IFOMPT 2016 Lorimer Moseley

Well, I'm a gentleman, if we want to start, welcome back, well, there's Chris McCarthy and welcome to this session with Professor Laura Mosely and Professor Tim Watson, if you want to turn on your phones, open the applications, put them on vibrate. If you go into the session, you'll see that there's a summary and at the bottom of that page there's a method to rate the session so that we can get your feedback on the session as the session progresses if you'd like. to receive feedback, use the app and of course add your questions; will appear on the iPad.

There we can prioritize them for the end of the session with Professor Mosley, so let's start by introducing our first speaker, so I have to start. glasses the first time I use Carter reading glasses, so most of you will have at least heard Lauren, well, you might have met him. In my opinion, she is one of the stars of musculoskeletal practice. She has taken a fantastic course before the conference. The comments about that. The course has been incredible. I'm very lucky to have it. She is a clinical and research physiotherapist. He is a principal investigator. She has a doctorate in medicine from the University of Sydney.

He was a Nuffield Fellow at the University of Oxford in the United Kingdom and is a professor of medicine. neurosciences and professor of physiotherapy at the University of South Australia the Australian Neurosciences Research Institute in Sydney is the author of over 180 articles is the editor-in-chief of the body and mind website and group as an exceptional speaker, we are very lucky to have it May I welcome Professor Laura Mosely to the stage? What a pity. I think I'm fine. Yes. Hello everyone. Great, welcome to the second session. What a privilege it is to follow An and Gwen and be part of this community.

I've been in this meeting for a while, but it feels like a meeting, so all those people I see when I run by say I think they're worried because my slides aren't arriving, which was about 15 minutes ago. I intend to catch you up and thank you for inviting me to be a part of what shocked and intimidated me a little because I am not a manual therapist, that's fine, however, I will find humans very, very fascinating and in particular, I find myself quite fascinating and I often find myself saying something and then thinking why did I say that?

Does anyone else relate to that? Well, yes, and I find other humans even more fascinating than I do, so it's a good field to be in when it comes to people with pain and My particular interest is people with chronic pain. As a scientist I am convinced that it is impossible to know what you are thinking and why you are thinking things, so you must be very careful to identify and eliminate as many biases as you can, I think it is very important that all of you know what conflicts I bring to this room and to my career, so I would like you to take a look at my revelations now normally when you are at a conference.

It works like this and here my disclosures well people were not fast enough I try to enter here my disclosures well that's very slow isn't it? anyway they don't show them long enough in my opinion I have conflicts of interest Here, for the last six years, some of the organizations that have supported my trip, if you like, attended a meeting that could have paid me a little money and that will influence my research decision making and I can't help. That's because I have a very complex brain and so does everyone, and the influences that are behind what we think and what we decide are sometimes very difficult to understand and see as relevant to that is this question and I suppose that the report they gave me was These lines are very long: let's introduce the biology of pain in patient care, but I am also very interested in what is the biology behind patient care, so there is a bidirectional relationship and this is a series of studies that They excited me a lot.

When I finished my degree in physiotherapy and I built the following images based mainly on this review, but on a whole piece of work by Braithwaite and Cooper looking at analgesia with placebos and this would be the amount of analgesia you get if you give someone an aspirin or a placebo and this would be the amount of analgesia you would get if you did nothing at all, which should make our training in clinical sciences a little easier because we could teach people to do nothing at all. and we would still have some kind of effect, it is better that we put the aspirin in a branded box, so if we put the aspirin in a branded box we will get a better result than if it is unbranded, but it is not surprising that if We put the mark on the placebo we also get a better response, so if we are doing a completely inert intervention we should mark it because we will have a more substantial analgesic effect, so what Braithwaite and Cooper suggested and there is a very large set of research now to replicate their work and really consolidate it to suggest that every time someone gets pain relief there are different contributors to their pain relief ranging from natural history, that's exactly what would happen anyway, the drug effect here is in Orange the act of taking a pill has an effect and this is what really piqued my interest.

