"Tree of Knowledge" : Part III "On the Razor's Edge"

When trying to understand how we think, the authors say:

"..our first tendency to describe what happens in each case centers, in one way or another, on the use of some form of the metaphor of "getting information" from the environment represented "within"."

But, they point out, there is no one home in there. There is no "little man" inside the brain, operating visual mechanisms to see the outer world on a representational "screen" inside the brain. If there were, who runs the "little man's" "brain"? Another "little man" inside his brain?

The authors have already, for the first 128 pages, explained that life forms itself, that organisms as small as single cells, no nervous system whatsoever, still manage to conduct themselves and all the processes that are inherent to life - seeking food, avoiding predation, metabolizing, growing, reproducing, etc.

"Our course of reasoning (...) has made it clear that to use this type of metaphor ( i.e., the "little man" in the brain idea) contradicts everything we know about living things. We are faced with a formidable snag because it seems that the only alternative to a view of the nervous system as operating with representations is to deny the surrounding reality. Indeed, if the nervous system does not operate - and cannot operate - with a representation of the surrounding world, what brings about the extraordinary functional effectiveness of man and animal and their enormous capacity to learn and manipulate the world? If we deny the objectivity of a knowable world, are we not in the chaos of total arbitrariness because everything is possible?

This is like walking on the razor's edge. On one side there is a trap: the impossibility of understanding cognitive phenomena if we assume a world of objects that informs us because there is no mechanism that makes that "information" possible. On the other side, there is another trap: the chaos and arbitrariness of nonobjectivity, where everything seems possible. We must learn to take the middle road, right on the razor's edge."

My bracketed comment. My bold.
At this point the authors direct the reader to a figure showing a version of the sailing of a ship between the sea monster and the whirlpool, the Scylla monster of representation and the Charybdis whirlpool of overly rigid solipsism.

They are suggesting that the Razor's Edge is a Third Way.

So, what is a "third way"? Dorko's essay is good doorway into what a "third way" means for a therapist. A visual idea that can help us understand how to travel or think a third way, on a razor's edge, is to contemplate a mobius strip:

"If you put an ant somewhere in the middle of the strip and get it to start walking in a line parallel to the edge, then after travelling a distance that is twice the length of the paper, it will arrive back at its starting point — without ever crossing the edge of the strip!"

What if we had that hypothetical ant walk on the edge of the mobius strip? It would be able to walk between the sea monster on one side and the whirlpool on the other.

I got this mobius-strip idea from Ramachandran. In his book, A Brief Tour of Consciousness, he says,

My own philosophical position about consciousness accords with the view proposed by the first Reith lecturer, Bertrand Russel, that there is no separate "mind stuff" and "physical stuff" in the universe: the two are one and the same. (The formal term for this is neutral monism.) Perhaps mind and matter are like the two sides of a Mobius strip that appear different but are in fact the same.

"Tree of Knowledge": Part II "The Razor's Edge"

The book is subtitled, The Biological Roots of Human Understanding. It was first published in 1987, an afterword by Varela was added in 1992, and the copy I'm holding was revised and published in English 1998.

I began to find the book riveting about page 129, when I got to this section:

"On the Razor's Edge
The most popular and current view of the nervous system considers it an instrument whereby the organism gets information from the environment which it then uses to build a representation of the world that it uses to compute behavior adequate for its survival in the world. This view requires that the environment imprint in the nervous system the characteristics proper to it and that the nervous system use them to generate behavior, much the same as we use a map to plot a route.

We know, however, that the nervous system as part of an organism operates with structural determination. Therefore, the structure of the environment cannot specify its changes, but can only trigger them."

Second bold mine.

There is no "little man" (or woman) inside the brain, running things from within. The whole thing runs itself, responds to and adapts itself to various external stimuli. If we want what we observe to make any sense, the "we" who we observers think we are, must each consider ourselves as only a "construct" of the nervous system within the organism that we actually are.

We as observers have access both to the nervous system and to the structure of its environment. We can thus describe the behavior of an organism as though it arose from the operation of its nervous system with representations of the environment or as an expression of some goal-oriented process. These descriptions, however, do not reflect the operation of the nervous system itself. They are good only for the purpose of communication among ourselves as observers. They are inadequate for a scientific explanation.

My bold.

It's good mental exercise to hold two or more ideas aloft at once, like juggling several balls; one's physicality as an organism, one's environment, one's nervous system, one's personal vantage point as a perceiver, one's social identity as an observer talking to other observers. That is at least 5 right there, more if you consider the nervous system as not monolithic but rather comprised of many levels of integrated function inherited from all "life" from simple sea creatures down through time, each level perhaps capable of "perceiving" a perturbation in its own way, and responding from its own "perspective", the ultimate unifying integration completely hidden from any outside observer.

Now consider and add to that the innocent expectation people have of you if you are their physiotherapist.
Think about it.
I, as a therapist, cannot "specify" changes in any patient. I have no power over someone else's nervous system. I cannot with any degree of legitimate or ethical or scientific certainty, say to someone, I will do x,y,z, and you are guaranteed to improve. No one can say this to anyone and still be honest. In general, maybe. Specifically, to any individual, no. You buy a treatment slot and you take your chances.

If you are a patient, you are juggling the same five ideas as I am, whether you know you are or not. I simply become part of your environment, from your nervous system's point of view. You have to do your own observing and perceiving, and your own nervous system will do its own observing, perceiving, adapting and stabilizing, in response to "changes" that I can help "trigger", in the combined "you", the organism or unity that you are.

More to come.

"Tree of Knowledge" Part I : Intro

I am starting a new series of posts bringing forward some of the book, Tree of Knowledge, by Humberto Maturana and Francisco Varela. They came up with a new term in biology, autopoiesis, in the 1970s. A short introduction to the authors is in order, starting with Varela.

In the comprehensive site about Varela's life and work appears this quote:

"Unless we accept that at this point in intellectual and scientific history that some radical re-learning is necessary, we cannot hope to move forward in the compulsive history of the ambivalent rejection-fascination with consciousness in philosophy of mind and cognitive science. My proposal implies that every good student of cognitive science who is also interested in issues at the level of mental experience, must inescapably attain a level of mastery in phenomenological examination in order to work seriously with first-person accounts. But this can only happen when the entire community adjusts itself to the corresponding acceptance of arguments, refereeing standards and editorial policies in major scientific journals, that can make this added competence an important dimension of a young researcher. To the long-standing tradition of objectivist science this sounds like anathema, and it is. But this is not a betrayal of science: it is a necessary extension and complement. Science and experience constrain and modify each other as in a dance. This is where the potential for transformation lies. It is also the key for the difficulties this position has found within the scientific community. It requires us to leave behind a certain image of how science is done, and to question a style of training in science which is part of the very fabric of our cultural identity."
Francisco Varela, Neurophenomenology : A methodological remedy for the hard problem, Journal of Consciousness Studies, "Special Issues on the Hard Problems", J.Shear (Ed.), June 1996.

As part of this vision Varela helped organize a series of nine meetings between scientists and Buddhist leaders including the Dalai Lama.


Maturana is an advocate of something called radical constructivism having contributed concepts supporting a Biology of Cognition. From Maturana:

"The Biology of Cognition is an explanatory proposition that attemps to show how human cognitive processes arise from the operation of human beings as living systems. As much, The Biology of Cognition entails reflexions oriented to understand living systems, their evolutionary history, language as a biological phenomenon, the nature of explanations, and the origin of humaness. As a reflection on how we do what we do as observers it is a study in the epistemology of knowledge. But, and at the same time as a reflection on how we exist in language as languaging beings, it is a study on human relations".

(I can almost hear his Chilean accent in this quote thanks to the spelling.)

I admit I don't understand even half of what he and Varela are trying to say or how, but I do get:

a) they are talking about life from single cell life on up, pointing out how life organizes itself

b) they are leaving out supernatural agency (of which I wholeheartedly approve)

c) they lean toward phenomenology, or first person "knowing", with which I am all too familiar.

Tree of Knowledge is a careful argument for how to think about the nervous system, perception and cognition. They begin to discuss the physical nervous system about half way through, which is where I'll pick up next time.

Mirror therapy for central pain in paraplegics

Please check out Neurotopian's latest blog post.

What a gorgeous idea this is. Thank you Neurotopian. Your smashingly good idea (and of course Dr. Moseley's test, and future clinical trials on every continent) could go a long way to save future generations of paraplegics from a great deal of pain.

