Interoception and Predictive Processing: Transforming Neuromusculoskeletal Care

As healthcare professionals and healers, our goal extends beyond treating symptoms—we aim to help patients fundamentally reshape their relationship with their bodies and pain. Understanding interoception through the lens of predictive processing offers a revolutionary framework for achieving this transformation in neuromusculoskeletal (NMS) care.

What is Interoception?

The National Institutes of Health defines interoception as “the representation of the internal states of an organism, and includes the processes by which it senses, interprets, integrates, and regulates signals from within itself.” Simply put, interoception is how we perceive our body’s internal state—where our autonomic, somatic, and visceral nervous systems meet.

But here’s what makes this particularly relevant: interoception isn’t just about receiving signals; it’s a key input for our brain to predict our energy needs and status. In addition, interoception is a primary sensory input for allostatic processes that interprets and responds to those signals. Along with homeostasis, allostasis and interoception shape how we feel, and how we behave.

The Predictive Brain and Pain Experience

Our brains don’t passively wait for sensory information. Instead, they constantly generate predictions about what we should feel, then compare these predictions against incoming signals. Pain emerges from the interaction between these top-down predictions and bottom-up sensory information—including interoceptive signals.

This has profound implications: the pain someone experiences isn’t solely determined by tissue state. Prior beliefs, past experiences, clinical language, and cultural context all shape the internal model that generates predictions. When someone’s been told they have “the spine of a 90-year-old” or that they’ll “end up in a wheelchair,” these predictions become part of their system, influencing what they experience. Then they predict more of the same- actively. Active Inference is the neurological mechanism of predictive processing, and it shapes how we view ourselves, and our world- for better or worse.

Why Traditional Approaches May Miss the Mark

Many NMS interventions focus primarily on tissue capacity—building strength, improving flexibility, or correcting biomechanical “dysfunction.” Yet research on exercise for conditions like back pain shows only modest effects, barely meeting minimal clinically important differences.

The philosophical mismatch is clear: if pain emerges from predictive processes involving multiple factors, why do most interventions target only tissue mechanics? Most trials acknowledge pain is biopsychosocial in their introductions, then test whether strength training helps—rarely specifying what mechanism they’re actually addressing.

The evidence reflects the approach. When interventions don’t target how pain actually works, we shouldn’t be surprised by underwhelming results.

Interoceptive Awareness as Model Updating

A 2023 systematic review by Locatelli et al. examining chronic NMS and psychological conditions found that weak interoceptive accuracy was linked to impaired body signal detection and reaction, while higher interoceptive sensitivity was associated with lower symptom severity and frequency. In other words, people more connected to their body’s internal signals experience less pain, less often.

From a predictive processing perspective, this makes perfect sense. Here’s why:

Differential weighting of sensory information: People in persistent pain become exceptionally good at detecting noxious signals while becoming poor at detecting non-noxious information. Their nervous system prioritizes—or “shines a spotlight on”—nociceptive input while suppressing competing sensory streams that would signal “I’m okay, this is normal.”

When someone co-activates muscles and braces, they’re not moving “maladaptively.” Rather, they’re moving in ways that confirm their system’s predictions. By stiffening and not moving, they also deprive themselves of the competing non-noxious interoceptive information that would challenge those predictions—information from normal movement that says “my body is capable and safe.”

The StrongPosture® BAM Framework: A Biobehavioral Solution

This is where the StrongPosture® Balance-Alignment-Motion (BAM) protocols become transformative. Rather than treating posture, balance, and motor control as purely biomechanical issues, the BAM approach recognizes them as opportunities for interoceptive learning and model updating.

Balance isn’t just about preventing falls—it’s about helping patients tune into subtle proprioceptive and vestibular signals, as well as the super-subtle interoceptive ones they’ve been ignoring to rebalance how their nervous system weights sensory information.

Alignment isn’t about achieving “perfect posture”—it’s about creating experiential awareness of asymmetries and demonstrating that small adjustments can create surprisingly positive changes in how movement occurs and feels.

Motion isn’t about exercise prescription—it’s about movement awareness of control with experimentation that creates “positive surprises”- experiences better than predicted, which update internal models about body capability.

This integrated approach addresses the very mechanisms that research shows actually matter: not just tissue capacity, but how patients perceive, predict, and respond to their body’s signals.

