Rehabilitation Matters

The Truth of the Quiet Box

A few weeks ago a friend was fund raising for charity by paticipating in the Iron Man Wales event.  My wife and I went to see him off - from a safe distance.  It's quite a challenge starting with a 3.8 km swim, followed by a 180k bike ride and finished off with a 42.1 km run. Not exactly something to take casually. 

Andy had just finished the bike section and was starting the run when he heard the PA system announce ".. And here comes the oldest competitor!" 

Just for a second Andy thought the announcer was referring to him but then as he looked back he saw right behind him was indeed the oldest competitor - a 75 year old man. 

I think most of us would think that a 75 year old doing Iron Man Wales was beyond belief.  After all we have evidence all around us that suggests such a feat would be impossible.

Isn't that the trouble with beliefs. We all hold them - and yet they have an often silent and unconscious grip on our lives.  My one time mentor, Michael Breen used to say something like, "If you are going to have beliefs - make sure you choose useful ones".  Sadly most of us don't.  We don't even know how strongly our lives are shaped by the beliefs we hold.  Our beliefs can be like stealthy parasites that steal our lives and infect those around us.

Working in rehabilitation I am very interested in my client's beliefs about what they can achieve in their lives as they recover from their injuries.  I meet many spinal cord injured people who would like to believe that they might walk again some day.  The challenge is that all around these people are others that want them to stay "realistic" - to accept that they will never walk again.  So often well meaning observers manage to "kill hope" rather than nurture realism.  Certainly this world requires that we take action in the moment; we can't neglect that.  However, the purpose with which we act shapes the way our world becomes.  Without mankind stretching what is possible and believable we would still be living in caves.

Here is a nice story from Kensho Furuya (Kodo - Ancient Ways)

The Master said, "Think about this.  I have here two small wooden boxes of the same size."  Holding up the boxes one at a time he told his students, "Listen. When I knock on this one, a loud sound resonates around the room.  When I knock on this other one, there is hardly any sound at all."

"Now tell me, from our experience of such things, what do we already know about the loud-sounding box?" asked the Master.  The students understood that the box was empty.

"And what do you make of the quiet box?" asked the Master again.  The students recognised that this box was full of something.

So the Master posed a question.  "Tell me, with human enterprise in mind, do we use the lessons of the wooden boxes?"

A student answered at once, "We certainly do not, Master.  We only take notice of who makes the loudest noise.  We don't pay attention to the quiet one."

A second student spoke up.  "I can see what you are suggesting but in our democracy the majority rules.  What the majority believes is desireable is supported and will grow in influence as a result."

"I agree," replied the Master.  "But keep in mind that the value of an idea or of a belief is is not determined by how many people believe it or choose to follow it."

In times gone by the majority may have believed that the world were flat or that the sun moved around the Earth.  The majority idea it didn't make it a fact.

There may be a deeper truth that is separate from the ideas of majority and minority.  If this truth exists it will lie within each of us awaiting cultivation.

Motor Neuron Lesions - Influence on FES following Spinal Cord Injury

One very popular and effective way for spinal cord injured persons to exercise their legs is through using Functional Electrical Stimulation (FES) - sometimes in combination with a FES bike (FES Cycle).  This taps into a knowledge of neurology to usefully activate paralysed muscle.

But not every individual can take advantage of this technology.  Let's see why.

In very basic terms, there are two groups of spinal cord injured persons.

One group has innervated and paralysed muscles (so called upper motor neuron lesions) and the Second group has denervated and paralysed muscles (so called lower motor neuron lesions).

There are formal explanations of  lower motor neuron and upper motor neuron lesions that you can read if you are interested.  Injuries around the lower thoracic level are likely to affect the lower motor neurons.

From the point of electrical stimulation and rehabilitation strategies these groups have to be treated differently.

FES, as we commonly see it, uses quite small levels of electrical energy applied to the surface of a leg muscle for example.  When a pulse of energy is applied in a "suitable" form to a person with an upper motor neuron lesion, the lower motor neuron is intact and the energy causes the intact nerve structure to "fire" propogate through the nerve structures and make the muscle contract. 

However, when the lower motor neuron is damaged, applying the same level of energy to a muscle seems to create no effect.  The nerve does not fire. In fact the nerve and muscle fibres may have regressed and the tissue quality deteriorated over time; especially when the injury is more than a couple of years old.

Whilst of course each person is unique to some extent, persons with upper motor neuron lesions can use a bike such as the RehaMove FES Cycle and in practical terms persons with denervated muscles cannot.

