Lacuna

[Barrett Dorko]

There are several definitions of lacuna, but for the purposes of this thread I prefer this one: an intentional, extended passage in a musical work during which no notes are played.

I want to carefully work through what I understand has been discovered about the nature of pain, both acute and chronic, as well as its treatment. Much of this is drawn from David Butler’s recent presentation at the APTA convention. I was personally in attendance.

In Plato’s Republic he uses what is called “the cave allegory” to describe what he believed to be the way most people perceived the world. Plato said it was as if they were chained against the wall of a cave, unable to turn in any direction and able only to see the light and shadows cast upon the wall before them by a nearby fire. Those in charge occasionally move figurines that are seen as certain shadows on the wall. This vision of the light and shadows contained all anyone chained in the cave knew of reality. One day a man was allowed to escape and see the world as it actually existed, which was, of course, a little different. When he returned to the cave in order to share his vision with the others he is received with mockery and resistance. The cave dwellers tell him he’s gone mad.

From The Matrix and Me

Much more to come.

[natdocpg]

When I first started reading this forum I thought of the cave allegory immediately. Wiki has a description of the allegory and in that it describes how those who escape the cave are in pain at first upon exposure to the light of the sun but do eventually acclimate. When they try to convince others to leave the cave the other prisoners are angry and fight them because it is painful to give up the dim surroundings they are used to to look into the sunlight. When I read your tales of meeting resistance when trying to convince others to "see the light" it was pure cave allegory material!

Paula

[Barrett Dorko]

I’m going to take a large liberty here and spend a couple days paraphrasing what I heard David say. Please remember that though these are his words (as I recorded them with a pen) I certainly agree with them.

The other speakers in this pain track have been telling stories and today I will continue that.

We’ve learned more about the brain’s functioning in the past seven years than we had in the previous thousand. Because of this, there are now “knowledge gaps” between what we know and clinical practice.

A paradigm is a story that moves us forward in thinking. Paradigms occasionally clash, and when they do a winner emerges. The biomechanical and biopsychosocial paradigms clashed when it came to chronic disease, and the former lost. The “bio” in biopsychosocial is NOT biomedical – it’s he big picture.

The hunt for cause makes people worse.

Pain is a defender – NOT an offender. It is one of many defenders marshaled by the brain.

[Jordan]

The hunt for cause makes people worse.

Pain is a defender – NOT an offender. It is one of many defenders marshaled by the brain.

This is great stuff. Both David's message and your paraphrasing are clear and concise. I am excited to see Butler team up with Moseley, Thacker, and Louw for a presentation next week at WCPT in Amserdam.

I am also very excited to see this thread grow. Thanks Barrett.

[John W]

I think the biomechanical paradigm was bestowed upon us by the orthopods, which is their biomedical/biomolecular guided missile for the cause of pain. We morphed into their little pain generator-/peripheral nociceptor-search and destroy ground team, with a strong dose of strengthening exercises and postural education thrown in for good measure (and added profit).

So, what I think Butler means by the "big picture" is the entirety of biology, rather than some fragmented and narrow perspective of how living things behave and survive.

Today, I had a young high school student shadowing me and I asked her what she planned on getting her undergraduate degree in. She mentioned something about "sports medicine". A 2nd year DPT student was standing nearby and I asked her what she would recommend. She got her undergrad in kinesiology- that's the currently recommended "pre-PT" degree at LSU- and thought that was the best way to go. She said that she was "stronger in some areas like therapeutic exercise than many of her classmates who got other degrees".

The irony of the term "stronger" was not lost on me.

I suggested that the high school student consider a general biology degree or, if she can find one, an undergraduate degree in neuroscience. Surprisingly, a PT colleague sitting next to me agreed that a kinesiology degree may be too narrow.

Bear in mind, this is essentially a free care clinic where all that the therapists care about, if anything, is getting patients better. No one's hounding them about their charges/visit or subtly expecting them to hook a patient up to some electronic gizmo. This is in the trenches, no nonsense PT.

If it weren't in a building with thin, temporary partitions for walls, cast-cutters blaring several times an hour and anguished cries and moans piercing regularly through the din of human bustle and conversation, I wouldn't at all mind working there.

