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>> Ran Gilad Bachrach: Delighted to host here today Dr. Dennis Turk. Dr. Turk
is a John and Emma Bonica Professor of Anesthesiology and Pain Research and
Director of the Center For Pain Research on Impact, Measurements and
Effectiveness at the University of Washington School of Medicine. He was
previously he was previously associate professor at Yale and professor at the
university of Pittsburgh School of Medicine.
He's a founding member of the American Pain Society. Dr. Turk is a fellow of
the Academy of Behavioral Medicine Research, Society of Behavioral Medicine and
American Psychological Association.
Dr. Turk has been active for many years in
organizations and is past president of the
member of the Council of the International
for six years. He is a special government
States Food and Drug Administration.
national and international
American Pain Society and was a
Association for the Study of Pain
employee advisor to the United
He has received a number of awards, including recipient of the Award for
Outstanding Scientific Contribution. He's contributed over 550 publications to
the healthcare literature and is currently editor-in-chief of the Clinical
Journal of Pain. Dr. Turk has authored 20 volumes in the areas of pain,
chronic illness and clinical decision making.
Going over the list of all your achievements and awards will take the entire
time slot. So I think I'll stop here and give you the stage to talk about
chronic pain, technological challenges and opportunities.
>> Dennis Turk: Thanks, Ran. Thanks for the nice introduction. All that
means is that I'm old. I got gray hair. The longer you do things, the more
degrees and awards and stuff that you get. I've been given an interesting and
dubious task, to speak to a very different audience than I'm used to speaking
to, to try to talk about, get you sort of a brief overview, but fairly quickly,
and I talk quickly, you'll notice, on what do we know about chronic pain.
What's the current status, current situation.
And then to talk about
hopefully with us, but
don't. One definition
less and less until he
challenges and opportunities that are available to you,
you because you have the technological knowledge that we
of an expert is someone who knows more and more about
or she knows nothing about everything.
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And I have thaw distinction on the pain side, but we can flip it around and
have the distinction that I know nothing about the technology and the future of
what's going to be happening, and you guys do. So in a sense, I'm the worst of
both worlds. I know nothing about pain and I know absolutely nothing about the
technology. So given that, it could be a very short talk or a very long talk.
Let's see if I can sort of catch you up. You though, ask the experts. And if
you ask the experts, the only thing they'll agree on is that the third expert
is incompetent, and you'll notice that one of the experts you have here is in
the picture.
So I'm going to try to demonstrate I know a little bit something about at least
the first part of this talk and hopefully won't discourage you from listening,
because I think from my talking to some people already, it would be nice if we
had real simple answers to things, and unfortunately I'm going to make them
more complex than simple, and your task is going to be to figure out how can
you take that complexity and get it down to something that's manageable, given
the technologies that you have. And you have tremendous opportunities.
So it is a great pleasure to be here to speak to you.
So let me tell you a little bit about pain, just so you understand the ground
work. And I'm going to be talking about exclusively about chronic pain. And
chronic pain is usually defined as pain of six months' duration or longer and
beyond the expected period of healing. So, for example if you injure your knee
and we expect you to be healed within six weeks and you're still reporting pain
in three months, that's begun to become a chronic problem.
However, it also could be the case you have progressive disease. So, for
example if you have arthritis, it might be progressive over time and it will
get progressively worse. So those are chronic conditions. Anything beyond the
expected period of healing or three to six months is what I'll be talking
about.
And I really am not going to focus on children, and I'm not going to focus much
on cancer pain, but a lot of what I'm going to say conceptually is just as
relevant for pain associated with cancer and any non-cancer related pain. And
you'll understand the kinds of pains I'm talking about.
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So just to give you some big overview picture, in case you were thinking this
is a small problem or if you, yourself, have the problem and thought you were
alone, I think you'll find out very quickly you're not. Nearly one half of
Americans see a physician with a primary report of pain each year. One half.
So if you look around the room, assuming that this is a normal distribution of
population in the United States, about half of you, when you go to a physician,
pain's going to be the symptom.
And this is separating out your normal annual visits, but just when you go to a
doctor, why you're there. Usually, pain is one of the major reasons.
The proportion of all physician visits, just for back pain, which is the most
common kind of pain in the United States, with arthritis being second although
back pain and arthritis you could have back pain associated with arthritis, so
it's a little tricky to say that. But back pain alone accounts for somewhere
in the neighborhood of 20 million visits a year to physicians.
And approximately, if you think what's the impact of these numbers have on the
real world, 149 million work days are lost each year due to back pain. So if
you think about the time, you've ever had back pain or you know somebody who's
had back pain who hasn't gone to work, then you'll understand what these costs
are. And that's estimated to be almost $20 billion in just lost productivity,
lost time on the job, other people filling in for you, et cetera.
We can look at different pain conditions. Arthritic pain, back pain, migraine
headaches and cancer related pain. And approximately 35 percent of the U.S.
adult population or, roughly 100 million people are predicted to have some type
of chronic pain. The United States is not different from the rest of the
world. Somewhere in the neighborhood of between 19 and 35 percent of each one
of the European countries that this has been looked at also reports significant
pain problems.
And usually, that's pain sufficient, depending upon how the wording of the
questions are, to impair some activity you're engaging in. So it's not just
oh, yeah, I have a pain but I do everything I'm supposed to do. It actually
has an impact on your life. And you can see the relative proportion of the
different types.
Remember, I said arthritis is going to potentially also be back pain. Although
back pain is the most common part of that, may be captured in the arthritis
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world. But those are millions of people, so it's a lot of people. And if
you've got family members, if you, yourself, have a pain problem, you're
talking about one third of the population.
And if we want to look at this by age, this will make all of you people feel
very good. It's getting worse, because as you age, you're going to see that
the frequency or the prevalence of having some type of pain increases
proportionally, and it's going up nicely. It's not going down in any way.
So any of you in the room, depending upon where your age, you can see where you
are on that, males versus females. And in every instance at every age, females
tend to report more pain than males do, and we can get into lots of interesting
discussions about why that may be. If you want to ask me about that later,
there are some speculations that we could talk about. But there's no need to.
Population is aging. So everybody in this room has this to look forward to.
If you make it to age 65, the likelihood that you're going to have a pain
problem is about 75 percent. If you get to be 85, it's more likely to be 85
percent so if you live long enough, you're going to have a pain problem.
>>:
Why did the male figure go down?
>> Dennis Turk: They're dying off younger.
that's what's happened.
>>:
Hate to give you bad news, but
I used to think that the female have children so [indiscernible].
>> Dennis Turk: Wrong, in that there's not good evidence one may or another
whether they're more tolerant. However, part of the problem is in how people
report and how men and women are treated in society and how they respond, how
they report symptoms.
When it
cluster
minute,
because
comes to pain in treatment, in every medical condition except for
headaches, the prevalence is more high -- I'll get your question in a
is higher on women than on men. But that's in clinical populations,
women more likely come for treatment for their problems than men do.
So if you do a community survey, the difference between males and females isn't
nearly as great as it is in community samples. Yes, ma'am?
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>>:
The label that you have on the graph, 95 percent CI.
>> Dennis Turk: This is -- that's what that is.
confidence interval.
>>:
What is that?
That's referring to the
Okay.
>> Dennis Turk: And if you want to look at some other conditions by millions
of people, there's just some more numbers. This is to give you an idea,
compared to some other conditions. So strokes, blindness, visual problems,
diabetes, other problems. By far, the largest percentage of people have pain
problems.
So everybody gets very exercised about cancer, by the way. If you noticed
several slide back. Cancer and pain is very dramatic. You'll notice
proportionately, that's a small peanut compared to what these other chronic
pain conditions are. And that's, again, 33 percent of the population has some
type of joint related symptoms. So arthritis is definitely a big and important
player. That's arthritis, OA, osteoarthritis is very much related to wear and
tear on your body.
So all you healthy people who are jogging and doing all those good things for
yourself, trust me, you're going to have arthritis problems if you don't
already have them.
So what's the annual cost? Given these numbers, what does this actually cost a
society? That's estimate per year. Anywhere from 560 to 635 billion dollars a
year is spent on health-related problems, related to pain. And we can look at
it compared to other kinds of conditions.
So again, these are different medical conditions, and here we're looking at
cost. We're going down to chronic pain, which I haven't filled in for you, and
chronic pain. And if with we go up to include indirect costs as well, there's
that 500 billion dollar number.
So you can look proportionally. Again, look at cancer, which everybody gets
very exercised about. Look at proportionate costs, and that's because of the
denominator. It's much fewer people are going to have cancer than have some
type of chronic pain. So it's a big problem.
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So given that big problem, of course, we would assume that we can take care of
these people very well. A couple of saying we have good treatments for pain
and I'm going to hopefully -- not hopefully. I'm going to convince you, I
think that we don't have such good treatments for pain.
But what are some of the impediments to people getting good treatment for pain?
Well, it's often viewed as a symptom and it's secondary. So it's not a
disease. So therefore if you go to the National Institute of Health, there is
no Institute of Pain. There is a National Institute of Arthritis,
Musculoskeletal and Skin Diseases. There's a National Cancer Institute.
