woensdag 13 juni 2018

Osteopathy in the Cranial Field: does it work?

Osteopathy in the Cranial Field: does it work?

Osteopathy in the Cranial Field (OCF) is a standard component of the toolbox of the osteopath. At the same time it is also the most controversial. More and more reviews appear that are questioning the evidence of OCF.

By Sander Kales, D.O.-MRO, M.Sc.
Published in De Osteopaat Magazine | May 2017 | Vol.18 | Nr.1

Various disciplines are currently involved in the cranial domain: there are about 175 registered mandibular physiotherapists, 150 Craniosacral therapists and 30 Craniofacial physiotherapists in the Netherlands. At the same time, there are increasing doubts about the effectiveness of the treatment of the cranium. What has been researched so far?

Most general reviews of cranium treatment conclude that there is little to no evidence for diagnostic reliability and effectiveness (Green, Hartman, Jakel, May, Rogers and Guillaud).
More specific studies have also been carried out. We explain the most important studies for each explanatory model from the ECOP model. We use the Moran method (2005) which classifies the literature on cranial tests and treatment methods in:
1) Reliability and validity of the tests of dysfunctions according to the models used in osteopathy in the Cranial Field (OCF).
2) Evidence that dysfunctions in the OCF can be linked to poor health outcomes.
3) Evidence of the effectiveness of OCF in changing health outcomes.
We focus on reliability (1) and effectiveness (3).


1. Biomechanical model
The earlier models about OCF from Sutherland (1984) and Magoun (1966) are mechanical models in which the brain fluid is driven by moving skull bones. However, influencing the mobility of skull bones is nonsense, according to Hartman (2002), Greenman (1970) and other authors. Cranial surgeons consider this theory as quackery.
Jayaprakasha (2013) concluded after studying hundreds of skulls that the suture patterns remain plastic until they reach a higher age. Fixation of the sutures, according to Steinmetz (2012) and Gabutti (2014), is due to the myofascial system. Kuchera (2009) indicates that myofascial somatic dysfunction is important in diagnosing the skull.
In addition to local and regional there is a mechanical global picture: this can be seen in posturology and how "strain patterns" (Zink, 1979) have manifested themselves throughout the body. Kroman (2009), an anthropologists, studied skulls and bones and concluded that there is a clear correlation between cranial dysfunctions and dysfunctions in the rest of the skeleton. This indicates a fascial relationship between the body and the skull.

Reliability of testing
A study by Greenman (1970) shows that palpation of the 3D structure is significantly similar to the X-ray images of the skull. Halma (2008) indicates that the intra-rater reliability is significant when determining strain patterns.
This cephalometry can be further refined by means of software and may serve as a measuring instrument for young children, in which it appears that the skull is still malleable (Jayaprakasha 2013, Philippi, 2006).

Effectiveness of the treatment
Lalouze Pol (2009), Lessard (2011), Cazala (2012) and Philippi (2006) have done studies where they mechanically treated the skull post-natally. This treatment to prevent preventive orthodontics is an important indication area for cranial osteopathy in young children and appears to be significantly effective. In contrast, Downey (2004) did not see any effect of a "Frontal Lift" on the sutures in rabbits. 

2. The circulatory model
The first models in the OCF based on circulation are from Sutherland, Magoun and Upledger (pressurestat model). In short, they state that the rhythms originate from liquid movements of the liquor. Chu (1998) shows that the pulsations in the liquor are a compilation of the different fluid rhythms. Fergusons (2003) hypothesis is that there are many different rhythms (arterial, venous, lymphatic respiration and liquor). This explains why the inter-assessors reliability would be low, as was found by Norton (1996) and Hartman (2002). Moskalenko (2003) indicated that arterial pulsation is the most prevalent. Furthermore, in his measurements he has seen a rhythm that is separate from the aforementioned rhythms: the intracranial fluctuations of 5-15 cpm. These are a composite of all rhythms. Gard (2009) based his model of cranial rhythms mainly on venous parameters. Gehlen (2017) shows that the collapse of the V. Jugularis has an influence on the liquor circulation by changing posture. De Bakker (2006) states in his review that this system should be viewed from arteries, veins and certainly also the lymphatic system that influence the circulation of liquor. The recent discovery of the Glymphatic system confirms this.

Reliability of the tests
Hartman (2002), Norton (1996), Wirth-Patullo (1994) and Sommerfeld (2004) looked at the intra-rater's reliability of the feeling of the rhythm, and found that this reliability is too low. The pulsations that osteopaths feel on the skull are a compilation of different rhythms. Sergueef (2011) has examined the reliability of CRI / PAM. She does, however, conclude a greater reliability (see also page XXX). Hiort provides an overview of the measuring methods that have been used and concludes that there is little evidence for measuring rhythms. Nelson (2006) states that the rhythm is less important, the position of the bones and the power of the pulsations are important.

Effectiveness of the treatment
Even if the osteopath manages to objectify this rhythm, whether it is rhythm or strength (Mokhov 2016), it is still questionable whether it has been found that the cranial treatment significantly improved the rhythms compared to a placebo.
There is still insufficient evidence that the systemic approach to circulation leads to better results compared to isolated treatment of the skull. Richter-Schulz (2010) is therefore of the opinion that the CRI or Primary Respiratory Mechanism (PAM) should be released as a diagnostic tool and that especially the sutures should be tested.

3. Biochemical model
The "Gut Brain axis" is seen as increasingly important. Studying the influence of the microbiome on pathologies such as Alzheimer's is increasing. There is still no evidence for influencing biochemistry. In short, here is no model about the influence of the abdomen on the cranium, no correlations between abdominal symptomatology/ dysfunctions and cranial dysfunctions, and no effect studies that show that a treatment of the abdomen changes the parameters of the cranium.

4. Neurological model
The tissue pressure model of Norton is based on the assumption that the nerve tissue is the motor for the rhythms. Brain tissue provides a pressure and also a rhythm via intracellular fluid. Moskalenko (2013) mentioned the function of the glial cells as a possible explanation for this, as also shown in the Glymphatic system. Richtsmeier (2013) has shown that it is the brain development that determines the shape of the skull.

Reliability of testing
There are no tests for brain and brain nerve functions in osteopathy, but there are neurological function tests. These have been validated.

Effectiveness of the treatment
Especially the CV4 technique has, according to some studies, influence on the functioning of the autonomic nervous system (Buschatzky 2014), (Collard 2009), (Cutler 2005), (Grill 2006). In contrast, Milnes (2007) and Cardoso (2015) found no significant effect of the CV4. The methodology and the results must be further examined in order to arrive at a conclusion.
Duncan (2008) and Raith (2016) examined the influence of cranial treatment on motor functioning. Duncan found an effect, Raith did not. Mataran (2011) showed that sleep and tension in fibromyalgia patients changed after cranial treatments. Sandhouse found an improvement in vision after a viscerocranium treatment.

5. Biopsychosocial model

In the model "the synchronization hypothesis" of McPartland it is indicated that there is a harmonization of electrical and electromagnetic rhythms between osteopath and patient. This has recently been confirmed by Liu (2017) and Stevens (2010). A biophysical exchange takes place, but the information that is exchanged can not be interpreted. Hendryx (2014) states that a bio-energetic model must be added to the ECOP model. The biopsychosocial translates into bioelectromagnetics in the natural sciences, because thinking is seen as an electromagnetic phenomenon of the brain. Stone, Fulford (1997) and Hendrikx (2017) developed models of the bioelectromagnetic field in osteopathy.

Reliability of testing
Testing the bioelectromagnetic field has not yet been investigated in osteopathy. A start has been made with the bio photon emission of the body (van Wijk, 2016). In his new book, Van Wijk will summarize the therapeutic influence (in mid-2018). So there is no question of dysfunctions and a correlation of this with symptomatology.

