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###########################################################1: Clin J Pain. 2005
Jul-Aug;21(4):323-9. Are the changes in postural control associated with low back
pain caused by pain interference?Moseley GL, Hodges PW.The University of
Queensland, Brisbane, Australia. l.moseley@fhs.usyd.edu.auBACKGROUND: Voluntary
limb movements are associated with involuntary and automatic postural adjustments
of the trunk muscles. These postural adjustments occur prior to movement and
prevent unwanted perturbation of the trunk. In low back pain, postural adjustments
of the trunk muscles are altered such that the deep trunk muscles are consistently
delayed and the superficial trunk muscles are sometimes augmented. This alteration
of postural adjustments may reflect disruption of normal postural control imparted
by reduced central nervous system resources available during pain, so-called "pain
interference," or reflect adoption of an alternate postural adjustment strategy.
METHODS: We aimed to clarify this by recording electromyographic activity of the
upper (obliquus externus) and lower (transversus abdominis/obliquus internus)
abdominal muscles during voluntary arm movements that were coupled with painful
cutaneous stimulation at the low back. If the effect of pain on postural
adjustments is caused by pain interference, it should be greatest at the onset of
the stimulus, should habituate with repeated exposure, and be absent immediately
when the threat of pain is removed. Sixteen patients performed 30 forward movements
of the right arm in response to a visual cue (control). Seventy trials were then
conducted in which arm movement was coupled with pain ("pain trials") and then a
further 70 trials were conducted without the pain stimulus ("no pain trials").
RESULTS: There was a gradual and increasing delay of transverses abdominis/obliquus
internus electromyograph and augmentation of obliquus externus during the pain
trials, both of which gradually returned to control values during the no pain
trials. CONCLUSION: The results suggest that altered postural adjustments of the
trunk muscles during pain are not caused by pain interference but are likely to
reflect development and adoption of an alternate postural adjustment strategy,
which may serve to limit the amplitude and velocity of trunk excursion caused by
arm movement.2: Brain Res Cogn Brain Res. 2005 Jun 14; [Epub ahead of print]
Experimental hand pain delays recognition of the contralateral hand-Evidence that
acute and chronic pain have opposite effects on information processing?Moseley GL,
Sim DF, Henry ML, Souvlis T.Department of Physiotherapy, The University of
Queensland, Sydney, Australia;Royal Brisbane and Women's Hospital, Brisbane,
Sydney, Australia; School ofPhysiotherapy, The University of Sydney, Sydney,
Australia.Recognising the laterality of a pictured hand involves making an initial
decision and confirming that choice by mentally moving one's own hand to match the
picture. This depends on an intact body schema. Because patients with complex
regional pain syndrome type 1 (CRPS1) take longer to recognise a hand's laterality
when it corresponds to their affected hand, it has been proposed that nociceptive
input disrupts the body schema. However, chronic pain is associated with
physiological and psychosocial complexities that may also explain the results. In
three studies, we investigated whether the effect is simply due to nociceptive
input. Study one evaluated the temporal and perceptual characteristics of acute

hand pain elicited by intramuscular injection of hypertonic saline into the thenar
eminence. In studies two and three, subjects performed a hand laterality
recognition task before, during, and after acute experimental hand pain, and
experimental elbow pain, respectively. During hand pain and during elbow pain, when
the laterality of the pictured hand corresponded to the painful side, there was no
effect on response time (RT).That suggests that nociceptive input alone is not
sufficient to disrupt the working body schema. Conversely to patients with CRPS1,
when the laterality of the pictured hand corresponded to the non-painful hand, RT
increased approximately 380 ms (95% confidence interval 190 ms-590 ms). The results
highlight the differences between acute and chronic pain and may reflect a bias in
information processing in acute pain toward the affected part.3: Rheumatology
(Oxford). 2005 Apr 12; [Epub ahead of print] Sensory-motor incongruence and reports
of 'pain'Moseley GL, Gandevia SC.School of Physiotherapy, The University of Sydney,
Sydney, Australia.4: Pain. 2005 Mar;114(1-2):54-61. Epub 2005 Jan 26. Is successful
rehabilitation of complex regional pain syndrome due to sustained attention to the
affected limb? A randomised clinical trial.Moseley GL.School of Physiotherapy, The
University of Sydney, Lidcombe, Sydney, NSW 1825, Australia.
