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Notes from Dr. Lorimer Moseley Lecture: "Pain: Is it All Just in Your Mind?"

I recently watched a video lecture by noted pain researcher and therapist Dr. Lorimer Moseley presenting on “Pain: Is it all just in your mind?”  The neurological basis for pain is a critical yet often overlooked element of the rehab process.  Athletes and non-athletes alike usually take a “tissue centric” approach to pain, which is appropriate in some circumstances but horribly inappropriate in others.  

At one extreme we have the typical injury-inflammation-remodeling process.  At the other extreme are cases like fibromyalgia.  Many conditions lie somewhere in between.    

Chronic, repetitive use injuries are frequently a byproduct not only of tissue damage, but also related to environment, psychology, nutrition, among others.  In the performance realm, understanding these concepts can help coaches become part of the solution to injuries rather than part of the problem.

Below are notes from the lecture, which you can view in its entirety HERE.

Lecture Notes

-No stigma attached to vision like with pain.  Vision is relatively simple in comparison.

-Perceiving a distorted version of the actual visual image can be biologically advantageous.  We economize information in ways that preserve our survival.

-Image on retina is tweaked by brain unconsciously.  Critical analogy to chronic pain when there is no confirmatory test.  What the eye sees can be different than what the brain perceives; what the body feels can be different than what the brain perceives as pain.

-Pain biology  - Two Different pain pathways…

1)  Fast conduction: If you step on something barefoot , Pacinian corpsucles and nerve fibers signal to brain = message of pain 

2)  Danger receptors/slower conduction:  nociceptors --> spinal cord release neurotransmitters --> then more nociceptors --> Thalamus -->Then brain 

-Example: was camping.  Felt pinch on foot.  Didn’t think anything of it.  Next thing he remembered....Three days later – Wake up in hospital as first survivor of brown snake bite!

-Months later – experience similar pinch on leg….jumps MADLY!  But there was nothing dangerous present!!??

-Pain works to protect us.

-First scenario (snake) – lot of danger, but no pain

-Second scenario (step on twig) – no danger but lot of pain

-This is NOT symptom exaggeration

“Why is he pretending that hurts so much?”  Erroneous question

-Right question =“Why is that hurting so much?”

-Complex reasoning mechanisms based on experience, context, environment….these provide MEANING

-Brain must evaluate many complex things….”what does this really mean?”

-“How dangerous is this really based on everything I know?”

-What is truly happening in the tissues VERSUS what the brain sees as the need to protect you.

-Who volunteers for pain experiment?  Normal people? (Ha!!)

-One famous experiment.  Sham stimulator – Subjects were attached to helmet-like device intended to deliver pain.  Device had intensity knob.  Intensity knob let subjects know how much intensity they were allegedly receiving.  Subjects experienced head pain according to intensity level of knob even though no painful stimuli was being provided!!!!  Brain’s implicit perception of danger; threat to body tissue perception.  Subjects expected to be in pain and as a result, experienced pain!

(Bayer TL, Coverdale JH, Chiang E, Bangs M.  The role of prior pain experience and expectancy in psychologically and physically induced pain. Pain. 1998 Feb;74(2-3):327-31.)

-Experiment 2…Subejcts probed with minus 21 degree Celsuis probe.  Sometimes were probed with blue light other times with red light.  Result: Red cue makes it hurt more.  One interpretation: Very hot things are very dangerous.  Won’t die immediately from cold but can die immediately from heat. 

(Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes.  Pain. 2007 Dec 15;133(1-3):64-71. Epub 2007 Apr 20.)

-Brain astounding in capacity to represent everything else – Uses networks of brain cells (“neurotag”)

-For pain to occur...Need sufficient excitement of member brain cells and sufficient inhibition of nearby cells

-Beliefs, knowledge = shares neurons with back pain; has capacity to modulate pain network

-Pain can depend on

1)  Beliefs: Believe you have weak back; Dad had bad back – Beliefs can modulate neurotag.  Neurotag will include anything relevant to the brain’s evaluation of the danger to the back

2)  knowledge/logic: Brain embraces information not from the body when it produces pain in the body

3)  other sensory cues: Cycling example: one cyclist at Australian Institute of Sport.  Pain could be triggered based on visual field. (hmmm...what does this say about the "Biomechanics" of bike fit...?) 

