Mirror Therapy For The Shoulder

Mirror Therapy comes in many flavours. ;-)
You can use it for a variety of different symptoms, injuries and conditions.

Normally you would use a mirror that is perpendicular to your body.
But for external rotation that just doesn't work very well.
As soon as the arm starts to move too far outwards effectiveness decreases.

This also happens with the rubber hand illusion:
if the hands are more than 60cm apart it is very hard to evoke the illusion.
Somehow the brains processing changes and it doesn't integrate the rubber hand any longer.

So for a lot of problems concerning the shoulder mirror therapy is of limited use.
This video shows you how I use this type of therapy to increase range of motion - especially external rotation.

The patient in this clip had a motorcycle accident a year ago.
After rehabilitation and a follow-up neurological exam there still was no measurable EMG activity in his deltoid and biceps muscles.
He had surgery about 4 weeks ago where they removed scar tissue to free up the nerve to help it regenerate.

When asked to externally rotate the arm his initial reaction was "I don't know what to do", i.e. he had lost even the ability to mentally perform the movement.
This is one of the - let's call it side effects of immobilisation:
it's not that the joint, the muscle can't physically do the movement - but the brain has forgotten how to do it.
This is called learned non-use and is a big problem for example in stroke patients.

So the focus of the first treatment session was to show him what external rotation looks like.
That's why he has to be able to see both shoulders in the mirror.
He moves the unaffected one and can see how it looks.
As an additional visual aid I drew lines on his scapula so that he can better see them moving towards his spine.

In order for him to be able to focus on external rotation the weight of the arm is carried by the sling.
This setup is difficult to use at home - who has all that stuff laying around? - but it works great in the clinic.

Mirror Therapy for Low Back Pain

Mirror Therapy is a very promising treatment approach for a range of chronic pain problems.
CRPS, Phantom Limb Pain, Brachial Plexus Injuries, Frozen Shoulder and a lot of other conditions can be treated with this simple technique.

It can also be used in neurological rehabilitation - for example in treating foot drop.

Several different groups of researchers have now also started researching it's effects in chronic back pain patients. One of those groups is us. ;-)

We used mirror therapy combined with a sensory discrimination training and movement training protocol: "A brief intervention utilising visual feedback reduces pain and enhances tactile acuity in CLBP patients."J Back Musculoskelet Rehabil. 2014 Nov 11.

Our initial thought was, that we needed to show the patients their unaffected side as you do when you use mirror therapy for the extremities.
That's why we used a webcam and a laptop - that way we could flip the image on the screen. We quickly found out however that that wasn't necessary at all.
Simply being able to see one's own back had a big effect on pain and the ability to move it.

Mirror Therapy in this case is used as a tool so that the patient can quickly learn how to move the back in a natural and fluid way. Not as guarded and stiff as they usually do when that part of the body hurts.

It's a "re-learning motor-control" approach as the first step of a comprehensive rehabilitation regimen. When proper motor control is established, the patient then can start functional exercises, weight training and so on and so forth.

But how are you going to train and strengthen muscles that aren't working properly because they are actively inhibited by the nervous system? Doesn't work.

In the clinic you don't have to use the high tech approach using a laptop. In this video I show you how I do it with my clients using 2 mirrors:



Since we have the space available at our clinic I like to use a mirror wall and a big mirror behind the patient. For home use you can also use 2 smaller mirrors - just set them up in such a way that you are able to see your lower back - ideally the left and the right side.

Since it's a treatment that's aimed at re-learning/re-training motor control you can move the unaffected side to see how it looks and feels. Then try it on the symptomatic side.

A lot of patients describe that when you show them a movement, they have no idea of how to do it themselves. They have lost the ability to mentally process movements that they see or do mental imagery movements themselves. This is normal, and mirror therapy is a great way to remove that "mental blockage" pretty quickly.

You can also touch the back while looking at it in the mirror. The brain doesn't care how it get's feedback from the body - just that there is some feedback to work with. ;-)

However: a combination of vision and touch is a great way to normalise maladaptive changes in the brain.
As you can see in the videos I start of the session with the patient sitting on a swiss ball. The movement I'm going for is a small lateral flexion of the lumbar spine (since that is what the low back does during walking).
The curvature of the ball helps make it easier to see and feel the back moving. After that we try the same thing while standing on an unstable surface.

I also used a pen to draw 2 lines on the back - again to make it easier for the patient to see what it should look like when he moves the spine. The lines have to go up and down just a little.

Have fun giving it a try! Questions and comments are welcome!

Spiegeltherapie für alle - Teil 4

Erweiterung der Spiegeltherapie - Feedbacktherapie

Die klassische Spiegeltherapie wird - wie der Name schon sagt - mit Hilfe eines Spiegels durchgeführt.

Betrachtet man aber das Prinzip hinter dieser Art der Therapie - und löst sich vom Gedanken an den Spiegel - öffnen sich ungeahnte Möglichkeiten, auch andere Arten von chronischen Schmerzen zu behandeln.

Bei Querschnittslähmungen hat man ja keine gesunde Seite mehr die man bewegen kann - also kann ein Spiegel auch nicht funktionieren?!

Dieses Problem - und die Lösung gleich dazu ;-) - habe ich im März 2003 beschrieben - in der Yahoo Gruppe Supertraining, Message 29357.
Zu meiner grossen Freude habe ich die passende Software Lösung dazu im April 2010 auf der NOI Konferenz in Nottingham kennengelernt: das NOI Move Programm.

Alles was man dazu benötigt ist ein Computer, eine Webcam und Internetzugang.
Man sitzt/steht vor der Webcam die den Oberkörper filmt. Im unteren Bereich des Bildschirms werden Beine eingeblendet die sich bewegen. So erhält unser Gehirn visuelles Feedback von den Beinen - auch wenn man diese aus eigener Kraft nicht mehr bewegen kann.

Grössere Studien, die den Effekt dieser Art der Therapie untersuchen, sind bereits geplant und sollten in den nächsten Jahren Ergebnisse liefern. Die Software ist kostenfrei verfügbar - nur leider hat es sich noch nicht genug herumgesprochen, dass es sie gibt.

Dabei gibt es doch nichts Schöneres als mit anderen zu teilen. ;-)



Unser Gehirn bevorzugt visuelles Feedback. Aber wenn, wie bei Rückenbeschwerden, der Rücken nicht zu sehen ist, dann gibt sich das Gehirn auch gerne mit taktilen Reizen (Berührung) zufrieden.

Das Problem liegt eher darin dass von unserem Rücken zu wenig Signale an das Gehirn gesendet werden.

Hier besteht die "Spiegeltherapie" - oder eben besser gesagt - die Feedbacktherapie - daraus, wieder Reize zu setzen:
mit Bürsten, Igelbällen, etc.

Das Gehirn kann den Körper gut steuern - muss aber wissen in welchen Bereichen es eingreifen muss.
Dazu braucht es Feedback - eine Rückmeldung die dem Gehirn anzeigt wie es seinen Output anpassen muss.