B. Subjectivity
Thinking and conducting conversations, which falls within the biopsychosocial model, takes place in the subjective domain. We leave the objectifiable. The osteopath is informed and must objectify the subjective experience of the patient. What do I experience with this patient, and is this true or is this a transfer?
When the domain of the psycho-emotional is viewed, it is striking that the boundaries of the domain are determined by psychopathology. It is debatable whether osteopaths know enough of psychopathology to be able to determine whether this is a spontaneously occurring emotional release, as Upledger (2002) states with his Somato-Emotional Release techniques, or a generalized anxiety disorder as a result of, for example, sexual abuse. The osteopath may play an important role here, but must then be trained in psychology and psychopathology to recognize issues such as transference counter-transference, attachment styles and DSM 5 axis 3 problems.

Cranial osteopathy is a combination of techniques. The models which have the possibility of looking at effectiveness and reliability, seem to lie mainly in the circulatory, neurological and bioelectromagnetic domain. Osteopathic clinical reasoning offers osteopaths the possibility to distinguish themselves. Looking locally, regionally and globally from the different models, using a terminology that is universal and not just for osteopaths, can give us a permanent place in the landscape of health care for the cranium.

For references and recommendations see also www.swoo.nl.

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vrijdag 2 december 2016

Wat kan de osteopaat doen bij whiplash

Het onderstaande verhaal is illustrerend voor patiënten met whiplashklachten. Het is tot stand gekomen dankzij vijfentwintig jaar praktijkervaring met mensen met whiplash, maar ook door de persoonlijke ervaring van de auteur.[/]
De osteopaat ziet veel mensen met een whiplash. Een vijfde van de mensen in de osteopathiepraktijk heeft nekklachten, waarvan weer een vijfde whiplashklachten. Grofweg gezegd heeft 2,5 procent van de patiënten in de osteopathiepraktijk wel eens een whiplash meegemaakt. Whiplash is een beeld dat ons dwingt om functionele onbegrepen klachten te onderzoeken en samen te werken met de verschillende disciplines die op de deelgebieden actief zijn. Dit is nog steeds een uitdaging binnen het huidige gezondheidsstelsel.’

Een voorbeeld
Stel u bent voor de tweede keer in vijf jaar van achteren aangereden. De eerste paar weken bent u nog druk bezig met de afhandeling van de schade, plus dat u op uw werk net in een project zit dat veel van uw tijd in beslag neemt. De eerste weken na het ongeval merkt u wel dat uw nek stijf is en dat uw concentratie minder is. Af en toe bent u licht in het hoofd. Na vier weken besluit u toch eens bij de huisarts langs te gaan. De concentratievermindering, duizeligheid en nekpijn blijven aanwezig, maar u merkt ook dat u lichter slaapt, vaker vermoeid bent, uw kaken gespannen zijn en u gevoeliger bent voor geluid. 

Het medisch circuit in
De huisarts constateert een Whiplash Associated Disorder (WAD) type 2 (nekklachten en andere klachten van het houdings- en bewegingsapparaat) en stuurt u door naar de fysiotherapeut. De fysiotherapeut is een specialist op het gebied van spieren en hij constateert dat uw nek- en kaakspieren gespannen zijn. Er wordt gemasseerd en u krijgt oefeningen mee om uw nekspieren op te rekken. Toch blijven de duizeligheid, de concentratieproblemen, het lichte slapen, de pijn, de vermoeidheid, de gespannen kaak en de gevoeligheid voor geluid aanwezig. 

De fysiotherapeut stuurt u door naar een collega die manueel therapeut is: een specialist op het gebied van gewrichten. De  manueel therapeut constateert dat uw bovenste nekwervels en kaak vast zitten en dat uw borstwervelkolom gespannen is. De behandeling wordt ingezet. Inmiddels bent u vijf maanden verder, de bewegelijkheid van de nek en kaak zijn toegenomen, maar de verminderde concentratie, de vermoeidheid, de duizeligheid, de pijn en de gevoeligheid voor geluid blijven. 

Inmiddels is het op uw werk duidelijk geworden dat u niet meer goed functioneert en men heeft u aangeraden zich ziek te melden. Volgens de bedrijfsarts is whiplash psychosomatisch en hij stuurt u door naar een psycholoog. De procedure met de afhandeling van de schade blijft ook maar voortslepen. Op het schoolplein ontmoet u een ouder die u adviseert om eens bij de osteopaat langs te gaan. 

Naar de osteopaat
De osteopaat is een specialist op het gebied van functionele onbegrepen klachten van het bewegingsapparaat, de bloedvaten, de stofjes in uw lijf en uw zenuwen. Hij kijkt waar u staat op de schaal van ziekte (0) naar gezondheid (10), waarbij eerst uitgesloten wordt dat er niet een duidelijke ziekte c.q. beschadiging aanwezig is. Indien u niet in dit domein valt (0-3) zit u in het domein van de functionele klachten (4-7). Er zijn dus klachten, maar er is geen duidelijk aanwijsbare anatomische oorzaak. Hier was u zelf ook al achter gekomen.
Verder kijkt de osteopaat naar de verbanden tussen de verschillende systemen en niet lineair of reductionistisch (bijvoorbeeld. is het de zenuw > neuroloog, is het de nek > orthopeed, et cetera).

Het eerste consult - klachtenanalyse
Hij onderzoekt u en constateert het volgende: Bij de eerste aanrijding is er al een overprikkeling van uw pijnsysteem (nociceptie) opgetreden. Verder is toen al een verminderde functie van uw oogmotoriek begonnen aangezien u toen al behoefte had aan een bril, maar deze was steeds net niet goed genoeg. Ook had de tandarts toen al geconstateerd dat u toch wel vaak lag te klemmen ’s nachts. De ogen en de kaak worden bezenuwd door hersenzenuwen vanuit de hersenstam, en de osteopaat concludeert dat deze al de afgelopen jaren meer geprikkeld was aangezien u toen ook al fysiotherapie gehad had.

Door de huidige aanrijding is het pijnsysteem verder overprikkeld geraakt en er is sprake van allodunia: normale niet pijnlijke prikkels leiden nu tot pijn. (Kasch, 2016)
Een mogelijke oorzaak van uw duizeligheid kan te vinden zijn in een verstoring van de beweeglijkheid van de bovenste nekwervels, prikkeling van de banden van uw nek door de klap of zelfs verstoring van de werking van uw oogspieren. Deze zaken kunnen ook de oorzaak zijn van de regelmatig vastzittende nek.

Onderzoeken van Curatolo (2011), Jun Li (2014), Oostendorp (1999, 2013), Yacovino, (2013), Sterling (2006) en Nacci (2011) hebben aangetoond dat achtereenvolgens een verstoring van de mobiliteit in de bovenste nekregio door prikkeling van de synoviale gewrichten, irritatie van de ligamentuur en verstoring van de intrinsieke oogmusculatuur oorzaken kunnen zijn van aanhoudende duizeligheid bij postwhiplashklachten.

De osteopaat constateert ook dat uw pupilreflex veranderd is (flutteren: afwisselend openen en dicht gaan als reactie op een lichtprikkel), dit is een overstimulatie van perifere sympathische neuronen. Blijkbaar heeft de pijnprikkel geleid tot een overstimulatie van een zenuwknoop in uw nek (het ganglion cervicale superior) waar het schakelcentrum is voor bijvoorbeeld de doorbloeding naar uw hoofd en de pupilreflex. Naast deze overprikkeling hoog in de nek constateert hij ook dat uw hartritmevariabiliteit veranderd is naar een meer ‘opgejaagd’ beeld  (Passatore, 2006, Brugnoni, 2014, Edwards, 2015). Ook uw tongmotoriek is veranderd, en u had al bemerkt dat af en toe een grote hap doorslikken niet altijd even makkelijk ging (Bordoni, 2015).

