Tuesday, September 17, 2013

Skin as a (therapeutic) social organ, and the nerves of my knee.

I've been WAY too busy to be able to blog on the paper, but before I return to it, decided I want to pour down a few reflections in a lull here, in a hotel room in Regina, awake from a heavy sleep after returning from Madrid where I taught this weekend. So I got in at about midnight, after leaving the nice Hotel Confortel at 7:30am, fueled by a couple or three cafe con leches, and comida.. from there to the aeropuerto, sitting for awhile to await boarding, flying to Charles de Gaulle in Paris, admiring the airport!, finding my new gate (always a couple kilometers between gates and a security check/passport check with the snaking lines, having to drag luggage.. ), boarding the cross Atlantic flight (I gotta say, the food was really good!), arriving in Toronto with customs, security check, snaking lines, take a bus, find the checkin counter, sit and wait for the next plane to Regina..

Anyway, long story short, I was upright for another Very Long Period of Time. Counting the 8 time zones with an hour lost every time, plus the three airport experiences, I'd guess it was more than 24 hours. Going to Spain was even longer. I'd already been traveling 14 hours by the time I got on a plane that would fly me to Europe out of Toronto.

So OK: Why am I telling you this? More moaning from the woman who hates traveling? Well, partly, but this time is not just a long sad moan: this time there is a point.

The point is, I had knee pain for a couple months previously, couldn't walk well, couldn't access smooth biomechanics, and now I can. Yay!

Even after all that sitting, snoozing, not moving, fast walking, pulling luggage, going up and down short steps to and from aircraft, no knee pain anymore. I'm delighted. So, that is really what I want to talk about.

In the beginning
On a previous flight in July, to teach in Minneapolis, which is a short flight, not even two hours, I sat with my left leg crossed, foot on knee, balanced an iPad on it, played games non-stop to kill time. I should have known better, but my urge to kill boredom and stress overwhelmed my good sense about taking care of nerves, and any nociceptive input that may have been coming from my knee. As I recall, that entire weekend, I felt some stiffness in my knee, but not pain. It didn't really bother me. A few days after arriving back home, though, huge pain developed along the inside of the knee, across the front. along the medial calf, and at the back, it felt like a thick short bungee cord took up space and prevented full flexion. It was worst standing up after sitting for any period of time.

It hurt a lot. There was swelling. I did exercises for sliding nerves, I used tape, I managed the pain, and managed to do everything (badly..) except be able to use stairs. I had to use those one by one, unless I wanted to feel pain... Sometimes I capitulated to it and went one step at a time. Other times I thought, no, hurt doesn't equal harm. I'm going to act as if my knee were normal, even if it hurts.

Facing the ordeal
I kind of dreaded having to go back on a plane, especially a long trip like to Spain, but some part of my
Class in Madrid Sept 14-15, organized by Zerapi
brain decided it would ask for help once I got there, and at an appropriate moment. (see class photo at the right - a wonderful class! people with hands like butter.)

When I arrived, I was in about the same condition as before I left. The class was a ten-minute walk from the hotel, but carrying computer, etc., and my knee, and stairs, and cobblestones, it took me about 15 minutes. The second day was the workshop on  lower body/leg. I had the guy who translated, whose name was Julio (see picture), perform the treatment for entrapment points for saphenous nerve, patellar plexus, and fibular nerve. That took care (immediately!) of all the biomechanical problems. After I could even use the knee for jumping. I could handle a few steps smoothly, even carrying a load. I could walk evenly, no limp. I could feel my knee lock and unlock smoothly and appropriately with each step back to the hotel. Yesterday morning I woke up with no awareness of knee pain for the first time in at least 6 weeks. I did that huge plane trip. Today I woke up with even less discomfort. It's getting even better! With normal use, and normal biomechanics, the nerves will receive normal mechanical input. The neurons will be fed by movement. The residual soreness will vanish.