Man sieht das bei gehörlosen Menschen sehr gut: sie hören sich selbst nicht - bekommen also kein Feedback - und lernen daher das sprechen nicht. Der gleiche Mechanismus steht hinter vielen Arten von chronischem Schmerz.

Die Feedbackschleife wird unterbrochen und die Steuerung läuft aus dem Ruder.

Spiegeltherapie für alle - Teil 3

Wirkungsweise

Die Therapie wurde das erste Mal Mitte der 90er Jahre beschrieben.
Das ist bei weitem nicht genügend Zeit, um die Wirkungsweise bis ins letzte Detail erforscht zu haben.

Das soll uns aber nicht daran hindern, schon jetzt überaus erfolgreich mit der Methode zu arbeiten und sie auszubauen.

Der wichtigste Punkt der sich aus den schon vorhandenen Forschungen ergibt ist:
unser Gehirn bleibt ein Leben lang lernfähig. Es ist "plastisch".

Dies ermöglicht es uns neue Sprachen zu lernen, neue Fähigkeiten zu lernen (z.b. jonglieren) - und auch uns nach schweren Traumen wieder mehr oder weniger zu erholen (z.b. Schlaganfall).

Diese Fähigkeit des Gehirns beruht auf verschiedenen Mechanismen:
- stumme Verbindungen sind Kontakte zwischen Nervenzellen die normalerweise nicht aktiv sind. Nur bei extremen Umständen werden diese aktiv.
- Neubildung von Nervenzellen in kleinem Ausmass könnte auch zur Erholung beitragen. Man hat erst vor wenigen Jahren herausgefunden dass überhaupt neue Nervenzellen gebildet werden. Wie diese dann im Gehirn verwendet werden ist bis jetzt noch nicht geklärt.
- angrenzende Bereiche übernehmen zum Teil die Funktion des Bereichs der ausgefallen ist.

Diese "Selbstheilungskräfte" des Gehirns sind erstaunlich - haben aber auch das Potential für Probleme zu sorgen.
Das Gehirn kann nämlich chronische Schmerzen erlernen.
Dabei werden bestimmte Areale, die für die Darstellung der Körperoberfläche zuständig sind, verändert.



Signale die von aussen an das Gehirn gesendet werden sind zunächst "neutral", d.h. es gibt kein Schmerzsignal auf dem Weg zum Gehirn.
Dass diesen Rezeptoren der Begriff "Nozizeptoren" (Schmerzrezeptoren) gegeben wurde, war ein grosser Fehler.
Besser ist es diese Signale als Warnsignale zu beschreiben - denn das ist ihre tatsächliche Aufgabe.

Denn letztendlich entscheidet erst das Gehirn ob Schmerz wahrgenommen wird oder nicht.

Bei chronischen Schmerzen geht man davon aus, dass das Gehirn gelernt hat, harmlose Warnsignale als schmerzhaft zu interpretieren.
Hier können u.a. Dinge wie ein falsches Verständnis von Schmerz eine Rolle spielen. Also im weitesten Sinn die Art und Weise wie man mit Schmerz umgeht, welchen Bewegungen/Tätigkeiten man die Ursache für die Schmerzen gibt usw.

Deswegen ist nach dem Biopsychosozialen Modell auch eine interdisziplinäre Therapie bei chronischen Schmerzen nötig. Hier arbeiten Ärzte, Therapeuten, Psychologen, Sozialberater und andere zusammen, um das Problem von allen Seiten anzugehen.

Zurück aber zum Gehirn:
werden Warnsignale über einen längeren Zeitraum als schmerzhaft empfunden, so kann sich ein Schmerzgedächtnis ausbilden.
Das heisst, das Gehirn hat den Schmerz fest abgespeichert bzw. erlernt.
So wird dann, auch wenn die Verletzung schon längst abgeheilt ist, weiterhin - direkt vom Gehirn aus (!) - Schmerz erzeugt.

Das Gehirn hat etwas erlernt, das für den Patienten nicht sinnvoll bzw. hilfreich ist - eher das Gegenteil.

Die Therapie muss also diesen Lernprozess rückgängig machen.
Therapie stellt ein umlernen dar - nicht ein reines Training im Sinne von Kraft- und Muskelaufbau wie es von vielen fälschlicherweise verstanden wird.

Und lernen funktioniert nur, wenn unsere Aufmerksamkeit auf das gerichtet ist was wir gerade machen.

Die Wirkungsweise der Spiegeltherapie kann man demnach so beschreiben:
"Spiegeltherapie ist ein (Um-)Lernprozess, bei dem man mittels gelenkter Aufmerksamkeit dem Gehirn ermöglicht zwischen harmlosen und echten Warnsignalen zu unterscheiden".

Das Gehirn muss "merken" wo die Grenze liegt, die bei chronischen Problemen im Laufe der Zeit immer mehr nach unten verschoben wird.

Dies kann dazu führen, dass bereits normale Bewegung schmerzhaft ist. Über die Spiegeltherapie kann man dem Gehirn eine Alternative anbieten: die Bewegung des gesunden Arms ist schmerzfrei. Über die Spiegelung "sieht" das Gehirn die betroffene Seite und wie sie sich ohne Probleme bewegen lässt. Diese Illusion reicht oft schon aus um auf der betroffenen Seite den Schmerz zu reduzieren.

Das Gehirn hört auf die Signale von der betroffenen Hand als schmerzhaft zu interpretieren.
Danach kann dann die restliche Therapie ansetzen.

Spiegeltherapie für alle - Teil 2

Durchführung

die klassische Spiegeltherapie wird so durchgeführt:



Die betroffene Seite (Arm, Hand, Bein) befindet sich hinter dem Spiegel (so dass man auch aus dem Augenwinkel nichts davon sehen kann), die nicht betroffene Seite vor dem Spiegel.

Im Bild wird nun die rechte Hand gespiegelt - und es entsteht die Illusion einer gesunden und frei beweglichen linken Hand.
Wichtig dabei ist, dass die gefühlte Position und die des Spiegelbildes übereinstimmen. Ist der Spiegel z.b. zu stark gekippt, dann funktioniert die Illusion bei weitem nicht so gut.

Zunächst sollte auch die Umgebung relativ frei von Ablenkungen sein.
Die Aufmerksamkeit muss komplett dem Spiegelbild gelten.

Auch dürfen die Arme nicht zu weit auseinander liegen. Abstände bis zu 50cm geben die besten Resultate.
Bewegt man die Hände, dann geht die betroffene Seite nur bis zur Schmerzgrenze - nicht darüber!

Spiegeltherapie muss als Training verstanden werden:
das Gehirn hat den (chronischen) Schmerz erlernt - und die Therapie muss diesen Lernvorgang rückgängig machen.
Analog zum sportlichen Training gibt es also ein paar einfache Regeln zu beachten:

1) den aktuellen Trainingslevel finden, d.h. auf welcher Stufe muss das Training beginnen?
Wenn möglich, bewegt man beide Hände gleichzeitig. Hier kann man seiner Phantasie freien Lauf lassen: Finger öffnen und schliessen, den Daumen und die Fingerspitzen zusammenbringen, das Handgelenk beugen und strecken, etc.

