{"id":151,"date":"2018-01-24T00:06:44","date_gmt":"2018-01-23T22:06:44","guid":{"rendered":"https:\/\/wordpress.usn.no\/214088\/?page_id=151"},"modified":"2018-01-24T00:25:17","modified_gmt":"2018-01-23T22:25:17","slug":"publiserte-artikler-2","status":"publish","type":"page","link":"https:\/\/wordpress.usn.no\/214088\/publiserte-artikler\/publiserte-artikler-2\/","title":{"rendered":"Physiotherapy Theory and Practice 2018"},"content":{"rendered":"<div id=\"a4d4fdd3-c594-4d68-9f06-b69b8b37ed56\" class=\"widget pageHeader none widget-none widget-compact-all\"><\/div>\n<div id=\"35d9ca18-265e-4501-9038-4105e95a4b7d\" class=\"widget pageBody none widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"page-body pagefulltext\">\n<div id=\"1728e801-36cd-4288-9f53-392bad29506a\" class=\"widget responsive-layout none publicationSerialHeader article-chapter-view widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"container\">\n<div class=\"row row-md gutterless \">\n<div class=\"col-md-5-12 search_container \">\n<div class=\"contents\">\n<div id=\"d46e3260-1f5c-4802-821a-28a03a699c82\" class=\"widget quickSearchWidget none search-customize-width widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"quickSearchFormContainer \">\n<form class=\"quickSearchForm \" title=\"Quick Search\" action=\"http:\/\/www.tandfonline.com\/action\/doSearch\" method=\"get\" name=\"quickSearch\">\n<div id=\"searchInSelector_chosen\" class=\"chosen-container chosen-container-single chosen-container-single-nosearch\" title=\"\">\u00a0<img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.tandfonline.com\/na101\/home\/literatum\/publisher\/tandf\/journals\/content\/iptp20\/2018\/iptp20.v034.i03\/iptp20.v034.i03\/20180104-01\/iptp20.v034.i03.cover.jpg\" alt=\"Publication Cover\" width=\"120\" height=\"156\" \/><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"col-md-7-12 serNav_container\">\n<div class=\"contents\">\n<div id=\"7730bfe1-9fca-4cf4-a6d6-2a0148105437\" class=\"widget literatumSeriesNavigation none widget-none\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none \">\n<div class=\"issueSerialNavigation journal\">\n<div class=\"info \">\n<div class=\"title-container\">\n<p><span class=\"titleHeading\">Journal<\/span><\/p>\n<h1><a href=\"http:\/\/www.tandfonline.com\/toc\/iptp20\/current\">Physiotherapy Theory and Practice <\/a><\/h1>\n<div class=\"subtitle\">\n<h1>An International Journal of Physical Therapy<\/h1>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"63f402e4-3498-4709-8d7d-ee8e69f93467\" class=\"widget responsive-layout none publicationContentHeader widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"container\">\n<div class=\"row row-md \">\n<div class=\"col-md-2-3 \">\n<div class=\"contents\">\n<div id=\"fa57727f-b942-4eb8-9ed2-ecfe11ac03f5\" class=\"widget literatumPublicationHeader none literatumPublicationTitle widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"toc-heading\"><\/div>\n<h1><span class=\"NLM_article-title hlFld-title\">Medically unexplained physical symptoms, misunderstood and wrongly treated? A semiotic perspective on chronic pain<\/span><\/h1>\n<div class=\"literatumAuthors\">\n<div class=\"publicationContentAuthors\">\n<div class=\"hlFld-ContribAuthor\"><span class=\"NLM_contrib-group\"><span class=\"contribDegrees corresponding \"><a class=\"entryAuthor\" href=\"http:\/\/www.tandfonline.com\/author\/Busvold%2C+Kari+Irene+H\">Kari Irene H. Busvold<\/a> , PT, MS &amp; <\/span><span class=\"contribDegrees \"><a class=\"entryAuthor\" href=\"http:\/\/www.tandfonline.com\/author\/Bondevik%2C+Hilde\">Hilde Bondevik<\/a> , PhD<\/span><\/span><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"5f562208-b1d5-4e5a-81c7-356431240f04\" class=\"widget responsive-layout none widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"container-fluid\">\n<div class=\"row row-md gutterless \">\n<div class=\"col-md-1-1 \">\n<div class=\"contents\">\n<div id=\"87ac5840-18fa-4a14-8eca-065b90ede3d7\" class=\"widget layout-inline-content none widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"inline-dropzone\">\n<div class=\"itemPageRangeHistory\">Pages 1-9 | Received 10 Apr 2016, Accepted 16 Mar 2017, Published online: 08 Jan 2018<\/div>\n<div class=\"itemPageRangeHistory\">Pages 1-9 | Received 10 Apr 2016, Accepted 16 Mar 2017, Published online: 08 Jan 2018<\/div>\n<div id=\"ed673666-7b5d-470e-bd33-c5c679d996cb\" class=\"widget literatumArticleToolsWidget none widget-none widget-compact-all\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none body-compact-all\">\n<div class=\"articleTools\">\n<ul class=\"linkList blockLinks separators centered\">\n<li class=\"downloadCitations\"><a href=\"http:\/\/www.tandfonline.com\/action\/showCitFormats?doi=10.1080%2F09593985.2017.1422164\">Download citation<\/a><\/li>\n<li class=\"dx-doi\"><a href=\"https:\/\/doi.org\/10.1080\/09593985.2017.1422164\">https:\/\/doi.org\/10.1080\/09593985.2017.1422164<\/a><\/li>\n<li class=\"cross-mark\"><a id=\"crossMark\" href=\"https:\/\/crossmark.crossref.org\/dialog?doi=10.1080%2F09593985.2017.1422164&amp;domain=www.tandfonline.com&amp;uri_scheme=http%3A&amp;cm_version=v2.0\"><img decoding=\"async\" src=\"http:\/\/www.tandfonline.com\/templates\/jsp\/images\/CROSSMARK_Color_horizontal.svg\" width=\"100\" \/><\/a><\/li>\n<\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"col-md-1-6 \"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"f4a74f7a-9ba2-4605-86b1-8094cb1f01de\" class=\"widget responsive-layout none publicationContentBody widget-none\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none \">\n<div class=\"container\">\n<div class=\"row row-md \">\n<div class=\"col-md-1-6 \">\n<div class=\"contents\">\n<div id=\"f15bd2de-bb18-4067-8ab9-03ea3be30bf7\" class=\"widget sectionsNavigation none widget-none close-nav\">\n<div class=\"wrapped \">\n<div class=\"widget-body body body-none \">\n<div class=\"sections-nav\">\n<p>ABSTRACT<\/p>\n<div class=\"tab-content \">\n<div class=\"tab tab-pane active\">\n<article class=\"article\">\n<div class=\"hlFld-Abstract\">\n<div class=\"abstractSection abstractInFull\">\n<p>Medically unexplained physical symptoms (MUPS) are a significant and increasing health issue in the western world. Chronic pain constitutes a considerable element of these symptoms, and the lack of a biomedical explanation of their cause challenges the clinical encounter. The limitations of biomedicine become evident in these encounters and expose the need for an expanded understanding of body and symptom. Semiotics, as an anti-dualistic meta-theory, closes the gap between natural science and the humanities and views the human body in an evolutionary and existential perspective. By focusing on interpretation and communication of signs as ongoing processes at all levels of life, biology and experience, the subjective and the measurable will be integrated. A special type of sign, the self-referential, is part of the body\u2019s internal communication. These signs may be viewed as the body\u2019s warnings to itself, for instance when the individual\u2019s consciousness, thought and action run counter to the organism\u2019s physiological and psychological needs. In a semiotic perspective, existential conditions may also activate the body\u2019s defense systems. In this context, the unexplained pain may be understood as a functional warning sign. The enhanced understanding of body and symptom that a semiotic approach calls for is relevant for the work of physiotherapists and may lead to more constructive clinical encounters with patients with unexplained chronic pain.<\/p>\n<\/div>\n<\/div>\n<div class=\"abstractKeywords\">\n<div class=\"hlFld-KeywordText\">\n<p>KEYWORDS: <a href=\"http:\/\/www.tandfonline.com\/keyword\/Medically+Unexplained+Physical+Symptoms\">Medically unexplained physical symptoms<\/a><span class=\"comma\">,\u00a0<\/span><a href=\"http:\/\/www.tandfonline.com\/keyword\/Semiotics\">semiotics<\/a><span class=\"comma\">,\u00a0<\/span><a href=\"http:\/\/www.tandfonline.com\/keyword\/Symptoms+As+Signs\">symptoms as signs<\/a><\/p>\n<div><\/div>\n<\/div>\n<\/div>\n<div class=\"hlFld-Fulltext\">\n<div id=\"S0001\" class=\"NLM_sec NLM_sec-type_intro NLM_sec_level_1\">\n<h2 id=\"_i3\" class=\"section-heading-2\">Introduction<\/h2>\n<p>Medically unexplained physical symptoms (MUPS) are a dominant group of afflictions in the western world\u2019s panorama of disease and receive significant attention in health and medical science and in the clinical setting. Chronic pain as part of the broad picture of MUPS, also including fatigue syndromes and digestive problems, has increased significantly and is considered to affect more than 15% of the world\u2019s population (Baliki and Apkarian, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2015<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span> <span class=\"NLM_year\">2015<\/span><span class=\"NLM_article-title\">Nociception, pain, negative moods and behaviour selection<\/span>. Neuron 87: <span class=\"NLM_fpage\">474<\/span>\u2013<span class=\"NLM_lpage\">491<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.neuron.2015.06.005\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=26247858\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000361145000005\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2015&amp;pages=474-491&amp;author=MN+Baliki&amp;author=AV+Apkarian&amp;title=Nociception,+pain,+negative+moods+and+behaviour+selection&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Murray and Lopez, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2013<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Murray <span class=\"NLM_given-names\">CJL<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Lopez <span class=\"NLM_given-names\">AD<\/span><\/span> <span class=\"NLM_year\">2013<\/span> <span class=\"NLM_article-title\">Measuring the global burden of disease<\/span>. New England Journal of Medicine 369: <span class=\"NLM_fpage\">448<\/span>\u2013<span class=\"NLM_lpage\">457<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0021&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1056%2FNEJMra1201534\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0021&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=23902484\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0021&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000322547400011\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2013&amp;pages=448-457&amp;author=CJL+Murray&amp;author=AD+Lopez&amp;title=Measuring+the+global+burden+of+disease&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Research suggests that 40% of all patients with chronic pain are dissatisfied with the help they receive. A review article from The Cochrane Library concludes that up to one in three medical consultations include MUPS and that studies of the effect of nonmedical treatment yield inconclusive and modest findings (van Dessel et al., <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">van Dessel <span class=\"NLM_given-names\">N<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">den Boeft <span class=\"NLM_given-names\">M<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">van der Wouden <span class=\"NLM_given-names\">JC<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Kleinst\u00e4uber <span class=\"NLM_given-names\">M<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Leone <span