>>WELCOME TO THE
17ANNUAL PAIN CONSORTIUM.
USE YOUR Q&A BOX.
THERE'S NO MICROPHONE OR CAMERA
OPTIONS FOR OUR ATTEND'S, FOR
OUR SPEAKERS AND PANELISTS
REMAIN ON MUTE UNTIL YOUR PANEL
SESSION IN Q&A AND KEEP YOUR
CAMERAS OFF UNTIL YOUR Q&A AND
DISCUSSION PANEL SESSIONS SUBMIT
QUESTIONS FOR OTHER SPEAKERS AND
ANY TIME DURING THEIR
PRESENTATIONS THROUGH THE CHAT
FUNCTION.
FOR TECHNICAL ASSISTANCE, IF YOU
NEED ZOOM, TECHNICAL ASSISTANCE,
DIRECTING MESSAGE HALIGONIANS HY
HARRINGTON OR SUBMIT A QUESTION
OR E-MAIL HOLLY AT THE WEBSITE.
PLEASE NOTE THIS WORKSHOP IS
STREAMING LIVE ON NIH WEBCAST
WITH LIVE CLOSED CAPTIONING AND
IT'S BEING RECORDED AND WILL BE
VIEWED AND ARCHIVED FOR LATER
VIEWING.
AND WE'D LIKE TO INTRODUCE Dr.
LEAH.
>> GOOD MORNING, EVERYONE.
I'M FROM THE OFFICE OF PAIN
POLICY AND PLANNING AT THE
NATIONAL INSTITUTE FOR
NEUROLOGICAL DISORDER AND
STROKE.
WE HOPE TO BE ABLE TO WELCOME
YOU ALL BACK IN THE FUTURE BUT
FOR NOW WE'RE STILL VIRTUAL SO
I'M GOING TO INTRODUCE YOU FOR
THE NEXT FEW DAYS.
THE CHAIRS OF THE PC SYMPOSIUM
PLANNING COMMITTEE THIS YEAR.
Dr. EINABELL FER FOR -- WHERE SE
MANAGED PART OF THE PAIN NCCI
PAIN FORT FOAL.
MELISSA GHIM SAY PROGRAM
DIRECTOR AT THE NATIONAL
INSTITUTE OF DIDN'TAL AND CRANE
YAN AND FACIAL RESEARCH WHERE
SHE MANAGES THE NEUROSCIENCE OF
(INAUDIBLE) AND THE DISORDER
FORT FOAL.
THEY HAVE WORKED TIRELESSLY TO
PUT THIS PROGRAM TOGETHER FOR
YOU AND LEAD US THROUGH THE NEXT
FEW DAYS.
YOU WILL SEE THEM POPPING UP TO
SHEPHERD US ALONG.
WITH THAT IT'S MY PLEASURE TO
INTRODUCE Dr. WALTER
KOROSHETZ, THE DISTRICT OR OF
NEUROLOGICAL STROKE AND CHAIR OF
THE NIH PAIN CONSORTIUM
EXECUTIVE COMMITTEE TO
OFFICIALLY WELCOME YOU TO THE
SYMPOSIUM THIS YEAR.
THANK YOU.
>> THANK YOU, VERY MUCH.
AND ARE YOU SEEING THE SLIDES
CORRECTLY?
>> THANK YOU.
SO AS I MENTIONED I'M WALTER
KOROSHETZ AND THIS IS OUR 17th
ANNUAL AND NIH PAIN CONSORTIUM
SYMPOSIUM AND I WANT TO WELCOME
EVERYONE AND EMPHASIS HOW
IMPORTANT THIS SYMPOSIUM IS FOR
PAIN RESEARCH GOING FORWARD AND
TODAY, THE FOCUS OF THE
SYMPOSIUM IS PAIN MANAGEMENT
THROUGH THE LENS OF A WHOLE
PERSON HEALTH.
CLEARLY, I'M SURE MANY OF YOU ON
THE SYMPOSIUM TODAY UNDERSTAND
HOW PAIN EFFECTS SO MANY
DIFFERENT OTHER SYSTEMS IN OUR
BODIES WHETHER IT'S MOOD,
MOBILITY, IT ALL CONTRIBUTES TO
DECREASING THE PERSON'S ABILITY
TO FUNCTION THE WAY THEY WOULD
LIKE TO IN THE WORLD AND THEN
ALSO, HOW THERE ARE SO MANY
OTHER THINGS THAT HAPPEN TO US,
CO-MORBIDITIES, WHETHER THERE
ARE HEALTH RELATED INJURY
RELATED THAT IMPACT ON PAIN.
SO BEING ABLE TO STEER THE
PROBLEM FROM THE PERSON WHO IS
EXPERIENCING IT, THROUGH THAT
LENS, IS WHAT WE'RE GOING TO BE
TALKING ABOUT TODAY AND I JUST
WANTED TO MENTION, WE CAN'T HELP
BUT MENTION THAT THE REASON WHY
THESE SYMPOSIUM NOW ARE MORE
PORT AN THAN EVER IS BECAUSE
WITH THE HEEL INITIATIVE HELPING
TO END ADDICTION LONG-TERM, NIH
HAS RECEIVED CONSIDERABLE FUNDS
TO KIND OF DO THINGS AT THE
RESEARCH LEVEL THAT WERE
PREVIOUSLY UNMANAGE ABLE SO WE
HAVE A TREE MEN -- UNIMAGINABLE.
SO WE CAN HOPEFULLY GET BETTER
TREATMENTS FOR PATIENTS AND
THESE ARE REALLY IMPORTANT IN
KIND OF ADVISING OR INFORMING
THE NIH FOLKS ON WHICH WAY TO
MOVE THOSE PROGRAMS.
SO, AGAIN, REALLY IMPORTANT
TOPIC AND GO TO THE NEXT SLIDE.
I HAVE THIS CONTROL.
SO, JUST TO MENTION THE PAIN
CONSORTIUM HAS BEEN AROUND AS I
SAID, FOR OVER 17 YEARS AND IT'S
MULTIPLE DIFFERENT INSTITUTES AT
NIH AND WE'RE ALL GALVANIZED BY
OUR MISSION TO ENHANCE PAIN
RESEARCH, PROMOTE COLLABORATIONS
ACROSS THE INSTITUTES AND TO
HAVE PROGRAMS AND ACTIVITIES
THAT ADDRESS PAIN AND AS I
MENTIONED WITH THE HEAL
INITIATIVE, WE ARE FUNDING THAT
WE NEVER HAD BEFORE TO DO THAT
KIND OF THING.
THE LEADERSHIP FOR THE PAIN
CONSORTIUM IS REALLY DISTRIBUTED
BETWEEN MYSELF THAT Dr.
LANGEVIN AND SHANNON ZENK, Dr.
D'SOUZA AND Dr. VOLKOW AND
THIS IS THE PEOPLE THAT PUT
TOGETHER FROM THE PAIN POLICY
AND PLANNING AND LEAH AND LAURA
WANDNER AND LINDA PORTER WHO
RUNS THAT OFFICE.
THANK YOU FOR THE PEOPLE DOING
THE WORK YEAR IN AND YEAR OUT.
THESE ARE THE LIST OF THE
INSTITUTES AND CENTER INVOLVED
IN THE PAIN CONSORTIUM AT NIH SO
IT'S PRETTY MUCH ANY DISEASE
ORGANIZATION AND NUMBER OF
DIFFERENT OFFICES ALL HAVE PAIN
AS PART OF THEIR MISSIONS AND
OUR JOB IN THE PAIN CONSORTIUM
IS TO KIND OF COLLABORATE ACROSS
ALL THESE INSTITUTES AND CLEARLY
THE EMPHASIS TODAY WILL BE
HEAVILY ON SOME OF THE
INSTITUTES PARTICULARLY NCCIH,
NURSING INSTITUTES, BUT ALL OF
THE INSTITUTES HERE LISTED WILL
HAVE INTEREST.
AND SO THE PANEL SESSIONS WE'LL
BE TALKING ABOUT IS THE COMMENT
PLEX TEE OF PLAIN AND
CO-MORBIDITY AND INTEGRATION
WHOLE PERSON TOOLS AND
APPROACHES AND WHOLE PERSON
APPROACHES TO PAIN MANAGEMENT.
AND WITH THAT I AM REALLY HAPPY
TO INTRODUCE OUR KEYNOTE
SPEAKER, TRACY GAUDET.
SHE IS THE EXECUTIVE DIRECTOR OF
THE WHOLE HEALTH INSTITUTE AND
IT'S A PHILANTHROPIC INSTITUTE
DEDICATED TO REALLY TRANSFORM
HOW HEALTH IS SEEN, DELIVERED,
ASSESSED, WITH THE WHOLE PATIENT
IN MIND AND SO COULDN'T HAVE A
BETTER SPEAK ARE FOR TODAY'S
SYMPOSIUM AND PRIOR TO GOING TO
WHOLE HEALTH, SHE WAS THE
EXECUTIVE DIRECTOR AT THE V.A.
ADMINISTRATION'S NATIONAL OFFICE
OF PATIENT CENTERED CARE AND
CULTURAL TRANSFORMATION AND SO
THROUGH A LOT OF EXPERIENCE AND
THAT HEALTH-CARE SYSTEM WHICH IS
THE ONE WE WORK WITH HEAVILY
HERE AT NIH TO ACTUALLY TEST NEW
WAYS OF MANAGING PAIN IN
HEALTHCARE SYSTEMS.
AND PREVIOUS TO THAT, OUR EXTENT
WITH THE V.A. SHE WAS WITH THE
DUKE UNIVERSITY HEALTH SYSTEM
AND SHE RECEIVED THE NATION'S
VETERANS WITH EX POLICE CAR'
SERVICE AWARD AND THE VISIONARY
AWARD OF THE ACADEMY OF
INTEGRATED HEALTH AND MEDICINE
FOR HER LEADERSHIP IN
TRANSFORMING HEALTHCARE AND
TRACY, WE'RE INTERESTED TO HEAR
YOUR THOUGHTS AND ON RESEARCH
AND PATIENTS SUFFERING WITH PAIN
AND NOT REALLY GETTING THE
RELIEF TO GET TO THE FUNCTIONAL
LEVEL THEY'D LIKE TO GET TO.
WITH THAT I WANT TO HAND IT OVER
TO TRACY.
THANK YOU, VERY MUCH.
I'LL STOP SHARING.
>> THANK YOU SO VERY MUCH AND I
WILL SAY A LITTLE BIT AT CLOSE
OF MY TIME WITH YOU THIS
MORNING.
HOW SIGNIFICANT I THINK THIS
MEETING IS AND HOW HONORED I AM
TO BE A PART OF LAUNCHING THE
CONVERSATIONS.
SO, THANK YOU VERY MUCH.
THERE'S NEVER BEEN A MORE
IMPORTANT TIME FOR THIS
CONVERSATION.
SO, I'M GOING TO MOVE RIGHT INTO
MY SLIDES.
I LOVE THE FACT THAT WE'RE
ASKING QUESTIONS OF HOW CAN A
WHOLE HEALTH APPROACH INFORM HOW
WE THINK ABOUT TREAT, RESEARCH,
THE ISSUES OF PEOPLE DEALING
WITH PAIN AND SO I THINK YOU
GUYS ARE OPERATING MY SLIDES IF
I AM UNDERSTANDING THAT RIGHT.
HE CAN GO AHEAD AND SAY THAT I
THINK YOU KNOW, I'M GOING TO
START WITH A FEW ILLUSTRATIONS
OF CONTEXT SINCE THIS IS THE
KICKOFF TO THE CONVERSATION OVER
THE NEXT TWO DAYS ABOUT -- ARE
YOU SEEING MY SLIDES BECAUSE I
AM NOT?
>> NOT YET.
>> GREAT.
NOW YOU CAN GO TO THE NEXT
SLIDE.
I WANTED TO MAKE SURE THAT I AM
ON THE SAME PAGE AS THE REST OF
YOU ALL.
IN TERMS OF SETTING THE LARGER
CONTEXT, I KNOW MOST PEOPLE IN
THIS AUDIENCE ARE VERY FAMILIAR
WITH THIS BUT I THINK IT'S
IMPORTANT THAT WE STOP AND PAUSE
AND LOOK AT LARGER CONTEXT OF
WHAT WE'RE DEALING WITH HERE
THAT IF WE THINK ABOUT
HEALTHCARE IN GENERAL AND THE
UNITED STATES, WE ARE IN A DIRE
SITUATION AS PEOPLE KNOW,
FINANCIALLY, IT'S INCREDIBLE AND
WE'RE UP TO 20% OF OUR G.D.P.
AND GOING TOWARDS HEALTHCARE
COSTS AND WHILE OUR OUTCOMES ARE
NOT WHAT WE WANT.
IF YOU LOOK AT LIFE EXPECTANCY,
ALL 2020 OUR LIFE EXPECTANCY
DECREASED TO 77 YEARS AND WHEN
YOU COMPARE US TO OTHER
COUNTRIES, COMPARABLE COUNTRIES
ARE ABOUT 81.1 YEARS IN 2020 SO
THE GAP BETWEEN US AND THE OTHER
PEER COUNTRIES IS WIDENING.
CHRONIC CONDITIONS ARE CONSUMING
A VAST MAJORITY OF THAT HAVE AND
THE KEY FOR THIS CONVERSATION IS
THAT MUCH OF CHRONIC CONDITION
IS IMPACTED BY PEOPLE'S
LIFESTYLE, BEHAVIOR, CHOICES,
AND THE BOTTOM LINE IS IN
CERTAINLY MY OPINION AND MANY
OTHERS IS ONE OF THE MAJOR
PROBLEMS THAT WE HAVE
UNDERLINING THIS CRISIS, IS THAT
THE CURRENT APPROACH TO HEALTH
AND DISEASE MANAGEMENT, ACTUALLY
DOESN'T FOCUS ON ENGAGING PEOPLE
AND OPTIMIZING THEIR SELF-CARE
AND WELL BEING SO WE DO PARTS OF
HEALTHCARE VERY EFFECTIVELY AND
THE ASPECTS THAT ARE SO CRITICAL
TO THESE OUTCOMES AND THE COST
WE DON'T REALLY PAY ATTENTION
TO.
THE SYSTEM ITSELF, NOT
INDIVIDUALS, THIS IS NOT ABOUT
THE INDIVIDUAL CLINICIANS OR
RESEARCHERS BUT THE SYSTEM IS
NOT DESIGNED AS A CORE
COMPETENCY TO ENGAGE PEOPLE IN
THEIR OWN SEVERAL CARE AND TEACH
THEM THE SKILLS THEY NEED TO DO
THAT EFFECTIVELY.
WE'RE GOING TO TALK MORE ABOUT
THIS.
I THINK THE OPIOID CRISIS FROM
MY PERSPECTIVE IS A VERY CLEAR
DEMONSTRATION OF THE LIMITATIONS
OF WHAT I WOULD CALL A FIND IT,
FIX IT OR A REDUCTION IS TICK
PARADIGM THAT I THINK WE NOW
HAVE WITH THE LEADERSHIP OF THIS
GROUP, HAVE AN OPPORTUNITY TO
REALLY, REALLY TRANSFORM IN A
VERY SIGNIFICANT WAY.
THIS IS A LITTLE SHOCKING WHEN
YOU LOOK AT THE LINE.
THE PURPLE LINE IS THE
PER-CAPITA SPENDING IN THE
NATIONS ACROSS THE BOTTOM.
TRACTOR-TRAILER THE AVERAGE LIFE
EXPECTANCY AND YOU CAN SEE AND
AND IT'S WAY DOWN THE LINE NEXT
TO CUBA IN TERMS OF LIFE EXPECT
ANTSY SO ANOTHER WAY TO PAINT
THE PICTURE OF THE PROBLEM WE'RE
FACING.
AND I LOVE THIS.
I WOULD ENCOURAGE YOU TO HOLD
THIS QUOTE IN YOUR CON SUNNESS
CONSCIOUSNESS.
PROBLEMS CANNOT BE SOLVED WITH
THE SAME LEVEL OF THINKING THAT
CREATED THEM.
AS I'M UNDERSTANDING THE
INTENTIONS FOR THE TWO DAYS,
IT'S TO LAUNCH US INTO ADVANCING
OUR THINKING ABOUT THE PROBLEMS
WE'RE FACING AND HOW WE THINK OF
THIS DIFFERENTLY.
IN A DIFFERENT WAY, DOING MORE
OF THE SAME IS NOT GOING TO FIX
THE PROBLEM THAT WE'RE CURRENTLY
FACING.
SO NEXT SLIDE, PLEASE.
A QUICK GLANCE AT -- IF YOU
CLICK AGAIN, I DIDN'T KNOW I
PHASED THAT.
THERE WE GO, THANK YOU.
A QUICK LOOK AT OVERLY
SIMPLIFIED VERSION BUT I THINK A
USEFUL PERSPECTIVE WHEN WE'RE
TALKING ABOUT CHANGING OUR
PARADIGMS AND LOOKING AT THE
COMMENT PLCOMPLEXITY OF PAIN, YK
ABOUT OUR SCIENCE IN THE 1900S
COMPARED TO THE 2000s, SCIENCE
HAS ADVANCED TREMENDOUSLY,
RIGHT.
WE'VE GONE FROM UNDERSTANDING
WHAT THE LIST AND WE'VE GONE
FROM A REDUCTIONISTIC APPROACH
AND THE 1900S AND RESULTED IN AN
APPROACH OF FINDING A CORE
PROBLEMS AND FIXING IT AND AND
THOSE THINGS ARE GREAT WHEN YOU
CAN DO THAT BUT WHAT WE LEARNED
IT'S NOT THAT SIMPLE AND THESE
THINGS ARE VERY COMPLEX AND OUR
SCIENTIST ADVANCE INTO MUCH MORE
OF A SYSTEMS APPROACH BUT I
WOULD PROPOSE TO YOU THAT OUR
MEDICAL APPROACHES HAVE NOT KEPT
PACE WITH THAT.
NEXT SLIDE.
WHEN WE THINK ABOUT THIS WHEN WE
TALK BASIS TOMORROW'S THAT THE
APPROACH AND PARADIGMS WE REALLY
FELT LIKE OK, IF WE CAN FIND THE
PROBLEM, WE CAN CREATE THE
SOLUTION AND FIX THE PROBLEM BUT
THAT IS A VERY CONCEPT OF A
SINGLE FACTOR AND THERE'S A
MICROBE CAUSING AN INFECTION AND
WE JUST CREATE THE CURE FOR THAT
AND WE'RE GOOD TO GO.
NEEDLESS TO SAY IT'S NOT THAT
SIMPLE.
CERTAINLY PAIN AND PEOPLE'S
SUFFERING WITH PAIN, ARE ONE OF
THE MOST IS POIGNANT
ILLUSTRATIONS OF HOW COMPLEX
THESE ILLUSTRATIONS ARE.
THERE ARE FACTORS IN THE PERSON
THEMSELVES AND ALSO IN THEIR
ENVIRONMENT.
THERE IS THEIR GENOMIC RISK AND
SOCIAL DETERMINANTS, LIFESTYLE
CHOICES, WE ARE COMPLEX ADAPTIVE
SYSTEMS AND YET I THINK OUR
MEDICAL APPROACH, AND I WOULD
LEAVE IT TO YOU TO SAY, IF OUR
RESEARCH APPROACH, HAS CAUGHT UP
TO THAT AND ADVANCED BEYOND THE
MORE REDUCTIONISTIC APPROACH.
IT'S A BIG CHALLENGE THAT WE'RE
FACING RIGHT NOW.
>> I'M A PHYSICIAN CLINICIAN AND
LOOKING AT HEALTHCARE DELIVERY
SO I'M BEING CRITICAL OF THE
WORLD I COME FROM AND THE
SCIENCE HAS ADVANCED MUCH
FURTHER THAN THE HEALTHCARE
DELIVERY AND ONE ILLUSTRATION OF
THIS, YOU KNOW, THE NOBEL PRIZE
IN 2018 WAS AWARDED BASED ON
THIS IS THE LANGUAGE THAT WAS
DESCRIBED, THAT THIS IS A NEW
PRINCIPLE FOR TREATMENT AND THIS
WAS CANCER TREATMENT AND WHERE
PREVIOUS TREATMENTS TARGETED THE
CANCER CELLS AND THIS TARGETED
THE HOST SO WHAT THAT MEANT IS
IN THE SCIENCE DONE BY THESE TWO
GENTLEMAN, INSTEAD OF FIGHTING
THE CANCER CELL AND THE FIND IT
AND FIX IT MODEL, WE'RE GOING TO
FIND THE CANCER CELLS AND FIND
NEW WAYS TO DESTROY THE CANCER
CELLS, THEIR PRIZE WAS AWARDED
BECAUSE THEY WERE ACTUALLY
LOOKING AT THE HOST, MEANING THE
PERSON, AND COULD THE TREATMENTS
FOCUS ON, THIS IS MY LANGUAGE,
NOT THEIRS BUT COULD THE
TREATMENTS FOCUS ON THE
AMPLIFYING THE BODIES OWN INNATE
CAPACITY TO FIGHT THE CANCER
CELLS.
IT'S A SWITCH IN THAT PARADIGM
THAT WAS RECOGNIZED AS VERY
TRANSFORMATIONAL AND I WOULD
PROPOSE TO YOU, IN MY
EXPERIENCE, THAT THE HEALTHCARE
DELIVERIES SYSTEM HAS NOT
ADVANCED IN THE SAME WAY.
AND THAT WE'RE STILL VERY MUCH
CAUGHT IN THE FIND IT-FIX-IT
REDUCTIONISTIC APPROACH IN LARGE
PART BECAUSE THAT'S WHAT THIS
SYSTEM IS SET UP TO DO AND
THAT'S WHAT WE'RE PAID TO DO
PRIMARILY SO IT'S NO ONE'S
FAULT, IT'S A SYSTEMS ISSUE BUT
THINK WE HAVE TO RECOGNIZE THE
SYSTEMS ISSUE IF WE'RE GOING TO
ADDRESS IT.
NEXT SLIDE.
I WANTED TO REFLECT A BIT ON HOW
WE'VE BEEN TRAINED TO THINK.
AGAIN, I'M A PHYSICIAN BY
TRAINING AND SO I AM JUST
REFLECTING AND I THINK WE HAVE
GOTTEN BETTER THAN WHEN I WAS IN
MEDICINE SCHOOL AND RESIDENTS
DEN SEE BUT IT'S USEFUL WHEN
WE'RE THINKING ABOUT CHANGING
THE LENS, THROUGH WHICH WE LOOK,
WHICH Dr. KOROSHETZ SHARED AND
WHAT HAPPENS WHEN WE CHANGE THE
LENS?
I WANTED TO TAKE A MOMENT TO
LOOK AT LENS THROUGH WHICH MOST
OF US HAVE BEEN TRAINED TO THINK
IF YOU THINK ABOUT WELL ASK
YOURSELF HOW DO ANTIBIOTICS
WORK?
MOST OF US WILL SAY THE
ANTIBIOTICS ANTI-BUYOT CURE THEE
THEY KILL OFF THE MICROBES.
A DIFFERENT WAY, PARALLEL TO THE
NOBEL PRIZE-WINNING CANCER SHIFT
AND A DIFFERENT WAY TO THINK
ABOUT THAT IS YEAH, THEY
ABSOLUTELY HELP BUT PERHAPS THE
WAY WE CAN THINK ABOUT THAT IN A
DIFFERENT LENS TO THINK ABOUT
THAT IS THE ANTIBIOTICS REDUCE
THE BACTERIAL LOAD SO THAT THE
BODIES INNATE CAPACITY TO HEAL,
CAN BE MORE SUCCESSFUL SOLVE
THAT MIGHT SOUND LIKE A SUBTLE
SHIFT BUT IT'S IMPORTANT IN HOW
WE THINK.
THE PARADIGM AND THE LENS WHICH
WE LOOK AND PARALLEL TO ARE WE
FIGHTING CANCER AND ENABLING THE
HOST AND THE INNATE MY NEXT
LIFETIME I WANT TO BE ANNAN
THROW POLL GIST.
SO TO REFLECT ON THE LANGUAGE WE
USE IN MEDICINE AND SCIENCE AND
WHAT DOES IT TELL US ABOUT OUR
PARADIGM?
IT'S VERY TELLING AND ANTI
EVERYTHING AND YOU HAVE A
PROBLEM AND I HAVE AN ANTI,
RIGHT.
WE HAVE ANTIBIOTIC.
YOU HAVE DEPRESSION AND I HAVE
AN ANTI A PARADIGM COMES BACK TO
THIS REDUCE IS TICK, HERE IS THE
FIND IT AND THE FIX IT AND IF IT
WERE THAT SIMPLE, IF THAT WERE
SUCCEEDING, THERE'S NOTHING
INNATELY WRONG IT'S JUST
INSUFFICIENT.
AND THE LANGUAGE HELPS US
RECOGNIZE WE'RE LOOKING THROUGH
THE LENS.
THE QUESTION OF, IS THERE AN
INNATE CAPACITY TO HEAL?
SOMETIMES THIS QUESTION TRIGGERS
PEOPLE BECAUSE THERE'S IT COULD
SAY IF DO YOU ANYTHING RIGHT,
YOU WILL NEVER GET SICK OR DIE
AND OBVIOUSLY IT'S NOT TRUE.
WE'RE ALL MORTAL BEINGS AND
WE'RE GOING TO GET SICK AND DIE.
IT'S NOT LIKE IF YOU DO IT ALL
RIGHT AND ARE WE DESIGNED AS
HUMAN BEINGS WITH INNATE
CAPACITY TO HEAL.
SIMPLE THINGS LIKE CUTS.
IF YOU REALLY THINK ABOUT IT AND
WE BECOME SO ACCUSTOMED TO WELL,
I GOT A CUT AND IT HEALED.
WE FORGET HOW AMAZING IT IS AND
HOW MANY MECHANISMS ARE IN PLAY
FOR THE BODY TO ACTUALLY HEAL A
CUT.
A BROKEN BONE.
EVEN MORE SIGNIFICANT IF IT'S
ALIGNED AND NOT OUT OF ALIGNMENT
OR COMPLEX BREAK, LEAVE IT
ALONE.
THE BODY HAS THE CAPACITY TO
HEAL THE BONE.
I MEAN, AGAIN, IF WE PAUSE AND
THINK ABOUT HOW AMAZING THAT IS,
IT'S SIGNIFICANT.
AND WHAT ABOUT AT THE MOLECULAR
LEVEL IT'S AMAZING WHEN YOU
THINK ABOUT, THERE'S TRANSFER
RNA AND THERE ARE ALL OF THESE
MOLECULES THAT ARE DESIGNED TO
HELP FIND ERRORS IN A MOM MOLECR
LEVEL AND CORRECT THEM, SIMPLY
PUT.
PULLING BACK AND SAYING, WHAT IF
WE LOOK THROUGH OUR CLINICAL
APPROACHES AND OUR RESEARCH
APPROACHES, JUST AS THE
GENTLEMAN WHO WON THE NOBEL
PRIZES, WHAT IF WE LOOK THROUGH
THE LENS OF HOW CAN WE OPTIMIZE
THAT CAPACITY TO HEAL?
HOW CAN WE, ANOTHER WAY TO SAY
THAT, HOW CAN WE ACTIVATE A
HEALING RESPONSE?
AND IN MY CONCEPT OF AK TA RATE
TA RATEISED HEALING, AK TA RATEA
HEALING RESPONSE IS PLACEBOS.
THE ONLY THING I WANT TO BRING
UP IN THIS CONTEXT IS WHEN I
BACK IN THE DARK AGES WHEN I WAS
IN TRAINING, PLACEBOS WAS A
THING TO TRICK PATIENTS TO SEE
IF THE REAL INTERVENTIONS WORKS
AND THE REFRAME IS, WOW, THINK
ABOUT A REAL PLACEBO EFFECT?
THE FACT THAT THERE COULD BE
SOMETHING LIKE A PLACEBO PILL,
OR A DIFFERENT INTERVENTION THAT
THEN AK TA VISITS THE MIND TO
HEAL WITHOUT AN ACTIVE AGENT.
WE SHOULD BE FIGURING OUT HOW TO
DO THAT MORE CONSISTENTLY AND
THAT IN MY OPINION SHOULD BE ONE
OF OUR QUESTS RIGHT.
IT'S A GREAT ILLUSTRATIONS OF
THE BODY'S INNATE CAPACITY TO
HEAL.
HOW WE DO THE RESEARCH AND WHAT
IF WE CHANGE THE LENS THROUGH
WHICH WE LOOK.
NEXT SLIDE, PLEASE.
I HAVE A COUPLE OF QUOTES
SPRINKLES IN HERE BECAUSE I LOVE
THESE.
DAVID BOR STEEN, NOT SOMEONE I
KNOW, HE WAS WITH A LIBRARY OF
CONGRESS BUT THE GREATEST
BARRIER TO DISCOVERY IS NOT
IGNORANCE, BUT THE ILLUSION OF
KNOWLEDGE.
NOW I'M GOING TO READ THAT AGAIN
BECAUSE PARTICULARLY THE
RESEARCH.
WHEN WE GET CAUGHT IN OUR OWN
WAY OF THINKING ABOUT THINGS,
IT'S REALLY RELATED TO THE FIRST
QUOTE, RIGHT, THAT WE CAN'T
SOLVE PROBLEMS WITH THE SAME
THOUGHT PROCESS THAT GOT US INTO
THE CIRCUMSTANCES WE'RE IN.
SO, I WOULD ENCOURAGE YOU TODAY
AND TOMORROW, TO REALLY STAY
OPEN AND BE AWARE OF PERHAPS
YOUR OWN ILLUSION OF KNOWLEDGE
IN CERTAIN AREAS AND WHAT MIGHT
HAPPEN IF YOU STEP OUT OF THAT.
SO THIS IS INTERESTING.
A LOT OF MY WORK IS IN THE
TRANSFORMATION OF HEALTH SYSTEMS
AND WHEN PEOPLE USE THE CONCEPT
OF TRANSFORMATION A LOT, I THINK
WE OVERUSE TRANSFORMATION.
A LOT OF WHAT WE CALL
TRANSFORMATION IS SIMPLY I WOULD
CALL IMPROVEMENT, CONTINUOUS
IMPROVEMENT OF THE CURRENT
SYSTEM.
BUT WHAT MAKES SOMETHING
TRANSFORMATIONAL IN MY OPINION
IS WHEN THE IF YOU WERE OF THE
SYSTEM HAS CHANGED AND THIS
PARALLELS THE RESEARCH, SO I
WOULD SAY THAT IT SIMPLIFIED THE
PRIMARY PURPOSE OF OUR CURRENT
SYSTEM TO CURE IT WHEN WE CAN
AND WHEN WE CAN'T CURE IT,
MANAGE IT.
I THINK THAT SIMPLY PUT IS THE
DOMINANT PARADIGM OF OUR CURRENT
SYSTEM AND WHEN WE TALK ABOUT
WHOLE HEALTH AND YOU CAN GO TO
THE NEXT SLIDE, WHAT DO WE MEAN
BY WHOLE HEALTH.
I THINK THAT THE PURPOSE OF
WHOLE HEALTH VERY DIFFERENT
PURPOSE, THAN THE PURPOSE OF THE
HEALTH, THE DOMINANT HEALTH
SYSTEM WE DESCRIBED.
IT'S TO EMPOWER AND EQUIP.
THOSE ARE TWO DIFFERENT ELEMENTS
THAT ARE BOTH CRITICALLY
IMPORTANT.
EMPOWER PEOPLE AND THEN WHEN
EMPOWERED, EQUIP THEM WITH THE
SKILLS THAT THEY NEED AND THE
SUPPORT THEY NEED SO THAT THEY
CAN TAKE CHARGE OF THEIR
PHYSICAL, MENTAL AND SPIRITUAL
HEALTH FOR WHAT PURPOSE?
SO THEY CAN LIVE A FULL AND
MEANINGFUL LIFE.
WHATEVER IS THAT MEANS FOR THEM.
AND THIS DOESN'T -- LOTS OF TIME
PEOPLE THINK WHOLE HEALTH IS
PREVENTION.
IT'S NOT.
PREVENTION IS AN IMPORTANT PIECE
OF THIS BUT WHOLE HEALTH, THIS
IS APPLICABLE AND THE LAST FEW
DAYS OF LIFE AS IT IS AT THE
BEGINNING OF HEALTH.
I'M EMPHASIZING THIS BECAUSE AS
YOU GO THROUGH THE NEXT TWO DAYS
AND YOU ARE ENTERTAINING, WHAT
DOES THIS MEAN FOR PAIN AND PAIN
MANAGEMENT AND THE RESEARCH THAT
WE'RE ADVANCING.
IF THIS IS THE PARADIGM AND TO
EMPOWER PEOPLE AND EQUIP PEOPLE
TO TAKE CHARGE OF ALL ASPECTS OF
THEIR HEALTH FOR THE INTENTION
AND PURPOSE OF LIVING THEIR FULL
TIME YOUR QUESTION AND RESEARCH
CHANGED DRAMATICALLY AND NEXT
SLIDE.
THIS IS GREAT.
NO INTENT SHOULD BE MADE TO CURE
THE WE'D WITHOUT THE SOUL.
LET NO ONE PERSUADE YOU TO CURE
CURE THE HEAD UNTIL HE HAS GIVEN
HIS SOUL TO BE CURED.
THIS IS THE GREATER OR OF OUR
DAY.
IT'S A LITTLE DISCOURAGING THAT
WAS THE GREATER OR OF THE DAY
WHEN PLATEAU WAS ALIVE BECAUSE I
WOULD SAY IT'S ONE OF THE
GREATERRGREAT ERRORSOF THE DAY .
SO VERY SIMPLY PUT, I REFERENCED
REDUCTIONISTIC APPROACH AND
SYSTEMS APPROACH AND WHEN I
THINK WE'VE COME FROM A
REDUCTIONISTIC PARADIGM AND I
HOPE WE'RE MOVING INTO A SYSTEMS
APPROACH AND WHAT DO WE MEAN BY
THAT CONCRETELY?
IT'S OFTEN REACTION TIVE AND WE
WAIT WELL THERE'S A PROBLEM AND
WE RESPOND.
SPORADIC INTERVENTIONS AND
BIOMEDICAL INTERVENTIONS AND WE
LET THE INDIVIDUAL ON THEIR OWN
TO HOPEFULLY ENACT THE
RECOMMENDATIONS.
WINDOW DOES A SYSTEM APPROACH
LOOK LIKE?
WELL, WE'RE FOCUSED ON THE
PERSON AND THEIR SENSE OF
MEANING AND PURPOSE IN THEIR
LIFE.
IT'S NOT JUST ADDRESSING THE
PROBLEMS, IT'S HELPING PEOPLE
REALIZE THAT THEIR ASPIRATION
AND HOW THEY CAN PARTNER WITH
THE TEAM TO REALIZE THAT IN
THEIR LIFE.
IT'S MUCH MORE LIFE-FOCUSED THAN
PROBLEM FOCUSED.
IT'S NOT ONLY MANAGING DISEASE
BUT OPTIMIZING HEALTH AND IT'S
NOT ONLY FINDING AND FIXING
PROBLEMS BUT IDENTIFYING THE
RISK AND MINIMIZING IT.
MUCH MORE PROACTIVE ACROSS THE
LIFESPAN AND ENGAGING WHOLE
HEALTH APPROACHES AND I'LL SHOW
YOU A GRAPHIC OF HOW WE THINK
ABOUT THAT IN A MOMENT AND VERY
IMPORTANTLY, NOT SAYING, HAVE AT
IT, HOPE IT TURNS OUT WELL,
LET'S SEE HOW IT GOES.
REALLY ADDRESSING THE SKILL
BUILDING AND THE SUPPORT THAT
PEOPLE NEED.
NOT ONLY IN THE HEALTH-CARE
SYSTEM BUT WHERE THEY WORK AND
WHERE THEY LIVE TO REALLY HELP
THEM OWN THEIR SELF-CARE AND
THEIR PART OF THE HEALING
PROCESS.
NEXT SLIDE.
MANY PEOPLE HAVE VERY SIMILAR
GRAPHICS.
THIS IS EVOLVED FROM DUKE TO THE
V.A. TO THE HEALTH INSTITUTE.
YOU CAN SEE THAT THE ELEMENTS
HERE, THE CARE TEAM AND THE
CLINICAL PIECE IS ONE PIECE THAT
A PRETTY -- ONE PIECE OF A WHOLE
WHERE WE START FIRST WITH THE
PERSON THEMSELVES AND WHAT
MATTERS MOST TO THEM.
THAT'S A REAL SHIFT.
AND YOU CAN SEE THAT IN THE PAIN
COMMUNITY AND I'LL TALK MORE
ABOUT THAT IN A MOMENT.
THE MIDDLE CIRCLE, THE SELF-CARE
CIRCLE ARE DIFFERENT DIFFERENT
ELEMENTS OF SELF-CARE.
MOST OF US ADDRESS VERY, VERY
SIMILAR ASPECTS AND WE MIGHT
LABEL THEM DIFFERENTLY BUT OF
COURSE IT'S THINGS LIKE
NUTRITION AND MOVING YOUR BODY
AND ALSO THE POWER OF YOUR MIND
AND SPIRITUALITY AND YOUR
RELATIONSHIPS AND YOUR SLEEP,
ALL OF THESE ASPECTS EFFECT
PEOPLE PARTICULARLY WHEN DEALING
WITH COMPLEX CHRONIC ISSUES LIKE
PAIN.
SO, THIS IS KIND OF THE VISION
OF, WELL, THIS IS WHOLE HEALTH.
IT STARTS WITH THE INDIVIDUAL
AND THEIR PURPOSE AND A BIG
EMPHASIS ON SELF-CARE.
YES THE CARE TEAM AND YES IN
COMMUNITIES BUT HOW DO YOU
ACTUALLY OPERATIONALIZE THAT
BECAUSE IF WE'RE GOING TO
RESEARCH THAT, WE HAVE TO HAVE A
SYSTEM AND APPROACH THAT SAY OK,
WELL THAT LOOKS NICE AND CONCEPT
AND THEORY, HOW DO YOU ACTUALLY
MAKE IT HAPPEN?
SO NEXT SLIDE.
LET'S THE QUESTION I JUST ASKED,
YOU CAN ADVANCE.
SO THIS IS OUT OF THE WORK IN
THE V.A. WHICH IS ON GOING AND
QUITE AMAZING UNDER THE
LEADERSHIP OF Dr. KIGLER AND
WE REALIZE THROUGH A LOT OF WORK
IN THE FACILITIES AND WITH
CLINICIANS AND RESEARCHERS
ACROSS THE NATION, THAT THIS IS
NOT ALL DONE IN THE CLINICAL
ENVIRONMENT IDEALLY THAT THE
CLINICAL ENVIRONMENT IS
INCREDIBLY IMPORTANT BUT THIS
QUESTION OF HELPING PEOPLE
UNDERSTAND WHAT MATTERS TO THEM
AND ENGAGING THEM IN THEIR
HEALTH IS A HUGE ISSUE THAT THE
HEALTH SYSTEM ISN'T DESIGNED TO
DO SO THE ABILITY TO USE PEER
PROGRAMS TO HELP EXPLORE THESE
NON CLINICAL QUESTIONS OF WHAT
MATTERS MOST TO YOU, WHAT DO YOU
WANT YOUR HEALTH FOR, THAT
EMPOWER PIECE IS IT DOESN'T TAKE
A CLINICAL TEAM IT'S
SKILL-BUILDING AND SUPPORT AND
WHEN THESE ARE ALIGNED AND
PEOPLE ARE CONNECTED WITH EACH
OTHER, THIS CAN HAVE AMAZING
IMPACT.
SO I'LL GO THROUGH THESE
BRIEFLY.
THE EMPOWER PIECE, AS I
MENTIONED, IS ABOUT HELPING
PEOPLE FIND WHAT MATTERS MOST TO
THEM IN THEIR LIFE AND GIVE THEM
A SENSE OF HOPE AND THERE'S A
REASON TO ENGAGE IN THEIR LIFE
AGAIN.
AND THIS IS BEST LED BY PEERS IN
OUR EXPERIENCE AND THE V.A. HAS
GREAT MATERIALS AND COURSES THAT
ARE OPEN SOURCE AND AVAILABLE TO
ALL.
MOVED YOUR BODY AND YOU NEED TO
KNOW HOW TO DO IT DIFFERENTLY
AND SUPPORT FOR REALLY ENGAGING
AND BEHAVIOR CHANGE SO THE GREAT
THINGS ABOUT THIS IS THESE
SELF-CARE APPROACHES ARE
CONSISTENT ACROSS BECAUSE AGAIN
THE PARADIGM IS DIFFERENT AND
WE'RE OPTIMIZING THE BODY'S
ABILITY TO HEAL AND SO WE
OPTIMIZE SELF-CARE AND IT'S THE
SAME WITH A FEW TWEAKS WHETHER
WHATEVER YOUR CONDITIONS IS AND
THIS IS DONE THROUGH INSTRUCTORS
AND COACHES AND ACROSS THIS
DIFFERENT AREA AND NEXT SLIDE.
IT MAKES A HUGE DIFFERENCE WHEN
THE CLINICIANS ARE UNDERSTANDING
THE CONCEPT OF THIS PARADIGM AND
SUPPORT IT AND I'LL JUST TELL
YOU A GREAT ILLUSTRATION OF THAT
APPROACH FROM THE V.A. IN LITTLE
ROCK.
AND THE CARE TEAM, THIS IS MY
STORY SO IF I GET IT WRONG I
APOLOGIZE.
THE CARE TEAM, AS I UNDERSTAND,
WAS NOT REAL EXCITED ABOUT THIS
NEW APPROACH AND REALLY LIKE
THEY HAVE ENOUGH ON THEIR PLATES
AND THEY'RE OVERWHELMED AND SO
WHAT THEY DID AND THEY CREATED
THE SELF-CARE PROGRAM TO WORK
WITH THE CLINICIANS AND THE PAIN
PATIENTS GOT SO ENGAGE FROM
THEIR OWN LIFE AND HEALTH AND
WERE GETTING THE OPPORTUNITY TO
ENGAGE WORKPLACES IS A HUGE
OPPORTUNITY THAT WILL SAVE FOR
ANOTHER TALK.
AND NEXT SLIDE.
SO DOES IT WORK ANY WANT TO
HIGHLIGHT A BIT OF THE RESEARCH
AND THERE WAS AN ARTICLE
PUBLISHED CAN YOU GO TO THE NEXT
SLIDE FROM ALL THE V.A. WORK
WHICH THIS IS JUST THE SUMMATION
BUT I THINK WE'RE TALKING ABOUT
PAIN AND I DID WANT TO HIGHLIGHT
THAT WHOLE HEALTH HAD A POSITIVE
IMPACT ON REDUCING OPIOID USE
AND IN THE VETERANS USING WHOLE
HEALTH AND THOSE WITHIN A
THREEFOLD REDUCTION IN THOSE
PATIENTS WHO ARE USING WHOLE
HEALTH APPROACHES VERSUS THOSE
WHO WERE NOT AND LOTS OF OTHER
BENEFITS FROM THIS APPROACH
INCLUDING THIS IS THE GRAPHIC
AND YOU CAN SEE THERE'S A DOSE
RESPONSE CURVE AND BETWEEN OPEN
REDUCTION AND THE DIFFERENT
LEVELS OF WHOLE HEALTH
APPROACHES SO THEY'RE DEFINED ON
THE SIDE AND THE INTENSIVE AND
MIDDLE GROWN POWER IS
COMPREHENSIVE INTEGRATION TIVE
APPROACH ONLY AND THE CORE WHOLE
HEALTH INTENSE AND CORE INCLUDES
THE PEER PIECE AND THE SUPPORT
AND THE COMPREHENSIVE INCLUDES
BOTH SO VERY INTERESTING DATA.
AND I'M NOT GOING TO GO INTO
DEPTH ON THIS BUFFET TALK ON
THIS LATER AND THIS IS WORK
WITH A SIGNIFICANT REDUCTION OF
SPINE PROCEDURES WITH VETERANS
USING WHOLE HEALTH VERSUS THOSE
WHO ARE NOT AND JUST TO LET YOUR
APPETITE THAT THIS ISN'T JUST
GREAT IDEAS, THERE'S REAL
OUTCOMES AND HAVING LOOKED AT
THE DATA LIKE THAT, I SHARE THIS
SLIDE OFTEN AND I THINK ONE OF
THE THINGS THAT WE'RE HERE TO
REALIZE IS THAT IT'S SO MUCH
MORE THAN JUST HOW MANY
OWNERSHIPS ARE TAKEN ALTHOUGH
IT'S CRITICAL AND HOW MANY
PROCEDURES ARE DONE.
THIS IS ABOUT PEOPLE'S LIVES.
THIS IS WHAT CHANGES WITH THIS
PARADIGM AND I WILL TAKE A
MOMENT TO READ THESE.
