TO WHIPLASH. WITH THIS APPROACH, INVESTIGATORS AGAIN USED KNOWN RISK FACTORS FOR THE DEVELOPMENT OF CHRONIC PAIN, WHICH INCLUDED INITIAL -- THE INITIAL SEVERITY OF BOTH DISABILITY AND PAIN AFTER AN ACUTE INJURY AS WELL AS SCORES ON THE IMPACT OF EVENT SCALE WHICH IS A MEASURE OF PSYCHOLOGICAL DISTRESS OR POST-TRAUMATIC STRESS, AND ALSO QUANTITATIVE SENSORY TESTING, AND THIS IS ANOTHER APPROACH THAT'S BEING INCREASINGLY INVESTIGATED FOR RISK FOR CHRONIC PAIN. WHAT THESE INVESTIGATORS DID WAS THEY USED THESE KNOWN PREDICTER OF RECOVERY IN ACUTE WHIPLASH TO PRESCRIBE MULTIMODAL TREATMENTS. THOSE TREATMENTS INVOLVED ANALGESIC MEDICATIONS PRESCRIBED BY A PHYSICIAN, AND BASED ON QUANTITATIVE SENSORY TESTING, SO I THINK THIS IS SORT OF A UNIQUE ASPECT OF THIS STUDY. PATIENTS WITH LOW LEVELS OF PAIN WERE PRESCRIBED EITHER NO MEDICATIONS OR -- AND PATIENTS WITH ENHANCED SENSORY RESPONSES TO QUANTITATIVE SENSORY TESTING WERE PRESCRIBED WITH HIGHER LEVEL ANALGESICS INCLUDING OPIOIDS AND ANTICON ANTICONVULSANTS/ANTIDEPRESSANTS. PATIENTS WHO PRESENTED WITH DEFICITS IN MUSCULOSKELETAL IMPAIRMENTS SUCH AS CERVICAL RANGE OF MOTION, MUSCLE ENDURANCE, BALANCE AND PROPRIOCEPTION WERE ADDRESSED -- THAT THEY PRESENTED WITH, AND THEN PATIENTS WHO PRESENTED WITH HIGH LEVELS OF PSYCHOLOGICAL DISTRESS WERE TREATED EITHER WITH PSYCHOLOGICALLY INFORMED PHYSICAL THERAPY, WHICH I TALKED ABOUT BEFORE, AS SORT OF A FIRST LINE OF DEFENSE, IF THEY WEREN'T IMPROVED AT SIX WEEKS WITH THAT APPROACH, THEN THEY WERE FURTHER REFERRED FOR COGNITIVE BEHAVIORAL THERAPY PROVIDED BY A PSYCHOLOGIST. SO UNFORTUNATELY THE TREATMENT OUTCOMES USING THIS STRATIFIED MANAGEMENT APPROACH WERE SOMEWHAT DISAPPOINTING. THERE WAS NO DIFFERENCE ACROSS TIME BETWEEN THE MULTIDISCIPLINARY CARE GROUP AB THE USUAL CARE GROUP IN EITHER DISABILITY OR PAIN INTENSITY. WHETHER THAT'S DUE TO THE MODE OF INTERVENTIONS THAT WERE USED, THE MODELS, WE'RE NOT SURE BUT I THINK IT'S AN AREA THAT REQUIRES ADDITIONAL INVESTIGATION. OKAY. SO WE'VE TALKED ABOUT TERTIARY PREVENTION, SECONDARY PREVENTION AND NOW I'M GOING TO TALK ABOUT PRIMARY PREVENTION. THIS IS REALLY WHERE THE LEAST AMOUNT OF RESOURCES HAVE BEEN DEVOTED. PRIMARY PREVENTION HAS BEEN DIFFICULT DUE TO A NUMBER OF REASONS, SPECIFICALLY FOR CHRONIC SPINE PAIN. I'LL SHARE WITH YOU THE RESULTS FROM A RECENT META-ANALYSIS. I'LL SHARE THE RESULTS OF A RECENT META-ANALYSIS WHICH BASICALLY CONCLUDED THAT THERE'S NO SMOKING GUN FOR LOW BACK PAIN PAIN. THAT'S BECAUSE THE IDENTIFIED RISK FACTORS ACROSS A NUMBER OF STUDIES WERE NOT REPLICATED BY OTHER STUDY, THEY WERE WEAKLEY PREDICTIVE OF LOW BACK PAIN INCIDENTS AND THIS IS FIRST ON SET OF LOW BACK PAIN AND MANY OF THOSE RISK FACTORS WERE NOT MODIFIABLE. SO WHAT THIS TELLS US IS THERE ARE LOTS OF DIFFERENT PHYSICAL AND PSYCHOLOGICAL STRESSORS AND EXPOSERS THAT CAN LEAD TO A FIRST INCIDENCE OF NECK PAIN, AND IT'S REALLY DIFFICULT TO PREDICT WHICH ONE OF THOSE EXPOSURES IS GOING TO CAUSE AN ACUTE EPISODE OF PAIN IN ANY GIVEN INDIVIDUAL. SO THE AUTHORS OF THIS STUDY WENT ON TO CONCLUDE THAT BECAUSE OF THIS, RESOURCES SHOULD REALLY BE DIVERTED FROM PRIMARY PREVENTION TO SECONDARY PREVENTION. AND I DISAGREE WITH THAT APPROACH AND I'LL TELL YOU WHY IN JUST A MINUTE. SO WHEN WE LOOK AT A SIMILAR META-ANALYSIS FOR THE RISK OF INCIDENT OR FIRST ONSET ACUTE NECK PAIN, WE FIND SIMILAR RESULTS. SO THIS WAS A STUDY LOOKING AT 15 PROSPECTIVE STUDIES ACROSS 14 COHORTS AND LOOKED AT 50 DIFFERENT BIOPSYCHOSOCIAL PREDICTERS AND AGAIN FOUND THERE WAS REALLY NO CONSISTENT TREND FOR ANY ONE PREDICTER FOR AN ACUTE EPISODE OF NECK PAIN, AND SO WE'RE SEEDING SORT OF A SIMILAR PATTERN ACROSS NECK PAIN AND LOW BACK PAIN. NOW THESE AUTHORS POINTED OUT THAT ONE OF THE REASONS FOR THAT IS BECAUSE SELDOM ARE STUDIES DONE THAT LOOK AT BIOPSYCHOSOCIAL PREDICTERS TOGETHER IN THE SAME GROUP OF PEOPLE. TYPICALLY THEY'RE LOOKING AT EITHER PHYSICAL EXPOSURES OR PSYCHOLOGICAL EXPOSURES, BUT THEY'RE NOT LOOKING AT EVERYTHING TOGETHER FOR A MORE COMPREHENSIVE APPROACH. SO WE CONDUCTED A STUDY RECENTLY WHERE WE ATTEMPTED TO DO THIS, SO WE LOOKED AT NEUROPHYSIOLOGICAL, PSYCHOSOCIAL AND PHYSICAL PREDICTERS OF PAIN IN A POPULATION OF OFFICE WORKERS WHO HAVE A VERY HIGH INCIDENCE OF NECK PAIN, BUT ALSO VERY LOW PHYSICAL EXPOSURES IN THE WORKPLACE, WHICH IS SORT OF A MYSTERY AT THIS POINT. OUT OF THE LAUNDRY LIST OF POTENTIAL CANDIDATE PREDICTERS WE LOOKED AT, WE FOUND FOUR PREDICTIVE OF CHRONIC PAIN. THE FIRST AND NOT SURPRISINGLY WAS DEPRESSED MOOD, SO PATIENTS WHO WERE -- OR INDIVIDUALS WHO WERE INITIALLY HEALTHY BUT WENT ON TO DEVELOP CHRONIC PAIN WERE MORE OFTEN REPORTED DEPRESSED MOOD. I WANT TO POINT OUT THAT THEY WERE FAR FROM CLINICALLY DEPRESSED. SO THAT'S THE THRESHOLD FOR CLINICAL DEPRESSION, AND THE INDIVIDUALS WE SURVEYED WERE WAY DOWN HERE, SO THESE ARE NOT CLINICALLY DEPRESSED INDIVIDUALS INDIVIDUALS. BUT THEY DO REPORT A HIGHER TENDENCY TOWARD DEPRESSED MOOD, WHICH I THINK IS IMPORTANT. THE SECOND PREDICTER WE FOUND WAS CONDITION PAIN MODULATION, ALSO KNOWN AS DIFFUSE NOXIOUS INHIBITORY CONTROL. THIS IS THE IDEA THAT THERE ARE SYSTEMS WITHIN THE BRAIN THAT CAN SUPPRESS OR INHIBIT THE SENSORY SIGNALS COMING FROM THE PERIPHERY. HEALTHY INDIVIDUALS WHO HAD INEFFICIENT DESCENDING INHIBITION AT BASELINE WERE MORE PREDISPOSED TO DEVELOPING CHRONIC NECK PAIN. THOSE WHO DEVELOPED CHRONIC NECK PAIN ALSO REPORTED LOWER LEVELS OF PHYSICAL ACTIVITY IN THEIR LEISURE TIME, AND THEY ALSO REPORTED LOW LEVELS OF MUSCLE ENDURANCE SPECIFICALLY OF THE CERVICAL EXTENSOR MUSCLES. SO PUTTING ALL OF THIS TOGETHER, WE CAME UP WITH A CONCEPTUAL MODEL, WHICH WE STILL NEED TO VALIDATE, BUT WHAT WE THINK IS GOING ON IS THAT HEALTHY OFFICE WORKERS WHO WORK IN A RELATIVELY SEDENTARY POPULATION, ESPECIALLY THOSE SEDENTARY DURING THEIR LEISURE TIME, DEVELOP CHANGES IN THE MUSCLE WHICH MAKE THEIR MUSCLES LESS EDURANT, IMPORTANT IN OFFICER TO STABILIZE THE GRAYS, HEAD IS ACTUALLY REALLY HEAVY, SO TO HOLD THAT UP ALL DAY LONG CAN BE DIFFICULT. IF WE DEVELOP FATIGUE DURING THE WORK DAY, METABOLITES PRODUCED ARE KNOWN TO BE POTENT STIMULATORS OF CHEMO RECEPTORS, WHICH TRANSMIT SIGNALS UP TO THE BRAIN. NOW IN A HEALTHY, FUNCTIONING NERVOUS SYSTEM, WE TYPICALLY WILL INHIBIT NONTHREATENING PAINFUL SIGNALS, BUT IN PATIENTS OR INDIVIDUALS WHO HAVE SORT OF INNATE LOWER LEVELS OF ENDOGENOUS PAIN INHIBITION, THEY'RE LESS ABLE TO INHIBIT THOSE SIGNALS SO MORE OF THEM GET UP TO THE BRAIN TO BE INTERPRETED AS PAIN, AND THEN WITH THE COMPOUNDING EFFECTS OF AN ANXIOUS OR DEPRESSED MOOD STATES, THOSE SIGNALS CAN BE FURTHER AMPLIFIED AT THE LEVEL OF THE BRAIN TO PRODUCE CHRONIC PAIN. SO REALLY I THINK THE INNOVATION IN PRIMARY PREVENTION OF PAIN IS TO LOOK AT NOT ONLY EXPOSURES TO PHYSICAL AND PSYCHOLOGICAL STRESSORS WHICH REALLY HAS BEEN THE FOCUS, BUT TO COMBINE THAT WITH BIOLOGICAL MARKERS OF SUSCEPTIBILITY, PERSONAL SUSCEPTIBILITY. SO IN THIS STUDY, WE FOUND THAT HEALTHY INDIVIDUALS WITH REDUCED LEVELS OF BASELINE ENDOGENOUS INHIBITION, A FEND TENDENCY TOWARD DEPRESSED MOOD, WERE MORE SUSCEPTIBLE TO THE EXPOSURE OF SEDENTARY -- OF BEING EXPOSED TO A SEDENTARY LIFESTYLE, CHANGES IN THE MUSCLE THAT RESULT IN MUSCLE FATIGUE, SO THEY'RE MORE SUSCEPTIBLE TO THE EFFECTS OF THOSE EXPOSURES AND GO ON TO DEVELOP CHRONIC PAIN. NOW INTERESTINGLY, THESE RESULTS HAVE BEEN REPLICATEED VERY RECENTLY IN A STUDY PUBLISHED THIS YEAR LOOKING AT SUSCEPTIBILITY TO TRANSITION FROM AN ACUTE TO A CHRONIC PAIN STATE IN ADOLESCENCE IN ADOLESCENTS AND CHILDREN WITH AN ACUTE MUSCULOSKELETAL I THINK RESUCH AS INJURY SUCH AS MUSCLE SPRAIN. REDUCED LEVELS OF ENDOGENOUS INHIBITION HAVE ALSO BEEN IMPLICATED IN THE TRANSITION FROM ACUTE POST SURGICAL PAIN INTO CHRONIC PAIN. AND SO IDENTIFYING MARKERS OF SUSCEPTIBILITY, ESPECIALLY THOSE MARKERS THAT CROSS DIFFERENT TYPES OF CHRONIC PAIN CONDITION, I THINK REALLY WILL ENHANCE OUR ABILITY TO TARGET SUSCEPTIBLE INDIVIDUALS AND PRIMARY PREVENTION PROGRAMS. SO I'LL JUST SKIP THAT IN THE INTEREST OF TIME, QUICK SUMMARY. SO WE ALL WRECK REC. NIEZ THAT PAIN IS A MULTIDIMENSIONAL EXPERIENCE. I WOULD SUGGEST THAT RECENT EFFORTS TOWARD IDENTIFYING PROGNOSTIC RISK INDICATORS IN BOTH PRIMARY AND SECONDARY PREVENTION OF CHRONIC PAIN WHERE WE HAVE THE POTENTIAL TO PREVENT PEOPLE FROM ENTERING INTO A CHRONIC CYCLE, WHICH IS DIFFICULT TO TREAT, IS REALLY AN IMPORTANT APPROACH. ALTHOUGH THERE'S LOTS OF WORK TO BE DONE IN OPTIMAL TIMING AND MODE OF DELIVERY IN THOSE PROGRAMS. AND THEN MULTIDISCIPLINARY APPROACHES CONSIDERING MULTIPLE FACTORS OF SUSCEPTIBILITY, COMBINED WITH EXPOSURE, IS REALLY WHAT WE NEED IN TERMS OF PRIMARY PREVENTION. SO WITH THAT, I WHETHER SAY THANK YOU FOR I WILL SAY THANK YOU FOR YOUR ATTENTION, SORRY I WENT OVER, AND ALSO THANKS TO NIAMS AND OTHER SUPPORTING AGENCIES FOR SUPPORTING OUR WORK OVER THE PAST 15 YEARS OR SO. THANK YOU. >> THANK YOU VERY MUCH. OUR SECOND SPEAKER EARNED HIS M.D. AND PH.D. FROM WASHINGTON UNIVERSITY IN ST. LOUIS, DR. ANDREW HERSHEY, DIRECTOR OF THE CINCINNATI CHILDREN'S HEADACHE CENTER AND SERVED AS ASSOCIATE DIRECTOR OF RESEARCH FOR THE DIVISION OF NEUROLOGY, AND IS THE ENDOWED CHAIR AND DIRECTOR OF NEUROLOGY AND A PROFESSOR OF PEDIATRICS AND NEUROLOGY AT THE UNIVERSITY OF CINCINNATI. DR. HERSHEY'S RESEARCH INTERESTS CURRENTLY INCLUDE THE IMPROVED DIAGNOSIS AND TREATMENT OF CHILDHOOD HEADACHE DISORDERS, CHARACTERIZATION OF OUTCOME RESPONSES, STUDIES IN NEW PHARMACOLOGICAL AND NON-PHARMACOLOGICAL TREATMENT REGIMES AND THE GENOMICS OF MIGRAINE. SO HE WILL TALK TO US TODAY ABOUT HIS WORK ON PREVENTION STRATEGIES FOR PEDIATRIC HEADACHE. SO DR. HERSHEY. >> THIS IS JUST MY DISCLOSURES. I DO HAVE TO THANK THE NIH FOR SUPPORTING US. WE'VE BEEN SUPPORTED FOR OVER 15 YEARS FOR OUR HEADACHE WORK AND SOME OF THE STUDIES I'M GOING TO SHOW TODAY. SO MY OBJECTIVE TODAY IS REALLY TOWPPED STAND THE LATEST UPDATES ON PREVENTION IN ADOLESCENTS ALTHOUGH MUCH OF THIS CAN BE EXTENDED AND APPLIED TO ADULTS WITH MIGRAINES, AS WELL AS CHRONIC MIGRAINES, AS WELL AS TO DEVELOP AT THE END SORT OF A TREATMENT STRATEGY WITH FITS IN LINE WITH A LOT OF WHAT WE'VE HEARD TODAY IN TERMS OF INTERDISCIPLINARY MULTIMODAL TREATMENT. IT MAKES SENSE THAT THE SAME THINGS THAT APPLY TO OTHER CHRONIC PAIN DISORDERS SHOULD ALSO APPLY TO MIGRAINES. SO FIRST OF ALL TO GET US ALL ON THE SAME PAGE TO HOW DO YOU CLASSIFY MIGRAINES, MANY PEOPLE THINK THEY KNOW HOW TO CLASSIFY MIGRAINES, MANY PEOPLE IN THE LAY PUBLIC ACTUALLY DON'T THINK THEY HAVE MIGRAINES WHEN THEY DO, SO USING STANDARDIZED CRITERIA IS IMPORTANT. WE'RE ACTUALLY NOW ON OUR THIRD EDITION, IT'S CALLED BETA, BUT WITHIN SIX MONTHS, IT WILL BE FINALIZED, PLANS RIGHT NOW, WE'LL RELEASE IT IN JANUARY, OF THE INTERNATIONAL CLASSIFICATION OF HEADACHE DISORDERS. THIS WAS EVOLVED FROM 1962, WHEN THE AD HOC COMMITTEE CAME UP WITH 12 DIFFERENT HEADACHE TYPES TO A POINT IN 1998 AND 2013, WHEN WE'VE CONTINUED TO REVISE IT. SO IF WE LOOK AT MIGRAINES, MIGRAINE CAN REALLY BE DIVIDED INTO MIGRAINE WITHOUT AURA, MIGRAINE WITH AURA AS WELL AS SOME OTHER COMPLICATIONS INCLUDING CHRONIC MIGRAINE, STATUS MIGRAINOSIS, AS WELL AS SOME EPISODIC SYNDROMES, WHICH WE USED TO CALL CHILDHOOD SO WHY STUDY MIGRAINE? IT'S VERY COMMON, UP TO 4% OF YOUNG CHILDREN, 10 1/2% OF CHILDREN 5 TO 15 AND IN 1 STUDY, ALMOST 28% OF 15 TO 19-YEAR-OLDS, GIRLS IN THIS CASE, HAD MIGRAINES. WE LOOK ATE ADULT WOMEN B18% OF ADULT WOMEN AND 5% OF ADULT MEN. SO MEN TO TEND TO GET A LITTLE BIT BETTER, IT DOES APPEAR TO BE GENETIC, IF WE LOOK AT INHERITANCE PATTERNS, I'LL TALK A LITTLE ABOUT THAT, BUT EARLY INTERVENTION, THAT'S WHERE WE ARGUE TREATING CHILDREN FOR MIGRAINE PREVEPTION MAY PREVENT OR HAVE LESS ON THE IMPACT THAN ADULTS. WE ACQUIRED UP TO -- IN $1,998, IT