Mirror Box Therapy - Part III

or: the bad part

As I've tried to explain: the maps of the body are what the brain uses to run the virtual reality simulation. And maps are plastic - to some degree.

Genetically every body map has 2 hands and 2 feet. Even when - through some defect you are born with only one hand! The map still says that there have to be two - and that is what the VR simulation represents. That's why people with one limb missing from birth still are able to feel a second "phantom" limb.

The brain doesn't care about reality since it regards the VR simulation as being reality.
It may take a while to get your hand around this - but trust me - this is what happens.

Let's have a look at this visual illusion:



Your brain - based on the models it has built over the years insists on seeing different sized tabletops. It just does. Why? Because the internal VR simulation is built on a model that says that illusionary perspective (fake 3D so to speak) means depth - even when - like on the monitor you are looking at - only 2D is present.

And so it decides to factor in this fake perspective and makes one tabletop seem bigger than the other.
This internal VR program can't be overridden (!) and is presented to you (your consciousness) - as being factual.
By the way: the tabletops have exactly the same shape and size - at least in"real" reality. ;-)

Or think back to a visit at the dentist when your cheek was anaesthesized: if felt bigger - much bigger - even when you looked at it in the mirror. Those sensory illusions are the results of the brain trying to make sense of conflicting information. It runs the data through the VR program and decides that the outcome - however ridiculous - has to be true.

Now for the really bad part:
if those maps - that form the basis for the VR program - are plastic - what about them running amok? What happens when something goes wrong and those maps change in a maladaptive way?
That's what happens in phantom limb pain, CRPS, chronic pain syndromes, anorexia, body image disorders, ...

Let's have a look at phantom limb pain:
here the real limb is amputated - but the map stays. It shrinks and adjacent map areas take over - but there is always a representation of the limb present. And the VR program is built on that. Watch someone who lost his arm slip - he still reaches out with his missing limb to steady himself.

Why? The VR program was built to save time - to enable us to react as fast as possible. If we didn't have something like it we could never regain balance. So it uses the basic blueprint (2 arms and 2 legs) when it comes to balance.
This invasion of adjacent areas has as an effect that people who lost an arm feel their arm being touched when you touch their cheeks - the area next to it.

A different thing happens in chronic LBP: the area starts expanding - probably as a way to increase spatial resolution as I suggested some time ago.
It invades other nearby area - that's why after a while - chronic pain start to spread. It doesn't do so by clear boundaries - there are no recognizable dermatomes affected - thereby making treatment more difficult.

This maladaptive plasticity is most probably driven by these factors:

1) lasting acute pain: pain demands attention and causes fear. Both are strong chemical reactions - probably accelerating learning in the map area (at a cost of course)

2) reducing of computational demand: the brain adapts to the pain - learns the pain to free up resources in the periphery. Hence learned pain. Herta Flor has done work in this direction.

3) favorable genetic disposition to develop chronic pain

So regardless of what happens behind the scene - either a shrinking of the map or it's expansion - pain is the result.
The most notable difference so far is that in conditions where no input exists the pain is often caused or ... by clenching or spasms whereas there is only pain and nothing else when the affected part is still there - as in LBP.

This is certainly a very interesting thing to go into - but has little to no effect on therapy as far as I know yet.

So why does pain occur?

Well - the brain does a good job with the VR program - an excellent job in fact; but there are times when it has to adjust the output that is produced by that program; this is especially true when we encounter new and unfamiliar situations.

Imagine yourself having lived in the desert all your life and then encountering snow and ice for the first time. Your brain can't anticipate what's going to happen when you step on that white surface - it has no experience what conditions it'll encounter - so it constructs a motor command anyway and checks the incoming sensory information on a regular basis to adjust the motor command accordingly.

That's why you are able to learn new stuff very quickly.
This is done by an area that we'll call the Comparator.

In the case of phantom limb pain however there is no feedback available. Not tactile, not visual, not kinesthetic. And since our brains can't just crash like a Computer it sends out a signal to a higher brain center to deal with the problem. It's similar to other emotions: they are produced by "lower" centers to inform the "higher" centers to please do something about them.

And that is it - the "secret" of chronic pain. It's a message from the Comparator saying "I can't make sense of this - the VR model is fine - but the feedback from the sensors doesn't match. Please deal with it - I don't care how and get back to me." (At least that's what I imagine is going on in a Woody Allen kind of way). ;-)

The solution: feedback therapy.

Mirror Box Therapy - Part II

or: the good part

A bit of Science - the "how does it really work" bit:
our brains build models of the external and internal world.
You could say that we have a virtual reality generator inside our heads that tries to anticipate the consequences of action (it's own and others).

Watch a puma or some other fast predator in the act of catching prey:
the puma's brain has to factor in speed (it's own and that of the prey), anticipate the course the prey is likely to take so it can plot an intercept course (this bit is like Star Trek) ;-), factor in the weight of the prey (!) - otherwise the moment the Puma catches it it is thrown off balance, open the jaws just so - not to wide or it takes to long to close them - nor too little or you catch nothing at all.
Pretty complex huh?!

