ArticlePDF AvailableLiterature Review

Abstract and Figures

Neural representations, or neurotags, refer to the idea that networks of brain cells, distributed across multiple brain areas, work in synergy to produce outputs. The brain can be considered then, a complex array of neurotags, each influencing and being influenced by each other. The output of some neurotags act on other systems, for example, movement, or on consciousness, for example, pain. This concept of neurotags has sparked a new body of research into pain and rehabilitation. We draw on this research and the concept of a cortical body matrix-a network of representations that subserves the regulation and protection of the body and the space around it-to suggest important implications for rehabilitation of sports injury and for sports performance. Protective behaviours associated with pain have been reinterpreted in light of these conceptual models. With a particular focus on rehabilitation of the injured athlete, this review presents the theoretical underpinnings of the cortical body matrix and its application within the sporting context. Therapeutic approaches based on these ideas are discussed and the efficacy of the most tested approaches is addressed. By integrating current thought in pain and cognitive neuroscience related to sports rehabilitation, recommendations for clinical practice and future research are suggested.
Content may be subject to copyright.
Neural representations and the cortical body matrix:
implications for sports medicine and future directions
Sarah B Wallwork,
1
Valeria Bellan,
1
Mark J Catley,
1
G Lorimer Moseley
1,2
1
Sansom Institute for Health
Research and PainAdelaide,
University of South Australia,
Adelaide, South Australia,
Australia
2
Neuroscience Research
Australia, Sydney, New South
Wales, Australia
Correspondence t o
Professor G Lorimer Moseley,
Sansom Institute for Health
Research and PainAdelaide,
University of South Australia,
G.P.O. Box 2471, Adelaide
5001, Australia;
lorimer.moseley@gmail.com
Accepted 8 November 2015
To cite: Wallwork SB,
Bellan V, Catley MJ, et al. Br
J Sports Med Published
Online First: [ please include
Day Month Year]
doi:10.1136/bjsports-2015-
095356
ABSTRACT
Neural representations, or neurotags, refer to the idea
that networks of brain cells, distributed across multiple
brain areas, work in synergy to produce outputs. The
brain can be considered then, a complex array of
neurotags, each inuencing and being inuenced by
each other. The output of some neurotags act on other
systems, for example, movement, or on consciousness,
for example, pain. This concept of neurotags has
sparked a new body of research into pain and
rehabilitation. We draw on this research and the concept
of a cortical body matrixa network of representations
that subserves the regulation and protection of the body
and the space around itto suggest important
implications for rehabilitation of sports injury and for
sports performance. Protective behaviours associated
with pain have been reinterpreted in light of these
conceptual models. With a particular focus on
rehabilitation of the injured athlete, this review presents
the theoretical underpinnings of the cortical body matrix
and its application within the sporting context.
Therapeutic approaches based on these ideas are
discussed and the efcacy of the most tested approaches
is addressed. By integrating current thought in pain and
cognitive neuroscience related to sports rehabilitation,
recommendations for clinical practice and future research
are suggested.
INTRODUCTION
Sports injuries and the pain associated with them
often lead to reduced movement and reduced par-
ticipation in sporting activity. A reduction in move-
ment might occur because of a physiological
impairment (eg, reduced range of motion or
muscle strength), external immobilisation (such as
splinting or bracing), for fear of pain provocation,
because of implicit instruction from a health pro-
fessional or because of fear of further injury or
re-injury. Usually, rehabilitation involves gradually
increasing movement, strength, endurance and skill,
until the athlete is able to full all the requirements
of their chosen activities. The focus of sports
rehabilitation is, understandably, on loading the
tissues in a graded fashion until the athlete and
their sports medicine team, are satised that they
can withstand the requirements of recommencing
sport. Another effect of sports injury that is less
readily considered in sports rehabilitation, is the
state of the various cortical representations that
subserve proprioception, movement, the body and
peripersonal space. That is, the role of the brain in
movement planning, preparation and execution,
and the graded exposure of such neural mechan-
isms when returning to sport after injury. Here we
discuss the potential application of current concepts
in cognitive and behavioural neuroscience related
to pain, movement and bodily awareness, to sports
rehabilitation.
THE COMPLEXITIES OF MOTOR PERFORMANCE
Movement and motor performance involve highly
complex interactions between the neural networks
in the brain that represent our body and the space
around us.
1
For example, skilled motor perform-
ance utilises neural representations from visual,
proprioceptive, spatial and tactile domains, enab-
ling us to establish body position and alignment in
relation to the external environment. Such informa-
tion gets continually fed into sensory-motor loops
that constantly update internal predictions about
the outcome of a motor command. This continu-
ous updating promotes smooth, efcient and accur-
ate motor performance
2
as well as optimal
protection and functionality.
1
Both a wide reper-
toire of possible motor strategies, and a precise and
efcient cortical predictive modelling capacity, are
considered important for high level motor com-
mands such as those required in sport.
3
Finely
tuning such a system after injury or inactivity
involves reinstating the capacity of the brain to
integrate these multiple representations and rapidly
run them in a constantly changing and updating
sensory-motor environment. The implications of
this neurological component to sports rehabilita-
tion depends on fundamental matters of neural
representations and their governance.
NEURAL REPRESENTATIONS OR NEUROTAGS
Neural representations, networks or neurotags
4
are large groups of brain cells that are distributed
across multiple brain areas and that are thought to
evoke a given output. The concept of neural repre-
sentations is a theoretical one, but the theory is
informed by a very large body of empirical data
from fundamental neuroscience research using
brain computer interface, for example,
5
in vivo
animal studies and modelling.
6
Available human
neuroimaging research is also supportive.
7
Conventionally, a neurotag is labelled according to
its output.
6
Each neurotag consists of numerous
brain cells, which can be called member brain cells;
each member brain cell is part of multiple neuro-
tags. A useful analogy for the concept of neurotags
is that of an orchestramember musicians contrib-
ute to many pieces (outputs) and each piece
(output) involves a group of musicians distributed
across the orchestra (see ref. 4 for a comprehensive
account of this metaphorical conceptualisation).
A primary neurotag effects an action at the end
organ such that its output results in a tangible
Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356 1
Rev i ew
outcome. For example, the primary neurotag acts on motor
units and thereby muscles, or evokes a perception such as pain,
or a belief such as my hamstring is weak (see also ref. 8 for
extensive review). A secondary neurotag effects an action by
modulating the neuronal mass and precision of primary neuro-
tags and therefore inuences the likelihood of that neurotag
being activated (gure 1). Skills required for sport can be con-
ceptualised as the result of activation of primary neurotags,
themselves inuenced by activation of secondary neurotags. It is
therefore important to consider the principles that govern the
operation of neurotags, in particular those principles of neur-
onal mass, neuronal precision and neuroplasticity.
5
Neuronal
mass refers to the number of member brain cells in a given neu-
rotag and the synaptic efcacy between them. Neuronal preci-
sion refers to the inhibition of non-member brain cells (see also
ref. 8). The strength of a neurotag determines its inuence and
depends on both its neuronal mass and its neuronal precision.
Larger neurotags will predominate over smaller ones; precise
neurotags will predominate over imprecise ones (see also ref. 9
for specic discussion of visual neurotags). The third principle
of neurotags that is very relevant here is that of neuroplasticity
that property of the nervous system to undergo functional
and structural change in response to activity and
reinforcement.
10
THE CORTICAL BODY MATRIX
A very large number of empirical studies have led to the pro-
posal of a cortical body matrixa network of neurotags that
subserves the regulation, control and protection of the body and
the space around it, on both a physiological and a perceptual
level
1
(see also refs 11 12 for relevant reviews). Extensive
review of the original experimental and clinical data that under-
pin the cortical body matrix theory is beyond the scope of this
paper, but the theory is captured to some extent by several key
ndings. For example, (1) people with pathological arm pain
and the feeling that the arm was swollen performed painful
movements of their hand under four conditions: watching the
arm through a magnifying lens so that the arm looked more
swollen, watching it through a minimising lens so that it
looked less swollen and two control conditions.
