With this article I want to answer some fundamental questions for the treatment of the hemiplegic patient who has suffered a stroke or brain injury. The questions are:
- What is the relationship between body and mind?
- Why is it said that after a stroke exercises should be directed over the brain?
- I do not have cognitive problems, I am the same as before and I remember all the keys and codes, why should I do neurocognitive therapy?
BODY AND MIND
When we prick a finger or hit our little finger with an object, it makes us wonder if the pain comes from the bruised part or the brain.
The same thing happens with perfumes, do we feel with the nose or the brain? And still, when we perform an action, do we move the body with the muscles or with the brain?
Revealing the mysteries hidden in perception was a desire that accompanied many scholars of the time, in a race of knowledge without rest to resolve the connection between mind and body. It is not possible to examine the mind without considering the body, just as it is not possible to study the mind-body unit, without considering the environment and the world around them.
When we talk about the environment, we are not only talking about the physical environment, nor the social one. Within this article where I will seek to address this particularly complex and at the same time fascinating subject, I will also try to always stay connected with our main objective, which is to understand how to act in the most effective way for post-stroke recovery, or anyway, from any brain damage.
The problem of the relationship between body and mind is a problem that is highly reflected on the panorama of rehabilitation after a stroke, and determines a delay from the methodological and scientific point of view.
However, first of all, it is preferable to argue better, as mind and body cannot be separated nor linked between them, as the mind itself is not an entity existing in isolation and above all: IT IS NOT IN THE HEAD!
I would add, moreover, that the mind is not hidden in the heart, or at least neither in the head nor in the heart … To enter into what the philosopher of the mind David Chalmers defined the difficult problem that linked to conscious experience, I I will take advantage of the studies of Francisco Varela Chilean biologist and neuroscientist who, together with Evan Thompson and Eleanor Rosch, who referred to the mind as “incorporated”, tried to overcome that mind-body dualism that has always accompanied us, and which in our field Regarding the rehabilitation of hemiplegia, it is even more evident and harmful.
Varela with the motto, “The mind is not in the head”, helps us understand that a mental capacity cannot exist without it being fully embodied and linked with the environment.
The mind is inextricably linked to an active body that moves and interacts with the world. Any existing object in the world will be under the dependence of this constant: perceptual and motor interaction. To better understand this concept, I will summarize Richard Held and Alan Hein’s famous 1963 kitty carousel experiment.
The purpose of the experiment was to confront the perceptive capacity of 2 kittens, both exposed to the same visual environment, but with the difference of their active participation in the exploration process.
In fact, inside this carousel, one cat could actively produce the movement to walk around the carousel, while the other moved transported as a reflection, thanks to the movement of the gondola. The kitten that was passively transported by the movement of the active cat, had developed much less perceptual faculties than those developed by the kitten that had the possibility of moving.
The fact that both kittens were immersed in a visual environment, forces us to search for the motivations of such differences in the active or passive role of the two.
Cognition is a property that is done by acting and actively fulfilling a certain process. For this, the mind cannot be said to be found inside or outside, or that is in the brain, heart, eyes, muscles, bones or in a specific place.
This motto joins one of mine found in my articles: “a stroke damages the brain, not the muscles, and there are cognitive processes in the brain”, just as, after a first input reading, we can already make a review. In fact, it is true that stroke damages the brain, but cognitive processes, such as consciousness and perception do not physically reside in the brain, are emergent properties due to the interaction with the internal, external, physical and social environment, with our intentionality. and corporeality.
The reason why my motto simplifies everything with “Stroke damages the brain, not the muscles, and in the brain there are cognitive processes”, is that I myself am immersed in an environment that is that of the world of rehabilitation, where today it is still difficult not to direct all resources and exercises to the parts of the body that are visibly paralyzed or who suffer from hypertonia, involving them in passive or reinforcement exercises without minimally considering a role in the process of perception or integration in the environment, or worse, without considering the person’s experience, not involving them cognitively in such processes.
Therefore today, I would be glad if the rehabilitation landscape locates in cognitive processes and brain functions, the core of the problem on which to direct rehabilitation after a stroke and not only with the joints without even considering the brain.