Op basis van deze bevindingen constateert de osteopaat dat er sprake is van een centrale sensitizatie, dat wil zeggen er is een overprikkeling van het pijnsysteem die geleid heeft tot een uitbreiding van de klachten naar het zogenaamde onwillekeurige zenuwstelsel  (Winkelstein, 2011).

Naast de overprikkeling van het zenuwstelsel is er door de lokale ‘ontstekingsverschijnselen’ van het gewricht en de zenuwen (Curatolo, 2011, Kasch, 2016) een belasting op het Neuro Endocrino Immunologische (NEI) systeem. Dit resulteert in verandering van de cortisol, een hormoon dat wordt afgescheiden in de bijnierschors, en dat ook van invloed is op vermoeidheid en slapen (Gaab, 2005).

De osteopaat legt uit dat het zenuwstelsel na twee posttraumatische nek-ongevallen in vijf jaar overprikkeld is, en dat de prikkel zich ‘gegeneraliseerd’ heeft. Dit is een belangrijk punt bij whiplash; de overgang van acuut naar chronisch. Bij deze overgang wordt in het dagelijks functioneren steeds duidelijker dat u niet meer op 100 procent zit. Dit gegeven breidt zich als een inktvlek uit, u begint te twijfelen of u wel het juiste werk heeft, vrienden merken dat u toch wat vaker afbelt en afwezig bent, kortom: uw psychosociale functioneren lijdt inmiddels ook. Daarnaast levert het onbegrip en de slepende juridische kwestie geen positieve bijdrage.

Na het eerste consult waarin de osteopaat dit alles heeft uitgelegd, gaat u beduusd naar huis. U probeert te bevatten wat hij u zojuist verteld heeft, maar het duizelt u. Toch heeft u tegelijkertijd het gevoel dat er iemand is die naar u in totaliteit kijkt, de tijd neemt en bovenal al die ‘vage’ klachten verklaren kan. Maar wat belangrijker is: wat kan hij er aan doen? Bij het volgende consult besluit u dit aan de orde te brengen.

Aanpak van de osteopaat
Duidelijk is dat het zenuwstelsel rust moet krijgen. Dit varieert van leren te ontspannen (bijvoorbeeld met behulp van mindfullness), herkenning van belasting-belastbaarheid en de aanpassing van uw leven daaraan, tot aan concentratieoefeningen. Hier is een multidisciplinaire aanpak van belang.
Ook moet voor de algehele tonus (sympaticotonus) van de bloedvaten een goed trainingsprogramma opgesteld worden. Tevens zal de osteopaat het autonoom zenuwstelsel trachten te reguleren.
Er moet gekeken worden naar uw NEI-systeem, en waar mogelijk ondersteund door een goed voedingsadvies (lage suikerinname).
Een functioneel optometrisch onderzoek is nodig om uw oogfunctie te beoordelen en hier mogelijk een brilcorrectie voor te doen. Allereerst doet de osteopaat dit onderzoek naast een schedel en hersenzenuw onderzoek en zal daar waar verlies aan mobiliteit is het gaan behandelen.. 
U zal door moeten gaan met de oefeningen voor de bewegelijkheid van de nek (alhoewel de stijve nek dus mogelijk een gevolg is van andere oorzaken, een somato-somatische reflex, Janig 2011). De oefeningen zullen het effect van de mobilisatie die de osteopaat uitvoert moeten ondersteunen.

Allemaal mooi en wel, maar wat doet nu precies die osteopathische behandeling? Een Cochrane review laat zien dat er geen eenduidigheid is of een actieve dan wel passieve behandeling beter zou zijn. Er zijn enkele studies naar osteopathie gedaan (Fryer, 2005, Schwerla, 2013, Bordoni, 2014? Giu, 2010, Sun Genese, 2013) waarin er een indicatie is dat osteopathie effect heeft. De vraag is natuurlijk: welk deel van de osteopathische behandeling is dan effectvol? 
De geïndividualiseerde behandeling, waarbij aandacht is voor het gehele lichaam (ook het bekken, onderrug, borstwervelkolom en het bindweefsel rondom de organen) heeft een effect, maar dit dient verder onderzocht te worden.

De conclusie
Uw klacht is na twee jaar duidelijk minder, u heeft uw werk weer hervat, alleen wanneer u te veel van uzelf vraagt, komen  de concentratieproblemen, de pijn, de duizeligheid en de vermoeidheid nog licht terug. Restklachten zijn er doorgaans nog, echter de mate van belemmering in het dagelijks leven kan wel degelijk beinvloedt worden door osteopathie.



1. Bordoni, 2016, the tongue after whiplash: case report and osteopathic treatment, International Medical Case Reports Journal 2016:9 179–182 
2. Boniver, 2014, Whiplash associated autonomic effects, Chapter 11, D.C. Alpini et al. (eds.), Whiplash Injuries, 281 DOI 10.1007/978-88-470-5486-8_27 
3. M. Curatolo, 2011, The role of tissue damage in whiplash associated disorders: Discussion paper 1, Spine (Phila Pa 1976). 2011 December 1; 36(25 Suppl): S309–S315 
4. I.J. Edwards et al., 2015, Neck muscle afferents influence oromotor and cardiorespiratory brainstem neural circuits, Brain Struct Funct (2015) 220:1421–1436 
5. G. Fryer, 2005, Research report: The effect of osteopathic treatment on people with chronic and sub-chronic neck pain: A pilot study, International Journal of Osteopathic Medicine (2005) 41-48
6. J. Gaab, 2005, Reduced reactivity and enhanced negative feedback sensitivity of the hypothalamus–pituitary–adrenal axis in chronic whiplash associated disorder, Pain 119 (2005) 219–224 
7. Giu, 2010, Rehabilitation and Osteopathic Manipulative Medicine for a Patient With Dysphagia Secondary to a Hyoid Somatic Dysfunction: A Case Report.
8. Janig, 2011, Functions of the autonomic nervous system, Chapter 2, The science and clinical application of manual therapy, Churchill Livingstone
9. Jun Li , et al., 2014, Sympathetic nerve innervation in cervical posterior longitudinal ligament as a potential causative factor in cervical spondylosis with sympathetic symptoms and preliminary evidence, Medical Hypotheses 82 (2014) 631–635
10. Kasch, 2016, Whiplash injury; perspectives on the development of chronic pain, IASP press, Philadelphia, pg.242
11. Nacci, 2011, Vestibular and stabilometric findings in whiplash injury and minor head trauma, Acta Otorhinolaryngol Ital 2011;31:378-389 
12. Oostendorp, 1999, Dizziness Following Whiplash Injury: A Neuro-Otological Study in Manual Therapy Practice and Therapeutic Implication, The Journal of Manual & Manipulative Therapy Vol. 7 No. 3 (1999), 123 - 130 
13. Passatore, 2006, Influence of sympathetic nervous system on sensorimotor function: whiplash associated disorders (WAD) as a model, Eur J Appl Physiol (2006) 98:423–449 
14. F. Schwerla, 2013,  Osteopathic Treatment of Patients with Long-Term Sequelae of Whiplash Injury: Effect on Neck Pain Disability and Quality of Life, THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 0, Number 0, 2013, pp. 1–7
15. Michele Sterling , 2006, The relationship between sensory and sympathetic nervous system changes and posttraumatic stress reaction following whiplash injury—a prospective study, Journal of Psychosomatic Research 60, p.387–393
16. J. Sun Genese, 2013, Osteopathic Manipulative Treatment for Facial Numbness and Pain After Whiplash Injury, The Journal of the American Osteopathic Association July 2013 | Vol 113 | No. 7 
17. Verhagen AP et al., Cochrane review: Conservative treatments for whiplash, Cochrane Database of Systematic Reviews 2007, Issue 2
18. B.A. Winkelstein, 2011, How can animal models inform on the transition to chronic symptoms in whiplash?, Spine (Phila Pa 1976). 2011 December 1; 36(25 Suppl): S218–S225 
19. Yacovino, 2013, Cervicogenic-Related Dizziness and Vertigo, Seminars in Neurology, Vol. 33, No. 3

zondag 18 januari 2015

Osteopathy: empathize with the essence of man.

