Zac Cupples Therapy Notes from EXPLAIN PAIN

Another enjoyable set of posts from Zac Cupples blog.  Really enjoying reading his entire blog, and thought I would post the material he has written about EXPLAIN PAIN, the well-known pain education book written by David Butler and Lorimer Moseley.  His summaries really help to reinforce the central points in the book.
Again, if you haven't read EXPLAIN PAIN, the notes are not a substitute, but these notes are definitely worth a read nonetheless.  Thanks Zac!

http://zaccupples.com/category/therapy-notes-explain-pain/

(Succinct & Excellent) Chapter Summaries - Sensitive Nervous System - David Butler

Universally accepted as a tremendous resource for modern neurobiology, pain science, and the biopsychosocial approach for nervous system and pain management, David Butler's "The Sensitive Nervous System" is essential reading.

Zac Cupples, a PT from Illinois, USA, has written some very excellent chapter summaries.  This link will get you to them.

http://www.somasimple.com/forums/showpost.php?p=154187&postcount=2

or can access his site directly:
http://zaccupples.com/

These are no substitute for reading the book, but once you have, these are excellent overviews and encapsulate the essential points in the book very well.  Great stuff!

Meditation and Pain

Another great post from Todd Hargrove at Better Movement. All about the role of meditation and mindfulness in training the ability to optimally filter sensory information.

http://www.bettermovement.org/2013/meditation-and-pain/

"Meditation seems like powerful medicine indeed, perhaps second only to general exercise in its health benefits. I find it fascinating that this all purpose mental muscle can be developed by something as simple as focusing attention on bodily sensations."

The Beautiful Brain - At the Juncture of Art and Neuroscience

Just found this one.  Very interesting and enjoyable to look through.

http://thebeautifulbrain.com/

The Beautiful Brain explores the latest findings from the ever-growing field of neuroscience through monthly long-form essays, reviews, galleries, short-form blog posts and more, with particular attention to the dialogue between the arts and sciences. The site illuminates new questions about creativity, the mind of the artist, and the mind of the observer that modern neuroscience is helping us to answer, or at least to provide part of an answer. Instances where art seeks to answer questions of a traditionally scientific nature are also of great interest, and for that reason you will hear from artists as well as scientists on The Beautiful Brain.

A classic drawing of a neuron by Santiago Ramón y Cajal:

Ten Steps to Understanding Manual and Movement Therapies for Pain

The moderators at SomaSimple (www.somasimple.com), have compiled a list of points related to manual and movement therapies for pain.  They have successfully presented succinct points derived from contemporary pain research, and have also included a reference list for those interested in gaining a more detailed understanding of the items on the list.  Super well done.

Here's the original link too:

http://www.somasimple.com/forums/showthread.php?t=4944

Nothing Simple - Ten Steps to Understanding Manual and Movement Therapies for Pain
1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus.

2. Nociception (warning signals from body tissues) is neither necessary nor sufficient to produce pain. In other words, pain can occur in the absence of tissue damage.

3. A pain experience may be induced or amplified by both actual and potential threats.

4. A pain experience may involve a composite of sensory, motor, autonomic, endocrine, immune, cognitive, affective and behavioural components. Context and meaning are paramount in determining the eventual output response.

5. The brain maps peripheral and central neural processing into each of these components at multiple levels. Therapeutic input at a single level may be sufficient to resolve a threat response.

6. Manual and movement therapies may affect peripheral and central neural processes at various stages:
- transduction of nociception at peripheral sensory receptors
- transmission of nociception in the peripheral nervous system
- transmission of nociception in the central nervous system
- processing and modulation in the brain

7. Therapies that are most likely to be successful are those that address unhelpful cognitions and fear concerning the meaning of pain, introduce movement in a non-threatening internal and external context, and/or convince the brain that the threat has been resolved.

8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.

9. Tissue length, form or symmetry are poor predictors of pain. The forces applied during common manual treatments for pain generally lack the necessary magnitude and specificity to achieve enduring changes in tissue length, form or symmetry. Where such mechanical effects are possible, the clinical relevance to pain is yet to be established. The predominant effects of manual therapy may be more plausibly regarded as the result of reflexive neurophysiological responses.

10. Conditioning for the purposes of fitness and function or to promote general circulation or exercise-induced analgesia can be performed concurrently but points 6 and 9 above should remain salient.

