Training The Brain 2 Behavioural

Complex Regional Pain
www.bodyinmind.com.au
Copyright GL Moseley 2009

Syndrome

CRPS Rehabilitation
(or training the brain)

Lorimer Moseley
NHMRC Senior Research Fellow
Prince of Wales Medical Research Institute & Faculty of Medicine, University of NSW, Sydney,
Australia

Why train the brain?

CRPS as an extreme protective response.


Our approach to treating CRPS
Cognitive Behavioural Brain changes
Understanding the Function & S1 reorganisation
problem movement
hierarchy Reorganisation
Other threatening elsewhere?
cues are relevant ‘training the brain
part 1’ ‘training the brain
Educate & explain part 2’


CRPS as an extreme protective response.
Cognitive Behavioural Brain changes
Understanding the Function & S1 reorganisation
problem movement
hierarchy Reorganisation
Other threatening elsewhere?
cues are relevant ‘training the brain
part 1’
Educate & explain

resources

DAVID BUTLER
|
LORIMER MOSELEY
|
ART SUNYATA
www.noigroup.com
www.physiouk.co.uk
www.OPTP.com

www.noigroup.com
www.OPTP.com
www.physiouk.co.uk

www.amazon.com
CA$35 & post.


The motor/behavioural heirarchy

Most Functional tasks
threatening

Movements
Reduce speed, range,
duration, frequency

Explicit motor imagery

Implicit motor imagery
Least
threatening Motor empathy



Most Functional tasks Pain
threatening

Movements
duration, frequency


Least



threatening

Movements Pain
duration, frequency

Least
threatening



threatening

Movements
duration, frequency


Least
threatening



threatening

Movements
duration, frequency


‘Training
the brain’
Least


Do imagined movements activate the
protective response?

threatening

Movements




Least

Moseley 2004 Neurology 62: 1644
Moseley et al 2008 Arth Care & Res 59, 623-31

Imagined movements

extensors
flexors
hyperthenar

thenar

5 sec
New picture


CRPS Non CRPS
8
Pain

4

0
125
Size
Ratio
(%)
110

95
Moseley 2004 Neurology 62: 1644 Pre Post 60 min


Experiment: Can visual input
alone activate CRPS neurotag?

Acerra & Moseley 2005 Neurology 65: 751‐3


experience

normal stimulus



experience
stimulus
CRPS1

“dysynchiria”


pain

experience
stimulus
CRPS1

“dysynchiria”


Parasthaesia
Allodynia

Response to light
touch on opposite
hand while looking
x x x in mirror
x x x
x x x x x
x x x x x x x x p = pain
x xx x x x x
x x xx op x x x
x x = ‘odd sensation’
p pp p p
p p x
pppp pp x 0 =nothing (normal
o pp p p response)
o o o o o o


Do imagined movements activate the
protective response?

threatening

Movements


Explicit motor imagery Reducing the
threat of
Implicit motor imagery imagined
movements.
Least



Graded motor imagery
1. Implicit motor imagery (left/right judgement task)

Moseley (2004) Pain; 108: 192-8;
Moseley (2005) Pain 114;54-61
Moseley (2006) Neurology 67 2129-34


Is this a left or a right hand?

One image is shown at a time
Software is online and via CD
“Recognise” www.noigroup.com
Objectives:
- Equal reaction times for left & right
- >80% accuracy



2. Explicit motor imagery (imagined movements)

Moseley (2004) Pain; 108: 192-8;
Moseley (2005) Pain 114;54-61

Imagined limb movements

One image is shown at a time
Software is online and via CD
“Recognise” www.noigroup.com

“Imagine adopting this posture with your
own hand and then returning it to where
it is. Imagine a pain-free, smooth
movement”.

Objectives:
- Little or no symptom provocation
- Task is easy or boring



2. Explicit motor imagery (imagined movements)

3. Mirror movements

Moseley (2004) Pain; 108: 192-8;
Moseley (2005) Pain 114;54-61

Mirror movements

“Gently adopt the posture shown with
both hands, while watching the mirror
image of your good hand”.

Objectives:
-Little or no symptom provocation
-Movement is not dystonic
-Movement L & R similar in range and
speed
- Task is easy or boring

www.bodyinmind.com.au Single

n

itio
blind

d
ine
gn
RCT

or
ag
co

irr
Im
Re

M
MIP MIP

50

Neuropathic
pain scale
Crossed over

20
0 2 4 6 12 18 24

Moseley(2004) Pain; 108: 192-8; Time (weeks)

Single
blind
• CRPS of arm or leg RCT
• 18-75 years old
• No other diagnoses Moseley (2006) Neurology 67 2129-34

• English-proficient
• Presented to GP,
physiotherapy, pain
management or
neurology

blind
RCT


blind
RCT

NNT to get a 50%
reduction in pain

Post-MIP = 3 (2-6)

6 months = 2 (1-5)

NNT to get a 4/10 point
increase in function

Post-MIP = 4 (2-11)

6 months = 3 (2-4)


Our approach to treating CRPS

Go to the Brain changes

next set of S1 reorganisation

slides: Reorganisation
elsewhere?

‘training the brain
part 2’

Training The Brain 2 Behavioural

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