Graded Macadamia Intervention

Peanut allergy treatment ‘a success’ via BBC news online

Doctors say a potential treatment for peanut allergy has transformed the lives of children taking part in a large clinical trial. The 85 children had to eat peanut protein every day – initially in small doses, but ramped up during the study. 

The findings, published in the Lancet, suggest 84% of allergic children could eat the equivalent of five peanuts a day after six months. Experts have warned that the therapy is not yet ready for widespread use. 

Build up

The trial, at Addenbrooke’s Hospital in Cambridge, tried to train the children’s immune systems to tolerate peanut protein. Every day they were given a peanut protein powder – starting off on a dose equivalent to one 70th of a peanut. 

The theory was that patients started at the extremely low dose, well below the threshold for an allergic response. Once a fortnight the dose was increased while the children were in hospital, in case there was any reaction, and then they continued taking the higher dose at home. The majority of patients learned to tolerate the peanut

Caution

Prof Simon Murch, an allergy expert at the Royal College of Paediatrics and Child Health, said: “This is clearly a promising paper but it certainly isn’t a cure.

“Nevertheless this study does point towards a promising new direction of therapy and once further testing has been carried out, and techniques refined, it may prove to be a therapy with widespread use in hospitals in future.”

But he added: ” This is not something that should be undertaken at home, or indeed outside specialist centres.”

Of course, so many parallels with that other GMI – sneaking in under the (neuro)immune radar, start small- really small if necessary, build gradually and carefully, be prepared for a reaction, it’s going to take some time…

Grading, ramping, building up; such a fine, and at times, delicate art. I think formulas fail; they don’t (can’t?) take into account the magnificent variety and sheer complexity of different human experience. That leaves listening, clinical reasoning, maybe a bit of trial and error. Metaphors and analogies can help; “baby steps”, you need to walk (left/right discrimination) before you can run (mirror box), one foot in front of another, the journey of 1000 miles starts with a single step, you can’t eat a whole salami in a single mouthful (anyone that’s taken a GMI course with David Butler will know this one!), pace it don’t race it, patience and perseverance, patience and perseverance, patience and perseverance….

But it can be hard; pacing and graded exposure don’t tend to have a lot of “sex appeal” in a quick fix world or where that “guy down the street reckons he can just crack it back in and I’ll be right”. By necessity, graded exposure will involve a LOT of repetition, possibly hours spent doing the same thing, with only incremental change if any, over and over again every day. How do you motivate a person in trouble to spend an hour, two hours, per day looking at body parts being flashed in front of them? I think the right education and grounding must be essential.

Then, how to progress? The book has some great ideas. Do I follow them by rote? Should I add some background music? When should we progress to some mirror box in the workplace? What happens if there’s a flare-up? Again, listening and clinical reasoning are rocks in the shifting sand.

I’d love to hear about your tips and tricks, successes and ‘opportunities for learning’ regarding graded exposure, the motor imagery kind or otherwise.

Tim Cocks

www.noigroup.com
http://www.gradedmotorimagery.com

As a side note, I wonder if there was any contextual effect in the study. Context is such a big part of GMI – location, environment, emotion, distraction, function. I wonder if eating some peanut protein results in a different reaction if it’s eaten in hospital surrounded by trained staff compared to being at home? What about eating something you *think* is peanut protein. What about watching someone else eat peanuts?

I know, the story is about peanuts, not Macadamia nuts, but you’ve all seen what I did there.

4 Responses to “Graded Macadamia Intervention”

  1. davidboltononoi

    I think you’ve hit the nail on the head Tim. There is no one protocol that fits all. Each sufferer is a unique being with a unique emergent pattern of suffering. Only trial and error and getting it wrong again and again will produce the track record that a practitioner needs to slowly become effective in influencing a change in the emergent yet plastic patterns that we witness. Following on from the perpetuai absorbance of the academia we need to learn to throw protocols to the wind and fly from the seat of our pants allowing our own beautiful emergent patterns the chance to instinctively form from the archives of our knowledge base. For me that is the essence of clinical reasoning…….