THESE NOT SPECIFIC TO PAIN
PATIENTS BUT THEY'RE THREE
PATIENTS WHO WE'RE NOT HAND
SELECTED OUT OF THE NATION AND
THE TOP IS THE 52-YEAR-OLD
GENTLEMAN AND IT'S A GOOD THE
CHANGE IN THIS APPROACH, THE
CHANGE IN THIS LENS AND PAUL
HEALTH HE SAYS BEGAN BY JOURNEY
TO JOY AND WHO SAYS IT WILL A
BEGAN BY I'M A CHANGE PERSON AND
NO LONGER NEED MY CANE.
SO THERE ARE CLINICAL IMPACT AND
THE WHOLE HEALTH GROUP HAS
BECOME MY FAMILY.
MY NEUROLOGY DOESN'T NEED TO SEE
ME.
YES, GREAT CLINICAL OUTCOMES.
AND 71-YEAR-OLD GENTLEMAN, I
HAVE LOST 33 POUNDS, I GO TO FIT
CLASS WHICH IS A MOVEMENT CLASS,
NUTRITION CLASS, BATTLED FIELD,
ACUPUNCTURE.
MY WIFE SAYS, I HAVE A POSITIVE
ATTITUDE NOW.
[LAUGHTER]
I LOVE IT SO MUCH.
AND MY DIABETES IS UNDER CONTROL
AND MY BLOOD PRESSURE IS DOWN
AND MY LIPIDS ARE GOOD AND I SEE
MY PRIMARY CARE DOCTOR MUCH
LESS.
AND A 37-YEAR-OLD WOMAN, I USED
TO DRIVE OVER THE MISSISSIPPI
RIVER BRIDGE TO THE JEFFERSON
V.A. AND THINK ABOUT JUMPING
EVERY TIME.
I WANT TO SHARE WITH YOU AS YOU
ASK YOURSELF THOSE QUESTIONS.
WHAT DOES IT LOOK LIKE WHEN YOU
APPROACH IT FROM A
REDUCTIONISTIC PARADIGM AND WHAT
CHANGES WHEN YOU THINK ABOUT IT
THROUGH A SYSTEMS' LENS.
I WOULD ENCOURAGE YOU TO
REMEMBER THAT WHAT MATTERS MOST
TO US, AS CLINICIANS, AND WHAT
MATTERS MOST TO US AS
RESEARCHERS, MAYBE NOT BE WHAT
MATTERS MOST TO THE PERSON.
AND I WANT TO SHARE A STORY
ACTUALLY THAT Dr. TOM INSUL
THE FORMER DIRECTOR OF NIMH AND
SHARED IN A BOOK AND I'LL
PARAPHRASE HIS STORY BUT IT'S
REALLY SIGNIFICANT AND HE WAS
TALKING ABOUT HOW HE WAS
SOMEWHERE GIVING A COMMUNITY
LECTURE ON ALL OF THE GREAT
WORK, THIS IS WHEN HE WAS STILL
WITH THE NIH.
ALL THE OF THE GREAT ADVANCES OF
THE RESEARCH OF NIMH AROUND
MENTAL HEALTH AND HOW AMAZING
THEIR ADVANCES ARE AND WHAT THEY
WERE LEARNING AND VERY PROUD OF
THIS AMAZING WORK AS HE SHOULD
HAVE BEEN.
FROM RACE ITSING AND WHEN IT
WENT AND HE WAS THE FIRST ONE AT
THE MICROPHONE AND SCHEER WHAT
THAT MEAN SAID TO HIM.
YOU REALLY DON'T GET IT.
MY 23-YEAR-OLD SON HAS
SCHIZOPHRENIA.
HE IS HOSPITALIZED FIVE TIMES
AND HAS MADE THREE SUICIDE
ATTEMPTS AND HE IS NOW HOMELESS.
OUR HOUSE IS ON FIRE.
OUR HOUSE IS ON FIRE AND YOU ARE
TALKING ABOUT THE CHEM IS TEE OF
THE PAINT.
WHAT ARE YOU GOING TO DO TO PUT
OUT THIS FIRE?
I THINK IT'S SUCH A POIGNANT
QUESTION.
I THINK THAT'S THE CHALLENGE FOR
US AS WE THINK ABOUT THIS IN THE
CONTEXT OF PAIN.
THE REDUCTIONISTIC RESEARCH IS
CRITICALLY IMPORTANT BUT IT'S
NOT ENOUGH.
SO WHAT CAN WE DO AND WHAT
CHANGES?
WHAT IS POSSIBLE WHEN WE LOOK AT
PAIN AND PAIN MANAGEMENT THROUGH
THIS DIFFERENT LENS.
I THINK FIRST OF ALL WE'LL ASK
DIFFERENT QUESTIONS AND SECOND
OF ALL WE ARE GOING TO SEE AND
EXPLORE NEW POSSIBILITIES THAT
WE OTHERWISE JUST WOULD NOT SEE
BECAUSE WE'RE LOOKING THROUGH A
DIFFERENT LENS.
SO NEXT SLIDE, PLEASE.
I'M SURE MANY OF YOU KNOW HIS
WRITING.
WE HAVE BEEN WRONG ABOUT WHAT
OUR JOB IS IN MEDICINE.
WE THINK OUR JOB IS TO ENSURE
HEALTH AND SURVIVAL BUT REALLY,
IT'S LARGER THAN THAT.
IT'S TO ENABLE WELLBEING AND
WELLBEING IS ABOUT THE REASONS
ONE WISHES TO BE ALIVE.
I LOVE THAT.
WELLBEING IS ABOUT THE REASONS
ONE WISHES TO BE A LIVE AND
THOSE REASONS MATTER NOT JUST AT
THE END-OF-LIFE, OR WHEN
DISABILITY COMES, BUT ALL ALONG
THE WAY.
NEXT SLIDE.
AND THE COST DECREASE SO IT'S
NOT AS IF WE'RE ABANDONING WHAT
THE OUTCOMES THAT WE NEED.
IT'S QUITE THE OPPOSITE.
IT'S THAT DOING MORE OF THE SAME
ISN'T GETTING US WHERE WE NEED
TO BE.
AND IN THIS WAY, WE CAN.
SO, IN CONCLUSION, I THINK
THAT'S MY LAST SLIDE, I JUST
WANTED TO SAY TO YOU ALL BEFORE
WE MOVED TO Q&A THAT I THINK
THAT YOU ALL HAVE A TREMENDOUS
OPPORTUNITY TO LEAD THE NATION
IN AN ENTIRELY NEW APPROACH TO
THINKING, TO TRAITING, AND TO
RESEARCHING THE ISSUES AROUND
PAIN.
AND I THINK THAT THE NUMBER OF
LIVES THAT YOU CAN IMPACT, THE
AMOUNT OF SUFFERING THAT YOU CAN
SOOTHE IS PHENOMENAL.
REALLY IT'S PHENOMENAL AND I
WANT TO A EMPLOYED THE ENTIRE
COMMITTEE AND THE ENTIRETY OF
NIH AND THE COP AGO RACE THAT
HAS FOCUSED AND TAKEN COURAGE,
IN MY OPINION, TO MAKE THIS WITH
THAT I'LL TURN IT OVER TO Q&A.
>> THANK YOU.
THANK YOU SO MUCH Dr. GAUDET.
THIS WAS EXCELLENT AND SO NEEDED
FOR THE FACE.
YOU REALLY SET UP THE SPACE FORT
NEXT TWO DAYS.
SO WE GOT QUESTIONS FROM THE
AUDIENCE AND I'D LIKE TO BRING A
COUPLE TO YOUR ATTENTION.
THE FIRST QUESTION, WHOLE HEALTH
IS LIMITED TO PATIENTS WHO HAVE
BEEN AT A CARE FACILITY AND
CONSTRUCT REQUCONNED BY PATIENTN
SPECIALISTS.
>> SO, I'M SORRY, SO THE
QUESTION IS --
>> THE WHOLE APPROACH IS IT
APPLICABLE OR A CARE FACILITIES
OR OUT PATIENT?
>> THANK YOU.
THANK YOU FOR THE SUMMARY OF
THAT, I APPRECIATE THAT.
NO, ABSOLUTELY.
IT IS VERY INTERESTING THAT IT
IS APPLICABLE ACROSS ALL
SEVERITY OF WHETHER IT'S PAIN OR
OTHER CONDITIONS AND ACROSS
SETTINGS SO IN A LARGE DEGREE,
BECAUSE SO MUCH OF THIS IS NOT
JUST CLINICAL, IT'S VERY, VERY
ADAPTABLE AND OFTEN OPTIMAL,
EVEN THE EXAMPLE I GAVE LIKE THE
LITTLE ROCK CLINIC WHERE THERE
WAS WELL BEING WHOLE HEALTH, YOU
KNOW, SELF-CARE APPROACH AND IN
COLLABORATION WITH THE CLINICAL
SO IT'S NOT IN ANYWAY LIMITED TO
INPATIENT AND IT'S OFTEN MOST
EFFECTIVE IN THE COMMUNITIES AND
IN THE PLACE WHERE PEOPLE LIVE.
>> GREAT.
THANK YOU.
TO WHAT DEGREE THIS APPROACH USE
COMPARED TO CONSCIOUS PRESENTED
UP FRONT IS THERE EVIDENCE THAT
THEY IMPROVE HEALTH OUTCOMES AND
COSTS AT THE POPULATION LEVEL?
>> SO, I WISH I WERE MORE OF AN
EXPERT ON THE POPULATION SIDE OF
THIS BECAUSE THOSE ARE
TREMENDOUSLY IMPORTANT QUESTIONS
AND I DO THINK THAT WHAT WE WERE
SEEING -- ONE OF THE THINGS I
VALUE ABOUT THIS V.A. WORK, MANY
THINGS, THAT YOU KNOW THERE'S
BEEN, LET'S SAY 20 YEARS AGO, A
PRESUMPTION THAT THESE KINDS OF
PHILOSOPHIES AND APPROACHES WERE
FOR PEOPLE WHO WERE PRIVILEGED.
LIKE PEOPLE WHO HAD ACCESS AND
HAD AVAILABILITY AND SERVICES
AND HAD BEEN QUITE HONESTLY
PEOPLE HAD THE PERCEPTION THAT
WELL, SURE, THAT'S GREAT TO
THINK ABOUT.
YOUR SENSE OF MEANING AND
PURPOSE IN YOUR LIFE IF YOU ARE
AFFLUENT AND YOU CAN DO THAT.
WELL, WHAT IS SHOWN OVER THE
LAST 10 YEARS OR SO THIS IS
EVERY BIT IS APPLICABLE IF NOT
MORE FOR THE HOMELESS
POPULATION, FOR PEOPLE WHO ARE
JUST TRYING TO GET THROUGH THE
DAY THAT ACTUALLY, AND AGAIN,
USING THE V.A., EXPERIENCE, WHEN
THIS APPROACH WAS OPEN TO ALL
VETERANS AND THE PRIMARY PEOPLE
COMING WERE PEOPLE STRUGGLING
WITH MENTAL HEALTH AND OR PAIN.
YOU KNOW, ACROSS THE NATION.
SO I THINK THE IMPACT AT THE
POPULATION LEVEL IS SIGNIFICANT.
I THINK IT'S ACTUALLY MORE OF A
POPULATION BASED APPROACH AND A
MOVEMENT IF YOU WILL.
THIS IS OUT OF THE SCOPE FOR
THIS MEETING TODAY AND TOMORROW
I WOULD LIKE TO SEE THE DAY
WHERE THIS APPROACHES TO EMBRACE
WHOLE HEALTH.
WHAT LINES OF EFFORT SHOULD WE
PRIORITIZE TO KEEP THING HEADED
IN THE RIGHT DIRECTION?
>> I ACTUALLY THINK THE CRISIS
IS A GOOD THING FOR THIS
TRANSFORMATION, RIGHT.
BECAUSE, LIKE WE STARTED AT THE
BEGINNING, WHAT WE'RE DOING IS
NOT WORKING AND IT'S EXPENSIVE
AND WE CAN'T SUSTAIN IT.
THE NATION CANNOT SUSTAIN THAT
LEVEL OF EXPENDITURES FOR
HEALTHCARE.
WE WILL FAIL TO BE COMPETITIVE
AND THE GLOBAL MARKETS.
I MEAN, IT'S JUST NOT
SUSTAINABLE SO THAT CREATES A
PRESSURE THAT I THINK IS GOOD
FOR US TO DRIVE TO WHOLE HEALTH
BECAUSE THE GREAT THING IS, YOU
KNOW, A LOT OF PEOPLE, WHEN THEY
START TO SEE THE DATA THAT OH,
OUTCOMES ARE BETTER AND COST
DECREASE.
WHAT DO WE NOT LIKE ABOUT THAT?
THAT'S FABULOUS.
THE CHALLENGE THAT WE HAVE IS
THE PAYMENT SYSTEM HAS TO CATCH
UP, RIGHT.
SO AS LONG AS WE STILL HAVE FEE
FOR SERVICE PAYMENTS, WHERE
THERE'S PAIN CLINICS AND THEY'RE
GETTING PAID FOR THEIR
INTERVENTIONS AND NOT FOR ANY OF
THIS, IT'S NOT SUSTAINABLE.
THE GOOD NEWS IS AND I DON'T
MEAN TO MAKE IT SIMPLE.
IT'S COMPLEX AND DIFFICULT OR IT
WOULD HAVE ALREADY HAPPENED.
THE GOOD NEWS IS AS WE SHIFT
MORE IN THIS NATION TO
VALUE-BASED PAYMENTS, THAT WILL
DRIVE THE NEED FOR VALUE-BASED
CARE, RIGHT.
SO, VALUE BASED PAYMENT WHERE
WE'RE PAYING FOR OUTCOMES, NOW
INCENTIVIZES SYSTEMS TO SAY OH I
NEED THAT WHOLE HEALTH APPROACH
ACTUALLY.
WE'RE NOT GOING TO SUCCEED IF WE
DON'T HAVE A APPROACH THAT
ADDRESSES HEALTH AND WELLBEING
AND EVERYTHING WE HAVE RIGHT
NOW, IS FEE FOR SERVICE BASED SO
THE PAYMENT AND THE POLICY SIDE
OF ALL OF THIS IS CRITICAL.
>> THANK YOU.
DO YOU CONSIDER THE WHOLE HEALTH
FRAMEWORK AS CONSISTENT WITH THE
SOCIAL MODEL OR FUNDAMENTALLY
DIFFERENT IN IMPORTANT WAYS?
>> GREAT QUESTION.
AND I THINK THIS IS VERY, VERY
CONSISTENT WITH THE BY OWE BIO-L
MODEL.
THE BIG SHIFT IN THIS APPROACH
IS ACTUALLY WHAT I WOULD SAY
STARTING FROM A DIFFERENT PLACE
SO CAN YOU DO A SHIFT OF A MODEL
OR HOLE IS TICK APPROACH AND NOT
SHIFT IS THAT PARADIGM AND I
HAVE FOUND AND I THINK THE
RESEARCH IS BEARING OUT, THAT
THAT SHIFT IS CRITICAL AND THERE
ARE MANY OF THESE CIRCUMSTANCES
AND OFFERINGS AT AVAILABLE TO
PEOPLE AND THEY'RE GOING TO TAKE
ADVANTAGE OF IT.
THE REAL SHIFT IS USING ALL THE
TOOLS AND APPROACH AND BIO
PSYCHOSOCIAL MODEL THAT'S IT BUT
STARTING FROM A THE QUESTIONS WE
DON'T ASK OURSELVES CANCER
DIAGNOSIS BUT WHAT BUT ALIGNING
THOSE APPROACH THAT PERSON CAN
HAVE A MORE FULFILLING LIFE AND
THEN IT'S OH, BY THE WAY, THEIR
PAIN SCORES COME DOWN AND THE
BIG SHIFT AND ALL THAT HAVE IS.
>> HOW CAN WE MAKE THEM OPTION
IN THE PROGRAMS AND ASSESS IS
STILL TOO LOW.
>> THE LAST PART, I'M SORRY, MY
AUDIO IS NOT GREAT.
>> SO, I'M STRUGGLE TO GO HEAR
JUST A LITTLE BIT, I APOLOGIZE.
>> NO PROBLEM.
THE QUESTION OF HOW WE CAN MAKE
NON DRUG OPTION FORCE PAIN MORE
AVAILABLE BECAUSE THE NUMBERS OF
THOSE WHO CAN ASSESS THE IS
STILL VERY LOW.
>> IT IS LOWER THAN IT NEEDS TO
BE.
THE V.A. HAS MADE ADVANCES
BECAUSE THEY HAVE GOTTEN
REGULATIONS CHANGED SO THESE
APPROACHES ARE INCLUDED IN THE
MEDICAL BENEFITS PACKAGE FOR
VETERANS AND IT'S CLINICALLY
INDICATE AND CERTAINLY PAIN
PATIENTS IT WOULD BE.
SO THAT IS A HUGE STEP AND THE
ONLY REASON I'M REFERENCING THAT
AS THE V.A. SHIFTS AND THE
SERVICES ARE COVERED AND WE'RE
ON THE RIGHT PATH, IT'S TOO SLOW
FOR SURE, BUT WE'RE ON THE RIGHT
PATH WE GET MORE OF THE DATA
THAT CAN SUPPORT THIS MORE
BROADLY A CROSS THE NATION SO I
THINK WE'RE ON THE RIGHT PATH OF
THE INCLUSION OF THOSE
APPROACHES IN THE MEDICAL
BENEFITS PACKAGE AND IT WAS A
HUGE STEP FORWARD AND THE
ABILITY TO ALSO FOR VETERANS TO
GET THE APPROACHES IN THE
COMMUNITY NOT JUST ONLY THROUGH
THE V.A. IS A HUGE ADVANCE AS
WELL AND AS EVERYBODY KNOWS, THE
V.A. IS A CHALLENGING
BUREAUCRACY TO WORK THROUGH AND
HOPEFULLY IT CAN LEAD THEM THE
NATION SAYING LOOK THIS IS
EFFECTIVE WHY IS IT NOT
AVAILABLE TO ALL PEOPLE?
>>
>> SO OUR HEALTH-CARE SYSTEM WAS
EXCEPTION OF THE V.A. AND MAYBE
KAISER.
FOCUS ON PROCESS RATHER THAN
COST SAVINGS.
IT SEEMS THE WHOLE CARE WILL
PRIOR PARADIGM SHAPE INCLUDING
WIDESPREAD HEALTHCARE QUALITY
CHANGES.
DO YOU HAVE AN IDEA ON HOW BEST
WE, AS RESEARCHERS, CAN ASSIST
IN MOVING THAT NEEDLE?
>> THAT IS A GREAT QUESTION.
I WOULD LOVE YOU ALL TO TELL ME.
[LAUGHTER]
BECAUSE I TOTAL TOTE TOTALLY AGF
WE DON'T ADVANCE HEALTH SECTOR
OF FINANCE AND POLICY, WE CAN
COME UP, AS YOU ALL KNOW, WE CAN
CAN COME UP WITH THE RESEARCH
AND DATA THEY'RE EFFECTIVE BUT
THEY WON'T BE EFFECTIVE.
SO I TOTALLY CONCUR THAT THE
POLICY SIDE, THE FINANCE POLICY
IS ABSOLUTELY PIVOTAL TO THIS
ACTUALLY GOING FROM THE RESEARCH
TO REAL IMPLEMENTATION
CONNECTING PEOPLE'S LIVES AND I
THINK IT'S A GREAT QUESTION THAT
I WOULD KIND OF THROWBACK AT THE
GROUP THE NIH CAN PLAY IN
ADVANCING THE CONVERSATION
AROUND POLICY CHANGE.
I ALSO DO THINK IT'S A PLACE
WHERE -- AT THE PANDEMIC, HAS
HELPED TO SOME DEGREE THAT WE
ARE RETHINKING HOW DO WE DELIVER
HEALTHCARE AND ADDRESS THE
POLICY SIDE OF THIS SO THERE'S
AN OPENING AND IT'S HARD AND
COMPLICATED.
>> THANK YOU.
CAN YOU DISCUSS HOW YOU
DETERMINE THE DOSE OF EACH
COMPONENT FROM THE COMPONENT
APPROACHES SO THAT YOU
UNDERSTAND WHAT IS THE EFFECT?
>> AH!
THAT'S A GRAY QUESTION TO END
ON.
BECAUSE I FAILED TO EXPLAIN, AND
THIS IS A REALLY IMPORTANT
THING, PARTICULARLY FUR A
RESEARCHER, THAT ONE OF THE
SHIFTS AROUND THIS IS IT'S
PERSON-DRIVEN.
SO, IF YOU ARE A PAIN PATIENT,
WE GO WHERE THE PERSON IS DRAWN
WHICH IS A HUGE SHIFT THAT I
DIDN'T CLARIFY.
WHICH IS KIND OF CRAZY MAKING IF
YOU ARE TRYING TO RESEARCH A
SPECIFIC APPROACH BECAUSE REALLY
WHAT WE'RE SEEING IS THAT
APPROACH IS DRIVEN BY THE
PERSON.
THAT'S PART OF THE MODEL THAT IF
IT'S AVAILABLE AND THERE'S
EVIDENCE THAT IT COULD BE
EFFECTIVE FOR THEM, THEY'RE
GIVEN THE OPTION AND WHAT THEY
ARE DRAWN TO IS WHERE THEY
START.
AND THAT IS A DIFFERENT SHIFT
BUT WE FIND THAT OH, IF THEY GO
WHERE THEY'RE DRAWN, NOW THEY
STAY ENGAGE AND THEY'RE READY,
IF THEY FOR EXAMPLE, IF THEY ALL
WANT TO TAKE ON NUTRITION BUT
THEY'RE INTERESTED IN
ACCUPAUNCHTURE, GREAT, WHEN THEY
GET PROGRESS THEY TAKE ON OTHER
ASPECTS SO IT'S CHALLENGING AS A
RESEARCHER BECAUSE IT DOESN'T
FIT THE TYPICAL RANDOMIZED
CONTROL TRIAL BECAUSE YOU HAVE A
BLACK BOX.
THAT IS INTEGRAL TO THIS
APPROACH AND CREATES RESEARCH
CHALLENGES I KNOW.
>> THIS IS GREAT.
THANK YOU.
MAYBE ONE MORE QUESTION JUST TO
START MAYBE CONVERSATIONS THAT
WE CAN HAVE LATER MAYBE ON THE
NETWORK TOMORROW.
CAN YOU DISCUSS THE COST OF THE
APPROACH TO THE SOCIETY AND TO
THE HEALTH-CARE SYSTEM?
>> YEAH, THAT'S A HUGE QUESTION.
I DO THINK BEN, WHO IS RUNNING
THE V.A. WORK AND HIS TEAM HE
HAS EXCELLENT RESEARCHER TEAMS
WORKING WITH HIM ARE VERY MUCH
LOOKING AT THE COST AND THE
IMPACT OF COST.
SO THAT IS A -- I WILL JUST SAY
TO END US, I KNOW THIS SESSION
IS OVER THAT WHAT IS REALLY
ENCOURAGING IS IT'S NOT -- IT
DOES NOT APPEAR TO BE COST
NEUTRAL BUT COST SAVINGS, NOT
JUST IN PAIN BUT IN OTHER AREAS
OF HEALTHCARE AS WELL WHICH
MAKES SENSE.
THESE ARE NOT HIGH COST
INTERVENTIONS SO IT MAKES SENSE
THAT, AND EVEN USING PEERS FOR
EXAMPLE, TO DELIVER A LOT OF
THESE APPROACHES, TO DELIVER THE
CONVERSATIONS AND THE ENGAGEMENT
RATHER THAN CLINICIANS AND YOU
CAN SEE PRACTICALLY WHERE THAT
WOULD BE SCALABLE AND COST
EFFECTIVE AND SO NA IS WHAT WE
ARE DISCOVERING AND THERE NEEDS
TO BE A LOT MORE RESEARCH ON
THAT AND THAT IS ON GOING AND
IT'S WE WOULD BE A BIGGER UPHILL
BATTLE IF IT WORKS MORE AND IT
DOESN'T.
>> THANK YOU FOR THIS VERY, VERY
CONVERSATION AND FOR THE
EXCELLENCE PRESENTATION AND
THERE ARE SO MANY QUESTIONS AND
AND THE QUESTIONS WE CAN'T POINT
TO DURING THIS Q&A, WHAT ARE THE
BIGGEST BARRIERS TO INCREASING
IMPLEMENTED WHOLE POSITIVE
APPROACH AND HOW CAN WE OVERCOME
THOSE BARRIERS SO HOPEFULLY THE
REST OF THESE TWO DAYS SYMPOSIUM
WILL RESPONSE TO THESE QUESTIONS
AND HOPEFULLY WE HAVE ANOTHER
CONVERSATION ON THESE QUESTIONS
THE NETWORK TOMORROW AND THANK
YOU AGAIN.
YOU GO AGAIN SO MUCH.
>> WE ARE NOW MOVING TO THE
SESSION AND I'M PLEASED TO
INVITE MY COLLEAGUES Dr. ALEX
TUTTLE WHO WILL WILL MODERATE
THIS SESSION.
HE IS THE PROGRAM DIRECTOR IN
THE MECHANISTIC BRANCH AS THE
NATIONAL CENTER FOR
COMPLIMENTARY AND INGRAY TIVE
HELP WHERE HE MANAGED THE MANUAL
THERAPY AND BASIC PORTFOLIOS.
Dr. TUTTLE OVERSEES SEVERAL
PROBLEMS IN THE HELPING TO END
ADDICTION LONG-TERM, HEAL
INITIATIVE INCLUDING THE
BIOMARKERS PROGRAM AND AS WELL
AS (INAUDIBLE).
Dr. TUSSLE OBTAINED HIS PH.D
IN PSYCHOLOGY FROM THE
UNIVERSITY OF MCGILL AND A
SPECIALIST AS A NATIONAL INNS
FOR NEUROLOGICAL DISORDERS.
WITH THIS, Dr. TUSSLE, PLEASE
CARRY AWAY.
>> THANK YOU.
I APPRECIATE THE INTRODUCTION
AND GOOD AFTERNOON, EVERYONE.
I AM DELIGHT TODAY MODERATE THE
FIRST PANEL SESSION OF THIS
YEAR'S SYMPOSIUM.
WE'LL BEGIN WITH AN OVERVIEW OF
THE COMPLEX OVERVIEW OF THE PAIN
AND CO MORBID TEASE PRESENTED BY
Dr. TRACY PEREZ KOEHLMOOS AS
WELL AS SUBSTANCE USE DISORDERS
FROM Dr. ILGEN AND Dr.
PATRICK FINAN AND SAWSAN
AS-SANIE WE WILL POSE YOUR
QUESTIONS TO THE PANELISTS,
PLEASE SUBMIT YOUR QUESTIONS
USING THE Q&A BOX.
IT IS NOW MY DISTINCT PLEASURE
TO INTRODUCE Dr. KOEHLMOOS THE
DIRECTOR OF HEALTH SERVICES
RESEARCH AND DIRECTOR OF
DOCTORAL PROGRAMS IN
PUBLIC-HEALTH AT THE UNIVERSITY
OF THE HEALTH SCIENCES.
WHICH SHE LEADS THE DEVELOPMENT
OF ROBUST HEALTH SERVICES,
POLICY RESEARCH, AND GRADUATE
PROGRAMS.
WITH 200 PUBLICATIONS SHE'S A
DISTINGUISHED HEALTH SYSTEMS AND
POLICY EXPERT AND SHE'S THE
NATIONAL SECRETARY OF GOLD STAR
WIVES OF AMERICA AND AS THE
DEPUTY CHAIR OF THE COCHRAN
LIBRARY OVERSIGHT COMMITTEE.
PRIOR TO JOINING USUHS IN 2015,
SHE SERVED AS THE SPECIAL THE
ASSISTANT TO THE ASSISTANT
COMMAND ANT OF THE MARINE CORE.
A FORMER ARMY AIR DEFENSE
ARTILLERY OFFICER SHE'S THE
WIDOW OF CORNUAL RANDEL
KOEHLMOOS AND A MOTHER OF THREE
MILITARY MEMBERS.
THANK YOU FOR JOINING US TODAY.
>> THANK YOU FOR THAT KIND
INTRODUCTION, ALEX.
SO WELCOME, EVERYBODY.
I HAVE ABOUT 40 SLIDES AND 20
MINUTES SO I DO HOPE TO MOVE
THROUGH THIS QUICKLY BECAUSE I'M
A TEACHER IN MY DAY JOB, I'M
GOING TO START MY TIMER SO THAT
I CAN STAY ON TRACK AND I DO
HOPE PEOPLE WILL ADD THEIR
QUESTIONS TO THE END AND FOR
EVERYONE WHO IS DIALED IN YOUR
IN FOR A TREAT.
IT'S RARE THAT ANYBODY GETS TO
BE ON THE CALL WITH MORE THAN
ONE TRACY AND WE JUST HEARD FROM
MY COLLEAGUE TRACY GAUDET AND
NOW YOU'VE GOT ME, WE'RE GOING
TO TALK ABOUT THIS ISSUE OF PAIN
AND COMPLEXITY AND CO-MORBIDITY
THROUGH THE LENS OF THE U.S.
MILITARY HEALTH SYSTEM.
IT'S THE STAND AR DISCLAIMER, I
AM A FEDERAL GOVERNMENT EMPLOYEE
AND ANYTHING THAT I SAY DOES NOT
REFLECT THE VIEWS OF ANY AGENCY.
THAT WAS TO SHOW YOU WHERE WE'RE
GOING.
LET'S TALK ABOUT PAIN.
I THINK THE AUDIENCE AND THE
PARTICIPANTS IN THIS PANEL DON'T
NEED ANY REMINDERS ABOUT WHAT
PAIN IS OR HOW IT IMPACTS OUR
ENVIRONMENT AND THERE'S
ENVIRONMENTAL FEELINGS,
BEHAVIORS ALL THAT TAKE PLACE
AND I WILL PACT OUR EXPERIENCE
OF PAIN.
THERE'S STANDARD ONES THAT COME
WITH CHRONIC PAIN WHEN WE'RE IN
PAIN AND OUR FOODS ARE ALTERED
AND WE CAN'T SLEEP AND WE MAY
HAVE DYSFUNCTION WHILE WE TRY TO
MANAGE THE THESE THINGS SO THEY
TREMENDOUSLY REDUCE THE QUALITY
OF LIFE FOR PATIENTS, FOR OUR
FRIENDS, OUR FAMILIES, OUR
LEVELS AND NEXT SLIDE, PLEASE.
WE TALK A LOT IF WE'RE GOING TO
TALK ABOUT WHOLE PERSONNEL
HEALTH, HOW WE CAN ASSESS TREAT
AND MANAGE PAIN AND CHRONIC PAIN
PARTICULARLY IN A HOLISTIC
PLANNER THAT BRINGS PEOPLE BACK
TO BOTH FEELING BETTER AND
BETTER FUNCTIONING.
I DO TALK ABOUT RESEARCH AND
WORK THAT WE'VE DONE AND YOU
MIGHT THINK IT'S BEING ACTIVE
DUTIES AND YOU WOULD BE
INCORRECT ONLY ABOUT 18% OF OUR
9.6 MILLION FIN FISH ARY ARE ON
ACTIVE DUTIES AND EVERYONE ELSE
COMES TO US AS GOD MADE THEM.
IT'S THE SPOUSES, THE CHILDREN
AND 2 MILLION CHILDREN WHO ARE
POPULATION OF THE CHILDREN IT'S
OUR RETIREES AND THEY OFTEN STAY
ON AND THEY ARE 9.6 MILLION
BENEFICIARIES SPREAD OUT ACROSS
THE COUNTRY.
DOB A RETIREE IN OUR SYSTEM
DOESN'T NECESSARILY MEAN THAT
YOU ARE AGE 65.
WE HAVE RETIREES WHO CAN BE AS
YOUNG AS PAGE 38 WHO SERVED
THEIR FULL 20 YEARS AND KEEP
THIS MILITARY TRY-CARE BENEFIT
INTO THEIR PERSONAL RETIREMENT
IN ADDITION TO PERHAPS SEEKING
CARE INSIDE THE VETERAN'S HEALTH
ADMINISTRATION.
AND THE SYSTEM ITSELF COST THE
U.S. GOVERNMENT A $53 BILLION A
YEAR WHICH IS A VERY SMALL 10%
OF THE ENTIRE BUDGET WHEN WE
TALK ABOUT HEALTH INSURANCE AND
EVERYBODY ON THIS CALL HAS SOME
FORM OF HEALTH INSURANCE AND
THIS IS HEALTH INSURANCE WITH NO
OR LOCO PAYMENTS NEW YORK CITY
PREMIUMS AND IT'S AN INCLUSIVE
WITH A TREMENDOUS BENEFITS SO
THERE'S HOWEVER, IN ORDER TO
HELP MEET THE SECURITY NEEDS OF
THE U.S. ARMED FORCES, WE
MAINTAIN AND OPERATE OUR
GLOBALLY REPRESENT TEN AND
GEOGRAPHICALLY DISBURSE THE
HEALTH-CARE SYSTEM WITH MORE
THAN 375 DIFFERENT CLINICS.
MAJOR MEDICAL HOSPITALS ACROSS
THE U.S. IN GUAM, JAPAN AND
OTHER PLACES, WE SET UP DEPLOYED
FACILITIES WHERE OUR ARMED
FORCES MEMBERS AND SOLDIERS,
SAILORS AND MARINES GO TO
NATIONAL SECURITY OBJECTIVES FOR
THE UNITED STATES SO WE CAN SET
UP A HOSPITAL AND STATION AND
DELIVER HEALTHCARE ON THE DROP
OF A DIME WE JUST HEARD FROM THE
OTHER TRACY WHO SPOKE ABOUT THE
VETERAN'S HEALTH ADMINISTRATION.
VETERANS HEALTH AND HEALTHCARE
AND IT'S IMPORTANT TO KNOW THESE
ARE TWO SEPARATE SYSTEMS WHEN WE
TALK ABOUT THE V.A. WE'RE
TALKING ABOUT INDIVIDUALS WITH
PRIOR ACTIVE DUTY MILITARY
SERVICE AND IT DOESN'T
NECESSARILY INCLUDE THE ACTIVE
DUTY SERVICE MEMBERS OR INCLUDE
THE DEPENDENCE OF SPOUSES FOR
THE CHILDREN AND IT CERTAINLY
DOESN'T INCLUDE ALL OF THE
PEOPLE WHO RETIRE OR LEAVE THE
MILITARY.
DON NECESSARILY QUALIFY FOR
HEALTHCARE IN THE V.A.
WE HAVE 9.6 MILLION
BENEFICIARIES AND WE TREAT OUR
PROVIDERS AND IT'S A DIFFERENT
STRUCTURE AND THE IMPORTANT
TAKEAWAY IS THAT THESE TWO
ELECTRONIC HEALTH RECORDS DO NOT
TALK TO EACH OTHER AND THEY'RE
TWO SEPARATE SYSTEMS AND IT'S
HELPFUL FOR PEOPLE TO REMEMBER
THAT.
WE'RE WORKING ON GETTING A
SINGLE ELECTRONIC HEALTH RECORD
SO IT'S NOT IN THE PROCESS OF
HAPPENING NOW BUT IT'S MORE OF A
LONG-TERM VISION.
AND THE CURRENT 20 YEARS OR I
GUESS WE JUST WRAPPED UP AND TRY
ADDS AND OUR NEXT SLIDE PLEASE.
THIS CONSIST OF TRAIN INJURIES
POST TRAUMATIC STRESS DISORDER
AND OFTEN FOR SOMETHING LESS AND
WE LOOKED INSIDE.
>> A CARE DOCTOR DEALING WITH
THE PAIN ISSUES AND SO WE SAW
DIFFERENT PROVIDERS.
IT WAS DISJOINTED.
SO, WE WENT OUT AND REALLY THE
FIRST STEP WHEN YOU HAVE A
PROBLEM IS IDENTIFYING THAT YOU
HAVE A PROBLEM AND IT'S LIKE A
12-STEP PROBLEM.
OVER A FIVE-YEAR PERIOD FROM
2010 TO 2015 COMING OFF THE
HEIGHT OF THE THE SURGE IN
AFGHANISTAN, WE IDENTIFIED
15,000PCT PATIENTS WHO SHOWED
THE SYMPTOMS USING OUR MILITARY
HEALTH SYSTEM REPOSITORY.
THIS IS THE GROUP OF PATIENTS WE
IDENTIFIED AND THIS IN DEED WAS
THE LARGEST GROUP WITH THE POLY
TRAUMA MEDICAL TRIAD AND THERE
WERE VETERANS THAT ARE STUDIED
IN SOME DETAIL AND ON THE
SURVIVORS IS IT ON GOING NOW BUT
OF COURSE THE FIRST STEP IS
ALWAYS TRYING TO FIGURE OUT WHO
DO YOU HAVE IN THIS POPULATION.
WHERE ARE THEY?
WHAT'S GOING ON WITH THEM?
WHAT ARE THEY DOING?
WHY DO THEY HAVE MUSS CUE TAL
PAIN.
ALL OF THAT WORK IS GOING ON NOW
ACROSS DIFFERENT VENUES IN THE
DEPARTMENT OF DEFENSE AND THE
MILITARY HEALTH SYSTEMS.
SO THE CORNER STONE OF THESE
LAST 20 YEARS OF COMBAT IN
AFGHANISTAN AND IRAQ.
IT WOULD BE TRAUMATIC BRAIN
INJURY, WHICH OF COURSE, WE
OFTEN THINK OF IT AS CONCUSSION,
CONTUSION, PENETRATING INJURIES
AND IT'S DIS ACT AND DEATH IN
ADULTS IN GENERAL AND YOU WILL
SEE THAT DURING AFGHANISTAN, WE
HAD A TREMENDOUSLY HIGHER RATE
OF HEAD INJURIES THAN ANY OTHER
TIME, HALF A MILLION TRAUMATIC
BRAIN INJURIES DURING THE OEF,
OPERATION ENDURING FREEDOM AND
SO THE SHARE OF WHICH WERE MILD
BUT NOT NEGLIGIBLE SO THIS WAS
REALLY THE TAKE-HOME THING WE
HAD TO DEAL WITH BOTH IN WAYS
WHERE THE CONCLUSION WE KNOW
FROM HIGH SCHOOL FOOTBALL OR
SPORTS, BUT ALSO THE SQUEEZE,
THE COMPRESSION INJURIES THAT
CAUSED A TRAUMATIC BRAIN INJURY
IN THE SENSE THAT THE SQUEEZING
MIGHT SOMEHOW BE DIFFERENT OR
MORE DAMAGING THAN OTHER TYPES
OF CONCUSSIVE EVENTS.
WE WENT OUT AND WE LOOKED
BETWEEN 2016 AND 2019 AT WHERE
ACTIVE NATIONAL GUARD YOU CAN
SEE IN THE MOUNTAIN AND TEXAS
AND WE LOOKED AT THE ESTABLISH
OF ESTABLISHING WHERE WE MIGHT
DEVELOP SERVICES BETWEEN THE
DEPARTMENT OF DEFENSE AND THE
V.A. AND IT MIGHT TREAT AND HELP
THESE PATIENTS LIVE AND MANAGE
THEIR CONDITIONS GOING FORWARD.
AS THEY REINTEGRATE INTO
POPULATION AND TRY TO ENJOY THE
REST OF THEIR HAPPY LIVES THE
OTHER THING THAT IS IMPORTANT
ABOUT TRAUMATIC BRAIN INJURY IS
MILD AND MODERATE IT HAS A
LONG-TERM IMPACT ON A PATIENT
AND THERE ARE MORE EXPENSIVE TO
TREAT SO FROM A HEALTH SYSTEMS
PERSPECTIVE, PEOPLE TALK ABOUT
THE MILITARY HEALTH SYSTEM OR
THE V.A. HEALTH SYSTEM BECAUSE
THERE'S NO PREMIUM DEDUCTIBLE
FOR ACTIVE DUTY INDIVIDUALS, NO
CO PAYMENT, THERE'S A SENSE OF
WE DON'T THINK ABOUT MONEY BUT
WE DO BECAUSE EVERY PENNY AT
LEAST IN THE DOD THAT GOES TO
HEALTHCARE, IS ONE THAT US
DOESN'T GO FOR AIRPLANES, TANKS,
WEAPONS, SHIPS AT SEA DURING
POWER PROJECTION FOR THE UNITED
STATES AND SO WE ACTUALLY CARE A
GREAT DEAL ABOUT COST.
AS WE MOVE FROM MILD TO MODERATE
AND SEVERE WE SEE HOW EXPENSIVE
THIS IS FOR THE PATIENT
POPULATION AND THE HEALTH SYSTEM
IN HEALTH SO NEXT SLIDE, PLEASE.
SO IDENTIFYING WE ARE HAVING A
MONSTER PROBLEM WITH THE CROP I
CAN ISSUES OF T BYE THE
DEPARTMENT OF STINTS STOOD UP
THE NATIONAL INTREPID CENTER
WHERE WORKING ON THE CAMPUS
ACROSS THE STREET FROM THE NIH
SO MAYBE NEXT YEAR, WHEN WE'RE
ALL TOGETHER AT THE NIH IT'S SO
NICE AND WE'LL BE RIGHT ACROSS
FROM THE STOOD UP IN 2010 AND
THEN THEIR SATELLITE SPIRIT
CENTERS ACROSS THE NATION
THERE'S 13 PARTNER SITES AND
RATHER THAN HAVING THIS PRAG
INVESTMENTED CARE WHERE WE TREAT
T BYE OR HEADACHES IN ONE PLACE,
DIFFERENT PROVIDERS AND MANAGING
THOSE SLEEP DISTURBANCES BALANCE
DISTURBANCE AND EYE DISTURBANCES
AND ALL IN DIFFERENT PLACES,
THESE WERE PRACTICE UNITS AND
MODELS THAT HAVE BEEN STOOD UP
AND REPEATEDLY SORT OF TEST SOD
SEE HOW THEY'RE WORKING IN
THROUGH THEIR INTENSIVE OUT
PATIENT AND THE THEY HAVE NICO
HAS A INTENSIVE MONTH-LONG
PROGRAM AS WELL WHERE ALL OF THE
SERVICES ARE COAL LATED AND ALL
THE PATIENTS SCREENING RESULTS
THAT ARE SHARED ACROSS THE
PROVIDERS AS THAT INDIVIDUAL
MOVES THROUGH THE PRACTICE UNITS
AND RECEIVES REALLY THE TAILORED
CARE THAT THEY NEED.
SOME OF WHICH IS STANDARD
PRACTICE OF CARE AND HEARING
AIDS VISION AND EYEGLASSES, PAIN
AND PAIN MANAGEMENT BUT IT'S
ALSO THINGS LIKE ENTA RATE IS
TIVE MEDICINE WHICH I'M GOING TO
TALK ABOUT THE NEXT FEW MINUTES
BEFORE MY TALK COMES TO A RAPID
CLOSE.
LET'S TALK ABOUT INGRAY TIVE
MEDICINE AND IN THE DEPARTMENT
OF DEFENSE WE ARE FANS OF ENTA
GREAT TIVE MEDICINE OUR
PROVIDERS, PATIENTS AND FAMILY
MEMBERS AND WE'RE MONSTER FANS
OF MEDICINE AND WE OFTEN TO OUR
DISMAY, GET UP SET WITH THE IDEA
THAT ACTIVE DUTY SERVICE MEMBERS
WOULD PREFER TO HANG UPSIDE DOWN
BY BOOTS OR WEAR A HAT WITH
ELECTRODES AND WATCH A CERTAIN
TYPE OF PROGRAMMING OR DRINK A
POSITION IN THEIR GLASS AND TAKE
AN FDA APPROVED PILL TO HELP
MANAGE THEIR PAIN OR CONDITION.
WHEN WE TALK ABOUT IM IT'S
THROUGH THE LENS OF ACTUALLY
TRYING TO MEET THE NEEDS OF A
POPULATION THAT IS DEMANDING
THINGS OTHER THAN OVER THE
COUNTER MEDICATIONS, OR
PRESCRIPTION MEDICATIONS AND
THERE'S A REAL BIAS TOWARDS NOT
BEING MEDICATED ON ACTIVE DUTY
EVEN IF IT'S REALLY SOMETHING
THAT WE MAKE INDIVIDUALS FEEL
BETTER AND BE MORE WHOLE AND
HEALED.
SO YOU CAN UNDERSTAND WHERE WORE
COMING FROM AND AGAIN, IT'S
REALLY, IT'S THIS WHOLE PERSON
APPROACH TO ACHIEVE OPTIMAL,
MENTAL, PHYSICAL, AND
ENVIRONMENTAL HEALTH AND SOME OF
THESE ARE QUITE CONVENTIONAL AND
OTHERS ARE LESS CONVENTIONAL AND
OF COURSE THE GOAL IS WHERE
THINGS ARE NOT CONVENTIONAL, TO
DEVELOP THE EVIDENCE ABOUT
WHETHER THEY SHOULD BE INCLUDED
IN PRACTICE OR NOT AND ALL OF
THIS CENTER WE COME TO THIS
EXPERIENCE WITH THE SAME DESIRE,
AT LEAST THE SCIENTISTS DO, NEXT
SLIDE, PLEASE.
SO THERE'S A NUMBER OF DIFFERENT
THINGS THAT CAN TOWARDS HEALTH
AND MUCH OF THIS IS
EVIDENCE-BASED.