Pain as aporia

One of my favorite article writers on pain, Dr. John Quintner, has a site, www.creativepain.com . He is one of the pain world's foremost deconstructionists. I admire his ability to cut through all sorts of erroneous nonsense about what pain is and isn't. I like that he prefers to regard peripheral pain as pain from nerves themselves, not from mesoderm of one sort or another, admirable especially in that he is a rheumatologist and one would expect, be all about "joint pain".

Anyway, if you read his webpage you'll discover that down near the end he states that pain is an "aporia". I became fascinated by the concept and spent a bit of time looking up what is meant by the term.

Here are some useful links to "Aporia":
1. Wikipedia
2. Literary encyclopedia
3. Postmodern terms
4. About.com Grammar and Composition

The gist of "aporia" seems to mean, a way that is blocked; "poria" must be the "way" and "a"-poria, the blockage of that way. Note that there is a subtext here, of movement, frustrated in its expression.

I did my own little deconstruction, working backwards from the wikipedia definition, following a few of the links. I know beans about philosophical discourse, but here's what I think I found out. First, I clicked on the word "elenctic", attracted by the novelty of a word I'd never before seen in my life. It went to a page about some long-dead guy I'd never heard of, Elenchus. From there I looked up "dialectic", which seemed interesting, a word I had heard in poly-sci circles long ago..

There it was. Sublation. A way to get around, over, through, out of the "a" part of "poria", past the impasse. Go Hegel:

"Sublation is an English term used to translate Hegel's German term Aufhebung. The German word Aufhebung literally means "out/up-lifting."

But what does any of this have to do with pain, an astute reader might wonder?
Everything, I would answer. Consider this.

"...the term Aufhebung has the apparently contradictory implications of both preserving and changing (the German verb aufheben means both "to cancel" and "to keep"). The tension between these senses suits what Hegel is trying to talk about. In sublation, a term or concept is both preserved and changed through its dialectical interplay with another term or concept. Sublation is the motor by which the dialectic functions."

Just as continuing dialogue helps to move a conflict past its flash point, or an argument towards resolution, so does having a kinesthetic "conversation" - an inner dialogue, help a person in pain's brain move past pain. It is at least a three way conversation. The therapist supplies a small amount of kinesthetic input to help the patient's brain settle and focus. Most of the dialogue however, is completely internal, between the patient and the various levels of his or her own nervous system. Eventually the impasse is surmounted, sublated, and pain resolves. Or doesn't. Usually it will, but sometimes it doesn't.. so, no guarantees can be be ethically made....

Neurotopian, would you concur? You are both German and a nervous system treater. Did I get the meaning of "aufhebung" correctly translated into Kinesth-ese?

Mirror therapy

It looks like the effectiveness of mirror therapy for phantom limb pain has been independently verified yet again.

Kent has sent a link to a video featuring Ramachandran.

He says, "This is a link to a TED talk by V.S. RAMACHANDRAN. In the middle of the half hour talk he describes stumbling on the mirror box as a means for dealing with phantom limb. It is a very engaging video. Thought you and your readers might be interested."

Thanks Kent. Thumbs-up.

Everything Oscillates

.... even the genome apparently. Scientists at Vanderbilt University have noticed that chromosomes contract in daylight and loosen their coils at night. Just a really interesting factoid - nothing to do with the gist of this blog. Except that everything eventually has something to do with everything else, in biology.

Anyway, the word "oscillation" in the article reminded me (yet again) of György Buzsáki's work.

Michael Merzenich, On the Brain

I've been exploring a site called On the Brain.com, a blogsite hosted by Michael Merzenich:

Dr. Michael (Mike) Merzenich is the Francis Sooy Professor in the Keck Center for Integrative Neurosciences at the University of California at San Francisco. In parallel with the landmark studies of his UCSF team in the science of neuroplasticity, he has worked with other scientists, medical specialists, psychologists, engineers and other technical specialists to develop training programs based on this science, and designed to improve the behavioral capacities and neurological abilities of children and adults in need of help. Almost a million individuals have now benefited from the use of these programs.

On his site I found a video about a man with traumatic brain injury whose cognitive function became improved via some mental exercises. I was impressed - thought I'd share it here.

Place cells and Grid Cells: Part II

You do not have to dig very deep to find good descriptions of place cells. (It is starting to become a bit more clear to neuroscientists how the brain works together as an entirety, to conduct "thought". No more dualism, please.)

It's interesting that both place and grid cells are at/in the hippocampus. György Buzsáki discusses hippocampal "theta" rhythm as fundamental to all brain function in his book "Rhythms of the Brain".

Grid cells were discovered more recently and are not quite as famous yet. Blakeslee discusses grid cells next: These map space too, but differently - they do not use external markers to orient you - they let you know where you are in space based on your own movements. These were discovered in 2005 by scientists in Norway.

The discoverers say,

Imagine coming up from an unknown subway station. You immediately look for a landmark to figure out directions and your position. The moment you find it, your cognitive map is calibrated, and things fall into place,” explain Edvard and May-Britt Moser. They reveal the secrets of memory.

Grid cells do this calibration. Blakeslee says,

"Located just one step higher in the cortical hierarchy from place cells, in a region called the entorhinal cortex, each grid cell acts as though the surface of your local environment had a triangular grid painted all over it... A grid cell is active when you are at the vertex of any of the triangles in the field in front of you but inactive for locations between the vertices. The grid persists like graph paper spread as far as you can see, or like the Holodeck on Star Trek before scenes are projected onto it. When you move through space, grid cells mark your position independent of context. Place cells "say" I am in the store, I am in my house, I am in a strange plaza. Grid cells keep track of where you are in all contexts, in all kinds of places, as if they were a property of the environment itself and not cells in your brain.... Moser, when asked, is willing to venture a guess that great athletes have highly developed place cells and grid cells. Yes, they need fast reflexes, trained muscles, great eyesight, and developed brain networks to compare different trajectories; but when Ronaldinho looks down a soccer field, he is mapping the entire field in his brain. He has an effortless, innate sense of where he is in space and time, thanks to how well his brain maps that space. Every time he takes a step, an entire new geometry of action is created within his brain. In ten seconds, Ronaldinho will see at least one hundred alternatives and will make choices that draw on his...place cells and grid cells."

I've done some traveling, enough to know that I get lost easily, turned around, hardly know up from down, don't have a clue which way is west without a good map. I've traveled with others who effortlessly (maddeningly) "know" where to find a site. They stand in the middle of a foreign city, gaze around for about 3 seconds and say, "over there" - and take off toward the place we've decided to go to. They are almost always right. My strategy when alone is to use a map, and double check my progress by stopping local people, asking them, to "feel" sure I'm going the right way.

Place Cells and Grid Cells: Part I

I spoke of Sandra Blakeslee's new book, The Body Has a Mind of it's Own, here and here.

On page 128, at a nice little section called "A Sense of Where You Are". The authors describe the eerie way certain basketball players and other athletes have of knowing exactly where they are in space, how balls go through hoops precisely even with backs turned. They duly note the advantages top athletes are born with: fast-twitch muscles, long limbs, high anabolic thresholds, extraordinary hand-eye coordination, lightning fast reflexes, excellent vision (including peripheral). They describe how certain athletes look at everything, focusing on nothing until the last moment of commitment; due respect is paid to the thousands of hours of accumulated practice manipulating ball and body in space. Then they go on:

"But there is one trait among great athletes especially those whose game is played on open courts or fields (like soccer, basketball, American football, rugby, lacrosse and hockey), that has not been described on ESPN or elsewhere. It explains why some people have an extraordinary sense of where their bodies are located in space, as well as the fast-moving bodies of all their teammates and opponents. Namely, the very best athletes have really great "place cells." And maybe even more important, they have spectacular "grid cells.

Place cells and grid cells are space-mapping neurons linked to a memory-forming region called the hippocampus. The hippocampus is evolutionarily much older than the cortex. So despite the amazing power and flexibility of our cortical space and body maps, this ancient system of place and grid cells is still very much with us - you could say it was "grandfathered in." Instead of mapping personal space from an egocentric point of view, as your parietal and premotor circuits do, place cells and grid cells are what scientists call geocentric."

The rest of the section is what they are, how they differ. Place cells were discovered in 1971 by researchers John O'Keefe and John Dostrovsky, who studied the hippocampus and memory. They appeared to encode parts of a maze the researchers' rats explored. Thousands of place cells combined in millions of ways to give the rats endless place-learning capacity.

The authors remark:

"You have place cells too. When you walk into your kitchen, certain place cells fire when you are standing in front of your refrigerator. As you move toward the sink, a different set of place cells will mark your new position in the room. If you walk into your dining room or living room, another combination of place cells will mark your spot in space."