class=\"NLM_given-names\">SS<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Terluin <span class=\"NLM_given-names\">B<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Numans <span class=\"NLM_given-names\">ME<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">van der Horst <span class=\"NLM_given-names\">HE<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">van Marwijk <span class=\"NLM_given-names\">H<\/span><\/span> <span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults<\/span>. Cochrane Database of Systematic Reviews 11: <span class=\"NLM_fpage\">CD011142<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=CD011142&amp;author=N+van+Dessel&amp;author=M+den+Boeft&amp;author=JC+van+der+Wouden&amp;author=M+Kleinst%C3%A4uber&amp;author=SS+Leone&amp;author=B+Terluin&amp;author=ME+Numans&amp;author=HE+van+der+Horst&amp;author=H+van+Marwijk&amp;title=Non-pharmacological+interventions+for+somatoform+disorders+and+medically+unexplained+physical+symptoms+(MUPS)+in+adults&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>The use of key terms such as etiology, pathology, and diagnosis in medical practice implies that much is contingent upon identifying the cause of illness and health issues. When the cause is not identified, disease mechanisms are unclear and suffering cannot be named, doubt, and uncertainty may arise, both on the part of the patient and the therapist. The lack of explanation of the patient\u2019s symptoms may result in a feeling of not being taken seriously, while the therapist is under pressure to define the problem and offer adequate treatment. This places a strain on the clinical encounter and may result in mutual dissatisfaction and negative expectations, which are known to affect the treatment results negatively (Benedetti, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Benedetti <span class=\"NLM_given-names\">F<\/span><\/span> <span class=\"NLM_year\">2011<\/span> The Patient\u2019s Brain. The Neuroscience behind the Doctor-Patient Relationship. <span class=\"NLM_publisher-loc\">Oxford<\/span>, <span class=\"NLM_publisher-name\">Oxford University Press<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;author=F+Benedetti&amp;title=The+Patient%E2%80%99s+Brain.+The+Neuroscience+behind+the+Doctor-Patient+Relationship&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Benedetti <span class=\"NLM_given-names\">F<\/span><\/span> <span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">Placebo effects: From the neurobiological paradigm to translational implications<\/span>. Neuron 84: <span class=\"NLM_fpage\">623<\/span>\u2013<span class=\"NLM_lpage\">637<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0005&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.neuron.2014.10.023\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0005&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=25442940\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0005&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000344168100015\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=623-637&amp;author=F+Benedetti&amp;title=Placebo+effects:+From+the+neurobiological+paradigm+to+translational+implications&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>Lasting or recurrent pain from the musculoskeletal system is of clinical relevance to physiotherapists. In contrast to acute and transient pain, which has a clear health-preserving function, the biological significance of chronic pain is problematic. It is often considered an illness in itself, with apparent changes in the peripheral and central nervous system (Baliki and Apkarian, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2015<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span> <span class=\"NLM_year\">2015<\/span><span class=\"NLM_article-title\">Nociception, pain, negative moods and behaviour selection<\/span>. Neuron 87: <span class=\"NLM_fpage\">474<\/span>\u2013<span class=\"NLM_lpage\">491<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.neuron.2015.06.005\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=26247858\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000361145000005\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2015&amp;pages=474-491&amp;author=MN+Baliki&amp;author=AV+Apkarian&amp;title=Nociception,+pain,+negative+moods+and+behaviour+selection&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Gereau et al., <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Gereau <span class=\"NLM_given-names\">RW<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Sluka <span class=\"NLM_given-names\">KA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Maixner <span class=\"NLM_given-names\">W<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Savage <span class=\"NLM_given-names\">SR<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Price <span class=\"NLM_given-names\">TJ<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Murinson <span class=\"NLM_given-names\">BB<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Sullivan <span class=\"NLM_given-names\">MD<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Fillingim <span class=\"NLM_given-names\">RB<\/span><\/span> <span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">A pain research agenda for the 21st century<\/span>. Journal of Pain 15: <span class=\"NLM_fpage\">1203<\/span>\u2013<span class=\"NLM_lpage\">1214<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0010&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.jpain.2014.09.004\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0010&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=25419990\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0010&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000346893100001\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=1203-1214&amp;author=RW+Gereau&amp;author=KA+Sluka&amp;author=W+Maixner&amp;author=SR+Savage&amp;author=TJ+Price&amp;author=BB+Murinson&amp;author=MD+Sullivan&amp;author=RB+Fillingim&amp;title=A+pain+research+agenda+for+the+21st+century&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). These pains, which represent frequent and recurring challenges to the physiotherapist, also involve patients who frequently return, termed as \u201crevolving door\u201d patients in the clinic. There is reason to claim that default perspectives on pain are not sufficiently accounted for or acted upon by physiotherapists and that the biomedical definitions of symptom and sign fall short in the context of MUPS.<\/p>\n<p>In this article, we address these challenges by presenting a theoretical perspective based on semiotics. Going beyond the biomedical concept of causation, we will bring forward what we believe to be an enhanced understanding of MUPS. A semiotic model can contribute to this at two levels. Being a meta-theory, it encompasses and integrates different fields of knowledge about illness and the human body, from the natural sciences, the social sciences, and the humanities. More directly, semiotics can elucidate the connection between certain bodily signs and circumstances in the patient\u2019s life and perception of reality. We investigate the possibility that the unexplained symptoms carry a message and thus perform a bodily or biological function; if this is the case, an alternative approach to the symptoms is necessary.<\/p>\n<p>Several authors point to the limitations of evidence-based medicine and the need to revise biomedical thinking (Eriksen et al., <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2013<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Eriksen <span class=\"NLM_given-names\">TE<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Kerry <span class=\"NLM_given-names\">R<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Mumford <span class=\"NLM_given-names\">S<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Noer Lie <span class=\"NLM_given-names\">SA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Anjum <span class=\"NLM_given-names\">RL<\/span><\/span> <span class=\"NLM_year\">2013<\/span> <span class=\"NLM_article-title\">At the borders of medical reasoning: Aetiolocical and ontological challenges of medically unexplained symptoms<\/span>. Philosopy, Ethics, and Humanities in Medicine 8: <span class=\"NLM_fpage\">11<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0009&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1186%2F1747-5341-8-11\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0009&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=24006875\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0009&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000420453100011\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2013&amp;pages=11&amp;author=TE+Eriksen&amp;author=R+Kerry&amp;author=S+Mumford&amp;author=SA+Noer+Lie&amp;author=RL+Anjum&amp;title=At+the+borders+of+medical+reasoning:+Aetiolocical+and+ontological+challenges+of+medically+unexplained+symptoms&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Greenhalgh, Howick, and Maskrey, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Greenhalgh <span class=\"NLM_given-names\">T<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Howick <span class=\"NLM_given-names\">J<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Maskrey <span class=\"NLM_given-names\">N<\/span><\/span><span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">Evidence based medicine: A movement in crisis?<\/span> BMJ 348: <span class=\"NLM_fpage\">g3725<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0011&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1136%2Fbmj.g3725\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0011&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=24927763\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0011&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000337410400001\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=g3725&amp;author=T+Greenhalgh&amp;author=J+Howick&amp;author=N+Maskrey&amp;title=Evidence+based+medicine:+A+movement+in+crisis?