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In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Lisa C. Silbert, MD, MCR, FAAN, who served as a guest editor of the Continuum® December 2024 Dementia issue. They provide a preview of the issue, which publishes on December 2, 2024. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Silbert is co-director at Oregon Alzheimer's Disease Research Center, a Gibbs Family Endowed professor of neurology, a professor of neurology at Oregon Health & Science University, a staff neurologist, director of Cognitive Care Clinic, and director of the Geriatric Neurology Fellowship Program at Portland Veterans Affairs Health Care System in Portland, Oregon. Additional Resources Continuum website: ContinuumJournal.com Subscribe to Continuum: shop.lww.com/Continuum More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology, clinical review and CME journal from the American Academy of Neurology.  Thank you for joining us on Continuum Audio, a companion podcast to the journal.  Continuum Audio features conversations with the guest editors and authors of Continuum who are the leading experts in their fields. Subscribers to the Continuum Journal have access to exclusive audio content not featured on the podcast. If you're not already a subscriber, we encourage you to become one. For more information, please visit the link in the show notes.  Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today I'm interviewing Dr Lisa Silbert, who recently served as Continuum's co-guest editor for our latest issue on dementia alongside Dr Lianna Apostolova. Dr Silbert is a professor in the Department of Neurology at Oregon Health and Science University of the School of Medicine in Portland, Oregon, where she's also the director of the Neuroimaging Core and now the co-director of the Alzheimer's Disease Research Center. She also serves as director of the dementia clinic at the VA Portland Healthcare System. Which, Dr Silbert, sounds like a lot of work? Anyway, welcome. I really appreciate you taking the time to join us today and co-guest editing this issue. Why don't you introduce yourself a little bit to our listeners?  Dr Silbert: Well, thank you so much for interviewing with me today and for inviting me to be the guest, co-guest editor of this issue. It's a really exciting time for dementia care and dementia research. As you already said, my name is Lisa Silbert. I'm in Oregon Health and Science University in Portland, Oregon. I've been involved in caring for dementia patients and their families for over twenty years now and been involved in a lot of really exciting research during that time. But I would say now is probably the most dynamic time in dementia research and care that I've seen. So, it's really, really exciting to be here.   Dr Jones: It really is an interesting time. So, I look back  in our last issue of Continuum focusing on dementia came out in 2022, which doesn't sound like that long ago, but a lot has changed, right? With the anti-amyloid monoclonals for Alzheimer's disease, new biomarkers and so on. And as the guest editor, you have this unique view, Dr Silbert, of the issue and the whole topic of dementia. As you were reading these really outstanding articles, what was the biggest “aha” moment for you or the biggest change in practice that you saw that's come up over the last couple of years?     Dr Silbert: I think, you know, in reading through the different manuscripts or chapters in this issue, it really struck home the advances that have been made throughout all the different areas of dementia. Not just- so, we hear a lot about Alzheimer's biomarkers and Alzheimer's treatments on the horizon, which is really exciting, but this is happening across other dementias as well. There's biomarkers on the horizon for a Lewy body disease and potentially for some of the frontaotemporal dementias. And so that to me really struck home as this is really, across the board, a change in the entire field that we're looking at.  Dr Jones: That is exciting. And I'd like to come back to some of those biomarker developments because I think that's an area where we've really been lacking in neurology as a specific way to diagnose those disorders. I think a topic which you just alluded to that a lot of our listeners and readers are thinking about are those antiamyloid monoclonal therapies for Alzheimer's disease. So, addicanumab, lecanumab and most recently the approval of donanemab. For these drugs specifically, how are you using them in your practice and how should our listeners be thinking about these drugs?  Dr Silbert: These are, you know, relatively new, really exciting new and emerging therapies for Alzheimer's disease. They are shown to remove amyloid from the brain. Patients who have clinical manifestations of Alzheimer's disease, and that is those in the stages of mild cognitive impairment or mild dementia. We are using lecanemab at Oregon Health and Science University through our therapeutics and clinical units. It's a really exciting time and it's a time where we have to be, also, cautious about who undergoes these therapies. So being really informed about the use, who's appropriate to undergo these therapies, what kind of safety tests need to be undergone, how do you assess risk in individual patients so that you can counsel them.  So, all of these factors need to be weighed in when you're making a decision about whether or not to treat a patient with a monoclonal antibody therapy. And specifically, we do neuroimaging to assess whether there are already the presence of microhemorrhages in the brain. We do genetic testing to look for APOE 4 genotypes that can increase the risk of Aria, which is amyloid-related imaging abnormalities. And all of these factors go into how we counsel patients and discuss whether or not to pursue treatment with monoclonal antibodies.    Dr Jones: So certainly a complex patient selection process and drug administration and monitoring of therapy for those patients.  And that- it brings to mind for me how we already have too few neurologists in the US. And now for a really prevalent disorder, Alzheimer's disease, we're making it a lot more complicated to deliver these new disease-modifying therapies. What do you think or what do you see as the role of the neurologists in caring for patients with dementia? And do these developments change that role?  Dr Silbert: For now, I think these developments make it even more important in a way that neurologists are involved in making a very specific clinical diagnosis of which dementia is playing a factor in the patient 's clinical presentation. I think one thing to note is with these emerging biomarkers, a lot of them can be positive before there are clinical symptoms and multiple etiologies are also very prevalent. And so just having one positive biomarker, it doesn't necessarily tell you what's going on with an individual patient. You need to take the whole picture into consideration. So, I think a really detailed evaluation by the neurologist, especially with these emerging therapies that have potential risks, is extremely important right now. Just getting a test is really not sufficient. You really have to take the entire clinical picture into account and know the ins and outs of the risks involved in these disease-modifying therapies.  Dr Jones: Which brings us back to something you mentioned earlier, right? Which is good news. We have on the horizon new potential biomarkers for other neurodegenerative causes of dementia. I can foresee and maybe I'm, you know, being an alarmist here, Dr Silbert, but if we have sensitive biomarkers for other neurodegenerative conditions, we know patients often have copathologies. Is that going to help clarify things? Is it going to confuse us? How is that going to work?  Dr Silbert: Well, I think ultimately, it's going to help clarify things. Because there are multiple pathologies that are common in age related cognitive impairment, any kind of additional specific input that we can get with different biomarkers is going to be helpful in putting the pieces together to come up with what's happening clinically with each individual patient. Ultimately, I think these biomarkers, they're not- any one biomarker isn't going to be a solution to diagnosis, but putting them together to help improve early and accurate diagnosis is really the goal here. Having a very early diagnosis, having a very accurate diagnosis will improve our ability to give prognosis and also improve effective treatment strategies moving forward. I think that these biomarkers have the promise in facilitating that for us.  Dr Jones: And progress is always a good thing. We just have to learn how to adapt and use the evidence appropriately. There have been and I think most of our listeners will be familiar with some of the controversies related to these, these new disease-modifying drugs for Alzheimer's disease. Do you want to walk us through a couple of those, and what are your thoughts about those controversies?  Dr Silbert: Yeah, these new therapies, they're very exciting for everyone in the field, but they, like you mentioned, they're not without their controversies. I think one controversy or one potential downside to these therapies is access to them. Like you already mentioned there, there's really not enough neurologists out there. There's not enough behavioral neurologists out there. There's limitations to infusion centers, sites and prescribers. Access to these therapies is is significantly limited. They are requiring infusions quite frequently. So, if you're not living near specialty care, you're not really able to feasibly undergo these kinds of treatments. Another controversy is the fact that the treatment effects are considered by some to be fairly modest when looking at the clinical data and in association with that, there are risks involved. Like I already mentioned, there's the amyloid-related imaging abnormalities, which sounds kind of like a benign thing, but they really consist of microhemorrhages that can lead to bigger hemorrhages and edema in the brain. These risks are relatively small - they are seeing more commonly in those who have a specific genotype, an APOE E 4 genotype - but they're risks nonetheless.  And so, there's controversy about the risk-benefit ratio and access to care with these new therapies.  Dr Jones: It's very exciting, but we should be cautious, right? I recall a few years ago as a program director, a neurology residency program director, interest in different areas of neurology would often follow developments in those areas, right? Lots of interest in autoimmune neurology when those developments would proceed in neuro oncology, etc. And I wonder if the therapeutic advances in in behavioral neurology and neurodegenerative cognitive disorders, I wonder if that's going to stimulate interest among our trainees to pursue behavioral neurology? Do you have a view on that or have you seen much change in interest in in this field?  Dr Silbert: You know, we are seeing a lot more interest in our trainees. The residents are very interested in these new therapies and how to apply them. And I'm really excited about that.  I'm hopeful that this will stimulate interest in the field. And we need those specialists, we need those sub specialists to undergo fellowship training in behavioral neurology and geriatric neurology so that we have more access to the subspecialty care and delivering these new therapies. So, I agree with you, I'm hopeful about it and I am seeing new interest in our trainees about these new therapies.  Dr Jones: We can hope so. And all the other fellowship directors will be anxious if neurology residents start leaving to go into behavioral neurology. But there's certainly demand. And I know that under the best of circumstances, dementia is so common. It's something that we have to care for in partnership with primary care and community resources. And these disease-modifying therapies capture a lot of attention, but it's really a small part of the continuum of care of these patients. And Dr Silbert as an expert, you know, if we put that disease-modifying therapy to the side for a second and just said, well, what are the biggest gaps in the care for patients with dementia? What do you see as those biggest gaps and, and what can we do to fix them at not just a neurology level, but at a societal level?  Dr Silbert: That's a big question. And you know, what I see almost every day are gaps in the support mechanisms for families who are caring for patients with dementia. These caregivers are under a lot of stress and oftentimes they just don't have the resources to take care of somebody who at some point will often need twenty-four hour care and supervision. Caregivers are older, usually of older age themselves and have their medical issues as well. And then we're just not doing a good job as a nation in in supporting patients and their families with like supportive care and respite care that's really needed. So, you know, I'm not just seeing and treating patients with dementia, but I'm seeing and I'm really trying to support and care for those who are taking care of patients with dementia. To me, that's the biggest gap in our system. Dr Jones: Yeah. And as I look through this issue of Continuum, we touched on not only the conventional topics in dementia and behavioral neurology. I'm really happy in hindsight that we have invited some discussion of the psychiatric symptoms in dementia, which I think are really important and often underrecognized and maybe undermanaged or mismanaged, and really also focusing on the caregiver burden and support services. We do have an article dedicated to that as well, and I think that'll be useful to our readers and listeners when we when we publish those podcasts. We we've heard this year especially a lot of public conversation about cognitive impairment and dementia. I sometimes wonder if that public attention is helpful and constructive for the population of patients with dementia. Sometimes I wonder if that conversation is counterproductive. What's your take on that?  Dr Silbert: You know, I think it's- it can be a mixed bag, but ultimately, it's in the conversation. We're talking about it. And I think that's only a good thing. There's more public awareness of it.  There is more interest in therapies. So, I think at the end of the day, talking about it, making it more prevalent in the ether, it stimulates the conversation and discussion. And even if there's controversies about it, we're talking about it. And I think that's kind of the first step in acknowledging that we need more support, we need more therapies.  Dr Jones: Yeah, I agree. And I think often patients with neurologic disorders and their caregivers and families often appreciate being seen.   Dr Silbert: Yeah, no, absolutely true. So, I'd say in regards to the monoclonal antibody treatments, you know, despite the controversies with these new treatments, I think there's a real promise and a real hope and a real excitement across a lot of behavioral neurologists, including myself, that this is just the beginning. That even if these first line, first generation therapies maybe have downsides, that there'll be second generation and third generation variations on these kinds of treatments that are going to be more accessible, have less side effects and hopefully be more clinically effective. And, and down the line, the other real hope for the field is that these maybe second generation therapies will actually delay the onset or prevent clinical manifestation of the disease. And that's the real goal here.  Dr Jones: And that's a great segue to the to the next thing I wanted to ask you about and you, you may have already answered the question. We talked about how we have and will have new biomarkers which will help us with diagnosis. We have hopefully the first phase in increasingly effective disease modifying therapies for Alzheimer, maybe prevent Alzheimer's disease. Wouldn't that be great? Are there any other things on the horizon that you see maybe for other neurodegenerative disorders from a therapeutic perspective? What do you, what do you think the next big thing will be in that area?  Dr Silbert: Well, that's a great question. I think, you know, there's a lot of exciting research in Lewy body dementia and targeting alpha synuclein pathologies. We really need biomarkers.  So, we're ways off from therapeutics, but I think there's a lot of exciting progress in that area.  Dr Jones: So, like many areas of neurology, there are rewarding and challenging aspects to the care of these patients. What  do you- what's the most rewarding aspect of your practice, Dr Silbert?   Dr Silbert: You know, a lot of… I hear from trainees over the years that, you know, they can't imagine or it's difficult for them to think about caring for patients who have a neurodegenerative disease that has no cure. But I feel like that's a lot of what neurologists do. We don't necessarily cure all diseases, but we treat the patient throughout their disease process. And to me that is extremely satisfying. You know, I enjoy listening to patients' stories and hearing about what they have been through over the years. And I really feel, like, appreciated for the care that I provide in giving not just an accurate diagnosis, which a lot of people come in lacking, but talking about future planning and, really, treatment throughout the course of the disease. And I was in clinic yesterday and talking to one of my patients' caregivers, and we were talking about a particularly difficult behavioral manifestation that her husband was going through. And we were talking through how to manage it. And she said to me, you know, Dr Silbert, I really feel like I have a partner in going through this disease. And you know, that's kind of what it's all about for me. So, to me, it's extremely rewarding field. It's also a very exciting field, especially right now with all these new biomarkers and treatments. So, I just think there isn't a better area of neurology to be involved in right now.   Dr Jones: What a great place to land and end the interview. And I hope our listeners and our readers really do enjoy this issue. It's really a fantastic, not just an update, but a survey of a very dynamic aspect of the field of neurology. And Dr Silbert, I want to thank you for joining us and thank you for such a thorough and fascinating discussion on caring for patients with dementia.    Dr Silbert: It was my pleasure. Thank you.    Dr Jones: Again, we've been speaking with Dr Lisa Silbert, co-guest editor, alongside Dr Leanna Apostolova for Continuum 's most recent issue on dementia. Please check it out, and thank you to our listeners for joining us today.  Dr Monteith: This is Dr Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. Thank you for listening to Continuum Audio. 

In the patient populations treated by neurologists, central neuropathic pain develops most frequently following spinal cord injury, multiple sclerosis, or stroke. To optimize pain relief, neurologists should have a multimodal and individualized approach to manage central neuropathic pain. In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Charles E. Argoff, MD, author of the article “Central Neuropathic Pain,” in the Continuum October 2024 Pain Management in Neurology issue. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Argoff is a professor of neurology and vice chair of the department of neurology, director of the Comprehensive Pain Management Center, and director of the Pain Management Fellowship at Albany Medical College in Albany, New York. Additional Resources Read the article: Central Neuropathic Pain Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Full episode transcript available here Dr Jones: This is Doctor Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, which features conversations with Continuum's guest editors and authors who are the leading experts in their fields. Subscribers to the Continuum Journal can read the full article or listen to verbatim recordings of the article and have access to exclusive interviews not featured on the podcast. Please visit the link in the episode notes for more information on the article, subscribing to the journal, and how to get CME. Dr Jones: This is Doctor Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today I'm interviewing Dr Charles Argoff, who recently authored an article on central neuropathic pain in the latest issue of Continuum covering pain management. Dr Argoff is a neurologist at Albany Medical College where he's a professor of Neurology, and he serves as vice chair of the Department of Neurology and program director of the Pain Medicine Fellowship Program there. Dr Argoff, welcome. Thank you for joining us today. Why don't you introduce yourself to our listeners?  Dr Argoff: I'm Charles Argoff. It's a pleasure to be here and thank you so much for that kind introduction. Dr Jones: I've read your article. Many of our listeners are going to read your article. Wonderful article, extremely helpful. Closes a lot of gaps, I think, that exist in our field about understanding central neuropathic pain, treating central neuropathic pain. You now, Doctor Argoff, you have the attention of a huge audience of mostly neurologists. What's the biggest point you would like to make to them, or the most important practice-changing advice that you would give to them? Dr Argoff: I think it's at least twofold. One is that central neuropathic pain is not as uncommon as you think it might be, and it occurs in a variety of settings that are near and dear to a neurologist's heart, so to speak. And secondly, although we live in an evidence-based world and we want to practice evidence-based medicine - and I'm proud to have formerly been a member of the Quality Standard subcommittee, which I think has changed its name over time. And so, I understand the importance of, you know, treatment based upon evidence - the true definition of evidence-based medicine is using the best available evidence in making decisions about individual patients. And so, I would urge those who are listening that, although there might not be as robust evidence currently as you'd like, please don't not take the time to try to treat the patient in front of you o r at least acknowledge the need for treatment and work with your colleagues to address the significant neuropathic pain associated with that central neurological disorder. Because it can be life-changing in a positive way to make even a dent and to really work with somebody, even though not clear-cut always what's going to work for an individual patient. Dr Jones: Well said. I'm glad you brought that up. So, to put it a different way, absence of evidence is not an excuse for absence of treatment. Right? Dr Argoff: Exactly. And I think that, I hope that we would agree that especially in neurology, what we do is about as far from, ‘Yep, you've got strep throat, here's that antibiotic that's going to work for you and all you have to do is take the medicine.' I mean, most of what we do is nowhere near that.  Dr Jones: It's complicated stuff. And this is a complicated topic. And I'll tell you, I learned a lot reading your article. I think most of us in neurology and medicine, when we hear the term neuropathic pain, it feels roughly synonymous with peripheral generators of that pain, such as diabetic neuropathy or posttraumatic neuralgia. But as you mentioned, there's central mechanisms for pain generation. How is it defined? What is central neuropathic pain? Dr Argoff: It's defined as pain caused by a lesion or disease of the central somatosensory system . Though neuropathic pain in general is pain associated with the lesion of the somatosensory system; and to your point, that can be peripheral, which of course is outside the spinal cord, or brain or central, which is within the spinal cord or brain. And central neuropathic pain is defined specifically as pain caused by a lesion or disease of the central somatosensory system. That's either brain or spinal cord. But there's an interesting follow-up, and I'm going to ask if you could remind me because I know we're talking about definitions now, but I'll just bring something up and we can come back to it. What's interesting about that is that my - whoever 's listening, that's not to say that they're not connected. And in fact, they are very much connected. And there's very new work, which I included in the article, down at Washington University in Saint Louis, that suggests you can actually affect central neuropathic pain by addressing peripheral input to the central nervous system. If you remember Ken Casey at the University of Michigan at the World Pain Congress in Vancouver, British Columbia many years ago, he ended his talk on pain with a limerick, of which the last line was, Remember, there ain't no such thing as pain without a brain. And so that kind of summarizes that. Dr Jones: Well, and it goes both ways too, right? We know that there's some central sensitization that can happen with peripheral generators, right? So we really have to think about the whole circuit. Dr Argoff: Yes. And that's been sometimes the bane of my existence as a colleague of others and a sometimes debater. Is the pain central? Is it peripheral? Well, it's everything. And it's important to know as many of the mechanisms and many of the targets that you could use for treatment so that you can affect the best outcome for your patients. Dr Jones: Yeah, so - and you mentioned in your article what some of the common causes of central neuropathic pain are. What are the big ones in your experience?  Dr Argoff: So, the biggest ones are spinal cord injury-related pain, MS-related pain - and I'd like to come back to a point and just if I do the third one - and central poststroke pain. And what struck me, I think Tim Vollmer published a survey about the incidence, the prevalence of ongoing pain in patients with multiple sclerosis. And it blew my mind several years ago because it was incredibly high. Like in this survey of MS patients who, you never hear about pain, you hear about these modifying treatments, all the wonderful expanses that have been made. I mean, like seventy something percent of people say they have moderate to severe pain. And when you think about how sensory processing occurs, it makes perfect sense that a demyelinating disorder is going to interrupt the flow of information for a person to feel normal.  Dr Jones: Yeah, I think it's a good example of, there are things that we tend to focus on as clinicians where we worry about deficit and function and capacity. But if we're patient-centered and we ask patients what they care about, pain usually moves up higher on the list. And so, I think that's why we, it's maybe underrecognized with some of those central disorders, right? Dr Argoff: I think so, and I and I think you hit the nail on the head that - and we're also trained that way. I tell this to my patients very often so that they are reassured when I examine them and I say, and I tell them that everything looked pretty OK. It's not a medical term, I understand that. Because what we do in a typical neurological exam, even if it's detailed, doesn't really address all the intricacies of the nervous system. So it's really a big picture and sensory processing and especially picking up sensory deficits; you know, we use quantitative sensory testing and research studies and things like that, but bedside testing may not reveal the subtle changes. And when we don't see overt changes, we often think - that can lead someone to think that everything is OK and it's not. Dr Jones: So, when you when you see a patient who you've diagnosed with a central mechanism, so central neuropathic pain, how do you approach the management of those patients, Dr Argoff? Dr Argoff: I always review what treatments and what approaches have been addressed already. And I see if - a handful of time, we actually just submitted a paper for publication regarding this in a group of patients with pelvic pain who had untreated, difficult-to-treat chronic pelvic pain, seen all the urological kinds, gynecological things. Look, we picked up two patients who had unknown MS. So, it's just interesting when it comes down to that level. And we also picked up some patients who had subacute combined degeneration. So that's another central kind of disorder as well. Again, the neurologist in us says to make sure that we have specific diagnosis that underlies the central neuropathic pain. And so interestingly, of course, for somebody with MS - or even though it's uncommon, it could be more than one. Somebody with MS might have a stroke, somebody with MS might have a cord injury due to cervical, you know, joint disc disease. Not to overcomplicate things. Know the lay of the land, know the conditions, know what you're battling and lay out so that you can treat the treatable; you want to treat whatever you can correct? So, for MS you simply want to have the best disease-modifying treatment on board, tolerable and appropriate for that person, and so on. And then you really want to take a history of past treatments - and your treatments can be everything and anything, including behavioral modification, physical rehabilitative approaches, as well as pharmacologic management. That's - as I think I put in my article, we concentrated in the article on pharmacologic management because honestly, that's what most patients are looking for, is ‘what can we, what can you do to help me now, in addition to what I can do myself.' And that's what we typically think of. There are also some more interventional approaches, invasive options, that have developed over time. And of course, those are the ones, some of them, especially in neuromodulation, that we have the least information about, but it appears somewhat promising.  Dr Jones: No, that's exactly what we need to hear. And you also mentioned something that I think is important. This is a common theme throughout the issue because I think it's true for the management of many different types of pain and interdisciplinary approach. In other words, not just honing in on pharmacotherapy or neuromodulation as a one-size-fits-all magic pill, right? So, that - tell us a little bit more about that interdisciplinary approach and how that's important for these patients. Dr Argoff: So, let me back up and give an example. Let's look at Botox for chronic migraine. So, the pre-M studies that led to the approval of Botox for chronic migraine: two treatment sessions versus two random, two placebo session in different patients. The mean headache frequency was, let's say, fifteen to twenty in each group. It was like seventeen, eighteen, something like that. But the mean pain headache day reduction was somewhere between four and five after two treatments compared to a lesser, a lower number in the placebo group. So, if you think about that, that means that you went from nineteen, let's say, to fourteen, thirteen, or twelve. Want to be generous, eleven or ten. But that means that person, everyone 's happy. We use treatment. We have better data than that because the longer you use it, the better it gets in general, but it means that people are still going to be symptomatic. So that drives home in a different painful disorder the importance of yes, treatment can be effective, but it's not the only treatment that a person is going to likely need. And so, I think that's what's so important about multidisciplinary approach. I- we may affect positive changes, reduction in pain intensity with a particular pharmacologic agent, but we don't anticipate it's like taking an antibiotic or a strep throat, not curative. And so, we want to, early on, to explain that logically, methodically, step by step. There are many options for you and we're going to, you know, systematically go through them. And I may need to call in some colleagues to help because I don't do everything. No one does everything, right? But don't feel as if there isn't any hope because there is. If we were to use intraspinal Baclofen for someone who has painful spasticity following a stroke or a spinal cord injury, combining that with physical therapy might give more effect, maybe synergistic. Some targeted muscles, some local muscles may not respond as well to the intraspinal Baclofen, so is that - what can we do? Well, we could use oral agents or we might be able to target that with botulinum toxin, and so on and so forth. So it's limitless, virtually, in what you can do. Dr Jones: There's kind of setting expectations and letting people know that you, you're going to need a lot of different approaches, right? To sort of get them the best possible outcome. Dr Argoff: Yeah, I think that's so important. And of course, no matter what we try to set out, there are going to be individuals - for those of you who are listening, we all know - who expect to be cured yesterday. That might be challenging for us not only to actually complete, but also, it's challenging for some individuals to appreciate that we're with them, we're going to work with them. It'll be a process, but we've got your back. Dr Jones: Great. And you know, this is a question that I get all the time from patients and from other clinicians is, you know, what about cannabinoids? What's the role of cannabinoids for the management of central neuropathic pain? Dr Argoff: First, I'll say that the short answer to that is we don't know. The second part of my response would be, there is new evidence that it might be helpful in the acute treatment of migraine. And I'm happy to say that the editor of this edition of Continuum is the person who developed that evidence, and it's been recently presented at the American Headache Society. But the challenge and the conundrum that we all face is, everywhere within our nervous system where there's pain being processed, there are endocannabinoid receptors. There also happen to be opioid receptors, but that's a separate issue. And the endocannabinoid system, the peripheral or central, you know, CB1, CB2, is very, very important, but we haven't figured out a way of harnessing that knowledge in developing an analgesic, an effective analgesic. And part of that is that there are so many chemical agents that have cannabinoid properties and there are different… the right balance has not yet been found. But even the legalization, the available of medical cannabis, hasn't led to a standardized approach to evaluating if a preparation does help. And that's part of the conundrum. It's like saying, ‘does medicine work?'Well, yeah, sometimes. But which medicine? Which receptor? How do you harness the right ratio between TBD, THC, other active agents, et cetera? And I think maybe as we go forward in the future, we'll be able to do that with - more precise. I mentioned Dr Schuster's study in which he had defined ratios of THC effect and CBD and was able to clearly show effect based upon that. But the average person going into a dispensary doesn't really get that. We don't get to study that. Each person's an NF1  and it's not very helpful to understand how to do that. I would say, as I'm sure you remember, there was a practice parameter that was published probably over a decade ago about using cannabis symptomatically in different neurological disorders. And I believe that it was what they studied or what they reviewed was helpful in MS-related urinary discomfort and spasticity, but not necessarily pain.  Dr Jones: And we're still in the early days of studying it, right? Dr Argoff: Yes.  Dr Jones: That's part of the point, as we got started late and we're still waiting for high-quality evidence. And I guess, if you look at the horizon, Dr Argoff, or the future of management of central neuropathic pain, what's going to be the next big thing?  Dr Argoff: One of the joys of being asked to get involved in a project like this is that inevitably we learn so many new things because, you know, that's when anyone says, oh, you must be an expert, I say, I don't know anything because I'm always learning something new. One of the reasons why I moved to Albany Medical College about seventeen years ago was to be able to further my interest in studying why people benefit from topical analgesics by working with a scientist at Albany Med who studied keratinocyte neurochemistry and its impact on pain transmission. And that's a separate issue, but it indicates my love for the peripheral nervous system. And one of my thoughts historically, that is, what the central nervous system processes is what it processes and it might get input, as you mentioned earlier, from the peripheral nervous system, so that topical agents could be dampening central mechanisms. And lo and behold, as I was doing research for this article, I learned that people doing peripheral nerve blocks - so blocking peripheral input at the into the spinal cord - at Washington University, Simon Guterian and colleagues, demonstrate that they could give prolonged benefit from central pain by blocking peripheral input. And that's wild because certainly the nervous system is a two-way street. It's an understatement. What I really found amazing was that, again, blocking input helped the injured central nervous system to behave better.  Dr Jones: That is kind of cool to think about. And I'll tell you, as editor of the journal, one of the funnest things is getting to learn all about neurology, including pain and including central neuropathic pain, when in the end you're doing all the work, I just get to sit here and enjoy it. And you're a program director of a pain fellowship. What's the pipeline look like? Are neurologists more interested in pain than they used to be?  Dr Argoff: I'm happy for this. We are seeing more and more applicants from neurology into our pain management programs. I would say… I was going to say tragically. If I say tragically, it's because what specialty better understands how to diagnose, figure out, assess, come to a conclusion? You can't have pain without your brain. It's always amazed me that more neurologists weren't interested, and I understand the background and such. Just like in migraine, it's only advances in understanding mechanisms of migraine that allow neuroscientific advances that are leading to great therapeutics - that's happening and increasing in ‘pain.' Today, as program director, we had our fellowship interviews earlier today and three of the nine applicants that we interviewed were neurologists. Last week, I think we interviewed two or three also. That would not have happened five years ago or six years ago. And if you think about it, we can not only diagnose, quote-unquote figure out what's happening, but we now, with pain management training, we can offer people a variety of both invasive and noninvasive options, all while understanding what we're doing with respect to the nervous system in a way that's different than the other specialties that typically go into pain med. And that's such - for me, it's a beautiful experience and something I really enjoy doing. There isn't a neurological condition in the most part that either doesn't have pain associated with it or doesn't have mechanisms that overlap. If you think about epilepsy, and please don't think I'm crazy, but epilepsy is associated with disinhibited hyper-excitatory behavior, just to put it loosely, among certain neurons. That's what pain and neuropathic pain is about too. And you, in fact, we know that several mechanisms since now what medicines are used for both. But what was interesting since, if I may just go back to another point, one of the advances since I brought up the migraine that's very exciting is the whole story about sodium channels. Dr Harouthounian at WashU and his group used lidocaine injection. Lidocaine's a more generalized sodium channel blocker, but some of the newest treatments for treating neuropathic pain. Our NAV specific sodium channel blocker's trying to match up mechanism to treatment. Not exactly the way that we do with migraine, but still a step forward to not just generally treat but really target different neuronal mechanisms. It's an exciting time.  Dr Jones: So, the pipeline is doing better because we're getting better understanding of disease, and hopefully that pulls in more interest because obviously there are big gaps in caring for patients with pain. And again, thank you, Dr Argoff, for an amazing article. Thank you for joining us and thank you for such a fascinating discussion. I enjoyed the article. I read the article, I learned from our conversation today. So, thank you for joining us to talk about central neuropathic pain. Dr Argoff: Thank you for having me. Dr Jones: Again, we've been speaking with Dr Charles Argoff, author of an article on central neuropathic pain in Continuum 's most recent issue on pain management. Please check it out, and thank you to our listeners for joining today. Dr Monteith: This is Doctor Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at Continpub.com/AudioCME. Thank you for listening to Continuum Audio.

