#PainAdelaide part 2

As well as presenting the very best in up to date pain science, PainAdelaide is also very tightly run thanks to ‘If-you-run-overtime-I’ll-put-a-fish-in-your-glovebox’ Moseley. Lunch was no exception with the well fed crowd being ushered back to their seats for a very special session.

Dr Francesca Panzironi spoke about her five year experience working with traditional Aboriginal healing and healers known as ngangkari. With Dr Panzironi was Mr Cyril McKenzie a ngangkari from the Anangu Pitjantjatjara Yankuntjatjara lands (simply known as the APY lands). Dr Fancesca spoke about her work culminating in the very first study into the use and place of ngangkari and the development of the Aṉangu Ngangkaṟi Tjutaku Aboriginal Corporation (ANTAC). You can listen to an interview with Dr Panzironi here.

Dr Panzironi then engaged in a question and answer session with Mr McKenzie, asking about the traditions of ngangkari, in particular some of the differences between learning western medicine compared with ngangkari. Mr McKenzie explained that ngangkari is “passed down from the grandfathers”, not learnt in books, and is also learnt from the land. Dr Panzironi spoke of her hopes, but also the challenges for an integrative collaboration between western medicine and ngangkari. In thanking Dr Panzironi and Mr McKenzie, Lorimer drew similarities between the successful integration of eastern meditative traditions into western medicine and Dr Panzironi’s hope for future collaboration.

Professor Bill Vicenzino took to the stage next, on time, to discuss lateral elbow pain, suggesting that there was more to it than just the tendon. Professor Vicenzino discussed research findings that demonstrated that in healthy controls, the presence of significant tendon changes ran at about 50%. Professor Vicenzino explained that there was simply not a strong association between tendon changes commonly seen on ultrasound and clinical symptoms and suggested that a better approach to tennis elbow, lateral epicondylagia/epicondylitis (or whatever we want to call it) is to focus on the most significant clinical finding, namely, pain.

Professor Vicenzio reported on findings by members of his group that demonstrated evidence of widespread hyperalgesia and spinal cord excitability (dorsal horn changes) present in people with chronic lateral elbow pain, at the same time as a reduction in the body’s natural ability to modulate nociception. Professor Vincenzino suggested that looking beyond the tendon and seeking to understand the underlying pain mechanisms would lead to better treatments and outcomes.

After two more mini PhD presentations, one from Audrey on a new, faster technique to map the hand and digits in the primary somatosensory cortex using a tactile protocol and fMRI, and Ebony who, echoing Dr Vicenzino, suggested that as a result of the lack of spread of pain from so called tendon injuries we have become too “tendoncentric” while explaining her findings of a relationship between patella tendinopathy and reduced ability to modulate transcranial magnetic stimulation of the motor cortex, was Professor Julio Licinio talking about what we can learn from translation psychiatry.

Professor Licinio is Deputy Director, Translational Medicine and Head, Mind and Brain Theme at the South Australian Health and Medical Research Institute SAHMRI and Strategic Professor of Psychiatry, Flinders University. But, what’s really important is that he gets to work in Adelaide’s newest, fanciest and most distinctive building, SAHMRI’s new home affectionately known as the pinecone or the cheese grater .

Professor Licinio explained that despite many years of neuropsychological research many treatments for mental health today are still based on 40-50 year old approaches, while the burden of mental health issues continue to grow with the financial cost alone in Australia estimated at A$192 Billion per year, or 12% of our GDP.

Professor Licinio has championed a bold call to launch a war on mental illness and is trying to raise the profile of mental health problems internationally by tackling the subject as a human rights issue.  Professor Licinio emphasised the importance of early intervention to prevent series mental health issues, but also warned of the dangerous and detrimental effects of premature labelling.

At the conclusion of Professor Licinio’s presentation, Lorimer asked the audience for a show of hands on the question of whether it would advantageous or disadvantageous to include chronic pain within the mental health domain. The spilt was about 50/50. Interestingly, the psychologist that I was sitting next to at the time voted for the former, while I voted for the latter.

Personally, I’m not sure that we need another “war on….” anything. The ‘war on drugs’ hasn’t worked out so well for anyone, neither has the ‘war on terror’ and are we ‘winning’ or ‘losing’ the war on cancer? In health, military metaphors abound and there has been much written on the detrimental effects that these metaphors can have. Susan Sontag is perhaps the most famous author who has spoken out against the potentially stigmatising effect of certain health metaphors. You can read more on these ideas here, here and here. During the talk of a ‘war on metal illness’ I couldn’t stop thinking of the quote that “the first casualty of war is truth”…

After a quick afternoon tea fix to get learning bodies in mind through the home stretch, Associate Professor Mark Hutchinson got up to convince us that “It’s the glia stupid”. A/Professor Hutchinson (@dmarkhutchinson on twitter with a few pics of the day) explained that glia provided an opportunity to make all of our jobs that much more complicated! But like Dr Neil O’Connell from the morning session, A/Professor Hutchinson has an infectious excitement and enthusiasm for his field and is a natural orator and entertainer behind the podium.

A/Prof Hutchinson suggested a ‘formula’ of sorts for chronic pain: Chronic Danger + hypernociception = chronic pain. However, he pointed out that his formulation highlights the fact that it is not all about hypernociception – there is more much more to it. A/Prof Hutchinson provided an overview of some of the roles of glia in the central nervous system, pointing out that they are active throughout the brain; checking in on the brain and its function, influencing synaptic activity via tripartite and tetrapartite synapses and communicating with each other via calcium waves. In the CNS, glia help to maintain function and health and are on a constant look out for danger.  Additionally, the immune products of some glia do a lot more in the brain than just “immune” stuff including influencing synaptic plasticity, learning and memory.

