Pain Throw Amputated Leg

This is a great story of how extreme the body can be in prioritising threat.

Pain has a geography in the body. Suffering is a bigger category and existential?

This is tricky territory, hence the question mark.1

My view is that in pain there is an explicit representation that involves the body. Considering suffering as initially experienced through thoughts and emotions is a broader category that acknowledges that thoughts feel primarily psychological. Of course mental events have correlates in body physiology, they have to; there is no such thing as a pure thought or pure mind outside of body.2 However it is an achievement to be embodied. Tracking psychology, thought, or emotion in our bodies is a skill that requires practice and discipline.

It is not efficient to always track every sensation associated with a thought, in exactly the same way that it is not efficient to track every muscle we contract to pick up a glass of water. The goal of the brain is predictions and outputs that work quickly in nature. When we are suffering and in pain then retraining our brain to operate differently necessitates bringing awareness to the steps that make up our thoughts and movements. Only then can we can chose to assemble the simple building blocks of how we think and move in more optimum, non painful ways.

‘I think this is a quote from Antonio Damasio that is worth repeating: “The mind is embodied, not embrained.”
Let’s consider some of the evidence that shows how important the body is to the mind. For example, the role of emotion. We’ve talked in the past about the importance of the parts of the brain that monitor the body’s internal state. Antonio Damasio is the one that has shown that when parts of the frontal lobe that are involved with getting emotional input are damaged, a person can’t even make decisions. So we need the body’s input. That’s why separating the brain out by itself is a dangerous example of reductionism. It’s the whole person that has experiences, not the brain.’ Ginger Campbell (2009)3

Pain is a conscious experience

‘Pain is an unpleasant conscious experience that emerges from the brain when the sum of all the available information suggests that you need to protect a particular part of your body.’ Lorimer Moseley4

You cannot be in pain and not know about it. Your body can be working poorly, be inhibited, have silent tumors growing, and have metabolic disorders humming away all outside of your awareness. That is disease. Pain is something that grabs attention as the brain decides the information it is receiving is dangerous. The goal of acute pain is to change behaviour to protect.

The body has other ways of changing behaviour. Tiredness is an output that limits behaviour, it is also a conscious perception like pain. Interestingly inflammation is increasingly being understood as a protective output, in parallel to pain but led by the immune system.5 However inflammation has the difference of running outside of our awareness and is non-conscious.

A consequence of embodied awareness is that as you pay attention and learn to feel you may suffer more. What you learn to feel is your suffering. Often as people come out of dissociation what they encounter is pain. The strategy of cutting off from sensation occurred because something was too much. This is why pacing and resources and are essential when meeting the body if there has been trauma. Levine (2010)6 offers that health is the ability to hold increasingly intense sensations and not get activated.

‘Let me tell you something really, really shocking. As late as the 1970’s young infants in hospitals, having major operations, including amputations, are having them without any form of anaesthetic, let alone analgesic.’ Jonna Bourke7

In the 18th century the baby was seen as exquisitely sensitive, there was a shift in 1870’s to infants being considered not at all sensitive and this continued for another century. Small children were not perceived to experience pain in the same ways as adults, it was thought you needed to have the capacity to suffer to feel pain. Presumably babies were thought to have no self consciousness and no memory. Oh dear, a sad example of why clear understanding of pain matters.

References

1 Bourke (2014 p60-62) gives a good discussion of pain versus suffering and relates it to an historical split between mind and body:

‘Finally, astute readers will already have noticed that I am using the terms pain and suffering interchangeably. It used to be radical to question the distinction between the mind and the body. Not any more. The assumption that there is a clear distinction between the mind (characterized as disembodied, rational, computational, and male) and the body (caricatured as presocial, emotional, impetuous, and female) has been attacked from all sides. Feminists have led the assault on the representation of the mind as some kind of superior, active, unique entity, which ‘feeds’ information to a passive, universal, and inferior physiology. In more recent decades, though, anthropologists, social scientists, and cognitive scientists have enthusiastically joined in the skirmish. Historians have been relatively slow to commit themselves.

