CHRONIC LOW BACK PAIN:

A MALADAPTIVE PERCEPTION MODEL

“So when everything seems to turn out for the better and I am on track again, the physiotherapist always finds something new in my back that is not OK and …….” (Afrell 2007)

(Moseley 2008)

Current Treatment For CNSLBP Is Not Very Effective

(Rubinstein 2011)(Hayden 2005)

No Matter What We Do

(Schaafsma 2013)

(Henschke 2010)

(Ibrahim 2008)

Managing Nociception Is Not The Same As Managing Pain

END ORGAN DYSFUNCTION MODEL•Focus on structure responsible for nociception

•Need to understand the back to understand LBP

•The back (& nociception) primary targets of

treatmentCNS PROCESSING MODEL

•Focus on structure responsible constructing pain

experience

•Need to understand the brain to understand LBP

•The brain (& pain experience) primary targets of

treatment

Long Appreciation That Some Aspects Of Brain Function Influence The

CLBP Experience

Also Appears The Brain Changes Structurally

Neurochemical profileDLPFC, ACC, In, S1, M1, Thal, OFC... (Grachev 2000, 2002, 2003, Siddall 2006, Gussew 2010, Sharma 2011, Sharma 2013)

Grey matterDLPFC, A/MCC, In, S1/2, MC, Th, PPC, midbrain, TL,

Hip, NAc…(Apkarian 2004, Schmidt-Wilcke 2006, Buckalew 2008, Gussew 2010, Seminowicz 2011, Ruscheweyh 2011, Baliki 2011, 2012, Mutso 2012, Ung 2012, Ivo 2013,

Vachon-pressau 2013, Kong 2013, Dolman 2013)

White matterCingulate, Insula, corpus callosum, SLF, ILF, ATT… (Buckalew 2008, Gussew 2010, Buckalew 2010, Ivo 2013, Buckalew 2013, Mansour 2013)

And There Are Associated Sensorimotor Changes• Sensory representation (Flor 1997, Lloyd 2008)

• Response to nociception(Flor 1997, Diers 2007, Giesecke 2004, 2006, Kobayashi 2009, Baliki 2006, 2008, Wasan 2011, Hashmi 2013)

• Non-noxious, verbal & visual stimuli

(Flor 1997, Lloyd 2008, Flor 1997b, Shimo 2011)

• Motor representation(Tsao 2008, Tsao 2011)

• Activation with movement(Jacobs 2010, Masse´-Alarie 2012)

• Corticospinal drive(Strutton 2005)

• Resting state(Baliki 2008, Buckalew 2010, Tagliazucchi 2010, Balenzuela 2010, Baliki 2011, Loggia 2012, Kornelsen 2013, Kong

2013)

A Cause Or A Consequence?

Are The Data On Brain Changes

Compatible With What Is Know About CLBP

“It is necessary to evaluate claims of causality within the context of the current state of knowledge within a given field and in related fields”.

Enhanced Nociceptive Efficiency?

• Local hyperalgesia

(Giesbrecht 2005, Farasyn 2005, Laursen 2005, Kobayashi 2009, Blumenstiel 2011, O’Neill 2011, Neziri 2012, Puta 2012, Puta 2013, Imamura 2013)

• Remote hyperalgesia (Flor 2002, 2004, Giesecke 2004, 2005, Laursen 2005, Lewis 2010, O’Neill 2011, Wang 2012, Neziri 2012, Puta 2012, Puta 2013, Biurrun Manresa 2013, Imamura

2013, O’Neill 2013, O’Sullivan 2014)

• Remote sensitisation(Kleinbohl 1999, Flor 2004, Diers 2007, Neziri 2012, Biurrun Manresa 2013)

• Lower NWR threshold, larger RRF(Biurrun Manresa 2013)

• Multi-modal sensitivity(Small 2006, Fann 2005)

Impaired Attentional Processing?

