Cognition & Injury Rehabilitation

What are the Implications for Injury Rehabilitation when Looking Through the Lens of an

Enactive Approach to Cognition and Embodied and Situated Views of the Mind?

This essay considers theories grounded in cognitive science to question implications for injury rehabilitation, focusing on enactive, embodied and situated views and their emphasis on the active role of the mind and body in dynamic engagement with the environment. Furthermore, the paper discusses traditional dualistic views held in current healthcare models and their implications for dancer and non-dancer populations.

The enactive view suggests cognition is deeply individualized, shaped by prior experiences (priors) and interactions, encouraging a long-term perspective on well- being (Di Paolo, 2009, Froese & Ziemke, 2009). Enactive theory draws on concepts such as perception action loops (Gibson, 2014), emphasizing the reciprocal relationship between an organism’s perception and its actions on the world. Embodied cognition suggests that the body is not only a passive vessel for the brain but integral to cognitive processing.

Sensorimotor experiences, perception and action are seen as fundamental to cognition (Varela et al,. 2017). Situated cognition processes are inherently tied to the context or situation in which they occur (Clancey, 1997). The environment is an essential aspect, influencing and being influenced by cognitive activities. Shomaker et al. (2022) state that where you learned or experienced something can impact memory recall. Adopting the enactive approach to cognition and embodied, situated views of the mind in injury rehabilitation shifts paradigms towards more person centered, holistic and dynamic understanding of individuals. It acknowledges the complexity of human experience, promoting interventions that address the interconnected aspects of cognition, emotion, and physicality for a more comprehensive and effective recovery process.

To start, injury has been reported among dancers to be at a lifetime incidence of 90% (Claus & MacDonald, 2017) and annual incidence of 76% (Ekegren & Quested, 2014). The current biomedical model for injury treatment is problematic for many reasons, the most common being an inaccurate endorsement of linear relationships between noxious stimuli and pain. Noxious stimuli in dancers could relate to actions or conditions that cause strain, stress or injury to muscles, joints or other tissues, leading to pain. For instance: stress on the knees from frequent jumping. However, Melzack (2013) states that the reality is highly variable as individual thresholds and perceptions differ. Tolerable discomfort for one dancer could prove to be a significant issue for another. Biomedical models are dualistic, pain is considered either somatic or psychogenic (Arnaudo, 2017) and is reductionistic, minimizing the role that psychological and environmental factors play in recovery (Dansie, 2013). The diversity of the lived pain experience underscores the importance of personalized injury management strategies tailored to each dancer’s individual experience and needs.

The biopsychosocial (BPS) model as coined by Engel (1977) contrasts the biomedical model as it takes a more holistic approach, recognizing a combination of biological, psychological and social factors play significant roles in human function. In practice however, the wide range of interpretations, applications and deviations from the model mean it falls short of integral as the boundaries are artificial and the model is often applied in a fragmented, compartmentalized manner (Mescouto, 2022). This could result in poor communication between healthcare providers, dance educators and dancers. Misdiagnosis, inappropriate treatment plans and neglect of psychological and social aspects of the dancer as an individual may lead to confusion and suboptimal care, which in turn could lead to prolonged recovery times, increased risk of reinjury and negative impact on mental and emotional health.

We will now seek strategies to improve the biomedical and BPS models through the lens of cognitive neuroscience. To build an integrated care paradigm we must recognize the problems with dualism (body and mind as separate) and reductionism (simple neural processes), considering the whole embodied person and how they interact with others and their surroundings (Varela et al., 1991). Throughout history, human minds have been compared to various machines, from water pumps to clocks, telegraphs to computers. Nevertheless, cognitive phenomenological research reveals that these metaphors fail to fully represent the complexity of living organisms and do not meet the lived experience of the individual. Indeed, these metaphors begin to break down as we move toward an embodied and situated viewpoint (Daugman, 1993 pp. 9–18). Mental processes influence external stimuli, creating an autocatalytic loop that produces cognition. This shifts our understanding of the mind from the logical computer metaphor, as attention is embodied in motor movement (Spivey & Huette, 2014).

Furthermore, frameworks grounded in ecological and enactive theory often use the 4Es theory embodied, embedded, enacted and extended (Varela et al., 1991). Together, the 4Es encompass a broad view of body, environment, active engagement and external tools as essential components of thinking and understanding. Through this view we may be better able to improve health care practice (Stillwell 2019)

We need care models that consider unique history and needs, aiming to restore and even enhance their performance capacity while simultaneously considering their holistic health, physical and mental. In the enactive view, individuals are seen as actively engaging with their environment. Implementing this view in clinical settings could encourage active participation in the patient’s rehabilitation, fostering agency and empowerment in the healing process. From my work with broad populations, ranging from professional dancers to non-dancers, chronic pain, neurological disorders and the elderly, I have witnessed remarkable results through this shift in focus from passive treatment to active methods. Dynamic nonlinear movement can lead to increased engagement. Through trying something novel, we can change narratives around injury and pain (Angel, 2018) so that the individual becomes an active agent in shaping their own recovery.

