Our brain is a buzzing network of communication, which creates learning capacity, focus, mood, behaviour, emotional stability and memory. It allows us to work, play, sleep, focus on specifics, remember salient events or facts and produce emotionally
appropriate responses. When the brain is functioning efficiently all these come into play successfully. However, if we are battling with mood swings, anger or memory lapses, it suggests there is a neurological inefficiency somewhere
Training clients with brain stem damage can be immensely rewarding for both parties. The impact of endorphins kicking in should not be underestimated, but it does take a degree of physical exertion to achieve that, and that may not be appropriate for clients in early stages of recovery. Despondency can quickly set in when a gym setting does not suddenly mean the client can exercise energetically. Expectations have to be managed. The sense of achievement, when a new movement has been retrieved, however, can be exhilarating in its own way.
Years ago, stroke and brain trauma implied high dependency, total disability, and a full dissociation from active living. This is no longer the case, and today many people make a recovery sufficient to return to work and sport, in the long term. Others will benefit from rehabilitation and a skilful trainer to help them retrieve some level of movement and independence. Many of the early assumptions about brain injury have been challenged in recent years, and now the plasticity of the brain is accepted, implying much greater scope for recovery, but the need for greater understanding of this recovery process persists.
Head injuries, when people first began to survive them, were seen as holding out only a small window of recovery, during the first 6-18 months post trauma. After this time, intensive rehab programmes were withdrawn and the assumption was that no further progress would be made. While physical problems could be managed fairly readily, it was deemed that the long term cognitive and behaviour problems would prejudice the individual’s ultimate recovery. Now the emphasis is on a longer term recovery, and understanding that the client who has sustained serious head injuries still has the ongoing ability to learn and to adapt his behaviour, and ultimately to lead a satisfying and positive life.
Stroke survivors are also now returning to productive lives, after a sometimes lengthy rehab process. Hemiplegia and hemiparesis (a weakness on one side of the body) are debilitating and force the body into dysfunction, but much can be done to
re-educate the body to accept functional movement patterns again. Working with clients post stroke or brain trauma can be very challenging for a trainer: a year ago, I would have told you it was all about understanding function and movement, but now I see things very differently for this special population, and believe the solutions to be rooted in left/right perception and visual cues.
Mood swings and depression are very common in patients with stroke. As much as 50% of survivors will feel depressed or moody after a stroke. (Source: Stroke Association) After a stroke there may be rapid changes in mood: survivors might feel happy but then experience a dramatic turnabout and begin to feel very sad. Emotions can be all mixed up, with a desire to cry and/or laugh at inappropriate times. Just like depression, these mood swings can appear when there is an injury to a specific area of your brain.
It is useful, maybe even before meeting your new client, to read around the subject, to gain some insight into what your client may have lost in terms of cognitive ability, physical strength and emotional resilience. Organisations such as Headway and The Stroke Association provide plenty of information for those working with these special populations. However, the advice is only generic, and doesn’t tailor itself to your client. Brain injury isn’t general, and the rehab will always need to be specific. The primary focus for the trainer will always be to help the client to find his own path to recovery. This is especially important in clients who are looking for answers and are emotionally vulnerable.
Progress will be halting, sometimes counter-productive, frustrating. I have worked with stroke survivors over a period of weeks to retrieve a single movement, such as picking up a tennis ball, only to see the new skill lost again following on from a mild respiratory tract infection or simply a reduction of sensation in the weaker hand. These blips can cause much heartache for the client.
Clients may have lost the ability to retain optimism, may seem very pessimistic or cynical, and this can have a knock-on effect on the trainer’s ability to empathise, or motivate his client, but I have found it helpful to remind myself that these are not necessarily characteristics known to the client before the brain trauma.
The brain injured client probably has a long list of things he/she now hates, or things that make them feel vulnerable or anxious. Often these include tight clothing, external noise, certain smells, tastes or textures. Things that should be pleasurable such as sex or being in a happy social setting may actually induce pain. Pain can also erupt spontaneously, or seem disproportionate to the trigger.
Trainers and therapists will need to learn to read their client’s body language, and this is a much more difficult task than usual, since facial expressions may have become dissociated from the underlying emotion. Weaknesses in facial muscles will further impair this. Motion at the limbs may also be counter intentional. Mood interpretation is going to be affected by brain stem damage. The brain stem can organize motor movements such as reflexes. It coordinates with the motor cortex and associated areas to contribute to fine movements of limbs and the face.
Visual cues to assist movement can be a boon. In their favour, they can boost confidence, allowing the weak side to mirror movements and enabling the weak limb to achieve more through prompts. Ultimately the client wants the arm or leg to move through the correct set of messages coming from the brain down to the limb and it was previously thought that shortcuts wouldn’t really cut it in the long term. However, what I believe matters is that if the body hasn’t recognised the movement as functional, it may reject the movement, and resort to another level of drastic shutdown. Visual affirmation could be the difference between progress and a downward spiral of uncontrolled movement.