13
The pain and
swelling evoked by movement was greatest in the magnied con-
dition and least in the minied condition even though the move-
ments themselves were identical; (2) when healthy volunteers
experience a cognitive illusion in which one hand seems to have
been replaced by an articial counterpart, then the hand that
has been replaced becomes cooler
14
and hyper-reactive to his-
tamine in a limb-specic manner that is positively related to the
vividness of the illusion;
15
when the limb is rst cooled, the illu-
sion is made stronger;
16
(3) when amputees with an intact
phantom limb learn how to perform a biomechanically impos-
sible movement with their phantom limb, they report simultan-
eous shifts in the internal structure of their phantom and the
ability to perform the movement. What is more, some physio-
logical movements are rendered more difcult in line with the
new structure of the phantom;
17
when people with pathological
arm pain and an associated cold arm cross their hands over the
body midline, then the painful hand warms up and the healthy
hand cools down relative to the healthy one and this effect
depends not on where the limbs actually are, but where they are
perceived to be.
18 19 20
Each of these ndings demonstrate a
tight connection between our bodily feelings, for example pain,
swelling, location and ownership, and physiological regulation,
for example, movement, swelling, temperature control and
inammatory responses.
The pertinence of the cortical body matrix theory to return
to sport after injury is threefold: (1) it provides a working
model that integrates the complex proprioceptive, motor and
spatial representations that are involved in sport, particularly
those sports involving equipment (eg, balls) or athlete-to-athlete
interaction; (2) it stipulates that neurotags, the outputs of which
act on end organs (eg, muscles or blood vessels) are closely
integrated with neurotags, the outputs of which are feelings
(eg, a feeling of warmth, or pain); (3) it implies that both exter-
nal and internal events or situations, including the location of
body parts, are mapped spatially according to a frame of refer-
ence centred about oneself (egocentric),
18 19 20
and according
to a frame of reference centred on an external object or limb
(allocentric).
21
This implies that spatial tasks that interrogate
both frames of reference should be incorporated into
rehabilitation.
Proprioception provides an excellent model with which to
understand the idea of secondary neurotags inuencing primary
neurotags. For example, proprioceptive awareness (where you
feel a body part to be) can be considered the output of a
primary neurotag. There are many inuences on this primary
neurotag, for example, that from visual input, somatosensory
Figure 1 Secondary neurotags are
those that exert their inuence over
primary neurotags. Primary neurotags
are those that evoke an output, for
example, a motor command, a feeling
or a conscious belief.
2 Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356
Rev i ew
input (that detected by mechanoreceptors and propriocep-
tive organs in the peripheral nervous system) and internally
generated inputs related to effort and force.
22
Each of these
inputs onto the primary neurotag is generated by secondary
neurotags.
These ideas have been explored previously in the body local-
isation and motor control literature where the terms stability
or reliability of the modality are reasonably analogous to the
neuronal mass and precision of the subserving neurotags. In par-
ticular the Maximum Likelihood Estimation theory
23
states that
the nervous system combines the information coming from the
different sensory modalities in a statistically optimal fashion.
Generally speaking, when both vision and proprioception are
available at the same time, vision dominates the output, suggest-
ing that the vision-specic neurotag carries much greater inu-
ence than the somatosensory-specic neurotag, according to
their relative neuronal mass and precision. This predominance
of visually encoded neurotags over somatosensory encoded neu-
rotags can be readily observed in illusions that exploit the usual
strength of vision to render the perceived location of a limb
inaccurate. For example, in the Disappearing Hand Trick
24
par-
ticipants are encouraged to look at their hands and maintain
their position relative to a visual cue, but are naïve to the
experimental trick that means their hands are actually moving
such that the felt location of one hand is rendered completely
inaccurate. In this scenario, the neuronal mass and precision of
the visually encoded secondary proprioceptive neurotag far out-
weighs that of the somatosensory encoded one, such that the
hand is felt to be in the location the visual system suggests it to
be, even though it is not (gure 2).
The third principle of neurotagsneuroplasticityimparts its
effects by modulating both the strength and precision of neuro-
tags. This is a critical consideration during rehabilitation
because neuroplasticity works both ways on neurotagsto
increase or decrease the likelihood of their activation. According
to the principle of neuroplasticity, changes in the movement and
behaviour repertoire lead to motor learning such that the ease
with which different motor outputs are generated is altered in
a use-dependent manner. The less active a particular neurotag,
the weaker and less precise it becomes; the more active a par-
ticular neurotag, the stronger and more precise it becomes (up
to a point, at which member brain cells appear to become
disinhibited
25
or imprecise, which has potentially profound
implications when considered within the cortical body matrix
frameworksee below).
These fundamental mattersof neurotags and the cortical
body matrixpresent three important implications for sports
rehabilitation: that by remaining cognisant of the principles that
govern neurotags, we can appreciate how (secondary) neurotags
related to actual or implied danger can inuence (primary) neu-
rotags of motor output; that by exploiting these principles we
can more effectively nd the optimal balance between protec-
tion and rapid return to full performance and we can ensure
that the neuroplastic effects of altered activity can be limited by
integrating virtual rehabilitation into physical rehabilitation;
that by remaining cognisant of the tight and bidirectional link
between neurotags that produce body-related outputs and those
that produce feeling-related outputs, we can use one to modu-
late the other.
To appreciate the potential importance of these implications,
let us consider the relationship between pain and motor output.
The dominant paradigm is that pain causes altered motor
control. We contend that this paradigm implants a false hier-
archy in which pain is considered a lower order event that
occurs to an individual, and that motor control will normalise if
pain is eradicated. That motor control changes might also cause
pain depends on nociceptive stimulation and the completion of
a vicious cycle. We suggest instead that pain and motor control
are outputs of primary neurotags, intimately linked but not hier-
archically differentiated. We contend that both are modulated
by a range of secondary neurotags (gure 3A). The common
experimental paradigm that underpins the dominant model
involves nociceptive stimulation, which evokes both pain and
altered motor output.
26 27
We are among those who have
naively attributed alterations in motor output to pain, when the
design does not allow us to differentiate pain from nociceptive
stimulation. That is, we mistake association for causation. There
is now a compelling body of literature that points to the pro-
blems with the dominant model at a theoretical and empirical
level
28 29 30
(also see ref. 31 for the theoretical underpinnings
of this contention). Nociception is neither sufcient nor neces-
sary for pain. That is, activity in primary nociceptorshigh
threshold free nerve endings located in the tissues of the body
and their projections, which are collectively responsible for
Figure 2 Localisation of a limb and performing a task, as conceptualised according to neurotags and the principle of neuronal mass and precision,
together constituting the strength of the neurotag and its resultant inuence over the primary neurotag. Here, the weight of the lines denotes
neuronal strength, itself a reection of the number of neurones in the neurotag and its synaptic efcacy, which determines its inuence over the
subsequent primary neurotag or end output. During localisation of the limb and task performance, the neurotag that represents the visually
identied location of the limb is very strong and exerts a greater inuence than the neurotag that represents the somatosensory or proprioceptively
identied location of the limb, over both the feeling neurotag (where does it feel to be?) and the movement neurotag (what motor command will
achieve the correct trajectory from the limbs current location).
Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356 3
Rev i ew
detecting, transforming and transmitting a danger message to
the brain, is now considered just one contributor to pain. We
suggest that the same applies for protective motor outputs
nociception is just one contributor, albeit an inuential one, to
protective motor outputs (gure 3B).
That movement prioritises protection is reective of a highly
complex and multifactorial process that promotes self-survival.
Enhanced protective movement and behaviour has been demon-
strated in a range of clinical pain disorders, where people in
pain have upregulated defensive reexes. In a recent
meta-analytical systematic review ( personal communication,
2015, Wallwork et al), we showed that the threshold at which
reex responses are triggered is lower in people with pain than
it is in healthy controls, but that this augmentation could not be
explained by tissue-based sensitivity, peripheral sensitisation or
spinal sensitisation. Rather, the augmentation of these thresh-
olds, appears to be driven by online descending facilitation.
That is, it seems that the immediate and current evaluation of
threat to body tissue modulates ne tuning of motor output
right down to the level of short-loop reexes. Moreover, the
hand blink reex is upregulated when the hand is closer to the
face. This upregulation occurs in real time and indeed in a feed-
forward manner if the hand is moving (personal communica-
tion, 2015, Wallwork et al), but the upregulation is absent if a
physical barrier is placed between the hand and the face.
