San Diego Pain Summit Reports
By Nik Gervae
I am a recently-graduated Feldenkrais® Practitioner in San Francisco. I attended this year's San Diego Pain Summit (with my kinematic skeleton, Mortimer) and wrote up this report from that perspective.
Pre-summit workshop 1 — Michael Shacklock, DipPhysio: Clinical Neurodynamics, Upper Body (2 days)
This is all about the biomechanics of nerves themselves (as opposed to neuronal connections)—sliding them through their sheaths, tensioning them, releasing tension, and opening up the containing tissues (such as the carpal tunnel or vertebral fossae). Most of the techniques are squarely outside the scope of the Feldenkrais Method—dealing with physiological or mechanical problems affecting the nerves rather than the overall behavior/learning of the nervous system—but they are fascinating nonetheless, and I could see how some of the phenomena he described just might be a factor in certain Functional Integration® techniques. Mr. Shacklock is an engaging presenter and I found myself wanting to go to PT school several times during this workshop. Feldenkrais practitioners who are also physical or massage therapists would do well to look into this.
The workshop was a firehose of information so I can't do more than provide that brief overview. If you are curious about it, a google search is likely to give you a good starting point. You can also get his book, which covers everything the workshop did and much, much more. Another author to look for is David Butler.
Pre-summit Workshop 2 — Kevin Vowles, PhD: Working With Acceptance, Awareness, & Values In Chronic Pain (ACT) (1/2 day)
Our morning workshop was an introduction to Acceptance and Commitment Therapy techniques in the context of pain care. We started with a little exercise to get the point across what it's like dealing with pain. Here's a video from another of his presentations.
Two main themes were the idea of not struggling against pain (likened to a finger trap, where pulling only makes things worse), and of focusing on life goals and values to continue functioning even in the presence of pain. A big part of this discussion was distinguishing the forms of patient/client behavior from the function: he showed a photo of a man with mouth open and eyes scrunched up and asked to say what he was doing. Interpretations varied from screaming in pain, to sneezing, to singing with a rock band. This led into being able to determine the value-based functions that a client wants (independence, self-reliance, social connection), from the means of achieving them (driving a car, being able to walk, meeting friends), and helping clients develop appetitive drives toward valued functions in preference to avoidant behaviors around pain. We learned about, and practiced, interview and listening techniques, orienting around a client's life goals rather than clinical problems, and more.
Regardless of your profession, though, if you deal with pain and you see he's presenting in your area, I recommend you go.
Pre-summit Workshop 3 — Todd Hargrove Insights On Movement Therapy From A Feldenkrais Perspective (1/2 day)
In the afternoon the largely physical therapist audience got a great overview of the Feldenkrais Method from Todd Hargrove. He stuck to what's directly relevant to their client needs, with occasional hints at the broader aspects of the work, and I think changed quite a few people's perceptions of the method. In 5 hours, he explained the major principles and approaches, alternating with ATM lessons or excerpts to demonstrate points. Again, the emphasis was on pain relief and management: how the method can help, the challenges in using the method with clients in acute or chronic pain, and some specific strategies to try. Given the time constraints, he avoided discussion of Functional Integration, the hands-on side of the Feldenkrais Method, only mentioning it in response to a question. The audience had plenty to absorb and, I think, left interested in learning more. See my notes on his presentation for details.
He played one of the Baby Liv videos and it was a big hit.
**Note: Links take you to a Youtube video clip of corresponding presenter's talk at the 2016 Summit**
Robert Sapolsky, PhD: Keynote — Why Zebras Don't Get Ulcers: Stress & Coping
The summit proper began with a keynote lecture by Dr. Robert Sapolsky on the effects of chronic stress. If you've watched any of his stuff or read his zebra book, you probably know the content, but he tossed out a lot of new insights and jokes. The Q&A session was particularly impressive as manual therapists asked questions specific to our work and got great, insightful responses. Unfortunately his talk won't have a recording available.