Of course, people-in-pain typically highlight one aspect of the pain-event over another (I am in physical pain because I burnt myself while making coffee; I am psychologically suffering because I have fought with my lover). The Cartesian distinction between body and spirit or soul is deeply embedded in our culture. Nevertheless, mental pain always involves physical events – neurochemical, muscular nervous, and so on – and physical pain does not exist without a mental component. My burn depresses me; my sadness weighs down my body. As physician and writer David Biro astutely argues in ‘Is There Such a Thing as Psychological Pain? And Why it Matters’ (2010), ‘psychic distress can itself be painful in a meaningful sense, that it can be phenomenologically akin to physical pain, and, therefore, should be categorized under the same rubric’. Furthermore, the Cartesian distinction made between ‘bodily pain’ and ‘psychological distress’ (often denigrated as the difference between ‘real pain’ and its ‘psychosomatic’ variety) has done a vast amount of ideological work for physicians, psychiatrists, psychologists, the pharmaceutical industry, and chronic pain patients. For researchers in the arts and humanities as well as in the sciences, however, mind/body dichotomies have been an impediment to scholarship. There are many grounds to be suspicious of them, including the vast scientific and medical scholarship that demonstrates the interconnectedness between physiological and mental processes. Bodies are actively engaged in the processes that constitute painful sensations. Mindfulness is engaged in a dialogue with physiological bodies. And culture collaborates in the creation of physiological bodies and linguistic systems. The body is mind-ful and the mind is embodied.’

2 Another very tricky bit: no pure, independent mind is the materialist view. Dualists and religions argue that mind/soul is distinct and independent from the body.

3 Campbell, G. (2009) Did My Neurons Make Me Do It? Brain Science Podcast Episode #53: Aired January 17, 2009

4 Mikkelsen S. (2014) Notes on Lorimer Moseley lecture 7 June 2014. Facebook post. https://www.facebook.com/ManuellterapeutSigurdMikkelsen?fref=ts. Accessed 17 July 2014 Manuellterapeut Sigurd Mikkelsen

5 ibid

6 Levine P. (2010) In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books.

7 Bourke J. (2014) The Story of Pain: From Prayer to Painkillers. Oxford University Press. http://www.bbc.co.uk/programmes/b046j8z5  Interview July 2014 @10.00mins.

 

I’ve Seen A Lot Dance Moves, But Nothing Like This. I Can’t Stop Watching This!

 

Dancers always inspire around how I can move my body.

Graded Exposure Helps Pain

‘If you perform some movement without pain that normally hurts, your brain is likely to get very interested. It is ‘good news’ that reduces threat. A major goal of any program for movement health should be to send as much ‘good news’ to the nervous system as possible about the state of the body and its ability to withstand the stress of movement’

Todd Hargrove (2014) Better Movement. p143 (A stunning book and blog)

Let’s say you have 10 muscles holding your shoulder in a given position. Let’s also say, being really simple, each muscle can be on, off or halfway. That’s three options per a muscle. That is already 1000 (10x10x10) options on how to hold your shoulder still. Even this number is orders of magnitudes below the actual degrees of freedom you have available to move your shoulder.

Maybe an injury has limited the range of movement or strength in one position – there is a tear in some tissues or some wear or tear (arthritis) in the joints. It turns out these are normal signs on medical imaging, they are commonly seen in pain free individuals. Consider how many other possibilities exist to perform any given motor act. At least 1000 if my maths is any good.

Feed your brain novel and non threatening ways to move. Try lots of small, gentle, movements and build up to more complex and long sessions. Visualise the movements to enhance the maps of your body in your brain (neurotags). Be persistent, it is about learning new, non pain habits; it may take the amount of work you would have to do to write with your opposite hand.

Your body and brain will accommodate to the limitation and you will be able to live and move without pain. And, yes, you are a little bit older and little more experienced than you were before. You may not have a tennis serve that is going to win Wimbledon, that can be sad and a loss, but it does not mean pain. You will still be able to do amazing things with your body.

Famous welcome sign, Las Vegas, Nevada.

Research into the fabulous vagus nerve is a gift that keeps on giving. Activating the vagus supports people to be less depressed, enhances the immune system, including regulation of inflammation, and reduces pain. The first section is a summary from Dacher Keltner of some vagal highlights. The second section has some tips on working with the vagus from a biodynamic craniosacral therapy perspective.

How can you become a vagal superstar? How can you help your clients become vagal superstars?

Vagal superstars

The following are all features of the vagus according to Dacher Keltner (1), researcher and author of ‘Born to be Good’.

  • The vagus nerve is almost like an alternative spinal cord.
  • When you stimulate the vagus you improve people’s capacity to make decisions, this is true of the vagus nerve but not so much the spinal cord.
  • The vagus stimulates the release of oxytocin.
  • It optimises your heart rate. It evolved to support communication, social engagement and prosocial emotions such as compassion.
  • Nice touch to the back, you see a smiling face, (compassion towards) images of harm; these all cause the vagus nerve to fire. It gives specific stimulation to emotional processing centres. (Italics added)
  • ‘Vagal superstars’ demonstrate elevated base activity in vagal tone. Vagal superstars are more generous, more trusted, and kids with high vagal tone break up play ground fights.