Bibliography:
Books:
Pain: The Science of Suffering - Patrick Wall
The Challenge of Pain - Patrick Wall, Ronald Melzack
Explain Pain - David Butler, Lorimer Moseley
The Sensitive Nervous System - David Butler
Phantoms in the Brain - V. S. Ramachandran
Topical Issues in Pain Vol's 1-5 - Louis Giffiord (ed)
The Feeling of What Happens - Antonio Damasio
Clinical Neurodynamics - Michael Shacklock
The Science and Practice of Manual Therapy - Eyal Lederman

Research articles:
Melzack R. Pain and the neuromatrix in the brain. J Dental Ed. 2001;65:1378-82.
Craig AD. Pain mechanisms: Labeled lines versus convergence in central processing. Ann Rev Neurosci. 2003;26:130.
Craig AD. How do you feel? Interoception: the sense of the physiological condition of the body. Nature Rev Neurosci. 2002;3:655-66.
Henderson LA, Gandevia SC, Macefield VG. Somatotopic organization of the processing of muscle and cutaneous pain in the left and right insula cortex: A single-trial fMRI study. Pain. 2007;128:20-30.
Olausson H, Lamarre Y, Backlund H, Morin C, Wallin BG, Starck G, Ekholm S, Strigo I, Worsley K, Vallbo AB, Bushnell MC. Unmyelinated tactile afferents signal touch and project to insular cortex. Nature Neurosci. 2002;5:900–904.
Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Ther. 2003;8:130-40.
Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 2003;4:184-89.
Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007;133(1-3):64-71.
Moseley, GL, Nicholas, MK and Hodges, PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20:324-30.
Crombez G, Vlaeyen JWS, Heuts PH et al. Pain-related fear is more disabling than pain itself. Evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80:329-40.
Zusman M. Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for manual therapy. Manual Ther. 2002;7:80-88.
Dorko B. The analgesia of movement: Ideomotor activity and manual care. J Osteopathic Med. 2003;6:93-95.
Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72:893-902.
Lederman E. The myth of core stability. Retrieved at: http://www.ppaonline.co.uk/
Lederman E. The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain (2010)

Integrating knowledge and improving clinical reasoning

This is an older, but still very relevant, posting about how to best integrate new knowledge within the broad field of manual therapy. With so many diverse streams of information, and instructors sometimes teaching with extreme bias to their techniques, how do we best integrate and synthesize this information?

http://download.journals.elsevierhealth.com/pdfs/journals/1356-689X/PIIS1356689X99901959.pdf

A few quotes...

"participants need to maintain their vigilance, and critically evaluate and question the material presented"...

"should demand evidence of speakers and objectively examine their arguments in the light of current scientific understanding, whilst keeping an open mind to new ideas, even if they seem to contradict previously accepted notions."

"the successful management of many clinical problems requires well-developed clinical reasoning, often drawing on a number of manual therapy approaches."

Early NOIJAM Blog post: Straining Scientist - Clinician Relationships

For those of you that already subscribe to the Neuro Orthopedic Institute (NOI) Group newsletter, you will have already been informed in the last few days about their new blog: NOIJAM (www.noijam.com).  It sounds as though David Butler is taking the lead on this blog and facilitating good discussion through it.  Very exciting!  Make sure to bookmark this one.

In their words:
"This blog is for clinicians in the world of science.
NOI jam is about:
• providing an open liberal discussion forum led by experienced clinicians, focusing on the treatment of ongoing pain states via nervous system changing therapies based on movement and education
• facilitating findings from science into clinical decision making,
• enhancing links between clinicians and researcher,
• bringing researchable ideas from the clinic to the fore."

The posting on Feb 1st titled "Straining Scientist - Clinician Relationships" (http://noijam.com/2013/02/01/straining-scientist-clinician-relationships/) has been particularly interesting so far.  David Butler has lead off with some things that scientists should be looking for from their relationships with clinicians, and some of the responses so far have pitched the ball right back at clinicians and the level of evidence-based scrutiny we require when treating patients.  Very great points and excellent food for thought as we continue to become better clinicians and researchers.

Contextually, at GF Strong we really are fortunate to have relatively easy access to researchers.  We have ample opportunities to create momentum towards having our research questions explored, and to get involved with research that is already underway in areas of our interest.  