WAS $17 BILLION, A RECENT STUDY WHICH I DIDN'T INCLUDE HERE BECAUSE IT JUST CAME OUT SAY IT MAY BE AS HIGH AS 60 TO $75 BILLION IN U.S. COSTS DUE TO MIGRAINES. FROM AN INDIVIDUAL COST, THERE'S BOTH INDIRECT CARE AND DIRECT CARE, AND CHRONIC MIGRAINES DO TEND TO BE MUCH MORE EXPENSIVE THAN WE LOOK AT EPISODIC MIGRAINES, BUT BOTH ON AN ANNUAL IF WE LOOK AT THE WORLD INSTEAD OF JUST THE UNITED STATES, PEOPLE AREN'T FAMILIAR WITH THIS, IT'S A VERY INTERESTING REVIEW THAT CAME OUT IN LANCET IN 2016, IN OCTOBER, BUT LOOKED AT THE 2015 GLOBAL BURDEN OF DISEASES. SO THESE ARE THE TOP 10 DISEASES ACROSS ALL THE DIFFERENT AGES, FROM EARLY NEONATAL PERIOD TO GREATER THAN AGE 80. IF WE JUST SORT OF HIGHLIGHT OR PHASE OUT EVERYTHING THAT'S NOT MIGRAINE-RELATED, YOU CAN SEE WHERE MIGRAINE REALLY WORLDWIDE IS UP WITH OF THE TOP DISEASES OF CHILDHOOD ALL THE WAY INTO ADULTHOOD. INTERESTING TALK WE JUST HAD, IF YOU LOOK AT BACK AND NECK PAIN, YOU CAN SEE ACTUALLY IT HITS NUMBER ONE ACROSS THE BOARD FROM 25 AND ABOVE. SO PAIN AND PAIN-RELATED DISORDERS ARE COMMON IN MIGRAINES SPECIFICALLY AS IT CROSSES THE AGES. SO DOES MIGRAINE CHANGE WITH TIME. NOW GETTING INTO DIFFERENT FEATURES THAT MAY BE RELATED AND APPLIED FOR INTERVENTIONS. SO ONE OF OUR SUMMER STUDENTS A COUPLE YEARS AGO LOOKED AT OUR DATABASE, AT THIS POINT THERE WAS JUST OVER 5,000 KIDS AGES 4 TO 18, THE AVERAGE AGE WAS ABOUT 12, AND LOOKED AT THE DIAGNOSTIC CRITERIA THAT DO APPLY TO MIGRAINES. SO IF WE LOOK WHAT HAPPENS TO MIGRAINES ACROSS THE AGES, WE CAN SEE THE FREQUENCY SEEMS TO CLIMB AND THIS IS ON PRESENTATION TO THE HEADACHE CENTER. IF WE LOOK AT THE DURATION, THE AVERAGE LONG DURATION CAN ACTUALLY START TO EXCEED IN INTO DAYS. IT'S NEARLY MOST OF THE DAY BY THE TIME WE GET TO THE LATE TEENS. IF WE LOOK AT THE HEADACHE FEATURES, THERE IS THIS CLASSICAL DEFINITION OF A TRANSITIONING FROM A BYE TEM BUY -- MORE UNILATERAL PAIN IN THE ADULTS AS WE GO THROUGH THAT TRADITION. ALSO AS WE LOOK AT THE CLASSIC NIGH TIER YA FORM MIGRAINES, WE CAN SEE THAT THE VOMITING EPISODES ACTUALLY IMPROVE AS KIDS GO THROUGH THEIR AGES, BUT INTERESTINGLY ONE THING WITH THE CRITERIA IS THAT LIGHT-HEADEDNESS SEEMS TO INCREASE. SO KIDS DO MEET THE CRITERIA, BUT THE CRITERIA DO SEEM TO CHANGE AS THEY GO THROUGH PUBERTY. COULD PART OF THE EFFECT BE A MENSTRUAL EFFECT? IS PUBERTY AND MENSTRUAL HORMONAL EFFECTS THE REASON FOR THIS? WE ASKED ALMOST A THOUSAND GIRLS BETWEEN 9 AND 18, HAD THEY HAD THEIR FIRST PERIOD, DO HEADACHES OCCUR OR WORSEN WITH THEIR PERIODS OR EVEN IF THEY HAVE ANOTHER PERIOD DO THEY HAVE A MONTHLY PATTERN. USUALLY YOU LOOK AT THE BLACK BARS, BY AGE 13, MOST GIRLS START TO HAVE A PATTERN, ALTHOUGH IN THE WHITE BARS, IT MAY TAKE A LITTLE LONGER FOR THEM TO CO-ASSOCIATE WITH THAT MONTHLY PATTERN WITH THEIR MENSTRUAL PERIOD. WE LOOK AT THE TIMING, IT'S VERY DIFFICULT AS AN ADULT WOMAN -- IT'S ONE TO TWO DAYS BEFORE THE PERIOD STARTS. SO VINCE MARTIN, A COLLEAGUE AT UNIVERSITY OF CINCINNATI, LOOKED AT ADULT WOMEN IN TERMS OF WAS THERE A HORMONAL EFFECT. AND WHAT HE WAS ABLE TO LOOK AT WAS DAILY URINE SAMPLES OF ABOUT 15 WOMEN THAT BASICALLY COLLECTED SAMPLES OF THEIR FIRST MORNING URINE EVERY KAY DAY FOR THREE MONTHS, AND THEN THEY CAN LOOK AT THE PREDICTIVE VALUE AND FOUND THAT THE MIGRAINE PEAK DOES CORRELATE MORE WITH AN ESTROGEN RESPONSE. SO WE WORKED TOGETHER AND DECIDED TO LOOK AT WHAT HAPPENS IN GIRLS. SO WE TOOK THE ADULT STUDY IDEA AND LOOKED AT GIRLS THAT WERE WEREPREPUBERTAL, AND THESE WERE THE METABOLITES WE WERE ABLE TO LOOK AT. THE THING ABOUT THESE GIRLS, ESPECIALLY, THEY'RE VERY ADHERENT. WE HAD 96% SAMPLE COLLECTION, WHICH MEANS THEY BARELY EVER MISSED A DAY OF COLLECTING THEIR MORNING URINE, SOME OF THE STORIES THEY TOLD US HOW THEY MADE SURE THAT HAPPENED, HAVING ICE SAMPLES ON AIRPLANES SO THEY COULD BRING THEIR SAMPLES BACK TO US WAS IMPRE SELF. WHAT WE FOUND, THE ESTRONE -- IF WE LACK AT MORE OF LOOK AT MORE OF A TRANS ITION PHASE, WE RECENTLY PUBLISHED THIS IN "HEADACHE," THERE DOES SEEM TO BE TRANSITIONS. WITHOUT GOING THROUGH THE DETAIL OF THE CAUSES, WHAT WE SEE IS PREPUBERTAL, THERE WAS NOT MUCH OF A PREDICTIVE FACTOR, WHICH IS REPRESENTED BY THE RED BARS. SO YOU SEE THE SLOPE ON THE LEFT DOESN'T CHANGE TOO MUCH. ALTHOUGH IN THE UPPER RIGHT, THERE DOES SEEM TO BE SOME PROGESTERONE EFFECT IF THE LEVELS GET TOO HIGH, AND THIS MAYBE SUGGESTS THE GIRLS ARE STARTING TO GO KNEW PEW PUBERTY. IN THE GREEN LINES, THAT THAT'S WHERE WE START TO SEE THE CHANGE. IN CONTRAST TO THE ADULT STUDY, IT SEEMED PROGESTERONE WAS MORE THE PREDICTER OF THESE GIRLS STARTING TO GO INTO PUBERTY. THE 16 TO 17 GIRLS ARE THOSE THAT -- THEIR CHANGES SEEM TO BE MORE ASSOCIATED WITH THE ESTROGEN. SO THERE DOES SEEM TO BE A HORMONAL EFFECT BUT THAT DOESN'T SEEM TO BE EXACT LIT RELATED TO ADULTS SO IT'S A COMBINATION OF THE ESTROGEN AND PRO JETION TROAN. SO WHAT ABOUT GENETICS? IF WE LOOK AT A FAMILY HISTORY OF MIGRAINES, WHAT THIS SHOWS IS ON THE BLUES, THE BLUE FOR BOYS, THE MALE SIDE OF THE FAMILY, THE REDS ARE FOR THE GIRLS SIDE OF THE FAMILY, BUT YOU DO SEE THAT THE MOMS HAVE A MUCH HIGHER PROPENSITY OF HAVING MIGRAINES THAN THE DADS. UP TO 70% OF THE MOMS HAD MIGRAINES OR HEADACHES, ONLY ABOUT 40% OF THE DADS COMPLAINED OF HEADACHES AND ABOUT 20% OF THEM RELATED IT TO MIGRAINES. SO THERE'S A GENETIC FACTOR BUT THERE ALSO SEEMS TO BE SOME GENDER INHERITANCE CONTRIBUTIONS CONTRIBUTIONS. I THINK THIS ACTUALLY HELPS REPRESENT THIS IDEA VERY WELL. THIS WAS A GROUP OF 1480 SWEDISH TWINS, SO THEY DIDN'T HAVE HIPAA, SO WHEN BABIES WERE BORN IN SWEDEN, THEY WERE FOLLOWED, AND THEY COULD LOOK FOR THEIR ASSESSMENT. AND SO THEY LOOKED AT BOTH MONO SIGH ZYGOTIC BOYS AND GIRLS AND THEN OPPOSITE SEX AND WHAT THEY COULD LOOK AT IN THESE DIFFERENT TWINS IS THEN A CONTRIBUTION OF HOW MUCH WATION RELATED TO A SHARED ENVIRONMENT, INDEPENDENT GENETIC ENVIRONMENT OR EXCUSE ME -- AN INDEPENDENT ENVIRONMENT, A SHARED ENVIRONMENT OR GENETIC FACTOR WHERE THERE WAS AUTOSOMAL DOMINANT OR RECESSIVE. AND THE BOTTOM LINE THAT'S SHOWN HERE, IF WE LOOK AT THIS THE GENETIC FACTORS REPRESENT ABOUT 70% OF THE REASON THAT TWINS EXPRESS THEIR MIGRAINES. THE COMMON ENVIRONMENT ACTUALLY HAD NO INFLUENCE AT ALL, SO THAT'S THE C. BUT THE INDEPENDENT ENVIRONMENT DID AFFECT 30%. SO WE REALLY CAN'T CHANGE THEIR GENETICS AS I TELL THEIR KIDS, BUT WE DO HAVE THAT OPPORTUNITY TO ALTER THAT 30% OF ENVIRONMENTAL EFFECTS THAT MAY BE GOING ON. THIS IS WHERE I THINK THE MULTIMODAL TREATMENT EFFECT HAS THE BIGGEST IMPACT FOR MIGRAINES. TO QUICKLY GO THROUGH AN EXAMPLE, AND THIS IS A VERY GOOD REVIEW THAT SORT OF LISTS THE CURRENT UP TO 46 DIFFERENT GENES THAT MAY BE ASSOCIATED WITH MIGRAINES, SO MIGRAINES ARE CLEARLY A POLYGENETIC DISORDER, BUT THEY WERE ABLE TO DIVIDE THESE POLYMORPHISMS INTO FOUR DIFFERENT CATEGORIES. THERE'S FOUR DIFFERENT NEUROLOGICAL GROUPS THAT MAY BE ASSOCIATED -- OR GENETIC GROUPS THAT MAY BE ASSOCIATED WITH MIGRAINES, INCLUDING ITS NEUROLOGICAL FACTOR, VASCULAR FACTORS, HORMONAL AND INFLAMMATORY. IF WE LOOK DOWN THE LIST, THESE CAN INCLUDE IN THE NEUROLOGICAL FACTORS THE SEROTONIN RELATED DREAMS GENES, THE DOPAMINE RECEPTOR GENES, THERE'S THE VASCULAR GENES, WHICH YOU CAN LOOK AT YOUR FAVORITE LIST HERE AND AGAIN, FOR THE LIST, I'D RECOMMEND YOU DO REALLY REFER TO THE ARTICLE AS I SEE PEOPLE TRYING TO TAKE PICTURE OF THIS, CAN YOU GET A MUCH CLEARER DETAIL OF THAT. THEN THERE'S HORMONAL CANDIDATE JEANS WHICH I TALKED ABOUT WITH THE ESTROGEN RECEPTORS AS WELL AS THE PROGESTERONE RECEPTORS THAT MAY BE CONTRIBUTING TO THAT EARLY EXPRESSION DURING PUBERTY, AND THEN FINALLY THE INFLAMMATORY GENES. SO THE GENES REALLY DO REFLECT THE CAUSE OF MIGRAINES BUT THE CAUSE IS POLYGENETIC, SO DEPENDING ON YOUR GENETIC LOAD, ALL THESE MAY HAVE INFLUENCE. WHAT THE NERVOUS SYSTEMS? WE'VE DONE STUDIES TO LOOK AT HOW SENSITIVE THE NERVOUS SYSTEM IS. WE DO THIS BY A FINGER TAPPING TECHNIQUE. TO BRIEFLY DESCRIBE WHAT THIS IS, IS THAT THE CHILDREN WILL HEAR A CLICK IN THE RIGHT OR LEFT EAR, THEN THEY'RE SUPPOSED TO TAP THEIR FINGERS. SO WHAT WE DID IS WE LOOKED AT KIDS BOTH WITH AND WITHOUT MIGRAINES, AND ONCE THEY GOT THE TRIGGER, WHAT WE CAN SEE THAT IS THAT THERE WAS ABOUT A 40% DELAY IN HOW LONG IT TOOK THEM TO PROCESS THE SIGNAL AND THEN DO A FINGER TAP DURING A MIGRAINE ATTACK. SO THIS REPRESENTS THE GLAI DELAY OF THAT FIRST SIGNAL THAT WAS LATENT. FORTUNATELY WHEN THEY'RE NOT HAVING A MIGRAINE, THEY'RE NORMAL AND BUT THIS SHOWS WHEN KIDS ARE HAVING A MIGRAINE IN SCHOOL, THEY'RE THINKING ABOUT 40% SLOWER, WHICH MAKES IT HARD TO DO YOUR SCHOOL WORK, HARD TO PROCESS THE INFORMATION YOU'RE SUPPOSED TO DO. THIS REALLY GOES ACROSS THE BOARD THROUGHOUT THE PROCESSING OF THE FIRST, SECOND AND THIRD LATENCY. IF WE LOOK AT THAT NEUROPHYSIOLOGICAL INFLUENCE, WE CAN LOOK AT THE SPREAD WITH MEG, SINCE MEG GIVES US BOTH THE ELECTRICAL PATTERN AS WELL AS THE ANATOMICAL PATTERN, WE SHOW DURING MIGRAINES, THIS SPREADS TO A BUY BICORTICAL FUNCTION. SO HOW -- WHAT ARE STRATEGIES THAT WE CAN PUT INTO PLACE? SO THERE'S THE PATHOPHYSIOLOGICAL COMPONENTS THAT WE SEE BUT WHAT WORKS BEST? WELL, WE NEED TO REDUCE THE FREQUENCY OF HEADACHES. SOME ADULT STUDIES HAVE DEMONSTRATED THAT GOAL SHOULD BE LESS THAN ONE A WEEK. IT'S ALSO SUGGESTED IT MAY TAKE 8 TO 10 SECONDS AS THEY SUGGESTED BECAUSE WE'RE ACTUALLY DEVELOPING SOME TRAJECTORY WORK THAT WE MAY FIND OUT MUCH QUICKER THAN EIGHT TO 10 WEEKS AND WE REALLY MAY NOT NEED THE FULL 16 WEEKS OF RESPONSE. I'LL SHOW A COUPLE INDICATORS FOR THAT. IF WE LOOK AT A LIST OF MEDICATIONS, THEY REALLY HAVEN'T BEEN UPDATED TOO MUCH BECAUSE WE HAVEN'T GAINED TOO MANY, ALTHOUGH THAT'S ABOUT TO CHANGE. AS NEW COMPOUNDS AND ANTIBODIES ARE STARTING TO BE DEVELOPED. SO REALLY THIS IS DATA FROM 1993, WITH THE EXCEPTION OF -- I -- THERE REALLY WASN'T MUCH ADDED. IF WE LOOK AT PEDIATRICS IN PARTICULAR, WHAT WE FIND FROM A 2011 STUDY IN -- IF WE LOOK AT THE LIST OF AGENTS THAT WE HAVE AVAILABLE, I WANT TO FOCUS YOUR ATTENTION ON THE RCT AND THE EVIDENCE LEVEL COLUMN. IF WE LOOK AT THE EVIDENCE LEVEL, THERE'S ONLY TWO STUDIES THAT HAVE LEVEL A EVIDENCE. BOTH OF THEM ARE OPEN TRIALS. MEANING IN 2001, WHEN WE'RE LOOKING AT THIS, THERE WERE NO STUDIES WE COULD RELIABLY SAID WERE GOOD PREVENTIVE AGENTS. MANY OF THESE WERE NON-SIGNIFICANT. OF THOSE THAT WERE SIGNIFICANT, THEY REALLY WERE NARROWED DOWN TO PLENARIZENE, AS WELL AS POTENTIALLY AMITRIPTYLINE. A WORLDWIDE PA PATTERN -- IF WE LOOK AT THE DIFFERENT COMPOUNDS THAT MAY BE INVOLVED, INCLUDE GAB NER JIK COMPOUNDS LIKE VAL PRO ATE, GAB AS APENTIN, WE SURVEYED EXPERTS AND FOUND THAT REALLY TOP IRAMATE AND AMITRIPTYLINE WERE THE TWO MEDICINES PEOPLE WERE MOST COMMONLY USING. SO WHAT WE DID WAS DEVELOPED -- TO TRY TO COME UP WITH A STRATEGY AT LEAST FROM A PHARMACOLOGICAL APPROACH IS DEVELOP THE CHAMP STUDY, SO SPONSORED BY THE NIH, A MULTICENTER STUDY, 8 TO 17-YEAR-OLDS, TRY TO USE A REAL WORLD APPROACH TO GET HEADACHES DOWN TO LESS THAN ONE A WEEK, SO THEY HAD TO START WITH MORE THAN FOUR HEADACHES PER MONTH, USING FAIRLY STANDARDIZED DOSES, A 1 MILLIGRAM AND 1 MILLIGRAM OF AM TRIP AMITRIPTYLINE AND 2 MILLIGRAMS A DAY OF TPM. TO DEFINE JUST FOR DEFINITIONS HEADACHE FREQUENCY CAN BE DEFINED IN MULTIPLE DIFFERENT WAY, INCLUDING A HEADACHE DAY, WHICH IS A 24-HOUR PERIOD IN WHICH THEY HAVE A HEADACHE, HEADACHE FREQUENCY, WHICH THE START TIME AND END TIMES ARE INDEPENDENT OF THE 24 HAD 24-HOUR CLOCK, AS WELL AS A MIGRAINE DAY IF THEY HAVE MIGRAINE FEATURES OR MIGRAINE EPISODES. WE CHOSE HEADACHE DAY. IT WAS THE MOST EASIEST FOR MOST KIDS TO COMPLY. THEY KNEW WHEN MIDNIGHT WAS AND THEY KNEW WHETHER THEY HAD A HEADACHE BETWEEN MIDNIGHT TO MIDNIGHT, AND I'VE ARGUED OVER AND OVER THAT REALLY SHOULD