I really thought about why the act of taking a pill has an effect and the branding effect, so that's an analgesic mediator that I think is really very interesting and for you to see. I know these are not just a few studies. I don't expect anyone to necessarily be able to read them, but the point of this is to illustrate how much research there is here. Each of the rows in this column talks about study groups. For example, this one is an analysis of 416 placebo-controlled trials by Myers, so this is a huge amount of research that supports some of these types of findings about the effects of inert treatments and here are some of the things that arise.

Which I think is interesting if you inject an inert molecule, it will have a greater effect than if you swallow it. On a molecule basis, capsules are better than tablets. Capsules that you can see and have a lot of red balls are better than capsules. I can't see in the capsules delivered with the left hand or more effect no, that's not sure, okay, I won't go on too much, so here we can compare exactly the same molecule in both the active treatment and the new inert treatment. treatment administered in two different ways has a different impact.

I think this is quite interesting. Can you raise your hand if you think you're a better than average therapist? Only the men raised their hands. It was interesting, very interesting, so let's apply this. to something we do, for example, doctors doing exactly the same treatment now, this is extremely unlikely actually, but let's pretend for a moment that that could happen and that one doctor gets a better analgesic effect than the other. I hope you agree. That's a reasonable possibility, so let's say these are the two doctors, on one hand we have someone who is getting a pretty big treatment effect here and then on the other hand we have someone who is getting a pretty big treatment effect here. small treatment and, as far as I can see in the literature, most of what we do, not only in physical therapy but in all interactive treatment disciplines, most of what we do, what we actually do has a small effect, but the change in someone's life is potentially quite large, so the package that we are fulfilling or participating in may be really effective, but what we are labeling as part of that that we are attributing it to has a small effect and I think that the data is quite compelling to justify that position and it is tempting for us to call all that green stuff that is not natural history a placebo effect.

Now I think placebo is a dumb idea, actually, because what it says is that there is an effect of an inert thing and inert things have no effect. this is a meaningless phrase if you will and I think I think placebo effects don't really exist. I don't think there's actually a placebo effect and I'll explain to you what I mean by that now we have empirical data that suggests that the better you are, the better your analgesic effects will be, so we have a doctor here with - and good looks and the other doctor. I showed her the photo of the other doctor - my 14 year old daughter and she said: did they know you took that?

The photo actually said Charlotte, look well, she's confused and then I had to leave and she understood immediately because the empirical data indicates that the perceived intelligence of your doctor, their eloquence, their experience affects the pain relief of anything they do, so I hope you can see. Also, what we thought was the placebo effect is getting smaller and the only reason it's getting smaller is that we're better understanding the interactions that are happening and the signals that have some kind of meaning to the brain. the person who does it. is suffering, if you like it, what about the doctor on the left who drops his Mercedes Benz keys on the table in front of you?

I can help? and then you realize there's also a set of BMW keys on the same keychain and you're thinking wow, they must be good or the person on the other end who has his push beam in the back of the office doesn't really care for you. confidence now I don't know of empirical data comparing the analgesic effect of owning a Mercedes or a scooter, but the principle I hope you agree, what a sense of fashion, well, this is the case. I managed to get a photo of the doctor standing there next to you in her very nice outfit and snorted at my very nice shirt.

Someone already congratulated me. on my shirt today I really don't think I'll go as far as Chris and this is the study that is still my favorite study it was published in a little known journal called Nature and it was a double blind placebo controlled trial of fentanyl which is a powerful painkiller , so you get a powerful painkiller after a wisdom tooth extraction, but they played a trick on the dentists, so what they really did and I love the idea of ​​a double blind dental trial. I imagine a blind dentist being quite unsettling as a patient, you know you're getting hot, that would be very difficult, but what they did in this test is they randomly assigned the dentist to two different types of information and a group of dentists were He said he was really sorry, but we don't have fentanyl for you.

They will inject the placebo, but do not tell the patient. The other group was told the truth, so to make it clear that both groups of dentists had a 50% chance of injecting placebo is something inert, but one group thought they had a 100% chance of doing something that doesn't work. . I hope you can see what's happening there and then you looked at the effect of the placebo injection on pain relief and these are the two groups and hopefully you can see it, but if the dentist thinks what they're doing you have no chance If it is an active medication, the pain worsens on a ten-point scale by about three points after the injection if they think there is a 50% chance it is pain with fentanyl it improves by two points on a ten-point scale, which represents a change of five points attributable to the dentist's belief that what they are going to do could have an effect.