Fabrizio Benedetti, MD: Placebo & Nocebo: Different Contexts, Different Pains
Next, Dr. Fabrizio Benedetti presented info on his research into the specific mechanisms behind placebo effects—plural. Different conditions and responses have different physiological mechanisms, hormones, and neurotransmitters, and Dr. Benedetti is mapping these out. There's a lot of exciting stuff happening in this field, even though the number of researchers is quite small. Effects of therapeutic context, ritual, and multimodal sensory input (or lack thereof) are all interesting factors in placebo response. One cool video he showed was a Parkinson's patient doing very poorly at a motor task, then given a placebo he was told would help, and then his hand was zooming around hitting targets like it was no big deal. Look Dr. Benedetti up if you want to find out more, or wait for the recording of the presentation to be available.
Alison Sim, MSc: Cognitive Behavioral Therapy In A Manual Healthcare Setting
Alison Sim spoke about Cognitive Behavioral Theory in a manual therapy setting. Her talk was largely a survey of research studies, rather than specifics of how to implement (the approach is pretty well known). Results are promising, and better than many other approaches being tried.
Ravensara Travillian, PhD: The Professionalization of Massage Therapy through Integration with Pain Science (This presentation is free to watch in its entirety).
Dr. Ravensara Travillian wrapped up day 1, speaking about the need for the massage therapy profession to professionalize via integration with pain science. This ranged broadly from perception (massage as seedy), to training (scaffolding, supervision, support), to continuing education based on science (as opposed, for actual example, to online courses on using crystals for pregnancy!). This talk was very well received by the audience.
Kevin Vowles, PhD: Willingness To Have Pain & Commitment To Valued Living In Chronic Pain
Dr. Kevin Vowles began the morning with his talk on Acceptance and Commitment Therapy (ACT), and the effect of values on quality of life in the face of pain. A big early point was a study in which pain patients were asked to perform motor tasks and either struggle against/through the pain, or to go more gently and not fight the pain (but still perform the task). Guess who fared better? The closing quotation was "People who have something better to do don't suffer as much" (Wilbert Fordyce), and Dr. Vowles finished by saying those few words expressed perfectly what he'd just spent 45 minutes presenting the details of.
Bronnie Thompson, PhD: Motivation, Confidence, and Communication
Dr. Thompson's practical talk was titled "Being like Water—Getting from maybe ... to yes, without tears". It was about Motivational Interviewing skills for interacting with clients/colleagues/friends/etc. For example, motivating your client to do their homework! She quoted Bruce Lee a lot, and quite appropriately. Some ideas are evoking your client's own motivation to change rather than telling them about consequences and such, empathizing when client resists rather than pushing. Sound familiar?—except this is in verbal conversation rather than Functional Integration. We did partner exercises during her session. You might have learned these verbal techniques in your training—if you didn't, check out her presentation! She was brilliant and her slides were fantastic (in spite of a small projector problem). Check out her blog at https://healthskills.wordpress.com/.
Gregory Lehman, DC, MScPT: Keeping The Bio Consistent With Psychosocial Intervention (No portion of this presentation is available for viewing).
Dr. Lehman's talk was "When biomechanics matters: keeping the BIO consistent with psychosocial intervention". This conference is all about the bio-psycho-social model of pain, and it tends to focus on the latter two because biomechanics has had almost exclusive focus in mainstream healthcare. One of his early slides said, "Movement quality is the cornerstone of the kinesiopathological model", which he examined in detail throughout the presentation. There was an emphasis on high load activities, which are necessary in some professions and sports—or more accurately, distinguishing high from low load activities. He was irreverent, witty, and lots of fun. He dissed both Todd Hargrove (jokingly), and Kelly Starrett (not so jokingly). Showed a video of Starrett ranting about bad texting posture, and equating its danger to doing deadlifts. Then he discussed arguments & studies against, and then in favor of, spinal flexion with regard to disc herniation, and its relation to back and leg pain. Hilarious video of a noted surgeon doing a lengthy dyskinesis eval on a young athlete, only to be told at the end that his pain was in the other shoulder to the one the surgeon was talking about (I haven't found this video yet). Dr. Lehman covered a lot of ground, in detail, so I found his talk hard to summarize, but it was so interesting. Check out his website at http://www.greglehman.ca/.
