The Role of Neuroplasticity in Rehabilitation for Brain Injuries

The brain is a very complex organ. It is the control centre of the body, and controls the conscious and automatic functions of our bodies. It is made of cells called ‘neurons’. Each one of these can house a ‘programme’ for a particular task, function, memory, ability, etc. The brain enables us to learn, use and hone new skills, and retain skills which are useful in our individual lives (because we are all unique).

As we grow from being in the womb and through childhood, the brain also works efficiently by grouping together neurons and using them all for similar functions, so that these are housed in certain areas of the brain, some examples are given in the diagram below:

The brain is also a very efficient organ, and when we stop using skills and abilities for a long enough period of time, it allows us to ‘forget’ these: which in reality means that the neurons which housed these are told they can become ‘available’ to be used for something else, like a new skill or piece of information that the brain is currently learning or interested in becoming skilled in.

How intelligence, skills and functions develop

The brain has a strict order for how it develops and matures, and for which skills have to be learned first, in order that other skills can then be built upon these foundations.

You will probably remember looking at baby developmental charts, and seeing where your child was on these: at certain ages typical babies should be achieving certain developmental milestones. At many of these stages the baby will also display a reflex/es which corresponds to these developmental stages. We continue to go through these stages at various speeds until we reach adulthood.

A newborn baby starts out by mastering certain foundation skills; and these are generally housed in more primitive (older/lower down) areas of the brain. To help to try and understand this, you can envisage the brain as having a number of arcs in it, like a rainbow; and it has to first grow the smallest, inner violet-coloured arc, and only when that is fully formed can it then sit the next (purple) arc securely on top of that. When the second arc is fully formed, then the next arc has a secure place on which to go, and so on until the whole brain is fully functioning and you can do everything which a human should be able to do.

Humans have a number of developmental pathways, such as vision, mobility (moving and walking), communication (speech, etc.), hearing, taste, behaviour, etc.; and each of these areas of development need to rest on strong foundations, in order for an adult to be eventually totally proficient and able in these. Babies start off using these pathways in very simple ways, and then progress on to more and more sophisticated use of them, as they are stimulated to do so.

For example, with movement, a baby starts learning how to move in the womb, and then builds upon this learning after it is born, progressing from being quite uncoordinated at first, to better and better abilities, such as rolling, commando crawling, all-fours crawling, cruising, walking, running, jumping, hopping; and gripping, grabbing, holding, letting go, feeding itself, holding a pencil, drawing, writing, and more.

It is crucial to understand that all babies progress their skills in an almost identical set sequence – this is the order the brain needs in order to organise itself and be proficient.

Importance of foundation levels in development

To understand the importance of having foundation blocks in each of your developmental pathways (vision, speech, mobility, behaviour, etc), imagine that each of these pathways are represented by a ladder. In order to get up the next rung of the ladder for each pathway, you first need the rung you are stood on to be fully formed. If it is not, then you either can’t get up to the next rung, or you can, but it takes you more effort and you won’t be very good at mastering it, as your ladder is a bit ‘dodgy’ at the bottom and you know that. Many children with a ‘broken ladder rung’ simply won’t be able to progress, and may appear to be ‘stuck’ at a developmental level (neurological age) in that skill/pathway. Broken or missing rungs represent ‘hurt’ areas of the brain, and good rungs represent healthy, well-organised brain tissue.

Another way to imagine the pathways of development, is to think of building a tower out of Lego, but you only use a small piece at the base (representing a poorly executed foundation block or skill). As you fit more and more larger Lego pieces on top of this small piece, so the instability of the foundation piece starts to be challenged, until the tower eventually falls over – i.e. it might not be until a child is older that it is recognised that they have difficulties, and that these difficulties actually stem right from infanthood.

I have also heard this concept described (by Matthew Newell from the Family Hope Center) as ‘putting more traffic on the highway’: people with neurological challenges might be able to get from A to B along their highway (which represents their brain), but if they only have one or two lanes open (and a few lanes ‘closed’ due to their brain being hurt), as they get older and are required to learn and do more things, so they have to ‘put more traffic on their highway’, but their highway is too narrow, and so they start to fail to keep up with their peers (which is why some neurological problems only present themselves as children age). The wider you can build that highway (i.e. the better your foundations), the further you can go in life.

We always need our foundation blocks

It is important to note that no matter what stage of life we are at, our brains always need to rest on the foundation blocks of learning and development which were mastered and laid down as we grew as an infant and child.

If a brain is damaged in any way, which includes surgery taking away sections of the brain, then certain skills and functions can be lost or diminished. Sometimes this is in a dramatic way, such as paralysis or blindness, loss of speech; and other times it is more subtle, like a slight reduction in what a person can taste or smell, or a slight lisp or stutter, a loss of feeling somewhere, or a memory which does not seem as sharp as pre-surgery.

The reasons for these losses, relate to losses of rungs of the ladder.

Sometimes brain injuries and surgery can take away entire functions, e.g. speech. However, in many cases the brain has a wonderful opportunity to recover these abilities, through something called neuroplasticity.

Neuroplasticity

The word neuroplasticity comes from the words ‘neuro’ – to do with the brain, and plastic – think of plasticine, and how you can shape and mould it, so this part of the word really means ‘changeable’, or the ability to be used for different purposes/uses.

The science of neuroplasticity covers the understanding of how a brain should develop, gain new skills, lose skills, age, be stimulated, and more. It also covers recovery of skills and functions after a brain has been injured.

After an injury, your brain has a special ability to recruit neurons (brain cells) which were destined to be used for other skills/functions and use them instead for the functions which have been lost, so that these skills and functions can be regained. Which is clearly great news for anyone who has had brain surgery and lost any of their neurons and associated functions! This change of use of neurons like this, is neuroplasticity in action.