Tips on applying the vagal brake: increasing vagal tone inhibits the sympathetics

Enhance vagal tone

  • Stimulating the new vagus (2) is the best way of switching of the sympathetics and supporting homeostasis (3), (4).
  • Be soft, slow and present.

Engage the extensors

  • Think of a monkey grabbing onto a tree trunk; all the muscles being used are flexors and are associated with sympathetics, stress and making ourselves small. The sympathetics are switched on when we contract into the fetal position.
  • We are in parasympathetic mode when we come into an upright posture with the extensors engaged. We feel safe enough to show our belly, heart and throat. We can engage with our environment, make ourselves big and move towards new things.
  • On the treatment table you can engage the extensors by getting your client to orient to the back of the body: ‘Can you feel the weight of your body on the table? Push your elbows and/or feet into the table.’

Engage the feet

  • Loss of the vagal brake results in a surge upwards as we orient; the head gets hot and tight, there is increased activity in the neck, cranium, heart, and lungs. We lose relationship to the bottom of the body and tend to disappear from our belly and our feet.
  • Grounding, being present and firing in parasympathetics nearly always involves engaging the lower half of the body and feeling the feet.
  • On the treatment table keep asking people if they can feel the size, shape and weight of their feet and their belly. Be persistent.

Facts_of_back_pain_a_man_sitting_straight_in_chair

Go slow and embody vagal states

  • Words associated with the vagal activity are trust, love, compassion, acceptance, joy. Work to find these qualities in your own body as you treat. The clients body will mirror your state.
  • Think of a perfect lazy afternoon, full of a delicious dinner, in front of a warm fire, cosy in a chair, chatting with old friends……

Know the anatomy of the vagus and its ganglia

  • The vagus can be influenced by supporting change around the jugular foramen, the superior and inferior sensory ganglia below the jugular foramen, the carotid sheath, the larynx (4), freedom in the breath and diaphragm, and resolving inertia in and around organs (especially the heart, lungs and sub diaphragm organs) to free up vagal motor ganglia and the enteric nervous system.
The Vagus. Left: The territory innervated by the paired vagus nerves above and below the diaphragm.     Right: Vagus nerves in black, and sympathetics in white, supply the heart and organs above the diaphragm.

The Vagus. Left: The territory innervated by the paired vagus nerves above and below the diaphragm.
Right: Vagus nerves in black, and sympathetics in white, supply the heart and organs above the diaphragm.

(1)  Keltner D. (2009) Born to Be Good: The Science of a Meaningful Life. 1st Ed, W. W. Norton & Company. See also Dacher Keltner in Conversation. http://fora.tv/2009/02/05/Dacher_Keltner_in_Conversation.

(2) The ‘new vagus’ refers to the mylinated vagus controlled by the ventral vagus complex (nucleus ambiguus) that co-ordinates oxygen control inline with muscles of facial expression. Porges, S. (2011) The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York: Norton

(3) ‘The relative sympathetic activation seen in anxiety disorders may represent dis-inhibition due to faulty inhibitory mechanisms.’ The vagus inhibits the sympathetics.   – Thayer J. and Lane R. (2000) ‘A model of neurovisceral integration in emotion regulation and dysregulation.’ Journal of Affective Disorders 61, 201–216.

(4) ‘We propose that these findings have important implications for the understanding of the two-way communication between the heart and the brain, and provide a connection among negative emotions and negative health consequences via the common mechanism of autonomic imbalance and low parasympathetic activity.’  – Thayer J. and Ruiz-Padial E. (2006) Neurovisceral integration, emotions and health: An update. International Congress Series 1287 (2006) 122–127

(4) ‘The vagus nerve innervates the larynx’ it carries ‘general sensation, including pain, touch and temperature’ from the larynx. –  Laryngeal nerve anatomy: emedicine.medscape.com accessed Feb 2014.

Image

Above is a fresh dissection showing a superior view of the cranial base with the dural lining intact, tentorium removed. The image is taken from here. You can see the olfactory and optic nerves passing through the dura. Fabulous. How shiny is the fascia lining the skull? This is very different from the dead bones you normally see.

Note how the shapes of each middle cranial fossa are quite different between the left and the right. The left greater wing seems to be anterior (towards the nose/ top of the picture). It does not look like a side bend to me – there is no bulge to the left? In Sutherland’s framework, probably a left lateral shear?

In palpating a clients head on a table, orienting to a squashed fluid balloon head, this pattern might present as the left hand towards the ceiling and the right hand towards the table. Often these are the obvious shapes and directions you feel in lateral shears, rather than feeling lateral translation of sphenoid.

