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The Thinking Practitioner Episode 09: Descending Modulation in Manual Therapy

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Til Luchau:

Happy spring everybody.

Whitney Lowe:

Yeah. Very good. Okay. It’s still wintertime while we’re recording this. A good day for us to be diving into some neurophysiology today. I think something like that. Is that what we’re doing today?

Til Luchau:

Always a good idea on a day like today. Yep. Neurobiology of descending modulation. I was glad you proposed that. It actually is a really interesting topic, but I wonder… You want to start off by telling us what it is? What is descending modulation?

Whitney Lowe:

Well, we’re sort of learning all kinds of new things about physiology. And to me, this is one of the most fascinating aspects that I’ve come across in recent years, talking about… Mainly for us as soft tissue manual therapists trying to figure out what is it that, or essentially why is it that the work that we do has the effects that it does? I think descending modulation is probably one of the most powerful and important sort of descriptors of what is actually happening when we do soft tissue manipulation. See if I can put this in a nutshell. If we think about the fact that there are neural receptors at the periphery of our body that are sending signals up to the brain and then those signals are eventually…

Whitney Lowe:

Keeping in mind too, this is sort of along a newer understanding of how pain works in the body, that there really aren’t pain signals sent from the periphery to the brain, but they’re just sensory signals and they eventually get interpreted by the brain to see pain.

Til Luchau:

Yeah. Sorry.

Whitney Lowe:

Go ahead.

Til Luchau:

I interrupted your punchline. To be pain… To be pain what?

Whitney Lowe:

Yeah. Essentially you’re not sending pain signals through the body, you’re sending sensory signals and they are eventually interpreted possibly as pain depending on a number of all kinds of factors that may or may not determine whether or not those sensations are pain.

Til Luchau:

All right. Let me see if I get it. So yeah, sensors in the periphery of the body, that’s out at the edges of the body. This is basically skin joints, is that right? That what we mean by periphery?

Whitney Lowe:

Right, yeah.

Til Luchau:

Okay. And they’re generating signals and you’re saying a signal is not pain in this point of view.

Whitney Lowe:

Right. So those, those peripheral receptors we call nociceptors and then they are sending signal back to the central nervous system, which we call nociception. The transmission of the signal is nociception, but it’s not pain really until the brain interprets it as pain based on all kinds of other factors. We’ll get into that.

Til Luchau:

Okay. Big important distinction between nociception and pain. Nociception being the signals that come from the tissues, the receptors within those, and the pain is the experience within the brain.

Whitney Lowe:

Yeah. Now the thing about descending modulation that’s fascinating is the brain has the capability to… The best way to explain that is in sort of a simplistic description of saying that we can either turn up the volume on those signals, which would make the pains or the sensation, the nociceptive signals more likely to produce pain. And turning up the volume is one means of sort of modulating those signals. So we refer to this as a descending facilitation, meaning it’s from the higher brain centers where the signals are eventually getting processed. The higher brain centers up there can create a process where it facilitates or enhances that signal. And that is one form of descending modulation. That’s called descending facilitation.

Til Luchau:

All right, so wait, hang on a second here. So modulation means what? Turning up or turning down?

Whitney Lowe:

Modulation means changing essentially, so turning up or turning down. Yeah, so we can do it one of two ways. We can turn it up through descending facilitation, or we can turn it down through something called descending inhibition, and that would be.

Til Luchau:

Got you. So when you told us about… Sorry. You told us about turning it up through descending facilitation, the brain can make it worse, you’re saying?

Whitney Lowe:

Yeah.

Til Luchau:

Or?

Whitney Lowe:

Or we can suppress those signals and keep them from causing pain sensations, and that would be descending inhibition. And again, this happens through a whole cascade of neuro chemicals, neurotransmitters and oxytocin and endogenous endorphins and all these types of neurochemical processes that may sort of tamp down the signal. That’s just one way that this descending inhibition can happen. But either way, either turning the volume up or turning the volume down would be what descending modulation essentially is. So we call it descending because it’s the higher brain levels that are sending signals down to lower level neurons to either enhance them or to suppress the signals that are coming from them.