In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Nathaniel M. Schuster, MD who served as the guest editor of the Continuum® October 2024 Pain Management in Neurology issue. They provide a preview of the issue, which publishes on October 2, 2024.  Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Schuster is an associate professor and associate clinic director in the Center for Pain Medicine and Department of Anesthesiology at the University of California, San Diego in La Jolla, California. Additional Resources Continuum website: ContinuumJournal.com Subscribe to Continuum: shop.lww.com/Continuum More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @NatSchuster Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME Journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal have access to exclusive audio content not featured on the podcast. If you're not already a subscriber, we encourage you to become one. For more information, please visit the link in the show notes.   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today, I'm interviewing Dr Nathaniel Schuster, who recently served as Continuum's guest editor for our latest issue on pain management and neurology. Dr Schuster is a pain neurologist at the University of California, San Diego, where he is an Associate Professor of Anesthesia. Dr Schuster, welcome. Thank you for joining us today. Why don't you introduce yourself to our listeners?   Dr Schuster: Thank you so much, Dr Jones, for having me. My name is Nat Schuster. I am a pain and headache neurologist at UC San Diego, in the Department of Anesthesiology. I do research, clinical practice, and of course, education of med students through pain fellows, and it's been a pleasure to be the guest editor for this forthcoming issue of Continuum.   Dr Jones: Well, I want to thank you for editing the issue. I want to thank you for putting together, really, an incredible list of topics and, really, expert authors. It's been a long time since Continuum has dedicated significant space in an issue to pain management, which is obviously a hugely prevalent, major problem in society, and I think a big gap for many of us – I know it is for me in my practice, so I've enjoyed learning about it – so I want to congratulate you on the issue and thank you for doing it.   Dr Schuster: Yeah. I was just at AAN a few weeks ago. I was chatting with the person who edited one nearly 20 years ago, a prior pain Continuum issue - so, really glad that for another generation of neurologists that we're going to have this as a reference, and hopefully, it'll serve them in their care of so many patients, because this is just such a ubiquitous problem facing Americans and people around the world.   Dr Jones: Yeah, and a lot's changed in 20 years, so let's get into it. And I will say, you know, now that with our open podcast model, we're interviewing the guest editors, you have, really, an incredible view of the entire field at the moment. And with your reading of the issue and your experience as a pain expert, Dr Schuster, what do you think is the biggest controversy in pain medicine right now?   Dr Schuster: Yes, certainly. I think the most controversial thing facing our practicing neurologists is the opioid issue and how things have been changing with national guidelines since 2016, and, fortunately, we are going to have an article by Dr Friedhelm Sandbrink - who is not only a neurologist, but he is the national director for the VA system - on pain management, opioid safety, and prescription drug monitoring programs. So, it's really wonderful that we have him as an author, and I hope that all the neurologists take an opportunity to read his really important manuscript, because it's dizzying, and, you know, if you're not reading the latest things from people like Dr Sandbrink pretty much every couple of years, you're probably falling behind when it comes to what are current attitudes, what is necessary to be, you know, most responsibly continuing your patients who have been on opioids for so long (many of whom have really debilitating neurologic conditions, nothing else is helpful for them), how are you able to best treat them, best monitor them in the appropriate ways to be doing things in compliance with guidelines.   Dr Jones: And I think monitoring is one of the things that, for neurologists who are uncomfortable with pain management, uncomfortable with the modern role of opioids, I think part of it is, well, what are my accountabilities? What are my responsibilities for doing that? That article will have great insights for our readers. Cannabinoids - that's another one I hear a lot of questions about, and it's obviously evolving. The science is relatively less mature there. From your perspective, what's the role of cannabinoids in a modern pain practice?   Dr Schuster: Yeah. Once again, so much controversy there and so much variability across the US, of course, between institutions, between states - hugely different. And as we speak, it's looking like cannabis will very likely be recategorized as being schedule III, so things are changing, you know, even between right now, probably, and when people are going to be reading the forthcoming Continuum and listening to this podcast. At UC San Diego, we certainly have been on the forefront of doing clinical trials, looking at these clinical trials. They're academic studies using the NIDA drug supply. So, they're not the size and scope of so many of the things that we use that have had industry-funded, large, multicenter studies done, but the research that we've done has shown promise for quite a few different neurologic conditions, ranging from my most recent research was in the migraine space, looking at acute migraine (and I just had the pleasure of presenting that data at AAN a few weeks ago), looking at other things over the years, looking at spasticity pain and multiple sclerosis, spinal cord injury pain, diabetic peripheral neuropathy, other peripheral neuropathies. So, in the conditions that we as neurologists so often do treat, that does seem like there is a lot of promise. It's something that in our practice, some of our doctors are more comfortable with it, others are less comfortable. I know, myself, I'm very conservative when I discuss it with patients, because there is, you know, addiction concerns, misuse concerns, abuse concerns - I don't believe that it's to the degree of opioids, and I don't think that the risks are anywhere close to what they are with opioids - and while it's less in opioids, we have other things, fortunately, in this field that don't carry those concerns, and so, I certainly try to use those other options as much as possible before having the discussions about cannabinoids. That said, so many people are using them, and so I'm able to guide them towards, you know, telling that very often, doses that are lower than what they might need to get intoxicated might actually be the doses that are therapeutic, and recommending using high CBD and low THC is probably going to have less side effects, and there's some evidence towards, hopefully, having more therapeutic benefit, especially in our most recent study looking at acute migraine that you want to have that CBD component with the THC.   Dr Jones: That's outstanding. So, we know more than we used to. It still feels like a relatively understudied area (and that's partly been the regulatory barriers to doing science on cannabinoids), so we'll look forward to hearing the latest and greatest in the issue. When we think about in neurology - and I'm thinking here as a clinician - when we think about pain and neurology, we often think about neuropathic pain. And, personally, you know, I see a lot of patients who have peripheral generators for those symptoms of neuropathic pain, but central neuropathic pain is an issue, too - and we have articles on both of those, one on peripheral neuropathic pain, one on central neuropathic pain. For our listeners, what should they know about the differences between those two and the treatment approaches to those?   Dr Schuster: Yeah. So, we fortunately have two wonderful articles - one of them from Dr Charles Argoff looking at central neuropathic pain, another one looking at peripheral neuropathic pain from Drs Misha Bačkonja and Victor Wang. And one thing that I think is really interesting about central neuropathic pain is that for these same patients, we don't need to only be thinking about the central neuropathic pain alone, and not everything that they're experiencing is going to be central neuropathic pain, because they can have “frozen shoulder” - post-stroke shoulder pain is actually a really big deal. Of course, you need to be concerned about things like sacral decubitus ulcers in so many of these patients. And so, they can have nociceptive components in those same patients, and us as neurologists, taking care of these very complicated patients, need to have our eyes open for the central neuropathic components, but also in those same patients, the other pain generators that we can do a lot for.   Dr Jones: So, the musculoskeletal and other generators of pain are relevant. I think that's something that many of us have experienced. Certainly, when I trained, Dr Schuster, the general construct around pain was that it was a really biological phenomenon, and it's an adaptive phenomenon, but it becomes a clinical problem when the pain is unmanageable or out of proportion to the patient's coping skills, and it seems to have evolved - at least in terms of our understanding of it, how it impacts people's lives. It's not just a physical or biological process, right? There are psychological factors here, there are social factors here. How does that inform your thinking about management of pain?   Dr Schuster: Yeah, so, I think that that's one of the most important running themes throughout this issue of Continuum that readers will find, is that there's a movement away from the biomedical model towards the biopsychosocial model in thinking about patients. And, at least for myself, when I was coming out of neurology residency, my training was much more on the biomedical model and on medication treatments. And throughout this issue, what you'll find is discussions of the importance of the biopsychosocial model, having pain psychology as being a component of the treatment for so many of these patients. That medications alone (for many of our most challenging patients) won't be the answer by themselves - that you'll need to have involvement of physical therapy, of pain psychology. And we have an article written by the pain psychologist who I work with at UCSD, Dr Mirsad Serdarevic, which I think will be very interesting for so many neurologists. It's also wonderful that we have an article on facial pain that's written by a neurologist, Dr Meredith Barad, together with a dentist, Dr Marcela Romero-Reyes. So, it really takes a team to treat so many of these very challenging patients who we are treating in our neurological practices.   Dr Jones: Yeah, thanks for that. I realize that with a complex problem, a lot of times you need more than one area of expertise, right? It's a team process and a team effort. When you think about your own practice, Dr Schuster, when do you bring in other specialists or other perspectives in the management of patients with pain?   Dr Schuster: So, one of the articles that I really enjoyed reading in this forthcoming issue of Continuum is the one from Dr Narayan Kissoon on widespread pain syndromes. These patients who have widespread pain syndromes very often are the patients that I'm referring to our pain psychologist. Neurologists can do so much for these patients by making the right diagnosis. So often, these patients might be treated by one specialist for one organ system, another specialist for another organ system, and they can have so many different specialists, and they can be going from institution to institution. And a neurologist is in a really good position to be able to take the full history, put everything together and say, “I think you have a chronic overlapping pain condition. I think you have central sensitivity syndromes” - to be able to talk to them about their central nervous system being amped up, and that there are treatments that we can give them to help to treat these conditions, fibromyalgia and others, that affect so many of our patients who we encounter in neurologic practice. So, the International Association for the Study of Pain now has this term, nociplastic, and some people use the term neuroplastic to talk about these central sensitivity syndromes, and while not all neurologists maybe are hearing those terms used yet in clinical practice, I think it gives us a good framework - and between Dr Kissoon's article, as well as Dr Beth Hogans' article on general principles of pain, I think that those will give the practicing neurologist a lot of good updates as to how our thinking about these patients has evolved.   Dr Jones: I know, as clinicians, we have a very cause-and-effect kind of component to our training, right? Here is the problem, here is the lesion, here is the result, and what do I do about it. I think patients also want to know what is the cause of the pain, and I think it's, maybe, historically been frustrating when someone clearly has pain and there's not a single factor, especially a removable factor, that causes it. So, I think, hopefully, having this language that we can use to communicate it with our better understanding of pain, hopefully that will help. Does that help you in your practice when you're talking to patients, when you explain what's going on? Is that well-received in general?   Dr Schuster: Yeah, you know, I think a lot of doctors are afraid to talk about fibromyalgia, for example, with patients. And what I'm finding in my practice, actually, is that a lot of patients are liberated when they can receive a diagnosis, such as fibromyalgia, that they can read about, they can learn about treatments for it, they can join support groups online and find that they're not alone - indeed, this condition affects 2 to 4% of people, and that very well could be a underdiagnosis. It keeps them from looking to different specialists for each painful body part and potentially having unneeded surgeries - and surgeries that might make things worse. So, I think physicians are understandably concerned because there is stigma - there's stigma around a lot of painful conditions, and there's stigma around some of the treatments that we use to treat these patients - and I think that physicians who are sensitive to that can sometimes be hesitant, but I'm really surprised how often patients are just really appreciative to get the right diagnosis.   Dr Jones: And you mentioned a minute ago that things have changed even since you came out of training, and, obviously, training is really important to know how to manage these problems. In my own world, I've seen, I think, an increase in the interest in pain management as a subspecialty among neurology trainees. There's obviously something that grabbed you, something that pulled you into this field. What's been your path to being a pain specialist?   Dr Schuster: Yeah, so I was a neurology resident at Ronald Reagan UCLA Medical Center, and fortunately, there, they have a few pain neurologists - and also, in the community, we have a few other pain neurologists as well that I had the great fortune to work with. And I was so impressed, especially those who are doing both pain and headache treatment, that you were able to help so many people treating very high-prevalence conditions - very often, younger patients, people who are going through school, building families - and being able to really reduce their disability, improve their quality of life and the quality of lives of their families is very gratifying. So, I encountered that as a neurology resident. I had their mentorship. And then, I applied for both headache and pain fellowships, and I did both a headache fellowship and a pain fellowship - and I think that that's been a wonderful combination for my career. To have that mix of patients has been really wonderful for preventing burnout. I think having a combination of slightly different patient populations between the headache population and the pain population, as well as, of course, those who have comorbid headache and pain conditions, has been very gratifying to treat people with these conditions. Not that many neurology residents think about doing a pain fellowship, and I wrote, together with my good friend and colleague Jacob Hascalovici, back in 2018 (that was published in the Green Journal), an article on pain neurology as an emerging subspecialty within neurology - and certainly, I would encourage any neurology residents who are interested in potentially pursuing a pain fellowship to read this article. There's such a need for neurologists in the pain field.   Dr Jones: It can be a little bit of a self-fulfilling prophecy, right? So, obviously, role modeling was important to you, right? You could see the practice when you were in training, when you could still make the decision, and if there aren't enough pain neurologists (which I think we can agree that there aren't), there are probably a lot of trainees who don't have that window into what that practice can be like, which, again, makes it kind of a barrier to folks entering the field - so, hopefully, being more comfortable with it will help our listeners and our readers, you know, integrate this into their practice and see it as a path forward for their own careers if they're interested. One last question for you, Dr Schuster, is - you know, looking into the future, obviously, when we have more options to treat these patients, it's rewarding and engaging and exciting - what do you think the next big thing in pain management is going to be? What should our listeners know that's coming down the road for these patients?   Dr Schuster: Yeah, so the interventional segment and the neuromodulation treatments are really changing a lot these last few years, and I believe are going to keep on evolving with new treatments coming down the pathway. And so, we have two wonderful and really nicely balanced articles on these topics: one of them from one of my former mentors from my UCLA days, Dr Vernon Williams, wrote one on spine pain, and he talks about the interventional pain treatments; and another from Dr Prasad Shirvalkar on neuromodulation for painful neuropathic diseases. And these are really wonderful articles for the neurologist who wants to learn about what treatments are available that, they might not personally be doing these, but that they can refer to colleagues - and these are changing a lot. Epidural steroid injections, for example: helpful for a lot of patients, but there's so much more to the interventional pain field than just that, and I think our practicing neurologists will learn a lot about, “Oh, what can neuromodulation be useful for within the pain field?” And, of course, because there's industry involvement in neuromodulation research, you need somebody who's really good at being very balanced, and I think Dr Shirvalkar did an incredible job about writing a really balanced article about the neuromodulation options that we have for patients with neuropathic pain disorders.   Dr Jones: It's exciting stuff. I think there's a lot to look forward to. I think the update that our readers and listeners will have from this issue will be extremely helpful for themselves in their practice and for their patients. For people who are audiophiles, each of these articles will have a corresponding podcast, so we'll refer people to that. And with that, Dr Schuster, I want to thank you for joining us for a really thorough, fascinating discussion on the field of pain neurology and our brand-new issue on pain neurology. And again, we've been speaking with Dr Nat Schuster, Guest Editor for Continuum's most recent issue on pain neurology. Please check it out. And thank you to our listeners for joining today.   Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information, important for neurology practitioners. Use this link in the episode notes to learn more and subscribe. Thank you for listening to Continuum Audio.