Definition Osteopathy.
According to the founder, AT Still, the definition of osteopathy is that Osteo means bone and Pathos stands for illness or suffering in general (1874). He is quoted: "The merging of these two concepts is inspired by the Indians who merged two tribal names". Later new interpretations were added. Osteo is bone and in the 19th century this was seen as the essence of man because it was the only thing that was left of him. Pathos is empathy (see empathy). Merged this means "empathising with the essence of man" (McKone, 2001).
According to the professional competency profile (BCS-1) in the Netherlands osteopathic manual medicine is an examination and treatment.
Osteopathy is a philosophy, a science and an art.

The osteopathic philosophy is about

A. Health and illness
B. Process
C. Three general principles

A. Illness and health are two aspects of development. The death of brain cells is required for the growth. The loss of memory is needed to get new impressions. Also, for the immune system disease is a conditioning for a better immune system. When the path of disease to health (or vice versa) is put on a scale of 0 (ill) to 10 (healthy), then regular medicine is engaged in the domain of disease (0-3), in the domain functional subclinical symptoms (4-7) osteopathy is engaged and things like yoga, Pilates, fitness in the spa are on the wellness end of the scale (8-10).

B. Process
In recognizing symptoms, functional symptoms and disease it is about placing the processes and patterns in time. Health care providers are accustomed to looking for the symptoms (what do I have) and causality (how I got it) of a patient. Causality is the way the brains organize experiences. Causality cannot be seen, it comes from the subjective experience (Fenomenon) and not from the world (noumenon). Therefore, the effect cannot be distinguished from the source, because it comprises both. For osteopathic clinical reasoning this means that the genesis of the neck problems in its totality is important, not the neck problem 'in itself' and not 'the cause'. In the identification of disease and dysfunction the osteopathic clinical reasoning is important. This reasoning is based on the general principles.
The recognition of the originality of the patient (why do I have this now), depends on the patient history and knowledge of physical, psychological and emotional development. The world of matter (eg. A fist) thus conceals the whole (the hand) and the process (the fisting of the hand). If we apply this reasoning to recognize symptoms and disease, this allows the processes, patterns and thus to understand the information that is stored in the symptom.

Osteopathy as a science.

In today's academic world, the latest development is that Evidence Based Medicine (EBM) moves in the direction of Outcome-Based Medicine (CBM). Osteopathy takes causes into consideration, making use of these two approaches. Fundamental research is used for hypothesis formation and experimental studies to evaluate the final result. INSERM has published a paper in 2012 in which the current experimental studies summarized in Osteopathy and geëvaluereerd (Falissard 2012).
The physical aspect of osteopathy is based on medicine and is approached in a scientific manner. Aspects of human functioning such as cytology (1), histology (1) anatomy (1), physiology (2 and 3) fluid dynamics (2), endocrinology (3), immunology (3), biophysics (3), neurology (4 ), and psychology (5) are the foundation on which osteopathic thinking is based. However, this will be considered from an osteopathic or health perspective, and not from an allopathic or illness perspective. A systems model is a mental image of a disease or functional complaint. A model can be tested, in contrast to a paradigm (faith structure).

In regular care, there is a progressive differentiation: cardiology, internal medicine, endocrinology, etc. Developmental Systems Theory (DST) not only provides the before mentioned "Model thinking", but also the connection between the different models, where the psycho neuro-immunology is an example of (Oyama, 2001). This connection between the different models is comparable with the general principle: the body is a unit. Therefore DST is important in osteopathic thinking.

According to the Dutch Association of General Practitioners (NVH) 40% visited their GP with somatic insufficiently explained physical complaints (SOLK). Because of the three general principles and the Ecop model osteopathy is suitable for assessing functional complaints. She works in this domain and thus osteopathy is a part of functional medicine.

The Osteopath goes beyond the complaint and the elimination of symptom:
- He identifies disease and assesses the primary disease.
- He identifies the functional "sub clinical" complaints, called dysfunction, and places them in time.
- He uses evidence-based guidelines and basic research in treating the dysfunction.
- He analyzes the factors affecting the life of the patient's disease so that health can be improved, and the body can heal itself.

Osteopathic authors base their treatment hypotheses on fundamental research and not yet on experimental studies, when they describe empirical techniques in the current osteopathic literature (Georges Finet 2013) (Barral).
If basic research changes the hypothesis that the treatment strategy is based on changes, while the effectiveness has not been studied.
An example of this is the fundamental investigation into the "glymphatic system" (Iliff, Wang et al, 2012). Because the researchers had used a smaller marker than the dye that was used in previous studies, they found that the drainage of CSF is also via the para vascular place in the parenchyma. This shows that the earlier hypothesis in osteopathy of liquor drainage, only via the arachnoid villi and the venous system is incorrect.

Based on this knowledge, the hypothesis about drainage in the Cranio Sacral system must be re-evaluated. Instead of focusing on the statements of the assumptions (which, incidentally, much more leads to be like sync dog rosen that are long mobile connections between dura and musculature at the height of the occiput) there should be focused on the effectiveness of the techniques.

Classically the treatment techniques were divided into parietal, visceral and cranio-sacral techniques. This subdivision is by region. The structures that are treated, however, can be summarized in the above five models. As an example the biomechanical model through the fascia, both parietal, visceral as cranial be treated. Neurogenic, autonomic nervous system may also apply to all three. However, the symptomatic approach is still the language of patients and physicians. They want to know if we can help with a specific complaint / symptom.
For example, osteopathy can help with my digestive problem ??
The functional complaints top 10, according to the directive SOLK (NVH): generic low
back pain, neck pain, sleep problems, fatigue, upset stomach, irritable bowel syndrome, headaches, dizziness, anxiety and restlessness. These are the complaints that are within the osteopathic domain.

Studies have been done, not all of them methodologically sound, but it's a start. The last 10-15 years, more and more studies done in Osteopathy. There is also an increase of Osteopathic doing masters and even PhD. There are several research centers in the world (CORE, NCOR, etc.). In the Netherlands there's Foundation Research in Osteopathy (swoo.nl) which is working on more support from the profession.

Osteopathy as an art.
The osteopathic contact can be divided into the exteroceptive contact between the patient and the osteopath and interoceptive contact the osteopath has with himself.
The qualities that we can palpate exteroceptief:
1. Mechanical (motility)
2. Rhythm and Heat (circulation)
3. Vitality (innervation and metabolic)

During the exteroceptive contact, an exchange takes place through various phenomena. Brainwaves (Stevens 2010) and heart rhythms (McCraty 1996) have been proven to synchronize during the contact. Besides these physical qualities that are palpated, there is also the "mental" aspect during palpation of the other. In osteopathy the body is seen as an expression of the subconscious.
The person is the context in which the "spirit" finds its expression. So the body which is palpated has a 'mental-spiritual' side. The philosopher Whitehead said: "There are no two substances body-mind, but experience has two aspects: physically and mentally."