Til Luchau:

Great, great description. So this model assumes that we’re standing up, doesn’t it?

Whitney Lowe:

Maybe, I never thought about it. That’s right. If you’re hanging upside down on a bar. Interesting. Never thought about that.

Til Luchau:

Yeah, let’s not go there. It’s confusing enough as it is.

Whitney Lowe:

In an anatomical position, is that still superior if you’re-

Til Luchau:

Uh-huh (affirmative).

Whitney Lowe:

…. Upside down, hanging down, if you’re going towards your head, right?

Til Luchau:

Okay. So anyway, the brain is either turning up or turning down these signals, inhibiting or facilitating them, and there’s all these great endorphins and endo cannabinoids and endogenous opioids and all this stuff, oxytocin, neurotransmitters involved in that. They generally turn it down, you said?

Whitney Lowe:

Yeah.

Til Luchau:

Yeah. Okay.

Whitney Lowe:

Right. So to me, and again, what we’ve learned now that there’s all kinds of processes that may sort of set this in motion, and one of the things is that we know that creating safe, compassionate, caring spaces and safe, compassionate, caring touch between two humans is one of the things that encourages the descending inhibition. So that’s one of the things that sort of encourages and inhibiting of those signals becoming the level that is reproducing a pain type of sensation. So that’s where the whole manual therapy thing comes in.

Til Luchau:

I get you. It sounds like oxytocin to me, for example. You’re talking about that safe connected affiliative feeling that actually makes the pain signals less loud when they reach the brain. Yeah, that’s something too that struck me from this paper you sent me that summarized it, the three neuron idea. You got the peripheral neuron that’s getting the signal, generating it, transducing it, getting a signal. You got the inter-neuron where the modulation happens, that’s in that central nervous system. And then you have a brain neuron that’s involved in transmitting that out the rest of the brain. That inhibition happens along that wire, so the oxytocin thing or the affiliative thing is actually turning down that signal along its transmission. It’s like having a speaker wire that turns down the music for you.

Whitney Lowe:

Yeah, yeah. That’s probably a really good analogy of getting a sense of understanding how that whole process works. And you did mention the fact that we were both reading this article that struck us as very interesting along this. And just for those who want to follow along, this article was originally published in massage and fitness magazine in October of 2019, the article title is Why Massage Therapy Can Alleviate Pain and the author Mark Olson goes into extensive description of some of these neurochemical and neural biological processes behind pain management associated with various manual therapy methods. Great, great article, so definitely take a look at it in there.

Til Luchau:

Kudos to Mark and everybody else involved in that. Yeah, it’s a complex topic and a great, great run through for it.

Whitney Lowe:

Yeah. And Mark is the director of the Pacific Center for Awareness and Body Work in Kauai in Hawaii. I’ve seen a couple other pieces he’s put out together too. He’s got some other stuff that he’s done that’s really, really nice. And if I remember correctly, he’s got a background in neurophysiology or something like that. I can’t remember off the top of my head, but very, very well versed in a lot of the academic aspects of what we’re talking about here.

Til Luchau:

Great. Where’d we leave off? You’re saying the music gets turned down just by this affiliative thing, just good feeling you have with someone. Is that right?

Whitney Lowe:

Yeah. So there’s a couple of different ways that this can happen and he goes over these in his article. So for one thing, we’ve all heard about Melzack and Wall’s gate theory of pain, which came out I believe in the mid sixties, is that right?

Til Luchau:

Yeah, yeah.

