A Unified Theory for Physical Therapy and the Treatment of Pain

[BB]

I wrote the following a couple of months ago at the urging of Nari...

On the Cusp of a Unified Field Theory

I think that our profession is a nation divided. We are many different therapists, using many different methods, to approach similar patients. A person practicing in method A, may work in a very different manner than a person working with method B. Both have success with their methods and therefore assume that it is the best. However, if A is right and B is wrong, then why do both work? And what do you do when neither A nor B work? Many often feel they have to throw out one method if they want to use another, or collect of bag of tricks, a toolbox, to run through until you find the "right one for that particular patient."

I'm not proposing that variation between therapists should not exist. However, a patient might get completely opposing explanations of mechanism of correction between therapists A and B.

We need to start looking for similarities between our treatments. The goal of this process would not be to find best practice, but instead to be able to explain WHY multiple methods work. What is the common ground, the generality between methods that allows both to have success? When this question can be answered then the concept of better practice can begin to be approached.

Inevitably, the answer to this question leads one to the nervous system. One must begin to consider the advances of neuroscience to find a broad enough framework to encompass the answer to the above question. The quest to achieve this understanding can lead one to the ability to answer that question from multiple perspectives. Outside-in and inside-out perspectives that are able to withstand scrutiny from what is known about the nervous system and the advances of neuroscience.

Einstein sought to create a unified fields theory. He reasoned that an explanation existed that would explain the divisions created in physics by his relativity theory. He was unable to find his unified field. However, his findings and his theory have allowed modern neuroscience to flourish. Our own unified theory may be within reach as a result.

[Diane]

Cory,
Thanks for putting up this thread. Very timely.

Occam is reputed to have said,"It is vain to do with more assumptions what can be done with fewer assumptions." In our case, probably fewer body tissues/systems. How about just one? The control system.

Ironic probably, that the very system, the understanding of which could encompass PT fragmentation, unite perspectives, account for similar outcomes from differing approaches, answer disparate questions, is the one that most mesodermal PTs run away from because they think it is too complex. Look forward to others' input on this.

[BB]

This is a task that has been on my mind for some time. Most on this board will agree that a certain shift in thinking needs to occur in the profession. I will contend that this shift can be facilitated through a Unified Theory.

Stating that this is going to be a big task for me is a large understatement. Therefore, as always, I encourage feedback, questions, criticism, etc.

As this thread will have the potential to grow quite large, I will occasionally come back to this page to add an index if needed, for ease of navigating through the information. I will attempt to present in a systematic manner for ease of reference.

I'm going to begin by organizing some topics into 3 categories.
-inside out neuromodulation
-outside in neuromodulation
-the placebo effect

[BB]

I'll start with inside out neuromodulation

I would like to start with an overview of several concepts that I will use throughout the thread. It will be important for these to be presented first.

The first concept that I would like to cover is Antonio Damasio's Somatic Marker Hypothesis. Damasio is a neuroscientist at the University of Iowa, and he presents his hypothesis in the book Descarte's Error.

Damasio contructed the somatic marker hypothesis from his work with patients with damage to the ventral medial prefrontal cortex.

The hypothesis states, that the mind when confronted with the need for any action is supplied with an extaordinary amount of possible actions from which to choose. The process of going through each possibility with costs/benefits computations would be cumbersome to say the least. Damasio argues that each possible action is linked with an emotion and its correlated body states based on past experience. These act as markers for each image. This allows the mind to quickly discard those images that are linked with a possible bad outcome as is evident by their emotional marker. The result is the choices are narrowed down to those that are marked to be the most likely to be advantageous, and therefore significantly reduces the amount of costs/benifits computing time necessary.

Damasio has been able to show in the population with ventral medial pre-frontal cortex damage have lost the ability to bring about the autonomic changes associated with emotion in regards to anticipated action. He tested this in a variety of ways using skin conductance. Chapter 9 in Descartes Error is devoted to testing of the hypothesis. People with medial pre-frontal cortex damage display normal intelligence, are able to describe social constructs properly, but are unable to function normally in a number of important ways. Most relevant, they often spend hours working on mundane tasks, unable to move on. Since they have lost the "somatic marker" that their emotions provide, they are presented with an unfiltered number of options through which they must navigate.

You should note that the hypothesis is not called the emotional marker, but is called the somatic (body) marker. It is called this because the marker consists of the visceral and non-visceral signals associated with emotions. Again, the somatic marker decreases the number of images presented as potential actions. What makes up these images is very important to this discussion and I will return to it soon.

For now, it is important to know that all of this is happening non-consciously. This brings me to the first point:

when you exclude consiousness (or better stated, prior to consciousness), the choice of action is based upon past experience and how the body responded to those decisions. The action chosen will be the one that will bring about the body response best suited to the task at hand, based on previous experience with similar situations.

Stated more simply: given the opportunity and the correct options, the nervous system will non-consciously chose the action that has proven most advantageous in meeting its needs in past experiences.

[Barrett Dorko]

Great stuff Cory. Before long I'll be speaking these words as if they were originally my idea, which, from me, is the greatest compliment I can give them.

I was wondering. Is there any indication from Damasio as to when this previously learned ideal reaction might have been learned? I couldn't find any, and if there isn't, wouldn't earliest childhood be the most fertile ground for such learning? Ideomotion as manifest in adults seems to be a return to this.

I'm reminded of a speech in the movie "Million Dollar Baby" by Morgan Freeman's character, describing how unnatural and counter-intuitive are the movements in boxing -certainly an adult activity. I'm also reminded that Hans Christian Andersen had the words "The Emperor has no clothes" emerge from the mouth of a child.

[BB]

Hi Barrett,

He contends that it is a continual process, but he does have the following to say:

From p.175 of The Feeling of What Happens

In a developmental perspective, I expect that in the early stages of our being there is little more than reiterated states of core self. As experience accrues, however, autobiographical memory grows and the autobiographical self can be deployed. The milestones that have been identified in child development are possibly a result of the uneven expansion of autobiographical memory and the uneven deploymenet of the autobiographical self.

