Sunday, December 30, 2007

And it's about brain parts: like Hippocampus

In reference to It's all about movement:

From our PT perspective it's might be about movement, Matthias, freedom from pain, but I would propose that from a functional perspective there are other considerations, such as having good working brain parts, understanding their contributions to movement, to pain processing, or purpose having us move from A to B in the first place.

The hippocampus has been a riveting study focus for me this fall and winter. Buzsáki has worked for decades to understand brain waves, and noticed that theta waves, his favorite, seem to come from there. My impression from reading his book is that theta waves are like a drum beat setting a rhythm for all the other kinds of waves.

If I may, further to the discussion about types of memory, Learning to Memory, I want to post a link to a fascinating lecture video, a 2005 talk by Sue Becker from McMaster called The Role of the Hippocampus in Memory, Contextual Gating, Stress and Depression. It touches on Hebbian learning, neurogenesis, topics we took a look at in History of Neuroplasticity. Becker is building on this to examine what the learning rules might be, and build models for them. She describes the hippocampus as a large convergence zone, where information from lots of other parts is "coded". Neurogenesis takes place here. A constant supply of new neurons seem to be necessary for coding memories over time, over temporal gaps. If neurogenesis is slowed by stress, new connections have trouble being made. (Sapolosky has mentioned this as well.) New neurons remain plastic (able to make new connections) for longer than old ones.

Single cell recordings of spatial coding cells in the hippocampus have been made with human subjects, as they move about in a virtual world (prior to this only rats had been examined). She touches on spatial hemi-neglect, neglect of the left half of a person's environment following a type of stroke; she is working on building a model that can account for both "egocentric" (sensory/self) and "allocentric" (other/outside) spatial coding.

Her third area of investigation is the role the hippocampus as a comparer and coder of personal behavior. This brings in the role of context. The hippocampus is crucial for determining context of a situation, and allow you to react appropriately in a stressful condition. Here we come back to producing movement again. If the hippocampus isn't working, how will you know what movement to choose? The hippocampus may exert a modulatory effect on other parts of the brain.

Also, here is a link to one of Ginger Campbell's brain science podcasts (Episode #3) which discusses Eric Kandel's book, In Search of Memory. In episode #12 she discussed another book, Memory: From Mind to Molecules, by Larry Squire and Eric Kandel.

The internet is absolutely full of great information.

It's all about movement

In response to: Cart ruts.

Diane, I think you described the basic thinking behind different forms of "movement therapy" quite well - it's not necessarily what one does - but how.
The focus has to be on the process of learning and creating the environment for learning - only then can the brain build new connections that it can use later on.

Yoga - if done right - is just one of the many forms of movement out there that has taken those principles and put them into a comprehensive system.
For those of you out there who want an alternative - here are some:

1) Somatics: based on the work of Feldenkrais - but shorter, faster and easier to do. The exercises in this book are great - plain and simple.

2) Feldenkrais: more complex than the Somatics stuff - but also great. You can start by doing just a few steps and working your way towards doing a whole session later on. Remember: it's all about learning something new. Break it down in smaller portions if you have to.

3) Ruthy Alon: also a Feldenkrais practitioner. Her book is a very good - on every level. She does a great job explaining why we move the way we do - what we can do better - and the principles behind "body learning". The exercises are also great - very easy to do.

4) Swimming: here and here. These two books are the best money can buy when it comes to a form of movement most are pretty familiar with. They concentrate on basic (and advanced) techniques - so swimmers at all levels will find something to work with. By breaking down the different swimming styles into small parts you can find out where your weaknesses are and work to correct them.

5) George Leonard: started with Aikido at the age of 40. Developed his own form of movement based body learning technique.

6) all the others. ;-)
Just think Alexander Technique, Dance in all shapes and sizes, .......

Fact is: do something - anything. ;-)

Saturday, December 29, 2007

Cart ruts: More about UN-doing something

In reference to Just UN-do it:

Some more thoughts have occurred to me since I wrote that post relating the activity of UN-doing to learning processes. (Perhaps this will turn into a start of the deconstruction of that interesting term either Feldenkrais or his student Hanna came up with, sensory-motor amnesia.)

First of all, we must remember that motor pathways or any other kind, once learned, are not really erased, but can be weakened or strengthened according to the tenets of neuroplasticity; if not entirely extinguished, they can at least be eclipsed by laying in new pathways over top. Receptors are constantly being torn down and new ones built, potentially sensitive to other substances (see extinction learning).

If you can introduce new behaviors or motor activities that counter others, this should in theory provide the brain with an opportunities to select options. "Not-doing" options can be reshuffled with/shuffled into "doing" options by executive function, and a movement created that is optimal in the moment. It may not be the fastest or most spectacularly athletic, but it should be at least sufficient to get the job done and not hurt - over a whole life span. I think yoga is a form of (non)exercise that (ideally, if done correctly) trains the brain for doing just that.

What does this mean? Think of a cart pulled by a horse. Think of the driver of the cart as the executive function of the brain, with access to information and ability to choose from a variety of options. Think of a cart rut on a grassy plain, a track that has been worn by repetition. Driving the cart deliberately in the rut every time might seem like the most sensible, efficient thing to do - after all the rut is smoother, in the straightest line from A to B, but the horse (brain) already knows it so well the driver ends up practicing monotony, being bored, daydreaming - which, on another level, are all ways of exercising self-reinforcing neuroplasticity (mental cart ruts) as well.

Remember, neuroplasticity can lead to bad habits just as fast as to good ones.
If the driver wants to exercise neuroplasticity s/he will do well to practice making new cart ruts deliberately.

A wise cart driver knows some things that horses may not; that boredom isn't good, that grass can re-grow and hide ruts (ruts can heal if left alone), that a new rut may be bumpy at first but will smooth with time, that taking a new route will not only assist nature by allowing regrowth of grass but will stimulate the horse to greater capacities as well, of observation and alertness.

