“I send the order correctly, but it is the hand the one that does not answer”.
Probably this is the most common phrase heard by all the professionals who take care of the post CVA rehabilitation. Very often, it comes together with an incredulity and surprise expression from the patient, who cannot understand how a part of their body, does not obey very clear movement orders given by the brain. This insubordination, is taken by the patient as a truly mutation of his body, which does not want to bend to the superior mind of its brain.
Sometimes, this rupture with the body is experienced in a conflictive manner, calling the hand with flashy terms, “that stupid does not want anything” “this sh… does not move”.
The same happens with the interpretation of the aphasic patients’ expressions which are deprived of the limit of the tongue in a more cautious manner, like if they wanted to tell them: “I have the words here at the tip of my tongue, but they just do not come out”.
I am sure that the patient who reads this first paragraph, is totally in agreement, and I want to begin to analyze it now with you, the aspects of this outlook which cannot lead us to anything good from the recovery point of view, but I want to propose throughout the article the interpretation keys more favorable to the recovery.
LIMITS OF THE INTERPRETATION WHICH THE MIND SENDS AND THE BODY OBEYS.
To completely understand the contents of this article, we should brace some premises in respect to the mechanisms through which the human being understands the phenomena related to its body, movement, and its own conscience. We have repeatedly referred in this web page to the concept of metaphor, not only as a rhetorical beautification of our speech, but rather as a real tool through which we learn and understand the world phenomena that surround us but also our internal world.
The most influential studious who takes care of the Metaphor is George Lakoff, Professor of Cognitive Sciences at the University of Berkeley in California, who begins the topic in his book: The metaphor and the daily life, and I invite my more attentive readers to go deeper on the topic.
The conceptual metaphor, is precisely what allows us to understand a phenomena which we do not know through the functioning of a phenomena that instead we know. This continuous exploitation of our knowledge to comprehend new things happens everyday and in all fields.
Let us try to make a practical example; many of you have heard of “cloud” services; the term in itself means cloud, and it offers in its terminology a metaphor to allow us to understand the functioning of these services. To place data in the “cloud”, means that it is not physically in your computer, but that it is above therefore accessible from other devices.
The idea of the cloud which we all know, helps us understand this technology in a more effective manner, offering us a mental support over which build a new and difficult concept.
If we have to explain a child what is a bat, somebody could say that it is a “small mouse with wings”. When we see a beautiful sea calmed, we could say that it is a table. These are explicit and easily interceptable metaphors in everyday speaking.
It is even easier to face a metaphor when we speak to a patient who has suffered a cerebrovascular accident and has seen changes in the behavior of his body and movements.
Test new sensations, and the only unique way to make an interlocutor understand them specially if he never has experimented anything like this in his experience is through a metaphor, or in a common area in order to help him understand what intimately is felt. For example when he talks about his leg and tells us that it is like “a log”, he wants to immediately get the interlocutor closer to what he is internally feeling, in fact when we hear the word “log”, our mind immediately associates the elements which may have something in common with the patient’s leg, like the pain, and the fact that it does not have any articulations and that it is an only one piece.
Even when I hear the phrase “it is like a rubber band that pulls” referring to the arm, the same process takes place, precisely to this last metaphor I speak in this article.
But there are metaphors which are much less visible and that now have entered our conscious and we use them without even noticing. They are conceptual metaphors, placed at a deeper level of our conscious which determine our behavior, for example we all know the saying: “time is money”, but what it is not at everybody’s sight is that it is not only a way of saying, but rather a frame where we organize our behavior in the time and the money, in fact, we get paid for hours worked, we stipulate yearly contracts, we lose time, we spend it and invest it like we do with the money.
All our knowledge is regulated by conceptual frames like these and also the consciousness and the behavior that we perform towards our body-mind and movement is reflected by the way that we have incorporated such metaphors.
For example, when we say an apparently innocent phrase like this one:
“I give the order correctly, it is she the one that does not answer”
referring to the hand, we are doing nothing more than using for the movement of our body, a scope of behavior that seems taken from a military hierarchy, as if the brain were a separate entity superior to the rest of the body, which in change represents the inferior executing part of the range.
In this frame, the hand is subject to the superior order of “Mr” brain. Unfortunately, this type of frame (brain-commandant, subject the body) cannot be favorable for the recovery of the movement after a cerebral injury, since there are a lot of tricks hidden within it.
- The order could not be so “just”, as it could be thought.
- The brain and the hand are not two separate entities which give and obey orders, but parts of the same integrated and non divisible unit.
The order given is it truly “just”?
As it was already said, we cannot speak of a real order, it would be more correct to speak about a behavior mode as Pëtr Kuz’mič Anochin defines, who tried to schematize it in this manner.
Even before the visible action, some processes are unchained which make up the base, for example, an analysis of all the information of the initiation which gives us a general outlook of the current situation of our body “afferent synthesis”, and that only after we prepare a development forecast and result of the action “accept the action”, and in parallel the motor program. The preparation of an action plan, allows us to constantly compare it with the results of the action thus we could reprogram the movement if the results do not coincide with the forecast.
