A Unified Theory for Physical Therapy and the Treatment of Pain

[BB]

Eric,
Thanks for posting those here. I read through much of the 1st link and will read through the rest soon.

I'd like to go forward with some concepts that have only recently been brought to my attention, but I think are very applicable here.

I'm going to start off with by introducing some new (to this thread) terms, and work my way back towards nociception and ideomotion.

In the Pain is an emotion thread, this paper was posted by Luke. In the paper, the term exteroceptive is used to describe sensation that is attributed to something that is non-self, something we are touching or the environment. Interoceptive is used to describe sensations that are attributed to arising from within the body.

From p. 304 of "A New View of Pain as a Homeostatic Emotion" (the article mentioned above):

The interoceptive system is distinct from the exteroceptive system associated with touch and movement, although there is overlap (in area 3a of the sensorimotor cortex) with respect to pain.

This got me to thinking about how a person in pain with an origin of mechanical deformation would respond to these 2 scenarios.

Exteroceptively, which would correlate with something being done to you from the outside (coersion) would correlate with a lot of techniques, if not most in PT. If a person is in pain, and something is done to them, it would make sense that it would be less threatening if it decreased nociception. My understanding is, that once a person is in pain and the peripheral sensitization has occurred, the brain tends to listen to its nociceptors very carefully at that point. So, if you are hoping to reduce threat level by touching your patient, your chances are going to be highest if it reduces nociception. It will be higher still if done in a way to reduce sympathetic tone. A novel stimulus that is also non-threatening.

There are many, many ways in which this can be accomplished, and thousands of treatment methods claiming to decrease nociception through use of one tissue or structure or another. Let me attempt to apply a description to encapsulate what all of those different techniques are doing. We often use the terms meso and ectoderm on this site. Mesodermally derived tissues include bones, muscles, tendons, ligaments, blood, pretty much all connective tissue (see Diane's embryology threads). Ectoderm involves the nervous system and the skin. All of these live together in the periphery. Now, in any given body part the various tissues of the meso and ectoderm co-exist and must move relative to eachother but the signalling to the brain about these various movements is done by the nervous system (and also hormonally in the blood for slow communication). As an example, lets consider an elbow extending. As the forearm drops, the various bicep fibers and bundles are sliding and contracting relative to eachother, the brachial plexus is moving toward the hand ever so slightly, both bicep and nerve are moving in relation to the humerus, and all are moving relative to the skin. Most importantly the complex branching of the nervous system is present at every spot. I'm just trying to make an example here of everything moving in relation to eachother, and remember that the brain is good at detecting changes.

Now, use this thought process to think about what is happening during a neurodynamic test like the straight leg raise. To make it simple think of tubes moving within tubes. The inner tube (bone) moves relative to the middle tube (muscle) which moves relative to the outer tube (skin) and the nervous system is present at every level. In concert with neurodynamic sequencing, we can effect the tension and therefore mechanical stress on the nervous system at any level. Neurodynamically speaking, rolling the skin inward on the thigh produces the same effect as externally rotating the thigh.

Appying this (finally) to exteroceptive physical therapy: we are always touching the skin when we touch a patient, and the various ways in which we are able to reduce nociception from mechanical deformation manually must all be working on this neurodynamic, tube within tube, mesoderm relative to ectoderm, concept. And for it to be successful, it must be done in a way that reduces threat, and/or fullfills expectation.

Whew! I havn't even gotten to interoception yet!

[BB]

OK. If I do a good job, there is a chance I can wrap up my thoughts for this section, and therefore finish the thread on this post.

Interoception.

To discuss this we need to introduce more terms. The first come from the Motor ontology paper that Jon posted in the mesoderm vs. ectoderm thread. Not an easy read, but very interesting.

I would place some qoutes from the paper here, but since I took me a dozen readings to follow their writing style I'll try to summarize.

The authors speak about "goal-related" neurons which, similarly to place cells, represent reward-producing actions as seen from no particular perspective. The movement parameters are not coded, but rather the goal outcome, and very generally. For example, when a monkey grasps an object these neurons fire regardless of whether they use their hand or thier mouth.

They go on to elaborate into what are called "goal-states" (which a lot like need states) which represent a successfully terminated action pattern.

I am going to use one quote about a goal-state to dine. P. 369:

The distal goal-state therfore seems to be attained through a series of multipurpose (I can phone my partner, I can drive to go see a move, I can eat at home) action schemata, which nevertheless have to be chained within a highl specific temporal sequence. Such a possibility to diversify the procedural sub-components while simultaneouwsly filing them within the same distal goal-state representation could be interpreted as the result of an incredibly higher intergrative capacity of the human brain.

On a similar note is the concept of the "end-state comfort effect" which Luke introduced in the exploration as a context for pain thread. It has been shown that a person will assume an ackward position to start a task in order to be able to end in a comfortable position. Movement wise, it is apparent that our brain is thinking towards the state it want us to eventually be in.