Ist dies nicht möglich, weil z.b. verstärkt Schmerzen auftreten, dann bleibt die betroffene Hand zunächst hinter dem Spiegel liegen und nur die gesunde Hand bewegt. Weiter reduzieren kann man das Training indem beide Hände auf dem Tisch liegen und man zunächst nur das Spiegelbild betrachtet.

Sollte auch dies zu Problemen führen müssen andere Therapien vorgeschaltet werden (Imaginationstraining). Dies ist aber nur bei einer sehr sehr kleinen Patientengruppe nötig die von CRPS (bzw. Morbus Sudeck) betroffen sind.

2) Steigerung:
je nach aktuellem Trainingszustand stellt sich die Steigerung so dar:
- beide Hände liegen, keine Bewegung
- betroffene Hand liegt, gesunde Hand bewegt
- beide Hände bewegen (einfache Muster)
- beide Hände bewegen (komplexe Muster)
- beide Hände bewegen - Ablenkung von aussen wird eingebaut

Steigern kann man oft sehr schnell. Sobald eine Stufe toleriert wird, d.h. es zu keiner Schmerzverstärkung kommt, probiert man die nächste Art von Bewegung. Es ist nicht ungewöhnlich innerhalb einer Therapieeinheit alle 5 Stufen zu durchlaufen.

Bei den nachfolgenden Einheiten kann man natürlich dann direkt bei der letzten erreichten Stufe einsetzen. Denn eine Reduzierung ist jederzeit wieder möglich, sollten sich Schmerzen einstellen.

3) Alltagsbezug:
wir dürfen in der Therapie nicht vergessen, dass unsere Arbeit (für den Patienten) sinnvoll sein muss.
Es gibt Alltagsbewegungen die gemeistert werden müssen.

Es ist nicht nur der Schmerz an sich, der eine grosse Beeinträchtigung darstellt, sondern auch das auf-andere-angewiesen sein, das als störend empfunden wird.

Die Therapie muss sich daher auch an genau diesen Einschränkungen orientieren und sie wieder trainieren. Dabei können Hilfsmittel wie Besteck, Geschirr, Bürsten, Stifte, etc. zum Einsatz kommen.

Bei Schulterproblemen bietet es sich an, z.b. die Haare zu kämmen. Dabei muss dann der Kopf noch etwas seitlicher vom Spiegel positioniert werden, damit man die Bewegung gut sehen kann.

4) Dauer und Häufigkeit:
In der Praxis zeigt sich, dass eine Dauer vom 10min pro Trainingseinheit ausreichend ist. Die Konzentrationsfähigkeit lässt auch nach dieser Zeit nach und der Effekt wird geringer.
Zur Häufigkeit: 2-3 mal pro Tag, täglich für mehrere Wochen (bis zum gewünschten Erfolg).

Bei periodisch auftretenden Schmerzen kann man die Therapie natürlich auch nur im Bedarfsfall anwenden.

5) Besonderheiten:
wird die Therapie nur zur Schmerzreduktion eingesetzt, so steht das Bewegungsausmass beider Gliedmaßen nicht im Vordergrund. Man bewegt einfach beide Körperteile synchron und geht keinesfalls über die Schmerzgrenze.

Möchte man aber ein Gelenk wieder "fit" machen, z.b. nachdem es mehrere Wochen in einer Schiene/Gips gelagert war, dann bewegt man die gesunde Seite (die sich ja dann als betroffene Seite spiegelt) - weiter als es eigentlich möglich ist.
Die betroffene Seite geht bis ans Bewegungsende, die gesunde Seite so weit wie möglich.

Durch die Ruhigstellung hat das Gehirn verlernt dass sich der Arm/die Hand bewegen lässt - und über die übertriebene Bewegung der gesunden Seite kann man diese Schonhaltung schnell "löschen".
Aus eigener Erfahrung mit Patienten, lassen sich diese "erlernten" Einschränkungen innerhalb von 1-2 Tagen vollständig beseitigen.

Auch auf die Gefahr hin mich zu wiederholen:
die Spiegeltherapie ist nur ein Teil der gesamten Therapie.
Besteht eine Frozen Shoulder schon über einen Zeitraum von 6 Monaten, so haben sich im Gelenk weitreichende Veränderungen ergeben.
Diese müssen natürlich nach und nach angegangen werden - durch intensives Training und Mobilisation.

Ist aber der Schmerz erstmal beseitigt, dann ist die nachfolgende Therapie wesentlich angenehmer. ;-)

Hier noch eine kleine Fallstudie die zeigt, wie schnell man bei einem Patienten die Beweglichkeit mit dem Spiegel verbessern kann:

Spiegeltherapie für alle - Teil I

Die Spiegeltherapie ist eine in den 90er Jahren entwickelte Methode zur Behandlung verschiedenster chronischer Schmerzyndrome.
Professor Ramachandran und sein Team haben sich zunächst auf Phantomschmerzen konzentriert und die Effektivität dafür nachgewiesen.
In den vergangenen Jahren wurden jedoch auch bei anderen Krankheitsbildern sehr gute Verbesserungen erzielt.

Therapie bedeutet in den meisten Fällen, dass der Patient jemanden aufsucht (einen Arzt, einen Therapeuten, etc.), der dann die geeignete Massnahme durchführt.
Unwillkürlich entsteht dabei oft der Eindruck, dass der Patient nichts selber gegen sein Problem unternehmen kann.

Spiegeltherapie geht hier genau den entgegengesetzten Weg:
der Patient muss selbst aktiv werden - sonst kann kein Effekt eintreten.
Auch die Regelmässigkeit des Trainings führt dazu, dass die Verantwortung für die Therapie beim Patienten liegt.

In der Praxis zeigt sich auch, dass die Spiegeltherapie sehr schnell zu einer Verbesserung (v.a. der Schmerzwahrnehmung) führt.
So ist der Patient motiviert die Therapie auch durchzuführen - weil sich nach jeder Eigenbehandlung Fortschritte zeigen.

Somit ergibt sich eine wesentlich bessere Zusammenarbeit zwischen Therapeut und Patient.

Bei welchen Krankheitsbildern lässt sich die Therapie anwenden?

Erfahrungsberichte gibt es aus den Bereichen Phantomschmerzen, CRPS (auch Morbus Sudeck genannt), Arthritis, Frozen Shoulder, Trigeminus Neuralgien, Querschnittslähmungen, Schlaganfälle, Dystonien und vielem mehr.

Bevor man sich zu viele Hoffnungen macht hier der wichtigste Punkt zur Spiegeltherapie:
es ist primär eine Behandlung, die den Schmerz beeinflusst!