Clearly, that day will come sooner or later, I have the new slogan ready that will replace the old one, where it will refer to experience and where mind and cognitive processes will not be physically placed somewhere.
To explain Francisco Valera’s second slogan again, “the mind does not exist, nor does it not exist”, we can trivialize the concept saying that it is like achieving the connection between the clock and the hour, the hour is not an entity that exists independently of the clock and by whoever entrusts the meaning to the concept of the hour and then we cannot dissociate or associate, but it is an emergent property for the organization and relationship between the parts.
The same thing is the mind, it is a property that emerges from the relationship of the elements that allow birth, such as the physical and social environment in which we are connected, our corporeality and processes that sustain experience.
Each of these elements participates in the construction of a consciousness that in turn influences the very elements from which it emerges, creating a circular flow. To return to our field of rehabilitation, as it is not conceivable to propose exclusive exercises for the mind without considering the body, in the same way it is not possible to propose rehabilitation exercises without considering the patient’s conscious experience. In recent years, more rehabilitation proposals and manuals that are proposed to hemiplegic patients affected by a stroke have also been enriched with requests for care by the patient during the execution of a certain maneuver or posture, although if the The purpose of the experience may be sterile, such integration is appreciable, however, it is obviously not sufficient to guarantee the exhaustiveness and effectiveness of the rehabilitation experience.
For example, if previously a patient had been subjected to an inflated balloon and the therapist from the outside began to push it by the trunk in several directions, to activate the patient’s parachute reflexes, hoping that he would recover the trunk, it might not be enough to start Saying “now I push you to a point you don’t know and try to feel what is happening in the spine”, although the attempt to involve consciousness is appreciable, it is not enough to transform the neuromotor maneuver like this into a neurocognitive or neurophenomenological experience (which consider experience).
I want to give you an even more practical example, comparing three different exercises.
I hope that nobody reads this article quickly, and stops on this first video and reproduces the exercises shown in it, because although they are classic exercises that are proposed in every part of the world, they are exactly the activity that I kindly ask you to avoid, if we don’t want spasticity to increase enormously.
In fact, if you who are reading to me are a patient or their relative, you will certainly recognize many, but have them as examples of confrontation. Even here you can see live what I was referring to before, that is, an intervention directly on the body without minimally considering its role in the process of consciousness and interaction
with the environment and missing the component of the patient’s conscious experience. In honor of the truth, the interaction with the environment is directed to the weight and the hand of the patient’s spouse, and also to the patient’s conscious experience that is found because each way is alert, but it is not an experience and an interaction aimed at recovering the patient’s abilities, returning to adapt her own body effectively, to an interaction with the environment that allows her to have an experience and to interact harmoniously.
Concentrate at minute 1:40 where a maneuver is performed for the wrist, it will serve to put it in comparison to the next video.
Focusing briefly on the part of the video that shows us a stretching or movement of the wrist with hypertonia of the patient, I would like us to do with an exercise modality that is often used in neurocognitive rehabilitation.
Having seen the video I ask you not to jump to conclusions. In fact, this is also an exercise that I define as “technical”, that is to say useful for the improvement of perception and for the introduction to what is the wide world of neurocognitive rehabilitation, but still obviously poor from the point of view of the experience and the intention of the interaction with the environment.
I find it anyway useful to show you the different levels of depth of therapeutic proposals.
This video is an excerpt from the exercises present in the video guides for family rehabilitation.
Obviously, this is a guide dedicated to the family, which has the value of finally turning physiotherapy towards a more reasonable operational side and also involving the “brain” and cognitive processes.
Whoever follows me directly in rehabilitation knows that I can hardly deviate from technical exercises to allow the patient to manage his more autonomous and more complete recovery in terms of interaction with the environment, conscious experience and with intent.
Obviously, the choice to create a basic video guide where a series of technical exercises feasible to be carried out at home by even a family member, has the task of creating a literacy about neurocognitive rehabilitation, still for many unknown or ignored, about which then build further suitability levels of the intervention as I will describe below.