

These tests quantify an individual’s ability to distinguish his own heartbeat at rest, by counting, tapping or by judging heartbeat timing relative to an external stimulus. For practical reasons, heartbeat detection tasks are measures largely utilised to assess differences among individuals regarding interoceptive accuracy and ability 23, 24, 25. Methods to measure interoceptive differences comprise the use of questionnaires and behavioural tests that either exploit natural fluctuations in internal physiological signals or manipulate organ physiology experimentally 21, 22. Detailed reviews of the interoceptive evidence are available elsewhere 2, 3, 20. In fact, the insula has been referred as a meeting point between external and internal milieus 16, 17, 18, 19. Moreover, in the anterior insula exteroceptive and interoceptive information overlap with emotional domains 11, suggesting an underlying commonality 15. pain, smell or taste, serve as body-mapped signals of the so-called peripersonal space 13, 14. Several neurobiological studies posed that the insula (INS) is a critical hub for multimodal interoceptive integration, involved in interoceptive processes, such as awareness of sensations from the body 4, but also exteroceptive elements, such as perception of pain 5, 6, taste 7, 8, 9, 10, smell 11, and touch 12. Those feelings can be modulated by different stimuli and sources, including touch, ultimately modifying the perception of the internal and external world 3. These include inputs from the physiological milieu of the body in terms of metabolic, structural and functional conditions at any given moment, a concept referred to as interoception 2. In the brain, the effect of this interaction produces different mental representations or experiences - also called feelings - of the body 1.


The interaction between the sense of touch and the body is a well recognised process that takes place at different neural levels, with different effects and mechanisms of action.
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The findings of this study provide an insight into the effects of manual therapies on brain activity and have implications for future research in the field. At T2, the response was the opposite: areas related to interoception (bilateral insula and ACC) as well as the rMFG and left striatum demonstrated significant decreased in BOLD response. At T1, a marginal increase of the BOLD response was observed in all the above-mentioned areas except the rMFG, which showed a decrease in BOLD response. The observed trend across the three time points appears uncharacteristic. The results revealed that the OMT produced a distinct and specific reduction in BOLD response in specific brain areas related to interoception, i.e., bilateral insula, ACC, left striatum and rMFG. Patients received 4 weekly sessions and fMRI was performed at enrolment (T0), immediately after the first session (T1) and at 1 month (T2).
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The present randomised placebo controlled trial explored the extent to which osteopathic manipulative treatment (OMT) affects brain activity, particularly the insula, during both an “interoceptive awareness” and “exteroceptive awareness” task in a sample of 32 right-handed adults with chronic Low Back Pain (CLBP) randomly assigned to either the OMT or sham group.