The treatment
Saphenous nerve exit point:
For the saphenous nerve I laid prone and had Julio put both his arms on the back of my leg, elbows apart, so he could elongate the skin along the back of the leg away from the knee crease. Then he located the "punta dolorosa" at the medial knee. Using both hands, he gently pulled the skin around the knee into more medial rotation around the leg. The point softened and was no longer tender. I felt extreme heat as if it were coming from his hands; actually it was coming from my leg itself as the sympathetic nervous system reacted. 80% of vasodilation occurs thanks to the sympathetic nervous system, and about 20% thanks to afferent C-fibres in the vascular plexus of cutis/subcutis. He could barely hold on to the skin, as a lot of sweating arose at the same time. But he did.
Patellar plexus:
Over the patella a bunch of nerves, cutaneous ones from the femoral nerve, all anatomose and form something called a rete. It contains lots of vasculature as well. The treatment for that is in supine: the therapist gathers as much skin circumferentially as possible, and lifts it up toward the ceiling, holding it there for a long period of time. This feels really good to the brain.
Fibular nerve:
The therapist sits beside the table, with the leg off the side of the bed, foot resting on their lap. The hip is in about 45 degrees abduction, full extension: The knee is in about 45 degrees of flexion. The therapist locates the "problem child" behind the knee. It might be a nerve, a vessel, a muscle.. I don't know for sure. There is a hard spot, anyway, large, and it feels tender.  The therapist places the other hand on the skin atop foot and the lateral side of the fibula at the lower end of the leg. They pull that skin obliquely away and into more internal rotation. The lower leg itself wants to move to follow the skin to which it is attached, into more adduction, but the top of the tibia can't move because the edge of the table is a fulcrum preventing that. But the bottom end of the leg moves slightly into adduction and internal rotation. This lengthens the fibular nerve slightly where it winds around the head of fibula, and maybe pulls it out of some deep grommet hole behind the knee at a branch point. Anyway, something in behind the knee lets go of the spinal cord reflexive guarding it was doing, or rather, was being told to do by the spinal cord. Intrinsic rotary movement at the knee restores itself. The position is completely comfortable and with the added pressure from the therapist results in a wonderful yes-ciceptive response experienced in the knee part of the body schema in the brain.
Today, my body schema is absolutely delighted with the outcome we obtained.


There wasn't enough time to present the lecture I have about operator vs. interactor models, unfortunately - translating everything means a class takes twice as long. I really really want to get across the point though, that implements are not necessary for treating anything in the periphery that has to do with pain. Only careful hands. The nervous system is absolutely self-corrective, as long as it's intact and has the ability to make any and all proteins, receptors etc., that it needs for its own maintenance. I saw this paper (full text) posted this morning and want to share it - Flexible Cerebral Connectivity Patterns Subserve Contextual Modulations of Pain.  Can you imagine the detriment to this sort of brain function if it has to put up with gouging tools, needles and high velocity manipulation? From a certain subset of practitioner who has decided they Must Be In Control of the Situation? And don't want to allow a nervous system have its own natural response? (To me, this is like a subset of rape culture.)

Another very short comment appeared in a wonderful blogpost by David Butler today, who apparently has been in Paris, visiting Pasteur's home: 
"I came out thinking “this man has saved far more lives than the Mona Lisa ever will, and why are scientists hardly revered these days – adulation goes to politicians, sportsmen and Kardashian types”. I am sure most people think the term “pasteurized/pasteurised” on the milk carton means the milk came from a pasture. And too many of my colleagues think they have to be doctors to get anywhere."

Oh yes. 
Such nonsensical and completely beside-the-point puffery. Egos walking on hind legs. I'd much rather be a SomaSimpleton.  

Saturday, September 07, 2013

The Skin as a Social Organ. Part 2f: Human allogrooming

The paper, The skin as a social organ

Previous introductory blogpost to this series.    Preamble: Random thoughts on spas

Part 1: Dual nature of touch: as PTs, do we "get" this? Part 1a: Touch can be pleasant, rilling Part 1b: Vallbo on C-tactiles 

Part 2a: Different kinds of touch Part 2b: Proxemics Part 2c: The sad dearth of manual therapy aspects in reviews of interpersonal touch Part 2d: Learning to sit still, learning to behave, learning to not be connected to oneself Part 2e: Touch early, touch often