Another view from the 4Es framework, extended cognition, posits that cognitive systems can incorporate elements from the external environment (Clark and Chalmers, 1998) and are not encapsulated within the individual brain or body (Rietveld & Kiverstein, 2014). In a rehabilitation clinic, utilizing physical tools as extensions of the mind may “open up affordances” (Vaz et al., 2023 p. 3), potentially enhancing the individual's experience and altering perceptions through action. A physical interpretation of this theory could be the addition of nonstandard objects into the space and asking the patient to manipulate them through specific goals, for instance building and balancing small wooden stick structures while maintaining single leg balance as shown in Figure 2.

Figure 2. Building Balance Through Dynamic Non-Linear Movement. Note. An example of non-linear novel movement for stroke recovery. Wooden blocks are manipulated to add coordinative complexity to the single leg balance task. Image by the author © 2020, Samantha Emanuel

Task-oriented training, rooted in the constraints-based approach, benefits functional outcomes and overall health in stroke rehabilitation, compared to traditional therapy (Rensink et al., 2009). Moreover, the use of music could be considered another practical example of extended cognition and opening the field of affordances through a person’s priors. I have used music chosen by the individual as a tool in rehabilitation and observed increased motivation, enhanced cognitive functioning, and consistent motor improvement. See Oliver Sacks “A Leg to Stand On”. In 2011, Weller and Baker published a systematic literature review on the effectiveness of music therapy (MT) in people experiencing physical impairments: “Consistent positive and significant results were found in MT methods in rehabilitation of most gait parameters, and fine and gross motor functioning” (Weller & Baker 2011, p.1). Contrast this to standard physiotherapy sessions that generally do not use music during sessions. Music, an inexpensive and accessible intervention, needs further consideration through further research.

Mindful movement has been defined as “any movement conducted with explicit awareness of intention, attention, and all the physical and mental sensations unfolding over time.” (Russel and Tatton-Ramos, 2014, p.120). Maintaining slower, contemplative movement whilst injured could help reduce the risk of reinjury when returning to training after a prolonged recovery period. Mindful movement practices, grounded in embodied and enactive perspectives can play a crucial role in recovery as they promote positive psychological states, enhancing resilience and emotional regulation (Todd et al., 2012). Current physiotherapy models tend to focus only on the injured body part, neglecting the complexity of the whole organism. A whole body, complex coordination-based practice adapted to each person, could help maintain health during time away from class. Variable, polyrhythmic, and polycentric movement performed either physically or imagined, may be able to decrease recovery time. Qualitative analysis of injured athletes concluded implementation of imagery enhanced recovery experience. It was also noted that the medical professionals responsible for athlete’s care need to understand the benefits of imagery to encourage its use (Driediger et al., 2006).

In conclusion, through existing research alongside my background as a professional dancer, patient in recovery, and healthcare worker, I have suggested the implications of both mindful movement and complex dynamic coordination in rehabilitation through the lens of ecological dynamics to be potentially beneficial to both dance and non-dance populations. Patients may be skeptical about using methods that differ from traditional biomedical models, however we can find grounding in the practical application of abstract concepts through shared understanding of the cognitive neuroscience behind the systems resulting in buy-in, enabling us to enhance their short-term recovery and build long-term resilience. This essay has explored the dynamic interplay between mind and body alongside strategies that promote ongoing cognitive and physical health. Tools for “opening up” the field of affordances and adapting to changing circumstances, become integral to the rehabilitation process. While the ecological dynamical view is by no means new, integrating these concepts into injury rehabilitation could be considered an emerging field as we recognize issues with current models of care across populations. There could be profound implications associated with a shift in focus from traditional, mechanistic perspectives towards multidisciplinary collaboration. Systematic positive change in current health care structures could be brought about by neuroscientists and dancers working alongside healthcare professionals on the ground within clinical settings.

Finally, more research into complex movement patterns, using music, and additionally outdoor environments (Ryan, 2010) within rehabilitation frameworks is needed.

References

Angel, S. (2018). Movement perceived as chores or a source of joy: A phenomenological- hermeneutic study of physical activity and health. International Journal of Qualitative Studies on Health and Well-Being, 13(1), 1516088. https://doi.org/10.1080/17482631.2018.1516088

Arnaudo, E. (2017). Pain and dualism: Which dualism? Journal of Evaluation in Clinical Practice, 23(5), 1081–1086. https://doi.org/10.1111/jep.12804

Clancey, W. J. (1997). Situated cognition: On human knowledge and computer representations (pp. xviii, 406). Cambridge University Press.