[Bas Asselbergs]

Great gems Barrett.
I think the orthopods were the first modern medical profession to develop a sense of increased control (power) by reducing their view of a human to a compilation of parts; this allowed them to address tissues rather than the biology (as per John and Dave) of the whole.
That semblance of control ended up being perfectly placed in an era of technological advances and automation, making it fit very neatly and seductively in our world views.
then.

John, I like your colleague's answer. Kinesiology is the undergrad degree of choice here as well - further perpetuating the "exercise-prescription above all" attitudes....
BTW, have you tried industrial strength earplugs at work?

[John W]

You know what, Bas, that's actually not a bad idea to have some of those little foam ear plugs handy in the "private" treatment room for both me and my patients.

Wouldn't that be funny if, each of us wearing earplugs, someone complained that I was yelling too loudly at my patients?

[Bas Asselbergs]

Would certainly enhance the non-verbal communication....

[Barrett Dorko]

Say “pain” with an Australian accent; Paaaain. And that hard “a” will make any patient worse.

The “Big 4” things to look for in order to determine whether or not you can help: These are things a patient believes or does:

1)Pain means they’ve been harmed

2)Fear avoidance behavior

3)They hunt for a passive maneuver that will “fix” them

4)They’ve withdrawn from their social life

Early in his life Mahler was told by a doctor, “That’s not a heart to be proud of” and now his music is most often played at funerals.

Brain smudging can change in a weekend. I don’t like the continual use of the word “management” when it comes to pain. We can do much better than that.

[nari]

Say “pain” with an Australian accent; Paaaain. And that hard “a” will make any patient worse.

Another laugh at this one. It's actually true, as well. Most of us say "paayin"

I don’t like the continual use of the word “management” when it comes to pain. We can do much better than that.

Of course we can, but the word has virtually replaced the old word "treatment" which sounds passively operative.

Nari

[Barrett Dorko]

When Butler speaks he displays a personal freedom in his movement I feel I must lack. Maybe it’s just not in me, and maybe this accounts for some of his influence and popularity.

He speaks of using metaphor to progress the story that may replace the one that is embedded in such a fashion as to generate an output of pain. I rather doubt he knows of James Geary’s thoughts on this. Maybe. He certainly has a connected mind, and I always appreciate that.

He knows what’s been discovered (or is being discovered) about the nature of delayed onset in response to stimulation. He knows in what sequence laterality, motor imagery and mirror therapy should be used. He knows more than I could find the time to write.

But there’s something missing. Whether others at the forefront of the neurobiologic revolution know about it is hard to say.

Stay tuned.

[John W]

When Butler speaks he displays a personal freedom in his movement I feel I must lack. Maybe it’s just not in me, and maybe this accounts for some of his influence and popularity.

Maybe. I've seen both of you speak, and Butler is certainly more animated, but that fits his personality and language use, which is not as economical as yours. Your movements are congruent with your speaking style.

I also don't think you'd look very good in bright green pants.

If Butler is the Steinbeck of manual therapy, then you're Hemingway.

[Karen L]

I think there is a missing link in the research and it is the ideomotor contribution to neuroplasticity. The freedom and authenticity is there, it is there for anyone to notice if they spend enough time with you en lacuna.

Active perception and perceiving action: The Shared Circuits Hypothesis

by: Susan Hurley
Abstract Recently research on imitation and its role in social cognition has been flourishing across various disciplines. After briefly reviewing these developments under the headings of behavior, subpersonal mechanisms, and functions of imitation, I advance the shared circuits hypothesis. This hypothesis about subpersonal functional architecture describes a unified framework for the mechanisms that enable control, imitation, and simulation, which makes explicit the relationships among them. It should have heuristic value in sharpening up questions and predictions at both higher, personal and lower, neural levels, while avoiding over-simple or a priori assumptions of isomorphism between the subpersonal and personal levels. A striking aspect of the shared circuits hypothesis is the way it connects a shared information space for action and perception with a shared information space for self and other, while at the same time illustrating how the distinctions between self and other, and between the imagined and the real, can be overlaid on these shared information spaces. In this model information about intentional agents arrives in the first person plural: without distinction or inference between self and other. The shared circuits hypothesis also illustrates a horizontally modular architecture: it avoids the common conception of perception and action as separate and peripheral to central cognition. Rather, it views perception and action as dynamically co-constituted and shows how cognitively significant resources, such as distinctions between self and other and between the imagined and the real, and information for action understanding and planning, might emerge from the information space that action and perception share.