32
These results clearly show that a complex evaluative process
associated with the perception of danger to body tissues modu-
lates sensitivity of supposedly automatic reex motor
responses. Applying the neurotag model to these discoveries, we
can see that each of the cues, for example, the presence of a
physical barrier, is represented by a secondary neurotag that
inuences the primary descending modulation neurotag.
THE EFFECT OF INJURY A ND INACTIVITY O N THE
CORTICAL BODY MATRIX
The effects of injury and inactivity on the cortical body matrix
can be considered in terms of both the change in secondary neu-
rotags that inuence motor output and perception, and the
effects of neuroplasticity. The idea that pain is simply a reec-
tion of tissue state was elegantly dismantled several decades
ago
33
and there is now widespread endorsement of a truly biop-
sychosocial conceptualisation of pain in the scientic,
34
clinical
4
and lay
35 36 37
literature outside of the sports rehabilitation
eld. A modern conceptualisation of pain emphasises its multi-
factorial naturea protective conscious feeling that compels the
sufferer to protect their body from danger.
38
As such, any infor-
mation that implies danger to body tissue will be represented by
secondary neurotags that inuence the primary ( pain) neurotag,
making it more likely to re. Any information that implies
safety to body tissue will also be represented by secondary
Figure 3 (A) The dominant, but we
contend less accurate
conceptualisation of the relationship
between pain and motor control using
the model of neurotags. Here,
movements are considered a
consequence of pain, instead of a
closely related but independent output
of the cortical body matrix. Line
weights denote the differential
inuence of different secondary
neurotags on the primary neurotag.
(B) Conceptualisation of pain and
motor control according to the
inuence of secondary neurotags. Line
weights denote the differential
inuence of different secondary
neurotags on the primary neurotag.
Here, secondary neurotags driven by
nociception have greatest inuence
over both the pain and movement
neurotags. Note that perceived current
body position/location exerts a strong
inuence over the movement neurotag
but not the pain neurotag.
4 Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356
Rev i ew
neurotags that also inuence the primary (pain) neurotag,
making the pain neurotag less likely to re.
35
This is conceptu-
ally simple even though the biological processes underpinning it
are very complex and far from completely understood. The con-
ceptual shift from the previous structural-pathology model to
the current biopsychosocial protection-based model, is now seen
as a therapeutic target, most obviously by explaining pain, a
range of educational strategies that teach people about pain
biology.
4353839
Indeed, reconceptualisation of pain is now
considered a fundamental objective of chronic pain rehabilita-
tion.
38
We contend that it should also be integral to sports
rehabilitation. These principles extend beyond pain, however, to
other protective outputs of the cortical body matrix, for
example, fatigue, anxiety, fear, dyspnoea, stiffness and weakness,
all of which can be conceptualised as protective feelings,
40
and
upregulated inammatory response, increased cortisol produc-
tion, elevated heart rate, all of which can be conceptualised as
protective regulatory responses.
Neuroplasticity
The principle of neuroplasticity can be applied to sports
rehabilitation in several ways. For example, repeated activation
of secondary neurotags that represent danger to body tissue will
increase their neuronal mass and precision, thereby increasing
their inuence on pain and the other protective outputs includ-
ing motor output; decreased activation of primary performance-
dedicated motor neurotags will decrease their neuronal mass
and precision, reducing the likelihood that they will be acti-
vated. That is, the potentially broad range of neurotags that are
associated with most sports, becomes less broad, and certain
neurotags become less easily accessible when sought for a quick
and efcient motor execution. According to Bayesian theory,
this shift in propensity to engage the optimal motor outputs is
conceptualised as reecting ne tuning of the relevant neurotag
based on previous experiences.
41
We also make predictions
about external environmental factors based on the probabilities
of events that have occurred in the past, also called priors, and
these probabilities are based on experience of such events.
Therefore, the less often these movements are performed, the
less efcient and less precise these movements become, by
virtue of the reduced neuronal mass and precision of their sub-
servant neurotags. The predictable consequence then, would be
greater error in motor performance and an increased risk for
further injury.
ASSESSMENTS
Motor assessments
Although these concepts are not new, their clinical application is
only just gaining ground. One objective of the research in this
area is the development of clinical assessments that target the
integrity of the neurotags of the cortical body matrix. The most
advanced of these research streams involves motor imagery,
8
with decits in performance being clearly related to clinical phe-
nomena such as pain and training being clearly related to
improvement in those clinical phenomena. Imagining movement
of ones own body is a form of explicit motor imagery. That is,
the person imagining the movement is aware that that is what
they are doing. Implicit motor imagery, on the other hand,
involves cortical motor processing or the activation of motor
neurotags, but without awareness.
8
Implicit motor imagery can
be assessed using choice reaction time tasks, most commonly a
judgement as to whether a pictured body part belongs to the left
or right side of the body.
42
Left/right judgements, such as of
hands, involves two stagesan initial automatic judgement,
followed by mentally manoeuvring ones own hand from its
current position into the position of the target handa process
called conrmation.
42
In terms of cortical representation
theory, the conrmation process engages secondary propriocep-
tive and spatial neurotags, which exert an inuence on the
primary motor neurotag, but do not activate itthus, there is
no movement.
43
Left/right judgements like this have been
widely studied in healthy participants
42 44 45
and in people with
pain. As a general rule, performance is reduced for implicit
motor imagery of the affected body part, but not unaffected
body parts. For example, people with low back pain perform
badly on the left/right trunk rotation task but not a left/right
hand judgement task;
45 46
people with complex regional pain
syndrome (CRPS) of the hand perform badly on left/right hand
judgement task but not the left/right knee judgement
task.
47 48 49
Similar segment-specicdecits have been reported
in people with neck pain,
50
painful knee osteoarthritis
20
and leg
pain.
51
Implicit motor imagery interrogates secondary neurotags, so
decits in motor imagery reect problems upstream to move-
ment executionin movement preparation processes, for
example. These reaction time tests provide two metricsaccur-
acy and reaction timewhich are thought to reect different
aspects of the task, and therefore different sets of neurotags.
Accuracy decits are interpreted as reecting disruption
(decreased neuronal mass or precision) of proprioceptive neuro-
tags that are then used for movement, and reaction time decits
are interpreted as reecting disruption of spatial neurotags,
whereby the neurotags that represent one side or area of space
have greater neuronal strength than those representing another
area and therefore exert a greater inuence on the automatic
decision stage of the task (see refs 852).
Implicit motor imagery is easily assessed using commercially
available software (eg, Recognise’—noigroup.com, Adelaide,
Australia) on computers, tablets or smart phones. Users can
obtain immediate data on both accuracy and reaction time and
keep online records to track performance over time. Clinicians
can monitor patient practice and performance remotely.
Tactile acuity
Tactile neurotagsthose that represent our feeling of touch on
the bodyare also implicated in many pain disorders and train-
ing tactile performance has been associated with pain reduc-
tion.
53 54
Tactile acuity depends on the integrity of tactile
transducersspecialised receptors on the terminals of Aβ neu-
rones,
55
transmission of the sensory signal to the brain and
activation of the appropriate secondary neurotag (see ref. 56 for
comprehensive review). Body part-specicdecits in tactile
acuity have been documented in people with CRPS,
57 58 59 60
non-specic chronic low back pain,
61 62 63
facial pain
64
and
arthritis.
65
These decits cannot be explained by detection of
the signal, transduction or transmission, but are instead attribu-
ted to disruption (decreased neuronal mass or precision) of the
subserving neurotag.
66
We would like to raise the possibility that the evidence
obtained from clinical populations, and outside the sporting
context, may be relevant to those with sporting injuries. Our
own clinical observations seem to uphold this possibility and
preliminary empirical studies are corroborative.
67 68
Perhaps sur-
prisingly, there are no systematic differences in motor imagery
performance between those who do and do not participate in
sport.
69
In fact, that regular participation in yoga does not
appear to enhance performance
70
and that people who experi-
ence regular bouts of dizziness do not appear to have disrupted
Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356 5
Rev i ew
performance,
71
strengthens the implication that disrupted per-
formance is reasonably specic for disrupted body-part specic
representations. Sporting injuries are clearly not a homogenous
groupthe implications of the body of literature in this eld are
probably different for those with chronic or recurrent sports-
related pain as compared to those with, for example, an acute
cruciate ligament tear. Implications may exist for both, however.