There's a National Heart, Lung and Blood Institute. Those are
disease-specific. So the reason pain doesn't get the attention is people get
very concerned about the disease, and they want to cure the disease, but they
tend to forget that almost all of the diseases that are particularly important
have pain as an important symptom related to that.
There's little consensus about how do you treat people with pain. If you go to
different medical specialists in different parts of the United States in
different parts of the state of Washington, you'll get different treatments
depending upon who you go to.
In different states in the United States, there's a ten-fold difference in the
number and types of surgeries you get for back pain. It's highly related to
the number of surgeons available. The more surgeons, the more likely you're
going to get surgery. Does that mean that you really need it? That's some of
the discussion.
Inadequate knowledge by the primary providers. How should a primary care
provider, we were talking earlier about the typical primary care provider,
you're going to see, has estimated that they're going to have 7 to 15 minutes
of time to spend with you, and assuming that they have 35 to 40 patients to see
in one day, how much time do they have to spend with you to talk about your
chronic pain problem and the impact it's having on your life?
So there's not a whole lot of knowledge about how to handle it, and they don't
have the time. My colleague who is sitting over there, [indiscernible] Patel's
wife is a pediatrician. She doesn't have time to deal with these complex
problems, because she's got to get you in and out pretty quick.
And imagine your appointment is for 8:30 in the morning and you have a chronic
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pain problem. What is that going to do to the rest of the schedule for the
rest of the day? So when you're waiting and your 4:00 appointment is turning
out to be 6:00 at night, now you know why, because somebody shifted -- and it's
not likely it's the physician's fault. It's likely what the presenting
symptoms are that created a problem.
It's perceived as very time-consuming. It takes a lot of time to see these
patients and a lot of primary care providers want you out as fast as possible.
There's a lack of really trained specialists, except if you're in university
medical centers or large cities. So if you happen to live in the Yakima or
Walla Walla, there's not a whole lot of specialists in pain care. You have to
come all the way to Seattle, which is a problem because it's a long trip.
Chronic pain, by definition, there's no cure. Chronic means it lasts for a
long time. Forever, potentially, as long as you're going to live. Therefore,
you're going to have to keep coming back and forth across the mountains to see
your provider to deal with your pain, and that's part of the problem.
You look at the distribution of the United States, pain specialists are in big
cities and universities. They are not in rural areas.
Prohibitive costs, specialty trained treatments are expensive and a lot of
insurers don't cover them. So even if we know what all the appropriate
treatments are, it doesn't mean that the insurance companies are going to pay
for those. That includes different types of medications, different types of
surgical intervention, different types of other types of interventions.
Geographic distances to travel to get to specialists, it's very costly for
people to have to come from Yakima to Seattle. It's time off of work. It's
travel time. And in addition to the healthcare cost, there's those indirect
costs.
And there's no cures. There are no cures for chronic pain. And make you feel
worse, there are no cures anytime in the future you're going to see for chronic
pain. I've been doing this since my hair was black. If you can't see my hair,
it's gray. I've spent approximately 30 some years working with pain patients.
The same patients I saw 35 years ago are essentially getting the same
variations of the treatments that they got 35 years ago, and they're still
waiting for the cure. And if I came back here in 35 years, that would be nice,
I think I'll be giving you the same message.
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We'll have some more technological advances on how to do the surgeries and
different medications may be developed as variations of the same classes. I
think I was telling somebody this morning, I forget who it was, Matt or Randy,
but what's the most potent medication we have right now? Opioids. When were
opioids first found and used? In the Ebers papyrus in 4 BC was the first time
there was reference of using opioids for headaches.
Nonsteroidals, aspirin, Aleve, these kinds of drugs, they're based on
acetylsalicylic acid. Willow bark, Hippocrates used willow bark for pain in
400 BC. So we haven't gotten very far in the major classes of medication.
There are two other classes that have come along that are slightly improvements
on what we had 400 to 4,000 years ago, but they're not that much better, as I'm
going to show you some data on.
Functional disabilities for a long time, and they're going to limit your
ability to get to care. So an important thing is if, in fact, you have a
chronic disease, a chronic problem of any kind and you come into a
rehabilitation type of facility and we provide you some type of treatment and
we didn't cure you what does that mean? And what that means is that people are
going to have to do a lot of self-managing over a long time.
So if the average age of a person who has a chronic pain problem is 44, which
it is, if you look at people coming to pain specialists, that means they're
going to have a long time -- they're not going to die, typically, from chronic
pain. They may be living 30, 40, 50 years with a chronic pain problem.
How are we going to treat those people over that time if we don't have cures?
And we'll get to that when we talk about some challenges that may be available.
What are some of the assumptions that physicians and probably lay people make
that are important to think about, and this is probably an over simplification.
It assumes, by medical perspective, that there's a close correspondence between
the objective pathology, the impairment, and the amount of symptoms or the
impact it has and disability.
The more pathology I have, the more pain I should experience, right? And the
more pane I have, and the more impairment I have the more disabled I should be,
right? There should be a close association. There's not. And we can
understand that.
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It assumes that if and when the symptom generator, the cause or the symptom is
identified, the treatment is going to remove it, cut it out, cut that nerve,
cut out that painful body part, or we take some medication to pharmacologically
block the signals. Pain signals have sentry information from the periphery of
the body, go centrally and the brain is where we interpret something as being
painful.
There's no pain with no brain. If I have you totally anesthetized, you go for
a major surgery, do you experience any pain during the surgery? How would we
know? Can I ask you? You're anesthetized. Can I measure some physiological
responses? They're not related. Can I observe your behavior? You're totally
anesthetized.
So how will I know how much pain you have? So therefore, we don't know, but
the assumption is that when you're totally anesthetized, you don't experience
any pain. So therefore, that requires a conscious organism, conscious human to
report on their pain.
It assumes that patients with the same symptoms and a diagnoses should be
treated with comparable intervention and have the same outcome. Two people,
same problem, same sorts of pathology, assuming we can find something. We
treat them the same way, and they should have the same response, right? It's
not true. Same people have the same diagnosis have the same surgical
intervention performed by the same competent surgeon in the same successful way
will report very differently on whether they got a benefit from that surgery.
Less than 20 percent of people who have surgery for back pain report that
they're pain-free after the back surgery.
It assumes that the symptoms that persist, despite appropriate treatment, are
likely psychologically caused or psychogenic. If, in fact, we blocked or cut
the pain signals, pathways, how could you have any pain? So if there's no
physiological basis, then it must be, ipso facto, it's psychological.
Psychogenic. Second gain, because I want to get insurance payments. I want
disability, or I want to receive medication that have euphoric effects, like
opioids can.
So that's an assumption. Now, are those assumptions valid? No. And I'll
demonstrate this to you, and I'll show you just shortly that an assumption is
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that patients objectively determined equivalent degrees and types of pathology
vary widely in their reports of pain.
Three of you here, I put you into
procedure, I get widely different
the same stimuli, electric shock,
hurting you. If we try those and
we'll get a wide variation.
a laboratory through the same pain induction
responses. Now how could that be? If I do
heat, cold, we've got a lot of ways of
I bring any two or three of you in there,
There were some funny studies that I always like to mention back in the 1960s
in which they brought people into laboratories, college students into
laboratories and did some kind of laboratory induction of pain, and then they
would say to the students, you know, you Yale students, people at Harvard, for
some reason, we don't understand why, their tolerance for pain is much higher.
And then they redid the test, and what do you think happened? The tolerance
went up. And then they told the people from Stanford that the people at
Harvard had -- and the numbers went up. And then they told the males that the
females, and vice versa. And then told Catholics and Protestants and Jews and
they went around.
And every time, in every instance, the instruction led to changes in how people
reported their willingness to tolerate pain and their thresholds for pain.
Lots of variation.
Asymptomatic people, people who don't have symptoms of pain, often reveal
objective evidence of structural abnormalities. You see all the different kind
of imaging procedures and I'll show that to you. This is -- this graph is
showing you, these are lumbar myelograms, CT scans, disco grams and MRIs.
These are asymptomatic people, and these are what they found on those different
laboratory procedures.
So for example, 24 percent of people who have no symptoms, who had lumbar
myelograms, had sufficient abnormalities that you would expect that they should
experience pain and you can see the different numbers.
These are people who have no symptoms. So you've got pathology with no
symptom. How would you understand that from that traditional model of pain,
that there should be a nice relationship?
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Conversely, patients with minimal objective evidence of pathology often
complain of intense pain. So on one hand, you've got people who have pathology
and no pain. Then you have people with pain and no pathology. So I guess -whoops, I guess what we must have is a disease deficit disorder. Can't find
anything wrong with you.
So here's the fundamental problem that we have. We look at these individuals,
and the patient reports back pain, and we look at their spines, it's an MRI,
and that's a perfect -- you're not radiologists, but that's about as clean as
you could possibly see, okay? Then we've got an asymptomatic person who shows
significant constriction on the nerve, which if you saw that and you were a
radiologist, you would predict this person's got significant pain. But they
may be asymptomatic? How could that be?
86 percent of people with chronic back pain have normal MRIs. 86 percent of
people who have normal MRIs report back pain. Are they all faking? They're
all making it up? How could that be?
30 percent of people with abnormal diagnostic images do not report any pain.
So you've got these numbers, they don't make sense if you take that
traditional, nice, physical model of pain.