If the brain of a predator had to start from scratch every time the hunt is on it wouldn't be able to catch anything at all.
Decisions have to be made instantaneously - speed is of the essence. The same goes for the prey by the way - without the jaw thing of course. ;-)



So how does a brain build a model of the world and the body?

Well - watch any toddler sitting at a desk - there comes a time during development when they start throwing things off the table - over and over again. They aren't called little scientists for nothing - throwing things is their way of learning about gravity. By throwing something off the table and hear it hit the floor beneath they learn that gravity is a constant and they are able to measure it's effect because the relation between the time it takes to hit the floor they can estimate the speed an object has.

There are literally hundreds of different experiments you can see going on during the first year of life - the visual tracking of objects for example. Infants - even when just a month old - learn that things in motion usually follow a steady course. That's why they are able to follow a point of light or an object on it's path even when the object is hidden from view for a short time. This truly is amazing stuff!

Again nature and nurture are at work here: the neuronal structures are laid down automatically - it's hardwired into our genome to develop these skills - but nurture "exercises" and strengthens these connections.

If you don't have the right environment present at the right time severe deficits turn up - as in the case of cats who couldn't move and were thus blind. Vision is dependent on movement - otherwise the brain can't make sense of the electrical signals coming in from the retina.

Not only does our brain contain models of the external world (physics, gravity, acceleration, ...) - but it also contains a body schema by having maps of the body surface all over the place.

The most important (and accessible) maps of the body are in an area called S1 - the Somatosensory Cortex - which is the funky way of saying "piece of brain that receives input from the outer body shell - skin".

And it is these maps that other parts of the brain use to run the virtual reality program - they are the basic building block of our sensory perceptions - or pre-perceptions as it were.

Say your brain wants to know how it would feel if you were to lift the arm straight up.
It doesn't send an actual motor command to do this - it runs an internal virtual reality simulation of you lifting the arm. It even anticipates the sensory feedback it would get from the receptors in your joints and muscles about you lifting your arm. These anticipatory sensory events are called pre-sensations.

The brain relies so much on these pre-sensations that it often acts on them instead on what really is happening. "Online" sensory feedback is only checked once in a while as it were. I will do a series on this some other time because it's such an important concept in treating chronic pain.

That way the brain can do every movement possible without you actually having to do anything in real life. This saves huge amounts of energy and time. Like in the example of the predator catching prey, saving time is a key function of our brains.

Again - nature and nurture: maps are hardwired - experience during childhood refine the maps (think babies sticking their feet into their mouths).

The big finding over the past decade or so has been that these maps are plastic and change constantly (within certain genetic boundaries).
If you use one part of your body more often the part of the map that corresponds is getting bigger - think violinists. One of their hand maps is huge.
If they stop playing the maps shrink again.
This has been shown for other forms of practiced movements too - juggling for example.
We have finally found one physical correlate of the motor skill learning process.

Even meditation - "just thinking" - is able to change your brain. Specific areas show remarkable differences between trained and untrained persons. This should convince even the greatest skeptics that the virtual reality simulation inside our brains is much more than a simple simulation - it actually is what the brain sees as being the real thing - a weakness that we can - among others - exploit in treating chronic pain.

Mirror Box Therapy - Part I

As stated in this posting Mirror Box Treatment was first described by V.S. Ramachandran and colleagues in 1995.

As always in the Sciences he built on the work that was done before him - he just happened to connect the dots. ;-)
There are some indications that even back in the 1920's or 1930's there was a German scientist who thought along these lines - but never followed through. Imagine how different the treatment of chronic pain syndromes would've been during the past 70 years if they'd started back then!

So how does it work?
Say you have one affected limb - be it that the limb was amputated or you are suffering from CRPS.
You put a mirror in front of you - put the affected limb behind the mirror so that it is hidden from view - the other one goes on front - and you start moving both in the same fashion.

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You of course know that the limb that you see in the mirror is just a reflection of the healthy one - but your brain can't.
Vision is a very useful but notoriously unreliable sense. Just look at any visual illusion to see how easy it is to fool the eyes/brain.
This is one of the best illusions ever: rotating spiral.

After staring at the spiral for about 20-30 seconds look at the back of your hand!
Even if you know that there cannot possibly be movement there you will still see something crawling under your skin - your brain gives you the illusion of movement.
There is no way you can override this illusion. Consciousness - like it or not - is just a bag of tricks.

The brain thinks that the limb in the mirror is perfectly alright (even when in reality you lost it through an amputation) - sensory-motor congruence is re-established and the brain stops sending warning messages to higher centers of the brain - what we call "pain".
Somatosensory maps are re-modeled (which happens very quickly) - and the pain is gone (forever).
This is one the key points of this type of treatment: it actually changes the very structure of your brain! (Flor, H.; M. Diers & C. Christmann et al. (2006), "Mirror illusions of phantom hand movements. Brain activity mapped by fMRI", NeuroImage 31: S159)

This type of treatment has been tested over and over again - most recently at the Walter Reed Medical Hospital - and success rates are well beyond 80% - some even report numbers as high as 95%.
All that with a treatment method that costs a maximum of 20 Dollars and only takes a few weeks.
There simply is no easier way to treat these conditions.
And the best thing: you can do it yourself!