That is, the commonalities between chronic and recurrent pain
problems experienced by professional, recreational or indeed
industrial athletes, suggests generalisability of ndings across
these groups. However, consideration of cortical representations
in acute sporting injury rehabilitation is a relatively unexplored
eld. One might propose a role in the maintenance of coherent
neurotags even when movement is not possible, but this idea
has not, to our knowledge, been investigated. Nonetheless, we
would contend that representation theory and the cortical body
matrix theory, insofar as they relate to human behaviour and
function, should be equally applicable to humans who are
engaged in sport as they are to humans who are not. Clearly
until empirical data are obtained, these contentions remain
theoretical.
THE POTENTIAL ROLE OF NEUROTAG REHABILITATION IN
RETURN TO SPORT
As mentioned above, treatments that target secondary motor or
tactile neurotags promote clinical recovery in those with chronic
pain. Evidence is most established for graded motor imagery
(GMI)
72
(see ref. 8 for a comprehensive review) and tactile dis-
crimination training
53 54 73 74
(see refs 11 and 12 for relevant
reviews) but other approaches are conned at this stage to case
studies and observational accounts.
The proposed mechanism behind GMI is that it uses a graded
exposure paradigm to reinstate normal (non-protective) motor
neurotags. GMI involves a three-step process; implicit motor
imagery, explicit motor imagery (imagined movements) and
mirror therapy.
8
The sequence of steps appears to be important,
at least for the severely disabling and painful condition of
CRPS.
75
Recommendations for GMI include performance
during exposure to cues that signal danger to body tissue. Such
cues are individually-specic but may include time of day, loca-
tion, noise, competition, stress, fatigue, cognitive load, all of
which may be addressed by simply modifying the context of
GMI training. Importantly, GMI can be undertaken well in
advance of physical rehabilitation. This is a key implication of
this emerging eldthat the normal decrease in neuronal
strength and precision that occurs when a neurotag is taken off
line might be avoided by regular and varied virtual training.
GMI forms an empirically tested subset of imagery applications,
but we contend that the principles captured by GMI should
apply to less formalised application of motor imagery. That is,
neurotag maintenance might be as simple as motor imagery in
the presence of performance-related cues. A thorough subjective
examination about the injury and associations related to the
injury could shed light on potentially threatening cues that
could be integrated into neurotag rehabilitation well in advance
of physical rehabilitation. For example, the extent and the
context of the injury, the time of day the injury was sustained,
the mood the athlete was in, weather conditions, background
noise, other team players involved, might all constitute cues of
danger to body tissue. To appreciate the potential importance
of these considerations, one must only appreciate that each of
these sensory and contextual cues are transformed into neural
activity and therefore exert some kind of inuence over lower
level neurotags within the cortical body matrix. It is worth
reiterating here that the inuence of neurotags on other neuro-
tags, and ultimately on outputs such as movement, immune
responses and feelings, is determined by neuronal mass and pre-
cision and that both are open to modication via the principle
of neuroplasticity.
Tactile discrimination training can also be undertaken well in
advance of physical and sporting rehabilitation. Such training
involves a forced choice between at least two different tactile
stimuli, relying only on somatosensory information to make that
choice. The most tested protocol is to rst identify several
potential locations at which the participant might receive a
tactile stimulus, stimulate at one location and ask the patient to
identify which location was stimulated.
53 54 74 76
According to
the principles of neurotags, the nature of the stimulus is not
important but the requirement to differentiate it from similar
stimuli is. That spatial neurotags can also be disrupted implies
that training spatial acuity will also offer benets, although evi-
dence for this is lacking and it remains, for now, conjecture.
Perhaps surprisingly, there is a dearth of research on the use
of such interventions for acute sporting injuries, despite known
motor performance disruptions in association with such condi-
tions. Those treatments could be delivered and tailored accord-
ing to the outcome of assessments and according to the array of
neurotags normally involved in the chosen sport; motor
imagery tasks could be modied to interrogate sport-specic
neurotags, for example, including context-relevant and
equipment-relevant images.
IMPORTANT CAVEATS AND FUTURE DIRECTIONS
We have proposed that the principles that govern neural repre-
sentations, or neurotags, are of fundamental importance to
sports rehabilitation. We contend that incorporating neurotag
assessment and retraining as a component of sport rehabilita-
tion, in the light of tight inter-relationships between how our
body is regulated and how it feels, will limit the deleterious
effects of inactivity on neurotags, and hasten and optimise
reinstatement of performance-related neurotags. We also
contend that motor output and other protective outputs might
be modulated by any credible evidence of danger regardless of
whether or not the individual is in pain. If so, in situations
where performance quality is key and executing a precise move-
ment is vital, identifying and eliminating potential danger-
related cues may be critical. Notably, the patients understanding
of the biological reasons to take this approach would also seem
critical.
Our contentions are based on a very large body of empirical
work outside of the sporting context, but, as it is applied to the
sporting context, it is limited to personal experience and anec-
dotal evidence. This is an important caveat and, in light of it,
this review primarily serves to provide a provocative account of
What are the ndings?
Recent advances in theoretical models of pain and
rehabilitation are relevant to sporting injuries.
The brains representation of movements and skills is a
viable target for rehabilitation.
Movements and skills can be thought of as outputs of
neurotags.
Recognised paradigms for understanding pain are applicable
for understanding movements and skills.
6 Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356
Rev i ew
current thought in pain and cognitive neuroscience and possibil-
ities for the sports medicine eld. That some of the assessments
and treatments that are based on these ideas are becoming more
common in the sporting context does not constitute evidence of
their prognostic or therapeutic value. Nonetheless, perhaps this
review will spark a new conversation and line of research
enquiry.
Contributors SBW and GLM contributed to the conceptualisation, planning,
literature review and writing of this manuscript. VB and MC contributed to the
literature review and writing of this manuscript. GLM is responsible for the overall
content of this manuscript.
Funding SBW is supported by an Australian Postgraduate Award from the
Australian Government. GLM is supported by a Principal Research Fellowship from
the National Health & Medical Research Council of Australia ID 1061279. This work
draws on ndings from projects supported by the National Health & Medical
Research Council of Australia IDs 630431, 1008017, 1047317.
Competing interests GLM receives royalties for books that are directly related to
the material presented here and payments for the delivery of professional
development courses. He consults to Pzer and to Workers' Compensation Boards in
Australia, Europe and North America.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1 Moseley GL, Gallace A, Spence C. Bodily illusions in health and disease:
physiological and clinical perspectives and the concept of a cortical body matrix.
Neurosci Biobehav Rev 2012;36:3446.
2 Wolpert DM, Ghahramani Z. Computational principles of movement neuroscience.
Nat Neurosci 2000;3:121217.
3 Classen J, Liepert J, Wise SP, et al. Rapid plasticity of human cortical movement
representation induced by practice. J Neurophysiol 1998;79:111723.
4 Butler DS, Moseley GL. Explain pain. 2nd edn. Adelaide: Noigroup Publications,
2013.
5 Nicolelis MAL, Lebedev MA. Principles of neural ensemble physiology underlying the
operation of brain-machine interfaces. Nat Rev Neurosci 2009;10:53040.
6 deCharms RC, Zador A. Neural representation and the cortical code. Annu Rev
Neurosci 2000;23:61347.
7 Bushnell MC, Villemure C, Strigo I, et al. Imaging pain in the brain: the role of the
cerebral cortex in pain perception and modulation. J Musculoskelet Pain
2002;10:5972.
8 Moseley G, Butler D, Beames T, et al. The graded motor imagery handbook.
Adelaide: NOIgroup publishing, 2012.
9 Desimone R, Duncan J. Neural mechanisms of selective visual attention. Annu Rev
Neurosci 1995;18:193222.
10 Chang Y. Reorganization and plastic changes of the human brain associated with
skill learning and expertise. Front Hum Neurosci 2014;8:35.
11 Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic
pain: a review. Neurorehabil Neural Repair 2012;26:64652.
12 Wand BM, Parkitny L, OConnell NE, et al. Cortical changes in chronic low back
pain: current state of the art and implications for clinical practice. Man Ther
2011;16:1520.
13 Moseley GL, Parsons TJ, Spence C. Visual distortion of a limb modulates the pain
and swelling evoked by movement. Curr Biol 2008;18:R10478.