Making new trails through the grass will require more deliberate attention and simultaneous quelling of ordinary anxiety, the kind the brain produces whenever you ask it to do a new thing. There will be some resistance, in other words, probably, from the brain/horse. In yoga, deliberate slow deep breathing easily overcomes this feeling. Practicing relaxing into each position three times (not in a row, but three times total in a single session) gives the executive function (cart driver) and the brain (horse) an opportunity to witness improvement necessary for positive feedback, which builds success, which in turn greatly enhances the learning.

Deliberately choosing new ways of moving/not-moving can build a better repertoire, a greater selection of cart ruts to choose from should external conditions change: for example, sticking with the metaphor a bit longer, if it rains hard, or the river floods and there is standing water on the grassy plain, some of the more well-worn (deeper) ruts may be too full of water and mud to be an efficient route anymore. If the driver has seen this possibility ahead of time, and has some other routes in mind to take instead, the load can still be delivered. Furthermore, if other ruts have been created and practiced, perhaps none of them will have become so deep as to be impassable in spite of bad weather or circumstances.

It is all about having taken some time to build in more options, just in case.
In terms of motor output (being able to do what you want to be able to do, on through a whole lifetime, without pain), building in options has to do with spending time with your body before any pain problem that might arise, and paying close attention to it, just out of curiosity.

If pain is already a feature in one's life, the good news is, one still can learn to "UN-do" un-useful movement patterns, or recover useful ones. Some special props or extra help might be needed, that's all.

Finally, I don't mean to make this post sound like some sort of long advert for yoga - there are many other movement therapy systems that can help achieve the same long term goals. You can make up a new one if you want! The key features are breathing, attending, enjoying, producing feedback for all systems, gaining information, and playing with the overall speed of an activity (especially slowing it way down), practicing something on the other side of the body for the novelty of it and to regulate pathway building.

Thursday, December 27, 2007

A long series of now moments

In reference to Memories vs: stories :
What bothers me most about memory is how misleading it can be.
Implanting false memories is in fact quite easy.

Matthias, so true.
(In this radio program, Elizabeth Loftus mentions how unpopular she and her research became.)

I think implanting false memories would fit with the illusion-of-truth type of implicit memory.

The program also goes into some detail about memory degradation, how in fact each time a memory is recalled, it has to be "recreated" in some ways. The participants talk about how the more a memory is repeated, the more it can potentially degrade. In effect the situation is that one doesn't really recall a "past" so much as one considers another reconstructed "now". Here is a link to an essay by Joseph LeDoux, explaining how his thinking on memory was changed by some work by Karim Nader that showed memory is reconstructed each time it is accessed.

This reminds me of Blakeslee's book, The Body Has a Mind Of It's Own. Even procedural memory (that of a skilled activity) can degrade. It may be more optimal to practice a movement (a golf stroke for example) mentally rather than physically, part of the time, to avoid an onset of dystonia.

So there we are. There is some sort of optimal amount to practice a behavior, to "learn" it well, to commit it to "memory": practicing it too much without enough rest will degrade it. Not knowing how to UN-do something and practice THAT as well, might be something to think about.

Memories vs. Stories

Reply to: From Learning to Memory

What bothers me most about memory is how misleading it can be.
Implanting false memories is in fact quite easy.

It seems as if our brains only remember a condensed version of what happened and re-construct the details later during recall.

What I would like to know is just how specific this is in regards to motor memory?
Does our brain "make up" parts of a motor response? - or are those motor memories "perfect"?

And how and why do these patterns degrade over time? - a process best described by sensorimotor amnesia.

Wednesday, December 26, 2007

From Learning to Memory

In reference to Just Do It:

We've talked quite a bit about all the various types of learning that exist, which, as Kandel pointed out, all occur at synaptic levels.

All this has made me think about memory. What's the point learning something if you can't remember it later? I've spent a number of weeks, months even, trying to soak up that Buzsáki book, Rhythms of the brain.

I found a footnote in it (p. 288) about the synesthetic memory of a Russian named Shereshevskii (which in his case was thought to have interfered with face recognition), explicit and implicit types, kinds of each, all of which use/are used by specific parts of the brain. It might be good to review these:

A. IMPLICIT: "previous experiences aid in the performance of a task without conscious awareness of these previous experiences (Schacter, 1987).

Types are:
a) Priming: "previous contact with something can implicitly aid in its subsequent recall or recognition", "can be conceptual or perceptual", "the remembered item is remembered best in the form in which it was originally encountered" (context is everything)

b) Illusion-of-truth effect: "a person is more likely to believe a familiar statement than a new one." (a danger for older people - they can become more easily preyed upon)

c)Procedural:"long-term memory of skills and procedures, or "how to" knowledge (procedural knowledge)." (linked to cerebellum and the basal ganglia function)

B. EXPLICIT (aka declarative memory): "conscious, intentional recollection of previous experiences and information", "some scientists suggest that episodic memory might be dependent on the right hemisphere, and semantic memory on the left hemisphere." (brain regions involved are medial temporal lobe; hippocampus and related areas of the cerebral cortex)

Types are:
a) Episodic: "memory of events, times, places, associated emotions, and other conception-based knowledge in relation to an experience."

b) Semantic: "memory of meanings, understandings, and other concept-based knowledge unrelated to specific experiences"

Neural structures involved in explicit memory:
"Most are in the temporal lobe or closely related to it, such as the amygdala, the hippocampus, the rhinal cortex in the temporal lobe, and the prefrontal cortex. Nuclei in the thalamus also are included, because many connections between the prefrontal cortex and temporal cortex are made through the thalamus.

The regions that make up the explicit memory circuit receive input from the neocortex and from brainstem systems, including acetylcholine, serotonin, and noradrenaline systems."