There is a caveat though.  I have clients who, during their time in early rehab, were classified as denervated and they didnt respond to stimulation.  However, they persisted using conventional FES and after a number of months had recovered enough to be able to use a full FES Cycle.  The problem with trying to draw conclusions from this is that we dont know whether this recovery was due to the bodies natural processes (and would have occured anyway) - or whether they were not completely denervated and the use of stimulation had strengthened the innervated component. (Hope this is clear!)

Anyway, we now have an innovative new product that uses direct muscle stimulation.  The Stimulette den2x is especially designed to rescue denervated muscles.  The stimulation parameters are quite different from those used with intact lower motor neurons.  Such stimulation has been a subject of interest for quite a considerable period and after many years of research - particularly in Austria - an effective technique has ben found. 

Clients with denervated muscles can now restore the tissue bulk and quality of thir limbs to reduce the risk of pressure sores, enhance circulation and ultimately develop improved fitness.

Biofeedback Methods to Assist Recovery After Spinal Cord Injury

I had a brief conversation with a client today on the topic of Biofeedback methods that could be used to assist in muscle functional recovery folowing a spinal cord injury.  Im going share some of my observations in this blog. 

In particular, I refer to the Brucker method and IMF (Intention Controlled Myofeedback) methods of so-called "operant conditioning". 

The basic idea has been around a long time and attributed to psychologist BF Skinner who experimented with the notion that

A behavior followed by a reinforcing stimulus results in an increased probability of that behavior occurring in the future.

His "Operant Conditioning" approach and its related methods has two elements -

The first is the detection of some useful event (the behaviour) - the second is to provide feedback to the observed entity with positive stimulus to reinforce the useful behaviour. 

 The classic studies were performed with Rats who were rewarded for succesfully pressing a lever. The stimulus used to reinforce the behaviour was the delivery of a tasty treat.  One of the issues that limits practicality is that the biofeedback tends to become less effective over time.  (In other words a hungry rat quickly learns to press the lever to get the treat but soon stops once the hunger is satisfied)

The field of Biofeedback developed and refined these ideas and applied them to a broad range of applications including a number in rehabilitation.

 So what's this got to do with spinal cord injury?

Well suppose that you have an "incomplete" spinal cord injury.  It may be the case that the muscles are partially denervated and yet a weakened inervated component remains.

Suppose it were possible to detect the faint traces of nerve activity deep in the muscle and then immediately provide a stimulus to the muscle to increase the likelyhood of that muscle activity becoming stronger?  Well that's the idea at work here.

EMG sensors "listen" for activity in the muscles of interest.  The client consciously imagines moving the legs or the muscles of interest and if an EMG signal is detected above a specific threshold, then muscle stimulation is provided through surface electrodes to make the muscles contract

These "therapies" are well known as complementary measures that have apprarently given support to many patients in the past.  They capitalise in natural recovery and training of any residual nerve function but may well recruit additional neural activity as well. 

They are relatively expensive and do not confer any additional benefit such as cardiovascular fitness as in FES Cycling or Rowing. The maximum benefit is within the first year but they certainly do no harm.  As always with these therapies and approaches - dont swallow claims whole - research carefully and balance hope with practical demonstrations of utility.

I tried the IMF method with one client who had denervated muscles in her thighs due to a low thoracic spinal cord injury.  The IMF method did not demonstrate to have any useful function for her.

You can also read this at the Institute of Spinal Cord Injury

Molecules of Emotion

We are all designed, as human beings, to respond to change as if our lives depended upon it.  Often our lives do depend on how we respond.  Change has effects that ripple not just through the structures and processes of an organisation, but down to the level of a single cell in each of our bodies. 

When we actively feel something, it is truly engaging our whole physiology and not just our thoughts and imagination.  Science tells us that every single cell in our body is influenced by our feelings through our nervous system and the flow of our “molecules of emotion”.  Candice Pert (1999) came up with this term to describe the many hormones within our body that literally act as a chemical nervous system having the power to make us well or make us ill.

In this article, we step back a few years to glimpse how science once viewed human physiology, before we can pin down why this is relevant to us.

Communication begins and ends with a single cell
It’s common knowledge that the computing power inside our skulls greatly exceeds that of any supercomputer in the world.  But for decades people thought of the brain and its extension, the central nervous system (CNS), as primarily an electrical communication system.  The CNS seemed to function in a manner not too different from the semiconductor-based electronic computer. 

It was common knowledge that the tiny neurons, or nerve cells, form something resembling a telephone system with miles of intricately criss-crossing wiring.  The dominance of this image in the public mind was due to the fact that science only had convenient tools to see and study the electrical signals.  Only relatively recently did we develop the tools that allow us to observe what we could call the “chemical brain”. 