Next (at last!!) 
"A major context for social touch among primates is grooming. For most primates, grooming one another (allogrooming) is not just about hygiene. Although it does serve this function, the amount of time many primate species devote to this activity is disproportionate to what is required for keeping fur and skin clean. In fact, some species (such as gelada baboons) may spend up to 17% of their time grooming despite requiring perhaps only 1% for strictly hygienic purposes (Lehmann et al. 2007; Dunbar 2008). Instead, allogrooming has taken on a new significance as a form of bonding and reinforcing alliances (Dunbar 1996, 2008).
In contrast to the work on grooming in nonhuman primates, research on human allogrooming is rare. It is possible that grooming is a comparatively more restricted behavior in humans (for example, in intimate or parent–offspring interactions, or in ritual or professional transactions), or that its social role has been largely replaced by language (Dunbar 1996). Nelson and Geher (2007) have defined human grooming broadly as including ‘‘any behavior in which an individual removes or mimics removal of something from the skin or body.’’ In nonhuman primates, such activity involves parting the fur. Typically, allogrooming movements involve a coordinated sweeping through the fur with one hand and plucking at debris with the other (Sparks 1967; Dunbar 2008). Humans, of course, have much less abundant hair than our primate cousins, but our allogrooming practices may have adapted to our nakedness. A homologue to the ‘‘sweep’’ may manifest in the stroking gestures over the skin surface common in the ‘‘dynamic’’ category of interpersonal touch. Such dynamic touch is also pleasant for the toucher, with others’ forearm skin rated more pleasant to touch than one’s own, and forearm skin as more pleasant than glabrous (palm) skin, whether one’s own or another person’s (Guest et al. 2009)." 

Lehmann J, Korstjens AH, Dunbar RIM (2007) Group size, grooming and social cohesion in primates. Anim Behav 74:1617–1629
Dunbar RI (2008) The social role of touch in humans and primates: behavioural function and neurobiological mechanisms. Neurosci Biobehav Rev (full text with a page missing)Dunbar R (1996) Grooming, gossip, and the evolution of language. Harvard University Press, Cambridge, MA
Nelson H, Geher G (2007) Mutual grooming in human dyadic relationships: an ethological perspective. Curr Psychol 26:121–140 (full text)Sparks J (1967) Allogrooming in primates: a review. In: Morris D (ed) Primate ethology. Weidenfeld and Nicholson, London
Guest S, Essick G, Dessirier JM, Blot K, Lopetcharat K, McGlone F (2009) Sensory and affective judgments of skin during inter- and intrapersonal touch. Acta Psychol (Amst). 130:115–126

All right, now maybe we can get somewhere. 

"In contrast to the work on grooming in nonhuman primates, research on human allogrooming is rare." 

Actually, no.. I would beg to differ: millions of hectares of trees have sacrificed their lives so that avalanches of research could be printed on this. People call it by any other name than what it actually is, human allogrooming. Instead it is called massage therapy or manual therapy. Those names are pretty generic - so hold onto your hat. There are a million "kinds." Acupuncture falls under this along with its supposedly a bit more biomedically acceptable version, dry needling. High velocity manipulation [the kind that paralyzes unfortunate victims who only want their necks to feel better, or who get hornswoggled into thinking they "need" to have their necks or spines cracked at least once a month forever], falls under this. Gouging with many different kinds of tools, often made of some sort of fancy material, falls under this. 


Alfred North Whitehead
I think this guy nailed it. 

"Reification (also known as concretism, or the fallacy of misplaced concreteness) is a fallacy of ambiguity, when an abstraction (abstract belief or hypothetical construct) is treated as if it were a concrete, real event, or physical entity. In other words, it is the error of treating as a concrete thing something which is not concrete, but merely an idea."

Another way to look at this is objectification. Buried deep in our social psyche is the regarding people as though they were interchangeable, fungible. Lip service might be paid to individuality, but in the end, in manual therapy, patient problems are relegated to various diagnoses or body parts. The tennis elbow in cubicle 17. The knee in stall 12. The low back in cubicle 8 - give that one to Jack - Jack has a knack with delivering the crack.

Individuality is allowed to flourish when it is to the advantage of the practitioner, however. Whoever comes up with the latest technique du jour, or fool proof system, gimmicky tool for sale, snazzy video to promote it, supposedly "wins."


I’ve always felt confused about what my profession is supposed to be about.