I think it's remarkable. I think it is a remarkable find, colleagues. made more noticeable by showing third parties showing someone else the video interaction and asking them to tell me which group you think the dentist is in and they can't guess they can't figure it out so the viewer can't see any of the signs. that are being administered and that end up providing analgesia and I think that's amazing and we all do highly interactive treatments, which makes me think, what are the signals that we are providing that are changing the pain production of that person's brain and this This finding still motivates me to learn more about pain and how it works, so we've done some research trying to look at these non-nociceptive signals that modulate pain.

It's a study we did some time ago. We get supposedly normal healthy volunteers and I always have to do it. let's say supposedly normal because volunteering for a painting experiment clearly not normal if you lived in Oxford ten years ago you may have passed by one of the community notice boards that had a sign saying they were looking for participants for a painting experiment calls this number so just raise your hand if you call the number I'm sorry for you I can say be careful you enter the laboratory and we will explain it to you well we are going to put a helmet on your head it is like a swimming cap with many electrodes, There are 64 electrodes and we only need to puncture the skin enough to make it bleed on each of those electrodes.

The science is still right and then once we have it, you'll fill out some questionnaires and then we'll. We will randomly assign you to one of two groups. Now a group will receive an injection of very salty water into the muscles of their pelvic floor that will cause painmoderate to intense abdominal and lumbar for about 20 minutes and you will have a 50% chance of taking yourself out who at the end says I'm in gray the Spanish brings back the Inquisition I say then these are not health they are not normal people so in this experiment we got supposedly normal healthy volunteers and we put a very cold thermode on the back of their hand and then we didn't tell them anything about this signal, but we gave them a light blue light or a red light at the same time they received that signal and the theory behind it. is that red light means something, it means heat, we have primary nociceptors in the tissues and some of those noisy sectors respond to changes in temperature up or down.

They are bidirectional thermal nociceptors, so they will activate when you place a very cold company in the back of the hand, but our theory is that the red light will be a signal for the brain to say it's hot and I know that hot is more dangerous than cold That's the theory behind it That's the other light A light appears light blue and we asked a lot of questions, but these are the most relevant data here. I'll skip my laser pointer, so these are individual. data and hopefully you can see that when people see the red light it hurts more than if they see the blue light, but the pleasantly separative stimulus is identical in those two scenarios and if you look closely you can see some people like this person here, a person. clearly there is an idiot because he does not pick up the sensory signal that has meaning for protection.

This is a study that we did more recently, so it is a PhD work by Daniel Harvey dr. Daniel Harvey, who is a leading innovator and scientist, so stay tuned to Harvey because there will be great articles from him throughout his career on this experiment. We were particularly interested in whether we could use a vibrotactile. stimulus to change the pain of a noxious stimulus applied to the same area, so this is the setup in which someone rates the unpleasantness and intensity of the painful stimulus which in this I think was an electrical stimulus, small electrodes just below the surface of the skin, but we are interested in paying in different contexts what this tells us is that the really painful stimulus hurts more than the non-painful stimulus this is not like my daughter would have said ten years ago that is not surgery rocket dad well that's true but this small difference This is what happens when we test a moderate noxious stimulus together with one of those two vibrotactile stimuli and this is a very small difference, but we are in a very artificial situation in the laboratory and a sister Statistically important, if you like, it's small, but it's there to show that the non-noxious signals are delivered at the same time and this shows that the non-noxious signals are delivered at the same time that the noxious Q is modulated up and down accordingly. with past experience, so according to associative learning or Pavlov's classical conditioning theory now this may not be the case.

It's very surprising to you, in fact, we now know Dr. Tori Madden's doctors, some of you would have been involved in her PhD because she did a survey asking people if they think it is possible to condition pain to classically conditioned pain and doctors overwhelmingly say yes; However, until this study was published there was no clear evidence to support this. that perspective, so we ask people if they think that's possible, yes, and I think it's really interesting and demonstrates the wisdom of clinical groups that doctors say yes because it's so consistent with what we see in the clinic that It looks like it's an associative Lee. learned experience well, now we can say well, this will probably happen, we can certainly make it happen in the laboratory with supposedly normal healthy volunteers, this is one of Tory's studies, so Tory manon, who is now at the University of Ciudad del Cape as a postdoctoral fellow in this study, I looked at the laser stimuli, so I'll just give you an idea of ​​what the laser feels like and you'll open your eyes wide.