BE THE STANDARD. THERE ARE STUDIES THAT HAVE HAVE ALL THE FEATURES THAT REPRESENT MIGRAINES BUT THEY'RE PROBABLY ALL MIGRAINES. SO JUST USING A HEADACHE DAY IS THE SIMPLEST APPROACH. I'M GOING TO FLIP THROUGH THESE FEW SLIDES PRETTY CLOSELY, PROTOCOL PAPER IN "HEADACHE" IN 2016, BUT WHAT THEY DO REPRESENT IS THE TYPICAL CHILD SEEN IN A HEADACHE PROGRAM. THE AVERAGE AGE IS 14, ABOUT TWO THIRDS ARE GIRLS, ONE-THIRD ARE BOYS, THE DEMOGRAPHICS RACIALLY ARE PRETTY WELL DISTRIBUTED TO THE POPULATION. MOST OF THESE KIDS HAVE HAD HEADACHES FOR FIVE YEARS BEFORE THEY CAME TO SEE A HEADACHE SPECIALIST, SO THIS WASN'T REALLY A NEW PROBLEM FOR THEM BUT EXISTING AND GROWING PROBLEM. AND MOST OF THEM AVERAGE ALMOST HALF THE TIME A MONTH WITH HEADACHES THIS IS REFERRAL TO A HEADACHE SPECIALIST CENTER SO THEY'VE GONE THROUGH THEIR HICK CARE OR OTHER CARE PROVIDER. MANY OF THEM DID HAVE LONG HEADACHES UP TO A DAY AT A TIME FOR THEIR LONGEST, BUT THE AVERAGE IS ABOUT SIX HOURS A DAY. MOST WERE IN THE MODERATE TO SEVERE RANGE. THE LOCATIONS WERE FAIRLY DISPERSED GOING FROM BITEMPORAL ALL THE WAY TO ALL OVER HEADACHES, AND THE PAIN WAS TYPICALLY THROBBING IN ABOUT 80% OF THE PATIENTS. NAUSEA WAS QUITE COMMON, ALTHOUGH VOMITING NIGHT QUITE SO, LIGHT AND SOUND SENSITIVITY WERE ALSO VERY COMMON. ALTHOUGH THERE WAS A LITTLE BIT OF A DIFFERENCE BETWEEN THE PLACEBO AND THE ACTIVE ARMS. WE LOOK AT THE BASELINE RESULTS, SO FOR 28 DAYS, THESE KIDS KEPT DIARIES, EVEN THOUGH THEY GOT A DIAGNOSIS, WERE GIVEN ACUTE TREATMENT AND TALKED ABOUT HEALTHY HABITS AND HOW TO BETTER TAKE CARE OF THEMSELVES, IT REALLY DID NOT CHANGE THEIR FREQUENCY. THEIR ODDS OF HAVING A HEADACHE WAS ABOUT 40% AND THAT'S WHAT THE RIGHT PANEL SHOWS. SO WHAT ARE THE RESULTS? WE LOOKED AT THE 50% REDUCTION IN HEADACHE KAYS, DAYS, THEN WE LOOKED AT THE SECONDARY RESULTS. THIS IS A DIAGRAM THAT SHOWS WE STARTED WITH 488 KIDS, THEY WERE DISTRIBUTED, 144 RECEIVED AMITRIPTYLINE, 72 GOT PLACEBO. THE SAME NUMBERS CONTINUED THROUGH THE END OF THE STUDY. 145 WERE ASSIGNED TO RECEIVE TOPIRAMATE. THOSE THAT DIDN'T COMPLETE THE STUDY WERE CONSIDER ADD FAILURE ALL THE WAY TO OBSERVED DATA WHICH WERE KIDS THAT COMPLETED THE STUDY. IF WE LOOKED AT AMITRIPTYLINE, ABOUT 50% OF THOSE THAT WERE ININTENT TO TREAT RESPONDED, 50% GREATER REDUCTION, UP TO 66% IF WE LOOK AT THE OBSERVED DATA. TOPIROMATE, IT NEARLY LOOKS IDENTICAL, IN FACT, STATISTICALLY IT IS, BUT THE SURPRISING THING FOR US IS WE LOOKED AT PLACEBO, IT WAS ALSO EXACTLY THE SAME. SO WHAT THAT SHOWS IS THAT THE KIDS CAN BE MADE TO GET BETTER, BUT IT MAY NOT BE THE BIOLOGY OF THE COMPOUND. SO OVER 50% OF THE KIDS HAD A GREATER THAN 50% REDUCTION IN THEIR HEADACHES, BY FOLLOWING THIS PROTOCOL, AND IT WASN'T JUST DUE TO HAVING A DIAGNOSIS AND ACUTE TREATMENT, HEALTHY HABITS, BECAUSE THEIR BASELINE DIDN'T CHANGE. IT WAS ONCE THEY RECEIVED A COMPOUND TO PREVENT THEIR HEADACHES THAT THEY SEEM TO RESPOND. IN FACT, IF WE LOOK AT THE HIGH LEVELS OF THIS, WE CAN ACTUALLY SEE WE COULD GET TO NEARLY 100%. SO SOME OF THE KIDS DID GET TO 100% IMPROVEMENT, WHETHER IT WAS PLACEBO ACTIVE OR IN THE ACTIVE ARMS. SO WHAT CAN WE DO? WE CAN DO NUTRICEUTICALS, THEY'RE STILL PILLS AND STILL POTENTIALLY HAVE SIDE EFFECT. THERE ARE SEVERAL THAT HAVE BEEN LOOKED AT. WE LOOK AT RIBOFLAVIN, RIBOFLAVIN IS INVOLVED IN MITOCHONDRIAL PRODUCTION, ONE SUGGESTION IS LOW ENERGY EFFECTS IS A CAUSE OF THIS. AND THIS JUST SHOWS WHERE RIBOFLAVIN IS INVOLVED ON THE RIGHT, A STUDY DID SHOW NEARLY 60% OF THE PEOPLE COULD RESPOND TO RIBOFLAVIN. THE PLACEBO RESPOND RATE IS ONLY 15. PEOPLE ARGUE THAT KIDS JUST HAVE A HIGH PLACEBO RESPONSE RATE, I'M GOING TO SHOW A SLIDE THAT MAYBE IT'S THAT THE DIFFERENCE HERE IS NOT THE ACTIVE ARM BUT THE PLACEBO EFFECT. WE LOOK AT RIBOFLAVIN DEFICIENCY, THIS JUST SHOWS OUR HEADACHE CENTER POPULATION. THE BLUE BAR AT THE TOP SHOWS WHERE YOUR NORMAL SHOULD BE, AND THIS SHOWS AT THE BOTTOM WHERE KIDS ARE TYPICALLY -- RIBOFLAVIN COMES FROM GREEN VEGETABLES, SO FOR THOSE THAT HAVE KIDS, TRYING TO GET THEM TO EAT GREEN VEGETABLE, RIBOFLAVIN IS ANOTHER GOOD REASON WHY. ROSEN WAS ABLE TO SHOW THAT WITH COENZYME Q10, YOU WERE ABLE TO REDUCE HEADACHE FREQUENCY. SIMILARLY IF YOU LOOK AT LEVELS, WE DEMONSTRATE THIS IN 2007, THE NORMAL LEVEL FOR COENZYME Q10 IS .5 TO .15. IF WE LOOK AT A CROSSOVER STUDY, NOW THIS WAS EARLY ON, BEFORE WE REALIZED WE NEEDED TO CHECK BASELINES, AND YOU SEE THE KID RESPONDED VERY QUICKLY TO COENZYME Q10 AND PLACEBO, AGAIN GETTING ABOUT A 60 TO 70% RESPONSE. IF WE LOOKED AT THE ACUTE KIDS, INTERESTINGLY THEY BOTH RESPONDED QUICKLY BUT WHEN WE DID THE CROSSOVER, THE COQ10 KIDS DID WORK WHEN THEY WENT TO PLACEBO, WHEREAS THE PLACEBO KIDS CONTINUED TO IMPROVE. ALL THE CHRONIC KIDS TEND TO GET BETTER BUT THERE'S SEPARATION. BUT STATISTICALLY, THERE'S SEPARATION ONLY POSITIVE SEPARATIONS AT A FEW OF THE TIME POINTS. WHAT ABOUT VITAMIN D? VITAMIN D HAS BEEN SHOWN TO BE LOW IN SEVERAL DIFFERENT COMPONENTS. IF WE LOOK AT VITAMIN D DEFICIENCY, THOUGH, WHICH IS A MOVING TARGET, THE LEFT PANEL DEMONSTRATES THAT MANY OF THE KIDS WE HAVE ARE LOW IN VITAMIN D, IF WE USE 40 AS A CUTOFF CUTOFF -- THERE IS SOME SEASONAL VARIATION. SO IF WE LOOK AT THE MONTHS WHICH ARE ON THE RIGHT FROM JANUARY TO FEBRUARY, THE PURPLE BAR IS THE VITAMIN D LEVEL DOES TIME, BUT IT DOES CLIMB TO ABOUT 40 FOR MOST OF OUR KIDS. SO I'M GOING TO GO PAST TIME FOR A FEW MINUTES I APOLOGIZE, BUT I DO THINK IT'S IMPORTANT TO TALK ABOUT THE COPING OF CHRONIC MIGRAINE STUDY WE DID, ALSO SPONSORED BY THE NIH. THIS LOOKED AT CHRONIC MIGRAINES WITH KIDS THAT WERE DISABLED. THEY WERE TAUGHT COGNITIVE BEHAVIORAL THERAPY FOR EIGHT WEEKS. THIS IS JUST ONE OF THE FEW MINI SLIDES THAT SHOWS THAT KIDS THAT LEARN COGNITIVE BEHAVIOR THERAPY PLUS AMITRIPTYLINE COMPARED AMITRIPTYLINE WITH THE EDUCATIONAL CONTROL, STATISTICALLY WERE BETTER BOTH AT THE END OF THE EIGHT WEEKS, WHICH IS THE CIRCLE ON THE LEFT, AND SUSTAIN THAT WAY FOR THE NEXT YEAR. SO KIDS LEARN COGNITIVE BEHAVIOR THAT YOU WERE AND CAN STAY BETTER WHETHER WE LOOKED AT THEIR -- FOR HEADACHE FREQUENCY OR HEADACHE DISABILITY, AND THEY'RE ABLE TO MAINTAIN THIS WITHIN EIGHT WEEKS. SO WHERE DO WE GO? WE KNOW WE CAN MAKE CHILDREN BETTER, THAT'S THE GOOD NEWS, UP TO 50 TO 70% IMPROVEMENT BUT IT MAY NOT NECESSARILY BEING THE PHARMACOLOGICAL AGENT, ALTHOUGH USING MULTIMODAL AND MULTIDISCIPLINARY TREATMENT COULD BE USEFUL. PLACEBO WOULD PROBABLY BE THE BEST OPTION BUT SINCE PLACEBO IS NOT CURRENTLY PRESCRIBABLE, USED TO BE, IT WAS ACTUALLY PLACEBO SPELLED BACKWARDS WAS HOW WOULD YOU PRESCRIBE IT AND I HAVE DONE THAT BEFORE, WE COULD ACTUALLY DO THAT. AS WE MENTIONED IN TALKS YESTERDAY, WHAT ABOUT THE 30 TO 40% THAT DON'T GET BETER? SO WHAT WE REALLY NEED TO FOCUS ON IS EXPECTATION RESPONSE, AND THIS COMES FROM A REVIEW FROM DR. -- THAT REALLY SHOWED THAT ALL THESE FACTORS THAT CAN CONTRIBUTE TO MULTIMODAL TREATMENT NEEDS TO BE APPROACHED TO IMPROVE THE EXPECTATION RESPONSE, BECAUSE IF WE CAN IMPROVE THE KIDS' EXPECTATION, THEN WE CAN MAKE THEM BETTER. SO ONE OF THE STRATEGIES IS HOW DO YOU TALK TO THE KIDS AND HELP WITH THEIR EXPECTATION? THIS IS JUST THE -- IT'S A NEW AREA, NOT PUBLISHED YET BUT JUST ONE THING I WANTED TO LOOK AT WAS IN EFFECT TO THE KIDS WHERE WE SAW THAT PLACEBO RESPONSE WAS VERY HIGH, I WANTED TO LOOK AT WHAT HAPPENED IN ADULT STUDIES. SO THIS IS ALL THE AGENTS THAT WE'RE CURRENTLY USING COMMONPLACE, DEVELOPMENT, INCLUDING BOTOX, CGRP, DEPAKOTE, AS WELL AS PLACEBO. THE SOLID BARS REPRESENTS THE EFFECT OF THE AGENTS, THE DASHED IS THE EFFECT OF THE PLACEBOS. THE DASHED LINES AND THE SOLID LINES ARE ALL MIXED UP TOGETHER. MEANING THEY'RE REALLY NOT GETTING CLEAR SEPARATION ON A LOT OF THESE AGENTS. THE OTHER THING IS TO POINT OUT THAT INSTEAD OF THAT 24 WEEKS OF TREATMENT THAT WE TYPICALLY RECOMMEND FOR MIGRAINE PREVENTION, WE KNOW BY FOUR TO EIGHT WEEKS WHETHER AN AGENT IS WORKING. SO WE DON'T NEED TO WAIT THE 16, 24 WEEKS BUT ACTUALLY CAN RESPOND EARLIER. SO PUTTING IT ALL TOGETHER, PATIENTS AND PARENTS, THEY PRESENT TO US BECAUSE THEY NEED TO DO SOMETHING, SO WE NEED TO PROVIDE SOMETHING FOR THEM DO. THE CHAMP RESULTS SHOW JUST BECAUSE YOU GIVE THE DIAGNOSIS IN ACUTE TREATMENT AND HEALTHY HABITS IS NOT ENOUGH, WE NEED TO PRODUCE EXPECTATION. EXPECTATIONS FROM THE PHARMACEUTICAL AGENT IF THAT'S WHAT THE KIDS ARE WANTING STO WE GIVE THEM THAT OPTION. DO THEY WANT TO START A PREVENTION MEDICATION, BECAUSE IF THEY DO, THEY'RE MORE LIKELY TO RESPOND. COGNITIVE BEHAVIORAL HAS BEEN DEMONSTRATE TODAY WORK WITHIN EIGHT WEEKS AND IT'S SUSTAINED FOR UP TO 12 MONTHS. A WAIT AND SEE OPTION IS AN OPTION. BUT REALLY THE EXPERT EFFECT OF COMING TO SEE AN EXPERT MAY BE PUTTING IT TOGETHER. SO WE CAN DIAGNOSE THE KIDS, WE NEED TO PROVIDE A -- USING THE MULTIDISCIPLINARY MULTIPLE TREATMENT, AND IN THE FUTURE, WE MAY WANT TO START LOOKING AT WHAT WE CALL SMART OR MOST DESIGNS. IN THE INTEREST OF TIME, IT MAY BE SOMETHING TO CONSIDER WHEN WE LOOK AT WHICH TREATMENT SHOULD BE DONE IN WHICH ORDER AND THAT'S WHAT A SMART DESIGN LOOKS AT. JUST TO THANK ALL OUR CHAMP THIS, IS ALL THE CHAMP LOCATION SITES AND THESE ARE THE CHAMP TEAMS AS WELL AS THE CINCINNATI CHILDREN'S TEAM ON THE LEFT AND THE CHAMP GROUP ON THE RIGHT FROM THE UNIVERSITY OF IOWA. DATA COORDINATING CENTER. SO THANK YOU, APOLL JAIZ FOR GOING OVER TIME, BUT THANK YOU FOR YOUR TIME AND INTEREST. [APPLAUSE] >> THANK YOU VERY MUCH. WE'RE GOING TO TAKE A SLIGHTLY SHORTER BREAK, I WOULD ASK YOU ALL TO BE BACK AT 10:40 FOR THE FINAL TWO TALKS, AND THEN WE'LL HAVE A PANEL DISCUSSION, A 20-MINUTE PANEL DISCUSSION AT THAT POINT. THANK YOU VERY MUCH. >> WELCOME BACK, EVERYBODY. OUR THIRD SPEAKER FOR THE SESSION THIS MORNING IS DR. DANIEL RIDDLE. THE AUTO D PATENT PROFESSOR AT VIRGINIA COMMONWEALTH UNIVERSITY. DR. RIDDLE HAS HELD BOTH CLINICAL AND ACADEMIC APPOINTMENTS AND HAS RECEIVED MANY AWARDS AND RESEARCH GRANTS FOR HIS RESEARCH ON MUSCULOSKELETAL EPIDEMIOLOGY, LOWER EXTREMITY ARTHRITIS, JOINT REPLACEMENT SURGERY AND FACTORS THAT INFLUENCE RECOVERY. ADDITIONALLY, DR. RIDDLE HAS STUDIED PSYCHOLOGICAL DISTRESS IN PERSONS WITH ARTHRITIS AND INLT INTERACTIONS BETWEEN PSYCHOLOGICAL DISTRESS AND PAIN AS WELL AS THEIR IMPACT ON FUNCTION. HE'LL SPEAK ABOUT AN INTEGRATED APPROACH TO POSTOPERATIVE PAIN MANAGEMENT FOR PREVENTION OF CHRONIC PAIN. DR. RIDDLE. >> THANK YOU. GOOD MORNING, EVERYONE. ON BEHALF OF THE SPEAKERS THIS MORNING, I WANT TO THANK YOU FOR COMING BACK AFTER THE BREAK AND HANGING IN THERE WITH US TO THE END. I DO WANT TO ACKNOWLEDGE AND THANK THE NIH PAIN CONSORTIUM FOR INVITING ME TO SPEAK. I THINK THIS TOPIC REALLY TIES IN NICELY WITH MR. MALUF'S VERY NICE PRESENTATION EARLIER REGARDING THE ROLE OF RISK STRATIFICATION AND USE OF COGNITIVE BEHAVIORAL THERAPY, WHICH IS DIRECTLY RELATED TO THE TOPIC I'M GOING TO TALK TODAY. I WANT TO ACKNOWLEDGE THE COLLABORATORS AND THE FUNDERS OF OUR STUDY. I'M GOING TO SPEND A GOOD BIT OF TIME IN SORT OF A GRANULAR WAY TALKING ABOUT A SINGLE STUDY, A LITTLE DIFFERENT ABOUT WHAT YOU'VE HEARD TO FAR. I'M FOCUSING ON STRICTLY A RANDOM ICED CLINICAL TRIAL FUNDED BY NIAMS AND THAT'S GOING TO BE THE TOPIC OF MY TALK TODAY. I HAVE NO CONFLICTS OF INTEREST TO DISCLOSE. I CERTAINLY WANT TO THANK THE PATIENTS FOR PARTICIPATING AND ALSO THE PTs, CLINICAL PSYCHOLOGISTS AND NURSE INTERVENTIONISTS WHO PARTICIPATED IN OUR TRIAL. THE INTEGRATED CARE MODEL I'M GOING TO TALK ABOUT TODAY IS A COLLABORATIVE CARE MODEL OR A TRANSDISCIPLINARY CARE MODEL AS DR. MALUF DEFINED FOR YOU EARLIER, AND THIS SPECIFICALLY RELATES TO A COLLABORATIVE APPROACH BETWEEN CLINICAL PSYCHOLOGISTS AND PHYSICAL THERAPISTS TREATING PATIENTS WHO ARE PREPARING TO UNDERGO KNEE REPLACEMENT SURGERY FOR