There are a few commercial suppliers of so called mirror boxes - all favor a different approach: some are collapsible, one here in Germany favors an occupational therapy approach so you can do more difficult hand functions, ....
Fact is: it's the basic principle behind the treatment thats key - by providing (visual) feedback.

How about bilateral problems?
Well - back in March of 2003 I proposed (on the Yahoo Group Supertraining, Message 29357) that the same principle could be applied to paraplegics who often suffer from central pain. The part of the body below the spinal lesion is often felt as being very painful. I proposed to put a mirror on top of a TV set so that the brain sees the reflection of the upper body - and have a video tape show a couple of legs walking. That way the brain might be fooled into thinking that the legs are able to move and the pain should be gone.

I didn't have the resources back then to do this experiment myself - so I described it to Dr. Mel Siff whose wife is paraplegic. Unfortunately before I could describe to them how to set up the experiment Dr. Siff died and the whole enterprise came to a stop.

Enter Lorimer Moseley - the genius from Australia and one the most incredible thinkers and teachers you can imagine - and his study he published in "Pain" in 2007. He actually did what I was thinking about in 2003.
And it gives me great pleasure to say: of course it worked!

This is what I want you to recognize: don't ever ever ever - not in your job, in life or - as in my case physiotherapy (and photography) - let yourself become stuck in thinking in techniques and applications - start thinking in principles.
That way you are able to adjust what you know according to the circumstances.

The same here: it doesn't matter if you have chronic pain in a limb or in the lower back - feedback is the key. You can't see your lower back - visual feedback is out of the question - so use tactile feedback which works just as well as Herta Flor (another genius) has proven.
If you become stuck in specifics you can't treat LBP because you are thinking that is has to be visual; thinking in principles of "just give feedback" enables you to do so much more.

As for the how to - here are a few pointers:

1) concentrate - by paying attention to what you see and feel you tell the brain that something important is going on

2) 10-15 minutes at a time: you really can't concentrate any longer. Try several sessions a day.

3) Vary the movements - pick up objects, do meaningful stuff

4) take your time - there's no advantage in rushing this

5) one session before bed-time. Sleeping helps with memory consolidation and learning new things (in this case it might "only" be re-learning old things) ;-)

6) and please change your thinking about what medicine is supposed to be and have a close look at what you expect from the medical services - by doing this we'll all be better off in the future.

7) don't let yourself be discouraged to give this type of treatment a try even when "medical professionals" tell you differently. The problems here are that a) most don't know about it and it is easier to say no to a new type of treatment than to take the time to learn about it and b) we medical professionals have shaped our own expectations of what constitutes treatment based on high-tech and other modalities and have often lost sight of what else is possible. We have to realize that it isn't we that heal a person - we are often only there to help a person heal himself - just managing the whole process. The medical field needs to acknowledge this more often I think.

8) at last: try it and share your experiences. Email and comments are always welcome because they provide me with important feedback (see!) ;-) so that I can update my thinking, learn and share it with others to help even more people.

9) be playful. Understand the principle (by reading this series) ;-) and find out how it works best for you.

Here's a short video - kind of a case study so that you can see the effect mirror therapy can have on improving range of motion:

Thanks

I was invited to do a posting for the monthly pain blog carnival over at howtocopewithpain.org - the topic being thankfulness.
What better way to do this than with this great video:



First of all I want to thank all the scientists who ever lived who allowed themselves to think about things creatively and who didn't care what others thought at the time.

This goes back hundreds of years - among many others to Dr. John Snow who charted the deaths caused by Cholera in London in the 19th century and was able to solve the problem by identifying the causes, to James Lind who found the cure for scurvy - even if no one believed him, to Ignaz Semmelweis who found that washing your hands before childbirth saved lives.

There are hundreds more that should be included in this list - heroes that often nobody has heard of - forgotten by history. But it was they who enabled us to live the way we do - and we should never forget that.

You have to realize that a lot of these people suffered enormously during their lifetime because what they said didn't happen to be the accepted wisdom of the day.
Some went crazy, some killed themselves - but despite that they never stopped telling the truth.

One guy - Werner Forssmann - who later got a Nobel - was fired because he proved (on himself as a guinea pig) that you could put a catheter into your own heart. This technique has saved hundreds of thousands of lives! Imagine people like him keeping quiet about it and watching out for their own welfare - imagine where we would be now - still living in caves waiting for lightning to strike a tree so we could have fire. ;-)

"Big Science" is like Big business - a tough world to live and work in.
And only the courage of creative individuals keeps us going.
My heartfelt thanks to them.

My second round of thanks goes to the Organizers of the TED conferences for putting the amazing talks online.
Never before in my life have I seen so much talent gathered in one place. Every talk is a piece of art. I have no idea about marine biology - but when I watched the talk by Tierney Thys i was deeply moved. I just love watching poeple being passionate about what they do - it reminds me of myself. ;-)

Is there a thing more beautiful than watching someone talk about his or her work - in the process inspiring others?

I don't think so. You just can feel that these people want to do what they do - even if they weren't paid to do so. I wish everyone could experience the satisfaction you can have if you really love your job or your hobby.

