Mirror Box Therapy - Part VII

F.A.Q.

This section tries to cover any question you might have and should serve as an additional resource so that the experiences people have with this kind of therapy can be recorded and shared.

1) Are there any known side effects?

None have been reported yet.
Things that can happen - depending on the condition are:
Lorimer Moseley reported a patient that was so distressed seeing the amputated limb move again that he had to withdraw from treatment.
Another interesting phenomenon is Dysynchiria - if you touch the unaffected limb and watch the reflection pain is felt in the affected limb.

2) How long should the sessions last?

Since you have to focus your attention on the treatment 10 minutes at a time are sufficient. Try to repeat it several times a day for a few weeks.
There are huge differences between individuals regarding how fast they respond.

3) Are there commercial suppliers of mirror boxes?

Yes - you can order them here and here for example.
Or you can make your own by following these instructions.

4) What do I do during the session?

If you have pain in your arms, hands or fingers try moving them in any way possible. Pick things up, count coins, do whatever you can. Vary the movements from simple to complex. And above all: watch what works best for you.
Jeiseas Blog is a great resource - see how she uses it. What works for her might also be good for you.

5) Which therapist should I see for mirror box treatment?

This is a tough one.
The treatment was developed by a Neurologist and is used (and expanded) by Physiotherapists, MD's, Psychologists and other professions.
In effect the treatment belongs to you - the person in pain.
Any attempt to bring it under the domain of only one profession is - in my view - completely nuts!
By explaining it in this series I hope you are able to give it a try yourself.

6) Which conditions can be treated?

First the obvious ones: phantom limb pain, CRPS, RSI.
Then the not so obvious one: central pain in paraplegia.
And last but not least those problems that can be treated by applying the principles of feedback therapy: low back pain, tinnitus, anorexia (?!), fibromyalgia.

Mirror Box Therapy - Part VI

or: Outlook - Possibilities - Thoughts

OK - our brains are built to predict the future - let's see if I can help that along. ;-)

Blakeslee - in her excellent book - has reported that there are preliminary results that viewed the problem of Anorexia from a body map disorder point of view. What if people with anorexia "just" have a different body map - one that is much much thinner than their real bodies.

Easy: they feel extremely uncomfortable in their own bodies. I imagine it like your whole body being numb (think of the effect you feel after you visited your dentist - now only include your whole body).

The only way to make the felt image and the actual image fit is to starve yourself - in 20% of cases even to death. That's how strong this urge is.

The thing we have to recognize about emotions and the urges they produce is that they are strong motivators - they "make us do things". And only when we have satisfied whatever the emotion tells us does the urge go away. Viewing pain as an emotion like hunger and so on makes it much easier to grasp what's it all about.

My best guess is that eventually all body dismorphic disorders will be recognized to really be "body map" disorders and be treated accordingly.

(I know that pain is not a real emotion - it's much more than that. But some of the effects it has on us and on our behavior are very similar which makes it easier to talk about it.)

Another very frequent condition where feedback therapy shows good results is tinnitus.
Again - peripheral thinking (i.e. in terms of damaged structures) hasn't amounted to much progress being made.

Now - thanks to brain imaging we can see that tinnitus is the same as phantom limb pain only for our sense of hearing. The auditory cortex where sounds are mapped becomes disorganized - creating random noise. By re-training the auditory cortex - as Herta Flor and Colleagues have done - having the patient distinguish different frequencies and so on - the symptoms can be markedly reduced.

Another treatment that is able to alleviate such symptoms is TMS (transcranial magnetic stimulation) which shows even better results.
One clinic in Germany at Regensburg University is working with this technique. And on a sad side note - largely unnoticed by the medical establishment as yet.

Migraines - with aura - are yet another field where neuroscience has found an identifiable cause - quickly spreading cortical depression. And the easiest way to describe treatment I have to think of the term "re-booting". It seems that a few neurons go haywire - causing others to join in. By zapping those neurons - which are located in the visual cortex - you can stop the effect from spreading.

A handheld device is currently undergoing final tests and should be on the market soon.