Additionally, there is currently hot debate on the value of core activities like stretching to improve range of motion or reduce contracture.  Clinicians are attempting to decipher a Cochrane review with generally limited experience in doing so. Clearly, as our profession moves forward, clinicians are going to have to become adept at understanding research, sifting through research recommendations, and integrating them into our clinical decision making.  

Every clinician is capable of single subject research design, and I can't help but think that this might be part of the middle ground.  The practice of developing ideas about what we expect from our treatments, collecting key information about them, and presenting it, is part of the work of being a clinician.  Anyone have any ideas about how to be more organized about it?  How to find the time? Perhaps a separate posting about it (single subject research design) in the near future is warranted.

Deconstructing/debunking the idea of "trigger points" & myofascial pain

Wow. I hadn't read this posting in a while, but it is essential reading for anyone who attempts to assess and treat/influence pain states that are felt in different areas of our & our patients bodies. A better understanding of the biology of why certain places in our body hurt when they are pressed on is essential to the effective treatment of these pains. Great posting Diane Jacobs!

An exerpt:

"no tissue other than neural tissue (i.e., neurons, direct ectodermal derivatives) can directly signal the brain (also direct ectodermal derivative) to provoke it into mounting a pain output/perception for our conscious awareness to,.. um, be aware of, consider. In other words, quite apart from the "trigger point" issue, is there really any such thing as "myofascial pain"? I would argue that no, there isn't. Only neural tissue can send sensory-discriminative information to the brain, and only the brain can mount that sort of cognitive-evaluative-motivational-affective-sensory-discriminative display known as "pain". Other kinds of tissue in the body are usually innocent victims, not guilty culprits."

Here's the posting link:

http://humanantigravitysuit.blogspot.ca/2011/07/why-i-dont-buy-idea-that-trigger-points.html

Remember to read the links from within this article.  Also great learning/reading.

Upcoming Webinar "Chronic Pain: Is it all in the Brain?"

The Canadian Institute for the Relief of Pain and Disability (CIRPD) is presenting a series of Webinars over the next 3 months.
On April 16, 2013, 1:00pm PST there will be a webinar entitled "Chronic Pain: Is it all in the Brain?" led by Dr. Fernando Cervero

Overview:
What changes happen to the brain when a person transitions from acute to chronic pain? Dr. Cervero will discuss these changes and help us understand that effective therapies must deal with both the cause of the pain and the change in pain perception that happens too.

Dr. Fernando Cervero will join us to explain these changes in pain perception and identify the brain mechanisms that cause them.

This webinar will help you:
To understand that the transition from acute to chronic pain involves the generation of increased excitability of the brain centres involved in pain perception.
To identify which brain mechanisms generate pain hypersensitivity and how these mechanisms cause chronic pain.
To understand how effective therapies for chronic pain must deal not only with the causes of pain (injury, inflammation etc) but also with the enhanced sensitivity of the brain to pain perception.

To register, see this link.

http://www.cirpd.org/GetInvolved/Webinars/Pages/ChronicPainIsitAllintheBrain.aspx

Sounds like a good one.  Will probably try to gather a group of people together at GF Strong to view it together.

Botox and the Brain

No big surprise, but interesting to read this research, from Neuroscience Research Australia (NeuRA)
http://neura.edu.au/news-events/news/don-t-let-botox-go-your-head-or-should-we

Botox reduces spasticity locally, at the site of injection, but also altered brain activity in the cortex – the brain region responsible for movement, memory, learning and thinking.

Read the full posting, and also the abstract from the Muscle and Nerve journal.

NOI Notes - "Pain off the Radar"

This is a useful posting from the NOI group. Particularly interesting for clinicians at GF Strong who work with clients with neurological conditions like SCI, stroke and MS.

http://noinotes.wordpress.com/2012/12/20/missing-out-at-christmas/

It really underlines how some of the patients we work with really aren't well represented in pain research. As a result, establishing useful pain treatments can be even more difficult.

