#MoseleyPQ

The day before yesterday was a one-day seminar with Lorimer Moseley. I managed to live tweet quite a bit of it. So I thought I might take a slightly longer break from the Melzack paper, bring the tweets, try to match them with the papers. I didn't always get the papers tweeted in the heat of the moment. Here is a list of all articles related to the seminar. (Some parts of the presentation were about material not yet  published, so tweeting about them was disallowed.)

Anyway, here is the tweet list as it happened.

• Sensory feelings - "I feel like my arm doesn't belong to me" etc.

[I.e, it isn't always necessarily about "pain" - there are disturbances in sensation in general and interoception, proprioception.]

• Ming from Singapore helped Lorimer obtain some rubber limbs. This story was told at #CPACongress2013 also. "Uhhhhhhhhhhhhhhhh.."

[Hilarious yarn about stealing rubber arms from some facility - Ming created a distraction by making a loud Uhhh sound, then abruptly stopped and ran away.]

• Rubber hand illusions - posterior parietal cortex will quickly shift ownership of sensation to the rubber hand - vision overrides
• Do you end up with 3 limbs in the brain? One hand will be disowned. "How vivid was the illusion? Hand temp reduces substantially
• Temperature change could start to implicate tissue health. Brain's rejection of a body part. Dis-ownership
• A cool arm is more easily disowned. You have to cool the arm but not the rest of the body.
• With histamine injections under the skin: placebo antihistamines work quite well.

[References included Henrik Ehrsson. See Ed Yong's blogpost, Out-of-body experience: Master of illusion, with a podcast interview embed to learn more about Ehrsson's fascinating work on dislocating sense of self from various brain systems, including the autonomic nervous system.] This just in May 29: Extending the self: some cold truths on body ownership [includes a video, about 3 minutes]. 

"Last year, researchers Lorimer Moseley, Alberto Gallace and Charles Spence introduced the idea of the “body matrix” in relation to this question. The body matrix, as they described it, is a multisensory representation of our whole body and the immediate space around it."

• Brain gauges effortfulness or perceived ease of an effort, and will recalibrate reality
• Brain recalibrates its perception of reality every fraction of a second
• Brain always is calculating "How threatening is this?" or "How safe is this?"

[The brain will literally make obstacles seem larger, heavier, higher - goals seem further away. This is all in accordance with large amounts of perception research.]

• Protection and regulation of the body are connected deeply - we can change blood flow by changing how much you own a body part. (Moseley et al 2012 Neurosci reviews)
• Cooling effect takes minutes.. histamine effect is a cascade that takes awhile to occur.
• More rapid changes are made visually. Visual illusions are also the most difficult to shift.

It's VERY hard to un-see a visual illusion. The brain decides quickly, based on clues it has internalized through evolutionary time, such as light source, where the ground is, etc. This applies to all systems, not just visual, because of built and sustained neurotags.

[By the way, "neurotag" is just Aussie for "Neurosignature," coined by Melzack. Neurotags look like graffiti tags, or doodles in the brain - hard to remove.. is that a buried linguistic connection? I think it might be..]

• Change the body of knowledge inside someone; it will shift.. maybe not rapidly, but it will shift over time.
• Cortical body maps consist of all neurotags involved in protection/reg. of body
• "Cortical body map" really... includes anything above level of foramen magnum
• ...including everything in brain that is subcortical
• Cortical body matrix: "network of neural loops subserving protection and regulation of body, physiologically & psychologically"

There isn't any specific cut off neuroanatomically. I asked. I would call these loops the relationship between critter brain and human brain, myself. "Cortical" isn't limited to merely cortex, in other words - it can refer to anything, any loop above foramen magnum, but I think we have to remember that long dock out into the ocean of the body and the body's physiology, also known as the spinal cord. It's still CNS after all..

• Wipe out cingulate cortex, pain will go away for a few months but returns eventually.. unfortunately..
• All neurotags rely on inhibition. This is key for any kind of precision.
• Recruiting brain cells is easy. Turning them off is the hard part. Inhibiting them is the hard part, to get precision.
• Migraines involve a sweeping activation over the brain - not enough inhibition
• Pain isn't a thing, it's an output produced -big lip after visiting the dentist feels big because of inhibition of sensory input

Pain isn't a noun - it's a verb! And it looms, because normal precision-creating inhibition decreases.