As for other frequent conditions:
focal dystonias, writers cramp, jips in golfers, RSI, .... are all due to some form or other of the map areas becoming deformed, fused or altered in some unintended way. Treatment as I stated before has to re-establish normal maps, creating congruence between the VR program and the actual sensory information.

If you don't suffer from any of these conditions count yourself lucky.

Not only was treatment unavailable till now - since no real cause could be found sooner or later people were accused of the symptoms being all in their heads - which in a way they were - but as real physiological manifestations - not some unexplained "psychological" phenomenon.

Don't get me started on the harm that was done to these people by so-called medical professionals who are too lazy to pick up a book or medical journal once in a while and are too arrogant to question their own knowledge.

A much more common problem everyone has to deal with sooner or later is aging and it's accompanying aches and pains.
The best term for this combination is sensori-motor amnesia - which - as far as I can tell - comes from Thomas Hanna who built on the work of Feldenkrais.

What do "old" people have in common?
Their posture, their way of walking, their difficulty in looking over their shoulders (which makes driving a car dangerous), and so on and so forth.

Yet - with a little hands on treatment - they are able to regain a lot of their mobility within minutes.

How come?
Well - I see daily life as a constant struggle between adaptive and (cumulative) maladaptive learning.

Babies learn all day long. They learn a language or two or three, they learn social norms and customs by imitation, they learn how to move their bodies in thousands of different ways. After a while they become school children - and learning takes on more of a purely "mental" form - the memorization of knowledge. "Body learning", i.e. different types of movement aren't explored any more.

Now you might say that during the teenage years most people pick up a sport - and you'd be right. But it is one sport - with one specialized way of moving - and not a great variety of things.

After that you have a job - and if you are really unlucky it either involves sitting or doing the same repetitive tasks over and over again.

What happens when you either have to little movement (sitting) or too much small movements is that your body maps change. Add to that that the tissue becomes hypoxic and you have a recipe for disaster:
this body map change is accelerated by the presence of pain.

Now - before pain becomes "felt" there is already nociceptive information being sent to the brain which uses reflex responses to automatically adjust posture and such. Just watch people at the cinema - they are constantly shifting position to distribute the pressure from sitting over a wider area of the body.

Only when those mechanisms don't suffice to change the nociceptive input pain is produced.

These two examples give you an idea about what aging is:
it is the slow accumulation of changes in our body maps with the effect that we un-learn how to move bit by bit. This process is accelerated/aided by sub-conscious pain and automatic reflex responses (reflexes are stereotypical - that's why old people "all" have the same posture).

It's not because our bodies can't move freely anymore - the brain simply has forgotten how to send the appropriate motor commands.

The solution: life-long body learning. Feldenkrais, Somatics, Yoga, .... - all build on this.

It's a bit more difficult to incorporate this into daily life - but things like the Nike Free are a good way to start.

Those shoes really do help your feet to become alive again.

What are you waiting for?
Go do something now or I will send them after you: ;-)

Mirror Box Therapy - Part V

or: Resources

I love the Internet - plain and simple.
All my life I knew there was something missing - till broadband came along and changed everything. ;-)

This collection of links is an ongoing project - feel free to suggest additional links, blogs, websites, ... in the comments or by email to matthias.weinberger(at)gmail.com

Medical Databases and Search Engines:
- PubMed
- HubMed - a much better interface than PubMed
- Google Scholar

Recommended Journals:
- Pain
- Neuroscience Letters
- Experimental Brain Research
- Neurology
- Brain
- Journal of Applied Physiology
- Journal of Neurophysiology

Videos:
- YouTube
- SciVee

People:
- Ramachandran
- Herta Flor
- Lorimer Moseley
- Candy McCabe

Products:
- NOI
- Mirrorboxtherapy.com

Blogs:
- Diane Jacobs
- Neurotonics
- Howtocopewithpain - including a monthly pain blog carnival
- Psychology of Pain
- David Butler's blogs: one, two, three
- Michael Merzenich
- Deric Bownds`MindBlog
- BPS Research Digest
- MindHacks
- Mixing Memory
- The Frontal Cortex
- Healthskills
- Jeisea