Whitney Lowe:

’65 ish or so, something like that I think. Essentially saying that certain types of signals may travel to the central nervous system faster than others. And this is a thing that I have found very pertinent for reframing my understanding of how some of the various massage techniques that we use are particularly effective. For example, those techniques that engage movement simultaneously with massage are giving a lot of sensory information back into the central nervous system about proprioception and body movement and engagement of muscle contractions. And all that sensory information is traveling back to the brain and the higher brain centers at a faster rate than any of the nociceptive signals. So oftentimes they may get there first and sort of close the gate on some of those signals. And that’s one method of descending inhibition that is directly, I think, responsive for the type of work that we’re doing with massage.

Til Luchau:

I love it that you brought that in. The way I understand, that’s actually ascending inhibition, but the gate theory is an example of going the other way, that the signals from the periphery beat out some of the other signals and actually inhibit it from the bottom up.

Whitney Lowe:

Exactly, yeah. So we could consider this as another means of modulation. Yes, you’re right. That’s what we frequently referred to as a sending inhibition because those signals are all coming in, and we’re trying to sort of, like you said, beat them to the punch, so to speak.

Til Luchau:

Yeah. I mean I should also mention this as a theory, huh?

Whitney Lowe:

Yes, definitely.

Til Luchau:

Most of the debate is about smaller points. The larger strokes there’s probably a reasonable consensus around, but I think most of the debate says, well, maybe the gate theory isn’t the whole story and that it’s complicated and there’s exceptions and things like that.

Whitney Lowe:

Yeah. So I think you know what we’re seeing too, there’s a number of different factors here, but one of the things that’s been particularly interesting to me about this whole idea of descending modulation, and I’d like to hear your take on this, is I was having a bit of a difficult time with some of the narratives around the physiological effects of some of the different massage techniques that I was teaching for example.

Whitney Lowe:

So I might be focusing on teaching this spreading or broadening technique with the thumbs or the hands. And I was taught, well what we’re doing is sort of spreading apart muscle fibers and helping to encourage their pliability. And it seems the more we’ve sort of dived into looking at the actual physiology of what happens under the skin, some of those narratives don’t seem to be following good physiological descriptions of what’s happening. But we know they get great results. And so the question becomes what’s really happening under our hands to that person? And I think my perception now is that a whole lot more of what we do that gets really significant clinical benefit has a lot more to do with these concepts like descending modulation than it may with the what we’re actually doing to manipulate or change tissue structure. So what are your thoughts about that? Has this impacted your perception of the narrative around what you’re doing with your work at all?

Til Luchau:

That’s the great question. Yes it does, quite a bit. I think it’s actually really important and I think it’s a big deal. And it does provide another explanation for what we’re doing that doesn’t involve say muscle, connective tissue, bone joints. Except as the location where the signal is generated. It provides a model or a way of thinking about, or a mechanism that explains how the brain controls the intensity of experience. And we all know from our hands on work that the way we go about things can make something feel really great, or can make it feel really bad. And even when somebody is in pain, the way we manage the interaction with them, the way we talk to them, the way we touch them, the pacing, all those things can make their pain better. And so that descending modulation idea gives an explanation for that, gives me a model to think about, “Okay, I’m turning down the volume for them of this intensity coming from their body.” So yeah, that is a useful explanation for me, a useful way of thinking about it.

Whitney Lowe:

Yeah. And I think even if that, and again, a lot of this stuff may change, we may learn more in the future about those things, our theories may change or evolve as they always do, but that doesn’t necessarily mean that we have to put away or not do or change the way that we’re doing things in the clinic that are working, because they’re working for a particular reason. But there is some benefit and value in looking at having a better understanding of what really is happening there because then we can find out how do we enhance that, how do we make it better? And this is one of the things that I’m always looking at. Well, if this really is… A lot of the effects of what we’re doing are really based on some aspect of this idea of descending modulation then I want to know how do we make it better?