ANdy, an Irish PT and poster to SomaSimple, said this recently, and eloquently:
"We do seem to have a problem with specialization where too many senior Doctors/Consultants seem to have far to narrow knowledge coupled with highly technical but limited skillsets and lack the general oversight that care so often demands. I think that too often we, as physiochiropathics, simply ape that, a pale shadow that haunts the passageway of healthcare leeching life from those who pass too close to our undead shades."
A few years ago, I was transfixed for awhile with an inner vision that resembled ANdy's. I saw this, on ScienceBasedMedicine blog, by Mark Crislip:
“Monkeys, and other animals, groom each other often with a marked reduction in stress. Touch is good, and one doesn’t need to wrap it up in pseudoscientific nonsense for it to be beneficial.”
Inspired by this, I wrote this, in order to try to gain clarity. Operator/Interactor.

It contains a slide of various animals performing social grooming, social contact. I always include this slide when I teach.


Skin has been disregarded. So I teach about skin. 
Nerves (cutaneous ones) have been disregarded. So I teach about nerves. 
The sensory nervous system has been completely disregarded. So I teach about the nervous system.
Pain has been misconstrued as being sensory input. So I teach from a Melzackian, "pain as output" point of view.

In my opinion, leaving these items and their interactions out of the picture led us down some pretty convoluted rabbit holes, leading nowhere but to mutually exclusive dead ends. I try to put individuality back into the picture. Every brain is unique, pain is always personal, be with your patient wherever they're at, try to see their life from the perspective of their neuromatrix, not your own. Not your profession's even. Not when your own profession has become just another sausage factory.

Hey, somebody has to do it, point out the obvious. 
Even though it makes people cringe, I use the term, Human Primate Social Grooming, at least once during the talk. 


Anyway, back to the paper, I look forward to greater clarification. 

More to come, because it's long.

Friday, September 06, 2013

The Skin as a Social Organ. Part 2e: Touch early, touch often

The paper, The skin as a social organ

Previous introductory blogpost to this series.    Preamble: Random thoughts on spas

Part 1: Dual nature of touch: as PTs, do we "get" this? Part 1a: Touch can be pleasant, rilling Part 1b: Vallbo on C-tactiles 

Part 2a: Different kinds of touch Part 2b: Proxemics Part 2c: The sad dearth of manual therapy aspects in reviews of interpersonal touch Part 2d: Learning to sit still, learning to behave, learning to not be connected to oneself

Next paragraph of the paper:

‘‘Protracted’’ touch, ‘‘dynamic’’ touch, and tickling can also have positive concomitants and outcomes in affiliative behavior. Holding a loved one’s hand can reduce the anxiety posed by an impending threat (Coan et al. 2006). Skin-to-skin contact has been shown to have clinical benefits for premature infants (Field 2001), as well as an analgesic effect in human babies undergoing minor tissuedamaging procedures (Gray et al. 2000). Stroking an infant can not only give rise to positive emotions in the baby, but can also modulate negative ones, compared to other forms of touch (Peláez-Nogueras et al. 1997). Tickling is a playful social act and is also seen in other mammals (Panksepp and Burgdorf 2003; Blakemore et al. 1998). It often gives rise to pilomotor responses like goosebumps, the elicitation of which is associated with the insula (Warren 2002). Interestingly, individuals with Asperger’s syndrome (associated both with social impairments and tactile hypersensitivity) rated the intensity and ‘‘tickliness’’ of a piece of foam on the palm as higher when the stimulus was applied by an experimenter than when the subjects touched their own palm with it (Blakemore et al. 2005)." 
  1. Coan JA, Schaefer HS, Davidson RJ (2006) Lending a hand: social regulation of the neural response to threat. Psychol Sci 17:1032–1039
  2. Gray L, Watt L, Blass EM (2000) Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 105(1):e14
  3. Peláez-Nogueras M, Field TM, Gewirtz JL, Cigales M, Gonzalez A, Sanchez A et al (1997) The effects of systematic stroking versus tickling and poking on infant behavior. J Appl Dev Psychol 18:169–178
  4. Panksepp J, Burgdorf J (2003) ‘‘Laughing’’ rats and the evolutionary antecedents of human joy? Physiol Behav 79:533–547 (Full text)
  5. Warren J (2002) Goosebumps and the insula. Lancet 360:1978
  6. Blakemore S-J, Bristow D, Bird G, Frith C, Ward J (2005) Somatosensory activations during the observation of touch and a case of vision-touch synaesthesia. Brain 128:1571–1583 (Full text)
I think we could file this paragraph under "Skin is the outside of the brain." 
Touch is like brain food. I think the message is obvious: get those little meaning-maker brains going early in life. The more input they get in the context of emotional safety and pleasure, the better they're going to work later on. 