No, I don't really do that, but the laser stimulates the nociceptors in the skin and in Tory's study again we just had two different vibrotactile stimuli here, they're labeled tactus, we got a third one that was for generalization and we compared what the pain is. is evoked or pain thresholds were looked at in your study, what is the pain threshold when combined with a previous stimulus that was always associated with a highly noxious input, so Dan's study shows classically conditioned hyperalgesia. Tory's study shows classically conditioned allodynia, so there is pain where before we would not have had pain and these two boxes point that out and for anyone on an ethics committee that you can see in the third one, we can extinguish that very quickly, so that there is no longer any effect.

Here's another one of Dan's studies and he's moving forward with this really exciting research, but in this study we were interested in whether visual cues that tell you that your head is rotating are important in causing pain during head rotation. during neck rotation. This is the setup, so this is virtual reality glasses and the image that he can see demonstrates what the person will see when he turns his head inward. those argon glasses, EO meters that tell us what the true rotation is and then we can manipulate the rate at which the visual field changes so that they are no longer congruent and Danis published a paper, I think in physical therapy, that looks at this as a proprioception detector.

The precision and accuracy that this data shows is that there is a new value between about 0.7 and 1.2 where people cannot detect that there is congruence between vision and proprioception, they do not realize that we have altered your feedback and your vision. is the most precise and therefore the most influential sensory system we have, so vision usually wins, so we know that if we are able to get people to move at that level of gain, they won't know that the We're cheating, I hope. that makes sense and this is data from patients with chronic neck pain when they turn their head so people on the left can move more because their visual field moves slower than actual movement so their visual cues they say: you haven't moved as much as you and there is no pain so this is the beginning of the pain and in red your movement allodynia when we make the vision move faster then the pain comes on earlier so these pain patients chronic your pain is being triggered at least in part by rotational visual feedback, not by nociception, that would be our interpretation of these results and it is not just pain, so pain is one of our protective outputs, but there are other outputs which are modulated by non-noxious signals and I think these studies are really wonderful and really relevant to the experience I had in the elevator this morning at the hotel because what these people did was observe the effect of an unpleasant smell on a pleasant reflection of receptive withdrawal.

Now I got into the elevator this morning. and if you're the person who walked out, I hope you realize that I know what you did there, it was really quite disgusting and disgusting, so bad that you know when you know that someone else has farted in the elevator and then leaves and then someone else walks in, so if you're here, know it wasn't me. I guarantee it was not me in this study. These people were observing the EMG response to a noxious stimulus. It's a classic nociceptive withdrawal reflex, but they also gave them odors. and the chart there shows that smelling an unpleasant odor and then receiving a noxious input that you know is going to happen increases your abstinence from that input.

Now I think this is a pretty profound find, and Sarah Wall Workers just finished her PhD in our group. has done a systematic review and meta-analysis of all of these types of protective reflexes and has shown quite clearly that the biggest modulator is our signals that tell you that you need to protect a little bit more, so the biggest modulator of protective signals that seem to be our protective reflexes. They can be danger signals and don't have to be body part specific at all, so in this experiment these supposedly normal healthy volunteers are in an unpleasant environment and their brain regulates a pleasant withdrawal acceptance reflex.

I think that's really cool. Here's another one. study carried out by Sarah in collaboration with Professor John Domenico Alessandro Magnifico Fantastico Perfecto Iannetta from University College London and uses the hand blink reflex. It is a truly wonderful reflection. If you stimulate the median nerve, you blink. 75 percent of people blinked until about three years ago. This was supposed to be a very basic, independent protective response left over from evolutionary processes under the control of the brain stem, and if you cut off your head you would still have this, although it would be difficult to check if you blinked.

