Asking The Right Questions - they key to preventing persistent pain?
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Transcript of Asking The Right Questions - they key to preventing persistent pain?
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
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
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Nociception to the brain
thalamus
Site of the
famous pain
gate
Relay/prioritisation centre -
“what is the most important
thing for the brain to know
about right now?”
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Nociception to the brain
thalamus
There are actually 3 different types of these...
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Nociception to the brain
thalamus
Periaqueductal Gray
There are about 600 descending neurons for every spinal nociceptor. 600 1
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Nociception to the brain
thalamus
Periaqueductal Gray
Projections to PAG come from all over the brain
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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
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Acute pain basics
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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.
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How does the brain produce a conscious protective response?
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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
www.bodyinmind.com.au© lorimer moseley 2010
BeliefsKnowledge, logic
Other sensory cuesSocial context
Anticipated consequencesFamilymedia
previous history culture
GPwork
physiotherapisteducation
activity self-efficacyaccess
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
www.bodyinmind.com.au© lorimer moseley 2010
BeliefsKnowledge, logic
Other sensory cuesSocial context
Anticipated consequencesFamilymedia
previous history culture
GPwork
physiotherapisteducation
activity self-efficacyaccess
exposure
Relay 2: The thalamus
Relay 1: The dorsal horn
Danger
+
It’s more dangerous than that
Pain
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Central sensitivity
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Nociceptors &
descending modulation
Normal state
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Nociceptors &
descending modulation
Normal state Sensitised spinal
nociceptorwww.bodyinmind.com.au© lorimer moseley 2010
Nociceptors &
descending modulation
Normal state Sensitised spinal
nociceptor
Really sensitised
spinal nociceptor
www.bodyinmind.com.au© lorimer moseley 2010
Familymedia
previous history culture
GPwork
physiotherapisteducation
activity self-efficacyaccess
exposure
BeliefsKnowledge, logic
Other sensory cuesSocial context
Anticipated consequences
mediasolicitorcase managerfinancesGFC9/11seasonallergies & illnessesfaithfashionself-efficacyworryloveetc etc etc
Pain
www.bodyinmind.com.au© lorimer moseley 2010
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
www.bodyinmind.com.au© lorimer moseley 2010
Contributions to threat
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
Function
Impact on activity
Everyday tasks
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
Do you have: pain spreading down arms or legs, back - neck or neck - back?
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Contributions to threat
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
Function
Impact on activity
Everyday tasks
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
Is there evidence of autonomic dysfunction? (swelling, colour)
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Contributions to threat
Function
Impact on activity
Everyday tasks
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
What sort of thoughts do you have about your pain/injury?
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
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Contributions to threat
Function
Impact on activity
Everyday tasks
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
What do you believe is the cause of your pain? Do you think it will get better?
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
www.bodyinmind.com.au© lorimer moseley 2010
Contributions to threat
Function
Impact on activity
Everyday tasks
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
How often/much are you worrying about your pain?
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
www.bodyinmind.com.au© lorimer moseley 2010
Contributions to threat
Function
Impact on activity
Everyday tasks
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
How bothered by your pain are you?Are you enjoying things as much as normal?
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
www.bodyinmind.com.au© lorimer moseley 2010
Contributions to threat
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
Is this threatening your quality of life?
Cognitive
Thoughts
Beliefs
Worry
Bothersomeness
Function
Impact on activity
Everyday tasks
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Back pain specific
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Back pain specific
Pain specific
I have burning, shooting pain: my skin is sensitive to touch
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What to do if not low risk....
Sensitisation et al
Peripheral neuropathia
central sensitisation
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
www.bodyinmind.com.au© lorimer moseley 2010
What to do if not low risk....
Sensitisation et al
Peripheral neuropathia
central sensitisation
brain changes
1. Remove the threats you can, cope with those you can’t.
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
www.bodyinmind.com.au© lorimer moseley 2010
What to do if not low risk....
1. Remove the threats you can, cope with those you can’t.
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
Peripheral neuropathia
central sensitisation
brain changes
Train the body & the brain!
www.bodyinmind.com.au© lorimer moseley 2010
b i mwww.bodyinmind.com.au
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