Whatever we name it, and it is easy to get confused here, there is clearly experience and shaping by conditional forces. A great clinical approach is to try and work out the forces that have acted on the babies skull to generate the shapes you perceive.

For comparison here are three more real skulls, showing a variety of shapes.

 

Cranial base - three real skulls side by side

Cranial base – three real skulls side by side

cranial base labelled

 

 

dp_planes-BB

Being in 3 dimensions is part of being a member of the Universe. It seems to be one of the major aspects of it actually. Though sometimes we can feel distinctly 2 dimensional and thats not a great feeling. Anyway here’s an easy way to find your 3D. Simply come into relationship with your planes.

Most of us in the modern world are oriented to the front part of the sagittal plane. We are so front. So best to start there and notice what happens when you shift to the full sagittal experience of front and back. Yes there is a back! The sagittal plane is significant, its not just an arbitrary plane, it’s the body in stereo, a body of two halves. We are a physiological left and right organism and the sagittal plane defines that. So hang out with the plane for a just a minute and notice how your body physically responds. It loves to be reminded of it.

Now to plane no.2. The coronal plane. Named after the coronal suture at the top of the head. This one is even more significant. It’s the plane of our embryonic disk. So no small thing and a really good reminder to the body to relate back to where it formed from. Best way to get into this plane is open up to the sides of your body. Start with the felt sense of the sides of your head then follow that feeling down the flanks of the torso and outsides of the legs. Now open up to the space left and right. The lateral spaces. This is such a great feeling. It makes you instantly feel spacious. Makes you realize how lacking in lateral space we are.

And finally the transverse (or axial plane in the image). This is about the horizontal. Notice the word comes from horizon. Its a plane that is resonant with the horizon and brings all the horizontal structures of your body into communication i.e. all your transverse diaphragms which therefore brings you into relationship with the interior of the body and its volume/length.

So that’s 3 minutes to find each plane and establish your 3 dimensionality. You can see you can not only use this in daily life but also as a way to establish a state of balance awareness in BCST.

skull da sein front v2 skull da sein inferior v1 skull da sein side v1
Real skulls are so fascinating. I took these pictures of a newly acquired skull at the Da Sein Institut recently.

There is a torsion across the occiput, notice the uneven shape of the foramen magnum. You can easily make out the borders of the temporal bone and the large mastoid processes of the temporals. And square eye sockets, bizarre.

This skull has a condylar canal on both sides – first time I understood that bit of anatomy could exist. You can see the canals in the middle image, posterior to the occipital condyles.

I recently came across Jerry Hesch writing on alignment and treatment of the sacrum. He makes a convincing case for the most common sacral misalignments being torsion on one of the two oblique axis as shown below. The graphic is mine (I found his images a bit hard to follow). The model is really simple, feel for the most posterior quadrant of the sacrum and you can work out how the sacrum is torsioned using the graphic below. Hesch says the most common pattern is posterior low left sacrum.

Sacrum Hesch_edited-2

From my experience of holding lots of sacrums over the last 13 years, I would agree sacrums are often torsioned along these oblique axis. It feels a really simple way to assess the sacrum and has helped me quickly clarify my experience during treatment this week.

He includes more testing in his full assessment of the sacrum, including springing (‘springing with awareness’) the ‘four corners’ or quadrants of the sacrum in childs pose. The most posterior corner will also be the stiffest, with no anterior posterior recoil. His treatment is really simple as well, sustained anterior posterior pressure of upto 20lbs for 2 mins.

The chapter is in a new book on soft tissue work by Eric Dalton. He has commissioned chapters from most of the leading fascia researchers and practitioners around right now. I have not heard of Hesch before, but he is in very good company in Eric Dalton’s book. Here is a video of him introducing his chapter.

Reference

Jerry Hesch chapter in (2013) Dalton E. (2013) Dynamic Body: Exploring Form, Expanding Function. http://erikdalton.com/products/textbook/

He obviously is a detailed thinker, you can access more of his writing here. (I have not explored in depth.)

http://www.heschinstitute.com/hesch-method-basics.html

Chronic pain is nearly always a habit in the nervous system. Acute pain is an interpretation of nociceptive signals indicating tissue damage and inflammation. The tissues optimise the local repairs after a few months, so if the experience of pain persists then it is far more likely your central nervous system still frames the region initially damaged as unsafe in some way.

Here is a really nice graph (adapted from a NOI group training manual) giving some sense of the shift from tissue damage making up 3/4 of the pain experience in acute pain, to central processing making up 3/4 of the pain experience in chronic pain.

pain gifford graph_edited-2

New Research – you can see the changes in the brain in chronic pain

Here is a video describing how brain changes can be seen in chronic pain patients on MRI scans. Wild stuff, pain is very strange, and not what I was taught at chiropractic college.