What we see after a cerebrovascular accident, is clearly the motor or linguistic deficit, but what we do not see is the cognitive repercussion that due to its invisibility in many cases the physiotherapist does not even consider it.
That a stroke damages the brain, I believe that we all agree, and that the brain is a key organ for the expression of the cognitive functions, I also imagine that we share… or at least I hope so.
Then it is consequent and easily comprehensible how a cerebral injury has the needed repercussions in the cognitive abilities. At this point, I know that the jump in the patient’s chair or the member of the family that when they listen to cognitive alterations, stop recognizing themselves in this article, knowing that the memory has been kept intact, “I do not have cognitive problems, I remember all the pins and passwords of my cards“,”I do not feel different than before and I got back to work”.
This I know very well, since for the life I lead the majority of my patients have become my friends, and I do not think that they are not 100% right in their heads.
When I speak of cognitive alterations, I speak about aspects that are more subtle and more difficult to identify, they are those abilities which allow us to move our body and to interact with the surroundings. The memory is not only remembering the pins or dates of happenings, anniversaries, or times to take a medications; there is also remembrances linked to the sensations and feelings of the body, which allow us to learn new movements and new interpretations, and that is precisely what we should evaluate after a cerebral hemorrhage.
Even in the case of the attention, which is one of the cognitive processes that we always talk about, not only superimposes to the concentration, or to the lucidity, it has aspects which allow us to to divide it in several parts of our body at the same time, in order to know how to move it easier from an aspect of our body to another, and above all to know how to direct it to the part of the body, or to the most relevant information during a determined action.
What in the outline of the behavior by Anochin was called “receiver of action”, today the scientific community only identifies it partly as motor image, that is to say the ability to know how to create a prediction of the movement, which has the spatial and perceptive characteristics of the movement, in order to help us to be always prepared during the movement.
The perception in itself after a cerebrovascular accident (CVA) can be altered, even though not always you have a total consciousness of the phenomenon. When I visit a patient for the first time, I always ask:
“And how is the sensibility?”, and very often the answers are:
“It is fine, it is fine, when I touch myself I feel it” or
“I was examined for the sensibility and I feel me”, at that time I make a couple of simple tests and answer:
“Then, if I ask you to close your eyes and afterwards move a finger, could you tell which is?”.
Many times it happens that there are mistakes in the answer of the finger during the execution of the test, or at least a longer answer time than the average. The perception of the body is something deeper than what we can evaluate with the classical or typical tests of sensibility which are done pricking the patient with a sharp object or asking him if he feels when we pass a brush over his skin. Another test that can help us find some disorders in the perception, is the movement of the mirror, that is to say, always with his eyes closed, we guide the hemiplegic arm of the patient in a position, moving the shoulder, the elbow and the wrist at the same time, and then have him do the exact same movement but with the healthy limb; here we can then see the mistakes of the evaluation of the direction, and the amplitude of the movements.
If what we identify as a motor order is in reality a complex gesture where all these cognitive functions participate, and if these cognitive abilities at different levels have suffered alterations, then we can deduce that the same motor order cannot be compared with one that we could generate before the injury.
Even though it could seem reasonable, nevertheless there is a fact that still could take us to doubt that the order is not altered, in fact after a stroke we most likely will have a motor difficulty (hemiplegia) in one side of the body, while in the opposite side, the healthy one, he moves it perfectly, and even we can say that in some circumstances we also become more skilled since we are obliged to use it twice due to the incapacity of the other one.
On this topic, there is a video that I would like for you to watch, in order to at least open the discussion on the fact that the order is good because it achieves been effective in handling the healthy side. It is a video made to evaluate the apraxia problem of my right hemiplegic patient and I also use it the first day of classes for my second year of physiotherapist students in order to open the concept of the cognitive processes and the movement.
To this patient of mine, if you give her a dish of soup and a spoon, she eats it alone, she pours her water and drinks it using her left hand, but as you saw in the video, if she has to do new and specific activities as I proposed in the test, she got confused. At this point, the objection could be reduced to only cases of left hemiplegia, where there is not apraxia, nor evident speech disorders. Furthermore, in this case, the alteration of the motor performance in the “healthy” side is even more difficult to intercept.
When I try to remodel this behavior with my patients, derived from the idea that the brain gives orders and the body executes them, I make this simple test even to insinuate a reasonable doubt, I help the patient to sit at the dining table, and have his legs hang by gravity but the feet do not touch the floor, then I raise the healthy foot extending the knee, I ask him to completely relax and that at any given time I will let the foot to balance backwards and that this oscillation should not find any resistance or help, it should balance as a pendulum and stop only by inertia. The result is always that the patient cannot play with the gravity and let himself completely go or he stops the oscillation or tries to manage it.
In this activity, you also need a motor order, apparently unusual because we need to eliminate the force of a limb and not induce it, but it continues to be an intentional motor action.
Consider what happens in the road, ours is a real game with the gravity laws, placing movement and allowing our body to keep the oscillation that the inertia and the gravity offers, I refer to the most obvious and evident manner, the oscillation of the legs and arms.