Place cells help you navigate around your home if the lights go off, help you find a candle. They internally map where you keep your objects in relation to one another, and in relation to your body as you move through space. Some keep track of where your head is turned and update you about your balance and your body schema. If you spin in place you'll be lost until you find an object you recognize - then you'll 'know' where the door is.

"place fields are calibrated according to fixed reference points - sofa, chair, table, window, door - that do not usually change. If you move your furniture around, your place fields reconfigure your map."

More to come on this. Much more.

Now back to function... Part II

2. UN-clear metaphor

In Part I, I introduced scenarios related to clear metaphors people use to describe pain. I used "icepick" and "fish hook" examples. When someone says they feel like they have a foreign object lodged somewhere, and it's perfectly obvious they don't, the comparison is at least acceptably clear as metaphor, even if the solution to the pain isn't yet clear.

What about if the metaphor used is not about a foreign object, but a body part that truly does exist inside the body? Suddenly comparisons are much less clear. Suddenly structures are blamed for misbehavior that is actually functional. Suddenly something that feels LIKE a "locked joint", becomes in a patient's mind, or in a therapist's mind, or a doctor's mind, a possibly 'real' locked joint. There are a million of these. Examples are, "I must have a bone out of place." "A muscle is cramped in my foot." "This tendon is too short - look". "I was fine until I lifted that couch, then my (whatever) seized up on me."

These are still metaphors, but now the issues the patient feels in the tissues are not clearly metaphoric at all. In fact, there has been nearly perfect reflection of metaphors like these, a verbal and investigative ping pong match of pain memes and memeplexes going on ever since humans have had pain and human primate social groomers have tried to help.

But.

Slowly it has begun to dawn on some of us who are fascinated by all the little tricks of the brain and the habits it has of setting up simulations of reality, that pain is something of a perception itself. A great example is phantom limb pain. This is pain that an amputee feels vividly and to his or her consternation, in the missing limb. It can't be the limb hurting, because the limb no longer exists.

But.

A representation of the limb does exist, in the brain. A brilliant neuroscientist/brain researcher named V.S. Ramachandran figured out that using a mirror box could help. The patient places the remaining limb in the box in a way that creates an illusion of a missing limb being present, and able to move freely. Even though the patient knows full well it's just a mirror image, moving freely and painlessly, some important part of the visual cortex actually will record this information and send it around the brain in such a way that pain is relieved in the "missing limb", the phantom of the missing limb, the virtual body part, the representational map of the part located in the brain. It's as if the brain thinks to itself, hmm, I must have made a mistake. It looks like that part can move ok.. Alrighty then, I'll take out the pain signal.

It gets even more strange - it turns out we all have these maps - everyone has them. And we all can feel pain in them, just as amputees do. Ready for more strangeness? Pain is usually in the brain map part instead of in the actual part. I know - this is where "what everyone knows" bumps into new science. Such apparent heresy! But not so strange if you accept the idea that the brain is a great big simulation producer. It can make you have a pain in a part that is not at all "damaged", just because it senses a threat to that part. Yes, you read that right. Nothing has to have happened to the part for the brain to make a pain in it. From my blogpost of September 4th, "Rhythms of the Brain" by György Buzsáki:

The short punch line of this book is that brains are foretelling devices and their predictive powers emerge from the various rhythms they perpetually generate. At the same time, brain activity can be tuned to become an ideal observer of the environment, due to an organized system of rhythms.

I really want you to know I did not make this up - György Buzsáki wrote an entire book about how this is not just possible but likely.

What can decrease pain? Helping the brain sort, refine, redraw its maps. How? Create an illusion for the brain in regular 4-limbed people in pain that is as powerful as the mirror box is for phantom limb pain. How? Well, movement is the key here. The brain needs to perceive some kind of movement before it can get off the square it is stuck on, pain-wise.

One can create a kinesthetic illusion of movement, through skin stretch. Simon Gandevia is the researcher who came up with this while studying cutaneous receptors. He is a lot less famous than Ramachandran is, but no less important to those of us who work with new ideas on how to pare back erroneous metaphor in our own thinking about pain. True, Simon Gandevia hasn't linked his own research yet to pain relief itself, specifically, but he has provided a huge clue. Putting this clue together with Patrick Wall's idea that pain is a "need state", and that pain relief follows a "consummatory movement", and bearing in mind the success of mirror therapy for pain in limb representations, is it really that hard to draw a line connecting the dots? Treating people who still have all their parts is much easier because you don't need a mirror, you just need to get on their skin and give their brain a movement illusion.

To me, this cuts through all the confusing metaphoric mesodermal tissue based wild goose chases that practitioners go on, led originally by convincing descriptions of pain given to them by patients, which they then go on and foist on other patients, and all of which becomes some version of gravely mistaken treatment orthodoxy. I am fond of saying three things to patients on their first visit:

1. There are people who have things on x-rays like degeneration (etc.) who don't have any pain
2. There are people who have pain, and have no x-ray changes
3. Pain and x-rays (or, pain and body weight, pain and posture, pain and... [etc.]) don't necessarily have anything to do with each other

(Truth is, I'm haunted a bit by all the years I worked as a PT, diligently and inadvertently contributing to peoples' pain experience by choosing wrong words, like, "looks like a disc problem", "Sudek's Atrophy? You'll need to wear this brace to keep your fingers from curling into your palm", "This looks like a tendon rupture", etc etc... I'm haunted by a past filled with thousands of faces of patients who intersected with my life, in pain, with ordinary nervous systems and intact tissue, looking at me as some sort of keyholder of relief for them, me having official human primate social grooming status and license but no key, no clue!- to how to really help them at all, other than temporary accompaniment and a set of protocols on how to get them to move anyway, even if it hurt, social manipulation/motivation. Cheer leader stuff. It makes me cringe nowadays - if I were in a patient's shoes I would want to shoot some kid fresh out of school who had the audacity to think she knew the first thing about what my brain and body were going through. But apparent sincerity and earnestness kept me alive, I suppose... Plus, to be fair to my former self, there was not all this nice research available back then, in the 70's. There is no excuse for continuation of perpetuation of inappropriate metaphor in my profession (or the medical profession) anymore, other than pure ignorance/being too busy to read/relying on the schools to have taught what is necessary to know to do the job. The schools are only just learning about this stuff themselves! It'll be awhile more before they figure out how to do the requisite "knowledge translation".)

Certainly there will be some hips that still need replacing and some knees, and so on, but the pain felt in those parts which have been sacrificed might not be relieved by the sacrifice, might not have been from those 'parts' in the first place!

Does it not make more sense to deal with pain first, provide the simulating brain with a movement illusion, see if it really is cranking out pain for no particularly good reason? If the pain goes away, great! Show the patient a few exercises to keep pain at bay. Another knee or hip or (insert name of structure) saved from sacrifice. If pain doesn't go away/stay away, then think about replacing the part.

Now back to function.. Part I

In the Butler blog is a post about painful words, how they conjure up horrible imaginings in peoples' minds, create needless stress and worsen pain. A comment from a reader of this blog about his knee pain, knee replacement, his surgeon's words reflecting insecurities about not being able to "fix" his patient's pain, and the reader's battle to withdraw from heavy pain meds came to mind immediately.

...I realized after months of difficult recovery from my joint replacement that one of the key things my surgeon said to me was "I am worried about our ability to control your pain". He is a great surgeon, and meant well. But he played directly into strong fears that I had about the surgery already. I obsessed on the idea that my pain might be uncontrollable. I believe that contributed a lot to me winding up on 350 mg per day of oxycodone.
I'm doing much better now and have been off the oxycodone for 5 weeks.

A battle is being fought by a tiny group of people in lots of ways, including through blogs (like this one), comprised of practitioners (myself among them) whose main agenda is to deconstruct pain for the sake of having less of it around perpetuating useless suffering. We are fighting an abstract battle, one of memes: the mindless and needless enticement of persistent pain into permanent suffering, through simple correctable things like word choice. We are trying to change this by presenting, studying, arguing, pointing out current pain science, science which refutes an entire historical mind set not only guilty of permitting needless suffering, but also of giving rise to a professionally reinforced sense of helplessness and avoidable drug use in patients.

There are at least two layers to this:

1. Clear metaphor

Some of the metaphors patients use are easy enough to understand as such: when someone says something like, "It feels as though I have an icepick through my shoulder here and a fish hook stuck in it back here", it's obvious both to them and to the practitioner that they have no such thing really - instead they are explaining how their pain "feels" to them. The practitioner response is often a little smile at the colorful language; if the patient is insistent after a few treatment attempts (based on having diligently tried to find and treat the offending tissue) the practitioner rapidly begins to feel helpless and either refers on or else decides the patient must be crazy with all that icepick talk.

