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

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http://www.bodyinmind.com.au/training-the-brain-1-cognitive-understanding-the-problem/




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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?











http://www.bodyinmind.com.au/training-the-brain-2-behavioural-function-and-movement-hierarchy/










http://www.bodyinmind.com.au/training-the-brain-3-brain-changes-s1-reorganisation/
















Cognitive



Educate & explain

Behavioural



Brain changes

S1 reorganisation

















Cognitive



Educate & explain

Behavioural



Brain changes

S1 reorganisation





DAVID

BUTLER | LO

RIMER M

OSELEY | ART SU

NYATA

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resources

www.amazon.comCA$35 & post.

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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

0

4

8Pain

Pre Post 60 min95

110

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”

CRPS1





stimulus

experience

“dysynchiria”

CRPS1





stimulus

experience

“dysynchiria”

pain

CRPS1





opoo

pp p

ppo

xxxx

x x x xx

xxxx x x

xx

xxxxxxx

xx

xxx

xx

x

xxxx

pp

pp

pp

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

50

200 2 4 6 12 18 24

Recog

nition

Imag

ined

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





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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Health & Medicine

Training The Brain 2 Behavioural