Am Beispiel von Amputationen ist dies gut zu sehen:
Phantomschmerz wird in den meisten Fällen empfunden, weil sich das Phantomgliedmass in einer verkrampften Stellung befindet, d.h. die Finger der amputierten Hand werden als permanent angespannt empfunden. Sie lassen sich nicht mehr in eine entspannte Position bringen.

Mit Hilfe der Spiegeltherapie kann man diese Verkrampfung lösen - und hat danach nur noch die Empfindung einer Phantomhand - die sich aber nicht störend oder schmerzhaft äussert.

Bei einigen Krankheitsbildern ist neben dem Schmerz auch die Beweglichkeit erheblich eingeschränkt - z.b. bei der Frozen Shoulder. Auch hier lässt sich teils innerhalb von wenigen Tagen der Schmerz massiv reduzieren - aber die Beweglichkeit bleibt trotzdem reduziert.

Hier ist die Spiegeltherapie also nur ein kleiner Baustein in der gesamten Therapie; wenn auch aus meiner Sicht einer der wichtigsten. Es ist ein erheblicher Unterschied, ob ich versuche eine schmerzhafte Schulter wieder "in Gang zu bringen" - oder ob ich das auch ohne Schmerzen erreichen kann.

Klassische "Hausaufgaben", die während der Therapie vermittelt werden, zeigen oft keinen unmittelbaren Effekt auf das Schmerzempfinden des Patienten.
Deswegen ist oft die "Compliance" (die aktive Mitarbeit an der Therapie) mangelhaft - und das zu Recht.
Wieso soll ich eine Massnahme durchführen die "mir nichts bringt".

Die Spiegeltherapie ist hier eine sehr gute Methode eben genau diese aktive Mitarbeit zu fördern - denn der Effekt ist in der Regel innerhalb der ersten 2-3 Minuten erreicht.
Selbst wenn der schmerzreduzierende Effekt länger auf sich warten lässt, ist doch das Gefühl der optischen Täuschung/Illusion so neuartig dass die meisten Patienten es gerne auch zuhause wiederholen.

Man könnte die Spiegeltherapie auch als die "ohne Worte" Therapie beschreiben - sie spricht für sich selbst. ;-)

In den folgenden Teilen beschreibe ich die tatsächliche Durchführung, die (vermutete) Wirkungsweise - und das was mir sonst noch dazu einfällt. ;-)

Als Zusammenfassung:

"Spiegeltherapie ist......"
- einfach anzuwenden
- primär eine Behandlung die der Schmerzreduktion dient
- Therapie die der Patient selbständig durchführen muss
- Training (und muss auch gesteigert werden)
- kostengünstig
- motivierend
- effektiv
- ausbaufähig (d.h. es steckt mehr dahinter als wir uns vorstellen können)

Kurz:
ich liebe die Spiegeltherapie ;-)

Embodied Cognition

Consider this: you are doing a jigsaw puzzle. You have started out - as most people do - looking for the easy pieces that make up the frame of the puzzle.
You did this because those pieces have a straight line on one side - making them relatively easy to pick out of the heap of a thousand or more pieces.

Now - as you start working on more difficult parts of the puzzle - you pick up each new piece and try to match the individual pattern and shape to other pieces that are already in place.
While you are doing this - you are automatically turning the piece you are holding around on it's different axes - trying to see if the piece will fit.

At this point allow yourself a break - lean back and start thinking. ;-)



What just happened?

I won't lie to you: I don't know.
But what I do know is that by examining this question we are one step further along in solving the problem of how to treat chronic pain.
That's a bold claim - but one I feel very confident about.

Here's why:
your brain is - as you will know - a great pattern recognition machine.
It's also pretty good at mental rotation and judging distances, etc. - just think about driving a car and trying to get through a tight alley; your brain creates a map of the space surrounding the car, factors in the dimensions of the car and "tells" you that you will fit through.
And as with everything else - some people are better at that stuff than others ;-) (think fighter pilots or Air Traffic Controllers).

So mentally rotating the piece you are holding in your hand should be pretty easy - right?
It is; but still most of us prefer to do it "in real space".
Why?

a) Brains are lazy
b) Brains take all the help they can get
c) the Brain doesn't care about the bodies boundaries
d) computation can take place anywhere

Let me explain:
a) Brains are lazy

Thinking uses up a lot of energy - tons of it.
And since brains evolved under circumstances where food was scarce saving energy makes sense.

Which brings us to:
b) Brains take all the help they can get

It makes sense to transfer the workload away from the brain.
Why not use a calculator instead of solving the problem in your head?
Why not write something down instead of remembering it?
It makes evolutionary sense to use "outside" help instead of having the brain do everything by itself. It's much more efficient that way.

You can of course debate these points as long as you like - they are by no means watertight ;-) - but what I'm trying to get to is this:
c) the Brain doesn't care about the bodies boundaries

"We" normally have the strong feeling to be inside our bodies.
Metzinger and others have shown that this feeling of "I" can be transferred to just about any place you want.
You can swap bodies with another person within a couple of minutes.
I myself had my hand "replaced" with one made of rubber which felt really weird - and that took just 20 seconds or so.

We also know that tools are quite easily and readily incorporated into the body schema - walking sticks, surgical tools and what not become parts of "us"; and if you want to speculate - sometimes even emotions and feelings come with that (just look at how some people feel and talk about their cars).

And here's why this is important:
the artificial boundary between "us" and the world simply doesn't exist.
We are part of the environment - and our surroundings are part of us.
We act on our environment - but also react to it.
And: most times we aren't even aware of how our environment "makes us do things".
As an artist I know how weird it can be when you are forced to take pictures like this ;-)):



Marketers, Magicians and others have known this for a long long time - and make a pretty good living off it.
Psychologists are just starting to unravel these complex relationships and describing what happens inside the brain when we encounter such situations.
Just read any book like "How we decide" and you will understand what I'm getting at - or watch Richard Wiseman's videos on YouTube.

Now you might think - as I did for a long long time - how is that helping me understand chronic pain - or even better: how is it helping me in treating chronic pain?
The answer:
d) computation can take place anywhere

Let's repeat:
a) Brains are lazy
b) Brains take all the help they can get
c) the Brain doesn't care about the bodies boundaries

If a+b+c are true - then d also has to be true. ;-))
The Brain doesn't care where the solution to a given problem comes from - as long as it's there eventually.

Just look at phantom limb pain:
using a Mirror Box a lot of people can achieve a significant reduction of pain within a few minutes.
The Brain has a problem - it tries comparing different sources of input and output which don't fit together (it has an unsolvable computational or information processing problem); by using a mirror "you" transfer this problem to the environment.

By doing this you are "reframing" the problem - making it easier for the brain to do it's work.
So part of the overall computing process now happens outside of the body and out of the brain.
The mirror image of the moving hand is like a computer moving ones and zeroes around.
It's all just information - which in itself is completely meaningless without context.

I could go on about this for a week or so ;-) - and maybe I will at a later date - but for now I want to leave you with this:
the treatment of chronic pain hinges on the fact that we - as therapists - have to find a way to make it easier for the brain to deal with the situation at hand.
By transferring the problem to the environment we reduce the complexity of the problem - make it easier to solve - and the Brain can stop creating pain.