So some more challenges for us, surgical procedures designed to inhibit the
symptoms by severing the neurological pathway, cut from the periphery up
centrally to the spinal cord to doing phlebotomies, which we've done as of the
1940s to try and prevent pain, and it didn't cure any problems.
So you've cut the nerves all the way up, how can the signals be getting to the
brain? How can you experience pain? How come you're not anesthetized?
>>: [indiscernible] so as far as I understand from the pain system is
[indiscernible] another system of the body [indiscernible] this is the purpose.
>> Dennis Turk:
You put your hand on a hot stove, you pull it off.
>>: That's right. So it's supposed to surface. In some cases, people indeed
have some problems, say [indiscernible]. In some cases, I don't have any
problem, but I reported pain. So that means that I might have a problem in the
pain.
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>> Dennis Turk: You're mixing up pain and chronic pain. Acute pain, that
reflexive response, everything is working the way it's supposed to. Over
time -- let's say back pain. Say you had an injury. We can see the injury.
It's the acute phase. You've now recovered, and most of the time for any kind
of back injury you're going to have, work in the garden and hurting yourself,
it's going to be gone in a couple weeks.
So the pathology's gone. The pain system is still somehow operating. What is
causing the pain system to keep firing if, in fact, the pain generator is now
resolved? And that's what we don't know.
>>: So this is what I'm suggesting, that the pathology is the pain system
itself in my back.
>> Dennis Turk: Exactly. Well, the pain is never in your back. It's always
in your brain. But yes, the pain system is altered and that's sometimes
referred to as central sensitization or the plasticity of the nervous system.
What's changed now is not the periphery. What's changed is the nerves and
there's something going on that's refiring and people have looked.
Remember, if we keep cutting the nerves, where is that system breaking down?
We can't do a total brain removal, lobotomy and thalamotomy, those are pretty
extreme surgical procedures and people still report pain.
>>:
Do they work?
>> Dennis Turk: They don't. They don't work, because pain's distributed -- if
you understood the pain system, it's widely distributed so you couldn't remove
enough chunks of the brain to get rid of it all.
So the pain -- there's a theory. This isn't well proven. There's a theory
that there's a change in the nervous system that's perpetuating these signals
getting to the brain or being recorded in the brain, even though the initial
cause of the pain is no longer present.
And if you look at the example of phantom limb pain, someone will have an arm
removed, and they'll report pain in the part of the limb that's not there. So
something is changing upstream for them. So you're right that that's what
people are trying to understand. We've been looking for the last 20 years on
this central sensitization theory, and we're not getting too far. So hang in
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there.
Have me back in 20 years and maybe we'll be able to answer it.
The key dilemmas, there's modest associations with the impairment, pain
reports, disability and response to treatment. To give you an example of
this -- I'm going to skip that one for now. So this is a person who's had
above the knee amputation. No question about it. This person has an
impairment. And an impairment is an objective alteration, functional or
structural aspect of the body.
Structurally, they're missing a limb. No question. That person impaired. Is
this person impaired? Well, he's impaired, but he's not disabled. Skins
Randy's here and he came from Israel, I'll refer to Itzhak Perlman, who is a
very famous violinist who some of you may know of, concert violinist,
internationally known, who had polio when he was a child. He had very heavy
braces on his legs and uses of crutches and canes.
He was asked by a journalist if he thought that having polio had interfered
with his career in any way. And his response to them was, if I played the
fiddle with my feet, it would have interfered with my career. Is he disabled?
I'm sorry. Is he impaired? Absolutely. Is he disabled? He would say no.
So there's not equal. You can't assume that these are going to be the same
thing, which is what our key dilemma is going to be. You're always stuck, and
I was talking to Ran this morning. We always have this dilemma of how do you
know how much pain someone has, and how do you decide whether you believe that
or not.
Because we really have this fundamental problem. Self-report scale, on a zero
to ten scale, rate your pain so I got a verbal report from you, and then I can
look at that x-ray, that MRI, and lo and behold, and you've got facial
expressions.
So what's the relationship between the self-report, the physical pathology and
the facial expression? Everybody would guess this guy is experiencing some
pain, right? So what's the relationship? Okay. Well, what we find out,
unfortunately, they're not highly correlated.
Well, if they're not correlated, what are you going to do? Which one's right?
Do you trust the report, do you trust the x-ray? Do you trust the face? And
this is the dilemma that healthcare providers have had and insurers have and
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attorneys have and disability claims people have, because how do you know? I
know by what people tell me, or I know by their behavior, both of which are
under voluntary control of the person who experiences them.
So can I trust them? Pathology says they've got nothing wrong them. But the
patient complains of a lot. He or she's faking? Look at their ratings, and it
looks like they got real pain, but their facial expression may be more stoic.
So which one do you believe? And this is the problem that I have for the last
35 years but everybody has had sips the beginning of time. How do you know how
much pain somebody has, and how much do you believe them?
So what's an unintended consequence? If we've got all this pain, it's so
costly and we're not treating it very well, well what's happening is we expose
patients to increasingly invasive diagnostic treatments, procedures that are
iatrogenic in and of themselves believe it or not, CT scans, exposure to
significant amounts of radiation. Giving you plane x-rays give you a
significant amount of radiation. PET scans, if I would show you those, we're
injecting radiographic material into you. These are not benign procedures.
False positives and negatives lead to inappropriate care. We see something on
the x-ray that could be related to pain, and we treat it. But I just showed
you that 30 something percent of people who have abnormalities don't have any
pain. So how do you know there's a correlation, pain report and the x-ray, but
they don't necessarily fit together. So how do you know you're treating the
right thing, or is it a chance finding?
Contribute to patient passivity, frustration and continuing quest for cures.
You keep searching for the next one. And when you have nothing better to do,
go on Bing and put some pain conditions in there and look at all the desperate
people telling you about all the things that they need and they're not getting
treated. We got a lot of people -- 30 percent of the U.S. population. Adult
population.
The Ds. Deconditioning, deterioration, depression, disability, and
demoralization. This is how I spend my time. This is who I see every day at
my job. And you want to know why I got gray hair. That's why. I'm really
only 30 years old. We divert resources, time, effort and we get away from
self-management, which I'm going to come back to, because I think that's where
you have a tremendous opportunity to help us. Self-management.
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If, in fact, we can't cure these people, if, in fact, they're going to have
symptoms for long periods of time, then it's dependent upon the person -patient, if you will. Patient when they're in my office, person when they're
out there, to do things to make their lives better, to function even if we can
find something to reduce, if not eliminate, their pain.
There are a lot of different treatments out there that are tried for people
with pain problems, and I'm not going to go through all the details. My
favorite is the sulphur mud baths that we talked about, which is a treatment in
Germany for fibromyalgia, which is quick successful, but we don't understand
why. There's a lot of different treatments. Everything from pharmacological,
surgical, nerve blocks, pumps, implantable pumps and stimulaters. Electronic
systems put into the body to block symptoms of the pain, not only spinal cord
stimulators, it's inserted into patient's back. There's a generator that looks
like a cell phone. There are wires that are tunnelled up along the spinal
cord. There are electrodes on the spinal cord. You send electric signals to
try to block the pain.
The implantable drug delivery systems, we implant reservoirs of opioids,
usually opioids, can be something else into the person's body, usually the
catheter is going up along the spine, and the medication is being dribbled out
in an attempt to block, get rid of the pain.
So lots of different things are done, and all the complementary, but a few of
them, acupuncture, spinal manipulation, nutraceuticals, et cetera
nutraceutical. Oh, and I should go back. And then there are behavioral or
psychologically oriented treatments. Cognitive behavior therapies, what CBT
is, biofeedback, hypnosis and there's something that became very popular in the
1980s, '90s, call it multi-disciplinary or inter-disciplinary pain
rehabilitation programs. These are non-curative. They're rehabilitation.
They're not called pain cure programs. They're called pain rehabilitation
programs.
Okay. So nihlism or reality? How good are these treatments? We've been
dealing with pain since at least earliest recorded memory, so you would think
by now we're doing really good, okay. So pharmacological treatments. By the
way, all these are cited. So if you want the references for these, despite the
variety of pharmacological agents, effective pain relief with conventional
medical management is achieved in less than half of patients with chronic pain.
16
And that's usually about 30 percent improvement. That's about what opioids,
nonsteroidals, anti-convulsants, antidepressants, some of the other common
treatments that are used for drug treatments. About 50 percent of people get
about a 30 percent benefit. 30 percent it's what's decided by some learn
people to be a clinically meaningful improvement.
>>:
What does it mean, 30 percent?
>> Dennis Turk:
>>:
On a zero to ten scale, if you say your pain is --
Self-report?
>> Dennis Turk: Your self-report scale, there will be a 30 percent -- if you
look at any of the drug literature, that's the way that they're reported is
percentage of your pain that's reduced.
Surgical intervention, so maybe they're really good. Pain and function, by the
way, in 30 percent and 17 percent are pain-free after spinal fusion, which is
the most common type of surgery for back pain.
Neuroaugmentive, meaning nerve blocks, steroids, facet joint injection,
epidural steroids, trigger point injections, all kinds of other injections have
not clearly shown to be effective and can consequently not be recommended, and
that's a cited from these different citations down there.