Evidence for the distinction between implicit and explicit
Brooks & Baddeley, 1976
Graf & Schacter, 1985, 1987
Jacoby & Dallas, 1981
Tulving, Schacter, & Stark, 1982


Longterm memory: anything longer than 30 seconds, stored as meaning

Short term memory: stored only for about 20 seconds and discarded

Sensory memory: "ability to retain impressions of sensory information after the original stimulus has ceased" Two types:
1. Iconic: "short term visual memory (a sensory memory), named by George Sperling in 1960"
2. Echoic memory : "the auditory version of sensory memory"

(Thank you Wikipedia.)

Here is a very entertaining WNYC radio program on memory, from June 07. It discusses one more kind, creative memory.

More about memory in this program also, about 11 minutes in.

Just UN-do it

In response to Just do it:

About procedural learning, Matthias says,
"This type of learning requires a lot of practice over time - so it has limited use in treating chronic pain I think.

But: maybe this non-conscious type of learning is one of the causes of chronic pain?!"

I'm sure it must be. How about "just UN-do it?"

I practiced yoga for a couple years (w-a-y back when I was 21, 22.., early 70's), about an hour every day. I was taught the basics in about 15 minutes by a Danish PT who worked at the same hospital and who was a yoga enthusiast. She was the same age then as I am now. I bought a book she recommended and carried on alone. My goal was to become perfect at every pose (a goal that was, of course, never realized, although I did conquer a small number of the easier ones). Lucky for me, she had managed to convey the importance of deliberate slow breathing, watching for and then stopping at the first tiny non-nociceptive tug, waiting, observing and just hanging out, waiting for the 'body' to let go by itself. (There's a lot of mystical clap-trap associated with yoga which never appealed to me; her version and the book I bought skipped all that entirely or I would never have bothered.)

In those days, the knowledge base was completely dichotomous - the 'body' was not regarded as part of the brain's ongoing motor expression. The main sensory-motor homunculus had been mapped but was not common knowledge in PT yet. The brain was considered to be that bump up at the top of the body, not the other way round. The idea of ordinary and trainable "virtual bodies" hadn't come along yet.

Even so, over thousands of years this practical system called "yoga" had evolved, whereby one set oneself up in various positions that recruited the help of gravity, then simply relaxed and waited patiently for it to take over. The most important part was to breathe slow and deep, and allow, to refrain from actively "stretching" anything. The job, in other words, assigned to one's subjective conscious awareness, was to take over breathing, then stay completely out of the way (keeping it busy, rendering it harmless).

Pretty smart idea actually: give it something rhythm-producing to do (an activity like breathing which would happen regardless, but that subjective conscious awareness has little or no practice at), keep it distracted from/less likely to interfere with the real activity, i.e., changes in tone, in motor output, keep that part all non-conscious, therefore non-nociceptive. When I look back at that, now I can see that it is much like the "jobs" people give to their big dogs when they are walking them on the street; get them to carry a small piece of rope or a ball so they feel useful and loved and a necessary part of the "pack." As long as the dog carries an object it will remain focused on its own mouth, it will feel engaged, it won't bark or bite, it will stay connected to its owner posing less threat to pedestrians or small children or other dogs.

Tuesday, December 25, 2007

An Odd Bit of Timing

In response to The User Illusion:

Quite so Matthias. Geörgy Buzsáki points out in his book on brain oscillations, Rhythms of the Brain, sentence number one:
"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 guess this means, perturb them just the right way (as part of their environment) and hope they can right their output.

I was listening to this podcast today from 2005, Beyond Time, concepts around time... one of the people included was Ramachandran discussing an experiment in which subjects were attached to electrodes and then asked to wiggle their finger, any time they wanted to. The data revealed that there was quite a lag time between the time the brain decided to move the finger, and the time the subjects thought they had decided to consciously move the finger. About a second. That's slow for brains. Ramachandran pointed out that from this one can only conclude that the subjective awareness of an action one takes is an after-the-fact story. The idea of "free will" is an illusion - the brain decides when one will move and how, and the sense we have of ourselves enacting a movement that "I" (or our idea of self) have/has chosen, is a confabulation, a story it tells itself.

The left hemisphere must be the part that makes up this particular illusion, as it is generally regarded as the explainer/confabulator after the fact.

When it comes to pain, perhaps the reason movement illusions (inputs) work to reduce brains' pain output is that something is changed or changes in the timing of the oscillations. Just a little pause, but enough to shift an moving output, like an oscillation here... a brain wave there...

Saturday, December 22, 2007

The User Illusion

Reply to: More On Learning


this is one of the key concepts people have to grasp when it comes to chronic pain:
If the expectation or "mental representation" is that moving will cause pain, then it will. But.. if another idea is supplied, i.e., "Find a way to move without causing pain", then different mental representations could be built, learned, attended to, become an endogenous "stimulus".
Alain Berthoz - in his excellent book "The Brains Sense of Movement" writes something along these lines:

if the brain "decides" to move the body - it produces so-called pre-sensations which are based on a copy of the motor command it sends to the muscles.
That way the brain is able to anticipate the consequences of the intended action - and we can already "feel" something - even if there is no actual sensory feedback (proprioception, touch, etc.) yet.

The data/feedback that is sent back to the brain from the periphery is only checked sporadically and only to alter the existing pre-sensation.

That's why - in chronic pain at least - movements can hurt before they have been carried out. The brain remembers that the movement hurt last time - and so pain is produced as an anticipatory effect.

By re-training movements by imagining them being carried out pain-free the virtual body/virtual movement program can be re-wired and re-trained.

This is something that Moshe Feldenkrais has built on in his Awareness through Movement method - you do the movement with one side of your body and mentally rehearse it for the other side before actually moving it.

It's very difficult to do this when you are starting out - training mentally is the same as doing it for real: you get better through repeated practice.
Our mental skills, tools, ... also need constant training - otherwise they waste away as fast as our muscles do when we stop exercising.

Just do it

Reply to: A Few Types Of Learning


the only additional form of learning I can think of is procedural learning.

It's basically learning by doing. I never learned to type - but after a few years writing emails and other stuff I have become fairly good at using the keyboard.