OSTEOARTHRITIS OF THEIR KNEE. THIS IS A TEAM OF TWO PTs, AND A CLINICAL PSYCHOLOGIST DELIVERING CARE OVER TIME IN THESE PATIENTS, AND THESE PHYSICAL THERAPISTS UNDERWENT QUITE A SIGNIFICANT AMOUNT OF TRAWNING IN DELIVERY OF PAIN COPING SKILLS TRAINING. THEY WERE INVOLVED IN MONTHLY CONFERENCES, CONFERENCE CALLS WITH THE HEAD PSYCHOLOGIST TRAINER AND THEY WENT THROUGH EXTENSIVE TRAINING WITH ROLE PLAY AND AUDIOTAPED PRACTICE SESSIONS WITH A CLINICAL PSYCHOLOGIST TRAINER. SO PAIN COPING SKILLS TRAINING WAS THE TARGETED INTERVNTION FOR THIS CLINICAL TRIAL THAT I'M GOING TO TELL YOU ABOUT TODAY. TRADITIONALLY US A KNOW, COGNITIVE BEHAVIORAL RELATED CARE IS VERY COMMON FOR PATIENTS WHO HAVE CHRONIC PAIN, AND THIS WAS OUR INTEREST, ALSO IN COGNITIVE BEHAVIORAL THERAPY RELATED APPROACHES, THEY HAVE TRADITIONALLY BEEN ALL-COMERS APPROACHES. IN OTHER WORDS, ALL PATIENTS WHO MEET THE CRITERIA ARE INCLUDED IN THE STUDY. OUR STUDY WAS REALLY FOCUSED ON A PHENOTYPIC SUBGROUP, SO THIS IS RISK STRATIFICATION AND ACTION, IF YOU WILL, AND OUR PATIENTS WERE ALL SCREENED FOR MODERATE TO HIGH LEVELS OF PAIN CATASTROPHIZING BEFORE THEY WERE INCLUDED IN THE STUDY. THE PAIN CATASTROPHIZING PHENOTYPE, AS I'M DEFINING IT TODAY, ARE INDIVIDUALS WHO HAD A SCORE OF 16 OR HIGHER ON THE PAIN CATASTROPHIZING SCALE AND THIS IS SULLIVAN'S SCALE, THE MOST COMMON SCALE USED TO QUANTIFY PAIN CATASTROPHIZING IN PATIENTS. THIS IS A SCALE THAT HAS BEEN CONSISTENTLY SHOWN TO PREDICT POOR OUT COME IN PATIENTS WHO UNDERGO KNEE REPLACEMENT SURGERY, AND I'M GOING TO GIVE YOU A LITTLE MORE INFORMATION ABOUT KNEE REPLACEMENT SURGERY IN A MINUTE. THE PATIENTS IN OUR TRIAL HAD A MEAN PAIN CATASTROPHIZING SCALE SCORE OF 30. THIS IS A SCALE THAT RANGES FROM SEER -- TYPICAL SCORES, MEAN SCORES FOR SAMPLES OF PATIENTS GETTING KNEE REPLACEMENT IS ALONG THE LINE OF 10. SO OUR PATIENTS HAD ABOUT TRIPLE THE A PAIN CATASTROPHIZING ON AVERAGE AS COMPARED TO STANDARD SAMPLES. THE NAME OF THIS TRIAL IS PAIN COPING SKILLS TRAINING FOR PATIENTS FITTING THE PAIN CATASTROPHIZING PHENOTYPE, AND THIS WAS AS I SAID A MULTICENTER RANDOMIZED TRIAL FUNDED BY NIH NIAMS, AND IT'S A UM MECHANISM. THE PARTICIPATING INSTITUTIONS FOR THIS TRIAL WERE WAKE FOREST, DUKE, VCU, AND NYU. SO WE HAD FOUR SITES COLLECTING DATA CONCURRENTLY. NIH WAS, OF COURSE, A COLLABORATOR IN THIS PROJECT. THE KEY TEAM MEMBERS OF THIS TRIAL, WE HAD PIs AT WAKE, WHICH WAS DR. DENNIS -- A RHEUMATOLOGIST, FRANK KEEFE, THE PSYCHOLOGIST AT DUKE HEADED THAT SITE, DR. JIM SLOVER, ORTHOPEDIC SURGEON AT NYU WAS THE LEAD PI AT NEW YORK UNIVERSITY, WE HAD TWO BIOSTATISTICIANS, THEN WE HAD SEVERAL CONSULTANTS INCLUDING MARK JENSEN AT UNIVERSITY OF WASHINGTON, MATT BAIR, CURT CROENKE AND SHELBY REID WAS THE HEALTH ECONOMIST. SO IF YOU TAKE A LOOK AT THIS SLIDE, IT'S PRETTY CLEAR THAT WE CAN IDENTIFY NORMAL KNEES FROM ARTHRITIC KNEES, AND WHEN YOU LOOK AT THE JOINT SPACE, THE JOINT SPACE IS REALLY WHAT WE'RE INTERESTED IN IN DEFINING ARTHRITIS, AN HERE YOU SEE NORMAL JOINT SPACES, AND THE R UP THERE IS THE KEY YOU'RE LOOKING AT THE RIGHT KNEE, AND THIS IS THE LEFT KNEE. FOR THE MIDDLE SLIDES, YOU SEE ONE KNEE APPEARS ABNORMAL AND THE MEDIAL COMPARTMENT AS YOU CAN SEE HAS LOST ITS JOINT SO THIS IS A KNEE THAT WOULD POTENTIALLY QUALIFY FOR A KNEE REPLACEMENT SURGERY. THE PICTURES ON THE FAR RIGHT SHOW THE NEW ANATOMY AFTER A KNEE REPLACEMENT SURGERY. KNEE REPLACEMENT SURGERY HAS BECOME THE MOST COMMON MAJOR SURGICAL PROCEDURE IN THE U.S. AS OF 2016, WE'RE SEEING OVER A MILLION, MILLION WITH AN M, MILLION KNEE REPLACEMENTS PER YEAR IN THE UNITED STATES. THAT'S INCLUDING BOTH PRIMARY AND REVISION SURGERIES. WHAT THIS SLIDE ILLUSTRATES FOR YOU IS THE PREVALENCE OF KNEE REPLACEMENT SURGERY BASED ON DECADES OF AGE FOR MALES AND FEMALES. THERE'S A COUPLE OF TRENDS HERE THAT YOU OBVIOUSLY SEE, THAT THE NUMBERS OF PEOPLE, THE PERCENT OF PEOPLE WITH TOTAL KNEE REPLACEMENT IN THE UNITED STATES INCREASES AS WE AGE, AND IT'S ALWAYS HIGHER FOR FEMALES THAN MALES, AND THIS PART OF THE -- PART OF THE REASON FOR THAT IS THAT OSTEOARTHRITIS OF THE KNEE IS MORE COMMON IN FEMALES. THIS IS ANOTHER EPIDEMIOLOGICAL SLIDE THAT ILLUSTRATES THE RISK OF HAVING A TOTAL KNEE REPLACEMENT FROM AGE 25 YEARS ON, AND AGAIN WHAT WE SEE BY AGE 60, WE SEE ABOUT 2% OF MALES AND ABOUT 4% OF FEMALES WITH TOTAL KNEE REPLACEMENT AND LESS THAN 1% HAVE HAD A REVISION TO THEIR TOTAL KNEE REPLACEMENT AND THE OTHER TREND WE SEE HERE IS THAT OVER A LIFETIME, MALE, AGAIN, HAVE ABOUT 3 PERCENTAGE POINTS LESS THAN THE TOTAL NUMBER OF KNEE REPLACEMENTS IN THE POPULATION, AND FEMALES ARE ABOUT DOUBLE THE RISK OF REVISION AS WELL. SO THIS IS A COMMON PROCEDURE, IT'S A PROCEDURE THAT'S DIFFICULT TO RECOVER FROM. WHY DID WE STUDY THE PAIN CATASTROPHIZING PHENOTYPE? THIS IS REALLY AN IMPORTANT GROUP TO STUDY WITH THIS PARTICULAR DISEASE PROCESS. PARTICULARLY BECAUSE PATIENTS WHO CATASTROPHIZE ABOUT THEIR PAIN TEND TO REPORT MORE SEVERE PAIN, THEY TEND TO BE MORE COMPROMISED WITH THEIR FUNCTION, THEY DEMONSTRATE SUBSTANTIALLY MORE PAIN BEHAVIOR, WHICH IS AN IMPORTANT -- RELATED TO TOTAL REPLACEMENT RECOVERY. THEY HAVE HIGHER RATES OF MENTAL HEALTH AND COPING CHALLENGES, THEN THE PATIENT WHO DOESN'T CATASTROPHIZE, AND THERE'S GREATER USE OF ANALGESICS. THE KEY HERE IS THAT ELEVATED ELEVATED PAIN CATASTROPHIZING IS ASSOCIATED WITH POOR OUT COME DESPITE A SOUND SURGICAL PROCEDURE. PAIN CATASTROPHIZING AS WE'VE HEARD IN SEVERAL OF THE TALKS OVER THE LAST DAY AND A HALF IS A MULTIDIMENSIONAL PAIN APPRAISAL CONSTRUCT RELATING TO RUMINATION, IN OTHER WORDS, PATIENTS WORRY ABOUT WHETHER THE PAIN WILL END, THEY TEND TO PERSEVERATE ON THAT NOTION. PATIENTS TEND TO FEEL HELPLESS, THEY REPORT THERE'S NOTHING THEY CAN DO TO REDUCE THE PAIN AND THEY TEND TO MAGNIFY THE SERIOUSNESS OF THE PAIN, SAYING THINGS TO THEMSELVES LIKE I WONDER IF SOMETHING SERIOUS MAY HAPPEN VUMENT OF MY AS A RESULT OF MY PAIN . SO THESE ARE THE KINDS OF APPRAISALS OR THOUGHTS PATIENTS HAVE THEIR PAIN AND THESE ARE THE TYPES OF PATIENTS WE TARGETED FOR THIS INTERVENTION. SO IN THE CONTEXT OF A CHALLENGING TOTAL KNEE REPLACEMENT SURGERY RECOVERY, WE KNOW THAT PAIN CATASTROPHIZEING IS A KEY PREDICTER OF OUTCOME IN THESE PATIENTS, AND IN FACT, WE KNOW THAT OF PATIENTS WHO GET KNEE REPLACEMENT, APPROXIMATELY 20 HAVE PERSISTENT FUNCTION LIMITING PAIN DESPITE A SUCCESSFUL SURGERY. AND THE DATA WOULD SUGGEST THAT PAIN CATASTROPHIZE SOMETHING LIKELY THE MOST POWERFUL PREDICTER OF THIS 20%, AND THAT'S WHY WE TARGETED THIS SUBGROUP. SO TO DEVELOP OUR TRIAL, WE HAD TO GO THROUGH A PLANNING PROCESS, OF COURSE, AND THE NIAMS FUNDING MECHANISM FOR RANDOMIZED CLINICAL TRIALS AND MULTICENTER RANDOMIZED TRIALS IS A TWO-STEP PROCESS, SO WE ACQUIRED AN R34 GRANT AND THEN FOLLOWED THAT UP WITH THE UM1, THE R34 WAS THE PLANNING GRANT THAT WE SPENT A YEAR PLANNING, AND PUTTING THE INFRASTRUCTURE TOGETHER, AND THE UM1 FUNDED THE GRANT ITSELF. WE HAD A PRE-TRIAL INVESTIGATOR MEETING THAT INVOLVED THE PLANNING AND WE USED THE PRECIS. FOR THOSE THAT DON'T KNOW THE PRECIS INSTRUMENT, IT IS A METHOD FOR MAKING DECISIONS ABOUT TRIAL DESIGN. SO IN FINALIZING THE DESIGN, WE HAD TO EXPLORE WHICH WERE PRAGMATIC AND EXPLANATORY. THESE WERE IMPORTANT DECISIONS OBVIOUSLY, AND AS MOST OF YOU KNOW WHO HAVE STUDIED COGNITIVE BEHAVIORAL INTERVENTIONS, THEY'RE TRADITIONALLY HIGHLY EXPLANATORY BY NATURE, AND THE ATTEMPT HERE IS TO CONTROL TO HAVE AS STRONG A SENSE AS POSSIBLE AS TO WHETHER THE EFFECT F IT OCCURS, IS DUE TO THE INTERVENTION OR SOMETHING ELSE. SO WHAT WE HAD TO DEAL WITH WAS A GROUP OF INVESTIGATORS WITH STRONG EXPLANATORY OR PRAGMATIC BIAS TO COME TO THE MEETING, THAT'S WHAT WE DID USING THE PRECIS. AND THIS IS THE ORIGINAL PAPER BY THORPE AND COLLEAGUES DESCRIBING THIS PRAGMATIC EXPLANATORY CONTINUUM SUMMARY TOOL TO HELP GUIDE DECISIONS ABOUT TRIAL DESIGN. WE USE THIS IN REALTIME DURING OUR MEETING TO COME UP WITH THE BEST STRATEGY FOR THE DESIGN OF THIS TRIAL. AND PUBLISHED THIS BACK IN THE JOURNAL OF CLINICAL EPI BACK IN 2010. ABOUT THREE MONTHS AFTER THAT PAPER, I GOT AN EMAIL FROM DR. DAVID SACKETT, WHO MOST PEOPLE ATTRIBUTE TO BEING SORT OF THE LEADER OF THE EVIDENCE-BASED PRACTICE MOVE MOVEMENT, AND HE TALKED AT LENGTH ABOUT THE USE OF THIS TOOL AND HE SAW A GREAT ADVANTAGE. THIS IS THE TOOL ESSENTIALLY AND I'M NOT GOING TO GO INTO ANY DETAIL HERE, BUT I DO WANT TO ALERT YOU TO THE FACT THAT THIS IS AN INSTRUMENT THAT IS READILY AVAILABLE AND WE THINK HIGHLY VALUABLE IN DESIGNING TRIALS, PARTICULARLY WHEN YOU HAVE COLLABORATIVE TEAMS OF DIFFERENT DISCIPLINES WHO BRING DIFFERENT BIASES TO THE PLANNING OF A GRANT, AND FOR EXAMPLE, WHAT YOU HAVE HERE IS THE PARTICIPANT ELIGIBILITY CRITERIA WHICH IS OBVIOUSLY SOMETHING YOU NEED TO CONSIDER WHEN YOU'RE PLANNING A TRIAL, THE PRAGMATIC TRIAL WILL ESSENTIALLY INCLUDE EVERYBODY, AND THE EXPLANATORY TRIAL GOES THROUGH GREAT LENGTHS TO TRY TO RECRUIT THOSE THOUGHT TO BE MOST HIGHLY RESPONSIVE TO AN INTERVENTION. THAT'S JUST ONE DIE DICHOTOMY OF THESE 10 DIFFERENT DOMAINS ONE NEEDS TO CONSIDER IN PLANNING A GRANT, A TRIAL. HIGHLY PRAGMATIC, HIGHLY EXPLANATORY TRIALS CAN BE DIAGRAMMED OND ON A SPIDER GRAPH YOU SEE HERE. DIAGRAM A SHOWS A HIGHLY PRAGMATIC TRIAL QR WHERE ALL THE DIFFERENT DOMAINS ARE OUT ON THE END AND THIS IS A HIGHLY EXPLANATORY TRIAL WHERE ALL. THIS IS WHAT WE FOUND. SO WHEN WE PLANNED OUR TRIAL, WE STARTED SORT OF IN THE MIDDLE BETWEEN PRAGMATIC AND EXPLANATORY, AND AS YOU CAN SEE WHERE WE ENDED UP, THE FINAL WAS MORE ON THE ECK PLANETARY EXPLANATORY REALM. WHAT DR. SACKETT WROTE TO ME AND SORT OF IDENTIFIED HERE WAS SOMETHING CALLED EXPLANATORY CREEP. I THINK THAT'S SOMETHING VERY APROPOS AND SOMETHING TRIAL PLANNERS NEED TO CONSIDER IS THAT THERE'S A STRONG TEMPTATION TO MAKE TRIALS MORE EXPLANATORY, AND SORT OF THE CULTURE HERE IN THE U.S. IS TO DESIGN AND IMPLEMENT TRIALS THAT ARE HIGHLY EXPLANATORY BY NATURE TO PROVIDE A STRONG ANSWER TO A QUESTION. I THINK AS WE IT BE TO EVOLVE IN TRIALS, WE NEED TO KEEP THIS IN MIND AS PRAGMATIC TRIALS BECOME MORE AND MORE POPULAR. THIS IS A NEW IMPROVED VERSION OF THE PRECIS, PRECIS2 AS PUBLISHED IN THE BRIT BRITISH MEDICAL JOURNAL IN 2015. IT IS, I THINK, A NEW AND IMPROVED WAY OF THINKING ABOUT TRIAL PLANNING. SO HERE'S THE BASIC STUDY DESIGN. THIS WAS A THREE ARMED TRIAL. WE SCREENED PATIENTS AS I MENTIONED EARLIER FOR PAIN CATASTROPHIZING AND VERY HIGH LEVELS OF DEPRESSION FOR SAFETY REASONS, WE INCLUDED THOSE PATIENTS AS WELL, WE DID A PACE LINE DATA COLLECTION SESSION, THEN WE RANDOMIZE TODAY THREE ARMS. THIS IS PAIN COPING SKILLS TRAINING DELIVERED BY PHYSICAL THERAPISTS, THIS IS EDUCATIONAL CONTROL DELIVERED BY NURSES, THIS IS ARTHRITIS EDUCATION, ATTENTION CONTROL ESSENTIALLY, AND THEN THE THIRD ARM WAS USUAL CARE RECRUITMENT. WE FOLLOWED PATIENTS FOR A YEAR. THEY RECEIVED THEIR SURGERY AS YOU CAN SEE AFTER BASELINE, AND THEN PATIENTS RECEIVE THESE INTERVENTIONS PERIOPERATIVELY, USUALLY STARTED A COUPLE OF WEEKS BEFORE SURGERY, FINISHED A MONTH OR TWO AFTER SURGERY. THERE WERE EIGHT SESSIONS IN EACH OF THESE TWO ARMS. I'LL TALK ABOUT THAT A BIT MORE IN A FEW MINUTES. AND THEN WE HAVE A 2 AND 6 MONTH FOLLOW-UP, AND HERE'S WHERE WE ARE TODAY. I GOT AN EMAIL TODAY SAYING WE HAVE ONE PATIENT LEFT FOR 12-MONTH FOLLOW-UP. SO WE ARE SO CLOSE TO THE END. THIS IS AIM 1 OF THE TRIAL. WE WERE INTERESTED MOSTLY IN OBVIOUSLY ASSESSING THE EFFECTIVENESS OF THIS PAIN COPING SKILLS TRAINING IN REDUCING KNEE PAIN. THE PRIMARY OUTCOME WAS THE WOMACK PAIN SCALE, WHICH IS PAIN WITH ACTIVITY. AND WE'RE INTERESTED IN REDUCING PAIN WITH ACTIVITY OBVIOUSLY WITH THE SURGERY AND WHAT THE AND ABOVE THE SURGERY ANDT OVER- RELIEVIN PAIN RELATIVE TO THE OTHER TWO ARMS? OUR