1. CHRONIC LOW BACK PAIN:
A MALADAPTIVE
PERCEPTION MODEL
“So when everything seems
to turn out for the better
and I am on track again, the
physiotherapist always finds
something new in my back
that is not OK and …….”
(Afrell 2007)
(Moseley 2008)
3. No Matter What We Do
(Schaafsma 2013)
(Henschke 2010)
(Ibrahim 2008)
4. Managing Nociception Is Not The Same As Managing Pain
END ORGAN DYSFUNCTION MODEL
•Focus on structure responsible for nociception
•Need to understand the back to understand LBP
•The back (& nociception) primary targets of treatment
CNS PROCESSING MODEL
•Focus on structure responsible constructing pain experience
•Need to understand the brain to understand LBP
•The brain (& pain experience) primary targets of treatment
9. Are The Data On Brain
Changes Compatible
With What Is Know
About CLBP
“It is necessary to evaluate claims of causality
within the context of the current state of knowledge
within a given field and in related fields”.
14. Altered Body Perception/Awareness
• Smaller than really is
• Midline shift
• Miss bits out (Moseley 2008)
• Neglect that side (Moseley 2012)
• Impaired visual recognition of actions
(de Lussanet 2012, 2013)
15. Altered Body Perception/Awareness
• Less precision with tracking
(Willigenburg 2013)
• Less able to detect postural drift
(Willigenburg 2012)
• Qualitative studies
(Smith & Osborn 2008, Crowe 2009)
–‘Not part of me’
– ‘Not controlled automatically’
– ‘Doesn’t belong
16. Self-Report Disturbances In Body
Perception (Wand 2014)
Never Rarely Occasionally Often Always
Not part of the rest of my body
49 26 20 4 2
Focus all my attention on my back to make it
move
22 22 29 18 10
Back moves involuntarily, without my control
55 22 14 10 0
I don’t know how my back is moving
39 26 20 12 4
Not exactly sure what position my back is in
51 29 12 4 4
I can’t perceive the exact outline of my back
39 29 22 8 2
My back feels like it is enlarged (swollen)
28 20 28 22 4
My back feels like it has shrunk
69 16 8 4 4
My back feels lopsided (asymmetrical)
12 16 26 29 18
17. Altered Body Perception Might Influence The
Clinical Condition In A Number Of Ways
Tissue loading
Reason for movement dysfunction
• Abnormal tissue loading
• Generate nociceptive input
• Motor control related to acuity
(Luomajoki 2011)
18. Altered Body Perception Might Influence The
Clinical Condition In A Number Of Ways
Tissue health
Disrupt homeostasis
• Cooling with disownership (Moseley 2008)
• Alters histamine response (Barnsley 2012)
• Goggles change swelling (Moseley 2008)
19. Altered Body Perception Might Influence The Clinical
Condition In A Number Of Ways
Enhanced Sensitivity
• Sensori-motor incongruence (Harris 1999)
• Expected ≠ Actual feedback
• Maybe information is more threatening
• Enhanced salience (Legrain 2011)
• Less safe
• Poor localisation
• Increase spatial summation (Defrin 2006)
20. Altered Body Perception Might Influence The
Clinical Condition In A Number Of Ways
Fear & Worry
• Poor localisation of inputs
• Unexpected inputs
• Unexplained inputs
• Wrong / strange / peculiar
• Loss of control /ownership
• Perceived vulnerability
21. Can We Build A Plausible
Model From That
Information?
22. We Really Need Some Longitudinal Data
Distress/Depression
Perceived persistence
Helplessness
Pessimism/Rumination
Activity is harmful
Something serious
Passive coping
Atrophy over time
Shift to emotional circuitry
Persistence predicted by
• Emotional pain score
• mPFC/NAcc connectivity
• mPFC over LPFC info sharing
• Avoid emotional pain stimuli
23. We Really Need Some Longitudinal Data
• Neutral reasoning
• Mediates analgesic effect of control
• Moderates catastrophisation and unpleasantness
• LPFC/NAcc - successful emotional reappraisal
• Emotional reasoning - Emotional persistence
• Mediates rel’ship clinical pain and depression
• Associated with spontaneous clinical pain
• mPFC/Nacc - related to anxiety
LPFC
mPFC
26. Looking At It Helps (Wand 2012)
• Cross-over experiment
• Standardised range, speed and reps – 60 reps
• Moving with visualisation v without visualisation
With visual feedback
mean (SD)
Without visual
feedback
mean (SD)
Mean difference
(95%CI)
p
Pain Intensity 7.75 (11.92) 17.00 (14.61) 9.25 (1.44-17.06) .022
Time To Ease 48.50 (56.09) 97.38 (80.17) 48.88 (19.53-78.22) .002
27. Sensory Discrimination Helps (Wand 2013)
• Cross-over experiment - acupuncture needles
• Control condition
– Relax and think of nothing
• Experimental condition
– Nominate which needle is being stimulated
• Pain intensity with ten active movements
Pain with training Pain without training Mean difference (95% CI) p
2.8 ± 2.5 3.6 ± 2.0 -0.8 (-1.4 to -0.3) p=0.011
30. And I know it isn't back pain but…Retraining the
working body schema might also
• Cross over experiment
• Chronic Achilles tendinopathy
• Pain on hopping
Feet training Hand training Mean difference (95% CI) p
50.33 ±19.107 63.5 ±25.018 13.17 (-20.4 to -0.7 ) p=0.04
32. And This One
(1) A cognitive component - vicious cycle of pain was outlined
(2) Specific exercises to normalize maladaptive movement behaviours
(3) Targeted functional integration of activities in their daily life
(4) A physical activity programme tailored to the movement classification
33. Functional Rehabilitation Which
Has Mutual Normalisation Of
Cognitive Perception And Self
Perception As Its Primary Focus
Stop reinforcing
• Fragility
• Hopelessness
• Vulnerability
Stop reinforcing
• Splinting
• Rigidity
• Lack of variability
34. In some more detail – cognitive perception
• Coherent explanation
– Neuroscience informed
– What they are feeling
– Reasons for treatment failure
– Controllable and reversible
– Pathway to resolution
• Though needs commitment
• Disavow pathoanatomy
– Robust
– Sore but safe
– Movement is helpful
– Movement is healthy
• Build confidence
• Restore hope
– Realistic timeframe
• Enhance self-efficacy
35. In some more detail – self perception
• Enhance self-perception
– Sensory awareness
– Spatial awareness
– Motor awareness
• Ownership and familiarity
– Sensory discrimination
– Motor empathy
– Laterality recognition
– Motor imagery
– Local muscle activation
• Delineation & Dissociation
– Independent movement
• Adequate local mobility
– Independent control
• Adequate remote mobility
• Awareness through range
• Functional integration
36. Questions?
Acknowledgements:
Dr Neil O’Connell
Prof. Lorimer Moseley
Dr James McAuley
Dr Anne Smith
Flavia Di Pietro
Verity Tulloch
Monique James
Jemma Keeves
Sam Abbaszadeh
Pam George
Claire Bourgoin
Pam Formby
Hinweis der Redaktion
WM volume, connectivity, hyperintensity
Diffusion tensor imaging or tractography anistrophy
Superior longitudinal fasciculus
Inferior longitudinal fasciculus
Anterior thalamic tract
Connect areas that share motor imagery, planning and execution – inability to integrate imaging the activity and its execution
Related to walking speed
Hohman post treatment diff -2.3 compared with wait list