I think the same thing happens in sports - when you ask someone how he or she does a certain movement they are unable to tell you - they just do but can't explain why or how.

This type of learning requires a lot of practice over time - so it has limited use in treating chronic pain I think.

But: maybe this non-conscious type of learning is one of the causes of chronic pain?!

One of the most important things you have to do when in pain is to try to get rid of things that make the pain worse or cause it in the first place.

But when you react non-consciously towards certain stimuli that's a problem - because you don't become aware of this negative influence.

In this case you first have to develop the necessary mental skills - namely Metacognition - to be able to watch yourself - then change the behaviors that aren't helpful.

Just do it. ;-)

Friday, December 21, 2007

More on Learning

Also in reply to The Devil is in the Details:

Matthias, you mentioned:
attention is the driving force behind cortical plasticity - the same stimulus is able to produce two different outcomes - depending on how much attention is directed towards the stimulus.

Stimulus discrimination (paying attention to what and where a stimulus is applied) - changes the cortex in a completely different way than simple passive tactile stimulation.

I agree, and it seems things can get even more complex. What if the "stimulus" which focuses "attention" (simple choice about what to attend to? Locus of control? The illusion of free will?) inside as opposed to outside? Endogenous as opposed to exogenous?

The authors of this paper, Differences Between Intention-based and Stimulus-based Actions set out to see if there was a difference;
Abstract. Actions carried out in response to exogenous stimuli and actions selected endogenously on the basis of intentions were compared in terms of their behavioral(movement timing) and electrophysiological (EEG) profiles. Participants performed a temporal bisection task that involved making left or right key presses at the midpoint between isochronous pacing signals (a sequence of centrally-presented letters). In separate conditions, the identity of each letter either (1) prescribed the location of the subsequent key press response (stimulus-based) or (2) was determined by the location of the preceding keypress, in which case participants were instructed to generate a random sequence of letters (intention-based). The behavioral results indicated that stimulus-based movements occurred earlier in time than intention-based movements. The EEG results revealed that activity reflecting stimulus evaluation and response selection was most pronounced in the stimulus-based condition, whereas activity associated with the general readiness to act was strongest in the intention-based condition. Together, the behavioral and electrophysiological findings provide evidence for two modes of action planning, one mediated by stimulus-response bindings and the other by action-effect bindings. The comparison of our results to those of an earlier study (Waszaketal.,2005) that employed spatially congruent visuo-motor mappings rather than symbolic visuo-motor mappings suggests that intention-based actions are controlled by similar neural pathways in both cases, but stimulus-based actions are not.

Perhaps you would be interested in deconstructing this paper with me to determine how it is relevant to PT and especially to pain perception as it concerns us. I'm sure it is, but I think it might require a team effort. What do you think?

Certainly learning is involved, as we see in page 14 in the results section. The authors considered "the ideomotor approach" in which "intention-based actions arise automatically through the anticipation of their sensory effects" (bottom page 9, top page 10).

When I read it a few days ago, something fell into place that never had before. If the expectation or "mental representation" is that moving will cause pain, then it will. But.. if another idea is supplied, i.e., "Find a way to move without causing pain", then different mental representations could be built, learned, attended to, become an endogenous "stimulus".

At least, that's how I'm interpreting it at the moment. Our work is supposed to be all about helping people physically regain their "illusion of free will".. ability to move freely as they wish, without hurting. Mirror therapy is a visual movement illusion and works well to provide the "brain" with a new "idea", skin stretching provides a kinesthetic movement illusion and works well (at least clinically/anecdotally) to do the same... If this is useful, simply asking a patient to initiate, develop, then operate their own "illusion" of moving without hurting, could be an idea-seed they could create and develop in their brain.


Tuesday, December 18, 2007

A Few Types of Learning

In reference to The Devil is in the Details:

Learning seems to be a recurring theme in this blog, so let's take it even further. Kandel says, "learning is in the synapses". How many kinds are there? Probably more than I have listed here, but this is a start:

1. Long Term Potentiation

Lately I've become caught up with Geörgy Buzsáki and his book Rhythms of the Brain. In chasing down things I've spotted in that book, namely the role of the hippocampus, the connection between theta rhythm and movement, orientation (space maps), memory and learning, it seems long term potentiation is A main if not THE main mechanism. "Learning" requires receptor breakdown and building, a process that is going on all the time anyway.. but when a signal comes in, repeatedly, the receptors will strengthen around the signal. (This is true for pain reduction, which is another sort of "learning", extinction learning, point 5.)

There is a very nice article from "Go Animal", a website linked in this blogpost by the same name. It's called "The Greatest Discovery You've Never Heard Of" by physical educator Frank Forencich.

Longterm potentiation (LTP) relates back to one of the other "tenets of neuroplasticity",
4. Initial changes are just temporary. While the brain can learn through impact (a powerful experience), usually it learns through lots of repetition.

In fact, we likely do NOT want to have to learn too many things through impact - such learning would tend to retain a heavy emotional overlay I should think, which could mess up integration, create large "hooks" for future learning of an inappropriate or counterproductive sort. Remember this other tenet:
5. Brain plasticity is a two-way street; it can change itself in positive or in negative directions. E.g., chronic pain, bad habits

... which leads us to another form of learning,

2. Sensitization

We know about this one from pain science, but its origins are with Kandel according to this Wiki page. This is described as short-term memory formation.

One of the most troubling (and confusing) aspects of pain states is mechanoreceptor sensitization, discussed in the Textbook of Pain, 5th ed.. This has led practitioners on merry goose chases after "the tissue at fault" (structure as opposed to function) for decades, centuries...

Sensitization can be "un"-learned, and quite rapidly, by something as easy as mirror therapy.

To overcome sensitization, and to utilize longterm potentiation, a "graded exposure" approach is usually recommended - this is a cognitive-behavioral approach which breaks down a learning or an un-learning movement objective into small, easily assimilative bits.