THINGS LIKE YOGA OR MEDICATION,
RIGHT, FOR PAIN MANAGEMENT AND
CHIROPRACTORS, COGNITIVE
BEHAVIORAL THERAPY IS A NORM BUT
IT'S ENTA GREAT TIVE MEDICINE
AND WE'RE MONSTER FANS OF
AFTERNOON YOU PUNCTURE IN THE
MILITARY HEALTH SYSTEMS SO THESE
ARE JUST ONCE THAT WE USE AND
SERVICE MEMBERS USE MILITARY
MEMBERS AND FAMILIES USE NON
CONVENTIONAL THERAPIES AT A MUCH
HIGHER RATE THAN CIVILIANS EARLY
SURVEYS OF SERVICE MEMBERS SHOW
THEY WANT MORE OF THIS SO IT'S
OUR CENTER ALIGN WITH THE
INTEREST OF GROUPS AT THE NIH
AND NEXT SLIDE, PLEASE.
I'VE GOT ABOUT THROW AND A HALF
MINUTES LEFT AND THERE'S SOME
THAT ARE EFFECTIVE CLEANING THE
POLY TRAUMA AND ACUPUNCTURE AND
I HAVE SLIDES I HOPE I CAN GET
TO AND YOGA NEXT SLIDE.
LET'S KEEP GOING.
AFTERNOON YOU PUNCTURE WE WENT
OUT AND WE LOOKED AT WHAT WAS
GOING ON IN THE MILITARY HEALTH
SYSTEM AND YOU WILL SEE A LOT OF
SERVICE MEMBERS WALKING AROUND
WITH THE RANK YOU PUNCTURE
TREATMENT AND WE KNOW THAT FOR
PAIN OPINIONS AND MORE THAN 83
MILITARY TREATMENT FACILITIES
ACROSS THE COUNTRY, OFTEN IS
THAT BUT WE ALSO TEACH OUR
PROVIDERS A DIFFERENT SCHOOLS
HOW TO DO ORAL ACU PUNK TIER SO
THEY CAN BRING IT TO THE SHIFT.
WHEN WE LOOKED AT THE DATA ON
RANK YOU PURETURE USE USING THE
MILITARY DATA REPOSITORY SO THIS
ISN'T SELF-REPORTED ACUPUNCTURE
USE THIS IS THE LOOKING AT THE
HEALTH RECORDS OF OUR
9.6 MILLION BENEFICIARY AND IN
2014, WE HAD 15,000 PATIENTS AND
THE MAJORITY WERE CAUCASIAN AND
MEN AND THE MAJORITY WERE IN THE
ARMY AND NOT A SURPRISE GIVING
THE DEMOGRAPHIC BREAKDOWN AND OF
THE MILITARY THE SAME WITH BLACK
RACE AND THERE IS OVER REPRESENT
IN THE MILITARY HEALTH SYSTEM SO
FOR US THIS IS ACTUALLY A VERY
THIS IS A VERY EQUITABLE RACE
WISE DISTRIBUTION OF ACUPUNC
ACUPUNCTURE.MILITARY HEALTH
SYSTEM.
A LITTLE BIT THROUGH NERVES AND
SENSES AND WE PUBLISHED A PAPER
LOOKING AT THE USE OF
ACUPUNCTURE AND I DON'T THINK
THIS RESULTS MADE IT IN HERE BUT
THAT PAPER IS OUT AND AVAILABLE
ON THE WESTBOUND YOU CAN FIND IT
NEXT SLIDE, PLEASE.
WE HAVE FIFTH DEMAND FROM OUR
PROVIDERS TO BE TRAINED IN THIS
SER ADVERTISE AND FROM OUR
PATIENTS, ESPECIALLY OUR ACTIVE
DUTY SERVICE MEMBERS FANS AND
NEXT SLIDE.
PAIN AS ALL OF YOU KNOW IS
MULTIFACETED AND COMPLICATED AND
WE STRUGGLE WITH THE POLY TRAUMA
CLINICAL TRIAD AND TRYING TO
FIGURE OUT HOW TO HELP BRING
ACTIVE DUTY SERVICE MEMBERS BACK
TO FULL HEALTH OR ENOUGH HEALTH
AND WELL BEING THAT THEY CAN
PERFORM THEIR SCROLL HAVE A
HIGH-QUALITY OF LIFE WHETHER
THEY'RE IN THE FOR THE FUTURE
AGAIN WE HAVE THE THE NEXT
SERIES OF SPEAKERS ARE COMING
AFTER ME AND I'LL BE FOLLOWED BY
Dr. SAWSAN AS-SANIE AND SO I
THINK THE OTHER SPEAKERS WILL BE
MORE FOCUSED ON INDIVIDUAL AREAS
OF PAIN SO SO WE HAVE THESE
SLIDES ANY QUESTIONS, COMMENTS,
FEEDBACK YOU ARE WELCOME TO
SHARE THOSE WITH ME AND THANK
YOU ALL FOR GOING NEXT.
>> THANK YOU SO MUCH.
IT WAS SUCH -- THANK YOU FOR A
LOVELY INTRODUCTION AS WELL AS
AN EXCELLENT LECTURE TO FOLLOW
SO I HAVE BIG SHOES TO FEEL.
I WOULD LIKE TO THINK THAT PAIN
CONSORTIUM ORGANIZERS TO SHARE
THE WORK ON REFRAMING
ENDOMETRIOSIS.
NEXT SLIDE.
SO THE OBJECTIVE OF MY TALK
TODAY ARE TO DEFINE
ENDOMETRIOSIS AND REVIEW IT'S
MOST COMMON SYMPTOMS AND I'M
GOING TO PRESENT SOME EVIDENCE
THAT WOMEN ARE PATIENTS WITH
ENDOMETRIOSIS SHARE CLINICAL AND
PHYSIOLOGICAL CHARACTERISTICS TO
CHRONIC OVERLAPPING PAIN
CONDITIONS AND THEN REVIEW THE
CLINICAL AS WELL AS THE RESEARCH
IMPLICATIONS OF PAIN IN THE
EVALUATION AND TREATMENT OF
PATIENTS WITH ENDOMETRIOSIS OR
PELVIC PAIN.
DROUIN-ULYSSE DROUIN-ULYSSE IS A
CONTINUE DEFINED BY THE PRESENCE
OF GLANDS AND STROM A OUTSIDE OF
THE UTERUS.
ON THE LEFT SIDE OF THE SCREEN
IS AN EXAMPLE OF ENDOMETRIOSIS
WITH A GLANCE IN STROMA AND A
TYPICAL SURGICAL IMAGE THAT WE
WOULD SEE AT THE TIME OF
LAPAROSCOPY FOR A PATIENT WITH
ENDOMETRIOSIS.
SO ENDOMETRIOSIS EFFECTS 10% OF
REPRODUCTIVE AGE WOMEN.
I WANT TO CLARIFY THAT
ENDOMETRIOSIS DOES EFFECT TRANS
AND BINARY PATIENTS AND I'LL
HOPE THAT EVERYONE UNDERSTANDS
THAT THIS COVERS ALL OF THOSE
PATIENTS.
SO THIS REPRESENTS OVER
200 MILLION PEOPLE GLOBALLY
MAKING IT MORE COMMON THAN
ASTHMA AND DIABETES.
THE PREVALENCE OF ENDOMETRIOSIS
IS MUCH HIGHER IN SPECIFIC
POPULATIONS SO IT OCCURS IN
ABOUT 30% OF PERSONS WITH SUB
FERTILITY AND 60% TO 80% OF
ADULTS WITH CHRONIC PELVIC BAIN
AND 50% OF ADOLESCENTS OF
CHRONIC PELVIC PAIN.
THE MOST COMMON PRESENTING
SYMPTOM OF ENDOMETRIOSIS IS
PELVIC PAIN AND THIS INCLUDES
DIS MEN ARIA DEFINED AS PAINFUL
PERIODS, NON MENSTRUAL PELVIC
PAIN AS WELL AS PAIN WITH SEXUAL
INTERNET ARE COURSE.
HOWEVER, PATIENTS ARE FREQUENTLY
REPORTING OTHER SYMPTOMS WHICH
ARE LISTED HERE.
ANY COMBINATION OF SYMPTOMS CAN
OCCUR, WHICH IS SHOWN IN THE
DIAGRAM AND IT'S ALSO IMPORTANT
TO NOTE THAT SOME PATIENTS HAVE
LITTLE TO NO SYMPTOMS AT ALL FOR
HAVING SIGNIFICANT DISEASE.
MUCH IS KNOWN ABOUT THE PATHO
PHYSIOLOGY OF ENDOMETRIOSIS AS
IT RELATES TO THE INFLAMMATORY
AND THE MECHANISMS THAT INITIATE
AND SUSTAIN THE PROLIFERATION OF
THESE ENDOMETRIOSIS.
REN TREE GRADE MENSTRUATION IS
THE MOST COMMON BUT NOT THE ONLY
INITIATING FACTOR AND
ALTERATIONS IN CELL ADHESION,
LOCAL PELVIC AND NERVE FIBER
FILTRATION AS WELL AS
VASCULARIZATION ARE NECESSARY
FOR THE ESTABLISHMENT OF THE
LESIONS AND WE KNOW THAT IT'S
NECESSARY TO STIM YOU LATE THIS
PROCESS AND THE SUPPRESSION OF
ESTROGEN IS IN SUPPRESSION AND
REGRESSION OF THESE IMPLANTS.
SO AS I PREVIOUSLY DESCRIBED,
THE MOST PROMINENT SYMPTOM IS
PELVIC PAIN AND THE TRADITIONAL
AND MOST WIDELY PREVIOUS HEALTH
VIEW IS ENDOMETRIOSIS IS A PAIN
CONDITION THAT OCCURS DUE TO
DIRECT ACTIVATION OF LESIONS.
THE OVERWHELMING MAJORITY OF
RESEARCH FUND TO GO DATE HAS
FOCUSED ON UNDERSTANDING THE
BIOLOGY OF ENDOMETRIOSIS LESIONS
AND CURRENTLY THE ONLY FDA
APPROVED TREATMENT ARE HOR
MONDAYAL MEDICATIONS THAT
SUPPRESSION PRODUCTION AND
SUPPRESSION THE LESIONS AS WELL
AS SURGERY OR DESTROYING
LESIONS.
IS IT THAT SIMPLE?
AS MOST OF US WOULD UNDERSTAND,
PARTICULARLY IN LIGHT OF THE
PREVIOUS LECTURES, IT REALLY
CANNOT BE THAT SIMPLE.
WHILE IT'S CLEAR THEY'RE
IMPORTANT THE RELATIONSHIP
BETWEEN DROUIN-ULYSSE
DROUIN-UENDOMETRIOSIS IS NOT EXD
SO THERE'S MINIMAL RELATIONSHIP
BETWEEN THE SEVERITY OF
ENDOMETRIOSIS AND IT THIS IS SIM
PAR TO PAIN CONDITIONS AND
DOCUMENTED THAT THERE ARE
PATIENTS WITH VERY ADVANCE
DISEASE WHO HAVE LITTLE OR NO
PAIN AND THAT ARE PATIENTS WITH
ONE OR TWO VERY SMALL DEPOSITS
THAT HAVE DEBILITATING
LIFE-ALTERING PAIN.
SECOND, TREATMENTS AIMED AT THE
LESIONS DO NOT CONSIST ENDLY A
MILLER' EIGHT SYMPTOMS SO PAIN
IS IN 25% OF PATIENTS WHO
UNDERGO MEDICAL AND SURGICAL
THERAPY SO THEY'RE UNRESPONSIVE
TO THAT AND PAIN RECURSE IN 50%
OF PATIENTS FOLLOWING INCISION.
THE PAIN COMES BACK AND IT
OCCURS UP TO 10 TO 25% OF
PATIENTS WHO UNDERGO
HYSTERECTOMY AND 450% OF THEM
THERE'S NO EVIDENCE OF RECURRENT
ENDOMETRIOSIS LESIONS SO WE NEED
TO REMEMBER THERE'S NO CHRONIC
PAIN CONDITION THAT IS EXPLAINED
BY PERIPHERAL PATHOLOGY BECAUSE
THE CENTRAL NERVOUS SYSTEM HAS A
POWERFUL ABILITY TO AMPLIFIED AS
WELL AS DAMPEN SIGNALS.
SO AS SUCH THE MODERN
UNDERSTANDING OF PAIN IS THAT
PAIN IS AN OUTPUT OF THE BRAIN
THAT IS A BALANCE BETWEEN THE
PERIPHERAL INPUT AND THE CENTRAL
NERVOUS SYSTEM VOLUME CONTROL.
SO PAIN IS DEFINED AS ANY NERVE
DYSFUNCTION THAT PLAYS A ROLE IN
MAINTAINING PAIN AND CAN LEAD TO
CRON INPAIN INDEPENDENT THE
SIGNALS.
NO SIS ACCEPTIVE CRON EASTBOUNDW
BACK PAIN AND -- AND THESE NO
SIM PLASTIC PAIN ARE BY
WIDESPREAD PAIN AND THESE
PATIENTS HAVE A PAIR LIFETIME
HISTORY -- PAIN IS
ASKER BATED BY STRESSORS.
AND THEN NOW NEXT SLIDE.
SO, IT'S VERY IMPORTANT TO KNOW
THESE CONDITIONS ARE NOT JUST
PAIN DISORDERS BUT THESE ARE
ALSO CHARACTERIZED BY GREATER
SENSITIVITY TO INTERNAL
SENSATIONS AS WELL AS GREATER
SENSITIVITY TO SOUND AND LIGHT
AND THESE PATIENTS ALSO
EXPERIENCE CHRONIC FATIGUE, POOR
OR NON RESTORATIVE SLEEP, MEMORY
DIFFICULTIES AS WELL AS HIGHER
PREVALENCE SUCH AS ANXIETY ASK
DEPRESSION.
SO THESE NOCIPLASTIC PAIN CO
OCCUR AND THE COEXISTING PAIN
CONDITIONS HAS BEEN RECOGNIZED
BY THE NIH PAIN COR SO MANYION O
ONE THANK THAT IS CLEAR IS THE
PAIN CONDITIONS CO AND YOU ARE
THIS IS A STUDY PUBLISHED BY
Dr. WILLIAMS WHO IS GOING TO
BE SPEAKING TOMORROW, AND USING
A LIST OF CODES AND THEY
DEMONSTRATED THAT ALL OF THESE
CHRONIC OVERLAPPING PAIN
CONDITIONS ARE ASSOCIATED WITH
HAVING AN INCREASE ODDS OF
HAVING AT LEAST ONE OTHER
CHRONIC OVERLAPPING PAIN
CONDITION SO THE STRONGEST
ASSOCIATIONS HERE ARE SHOWN IN
RED WHICH HAVE GREATER THAN FIVE
AND THOSE THAT ARE MODERATE AND
ODDS RATIO OF THROW TO FIVE AND
MILD ONE TO THREE AND SO WHAT
YOU CAN SEE HERE, FOR EXAMPLE,
IS THAT PATIENTS WITH DEGREE
TREMENDOMETRIOSISHAVE A 16 TIMES
AND FIVE TIMES THE ODDS OF
HAVING IRB AND FOUR TIMES THE
ODDS OF HAVING FIBER MYALGIA.
SO WHAT DO WE KNOW ABOUT
ENDOMETRIOSIS SO I WAS ASKED TO
TALK ABOUT THE RESEARCH THAT
WE'VE BEEN DOING HERE AT THE
UNIVERSITY OF MICHIGAN ON THIS
TOPIC.
AND WHAT OUR GROUP IS STUDIED
THIS QUESTION BY COMPARING WOMEN
OR PATIENTS WITH CHRONIC PELVIC
PAIN INCLUDING THOSE WITH AND
WITHOUT ENDOMETRIOSIS AND WE'VE
COMPARED THEM TO PAIN-FREE
HEALTHY CONTROLS AND WE FOUND
THROW MAIN FINDINGS.
FIRST, SO, NEXT, INCREASE
SENSITIVITY TO THESE PATIENTS
WITH CHRONIC PELVIC PAIN HAVE
INCREASED SENSITIVITY TO PAIN
AND SENSORY STIMULI AND THIS IS
FOUND IN THE PEL VISION AS WELL
AS A REGION DISTANT FROM THE
SITE OF CLINICAL PAIN.
CHANGES IN BRAIN STRUCTURE
SIMILAR TO PAIN CONDITIONS AND
WOMEN WITH CHRONIC PELVIC PAIN
DEMONSTRATE VOLUME IN PAY
REGULATORY REGIONS SUCH AS THE
THALAMUS, AND NEXT.
CHANGES IN BRAIN FUNCTION WITH
INCREASE LEVELS OF NEURO
TRANSMITTERS IN THE INSUL A AS
WELL AS INCREASE DETECTIVE TEE
BETWEEN PAIN REGULATORY REGIONS
SAYS THE PRE FRONTAL CORTEX.
SO THIS SUGGESTS THAT ONE
POSSIBLE REASON THAT WOMEN WITH
PAIN FREE ENDOMETRIOSIS
EXPERIENCE LITTLE TO NO PAIN IS
THEY MIGHT HAVE SOME ADAPTIVE
BRAIN CHANGES THAT OFFSET OR
DAMPEN THE INPUT.
SO, IT'S WELL ESTABLISHED THAT
ENDOMETRIOSIS IS AN ESTROGEN
DISEASE THAT IS CHARACTERIZED BY
PELVIC INFLAMMATION AS WELL AS
SYSTEMIC INFLAMMATION SO THIS
RAISES AN IMPORTANT QUESTION OF
WHETHER THERE'S A LINK BETWEEN
SYSTEMIC INFLAMMATION AND NO SIS
PLASTIC PAIN SO THIS IS A
COURTESY OF ONE OF MY COLLEAGUES
AND COLLABORATORS AT THE
UNIVERSITY OF MICHIGAN AND
ILLUSTRATES --
SO THESE CELLS ARE KNOWN TO
MODULATE COMMUNICATION BETWEEN
NERVE FIBERS WHICH ARE STAINED
RED HERE AND THESE CELLS ARE
KNOWN TO EXPRESS RECEPTORS SO
STIMULATION OF THESE RECEPTOR
HAS BEEN SHOWN TO INDUCE RELEASE
OF PRO INFLAMMATORY CYTOKINES IN
THE SPINAL CORD.
AND THIS IS THOUGHT TO BE ONE
CONTRIBUTING MECHANISM FOR
NOCIPLASTIC PAIN CHARACTERIZED
BY THESE SYMPTOMS HERE.
SO LYPO POLICY AK OWE RIGHT IS A
WELL-KNOWN AGO A NICE AND USED
TO STUDY THE RELATIONSHIP
BETWEEN RECEPTOR STIMULATION
MARKERS FOR CENTRAL SENSATION.
SO, MEMBERS OF THE NIH FUNDED
NETWORK HAVE INVESTIGATED THIS
RELATIONSHIP IN FEMALE PATIENTS,
AND IN THIS PAPER THAT WAS
PUBLISHED IN 2015 THEY EXAM THE
RELATIONSHIP BETWEEN THE SITE
OWE KEEN RESPONSE TO LPS
STIMULATION OF ISOLATED MONO
NUCLEAR CELLS AND THEY FOUND
THAT FOR EVERY ONE STANDARD
DEVIATION IN INCREASE IN THE
RECEPTOR FOR IN FLAM TORI
RESPONSE THERE WAS A 60%
INCREASE IN THE LIKELIHOOD OF
REPORTING WIDESPREAD PAIN.
AS SHOWN WHERE DARK COLOR
REPRESENT A PREPORTION THOSE
PATIENTS WITH THE LOW TAYLOR OF
FOUR RESPONSE GENERALLY HAD
LOCALIZED PAIN.
HOWEVER, THIS IS IN STARK CON
TCONTRAST WITH THOSE THAT ARE
CHARACTERIZED BY HAVING
WIDESPREAD PAIN WHICH IS NO SEE
PLASTIC PAIN.
SO THEY DETERMINE WHETHER A
SIMILAR RELATIONSHIP OCCURS IN
WOMEN WITH CHRONIC PELVIC PAIN
AND IT'S A PROSPECTIVE
OBSERVATIONAL COHORT STUDY
INVESTIGATING WHETHER PER I HAVE
PRO DICTIONARIORS ARE PRESENT
FOR PAIN.
SO, IN THOSE PRELIMINARY DATA,
WE EXAM 17 WOMEN AWAITING HISS
TERRECTOMY AND NOT USING
HORMONAL THERAPY AND THEY WERE
STIMULATED WITH LPS FOR 24 HOURS
AND WE SHOW A CORRELATION PLOT
AND WHAT WE FOUND WAS IS THAT
MID ONE ALPHA, ONE OF THE
CYTOKINES MEASURED WAS
ASSOCIATED WITH ALL SUB TYPES OF
PELVIC PAIN SYMPTOMS, AND NEXT
TO VALIDATE THESE FINDINGS IN A
SECOND COHORT THERE WAS A
SIMILAR ANALYSIS IN 15 PRE
MENOPAUSAL WITH ENDOMETRIOSIS AS
WELL AS YOU'RE LOGIC PAIN OF THE
MAP NETWORK AND CONFIRMED THE
SAME RELATIONSHIP.
SO WE THEN EXAMINED THE
RELATIONSHIP BETWEEN THE
PROVOKED INFLAMMATION AS WELL AS
FUNCTIONAL BRAIN IMAGING AND WE
CONDUCTED A SEED REGION TO HOLD
BRAIN ANALYSIS IN THESE SAME
PATIENTS TO IDENTIFY WHETHER
THEY WERE BRAIN REGIONS THAT
WERE MODULATED BY SYSTEMIC
INFLAMMATION AND THE SEED WAS
PLACED IN THE PELVIC TRUNK IN
THE S1 CORTEX WHICH IS SHOWN IN
PANEL A.
AND WHAT WE FOUND WAS THAT AS
MID 1 ALPHA LEVELS SHOWN IN
PANEL C, THE CORRELATION BETWEEN
PELVIC S1 AND IT STRONGLY
SUGGESTS THAT THE RELATIONSHIP
BETWEEN SYSTEMIC INFLAMMATION IN
THE CENTRAL NERVOUS SYSTEM AND
THE PRO SIGHSLY EXPECTED BRAIN
REGION IS A PELVIC PAIN SAMPLE.
WE FEEL THIS IS UNLIKELY TO BE
FINDING SINCE THE CORTEX WAS
IMPLICATED AND SYSTEMIC
INFLAMMATION AND BRAIN
CONNECTIVE TIE AND THAT WAS
PUBLISHED IN 2018.
SO WHY DOES THIS MATTER?
I AM A CLINICIAN AND I SPEND MY
TIME ACTUALLY SEEING PATIENT IN
CLINIC SO HOW DO WE APPLY THIS
TO CLINICAL CARE AS WELL AS
RESEARCH?
SO FIRST AND FOREMOST,
IDENTIFYING RELEVANT BIOLOGICAL
MARK OFFICERS IMPORTANT FOR
DECISION MAKING AND WE NEED TO
MAKE OUR DEXES BASED ON THE
UNDERLINE PAIN MECHANISM.
SO WHILE ENDOMETRIOSIS IS A
PATHWAY THERE ARE MANY OTHER
PATHWAYS INCLUDING SENSE
TAIZATION.
AND AS WELL AS ALL OF THESE
THINGS CAN BE MODIFIED BY
INFLUENCED BY GENETIC
VARIABILITY AS WELL AS TRAUMA.
WE ALSO NEED TO RECOGNIZE THAT
THESE PATIENTS ARE HETEROGENEOUS
AND THEY CAN BE DIFFERENT FROM
EACH SO MIGHT HAVE NO SUN
ACCEPTIVE PAIN LIKE ON THE
FAR-LEFT AS WELL AS SOME
PATIENTS YOU HAVE NOCIPLASTIC
PAIN IN THE LEFT AND THE MIDDLE
WHO HAVE MIXED PAIN CONDITION.
>> WE NODE TO MOVE ON TO THE
NEXT SPEAKER, PLEASE.
GIVE A CONCLUDING SENTENCE,
THANK YOU.
>> SO, I APOLOGIZE.
IN CONCLUSION, I THINK THAT IT'S
JUST CRITICAL TO UNDERSTAND THAT
REALLY ENDOMETRIOSIS WE NEED TO
MOVE BEYOND THE LESION AND THINK
OF IT AS A SYSTEMIC DISEASE.
THANK YOU.
>> THANK YOU.
WE HAVE Dr. FINAN NEXT.
>>
>> FANTASTIC.
THANK YOU SO MUCH FOR THAT TALK.
THAT WAS REALLY ENLIGHTENING.
AND THANK YOU ALL FOR ATTENDING
OUR SESSION TODAY.
MY NAME IS PATRICK FINAN FROM
THE DEPARTMENT OF PSYCHIATRY AND
BEHAVIORAL SCIENCES AT JOHNS
HOPKINS SCHOOL OF MEDICINE.
FIRST OF ALL, THANK YOU TO THE
PAIN CONSORTIUM FOR THE
INVITATION TO SPEAK HERE TODAY.
IT'S AN HONOR TO BE HERE.
TODAY I'M GOING TO TALK ABOUT
THE ASSOCIATION OF SLEEP AND
PAIN BUT IN THE SPIRIT OF
TACKLING THIS ISSUE FROM A WHOLE
PERSON PERSPECTIVE, I'M GOING TO
FOCUS THE DISCUSSION BY
CONTEXTUALIZING THAT
RELATIONSHIP IN TERMS OF
EFFECTIVE FUNCTION WHICH I THINK
IS A CRITICAL FOCAL POINT IN
UNDERSTANDING HOW THESE TWO
MAJOR BIO PSYCHOSOCIAL SYSTEM
INTERACT.
NEXT SLIDE, PLEASE.
SO, I SHOULD NOTE I'M ON THE
SCIENTIFIC ADVISORY BOARD ON A
COMPANY NOT RELATED WHAT I'M
GOING TO TALK TO YOU ABOUT
TODAY.
SO, THE EFFECTS OF SLEEP ON PAIN
ARE NOW QUITE WELL ESTABLISHED.
WE KNOW FOR EXAMPLE THAT UPWARDS
OF 50% OR MORE OF PATIENTS WITH
CHRONIC PAIN, REPORT SLEEP
DISTURBANCES WHICH IS INSOMNIA
OR DIFFICULTY FALLING OR STAYING
ALI WITH ACCOMPANIES DAYTIME
IMPAIRMENTS.
MANY PATIENTS WHO MAY NOT MEET
CRYIA AND AND STUDIES HAVE
INCORPORATED PROSPECT OF DESIGNS
A TREND IN THE DATA IS EMERGED
AND SUPPORTING THE HYPOTHESIS
THAT SLEEP PROBLEMS MAY CAUSE
INCREASE PAIN PER EXPERIENCE AND
THE INCIDENTS OF CHRONIC PAIN
AND THEY SUPPORT INCREASES PAIN
SENSE ACTIVITY AND SO HOW DOES
THIS HAPPEN?
THERE ARE OF COURSE A NUMBER OF
PLAUSIBLE MECHANISM TO CONSIDER
LIKE INFLAMMATION, OR NEURO
ENDOCRINE FUNCTION, DIRECTION
BUT THE WORK HAS CENTERED
PRINCIPALLY AROUND EFFECTIVE
FUNCTION AND POSITIVE EFFECT AND
THE SO-CALLED REWARDS SYSTEM.
WE HAVE TO EFFECT MODELS OF
EITHER SLEEP OR PAIN FOCUSED ON
NEGATIVE AFFECT AND AND AS THIS
STARTED TO CHANGE WHICH OCCURRED
WITH INFLUENTIAL NUDGING BY MY
LATE, GREAT, ALEX SALTRA AND
MARY DAVIS AMONG OTHERS IN THE
PAIN SPACE AND IN POSITIVE AND
TO SLEEP LOSS THAN NEGATIVE
EMOTIONAL RESPONSES.
THIS WAS WORK I'VE BEEN DOING
FROM THE EARLY SLEEP DISRUPTION
EXPERIMENTS SO WE SET OUT TO
BUILD A MODEL THAT INCORPORATED
EFFECT THERE ARE COMPONENTS OF
COGNITIVE THERAPIES CRUX LIKE
POSITIVE REAPPRAISAL, PRO SOCIAL
COPING, STATE MINDFULNESS AND
OTHERS THAT MAY BE
THERAPEUTICALLY HARNESSES TO
ENGENDER A STATE OF RESILIENT
PAIN SELF-MANAGEMENT AND THAT
THEY MAY DO SO BY OPTIMIZING FOR
ENHANCED POSITIVE EFFECT AND
OTHER POSITIVE STATES IN AN
EFFORT TO DIMINISH THE MAGNITUDE
OF COUPLING BETWEEN PAIN AND
EFFECT NIH AFFECT OR NEGATIVE
AFFECTIVE OF REACTIVITY TO PAIN.
SO OUR SLEEP WORK IS REALLY AN N
EXTENSION OF THIS MODEL AND
WE'RE INTERESTED IN
UNDERSTANDING TO WHAT EXTENT DO
SLEEP PROBLEMS OPERATE UPSTREAM
OF THESE PROCESSES.
AND CAN WE MODIFIED SLEEP
THERAPEUTICALLY OR
EXPERIMENTALLY IN A WAY THAT
INVESTIGSTRENGTHENS THESE EFFEC.
WE FOUND DIRECT EXPERIMENTAL
SUPPORT FOR THE OBSERVATION FOR
PALMER ANDAL FAN OWE LITERATURE
REVIEW THAT SLEEP LOSS, UNDER
CERTAIN CONDITIONS, TARGETS
POSITIVE EFFECT OVER NEGATIVE
AND IN THIS STUDY 45 HEALTHY
PARTICIPANTS WERE ENROLLED
WITHIN SUBJECT AND
COUNTERBALANCED EXPERIMENT WHERE
EVERYONE RECEIVED ONE NIGHT OF
NORMAL SLEEP AND ONE NIGHT OF
SLEEP DISRUPTION FORCED
NOCTURNAL AWAKENINGS.
SO, JUST REMEMBER THAT GENERAL
EXPERIMENTAL PARADIGM THAT I'M
GOING TO COME BACK TO SEVERAL
TIMES THROUGHOUT THIS TALK.
WE ADMINISTERED A NUMBER OF
MEASURES IN TASKS RELEVANT HERE.
IN THIS CASE WE SAW A
SIGNIFICANT REDUCTION IN
POSITIVE EFFECT FOLLOWING FORCED
AWAKENINGS BUT NO INCREASE IN
NEGATIVE EFFECT.
AND IMPORTANTLY, THIS APPEARED
TO GENERALIZE TO BOTH HIGH AK
TAIZATION POSITIVE EMOTIONAL
STATES LIKE JOVIALITY AND LOW
STATES LIKE SERENITY.
NOW ASSISTANT PROFESSOR AT
ARIZONA STATE UNIVERSITY
EXTENDED THESE EXPERIMENTAL
FINDINGS INTO THE CLINICAL REAL.
THIS WAS ANALYSIS OF TWO WEEKS
IN MORNING AND EVENING ELECTRIC
I DO A REIN PATIENTS WITH CO
MORBID INSOMNIA WHICH I SHOULD
MENTION DERIVES FROM A LARGER
CLINICAL RILE LED BY MICHAEL
SMITH AND HERE WE OBSERVED THAT
BOTH LOWER TOTE SLEEP TIME AND
HIGHER NUMBER OF MINUTES SPENT
AWAKE AFTER SLEEP ONSET OR WHAT
WE CALL LASO PREDICTED LOWER
POSITIVE EFFECT THE NEXT MORNING
AND THAT LED TO HIRE DAILY PAIN
SEVERITY RATED IN THE EVENING
AND A SIMILAR EFFECT FOR PAIN
EXACT AROUNDLY AND THEY SHARE
VARIANTS AND NOTABLY HERE, WE
SEE ALTHOUGH THE SLEEP MEASURES
WERE PRO DICK TIVE OF NEXT
MORNING NEGATIVE AFFECT OF
STATES, THOSE ASSOCIATIONS
DIDN'T TRANSLATE INTO HIGHER
PAIN SO IT WAS THROUGH POSITIVE
BUT NOT NEGATIVE EFFECT.
IN THIS ANALYSIS, THEY FLIPPED
THE QUESTION AROUND A BIT.
INSTEAD OF LOOKING AT SLEEP ON
AFFECT, SHE ASKED WHETHER TRAIT
LEVELS OF POSITIVE EFFECT WERE
PROTECTIVE AGAINST THE EFFECT OF
SLEEP DIS RISK ON NEXT DAY
INFLAMMATION WHICH AS Dr.
SAWSAN AS-SANIE JUST EXPLAINED
IS ANOTHER RISK FACTOR FOR PAIN.
AND AGAIN THESE WERE OTHERWISE
HEALTHY PARTICIPANTS UNDERGOING
A NIGHT OF NORMAL SLEEP AND A
NIGHT OF FORCED AWAKENINGS AND
WE SEE THAT SLEEP DISRUPTION LED
TO INCREASED CELLULAR EXPRESSION
OF THE CYTOKINES IL6 AND TNF
ALPHA AS WELL AS THEIR CO
EXPRESSION BUT IT HAPPENED ONLY
AMONG PARTICIPANTS WITH LOW
LEVELS OF POSITIVE AFFECT.
SO IN THIS CASE, HAVING HIGHER
TRAIT POSITIVE EFFECT WAS
PROTECTED AND IT BUFFERED
AGAINST THE EFFECT OF SLEEP
DISRUPTION ON INFLAMMATION AND
THIS PERHAPS REPRESENTS ANOTHER
MECHANISTIC PATHWAY TO CON
ACCEPT TYPEACTUALIZE IN THE BROT
OF SLEEP AND PAIN.
SO ANOTHER RELATED MECHANISM
WE'VE BEEN INTERESTED IN IS
AFFECTIVE PAIN MODULATION OR THE
DEGREE TO WHICH AFFECTIVE
STIMULI ALTER PAIN PROCESSING
THAT BEHAVIORAL AND NEURO
BIOLOGICAL LEVELS.
IN OUR STUDY, WE ASKED WHETHER
FORCED AWAKENINGS ALTERED THE
BUILT OF POSITIVE EFFECT TO
INHIBIT PAIN SO WE EXPOSED
PARTICIPANTS TO A STANDARD
AFFECTIVE PAIN MODULATION TASK
IN WHICH THEY VIEWED POSITIVE
AND NEGATIVE OR NEUTRAL SLIDES
THAT WERE PAIRED WITH STIMULI
AND THEY RAIDED THE PAIN
ASSOCIATED WITH THE STIMULI.
AND UNDER NORMAL SLEEP, WE SEE
THE CLASSIC EFFECTIVE PAIN
MODULATION OCCUR AND IN THIS
CASE, PAIN IS LOWER UNDER
CONDITIONS OF POSITIVE RELATIVE
TO NEUTRAL OR NEGATIVE EFFECT OF
STIMULI AND FOLLOWING FORCED
AWAKENINGS, THAT CURVE FLATTENS
SO WE SEE ESSENTIALLY ANNA
ABOLISHMENT.
NEXT SLIDE.
I THINK IT'S IMPORTANT TO NOTE
THAT THIS PATTERN FINDINGS THAT
WE OBSERVED UNDER CONTROLLED
CONDITIONS ALMOST DIRECTLY
MIRRORS EFFECTS THAT JAMIE
RUDY'S GROUP OBSERVED IN BETWEEN
GROUP ANALYSIS OF HEALTHY
SUBJECTS AND INDIVIDUALS WITH
MODERATE TO HIGH INSOMNIA SO
THESE DATA TELL US THAT SLEEP
DISTURBANCES NOT ONLY ATTENUATE
POSITIVE EFFECT LEVELS BUT ALSO
THE FUNCTION OF POSITIVE AFFECT
TO INHIBIT PAIN.
SO FINALLY, I'D LIKE TO
HIGHLIGHT THAT THE AFFECTS THAT
HAVE JUST BEEN TALKED ABOUT,
APPEAR TO BE TIED TO FUNCTIONING
WITHIN THE MESS OWE CORTICAL
REWARDS SYSTEM.
AND IN OUR EXPERIMENTAL WORK
AGAIN, FOR EXAMPLE, WE'VE
EXAMINED SLEEP DISRUPTION ON
REWARD RESPONSIVENESS AND IN
THIS TASK, WE KNOW IT TO BE
QUITE SENSITIVE TO VARIATION IN
REWARD SYSTEMS FUNCTION AND
PARTICULARLY CHANGES IN DOPAMINE
ACTIVITY AND IT'S BEEN SHOWN TO
DIFFERENTIATE PATIENTS WITH
DEPRESSION FROM CONTROLS.
ESSENTIALLY PARTICIPANTS ARE
TASKED WITH DISCRIMINATING
BETWEEN TWO NEARLY IDENTICAL
STIMULI BUT THEIR
DISPROPORTIONATELY REWARDED FOR
CORRECT RESPONSES ATTRIBUTED TO
ONE OF THE STIMULI.
OVER TIME, PEOPLE WILL DEVELOP A
BUY AS TOWARDS THE STIMULUS
THAT'S REWARDED MORE FREQUENTLY.
PATIENTS CAN DEPRESSION, FOR
EXAMPLE, SHOW DIMINISHED REWARD
RESPONSIVENESS AND THIS PRESENTS
AS A FLATTER SLOPE OF CHANGE IN
REWARD RESPONSE BIAS OVER BLOCKS
OF THE TASK.
SO, IN OUR SLEEP DISRUPTION
STUDY WE SHOWED THAT POSITIVE
EFFECTIVE CHANGES FOLLOWING
SLEEP DISRUPTIONS, ESSENTIALLY
DICTATED THE PATTERNS OF REWARD
RESPONSIVENESS THAT WE ZO OBSER.
THOSE WHO HAVE POSITIVE
EFFECTIVE DEFICITS SHOWED IN
REWARD RESPONSIVENESS FOLLOWING
SLEEP DISRUPTION BUT THOSE ABLE
TO MAINTAIN POSITIVE LEVELS
SHOWED AN INCREASE IN REWARD
RESPONSIVENESS FOLLOWING SLEEP
DISRUPTION AND THIS CAN BE
HIGHLIGHTS THE DEGREE OF
INTEGRATION BETWEEN SLEEP LOSS
AND EFFECTIVE FUNCTION AND THE
REWARDS SYSTEM.
NEXT SLIDE.
NOW, WE OBSERVED AN INCREASE
REWARD RESPONSIVENESS AFTER
SLEEP DISRUPTION AMONG THOSE WHO
RE MAY DESCRIBE AS RESILIENT
INDIVIDUALS.
THOSE WHO WERE ABLE TO PRESERVE
POSITIVE EFFECT IN THE FACE OF
ACUTE SLEEP LOSS.
PRIOR WORK HAS ALSO SHOWN THAT
SLEEP LOSS UNDER CERTAIN
CONDITIONS IS ASSOCIATED WITH AN
INCREASE IN FUNCTION AND
POSITIVE SYSTEMS.
AND FOR EXAMPLE, A STUDY BY
MATTHEW WALK ARE'S GROUP SHOWED
THAT HEALTHY INDIVIDUALS
INTENDED TO SHOW A BUY AS FOR
POSITIVE EMOTION APPRAISALS
FOLLOWING TOTAL SLEEP
DEPRIVATION WHICH THEN
CORRESPONDED TO VARIATION IN
CORTICAL BRAIN REGIONS THAT
BROADLY FALL INTO A REWARD
NETWORK.
GETS THE BACKDROP OF WORK IT'S
IMPORTANT TO CONTEXTUALIZE THESE
TYPES OF FINDINGS WITH
INDIVIDUAL DIFFERENCES IN LEVELS
AND THE STABILITY OF POSITIVE
EMOTIONS.
WHICH IN OUR STUDY REVEALED
IMPORTANT SUBGROUPS OF
RESPONDERS.
SO, FINALLY, HOW DO THESE REWARD
RELATED FINDINGS INFORM OUR
UNDERSTANDING OF SLEEP AND PAIN?
SO TO ADDRESS THAT QUESTION, IN
COLLABORATION WITH MY GOOD
FRIEND AND COLLEAGUE DAVID, WE
DEVELOPED A REWARDING MUSIC TASK
AND WHICH PARTICIPANTS WERE
EXPOSED TO A SERIES OF
PERSONALLY MEANINGFUL SONG CLIPS
THAT HAD HIGH LEVELS OF POSITIVE
EFFECTIVE OR SONG CLIPS RATED
NEUTRAL WITH NO PERSONAL
SIGNIFICANCE.
WE PAIRED THESE SONGS WITH A
RAMP AND HOLD NOXIOUS TERMAL
STIMULATION PARADIGM RAMPING
TEMPERATURES UP TO A PAINFUL
LEVEL.
WE DID THIS IN A MRI MACHINE AND
OBTAINED SCANS WHILE THEY WERE
EXPOSED TO THESE REWARDING OR
NEUTRAL STIMULI AND PAIN.
>> TWO MINUTE WARNING.
>> AND FURTHER PARTICIPANTS DID
THIS TASK AFTER A NIGHT OF
NORMAL SLEEP AND AFTER A NIGHT
OF SLEEP DISRUPTION.
WE FOUND FIRST THAT THE SUB WAS
AK TA RATE IS BID REWARDING
MUSIC AND IT WAS STRONGLY AK TA
RATE ISED BY THE ONSET OF
PAINFUL THERMAL STIMULI AND
REWARDING MUSIC A LOT ERT
NUCLEUS ACTIVITY WITH KEY NODES
OF THE CIRCUITS AND ALSO DURING
PAIN ONSET AND SLEEP DISRUPTION
ATTENUATED THE ACTIVATION AND
THE ANTERIOR MID SINGULAR CORTEX
ALSO A PAIN ONSET.
WE WERE INTERPRET THIS, ONE
POSSIBLE INTERPRETATION OF THE
INCREASED REWARD RELATED
CONNECTIVITY BETWEEN THE NAC AND
THE AMCC COULD BE THAT IT'S
REFLECTIVE OF A RECRUITMENT OF
THIS REGISTER ON TO RECOVER
COGNITIVE CONTROL OF PAIN
FOLLOWING SLEEP DISRUPTION.
SO, TO SUMMARIZE, WE SEE THAT
SLEEP DISRUPTION MODULATES
POSITIVE EFFECT AND POSITIVE
EFFECT OF PAIN AND NOT JUST AT
BEHAVIORAL LEVEL BUT ALSO
OBSERVABLE VIA CHANGES IN
ACTIVITY WITHIN THE CIRCUITS.
THESE FINDINGS SUPPORT THE MULTI
SYSTEM VIEW OF THE SLEEP AFFECT
AND PAIN DYNAMIC AND POINT TO
POSSIBLE AREAS FOR FURTHER WORK
TO INFORM FOR EXAMPLE NEURO
MODULATORY THERAPEUTICS OR
PSYCHOSOCIAL INTERVENTION TO
BOOST POSITIVE EFFECT AND THE
FACE OF SLEEP LOSS.
AND WE COMPLETED A STUDY OF A
BRIEF POSITIVE EMOTION SAVORING
MEDICATION THAT I'D LIKE TO TALK
ABOUT IF WE HAD MORE TIME BUT
THERE ARE OF COURSE NUMEROUS AVS
TO TRAVEL AND IT'S MY BELIEVE
AND WE MAINTAIN A FRAMEWORK FOR
UNRATTLING THE ASSOCIATION
BETWEEN SLEEP AND PAIN WE'LL
DRAW CLOSER TO DISCOVERING AN
INTERVENTION THAT OPTIMIZES THE
WHOLE PERSON AND TARGETS
OUTCOMES BEYOND PAIN SEVERITY.
>> TIME HAS EXPIRED.
>> SO, THAT'S ALL I HAVE FOR
YOU.
THANK YOU SO MUCH.
AND I CAN'T WITHOUT
ACKNOWLEDGING THE POSTDOC TO BAL
FELLOWS AND THE COORDINATORS WHO
MAKE THIS WORK AND OF COURSE THE
SUPPORT WE'VE FROM THE NIH
PARTICULARLY NCCIH, NIADA.
THANK YOU FOR YOUR TIME AND I
WILL TRANSITION NOW TO Dr.
ILGEN WHO IS NEXT.
>> GREAT.
THANK YOU.
AND THANK YOU TO THE PAIN CON
COR SLUM TO PRESENT TODAY.
I'M GOING TO TALK ABOUT THE
OVERLAP BETWEEN CHRONIC PAIN AND
SUBSTANCE USE DISORDERS AS WELL
AS RESOLVED FROM -- MAYBE
SUBSTANCE USE DISORDERS AND
SUBSTANCE RELATED ADVERSE EVENTS
AMONG THOSE WITH CHRONIC PAIN.
FOR TODAY'S TALK, WE'RE GOING TO
KIND OF FLIP THAT A LITTLE BIT
AND TALK ABOUT INDIVIDUALS WHO
HAVE ESTABLISHED SUBSTANCE USE
DISORDERS AND WHAT CAN BE DONE
ABOUT THE LARGE GROUP OF FOLKS
WHO HAVE CHRONIC PAIN AND COULD
BENEFIT FROM SOME ADDITIONAL
TREATMENT.