From the NOI Posting:
"What can we do about it?
In our very own small way, we are planning to do something. We have had our first course in neurological disease and pain last month and introduced therapies such as graded motor imagery and therapeutic neuroscience education for these once untouched neuropathic pains. There are more courses planned in Australia and later for overseas. We are well on the way in planning for pelvic pain courses under neuroimmune refreshed biopsychosocial thinking. And we will fund imagery studies on face pain, pelvic pain and therapeutic neuroscience education for stroke pain, but I think we can all start by listing awareness on groups that are missing out on the very first stage of treatment – "an understanding of why I hurt".  Tell us who you think is missing out."

Understanding the biology of the pain states that exist for some of our patients, and how we successfully work with patients to reduce their pain will be very important information for us to share in order to move forward.

Another Course: Graded Motor Imagery - One Day Seminar with Sam Steinfeld, BSc, BMR (PT), Sunday February 10, 2013

This one is being offered through Vancouver Coastal Health.  Good for us!

Sam Steinfeld has been teaching NOI - Neuro Orthopedic Institute - courses in Canada since 1997.

Graded Motor Imagery (GMI) is an emerging new rehabilitation strategy for chronic pain states. GMI comprises a sequence of strategies including laterality restoration (being able to identify left and right limbs, or movement to the left or right), motor imagery and mirror therapy via use of a mirror box.

Evidence for the use of GMI comes from basic sciences (neuroscience) and clinical trials. It can offer substantial improvements in pain and disability in complex regional pain syndrome and phantom limb pain and anecdotally, the GMI programme, or parts of it may offer improvements in a range of chronic pain states such as brachial plexus lesions and osteoarthritis.

Course description

The GMI course provides the most up to date basic sciences, clinical trials, and clinical use of the programme. The course is a series of lectures, practical sessions and clinical applications.

Course objectives:

1. Knowledge of the basic sciences underpinning the use of GMI, including the neuromatrix paradigms, neuroplasticity and mirror neurones

2. Practical knowledge and skills on the use of laterality reconstruction, motor imagery and mirror therapy.

3. The skills to adapt the GMI programme to various patient groups

4. An awareness of the ongoing research programmes in GMI and the basic sciences validating its use 

5. Perhaps a desire to contribute to ongoing research programmes. 

Course Program – 8:00am to 4:00pm

• Registration 8:00 to 8:30am 
• Introduction and history of GMI 
• Neuroscience 1 The neuromatrix paradigm 
• Neuroscience 2 Mirror neurons
• Neuroscience 3 Plasticity and contextualization
• Graded exposure principles and application to GMI
• Neuroscience Education as GMI ally – what do you tell them?
• Laterality reconstruction: theory, principles and techniques
• Motor imagery: theory, principles and techniques 

This course is open to health professionals involved in pain and stress management. While there are no prerequisites for this course attendance at an Explain Pain course would certainly assist, as would study of the information and resources provided at www.gradedmotorimagery.com.

Logistical Information:

Vancouver, BC | 10 February 2013 
Venue Multipurpose room 1 + 2, Level 1, Jim Pattison Tower 
855 West 12th Ave, Vancouver BC Time 8:00 am – 4:00 pm 
Cost $250 per person 

Host Vancouver Coastal Health 
Morning coffee and lunch will be provided. Parking $15/day or with VCH ID staff rate $8.50/day. 

To register or for more information:

Direct your enquiry via e-mail to either: 

Dolores.Langford@vch.ca or, Catherine.LeCornuLevet@vch.ca  

Complete and forward the form below along with payment by cheque to: Catherine Le Cornu Levett, Rehab Services, Level 1 Jim Pattison Tower 855 West 12th Ave Vancouver BC V5Z 1M9

Upcoming Course: Pain Science and Innovative Physiotherapy for People in Pain with Neil Pearson, March 16 & 17, 2013

This one has just been posted on the PABC site. It will definitely be a good one and will likely fill up fast.

Outline:
The objectives of this two-day course are to bring physiotherapists up-to-date on pain neuroscience research and clinical practices, and to enhance physiotherapy practice by providing practical methods to integrate pain science into our daily physiotherapy practice.

Day 1 provides detailed current physiological understanding of pain, chronic pain and the lived experience of pain. This information is the biological foundation from which we can better understand the positive effects of our current physiotherapy treatments on outcomes of pain, function and quality of life. It is also the foundation from which we can analyze and develop new physiotherapy interventions for people in pain.

Day 1 also includes a review of neurophysiology of peripheral, central and autonomic systems, recent and ongoing research of neurophysiology and neuroplasticity, as well as treatments that will promote positive neurophysiological changes, and language with which to provide people in pain with an optimistic and realistic perspective of pain management.