14 Moseley GL, Olthof N, Venema A, et al. Psychologically induced cooling of a
specic body part caused by the illusory ownership of an articial counterpart. Proc
Natl Acad Sci USA 2008;105:1316973.
15 Barnsley N, McAuley J, Mohan R, et al. The rubber hand illusion increases
histamine reactivity in the real arm. Curr Biol 2011;21:R9456.
16 Kammers MPM, Rose K, Haggard P. Feeling numb: temperature, but not thermal
pain, modulates feeling of body ownership. Neurospychologia 2011;49:131621.
17 Moseley G, Brugger P. Interdependence of movement and anatomy persists when
amputees learn a physiologically impossible movement of their phantom limb. Proc
Natl Acad Sci USA 2009;106:18798802.
18 Moseley GL, Gallace A, Spence C. Space-based, but not arm-based, shift in tactile
processing in complex regional pain syndrome and its relationship to cooling of the
affected limb. Brain 2009;132:314251.
19 Moseley GL, Gallace A, Iannetti GD. Spatially dened modulation of skin
temperature and hand ownership of both hands in patients with unilateral complex
regional pain syndrome. Brain 2012;135(Pt 12):367686.
20 Stanton T, Lin C, Smeets R, et al . Spatially dened disruption of motor imagery
performance in people with osteoarthritis. Rheumatology (Oxford)
2012;51:145564.
21 Behrmann M, Tipper SP. Attention accesses multiple reference frames: evidence
from visual neglect. J Exp Psychol Hum Percept Perform 1999;25:83101.
22 Proske U, Gandevia SC. The proprioceptive senses: their roles in signaling body
shape, body position and movement, and muscle force. Physiol Rev
2012;92:165197.
23 Ernst MO, Banks MS. Humans integrate visual and haptic information in a
statistically optimal fashion. Nature 2002;415:42933.
24 Newport R, Gilpin HR. Multisensory disintegration and the disappearing hand trick.
Curr Biol 2011;21:R8045.
25 Di Pietro F, McAuley JH, Parkitny L, et al. Primary motor cortex function in complex
regional pain syndrome: a systemtic review and meta-analysis. J Pain
2013;14:127088.
26 Arendt-Nielsen L, Graven-Nielsen T, Svarrer H, et al. The inuence of low back pain
on muscle activity and coordination during gait: a clinical and experimental study.
Pain 1996;64:23140.
27 Graven-Nielsen T, Svensson P, Arendt-Nielsen L. Effects of experimental muscle pain
on muscle activity and co-ordination during static and dynamic motor function.
Electroencephalogr Clin Neurophysiol 1997;105:15664.
28 Moseley GL, Hodges PW. Are the changes in postural control associated with low
back pain caused by pain interference? Clin J Pain 2005;21:3239.
29 Moseley GL, Hodges PW. Reduced variability of postural strategy prevents
normalization of motor changes induced by back pain: a risk factor for chronic
trouble? Behav Neurosci 2006;120:474
6.
30 Moseley GL, Nicholas MK, Hodges PW. Does anticipation of back pain predispose
to back trouble? Brain 2004;127:233947.
31 Moseley GL. Trunk muscle control and back pain: chicken, egg, neither or both?
In: Hodges PW, Cholewicki J, van Dieen JH, eds. Spinal control: the rehabilitation of
back pain. Oxford, UK: Churchill Livingstone Elsevier, 2013:12331.
32 Sambo CF, Forster B, Williams SC, et al . To blink or not to blink: ne cognitive
tuning of the defensive peripersonal space. J Neurosci 2012;32:129217.
33 Wall PD, McMahon SB. The relationship of perceived pain to afferent nerve
impulses. Trends Neurosci 1986;9:2545.
34 Wiech K, Vandekerckhove J, Zaman J, et al.Inuence of prior information on
pain involves biased perceptual decision-making. Curr Biol 2014;24:
R67981.
35 Moseley GL, Butler DS. The explain pain handbook: protectometer. 1st edn.
Adelaide, Australia: Noigroup Publications, 2015.
36 Moseley GL. Painful yarns. Metaphors and stories to help understand the biology of
pain. Canberra: Dancing Giraffe Press, 2007.
37 Wall P. Pain. The science of suffering. London: Orion Publishing, 1999.
38 Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present and
future. J Pain 2015;16:80713.
39 Lotze M, Moseley GL. Theoretical considerations for chronic pain rehabilitation.
Phys Ther 2015;95:131620.
40 Williams MT, Gerlach Y, Moseley L. The survival perceptions: time to put some
Bacon on our plates? J Physiother 2012;58:735.
41 Kölding KP, Wolpert DM. Bayesian decision theory in sensorimotor control. Trends
Cogn Sci 2006;10:31926.
42 Parsons LM. Imagined spatial transformations of ones hands and feet. Cogn
Psychol 1987;19:178241.
43 Parsons LM. Integrating cognitive psychology, neurology and neuroimaging. Acta
Psychol (Amst) 2001;107:15581.
44 Wallwork SB, Butler DS, Fulton I, et al. Left/right neck rotation judgments are
affected by age, gender, handedness and image rotation. Man Ther
2013;18:22530.
45 Bowering KJ, Butler DS, Fulton IJ, et al. Motor imagery in people with a history of
back pain, current pain, both, or neither. Clin J Pain 2014;30:10705.
46 Bray H, Moseley GL. Disrupted working body schema of the trunk in people with
back pain. Br J Sports Med 2011;45:16873.
47 Schwoebel J, Coslett HB, Bradt J, et al. Pain and the body schema: effects of pain
severity on mental representations of movement. Neurology 2002;59:7757.
48 Schwoebel J, Friedman R, Duda N, et al. Pain and the body schema: evidence for
peripheral effects on mental representations of movement. Brain
2001;124:2098104.
How might it impact on clinical practice in the future?
Broaden the assessment of those in pain to include domains
implicated in modern pain-related theory.
Broaden intervention, for example:
Training neurotags to prevent deleterious impact of
neuroplasticity after sporting injuries
Training neurotags to optimise rehabilitation after
sporting injuries
Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356 7
Rev i ew
49 Moseley GL. Why do people with complex regional pain syndrome take longer to
recognize their affected hand? Neurology 2004;62:21826.
50 Elsig S, Luomajoki H, Sattelmayer M, et al. Sensorimotor tests, such as movement
control and laterality judgment accuracy, in persons with recurrent neck pain and
controls. A case-control study. Man Ther 2014;19:55561.
51 Coslett HB, Medina J, Kliot D, et al. Mental motor imagery and chronic pain: the
foot laterality task. J Int Neuropsychol Soc 2010;16:60312.
52 Bellan V, Gilpin HR, Stanton TR, et al. Untangling visual and proprioceptive
contributions to hand localisation over time. Exp Brain Res 2015;233:1689701.
53 Moseley GL, Wiech K. The effect of tactile discrimination training is enhanced when
patients watch the reected image of their unaffected limb during training. Pain
2009;144:31419.
54 Moseley GL, Zalucki NM, Wiech K. Tactile discrimination, but not tactile stimulation
alone, reduces chronic limb pain. Pain 2008;137:6008.
55 Johnson KO, Yoshioka T, Vega-Bermudez F. Tactile functions of mechanoreceptive
afferents innervating the hand. J Clin Neurophysiol 2000;17:53958.
56 Gallace A, Spence C. In touch with the future: the sense of touch from cognitive
neuroscience to virtual reality. Oxford: Oxford University Press, 2014.
57 Pleger B, Ragert P, Schwenkreis P, et al. Patterns of cortical reorganization parallel
impaired tactile discrimination and pain intensity in complex regional pain
syndrome. Neuroimage 2006;32:50310.
58 Lewis JS, Schweinhardt P. Perceptions of the painful body: the relationship between
body perception disturbance, pain and tactile discrimination in complex regional
pain syndrome. Eur J Pain 2012;16:132030.
59 Maihofner C, DeCol R. Decreased perceptual learning ability in complex regional
pain syndrome. Eur J Pain 2007;11:9039.
60 Reiswich J, Krumova EK, David M, et al. Intact 2D-form recognition despite
impaired tactile spatial acuity in complex regional pain syndrome type I. Pain
2012;153:148494.