Til Luchau:

Yeah, absolutely. I’m not sure about the really part yet. Is this what we’re really doing? I guess I tend to be even more of a skeptic around even the newest explanations, but I think it’s a really useful model and it seems to make sense. The other stuff I learned made sense at the time it did too, so who knows? But as somebody, and like you did too, with original background and training in psychology, it’s not a big leap for me to go, ‘Okay, yeah, the brain controls experience. Oh, maybe there’s ways the brain is actually changing the signal on its way.” Not a big leap for me at all. Now there. Go ahead. Me?

Til Luchau:

All right. I’m wondering if it’s time for a halftime break, because there are some quibbles or debates or controversy around this idea I thought it’d be interesting to bring up and think through. Should we do our halftime spot first?

Whitney Lowe:

That sounds good. So who is our halftime sponsor today?

Til Luchau:

This episode is sponsored by Handspring publishing. And my story is when I wrote my Advanced Myofascial Techniques books, I was lucky enough to have two offers. One from a big international company that did a lot of media and a lot of different channels, and the other from Headspring, which is for great people who run their own publishing house out of Edinburgh, Scotland. And I’m really glad I went with him for my books because not only did they help me make the books I wanted to make, but their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers, and like they say, all professionals who use movement or touch to help patients achieve wellness.

Whitney Lowe:

Yeah, certainly by all means, they’ve done a great job of expanding their offerings for the whole movement and manual therapy professions. And their author list reads like a who’s who for many of the leading thinkers in our fields. So head on over to their website at handspringpublishing.com and browse their excellent catalog over there, where you’ll find great books like Till’s book on a myofascial techniques over there. And once you find the gems, you must have used that code TTP, like The Thinking Practitioner at checkout for a discount.

Til Luchau:

You mentioned my book. I know you know them, and have a great relationship with them, have you written a book for them?

Whitney Lowe:

No, actually I was working with all of the Handspring group when they were still with another big publishing company. They used to be with Elsevier and I worked with them when they were all with Elsevier before they went over and before Handspring existed. So that’s how I know them and have wonderful respect for them. And I think they’re great folks over there.

Til Luchau:

That’s right. All right, so I mentioned some of the controversies or quibbles with this descending modulation idea. And I dug into that a little bit because I was aware that there were some, and I wanted to get clear on what they were, perhaps. Shall we go through those?

Whitney Lowe:

Yeah. Let’s dive into that a little bit.

Til Luchau:

One of the quibbles has to do with duration. So if I can turn down the signal, is that a lasting effect? Is that a permanent change, or is that just like making them feel better while I have my hands on them or where they are in my practice room?

Whitney Lowe:

Yeah, that’s a really good question. There was something, I think this was in… It may have been in the Paper. There’s another paper we’ll put in the show notes that has a really good description of this idea of descending modulation in manual therapy. There was something, and I think it may have been in the Vigodsky paper where they were talking about this lasting for somewhere around, and I may misquote the timeframe, but it’s something like 90 minutes or something like that, specifically that they were… And what they had been studying was lasting for that period of time.

Whitney Lowe:

There’s all kinds of other factors that may come into the equation to affect how long or how powerful and impactful those sensations are. But you know, I think even if that sort of level of modulation is only impacted for a shorter period of time, to me there are other potential benefits of that process. If you can change some aspects of proprioception and some aspects of pain management, of reducing the pain sensations to some degree that a person experiences it can encourage greater freedom of movement, greater sense of confidence, of movement, of being able to do things without as much discomfort or pain. And those can have very long lasting effects, I think. Much more long lasting effects than some of the processes of getting people back to good full activity again.

Til Luchau:

Okay, so that’s interesting. Yeah, I’ve had my own take on it too, but you’re saying that even if the descending modulation is measurable for, you said 90 minutes, I’ve read different amounts and who knows? Like you said, there’s lots of factors. But even if it’s on the order of hours or days and not weeks and months, then maybe it provides a context, or a respite, or a period of time where people can do different things and change their minds, or change their reactions to what they’re doing in a way that’s helpful over time.