Whith interoceptive contact the inner world of the osteopath plays a role. Michael Shea emphasizes the development of an inner "resting" state during treatment (Shea, 2008). It should be considered that through supervision / peer review and biofeedback it is made clear what this "rest" state is and than what the content of the interoception is. Therefore an open balanced attitude is a prerequisite for observing the impression that the patient has on the osteopath, so it can be properly interpreted.
Subjectivity further calls for a development of one's own observations, so that a reproducible reference system can be developed. Nothing is greater than self-knowledge. This permits the osteopath to maintain distance and proximity and to let go of judgmental thoughts so openness arises for what is there. Therefore, the patient-osteopathy relationship is a collaboration system that promotes the health of the patient. Things like intuition and palpation are examined in relation to the inner world of the osteopath (McNeill, 2013).
The sense of touch is developed by the feedback obtained. Is it really the intestine or ligament that is felt? The feedback in the past was obtained by X-ray or ultrasound. For "hand-workers" the anatomy, histology, physiology and psychology of the nervous system act as a navigation system during palpation.

It can be concluded that during the osteopathic contact more will be observed than just the mechanical, physical, but that these things should be distinguished in the phenomenological experience of the osteopath and the existential á priori aspect of perception. Both must be reproducible and verifiable. Therefore, the name Osteopathy can be questioned, which literally means disease of the bone. The name empathize with the essence of the human being from the functional medicine would be more appropriate.

the Future
Problems for osteopathy are the recognition of the profession, which should be by the BIG register. To join this, first one needs  to develop a NVAO accredited full-time training. Furthermore, the experimental research will also be extended.
Furthermore, anyone can learn the techniques ("skills") and do "osteo therapy", such as craniosacral therapists, visceral techniques by manual therapists, etc. However, the clinical reasoning and competencies are more complicated and require more study so that the osteopathic medicine, and most importantly the clinical reasoning must be based on adequate knowledge of anatomy, physiology, histology and cytology.
Future directions for osteopathy are increasing the basic medical knowledge. Than the clinical reasoning should take place from an osteopathic conceptual framework, ie how health is defined and what are functional problems (tired, stiff, pain, etc.)? Additionally an osteopath as first-line worker must master sufficient knowledge of the pathology to distinguish the red and yellow, the green flags.

In Summary:

The osteopathic philosophy has phenomenological, empirical and process aspects. There are three principles of osteopathy: unity, process of structure and function and self-healing / health.
The science of osteopathy is still in its infancy. Clinical reasoning is based on the statement of five models: biomechanical, circulation / respiration, metabolic, neurological and biopsychosocial.
The art of osteopathy lies in a refinement of feeling, extero- as well intero-ceptief.


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vrijdag 16 augustus 2013

On the possibility to identify the importance of HRV studies in analysis of our mental entities.
by Sander Kales, D.O.

When Descartes started his writing’s on the division of mind and matter, he could not have foreseen the length to which this was taken. Not only in medicine is there a division between the mind (psychology) and matter (biology). Also in our everyday lives we make this division. We live in our world of thoughts, or are confronted with the sensations of our body. Our understanding of our mental lives has led us to think that it is our brain that generates emotions and feelings. 2014 will be the year of the brain in Europe so neurologists and neuropsychologists are more and more on the forefront of medical development and we will start forgetting what our bodies are for.

On the other hand, the latest research on heart rhythms, have shown that it is our physiology which leads to emotions, which leads to feelings, which leads to thinking. Our mental activity is founded upon our physiology. In the works of McCraty this has been demonstrated (McCraty 2006, McCraty, Atkinson et al. 2006). The activity of our heart influences directly the state of our brain. Thus the seperation between our mind and our body becomes blurred. We cannot seperate mind and matter anymore.
In this article, the current assumption that it is our mental activity, that influences our Heart Rate Variability will be renounced. But taking this even further, the generation of the heart rate variability is based on the information from our body. This is what is expressed in the variability. Current methods of studying HRV, such as the Fast Fourier Transform (FFT) which is a linear method will not be sufficient to explain this connection between our bodily functions, such as the state of functioning of our kidneys, and the HRV. New methods, like the Conte Ziblut Federici (CZF) method (Conte, Federici et al. 2009), which is based on non-linear methodology, are able to show this connection.

Emotions, Feelings and Physiology.
We are all familiar with the term: ”it has a visceral feel to it” . In our language we our confronted with this connection between our physiology and our emotions: “it makes me sick to my stomach”, “I have butterflies in my belly”, etc. There is a distinction between emotions (or Energy in motion) and feelings, the former being the sensation of our physiology, and the latter is more the association of brain patterns to the bodily patterns (Lane 2008). We describe this bodily sensation and associate all kinds of mental phenomena to it. So our thoughts arise from within us and are based on our bodies patterns.

The mind-Body connection.
McCraty has demonstrated that a change in HRV corresponds with different emotional states. He differentiated the four basic modes: Mental Focus, Psychophysiological Incoherence, Relaxation and Psychophysiological Coherence. Besides these four modes, which he has shown to be basic axis on which we can draw our emotional functioning, there are two more modes: Positive Hyperstate or Emotional Quiescence and Negative Hyperstate of Negative Emotional State (McCraty, Atkinson et al. 2006).
The differentiation of these emotions into for instance acceptance, grief, etc. goes beyond the possibilities of his type of research. This could be because he uses a FFT, linear method, with which he cannot describe the subtleties of the HRV. It is like transforming a piece of Mozart into basic chords. This is an oversimplification of what Mozart’s music is like, and in that sense what our heart functioning is like. Nonlinear methods are better able to grasp this kind of “music”.
Heart beats
The classical notion is that the heart is a pump. Chitty has demonstrated that the heart is more an integrator of several types of information: haemodynamics, hormonal, electromagnetically, electrically, etc (Chitty 2010). Every heart beat is a taking up of information and changing the parameters slightly. With each ejection phase the direction of the vortex is slightly changed so that blood receives information and through this new vortex, will arrive at the place it needs to be (for instance the kidney’s). In embryonic development of the heart wall, it is demonstrated that the vortices form the trabeculae.
Goncharenko went even further (Goncharenko 2003). In studies of thrombi in baboons, he demonstrated that the thrombus originating from a particular part of the wall of the heart, will always end up in a certain place (for instance the left iliac artery). He studied this in a lot of baboons and was able to come up with a somatotopy of the body on the walls of the heart.
Interesting in this study is that a small change of the contractility of a particular part of the heart wall will result in a change in the electrical conductivity of that part. This will result in a different contraction, and thus a different distance to the R top on the ECG. Thus the HRV will come into place.
So now we can deduce that this change in contraction as a result(!) of different information from a peripheral organ (for instance the kidney) will result in differences in R-R intervals and also account for the dynamics of the HRV.

Measurement of HRV
The classical method of measuring the HRV is through first measuring the distance between the R-R intervals. This interval is than put in a Tachograph, where you can see the fluctuations of the intervals between the heart beats, also called: a time analysis. This is a linear method of measuring. Conte et al. have shown that already here we can apply the principles of Quantum Mechanics and measure not just the change between subsequent beats but also the change between the first and the second, between the first and the third, etc. This will result in a non-linear analysis and give more results (Giuliani, Giudice et al. 1996, Conte, Federici et al. 2009).

The next step in the data processing is taking the frequencies that compile to make up the fluctuations of the tachogram and transforming them into a Power Density Spectrum. When you look at the fluctuations of the HRV you can imagine that it is a combination of all sorts of frequencies, ranging from .04 Hz to .9 Hz. The number of times a certain frequency is there, it will be added up and put into a PSD. This transformation is done on the basis of a frequency analysis: a Fast Fourier Transformation (FFT). Again here a linear method is used, because of the standard frequencies. It is like taking the accords of a Mozart piece and concluding that, that is the music piece, instead of noting that one “off” note that makes the piece dynamic, and not just a static rhythm. This last can be done through the CZF method.

After the PDS is made, several major frequency bands are distinguished, of which the Very Low Frequency (VLF), the Low Frequency (LF) and the High Frequency (HF) are the major ones. These frequency bands have been associated with the functioning of the Sympathetic Nervous System (SNS): VLF, the Baroreceptor system: LF and the Para Sympathetic Nervous System (PSNS): HF. McCraty has based his emotional grid on the functioning of these nervous systems.

