I’m just back from this year’s San Diego Pain Summit (SDPS), and thought I’d share some of my notes and impressions while they’re still fresh. About a dozen presenters spoke about pain-science, ranging from the neurology of body/brain interactions, therapeutic relationships, and compassion to brain imaging, the role of patient/client expectations, and more. Here are some notes on my personal favorites.

• Neuroscientist Antonio Damasio, PhD (Image 1), has written extensively on the ways the body informs the mind. To help explain this interaction, Damasio makes a neurological distinction between feelings and emotions. Emotions, in this model, are bodily reactions that serve to maintain homeostasis: physical reaction, retraction, and movement. For example, Damasio says, “When we are afraid of something, our hearts begin to race, our mouths become dry, our skin turns pale, and our muscles contract. This emotional reaction occurs automatically and unconsciously.”

The brain shapes this bodily emotion into mental feelings by assigning valence: the mental valuing that determines meaning and preference. “Feelings,” Damasio says, “occur after we become aware in our brain of [emotion’s] physical changes; only then do we experience the feeling of fear.”1 “And pain,” he says, “needs to be treated as a feeling,” implying a deep role for the mind in the pain experience. (For more, see Damasio’s book Descartes’ Error (Penguin, 2005), or his TED talk at http://bit.ly/2Jx4QoG).

• When Maxi Miciak, PT, PhD, was writing her doctoral thesis about how the practitioner/patient relationship influences the effectiveness of physical therapy, she found almost no existing research and very little formal study into the therapeutic relationship in any field.2 What research she found, she says, showed (unsurprisingly) that the quality of the practitioner/patient relationship is linked to better patient satisfaction, and to better therapeutic outcomes. Her own research into the question (using an interpretive description qualitative method, followed by quantitative analysis) led to her model of the conditions of engagement necessary for therapeutic effectiveness (Image 2). One of her practical suggestions: since listening can be a powerful therapeutic intervention itself, practice making room for your client’s story and try waiting for eight seconds after the patient speaks before responding.

• Australian physical therapist Mark Bishop, PhD, shared his thought-provoking research into how patient/client expectations influence the outcomes of manual therapy, and his thoughts on placebo mechanisms (a favorite topic of my own: see “Are You a Placebo,” Massage & Bodywork, July/August 2018, page 80). Bishop says that placebo has a “branding problem” because “people think placebo is nothing; a sugar pill. Placebo mechanisms, however, are far from nothing,” since the mechanisms behind placebo responses are physical, hormonal, endocrine, and neurotransmitter changes in the body. Bishop emphasized that placebo effects are always present in our treatments, whether we consciously use them or not. “We always provide care within a context,” Bishop says. “I’ve never walked into a black room, in a dark spandex suit, to treat someone lying on a table who’s blindfolded, with earplugs, and asleep.”

But it was his findings on client and practitioner expectations I found most interesting:

• In a 400-person comparative study of spinal manipulation versus spinal mobilization effectiveness for back pain, therapeutic touch (or TT, in which therapists simply “place their hands on or near their patient’s body with the intention to help or heal”3) was used as sham treatment (i.e., as a placebo comparison, intended to reveal the direct effects of the spinal methods). In a surprise to the researchers, at the end of the six-year study, TT was the most desired treatment by the participants, and the treatment they most expected to help their pain.4

• In another comparative study, massage therapy was the neck pain treatment that study participants most expected would help (Image 3).5

• In studies of cervical, shoulder, and lumbar complaints, patients’ general expectation of recovery has been repeatedly found to be the strongest predictor of recovery; stronger than the therapeutic method used, practitioner experience, or other factors.6 Given this, Bishop says, our skills at building an alliance and keeping clients engaged are probably more important to pain recovery than any particular method or therapy.

• And perhaps most importantly, Bishop’s research showed that method does matter, but on the providers’ (rather than clients’) side: when practitioners had a strong preference for a particular treatment, that treatment had better results, no matter what that treatment was.7

Is Pain Science Passé?

This was the fifth San Diego Pain Summit, and with 111 participants in attendance, this summit was a bit smaller than in previous years. Does this dip in size mean that interest in pain science is waning? There are signs elsewhere that perhaps the initial gush of enthusiasm about biopsychosocial approaches might be fading. In the manual therapy blogs and podcasts I follow, “pain” is much less frequently a topic than it was just a couple years ago; and on one (formerly?) pain-science–friendly podcast, the hosts audibly snickered when “pain science” was mentioned among the list of trendy topics that are no longer in the fore.8

Or could it be that biopsychosocial perspectives on pain have by now percolated deeply enough into our field that they are no longer quite so radical or new? No idea stays on the cutting edge indefinitely; at some point, a novel view either fades away or becomes part of the mainstream. Though some would argue that pain science hasn’t penetrated deeply enough into massage and bodywork yet, its influence on our field is well-established and maturing. After all, these ideas have been around for some time now. Many physical therapists trace pain science ideas to David Butler’s neurodynamic work in the 1990s; or MTs, to Diane Jacob’s Dermoneuromodulating approach, which she developed in the last decade. But biopsychosocial concepts have parallels in earlier concepts of body-mind holism, including Feldenkrais’s work from the 1970s, and many other early influences on massage and bodywork.