UNFORTUNATELY, ESPECIALLY WITHIN
SPECIALTY SUBSTANCE USE DISORDER
TREATMENT PROGRAMS, THOSE WITH
CHRONIC PAIN ARE OFTEN THEY ARE
OFTEN GIVEN LITTLE IN TERMS OF
GATE AN ABOUT HOW TO BERMAN AGE
THEIR PAIN AND SO THAT IS
SOMETHING WE'VE BEEN LOOKING AT
AND I'LL TALK ABOUT OUR RESEARCH
ON INTERVENTIONS TO EMIGRATED
DISCUSSIONS OF PAIN AND
SUBSTANCE ABUSE DISORDERS.
IN ELSE TERMS OF ACKNOWLEDGMEND
DISCLOSURE I WILL FOCUS ON OUR
RESEARCH FUNDED BIT V.A. AND AS
WELL AS NIADA AND I'LL TOUCH ON
AN ONGOING STUDY FROM NCCIH AND
I'M A PART OF A SMALL COMPANY
AND I DON'T THINK IT'S RELATE
TODAY THIS CONTENT BUT I WANT TO
MAKE SURE THAT OTHERS ARE AWARE.
SO, YOU CAN GO AHEAD AND
ADVANCE.
>> CHRONIC PAIN IS HIGHLY COMMON
IN ADDICTION SETTINGS.
50% TO 80% SHOWING UP TO DRUG
AND ALCOHOL TREATMENT REPORT
SOME TYPE OF PERSISTENT AND
DEBILITATING PAIN.
THE GENERAL RULE OF THUMB IS
THAT THE MORE THAT THE SUBSTANCE
USE DISORDER TREATMENT SETTING
FOCUSES ON OPIOID USE DISORDERS
THE MORE COMMON THE CHRONIC PAIN
CONDITION IS SO FUR LOOKING AT
MAINTENANCE PROGRAMS OR
MEDICATION TREATMENTS FOR OPIOID
USE DISORDERS, YOU CAN SEE RATES
OF CO OCCURRING PAIN THAT
APPROACH 80%.
AND WHEN PAIN IS PRESENT,
OBSERVATIONAL DATA INDICATES
THAT IT IS ASSOCIATED WITH
POORER TREATMENT OUTCOMES, NOT
JUST IN TERMS OF PAIN AND
FUNCTIONING BUT ALSO IN TERMS OF
GREATER LIKELY HOOD OF POOR
SUBSTANCE RELATED OUTCOMES UP TO
ONE YEAR OF POST TREATMENT.
UNFORTUNATELY, PAIN IS RARELY
COMPREHENSIVELY ADDRESSED DURING
STANDARD S.U.V. TREATMENT WHICH
RAISES THE POSSIBILITY THAT
POTENTIALLY IMPROVING PAIN
TREATMENT DURING SUD TREATMENT
COULD LEAD TO BETTER OUTCOMES TO
PAIN AND SUBSTANCE USE DISORDERS
AND THERE'S SOME RESEARCH ON
THIS TOPIC INCLUDING PROBABLY
MOST DIS BLEE ERIC GARLAND AND
COLLEAGUES WORK ON MINDFULNESS
BASED INTERVENTIONS AND THESE
ARE CONDUCTED IN AN SUD SETTINGS
BUT IN GENERAL FOR THEIR
PATIENTS WHO HAVE CHRONIC PAIN
AND EMERGING SUBSTANCES THERE'S
A SENSE THAT INTERVENTION CAN
IMPROVE OUTCOMES IN BOTH OF
THOSE DOMAINS AND I'LL TALK
ABOUT A FEW TRIALS THAT WE'VE
DONE IN A SIMILAR VANE.
NEXT SLIDE, PLEASE.
OUR WORK USES A COMBINATION OF A
COGNITIVE BEHAVIORAL MODEL FOR
THINKING ABOUT CHRONIC PAIN AND
FOR THINK WE THINK OF SUBSTANCE
USE AND THOUGHTS AND PERCEPTIONS
OF SUBSTANCE USE FIGHTING NICELY
IN A CHRONIC PAIN FOR A LONG
TIME LIKE THE FEAR AVOIDANCE
MODEL.
FEARS ABOUT PAIN CONCERNS ABOUT
THE INABILITY TO MANAGE PAIN AND
EXPECTANCY AROUND SUBSTANCE USE
CAN PERPETUATE AVOIDANCE OF
POTENTIALLY PAINFUL STIMULI AS
WELL AS THE USE OF SUBSTANCES TO
COPE AS AVOIDANCE COPING
MECHANISM AND THIS CAN KIND OF
LEAD TO A SPIRAL OF NEGATIVE
OUTCOMES THAT CHARACTERIZE
CHRONIC PAIN AND FROM AN
INTERVENTION PERSPECTIVE, YOU
ARE LOOKING TO HELP SHAPE
PERCEPTIONS OF PAIN AND
SUBSTANCE OF USE AS WELL AS
ENGAGEMENT IN FEWER AVOIDANCE
RELATED BEHAVIORS INCLUDING
SUBSTANCE USE AND MISUSE AS A
WAY TO BREAK OUT OF THAT CYCLE.
NEXT SLIDE.
PLEASE.
WE DEVELOPED THIS INTERVENTION
AND WE CALL IT IMPACT AND IT'S
THE BASIS OF WHAT I'LL DESCRIBE
HERE TODAY AND THIS IS SOMETHING
THAT CAN BE OVER LAID ON TO AN
EPISODE OF EXISTING SUBSTANCE
USE DISORDER TREATMENT AND IT'S
MEANT TO BE COMPLIMENTARY TO A
LOT OF MESSAGES THAT WE WILL
RECEIVE IN STAND AR ADDICTION
TREATMENT AND IT HIGHLIGHTS
THOSE LINKS BETWEEN SUBSTANCE
USE AND CHRONIC PAIN THROUGHOUT
AND ENCOURAGES DIFFERENT COPES
OF COPING WITH NEGATIVE THOUGHTS
OF PAIN AND NEGATIVE EXPERIENCES
SUCH AS SPIKES IN PAIN.
SO, FOR TODAY, I AM GOING TO
DESCRIBE THE RESULTS OF TWO
RANDOMIZED TRIALS BOTH OF THE
SAME INTERVENTION.
THE FIRST OF WHICH WAS CONDUCTED
IN THE V.A. AND IN AN OUT
PATIENT SETTING, THE OTHER WAS
CONDUCTED IN A COMMUNITY
RESIDENTIAL DRUG AND ALCOHOL
TREATMENT PROGRAM.
NEXT SLIDE, PLEASE.
SO FOR THE V.A. STUDY, WE
RECRUITED 130 PATIENTS STARTING
AN EPISODE OF VA TREATMENT THEY
WERE RANDOMIZED TO ONE OF TWO
12-WEEK GROUPS AND IN THIS
IMPACT INTERCEPTIONS AND OR ANNA
TENSION MATCH CONTROL CONDITION
THIS WAS REALLY JUST KIND OF A
PSYCHO EDUCATIONAL CONTROL WHERE
THEY MET WITH A THERAPIST AND
OTHER PATIENTS FROM THE SAME
LENGTH OF TIME AS THE
INTERVENTION AND IT DID NOT
OVERLAP IN TERMS OF THE SPECIFIC
CONTENT AND OUR FOLLOW-UP RATES
WERE HIGH FOR THIS PATIENT
POPULATION.
NEXT SLIDE, PLEASE.
NET CONSISTENTLY LOWER PAIN OVER
THE FOLLOW-UP INTERVAL COMPARED
TO THOSE RANDOMIZED TO THE
CONTROL CONDITIONS AND YOU SEE
THAT IN TERMS OF FUNCTIONING
THEY REPORTED HIGHER FUNCTIONING
ON AVERAGE AND DID THOSE IN THE
LOCAL CONDITION OVER THE
12-MONTH FOLLOW-UP.
NEXT SLIDE, PLEASE.
TURNING TO SUBSTANCE RELATED
OUTCOMES, THE UPPER LAST CORNER
AND WE LOOKED AT ALCOHOL AND
OTHER DRUG USE SEPARATELY FOR
THIS STUDY AND IN TERMS OF COL
USE YOU SEE THE NATIONAL
FOLLOW-UP THE TWO CONDITIONS
LOOK SIMILAR AND THERE'S NO
DIFFERENCE THERE AND THEN OVER
TIME, A DIFFERENCE EMERGES WHERE
THOSE IN THE CONTROL CONDITIONS
AND RETURNED TO MORE REGULAR
ALCOHOL USE WHERE THOSE IN THE
INITIALLY FOLLOWING TREATMENT.
AND IN THE BOTTOM RIGHT-HAND
CORNER LOOKING AT YOU SEE THE
WIDER OR BARS AND WE HAD A LOT
OF OVER HAPPEN BETWEEN
CONDITIONS AND NO REAL VERSUS
THE CONTROL CONDITION.
AS THE LAST SLIDE OF THIS TRIAL,
THIS IS A KEY MECHANISM OF THE
INTERVENTION AND YOU CAN SEE
CONSISTENCES FOR CONDITIONS FOR
THOSE IN THE CBT OR IMPACT
CONDITION AND NEXT SLIDE,
PLEASE, SO TURNING TO THE NON
V.A. STUDY THEY WERE CREATED
DURING AN EPISODE OF COMMUNITY
RESIDENTIAL DRUG AND ALCOHOL
TREATMENT IN LARGE TREATMENT
UNIT IN THE DETROIT AREA
MICHIGAN AND WE TRIED TO RECRUIT
MEN AND WOMEN INTO THIS TRIAL
AND THEY WERE RANDOMIZED TO THE
SAME CAN'T WE SHORT END THE
CONDITIONS AND MET MORE
FREQUENTLY WHERE WE DELIVERED
THEM TWICE A WEEK AND WE
FOLLOWED FOLKS FOR THREE, SIX
AND 12 MONTHS AND AGAIN YOU CAN
SEE THE FOLLOW-UP RATES.
ADDITION TO THE PAIN LEVEL
FUNCTIONING ALCOHOL USE AND DRUG
USE FREQUENCY, WE HAVE A MEASURE
OF PAIN TASK AND WE LOOKED AT
PAIN TOLLENNANCE IN THIS STUFF.
NEXT SLIDE, PLEASE.
THE RESULTS ARE LESS IMPRESSIVE.
WE SEE DIFFERENCES ON TWO OF
THEM AND THOSE WOULD BE ENTA
INDICATION OF HIGHER PAIN
FUNCTIONING OVER THE FOLLOW-UP
INTERVAL AND HIGHER PAIN DOLL
ORANCE AND THERE WAS NO
DIFFERENCES ON SELF-REPORTED
PAIN LEVEL AND ALCOHOL USE AND
DRUG USE.
AS A ANALYSIS GETTING OUR HEAD
AROUND WHAT IS MAYBE DIFFERENT
BETWEEN THIS STUDY AND THE PRIOR
STUDY WE EXAMINED SELF-EFFICACY
YOU SAW IN ONE OF THE LAST
SLIDES ON IT DOES DIFFER BY
CONDITION AND WE SEE THAT THE
ASSOCIATION BETWEEN
SELF-EFFICACY AND PAIN LEVEL AND
PAIN LEVEL FUNCTIONING OVER THE
FOLLOW-UP INTERVAL BUT NO LINK
BETWEEN THAT MEASURE AND THE
ALCOHOL AND DRUG RELATED OUTCOME
SHOWING THERE'S POPULATION OF
PATIENTS AND EVEN THOUGH THEY
FEEL BETTER THEY GET THE
BEHAVIORAL PAIN MANAGEMENT
INVENTION AND THEY'RE NOT
NECESSARILY BEHAVING DIFFERENTLY
IN TERMS OF THEIR SUBSTANCE USE
AND ONE FINAL POINT IS THAT OUR
FINDINGS WERE GENERALLY LARGER
IN THOSE NOT IN THE CONTROLLED
ENVIRONMENT.
ONE, CHALLENGE IN THE PATIENT
POPULATION WE WERE FOCUSING ON
IS THAT MANY OF THE PEOPLE
RECRUITED INTO THE STUDY WERE
HOMELESS AND HAD UNSTABLE
HOUSING FOLLOWING TREATMENT AND
OFTEN THEY ENDED UP IN ENDED UP
IN JAIL OR PRISON SO IT WAS
DIFFICULT TO DETECT EFFECTS WITH
THEY WERE NOT OUT IN THE
COMMUNITY AND IF WE LIMIT
OURSELVES TO THOSE PARTICIPANTS
WHO WHEN THEY LEFT TREATMENT,
SOME OF THE FINDINGS WERE A
LITTLE MORE CONSISTENT AND
ENCOURAGING.
>> TWO MINUTES REMAINING.
>> THANK YOU.
SO AS A WRAP-UP, WE BELIEVE THAT
NON MEDICATION TREATMENT HAVE A
ROLE TO REPLY IN ADDRESSING PAIN
IN THOSE WITH SUBSTANCE USE
DISORDERS AND THOSE IN
TREATMENT.
I DIDN'T TALK ABOUT THE INFORMAL
TREATMENT BUT THEY WERE REALLY
APPRECIATIVE AND WE WERE ASKING
ABOUT THEIR PAIN AND VALIDATING
THE IMPORTANCE AND WORKING WITH
THEM TO DEVELOP SOLUTIONS TO
THEIR PAIN THAT WAS VERY
DIFFERENT FROM WHAT MIGHT BE
DRUG AND ALCOHOL AND THEY ATTEND
RATES WERE VERY GOOD FOR OUR
GROUPS AND THEY SEEMED REALLY
ENGLISH GAGEDREAL --ENGAGE IN T.
RESULTS WERE ENCOURAGING
ESPECIALLY AROUND THE PAIN
OUTCOMES AND THEY WERE LESSEN
COURAGING AND WE DID SEE
EVIDENCE THE MECHANISMS OF
ACTION OF THE INTERVENTIONS WERE
CHANGING IN THE CONDITION AND
THESE FACTORS RELATED TO
SELF-ADVOCACY AND THE GENERAL
ABILITY TO COPE WITH PAIN ARE
IMPORTANT AND THEY ARE CLOSELY
LINKED WITH THE PAIN OUTCOMES
THAN THE SUBSTANCE ELATED
OUTCOMES SO WHAT IS THAT LINK
BETWEEN PAIN AND WHAT CAN BE
DONE TO HELP PATIENTS HAVE
BETTER OUTCOMES.
AND BOTH OF THESE STUDIES DID
AND NA IS PROBABLY PARTICULARLY
TRUE FOR THOSE WITH OPIOID USE
DISORDERS SO WE ARE DOING FOLLOW
UM TREATMENT TO SEE IF THAT TYPE
OF INTERVENTION CAN HELP IMPROVE
OUTCOMES IN THAT GROUP.
NEXT SLIDE, PLEASE.
THAT'S IT FOR MY PRESENTATION.
WE'LL GO AHEAD AND HAND OFF TO
THE NEXT PRESENTER.
>> THANK YOU FOR HAVING ME HERE
TODAY.
MESH SLIDE, PLEASE.
I HAVE PREVIOUS RESEARCH BUT NOT
RELATED TO THIS PRESENTATION.
WHEN WE THINK ABOUT CHRONIC
OROFACIAL PAIN YOU THINK ABOUT
DISORDERS BUT THEY CAN BE
SUBDIVIDED TO NEURO VASCULAR
PAIN AND IT'S A TERM EMBRACING A
GROUP OF MUSCULAR SKILL TAP AND
JOINT PAIN INFLAMMATORY OR A
COMBINATION THEY MAY HAVE
DIFFERENT DIRECTORY.
THEY LOOKED AT FOUR OTHER PAIN
CONDITIONS.
FIBROMYALGIA, LOW BACK PAIN, IBR
AND HEADACHES.
YOU SEE THIS IN 2020 AND SHOWING
IN RED PAINFUL AREAS AND IN BLUE
AREAS THAT ARE NOT PAINFUL AND
PATIENT WITH FINAL MYALGIA, LOW
BACK PAIN, IRB AND HEADACHE AND
YOU CAN SEE THAT THE RED PAINFUL
AREAS EXTEND IN THE PATIENT
BEYOND THE OROFACIAL REGION AND
THE PATIENT WITHOUT THE CHRONIC
PAIN CONDITION REPORT PAIN IN
THE REGIS REGION AS WELL.
AND NOW THE VERY COMMON PAIN OR
CHRONIC PAIN THAT WE SEE IN THE
OR OFFICIAL PAIN CLINICS IS
PAINFUL POST DRAMATIC NEWER ON
THEE AND IT'S TO THE OROFACIAL
REGION AND IT CAN FOLLOW A
DENTAL PROCEDURE LIKE SURGERY,
IMPLANTS BUT IN CERTAIN PATIENTS
IN SOME PATIENTS IT MAY FOLLOW
WITH DENTAL PROCEDURES SUCH AS
CROWN PREPARATION, EVEN
CLEANING, SCALING AND MORE THAN
ANOTHER CONDITIONS IN THERAPY A
ROOT CANAL TREATMENT.
AND IT'S SURPRISING THAT FIVE TO
SEVEN HAVE SUCCESSFUL ROOT CANAL
TREATMENT WITH NO COMPLICATION
AND THIS IS A MILD PAIN AND IT
MAY LAST SEVERAL YEARS FOLLOWING
THE COMPLETION.
NEXT.
THE GOOD NEWS THAT OVER ALL
PERSISTENT PAINFUL AND AREAS IS
SIGNIFICANT LESS COMMON THAN
PAIN FALLING SPINAL NERVE
INJURY.
IT'S GO AHEAD NEWS BECAUSE IT'S
DENTIST MOST PROCEDURES THAT WE
DO CAN CAUSE TRAUMA TO THE AREA
AND THE QUESTION THAT HE WAS
ASKED, WHY SOME IS MORE
RESISTANT AND ONE THING WE TALK
ABOUT IS THE ONLY AREA THAT IS
PROGRAM FOR THE INNOVATION AND
ONE SET OF REPLACING THE OTHER
AND ANOTHER POINT IS RELATED TO
THE INJURY BARRAGE AND IT'S BEEN
SHOWN THAT THE INJURY BARRAGE
INCIDENTS IS MUCH LOWER COMPARED
TO THE CONSUMPTION AND IN
ADDITION, MOST OF THE PROCEDURES
IN THE OFFICE OF THE LOCAL
ANESTHESIAIA THAT AND IT
REPORTED THAT THIS SPROUT THAT
ARE FOUND FOLLOWING NERVE
INJURIES IS NERVE SECTION ARE
HARDLY PRESENT OR NOT PRESENT AT
ALL FOLLOWING THE TRANCE
SECTION.
AND A RECENT STUDY FROM OUR
GROUP, DEMONSTRATED DIFFERENT
GENE EXPRESSION IN THE DOSAL
ROOT GANGLION AND THIS IS
IMPORTANT BECAUSE IF WE SAY THAT
THE SYSTEM IS MORE RESISTANT TO
CHRONIC PAIN, FINDING MAY HELP
AND DOWN THE ROAD EVEN POTENTIAL
TREATMENT.
OF COURSE, THE VERY INTERESTING
QUESTION IS, WHAT IS MAKING SOME
PATIENTS DEVELOP CHRONIC PAIN
FOLLOWING INJURY AND SOME TO
DEVELOP ONLY ACUTE PAIN THAT
HEALS?
OF COURSE, IT'S AN IMPORTANT
ROLE IS GENETICS AND
PSYCHOLOGICAL FACTORS ARE
SIGNIFICANT AND WE MENTIONED
ALREADY THE SYMPATHETIC NERVOUS
SYSTEM AND INFLAMMATION WE'VE
ZONE IN STUDIES AND I WOULD LIKE
TO FOCUS ON THE ROLE OF PAIN
MODULATION.
TO TRY TO DEFINE IT IS DIFFICULT
AND WE WILL SUMMARIZE AND SAY
THAT THE CENTRAL NERVOUS SYSTEM
WILL MODULATE PAIN THROUGH EX
CITATION AND WE CAN TEST IT WITH
SUMMATION AND IT'S A TEST HOW DO
WE DO THAT WE APPLY A PAINFUL
STIMULUS AND REPORT THE
INTENSITY AS CAN YOU SEE ON THE
RED BARON THE RIGHT.
AND SYSTEMS WE WILL NOT SEE THE
SAME REDUCTION IN PAIN
SENSITIVITY AND THERE'S ARE A
LOT OF STUDIES TO SHOW IS THAT
LESS EFFICIENT THEY ARE ON
LIMITED TO A NUMBER OF STUDY
FOCUSES ON THE OROFACIAL REGION.
IN THAT ALL, WE COMBINED
SUMMATION AND CTM AND WE USE 30
REPEATED MECHANICAL STINZIANO
YOU EYE AND THEN WE SECRETARY
PATIENT TO REPORT AGAIN
INTENSITY FOLLOWING THE FIRST
10, 20 OR 30 STIMULI THAT CAN BE
DONE OBVIOUSLY WE GET SUMMATION
AND THE CONTINUING PAIN FALL
STIMULATION CAN SEE HERE AND
REDUCE THE PAINENS TENSE TEE AND
WE TESTED PAIN FOLLOWING ROOT
CANAL AND THE MOST COMMON DENTAL
PROCEDURE AND IN BLUE AND WE CAN
SEE THE PAIN AND MINIMUM PESK O
AND WE CAN STEL THE STUDY AND
THE PATIENTS THAT DEVELOPED
CHRONIC PAIN TO BEGIN WITH AND
LESS EFFICIENT PAIN POPULATION
AND WE CAN CONCLUDE THAT SIMILAR
TO OTHER CHRONIC PAIN CONTINUES,
PATIENTS SUFFERING FROM CHRONIC
PAIN FROM A ROOT CANAL HAVE LESS
SUFFICIENT PAIN MODULATION.
AND AS I MENTIONED EARLIER,
EXERCISE IN HOWEVER, IT EFFECT
IS LIMITED TO THE TIME OF THE
CONDITIONING PAINFUL STIMULUS
AND WHILE EXERCISE EFFECT CAN
LAST BEYOND AND AFTER THE
EXERCISE ENDED.
AND IN OTHER STUDIES TO SHOW
THAT THERE'S NOT A CORRELATION
BETWEEN THE TWO PATIENTS WOULD
HAVE EXCELLENT EXERCISE AND NOT
NECESSARILY HAVE GOOD.
NEXT.
HERE IN THIS STUDY, WE USED
EXERCISE TO COMPARE THE
INHIBITOR SYSTEM OF PATIENT WITH
CHRONIC MYALGIA WHICH IS SUBTYPE
AND THEY CREATED TO PAIN AND
HEALTHY CONTROLS.
AND TO ACHIEVE EXERCISE IN
HYPOAGLESIA THEY 50% OF THE
MAXIMUM NUMBER OF STEPS THEY CAN
HAVE IN ONE MINUTE AND SUB
STUDIES ARE USING MORE INTENSE
EXERCISES AND WE FOUND THAT MORE
INTENSE EXERCISE REDUCED THE
COMPLIANCE OF PATIENT THAT
ALREADY HAVE CHRONIC PAIN.
SO SIMILAR TO THE R ROOT CANAL -
>> WE CAN CONCLUDE FROM THIS
STUDY THAT PATIENTS HAVE LESS
EFFICIENT PAIN AND EXERCISE AND
HOWEVER THEY HAVE A DELAYED
RESPONSE AND THE RESPONSE IS
STILL EXISTING WE CAN USE THE
TREATMENT IN THE FUTURE.
NEXT, PLEASE.
TO FURTHER STUDY EXERCISE AND WE
WILL ANIMAL MODEL WHERE WE
TESTED RODENTS SENSITIVITY TO
MECHANICAL STIMULATION BEFORE
AND AFTER THREE MINUTES ON A
ROTATING ROLL AND YOU CAN SEE ON
THE DRAFT, SOME DEVELOP SIGNIFIT
AND SOME WERE MEANINGFUL AND
THEY HAD MORE THAN 70% REDUCTION
IN AT LEAST THREE REPEATED TESTS
AND THEY HAVE VERY MINOR ARE
LOWER THAN 30% REDUCTION IN AT
LEAST REPEATED TESTS AND THOSE
ARE THE SIGNIFICANT RATES THAT
WE CONCEDED AND BY EXERCISING
AND THOSE WITH MINUTE YUM AS LOW
THAT HAVE LESS SUFFICIENT.
NEXT.
LOW AND HIGH IN PAIN POPULATION
AND THE SIGH ATTIC AND TO
SUMMARIZE THE RESULTS, LOW RATES
DEVELOP SIGNIFICANTLY MORE
PAINFUL NERVE INJURY AND THAT
MEANS LOW LESS PAIN AND DEVELOP
MORE PAIN.
IN ADDICTION, LOW EIH RATS
DEVELOPED PAIN IN THE CONTRA
LATERAL UNEFFECTED NERVE
TERRITORY BUT THAT WAS ONLY FOR
SIGH ATTIC NERVE INJURY AND NOT
THE, AND RELATION TO.
WE FOUND THE MIRROR IMAGE IN
HIGH EIH RATS ONLY IN THE
SCIATIC NERVE THIS IS ANOTHER
EXAMPLE OF THE SYSTEM RELATIVE
RESISTANCE TO CHRONIC PAIN
FOLLOWING INJURY.
AND NEXT SLIDE.
I THINK TO RESPECT THE TIME
WE'LL SKIP THIS ONE.
SKIP THIS SLIDE.
ONE OF THE PROBLEMS WE HAVE IN
THE OWE OFFICIAL PAIN CLINICS IN
AND AND OUR TREATMENT IS TRIAL
AND ERROR.
PATIENTS WILL BENEFIT MORE FROM
TREATMENT AND SO WHAT WE DID IS
WE TREATED LOW AND HIGH EIH RATS
STRONG AND WEAK PAIN SYSTEMS AND
WITH A RANGE OF MEDICATION THAT
ARE USED IN THE PAIN CLINIC AND
WE DID IT AFTER FOLLOWING RAIN
-- TO SUMMARIZETHE FINDING WE D
LESS SUFFICIENT PAIN RELATED
SYSTEM THEY HAD BENEFITED MORE
FROM -- NEXT LIED, PLEASE.
SO THE NEXT QUESTION THAT WE HAD
WAS TO ASK OURSELVES, ARE THOSE
MEDICATIONS THAT ARE
SPECIFICALLY BETTER WITH
PATIENTS AND THE REST THAT IT
HAS LESS EFFICIENT PAIN, DO
SOMETHING TO THEIR CLAIM OF
RELATION --
>> A MINUTE WARNING.
>> WE GAVE THOSE MEDICATIONS TO
THE RATS TO LOW AND HIGH EIH
RATS AND WE FOUND THAT FOUR DAYS
OF TREATMENT TURNS FORM 70% OF
THE LOW RATS THAT HAD LOW PAIN
AND LOW EXERCISE INTO HIGH OR
MEDIUM AND IT IMPROVES THAT PAIN
OF RELATION SYSTEM AND THIS MAY
HAVE A CLINICAL RELEVANCE.
NEXT, PLEASE.
MODEL THAT WAS DEVELOPED BY
DAVID SUGGESTED THAT PATIENTS
WITH LESS EFFICIENT PAIN OF
RELATION RED IN THIS SLIDE AND
ARE AT HIGH-RISK OF DEVELOPING
CHRONIC PAIN AND BLUE IS REDUCED
RATES OF CHRONIC PAIN SO IF
PATIENTS ARE HAVING INJURY IN
RED THEY WILL DEVELOP PERSISTENT
PAIN.
>> YOU ARE MUTED.
>> YOU HAVE MUTED YOURSELF.
HOW DID I DO THAT?
NEXT, PLEASE.
SO IF A PATIENT IS IN THE RED
AREA, AND HE IS A PIE RISK OR
SHE IS AT HIGH-RISK TO DEVELOP
CHRONIC PAIN IF WE CAN IMPROVE
BY THEY WERE PEE AND OR EXERCISE
PROTOCOL, THE HOPE IS THAT THOSE
PATIENTS WILL DEVELOP ACUTE PAIN
BUT NOT A PERSIST APARTMENT PAI.
TO SUMMARIZE WE CAN SAY THAT
CHRONIC OR OFFICIAL PAIN ARE
COMMON AND OPEN LAP WITH OTHER
PAIN AND THE GENERAL SYSTEM IS
MORE RESISTANT TO PAIN FOLLOWING
INJURY AND INEFFICIENT PAIN
MODULATION SYSTEM IS ASSOCIATED
WITH CHRONIC PAIN AND IT MAY
IMPROVE THE PAIN POPULATION
SYSTEM.
THANK YOU, VERY MUCH.
>> THANK YOU.
I BELIEVE WE ARE NOW GOING TO
MOVE TO THE Q&A SESSION FOR THIS
FIRST PANEL.
THANK YOU WHO SUBMITTED
QUESTIONS.
I HAVE ONE FOR EVERYBODY.
AND THEN WE'LL SEE HOW WE'RE
DOING ON TIME.
SO, Dr. KOEHLOMOOS.
PAIN WITH MILITARY MEMBERS WITH
POLYTRAUMA YOU DESCRIBED, IT
APPEARS YOU ARE USING CBT OR
MINDFUL LESS FOR THERAPY, HAS
ANYONE ALREADY USED ACT
ACCEPTANCE AND COMMITMENT
THERAPY AS PART OF THE CARE
PLAN?
>> GREAT.
THANK YOU FOR ASKING THAT
QUESTION.
I WAS ACTUALLY HOPING THAT WE
WOULD GET TO TALK A LITTLE BIT
ABOUT THE OR I ORLICULA AR ACUPO
I WRITE THE ANONYMOUS POSTER OF
THOSE QUESTIONS TO KNOW I'M
HAPPY TO ADDRESS THAT LATER.
I AM LESS CLEAR ON THE
INTERVENTION THAT YOU MENTIONED.
IT MIGHT BE BEING TESTED.
WE DO A LOT OF EXPERIMENTATION.
CLINICAL TRIALS OF DIFFERENT
METHODS BOTH FUNDED BY THE DOD
AND ALSO IN PARTNERSHIP WITH THE
V.A.
SO I'M NOT AWARE OF ANY TRIALS
OF THAT BUT I WOULDN'T BE
SURPRISED.
THERE'S A LOT OF DIFFERENT --
FOR ANY OF YOU, FOR THOSE OF YOU
WHO ARE ON THE CALL, IF YOU ARE
RESEARCHERS, YOU KNOW, IF YOU
DON'T KNOW THIS, I KNOW THAT
MOST YOU LOOK TO THE NIH FOR
FUNDING BUT YOU MIGHT LOOK TO
CDMRP THE CONGRESSIONAL AND
MEDICAL RESEARCH AND MATERIALS
MRMC.
WRITE TO ME AND I'LL LET YOU
KNOW.
WE HAVE FUNDING FOR A LOT OF
THESE DIFFERENT THINGS.
YOU DON'T NECESSARILY HAVE TO DO
YOUR WORK ON A MILITARY
POPULATION, ALTHOUGH IT'S NICE.
BUT DO LET ME USE THIS AS AN
OPPORTUNITY TO ATTRACT MORE
TALENT TO ISSUES THAT ARE
IMPORTANT TO THE DOD LIKE WHOLE
PERSON HEALTH AND PAIN
MANAGEMENT AND DIFFERENT
INTERVENTIONS FOR BEHAVIORAL
HEALTH DISORDERS SO THANK YOU.
>> THANK YOU.
Dr. SAWSAN AS-SANIE.
WHAT ARE SOME CAUSES FOR
SYSTEMATIC OR SYSTEMIC
INFLAMMATION IN THE CONTEXT OF
ENDOMETRIOSIS OR CHRONIC PELVIC
PAIN?
THERE WAS ANOTHER QUESTION ABOUT
INVOLVEMENT OF A PATHOGENIC
MICROBIOME?
IS THERE ANYTHING CAN YOU SAY
ABOUT THAT AND FOR A GIVEN
PATIENT, IS THERE A SIMPLE WAY
TO TELL IF THE PAIN IS
NOCIPLASTIC.
>> THOSE ARE ALL EXCELLENT
QUESTIONS AND IN TERMS OF
SYSTEMIC INFLAMMATION THERE'S
ACTUALLY NOT A TREMENDOUS AMOUNT
OF WORK THAT HAS BEEN DONE IN
THAT AREA OF ENDOMETRIOSIS.
MOST OF WHAT WE KNOW IS THAT A
VERY STRONG LOCAL LEVELS OF
LOCAL PELVIC INFLAMMATION AND
THERE'S SOME DATA THAT SUGGESTS
THIS EXTENDS TO A SYSTEMIC LEVEL
BUT THE AMOUNT OF BODY OF
EVIDENCE IN THAT IS A BIT MORE
LIMITED AND THE RELATIONSHIP
BETWEEN THE INFORMATION IS
COMPLETELY UNKNOWN.
WITH REGARDS -- I'M SORRY, THERE
WERE THREE QUESTIONS.
I FORGOT ALREADY THE SECOND ONE.
>> PATHOGENIC MICROBIOME.
>> AND YES, THERE'S VERY EARLY
WORK LOOKING AT PATHOGENIC
MICROBIOME BUT AGAIN, YOU KNOW,
ITS RELATIONSHIP BETWEEN THESE
OTHER FACTORS STILL REMAINS
UNKNOWN AND SO IT'S WHERE WE ARE
WITH RESEARCH AND REALLY JUST
VERY SMALL MICROSCOPES IN
DIFFERENT, YOU KNOW, AREAS OF
DISEASE BUT NONE OF REALLY BEEN
INTERCONNECTED YET.
AND THEN THE THIRD QUESTION WAS,
HOW DO WE MEASURE NOCIPLASTIC
PAIN AND I WOULD SAY WHILE
THERE'S A LOT OF REALLY
EXCELLENT WORK THAT HAVE BEEN
SCRUBBED BY ALL OF THESE
INVESTIGATORS, ON WAYS TO
MEASURE IT IN THE LAB WHEN WE
ARE THINKING ABOUT IT CLINICALLY
THEY'RE REALLY AREN'T
STANDARDIZED WAYS OF PROBABLY I
WOULD SAY THE BEST WAY BASED ON
WHAT I HAVE LEARNED IF MY MEN
STORES IS LOOKING AT A BODY MAP
AND TRYING TO UNDERSTAND FROM A
PATIENT WHAT ARE THE OTHER
REGIONS IN THE BODY THAT THEY'VE
EXPERIENCED PAIN AND THAT SAY
PRETTY GOOD ROUGH ESTIMATE OF
WHERE THEY ARE IN THAT SCALE.
>> THANK YOU.
DO ANY OF THE OTHER PANELISTS
WANT TO CHIME IN.
A WAY TO TELL DIFFERENT TYPES OF
CHRONIC PAIN?
>> ANY OTHER VIEWPOINTS.
I'LL MOVE ON TO THE NEXT
QUESTION.
Dr. FINAN, HAVE YOU STUDIED AN
ASSOCIATION OF PAIN AND SLEEP
LOSS WITH COUPLES WHO HAVE YOUNG
CHILDREN OR BABIES THAT LEAD TO
SLEEP REDUCTION AND I'M ASKING
PERSONALLY.
DO POSTPARTUM CHANGES SEX
DIFFERENCES BETWEEN MALES AND
FEMALES AND IF SO DOES THIS SEX
DIFFERENCE NEUTRALIZE OR GO BACK
TO NO SIGNIFICANT DIFFERENCES
AFTER A CERTAIN AMOUNT OF TIME?
>> YEAH, SO, THAT'S A GREAT Q
THE MODEL THAT WE USE
EXPERIMENTALLY, ONE OF THE
REASONS WE LOOK AT THIS FORCED
NOCTURNAL AWAKENINGS PARADIGM IS
BECAUSE REPEATED A -- AWAKENNES
IS A HALLMARK OF SLEEP
MAINTENANCE INSOMNIA IN PATIENTS
WITH CHRONIC PAIN WHO MAY BE
AWAKENED THROUGHOUT THE NIGHT
BUT THEIR PAIN.
IN THE EXPERIMENTAL CONTEXT,
IT'S REALLY A GOOD BIT MORE
SEVERE FROM AN AWAKENING
STANDPOINT THAN PEOPLE WITH
INCOM SOMNIA EXPERIENCE.
IT'S OUR ABILITY TO KIND OF
GENERALIZE THE CLINICAL
POPULATIONS WITH ONE EXCEPTION,
AND THAT IS HAVING A BABY IN THE
HOUSE, PARTICULARLY IF YOU ARE A
MOTHER, OR FATHER WHO IS DOING
MIDDLE OF NIGHT CARE.
SO, I'VE GOT A COUPLE YOUNG KIDS
NOW AND SO I RECENTLY WENT
THROUGH ALL OF THAT AND CAN SAY
FOR SURE THAT OUR FORCED
AWAKENINGS PARADIGM IS SIMILAR
SO LOTS OF PEOPLE UNTIL THE REAL
WORLD GO THROUGH EXTENDED
PERIODS THAT ARE CONSIDER THEY
EXPERIENCE SIMILAR THINGS THAT
WE ARE DOING IN THE LAB.
WHEN WE LOOK AT THE DATA, WE
HAVE RECENTLY PUBLISHED SOME SEX
DIFFERENCES IN RESPONSE TO THE
FORCED AWAKENINGS PARADIGM AND
ONE THAT WAS PARTICULARLY
INTERESTING TO US WAS THAT
FEMALES WERE ABLE TO -- THEY
WERE MORE RESILIENT IN TERMS OF
THEIR STAGE N3 SLEEP.
THEIR SLOW WAVE SLEEP FOLLOWING
THE FORCED AWAKENINGS PARADIGM
AND IT'S SOMETHING THAT'S
DIFFICULT TO LOOK AT IN MANY
SLEEP DEPRIVATION PARADIGMS
PARTICULARLY TOTAL SLEEP
DEPRIVATION BECAUSE YOU DON'T
HAVE THE OPPORTUNITY TO SEE IN
THE COURSE OF THIS KIND OF SLEEP
DISTURBANCE, WHAT IS HAPPENING
IN YOUR SLEEP.
THEY'RE SLEEP DOUGH, WE ALLOW
PEOPLE TO FALL ASLEEP, WE WAKE
THEM UP, ALLOW THEM TO FALL BACK
ASLEEP OVER EIGHT HOURS SO WE
ESSENTIALLY DEPRIVE THEM OF FOUR
HOURS OF SLEEP AND WE CAN SEE
WHAT IS GOING ON AND IN TERMS OF
THEIR SLEEP EEG IN THE INTERIM
AND WE SAW THAT FEMALES WERE
BETTER ABLE TO PRESERVE SLOW
WAVE SLEEP FOLLOWING A SLEEP
LOSS.
WE HAVEN'T FOLLOWED UP IN TERMS
OF PAIN BUT IT'S A INITIAL
FOLLOWING WE CAN GO OFF.
>> VERY INTERESTING.
Dr. ILGEN, HAVE YOU EXAMINED
MODERATORS OF TREATMENT EFFICACY
IN YOUR CBT TRIAL?
PATIENT CHERER PHYSICS SUCH AS
SEX DIFFERENCES?
>> THEY LOOKED SOMEWHAT SIMILAR
BUT WEAKER WHEN SPLIT OUT BY
GENDER AND THEN, OUR BY SEX AND
THAT WE REALLY DIDN'T SEE AN
EMERGING PATTERN OF RESULTS THAT
WAS ALL THAT COMPELLING AND OUR
MAIN OUTCOME PAPER PRESENTED IT
SEPARATELY IN MEN AND WOMEN FOR
THE PRESENTATION TODAY.
I GROUPED EVERYONE TOGETHER.
WE'VE LOOKED AT A NUMBER OF
DIFFERENT MODERATORS AND MY
SENSE IS THAT THE DRIVERS OF
CLINICAL OUTCOMES IN THIS GROUP
HAVE A LOT TO DO WITH HOW PEOPLE
LEAVE RESIDENTIAL TREATMENT AND
MORE THAN HOW THEY LOOK WHEN
THEY SHOW UP AT TREATMENT.
THERE IS OBVIOUSLY RELATIONSHIP
THERE AND THAT SOMEONE IS
BASELINE CHARRER ADVE CHARACTERF
THEY LEAVE AND GO TO JAIL AND GO
IN THTHEY'RE HOMELESS, THEY HAVA
DIFFERENT COURSE THAN PEOPLE
THAT LEAVE AND GO TO A STABLE
HOME ENVIRONMENT AND EXAMINING
SUB GROUP DIFFERENCES WITHIN AN
INTENT TO TREAT ANALYSIS AND
RANDOMIZED TRIAL IS DIFFICULT
BECAUSE YOU ARE TALKING ABOUT
THINGS THAT HAPPENED POST
BASELINE AND SO YOU REALLY DON'T
KNOW THAT BASED ON HOW THEY LOOK
WHEN THEY SHOW UP TO TREATMENT
SO I THINK FOR US, YES, WE'VE
EXAMINED MODERATORS BY
IMPRESSIONIST THAT THE RESULTS
ARE NOT ALL THAT INFORMATIVE IN
ALL LICK LIKELIHOOD THEY HAVE HE
POSITIVE AND NEGATIVE OUTCOMES
IN IDENTIFYING WITCH FACTORS
MATTER IN WHICH GROUPS AS THEY
EXIT TREATMENT.
>> A QUICK FOLLOW-UP, HOW DO YOU
ATTRIBUTE YOUR EXCELLENT
RETENTION RATES IN YOUR V.A. AND
RESIDENTIAL STUDIES.
WHY DO SO MANY PEOPLE FINISH THE
TRIAL IN YOUR CASE?
>> IT HELPS TO DELIVER AN
INTERVENTION DURING RESIDENTIAL
TREATMENT BECAUSE PEOPLE ARE
THERE AND THEY'RE GOING TO DO
YOUR TREATMENT AND ADHERE TO
YOUR PROTOCOL.
IN TERMS OF POST TREATMENT
FOLLOW-UP RATES IN THE V.A. FOR
THOSE PEOPLE ON THE CALL WHO DO
V.A. RESEARCH YOU KNOW THAT THE
ELECTRONIC MEDICAL RECORDS IS A
GREAT RESOURCE AND WE'RE ABLE TO
TRACK PEOPLE.
THANK YOU TO ALL THE SPEAKERS
FROM THE FIRST SESSION.
I REALLY APPRECIATE THE CHANCE
TO MODERATE AND FEEL IS FREE TO
LEAVE THE QUESTIONS IN THE Q AND
A AND WE'LL GET THEM TO THE
SPEAKERS.
>>ON BEHALF OF THE ORGANIZERS,
I'D LIKE TO APOLOGIZE FOR THIS
TECHNICAL GLITCH AND HOPEFULLY
WE'LL RESOLVE ALL THE ISSUES
DURING THE BREAK.
THANK YOU VERY MUCH AND THANK
YOU TO ALL THE SPEAKERS OF THE
WONDERFUL PANEL AND WE STILL
HAVE UNANSWERED QUESTIONS SO WE
WILL BE GLAD TO REJOIN WITH OUR
SPEAKERS DURING THE NEXT WORKING
SESSION TOMORROW AT 3:45 AND NOW
WE'LL HAVE A 30-MINUTE BREAK
>>IT'S MY PLEASURE TO WELCOME
YOU BACK FROM THE BREAK.
FOR THOSE WHO GOT CUT OFF FROM
THE BREAK, ACCEPT OUR SINCERE
APOLOGIES FOR THE TECHNICAL
GLITCH.
HOPEFULLY THE REST OF THE
MEETING WILL GO SMOOTHLY.
"HOPE EVERYONE TOOK ADVANTAGE OF
THIS TIME TO STRETCH YOUR LEGS
AND GET NOURISHMENT.
WE HAVE A FULL AGENDA TODAY, WE
WILL GET STARTED.
NEXT IS LAURA WANDNER.
A PROGRAM DIRECTOR IN THE OFFICE
OF PAIN POLICY AND PLANNING AT
THE NATIONAL INSTITUTE OF
NEUROLOGICAL DISORDERS AND
STROKE.
SHE MANAGING PROGRAMS WITHIN THE
ACUTE TO CHRONIC PAIN PROGRAM
AND THE HELP TO END ADDICTION
LONG-TERM INITIATIVE OR HEAL
INITIATIVE AND SHE LEADS THE
HEAL COMMON DATA INITIATIVE AND
Dr. WANDA TREATS PAIN PATIENTS
AT THE MILITARY MEDICAL CENTER
AND SO PLEASE WELCOME Dr.
WANDNER.
>> WELCOME TO THE JUNIOR
INVESTIGATE POSTER SESSION THERE
WILL BE THREE INVESTIGATOR
SESSIONS DURING THE NIH
SYMPOSIUM AND THE TIMES OF THE
OTHER POSTER SESSIONS ARE LISTED
HERE ON THE SLIDE.