None of what I'm showing you is single studies. They're all review papers,
meta analysis on and Cochrane collaboration, which is a not-for-profit group
that goes out from England and actually develops, evaluates the available
research so that's where these are coming from, in case you're wondering.
Physical modalities, transcutaneous electrical nerve stimulation. I won't go
into the details. Ultrasound. The net benefit for any of these different
physical modalities is unclear and the evidence that is available is poor.
>>: Is the 30 percent increase 30 percent more than [indiscernible] decreased
it, or is that just 30 percent?
>> Dennis Turk: I'm glad you asked me that question. It depends, first of
all, on whether you're talking about an inactive placebo or an active placebo.
An inactive placebo has no side effects. An active placebo mimics the side
17
effects of the true drug. If you look at the inactive placebos, compared to
opioids, the reduction pie inactive placebos is about 10 to 12 percent. So
you've got 30 percent versus 10 to 12 percent.
If you use an active placebo, the active placebo is about 22 percent. So now
you're 22 percent to 30 percent. So there's a big difference, and for those of
us that work in this world and read that literature, you have to be very
careful to what the placebo condition was, because the inactive placebo, if I'm
a pharmaceutical company, I want to demonstrate my product is more effective
than placebo, I'm going to use an inactive placebo, okay?
And almost all the studies are inactive placebos. So that's the placebo rate.
Somewhere between -- and it will depend on the study by study, but somewhere
between 12 and 20 percent placebo response. 30 to 35 percent for the -- for on
opioid. It's about the same for nonsteroidals, for anti-convulsants.
>>: What does that mean, an active placebo, like for an opioid?
it --
Does it mean
>> Dennis Turk: It means I give you diphenhydramine, which will give you dry
mouth and some of the dizziness, which is comparable to the side effects you'll
see with an opioid. That's what I mean. Active, it tries to mimic some of the
side effects of the specific drug you're taking.
>>: This is so fascinating. So if you give the passive placebo but tell the
people that they might have these side effects ->> Dennis Turk: I could talk for a long time on a lot of different topics, and
that's a very interesting one. The patient expectation is extremely important
on these things. So therefore, if you're in a study, you have to fill out a
consent form. And that consent form, it starts describing all the side effects
and all the possibilities. You will see that the side effects people have will
mimic the side effects of the active treatment, and they won't come up with
side effects that weren't mentioned in there.
So there's obviously something that goes on. For those of you that ever watch
television, I'm sure none of you ever do, but there's something called direct
to consumer marketing. You see drug companies are trying to tell you products.
And they list all the possible side effects as fast as they can possibly talk,
faster than me. What they're trying to do, by the way, they're trying to
18
legally protect themselves.
But they're telling you everything.
Now what do you think happens to a patient when he or she hears about that
stuff? They start having some of the side effects. So there's called no-cebo,
which is the opposite of placebo, which is a negative effect of taking an
active drug. That's another story. We can go off on that if you want to talk
some other time.
Exercise. Maybe if you just gave people the right physical exercises that
would take care of all the problems, right? Well, if the criteria for
clinically meaningful difference is 30 percent for pain and 20 percent for
function, none of the published randomized control trials would have a
difference between a treatment and a control group. Not one. If that's your
criteria of success.
Now, if you use statistical significance, whether it's a statistically
significant benefit, we can get a statistically significant benefit, but that's
not the same thing as saying what change you have. And to give you just a
little humor on the aside, if you want, in most clinical trials, the entry
criteria to be in a criminal trial for pain is your pain must be at least a
four on a zero to ten scale. Zero is no pain, ten is the worst pain you can
imagine, worst pain possible.
The reason for the four is that's the cut-off between mild and moderate. If
you look at the percentage of patients after the study who are now pain below
four, it's a very small percent, which means that even though the drug was
successful, you'd be eligible for the next study because your pain was still
above four. So therefore, the successful treatment wasn't so successful.
Complementary, spinal manipulation, I won't read these to you, but bottom line
is they fail. Chiropractic manipulations, other kind of spinal manipulation,
I'm sorry if I'm offending anybody. I'm just citing the data. The data isn't
very good, and it's not good for all kinds of things. Back pain, headaches,
neck pain, carpal tunnel syndrome, dysmenorrhea, lateral epicondylitis, pain in
your arm here, musculoskeletal pain, nonspinal pain. Doesn't help. Especially
in the long-term. Yes, ma'am?
>>: Being someone who's had lots of physical therapy that's always helped a
lot.
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>> Dennis Turk:
That's the trouble [indiscernible].
>>: What I get told a lot by the physical therapist is that most people don't
go and do the exercises the way you do. So I will always religiously do them
every day after I leave the ->> Dennis Turk: You are a compliant or adherent person, and we will talk a lot
about that, because that's one of the major concerns is that when people are
asked to do things for long periods of time, they tend to drift and not
continue.
Since we don't cure people, you have to do these forever. And you have to do
them forever if you've had a chronic problem. I don't know what the condition
was, but if it was following a sports injury, you don't have to do it forever.
But if it was following a car accident, you're probably going to be doing it
forever.
So yes, you have to be compliant. And exercise can work. And exercise, by the
way, is a generic term. There are 50 different schools of thought about what
kinds of exercises you should be doing. No evidence that any one is any better
than the other.
Acupuncture, maybe that's the solution.
improvement.
Little to no clinically significant
Uh-oh. Drugs don't work. Surgery doesn't work, exercise doesn't work,
complementary approaches don't. Spinal surgery, nerve blocks don't work.
Acupuncture doesn't work. What do we do? 30 million people. What are you
going to do with them? I'm sorry, 30 percent of the population, a hundred
million people.
Well, recent studies document over the last decade, 529 percent increase in
Medicare expenditures for epidural steroids, which don't work. 423 percent
increase in opioids for back pain. 307 percent increase in lumbar MRIs. 220
percent increase in spinal fusions, which don't work.
They work for -- they don't work for pain. They work for spinal deformities.
If a patient has a spinal deformity then, in fact, that's an appropriate
treatment, but it's probably not an appropriate treatment. And if you live in
the state of Washington and you're on one side of the mountain to the other,
20
the likelihood of your having spinal fusion surgery goes up tenfold for the
same condition.
How should pain be treated? Well, according to Cochrane review, and Cochrane
is this group from England, U.K., that brings together all this information and
tries to be a non-biased presentation. They said that cognitive or
psychological interventions combined with exercise, so it's a combination, is
what should be used for chronic pain. And fusion may be considered only in
carefully selected patients after active rehabilitation. Not before. And I'm
going to show you that most of the time, the surgery comes before the
rehabilitation instead of the other way around.
And it's got to be at least two years. So what you should be doing is a
combination of some behavioral health and exercise. That's probably the most
effective treatment for back pain. Common features of what is cognitive
behavior. I said cognitive behavioral. And what they tend to do are the
following. I'll show them quickly so you can see what they are. Those are the
characteristics of what these treatments are.
Importantly, they try to change the patient's view of him or herself from
having a condition that's uncontrollable. People who have a chronic pain, any
chronic disease, feel out of control. They can't do anything. Since we don't
have a cure, you'd better learn how to do something, and these programs try to
teach you.
They foster optimism and try to deal with demoralization, encourage patients to
attribute success to their own efforts. They teach certain skills. They
emphasize active patient responsibility. This is really an important one.
It's the active patient involvement. It is not what the physical therapist
does to the patient. You doing the exercise is what helped you. It wasn't the
physical therapist doing massage. And you've got to individualize some aspects
of this.
And cognitive behavioral treatments, so they're pretty effective, relatively.
And cognitive behavioral treatments have modest benefits. Long over
short-term, long-term effect are not known because there are no long-term
studies. And they're usually, these behavioral health treatments are usually
incorporated within rehabilitation programs and not usually done by themselves,
instead of physical therapy, instead of medication. They're done in
combination with.
21
Okay. And MPRP is multi-pain rehabilitation programs, and what are they? They
just have a lot of stuff. I don't want to go through them. They involve PT,
psychologist, all kinds of different physicians, lots of physical conditioning,
et cetera. So that's sort of what they do, but notice it's not a cure. It's
rehabilitation. Often trying to stop the opioids, which is another lecture I
could give you about opioids. Opioids, in the long-term, may have bad
consequences, and I don't mean abuse and misuse. I mean physiological bad
effects.
So we need
responds?
percentage
people did
to give attention to who's the responders to these treatments. Who
One of the troubles with all of the slides I showed you about the
of pain reduction is the average, but the average means that some
really well. And we haven't got a clue as to who they are.
So when you talked about physical therapy, we know you're a responder. What do
we know about you? Well, that's what whole bunch of other things. But what
about the people who didn't respond? We don't know. Right now, we don't know
who gets what treatment. Right now, whatever treatment you get, it's the
hammer in the nail. Wherever you go, whatever their preferred treatment is,
you're getting it.
And maybe it works very well for 30 percent.
percent get minimal benefit.
Miserably for 30 percent and 40
Long term follow-ups, we don't really know. There aren't long-term studies.
In the pharmaceutical industry, the long-term studies are three months. So put
people on chronic medication for the rest of their lives and it's based on
research that took place in three months. What happens over time? We have no
clue what happens to these.
