A Unified Theory for Physical Therapy and the Treatment of Pain

[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. :thumbs_up
We should stick this thread later. :lightbulb

[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.