The Theory of Event Coding (TEC): a framework for perception and action planning (with commentary)

by: B. Hommel, J. Müsseler, G. Aschersleben, W. Prinz

Behavioral and Brain Sciences, Vol. 24, No. 5. (October 2001) Key: citeulike:731541
Abstract

Traditional approaches to human information processing tend to deal with perception and action planning in isolation, so that an adequate account of the perception-action interface is still missing. On the perceptual side, the dominant cognitive view largely underestimates, and thus fails to account for, the impact of action-related processes on both the processing of perceptual information and on perceptual learning. On the action side, most approaches conceive of action planning as a mere continuation of stimulus processing, thus failing to account for the goal-directedness of even the simplest reaction in an experimental task. We propose a new framework for a more adequate theoretical treatment of perception and action planning, in which perceptual contents and action plans are coded in a common representational medium by feature codes with distal reference. Perceived events (perceptions) and to-be-produced events (actions) are equally represented by integrated, task-tuned networks of feature codes--cognitive structures we call event codes. We give an overview of evidence from a wide variety of empirical domains, such as spatial stimulus-response compatibility, sensorimotor synchronization, and ideomotor action, showing that our main assumptions are well supported by the data.

Karen

[Bas Asselbergs]

That is great stuff Karen!

[Barrett Dorko]

Karen,

Wonderful.

In the 1960s Libet discovered that people became aware of an urge to move about a quarter of a second before they actually made the move. Even more surprising, he found that the activity in their brain began to rise before they felt the urge to move.

David Eagleman in Incognito

There are many ways I might approach the reality of instinctive movement that we will forever remain suspicious and willfully unaware of, but, to me, Libet’s discoveries (which have never been refuted) demonstrate something we must acknowledge, and they seriously call into question the concept of “free will.”

On numerous TV shows when trying to explain some especially henious act, people will say, "I just snapped." I don't know about you, but I find this less than satisfying. It's actually kind of funny, but maybe that's just me.

There’s a difference between ignorance and simply refusing to acknowledge something. If that “something” is of particular significance, I presume that there are forces at play more powerful than those we suppose usually run things.

I want to write about the use of instinctive, unconsciously driven movement as it plays a part quite naturally in pain relief and I’ve done this countless times in the past. My question: Why is this part of movement therapy absent from Butler’s presentation?

[John W]

Why is this part of movement therapy absent from Butler’s presentation?

"Free will" is one of the most loaded terms of modernity. Perhaps Butler is aware of the implications of stirring up that hornet's nest and just chooses not to go there.

I understand that you're fearless in this regard, but I'm not sure challenging the concept of "free will" through an explication of ideomotion is the necessary tack to take.

[Jon Newman]

Originally Posted by Barrett Dorko

My question: Why is this part of movement therapy absent from Butler’s presentation?

I think only David Butler can answer that.

[Barrett Dorko]

I've spent a couple of days carefully considering John's last post. I consider it a friendly warning. It certainly reminded me that while Butler's course and writing remain enormously popular my own have remained frozen in some sort of limbo - never dismissed entirely, but ignored to such a degree that I've been unable to get them into any serious (read influential) discussion about the reality of manual care and movement therapy.

If that is to happen I need something, and a passage from Geary's I is an Other comes to mind:

This is one of the marvels of metaphor. Fresh, successful metaphors do not depend upon conventional pre-existing associations. Instead, they highlight novel, unexpected similarities not particularly characteristic of either the source or the target - at least until the metaphor itself points them out.

Perhaps Butler has some metaphors that achieve this. Maybe I don't.

I'm working on it.

[Barrett Dorko]

Your consciousness is like a tiny stowaway on a transatlantic steamship, taking credit for the journey without acknowledging the massive engineering underfoot.

David Eagleman in Incognito

I am the king of the world!

Jack Dawson in Titanic

We all know what happened to Jack.

[Barrett Dorko]

Now I'm going through Sex, Murder and the Meaning of Life by Kenrick. There are back cover recommendations from Steven Pinker and Robert Sapolsky.

More bad news for those who ignore unconsciously driven processes and movements.