HYPOTHESIS, OF COURSE, WAS THAT PAIN COPING SKILLS TRAINING WAS MORE EFFECTIVE THAN THE OTHER TWO ARMS. AIM TWO, COST-EFFECTIVENESS COMPONENT, REDUCING MEDICAL COSTS AND INDIRECT COSTS RELATIVE TO ARTHRITIS CARE EDUCATION AND USUAL CARE. WE USED PATIENT DIARIES TO COLLECT HEALTHCARE UTILIZATION INFORMATION OVER THE YEAR AFTER THEIR SURGERY. AIM THREE WAS A MECHANISTIC AIM. SO THIS GETS CLOSE INVENTORY THE EFFICACY QUESTION. WE HIGH HYPOTHESIZE HERE THAT IT MEDIATES TREATMENT RELATED IMPROVEMENTS IN PAIN AND SELF-REPORTED FUNCTION DURING RECOVERY, AND THIS IS WHAT THE CAUSAL MEDIATION MODEL LOOKS LIKE, SO YOU HAVE THE THREE TREATMENT ARMS, THE PRIMARY OUTCOME OVER HERE, THE PAIN CATASTROPHIZING SCALE SCORE WHICH WE COLLECTED INTERMITTENTLY OVER THE COURSE OF THE DELIVERY OF THE INTERVENTION AND OVER THE COURSE OF RECOVERY, AND WE HYPOTHESIZE THAT THE CHANGES IN PAIN CATASTROPHIZING WOULD MEDIATE CHANGES BETWEEN THE INTERVENTION ARM AND THE WOMACK PAIN SCALE AFTER ADJUSTING FOR CONFOUNDERS. THE PAIN COPING INTERVENTION WAS AN INTERVENTION THAT KEEFE DEVELOPED AND HAS USED IN MANY STUDIES IN ARTHRITIS AND OTHER DISORDERS INCLUDING CANCER. IT WAS TELEPHONE-BASED, AND THE INTERVENTION WAS DELIVERED PERIOPERATIVELY, BOTH PRE AND POSTOPERATIVELY. THERE WAS ONE SM IN-PERSON SESSION AND SEVEN TELEPHONE BASED SESSION OVER THIS TWO MONTH PERIOPERATIVE PERIOD FOR A TOTAL OF ABOUT EIGHT HOURS OF INTERVENTION. THE PHYSICAL THERAPISTS THAT WERE INVOLVED IN THE STUDY DID THE DELIVERY OF THE PAIN COPING SKILLS TRAINING. WE CHOSE PTs FOR A COUPLE OF REASONS. FIRST, THERE ARE WITH 200,000PTs IN THE COUNTRY VERSUS ABOUT 35,000 PSYCHOLOGISTS, PTs ARE ON THE FRONT LINE OF CARE DELIVERY IN KNEE ARTHROPLASTY FROM INPATIENT CARE THROUGHOUTPATIENT CARE, SO THEY'RE IN THE BEST POSITION TO OPTIMALLY PROVIDE THIS INTERVENTION IN THE CONTEXT OF PHYSICAL THERAPY DELIVERY. THE CHALLENGE, OF COURSE, IS THAT PTs ARE NOT TRAINED TO DO THESE PROCEDURES OR DELIVER THESE KINDS OF TREATMENTS. THE PAIN COPING SKILLS INCLUDED WHAT WE TYPICALLY THINK OF WHEN WE THINK OF COGNITIVE BEHAVIORAL THERAPY IN A PAIN -- CHRONIC PAIN CONDITION. THIS IS JUST A FEW ILLUSTRATIVE EXAMPLES OF HOW THE INTERVENTION WAS TAILORED TO PATIENTS WHO GET KNEE REPLACEMENT. SO FOR EXAMPLE, THEMES DURING THE PREOPERATIVE PERIOD -- BY THE WAY, THIS WAS PUBLISHED IN THE ARCHIVES OF PHYSICAL MEDICINE IN 2011 BASED ON SOME PILOT WORK WE DID. SO FOR EXAMPLE, PATIENTS HAVE UNCERTAINTY ABOUT THEIR OUTCOMES OF SURGERY, SO I'VE HAD SO MANY SO ORANGES I JUST DON'T KNOW IF THIS SURGERY IS GOING TO DO THE TRICK. AND THE INTERVENTION WOULD, THEREFORE, ADDRESS THE COPING THOUGHTS THAT THIS PATIENT MIGHT HAVE IN COMMUNICATING WITH HEALTHCARE PROVIDERS AND GOAL SETTING. SO THAT'S HOW THE PAIN COPING SKILLS INTERVENTION WAS TAILORED TO THE INTERVENTION. THERE ARE A VARIETY OF OTHER EXAMPLES DESCRIBED IN THIS ARTICLE. THE COMPARISON GROUP WAS THE ARTHRITIS EDUCATION CONTROL GROUP, INTENDED PRIMARILY TO CONTROL ATTENTION EFFECTS. THEY GOT THE SAME A TIME WITH THE NURSE. THEY GOT THE SAME AMOUNT OF ATTENTION BY A CARING PROVIDER. THEN THERE WAS THE USUAL CARE ARM. SO WE GOT A PRAGMATIC LOOK AND AN EFFICACY-BASED LOOK AT THE SAME TIME. SO HERE'S THE STUDY FLOW. AS I MENTIONED EARLIER. SUBJECT RECRUITMENT OCCURRED AS YOU CAN SEE HERE FROM JANUARY 13TH TO MAY OF 16, WE'RE NOW COMPLETED AND WE HAVE, AS I MENTIONED, JUST ONE PATIENT LEFT TO COMPLETE THE ONE-YEAR DATA COLLECTION. WE ACTUALLY SCREENED 4,000 PATIENTS TO GET 400. AND THE GREAT MAJORITY OF THESE WERE BECAUSE THEY WERE -- THEY WEREN'T KA TATREAU WERE GOING TO HAVE A REVISION PROCEDURE OR HAD A PHQ8 SCORE OF GREATER THAN 20 OR THEY WERE GOING TO HAVE A SURGERY EITHER SIX MONTHS PRIOR TO WHEN THEY WERE GOING TO HAVE THEIR CURRENT SURGERY OR THEY WERE PLANNING A FOLLOW-UP SURGERY WITHIN SIX MONTHS. KRUX OF THE SAMPLE, YOU CAN SEE HERE I'M JUST GOING TO MENTION VERY BRIEFLY, THE AVERAGE AGE WAS 63, WHICH IS ABOUT WHAT WE'RE SEEING THESE DAYS. ABOUT TWO THIRDS OF THE PATIENTS WERE FEMALE, THAT'S FAIRLY TYPICAL, AND THE REST OF THE CHARACTERISTICS ARE QUITE SIMILAR TO WHAT WE TYPICALLY SEE. I WANT TO SHOW YOU JUST A FEW PRELIMINARY FINDINGS, THEN I'LL STOP. ONE OF THE ISSUES OF DATA WE COLLECTED WAS OPIOID USE AT BASELINE, I THOUGHT THAT WOULD BE APPROPRIATE FOR TODAY'S SESSION. WE FOUND THAT ALMOST A THIRD OF PATIENTS IN THE TRIAL WERE TAKING OPIOIDS PRIOR TO SURGERY. AND I THINK THE MOST INTERESTING FINDING IN RELATED OPIOID USE IS THE TREMENDOUS VARIATION ACROSS SITES. ONE SITE, THERE WAS OVER 50% OF PATIENTS TAKING OPEN OPIOID, ONE SITE ONLY HAD 15% TAKING OPIOIDS. HERE YOU CAN SEE THE DISTRIBUTION OF THE TYPE OF OPIOIDS. GENERALLY THE DOSAGES ARE FAIRLY SMALL. INDEPENDENT PREDICTERS OF OPIOID USE WERE FOUND AFTER ADJUSTING FOR SURGEON AND SITE WAS YOUNGER AGE, AFRICAN-AMERICANS, HIGHER SELF-EFFICACY AND HIGHER CO-MORBIDITY SCORES INCREASE THE PROBABILITY OF OPIOID USE AT BASELINE. CHARACTERIZING THE PAIN CATASTROPHIZING PHENOTYPE AGAIN USING RADAR PLOTS, WHAT I DID WAS I HAVE THE MODERATE CATASTROPHIZING GROUP OVER HERE, SCORE 16-28. THIS IS THE HIGH CATASTROPHIZING GROUP SCORES 29 TO 52. SO FOR THE MODERATE GROUP, ALL SCALES ARE SCORED ZERO TO 100, YOU CAN SEE THE COMPARISON HERE SO THERE'S THE CATASTROPHIZING SCORE, THERE'S THE GENERALIZED ANXIETY SCORE, THERE'S THE DEPRESSIVE SYMPTOMS SCORE. THE KEY COMPARISON HERE IS THAT THESE PATIENTS' DEPRESSIVE SYMPTOMS SEVERITY AND GENERALIZED ANXIETY SYMPTOMS ARE DOUBLE. THE TRUNK PAIN, AS YOU CAN SEE, IS FAIRLY SUBSTANTIAL, ABOUT 25% HAVE MODERATE PAIN, ABOUT 20% HAVE SEVERE, AND ABOUT 15% HAVE VERY SEVERE BACK PAIN. SO BACK PAIN IS A VERY COMMON SEQUELLA WITH PATIENT WHO ARE CATASTROPHIZING GETTING A KNEE REPLACEMENT. CONTRALATERAL LOWER EXTREMITY PAIN, WE SEE A LOT OF, AS WELL AS INDEX LOWER EXTREMITY PAIN BEYOND THE KNEE THAT'S GETTING SURGERY. SO IN CONCLUSION, THE PAIN CATASTROPHIZING PHENOTYPE DEMONSTRATES SUBSTANTIAL VARIABILITY ACROSS A VARIETY OF HEALTH DOMAINS, AND IN OTHER WORDS, THIS IS NOT A SIMPLE PHENOTYPE. WITH SOME SUPERVISION, PTs WERE CAPABLE OF DELIVERING THE PAIN COPING SKILLS TRAINING TO THIS VERY CHALLENGING POPULATION OF PATIENTS. AND WE'LL HAVE TO WAIT TO SEE THE RESULTS TO DETERMINE WHETHER PAIN COPING SKILLS TRAINING IS DELIVERED COLLABORATIVELY WITH THE CLINICAL PSYCHOLOGISTS AS EFFECTIVE AND COST-EFFECTIVE. THANK YOU. [APPLAUSE] >> THANK YOU VERY MUCH. SO OUR FINAL SPEAKER TODAY IS DR. JAMES FRICTON, EMERITUS PROFESSOR IN THE UNIVERSITY OF MINNESOTA SCHOOLS OF DENTISTRY, MEDICINE AND PUBLIC HEALTH. SENIOR INVESTIGATOR FOR HEALTH PARTNERS INSTITUTE FOR EDUCATION AND RESEARCH. AND A PAIN SPECIALIST AT THE MINNESOTA HEAD AND NECK PAIN CLINIC. HE'S HELD A NUMBER OF LEADERSHIP POSITIONS FOR EXAMPLE IN THE AMERICAN ACADEMY OF OROFACIAL PAIN, AMERICAN BOARD OF OROFACIAL PAIN, THE AMERICAN PAIN SOCIETY, AND IS CURRENT PRESIDENT OF THE INTERNATIONAL MYOPAIN SOCIETY. HE TEACHES A MASSIVE OPEN ONLINE COURSE, WE CALL A MOOC, CALLED PREVENTING CHRONIC PAIN, WITH OVER 40,000 INTERNATIONAL PARTICIPANTS. SO HE'LL BE TALKING TO US TODAY ABOUT SELF-MANAGEMENT STRATEGIES AS PART OF AN INTEGRATED APPROACH FOR PAIN MANAGEMENT. DR. FRICTON. >> THANK YOU, MARK. AND THANK YOU, DR. PORTER, FOR ORGANIZING THIS CONFERENCE. THANK YOU FOR BEING HERE TODAY. I APPRECIATE IT. AND HAVING THE OPPORTUNITY TO SPEAK TO YOU TODAY. BECAUSE VI 20 MINUTES, I'M GOING TO FOCUS A LITTLE BIT MORE ON BACKGROUND AND CHARACTERISTICS OF THE INTERVENTION ON SELF MANAGEMENT VERSUS DATA SO YOU KIND OF GET AN IDEA WHERE WE'RE COMING FROM LOOKING AT VERY MUCH THE BIG PICTURE OF CHRONIC PAIN AND HOW SELF MANAGEMENT PLAYS A SIGNIFICANT ROLE WITHIN OUR MANAGEMENT STRATEGIES. I'D LIKE TO DISCLOSURE, HAVE NO DISCLOSURE INFORMATION, AND ACKNOWLEDGE MANY OF MY COINVESTIGATORS AND RESEARC STAFF WHO HAVE PUT TOGETHER A WONDERFUL SELF MANAGEMENT PROGRAM, AND I ALSO APPRECIATE THE FUNDING FROM THE NATIONAL INSTITUTE OF DENTAL AND CRANIOFACIAL RESEARCH FOR THIS, AND WE HAD AN R34 AND A UL1 TO DO A PILOT STUDY AND WE'RE PLANNING TO DO MORE OF A MULTISITE STUDY WITH THIS ALSO. AS YOU KNOW, THIS CONFERENCE IS ALL ABOUT THE BIG ELEPHANT IN THE ROOM. CHRONIC PAIN IS CLEARLY THE MOST SIGNIFICANT CLINICAL PROBLEM THAT WE HAVE IN OUR HEALTHCARE SYSTEM RIGHT NOW. FOR MANY REASONS. IT'S THE NUMBER ONE REASON WE SEEK CARE, 67% OF ALL VISITS RELATED TO PAIN CONDITIONS. IT IS THE MOST COMMON CHRONIC CONDITION, YOU CAN SEE THE PREVALENCE COMPARED TO DIABETES, HEART DISEASE, CANCER AND STROKE STROKE. IT ALSO IS THE NUMBER ONE CAUSE OF DISABILITY, PARTICULARLY ARTHRITIS, RHEUMATISM, BACK AND SPINE PROBLEM. SO WE NEED TO REALLY UNDERSTAND HOW OUR TREATMENTS ARE WORKING, AND THE BROAD RANGE OF TREATMENTS. OF COURSE ONE OF THE BEST AVENUES TO UNDERSTAND THAT IS LOOK AT SYSTEMATIC REVIEWS. THERE HAVE BEEN TONS OF SYSTEMATIC REVIEWS OUT THERE, VERY NICE CLINICAL TRIALS THAT ARE ALL AGGREGATE -- AGGREGATE THE DATA TO REALLY LOOK AT WHAT IS THE COMPOSITE DATA SHOW IN TERMS OF CLINICAL TRIALS COMPARED TO PLACEBO OR COMPARED TO OTHER TREATMENTS? AND WE DID AN EXTENSIVE REVIEW OF THESE SYSTEMATIC REVIEWS FOR THIS COURSE ON PREVENTING CHRONIC PAIN, LOOKING AT ALL OF THESE DIFFERENT TREATMENTS. IT WAS INTERESTING WHAT WE FOUND WAS THAT THE GOOD NEWS IS THAT JUST ABOUT EVERY TREATMENT SEEMED TO WORK ABOUT 10 TO 20% ABOVE PLACEBO. UNFORTUNATELY THAT'S ALSO THE BAD NEWS. IT'S ALMOST EVERY TREATMENT WORKS ONLY ABOUT 10 TO 20% ABOVE PLACEBO, BUT MOST OF THESE STUDIES, IT WAS SHORT TERM. NOW THERE HAVEN'T BEEN A LOT OF LONG TERM CLINICAL TRIALS THAT WE CAN LOOK AT. BUT IT'S NOT VERY GOOD, OUR OUTCOMES ARE POOR WITH REGARD TO TREATMENTS, AND WE NEED TO RECOGNIZE THAT. UP FORTUNATELY, DELAYED RECOVERY IS VERY COMMON, AND SEVERAL STUDIES HAVE FOUND THAT OVER HALF THE INDIVIDUALS WITH PAIN CONDITIONS AT ONE MONTH STILL HAVE PAIN AND SEEK CARE FIVE YEARS LATER. SO WE NEED TO DO A BETTER JOB AT THE EARLIER PART OF THE DEVELOPMENT OF PAIN CONDITIONS. SO MANY OF THESE PATIENTS CONTINUE TO SEEK CARE FOR THEIR PAIN YEARS AFTER THEIR ONSET, AND MOST OF THE STU CAN IS CAN STUDIES LOO K BEING AT WHAT ARE THE FACTORS THAT LEAD TO THIS DELAYED RECOVERY ARE RISK FACTORS OFTEN DUE TO MANY PHYSICAL, PSYCHOLOGICAL, BEHAVIORAL RISK FACTORS THAT ARE OFTEN NOT ADDRESSED IN THE CONTEXT OF TREATMENT. SO WE NEED TO LOOK AT A DIFFERENT MODEL, REALLY, AND OF COURSE WE CAN ALWAYS GO BACK TO SOME ANCIENT WISDOM BY HIPPOCRATES. IT'S MORE IMPORTANT TO KNOW WHAT KIND OF PERSON HAS A DISEASE THAN TO KNOW WHAT KIND OF DISEASE THE PERSON HAS. VERY IMPORTANT, INSIGHTFUL COMMENT. SO WE'RE LOOKING AT WHAT ARE THESE RISK FACTORS THAT CAUSE DELAYED RECOVERY AND DEVELOPMENT OF CHRONIC PAIN? AND ALSO WHAT ARE THE PROTECTIVE FACTORS THAT KEEP PEOPLE FROM DEVELOPING CHRONIC PAIN AFTER AN INITIALACUTE INJURY. BOTH ARE IMPORTANT, AND THESE ARE CHARACTERISTICS, CONDITIONS OR BEHAVIORS SUCH AS POOR SLEEP, DIET, STRESS, SMOKING, OTHER THINGS THAT INCREASE THE POSSIBILITY OF ILLNESS, INJURY AND PAIN, PARTICULARLY THROUGH PERIPHERAL AND CENTRAL SENT TIIZATION. WHEREAS PROTECTIVE FACTORS ARE LIKE THE CURES WE KIND OF EXPLAIN THAT TO PATIENTS, IS THE SAME THING SUCH AS EXERCISE, HEALTHY DIET, BETTER SLEEP THAT PREVENTS OR REDUCES THAT VULNERABILITY TO DEVELOPING AN ILLNESS. AND BOTH OF THEM ARE VERY IMPORTANT IN TERMS OF THE PERPETUATION, INCREASING BOTH PERIPHERAL SENSITIZATION THROUGH INJURY, STRAIN AND INFLAMMATION, AS WELL AS CONTRIBUTING TO WIND UP CONVERGENCE AND OTHER MECHANISMS BOTH ASCENDING AND DESCENDING FACILITATION AND INHIBITION, AS WELL AS CONTRIBUTING TO CENTRAL SENSITIZATION, SO RISK FACTORS PLAY A ROLE IN EACH OF THESE MECHANISMS OF PAIN. SO HERE'S SOME OF THE STUDIES THAT WE REVIEWED IN THE LITERATURE LOOKING AT WHAT ARE THESE