I guess what John des and Sarah have shown to John des with this particular finding is that this reflux is greater if your hand is close to your face, so the circuit is identical, but the spatial data is such that the The brain regulates this protective response because your hand is close to your face. If your hand is moving away from your face, that positive regulation is gone, so how cool is it that it's like the brain says, well, you're moving away, it doesn't matter. , I don't need to protect you as much if you're moving towards your face.

We face that it's regulated early, so this is a predictive protective modulation of a reflex that we assumed was just a spinal or brainstem equivalent of a spinal reflex, but here's the interesting part that these guys have also shown is that if you put a barrier between your hand and your face, whose positive regulation is lost, so the cognitive information knowing well that there is a protection between the place where the stimulus occurs and the eye is enough to prevent the brain from increasing the protection, to Unless it's a weak barrier if you put a piece of tissue up there, the brain still reestablishes this protection, so it's highly sophisticated cognitive processing in real time that changes basic reflexes.

Here is an interesting study that has not yet been published and I really hope that Tasha Stanton, who is not, is a prominent young researcher in our country. group probably not so young now the mid-career researcher is winning every award she's eligible for from the Australian government's International Association for the Study of Pain she's an absolute absolute and she thought of this idea we had talked about previously stiffness like we talk about pain and people often say well I feel like my back is stiff, my knee is stiff and that stiff feeling and a former supervisor of yours named Gregor Chuck has this incredible incredible indentation or that measures the stiffness of the spine lumbar what Tesla and Greg have shown is that the true stiffness of the lumbar spine does not match the felt stiffness, so they felt that the stiffness does not depend on the true stiffness, but what Tasha thought it would do is what happens if set the notch, sync it with the sound of a squeaky door and there is no harmful and, in many ways, ridiculous, glue associated with rigidity, which is what Tasha did.

The difference between these two is perceived stiffness, so how stiff does your back feel when you're listening? to a squeaky door along with the cracks on the right versus when you're listening to a sushi sound. Now in science these soft sounds are called sushi sounds, but hopefully you can see that there is a really profound difference in these two scenarios. It's called cross-modal modulation and I think it targets our highly sophisticated ii modulator system to even feel rigidity, how much more should we be able to modulate that if we intentionally target sophisticated cognitive strategies and I think there's a lot of emotion that comes out of a study like this and everything.

This leads to what is officially known as the grand pooh-bah theory of pain. Pain is the unpleasant sensation that is felt in some part of the body and that urges us to protect that part of the body and What is happening in pain science now is a fairly rapid journey towards pain, which has to do with protection, it is about protective behavior, not the state of the tissues, and in fact, even in highly controlled experiments, nociception is not even about the state of the tissue. Tissue nociception is about triggering protective responses, even in experiments highly controlled.

Nociception is not about the state of the tissues, it is about triggering protective responses. Pain is an exit, not an entrance. Many of you would have heard me say this before and others have said this before. It's not my idea at all, it's just the idea that I think makes the most sense, so I spent a lot of time putting together an outline to capture this highly complex distinction. The pain does not reach the brain. Pain reaches consciousness from the human being andWe could say that it is the brain that produces pain, but that wouldn't really be correct.

It's the human being that produces pain, but the brain is the obvious Big Kahuna organ that contributes to that, I guess, and it's just one of our protective mechanisms and there are other protective mechanisms. that's happening all the time now as a physiotherapist we know the movement right, we know the movement I think Anna the beautiful Anna who I share my life with I think she could have fallen in love with me because the first time we went out I could choose that she had an old injury ankle and you know everyone has had an old ankle injury, right?

And I was able to say Oh, you hurt your ankle when you were younger, she's a lot shorter than me, that's why she's doing that. So if someone is feeling lonely, the best way to get a life partner is to bring up your old ankle injury, think about it and then when they say it's amazing, say: I'm a physiotherapist and I promised someone. I hate to do this, but I promised someone. Six months ago I would show you what we love most as physical therapists: we know we can do pelvic tilt better than anyone else on the planet and we couldn't wait for that patient to come in who has chronic low back. pain because we know that now we will say how are you Martha, how is your back, oh I'm 20 years old like this, whatever Martha, you want to see my pelvic tilt and Martha says what it is and you say it's just a pelvic tilt and Martha They fall off eyes, can you do that again?