[Barrett Dorko]

I'm still thinking about John's comment:

I'm not sure challenging the concept of "free will" through an explication of ideomotion is the necessary tack to take.

What options do I have? I can't imagine abandoning the neuroscience that teaches us how important this is.

[John W]

Barrett,

I think if you qualify or provide a tighter context, then I think we might be able to get somewhere. The wikipedia entry on free will might help, particularly the part that defines the different types of determinism.

[Barrett Dorko]

Ginger Campbell’s speech in London, recently linked to Diane’s neuroscience Facebook page is wonderful. Like me, she’s not a neuroscientist, but she is a clinician informed by neuroscience. And when she says that, she means all of it.

So do I.

Her comments about the unconscious were especially interesting to me and I’ve edited them slightly below.

I’m talking about the unconscious. What we’re learning is that most of what our brain does—or what our mind does—it does outside of our conscious awareness. It’s not even accessible to conscious introspection. You just can’t get to it.

One of the things that’s not accessible to us is the source of our basic emotions. We might be aware of our emotions, but where they come from is in the part of our brain that is not accessible to us. So, you can’t will yourself not to have an emotion. You might be able to make decisions about how you deal with the emotion, but you cannot not have an emotion.

Robert Burton says:

“Once you realize that a lot of what we do is unconscious, then free will or decision-making—if you step back from free will, just change the one word to ‘choice’—the unconscious has all kind of choices, because it’s making them all the time.

Free will implies that it’s free of material influence, which is probably a non sequitur. Probably it’s meaningless.”

When Burton says, “free will is meaningless,” he’s talking about the traditional definition of free will as something that’s somehow outside of the physical realm (read "material influence").

I titled this thread Lacuna for a reason. It remains my contention that though the NOI group has done a masterful job of examining and explaining what has been discovered about neurological processes in response to stimuli. Knowing this as best we can, methods of management for pain can be reasonably devised, and they have been.

My problem, obviously, is with the absence of any discussion regarding unconsciously generated movement.

More about that soon.

[Diane]

Here is the link to the actual podcast. Why Neuroscience Matters.

[Karen L]

John and Barrett,

From American Psychologist July, 1999; Apparent Mental Causation: Sources of the Experience of Will, by Daniel M. Wegner and Thalia Wheatley of the University of Virginia:

Karen

[Barrett Dorko]

Great article Karen. How can we get people to read it?

As long as causation is apparent and not actual we are going to have little success in changing anyone's perception of free will.

We’re dead.

But you already knew that.

[Jon Newman]

Originally Posted by Diane

Here is the link to the actual podcast. Why Neuroscience Matters.

Hey! I really like the new opening music. I thought the old intro music sort of had a Jaws/Psycho feel to it. I felt afraid to go into the water.

[Jon Newman]

Originally Posted by Jon Newman

Hey! I really like the new opening music. I thought the old intro music sort of had a Jaws/Psycho feel to it. I felt afraid to go into the water.

Oops. That was Books and Ideas theme music not Brain Science theme music. Well, now everyone knows my preference.

[Karen L]

Might explaining Simple Contact as a feedback loop, assist moving ideomotion into the mainstream treatment arena.
Harnessing the Power of Feedback Loops By Thomas Goetz June 19, 2011

A feedback loop involves four distinct stages. First comes the data: A behavior must be measured, captured, and stored. This is the evidence stage. Second, the information must be relayed to the individual, not in the raw-data form in which it was captured but in a context that makes it emotionally resonant. This is the relevance stage. But even compelling information is useless if we don’t know what to make of it, so we need a third stage: consequence. The information must illuminate one or more paths ahead. And finally, the fourth stage: action. There must be a clear moment when the individual can recalibrate a behavior, make a choice, and act. Then that action is measured, and the feedback loop can run once more, every action stimulating new behaviors that inch us closer to our goals.

The potential of the feedback loop to affect behavior was explored in the 1960s, most notably in the work of Albert Bandura, a Stanford University psychologist and pioneer in the study of behavior change and motivation. Drawing on several education experiments involving children, Bandura observed that giving individuals a clear goal and a means to evaluate their progress toward that goal greatly increased the likelihood that they would achieve it. He later expanded this notion into the concept of self-efficacy, which holds that the more we believe we can meet a goal, the more likely we will do so. In the 40 years since Bandura’s early work, feedback loops have been thoroughly researched and validated in psychology, epidemiology, military strategy, environmental studies, engineering, and economics. (In typical academic fashion, each discipline tends to reinvent the methodology and rephrase the terminology, but the basic framework remains the same.) Feedback loops are a common tool in athletic training plans, executive coaching strategies, and a multitude of other self-improvement programs (though some are more true to the science than others).