&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Kirkengen and Thornquist, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2012<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Kirkengen <span class=\"NLM_given-names\">AL<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Thornquist <span class=\"NLM_given-names\">E<\/span><\/span> <span class=\"NLM_year\">2012<\/span> <span class=\"NLM_article-title\">The lived body as a medical topic: An argument for an ethically informed epistemology<\/span>. Journal of Evaluation in Clinical Practice 18: <span class=\"NLM_fpage\">1095<\/span>\u2013<span class=\"NLM_lpage\">1101<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0013&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1111%2Fj.1365-2753.2012.01925.x\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0013&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=22995016\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0013&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000309069800030\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2012&amp;pages=1095-1101&amp;author=AL+Kirkengen&amp;author=E+Thornquist&amp;title=The+lived+body+as+a+medical+topic:+An+argument+for+an+ethically+informed+epistemology&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Nicholls and Gibson (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2010<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Nicholls <span class=\"NLM_given-names\">DA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Gibson <span class=\"NLM_given-names\">BE<\/span><\/span> <span class=\"NLM_year\">2010<\/span> <span class=\"NLM_article-title\">The body and physiotherapy<\/span>. Physiotherapy Theory and Practice 26: <span class=\"NLM_fpage\">497<\/span>\u2013<span class=\"NLM_lpage\">509<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/doi\/10.3109\/09593981003710316\" target=\"_blank\" rel=\"noopener\">[Taylor &amp; Francis Online]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2010&amp;pages=497-509&amp;author=DA+Nicholls&amp;author=BE+Gibson&amp;title=The+body+and+physiotherapy&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>) aimed for a more theoretical and holistic understanding of the body among physiotherapists. They explored the term \u201cembodiment\u201d and wished to highlight the body\u2019s significant and existential aspect in the minds of physiotherapists. In line with these authors, our intention is to present and discuss symptoms and signs in a semiotic perspective. We will begin with some general reflections on these terms, including a short update on the pain concept. Some examples of the relationship between bodily signs and existential factors will follow; this would be life circumstances physiotherapists face in their daily practice. Clinical implications, also in relation to other approaches of treatment, will be discussed, constructive clinical encounters being the ultimate goal.<\/p>\n<\/div>\n<div id=\"S0002\" class=\"NLM_sec NLM_sec_level_1\">\n<h2 id=\"_i4\" class=\"section-heading-2\">Symptoms and signs in a semiotic model<\/h2>\n<div id=\"S0002-S2001\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i5\" class=\"section-heading-3\">Reflections on pain<\/h3>\n<p>The prevailing definition of pain is based upon a subjective and emotional experience of actual and or potential tissue damage (Merskey and Bogduk, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">1994<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Merskey <span class=\"NLM_given-names\">H<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Bogduk <span class=\"NLM_given-names\">N<\/span><\/span> <span class=\"NLM_year\">1994<\/span>Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. <span class=\"NLM_publisher-loc\">Seattle<\/span>, <span class=\"NLM_publisher-name\">IASP Press<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=1994&amp;author=H+Merskey&amp;author=N+Bogduk&amp;title=Classification+of+Chronic+Pain:+Descriptions+of+Chronic+Pain+Syndromes+and+Definitions+of+Pain+Terms&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). However, more recent research in pain physiology indicates the overlap between the brain\u2019s representation of bodily versus emotionally conditioned pain experience and activation of the same neural circuits in the somatosensory cortex. This is one example of how pain perception also occurs independently from nociception (Kross et al., <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Kross <span class=\"NLM_given-names\">E<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Berman <span class=\"NLM_given-names\">MG<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Mischel <span class=\"NLM_given-names\">W<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Smith <span class=\"NLM_given-names\">EE<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Wager <span class=\"NLM_given-names\">TD<\/span><\/span> <span class=\"NLM_year\">2011<\/span> <span class=\"NLM_article-title\">Social rejection shares somatosensory representations with physical pain<\/span>. Proceedings of the National Academy of Sciences in the USA 108: <span class=\"NLM_fpage\">6270<\/span>\u2013<span class=\"NLM_lpage\">6275<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0015&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1073%2Fpnas.1102693108\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0015&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=21444827\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0015&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000289413600067\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=6270-6275&amp;author=E+Kross&amp;author=MG+Berman&amp;author=W+Mischel&amp;author=EE+Smith&amp;author=TD+Wager&amp;title=Social+rejection+shares+somatosensory+representations+with+physical+pain&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Besides, pain does not always have to have a negative connotation (Bastian, Jetten, Hornsey, and Leknes, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Bastian <span class=\"NLM_given-names\">B<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Jetten <span class=\"NLM_given-names\">J<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Hornsey <span class=\"NLM_given-names\">MJ<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Leknes <span class=\"NLM_given-names\">S<\/span><\/span> <span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">The positive consequences of pain: A biopsychosocial approach<\/span>. Personality and Social Psychology Review 18: <span class=\"NLM_fpage\">256<\/span>\u2013<span class=\"NLM_lpage\">279<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0003&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1177%2F1088868314527831\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0003&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=24727972\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0003&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000338912500003\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=256-279&amp;author=B+Bastian&amp;author=J+Jetten&amp;author=MJ+Hornsey&amp;author=S+Leknes&amp;title=The+positive+consequences+of+pain:+A+biopsychosocial+approach&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). The experience of pain involves important learning, while also increasing the capacity for self-regulation with regard to cognitive control, coping, and achievement.<\/p>\n<p>Modern neuroscientific research tells us much about how pain perception and pain behavior are reinforced through factors such as vulnerability, negative learning, maladaptation, and sensitization (Baliki and Apkarian, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2015<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span> <span class=\"NLM_year\">2015<\/span><span class=\"NLM_article-title\">Nociception, pain, negative moods and behaviour selection<\/span>. Neuron 87: <span class=\"NLM_fpage\">474<\/span>\u2013<span class=\"NLM_lpage\">491<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.neuron.2015.06.005\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=26247858\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000361145000005\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2015&amp;pages=474-491&amp;author=MN+Baliki&amp;author=AV+Apkarian&amp;title=Nociception,+pain,+negative+moods+and+behaviour+selection&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Apkarian, Hashmi, and Baliki, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Hashmi <span class=\"NLM_given-names\">JA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span><span class=\"NLM_year\">2011<\/span> <span class=\"NLM_article-title\">Pain and the Brain: Specificity and plasticity of the brain in clinical chronic pain<\/span>. Pain 152: <span class=\"NLM_fpage\">S49<\/span>\u2013<span class=\"NLM_lpage\">S64<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0001&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.pain.2010.11.010\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0001&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=21146929\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0001&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000287307200008\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=S49-S64&amp;author=AV+Apkarian&amp;author=JA+Hashmi&amp;author=MN+Baliki&amp;title=Pain+and+the+Brain:+Specificity+and+plasticity+of+the+brain+in+clinical+chronic+pain&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). There are however fundamental questions connected to the origin of unexplained pain; in which context did it first appear; what were the early symptoms of an expression; and how could they be understood in a biological, psychological, and existential sense? Central to our contribution is the notion that unexplained pain has its reasons, a purpose, and a meaning, hidden in the patient\u2019s mental and bodily history. This may seem obvious; however, it is rarely expressed explicitly in clinical practice.<\/p>\n<\/div>\n<div id=\"S0002-S2002\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i6\" class=\"section-heading-3\">Individual and cultural sensitivity of symptoms<\/h3>\n<p>In biomedical terminology, the term \u201csymptom\u201d is understood as patients\u2019 subjective description of their ailments (Dorland, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Dorland <span class=\"NLM_given-names\">WA<\/span><\/span> <span class=\"NLM_year\">2011<\/span> Dorland\u2019s Illustrated Medical Dictionary, <span class=\"NLM_edition\">32nd<\/span> edn, <span class=\"NLM_article-title\">Philadelphia, PA, Elsevier Saunders<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;author=WA+Dorland&amp;title=Dorland%E2%80%99s+Illustrated+Medical+Dictionary&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Based on their description, the doctor or therapist will look for signs that may explain the cause of the symptom. This entails distinguishing between symptom and sign, whereby the sign, if it can be verified through technological examinations, laboratory tests, or clinical tests, provides an objective explanation or endorsement of the symptom. Despite the fact that signs that can be visualized and measured must also be interpreted, based on the interpreter\u2019s knowledge and experience, the relevant context, and prevailing medical culture, the sign is considered to have greater credibility and legitimacy than the symptom (Staiano-Ross, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2012<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Staiano-Ross <span class=\"NLM_given-names\">K<\/span><\/span> <span class=\"NLM_year\">2012<\/span> <span class=\"NLM_article-title\">The symptom<\/span>. Biosemiotics 5: <span class=\"NLM_fpage\">33<\/span>\u2013<span class=\"NLM_lpage\">45<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0023&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1007%2Fs12304-011-9112-6\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0023&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000305561000004\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2012&amp;pages=33-45&amp;author=K+Staiano-Ross&amp;title=The+symptom&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). However, for the patient, the symptom will always be a sign; a sign that something is wrong, and one that generates worry and anxiety.