• Re: manual therapy - giving the brain a new input will change pain easily.
• What do we do with conflicting conceptual paradigms? They change anyway. Slowly.
• Less back surgery is being done (for pain).
• The evidence is against surgery for mere garden variety back pain.
• We have to let go of causality fantasies in therapy (Leake et al 2012 proprioception, neck..)

Yes.. there are quite a few papers related to how abnormal findings shouldn't be an excuse for surgery, because they can be found in asymptomatic people too - just like grey hair or wrinkles.

• Systematic reviews on "proprioceptive deficits in the neck"
• Is the "cause" to do with the proprioceptive organs? Just because there's a deficit doesn't mean the receptors aren't working
• Disruption of motor maps. Only interrogate the map of the neck, not the neck itself - looking at a laterality picture.
• Again, precision deficit, at the OTHER end of the NS, not at the peripheral end
• Imprecise proprioceptive response - implies lack of inhibition. Not a deficit of proprioception.
• Disinhibition, loss of precision: Does this apply to CRPS?
• CRPS, hand size precision is impaired - precision is way reduced. Feels bigger than it really is. Sometimes feels missing.

Such a lot of exciting possibilities for mapping of space.

• The better your tactile acuity the better your performance on tasks
• Accuracy of left/right judgements goes down with decreased tactile acuity
• Tactile acuity deficit goes with proprioceptive deficiency
• Tactile acuity and motor imagery are linked. Stanton et al Rheumatology 2012
• Painful knee osteoarthritis - won't likely get much improvement by training two-pt discrimination.
• Works better for backs
• Brain likes to know where is something according to the midline
• With stim, tactile neglect of painful hand.. hands crossed over, they still neglect the space, but NOT the hand. That's from Moseley et al Brain 2009
• Moseley et al 2012 Neurology
• Spatial maps and autonomic control
• A painful hand seen through a magnifier to make it look bigger makes it hurt more. Moseley et al 2008
• ... and the swelling increases!
• When the hand is seen through a minimizing lens, the swelling DE-creases. (Isn't that cool?)

This is from work done on CRPS, I think.

On to glia!

• Every synapse is hugged by a glial cell.

This relates to the exciting work done by Seth Grant who showed that synapses (with their glial control) may drive evolution.

• When the glial cell releases inflammatory cytokines, which affects the next neuron, creates disinhibition and loss of precision.

This happens when a synapse is used way too much. [Maybe the glia cell starts to get tired? Anyway, this is like in the PNS, where Schwann cells can start to impersonate immune cells by producing cytokines, etc. File under "Neural crest derived cells are brilliant but can get weird"]

• Rumination on how bad something is. Like life..
• ....keep running neurotags, whole body becomes sensitive. Imprecision will create a spread.
• Ornithology hijacked amazing grace - the clarinet story from Painful Yarns

I finally understood what this story was about. I think in the book, a big (and critical) chunk must have been accidentally chopped.

It had to do with a music neurotag that was augmented by leaning back against a door handle in a truck, and the position of leaning, and darkness... then playing in a club where the clarinet player (Lorimer) sat on a truck seat replica inside the club, leaned back, and was surprised to find himself playing Orthinology instead of what he should have been playing, which was Amazing Grace.

• If brain cells are used to turning on repeatedly, they might stay turned on. That's one type.
• Another type is, the cells stay turned on with less cueing.

That would be, central sensitization.

• Lack of turning off because of disinhibition/loss of precision. It's bad if in the motor cortex.

Focal dystonia in musicians is a common problem.

• How we use pain as an informant to state of nervous system. There are different qualities and patterns which provide clues

The poster outlining guide to contributing mechanisms.

• Axon reflex: clinical nugget. Heat will increase mechanically evoked pain if it's primary nociceptive.
• [But why would we do that to people anyway?? #DoNoNocicepting = first law of human primate social grooming]
• Sensitivity to do with behaviour: Immediately or next day, flareup - pretty much CNS derived in a sensitive system.
• [Long philosophical sidetrack into what manual therapy does at a biological and interactive level]
• The best pain stuff has come along in the last 25 years
• We know the immune system is a big player in pain. A problem is that we don't know what to do about it.