Because of the possibilities of the CZF measuring method, more information is taken from the HRV. This information can than be investigated to see if it correlates with for instance a kidney, spleen, liver, etc. disfunction. We can start to investigate if the stimulation of one organ function will result in a change in HRV. This can only be done through the CZF method, and not the traditional FFT.

It has been demonstrated that our HRV is comprised of several factors originating in the body. This information is than the foundation for the development of “emotions” which will later on be transformed into feelings and thinking. Thus an anxious person, with a certain cortisol expression from his kidney glands, will have a certain HRV, as can be measured through the CZF method. This will result in the feeling of being “anxious”. We can even question where the memory of a previous episode of anxiousness is stored; is it in the brian, or in a certain pattern of the kidney glands. This non-locality of information is what Conte has investigated with the quantum foundations of our thinking. Thus it would be interesting to redo the experiments of McCraty with the CZF method and than elaborate on them to see if specific emotions show specific frequencies on the PSD. 

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donderdag 9 augustus 2012

Neuropsychological Foundations of Conscious Experience by Jason Brown, A Review by Sander Kales, D.O.

The sequence in this review is the same as the Microgenetic and Morphodynamic process described by Brown and his own Ontogenesis. It will start with the philosophy because it will give us a general starting point. From there we start in the physical Outside world with Pathology, and the brain processes, both in functioning and in growth, while Brown’s work has been as a neurologist with patients who have brain damage. Working with patients always requires a psychological insight, so this is our next phase in discussing this book while it corresponds with the world Inside.  This review will end with a view on time, so more on a Quantum level.

The brilliance of Brown for me lay in the bringing together of the Outside World (Neurology: processes in the brains and growth of the Brain) and the Inside World (Psychology). Brown is a great analyst, also concerning his own experiences, as in dreams. The bringing together shows up in that he realized that the processes that can be seen in Morphogenesis, or on a cellular (Body) level, also can be seen on a psychological, or Mind level. So we start off with his Philosophical views, or to state in his terms: “The Whole”.

Philosophy, Microgenesis and Process Theory 
As William James states: “Philosophy is more a matter of passionate vision than logic, the logic coming afterwards to justify the vision” the same goes for his development of Microgenesis Theory. 
An important insight of Brown, he describes as follows: “The shift from process to substance theory was one from continuities, transitions and internal relations to logical solids, discrete brain areas or components. 
For substance theory, being is the source of becoming. For process theory becoming is the source of being. For microgenesis and process theory, the mental evolves with the physical by an expansion of proto-psychic features”.  In other words, how do things or thoughts come about and not what are they.
So in this book, the focus is continually on process/ development/ growth, and not on, can we pinpoint this function to this structure: “The whole is not constructed from the parts but is antecedent to them”. Now we will see where the development of this theory started.

Brown describes a couple of cases in this book. For the reader this gives a daily reality to the theory. That is the reason to start from here, and we can see that the diagnostic skills of Brown are to be reckoned with. “A patient of mine with a retrograde amnesia did not recall being in an accident in which his fiancé was killed, nor did he show an affective reaction when he was repeatedly told what happened. As recall improved, he developed nightmares for some days prior to the return of sufficient recall to ask what occurred in the accident, at which point, when told, he was overcome with grief. The nightmares, however, were not directly about the accident; they reflected the anxiety that forecasted the recall. The symptom is not a bizarre occurrence unrelated to the normal, but reveals preliminary or “pre-processing” phases in the elaboration of normal function”. 

So early on Brown realised that he should look at the process of conscious experience and not on the fragments or presentations. “In this respect the symptoms of brain pathology are fragments of unconscious phases that are usually inaccessible to waking cognition. One of Freud’s more important insights was the recognition that psycho-pathological symptoms are not additions but uncoverings”. 

Brain Processes
He than sets about to look at the brain processes that take place, from a Process Theory viewpoint. “The activation of neurons by external stimuli does not mean neurons are responsible for the perception of those stimuli. Levitan (2006) gives the example of regions in left hemisphere shown to be active in the perception of musical structure that are also active in the perception of sign language”. He than states that it is not just at the neurons but also in the localisation in left and right hemispheres and Antero Posterior within a hemisphere. 
“Some writers have looked at the shift from the simultaneity of spatial cognition to the successivity of the temporal in speech or action. This has also been framed in terms of a shift from the (spatial) right to the (temporal) left hemisphere (e.g. Teuber, 1958) or from posterior to anterior brain processes in language”.
Also on the brain stem level he sees a phylontogenetic development, where a tremor is basic and voluntary movements develop on top of it. “A simpler observation is that a voluntary movement such as lifting the finger develops at the cyclical peaks of normal resting “tremor”. This indicates that unconscious rhythms or oscillators underlie voluntary action, as in the respiratory timing that frames an utterance”. 

So we see here that Brown focuses on process rather than on functions:
“Most imaging studies localize functions rather than display mental or neural process. This is no doubt true for most, if not all, studies that purport to map brain areas to cognitive function. 
A single process is iterated at multiple phases rather than multiple processes acting at different loci”. Here we see a clear break with current popular research where fMRI studies appear daily stating that fear is amygdala, decisions are Pre Frontal Cortex, etc.
A brain state is that configuration of neuronal activity generating a mental state. A mental state is a virtual duration that corresponds with an epoch of brain activity. Identification of the mental state with the brain state does not apply just to its vegetative core but to every phase in transition. 
So we see a shift from Brain State towards Mental State.

Interesting here is that Phylontogenetic older information comes from organs and Autonomic Nervous System (Vegetative system) “The transition from limbic to neocortical formation is the forward direction of microgenesis”. This information arrives at the brain. Then it continues towards Limbic System and ends at the Cortex, traversing the same path as the Phylontogeny.

Corner (1) also describes the phylontogenetic development of sleep. The REM is the basic activity level of nerves, which develop every moment. On top you have successive states (Sleep stages 1-4 through Dreams to a Waking state).

From this view we can understand his remark: “The preponderant opinion is that the precursors of consciousness do not extend “all the way down” but that consciousness arises at some level of neuronal complexity”. So at some point in this traversing the Phylontogeny consciousness arises.

Let us have a closer look at this Phylontogenetic development. It was a realisation from Brown that brain mental processes show the same pattern as Morphogenetic development. This viewpoint that Phylontogeny takes place on different levels and not, like Darwin stated, on the level of the human being, is supported by several authors: Kupiec (2), Corner (1). But also in the analysis of the development of cities, sand dunes, etc. “Microgenesis exhibits and extends to cognition the pattern of growth in morphogenesis”. 

Brown sees this pattern also on the smallest level: the cell: “Mitosis is the model of individuation as complexity grows from within. Some have argued that the tension between the active and the passive in cognition traces back to the biology of approach and avoidance in unicellular organisms (Schneirla, 1965), which evolves to grasping and withdrawal, extro- and introversion, and even aggressive and dependent personality types”. 

What does this Morphogenetic process entail? It is a balance between live and death: Growth and Apoptosis. Also on a genetic level this takes place (Kupiec(2)). Again we see the underlying process. “In a mature cognition, the endogenous constraints of the just-prior act are comparable to genetic influences on growth, while the exogenous constraints of the external world (sense-data) are comparable to the effects of the micro-environment on gene expression. Polygenes and timing mechanisms limit the degrees of freedom in the growth process, increasing the likelihood of a given outcome”. 

The development can be seen as the growth of the tree, where in the trunk you see all the growth circles. One is on top of the other. “The similarity of the process of growth to that of cognition becomes clear when we consider morphogenesis not as an open end linear succession but as a recurrent pattern, in which new form is laid down over antecedent structure. This shift in perspective helps us to see how the same process that is responsible for the growth of the brain continues as the process that is responsible for behaviour”. 