Other great - must watch talks are:
- Sir Ken Robinson on education
- Hans Rosling on the developing world
- Dan Gilbert on Happiness
- Robert Fischell on Migraines
- Dean Kamen: watch a genius at work

My thanks also goes to BMW for sponsoring the talks - Bandwidth ain't cheap. ;-)

And now for some special thanks to the person who has influenced my work and my thinking more than anyone else on the planet:
V.S. Ramachandran.

He wrote a book (actually Sandra Blakeslee did - a gifted science writer) - called Phantoms in the Brain - that is still one of the best books about neuroscience out there.

After reading that book in about 2000/2001 I was hooked. The cases he described were just too weird to be true - but as it turned out it's even weirder than we can imagine.

In this talk he gives the example of Capgras Syndrome, Phantom Limb Pain and Synaesthesia.

You can also listen to his 2003 Reith Lectures covering much of the same material.
That's one the things I like about his talk: it's the same stuff he has covered over the past few years - there really is not much new material - but it is also the most succinct version of the issues involved that you can imagine.

Everything you need to know about the neuroscience of the self and pain is contained in that talk. It is the best starting point for your own exploration imaginable.

Starting at 13 minutes into the talk he introduces the biggest breakthrough in treating chronic pain syndromes ever: mirror box therapy.
I especially like the way that he clearly states that it doesn't have to be "high-tech" or expensive to work - but that the treatment is based on solid science. If you are able to exploit the weaknesses of our brain and our senses - go for it any way you like.
I cannot stress enough how important this is!

The medical establishment has - knowingly or unknowingly - created the expectation that big problems require big (and expensive) solutions. An MRI scanner costs millions of dollars and quite a bit of space. It's impressive just to look at - but don't let that fool you into thinking it'll help you one bit.

Yet this exaggerated reliance on for example imaging technology has created expectations that the health care providers are not able to keep up with - costs are going through the roof as more and more people get older and older.
We need to tone treatment down a little - find a new balance between too much and too little.

Mirror Box Therapy has none of the trappings of high tech medicine - yet it is incredibly effective.

And what's even better - it puts treatment back into the hands of the patients!
That's right - you are finally able to treat yourself again.

Structure vs. Function - Part III

Why this debate should matter to you - the therapist and the patient.

The search for structural faults that are causing pain is still going on.
And it'll continue to do so.
I think it has do do with basic human psychology - we have this need to put labels on everything we see. Our brains want easy explanations - all the time.
Our brains produce visual (and other) illusions because they are hardwired to resolve every computational problem they encounter.

They are not computers running Windows; they can't just crash - they have to continue functioning - even if that means finding patterns in meaningless noise (pareidolia, conspiracy theories, astrology).

So where do you - the patient come in?
Well - your expectations are shaped by this mechanism. You want answers when you consult a health care professional. And those answers better fit your view of the world - or else!

Structural faults like ruptured discs, degenerated vertebrae, pulled muscles are easy to put a finger on - just think of an MRI scan that shows a bulging disc. What's easier then to show you - the patient in pain - that picture and explaining that that bulge causes all your problems. And since an operation could clear that right up you could be pain free again in a week or so.
It's convenient, easy, convincing - and even fits the symptoms sometimes.

Now compare this to a more functional explanation - with or without the scan if you like.
The doctor would explain to you that yes - there is a bulge - but it could be an old one you've had for a year already (without symptoms) - and that the reason you are in pain now is that your brain "has decided" to produce a painful sensation because of some factor that could be biological, social, psychological or all three.

His advice is to keep active, distract yourself as much as possible and adjust your daily life accordingly and check back in one or two weeks if things don't get worse.

Which would you rather pick?
Exactly - option one is simple the better sounding one. Until you had the operation of course and the pain is still there.

That's not to say that all operations are for nothing. But even orthopedic surgeons have started to admit over the past few years that the outcomes weren't that great in cases where the main reason for an operation was pain as a symptom.
Long term studies show that the outcome over the long run is even the same compared to conservative care.
This goes for spinal surgery and other kinds too (think osteoarthritis of the knee).

Pain - like it or not - is in your brain!
It always is - and always will be. It's an emotion like anger, fear, love and all the others. And like all the others it's being put together according to the circumstances you find yourself in.

So if you change the context - you can change the pain - your pain.

Some methods and influencing factors I already have described in my Pain for Dummies Series.

Here are a few more:

- Kinesiotape: How does it work? It's all about low-level cutaneous neural system input - or "grooming" as it's known in primate circles. Have you ever seen chimpanzees grooming each other? That's what kinesiotape does. And if you can honestly say that you wouldn't like to be groomed for a few hours each day you are a liar!

- Feldenkrais: that guy was a genius. Simply brilliant! He recognized that the brain is plastic and likes to learn. That's what happens when you do those exercises - your body learns how to move more efficiently. It's all about feedback and re-programming better motor patterns. When I say Feldenkrais I also mean all the other offshoots his work created: Somatics (faster, shorter - equally cool), Alexander Technique, Rolfing, Yoga, ...
And of course - when you try new movements you have to concentrate a lot - distracting yourself - again.