Candice Pert coined the term molecules of emotion to describe the flow of chemicals that make up this very special part of us.  Even when we had the evidence, it was hard for science to grasp the idea that we had this second nervous system; one that operated on a much longer time scale and over greater biological distances. 

Especially difficult to accept was that this chemical-based system was indisputably more ancient and far more basic to the human organism than the one we had studied before.  There were peptides such as endorphins, for instance, being made inside cells long before there were dendrites, axons, or even neurons – in fact - before there were brains. 

Since the 1980’s, scientists have been abe to talk of information molecules – the basic units of a complex language used by cells throughout the body to communicate across systems such as the endocrine, neurological, gastrointestinal and even the immune system.  Our bodies literally listen to our emotional state and respond accordingly.  In this respect thoughts are things.

Hundreds of hormones flow through our bodies because of our emotions and then our bodies will ultimately manifest the consequence of those feelings.  Sad feelings actually produce sad bodies.  Depressed feelings produce depressed and ageing bodies and happy feelings produce healthier and youthful bodies.  This is important because it implies what science confirms.  In the developed countries of the world, the three things that kill most people – cancer, heart attacks and stokes, are linked to how we respond to change.

The human body is a dynamic, constantly changing system in it’s own right.  A Greek Philosopher said - “You cannot step into the same river twice – new water is always flowing in”.  In fact, science now knows that our bodies are very much like that river.  In every second of your existence you are creating a new body.  Every year you replace 98% of the atoms in your body. You make a new liver every 6 weeks, a new skeleton every 3 months, a new stomach lining every 5 days and a new skin once a month.  Even the very brain cells you think with today weren’t there last year. When faced with stress we are influencing how that change takes place.  The organisational response to change is echoed by a response within the living cells of each member the organisation. 

Did you know that our physiology has hardly evolved since sabre tooth tigers roamed the Earth?  In those days our “fight or flight” physiology equipped us very well for survival and allowed our hormones to naturally achieve balance once a threat was relieved. 

In comparison, the environment in which we must live and work today changes unceasingly.  A swarm of emails, aggressive or demanding colleagues, sales targets, more plans and pressure to perform, an unreasonable Board of Directors, and so on have replaced the sabre tooth tiger. 

The trouble begins because even though these daily demands may not be consciously perceived by us as a threat, their effects can still be profound.  This is because our bodies just might tend to respond in a way that true balance is rarely achieved.  These stress hormones may feel temporarily energizing but when they circulate for too long they promote symptoms such as aggressiveness, impatience, anger and insensitivity. Not exactly a recipe for good health or effective leadership. 

I know plenty of carrot and stick entrepreneurs. They believe and act to gain and keep control.  In some cultures, this is still a persistent view of what it takes to lead; unconsciously built on the fact that stress hormones may actually be addictive.  However, work with such an adrenaline fuelled feeling for too long and business performance, relationships and individual health will suffer.

The good news is that it is not necessary to withdraw from work and life to achieve balance again.  Our body does have the ability to achieve balance in real-time and the key is in recognising when stress is at work for us and in learning techniques to adjust our own state.  Leaders therefore have a particular responsibility and a great opportunity.  A single word can have great impact.  A misplaced gesture or inappropriate tone from a leader can add to the turbulence and the perception of stress of hundreds, perhaps thousands, of people.

When leaders learn how to manage their personal state they can be calm and balanced in the most turbulent business conditions.  Such calmness and balance also brings clarity of thought and the opportunity to speak and act clearly and confidently. 

Science tells us that in our times of greatest stress our ability to think clearly is compromised – we are literally disconnected from the ability to be creative, thoughtful, intelligent or reasonable human beings.  When we can learn to be calm and balanced and in the right state others will entrain to our coherent words and actions.

Perlow and Williams (2003) point out that even silence – lack of communication – can set in motion powerful, destructive forces.  Referring to “vicious spirals of silence” the authors point out that often – behind failed products, broken processes, political wrangling and mistaken career decisions, are people who chose to hold their tongues.  Breaking the silence can bring an outpouring of fresh ideas from all levels of an organisation, potentially taking performance to a whole new level.  Leaders need to do better.

On a brighter note, Frans de Waal (2003) author of a book on “Chimpanzee Politics”, also hints that leadership just might have other privileges.  He describes the contests for leadership amongst male chimps in a Dutch zoo.  The contests appear to be mainly about the ability to build a coalition of supporters and to outwit rivals rather than anything to do with size and strength. 

Michael McGuire, a neuroscientist found that high ranking monkeys had high levels of serotonin – one of those natural chemicals associated with feelings of calm, well-being, confidence and general absence of stress.  The high level of serotonin appeared to be the consequence rather that the cause of the attainment of high rank.  When a leader was removed from the group his serotonin levels crashed.  As a new leader emerged, his levels started to climb until they were twice that of the next dominant male.