<\/p>\n<p>It is common to both patient and therapist that the symptom, as a bodily experience, can primarily be ascribed to a disruption or malfunction in the body. This may contribute to a fixed, narrow perception of the relationship between body and symptom. The fact that the existence and expression of symptoms has changed over various historical periods and cultural currents indicates that the symptom is a dynamic and mutable entity (Lian and Bondevik, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2015<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Lian <span class=\"NLM_given-names\">OS<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Bondevik <span class=\"NLM_given-names\">H<\/span><\/span> <span class=\"NLM_year\">2015<\/span> <span class=\"NLM_article-title\">Medical constructions of long-term exhaustion, past and present<\/span>. Socialogy of Health and Illness 37: <span class=\"NLM_fpage\">920<\/span>\u2013<span class=\"NLM_lpage\">935<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0016&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1111%2F1467-9566.12249\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0016&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=25912053\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0016&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000358925800008\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2015&amp;pages=920-935&amp;author=OS+Lian&amp;author=H+Bondevik&amp;title=Medical+constructions+of+long-term+exhaustion,+past+and+present&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Staiano-Ross, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2012<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Staiano-Ross <span class=\"NLM_given-names\">K<\/span><\/span> <span class=\"NLM_year\">2012<\/span> <span class=\"NLM_article-title\">The symptom<\/span>. Biosemiotics 5: <span class=\"NLM_fpage\">33<\/span>\u2013<span class=\"NLM_lpage\">45<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0023&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1007%2Fs12304-011-9112-6\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0023&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000305561000004\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2012&amp;pages=33-45&amp;author=K+Staiano-Ross&amp;title=The+symptom&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Likewise, patients\u2019 perception and description of the symptom will be characterized by their living conditions and life histories, psychological factors, and the prevailing cultural and social context (i.e., the patient\u2019s life world). These factors form the basis for the patient\u2019s meaning-making activity and are reflected in the patient\u2019s way of understanding, relating to and communicating the symptom. This provides a basis for regarding the symptom as a biocultural phenomenon, and symptom debut, development, and changing expression as biocultural events (Staiano-Ross, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2012<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Staiano-Ross <span class=\"NLM_given-names\">K<\/span><\/span> <span class=\"NLM_year\">2012<\/span> <span class=\"NLM_article-title\">The symptom<\/span>. Biosemiotics 5: <span class=\"NLM_fpage\">33<\/span>\u2013<span class=\"NLM_lpage\">45<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0023&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1007%2Fs12304-011-9112-6\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0023&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000305561000004\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2012&amp;pages=33-45&amp;author=K+Staiano-Ross&amp;title=The+symptom&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<\/div>\n<div id=\"S0002-S2003\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i7\" class=\"section-heading-3\">Symptoms as signs that carry meaning<\/h3>\n<p>Instead of distinguishing between symptoms and signs, the doctor and psychoanalyst Irene Matthis (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2007<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Matthis <span class=\"NLM_given-names\">I<\/span><\/span> <span class=\"NLM_year\">2007<\/span> <span class=\"NLM_chapter-title\">Sykdommens historie er en fortelling<\/span>. In: <span class=\"hlFld-ContribAuthor\">Bondevik <span class=\"NLM_given-names\">H<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Kveim Lie <span class=\"NLM_given-names\">A<\/span><\/span> (Eds). Tegn p\u00e5 Sykdom: Om Litter\u00e6r Medisin og Medisinsk Litteratur, pp. <span class=\"NLM_fpage\">63<\/span>\u2013<span class=\"NLM_lpage\">85<\/span>, <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Scandinavian Academic Press\/Spartacus Forlag<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2007&amp;pages=63-85&amp;author=I+Matthisauthor=H+Bondevik&amp;author=A+Kveim+Lie&amp;title=Sykdommens+historie+er+en+fortelling&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>) distinguishes between the significance of symptoms and their meaning. She describes the symptom\u2019s significance as that which is actually present: pain or exhaustion, ascertainment of myocardial infarction or arthrosis of a joint, in other words, a what. The meaning aspect of a symptom alludes to questions of how and why. Biomedicine is very frequently able to answer questions of \u201cwhat\u201d and \u201chow,\u201d but \u201cwhy\u201d is another matter: Why me, precisely? Why now, exactly? Why precisely these symptoms? The actual and universal significance of a symptom will differ from the particular, experienced content of thoughts and emotions that the symptom entails for the individual. Even when verifiable signs are present, the question of <i>why<\/i> will usually remain unanswered. This implies that signs which explain the cause only exist at a particular level: even when the cause of the symptom is known, the basis for it is frequently unknown. It may therefore be appropriate to differentiate between causes and reasons.<\/p>\n<\/div>\n<div id=\"S0002-S2004\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i8\" class=\"section-heading-3\">Semiotics<\/h3>\n<p>Semiotics is the study of signs and the term used for a theory of signs developed by the scientist and philosopher Charles S. Peirce (1839\u20131914). The professor of literary studies, Drude von der Fehr, in whom we lean on in this presentation, is inspired by Peirce and his version of semiotics. In her work, she aims to understand specific and subjective experiences of illness, including unexplained symptoms. The human can only be understood as an \u201cI\u201d (von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>Semiotics is interdisciplinary and anti-dualistic, based on the idea that humans in their endeavors to understand and relate to themselves and their reality will seek, communicate, and exchange meaning through signs. According to von der Fehr (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>), knowledge of the sign can form the theoretical basis of subjective experience.<\/p>\n<p>A sign bears a message and must be interpreted, whether it is expressed in the external world (our surroundings) or the internal world (the body). The sign may be an expression of pain, a muscular or autonomic reaction, a fracture line in a bone, or loss of cartilage in a joint. Signs are produced and interpreted at all levels of human life, from cell to society. Blushing is both a reaction to something (i.e., another sign) in the autonomic nervous system, and a sign that is expressed in the external world. The sign tells of a biologically emotional state and will be observed and interpreted by individuals themselves as well as by their environment. Thus, signs are simultaneously natural and cultural.<\/p>\n<p>A sign may be described as a phenomenon that represents another phenomenon (an object, state, or situation), and its characteristics can only be defined based on its relationship to this other phenomenon (von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2010<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2010<\/span> <span class=\"NLM_article-title\">Symptomer som ikke er \u00e5rsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological &#8211; A sign theoretical input]<\/span>. Michael Quarterly 2010(Suppl 9): <span class=\"NLM_fpage\">28<\/span>\u2013<span class=\"NLM_lpage\">34<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2010&amp;pages=28-34&amp;issue=Suppl+9&amp;author=D+von+der+Fehr&amp;title=Symptomer+som+ikke+er+%C3%A5rsaksforklarende+et+tegn+teoretisk+innspill+[Symptoms+that+are+not+etiological+-+A+sign+theoretical+input]&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). In other words, pain as a primary sign represents the body\u2019s current condition and can only be characterized on that basis. The simplest examples are those in which pain represents or is clearly related to the condition, as in the case of physical injury. The body has interpreted its situation and initiates its own self-healing measures. The process of repair is underway, and the interpretation has led to appropriate consequences. The interpretation occurs at all levels of consciousness in the patient\u2019s body from physiological reactions to cognition and reflection at a high level of consciousness. The physiotherapist interprets the signs from the outside and subsequently this will of course influence the patient\u2019s interpretation. Thus, during the process of interpretation, new signs constantly appear which must in turn be interpreted, and this entails an ongoing, dynamic process both within and outside the body.<\/p>\n<\/div>\n<div id=\"S0002-S2005\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i9\" class=\"section-heading-3\">Biosemiotics<\/h3>\n<p>Biosemiotics is a field of knowledge that has its roots in natural science and philosophy, as well as biology and semiotics, respectively (Hoffmeyer, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2005<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Hoffmeyer <span class=\"NLM_given-names\">J<\/span><\/span> <span class=\"NLM_year\">2005<\/span> Biosemiotikk: En Avhandling om Livets Tegn og Tegnenes Liv. <span class=\"NLM_publisher-loc\">Ries<\/span>, <span class=\"NLM_publisher-name\">Charlottenlund<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2005&amp;issue=Suppl+9&amp;author=J+Hoffmeyer&amp;title=Biosemiotikk:+En+Avhandling+om+Livets+Tegn+og+Tegnenes+Liv&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Biosemiotics seeks to describe the sign processes that control and form the basis for the development of biological interplay, between organisms in relation to each other, and physiologically and biochemically in the individual organism. The biologist Jesper Hoffmeyer (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2005<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Hoffmeyer <span class=\"NLM_given-names\">J<\/span><\/span> <span class=\"NLM_year\">2005<\/span> Biosemiotikk: En Avhandling om Livets Tegn og Tegnenes Liv. <span class=\"NLM_publisher-loc\">Ries<\/span>, <span class=\"NLM_publisher-name\">Charlottenlund<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2005&amp;issue=Suppl+9&amp;author=J+Hoffmeyer&amp;title=Biosemiotikk:+En+Avhandling+om+Livets+Tegn+og+Tegnenes+Liv&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>) calls the myriad of signs that we relate to and that appear both within and outside of ourselves, \u201cthe semiosphere.