Books:
- V.S. Ramachandran "Phantoms in the Brain"
- Sandra Blakeslee "The Body has a mind of it's own"
- Herta Flor "Psychobiologie des Schmerzes"
- David Butler, Lorimer Moseley "Explain Pain"
- Patrick Wall, Ronald Melzack "Textbook of Pain", "Pain"
- Alain Berthoz "The Brains Sense of Movement"
- Michael Gazzaniga "The Mind's Past"
- Jeffrey Schwartz "The Mind and the Brain"

Forums:
- NOI - the forum closed some time ago - but the archive is still there
- SomaSimple

Podcasts:
- Brain Science Podcast
- All in the Mind
- TED Talks

I thought about including a section about the most important scientific papers - but there simply are too many out there.
For those who want to dig into this stuff: start here.

Mirror Box Therapy - Part IV

Feedback.

That's what the treatment of chronic pain boils down to: you have to send feedback - be it visual, tactile, auditory, ... to the brain so it can update the VR model. Only if the model and the corresponding motor command generated by it and the information from the external sensors matches up will the pain stop - very rapidly as several studies have shown.

Now - the really great thing about any type of feedback therapy is that the corresponding map which was altered in a maladaptive way starts to get reorganized while doing the therapy. That's what the studies report: during the first few training sessions the pain diminishes very rapidly - but comes back after a short amount of time (15 minutes,...).

But after the 5th or 6th session most people are able to get more lasting pain relief - and after just 3 weeks of daily practice most people can stop doing mirror box therapy altogether because the pain doesn't return.

This is all due to the positive effects of brain plasticity: the brain is able to re-organize very very quickly - provided it has the right incentive to do so.

As yet there are no long terms studies out that show how people with phantom limb pain that were treated with mirror box therapy have done over the years - this method is simply to new. I expect the first big trials to show up in the next 5 years or so in the wake of the studies done now at Walter Reed Medical Hospital with Veterans of the Iraq War.
That should give us an even better picture about what causes the process of maladaption in the first place.

My best guess is that initial pain (a painful limb that hurts before amputation) is the single most important factor - the brain learns the pain.
That's why amputations done where the limb was anaesthesized first show much better outcomes than traumatic amputations.

If you look at the case of CRPS - and to some extent after a stroke - you see another interesting thing:
the immobilization phase you have to go through after breaking a bone or suffering from a stroke tells your brain that - despite it sending motor commands to your limb - there is no proprioceptive feedback from the sensors in that limb.
If you can't move your hand because it's in a cast it can't send enough feedback to the brain.

So gradually over the weeks the hand map is adjusted - resulting in a limb that actually can't be moved even after the cast is removed. The brain has un-learned that the hand can move a great deal. And since the VR simulation in our brains is the basis for our actual perceptions and thoughts and feelings and everything else a lot of people describe their afflicted hand as no longer belonging to them.

An even more extreme example with different causes is the so called Alien Hand syndrome in which people don't recognize the hand being theirs at all.

What happens with the hand during CRPS - the swelling, osteoporosis and all the other stuff is secondary to the changes in the brain!

By using a mirror to give the brain visual feedback of an intact, healthy and freely movable limb re-organizes the map and symptoms vanish very quickly.
There are some preliminary results that show that even in stroke - at least part of the paralysis that results is not "real" paralysis - but learned paralysis - the brain just thinks that one side can't move any longer.

And even if that only accounts for say 20% - every bit of function you are able to regain after a stroke is better than nothing.

What sets CRPS apart from other chronic pain syndromes is that in addition to the hand map becoming distorted is that people aren't able to distinguish between a picture of a left hand and a right hand. They loose the sense of laterality.

This could be due to the fact that the brain uses the representations of the hands in it's internal model to construct laterality in the first place.

This would amount to the loosing of one of the models of the physical world that was established during childhood. Imagine yourself loosing your sense of gravity - one could no longer throw things accurately because you wouldn't be able to plan a parabolic trajectory - you would think that things always just fly in straight lines.

The NOIgroup Institute has developed a set of cards and a computer program with which you can re-learn this basic first step called Recognize.

If CRPS is in full swing however and sort of movement might aggravate pain.
That's why in severe cases you have to wait a little before you can do visual feedback therapy (mirror box).

