Interoception and Personal Training- Part II

Interoception and personal training- Part II

Last month, I discussed proprioception as a useful training tool. If you missed that blog, it can be found here: Today, I am hoping to shed some light on what exactly interoception means and how it relates to the world of movement. 

Interoception is commonly defined as the sense of the physiologic condition of the body (1). The literature describes this as the ability to sense functions such as breath, heartbeat, and feelings related to thirst and hunger (2); it can also be thought of as the ability to recognize the body’s subtle cues, including conscious awareness, emotions, and behavior (1). From a training perspective, interoception can be related to the experience of a movement (what do you feel is actually happening to perform the exercise), and the emotional response to a movement, particularly if the movement has caused pain in the past. Further, if you work with individuals that frequently suffer from bouts of anxiety, interoception can be an extremely valuable tool, particularly as it relates to breath (3). Breathing changes for a variety of reasons, including when a threat is perceived and/or when a person begins to feel anxious. (A word of caution- sometimes breath work can invoke a sense of anxiety. Often when I am working with someone that experiences anxiety regularly, we work on other interoceptive markers first and save breathing for later sessions, once a sense of trust has been established). While interoception is related to body awareness, it differs from proprioception and should be addressed in a more subtle way.

There is an emphasis currently in the movement world on external focus. Research consistently shows directing a movement externally (“when you jump, push the floor away from you”) is more  effective at reducing movement variability and improving economy than asking someone to perform a movement with an internal focus (“use your legs to generate force when you jump”) (4). This might happen because internal focus interferes with the body’s natural control processes, ultimately interfering with motor learning (5). This makes sense, especially when you consider proprioception and interoception are so closely related. External cueing uses outside stimulation and awareness to accomplish a motor task (6). Internally focused cues will lead to an increase in awareness of self, or interoception. As soon as human beings begin focusing on what they are experiencing, emotions get in the way, which definitely conflicts with motor outcomes (“am I using my legs the way I am supposed to? I’m not feeling my hamstrings. Is that okay?” rather than, “just keep pushing the floor away”). However, sometimes the goal of a specific exercise or movement is to help a client draw connections. For instance, if I am trying to help someone understand dow the feet can affect the hips, I might place the person in a a 1/2 kneeling position with the front knee over the front heel. From there, I might have the person press down into the floor with different parts of the foot and observe how that changes what he experiences in the hip. Asking the person to verbalize what he experiences by pressing into different parts of the foot has worked well for me when I want to re-create that sensation in a more challenging position, such as standing or single leg stance. While I am still using an externally focused cue (“press into the floor with the inner heel, middle heel, and then outer heel), I am asking the person to internally focus on how the body responds. 

Interoception can also be a valuable tool when working with individuals with chronic low back pain. It is not unusual for individuals with chronic low back pain to desire a supervised exercise program after going through physical therapy. While it is important to not dwell on the pain, it is also important to not ignore the pain (otherwise, how do you know if you made things worse?). Mehling, et.al, point out that somatic therapies, such as Feldenkrais and yoga, appear to be successful modes of mindfully based movement therapies for people with chronic low back pain. One of the rationales for the success of these programs is the increase in interoceptive awareness that occurs with this type of training. “Notice where you are feeling any excess tension. Can you let that go and perform the movement,” or, “observe your breath. First, make sure you are always breathing. Then, observe whether you inhale or exhale while moving your arm,” are examples of cues that are frequently given during these types of exercise modalities. While it is possible that this type of self awareness plays a role in reducing nociception, it is impossible to control for all of the factors that go into a person experiencing a reduction in long term pain. What we do know, and what can be used practically in a training setting, is these types of cues definitely don’t hurt. I have worked with many individuals with chronic low back pain over the years. For clients that are open to it, I frequently borrow from the Feldenkrais world and begin with them observing how they feel while walking at the beginning of the session. I ask them to verbalize their experience. About 30 minutes into the session, I ask them to walk again and tell me how they feel. This does several things. If the client has fear surrounding movement, it teaches movement can be safe to perform, reducing a sense of threat. It forces the client to observe how he moves when he walks and allows the individual an opportunity to witness movement can change. You can do this with any movement (walking is the one I use most frequently, though I have done this with lifting the arm, squatting, raising the leg, balancing… You get the idea). It brings people into the here and now and, in my opinion, gives them a sense of autonomy. I always tell people if you can achieve a sense of lightness and integration in the studio, you can achieve it while doing anything. It’s just figuring out what tends to hold you back (breath, excess tension, anxiety, etc.). 