Cranial neuralgias comprise a distinct set of disorders typified by short-lasting attacks of intense pain in the distribution of a particular nerve in the cranium. Cranial neuralgia syndromes are rare but can be debilitating and go undiagnosed or misdiagnosed for years. In this episode, Lyell Jones, MD, FAAN, speaks with Stephanie J. Nahas, MD, MSEd, FAAN, MD, an author of the article “Cranial Neuralgias,” in the Continuum® April 2024 Headache issue. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Nahas is an associate professor of neurology at Thomas Jefferson University and assistant director of the Headache Medicine Fellowship Program at Jefferson Headache Center in Philadelphia, Pennsylvania.   Additional Resources Read the article: Cranial Neuralgias Subscribe to Continuum: continpub.com/Spring2024 Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @ LyellJ Guest: @stephanieJnahas Full transcript available here  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members, stay tuned after the episode to hear how you can get CME for listening.    Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today, I'm interviewing Dr. Stephanie Nahas, who has recently authored an article on cranial neuralgias in the latest issue of Continuum on headache. Dr. Nahas is a neurologist at Thomas Jefferson University where she is an Associate Professor of Neurology and serves as Assistant Program Director of the Headache Fellowship program there. Dr. Nahas, welcome, and thank you for joining us today. Dr Nahas: Thanks for having me. Glad to be here. Dr Jones: So, for our listeners who are new to Continuum, Continuum is a journal dedicated to helping clinicians deliver the highest possible quality neurologic care to their patients, and we do so with high quality and current clinical reviews. Dr. Nahas, your article is a perfect example of that - it's full of really helpful (and I think clinically relevant) recommendations for neurologists who take care of patients with cranial neuralgias. And now that at this moment (during this podcast interview), you have the attention of a huge audience of neurologists - what's the one most important practice change that you would like to see in the care of these patients?  Dr Nahas: I would like to see the recognition of these cranial neuralgias and related syndromes as distinct and overlapping with other primary headaches much more often. I think far too often, clinicians will try to pigeonhole these headache and facial pain diagnoses and try to make just one diagnosis the main one, and any other symptomatology that comes along with it – “Oh, that's just a weird part of your primary syndrome, right?” I know I've fallen into this trap a number of times, because mostly what we see in a headache clinic is going to be migraine, so we kind of have a laser focus towards migraine-type symptoms (and we know migraine can do just about anything). So then when we hear a little bit about a facial pain, a little bit about some sort of neuralgia, we just try to wrap it up into migraine - but that's not always necessarily the case. You know, we know that any person on the planet can have as many diseases as they darn well please, so why not ascribe two diagnoses when it's appropriate? That can lead to better treatment outcomes, in fact. If you are focusing your treatment on two distinct, but overlapping, entities, you tend to get better results, because the treatments may not be identical (and they rarely are). Dr Jones: And that's a great example of it's Occam's razor on one side (there's one problem) versus - what is it, Hickam's Dictum? Dr Nahas: Something like that. Dr Jones:  - where you can have as many problems as the patient wants to have, so I think that's a great example of that. And, earlier, in the same issue on headache, we do have a wonderful article by Dr. Deb Friedman, who walks through that really important history component of trying to, you know, determine which headache syndrome the patient is dealing with (which is obviously a prerequisite for the diagnosis and management) - so that's a great point. So that's the one takeaway - recognition of cranial neuralgias as a distinct entity. Keep it in mind – otherwise, we'll miss it. Is that right? Dr Nahas: You got it. Dr Jones: Okay, good. If we learn nothing else, we'll take that away. So, speaking of the history, Dr. Nahas, for many pain syndromes (including these), the history is really paramount in establishing the diagnosis for patients, specifically with trigeminal neuralgia. How do they usually describe that pain to you?  Dr Nahas: The whole spectrum of descriptors for trigeminal neuralgia-form pain is, actually, maybe broader than you would think, and I actually find that, sometimes, patients have a real hard time verbalizing and describing the way it feels, because it's so unusual - it doesn't remind them of anything they've necessarily felt before.  Sometimes, it can. For example, a patient who's no stranger to having lots of dental work - that pain that when they drill in or if they hit an irritated part of the tooth or the gums, that's usually kind of neuralgia form-like. But at the same time, patients will say, “It's still not quite like that. You know, it's really hard for me to explain. It's sharp and it's terrible like that, but it has a different quality.” And I think they just don't necessarily have the terminology, but I encourage them to try to be creative. You know, some of my patients will personify the pain - they'll describe as if there's some little creature in there that's clawing, or scraping, or pulling, or stabbing. Or they might use other descriptors, such as burning like a fire (like a blow torch is there). Or they may even use colors. You know, some of my patients are really creative, and I don't know if they actually have synesthesia or they're just bordering on that, but they'll describe different colors for the qualities of pain. (“Is it more red? Is it more like icy blue? Is it black or white?”) I don't hear that too often, but I do like to just open the door and let my patients describe for themselves in their own words - and if they can't have any words, I give them some examples and that usually gets the ball rolling. Dr Jones: So, a combination (like we usually do) with some open-ended questions, and then some directed ones to kind of clarify. That's really interesting, and it gives you some immediate empathy and sympathy for the discomfort these patients have to deal with, right (as when they describe it in those burning, clawing kind of terms)? Dr Nahas: Exactly, and they'll also put it into context for you - so not just describing what the quality of the pain is like, but they'll give you good examples of when they feel these symptoms, what brings them on, what alleviates them, how the symptoms may change from day to day depending on the situation or circumstance. And again, it just gives them an open door to express themselves, and it really does help to strengthen that alliance you're trying to create and maintain with your patient. You do get useful and valuable information when you just let them go on and describe things. Dr Jones: So, there are, I think, misconceptions in the popular world and also in the clinical side of care that, you know, folks will have a perception of a disorder that maybe doesn't really match reality. What do you think is a common misconception you've encountered in taking care of patients with cranial neuralgias?  Dr Nahas: The patients that I see tend not to have the clear-cut textbook descriptions  (like it's almost as if they're reading the criteria when they tell you your symptomatology) - because those cases are a little bit easier, they get identified more readily, they get appropriate treatment sooner, their disease doesn't necessarily progress and become complicated by, you know, any number of things that can happen with unmanaged neuralgia-form craniofacial pain. The ones that I see - they've been around the block several times, because maybe their syndrome isn't quite so typical. Maybe they didn't really have the terminology to be able to describe their symptoms. Maybe nobody really opened that door for them and invited them to just talk about what it is. Perhaps they, or whoever they were seeing, were more focused on diagnostic testing, and so their focus is more on, “Why is my MRI not showing anything? Why is my x-ray completely normal? You know, I have these symptoms. There must be an explanation.” Because that's what patients want - they want solutions. They have a problem, they want to know why they have it, and they want a solution to it. And they can get too focused on the hard data and ignore that it's a subjective experience that really guides us to help treat their symptoms, especially when we don't have necessarily an anatomic target to go after. (When we do, that's great.) But again, these straightforward cases tend not to come to me, because they're easier to take care of. Dr Jones: Still, just as legitimate a diagnosis, even with a normal MRI, right? I do find it's sometimes hard to kind of get around that with a patient, isn't it? Dr Nahas: Absolutely, it is. You know, they're both relieved and disappointed. I often find if we order imaging for an unusual syndrome (or even a typical syndrome) and they see that, “Well, there's nothing on this report to go for. What does that mean? Does that mean that I'm crazy? Does it mean that this is all in my head, that I'm imagining it, that I'm amplifying my symptoms somehow? Is this my fault?” You know, all this self-doubt comes in, and you have to reassure these patients that, “Yes, your symptoms are real. They are in your head, because your brain is in your head, and your brain is the source of your perception and your experience. So, let's take your symptoms at face value and let's give you treatments that are directed at those symptoms.” Dr Jones: Well said, and that's where we like to keep it, the brain inside the head. I think that was day one of neuroanatomy. I know that the treatment for many of these cranial neuralgias overlaps, right? There's some common approaches to several of these. There are some things that we put in our academic writing, but there are some things that we just kind of learn from experience. Do you have any tips or tricks that you would like to share with our listeners about the management of the cranial neuralgias?  Dr Nahas: First and foremost (and I think this kind of goes for any of the disorders in the spectrum of headache and facial pain) is you need to be patient, and you need to set up appropriate expectations that, by and large, this is a trial-and-error process where we need to introduce a therapeutic intervention gradually and titrate the dose gently to effect while following for clinical response, but also keeping an eye on what our guardrails are. What do I mean by that? Let's say, for example, we're using oxcarbazepine for some sort of neuralgia-form disorder (I mean, take your pick for any of them – it's fair game for most of these as a good initial trial). Dr Jones: Sure. Yeah. Dr Nahas: So, you want to start it at a low dose, start building it up slowly, and in addition to following for their clinical response - which I counsel them it may take a while  (even once we hit a target dose, it may take several more weeks, we've got to give it time) - you can monitor a serum level of oxcarbazepine and certain other antiseizure medicines for that matter. So, that can help guide you to know how high you can go. This is a little bit different from the situation with epilepsy, where you're checking levels to ensure that it's in a therapeutic range to make sure that it's not toxic - maybe to assess for adherence - but here, we're using it as a guide to know how much farther can we push the dose on this drug. And, of course, also, you want to be monitoring for any adverse events that can occur with that drug (such as hyponatremia, or changes in the CBC, et cetera) - so I do monitor these folks a little bit more closely than I otherwise ordinarily would, especially when I have a therapeutic intervention where I can actually monitor the drug level of it and be very, very precise in trying to maximize and optimize their treatment. Dr Jones: Got it. So, patience with each trial, and then patience that there might be (and I mean patience with a ‘c' that there might be) multiple trials – I think that's a good takeaway for all of these cranial neuralgias with pretty much all of the medication treatments, right? Dr Nahas: Yes, and I do find that in some cases, one treatment is not quite enough. Because most of the treatments we draw from our antiseizure medication category, it can get complex trying to balance two, or even three, antiseizure medicines and finding the optimal dose for each. Do we push all of them to the max? Do we say this one is the undercurrent (we just want to keep it at a low level) and these other two are going to be doing the lion's share of the work? It becomes kind of fun if you like uncertainty and if you like to be creative. If you're the type of person who likes checkboxes and checklists and cut and dried results, you know this is not the game that you want to play - but that's one of the reasons that I enjoy doing this, because I have so much freedom to be creative and really finely tailor and tune the treatment specifically to the individual patient's needs. Dr Jones: That's fantastic, and in a minute, I think we can come back to maybe what drew you to this - I'm curious to hear that. But before we get to that, you know, when we think about the medications that are available (and again, your article does a phenomenal job summarizing the therapeutic approaches to the cranial neuralgias) - what do you see on the horizon, Dr. Nahas, for the care of these patients?  Dr Nahas: I want to see a lot more research being done in this population of patients and across this spectrum of disorders. What makes it so hard is because they are somewhat rare, and because they very often co-occur with another primary headache disorder - so that makes it extraordinarily difficult to create a research study on a population that's so heterogeneous, right? That's, I think, the biggest challenge - is that we have so little to guide us other than our own clinical experience. There are not a ton of clinical trials for any of these disorders. I think one in particular that can be both underdiagnosed and overdiagnosed is occipital neuralgia - and I mentioned before that I, myself, have found myself falling into this trap of once I see a signal for migraine, I just call everything migraine, right? And, sure, with migraine, there can be allodynia in the scalp, and oh, sure, we all hear that if you push on something sore, you can have some lancinating pain. Oh, that occipital neuralgia that somebody told you about? No, no, that's just part of your migraine. You don't actually have occipital neuralgia. Well, you know, if you look at clinic-based studies (there's one in particular that I cited), most of the presentations of occipital neuralgia actually co-occurred with another headache diagnosis (either primary or secondary), and very commonly, it was migraine or probable migraine or chronic migraine. And why this is important is because you need to validate for these patients that they do have more than just migraine. They have a separate problem that, yes, it's interrelated, it's interconnected, they can influence each other - but we might have to treat them both differently. So, you have your suite of migraine treatments which might not include an antiseizure medication. Then, for the occipital neuralgia, maybe you are pulling in an antiseizure medication, or maybe you're focusing more on peripheral nerve blockade or physical therapy - or even considering a surgical referral, because as surgical treatments for nerve decompression or ablation or other interventional procedures also continue to evolve, that helps to give us some more hope in giving  these patients more relief with fewer complications. I'd also like to see some more creative solutions, not just more antiseizure medicines, not just more targeted anatomic interventions. But, hey, is there a role for some other peptides or neurotransmitters that we just haven't identified yet? Might some novel treatment approaches actually be useful for some of these patients? And, you know, again, how do we get at those answers? It's going to be challenging, because the patients - while they're out there, they're not really a homogeneous group, and the results from a particular study might not be so generalizable. Dr Jones: And we've seen such great success in the world of migraine, right (looking for novel targets) And so it would be nice to transport that over to the cranial neuralgias, right? Dr Nahas: Yes, absolutely. Dr Jones: Yeah. We should always be mindful of disparities in care of patients who have neurological problems. Are you aware of any literature around the care of these patients related to health care disparities that our listeners should be aware of? Dr Nahas: Nothing focused specifically on disparities in this population or subpopulations within this population (based, for example, on ethnicity, or race, or socioeconomic status). You're looking for subpopulations within a huge population, almost like a needle in a haystack - not quite that difficult, but again, it takes a lot of effort and diligence to try to find these individuals and then to get them to agree to enroll in some sort of research study, even if it's just a survey study or doing interviews with them trying to understand their symptomatology better. It can be quite challenging. And then again, let alone designing a rigorous clinical trial for these folks - who, again, such a heterogeneous presentation - and the willingness to participate in a placebo-controlled trial for pain that can be so heinous can be very, very challenging. You know, we've seen this as a challenge with cluster headache, too - not just because of the nature of the disease (when the cycles come and go somewhat unpredictably). But these folks aren't necessarily willing to forgo treatment for the purposes of a clinical trial - I mean, many are, and I thank them - this is another one of the reasons that research is really lacking in some of these rarer syndromes. Dr Jones: So, another part of the rationale for more investigation for these uncommon and probably underserved disorders. So, Dr Nahas, I know caring  for patients with craniofacial pain, I imagine it can be challenging. I can imagine it's also pretty rewarding as well. What drew you to this work, and what do you find most exciting about it?  Dr Nahas: Well, what brought me to headache to begin with was kind of random chance, and really, it revolves around mentorship. When I very first started as a neurology resident, Dr. Silberstein took me under his wing and wanted to turn me into a headache specialist (that was one of his goals). And, thankfully, he was successful, although he didn't really have an easy job of it, because back then, I didn't really see or understand how studying headache and facial pain could really satisfy that hunger that I have to understand the brain and the nervous system. I mean, that's why I became a neurologist in the first place, right? (I think that's why most of us did.) You know, not only are we drawn to medicine to help people and be altruistic and to study a fascinating topic, but particularly with the brain and the nervous system - I mean, this is what makes us human. This is what's so fascinating to me. And until I started to learn more about headache, I thought the best way to really learn about brain function is through disease (such as stroke or epilepsy, or movement disorders, cognitive disorders, degenerative disorders). This is how we learn, right? This is what I was taught, at least in college and med school. And then you get to the real world of actually practicing medicine or being in training. You start talking with these folks, and you hear their stories and how distinct they are from the textbooks. And again, when you invite them to really describe their experience, you see the human side of it, and you listen to them describe their symptoms - and you start to imagine yourself, what's really going on in their brain and their nervous system for them to experience that? So you start reading a lot of the literature about cortical spreading depolarization and how that can activate the trigeminal system and sensitize it - how that might be linked to the expression of aura (for example) - then, you can actually really parse out the anatomy and understand why somebody experiences those symptoms when you understand the anatomy. And there are just countless examples of this - about how studying the symptoms and what brings them about, what the pathophysiology is, and then what the treatment is, how that really informs our understanding of how the brain functions - that's really what's kept me excited about this. That, and again, forming relationships with patients and sometimes being the first person who ever just sat down and listened to them and let them talk, and they really feel like they're cared about and like they're important - because they are. I think far too often, patients with headache and facial pain disorders are stigmatized, and they're left feeling like it's not worth it trying to get better, that there is no solution. Society has beat them down, the medical system has let them down, and they just want to give up. Then, when we can finally sit and listen and give them some hope, and they see some improvement - the transformation that occurs right before your eyes is extraordinarily gratifying. Dr Jones: So, it's fascinating, and you can help people - and I can't think of a better advertisement for headache fellowship for all those neurology trainees out there.  Well said, Dr Nahas. So I've got one more question for you before we close. And I know that the headache community, including yourself, are very strong advocates for your patients and for more research (as we've talked about today) into headache disorders, understanding the pathophysiology, developing better treatments. What is it about purple hair? I've seen several headache specialists (and maybe someone on this call) post online some purple hair. What's the story behind that? Dr Nahas: A number of years ago, as part of advocacy efforts, we recognized there's got to be a way to really improve the awareness of such a common condition, of headache in general. It affects so many people, it almost becomes, again, brushed off. We say headache, it's just a nuisance. Well, no it's not. It's actually fascinating as part of the human condition. One of the things we needed was a color - our signature color - and we chose purple. We know that we share this color with other advocacy groups, but it's a great color, it's eye-catching, and you can utilize it in a number of different ways. One of the early ways was people dressing up in all kinds of purple garb - putting purple makeup on, purple sunglasses, purple tutus, purple T-shirts, and even purple wigs. A lot of us have been donning purple wigs for advocacy and for awareness efforts, particularly for events (such as Miles for Migraine, for example) - but some of us have been so bold as to not just put on a purple wig, but to actually go to a salon, bleach the hair, and dye it bright purple. I have at least one male colleague who also did this to his beard. Last year, we did it together at the same salon, took a bunch of pictures to post about. It really created a big splash online and for our social media efforts and outreach, and it caught on. Lots more people now are thinking about dying their hair purple. One of our current fellows actually did it this year. At our center, we have about 30 different purple wigs that we bought with some funds that we procured, and on the Shades for Migraine Day (June 21), we all went out parading around Center City, Philadelphia wearing our purple T-shirts and our purple wigs, and handing out flyers trying to raise awareness. We got a lot of strange looks, but we also got a lot of good feedback. And I think we actually reached some people who didn't realize that there's such a thing as a headache center that they could actually come and see us and get relief for this problem they thought was just a part of everyday life. That was kind of a long-winded answer, but - Dr Jones: No, that's great, and it worked. It got me to ask you about it, right? And I will say I admire your commitment and dedication. The best I could do today, Dr Nahas, was wear a purple tie, but I'm sure your patients appreciate that level of investment, too. It's really, really cool. Really impressive. Dr Nahas: Yeah. A lot of them this past year have asked me, “Where's the purple hair? I thought you were going to do it every year around this time.” And, you know, it is a bit of a commitment. Dr Jones: It's a commitment, yeah. Dr Nahas: And there's some upkeep that is required and you're kind of stuck with it for a while (unless you want to go to the trouble of reversing the process, but that's really just covering it up). I said, "We've moved beyond dying the hair. We're doing wigs, and we're thinking of the next thing.”  Dr Jones: Good for you. Dr Nahas, thank you so much for joining us, and thank you for such a thorough and fascinating discussion on symptomatic management of cranial neuralgias and such a wonderful article in the latest issue of Continuum.  Really appreciate you being here today. Dr Nahas: I can't thank you enough. It's been my pleasure.   Dr Jones: Again, we've been speaking with Dr Stephanie Nahas, author of an article on cranial neuralgias in Continuum's most recent issue on headache. Please check it out, and thank you to our listeners for joining today.  Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal which is full of in-depth and clinically relevant information important for neurology practice - and right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024, or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members, go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

Jones asks the big Q @2:00: How far can the Celtics go without better performances from Jayson Tatum? We are talking about the lack of efficiency. 41% from field and worse from three. The same thing we have talked about in the past. When Derrick White is not knocking down seven threes a game Tatum is going to stand out more. Jones: It is very rare for a team's best player to get carried in the playoffs. I think he is pressing, science bitches will say he is due, but I do not. Everyone agrees in order for the Celtics to win, he has to be the best player on the floor, not a passenger.

Headache is among the most common neurologic disorders worldwide. The differential diagnosis for primary and secondary headache disorders is broad and making an accurate diagnosis is essential for effective management. In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Amy Gelfand, MD, who served as the guest editor of the Continuum® April 2024 Headache issue. They provide a preview of the issue, which publishes on April 3, 2024. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Gelfand is an associate professor at Benioff Children's Hospitals, University of California San Francisco in San Francisco, California. Additional Resources Continuum website: ContinuumJournal.com Subscribe to Continuum and save 15%: continpub.com/Spring2024 More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @aagelfand Full transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by clicking on the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes.   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum Lifelong Learning in Neurology. Today, I'm interviewing Dr Amy Gelfand, who recently served as Continuum's guest editor for our latest issue on headache disorders. Dr. Gelfand is a child neurologist at the University of California, San Francisco, where she is an associate professor of neurology, and she also happens to be Editor-in-Chief of the journal Headache. Dr Gelfand, welcome, and thank you for joining us today. Dr Gelfand: Thank you so much for having me. Dr Jones: Dr Gelfand, this issue is full of extremely helpful clinical descriptions and treatment strategies for headache disorders. With your perspective as the editor for this issue - and you've just read all these wonderful articles and edited these articles - what were you most surprised to learn? Dr Gelfand: I would say that the medication overuse headache article I think is where you'll find the most surprising content. This is an area in headache medicine that has been controversial. I think what we've got is new data - relatively new data, published in Neurology (in the Green Journal) in 2022 - the MOTS trial, showing that what we all thought was not necessarily true. In headache medicine, there was this mantra that, if somebody is overusing (too frequently using) a certain kind of headache acute medication, you've got to stop them; you've got to have them stop it completely before you can get them on a preventive treatment if you expect it to work. Turns out, in this trial, that's not the case. People were randomized to either stopping the overused acute medicine and starting a preventive versus continuing it and starting a new preventive, and they did equally well. I think that's really taught us that that dogma was not based in evidence (was not true), and what really matters is getting a patient started on an effective migraine preventive treatment. Dr Jones: Wow, that is really – that is kind of ground shaking, isn't it? That's going to change a lot of practices for a lot of neurologists out there. Do you think that's going to be well received, or has it been well received so far? Dr Gelfand: I think it has. I want it to get out there further, so I hope everybody will read in that chapter and really pick up on that piece. I think it's helpful for patients, too - that we don't necessarily need to disrupt what makes them feel like they're getting some acute, in-the-moment relief. We just need to make sure we're getting a good-quality migraine preventive therapy started. That's the most important thing. We don't necessarily need to ask them to change something about their acute treatment. Dr Jones: That's fantastic, and it certainly could make things a little more straightforward, I think for people who are helping patients manage this. To be honest with you, the term, “medication overuse” almost sounds like it's putting the onus on the patient a little bit. Dr Gelfand: It very much does sound that way. It is a very challenging term for a lot of reasons. And I agree with you that that's a problematic part of this whole terminology. Dr Jones: Well, just three minutes into the interview here and, Dr Gelfand, you've already changed people's practice. I think that's wonderful, and we'll look forward to reading that specific article in the issue. Again, from your view as a headache specialist and a leader in the field, what do you think the biggest debate or controversy is in headache medicine right now? Dr Gelfand: I think where we're really a little bit stuck in trying to figure out how to move forward is how to take care of patients who have continuous headache. It's not even really a fully defined term, but if you imagine a person who - they wake up, headache is present; it continues to be present throughout the entire day; they go to bed- it's still present; if they happen to wake up in the middle of the night to go to the bathroom, it's there then - it's just there all the time. It can be hard to imagine that situation is real - that somebody could have a headache that is continuously present for weeks, months - but this is true of some of our patients who have chronic migraine, our patients who have new, daily, persistent headache, certain other headache disorders. This entire group of patients who have continuous headache have historically been excluded from treatment trials, so our existing data don't necessarily generalize to how to treat their condition. And we need to change that, because this is a group that is arguably most in need of research, most in need of effective therapies. The question is how? Who exactly should be included in the inclusion criteria? And then, what are your outcome measures? Historically, in migraine treatment trials, we use headache days per month or migraine days per month. Days of headache per month may or may not be the right primary outcome measure for somebody who's starting from a point of continuous headache. Maybe more appropriate is, how many severe headache days you're having in a month, or how much disability you have from your headache disease. It's an area that's evolving and really does need to evolve, because this is a patient population that has been underserved in research thus far. Dr Jones: I learned that, I think, in reading one of the articles talking about continuous headache at onset – so, the headaches that are continuous from day one, which is, as I understand it, pretty uncommon. But really very little of the clinical trial data speak to how to care for those patients - is that right? Dr Gelfand: That is exactly right. And, epidemiologically, maybe not as common. But in a headache clinic, we certainly see patients who have had these headache disorders where it starts on one particular day, it becomes continuous within twenty-four hours of onset and has now been going for at least three months, and we would call that new, daily, persistent headache. Or equally commonly, people with chronic migraine where it ramped up over maybe a short to medium-long period to daily and continuous. And now they have been experiencing continuous headache for some number of months, if not longer. Dr Jones: This question may be a little bit of an unfair question. One of the challenges with headache is that, unlike some other areas of a diverse specialty of neurology, there aren't as many biomarkers as you might have for dealing with patients who have cerebral ischemia or neuromuscular disease. Do you find that that leads to more differences of opinion or more variability in diagnosis and management than you might see in other areas? Dr Gelfand: I'm so glad you asked that question. What I find that leads to is more stigma. Many of our patients are not believed, including by medical professionals who they've met before. People might think they are faking their symptoms, or that there's some sort of secondary gain, or this is something related to - they just don't know how to manage stress. This is a real problem for patients with migraine to be encountering so much stigma. As a headache medicine clinician, when I'm meeting a patient, oftentimes I need to make sure to acknowledge that, almost certainly, they've encountered that before. I need to reassure them that they're not going to be experiencing that in our headache clinic, and really try to undo some of that harm to be able to build trust that we're going to have a collaborative relationship moving forward - we're going to be a team; we're going to be determining the next steps in treatment together - and that I 100% believe them that the symptoms they are experiencing are real, are very challenging. Because migraine and other primary headache disorders are real neurologic diseases that can be quite severe. But because we have a paucity of biomarkers, it's hard for some people outside the field to recognize that. And that, I think, has been really difficult for patients historically. Dr Jones: So, a challenge for clinicians has become really more of a burden for patients. Dr Gelfand: Yes - well said. Dr Jones: Yeah. That's too bad, and maybe someday that will change, and probably can be approached from a couple of different directions, right? - from educating clinicians' perspective and also pursuing the science. This might be a related question, Dr Gelfand - what do you think the biggest misconception you've encountered in - I'm thinking mostly from the provider of the clinician community - what do you think the biggest misperception or misconception there is about patients who have headache and the management of those patients? Dr Gelfand: Well, I think it is tied in, in some way, to this notion that the patients are somehow causing their problem; that it's something about - well, I'm a child neurologist; I see adolescents and children – so, their parent is causing their problem because they're a helicopter mom or whatever it is, or they're just not managing stress in an appropriate way. I think that that is really an issue that patients are sort of handed from the medical community. Whereas if I step back and think about it, before 2018, no migraine-specific preventive therapies existed. We were borrowing from all other corners of medicine. We were borrowing from antihypertensives, antiseizure medicines, antidepressant medicines, but there was no actual migraine-specific therapy. Then came the monoclonal antibodies targeting CGRP (calcitonin gene-related peptide) - they're targeting either the ligand or the receptor. We now also have the oral forms that target the receptor, the gepants. So, we do have this one or two classes, depending on how you break that out, that are migraine-specific preventive therapies. But that's not enough for a complex disease like migraine - we need twenty of them. Look at epilepsy; there are probably twenty-plus antiseizure medicines, and yet, some patients still seize. Is that because they're anxious or stressed, or their mothers are too stressed? No - it's because some people have terrible epilepsy. And yet that same explanation has not been afforded to people with difficult migraine disease, that with just one class of migraine-specific preventive (or two, if you break out the monoclonals and the gepants) - that, somehow, they're supposed to have magically stopped with this treatment. That really doesn't make any sense. It's because we don't have enough effective therapies that they're still having difficult migraine - it's not because they're causing their disease. Dr Jones: Thank you - that's a great example. That is important to understand - that misconception about causation. And we may come back to causation here in a moment. It really doesn't make any sense that there are few specific, disease-modifying therapies for migraine, which affects tens of millions of people in the United States alone, right? Why is that? Why are there so few? Dr Gelfand: First of all, Dr Jones, I love it that you called it disease-modifying therapy, because that's how I think about it, too. The term, “preventive migraine therapy,” which is the more commonly used therapy, is not always really useful because - some people who have continuous headache will say, “Well, what are you trying to prevent? I've got headache all the time.” But this is really just treatments that are designed to dampen down disease activity in any form - how frequent, how long of duration, how intense - and I think it is really better conceptualized as disease-modifying therapy, so I love that you use that term. Why have there been so few? I think that it comes down to a paucity of research. Historically, NIH has underfunded migraine and other primary headache disorder research quite a bit, compared to how much disability those diseases cause in Americans each year. Hopefully, that will be getting better soon; I think there are some positive signs that that could be moving in a more positive direction. But I think, because migraine and other primary headache disorders are “invisible” illnesses - can't show you an x-ray with a broken bone; can't show you a lab readout with what your disease activity is; like you said, there's not a lot of biomarkers. Because of that, it's been hard for funders to really get behind it, and I think that's put us a little bit behind where we need to be. More research will lead to more therapies. Dr Jones: Let's hope so. It certainly is very common and affects, again, millions upon millions of people and leads to impaired quality of life and disability, as you point out. You are also the editor-in-chief of a leading journal in your field, Headache. I know many of our listeners who are neurologists and perhaps interested in editorial work as a career path might be curious - what led you to that, and how has it helped you as a clinician (being in that role)? Dr Gelfand: Yeah - I love being the editor of Headache. It's the journal of the American Headache Society. I think it's where the most interesting new science and work in headache medicine is coming out of. I have always found that reading helps me learn. If I want to learn about a topic, I need to read about it and I need to synthesize everything I read about. Being an editor makes that so accessible and fun. I really enjoy reading all of the articles that are coming in. It really helps me to think about everything I know, and thought I knew, in the field. And keeps my mind really questioning – do I really know that that's true or did I just think that's true? - and now this new data shows me that, actually, it's something else. And I really enjoy being challenged that way, on a daily basis, by new science that's coming in. So for anybody out there who has an interest in editing and playing an editorial role, I definitely encourage you to pursue that. There are programs - I know that the Green Journal has a resident and fellow section; that's where I started out, and I really had a wonderful experience in that. And then in our journal, in Headache, we have an assistant editor program for junior people - residents, fellows, postdocs - people who want to learn more about how to be an editor. I think that you learn so much about how to be a better writer, how to be a better scientist, how to communicate your findings in the most effective way. It's just invaluable and it's very fun. Dr Jones: It is kind of selfishly fun, isn't it? Dr Gelfand: Right, right. Dr Jones: Yeah, and it's important work, obviously - to put good information out into the world. At Continuum, we also have - on our editorial board, we have two residents and fellow positions, again, for that career development. I have to ask you a really hard question here, Dr Gelfand. You mentioned you read to learn; if you had to make a choice - electronic or print - what would it be? Dr Gelfand: Electronic. I know that many journals, including ours, are having to make some of these decisions right now. But I read my PDFs and I store them so that I can come back to them and search for them, and make sure, when I'm citing them, that they actually say what I thought they said because sometimes I need to look back at that. So, I am an electronic person. How about you? Dr Jones: I think I'm print. Dr Gelfand: Uh huh. Dr Jones: And I'm just sitting here thinking, there are so many people listening to this interview, and they're screaming at their device, saying, “Electronic is the answer,” or “Print is the answer.” Like you, we want to meet our subscribers where they are, and I think neurologists are very clear in their preferences. Let's just say we'll agree to disagree, and no one is right and no one is wrong – how about that? Dr Gelfand: Fair enough - I can respect that. Dr Jones: All right. I have one more question for you. This might sound like a strange question in an interview between two neurologists talking about headache - what can you tell us about chicken farming? Dr Gelfand: Well, I'd be delighted to tell you about chicken farming. As you know, because they were squawking earlier in our chat, I've got a little flock of chickens in our backyard and they are an absolute joy in my life. One thing I can tell you is that chickens respond to the photo period (how long the daylight is in a year). Now that it's November, it's the time of year when they don't get a lot of light, so they stop laying very much. I find that between Thanksgiving and about Valentine's Day, we actually start to need to buy eggs, which makes me very sad because I love having our egg supply come completely from our chickens. But we want them to rest and so that's what they're doing. Chickens will not lay very much at this time of year. During the summer and the spring and the fall (in the earlier part of the fall), they will lay almost daily, depending on which breed and how old they are. But at this time of year, it's really quiet - really, just one or two a week, I would say, right now. Dr Jones: It sounds like a fun hobby. Hopefully the chickens don't mind that you're buying chickens in the winter, and they don't feel offended by that or jealous. Dr. Gelfand: I worry that they do. I try not to show them the grocery bags. Dr Jones: Well, Dr Gelfand, thank you so much for joining us today, and thank you for such a thorough and fascinating discussion on headache disorders from your unique position as a guest editor for Continuum, I do encourage all of our listeners to check out that issue. It's really full of phenomenal pointers on practice-changing tips and tricks for managing patients who have headache disorders. I'm really grateful for your time today. And thank you for telling me a little bit about chicken farming. Dr Gelfand: Thank you so much for having me. It was really fun. And thank you for your interest. Dr Jones: Again, we've been speaking with Dr Amy Gelfand, guest editor for Continuum's most recent issue, on headache. Please check it out and thank you to our listeners for joining today. Dr. Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. Right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024, or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024.