Second, collecting data on the cheap is cumbersome. Although the basic idea of self-tracking has been available to anyone willing to put in the effort, few people stick with the routine of toting around a notebook, writing down every Hostess cupcake they consume or every flight of stairs they climb. It’s just too much bother. The technologist would say that capturing that data involves too much friction. As a result, feedback loops are niche tools, for the most part, rewarding for those with the money, willpower, or geeky inclination to obsessively track their own behavior, but impractical for the rest of us.

My bolds 1 sounds like the fascination with concrete recipes manual therapy is so fond of.
My bold 2 sounds like the thoughtful manual therapist perhaps practicing Simple Contact or DNM who is an interactor and not and operator.

Rose grapples with an essential challenge of feedback loops: Make them too passive and you’ll lose your audience as the data blurs into the background of everyday life. Make them too intrusive and the data turns into noise, which is easily ignored.

The best sort of delivery device “isn’t cognitively loading at all,” he says. “It uses colors, patterns, angles, speed—visual cues that don’t distract us but remind us.” This creates what Rose calls “enchantment.” Enchanted objects, he says, don’t register as gadgets or even as technology at all, but rather as friendly tools that beguile us into action. In short, they’re magical.

[Barrett Dorko]

Karen,

You've given me a lot to consider.

Twice today I listened to David Eagleman interviewed on Philosophy Bites (15 minutes). Find it, listen to it and think about what has been discovered about what the unconscious actually does – almost all of it inaccessible to any direct measure.

I continue to wonder how any therapist dependent upon their patient’s learning cannot consider the enormity of this.

[Barrett Dorko]

I'm going to be doing a radio interview in a few days just two weeks after Butler did the same show. Details will be forthcoming.

One of the topics I want to duscuss is the contribution of the unconscious to our movement and how that has come to be ignored.

Do you think that's a good idea?

[Jon Newman]

Yes!

Is there a link to the show? I'm interested to hear what David had to say.

[Barrett Dorko]

Jon,

I found it in the list of podcasts from them on iTunes. I didn't see it elsewhere.

[Jon Newman]

Oh. I meant David Butler, not Eagleman. I subscribe to Philosophy Bites in iTunes and listened to the Eagleman interview, but for others, here's the link to the Eagleman interview.

What is the name of the show you'll be on?

[Barrett Dorko]

I'll compose some details about this tonight.

Thanks for asking.

[Barrett Dorko]

Today I heard Simon Blackburn describe Plato’s Cave on Philosophy Bites. I’ve heard of this place, read of it, written about it and often come across this allegory in my reading. Still, I heard a phrase I hadn’t heard before and it made me think of this thread and my struggle with it. Believe me, I’ve struggled.

What Blackburn described was the use of marionettes dancing behind the occupants of the cave, the light from a fire behind them used to cast shadows to the wall in front of the occupants. He said, “All they’re seeing then is the shadow of an illusion.”

I can’t help but think that an absence of reference to unconscious activity, motivation and the movement it generates (ideomotion) places a therapist in much the same position (allegorically, of course) to those chained in the cave, gazing at something that is twice removed from reality.

At the very least, we should turn to see that these are only puppets.

[smith]

Ah, but the philosopher brings the marinettes/pts into the light of reason, and science. Out of the darkness of the cave. In this case the philosopher is the man/woman who understands the ectoderm approach.

[Barrett Dorko]

Part of my struggle with this is the notion that I may have seen something not evident to many others with a lot more education than I.

I can't imagine leading any of those people out of the cave or implying that I'm not chained in much the same manner.

All I've managed to do is turn around. I think.

[Jon Newman]

Originally Posted by Barrett Dorko

Part of my struggle with this is the notion that I may have seen something not evident to many others with a lot more education than I.

I think this is very astute Barrett. I expect Diane has had a similar experience.

