Last month, I was fortunate to have attended the San Diego Pain Summit (#SDPain). #SDPain was the brainchild of Rajam Roose, who organized a tremendous event, featuring a variety of speakers with experience in the fields of manual therapy, with Dr. Lorimer Moseley as a keynote speaker. #SDPain was a tremendous inaugural event, which has already scheduled an impressive line-up of speakers for next year – I would strongly encourage anyone who works with patients/clients with painful complaints to consider attending for both the engaging speakers and great company/networking opportunities. Additionally, if you have a desire to watch any of the presentations (with the exception of Dr. Moseley who was not recorded), streaming video subscriptions are available here. But I digress…
Dr. Moseley ‘kicked off’ #SDPain with a detailed overview of what the pain-science literature informs manual therapists of how pain presents and how various interventions impact the patient’s painful experience.
Throughout the weekend, various other presenters discussed (both on-stage and off-stage) how they work with the patient’s nervous system to reduce and abolish pain. Most presenters spoke of their clinical reasoning process and how they interact with the patient using a biological-psychological-social approach. Nearly every presenter featured a slide of Melzack’s neuromatrix and discussed how therapy can impact a variety of inputs into the neuromatrix, especially with regards to sensory-discriminative and motivational-affective inputs.
Throughout the weekend presenters shared an understanding of the specific and nonspecific effects of therapy care. Each presenter, at one time or another, stated (confidently), “I don’t know,” sharing a degree of humility often lacking from expert-presenters.
At the end of the weekend, Dr. Moseley closed #SDPain with a presentation specifically addressing questions that had been asked throughout the weekend. He discussed how he, with his Body in Mind team, is trying to scientifically test the imprecision hypothesis of chronic pain. He offered a few anecdotes and a handful of stories. After his presentation, he opened the floor to additional questions. One of the people that asked a question was Eric Kruger, DPT. Eric had presented earlier in the day.
My question is about Pavlovian conditioning [with regards to the imprecision hypothesis] and have you considered operant conditioning, as well, in that mix?
Dr. Moseley replied,
“Yeah, at length actually. The data that we have, from a pain perspective, I mean – Historically in all possible conditioning, pain is considered the stimulus, right? … So, we have really worked on the idea of, ‘Does the classical conditioning paradigm [fit with] our [imprecision] hypothesis?’ Based on what we have seen so far, it does. So, now we go and prove it wrong.
There is a lot more work in operant conditioning and I know that you are very familiar with, and interested in, the social aspect of these things – Fordyce kicked that off…and I think that you could talk with more authority on what that body of literature tells us, but in my perspective, it doesn’t explain chronic widespread pain.”
I was surprised to hear his response. As I understood it, predictive processing would demonstrate that operant conditioning has the potential to be incredibly important – our life’s experiences are the stuff from which top-down inferences are anchored. To disregard the value of operant conditioning seemed to leave out an all-too-large piece of the puzzle, I thought.
All weekend I had avoided speaking with Dr. Moseley, not because he was not open or available – to his credit he was available for people to speak to throughout the weekend and attended each presentation – but because I am terrible at small talk and, if I were in his shoes, I would loathe answering the same questions (albeit from the different people in different places) every day. After all, he has an opportunity to engage with the most insightful minds in the world of neuroscience and therapy – a conversation with me is a BIG step down (seriously).
But after Eric’s question, and Dr. Moseley’s response – I felt compelled to ask Dr. Moseley my question, which had been ‘eating at me’ for the last few months. With the help of some difficult reading (which, admittedly, I don’t fully comprehend), I had arrived at a conclusion that was mostly uncomfortable. Throughout the weekend, I would ask others what their thoughts were on the subject, and no one had read as much as I had on the subject (and I certainly understand that I have only scratched the surface).
So, I was left to awkwardly wait in a short line to (a) thank Dr. Moseley for making the effort to put together a presentation over the weekend (complete with powerpoint slides) that directly addressed questions and concerns that participants had shared with him since the start of #SDPain and (b) to ask him my question:
“I have been reading a bit about predictive modeling and the “Bayesian” brain, and I know that Dr. Thacker is hoping (or planning) to work with Andy Clark to explore some of the possibilities pertaining to this line of reasoning. As you were answering Eric’s question about operant and classical conditioning, it struck me that I had to ask: If the predictive model were to be true, wouldn’t it be possible (if not likely) that science – as we know it – is likely going to be ultimately inadequate in being able to answer these questions pertaining to persistent pain? It would seem that classical conditioning would only account for a small portion of the influence over the top down predictive processing and operant conditioning would also play a role, but is too difficult to capture in studies?”
Of course, this is how I remember saying it, but I have mentioned this story to friends a dozen times already, so my delivery was (most certainly) not so clean. I was a bit intimidated (after all) using language that I am not conversational with about a concept I don’t understand fully, especially to someone I would prefer not think that I am a blithering idiot. So imagine a few stutters, a shaky voice and 70% accuracy of my recollection of the event, despite having rehearsed how I was going to ask the question for about 4 minutes while waiting to speak to him.
Dr. Moseley, to his credit, was kind and did not laugh at me. He answered my question politely and I thanked him again for his time – there were others behind me that wanted to speak to him and take pictures.
I cannot share, specifically, what Dr. Moseley said, because I do not wish to put words in his mouth, and I do not recall precisely what he said. He chooses his words carefully in discussion, so I will paraphrase only so as to try to not misrepresent his thoughts, and the specific words here are my own. The 2 words that I clearly remember, though, were “insightful” and “maybe”.
He said that my question was ‘insightful’ – probably to be nice.
The answer to my overall question was, “Maybe.” He kindly explained to me that classical conditioning is more challenging for pain researchers to study (due to ethical considerations) than operant conditioning, but he conceded that it is possible that science may not ultimately have what it takes to figure out, in some instances, the driving mechanisms behind the experience of persistent pain (again, my word choice and phrasing, not his own).
As I was walking away (I did not want to monopolize his time with drivel that I barely understand, namely philosophy and psychology), it occurred to me that my idea of operant conditioning (in the context of my brief conversation with Dr. Moseley) was much different than his own. In retrospect, I suspect that he thought that I was looking at operant conditioning as a variable to be studied in a research project – I was actually thinking bigger. I was thinking of operant conditioning as a lifetime of experiences that reward and punish an individual for various expressions and manifestations of their self. I was thinking of a lifetime of priors that later drive, and have influence over, that person’s experience. I was thinking that researchers can control for as many variables as they want in the lab, but if the brain is working as a top-down Bayesian inference machine, the complexity of an individual’s previous experience has the potential to render science impotent in many respects as it tries to understand the phenomenon of persistent pain states.
If I were bolder, or perhaps a bit more self-important, I would have approached Dr Moseley earlier in the weekend. If I were a bit more brutish, I would have asked more questions and I may have walked away with a few more answers, but I still would have felt guilty for boring a man with the same questions that he has probably fielded so often before.