At least three scenarios can ensue from here:

a). With any luck the patient will be referred to a PT who understands pain, and can reassure the patient that perhaps that's really all it amounts to. A few little manual therapy maneuvers, voilá, some cranky neural tissue somewhere in the vicinity has more oxygen, the brain maps all overlap perfectly again, the protective motor reflexes dissolve, needless ion channels vanish, stress is gone, all is well, patient can move the shoulder just fine again. Metaphoric icepick and fishhook are gone as if they had never been there, even as "just" a feeling or sensation that was turned into an image in the patient's mind to help him or her communicate verbally something ineffable like pain that has no words of its own.

b). In scenario two, the patient may be referred for further imaging and possibly surgery. Diligent medical practitioners will diligently look for and usually find some aspect of the patient's body that they decide must be responsible for the pain, and will schedule a surgical intervention. They may be referred before or after to a PT who closely follows the medical tissue-based model for pain. The PT will do all sorts of things to try to help, but if their word choice is not careful, they will merely reinforce pain while trying to get the patient to do all sorts of activities in spite of the pain.

c). In scenario three, the patient is referred to a psychiatrist.

Stay tuned for Part II, Unclear metaphor.

OK, back to structure for just a minute...

I'm so pleased to announce (with Michael Shacklock's permission and blessing) that he will soon be re-publishing portions of a classic text of great interest to all nerve-o-philes, namely Alf Breig's book, Adverse Neural Tension in the Central Nervous System, long out of print.

The new release will be called Biomechanics of the Nervous System Revisited. It will explain to all manual therapists new to thinking about this particular structure called the "nervous system", the physicality of it, how it slides around inside the body, how to treat it (respectfully, we hope). It will contain many of the original photos taken by Breig himself, during surgical procedures, and published in the original book in 1978, which clearly show how nerves move, especially nerve roots.

Breig's book, very scarce, out of print, attained near-mythic fame. The pioneers of neurodynamic treatment had obtained copies nearly three decades ago, but not many books had been printed, and no one else in later waves of interested neural treaters could lay hands on it, or on any of these pictures, much to our collective frustration. This sad fact created a bit of a dip in the understanding of nerve mechanics for a long time. Until now. Make that until soon. Until January 2008.

Michael made trips to visit relatives of this recently deceased surgical explorer, and the explorer himself before he died, and was able to obtain rights to reproduce much of the content. Thank you so much for this, Michael. What a gift you are bringing manual therapy.

Deconstructing and rehabilitating the concept "placebo effect"

We have the conventional definition of "placebo" versus the Patrick Wall definition, which is the same definition used by PTs interested in treating pain.

For anyone who still doesn't know who Patrick Wall was, he and Ronald Melzack combined efforts to research pain for over 4 decades. (Tip: Read the paper linked to Ronald Melzack. It explains his neuromatrix theory of pain. It's the best pain theory in existence to date, in my humble opinion.)

But now, back to placebo. Placebo is a loaded word, charged with centuries of flimflam, misunderstanding, and exploitation. Patrick Wall figured out what placebo response really is, how that works, and worked together with PTs to determine how it could be harnessed ethically for relief of pain.

I count myself among this slowly growing cadre of PTs who are laying aside our old tissue-based belief system based on 3 or 400 years of ignorance about pain, in favor of instead understanding the science that has developed around pain. Patrick Wall said (paraphrased), "Placebo is not something administered TO a patient, it is something to be elicited FROM a patient." He went on to describe the perfection of a placebo response. It was something the patient's brain made by itself, a chemical substance, antidote, precise in dosage and specific to the problem, which went straight to the receptors in need of it. It was allowed to exist in the brain for only as long as necessary, whereupon the brain would dismantle it by itself. In other words, one sort of nature (placebo response) taking care of another kind of nature (pain response).

After a brief nervous system explanation, it's a lot easier to explain effects that are "placeboic" in a way such that people will be more inclined to think of "placebo" in a positive light rather than negative - at least they catch a glimpse that it will be good for pain, that you don't think it's undesirable, that you want to help them make their very own, and begin to see achieving it as a victory not a defeat. It must be reframed/ redefined as a treatment effect that is desirable and unique to them, something that is produced naturally as a consequence when a "team" (comprised of patient and therapist) develops a temporary third entity (the interaction of nervous systems) to help a fourth entity (the patient's own nervous system) wrestle with and overcome a fifth, the "foe" (pain output). When people have the Wall definition of placebo explained to them they are not at all disinclined to go for it. They are willing to set up a treatment improv mini-drama with you in which all these entities can exist on their own for a short while, and change places, play musical chairs until all the chairs are taken and pain has nowhere to sit. They become co-conspirators in the development of a "placebo" effect that will fix their own system, in fact they get that it is up to them, by doing very little except waiting patiently and tracking processes. The right frame around that charged concept, "placebo", is everything.

The team can be dissolved. The patient can go off with new strength derived from new cognition around the problem, a new understanding that while their nervous system includes "them", it is not "them" entirely. Instead it is something they can successfully interact with, as one might find oneself interacting with an unruly child or a screaming baby. Do not abuse the nervous system. Do not permit anyone else to abuse it. Figure out what it needs (usually some form of movement developed slowly and carefully, with close attention to a sense of timing), then supply it, and be patient. Do this for short periods of time (minutes), frequently (as one would feed a starving baby, perhaps every hour or two). It will take a good three days for abnormal and too numerous receptor sites (associated with pain sensitization) to dismantle and (hopefully better ones) to reform. Allow time for improvement to establish itself. Get on a better track and find ways to enjoy the rest of your hours per day while waiting optimistically.

More on Michael Shacklock

I've had Michael Shacklock linked to my website for years, and decided it was high time to link him to this blog, where I spend more time now.

I wrote about Michael a couple years ago ( see archives for November 2005). At the moment, he is working hard to get a book republished. It will be very exciting for all of us who are human primate social groomers of the "functionalist" persuasion, and wonder about what bits of "structure" we really need to bear in mind (thank you to Neurotopian Matthias Weinberger for clarifying the two broad camps of debate) ... you'll get a hint or two about this by reading his newsletters.

I don't want to spoil the surprise, so that's all for now - over and out.

Boiling the flimflam off human primate social grooming

Every so often something crosses my path which cheers me up. Recently I found this blog by an ex-chiropractor who no longer tolerates wool pulled down over his eyes or his mind. Good for him. Here's another.

The sooner hucksterism leaves my field of endeavor the sooner I'll be way more happy. To get hucksterism out of this field requires that individuals like this begin to save themselves from replicating it, and then talk about it.

Really, it comes down to just this: Someone in pain, Person A, goes to see someone, Person B, about it. Hopefully Person B has been trained to be ethical and scientifically respectful. Hopefully Person B does not take on a hero's role. Hopefully Person B has been around long enough to have discarded uselessness in favor of honesty. Hopefully Person B is current with pain science.

Person B will do what he or she can to provide a favorable no nonsense context for the patient to conduct his or her own exploration. There will be usually some provision of exteroceptive input of some kind. There will be no funny business - Person A will be told what is expected of them, taught what to look for, asked to proceed at their own rate. It will have been made clear, one way or another, in some way Person A can understand, that it's their job to get themselves better, and that Person B is a helper.

Person B will realize all along that he or she is nothing but a catalyst. Person A will be doing all the hard work of sensing and learning, changing their own nervous system (or rather, allowing their own nervous system to change itself) to something more optimal. The desired reaction occurs entirely within the patient, and the only reagent is the patient and all their inTRA-relationships. None of this is a simple thing to understand at a scientific level, but progress is being made and the science base is growing; maybe one day the physical contact aspect of human primate social grooming will be not only stripped of flimflam but will have vindicated itself.

Changes occur, usually in the direction of improved function and decreased pain. But not always, and not in any sort of predictable way or speed. All this depends on the patient, the context, and on the quality of therapeutic contact within a treatment room.

Let's discuss "crucible". On the surface it means a container such as the ones used in chemical labs, able to stand high heat etc. A deeper level of meaning (without being religious in any way) is "cross", an intersection or crossroads, a place where a change of direction can take place. Other words contain the same root, words such as "crucial", or something that is the "crux" of a matter.

A treatment room is, then, a metaphoric crucible. As such it should be able to stand the metaphoric equivalent of "high heat" - the patient should sense that the room they are in is safe for them to be who they are, express whatever they want. And they may well need to.