A/Prof Hutchinson spoke a lot about the notion of danger, and the fact that glia can not only detect danger, but can also ‘remember’ the presence of danger and a response to it. It was wonderful to hear a researcher who spends a lot of time at the molecular level talk about the notion of danger – a central theme in explaining pain. While there were a couple of presenters (who shall remain anonymous) who let slip with a few “pain fibres” and “pain pathways”, there was no conflation of nociception and pain from A/Prof Hutchinson, rather, the notion that we want a change in the chronic danger signal and a search for how glia might help in this story.

The complexity of this field is nearly overwhelming. A/Prof Hutchinson explained that there were about 600 genes or ‘molecular switches’ that were involved (switched on) in chronic pain states possibly leading to glia that initially played a vital protective and reparative role, remaining activated months after injury as an unwanted memory of the danger and no longer performing a useful or desirous role.  A/Prof Hutchinson concluded with a discussion of research he has conducted to develop a human model of glia and neuroimmune interactions that will help further research.

Associate Professor Mike Ridding took us on a journey into the world of Transcranial Magnetic Stimulation, a technique that allows non-invasive, targeted stimulation or inhibition of the brain.  A/Prof Ridding suggested that TMS may provide insight into the pathophysiology of certain pain states and further clues as to the contribution of neuroplasticity to chronic pain, however cautioned that there were relatively few studies in the field of TMS that focussed on pain and more work had to be done to develop protocols and the possible therapeutic potential of TMS.

The final presentation of the day went to Professor Jason White talking about the state of play regarding opioids and addiction.  Professor White characterised addiction to opiates as an adverse drug reaction – but one that little is known about, especially regarding what percentage of patients develop an opioid addiction, with the literature ranging from 0%-30%. A few key points; addictive drugs share the characteristic that they increase dopamine release in the nucleus accumbens, with addiction there is synaptic remodelling and neuronal growth (which can make treating addiction very difficult), the withdrawal of opioids can lead to dysfunction within the endogenous opioid system (a bit of a double whammy right there really) and that the very feature that allows opioids to work is what makes them addictive (a triple whammy).

Professor White explained that there was a moderately high heritable risk of opioid addiction, but environmental factors, namely stress (for example war veterans with PTSD and similar) and impoverished environments played a major role, with evidence demonstrating that in animal models stress amplifies addiction to opioids, while environmental enrichment and social interaction has a positive and protective effect. Professor White also explained that chronic pain can be a significant stressor, hence providing one of the single highest risk factors for addiction while at the same time leading to reduced social engagement and interaction with further risk of addiction.

Professor White  summarised the problem of opioid addiction as a delayed (by months or even years) adverse reaction to a drug with genetic and environmental risk factors that can be amplified by comorbidity with chronic pain.

I could’t help but think on the day that a simple solution to the problem would be to just stop prescribing opioids for chronic pain – not only given the dire situation with addiction, but also because a lot of evidence (as presented by Dr Dilip Kapur last year at PainAdelaide) suggests that opioids at best, are not efficacious for treating chronic pain and can in fact lead to increased pain via glial activation and, at worst, kill people.

Professor Paul Rolan closed the day with the stated goal of determining whether PainAdelaide was indeed “Possibly the best pain meeting in the world”. After running through the many highlights of the day he decided that PainAdelaide was not possibly the best pain meeting in the world, but in fact was probably the best pain meeting in the world and confirmed that “probably the best pain meeting in the world” would be back in 2015!

 

For me, in no particular order, the top three presentations of PainAdelaide 2014 came from Dr Tasha Stanton, whose work with visual illusions and perception is not only providing hope for novel pain treatments but is also providing insight into the very nature of the bodies in our minds and the minds in our bodies, Dr Neil O’Connell who is challenging the physical therapy professions to really understand and embrace evidence based practice as necessary due diligence to move the profession into the future and Associate Professor Mark Hutchinson whose research in the field of glia is helping to provide and explain the brain and nervous system as a neuroimmune target for a range of therapies.

And so it ended, another brilliant day of pain science representing a huge effort from a lot of very hard working people. My thanks go out to the presenters, the sponsors and especially the organisers, who will hopefully get a bit of a break before launching into the organisation for PainAdelaide 2015.

 

-Tim Cocks

ww.noigroup.com

 

Just a reminder that the entire day was “live tweeted” by a few attendees including yours truly – a search of Twitter for the hash tag #PainAdelaide will bring up the timeline, or you could have a look at @altThinq, @bodyinmind and @Trevail

 

 

Missed out on PainAdelaide? Don’t fear, noi has you covered with probably, nay, definitely, the best courses going around. Get your think on and get up to date at a course near you!

4 Responses to “#PainAdelaide part 2”

  1. davidboltononoi

    Wonderful summaries thanks a million………I come down on the side of placing persistent pain – haven’t we stopped saying chronic yet !!!! – in the realms of mental health………I can only add my personal experience of persistent pain to my humble knowledge of the subject as a basis for my vote. Psychological unresolved ” Danger” or better said, primal unresolveable psychological issues are powerful forces highjacking pain memories and playing them back whenever those Dangers are re-experienced…….Two weeks in the Maldives with the love of my life gave more pain relief to me than anything on offer back here in reality……..

    Reply

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