Just look at how little help a toddler for example needs when learning to walk:
his or her gait pattern without help is often pretty unstable - but even the softest touch suffices to make it much more robust. All your one finger touching his hand does is provide him with input; the brain doesn't have to compute a problem in 4 dimensional space anymore (don't forget the importance of timing!) - but it can reduce the problem to a 2 or 3 dimensional one.
Let me rephrase: your finger is not providing physical support - but informational support only - telling the brain "Look - just treat this part of space as a constant - because it's as stable as the surface this body is walking on".

Get it yet?
Don't worry - I didn't either.
It takes a while to sink in. ;-)

This is the hard part about the science of embodied cognition - getting your head around the concept of you not actually being where you think you are.
The illusion of having this egocentric worldview is so strong and so pervasive that we just can't override it.
But if we look closely enough we can spot it out of the corner of our eyes. ;-)
Like Douglas Adams wrote in the Hitchhikers Guide: flying is easy - just throw yourself at the floor and try to miss. ;-)

In order to show you how this actually looks when applied to patients I will talk about sensory discrimination training in another post.

There really is no spoon - Part II

The starting point is of course our minds.
The mind is our way of interacting with the outside world - and also with our bodies. Being the artist that I am I postulate that there really is no difference between the two: our bodies (yes - even the one you feel you inhabit) - are the same as the outside world.

For me - in terms of the "Theory of Everything" - our bodies and the outside world are one and the same thing. Why? Because our bodies don't have fixed boundaries. Our body schema is flexible - enabling us to incorporate tools, peripersonal space and other things.
And once something is incorporated into our body schema we show the same stress response as if our real body were in danger.

And yes - you even can swap bodies or faces in a few minutes if you want to.

I don't think this happened "on purpose" - but is simply a happy/serendipitous effect of us being able to use tools. It's just one of the mechanisms we can exploit if we want to.

However - I also wonder about the effects it has on us - even if we are not consciously attending to them. As we have shown the brain is remarkably plastic - it changes all the time. And since the mind is a product of the brain it also changes with it.

So if our body schema is changed by tool use - what happens to our minds? For those who want to rant about the Internet - remember that language is an invention and a tool also - albeit without an external power source.

The Alphabet is a tool any of us uses on a daily basis - and yet we don't think about it that way. But it has to have an effect on us - as we can see when scientists compare peoples way of thinking that are from different cultural backgrounds.



"You" are changed by where you were born and where you live and what language you use. Twins raised apart show strikingly similar behavioral patterns - I wonder what would happen if you compared twins that were raised apart - one in the US and the other one in China for example. My guess is that only then could you clearly show how much genetics (really) influences a persons behavior.

Our brains use a lot of tricks, shortcuts and even lies to present a coherent world to our minds - and we can exploit those weaknesses almost at will. That's very useful in treating chronic pain syndromes as shown by mirror therapy.

But what about all the drawbacks this haphazard way of creating the world has?
What effect on the mind has sitting in a chair all day long? I'm not talking about back trouble here - but by not moving we are changing our cortical maps. And the mind is based on those maps. So what happens to the mind - your way of thinking - when you sit for long periods of time?

I know from my own experience that I can't do any serious work when sitting in my otherwise excellent Stokke Gravity. It is the best piece of furniture I have seen in my entire life - comfortable, well made, sturdy, gorgeous to look at - but I can't think when in the sitting position.

For me pacing around is the best way to come up with new ideas.

This folks is the riddle of the embodied mind. Our minds are based on our brains and bodies - and what you do with one of them has an effect on the other. Which one has which - well - that's for you to find out.

The only thing that seems pretty clear to me so far is this: as you exercise your body - you also have to exercise your mind.

And I'm not talking Sudoku here - but "deeper stuff" like focusing attention, meditation and the like. As one improves - so will the other. Attention in itself seems to be the most important part - but that requires a whole series of postings on itself.

There is no spoon - Part I

A while ago I did a series of postings about pain and about mirror therapy for phantom limb pain and other chronic pain syndromes.

The good news is that all of the information contained in that series of articles is still as accurate as when I wrote it - and is a good starting point for most laypersons, therapists and those who suffer from chronic pain and want to try a new form of treatment.

From the feedback that I got it is clear to me that I did a good job of explaining the very often difficult science behind it and made it accessible and understandable for everyone.

However - as an Artist and Visionary (I took a test that said that I am both) ;-) my brain refuses to stop thinking about that stuff.
And that's what I have been up to for the last year or so.

In order to go even farther - to develop even better and faster ways to treat pain we have to construct a "Theory of Everything" as I like to call it - because only then will we be able to see how we can exploit the weaknesses of the brain even more to our advantage.

The good news: there is enough experimental data available from a lot of different fields that we can start to construct such a theory. The bad news: it's a lot of different disciplines from which I have to "borrow" from and try to integrate them into one comprehensive overview. And new stuff keeps cropping up all the time which makes it hard to keep up with all the new input.

In the past I've made a few pretty wild guesses (based on the data available at the time) - and most of them were shown to be true. See for example my description of how to treat chronic pain in paraplegics (Yahoo Group Supertraining, Message 29357).
My idea of using visual feedback in treating chronic low back pain by showing the patient an image ofhis back on a monitor is now undergoing trials in Australia.

So I want to start this series with a few questions that are on my mind right now and that show where my "Theory of Everything" is heading at the moment.
And - since I am an Artist - I don't recognize authorities or self-made boundaries I'm going to sound pretty weird at times. ;-)

Here we go:

- We are still accustomed to thinking in terms of influencing the real body when treating patients. However research on Phantom limb pain has shown that there is a virtual body which our brain constructs. The simple solution to phantom limb pain turned out to be not to treat the real body - but the virtual one.

Something similar happens in CRPS - the symptoms we see in the real body are just that - symptoms. The real disease is in the brain - in the representation of the affected limb - a software error so to speak. And treatment that tries to correct that software error leads to automatic changes in the body. We simply have to tell the brain what we want it to do and it does all the things necessary - like increasing blood flow and so on.

In the talks I give I always try to teach my students to shift their perspective from a hardware based model to a software based one.

Now - what if we took this idea even further? What if we applied this model to all forms of pain? What if instead of: "When I want to move my arm I tell my boy to do it." we were to say "If I want to move my arm I move my virtual body - which then sends out a signal to the real body to replicate the movement."?

This might not sound like a big difference - but in terms of rethinking movement and movement control it's huge. Remember that the virtual body can be quite different from the real one!

What happens when a distorted virtual body is simulating a movement that the real body can't replicate because there is a limb missing? Phantom pain is the answer.

Now take chronic low back pain - and you can see the same mechanism at work - the cortical field of the low back is enlarged - and yet the real lower back stays the same. Pain is the result.

Giving up the idea of treating/working with/even having a real body is difficult - one of the drawbacks of having an embodied mind - but I think it's crucial for us to "just let go" if we want to develop new ideas and treatments.



