Here’s a common frustration for therapists of all kinds (and their clients.) After a session, whether it’s massage, chiropractic, a Feldenkrais movement lesson, Rolfing, osteopathy, whatever, the client feels great, as if there has been a major progress. Pain is reduced, coordination improves, movement feels easier, lighter, more efficient. And then, two days later, things are pretty much back to normal. Of course this doesn't always happen, but I'm sure it is a familiar situation for many therapists. I know one (ex) chiropractor who called it the parking lot effect, because his clients looked great when they left his table but were already degenerating by the time they reached their cars. I’ve always been very curious about this and have wondered why. Although I don’t have any definite answers, perhaps this has something to do with what neuroscientist Alvaro Pascal Leon called the Monday Effect.
The Monday effect
Pascal used transcranial magnetic stimulation (TMS) to look at the brains of subjects in the process of learning to read Braille. The subjects studied Braille five days a week, two hours a day. The TMS revealed that the parts of the brain devoted to sensing the reading fingers grew bigger than the parts for sensing the non-reading fingers. Further, these parts, called maps, got even bigger as the students’ reading got faster. This makes sense - if you want better sensation in your fingers, you might want more brain area devoted to the task of sensing. The interesting part was the pattern of progress and regression in map growth.
Pascal noticed that map growth regressed during each weekend when practice did not occur. Specifically, the maps he measured on Friday showed dramatic expansion as a result of five days of practice, but by Monday the maps were returning to their baseline size. This happened for about six months, then the pattern changed. Now the Friday maps grew slower, and the weekend regressions were less, so that the Monday maps were starting to grow. The growth of the Monday maps leveled off at ten months. At this point the students took two months off. When they returned their maps suffered no regression - their size was unchanged.
The stages of learning
The fact that the Braille skills eventually became permanent after some threshold of practice is consistent with conventional motor learning theory, which observes that the process of learning a physical skill proceeds in stages. First, in what is called the cognitive stage, performance of the skill requires great mental effort and conscious attention. After enough practice, performance of the skill eventually becomes “automatic”, it requires almost no conscious attention or effort at all. Imagine the first time you drove a car. You really had to pay attention to exactly what you were doing – where to put the right foot, the left foot, etc. After a while, these skills become automatic, freeing your conscious brain to perform other activities while driving, such as talking on a cell phone, enjoying a delicious beverage, texting, or offering helpful suggestions to other drivers with appropriate hand gestures. And, not only does the skill become automatic, it becomes relatively permanent, i.e. not something you will ever forget how to do, like riding a bike.
So the fact that Pascal’s Braille students eventually reached a larger map size that was stable during layoffs is not surprising. But why did the changes evaporate each weekend for the first six months? Why was there a Monday effect? Pascal explained the results in the following way. The great initial improvements that occurred by Friday were the result of strengthening existing neuronal connections in the brain, as opposed to growing new connections. This process is quick but temporary. The improvements that remained on Mondays were long-term changes that required the formation of new neuronal linkages. This process is more time consuming but has greater permanence. The pattern should be easy to recognize because we have all experienced numerous examples in real life.
When we cram for a test, we can quickly accumulate great amounts of knowledge sufficient to pass the test, but the information will soon be forgotten. The maps were only temporary. On the other hand, any skill that we develop to the expert level, such as fluency in a language, or mastery of an instrument or sport will always be there to some extent. Even after years of neglect, the foundation will remain, and the prior level of skill can be recovered fairly easily with just a little brushing up. The maps are fairly permanent.
So what does this have to do with therapy?
As readers of this blog know, I believe that many problems with chronic pain or physical performance are related to problems with the body maps. For example, as seen above, good coordination or movement skill depends on good body maps. Moving without pain and accurately sensing what is going on in the body is also very much of a skill. In fact, research shows that confusion in the brain’s sensory maps can lead to pain and that correcting such confusion can reduce pain.