Not only should the room be designed to take the "heat", the therapist should be "fireproof" as well, able to tolerate whatever sorts of pain offerings a patient might bring, emotional or physical, without flinching. Flinching is a non-conscious, mirror-neuron, socially connective, social behavior. To NOT flinch and still retain good therapeutic contact is definitely a learned behavior. Here, I must confess, I am still working on getting the right proportions of non-flinch combined with solid connection during the interview. I'll never be perfect - no therapist will ever be perfect. It keeps one humble and honest. I would like to add, however, that not very many people are "high heat" people - most cases of persistent pain are very straightforward.

The therapist will have tried to eliminate as many distractions and noceboic elements as possible from the crucible. He or she will have made it as clear as possible that the pain issue is something the patient must permit themselves to work through. This needn't mean having to experience more pain. In fact, the less the process "hurts" the better. No point in reinforcing the pathways associated with the very thing the patient has come in to try to learn how to deal with, get rid of.

Eventually the time will come for the reaction. I usually spend a half hour or so, interviewing, examining, explaining, which leaves a half hour for the patient to experience a sample of what happens on the table. Subsequent visits are much more tabletime. Usually at least two visits, sometimes as many as 4, are required to complete the process. (A few of my patients come in long term for various reasons, but very few indeed. It is not encouraged.)

Hands-on is definitely involved - for most people who come. Anything that sounds like wind-up pain, I like to leave alone, at least in visit one. I've had people leave disappointed, people who just didn't get that they would require more prep time, and who didn't return. C'est la vie. Better they leave in the same shape they came in, than feeling worse. I'm happy to say this is so rare it's only happened twice. I learned my lesson with a patient one time whose pain flared suspiciously with the sort of hands-on I do, so I learned to spot the signs, and do not use manual therapy in the first visit with a patient who says something like, "I've always noticed, whenever I get an injury and it heals, even just a scratch, it always feels painful after that - the pain never goes away." Fortunately these sorts of patients (highly sensitized ones with abnormal pain processing) are pretty rare. Most people just have regular persistent pain, good processing, but need some assistance so they can connect dots within their own nervous systems.

Finally, the hands-on part is nothing more than contact with skin, at varying pressures and angles, but mostly lateral stretch. This does nothing TO a person's "body", or TO any of the mesodermal derivatives that lie within it, rather it sets up volleys of firing sequences that have been mapped and studied by neurophysiologists and other curious people, and documented scientifically (by Simon Gandevia and others). One can predict that if one has chosen one's patients wisely, and guided the therapeutic relationship appropriately, Person A will let their own non-conscious system take over all the heavy lifting, let it will change itself/its output into something easier to live with, something less mechanosensitive, less painful, with easier movement to follow.

Like any catalyst, the therapist will have added nothing to this reaction, will have only functioned to help speed it up, and will leave nothing of themselves in the final product.

Ineffability

Speaking of ineffability, there is a manual therapist essayist who is very very good at writing about the kinesthetic kinds of ineffability from a therapist point of view. Please check out Barrett Dorko's essays (listed in the menu to the right).

Right Front Insula

I am about to read Sandra Blakeslee's book, The Body has a Mind of its Own for the second time.

Chapter 10, entitled "Heart of the Mandala", discusses a part of the brain I am particularly interested in because of my work as a manual therapist, the insular cortex. It registers all "incoming" from the body including interoception from organs. You could say it monitors 'business as usual' and remains alert to any fluctuations. It reads the body surface as well. It is both threat detector and interpreter. It is very important in my work to realize this region exists, that it is reading one's interventions continually, and to not trigger it the wrong way.

This region is found in other mammals, but in a rudimentary form. In primates it is much more developed, and humans alone have a level of integration nonexistent in any other animal:

From p. 186:

After reading off the internal state of the body from both the left and right insulas, the human brain - and only the human brain - performs yet another level of integration. The information from both your insulas is routed to the right frontal insula, the same region Critchley found corresponding in size and metabolic vigor to a person's empathic talent.

Your right front insula "lights up" when you feel all the quintessential human emotions - love, hate, lust, disgust, gratitude, resentment, self-confidence, embarrassment, trust, distrust, empathy, contempt, approval, disdain, pride, humiliation, truthfulness, deceit, atonement, guilt.

One's touch, one's handling conveys all manner of conscious and non-conscious intent - the best one can do is intend to be as helpful as possible.

One of the hardest challenges is describing something that has no words, something ineffable. Many years ago while writing a pamphlet describing to potential patients what to expect during a visit, I struggled to describe that elusive interface of manual treatment, that completely subjective zone where hands touch person and physical boundaries disappear for awhile. I wanted to reassure potential patients that I knew how to be helpful without being overwhelming. Finally I came up with a sentence describing my hands. I used the words "slow, light, kind, intelligent and effective". Looking back, I'm quite sure now that the feeling those terms encompass came up from my right frontal insula via the left cortical hemisphere and out through my typing fingers. In fact I'd lay odds that if an fMRI were done on me while writing, it would show that zone never shuts down - it's both my biggest impetus and harshest editor, for better or worse.

David Butler Blogs

David Butler is a PT pain pioneer from Australia. He is researcher, clinician, university professor, and author of three books, two for therapists and one for people with pain. His website is www.noigroup.com ; there is a discussion forum attached to his site which has, alas, been closed for some time now, although it can still be accessed for reading.

This fall he began to publish three blogs. One of these is on Neuromatrix Training. The other two are linked into the banner of this one. I've also linked David's blogs into the menu on the right. Pay him a visit - he has much to offer.

I met David about 10 years ago as a participant in one of his dozens, possibly hundreds, of workshops he has taught all round the world. He certainly lit a fire under my brain, but I seriously doubt I'm the only PT to have been so affected. Carry on David, carry on.

Neil Pearson's Pain Webcasts

On October 15th, CPPSG (Canadian Physiotherapy Pain Sciences Group) co-chair Neil Pearson did a free three-hour presentation on pain to a group of about 60 women who had gathered to listen. About half of the audience was there to participate in a study that Neil is conducting, to determine the effects of education alone on persistent pain.

He has agreed to allow me to post links to the entire talk, in three sections.

This information is freely available here to anyone who would like to learn more about pain, whether it is pain they have, pain they are treating in patients, or pain in a family member/friend.

I've also put these links in the menu to the right.

Neil Pearson's Webcast Part 1 (45 minutes)

Neil Pearson's Webcast Part 2 (42 minutes)

Neil Pearson's Webcast Part 3 (60 minutes)

It is a really good series. Educate yourself - it's the best way to grow hope.

Neurotopian's "Pain for Dummies" series

Neurotopian is a German PT I met online long ago, named Matthias. He is and was brilliant - I am so glad he is writing his blog in English for those of us who don't speak, write, or communicate in any way in German.

Recently I came to realize that people actually do read this blog, that it comes up when they search for certain words, like "pain", etc.. If that's the case, I really want to give Matthias and his Neurotopian blog some press.

Check out his latest post, Pain for Dummies VI. Read through his older posts in the series as well. This is a guy who never stops thinking. Thumbs up Matthias. :)

Thoughts on zombie states

Deric Bownds always has interesting bits blogged at his site, Mindblog (see link to the right). Today, he offered up this: Some Rambling on Selves and Purposes.

I won't recreate the links in his post. Just go to his post and click on them yourself. Especially, read the quote from the Blakeslees' book.

Ginger Campbell recently interviewed Christof Koch (neuroscientist) (see her show notes page for podcast #22) who has many insights into what he calls "zombie" behavior. Zombie behaviors are those which have grown so automatic that no one really has to really be "home" for them to be enacted. Much ordinary social exchange could go into this category - conventional behavior, smiling, etc. I think much PT practice can easily become zombie-like as well. This is a little-recognized and glossed-over possibility. If I am in pain, and am taking my body in to see if I can get some help for it, I don't want a zombie PT treating me. I want someone who will come alive to the pain output my nervous system is broadcasting throughout my body, and I want that individual to care about it and for it. I want her or him, to demonstrate this care, by handling me gently.

I will need this consideration from them, for no matter how together I may seem on the outside, inside I will feel thoroughly discombobulated. My nervous system will be completely sensitized to any hint of any lack of attentive care, especially while being touched - my nervous system will be reading theirs like mad. It will be like I have no boundaries, and I will rely on my caretaker to have ones that are adequate, both with respect to my physicality AND inside themselves, a simple ability to attend, to stay focused, to not permit interruption from outside the treatment room during this process, and to set up the treatment crucible with an optimum length of time in which our two nervous systems can be connected through manual contact.