- Placebo. Placebo is a fact. There are enough studies out there showing that it works - and works really well.
And yet - the mechanism of action is as yet unknown. Really?
Again - think about the difference between a virtual and the real body. What if the placebo (be it a procedure or a pill) - is simply becoming a "piece of software" - and the brain tries to simulate it's effects on the virtual body - thereby changing the real body.

The brain has to represent the outside worlds so our minds have something to act upon. This is where the mirror neuron system comes in. So while the brain simulates the interaction with the placebo it accidentally changes the real body in response - setting free endorphins and the like.

This of course is just a rough idea at the moment - but what if placebos manage to - once again - fool the brain by using this "trapdoor"? The mirror system wasn't "meant" to be there for placebos - but for understanding others/empathy and so on - for all the stuff you need to be able to do when living in groups. It seems to me that placebos exploit this weakness of our brains quite efficiently.

- Environment changes behavior. Lasting behavior change is difficult. We are after all creatures of habit. But again - what study after study shows is that the environment we find ourselves in actually determines some of our behavioral responses.

We are not "in charge" - but are influenced by what and who is around us. And yet - our brains still hold up the illusion that "we" are in charge and give us the feeling that we wanted to do this or that. The short story is this: if you have identified a behavior that you want to change - don't try to change it directly - but try to change the environment in which it manifests itself.
Remove the "cues" if you will that "make your brain do things automatically" - and you will succeed far more quickly and it will last.

As I've written before - starting an exercise regime is often quite difficult - because there really is no spare time left in a day. By identifying "empty time" - time that is spent doing meaningless tasks you create time in which to exercise.

And just to make clear that it works really really well: I've been going to the Gym for a year now - doing 3 sessions each week (1 hour each) - and have lost 45 pounds. Just as I said I would. And I'm not going to stop there ;-) - because by now it's turned into a habit - like brushing my teeth.

- "Me". Our brains create the illusion of "I" in order to .......? What is a feeling of "Me" good for? Based on the fact that our environment changes our behavior quite dramatically I think we should take a closer look at the concept of "I".

What if we really are like worker bees - mindless robots following a few simple rules in order for the queen to survive? Would it make us less happier? Look at the people around you: seems to me that most of them are unhappy anyway.

Since this feeling of "I" is so strong I think it's pretty much impossible to try to imagine a theory without it - the drawback of an embodied mind again. But if you look at the Hardware/Software approach I think it's one well worth pursuing. What if "we" are really just cogs in the machine being made to think we actually have a say in the matters of what the bigger machine does?!

One of the first steps in this direction is the Biopsychosocial Model. It recognizes that we as people are a part of different environments and groups - and looks at what influences us.



- Another trapdoor of our minds. Here is more evidence for my hunch that "we" don't really exist: you can be made to swap your body within a few minutes. One can - by visual trickery and exploiting our sensory system - be made to experience another body as one's own.

We can also include objects into our body schema quite easily. "We" don't really have fixed boundaries. What we think of as our body is really just a constantly changing "sphere of influence". This helps us in using tools.

It was never "meant" to be more than that - but this is the beauty of the brain: you can use all these mechanisms that evolved over time and do some crazy stuff with them. As you can see our bodies aren't real in any way - you can change them, make them bigger or smaller, give them extra arms - even swap bodies completely.

What if the same goes for our minds? What if our mind is just a tiny part of a bigger (hive) mind? After all - culture looks to have a mind of it's own sometime. The culture you grow up in shapes you and your brain - and you become part of it by reinforcing the same behaviors and cultural norms. You become part of it. And that becoming part of it is manifest in your brain.

And since your brain creates your mind it changes you. If you grew up in a different culture you would be different and have different ways of thinking and acting. But you'd still feel as if "you" were in charge - which you are quite clearly not. I wonder what would happen if you got rid of the "Me" module in your brain and would start to experience yourself as part of something bigger - a hive mind.

I sometimes get the feeling that there are people who either have achieved this or are close to it: people who are driven by the need to do something to benefit humanity as a whole. (or it's just the endorphins released by doing something good which you can get hooked on too). Either way - I guess this approach would give us some pretty far-reaching insights.

As I've said - these are the questions that keep me up at night at the moment. ;-)
The difficulty in making progress is that the feeling of "I" is so strong that you can't run a simulation in your head without the "I" part being central to it.

We'll see where it leads as more evidence is produced in labs around the world.
The following postings will show different aspects as the relate to my development of the "Theory of Everything" and present proof that most of my crazy ideas are based on science and solid facts.
Have fun! (It's just a ride)

Relax

Regular Readers of this blog will have noticed the absence of new posts during the past couple of weeks.

Well - the blog was never intended to be updated regularly.
I always wanted to create some kind of "database" for interested therapists and patients alike. So you can always go back to the archives and start exploring. ;-)

There are a lot more topics I'm working on - but between "regular" work and photography there is just too little time left at the moment to ensure that new articles would adhere to the standards I have set for myself.

To make it official: I'm taking a break from blogging. I guess I should "be back" in a few more weeks.

If you find yourself a bit overwhelmed too - just look at this picture for a few minutes and you'll be relaxed like never before: ;-)

Interview with Diane Jacobs - Part III

Part I is here.
Part II here.

Matthias:
"Gandevia and others have shown that by displacing skin - for example at the fingers - gives the patient the illusion that the finger has moved. The same thing happens when you vibrate tendons - depending on the context people think their limbs start moving. It seems from this line of research that our brain constructs a Virtual Reality Simulation of the body - a virtual body as it is often called. Do you think that the brain regards the virtual body being real and that problems in the real body (only) arise because of discrepancies between the virtual and the real body? What I mean by this is: the brain tries to adjust the real body so that it fits the virtual body?"

Diane:
That is a good testable treatment construct, I think. Butler has been thinking along these lines as well.

Matthias:
"What can patients do on their own to keep their virtual body flexible and healthy? What are some of the things you yourself do in everyday life to keep it fit?"

Diane:
Well, everyone knows that pain can arise when the real body gets impacted, jolted, injured as in a car accident, etc. Most people do not realize pain can arise through ordinary daily habits. I usually ask patients what their "default" positions are, the positions they adopt while being sedentary.

These positions often leave lasting impressions on the nervous system. For example, most people relax in the evening, sit with a leg crossed over the other. Many people always cross the same leg, have for years, never the other. Or they will pick a corner of the couch to watch TV from, and tuck their legs up to the side - always the same direction. Or lean on one elbow - always the same elbow.

I once treated a woman who had an enormous dint in the side of her leg from her other knee pressing in. You can learn to spot the sedentary habits from the impressions they leave on the actual body! But think what this must also do to their virtual bodies after awhile.

I make people aware of the need to observe themselves at home, become aware of their default positions, change them. I explain it simply - let them know that nerves need fed evenly from all sides or eventually they'll set up a distress call.