Day 2 provides practical sessions combined with a deeper look into current interventions provided by physiotherapists for people with pain - specifically discussing situations in which the person does not respond as we would expect to our traditional biomechanical and exercise-based approaches. Given the recent academic disputes related to myofascial techniques and to acupuncture, the day will start with a discussion of these interventions, specifically related to pain biology.Exercise in the face of persistent pain will be considered in light of recent outcome studies. Specific movement practices, and their associated outcome studies will be analyzed, including yoga, Tai Chi and Qi Gong for people in pain. The NOI group’s graded motor imagery techniques will be reviewed, and participants will discuss how these innovation could be beneficial with in broader populations rather than only for those with complex regional pain syndrome.

Link for the course description is here:
http://www.bcphysio.org/content/pabc-education-pain-science-and-innovative-physiotherapy-people-pain-neil-pearson-march-16-1

Direct link for registration is here:
http://painscience.eventbrite.com/

First person Neuroscience and the Understanding of Pain

A great article by Michael Thacker and Lorimer Moseley that takes a step back to think about where we've come from and where we need to go.

http://cdns.bodyinmind.org/wp-content/uploads/tha10468_fm.pdf

Some quotes:

"We were invited to reflect upon brain–mind–pain interactions and to opine on whether modern neuroscience adequately considers pain phenomena and experience"...

"Our perspective is that pain is emergent. Emergent properties are those that are possessed by entire systems.  A system comprises several distinct parts, and these parts interact with one another to give the system its emergent properties."...

"Clearly, the conceptual gap between pain as an injury, a dysfunction or even a disease and pain as a state that emerges from the whole person is vast. If we are to bridge this gap, we need conceptual frameworks that provide a way of integrating first- and third-person perspectives into our thinking about pain."

NOI Group - Pain, Plasticity, and Rehabilitation

The latest NOIgroup (Neuro Orthopedic Group) newsletter includes some great clinical reviews of Graded Motor Imagery work out in the clinics.

http://noinotes.wordpress.com/2012/10/24/learning-from-the-shadows/

Also, have a look at this 2-day seminar/workshop being hosted by NOI (Brendan Haslam, David Butler) in Melbourne this November.

http://www.noigroup.com/documents/noi_ppr_course_flyer_bh_2012.pdf


This lecture, practical and interactive course is about developing management strategies for the neurological patient with pain. It will help you to understand how the pain system works, the notion of pain as an output, and how this fits with neurological diagnoses/conditions. The relationship of pain to other homeostatic and response systems such as the immune and endocrine systems, cognitions and language will be introduced.

We know from research that neurological populations (such as Stroke, Spinal Cord Injury, Parkinson’s Disease and Multiple Sclerosis) experience higher incidences of chronic pain than that of the neurologically intact population. The addition of pain compounds the already disabling effects of the neurological condition, 
causing greater functional difficulties in task performance. Despite this, clinical guidelines remain consistently vague with regards to recommendations as to how to address this significant problem, and it is too often neglected in patient care.

This course will cover assessment and management strategies for this population, utilising strategies such as graded motor imagery, sensory retraining, neuroscience education and neurodynamics. You will learn how to utilise these strategies to influence pain and other outputs as appropriate, develop ideas of progression, and, importantly, learn how these fit within the rehabilitation model utilised in neurological rehabilitation, in both the acute and long-term setting.

Course aims
1. To introduce the concept of pain as one of many output systems that may be perturbed in neurological patients.
2. To expand the clinical framework of neurological rehabilitation to incorporate pain rehabilitation, via the paradigms of neuromatrix and pain mechanisms.
3. To reconceptualise pain in terms of modern neuroscience and philosophy.
4. To introduce an array of established and novel treatment strategies targeting the neurological patient with pain, based on clinical reasoning and evidence from clinical trials and neurobiology.
5. To introduce the role of education in effective pain treatment, based on current research.