61 Luomajoki H, Moseley GL. Tactile acuity and lumbopelvic motor control in patients
with back pain and healthy controls. Br J Sports Med 2011;45:43740.
62 Moseley GL. I cant nd it! Distorted body image and tactile dysfunction in patients
with chronic back pain. Pain 2008;140:23943.
63 Wand BM, Di Pietro F, George P, et al
. Tactile thresholds are preserved yet
complex sensory function is impaired over the lumbar spine of chronic
non-specic low back pain patients: a preliminary investigation. Physiotherapy
2010;96:31723.
64 von Piekartz H, Wallwork SB, Mohr G, et al. People with chronic facial pain perform
worse than controls at a facial emotion recognition task, but it is not all about the
emotion. J Oral Rehabil 2015;42:24350.
65 Stanton TR, Lin CW, Bray H, et al. Tactile acuity is disrupted in osteoarthritis but is
unrelated to disruptions in motor imagery performance. Rheumatology (Oxford)
2013;52:150919.
66 Catley MJ, OConnell NE, Berryman C, et al. Is tactile acuity altered in people with
chronic pain? A systematic review and meta-analysis. J Pain 2014;15:9851000.
67 Rio E, Moseley GL, Purdam C, et al. The pain of tendinopathy: physiological or
pathophysiological? Sports Med 2014;44:923.
68 Debenham JR, Krummanacher SA, Skinner AW, et al., eds. Motor imagery training
decreases pain on loading in people with chronic achilles tendinopathy: a
preliminary rendomised cross-over experiment. Australian Pain Society 35th Annual
Scientic Meeting, 2015.
69 Dey A, Barnsley N, Mohan R, et al. Are children who play a sport or a musical
instrument better at motor imagery than children who do not? Br J Sports Med
2012;46:9236.
70 Wallwork SB, Butler DS, Wilson DJ, et al. Are people who do yoga any better
at a motor imagery task than those who do not? Br J Sports Med
2015;49:1237.
71 Wallwork SB, Butler DS, Moseley GL. Dizzy people perform no worse at a motor
imagery task requiring whole body mental rotation; a case-control comparison.
Front Hum Neurosci 2013;7:258.
72 Bowering KJ, OConnell NE, Tabor A, et al. The effects of Granded Motor Imagery
and its components on chronic pain: a systematic review and meta-analysis. J Pain
2013;14:313.
73 Flor H. The modication of cortical reorganization and chronic pain by sensory
feedback. Appl Psychophysiol Biofeedback 2002;27:21527.
74 Flor H, Denke C, Schaefer M, et al. Effect of sensory discrimination training on
cortical reorganisation and phantom limb pain. Lancet 2001;357:17634.
75 Moseley GL. Is successful rehabilitation of complex regional pain syndrome due to
sustained attention to the affected limb? A randomised clinical trial.
Pain
2005;114:5461.
76 Wand BM, Abbaszadeh S, Smith AJ, et al. Acupuncture applied as a sensory
discrimination training tool decreases movement-related pain in patients with
chronic low back pain more than acupuncture alone: a randomised cross-over
experiment. Br J Sports Med 2013;47:10859.
8 Wallwork SB, et al. Br J Sports Med 2015;0:18. doi:10.1136/bjsports-2015-095356
Rev i ew
... Many researchers concur that pain can be better understood when viewed as one of the body's protective systems (Moseley, 2007;Wallwork et al., 2016). Pain promotes a variety of protective behaviors to address threats to bodily integrity and increase the chances of survival, like withdrawing of a limb, guarding, resting, and seeking help. ...
... After learning about pain, participants engaged in various activities involving proprioception and active movement, including tactile acuity tasks, observation and mental rehearsal of different body configurations, and a gradual progression to physical movement. These activities are intended to reestablish nonprotective patterns of neural activity and movement (Wallwork et al., 2016). A recent large trial found that graded sensorimotor training led to modest and sustained improvements in low back pain (Bagg et al., 2022). ...
... AT lessons often involve directing while performing a functional task such as walking or bending. This way of performing the task integrates multiple senses and thus may improve sensorimotor disruptions, proprioception, and spatial acuity-all of which are relevant to pain (Moseley & Flor, 2012;Wallwork et al., 2016). ...
Article
Full-text available
This article brings together research from the fields of pain science and Alexander Technique (AT) to investigate the mechanisms by which AT helps reduce pain. AT is a cognitive embodiment practice and a method for intentionally altering habitual postural behavior. Studies show that AT helps with various kinds of pain, although the mechanisms of pain reduction are currently not well understood. Advances in pain science may give insight into how this occurs. Modern interventions with efficacy for improving pain and function are consistent with active approaches within kinesiology. They also share similarities with AT and may have common mechanisms such as learning, mind–body engagement, normalization of sensorimotor function, improvement of psychological factors, and self-efficacy, as well as nonspecific treatment effects. AT likely has additional unique mechanisms, including normalization of muscle tone, neuronal excitability, and tissue loading, as well as alterations to body schema, attention redirection, and reduction in overall reactivity.
... 27,52,57,61 One hypothesis is that pain from an index hamstring injury may induce reorganisation of somatosensory representations, which are cortical networks integral to pain processing. 49,68 Consequently, reorganised somatosensory representations may lead to disruptions in the processing of tactile, proprioceptive, and peripersonal spatial inputs. 37,68 These disruptions may ultimately affect movement patterns or interactions with the environment during sports and contribute to hamstring reinjury. ...
... 49,68 Consequently, reorganised somatosensory representations may lead to disruptions in the processing of tactile, proprioceptive, and peripersonal spatial inputs. 37,68 These disruptions may ultimately affect movement patterns or interactions with the environment during sports and contribute to hamstring reinjury. 68 Indeed, such reorganisation, measured by behavioural tasks that are thought to interrogate somatosensory representations, has been observed in musculoskeletal pain conditions affecting the upper body. ...
... 37,68 These disruptions may ultimately affect movement patterns or interactions with the environment during sports and contribute to hamstring reinjury. 68 Indeed, such reorganisation, measured by behavioural tasks that are thought to interrogate somatosensory representations, has been observed in musculoskeletal pain conditions affecting the upper body. 2,8,9,12,13,69 Recent evidence has also demonstrated deficits in tactile, proprioceptive, and peripersonal spatial representations in athletes who developed chronic posterior thigh pain following a hamstring injury. ...
Article
Recurrent hamstring injuries are highly prevalent amongst sporting populations. It has been hypothesised that pain from an initial hamstring injury may induce reorganisation of somatosensory representations that could contribute to reinjury. However, because of the cross-sectional nature of existing research, it remains unknown whether somatosensory changes are a cause or effect of pain or if they are driven by other potentially confounding factors. Here, we explored the effect of experimentally induced sustained hamstring pain on tasks that interrogate somatosensory and spatial representations. Fifty healthy participants were randomly allocated to an experimental group that performed an eccentric exercise protocol on the right hamstring to induce delayed onset muscle soreness or a control group performing a repetition-matched concentric exercise protocol. The tactile cortical representation was assessed using two-point discrimination and tactile localisation, whereas the proprioceptive representation was assessed using a left-right judgement task. Peripersonal spatial representations were assessed using an auditory localisation task. Assessments were performed at baseline and day 2. No between-group differences in tactile acuity were observed. However, improvements in left-right judgments and worsening of auditory localisation occurred in the experimental group compared with the control group. This study provides preliminary evidence showing that somatosensory changes occur in response to sustained hamstring pain. Experimentally induced, sustained hamstring pain elicited enhancements in proprioceptive processing and deficits in peripersonal spatial processing, suggesting a shift in the allocation of attentional resources from the external (peripersonal) to internal (body) environment. These findings may hold important implications for reinjury risk and rehabilitation following hamstring pain.
... This is the definition that modern neuroscience has created and displays the complexity of pain. The idea that pain reflects the state of tissues has been challenged over the last three decades, but a four-hundred-year-old methodology persists [2]. This persistence has manifested an idea that chronic pain is a disease, creating medicalised healthcare systems and the development of a false sanctuary that pain is a biomedical certainty [3]. ...
... This level of precision of pain based on the weather conditions described by participant E2 can be associated with central sensitisation [2]. The social dimension of a shared experience must not be underestimated as we constantly influence each other's perception and beliefs of pain. ...