People often ask me if I can do dermoneuromodulation on myself. 

The answer is yes. If I can reach whatever part of my body is "hurting" me, without much struggle, and can pull my skin organ in a direction that alleviates whatever kinking might be going on in some vascular array inside some cutaneous nerve or other, and hold it there long enough for it to get over itself, then yes, it means I can do dermoneuromodulation on myself. 

The answer is no. I can't feed my own brain the way it can be fed by the careful handling of another; I want to relax, not have to think or do anything, produce any deliberate motor output, and use all my whole brain to just feel, and breathe, perceive and create yes-ciception. 

Wednesday, September 04, 2013

The Skin as a Social Organ. Part 2d: Learning to sit still, learning to behave, learning to not be connected to oneself.

The paper, The skin as a social organ

Previous introductory blogpost to this series.    Preamble: Random thoughts on spas

Part 1: Dual nature of touch: as PTs, do we "get" this? Part 1a: Touch can be pleasant, rilling Part 1b: Vallbo on C-tactiles 

Part 2a: Different kinds of touch Part 2b: Proxemics Part 2c: The sad dearth of manual therapy aspects in reviews of interpersonal touch

We continue with the paper:
"Effects of touch in social interactions have been found to increase liking of a person or place, and to facilitate a footing of trust or compliance, often manifesting in increased prosocial behavior. For example, a half-second of hand-to-hand touch from a librarian fostered more favorable impressions of the library (Fisher et al. 1976), touching by a salesperson increased positive evaluations of the store (Hornik 1992), and touch can also boost the attractiveness ratings of the toucher (Burgoon et al. 1992). Recipients of such ‘‘simple’’ touches are also more likely to be more compliant or unselfish: returning money left in a public phone (Kleinke 1977), spending more money in a shop (Hornik 1992), tipping more in a restaurant (Crusco and Wetzel 1984), or giving away a cigarette (Joule and Guéguen 2007). The greater degree of compliance, or even generosity, with resources in these studies implies that such rudimentary social touches can potentially provide a platform for trust and cooperation in future exchanges." 
  1. Fisher JD, Rytting M, Heslin R (1976) Hands touching hands: affective and evaluative effects of an interpersonal touchSociometry 39:416–421 (Preview)
  2. Hornik J (1992) Tactile stimulation and consumer response.Consum Res 19:449–458 (full text)
  3. Burgoon JK, Walther JB, Baesler EJ (1992) Interpretations, evaluations, and consequences of interpersonal touch. Hum Comm Res 19:237–263
  4. Kleinke CL (1977) Compliance to requests made by gazing and touching experimenters in field settings. J Exp Soc Psych 13:218–223
  5. Crusco AH, Wetzel CG (1984) The Midas touch: the effects of interpersonal touch on restaurant tipping. Personal Soc Psych Bull 10:512–517
  6. Joule RV, Guéguen N (2007) Touch, compliance, and awareness of tactile contact. Percept Mot Skills 104:581–588

Well, there seems to be quite a bit of interest in, and study of, how to create a good impression with interpersonal touching. Most of looks like it has to do with social manipulation, deception, priming non-conscious brain function by touching in a way that is deliberate, but that touchees don't even notice. Distracting the touchees so that they don't even notice that somebody (in on the project) touched them right in the critter brain, bypassing their human brain, or at least disarming it so that it doesn't make a "thing" out of having been touched without permission. 

Not that it isn't easy enough for the human part of the brain to be distracted away from the critter brain most of the time, anyway - maybe because of the "proxemics" we touch-deprived, northerly, cold-climate, big-personal-space, culturally-imprisoned human primates have allowed our culture to train us into from childhood, generation after generation. 