Movement Experimentation as Interoceptive Learning

Many promising interventions align with this biobehavioral understanding:

The mechanism isn’t building tissue capacity—it’s updating internal models about body capability.

Experiential learning updates their internal model far more powerfully than any explanation of neurophysiology.

For example, on initial evaluation if a potential patient says “I can’t lift my arm more than halfway up.”

SAY>>”SHOW ME. Now, find the edge where it just starts to hurt. When you JUST START to feel the pain… STOP!!”

Then, WATCH what they do. OBSERVE them explore, and HOW they explore to find the edge between pain-free and pain-ful (not full of pain, just kissing the edge) until they hold the arm at a position.

Then SAY>> “THAT’s THE EDGE where PAIN begins. GREAT!” Direct them to a wall (or a tree) to note how high they can life pain-free.

This is the beginning of curating interceptive awareness with somatic communication and starting a StrongPosture® alignment protocol:

Have the person stand tall, roll their shoulders all the UP; then keeping them up, press them BACK; then keeping them back, depress the blades all the way DOWN so they descend inferiorly on the posterior ribcage. Done correctly this opens up the front of the torso. Then maintaining that stronger posture, ask them to repeat lifting up their arm, measuring it against the wall (or tree).

Sometimes their elevation will markedly improve, sometimes it will move or feel a bit better… or worse. But most always it change their perception of pain, as well as their awareness of how they are moving.

This is precisely the type of movement experimentation taken with a Biobehavioral approach, using the StrongPosture® concepts and BAM protocols.

Graded sensory motor retraining works, as does biopsychosocial, cognitive and experiental retraining. Multiple studies show non-surgical, non-pharmacological care can equal or surpass results for many NMS conditions. It’s more than placebo, and it’s more than the “everything gets better over time” effect. Systematically integrating common-sense biomechanic concepts with somatic communication to cue novel perceptions recruits active inference to qualitatively reshape all in-office and at home exercise. It’s creating experiences that engage people to actionably shift subtleties of their posture, body and movements, building conscious awareness and non-conscious small muscle fiber recruitment towards greater symmetry and control during activities of living.

That’s the essence of the StrongPosture® methodology taught by thousands of doctors, therapists and CPEPs, healers who have found these ideas are force multipliers for their other therapeutics. Taking a Biobehavioral approach makes guiding each individual (and practice) to go deeper with a tailored approach that improves outcomes for clinicians and patients, as well as being a framework to teach everyone how to use their body more effectively in everything they do.

The Clinical Touch: Assessment as BodyMind Care from the Initial Visit

NMS professionals are often the first to touch patients where they hurt. This experience carries profound potential when understood through a predictive lens.

A skilled, systematic physical examination isn’t just assessment—it’s intervention. When done with clear communication and thoughtful progression, it can demonstrate that “the system is better than I thought it would be.”

The StrongPosture® approach leverages this power by coupling somatic awareness of subtle asymmetries with experiential exploration of biomechanic function. When you guide patients to explore how their body moves (and can move) with attentional focus, they find hidden restrictions…and potential capacity. The active inference mental process is updating their prediction of how it would feel, or how they could move, in real-time. It’s a different kind of awareness because theres a strong interoceptive sensory input, sensations that are transmitted to the brain differently than proprioception, and processed in a different part of the brain- the insula. Done well, and coupled with manual therapies that unlock restrictions, it creates experiences that people remember, and often makes them say “Wow!”.

Where do you start: Consider incorporating balance into your exam for every, especially anyone with a recent head injury or who has suffered an auto accident injury. By systematically testing balance and movement, communicating throughout, and demonstrating capability, you create opportunities for model updating. Testing instability is experiental- the patient isn’t being told they’re unstable, they’re experiencing it, feeling it, seeing it move normally. Creating memories that persist, learning that sticks.

That’s Interoceptive learning: bringing unconscious predictions into conscious awareness through focused attention and novel sensory experiences.

Practical Strategies for Building Interoceptive Awareness

1. Movement experimentation over exercise prescription Rather than “three sets of ten,” explore movement variations that create positive surprise. Can we find a way to do this task that’s less painful, less fear-laden, more capable than expected? That becomes the foundation of your program—funneling efforts down pathways that violate negative predictions.