Article
Full-text available
Background Pain attributed to musculoskeletal disorders are a significant hinderance to work ability and economic growth, especially in developing countries. Quality of life and lived experience of workers with musculoskeletal disorders have not been explored enough to determine whether person-centred care is provided. There is a wealth of evidence for using the biomedical approach in the management of workers with musculoskeletal disorders, which has proved ineffective in reducing absenteeism and symptoms experienced by workers. The purpose of this study was to explore the lived experience of workers seeking care for musculoskeletal disorders and how their pain attitudes and beliefs influenced their experience. Methods A qualitative approach with thematic analysis was used. Purposive sampling was used to recruit six participants for semi-structured interviews. All participants were either experiencing pain attributed to a musculoskeletal disorder or had received care for a musculoskeletal disorder. Results Pain attitudes and beliefs of workers with a musculoskeletal disorder and healthcare professionals greatly influenced the care and recovery process of musculoskeletal disorders. There is a primary biomedical lens informing care of workers with musculoskeletal disorders received. Workers expect healthcare professionals to explore their concerns further, but the focus of care for most participants was their presenting complaint. There is also a need for the autonomy of workers to be preserved, and communication between healthcare professionals and workers with musculoskeletal disorders needs to improve. Conclusions Many stakeholders are involved in the recovery process from musculoskeletal disorders. There is a need for a biopsychosocial informed practice to improve return-to-work (RTW) in workers with musculoskeletal disorders. Change is needed at all healthcare system levels to reduce the negative experiences of workers and maladaptive pain beliefs that is associated with persisting symptoms and extended absenteeism.
... In amputee or hemiparetic patients, a sensorimotor interruption following injury, arm amputation or a paresis of a body part can alter the internal representation of the body, leading to different phenomena such as phantom limb or motor anosognosia (denial of motor deficits [128]). There is also evidence that brain damage can result in distorted body representations, which can alter proprioceptive and kinesthetic signals, as well as perceptions of peripersonal space [144]. These sensory changes influence the planning, the preparation and the execution of movements, because the motor performance is continuously improved by sensorimotor circuits that constantly update internal predictions about a motor command's outcome [46]. ...
Article
Full-text available
Given the widespread debate on the definition of the terms “Body Schema” and “Body Image”, this article presents a broad overview of the studies that have investigated the nature of these types of body representations, especially focusing on the innovative information about these two representations that could be useful for the rehabilitation of patients with different neurological disorders with motor deficits (especially those affecting the upper limbs). In particular, we analyzed (i) the different definitions and explicative models proposed, (ii) the empirical settings used to test them and (iii) the clinical and rehabilitative implications derived from the application of interventions on specific case reports. The growing number of neurological diseases with motor impairment in the general population has required the development of new rehabilitation techniques and a new phenomenological paradigm placing body schema as fundamental and intrinsic parts for action in space. In this narrative review, the focus was placed on evidence from the application of innovative rehabilitation techniques and case reports involving the upper limbs, as body parts particularly involved in finalistic voluntary actions in everyday life, discussing body representations and their functional role.
... A severe brain injury after a stroke affects neural plasticity and changes the survivors' embodied experiences, which means the experiences of how post-stroke patients perceive the world through their bodies (Chen et al. 2010;Hosp and Luft 2011;Lo et al. 2023). Hence, brain damages distort the body representations that control proprioceptive and kinesthetic signals and the perception of peripersonal space, thus preventing the correct limbs' planning, preparation, and execution (Connell et al. 2008;Corredi Dell'Acqua and Tessari, 2010;Wallwork et al. 2016). In this perspective, stroke modulates the sense of embodiment referred to the feeling of being inside the body (ownership), in the place where the body is located (location), and moving the body according to own intentions (agency) (Kilteni et al. 2012). ...
Article
Full-text available
Stroke is the leading cause of motor impairments and generates distortion of body representation. Hence, stroke can modulate the sense of embodiment, namely the feeling of being inside the body (ownership), in the place where the body is located (location), and moving the body according to its own intentions (agency). A growing number of studies have adopted virtual reality (VR) to train motor abilities. However, the impact of the body illusion on the rehabilitation outcome is not fully understood. The present systematic review investigates the modulating role of the body illusion elicited by VR on motor rehabilitation in post-stroke patients after embodying a virtual avatar. The research was led in the main databases-PubMed, Scopus, PsychINFO, and Web of Science-and four studies matched the inclusion criteria (e.g., to have a sample of adult post-stroke patients, to use VR as an instrument for motor rehabilitation, to adopt the paradigm of the body illusion as a modulator for motor rehabilitation, to test the sense of body illusion outcome). Research outcomes demonstrated that two studies adopted the immersive and two the non-immersive embodied VR; three studies focused on the upper limb, and one on lower limb rehabilitation. Two studies compare VR training with traditional therapy, and two are pilot studies with only one experimental group. The studies demonstrated the feasibility of the body illusion as an accelerator for motor rehabilitation compared to the non-embodied condition, and as a positive correlator of the rehabilitation outcome. The finding should be taken with caution due to the limited studies included; however, they are encouraging to justify further research efforts in this area.
... Triggers can act individually or in combination to impact the outcome. This can be different from person to person according to the concept of neural representations (neurotags) and pain perception [32,33]. ...
Article
Full-text available
Migraine is a highly prevalent disorder with an enormous burden on societies. Different types of medications are used for controlling both acute attacks and prevention. This article reviews some non-pharmacological recommendations aiming to manage migraine disorder better and prevent headache attacks. Different triggers of migraine headache attacks, including environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes, are discussed. It is advised that they be identified and managed. Patients should learn the skills to cope with the trigger factors that are difficult to avoid. In addition, weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients’ knowledge about the disease are recommended to be parts of migraine management. In addition, using neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10 and magnesium, and acupuncture can be helpful. Non-pharmacological approaches should be considered in migraine management. Furthermore, the combination of pharmacological and non-pharmacological approaches is more effective than using each separately.
Article
Cognitive functional therapy (CFT) is a person-centered biopsychosocial physiotherapy intervention that has recently demonstrated large, durable effects in reducing pain and disability in people with chronic low back pain (CLBP). However, exploration of the treatment process from the patients’ perspectives, including the process of gaining control and agency over CLBP, is relatively understudied in this patient population. This qualitative study explored the experiences of eight participants from the RESTORE trial through longitudinally following their experiences, including interviews during baseline, mid-treatment, end-treatment, and 12-month follow-up. Data were analyzed according to a narrative approach. Findings described the overarching narrative themes of “The Journey to Self-Management.” Within this overarching narrative, four distinct narratives were identified, beginning with “Left High and Dry,” capturing the experience of isolation and abandonment with CLBP before commencing CFT, and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included “Plain, Smooth Sailing,” describing a journey of relative ease and lack of obstacles; “Learning the Ropes and Gaining Sea Legs,” capturing an iterative process of learning and negotiating setbacks; and “Sailing Through Headwinds,” describing the experience of struggle to gain agency and control over CLBP through CFT. Clinicians treating individuals with CLBP can use these insights to more effectively facilitate self-management, and people living with CLBP may find resonance from the narrative themes to support their journeys.
Article
Full-text available
Introduction Stroke is the second leading cause of death in Europe. In the case of stroke survival (almost 70%), only 25% of patients recover completely, while the remaining 75% will undergo a rehabilitation phase that varying from months to years. The primary outcomes of a stroke involve motor impairment in the upper limbs, resulting in a partial or complete inability to move the limb on the right or left side, depending on the affected hemisphere. Furthermore, the motor deficit distorts the proprioception of the body and the embodiment ability of the injured limb. This could be rehabilitated through the paradigm of body illusion that modulates the motor rehabilitation. The present protocol aims to investigate the effectiveness of a Virtual Reality system for sensorimotor and proprioception upper limb deficit compared to a traditional upper limb rehabilitation program. Method This study has a randomized and controlled design with control and experimental groups, and 4 measurement times: pre-intervention, immediately after the intervention, and two follow-ups (at 6 and 12 months). The inclusion criteria are: (a) Being 18 to 85 years old, both males and females; (b) Suffering from ischemic or haemorrhagic stroke; (c) The stroke event must have occurred from two to eighteen months before recruitment; (d) Patients must have moderate to severe upper limb motor deficit, and the alteration of sensorimotor and proprioception abilities of the injury upper limb; (e) Patients must understand and sign the written consent for enrolment. The rehabilitation last four weeks with three sessions per week at Bellaria Hospital of Bologna (Italy). The VR protocol uses two types of technology: immersive and non-immersive, and the control group follow the traditional rehabilitation program.