Earlier today I listened to a radio program, Ontario Today, What Every Parent Should Know About School, an interview with Michael Reist. Not that I have ever had any kids, or am remotely interested in what school is like these days; however, the radio was on while I was buried in a photoshop project, and bits crept in.. 

Apparently educators find themselves feeling as overwhelmed by neuroscience as I do. Apparently a few have woke up to the fact that the institutions they are part of, proud to represent even, are dinosaurs modelled after sausage factories. Much like my own is. 

Apparently a few have done enough reading to realize that every kid is an individual who would turn into a way more successful adult (happier, more creative, smarter, confident, etc.) if they were treated as such; taught according to whatever learning style they inherently possess, had contact with nature, had contact with lots of people of different ages (the better to build mental representations of diverse "other" instead of being pancaked into a group of 25 kids all the same age, none of whom can learn to relate to any other age, therefore), were allowed to move around, weren't bullied or accused of being stupid or fat (by the teacher! right in front of the child! and the parent!).

Apparently it is dawning on a few people that just because they enjoyed sitting quietly, listening, learning, taking notes, this method of transferring knowledge just doesn't work for lots of kids, for whom school, as graded exposure to being distanced from their own critter brains, doesn't feel good. It just stresses them out. Or in any event, stresses out their little critter brains. 

Then the kid grows up into an adult whose brain has neuroplasticized around huge school-induced social stress. 

I count myself lucky that I attended a prairie one-room school, nature right outside. The same room,  same teacher, from grade 1 through grade 8. Eight years in one room. Sometimes only one kid in a grade, sometimes as many as three, usually only 12 or 13 kids in the whole room. By the time I got to the grade 8 sized desks on the north side of the room, away from the grade 1 sized desks on the south side, by the big windows you could gaze out periodically to give your brain a rest, I was 8 years older, quite a bit taller, I had heard all the material 8 times, and easily passed all the exams. I'd played softball with kids much older, and much younger. Fairness had been installed - I could relate, at a kid level, anyway, to other kids of many different ages. 

Every day after lunch, the teacher (same teacher for 6 years) read to us from a book. I can't remember any of the books. It doesn't matter. It was a time when she let us move around the room a little. Our favourite thing (as girls) was to sit behind each other and take turns combing each others' hair while being read to. It felt really good.  

Otherwise, you had to sit there. If you wanted to move, you had to pretend your pencil needed to be sharpened. You had to raise your hand, ask permission to go to the back of the room and sharpen it at the sharpener, which was bolted to the back windowsill, beside the piano. Or you had to pretend you had to visit the bathroom. The girls' bathroom was on the same floor. The boys' bathroom was in the basement. Boys could move more, get some stairs in. Michael Reist would approve, because he thinks boys have a whole lot harder time with the no moving thing. He's probably right.

Anyway, I guess the point of writing about this, is, rumination about how much I was trained in school to not move freely. 

Another reflection is, is it any wonder we now have an epidemic of chronic pain? All those invisible, socially imposed chains? Not enough allowance for learning how to reduce stress in each other through simple interaction as children, like gently and slowly combing each other's hair, just for the beauty of how nice that feels? Both parties fully aware and engaged, fully attentive? The recipient fully connected interoceptively, exteroceptively, and socially, all at the same time? No deception? 

Sunday, September 01, 2013

The Skin as a Social Organ. Part 2c: The sad dearth of manual therapy aspects in reviews of interpersonal touch

The paper, The skin as a social organ

Previous introductory blogpost to this series.    Preamble: Random thoughts on spas

Part 1: Dual nature of touch: as PTs, do we "get" this? Part 1a: Touch can be pleasant, rilling Part 1b: Vallbo on C-tactiles 

Part 2a: Different kinds of touch Part 2b: Proxemics


Next paragraph:
"Affiliative behavior is that which reflects or increases the disposition of one or more members in an interaction to seek close contact with another member. This is assumed to be accompanied by positive affective feelings, such as fondness, or with the alleviation of stress or anxiety. The motivational-affective dimension of social touch may provide mechanisms for the promotion of such positive consequences, ultimately pertaining to the desire to seek a touch (‘‘wanting’’) or to continue a tactile interaction (‘‘liking’’; see Berridge and Kringelbach 2008 for the ‘‘liking–wanting’’ distinction). Evidence that social touch encounters are accompanied by, and engender, positive affective consequences comes mainly from social psychological research investigating the relationship between interpersonal touch interactions and positive evaluations of  people and surroundings. These studies usually involve ‘‘simple’’ touch, though without designating it as such (hand-to-hand, hand-to-arm, hand-to-shoulder, etc.)."
Berridge KC, Kringelbach ML (2008) Affective neuroscience of pleasure: reward in humans and animals. Psychopharmacology (Berl) 199:457–480 [full text]