I will most definitely need to be reassured in the midst of my decompensation, wittingly or unwittingly, and will need a helper who is NOT enacting behaviours from some disconnected state of awareness or attention. I want nothing less from a care giver of mine than I offer to others as their chosen Human Primate Social Groomer.

The only way to not become a zombie, insofar as I can gather, is to practice attending to things (with whatever illusion we can scrape together as an "I" construct), simple, physiological things like breath, like one's own movement/motor output, finding something fresh and new in it every single day, until the day comes when finally we no longer need to think about constructing any more "days" - our personal arrow of time will have hit its mark.

Sorting out manual therapy

As far as I know, no one has really taken this on in any sort of serious way. So what the heck, I'll give it a bit of a go.

First there are a few self-explanatory truths to base this project on, that are beyond dispute in my opinion:
1. Energy concepts do not belong in manual therapy.
2. The nervous system is the part keeping a human organism "alive", and it is the part responsible for the phenomenon of felt and experienced pain. Nothing about the pain experience will change until this system is ready to change it, or to let it change.
3. Neuro-modulation in the broadest sense means, supplying a novel input in order to facilitate a new output.


If we are faithful to these three basic concepts, and use Occam's razor, ever so carefully, ever so precisely, we will end up with the following idea: All manual therapy involves touching the body somehow, so therefore all of it is neuromodulatory. The receptors that are affected are mostly mechanoreceptors and exteroceptors, all afferents. We could call ALL manual therapy, "Extero-Mechanorecepto-neuromodulation."

Some forms of manual therapy, or mechanorecepto-neuromodulation, focus on the surface more, while other forms focus on what lies below the surface. For example, acupuncture and needling in general supposedly treat something underneath the skin, but given the depth of cutis/subcutis, and the ubiquity of cutaneous neural twigs, it is more likely that needling stimulates mostly exteroceptors, maybe a few mechanoreceptors. Which is fine. Let's move on.

Manipulative therapy purports to treat joints, including those mechanoreceptors known as proprioceptors. To get to those, it is necessary to get past mechanoreceptors in skin and other tissue; however, manipulative therapy ignores more superficial mechanoreception as if it were not even there.

Soft tissue sorts of therapies, of which there are too many to call out by name, stimulate mechanoreceptors in skin mostly, and in layers just deep to it. So we could classify all these as neuromodulation of the exteroceptor/mechanoreceptor classes of afferents.

So, we could end up with a very small flow chart that depicts all of the manual therapies, with "Manually Applied Neuromodulation" at the top. There would be two branches off this item. One would read, "Extero-mechano-proprio- neuromodulation" (for manipulation of joints) and the other would read "Extero-mechano-neuromodulation" - exactly the same but for proprio (everything else).

Now, the razor can be pulled away for a time, until it is shown that Extero and Mechano only are more than enough effective to permit the dissolution and gradual fading entirely away of that whole first branch of the tree, which basically includes only joint manipulation.

I contend that any "proprio" stimulation necessary can be done without the audible pop noise. Studies support this. I contend also that joint manipulation by whatever name, as a manual therapy, has been kept on life support for a hundred years, and it is time to pull the plug on it. If it can stay alive under its own steam, fine, but no extreme efforts should be made to maintain its existence as a set of "special" knowledge to be handed along in a cult-like manner.

Body Maps

Since my new book, The Body Has a Mind of its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better arrived I've been buried in it. The Blakeslees have written a very good book, (even if they didn't include a reference list).

Ginger Campbell MD has an excellent podcast about this book. Visit her show notes here.

This book, and for those in a hurry, the podcast, affords us a long leisurely look into the brain and its workings (especially after having just read Rhythms of the Brain!) The brain creates several maps, mostly in the parietal lobes, mostly of the body itself (the human antigravity suit itself, inside and out) but also of the space around the body - it will change the maps to include any tool that is being used, for example, a cane used by a blind person to navigate along a street. The kinesthetic/motor map stretches out to include the cane, spreads over the visual cortex, and enables the person to "see" the sidewalk through their body.

The brain turns on as soon as it forms embryologically, starts to function even as it still grows (the frontal lobes are not fully grown for a couple decades), and does not ever turn off until the moment we die. Even while we are sound asleep, it is still working away, keeping our lungs breathing and our heart beating. Amazing. First there is movement, then through feedback from the movement and subsequent encounter with the environment, the brain refines its maps of space and how the body fits into them. Strokes and other neurological twists of fate can lead to some very strange mapping problems, like the feeling of having three arms, or only one, or that a limb does not belong to one and must be amputated.

Of interest to me as a manual therapist is a careful and lengthy explanation of various dystonias and what is thought to happen to the mapping in association. Stress-free practicing of any honed motor skill is advised; just practicing mentally (e.g., golfing) will preserve mapping with good fidelity - the brain will use premotor maps, so no need to burn out your actual motor maps. Musicians will find this an important book to read, sports enthusiasts, anyone who uses their body for skilled performance of any sort.

When I think about how I use my own body, I realize I'm not apt to incur dystonia over time. For one thing, I don't rush, and for another, I never do the same thing twice, the same way, ever.

"Rhythms of the Brain" by György Buzsáki

I've been engrossed in this book ever since it arrived into my hot hands last week. The first sentence reads:

The short punch line of this book is that brains are foretelling devices and their predictive powers emerge from the various rhythms they perpetually generate. At the same time, brain activity can be tuned to become an ideal observer of the environment, due to an organized system of rhythms.

He writes in the introduction;

My connection with brain rhythms began in April 1970, during a physiology lecture given by Endre Grastyán in the beautiful town of Pécs, on the sunny slopes of the Mecsek mountains in Hungary. The University of Pécs, or Universitas Quinque Ecclesiensis, as it was called when founded in 1367, has produced a remarkable set of neuroscientists, including János Szentágothai, the legendary neuroanatomist; Béla Flerkó and Béla Halász, pioneers of neuroendocrinology; György Székely, the renowned spinal cord physiologist; and Ferenc Gallyas, the creator of the silver impregnation methods widely used for neuronal labelling.

He goes on to talk about Grastyán's path to neuroscience, then comes back to the intersection of his own life with that of his mentor and inspiration, i.e. Grastyán himself:

In that particular lecture of April 1970, he talked about how the brain outputs, such as movement and cognition, control its inputs, rather than the other way around. His key idea was that control in living systems begins with the output. This is the seed for further evolution of the brain. Even in the most complex animals, the goal of cognition is the guidance of action. Indeed, the first simple biological systems did not have any inputs; they did not need them. They simply used an economical motor output, a rhythmic contraction of muscles. This is, of course, sufficient only when food is abundant in the sea environment. More complex forms of life evolved from this simple solution by modifying the simple rhythmic output. Sensation of direction and distance developed only after the "invention" of movement through space. The idea of output control and feedback is a profound thought even today. Back then, when Pavlovian sensory-sensory association was the dominant ideology in the East and the stimulus-decision-response paradigm dominated Western thinking, Grastyán's teachings were unusual, to say the least... in his physiology lecture, Grastyán was talking about some truly intriguing questions that sparked my interest. I applied to become his apprentice and spent most of my student life in his lab.

A note - Buzsáki was in med school at the time.

His book is a treasure, deliberately written for general readership but minus any dumbing down or tedious linearity/tunnel vision. He reminisces about lunchtime conversations fondly;

The best training in Grastyán's laboratory occurred through my participation in the regular lunch discussions that could go on for several hours, where topics meandered chaotically from homeostatic regulations of the brain to complex philosophical topics. It was during those lunch lessons where I first leaned about the hippocampal "theta" rhythm, the oscillation that has become my obsession ever since... As I have repeatedly discovered in my career, the informal lunch-seminar approach to science is hard to substitute with formal lectures or the reading of dense scientific papers. Seminars are tailored for an average group of people with the naive assumption that the audience retains all the details and follows and accepts the fundamental logic of the lecturer. In contrast, the essence of lunch conversation is to question the fundamental logic, a quest for clarification and simplification, a search for explanations and answers without a rigid agenda, where the focus is not on covering large chunks of material but on fully understanding even the smallest details. Of course, one can follow up a lecture by finding and reading the relevant published papers on the topic. However, most of the exciting findings in neuroscience are hidden in the small print of specialty journals, often written in a specialized and arcane language comprehensible to, at most, a handful of specialists. Overwhelmed with new and important discoveries in the various sub-subspecialties, the practicing neuroscientist, such as myself, tends to forget that neuroscience is of startling relevance to a contemporary society wrestling with complex issues such as social behavior, depression, and brain aging. It is hard to predict which of the numerous fundamental discoveries could alter the face of such large issues, and unless they are conveyed to others, they might be overlooked without making an impact. This is mainly so because the explanations we provide in papers to the superspecialists may be impenetrable to the uninitiated. Without attempting to place our work into a larger context from time to time, we deprive ourselves of the chance to be able to connect to the more macroscopic and microscopic levels of research. Yet, discoveries and insights realize their power only when understood by others. Understanding this important connection is what mostly motivated me to write this volume.