Michael Shacklock, DipPhysio: Clinical Application of the Pain Paradigm: Challenging the Challenge
Prof. Shacklock's talk moved from Descarte's early model of pain with body/mind separation (implying that "if pain occurs in absence of physical injury, it must be in your head"), to the Melzack/Wall gate theory and neuroplastic models, and beyond. Much of this was about pathophysiology causing nociception and central sensitization, which leads to what *looks* like neurological or musculoskeletally-induced pain—in other words, central sensitization often leads to false positives in diagnosis. Next up was the apparent lack of correlation of tissue injury with pain—except, often enough, when the injury is neural, and more on how we're still learning about the body and correcting mistaken ideas about what leads to pain (such as that flexion makes discs bulge back and aggravates spinal pain, which turned out to be exactly the opposite of what usually happens). This led to the idea that helping musculoskeletal problems can actually help the nervous system (both physiologically and in learning). He finished with a detailed discussion of neurodynamic effects of various kinds of movements and tests, including some cool ultrasound videos showing the neurodynamic effects of various shoulder girdle movements on the brachial plexus. Very geeky, very fun.
Sandra Hilton, PhD: Practical Pain Science In The Clinic
Dr Hilton focuses on complex pelvic pain for both women and men, and wrote the book "Why Pelvic Pain Hurts". Tons—TONS—of useful info beginning with office decor & furniture, establishing client relationship ("What does better mean to you? How will you know when you are better?"), clinical evaluation, importance to client of various evaluation factors, Maslow's hierarchy of needs and what should be inherently pleasurable ("having an absolutely wonderful bowel movement is pleasurable"), to all kinds of pain education techniques. She gave several shouts out to the Feldenkrais Method. I won't go on with a laundry list of things, but there was so much good stuff that a Feldenkrais—or any—practitioner could use. Good emphasis on problems being not in body, not in mind, but in the person, and on being purposively non-threatening. Her website is http://entropy-physio.com/.
Todd Hargrove: Insights On Movement Therapy From The Feldenkrais Movement (As a gift from the Summit, this presentation is available to watch free in its entirety).
Todd Hargrove concluded the conference with "Insights On Movement Therapy From The Feldenkrais Method". He presented four of Dr. Feldenkrais's central ideas to the audience of physiotherapists, massage therapists, personal trainers, etc. I took nearly slide-by-slide notes on this one as I was sure my Feldenkrais colleagues would be keen to know what he said.
IDEA #1) Focus on the nervous system, on function over structure. "We act in accordance with our self image". He covered the sensorimotor maps & homunculus, their adaptability based on meaningful/functional movement demand, and the idea that the maps can "smudge" or become less clear, leading to cruder or less efficient sensorimotor function—mentioning Thomas Hannah's idea of "sensorimotor amnesia" (with a picture of Homer Simpson lying on a couch, thinking about lying on a couch). Again he brought up the classic pelvic clock model. Pain depends on perceived threat, not actual threat. Increase evidence of safety, decrease signals of danger. How we do that via slow, gentle movements. Breaking associations of movement and pain (extinction).
IDEA #2) Awareness and (chronic) pain. Outlining the back, or locating the spine, to clarify the image, maybe sharpen those fuzzy portions. Pain leads to poorer two-point discrimination, right/left discrimination, voluntary lumbopelvic movement. Does pain cause poorer body sense, or does poorer body sense cause pain? Which is causal? Maybe it's a dynamic, complex relationship. Rubber hand illusion. Immune system's job is to recognize what is self and what is foreign—this can apply to movement as well as tissue—so include as many movements as you can. And much, much more.
IDEA #3) "It is incorrect to correct". Corrective vs. creative, exploratory, allowing client to choose the right movement for themself. Avoid nocebos (threats)—interesting example of clients who avoid natural posture or movement because of prescriptive evaluations that their natural way is dysfunctional. Allowing for individual differences, photos of bones with greatly different structure. Variability: vs. optimality, in motor learning ("do it wrong, but do it!"), in movement skill, and relation to injury risk. "Better to move 100 different speeds & ways than 200 times in the same way" (I've summarized this Merzenich quotation).