\u201d His manner of describing it is that at birth we are thrown out into this sphere of signs, significance, and meaning. Everything that we sense means something and entails communication of meaning, whether it is a matter of soundwaves, sensory impressions, touch, movement, electrical impulses, or chemical signals. All life forms must orientate themselves and act appropriately in this sphere in order to survive, and the prerequisite for managing and functioning in it consists of experiences in evolutionary terms and in our life histories.<\/p>\n<p>The human body is understood to be a biological organism, at all times carrying with it its own history, that of the species and of the individual, and with a consciousness of self. Body consciousness seeks survival, self-fulfillment, and meaning. Like other living organisms, the human body will also seek to maintain homeostasis and fulfill its function. However, human behavior often runs counter to natural physiological and psychological needs, for various reasons\u2014more or less voluntarily and more or less consciously. The individual neither thinks nor acts in all situations in his\/her own best interests as a biological organism (Lille\u00e5s and von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Lille\u00e5s <span class=\"NLM_given-names\">UB<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2011<\/span><span class=\"NLM_article-title\">Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure<\/span>. Nordisk Sykepleijeforskning 4: <span class=\"NLM_fpage\">257<\/span>\u2013<span class=\"NLM_lpage\">269<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=257-269&amp;author=UB+Lille%C3%A5s&amp;author=D+von+der+Fehr&amp;title=Chronic+pain+syndrome+explained+as+a+bodily+state+of+preparedness+for+others+and+why+it+is+hard+to+cure&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Self-destructive behavior as in eating-disorders and self-loathing are obvious examples, but as we will see, there are also more subtle forms.<\/p>\n<p>Irrespective of the situation in which individuals find themselves, they will produce, interpret, and relate to all types of signs, based on what gives meaning in a given moment. Interpretation involves biological, cognitive, and emotional factors, and results in physiological reactions and mental and emotional activity, at various levels of consciousness and in different parts of the brain. In this way, biology, experience, consciousness, and behavior are all integrated. At the same time, sign processes also encompass possibilities, creation, and change.<\/p>\n<\/div>\n<div id=\"S0002-S2006\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i10\" class=\"section-heading-3\">Indexical signs<\/h3>\n<p>In a semiotic model, medical symptoms are considered as indexical signs. An index indicates that something occurs or is, and points to a natural or existential connection between things and phenomena (von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2010<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2010<\/span> <span class=\"NLM_article-title\">Symptomer som ikke er \u00e5rsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological &#8211; A sign theoretical input]<\/span>. Michael Quarterly 2010(Suppl 9): <span class=\"NLM_fpage\">28<\/span>\u2013<span class=\"NLM_lpage\">34<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2010&amp;pages=28-34&amp;issue=Suppl+9&amp;author=D+von+der+Fehr&amp;title=Symptomer+som+ikke+er+%C3%A5rsaksforklarende+et+tegn+teoretisk+innspill+[Symptoms+that+are+not+etiological+-+A+sign+theoretical+input]&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). The index will often point to a causal relation. A bone fracture manifests itself with visible signs, both clinical and radiological. The accompanying pain, which is expressed through other signs, has a clear causal relationship to the fracture. The pain points back to the injury, and the injury explains the pain. High blood pressure is another example; a measurable sign that may be accompanied by dizziness, which is also a sign in the way that we understand it here. The two signs can be placed etiologically; the measurable sign, blood pressure, can explain the sign that is experienced, dizziness.<\/p>\n<p>As physiotherapists well know, dizziness can also occur without measurable, etiological signs. However, the physiotherapist will look for and often find other signs in the body; in musculature, posture, movement, and respiration. Tension and stiffness in the neck muscles are signs that are often accompanied by dizziness. Likewise, dizziness is one of several signs when patients tell of anxiety.<\/p>\n<p>A relation based on association and proximity to the phenomenon exists here, rather than a direct causal relationship between the signs. The signs exist in the same body and appear to involve each other in different ways. When the sign is pain, and no other explanatory signs can be identified, it nevertheless tells us that something is wrong. These signs are also indexical signs, but of another kind. In the following, we will explain the important difference between indexes based on causal relations and the ones that are based on association and proximity. These signs make up the essence of the contribution of semiotic theory regarding MUPS. Something is, but there is no obvious relationship between the sign as it is expressed and its explanation. If a sign like this manifests as pain, it tells us of a body that is unwell and that the individual\u2019s welfare is threatened, but in itself it does not indicate a cause nor an obvious solution. Nevertheless, the sign may be regarded as an announcement, first and foremost to the individual itself; it carries a message, a meaning. Apparently it communicates other aspects about the patient\u2019s life and body than measurable realities, and generally the meaning will be hidden also for the patient.<\/p>\n<p>Going beyond the measureable realities makes it possible to explore the signs and their meaning in a wider perspective and interpret them based on different, but equivalent sources of knowledge and experience, both on the part of the therapist and the patient. It becomes irrelevant to denote the knowledge as objective or subjective, as more or less valid. Knowledge and experience, be they medical or originating from a lived life, will always be characterized by the context to which they relate, the \u2018zeitgeist\u2019 and the previous history.<\/p>\n<\/div>\n<div id=\"S0002-S2007\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i11\" class=\"section-heading-3\">Self-referential signs represent the body speaking to itself<\/h3>\n<p>Based on biosemiotic and humanities-inspired research into disease, von der Fehr (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;issue=Suppl+9&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2010<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2010<\/span> <span class=\"NLM_article-title\">Symptomer som ikke er \u00e5rsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological &#8211; A sign theoretical input]<\/span>. Michael Quarterly 2010(Suppl 9): <span class=\"NLM_fpage\">28<\/span>\u2013<span class=\"NLM_lpage\">34<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2010&amp;pages=28-34&amp;issue=Suppl+9&amp;author=D+von+der+Fehr&amp;title=Symptomer+som+ikke+er+%C3%A5rsaksforklarende+et+tegn+teoretisk+innspill+[Symptoms+that+are+not+etiological+-+A+sign+theoretical+input]&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>) describes this other type of indexical signs as self-referential. These are bodily signs that refer to the body itself, in the quality of a biological, experiencing organism. The signs may be expressed as pain or other MUPS and are part of the body\u2019s internal communication. von der Fehr (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2010<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2010<\/span> <span class=\"NLM_article-title\">Symptomer som ikke er \u00e5rsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological &#8211; A sign theoretical input]<\/span>. Michael Quarterly 2010(Suppl 9): <span class=\"NLM_fpage\">28<\/span>\u2013<span class=\"NLM_lpage\">34<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2010&amp;pages=28-34&amp;issue=Suppl+9&amp;author=D+von+der+Fehr&amp;title=Symptomer+som+ikke+er+%C3%A5rsaksforklarende+et+tegn+teoretisk+innspill+[Symptoms+that+are+not+etiological+-+A+sign+theoretical+input]&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>) regards the self-referential signs as important reminders, originating from the body\u2019s own knowledge regarding what is good for it. Just as the heart knows that it should beat, and will react to changes in working conditions and disruptions that affect its normal function, so the body as a whole will react when living conditions, thinking, and behavior pull in a negative direction. It may be possible that the individual is establishing mental or bodily (interpretive) habits that prevent the self-healing function of the body (Lille\u00e5s and von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Lille\u00e5s <span class=\"NLM_given-names\">UB<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2011<\/span><span class=\"NLM_article-title\">Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure<\/span>. Nordisk Sykepleijeforskning 4: <span class=\"NLM_fpage\">257<\/span>\u2013<span class=\"NLM_lpage\">269<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=257-269&amp;author=UB+Lille%C3%A5s&amp;author=D+von+der+Fehr&amp;title=Chronic+pain+syndrome+explained+as+a+bodily+state+of+preparedness+for+others+and+why+it+is+hard+to+cure&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). When chronic pain is a fact, the habit is entrenched both bodily and mentally.<\/p>\n<p>Patients as well as health-care workers acknowledge the general need for nourishment, sleep and rest, physical activity, and fresh air as prerequisites for good health. Similarly, we know that psychological needs such as those for affirmation, affiliation, intimacy, and respect are fundamental to our experience of wellness. However, when these needs are insufficiently catered for, ignored, or counteracted, it can be difficult to assimilate how this can lead to specific bodily ailments and ill health. Despite a growing understanding of how body and brain communicate in monitoring and regulating the organism, it is easy to forget that the human body is also a living, purposeful biological organism that knows what is best for itself, and \u201cwants\u201d to function optimally and fulfill its function. When the body is prevented from doing this, it will have to speak out, to itself, in other words to the individual. As a body, it will naturally use its own language (i.e., bodily signs such as pain and fatigue). From a semiotic or biosemiotic perspective, we may say that the body expresses its wisdom and knowledge through bodily signs, as a message to the individual that \u201cthings are taking a wrong turn!