The treatment in these cases starts by doing imaginary movements.
Those activate the same brain areas as actual movements - after all the brain does the same while running the VR program - the only thing that's missing is the actual motor command which is actively inhibited.

That way you can train the neuronal/mental circuitry which later will be activated for real.

As for areas of the body that have no limb like features - like the back:
you could have the patient lie down and point a video camera at his back and show him the image on a monitor.

But - as a few clever scientists have found out long ago - visual and tactile feedback are treated as equal in the brain.
Here finally the hands of the therapist come into play. ;-)

By touching the skin over the area you want the patient to move you can facilitate the whole process.
Once he has established motor control over that area again he is instructed to activate the muscles in that area every day so that the brain receives proprioceptive information from that area on a constant basis.
I advise some variation of primate grooming for home use: back rubs, brushes, whatever is available.

Regardless of which type of condition you have or want to treat:
the basis is always to send feedback about a limb or another part of the body to the brain (the comparator).

Feedback in daily life is important: remember how hard you had to hit the keys on an old typewriter?



Today's keyboards - especially the new one's from Apple are awesome!
Touch screens however are tricky because they don't provide any feedback. If the manufacturers were clever they'd introduce a very slight vibration - that would do the trick.

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.

>

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.

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!

Pain for Dummies – Part VI

Or: can you handle the truth? ;-)



When taking the history of a patient one phrase comes up all too frequently: “I have tried everything”.
To be honest: no – you haven’t.

Here’s why:
We – and this concerns all of mankind – have a huge problem: there is so much information available that we have a hard time keeping up. Add to that that not only would you have to read all this new information – but also understand it and use it – while also working your usual 40 hour+ work weeks.

Change is hard – as explained here. Old patterns – be they motor patterns or other behaviors – are more efficient than new ones. That’s why - especially in times of stress - we use them over the new ones.

The treatments you as a health care professional provide are on the safe side – something you have established over the years. You think you know that they work and you apply them over and over again.
Problem is that they are mostly based on what I call the old paradigm – the purely body based approach (structural thinking).

You have to remember that the brain was out of reach of serious scientific study until 10-15 years ago. People in pain could describe their problem – you could look for clues what’s wrong with their body – but there was no way to have a look at their brain in pain. That’s why treatments for tinnitus, phantom limb pain, fibromyalgia, CRPS and other similar ailments focused on the changes that were visible to the naked eye so to speak.

That’s why – when you look at the studies done using those kinds of treatments you always end up with the “rule of thirds” as I call it – a third of the patients got better, another third stayed the same and the rest got worse.
It's like using a shotgun: some pellets hit the bad guy - the rest misses or injures an innocent bystander. In medicine you prefer the magic bullet that is able to hit the problem directly - nothing more - nothing less.

It’s no ones fault really: there simply was nothing better at the time.

This however has changed rapidly during the “Decade of the Brain” – now we have treatments that are able to address the cause of the problem. And here we encounter the second obstacle on our way forward: health care professionals have applied those old treatments for years – with moderate success (think shotgun). But since those illnesses were so hard to treat even 30% improvement seem like a good deal. Those old treatments are “hardware” based – flashing lights, infusions, pills, … - they all seem very thought out.

They are – there really is no other way of describing it – “sexy”. They are what you – the average Joe – came to expect from medical professionals (in a future posting I'll write at length about the link between expectancies and experience).

Along come the neurosciences and take away all the fun by having you use a mirror.
And even I have to admit: it just sounds too simple. Moving both hands while looking into a mirror? – you dare call that a treatment? Are you nuts?
Even worse – you – the health care professional – doesn’t have to do anything but explain what to do?
Remind me why I should pay you for just talking to me?
The next guy is even worse – telling me not to move anything but just think about it!
Has everybody gone crazy?

Now imagine having to explain this type of treatment to others in your field – can you imagine how a hands-on trained physiotherapist is going to react?
Asking someone to change their whole approach of thinking about a medical problem and changing his treatment methods accordingly isn't a step taken lightly.