The entire book is written in this conversational style, but be aware that footnotes are to be found on nearly every page, dense with bibliographical/ historical/ explanatory detail. He explains the impact on neuroscience of several fields of science, including but not confined to complexity theory, consideration of temporal domain, why fundamental mathematical understandings are important. He takes care of both "why", and "how". His book does not contain chapters, instead he has broken his book into "Cycles", that unfold outward sequentially but also radially from a core, like a good orchestral symphony. If anyone has ever succeeded in giving a readership a sense of kaleidoscopic expansion of concept, a feeling of putting new ideas into order, it is this writer. A sense of movement is part of the reading of this book - he carries the reader along swiftly, effortlessly, gently and surely, providing long, sustained, spherical vistas into the knowledge base from lofty heights, as surely as any experienced and people-skilled mountaineering guide would do for a novice hiking group (minus sweat and exhaustion!), providing opportunities to examine the view from various pinnacles, ensuring not only that the experience provides memories to last a lifetime, but taking great personal pains to provide the possibility that the reading experience itself will be life-changing/enhancing/motivating. No one will come away from this book still ignorant of neuroscience, with no clue of how the brain works, of how the organism is integrated into it, of how it is integrated into the organism, or not able to "feel" the material on some level of being.

No one would regret reading this book. Highly recommended.

I will be bringing more of his book here over the next little while.

Trailblazing; No Time Left for Making Nice

Yet another discussion cropped up on SomaSimple, necessary though not without misunderstandings. It had to do with a "health performance solution" system dreamed up by a chiro and sold for major bucks to athletic trainers (among others), a rehash of everything that's already known and recycled endlessly in what I like to think of as "Mesodermolandia", a mythical "rain forest primeval" that gave rise to the world of human primate social grooming. Here is where reliance on "what works" feeds and fosters a conceptual anything goes attitude. Here, safe from challenge to status quo, a predatory spirit of postmodern what-the-bleep-do-we-know-anyway retreat into confused troop mentality flourishes, and a dense fast-growing tangle of argument based on next to nothing at all, combined with the blistering humidity of interpersonal opinion, chokes any real effort to think scientifically or even logically; all ideas underpinning this little subculture remain unexamined yet vigorously exchanged for coin.

After a reasonably successful deconstruction, the thread postmortem included the usual comments re: we weren't "nice" to the bringers - we pressed them for detail on their treatment construct (something seen as a bit rude in this world, believe it or not..), our interchange was seen to be "sarcastic", we seemed "hostile". I wrote the following post in response to these criticisms of our seemingly poor demeanor.

I'd like to point out that therapeutic niceness and politeness is likely what got us the deepest into this boggy morass in the first place, the swamp of erroneous belief, unsupportable treatment construct, and mesodermal bias, out of which grow giant trees of nonsense, treatment systems with deep roots down into the economy, choking out rational thought and real scientific advance of our human primate social grooming professions.

We each wake up one day and realize we have a choice to make - continue playing nice and do nothing, the mental equivalent of living wild and swinging from vine to vine like our primate siblings, OR.... learn to exercise our minds and their capacity to think, sort, discriminate, categorize, make sense, link, develop and strategize a way out of the mental jungle we have found ourselves in. Occam's razor isn't nearly big enough to do the job required in this profession. We need Occam's chainsaw. And when wielding Occam's chainsaw, inevitably some sawdust will get in someone's eye from time to time, or a wood chip hit them on the head, or the roar of the machine itself may sound uncomfortable.

But it's necessary. We mean no one any personal harm. Wear a hard hat and stay out of the way when the big trees topple. We're going to do this, blaze a trail of deconstruction, because we have to find a way for this profession to get itself out to the main road. Don't worry, it's far from being a clearcut.

Personally I'm determined to cut down whatever I need to, and in my tiny backpack I'm salvaging and carrying the essentials of soft kind gentle manual therapy. I get ever more invigorated to the task when more mesodermal bias looms in front of me, blocking my way.

The Brain's Kindness Detector? Right Anterior Insula

There is a long thread on SomaSimple to do with the insular cortex, a part of the brain that was researched heavily last winter. Well, the fun never stops, and now there's a book by Sandra and Matthew Blakeslee called The Body Has a Mind of its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better, not quite published yet. I will be reading the book not only as the owner-operator of an insula, but as a therapist who treats patients with persistent pain, who therefore deals with other peoples' insulae on a daily basis.

The September edition of Scientific American Mind features an excerpted chapter that has definitely sharpened my appetite for the book. The Blakeslees discuss the point that this region is found only in primates and by extension, us. Frogs, even other mammals like dogs etc, even though they can act sometimes as if they can feel everything the way we do, can't/don't. But first they explain the system. Here is a small part of it:

Quote:
Just as a road atlas is full of maps that represent real-world locations, your brain is full of body maps that represent aspects of yourself, inside and out. In contrast, the main goal of exteroception, externally oriented perception, is to create maps and models of your body, the world around your body, and your body's relation to the world. Your brain creates and maintains maps of your skin surface, limb position, joint movement and musculoskeletal system so that you can move about and interact with objects and people. You have distinct fibres in your spinal cord that carry such information in both directions: up from your body to your sensory maps and back down from your motor maps to your muscles.

Interoception is a separate realm of somatic sensation that is oriented inward. It has two sources. The first is the internally mapped state of your body. Bring your attention to the sensation these maps are generating in you right at the moment. Think about your heart, lungs, stomach, intestines, rectum, larynx, throat. Try to feel their activity if you can. All your innards have receptors that send information up to your brain for mapping your "gut" feelings of hunger, thirst, air hunger and other visceral sensations.

The second source of your interoceptive maps consists of a different class of receptors found on your body's surface, including your teeth, gums and tongue. Unlike the touch receptors that deal in pressure and vibration and are tied mainly to deliberate touch and action, these other receptors carry information about the "homeostatic" condition of your body - temperature, pain, itch, muscle ache, sexual arousal, crude touch and sensual touch. Homeostasis refers to your body's ability to maintain internal balance. Your spinal cord contains an evolutionary older set of fibres that carries this information to and from your brain.

This may seem strange at first, because many of your body parts end up being mapped by both systems. If someone pinches your arm, the pressure and pain will be represented in your primary touch map. But the pain will be rerepresented in your insula. Why is pain from one pinch mapped in two places? Because your insular maps serve a different function from your primary touch and motor maps. They are the command center for homeostatic self-regulation. For example, to run your body's thermostat properly - to keep your body temperature constant - your brain needs to know not just about your core temperature, but also about air touching your skin. Pain in your muscles, lungs and joints is important for marshaling your body's resources during exertion, but so are sensations of strain and movement and resistance in your joints and skin. So the primary brain maps for homeostatic signals from your body surface - about itch, sharp pain, dull pain, burning pain, tickle, sensual touch, heat and cold - as well as the sensations arising from your body's interior, are mapped in your insula, not in your primary touch cortex. You use those feelings less to deal with the outside world than to seek balance within your body and put your internal sensations in context. And as Critchley's results imply, interoception does far more for you than just letting you know your are hungry or exhausted or sexually sated. It is also a crucial ingredient in some of the most important aspects of human beingness: sentiment, sentience and emotional awareness.

The take home point here, is, keep your handling of patients, above all, kind.

Let kindness and slowness and non-invasiveness and invitation to move be the first and the main kinesthetic food you feed your patients' insulae, and all will be well.

This is the part of the brain you really need to impress with what a wonderful manual therapist you are, by being kinesthetically non-noceboic. Because it picks up emotional content so easily, make darn sure you are operating from your own best/highest emotional ground - THIS is the part of your patient's brain that can read your intention, emotionally. Give it NO reason to be suspicious of you in any way whatsoever. Make sure you get to know your own insula intimately, and inspect and repair the fence you put up around it, daily. These are your personal boundaries. In no way should your patient ever come to know what its contents are. What's in your own insula is absolutely none of their business.

"A memory is a moment when the past meets the future in the present" - Joseph LeDoux

Narrow Trail Walking

In this age of reduced car use I've developed a personal practice/ treatment strategy/ homework piece that I call "Narrow Trail Walking". It involves walking at a normal pace, with a normal length stride, but with one foot directly in front of the other as if one were walking on a narrow trail. Feet are to be kept pointing forward.