\u201d<\/p>\n<p>The self-referential signs thus function as warnings and are triggered when the individual\u2019s thinking and behavior run counter to the fundamental needs of the organism, such as when the individual relates inappropriately to his\/her own welfare and integrity. This type of warning must be acknowledged and followed up by the individual him\/herself (Lille\u00e5s and von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Lille\u00e5s <span class=\"NLM_given-names\">UB<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2011<\/span><span class=\"NLM_article-title\">Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure<\/span>. Nordisk Sykepleijeforskning 4: <span class=\"NLM_fpage\">257<\/span>\u2013<span class=\"NLM_lpage\">269<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=257-269&amp;author=UB+Lille%C3%A5s&amp;author=D+von+der+Fehr&amp;title=Chronic+pain+syndrome+explained+as+a+bodily+state+of+preparedness+for+others+and+why+it+is+hard+to+cure&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Some aspect of life, thinking or action, has to change in order for the body, i.e., the person, to regain its balance, physiologically and mentally. Perhaps it is as a qualified partner in exploring what this \u201csomething\u201d is, that we can best help the patient. However, one can also regard the experience of peace, relaxation, and well-being as self-referential signs, as a positive feedback from the body itself; I am in balance, I am well.<\/p>\n<p>As mentioned, neurobiological research confirms not only how the brain\u2019s various networks communicate in monitoring and adjusting the condition of the body, but also how the plasticity of brain cells renders them vulnerable to inexpedient learning and maladaptation (Apkarian, Hashmi, and Baliki, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Hashmi <span class=\"NLM_given-names\">JA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span><span class=\"NLM_year\">2011<\/span> <span class=\"NLM_article-title\">Pain and the Brain: Specificity and plasticity of the brain in clinical chronic pain<\/span>. Pain 152: <span class=\"NLM_fpage\">S49<\/span>\u2013<span class=\"NLM_lpage\">S64<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0001&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.pain.2010.11.010\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0001&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=21146929\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0001&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000287307200008\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=S49-S64&amp;author=AV+Apkarian&amp;author=JA+Hashmi&amp;author=MN+Baliki&amp;title=Pain+and+the+Brain:+Specificity+and+plasticity+of+the+brain+in+clinical+chronic+pain&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>; Benedetti, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Benedetti <span class=\"NLM_given-names\">F<\/span><\/span> <span class=\"NLM_year\">2011<\/span> The Patient\u2019s Brain. The Neuroscience behind the Doctor-Patient Relationship. <span class=\"NLM_publisher-loc\">Oxford<\/span>, <span class=\"NLM_publisher-name\">Oxford University Press<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;author=F+Benedetti&amp;title=The+Patient%E2%80%99s+Brain.+The+Neuroscience+behind+the+Doctor-Patient+Relationship&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). The latter may be the origin of negative interpretive habits that entail a conflict between the organism\u2019s search for balance and well-being, and the individual\u2019s learned patterns of thought and behavior. Humans do not always act in their own best interests and are often driven by forces other than those of self-preservation. The precondition for learning, either positive or negative, is the interpretation of the meaning of a sensory impression or situation. What gives meaning is again based on the interpretation of signs: is the sensory impression interpreted as pleasant or unpleasant? Do the signs indicate that the situation is safe and positive, antagonistic or threatening? Since the interpretation is characterized by context and experience, motivation and expectation, it has its own innate logic, but its consequences will not necessarily appear rational or serve the individual as a biological organism and integrated self. According to von der Fehr (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>), MUPS constitute a progression from constructive warnings to negative bodily interpretive habits, from self-referential signs to prolonged, unexplained symptoms.<\/p>\n<\/div>\n<\/div>\n<div id=\"S0003\" class=\"NLM_sec NLM_sec_level_1\">\n<h2 id=\"_i12\" class=\"section-heading-2\">Existential relationships as a basis for self-referential signs<\/h2>\n<p>It is important to remember the time aspect in this development; the bodily signs have existed on a time continuum before they came to be described at a particular point in time as symptoms. They have appeared, reached the level of consciousness, and been interpreted, lived, and felt with a varying degree of presence and intensity. The signs may have been interpreted as threatening or harmless, created anxiety, or been ignored. Individuals react in very different ways to bodily signs, and only through insight into the basis for interpretation and formation of meaning can reactions and action be understood at a deeper level. Since the origin of dysfunction, negative learning and maladaptation has to do with existence itself, attention must be paid to the individual patient\u2019s experience of their history. The history will perhaps show that signs that were ignored should have been taken seriously, that what was interpreted as harmless was, in reality, an early warning. Signs of pain and fatigue as a result of injury, over-exercising, or overwork may serve as examples. In other cases, signs that are essentially harmless may lead to fear-based interpretations and inexpedient strategies, referred to as \u201cfear-avoidance beliefs\u201d (Linton and Shaw, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Linton <span class=\"NLM_given-names\">SJ<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Shaw <span class=\"NLM_given-names\">WS<\/span><\/span> <span class=\"NLM_year\">2011<\/span> <span class=\"NLM_article-title\">Impact of psychological factors in the experience of pain<\/span>. Physical Therapy 91: <span class=\"NLM_fpage\">700<\/span>\u2013<span class=\"NLM_lpage\">711<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0018&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.2522%2Fptj.20100330\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0018&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=21451097\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0018&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000289961000010\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=700-711&amp;author=SJ+Linton&amp;author=WS+Shaw&amp;title=Impact+of+psychological+factors+in+the+experience+of+pain&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>In the encounter with unexplained pain, an approach that goes beyond a description of symptoms, disease history, and mapping of findings seems necessary. It is essential to search for the origin of the signs and how they were interpreted in time and context. A biopsychosocial perspective, which is intended to encompass the influence of various factors with regard to the patient\u2019s experience of health (Engel, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">1977<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Engel <span class=\"NLM_given-names\">GL<\/span><\/span> <span class=\"NLM_year\">1977<\/span> <span class=\"NLM_article-title\">The need for a new medical model: A challenge for biomedicine science<\/span>. Science 196: <span class=\"NLM_fpage\">129<\/span>\u2013<span class=\"NLM_lpage\">136<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0008&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1126%2Fscience.847460\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0008&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=847460\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0008&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=A1977DA10600006\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=1977&amp;pages=129-136&amp;author=GL+Engel&amp;title=The+need+for+a+new+medical+model:+A+challenge+for+biomedicine+science&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>), will not in itself reveal the possible function of symptoms. Knowledge and understanding of the patient\u2019s interpretation and management of their living conditions and life events will be crucial.<\/p>\n<p>Life experiences that mask themselves in unexplained pain may include traumas: physical injuries or violations of personal integrity. Keywords for this are abuse, threats, bullying, manipulation, or rejection. Loss, neglect, unreasonable work pressures, unpredictable working conditions, and overwhelming care responsibilities are other examples of life experiences that we now know are integrated in the body, with structural and functional changes in biology. The expression \u201cpathogenetic life circumstances\u201d summarizes this (Vogt, Ulvestad, Eriksen, and Getz, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Vogt <span class=\"NLM_given-names\">H<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Ulvestad <span class=\"NLM_given-names\">E<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Eriksen <span class=\"NLM_given-names\">TE<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Getz <span class=\"NLM_given-names\">L<\/span><\/span><span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">Getting personal: Can systems medicine integrate scientific and humanistic conceptions of the patient?<\/span> Journal of Evaluation in Clinical Practice 20: <span class=\"NLM_fpage\">942<\/span>\u2013<span class=\"NLM_lpage\">952<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0025&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1111%2Fjep.12251\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0025&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=25312489\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0025&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000350450200031\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=942-952&amp;author=H+Vogt&amp;author=E+Ulvestad&amp;author=TE+Eriksen&amp;author=L+Getz&amp;title=Getting+personal:+Can+systems+medicine+integrate+scientific+and+humanistic+conceptions+of+the+patient?&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>The traces of such experiences most often manifest at a pre-reflective level of consciousness, not only as anxiety or depression but also as pain, difficulty in concentrating, sleep disorders, and digestive problems. Physiotherapists will be able to observe prolonged, raised bodily activation, with an effect on cardiac rhythm, blood pressure, respiration, and muscle tone.<\/p>\n<p>We are familiar with this activation as a physiological response to stress and a feeling of discomfort and danger. We also know that if the danger is physical, specific, and external, the response is the same as when the danger is a threat to or an actual violation of the person\u2019s integrity (Kirkengen and Thornquist, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2012<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Kirkengen <span class=\"NLM_given-names\">AL<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Thornquist <span class=\"NLM_given-names\">E<\/span><\/span> <span class=\"NLM_year\">2012<\/span> <span class=\"NLM_article-title\">The lived body as a medical topic: An argument for an ethically informed epistemology<\/span>. Journal of Evaluation in Clinical Practice 18: <span class=\"NLM_fpage\">1095<\/span>\u2013<span class=\"NLM_lpage\">1101<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0013&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1111%2Fj.1365-2753.2012.01925.x\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0013&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=22995016\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0013&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000309069800030\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2012&amp;pages=1095-1101&amp;author=AL+Kirkengen&amp;author=E+Thornquist&amp;title=The+lived+body+as+a+medical+topic:+An+argument+for+an+ethically+informed+epistemology&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). The physiological stress response is intended to trigger expedient behavior, the purpose of which is to protect life and health. Expedient behavior may in some cases mean engaging in combat, in other cases fleeing, but a third possibility is to \u201cplay dead.