Whitney Lowe:

Yeah, there was something that Mark had put in his paper when he was talking about in many chronic pain patients, it seems as if some of the strategies or processes for descending inhibition become impaired and that’s why people get into these cycles of chronic pain, and unable to find any real serious tissue damage, but there is still a pretty significant level of ongoing pain sensation with them. And that’s because the descending inhibition is getting impaired. And so if we go back to this idea of, “Hey, if we can do things that encourage people to think, “I can do this without pain, I can do this particular thing. I’m going to be okay, I’m not going to be in pain forever.”” Those very thought processes also get engaged in the as one piece of the puzzle for encouraging greater degrees of the descending inhibition as well.

Til Luchau:

Mm-hmm (affirmative). And then I know that I have it on my wishlist of topics, just the question of lasting change and duration. I don’t want to get too far down that path. There’s so much to say about it, but briefly I think about it… Again, with my background being in psychology, it wasn’t a big leap for me to think, “Okay, what I’m doing is changing the way people think and feel and react to what’s happening.” And maybe there are tissue effects too, but if I can do that, like you said, even temporarily, the that by itself can have a lasting impact. It’s the idea that we’re actually maybe educating or providing an experience, even more than we’re being tissue mechanics. We probably are having a mechanical effect on the tissues to some level, but we’re also having a lot of impact on giving people an experience, and people change from having experience, to a certain extent.

Whitney Lowe:

Yeah. So those aspects of touch experience are also ingrained in both memory and perceptual awareness that I think really enhances a lot of what we’re doing. And as we get kind of back to this whole idea of the benefits of what we do in manual therapy in relation to some of this neurophysiology, in terms of the way the brain works, we are hardwired essentially from the time of infancy, when you’re crying as a baby and you get the soft soothing stroking from your parent, that gets encoded as, “Hey, this is good, this is a good thing. This settles down my discomfort.” And that’s what we’re doing a lot of the time in the treatment room with people, is helping them feel that same sensation of comfort, safety, and caring, interactive human touch. And that’s, as we said, it’s hardwired into the nervous system to say, “This is a beneficial response. This is a good thing.” So I think it’s not as much technique dependent as it is context dependent. You and I have talked about this a lot before.

Til Luchau:

Down the list of quibbles, I wrote Jeffrey Bove who is a researcher. He was the guy that really dug into the nervi nervorum and how it’s involved in neuropathic pain and has done a-

Whitney Lowe:

Yeah. And can you elaborate on that? Where the nervi nervorum is for those that.

Til Luchau:

The nervi nervorum are the nerves of the nerves. It turns out your nerves themselves have sensation and that they may be implicated in chronic pain, but certainly in neuropathic pain where you have pain that’s coming from the nerve itself, not the nerve transmitting a signal, but the nerve generating a signal.

Whitney Lowe:

I think it’s fascinating, isn’t it?

Til Luchau:

He’s an interesting guy. He, I saw him first presented at the Fascia Congress maybe four, eight years ago, I don’t remember. And he tends to take a gadfly position. He likes to question things and shake them up. And so when I was looking for, “Okay, so what are the reservations about descending modulation?” I thought he’s the guy I’m going to ask. And he actually wrote back with some interesting stuff. He said it’s actually really important, this idea, and it’s a big deal. But the place we get trapped as we can start stating opinion as facts. And he had specific critiques about both those papers I sent him.

Til Luchau:

He says, “They’re saying stuff that… They’re opinions, they’re points of view, but there’s not always consensus on this is exactly how it works.” Here’s a quote. And it makes me realize that I need to go back and change our tag from clean to explicit on this podcast on Apple. Because he said, “The problem we have boils down to that we have no idea about what the fuck we are doing.” He said, “Quote me on that.”