Regardless of the underlying cause of spinal cord disease, we have many tools at our disposal to improve symptoms and function in these patients. Even better, technology in this area is advancing rapidly. In this episode, Lyell Jones, MD, FAAN, speaks with Kathy Chuang, MD, author of the article “Symptomatic Treatment of Myelopathy,” in the Continuum February 2024 Spinal Cord Disorders issue. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Chuang is an instructor in neurology at Harvard Medical School and assistant in neurology co-director at Paralysis Center, Massachusetts General Hospital and Spaulding Rehabilitation Hospital in Boston, Massachusetts. Additional Resources Read the article: Symptomatic Treatment of Myelopathy Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Transcript  Full transcript available on Libsyn   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members, stay tuned after the episode to hear how you can get CME for listening. Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum Lifelong Learning in Neurology. Today, I'm interviewing Dr Kathy Chuang, who has recently authored an article on symptomatic management of myelopathy in the latest issue of Continuum, on spinal cord disorders. Dr. Chuang is a neurologist and physical medicine and rehabilitation specialist at Mass General, where she serves as Co-Director of the MGH Paralysis Program and Chief of the Neuromuscular Rehabilitation Program. Dr Chuang, welcome, and thank you for joining us today. Would you introduce yourself to our listeners? Dr Chuang: Hi, my name is Kathy Chuang. As you said, I'm a neurologist at Mass General Hospital specializing in neuromuscular medicine, also physiatry, physical medicine, and rehab. And I'm glad to be here. Dr Jones: Thank you for joining us. Basically, if we want to know more about managing spinal cord disorders, we have come to the right person, right? Dr Chuang: I try to do my best with all patients - yep. Dr Jones: For our listeners who are new to Continuum, Continuum is a journal dedicated to helping clinicians deliver the highest quality neurologic care to their patients, and we do this with high-quality and current clinical reviews. For our long-time Continuum Audio listeners, you'll notice a few different things with our latest issue and series of author interviews. For many years, Continuum Audio has been a great way to learn about our Continuum articles. Starting with our issue on spinal cord disorders (this issue), I'm happy to announce that our Continuum Audio interviews will now be available to all on your favorite open podcast platform, with some exciting new content in our interviews. Dr. Chuang, your article is absolutely full of extremely helpful and clinically relevant recommendations for the treatment of myelopathy, regardless of the cause. If there were one single most important practice-changing recommendation that you'd like our listeners to take away, what would that be? Dr Chuang: I think the most important thing to take away is that spinal cord injury of any type spans so many organ systems, it is good to get people - or multidisciplinary care - involved early on. There's eighteen model systems for spinal cord injuries scattered across the US. Those can be great avenues of resources for patients and for practitioners, for people around. Physical medicine and rehab specialists (our physiatrists or spinal cord injury specialists) can be very useful. And then, also for each individual organ system, there are specialists involved. And so, having that multidisciplinary care is probably the most important thing for a patient that's suffering from myelopathy because every patient is different and coordinating that care is so important to them. Dr Jones: So, teamwork is probably the most important thing, and I think most of our listeners who have taken care of patients with spinal cord disorders realize that that's really key. Your article - it leads off with such a great review of one of the big problems with myelopathy, which is spasticity management. From a medication perspective, I think many of us struggle with the balance between controlling the spasticity and some of the side effects of those medications, like sedation. How do you walk that fine line, Dr. Chuang? Dr Chuang: Spasticity management, like everything else, is patient directed. It depends on what the patient is most complaining of. If a patient has spasticity but they're not actually having any complaints from it, we don't need to treat, because of fear of side effects. I tend to try to use focal procedures (like botulinum toxin injections) earlier on, in order to try and spare side effects of antispasticity medications. Use of other conservative therapies, like bracing, stretching, is very essential. Another thing to consider is that dantrolene doesn't usually have side effects - cognitive side effects, at least - and actually can be monitored pretty closely for hepatotoxicity, which is its major side effect. Other possibilities are the baclofen pumps, which can be very useful in patients with spinal cord injury because their spasticity is often more in their lower limbs than in their upper limbs. By using multimodality approaches, we can definitely limit the amount of cognitive side effects of medications. Dr Jones: That's fantastic. Do you start with that multimodal at the beginning, or do you step into it with one, then the other, then the other? Dr Chuang: I usually start off with a low-dose baclofen because they usually have generalized tone - first, in order to see if they have cognitive side effects with it and if so, at what dose. Also, so that insurers have a trial of some medication before we proceed to something as expensive as botulinum toxin injection. But yes, if there's significant focal spasticity, especially, I try to bring in botulinum toxin injections as early as possible, just because of the possibility of minimizing the effect. Dr Jones: That's a great point - that you can start these from multiple angles and start them early. And great point about dantrolene - I think the hepatotoxicity makes many of us nervous. But it's a key point there - that it can spare some of the cognitive side effects. Dr Chuang: Yes, and actually, it can be monitored pretty closely. As long as a patient has access to labs, we can check liver function tests weekly or every two weeks until you're on a stable dose, and after that, only at intervals. And it can be weaned off just as quickly. Dr Jones: Fantastic. Another issue that you cover really nicely in the article, that I think is an underrecognized complication of spinal cord diseases - neuropathic pain. What's your approach to that problem, Dr. Chuang? Dr Chuang: Neuropathic pain is very, very tough to treat a lot of times. I usually give the chance of gabapentin, pregabalin, and duloxetine early, just to see if we can start managing their pain early and to try to prevent potentiation of pain. But I also tend to try to get pain management specialists on early, and also keep in mind that there can be other causes of pain other than just the actual spinal cord injury itself. Because of deafferentation and reafferentation, patients may think of neuropathic pain, and it could be something as simple as appendicitis. If there's a change in pain, there always needs to be a workup for acute causes. Again, multidisciplinary treatment, especially with pain specialists, can be really helpful. Dr Jones: Great point about thinking of other causes, including appendicitis or the musculoskeletal things that I'm sure can be pain generators in this pain population, right? Dr Chuang: Yeah, it's very common. Patients can often fracture themselves just with a simple transfer and that can cause a huge flare-up of pain. So, not all pain should be just dismissed as being neuropathic or just from the spinal cord injury itself. Dr Jones: Great point - thank you. Another topic that you cover - that I think is mystifying to many of us - is the neurogenic bladder problems that occur in patients with myelopathy. You talk about the different types - how do you tell them apart? Dr Chuang: It's hard to tell them apart from a patient perspective because a patient will just say that they have difficulty with urination. With a spastic bladder or detrusor sphincter dyssynergia, oftentimes, patients will complain of a short stream and having to force things out. And with an atonic bladder or flaccid bladder, they have difficulty initiating a stream. What can be useful are postvoid residuals - where, if a patient is in the hospital, or if you have access to an ultrasound, or if they see a urologist - after they void, you measure the amount of urine left in their bladder. You can see whether it's a smaller amount, which is suggestive of a spastic bladder, versus a large amount, or an atonic or flaccid bladder. The standard procedure that's done to measure these are also urodynamic studies that are done, oftentimes, by urologists, where they can actually measure pressure volumes and oftentimes get EMG recordings of the actual bladder - the sphincters. Dr Jones: Perfect. When you do those postvoid residuals (easiest done with ultrasound), what's the general cutoff you use to say - that's a small amount that might be suggestive of a spastic bladder? Dr Chuang: I would say, probably less than a hundred. And then, if it was flaccid, more than five hundred. If there's in between, it may fall into either category. Dr Jones: Got it. When you think about neurogenic bladder, what are the treatment options? How do they vary between the different types that patients may have? Dr Chuang: If you have an atonic or flaccid bladder, the main possibilities for patients just are, oftentimes, Credé maneuvers (or pressure on the bladder) in order to try and help with the bladder to squeeze urine out. But a lot of times they need clean intermittent catheterization or maybe placement of a suprapubic catheter long term. For patients who have a spastic bladder or detrusor sphincter dyssynergia, we can use anticholinergic medications, like bethanechol, tolterodine - those medications - in order to try to relax the sphincter a little bit and then allow the urine to pass through. You can also have BOTOX injections to these sphincters of the bladder as well, which can be useful to relax them so that they can allow the urine to pass through. But a lot of times, a mainstay of treatment is intermittent catheterization, also for patients with severe detrusor sphincter dyssynergia, so that we can maintain small bladder volumes and not develop hydronephrosis, urinary tract infections, and complications of holding urine in the bladder. Dr Jones: Thanks for that, Dr. Chuang. Another part of your article that I thought was really fascinating, and probably will cover some new ground for our readers and listeners, is the use of nerve transfers or surgical treatment of weakness, basically. Tell us about that and how it's used in patients with myelopathy. Dr Chuang: For patients with myelopathy, it's used often in the upper extremities. If a patient has voluntary control of either elbow flexion or elbow extension (usually, elbow flexion), you can oftentimes have the ability to transfer nerves into the finger flexors and allow voluntary hand closure. If there's supination or wrist extension, you can oftentimes allow transfers of branches of the nerve - for example, from the supinator, or from the branch to the extensor carpi radialis brevis, into the finger extensor - so that, over a period of nine to twelve months, we'll be able to slowly regrow the nerve back in and allow the denervated muscle to become reinnervated with a voluntary controlled muscle and then restore voluntary finger extension, which can be extremely beneficial - just being able to voluntarily open and close their hands. Dr Jones: Right. And it sounds like the goal is really that functional use of grip and use of the upper limb. Not really so much for transfers, I imagine - is that not so much the goal? Dr Chuang: If there's less than antigravity strength of elbow extension and reasonable external rotation strength, you may be able to get elbow extension strong enough antigravity, and at that point a patient may be able to transfer independently - with a lot of training. Dr Jones: Wow, that's fantastic - thank you. There's lots of therapeutic options, really, for many of these complications, which I think is an important point for our readers and our listeners to take home. When you look into the future, Dr. Chuang, what do you see on the horizon as the next generation of care for patients with spinal cord disorders? Dr Chuang: I see a huge, expanding field, both of therapeutics - there are stem cell trials all over the world; there are neurorestorative hormones that are being tried. I'm very excited about the advent of robotics, with motors being basically shrunk down to the size of millimeters, and exoskeletons becoming lighter and lighter. I suspect that, long term, we'll be able to have robotic exoskeletons to be able to help patients walk and move their limbs normally. I know there are clinical trials right now involving orthoses that are controlled with brain interfaces that will hopefully help restore function in patients who need it. Dr Jones: It sounds like science fiction, but a lot of that technology exists now, right? Dr Chuang: Yes, it does. We definitely have prototypes of multigear hands with multiple directions. Now, the problem is trying to find the way to control these motors and to control these robotic hands and legs. Dr Jones: Caring for patients with myelopathy I imagine can be challenging, but I imagine it can also be quite rewarding. Tell us, Dr. Chuang, what drew you to this work specifically, and what do you find most exciting about it? Dr Chuang: I want to help people move better. I'm a physiatrist by training, and our job as physiatrist is to try to get people back to their activities of daily living as soon as possible; to try to remove any barriers to becoming active, independent people in their society. And so, I think that spinal patients that suffer from myelopathies or other spinal cord injuries have a lot of potential in the amount of activities that they can do and the way that they can contribute. I've seen patients who have been paralyzed and unable to move their hands at all develop tenodesis scripts, initially in order to just pick up things and then later obtain voluntary control of opening and closing their fingers. And it's huge in terms of what they can do in their everyday lives. Just being able to see that is just really rewarding. And even being able to help patients navigate society around them is just a hugely rewarding experience. Dr Jones: I imagine that must be really fantastic to see folks regain those milestones. Dr Chuang: Yes. Dr Jones: It's pretty unusual for someone to have done a neurology and a physiatry residency. So, between me and you and all of our listeners, which residency was better? Dr Chuang: Wouldn't trade one without the other. Probably wouldn't have done the one without the other, either! Dr Jones: What a great, diplomatic answer. Okay, good. Dr Chuang: It's true. Dr Jones: Yeah. You avoided offending all the neurologists and physiatrists out there. And really fascinating discussion, Dr. Chuang. It's an outstanding article. I think it's a must-read for anyone who takes care of patients with spinal cord disorders. I want to thank you Dr. Wang for joining us and for such a thoughtful, fascinating discussion on symptomatic management of spinal cord disorders. Dr Chuang: Thank you, Dr. Jones for having me today. Dr Jones: Again, we've been speaking with Dr. Kathy Chuang, author of an article on symptomatic treatment of myelopathy in Continuum's most recent issue on spinal cord disease - please check it out. And thank you to our listeners for joining today. Dr. Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, please consider subscribing to the journal. There's a link in the episode notes. We'd also appreciate you following the podcast and rating or reviewing it. AAN members, go to the link in the episode notes and complete the evaluation to get CME for this episode. Thank you for listening to Continuum Audio.

Spinal cord disorders are common and frequently disabling. Despite advances in our ability to diagnose and treat patients with spinal cord disease, many are underserved by their health care systems due to gaps in knowledge and care. In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Shamik Bhattacharyya, MD, FAAN, who served as the guest editor of the Continuum® February 2024 Spinal Cord Disorders issue. They provide a preview of the issue, which publishes on February 8, 2024. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Bhattacharyya is the Anne M. Finucane Distinguished Chair in Neurology and chief of the division of spinal cord disorders at Brigham Women's Hospital and an assistant professor of neurology at Harvard Medical School in Boston, Massachusetts. Additional Resources Continuum website: ContinuumJournal.com Subscribe to Continuum: shop.lww.com/Continuum American Academy of Neurology website: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @shamik_b Full transcript available here Transcript  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today I'm interviewing Dr. Shamik Bhattacharyya, who recently served as Continuum's Guest Editor for our latest issue, on spinal cord disorders. Dr. Bhattacharyya is a neurologist at Brigham and Women's Hospital, where he serves as Chief of the Division of Spinal Cord Disorders and as an Assistant Professor of Neurology at Harvard Medical School, in Boston, Massachusetts. Dr.  Bhattacharyya, it's great to see you - welcome. Thank you for joining us today. Dr Bhattacharyya: Good to see you, Dr. Jones. I look forward to speaking. Dr Jones: So, for our listeners who are new to Continuum, Continuum is a journal dedicated to helping clinicians deliver the highest neurologic care to their patients. We do so with high-quality clinical reviews and content in our journal and in our audio format. For our long-time listeners to Continuum Audio, you'll notice a few different things with our latest issue and our latest author interviews. For many years, Continuum Audio has been a great way to learn about Continuum articles. Starting with this issue on spinal cord disorders, I'm happy to announce that our Continuum Audio interviews will now be available to all on your favorite open podcast platforms. We'll hear some exciting new content in our interviews, and we're also going to introduce interviews with our guest editors, like Dr Bhattacharyya, who are really indispensable in putting these issues together. In this issue, specifically, Dr. Bhattacharyya is full of extremely helpful clinical descriptions and treatment strategies for patients with spinal cord disorders. As the editor, you got really a broad view of the whole range of spinal cord disease. What was the most surprising thing when you were reviewing these articles? Dr Bhattacharyya: I think as a field, neurology - the knowledge base in neurology - grows bigger and bigger and bigger each day and in fields hard to keep up and how to integrate all of it together, right? I think all of us deal with it. And that's the hope of Continuum, is that you can provide these periodic refreshers. I got refreshed myself! Even though I see the patients day in and day out, when you actually read about the advances, for example, in hereditary spastic paraplegias, or the nuances of how neoplasms in the spinal cord are now classified- you say “wow”, I didn't actually know that. The knowledge spreads and grows, and I think that's the beauty of being an editor of some of these issues - is that you get to learn yourself and maybe perhaps even apply them in the clinical situation. Dr Jones: You and I are both educators. And that's, I think, one of the secret joys of teaching is that you end up learning a lot, sometimes from the people you're teaching, right? I guess maybe that's not a surprise - that you learn something by reading it. I guess it was probably pretty nice, huh? Dr Bhattacharyya: It was very good. I think the authors all come from different geographic backgrounds, even from different training backgrounds. In spinal cord disorders, there are trials in some aspects, but in other aspects it's really opinion-based practice, right? So, it was good to also see how other institutions do it. And I imagine it's the same for readers when they see how they do it at their institution and also get a viewpoint of how it's done at other places. That's the valuable perspective piece for putting together a different of authors and see how people do it at different places. Dr Jones: Always nice to learn from others. And speaking of learning - for our clinicians who are listening to our interview today, Shamik, tell us a little bit about the basics of how spinal cord disorders present. I know as an educator, sometimes for, especially junior learners, it's a little mysterious and I'm not really sure why that is, but what are some of the basic clinical tenets of how spinal cord disorders present? Dr Bhattacharyya: I'm glad you brought this up, because in some ways, spinal cord is the orphan child of neurology, right? I think for most neurology trainees, the nervous system stops at the brainstem and then progresses again at the nerves. The spinal cord is really just viewed as this conduit of tracts up and down, and that's all it does is a big set of wires, which is not true, right? A lot of primary neurological processing happens at the level of the spinal cord, and it really is a continuation of the central nervous system. And I hope, with this issue, people get a sense of that. For spinal cord disorders (also called myelopathy; the name goes, synonymously, hand in hand), I think one of the principal functions of the spinal cord is balance. A lot of the program - the neural programming of balance on postural reflexes are hard wired into the spinal cord. I think one of the key aspects of spinal cord disorders is imbalance. I think that people should think of this as a core feature of myelopathy. If you take an example for cervical spondylotic disease, people think, is it going to be off your hands? Well, I think most patients with cervical spondylotic myelopathy actually complain of gait imbalance as one of the early features of the disease. So, imbalance, bilateral weakness, and/or bilateral numbness, tingling, paresthesia - those aspects are suggestive of spinal cord disorder. Bowel and bladder dysfunction can be, but it's not universally true. Now, there's some specific symptoms that I think are especially suggestive of spinal cord disorders I think that are kind of fun to ask about, and if true, can help you localize. One is the Lhermitte sign; you ask people to flex their neck and say, like, “Do you feel sharp, shooting thing, like, down your hands or your back?” In your legs? If true, you have something, right? That's a spinal cord disorder. The other sign that I think is clinically helpful is weakness on one leg and numbness on the other, like Brown-Séquard syndrome or hemicord syndrome. If you find that to be true - and you often see that with multiple sclerosis lesions or other traumatic lesions - that is a spinal cord disorder. I think those clues can come out in history and on exam, and can help you localize it better. Dr Jones: It's nice to know those specific features - in other words, those things that, when you do see or hear them, really should make us think about spinal cord disorders, right? Again, they might not be the most common way they present, but it's good to have those in your pocket, right? Dr Bhattacharyya: Right. Dr Jones: You mentioned this - spinal cord pathology occupies kind of an interesting place in the neurological world, right? There really aren't “myelopathists,” but you direct a division on spinal cord disorders, which is - I think is pretty uncommon. Tell us a little about that. How does that work at your institution? Dr Bhattacharyya: Maybe I can start with the history of this, right - of how this actually came about. I was graduating as a fellow and entering as a faculty in our neurology department. Initially, my interest was in autoimmune neurological disorder - it still is in autoimmune neurological disorders. And yet, when they saw patients who came in for myelitis and turned out they didn't have an inflammatory myelopathy, there really was no home for them, right? - it's a strange space. And that includes even for garden-variety, cervical spondylotic disease that's causing myelopathy - there is no good neurology home for those patients. After the first year of seeing patients, I felt that we need to do better for that. That's why we ended up opening the spinal cord disorders clinic, which was actually the only neurology-based one in our system. There are plenty run by physiatry, surgery, pain management, and other services. But the only neurology one in our system focused specifically on neurologic management of patients with any type of spinal cord pathology. Dr Jones: That's a distinctive way that it came about at your institution and in your own career. It sounds like this does need to be a team effort. Who are the other disciplines or specialists who need to be involved in the care of these patients? Dr Bhattacharyya:  Our spinal cord clinic itself is a part of the comprehensive spine center in our hospital. In that center are pain management doctors, physiatry, as well as different spine specialties, including orthopedics and neurosurgeons and interventional radiologists. So, it's kind of a multidisciplinary group effort to take care of these patients. Dr Jones: I know it'll vary according to the problem with the spinal cord, right? There's dozens or hundreds of different diseases that can affect the spinal cord. So, treatments are different for different diseases, right? But what do you see, therapeutically, as being some of the next big things on the horizon for patients with spinal cord disease? Dr Bhattacharyya: I think one of the common, unifying aspects is pain from spinal cord injury. Especially if there's interruption in the spinothalamic tracts, the pain can be a very severe thing that ranges all the way from neuromyelitis optica, the tonic spasms, to spinal cord infarcts, chronic sequelae of pain, to trauma (spinal cord trauma) - pain is such a big aspect. And our both interventional and oral neuropathic pain medicines don't do a good job with it. I think there's a wave of new medications that are in trials for neuropathic pain and I'm hopeful that they will be helpful and that they will improve pain control and quality of life for our patients. The medication approaches to pain also come with side effects that all of the medicines have. Some of our patients are on high doses of multiple medicines and have cognitive impairment, right? I think that was also the motivation behind our getting a specific section in this issue on symptomatic management of spinal cord injury. Because I think no matter where you are in the spectrum of spinal cord disorders, whether you're a vascular doctor or a family doctor, you will be prescribing gabapentin and baclofen, right - as for helping the patient, and it's good to know how to do it. The other aspect that I'm really hopeful about are sort of second-generation prosthetic devices. These are some of the electrostimulation devices where there's intelligence built into the device that detects you moving your leg and then artificially stimulates a peroneal nerve. This is much better than foot braces, for example, for foot drops. And there are now multiple companies who make these devices, and for some of our patients who have had spinal cord disorders and had difficulty walking or tripping, these have actually made a big difference. I think prosthetic and electric stimulation also has potential of helping a broad range of patients with spinal cord disorders. Dr Jones: And I'm glad you mentioned that article on the symptomatic management of the problems with spinal cord disease, regardless of the cause. And it's a wonderful article that will encourage our listeners to seek out. To go back to the pain, this is something that - many of us who care for patients with spinal cord problems - we encounter is this. And I think it's underrecognized (the pain complications of spinal cord disease). Medications on the horizon - what about devices and neuromodulation? This is another thing I get asked about a lot. Dr Bhattacharyya: Exactly. I think the - for example, spinal cord stimulators for pain management - I think it's been controversial in the sense of who are the best people for it. The history of neuromodulation in spinal pain in some senses has been unfortunate because it was first approved for so-called “failed back syndrome,” right? And the name is terrible. The patient population is heterogeneous. And it has come to a point where it was unclear who it was helping and what the right indications were. I think for neuropathic pain and, in particular, for spinal cord injury pain, I think there is now a renewed push to study neuromodulation, both implantable devices and external devices, to see if those aspects can help. I think they're part of the new wave of things. I think the question patients often ask me is, “Can you regrow my spinal cord?” - right? “Is there something on the horizon yet?” As far as I know, right at this moment, there is not, that's clinically applicable, but perhaps in the future that might be true. But I think, short of regrowing the spinal cord, we can help function and help pain in meaningful ways. Dr Jones: We'll be hopeful about cell therapies and other regenerative therapies down the road. I don't think it's in our immediate future, but we maintain hope. You know, I know this is an area that, again - spinal cord problems are common, spine disease is common - but it does kind of fall between the cracks clinically. If there were one point, Dr Bhattacharyya, that you would want to make to our listeners about the one thing not to miss, or the thing that you most commonly see being missed in the clinical evaluation and/or care of these patients, what would that one thing be? Dr Bhattacharyya: I think the time to clinical evolution of myelopathy probably has the biggest value in determining the cause of it. I think this was beautifully brought out by the article by Dr. Pardo, where he talks about an integrative approach to myelopathy, and in contrast to prior conceptions of whether it's inflammatory based on your CSF cell count or your MRI features, it's actually based on time - time from onset of symptom to nadir of symptom. Is it a few hours, is it days, is it months, right? And having that diagnostic framework is, I think - I go back to it time and time again - is key in trying to figure out, because none of the measures we use, both on imaging or CSF or laboratories, are very sensitive or specific, and actually do not outperform just categorizing by time alone, right? So, I think the one take-home message is, if you have sudden, rapid-onset myelopathy that evolves over minutes, it's probably a vascular process. Even if you find ten cells in the CSF, it's still vascular, right? If it's something that evolves over days, maybe 7, 8, 9 days, and then you find diffusion restriction in the spinal cord on imaging, it's probably still an inflammatory process rather than a sudden spinal cord infarct, right? So, I think that the time aspect cannot be ignored and should play a central role in decision making. Dr Jones: That's very helpful. And I think maybe the corollary to that is - there are chronic spinal cord disorders, right? And I think clinicians, especially if you're not familiar with spinal cord disease, it's terrifying, right? As soon as you start to think, “Wow, this patient's telling me a story and I'm worried this could be a spinal cord problem - should I send them to the emergency department?” - right? They have some bladder dysfunction; they have some gait disorder. But if it has been going on for years, the emergency department is probably not the best place to evaluate that, is it? Dr Bhattacharyya: I'm glad you mentioned it because we see that in the emergency room, right? Someone clearly has a myelopathy; you asked him how long it's going on – it going for months or even years sometimes, right? And it was first noticed and sent out. So, yes - there are multiple causes of chronic myelopathies. They range all the way from structural causes, where you can have things like, for instance, webs, of arachnoid webs, that cause slow progressive myelopathies, to vascular malformations of myelopathies, to nutritional causes (even that can cause a slow, progressive myelopathy), Not to speak of infections; I think we often think of infections as causing fast myelopathies, but especially with HTLV-1-associated myelopathy, the usual clinical progression is slow and progressive. I think across all categories of disease, there are instances of slow, progressive myelopathies that really require thoughtful workup but doesn't require an emergency workup. Dr Jones: Yeah, it's good to know that not every spinal cord problem is an emergency. I think it does terrify clinicians, right? I mean, this is the broadband connection between the brain and the body, and it's fragile, and it's unforgiving, and it's every command sent to the body - every piece of information sent back to the brain, all traveling through a billion neurons with a maximum diameter slightly larger than a dime, right? I think that's why it creates consternation. But I imagine it's also - on the clinical side - it's probably in part challenging and in part rewarding to care for these patients. When you think about what's most rewarding about the care of patients with spinal cord disorders, what comes to mind for you? Dr Bhattacharyya: I think, a couple of aspects. And just thinking back to my last clinic - I put it on Fridays, just because I get the most joy out of this clinic, right? The first is that there's no single piece of test that gives you the answer totally, right? It's usually about putting the history together, the labs, the imaging, and talking about it together, right? And I think it's that integrated piece that, as clinicians, I think that brings us joy; it's that figuring something out, that's more than saying, “Is there diffusion restriction or not on the brain MRI?” – right? The second piece that I think is helpful is that, that patients really want to learn, and for spinal cord disorders in particular, there's easy anatomic things that you can point to patients and say, like, “This is why you are weak in the arm and maybe numb in the leg, and that's causing your problem, and this is what we're going to do about it.” And I think, the ability to communicate that with the patient through images is, I think, unique in the sense that patients understand it - that this is the connection and there's something wrong here and that's why I'm having these symptoms. I think those are aspects of spinal cord disorders that I think are really neat. I will say that I also hope that, for our trainees, right, - I think their comfort with imaging stops at the brainstem, right? The moment it gets below the spine, whether looking at foraminal narrowing or canal stenosis, it's about, “Do they have a T2-hyperintense lesion or not?” And beyond that, people are hesitant. I hope that if this issue can give a different categories of spinal cord disorders, our trainees also become a little bit more facile with different aspects of spinal pathology. Dr Jones: I think a lot of neurologists are drawn to our field because of the problem-solving nature, right? Which is what you have to do before you start helping the patient. And you clearly have a lot of enthusiasm for this - I mean, it's contagious, right? There aren't a lot of myelopathists right now, but maybe after listening to your interview, Dr Bhattacharyya, reading your issue in Continuum, maybe you've created some myelopathists. Dr Bhattacharyya: And just remind, there's an AAN spine section that exists in the American Academy of Neurology, and it's very small and can use more members. Certainly, you're welcome to join. Dr Jones: Well, that's a great plug and, Dr Bhattacharyya, once again, I want to thank you for joining us and thank you for such a thorough, fascinating, engaging discussion on spinal cord disorders. Thank you for guest editing a really phenomenally well-done issue that I think is going to be really informative to our readers and our listeners. Again, we've been speaking with Dr Shamik Bhattacharyya, Guest Editor for Continuum's most recent issue, on spinal cord disease. Please check it out, and thank you to our listeners for joining today. Dr. Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, please consider subscribing to the journal. There's a link in the episode notes. We'd also appreciate you following the podcast and rating or reviewing it. Thank you for listening to Continuum Audio.