This ties in with

3. Habituation

This type of learning seems to be about just adapting to (learning to ignore) something in the environment or inside, consciously or unconsciously, be it initially positive or negative, although psychology definitions hold out for "decline in the response elicited by repeated stimulation, not due simply to adaption". My pick is "A decrease in the behavioural response to a repeated, benign stimulus." This would be best avoided in treatment of pain. I doubt we want our patients to "habituate" to either us OR our treatment. Which is why we should stay nimble and novel, in my opinion.

Habituation is classified as non-associative in psychology, which takes us to ..

4. Learning by Association, or Classical Conditioning

Here, the relationship between a stimulus and a response is strengthened, or (see above) "sensitized".

Here is one more:

5. Extinction Learning
We are now back with definitions that involve proteins at the neuron level of memory.

While this little list of definitions hops around among scholarly domains and perspectives, it is important to realize that, as per Kandel, nothing can happen with learning and memory regardless of domain, unless neurons and their receptors change. When dealing with patients whose overriding issue is persisting pain, the "locus of control" (another one of those catchy psych terms) must be with the patient at all times. They must be given ample opportunity to "learn" to downregulate their not-very-successful prior sensitization learning, given support, and sufficient time, especially if manual treatment (a form of exteroceptive neuromodulation) is involved.

Matthias, can you think of any other types of neural learning to add to the list?

The Devil is in the details

Reply to: Neuroplasticity

I want to expand on this thought a bit more:

1. The focus, the inner attention, has to be on the process of learning the action, not the desired action itself.
There are several studies out there that shows how important this is and how we can use this during treatment:

Lorimer Moseley for example has done it again - a study published in Pain, January 2008 in CRPS shows that there is a big difference in how attention influences treatment.

It's been known for some time now that attention is the driving force behind cortical plasticity - the same stimulus is able to produce two different outcomes - depending on how much attention is directed towards the stimulus.

Stimulus discrimination (paying attention to what and where a stimulus is applied) - changes the cortex in a completely different way than simple passive tactile stimulation.

The process of attention is crucial in treating chronic pain; unfortunately the mental processes behind it are as yet poorly understood and there is a lot of controversy about even defining this mental capacity.

For us - PT's and others who work with patients we can focus on making the tasks we give the patient meaningful, functional and fun - that should be more than enough for now. ;-)

Monday, December 17, 2007

Get your game on, ease your pain

In reference to Neuroplasticity:

Matthias, you'll love this I think...

Susan at Gamelife linked to this article, Video games beat drugs for chronic pain.

It kind of fits in with observations made about neuroplasticity - using games that can hold attention while involving whole body movement will be very good for downregulating pain. Movement is a requisite for down-the-road pain relief, but if it can be linked to motivation, fun, attention and learning, all the better, right?

Sunday, December 16, 2007

About Mirror Therapy

In response to Haptic Vest:
It's kind of funny and tragic at the same time that all the technology for preventing and treating most forms of back pain is already (widely) available. But: the models health professionals have in their heads and base their choice of treatment on are outdated - that's why it's so difficult for new treatments to take hold.

I've written about this in my Mirror Box Treatment series.

Matthias, I couldn't agree more.

By the way, on a housekeeping note, the reader will now find Matthtias' excellent blog series on mirror therapy here, in a section called "Matthias Weinberger PT Mirror Therapy Series" to the right.

It makes perfect sense to use "rehab" methods that are fun and engaging, otherwise attention and motivation will lag, and the brain just won't use that neuroplasticity capacity as fully.

On the topic of haptic clothing, I can see it's potential in terms of communication, new levels of integration re: social grooming etc... however, I also feel sad that we have learned to "un-learn" or inhibit so much integral sensorimotor connection to the natural humanantigravitysuit our species comes with. Could that be why we've ended up with a lot of chronic pain, at least in part?

I also wonder about how much less physically intelligent we will become as a biological species once we've learn to rely on the enhanced sensory input from this "intelligent clothing"... Maybe the day will come when we can't feel anything connective with other people unless we are wearing special sensory input clothing.

Taking a long view though, it's apparent that we humans trained ourselves out of natural adaptive sensorimotor response to our environments by taking up wearing clothing and shoes, living in controlled environments etc., in the first place; this is likely just a natural cultural extension of our already technically embedded cyborg-like lives, enhancements which began long ago with eyeglasses and prosthetics, progressed to hearing aids, joint replacements, etc., have continued on with plastic surgery, implants, transplants, and now intelligent communicative clothing...


Response to: History of Neuroplasticity.

This is one of the most important things we have to recognize:

Ramón y Cajal was in the forefront of neuroscience, and had dazzling, substantive, convincing and irrefutable research work to offer up. His opinion on fixedness, immutability, unchangingness in the nervous system was pretty much conflated with his actual research for the next century.
Just because someone is very good at what he or she does doesn't mean they are right about everything else. I think it is based on the same principle as the Halo effect.

What I don't get however is how those people were able to explain what learning is. If the brain is a fixed structure - then how are we able to learn new skills?
And even if it's just new synapses forming - that is a form of plasticity as well?

Looking back from where we are now it all seems to be so obvious - how could anyone resist the idea of a changeable, plastic, constantly adapting brain?

That I guess is the big lesson we can learn from history: it's always easier to see the connections in hindsight.

It's always nice to have a paradigm to work from - but at the same time we have to recognize it's weaknesses and work on finding solutions which eventually will lead to a new and better one.

Just look at how Wall and Melzack went from the Gate-Control-Theory to the Neuromatrix Theory.

Haptic Vest

Response to: Visual Feedback for Backs.

It's kind of funny and tragic at the same time that all the technology for preventing and treating most forms of back pain is already (widely) available. But: the models health professionals have in their heads and base their choice of treatment on are outdated - that's why it's so difficult for new treatments to take hold.

I've written about this in my Mirror Box Treatment series.