• Attentional bias pain related words (Haggman 2010,

Sharpe 2013)

• Difficulty disengaging threat pictures (Roelofs

2005)

• Distraction less analgesic in CLBP (Johnson 1997,

Goubert 2004)

• Working memory• Selective attention• Mental flexibility (Grisart 1999, Weiner 2006, Ling 2007, Jorge 2009, Buckalew 2008, Gijsen

2011, Schiltenwolf 2014)

Altered Body Perception/Awareness

• Certainly move differently• Slower

• Altered muscle recruitment – Co-contraction / Increased rigidity– Decreased variability

• Decreased proprioceptive acuity(Brumagne 2000, Gill 1998, Lee 2010, O'Sullivan 2003, Taimela 1999, Sheeran 2012, Astflack 2013, Hidalgo 2013)

• Less sensitive to back muscle vibration– Performance isn't worse with vibration

(Brumagne 2004, Brumagne 2008, Claeys 2011, Claeys 2012)

Altered Body Perception/Awareness

• Decreased sensory acuity (Moseley 2008, Wand 2010, Luomajoki

2011, Stanton 2013)

• Poorer graphaesthesia (Wand 2010)

• Mislocalise information (Wand 2012)

• Poorer laterality recognition (Bray 2011, Bowering 2014)

Altered Body Perception/Awareness

• Smaller than really is• Midline shift• Miss bits out (Moseley 2008)

• Neglect that side (Moseley 2012)

• Impaired visual recognition of actions

(de Lussanet 2012, 2013)

Altered Body Perception/Awareness

• Less precision with tracking (Willigenburg 2013)

• Less able to detect postural drift

(Willigenburg 2012)

• Qualitative studies (Smith & Osborn 2008, Crowe 2009)

– ‘Not part of me’– ‘Not controlled automatically’– ‘Doesn’t belong

Self-Report Disturbances In Body Perception (Wand 2014)

Never Rarely

Occasionally

Often

Always

Not part of the rest of my body 49 26 20 4 2Focus all my attention on my back to make it move

22 22 29 18 10

Back moves involuntarily, without my control 55 22 14 10 0I don’t know how my back is moving 39 26 20 12 4Not exactly sure what position my back is in 51 29 12 4 4I can’t perceive the exact outline of my back 39 29 22 8 2My back feels like it is enlarged (swollen) 28 20 28 22 4My back feels like it has shrunk 69 16 8 4 4My back feels lopsided (asymmetrical) 12 16 26 29 18

Altered Body Perception Might Influence The Clinical Condition In A

Number Of Ways

Tissue loading

Reason for movement dysfunction

• Abnormal tissue loading

• Generate nociceptive input

• Motor control related to acuity(Luomajoki 2011)

Altered Body Perception Might Influence The Clinical Condition In A Number Of Ways

Tissue health

Disrupt homeostasis

• Cooling with disownership (Moseley 2008)

• Alters histamine response (Barnsley 2012)

• Goggles change swelling (Moseley

2008)

Altered Body Perception Might Influence The Clinical Condition In A Number Of Ways

Enhanced Sensitivity

• Sensori-motor incongruence (Harris 1999)

• Expected ≠ Actual feedback

• Maybe information is more threatening

• Enhanced salience (Legrain 2011)

• Less safe

• Poor localisation

• Increase spatial summation (Defrin 2006)

Altered Body Perception Might Influence The Clinical Condition In A Number Of

Ways

Fear & Worry

• Poor localisation of inputs

• Unexpected inputs

• Unexplained inputs

• Wrong / strange / peculiar

• Loss of control /ownership

• Perceived vulnerability

Can We Build A Plausible Model From

That Information?