THE JUNIOR INVESTIGATORS WERE
SELECTED BY PROGRAM STAFF AND IN
ORDER TO QUALIFY AS A JUNIOR
INVESTIGATOR, WHO IS ELIGIBLE TO
PRESENT OF THIS SYMPOSIUM, ALL
OF THE PRE-RECORDED TALKS WILL
PLAY ONE AFTER ANOTHER AND THE
JUNIOR INVESTIGATORS WILL BE
AVAILABLE TO ANSWER QUESTIONS OF
THE END OF THE SESSION SO
ATTENDEES PLEASE SUBMIT YOUR
QUESTIONS OR THE JUNIOR
INVESTIGATORS IN THE Q&A BOX AND
THE MODERATORS OF THE POSTER
SESSIONS WILL REVIEW THE
QUESTIONS TO THE JUNIOR
INVESTIGATORS.
WITH THAT I'M HONORED THE
INTRODUCE THE FIRST GROUP OF
JUNIOR INVESTIGATORS.
THE FIRST SPEAKER IS A POSTDOC
TO BAL IRT FELLOW AT THE
NATIONAL CENTER OF COM TRAMENT
TREE AND INGRAY TIVE HEALTH AND
WILL PRESENT ON THE IMPACT OF
CRON I OBJECT PAIN CONDITIONS
AND AND Dr. TEEN POWELL THE
DIRECTOR OF BREAST ON COL TEE AT
CANCER CENTER AND WILL PRESENT
ON ACUPUNCTURE FOR CHEMOTHERAPY
INDUCED NUR ON AGENT' AND Dr.
JEFF' BOISSONEAULT FROM THE
DEPARTMENT OF CLINICAL AND
HEALTH SIGN SIGHEALTHPSYCHOLOGYY
DELDINE FROM THE JOINT GRADUATE
PROGRAM OF INSTITUTE AND THE
NATIONAL CENTER OF COPMENT TREE
AND INGRAY TIVE HEALTH AND HE
WILL PRESENT ON EVALUATING
POTENTIAL DISPARITIES AND
SOCIOCULTURAL FACTORS AND
ASSESSMENT AND Dr. MINHAUN AT
THE NATIONAL INSTITUTE OF DENTAL
AND CRANIAL FACIAL RESEARCH AND
WILL PRESENT ON VISUALIZATION.
WITH THAT, WE'LL GET STARTED
WITH THEPRE-RECORDED TALKS.
>> I'M A POSTBAC AT THE NCCIH
AND I'LL TALK ABOUT MENTAL
HEALTH OUTCOMES FOR DIFFERENT
CHRONIC PAIN CONDITIONS DURING
THE COVID-19 PANDEMIC.
SO, AS MANY OF YOU ARE AWARE THE
PANDEMIC HAS HAD EXPENSIVE
PHYSICAL AND PSYCHOSOCIAL
RAMIFICATIONS FOR THE GENERAL
PUBLIC AND STUDIES SHOW CHRONIC
PAIN PATIENT MAY BE VULNERABLE
TO THE IMPACT OF THE COVID-19
PANDEMIC.
EXISTING LITERATURE EXAMINING
CHRONIC PAIN PATIENTS, SHOW
CONFLICTING HEALTH AND PAIN
OUTCOMES SUGGESTING THAT THESE
OUTCOMES MAY ACTUALLY DEFER
BASED ON CHRONIC PAIN
CONDITIONS.
TO INVESTIGATE THIS WE WOULD
DISTRESS, LONELINESS AND ANXIETY
DIFFERENTIALLY AND WE ALSO HAVE
HYPOTHESIZED HAVE HAVING PAIN
CONDITIONS WOULD OUTCOME THESE
OUT COMES AND IT WAS 804 CHRONIC
PAIN PATIENTS FOCUS ON THE 481
PATIENTS AND WHO ENDORSED ONE
WON I CAN PAIN CONDITION ONLY.
MENTAL HEALTH OUTCOMES WERE
SELECTED OVER A SIX MONTH PERIOD
AND PAIN INTENSITY WAS COLLECTED
AT THE END OF THE STUDY AND
PRIOR MENTAL HEALTH STATUS WAS
EVALUATED AT BASELINE.
CHRONIC PAIN CONDITIONS WERE
CATEGORIZED USING THE
CLASSIFICATION OF DISEASE AND
BASED ON FREE RESPONSES INCLUDED
IN THE CHRONIC PAIN SCALE.
MOVING ON TO OUR RESULTS ARE
THEY SHOWED MAIN EFFECTS OF
CHRONIC PAIN CONDITIONS AND ONLY
TWO OUTCOMES ARE SHOWN IN THE
FIGURES ON THIS POSTER, SIMILAR
TRENDS WERE OBSERVED FOR ALL-OUT
COMES.
TO KEEP POST HOCKEY ANALYZE
REVEALED PARTICIPANTS OF CHRONIC
PRIMARY PAIN HAD GREATER LEVELS
OF DISTRESS DEPRESSION AND
SANITY AND LONELINESS AND THEN
THOSE WITH PATHIC PAIN, MUSCULAR
SKELETAL PAIN AND VISCERAL PAIN
AND THOSE WITH HEADACHE OR ORAL
FACIAL PAN HAD GREATER LEVELS OF
DISTRESS, LONELINESS THAN THOSE
WITH MESS CUE LALL SKELETAL
PAIN.
WE FOUND THAT PAIN INTENSITY AND
A NUMBER OF PAIN CONDITIONS OF
ANXIETY AND DISTRESS.
IT'S PAIN INTENSITY AND ON THE
FAR PLOT SHOWING THE ASSOCIATION
BETWEEN THE NUMBER OF PIN
CONDITIONS AND MAIN ANXIETY AND
HE WILL NOTE HERE, THAT THE
MAJORITY OF OUR PARTICIPANTS
HAVE EITHER ONE, TWO OR THREE
PAIN CONDITIONS WHERE WE SEE
THIS TREND.
SO THESE PROVIDE A POSSIBLE
EXPLANATION FOR THE VARIABILITY
WE SEE IN MENTAL HEALTH OUTCOMES
IN CHRONIC PAIN ANCIENT DURING N
MANAGEMENT MANY TO CONSIDER THE
UNIQUE NEEDS AND OUR STUDY
HAVE AND OUR MEASURES OF PAIN
ALSO ROW LIED ON THE
PARTICIPANTS RETROSPECTIVE
MEMORY OF PAIN, SO THAT'S
ANOTHER LIMITATION.
AND FOR FUTURE DIRECTIONS, WE'LL
INVESTIGATE HOW DIFFERENT
CHRONIC PAIN CONDITIONS
INFLUENCE VARIOUS OTHER MENTAL
HEALTH AND BEHAVIORAL OUTCOMES
AND WE'RE EXCITED TO CONTINUE
EXPLORING THESE QUESTIONS.
THANK YOU.
>> GOOD MORNING, MY NAME IS TIN
BELL AND THE TITLE OF OUR
PRESENTATION IS ACUPUNCTURE FOR
CHEMOTHERAPY INDUCED PERIPHERAL
NER ON AGENT' AND IT'S A PAINFUL
COMPLICATION OF NEURO TOXIC
CHEMOTHERAPY.
IT AFFECTS 68% OF CANCER
PATIENTS.
IT CAN LAST FOR YEARS AND
ASSOCIATE IN PAIN AND WORSEN
FUNCTION AND QUALITY OF LIFE.
CURRENTLY, THERE'S NO GOOD
TREATMENT FOR IT AND ACUPUNCTURE
IS A WIDELY USED, MINIMUMLY
INVASIVE AND SAFE TRADITIONAL
CHINESE MEDICINE TECHNIQUE
CURRENTLY AVAILABLE FOR PATIENTS
IN 75% OF ACADEMIC CANCER
CENTERS IN THE U.S.
EVEN THOUGH IT HAS BEEN
ESTABLISHED AS THE EFFECTIVE
TREATMENT FOR REDUCING CHRONIC
MUSCULAR SKELETAL PAIN IT'S
PATHIC PAIN HAS NOT BEEN
ESTABLISHED.
SO OUR GRO COMPLED A PILOT SHOWE
AMONG SOLID TUMOR PATIENTS WITH
MODERATE TO SEVERE CIPN
SYMPTOMS.
THE PATIENTS WERE RANDOMIZED TO
ELECTRO ACUPUNCTURE, SHAM
ACUPUNCTURE AND USUAL CARE FOR
EIGHT WEEKS AND THEN FOR FOUR
WEEKS.
SO AS YOU CAN SEE, AT THE END OF
WEEK EIGHT, THEY RECEIVED EIGHT
WEEKS INTERVENTION AND FOLLOW-UP
AT WEEK 12, WEEK 18 AND WEEK 24.
THE TRIAL IS ON GOING.
THE TARGET IS 250 PATIENTS.
RIGHT NOW, WE HAVE 39 PATIENTS.
THANKS FOR YOUR INTEREST.
>> HI, EVERYONE, I'VE JEFF
ASSISTANT PROFESSOR IN THE
DEPARTMENT OF CLINICAL AND
HEALTH PSYCHOLOGY AT THE
UNIVERSITY OF COLOR WHERE "HAVE
BEHAVIORAL HEALTH I'M GOING TO
TALK TO YOU TODAY ABOUT NEW
INSIGHTS INTO MECHANISMS
UNDERLINED ALCOHOL ANDAL GEESIA
AND WE HAVE COMBINED DATA FROM
TWO LABS IN THE CONTEXT OF
PAIN ALTHOUGH WE DO UNDERSTAND
FROM A LIMITED EXPERIMENTAL
LITERATURE ACUTE ALCOHOL INTAKE
DOES INCREASE PAIN THRESHOLD AND
REDUCE PAIN INTENSITY ACROSS
EXPERIMENTAL PAIN INDUCTION
MODALITIES IN PEOPLE WITHOUT
CHRONIC PAIN, THERE'S NEVER BEEN
STUDIES EXAMINING THE ACUTE
ANALOGY IN PEOPLE WITH CHRONIC
PAIN OR THE EXTENT TO WHICH
FACTORS OTHER THAN QUANTITIVE
CHANGES AND SENSORY FUNCTION BE
FROM PAIN THAT COMES WITH
CONSUMING ALCOHOL.
WE HAD A TOTAL SAMPLE OF 119
PEOPLE AND FROM TWO STUDIES AND
STUDY 2, 21 INDIVIDUALS OR 41%
HAD CHRONIC JAW PAIN.
WE ASSESSED PAIN THRESHOLD,
PAINEN TEES TEE AND PERCEIVED
RELIEF USING HEAT PAIN IN STUDY
ONE AND PRESSURE AT THE MASS IN
STUDY 2 AND WE EXAMINED CENTRAL
FACTORS CONTRIBUTING TO PAIN
RELIEF USING HIGHER AGGRESSION
WHICH WILL BE ON THE NEXT PAGE.
AS YOU CAN SEE FROM THE RESULTS,
WE DID FIND THAT CONSISTENT WITH
THE LITERATURE, ALCOHOL INTAKE
SIGNIFICANT INCREASE PAIN
THRESHOLD COMPARED TO PLACEBO.
THESE WERE LARGE EFFECTS.
AND HIGHER AGGRESSION DID
INDICATE THAT ALTHOUGH EXPECTED
OF ALCOHOL ANALOGY SEE YA AND IT
WOULD RELIEF PAIN -- AND PROBLEE
NOT SIGNIFICANTLY PREDICTORS.
FINALLY, ALTHOUGH WE FOUND THAT
ALCOHOL DID SIGNIFICANTLY REDUCE
PAIN INTENSITY, ESPECIALLY IN
STUDY 2, THESE EFFECTS DID NOT
DIFFER BETWEEN INDIVIDUALS WITH
AND WITHOUT CHRONIC JAW PAIN
ALTHOUGH PEOPLE WITH CHRONIC JAW
PAIN DID REPORT MORE PAIN.
SO TAKEN TOGETHER, THESE RESULTS
SUGGEST THAT ALCOHOL DOES HAVE
ANNAL GEESE I CAN EFFECTS IN TAB
LORI SETTINGS AND AND THEY HAVE
ANALGESIA AND INCLUDING
INTOXICATION.
THE MEASURES OF PAIN AND
THRESHOLD ARE INTENSITY PER SE.
>> PAIN ARE RAMPANT AND WOMEN
AND BLACK PATIENT EXPERIENCE
MORE PAIN, LESS PAIN ASSESSED
AND LESS PAIN IS TREATED IN THIS
GROUP TOO.
THIS LARGE LITERATURE IS ON
PURPOSE OF SUPPORT AND HOWEVER
THERE HAVE BEEN STUDIES LOOKING
AT THE ROLE OF PAIN EXPRESSION
AND RESULTS HAVE BEEN QUITE
INCONSISTENT AND THAT IS IN PART
BECAUSE THERE ARE NO DIVERSE
DATA OF PAIN.
OUR WORK IS DEVELOPING THOSE.
WE BELIEVE PARTICIPANTS RELATE
MORE PAIN WITH HIGHER INTENSITY
AND WHITE AND MEN TARGETS
COMPARED TO BLACK PERSPECTIVELY.
WE HAVE PARTICIPANTS WATCH VIDEO
OF PAIN SIMULATION AND BASED ON
THIS PERSON WAS IN PAIN OR NO
PAIN AND THEY VARY HOW INTENSE
THAT SENSATION WAS.
THEY ANSWERED A FEW QUESTIONS.
49% COMPLETED THIS TASK ON-LINE
OVER TELE CAST AND WE USED
MODELS AND TO ASSESS PAIN
COMPETITION AND INTENSITY.
THERE'S A PAIN CATEGORIZATION
AND WE SAW A TARGETED PATIENTS
BEING PAIN INCREASED THE ODDS OF
PAIN AND WE DO NOTE THE OVER ALL
PAIN WAS LOW AND ONLY 50% HERE
ON THIS GRAPH AND AS IT TARGETS
FABLE EXPRESSION TARGET TEE
INTEENSED THERE'S A GREATER
LIKELIHOOD OF THE PAIN AND WE
ALSO BIASES PRESENT SO WE SAW
THAT THEY ARE PAIN IN MEN
COMPARED TO AS WEL MEN.
WE DID SEE MODERATION HERE WITH
GREATER RACIAL BIAS ENDORSEMENT
IN GROWN LEADING TO GREATER ODDS
OF PAIN FOR WHITE TARGETS
COMPARED TO BLACK TARGETS 6789 E
TRIALERS HERE IN BLUE INCREASED
PERCEIVERS INTENSITY RATINGS.
WE SAW THERE WAS NO EFFECT ON
FACIAL EXPRESSION INTENSITY ON
RATINGS AND IT'S INTERESTING TO
US AND WE DID SEE BIAS FOR WHITE
TARGETS COMPARED TO BLACK
TARGETS.
WE DIDN'T SEE TARGET GENDER ON
PERCEIVED INTENSITY AND ONCE
AGAIN, WE DID SEE AN EFFECT OF
FOR WHITE COMPARED TO BLACK
TARGETS IT WAS A PAIN AND
RECEIVER PERCEIVED PAIN WITH A
TARGET RATED PAIN GREATER FACIAL
EXPRESSIONS AND FOR ANY OTHER
INTENSITY AND AND PAIN MORE IN
MEN AND AND WE BELIEVE IT'S
INCREASED TO OUTCOMES AND
ADDRESSING PROVIDING
INTERVENTIONS FOR RACIAL BIAS
WILL NEED TO DECREASE IN BIASES
FOR PAIN ASSESSMENTS.
>> I'M FROM NATIONAL INSTITUTE
OF DENTAL AND CRAN Y'ALL
RESEARCH AND TODAY I WOULD LIKE
TO TALK ABOUT REALIZATION OF
LABELED HERE WITH 6 TO
SIMULTANEOUSLY MONITOR NEURO
RESPONSE TO AND NOXIOUS STIMULI
INCLUDING MECHANICAL, THERMAL
AND ALL KINDS INDUCE DIFFERENT
ACTIVITIES TRANCE ANT AND SECOND
DEPENDING IS A KEY NEURO
INVOLVED IN PAIN SIGNALING AND
WE USE TRANS AGAIN WE CONDUCT F
IMAGING AND ACTIVITY ANYWAY AND
TO THE MICE THE TOTAL INTENSITY
INCREASED AS WELL AS THE NUMBER
OF AK TA RATE ISED NEURONS AND
WE ALSO FIND OUT THAT -- IT INCD
COMPARED WITH CONTROL.
THE DATA SHOWS INCREASING
ACTIVITY SHOWED SIGNIFICANT PAIN
PERCEPTIONS.
BETTER FACIAL INFORMATION PAIN
IN MICE COULD BE ALLEVIATED BY
BEHAVIOR TFP5.
AS YOU CAN SEE HERE, THE NEURO
RISK RESPONDS TO BOTH BRUSH AND
WITH WHITE IF SIGNIFICANTLY
DOUGH CREASED AFTER A
APPLICATION OF 5 AND
SPECIFICALLY DECREASED A TOTAL
COST OF INTENSITY IN RESPONSE
FOR STIMULI SO THE INHIBIT INHIR
INHIBITS AK TAIZATION OF SENSORY
NEURONS AND IT DEMONSTRATES WITH
A PATH WAY TO THERAPEUTICS.
THE ACTIVITY AT PARAMETER
SENSORY NEURONS COULD OFFER
BETTER AND SAFER TREATMENT FOR
FACIAL PAIN.
THANK YOU FOR YOUR ATTENTION.
>> THANK YOU FOR YOUR TALKS.
I'LL ASK YOU TO TURN ON YOUR
CAMERAS AND ATTENDEES FEEL FREE
TO SUBMIT QUESTIONS AND FOR THE
ATTENDEES TO ANSWER IN THE Q&A
SESSION AND YOU WILL GET STARTED
WITH SOME OF THE INITIAL
QUESTIONS THAT HAVE BEEN
SUBMITTED ALREADY.
SO THE FIRST QUESTION IS TO MYA,
ANY HYPOTISIESE WHY PRIMARY
CHRONIC PAIN HAS WORSE MENTAL
HEALTH OUTCOMES COMPARED TO
OTHER CHRONIC PAIN CONDITIONS?
>> YES, SO, ACTUALLY ONE OF THE
PAIN CONTINUES THAT IS
CATEGORIZED IN CHRONIC PRIMARY
PAIN IS FIBER HIGH GAL AND AS
MANY OF YOU NOW THE IDEOLOGY IS
UNKNOWN AND THERE'S NO LESION,
OR BLOOD WORK OR ANYTHING THAT
CAN BE DONE THAT COMES BACK AND
SAYS THIS IS FIBER MYALGIA AND
SO WE HYPOTHESIZE THAT SENSE OF
UNCERTAINTY AS WELL AS THE LACK
OF CONCRETE PLANNER AND
TREATMENT AROUND FIBER MYALGIA
MAY LEED TO ANXIETY AND
DEPRESSION AS OPPOSE TODAY SOME
OF THE OTHER CHRONIC CONDITIONS.
AND WE DID PREVIOUSLY RUN SOME
OTHER ANALYSIS USING A BROADER
CATEGORIZATION WHERE FIBER
MYALGIA WAS ITS OWN CATEGORY AND
WE DID SEE A DRASTIC DIFFERENCE
FOR THAT AS WELL.
>> GREAT THANK YOU SO MUCH FOR
THAT ANSWER.
I REALLY APPRECIATE IT.
THE NEXT QUESTION IS FOR YOU,
ARE CITATIONS OR WESTBOUND LINKS
AVAILABLE FOR YOUR WORK THAT YOU
CAN SHARE TODAY?
>> YEAH, I THINK THAT IT'S
ACTUALLY ON THE FIRST SLIDE.
SO, THE PILOT DATA WAS PUBLISHED
AT THE NETWORK AND I THINK IT
WAS LAST YEAR OR 2021 AND THAT
IS BASICALLY SUMMARIZING THE
RESULTS.
WE NOTICED THE ELECTRO
ACUPUNCTURE WAS BETTER THAN SHAM
ACUPUNCTURE IN TERMS OF REDUCING
PAIN BUT IN TERMS OF TINGLING
NUMBNESS, THEY ARE BOTH BETTER
WITH THE USUALLY CARE OF
ACTUALLY REAL ACUPUNCTURE IS NOT
THAT MUCH BETTER THAN SHAM
ACUPUNCTURE THAT'S WHY IT'S CIP
AND PAIN.
>> GREAT.
THANK YOU, THAT'S SO
INTERESTING, REALLY APPRECIATE
IT.
>> JEFF, THE NEXT QUESTION IS
FOR YOU.
THE QUESTIONS IS VERY
INTERESTING TALK AND THEY'RE NOT
SOCIOCULTURAL EFFECTS, ARE THERE
CURRENT EXPERIMENTAL MODEL TO
SIMULATE THE POTENTIAL SOCIAL
EFFECTS, TO REPLICATE LIKELY
SOCIAL SETTING FOR MANY DRINKING
IN REAL SETTINGS.
>> THAT'S A GOOD QUESTION, THERE
ARE NOT STUDIES OF ALCOHOL
ANALGESIA IN THE CONTEXT OF
SOCIAL INTERACTIONS.
THERE ARE STUDIES OF SOCIAL
EFFECTS OF DRINKING AND DIE ADDS
AND GROUPS IN LABORATORY
SETTINGS AND IN NATURALISTIC
SETTINGS AS WELL.
I HAVE NOT SEEN THEM COMBINED
WITH PAIN IN THAT WAY.
IT'S A REALLY INTERESTING THING
TO PURSUE MOVING FORWARD.
>> GREAT.
THANK YOU FOR ANSWERING THAT
QUESTION.
WE APPRECIATE IT.
>> Dr. DILDINE.
BASED ON YOUR RESULT, DO YOU
HAVE ANY RECOMMENDATIONS ON THE
TYPES OF INTERVENTIONS NEEDED TO
REDUCE BIASES WITHIN THE PAIN
MANAGEMENT FIELD?
>> THAT IS A BIG QUESTION.
[LAUGHTER]
>> IT'S A VERY BIG QUESTION.
>> I THINK ULTIMATELY I THINK
THERE'S BEEN A LOT OF GOOD DONE
IN RECENT YEARS AND THE FIRST
STEP IS AWARENESS ON THE
PROVIDER END BUT THERE ARE
POTENTIAL BIASES IN ASSESSMENTS.
NOT JUST RACIAL AND GENDER BUT
ALSO ACROSS ALL POPULATION AND
UNDER ASSESSING PAIN.
SO IT'S A BIG ONE TO CONSIDER.
AND I THINK BEYOND IT, THERE'S
BEEN SOME INITIAL WORKS SEEING
SOME BENEFITS AND PAINING THAT
CAN BE OFFICIAL IN TRAINING
MEDICAL WRITERS TO EMPHASIS AND
BE ABLE TO BETTER ASSESS THE
THEME AND SOMETHING THAT WE'RE
INTERESTED IN TRYING TO RUN THAT
CAN PROVIDE INTERVENTIONS WITH
FEEDBACK HELPING DOCTORS
UNDERSTAND HOW MUCH WE NEED
SOMEONE IN IF THAT WOULD IMPROVE
THEIR ABILITY TO SEE PAIN AND
THEN OBVIOUSLY WE SAW MODERATION
IN OUR TASK WITH RACIAL BIAS AND
THAT MAKING THOSE OUTCOMES
WORSE.
AND THAT CAN GET INTO SOME
CONTROVERSIAL TOPICS IN TERMS OF
WHAT IS THE BEST WAY TO DEAL
WITH THAT OBVIOUSLY, LOTS OF
ORGANIZATIONS HAVE TRIED TO DO
TRAININGS ON IMPLICIT BIAS AND
ALL OF THOSE THINGS AND I THINK
THEY'VE HAD KIND OF MINIMAL
POSITIVE OUTCOMES AT THIS POINT
SO I NEED RECOGNITION OF BIAS
IMPLICIT ON THEIR OWN AREN'T
MAKING THAT MUCH OF A DIFFERENCE
IN TERMS OF WORKFORCE CHANGE SO
THERE'S NO LOT FOR US TO
CONSIDER AND THERE'S A LOT TO BE
DONE IN THE FIELD AND BEYOND
THIS PAIN AND HEALTH AND HOW TO
MAKE INTERVENTIONS THAT ARE
ACTUALLY LONG LASTING AND CHANGE
BEHAVIORAL OUTCOMES.
>> IT'S SUCH AN IMPORTANT TOPIC
AND I'M GLAD TO SEE THAT YOU ARE
WORKING ON IT.
NEXT QUESTION, IS FOR Dr. HU.
DO THEY REGULATE ALL TIMES OF
PAIN, MECHANICAL, CHEMICAL AND
THERMAL OR ONLY CERTAIN TYPES OF
PAIN?
>> SO, THAT'S A GOOD QUESTION,
THANK YOU.
SO, IN MY EXPERIMENT I TRIED ALL
DIFFERENT KINDS OF STIMULATIONS
INCLUDING MECHANICAL, YEAH, AND
ALSO I TRIED HAIR STIMULATION
AND WHICH LIKE I ALSO CALL IT AS
PINCH SO REGULATED,.
I'D LIKE TO WELCOME YOU BACK,
AGAIN.
YOU STILL HAVE ANOTHER VERY
INTERESTING PANEL, WHICH FOCUSES
ON THE INTEGRATION OF
WHOLE-PERSON TOOLS AND
APPROACHES.
AND I'D LIKE TO INTRODUCE Dr.
LIN.
A PROGRAM DIRECTOR IN THE INTRA
GRAY TIVE NEUROSCIENCE BRANCH
WHERE HE MANAGED A PORTFOLIO ON
CLINICAL AND TRANCATIONAL
RESEARCH IN THE AREAS OF PAIN
AND HIV/AIDS.
THIS PARTICULAR AREA OF FOCUS
ARE ON CHRONIC PAIN AND -- ON
THE INTERACTIVE OF ADDICTIVE
DRUGS ON COGNITIVE FUNCTIONING
PATIENTS OF HIV/AIDS AND HE WAS
AN ANESTHESIOLOGIST AND A
PHYSICIAN SCIENTIST AND ENTA
GRAY TIVE HEALTH SO PLEASE
WELCOME Dr. LIN.
>>
>> HI, EVERYONE, GOOD AFTERNOON.
IT'S MY PLEASURE TO TEAM UP WITH
EXCELLENT INVESTIGATORS TO CARRY
OUT THIS PANEL AND THIS DECISION
WAS STARTED BY Dr. MARK PAIN
RESEARCH TO INTRODUCE AND
FOLLOWED BY Dr. LAUREN ATTARS
A PROCESAROUSAL OF THE FRONTAL X
AND THEN Dr. DANIEL BAUER WILL
TELL A PERSON ORIENTED APPROACH
AND ASSESSING CHRONIC CONDITIONS
WITH INDIVIDUALS DELIVERED BY
DAVID WILLIAMS.
Dr. MARK JASON IS A PROFESSOR
OF THE UNIVERSITY OF WASHINGTON.
HE IS THE CURRENT
EDITOR-IN-CHIEF FOR THE JOURNAL
OF PAIN WHO HAS EFFECT AND
MECHANISM FOR PAIN INTERVENTIONS
AND HE PUBLISHED OVER 600
ARTICLES IN PEER REVIEW
JOURNALISTS AND HIS CO-AUTHOR OF
OVER 40 BOOKS AND CHAPTERS AND
HAS ADDED BOOKS WITH THAT, Dr.
JANSSEN.
>> ARE THE SLIDES GOING TO BE UP
THERE THEY GO.
I'LL TALK AS Dr. ELLEN SAID
ABOUT THINKING OF PAIN RESEARCH
FROM THE WHOLE PERSON
PERSPECTIVE NEXT SLIDE, PLEASE.
AND I'M GOING TO TALK BRIEFLY
ABOUT THE STRENGTH AND
WEAKNESSES OF TRADITIONAL
APPROACHES TO STUDYING PAIN
TREATMENTS AND FOCUS ON LOOKING
ABOUT, TALKING ABOUT ALTERNATIVE
APPROACHES THAT ARE MORE PERSON
ORIENTED AND THE CENTRAL IDEA IS
THAT I'M THINKING THESE NEW
APPROACHES MIGHT BE MOST USEFUL
TO US FOR HELPING PEOPLE WITH
PAIN.
AND SO OF COURSE, THE
TRADITIONAL EXPLANATORY TRIAL
ARE TO TEST THE EFFICACY OF A
PARTICULAR TREATMENT AND TO DO
THAT WE DESIGN STUDIES THAT
CONTROL FOR THE VARIABLES EXCEPT
FOR THE TREATMENT CONDITION.
WE WANT TO REALLY MINIMIZE
PARTICIPANT HETEROGENEITY AND
LOOK AT SUBGROUPS OF PATIENTS
AND STANDARDIZE THE TREATMENTS
TO MAKE SURE THAT THEY'RE ALL
SIMILAR DONE IN THE SAME WAY AND
INCLUDE CONTROLLED CONDITIONS
THAT CONTROL FOR EVERYTHING
GIVEN IN THE ACTIVE TREATMENT WE
WANT TO TEST FOR WHAT WE THINK
IS THE ACTIVE COMPONENT, NEXT
SLIDE, PLEASE.
AND VERY STRONG APPROACH IT
MAXIMIZES POWER AND ALSO WE
ALMOST ALWAYS HAVE THIS ONE
OUTCOME VARIABLE BECAUSE WE WANT
TO MAXIMIZE AND WE JUST DO ONE
TEST, IS THIS STUDY TREATMENT
EFFECTIVE OR NOT?
NEXT SLIDE, PLEASE.
AND SO THIS APPROACH WE CAN DRAW
VERY FIRM CONCLUSIONS WHEN IT'S
DESIGNED REGARDING WHETHER OR
NOT THE TREATMENT IS EFFECTIVE.
AND THIS FOCUSES ON THE
TREATMENT.
AND SO IT'S A HIGHLY
STANDARDIZED TREATMENT USUALLY
IN THE STUT STUDIES.
IT'S NOT PROVIDED IN THE REAL
WORLD AND THE FOCUS IS ON THE
TREATMENT NOT THE PERSON OR EVEN
THE WHOLE PERSON.
NOT EVEN A PART OF THE PERSON,
IT'S ABOUT TREATMENT.
NEXT SLIDE, PLEASE.
AND IT ONLY LOOKS AT THE EFFECTS
FOR A HIGHLY SELECTED GROUP THAT
ARE NOT THE NORM SO NEXT SLIDE,
PLEASE.
AND SO, IN GENERAL, ALSO THE
EFFECTS TEND TO BE MODEST AT
BEST SO WE DON'T SEE OFTEN THESE
HUGE GROUND-BREAKING THESE ARE
POPULAR FOR GOOD REASON.
THEY ALLOW FOR TESTING OR
INTERVENTIONS IN REAL WORLD
CONDITIONS AND THEY ALLOW FOR
GREATER HETEROGENEITY IN THE
STUDY SAMPLE WHICH IS THE
PATIENTS THAT WE ACTUALLY SEE
AND IT ALSO GREATER
HETEROGENEITY IN THE TREATMENT
AS DELIVERED WHICH IS HOW
TREATMENTS ARE DELIVERED.
NEXT SLIDE, PLEASE.
AGAIN, THIS FAVORS EXTERNAL DATA
THAT WE CAN DRAW CONCLUSION 0
THESE TRIALS REGARDING TREATMENT
EFFECTS AS THAT YOU ARE
PROVIDED.
NEXT SLIDE, PLEASE, THE FOCUS IS
STILL ON THE TREATMENT AND NOT
THE PERSON.
AND AGAIN, THE EFFECTS TEND TO
BE EVEN MORE MODEST WHEN YOU ADD
THE NOISE OF A PRAGMATIC TRIAL
SO MY OWN BELIEVE IS WE DON'T
HAVE THE RESOURCES TO DESIGN
SUCH STUDIES FOR EVERY TREATMENT
WE WANT TO EXAM AND THEY MAY NOT
BE THE MOST EFFICIENT WAY FOR US
TO UNDERSTAND HOW TO DELIVER TO
PEOPLE SO THAT REDUCE OUR
SUFFERING AND A DIFFERENT
APPROACH IS TO EMBRACE
VARIABILITY RATHER THAN LIMIT IT
AND MEASURE THAT VARIABILITY AND
CONDUCT ANALYSIS TO UNDERSTAND
HOW THAT VARIABILITY IS RELATE
TODAY OUR OUTCOMES TO UNDERSTAND
TWO THINGS, WHY THE TREATMENT
WORKS AND FOR WHOM IT WORKS.
AND THIS SHIFTS THE FOCUS REALLY
TO THE PERSON.
NEXT SLIDE, PLEASE.
AND SO THREE EXAMPLES OF THESE
APPROACHES I WANT TO INTRODUCE
ARE THE MEDIATION, MODERATION
AND MODERATED MEDIATION
APPROACHES.
NEXT SLIDE, PLEASE.
AND IT MEDIATION ANALYSIS, NEXT
SLIDE, PLEASE, WE CAN ON AND A
ASSIGN AND WE CAN LOOK AT THE
EFFECTS OF THAT ON AN OUTCOME.
THIS IS A CLASSIC EXPLANATORY
TRIAL AND EFFICIENCY TRIAL.
NEXT SLIDE, PLEASE.
BUT WE CAN ALSO MEASURE AS PART
OF THAT, POTENTIAL MECHANISM
VARIABLES WE THINK THAT WILL
PLAIN HOW AND WHY THE TREATMENT
WORKS AND WE CAN COMPUTE THE
EFFECTS OF THE TREATMENT ON THAT
MECHANISM AND THEN STUDY HOW
CHANGES IN THAT MECHANISM EFFECT
OUTCOME AND THE CO EFFICIENT
THERE.
IT'S STRONG BECAUSE WE'RE ABLE
TO DRAW CONCLUSIONS ABOUT THE
TREATMENT ON THE MECHANISM
VARIABLE, NEXT SLIDE, PLEASE.
WE CAN UNDERSTAND THE EXTENT TO
WIT MECHANISM VARIABLE EXPLAINS
OUTCOMES AND IT CAN SUPPORT THIS
ANALYSIS IS NOT CAUSAL BUT IT
CAN HELP RULE OUT POTENTIAL
MECHANISMS THAT WE THINK ARE
VARIABLE AND YOU CUT AWAY FROM
WOOD ALL THE PIECES THAT AREN'T
A GUITAR AND WHAT IS LEFT, THE
MECHANISMS THAT ARE MOST LIKELY
PLAYING A ROLE AND WE CAN STUDY
MANY VARIABLE AND WE CAN STUT'
THE WHOLE PERSON BIOLOGICAL
VARIABLE, SOCIAL VARIABLE,
ENVIRONMENTAL VARIABLE AND WE
CAN UNDERSTAND ALL THE
MECHANISMS TA CAN PLAY A ROLE
HERE.
NEXT SLIDE, PLEASE.
SO AGAIN, THIS IS UNDERSTANDING
WHY THE TREATMENT WORKS AND IT'S
NOT ABOUT IF IT DOESN'T WORK BUT
WHY.
AND ANOTHER APPROACH IS A
MODERATION ANALYSIS.
AND THIS CASE AGAIN WE CAN
DESIGN A STUDY COULD CAM PAIR
TWO TREATMENTS AS A PRAGMATIC
TRIAL WE PRESSURE A PERSON
VARIABLES TO UNDERSTAND WHAT IT
IS ABOUT THE PERSON THAT
INTERACTS WITH THIS OUTCOMES AND
TO EXPLAIN HOW, FOR WHOM THE
TREATMENT WORKS.
BECAUSE WE MEASURE THE PERSON
VARIABLES THEY HAPPEN BEFORE THE
TREATMENT IS GIVEN WE GET
PRECEDENT SO IT'S A PREDICTIVE
ANALYSIS.
NEXT SLIDE, PLEASE.
SO YOU CAN ALSO LIKE WITH
MEDIATION CAN STUDY A WHOLE
VARIETY OF VARIABLES AND IT'S
BEST TO STUDY WHEN THEY'RE
THEORETICALLY RELATED AND WE
HAVE A THEORY TO EXPLAIN AND
TEST ABOUT WHY THEY MIGHT BE
MODERATORS.
AND AGAIN TO UNDERSTAND FOR WHOM
TREATMENT WORKS AND AGAIN THE
FOCUS IS ON THE PERSON AND HOW
THAT PERSON INTERACTS WITH
TREATMENT.
AND THEN I WANT TO TALK ABOUT
MODERATED MEDIATION AND IN THIS
CASE, THEY HAVE SIMILAR WAYS OF
A VARIETY OF MEDIATORS.
BUT THEN LOOK AT WHAT IT IS
ABOUT THE PERSON THAT MIGHT
EXPLAIN HOW THESE DIFFERENT
TREATMENTS WORK.
SO AN POXEL OF A EXAMPLE OF EES
WHO MIGHT SPEND BEST TO WHAT
TREATMENT AND PREDICTS THE
PARTICULAR MEDIATORS AND IT'S A
HIP NOD I CAN TO PAIN OUTREACH
AND IT'S TO UNDERSTAND IN THIS
CASE THE PERSON FACTORS THAT
IMPACT THE EXPLANATORY
VARIABLES, DIFFERENT PEOPLE
MIGHT RESPOND TO DIFFERENT
TREATMENTS FOR DIFFERENT REASONS
AND THIS ANALYSIS ALLOWS FOR
THAT.
THE PRIMARY CONCERN RAISED BY
REVIEWERS OF GRANTS AND EDITORS
OF JOURNALS, IS THAT WHEN YOU
EXAMINE ALL OF THESE PERSON
VARIABLES, YOU ARE FINDING ONES
THAT ARE SIGNIFICANT BUT THAT
AREN'T IN FACT SIGNIFICANT IN
POPULATION.
SO, TO ADDRESS THIS FOUR
REVIEWERS AND EDITORS OF GRANTS
AND EDITORS OF ARTICLES, I
USUALLY SELECT JUST ONE OR A
SMALL SUBSET OF PRIMARY
VARIABLES TO LOOK AT AND MAKE
HYPOTHESIS ABOUT THAT AND MAKE
THE OTHERS EXPLANATORY SECONDARY
BUT MY VIEW IS THAT WE ARE TOO
DEPENDING ON THE P-VALUE THAT
IS, WE DON'T THINK WE SHOULD USE
ONE STUDY TO TEST ONE QUESTION
USING ALL THE POWER BUT RATHER
TO USE OUR RESEARCH TO
UNDERSTAND EFFECT SIZES AND LOOK
AT MULTIPLE STUDIES OVER TIME TO
SEE WHAT THE TRUE EFFECT SIZES
ARE ON AVERAGE SO, I'M HOPING
THAT AS A FIELD WE'LL MOVE FROM
GOALS OF EXAMINING THE
RELIABILITY OF THE SINGLE EFFECT
PROVIDING RELIABLE ESTIMATES OF
MANY EFFECTS, THE WHOLE PERSON.
NEXT SLIDE, PLEASE.
I THINK WE'VE BEEN USING
RIGOROUSLY DESIGNED EXPLANATORY
TRIALS FOR DECADES AND THEY'RE
VERY STRONG TO DEFINITIVELY
ANSWER ONE QUESTION -- DOES THE
TREATMENT WORK?
BUT, I HAVE A CONCERN THAT THE
FONDINGS MAY BE OF LIMITED
PRACTICAL USE BECAUSE I THINK WE
CAN CONSIDER PUTTING THE WHOLE
PERSON BACK INTO OUR CLINICAL
RESEARCH AND ALLOWING GREATER
VARIABILITY AND EMBRACE
VARIABILITY LIKE THERE IS IN THE
REAL WORLD AND RIGOROUSLY
MEASURE THAT VARIABILITY AND
ASSESS KEY BIOLOGICAL FACTORS
AND AT BASELINE TREATMENT OF
POST TREATMENT AND THEN CONDUCT
ANALYSIS TO UNDERSTAND THE
VARIABLE THAT'S EXPLAIN WHY
TREATMENTS WORK AND FOR WHOM
THEY WORK.
AND, CONSIDER MODERATED
MEDIATION TO UNDERSTAND FOR WHOM
DIFFERENT MEDIATORS PLAY A ROLE.
AND THAT IS IT.
THANK YOU VERY MUCH.
I'M LOOKING FORWARD TO HEARING
Dr. ATLAS' TALK ABOUT
VENTROMEDIAL PREFRONTAL CORTEX
BECAUSE WE ARE STUDYING INTERIOR
ACTIVITY IN THE LEFT ANTERIOR
BECAUSE WE'RE FINDING A LOT OF
ACTIVITY THERE IS GOOD IF YOU
WANT TO BE COGNITIVE THERAPY BUT
CAN GET IN THE WAY OF HYPNOSIS
SO WE'RE TRYING TO UNDERSTAND
THIS FOR PRECISION MEDICINE SO
I'M LOOKING FORWARD TO HEARING
Dr. ATLAS, THANK YOU, VERY
MUCH.
>> THANK YOU VERY MUCH.
THANK YOU FOR THAT SET UP WITH
MEDIATION ANALYSIS BECAUSE I
ACTUALLY HAVE MODERATED
MEDIATION IN THIS TALK.
SO, I AM A TEN YOUR TRACK
INVESTIGATORS WITH AFFECT OF
NEUROSCIENCE IN PAIN IN THE
NATIONAL CENTER FOR COMMENT TREE
ENTA GRAY TIVE HEALTH AND OUR
LAB IS INTERESTED IN MECHANISMS
OF HOW EXPECTATIONS SHAPE PAIN.
WE USED AS A GUIDED MODEL IN
ORDER TO UNDERSTAND HOW THE
PSYCHOSOCIAL CONTEXT SURROUNDING
TREATMENT INFLUENCES CLINICAL
OUTCOMES AND BECAUSE PLACEBO
EFFECTS ARE LARGEST IN PAIN AND
SA DETECTIVE OUTCOMES THIS IS A
REALLY MOTIVATING FACTOR FOR WHY
WE SHOULD STUDY PLACEBO TO
UNDERSTAND HOW PSYCHOLOGICAL
FACTORS CAN DIRECTLY AFFECT
PATIENT OUTCOMES.
SO, OUR APPROACH IS TO USE BASIC
SCIENCE TO ISOLATE COMPONENT
MECHANISMS AND DO CLINICAL
EXTENSIONS AND WE CAN TEST
WHETHER THEY'RE ALTERED IN
PATIENT POPULATION AND OUR GOAL
IS TO INTEGRATE THESE
PSYCHOLOGICAL FACTORS ALONGSIDE
TREATMENT TO MAXIMIZE PATIENT
OUTCOMES.
NEXT SLIDE.
SO OUR APPROACH YOU CAN CLICK
THROW TIMES.
IS BASICALLY TO MANIPULATE THE
STIMULUS INTENSITY,
PSYCHOLOGICAL FACTORS ASK
CONTEXT SURROUNDING TREATMENT TO
MEASURE A WHOLE HOST OF
DIFFERENT PARALLEL MEASURES
RELATED TO PAIN INCLUDING
REPORTS ON RESPONSES AND
MEDIATORS AND TO UNDERSTAND HOW
THESE RESPONSES ARE MODERATED BY
THINGS LIKE PATIENT DYING KNOW
PAY DIAGNOSIS, TODAYI'LL TALK AE
OF THIS WHOLE-PERSON HEALTH,
I'LL TALK ABOUT THE RELATIONSHIP
BETWEENDEDUCK TIVE PAIN HOW IT S
PAIN EXPECTANCY AND AROUSAL.
PAIN IS AN UNPLEASANT SENSORY
AND EMOTIONAL EXPERIENCE WITH
TISSUE DAMAGE AND IT IS DISTINCT
FROM THOSE THE NEURAL PROCESS OF
ENCODING STIMULI.
PAIN CAN GO FURTHER DIVIDED INTO
IT'S SENSORY OR DIS CRIMINAL NA
TIVE COMPONENT AND IT OF COURSE
TIVE IN MOTIVATIONAL, PAIN
UNPLEASANT.
SO, BASICALLY, WITH THIS
DISTINCTION, THE IDEA IS IF WE
CAN UNDERSTAND HOW PSYCHOLOGICAL
FACTORS WERE ALONG THIS PATHWAY
WITH NO SUSPENSION TO PAIN DO
THEY HAVE THEIR IMPACT.
AND WE'VE IDENTIFIED GRADIENTS
ALONG THE CINGULAR LET RELATED
TO NO SUN EXCEPTION TO PAIN OR
THAT FORMALLY MEDIATE THE LINK
BETWEEN PAIN.
SO, MY POSTDOC WAS INTERESTED IN
TESTING WHETHER AUTO NOM I CAN
ACTIVITY IS MORE RELATED TO NO
SUN ACCEPTION THAN PAIN AND HOW
PAIN SPEEXPERIENCE TO PAIN.
SO, DON DEVELOPED A TWO-STEP
PAIN ASSESSMENT TASK WHERE
INDIVIDUALS CAME INTO THE LAB
AND EXPERIENCED ACUTE PAIN WITH
A THERMO DEVICE ON THE LEFT
WHICH HEATS UP TO DIFFERENT
TEMPERATURES.
AND EVERYBODY RECEIVED A WHOLE
DIFFERENT RANGE OF TEMPERATURES
ON EACH TRIAL THEY WOULD TELL US
IF IT WAS PAINFUL OR NOT, CLICK.
AND THEN HOW PAINFUL IT WAS.
OR HOW INTENSE IT WAS IF IT
WASN'T PAINFUL.
IN IN ADDITION WE MEASURED
STAYING CONNECTED AS WELL AS
PUPIL DILATION.