And then there is the word “psychological”.
I treated a MD once who himself suffered from phantom limb pain. When I asked him about mirror training he said that he read an article about it once but never tried it because it was published in a Psychology journal.
If you can’t convince people like these – imagine how long it’ll take till a new generation of health care professionals is in the majority and the “new” treatments become universally accepted.

As for you – the patient: what can we learn from this.
a) Again: no - you haven’t tried everything because the people treating you aren’t aware of every option available.
b) the Internet comes to the rescue: information is free – you can read the articles yourself; the better educated you are about your problem the better you can help yourself
c) forget “the media” – they have the “empty space” problem, i.e. they have to fill 24 hours of programming and the pages of their magazines and are very unreliable sources of information. They are clutching at straws –producing huge amounts of "Fark" - hyping everything; pain is serious business – it doesn’t need the latest trend – but good science.

Pain For Dummies - Part V

The social aspects of pain.

Humans are social animals through and through. Our brains are hardwired to enable us to live in groups of up to 150 people - what others sometimes call a tribe.
Nowadays with over 6 billion people around we have to be more open and willing to meet and interact with others - but our peer groups (those that are close to us) - remain relatively small.

How do children learn to speak a language? How do they learn how to eat with tools? Where do they get their behavioral norms from?
At first from their parents - since they are there 24/7. They observe behavior, speech patterns, motor patterns and simply try to do the same.
As they grow older other people come into their lives - and they adapt to those as well. As social animals we want to be able to fit in and communicate with others - so we have to find a way to connect with them.

That's why babies and children have no problems learning several different languages at once - the need to connect and their ability to learn is nearly limitless.

What about pain?
First we have to distinguish between the subjective experience of pain which isn't visible and the outward expression of someone in pain. It has been suggested that the basic pain threshold is pretty much the same in every person (apart from "redheads" who are more sensitive).

The most striking difference however occurs in how people of different cultures express their pain - how they show the world around them that they are in pain. Remember - this is also a learned response! But if you are from a different culture that has it's emphasis on let's call it "quiet suffering" - you might be overwhelmed when someone shows up who is very agitated although he has only a minor injury.

That's why it's so essential to have some kind of objective measurement. I had a patient once who - despite rapid improvement in function - still complained about the pain in the most exaggerated fashion. Even tests that are meant to provoke the pain were negative - but asking him about how he felt got me the same response every time. Since in his case there was only acute trauma and pain I felt very confident that his description was something cultural and no longer something physical.

We should also be aware that the behavior we see in people is sometimes a reflection of what the medical community has "done" to them. Imagine someone in chronic pain who keeps on going - someone with a positive and life-affirming attitude.
Now put that person through a medical journey from hell - no one takes him seriously, no one listens time to listen and so on and so forth.
One simple response to such treatment is to start to exaggerate the outwardly visible part of the pain experience!

If people don't pay attention - you have to do something to change that; small children are masters at this - they use their acting skills to the fullest and without holding back.
Just watch them when they feel they don't get the attention they deserve - suddenly they start limping, develop "stomach pain", .... - they learn that by faking symptoms they can get what they want!

I'm not saying that these responses are intentional - they are learned and become automated - like the rest of our behaviors. In principle they work like a simple reflex - if you get the desired outcome the behavior is reinforced.

But as we have seen before we have this thing called metacognition and can become aware of these behaviors and change them.

The lesson for therapists is this: if you see exaggerated illness behavior (that's the technical term) - listen, educate and be a honest health care practitioner. These people don't need another snake oil salesman.

Is there a message for patients as well?
To be honest - I don't know yet. As soon as I come up with something for you to work with I'll let you know.

Hollywood also uses exaggeration as a tool: ;-)

Pain For Dummies - Part IV

Metacognition - the coolest feature you have and didn't know about.

Let's face it - changing one's habits isn't easy.
Just watch smokers who unsuccessfully try to give it up.
Our brains are prediction machines - they use experience and other stored information (motor patterns) to get us through the day.
That's why we are able to identify people by the sound alone that they make when they walk - because they always walk that way (the same motor pattern is used over and over again).

Using established motor patterns and habits makes sense because it doesn't require any attention and is therefore a very efficient process - as long as things go according to plan.