Gotta go now. More later...

[BB]

Back to finish the last post....

I'm going to come back to the idea of "self" as it will play a big part in the discussion.

For now, let me say that the autobiographical self is built on memories of experience, and therefore bring in social and cultural influences. In the above quote, Damasio is saying that, in children, the machinery for memory is still in the process of developing, limiting access to this system. Additionally, the younger the person, the less autobiography has been built. Since in early stages the non-conscious markers have little autobiography to be compared to, they are more likely to be expressed as is.

wouldn't earliest childhood be the most fertile ground for such learning? Ideomotion as manifest in adults seems to be a return to this.

I would think that the learning of this nature would continue throughout life, but the expression of such actions early in development, without the social and cultural constraints from the autobiographical self, and the pure expression of ideomotion in an adult would be comparable.

[BB]

I want to next expand on what images are as they pertain to the non-consicous mind.

Damasio says the following on p. 318 in The Feeling of What Happens:

By the term images I mean mental patterns with a structure built with the tokens of each of the sensory modalities- visual, auditory, olfactory, gustatory, and somatosensory. The somatosensory modality includes varied forms of sense: touch, muscular, temperature, pain, visceral, and vestibular.

In other words, an image is not just a visual picture in our head. It is an activation of the neural maps of all the above mentioned sensory modalities that go along with that choice.

As an example, when you think about sitting in your car, the image that you consider includes the sight, smell, temperature, feeling of the seat and/or steering wheel, body position of sitting, etc. All of these neural maps have been activated in just thinking about your car. It is the architecture of this experience and it is a good example of how our mind thinks in terms of context.

Now if you go back to the description of the somatic marker hypothesis, you will appreciate even more so, the amount of information that is processed in every decision, and how having a marker system (emotion) helps with efficiency.

More on images coming from Patrick Wall next....

[BB]

Patrick Wall was perhaps the worlds leading neuroscientist on pain prior to his death in 2001 after a battle with cancer.

In his book, Pain: The Science of Suffering, he had this to say on p. 146:

Classical theory is that the brain analyzes the sensory input to determine what has happened and presents the answer as a pure sensation. I propose an alternative theory: that the brain analyzes the input in terms of what action would be appropriate.

This is where we are going to begin talking about pain.

We are getting a bit more specific with our images now. Not only are the images provoked consisting of representations of neural maps, they are analyzed in the context of an appropriate action or a motor plan.
Damasio parrellels this in The Feeling of What Happens in his discussion of "objects" percieved as an image, with the corresponding neural maps, in addition to the changes that occur as a result of our relationship to the object, or motor plans for response to the object.

Wall goes on on p 147 to say:

There are elaborate and extensive areas of our brain concerned with motor planning as distinct from actual motor movement. It is precisely these areas that are most obviously active when the brain is imaged in subjects who are in pain but quite stationary.

Let me re-state that: People in pain demonstrate activity in the areas of the brain responsible for motor planning even when they are not moving.

[EricM]

Really enjoying this Cory. I have just one question regarding the last statement. I cite this passage from Wall several times when doing inservices or in explaining pain with patients. To be clear, do people without pain, who are similarly in states of non-movement, not show any activation of motor planning areas? Or if they do, are these studies showing that the patterns of activation are sufficiently different? Is anyone familiar with the finer details of these studies?

eric

[Diane]

I've read that premotor and motor planning areas are active even in thought. Which would be why meditation would be a different form of brain (non)activity.. "stills" the mind. One wonders however if meditation can "still" pain. Maybe Ian will have some info on that.

[nari]

Motor areas are active when imagining movement - hence one can increase muscle bulk just imagining the action - but I don't know the degrees of difference in activity between the groups.

Keep going, Cory - this is good revision and tying up of thoughts!

Nari

[Synergy]

Great topic Cory! I happened upon this article while I was browsing my Yahoo! feeds. I think it's applicable to this discussion.

Mental Activity Seen in a Brain Gravely Injured

[BB]

Eric,
Since the brain analyses in the context of a potential action, both those in pain and those not in pain would demonstrate motor planning activity. Anyone who is "sensing" would display this.

Wall actually goes on to say this on p.148 after describing similar findings in those learning new words by listening:

In the case of pain, the analogy would be that the overt defensive reaction to a noxious input observed in the baby is suppressed in the adult although the pattern of responses is retained as a possible reaction.

(more support for your earlier statement, Barrett!)

The important thing to take away here, is that sensation is expressed in the form of a potential action.

A great example is given describing those who have suffered a stroke resulting in left side neglect. These folks cannot sense anything that is on the left. They will even draw only the right side of a picture, cannot recognize their own left hand, etc. Wall describes a remarkable finding on page 149:

Italian doctors, whose results were confirmed by many others, discovered that stimulation of the vestibular system in the ear completely resotred all sensation on the left side. It disappeared again as soon as the stimulation stopped. What could be going on? The vestibules in the ear continually inform the motor system about the body's position in the up-down and sideways directions. It is our major organ of balance. it is obvious that the map had not been destroyed in the patients but that they did not have the ability to refer to the entire left side of the map. How could that be? Disturbed messages from the vestibular system, which controls sensory motor posture, had slammed the frame of reference for the whole brain so far the the right that it was unable to perform both its sensory and motor tasks on the left side. It is apparent that we can sense only those events to which we can make an appropriate motor response.

bold mine

Quite a profound finding.

What makes this situation in pain different from other sensations, is that it in pain when the action is met the sensation is terminated and cancelled. The sensation of pain needs to have it's motor plan satisfied. This is what makes it a need state, like hunger and thirst.

Much more on this when we get to placebo...

Chris,
Made me think of Locked in syndome. A quite sad, and interesting condition. Sometimes they are thought to be commatose until someone notices that their eyes are moving. They are completely conscious, yet can only move their eyes up and down. Damasio talks about the condition in The Feeling of What Happens.

[nari]

I have seen and treated quite a few locked-in patients, and without fail, the spouse or friends report: "I know he/she is awake"! and no-one takes any notice for days. They do, after all, know the patients better than anyone else.
I noticed that there was something different even when they weren't moving eyes at the time; couldn't pinpoint it, but the patient seemed alert. It is a strange thing.