l.moseley@fhs.usyd.edu.auIn complex regional pain syndrome (CRPS1) initiated by
wrist fracture, a motor imagery program (MIP), consisting of hand laterality
recognition followed by imagined movements and then mirror movements, reduces pain
and disability, but the mechanism of effect is unclear. Possibilities include
sustained attention to the affected limb, in which case the order of MIP components
would not alter the effect, and sequential activation of cortical motor networks,
in which case it would. Twenty subjects with chronic CRPS1 initiated by wrist
fracture and who satisfied stringent inclusion criteria, were randomly allocated to
one of three groups: hand laterality recognition, imagined movements, mirror
movements (RecImMir, MIP); imagined movements, recognition, imagined movements
(ImRecIm); recognition, mirror movements, recognition (RecMirRec). At 6 and 18
weeks, reduced pain and disability were greater for the RecImMir group than for the
other groups (P<0.05). Hand laterality recognition imparted a consistent reduction
in pain and disability across groups, however, this effect was limited in
magnitude. Imagined movements imparted a further reduction in pain and disability,
but only if they followed hand laterality recognition. Mirror movements also
imparted a reduction in pain and disability, but only when they followed imagined
movements. The effect of the MIP seems to be dependent on the order of components,
which suggests that it is not due to sustained attention to the affected limb, but
is consistent with sequential activation of cortical motor networks.Publication
Types:
Clinical Trial
Randomized Controlled Trial5: Aust J Physiother.
2005;51(1):49-52. Widespread brain activity during an abdominal task markedly
reduced after pain physiology education: fMRI evaluation of a single patient with
chronic low back pain.Moseley GL.Department of Physiotherapy, Royal Brisbane and
Women's Hospital & TheUniversity of Queensland, Brisbane, Australia.
l.moseley@fhs.usyd.edu.auThe way people with chronic low back pain think about pain
can affect the way they move. This case report concerns a patient with chronic
disabling low back pain who underwent functional magnetic resonance imaging scans
during performance of a voluntary trunk muscle task under three conditions:
directly after training in the task and, after one week of practice, before and
after a 2.5 hour pain physiology education session. Before education there was
widespread brain activity during performance of the task, including activity in
cortical regions known to be involved in pain, although the task was not painful.
After education widespread activity was absent so that there was no brain
activation outside of the primary somatosensory cortex. The results suggest that
pain physiology education markedly altered brain activity during performance of the
task. The data offer a possible mechanism for difficulty in acquisition of trunk
muscle training in people with pain and suggest that the change in activity
associated with education may reflect reduced threat value of the task.Publication
Types:
Case Reports
Evaluation Studies6: Brain. 2004 Oct;127(Pt 10):2339-47.
Epub 2004 Jul 28. Does anticipation of back pain predispose to back trouble?Moseley
GL, Nicholas MK, Hodges PW.Prince of Wales Medical Research Institute, Randwick,

Sydney, Austalia.l.moseley@fhs.usyd.edu.auLimb movement imparts a perturbation to


the body. The impact of that perturbation is limited via anticipatory postural
adjustments. The strategy by which the CNS controls anticipatory postural
adjustments of the trunk muscles during limb movement is altered during acute back
pain and in people with recurrent back pain, even when they are pain free. The
altered postural strategy probably
serves to protect the spine in the short term, but it is associated with a cost
and is thought to predispose spina structures to injury in the long term. It is not
known why this protective strategy might occur even when people are pain free, but
one possibility is that it is caused by the anticipation of back pain. In eight
healthy subjects, recordings of intramuscular EMG were made from the trunk muscles
during single and repetitive arm movements. Anticipation of experimental back pain
and anticipation of experimental elbow pain were elicited by the threat of painful
cutaneous stimulation. There was no effect of anticipated experimental elbow pain
on postural adjustments. During anticipatedexperimental back pain, for single arm
movements there was delayed activation of the deep trunk muscles and augmentation
of at least one superficial trunk muscle. For repetitive arm movements, there was
decreased activity and a shift from biphasic to monophasic activation of the deep
trunk muscles and increased activity of superficial trunk muscles during
anticipation of back pain. In both instances, the changes were consistent with
adoption of an altered strategy for postural control and were similar to those
observed in patients with recurrent back pain. We conclude that anticipation of
experimental back pain evokes a protective postural strategy that stiffens the
spine. This protective strategy is associated with compressive cost and is thought
to predispose to spinal injury if maintained long term.7: Clin J Pain. 2004 SepOct;20(5):324-30. A randomized controlled trial of intensive neurophysiology
education in chronic low back pain.Moseley GL, Nicholas MK, Hodges PW.University of
Queensland, Brisbane, Australia. l.moseley@mailbox.uq.edu.auOBJECTIVES: Cognitivebehavioral pain management programs typically achieve improvements in pain
cognitions, disability, and physical performance. However, it is not known whether
the neurophysiology education component of such programs contributes to these
outcomes. In chronic low back pain patients, we investigated the effect of
neurophysiology education on cognitions, disability, and physical performance.