Other cues worth using, but not wholly depending on, are texture and sound. Texture and temperature can really help with simple movements. So much of my early stuff is about picking up extra cues to make movement flow. I have had some success with working barefoot, or bare armed, in order to pick up as many sensorial and kinaesthetic experiences as possible. Training on different ground surfaces has been beneficial: sand, grass, cushioned flooring and concrete all provide different stimuli.
Sound, too, can increase the client’s ability to respond. Try clapping, or pad boxing, and it is quite likely that a surprising level of reaction is achieved. The brain responds to the extra stimuli of the sound impact, encouraging the weak side to react. Again, this can be very rewarding for the client. A few years ago, I spent some time observing at Standing Start in Cambridgeshire, an innovative spinal column injury rehab unit. I was amazed at these guys, many of them with devastating spinal column injuries, learning to box. The level of response achieved from limbs officially paralysed was incredible, and set me thinking about sound impact. More recently, I have seen with a stroke survivor client of mine a retrieval of sensation in his weak arm soon after we began pad boxing. Even as we trained, he was exclaiming at renewed feeling. An hour or more after the session, the sensations persisted, increased even. Not pain, just renewed awareness of the limb.
Left/ Right Recognition
So, post-stroke, the brain would seem in some cases to have great difficulty in recognising the two sides of the body as different (tending to view them as interchangeable), leading to sensations such as “feeling” right arm overhead when it is the left arm in that position, or “feeling” the leg kicking out a roundhouse kick, some hours or days after the training session. If I cannot see or hear my weak arm moving I do not always know the speed or direction in which it is travelling. I cannot necessarily instigate movement starting from the weak limb – it gets glued to the spot in a panic reaction to the brain’s request.
I began to get interested in studies of others experiencing left/right recognition difficulties, and looked at the evidence from upper limb amputees(1), as well as a study dating back to 1977 on the developments of recognition memory for the left right orientation of images (2). It was all fascinating reading, but I still struggled to see how this might possibly be connected to my own left/right confusion and the symptoms my own clients are living with.
In “The Body has a Mind of its Own” (3), the authors describe how some of their patients displayed denial of paralysis, which has a specific underlying brain pathology. These “denial patients” presented with brain damage in the supplementary motor area, responsible for the mental stimulation of movements. We activate this section of our brain simply when we close our eyes and imagine a movement. When we ask a stroke survivor to move the paralysed limb, the supplementary motor area produces a familiar pattern of activity in the brain. But the regions of the brain that actually carry out the movements are not working. In this situation, the patient experiences a very strong conviction that the movement was achieved successfully. The paralysis is indisputable. The solution is for the patient to create a story. I find this explanation useful as a powerful reminder that the brain holds the answers for so much of the dysfunction that we see.
What I wanted to do was introduce a measured feed of images and information to the brain regarding left/right recognition, in the hope of firing up improved responses. Fortunately for me, someone had thought of it before me! I found an awesome resource via NOI (Neuro Orthopaedic Institute, Australia) and I got reading. NOI stipulates 5 “critical conceptual change issues” (4)
- Injury or disease does not mean that you feel pain
- The nervous system moves and stretches as we move
- Pain, stress and performance are outputs of the brain
- Knowledge and movement are the greatest pain and stress liberators
- Nervous system plasticity gives new hope and technique
(taken from www.gradedmotorimagery.com)
So I began to understand that I needed to change the brain’s left/right perceptions, and that there was a possibility that this could positively affect the pain output for myself and my clients. If I could provide improved information, along with movement patterns that would reinforce that new information, maybe I could reduce a body’s panic/pain response. It would be worth a try, at least.
I have been working with an improvised mirror box for a couple of months now, and have recently started using an NOI iPad App to test and hopefully educate the brain in spontaneous responses to images of left/right.
In their book, Phantoms in the Brain, (5), the authors describe the dramatic use of mirrors with patients unable to move a limb without them, a presentation described as “learned paralysis”. Mirrors have many uses in the rehab environment: affirming, reassuring, deceiving and defying learned assumptions.
I have many more hours ahead of me with mirrors and audio cues, in search of progress in left/right perception, and a path to pain/panic reduction. However, I feel it is a route worth pursuing in my struggle against the destructive neural dysfunction I have personally been experiencing, and I fervently hope to find some solutions for my clients and others in my own modest way.
(1) Left and right hand recognition in upper limb amputees. Nico D, Daprati E, Rigal F, Parsons L, Sirigu A. Dipartimento di Psicologia, Universita La Sapienza, and IRCCS Fondazione S. Lucia, Rome, Italy. Brain 2004 Jan; 127 (pt 1); 120-32. Epub 2003 Nov 7.
(2) The Development of Recognition Memory for the Left-Right Orientation of Pictures, Juliet M Vogel. Child Development Vol. 48 No. 4 (Dec. 1977), pp 1532-43)Blackwell Publishing
(3) The Body Has A Mind of its Own, Sandra Blakeslee & Matthew Blakeslee, Random House 2008
(4) NOI: Neuro Orthopaedic Institute Australia www.gradedmotorimagery.com
(5) Phantoms in the Brain, Sandra Blakeslee & V.S. Ramachandran, Harper Perennial 2005