Practical Science on Movement and Pain

Review of Conference with Moseley and Hodges on Pain and Motor Control

This weekend I went to Portland, Oregon to attend a conference sponsored by the APTA Section on Women’s Health, featuring talks by Lorimer Moseley and Paul Hodges on the issues of chronic pain and motor control. It was a fantastic experience, and most of the time I was buzzing with geekcitement.

Jealous you missed it? Don’t worry I will summarize the highlights. This post will address the talk by Lorimer Moseley.

The man

First of all, I should point out that Lorimer is an extremely engaging and humorous speaker. And a total character as well. How can I describe him?

He’s kind of like a rough cross between Steve Irwin the crocodile hunter and Austin Powers. An international man of mystery/naughty school boy with a thick Aussie accent and huge enthusiasm.

Even though this guy has taught neuroscience at Oxford, he lectures about it like a guy reviewing a rugby game with his mates at a pub. One day he lectured in a dress. Oh behave! (Of course he did that to raise money to help girls in Sierra Leone attend school. Good on ya mate!)

OK enough with the personality. What did he talk about? Here is a summary of the main take aways for me.

Pain does not equal nociception

If there is only one lesson to be learned from the talk it would be that nociception (often erroneously referred to as pain signals) does not equal pain. Here’s the difference.

Nociception is defined as activity of high threshold Adelta and C nerve endings, which are designed to detect mechanical, thermal, or chemical changes in the tissues.

Pain is defined as a conscious unpleasant experience designed to evoke a protective response.

Although nociception is an input to the brain that often results in the output of pain, the brain considers many other inputs before deciding to create pain, some of which may be far more decisive than the level of nociception. In fact, nociception is neither sufficient nor necessary to create pain. In other words, you can have pain without nociception and nociception without pain.

Inputs, outputs and Infinite loops

Before the brain creates pain on the basis of nociception, it will essentially ask a key question: how dangerous is this really? To answer that question, it will consider many different kinds of inputs, which can be divided into four basic categories:

1. proprioception (information from joints, muscles, tendons and skin about the positions and movements of the body parts)

2. interoception (information from nociceptors about the thermal, mechanical and chemical condition of the tissues)

3. exteroception (the five senses)

4. cognition (knowledge, memory, feelings, perceptions, belief, logic, attention, expectation, etc.)

If the brain processes the different inputs and concludes that some form of protective action is necessary, it can choose between several different kinds of protective outputs, such as pain, immune responses (e.g inflammation) or protective movements such as flinching, limping, muscle guarding, stiffness and other motor control changes. (Now which kind of protective output would you rather have, movement or pain?)

One important point to consider is that any output will almost immediately become a new input into the system. For example, a protective movement will modify the proprioceptive and exteroceptive inputs to the brain. Pain will create new thoughts, feelings and knowledge about dangers to the body. Inflammation will sensitize nociceptors. And so new outputs are created which then immediately become inputs again.

The point is that this is an incredibly complex and dynamic system that loops back on itself every second in an unpredictable and inherently personal and individualized manner. To illustrate this, Lorimer asked us to consider several simple scenarios and to write down all the inputs and outputs which might be involved.

For example, let’s assume that some guy bends forward in a way that activates mechanical nociceptors in the low back. How does the brain weigh this information and decide whether this is a dangerous event that requires pain for protection?

The brain will consider all the inputs, and there are many. Proprioceptive and exteroreceptive information will report the positions of all the different body parts and whether they are controlled and balanced. Perhaps they will provide information showing that balance is very poor and that a fall may be coming. Perhaps cognition will report that this is the exact same position the body was in last year when it experienced extreme back pain that lasted for several weeks. Maybe another part of the brain remembers that a doctor once told him he has a bulging disc. Or a physical therapist told him that forward flexion is a great way to blow out a disc. Maybe other cognitive inputs will report that he has just lost his job and has no way to pay for medical care.

Will this person have the same pain experience as someone else who has the same level of nociception, but who moves with good balance, has never had back pain before, is not afraid of movement, and has excellent financial and social support? No way!

Why do hills hurt?

Lorimer told a great story that illustrated the power that cognitive inputs can have over the output of pain. He once worked with an elite biker who had back pain with riding. After a great deal of progress, she could ride the flats but was still experiencing pain while climbing hills. Most therapists would assume that the problem with hills was related to some mechanical factor that comes into play when the relationship to gravity is changed.

But Moseley was curious whether hill climbing was problematic for visual or cognitive reasons. So he set up some cameras on a bike treadmill in a way that created an illusion of hill climbing for the rider, even as she rode over flat ground. She immediately reported back pain, based solely on the new visual input. After it was explained to her that this was an illusion, she regained the ability to climb without pain. Apparently the recognition that her pain was not caused by a mechanical factor modified her cognitive inputs in a way that convinced the brain that hill climbing was not dangerous.

Cool stuff huh? Actually nowhere near as cool as the rest of the talk, which I won’t be able to get to until another day or two. See you soon, mate!

Click here for part two.

If you want to read more about pain and some of Lorimer Moseley’s research, check out some of the posts below:

Great Ted Talk on Why Things Hurt

Great New Paper on Targeting the Brain for Treatment of Pain

The Thermal Grill Illusion

The Rubber Hand Illusion

More on Pain and Illusions

A Skeptical Look at the Theories of Dr. John Sarno

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22 Responses to Review of Conference with Moseley and Hodges on Pain and Motor Control

  1. Diane Jacobs says:

    Great post Todd! Thank you!!

  2. Sandy says:

    Excellent – I particularly like your review of the exercises we did, that was slippery for people, I’m gonna send them here.