4)  social context: maybe no back pain at PT; maybe more pain at insurance doc?

5)  anticipated consequences: When brain produces pain in response to perceived threat of danger, it will correct the spinal cord

-If brain concludes thalamus overestimates the threats, it will conclude the spinal cord is just overdoing it (tell spinal cord to be quiet = “descending inhibition”)  - This is good!! 

-What if the brain says spinal cord is underestimating the danger?  “Descending facilitation” This is bad!!!  Sends more messages to the spinal cord to excite; it produces a self fulfilling prophecy.

-We move according to demand and the brain’s capacity to meet it

1)  Example: expect to pick up heavy bag of books; brace in anticipation

2)  Fatigue example: effort to failure on stationary bicycle.  Subjects can push the button to quit, but button is rigged to produce image on screen of finish line.  Subjects keep going when see a picture of the finish line. (brain knows they can go little bit more and don't need to shut down the body yet)

-Fatigue = experience produced by the brain to protect the body (same as thirst)

-Anxiety = brain’s estimation of ability to cope with demands

-What happens when pain persists?

1)  Normal course of pain = inflammation, remodeling, pain goes away

2)  …but this doesn’t always happen!!

-Hypersensitized nociception = Need fewer inputs to receive painful output.  This happens in spinal cord, not the tissues.

-The longer you have pain, the better your spinal cord gets at producing danger messages to brain, even if there is no danger in the tissue

-What happens in the brain?  You can have completely sensitized nociception but not be in pain.  Example: you can lose limb but won’t necessarily get phantom limb pain.  Sensitized nociception is not enough for chronic pain but is commonly related.

-The more you run the pain neurotag, the better it gets at running.  The more you learn it.

-Implication – Overexcitement of member brain cells responsible for pain; Under-inhibition of nearby brain cells.

-Brain imaging data confirm that some back pain patients feel pain when see someone else pick up box, for example. 

-Lose precision when the brain loses the ability to inhibit – pain jumps around to areas where there is no threat. 

-Brain loses ability to differentiate movements (lose ability to pelvic tilt is common in back pain)

-Disinhibition/lack of precision causes the pain

-Re-igniting inhibition has symptomatic benefits

-Randomized controlled trials –> disinhibition contributes to problem; contribute to physiological dysfunction in the tissues: Opportunities at the brain to change the body.

-Change the way we think about chronic pain – Pain in the brain, immune system, endocrine system, feels the same as tissue pain.

-Nothing unauthentic about that type of pain! 

-Understanding this concept reduces pain and increases participation

-Ultimately train the brain – Most of what we do focuses on tissue input, but we need to look beyond that – Next step: optimize training inhibition

Implications

Athletes who are always hurt, or seem to get hurt at the wrong time of the season.  Is it training load?  Perhaps, but maybe the coach is creating environment and set of expectations internalized by athlete linked to painful output from the brain.

Athlete’s perception of how much they are doing?  Is training an epic quest each day, or do you just show up and take care of business?

Are we doing any favors with syndrome-ing everything?  There’s certainly some value in this from a clinical perspective, but do people talk themselves into long term pain by latching onto label thinking “I have [fill in the blank]."  Since they have "X" have they been conditioned to think that some magic touch from the ART/Graston person will whisk the evil spirits away?  Not saying this is without value, but instead that in chronic repetitive use cases, complete resolution of symptoms must often look beyond the tissues and explore psychosocial elements.  

As coaches it is important to regulate the environmental factors in our control.  As adjuncts to the rehab process, we must also consider the role of psychosocial education and not just sets and reps. 

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