WHAT WE FOUND IS THAT WHAT WE
SEE WHEN INDIVIDUALS AND ON THE
WHY EXAMINATION IS AND THE HEAT
AND IT COMES ON SLOWLY AND IT'S
AT MAXIMUM AND YOU CAN SEE
THERE'S AN EFFECT OF
TEMPERATURES ON A TRIAL WHICH
SUBJECTS CALLED IT NOT PAINFUL
WHEN PEOPLE CALL THOSE
TEMPERATURES PAINFUL.
AND WHAT WE FOUND IS EVIDENCE OF
MODERATED MEDIATION WHERE WHAT
WE CAN SEE IS ON THE TRIALS ONE
SUBJECT IS CALLED THE
TEMPERATURE NOT PAINFUL AND THEN
IT DROVE THE SKIN CONDITION AND
ON THE TRIALS WHEN INDIVIDUALS
CALLED IT PAINFUL, WE FOUND THAT
IT AFFECTS THE TEMPERATURE ON
SKIN WERE FULLY MEDIATED BY THE
SUBJECTIVE PAIN READING SO
REALLY WHEN IT'S PAINFUL, IT'S
HOW PAINFUL IT IS THAT IS
DRIVING YOUR BODY'S RESPONSE
WHEREAS IF YOU CHARACTER EYES IT
AS NOT PAINFUL IT'S JUST THE
INPUT THAT MATTERS.
YOU CAN CLICK THIS THREE TIMES.
WHAT WE FIND IS THAT THE NERVOUS
SYSTEM RESPONSES TO NOXIOUS
STIMULI ARE MEDIATED BY
EXPERIENCED PAIN AND I SWEAR
THAT Dr. JENSON AND I DID NOT
HAVE A SET UP YOU WOULD TEACH
YOU UP THE BACKGROUND ABOUT
THIS.
WE REPLICATED THIS IN A SEPARATE
PAIN ASSESSMENT TEST AS WELL AS
THE PUPIL DILATION AND IT SHOWS
LABELING THE STIMULUS AS
PAINFUL, SHAPES HOW YOUR BODY
RESPONDS TO IT.
AS A PSYCHOLOGIST, THIS IS
ACTUALLY NOT TOO SURPRISING.
THIS IS CONSISTENT WITH THE
APPRAISAL THEORY OF MOTION AND
THE IDEA HOW WE APPRAISE EVENTS
IN THE ENVIRONMENT CAN SHAPE HOW
OUR BODY RESPONDS TO THEM.
NOW AM I ALLOWED THIS MOVING
FORWARD TO LOOK AT THIS KIND OF
DECISION THAT IS MAKING PROCESS
SURROUNDING PAIN AND TO
UNDERSTAND HOW THIS CAN DRIVE
OUR BODY'S RESPONSES.
IT'S REALLY THE CORNER STONE OF
WHAT IS CALLED THIS MARKET AND
HYPOTHESIS THAT WAS INTRODUCED
IN 1994 AND IT'S THOUGHT THAT
THE VMPSC AND THE AND IN ORANGE
IS CRITICAL LINKING EMOTION
AROUND AROUSAL AND
DECISION-MAKING IT COMES FROM
BILATERAL LESIONS AND PREFRONTAL
CORTEX WHERE THEY FIND, YOU CAN
CLICK, THAT INDIVIDUALS WITH
LESIONS AND SHOW DEFICITS IN
DECISION-MAKING AND IN SHOW
BLUNTING THE SKIN CONDUCTANTS
WHERE THEY MAKE DIFFERENT
DECISIONS ABOUT TRYING TO FIGURE
OUT WHAT IS THE OPTIMAL DECK.
AND SO BASICALLY, THEY DON'T
SHOW SCR IN RESPONSE TO A
POTENTIALLY ADVANTAGEOUS DECK
AND IT'S THOUGHT THAT IN TURN
EXPLAINS WHY THEY SHOW LESS
OPTIMAL BEHAVIOR ON THIS TASK.
SO THE IDEA IS THAT THE VENTURE
PREFRONTAL CORTEX ACTS AS A
REPOSITORY BETWEEN REGULATORY
STATES SO ON THE LEFT,
BASICALLY, IS A LOOP WHERE THE
VMPFC GETS IMPACT THROUGH THE
BODY AS WE GO THROUGH EMOTIONAL
EXPERIENCE AND ON THE RIGHT IT'S
OVER TIME, THE VMPSD CAN USE
THAT LEARNING TO GUIDE FUTURE
DECISIONS.
SO OUR HYPOTHESIS, BEGIN THIS
LINK BETWEEN AUTO NOM I CAN
RESPONSES AND PAIN IS THAT
INDIVIDUALS WITH VMPS LESIONS
WILL SHOW ALTERED PAIN ACTIVITY
HOWEVER IT'S NOT THAT SIMPLE,
CLICK.
IT'S ALSO KNOWN TO BE A HUB FOR
EXPECTATIONS, VALUE AND
EFFECTIVE MEANING.
SO OVER THE PAST 25 YEARS OR SO
THERE'S BEEN SO MANY DIFFERENT
REVIEWS ON THE ROLE OF THE OSD
BUT THEY ALL CONVERGE ON THE
IDEA OF THIS REGISTER ON IS
CRITICAL FOR PREDICTION AND
GENERATING RULES FROM
EXPERIENCE.
AND AS I MENTIONED EARLIER AND
WE HEARD EARLIER TODAY,
EXPECTATIONS DIRECTLY AFFECT
PAIN IN THE FORM OF PLACEBO
EFFECTS.
SO THE IDEA IS, BY LEARNING FROM
INTERACTIONS OF PHYSICIAN, THE
CLINICAL CONTEXT, OUTCOMES, WE
DEVELOP EXPECTATIONS WHICH CAN
SHAPE OUR BODIES' RESPONSES AND
WE SHOWED THAT RESPONSES TO PAIN
PREDICTIVE ISSUES AND THE TRY
EIGHT UM PREDICTS RESPONSES IN
PAIN PROCESSING MEDIATORS THAT
IN TURN DRIVES SUBJECTIVE PAIN.
OUR SECOND HYPOTHESIS, THE
LESIONS WOULD REDUCE THE IMPACT
OF EXPECTATIONS ON PAIN.
AND FINALLY, MORE BROADLY,
THERE'S ALSO A POSSIBILITY THAT
THE MPSD MIGHT IMPACT PAIN ON
PLEASANTNESS IN GENERAL SO IT'S
BEEN KNOWN FOR A LONG TIME, IT
CAN ALTER PAIN ON PLEASANTNESS
IN TERMS OF PAIN EFFECT AND
STUDIES OF NEUROIMAGING SHOW
THAT PAIN RELIEF, WHICH IS -- WE
COLLABORATED TO MEASURE THE
EFFECTS OF VMPS LESIONS ON PAIN
MODULATION.
WE MEASURED RESPONSES IN FIVE
PATIENTS WITH BILATERAL NEWER
SURGICAL LESIONS AS A RESULT SO
THEY HAD TISSUE REMOVED SO WE
KNOW THAT IT'S BILATERAL AND CAN
FIND TWO PREFRONTAL CORTEX AND
NO OTHER REGIONS THAT ARE
EFFECTS THE PAIN.
AND WE COMPARED THEM TO 20
HEALTHY INDIVIDUALS AND
EVERYBODY WENT THROUGH THIS
ADAPTIVE STAIRCASE CALIBRATION
TASK THAT I WON'T DESCRIBE IN
DETAIL BUT BASICALLY THROUGH AN
ITERATIVE TASK SIMILAR TO
EARLIER, WE CAN FIND EACH
INDIVIDUAL'S PAIN SENSITIVITY
AND THE TEMPERATURES THAT HAVE
ASSOCIATED PAIN THRESHOLD AND
TOLERANCE.
AND WE HAD PEOPLE RATE PAIN
INTENSITY BUT ALSO
UNPLEASANTNESS BECAUSE OF THIS
HYPOTHESIS AND HERE IS AN
EXAMPLE INDIVIDUAL IN THE LESION
GROUP, CLICK.
WE FOUND THAT VMPS LEGION DID
NOT IMPACT PAIN SENSITIVITY OR
UNPLEASANTNESS SO YOU CAN SEE ON
THE Y AXIS IS INTENSITY OR PAIN
AND UNPLEASANTNESS AND ON THE X
AXIS IS TEMPERATURE AND THE
PATIENTS' IN BLUE SHOW VERY
SIMILAR RESPONSES TO THE HEALTHY
CONTROLS.
SO, YOU CAN SKIP THIS.
SO TO TEST OUR FIRST HYPOTHESIS
WE FOUND THAT IN FACT THERE WAS
NO IMPACT OF THE LESIONS ON OVER
ALL PAIN SENSITIVITY.
AND OUR NEXT TEST WAS WHETHER
THE VMPFC HAS EFFECTED ON PAIN.
AND BASICALLY WHAT WE DID IS WE
HAD INDIVIDUALS UNDERGO A A TASK
IN WHICH THEY WERE INSTRUCTED
THEY WOULD PREDICT LOWER HIGH P
AND THEY WENT THROUGH
CONDITIONING WHERE IT WAS
REINFORCED WITH A LOWER
TEMPERATURE AND HIGH TEMPERATURE
AND DURING A TEST PHASE,
INDIVIDUALS RECEIVED SIM YOU LIE
CALIBRATED TO MODERATE PAIN.
AND WHAT WE'VE SHOWN ACROSS MANY
DIFFERENT PAPERS IS THAT WHEN
THE SAME MEDIUM TEMPERATURES IS
PROCEEDED BY LOW PAIN CUES IN
YELLOW RELATIVE TO HIGH PAIN
CUES IN RED, INDIVIDUALS REPORT
LESS PAIN AND CLICK.
SO WE MEASURED BOTH PAIN RATINGS
AND AUTO NOM I CAN RESPONSES IN
RESPONSE TO NEED MEDIUM
TEMPERATURE STIMULI AND SO WE
CAN CLICK AGAIN.
AND THESE WERE SUSTAINED AND
GREW OVER TIME AND SO BASICALLY,
INDIVIDUALS WITH VMPS LESIONS
EXPECTED MORE PAIN WITH A PIE
PAIN CUE AND THEN INDIVIDUALS
WITHOUT LESIONS AND THAT WAS
BASICALLY DRIVEN BY LESS
UNLEARNING WHEN WE INTRODUCED
THE MEDIUM HEAT TRIALS.
SO, BASICALLY WHAT WE FIND IS
THAT THE GROUPS DID DIFFER IN
TERMS OF EXPECTANCY WHERE
PATIENTS EXPECTED LARGER
DIFFERENCES AS A FUNCTION.
WE TESTED HOW THIS MODULATED
MEDIUM HEAT PAIN.
AND FOCUSING SPECIFICALLY ON
PAIN AND UNPLEASANTNESS WE SEE
THAT RESPONSES TO LOW INTENSITY
STIMULI IN YELLOW AND HIGH
INTENSIVE STIMULI IN RED ARE THE
SAME BETWEEN THE GROUPS SHOWING
THAT PAIN SENSATION IS NOT
ALTERED, AND WHEN WE LOOK AT
RESPONSES TO THE CRITICAL MEDIUM
HEAT TRIALS, CLICK ONCE MORE, WE
FIND PATIENTS WITH LESIONS
REPORT LARGER DIFFERENCES AS A
FUNCTION OF CUE SO BASICALLY
THEY'RE REPORTING HIGHER HEAT.
SO, THIS SUGGESTS THAT THE
LESIONS ACTUALLY ENHANCE
EXPECTANCY EFFECTS ON PAIN.
WE TEST TESTED THIS MARKER.
WHAT WE FOUND IS THAT VMPFC
LESIONS DID HAVE OUGHT KNOT I
CAN RESPONSES BUT NOT THE PAIN
PREDICTIVE CUES.
WHEN WE NORMALIZE THAT AND
ACCOUNT FOR THE FACTS THAT
PATIENTS ARE DOWN OVER ALL THEY
SHOW HIGHER WHEN MEDIUM HEAT IS
PROCEEDED BY THE HIGH PAIN CUE
RELATIVE TO THE LOW PAIN CUE.
CLICK AGAIN.
WE CAN SEE THIS ALSO WHEN WE
LOOK AT THE RAW RESPONSES AND SO
YOU CAN SEE THIS IS MEDIUM HEAT
PROCEEDED BY THE HIGH IN ORANGE
AND THE LOW PAIN CUE IN GREN AND
YOU CAN SEE BOTH GROUPS ARE
SHOWING ELEVATED SKIN CON
ACCEPTANCE A PAIN PREDICTIVE CUE
AND THE CORRESPONDENCE BETWEEN
AROUSAL AND IT'S INTACT WITH
PATIENTS.
THAT THE LESIONS ENHANCE THE
EFFECTS ON PAIN AND DIFFERENCES
IN EXPECTATIONS ARE PRIOR TO
LEARNING BASED ON INSTRUCTION
AND WE SEE STRONGEST EFFECTS AND
PERCEIVED UNPLEASANTNESS AND
THERE'S NO DIFFERENCE IN THE
EFFECTS ON SKIN CONDUCT ANTS
WHICH IS CONSISTENT --
INCONSISTENT WITH A MARKER
HYPOTHESIS.
AND SO OUR HYPOTHESIS GOING
FORWARD IS THAT THIS MIGHT MEAN
THAT THESE PATIENTS ARE RELYING
MORE ON THE INSTRUCTIONS ABOUT
UPCOMING PAIN AND LESSON THE
ACTUAL LEARNING.
AND WE KNOW FROM OUR OTHER WORK
THAT INSTRUCTIONS CAN LEAD TO
MODULATION THROUGH MECHANISMS
SUCH AS ENHANCING RESPONSES IN
THE PREFRONTAL CORTEX THAT MIGHT
BY PASS THE PREFRONTAL CORTEX TO
ENGAGE SUB CORTICAL CIRCUITS
THAT EFFECT AROUSAL.
OVER ALL, PAIN IS A
DECISION-MAKING PROCESS THAT IS
FACTORS AND MULTIPLE FACTORS
DRIVE ON RESPONSES TO NOXIOUS
STIMULI AND WE HAVE A BASIC
RESPONSE TO THE STIMULUS BUT
THAT CAN BE A LOT ALTERED BY CS
AND THE LESIONS ENHANCE
EXPECTANCY EFFECTS ON PAIN AND
AUTONOMIC RESPONSES TO CUES ARE
MEDIATED OUT OF THE VMPFC SO
WITH THAT I WANT TO ACKNOWLEDGE
MY COLLABORATORS AND MY FORMER
POSTDOC AND THANK YOU FOR IN
INVITING ME TO PARTICIPATE
TODAY.
THE NEXT SPEAKER IS DANIEL BAUER
WHO WILL BE TALKING ABOUT A
PERSON ORIENTED APPROACH TO
RESEARCH ON PAIN AND PAIN
MANAGEMENT.
>> THANK YOU SO MUCH.
I WANT TO SAY, I'M REALLY
PLEASED TO BE HERE AND I
APPRECIATE THE INVITATION TO
GIVE A TALK HERE.
I AM NOT A PAIN RESEARCHER
MYSELF.
I'M MORE OF A METHODOLOGIST
FOCUSED ON DEVELOPMENTAL
METHODOLOGY BUT I THINK THAT CAN
BE AN ADVANTAGE BECAUSE
SOMETIMES THE WAY RESEARCH MOVES
FORWARD IS BY DIFFERENT SUB
FIELDS INTERFACING WITH ONE
ANOTHER AND DRAWING IDEAS FROM
ONE ANOTHER SO I WILL INTRODUCE
YOU TO AN IDEA THAT IS QUITE
PREVALENT IN DEVELOPMENTAL
SCIENCE AND HAS POTENTIAL TO
OFFER A PERSON ORIENTED
VIEWPOINT TO RESEARCH ON PAIN
AND PAIN MANAGEMENT.
AND SO IN THAT WAY IT BUILDS ON
THE PREVIOUS PRESENTATIONS AND
PARTICULARLY THE ARGUMENT THAT
Dr. JENSEN MADE THAT WE NEED
TO FOCUS MORE ON THE PERSON.
THE PERSON AS A WHOLE AS OPPOSED
TO VARIABLES OR TREATMENTS AS
MECHANISMS IN PARTICULAR.
SO, I'M GOING TO BEGIN BY
TELLING WHAT YOU IS A PERSON
ORIENTED APPROACH.
AT LEAST AS DEFINED IN MY NECK
OF THE WOODS AND WE'LL TALK A
LITTLE BIT ABOUT SOME QUANTITIVE
METHODS CAN BE USED TO OBTAIN A
PERSON ORIENTED KIND OF RESEARCH
ORIENTATION AND LATE IN CLASS
AND PRO VILE ANALYSIS ARE WHO I
FOCUS ON.
I'LL GIVE YOU AN APPLICATION
FROM MY AREA, DEVELOPMENTAL
PSYCHOLOGY AND I'LL TALK ABOUT
POTENTIAL APPLICATIONS IN THE
WHOLE PERSON PAIN RESEARCH AND
CLOSE OUT WITH SOME PROS AND
CONS OF THIS APPROACH.
SO, THE PERSON ORIENTED APPROACH
COMES FROM DEVELOPMENTAL SYSTEMS
THEORY AND HERE A LITTLE QUOTE
ON THIS A DEVELOPMENTAL SYSTEM
IS COMPRISED OF MULTIPLE LEVELS,
BIOLOGICAL, PSYCHOLOGICAL,
SOCIOLOGICAL, CULTURAL THAT ARE
FUSED TO CREATE A FUNCTIONING
WHOLISM, THIS FUSE REFLECTS HIGH
LEVELS OF INTERACTION WITHIN AND
BETWEEN LEVELS OF THE SYSTEM AND
SO THERE ARE A COUPLE THINGS
HERE THAT I THINK ARE USEFUL TO
HIGHLIGHT.
THIS IDEA THAT THINGS ARE
INFUSED AND WE HAVE HIGH LEVELS
OF INTERACTIONS AND THAT WE'RE
TRYING TO CAPTURE A FUNCTIONING
WHOLISM.
THESE ARE THE CRITICAL IDEAS OF
THE PERSON O ORIENTED APPROACH.
IT'S THE THERAPY OF GILBERT.
HE WAS AN ANIMAL RESEARCHER AND
INTERESTED DOES DEVELOPMENT TAKE
PLACE.
WHAT ARE THE DIFFERENT FACTORS
THAT CONTRIBUTE TO INDIVIDUAL
DEVELOPMENT AND HE ARTICULATED
THE LEVELS OF THE SYSTEM THAT HE
WAS INTERESTED IN AND HE SAID
WELL OVER THE COURSE OF
DEVELOPMENT, THERE ARE THESE
INTERACTIONS AND CO ACTIONS THAT
OCCUR, THIS BY-DIRECTIONAL
EFFECTS OF THESE SYSTEMS
INTERACTING WITH ONE ANOTHER TO
PUSH IT FORWARD SO THERE'S A
MULTI LEVEL PERSPECTIVE AND IT'S
AIN'TER ACTIVE AND WHOA SAY CO
ACTIVE IT'S NIAAA NATURE AND AND
AND THAT WE FIRST KNOW AND
LEARN.
WE THINK ABOUT NOVA AND WHAT
WE'RE FOCUSED ON THERE IS
VARIABLES, RIGHT.
WHAT IS THE EFFECT OF A GIVEN
VARIABLE ON AN OUTCOME AND IN
THAT SENSE, IT'S RATHER WE'RE
NOT LOOKING AT THE PERSON AS A
WHOLE, WE'RE LOOKING AT A
PARTICULAR VARIABLE.
WHAT ARE THE INDIVIDUAL
DIFFERENCES ON THAT VARIABLE AND
WHERE DOES THIS PARTICULAR
PERSON RANK RELATIVE TO OTHER
PEOPLE ON THIS PARTICULAR
VARIABLE.
SO WHEN WE RUN SOMETHING LIKE A
REGREREGRESSION MODEL, HOW ARE E
CONTROLLING FOR ALL OTHERS,
HOLDING ALL ELSE CONSTANT AND
THAT'S A POWERFUL IDEA AND IT'S
THE IDEA OF STATISTICAL CONTROL.
I WANT TO KNOW WHAT IS THIS
VARIABLE I CAN CONTROL FOR ALL
OTHER VARIABLES AND HOLD THEM
CONSTANT AND LOOK AT ITS UNIQUE
EFFECT.
IT'S A COOL IDEA AND VERY
POWERFUL WE KNOW THINGS DON'T
STAY CONSTRUCTOR S TANT.
IT'S NOT THEIR VARIABLE SCORE ON
ONE BUT THEIR CONFIGURATION OF A
SET AND WHEN WE INCLUDE
INTERACTIONS IN OUR MODEL, WE
TALKED ABOUT HOW THESE SYSTEMS
ARE HIGHLY THEY ARE LOW ORDER SO
THE BUY LYNN Y'ALL ACTION AND
GIVE X1 AND X1 THERE ARE
TECHNIQUE THAT CAN RECOVER MORE
COMPLEX INTERACTIONS PATTERNS
BUT THE TECHNIQUES THAT WE GREW
UP WITH LOW ORDER INTERACTIONS
EFFECT.
THEY SAY I'M NOT INTERESTING IN
THIS VARIABLE CONTROL FOR ALL
OTHERS BUT I'M INTERESTED IN
PEOPLE AND PEOPLE ARE
CHARACTERIZED BY THEIR VALUABLE
OF SETS THAT ARE INTERESTED FOR
THE PROCESS THAT WE'RE STUDYING
SO WE LOOK AT CON FISSIONATION
AND ON THESE VARIABLES THAT
REFLECT PATTERNS OF FUNCTIONING
YOU LET'S SAY YOU HAVE WE ARE
LOOKING FOR THE SENSE AREAS AND
THE AWAY WANT TO IDENTIFY THOSE
LUMPS THAT REPRESENT PROTO TIP I
CANAL PATTERNS OF INDIVIDUAL
FUNCTIONING AND THE KINDS OF
TOOLS WE USE ARE THINGS LIKE K
MEANS CLUSTER ANALYSIS AND WHAT
I AM EMPHASIS MODELS AND THESE
FALL WITHIN THE REALM OF WHAT IS
NOW REFERRED TO WIDELY AS YOU
KNOW SUPERVISED PERSON AND THE
MACHINE LEARNING LITERATURE.
NEXT PLEASE.
AND PROFILE ANALYSIS IS THAT WE
HAVE K CLASSES OF INDIVIDUALS
MIXED TOGETHER AND THE
POPULATION AND WE DON'T KNOW WHO
IS A MEMBER WE SAY I IF WE
IDENTIFIED THESE PROFILES OF
DIFFERENT INDIVIDUALS CAN WE PRO
DICTIONARY WHO IS IN THAT CLASS
AND SO WE ADD OUR PREDICTORS TO
OUR MODEL AND WE SEE IF WE CAN
PRO DICTIONARPREDICTWHO IS A MES
AND WHAT ARE THE ASSOCIATED WITH
BEING IN A PARTICULAR CLASS AND
HOW DOES YOUR CLASS MEMBERSHIP
INFLUENCE YOUR ULTIMATE OUTCOME
ON SOME VARIABLE OF INTEREST.
AND THE OTHER THING WE CAN DO
WHICH IS REALLY COOL WE CAN SAY,
HEY, I'VE GOT THESE PREDICTORS
AND I KNOW RELATE TO MY OUTCOME
OF INTEREST BUT DOES IT RELATE
DIFFERENTLY FOR PEOPLE WHO SHOW
DIFFERENT CONFIGURATIONS ON
THESE INTEREST.
AND SO THAT IS THE THE THIRD
KIND OF RELATIONSHIP WE CAN LOOK
AT IS A LATENT CLASS MODERATION
MODEL.
NEXT, PLEASE.
SO JUST A VERY SIMPLE EXAMPLE
FROM AN EARLY PAPER USING A
PERSON ORIENTED APPROACH BY BOB
CARRENS IN 199 AS 1989 AND HOW Y
MIGHT RELATE TO HIGH SCHOOL DROP
OUT.
SO THE FEATURE OF INTEREST THAT
HE HAS THAT HE WANTS TO IDENTIFY
INDIVIDUALS ON, ARE AGGRESSION,
ACADEMIC PERFORMANCE, POPULARITY
IN THIS THING HE CALLED
ALL-AMERICAN REFERRED TO AS OLE
I AMANOLYMPIAN.
SO HE IDENTIFIED THESE DIFFERENT
PROFILES HERE AND I'M NOT GOING
TO SPEND A LOT OF TIME ON THIS
PLOT BUT IT'S SHOWING HOW THE
LEVEL OF EACH OF THESE SOCIAL
COMMENT TECOMPETENCY ANDTHE DIFD
THE VARIABLE ORIENTED APPROACH
IS WE SEE THERE ARE THREE LATENT
CLASSES HERE THAT ARE SIMILAR IN
THEIR ACADEMIC PERFORMANCE AND
NOTICE THAT THEY ARE QUITE
DIFFERENT IN THEIR PROBABILITY
OF HIGH SCHOOL DROP OUT.
WHY?
IT'S THE OTHER VARIABLES.
IT'S THE WHOLE PERSON THAT
MATTERS NOT THE SCORE JUST ON
THIS ACADEMIC VARIABLE.
AND THEY'RE VERY SIMILAR AND
SOME RESPECT ON AGGRESSION AND
THEY ARE VERY SIMILAR ON
ACADEMIC BUT THEY'RE DIFFERENT
IN OTHER WAYS AND THIS IS VERY
LOW IN POPULARITY AND ALL
AMERICAN AND THEY'RE TRYING TO
CHARACTERIZE AND THESE THREE
CONFIGURATIONS AND RELATE TO THE
ULTIMATE LIKELIHOOD OF DROP OUT.
SO NOW HOW CAN THIS BE USED IN
PAIN RESEARCH.
WELL I DID A LITTLE BIT OF
RESEARCH AND I WAS HELPED BY
Dr. JENSEN SENDING A FEW OF
HIS ARTICLES SO I APPRECIATE
THAT AND I CAME ACROSS A FEW
QUOTES THAT I THOUGHT REALLY
HIGHLIGHT THE NEED FOR A PERSON
ORIENTED APPROACH IN THIS AREA
SO EACH PAIN PROBLEM IS UNIQUE
AND NOT ALL PATIENTS WILL AND
EVALUATE TREATMENT EFFECTIVENESS
AND SO WE COULD IDENTIFY LATENT
PROFILES THAT REPRESENT
INDIVIDUALS AND WE CAN IDENTIFY
FOR ANY GIVEN PATIENT WHICH
PROFILE DO THEY BELONG TO EX
WHAT MIGHT BE THE MOST
APPROPRIATE TREATMENT.
SO JENSEN CONSIDERED SOCIAL
FACTORS AS POTENTIALLY IMPORTANT
HERE SO BRAIN STATE, COGNITIVE
CONTENT, COGNITIVE COPING,
BEHAVIORS LIKE GUARDING, REST,
SOCIAL SUPPORT AND OTHER
ENVIRONMENTAL FACTORS AND THE
FIRST STEP IN ANY KIND OF
CONFIGURATIONAL PERSON ORIENTED
APPROACH IS TO IDENTIFY WHAT ARE
THE KEY FACTORS THAT
CHARACTERIZE INDIVIDUALS THAT
ARE RELEVANT FOR WHAT I'M TRYING
TO STUDY.
AND IN ANOTHER PAPER IN 2015,
THIS IS SUPPOSED TO BE PERHAPS
YOU WOULD SEE FOUR PATIENT
PROFILES, A LIMIT PROFILE WITH
AN EXCESS OF MALE ADAPTIVE
COPING AND ACTIVATE PROFILE WITH
A DEFICIT OF HELPFUL COPING AND
ENHANCE PROFILE WITH STRONG
BASELINE COPING WITH NEED OF
ENHANCEMENT AND A COMBINATION
PROFILE WITH BOTH AN EXCESS OF
MALL ADAPTIVE COPING AND A LACK
OF HELPFUL COPING SO WE CAN SEE
DO THOSE SORTS OF PROFILES
EMERGE FROM THE EMPIRICAL
ANALYSIS AND IF THEY DO DOES THE
TREATMENT VARY IN ITS
EFFECTIVENESS ACROSS THE CLASSES
AND DO WE CHOSE DIFFERENT
TREATMENTS FOR DIFFERENT GROUPS?
NEXT, PLEASE.
SO WE CAN IMAGINE FOR SINCE AND
THESE PATIENTS PROFILES IN ANY
GIVEN SAMPLE THAT WE MIGHT HAVE
OF A HETEROGENEOUS SET OF
PATIENTS AND WE HAVE A TREATMENT
STUDY FOCUSES ON HYPNOSIS FOR
INSTANCE AND WE CAN SEE IT'S
COGNITIVE THERAPY AND OR SOME
COMBINATION OF TREATMENTS BUT
THE IDEA SO TO KIND OF MOVE
TOWARDS THIS IDEA OF A UNIQUE
INDIVIDUAL AND TRYING TO TARGET
TREATMENTS TOWARDS UNIQUE
INDIVIDUALS AND WHILE WE CAN'T
BUILD STATISTICAL MODELS
NECESSARILY FOR A SINGLE PERSON,
WE CAN MOVE TOWARDS THAT MORE
I'D YO GRAPHIC APPROACH BY
IDENTIFYING PROFILES AND
SUBSETTING AND IDENTIFYING
MEANINGFUL SUBGROUPS IN OUR
POPULATION FOR WHOM WE MIGHT SEE
DIFFERENTIAL EFFECTS.
NEXT, PLEASE.
THIS CLASS MODEL COULD BE USED
AND FOR THE LIKELY OUTCOMES OF A
GIVEN TREATMENT.
BASED ON THESE KINDS OF
FINDINGS, AND BASED ON A PATIENT
AND IT BELONG TO ANY LATENT
CLASS AND THEN WE CAN SAY OK,
WELL, GIVEN TO THE PROBABILITY
THEY CAN BELONG TO OTHERS AND IT
IS A .8 OF ONE CLASS AND OF
ANOTHER AND .1 PROBABILITY OF A
THIRD AND A ZERO PROPER ABILITY
OF A FOURTH, GIVEN THAT, WE
MIGHT SAY MOST LIKELY THEY'RE IN
THIS GROUP AND WE CAN TAKE THAT
PROBABILITY AS WELL AS OUR
DEMONSTRATED EFFECTIVENESS OF
THE TREATMENT FOR INDIVIDUALS IN
THAT CLASS, TO GENERATE AN
INDIVIDUAL PRO DICTION OF
TREATMENT EFFECTIVENESS FOR THAT
PATIENTS.
FOR THIS PATIENT IT WILL BE
DIFFERENT WITH THAT CLASS BUT
FOR A PATIENT WHO MIGHT HAVE A
NEXT PLEASE.
>> SO I THINK THAT IS A PRETTY
COOL IDEA.
IT GETS US CLOSER TO INDIVIDUALE
INDIVIDUALIZE PERSONS AND HOW WE
MIGHT HAVE TREATMENT BY
VARIABLES AND NOW WE CAN LOOK AT
TREATMENT BY PERSONS AND SO WE
CAN INCLUDE VIS LOGICAL
INDICATORS AND ASPECTS OF THE
SOCIAL ENVIRONMENT AND SO FOURTH
AND PROFILES FOR OUTCOMES RATHER
THAN JUST LOOK AT ONE OUTCOME AT
A TIME SO WE CAN HAVE PREDICTORS
OF OUTCOMES.
>> TWO MINUTE WARNING.
WHETHER THEY'RE EFFECTIVE
BETWEEN LATENT CLASSES AND SO WE
CAN LOOK AT OVER TIME RESPONSES
TO TREATMENT AND DO WE SEE
DIFFERENT SUBSETS OF INDIVIDUALS
RESPOND NORTH DIFFERENT WAYS TO
TREATMENT AND SO DO YOU SEE AN
EARLY IMPROVEMENT GROUP SO THERE
ARE RELATED KINDS OF MODEL
THAT'S LOOK AT THESE PATTERNS OF
CHANGE AS WELL.
NEXT, PLEASE.
THIS IS OBVIOUSLY A LITTLE BIT
OF SELF CITATION IN HERE WHICH
IS ALWAYS FUN AND AND TO LOOK AT
IF YOU ARE INTERESTED IN THIS
APPROACH TO RESEARCH.
AND THAT IT S IT FOR ME NEXT UP
IS DAVID WILLIAMS AND THANK YOU
VERY MUCH.
>> GOOD AFTERNOON.
I ENJOYED YOUR TALK.
I'M GOING TO TALK ABOUT
ASSESSING CHRONIC OVERLAPPING
PAIN CONDITIONS WITHIN THE
INDIVIDUALS AND NEXT SLIDE.
JUST A COUPLE DISCLOSURES, I DO
CONSULTING WITH COMMUNITY HEALTH
FOCUS AND FUNDING FOR NIH.
SO, WE'VE HEARD A LITTLE BIT
TODAY ABOUT CHRONIC OVERLAPPING
PAIN CONDITIONS AND JUST TO
REMIND YOU, THE CONDITIONS THAT
KIND OF FALL INTO THIS
CLASSIFICATION WOULD BE THESE 10
CONDITIONS AND IRRITABLE BOWEL
SYNDROME, CHRONIC LOW BACK PAIN,
CHRONIC PROSTATITIS ALSO KNOWN
AS UBPS AND HEADACHES AND
PAINFULLEN ENDOMETRIOSIS AND
FIBER MYALGIA AND MYALGIA OR
CHRONIC FATIGUE SYNDROME SO
THESE ARE THE 10 CONDITIONS THAT
TEND TO FOLLOW INTO THIS
CLASSIFICATION.
SO THE QUESTIONS THAT ARE RAISED
AND HOW THEY CAN BE LINKED AND
WE SHOULD BE TREATING SEPARATELY
OR SHOULD WE BE ADDRESSING SOME
COMMON UNDERLYING CAUSE OF THE
OVERLAP.
NEXT SLIDE.
WE RUN INTO A BARRIER AND THE
BARRIER THAT WE RUN INTO IS THAT
WE DON'T REALLY HAVE A RELIABLE
AND VALID WAY OF ASSESSING AWFUL
THESE CONDITIONS IN THE SAME
INDIVIDUAL AND THE UNTHINKABLE
WAY WOULD BE TO HAVE A COLLISION
DELIVER ALL 10 CRITERIA TO THE
SAME CRITERIA AND IT WON'T
HAPPEN IN THE REAL WORLD.
AND MORE COMMONLY WHAT HAPPENS
IN CLINICAL PRACTICE IS IF YOU
HAVE JAW PAIN YOU GO TO YOUR
DENTIST AND THE DENTIST ASKS YOU
ABOUT YOUR JOB JAW PAIN AND
ABOUT OFFERS TREATMENTS FOR JAW
PAIN AND IT'S PROBABLY UNLIKELY
TO ASK ABOUT PELVIC PAIN.
AT THE SAME TIME, WITH THE
PERSON GOES OVER TO THEIR G.I.
DOCTOR AND G.I. DOCTOR WILL ASK
ABOUT THEIR GUT AND OFFERS
TREATMENTS FOR IBS AND GUT
DISTRESS AND AGAIN IS PROBABLY
NOT GOING TO BE ASKING ABOUT
OTHER AREAS OUTSIDE OF THEIR
SPECIALIZATION.
SO SIMILARLY IF THE PERSON GOES
TO NEUROLOGIST WITH HEADACHES,
THEY'RE LIKELY TO ASK ABOUT
HEADACHES THEY WON'T ASK ABOUT
OTHER CONDITIONS THAT THE PERSON
MAY HAVE.
SO, AS A CONSEQUENCE WE TEND TO
HAVE A LOT OF INDEX CONDITIONS
AND THIS IS THE CONDITION THAT
THE PERSON GETS DYING KNOWED
WITH AND AT LEAST INITIALLY AND
MANY TIMES IF YOU LOOK AT
SOMEONE'S CLINICAL RECORDS, YOU
WILL SEE THAT THEY'VE BEEN TO
MANY DIFFERENT DOCTORS, EACH
GETTING INDIVIDUAL DIAGNOSIS BUT
NOT NECESSARILY SEEING ANY
LINKAGE BETWEEN THESE AND THERE
HAVE BEEN A COUPLE OF LARGE
WHERE THEY WERE ADULT AND WE GOT
A HANDLE ON SOME OF OVERLAP AND
EVEN THOSE VERY LARGE NETWORKS
IN STUDIES DID NOT A SASS ALL
THREE WITH THE SAME INDIVIDUAL
AND NEXT LIED, PLEASE.
AND JUST TO GIVE AN EXAMPLE OF
HOW IMPORTANT IT CAN BE THEY
LOOKED AT 424 PATIENTS WITH
PELVIC PAIN AND WE'RE DYING
KNOWS WITH CHRONIC PROSTATE US
AND EVEN THOUGH THEY CAME IN,
WITH THIS AS THEIR INDEX
CONDITION, ONLY 25% ONLY HAD
PAIN IN THE PELVIC REGION THEY
EXTENDED BEYOND JUST THE BELL
VICTIM REGION WITH THIS
DIAGNOSIS.
IT'S ONE TO TWO TO THREE TO
SOUTHERN REGIONS AND DESCRIBING
MORE WIDESPREAD PAIN AND 38%
QUALIFIED FOR WIDESPREAD PAIN
EVEN THOUGH THEY CAME IN ONLY
EXPECTING TO HAVE ONE CONDITION
WHICH WOULD BE PELVIC PAIN AND
OTHER TYPES OF PROBLEMS AND CORE
QUALITY OF LIFE AND NEXT SLIDE,
PLEASE.
WHAT I'M GOING TO DO BRIEFLY
TODAY IS DESCRIBE TWO METHODS
AND PAIN CONDITIONS AND FOR
CLINICAL RESEARCH AND THE FIRST
USE NOT THE COMPUTE ABLE
PHENOTYPE APPROACH AND THIS IS
FOR USE IN ADMINISTRATIVE
DATABASES AND THEN THE SECOND IS
THE CHRONIC OVERLAPPING PAIN
CONDITIONS.
NEXT SLIDE.
IF YOU HAVE AN ADMINISTRATIVE
DATABASE AND YOU WANT TO TAKE A
LOOK AT AND THIS IS A STUDY THAT
WAS LED BY ANDREW FROM THE
UNIVERSITY OF MICHIGAN AND BY VI
FAWN WHO WAS AN UNDERGRADUATE
AND IS NOW IN MEDICAL SCHOOL AT
GEORGETOWN.
THIS STUDY HAD SEVERAL PARTS TO
IT AND WE DID ASSEMBLE AN EXPERT
PANEL AND WE HAD THREE EXPERTS
SO 30 EXPERTS AND THESE WERE
INDIVIDUALS WHO FOCUSED ON THE
SPECIFIC CHRONIC OVERLAPPING
PAIN CONDITIONS AND MANY TIMES
WHERE PEOPLE WHO ARE INVOLVED IN
THE DEVELOPMENT OF THE
DIAGNOSTIC CRITERIA AND WE HAD
THEM RECOMMEND ICD CODES THAT
WOULD MAP ONTO THE VARIOUS
CONDITIONS OF INTEREST AND WE
THEN ALSO DID A NATURAL LANGUAGE
PROCESSING APPROACH WHERE WE
LOOKED FOR THE MEDICAL RECORDS
FOR DESCRIPTIVE TERMS FOR THE
OVERLAPPING PAIN CONDITIONS AND
THEN WENT IT MAKE SURE WE CAN
MAP THOSE DESCRIPTIVE TERMS WITH
THE CODES ACODES FORT INDIVIDUA.
WE RETAINED THAT CODE WHEN WE
FOUND THE CODE LINING UP WITH
THE DESCRIPTION IN THE CHARTS.
AND THEN FINALLY WE IN ONE
MEDICAL SYSTEM WE DID A
DEMONSTRATION PROJECT WITH
12,000 INDIVIDUALS AND USING THE
RETAIN CODES TO TAKE A LOOK AT
THE DEGREE OF OVERLAP THAT WAS
GOING TO BE PRESENT AND IN THESE
CONDITIONS.
THIS WAS LITTLE CONTROVERSY AND
ONLY ONE CODE AND THE AGREEMENT
THERE WAS GREAT AND IN OTHER
CONDITIONS, WHERE THERE WAS LESS
AGREEMENT ON THE DIAGNOSTIC
CRITERIA AS WELL AS THE CODES,
THAT WAS GREATER RELIANCE MAKING
SURE WE HAD ALIGNMENT BETWEEN
THE ICD CODES AND THE
DESCRIPTIVE TEXT AND THE CHARTS.
NEXT SLIDE.
THIS IS A CHART.
WE SAW A SIMILAR ONE IN Dr.
SAWSAN AS-SANIE TALK EARLIER
FROM THE SAME ARTICLE.
SHE WAS SHOWING ODDS AND RATIO
AND THIS LOOKED AT THE
PERCENTAGE OF OVERLAP IN THE
VARIOUS CONDITIONS WHERE THE
INDEX CONDITIONS AND AGAIN, WHAT
WE'VE NOTICED FROM THIS IS THAT
WHILE THESE CONDITIONS DO ALL
TEND TO OVERLAP WITH EACH OTHER
MORE THAN THE CONTROL
CONDITIONS, THE LAST THREE ON
THE BOTTOM, COPD, AND
CARDIOVASCULAR DISEASE, DIABETIC
MEASURE ON AGENT' WE SEE THERE'S
LITTLE OVERLAP WITH THE CONTROL
CONDITIONS BUT THERE'S A LOT OF
OVERLAP AMONG THESE 10
CONDITIONS.
AND SOME TEND TO OVERLAP MORE
THAN OTHERS, FIBER MYALGIA AND
IRRITABLE BOWEL OR FIBER MYALGIA
LOW BACK PAIN WITH HEADACHE AND
IBS AND UCPCS WITH HEADACHE FOR
EXAMPLE ANDEN DOUGH WITH
MIGRAINE HEADACHE.
SO WITH DO SEE SOME CONDITIONS
HAVE A HIGH DEGREE OF OVERLAP
AND OTHERS LESS SO AND SOME HAVE
A SPECIFIC OVERLAP AND SOME
CONDITIONS AND ABOUT WHAT IS
INTERESTING THOUGH, IS THAT WHEN
THE OVERLAP DOES OCCUR, IT'S
USUALLY SOME OTHER REGION OF THE
BODY, FOR EXAMPLE, HAVING PELVIC
PAIN AND HEADACHES AS WELL.
NEXT SLIDE, PLEASE.
SO, THESE SECOND APPROACH I
WANTED TO TALK ABOUT IS THE
CHRONIC OVERLAPPING PAIN
CONDITIONS AND THIS IS A
SCREENER THAT WE HAD BEGIN USED
THAT SAME PANELIST 30 EXPERTS TO
GIVE US ADVISE ON THE DIAGNOSTIC
CRITERIA AND WE WANTED TO MAKE
SURE THAT WE COULD, VERY
EFFICIENT LIKE ADMINISTERED THE
10 DIAGNOSTIC CRITERIA TO ANY
GIVEN INDIVIDUALS AND TO HELP US
TRIAGE THAT WE USE A BODY MAP
AND SHOWN ON THE SLIDE AND SO WE
HAVE PEOPLE COMPLETE THE BODY
MAP.
IF THEY DON'T INDICATE HEADACHE
FOR EXAMPLE, THEN WE WILL NOT
ADMINISTERED THE HEADACHE
CRITERIA TO THAT INDIVIDUAL WHO
IS NOT SOME PLACE THEY'RE
EXPERIENCING PAIN BUT ANY REGION
WHERE THEY DO INDICATE PAIN AND
IT'S A RELEVANCE TO THE
DIAGNOSTIC CRITERIA THEN WE WILL
ADMINISTERED THE PUBLISH
DIAGNOSE TICK CRITERIA OR THE
MODIFIED CRITERIA TO THEM.
WE HAVE WORKED TO MAKE SURE THAT
THIS IS A LOGIC-DRIVEN APPROACH
AND SO AS SOON AS SOMEONE IS NOT
GOING TO QUALIFY FOR THE
DIAGNOSTIC CRITERIA, THEY CAN
BAIL OUT OF THAT AND THEY MOVE
ONTO THE NEXT CRITERIA.
WHAT WE FIND IS THAT FOLKS ARE
ABLE TO USUALLY GET THROUGH THIS
IN ABOUT 10 MINUTES SO IT
DOESN'T TAKE A GREAT DEAL OF
TIME SO IT'S A LOT MORE
EFFICIENT THAN ADMINISTERED ALL
THE CRITERIA TO ANY GIVEN
INDIVIDUAL AND AT THE END, WE'RE
ABLE TO GET A REPORT THAT COMES
OUT AND THAT BASICALLY TELLS YOU
WHETHER YOU QUALIFY OR NOT FOR
EACH OF THE CONDITIONS AND THEN
IT TELLS YOU HOW MANY OF THE
CONDITIONS YOU QUALIFY FOR BASED
ON THIS SCREENER.
NEXT SLIDE, PLEASE.
AND THE SCREENER IS NOW IN
VERSION 11.
VERSION 11 IS A VERSION THAT'S
ABLE TO RUN ON RED CAP.