METHODS: This study was a blinded randomized controlled trial. Individual education
sessions on neurophysiology of pain (experimental group) and back anatomy and
physiology (control group) were conducted by trained physical therapist educators.
Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)),
and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland
Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1)
straight leg raise (SLR), (2) forward bending range, and (3) an abdominal "drawingin" task, which provides a measure of voluntary activation of the deep abdominal
muscles. Methodological checks evaluated non-specific effects of intervention.
RESULTS: There was a significant treatment effect on the SOPA(R), PCS, SLR, and
forward bending. There was a statistically significant effect on RMDQ; however, the
size of this effect was small and probably not clinically meaningful. DISCUSSION:
Education about pain neurophysiology changes pain cognitions and physical
performance but is insufficient by itself to obtain a change in perceived
disability. The results suggest that pain neurophysiology education, but not back
school type education, should be included in a wider pain management approach.
Publication Types:
Clinical Trial
Randomized Controlled Trial8: Man Ther.
2004 Aug;9(3):157-63. Impaired trunk muscle function in sub-acute neck pain:
etiologic in the subsequent development of low back pain?Moseley GL.Division of
Physiotherapy, The University of Queensland, Australia.l.moseley@uq.edu.auLow back
pain (LBP) and neck pain are associated with dysfunction of the trunk and neck
muscles, respectively, and may involve common or similar mechanisms. Inboth cases,
dysfunction may compromise spinal control. Anecdotally, neck pain patients commonly
develop LBP. This study investigated the possibility that trunk muscle function is
compromised in neck pain patients and that compromised trunk muscle function is
associated with increased risk of LBP. Fifty-four neck pain patients and 52

controls were assessed on an abdominal drawing-in task (ADIT) and on self-report


tests. Performance on the ADIT was able to detect neck pain patients with 85%
sensitivity and 73% specificity. Catastrophizing and McGill pain questionnaire
(affective) scores were higher in patients with an abnormal task response than in
patients with an uncertain or normal response, although the self-report data did
not predict task performance. Fifty subjects from each group were contactable by
telephone at 2 years. They were asked whether they had experienced persistent or
recurrent LBP since the assessment. Subjects (patients and controls) who obtained
an abnormal response on the ADIT were 3 to 6 times more likely to develop
persistent or recurrent LBP than those who obtained an uncertain or normal
response. ADIT performance was the main predictor of development of LBP in
patients. The results suggest that reduced voluntary trunk muscle control in neck
pain patients is associated with an increased risk of developing LBP.PMID: 15245710
[PubMed - indexed for MEDLINE]9: Neurology. 2004 Jun 22;62(12):2182-6. Why do
people with complex regional pain syndrome take longer to recognize their affected
hand?Moseley GL.Department of Physiotherapy, The University of Queensland, and
Royal Brisbane &Women's Hospital, Brisbane, Australia. l.moseley@uq.edu.au
BACKGROUND: People with complex regional pain syndrome (CRPS) take longer to
recognize the laterality of a pictured hand when it coincides with their affected
hand. The author explored two aspects of this phenomenon: whether the duration of
symptoms relates to the extent of the delay and whether guarding-type mechanisms
are involved. METHODS: Eighteen patients with CRPS type 1 of the wrist and 18
matched control subjects performed a hand laterality recognition task. McGill pain
questionnaire, Neuropathic Pain Scale, and response time (RT) to recognize hand
laterality were analyzed. Regressions related 1) mean RT for patients to the
duration of symptoms and to pain intensity; and 2) mean RT for each picture to the
predicted pain on executing that movement as judged by the patient, and to the
awkwardness of the movement that would be required. RESULTS: For patients, the
duration of symptoms correlated with mean RT (Spearman rho = 0.44; p = 0.02).