IDEA #4) The Optimal Learning Environment Involves Play. Play is the fastest way to learn: All intelligent animals play to learn, toddlers are all play no work. Play is fun/absorbing, voluntary, no obvious purpose, improvisational/creative, involves repetition with variation. Contrast with an animal making exactly the same movements over and over—neurotic (or Crossfit). Play is experimenting. Putting elements of play into movement therapy, regardless of your modality, will probably.
A good Q&A session followed; it was the end of a long day and folks were still engaged and interested. Todd's website is http://www.bettermovement.org/.
Post-summit Workshop: Simple Contact with Barrett L. Dorko (2 days)
The postscript to the conference proved to be quite the highlight. Barrett is a PT with a decidedly zenlike approach to manual care, and a decidedly curmudgeonly approach to teaching. He contradicted himself several times, argued with attendees (even during manual demos)—or perhaps they argued with him—and alternately praised and criticized certain people or modalities. Sounds like a certain found of the method I practice. I found him highly entertaining and informative in spite (or perhaps because!) of all that.
His main thing is the idea of ideomotion: spontaneous movement that relieves mechanical/physiological strains on the nervous system engendered by culturally-induced inhibitions to movement (this is not exactly how he described it but I wrote this part after much sleep deprivation). In manual care, it involves contact and waiting briefly for spontaneous movement, which the practitioner joins in. I found this the other side of the coin I was missing in Feldenkrais Functional Integration (the hands-on part of our method) and it brought a huge smile to my face every time I did it.
When I learned Functional Integration, it was described with the metaphor of a dance, but it seemed I was always supposed to be the lead, proposing movements and looking for a "yes". In Simple Contact, I can also be the follow—my client proposes the movement and it's my job to say "yes" and support that movement. This is not the same as instructing the client to perform a movement and then "going for a ride"; there is no agenda, and the client often makes quite surprising movements (surprising to both of us), and not necessarily where my hands are. There's a very cool sensation of the movement not being performed by the client, nor by me, but by *us*. (One attendee later told me this is not some new thing, and I didn't expect that to be the case, but it was new to me.)
So all by itself, this doesn't really sound like Functional Integration—again, at least as I understand it so far. But, as I have seen tango where the partners switching roles makes for a much cooler dance, I can see how switching roles this way in a Functional Integration session will be a huge boost for me and my client.
On day 2 we continued Barrett's workshop with more info on theory and practice, and of course some actual practice. Barrett brought more role-switching into his demos today, clarifying (for me, at least) the nature of the dance and the dynamic between lead and follow, client and practitioner. I lucked into a second turn as the demo model, which brought about huge changes and learning in my nervous system. (For several years I have experienced tics and muscle contracture that resemble Tourette syndrome or focal dystonia, as well as general ANS dysregulation. I found that after a few sessions on the demo table with Barrett, those symptoms are nearly gone and have remained so for a couple days. I am very interested to see if this will be a lasting effect.)
For those who follow pain science, I'll say that a lot of the lecture/talk portion of his workshop is likely to be pretty familiar, but even though I've been following it pretty closely, there were good nuggets sprinkled throughout.
My reading list got substantially longer, so I think I'm going to have to spend a day on Amazon prioritizing books to get, and also research papers. Top priority though will be working with more people to put what I've learned to action. (Speaking of which, I've got a regular teaching gig starting in a week at Athletic Playground in Emeryville.)
And so this jam-packed week ends, on a very high note. Four workshops, ten amazing presentations, a live podcast with five of those presenters (I'll link to it when it's up), and a networking event, in which I met practitioners, researchers, and educators from around the world. I cannot recommend this event highly enough, particularly for those involved in more clinical cases, whether directly or via interaction with clinicians. Check http://sandiegopainsummit.com/ for news on next year's summit. Rajam Roose already has a few speakers lined up, but I'm not at liberty to say who they are. :-)