Nari

[BB]

I want to draw out more obviously one conclusion made in my last post.

We've established that an input is analyzed in terms of the potential action. We've extended this to sensation now as well.

As is evident in the left side neglect example, if this analysis, resulting in a motor plan, is not present then no sense will occur.

I wanted to make sure this jump was clear, because next we are headed to consciousness and how a sensation occurs.

[Diane]

I'm really liking how you are corraling all this info Cory, highlighting the pertinent bits that sustain the argument but have no conflict with any other basic science, using at least two sources at once to orchestrate your argument. It's a beautiful thing.
We should stick this thread later.

[BB]

Thanks Diane. I'm trying to provide a logical background in order to use it in the real purpose for this thread. That is describing why different treatment methodolgies work, providing a unifying theory for their mechanisms. Stay tuned folks. We'll do the first round of that after we talk about consciousness.

Also, before we move on to consciousness...

We havn't talked about output or actual action other than briefly at the beginning with the somatic marker hypothesis. We will very soon. At this point however, after talking about motor plans and their role in sensation, I think it is appropriate to go ahead and mention an aspect of action.

The carrying out of a non-conscious motor plan, such as we have been describing, is called ideomotion. Wall calls it "overt motor movements." We will be talking much more about this.

Another topic that ties in nicely with motor planning is that of learning. Giacomo Rizzolatti at Parma in Italy found single cells that respond when a monkey closes its hand, and also found that those same cells respond when it sees another monkey closing its hand. The monkey recognizes the action based on the activation of the motor plan for the same action in itself. The cells he is referring to are mirror neurons. They allow for a neural version of mimicry.

V. Ramanchandran has found evidence of comparable neurons in the premotor cortex of people. He has also described, as a result of his work with people with synesthesia, how this mechanism forms the basis for metaphor, and has hypothesized how it may be the mechanism reponsible for human development of language. His book A Brief Tour of Human Consciousness, describes this work. We will be, no doubt, returning to it in our discussion of conciousness as well.

I strongly recommend taking a look at this link. It is a conference in which Ramanchandran presents these findings in a lecture. Damasio gives 2 lectures on the link as well. They are great, understandable, and relatively brief for neuroscience lectures.

[Jon Newman]

Hi Cory,

I'm enjoying the lectures in your "Becoming Human" link (strangely, in a way, sponsored by the Templeton foundation.)

Keep it up.


ps Responses to Templeton concern

pss See also the thread on E.O. Wilson.

[BB]

Jon,
Thanks for linking EO Wilson to here.

I hadn't noticed the Templeton Foundation on that link before. That is interesting.

Here is another link with video of lectures of those two once again. This time in a symposium on Art and Neuroscience. It also has lectures from Nobel Prize Winner Eric Kandel, and Joseph LeDoux, both of whom we will be discussing in the near future(in case anyone wants to read, or watch, ahead).

[BB]

Consciousness consist(s) of constructing knowledge about two facts: that the organism is involved in relating to some object, and that the object in the relation is causing a change in the organism.

These are Damasio's words from p. 133 of The Feeling of What Happens.

In order for an organism to know that a change is happening to itself, it must have a sense of self, a frame of reference upon which to compare changes.

Damasio goes on to state that "continuity of reference is in effect what the self needs to offer." There needs to be an organization for the organism that defines what is in (self) and what is out (non-self).

The dispositional arrangement ensures that the environmental variations do not cause a correspondingly large and excessive variation of activity within. When variations that trespass into a dangerous range are about to occur, they can be averted by some preemptive action;

Bold mine. He is talking about avoidance to stay away from danger here.

and when dangerous variations have already occurred, they can still be corrected by some appropriate action.

Bold is mine again. We have already discussed how a motor plan emerges in response to any percieved input. Here he is applying this thinking to a threatening stimulus and is extending it from planning to actual action. This is important because it says that dangerous variations are percieved as a threat to the self and are dealt with by avoidance or action. This is the underpinnings of the "threat value of pain" spoken of by Moseley and Butler in Explain Pain, as well as in Moseley's research.

Pain is a response (read sensation) to something the body percieves as a threat (see above) that requires an action.

Now, considering what we have talked about, this phrase should have deeper meaning.

Now that we know why it is important to have a sense of self, let's start unraveling what makes up the self, neurally.

[BB]

Damasio organizes the self into 3 categories
Proto self
Core self
Autobiographical self

We'll tackle proto self first.

As mentioned above, there must be a stable reference of a continueing self. This is what the proto self provides. It is the baseline upon which any change is compared. This comparison is how a change is percieved.

From p. 136 of The Feeling of What Happens:

One key to understanding living organisms, from those that are made up of one cell to those that are made up of billions of cells, is the definition of their boundary, the separation between what is in and what is out. The structure of the organism is inside the boundary and the life of the organism is defined by the maintenance of internal states with in boundary. Singular individuality depends on the boundary.

The proto self consists of the background state of the internal mileu. Since the self needs to be a reference with some stability, we have a process that helps keep that state stable: homeostasis. Homeostasis serves to return the state of the internal mileu back to baseline. As a result any changes to that internal state can be percieved.

The proto self also uses a boundary for its stable reference. Guess what makes that boundary.....skin.

p. 231 from Descarte's Error:

A representation of the skin might be the natural means to signify the body boundary because it is an interface turned both to the organisms interior and to the environment with which the organism interacts.

More on skin from Descarte's Error p230-231:

The first idea that comes to mind when we think of skin is that of an extended sensory sheet, turned to the outside, ready to help us construct the shape, surface, texture, and temperature of external objects, through the sense of touch. But the skin is far more than that. First, it is a key player in homeostatic regulation: it is controlled by direct autonomic neural signals from the brain, and by chemical signals from numerous sources. When you blush or turn pale, the blushing or pallor happens in the "visceral" skin, not really in the skin you know as a touch sensor. In is visceral role- the skin is, in effect, the largest viscus in the entire body- the skin helps regulate body temperature by setting the caliber of the blood vessels housed in the thick of it, and helps regulate metabolism by mediating changes of ions (as when you perspire). The reason why people die from burns is not because they lose an integral part of their sense of touch. They die because the skin is an indespensible viscus.