Based on these ideas, I believe that a significant portion of the benefit seen in most therapies, whether movement oriented or hands on, is a result of making beneficial changes in the maps. (If you are lost at this point maybe it would help to click on the links above for some background.) In other words, if you feel better after a massage session or a yoga class, one important reason is that your maps have been altered for the better. If you feel back to normal a few days later, perhaps this is akin to the Monday effect – the map changes were only temporary. So does this mean you need to do some form of therapy every day for six months to see a lasting benefit? I think the answer depends on whether your improvement requires learning totally new skills or just brushing up on or modifying old ones. I’ll use two opposite examples from either end of the spectrum to explain.
Brushing up versus starting over
Imagine someone who sustains a major injury to their body such as an amputation, or broken bone, or major soft tissue scar that substantially changes the structure of the body and makes certain old movement patterns simply impossible. It is obvious that this person needs to learn some new movement skills from scratch. This means building new maps, and this takes time and effort comparable to learning a new language or instrument. We can expect that the rehab process may take a long time, and might involve many set backs or Monday effects on the way.
On the other hand, imagine a healthy and athletic person who has developed some back pain following recovery from a sprained ankle. Perhaps the back pain was caused by some faulty movement or sensory habits (sensory motor amnesia) that developed during the process of protecting the ankle while it was healing. Maybe all that he needs is a reminder of the old healthy sensory motor patterns that he used successfully for years, but then put on hold for a month or two while the ankle healed. In other words, this person already has the maps needed for a pain free back, he just needs to brush up on them a little. For this person, it is not unreasonable to hope that he could be cured with just one movement or massage session, or any other stimulus that reminds him of the capabilities of his old self. He will not necessarily have a Monday effect, because the maps are already there.
Of course, most clients fall somewhere in between these two extremes. We might expect that any one person will have a variety of issues, some of which can be resolved with a little brushing up, others that will require some new skill building. Most people who do not regularly move their bodies through a full range of options will get a little rusty with certain sensory/movement skills. These smudged maps might be easily clarified with appropriate movement or bodywork. Improving these rusty spots is like grabbing some low hanging fruit – it accounts for the easy successes that have permanent effects.
At the same time, the average person will also probably have some pain or movement defects that are not so easily fixed. The bodies we live in are always changing their structure day by day – sometimes suddenly from a traumatic accident but always gradually from the aging process – muscles get weaker, bones and cartilege get rougher, discs bulge, rotator cuffs tear, connective tissue gets scarred and stiff. As I stated in an earlier post, it is very possible and even likely that these structural problems will not result in pain, but this will depend on the brain’s ability to start sensing and moving the altered body parts in at least slightly different ways. In other words, a changing body requires changes and updates to existing movement and sensory skills. Hopefully the body changes happen gradually, and you make frequent minor updates. But if the brain maps don’t keep up with the body structure for whatever reason, either because of a long layoff from skilled movement and sensation, or because of a traumatic injury, you might end up with a major disconnect between body and brain that requires some real work to be cured. For example if you haven’t thrown a baseball for twenty years, you probably won’t find your old technique useful or safe anymore. The old maps for throwing are now useless – you need to build a whole new set of throwing maps before you can throw safely again.
So what can we do with this information? First, prevent map confusion – keep moving so that your brain is always up to date on how to move and sense the ever-changing body. Second, brush up on old skills. This is the low hanging fruit. Maybe you can get some quick and easy benefits by remembering how to use some maps that are already in place. Some good options for curing sensory motor amnesia might be the Feldenkrais Method, Z-Health, martial arts, yoga or some bodywork. Third, if these things don’t work, build some new maps. This might take some time and effort, in the form of frequent movement practice like one of the above or a daily sensory practice like meditation or just mindfulness.
Fourth, be aware of what is perhaps the most challenging problem in regard to chronic pain and the remapping process. I have been talking about how to build new maps and skills, but not about how to dismantle old maps. What if you spend so much time moving and sensing in a painful way that the painful pattern becomes an ingrained habit? The bad habit now has its own well-established map in long-term storage. The painful pattern will compete with any new healthier skills you try to substitute. The problem now is not just one of how to learn new skills, it is how to unlearn old ones. And that’s a big problem that requires real patience. Perhaps the subject of a different post.