The full original article on brain changes can be seen here

http://americannewsreport.com/nationalpainreport/scientists-say-brain-hot-wired-chronic-pain-8821714.html

The video below is another wonderful development of how pain works. There is a revolution in how researchers are framing pain over the last few years. As teachers in the cranial community we are trying hard to catch up. We have changed our essential reading list to include Painful Yarns by Lorimer Moseley and tweaked the Body Intelligence Training manuals and teaching to reflect these new understandings.

The good news is that much of the territory we have been exploring for many years. The video below gives some great science backing up the model of using WOSI (Weight Outline Skin and Inside) as a framework of exploring how people actually perceive their body and our general goal of being embodied.

The research on two point discrimination described about half way through is fabulous. Also the left right discrimination. In fact the whole thing is just great.

Osteoarthritis pain is at least as much about the perception in your brain as it is tissue damage to the joint:

Screen Shot 2013-09-16 at 18.17.40

You can access many of the papers here   http://www.bodyinmind.org/resources/journal-articles/  A really good start is scroll down to 2008 to: Moseley,GL (2008) I can’t find it!  Distorted body image and tactile dysfunction in patients with back pain. Pain 140,1 239-43.

Wonderful article on mini brains in the New Zealand Herald – contributed by Angela Wheeler

A miniaturised “brain-in-a-bottle” has been grown by stem cell scientists who hope it will lead to new treatments for neurological and mental diseases. The tiny hollow “organoids”, measuring three to four millimetres across, have a structure similar to that of an immature human brain, including defined regions. But the scientists insist they are still far from the science fiction fantasy of building a working artificial brain – or even replacement parts for damaged brains. The goal was to produce a biological tool that can be used to investigate the workings of the brain, better understand brain diseases, and test out new drugs. One expert predicted the future creation of a simple animal-like brain that could be linked to sense organs and had the ability to learn.

Scientists have previously grown other laboratory “models” of human organs from stem cells, including those replicating the liver, intestine, pituitary gland and eye. But none possess the daunting intricacy of the human brain, the most complex structure in the universe. The key to the new research involved nourishing immature cells in a gel-like “matrix” that allowed the complex organoid structures to develop. These were then transferred to a spinning bioreactor which provided extra nutrients and oxygen, enabling them to grow much larger in size. After two months of development the “mini-brains” had become globular spheres up to four millimetres in diameter. Each one surrounded a ventricle-like inner cavity and mimicked the layered structure of a human brain growing within a developing foetus. Among the identifiable regions were a cerebral cortex, forebrain, choroid plexus – the body that produces cerebro-spinal fluid – and even a rudimentary retina. Tests showed that they contained active neurons.

The raw material the scientists started with consisted of human stem cells – immature cells with the potential to develop along many different pathways. Both embryonic stem cells, originating from early-stage embryos, and artificially “reprogrammed” skin cells known as induced pluripotent stem cells (iPS) cells were employed.

In a further experiment to show the technique’s potential, the researchers used cells taken from a patient with the brain disease microcephaly to create the mini-brains. They found that the organoids’ growth was stunted, mimicking the disease which causes the brain to be much smaller than normal.

Professor Juergen Knoblich, from the Institute of Molecular Biotechnology in Vienna, who led the Austrian and British team, said: “We’ve been able to model one disease which is microcephaly. But ultimately we’d like to move to more common disorders like schizophrenia or autism. We are confident that we might be able to model some of these defects.” He said the extreme complexity and inter-connectivity of the adult brain made him “pessimistic” about the possibility of replacing whole brain structures with laboratory-grown versions. Professor Knoblich added: “Our system is not optimised for generating an entire brain and that is also in no way our goal.” Although the organoids were small, they were not very different in size from an early stage developing brain in the womb.

Scientists commenting on the research, published in the online edition of the journal Nature, spoke of its potential and implications, but also limitations. Dr Dean Burnett, lecturer in psychiatry at the University of Cardiff, said: “Saying you can replicate the workings of the brain with some tissue in a dish in a lab is like inventing the first abacus and saying you can use it to run the latest version of Microsoft Windows; there is a connection there, but we’re a long way from that sort of application yet.”

Neuroscientist Professor Paul Matthews, from Imperial College London, said: “This study offers the promise of a major new tool for understanding the causes of major developmental disorders of the brain such as autism and schizophrenia, as well as testing possible treatments. Treatments are still a long way off, but this important study illuminates part of the pathway to them.”

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