Big picture here is that the skin and the internal state of the organism supply of sense of self that is stable day to day, moment by moment.

Here is how Damasio defines the proto self:

The proto self is an interconnected and temporarily coherent collection of neural patterns which represent the state of the organism, moment by moment, at multiple levels of the brain. We are not conscious of the proto self.

[Diane]

Wow Cory, keep it coming. I'm loving this.
Please ignore this post if it derails your line of thought in any way.. but I've always wondered if one sort of "self", or firing pattern in the brain, or portion of the neuromatrix, registers skin as boundary to its"self", while another part (maybe even more primitive) registers its-"self".. relative to, as different from, the mesoderm - mesoderm being part of the "environment" within which it lies embedded and feels as "other." I'll look for clues in your writing/thinking as it proceeds.

[BB]

Diane,
As for as I know there isn't any evidence that the mesodermally derived structures, such as bones, muscles, blood, and other connective tissue, would be considered distinct from the self. However, the use of the information they provide through proprioception is used in a particular way at another category of the self, the core self, and is therefore compared against the proto self. I'm going to the core self next.

One other thing about homeostasis and the proto self. The proto self can change over time in small shifts. Our internal state is not the same now as when we were born for example.

Robert Sapolsky is a neuroendecrinologist who is an expert on the stress response. He has written a book titled, Why Zebras Don't Get Ulcers that describes how long term activation of the sympathetic nervous system, which regulates homeostasis, causes changes in the body. It is a great book that goes through the body by system and I wish we could talk at length about it here, but I don't want to make this more cumbersome reading than it already is. He is also a speaker on the first video link a few posts back, and his presentation is very interesting and entertaining.

He does make some general recommendations to decrease the stress reponse by situation in his book, and we may get to that. Otherwise, I recommend reading the book. Well worth it.

[BB]

Now it's time to start tying some stuff together. It's time to talk about the Damasio's next category of self: the core self.

The core self represents what changes occur as a result of our interacting with an object. The term object here is a broad term for a diverse array of entities, which could be a person, place, melody, toothache, etc.

The organism is mapped using the stability keeping structures of the proto self. An object is mapped as well (as discussed earlier in the form of a motor plan). This object causes bodily changes/responses, changes to the proto self. These changes themselves become mapped.

So, in effect, having a stable proto self allows for a comparison upon which changes can be percieved. It allows for a neural representation of the consequences of relating to an object.

This gets a bit confusing, especially when presented in such a brief summary. So, let me attempt an example, and I'll try to use one that should be relevant to the conversation.

You are the organism in question. The object in this scenario is being touched by a physical therapist. The touch brings about an emotional response, let's say fear (fear of being harmed), and its corresponding bodily responses: increased heart rate, tensing of certain muscles, increased respiratory rate. Your proto self is a map of your steady state (boundary and homeostasis) and is mapped. The touch of the therapist is mapped as a motor plan. The changes that occurred in the body as a result of the touch are also mapped.

Here is Damasio's definition of the core self from p. 174 of The Feeling of What Happens:

The core self inheres in the second-order nonverbal account that occurs whenever an object modifies the proto-self. The core self can be triggered by any abject. The mechanism of production of core self undergoes minimal changes across a lifetime. We are conscious of the core self.

The core self allows us to sense not only the object, but also the changes that our interaction with an object cause on us.

Let me know if this isn't making sense.

[Diane]

It makes some sense. I wonder if the core self is the one/ that which pulls the rest of the selves back together after a shock to the system, a big emotional ding, like death of someone close, that sort of thing.

Something else.. the fit between the core self and the culture or the troop, and how it fits with social grooming, be it human primate or other primate; in the Sapolsky video he talks about how, if an alpha male thumps on a lower status male who "has it coming", i.e., deliberately waltzes into the alpha's trerritory or something, and gets beat on, the others won't go over to soothe/help him. However, if the alpha male is in a bad mood and just arbitarily selects a lower ranking male to beat on to drain off some cortisol or something, that second individual who's been thumped for no reason will get a lot of grooming. It is an example of something like empathy found in apes (I forget which species, I don't think it was baboons). I was very struck by the observation.

I wonder if it's the core self that produces this innate sense of justice served, or injustice committed and resultant socially provoked empathy. Sorry if this is a meander off topic.

[Barrett Dorko]

Changing ourselves when in relation to something else would require that we remain aware of that “other,” and this is where I think that manual care offers the therapist something that modality care or education cannot, not that those don’t offer anything – it just doesn’t enter the therapist’s awareness through their skin.

I was reading about a pitcher for the Cleveland Indians on Sunday. Jeremy Sowers, a rookie, has had a wonderful season despite the fact that he doesn’t have an overwhelming fastball or exceptional curve. What he has is the ability to watch the batter swing at every pitch whereas most other pitchers have a motion that carries them away from this view. By watching them swing each time Sowers is able to gather information about the batter’s tendencies that help him decide what to throw the next time he faces them. Other pitchers learn this by watching tape or looking at the stats, but Sowers has seen it in conjunction with his own motion in real time. This is what makes the difference.

When I touch another in my eccentric way they begin to move and sense that motion in ways unique to the moment of my contact. I describe this as a consequence of their inherent ideomotion, the fact that they are alive and my understanding combined with patience. I contend that my personal sensitivity is a minor issue and that sufficient sensitivity will grow in any therapist very rapidly if they just spend a few minutes looking for it. I think I’m right about this. But when Damasio says, “The core self can be triggered by any object” I begin to wonder how many times I’ve been personally altered over the years by my patient’s response to my “pitch.” I wonder at my own ability to sense change some distance from my hands with surprising ease and clarity and, most of all, my certainty about where to go next with my hands. In effect, what “pitch” to throw at them.