  How do you cultivate deeper connection through communication? How can you summon compassion in the heat of conflict? How do you define non-violent communication? What is polyvagal theory?           Sander T. Jones joins Jess and Brandon to explore these questions and share additional concepts from their book, Cultivating Connection: A practical guide for personal and relationship growth in ethical non-monogamy.  Have a listen and follow Sander on socials: Facebook and Instagram. And to learn more check out Sander's website here Save with code PODCAST on the Mindful Sex Course on the Happier Couples website. And if you have podcast questions, please submit them here. You can find the podcast on Apple Podcasts, Spotify, Podbean, Google Podcasts, Amazon Music & Stitcher! Rough Transcript: This is a computer-generated rough transcript, so please excuse any typos. This podcast is an informational conversation and is not a substitute for medical, health, or other professional advice, diagnosis, or treatment. Always seek the services of an appropriate professional should you have individual questions or concerns. A Guide to Compassionate Communication Episode 334 [00:00:00] You're listening to the sex with Dr. Jess podcast, sex and relationship advice. You can use tonight [00:00:15] Jess O'Reilly: here in Atlanta at sex down south. And the reason you know, we're at six down south is that I have no voice left. [00:00:21] Brandon Ware: I was going to say, you got your sexy voice going on. [00:00:23] Jess O'Reilly: Oh my dear God. And it's not from being in the dungeon. [00:00:25] Jess O'Reilly: It's not from doing anything fun. I think it's just from dry air. [00:00:28] Brandon Ware: You should have said it was something fun. [00:00:29] Jess O'Reilly: I know. I know. I wish it was something more fun, but we are having a great time. And if you've ever listened before and heard me talk about Sex Town South, I think it's the most brilliant sex conference. [00:00:39] Jess O'Reilly: It is my absolute favorite. Uh, I'm such a massive fan of Marla and Tia, the founders. Marla, of course, is the coauthor of our latest book. And, uh, among the brilliant minds who are presenting here in Atlanta, we have with us right now, Sander T. Jones, a licensed clinical social worker, certified hypnotherapist. [00:00:55] Jess O'Reilly: Ooh, I want to ask you about that. author. Uh, you're located in Atlanta. You have over a decade of experience and you've recently released Cultivating Connection, a practical guide for personal and relationship growth in ethical non monogamy. Thank you for chatting with us. [00:01:08] Sander T. Jones: Thank you so much for having me. [00:01:10] Sander T. Jones: It's really an honor to be on your show. [00:01:11] Jess O'Reilly: Oh, well, we're, we're so appreciative. I'm excited to learn from you. I've looked over all of the wealth of info. in your latest book, Cultivating Connection. I think it's your first book, right? It is my first book. Yes. Congrats on that. Well, first and foremost, tell us about you. [00:01:24] Jess O'Reilly: Tell us a little bit about your background, professional, personal, anything you feel like sharing. [00:01:27] Sander T. Jones: Okay. Professional background. I specialize in treating people in the ethically non monogamous communities. Also LGBTQ plus communities, kink, BDSM and leather communities and people who do voluntary sex work. [00:01:39] Sander T. Jones: Therapeutically, I specialize in treating trauma and doing relationship therapy. My personal background is one where I come from a background where I went through a lot of abuse as a child and spent a good 25 years working on myself before I became trained to be a therapist. And so a lot of what has motivated me to write a book and the future books I plan on [00:02:00] writing is that when I was young,

https://www.youtube.com/watch?v=ncFy1zRA9HM 28 DAYS LATER Written by Alex Garland CLOSE ON A MONITOR SCREEN: Images of stunning violence. Looped. Soldiers in a foreign war shoot an unarmed civilian at point- blank range; a man is set on by a frenzied crowd wielding clubs and machetes; a woman is necklaced while her killers cheer and howl. Pull back to reveal that we are seeing one of many screens in a bank of monitors, all showing similar images... Then revealing that the monitors are in a... INT. SURGICAL CHAMBER - NIGHT ...surgical chamber. And watching the screens is a... ...chimp, strapped to an operating table, with its skull dissected open, webbed in wires and monitoring devices, muzzled with a transparent guard. Alive. Behind the surgical chamber, through the wide doorframe, we can see a larger laboratory beyond. INT. BRIGHT CORRIDOR - NIGHT A group of black-clad ALF Activists, all wearing balaclavas, move down a corridor. They carry various gear - bag, bolt cutters. As they move, one Activist reaches up to a security camera and sprays it black with an aerosol paint can. INT. LABORATORY - NIGHT The Activists enter the laboratory. CHIEF ACTIVIST Fucking hell... The Chief Activist takes his camera off his shoulder and starts taking photos. The room is huge and long, and darkened except for specific pools of light. Partially illuminated are rows of cages with clear perspex doors. They run down either side of the room. In the cages are chimpanzees. 2. Most are in a state of rabid agitation, banging and clawing against the perspex, baring teeth through foam-flecked mouths. They reach the far end of the lab, where on a huge steel operating table they see the dissected chimp. FEMALE ACTIVIST Oh God... The dissected chimp's eyes flick to the Activists. Blood wells from around the exposed brain tissue. Tears starts to roll down the Female Activist's cheeks. CHIEF ACTIVIST (to Female Activist) Keep your shit together. If we're going to get them out of here... The Finnish Activist is checking the perspex cages. FINNISH ACTIVIST I can pop these, no problem. CHIEF ACTIVIST So get to it. The Finnish Activist raises his crowbar and sticks it around the edge of one of the doors - about to prise it open. At the moment, the doors to the laboratory bang open. The Activists all turn. Standing at the entrance is the Scientist. A pause. The Scientist jumps to a telephone handset on the wall and shouts into the receiver. SCIENTIST Security! We have a break-in! Get to sector... A hand slams down the disconnect button. SCIENTIST ...nine. The Chief Activist plucks the receiver from the Scientist's hands, and then rips the telephone from the wall. A beat. 3. SCIENTIST I know who you are, I know what you think you're doing, but you have to listen to me. You can't release these animals. CHIEF ACTIVIST If you don't want to get hurt, shut your mouth, and don't move a fucking muscle. SCIENTIST (BLURTS) The chimps are infected! The Activists hesitate, exchanging a glance. SCIENTIST (continuing; stumbling, FLUSTERED) These animals are highly contagious. They've been given an inhibitor. CHIEF ACTIVIST Infected with what? SCIENTIST Chemically restricted, locked down to a... a single impulse that... CHIEF ACTIVIST Infected with what? The Scientist hesitates before answering. SCIENTIST Rage. Behind the Activists, the bank of monitors show the faces of the machete-wielding crowd. SCIENTIST (desperately trying to EXPLAIN) In order to cure, you must first understand. Just imagine: to have power over all the things we feel we can't control. Anger, violence... FINNISH ACTIVIST What the fuck is he talking about? 4. CHIEF ACTIVIST We don't have time for this shit! Get the cages open! SCIENTIST No! CHIEF ACTIVIST We're going, you sick bastard, and we're taking your torture victims with us. SCIENTIST NO! You must listen! The animals are contagious! The infection is in their blood and saliva! One bite and... FEMALE ACTIVIST They won't bite me. The Female Activist crouches down to face the wild eyes of the infected chimp behind the perspex. SCIENTIST STOP! You have no idea! The Scientist makes a desperate lunge towards her, but the Chief Activist grabs him. FEMALE ACTIVIST Good boy. You don't want to bite me, do you? The Female Activist gives a final benign smile, then the Finnish Activist pops open the door. SCIENTIST NO! Like a bullet from a gun, the infected chimp leaps out at the Female Activist - and sinks its teeth into her neck. She reels back as the chimp claws and bites with extraordinary viciousness. At the same moment, a deafening alarm begins to sound. FEMALE ACTIVIST (SHRIEKING) Get it off! Get if off! The Finnish Activist rips the ape off and throws it on to the floor. The infected chimp immediately bites into the man's leg. He yells with pain, and tries to kick it off. 5. Behind him, the Female Activist has started to scream. She doubles up, clutching the side of her head. FEMALE ACTIVIST I'm burning! Jesus! Help me! SCIENTIST We have to kill her! FEMALE ACTIVIST I'm burning! I'm burning! CHIEF ACTIVIST What's... SCIENTIST We have to kill her NOW! Meanwhile, the Female Activist's cries have become an unwavering howl of pain - and she is joined by the Finnish Activist, whose hands have also flown to the side of his head, gripping his temples as if trying to keep his skull from exploding. CHIEF ACTIVIST What's wrong with them? The Scientist grabs a desk-lamp base and starts running towards the screaming Female Activist... ...who has ripped off her balaclava - revealing her face - the face of an Infected. She turns to the Scientist. SCIENTIST Oh God. She leaps at him. He screams as they go tumbling to the ground. The Chief Activist watches in immobile horror as she attacks the Scientist with amazing ferocity. INT. CORRIDOR - NIGHT Another ACTIVIST makes his way down the corridor towards the lab. ACTIVIST (HISSES) Terry? Jemma? 6. No answer. ACTIVIST Mika? Where are you? He reaches the door to the lab, which is closed - and... ...as he opens it, we realize the door is also soundproofed. A wall of screaming hits him. He stands in the doorway - stunned by the noise, and then the sight. Blood, death, and his colleagues, all Infected. ACTIVIST Bloody hell. The Infected rush him. FADE TO BLACK. TITLE: 28 DAYS LATER INT. HOSPITAL ROOM - LATE AFTERNOON Close up of Jim, a young man in his twenties, wearing pale green hospital pyjamas. He has a month's beard, is dishevelled, and asleep. We pull back to see that Jim is lying on a hospital bed, in a private room. Connected to his arms are multiple drips, a full row of four or five on each side of his bed. Most of the bags are empty. Jim's eyes open. He looks around with an expression of confusion. Then he sits up. He is weak, but he swings his legs off the bed and stands. The attached drips are pulled with him and clatter to the floor. Jim winces, and pulls the taped needles from his arm. JIM Ow... His voice is hoarse, his mouth dry. Massaging his throat, he walks to the door. 7. INT. COMA WARD - LATE AFTERNOON The door to Jim's hospital room is locked. The key is on the floor. He picks it up and opens the door. Jim exits into a corridor. At the far end, a sign read: COMA WARD. There is no sign of life or movement. Jim walks down the corridor. One of the doors is half-open. From inside, there is the sound of buzzing flies. INT. HOSPITAL WARDS - LATE AFTERNOON Jim moves as quickly as he can through the hospital, still weak, but now driven by adrenaline. All the wards and corridors are deserted. Medical notes and equipment lie strewn over the floors, trolleys are upended, glass partition doors are smashed. In a couple of places, splashes of dried blood arc up the walls. He reaches A&E. On one wall is a row of public pay phones. He lifts a receiver, and the line is dead. He goes down the line, trying them all. In the corner of the A&E reception is a smashed soft-drinks machine, with a few cans collected at the base. Jim grabs one, rips off the ring-pull and downs it in one go. Then he grabs another, and heads for the main doors. EXT. HOSPITAL - LATE AFTERNOON Jim exits and walks out into the bright daylight of the forecourt. The camera begins to pull away from him. JIM Hello? Aside from a quiet rush of wind, there is silence. No traffic, no engines, no movement. Not even birdsong. EXT. LONDON - SUNDOWN Jim walks through the empty city, from St. Thomas's Hospital, over Westminster Bridge, past the Houses of Parliament, down Whitehall, to Trafalgar Square. 8. A bright overhead sun bleaches the streets. A light drifts litter and refuse. Cars lie abandoned, shops looted. Jim is still wearing his hospital pyjamas, and carries a plastic bag full of soft-drink cans. EXT. CENTRAL LONDON ROAD/CHURCH - NIGHT Jim walks. Night has fallen. He needs to find a place to rest... He pauses. Down a narrow side street is a church. He walks towards it. The front doors are open. INT. CHURCH - NIGHT Jim walks inside, moving with the respectful quietness that people adopt when entering a church. The doors ahead to the main chamber are closed. Pushing them, gently trying the handle, it is obvious they are locked. But another open door is to his left. He goes through it. INT. CHURCH - STAIRWELL - NIGHT Jim moves up a stairwell. Written large on the wall is a single line of graffiti: REPENT. THE END IS EXTREMELY FUCKING NIGH INT. CHURCH - GALLERY LEVEL - NIGHT Jim moves into the gallery level, and sees, through the dust and rot, ornate but faded splendor. At the far end, a stained- glass window is illuminated by the moonlight. Jim pads in, stands at the gallery, facing the stained-glass window for a moment before looking down... Beneath are hundreds of dead bodies. Layered over the floor, jammed into the pews, spilling over the altar. The scene of an unimaginable massacre. Jim stands, stunned. Then sees, standing motionless at different positions facing away from him, four people. Their postures and stillness make their status unclear. Jim hesitates before speaking. 9. JIM ...Hello? Immediately, the four heads flick around. Infected. And the next moment, there is the powerful thump of a door at the far end of the gallery. Jim whirls to the source as the Infected below start to move. The door thumps again - another stunningly powerful blow, the noise echoing around the chamber. Confused, fist closing around his bag of soft drinks, Jim steps onto the gallery, facing the door... ...and it smashes open. Revealing an Infected Priest - who locks sight on Jim, and starts to sprint. JIM Father? The Priest is half way across the gallery JIM Father, what are you... And now the moonlight catches the Priest's face. Showing clearly: the eyes. The blood smeared and collected around his nose, ears, and mouth. Darkened and crusted, accumulated over days and weeks. Fresh blood glistening. JIM Jesus! In a movement of pure instinct, Jim swings the bag just as the Priest is about to reach him - and connects squarely with the man's head. JIM Oh, that, was bad, that was bad... I shouldn't have done that... He breaks into a run... INT. CHURCH - STAIRWELL - NIGHT Down the stairwell... 10. INT. CHURCH - NIGHT ...into the front entrance, where the locked door now strains under the blows of the Infected inside. JIM Shit. EXT. CHURCH - NIGHT Jim sprints down the stone steps. As he reaches the bottom the doors are broken open, and the Infected give chase. EXT. CENTRAL LONDON ROAD - NIGHT Jim runs - the Infected have almost reached him. A hand fires up a Zippo lighter, and lights the rag of a Molotov cocktail. As Jim runs, something flies past his head, and the Infected closest to him explodes in a ball of flame. Jim turns, and sees as another Molotov cocktail explodes, engulfing two in the fireball. He whirls, now completely bewildered. WOMAN'S VOICE HERE! Another Molotov cocktail explodes. The Infected stagger from the blaze, on fire. WOMAN'S VOICE OVER HERE! Jim whirls again, and sees, further down the road... ...Selena, a black woman, also in her twenties. She wears a small backpack, a machete is stuck into her belt - and she holds a lit Molotov cocktail in her hand. ...Mark, a tall, good-looking man - throwing another bottle. It smashes on the head of the last Infected, bathing it in flame... The burning Infected bumps blindly into a car. Falls. Gets up again. 11. Blindly, it staggers off the road, into a petrol station - where an abandoned car has run over on the pumps. The ground beneath it suddenly ignites, and the petrol station explodes. EXT. SIDE STREET - NIGHT Selena and Mark lead Jim into a side street. JIM (DAZED) Those people! Who were... who... MARK This way! Move it! Jim allows himself to be hurried along. EXT. SHOP - NIGHT Selena stops outside a newsagent's shop. The shop's door and windows are covered with a metal security grill, but the grill over the door lock has been prised away enough for Selena to slip her hand through to the latch. INT. SHOP - NIGHT Inside, most of the shelves have been emptied of confectionery. Newspapers and magazines litter the floor. The magazine covers of beautiful girls and sports cars have become instant anachronisms. At the back of the shop, a makeshift bed of sheets and sleeping bag is nestled. This has obviously been Selena and Mark's home for the last few days. INT. NEWSAGENT - NIGHT Jim, Mark and Selena enter the newsagent's and pull down the grill. MARK A man walks into a bar with a giraffe. They each get pissed. The giraffe falls over. The man goes to leave and the barman says, you can't leave that lying there. The man says, it's not a lion. It's a giraffe. 12. Silence. Mark pulls off his mask and turns to Selena. MARK He's completely humorless. You two will get along like a house on fire. Selena, who has already taken off her mask, ignores Mark. SELENA Who are you? You've come from a hospital. MARK Are you a doctor? SELENA He's not a doctor. He's a patient. JIM I'm a bicycle courier. I was riding a package from Farringdon to Shaftesbury Avenue. A car cut across me... and then I wake up in hospital, today... I wake up and I'm hallucinating, or... MARK What's your name? JIM Jim. MARK I'm Mark. This is Selena. (BEAT) Okay, Jim. We've got some bad news. Selena starts to tell her story, and as the story unfolds we see the images she describes. SELENA It began as rioting. And right from the beginning, you knew something bad was going on because the rioters were killing people. And then it wasn't on the TV anymore. It was in the street outside. It was coming through your windows. We all guessed it was a virus. An infection. You didn't need a doctor to tell you that. It was the blood. 13. Something in the blood. By the time they tried to evacuate the cities, it was already too late. The infection was everywhere. The army blockades were overrun. And that was when the exodus started. The day before the radio and TV stopped broadcasting there were reports of infection in Paris and New York. We didn't hear anything more after that. JIM Where are your families? MARK They're dead. SELENA Yours will be dead too. JIM No... No! I'm going to find them. They live in Greenwich. I can walk. (heading for the exit) I'm going to... to go and... SELENA You'll go and come back. JIM (pulling at the grill) Yes! I'll go and come back. MARK Rules of survival. Lesson one - you never go anywhere alone, unless you've got no choice. Lesson two - you only move during daylight, unless you've got no choice. We'll take you tomorrow. Then we'll all go and find your dead parents. Okay? EXT. TRAIN TRACKS - DAY Jim, Selena and Mark walk along the Docklands Light Railway in single file. Ahead is a train. Behind the train, as if spilled in its wake, are abandoned bags, suitcases, backpacks. Mark drops pace to let Jim catch up. 14. MARK How's your head? Fucked? No reply. MARK (gesturing at the city) I know where your head is. You're looking at these windows, these millions of windows, and you're thinking - there's no way this many people are dead. It's just too many windows. Mark picks up a handbag from the tracks. MARK The person who owned this bag. Can't be dead. Mark reaches in and starts to pull things out as they walk, discarding the personal possessions. MARK A woman - (car keys) - who drove a Nissan Micra - (teddy) - and had a little teddy bear - (condoms) - and carried protection, just in case. Marks tosses the condoms behind him. MARK (DRY) Believe me, we won't need them anymore than she will. He hands the bag to Jim and walks ahead. Jim pulls out a mobile phone. He switches it on. It reads: SEARCHING FOR NETWORK. The message blinks a couple of times. Then the screen goes blank. Jim looks left. He is now alongside the train. The inside of the windows are smeared with dried blood. Pressed against the glass is the face of a dead man. 15. Jim drops the phone and breaks into a run - running past Mark and Selena. MARK (HISSING) Hey! EXT. GREENWICH COMMON - DAY Jim, Selena and Mark jog across Greenwich Common. Jim gestures towards one of the streets on the far side of the green. JIM (LOW VOICE) Down there. Westlink Street. Second on the left. EXT. WESTLINK STREET - DAY The street is modest red-brick semi-detached houses. They stand outside Number 43. Jim waits while Selena scans the dark facade. SELENA If there's anyone in there who isn't human... JIM I understand. SELENA Anyone. JIM I understand. Selena shoots a glance at Jim. Jim is gazing at the house. MARK Okay. EXT. BACK GARDEN - DAY Jim uses the key under the flowerpot to open the back door. INT. HOUSE - DAY Jim, Selena and Mark move quietly through the kitchen and the downstairs of the house. 16. Surprisingly, everything is neat and tidy. Washed plates are stacked by the sink, newspapers on the table are neatly piled. The headline on the top paper reads simply: CONTAINMENT FAILS. They reach the bottom of the stairs. Selena gestures upwards, and Jim nods. They start to ascend. At the top of the stairs, Selena sniffs the air, and recoils. Jim has noticed it too. His eyes widen in alarm. MARK (WHISPERS) Wait. But Jim pushes past and advances along the top landing, until he reaches a door. By now the smell is so bad that he is having to cover his nose and mouth with the sleeve of one arm. Jim pushes open the door. Inside, two decomposed bodies lie side by side on the bed, intertwined. On the bedside table are an empty bottle of sleeping pills and a bottle of red wine. Mark appears behind him. Jim stares at his parents for a couple of moments, then Mark closes the door. INT. BATHROOM - DAY Jim sits on the toilet, alone. He is crying. In his hand is a piece of paper: "Jim - with endless love, we left you sleeping. Now we're sleeping with you. Don't wake up." The paper crumples in his fist. INT. LIVING ROOM - DAY Jim, Selena and Mark sit in the living room, on the two sofas. Jim looks dazed, uncomprehending. Selena watches Jim, her expression neutral. SELENA They died peacefully. You should be grateful. JIM I'm not grateful. Jim's words hang a moment. Then Mark talks, simply, unemotionally, matter-of-fact throughout. 17. MARK The roads out were all jammed. So we went to Paddington Station. Hoping: maybe we could get to Heathrow, maybe buy our way on a plane. My dad had all this cash, even though cash was already useless, and Mum had her jewellery. But twenty thousand other people had the same idea. (A MOMENT) The crowd was surging, and I lost my grip on my sister's hand. I remember realizing the ground was soft. I looked down, and I was standing on people. Like a carpet, people who had fallen, and... somewhere in the crowd there were infected. It spread fast, no one could run, all you could do was climb. Over more people. So I did that. I got up, somehow, on top of a kiosk. (A MOMENT) Looking down, you couldn't tell which faces were infected and which weren't. With the blood, the screaming, they all looked the same. And I saw my dad. Not my mum or my sister. But I saw my dad. His face. A short silence. MARK Selena's right. You should be grateful. SELENA We don't have time to get back to the shop before dark. We should stay here tonight. Jim nods. He isn't sure what he wants to say. JIM My old room was at the end of the landing. You two take it. I'll sleep down here. SELENA We'll sleep in the same room. It's safer. 18. EXT. LONDON - DAY TO NIGHT The red orb of the sun goes down; the light fades. As night falls, London vanishes into blackness, with no electric light to be seen. Then the moon appears from behind the cloud layer, and the dark city is revealed. INT. HOUSE - NIGHT Jim is on the sofa. In the moonlight, we can see that his eyes are open, wide awake. Selena is curled on the other sofa, and Mark is on the floor - both asleep. The house is silent. Jim watches Selena sleeping for a couple of moments. Then, quietly, he gets off the sofa and pads out of the living room, down the hall to the kitchen. INT. KITCHEN - NIGHT Jim enters, standing just inside the doorway. He looks around the room. On one wall, a faded kid's drawing of a car is framed. Above the counter, on a shelf of cookery books, an album has a handwritten label on the spine: "Mum's Favorite Recipes". Jim walks to the fridge. Stuck to the door is a photo of Jim with his parents, arm in arm, smiling at the camera. Jim is on his mountain bike, wearing his courier bag. FLASH CUT TO: Jim, sitting at the kitchen table as his Mum enters, carrying bags of shopping. Jim walks over to the bags and pulls out a carton of orange juice, which he pulls straight to his mouth and begins to gulp down. His Dad walks in from the garden. JIM'S DAD Give me a glass of that, would you? JIM (draining the carton, and giving it a shake) It's empty. CUT BACK TO: 19. Jim touches the photo, their faces, lightly. Jim is facing away from the back door, which has a large frosted-glass panel. Through the glass panel, unseen by Jim a dark silhouette looms against the diffused glow from the moonlight. Through the kitchen window, a second silhouette appears. Then there is a scratching noise from the back door. Jim freezes. Slowly, he turns his head, and sees the dark shapes behind the door and window. A beat - then the door is abruptly and powerfully smashed in. It flies open, and hangs loosely held by the bottom hinge. Standing in the doorframe is an Infected Man. Jim shouts with alarm as the Man lunges at him - and they both go tumbling to the floor. At the same moment, the figure behind the kitchen window smashes the glass, and an Infected Teenage Girl starts to clamber through the jagged frame. The Man gets on top of Jim, while Jim uses his arms to hold back the ferocious assault. A single strand of saliva flies from the Man's lips, and contacts Jim's cheek. JIM (SCREAMS) Help! Suddenly, Selena is there, holding her machete. The blade flashes down to the back of the Man's neck. Blood gushes. Jim rolls the Infected Man off, just in time to see... ...Mark dispatch the Girl half way through the kitchen window. The Girl is holding Mark, but her legs are caught on the broken glass. Mark jabs upwards into the Girl's torso - she stiffens, then slumps, and as Mark steps back we see he is holding a knife. Jim hyperventilates, staring at the corpse on the kitchen floor. JIM It's Mr. Bridges... Selena turns to Jim. She is hyperventilating too, but there is control and steel in her voice. 20. SELENA Were you bitten? JIM He lives four doors down... Jim turns to the Girl sprawled half way through the window. JIM That's his daughter... SELENA Were you bitten? Jim looks at her. Selena is still holding her machete at the ready. JIM No... No! I wasn't! SELENA Did any of the blood get in your mouth? JIM No! SELENA Mark? Jim turns to Mark. He is standing in the middle of the room. Stepped away from the window. The Girl's blood is on his arm - and he is wiping it away... ...off the skin... where a long scratch cut wells up fresh blood. A moment. Then Mark looks at Selena, as if slightly startled. MARK Wait. But Selena is swiping with her machete. Mark lifts his arm instinctively, defensively, and the blade sinks in. Selena immediately yanks it back. MARK DON'T! Selena swipes again - and the blade catches Mark hard in the side of the head. Mark falls. 21. Jim watches, scrabbling backwards on the floor away from them, as Selena brutally finishes Mark off. Selena looks at Mark's body for a couple of beats, then lowers the blade. She picks up a dishcloth from the sink counter and tosses it to Jim. SELENA Get that cleaned off. Jim picks up the rag and hurriedly starts to wipe the Infected's blood from around his neck. SELENA Do you have any clothes here? JIM (fazed, frightened of her) I... I don't know. I think so. SELENA Then get them. And get dressed. We have to leave, now. With practiced speed, Selena starts to open the kitchen cupboards, selecting packets of biscuits and cans from the shelves, and stuffing them into her backpack. SELENA More infected will be coming. They always do. EXT. HOUSE - NIGHT Jim and Selena exit the front door. Jim has changed out of his hospital gear into jeans and a sweatshirt. He also has a small backpack, and is carrying a baseball bat. EXT. LONDON ROAD - NIGHT Jim and Selena walk: fast, alert. But something is not being said between them... until Jim breaks the silence. JIM (QUIET) How did you know? Selena says nothing. Continues walking. JIM (INSISTENT) How did you know he was infected? 22. SELENA The blood. JIM The blood was everywhere. On me, on you, and... SELENA (CUTTING IN) I didn't know he was infected. Okay? I didn't know. He knew. I could see it in his face. (A MOMENT) You need to understand, if someone gets infected, you've got somewhere between ten and twenty seconds to kill them. They might be your brother or your sister or your oldest friend. It makes no difference Just so as you know, if it happens to you, I'll do it in a heartbeat. A moment. JIM How long had you known him? SELENA Five days. Or six. Does it matter? Jim says nothing. SELENA He was full of plans. Long-distance weapons, so they don't get close. A newsagent's with a metal grill, so you can sleep. Petrol bombs, so the blood doesn't splash. Selena looks at Jim dispassionately. SELENA Got a plan yet, Jim? You want us to find a cure and save the world? Or fall in love and fuck? Selena looks away again. SELENA Plans are pointless. Staying alive is as good as it gets. Silence. 23. They walk. Jim following a few steps behind Selena. A few moments later, Jim lifts a hand, opens his mouth, about to say something - but Selena cuts him off without even looking round. SELENA Shhh. She has seen something... A line of tower blocks some distance away, standing against the night sky. In one of them, hanging in the window of one of the highest stories, colored fairy lights are lit up, blinking gently. INT. TOWER BLOCK - NIGHT Jim and Selena walk through the smashed glass doors of the tower block. It is extremely dark inside. Selena switches on a flashlight and illuminates the entrance hall. It is a mess. The floor is covered in broken glass and dried blood. The lift doors are jammed open, and inside is a dense bundle of rags - perhaps an old corpse, but impossible to tell, because the interior of the lift has been torched. It is black with carbon, and smoke-scarring runs up the outside wall. Selena moves the flashlight to the stairwell. There is a huge tangle of shopping trolleys running up the stairs. Selena gives one of the trolleys an exploratory tug. It shifts, but holds fast, meshed in with its neighbor. Then she puts a foot into one of the grates, and lifts herself up. Shining her light over the top of the tangle, she can see a gap along the top. JIM Let's hope we don't have to get out of here in a hurry. She begins to climb through. INT. TOWER BLOCK - NIGHT Jim and Selena move steadily and quietly up the stairwell, into the building. Reaching a next landing, they check around the corner before proceeding. Through a broken window, we can see that they are already high above most London buildings, and on the wall a sign reads: LEVEL 5. 24. SELENA Need a break? JIM (completely out of breath) No. You? SELENA No. They continue a few steps. JIM I do need a break, by the way. Selena nods. They stop on the stairs. Jim slips off his backpack and sits, pulling a face as he does so... SELENA What's up? JIM Nothing. She gives him a cut-the-crap expression. JIM I've got a headache. SELENA Bad? JIM Pretty bad. SELENA Why didn't you say something before? JIM Because I didn't think you'd give a shit. A moment, where it's unclear how Selena will react to this. Then she slips off her own backpack. SELENA (going through the bag) You've got no fat on you, and all you've had to eat is sugar. So you're crashing. Unfortunately, there isn't a lot we can do about that... 25. Selena starts to produce a wide selection of pills, looted from a chemist. SELENA ...except pump you full painkillers, and give you more sugar to eat. She holds up a bottle of codeine tablets, and passes it to Jim. SELENA As for the sugar: Lilt or Tango? JIM (CHEWING CODEINE) ...Do you have Sprite? SELENA Actually, I did have a can of Sprite, but... Suddenly there is a loud scream, coming from somewhere lower down the building. Jim and Selena both make a grab for their weapons. JIM Jesus! SELENA Quiet. The scream comes again. The noise is chilling, echoing up the empty stairwell. But there is something strange about it. The noise is human, but oddly autistic. It is held for slightly too long, and stops abruptly. SELENA That's an infected. Then, the sound of metal scraping, clattering the blockade. SELENA They're in. INT. SHOPPING TROLLEY BLOCKADE - NIGHT Two Infected, a Young Asian Guy and a Young White Guy, moving with amazing speed over the blockade. 26. INT. STAIRS - NIGHT Jim and Selena sprint up the stairs. Behind them, we can hear the Infected, giving chase, howling. They pass level eight, nine, ten... Jim is exhausted. SELENA Come on! JIM (out of breath, barely able to speak) I can't. Selena continues, and Jim looks over the edge of the stairwell, to the landing below... ...where the two Infected appear, tearing around the corner. INT. STAIRWELL - NIGHT Selena sprints up the stairs... and Jim sprints past her, in an amazing burst of energy and speed. They round another bend in the stairwell... ...then both Jim and Selena scream. Standing directly in front of them is a Man In Riot Cop Gear - helmet with full visor, gloves, a riot shield in one hand, and a length of lead pipe in the other. The Man lunges past both of them, barging past, where the Infected White Man has appeared at the stairwell. The Riot Gear Man swings his lead pipe and connects viciously with the White Man's head. The White Man falls backwards against the Asian Man. Both fall back down the stairs. The Riot Gear Man turns back to Jim and Selena. MAN Down the corridor! Flat 157! Jim and Selena are stunned, but start to run down the corridor. The Asian Man is coming back up the stairs. Jim looks back over his shoulder in time to see the Riot Gear Man deliver a massive blow to the Asian Man's head. 27. INT. CORRIDOR - NIGHT Jim and Selena run towards Flat 157. The door is open, but as they approach, it suddenly slams shut. JIM AND SELENA (hammering on the door) Let us in! GIRL (O.S.) Who is it? SELENA Let us in! The door opens a fraction, on the chain. The face of a girl appears. She is fourteen, pale, solemn-faced. GIRL Where's Dad? Jim looks back down the corridor. At the far end, the Man appears. He is holding the limp body of one of the Infected - and he tips it over the balcony, where it drops down the middle of the stairwell. MAN (CALLS BACK) It's okay, Hannah. Let them inside. The door closes, we hear the chain being slipped off, then it opens again. INT. FLAT - NIGHT Jim and Selena enter past the pale-faced girl. The flat is council, three-bed, sixteenth floor of the block. It has patterned wallpaper, and nice but boring furnishings. It is lit by candles. The entrance hall leads straight to the living room, which has French windows and a small balcony outside. On one wall, a framed photograph hangs, which shows the Man standing beside a black taxi cab. Next to him is a middle aged woman - presumably the Man's wife. Hannah sits at the cab's steering wheel, beaming. Another photo, beside, show Hannah sat in the seat of a go- kart. The Man follows Jim and Selena inside. 28. MAN Come in, come in. They follow the Man through to the living room, and Hannah recloses the front door, which has an impressive arrangement of locks and dead-bolts. INT. FLAT - LIVING ROOM - NIGHT In the living room, the fairy lights hang in the window, powered by a car battery. Lit by their glow, the Man goes through a careful ritual of shedding his gear, helped by Hannah. First, he lays down the riot shield. Then he puts the bloodsmeared lead pipe on a small white towel. Next, he removes his gloves - and places them beside the bar on the towel. Then he folds the towel over the weapon and gloves, and puts it beside the riot shield. Finally he removes the visored helmet. Jim and Selena watch him. They look pretty rattled, not really knowing what to expect. After the Man has finished shedding his gear, he turns. MAN So... I'm Frank, anyway. He extends his hand to Jim and Selena. Jim hesitates very briefly, then shakes it. JIM I'm Jim. SELENA Selena. Frank beams, and suddenly he seems much less frightening and imposing. If anything, he is just as nervous as Jim and Selena. FRANK Jim and Selena. Good to meet you. And this is my daughter, Hannah. (turning to Hannah) ...Come on, sweetheart. Say hello. Hannah takes a step into the room, but says nothing. FRANK So... so this is great. Just great. It calls for a celebration. 29. I'd say. Why don't you all sit down, and... Hannah, what have we got to offer? HANNAH (QUIETLY) We've got Mum's creme de menthe. An awkward beat. FRANK Yes, her creme de menthe. Great. Look, sit, please. Get comfortable. Sit tight while I get it. Frank exits. Selena, Jim and Hannah all stand, until Selena gestures at the sofa. SELENA Shall we? Jim and Selena take the sofa. Hannah stays standing. FRANK (O.S.) Where are the bloody glasses? HANNAH Middle cupboard. FRANK (O.S.) No! The good ones! This is a celebration! HANNAH Top cupboard. Another short, uncomfortable pause. Hannah looks at Jim and Selena from her position near the doorway. Her expression is blank and unreadable. JIM This is your place, then. Hannah nods. JIM It's nice. Hannah nods again. Frank re-enters. Frank is beaming, holding the creme de menthe, and four wine glasses. 30. FRANK There! I know it isn't much but... well, cheers! EXT. TOWER BLOCK - NIGHT The moon shines above the tower block. INT. FLAT - NIGHT Jim, Selena and Hannah all sit in the living room, sipping creme de menthe. Frank is disconnecting the fairy lights as he talks, and pulling the curtains closed, rather systematically checking for cracks along the edges. FRANK Normally we keep the windows covered at night, because the light attracts them. But when we saw your petrol station fire, we knew it had to be survivors... So we hooked up the Christmas tree lights. Like a beacon. Finished with the sofa, he sits on the armchair. SELENA We're grateful. FRANK Well, we're grateful you came. I was starting to really worry. Like I say, we haven't seen any sign of anyone normal for a while now. JIM There aren't any others in the building? Frank shakes his head. SELENA And you haven't seen any people outside? Frank's eyes flick to Hannah. FRANK We haven't left the block for more than two weeks. Stayed right here. Only sensible thing to do. Everyone who went out... 31. SELENA Didn't come back. FRANK And there's two hundred flats here. Most of them have a few cans of food, or cereal, or something. SELENA It's a good set-up. FRANK It isn't bad. He puts a hand on Hannah's shoulder, and gives it a squeeze. FRANK We've got by, haven't we? INT. BATHROOM - NIGHT

