This document discusses complex regional pain syndrome (CRPS) and an approach to treating it called "training the brain". It involves three parts: cognitive understanding of the problem, behavioral changes like graded exposure to movement, and inducing brain changes through techniques like graded motor imagery. The goal is to reduce the extreme protective response of the brain and body in CRPS by making subtle threats like imagined movement less threatening over time. Studies show this approach can significantly reduce pain and increase function for people with CRPS.
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Training The Brain 2 Behavioural
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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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. 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. 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
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
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
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. 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. 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
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. 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’