Too much of anything, of course, isn’t necessarily a good thing, and this appears to be true with both mobility and interoception. In fact, there seems to be a link between a heightened sense of interoception, hyper-mobility, and anxiety (7). And, despite what I wrote earlier about how improving interoception can reduce anxiety, in the case of the hyper-mobile individual, the heightened sense of self, including hyper awareness of heart beat and breath, can lead to anxiety. (Interestingly, those with hyper-mobility manifest larger amygdala volumes. The amygdala is involved with emotional responses, including fear perception, so again, having more might not necessarily be better). This is something to be aware of if you work with dancers, gymnasts, or yogis. In my experience, this group does well with external cueing. While I still do a little bit of self observation with walking or squatting, I ask for less feedback about how the body is responding. Otherwise, there can be a fixation on, “am I doing this right? Am I feeling what I am supposed to be feeling?” There is no right or wrong with movement, and I think it is important to eliminate as much over analyzing as possible.

Finally, both proprioception and interoception appear to decrease with age (2). The research on this is fairly limited, but one might argue that perhaps the reason our sense of body position and sense of self decreases with age is because most of us move a little less and pay a little less attention as we get older to these sorts of things. Our every day life doesn’t demand that we know whether we can jump over a large rock (proprioceptive), for example, or whether our jaw is clenched during our time at the computer (interoceptive). We lose track of our physical selves as we age because, as with everything else, atrophy occurs if we don’t use these senses, until eventually, it becomes difficult to get them back. Many of my clients are over the age of 50 and one of the things I hear over and over again is much they appreciate the increased body awareness that comes with training. If the body is used in a mindful way and open monitoring is practiced,* one could logically conclude interoception and proprioception wouldn’t be doomed to a steady decline.

Interoception is one of the key concepts in understanding the effects the mind has on the body and vice versa. Implementing open monitoring techniques, such as asking clients to observe what they are feeling, can be valuable tools in improving the mind body connection. The final idea I will leave you with is everyone deals with a threat response differently. Many times, people use muscular tension when a threat is perceived. This shows up often in the gym when you ask someone to do something that is challenging, either mentally or physically. If you begin to ask the client to draw attention to what’s clenching unnecessarily, let that go, and return to the breath, the client might begin to notice when these tension patterns show up during the day. Empowering someone with the knowledge of how the body works when a threat is perceived and changing the physiological reaction and pattern can have far reaching benefits for a person’s health and well-being.

Yours in health and wellness,
Jenn

*Open monitoring is a frequently used meditation technique. It simply means to observe without judgement. 
**Aaron Swanson and Seth Oberst have both written excellent blogs on this topic. Links are below.
Aaron’s: http://www.aaronswansonpt.com/coaching-cueing-part-4-internal-verbal-cues/
Seth’s: http://www.sethoberst.com/blog/neuroception-and-the-hierarchy-of-needs

References:
1. Mehling, W.E., Daubenmier, J., Price, C.J., Acree, M., Bartmess, E., & Stewart, A.L., (2013). Self-reported interoceptive awareness in primary care patients with past or current low back pain. Journal of Pain Research, 6, 403-418.
2. Khalsa, S.S., Rudrauf, D., & Tranel, D., (2009). Interoceptive awareness declines with age. Psychophysiology, 46(6), 1130-1136.
3. Paulus, M.P., (2013). The breathing conundrum-interoceptive sensitivity and anxiety. Depress Anxiety, 30(4), 315-320.
4. Zachry, T., Wulf, G., Mercer, J., & Bezodis, N., (2005). Increased movement accuracy and reduced EMG activity as the result of adopting and external focus of attention. Brain Research Bulletin, 67(4), 304-309.  
5. Peh, S.Y-C., Chow, J.Y., & Davids, K., (2011). Focus of attention and its impact on movement behaviour. Journal of Science and Medicine in Sport, 70-78.
6. Garfinkle, S.N., & Critchley, H.D., (2012). Interoception, emotion and brain: new insights link internal physiology to social behaviour. Social Cognitive and Affective Neuroscience 8(3), 231-234. 
7. Mallorqui-Bague, N., Garfinkle, S.N., & Critchlet, H.D., (2014). Neuroimaging and psychophysiological investigation of the link between anxiety, enhanced affective reactivity and interception in people with joint hypermobility. Frontiers in Psychology, 5, 1-24.