Now, I'm not sure if this is really appropriate to the term interoception, but it created a bridge for me. When an action is allowed to be generated internally, from the self, toward a goal state that is consistent with pain resolution, it would make sense that an action would arise which is meant to bring us to a certain end state, and would have as many options as we can create to get there. When the body is allowed to advance in this way, focusing on the end state, the need to advance in a way that always reduces nociception may not be necessary as long as the goal state (resolved threat) is being approached. This, to me, makes a lot of sense in terms of ideomotion towards pain resolution, and would be consistent with the surprising, creative motion that Barrett describes that he sees in his patients.

[BB]

Well, I'll wait for any comments that might arise before I officially call the section finished. Of course, my being done with my "presentation" or whatever you would call this, wouldn't mean the discussion has to end.

[nari]

It makes sense to me. It goes a long way to explain why nociception isn't needed for a pain experience; the goal state and end state comfort effect seem crucial to resolution. It also explains better my belief, right or wrong, that PT-determined actions (as opposed to patient-determined) are rather hit and miss in effect, as we are not their brain.

Cory, are you an insomniac or does it just seem that way?

Nari

[Diane]

Gosh Cory, that #121 post sums up everything I think, as an ectodermalist and outside in treater... How do you do that! What a synthesizer you are. Thanks again for this thread.

[Barrett Dorko]

Cory,

I've already taken a couple of lines from your last two posts and placed them in my Power Point presentation. When you come to my class in Sherman Oaks CA in December I'll be sure to give you credit for them. I can't make any promises otherwise (ha,ha).

Remember, dinner's on me.

I should also congratulate you on being asked by Nari if you ever sleep. I've been getting this same question for years, and I tell you, I sleep a lot more since Soma Simple has grown.

Thanks. As far as I'm concerned, this is The Mother of All Threads

[Diane]

I found this this morning, and while I don't think the title does anything toward burying Descartes outdated ideas about the nervous system, the content is interesting:

A neuroscientist from Indiana University and a roboticist from the University of Tokyo have created a new way to objectively quantify an idea that philosophers, educators and psychologists have discussed for decades -- that the many ways in which our bodies interact with our environment produces better information that helps the brain.

Olaf Sporns, associate professor in the Department of Psychological and Brain Sciences at IU Bloomington, and UT's Max Lungarella used real and simulated robots in Sporns' Computational Cognitive Neuroscience Laboratory to create this mathematical framework, which they consider the first step toward the development of an explicit quantitative framework that unifies neural and behavioral processes.

Their findings, published in the journal Public Library of Science Computational Biology on Oct. 27, could provide insight into how the brain operates and shed light on how it may have evolved, Sporns said.

"Really, this study has opened my eyes," Sporns said. "I'm a neuroscientist, so much of my work is primarily concerned with how the brain works. But brain and body are never really separate, and clearly they have evolved together. The brain and the body should not be looked at as separate things when one talks about information processing, learning and cognition -- they form a unit. This holds a lot of meaning to me biologically."

An example of this union is how body morphology (the structure of sensors such as the eyes, for example) played a role in the kind of sensory information produced by Sporns' robots, a role that could be precisely measured. The production of good information and how an organism acts on it ultimately could mean the difference between survival and extinction. Sporns can see the mathematical framework, as it develops, being used for designing more capable robots and as a tool in basic research on how organisms have evolved.

A classical view of cognition is one of inputs and outputs -- the brain receives information to process and then produces an output -- all independent of the rest of the body as if the brain were a machine or computer. Philosophers such as educational reformer John Dewey have argued long ago that "doing" is a key part of learning, espousing the influence of a person's engagement in his or her environment on cognition. Any living thing with a nervous system is continually interacting with its environment, Sporns said. He and others in the growing field of embodied cognition think this interaction leads to better and more information. Quantifying this neural-behavioral relationship, however, has been difficult, if not impossible, until recent mathematical advances let Sporns and others begin to create critical measurement tools.

Sporns and Lungarella measured the information flow from the environment to a series of robots, and then from the robots back to the environment by recording what the robots saw and what they did. They altered the robots' visual sensors during the study by changing the density and spatial arrangement of their photoreceptors. At times, they also disrupted the coupling between the robots and their environment. They also looked at it in a simple learning context by including a "rewarding object" component to the study design. Sporns and Lungarella consistently found that well-coordinated and learned actions of the robots created additional structure in their own sensory inputs. This additional structure may be used by the brain to more efficiently process information.

"When it comes to information processing, brain and body work together. If this insight is correct, there is a strong message here for how we might understand the human mind, and for how we might go about designing artificial intelligence," Sporns said.

The research was funded by the Japanese Society for the Promotion of Science and by the James S. McDonnell Foundation.