RISK FACTORS AND WHAT ARE WE DID A SEARCH AND FOUND THAT THEY ARE -- CAN YOU CATEGORIZE THEM IN ABOUT SEVEN DIFFERENT DOMAINS, BODY, LIFESTYLE, EMOTION, SPIRIT, SOCIETY, MIND, ENVIRONMENT, AND SOME OF THE EXAMPLES OF THEM, THERE'S A WEALTH OF LITERATURE OUT THERE LOOKING AT THESE FACTORS AND HOW THEY CAN PLAY A ROLE IN CHRONIC PAIN. SO THE KEY HERE IN TERMS OF RECOVERY, THIS IS THE BASIS BEHIND OUR SELF MANAGEMENT PROGRAM, IS REALLY TO FOCUS ON TRYING TO REDUCE THE RISK FACTOR, SO FEWER RISK FACTORS, NOBODY'S PERFECT, WE ALL HAVE RISK FACTORS, WE'RE ALL SITTING IN BAD POSTURES, SIT AROUND TOO MUCH DURING THE DAY, WE MAY HAVE REPETITIVE STRAIN, THERE'S SO MANY DIFFERENT RISK FACTORS OUT THERE. WE NEED TO DO WHAT WE CAN TO TRAIN PATIENTS TO REDUCE THOSE RISK FACTORS. BUT WE ALSO NEED TO IMPROVE OUR PROTECTIVE FACTORS. WHAT DO WE DO EVERY DAY THAT REALLY MAINTAINS OUR HEALTH AND WELL-BEING AND RELIEF AND PREVENTION OF PAIN? I MEAN, I DO YOGA EVERY MORNING, IF I DON'T, I GET BACK PAIN. I KNOW THAT. IT'S SOMETHING THAT'S JUST STRAIGHTFORWARD TO ME, AND SO I NEED TO PRACTICE THOSE PROTECTIVE FACTORS. I NEED TO EAT WELL. I NEED TO SLEEP WELL, I NEED TO SIT WELL, GOOD POSTURE. I'M TALL AND THIN, I'M GOING TO HAVE ERGONOMIC PROBLEMS IF I HAVE A LOT OF REPETITIVE STRAIN WITH POOR POSTURE. I LEARNED THESE THINGS OVER TIME, BUT MOST PATIENTS DON'T HAVE THAT SAME INSIGHT. THEY HAVEN'T REVIEWED THE LITERATURE ON RISK FACTORS. WE NEED TO TRAIN PATIENTS ON HOW TO DO THESE BASIC THINGS THAT WE PROBABLY KNOW ABOUT. SO WE NEED A NEW MODEL OF CARE. WE CALL IT TRANSFORMATIVE CARE BECAUSE WE HAVE A POTENTIAL OF TRANSFORMING THE PATIENT FROM PAIN AND ILLNESS INTO HEALTH AND WELL-BEING. AND TET, WE HAVE AT THE SAME TIME, WE HAVE THE POTENTIAL OF TRANSFORMING THE HEALTHCARE SYSTEMAT THE SAME TIME. IT'S NOT MYSTERIOUS, IT'S SIMPLE. ALL WE NEED TO DO IS STILL TREAT AS WE DO CURRENTLY, WHETHER IT'S MEDICATIONS, THERAPIES, SURGERIES, INJECTIONS, MANY OTHERS, BUT WE ALSO ADD A VERY CRITICAL COMPONENT TO OUR CARE MODEL. WE NEED TO TRAIN THE PATIENTS IN SELF-MANLAGEMENT STRATEGIES TO REDUCE THE RISK FACTORS AND BOOST PROTECTIVE FACTORS. OBVIOUSLY WE NEED TO DO THIS AS PART OF AN INTEGRATIVE TEAM, AND THAT'S WHY TODAY'S SESSION IS VERY HELPFUL BECAUSE WE NEED TO WORK AS A TEAM. A HEALTH COACH IN A BROAD SENSE CAN BE PHYSICAL THERAPISTS, PSYCHOLOGISTS, NURSE PRACTITIONERS, MANY OTHER CLINICIANS PROVIDING THE SUPPORT TO HELP THE PATIENT MAKE THE CHANGES TO LEARN WHAT THEY NEED TO DO. SO WITH TRANSFORMATIVE CARE, IT WILL SUPPORT THE INSTITUTE OF HEALTHCARE'S IMPROVEMENT TRIPLE WIN. IT'S A BETTER QUALITY OF CARE, WE'LL HAVE A BETTER OUTCOMES OF CARE, AND THE LOWER COST OF CARE IF WE DO THE SIMPLE THING OF INTEGRATING TRAWNING WITH TRAINING WITH TREATMENTS. HOWEVER, IT'S NOT AS EASY AS I MAKE IT SEEM. I'M GOING TO TRY TO MAKE IT EASIER LATER ON, BUT SELF MANAGEMENT IS OFTEN NEGLECTED FOR MANY DIFFERENT REASONS. ONE, OF COURSE, IT'S NOT PART OF OUR BIOMEDICAL MODEL. THAT'S WHY WE NEED A BROADER MODEL, THE BIOPSYCHOSOCIAL MEDICAL MODEL IS MOVING IN THE RIGHT DIRECTION. WE HAVE INADEQUATE TIME TO REALLY TRAIN PATIENTS. THERE'S LACK OF REIMBURSEMENT FOR TRAINING, WE'RE TRYING TO CHANGE THAT. HEALTHCARE REFORM AND REGULATION BY HEALTH PLANS OFTEN PREVENT TRAINING, TEDIOUS ELECTRONIC HEALTH RECORDS, INADEQUATE TRAINING OF HEALTH PROFESSIONALS, MANY DIFFERENT REASONS FOR NOT TRAINING PATIENTS, BUT WE NEED TO CHANGE THAT AND WE SHOULD START NOW. SO WE DEVELOPED A COURSE TO TRAIN HEALTH PROFESSIONALS ON HOW TO TRAIN PATIENTS IN REDUCING RISK FACTORS AND ENHANCING PROTECTIVE FACTORS. THIS IS A COURSE THAT'S FREE TO ANYBODY IN THE WORLD. IT'S CALLED PREVENTING CHRONIC PAIN, A HUMAN SYSTEMS APPROACH. WE LOOK AT THOSE SEVEN AREAS OF A PERSON'S LIFE AND WE JUST GO THROUGH THE LITERATURE. WHAT ARE ALL THE FACTORS THAT PEOPLE NEED TO KNOW? INTERESTINGLY ENOUGH, BECAUSE IT'S FREE, WE'VE HAD ABOUT, OH, 30,000 PATIENTS WITH PAIN PROBLEMS TAKE THE COURSE. SO THEIR COMMENTS HAVE BEEN VERY INTERESTING. SO WE DID A RATING OF 771 IN THE FIRST COURSE THAT WE OFFERED. THIS IS ONLINE, IT'S FREE FOR ANYBODY, YOU CAN GET CME CREDIT ALSO FOR IT, AND 95% SAID THE QUALITY OF THE LESSONS WERE VERY GOOD TO EXCELLENT, 93% SAID IT CHANGED THEIR LIFE AND THEIR PAIN, JUST BY HAVING THIS KNOWLEDGE, HAVING THIS INFORMATION JUST PROVIDING THEM WHAT THEY NEED TO DO IN TERMS OF THEIR LIFESTYLE CHANGES. 85% CHANGED THEIR CARE. CAN YOU SEE SOME OF THE COMMENTS ABOUT THE COURSE. A COUPLE OF THEM SAID EVERY HEALTH PROFESSIONAL SHOULD GO THROUGH A COURSE LIKE THIS SO WE ALL GIP TO REALLY UNDERSTAND HOW IMPORTANT THE PATIENT'S ROLE IS IN THEIR CARE. IT'S NOT ABOUT THE TREATMENT, IT'S REALLY ABOUT WHAT THE PATIENT DOES ON A REGULAR BASIS. SO WHAT WE DEVELOPED FROM THIS COURSE IS LET'S SEE IF WE CAN HELP HEALTH PROFESSIONALS DO TRAINING A LITTLE MORE EASILY AS PART OF ROUTINE CARE, SO WE DEVELOPED A SERIES OF TOOLS IN A TOOL KIT CALLED THE PAC PROGRAM. THIS IS A PERSONALIZED ACTIVATED CARE AND TRAINING PROGRAM, IT'S A SERIES OF SELF MANAGEMENT TRAINING TOOLS COVERING ALL OF THESE RISK FACTORS AND PROTECTIVE FACTORS. AND IT'S PERSONALIZED BASED ON A RISK FACTOR ASSESSMENT, WE HAVE TELEHEALTH COACHING. THEY CALL THE PATIENT, THEY WORK WITH THE PATIENT OVER A PERIOD OF TIME, AND THE GOAL, OF COURSE, IS TO IMPROVE NOT ONLY THE OUTCOMES OF TREATMENT, BUT ALSO MORE IMPORTANTLY RELIEVE THE PAIN LONG TERM, NOT JUST SHORT TERM. SO THE 32 ONLINE TRAINING TOOLS, HERE IS THE FOCUS SO FAR, THESE ARE THE 8 TOOLS, MODULES. THESE ARE THE FOCUSES OF ALL THE DIFFERENT TRAININGS THAT WE DO. OUR THOUGHT IS WHILE THIS IS OVERWHELMING FOR PATIENTS, THEY CAN'T GO THROUGH EVERYTHING, INTERESTINGLY ENOUGH, I HAD AN EMAIL IN OUR COURSE, WE HAVE A COURSE THAT'S 24 HOURS, THIS TAKES ABOUT AN HOUR AND A HALF A WEEK OR SO OR EVERY TWO WEEKS, EMAIL ME AND SAID, THIS WAS SO FASCINATING THAT I WENT THROUGH EVERYTHING, 24 HOURS OF LECTURE, ON THE MOOC COURSE, IN ONE WEEK. AND I THOUGHT, OH, MY GOSH, THEY WANT THIS KNOWLEDGE. THE PATIENTS DO WANT TO KNOW HOW TO REDUCE THE FACTORS THAT ARE CAUSING THEIR PAIN. SO EACH ONE, IT'S ABOUT A 10 TO 15 MINUTE VIDEO, LECTURE, PRENTING THE, PRESENTING THE INFORMATION, BUT THEY'RE INTERESTED IN ALL OF THESE THINGS, PARTICULARLY ABOUT SAFE LIVING, MINIMIZING RISK, MINIMIZING INJURY, OUGHT THE THINGS THAT MAY INITIATE PAIN. SO PAIN AND RISK ASSESSMENT, PERSONALIZED COGNITIVE BEHAVIORAL TRAINING TO REDUCE THE RISK FACTORS AND STRENGTHEN PROTECTIVE FACTORS, WE BELIEVE THIS IS MUCH MORE IMPORTANT THAN RIS BE RISK FACTORS. PERSONAL STORIES OF REAL PEOPLE, A DAILY ACTION PLAN, DOCUMENTING OUTCOMES AS PART OF YOUR ROUTINE CARE, SO YOU KNOW WHAT'S HAPPENING TO THIS PATIENT OVER TIME. I'LL SHOW YOU THAT IN A SECOND. AS WELL AS OVERCOMING BARRIER, LOTS OF BARRIERS TO LIFESTYLE CHANGE. WE HAVE A LOT OF ENGAGING CHARACTER, THREE OF THEM, PROFESSOR PAINE, ACTION ANNIE, CALMING CADE DOES A LOT OF THE MEDITATION, MINDFUL NUSS, WE MINDNESS, BAR RIER BOB. THEY'RE INTERESTING, ENGAGING CHARACTERS. WE DEVELOPED AN ACTION PLAN FOR EACH OF THOSE TOOLS THAT WOULD CLUL -- AND INCLUDE -- HEALTHY HABITS. WE HAVE ACRONYMS TO HELP PEOPLE REMEMBER THINGS, BECAUSE IT IS A LOT OF INFORMATION. AND HEALTHY ACTIONS BRING IMPROVEMENT AND TRANSFORMATION. WE REFER TO STUDIES ON EXERCISE, POSTURE, DIET, SLEEP, SOCIAL SUPPORT AND A VARIETY OF THINGS. SYSTEMATIC REVIEWS ON THIS HAVE BEEN VERY POSITIVE, FAVORABLE. AND THE SECOND PART OF THE ACTION PLAN IS TO TAKE PAUSES, THE WHOLE CONCEPT OF MINDFULNESS, JUST BE AWARE OF WHAT'S HAPPENING TO YOU RIGHT NOW IN EACH OF THOSE AREAS OF YOUR LIFE. TAKE A PAUSE MEANS ASSESS, UNDERSTAND, START NEW AND ENJOY THE MOMENT, AND WE REFER TO THE STUDIES ON A VARIETY OF DIFFERENT CONCEPTS HERE. THEN THE THIRD PART OF THE ACTION PLAN IS TO PRACTICE CALMING. CALMING ACTIONS THAT LIGHTEN THE MINE, AND THIS IS THE STUDIES ON MEDITATION, BIOFEEDBACK, SELF HYPNOSIS, EE EMOTIONAL CALMING HAVE ALL BEEN INCORPORATED INTO THIS LESSON. EACH OF THESE ARE INCORPORATED ABOUT 10 MINUTES, SO THERE'S A HUGE AMOUNT OF CONDENSATION THAT WE HAD TO DO TO SIMPLIFY THE CONCEPT, SO IT REALLY IS A LEVEL OF ABOUT A 7 OR -- 7TH GRADE, 8TH GRADE, 9TH GRADE LEVEL. VERY COMPLICATED PROCESS THERE, WE USE A LOT OF EDUCATIONAL EXPERTS, ONLINE TRAINING EXPERTS TO GIVE US ADVICE ON HOW DO WE DO THIS IN A WAY THAT'S ENGAGING AND NOT TOO COMPLICATED. THEN WE USE HEALTH COACHES AND A SUPPORT TEAM, SO WE ALLOW THEM TO BRING IN FAMILIES AND FRIENDS INTO THE COURSE TO SEE HOW THEY'RE DOING AND TO READ THE COURSE PROGRESS. WE HAVE A COACH THAT CALLS THEM A MINIMUM THREE TIMES BUT A MAXIMUM OF EIGHT TIMES DURING THIS 8 TO 16-WEEK CLINICAL TRIAL THAT WE'RE CURRENTLY DOING. IT IMPROVES ADHERENCE AND HELPS THEM ACHIEVE THEIR GOALS AND THERE'S A LOT OF EVIDENCE AGAIN ABOUT THE USE OF SOCIAL SUPPORT IN MAKING LIFESTYLE CHANGES AND HELPING PAIN. THEN WE HAVE A VARIETY OF RESOURCES AVAILABLE TO THE PATIENTS, THE PARTICIPANTS ALSO INCLUDING WE'RE DEVELOPING A SMARTPHONE APP, AND ALL OF THIS ONLINE TRAINING, CAN YOU GO TO YOUR CELL PHONE AND WATCH IT. IT'S ALL RESPONSIVE IN TERMS OF THE WEBSITE. WE HAVE WORKSHEETS THAT INCLUDE THE REFERENCES SUMMARIZING EACH LESSON ACTION PLAN, DAILY LOGS, PRECAUTIONS AND WIN -- MOST IMPORTANTLY, WE DON'T WANT TO RELY ON SELF CARE ONLY, BUT WHEN DO THEY NEED TO SEEK CARE, WHEN ARE THERE SOME RED FLAGS THAT ARE BROUGHT UP TO REALLY HELP THEM BRING THIS UP TO THEIR CLINICIAN? SO WE DON'T THINK THIS IS SELF-MANAGEMENT INDEPENDENT OF TREATMENT OR PROPER DIAGNOSIS. WE BELIEVE IT SUPPLEMENTS THAT. AND SO WE HAVE AN OUTCOME MEASURES, WE LOOK AT THE LESSONS COMPLETED, THEIR ACTION PLAN, HOW MUCH ENGAGEMENT ARE THEY DOING, THEIR PAIN LEVELS, THEIR INTERVEERNS LEVELS AND KIND OF A BACKGROUND HISTORY SO THE HEALTH COACH KNOWS WHO THEY'RE WORKING WITH, THE HEALTHCARE PROFESSIONAL KNOWS THE PERSONAL CHARACTERISTICS OF THE PATIENT, INCLUDING THEIR WORST PAIN, SECOND WORST PAIN, THEIR EDUCATION, DISABILITY, HEALTHCARE USE IN THE PAST, CURRENT SELF CARE, THEIR GOALS, THEIR MEDICAL HISTORY, AND THEN YOU CAN SEE LONGITUDINALLY WHAT HAPPENS. WE ALL NEED DASHBOARDS IN MANAGING THESE PATIENTS. WE NEED TO BE ABLE TO SEE, OKAY, THE PATIENT STARTED HERE THIS WEEK AND NOW WE'RE 16 WEEKS DOWN THE LINE, WHAT HAS HAPPENED TO THE PAIN AND THEIR FUNCTIONAL LEVEL TOURING THAT COURSE OF TIME? SO THERE'S ONE SIMPLE CHANGE THAT A CLINICIAN HAS TO DO TO REALLY INTRODUCE SOMETHING LIKE THIS INTO THE PRACTICE, AND I DO THIS WITH EVERY ONE OF MY PATIENTS. I SAY TO THEM OR I ASK THEM, ACTUALLY, I'M HAPPY TO PROVIDE YOU TREATMENT, BUT IT'S MORE EFFECTIVE LONG TERM IF WE ALSO REDICE THE LIFESTYLE CAUSES OF YOUR PAIN. ARE YOU INTERESTED? NOW THAT'S A HARD THING FOR MANY HEALTH PROFESSIONALS TO SAY. BUT IT'S CRITICAL, BECAUSE IT'S NERVOUS, YOU KNOW, OKAY, I'M SUPPOSED TO TRAIN THE PATIENT ON HOW TO REDUCE ALL THESE LIFESTYLE FACTORS? I DON'T HAVE TIME FOR THAT. I HAVE 10 MINUTES. AND SO BUT IF THERE'S A WHOLE SUPPORT TEAM AND ONLINE TRAINING BEHIND THE CLINICIANS, WEE BELIEVE IT WILL WE BELIEVE IT WILL BE ADOPTED MORE READILY. AND MY PATIENTS, WHEN I PRESENT THIS -- OF COURSE WE HAVE A BEHIND IT, ONLINE TRAINING AND THINGS, ZERO PATIENTS SAY NO TO THIS, NO, I'M NOT INTERESTED IN REDUCING MOO COSTS. SO IT'S SOMETHING THAT WILL BE VERY EASILY TRANSFORMATIVE FOR THAT PARTICULAR PATIENT. SO THE STUDY THAT WE'RE CURRENTLY INVOLVED IN, THE PILOT STUDY IS TO LOOK AT THE UTILITY AND METHODS TO LOOK AT THE MULTISITE STUDY OF SELF MANAGEMENT, WE'LL COMPARE USUALLY SELF CARE, HANDOUTS WE GIVE PATIENTS COMPARED TO MORE ROBUST PACKED PROGRAM. WE HAD INTERESTINGLY ENOUGH WITH JUST SENDING OUTPUTTING PRO SURES IN THE CLINIC, WE HAD 50 PATIENTS PARTICIPANTS IN THREE WEEKS WITH JUST TWO CLINICS