I think Sowers’ tendency to know what the batter wants next because he has watched all of this before is similar. Of course, he doesn’t give that to them. What my patients want next is what I offer and all of this proceeds from nonverbal messages that I think are certainly palpable and to some extent visual. There’s only one catch: the therapist must maintain a sense of the patient from moment to moment. Perhaps eventually the core selves of both will change, but only if we gain access to it through the course of care.

Given that sort of attention, even a hardcore mesodermalist will be more likely to throw the proper pitch the patient’s way. Aside from the unifying theme of the nervous system from one patient to the next we might also consider what unifies successful therapists. Maybe it's the inevitable changes in the core self of the therapist who actually pays attention and is thus changed by what they perceive through their hands and in their attentive vision. I’ve personally watched Bobath, Feldenkrais, McKenzie, Maitland and Kaltenborn display this to my satisfaction. I didn’t see it in Cyriax or Paris.

Think there might be a lesson there?

[BB]

Great examples from both Diane's and Barrett's posts. I think that considering them further may help with understanding core self and proto self, and also help us charge forward to the autobiographical self.

Let's start with Diane's example of the primates demonstrating empathy for a fellow from the group who has been bullied. I want to consider the ape who was bullied and consequently groomed, and not the bully himself.
This ape gets bullied. The other ape's are sitting around watching this. Seeing this bullying episode causes a change in thier body states, triggers emotions, causes the subsequent bodily changes, and thus uses the core self to map these changes. Also, it triggers in their memory times when they have been bullied or have previously witnessed bullying behavior. This allows them to compare the changes mapped by the core self to be compared against past experience (the autobiographical self) to further modify the body state. This is where culture and social interaction comes into play as they modify our actions and memory.

So, the other ape's having seen this occurrence are able to
1) Have a change in body state from witnessing the events.
2) Compare those changes with previous times they have witnessed similar events.
3) Use their mirror neurons to map what they feel the bullied ape is feeling
4) Pull all of this together with their experience to make a decision to be empathetic for this ape's predicament.
5) Act upon this empathy

Here is Damasio's definition of the autobiographical self from p.174 of The Feeling of What Happens:

The autobiographical self is based on autobiographical memory which is constituted by implicit memories of multiple instances of individual experience of the past and of the anticipated future. The invariant aspects of an individual's biography form the bases for autobiographical memory. Autobiographical memory grows continuously with life experience but can be partly remodeled to reflect new experiences. Sets of memories which describe identity and person can be reactivated as a neural pattern and made explicit as images whenever needed. Each reactivated memory operates as a "something-to-be-known" and generates its own pulse of core consciousness. The result is the autobiographical self of which we are conscious.

Now let's move on to Barrett's example. Instead of using the pitcher, however, I would like to consider the correlations to the therapist.

When Barrett touches his patient it causes a change in the patient. This change elicits a change in Barrett as well and is mapped by the core self. This change is then compared with the thousands of other previous experiences in which Barrett has similarly changed with a patient to make a conclusion about this current change.

we might also consider what unifies successful therapists. Maybe it's the inevitable changes in the core self of the therapist who actually pays attention and is thus changed by what they perceive through their hands and in their attentive vision.

This is pretty important as well. If this change is not attended to, it will not become conscious. We are definately going to be considering what unifies successful therapists as well. We'll talk about the hippocampus and amygdala a little and how they tie in with the autobiographical self, and then we'll finally start this consideration.

Hopefully I'll get these going tonight.

[BB]

The hippocampus is a brain structure that is thought to be an association making machine.

Joseph LeDoux is a neuroscientist who has written a book called The Emotional Brain.
John O'Keefe found that cells in the hippocampus become very active when a rat moved into a certain part of a test chamber. He called these "place cells." He showed that the firing of the cells was controlled by the rat's sense of where it was in the room, for if the various cues around the room werre removed, the firing pattrens changed dramatically. They were not responding only to visual cues though, because they maintained their represenation when the space was dark. These spatial representations, they believe, create a context in which to store memory.

From the emotional brain p. 199.

Context makes memories autobiographical, locating them in space and time, and this, they (O'Keefe and Lynn Nadel that is) say, accounts for the role of the hippocampus in memory.

The hippocampus as a spatial machine only has been questioned however.

p. 200

Howard Eichenbaum, for example, questions the role of the hippocamus in spatial processing per se, arguing that what the hippocampus is especially good at and important for is creating representations that involve the multiple cues at once, with space being a particular example of this rather than the primary instance of it.

What seems to be clear is that the hippocampus is designed to make connections to many brain areas creating associations.

This mechanism allows a memory to be created with associations of for example the sight, smell, sound, feel, emotion, temperature, etc. of a single object. All of which are mapped and percieved in different parts of the brain.

So, thinking back to the idea of pain as a threat. Your brain has a mechanism in place that is designed to make lots of associations so that it can better recognize the next time it encounters a threat. It is so good in fact that it is thought that phobias might be a result. Some fears are evidently innate. Humans for example might have a natural fear of snakes, or at least objects that slither on the ground. If a snake is witnessed in a forest on a rainy day. The next time you are in a forest on a rainy day you might feel a bit uneasy and not realize why. These associations can continue to build onto one another until fear becomes associated with illogical objects such as open spaces. Pain is the same way. It can become associated with more and more movements and scenarios.

One last thing before we start getting into thoughts on treatment while we are talking about fear. The amygdala is the structure in the brain that signals the bodily sensations associated with fear, as demonstrated by LeDoux's work.

Eric Kandel, neuroscientist and Nobel Prize winner, did some research on the amygdala response and consciousness. A picture that was known to elicit a fear response was shown both in a non-conscious manner (so fast it could not be percieved) and consciously (long enough it could be reflected upon). Even in groups who had been identified as having a high background state of anxiety, the response was larger in the non-conscious group. This is an important insight into a role of conscious awareness. The conscious group was able to reflect on the picture shown to them and determine that it was not a threat to them thereby reducing their fear response.

I'm excited to move on. Tomorrow (hopefully) it's on to treatment.