- Meditation: training how to calm "the mind" - to get the same level of control over your "mental muscles" as over the ones you exercise in the gym.




- Feedback therapies: Mirror Box for CRPS, Phantom Limb Pain and the like. Tactile input for parts of your body you can't see - like our back. And auditory training for tinnitus.

- Redcord: we use this device in our clinic and I have to say it's phenomenal! There simply is no faster way to re-program motor patterns.

- Motor imagery: works. Close your eyes and work out at the same time. Mentally rehearse things that you have to do every day and try to make them more efficient.

- Neuromatrix training: read the blogs - mine, David's and Diane's.

- Educate yourself: the 20th century is over. The expansion of the Internet puts the worlds knowledge at your fingertips (otherwise you wouldn't be reading this!). The more you know about yourself the better off you are.

- Give back: there's nothing like sharing what you have learned or experienced with the rest of the world. By putting your thoughts into words you go over the experiences again - putting them into proper perspective. The only thing you can do wrong is not doing it.

Pain For Dummies - Part X

or: The End (?)

Over the past few weeks I've tried to explain a few things about pain, you and your brain - and why science is important and how it helps us to understand ourselves.

I will of course continue to post about these topics - but the Pain for Dummies Series comes to an end with this posting.

To sum up the series:

Pain is incredibly complex - it involves the whole brain, it can (and must) be tackled using different approaches (hence biopsychosocial). And we are far from understanding it completely.

Most important however is the fact that there is such a thing as a "brain in pain" - a brain that has learned that there is pain to be expected regardless of what the person does - and that you can re-learn to be pain free!

That doesn't happen overnight of course - you'll need lots of patience - but there is a basic entry level for everyone. Find it and start (re)training - now!

Here's what I covered over the past few weeks:

Part I: What is Pain?, Pain and the Stress Response

Part II: The Multidimensionality of Pain and the Biopsychosocial Model

Part III: The Psychology of Pain

Part IV: Metacognition - the coolest feature you have and didn't know about

Part V: The social aspects of pain

Part VI: Can you handle the truth?

Part VII: What’s this new approach all about?

Part VIII: Practice what you preach!

Part IX: What’s the economy got to do with pain?

I hope that you can use some of the tips and tricks I put into my postings and that they will make your life easier - or better yet point you towards a pain-free future.

Coming up are a few postings about how we can tackle chronic pain from a therapeutic point of view - by exercising the virtual body and giving non-nociceptive feedback for example.

Stay tuned!

Structure vs. Function - Part II

Let's examine the debate between structuralists and functionalists some more with the ubiquitous ankle sprain for example.

Treatment for such an injury until a few years ago focused mostly on reducing swelling, early weight bearing, .... - and yet the single most important risk factor to suffer from another ankle sprain is still a preceding ankle sprain. The same happens in low back pain (LBP). Your "risk" to suffer from another episode of LBP is greatly enhanced by an episode of LBP in the past.

How come?

Well - the sad truth is that you cannot guarantee joint stability with sheer muscle force - and that was - and unfortunately still is - the theory behind most training regimens. It went something like this: if a joint is injured the best way to provide stability in the future is to exercise the muscles surrounding the joint.

Along come journals like the Journal of Applied Physiology (and others) and show that this simply doesn't work: muscles are way too slow to provide stability.

If you jump on a platform that suddenly tilts under your foot it takes just 10 milliseconds for your ankle to get hurt.

On the other hand muscle takes at least 50 milliseconds to react in the most basic and "primitive" way - with a reflex action.

Let me spell it out for you: muscles contract after (!) the injury has taken place - often making it worse in the process.

Interestingly enough students are taught this in physiology classes - the contraction times I mean. Yet 99.99% fail to make the connection that muscle action isn't sufficient to provide stability.

Lateral thinking rules the day once again. ;-)

You mean to say that training doesn't help at all?

Of course not - but the focus has to be on the timing of the muscle action. Scientists call this the "feed-forward" approach.

Your brain (using the eyes) continually scans your surroundings and the ground in front of you. It then prepares motor patterns based on the visual impression of the surface you are going to step on. In short: your muscles contract way in advance so that they are prepared for the moment when your foot hits the floor. That's when you need the braking force your muscles provide.

It's the same when you try to catch something: your brain computes the path the object travels, factors in gravity (or not - as Alain Berthoz has shown with Space Shuttle Astronauts) - and adjusts your hand muscles so that they are ready to intercept the object. It's all about predicting future events - even when they are just a few milliseconds away.

As for LBP, the same feed-forward mechanism applies: your brain tries to prepare the body for, say - catching (heavy) things by contracting the muscles around your "core". This increases intra-abdominal pressure - thereby enhancing spinal stability and providing a stable "platform" as it where for the extremities. Once you suffer from an episode of LBP this mechanism is put out of action - from then on you use a different motor pattern to control your trunk which isn't up to the demands of everyday life. The deep muscle system of the back stops working and the more superficial muscles take over. They have to exert a lot more force though to keep the trunk rigid during heavy tasks - so they tend to tighten considerably.

On a side note: Rectus Abdominis (the famous "six-pack" muscle) doesn't do anything for increasing intra abdominal pressure. For me it's still the most useless muscle out there.