Do you ever feel overwhelmed by social media? Have you looked at social media as a way to be more fulfilled in your friends and community domain?  How do you know who and what to pay attention to? In this episode Kathryn speaks with Andréa Jones, the host of the Savvy Social Podcast, creator of […] The post How to Effectively Use Social Media with Andréa Jones | IT 034 appeared first on Imperfect Thriving - Kathryn Ely.

Exactly What To Say - Building Your Public Speaking Business James Taylor interviews Phil M. Jones and they talk about exactly what to say to build your public speaking business. In today's episode Phil M. Jones talks about Building Your Public Speaking Business. What we cover: Building the base of your public speaking business The 6/6/6 rule The one phrase you need to sell yourself as a public speaker Please SUBSCRIBE ►http://bit.ly/JTme-ytsub ♥️ Your Support Appreciated! If you enjoyed the show, please rate it on YouTube, iTunes or Stitcher and write a brief review. That would really help get the word out and raise the visibility of the Creative Life show. SUBSCRIBE TO THE SHOW Apple: http://bit.ly/TSL-apple Libsyn: http://bit.ly/TSL-libsyn Spotify: http://bit.ly/TSL-spotify Android: http://bit.ly/TSL-android Stitcher: http://bit.ly/TSL-stitcher CTA link: https://speakersu.com/the-speakers-life/ FOLLOW ME: Website: https://speakersu.com LinkedIn: http://bit.ly/JTme-linkedin Instagram: http://bit.ly/JTme-ig Twitter: http://bit.ly/JTme-twitter Facebook Group: http://bit.ly/IS-fbgroup Read full transcript at https://speakersu.com/sl067-exactly-what-to-say-building-your-public-speaking-business/ James Taylor Hi, it's James Taylor, founder of SpeakersU. Today's episode was first aired as part of International Speakers Summit the world's largest online event for professional speakers. And if you'd like to access the full video version, as well as in depth sessions with over 150 top speakers, then I've got a very special offer for you. Just go to InternationalSpeakersSummit.com, where you'll be able to register for a free pass for the summit. Yep, that's right 150 of the world's top speakers sharing their insights, strategies and tactics on how to launch grow and build a successful speaking business. So just go to InternationalSpeakersSummit.com but not before you listen to today's episode. Hey, there's James Taylor. I'm delighted today to be joined by Phil M. Jones. Phil Jones has made it his life's work to demystify the sales process reframe what it means to sell, and help his audience to learn new skills and power, confidence, overcome fears, and instantaneously impact bottom line results. Author of six international best selling books and the youngest ever winner of coveted British excellence in sales and marketing award. Phil is currently one of the most in demand speakers and advisors to companies worldwide. It's my great pleasure to have Phil join us today. So welcome Phil. Phil M. Jones Great to be here. James. Thanks for inviting me on. James Taylor So share with everyone what's going on in your world just now. Phil M. Jones Oh, what's going on in my world? Like always, my world is chaotic and busy in an organized mess of travel quandaries and, and client demands and different types of audiences in different ways. So I'm forever putting my hat on saying what group of people is it that I'm serving today? So I've just just come off the run of of six weeks worth of an abundance of different types of events across the world in different ways. So what's happening for me right now, today Here's the first day I get to breathe in a little while. So I'm kind of excited about that. James Taylor Now, I'd love to know your journey into speaking because I was looking very early on in your life. You've also had a very strong, entrepreneurial, bent to what you do as well, I think I saw that you by the age of 15, you're actually earning more than your teachers school, because you hear out some friends now. So tell us that that journey from from budding entrepreneur at school into what you do today is really known as a keynote, keynote speaker and author and trainer. Phil M. Jones Yeah, I mean, I started in business from a very young age. So I wanted to make some extra money to better get some of the things that my parents decided they didn't want to buy for me. So I started a little cleaning business at the age of 14, like we realized there by the age of 15. I was kind of not going to school as often as I should. And I remember getting invited in by my school teachers questioning my attendance. And I responded to those guys with the questions like how much money are you making, and they refused to tell me at the time but I was making more money. than most of my school teachers by my 15th birthday. And I continued like on an entrepreneurial journey through my teens still built studies around my businesses. So I still took school pretty seriously. But I viewed them as quizzes and puzzles that was a was a fun thing for me is that I had to kind of get these these puzzles dealt with in the most efficient period of time. And at the age of 18, I had a dilemma, big university opportunity in front of me to go to one of the best schools back in the UK. I didn't want to go and I became the youngest ever sales manager for business called Debenhams department stores that you'll know from the UK. And I guess even from my early kind of corporate days, I had a speaking inspired background even though I didn't know that's what it was at the time. So I did a lot of store openings, a lot of trainings towards store openings in those retail world. So I guess my first gigs was me at 18 years of age stop stood at the top of escalators in a new department store environment, addressing an audience full of employees, getting them inspired about what we're going to go on and achieve over the next six weeks and then keeping that updated. So that got me very, very comfortable. But also going through that environment of being a very aspirational employee in a leadership role is we'd have a lot of leadership conferences, we'd have a lot of guest speakers coming together to talk to our audiences and I thought one day I'd love to be able to do that. Now I continue through a number of a number of kind of things with my career where I became a store manager sales training consultant for DFS furniture group, went from there to become head of retail at Birmingham City Football Club. And from there to do the same at Leicester City Football Club with Mila Mandarin, then I built a big property business, property business was were quite a lot of our clients through seminars. So again, that always had me stood in front of rooms full of people and in fact, every one of my entrepreneurial career choices or corporate lead career choices always have me speaking to a roomful of people. My property, business and a bump in 2008 I'm sure some people might look to be able to have some memory towards that too. And we had a great business on a Monday. By Friday, we had a product we couldn't give away. So wondering what I was going to do next, I was being invited by business networking groups to say, can you come and help some of these local business owners? through some of these recessionary times by delivering back some sales skills, I was at quite a strong voice in those small business environments, of offering advice and guidance. And I was delivering those education slots for free didn't think about it being a speaking career. And then I thought, well, there were just so many people in this world are good at a thing, but don't know how to acquire customers or grow that business so they can get to really be good at the thing. So I wrote a one day sales training course. And I started to invite people from that small business environment to my one day program. And that was, yeah, back into 2008. So almost 10 years ago, and six people became 12 people became 20 people became 30 people became Can you come deliver this to my team became me then speaking externally to sell places on my workshops. So I'd speak at larger events for without fee to be able to drive people towards my workshop that then became a coaching business, then became a consulting business. Then I wrote my first book in 2012. And then I went on the road internationally delivering more of what we would now call speeches. But my business here today is I deliver somewhere in the region of 100 paid presentations a year takes me all around the world, written six best selling books. And I do anything from a from a 12 minute keynote up to a three day program with audiences and then have somewhere like 30 different revenue streams in my business around that to the that have now become remarkably fun, but it's been a it's been a beautifully organic journey driven by ambition, aspiration, and a simple belief that if somebody else can do it, can somebody else be me? James Taylor Well, I've always looked at what a great journey well, fascinating journey through all those everything. Obviously, sales is Been that has been the kind of golden thread that's kind of gone through a lot of that as well. And I'm wondering, like, as you were kind of going, you mentioned, almost 10 different types of presenting. So there was the more kind of workshop training style, then there was more platform selling style, where you're giving a talk for free in order to get people to come to your workshop or consulting. And then there's more keynote speaking. So which I can know you for for today, who are your mentors, because they're all slightly different flavors. And and they require slightly different skills I would imagine. Phil M. Jones Yeah, it is hard to define specific mentors if I if I'm to look, early days, I was always hugely inspired by Guy new call Peter Lee and Peter Lee was somebody I collaborated with and work with and was taught by when I was part of a management training program back in, in the furniture days, maybe 1520 years ago, and he was the first guy who bought the Dale Carnegie programs to the UK. So I got to study Dale Carnegie's work quite in depth for that and I loved the way that Peter would engage Ah, and would facilitate within an audience and had both the gravitas of a powerful speaker, but also had the charm of, you know, the guy in the pub that would be able to have a conversation. And quite often when you say these audience didn't matter how many people were in it, you felt like he was talking just to you. So I love that. There's also a guy in the UK called Richard Denny. Richard Denny is kind of like the godfather of professional speaking when it comes to UK background. And I remember being in a conference that Richard delivered and I may have been 17 years of age at the time, and I thought that guy's cool. And I got to know Richard quite well through the years and got to learn a little from him. And then on the marketing side of the business, and we might link into this shortly is is a guy called Peter Thompson. So Peter Thompson is somebody who's been around a long, long time. When we then look towards role models outside of of those three, there's two other categories I would consider. One is is the people that have mentored me from a distance, so I might not have had personal conversation with them but I've studied and and and then model their behavior. So that could be as much as as a Jim Rowan. And but it could also be the fact that I'd stick myself in the audience as often as I possibly can about the people performing to say, what would I like about that? What worked well? Where can I get some role modeling from other people's efforts, and then also stand up comedians. So I've got like an abundance of stand up comedians, because I think in the world of professional speaking, stand up comedy is about as tough as it gets. So to look towards that, to to push the envelope was huge. And then the flip side of all of this role model stuff is all the negative role models. James Taylor So you basically look at them and say, This is not why I want to become not the kind of Correct, Phil M. Jones correct and I think this is important to look towards those groups of people as it is towards those that you have aspiration towards. Because there are hundreds of ways you can build a business as a professional speaker hundreds, and it's very easy, particularly in today's marketplace where information is so easily and readily available. That what you do is that you think you have to be all things to all people that you that you think, well, if somebody else is successful, I need to be more like that. And we end up then seeing copycat speakers. And the trouble with that is you can't be what you're not. It's like an impossibility. You can take influence from other people. But if you're trying to be what you're not, then what happens is one that you get found out or you feel bad, because you don't feel like you're being you and what it is you're doing, but you've built a reputation for being something you're not and you can't break out of that shell. So a level of authenticity is important, but you need to discover that through looking at what it is that other people do. I'll take a piece of that. I'll try it on for a while. And I view it like, like, if you went out shopping for a day, you might have an idea of what you would like but until you put something on, and you take it for a walk or you look at yourself back in the mirror with it. You don't decide whether it's something you like or not. So, people early on in their career, I think they should they should just soak themselves up. In the world, and learn it, learn the different business models. And the business models are as important as the as the presentations themselves. Because without a business model that supports your ability to get to speak regularly, then the game gets over real quick. James Taylor What do you use? I mean, on this summit, we've got there was a thing I was a little bit concerned about when I'm interviewing so many different speakers and they have such different role, different business models and what they're doing. Yeah, was that for the for the someone that's watching this, just now they can feel a bit discombobulated, and they can feel that, oh, that's what I want to do. Any advice that you would give in terms of helping the speaker that's watching this, or the aspiring speaker that's watching this, to have some kind of compass to kind of help them guide themselves so they can know? Those things are not, you know, they're interesting, but I don't necessarily want to want to do Phil M. Jones in order to be able to successfully speak you need a number of audiences and then clients that would pay to put you in front of those audiences. What often people don't do is put themselves in one singular box. When it comes to winning business, you can't aim at just one thing any one period of time because what you need is you need some business that will feed your family on Friday. You need some business that can sustain you to be able to live for a year and then you need something to be able to chase. I'm a big believer that the in the world of sales, you cannot manage any more than 18 prospects at any one period of time. And having trained over 2 million people, I've still found that same thing to be true 18 prospects is the most that you could ever have. So if you can get yourself laser focused on 18 prospects, you can become what I call devilishly productive. And the reason I call it devilishly productive is because we split that magic a team into groups of six, six and six. My advice would be at any given period of time when you're looking at what kind of speaking business you want to build is give yourself three different categories of types of events or types of things that you might want to do. So say for example, it might be where the low hanging fruit is at that bottom end. Is this is what I have within arm's reach right now this is where I have some wind at my back. This might be the industry that you've grown out of this might be the geographic location of where you based it might be something you deliver online because you've already built an audience, low hanging fruit, which was when with easy reach that you can get a yes to relatively quickly put some money on the table for Friday. For me at the early stage of my business, that was my one day sales workshop. always working six prospects towards my one day sales workshop. What did I really want to do? Well, when I first started, I wanted corporate training events that could give me 40 5060 people in the room, pay me a handsome fee to be able to deliver a half day or a full day workshop. What that would then be is a slightly longer pipeline but always be working six prospects there. And then my dream gigs at that point in time when I was first starting was i'd love the keynote the main stage, the 45 minute keynote the 60 minute the 90 minute the big fee, everybody like loves you. You love them. You sell a load of books every Things beautiful then you disappear again for the next day. So always be working six prospects in those camps. What then happened though was is as your career progresses, is what was then my low hanging fruit now becomes something we don't do anymore things then start to be able to shift through that moment. So always what you're looking for is to say, what is going to feed my family right now? What is going to give me some sustenance to mean that I can have peace of mind and reassurance and then what am I shooting at big time. So we're playing three different business models that potentially feed each other at the same time. And then try those three on if you then find something that doesn't work, switch one out, play with something else but three target markets, three different types of businesses progressive step two business model, and you'll find what you love. This is the most the best job in the world and the worst job in the world. If you're not with your people, if you're not serving audiences that serve you back, if you are putting yourself into a situation Where your travel schedule is overwhelming your life, then it takes over your ability to better enjoy what you do on the platform. James Taylor So wondering that terms as you as you have been building that, and now where you are in your own career, thinking about the kind of the sustainability. So moving out of the, I just need to get speaking gigs, where it was workshops, public workshops, corporate, you're now at a stage in your career, where you're making different types of decisions. And wondering the weather. Let's think like the recurring type of models start to come into that. So going up and keynotes is amazing. But it's like a little bit like being the kind of rock star going to a gig and you're doing those shows, and that's great, or being that comedian going doing that live tour. But when you're not on the road, there's maybe nothing happening. So how do you start to think about like building in sustainability and things that those revenue streams that could be coming in when you don't necessarily have to be on the road? Phil M. Jones Yeah, and I think that's what you're always looking at in that middle group of six people that you're working with. different things for different people. And if I gave a child a cupcake, what is the only part of the cupcake but they would like to eat James Taylor that nice cherry sitting on the top there. Phil M. Jones They want the cherry on the top of the frosting and sprinkles but they don't want the cake itself. They want all the stuff that's on top of the cake. Now most speakers are the same. What they want is they want the cherry they want the frosting, they want the sprinkles on all the good stuff. Trouble is you can't live on that sweet tooth piece alone, we needed some substitutes. So I encourage anybody looking to build a speaking business to go build the base of the cupcake first. The way I look to do that is firstly understand what your what your livelihood personal expenses are, whether it's 3000 a month, 5000 a month, 10,000 a month, 15,000 a month, whatever it might be, build a sustainable business model in that place that says my bills are covered, I can live my life. from that position. You can have a down sell and upsell from that position. So for me right now my author business sustains my life. I make it recurring revenue based revenue from my books and the work we've done to mean that I can pay for everything we have in our life. And it doesn't leave me a comfy comfy life. But I don't have to worry about paying a single bill based on the author business that we built. Historically, that used to be a coaching business. Historically, that used to be a retained number of training events like a 20 gig contract with one client that the paid me out. And it's also been recurring revenues off online coaching programs too. But I've always had something in that space that says, I've got something working here that pays for everything, and I focus on that but it's not sexy. What that means though, is then when I get a hifi speaking gig come in. It feels like it should feel it feels like Rockstar money because it's on top of what I need if I had to take that Rockstar money and then use it to pay my bills this month. I don't feel like the rock star should feel like it feels a little incongruent with that rock star. So it's worth building the base to give you the feeling of saying that the good stuff is the good stuff. Now the down sell there also could then be the good stuff. So then means you could start to look at it and say well when I do these workshops or these training events, what can I do to get extras? I was at an event yesterday in Rochester, New York, it was a small group full of people it was like 35 people. My down sell for fun was that we did a book for everybody in the room. Like 35 $15 now I don't care and the fact that I get big six figure fees and things on occasions for contracts, I still love walking out with 500 bucks extra on the back of an event. I still love it. It's like a buzz. But we can then look at say how do we commercial be commercial? As we build a business but getting your speaking business right means that you should try on different models but always be working three always work the base of the cupcake then you enjoy the sprinkles love that love James Taylor that analogy. And what's your cause your background, you have such a strong background in the sales piece. I wonder what advice you would give To the speakers out there when it comes to, I mean, actually, I see sales. But one of the things I've noticed about you is actually how brilliant your branding is. And so that's kind of going but I didn't, I class can, like marketing moving into sales in this kind of place in between. But I can look at your book, I can look at your website from standing at a distance. And I know it's you. Right? And because there's a look at some feel it pulled, some people may not appeal to others, but I'm guessing for your target audiences. It's this the thing that connects and it's very it's kind of a classy kind of thing. Does it have a black background with orange writing, it's kind of feels like New York Times there's a there's a substitute like a substantive there. So I'm interested to know a little bit the branding piece of what you do, how much you kind of thinking about that for what you do, but also how the the any advice you would give to speak as in terms of the sales especially as they starting to just be speaking more and they're getting more and more band coming in and how to do those inquiries? Phil M. Jones Well, let's do the two things is is to develop the piece of the brand. It takes forever of trial and error like like you. I mean in this game 10 years right now we are on website iteration number 23. We, you know, I rewrite my copy. I have a recurring piece in my schedule every six weeks or a story look at things seasonal needs to tweak what needs to change and if your career is doing this, your BIOS out a day every three months. Right and so things need to continue to look to change. What you do want to look at though in terms of setting your stall out is the biggest thing that a potential buyer is thinking when they're looking towards booking somebody it's not Will you be brilliant? It's Will you not suck if this risk mitigation, correct is is what they're looking at is to saying you know, if I'm putting my reputation on the line, is my reputation potentially going to be tarnished by this not is my reputation going be amplified by this. So what they want is anything that can give them some confidence that you've done this before and people like them have had a pleasant experience in the past. This means getting real authentic testimonials. This means getting great photography. One of the reasons that my branding materials look so good is that we've been photographing and recording every event since I first started and I've been putting my own people in to be able to do that most of the time. video content is key. So don't think you have to have all of these things in the first instance But no, it's your quest to get them and continually be on the quest of being able to make it better. And model off somebody if you need to write is find somebody that you quite like this stuff and you draw influence from it and say how do I make my stuff at the same but the brand is key and build it out on everything you know, business card, email signature, your thank you cards that then follow up towards other people. If you're running your own events, what do your banners look like in the room? What are the pens look like that your your delegates Using what are the pads look like that they're working on? We see we control that entire process. And I have done since my very first workshop to create an experience that says, This guy looks like he's done this 100 times before even my first workshop, we look like a giant organization. But what did I spend? I spent a few hundred pounds on making you look like we've done that before. That's the goal of most of your branding. James Taylor And then when it goes like when I think about something like Debenhams, for example, they've always been very good at that the aim of a certain type of customer My wife is probably like the type of customer and and everything you go in has a certain kind of feel as a certain quote, you know, certain kind of quality. You can see it trends and it has obviously changed over the years. You can see it being replicated in their print their TV as they're online, you can stand a distance you can go into the store, there's all those little triggers that you get to see that it relates to that brand. Phil M. Jones Now when it comes to the sales piece, there's two things that I want everybody to think about is First things first, there are two questions that you need to know the answers to before you Entering into this world of professional speaking. And I think many people forget this because what they want to do is want to be a speaker, they can speak on anything to anybody about like almost any subject. That's where they think often. Two questions that people should know the answers to ahead of time is number one, who are the people that they serve. And the narrower that position is, the easier is to start going out hunting and looking for opportunities. And the second lowest questions is which problems do you solve for them? I'll share this super quick with an analogy is if you are looking to open a tin of beans, what would you be looking for to better help you on that quest? You know, not a Swiss Army knife. Yeah. I might. I might do a few in a pretty desperate thing. You take a Swiss Army knife. Yeah. But first thought is I want to open a tin of beans. I need a tin opener on open a can of beans. I want to count out right. That's what you're looking for. And the same thing is true when it comes to people looking for a speaker. So if you're a leadership speaker, well, there's 1000 leadership speakers in the world. If you're a leadership speaker that helps independent retailers and you're an independent retailer, it now becomes easy for me to pick you if you are a you know an innovation speaker, but you're an innovation speaker for the accountancy profession they can't see professional looking and so you get me what an audience is looking for to get the show me that you know me type vibe. So the more that you can say these are my people, the easier it becomes to find business and I know that's kind of counterintuitive, but when you're aiming everybody you're not the right fit for them and they're not the right fit for you. When you say I'm aiming here, we can find a perfect match a little bit easier. James Taylor Can you mention those those two the six six and six years so can would you advise the someone who's maybe just getting started to fitting say people that are already up and running with the speaking of those those those three buckets? would you advise that maybe it's the same same kind of problem that they're solving, but maybe do you choose different audiences or should you go that's that's maybe the way to do it. Phil M. Jones Yeah, yeah, the the problem that you solve is is, is really kind of straightforward. And the problem is, for example, the problem that I solve for my audiences, and I help them make more of their conversations count. But that's what I do for people. And I help them understand how the importance of the right words at the right time can drive the right kind of actions. Now, as my reputation is growing, that means that the breadth of audience can start to get wider because I get bookings, because I'm Phil Jones, not because of the problem that I solved. But it's taken 10 years to get to that point in time. I started saying I helped small independent business owners that didn't understand the sales process to understand how they could sell more effectively to try to have a recession. So that was the problem that I helped solve. That was a group of people, small, independent business owners that were looking to trade our recession. Well, I'm a small independent business owner, I'm looking to trade our recession, this guy could probably help but positioned myself as a sales trainer that think they didn't need it. sales training was what I delivered. But the people I helped in the program myself are two completely different things and see I changed the conversation. James Taylor Yeah. As my friend said, recently, you had something you have to hide the broccoli in the cake. So, so that I'm interested as you were kind of going your own journey, because I think this is one that maybe maybe platform speakers can struggle with when they can start to move out into the corporate world. So you were even that small business owner. It's It feels like more of a b2c type of relationship because they don't have the credit card. Phil M. Jones their money. James Taylor Yeah. How do you when you started moving, so you develop that market? And as you started moving into the more the corporate world, which is more of a b2b relationship, so it's in on invoice, let's say, and yeah, how did you did you? What did you have to change to make that make that move? Phil M. Jones The biggest commonality is more apparent than the differences. The commonality is, is you're in the people business. What starts to happen though, is that Firstly, you realize you're spending other people's money so instead of them investing money with you to mean that they might be able to send the kids on vacation this year. You're they're spending money with you to help And get that promotion. So so what happens is the motivation in the individual that's responsible for making the purchase changes, that's the only thing that changes, you're still helping people. The other difference is, you've got to be aware that the procurement process is sometimes different that you're going to wait 90 days on invoice or that you have to then have more rigid