[Diane]

I want to link this thread to this other thread, specifically on Damasio, so that they are together. It has lots of meat in it.
Here's another link, to some work done by Sapolsky on stress, and what happens to memory/hippocampus.
Here is the whole Sapolsky article.

[BB]

Thanks for the links Diane.

Now let's get to the fun stuff. The purpose of my starting this thread was to spell out a theory of what common threads lie behind successful physical therapy treatments, whatever the method. So far we have really only discussed neuroscience in general. Now it is time to put this background to use.

We have so far discussed how things from what I'm calling an inside-out approach. That will continue in this section as well. I'll try to make some points from the perspectives discussed above already.

After treatment is considered from this perspective, I am going to move on and attempt to describe from 2 other perpectives, that of explanatory mechanisms and placebo, as well as an outside-in approach. All go hand in hand and the story won't be complete until we are all the way through, but waiting till then to start drawing some conclusions would not be ideal based on the amount of information.

Therefore, lets talk a bit about what successful treatments have in common from an inside-out approach....

[BB]

Remember above when we talked about how we can only sense those events to which we can make an appropriate motor response?

From Patrick Wall's Pain: The Science of Suffering p. 150:

What are appopraite motor responses to the arrival of injury signals? They attempt: first, to remove the stimulus; second, to adopt a posture to limit further injury and optimize recovery; and third, to seek safety, relief, and cure.

So, with pain 3 types of motor plans are made, 1) remove the stimulus 2) protective posturing 3) seek safety, relief, cure.

We also talked about how pain is a need state. In order for pain to be extinguished the mind must be satisfied that the motor plans have been fulfilled.

again on p. 150

If the sequence is frustrated at any stage, the sensation and posture remain.

and:

we need to reexamine whether pain signals the presence of a stimulus or whether it signals the stage reached in a sequence of possible actions.

In the most general terms, those treatments which satisfy the needed action sequence will be successful.

[BB]

The next logical question is, "What happens when the sequence is frustrated before being completed?"

Answer: persistent pain.

This is where all that talk of the different types of self are going to come into play. Let's imagine that the action needed for relief is to stick out the belly as far as possible, for the rest of the week. As soon as a person does this it stimulates the change in core self. This action and is then compared against the autobiographical self, which in western society is going to contribute past memory which says sticking out your belly looks funny, people might laugh, they definately won't think you are beautiful. The result is that the person makes the decision (consciously or non-consciously) to inhibit this action and continue to walk around with their belly sucked in tight.

The action sequence is interupted and the pain continues.

Now this person is going to have pain with movement. The hippocampus (the association maker) is going to associate any movement made in the sympathetic state (that which is correlated with pain), that is similar to the original offending and therefore threatening movement, with other implicit memories that have been associated with the history of this pain (applying the autobiographical self based on experience). This tells the processing centers of the brain that this movement is a threat and pain remains necessary. Since the hippocampus is constantly making new associations, the things associated with this threat continue to grow and the result is more and more movements hurt. The pain spreads.

Looking back again, we discussed how Damasio stated that "When variations that trespass into a dangerous range are about to occur, they can be averted by some preemptive action." A person in persistent pain will learn quickly avoidance by a pre-emptive action. Splinting for example. We will talk more about this in the outside-in discussion, but mechanical input from the periphery (nociception) can be averted by protective splinting. The hippocampus continues to make its associations and build on the autobiographical self, which now has memory of splinting. Since the pain persists, the splinting avoidance behaviour continues and quickly becomes compulsive. By compulsive, I mean that it becomes well enough engrained that consciousness no longer attends to it. It becomes a background action. Of the possible actions that are presented to the organism the dominant compulsive action has been chosen so many times in the past that it becomes the only option considered non-consciously.

I think we can even make a generality from this description. I believe that there are treatments that actually foster compulsive avoidance of painful movements. I feel that they often do not actually bring about resolution but simply avoidance of pain, and therefore can also foster fear of movement, at their worst. If resolution of pain does occur, the threat associations with certain movements remain and are likely to be easily re-provoked.

I'm curious on thoughts about this before I move on.

[nari]

Cory,

This is all great stuff; but for me it needs time to extrapolate the thoughts to real life clinical situations.
Two things have grabbed my attention, amongst many:
Wall states:

If the sequence is frustrated at any stage, the sensation and posture remains

.

and

We need to re-examine whether pain signals the presence of a stimulus or whether it signals the stage reached in a sequence of possible actions.

I like the second possibility in the second quote.
I keep thinking of regimes like those of Maitland and McKenzie, where good results happen to begin with but tend not to persist into full resolution. In other words, some systems settle down well, and others do not; and it is these latter folk who may be in the category of "frustration".
These frustrated systems are the ones I see at present with every patient. In simplest terms, we should attend to the need states more, recognising them for what they are. I don't think it matters what models or methods we use, we can use them better than we do.
This is the great advantage of ideomotion - we stay out of the risk of messing up the sequences.
With traditional physiotherapy, I am extremely cynical of most of its long term effectiveness; so I have to think a lot more about a unified theory....

Nari

[Barrett Dorko]

Cory,

I think Nari's on the right track and this is what I try to teach.

The "splinting" you speak of might very well be the beginning of resolution. After a brief period of time I think that we can assume it is. If at that point we misinterpret it as the protective response then care designed to help will have the opposite effect. Simply put, the isometric activity we can easily palpate is a defense and not a defect. Using evolutionary or ultimate reasoning the former should be allowed to complete its action and the latter should be ablated if possible. In this case the isometric is encouraged to become an isotonic and corrective, pain-relieving movement will emerge - theoretically. If this is not allowed for whatever reason the sequence is frustrated and Wall becomes amazingly prophetic.

See Asking Why - Evolutionary Reasoning and Manual Care for more on this.

In effect Wall says, "Food is to hunger what movement is to pain." Of course, not just any food would be ideal, and not just any movement would be either.

[BB]

I am glad I requested comments. Very helpful.

Barrett,
Your post makes it clear that I need to separate protective avoidance as I described it, with persistant defense, as you did.