Only by re-establishing normal motor function - by training coordination and by re-establishing the feed-forward mechanism can you reduce the risk of suffering from another episode of LBP.

Modern rehabilitation has to focus on two things:

one - restoring normal joint play and range of movement (Motion is lotion and creates lots of feedback)

and

two - training the feed-forward mechanism so that the brain becomes better (and a bit faster) at predicting the future, proprioception and reacting faster.

For the first task you are welcome to think in purely structural terms - damaged ligaments, scar tissue formation and so on and so forth.
But for the second one - re-programming motor patterns you have to think like your brain. Sounds strange - I know.

But think about it: your brain has to prepare itself and the body it resides in for a lot of tasks and challenges each and every day. It does so by storing information about previous events (called memories) and building up a huge database about the properties of different objects and surfaces so that it is prepared for the things that lie ahead.

I will come back to this topic with a series about Alain Berthoz book "The Brains Sense of Movement".



How does this picture fit the topic?
Well - some of the same principles are at work here: most people - when the see a fibre optic lamp - just think "lamp".

Me - I see a thousand possibilities. I see movement that can be captured over a period of a few seconds - creating very interesting patterns.

This is what purely structural thinking has lost: it only looks at static structures, snapshots of tissues in different stages (of healing).

Functionalists see change over time, function in a bigger context - and above all a brain that tries to make sense of an outside world and a virtual reality simulation of that world on the inside.

Pain for Dummies – Part IX

Or: what’s the economy got to do with pain?

Economics is a difficult field to study. Making accurate predictions is hard because human behaviour and decision making are so erratic it’s beyond belief. The emerging field of neuroeconomics is trying to rectify that situation by looking at the brain during decision making processes. Some of the findings are really scary – people prefer short term gain over long term gain for example. Doesn’t bode well for things like working on issues like climate change.

But this blog is about pain – your pain – so how does economics help us deal with it?
I’ve written about the positive effects of work on pain by providing a source of distraction.
But what I want to explore now is one of the basic premises of the science of economics: people react to external factors (without necessarily being aware of them) .
Or: your environment influences your behavior – much more than you know.

Consider my own example: I like to move. I like to exercise. But for the past few years my external environment "didn't let me". There simply was no incentive for me to take care of my own body. I knew that I should've been doing something - but was literally unable to follow my own advice. ;-)
After changing jobs and the place where I live the situation improved dramatically and now "I'm back"!

Even more dramatic are some of the experiments of the 60’s in social psychology:
Zimbardo and Milgram took well adjusted people and put them in difficult situations – Zimbardo used a made up prison environment and Milgram used an authority figure – and look what happened.
Experiments like this show that everyone of us has a range of possible behaviors within him or her – if they are triggered depends on the circumstances we encounter in life.

It’s like the old debate over nature and nurture. Some out there – adherents of the black and white world view still talk about nature vs. nurture. But that’s nonsense: it’s genes and how the environment acts to activate them. If you have a genetic disposition to be afraid of water and you live in the desert those genes are never activated. It’s the combination that determines what happens.

The same with you and your pain: if you are more likely to develop chronic pain due to a genetic disadvantage you have to work on the “nurture” part – that is your environment to reduce the impact. You can’t change your genes – yet – but you can try to lower the chance of those genes being expressed (the fancy way of saying “activated”).
Work on developing helpful coping strategies for example – the pain itself doesn’t necessarily go away – but the impact it has on your life is greatly reduced. Work on distracting yourself – don’t let the pain rule your life.

If you are prone to develop stress related diseases – again: coping, relaxation and distraction are key. But here is where it gets interesting:
“de-stress” your environment – i.e. your surroundings at work and at home.
Peripheral vision works by checking your surroundings for (sudden) movement and drawing your attention towards it; it is one of the systems we have that helps to protect us from dangerous predators – sabre tooth tigers and the like. Since those aren’t around anymore it now reacts to everything that moves – decidedly unhelpful in our modern world.
If your desk or workspace is too open to such intrusions – close it of. Walls are there for a reason!

The same applies to your desk itself: to much clutter is unhelpful – “visual clutter” is enormously distracting. Your brain scans all the items lying around and uses up a lot of energy doing that. That’s why we have bookshelves, cabinets and the like at home – when everything is in it’s place the atmosphere is a lot more relaxed.

Use indirect lighting to create “mood”. Direct light is very harsh – indirect lighting creates softer light which most people find pleasing. Color is another great way to “de-stress” your surroundings. You can choose warm (yellow, red) or cold ones (blue).



One of my favorites is smells: they are very powerful since they are directly channeled into the brain – not having to go through several processing steps like the other senses. It all depends on what you like – but give it a try and find something that’s just right for you.
Same with music – that’s why there are songs for driving, working out, … – the rhythms are able to influence your heart rate.

There are of course things you simply can’t change – but try to find workarounds wherever possible. Know your strengths and build on them – manage your weaknesses.
Use Metacognition to identify which things, objects and situations in your daily life cause problems and work on changing their impact.

Structure vs. Function - Part I

I guess every field has it's own "vs." debate. They usually last for years without ever coming to a real conclusion.