procedures in your place when it comes to having things like your insurances, your contracts, your just your procedures in place to say that I'm going to play your game when it comes to getting paid in terms of doing the work, what doesn't change that much, just how you pay gets James. James Taylor So you talking about this moving into the sales piece, as those speakers once they can identify, you know, who do they serve? What problems they're solving for people as well. Where does it need to go? Where does it need to go next on that Phil M. Jones we're going to find yourself in conversations with people and what we must firstly understand is what selling really is and selling is earning the right to make a recommendation. What selling isn't is is isn't embellishing a product or service with features or benefits hoping something's going to stick. The mistake here is what people do is that they were looking for is we're looking to get validation that the problem that we believe that they have is a problem that is true to them, and then find credibility towards the fact that we might be the people to fix it. Take for example, a typical inbound inquiry for speaker, typically inbound inquiry for speaker. Isn't the phone ringing. It's a web contact form or an email coming in. And that email typically asked the same two questions. Number one is are you available number two is what you see. That's the typical kind of doesn't matter how it's flowered out. That's the typical inquiry that comes in. We're going to know the answers to those questions. And Firstly, we don't actually know the need to know the answers to those questions. Because who's the person who's in control of every conversation? James Taylor It should be you as the as the because you don't have almost no have enough information at that point? Phil M. Jones Yeah, the person who's in control of every conversation is the person who's asking the questions. So what happens is when you get questions asked of you, if you want to gain control of that conversation, it isn't an answer that you need. What it is that you need is a question. Yeah. So the answer to the question isn't an answer at all is the question to the question. That's what we should be looking to better think about. Okay. So inquiry comes in and says, Are you available? What's your fee? What the typical response is, is yes, hell yes. I'm definitely available and what's your budget? That's what many people come back with, which is the worst thing we could do. Something every speaker needs to know for certain is their fee. What is your fee? Now I don't care what that number is. But you need to know that you have a thing or not, you're prepared to accept whatever you can get. What is it you place a value of your time in now you might get paid different numbers to that fee, but you've got to know at every given period of time, what your fears. I also don't want you necessarily to disclose this at this point in time inquiry. He comes in, what I would like to do is to respond to that inquiry using a different means of communication to the one in which the inquiry came in. So if the inquiry comes in via an email, my first response would be via telephone, I'd be calling them myself, because I want to be seen as demonstrably different to every other person that they have put a an application out towards. So I would respond, my words would be something along the lines of it's just a quick call. Why would I say it's just a quick call, because I don't want to get into the meat of the discussion right now. Thank you so much for your inquiry coming in. I've checked my schedule. And as I can see, right now, I do have some availability on that date. I'm happy to be able to place it on hold for you. But answer me this Just tell me what is it about me in my work that makes you think that I might be the right fit for this kind of event? James Taylor So I responded with a question what do they now do that providing more information to you as well and you're getting more nuance? Phil M. Jones Yeah, and I'm getting the whole backstory more often than not, they do my job for me. James Taylor So they start to almost tell you the things and you're sitting there, able to able to speak that but actually to speak This is what any good salesperson is doing. It kind of goes back to Dale Carnegie's, seek first to understand then be understood, Phil M. Jones same difference. And what we're doing is we're getting, we're getting some backstory on it. So I think it's remarkably important that we ask those kinds of questions of people. We can then go on to ask kind of ongoing questions. We can ask things like, so what's your experience of working with a paid professional speaker? James Taylor That's an interesting one, because that's, that's. And that's a very interesting one, because you're basically pulling it you mentioned earlier, they're just speaker's negative role models as well. So you're in their head, you're getting all the things that they really really dislike about working with speakers, Phil M. Jones I'm getting the whole thing but also just like the new ones, and I'm one of the world's leading experts when it comes to writing intelligent questions to avoid objections. It's like the thing that i doing any of my consulting work and I love it for fun. But that question there is what's your experience of working with pay professional speakers does a few things. Number one, it positions you as a paid professional speaker Yeah. The other thing is is you find out where you've been out with things in the past so they say things like well last year we booked someone so and we've had this person in the past etc, etc, etc. They want to have a conversation with you about money so you say well what have you paid your previous speakers? Now I get some form of benchmark if they choose to be able to tell me I haven't said what's your budget I've said What did you pay your previous speakers? What I can now say is I can say things while you're looking for this your speaker to be better or worse. They could say things well, hopefully better you could say well, would it be fair to say that you want it better than you've had before that it would make sense that you might need to pay a little more James Taylor you're having a very very different conversation there and and, and obviously, it was important that you switched modalities got switched mediums in terms of going from someone on email to going on the phone. I wonder about that question or that part there. Where you know, we hear more and more, maybe less on the CEOs but maybe on the on the event planners, maybe younger, they might you know, phone is not such a Big things. How do they feel when they get that call from you? Phil M. Jones More often than not, they feel great. I mean, I had one yesterday, right? So yesterday inquiry comes in via referral for a multi gig event across the US. Join email goes in, somebody might want to consider for the event is Phil Jones, response comes back. Thank you for the introduction. Phil, can you let us know some times that we might need to get together to have a conversation? What do I do? I pick up the phone. So I don't respond saying hey, sometimes meet my meet my assistant, Bonnie, I'll get something set up for you, etc. I respond with a phone call. Hey, Leah, it's Phil whenever an email dialog right now. I got 45 minutes before I go on stage in a second. And I thought I'd try and catch you right now without clogging up some future time. She says Well, that's great. Thanks for jumping on this. I wish more speakers would do this. Where am I in this negotiation. Now, James Taylor you're in a very strong position because you're set yourself apart once again, from all the other speakers that probably would just done an email response. Or unfortunately, we hear a lot of speakers that don't even respond as well. So you're, you're instantly at that top of that, that that line now, Phil M. Jones and I want the listeners in to understand something really important right now is there's nothing that I'm sharing today that will work with all of the people all the time. So it's not like oh, feel free to call and I try to call them and they didn't pick up or they didn't like it. That's a load of rubbish. It's this is stuff that works with more of the people more of the time, should you choose to apply it. So it's not for everybody. But what would happen if I didn't get to connect on that phone call? Well, I might shoot a quick email, I might do it deliberately from my phone. So it says sent from my iPhone on the bottom as opposed to with my six email signature. My response might be, hey, received your inquiry, just try to reach on the phone. Just so you know, I'm free between four and six this evening. And I'm going to be traveling to the airport on my way back from a gig it might be a great time for us to be able to connect, shoot me know if we can make that time work. So I'm moving out of that. Corporate piece and out of that scheduled formality rigidness and moving it towards a more friendly conversation and showing that I'm in on this too. And that they're going to have a conversation with the person as opposed to be pushed through the process. James Taylor And on that call, sometimes, if that email has come initially from let's say, not the final decision maker, let's say it's come from the persons organizing the conference. So you're calling back the person that has organized the conference, not as a decision maker, how are you? Are you are you trying to get onto that, get that decision maker then on the call after that, so that you can do that or you just happy to go with just the the person who is contacting you initially? Phil M. Jones Well, what you generally find in the speaking world is the decision maker is the person who's going to sign off on it, but that decision maker takes 95% of the influence over that decision from the person that you're speaking to. Okay, so, you know, they might not be signing off the purchase order or the check, etc. The event planner or the initial inquiry person is somebody who actually carries a huge amount of influence in that The minute I try to disregard the level of influence of that first person has and go over their head, I actually lose their support. So what I want to do is I want to train this person to have an effective conversation internally to mean that I'm the only choice. James Taylor So how do you do that? And when you're having one of the things that you want to ensure this person understands, and all that they're going to when they have that conversation with with their boss, then they can ensure that they're helping you in doing your job? Phil M. Jones Well, the things that I want to understand from them is not what they need to understand about me is I want to get them to have the confidence that I understand what they need. So what I'm looking at is, those series of questions again, is tell me what's your experience of working with a paid professional speaker in the past? So how many people you've got coming to the event? Is this the first time that you've done an event of this nature? What is the theme or the outcome that you're looking for? Tell me if somebody was also what could they deliver in this session for you right now that would mean that you would go away feeling them and Be proud of you choice. No, I'm asking series of questions that they get this other person to say, I understand your problem as well, if not better than you do. So there's no Let me tell you how freaking awesome I am. What there is, is let me discover and understand what it is you're looking for and see if that see if these fit is right. Now sometimes I go through this round of discovery with the client, and I'm like, I don't think I'm the right guy. Sounds to me, what you're looking for is somebody that's more like this. Would this be fair? Well, yeah, that's kind of what I'm looking for. All right, somebody you need to speak to is, yeah, would you welcome an introduction to somebody like that? Because I think they might be able to deliver your brief slightly better than I can. James Taylor So it's almost like what you're doing there is instead of going, this is me, I'm brilliant. Here's the problem. here's, here's, here's how I solve your problem. Here's how I deliver the solution. And then finally, you this your problem. You have basically flipped around the other side, you're focusing on one Your challenges, what's your problem? Finding out from then? Like, how has the waste of solute, solve that problem? Maybe not just the keynote, maybe there's other things that you can also be doing in terms of training and other stuff. And then finally, you're coming to yourself. Phil M. Jones It's got it's kind of flipped. And very rarely do I need to tell somebody about my ability to be able to train and deliver from the stage because they already knew that that's why they reached out to me in the first place. Yeah, that's we think about the way the world is right now. It's rare that somebody jumps into a conversation or reaches out to somebody or finds themselves considering a conversation with you, without them, having a look across your website, checking out your LinkedIn profile, watching a video or two. They understand that you've got something about you. What they're looking for is, is Do you understand the problem that we have? And do you feel that you've got the ability within your toolkit to go out and be able to do over deliver in this environment? Is that something you feel confident about? And I've learned to walk away from more opportunities recently. Then Then try and force myself into something that isn't right. And the busier you get, you start to learn so I probably have room in my schedule for around 50 keynotes a year that limitation is fun because it means what I could do is I could be on stage in the wrong gig delivering the wrong message to the wrong audience. And okay Am I got paid and they might have been like a solid performance or I could have took that same day that same moment and made a real difference with people that really have a need and a requirement for the problem I solve and I could have had a blast, the day would have passed regardless so James Taylor one of the things that helps you do that is kind of going back to what we spoke at right at the start is your belt that base so that you can you're having those conversations from a position of of confidence of strength and feeling you can you can walk away You don't have to be taking this if you're not the race speaker, they don't say I'm already speaking you may suggest someone else for example, but your if you didn't have that base, it might feel you might feel okay, just Yes. Phil M. Jones You have to Yeah, and I've been there too in the past but and that's what taught me the importance of the bass. So I you know, every year I want to start every year saying my bills are covered. And and you know, I do 20 gigs a year with the same client year in year out, that isn't my dream work. It isn't like me doing the thing that I love. I just quite like it. Like I quite like it. I'm really good at it and it delivers a result. It isn't me living my dream. But it is me getting a regular recurring revenue coming in every month teaching teaching, teaching teaching, which allows me the freedom to go find the things that make my heart sing to make those decisions. James Taylor So when when you when we don't have too much time this because I'm conscious of your time just now as well. And when we start to you get on the gig itself and you get there to the to the place other other things that you're looking to do, when you're actually there to ensure that you really over deliver on outside of just that the keynote, there are other things that you're enjoying that you want to try and do there, Phil M. Jones there's a few things that I do is number one is I always like to get to my venue the day before the event. Like it's not always possible. And I want to see the room before I close my eyes. sounds stupid. But if I've seen the space that I'm going to work in, then what I've got is I've got some familiarity to how I'm going to use that room, how I'm going to work that room, what potential constraints could exist to me, I want to get there early, I want to shake the hands of the AV crew. I also do something that almost no speakers do. But I think for me is absolutely essential. And every time I do it, I get further positive reinforcement. That's the right thing to do. It doesn't matter what time I'm speaking, whatever that audience have heard that day. Ahead of my speech is imperative to me. So if I'm on at 4pm, I'm in that room from 9am fly on the wall at the back listening to everything was delivered before me. Because my job is to serve that audience not to deliver my speech. The mistake could happen is that if I deliver something out of context, but don't tie it back to something That was said by somebody else earlier, don't link those examples. I could be in conflict when in fact, so I'm actually saying the same thing from a slightly different angle. Yeah. And that is disservice to my audience. So I do that without fail ahead of time. I also plan how I'm going to utilize the stage. What am I doing in terms of props, I come on and off the stage, you know that I kind of actively work in audio. That James Taylor was one of the things I really enjoyed about your I mean, there's last thing I enjoyed about hearing you and seeing you speak before but one of the things that I thought made a really big impact in the room was that you were you were moving around, you were having that and it feel much more interactive. And you you were going and spending time with an individual person in the room having that conversation. The whole room was then transfixed on you having that that conversation with that person. Phil M. Jones Yeah, so that requires prep, too. So what I might need to do is I might need to find the types of personalities in that room that if I'm going to pick on somebody individually, how do I get the right Love energy or vibe? Or do I see somebody as a as a strong influencer, particularly in a smaller room that I think will if I can sway that person and get engagement from them then I'll change the energy in the whole room. How am I going to map if I'm going to work through a set of tables or down some some rows and alleys etc? Where is my safe places to walk? Have I tested the microphone towards any potential feedback spots with speaker systems etc? What am I doing to be other than get back onto the stage because that could be Crikey embarrassing, like I jump off the stage, realizes no steps, and I've got to get back on elegantly in some way. And I I live in this fear of rip in the back of my trousers or pants, and that being the thing that I get remembered for so I I try and mitigate any any kind of risks there. And what I'm looking at is a really simple principle is that I always want to control my controllables there's so much stuff that you're at sea with so much stuff that you rely on your experience you rely on being able to be in the moment. And the more that you control your controllables in your performance, the more you can actually find freedom and enjoyment in the delivery of your performance. Because what you've done is you've anchored down everything you possibly could do to allow you to be able to bring your true brilliance in the moment. James Taylor So on that control your controllables wasn't your speaker bag, what is in that bag that you carry with you to all of your speaking engagements that you'd never, never leave home without, Phil M. Jones um, I have three slide clickers. Because I'm always fearful of one guy and wrong. Replacement batteries. I have two versions of every adapter that I could possibly ever need. If I need my slides to go on. I have photographs of my passport in case I ever lose it. I have multiple thumb drives with presentation decks on them as well as the things that I've sent across. I carry throat coat tea. I carry entertain the secret to be able to lubricate my throat sometimes if I'm struggling a little bit on the road I carry airborne or Baraka, you know like the vitamin things in order to be able to take care of my health when I travel what else is in my bag and extra extra charges I got this great little charger In fact I was gonna show it to you where it's like a portable pack that has multiple USBs in it as well and replaces the need to be able to put an outlet in the wall. So anything I can that I'm kind of gadget like, like mad it can save me save me time. In fact, I got this little thing as well I bought the other day this is kind of super cool. So this is like an outlet and then it's multiple USBs and things so if I want to work on a plane, instead of having like something plugged in somewhere I can plug this little thing in that doesn't fall out that then allows me to better plug multiple things in on my desk when I'm traveling and compression socks to make sure that I don't like lots of stuff to be able to make sure I'm still healthy on the road. Yeah, more Other than delivering the performance, thank you cards. And then I have a bag full of thank you cards, because there's always people I meet on the road. And I want to say thank you to. And I carry stamps for both of us in the UK with me at all given times to if I want to mail something to somebody. James Taylor And what about apps? Is there any particular apps, online tools, online resources, you find really useful for yourself as a speaker, Phil M. Jones I guess probably the biggest resource for me as a speaker outside of all the ones that you're going to hear from everybody else is I use an app called I talk. And I talk is a voice recording app that directly syncs up with Dropbox. And sometimes if I'm working on a new bit, or I'm playing with the idea of a new opening, or perhaps even that I want to take a recording of my own speech, then sometimes what I do is I I run I talk recording in my in my pocket, or I talk into ahead of time, and then what I've got is it is an audio file of my speech. Some of the things I can then do with that is if I deliver something that I really liked, but I didn't know what he was I've got the audio track to better go back to I'll then push that through rev calm. Yeah. And rev.com is a transcription service. There's lots of others out there. And I'll rip out the the transcription word dot play with that, dial it up. Now sometimes I'll get blog articles from there. Sometimes it's just for my own reference. And you'll know what it's like as a speaker. Sometimes you do something in the moment, and it's brilliant. But you can't remember what you did. James Taylor Yeah, yeah. Or there may be as a camera sitting up up there, fixed up to the back of the room. And the audio is lousy, because you don't have anything near you to be able to pick that up. Phil M. Jones Yeah. So so so the ability to be able to do that. And equally, you know, I'm often just dropping ideas into a talk for me just and I might have my headphones on while I'm walking through an airport and it's recording in the background. And I'm, I'm talking to myself about, you know, planning in a new opening. I do a lot of customized openings events, particularly given that I've listened to the whole session in the morning on the closing keynote. I'll read Work my opening, in order to be able to bring contrast or something has happened towards the rest of the event. And it kills because they realize this isn't a canned presentation yet, even though so much of it is structured, the ability for me to be able to create a level of tailoring in is is something that event organizers really enjoy. James Taylor What that book is there one particular book, you would recommend not one of your own books as Yeah, I've got your book. And it's I'm actually starting to go through your book just now. And I would say of this summit, if there was a one book that was recommended more than any other book, it's actually been your book this year. speakers, which is a great testament to you. So that's exactly exactly what to say Phil M. Jones or exactly how to sell James Taylor exactly what to say. Yeah, exactly what to say. So if it was one book, we're gonna have links to your book here as well. If there's one other book you would recommend to speakers or aspiring speakers, what would that book be? Phil M. Jones I think there's a book that everybody should read. And it's a book called the coaching habit by Michael bungay stanier. Yeah. And it's a really short and easy read. It's meant with the purpose of helping busy managers, so Have more effective coaching, coaching conversations. But the brilliance in that book is just about having more effective meaningful conversations there is there is links towards sales language in that that it was never intended to be. But often what we're looking to do with our clients is to coach them into doing what it is that we would like to be able to do or to coach them into seeing that we're the right choice not to tell them and Michael's book there, I think it opens up, maybe the ability to look at something that you've previously seen as something you might deliver to your clients, but learn to how you can use it to have more effective conversations to get more of what you want. That would be maybe a random but useful recommendation. This James Taylor is a great book. I had Michael on the on the podcast A while ago. And actually, if anyone is thinking about releasing a book and be as an author, his description of how he launched that book is fascinating because he didn't go the traditional route, especially in the marketing so it's worth just checking out but we'll put a link in here but guys a great book. So a final question. For you, let's imagine you woke up tomorrow morning. And you have to start from scratch. So you have all the skills, all the tools that you've acquired over the years. But no one knows you, you know, no one, what would you do? How would you restart Phil M. Jones a self hosted event that that fixes the problem I know that exists within my locality. And, and I would charge for that event. So I take the skill that I'm good at, I find groups of people who can make quick decisions. And I'd go back to where I very first started. And when it comes to being able to host a live event, then what you do is you take the problem that exists. So let me talk you through the exact language pattern here. So I wrote a sales training workshop that helps independent business owners to get a train out of a recession. I'd ask a series of questions to people like me, and I'd network like crazy to better filters. First question would be How's business? Everybody says business, you know, yeah, that's good. So So I follow up with another question. It's not really a question. I just phrased it as a question. The question I'd ask is the word really And I said, Well, you know, what things could you know, things could always be better? I'd say, Well, what kind of things are you doing right now in order to be either improve or grow your business? And you know, they'd say, No, no law. I'd say how open minded would you be to running through a program and spending a day together for us to better learn some new skills you could put into practice that might help you improve your business from where it is right now? Let's say Yeah, sounds good. That say, well, when is it? I'd say, What do you free the 24th of April? that say, Well, I'm not so sure yet. I'd say what are you free on all? This? Oh, no, I could probably be free. I'd say great. Well, I'm running a one day workshop. And these are the details. Let me get your pencil in and out, go out and have those conversations. And the thing that everybody needs to remember is that questions, create conversations, conversations, build relationships, relationships, create opportunities and opportunities lead to sales. Everybody goes looking for sales, what we should be looking to do. Where can we ask questions of the type of people that we'd like to help? So the same thing that happens here, right is that say, for example, that you know who it is that you want to serve back to the point that we made earlier on? How can you get into a position where you're asking questions of those people? Because those questions were great conversations will build relationships as relationships, great opportunities and opportunities will lead to sales. could be as simple as a workshop could be as simple as something like what you're doing here where you're interviewing experts, that you could start asking questions of the experts that you'd like to be able to serve. And chances are, then that will result in you having some conversations, building some relationships, create some opportunities, and making some sales James Taylor asking better questions. I love that. I love that idea. And where should people go if they want to learn more about you? We've spoken about some of the books here as well, where's the best place? Where's your central hub for all that? Phil M. Jones I'm PhilJones.com is my website. That's the site that you talked about earlier on. And from there, you can find all of my social channels you can link out to any of the other stuff that we do and and I love to hear people when they put things into action, so come find me on LinkedIn or Twitter or my Facebook page, any of those things. Tell me what you'd like. Tell me what you put into practice. Tell me what's worked. And I'll answer your questions. If your questions relate to something you've tried, and you want to learn how to do it better. If you're asking questions about something you haven't had to go out yet, have it go in at first, then I'll give you some time. James Taylor Awesome. Well, first of all, a pleasure speaking to you again, I love the work that you do. I think you do. You're doing some amazing, amazing, cool things just now. I look forward to getting a chance to hear you again on stage really soon and catching up. So thanks so much for coming on today. Phil M. Jones You're welcome, James. Thanks, everybody for listening. Real pleasure. James Taylor Today's episode was sponsored by speakers you the online community for speakers and if you're serious about your speaking career then you can join us because you membership program. I'll speak as you members receive private one on one coaching with me hundreds of hours of training content access to a global community to help them launch and build a profitable business around their speaking message and expertise. So just head over to SpeakersU.com to learn more Website: www.philmjones.com More of Phil M. Jones Learn More About SpeakersU #speakerslife #speakersU

After the fallout of the attempted team oriented 'warm fuzzies' by Jones IT and House Friends respectively, Tyler, Josh, Bobby, Emma, Darren and Mook stake their forks in the grass and take necessary actions.  From Vol. 92, MONDAZE is the show for the Millennial Employee. Created, written, co-edited and directed by Richie Kamtchoum; sound design, audio engineering and editing by Marcus Smith. Episode 7 "Necessary Actions", features performances by Penelope Tangamu as Emma, Frantz Saint-Val as Josh, Richie Kamtchoum as Darren and Brad, Cindy Kamtchoum as Tammy and Faye, Nate Brook as Mook, Ben Martindale as Tyler and Fantz, Jimmy Keegan as Bobby, Eve Mendoza as The Waitress and Daniel Frazier as Stewart. Original songs featured in Episode 7 includes "Grown" by Saint-Val, "Bananas" by Kemal and "Long Way" by Shai Va. Subscribe to the show anywhere you listen to podcasts! Feel free to follow us on Instagram, Facebook and Twitter @mondazeshow . To help support future episodes of the show, or potentially contribute to the show becoming a web series, please subscribe to us on patreon, https://www.patreon.com/mondazeshow All episodes and overall information can be found on our website, https://mondaze.simplecast.com .