Article
Objectives Low back pain (LBP) is common in elite athletes. Several peripheral and central factors have been identified to be altered in non-athletic LBP populations, however whether these alterations also exist in elite athletes with LBP is unknown. The aim of this study was to determine whether elite basketballers with a history of persistent LBP perform worse than those without LBP at a lumbar muscle endurance task, a lumbar extension peak-torque task, and a lumbar motor imagery task. Method An observational pilot study. Twenty junior elite-level male basketballers with ( n = 11) and without ( n = 9) a history of persistent LBP were recruited. Athletes completed a lumbar extensor muscle endurance (Biering-Sorensen) task, two lumbar extensor peak-torque (modified Biering-Sorensen) tasks and two motor imagery (left/right lumbar and hand judgement) tasks across two sessions (48 hours apart). Performance in these tasks were compared between the groups with and without a history of LBP. Results Young athletes with a history of LBP had reduced lumbar extensor muscle endurance ( p < 0.001), reduced lumbar extension peak-torque ( p < 0.001), and were less accurate at the left/right lumbar judgement task ( p = 0.02) but no less accurate at a left/right hand judgement task ( p = 0.59), than athletes without a history of LBP. Response times for both left/right judgement tasks did not differ between groups (lumbar p = 0.24; hand p = 0.58). Conclusions Junior elite male basketballers with a history of LBP demonstrate reduced lumbar extensor muscle endurance and lumbar extension peak-torque and are less accurate at a left/right lumbar rotation judgement task, than those without LBP.
Article
Full-text available
Research on brain-machine interfaces has been ongoing for at least a decade. During this period, simultaneous recordings of the extracellular electrical activity of hundreds of individual neurons have been used for direct, real-time control of various artificial devices. Brain-machine interfaces have also added greatly to our knowledge of the fundamental physiological principles governing the operation of large neural ensembles. Further understanding of these principles is likely to have a key role in the future development of neuroprosthetics for restoring mobility in severely paralysed patients.
Article
Full-text available
Conventional rehabilitation of patients with chronic pain is often not successful and frustrating for the team. However, theoretical developments and substantial advances in our understanding of the neurological aspects of chronic pain, is changing these experiences. Modern theoretical models of pain consider it a perceptual inference that reflects a 'best guess' that protective action is required. We argue that keen observation, and open and respectful clinician-patient and scientist-clinician relationships, have been critical for the emergence of effective rehabilitation approaches and will be critical for further improvements. We emphasise the role in modern pain rehabilitation of reconceptualising the pain itself by Explaining Pain, careful and intentional observation of the person in pain, and the strategic and constant communication of safety. We also suggest that better understanding of the neural mechanisms underpinning chronic pain has directly informed the development of new therapeutic approaches, which are being further refined and tested. Conventional pain treatment, where the clinician strives to find the pain-relieving medication or exercise, or pain management, where the clinician assists the patient to manage life despite unabating pain, is being replaced by pain rehabilitation, where a truly biopsychosocial approach allows the clinician to provide the patient with the knowledge, understanding and skills to reduce both their pain and disability. We briefly overview the key aspects of modern pain rehabilitation and the considerations that should lead our interaction with patients with chronic pain. © 2015 American Physical Therapy Association.
Article
Unlabelled: The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift one's conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation. Perspective: EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.
Article
Some accounts of body representations postulate a real-time representation of the body in space generated by proprioceptive, somatosensory, vestibular and other sensory inputs; this representation has often been termed the `body schema'. To examine whether the body schema is influenced by peripheral factors such as pain, we asked patients with chronic unilateral arm pain to determine the laterality of pictured hands presented at different orientations. Previous chronometric findings suggest that performance on this task depends on the body schema, in that it appears to involve mentally rotating one's hand from its current position until it is aligned with the stimulus hand. We found that, as in previous investigations, participants' response times (RTs) reflected the degree of simulated movement as well as biomechanical constraints of the arm. Importantly, a significant interaction between the magnitude of mental rotation and limb was observed: RTs were longer for the painful arm than for the unaffected arm for large-amplitude imagined movements; controls exhibited symmetrical RTs. These findings suggest that the body schema is influenced by pain and that this task may provide an objective measure of pain.
Article
Previous studies showed that self-localisation ability involves both vision and proprioception, integrated into a single percept, with the tendency to rely more heavily on visual than proprioceptive cues. Despite the increasing evidence for the importance of vision in localising the hands, the time course of the interaction between vision and proprioception during visual occlusion remains unclear. In particular, we investigated how the brain weighs visual and proprioceptive information in hand localisation over time when the visual cues do not reflect the real position of the hand. We tested three hypotheses: Self-localisations are less accurate when vision and proprioception are incongruent; under the same conditions of incongruence, people first rely on vision and gradually revert to proprioception; if vision is removed immediately prior to hand localisation, accuracy increases. Sixteen participants viewed a video of their hands, under three conditions each undertaken with eyes open or closed: Incongruent conditions (right hand movement seen: inward, right hand real movement: outward), Congruent conditions (movement seen congruent to real movement). The right hand was then hidden from view and participants performed a localisation task whereby a moving vertical arrow was stopped when aligned with the felt position of their middle finger. A second experiment used identical methodology, but with the direction of the arrow switched. Our data showed that, in the Incongruent conditions (both with eyes open and closed), participants perceived their right hand close to its last seen position. Over time, the perceived position of the hand shifted towards the physical position. Closing the eyes before the localisation task increased the accuracy in the Incongruent condition. Crucially, Experiment 2 confirmed the findings and showed that the direction of arrow movement had no effect on hand localisation. Our hypotheses were supported: When vision and proprioception were incongruent, participants were less accurate and initially relied on vision and then proprioception over time. When vision was removed, this shift occurred more quickly. Our findings are relevant in understanding the normal and pathological processes underpinning self-localisation.
Article
Clinically, CRPS is characterized by allodynia, severe pain, hyperalgesia, and autonomic signs and symptoms (Marinus J et al, Lancet Neurol 2011;10:637-48). The precise underlining mechanisms resulting in CRPS are unknown; however, a number of studies have suggested an inflammatory state of some sort characterizes both acute and chronic CRPS (Huygen FJ et al, Immunol Lett 2004;91:147-154; and Groenweg JG et al, BMC Musculoskelet Disord 2006;7:91). Identification of specific inflammatory modulators in acute and chronic forms of CRPS could guide therapy to modify specific inflammatory states and, potentially, improve CRPS symptoms. The authors therefore conducted a systematic review and meta-analysis to determine whether CRPS is associated with a specific inflammatory profile. They also sought to determine whether such an inflammatory profile might be dependent on duration of the condition. A comprehensive search of the literature using online databases was performed. Articles that measured inflammatory factors in CRPS were identified. Two independent investigators screened titles and abstracts and also performed data extraction and risk of bias assessments. Studies were grouped by medium of fluid analyzed (blood, blister fluid, and CSF) and duration of the CRPS condition (acute vs chronic). When possible, meta-analysis of inflammatory factor concentrations was performed. Pooled effect sizes were calculated using random-effects models. The authors identified 22 studies for the systematic review and included 15 in the meta-analysis. In acute CRPS, the concentration of interleukin (IL)-8 and soluble tumor necrosis factor receptors I and II were increased significantly in blood. In chronic CRPS, there were (1) significant increases in tumor necrosis factor-α, bradykinin, soluble (s)IL-IRI, IL-IRα, IL-2, sIL-2Rα, IL-4, IL-7, interferon-γ, monocyte chemoattractant protein-1, and soluble receptor for advanced glycation end products in blood; (2) IL-IRα, monocyte chemoattractant protein-I, macrophage inflammatory protein-Iβ, and IL-6 in blister fluid; and (3) IL-Iβ and IL-6 in CSF. Chronic CRPS was also associated with significantly decreased substance P, sE-selectin, sL-selectin, sP-selectin, and sGPI30 in blood. There were also decreased levels of soluble intercellular adhesion molecule-I in CSF.