Til Luchau:

He says, “This is all shooting in the dark, but even our current work clearly shows that mobilization has profound effects on inflammation and fibrosis, at least in terms of maintaining normal.” So he’s going into some of the tissue effects that I’m getting… That’s the rabbit hole that I spend my time diving down is what are we actually doing to the tissue? And then he comes back out. He says, “Do we know what parts we’re working on altogether? Mostly the list is not that long. There’s not that many possible things we could affecting. How about which ones are important?” He says, “No way. We don’t have no idea yet.” But he says for him, it’s all about the nerves, always has been, but he admits he’s got a nerve bias.

Whitney Lowe:

Uh-huh (affirmative), yeah. It’s fascinating times that we live in trying to come to better understandings of what we’re doing. And I think it can be challenging for people, because some of these things disrupt paradigms of the way you were taught about what’s happening or what you’re doing or what the rationale is behind the work that we’re doing. So I always try to encourage people, say, don’t get too caught up in that whole aspect of thinking that everything is different or the ground is constantly shifting out from under your feet. We know that clinically what in that room is very profound and very effective on a number of different levels and we just keep trying to figure out exactly why it does what it does. And there’s an important reason behind that is that because when we really understand the mechanisms better, we can figure out how to encourage them and enhance them and you know, really use them to their advantage.

Til Luchau:

Yep. There’s also some debate around the role of deep touch, which is interesting.

Whitney Lowe:

Tell me about that.

Til Luchau:

Well, there’s one point of view on one side of this debate says deep touch sensitizes. Deep touch always facilitates, it doesn’t inhibit pain signaling. And certainly the DNM people can tend to go there. Not to single anybody out at all. In fact when I’ve tried to pin down people on that they’ll say, “Well actually, maybe not.” But sometimes there’s that assumption that deep work will make things worse no matter what. And for sure there’s people that happens with. But again, my bias as somebody with a background, is we use a lot of deep touch and didn’t see it make things worse, not make things better.

Til Luchau:

So in the descending modulation literature, there’s the discussing of conditioned pain modulation where it was actually poor mice… They experimented with hot water and mice, looking at their pain responses. If you give a mouse a pain experience, this experience with hot water, they don’t notice other pain experiences as much. And so a lot of pain experiments, they’ll do a conditioned pain modulation where they’ll have you poke yourself with a pin or do something that causes some pain because that is thought to activate that response, and then they take that out of the equation. So deep touch is anything that produces a bit of pain, also makes other pain less bothersome, you could say.

Whitney Lowe:

Yeah, yeah. I would have to say I’m in full agreement with you there because I’ve had some of those same discussions with some of the practitioners who have shifted a perspective onto doing just really light work, focusing predominantly on the supposed affects with the cutaneous nervous system receptors saying that’s where it’s all happening. But I can’t argue with my own personal experience of my own body in that every time I go out and work in the yard, moving rocks around, I come in the next day and my back is killing me. I do light, gentle, soothing kinds of touch things on it and it feels nice, but it does not help my back pain, until I get out my Theracane and start really doing a lot of deep work on those chronically tight sore muscles. And that’s what really helps them.

Til Luchau:

Yeah, sometimes you just.

Whitney Lowe:

For whatever reason.

Til Luchau:

Sometimes there’s nothing like an elbow. And it’s how you use the Theracane or the elbow or whatever that makes it either facilitating or inhibiting on your overall pain experience.

Whitney Lowe:

Yeah. Do you think about this perspective or idea as you’re doing particular types of techniques, or do you sort of-

Til Luchau:

Oh, yeah.

Whitney Lowe:

Think along the lines of, “What am I really doing here? What’s sort of enhancing this, or whatever?”

Til Luchau:

I try not to say that really word again, just because I have no idea, but I do think about it a lot. I try to get my students to think about it in workshops, to think that the tissue we’re probably having the biggest impact on is the tissue between your ears. It really is the way the brain is experiencing things, or our target as experience, as opposed to our target being fascia, or nerve, or bone, or skin, or whatever. That actually, the ultimate impact we want to have is on people’s experiences. We want them to feel better, whether or not they’re in pain. So, yeah, in that sense, I think about it all the time.

