Last week I described a graduated movement therapy for chronic pain about which Dr. Lorimer Moseley published a study in Neurology.  I’ve asked Dr. Moseley to help us better understand this exciting work.

Dr. Moseley got a PhD from the University of Sydney in 2001 and is currently the Nuffield Medical Research Fellow at Oxford University, United Kingdom.  He is also a College Research Fellow at Oxford.

How to Cope with Pain: What is your research practice like?  Do you have a clinical practice?

Dr. Lorimer Moseley: At the moment, I guess I have three areas of research.  First, research that aims to determine why some people get complex and chronic pain problems and others don’t.  We are looking at a variety of factors, including the way the immune system responds to injury and the way the brain responds to injury.  The immune stuff we investigate by taking blood and tissue samples from people with pain problems.  The brain stuff we assess by brain imaging and different types of laboratory tests.

The second area of research aims to develop and test new treatments for people with chronic and complex pain problems.  There are two main areas of interest at the moment - one is motor imagery.  We have trials with patients with complex regional pain syndrome, which is a nasty condition some people get, usually after relatively minor injuries. We also have trials of motor imagery with people with phantom limb pain after an amputation or pain in paralysed legs after an injury to the spinal cord.

The third area of research looks at how we as clinicians can present patients with information about their situation that really helps them to understand it and to take their own steps to manage it.  Most of this work has focussed on people with chronic pain, but there are clinical trials underway with people with acute pain problems too.

I don’t work clinically here in UK at the moment.  I intend to start that up again when I have a couple of big projects under control.  I’m enjoying spending time with my family actually, so work is on a bit of a backburner right now!

HTCWP:  How did you get interested in Pain Medicine?

Dr. M: This is a good question.  Like most people interested in anything, I was on the other side of the fence at one stage - as a young person I hurt myself playing football.  I noticed that what the doctors told me and what I read in journals didn’t seem to make sense.  So, I read more and more.  My general clinical experience also reinforced to me the complexity of the human experience and that pain is a fundamental human experience.  Finally, I guess I have for a long time been fascinated in the fact that we are indeed fearfully and wonderfully constructed and that all these things are mediated by biology.  I love that.

HTCWP: What pain disorders do you research or treat most often?

Dr. M: Complex regional pain syndrome, phantom limb pain, chronic back pain, chronic neck pain.

HTCWP: Your recent article in Neurology looked at a graded motor imagery treatment - can you tell us about what that is, and how it treats pain?

Dr. M: I don’t really know how motor imagery works.  The theory behind it was that some patients seem to get worse when they even think about moving.  There are data that support that now I think.  Anyway, we thought that motor imagery might be a way of getting under the radar of a really sensitive pain production system.  We know the system gets really sensitive and we know from other conditions that if you can get under the radar and then gradually expose the system, then it should respond.  So, that was the theory - start really conservative and then slowly increase.  It’s possible that it works by refreshing the representation of the affected limb in the brain, but I don’t understand that very well just yet.

HTCWP: A previous study of yours which was published in Pain several years ago showed that doing the same exercises, but in a different order, doesn’t work.  How come?

Dr. M: Nice question!  I think, though I’m not sure, that the above theory applies to this.  I think that the first stage seems important because it might unlock the connection in the brain, a completely unconscious connection, between limb movement and danger.  The second stage seems to be important because it reinforces this without moving the sensitive body part.  The third stage with the mirrors might use visual information, which says that everything is fine, to continue this.

There is another theory that the process remaps the body part without activating the pain networks.  I’m not sure if one theory is better than the other.  Perhaps both are wrong.  All I think I’m confident about is that if you change the order, it doesn’t work.

HTCWP: How soon will your treatment be routinely available?

Dr. M: I have no idea.  It’s not really my treatment - I just put other stuff together.  Anyone can do it.  There are commercially available software programs for doing the laterality recognition thing - www.noigroup.com has one called “Recognise,” which I think is excellent.  There may be others too.  So, there’s nothing stopping anyone doing it.

The information that we give to people is well covered in a book called Explain Pain.  It’s a great book and is aimed at patients to go through with their clinicians - I reckon, as does the American Pain Society newsletter apparently, that every clinician should have one that they should read, and then let their patients look at.

HTCWP: Any other research about pain treatment that you’re doing?

Dr. M: Yeah, we are doing other stuff.  The main thing at the moment is in people with CRPS, and others, who haven’t responded to motor imagery and in people with other conditions who haven’t been told how their biology is making it happen.  We are getting encouraging results but it is in the early days.

HTCWP: Who else is doing research in pain treatments that you feel is promising and exciting?

Dr. M: I think the mindfulness stuff that some people are doing is potentially exciting, but I don’t think there is much evidence yet.  I think that a group in UCLA did a groovy study that used biofeedback to help people turn off their pain - it was with brain imaging in real time - seemed potentially excellent.  Don’t know where that is up to, but it is potentially cool.

HTCWP: What advances in treatment can patients look forward to in the next 3 or so years?  What great things are coming in 5-10 years?

Dr. M: No idea really.  I think that the more we learn about consciousness, the more we’ll learn about pain and pain management.  However, to comment on where we’ll be in 3, 5, or 10 years requires a crystal ball I don’t have.  So, no idea.  Sorry.

Thanks to Dr. Moseley for a thoughtful, educational interview.  In addition to the vast knowledge that Dr. Moseley has, he also shows the humbleness and ability to say ‘I don’t know’ that great clinicians and researchers share.  We’ll look forward to more exciting work from Dr. Moseley and his colleagues.

In posts coming up soon, we’ll look more closely at the mirror image work that’s part of Dr. Moseley’s treatment.  Also, at the work at UCLA involving MRI’s that really exciting, too. - How To Cope With Pain

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