2. Breath and body awareness as gateways Breathing is an accessible point for interoception—an unconscious function we can bring into conscious awareness. But the goal isn’t just relaxation; it’s demonstrating modifiability. When someone experiences that they can influence their internal state, it challenges fixed models about their body being “broken” or “out of control.”

3. Reframe the physical examination Your neuro exam is clear—that’s the essential beginning of an authentic healing relationship. “We’ve ruled out serious pathology. Your joint is stable through every test—it’s stronger than you expected. That” These aren’t just findings; they’re opportunities for experiential learning that shapes the patient’s internal model.

4. Posture awareness as an interoceptive gateway The StrongPosture® protocols use posture awareness not as a correction tool, but as a gateway to strengthen interoceptive awareness, and then strengthen somatic control. By focusing attention on ever-present but subtle sensations—where weight distributes through your feet, how your ribcage sits over your pelvis, the quality of movement through your spine—you bring unconscious input into conscious awareness. This is the same process by which we learn a new sport or modify unconscious functions like breathing.

5. Context and language matter profoundly Avoid language that reinforces predictions of fragility, damage, or inevitable decline. Instead, demonstrate capability, highlight what’s working well, and frame findings in ways that open possibilities rather than close them.

From Rehab to Performance to Healthy Aging

What makes this biobehavioral approach truly revolutionary is its universality. The same principles that help someone overcome chronic pain also enhance athletic performance and support healthy aging:

In rehabilitation: Patients learn to reweight sensory information, challenge predictions of fragility, and experientially discover their body’s resilience.

In athletic performance: Athletes develop refined interoceptive awareness that improves movement efficiency, reduces injury risk, and enhances the mind-body connection essential for peak performance.

In healthy aging: Older adults maintain body awareness and movement confidence, preventing the downward spiral where fear of movement leads to reduced activity, deconditioning, and increased pain.

All three populations benefit from the same core mechanism: updating internal models through interoceptive learning and movement experimentation.

What We’re Really Teaching

When we improve interoceptive awareness through approaches like the StrongPosture® BAM protocols, we’re not just helping patients “listen to their body.” We’re helping them:

Update predictions about their body’s capability and safety
Reweight sensory information to include non-noxious signals alongside nociceptive input
Build new models through experiential learning rather than explanation
Self-evidence their capacity through action and exploration
Develop sustainable habits based on body awareness rather than fear avoidance

This is why exercise can be enormously useful when applied compatibly with how pain works—not as tissue conditioning, but as laying down and reinforcing models that “my body is capable.”

Expanding Your Clinical Impact

My new course, Biomechanics and Interoception: A Biobehavioral Approach is a novel integration in the synthesizes these emerging insights with the proven StrongPosture® BAM protocols. We’re creating a comprehensive framework grounded in active inference and contemporary pain science.The integration of interoception and predictive processing into clinical practice represents a paradigm shift—If you’re helping people now, it’s one that enhances and expands how people view your care. Rather than replaces your existing skills, your hands-on expertise, movement assessment capabilities, and therapeutic touch all become more powerful when understood through this lens.

Whether you’re:

New to these concepts: The StrongPosture® BAM protocols from the original Posture, Balance and Motor Control Exercise course provides a structured, immediately applicable system for integrating balance, alignment, and motion work with interoceptive awareness
Already using StrongPosture® protocols, or want to focus deep to start: Biomechanics and Interoception is a Biobehavioral Approach to Body-Mind Methods for Pain, Performance and Healthy Longevity. You’ll learn to understand underlying mechanisms of why these approaches work, allowing you to apply them more effectively and adapting them to diverse populations

Both pathways equip you to create the memorable, transformative patient experiences that build lasting change.

Steven Weiniger DC, DIANM

Creator StrongPosture® protocols & CPEP®

Ready to transform your practice?

Explore the StrongPosture® BAM protocols to integrate balance, alignment, and motion work with cutting-edge interoceptive awareness training—or advance your existing StrongPosture® skills with the Biomechanics and Interoception: A Biobehavioral Approach Course to master Dr. Weiniger’s novel integration of active inference for rehabilitation, athletic performance, and healthy aging.

References:

Khalsa SS, et al. Interoception and Mental Health: A Roadmap. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(6):501-513.
Locatelli E, et al. What is the role of interoception in the symptom experience of people with a chronic condition? A systematic review. Neurosci Biobehav Rev. 2023;154:105394.