We Really Need Some Longitudinal Data

Distress/Depression Perceived persistenceHelplessnessPessimism/Rumination Activity is harmfulSomething serious Passive coping

Atrophy over timeShift to emotional circuitry

Persistence predicted by• Emotional pain score• mPFC/NAcc connectivity • mPFC over LPFC info sharing• Avoid emotional pain stimuli

We Really Need Some Longitudinal Data

• Neutral reasoning

• Mediates analgesic effect of control

• Moderates catastrophisation and

unpleasantness

• LPFC/NAcc - successful emotional reappraisal

• Emotional reasoning - Emotional persistence

• Mediates rel’ship clinical pain and depression

• Associated with spontaneous clinical pain

• mPFC/Nacc - related to anxiety

LPFC

mPFC

THE MALADAPTIVE PERCEPTION MODEL

A CAUSAL MODEL?

Is There Any Experimental Research To

Support These Ideas?

Looking At It Helps (Wand 2012)

• Cross-over experiment • Standardised range, speed and reps – 60

reps• Moving with visualisation v without

visualisationWith visual

feedback

mean (SD)

Without visual

feedback

mean (SD)

Mean difference

(95%CI)

p

Pain Intensity 7.75 (11.92) 17.00 (14.61) 9.25 (1.44-17.06) .022

Time To Ease 48.50 (56.09) 97.38 (80.17) 48.88 (19.53-78.22) .002

Sensory Discrimination Helps (Wand 2013)

• Cross-over experiment - acupuncture needles

• Control condition – Relax and think of nothing

• Experimental condition– Nominate which needle is being stimulated

• Pain intensity with ten active movementsPain with training Pain without

trainingMean difference

(95% CI)p

2.8 ± 2.5 3.6 ± 2.0 -0.8 (-1.4 to -0.3) p=0.011

Graded Cortical Retraining Might Also? (Wand 2011)

Sensory training• Localisation of

stimulus

• Localisation & Type

• Graphaesthesia training– Letters– Words– Sums

• Size• Orientation• Speed • Overlap

Motor training• Laterality recognition

– Recognise©

• Imagined movements– Small range – Large range

• Local muscle activation– Local mm contraction– Dissociation exercises

• Feedback enriched mvt– Small range– Large range– Functional activities

And I know it isn't back pain but…Retraining the working body schema

might also • Cross over experiment• Chronic Achilles tendinopathy• Pain on hopping

Feet training Hand training Mean difference (95% CI)

p

50.33 ±19.107 63.5 ±25.018 13.17 (-20.4 to -0.7 ) p=0.04

Check Out These Three RCT’s

And This One

(1) A cognitive component - vicious cycle of pain was outlined

(2) Specific exercises to normalize maladaptive movement

behaviours

(3) Targeted functional integration of activities in their daily

life

(4) A physical activity programme tailored to the movement

classification

Functional Rehabilitation Which Has Mutual

Normalisation Of Cognitive Perception And Self

Perception As Its Primary FocusStop reinforcing

• Fragility• Hopelessness• Vulnerability

Stop reinforcing• Splinting• Rigidity• Lack of variability

In some more detail – cognitive perception

• Coherent explanation– Neuroscience informed– What they are feeling– Reasons for treatment failure– Controllable and reversible– Pathway to resolution

• Though needs commitment

• Disavow pathoanatomy– Robust– Sore but safe– Movement is helpful– Movement is healthy

• Build confidence• Restore hope

– Realistic timeframe

• Enhance self-efficacy

In some more detail – self perception

• Enhance self-perception– Sensory awareness– Spatial awareness– Motor awareness

• Ownership and familiarity– Sensory discrimination– Motor empathy– Laterality recognition– Motor imagery– Local muscle activation

• Delineation & Dissociation– Independent movement

• Adequate local mobility

– Independent control• Adequate remote mobility

• Awareness through range• Functional integration

Questions?Acknowledgements: Dr Neil O’ConnellProf. Lorimer MoseleyDr James McAuleyDr Anne Smith

Flavia Di PietroVerity TullochMonique JamesJemma KeevesSam Abbaszadeh

Pam GeorgeClaire BourgoinPam Formby