Til Luchau:

Now, again, from a psychology point of view, even signals are biological. Even this idea that we’re changing experience by turning down signals is kind of science-y and tangible in a way that I don’t even need from a purely psychological point of view. We’ve known for a long time that we can help people feel better by thinking about their brain reactions. Now we could go into a whole… Maybe we should just do a whole episode on it. All the ways that the brain changes our physical experience, the contextual effects, the conditioned responses, the expectation, all that stuff. Because I think good practitioners use those all the time. They’re setting up the situation, they’re managing expectations, they’re using their voice, they use the power of the environment, the therapeutic ritual, that ends up giving people a great experience. So that’s a descending modulatory process. We’re probably making the pain less intense to them just by the mindset we create.

Whitney Lowe:

Mm-hmm (affirmative), yeah. And for many of those practitioners who… I’ve often found this to be the case too, in some of the different times of my career when I was working in other healthcare environments with other health professionals who worked in more of a clinical type of environment where it’s the sort of typical clinical treatment room, the hard floor, bright fluorescent lights, cold temperature in the room. And talk to them about what we try to do in a manual therapy experience with people with soft, dim lighting, warm room, often soft, pleasant music playing in the background. Those things are actually a big part of the therapeutic encounter that helps that sense of descending modulation without having anything to do with what we’re doing touching them. And it is certainly a very important and valuable part of what we do in our treatment processes with everybody.

Til Luchau:

That’s right. I mean, we spent our first episode talking about our background and you’re taking me back to my days at the Esalen Institute where we learned and practiced on a deck overlooking the Pacific Ocean, halfway down a cliff, surrounded by wilderness. There’s waves crashing, there’s whales, there’s dolphins, there’s fog banks rolling in. And we’re doing body work out in the open there. And every session was amazing, and then people would leave, practitioners like me would leave Esalen and the question was always, “Can I do a great session anywhere else?” So that’s been a great inquiry along the way. How do I create an experience? How do I create… Including the use of the environment.

Til Luchau:

And you mentioned a clinical setting. But it makes me think it’s not always about just recreating Esalen or recreating a warm soft environment. It’s not always about warm and fuzzy. Sometimes a clinical environment creates the expectations of a particular response that’s helpful too. There’s a certain level of relativity where we just respond to whatever is most helpful. Doesn’t have to be a certain way. It doesn’t have to be the right music. It doesn’t even have to have music. It’s more like can we create the conditions where people have the experience we want them to have?

Whitney Lowe:

Yeah. Right. And so we do our very best, I think, to enhance… How do we enhance as many of those different pieces at a time as we can? And we can’t get them all. And you may have… I know I have gone to massage sessions where somebody has got this soft, pleasant music playing and then all of a sudden Pachelbel’s Canon comes on there, and I can’t stand that song because I’ve heard it 53 billion times.

Til Luchau:

Ad nauseum.

Whitney Lowe:

Over and over. It’s like, “Oh, now I feel my nervous system just tightening up and getting so…”

Til Luchau:

Yes, that’s true.

Whitney Lowe:

Facilitated, the irritability getting facilitated in that process. So we don’t have control over all those things, but we try to maximize as many of them as we can here.

Til Luchau:

That’s right.

Whitney Lowe:

Yeah, so…

Til Luchau:

Oh. One more thing. Looking over my notes. I am into signals. It’s not all psychology for me at all. I am into this signal stuff and the distinction that Olsen mentioned in his paper between unpleasantness and uncomfortable?

Whitney Lowe:

Uh-huh (affirmative).

Til Luchau:

That’s a big one to dive into. The idea that “pain” or let’s say sensation is reflected onto your sensory cortex in your brain and then pleasant/ unpleasant is projected onto your insula, a different part of your brain, that has more to do with typically emotion and sense of self. While the sensory, the sensation stuff, is more about position and motion and motor things. That’s a fascinating distinction to me.

