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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
www.bodyinmind.com.au
Copyright GL Moseley 2009
                            Why train the brain?



      CRPS as an extreme protective response.
www.bodyinmind.com.au
Copyright GL Moseley 2009
                                                             Why train the brain?


                               Our approach to treating CRPS

                                                             Recent developments
  Cognitive      Behavioural              Brain               Neglect and   Disrupted bodily
 Understanding      Function &           changes               ownership       awareness
 the problem        movement
                                       S1 reorganisation
                     hierarchy                                                Disruption of
 Other
 threatening     training the brain    Reorganisation                         high-order
                                         elsewhere?
 cues are               part 1                                                cognitive
 relevant
                                       training the brain                  representations.
 Educate &                                    part 2
 explain
www.bodyinmind.com.au
Copyright GL Moseley 2009
                            Why train the brain?




                            Recent developments
                             Neglect and
                              ownership
www.bodyinmind.com.au
Copyright GL Moseley 2009


  Does it feel like it is mine?
                              Many patients report feelings of
                             foreigness & hostility towards the
                                                          limb.

                            I feel like it is not mine, like it is an
                                                          imposter


                                                     Lewis et al 2008 Pain
www.bodyinmind.com.au
Copyright GL Moseley 2009




             Could this disownership contribute to
                                        symptoms?
www.bodyinmind.com.au
                              The rubber hand
        Copyright GL Moseley 2009


                              illusion
Moseley et al 2008 PNAS 105(35), 13169-73
www.bodyinmind.com.au
                              The rubber hand
        Copyright GL Moseley 2009                              Ctl    RHI   Ctl

                              illusion                   10

                                                  Vividness
                                                     of RHI


                                                          0


                                                          0尊
Moseley et al 2008 PNAS 105(35), 13169-73




                                                       Foot
                                                temperature

                                                         -1尊
                                                               60 s


                                                          0尊
                                                      Hand
                                                temperature
                                                         -1尊
www.bodyinmind.com.au
        Copyright GL Moseley 2009




                                                             10
Moseley et al 2008 PNAS 105(35), 13169-73




                                            33.0




                                            32.0
                                                   Control        Rubber hand illusion
Pre
         www.bodyinmind.com.au
        Copyright GL Moseley 2009                                          Post




                                                               10
Moseley et al 2008 PNAS 105(35), 13169-73




                                            33.0




                                            32.0
                                                     Control        Rubber hand illusion

                                                                    www.bodyinmind.com.au
Pre
         www.bodyinmind.com.au
        Copyright GL Moseley 2009                                                Post




                                                                          10
Moseley et al 2008 PNAS 105(35), 13169-73




                                            30.5



                                                       Synchronous
                                                       tapping eyes
                                                          closed           RHI
                                            29.5

                                                   0                  2   Time          5
www.bodyinmind.com.au
        Copyright GL Moseley 2009




                                                          0尊
                                            Skin
                                            temperature
Moseley et al 2008 PNAS 105(35), 13169-73




                                                      -1尊          R =0.50*


                                                               0                5              10
                                                                   Vividness of the illusion
                                                          10
www.bodyinmind.com.au
Copyright GL Moseley 2009




                                           Yes.
             Could this disownership contribute to
                                        symptoms?
www.bodyinmind.com.au
Copyright GL Moseley 2009

                    The neglect question...
www.bodyinmind.com.au
Copyright GL Moseley 2009


               Vibrator
www.bodyinmind.com.au
Copyright GL Moseley 2009


               Vibrator
www.bodyinmind.com.au
Copyright GL Moseley 2009


               Vibrator
www.bodyinmind.com.au
Copyright GL Moseley 2009


               Vibrator
www.bodyinmind.com.au
Copyright GL Moseley 2009
www.bodyinmind.com.au
Copyright GL Moseley 2009




                            Stimulator
www.bodyinmind.com.au
Copyright GL Moseley 2009




                            Stimulator
www.bodyinmind.com.au
Copyright GL Moseley 2009




                   Left




                            Stimulator
www.bodyinmind.com.au
Copyright GL Moseley 2009




                            Stimulator
www.bodyinmind.com.au
Copyright GL Moseley 2009




                            Stimulator
www.bodyinmind.com.au
Copyright GL Moseley 2009




                                         Right




                            Stimulator
www.bodyinmind.com.au
Copyright GL Moseley 2009

In chronic CRPS,
   you have to
  stimulate the
 affected hand
   about 25ms
before the other
   to think the
stimuli occurred
   at the same
       time


                            Moseley et al 2009 Brain (published on-line 150909)
www.bodyinmind.com.au
Copyright GL Moseley 2009

    But when you
 cross your arms,
     the opposite
      occurs - you
           have to
     stimulate the
      UNaffected
 20ms before the
       affected to
  think the stimuli
 occurred at the
        same time
                            Moseley et al 2009 Brain (published on-line 150909)
www.bodyinmind.com.au
Copyright GL Moseley 2009
           This shows that the
            bigger the shift in
               processing, the
            colder the limb is,
                 relative to the
                 opposite one.




  The shift away from the affected limb is opposite to what we see
             with acute threatening stimuli Van Damme et al 2009 Brain Res.
                                                                 2009;1253:100-106.




                                        Moseley et al 2009 Brain (published on-line 150909)
www.bodyinmind.com.au
Copyright GL Moseley 2009
                            Why train the brain?



                             Recent developments


 Go to the next                       Disrupted bodily
                                         awareness
 set of slides on
                                         Disruption of
 Recent                                   high-order
                                          cognitive
 Developments                          representations.

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Training The Brain 4 Recent Developments Neglect