I don't teach "exercise" anymore, instead I teach sensory awareness, i.e., anything that will change sensory discriminative input into the neuromatrix. Change the relationship to gravity - lie down on the floor. Attend to breathing. Stay focused on the breathing and lengthen out an arm along the floor, see how it feels.

Do telescoping movements instead of stretching. Shorten and lengthen. Breathe. Feel what parts are trying to help and which ones feel as though they don't help, or resist. And don't worry about trying to make them do anything they can't seem to. Stop trying to override everything, just notice things, let them be, let them change by themselves, but keep checking on them periodically.

Do not cause more pain.
Practice moving without pain, practice what you can inside the comfort zone - there's lots to work on without trying to push the boundaries. Wait. Do small amounts frequently. Think of this work as feeding the nervous system.

Like a very young and cranky baby, it cannot absorb very much at a time. It needs your help and caregiving and attentiveness and feeding, but it needs small amounts frequently to turn itself around and thrive. A big "meal" once a day would be counterproductive, to say the least.

I use the example of learning to ride a bike - here's a complex motor skill that requires about three days to learn. All that's required is repeated exposure to the task, practice. Nothing is going to happen until that exposure has made its way all through every part it needs to go.
Patience and repeated exposure is all that is required.

Suddenly, on about day three or four, the task is accomplished - suddenly, the brain has figured out how to help your body achieve balance and coordination sufficient to ride a bike, and it's without effort. It's the same for learning to move without pain.

Matthias:
Diane – thank you very much for sharing these fascinating insights!

I hope more people will be inspired by your example.

Interview with Diane Jacobs - Part II

The first part of the interview is here.

Diane:

From that point on I became an ectodermalist. I deliberately gave up worrying about muscle function, joint alignment, posture, all that stuff. I became mainly interested in helping people downregulate pain, manually, but since then I've focused my efforts on learning all I can about that first layer that is contacted in manual therapy, about how it reads contact from another nervous system.

This has taken me into learning about the brain faster than anything ever did previously. I've read all I can lay hands on about pain, how the brain works, how it evolved, how it produces movement, pain, and perception as output, how it "feels" its environment, how it constructs strategies for its own survival and for that of its "organism". As fast as I can learn, more info is being produced. Is it possible to ever know enough?

I've learned about the cutis-subcutis layer, how it regulates homeostasis, about the importance of the cutaneous nervous system in this regard, how although it doesn't innervate "muscle" it is still "motor" in that it has autonomic efferent function as well as afferent sensory function.

I've done a dissection of the arm, to learn how the underlying cutaneous nerves (which run parallel to the skin) send off many mechanosensitive disseminating twigs that embed into skin from below, via tubular skin ligaments. I was allowed to photograph this work, about which I'm currently writing an article.

All this sensitivity built into skin is adaptive, and can be construed as the brain's own sensors, feelers, into the environment. Touch skin in a therapeutic context and it is as if you are touching someone's brain, on many levels. Knowing the levels and knowing how to help them downregulate themselves properly is the whole knowledge base that helps manual therapy make more sense.

I'm involved in a study to determine the effects of a completely nervous system based form of treatment, which I have called "dermoneuromodulation", on pain. It considers the cutaneous nervous system closely, tries to move it carefully according to the principles of neurodynamics.

I am still in the process of de-programming myself from all the mesodermalist learning I took on, but have made a lot of progress. Instead of viewing manual therapy as something I do "to" someone's body, I see it now as interaction "with" someone's nervous system.

Matthias:
"From what we heard so far - it seems that your approach could be described as helping people heal/help themselves - pointing their brain in the right direction. It seems to me that this dermoneuromodulation is different from other treatment methods because you emphasize downregulating much more than others which are more about adding strength here, increasing mobility there and so on and so forth. Your treatment is more about removing obstacles so that the brain/body can heal itself. Would you agree with this assessment?"

Diane:
I would agree with you in general, especially the part about obstacle removal. But I wouldn't say my treatment does this - when the brain is ready to change its output, it does. That's all.
The whole illusion that I, the therapist, create change in someone else's nervous system, is fantasy. I like to think of my work as pointing out possibilities to the patient's brain.

I feel like I just hold up a flashlight while the patient's brain gets busy fixing the "problem". :) I think my presence is necessary so the nervous system can get a good "read" or "fix" on some body part, but it does all the heavy lifting - my role is to feel the changes as they occur.

Matthias:
"It sounds to me that by using skin and it's cutaneous nerve system you are in a way talking directly with the patients brain - trying to establish “first contact” so to speak. What role does the patient play during this treatment process? What are your instructions to them? Should they try to move the part of their body that is being treated? Should they just observe?"

Diane:
The patient plays an observing role, but it's a lot bigger than it sounds: I ask them to let me know immediately if they experience any discomfort. Most people willingly take this task on - it not only gives them a tiny, manageable, focused task to do, it reminds them that they have charge of that all important "locus of control" - they become treatment manager/gate keeper, in a way.



Several other important objectives are met. They immediately realize they must be engaged in the process, mentally. They came in thinking it was I who would do all the work and they would just lay there, but now they realize it's about them focusing, breathing, staying in the process. All this from just one simple instruction - "I can't 'feel" your body the same way you can.

I want you to tell me if you experience any discomfort, because there is no point in reinforcing any pain pathways - that would be completely counterproductive - and besides, if you are experiencing discomfort it will be harder for you to relax and let your nervous system change itself."

Then I ask them to feel their breath go past their nose, on the way in, and on the way out. If I have a rapid or shallow breather to deal with, I ask them to breathe out for twice as long as they breathe in. That's about all.

It's like learning to meditate. The outward mechanics are rather simple, but a lot of processing goes on. I let them figure out how to do that themselves. Our connection is through the skin, and they've been instructed to tell me about any discomfort they might feel. Some people go for complete silence immediately. Others like to stay in more verbal contact.

I let them decide what level of engagement with the process they want - it's up to them, and I realize they need to establish rapport with me in their own time. As long as they can process something, dip in and out of the process even, it will be fine. Lots of people give me a running commentary of what they are sensing.

A useful metaphor is skin diving. Skin diving is the process. On one level it looks like I'm the one "doing" the skin diving, but in reality, I'm the one left on the boat managing the lines, staying alert to danger, and the patient is the one doing the dive, for the first time perhaps, diving right into their own processes, sometimes scary, sometimes wonderful, but it is they who have to do the "work", exploring, bringing up the sunken treasure - which turns out to be a fleeting realization that they can in fact move some part without pain, if they like.

They realize they have an option. It's a lot like mirror therapy I think. Instead of accessing a visual part of the cortex to convince the motor map that movement is possible, the kinesthetic sensing part of the cortex (or perhaps subcortical maps as well) are accessed somehow. And most patients will choose freedom to move over pain.

A space opens up, an opportunity to move without pain, and the patient accepts the possibility as their new reality. This decision-making is done well back of their "ordinary" decision-making capacities - it's quite automatic, although they get to be aware of it in the moment.