  3. Tracy Sher says:

    Thanks so much for sharing this information. I posted it on the Pelvic Guru Facebook page: http://www.facebook/pelvicguru for all to see! We have received great feedback so far. For those of us who could not attend, this is great info. I have had the pleasure of hearing Lorimer talk before. It would have been a treat to hear both of them speak.
    Thanks again!

  4. stacy says:

    Thanks for your post Todd, and great review. I just went to hear Lorimer speak again last Tuesday night to a full crowd of PTs. He does speak about a new way to look at pain and thankfully so! If you haven’t read his book on Explain Pain, I would recommend it for your library. Also, when I spoke with Lorimer earlier in the year and asked him about the NOI (which is his coauthor’s org.) and Feldenkrais he was aware of the FM. The presentation for the 2012 NOI: Neurodynamics and Neuromatrix Conference offered a workshop on Feldenkrais and the Neuromatrix; Susan Hillier PhD, presented a workshop –http://www.noigroup.com/marketing/noi2012-update-flyer-sept2011-A4.pdf
    You might recognize her, she also spoke at the FGNA conference on The Dynamics of Body Image
    and was well received. http://www.feldenkrais.com/events/conference/2012_public/conf_event/4897;

    Looking forward to the rest of your review!

  5. stacy says:

    If you are curious about the NOI, here is a youtube on the Neurodynamics & the Neuromatrix conference 2012: http://www.youtube.com/watch?v=C08H9rGZf8g

  6. Nicolás S says:

    So funny! Did Hodges talk about posture? I took a course with him last year and that was a BIG part of his treatment.
    Thanks for sharing!

  7. Michael Li says:

    Thanks for sharing Todd!

    Another book I recommended from Lorimer is “The painful yawn”. I found it more reader friendly for patients.

  8. Lucia says:

    Great summary Todd! So helpful that you were able to do this for all of us at the course that were a bit overwhelmed by all the new info. The book Michael Li mentioned is actually called: “Painful Yarns”, lol “yawn” must be a Freudian slip! :D

  9. Diane Van Duzen says:

    I’m totally new to any of this stuff. So, maybe what you’re talking about explains why I walk with no pain in my feet, although my rhuematologist says due to the deformation in my feet from rhuematoid arthritis I should be in pain at every step. He says I must have high pain tolerance, which I found hard to believe, but maybe I brain really does just ignore it.

    • Todd Hargrove says:

      Hi Diane,

      Congrats on your pain free walking. Your feet may be sending quite a bit of nocicpetive signaling to the brain. But this is just one bit of information that the brain uses to answer the question – how dangerous is this really, and is pain a good output right now? Apparently your brain is just fine with letting you walk pain free, which sounds like great news. Pain tolerance is the ability to tolerate pain. You don’t have any pain to tolerate. You have a high pain threshold, not tolerance. Big difference.

  10. Karen Thomas says:

    Very useful info. Thanks!

  11. Excellent post Todd! I can’t believe it took me this long to get to read it. I hear the hammer headed shark story was a hit :). I love his book painful yarns.

    • Todd Hargrove says:

      Thanks Byron. I agree Painful Yarns is great. Probably a better read than Explain Pain for most people I think.

  12. Awesome write-up Todd!!!

  13. Tim says:

    About your bending forward example. If bending forward is not a good idea, is pain the only way to get that message through? If pain is the only way, then I imagine there can be a ton of reasons one can have back pain.

    It’s a little puzzling. Halfway through a forward bend the brain figures out it’s nog a good idea to continue the movement. The brain could then just initiate the movement back and everything is fine, but sometimes (or always?) there is a pain sensation. Is that pain signal a way for different parts of the brain to communicate or is it a way to strengthen the inputs from the situation so it’s not forgotten so easily? I guess the question really is what is pain exactly anyway.

    I’ll follow your links, maybe you’ve written about it before. Thanks.

    • Todd Hargrove says:

      Hi Tim,

      Pain is an output of the brain which creates an unpleasant sensation, the purpose of which is to encourage you to take protective action against perceived danger. Now if the brain concludes that there is danger associated with forward bending, it can chose from several protective outputs – pain is only one of them. It could make the muscles tight, it could cause the back to “lock” or spasm or feel paralyzed, it could change coordination patterns to avoid mechanics that are causing the problem, it could make you feint. Everyone is different and their brains will favor different protective mechanisms. Pain seems to be a very popular one, although stiffness and altered coordination are incredibly common as well.

      • Tim says:

        Great, that makes perfect sense.

        There’s something puzzling me still though. Rephrasing your first sentence: Pain is an output of the brain with the purpose to encourage the brain to take protective action. So 1) the brain knows something is wrong, 2) the brain outputs pain 3) the brain takes action because of the pain. Why can’t the brain just take action after step 1 without going through step 2? Or maybe they don’t happen sequentially (1 then 2 then 3), perhaps 2 comes slightly after 3 or perhaps 2 and 3 happen in parallell? Or maybe the part of the brain that konws something is wrong does not know how to take action so a pain signal is sent so other part of the brain can take action? Speculating heavily here…

        • Todd Hargrove says:

          Good question. I think the answer might requires some very deep thinking, and maybe has something to do with the fact that there isn’t just one decision maker in the brain, but many. Its made of 15 billion neurons, no one of which is smarter than a bacteria. “Decisions” are made by millions of interactions per second, or loops. So it’s not a one step process, even though that might seem more efficient or logical from our perspective.

  14. Mary Brocato says:

    I found this post via Herman/ Wallace pelvic rehab (I’m a pelvic floor PT.) I heard Mr. Mosely speak in LA a few years ago- I love your synopsis of austin powers meets Steve Irwin! truly an experience. Mostly, just wanted to thank you for the recaps, I was unable to attend the course.

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