Whitney Lowe:

Yeah, yeah. I thought that was particularly interesting too, yeah.

Til Luchau:

Mm-hmm (affirmative), a researcher around the neuroscience of neuroception, he’s got some really great stuff to say about how itch and temperature and some pain signals, depending on the type of pain, and then also the affect of touch, the pleasant touch, all share similar pathways that project onto the insula, while joint position and pressure of other kinds and different kinds of sensations project onto your sensory cortex. The simple version is you have sensation, and then you have pleasant/ unpleasant, and they come together in the back part of the insula there and that’s actually the area that maybe I’m thinking about the most when I’m touching. How do I merge my inputs in a way that includes pleasant/ unpleasant. Well actually, I’m going for the pleasant of course, and then sensation so that people can actually be remapping their responses and reactions around whatever presenting symptom they have.

Whitney Lowe:

Yeah. And that gets into that idea that many people speak about in the manual therapy world of something, when you’re doing a particular type of work with somebody and they say… Let’s say you’re doing something that’s moderately deep or intense with them, they say “It hurts good.” There is a sensation, maybe my nociceptors are really sort of firing there from that, but the interpretation of this sensation is, “I really actually like that. It feels like it is either changing something or enhancing something or doing something to help decrease my discomfort level with that.” So that’s a positive sensation.

Til Luchau:

That’s right. Or it goes along with some of the research into cannabinoids that show that people with pain who use those actually report the same levels of intensity, but the unpleasantness goes way down, so that it’s just as painful, but it doesn’t bother him half as bad. And sometimes, when we can’t diminish the intensity any other way, certainly we can diminish the unpleasantness, and that’s a godsend for some of it’s in pain.

Whitney Lowe:

Yeah, yeah. Well good stuff. I think there’s a lot of fascinating things in here too. One of my key takeaways from this discussion, I liked the thing that you said a little while ago, that’s going to be our bumper sticker of the show of, the tissue that we’re affecting the most is the one between the ears. I liked that. That’s a tee shirt quote.

Til Luchau:

All right. Good.

Whitney Lowe:

All right, very good. Well, we’ll wrap that up here for today. We would like to say a big thank you to our sponsors for the show, and you can stop by our site for show notes, some updates on CE credits and extra there, and we are over at thethinkingpractitioner.com. And Til, where can people find you on the web?

Til Luchau:

Yep, advanced-trainings.com, advanced-trainings.com. You can go there for the full transcript of our conversation today. And I know you can go to your site too, Whitney, for those things. What’s your site?

Whitney Lowe:

They can also find that stuff over at theacademyofclinicalmassage.com so those things will live over there, and if you’ve got questions on anything else from the show, please feel free to email us at [email protected], or look for us over on social media. Number of different locations. Til, where can they find you on social media at other places?

Til Luchau:

@tilluchau T-I-L L-U-C-H-A-U. That’s everywhere. And yeah, questions, suggestions for topics, requests, hate mail. We haven’t gotten to that yet, but it’s coming, I know.

Whitney Lowe:

Not yet. Okay.

Til Luchau:

But yeah, we’re looking forward to that. So, stay in touch.

Whitney Lowe:

Sounds good. And please, if you will, take a moment to rate us on Apple podcast or whatever is your podcast listening platform of choice. It really does help everyone else get a chance to locate and find us there as well. So thank you all to the listeners who are diving in and staying with us here. We certainly appreciate your time and investment of your efforts to listen to us and hopefully that’s expanding and helping some things with your practice and helping you become the thinking practitioner as well.

Til Luchau:

Pleasure talking to you, Whitney. Thank you.

Whitney Lowe:

All right, sounds good, we’ll do it again. We’ll see you in two weeks.

Til Luchau:

Bye bye.

Whitney Lowe:

Okay.

 

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