Why three months? Because that's what the FDA requires for a drug to get
approved. So therefore, the drug companies are going to do whatever they need
to do to get a drug approved because it stands to make them billions of
dollars.
We have long-term -- there's a few long-term follow-ups. Maintenance is a
major problem. Generalization beyond the clinic is a major problem. We bring
people into a clinic, and then we send them home. And we didn't cure them, so
what happens at home? They relapse.
22
>>: Does this characterizing responders, is this a direction that people are
heading, or are you saying this is something people should be doing.
>> Dennis Turk: Some of us are doing it. Some of us at NIH fund grants for us
to do it, but not everybody is doing it. The pharmaceutical industry doesn't
want to do that, because they want 100 percent of the market. So if they find
out it works for 30 percent of the patients, you mean we're only going to be
able to use our drug for 30 percent of the people. We want to use it for 100
percent. So they don't want to know.
So that's partially the problem. But NIH has been funding a number of studies,
and there is -- I don't know. It's starting to be more and more people are
talking about this is stupid what we're doing. We're giving people generic
treatments, and we need to find out more about it. And if I come back, I'll
give you another lecture on how we're trying subdivide patient.
>>: That's kind of parallel to things you could think of and see in cancer,
for example, where chemotherapy responders and not responders is coming down to
the peculiar genetic malformation that was responding to that particular
patient's cancer.
>> Dennis Turk: One way to subdivide patients is based on genetic factors.
One may be based on physical pathology factors. You could subdivide them on a
whole range of different possibilities. Again that's another lecture that I
could give you. But people are looking for that.
>>:
Right, what makes a responder?
A responder is --
>> Dennis Turk: It's unknown at this point what they are, and it's not for
some of us not trying to identify. As I said, if I had more time, I could give
you a lecture on some of the research that's out there.
>>: What makes people who have anomalies and don't experience pain.
makes them --
What
>> Dennis Turk: Thank you. If you want to write a letter to NIH to support
the grants that I write, I'd be more than happy to use that letter, because
I've been submitting those grants. And they've been getting funded so I can't
complain too much.
23
>>:
That's okay.
>> Dennis Turk: Okay. That is exactly the future of what we have to be doing.
But don't think it's going to happen in the pharmaceutical world, because
there's no incentive. So it has to happen through somebody else funding the
research. And trust me, the pharmaceutical industry does not really underfund
research on exercise. They're not going to fund research on spinal cord
stimulators unless they're device manufacturer. They're going to fund research
on drugs. So that's why you see a lot of attention given to drugs and much
less given to any other type of treatment that's out there. But another
lecture.
>>:
Not a good business model.
>> Dennis Turk: It's not a good business -- and poor physical therapists, they
don't have a whole lot of people out there rushing to support and pay for their
research to demonstrate that they're doing something beneficial to help you
out.
So we're not curers. We're not going to eliminate pain in all the patients.
And we should not be naive to assume that these major life style changes are
going to last for long periods of time. Just to give you an idea, these are
people who go to rehabilitation programs. These are characteristics. Notice
the duration of their pain. 85 months. So that means they've been living with
it for a long time. And they've all had surgery before so instead of -- it's
the opposite of what their recommendation is. Their recommendation is have the
surgery only after rehabilitation. It's the converse. They're having surgery
first, and then they go for rehabilitation.
I'm going to pass these things. And are these treatment programs, rehab
programs any good? Standard care, pain rehabilitation, opioids, antidepressant
or anti-convulsant medication, which are two other classes of drugs that are
used for pain and spinal cord stimulators, this is pain reduction and this is
what you would expect. This strange one over here, spinal cord stimulaters.
In very select patients, that's a small numbers of highly selected patients if,
in fact, we put these in dwelling catheters along the spine, 30,000 to 50
thousand dollars per patient per five years, and it has to be redone. So it's
a very expensive procedure.
24
>>:
I didn't understand the rehabilitation thing and the cognitive behavioral.
>> Dennis Turk: Cognitive behavioral therapy is -- doesn't include exercise,
doesn't include medication, doesn't include physician education or information.
It's just focusing on patients learning self-management skills. That approach
is often embedded within rehabilitation programs where they get physical
therapy, medication management, information from physicians, exercise and that.
So it becomes a component.
I'm sorry, I'm rushing because I'm seeing my time is not going well. By the
way, although statistically significant, pain is not eliminated. Notice pain
gone. Very, very, very few people. It's good to feel better, but it's better
to feel good. So these people feel better, but they don't really feel very
good, because imagine the worst pain you've ever had. You're going to have it
24 hours a day, 365 days a year, for 7 to 20 to 30 years. And I can reduce it
by 30 percent. You'd be happy to get the 30 percent, but you've still got a
lot of problem, which is why I'm so interested in the kind of things you do and
I'm going to get past this.
So let's remember the person that's between these symptoms, between the
pathology and the symptoms, and this is where that individual difference is
that you're talking about starts coming in. This is common and this may be
common, but what's different is who's in there. And pain affects all aspects
of people's lives. I don't have to tell you that.
This is just showing you, as pain goes up, what happens to how it interferes
with your life. So, for example, on a zero to ten scale, if you rate your pain
a three, you will also say that their enjoyment in life goes down. If you say
your pain is a four, enjoyment goes down, and it affects your ability to work
and goes up.
As pain goes up, things are more impacted. So by the time you get here, if you
rate your pain as an eight or a patient rates their pain an eight, it's
affecting their enjoyment of life, their work, their mood, their activities,
their ability to sleep, their ability to walk, and interact with people. So
it's a big problem.
And I'm going to have to do this quick because of time. I just want to remind
you of the average person who comes to a pain clinic has had their pain for
seven years. Their average age is 44. So that means their pain began when
25
they were 37. So by the time that I see them, rehabilitation sees them,
they've had seven years to have to live with their pain.
And don't forget that people have histories, genetics, anatomy, physiology and
learning history. They had 37 years to get to be the person they were before
their pain developed. Does that matter? Do you think any of this influences
how people adjust, adapt, respond to their pain?
And we're going have people live for a longer period of time and they have
different resources, and all this happens in a social context. People don't
live alone. Social context are family members, next door neighbors, other
relatives, what have you. Doctors, nurses.
So this is what it's like. So even though I might see them cross-sectionally
here, if I forget all of this, I'm going to not be very successful with that
patient. And if I saw them even farther, I have to understand that since I'm
not curing them, they're going to be going this way.
So what am I going to be doing for them here? I'm going to get rid of this
stuff because of time. I want to show you about depression, but you don't need
to see that. So self-management. Main health and wellness dates back to at
least the 18th century. John Wesley, for any of you at methodist or know about
methodist, John Wesley was the founder of methodism. He actually was talking
about self-management for health back in 1647. So it's not a new concept.
Forget the cartoon because of time.
So what do these have in common, smoking cessation substance abuse treatment,
weight loss, new year's resolution, diabetes care, stroke rehabilitation,
management of chronic pain. When do they have in common? They're all chronic.
They involve self-management. New Year's resolutions. What happens to most
New Year's resolutions? They fail very soon. What happens to weight loss
programs, substance abuse programs, diabetes care, et cetera? It doesn't get
maintained.
Requires long-term maintenance or else it doesn't have any beneficial effect.
There's poor adherence to them. High relapse rates, poor maintenance of any
initial beneficial effects. And here's a typical pre/post, short-term follow
up, long-term follow up. The patient starts with their symptoms, whatever they
are, I assume it's pain up here. By the end of the treatment, it would be nice
if they came down this low. What happens is the starts relapsing and then it
26
goes back.
Because we didn't cure them.
So what can you do, if this is a good benefit a good outcome, how can you make
the curve go like that, versus like that? Well, Niels Bohr, predictions are
difficult, especially about the future. Some of you know Neils Bohr. And if,
in factors we're going to start switching now from just the pain to what could
we do about the problem, and I'm running out of time so I better talk even
faster, well, for consideration of a successful intervention, meaning something
successful beyond what we're doing, and here I'm thinking about technological,
we've got to think of clinical consideration, technical considerations, and
acceptance by the clinician, the patient, the payer, and policymakers.
So let's assume we could develop some new intervention. We'd have to be able
to make sure it took care of these kinds of things. You have to deal with all
the technological -- this is where you guys are the experts. And we'd have to
find a way to make these people accept it.
So some considerations. And these are not independent, and this is where I'm
going to start getting into deep water. So if you start hearing me mumbling
and bumbling, you'll know why.
Clinical considerations. Well, here's easy. But we do have to worry about who
is the population. Is it for everybody? Do we have to worry about are there
specific physical limitations, specific symptoms? Would the treatment to be
different?
So let's assume we're going to develop some technological approach to help
people do some type of exercise. Does everybody get the same one? Do the
symptoms matter? Do limitations matter? How about the variables and
demographics, learning style, computer skills and experience, fears of being
abandoned that if you use this technology, I won't see the physical therapist.
No support. Sensory or cognitive limits. That means what happens if they have
visual or hearing problems. Therefore if you're going to start thinking about
developing some type of technological applications, you're going to have to
take into consideration this variability.