However, to induce neuroplasticity requires some specific interventions and stimulation – which may happen almost naturally (by accident, if you like) for some people, but other people might need more intense, frequent and/or obvious interventions and therapies.

Neuroplasticity in rehabilitation: go back to the foundations

After brain surgery, generally, the rest of the brain (in the way it works) will not recognise that there is an area of the brain which is missing. It may continue to send signals to that area, and it will almost certainly ‘lean on’ that area particularly (as in many cases) if it has any neurons which were used in the foundation blocks in the person’s developmental pathways. And, when it leans on them (wants to use them to under-pin another skill, learning or function) things start to go wrong, and we can observe any subtle and not-so-subtle post-neurosurgery symptoms (losses of skills or functions).

If you remember the ladder example, what has happened is that there is now a broken rung of the ladder. And the good news about neuroplasticity is that this can, in many cases, be fixed. However, also in many cases, we need to ‘trick’ the brain into a) realising that it is missing and b) into fixing that rung.

So, how do we do this?!

Simply, by taking the brain back to all those developmental milestones and reflexes we gained as a child, and checking that they are all still working. When we come across one which is not working, we use therapies, activities and techniques to re-stimulate the brain to tell it that “this is a skill you need to learn”. It will then find some good brain tissue (group of neurons) who are available, and will train them up in this skill.

And thus, you will have a lovely new ‘rung of the ladder’.

Often within milliseconds the rest of the brain adapts to realise that this is the ‘new home’ for this developmental milestone or reflex, and will then lean on and use this area to underpin all of the related functions and skills. Thus any post-surgery losses start to be resolved.

The incredible speed at which the brain adapts to the neuroplastic change which has been stimulated can be thought of like dominos: once you have flicked the first one down, the rest just automatically go. What is KEY is that you absolutely have to have the right tools (stimulation) to knock that first one down though, which is where the knowledge and tools of neuroplasticity rehabilitation come in.

It should be noted that sometimes more than one ‘rungs of the ladder’ have been damaged, hence a number may need ‘fixing’ via neuroplasticity.

Additionally, it is important that you use neuroplasticity rehabilitation modalities in the correct order, this is because you need to find the ‘lowest down rung’ which has been damaged, and resolve that one first, before you progress onto trying to fix other ‘higher up’ rungs.

If you try to fix higher up rungs first, you are likely to fail, feel frustrated, and will have wasted precious time and energy. Working with a professional can help you to understand the best starting points.

What sort of therapies will fix the brain?

First, all of your ability to do all of the early developmental milestones and react to all the early reflexes will be checked and assessed.

Where any of these is malfunctioning, a particular modality (therapy / activity / stimulation) will be needed to restore this.

For example, if you were asked to do commando crawling on the floor, and you found that, after surgery, you could not do this, then (even if you could still walk) commando crawling would become a part of your post-neurosurgery rehabilitation programme, and you may do this on your own, or with assistance (if required) so that you do it correctly, and completely re-learn it.

If your sense of taste or smell was malfunctioning post-surgery, then your programme would include therapies which stimulate the regions of the brain associated with these functions.

If you no longer had a reflex which you should have, then you might be stimulated with that reflex, and/or some interventions (e.g. manual manipulation, or auditory stimulation) might be used to recreate that reflex, so the brain ‘experiences’ it, despite it not being automatic.

What is very important to understand, is that it is known that the brain needs a certain amount of persuasion to recognise how important it is that we want it to learn something. It will only put its resources into learning this if the signal is loud and clear. To create such an obvious, loud and clear, signal for the brain, three things are necessary:

• Frequency – do the modality as often as possible
• Intensity – at the right level to call the brain’s attention to this
• Length of time – do the activity for a required period of time in order that sufficient neurons are recruited to fully master this (e.g. a month or two) and in bursts which keep the brain interested (not bored) and allow it time to process and retain what it has learnt (e.g. 5-20 minute sessions).

Repetition is essential to really strengthen (use) pathways through the brain – it is the same reason top class sports professionals and musicians practice the same skills over and over again: to be the best they can be at them.

This is because of the way that neuroplasticity works in the brain, and a rule called “use it or lose it” – meaning that if you don’t stimulate neurons enough, then they will cease to work on that task, and become available to be used for other tasks, or just remain redundant. However, when neurons are stimulated regularly, and the brain recognises a skill as of importance, the brain will not only use the existing neurons which have that function typically associated with them, it will also want to recruit other nearby/adjacent neurons (which are available / currently redundant) to also learn that skill, so that it can become truly excellent at it. In this way, through doing a neuroplasticity therapy a number of times each day, so you will be ‘growing’ an area of the brain (NB the brain does not grow in volume, but more neurons just become allocated to that skill/function).

I once read about the very best tennis players in the world. They place a penny on the opposite side of the court, with time and practice they can hit a ball and make it bounce exactly on the penny. It was a sports science article, and they measured that a player had to hit the ball exactly on the penny around 2,000 times for the player to become a master of that degree of accuracy. Bearing in mind the number of ‘misses’ they were likely to have had along with their 2,000 ‘hits’, this means they practiced an extraordinary number of hours to achieve this level of excellence. The same principal is true for resolving malfunctions via neuroplasticity modalities: the more you expose the brain to them, the sooner it will resolve its issues.

Sleep

Sleep is an important part of neuroplasticity.

Whilst you are doing the neuroplasticity rehabilitation programme, the brain will be very busy doing lots of reorganising and learning. It needs sleep to help it to process and embed what it has learnt. Hence sleep, whenever it is needed, is another crucial part of the recovery.