We aren’t going to stop change but we can learn to notice and influence its effects upon us.  From this balanced foundation, leaders can communicate coherently and effectively.  Balance is an important word.  It implies a position of effortless, stillness from which it is possible to move instantly in any direction. 

A senior manager in the pharmaceutical industry commented on an early draft of this document and told me that one of their key organisational values for leaders was a “sense of urgency”.  But what happens when everything is urgent?  Sometimes the most urgent thing to do sometimes is – nothing.

Leaders are masters of balance.  Sensing the time to act and the time to do nothing as well as understanding that they provide the leverage from which a whole organisation can turn.

References
Frans de Waal (2003) quoted in “Creating Leaders” from The Economist, “Tough at the Top – A survey of corporate leadership”, October 25th 2003, p 8

Perlow, L; Williams, S (2003), “Is silence killing your company?”, Harvard Business Review, May 2003, Vol. 81, Issue 5, p 52

Pert, C (1999), “Molecules of Emotion: The Science Behind Mind-Body Medicine”, Simon & Schuster, ISBN: 0684846349

Buddist Biker Beats Cognitive Decline

The Dalai Lama, watched a brain operation during a visit to an American medical school in the early 1990s and asked the surgeons a startling question: Can the mind give shape to brain matter?

When you think about it, why is it that older people drive so slowly in the outside lane of the motorway?  You can picture how it is – cloth cap, sitting close to the wheel, a white-knuckle grip and oblivious to what is happening around them.  

Wouldn’t you think that being older they would be in more of a hurry to get somewhere – less time to live and all that?  Now whenever I have offended someone with ranting about this they usually say,  “This decline you see - Its natural – its about cognitive decline – reflexes, balance, eyes etc getting poor with age.” 

I have for a long time wondered how much ageing is a natural event and how much of it is based on a belief – albeit a deeply held unconsicous one -  that we have been conditioned to turn into reality.  It seems that science is starting to agree with me.

A few years I was presenting at a conference on the topic of "orthotic management of stroke". The presentation had a few controversial elements to it.  Leaving aside the orthotic element, I mentioned the emerging science of neuroplasticity and how potentially this could be an area to watch in terms of stroke rehab.   Whatever happens, this topic will be a “Hot” one in years to come. 

My thought was – would it be possible to increase the plasticity of our cognitive processes with some form of exercise to allow much faster recovery in the event of a stroke? Or would it be possible to create some form of after-the-event exercise that would enhance stroke recovery?

 Until recently my master plan for prevention of cognitive decline was to give everyone over 50 a high powered motorcycle.  There are some other techniques being developed that might be more palatable for the majority.

 In response to the Dalai Lama's question,  neuroscientists had explained to him that since the 1980's we know that mental experiences reflect chemical and electrical changes in the brain. When electrical impulses zip through our visual cortex, for instance, we see; when neurochemicals course through the limbic system we feel.

But something had always bothered him about this explanation.

The Dalai Lama asked “Could it work the other way around?”

That is, in addition to the brain giving rise to thoughts and hopes and beliefs and emotions that add up to this thing we call the mind, maybe the mind also acts back on the brain to cause physical changes in the very matter that created it.  If so, then pure thought would change the brain's activity, its circuits or even its structure.

 One brain surgeon hardly paused. Physical states give rise to mental states, he asserted; "downward" causation from the mental to the physical is not possible.  Despite this slap down ten years ago, the Dalai Lama had put his finger on an emerging revolution in brain research.

Neuroscientists have since overthrown the dogma that the adult brain can't change.

We now know, its structure and activity can morph in response to experience, an ability called neuroplasticity.  The discovery has led to promising new treatments for children with dyslexia and for stroke patients, among others.

But the brain changes that were discovered in the first rounds of the neuroplasticity revolution reflected input from the outside world. For instance, certain synthesized speech can alter the auditory cortex of dyslexic kids in a way that lets their brains hear previously garbled syllables; intensely practiced movements can alter the motor cortex of stroke patients and allow them to move once paralyzed arms or legs.

The kind of change the Dalai Lama asked about was different. It would come from inside.

Something as intangible and insubstantial as a thought would actually rewire the brain. To the mandarins of neuroscience, the very idea seemed as likely as the wings of a butterfly leaving a dent on an armored tank.

What I know for sure - and science is reinforcing - Is that visualisation of tasks helps an athlete reach higher levels of performance.  So why should it be a surprise that stroke survivors who can visualise correct movement of their arms using Tailwind will make faster progress.  Our spinal cord injured clients should visualise their legs pedalling their FES bike if they want to make faster progress. Thoughts are things.