Gege - April 2020 recorded at home 04/04/2020 - Tracklist : 01 - Kid Fonque, Sio - In Love (Jazzuelle Rotary Dream Mix) 02 - Chaos In The CBD & Lee Pearson Jr Collective feat. K LaDawn & J.A.Jones - It's up to Me 03 - Dave + Sam feat. Mike Dunn - Til The World Blow Up 04 - The Vision feat. Andreya Triana - Mountains (Danny Krivit Remix) 05 - Jimpster feat. Casamena - One 06 - Omar S feat. John C & L'Renee - Ambiance 07 - Chez Damier - Never Knew Love (Kai Alcé Unreleased Mix) 08 - SBTRKT feat. Ezra Koenig - New Drop, New York (Florence006 edit) 09 - Black Jazz Consortium feat. Christina Wheeler - Resonate 10 - The Mauskovic Dance Band - Space Drum Machine (Detroit Swindle's Flute Mix) 11 - Active Surplus - Peppermint 12 - Antonio - Hyperfunk (Instrumental) 13 - Route 8 - All Those Djs 14 - Dan Shake - Hide & Seek 15 - Joey Anderson - Live It 16 - Warwick - CTO 17 - Matthieu Faubourg - Please, Stay

#RTG #UFCBoston #JonJones #BenAskren Respect The Game! Episode 11 is HERE! Thank you so much for Watching PLEASE like, subscribe, and click the bell :) It helps the channel out tremendously. UFC Boston: Dominick Reyes vs Chris Weidman was October 18th at TD Garden Arena, in Boston USA. Reyes again landing a devastating KO against a former Middleweight Champion in Chris Weidman. Scary power… What is next for Reyes? Is it Jones? It should be and I will discuss why here. Conor McGregor's recent behavioral issues. I discuss what is going on with Conor McGregor rumors as of now. I discuss Yair's MASSIVE win at UFC Boston against a very tough Jeremy Stephens who wanted to rip his head off. I discuss Askren vs Maia that is taking place in Signapore this Saturday October 26th 2019 and what this means for Ben Askren's potential Future with the UFC. Links used during Podcast: Jon Jones Tweet about Dominick: https://twitter.com/JonnyBones/status/1186883579826987008 Jones distasteful attack on Tony Ferguson: https://www.bloodyelbow.com/2019/10/23/20928225/jon-jones-tweets-and-deletes-attacks-at-tony-ferguson-mental-health Greg Hardy vs Volkov: https://mmajunkie.usatoday.com/2019/10/greg-hardy-vs-alexander-volkov-booked-ufc-moscow-co-main-event?utm_campaign=trueAnthem%3A+Trending+Content&utm_content=5daff38e8021ed0001322d19&utm_medium=trueAnthem&utm_source=twitter UFC Reyes vs Weidman: https://www.ufc.com/event/ufc-fight-night-october-18-2019 UFC Maia vs Askren: https://www.ufc.com/event/ufc-fight-night-october-26-2019# Demian Maia UFC athlete: https://www.ufc.com/athlete/demian-maia Ben Askren UFC Athlete: https://www.ufc.com/athlete/ben-askren Chael Sonnen's Channel: https://www.youtube.com/channel/UCRlvF4jIeBWqXJDGNXfPyVw/videos Other Videos You May Like :) Respect The Game! With MMA_Mando Episode 10: The Adesanya/Stylebender Era | UFC 243 | UFC Tampa: Joanna vs Waterson | Respect The Game! Ep. 10 Who is MMAs GOAT? (Khabib Nurmagomedov, Jon Jones, or Georges St Pierre): https://www.youtube.com/watch?v=l6UV9zCK1b8&t=154s How to Watch Respect The Game! With MMA_Mando: Anchor: https://anchor.fm/respect-the-game Spotify: https://open.spotify.com/episode/1fklAwiLEVzic7aPxfSiMr?si=oIekEXVUQGiarOUv4krThQ Google Podcasts: https://podcasts.google.com/?feed=aHR0cHM6Ly9hbmNob3IuZm0vcy9kMjBjZDNjL3BvZGNhc3QvcnNz IF YOU WANT TO CONTACT ME or CONNECT: Email: MMAwithMando@gmail.com My Twitter Handle is: @MMA_Mando: https://twitter.com/MMA_Mando Instagram account: https://www.instagram.com/mma_mando/ --- Support this podcast: https://anchor.fm/respect-the-game/support

https://discord.gg/Mmn2FPW Or join us on reddit... https://reddit.com/r/thecitywithinthewalls [Narrator] When a child is born into this fine city, a communication device is placed just beneath the left ear. The device can, connect to a car or house depending on the owner's setting, so communication appears more...normal, and this is how our story begins. Aleen wakes startled, by an incoming call broadcast by her house com, she quickly press's the coms button on her night stand and says... *ANSWERING NOISE* [Aleen] (Waking up to the phone ringing) Mmmm....hello [Jones] Ah Miss Harris. Sorry to call you. However,  I'm a very busy man...and quite impatient. I'm calling for an update...how'd the date go. [Aleen] (Aleen is totally disgusted) (Breath) That's really none of your business Jones...and wasn't I suppose to call you? [Jones] Yes, but as I said before I'm very busy...not to mention, impatient. As far as my business...yes, it kind of is. Now about my update...would it make you feel better if I asked please? [Aleen] (Breaths again) Tharin didn't really want to talk about it. All he told me was, Sorrel placed Dayton in Saris's place and the council isn't happy...at all. That's all he told me. [Jones] (False positivity with Aleen, feels this interaction was on the verge of ‘wasting time’) Well...its not much...and information we already knew...but I'll give you credit for the attempt at least. Thank you Miss Harris, we'll be in touch. (Phone hangs up) [Aleen] Jerk (Song and intro) [Narrator] (Keeping its normative pace, the city is hard at work, ignoring the dangers that loom with each political checkmate. In the heart of the city, a light morning fog sets in around a workshop. The sun, always in it's own power struggle with the thick clouds, lends a slight glow, that gleams lightly off Ross’s spotless high-tech workshop. Tharin enter the shop, eager to see his commissioned device. Ross reveals his genius machine, Tharin looks over it for a second and says...) [Tharin] So I just push this button...and what? It shows me the location of Saris? [Ross] The location of his tracking device at least. Last night I tested it on my own pps unit and it works fine. I just put in Saris's. Once it's done...you just push the button...and it should, yes, show you his location. [Tharin] Perfect, what are we waiting for? [Ross] It has to go through the calculations. [Tharin] Hmmm...how long does that take? (Ding) [Ross] It's done...go ahead. [Tharin] Well that went quicker than I was expecting. Here goes nothing. (Machine makes noise) [Tharin] Is this some kind of joke Mr Ajin? [Ross] What do you mean? [Tharin] Have a look for yourself, see if you can figure out what I mean. [Ross] How is that....what's it doing? [Tharin] Well if you can't figure it out, how am I supposed to know? [Ross] They must have encrypted the signal somehow. [Tharin] Or it doesn't work. [Ross] I assure you, commissioner Grady it works. [Tharin] Ok then, if that's not it, there appears to be, by my count, around 50 Saris's all over the city. [Ross] Yes I see that. They've encrypted his passcode somehow, see how they're all moving around. They've tied his code to others throughout the city. It's going to take a while to figure out. [Tharin] Right....let's hope you can figure it out Mr Ajin. If not, someone must be held responsible...is that clear? [Ross] As a bell. [Tharin] Good...well don't let me stop you...get to work. [Narrator] (Tharin, in a moment of frustration abandons the desk that holds the device. Ross sits in the background behind him, leaning against the duos new machine, he stares at it for a moment, hopelessly as if the answer will reveal itself. Tharin paces back and forth, pressing the coms button just below his left ear saying...) [Tharin] Call father... It doesn't work... [Ross] (Loudly speaking to Tharin as he walks away) It works fine... (Under breath) I just have to figure out the code [Tharin] Hes working on it now. I'll talk to you in a bit.   [Narrator] (Ross Ajin continues his work, continuing to question how ‘he,’ of all people, could be outwitted by the Theosin. Tharin steps away from the workshop for a break from the discord within in his very political life. He makes his way towards Aleen’s, glancing at her coat from the night before that now looks at home, on his passenger seat. He smiles for a moment, and begins to wonder if Aleen enjoyed the night as much as he did.)   (Knock, knock, knock) [Aleen] (Surprised and concerned, but there is a moment of flickering happiness.) Tharin, what are you doing here?   [Tharin] I just wanted to return your coat...and apologize.   [Aleen] Apologize for what?   [Tharin] For not trusting you with the investigation. I have a very hard time trusting anyone, the city is full of people trying...to do...bad things, anyway. I'm sorry to insult your character in that way.   [Aleen] No need to apologize, and I know what you mean about...bad people.   (Awkward silence) (Both talk at the same time)   [Aleen] Thanks for taking….   [Tharin] Well, I just wanted to…   [Aleen] I'm sorry (laughing)   [Tharin] No, I'm sorry go ahead.   [Aleen] I was just going to say, thank you for taking me to Madison Fare last night.  I know you had to, with the bet and all, but...I really had a good time thank you.   [Tharin] I also had a good time. You're quite an entertainer and I needed a break so, thank you, for...forcing me to take you.   [Aleen] We should do it again sometime.   [Tharin] (Momentary pause, considering his next words) I think we should.   [Aleen] Really?   [Tharin] Yes, really...maybe something a little less expensive next time though.   [Aleen] (Laughing) Right, I hope it didn't set you back to far.   [Tharin] No it's fine. Anyways…(breath) I'd better go. We'll talk later though?   [Aleen] Ya   [Tharin] Ok, goodbye Aleen.   [Aleen] Goodbye Tharin.   [Narrator] (Aleen closes the door behind Tharin, watching him for a moment through the looking glass. She smiles. Leaning against the door, she clutches the moment.)   [Aleen] He trusts me…   [Narrator] (Her hands dropping to her sides, her eyes widen, as concern blankets her face… [Aleen] Oh crap...he trusts me.   [Narrator]   (Aleen contemplates the dilemma before her; foster a newfound trust, or betray it.   *pause* Before us sits a warehouse at the edge the city border: windows boarded, corrugated sheets cracked, and fallen from the rooftop, rafters aged, bent and breaking. A swathe of dust would be collected on them if it were not for the mice running to and fro from their homes, rested neatly in unperturbed corners of this uninhabited warehouse.   Saris sits alone. Wrists and ankles burned by the ropes that bind him. His sight darkened by the blindfold. Alone with his thoughts, confined within the silence of this abandoned building. They practically echoed in his mind.   But what's this? Another sound? A foot step. Multiple in fact. They echo off the concrete, shaking the rust from the rafters above…)   [Jones] Moose   [Moose] Yes sir?   [Jones] It would appear our adversaries have found a way to track Saris.   [Saris] (Laughing in his evil “you're so dead” laugh)   [Jones] (Pausing for a moment to recognize Saris's laugh) So here's the plan. Saris is to be moved every 8 hours. Here's the next location, you now have 7 hours and 22 minutes and….23 seconds 22, 21. Anyways, keep him moving.   [Saris] (Laughing again at the plan) If they've already found a way to track me, your dead where you stand.   [Moose] What's the likelihood they'll find us?   [Jones] I'm told by our techs, that we have a 99.7% success rate if we move every 8 hours. That goes down by 20% every half hour afterwards. So I suggest you keep him on the move. (Jones now speaking to Saris in a calm manner) Oh and don't worry Saris, Sorrel has all but abandoned you. Hes placed Dayton in charge. The one looking for you is Tharin. So as you see Sorrel has written you off...the offer still stands if you want to, oh I don't know, help?   [Saris] (A mixture of disbelief, and potentially fostered anger) Sorrel wouldn't abandon me. Not after all that I've done for him, and Dayton won't last a week.   [Jones] Yes well...offer still stands, let me know when you wake up and realize Sorrel cares only for himself...and Dayton. (Jones starts to walk away but stops for one last comment) Oh and...one last thing...don't test my patients by pretending to care for the council. I know your disdain, and soon Sorrel will show his lack of interest in you. When that happens I'll be here to give you a...shot at revenge. Goodbye for now Saris.   (Jones leaves the room)   [Saris] Was he telling the truth Moose? Has Sorrel made Dayton Enforcer?   [Moose] Ya. It's not official yet, but as of right now...Dayton is filling the spot.   [Narrator] (Under Saris’ breath is a growl. His breath feels heavy. His chest knotted, heat rising up the back of his neck. He pulls at his bindings to distract himself. Light trickles of blood scatter on the concrete floor. A new sound, alone once again with Saris’ thoughts.)   *pause*   Tharin, frustrated sits in his car. Unsure if he is more angry by the lack of results from Ross's device, the case to find Saris, or the indent left by the wheel in the palm of his hand. Moments pass, feeling like hours. Even committing to conversation with his car, Salistine.   [Tharin] I am beyond frustrated Salistine. There are so many variables.   [Salestine] Variables you have invariably been trained in, sir.   [Tharin] Yes this is true Salistine.   [Salistine] I just want to say sir...I have done nothing but help when I can, that said sir, I was wondering if you could stop hitting my control wheel?   [Tharin] Yes of course Salistine, I'm sorry. It's just...what do I do with Ross. I know he's not sabotaging the machine, but the lack of results is quite disappointing. I mean, it's not like I can just kill him, we need him.   [Salistine] Sorry to interrupt sir, but an incoming call from councilman Grady's office, do you accept?   [Tharin] Yes of course Salistine, patch it through.   [Salistine] Patching through now sir.   [Jarrett] Tharin, are you sitting down?   [Tharin] Yes, I'm in the car why?   [Jarrett] Sorrel is about to give an address to the entire city.   [Tharin] An address about what?   [Jarrett] He thinks it's a good idea to quell some of the concern over Saris's disappearance.   [Tharin] He's actually going to tell people Saris is missing?   [Jarrett] No...hes going to tell people Saris is Ill and unable to perform his duties as Enforcer.   [Tharin] Well that's better than telling them he's missing.   [Jarrett] I don't agree that lying to the people is a good idea. He's going to dig a hole for the council.   [Tharin] Hmmm, is there anyway to delay him for a few days?   [Jarrett] No, he's going to go live in a few minutes. I have to go. The council has been requested to stand behind him in the address.   [Tharin] Of course, that way you can't deny knowing…   [Jarrett] Exactly...I'm truly concerned Tharin. Find Saris, and do it soon...or we'll have more than just his disappearance to worry about.   [Tharin] I'll do my best father.   [Jarrett] Of course you will, goodbye son.   [Tharin] Goodbye father. Salistine?   [Salistine] Yes sir?   (Salistine is interrupted by an official address. It starts with a bong then the city anthem begins)   [Sorrel] Greeting, salutations, hello and blessings be with you all. My brothers and sisters, I apologize for the interruption of your evening, but I have a grave concern. I've been notified that there are rumors flying about this fine city, about the disappearance of our beloved Saris. Know that he, our sworn protector, our refuge from chaos, our friend and our brother has not disappeared. He is right now...unable to tend to his sworn duties do to an illness, an illness that has him more than just under the weather. I feared, having to inform you of this, because I wanted to save you from the stress you might incur having heard said news. However, I also feared the rumors might cause more damage, so in the Hopes that I, councilman Sorrel, could save you the more stressful thing, I have decided to release this news to you here. My fellow citizens, the council and I care a great deal for you, so know that we always take the actions necessary to keep you all safe. This being said, we have placed Dayton in Saris's stead, til he is either able to return to his regular duties or is forced to retire his title to Dayton. I apologize for the delayed announcement, but as I said before we were hoping to save you the stress. Know that the doctors are working around the clock taking care of our Saris. I ask that you keep the hope that he will be returned to us soon...healthy and ready to resume his responsibilities. I will leave you tonight with our blessing, and pride. For we are proud of the great people of this majestic city, for the way they handle such situations. That is with confidence and courage. Until next time my brothers and Sisters...may the blessing of the council be with you always...goodnight.   [Narrator] Sorrel’s voice echoes in every corner of the city. Across all mediums, his lies spread to an all too trusting populace. Well, trust from some of “his” population. There was one set of ears in particular whose call was interrupted by the message. The man who has Saris himself. The man who without a doubt knows of Sorrel’s lies.   [Jones] Well played Sorrel, but you aren’t the only one with a hand in this game. You want to play?.....Let's play.

What follows is an edited partial transcript of my conversation with Stephen M. Jones. He is an economist for the US Coast Guard. However, we are discussing his own research, so nothing in this conversation should be taken to represent the official views of the US Coast Guard. Petersen: So Stephen, let's start just by defining regulatory discretion. What does that mean in this context? Jones: Sure. So, I think first off, we should probably define regulation because when Congress writes a law, they pass the law on to regulatory agencies and it will say something to the effect of "agencies: issue a regulation." So, when we talk about regulations this point isn't always clear because people just aren't familiar with this process. The regulation is a statement that kind of clarifies existing congressional law or is written in direct response to congressional law. And this could be as specific as, say, Congress can direct an agency to set an exact amount of pollution that is permitted for an industry to as broad as saying something like "protect consumers from unreasonable risks." And then the agency has room to interpret that statement as wide as it wants to. So, when I talk about agency discretion what I'm really talking about is Congress wrote a rule that gave the agency power to issue legally binding rules that may or may not trace directly back to Congress. Petersen: Yes. So, in the example you use with the pollution, Congress has something fairly specific in mind---a specific type of pollution---but the agency might have to clarify and to say what counts as pollution and how much they're measuring it and maybe they might establish a quota system, they might have specific rules for specific firms. And in the other example you gave, which is just protecting consumers from unnecessary risk, in that case they can basically write rules as if they were their own legislator, they're essentially doing what Congress is ostensibly meant to do. Is that correct? Jones: I'm not sure I would go that far. So, there are various theories of the purpose of the regulatory apparatus in the bureaucracy. Some people---I cite them in the paper---Baumgartner and Jones and Workman have one that is called 'The Politics of Information' and I forget what the other is called, it was written in 2015. And their theory instead is that Congress gives the agencies discretion because Congress doesn't know the problems it needs to solve and so the agency is kind of like the specialists that you subcontracted to figure out what Congress wants them to solve without actually knowing, say the relevant information to determine that. That's one theory. You've got other people like Philip Hamburger notably, who has written a whole book on how administrative law, which is another word for regulation, is unlawful and so he goes through sort of the common-law tradition and cites numerous pieces of evidence to say, exactly in the way that you put it, that it's a deep legislative function and only Congress should be performing that. And so, whether that's true I think depends on a number of different assumptions that aren't always discussed directly in the literature. That would be my interpretation if that makes sense. Petersen: Right. And of course, we're approaching this from an economic standpoint so there are important public choice issues involved with this. The same rule whether it's written by a legislator or a bureaucracy---a regulatory agency--- it's the same rule and so in principle, there should be no difference. But the important thing is that the agency and the Congress may have different incentives and may write different rules. That's what I interpret as an important underlying theme in your paper. Jones: That's most certainly true. So, that's actually one of the things that frustrate me greatly about reading a lot of these other, I think, great researchers who don't in my opinion sufficiently consider the role of incentives. To couch it in Baumgartner's or in Jones' and Workman's terms, okay, let's assume that the purpose of the bureaucracy is to create the information that's necessary to solve the national problems, whatever these supposed national problems are. Why would you assume that bureaucrats would supply the right amount of information in the right ways consistently throughout time? And it's not clear to me that those incentive systems are ever worked out; or if you do work them out, I don't think it actually shows that bureaucrats are beholden directly to Congress. So the big terminal literature, which comes from McNollgast, which is McCubbins, Noll, and Weingast, in the 80s is called Congressional dominance. They basically say that because Congress writes the rules they structure all the incentives and have all the tools at their disposal to monitor and police agencies. And I'm just deeply skeptical that that works as well as they describe. Petersen: Right. Your paper mentions the Administrative Procedure Act which is sort of an attempt by Congress to keep these agencies in check. Could you describe that act and what exactly it does? Jones: Sure. So, the Administrative Procedure Act is the main document that governs how agencies regulate. It defines the process by which regulation is made. And the chief component is that it really says before an agency issues a regulation it has to go through notice-and-comment. And what that means is when it sends out a rule it issues it in the Federal Register, which is the government's journal of record, and then it allows everybody to comment on this rule, and literally anybody will comment on these rules, and the agency is legally required to respond to all comments. So, the basic theory is this, it's kind of got a two-part mechanism here. On the one side, it's a sort of direct structural constraint and doesn't really affect agency decision making because all it's really saying is you have to send out all rules---if the fire alarm is triggered it acts like a fire alarm. So, if you get a whole bunch of comments it's a really easy way for Congress to tell, "oh there's a problem with this policy" or it's a contentious policy because all of these people commented it and it's really loud, it's like a fire alarm. But it doesn't necessarily mean that an agency, that an individual bureaucrat in that agency really feels that alarm. It's more like it'll just be triggered, make sure just do something that doesn't trigger that alarm and you should be okay. The other way in which it might change agency behavior is that by forcing agencies to publish rules they reveal a lot of information and in the rule itself you have to describe, say, the cost of the benefits. You have to describe whether or not it has impacts on Native American tribes, or on the Federal structure, or various other executive orders that have been issued. So, one of the main ways in fact that notice-and-comment system has changed is executive orders that define how in a very practical sense these final rules will be constructed. And so, they're all today reviewed in an office inside of the OMB---the Organization for Management and Budget---and the office is called a wire at the Office of Information and Regulatory Affairs. And so, they're responsible for reviewing all regulation and they are an Office of the president. So, some people then conclude that the President has all this power, in effect, of rulemaking in general. Petersen: I guess the idea of the President is that it's the executive branch and so it executes and it sort of makes sense that these agencies that are executing laws would ultimately be beholden to the President. It sort of fits. So, do you know quantitatively how many comments? Are these regulatory agencies writing regulations and getting hundreds of comments every time, or is it rare to get even one comment? Jones: It depends on the agency and it depends on the rules. So EPA because many of its rules will have national effects, and then there are national environmental organizations that you can say are key stakeholders in the outcome of all these rules could very easily generate hundreds of thousands of comments. And so, they'll actually have computer programs that scrape the comments and kind of try to sort them in the boxes. You have other organizations, like FRA for instance, they might have a rule that only gets 30 comments. Petersen: Sorry what does FRA stand for? Jones: Sorry, that's the Federal Railroad Administration and that's one of the two main regulators of railroads in the United States. The other regulator, the Service and Transportation Board, is primarily focused on business practices, antitrust type issues, and FRA is focused primarily on health safety and welfare of anything railroad related. So that's everything from, say, the occupational safety of railroad workers to the safety of passengers on trains. And so, the Federal Railroad Administration might only get 30 to 40 comments on a normal rule, they might even get less than that. It really depends on the rule itself. Petersen: And typically, this would be if a rule affects my business and I might pay attention to the new rules coming out in my industry and if one I thought was going to be detrimental to my bottom line if I work for or run a private business, then I would comment. Is that the typical thing that happens? Jones: Probably. I really think the diversity of interaction is so high it's really hard to characterize exactly what normal public commenting looks like. Because it could be everything from "I'm a regulated businessman who wants this," there might be somebody on the other side who benefits directly because the new rule sets a standard and the standards organization writes in and says your standard isn't strict enough. It could be something like there's a proposed rule that the Federal Aviation Administration, which regulates commercial flying, or anything air related at all pretty much, and they have a rule on the use of cell phones on planes. They've got about 5,000 comments, 6,000 comments. It's quite a number. Once you get above 100 that's usually quite significant. And a lot of those could be something as simple as "we just think phones shouldn't be on planes" and just average citizens writing in upset at the very concept of a phone being on a plane. So, there's quite a diversity of interactions between the agency and public on that. Petersen: So, getting into the main topic of your paper you discuss what you call channels of influence. So, what are those and why are they important? Jones: Yes. The way I think about it is this. I think the chief question of the bureaucracy literature is who does this regulatory bureaucracy exist for? Does it exist for interest groups? Does it exist for Congress to ultimately provide information that Congress needs? Does it exist for the President to carry out the President's wishes and his policy? Or does it exist for the bureaucrats themselves which is the one I also like to emphasize because the literature on that one is not very common today. It was more common I think about 30 years ago but the framing of it is a little different. And so, my point is to say each one of these separate groups should have an effect on the outcome itself of the final rule which changes say the regulatory set. Some rules may be demanded by bureaucrats, some rules are demanded by interest groups in Congress. If I were to put it in the econ speak---because I'm writing this paper probably more for a political science literature---but if I had to put it in an econ speak my I'm kind of saying you have four different demanders for this product and so who is the regulatory agency really supplying this for? It's I think really how I'm thinking about it. For the full conversation, listen to the episode.