One would think that by now most people would've noticed that it's not a question of "vs." but of interconnectedness - nature and nurture - not nature vs. nurture.

If you have a gene that makes you more susceptible to developing a certain illness there have to be factors in your environment that activate those genes - otherwise you don't get sick (in that specific way).

The old "vs." debate in Physiotherapy and similar fields is one between structure and function.

There are some who see treating tissues as their main approach - others like me have abandoned those models of thinking (long ago) ;-) and see themselves as "functional therapists" - or neuromodulators - as for example Diane Jacobs does (her excellent blog is here).

Why is there a debate at all?

Well - medicine is still influenced by what scientists/pioneers started when they cut up the first human bodies centuries ago - gross anatomy.

Even today - with all the new techniques that were developed since - medical students start by dissecting bodies and learning about the human animal that way.

What's more - starting with Mixter and Barr in the 30's - every decade more and more and finer and finer structures have been found and are presented as the "pain causing structure". First it was the ruptured disc - now we are down to the vessels that supply the disc and their pressure being elevated causing constricted flow and a sharp rise in pressure. With structural thinking there is just no end in sight - next they are going to focus on molecules being bent out of shape.

And if you haven't realized it by now: those people are dead! Yet medical professionals treat humans that are alive!

You can study the mechanics of flight in this picture - but not flight itself:



Do you see the problem now?

We - as examiners can see muscles and tendons and bones - all clearly discernible - but the Neurosciences haven't found a representation of a single muscle inside the brain yet - they just don't exist from the brains point of view. The brain "thinks" in movements, goals and actions to perform - and uses what's available at the time.

Have you ever seen a runner without legs? With special prosthetics - which are in some ways much better than legs they run just like you and me - yet they have only half (?) of the muscles we think a human being needs to be able to run.

Look at people who had polio - the muscles that weren't affected take over the function of those muscles that are paralyzed.

How does this affect treatment?

Let's look at the example of phantom limb pain: the missing limb hurts, it might be an involuntary clenching or burning pain or whatnot. So the "structural" oriented practitioners started looking for clues in what was left of the extremity. Some of the pain was attributed to the site of the amputation - resulting in another shortening operation, nodules of scar tissue being removed from the stump, the cutting of nerves from the spinal cord to the limb and so on and so forth.

Again the rule of thirds came into play: some got better, some stayed the same, some got worse.

In come the "functionalists" - led by V.S. Ramachandran - building on the work of others of course.

They realized that the cortical map of the amputated limb was still present in the brain - most accessible to study in the somatosensory cortex in the brain. And so called higher centers in the brain act on the information that is contained in those maps - not on what's outside in the real world.

Since pain is produced in the brain Ramachandran speculated that the cause of the pain could lie in the fact that the representation and the visual feedback from the limb didn't match (see Harris Hypothesis for more).

So he gave those amputees visual feedback of an intact limb with a mirror - and the pain vanished quickly.

Those findings have been replicated over and over again - Walter Reed is running a big trial with Iraqi War Veterans to see if mirror treatment is a viable treatment. Traumatic amputations are often much more difficult than "planned" ones.

The sucess rate of this kind of treatment is - at least in small trials well over 90%.

This doesn't mean that the "structuralists" are wrong - but just that they should try to "expand their thinking".

The techniques they use are still useful and are applied by me as well - but the reason why you do something and how you do it is different - helping you in cases when a patient fails to improve.

One kind of therapy that finally started to get around to acknowledging this is the McKenzie method. It originated as a purely mechanical way of treating back pain - but has since then evolved into a method that is able to treat the whole body. The term "derangement" now encompasses all things in a joint that can be "out of whack" - and only cares about if the patient gets better with repeated movement in the preferred direction.
Even large scale trials show that this kind of treatment is very effective. People aren't put into groups based on structural findings - their functional status is all that counts.

I've had discussions with the top people in Germany and the US about openly admitting that they "are only changing neural firing patterns" - not doing anything mechanical with a specific structure - and at least behind closed doors the Germans agreed - the US guru is still not talking to me. ;-)

And this despite the fact that they see how fast people can improve with this method.

Structural thinking is just so easy to grasp and not as "nebulous" as functional thinking - at least to some.

Pain for Dummies – Part VIII

or: I'll be back!
or: practice what you preach!
or: change in action!




Yes folks - I did what I always said I would: I started working out again.

There was no doubt in my mind whatsoever that I would start doing some form of workout again - I just had to find the right time and the right circumstances. That's what I call the economics of change - but that's the topic of another posting.

And - having paused for quite some time - it feels so good to physically exhaust oneself again.

You guessed right - I didn't take the slow methodical approach - I'm more along the lines of Jeremy Clarkson yelling "Power" when I start and "More Power" when something isn't going according to plan. ;-)

The biggest difficulty in starting an exercise program (or any other training regimen) is always the (felt) lack of time.

And while everyone knows that's not really the problem it is the most frequent reason people give when asked why they don't do regular exercise.

For me - as always - the problem can be tackled from a neuroscientific point of view - that's why the title of the blog is "The Neurotopian"; I envision a future in which every question can be answered from a neuroscientific basis.