Course Programme – Day 1
• Pain in the Neurological Population: incidence, classification and impact
• Biopsychosocialism and use of paradigms
• The output and homeostatic pain mechanisms
• Nociceptive, Neuropathic and Neuroplastic Pain: What does it all mean?
• Making sense of Peripheral and Central Sensitization

Course Programme – Day 2
• Graded Motor Imagery: “Sliding under the radar”
• Therapeutic Neuroscience Education: “Taking the threat out of pain”
• Facilitating Representational Change 1: Utilisation of Sensory Retraining in treating pain 
• Facilitating Representational Change 2: Incorporating Neurodynamics into Sensory Retraining to influence outputs

All I can say is that I want to be at the next one of these that is run, and I hope someone else reading this might want to go too.  

Review of Conference with Moseley and Hodges on Pain and Motor Control

A great post by Todd Hargrove on a talk by Lorimer Moseley he recently went to in Portland.
http://www.bettermovement.org/2012/review-of-conference-with-moseley-and-hodges-on-pain-and-motor-control/

A short excerpt...
Before the brain creates pain on the basis of nociception, it will essentially ask a key question: how dangerous is this really? To answer that question, it will consider many different kinds of inputs, which can be divided into four basic categories:

1. proprioception (information from joints, muscles, tendons and skin about the positions and movements of the body parts)

2. interoception (information from nociceptors about the thermal, mechanical and chemical condition of the tissues)

3. exteroception (the five senses)

4. cognition (knowledge, memory, feelings, perceptions, belief, logic, attention, expectation, etc.)

If the brain processes the different inputs and concludes that some form of protective action is necessary, it can choose between several different kinds of protective outputs, such as pain, immune responses (e.g inflammation) or protective movements such as flinching, limping, muscle guarding, stiffness and other motor control changes. (Now which kind of protective output would you rather have, movement or pain?)

One important point to consider is that any output will almost immediately become a new input into the system. For example, a protective movement will modify the proprioceptive and exteroceptive inputs to the brain. Pain will create new thoughts, feelings and knowledge about dangers to the body. Inflammation will sensitize nociceptors. And so new outputs are created which then immediately become inputs again.

The point is that this is an incredibly complex and dynamic system that loops back on itself every second in an unpredictable and inherently personal and individualized manner.

Our Words Can Really HURT

Following from the last post...
Lately I have really been thinking hard about what David Butler, PT has been speaking of for a long while now.  The idea of therapists' crucial role as linguists - how we speak to our patients and how we speak to each other.  Our words are essential tools in educating and providing therapeutic value.  Thoughts are nerve impulses that affect the neurochemistry  within our nervous system.  The words we use affect how our patient's think/believe/feel about their pain states. 

http://forwardthinkingpt.com/2012/10/18/our-words-can-really-hurt/

The Problem with MRI's

An excellent post from the Better Movement (Todd Hargrove) blog.

http://www.bettermovement.org/2012/the-trouble-with-mris-and-my-brother/

Though undoubtedly an important diagnostic/imaging technique that can be useful...

"many studies have shown that almost no matter where you point an MRI on a body, you can find something wrong there, even parts that are completely free of pain."

"many doctors assign too much importance to abnormal findings on an MRI. There are several recent articles discussing this."

"the problem is that ”finding out what is in going on the tissues” can really scare people about the condition of their body, which can make pain and disability worse. "

Very important for patients and therapists to think about, huh.

"MRIs are obviously useful and sometimes completely necessary tools that can be used to accomplish a great many good things. But like any tool, they can be abused, and it seems that there is currently an epidemic of MRI abuse."

The Amazing World of Psychiatry: A Psychiatry Blog

Well,  just when you think you have too much interesting material to read, along comes another great blog...

http://theamazingworldofpsychiatry.wordpress.com/

A recent post ("Building a Model of the Insular Cortex") gets into the features and facets of our insular cortex, the part of the brain that is involved in integrating sensory information as well as appearing to play a significant role in emotions.

http://theamazingworldofpsychiatry.wordpress.com/2012/10/15/building-a-model-of-the-insular-cortex-part-2/

Manual Therapy in a Neuroplastic World

An excellent summary of David Butler's concepts ("Manual Therapy in a Neuroplastic World"), written by Erson Religioso III, on his blog...

http://www.themanualtherapist.com/2012/10/manual-therapy-in-neuroplastic-world.html

Very much worth reading through.

Explaining the idea of a manual therapist being a:
1) biopsychosocialist
2) brain reinhibitor and sculptor
3) immunotherapist
4) linguist

As always, read on...