Training The Brain 2 Behavioural

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Part of training the brain series focused on Complex Regional Pain Syndrome (CRPS) but relevant to all types of pain.

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Training The Brain 2 Behavioural

  1. 1. 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
  2. 2. www.bodyinmind.com.au Copyright GL Moseley 2009 Why train the brain? CRPS as an extreme protective response.
  3. 3. www.bodyinmind.com.au Copyright GL Moseley 2009 Why train the brain? 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’
  4. 4. www.bodyinmind.com.au Copyright GL Moseley 2009 Why train the brain? 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
  5. 5. www.bodyinmind.com.au Copyright GL Moseley 2009 Why train the brain? 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
  6. 6. 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.
  7. 7. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Reduce speed, range, duration, frequency Explicit motor imagery Implicit motor imagery Least threatening Motor empathy
  8. 8. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks Pain threatening Movements Reduce speed, range, duration, frequency Explicit motor imagery Implicit motor imagery Least threatening Motor empathy
  9. 9. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Pain Reduce speed, range, duration, frequency Least threatening
  10. 10. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Pain Reduce speed, range, duration, frequency Least threatening
  11. 11. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Reduce speed, range, duration, frequency Explicit motor imagery Least threatening
  12. 12. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Reduce speed, range, duration, frequency Explicit motor imagery Implicit motor imagery Least threatening
  13. 13. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Reduce speed, range, duration, frequency Explicit motor imagery Implicit motor imagery Least threatening Motor empathy
  14. 14. www.bodyinmind.com.au The motor/behavioural heirarchy Copyright GL Moseley 2009 Most Functional tasks threatening Movements Reduce speed, range, duration, frequency Explicit motor imagery Implicit motor imagery ‘Training the brain’ Least threatening Motor empathy
  15. 15. www.bodyinmind.com.au Copyright GL Moseley 2009 Do imagined movements activate the protective response? Most Functional tasks threatening Movements Reduce speed, range, Explicit motor imagery Implicit motor imagery Least threatening Motor empathy Moseley 2004 Neurology 62: 1644 Moseley et al 2008 Arth Care & Res 59, 623-31
  16. 16. www.bodyinmind.com.au Copyright GL Moseley 2009 Imagined movements extensors flexors hyperthenar thenar 5 sec New picture Moseley 2004 Neurology 62: 1644 Moseley et al 2008 Arth Care & Res 59, 623-31
  17. 17. www.bodyinmind.com.au CRPS Non CRPS Copyright GL Moseley 2009 8 Pain 4 0 125 Size Ratio (%) 110 95 Moseley 2004 Neurology 62: 1644 Pre Post 60 min Moseley et al 2008 Arth Care & Res 59, 623-31
  18. 18. www.bodyinmind.com.au Copyright GL Moseley 2009 Experiment: Can visual input alone activate CRPS neurotag? Acerra
&
Moseley
2005
Neurology
65:
751‐3
  19. 19. www.bodyinmind.com.au Copyright GL Moseley 2009 Acerra
&
Moseley
2005
Neurology
65:
751‐3
  20. 20. www.bodyinmind.com.au Copyright GL Moseley 2009 Acerra
&
Moseley
2005
Neurology
65:
751‐3
  21. 21. www.bodyinmind.com.au Copyright GL Moseley 2009 Acerra
&
Moseley
2005
Neurology
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751‐3
  22. 22. www.bodyinmind.com.au Copyright GL Moseley 2009 Acerra
&
Moseley
2005
Neurology
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751‐3
  23. 23. www.bodyinmind.com.au Copyright GL Moseley 2009 experience normal stimulus Acerra
&
Moseley
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Neurology
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  24. 24. www.bodyinmind.com.au Copyright GL Moseley 2009 experience normal stimulus Acerra
&
Moseley
2005
Neurology
65:
751‐3
  25. 25. www.bodyinmind.com.au Copyright GL Moseley 2009 experience normal stimulus Acerra
&
Moseley
2005
Neurology
65:
751‐3
  26. 26. www.bodyinmind.com.au Copyright GL Moseley 2009 experience stimulus CRPS1 “dysynchiria” Acerra
&
Moseley
2005
Neurology
65:
751‐3
  27. 27. www.bodyinmind.com.au Copyright GL Moseley 2009 experience stimulus CRPS1 “dysynchiria” Acerra
&
Moseley
2005
Neurology
65:
751‐3
  28. 28. www.bodyinmind.com.au Copyright GL Moseley 2009 pain experience stimulus CRPS1 “dysynchiria” Acerra
&
Moseley
2005
Neurology
65:
751‐3
  29. 29. www.bodyinmind.com.au Copyright GL Moseley 2009 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 Acerra
&
Moseley
2005
Neurology
65:
751‐3
  30. 30. www.bodyinmind.com.au Copyright GL Moseley 2009 Do imagined movements activate the protective response? Most Functional tasks threatening Movements Reduce speed, range, Explicit motor imagery Implicit motor imagery Least threatening Motor empathy Moseley 2004 Neurology 62: 1644 Moseley et al 2008 Arth Care & Res 59, 623-31
  31. 31. www.bodyinmind.com.au Copyright GL Moseley 2009 Do imagined movements activate the protective response? Most Functional tasks threatening Movements Reduce speed, range, Explicit motor imagery Reducing the threat of Implicit motor imagery imagined movements. Least threatening Motor empathy Moseley 2004 Neurology 62: 1644 Moseley et al 2008 Arth Care & Res 59, 623-31
  32. 32. www.bodyinmind.com.au Copyright GL Moseley 2009 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
  33. 33. www.bodyinmind.com.au Is this a left or a right hand? Copyright GL Moseley 2009 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
  34. 34. www.bodyinmind.com.au Copyright GL Moseley 2009 Graded motor imagery 1. Implicit motor imagery (left/right judgement task) 2. Explicit motor imagery (imagined movements) Moseley (2004) Pain; 108: 192-8; Moseley (2005) Pain 114;54-61 Moseley (2006) Neurology 67 2129-34
  35. 35. www.bodyinmind.com.au Imagined limb movements Copyright GL Moseley 2009 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
  36. 36. www.bodyinmind.com.au Copyright GL Moseley 2009 Graded motor imagery 1. Implicit motor imagery (left/right judgement task) 2. Explicit motor imagery (imagined movements) 3. Mirror movements Moseley (2004) Pain; 108: 192-8; Moseley (2005) Pain 114;54-61 Moseley (2006) Neurology 67 2129-34
  37. 37. www.bodyinmind.com.au Mirror movements Copyright GL Moseley 2009 “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
  38. 38. www.bodyinmind.com.au Single n Copyright GL Moseley 2009 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)
  39. 39. www.bodyinmind.com.au Copyright GL Moseley 2009 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
  40. 40. www.bodyinmind.com.au Single Copyright GL Moseley 2009 blind RCT Moseley (2006) Neurology 67 2129-34
  41. 41. www.bodyinmind.com.au Single Copyright GL Moseley 2009 blind RCT Moseley (2006) Neurology 67 2129-34
  42. 42. www.bodyinmind.com.au Single Copyright GL Moseley 2009 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) Moseley (2006) Neurology 67 2129-34
  43. 43. www.bodyinmind.com.au Copyright GL Moseley 2009 Why train the brain? Our approach to treating CRPS Go to the Brain changes next set of S1 reorganisation slides: Reorganisation elsewhere? ‘training the brain part 2’

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