Treatment content, you're going to start tailoring it. Are different people
going to get different content? Should everybody get the same thing, or do we
use machine learning and artificial intelligence to learn about people and
27
start modifying, customizing the treatment. What's the dose? How much do they
need? Is more always better? And I'm going to suggest to you not always.
And what's the timing? When does this occur? Is it early in rehabilitation?
Is it late in rehabilitation? Would it be different if you got people in the
seven or eight months after their pain began than if you got them seven years?
Would that differ?
What about usability, engagement, connectedness. Can you get the person to
engage in this activity. We've been talking or I've been talking about Ran
about using Kinect. How do you keep people engaged in something like that.
How do you keep them going. If the we want them to do this not for three weeks
or four weeks, but we want them to do this for seven, ten, 20 years, what are
you going to do to make that specific?
How are you going to motivate them, encourage maintenance and generalization?
I think you have tremendous opportunities to use the technologies that you guys
are good at to help us, because we, health providers, are miserable at doing
this.
What about monitoring? We've got to worry about the clinician and the patient,
monitoring what's going on, feedback that they're getting. How about
flare-ups? What should happen if a patient has a good day or a bad day? What
about deterioration? What happens if the patient starts doing well and then
starts getting worse? What should they do? Who's going to be responsible for
that person? Is the clinician still involved?
What about red flags? If you see something bad happening, what should happen?
Are there parameters? Are there cut points? Are there decision points about
if, in fact, certain things happen, you stop doing that.
What about feedback. Should you give confirmatory feedback, corrective
feedback, diagnostic feedback, explanatory, prescriptive, elaborative? How do
you give people information? So they've done an activity, they've engaged in
it. Now you want to tell them, you did well, you did wrong. You varied in
some way. That's useful for us to know, but it means you're doing something
different. How are you going to use that information? So you're going to have
to program that in some way to try to decide what kind of feedback are you
going to give people. So that's what the clinician is thinking about, how much
clinician time can these be free standing or do you have to have clinicians
28
involved in some way, shape or form and how much contact does the clinician
have with the patient?
So if somebody's gone through a three-week rehabilitation program and now
they're going to go home, can they go home for the next seven, 20 years, or do
they need to come back periodically? So those are some clinical
considerations.
For you guys, and here's where I'm in really deep water, you need to be able to
personalize the needs and desires of the patients and how do you query these
patients and how do you learn about them and test them? And what I mean by the
needs and desires, if you develop a very nice excess program that is of little
interest to the person you're trying to get to use it, if I have a 75-year-old
woman, I'll use that, who is very interested in learning how to be -- has had
some type of arthritis, would like to improve her sewing activities, and you
think that a good activity is to do something with her hands, and you have a
little game in which she gets to follow the fish around like this, how long do
you think she's going to be interested in doing that?
Unless you find some way to get her to buy in, that this is going to be leading
toward what she wants to do, and I think that's going to be a challenge that
you're going to have to -- or you should focus on.
Format, platform, organization, multimedia, you're going to using text, audio,
graphics, pictorial, video. Is it live, is it animated? Those are the kind of
things you want to build into this.
Pattern recognition is going to be particularly important as you're making
decisions about when to modify criteria that you want. Is the patient in or
out of bounds or range. Do you want learning and automated adaptation to
maintain your engagement? Can you design in such a way that other time, it
starts doing things differently and leading to different kinds of innovations
that will keep the people engaged. You're getting them closer to things you
want to do. You're switching to other activities.
So you're going to deal -- you're going to interact with your clinician friends
who want to tell you, here's the skills, here's the exercises we need these
people to do, and your job is to say okay, how do I take what they need to do
and put that into a gaming format that they can, in fact, use and expand over
time and also build in the patient's interests to make it relevant for them.
29
Dynamic tailoring to match the clinical needs to the patient's interests. I
just said that. Intelligent and conditional prompts. When do you prompt, how
do you prompt, what do you say? Again, this is going back to the feedback.
Integration of feedback, guidance, reinforcement and finally, what's the
frequency and appropriate use of these kinds of things. How are you using this
kind of feedback? And then for the acceptance standpoint, is it clinically
effective? You have to convince the clinician who you want to use this that,
in fact, this is useful. And you have to also be a little bit careful you're
not displacing them. Oh, we're going to put all the physical therapists out of
business? They don't want to hear that. What they want to hear is that
they're still needed.
What's the patient's engagement and satisfaction. From the payer, is it cost
effective? Doesn't it have to be -- it doesn't have to be perfect. It only
has to be worthwhile. So if they can save money on this, even if it's not
perfect, it's cheaper, accomplishing even partially what you're going to
accomplish with the face-to-face. It may be worth their effort to do it. And
you need to be able to look at it.
Policymakers are worried about service demand, utility, variability,
efficiency, resource sharing, and burden. I could go on to all of these, and
I'm assuming you're familiar with some of these concepts.
And then chronic pain, why is there an opportunity for you? And there are
technological solutions. It's huge in growing population. A lot of people.
They're not going away. No significant advance in treatment. So self-care and
self-control is going to continue to be essential for a long time. So you've
got a lot of people who need to be doing things over long periods of time and
we don't have ways right now. We, the health providers, don't have ways of
doing it.
There's wide variability in response to the existing treatments, and we need to
look at the responder analysis and customization of treatment. Can we find out
different characteristics of people and then can we customize the treatment
whether you do this through artificial intelligence or whether you do it
through machine learning. These may be equivalent terms or have unique
meanings, but you understand you're learning about the person. And you're
modifying things so that not everybody gets the same thing. It may be at base
30
you start the same point, and then as you learn about the person, you start
modifying it.
Maintenance enhancement benefits over time, using ought made mated
knowledge-based reasoning, strategy matching, motivation for different prompts.
And this is an important one. This empathy concept, because one of the things
that they've done some focus groups on patients using gaming devices about what
would be useful and helpful to them, and what they're worried about, and what
they're mostly worried about is lack of support. If they're face-to-face with
a therapist or if they're in a group of other people receiving therapy, they're
getting support.
What happens if I'm at home and I did some consulting in New Zealand a long
time ago and we had a rehabilitation program and they were sending people back
to their homes, and the last day of an inpatient treatment, I ran the group and
we had 12 patients, and they sat around. I said Mary, what do you think it's
going to be like when you go home? And Mary started crying. So they'd been
there for three weeks. I'm there the last day. They brought me from the
United States to make the patient cry.
So I finally calmed her down. We asked her what's going on. She said I just
hadn't started thinking about that. I live on a farm. It's cold and it's damp
and I have two little kids. My husband's on a tractor all day. What do I do?
And no attempt had been made to say how are we going to transfer this to the
Mary's existence.
Opportunities. More individualization. You guys can do this. I don't want to
go through all these details because of time. It's in, by the way, the
handout. The symptoms are going to persist. There will be flare-ups. Going
to monitor these things so you can potentially have all types of ways to
provide useful information. And that information from some demonstration I've
seen, can give reports back to the clinician, who can be monitoring from a
distance and make decisions along the way and you can interact with them.
Identification of slips and intervene. When is somebody getting out of range.
You can develop different parameters, different rules, govern behaviors about
when you decide to intervene.
Now, be careful, some challenges of methodolatry and technophilia. These are
dread diseases for people in your field. You get so caught up with the beauty
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and the lovely things you can do, the technology, but you got to make sure that
that meets with the clinical needs of the patients. Got to make sure that the
clinicians are interacting with you as you're evolving those.
It's very exciting to see some of the things you guys can do. Then the next
question is, can that be translated into a clinical context that's useful. The
gee whiz factor is gee whiz, but it's got to have some practical use.
Optimize the treatment, and individualize and customize so those are some
challenges for you. And determine optimal dosage. I'm not going to go over
those. There's more. This we've talked about. Because of time, I'm going to
get out of those.
I'm going to get to basically what you're trying to do is this. You're going
to have to find some way to balance the clinical needs of security, support,
discipline, low tech skills that some people may have and how are you going to
match that to what happens at home. In the clinic, these things are well
controlled. If they're doing these things at home, what are you going to do
and how are you going to deal with fatigue, the advantages -- you have to deal
with the advantage of flexibility, convenience and availability, but you don't
have -- so how are you going to balance those things in the future?
And demonstrate successful intervention, depend on systematic and programatic
research and we just put it all down there. These are the kind of studies -- I
hate to scare you -- that you're going to need to do to be able to demonstrate
that your device, your treatment is going to be beneficial if, in fact, you
want them to be adopted by anybody out there.
Adopted means you want the clinicians to -- I'm making an assumption that all
of you care about the things you develop being an I applied and being used out
there to make a change in people's lives. And if you don't think that, then
you came to the wrong talk. So I'm assuming that about you.
In, in fact, you want to do that you're going to have to have the patients
accept it. You're going to match things to them. The clinicians have to
accept it. The payers have to be willing to pay for it, and the decision maker
is going to have to make these things available. And to convince them, you're
going to have to do these kinds of things.
So what I tried to do, and unfortunately way too much information, all too
32
quickly, pain's a big problem. We don't have a cure. Treatments that we have,
have to be maintained over long periods of time. We, the healthcare providers,
do not have good ways of keeping these people involved and engaged in the
treatment.