Interesting is that a Process Theory like Microgenesis Theory introduces time as a new component, from 3D towards 4D (Heterochrony is the rate or timing of this process). 
As Beloussov (3) describes: “to understand a landscape we must not just understand the structures that are there, but also its history in order to analyse it”. So Brown states: “Behaviour is four-dimensional morphology or structure over time. Memory is the obvious link from structure to function. Early in development, the persistence (recurrence) of brain structure is a kind of organic or “physical” memory. The “permanence” of a learned or remembered item is the structural aspect of thought”.

In Morphogenesis it is not just time that is important, but also the axles. Grid patterns are laid down first, before further development. This can be compared to the development of roads before a city develops. “The development that goes from archaic to recent in evolutionary structure corresponds with the transition from axial to distal innervation, from bodily space to the external world, from symmetry to asymmetry, from low frequency kinetic rhythms that mediate inter alia walking and respiration, to higher frequency oscillators or harmonics that mediate selective kinetic patterns such as those involved in prosody or asymmetric limb movement”.

Asymmetry is a new field of study, which Quantum Physicists started and which now comes to the Biological Sciences. More and more literature appears on Left Right asymmetry in the body.“The dissolution of the self and the inter-penetration with the other accompany a retreat from asymmetric and deliberate limb movements to automatic and symmetrical axial motility. Focal voluntary actions are replaced by rhythmic impulses”. The body strives for symmetry while it is not symmetrical. A symmetrical face is seen as more beautiful.

Fractal development, like the Mandelbroth set, is well known in the Biological science. Brown: “Growth does not lay down a fixed anatomy, but rather morphology is the behaviour of a developing brain. Microgenesis entails a single fractal-like process. The remedy is a concept of brain and psyche in terms of fields or fractals instead of cities and highways”.

There are two morphogenetic processes which shape growth:
  • parcellation or pruning (The equivalent of parcellation in growth, or surround inhibition in physiology, is the whole-to-part or context-to-item transformation in cognition) 
  • neoteny lay down “force lines” that become the process of cognition. It is a selective retardation or prolongation of a juvenile stage that can be a springboard of evolutionary growth.

Brown’s personal Development
As we have seen that Brown’s development as a Neurologist was getting to know first the structures in order to analyse the development. This same approach he took to analysing Psychology (Psychoanalysis) and also his own dreams. So here we see an analysis of the inside world. His personal experience with dreams is also a factor in the development of Microgenesis Theory.
I awoke and could only remember the first two lines of what seemed to be a wonderful poem. The lines were: 
Run thee a poem in thy time ‘ 
Pay not a fare to the rhyme or the meter. 
However brief, this was not at all a poem I could have written awake. 

The interpretation of the dream tells us more about the dreamer than the content that is interpreted.  We study the reality given in mind, not a reality mind can perfectly measure.

The difference between Brown and colleague’s is that he approached it from a Process and Morphogenetic point of view. “Consciousness is always preceded by, and enfolds, an unconscious transition, so that an attenuated mental state could exist without realizing consciousness. For most psychologists it is the other way around, i.e. experience first passes through consciousness in order to be revived in the unconscious”. Let us look more closely at this Inside World:

World Outside – World Inside
Here he comes up with a good example: “Consider brain and perception like a celluloid film and moving picture. The celluloid is felt to be more real than the movie because it does not represent something other than what it is, whereas events in the film have no actual correlates. We might think a documentary is more real than an ordinary film, but we are still looking at images, not “real” objects. Since all films (and objects) are images, it is not the imaginary or perceptual quality that counts for the unreality. There is a presumption that some mental objects – ideas more than dreams, words more than ideas, objects more than words – are more real than others. Independent of whether or not the self is illusory. We refer to the mental objects as a footprint. We are in error, we should say, it has the shape of a footprint”.

“To exist and to be real are different states of affairs.  When psychic experience does not conform to the physical world, survival is in danger”. 

In this dialogue between Inside and Outside world, Brown states that a Self develops: “The sense of causal power in the infant who reaches for a rubber ball is perhaps no more than the behaviour of a cat that reaches for a rolling ball of wool. Further individuation of self and object leads to greater autonomy and a feeling of a self opposed to inner and outer contents.”

When we look at the psychological “development” that Brown mentions, there are of course different points of view. As Brown describes a development from Core to Outside world, and states that it is unidirectional, Indian Philosophy (i.e. Swami Rama(4)) describes a movement where it is a circle coming back: from core to consciousness and back to the core. Through Self-Reflection, dream analysis we get to know our Core. In India the path also entails that one can stay in this state, and not in an outside state/ phase.
So to follow this path back inwards we start with perception, through consciousness, Ego, Dream state towards Self and finally Non Self. Again this is another point of view than Brown while he states that the movement is unidirectional (from Core towards Consciousness) and ends in the Non-Self (Outside World). 

So the dream state, like in Psychoanalysis is a chance to see the unconscious processes. It is a natural state. But:“A delusion is intermediate between the pathological symptom with its delimited interpretation and the dream as a natural phenomenon relating to one’s life. The thin line that separates the passive intention of dream from the active volition of agency is a point in the passage of internal to external mind”. This means that it is the shaping of the outside world that determines if we experience a dream state or a delusion. In the dream there is no outside perception and we experience the dream in an awake state. In a delusion there is outside perception but we experience it in a dream state.

Brown continues: “Given the relation between inner speech, hallucination and perception, the relative depth of realization in perception and action, or the dominant segment of the actualization, determines whether a verbal image is apprehended as voluntary, passive (hallucination), or mind-independent (perception)”. 

The next stage which we encounter on our path inside, is the ego.

Ego: I and me
“The distinction is embodied in the unconscious and timeless self of the “me”, and the conditional or temporal self of the “I”, one constant and authentic, another transient and adaptive. In the child the “me” precedes the ‘I’. The agent – the “I“ – is inferred from the activity of thinking. The state is not divisible into a self, an object and a direction. Without the object, there is no self. The “I” is always “I am (think, want, etc.)”. The ‘’I’’ does not exist without a verb or relation.” 
Here it is a matter of how we define the “I” and the “me”. Like the Ipad, or Iphone, one can also take the I as the Core and the “me” as the outward development. Interesting here is that in the Indian tradition of Vedanta the whole meditation is on “Who am I” (Nisargadata Maharash(5)). Also Eckhart Tolle (6) describes, while in deep depression, the realisation that I want to kill myself, made him realise the “I” is different from the “myself”. Is it Ego and Self? Again there are many viewpoints possible on this.

Fact remains that more and more research shows that most of our behaviour is an Inside Out development. Core drives and experiences determine our perception. For instance, when holding a heavy object we experience a conversation as heavier, than when holding a light object.  
So: “A person can either mistakenly believe his act is intentional, or unknowingly act intentionally”.

Next phase on our way to the Core is the Self:

The Self
“The relation of the self to inner objects is introspection or reflection. The relation of the self to outer objects is exteroception or perception. In perceiving an object, the self, indeed the entire perception, is generated with the object”. 

Again we encounter here the matter of defining Self. “There are two categories of the self, a deep core or unconscious self aligned with values, implicit beliefs and character, and a liminal, conscious or empirical self that adapts to momentary needs and future expectations.
Core self and its drive-representations, which are then derived to an empirical self and its conceptual feelings, then to images, and to objects and external space”. 

Also there is the fact of Inner Speech. “In passing to a perceptual development, inner speech dissociates from the self of agency, and actualizes in voices distinct from the patient”. 