THIS WAS A REQUEST THAT WOULD BE
PUT INTO RED CAPS OF MORE
UNIVERSITIES AND MORE
INSTITUTIONS WOULD BE ABLE TO
TAKE ADVANTAGE OF THIS SCREENER
AND SO THIS COMPANY IS YOUR
GUIDE THAT TALKS ABOUT THE
DEVELOPMENT OF THE COPC SCREENER
AND LISTS OF ITEMS AND SCORING
AND THE OUTPUT AS WELL AS THE
VALIDATION PROPERTIES AND THIS
LATEST VERSION HAS GONE THROUGH
ADDITIONAL VALIDATION AND WE'VE
WORKED WITH A LOT OF PATIENT
GROUPS AND WE HAVE A LOT OF
PATIENT INPUT AND FOR EXAMPLE ON
THE BODY MAP, YOU PROBABLY
NOTICED THE COLORING OF THE BODY
MAP AND THIS WAS THE
RECOMMENDATION OF OUR PATIENT
GROUPS SO PEOPLE WHO MIGHT BE
COLOR BLIND WOULD BE ABLE TO USE
IT AND WE ACTUALLY DID THE
UNTHINKABLE IN THE VALIDATION
WHERE WE ACTUALLY HAD CLINICIANS
DELIVER ALL 1 10 DIAGNOSTIC
CRITERIA TO THE SAME INDIVIDUAL
AND WE HAD FOLKS IN EACH WHAT
THE CLINICIANS WERE GETTING AND
WHAT WE GOT WITH OUR A GROVATED
STRAINER.
IF YOU ARE INTERESTED IN
ACCESSING THE SCREENER, THERE'S
A WEBSITE AND WE HAVE SEVERAL
THINGS.
WE HAVE A DEMONSTRATION OF
SOMEONE USING THE SCREENERS SO
IF YOU WANT TO SEE HOW THAT'S
DONE, THE USER GUIDE WHICH I
JUST REFERRED TO IS AVAILABLE
FOR DOWNLOAD AND THERE'S AN
ON-LINE DEMONSTRATION -- TO
FOLKS WHO WANT TO USE IT AND THE
REQUIREMENT IS YOU HAVE TO HAVE
RED CAP IN ORDER TO USE IT.
NEXT SLIDE, PLEASE.
AND AGAIN HERE IS THE URL.
IF YOU DO YOU CAN ACCESS THIS
FOR FREE IF YOU ARE AN ACADEMIC
USER.
I'LL STOP THERE.
THANK YOU.
>> THANK YOU ALL FOR MY PANEL
MEMBERS.
WE HAVE VERY INTERESTING FOUR
PRESENTATIONS.
IT'S VERY DIFFERENT FROM OUR
FIRST PANEL DISCUSSION THIS
MORNING.
NOW THE FIRST PANEL DEFINITELY
INDICATED THE NEED TO GO ABOVE
AND BEYOND WHAT THE MAINSTREAM
SO WHAT CURRENTLY IS A WAY OF
LOOKING TO THE PAIN AND
EMPHASIZE THE NEED TO HAVE A
WHOLE-PERSON APPROACH.
NOW, FOR THIS PANEL, WE STARTED
WITH JENSEN'S OVERVIEW
INDICATING ABOUT THE APPROACHES,
ABOUT THE TOOLS AND ALL THE THE
DIRECTIONS, WHAT WE CAN DO TO
ADDRESS THE ISSUE RAISING THE
FIRST PANEL.
Dr. ATLAS PROVIDE HER RESEARCH
DATA USING BRAIN IMAGING THAT
CAN SERVE AT LEAST TWO THE WAY I
SEE IT.
ONE TO IDENTIFY THE BRAIN
SUBSTRATES, YOU KNOW, BRAIN
CIRCUITRIES THAT MAY PLAY
IMPORTANT ROLES IN PAIN
MANAGEMENT THAT BEYOND TO THE
PAIN SENSORY AND TO EVOLVE
EFFECTIVE PART OF THE PAIN AND
ALSO THEY HAVE POTENTIAL WERE
INFORMED THE HOW WE CAN PREDICT
PAIN USING DIFFERENT APPROACHES
AND IT'S NOT NECESSARY TO SAY
THAT WE HAVE TO USE BRAIN
IMAGING AS A PREDICT OR BUT THEN
THESE INFORM THE DIRECTIONS.
AND OF COURSE, WE HAVE Dr.
BAUER GIVE US A VERY INTERESTING
IDEA.
THIS IS HER EXPERTISE AND WHAT
WE CAN USE IN TERMS OF
METHODOLOGY WIDE TO LOOK INTO
SOME DIFFERENT ANGLES INTO THE
QUESTIONS THAT WE ARE ASKING
ABOUT THE DAY AND FINALLY, IN A
THE IDEAS STARTING FROM THE
CHRONIC OVERLAPPING PAIN
COMMISSIONERS AND USE THIS AS
EXAMPLES AND INTRODUCE US ABOUT
SCREENERS WITH THIS LET'S COME
TO THE DISCUSSIONS AND WE HAVE A
FEW EXTRA MINUTES BEYOND WHAT
WE'RE ASSIGNED FOR.
BECAUSE A FEW QUESTIONS ARE
SIMILAR APPROACHES AND FOR
EXAMPLE, EMPHASIZING SO WE START
FROM THIS QUESTION AND IT'S FOR
Dr. JENSON, SAYS IT'S UNLEARN
HOW YOU CAN DETERMINE BETWEEN
THE MECHANISMS IN THE MEDIATION
AND ANALYSIS WHERE THERE'S NOT
ENOUGH POWER FOR THOSE
MECHANISTIC OUTCOMES OR IT COMES
FROM THE SECONDARY OUTCOMES
BECAUSE THE TRIALS ARE POWERED
FROM THE PRIMARY CLINICAL
OUTCOME.
CAN YOU EXPLAIN THE POWER ISSUES
HERE?
I NEED TO REPEAT?
>> I THINK WE'RE GOOD.
THAT'S A FANTASTIC QUESTION AND
GETS AT THE CRUX OF THE ISSUE OF
DOES THIS ONE STUDY, CAN WE USE
THIS ONE STUDY TO ANSWER A
SERIES OF QUESTIONS AND THE
ANSWER TO THAT I THINK IS NO AND
MY VIEW IS THAT A SINGLE STUDY
IS USUALLY DESIGNED TO ANSWER
ONE QUESTION, IT'S USUALLY
POWERED FOR THAT.
WE CAN SHIFT OUR VIEW FROM
THINKING OF HAVING, SPENDING ALL
THIS MONEY AND ALL THIS
RESOURCES TO ANSWER ONE QUESTION
AND TO ASKING OURSELVES TO
DESIGN STUDIES THAT CAN CREATE
ANSWERS TO MULTIPLE QUESTIONS
AND SO NOT GET A DEFINITIVE
ANSWERS BUT EFFECT SIZE SO, YOU
KNOW, THE ROLE OF SELF-EFFICACY
AS TO EXPLAIN THE BIO FEED BACKS
IMPACT ON HEADACHE IN THIS STUDY
THAT IS .38 AND IF WE INCLUDE
THESE ANALYSIS ACROSS MULTIPLE
STUDIES, WE'LL SEE MULTIPLE
EFFECT SIZES .1, .38, .45, .12,
ET CETERA, AND WE'LL OVER TIME,
UNDERSTAND WHAT IS THE EFFECT,
WHAT IS THE ROLE OF THIS AS A
MECHANISM WHEN YOU EXAMINE A
CROSS MULTIPLE STUDIES, SO,
POWER, HE WANT TO POWER STUDIES
TO BE ABLE TO CREATE RELIABLE
EFFECT SIZES.
NOT TO ANSWER A DEFINITIVE
QUESTION.
THE POWER QUESTION GETS TURNED
ON ITS HEAD HERE.
I'M ADVOCATING FOR A SHIFT HOW
WE
I THINK WE SHOULD GET RID OF THE
P VALUE AND THINK ABOUT IT
DIFFERENTLY.
I WOULD LOVE TO HEAR DR. BAUER'S
RESPONSE ON IT, BECAUSE I THINK
WE MAY BE CONSTRAINED BY WHAT
I'M CALLING IN MY VIEW THE
TYRANNY OF THE P VALUE.
PRACTICALLY, WE NEED TO GET OUR
RESEARCH FUNDED SO I WILL OFTEN
IN MIGRANTS SAY WE'RE GOING TO
TEST THIS ONE QUESTION AND WE'RE
POWERED FOR T BUT BY THE WAY,
WE'RE GOING TO DO SECONDARY
ANALYSES TO GET THESE ESTIMATES
THAT FUTURE RESEARCHERS AND
SCIENTISTS CAN USE.
SO THAT'S MY THINKING.
BUT IT'S A LONG CONVERSATION.
>> ANY COMMENT, DR. BAUER?
>> SURE.
I MEAN, THERE HAVE BEEN A FEW
MOVEMENTS AFOOT IN SCIENCE,
PARTICULARLY IN PSYCHOLOGY, TO
TRY TO BAN P VALUES, AND THE
PROBLEM SEEMS TO BE FINDING, YOU
KNOW, ENOUGH PEOPLE TO BUY IN TO
THAT MOVEMENT AND THEN FINDING
GOOD ALTERNATIVES.
FOR A WHILE, PEOPLE SAID, OH, WE
COULD DO CONFIDENCE INTERVALS.
CONFIDENCE INTERVALS ARE BETTER.
SURE, BUT TO GET YOUR TEST
STATISTIC FOR THE P VALUE,
YOU'RE JUST TAKING AN ESTIMATE
AND DIVIDING BY THE STANDARD
ERROR, IT'S REALLY NOT
TREMENDOUSLY DIFFERENT IN TERMS
OF THE KIND OF INFORMATION
THAT'S BEING GIVEN THERE, BUT I
DO, YOU KNOW, CERTAINLY AGREE
THAT A GREATER FOCUS ON EFFECT
SIZES IS IN ORDER, AND
OFTENTIMES IN ALL HYPOTHESES, WE
TEST WITH P VALUES, CAN BE A BIT
SILLY AND NOT THAT INFORMATIVE,
AND SO I THINK IT'S ALL TO THE
BETTER TO FOCUS ON THOSE EFFECT
SIZES AND TO TRY TO AGGREGATE
INFORMATION ACROSS STUDIES BY
HAVING KIND OF STANDARDIZED
EFFECT SIZES THAT WE CAN LOOK
AT.
SO I DEFINITELY LIKE THOSE
IDEAS.
I DON'T KNOW IF THE P VALUE WILL
EVER BE BANNED, BUT WE CAN
CERTAINLY COMPLIMENT IT WITH
MORE FOCUS ON EFFECT SIZES.
>> THANK YOU, DR. BAUER.
NOW, THIS AGAIN IS ANOTHER
QUESTION RELATED TO -- DIRECT TO
DR. JENSEN.
YOU MAY HAVE ALREADY ANSWERED IN
PART, AT LEAST PARTIALLY THE
QUESTION BUT LET ME THROW IT OUT
ANYWAY JUST IN CASE YOU HAVE A
DIFFERENT -- THE QUESTION IS,
WITH THE ABILITY TO EXAMINE
MANY -- FACTORS IN -- ANALYSIS,
HOW DOES ONE ASSURE SUFFICIENT
POWER TO EXAMINE ALL FOUR OF
THOSE INDIVIDUAL
CHARACTERISTICS?
>> SO YOU'RE ABSOLUTELY RIGHT,
THAT THAT, IN MY VIEW, IS A
DIFFERENT WAY OF LOOKING AT THE
SAME QUESTION, THAT I DON'T
THINK WE DO HAVE THE POWER, IF
WE'RE THINKING IN TERMS OF P
VALUES, TO EXAMINE 30
RELATIONSHIPS.
WHAT WE DO IS, IF A STUDY IS
DESIGNED WELL, ARE RELIABLE
MEASURES, ADEQUATE SAMPLE SIZE
TO BE ABLE TO CREATE RELIABLE
EFFECT SIZES THAT THEN CAN BE
EVALUATED -- REPLICATED IN OTHER
STUDIES.
SO IF A CERTAIN MECHANISM
EMERGES AS HAVING A POWERFUL
EFFECT ACROSS STUDIES REGARDLESS
OF THE POWER IN EACH OF THOSE
INDIVIDUAL STUDIES, WE CAN
PROBABLY TRUST, YOU KNOW, THAT'S
A PRETTY IMPORTANT VARIABLE.
SO I DON'T THINK WE SHOULD -- IN
MY VIEW, AGAIN, IT'S GOOD TO
HAVE A SINGLE PRIMARY ANALYSIS,
A SINGLE PRIMARY OUTCOME, WE CAN
TEST THAT DEFINITIVELY, ANSWER
THE QUESTION YES OR NO, BUT MY
PERSONAL INTEREST IS ALWAYS IN
THE SECONDARY ANALYSES, TO SEE
WHAT I CALL DISCOVERY ANALYSES.
WHICH THEN CAN LEAD TO INFORMED
FUTURE RESEARCH.
SO MY ANSWER TO THE QUESTION,
HOW DO YOU HAVE ADEQUATE POWER?
YOU CAN'T.
BUT I DON'T THINK THAT'S THE
IMPORTANT QUESTION HERE.
THE IMPORTANT QUESTION IS,
WHAT'S HAPPENING HERE, AND
WHAT'S HAPPENING WITH THESE
PEOPLE, AND IN OUR ONE STUDY WE
SAY THIS IS WHAT LOOKS LIKE IS
LAPPING AND THEN WE DO ANOTHER
STUDY TO SEE, HEY, OF THOSE 10
THINGS, SEVEN SEEM TO BE
HAPPENING ACROSS TWO -- AND
THOSE THINGS REPLICATE.
THAT'S THE STUDY OF SCIENCE OVER
TIME, I THINK.
>> THAT'S INTERESTING.
IF WE HAVE TIME, WE'LL BRING
BACK THIS QUESTION AGAIN BECAUSE
I HAVE SOME RELATED QUESTIONS,
AND SOME THOUGHTS.
BUT FOR NOW, LET'S MOVE TO A
QUESTION, HOW DO WE MEASURE
TREATMENT EXPECTANCY IN CLINICAL
SETTINGS?
CAN YOU SHARE YOUR COMMENTS?
>> THERE ARE A NUMBER OF
QUESTIONNAIRES THAT EXIST TO BE
ABLE TO ASK QUESTIONS ABOUT
THE -- THEY'VE HAD IN ADVANCE OF
A PROCEDURE.
BUT ONE OF THE APPROACHES THAT I
THINK IS MOST EXCITING THAT HAS
EXISTED FOR A LONG TIME BUT
BECAUSE IT REQUIRES DECEPTION IS
A LITTLE BIT TOUGH TO USE, IS
WHAT'S CALLED THE BALANCED
PLACEBO DESIGN IN THE CONTEXT OF
CLINICAL TRIALS.
AND THERE, WHAT YOU CAN DO IS,
RATHER THAN JUST HAVING A
TREATMENT AND A PLACEBO ARM, YOU
CAN CROSS THE ADMINISTRATION OF
THE TREATMENT WITH KNOWLEDGE
ABOUT THE TREATMENT.
SO BASICALLY PEOPLE CAN RECEIVE
A TREATMENT WHEN THEY KNOW
THEY'RE GETTING IT, OR WHEN THEY
BELIEVE THEY'RE NOT RECEIVING A
TREATMENT, AND LIKEWISE, WE CAN
RECEIVE PLACEBO WHEN YOU BELIEVE
YOU'RE RECEIVING A TREATMENT OR
BELIEVE YOU'RE NOT RECEIVING A
TREATMENT.
AND THIS ALLOWS YOU TO SEPARATE
OUT THE EFFECTS OF THE TREATMENT
ITSELF FROM BELIEF IN THE
TREATMENT.
AND SO I'M -- I THINK IT USES --
IT LEVERAGES CAUSAL
MANIPULATIONS TO ACTUALLY
UNDERSTAND HOW EXPECTATIONS
COMBINE WITH DIFFERENT TYPES OF
TREATMENTS.
AND WE'VE SHOWN THAT
EXPECTATIONS OR KNOWLEDGE ABOUT
DRUG DELIVERY HAVE ADDITIVE
EFFECTS WITH THE NEW OPIOID
AGONIST BUT DIFFERENT TYPES OF
TREATMENTS SEEM TO HAVE
DIFFERENT TYPES OF COMBINATIONS
WITH EXPECTANCY.
SO BASICALLY I WOULD OFFER THAT
AS SOMETHING THAT I WOULD HOPE
MORE AND MORE RESEARCHERS
THINKING ABOUT DIFFERENT
INTERVENTIONS CAN THINK ABOUT
CAN YOU ALSO ISOLATE
MECHANISTICALLY THE CONTRIBUTION
OF EXPECTANCY, AND THEN, OF
COURSE, YOU CAN ADD THOSE
INDIVIDUAL DIFFERENCE --
QUESTIONNAIRES AND THINGS LIKE
THAT ON TOP AS PERSON LEVEL
MODERATORS.
>> THIS IS A QUESTION, VERY
SHORT, HOPEFULLY IT WILL BE AN
EASY ANSWER.
IT SAYS, HAS THE COPCs, THE
CHRONIC -- SCREENER, SORRY, COPC
SCREENER BEING TRANSLATED?
I'M NOT SURE TRANSLATED HERE
MEANS FROM RESEARCH TO CLINIC OR
SOME OTHER TRANSLATIONS.
BUT LET ME THROW IT OUT.
>> I ASSUME IT -- HAS IT BEEN
TRANSLATED INTO OTHER LANGUAGES.
CURRENTLY, NO, RIGHT NOW IT'S
ONLY IN ENGLISH, BUT I ASSUME
THE TRANSLATION INTO OTHER
LANGUAGES IS SOMETHING THAT
PEOPLE WILL BE INTERESTED IN
DOING.
WE'RE OPEN TO THOSE
COLLABORATIONS.
>> THERE IS ANOTHER SHORT ONE
DIRECT TO YOU.
WILL THE COPCs WORK IN ONCO?
>> RIGHT, THAT'S PROBABLY --
THAT'S ANOTHER PLATFORM.
CURRENTLY, THE VERSION 11, WHICH
IS THE MOST RECENT VERSION THAT
HAS BEEN VALIDATED, IS ONLY
AVAILABLE IN REDCAP.
WE DO HAVE PLANS TO MAKE A
QUALTRICS VERSION AND PROBABLY
ANOTHER VERSION IN OTHER
PLATFORMS, BUT RIGHT NOW IT'S
ONLY AVAILABLE IN REDCAP.
>> ALL RIGHT, THANK YOU.
THIS IS -- NEXT QUESTION
PROBABLY CAN BE DIRECT TO ANY
ONE OF MY PANEL MEMBERS.
IT SAYS, THANK YOU ALL FOR YOUR
WONDERFUL TALKS IN ADDITION
TO -- WHAT ARE SOME OTHER STUDY
DESIGN AND METHODOLOGICAL
CONSIDERATION FOR STUDIES IN
WHICH AN INVESTIGATOR MIGHT WANT
TO USE -- AND THE LATENT CLASS
AND PROFILE ANALYSIS?
ANYONE LIKE TO TAKE A LEAD?
>> I'LL JUMP IN JUST BECAUSE I
HAD SOME THOUGHTS.
ONE IS, I'M SORRY THE QUESTION
WAS ASKED LIKE THAT BECAUSE I
THINK IN MY VIEW, THE FIRST
THREE ISSUES ARE SAMPLE SIZE,
SAMPLE SIZE AND SAMPLE SIZE.
SO THAT'S JUST CRITICAL.
AND THEN, YOU KNOW, HOW MUCH OF
A SAMPLE SIZE, I DEFER TO MY
STATISTICIAN EXPERTS, BUT THE
ANSWER I OFTEN GET IS, MORE.
BUT THE SECOND ISSUE IS THAT I
WOULD -- THE SELECTION OF THE
MEASURES BE THEORY-DRIVEN.
BY THAT, I MEAN SO MANY OF PRIOR
MODERATION ANALYSES EXAMINE THE
MODERATORS OF CONVENIENCE, THE
ONES YOU HAPPEN TO HAVE
ASSESSED.
DEMOGRAPHIC VARIABLES, MAYBE
OUTCOME VARIABLES AT BASELINE,
BUT WHEN YOU DO IT THAT WAY, THE
CHANCES OF FINDING SOMETHING
THAT'S OF IMPORTANCE ARE
LIMITED, AND PROBABLY NOT
REPLICABLE.
SO THE IMPORTANT ISSUE IS TO
THINK AHEAD OF TIME BASED ON OUR
THEORIES AND BASED ON OUR
CLINICAL EXPERIENCE EVEN, WHAT
ARE THE MODERATORS AND
MEDIATORS?
WHY DO WE THINK THIS WORKS?
AND THEN FOR WHOM DO WE THINK
THIS WORKS, AND WRITE THOSE
DOWN, AND THEN FIND THE BEST,
MOST RELIABLE MEASURES OF THOSE
THINGS.
PERSONALLY, I OFTEN MAKE THAT
LIST AND THEN I ASK MYSELF, HOW
MIGHT IT WORK?
SO THEN I HAVE KIND OF
EXPLORATORY ONES.
DISCOVERY ONES.
AND SO WE MIGHT ADD SOME MEASURE
TO THOSE JUST TO SEE TO START TO
BUILD THE EMPIRICAL BASE.
SO THE FOUR ISSUES: SAMPLE
SIZE, SAMPLE SIZE, SAMPLE SIZE,
AND THEORY.
>> SAMPLE SIZE, SAMPLE SIZE,
SAMPLE SIZE, AND THEORY.
GREAT.
>> IF I COULD -- IS IT OKAY IF I
ADD TO THAT, DR. LIN?
>> PLEASE GO AHEAD.
>> I WAS GOING TO ECHO
DR. JENSEN'S COMMENT ABOUT FIND
THE MOST RELIABLE MEASURES
POSSIBLE FOR THE THINGS YOU'RE
INTERESTED IN.
I THINK SOMETIMES WHEN WE ARE
FIRST EXPOSED TO POWER ANALYSIS
AND THINK ABOUT POWER, WE THINK,
OH, POWER IS A FUNCTION OF
EFFECT SIZE AND POWER IS A
FUNCTION OF SAMPLE SIZE.
IT'S INCLUDED IN RELIABILITY
BECAUSE IF YOU HAVE A POOR
MEASURE THAT HAS A LOT OF NOISE
IN T THAT'S VARIABILITY YOU'LL
NEVER PREDICT SO YOUR EFFECT
SIZE GOES DOWN SIMPLY DUE TO
POOR MEASUREMENT.
AND SO IF UZ ARE LIMITED IN THE
SAMPLE SIZE THAT YOU CAN GET,
INVEST YOUR TIME IN IDENTIFYING
AND DEVELOPING HIGHLY RELIABLE
MEASURES.
ANOTHER THING THAT CAN HELP YOU,
AGAIN, IF YOU'RE WORKING WITH
LIMITED SAMPLE SIZE IS REPEATED
MEASURES.
SO IF YOU'RE DOING SOME KIND OF
A TREATMENT STUDY, IF YOU CAN
GET MULTIPLE PRE-TESTS AND
MULTIPLE POST-TESTS AND LOOK
TETRAJEK TRI SOMEONE K
TRAJECTORY, YOU CAN GAIN A LOT
OF POWER SIMPLY BY HAVING THOSE
REPEATED MEASURES.
SO SAMPLE SIZE, SAMPLE SIZE,
SAMPLE SIZE, SAMPLE SIZE PLUS
WILL ADD REPEATED LIABILITY AND
MEASURES ON TOP OF THOSE.
>> THIS IS ALL ABOUT SAMPLE
SIZE, RIGHT?
NEXT QUESTION IS DIRECT TO
LAUREN.
IT'S VERY INTERESTING DATA,
LAUREN.
DID YOU ASSESS PAIN
COMORBIDITIES IN THE PATIENTS
AND THEIR SPECIFIC DISEASE AND
HEALTH CONTROLS THAT YOU HAD
ENROLLED IN YOUR STUDIES, SINCE
COPCs COULD INFLUENCE THE
RESULTS?
NOW THE DISEASE SPECIFIED HERE
IS ME NIN --
>> THIS WAS ACTUALLY A BRAIN
LESION STUDY SO WE COMPARED
PATIENTS WITH LESIONS TO
CONTROLS AS WELL AS SAMPLE OF
PATIENTS WITH LESIONS IN OTHER
BRAIN AREAS, AND THERE WERE NO
DIFFERENCES IN ANY PAIN MEASURES
OR ANY PSYCHOLOGICAL INDICES.
SO REALLY, THE DIFFERENCES WE
SAW WERE SPECIFIC TO THIS
LEARNING COMPONENT.
AND TO OUR SURPRISE, THERE WERE
NO DIFFERENCES IN GENERAL
CHRONIC PAIN QUESTIONNAIRES OR
ANY KIND OF MEDICAL OR
PSYCHOLOGICAL FACTORS.
SO IT WAS QUITE SURPRISING TO US
BUT I THINK VERY CONSISTENT WITH
CURRENT VIEWS ON THE ROLE OF --
PREFRONTAL CORTEX.
>> THANK YOU VERY MUCH.
NEXT QUESTION IS DIRECT TO
DR. BAUER.
VERY INFORMATIVE TALK.
LATENT CLASS ANALYSIS AND A
SIMILAR APPROACH ARE BASED ON
PROBABILITY.
IN RESEARCH AND CLINICAL
PRACTICE, WHAT DO WE DO WITH
PEOPLE WHO DON'T FIT PERFECTLY
WITH ONE GROUP?
IN OTHER WORDS, NOT TYPICAL?
>> YEAH, THAT'S A GREAT
QUESTION.
ONE OF THE REASONS WHY I LIKE
LATENT PROFILE AND LATENT CLASS
ANALYSIS IS IT CREATES A FUZZY
CLUSTERING, SO IT'S NOT FORCING
A PARTITION ON YOUR SAMPLE, IT'S
SAYING, WELL, THIS PERSON HAS
90% CLANS OF BEING IN S
CLASS AND THIS PERSON HAS 60%
CHANCE OF BEING IN THIS CLASS.
IF YOU HAVE INDIVIDUALS THAT
DON'T CLASSIFY VERY NEATLY, THEY
MIGHT HAVE KIND OF A SPLIT.
YOU MIGHT NOT BE SURE.
THEY MIGHT BE OVER HERE, BUT
THEY ALSO MIGHT BE OVER THERE.
WE CAN CALCULATE ESSENTIALLY
WEIGHTED ESTIMATES OF WHAT
SOMETHING LIKE TREATMENT MIGHT
LOOK LIKE FOR THAT PERSON GIVEN
THEY'RE 60% LIKELY TO BE IN THIS
CLASS AND 40% LIKELY TO BE IN
THAT ONE.
SO IT'S CERTAINLY POSSIBLE TO
HAVE PEOPLE WHO KIND OF LIE IN
BETWEEN, AND THE WAY I LIKE TO
THINK ABOUT IT IS THE PROFILES,
THEY'RE SORT OF LIKE LANDMARKS
IN THIS COMPLEX MULTIDIMENSIONAL
SPACE OF ALL THESE VARIABLES,
RIGHT?
WE CAN'T THINK IN 10 CONTINUOUS
DIMENSIONS AT ONCE, BUT WE CAN
IDENTIFY PROFILES WITHIN THAT 10
DIMENSIONAL SPACE AND SAY OH,
THIS PERSON KIND OF LOOKS LIKE
THAT, OR THIS PERSON MIGHT BE IN
BETWEEN THESE TWO PROFILES BUT
LOOKS DIFFERENT THAN THOSE OTHER
THREE.
AND SO IN THAT SENSE, I THINK
IT'S OKAY TO HAVE SOME PEOPLE
WHO DON'T FALL NEATLY INTO ONE
CATEGORY VERSUS ANOTHER.
THERE ARE SOME MORE COMPLEX
APPROACHES THAT KIND OF ALLOW
FOR UNCLASSIFIABLE INDIVIDUALS,
SO YOU KIND OF HAVE LIKE A CLASS
THAT'S JUST ALMOST LIKE NOISE,
IT'S LIKE THE PEOPLE WHO DON'T
FIT, AND THEN THE OTHER CLASSES
CAPTURE THE DENSE REGIONS WHERE
YOU DO SEE PEOPLE KIND OF
CLUSTERING IN THEIR
CONFIGURATIONS.
>> THANK YOU, THANK YOU.
AND NEXT QUESTION IS DIRECT TO
DR. JENSEN.
THE QUESTION ACTUALLY FOLLOWS
WITH CLARIFICATION THAT IT'S NOT
RELATED TO COMMENTS ON NOT USING
P VALUE, SO THEN WE COME TO THE
QUESTION ITSELF.
DR. JENSEN, WOULD YOU ADVOCATE
FOR INSTEAD OF PHASING
IESKTTIVENESS
EFFECTIVENESS ON PATIENTS
EXPECTATIONS WHAT PAIN IS
MEANINGFUL TO THE PATIENTS?
IF SO, CAN YOU COMMENT ON HOW
YOU WOULD CONSIDER THIS IN THE
CONTEXT OF VARIABLE INDIVIDUAL
PATIENTS' EXPECTATIONS?
SHOULD WE BE MEASURING
EXPECTATIONS MORE CONSISTENTLY
AND USING THAT TO GUIDE OUR
TREATMENT?
SO ESSENTIALLY RELATED TO PAIN
AND EXPECTATION.
>> SO WE DO MEASURE OUTCOME
EXPECTANCIES IN EVERY ONE OF OUR
CLINICAL TRIALS.
I THINK IT'S IMPORTANT TO
MEASURE, AND I THINK IT'S
IMPORTANT TO EVALUATE WHAT IS
THE ROLE OF EXPECTANCIES IN THIS
PARTICULAR TREATMENT VERSUS
OTHER TREATMENTS, BECAUSE THEY
DO VARY FROM TREATMENT TO
TREATMENT.
SOME TREATMENTS ARE MORE
RESPONSIVE TO ECT PECK EXPN
OTHERS.
SO I DO THINK IT'S IMPORTANT TO
ASSESS IT IN EVERY TRIAL,
EXAMINE THAT, AGAIN, OFTEN IN
SECONDARY ANALYSES.
I WASN'T -- IF I UNDERSTOOD THE
FIRST PART OF THE QUESTION
CORRECTLY ABOUT LOOKING AT
MEANINGFUL CHANGE IN PAIN, IN
OUR STUDIES, WE OFTEN MEASURE
NOT JUST IS THERE A
STATISTICALLY SIGNIFICANT
DIFFERENCE BETWEEN THE
CONDITIONS, WHICH IS OFTEN OUR
PRIMARY ANALYSIS, BUT AGAIN,
ANOTHER SECONDARY ANALYSIS IS A
RESPONDER ANALYSIS.
HOW MANY PEOPLE IN EACH GROUP
OBTAINED A MEANINGFUL CHANGE IN
PAIN.
AND THE STANDARD IN THE FIELD IS
USUALLY ABOUT TWO POINTS ON A
ZERO TO 10 SCALE FOR SOMEBODY TO
REPORT THAT MUCH CHANGE, PEOPLE
ON AVERAGE SAY THAT WAS
MEANINGFUL TO ME.
IT WASN'T AN ELIMINATION, IT
WASN'T A COMPLETE REDUCTION, BUT
MEANINGFUL.
LESS THAN 2 OUT OF 10, PEOPLE
CAN NOTICE, BUT THEY SAY OFTEN
IT WASN'T THAT MEANINGFUL.
SO I THINK IT'S VERY USEFUL TO
INCLUDE RESPONDER ANALYSES IN
YOUR ANALYSES AND THEN LOOK AT
PREDICTS WHO RESPONDS TO THIS
TREATMENT, WHO IS A RESPONDER
VERSUS A NON-RESPONDER.
AGAIN, THESE ARE SECOND DI SECOY
ANALYSES, OF WHICH THERE ARE
TENS AND MAYBE EVEN A HUNDRED
WHEN THEY'RE REPORTED, SO IT'S
IMPORTANT TO SAY, TO MAKE IT
CLEAR, THESE ARE SECONDARY
EXPLORATORY ANALYSES THAT THEN
NEED TO BE REPLICATED.
BUT GET THEM IN THE FIELD, I
WOULD SAY SUBMIT THOSE TO THE
JOURNAL OF PAIN.
THANK YOU FOR THE CITATIONS FOR
THOSE OF YOU SPEAKERS WHO
REPORTED YOUR RESULTS FROM THE
JOURNAL PAIN, BUT I'M LEAVING AS
EDITOR THIS MONTH SO I WON'T BE
NECESSARILY ADVOCATING STRONGLY
FOR THE JOURNAL PAIN OTHER THAN
IT'S A GREAT JOURNAL.
BUT ANYWAY, AS AN EDITOR, I LOVE
TO SEE SECONDARY ANALYSES ABOUT
THESE CRITICAL ISSUES.
>> WONDERFUL, WONDERFUL.
NOW, THE CORE QUESTION FOR THIS
PANEL REALLY IS ABOUT THE TWO
WORLDS AND APPROACHES THAT CAN
BE USED TO ADDRESS THE BIG
QUESTION THAT RAISED IN THIS
YEAR'S SYMPOSIUM, THAT IS, WHOLE
BODY, WHOLE PERSON APPROACH.
NOW WE DEFINITELY TALK A LOT
ABOUT DIFFERENT APPROACHES,
DIFFERENT TOOLS, AND THERE'S
EVEN MORE, WE DO NOT HAVE ENOUGH
TIME TO COVER, AND ALSO THE
DIRECTIONS PRESENT IN YOUR
OVERVIEW -- NOW ONE OF THE
THINGS THAT YOU ALSO MENTIONED
THIS PROBLEMATIC APPROACH, THAT
IN FACT WE TALK VERY LITTLE -- I
MEAN, THE QUESTION RAISED VERY
LITTLE ADDRESS TO THAT.
MOST QUESTIONS STILL ADDRESS TO
HOW TO DESIGN THE STUDY.
HOWEVER, THE PRAGMATIC APPROACH
REALLY IS TALKING ABOUT WHAT
HAPPENED REAL WORLD FOR THE
PURPOSE OF TREATMENT.
SO I JUST WONDER, ANOTHER
APPROACH WE NEVER MENTIONED HERE
COULD BE USEFUL, I INVITE
COMMENTS FROM MY PANEL MEMBERS,
THAT IS DATA SCIENCE.
IF WE COMBINE THE PRAGMATIC
APPROACH, NOT NECESSARILY
PRAGMATIC TRIAL BECAUSE THIS MAY
HAVE DIFFERENT DEFINITIONS IN
DIFFERENT PEOPLE'S MIND, BUT I'M
TALKING ABOUT THE REAL WORLD
APPROACH, COMBINED WITH BIG DATA
SCIENCE, COMPUTATIONAL SCIENCE
AND COMBINE THOSE DIFFERENT
APPROACHES TO ADDRESS REAL WORLD
QUESTIONS.
MIGHT THAT BE A WAY TO RESOLVE
SOME ISSUES LIKE POWER ANALYSIS?
WE MENTIONED WE TALK A LOT,
THERE'S OTHER QUESTIONS RELATED
TO THAT, SO I WILL STOP HERE AND
JUST INVITE YOUR COMMENTS, MY
PANEL MEMBERS.
>> SO THE QUESTION IS,
BASICALLY, IF WE MOVE TOWARD BIG
DATA AND NATURALISTIC DATA, WILL
IT HELP ADDRESS SOME OF THESE
QUESTIONS?
>> LET ME ELABORATE FROM A
DIFFERENT APPROACH.
NOW, GOOGLE.
GOOGLE MAKES A BIG SPLASH A FEW
YEARS AGO ANNOUNCING THAT THEY
ARE ABLE TO PREDICT THE
INFLUENZA, THE FLU SEASON.
WITHOUT ANY BIOLOGICAL DATA.
WHAT THEY ARE BASED ON IS HOW
MUCH THE FACE MASK HAVE BEEN
SOLD IN ONE AREA.
IN COMPARISON TO OTHER.
AND THAT GIVES THEM A HINT.
AND THAT'S BASED UPON SALES AND
THERE'S BIG DATA COLLECT ALL
TOGETHER, GIVE THEM THE POWER TO
PREDICT THAT.
AND THAT TURNED OUT TO BE VERY
ACCURATE.
SO I'M THINKING IN THE CLINICAL
PRACTICE THAT EVERY -- IF WE
HAVE THE SYSTEM.
I'M ASKING THIS WITHOUT THINKING
HOW MUCH COST THERE WOULD BE AND
IT MIGHT NOT BE -- IT MIGHT BE A
LOT, JUST TALKING ABOUT APPROACH
SAYING ALL CLINICS, WE COLLECT
SYMPTOMS, AND WE -- SYMPTOMS
RELATED TO PAIN WITH DIFFERENT
TREATMENTS, AND ACCUMULATE ALL
THE PIECES OF INFORMATIONS AND
OF COURSE GRADUALLY AFTER A
WHILE, WE CAN IDENTIFY WHAT ARE
MEANINGFUL DATA ELEMENTS THAT
CAN BE USED FOR BIG DATA
APPROACHES THAT MAY GIVE US A
DIFFERENT ANGLE TO ADDRESS THE
ISSUES OF THEIR WHOLE PERSON OR
WHOLE BODY APPROACH.
YES.
>> 2-MINUTE WARNING.
>> I'LL MAKE A QUICK COMMENT.
I THINK IT DEPENDS ON HOW GOOD
OUR DATA ARE.
IF ALL OF OUR DATA ARE MEASURED
ON WHITE MALES, THEN I THINK
THAT THE MACHINE LEARNING
APPROACHES AND ALL THAT ARE
GOING TO BE BIASED JUST LIKE OUR
TREATMENTS CURRENTLY ARE, SO WE
KNOW THAT WOMEN AND NON-WHITE
INDIVIDUALS ARE LESS LIKELY TO
BE TREATED FOR PAIN, AND THE
STIMULUS SETS THAT WE HAVE OF
PATIENTS AND PAIN THAT ARE USED
FOR TREATMENT ARE GENERALLY ALL
WHITE INDIVIDUALS.
SO I THINK THAT ANY OF THESE
KINDS OF BIG DATA APPROACHES ARE
SENSITIVE TO WHAT DATA ARE PUT
INTO THE MODELS, AND SO I THINK
WE AS RESEARCHERS AND CLINICIANS
HAVE A RESPONSIBILITY TO MAKE
SURE THAT THE DATA THAT ARE USED
FOR THESE KINDS OF APPROACHES
ARE REPRESENTATIVE OF THE
POPULATION THAT WE KNOW THE
LIMITATIONS IN THESE APPROACHES.
SO I THINK LIKE A.I. IS GREAT,
BUT IT DEPENDS ON HOW GOOD THE
DATA ARE.
WE KNOW THERE'S A LOT OF BIASES
THERE.
SO THAT'S MY 2 CENTS.
>> WE HAVE ABOUT 30 SECONDS.
ANY LAST COMMENTS?
IF NOT, I WOULD LIKE TO TAKE
THIS OPPORTUNITY TO THANK YOU
VERY MUCH, ALL OF MY SPEAKERS,
AND VERY ENJOYABLE TO WORK
TOGETHER ON THIS PANEL.
THANK YOU VERY MUCH.
>> THANK YOU.
>> THANK YOU, EVERYONE, FOR THAT
WONDERFUL TALK.
I'M MO NOW GOING TO INTRODUCE MY
COLLEAGUE, DR. SARAH WOLLER.
SHE IS THE SCIENTIFIC PROJECT
MANAGER WITHIN THE NATIONAL
INSTITUTE OF NEUROLOGICAL
DISORDER AND STROKE DIVISION AND
SHE'S GOING TO TAKE US THROUGH
OUR SECOND JUNIOR POSTER
SESSION.
THANKS.
>> THANKS FOR THAT INTRODUCTION.
SO AS THE FIRST SESSION, WE'LL
HAVE FIVE PRERECORDED TALKS AND
WE WILL HAVE TIME FOR QUESTIONS
FOLLOWING THE TALK VIDEOS.
SO IF YOU HAVE QUESTIONS, PLEASE
PUT THEM IN THE Q & A BOX.
TODAY OUR SPEAKERS INCLUDE MOLLY
JARMAN, ASSISTANT PROFESSOR OF
SURGERY AT BRIGHAM AND WOMEN'S
HOSPITAL IN HARVARD MEDICAL
SCHOOL, AND SHE'LL BE PRESENTING
A PRE-HOSPITAL OPIOIDS AND SHORT
TERM OUTCOMES FOR OLDER ADULTS
WITH FALL-RELATED INJURY.
NEXT WILL BE MAICHOU LOR,
ASSISTANT PROFESSOR AT THE
UNIVERSITY OF WISCONSIN-MADISON
SCHOOL OF NURSING PRESENTING
"ENGAGING A LIMITED ENGLISH
PROFICIENT POPULATION IN
DESIGNING AND EVALUATING A PAIN
QUALITY ASSESSMENT INFORMATION
VISUALIZATION TOOL TO IMPROVE
PATIENT-INTERPRETER-PROVIDER
COMMUNICATION."
NEXT WILL BE LIZ LOSIN,
ASSISTANT PROFESSOR IN THE
DEPARTMENT OF PSYCHOLOGY AT
UNIVERSITY OF MIAMI, AND SHE'LL
BE PRESENTING "SOCIOCULTURAL
MECHANISMS UNDERLYING
DISPARITIES PAIN ASSESSMENT AND
TREATMENT DURING TELEMEDICINE."
NEXT WILL BE SARAH NELSON,
ASSISTANT PROFESSOR IN THE
DEPARTMENT OF PSYCHIATRY AT
HARVARD MEDICAL SCHOOL AND
DEPARTMENT OF ANESTHESIOLOGY
CRITICAL CARE AND PAIN MEDICINE
AT BOSTON CHILDREN'S HOSPITAL,
AND SHE'LL BE PRESENTING THE
ROLE OF NEUROBIOLOGICAL
MECHANISMS OF STRESS IN PAIN
MAINTENANCE AND MIND-BODY
INTERVENTION RESPONSE IN YOUTH
WITH CHRONIC PAIN.
AND FINALLY, ELLEN STAEDTLER,
VISITING FELLOW IN THE
DEPARTMENT OF PERIOPERATIVE
MEDICINE AT THE NIH CLINICAL
CENTER WILL BE PRESENTING "STEP
BY STEP TOWARDS IMPROVED HEALTH
SENSORY PHENOTYPING OF FEET
AFFECTED BY MORTON'S NEUROMA AND
REDUCING REFRACTORY PAIN WITH AN
INJECTION OF RESINIFERATOXIN."
SO AT THIS TIME WE'LL PLAY THE
VIDEOS.
>> HELLO.
I'M MOLLY JARMON.
THE WORK I'M PRESENTING TODAY
WAS SUPPORTED BY A K01 AWARD
FROM THE NATIONAL INSTITUTE ON
AGING.
3 MILLION OLDER ADULTS
EXPERIENCE A FALL-RELATED INJURY
EACH YEAR IN THE UNITED STATES.
ACCOUNTING FOR 17% OF ALL
911 CALLS FOR EMERGENCY MEDICAL
ASSISTANCE.
NATIONAL GUIDELINES FOR EMS CARE
RECOMMEND OPIOID ANALGESIA FOR
THE TREAT M OF TREATMENT E
INJURED PATIENTS REACH THE
HOSPITAL.
PAIN MANAGEMENT IN OLDER ADULTS
REQUIRE SPECIAL CONSIDERATION
DUE TO THE RISK OF DELIRIUM,
WHICH IS INCREASED BOTH BY
PSYCHOACTIVE MEDICATIONS LIKE
OPIOIDS AND BY SEVERE ACUTE
PAIN.
CURRENTLY, THERE ARE NO SPECIFIC
GUIDELINES FOR PRE-HOSPITAL PAIN
MANAGEMENT IN OLDER ADULTS.
OUR EARLY WORK IN THIS DOMAIN
SHOWS THAT 7% OF INJURED OLDER
ADULTS RECEIVE OPIOIDS IN THE
PRE-HOSPITAL SETTING.
AND TREATMENT OF PAIN WAS
CORRELATED WITH HIGHER PAIN
SCORES AND MORE SEVERE INJURIES.
AND WAS NOT ASSOCIATED WITH
INCREASED RISK OF COMPLICATIONS
SUCH AS ALTERED MENTAL STATUS OR
RESPIRATORY DISTRESS REPORTED BY
EMS.
TO DETERMINE IF PRE-HOSPITAL
OPIOID PAIN MANAGEMENT WAS
ASSOCIATED WITH SHORT TERM
CLINICAL OUTCOMES FOLLOWING
FALL-RELATED INJURY, WE LINKED
EMS PATIENT CARE REPORTS FROM
THE ILLINOIS DEPARTMENT OF
PUBLIC HEALTH WITH MEDICARE
CLAIMS DATA FOR OLDER ADULTS
DIAGNOSED WITH A FALL IN 2014
AND 2015.
