moseley asking the right questions

Asking the right questions.The key to preventing persistent pain?

Lorimer MoseleyNHMRC Senior Research FellowPrince of Wales Medical Research Institute & School of Medical Sciences, University of New South Wales, Sydney, Australia

b i mwww.bodyinmind.com.au

http://www.bodyinmind.com.au


Basic motor response

Coordinated motor response

Memory response

Sympathetic nervous system response

Endocrine system response

Immune system response

Consciously motivated behaviour

It is all about protection

Nociception

Pain

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Nociception to the brain

“Danger in my area”

thalamus







thalamus

Site of the

famous pain

gate

Relay/prioritisation centre -

“what is the most important

thing for the brain to know

about right now?”







thalamus

There are actually 3 different types of these...







thalamus

Periaqueductal Gray

There are about 600 descending neurons for every spinal nociceptor. 600 1







thalamus

Periaqueductal Gray

Projections to PAG come from all over the brain






Nociception

All happens without us knowing about it

Can activate protective responses without us knowing about it

Nociception is happening now Right now.

to the brain

thalamus






Acute pain basics






Pain emerges from the brain with activity in a particular and peculiar network of brain areas

TextHoffman et al (2004) NeuroReport

MacIver et al (2008) Brain

Professor Wiki Pedia (2010)

Individually specific

Every brain cell involved also does other things

Obliteration of one ‘node’ does not remove pain - the brain works out how to produce pain using other brain cells.






How does the brain produce a conscious protective response?






BeliefsKnowledge, logic

Other sensory cuesSocial context

Anticipated consequences

Denote synaptic modulation

Familymedia

previous history culture

GPwork

physical therapisteducation

activity self-efficacyaccess

previous exposure

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mediasolicitorcase managerfinancesGFC9/11seasonallergies & illnessesfaithfashionself-efficacyworryloveetc etc etc










Anticipated consequencesFamilymedia


GPwork

physiotherapisteducation


exposure

Relay 2: The thalamus

Relay 1: The dorsal horn

Danger

-

It’s not that dangerous

Pain

mediasolicitor

case managerfinances

GFC9/11

seasonallergies & illnesses

faithfashion

self-efficacyworry

loveetc etc etc








Anticipated consequencesFamilymedia


GPwork



exposure

Relay 2: The thalamus

Relay 1: The dorsal horn

Danger

+

It’s more dangerous than that

Pain






Central sensitivity






Nociceptors &

descending modulation

Normal state






Nociceptors &


Normal state Sensitised spinal

nociceptorwww.bodyinmind.com.au© lorimer moseley 2010





Nociceptors &


Normal state Sensitised spinal

nociceptor

Really sensitised

spinal nociceptor






Familymedia


GPwork



exposure



Anticipated consequences

mediasolicitorcase managerfinancesGFC9/11seasonallergies & illnessesfaithfashionself-efficacyworryloveetc etc etc

Pain






Contributions to threat

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Function

Impact on activity

Everyday tasks

Do you have: burning, shooting pain, allodynia?

Sensitisation et al

Peripheral neuropathia

central sensitisation

brain changes







Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Function

Impact on activity

Everyday tasks

Sensitisation et al



brain changes

Do you have: pain spreading down arms or legs, back - neck or neck - back?







Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Function

Impact on activity

Everyday tasks

Sensitisation et al



brain changes

Is there evidence of autonomic dysfunction? (swelling, colour)







Function

Impact on activity

Everyday tasks

Sensitisation et al



brain changes

What sort of thoughts do you have about your pain/injury?

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness







Function

Impact on activity

Everyday tasks

Sensitisation et al



brain changes

What do you believe is the cause of your pain? Do you think it will get better?

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness







Function

Impact on activity

Everyday tasks

Sensitisation et al



brain changes

How often/much are you worrying about your pain?

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness







Function

Impact on activity

Everyday tasks

Sensitisation et al



brain changes

How bothered by your pain are you?Are you enjoying things as much as normal?

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness







Sensitisation et al



brain changes

Is this threatening your quality of life?

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Function

Impact on activity

Everyday tasks






Back pain specific






Back pain specific

Pain specific

I have burning, shooting pain: my skin is sensitive to touch






What to do if not low risk....

Sensitisation et al



brain changes

1. Remove the threats you can, cope with those you can’t.

Function

Impact on activity

Everyday tasks

Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Explain, biol

ogise,

reassure, lea

rn

how to cope







Sensitisation et al



brain changes


Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Explain, biol

ogise,

reassure, lea

rn

how to cope

2. Gradually expose to all identified threats.

Function

Impact on activity

Everyday tasksGraded exposure








Cognitive

Thoughts

Beliefs

Worry

Bothersomeness

Function

Impact on activity

Everyday tasksExplain, biol

ogise,

reassure, lea

rn

how to copeGraded exposure

2. Gradually expose to all identified threats.

3. Maximise health of the tissues, the nerves & the brain.

Sensitisation et al



brain changes

Train the body & the brain!






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