Antibiotics for back pain: hope or hype? BMJ May 17 G Lorimer Moseley

• About that study about antibiotics and LBP....
• About 90 finished the study. It was an RCT. Conclusions don't really match the results.
• Placebo group had no result whatsoever. Suggests they weren't blinded.. and there were side effects.
• Treatment FX could be explained by placebo. Disappointingly overplayed by the media group.
• We need to be precise and honest as researchers and as clinicians. It's easy to slip up on communication. Very disappointing.
• All the LBP patients will hear about it because of the buzz. Poor patients. Poor researchers.
• New topic: Recognize, training the brain. It takes about 50 photographs to get past the explicit learning system into implicit

Graded Motor Imagery (Book Review)

• So far, no reports of hurt with GMI. There have been a few incidents of inc. pain with mirrors. Some mirrors were distorted
• Management plan: Target pathological findings
• Target cognitions. Meaning and mood. Consider conceptual grains - "I shouldn't hurt if I move" - D Butler
• Dethreaten them. Provide info to dissolve the neg neurotags
• Change "I have pain therefore I am damaged" to "I have pain therefore my brain is trying to protect me."

Look to other fields for how they reduce threatening cognitions. Look to Cognitive Behavioural Therapy, Adult Education, etc.

• Offer evidence, twice. Provide an alternative. Give novel examples, twice.
• Got to get them engaged. Activate emotional systems. Provide novel reinforcements. Practice.
• Change "I have pain therefore I am damaged" to "I have pain therefore my brain is trying to protect me."

It was a wonderfully full and interesting day. Lots of SomaSimplers were there, all the ones who live in Montreal, anyway: here they are standing with Lorimer Moseley.

From left to right: Moseley, Eric Ouellet, Carol Lynn Chevrier, Randall Lightbrown.

The room was packed, mostly PTs. Susan Tupper thought there were at least 10 rows of ten people each, which would be roughly 100 attending.

MORE: Neuroanthropology on Brain Science Podcast Excellent, excellent podcast - Ginger Campbell interviews the authors of the new book, The Encultured Brain. Neuroanthropology: What Is It and Why Should You Care?
The authors point out that the brain is where culture and biology come together and influence each other. An example; about an hour into the podcast one of the authors describes how his vestibular system had to adapt to his training in capoeira. The challenge in capoeira is that it's a martial art form, fought with an opponent, while standing on your head or your hands. Gymnasts do this all the time but they exploit their visual system by always looking to see where the ground is. In capoeira you have to look at your opponent, or risk getting thumped by him/her. The vestibular system is forced to neuroplasticize in other ways. It has to make unusual neurotags.

What does this have to do with pain? It has everything to do with how brains neuroplasticize themselves in relation to inputs. Pain is an output, just like movement is an output. Brains practice and practice until their predictive ability matches what they produce as output. This occurs once surrounding inhibition produces accuracy, precision. After that, the brain has "got it." It has a sturdy neurotag built. Norman Doidge called pain "the dark side of neuroplasticity."

I think, first, you have to pick your parents well. They will be your world for much of the time your brain is busy soaking up your world. Not to mention, you don't want to end up with funky genetics, particularly, or epigenetics. It will help if you are not born into relative poverty/low social status. Emphasis on the word "relative." As long as most of your neighbours are in the same boat, and you have basics (food, clothing, shelter) covered, there won't be any social stigma.
Then you have to not be exposed to violence or abuse in the home, either to yourself or of any primary caregivers you depend on. Your vulnerable child brain will totally load up on stress from watching your mother be battered, for example.
It's great if your primary caregivers hold you a lot, provide long loving sessions of direct skin contact to you when you are an infant. It will help your brain develop.
It's great if you don't get seriously injured too much, yet get lots of exposure to your environment in terms of graded challenge to your immune system, and to your nociceptive system. If you're having fun playing with your peers, your brain will build up robust pathways dedicated to descending modulation of all the right kinds. Having educational opportunities is a very very nice bonus. Brains need to learn how to distract themselves. They need things to practice thinking about. Some sort of music training in addition to cognitively delivered cultural input is great. Lots of exercise too.
If all goes well you will grow up into an adult with a nervous system in good shape, able to do what it needs to do from a bank of successfully mounted resolutions to physically and emotionally generated experiences and challenges.

As long as you have genes that can make all the necessary proteins, your nervous system should be able to get itself out of pain. Sometimes it might need a bit of help, from the culture, just to get it started, but after that, it should be good to go.

Philosophically speaking, it will never be able to be "the way it was before the thing happened", but it should be able to get back to coping easily with struggles and strains without hurting you in the process.