Full text! How handy. Berridge and Kringelbach ferret through all the neuroscience that has to do with "reward." They discuss three kinds: liking, wanting, and learning.

Liking: the actual pleasure component or hedonic impact of a reward.
Pleasure comprises two levels:
(1) core ‘liking’ reactions that need not necessarily be conscious;
(2) conscious experiences of pleasure, in the ordinary sense of the word, which may be elaborated out of core ‘liking’ reactions by cognitive brain mechanisms of awareness (see “A glossary of reward definitions” below for more detail on definitions).

Wanting: motivation for reward, which includes both
(1) incentive salience ‘wanting’ processes that are not necessarily conscious
(2) conscious desires for incentives or cognitive goals.

Learning: associations, representations, and predictions about future rewards based on past experiences.
Learned predictions include both
(1) explicit and cognitive predictions
(2) implicit knowledge as well as associative conditioning, such as basic Pavlovian and instrumental associations.

The thing that stands out for me right away whenever I read anything like this is the way researchers automatically classify everything into two baskets, core and conscious. I think the labels "critter brain" and "human brain" work reasonably well..

The authors continue:
"Of the three types of reward component, pleasure or hedonic ‘liking’ has probably been the least addressed in neuroscience studies. There is a special need for better understanding of how pleasure is generated by brain systems, and so we will focus particularly on pleasure in this paper."
They go on to explore the matter under the folowing headings:
From sensation to pleasure
Is human pleasure similar or different to that of other animals?
Pleasure coding versus causality
The consciousness of pleasure: can ‘liking’ ever be unconscious?
Pleasure generators: hedonic hotspots in the brain
Cortical cognition and pleasure
Orbitofrontal cortex: apex of pleasure representation?
Cortical causation of human pleasure?
Controversial subcortical pleasure generators? Dopamine and electrical brain stimulation
In what ways are the brain mechanisms of pleasure linked to human happiness?
It's quite a detailed paper. I very much appreciated the diagram of the orbiotfrontal cortex ("human" or at least part of prefrontal lobes of the brain) and all the ways it connects with "critter" brain.

Orbitofrontal cortex connectivity

These authors seem to think orbitofrontal cortex may well be a main train depot for loops that have to do with pleasure.
Morten Kringelbach
Pleasurable touch.

Kringelbach's entire mission in life seems to be to learn everything about pleasure in the brain that he possibly can in a single lifetime.
Here is a pubmed list of his publications.

Kent C Berridge

Kent Berridge is in Michigan, I think.
His list of publications in pubmed is longer still.

It looks as though these two have written an entire text, Pleasures of the Brain. 


In "A glossary of reward definitions" they lay out the distinctions. There are many. There is liking without quote marks, and "liking" with quote marks.
Liking (without quotation marks) Subjective hedonic reactions. This is the everyday sense of the word liking or pleasure, referring most directly to a conscious experience or subjective feeling of niceness.
‘Liking’ (with quotation marks) An objective hedonic reaction, measured behaviorally or neurally, whether or not accompanied by conscious pleasure. Core ‘liking’ reactions result from activity in identifiable brain systems that paint hedonic value on a sensation such as sweetness. Behavioral ‘liking’ reactions have been especially useful for mapping causal hedonic hotspots in the brain, particularly in the form of ‘liking’/‘disliking’ facial expressions to tastes that are homologous between humans and many other mammals. In humans, ‘liking’ reactions on their own have been shown in the form of unconscious pleasures, in cases where people remain unaware of an emotional stimulus and of their own hedonic reaction to it.