I'm sure I'm not worried about anything happening. In fact, when you go and look down the road towards Glasgow Main Street, you can sit and just look at all the other delegates I love because they walk like this anyway, so thank you, the motor system is the system that is almost like our currency. We can see when the motor system is protective and some of what Gwen went through this morning seemed just fantastic to me. Looking at when this understanding that returning things to functional limits could play an important role in our management of patients and the motor system is what I grew up in, if you will, I did my PhD under the ride in the cortex, actually now. the functioning cortex Paul Hodges, who apparently tried to forget something a few years ago and couldn't do it, but there are other systems that are relevant to us and they are becoming more and more relevant and I want to convince you of that.

This is a book, an image taken from a book by David Butler and I called it Explaining Pain trying to capture all the other protective mechanisms that are at play when the brain concludes that that is what is best for us. It's not just pain, but I hope you see it. the wording here that we subscribe to is the pain production system the pain production system because pain is the only one that we are necessarily aware of you cannot have pain and not know it you can have a change in interleukin 4 you can have a cortisol change you can probably change your heart rate and breathing rate without knowing it, but you can't have pain and not know it, so where does it fit?

So we would argue that nociception is what happens in the nerves and in the immune mechanisms in The pathways that carry danger messages to the brain are pain that occurs in consciousness and is modulated by any credible evidence of threat and I think that the The data now is really compelling to say that's the case, so here are some discoveries that I think should rock your world in the next decade and I imagine there will be a chapter or two in Greaves 2025 that incorporates these discoveries that I think are fundamental. for us as physiotherapists. This is a really bad drawing that I did in a bit of a hurry, but it's meant to capture the spinal septa, I don't see here, running towards the gross primary.

How well you said this going into those records and these are flying immune cells or astrocytes and this is Homer Simpson. I have to explain it to Marge if you're here, Marge this. This is what Homer Simpson looks like and Homer Simpson represents a toll-like receptor and instead of going into all that, just know that this synapse cannot function without the glial cell, the synapse is useless without the glial cell and the glial cell is maintains. This works in a very simplified sense by the balance between the pro-inflammatory cytokines and the anti-inflammatory cytokines that they release and they do so in response to activation or alteration in the synapse.

Homer is really important because Homer, the toll-like 4 receptor, is It's a stupid receptor, but it has a very long memory and that's very important for us as doctors because now in that neuroimmune space I work closely with a guy named Mark Hutchinson , who specializes in this, he's a neuropharmacoimmunologist or something, he's a good guy too and we're now recognizing that the toll-like receptor will respond to particular molecular patterns associated with damage or danger called moistures, pathogens, viruses, bacteria, toxins, We call them pants and anything that is foreign, maybe not foreign substances. Obviously, morphine we call it after a xenobiotic-associated molecular pattern that is really important for us not only at the spinal level but also in the brain, so in the brain these immune cells interact very closely. 90% of the brain is our immune cells and they interact very closely in our thinking and in our conductance in an electrophysical sense, the mark would even go so far that it's hard to get away from animal studies, but I would go as far as to say that there are molecular patterns associated with cognition, so the things you think affect your immune activation and that's well established in a basic sense from animal studies and Mark would describe it as our immune cells move toward a thought.

Now there's pretty strong speculation with that, but I hope you can get an idea of ​​that when we think we're in danger. It is a reasonable prediction to say that our immune system regulates itself in response to that thought. It's a reasonable prediction that hasn't been proven, but I hope that by 2025 that will be the case. I have a new respect. for good accepting wiring, here is a simple schematic of a good receptive system, but if we look closer at the essence of the dorsal horn, the dorsal horn in humans and animals has a massive, absolutely massive computational capacity, there are thousands of intraspinal interneurons . involved in pleasant receptive transmission and modulation by higher centers, there are many different types.

The image to your left here gives you an idea of ​​the influence of a single incoming neuron at the level of the dorsal horn. It's huge and now I would say it's like the brain started there primarily concerned with spatial and magnitude calculations. I think this should shake our world too. What we now know about glare is that they prime themselves to remember and this is where Homer Simpson comes in the more they are exposed. these damps maybe zaps and possibly camps, then the more prepared they become for when there is a signal of nociceptors running so that throughout life we ​​can have little immunological insults associated with any of those things that mean that ultimately , when the noisy septic system is activated, the pain that emerges is out of place with the good set of stimuli, so this is a preparation before the injury and I think this will really change our world.