In my description I had in mind an active inhibition, an order protect from the the autobiographical self. For example, someone who has pain with dorsiflexion when they step, and therefore "splints" in plantarflexion. Avoidance of a painful movement.

The "splinting" you speak of might very well be the beginning of resolution.

By this, I think you are referring to the second step of "appropriate action" of which Wall speaks: "Adopt a posture to limit further injury and optimize recovery."

Thinking in terms of neural sensitivity (which we will discuss at length in the outside-in discussion), it would make sense that such a posturing would be accomplished through an isometric contraction of the muscle surrounding the nerve that has become sensitive, thereby reducing it's mechanical stimulation of stretch and pressure mediated receptors locally. So, in these terms the posturing is absolutely a part of the resolution process.

Simply put, the isometric activity we can easily palpate is a defense and not a defect.

To everybody reading: please read Barrett's link below.

I don't believe the isometric defense would still be considered compulsive itself (that is the term in the manner used by Moshe Feldenkrais, by the way), but would contribute to all movements in a way that would make them compulsive, as I described above.

And Nari,
A thought I had on a clinical correlation to my previous post would be splints or braces applied to those in pain in the absence of an orthopaedic pathology. For example, wrist splints for wrist pain, slings for shoulder pain, etc.

[BB]

Continueing.....

Nari,
McKensie's system takes controlled avoidance to a whole other level. It does promote movement, but also systematically describes those motions that are to be avoided like the plague. Avoidance on a whole other level. I believe that his system does advocate eventually re-introducing previously painful movements, however.

Here is an interesting discussion about McKensie and avoidance that includes responses from the McKensie institute.

[Gil Haight]

Cory,
Interesting thread. I think we must see Wall's sequence as being bidirectional. A fear of slipping back into withdrawal can reasonably perpetuate a protective stance. Furthermore the PT community is actually quite good at helping individuals from withdrawal to protection. Unfortunately, we are quite poor at facilitating the next sequence. This is probably due to the fact that as we proceed through the sequence, the process becomes increasingly idividualized. In other words choreography is germane early on as the patterns are likely more steorotypical. Gil

[BB]

Gil,
Please post more often!

I think we must see Wall's sequence as being bidirectional. A fear of slipping back into withdrawal can reasonably perpetuate a protective stance.

A great way of looking at it. I think what I was trying to say fits in with fear of slipping back into withdrawal. Defensive posturing in the context of avoiding pain.

Context is very important here. I'll present it more fully in the explanatory style/placebo discussion, but it is worth bringing up here. This quote is also from Gil in the "Brain in conflict" thread.

The number ( as in too many) of options is not the problem. How and upon what basis we choose is however a different story.

The core self provides the autobiographical self with many potential action options, all of which are somatically marked (see somatic marker hypotheses above). This is then mapped against the autobiographical self. The autobiographical self is very context driven, as seen in the discussion of the hippocampus. The option chosen will depend upon the context through which the autobiographical self filters and upon the somatic marker most successful in that context in previous experience.

A choice made in the context of "avoid pain" will be different from one made in the context of "resolve pain" and will be different from one made in the context of "don't get laughed at."

From this we can add to the previous generality:

Those treatments which satisfy the needed action sequence in the context of resolving pain will be successful.

[BB]

The last addition to the general statement needs some defining. What is "the context of resolving pain?"

I want to bring back the quote from Damasio in post 21:

The dispositional arrangement ensures that the environmental variations do not cause a correspondingly large and excessive variation of activity within. When variations that trespass into a dangerous range are about to occur, they can be averted by some preemptive action; and when dangerous variations have already occurred, they can still be corrected by some appropriate action.

Pain would be the result of a variation that trespasses into a dangerous range. A threat. The context of resolving pain is the context for acting to correct a threatening variation by some appropriate action, according to the above statement. This is consistent with what Wall has said with the three stages of resolving pain.

[BB]

Now we need to determine what would be a dangerous variation.

Martin Seligman is a psychologist and author of the book Learned Optimism. In Ledoux's book The Emotional Brain the following is described on page 236:

He (Seligman) argued that perhaps we are prepared by evolution to learn about certain thigs more easily than othes, and that these biologically drived instances of learning are especially potent and long lasting.

Several studies have been performed on preparedness theory which have in fact shown that bodily fear responses are stronger to certain biologically plausable stimuli, however it has also been shown that learning is particularly important in this process.

p. 237

It has long been thought that monkeys have an inherited fear of snakes, so that the first time a monkey saw a snake it would act afraid and protect iteslf. However, Mineka showed that laboratory-reared monkeys are in fact not afraid on the first exposure to a snake. If the young monkey is shown the snake when separated from its mother, it doesn't act afraid. It appears that the infant learns to be afraid of the snakes by seeing its mother acting afraid. The young monkeys did not learn about nonfrightening things in this way, suggesting that there is something special about biologically relevant stimuli that makes them susceptible to rapid and potent observational learning.

biologically relevant stimuli are related to survival.

This applies directly to the uses of the self. The autobiographical self is then able to build upon experience to form associations that will act as reminders of dangerous situations.

From p. 239

during a traumatic learning situation, conscious memories are laid down by a system involving the hippocampus and related cortical areas, and uncounscious memories established by fear conditionaing mechanisms operating through an amygdala-based system. These two systems operate in parallel and store different kinds of informatinon relevant to the experience. And when stimuli that were present during the inital trauma are later encountered, each system can potentially retrieve its memories. In the case of the amygdala system, retrieval results in expression of bodily responses that prepare for danger, and in the case of the hippocampal system, conscious remembrances occur.

This is a lot of quotes to make the point that a dangerous variation is going to be determined by
1) Threat related to evolutionary survival needs
2) Learned responses to those threats
3) Other factors associated with those threatening situations

[BB]

When our patients come to us in pain with movement, they display the findings just described.
A threat to survival: real or potential tissue damage
Learned responses to that threat: pain behaviour
Associations made with that threat: experiences in the past which have caused continued or increased pain, or that they thought would cause continued or increased pain.

