Asking the right
                        questions.
      bim
www.bodyinmind.com.au
                        The key to pre...
www.bodyinmind.com.au
© lorimer moseley 2010   It is all about protection


       Basic motor response
       Coordinated...
Nociception            to the brain
www.bodyinmind.com.au
© lorimer moseley 2010

                             thalamus


...
Nociception             to the brain
www.bodyinmind.com.au
© lorimer moseley 2010
                              -
Relay/pr...
Nociception                   to the brain
www.bodyinmind.com.au
© lorimer moseley 2010

                                 ...
Nociception                     to the brain

www.bodyinmind.com.au
© lorimer moseley 2010

                              ...
Nociception                      to the brain
www.bodyinmind.com.au
© lorimer Projections
                    to PAG come ...
Nociception                      to the brain

All happens without us knowing
about it
                                   ...
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

                          ...
How does the brain produce a conscious protective
                                                         response?
www.b...
Denote synaptic modulation
www.bodyinmind.com.au
© lorimer moseley 2010
                               Beliefs
           ...
Beliefs                                                                         Pain
          Knowledge, logic
         O...
Beliefs                                                              Pain
         Knowledge, logic
        Other sensory ...
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 2...
Normal state         Sensitised      Really
                            spinal      sensitised
www.bodyinmind.com.au    no...
www.bodyinmind.com.au
© lorimer moseley 2010

     Pain
                            Beliefs
                 Knowledge, lo...
www.bodyinmind.com.au
© lorimer moseley 2010
                                  Contributions to threat

                 D...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   Do you have: pain spre...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   Is there evidence of a...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   What sort of thoughts ...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   What do you believe is...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   How often/much are you...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   How bothered by your p...
www.bodyinmind.com.au
© lorimer moseley 2010            Contributions to threat

                   Is this threatening yo...
Back pain specific


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


www.bodyinmind.com.au
                                                   Pain specific
© lorimer mose...
What to do if not low risk....
  1. Remove the threats you can, cope with those you can’t.

    www.bodyinmind.com.au
    ...
What to do if not low risk....
 1. Remove the threats you can, cope with those you can’t.

                    2. Graduall...
What to do if not low risk....
 1. Remove the threats you can, cope with those you can’t.

                     2. Gradual...
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Asking The Right Questions - they key to preventing persistent pain?

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Asking The Right Questions - they key to preventing persistent pain?

  1. 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. 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. 3. Nociception to the brain www.bodyinmind.com.au © lorimer moseley 2010 thalamus “Danger in my area”
  4. 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. 5. Nociception to the brain www.bodyinmind.com.au © lorimer moseley 2010 thalamus There are actually 3 different types of these...
  6. 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. 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. 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. 9. Acute pain basics www.bodyinmind.com.au © lorimer moseley 2010
  10. 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. 11. How does the brain produce a conscious protective response? www.bodyinmind.com.au © lorimer moseley 2010
  12. 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. 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. 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. 15. Central sensitivity www.bodyinmind.com.au © lorimer moseley 2010
  16. 16. Normal state www.bodyinmind.com.au © lorimer moseley 2010 Nociceptors & descending modulation
  17. 17. Normal state Sensitised spinal www.bodyinmind.com.au nociceptor © lorimer moseley 2010 Nociceptors & descending modulation
  18. 18. Normal state Sensitised Really spinal sensitised www.bodyinmind.com.au nociceptor spinal © lorimer moseley 2010 nociceptor Nociceptors & descending modulation
  19. 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. 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. 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. 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. 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. 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. 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. 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. 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. 28. Back pain specific www.bodyinmind.com.au © lorimer moseley 2010
  29. 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. 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. 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. 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. 33. bim Blog Slides for your use Articles Seminars www.bodyinmind.com.au Books
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