So why don't people have time?

Well - it's the same process that's at work when it comes to visual perception - it's called filling-in.

Our eyes have a region called the blind spot - it's where the optical nerve leaves the eyes. There are no receptors there - so we have a big hole in our field of vision. You can test your blind spot and even map the size of it - here.

Curiously enough we don't notice it at all in normal life.

The brain employs a mechanism known as "filling-in" where it "calculates/estimates" what should be in that blind spot and fills in the missing information.

The same goes for touch, for hearing and all the other senses we have. If something is not there the brain doesn't leave a hole but presents us with a complete and whole picture.

Now try this experiment:

take a normal workweek - 24 hours and 7 days and try to remember what you did during that time.

Notice the times you slept, ate, drove to work, ...

Finally - try to remember the times when you did absolutely nothing! Nothing except breathing and staring at the wall waiting for the clock hands to move forward an hour.

I bet you can't find any such time.

Even "doing nothing" involves doing something - even something completely meaningless.

And those are exactly the times you have to identify. There is your ideal workout time!

For me it was coming home on Tuesday evenings at 8pm and just checking emails, looking through Flickr, reading a few blog entries and similar stuff - nothing really groundbreaking. But it became a habit.

Till I realized that none of it was really useful - I could do the same a day later too and have enough time to exercise for a full hour.

Surprise surprise - it worked perfectly. Even better than that - by exercising somehow time afterwards seemed to move more slowly - maybe all those endorphins kicking in - and I still had time to check my email and read a bit.

The problem like I said is not that there is no time - but time that is simply filled with something - anything.

Find it - use it.

Pain for Dummies – Part VII

Or: what’s this new approach all about?

As described in the previous posting the old paradigm – the body based approach - is still alive and used widely.
The new one is radically different – so much in fact that it seems strange and too simple.
How to explain it so that everyone can understand and benefit from it?

A good starting place are these two great books: Phantoms in the Brain and The Body Has A Mind Of Its Own. They are able to give a much more in-depth view of what it means to have a brain. ;-)

In short: imagine yourself having to drive from say Paris to Berlin. In order to prepare yourself for the journey and to be able to estimate the resources you need (time, food, gas,…) you use a map. The map isn’t the territory – it would have to be on the scale of 1:1 to do that – but it is a representation of the actual landscape you are going to be traveling through.



With the help of this map you can easily measure distances which – combined with speed – give you a rough approximation of how long the journey is going to take. You can check for elevations, roads, highways, restaurants and so on. You are able to plan the journey – including rest stops and a whole lot more solely based on the representation you have lying before you.

Maps are so great in fact that our brains have discovered them millions of years ago. Even better – we not only have one map but hundreds of them – each for one specific function.
Maps of the body are so old that they are hardwired into the genetic structure of our brains – meaning that even when you are born with a missing limb the map for it is still there in your brain.

The modular structure of our brains is laid down very early during development – congenitally blind people (blind from birth) still have a visual cortex and so on.

Maps are so useful because they enable us to react lightning fast; if your brain had to check if there really are two legs when you slip you’d have fallen to the ground before you could react. With a map in place everything is sped up and you are able to recover balance. Most of the time anyway. ;-)

The old paradigm focused on the terrain itself – in CRPS for example treatments were aimed at restoring circulation to the injured limb. What neuroscience has found is that instead the arm being the cause – it’s actually the hand representation (the hand map) that is the cause of the changes we can see.

Other – so called higher centers of the brain – then act on that distorted information; no wonder that the output they produce isn’t the right one – they simply don’t "know" better. The brain is acting on distorted information.

Treatment has to focus on the cause: re-modeling the hand representation as fast as possible.
Fortunately these maps are plastic – that means they have the ability to change. That’s how we are able to learn and acquire new skills – if we learn to ride a bike for example those new motor patterns become hardwired into the structure of our brains. In the case of chronic pain that whole process of learning goes haywire – there is such a thing as too much of a good thing.

Re-training or re-modeling can take different forms – depending on where your individual starting point is: if really all movement with the affected limb is painful then start with motor imagery, i.e. imagining moving the limb. Motor imagery is very effective as a stand alone treatment since it activates the same neural circuits in your brain that you use to do the actual movement. All that’s missing is the motor command that tells you muscles to contract.

After this first step you can start actually doing the movement with a mirror box – the affected side behind the mirror so that your brain is fooled into thinking that the limb it can see is doing what it wants.

You create a congruence of motor intent, motor output and feedback that way.
Gradually the map is remodeled and function returns.

As Harris points out it’s enough for pain to occur when the brain is unable to make sense of divergent information – so pain should subside very quickly when you do the few first sessions – only to return a short while afterwards.
Don’t despair – it just shows that your brain is still able to turn of the pain and willing to learn.

At least this should give you the hope and motivation one so desperately needs when so else has failed.
And the best thing: it’s easy to do.

One can only hope that these new findings spread as fast as possible since even some of the most serious illnesses out there – think anorexia with a 20% death rate – most probably have their origin in these body map disorders.
Reestablishing those maps can alleviate symptoms very quickly and help save thousands of people from suffering.
Spread the word!