Here's some more fodder for your upcoming interview--Mind Wide Open (hat tip: BPS Digest)

[Barrett Dorko]

Thank you Jon. Great find.

“I think that this feeling of knowing must be enormously powerful. It must subvert reason when the two come into conflict. One is more biologically necessary. I think reason came much later, and is much less of an evolutionary necessity than this feeling of correctness, which is at the heart of learning—at the heart of what causes reasoning in the first place. The reasoning is dependent on this feeling. The feeling isn’t dependent on the reason.”

Robert Burton (quoted by Ginger Campbell)

How did I get to the point where I felt certain that attention to unconsciously motivated behavior was required? How is it that I can’t let this go despite the fact that I’m in complete agreement (otherwise) with those who ignore it?

I think it has something to do with the stack of notebooks pictured below.

For years I’ve written down my dreams. I’ve written about dreams here and here. I read about interpretation from a Jungian perspective and consider this manifestation of my unconscious each night a great treasure. I consider the notebooks priceless.

My certainty about the contribution of the unconscious to correction of mechanical deformation has only grown as the neuroscience proceeds to uncover its massive influence.

I attend to my dreaming, and as I do I have changed; my body has changed. I can’t imagine letting this change go.

[Diane]

Originally Posted by Barrett Dorko

How did I get to the point where I felt certain that attention to unconsciously motivated behavior was required?

Was it when you were faced with having to tame/befriend your inner sled dog? I think we all have to do this sooner or later, one way or another.

[Barrett Dorko]

Diane,

Great blog entry. I like the analogy derived from Bownds (and others). I've also always liked what Keen says:

Stress means you're living someone else's life.

It's easy enough to say that not pursuing the ideomotor angle became "someone else's life" for me.

Easy to say - harder to act upon.

I seem to be doing it anyway.

[Diane]

I was just getting warmed up, in that conversation. I was going to tell her that she needed to watch the dog, let it get used to having her attention on it, start hand feeding it, let the dog run around out of harness, enjoy its frolic (free movement), send it after sticks, reward it with a small piece of steak every time it came back when she called it, until it learned to come back by itself of its own accord. Playing in other words. Free movement. The steak treats for this metaphorical dog would be a nice big breath, all the way in, in and then all the way out. Attention on the skin of the nostrils. The dog would learn she was its friend because she was giving it what the brain wants and needs, which is oxygen. That she should be able to befriend/tame her whole brain that way, without in the least interfering with any of its ordinary and useful and desirable function. She was really into the metaphor, but her phone kinda stopped the chat.

I'm going to make sure her phone is turned off next time. It rang 4 times during that hour. I hate cell phones. I used to have a sign that asked people to turn them off, but this is a new space, and I'm a bit rusty with remembering what signs I need to put up.

Anyway, the interaction: taming/frolicking/hanging out with the dog when it isn't in the harness is the ideomotor part, I figure.

[Diane]

There are several nonverbal "creatures" housed in human brains, all fundamental to how the human one operates (or doesn't) movement-wise. They probably all like being allowed to move how they like, sometimes. They all need opportunities probably.

• Fish brain non-consciously moves the spinal muscles.
• Amphibian brain worked out a few reflexive social gestures once legs/feet came along.
• Reptile brain added more nuance.
• Mammal brain added more variety of emotional overtone to movement
• Primate brain made the face expressive.
• Human brain added speech and much much more facial expression.

Center for nonverbal studies.

[Barrett Dorko]

Wonderful links Diane.

I've always loved this poetic take on the animals within us by Carl Sandburg.

[Diane]

What a great poem. Thank you.
Human brain as a zoo, an evolved structure/function with all those old bits ready to veto whatever the new bit, the human bit comes up with, because they are older bits that have survived a lot longer. And they can't talk, they can only feel and act. I love that idea.

[Jon Newman]

[Jon Newman]

Originally Posted by Barrett Dorko

What Blackburn described was the use of marionettes dancing behind the occupants of the cave, the light from a fire behind them used to cast shadows to the wall in front of the occupants. He said, “All they’re seeing then is the shadow of an illusion.”

I'd forgotten that the shadows weren't shadows of people passing by the cave entrance but rather shadows of marionettes. That's an important distinction. Anyway, I thought of this thread when I saw how compelling shadows can be (hat tip: Imaginary Foundation).