Training The Brain 2 Behavioural

Lorimer MoseleyNHMRC Senior Research FellowPrince of Wales Medical Research Institute & Faculty of Medicine, University of NSW, Sydney, Australia

CRPS Rehabilitation (or training the brain)

www.bodyinmind.com.au Copyright GL Moseley 2009 Complex Regional Pain

Syndrome

Why train the brain?

CRPS as an extreme protective response.

www.bodyinmind.com.au Copyright GL Moseley 2009

Our approach to treating CRPS

Cognitive

Understanding the problem

Other threatening cues are relevant

Educate & explain

Behavioural

Function & movement hierarchy

‘training the brain part 1’

Brain changes

S1 reorganisation

Reorganisation elsewhere?

Cognitive

Educate & explain

Behavioural

Brain changes

S1 reorganisation

Cognitive

Educate & explain

Behavioural

Brain changes

S1 reorganisation

BUTLER | LO

RIMER M

OSELEY | ART SU

www.noigroup.comwww.OPTP.comwww.physiouk.co.uk

www.noigroup.comwww.physiouk.co.uk

www.OPTP.com

resources

www.amazon.comCA$35 & post.

The motor/behavioural heirarchy

Most threatening

Least threatening

Functional tasks

Movements

Reduce speed, range, duration, frequency

Explicit motor imagery

Implicit motor imagery

Motor empathy

Movements

Motor empathy

Functional tasks PainMost threatening

Least threatening

Functional tasks

Movements PainReduce speed, range,

duration, frequency

Most threatening

Least threatening

Functional tasks

Movements PainReduce speed, range,

duration, frequency

Most threatening

Least threatening

Functional tasks

Movements

Most threatening

Least threatening

Functional tasks

Movements

Most threatening

Least threatening

Functional tasks

Movements

Motor empathy

Most threatening

Least threatening

Functional tasks

Movements

Motor empathy

Most threatening

Least threatening

‘Training the brain’

Do imagined movements activate the protective response?

Moseley 2004 Neurology 62: 1644Moseley et al 2008 Arth Care & Res 59, 623-31

Functional tasks

Movements

Reduce speed, range,

Motor empathy

Most threatening

Least threatening

extensors

flexors

hyperthenar

thenar

Imagined movements

5 secNew picture

CRPS Non CRPS

Pre Post 60 min95

125SizeRatio(%)

Experiment: Can visual input alone activate CRPS neurotag?

Acerra&Moseley2005Neurology65:751‐3

stimulus

experience

normal

stimulus

experience

normal

stimulus

experience

normal

stimulus

experience

“dysynchiria”

stimulus

experience

“dysynchiria”

stimulus

experience

“dysynchiria”

x x x xx

xxxx x x

xxxxxxx

p poo o o

p pp p

Allodynia

Parasthaesia

Response to light touch on opposite hand while looking in mirror

p = pain

x = ‘odd sensation’

0 =nothing (normal response)

Functional tasks

Movements

Motor empathy

Most threatening

Least threatening

Functional tasks

Movements

Motor empathy

Most threatening

Least threatening

Reducing the threat of imagined

movements.

Graded motor imagery

1. Implicit motor imagery (left/right judgement task)

Moseley (2004) Pain; 108: 192-8;Moseley (2005) Pain 114;54-61Moseley (2006) Neurology 67 2129-34

Is this a left or a right hand?

One image is shown at a timeSoftware is online and via CD “Recognise” www.noigroup.comObjectives: - Equal reaction times for left & right- >80% accuracy

2. Explicit motor imagery (imagined movements)

Imagined limb movements

One image is shown at a timeSoftware 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

2. Explicit motor imagery (imagined movements)

3. Mirror movements

Mirror movements

“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

Time (weeks)

Neuropathic pain scale

200 2 4 6 12 18 24

nition

Mirror

MIP MIP

Moseley(2004) Pain; 108: 192-8;

Crossed over

Single blind RCT

• CRPS of arm or leg• 18-75 years old• No other diagnoses• English-proficient• Presented to GP, physiotherapy, pain management or neurology

Single blind RCT

Moseley (2006) Neurology 67 2129-34

Single 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)

Single blind RCT

Our approach to treating CRPS

Brain changes

S1 reorganisation

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