Predicted pain rating explained 45% of the variance in RT for each picture for each
patient (p < 0.01). CONCLUSIONS: The results suggest that in patients with complex
regional pain syndrome type 1, delayed recognition of hand laterality is related to
the duration of symptoms and to the pain that would be evoked by executing the
movement. The former is consistent with chronic pain and disuse and may involve
reorganization of the cortical correlate of body schema. The latter is consistent
with a guarding-type response that probably occurs upstream of the motor cortex at
a motor planning level.10: Neurology. 2004 May 11;62(9):1644. Imagined movements
cause pain and swelling in a patient with complex regional pain syndrome.Moseley
GL.University of Queensland and Royal Brisbane & Women's Hospital, Brisbane,
Australia. l.moseley@uq.edu.auPublication Types:
Case Reports11: Exp Brain Res.
2004 May;156(1):64-71. Epub 2003 Dec 19. Pain differs from non-painful attentiondemanding or stressful tasks in its effect on postural control patterns of trunk
muscles.Moseley GL, Nicholas MK, Hodges PW.Department of Physiotherapy, Royal
Brisbane Hospital, 4029, Herston, Queensland,Australia. l.moseley@uq.edu.auPain
changes postural activation of the trunk muscles. The cause of these changes is not
known but one possibility relates to the information processing requirements and
the stressful nature of pain. This study investigated this possibility by
evaluating electromyographic activity (EMG) of the deep and superficial trunk
muscles associated with voluntary rapid arm movement. Data were collected from
control trials, trials during low back pain (LBP) elicited by injection of
hypertonic saline into the back muscles, trials during a non-painful attentiondemanding task, and during the same task that was also stressful. Pain did not
change the reaction time (RT) of the movement, had variable effects on RT of the
superficial trunk muscles, but consistently increased RT of the deepest abdominal
muscle. The effect of the attention-demanding task was opposite: increased RT of
the movement and the superficial trunk muscles but no effect on RT of the deep
trunk muscles. Thus, activation of the deep trunk muscles occurred earlier relative
to the movement. When the attention-demanding task was made stressful, the RT of
the movement and superficial trunk muscles was unchanged but the RT of the deep

trunk muscles was increased. Thus, the temporal relationship between deep trunk
muscle activation and arm movement was restored. This means that although postural
activation of the deep trunk muscles is not affected when central nervous system
resources are limited, it is delayed when the individual is also under stress.
However, non-painful attention-demanding task does not replicate the effect of
pain on postural control of the trunk muscles even when the task is stressful.12:
Pain. 2004 Mar;108(1-2):192-8. Graded motor imagery is effective for long-standing
complex regional pain syndrome: a randomised controlled trial.Moseley GL.Department
of Physiotherapy, The University of Queensland and Royal Brisbane andWomen's
Hospital, Herston, 4029 Brisbane, Qld, Australia.l.moseley@mailbox.uq.edu.auComplex
regional pain syndrome type 1
(CRPS1) involves cortical abnormalities similar to those observed in phantom pain
and after stroke. In those groups, treatment is aimed at activation of cortical
networks that subserve the affected limb, for example mirror therapy. However,
mirror therapy is not effective for chronic CRPS1, possibly because movement of the
limb evokes intolerable pain. It was hypothesised that preceding mirror therapy
with activation of cortical networks without limb movement would reduce pain and
swelling in patients with chronic CRPS1. Thirteen chronic CRPS1 patients were
randomly allocated to a motor imagery program (MIP) or to ongoing management. The
MIP consisted of two weeks each of a hand laterality recognition task, imagined
hand movements and mirror therapy. After 12 weeks, the control group was crossedover to MIP. There was a main effect of treatment group (F(1, 11) = 57, P < 0.01)
and an effect size of approximately 25 points on the Neuropathic pain scale. The
number needed to treat for a 50% reduction in NPS score was approximately 2. The
effect of treatment was replicated in the crossed-over control subjects. The
results uphold the hypothesis that a MIP initially not involving limb movement is
effective for CRPS1 and support the involvement of cortical abnormalities in the
development of this disorder. Although the mechanisms of effect of the MIP are not
clear, possible explanations are sequential activation of cortical pre-motor and
motor networks, or sustained and focussed attention on the affected limb, or both.
Publication Types:
Clinical Trial
Randomized Controlled Trial13: Eur J Pain.