You have the technological knowledge and abilities to address the concerns in
the questions that we have and to make these things real. But the only way
it's going to happen is if we do some interacting. So it's been a pleasure to
have the opportunity to come out and talk to you about this. And I do
apologize for the speed, because I planned too much, which is normally my
problem.
I don't talk too much, just a lot.
>>:
Thanks a lot.
Any questions?
Your slide said life expectancy of 76 years.
>> Dennis Turk:
There was a plus.
>>: I presume that's [indiscernible] is that an approximation of life
expectancy at age 44?
>> Dennis Turk: Actually, yes. That wasn't -- it was 76-plus, and the reason
for the plus, it's getting longer. If you get past the first six months of
life, you will potentially live longer. In the United States right now, I
believe the age is, if you get past the first five years, is somewhere about in
the neighborhood of 82 to 84, and it's different for males or females. So
that's assuming that you've got -- you made it to age 44. You got a good
chance you're going to live -- depending upon medical problem that are going to
develop, car crashes and what have you.
But if we don't have that, yeah, you're okay.
You and I are okay.
>>: I want to get back to this question again of different patients who will
respond differently and is there a way to identify which ones will respond
well, won't respond well. So we're used to dealing with data, right? So if we
have the data of, you know, every treatment applied to every person, whether it
worked or not, this has sort of become trivial -- trivial is probably too
strong. But it would probably become really easy to identify some patterns
about which people are responding well. I assume that data is not available.
33
So what's standing in the way of ->> Dennis Turk: Well, what stands in the way is we have to decide since you
can't have an infinite number of variables, because you have an infinite number
of subjects that we would need, you would have to say, what are the potential
predictors that could be important. Genetic factors, demographic factors,
physical factors, learning history factors, support factors. Okay, that's big
classes.
Within those, there's a huge number of variables. So what's holding back -- I
wouldn't say holding back, but where the research is going is trying to
identify what's the best predictor. So assuming that I had a sample of a
thousand patients and I said that 30 percent of these people responded to
treatment X, whatever treatment X was, I could then say can I look at the
information I have and predict who those people are. That's the beginning
point.
The next point would be, okay, now what I have to do is say okay, can I give
the treatments uniquely to that group and will they do better, because we can
always find predictors, but it's got to make a difference. So that's the
research that we're trying to do. That's the research that a number of people
are trying to do.
The trouble is that there's a lot of -- I just use the word demographic.
There's a huge amount of potential -- it's age, sex, pain history, work
history, social. You can go on. That's just demographics. The same thing
would apply to all the categories. Genetics, which sounds wonderful. Remember
when we had the human genome and it was going to solve everybody's problem?
Have you seen any recent treatments developed? No.
It's going to be a long time, because it's not simple.
It's not one gene.
>>: A lot of those characteristics, like age, whatever, are in the patient
record already, right? So if you had a lot of, I don't know if one hospital is
enough data or a lot of hospitals. But it's in there. So you're saying the
hard part is this follow-up pass where okay, you found some potential
predictors, now you want to do the clinical trials.
>> Dennis Turk:
predictor side.
And you have to do a clinical trial. First of all, even the
Let's take the predictor side. If it was just looking at
34
demographics, hospitals collect that information routinely.
at demographics.
So we could look
But let's assume I thought, well, maybe patients' levels of depression were
important predictors of who responded. Those are not standardly captured. So
that means -- let's assume there's ten or X number of those out there. That
means you would have to get different facilities willing to administer
questionnaires or do clinical interviews. Very costly. Then you have patient
burden; that is, how many questions, how much can we ask people to do?
So there are a lot of -- it sounds nice, yeah. We have -- the V.A. system is
the largest medical system in the United States. They have wonderful medical
records so they ought to be answer these questions. They can on demographic,
but as my friend who works in the V.A. said, you've seen one V.A., you've seen
one V.A., because they're all different in how they actually do things.
Even though they're supposed to be collecting things in the same way, it would
be nice if it was as simple as I wish it was. But even on the demographics,
it's not so simple.
Then there's all these other variables that we don't even -- we don't even know
what we don't know. So I said physical pathology or physical functioning.
Gait analysis. We think gait is important in predicting who responds to
treatment. As we were talking, how many parameters are there potentially
available to try to analyze gait so that you have to put all those in there.
Every time you increase one of those predictors -- I'll use a crude rule of
thumb. How many, what, 10-to-1, 100-to-1? Ten patients to every one variable
you would put. So imagine you've got a hundred variables. You could see what
happens. And then that only identifies a predictor. Than you have to do a
clinical trial. When you do a responder analysis clinical trial, like on the
power calculation, how many subjects do you need to do this study escalates
dramatically.
>>: You've been doing this for a long time, though, so if you were making kind
of an intuitive guess, and you must have made a million of them.
>> Dennis Turk:
are.
I have.
I know.
I know the truth.
I know who the responders
35
>>:
Do you know the truth?
>> Dennis Turk:
>>:
I know the truth, with a capital T.
I've been looking for it for a long time.
>> Dennis Turk: Let me give you one bit of information. We have a 61-item
questionnaire that asks people about the impact -- how many pain they have,
impact on their life, their ability to function, the activities they engage in,
and how much support they get from a significant other and how people respond
to them.
We did a statistic called a cluster analysis to see if, in fact, you'd find
patterns of responses within those -- how patients respond to that 61-item
questionnaire. We found three different types of patients. We then looked at
three different types of patients to see whether those types differed by
physical pathology. No. Do they differ on anything else we could find out
about them? No.
We looked across different diseases, the same three types. Cancer -metastatic cancer, [indiscernible] cancer, lupus, back pain, headaches,
fibromyalgia and one more that I can't think of. We found the same three
sub-groups of patients occur.
We then did a clinical trial in which we gave all those patients a standard
rehabilitation treatment. We found that one of those sub-groups of patients,
two-thirds of the patients got significant benefits, one of the other groups,
only a third got a significant benefit.
So we now know, we could predict who was going to do well with that particular
treatment on that one study. So we got one study to show that we can, in fact,
identify responders. We can then tailor -- we can give a standard treatment,
identify who responded to the treatment. The next step would be to say okay,
now that we know these three sub-groups, can we have a specific treatment
that's different for each one of those three. That hasn't been done yet.
So that's to be -- have me come back, and we will have the answer for you
within the next three years. So we know, at least for rehabilitation oriented
treatment -- but remember, I showed you drug treatments.
36
>>: I have some curiosity.
one cluster group that --
Tell us about that one group.
So you found this
>> Dennis Turk: Okay. We looked at patients who came to a pain rehabilitation
program. So they were all referred. Now the thing you need to be aware of is
who gets referred to those programs? They're not the average person on the
street who has arthritis in their shoulder. They're the people who are the
most difficult to treat. So we're getting a very difficult population.
So we're looking at, within that set of people, there are three sub-types. One
type we referred to, based on their response, as being, quote, dysfunctional.
They have a lot of pain, interfere as lot with their life. They have high
levels of mood problems, mood, distress, depression and anxiety. They say they
get modest support from people in the environment, and they're very inactive.
My first thought and your first thought should have been, well, that's all of
them. Aren't they all like that? No. Another third of the patients had those
characteristics but what was most unique about them, they said they got no or
limited support from people in the environment. People are very negative to
them. They don't get encouragement from family members so that the social
support system seemed to be very different than that group of people.
A third group of people we referred to as being, quote, adaptive copers.
They're all coming pain clinics. They're all the worst of the worst. Relative
to these other two groups, they were doing better. For the people who were
dysfunctional, a lot of pain, a lot of distress, a lot of mood problems,
inactive, this rehabilitation program, at least for two-thirds of them, seemed
to be pretty good treatment. Pretty good doesn't mean cure, remember. Pretty
good means we got 30 to 40 percent benefit, statistically significant.
For the people who somewhere inter-personally distressed, less than half of
that other group got that kind of benefit. The treatment that we had did
nothing about inter-personal problems, did nothing about social support, did
nothing about how to communicate with family members. So for that group of
people, maybe what we need to do is take some of the part of the other
treatment and add on a module that focuses on that.
>>:
[indiscernible].
>> Dennis Turk:
No, no, no, we don't give lobotomies.
We don't do that.
We
37
stopped that in 1944. Last lobotomy I heard of. They still do ECT, electro
convulsive shock therapy for patients. You had a question in the back?
>>: Yes, I was watching from downstairs. So I wanted to ask you about the
[indiscernible] technological involvement and serving tools that exist in that
space. So some of us use crowd sourcing tools like Mechanical Turk and a few
other sites of that nature. Given that these chronic pain conditions are so
common within just any kind of group, is there any experience on using those
kinds of [indiscernible] tactics to assess the effectiveness of anything, or do
you actually have to go to much more [indiscernible].
>> Dennis Turk: In my experience, in my reading literature, very little effort
has been done to use that, except for one minor area. People are interested in
misusing opioids have used crowd sourcing techniques to go in to try to learn
about those groups. But as a general rule, it has not been a technology -- I
haven't seen anything that's used -- I'm embarrassed to say that 99 percent of
the things that you guys can do, I don't see it being used very well in the
healthcare world, in the rehabilitation world. Not just pain. I would say the
same thing about the way if we were talking about diabetic patients.