WE USED INVERSE PROBABILITY OF
TREATMENT WAITING TO ADJUST FOR
COMPOUNDING BY AGE, SEX, RACE,
FRAILTY, COMORBIDITIES, INJURY
SEVERITY, PRESENCE OF A
TRAUMATIC BRAIN INJURY, TOTAL
PRE-HOSPITAL TIME, PRE-HOSPITAL
VITAL SIGNS AND TRAUMA CENTER
DESIGNATION.
WE USED REGRESSION TO COMPARE
TOTAL PATIENT DAYS AND INTENSIVE
CARE DAYS -- FOR PATIENTS WITH
AND WITHOUT PRE-HOSPITAL OPIOID
PAIN MANAGEMENT.
IN OUR SAMPLE OF 28,000 OLDER
ADULTS, 70% WERE FEMALE, 94%
WERE WHITE AND THE MEAN AGE WAS
82.
3% RECEIVED A A PRE-HOSPITAL
OPIOID PAIN MANAGEMENT, THE MEAN
LENGTH OF STAY WAS 4 DAYS, 2%
WERE DIAGNOSED WITH DELIRIUM
DURING THEIR HOSPITAL STAY.
PRE-HOSPITAL OPIOID PAIN
MANAGEMENT WAS ASSOCIATED WITH A
9% DECREASE IN TOTAL LENGTH OF
STAY AND A 20% DECREASE IN ICU
LENGTH OF STAY, WHILE ODDS OF
DELIRIUM DIAGNOSIS WERE NOT
SIGNIFICANTLY DIFFERENT FOR
PATIENTS WITH AND WITHOUT
PRE-HOSPITAL OPIOID PAIN
MANAGEMENT.
OUR FINDINGS SHOW PRE-HOSPITAL
OPIOID MANAGEMENT DOES NOT
DECREASE FOR ADULTS WITH A FALL
RELATED INJURY AND MAY REDUCE
TIME SPENT IN THE HOSPITAL.
OUR NEXT STEPS INCLUDE
ASSESSMENT OF LONG TERM OUTCOMES
INCLUDING DEMENTIA AND CHRONIC
PAIN --
>> HI, I'M AN ASSISTANT
PROFESSOR FROM THE UNIVERSITY OF
WISCONSIN-MADISON.
CURRENTLY THERE ARE NO
CULTURALLY APPROPRIATE
INFORMATION VISUALIZATION INFO
VIZ TOOLS FOR LEP PATIENTS AND
INTERPRETERS TO COMMUNICATE WITH
HEALTHCARE PROVIDERS DURING PAIN
ASSESSMENT AND MANAGEMENT.
THE PURPOSE OF THIS STUDY WAS TO
DEVELOP A CULTURALLY APPROPRIATE
INFO VIZ PAIN QUALITY ASSESSMENT
TOOL USING A MULTISTEP USER
CENTERED APPROACH.
WE CONDUCTED THIS STUDY IN THREE
PHASES ADDRESSING THREE AIMS.
PHASE ONE ADDRESSES A1 WHERE LEP
AND BILINGUAL HMONG PARTICIPANTS
AND INTERPRETERS EVALUATED AND
PROVIDED SUGGESTIONS DOCTOR FOR
INITIAL SET OF PAIN QUALITY
INFOGRAPHICS CREATED IN A
PREVIOUS STUDY.
PHASE TWO ADDRESSES WHERE WE
NARROW THE NUMBER OF PAIN INFO
GRAPHICS TO 15 AND CONDUCTED
CARD SORTING SESSIONS TO GATHER
DATA ON ORGANIZING THE 15 PAIN
QUALITY INFOGRAPHICS ON INVO VIZ
TOOL ACCORDING TO THE MENTAL
MODELS OF THE YOUNG ADULTS.
PHASE 3 ADDRESSES AIM 3 WHICH IS
TO IDENTIFY A TOOL THAT
ACCURATELY REPRESENT MENTAL
MODEL AND IS PREFERRED TO BE
USED IN THE CLINICAL SETTING.
OVERALL, THE MAJORITY OF
PARTICIPANTS WERE FEMALE WITH
THE MEAN AGE OF 62 FOR LEP
HMONG, 39.5 FOR BILINGUAL HMONG,
AND 39 FOR HMONG INTERPRETERS.
FOR AIM ONE, THERE WERE THREE
COMMON THEMES THAT AROSE FROM
PARTICIPANTS' SUGGESTIONS DURING
THE PARTICIPATORY DESIGN
SESSIONS.
THE FIRST WAS THE USE OF
CULTURALLY RELEVANT COLORS.
PARTICIPANTS CONSISTENTLY
EMPHASIZED TWO COLORS THAT HAVE
CULTURE MEANINGS AS VISUAL
SYMBOLS, RED AND WHITE.
RED CULTURALLY INDICATE PAIN OR
HURTING AND DIFFERENT SHADES OF
RED INDICATE PAIN SEVERITY.
FOR EXAMPLE, LIGHT RED IS LESS
INTENSE PAIN WHILE DARK RED IS
MORE OR SEVERE PAIN.
HENCE PARTICIPANTS ADJUSTED
ADDING RED TO PAIN QUALITY THAT
THEY PERCEIVE AS PAINFUL, AND
THIS IS ALSO ILLUSTRATED IN THE
SAMPLE QUOTE HERE.
SEVERAL PARTICIPANTS SUGGESTED
THAT CREAMY WHITE SHOULD
REPRESENT NUMBNESS TO
DISTINGUISH IT FROM PAIN SINCE
IT DID NOT ASSOCIATE NUMBERS
WITH PAIN.
THE SECOND THING WAS USE OF INFO
GRAPHICS TO RESEMBLE HUMAN
ANATOMY.
MANY EXPRESS THAT WITHOUT HUMAN
FIGURE IT WAS UNCLEAR WHETHER
THE PAIN WAS REAL AND THEY COULD
NOT UNDERSTAND WHAT THE PAIN
WAS.
THE THIRD THING WAS THE USE OF
ACTION-SPECIFIC QUIGLEY LINES.
PARTICIPANTS CONSISTENTLY
REQUESTED SQUIGGLY BEING BE
ADDED FOR CRAMPS, NUMBNESS,
SORENESS, PRESSURE AND ACHINESS
AS ILLUSTRATED IN THIS QUOTE.
FOR AIM TWO, WE IDENTIFIED THREE
MAIN THEMES FROM THE CODE
SORTING SESSION AMONG
PARTICIPANT CREATED CATEGORIES.
THESE INCLUDED SENSATION,
LOCALIZATION, AND SEVERITY.
FOR AIM THREE, 13 OF THE
21 PARTICIPANTS SELECTED THE
LOCALIZATION OF PAIN QUALITY AS
THE MOST APPROPRIATE TOOL
REPRESENTING THEIR MENTAL MODEL
AS PREFER TO USE IT IN THE
CLINICAL SETTINGS.
IN CONCLUSION, WE USE A
MULTISTEP USER CENTERED APPROACH
TO -- ASSESSMENT TOOL FOR
QUALITY OF PAIN IN LEP HMONG
PATIENTS.
WE ARE CURRENTLY TESTING THIS
TOOL IN THE PRIMARY CARE SETTING
AND HOPE THAT IT WILL INCREASE
THE CHANCES OF SUCCESSFUL
IMPLEMENTATION.
THANK YOU.
>> HI.
I'M DR. ELIZABETH LOSIN,
CURRENTLY ASSISTANT PROFESSOR IN
THE DEPARTMENT OF PSYCHOLOGY AT
THE UNIVERSITY OF MIAMI.
IN MARCH 2023, I'LL BE STARTING
A POSITION AS THE BENNETT PIERCE
ASSOCIATE PROFESSOR OF CARING
AND COMPASSION IN ADULTHOOD IN
THE DEPARTMENT OF BIOBEHAVIORAL
HEALTH AT PENN STATE UNIVERSITY.
TODAY I'M GOING TO BE PRESENTING
PRELIMINARY RESULTS FROM A STUDY
ON SOCIOCULTURAL MECHANISMS
UNDERLYING DISPARITIES IN PAIN
ASSESSMENT AND TREATMENT DURING
TELEMEDICINE.
SUPPORTED BY MY K01 AWART FROM
THE NATIONAL INSTITUTE ON DRUG
ABUSE.
OUR MAIN RESEARCH QUESTION WAS
HOW DO CLINICIANS CONTRIBUTE TO
PAIN TREATMENT DISPARITIES,
NAMELY, WOMEN AND MINORITIZED
INDIVIDUALS TEND TO BE
PRESCRIBED LESS PAIN
TERRITORIMENT THAN IS CLINICALLY
INDICATED LEADING TO POOR PAIN
MANAGEMENT IN THESE GROUPS,
WHILE MEN AND NON-HISPANIC WHITE
INDIVIDUALS ARE OFTEN PRESCRIBED
MORE PAIN TREATMENT THAN IS
CLINICALLY INDICATED
CONTRIBUTING TO THE OPIOID
EPIDEMIC.
WE HAD MEDICAL STUDENTS AND
RESIDENTS PLAY THE ROLE OF
CLINICIANS IN SIX TELEMEDICINE
APPOINTMENTS EACH.
PATIENTS WERE TRAINED COMMUNITY
MEMBERS WITH FICTITIOUS SHOULDER
INJURIES, ALL MET CLINICAL
CRITERIA FOR THE USE OF OPIOID
ANALGESICS.
EACH CLINICIAN WOULD TAKE A
MEDICAL HISTORY, PERFORM THE
MAYO CLINIC REMOTE
MUSCULOSKELETAL SHOULDER EXAM.
YOU CAN SEE A SCREEN SHOT HERE.
THEY'RE NOT JUST DOING A DAB.
AND FINALLY, THE CLINICIAN WOULD
MAKE AN ASSESSMENT OF THE
PATIENT'S PAIN AND
PHARMACOLOGICAL AND
NON-PHARMACOLOGICAL TREATMENT
DECISIONS.
MY GRADUATE STUDENT AND I USED
STRUCTURAL EQUATION MODELING TO
TEST WHETHER PATIENT
DEMOGRAPHICS INFLUENCE PAIN
ASSESSMENT AND TREATMENT
DECISIONS, AND IF SO, WHETHER
DEMOGRAPHIC STEREOTYPES AND
OPIOID ABUSE STEREOTYPES
MEDIATED THIS RELATIONSHIP.
WE ALSO CONTROLLED FOR SEVERAL
VARIABLES INCLUDING THE
CLINICIAN'S MEDICAL EXPERIENCE.
INTERESTINGLY, IN THE 119
INTERACTIONS ANALYZED HERE,
ABOUT 30% OF OUR FINAL SAMPLE,
PATIENT RACE AND ETHNICITY DID
NOT INFLUENCE PAIN ASSESSMENT
AND TREATMENT HOWEVER, IN THE
RED PACK, YOU CAN SEE THAT THE
MORE SENSITIVE THE CLINICIAN
PERCEIVED THE TYPICAL PERSON
FROM THAT PERSON'S RACIAL GROUP,
THE MORE INTENSE THEY PERCEIVED
THAT PATIENT'S PAIN.
AND THE MORE LIKELY THEY
REPORTED THEY WOULD BE TO
PRESCRIBE THEM OPIOIDS.
STRIKINGLY, THE RATINGS THE
PATIENTS PROVIDED OF THEIR OWN
PAIN IN BLUE DURING THE CLINICAL
EXAM DID NOT INFLUENCE THE
CLINICIAN'S PERCEPTIONS OF THEIR
PAIN INTENSITY OR LIKELIHOOD OF
PRESCRIBING ANALGESICS.
TOGETHER THESE PRELIMINARY DATA
SUGGEST THAT UNDER SOME
CIRCUMSTANCES, CLINICIANS MAY
RELY MORE HEAVILY ON THEIR
STEREOTYPES ABOUT THE TYPICAL
PAIN SENSITIVITY OF PEOPLE FROM
A PATIENT'S ETHNIC OR RACIAL
GROUP THAN THE PATIENT'S OWN
PAIN REPORT.
PROVIDING A POTENTIAL TARGET FOR
INTERVENTION.
THANKS.
>> HELLO, DR. SARAH NELSON,
PRESENTING ON MY RESEARCH
LOOKING AT THE NEUROBIOLOGICAL
MECHANISMS OF STRESS IN
PEDIATRIC CHRONIC PAIN.
WE KNOW PEDIATRIC CHRONIC PAIN
IS A SERIOUS PUBLIC HEALTH ISSUE
AND IS OFTEN ASSOCIATED WITH
HIGH LEVELS OF PSYCHOLOGICAL
STRESS AND EXPOSURE TO ADVERSE
CHILD HOOD EXPERIENCES.
PRELIMINARY MECHANISTIC WORK HAS
ALSO IDENTIFIED ALLOSTATIC LOAD
AND BRAIN DEVELOPMENT INCLUDING
THE HIPPOCAMPUS AS POTENTIALLY
IMPLICATED IN PARALLELS BETWEEN
STRESS AND PAIN PERCEPTION AND
PAIN RESPONSE, HOWEVER, THESE
REMAIN POORLY UNDERSTOOD.
IN ADDITION TO THIS,
INTERVENTIONS THAT ADDRESS THE
MALADAPTIVE STRESS RESPONSE LIKE
MINDFULNESS BASED THERON HAVE
BEEN PROPOSED TO BE PARTICULARLY
RELEVANT TO PEDIATRIC CHRONIC
PAIN DUE TO THEIR PREVIOUS
EVIDENCE IN MODULATING STRESS
AND ALTERATIONS IN THESE AREAS
HOWEVER THESE INTERVENTIONS IN
PEDIATRIC CHRONIC PAIN
POPULATIONS PARTICULARLY FROM A
MECHANISTIC STANDPOINT HAVEN'T
BEEN SIGNIFICANTLY STUDIED.
THEREFORE, OBJECTIVES OF MY
CURRENT INVESTIGATION INCLUDE
SUMMARIZING MY RESEARCH TO DATE
AND NUMBER TWO, HIGHLIGHTING AN
ONGOING RESEARCH FUNDED BY NCCIH
THAT LOOKS AT THESE MECHANISMS
IN RELATION TO MIND-BODY
INTERVENTION RESPONSE IN
PEDIATRIC CHRONIC PAIN.
PRIMARY RESULTS OF MY STUDIES
LOOK AT ALLOSTATIC LOAD AND HAVE
FOUND THAT OVER 50% OF YOUTH
WITH CHRONIC PAIN ARE AT HIGH
RISK FOR ALLOSTATIC LOAD MEANING
GREATER THAN TWO RISK FACTORS.
WE'VE ALSO FOUND ALLOSTATIC LOAD
MODERATE THE -- WHICH HIGHLIGHT
THE POTENTIAL ROLE OF STRESS,
WEAR AND TEAR AND MODULATED PAIN
RELATED FUNCTIONING.
IN THE CONTEXT OF MY K23, THE
AIMS ARE TO FURTHER ELUCIDATE
THE ROLE OF ALLOSTATIC LOAD AND
BRAIN BASED MALL ADAPTATION TO
STRESS IN MIND-BODY INTERVENTION
RESPONSE TO GET A BETTER
UNDERSTANDING OF THE MECHANISMS
OF THESE INTERACTIONS AND
INTERVENTIONS, I'M RECRUITING
YOUTH WITH CHRONIC WIDESPREAD
PAIN, A BASELINE VISIT INVOLVES
AN FMRI AND QUANTITATIVE SENSORY
TESTING IN ADDITION TO A
MULTIFACTORIAL ALLOSTATIC LOAD
COMPOSITE INCLUDING
GLUCOCORTICOIDS, WAIST-HIP RATIO
AND BMI AND THEN WE'RE GOING TO
BRING THEM BACK FOR FOLLOW-UP
FOR REPEAT COLLECTION OF
ALLOSTATIC LOAD.
PRELIMINARY RESULTS IN MY
RECRUITED PATIENTS TO DATE FOR
PAIN AND FOR HEALTHY CONTROLS
OBVIOUSLY INTERPRETED WITH
CAUTION BUT SHOW THAT YOUTH WITH
CHRONIC PAIN ON AVERAGE ENDORSE
OVERWHELMINGLY MUCH HIGHER RATE
OF TRAUMATIC EVENT EXPOSURE THAN
HEALTHY CONTROLS.
PRELIMINARY IMAGING ANALYSES IN
RESTING STATE ALSO FOUND
SIGNIFICANT DIFFERENCES IN THE
PERIHIPPOCAMPAL GYRATION AND
LEFT HIPPOCAMPUS, SO INTERESTING
PRELIMINARY RESULTS.
SIGNIFICANCE OF THESE FINDINGS
SHOW THAT EVIDENCE OF ALLOSTATIC
LOAD RISK FACTORS AND FUNCTIONAL
CONNECTIVITY MAY BE IMPORTANT TO
LOOK AT AND WOULD OFFER STRONG
SUPPORT FOR TARGETING THE
PHYSIOLOGICAL RESPONSE FOR USING
A MIND-BODY APPROACH.
THANK YOU.
>> MY A VISITING FELLOW IN THE
DEPARTMENT OF PERIOPERATIVE
MEDICINE.
ON THE BASIC SIDE OUR LAB IS
INTERESTED IN THE MOLECULAR
MECHANISMS UNDERLYING ACUTE AND
CHRONIC PAIN.
ON THE CLINICAL SIDE, WE FOCUS
ON OTHER TREATMENTS FOR RELIEF
OF REFRACTORY PAIN.
INJURY INDUCED NEUROPA TICK NEWN
PROBLEMS FALL INTO THIS CLASS.
MORTON'S NEUROMA IS A HIGHLY
LOCALIZED LESION IN THE BOTTOM
OF THE FOOTWEAR THE NERVE IS
NATURALLY EXPOSED TO REPEATED
MECHANICAL STRESS.
WHICH CAN BE AGGRAVATED BY
ENGAGING HIGH IMPACT SPORTS,
POOR FOOTWEAR CHOICES.
IN SOME INDIVIDUALS, THIS LEADS
TO AXONAL DAMAGE, ENLARGEMENT TO
FORM A NEUROMA.
WE DESIGNED A CLINICAL TRIAL TO
TREAT MORTON'S NEUROMA PATIENTS
WITH REFRACTORY PAIN AFTER
NON-SURGICAL PROCEDURES.
THE POTENTIAL KEY SET OF
NOCICEPTIVE -- TRIP V1.
WE KNOW FROM ANIMAL STUDIES AND
OTHER CLINICAL TRIALS THAT A
ONE-TIME INJECTION OF RTX LEADS
TO A LONG LASTING PAIN
REDUCTION.
RTX IS A VERY OLD REMEDY DIRECT
FROM THE PLANT -- RTX EXPOSURE
LEADS TO OVERFLOW INTO FIBERS
AND CONDUCTION BLOCK THAT LASTS
AT LEAST SEVERAL MONTHS.
THIS IS SELECTIVE AND DOES NOT
AFFECT MECHANICAL SENSATIONS OR
MOTOR FUNCTION.
WE ALSO AIM TO UNDERSTAND THE
UNDERLYING PATHOPHYSIOLOGY TO
ESTABLISH COLLABORATION WITH
LOCAL PODIATRISTS THAT PROVIDE
US WITH SURGICAL SPECIMENS OF
THE NEUROMA.
THIS ALLOWS US TO STUDY IN
COMPARISON TO HEALTHY NERVE
FIBERS AND POTENTIALLY IDENTIFY
ADDITIONAL PHARMACOLOGICAL
TARGETS FOR PAIN TREATMENT.
IN COLLABORATION WITH THE PAIN
RESEARCH CENTER, WE CHARACTERIZE
THE SENSORY PROFILES OF PATIENTS
WITH MORTON'S NEUROMA BY
APPLYING A COMPREHENSIVE SET OF
MECHANICAL AND THERMAL
SOMATOSENSORY TESTS.
THESE TESTS WILL NOT ONLY REVEAL
HOW PATIENTS WITH MORTON'S
NEUROMA PERCEIVE DIFFERENT
SENSORY STIMULI BUT ALSO PROVIDE
SAFETY AND EFFICACY OUT COME
MEASURES OF CLINICAL TRIAL.
WE THINK THAT THE KNOWLEDGE WE
GATHER FROM THIS PROJECT WILL BE
APPLICABLE -- POTENTIALLY
RELIEVE THESE PATIENTS' PAIN.
THANK YOU.
THANKS TO ALL THE PEOPLE
INVOLVED IN THIS PROJECT.
>> ALL RIGHT, THANK YOU,
EVERYONE, FOR THOSE
PRESENTATIONS.
IF YOU WOULD ALL TURN ON YOUR
CAMERAS NOW, WE CAN GO TO A FEW
QUESTIONS.
THE FIRST QUESTION I HAVE IS FOR
DR. JAR MAN, ONLY ASSOCIATED
WITH OPIOIDS OR WITH OTHER
ANALGESICS POTENTIALLY HAVE A
SIMILAR EFFECT?
>> SO I WOULD SAY THE SHORT
ANSWER IS WE DON'T KNOW.
LIKELY WE WOULD SEE A SIMILAR
BENEFICIAL EFFECT, THE BENEFIT
IS FROM MANAGING THE PAIN.
CURRENTLY THERE ARE NO
ALTERNATIVES AVAILABLE FOR
MANAGEMENT OF THAT TYPE OF
SEVERE ACUTE PAIN FROM SOMETHING
LIKE A HIP FRACTURE: THE
OPTIONS ARE IBUPROFEN AND
USUALLY FENTANYL.
>> GREAT.
THANK YOU.
IN A FOLLOW-UP QUESTION, THE
MAJORITY OF THE PEOPLE IN YOUR
STUDY WERE WHITE FEMALES.
CAN YOU COMMENT ABOUT WHETHER
YOU EXPECT YOUR RESULTS TO
GENERALIZE TO OTHER POPULATIONS?
>> SO THE POPULATION, IT IS
PRIMARILY WHITE FEMALES, IS
ACTUALLY FAIRLY REPRESENTATIVE
OF THE POPULATION EXPERIENCING
THESE INJURIES AT THAT AGE
RANGE.
I DON'T HAVE ANY REASON TO
BELIEVE THE EFFECTS WOULD BE
DIFFERENT.
THE ONLY MECHANISMS I CAN REALLY
THINK OF WOULD BE VARIATION IN
KIND OF PROFILE OF
COMORBIDITIES.
ONE IN PARTICULAR BEING PEOPLE
WHO MIGHT BE IN THE EARLY STAGES
OF COGNITIVE DECLINE AND
EXPOSURE MIGHT -- DEMENTIA.
AT THE SAME TIME EXPOSURE TO
PAIN MAY ALSO PRECIPITATE THEIR
DEMENTIA, SO IT WOULD BE GREAT
TO HAVE ACCESS TO DATA WITH A
RICHER DEMOGRAPHIC PROFILE.
>> GREAT, THANK YOU.
AND THANK YOU FOR YOUR
PRESENTATION.
THE NEXT QUESTION WE HAVE IS FOR
DR. LOR.
THERE WAS A COMMENT, THE INFO
GRAPHICS ARE GREAT.
AND WHEN LANGUAGE IS LESS OF A
BARRIER, ARE THERE
RECOMMENDATIONS FOR IMPROVING
VERBAL REPORT TOOLS, ESPECIALLY
IN CASES WHEN A VISUAL DOESN'T
SUFFICE?
>> THAT'S A REALLY AWESOME
QUESTION THAT I THINK I DON'T
HAVE THE ANSWER TO, BUT I CAN
KIND OF DRAW ON MY CURRENT
KNOWLEDGE JUST LOOKING AT THE
LITERATURE.
I THINK IN TERMS OF TOOLS IN
GENERAL FOR PAIN ASSESSMENT,
THERE'S BEEN A LOT OF WORK DONE
WITH PAIN SEVERITY TOOLS, SO
YOU'LL GET THE SMILEY FACES,
REVISED FACE THAT COULD BE USED
FOR PAIN INTENSITY, BUT I THINK
ONE OF MY RECOMMENDATIONS FOR
IMPROVING VERBAL REPORT TOOL IS
TO DO MORE RESEARCH, BECAUSE THE
EXISTING RESEARCH HAVE ALWAYS
BEEN JUST TRANSLATING INTO
ANOTHER LANGUAGE AND THEN AROUND
TESTING IT WITH THE POPULATION
BUT NOT REALLY GROUNDED FROM THE
PATIENT'S PERSPECTIVE UP.
SO I THINK THERE NEEDS TO BE
SOME MORE RESEARCH DONE TO MAKE
SURE THAT PAIN INFORMATION ARE
COLLECTED ACCURATELY,
PARTICULARLY FOR VERBAL.
I THINK ONE OF THE
RECOMMENDATIONS DRAWING FROM
SOME OF THE HEALTH LITERACY --
IS TO USELESS USE LESS JARGN
YOU'RE TRYING TO ASSESS PAIN AND
GET THE INFORMATION FROM
PATIENTS, AS WELL AS VISUAL,
BECAUSE I KNOW THAT WORKS VERY
WELL, BUT OF COURSE YOU'RE
COMMENTING ABOUT WHEN VISUAL
DOESN'T WORK.
SO I RO RECOMMEND WOULD E
PROVIDERS REALLY TRY NOT TO USE
JARGON AND PROVIDE EXAMPLES TO
TALK WITH PATIENTS IN EXCESSIVE
PAIN.
I HOPE THAT ANSWERS YOUR
QUESTION.
>> HOW CAN YOUR VISH VAITION YON
TOOL BE WIDELY IMPLEMENTED
ACROSS SITES AND DOES IT REQUIRE
TRAINING?
>> YES, THAT'S A GREAT QUESTION
AS WELL.
WHAT WE HAVE -- ONE UNIQUE THING
ABOUT THIS TOOL THAT WE REALLY
TRIED TO DO IS CREATE A
METHODOLOGY THAT WE CAN
POTENTIALLY REPEAT TO CREATE THE
VISUALS THAT WOULD WORK FOR
THEM.
WE HAVE ALSO INVOLVED PROVIDERS
IN THE PROCESS WHICH I DIDN'T
REPORT ON BUT TO GIVE US
FEEDBACK ON WHAT ARE THE MOST
IMPORTANT PAIN QUALITIES THAT
THEY PRIORITIZE IN ASSESSING
PAIN.
SO WE DID INCLUDE THEM.
>> ANOTHER QUESTION, DR. LOR,
YOUR -- ON A -- WHAT THOUGHTS DO
YOU HAVE ABOUT SYSTEMATICALLY --
AWARENESS AND PAIN IN DIFFERENT
CULTURES AND DO YOU PLAN TO
PROMOTE OR -- THESE TOOLS SO
THEY CAN BE USED THROUGHOUT THE
U.S. IN HOSPITALS AND CLINICS?
>> YEAH, DEFINITELY.
THAT'S A REALLY GOOD QUESTION.
AS YOU'VE MENTIONED, YOU KNOW,
PAIN IS EXPRESSED DIFFERENTLY
ACROSS CULTURE, AND I'M
CURRENTLY DOING A SYSTEMATIC
REVIEW NOW TO LOOK AT HOW PAIN
IS BEING EXPRESSED, SPECIFICALLY
FOR POPULATION WITH LIMITED AGE
PROFICIENCY BECAUSE I FEEL THAT
THEY HAVE BEEN LEFT OUT OF THE
PAIN CONVERSATION.
SO FAR THERE'S NOT A LOT OF
RESEARCH DONE IN THAT AND NOT A
LOT OF TOOLS THAT HAVE BEEN
CO-CREATED WITH THE POPULATION.
I'M REALLY HOPING THE WORK WE'VE
STARTED FOR THIS K CAN BE A ROAD
MAP TO REALLY EXPAND TO OTHER
POPULATIONS AND TO MAKE IT MORE
ACCESSIBLE TO DIFFERENT PATIENT
POPULATION AND CLINICIANS TO
USE.
WE'RE PILOT TESTING IT RIGHT NOW
SO I CAN'T GIVE YOU WHAT THE
EFFECTIVENESS IS BUT I'M HOPING
THAT WILL BE THE ULTIMATE GOAL
IN THE NEXT FIVE YEARS TO
IMPLEMENT IT AND TO MAKE SURE WE
CAN EXPAND TO OTHER POPULATIONS.
>> THANK YOU SO MUCH, AND AGAIN,
THANK YOU FOR YOUR PRESENTATION.
I HAVE A QUESTION HERE FOR
DR. LOSIN.
AT THE END OF YOUR TALK, YOU
MENTIONED A TARGET FOR
INTERVENTION.
CAN YOU EXPAND ON THAT?
>> YEAH, SO THE IDEA WOULD BE
IF -- YOU KNOW, THESE
PRELIMINARY DATA SUGGEST THAT AT
LEAST SOMETIMES CLINICIANS MAY
BE RELYING MORE ON THEIR STEREO
TIME TYPES ABOUT A PATIENT'S
DEMOGRAPHICS, THE TYPICAL PERSON
FROM THAT PATIENT'S DEMOGRAPHIC
GROUP, VERSUS THE INFORMATION
THE PATIENT IS PROVIDING ABOUT
THEIR OWN PAIN.
SO WE ARE ULTIMATELY HOPING TO
INFORM AND INTERVENTION AND
ACTUALLY TEST IT BASED ON THESE
DATA.
BUT THE IDEA WOULD BE SOMETHING
THAT HELPS CLINICIANS TO SHIFT
THEIR FOCUS TO THE INFORMATION
THAT THE PATIENTS ARE PROVIDING
THEM TO VALUE THAT MORE OR
WEIGHT IT MORE HEAVILY IN THEIR
PAIN ASSESSMENT AND TREATMENT
DECISION-MAKING PROCESS.
SO WHAT IS, WE HAVEN'T GOTTEN
THERE YET.
>> GREAT.
THANK YOU.
THE NEXT QUESTION IS FOR
DR. NELSON AND THE QUESTION IS,
DOES THE MIND-BODY APPROACH
DEPEND ON THE AGE OF THE
PATIENT?
YOU'RE MUTED.
>> SORRY ABOUT THAT.
CAN YOU REPEAT THAT?
>> THE QUESTION WAS, DOES THE
MIND-BODY APPROACH DEPEND ON THE
AGE OF THE PATIENT?
SO I THINK ESPECIALLY IN A
PEDIATRIC POPULATION, THERE'S
JUST A BROAD RANGE IN THE
OVERALL DEVELOPMENT TO THE STAGE
OF THE PATIENT AND DOES THE
APPROACH YOU TAKE DEPEND ON THE
AGE?
>> ABSOLUTELY.
I MEAN, AS A PSYCHOLOGIST, WE
DEFINITELY WANT TO CATER THE
MIND-BODY APPROACH TO THE
DEVELOPMENTAL LEVEL OF THE
PATIENT, BUT A LOT OF THESE MORE
BURGEONING MIND-BODY
INTERVENTIONS LIKE MINDFULNESS
BASED STRESS REDUCTION ACT,
THINGS LIKE THAT, CAN BE CATERED
TO ANY NUMBER OF DEMOGRAPHICS,
ANY NUMBER OF AGE RANGES
DEPENDING ON THE PRESENTING
PROBLEM.
>> AND THERE'S A FOLLOW-UP
QUESTION THAT SAYS YOU TALKED
ABOUT DIFFERENT MEASURES OF
ALLOSTATIC LOADS.
WHAT ARE THE PROS AND CONS FOR
THOSE MEASURES, AND WHAT ARE THE
CONSIDERATIONS FOR TIMING THESE
MEASUREMENTS?
>> I THINK ALLOSTATIC LOAD IS A
STILL AN UP AND COMING MEASURE.
THINK THE BASELINE IS YOU NEED
TO HAVE A MULTIFACTORIAL --
LOOKING AT DIFFERENT TYPES OF
PHYSIOLOGICAL FUNCTIONING TO
KIND OF ACCUMULATE THAT RISK FOR
ALLOSTATIC LOAD.
THE PROS AND CONS ARE JUST
LACKING AT DIFFERENT KINDS OF
DEMOGRAPHICS, RISK
STRATIFICATIONS, THERE'S BEEN
SOME GOOD STUDIES COMING OUT
LOOKING AT PEOPLE IN DIFFERENT
NEIGHBORHOODS, DIFFERENT
SOCIOECONOMIC STATUS.
I THINK THERE'S A LOT OF
CONFOUNDING FACTORS THAT COULD
BE TAKEN INTO ACCOUNT THERE, BUT
WE'RE REALLY EXCITED ABOUT WHERE
THE FIELD IS GOING AND LOOKING
AT THIS IN THE CONTEXT OF PAIN.
>> GREAT, THANK YOU.
WE HAVE A QUESTION FOR
DR. STAEDTLER.
FIRST IS WHAT ARE THE SIDE
EFFECTS AND HOW LONG AFTER
INJECTION BEFORE YOU CAN WALK?
AND ALSO ARE MANY PEOPLE
ALLERGIC?
>> SO I'LL START WITH THE LAST
QUESTION.
NO, NOT MANY PEOPLE ARE ALLERGIC
TO RTX, IT'S A CAP SIGH SIN
ANALOG THAT HAS BEEN USED IN
MANY DOZENS OF PEOPLE WITH
DIFFERENT ROUTES OF
ADMINISTRATION, INTRATHECALLY OR
INJECTIONS EPIDURALLY, AND THERE
HAS NEVER BEEN A REPORT OF AN
ANAPHYLACTIC OR ALLERGIC
REACTION, SO IN THEORY THAT'S
POSSIBLE BUT HAS NOT BEEN
OBSERVED SO FAR, SO IT DOESN'T
SEEM TO BE A STRONG ALLERGEN PER
SE.
THE SECOND ONE, THE SIDE EFFECT
IS IT ACTIVATES NOCICEPTIVE
FIBERS, HEAT AND PAIN
TRANSMITTING FIBERS, SO WHEN YOU
INJECT IT OR YOU EXPOSE YOURSELF
TO IT, YOU HAVE BURNING PAIN,
BURNING PAIN SENSATION, WHICH
CAN BE REDUCED BY INJENGTING A
LOCAL ANESTHETIC FIRST SO YOU
HAVE NO PAIN CONDUCTION, IT'S
BLOCKED, THEN YOU INJECT THE RTX
AND IN IDEAL CASE, YOU COULD
HAVE PANT ANYMORE.
PAIN ANYMORE.
THAT'S WHAT REAR PLANNING TO DO
AND ARE CONFIDENT IT CAN WORK.
IT ONLY AFFECTS A CERTAIN
SUBPOPULATION OF FIBERS, SO IT
DOESN'T AFFECT MOTOR FIBERS, SO
USUALLY RTX ITSELF DOES NOT
PREVENT WALKING ABILITY, SO THAT
IS TOTALLY PRESERVED.
THE LOCAL ANESTHETIC THAT YOU
WILL INJECT MIGHT LEAD TO A
LITTLE BIT OF MAYBE -- BUT
HONESTLY MOTOR FIBERS FOREFOOT
MUSCLES IN THAT STAGE WHERE THE
NEUROMA SITS HAVE ALREADY LEFT
THE NERVE, SO THERE SHOULD BE NO
MOTOR -- REDUCTION MOTOR
FUNCTION AT ALL, NOT EVEN FOR
THE TOES.
BUT THE RTX PER SE DOES NOT
AFFECT MOTOR FUNCTION.
THAT WOULD BE ONLY A SIDE EFFECT
OF LOCAL ANESTHETIC, IT WOULD BE
VERY SHORT LASTING.
ANOTHER EFFECT THAT IS KNOWN
THAT IT ALSO REDUCES THE
SENSITIVITY TO NOXIOUS HEAT, SO
THIS IS A SMALL AREA THAT WILL
BE NUMB FOR HEAT SENSITIVITY IF
THE FOREFOOT BUT IF YOU HAVE
INTRATHECAL APPLICATION, YOU
HAVE TO WARN PATIENTS THAT THERY
MIGHT NOT FEEL WHEN THEY STEP
INTO A HOT BATH, FOR EXAMPLE.
THAT'S IMPORTANT TO EDUCATE THEM
ABOUT THIS.
>> GREAT, THANK YOU.
HOW IS THE DOSE OF RTX
DETERMINED THAT YOU'RE USING FOR
THE STUDY?
>> HOW IT'S DETERMINED?
IT WAS INFERRED FROM CLINICAL
TRIALS, STUDIES WHERE WE USED,
MY COLLEAGUES USED INJECTION IN
A NERVE IN THE RAT'S LEG, AND
THEN LOOK FOR EFFECTS ON
INFLAMMATION, PAIN, AND SO WE
USED THE DOSE THAT WAS EFFECTIVE
IN PRE-CLINICAL TRIALS AS A
STARTING DOSE AND THEN HAVE LIKE
FOUR STEPS THAT THEY WILL
INCREASE THE DOSES.
IT'S USED IMMENSELY LOW
CONCENTRATION SO WE START AT
SOMETHING LIKE 250 NANOGRAMS.
IT'S A REALLY LOW DOSE THAT'S
EFFECTIVE.
AND IF WE ARE POSITIVE THIS WILL
HAVE AN ANALGESIC EFFECT AND
WE'RE FAR AWAY FROM ANY DOSE
THAT WOULD VERY LIKELY HAVE SOME
SIDE EFFECTS ACTUALLY.
>> THANK YOU SO MUCH.
WE HAVE ANOTHER QUESTION FOR DR.
THE COMMENT SAYS IT'S VERY
INTERESTING THE ENDORSEMENT OF
STEREOTYPE BUT NOT TARGET
DEMOGRAPHICS PREDICTED PERCEIVED
PAIN INTENSITY THAT THESE
STEREOTYPES APPLY TO ALL
CATEGORY, FOR EXAMPLE, FOR WHITE
PATIENTS IN CONSIDERATION OF
RACE, OR WERE THEY DRIVEN BY
STEREOTYPES FOR CERTAIN TARGET
DEMOGRAPHICS?
>> THANKS FOR THAT QUESTION.
SO THE WAY WE HAVE RUN THE SEM
MODELS SO FAR, IT'S JUST
PLUGGING IN THAT PARTICIPANT'S
RATING OF STEREOTYPICAL PAIN
SENSITIVITY FOR EACH ETHNIC AND
RACIAL GROUP, AND THEN THAT'S
PUT IN THE MODEL FOR EVERY
PATIENT FROM THAT ETHNIC OR
RACIAL GROUP.
SO I CAN'T -- WITH THE WAY WE'VE
DONE THE ANALYSIS SO FAR, I
CAN'T SAY WHETHER STEREOTYPES
ABOUT ONE SPECIFIC GROUP ARE
DRIVING THAT RESULT MORE THAN
OTHERS, BUT THAT IS DEFINITELY
THE PLAN FOR THE NEXT STEPS IN
THE ANALYSIS, BECAUSE CLEARLY
THAT WELL MAY BE THE CASE.
SO I DON'T KNOW YET, BUT WE'RE
GETTING THERE.
>> THANK YOU.
AND AS A BROADER QUESTION FOR
ALL OF THE PANELISTS, THAT IS,
CAN YOU COMPARE AN
INTERVENTIONAL TREATMENT LIKE
WHAT DR. STAEDTLER WAS PROPOSING
COMPARED TO THE OTHER TYPES OF
TREATMENTS THAT WERE DISCUSSED
ON PAIN?
>> I MEAN, I CAN ADD SOMETHING.
I THINK AS A PAIN PSYCHOLOGIST,
ONE OF THE BIG MESSAGES THAT WE
LIKE TO CONVEY IS THAT CHRONIC
PAIN ESPECIALLY IS A
MULTIPRONGED APPROACH, WHERE YOU
COME AT IT WITH A VARIETY OF
BOTH KIND OF MEDICAL AND
PHARMICOLOGICAL, PHYSICAL AND
MIND-BODY INTERVENTION, FIT TO
MEET THE NEEDS OF EACH
INDIVIDUAL PATIENT.
>> THANK YOU FOR THAT.
DOES ANYONE ELSE WANT TO
COMMENT?
>> I HOPE THAT WAS HELPFUL.
>> SO IN OUR CASE, WE'RE
STUDYING CLINICIANS AND THEIR
PAIN TREATMENT DECISIONS, SO
WHILE WE'RE NOT INTERVENING
DIRECTLY ON THE PATIENT'S PAIN,
I IMAGINE THAT TRAINING
CLINICIANS DIFFERENTLY TO
INCREASE THE EFFECTIVENESS OF
THEIR PAIN MANAGEMENT AND
DECREASE ANY BIASES THEY MAY
HAVE WILL OBVIOUSLY HAVE AN
EFFECT ON PATIENTS' PAIN AND
HOPEFULLY PARTICULARLY IN
ALLEVIATING PAIN OF GROUPS THAT
HAVE HISTORICALLY BEEN RECEIVING
LESS ADEQUATE TREATMENT.
>> I CAN SHARE OURS TOOL.
WITH OUR TOOL, THE GOAL IS TO
REALLY FACILITATE THAT
COMMUNICATION SO THAT PROVIDERS
DON'T NEED TO LEARN THE
PATIENT'S LANGUAGE OR MENTAL
MODEL OF HOW PAIN IS BEING
CONCEPTUALIZED, AND SO THE WAY
WE HAVE MAPPED OUR TOOL IS TO
HAVE THE PATIENT'S PAIN
DESCRIPTOR IN THEIR OWN LANGUAGE
THAT ARE METAPHORS OF HOW THEIR
PAIN IS BEING EXPRESSED.
THE ROLE OF THE INTERPRETER IS
REALLY TO HELP FACILITATE THAT,
NOT TO GIVE MORE WORK TO THE
INTERPRETER, WE'VE MAPPED OUT
THOSE METAPHORS TO WHAT
PROVIDERS WOULD EXPECT FOR PAIN
QUALITY OR PAIN SEVERITY AS
WELL.
I DIDN'T FOCUS ON PAIN SEVERITY
BUT THAT'S ALSO PART OF THE WORK
WE'RE WORKING ON AS WELL.
SO HOW THAT COMPARED TO USUAL
CARE, USUAL CARE, YOU KNOW,
PATIENTS ARE BEING ASKED HOW TO
DESCRIBE THEIR PAIN OR IF YOU'VE
NEVER HAD PAIN BEFORE, YOU MIGHT
EXPRESS IT DIFFERENTLY THAN WHAT
YOU WOULD EXPECT IN THE WESTERN
KIND OF CULTURE FROM PROVIDERS.
SO THAT'S KIND OF HOW WE'RE
TESTING IT, COMPARING IT WITH
USUAL CARE, JUST THE USUAL --
COMPARE IT WITH WHAT PROVIDERS
WOULD ASK THE PATIENT, WHAT THAT
COMES OUT TO BE, AND COMPARE IT
WITH OUR TOOL, HAVING THIS
MAPPED OUT INFOGRAPHIC TOOL THAT
WOULD HELP FACILITATE THAT
COMMUNICATION BETWEEN PATIENTS,
PROVIDER AND THE INTERPRETER,
WHAT THAT WOULD LOOK LIKE FOR
PAIN ASSESSMENT AND TREATMENT AS
WELL.
>> THOSE ARE ALL REALLY
IMPORTANT POINTS AND IS THERE --
DO ANY OF THE OTHER PANELISTS
HAVE ANYTHING TO ADD?
ALL RIGHT.
I THINK WE DON'T HAVE ANY MORE
QUESTIONS AT THIS TIME, SO I CAN
GIVE YOU ALL ONE MORE CHANCE IF
YOU HAVE ANYTHING ELSE TO ADD OR
ANYTHING ELSE YOU'D LIKE TO
MENTION.
IF NOT, I CAN TURN THIS BANK
OVER FOR THE WRAP-UP.
ALL RIGHT.
THANK YOU ALL.
INA, ARE YOU ON NOW?
INNA, ARE YOU ON NOW?
SORRY, LEAH, DO YOU OR ANY UNONE
ELSE HAVE THE -- DO YOU WANT TO
DO THE CLOSE OF THE SESSION?
>> SURE, I CAN GIVE CLOSING
REMARKS.
>> THANKS, MELISSA.
>> THEY MAY HAVE JUST STEPPED
AWAY.
I THANK ALL THE OTHER
ORGANIZERS, THE -- THE
MODERATORS, THE FACILITATORS,
EVERYONE HAS REALLY PUT IN --
INTO THE CONTENT.
HELLO, INNA.
>> HELLO.
I WAS FROZEN.
BUT THANK YOU FOR STEPPING IN.
>> TAKE IT AWAY.
>> NO PROBLEM.
THANK ALL THE JUNIOR
INVESTIGATORS FOR THIS EXCELLENT
SESSION, AND FOR ALL THE DATA
THAT YOU WORKED ON.
THIS WAS REALLY GREAT.
FOR ALL THE QUESTIONS, THANK YOU
FOR THE -- TO OUR DEDICATED
AUDIENCE, AND I ALSO LIKE TO
THANK EVERYONE WATCHING THE
VIDEOCAST FOR JOINING TODAY, AND
REMIND YOU ALL THAT YOU PLEASE
SHOULD JOIN US AGAIN TOMORROW
FOR DAY TWO, BEGINNING AT
11:00 A.M. EASTERN TIME.
THE NIH VIDEOCAST.
AND PLEASE USE YOUR SAME LINK TO
LOG IN TOMORROW, AND WITH THIS,
HAVE A GREAT EVENING.
THANK YOU SO MUCH.
AND SEE YOU TOMORROW.