Psychology: Drives
When we go deeper down into ourselves we arrive at, what Brown calls the Core Self. This is where the basic drives are. In the work of Stephen Porges (7) we come across the same Phylontogeny, but then for the Autonomic Nervous System. We start with Visceral sensations, which correspond with the Enteric Nervous System (Reptilian, Freeze), than up through the Sympathetic Nervous System (Mammalian, Fight/ Flight) up to the Parasympathetic Nervous System (Communication). Here we see again a “rising up” of information from deeper levels towards the surface. Again from a Process Theory point of view, the same Phylontogeny. This information reaches the Brain Stem, where for Brown his Microgenesis starts. So we could assume that it is the interoceptive experience from the body, and its memories, where the Core feelings arrive from. 
Brown:” The initial phases of the mental state arise out of an instinctual core – the inherited repertoire of drive categories - then pass through a phase of affective and experiential memories that shape conceptual feeling in the direction of perception. Instead of perception laying down memory, memory lays down perception. The transition from self to world is from contents that are memory-like to those that are perception-like, from the personal past to the impersonal present. A memory is an incomplete perception, and a perception is a memory specified to an object”. 
Also: “We come to understand that feeling is not applied to objects but develops into them.  Generally Feeling is more intense at early phases of drive and desire, less so at distal ones of object and word-production. Moreover, feeling is felt as a pressure behind or directed to the object, not in it”.

Psychology: Non-Self
At the point where we go even further down into our Mind, we come to a point where Indian Philosophy places the Non-Self. Brown names the Non-Self the experience outside oneself “The end-point of the outward-going development is non-self (other, object)”. When we get to this core, according to Indian Philosophy, this is where our convictions, and even deeper our universal feeling of connectedness, bliss, the feeling of divinity is located. Brown states:”This is where Conviction (non-self) replaces the need for choice and decision. It is closer to drive, desire and the core self, often bound up with the self-concept. The continuance of the core due to the overlap of initial phases explains the “persistence”, i.e. recurrence, of implicit beliefs and values, or character, while the rapid vanishing at the perceptual surface “clears the slate” for the next perception”.

The Trilogy that is common in Osteopathic Philosophy is that of Body – Mind – Spirit. So Spirit is the deepest level in ourselves, according to Indian and Osteopathic Philosophy. Brown: “Soul and other forms of spirit are not of mind or matter. They inhabit a nether world between the cognitive and the physical. The common belief in spirits indicates that it is not necessary to have a body (or any substrate) to infer a mind”. 

But we can see that there is not much difference in Brown’s point of view and these philosophies. “To be selfless is not to be without a self, but to revive the other in the self before it individuates. 
When such relatedness occurs with full absorption and abolition of self and a disappearance of the self, is a kind of death from which a return to life and consciousness is possible. 
To be worthy is to be selfless. Self-denial is a mode of active passivity that is the primary condition of submission. In Buddhism, as in most religions, self-denial is central. It is the timelessness of the category that inspires the belief that individuals persist after death as souls, or as ideas in god’s mind”.  

Quantum Physics
When we arrive at this core level within ourselves, the question arises if this is also on a deeper physical level. Fantappie (8)states that if we go beyond 200 Angstrom, we arrive at the Quantum level in ourselves. At this level Newtonian laws do not apply and Quantum Laws come into play. Also at this level Time is not the lineair unidirectional movement we are so familiar with.
Brown:“In organic systems the becoming of the organism is unidirectional. In basic or elementary physical entities the becoming may be reversible or isotropic. The becoming or directionality of the mental state is fundamental to its existence, its being”. 

Also on Quantum Physics and Time: “In my view, subjective time is neither particle, nor wave but in some sense both; wave-like in an actualization over the temporal extensibility of elementary physical entities or brain states, and particle-like in the modularity of the state once it actualizes”.

Time plays an important role in Microgenesis Theory, and Brown, like Bergson, studies Time from a phenomenological viewpoint. First of all there is the important fact that a becoming of consciousness takes place at a fast rate, so that we experience everything as a continuum. Brown uses the following example: “In a movie continuity requires a frequency of around 40 milliseconds per frame, which is close to the estimated duration of a mental state, thus the rate postulated for the replacement. This rate is likely governed by a pacemaker and is relatively constant. Think of the mental state as having a duration of about 50 to 100 milliseconds. The present does not have a fixed duration. James wrote of fuzzy boundaries. In meditation, the present may expand in states of confusion, it may contract”. 
Pacemakers have been identified in the brain, both in Brain Stem and in Hypothalamus, comparable to the AV and SA knot in the heart. It could be hypothesized that this pacemaker generates an electrical signal that travels through the body and returns to the Brain stem where the becoming of consciousness further advances. We have to keep in mind that information is not just transferred through electrical signals, bit also through electromagnetic fields, light, sound, etc. A new mental state thus comes about every 40-100 milliseconds.
“The acceleration and deceleration of events in pathological cases, as in the speed of a film projector, might reflect the frequency of replacement. Subjective time does not exist until the process is completed. The existence of a thing depends on the duration over which it actualizes. A tree that exists for a millisecond is not perceived at all. Sustained recurrence creates objects, novelty in the recurrence creates events. All objects are events in which change (recurrence) is more or less imperceptible”. 
“The future is not what the present moves into, it is another present that the past deposits”.

Also the origin of Time comes from symmetry. Feynman (9) also elaborates on symmetry being the origin and dissymmetry the end point. “If the Inception of the mental is simultaneous, and temporal order occurs at the conscious endpoint, simultaneity and seriality refer to earlier and later in a single epoch. Less coherent music, the less a sequence can be anticipated, the less revival is facilitated”.

Teleo Dynamics
Terence Deacon (10) describes three levels, starting with Physics to Morphodynamics and ending with Teleodynamics. This means that there is a direction giver. It is hypothesized by several authors (Lazlo(11), Haisch(12), Sheldrake(13), Fantappie(8)) that  on a Quantum level time is reversible and thus can inform the past. Brown states: “In a process approach, objects are states of flux that only appear to be solids. The flux is not random or chaotic but has a direction. In the mind, possibility is the ground of freedom and fact is the final stage of belief. In mind, the progression is from potential to actual, in the world, from cause to effect. A transition from the voluntary to the involuntary in the passage outward to objects”. 

To conclude: “That a model of the real should grow out of fantasy, that objects are recognized before they are consciously perceived, that the world is an extension of the mind, that succession in time is generated out of simultaneity”. 
In this book we see that Brown has done an excellent job on bringing the Outside World and the Inside World together. The dichotomy of Descartes is slowly fading away, and we are becoming more and more a unity, and can experience ourselves as a whole. Also the difference between our perception of the other and ourselves can significantly change. In this sense we can see the world more and more as ourselves.

  1. Michael Corner, Sleep Evolution, 2011, 
  2. Jean Jacques Kupiec, The origin of Individuals, World Scientific, New Jersey, 2009
  3. Lev Beloussov, The dynamic architecture of a developing organism, Kluwer, Dordrecht, 1998
  4. Swami Rama, Science of breath, Himalayan Institute, Pennsylvania, 1979
  5. Nisargadata Maharesh, Who am I, The Acorn Press, 1973
  6. Eckhart Tolle, De nieuwe aarde, Ankh Hermes, 2005
  7. Stephen Porges, The Polyvagal perspective, Biological Psychology, 2006 
  8. Ulisse Di Corpo, Syntropy (Luigi Fantappie), 1996
  9. Lawrence Krauss, Quantum man, Richard Feynmann’s life in science, Kindle, 2011
  10. Terence Deacon, The Remergence of Emergence, Chapter 9,
  11. Ervin Lazlo, Science and the akashic field, Inner Traditions, Vermont, 2004
  12. Bernard Haisch, The God Theory, Weiser Books, San Fransisco, 2006
  13. Rupert Sheldrake, The presence of the past, Park Street Press, Vermont, 1988

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