It is also very quick - so that you are able to regain your balance very quickly after you slip. If you had to do something like that consciously you would start sending signals to your muscles only after you were already lying on the floor. It's incredible to see just how slow our brains get when the cognitive demand is even just upped a little: see these kind of tests/games for example.

The message is this: learning/re-learning requires time and a non-threatening/not-distracting environment. If you want to learn something new your brain has to be convinced not to use the fast and efficient old pattern - but the slow, inefficient new one.

Try this simple little experiment at home: brush your teeth with your other hand tonight. Sounds simple enough - right?
After you've done this think about people who have to learn to walk again after a stroke and maybe you'll be able to understand what they have to achieve.
I'd rather climb Mt. Everest than ever having to do that!

This far we have only talked about motor patterns - but what about habits?
Well - it's all just electric signals - so we can treat them the same - the brain does so too.

Thoughts - those that are automatic - are the same as motor patterns. They just aren't visible to an outsider. They are also stereotypical - based on experiences and memories. If you express them outwardly they are mostly called "prejudice".

Think about it: our brains form categories for everything around us - they have to in order to be fast enough. When you look at a picture like this your brain doesn't really "look" at it but simply calls up the appropriate categories (toys, Playmobil, bath, ...) and constructs the visual experience you have.
And it has no problem making huge mistakes doing this. That's why 99% of people fail to notice that the Playmobil figure has a frowny face!

And that's why we are prejudiced: experiences we have with only one person with a "special" characteristic are applied to the whole category that person belongs to!
"All Men are the same" is just one of those things we say and hear all the time.
But the same goes for skin colors, professions, weight, height - every observable difference to oneself really.

Where does chronic pain fit into all this?
Pain is in your brain - it has to be. And we know from research that people who suffer from chronic pain react automatically with a stress response when they just read words that are associated with pain! This alone can lead to an increase in their pain!
Do they know this - are they aware of it? No.
It's an automated learned response that is outside of conscious awareness.

But - and this is where the cool feature of Metacognition comes in - you can learn to become aware of this automatic reaction if you choose too.

Metacognition means "thinking about thinking" and is the same as watching yourself walk in front of a mirror. You observe an automated motor pattern/habit - thereby creating feedback that you can use to change the pattern.

Let's say you don't like dogs - your automatic thought is something like "He is jumping up and down because he is going to bite me in the leg."
Changing this reaction requires you to become aware of it - just "stand back" and watch what your brain and your body does when you see a dog. Heart rate? Pulse? Breathing? Muscle tension?, ... - just observe these reactions.

That's the first step you have to master: you have to notice all those little things - especially the rise in muscle tension in stressful situations. You have to become aware of the position of your shoulders in order to be able to change it later on.

And just to give you a rough idea of how long this first step takes: it'll be well into 2008 - still 3 months away at this point - before you are any good at it. Think weeks and months instead of days. That's why "old habits die hard".

The good point is that even a little experience is better than nothing and you can start improving the situation right away.

The second step is to actively stop the automated reaction. As soon as you start thinking "He is going to bite me!" - interfere.
Rationally observe the situation, look at the real facts - not the ones your brain is pumping out - and act on it. The best way to do this is to find someone who has a dog and explains their body language to you. Interact with one (a friendly one of course) and simply get to know them.
I did this myself a few years ago and am no longer afraid of them because I can tell from the way they move that they are mostly just curious about who you are and want some attention.

Again - when it comes to chronic pain - stop those automatic reactions.
Since the stress response is the easiest to feel and observe it's a good starting point - that's why relaxation techniques often bring fast relief. Like taking a bath:



The other things like thinking "This is going to hurt" when you perform a movement are a little harder to change - but it's not impossible.
Take your time doing them, don't do too much at once (pacing) and gradually expose yourself more and more in order to adapt. Sleep on it in order to establish new patterns.

By the way: in Psychology this form of therapy is called Cognitive behavioral therapy - and it is extremely effective.

Pain For Dummies - Part III

The Psychology of Pain.

This is a big one - probably the most important factor contributing to the development and treatment of chronic pain.

First let me get one thing out of the way: there is a link between chronic pain and psychological problems (depression, ...) - which means that yes - pain is (only) in your mind/brain.
But - and this is good news: we still can't tell for sure which comes first!

