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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
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
Nociception            to the brain
www.bodyinmind.com.au
© lorimer moseley 2010

                             thalamus




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

                                    thalamus




        There are actually 3 different
        types of these...
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
Nociception                      to the brain
www.bodyinmind.com.au
© lorimer Projections
                    to PAG come from
          moseley 2010

        all over the brain          thalamus



                         Periaqueductal Gray
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
Acute pain basics

www.bodyinmind.com.au
© lorimer moseley 2010
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
www.bodyinmind.com.au
© lorimer moseley 2010
How does the brain produce a conscious protective
                                                         response?
www.bodyinmind.com.au
© lorimer moseley 2010
Denote synaptic modulation
www.bodyinmind.com.au
© 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
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
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
Central sensitivity




www.bodyinmind.com.au
© lorimer moseley 2010
Normal state

www.bodyinmind.com.au
© lorimer moseley 2010


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


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

Nociceptors
     &
descending
modulation
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
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
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
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
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
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
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
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
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
Back pain specific


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


www.bodyinmind.com.au
                                                   Pain specific
© lorimer moseley 2010

I have burning, shooting pain: my skin is sensitive to touch
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
          , biolog
    plain        learn Everyday tasks
                                               Peripheral
E x
           ure,
  Beliefs                                     neuropathia

   r ea s
  Worry s          ope
             to c
                                                central

      how
                                              sensitisation
  Bothersomeness
                                             brain changes
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
          , biolog
    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
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
bim
                        Blog
                        Slides for your use
                        Articles
                        Seminars
www.bodyinmind.com.au   Books

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Moseley Asking The Right Questions

  • 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
  • 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 www.bodyinmind.com.au © lorimer moseley 2010
  • 11. How does the brain produce a conscious protective response? www.bodyinmind.com.au © lorimer moseley 2010
  • 12. Denote synaptic modulation www.bodyinmind.com.au © 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
  • 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
  • 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 , biolog 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 , biolog 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