The study will be available at http://dx.doi.org/10.1371/journal.pcbi.0020144 on Oct. 26 at 5 p.m. PST.

"Mapping information flow in sensorimotor networks," PLoS Computational Biology, vol. 2, no. 10.

Really when they say "body" they mean neural crest sensory info gathering capacity - it's still all ectoderm doing the sensing.

Butler says the nervous system "learns" I think he means at any level even at a cord level. After all, even tunicates can "learn" to spit out "that which is not food." Their nerves aren't very "advanced." But the human nervous system is built up of such components and simply rewired in ways that act as step-up transformers and amplifiers. It ties in a bit with Cory's latest synthesis on intero- and exteroception in his Unifying Theory thread..

It made me wonder about "kinesthetic" images (images in the Damasio sense) that might become established. These would be entirely pre-non-verbal perceptions that might present themselves to the higher order processing levels as raw material for the "neuromatrix" Melzack introduced. Only after they've been processed would they become "neuromodules", and the outgoing action the "neurosignature" the brain uses as shortcut action, at least to the soma motor control areas, be they "voluntary" to striated mesoderm or "involuntary" to striated, smooth, or glandular mesoderm, or even other levels of ectoderm. We come prewired for some of them, the "survival" modules like breathing and swallowing, but the rest must be learned on the fly because of our neotenous state.
Just some thoughts.. still quite jumbly.

The other thing is, I'm re-reading Butler's Mobilization of the Nervous System to prepare for my next little workshop adventure, and refreshing my memory of all the bits of padding around nerve trunks, all stuffed with nociceptors, all permiting sliding and sideways movement of neural stuctures while still anchoring them, at intervals providing openings for capillaries to come and go. That nerve trunk anatomy is truly a world within a world within a world. Just thinking of all the input the brain must downregulate from these alone is making me slightly dizzy.

[BB]

Nari,
I was a bit of an insomniac a ways back. Not anymore though.

Barrett,
I can't wait.

Thanks to everyone for reading along and discussing.

[nari]

Cory,

I reckon you will find Barrett's class enlightening, intriguing and answering a lot of why-type questions. But, be prepared for the temptation to ditch a lot of what you have learned over the years since first year undergrad!

Nari

[Diane]

The "I" Illusion

I think a link to this Deric Bownds essay definitely belongs on this thread. In it, he explains how our conscious mind is always a bit behind our nonconscious action. He has a flow chart here too. Enjoy.

[BB]

Found this link today, written in 1988 and published in PT Forum.

[nari]

1988!?

Nari

[Barrett Dorko]

Frank Wildman isn't a PT but rather a bodyworker specializing in Feldenkrais. His educational background is elusive.

I met him on a couple of occasions in the 80s and he always wanted me involved in his teaching but never figured out how to pay me for that.

[Diane]

I think he offered good advice. I think 18 years went by without much of a ripple because of mesodermal bedazzlement.

[Diane]

This thread that started out being about do-it-yourself ideomotion and turned to a new topic, what is and what isn't essential minutiae to learn/know, has made me think.

Usually when something makes me think, the startup part of the process activates my sympathetics - then, as the process of thinking continues I start to get more parasympathetic about continuing the process. (If that makes any sense to anyone.) Re: the intrinsic value/non-value of learning minutiae about ectodermal tendrils (nerves), Barrett wonders,

I'm wondering if we can prioritize its usefullness. As you say, the names don't mean much, but given that the nervous tissue all terminates in the skin, and in every part of it, does it make a difference in the clinic to know where the major trunks run close to the skin?

Isn't the nature of the cellular structure of the skin (membranous tautness specifically) more important when it comes to touch?

I don't think the question is answerable from the perspective of what we do or think might be important to know for application of "technique", in this case monkeying around with direct physical contact (and I used the word "monkeying" deliberately).

In physiotherapy we do not seem to have any sort of scaffolding yet for our information and how we use it. It's as if we have not yet decided what we're going to be when we grow up, as human primate social groomers. Cory, whose thread this is, seems to have a knack for developing systems, or for applying logic, or for building containment around concepts and then hooking them together. (I nodded along when I read his post about interoceptive versus exteroceptive differences/ forms of treatment.)

I'm seeing this from a few different sides now. In no particular order, randomly generated thoughts I'm having on the topic are as follows:

1. We are and always have been human primate social groomers. But who is the troop? There are always two troops at the same time, the one we treat and the one we are. We seem to have gotten perpetually stuck in how we will define who or what our (PT) troop is, and what it should stand for and against, what it should know or what it shouldn't have to worry about. (I say, don't take any chances on trusting any HPSG profession, even your own, to know for a fact what is or isn't necessary to know. Learn everything your brain can take on and be ready to pitch without hesitation anything that proves to be useless in the long run.)