This last one is big. People who have been abused are going to be more threatened by touch. People who have been hurt in physical therapy are going to be threatened by physical therapists and any associations that were made to that physical therapy experience. Movements that have been causing pain are going to be a threat. Etc.


Those interventions which allow a movement to be perfomed in a non-threatening context will be successful.

[nari]

This one:

Those interventions which allow a movement to be performed in a non-threatening context will be successful

is right up with my priorities.

Working in a pain clinic brings to attention the nociceptive nature of many patients' past experiences with a PT, and really drives this unhappy situation home. When it is clear a patient is anxious with me and trying madly not to show it, I often say: I'm not going to do anything at present - no hands-on - what sort of PT have you had in the past.?...
It usually pours out: how painful and scary going to a PT is....

I think that is a major problem with our profession but I also think we all know it is.

Nari

[EricM]

The scientific community must be paying attention to your thread Cory. I found this abstract today. Does unconventional medicine work through conventional modes of action?

eric

[Gil Haight]

I am really excited about how we are continuing to develop our concept of appropriate movement. We have at length, over many months promoted and supported the notion that appropriate movement is best identified somatically. Cory’s, posts and proposed model continue to support that notion, but also introduce a new fly in the ointment. What happens when the biologically appropriate response does not feel appropriate? Surely this would have a negative influence on the process. This is a real tough situation that I see regularly. What do we do?
Gil

[Marc]

Originally Posted by EricM

The scientific community must be paying attention to your thread Cory. I found this abstract today. Does unconventional medicine work through conventional modes of action?

eric

Here is the full text.

[Barrett Dorko]

Hi Gil,

So sorry about the Packers.

Now that I’ve got that out of the way, after I read your post I opened Richard Brodie’s classic Virus Of The Mind – The New Science of he Meme and found this passage: “ According to the new paradigm of memetics, the mind works as a combination of instinct and memetic programming…A cultural institution that programs people with self-serving memes is a virus of the mind. That doesn’t necessarily mean it’s a bad thing, but if I were you I’d want to know what mind viruses were competing for use of my life so I could at least pick and choose among them, if not invent my own…It’s possible to consciously choose your own memetic programming to better serve whatever purpose you choose, upon reflection, to have for your life.”

The words “upon reflection” struck me, and I think they directly connect to the dilemma we all face along with our patients. It seems to me that it’s our job to help people reflect upon their problem and the naturally occurring biologic resolution rather than the culturally imposed “rightness” of some other behavior.

I tell my patients that the culture is out to control them and sell them stuff and, upon reflection, they typically agree. This agreement grows the more they think about it. Once that meme is in place getting them to behave "counter-culturally" isn't that hard.

[BB]

What happens when the biologically appropriate response does not feel appropriate? Surely this would have a negative influence on the process. This is a real tough situation that I see regularly. What do we do?

Barrett's answer was in the context I believe you were aiming for, Gil. I would like to approach it in another way though, working through some other issues that will bring us into that context more fully.

If a biologically appropriate response, or movement, is carried out in a context that remains threatening (perhaps by a physical therapist, like the one that hurt my mom, and is standing next to that scary looking machine) then this would have a negative influence on the process and I don't think it would be likely to meet the need state.

We must intervene in ways that decrease the threat value. We must provide stimuli that are not associated with the threat. Nari's example is a great example of one way in which this can be accomplished in the scary PT problem. Don't fulfill their worries. Gain their trust that you won't harm them.

Thinking in terms of the discussion thus far, we must create new somatic markers with non-threatening associations, and integrate them with the previously threatening stimuli. I imagine this happening in a successful way in PT interventions through the 1) environment we create, 2) novel stimuli, and 3) graded exposure.

[BB]

The environment we create:

Think about all of the associations that could possibly be working against us for a threat. The layout of our clinic, the colors of the room, the temperature of the room, the tone of our voice, whether we are male or female, our reputation, their social situation.

Robert Saposky writes in Why Zebras Don't Get Ulcers on p. 403:

More predictive information about impending stressors can be very stress-reducing.

Too much of a sense of control can be crippling, whether the sense is accurate or not.

He says this in the context of saying a sense of control is a good thing, but not when it is to the degree that the person feels at fault. Sapolsky's book is all about the stress response and its chronic and acute effects. These are from the end of the book when he is giving advice based on the evidence of how to reduce the stress response.

The take away message for me here is that the stress response (which will always be present with a threat and is synonymous with a sympathetic state) can be reduced through education. The ways in which we present ourselves, our clinics, our approach, what our intervention is about, what is pain, even our cleanliness is allowing the patient to re-evaluate their environment, how much control they have in what will be done to them, and allowing them to predict what the outcome will be.

The bad news here is that some things we just can't change about their environment which might explain why often we fail. We can't change the fact that they have 15 cats, 8 kids, 3 jobs, and are going through a divorce. Although, we can point them in the direction of a professional who can help them cope. Hopefully, if you have a patient who is threatened by males, there is a female co-worker or colleague that can be pulled in.

[BB]

Novel Stimuli:

By novel stimuli, I mean a stimulus that is not currently associated with the threat. This could include a movement, an external input through touch, a new functional context, etc.

Thinking in terms of the somatic marker again, a novel stimulus would allow for an input to be processed and percieved, determined to be threatening or not, and then associated with whatever else is avaible to create context.

Once a novel input is percieved as non-threatening, the association/context making hippocampus can be used to our advantage. Previously threatening contexts can be processed with the novel input that has been deamed non-threatening. This combined input is then processed and percieved and, if sufficiently associated with the non-threatening aspects, can become non-threatening itself. A previously threatening input now is non-threatening in whatever context was used.

Think about some of the potential novel stimuli that are provided by the myriad of manual therapy techniques that provide proprioceptive, stretch, pressure, vibration, temperature input. We'll actually talk about this again in the outside-in neuromodulation discussion when we talk about peripheral neural sensitivity.

It would be interesting, in a discussion of better practice (instead of best practice, which implies perfection and is therefore unachievable), to discuss the relative benefits of many types of novel stimuli in comparison. I'll leave that to another discussion on another day.