Certainly they are free to move in the moment if they would like, but usually I ask them to sit up periodically to move, see if they can move more easily. Most of the "movement" during treatment is palpable to me - it feels like physiology - little pulses start up then fade away, elongations occur, muscles twitch or feel as though they gently writhe,... small things that signal something rather large and non-conscious is happening below the surface.

Interview with Diane Jacobs - Part I

Some of you might already be familiar with Diane Jacobs from her blog Humanantigravitysuit or from the Teamblog Neurotonics where we share our views on certain topics.

I asked Diane a while ago if she would like to do an interview – and I’m happy to say she agreed.

She has over 35 years of hands-on experience, reads everything she can get her hands on and is a devoted student of the human body and it’s inner workings.

She has developed her own approach to treating pain and movement dysfunction – called Dermoneuromodulation.

By showing how she developed her style and treatment over the years I hope others will find some inspiration.

Here’s Part one:

Matthias:
Diane, glad you agreed to do this interview.

Please tell us how you came into the profession and what factors shaped your career:

Diane:

I entered PT school (a diploma program at U. of S.) in 1968, at age 17. I entered into the program hoping to be taught how to use my hands to help people rid themselves of pain. Three years later, I was a graduate with a license, and lots more growing to do. The hands were trained for a lot of things, but helping to relieve pain somehow had escaped inclusion in the curriculum.

The first decade out of school was mostly about growing up, learning to be independent. I worked in hospitals, took university classes frequently, figured my adult self out. I played by the rules and enjoyed life. I still wanted to learn to use my hands to help relieve pain, but hope was fading that I'd ever learn to do this within the profession of PT.

Around 1983 I went to a workshop taught by an osteopathic physician. There, I learned techniques for handling spinal dysfunction and other kinds of pain, muscle energy technique and positional release. I thought I was the luckiest person on the planet, bumping into this teacher.

Based on this single workshop, I pulled up my life in Saskatchewan, moved to BC, to be closer to the manual therapy school he taught at. For the next 20 years, on and off, I attended his school and became very good at using the techniques taught there. I began attending orthopaedic training workshops taught within the PT community, but dropped out, having lost interest - they were about learning to manipulate joints, and I was decidedly uninterested in pursuing that direction. The osteopathic techniques were more clinically interactive and very helpful to people.

By now I had my own practice, successfully treating all manner of patients with these gentle techniques. There was still something missing however - the treatment constructs were very biomechanical, and I was ready for more understanding.

Enter David Butler in 1998. He spoke a new fresh (to me) language - suddenly I was hearing all about physiology and brain and peripheral nerves. Peripheral nerves? They can "hurt"? This new layer of information and the emphasis on careful handling compared very favorably with the techniques I'd been using - I realized that all along, they had been "neurodynamically" friendly without the originators' ever having known the first thing about neurodynamics or any other concept about the physicality or structure or preferences or sensitivities of nerves in the body.

The techniques had simply been developed in concert with patients with treatment constructs tacked on after the fact, treatment constructs that didn't make any real sense because they were (archaic to me now) bio-mechanical, joint-based, structure-based (e.g., bones, fascia) - if they involved consideration of the nervous system at all it was a convoluted construct involving some sort of influence of treatment on muscle innervation, as if skin didn't exist at all.

Matthias:

Please explain why skin is so important in the approach you developed?:

Diane:

I realized no one seemed to care about skin. No one cared about the fact that all manual techniques are applied through skin. That the cutaneous system reads every kind of handling first. That the brain reads every kind of handling first. Practitioners only seem to care about what is underneath skin. This suddenly seemed ludicrous to me.

Then something else clunked into place, cognitively - a lot of detailed study of embryology. I remembered that skin came from ectoderm and so did the brain. At the manual therapy school all this embryology was taught, yet the techniques themselves were taught from a mesodermal or structural perspective, not from a nervous system perspective.

For me, cutaneous innervation became the transition; it is still structure, but helped me bridge the techniques I loved to do into a context that made much more sense as to why on earth they seemed so helpful. I realized they were brain-friendly - that when performed expertly, with attention in the moment to every detail in the moment, not in any zombie-like or mechanical fashion, but slowly, with feeling, they helped the brain down-regulate pain.

Matthias:

I hear you!

The focus – at least here in Germany – is still very much tissue based.
Neuroscience isn’t mainstream yet.
I want to point out to all the therapists out there who read this that they don’t have to give up their favorite techniques – just that they have to look at what they are doing based on the bigger picture.

If you are manually mobilizing a joint – you have to touch the patient – there is no other way to do it. This fact is sadly overlooked in most approaches.
By thinking in terms of altering nervous system input you can achieve miracles since the brain takes care of the rest.

Again: use what you have learned – but change your thinking about why you apply it and how!

Play As If Your Life Depends On It

That's the title of a book I bought recently. I haven't read it yet - but the title alone is worth it's weight in gold. ;-)

I don't know if there is a proper definition of play and playful out there - but here is mine:
"Play is the joyful exploration of oneself and one's surroundings/environment" (this also includes interaction with said environment).

I want to stress the joyful aspect of it here. If you are doing things because you love to do them - then that's one of the strongest and best motivators out there. And motivation means that the sky's the limit. ;-)
(Fear by the way is an equally strong motivator - unfortunately accompanied by a lot of detrimental side effects).

Why are babies and children able to learn so much so quickly?
Because they are motivated, hardwired to learn and have fun exploring everything around them.

If they are interested they focus intensely on one thing - and one thing only. They have no problem whatsoever trying hundreds (?) of different ways to interact with objects in their environment. They are exploring things from perspectives we - as adults - would never think about.

Who would voluntarily go inside a closet and pull the door closed behind them?
Who would sit under a table and declare it to be a cave?
Who would insist on wanting to lie in the trunk of the car on the way home? (I did once - and my wish was granted) ;-)

By not doing things like that - even simply lying on the floor reading a book for example - we forgo certain experiences. Our interaction with the environment becomes "dulled down" and repetitive.

Once you try a couple of new things you suddenly realize how "liberating" and refreshing they actually can be.

Give it a try - lie down on the floor and read a book down there. Or draw something - anything.
Compare that to your favorite spot on the couch or in your favorite chair and see how much more feedback the floor provides.

I'm not saying that this particular exercise is joyful - in most cases it even hurts a little because you are simply no longer accustomed to it.
But it's one of the best ways to get quick feedback from your body.

Now think of you going to the gym every week - doing the same exercises over and over again.
Not really inspiring isn't it?

Try to adopt a playful attitude here too: do the exercises differently - with your eyes closed for example. You'd be surprised how different things can become when you change them even a little bit.

There are restaurants now that have no lights. The staff are blind and the food is served - and eaten - in total darkness.

Since taste is integrated with our sense of vision the food tastes completely different.
Shake things up to keep them interesting and fresh. Brains like novelty!

As for chronic pain: in order to re-wire the brain you need attention and motivation. Those two ingredients are the best recipe for quick changes.

So find movements that you like, ways to do things that you like - set the mood - and go play!

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.