There is another one about brands, so I really like this slide because it reminds us that that week we simply thought. about the body as a machine, we also have to think of the body as a garden and if you imagine a garden, when something goes wrong with your tomatoes, suddenly something happens with your asparagus on the other side and we don't understand it. Some of those connections are not like hardwired connections, there is a lot of influence, we are one organism. I think that is becoming very clear and the old things still ring true. Then George Engle proposed the biopsychosocial model in 1960, this was almost 60 years ago. and all the research is really pointing us more and more towards that and I completely agree again with what Gwen said this morning about a truly biopsychosocial approach to people who are in trouble, but this is the wisdom of George Engle.

I guess it's not like that. It is more valid to attribute the entirety of a change in human state to an isolated cell or tissue event than to isolate that cell or tissue and expect that once removed it will generate the same signs and symptoms that were present before its removal, this is a nuisance. and and this is one of George's quotes, but the biopsychosocial model itself has been corrupted, I think, over time and has been lost up here, you can see the original for the application of the diocese in the field of painting. This is the version shown by John Lowe.

This is what David Butler and I did the same thing and this has limitations and inaccuracies and it's not intriguing that Dave and I are out of focus. I'll really feel like at this point in life I feel like this is because I got this. outside of Google Children's Mercy Hospital I think in Kansas or somewhere in the United States because I really like it, I'll come back to that, but here are some situations from Google where it's been filled in, this is not the biopsychosocial model of pain here , its biological is the intensity in the nature of pain psychology the anguish it brings and sociology the effect on daily functioning is not how the biopsychosocial model fits according to George and how it has been applied in other fields nor is it biological the psychological body symptoms how you feel about them and social how it affects your relationships that is not the biopsychosocial model but clearly the biopsychosocial model rejects the biomedical model this is from George the first parts of George because the biomedical model by definition does not care about the person but the model biopsychosocial does not reject the role of structural, biomechanical and functional alteration of body tissue as potentially powerful drivers of protection.

It's integrated and take a look at this one from Children's Mercy Hospital. I love it. Talk about chronic abdominal pain. Some of the biological things that are relevant. happening in your viscera in your nerves inflammation bacteria in the gut your mood anxiety your beliefs your relationships but critically they all influence each other that's the difference there is a constant interaction that is relevant to that idea of ​​the matrix of the cortical body which is a conceptual idea that links the things we feel and what happens in your body and I want to give you an example of a couple of these things, sorry for that little extra, there it is, can everyone do this?

Please, I want you to do that and then I want you to move your hand over there as far as you can, back up to the other side and now you can go from there but do it the shortest way. Oh, we can't do it right, we can't, it's impossible for us. but what if you hadn't if you didn't have an arm but you had a ghost? This is an experiment we did with seven amputees with an intact phantom and we said, can you learn to do that impossible movement? and four of Them said yes and instead of explaining this to you, you can look at the document, but these are the four that said yes on one of our tests that you can't cheat on and these are the four that said yes on our other tests where you can cheat.

Don't cheat, that tells us that they were telling the truth when they said I can do it but they all simultaneously when learning the movement changed the felt structure of their ghost and here is the drawing that one of them gave simultaneously of how our body feels and what we can do with it changes and I think that's really interesting for us. What was also interesting about this is that these people lost the ability to do this with their ghost because now everyone had access through the hand that they couldn't. let them do it shuriken it's pretty amazing okay sorry I've got something really slow here maybe you can help me up there Kevin what's up with touch?

This is an experiment we did with just a small number of people with low back pain who were asked to draw how they felt their back was the outline of their back and then we measured two point discriminations. Fresh Holdren now, when this guy got here, he said, I can't feel it anymore, I can't find it and that was the point where the tactile acuity was low but the sensory detection was normal, so there's a problem with the representations in the brain. . The same thing happened with the next five people who came and the title of this article was I can't find it because they were all saying that or words.