As Bach-Y-Rita found out our brain doesn't depend on visual feedback alone - touch is "created equal". ;-)
So for areas of the body that we can't see directly with our own eyes we can use touch instead.

The US Military is developing a haptic vest that would allow soldiers to communicate by touch signals applied to their backs. Imagine if all commercially available clothing had that feature!
Finally social grooming and communicating would be reunited again!

Talking with someone - however far away they are - could be "translated" into a form of touch.
I guess that would be the end of back pain for good. ;-)

Another great tool increasingly used in Rehabilitation is the Nintendo Wii.
I was very skeptical when I heard about Nintendos new gaming console - but it has been a huge success so far. It puts the gamer right into the action by having him move the controller around.

Lots of people are already using it as a Rehabilitation tool - the new field of Rehabitainment (Rehabilitation and Entertainment) was thus born.
Other forms of this type of treatment is the use of VR (virtual reality) for burn victims.

All we need now is someone who starts applying the same principles to chronic low back pain.
Any takers?

Saturday, December 15, 2007

Visual Feedback for Backs

Response to Visual Feedback.

Matthias, I can see how treating could be done right now, with the right equipment.. much like your idea about treating paraplegic central pain.
I was thinking of something perhaps a bit more ambitious and potentially devious, however; how one might design a study to determine if back pain could be treated virtually, using these "virtual back" studies as a point of departure.

Think of the possibilities: if it could be shown that back pain/neck pain could be treated visually/virtually instead of being the huge treatment morass it is right now, several ramifications might ensue.

1. Heavy, structurally based manual therapy could potentially be made obsolete in the future. (:D)

2. Potential big cost savings for everyone; patients wouldn't have to suffer as much for as long. Employers would save insurance costs. Insurers would save on disability claims. Aspiring professional human primate social groomers wouldn't feel obliged to pay out huge $ for manual therapy courses of under-studied or dubious quality taught by greedy "gurus".

3. Humans might actually suffer, overall, less low back pain as an industrialized, domesticated species, in the future.

Just some wild and crazy thoughts. Dare to dream I say..

Visual Feedback

Response to: Virtual Body Experience

Diane - great posting.

Those are very good examples of just how slim our hold on reality really is. ;-)
Consciousness and all it entails is just a bag of tricks - and by conducting experiments like these we can show what's really going on behind the scenes.

The same mechanism that makes these out-of-body-experiences possible is responsible for our capacity to use tools so well - they are integrated into our body schema - they are well and truly part of us.

It also shows just how important skin - and input received via skin is in updating the body schema. Think about what you are for example doing to the skin of your lower back during a normal workday: is there any "real" input? Or do you put on clothes in the morning and sit all day? There is not much feedback coming from that area if you do this - a problem other primates have solved quite well by the practice of social grooming.

Some say that humans have taken social grooming to the next level by adopting speech as a tool to keep track with larger peer groups - but I think touch is still the most important and basic sense there is. Language is a poor substitute.

As for a way how to use this in the treatment process:
take a cheap digital camcorder - hook it up to a screen and have the patient watch his back live in front of him. Now you can touch his real back and show him how you want him to move it. That way the patient has visual feedback with which to correct the movement appropriately.

My guess is that - even in chronic pain conditions - the time you'd need to treat someone successfully wouldn't be more than a couple of weeks with 20 minutes of training daily.

If you look at the studies done with phantom limb pain and CRPS - using mirror box treatment - this kind of therapy works incredibly fast. And: you feel the effect within the first treatment session.

I think that this is one of the most promising techniques ever invented.

Friday, December 14, 2007

Virtual Body Experience

Check out the article, How to Excuse Yourself From Your Body, from the magazine Discover.

Swedish scientist H. Henrik Ehrsson devised a way to convince people's brains that what they were looking at, an image of their bodies projected in front of them, were in fact occupied BY them. He proved that the brains responded to the illusion "as if" it were real; he provoked measurable autonomic distress output by threatening to hit the "virtual" body with a hammer.

His study “The Experimental Induction of Out-of-Body Experiences” was published in Science, Aug. 24, 2007.
(See here for list of 30 of his articles.)

Swiss scientist Bigna Lenggenhager induced virtual body illusions in her subjects, then had them move themselves out of position, then back into positions where they thought they had previously been, but which were in fact where their "virtual" bodies had been.

Her paper “Video Ergo Sum: Manipulating Bodily Self-Consciousness” was also published in the August 24, 2007, issue of Science.

How is this possible?

The Discover article says,
"While we navigate the world, our brains are constantly integrating sensory information gathered by sight, touch, and hearing. But sometimes the system goes haywire, and people experience the illusion that they are outside their physical bodies, floating above them and peering back from a distance of about 6 to 10 feet. These “out of body” experiences typically occur when people suffer strokes, epileptic fits, or migraines or are taking drugs. Two cognitive neuroscientists explored the boundaries of body perception by reproducing an out-of-body experience in the lab."

Experiment I:
Henrik Ehrsson, Karolinska Institute in Stockholm, Sweden

- 18 healthy individuals were seated. Their backs were filmed with a pair of video cameras while they wore goggles that
a)gave them a stereoscopic view of their backs
b)captured the video from both cameras.
- Ehrsson induced the illusion; he "repeatedly touched each person’s actual chest with one rod while, with another rod, he jabbed toward a point below and in front of the two cameras that corresponded to the “virtual chest” of the image projected into the goggles. With the shift in perspective through the goggles, subjects reported that they felt as though they were physically embodying a space six and a half feet behind where they actually were."

Experiment 2:
Ehrsson wanted to find out if the subjects would respond "as if" they were located in the illusory position.
- Sensors that monitor electrical conductance were applied to the subjects.
- The first experiment was duplicated.
- This time, "he swung a hammer toward the two cameras at a point corresponding to the center of the face of the camera-generated illusory body"...and, "the subjects’ skin showed a spike in electrical conductance—a sign of increased sweating and emotional arousal—and they reported immediate anxiety."