Likewise, wanting comes with and without quote marks:
Wanting (without quotation marks) The everyday sense of the word as a subjective desire. Conscious wanting typically is distinguished by requiring cortical mechanisms that generate declarative goals (based on memory or imagery): you want something in particular and may imagine it in advance of getting it. 
Wanting’ (with quotation marks) Incentive salience, a motivational process within reward that mirrors hedonic ‘liking’ and makes stimuli attractive when attributed to them by mesolimbic brain systems. Incentive salience is highly influenced by mesolimbic dopamine neurotransmission (though other neurotransmitters and structures also are involved). Importantly, incentive salience is not hedonic impact or pleasure. That is why one can ‘want’ a reward without necessarily ‘liking’ the same reward. Irrational ‘wanting’ without liking can occur via incentive sensitization in drug addiction, false pleasure electrodes, and similar cases because ‘wanting’ mechanisms are largely subcortical and separable from cortically mediated declarative expectation and conscious planning. Thus, for example, addicts may irrationally and compulsively ‘want’ to take drugs even if, at a more cognitive and conscious level, they do not want to do so.

So, basically, anything in the inner world of human experiential existence looks like it divides out into subjective first-person human brain perception with meaning assigned, and objective third-person critter brain observation.

Including pain. Except we have two words, nociception for objective observations of critter brain function, especially for when descending modulation is working fine, and pain for subjective human brain function, when it doesn't. Not that there isn't overlap. E.g., nociception feels "pain"-ful, at first anyway, shocking even, as when one cuts one's finger on a piece of paper or broken glass. Then it goes away. End of story. Pain is "sensed" as nociceptive input. But it can occur even when there is no part "hurting" or being "nociceptive." E.g., phantom limb pain.

A good trick in manual therapy is to always feel better than the person with whom you are working. Another way to say this, is never treat anyone who feels better than you do.

If you want to blow your mind on how easily somebody else's brain can pick up how you might happen to be feeling, even to the point of distinguishing 8 separate emotions, check out Matthew J. Hertenstein, Rachel Holmes, Margaret McCullough, Dacher Keltner; The Communication of Emotion via Touch. Emotion 2009, Vol. 9, No. 4, 566–573 [full text].

Also recommended: Living with Touch, by Alberto Gallace

Also recommended: Alberto Gallace, Charles Spence; The science of interpersonal touch: An overview. Neuroscience and Biobehavioral Reviews 34 (2010) 246–259

This is a review paper of nearly everything that has anything whatever to do with physical contact between humans. Glaringly absent from the paper is any mention of contact for therapeutic purpose. Not the authors fault - it's a review paper, and they reviewed whatever they could find. There ISN'T anything manual therapy-esque out there, for them to review, because no one in manual therapy thinks about or writes about it, yet, in any neuroscientifically scholarly manner for scholarly purposes. 

Not yet. 

Why is manual therapy not in this picture?

Manual therapy is still lumbering along like a big dumb robot under the illusion that it physically "does" "stuff" to "stuff." Maybe after it grows up a bit more, it will be able to justify its existence by way of neural mechanisms instead. But it won't happen in my lifetime, probably. I'll likely not live to see people like Gallace and Spence include scholarly manual therapy input into any review of interpersonal touch. The problem from the other side is that manual therapy continues to not be interested in studies of interpersonal touch, possibly because it doesn't see itself reflected in them or by them. 

Yeah, I know, I'm an oddball for concerning myself with matters like this. Who cares? I do! What a project though. Get neuroscience in under manual therapy. I must be crazy, right?
So be it. All I can do is complain about it, right now. 

Maybe someday things will change. I know Lorimer Moseley works hard, has madly laid groundwork, has taken on looking at pain, at least, from a neuroscientific perspective. Has published with several neuroscience people including Gallace and Spence. (See Moseley, GL, Gallace, A & Spence, C. (2008) Topical Review: Mirror Therapy: Is it all it is cracked up to be? Pain, 138(1) 7-10.)

So, faint rays of hope do shine through occasionally, into our self-made manual therapy dungeon of mesodoom. Even though there are wide heavy dark bars built from orthopaedic biomedicine, equally operative, third-person, equally deluded about "fixing" pain, by "fixing" tissue, or injecting it, or needling it, or ... oh, don't get me started, or I'll get off track over this. We'll be back to Skin as a Social Organ next time.