\u201d The latter involves dissociation, or a separation of body and self. Dissociation may also be a necessary and appropriate survival strategy in certain cases, but if it persists as a pattern when the real danger has passed, it becomes very difficult to preserve one\u2019s status as an integrated and whole human being. Knowledge of traumatic events and circumstances in the patient\u2019s life is crucial in order to understand bodily reactions and interpretive habits.<\/p>\n<p>When traumatic experiences are not necessarily the cause, a persistently elevated bodily state of alert, a fight or flight mode, will wear on the body\u2019s resources. Over time, this can overtax and impoverish the body\u2019s natural adaptation systems (Kirkengen and Ulvestad, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2007<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Kirkengen <span class=\"NLM_given-names\">AL<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Ulvestad <span class=\"NLM_given-names\">E<\/span><\/span> <span class=\"NLM_year\">2007<\/span><span class=\"NLM_article-title\">Overlast og Kompleks Sykdom \u2013 et Integrert Perspektiv [Heavy burdens and complex disease\u2013an integrated perspective]<\/span>. Tidsskrift for Den Norske Legeforening 127: <span class=\"NLM_fpage\">3228<\/span>\u2013<span class=\"NLM_lpage\">3231<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0014&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=18084366\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2007&amp;pages=3228-3231&amp;author=AL+Kirkengen&amp;author=E+Ulvestad&amp;title=Overlast+og+Kompleks+Sykdom+%E2%80%93+et+Integrert+Perspektiv+[Heavy+burdens+and+complex+disease%E2%80%93an+integrated+perspective]&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Studies show that apart from pain and exhaustion, signs of disease may appear at cellular, hormonal, and tissue level, vulnerability to infections, inflammation, and pathological cell division (Kirkengen and Ulvestad, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2007<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Kirkengen <span class=\"NLM_given-names\">AL<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Ulvestad <span class=\"NLM_given-names\">E<\/span><\/span> <span class=\"NLM_year\">2007<\/span><span class=\"NLM_article-title\">Overlast og Kompleks Sykdom \u2013 et Integrert Perspektiv [Heavy burdens and complex disease\u2013an integrated perspective]<\/span>. Tidsskrift for Den Norske Legeforening 127: <span class=\"NLM_fpage\">3228<\/span>\u2013<span class=\"NLM_lpage\">3231<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0014&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=18084366\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2007&amp;pages=3228-3231&amp;author=AL+Kirkengen&amp;author=E+Ulvestad&amp;title=Overlast+og+Kompleks+Sykdom+%E2%80%93+et+Integrert+Perspektiv+[Heavy+burdens+and+complex+disease%E2%80%93an+integrated+perspective]&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). The affliction is an expression of an existence under threat, a body that has become its own opponent.<\/p>\n<p>Several authors have investigated the conditions of women\u2019s bodies and seen how women in particular have internalized expectations, demands, and attitudes toward themselves and their lives (Lille\u00e5s and von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2011<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Lille\u00e5s <span class=\"NLM_given-names\">UB<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2011<\/span><span class=\"NLM_article-title\">Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure<\/span>. Nordisk Sykepleijeforskning 4: <span class=\"NLM_fpage\">257<\/span>\u2013<span class=\"NLM_lpage\">269<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2011&amp;pages=257-269&amp;author=UB+Lille%C3%A5s&amp;author=D+von+der+Fehr&amp;title=Chronic+pain+syndrome+explained+as+a+bodily+state+of+preparedness+for+others+and+why+it+is+hard+to+cure&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Social inheritance and cultural norms such as perfectionism can establish themselves as automated thoughts and bodily habits that are inconsistent with the needs of the organism.<\/p>\n<p>Young people form an apparently growing patient group who, in addition to their experience of pain, fatigue, anxiety, and depression, tell of self-loathing and self-destructive behavior (Bonvanie et al., <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2015<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Bonvanie <span class=\"NLM_given-names\">IJ<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Rosmalen <span class=\"NLM_given-names\">JG<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Van Rhede Van Der Kloot <span class=\"NLM_given-names\">CM<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Oldehinkel <span class=\"NLM_given-names\">AJ<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Janssens <span class=\"NLM_given-names\">KA<\/span><\/span> <span class=\"NLM_year\">2015<\/span> <span class=\"NLM_article-title\">Short report: Functional somatic symptoms are associated with perfectionism in adolescents<\/span>. Journal of Psychosomatic Research 79: <span class=\"NLM_fpage\">328<\/span>\u2013<span class=\"NLM_lpage\">330<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0006&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.jpsychores.2015.07.009\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0006&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=26279124\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0006&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000362310100012\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2015&amp;pages=328-330&amp;author=IJ+Bonvanie&amp;author=JG+Rosmalen&amp;author=CM+Van+Rhede+Van+Der+Kloot&amp;author=AJ+Oldehinkel&amp;author=KA+Janssens&amp;title=Short+report:+Functional+somatic+symptoms+are+associated+with+perfectionism+in+adolescents&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). These represent an explicit form of waging war on one\u2019s own body, by directly counteracting the organism\u2019s attempt to ensure its own welfare.<\/p>\n<\/div>\n<div id=\"S0004\" class=\"NLM_sec NLM_sec_level_1\">\n<h2 id=\"_i13\" class=\"section-heading-2\">Discussion<\/h2>\n<div id=\"S0004-S2001\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i14\" class=\"section-heading-3\">Clinical implications in a semiotic perspective<\/h3>\n<p>It is an obvious goal for physiotherapists to alleviate patients\u2019 suffering, but equally important is to render them capable of self-help in the longer term. The latter is considered particularly urgent in the treatment of MUPS. Positive clinical encounters with this patient group require first and foremost that physiotherapists raise their awareness and deepen their own understanding of the body. According to Nicholls and Gibson (<span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2010<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Nicholls <span class=\"NLM_given-names\">DA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Gibson <span class=\"NLM_given-names\">BE<\/span><\/span> <span class=\"NLM_year\">2010<\/span> <span class=\"NLM_article-title\">The body and physiotherapy<\/span>. Physiotherapy Theory and Practice 26: <span class=\"NLM_fpage\">497<\/span>\u2013<span class=\"NLM_lpage\">509<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/doi\/10.3109\/09593981003710316\" target=\"_blank\" rel=\"noopener\">[Taylor &amp; Francis Online]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2010&amp;pages=497-509&amp;author=DA+Nicholls&amp;author=BE+Gibson&amp;title=The+body+and+physiotherapy&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>), the body as a philosophical and theoretical construct has not been a topic for physiotherapists. They claim that \u201cPhysiotherapists have a paradoxical relationship to the body, which is ubiquitous in practice but absent in theory.\u201d The challenges related to MUPS reflect this. Little attention is paid to the body as a self-conscious and self-preserving biological organism in an evolutionary perspective. In order to communicate knowledge about the body as a purposeful biological organism governed by its own experience and evolutionary knowledge, physiotherapists themselves must assimilate this insight. The need for revision is also now being expressed within the ranks of evidence-based medicine, with a new focus on context and individualism through meaningful dialogue (Greenhalgh, Howick, and Maskrey, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2014<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Greenhalgh <span class=\"NLM_given-names\">T<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Howick <span class=\"NLM_given-names\">J<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Maskrey <span class=\"NLM_given-names\">N<\/span><\/span><span class=\"NLM_year\">2014<\/span> <span class=\"NLM_article-title\">Evidence based medicine: A movement in crisis?<\/span> BMJ 348: <span class=\"NLM_fpage\">g3725<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0011&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1136%2Fbmj.g3725\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0011&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=24927763\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0011&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000337410400001\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2014&amp;pages=g3725&amp;author=T+Greenhalgh&amp;author=J+Howick&amp;author=N+Maskrey&amp;title=Evidence+based+medicine:+A+movement+in+crisis?&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>A further element in a semiotic approach will be a conscious focus on the meaning aspect of symptoms. When the significance of a symptom has been examined as thoroughly as possible in a medical sense, an investigation of its meaning becomes important. This means that the physiotherapist must acquire an understanding of the patient\u2019s experience, thoughts, notions, and expectations with regard to the symptom, as well as the feelings related to it. Insight into this enables an understanding of the symptom in light of the patient\u2019s learning and life history and of the current situation as it stands. A dialogue that seeks to identify the meaning of the pain is based on the idea that the solution to the problem lies with the patient him\/herself, not with the physiotherapist or doctor, and that the possible function of the signs will emerge through the conversation. In this context, we have referred to the function of self-referential signs as warnings and reminders, but what the warning actually implies will be specific to the individual. Using the physiotherapist\u2019s knowledge and understanding of the experiencing body, the patient can be guided into an awareness-raising process in which negative interpretive habits can be revealed and broken.