Imagine yourself having to live with chronic pain day in and day out. Going from doctor to doctor - spending a lot of time and money on treatments that don't work - loosing friends, social support, .... - who wouldn't get depressed? It's damn near impossible to stay happy when you hear the stories of people who went through hell for years on end. It's normal to become depressed when there simply is no end in sight to the suffering you have to endure.

What it comes down to is this: there are people who are just better at coping with difficult situations than others - copers vs. non-copers. Some people are just able to handle everything that life throws at them - no matter how horrible we think it is what they have to go through. Think imprisonment (concentration camps), torture, war, accidents where you have to cut of your own arm in order to survive.



Impossible? Definitely not - there are tens of thousands - hundreds of thousands (?) of people who are able to cope with such things. What happens is that just as we have a healing response when it comes to our tissue we also can heal psychologically. Our psyche receives "damage" and goes through the same stages that healing tissue does.

The basis for who is a coper or a non-coper are probably the same as for everything else: it's partly genetic - so choose your grandparents wisely ;-) - and the environment either activates those genes or it doesn't.
Nature and nurture instead of nature vs. nurture.

Let's say you are one of those who was unfortunate enough to have the wrong genetic code and is more likely to be a non-coper/pessimist.
What can you do to improve your situation?

- Distract yourself: attention is a limited resource; if you concentrate on the pain it gets worse - shutting out everything else. Focus your attention on something else and pain is reduced.

- Find an outlet: put a rat in a cage and give it random electric shocks; the rat has a chronic stress response leading to high blood pressure, osteoporosis and ulcers. Give the rat an outlet - something it can bite for example - and nothing happens. If you put a weaker rat in an adjacent cage the rat that gets the shocks runs over and bites the other rat that is just sitting there. Guess who gets the ulcers now?
I think everybody knows these two types of people: the ones who have to jog for miles every day and the others who take out their frustration on their subordinates. I recommend the first way of coping!
And while you are at it buy this book. Trust me. It doesn't get any better than this.

- Write about it. Pennebaker has done some amazing work on this. Expressing emotions helps enormously in dealing with them. I think that this has to do with the way our brains are built - we have two hemispheres that are organized differently. One hemisphere is the "human" part - emotional, creative, ... - the other is the more "robot" like part: pure rationality. There is a bridge between the hemispheres - the corpus callosum - but it can't transmit every bit of information - it's bandwith is limited.
If you use your eyes however - by reading something you just wrote down - the part of the brain that didn't have anything to do with the creation of those words and thoughts gains access to them through a different channel and is able to contribute too.
That's why it's also helpful to take out pen and paper and start drawing sketches when you are stuck working on a concept or a presentation.
Mind Maps also work by using this pathway; as soon as you are able to use all of your brain - and the differing points of view the hemispheres have to offer - the sky is the limit. ;-)

- Do something different. I can't stress this enough: keep learning - forever. Novelty is one of the best ways to distract yourself because learning a new skill - be it a new sport, a new language, a new way to move your body needs a lot of resources. It is estimated that we can only keep our focus for a maximum time of 15 minutes - after that our brains start to get tired.
Compare your sleep quality after a normal day with the quality you have when you solved a new type of puzzle before going to bed.
Our brains use the time we are asleep to consolidate memories and to add to the "experience database". If you give your brain something to do during the night it'll do so happily - leading to deeper and more refreshing sleep.
Yes - you can distract yourself even when you are unconscious!
Problems that seemed unsolvable the day before are often gone the next day; I had that experience a few years ago playing Panzer General: I just couldn't get past the Russian Defences at the battle of Kursk. After dreaming about it (!) I woke up and was easily able to smash a hole into their front line after which my tanks were able to pour through.
Imagine that: achieving victory through sleeping well - not by working harder. ;-)

If you want even more advice on how to become a better coper familiarize yourself with this very exiting branch of psychology: Positive Psychology - initiated mainly by Martin Seligman.

For those to take the test - don't despair - pessimists (like myself) are more prone to depression but at least we are able to see the world "as it really is" - and not through pink-colored glasses. That has it's advantages too.