2. Mostly we know who our troop isn't, and easily move away from other HPSG troops that don't share the same values our particular one does, but we can't seem to get over the hump into defining what we DO stand for. I think the issue under discussion falls into this longstanding conundrum.

3. The world needs our services, that much we know. Doors at every level fell open to us, and continue to fall open to us, money falls into our laps (not a ton, but ample amounts), universities strive to create programs and compete to have us come to be educated by them, whereas other HPSGs (mostly the self-defined ones) are not permitted. So, have we traded something important, like self-understanding/self-definition, for the privilege of being admitted to halls of learning and societal approval? (E.g.: At least we avoided becoming a spinal manipulation cult for a very long time, and waited until we were vast enough and established enough to take SMT on board, for those who wanted to, without it coming to define or dominate the entire profession. Although sometimes I think the ones who take it on would like to have their particular HPSG worldview come to dominate.. ...)

4. One way HPSGs are defined or define themselves is by who they will or can or want to treat and how. We can't do that because we must have agreed, somewhere along the line, to take on every kind of HPSG problem that comes our way. This left us free to develop ways of interacting that could evolve. There was never any right or wrong way defined by some sort of cult identity or word from on high. We've always been experimental, and socially permitted (within proper personal boundaries) to be so. This original humility gave us access and freedom to roam in very wide pastures indeed. But roaming must result in trails; trails must lead to patterns that form networks of cognitive conclusions, not just to good grazing and ponds of clean water.

5. Neuroscience was always the frontier. I think PT (on the whole) was always frontier-minded. I still think this is the best place to be, as a PT, as a profession, as an individual. Our core has always been neuro. When I look at the profession, the orthopaedic (mesodermal) types usually make the most noise, but the neuro types, who have always been quietly toiling away, represent (IMO) the best the profession can offer to the rest of humans.

6. Pain science is upon us all, and can be a real connector. It can:

• connect what our patients "feel" with the constructs we use to treat them;
• bring back together the ortho people with the neuro people again (someday);
• connect practitioners who are non-orthopaedic with patients who were mis-labeled as orthopaedic outpatients or else crazy for having pain with no discernible (image-able) tissue lesion;
• provide endless ways to vary the therapeutic container, to allow it to become whatever it needs to be in the moment to accommodate any given patient - this is pure freedom for a HPSG;
• provide endless amounts of mental fodder/opportunities to compost/ chance to grow new varieties of treatment ideas based solidly in science.

7. The thing I like most about nerves, about learning about them, about teaching about them, is the way that this information can help people/patients learn to help themselves, by improving the intraBONDING mechanisms amongst the different parts of the human brain. What do I mean?

Here's the thing.
a) We all know there is no split, that the mind is not separate from the brain or the body, that there is no such thing as an objectively detached "mind" part.
b) Somehow our task as PT HPSGs is to help the patients we see to plug into their own resources to get themselves better. I think we can all agree that we don't want to encourage dependency (a PT value), that we want to see people learn to look after themselves, become independent of any need to see HPSGs at all.
c) By teaching people about pain, pointing out that these body bits (nerves) are connected to their own brain, and mind, how the brain makes pain, how it ends up being about them, but also about these bits out in the periphery, how it's all connected, people really do seem to take on a different level of relationship to their pain, not as a nuisance any more, but ownership of dealing with their pain as if it were a desirable project, like raising a baby - babies can be a dominating force in one's life but a reasonable parental attitude (fueled of course by oxytocin or vasopressin) will contain good will and willingness to sacrifice and optimism. They can learn to interpret pain's nuances differently by paying the right kind of attention to it at the right times. Maybe they even produce a bit of oxytocin or vasopressin in the process! Wouldn't that be fun to study some day? :angel:

In any case, I think this is a useful bit of factual info to give people to CBT them away from their hopeless/helpless attitude and into getting more active and self-reliant, at an emotional level, without having to get all psychologically educated or adept, or without having to know anything about their personal lives or without prying into their personal "stuff". I think it taps into a perfectly real primate proclivity that we have, for free, a nurturing capacity that is lying around in there anyway. Getting people to apply that to themselves is, I think a good way of being a good PT HPSG, going one better than mere tissue manipulation for its own sake (the ritualness of it, or attempt to turn it into cash-cow-dom).

Back to the take-off point here.. where this info fits in, into our PT frame.. I think we won't really know for sure until the frame is finally built. And I hope I never live to see that day. Because our freedom to practice our craft, profession, whatever it is that we think we do, i.e., give individual human primates back to themselves, restored and whole or with the means to become so, within the bounds of science, however we might choose, seems like an ongoing miracle to me. I'd hate to see this sweet deal get screwed up by some frame that doesn't really fit the bigger picture (and danged if the picture doesn't just keep getting bigger and bigger as more is learned!)

I see this has turned into a bit of a ramble. Sorry about that. I expect the ramble will clarify itself better some day.