1. Asking the right
questions.
bim
www.bodyinmind.com.au
The key to preventing
persistent pain?
Lorimer Moseley
NHMRC Senior Research Fellow
Prince of Wales Medical Research Institute & School of Medical Sciences, University of New South Wales,
Sydney, Australia

2. www.bodyinmind.com.au
© lorimer moseley 2010 It is all about protection
Basic motor response
Coordinated motor response
Memory response Nociception
Sympathetic nervous system response
Endocrine system response
Immune system response
Consciously motivated behaviour Pain

3. Nociception to the brain
www.bodyinmind.com.au
© lorimer moseley 2010
thalamus
“Danger in my
area”

4. Nociception to the brain
www.bodyinmind.com.au
© lorimer moseley 2010
-
Relay/prio ritisation centre
ant thalamus
“what i s the most import
know
thin g for the brain to
”
about right now?
Site of the
famous pain
gate

5. Nociception to the brain
www.bodyinmind.com.au
© lorimer moseley 2010
thalamus
There are actually 3 different
types of these...

6. Nociception to the brain
www.bodyinmind.com.au
© lorimer moseley 2010
thalamus
Periaqueductal Gray
There are about 600
descending neurons for every
spinal nociceptor.
600 1

7. Nociception to the brain
www.bodyinmind.com.au
© lorimer Projections
to PAG come from
moseley 2010
all over the brain thalamus
Periaqueductal Gray

8. Nociception to the brain
All happens without us knowing
about it
thalamus
Can activate protective
responses without us knowing
about it
Nociception is happening now
Right now.
www.bodyinmind.com.au
© lorimer moseley 2010

9. Acute pain basics
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© lorimer moseley 2010

10. Pain emerges from the brain with activity in a
particular and peculiar network of brain areas
Individually specific
Every brain cell
involved also does
other things
Hoffman et al (2004) NeuroReport
Text Obliteration of one
‘node’ does not
remove pain - the
brain works out how
to produce pain
Professor Wiki Pedia (2010) using other brain
cells.
MacIver et al (2008) Brain
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© lorimer moseley 2010

11. How does the brain produce a conscious protective
response?
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© lorimer moseley 2010

12. Denote synaptic modulation
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© lorimer moseley 2010
Beliefs
Knowledge, logic
Other sensory cues
Social context
Anticipated consequences
Family
media
previous history media
solicitor
culture case manager
GP finances
GFC
work 9/11
physical therapist season
allergies & illnesses
education faith
activity self-efficacy fashion
self-efficacy
access worry
previous exposure love
etc etc etc
www.bodyinmind.com.au

13. Beliefs Pain
Knowledge, logic
Other sensory cues
Social context
Anticipated consequences
Family
media
previous history It’s not that
culture
GP
Relay 2: The thalamus dangerous
work
physiotherapist
education
activity self-efficacy
access
exposure
media
solicitor
case manager
finances
GFC
9/11
season
allergies & illnesses
faith
fashion
self-efficacy
worry
love
etc etc etc
-
Relay 1: The dorsal horn
www.bodyinmind.com.au
© lorimer moseley 2010
Danger

14. Beliefs Pain
Knowledge, logic
Other sensory cues
Social context
Anticipated consequences
Family
media
previous history It’s more
culture
GP
Relay 2: The thalamus dangerous
work
physiotherapist
education than that
activity self-efficacy
access
exposure
+
Relay 1: The dorsal horn
www.bodyinmind.com.au
© lorimer moseley 2010
Danger

15. Central sensitivity
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© lorimer moseley 2010

16. Normal state
www.bodyinmind.com.au
© lorimer moseley 2010
Nociceptors
&
descending
modulation

17. Normal state Sensitised
spinal
www.bodyinmind.com.au nociceptor
© lorimer moseley 2010
Nociceptors
&
descending
modulation

18. Normal state Sensitised Really
spinal sensitised
www.bodyinmind.com.au nociceptor spinal
© lorimer moseley 2010 nociceptor
Nociceptors
&
descending
modulation

19. www.bodyinmind.com.au
© lorimer moseley 2010
Pain
Beliefs
Knowledge, logic
Other sensory cues
Social context
Anticipated consequences
Family
media
previous history media
culture solicitor
case manager
GP finances
work GFC
9/11
physiotherapist season
education allergies & illnesses
activity self-efficacy faith
fashion
access self-efficacy
worry
love
exposure etc etc etc

20. www.bodyinmind.com.au
© lorimer moseley 2010
Contributions to threat
Do you have: burning, shooting
pain, allodynia?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

21. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
Do you have: pain spreading
down arms or legs, back - neck
or neck - back?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

22. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
Is there evidence of autonomic
dysfunction? (swelling, colour)
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

23. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
What sort of thoughts do you
have about your pain/injury?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

24. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
What do you believe is the
cause of your pain? Do you
think it will get better?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

25. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
How often/much are you
worrying about your pain?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

26. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
How bothered by your pain are
you?
Are you enjoying things as much
as normal?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

27. www.bodyinmind.com.au
© lorimer moseley 2010 Contributions to threat
Is this threatening your quality of
life?
Cognitive Function Sensitisation
et al
Thoughts Impact on activity
Peripheral
Beliefs Everyday tasks neuropathia
Worry central
sensitisation
Bothersomeness
brain changes

28. Back pain specific
www.bodyinmind.com.au
© lorimer moseley 2010

29. Back pain specific
www.bodyinmind.com.au
Pain specific
© lorimer moseley 2010
I have burning, shooting pain: my skin is sensitive to touch

30. What to do if not low risk....
1. Remove the threats you can, cope with those you can’t.
www.bodyinmind.com.au
© lorimer moseley 2010
Cognitive Function Sensitisation
ise, Impact on activity et al
Thoughts
, bi olog
plain learn Everyday tasks
Peripheral
E x
ure,
Beliefs neuropathia
r ea s
Worry s ope
to c
central
how
sensitisation
Bothersomeness
brain changes

31. What to do if not low risk....
1. Remove the threats you can, cope with those you can’t.
2. Gradually
www.bodyinmind.com.au expose to all identified threats.
© lorimer moseley 2010
Cognitive Function Sensitisation
ise, Impact on activity et al
Thoughts
, bi olog
plain learnraded extaskssu
Peripheral
E x
Beliefs
, G Everyday po re
ure
neuropathia
r ea s
Worry s ope
to c
central
how
sensitisation
Bothersomeness
brain changes

32. What to do if not low risk....
1. Remove the threats you can, cope with those you can’t.
2. Gradually expose to all identified threats.
3. Maximise health of the tissues, the nerves & the brain.
Cognitive Function Sensitisation
ise, Impact on activity Trai
n the et al
Thoughts
bio log body &
Exp lain, rn Everyday tasks thePeripheral
Beliefs
e , leaGraded exposure brain!
neuropathia
Worry s
sur
rea c ope central
to
h ow
Bothersomeness
sensitisation
brain changes
www.bodyinmind.com.au
© lorimer moseley 2010

33. bim
Blog
Slides for your use
Articles
Seminars
www.bodyinmind.com.au Books