    Reply
  2. Efwef Gwerb

    G’day Tim,

    I’ve noticed that it’s always the kids with anxious parents who have food allergies. I don’t know how researchers would have not noticed this themselves, because it’s very obvious.

    I think a good way to investigate this would be to have a proper placebo control. In this study, their “control” was a peanut avoidance. Not only that, but the groups weren’t masked. How can anyone draw conclusions from this?

    Instead they need to covertly inject peanut proteins (using IV route) at random time intervals and continuously measure the allergic response. Then they should repeat this with suggestion of “now you are receiving saline”, when the subject is receiving peanut protein. And so on. Much better ways to do this sort of study, imo.

    Reply
  3. timcocks0noi

    Hi EG
    Reckon you might be running into some serious issues with ethics with that approach!

    My take on the research was simply that a carefully graded exposure to the allergen (the idea of the allergen?) reduced the response over time. I reckon you’re onto something in regards to thinking deeper about causation, but potentially pretty risky to pretend to gradually expose a child to peanut protein and then, I guess, at some point test this out with the real thing.

    Not sure about the kids with anxious parents idea. When I went to primary school there were no bans on peanut butter or that other delicious hazelnut spread – I can’t recall a single kid having a nut allergy (doesn’t mean it didn’t exist) but I’m pretty sure there were still anxious parents back then. If we take an allergic reaction to be some kind of protective response emerging from a human, like pain in a sense, I think we need to be careful reducing any ’cause’ down to one factor. Equally, we can’t ignore psychological, social and cultural influences either and pretend that its ‘just’ biological.

    I think the context of anxious parents raises the notion of an emergent, recursive, dynamic system between parent, child and nut (and perhaps the world at large…). Maybe it’s only at this dynamic systems level that we’ll find the answer?

    Thanks again for your thoughtful and thought provoking comments here and elsewhere.

    Tim

    Reply
  4. Efwef Gwerb

    Hi Tim,

    Before RSD became common knowledge in the 80’s, there was no way of being anxious about it. In the same way, before food allergies became common knowledge in the 90’s, how could a parent be anxious about it? They would just have to be anxious about something else that was floating around in the zeitgeist of the time.

    In my view, food allergies are the June bug of modern times.
    http://en.wikipedia.org/wiki/Hysterical_contagion

    I think my suggestion for testing whether nut allergies would pass an ethics board’s scrutiny. In a hospital setting, there’s adrenaline readily available in case of severe reaction, and the IV is already in place. If such testing isn’t done covertly, the risk of multiple confounding factors influencing outcome would be way too high for my liking. I hate seeing study after study after study not adequately cover bases in terms of confounding factors.

    To do this test properly, there’s heaps of combinations that need to be considered, for example:

    – with parent in the testing room and allowed to interact with child…
    – parent and child aware of true substance being administered
    – parent and child told “peanut protein” when saline is administered
    – parent and child told “saline” when peanut protein administered
    – parent only aware of true substance being administered, child not
    – parent only told “peanut protein” when saline is administered, child not
    – parent only told “saline” when peanut protein administered, child not
    – child only aware of true substance being administered, parent not
    – child only told “peanut protein” when saline is administered, parent not
    – child only told “saline” when peanut protein adminisitered, not parent
    – then repeat whichever of the above are still necessary when the parent is not present.

    An experimenter would be present, but totally blinded. Peanut protein is administered by computer randomizing both time and dosages over a 12 hour period. Computer records all of this in real time and also records signs of stress response (say GSR or HRV) plus signs of allergic responses. None of this is fed back to the patient. The experimenter would only be called to action if he noticed symptoms of distress of allergic reaction.

    This study design has taken me only 5 minutes to write. Seriously…. how hard is it?!!!

    Reply

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