THAT WE ARE RECRUITING FROM. NEARLY EVERYBODY WANTED TO PARTICIPATE IN THE STUDY, AND WE WERE OVERWHELMED IN TERMS OF THE AMOUNT OF STRONG INTEREST. AND SO WITH THAT, I HAVE ABOUT 9 SECONDS, WE ALSO HAVE INITIATED A CAMPAIGN TO PREVENT CHRONIC PAIN. NOT JUST TO PREVENT THAT ACUTE TO ACUTE, ATE CUTE TO CHRONIC, CHRONIC TO INTRACTABLE PROGRESSION, BUT WE BELIEVE VERY MUCH -- OBVIOUSLY IT'S REAL, WE HAVE A LITTLE WEBSITE ON IT, SO WITH THAT, I'LL JUST LEAVE YOU WITH -- DEVINE IS -- TO PREVENT PAIN. AND WITH THAT, I THANK YOU FOR YOUR ATTENTION. THANK YOU VERY MUCH. [APPLAUSE] >> THANK YOU VERY MUCH. I WOULD INVITE ALL THE PANELISTS TO COME AND HAVE A SEAT AND RESPOND TO SOME QUESTIONS. DR. HERSHEY HAS TO LEAVE A LITTLE EARLY SO IF IT POSSIBLE TO DIRECT ANY QUESTIONS TO HIM FIRST, THAT WOULD BE HELPFUL. THANK YOU. >> -- UNIVERSITY OF TEXAS. THIS QUESTION IS FOR DR. MALUF. YOU HAD MENTIONED AS PART OF SOME MORE COMPREHENSIVE STRATIFICATION INCLUDING ENDOGENOUS INHIBITION MEASURES, DO YOU HAVE A SUGGESTION ON HOW THOSE MEASURES CAN BE EMPLOYED IN A CLINICALLY FEASIBLE WAY, SINCE OFTENTIMES THEY'RE MORE LABORATORY-BASED? >> SO THANK YOU FOR THE QUESTION. I THINK THIS -- THE CLINICAL USE OF QUANTITATIVE SENSORY TESTING AND INCLUDED IN THAT WOULD BE TESTS OF ENDOGENOUS PAIN INHIBITION, BE DONE RELATIVELY SIMPLY WITH TOOLS IN THE CLINIC AND RELATIVELY QUICKLY. RIGHT NOW WE'RE IN THE STAGE WHERE THEY'RE TYPICALLY ONLY APPLIED IN RESEARCH LABORATORY SETTINGS, BUT I THINK THESE ARE PRIME TARGETS FOR TRANSITIONING IN TO CLINICAL SETTINGS BECAUSE OF THE FEASIBILITY AND RELATIVE LOW COST AND RELATIVELY QUICK NATURE OF DOING THEM. WHAT WE NEED TO DO FIRST IS, ARE THEY VALID PREDICTERS OF TREATMENT RESPONSE AND OF CLINICALLY MEANINGFUL OUTCOMES, AP THAT'S WHERE THE RESEARCH REALLY IS FOCUSED NOW. SO WHAT I DIDN'T TALK ABOUT AT THE END OF MY TALK WAS THERE'S EMERGING EVIDENCE NOW THAT ENDOGENOUS PAIN INHIBITION IS ASSOCIATED WITH LEVELS OF PHYSICAL ACTIVITY. IT'S ASSOCIATED WITH TOP DOWN PROCESSING SO CORTICAL CONTROL HAS BEEN SHOWN IN PATIENTS WITH FIBROMYALGIA THAT YOU CAN MODULATE, AND IT ALSO PREDICTS RESPONSES TO SOME ANALGESIC MEDICATIONS, SO I THINK THAT THAT IN PARTICULAR, IF WE CAN TEST IT QUICKLY IN THE CLINIC, AND IF IT PREDICTS RESPONSIVENESS TO INTERVENTIONS IS A PRIME TARGET FOR STRIKE THAT STRATIFICATION BUT WE'RE NOT THERE YET, BUT THERE IS ACTIVE, ACTIVE RESEARCH IN THAT AREA. >> -- NCCIH. I WAS WONDERING IF YOU COULD COMMENT A LITTLE FURTHER ON THE STUDY YOU DID, THE 2015 STUDY WHERE YOU WERE LOOKING AT HEALTHY PEOPLE IN THE OFFICE WHO THEN WENT ON TO DEVELOP CHRONIC NECK PAIN, SO MY UNDERSTANDING IS IT WAS ROUGHLY 30% OR 20 TO 30% OF THE PEOPLE WHO WERE HEALTHY TO START WENT ON TO DEVELOP CHRONIC NECK PAIN WHICH WAS THE MEASURE OF THEY HAD PAIN FOR GREATER THAN THREE MONTHS IN THE PERIOD OF TIME. AND THE QUESTION I HAD ON THIS WAS DID THESE PEOPLE ALSO ENGAGE IN SOME SORT OF TREATMENT? MOST PEOPLE WHO DEVELOP CHRONIC PAIN, THEY DO SOMETHING ABOUT IT, BUT THEY MET OF DEFINITION OF CHRONIC PAIN BUT IT WAS NOT ENOUGH TO CAUSE THEM TO SEEK TREATMENT, AND TO WHAT EXTENT WAS THE -- IF THEY DID GET TREATMENT D IT HAVE ANY EFFECT, IT WAS THAT SORT OF THE KIND OF QUESTION. >> RIGHT, GREAT QUESTION. SO OUR DEFINITION OF NECK PAIN AND ALMOST EVERYBODY IN THIS ROOM HAS PROBABLY EXPERIENCED NECK PAIN, WE USED A DEFINITION WHICH INCLUDED INTERFERENCE IN PHYSICAL ACTIVITY, OR ACTIVITIES OF DAILY LIVING, SO IT HAD TO BE INTERFERING NECK PAIN AND PATIENT HAD TO DEVELOP IT FOR AT LEAST THREE MONTHS OUT OF A 12-MONTH FOLLOW-UP PERIOD, SO THAT'S HOW WE DEFINED DEVELOPMENT OF CHRONIC NECK PAIN. IN GENERAL, THE SEVERITY OF THE PAIN THAT PEOPLE DEVELOPED WAS LOW ENOUGH THAT THEY ONLY USED VESSEL MAPPAGEMENT TOOLS, AND WE DIDN'T FOLLOW THEM TO SEE WHAT PROFESSIONAL INTERVENTIONS THEY SOUGHT. PAUSE THEY WERE AT THE EARLY STAGES, THEY DIDN'T SEEK TREATMENT. BUT THOSE ARE THE TYPES OF PEOPLE THAT IF WE CAN CATCH EARLY AND PROVIDE THEM WITH SELF MANAGEMENT TOOLS THAT WERE DESCRIBED, HOPEFULLY WE CAN PREVENT THAT TRANSITION INTO MORE SEVERE CHRONIC PAIN. PEOPLE USUALLY WAIT TOO LONG TO SEEK PAIN, OR SEEK TREATMENT FOR PAIN. THANK YOU. >> HI, LINDA PORTER AT NINDS. I HAVE A QUICK QUESTION FOR ANDREW HERSHEY BECAUSE I KNOW HE HAS TO RUN OFF THE STAGE. DO YOU HAVE A SENSE THAT CBT IS EFFECTIVE IN REDUCING HEADACHES IN KIDS, THE TWO DRUGS YOU LOOKED AT, THE PLACEBO EFFECTS ARE PRETTY SIMILAR, HAVE ANY ACCEPTABLE CHANGES IN YOUR RESEARCH NETWORK AS FAR AS HOW THE PROVIDERS ARE REALLY APPROACHING TREATMENT FOR THEIR KIDS AT THIS POINT? IT'S EARLY, I KNOW, BUT JUST -- DO YOU HAVE A SENSE OF WHETHER PEOPLE HAVE STARTED TO CHANGE HOW THEY ATTEND TO THE KRIRN? >> CHILDREN? >> THAT'S AN ONGOING DISCUSSION -- FOR ABOUT TWO YEARS, AND WHAT IT DOES -- WHAT WE'VE DONE IS TYPICALLY IF THEY WERE ONE WEEK OR MORE, WE WOULD PROBABLY BE INTRODUCING PHARMACOLOGICAL AGENTS IN THE PAST. WE'RE NOW MORE LIKELY TO WAIT IF THEY'RE ONE TO TWO IN THE WEEK, COME BACK EARLIER, MORE THAN THREE A WEEK WE OFFER TO THE PATIENTS, A MAJORITY OF THE PATIENTS ARE CHOOSING TO GO ON A PHARMACOLOGICAL AGENT, THEY WANT THAT BENEFIT OF WHAT THEY PERCEIVE. IT'S NOT LIKE WE CAN'T TELL THEM IT DOESN'T WORK, WE TELL THEM IT DOES WORK, IT'S JUST THE PLACEBO ALSO WORKS. SO THEY'D RATHER NOT CARE IF IT'S MEDICINE OR PLACEBO, IF IT WORKS, IT WORKS, SO THE BIGGEST CHANGE THAT'S MADE IS THAT SORT OF MIDDLE ZONE. THE KIDS THAT IN THE PAST WE WOULD HAVE PROBABLY TREATED BUT AT LOWER FREQUENCY OF THE WAIT AND SEE COMPONENT. >> GREAT. THANK YOU. >> TWO QUICK QUESTIONS. IS THERE ANY REASON TO THINK THAT ANTIBODIES TO CPRG WILL WORK AS WELL IN KIDS AS THEY WOULD IN ADULTS? >> WELL, WE DON'T KNOW HOW THEY WORK IN ADULTS SO IT'S HARD TO ANSWER THE QUESTION IF IT'S GOING TO WORK IN KIDS OR NOT. THE BIGGEST THING, IT'S PARTLY -- THEY'RE ALL IN PHASE 3 RIGHT NOW , THAT ALTHOUGH THEY'RE SIGNIFICANTLY RESPONDING, THE DIFFERENCE BETWEEN THE CGRP ANTIBODY RESPONSE AND PLACEBO RESPONSE IS ONLY ABOUT TWO HEADACHES A MONTH. SO PART OF THE QUESTION IS YES IT WORKS BUT IS THAT REALLY WORTH 29 TO $3,000 A MONTH 2 TO $3,000 A M ONTH IT'S GOING TO COST? SO WE DON'T KNOW IF IT'S GOING TO BE ANY DIFFERENT IN KIDS, BUT PRESUMABLY THE BIGGER QUESTION IS, IS THIS GOING TO ULTIMATELY BE PUT INTO GENERAL PRACTICE, GIVEN THE KROS RESTRICTIONS THAT ARE BEING PLACED, AND SO THE CGRP ENTERPRISE WILL PROBABLY BE A SECOND OR THIRD LINE TREATMENT, EVEN IN ADULTS, AND SINCE WE CAN MAKE 70 TO 80% OF KIDS BETTER POTENTIALLY BEFORE THEY GET TO THAT POINT, WHETHER WE UTILIZING IT AS MUCH IS PROBABLY THE OTHER QUESTION. >> WHY DON'T YOU GO AHEAD AND I'LL ASK ONE AFTER. >> THAT'S ALL RIGHT. GO AHEAD. >> SO FOR DR. RIDDLE, I'M KIND OF CURIOUS ABOUT -- SO HIPS, POST OP PAIN AFTER HIP REPLACEMENT IS SO MUCH LESS THAN AFTER KNEE REPLACEMENT, RIGHT? AND SO I DON'T KNOW IF THERE'S ANY DATA ON THIS, ONE COULD COME UP WITH STRUCTURAL REASONS WHY THERE'S SUCH A -- BUT NOW I WANT TO GO BACK TO THE ISSUE OF CATASTROPHIZING. IF YOU HAVE AN INDIVIDUAL THAT HAS BOTH A HIP -- OVER THEIR LIFE HAS BOTH A NIP AND A KNEE REPLACEMENT, I IMAGINE THERE'S A REASONABLE NUMBER OF THOSE FOLKS OUT THERE, THIS IS A HIGH CATASTROPHIZER ALSO HAVE LONGER POST OP HIP PAIN. >> YOU'RE ABSOLUTELY RIGHT THAT RECOVERY AFTER A TOTAL HIP REPLACEMENT IS A MUCH MORE RAPID RETURN TO NEAR PAIN-FREE FUNCTION THAN WHAT WE SEE FOR THE KNEE AND THIS IS PROBABLY DRIVEN MOSTLY BY THE AN ANATOMICAL COMPLEXITY AND THE EXTENT CH TISSUE CHANGES THAT OCCUR, AND THE TISSUES THAT REX POSED TO THE SURGICAL ENVIRONMENT. AT THE MECHANICS ARE MORE COMPLEX AT THE KNEE THAN THEY ARE AT THE HIP. THERE ARE NO STUDYS THAT I KNOW OF THAT HAVE STUDIED THE POTENTIAL INFLUENCE OF PAIN CATASTROPHIZING IN PATIENTS WITH HIP REPLACEMENT SURGERY THAT I'M FAMILIAR WITH. >> THE PAPER YOU ACTUALLY QUOTED WAS KNEE. >> YOU'RE ABSOLUTELY RIGHT, IT WAS, BUT I DON'T BELIEVE IN THAT STUDY THERE WERE ANY STUDIES OF CATASTROPHIZING IN TOTAL HIP REPLACEMENT PATIENTS, BUT IT LOOKED AT A GAMUT OF MENTAL HEALTH CONSTRUCTS, NOT JUST CATASTROPHIZING. >> THANK YOU. >> I THINK IN ORDER TO REALLY BE ABLE TO STUDY THAT ISSUE IN HIPS, IT WOULD TAKE A VEL LARGE SAMPLE SIZE TO BE ABLE TO HAVE ENOUGH NON-RESPONDERS TO BE ABLE TO REALLY STUDY ANY PREDICTERS OF POOR OUT COME, BECAUSE SO MANY DO SO WELL. THANK YOU. >> DR. HERSHEY HAD TO LEAVE, I WAS HOPING HE COULD WEIGH IN ON THIS BUT I'M SURE ALL OF YOU CAN DO THIS AND IT GETS AT THAT ISSUE LINDA JUST ASKED ABOUT IN PLACEBO. IS THERE SOMETHING THAT NIH OR OTHER SCIENTIFIC GROUPS CAN DO TO GET BEYOND ONE OF THE CHALLENGES I DIDN'T SEE LISTED UP THERE, IN ANY OF THE TALKS AROUND DELIVERING MULTIMODAL, WHICH IS THIS CONCEPT OF A PLACEBO RESPONSE? FLIPPING IT ON ITS HEAD, MOST OF THE FACTORS THAT ARE IN MANY OF THE PROGRAMS THAT HAVE BEEN DESCRIBED THE LAST TWO DAYS, AT ONE TIME OR ANOTHER, WERE CLASSIFIED AS FACTORS IN PLACEBO OR PLACEBO FACTORS. IS THERE A WAY WE CAN SORT OF GET BEYOND THAT AND SAY PLACEBO IS REALLY -- CAN WE DIG IN, FIND OUT WHAT THOSE ARE, BECAUSE WHEN WE'RE TESTING THINGS AGAINST PLACEBO, WE'RE JUST TESTING AGAINST OUR OWN THEORY, AREN'T WE? AND YET PEOPLE MIGHT WANT TO DELIVER THAT, EVEN IF IT'S AN OPEN PLACEBO, WHICH HAS BEEN NOW STUDIED AND SHOWN TO BE EFFECTIVE ESPECIALLY IN PAIN. IS THERE SOMETHING THAT THE SCIENTIFIC GROUPS LIKE NIH CAN DO TO KIND OF PUSH THROUGH THIS CONCEPT SO WE CAN GET A BETTER PERCEPTION OF HOW TO UTILIZE FACTORS OF PLACEBO AND, THEREFORE, LEGITIMIZE SOME OF THE PRACTICES THAT YOU ALL HAVE DESCRIBED? >> THAT'S A VERY IMPORTANT QUESTION BECAUSE AS YOU'VE SEEN BY SYSTEMATIC REVIEWS OF ANY TREATMENT, PLACEBO IS REALLY THE MOST POWERFUL EFFECT THAT WE HAVE. SO WHAT ARE THE CHARACTERISTICS OF THAT? WE BELIEVE THAT IT'S PART OF THE PERSON'S BELIEF SYSTEM. AND THE BELIEF SYSTEM IS VERY MOTIVATING IN TERMS OF BOTH CHANGING BEHAVIORS AS WELL AS CHANGING CENTRAL SENSITIZATION, CALMING, MINDFULNESS. THERE'S PROBABLY MANY DIFFERENT COMPONENTS WITHIN THAT, BUT WE BELIEVE THAT THIS IS THE PATH THAT THEY ARE ON AND THIS IS THE TREATMENT THAT IS GOING TO WORK FOR THEM, I MEAN, IT HAS A POWERFUL EFFECT IN DRAMATICALLY REDUCING PAIN. NOW, THAT EFFECT IS OFTEN SHORT TERM UNLESS YOU SUSTAIN IT WITH REAL LIFESTYLE CHANGES OR WHATEVER NEEDS TO BE DONE. SO I THINK IT IS A POWERFUL EFFECT AND WE NEED TO LEVERAGE IT AS MUCH AS POSSIBLE. >> I'LL ADD TO THAT BY SAYING THERE'S SOME REALLY NICE IMAGING STUDIES SHOWING PLACEBO IS NOT PLACEBO, IT'S AB ACTIVE AN ACTIVE TREAT. WE ENGAGE CANNABINOID PATHWAYS WITH PLACEBO -- ACTIVATION OF PLACEBO EFFECT, SO REALLY THE CHALLENGE IS HOW DO WE ADMINISTER THIS CLINICALLY IN AN ETHICAL WAY. SO I WOULD LOVE TO SEE STUDIES ON HOW TO IMPLEMENT WHAT WE KNOW ABOUT PLACEBO. I TEACH MY STUDENTS THAT PLACEBO IS AN ACTIVE EFFECT. WE CAN IMPROVE IT BY USING COGNITIVE-TYPE STRATEGIES TO CHANGE BELIEF SYSTEMS, AND THAT THAT IS A LEGITIMATE TREATMENT, BUT TELLING PATIENTS FROM THE START THAT I'M NOT ACTUALLY TREATING YOU, THIS IS PLACEBO, IS COUNTER ACTIVE, SO ENGAGING THAT ETHICALLY HAS HUGE POTENTIAL, BUT HOW WE DO THAT, I'M NOT SURE. >> JUST ONE LITTLE CORRECTION, THERE HAD BEEN AT LEAST THREE GOOD CONTROL TRIALS WHERE THEY TOLD PEOPLE THIS IS A PLACEBO, BUT IT'S GOING TO WORK, AND IT ACTUALLY DOES WORK. SO THERE MAY BE WAYS OF MANIPULATING THAT. THANK YOU FOR YOUR RESPONSE. MAYBE NEXT YEAR'S THEME COULD BE ON CHRONIC PAIN AND PLACEBO. >> I LIKE THAT SUGGESTION. >> JUST A COMMENT ABOUT PLACEBO IN THE CONTEXT OF THE OPIOID EPIDEMIC. SO THE DATA IS VERY CONVINCING NOW THAT PLACEBOS DO ENGAGE AN ENDORPHIN SYSTEM, IMAGING STUDIES, PHARMACOLOGICAL STUDIES HAVE IMPLICATED THAT BUT I DON'T KNOW OF ANY STUDY THAT SAYS YOU MISUSE PLACEBOS. SO THE IMPLICATION IS