2004 Feb;8(1):39-45. Evidence for a direct relationship between cognitive and
physical chang during an education intervention in people with chronic low back
pain.Moseley GL.Departments of Physiotherapy, Royal Brisbane Hospital and The
University ofQueensland, Herston, 4029, Australia. l.moseley@mailbox.uq.edu.au
BACKGROUND: Unhelpful pain cognitions of patients with chronic low back pain (LBP)
may limit physical performance and undermine physical assessment. It is not known
whether a direct relationship exists between pain cognitions and physical
performance. AIMS: To determine if a relationship exists between change in pain
cognitions and change in physical performance when chronic LBP patients participate
in a single one-to-one education intervention during which they have no opportunity
to be active. METHODS: In a quasi-experiment using a convenience sample, moderately
disabled chronic LBP patients (n=121) participated in a one-to-one education
session about either lumbar spine physiology or pain physiology. Multiple
regression analysis evaluated the relationship between change in pain cognitions
measured by the survey of pain attitudes (SOPA) and the pain catastrophising scale
(PCS) and change in physical performance, measured by the straight leg raise (SLR)
and standing forward bending range. RESULTS: There was a strong relationship
between cognitive change and change in straight leg raise (SLR) and forward bending
(r=0.88 and 0.79, respectively, P<0.01), mostly explained by change in the
conviction that pain means tissue damage and catastrophising. CONCLUSIONS: Change
in pain cognitions is associated with change in physical performance, even when
there is no opportunity to be physically active. Unhelpful pain cognitions should
be considered when interpreting physical assessments.16: Exp Brain Res. 2003
Jul;151(2):262-71. Epub 2003 Jun 3. Experimental muscle pain changes feedforward
postural responses of the trunk muscles.Hodges PW, Moseley GL, Gabrielsson A,
Gandevia SC.Department of Physiotherapy, The University of Queensland, Brisbane,
QLD 4072,Australia. p.hodges@shrs.uq.edu.auMany studies have identified changes in
trunk muscle recruitment in clinical low back pain (LBP). However, due to the

heterogeneity of the LBP population these changes have been variable and it has
been impossible to identify a cause-effect relationship. Several studies have
identified a consistent change in the feedforward postural response of transversus
abdominis (TrA), the deepest abdominal muscle, in association with arm movements in
chronic LBP. This study aimed to determine whether the feedforward recruitment of
the trunk muscles in a postural task could be altered by acute experimentally
induced LBP. Electromyographic (EMG) recordings of the abdominal and paraspinal
muscles were made during arm movements in a control trial, following the injection
of isotonic (non-painful) and hypertonic (painful) saline into the longissimus
muscle at L4, and during a 1-h follow-up. Movements included rapid arm flexion in
response to a light and repetitive arm flexion-extension. Temporal and spatial EMG
parameters were measured. The onset and amplitude of EMG of most muscles was
changed in a variable manner during the period of experimentally induced pain.
However, across movement trials and subjects the activation of TrA was consistently
reduced in amplitude or delayed. Analyses in the time and frequency domain were
used to confirm these findings. The results suggest that acute experimentally
induced pain may affect feedforward postural activity of the trunk muscles.
Although the response was variable, pain produced differential changes in the motor
control of the trunk muscles, with consistent impairment of TrA activity.
Publication Types:
Clinical Trial18: Aust J Physiother. 2003;49(4):263-7. The
threat of predictable and unpredictable pain: differential effects on central
nervous system processing?Moseley GL, Brhyn L, Ilowiecki M, Solstad K, Hodges PW.
Department of Physiotherapy, Royal Brisbane Hospital, Brisbane, Australia.
l.moseley@uq.edu.auCentral nervous system performance is disrupted by pain and by
the threat of pain. It is not known whether disruption caused by the threat of pain
is dependent on the likelihood of pain occurring. We hypothesised that when a
painful stimulus is possible but unpredictable central nervous system performance
is reduced, but when the pain is predictable and unavoidable it is not. Sixteen
healthy subjects performed a reaction time task during predictable and
unpredictable conditions (100% and 50% probability of pain, respectively). Group
data showed increased reaction time with the threat of pain by 50 ms (95% CI 16 to
83 ms) for the predictable condition and 46 ms (95% CI 12 to 80 ms) for the
unpredictable condition (p lt 0.01 for both), but there was no difference between
predictable and unpredictable conditions (p = 0.41). However, individual data
showed that there was a differential effect in 75% of subjects (p lt 0.05 for all)
and that there was a greater effect of predictable pain for some subjects and a
greater effect of unpredictable pain for others. Reaction time was related to
reported anxiety (r = 0.49, p = 0.02 for both conditions). The predictability of a
painful stimulus may have a differential effect on central nervous system
performance within individuals, but anxiety about the impending pain appears to be
important in determining this effect.Publication Types:
Clinical Trial
Randomized Controlled Trial
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