Experiment 3:
Bigna Lenggenhager et al., École Polytechnique Fédérale in Lausanne, Switzerland

- A camera was placed six and a half feet behind the back of each of 14 participants wearing 3-D video goggles.
- Their backs were stroked with a large pen; they could simultaneously see and feel their backs being caressed.
- The subjects were guided backward, then asked them to return to their previous position.
- "Participants overshot the distance by an average of 10 inches, moving closer to the position of their “virtual” bodies."

- The back of a mannequin's body was stroked, and the image projected into the subjects’ goggles. Subjects felt that the mannequin’s body was their body.

“We now understand how the brain combines information from the eyes and from the skin to compute or determine where the self is located in space,” Ehrsson says. Both experiments show how easily the brain can be tricked or how it “cheats,” he says, using memory and prior experiences to fill in data gaps."

Here is a youtube video about this. (Olaf Blanke, shown in the video, was Lenggenhager's team leader.)

Here is a link to Sandra Blakeslee's new book, The Body Has a Mind of its Own, which discusses these kinds of phenomena and attendant research in greater detail.

Just one additional thought for now.. why wouldn't this setup work for treating back pain? Someone could find 20 or so subjects with back pain, any old kind of back pain at all, acute, chronic, what have you, any age, any sort of work, any socioeconomic group... put the goggles on them, induce the illusion. Instead of getting the subjects to move forward and back or instead of eliciting threat responses from their autonomics, instead, the "virtual" backs, could be "treated". Or a film clip of the "virtual" back could be shown to move freely. I wonder if this illusion would be sufficient to get the subjects' brains to stop producing the pain output?

Dec. 29th '07: Back in to add a link to a youtube video on goggle-induced virtual reality games for phantom limb pain.

Wednesday, December 12, 2007

History of Neuroplasticity

Matthias, I agree. And thanks for introducing Dean Kamen. Seems pretty clear his work designing arm prostheses that can "feel", will make the wider PT/OT rehab role lots easier. :)

You highlighted him as a good example of someone who is not afraid of "learning" and gave some of the important characteristics of that:
"creativity, an ability for lateral thinking, the ability to make connections between seemingly unrelated fields (of science) - and disrespect for authority."

I agree although I would translate "disrespect for authority" into "an ability to recognize and bypass conventional dogma or "groupthink" in favor of considered scientific reflection of all possibilities."

On the topic of neuroplasticity, Sharon Begley, in her book Train Your Mind, Change Your Brain, recounts how difficult it is for dogma to be overturned in favor of counter-information. She traces the history of the scientific study of neuroplasticity starting with William James, who said, in 1890: "organic matter, especially nervous tissue, seems endowed with a very extraordinary degree of plasticity", meaning, according to Begley, "a structure weak enough to yield to an influence". No one picked up on this at the time. Ramón y Cajal was in the forefront of neuroscience, and had dazzling, substantive, convincing and irrefutable research work to offer up. His opinion on fixedness, immutability, unchangingness in the nervous system was pretty much conflated with his actual research for the next century.

In the 1940's, Donald Hebb at McGill came up with
"When an axon of cell A is near enough to excite cell B and repeatedly or persistently takes part in firing it, some growth process or metabolic change takes place in one or both cells such that A's efficiency, as one of the cells firing B, is increased"

..which became known as Hebbian learning, and gave rise to the quip, "Neurons that fire together wire together."

Along came researchers like Fred Gage (a shirttail relative, apparently, of the famous Phineas, according to Begley), who runs a lab at the Salk Institute in La Jolla, California.

Starting in the 1960's, other researchers, like Joseph Altman at MIT, Michael Kaplan at Boston U., and Fernando Nottebohm who studied birds that produce new songs continually throughout their lives, William Greenough, showed evidence that went against dogma, but weren't able to budge it. Elizabeth Gould showed in the 1990's that primates demonstrated neurogenesis. Slowly, the dogma finally started to dissolve.

Then researchers tried to figure out how to show neuroplasticity exists in the human brain - they wanted to know not just if the human brain could rewire itself, but also if it could grow new cells. It was hard to deal with all the ethical dilemmas involved, but they finally got permission to look at brains of a group of people who were terminally ill, at autopsy. Specifically, Peter Eriksson and Fred Gage worked together to determine that new neurons are born constantly, even in the brains of old and sick humans. You can read more about how the dogma was made to melt down in this history module.

Suffice it to say, human neuroplasticity is a fact of life, and cannot be pushed back into the shadows. From a physiotherapist point of view, this is good news! It shows that our work, i.e., helping people, helping patients in pain, bolstering them and supporting their efforts to improve, now has irrefutable science to back it. Now we can show people studies (should we have to) to prove they can recover from even the most debilitating injury, but even more so we can turn around and challenge various dogmas that still exist right in our own profession, dogmas about pain and how best to help relieve it, help move the profession from one that is still mesmerized by structure into one that smoothly understands and supports function.


Diane, I think that one of the most important statements from that program is this:

1. The focus, the inner attention, has to be on the process of learning the action, not the desired action itself.
That means that you have to learn how to learn.
If you develop good learning skills - you can apply those anywhere and everywhere - all your life.

If you look at a genius like Dean Kamen - a great inventor - you will see what I mean.
He is creative and simply doesn't give up.

All geniuses throughout history have shown some or all of the same skills:
creativity, an ability for lateral thinking, the ability to make connections between seemingly unrelated fields (of science) - and disrespect for authority.

Only by letting your mind wander to places that don't exist - by freeing yourself from the constraints society and/or peer pressure impose upon you can you really become creative and innovative.

In this case it's more important to un-learn constraining patterns of behavior than to learn new ones!

So where does pain fit in?

Learn to observe yourself - use Metacognition to identify situations, thoughts, habits, .... that aren't helpful. Start today.
Because if you learn to develop this crucial skill to it's full potential, you can use it - as stated above - anywhere, everywhere, anytime.