People with diabetes don't get cured by our treatments for diabetes. Their
symptoms get normalized, which means that they've got to continue to watch
their diet. They've got to test their urine or their blood. They've got to
watch their exercise problems, they've got to be careful about infections.
They've got to worry about travelling in time zones and changes. That means
self-responsibility, self-management for any chronic disease.
And I don't think, to my knowledge -- we are so far behind what you have the
opportunity and the tools available to help us with that we have essentially
lost out on all the things that you guys are doing. I'm delighted that there
was any interest in me even coming to talk to you because if, in fact, I could
get any of you interested in doing that, you potentially could have -- that's
why I was trying to hit you with the numbers. A lot of people, it's very
expensive. It's getting worse.
So there's an opportunity here, and to the extent that you can use any of the
technologies that you have, there's really virgin territory. It's just all -everything you want to do needs to be done, and hasn't been. That's good news
and bad news. The good news is you've got a lot of opportunity. The bad news
is you've got to do a lot of stuff. Yes, sir?
38
>>: This is a random idea. Have you come across [indiscernible]?
name ring a bell? Look him up. He can ->> Dennis Turk:
>>:
Spell his last name.
V-o-n-a-h-n.
>> Dennis Turk:
Does the
Two words.
Okay.
>>: He set up a game to make people identify pictures on the web and he had to
shut down his website because oversubscribed, and I think he sold it Google.
>> Dennis Turk: What I would want to do is take that knowledge in finding a
way to craft it so that it becomes appropriate for the kind of things -- again,
I did it fast, but I showed you all the individual variation things that a
clinical person is going to be concerned about that's different from if you
just go to people on the web in general.
So I think there's going to have to -- get out of the silos, you know. We're
over here doing it at the University of Washington, department of medicine or
healthcare and you're offer here in Microsoft Research. And if we don't talk
to each other, if we don't learn about the things that you're being able to do,
and if you don't see the kinds of concerns and problems we're having, we're
going to keep going parallel. We're not going to get to it. So thank you for
having us come out. We greatly appreciate it.
So thank you for that bit of information and the question is going to be how do
you take that technology and craft it so that it can be used for these
populations. So good for you. I hope I answered your question.
>>: So you mentioned clustering populations, you mentioned trying to predict
effectiveness. This is sort of getting into an area a lot of us are familiar
with in machine learning. So this is a question for you.
The clustering approach is beneficial because you can see, okay, here's a group
of people that it's not effective on and why. What's different between these
clusters. So it's very interpretable. Would it be useful if you had something
that instead of was very good at predicting, but you have no idea why it
predicted this?
39
>> Dennis Turk:
>>:
I don't care why.
High accuracy, this will work well, this will not work well.
>> Dennis Turk: I don't care why initially. Show me that something has that
ability, then I'll work backwards and try to understand why. Going forward -let's assume I gave a complicated rehabilitation treatment program, which has a
lot of components to it.
First, I want to see can I make that work. Then I want to see what's necessary
and sufficient from that. I want to dismantle it so it's not the psychologist,
it's not the physical therapist. It's only what they really need is support
from people in the group. Maybe that's all that's really important. First,
let's see it works. Then we'll work backwards and try to get those -- and the
content and the predictors all that we worked out to be continued.
>>: I don't know if I explained very well. What you're saying, well, once we
know that it works then you can back up. Instead if I was only able to tell
you what you've come up with already, it will work for that person, it won't
work for that person, and I can't tell you why is that useful?
>> Dennis Turk: It's useful in the short-term, because I could prescribe,
okay, people with these characteristics get that treatment. People get that
treatment. But I, as a scientist, I want to know what's the mechanism by why
that is working. What is there special about -- what's different or special
about this person?
So I don't want to use demographic, I think, but let's use, over simplify it.
People who are more educated do well with this than do well with that. But I
want to work backwards to understand what that is. But if tomorrow I was going
my office and you said to me I can predict with an 80 percent accuracy that
people like this do well with this, and you have good data to support that,
let's do it.
I mean, let's help the patient, but then I want to start -- the scientific part
of me says let me understand that.
>>:
Okay.
40
>>: I think there is a patient acceptance in that sort of thing. Certainly,
if you tell me I'm in this group and I want to give you this treatment, I'm
going to really push back on why. And if it's just, you know, well, the
machine learning said such and such versus we determined that it's because you
have this particular physical attribute, which one's going to make me happier?
>> Dennis Turk: What if I said to you, we have two different treatments we
could offer you. With one treatment, given what we know about you, you have a
70 percent chance of really getting a benefit that's important to you. If we
give you this other treatment, we have about a 30 percent chance. Which one
would you prefer?
>>:
As long as you've got enough to convince whatever --
>> Dennis Turk: I have to convince you. So if we have the data -- if
[indiscernible] knows with a certain amount of predictability that the
likelihood you're going to benefit, I'm still going to have to be a clinician.
I still have to explain it. I would never bring a patient in and say machine
said do it. What I'm going to have to say is I've go the to help you get to
the point, which is where I've rushed through, kind of things the clinician is
thinking about are not necessarily the things you're thinking about but if you
work with them, they can start saying, this technology is great. What you've
just said is we've got to figure out how are we going to get that into the
hands of patient.
>>: How do you get the information, and how do you communicate with the
patient.
>> Dennis Turk: That's my training. That's what I do. My training as a
behavioral health psychologist so I know how to do that, and there's good
literature to help on that. What I don't have any clue on is how do I take the
opportunities that the technology provides to be able to get to the point where
I can say to the patient, hey, let's have this conversation. I don't have that
conversation.
Right now what happens is depending upon what specialty doctor you go to, or
where you go to them, you're going to get that treatment because that's what
they like. You need biofeedback. I'm recommending it.
Now, a discerning patient says wait a second, how do you know?
The average
41
patient says the doctor thinks I should have that, maybe I ought to have that.
That's when I get. I don't think the average patient is going to be -- when
patients go to see a doctor, they are usually at the point of needing somebody,
some help and support, and they're happy for somebody to give them guidance and
tell them what to do.
So it's not -- more information and more choice is not always what people want.
If you developed a problem of some type of cancer, and you went to an
oncologist and the oncologist said, well, it's up to you, what treatment would
you like? I have a hunch that that you would probably say, well, you're the
expert, what would you give a family member if you had a family member? And
you'd probably be happy to have that, because you're not the expert in
oncology.
So there's some -- in the same way if I come to you and talk about machine
learning, different stuff like that, and you say, well, you should use this
approach, I'm not going to say well, no, I don't know if I like that approach.
It doesn't sound too good. My Aunt Mary told me that if I use the Wii system,
it's better than the Kinect system. I'm not going to do that. I'm going to
trust.
If a plumber comes to my house, I know nothing about plumbing, plumber says I
need something, fix it. Mechanic says I need something, fix it. I know
nothing about cars.
So if you know nothing about it, you're dependent upon the, quote, expert who
came, who knows everything about nothing, to answer your problem. But I think
don't lose sight of that clinical interaction is a very different one than if
you're selling a product, buying used cars or selling insurance. There's
something about a doctor or a healthcare provider patient interaction. There's
a power to that interaction, and the acceptance level from the patient of all
kinds of horrible things being done to people, we've done terrible things to
people. But there's an acceptance of that, because you're trusting that the
healthcare person has your best interest at heart. They're more knowledgeable
than you are.
But sure, I've got to explain it to you. I wouldn't just say shut up, which I
used to do, by the way. Come into the doctor. When women were going to have
babies, they weren't given choices about what kind of anesthetic or -- they
were told, this is what you're getting. There was no choice given to them.
42
That's changed.
So you do have some choice, but you do still listen to the provider, to some
extent, and balance what they're saying. You're a highly educated person so
you may be a little bit more critical. But the average person who goes to the
doctor pretty much wants the doctor to tell them what do I need, fix -- help me
to get rid of this problem.
>>: There is a lot of evidence also showing that having choice is also
important. So you want to have, yes, you want to have the experience, but you
still want to control.
>> Dennis Turk: If the choice is between two treatments that are reasonably
comparable, yes. If the choices are between you could have surgery or you
could have sulphur mud baths, I don't know ->>: Something that has 70 percent of helping you, but might have this side
effect. Versus this has 30 percent but have that side effects.
>> Dennis Turk: Some people like choice. Some people get very stressed by
having to make that decision, because they would prefer to have an expert tell
them so choice is not always -- we have to be very careful of stereotypes of
assuming everybody wants. I think there's huge variability in what people
want, and I think a good clinician, without realizing it, is actually sort of
deciding what information to give and how much to give based on his or her
perceptions of you and the kind of questions you're asking and how anxious
you're looking. They're paying a lot of attention.
And touching you. Believe it or not, physically being touched, from when they
surveyed patients about what they did and didn't like about the distant
learning kinds of stuff was there's something about somebody touching me and
making sure, reassuring me that I'm doing it, that, you know, you can send me a
message over the phone or send me a graphic telling me I'm doing fine, but
there's something about that clinics.
So that's a little bit of -- and I think where the fun's going to be is how can
you have some type of monitoring by a clinics periodically going on so the
patient feels they're getting some, but it's not all the time that they're
constantly be given. And I think that will be creative what we can come up
with.
43
Thanks for hanging in there.
>> Ran Gilad Bachrach:
Thank you very much.