We become awfully lazy walkers on our smooth, sprawling sidewalks. Most people walk as if they were on a trail about a foot wide; I ask them to practice walking on one that is just one foot-width wide. At first people walk as if they were walking a plank (all tentative, slow, eyes to the ground, arms out to the side for balance) and need to be reminded that they're still on the flat ground, won't fall, to just stride along.

To stride requires elongation of forward leg and telescoping or shortening up into the body of the back leg. Of course, all this is handled by the pelvis and low back, not the legs themselves, but it's a useful sensory cue to give a patient at first. Once they've got the rhythm, then one can tell them to become aware of how the pelvis has to rock and roll to get the legs smoothly organized, how the back has to sidebend/shorten on one side, while elongating on the other. Both lumbosacral plexuses get flossed alternately.

Next, I ask them to become aware of how their trunk must be capable of twisting and "wringing" to remain facing forward. This is a bit of a "stretch" for most people accustomed to walking like robots, with no trunk motion whatsoever.

The next piece is the arm swing. Invariably people try to swing the same side arm and leg at first, but they correct it easily once they know to, alternate to the legs which are going along fine by now. Voilá, all the peripheral nerves are now flossing through the body from the neck down. The spinal cord is rotating/wringing like a non-rigid bidirectional washing machine agitator, flexing and elongating, feeding itself inside its columnar support with every step.

The last piece is to ask them to keep their eyes level on the horizon, looking for food/predators, like any proper biped. It's interesting how fast heads stop bobbing. The neck automatically starts to do what it's supposed to do, i.e., adapt to movement from below, and balance a still head effortlessly over a moving body.

This N. American culture does not model simple walking very well to its children. I started imitating runway models, but they prance too much. So I kept the crossover portion but toned down the prance, then realized I was walking the way we bipeds likely evolved, on little trails through long grass, every cubic inch of body generating or receiving some sort of motion in the process. My kinesthetic input conjured up visual images of every example of truly graceful walking I'd ever seen. After awhile it does feel effortless and natural, and one needn't be a woman to walk gracefully. Narrow trail walking can take care of lower limb pain to a large extent, and keeps the outside of the legs stretchy and extensible.

"Go Animal"

I've placed a link to this site in the link menu to the right. I found this site quite by chance one day while googling info on long term potentiation.

Frank Forencich is a combination physical educator, neuro science lover and author. His newsletters are a delight to read, although sadly he seems to write them quite rarely. I guess he's out doing what he loves, which is moving.

"Sicko"

I went and saw this movie last night. It had some shocking, several touching, and many hilarious moments, all the better to convey the main point, i.e., the absurdity of the U.S. healthcare system's provision of health care BY bottom line profiteers.

In one scene, Michael Moore is sitting at a table of American ex-pats in France, sipping wine with them while they tell of the ease with which they raise their families in a family centered place like France. The government supports child-rearing by providing heavily-subsidized, universal daycare and even nanny-support. When the spectre of high taxes for such exquisite provision is raised for discussion, we see into a typical middle class French home complete with children, decorated with original art and souvenirs of trips abroad, taken with the 5 weeks of (paid) holidays commonly enjoyed for family bonding time. The homeowners state that holidays are probably their biggest household "expense".

At the table of ex-pats, Michael Moore can't take it anymore, sticks his fingers in his ears and sings "La-la-la-la...."

A touching moment (for me) was his interview with a Canadian on a golf course, who although he identified himself as a Conservative, wouldn't dream of trying to change the Canadian health care system as was envisioned by T.C. Douglas.

The movie captures all the blank looks of disbelief and smiles on the faces of citizens of non-US countries as Moore probes them for the political dirt - surely there must be a catch, right? After all, the powers-that-be in the US talk about all the terrible conditions that exist in socialized medicine countries, so they must be hiding the real truth, right? What is the true "cost" of all this "free" care? Try as he might, he just can't seem to find any smut to highlight. People seem happy, secure, peaceful, and in control of their lives. Governments in charge of operating egalitarian health care systems exist to carry out the "will" of the "people" to have the right to ...normal existence; happy, peaceful, secure and in control of their personal lives. Not the other way round.

By contrast, in the U.S., people, even those who can afford the $600 or so per month insurance premiums, have no guarantee they will be covered. A man who used to work for a health insurance company is interviewed - his job once was to screen out people as ineligible AFTER they received a medical diagnosis or treatment. They are rewarded for saving the company money by denying claims.

What if a patient has no insurance? They can end up dumped by a cab in front of a homeless shelter in the middle of the night, still wearing a hospital gown.

TakeHome Points about Autonomics to Skin

Here is a section of the concluding remarks Gibbins makes towards the end of his chapter, my bolds.

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GENERAL FEATURES OF AUTONOMIC PATHWAYS TO CUTANEOUS EFFECTORS

From the preceding account, it is obvious that the skin is a major target of the autonomic nervous system in most vertebrate groups. In mammals with hairy skin, up to 25% of neurons in the paravertebral sympathetic ganglia lie in pilomotor pathways in addition to various populations of vasomotor neurons. Although few details are known, there is likely to be at least as large a pool of neurons supplying the dense innervation to the sophisticated pennamotor system of birds. Mammals with extensively innervated and widely distributed sweat glands, such as humans, have up to another 15-25% of their paravertebral sympathetic neurons in sudomotor pathways. Similarly, 25-50% of neurons in the sympathetic ganglia of anuran amphibians lie in cutaneous secretomotor pathways. Overall the skin represents a substantial target of the autonomic outflows, rivaled in size and number of neurons only by the sympathetic vasoconstrictor pathways that supply virtually all of the vasculature in most vertebrate species.

Despite significant and marked differences in the details of the cutaneous autonomic pathways, some common features are apparent. Most obvious of these is that the final motor neurons in the cutaneous pathways tend to run out to the skin in a segmental fashion, travelling with the sensory fibres in cutaneous branches of the spinal nerves to the dermatomes. The autonomic dermatomes usually are not as well defined as the sensory ones, but they have the potential to allow a unique insight into the organization of peripheral autonomic function. This characteristic has been utilized well in studies of the control of colour change in teleost fish and in abnormalities of sweating function in humans.

The final motor neurons in cutaneous pathways show surprisingly constant differences in the pathway-specific expression of their morphology and neurochemistry (Figure 1.11). In all species examined to date, neurons in vasoconstrictor pathways have the smallest cell bodies. Moreover the smallest of the vasoconstrictor neurons are those projecting to cutaneous vascular beds. As in the case elsewhere in the nervous system, it is generally accepted that the size of a sympathetic motor neuron and the complexity of its dendritic arborisation is related to the number of synaptic inputs it receives. It is likely therefore, that cutaneous vasoconstrictor neurons receive less synaptic input than do pilomotor neurons in mammals or cutaneous secretomotor neurons in frogs. The size of neurons cutaneous vasoconstrictor neurons generally have slower conduction speeds than autonomic motor neurons in other cutaneous pathways. Why this should be so is not clear. However, one potentially important factor is that the vasoconstrictor pathways tend to be tonically active, whereas the pilomotor and secretomotor pathways tend to be activated only in specific circumstances. Synaptic transmission in vasoconstrictor pathways tends to be very reliable, often requiring only one suprathreshold preganglionic input. In contrast, it might be predicted that the larger pilomotor and secretomotor neurons are only activated after summation of several preganglionic inputs. This prediction remains to be tested.

The neurochemical differences between different functional classes of neurons in cutaneous autonomic pathways provides unambiguous evidence for the presence of highly specific pools of neurons projecting to well defined effectors. Within the cutaneous vasculature it is clear that there are separate populations of neurons projecting to the proximal vessels, small distal vessels and AVAs and veins. It is also clear that pilomotor neurons form a well-defined population distinct from any of the vasomotor neurons. Furthermore, it is likely that cutaneous vasodilator neurons, when present, are distinct from sudomotor neurons. These results are consistent with more recent studies on the central pathways responsible for autonomic activity which indicate that there is a series of distinct areas in the periaquaductal grey, hypothalamus, and medulla that activate specific autonomic pathways in response to well defined changes in the external or internal environment. Furthermore, it is clear from physiological and anatomical studies that there are separate pools of preganglionic neurons projecting to different functional population of cutaneous motor neurons. Although we still do not know how the central areas are connected to the final autonomic motor and premotor neurons responsible for generating the appropriate effector activity, it is absolutely clear that there is no such thing as a generalized autonomic outflow, and that the widespread activation of different cutaneous effectors must require the coordinated recruitment of multiple independent autonomic motor pathways.