<\/p>\n<p>Each and every symptom will have a meaning, irrespective of whether the signs are self-referential or point to a causal explanation, explained or unexplained symptoms. The meaning that pain has for the patient will color his\/her experience of it and the way in which the patient relates to it. At the same time, the life situation of the patient and his\/her roles in life will be decisive: active sportsperson, new employee, mother of small children, pensioner? Back pain, regardless of the cause, will have a different meaning for an active sportsperson than for a pensioner. In both cases, it is essential to gain an insight into this, providing a better opportunity to approach the patient where he\/she is, mentally and emotionally. In this way, we can come to an understanding of what drives and motivates the patient, i.e., what is at stake for the individual.<\/p>\n<p>In line with the distinction between the significance of the symptom and its meaning, there is a third point in the clinical approach we argue for here: the differentiation between causes and reasons. Various reasons may exist alongside well-defined, verifiable causes. Personality factors such as vulnerability and disposition may be both underlying and maintaining reasons, while disease or injury may be triggering and appear as causally related signs. Living conditions and serious life events can presumably be underlying, maintaining, and triggering. Thus in many cases, both types of indices appear in parallel; however, the self-referential signs, which perhaps reflect reasons to a greater degree, require a different insight and a different approach. In other words, various complex access points exist to a condition of MUPS, and the exit points are highly individual. Evidence-based medicine as we know it will fall short here, based as it is on the average person. It will be crucial for the physiotherapist, in liaison with the patient, to attempt to sort through this complex picture in order to see associations and understand the origin and development of the pain. It will then be possible to explain the unexplained, or at least make some progress, not only based on medical premises but also existentially.<\/p>\n<\/div>\n<div id=\"S0004-S2002\" class=\"NLM_sec NLM_sec_level_2\">\n<h3 id=\"_i15\" class=\"section-heading-3\">A semiotic model can integrate various types of knowledge<\/h3>\n<p>Unexplained pain is rarely perceived as a meaningful sign in the service of the organism, in the way that we see it. The meaning aspect of signs runs the risk of being overlooked in the solution and action-oriented therapist\u2019s focus on repair. But should pain, irrespective of what it may be an expression of, be alleviated in every situation? In contrast to etiological signs, self-referential signs do not call for an external solution, such as medication or surgery, or physiotherapy directed at symptoms. Relief of unexplained symptoms may undermine important premises for change, lead to overtreatment, and render the condition more entrenched.<\/p>\n<p>Many physiotherapists are concerned with, and now receive training in, cognitive forms of treatment. They communicate knowledge of the associations between experience, interpretation, and perception of pain. A cognitive approach is highly relevant and is encompassed by a semiotic perspective, whereby the patient is guided toward raising his\/her awareness of automatic patterns of thought and action and, as von der Fehr expresses it, \u201cis helped towards a constructive doubt\u201d (von der Fehr, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2008<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">von der Fehr <span class=\"NLM_given-names\">D<\/span><\/span> <span class=\"NLM_year\">2008<\/span> N\u00e5r Kroppen Tenker. <span class=\"NLM_publisher-loc\">Oslo<\/span>, <span class=\"NLM_publisher-name\">Universitetsforlaget<\/span>.<span class=\"ref-links\">\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2008&amp;author=D+von+der+Fehr&amp;title=N%C3%A5r+Kroppen+Tenker&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>).<\/p>\n<p>Also recent research in pain physiology forces us to reevaluate traditional understandings of the mechanisms and perception of pain. It appears that nociception occurs continually at unconscious, subconscious, and pre-conscious levels, as an ongoing bodily defense mechanism (Baliki and Apkarian, <span class=\"ref-lnk\"><a href=\"http:\/\/www.tandfonline.com\/eprint\/E4cJ68rtGX7NfSvDTvBP\/full#\">2015<\/a><span class=\"ref-overlay scrollable-ref\"><span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span> <span class=\"NLM_year\">2015<\/span><span class=\"NLM_article-title\">Nociception, pain, negative moods and behaviour selection<\/span>. Neuron 87: <span class=\"NLM_fpage\">474<\/span>\u2013<span class=\"NLM_lpage\">491<\/span>.<span class=\"ref-links\"><span class=\"xlinks-container\"><a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=16&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=10.1016%2Fj.neuron.2015.06.005\" target=\"_blank\" rel=\"noopener\">[Crossref]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=8&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=26247858\" target=\"_blank\" rel=\"noopener\">[PubMed]<\/a>, <a href=\"http:\/\/www.tandfonline.com\/servlet\/linkout?suffix=CIT0002&amp;dbid=128&amp;doi=10.1080%2F09593985.2017.1422164&amp;key=000361145000005\" target=\"_blank\" rel=\"noopener\">[Web of Science \u00ae]<\/a><\/span>,,\u00a0<span class=\"googleScholar-container\"><a class=\"google-scholar\" href=\"http:\/\/scholar.google.com\/scholar_lookup?hl=en&amp;publication_year=2015&amp;pages=474-491&amp;author=MN+Baliki&amp;author=AV+Apkarian&amp;title=Nociception,+pain,+negative+moods+and+behaviour+selection&amp;\" target=\"_blank\" rel=\"noopener\">[Google Scholar]<\/a><\/span><\/span><\/span><\/span>). Again, these mechanisms can be understood as the body\u2019s sign-based internal communication. At the moment in which the pain is consciously experienced, it is a final product of interpretation, at both a peripheral and central level, and the result of the interaction and influence of various cerebral networks, based on learning and adaptation.<\/p>\n<p>A survey of various factors, in accordance with the biopsychosocial model, will help to obtain an overview and an insight into the patient\u2019s situation. However, unless attention is paid to interpretation as a crucial factor in learning and adaptation, a deeper understanding of the patient\u2019s lived experience may be lost. Nor will the biopsychosocial model enable the physiotherapist to differentiate between different types of sign; the causally related and the self-referential. As we have seen, these occur in a complex interplay and will mutually affect each other. The former can, in the best case scenario, be alleviated by means of evidence-based knowledge and practice. The latter requires an approach that extends beyond, but may include, both the biopsychosocial model and evidence-based medicine.<\/p>\n<\/div>\n<\/div>\n<div id=\"S0005\" class=\"NLM_sec NLM_sec_level_1\">\n<h2 id=\"_i16\" class=\"section-heading-2\">Conclusion<\/h2>\n<p>Various narratives lie concealed behind life and disease histories. In the interpretation of subjective reality, thought and behavior can establish themselves as bodily habits that conflict with the organism\u2019s attempts to maintain a dynamic balance. From a body-logic and evolutionary perspective, it seems reasonable that the organism notifies or warns itself of dysfunctional conditions and inexpedient behavior, as it does in cases of acute and transient pain. The understanding of self-referential signs is most important here.<\/p>\n<p>A semiotic model offers a conceptual framework into which the physiotherapist\u2019s knowledge and understanding of the body and its symptoms can be placed. As a meta-theory, it will encompass and integrate knowledge from disciplines that are all relevant in the encounter with the interpretive body: biology and neuroscience, psychology and sociology. In this context, the biopsychosocial model can help to provide a structured, holistic overview of significant factors in the patient\u2019s life and health. However, in order to understand the individual on the body\u2019s premises, as a biological mechanism saturated with experience, the person\u2019s meaning-making activity must be explored.<\/p>\n<p>In accordance with neurobiological knowledge, the dichotomies of body\/mind, objective\/subjective are set aside, making it possible to free ourselves from the restrictive effects of dualism and biomedicine on health science\u2019s thinking, language, and practice. Doctors and physiotherapists are provided with a basis for differentiating various types of bodily signs and integrating knowledge from different philosophies of science in their approach to the patient. Greater attention to first-person experience includes the patient in a manner that removes an unnatural separation between the patient and the affliction. This means both acknowledging patients and making them accountable, which we believe will enable constructive clinical encounters.<\/p>\n<\/div>\n<div id=\"S0006\" class=\"NLM_sec NLM_sec_level_1\">\n<h2 id=\"_i17\" class=\"section-heading-2\">Declaration of interest<\/h2>\n<p>The authors report no declaration of interest.<\/p>\n<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<h2 id=\"figures\">References<\/h2>\n<ul id=\"references-Section\" class=\"references numeric-ordered-list\">\n<li id=\"CIT0001\"><span class=\"hlFld-ContribAuthor\">Apkarian <span class=\"NLM_given-names\">AV<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Hashmi <span class=\"NLM_given-names\">JA<\/span><\/span>, <span class=\"hlFld-ContribAuthor\">Baliki <span class=\"NLM_given-names\">MN<\/span><\/span> <span class=\"NLM_year\">2011<\/span> <span class=\"NLM_article-title\">Pain and the Brain: Specificity and plasticity of the brain in clinical chronic pain<\/span>. 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A semiotic perspective on chronic pain Kari Irene H. Busvold , PT, MS &amp; Hilde Bondevik , PhD Pages 1-9 | Received 10 Apr 2016, Accepted 16 Mar 2017, Published online: 08 Jan 2018 Pages [&hellip;]<\/p>\n","protected":false},"author":61,"featured_media":0,"parent":161,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-151","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/pages\/151","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/users\/61"}],"replies":[{"embeddable":true,"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/comments?post=151"}],"version-history":[{"count":5,"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/pages\/151\/revisions"}],"predecessor-version":[{"id":163,"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/pages\/151\/revisions\/163"}],"up":[{"embeddable":true,"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/pages\/161"}],"wp:attachment":[{"href":"https:\/\/wordpress.usn.no\/214088\/wp-json\/wp\/v2\/media?parent=151"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}