Here at Advanced-Trainings.com, it’s been about six years since we offered our first pain-science–focused course (“Chronic Pain,” also available in ABMP’s online member library at www.abmp.com/ce), and it’s not an exaggeration to say our entire in-person curriculum has been accordingly revised in the years since. We are not alone in this: several of my esteemed continuing education colleagues (such as Erik Dalton, Walt Fritz, Whitney Lowe, Ruth Werner, and others) have also incorporated pain science or biopsychosocial concepts into their approaches. And to be fair, the purpose of the San Diego Summits is not research (nor manual therapy) per se. None of the presenters at this year’s summit claimed to be presenting radical new pain research or novel, game-changing ideas. Instead, the Pain Summit’s role has been bringing people together to share their application and continuing refinement of existing concepts.

A question I heard several times while there was, “Why don’t more massage therapists and bodyworkers attend the summit?” According to the event’s organizer, Rajam Roose (featured last year in “Reframing Pain,” Massage & Bodywork, May/June 2018, page 80), most of the summit’s attendees are physical therapists or physical therapy students. Massage therapists are indeed a minority (though interestingly, about half of the MTs in attendance traveled from a single Canadian province, British Columbia, where, I was told, pain science ideas have a strong following among massage therapists). But the BC exception aside, we saw this same phenomenon when Advanced-Trainings.com cosponsored an “Explain Pain” training (from the Australian NOI Group) in Colorado in 2015. Most attendees were physical therapists, with only a few Rolfers, structural integrators, and even fewer massage therapists attending.

Could it be that the “science” emphasis in pain science isn’t appealing to as many MTs as PTs? Though massage therapy is moving toward greater science literacy, none of the presenters at the summit were massage therapists or bodyworkers. There were no hands-on manual therapy preconference workshops, and only one presenter identified himself as a manual therapist (physical therapist Mark Bishop). Or perhaps, as I also heard several times in my conversations there, it’s not always obvious to massage therapists how they might apply pain science’s education- or rehabilitation-focused material within their skill set and scope of practice (which is where my educator colleagues and I come in).

Next Year’s Summit

With about 60 percent of this year’s attendees being first-time summit-goers, Roose is optimistic about next year’s attendance. She says her focus in 2020 “is going to be more on the ‘psych’ in biopsychosocial (BPS).” As she sees it, “There is this pervasive idea that things like motivational interviewing or acceptance and commitment therapy are out of scope for the clinician, which really isn’t true. It’s not out of scope for us to understand how to communicate with our patients/clients and give them a sense of self-efficacy. There’s also going to be a presentation on the limitations of the BPS model, which I think will be really interesting!”

Whether you think the pain science trend in our field is the next big thing, already passé, or maturing into an integral part of our field’s way of thinking, there is still plenty to learn together about pain and the many ways to work with it, both on and off the table.

Special thanks to Ruth Werner for her contributions and collaboration.

Notes

1. Antonio Damasio, quoted in Lenzen, Manuela, “Feeling Our Emotions,” Scientific American Mind 16, no. 1 (April 2005): 14–15, https://doi.org/10.1038/scientificamericanmind0405-14.

2. M. Miciak et al., “The Necessary Conditions of Engagement for the Therapeutic Relationship in Physiotherapy: An Interpretive Description Study,” Archives of Physiotherapy 8 (2018): 3, https://doi.org/10.1186/s40945-018-0044-1.

3. University of Minnesota, “Therapeutic Touch,” accessed March 2019, www.takingcharge.csh.umn.edu/therapeutic-touch.

4. M. D. Bishop, “What Effect Can Manual Therapy Have on a Patient’s Pain Experience?” Pain Management 5, no. 6 (November 2015): 455–64, https://doi.org/10.2217/pmt.15.39.

5. M. D. Bishop, “Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes,” Journal of Orthopaedic & Sports Physical Therapy 43, no. 7 (July 2013): 457–65, https://doi.org/10.2519/jospt.2013.4492.

6. M. E. Menendez and D. Ring, “Factors Associated with Greater Pain Intensity,” Hand Clinics 32, no. 1 (February 2016): 27–31, https://doi.org/10.1016/j.hcl.2015.08.004.

7. M. D. Bishop et al., “The Influence of Clinical Equipoise and Patient Preferences on Outcomes of Conservative Manual Interventions for Spinal Pain: An Experimental Study,” Journal of Pain Research 10 (April 2017): 965–72, https://doi.org/10.2147/JPR.S130931.

8. Jack Chew, The Physio Matters Podcast, “Session 61—Looking Backwards and Forwards with Team TPMP,” (January 6, 2019), http://chewshealth.1devserver.co.uk/tpmpsession61.