Clark, A., & Chalmers, D. (1998). The extended mind. analysis, 58(1), 7-19.
Claus, A. P., & MacDonald, D. A. (2017). Interpreting Pain Symptoms and how Pain

Affects Neuromuscular Control in Dancers: If I’m in Pain, How Should I Train? Journal of Dance Medicine & Science, 21(1), 5–12. https://doi.org/10.12678/1089- 313X.21.1.5

Dansie, E. J., & Turk, D. C. (2013). Assessment of patients with chronic pain. BJA: British Journal of Anaesthesia, 111(1), 19–25. https://doi.org/10.1093/bja/aet124

Daugman, J. G. (1993). Brain metaphor and brain theory. In E. L. Schwartz (Ed.), Computational neuroscience (pp. 9–18). Cambridge, MA: MIT Press.

Di Paolo, E. (2009). Extended Life. Topoi, 28(1), 9–21. https://doi.org/10.1007/s11245- 008-9042-3

Driediger, M., Hall, C., & Callow, N. (2006). Imagery use by injured athletes: A qualitative analysis. Journal of Sports Sciences, 24(3), 261–272. https://doi.org/10.1080/02640410500128221

Ekegren, C. L., Quested, R., & Brodrick, A. (2014). Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences. Journal of Science and Medicine in Sport, 17(3), 271–275. https://doi.org/10.1016/j.jsams.2013.07.013

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science (New York, N.Y.), 196(4286), 129–136. https://doi.org/10.1126/science.847460

Froese, T., & Ziemke, T. (2009). Enactive artificial intelligence: Investigating the systemic organization of life and mind. Artificial Intelligence, 173(3), 466–500. https://doi.org/10.1016/j.artint.2008.12.001

Gibson, J. J. (2014). The Ecological Approach to Visual Perception: Classic Edition. Psychology Press. https://doi.org/10.4324/9781315740218

Melzack, R., & Katz, J. (2013). Pain. WIREs Cognitive Science, 4(1), 1–15. https://doi.org/10.1002/wcs.1201

Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2022). A critical review of the biopsychosocial model of low back pain care: Time for a new approach? Disability and Rehabilitation, 44(13), 3270–3284.https://doi.org/10.1080/09638288.2020.1851783

Rensink, M., Schuurmans, M., Lindeman, E., & Hafsteinsdóttir, T. (2009). Task-oriented training in rehabilitation after stroke: Systematic review. Journal of Advanced Nursing, 65(4), 737–754. https://doi.org/10.1111/j.1365-2648.2008.04925.x

Rietveld, E., & Kiverstein, J. (2014). A Rich Landscape of Affordances. Ecological Psychology, 26(4), 325–352. https://doi.org/10.1080/10407413.2014.958035

Ryan, R. M., Weinstein, N., Bernstein, J., Brown, K. W., Mistretta, L., & Gagné, M. (2010). Vitalizing effects of being outdoors and in nature. Journal of Environmental Psychology, 30(2), 159–168. https://doi.org/10.1016/j.jenvp.2009.10.009

Schomaker, J., Baumann, V., & Ruitenberg, M. F. L. (2022). Effects of exploring a novel environment on memory across the lifespan. Scientific Reports, 12(1), 16631. https://doi.org/10.1038/s41598-022-20562-4

Spivey, M., Huette, S., & Shapiro, L. (2014). The Routledge Handbook of Embodied Cognition.

Stilwell, P., & Harman, K. (2019). An enactive approach to pain: Beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences, 18(4), 637– 665. https://doi.org/10.1007/s11097-019-09624-7

Todd, R. M., Cunningham, W. A., Anderson, A. K., & Thompson, E. (2012). Affect-biased attention as emotion regulation. Trends in Cognitive Sciences, 16(7), 365–372. https://doi.org/10.1016/j.tics.2012.06.003

Varela, F. J., Thompson, E., & Rosch, E. (2017). The Embodied Mind, revised edition: Cognitive Science and Human Experience. MIT Press.

Vaz, D. V., Stilwell, P., Coninx, S., Low, M., & Liebenson, C. (2023). Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management. Brazilian Journal of Physical Therapy, 27(5), 100554. https://doi.org/10.1016/j.bjpt.2023.100554

Weller, C. M., & Baker, F. A. (2011). The role of music therapy in physical rehabilitation: A systematic literature review. Nordic Journal of Music Therapy, 20(1), 43–61. https://doi.org/10.1080/08098131.2010.485785