In that sense, this is a situation where we are interested in knowing how important it is that you have a sense of ownership over your body. This is a postdoc in my lab when I was in the UK and he's doing the rubber hand illusion that gives you a convincing illusion that you can feel a touch on this rubber hand even though you're actually being touched here. , but you can see the twist in this. These studies were carried out by a group of Dutch students who came to spend some time in our laboratory and they were exceptional and I had the pleasure of meeting one ofthem yesterday.

He is at this conference. Thanks to Sonica and welcome. What these studies showed is that when you get the rubber hand illusion, your own hand behind the board moves. cold, you know, the reduction in blood flow to that hand is very specific to that hand, so the sense of ownership or representation of how your arm feels changes the blood flow to your arm, this shows that it also increases the histamine reactivity, so if you put on a rubber Hand Illusion you become more reactive to immune insults in the limb, so how you feel about your hand affects your immune responses to protect it.

This study here shows that if you have complex regional pain syndrome and you look at your arm as you move it, it hurts. nothing very surprising but if you look at your arms through magnifying glasses it hurts more when it looks big when it looks swollen it hurts more but the cold part swells more when you look at your arm if you look up yes and your arm is swelling it does cause swelling look worse, their swelling gets worse and we did the control experiments, it's not because of how they move and if you're wondering what happens when you turn the binoculars upside down, the effect is reduced, so the increase in swelling is reduced, so so there is a clear bidirectional relationship between what it looks like and what it does.

Well, what would I like to do? Kevin. This would take me a long time. Can you take me to the fourth and final slide? Please can you come back? to please Kevin, great, okay one more, so skip to my last slide because I'm running out of time and the beauty of doing another talk on Thursday is that I can turn them into that, which means I have to do less. preparation between now and then, which is great. I think the evidence tells us, and this is relevant to patient care, that pain itself is truly biopsychosocial, it is modulated by any credible evidence that protection is needed in a biological framework, the state of the inflammatory ensemble of the tissues. . bacterial pathogens cognitions xenobiotics obviously morphine all of that affects the compulsion to protect and the only thing that forces us to protect with real vigor is pain, possibly stiffness, but now we are learning that the same thing happens with rigidity, we know that, and there is a workshop this afternoon and will talk more about this on Thursday.

We know that there is level one empirical data, evidence that understanding this really biopsychosocial phenomenon, that is, pain is good, it improves outcomes, pain, disability and function, outcomes and I would say there is very clear evidence that reassuring, sophisticated reassurance and explaining pain have a clear role in our interventions and we are required to ensure that all our explanations for what we do are consistent with what we currently know about what we do. It seems that we have an internal protection meter that is modulated at all times in real time and it is only when that internal protection meter reaches a threshold that we feel pain and it depends on a balance between danger and safety signals and we can exploit that clinically and the Pathophysiological findings associated with chronic pain now extend to inflammation-mediated changes in the brain.

I'll talk about that on Thursday and what we could do about it. In conclusion, I would really like to thank the people in my research group who do excellent work. I am lucky to work with smart, kind, community-minded people. Some of these people in yellow at the top have now moved on and are now postdocs in other labs, but I want to especially thank Dan Dan Harvey, who I mentioned Tasha Stanton, Tory Madden, and Emily Reed, and I collaborate closely with people of white. This is a photograph from our last group retreat where a few of us met for wine in the Clare Valley and were lucky enough to be joined by John Domenica Alessandro Magnifico.

Fantastic opportunity and Frank Keith. Now the last thing we do is do you a favor and come to Australia next April to participate in the pain revolution trip. We'll be traveling from Melbourne to Adelaide for six days and along the way at each of those sites we'll be doing painting education for psychologists physiotherapists GPS and the public, so if you come with us you can go to the meeting of the Australian Painting Society. Next week in Adelaide, seven days, eight hundred and eighty, k2 day, explanatory course on pain, five public play seminars, five multidisciplinary workshops, you can be part of them strictly with 30 participants, so you must participate and be part of that, and this is our goal. to raise money for the Pain Revolution Foundation to raise awareness about the problem.

Provide knowledge. Provide skills. Consolidate those achievements and measure those results. So do yourself a favor if you are a cyclist of any kind or want to be one, contact Tracey. Thank you very much for my rushed ending, let me have my rusty ending, but thank you very much.