WHEN THE PLACEBOS ARE ENGAGING IN ENDORPHIN SYSTEM, IT'S KIND OF LIKE TAKING AN ANTIDIURETIC -- NOT A DIURETIC, SOMETHING FOR CONSTIPATION, IT JUST TARGETS ONE SIDE. SO IF WE COULD COME UP WITH AN OPIATE, WE HEARD A LITTLE ABOUT THAT YESTERDAY, THAT SELECTIVELY ENGAGES OPIOID RECEPTORS THAT ARE MORE RELEVANT TO PAIN RELIEF RATHER THAN OTHER SITES, THEN YOU HAVE A POTENTIAL APPROACH TO GETTING AROUND THE FACT THAT OPIOIDS ON THE ONE HAND CAN BE GOOD DRUGS, ON THE OTHER HAND, THEY JUST HAVE LOUSY SIDE EFFECTS. >> I LIKE THAT SUGGESTION. I THINK THE QUESTION OF WHETHER THE PLACEBO EFFECT, WHETHER THERE'S A TOLERANCE TO THAT IS ALSO AN INTERESTING QUESTION. SO LOTS OF GOOD QUESTIONS WITH PLACEBO. >> GREG, UNIVERSITY OF WASHINGTON, SEATTLE. I GUESS FOR DR. RIDDLE, THOUGH DR. MALUF MAY HAVE A COMMENT. YOU CHOSE HIGH CATASTROPHIZERS, BUT I SUSPECT THAT PATIENTS THAT WEREN'T HIGH CATASTROPHIZERS ALSO GOT A SIMILAR PAIN COPING HELP FROM THEIR PHYSICAL THERAPISTS. IN THE SAME SITE. DID YOU GET PUSHBACK FROM PHYSICAL THERAPISTS AS YOU WERE TRYING TO TRAIN THEM TO DO THESE PAIN COPING SKILLS OR DO THEY EMBRACE THAT TRAINING, ARE THERE DOWN SIDES TO THE TRAINING THAT YOU HAD TO DO IN TERMS OF EXPANDING IT TO ALL PEOPLE GETTING POST KNEE SURGERIES? >> THANKS FOR THE QUESTION. IT'S AN IMPORTANT ONE BECAUSE THERE'S A MOMENTUM TO FRONT LINE CLINICIANS PROVIDING THIS INTERVENTION BECAUSE THE NUMBERS OF CLINICAL -- ARE LIMITED. I GOT ABSOLUTELY ZERO PUSHBACK, AND IN FACT, I GOT PUSHFORWARD BY A LOT OF PTs WHO WANTED TO ALSO PARTICIPATE, BUT WE COULDN'T ENGAGE THEM. I THINK PTs ARE IMMEDIATELY AWARE OF THE GAP THAT THEY'RE EXPERIENCING AND THE CONTENT NECESSARY TO DELIVER THIS KIND OF INTERVENTION COMBINED WITH THEIR IMMEDIATE AWARENESS OF THE FACT THAT THIS INTERVENTION IS BADLY NEEDED. AND SO I THINK WE'RE SORT OF EXPERIENCING THIS MASSIVE MOMENTUM WITHIN OUR PROFESSION OF THE ACKNOWLEDGMENT THAT THIS IS A KEY PRACTICE AREA AND WE'RE NOT PREPARED TO DELIVER IT. I THINK THE ONE THING THAT I'M A LITTLE BIT CAREFUL ABOUT, AND IT'S PROBABLY A FUNCTION OF THE FACT THAT I STUDIED PEOPLE WHO WERE HIGH CATASTROPHIZERS, AND THAT AS YOU ALL KNOW IS COUPLED A LOT OF TIMES WITH OTHER MENTAL HEALTH DISORDERS, AND INCLUDING SEVERE DEPRESSION, IS THAT THERAPISTS -- TO HAVE AT LEAST INTERMITTENT CONTACT WITH A COLLABORATIVE CLINICAL PSYCHOLOGIST IF THEY'RE GOING TO BE DOING THIS ON A REGULAR BASIS PARTICULARLY WITH HIGH RISK POPULATIONS, BUT BEYOND THAT, I SEE NOTHING BUT UPSIDE, PARTICULARLY WHEN WE CAN HAVE A CLOSE COLLABORATIVE RELATIONSHIP WITH A PSYCHOLOGIST. DR. MALUF, ANY OTHER THOUGHTS? >> I DEFINITELY AGREE WITH THAT. PHYSICAL THERAPISTS IN MY EXPERIENCE ARE -- FOR THIS TRAINING, I THOUGHT IT WAS INTERESTING, THE TALK YESTERDAY ABOUT DENTISTS ACKNOWLEDGING THAT PATIENTS HAVE A FEAR OF DENTISTS. PHYSICAL THERAPISTS DON'T NECESSARILY ACKNOWLEDGE THAT PATIENTS HAVE A FEAR OF PHYSICAL THERAPISTS. IT'S REALLY A FEAR OF MOVEMENT. WE WORK WITH PATIENTS ALL THE TIME AND ENCOURAGE INCREASES IN MOVEMENT AND PATIENTS ARE FEARFUL OF THAT BECAUSE IT'S PAINFUL, SO HAVING THE TOOLS TO KIND OF BRIDGE THAT MIND-BODY GAP BECAUSE WE WERE WORKING ON PHYSICAL TREATMENTS BUT ARE NOT TRAINED IN COGNITIVE TREATMENTS NECESSARILY OR YET, I THINK THAT'S A CRITICAL GAP IN PRACTICE THAT THE PROFESSION IS HUNGRY FOR. >> A LOT OF PATIENTS HAVE KOIND THE EUPHEMISM PHYSICAL TORTURE FOR PHYSICAL THERAPY, AND THAT'S JUST EMBLEMATIC OF THE CHALLENGES THAT PTs FACE ON DAY TO DAY AND NOT NECESSARILY KNOWING HOW TO DEAL WITH THE PATIENT'S CONFRONTATION WITH TORTURE. >> SO IN THERE ARE NO FURTHER QUESTIONS OR COMMENTS, DO THE PANELISTS HAVE ANY OTHER COMMENTS? I'D LIKE TO THANK ALL THE PANELISTS AND EVERYBODY WHO CAME TODAY, AND WE'LL MOVE ON TO THE NEXT SECTION. THANK YOU VERY MUCH. [APPLAUSE] >> GOOD MORNING, EVERYONE. I'M NORA VOLKOV AND I DIRECT THE NATIONAL INSTITUTE ON DRUG ABUSE. I'M GOING TO ACTUALLY END THE MEETING TODAY. BEFORE I DO THAT, I'M PUTTING SOME COMMENTS, I WANT TO THANK VERY MUCH THE PAIN CONSORTIUM, BOTH DIRECTORS OF THE INNINGS INCHES TEUTS THAT FORM PART OF IT BUT IMPORTANTLY THE WORKING GROUP, AND VERY SPECIFICALLY AMONG OTHERS, LINDA PORTER BECAUSE OF THE AMOUNT OF WORK THAT IT DOES ENTAIL NOT ONLY IN ACTUALLY CONSIDERING THESE ANNUAL MEETINGS BUT IMPORTANTLY ON CARRYING OVER THE LEADERSHIP AS WHAT ARE THE AREAS OF SCIENCE THAT WE NEED TO ADVANCE FOR ADDRESSING THE COMPLEXITIES OF PREVENTING AND TREATING CHRONIC PAIN. I REPRESENT THE -- DISORDER SIDE OF THINGS SO I HAVE BEEN VIEWING IT FROM THE PERSPECTIVE OF THE CONSEQUENCES OF THE IMPROPER PRESCRIPTION PRACTICES THAT HAS LED TO THE DIVERSION OF OPIOIDS THAT HAS LED TO THE ABUSE OF OPIOIDS THAT HAS LED TO THE ADVERSE CONSEQUENCES. I ALSO AM VERY, VERY SENSITIVE TO THE ISSUE THAT THERE ARE NOT MANY -- FOR THE MANAGEMENT OF CHRONIC PAIN AND THAT AS A RESULT OF THAT, PHYSICIANS SOMETIMES PRESCRIBE OPIOIDS WHEN EVEN THE GUIDELINES DO NOT NECESSARILY RECOMMEND F IT. I'M ALSO AWARE THAT THE STRUCTURE OF THE CLINICAL SYSTEM DOES NOT NECESSARILY FACILITATE THE PROPER USE GUIDELINES FOR MANAGEMENT OF CHRONIC PAIN, BECAUSE THE INSURANCE IS NOT THERE TO COVER BARRIERS IN ORDER TO BE ABLE TO PROVIDE THE INTEGRATED TYPE OF TREATMENT THAT IS RECOMMENDED BY THE CDC AND THAT HAS BEEN THE FOCUS OF THIS MEETING. MAKES IT VERY HARD FOR MANY CLINICIANS TO ACTUALLY BE ABLE TO PRACTICE IT. SO AS WE'RE FACING THE PRESCRIPTION OPIOID EPIDEMIC OF COURSE IT'S DEVASTATING AND WE'VE NEVER SEEN ANYTHING LIKE THAT IN DRUG USE HISTORY IN THE UNITED STATES. AS I LOOK AT IT, I ALSO REALIZE THAT IT HAS MADE IT VERY, VERY CLEARLY THAT WE NEED TO FOCUS OUR RESOURCES IN TERMS OF ADVANCING OUR KNOWLEDGE ABOUT CHRONIC PAIN. BECAUSE IF WE DON'T ADVANCE THAT KNOWLEDGE AND IF WE DON'T PROVIDE ALTERNATIVE TREATMENTS AND PREVENTION EFFORTS, WE ARE GOING TO CONTINUE TO OVERRELY ON OPIOIDS AND UNLESS WE HAVE, OF COURSE, OPIOIDS THAT DON'T HAVE ADICK TIM QUALITIES OR THE SERIOUS SIDE EFFECTS ASSOCIATED WITH THEM, WE ARE NOT GOING TO BE ABLE TO CONTAIN THE DEVASTATION OF WHAT WE'RE CURRENTLY LIVING. SO IN TERMS OF WHERE WE MOVE FORWARD, THE NIH AND ONE OF THE INSTITUTES ENGAGED WITH THAT, AS YOU KNOW, OF THE VARIOUS INSTITUTES INVOLVED WITH THE PAIN CONSORTIUM -- THINKING ABOUT HOW SCIENCE HELPS US ACTRESS THE PROBLEM OF THE OPIOID CRISIS. AND IT IS VERY CLEAR THAT AS WE THINK ABOUT HOW DO WE ADDRESS, WE'RE THINKING OF THE TWO COMPONENTS, ONE OF THEM COMING FROM THE DRUG ABUSE INSTITUTE OF COURSE WE NEED TO ADDRESS THE NEEDS OF PEOPLE THAT ARE ADDICTED TO THEIR MEDICATIONS AS WELL AS THE NEEDS TO PREVENT OVERDOSES. BUT AS PART OF THE NATIONAL INSTITUTE ON DRUG ABUSE AND ENGAGE WITH UNDERSTANDING AND COMING UP WITH SOLUTIONS FOR PAIN, THE SECOND COMPONENT IS HOW WE CAN DO AS AN AGENCY, NIH, TO ACCELERATE KNOWLEDGE THAT CAN FACILITATE DEVELOPMENT OF NEW THERAPEUTIC INTERVENTIONS. AND AS YOU KNOW, OUR PORTFOLIO IN RESEARCH IS ACTUALLY QUITE DIVERSE FROM VERY BASIC SCIENCE TO IMPLEMENTATION AND SERVICES SIGH EBBS. THIS IS ALSO RELEVANT IN THE CASE OF PAIN. AND WE'RE GOING TO CONTINUE DOING IT, BUT ONE OF THE AREAS WE WANT TO EMPHASIZE, AND FOR WHICH WE ARE ACTUALLY PLANNING A SERIES OF SEMINARS IS IN THESE STAGE OF NEEDS, HOW CAN WE CREATE THE PUBLIC-PRIVATE PARTNERSHIPS THAT CAN HELP ACCELERATE THE KNOWLEDGE THAT WE HAVE INTO TRANSLATIONAL PRODUCTS THAT CAN RESULT EITHER IN BETTER MEDICATIONS OR BETTER TREATMENT. SO FRANCIS COLLINS HAS CALLED IN A SERIES OF THREE MEETINGS NOT GOING TO BE THE USUAL TYPE OF MEETINGS THAT WE HAVE AT THE NIH IN THAT WE NORMALLY GO OVER AND DO A REVIEW OF THE STATE OF THE SCIENCE, BUT INSTEAD WE'RE GOING TO BE BRINGING SCIENCE EXPERTS ON THE AREA OR THAT ARE -- TO THE AREA, AND AT LEAST 50% REPRESENT TAITION REPRESENTATION FROM PHARMACEUTICALS AND BIOPHARMA. IN THESE THREE AREAS HERE, THAT CAN HELP US ADVANCE KNOWLEDGE THAT COULD ULTIMATELY HELP US ADDRESS THE EPIDEMIC OF PRESCRIPTION OPIOIDS, HEROIN AND NOW SYNTHETIC OPIOIDS. THE FIRST ONE IS GOING TO BE ACTUALLY THIS MONDAY, JUNE 5TH, AND IT'S ON THE MEDICATION DEVELOPMENT FOR OPIOID USE DISORDERS AND OVERDOSE PREVENTION AND REVERSAL. THE SECOND MEETING IS GOING TO BE ON THE DEVELOPMENT OF SAFE, EFFECTIVE, NON-ADDICTIVE PAIN TREATMENTS WHICH WILL BE JUNE 16, 2017. AND THE FINAL ONE IS UNDERSTANDING THE NEUROBIOLOGICAL MECHANISMS OF PAIN. JULY 7, 2017. SO WHAT WE'VE ASKED THE PARTICIPANTS IS TO SEND BEFOREHAND THE AREAS IN WHICH THEY ARE ACTUALLY CONCENTRATING MOST OF THEIR EFFORT, THE CHALLENGES IS THAT THEY HAVE IN ORDER TO ACHIEVE THE DEVELOPMENT OF MEDICATIONS ORAL NEW TREATMENT, AND WHAT IS IT IN TERMS OF KNOWLEDGE OR MECHANISM THAT COULD ACCELERATE A DISCOVERY. WE WILL BASICALLY -- THESE MEETINGS WILL BE AVAILABLE, THEY WILL BE -- THE SUMMARY FROM THEM WILL BECOME AVAILABLE AND WILL HELP US GUIDE WITHIN THE NIH BOTH AS INSTITUTE DIRECTORS OR AS PART OF THE CONSORTIUM -- THE PAIN CONSORTIUM AS WELL AS PART OF THE COMMON FUND OF PROJECTS THAT WE'LL WILL ALSO ALLOW US TO MOVE FORWARD OUR UNDERSTANDING OF PAIN. AS WE'VE HEARD TODAY AND AS WE'VE ACTUALLY COME ACROSS AS WHAT IS ONE OF THE CHALLENGES AND BARRIERS IN KNOWLEDGE, WHAT HAS BEEN DISCUSSED HERE, WHICH IS WHAT IS IT THAT DRIVES THE TRANSITION FROM ACUTE TO CHRONIC PAIN? SO OF COURSE THERE'S NOT JUST ONE PATH, BUT BEING ABLE TO IDENTIFY THAT TRANSITION IS GOING TO BE EXTRAORDINARILY IMPORTANT AS WE START TO MAKE IT MORE FREQUENT AS A GOAL, HOW IS IT THAT WE PREVENT CHRONIC PAIN. THE OTHER AREA THAT THAT A MARRIAGE CLEARLY AND VERY MUCH EXEMPLIFIED IN ALL OF THE STRATEGIES THAT ARE AIMING TO DO INTEGRATED CARE IS A CONCEPT OF RECOGNIZING THAT AS WE'RE SPEAKING CHRONIC PAIN, THESE ARE COMPLEX CONDITIONS, MEDICAL CONDITION, PERHAPS SOME OF THE MOST CHALLENGING ONES TO DEAL WITH, SO THE RECOGNITION THAT JUST ADDRESSING CHRONIC PAIN IN GENERAL IS NOT LIKELY TO BE THE MOST BENEFICIAL, BUT THE IMPORTANCE OF UNDERSTANDING THE HETEROGENEITY BETWEEN THE CHRONIC PAIN CONDITIONS AND VERY IMPORTANTLY THE UNIQUE CHARACTERISTICS OF THE PATIENTS INCLUDING THEIR COMORBIDITIES. SO AS YOU SEE, THIS IS JUST ONE OF THE FIELDS THAT WE ARE -- HOW DO WE GET PUBLIC-PRIVATE PARTNERSHIPS MORE ENGAGED. IN TRYING TO, AGAIN, ADDRESS THE NEEDS OF PAICIALTS SUFFERING PATIENTS SUFF ERING FROM CHRONIC PAIN. FROM ME COMING FROM THE OTHER SIDE, I'VE BEEN PLACED IN SITUATIONS WHERE PEOPLE SORT OF SAYS OKAY, LET'S GET RID OF THE OPIOID MEDICATIONS, THE PHARMACEUTICAL IS THE ONE RESPONSIBLE FOR THIS CRISIS THAT WE ARE OBSERVING, AND THAT THE REALITY IS MUCH MORE COMPLEX THAN THAT. THE REALITY IS THAT -- IS COMPLEX, THAT IN THE PAST WE DO NOT HAVE THE KNOWLEDGE TO PROPERLY ENVIRONMENTAL MEDICAL SOLUTIONS AS ACTUALLY WAS DISCUSSED IN THE MEETING, THE POSSIBILITY OF GETTING BIASED OPIOID AGONISTS COULD BE POTENTIALLY TRANSFORMATIVE IF, IN FACT, THE CLINICAL TRIALS SEW THAT INDEED THEY DO NOT HAVE NEGATIVE SIDE EFFECTS. SO WE ARE NOW IN A MOMENT WSH KNOWLEDGE CAN HELP US ADVANCE THAT FURTHER. AT THE SAME TIME, RECOGNIZING THE IMPORTANCE OF COMPREHENSIVE APPROACHES WHICH WILL REQUIRE JUST AS HAS BEEN PRESENTED IN THE MEETING SCIENCE ABOUT HOW DO YOU IMPLEMENT THESE INTEGRATED APPROACHES AND CERTAINLY HOW DO WE ENSURE THAT THOSE INTEGRATED APPROACHES WILL BE COVERED BY THE HEALTHCARE SYSTEM AND THAT PEOPLE WILL HAVE THE PROPER TRAINING TO DELIVER THEM. WITH THAT, I WANT TO THANK ALL OF THE PRESENTERS, AND I ALSO WANT TO THANK ALL OF THE ATTENDANTS FOR THEIR IMPORTANT WORK IN THE AREA OF CHRONIC PAIN. WE LOOK FORWARD TO HEARING YOUR COMMENTS AND IF YOU HAVE ANY SUGGESTIONS, YOU ALWAYS CAN REACH OUT TO US. OUR JOB IS ACTUALLY TO BE ABLE TO FACILITATE SCIENCE AND TO CONVENE THAT EXPERTISE AND COME UP WITH TRANSFORMATIVE SOLUTIONS IN ORDER TO SOLVE PROBLEMS. THANKS VERY MUCH.