You have to realize that chronic pain is (mostly) a learned condition. The brain learned to be in pain all the time on it's own - what's called maladaptive plasticity.

But - by learning how to learn - and thus making use of "good" neuroplasticity - one can unlearn chronic pain.

Tuesday, December 11, 2007


Matthias, maybe we could start with neuroplasticity. One of the best sites online on this topic is On the The brain seems to be, basically, a big learning machine. One learns, slowly, to take control of its plasticity. The frontal lobes of humans are not fully formed until into the third decade of life.

What does neuroplasticity have to do with Pain?
You could say pain can happen if/when neuroplasticity gets out of control. Pain is noted as being a "dark side" of neuroplasticity. But, if the brain can learn its way into pain, it can learn its way back out.

I recently watched a PBS program (and took a few notes) on the topic of neuroplasticity in general and aging in particular - how to keep one's brain young, and how to help it if it became damaged. It featured Dr. Merzenich from the site mentioned higher up. According to the program, four fundamentals had to be in place for gaining control, "harnessing" this ordinary activity the brain does all the time anyway:

1. The focus, the inner attention, has to be on the process of learning the action, not the desired action itself.

2. The heart has to be in good shape. Cardiovascular capacity needs to be there. The brain needs lots of oxygen when it's in learning mode. Deep breathing can help.

3. Training must be incremental, and just a little bit taxing. (Does this not sound just like any form of "exercise"?) The brain will build itself best on a sense of consistent accomplishment.

4. The desired goal needs to be interesting.

The program listed seven tenets of neuroplasticity.

1. Change can occur only when the brain is in the mood: alert, on the ball, ready for action.

2. Change strengthens connections between neurons engaged at the same time. The brain builds on its successes.

3. "Neurons that fire together wire together" (-Donald Hebb, psychologist from McGill Uni. Montreal) This helps the brain get better at its predictive capacity. Associations can be made more easily.

4. Initial changes are just temporary. While the brain can learn through impact (a powerful experience), usually it learns through lots of repetition.

5. Brain plasticity is a two-way street; it can change itself in positive or in negative directions. E.g., chronic pain, bad habits

6. Memory is crucial for learning. Where you put your attention is important. Practicing something while distracted won't help the brain change.

7. Motivation is a key factor. The program told the story of Paul Bach-y-Rita's father, who sustained a huge stroke. Eventually he learned to get around, crawling at first - his motivation was that he hated being dependent. He gradually recovered most of his function! Later, after an autopsy, Paul Bach-y-Rita was able to see his own father's brain, could see how enormous the damage had been, and marveled at the recovered function his father had gained.

Also featured on this program was Sharon Begley, who has written a book called Train your Mind, Change your Brain, which I am currently reading. It reads like an historical novel, a huge wedge of perspective back through time into all the scientific background leading up to current research on neuroplasticity, some of the best neuroscience news in the last twenty years. In a nutshell: if your brain has "learned" pain, it can "unlearn" pain.

Matthias, I think each one of these points could probably grow into a whole post series, but I'll just leave it here for now. If you think this is a good jump off point, feel free to expand.

P.S. (Dec. 15):
Here are a couple of Dr. Ginger Campbell's podcasts on neuroplasticity:
Brain Science Podcast #10: Neuroplasticity- how our brains change throughout our lives - (discusses the Sharon Begley book, Train Your Mind, Change Your Brain)

Brain Science Podcast #26: More on Plasticity-an interview with Dr. Norman Doidge (Doidge has written a book on neuroplasticity called The Brain that Changes Itself.)

Monday, December 10, 2007

Scientific literacy

Hi Diane!

Looking forward to the whole project.

"Neurotonics" - what a great name and concept.
The term was used as the title for a book in the 19th century meaning "the Art of Strengthening the Nerves, containing Remarks on the influence of the Nerves upon the Health of Body and Mind, and the means of Cure for Nervousness, Debility, Melancholy, and all Chronic Diseases".

As you can see - what Diane and I are trying to do here is not that different. ;-)
But - we base our writings on a scientific basis whereas others still grope around in the dark and try to find explanations based on mystical forces.

There is only one drawback to the whole endeavour - scientific illiteracy.
To be able to discuss scientific studies you have to learn some of the language and some of the concepts scientists use. There is simply no way around that.

And from what I hear, read, and see a lot of people are not willing to put up that effort.
Trust me - it's well worth it!

Back to the name: "Strengthening the Nerves" - that definitely works for me!

1) if you learn about Neuroscience you also learn something about your brain and yourself. And since learning re-wires your brain you are strengthening and building new synaptic connections.

2) Educating people in chronic pain about what pain is, what it means and how to deal with it also "strengthens the nerves" because you reduce fear and give meaning and controllability to the whole experience.

So lets start working out! ;-)

A new PT team blog

This is my first attempt at PT blog "community-building"; there are going to be bumps probably, but I think the effort will be worthwhile.

Some introductions:

My name is Diane Jacobs - I am Dermoneuromodulator from HumanAntiGravitySuit. I've been a PT all my life, and have a small private practice in Vancouver.

Matthias Weinberger in Germany will be co-author/administrator here. His blog is called, aptly enough, The Neurotopian.

We would like to invite other PTs interested in treating from a nervous system/pain point of view to join us here as guests, eventually.

The name:

We chose the name "Neurotonics" because it suggests improvement of neural function. As PTs, we've each independently figured out that this is what our work is really all about. Both of us have given up putting structure first, as our profession tends to do, and are more interested in helping people inhabit their bodies better (i.e., with less pain). We've learned how to put the horse in front of the cart.

Yes, we still help peoples' bodies feel better to inhabit (we won't lay aside physicality any time soon) but I think it's safe to say we have learned not just how to "fix carts", but also the current best ways to "train a horse", how to put the horse in front of the cart for efficient pulling, teach people how to treat their horse better, to steer the horse, motivate it to pull the cart, and so on...

Matthias, over to you.