If our road could see that each part of our body, instead of making use of the inertia and the gravity, were constantly pushed and encouraged, we would lose all the economy of this marvelous function, and the tiredness and lack of harmony in the steps are only aspects that the hemiplegic patient complains about and reasoning together we can attribute it to the motor difficulties of the hemiplegic side.
To conclude, if our motor order has also suffered modifications in the handling of the healthy side, we could imagine how the same order for a side of the body where the rules have been changed then it could not have the desired effects.
THE DANGER OF THE MIND-COMMANDANT AND BODY METAPHOR SUBMITTED
I should say that the previous task places a reasonable doubt that the motor order which we give after a cerebrovascular accident, is not at all correct as we think, it is much simpler than this one which I will deal with in the next paragraph. We are talking about a concept, which is the difference between mind and body and their different positions in a hierarchical scale, which is not only rooted, but to all effects is “incorporated” using a term loved by the academics who deal with the metaphor topic.
The relation between mind and body has attracted thinkers from all over the world, and from all times, we think about Descartes with his “Res cogitans” and “Res Extensa”, when referring to the “thinking entity” and the “material entity”, of the body, thus identifying a separation among the two.
There is a book from Antonio Damasio, entitled “El error de Descartes”, where he approaches this topic and the evolution of the interpretation which in all reality seems to be an indivisible unit where one of the two elements cannot exist without the other one.
However, since I mentioned this book, I cannot keep quiet about a small injustice against Descartes; in fact, Damasio’s text is very interesting, pleasant and easy to read, and I recommend reading it, I cannot stop insisting that if today we can talk about that integrated unity, it is also thanks to him, that it has had this intuitive jump, and has allowed to better understand the relation between the body and the brain, without forgetting that in that historic period, to be a thinker was the most dangerous mission in the world and you could have been detained as a herectic and be burned for a lot less.
Before getting deeper in the topic, the reason of the limitation of interpreting our being as an assamble of parts which have a different hierarchical role, I would like to place other conceptual metaphors over which we base the comprehension of the body, and I am referring to the cerebral control unit, body-machine and also mind-software and body-software (unfortunately very often we who are performing this work, propose these metaphors to explain and we are not aware that we trench even more our patients within these unfavorable frames).
As we can understand, these metaphors share in great part the same outlook that are seen in the brain and the mind, the noble part above the body, the mero interpreter to the service of the master brain, and subject to severe reproaches at the moment when escapes its executive functions.
“It is this sh…t that does not want to move”.
Even when we refer to the body in third person, like it it were outside of us, but I believe that this is normal, because we tend to understand the relation between things in the same way that we understand the relations between people.
Then, let us try for a moment to support this tendency to anthropomorphize the rules of our being and understand what would really happen if a chief brain were in the condition of ordering something to its subordinate and that this last one did not hear or did not complete such orders.
Any superior in our imagination will only repeat the order, but this time more vehemencely until shouting and punishing is subordinate in the best style of Sergeant Hartman from “Born to Kill” and stolen with cellulose by Stanley Kubrick in “Full metal jacket”.
Without making spoilers for those who have not seen the film, you can imagine that a relation of this kind does not take you to a productive collaboration.
We divulge this sovereign-subordinate relation to the case of hemiplegia, where most probable our hemiplegic joint registers hypertonia and irradiation, the order comes from superior levels and are identified as the driving motor, and that if it is not heard in the engine room, then it will simply be amplified in terms of intensity and effort, making the limb to stiffen and reducing even more its ability to efficiently answer more orders. The final result is the obvious conflict and exclusion, until occasions where is a real mourning of the body.
There are patients who very often want to learn to create a motor order, and they ask me: “What muscle should I use to do this?”, I always try to get the irony out of the question, and answer that the day that they explained that at the University, I was sick at home. When we reason in health matters, we never would have a thought like this, addressed to a muscle, we simply move and the body can feel it only if it hurts, and much less if we look at the muscle with wide open eyes trying to move it as if we had telekinetic powers which could lead us to something so good.
Kubrick is my second favorite director, immediately after Quentin Tarantino, who I will use to show what we believe that can function in order to find the movement, but unfortunately we do not have the same results that you can see in the beautiful Uma Thurman, who plays the role of Black Mamba in “Kill Bill vol 1”, who has just going out of a coma tries to recover the control of her body.
Going back to the insidious request that a muscle allows to make a certain movement, we should consider that the muscle just as we know it, could not be the same muscle that nature knows.
We know that each nerve ending covers a certain amount of fibers of the muscle, it ca be a dozen like in the case of the superior limbs or hundreds like in the case of the inferior limbs. These group of muscular fibers which answer to the same nerve ending are known as motor units and represent the minimum unit of the muscle, a type of muscle in the muscle. The motor units are organized in motor compartments, that is to say different regions of the muscle which are able to function at different times and modalities. In this 2015 study, for example, it shows that the masseter muscle which allows us to move the jaws, sees the activation of its muscular compartment in different ways, if the task is to bite, to chew or to swallow. Already in 1984, the researchers English and Weeks, studied the neuromuscular compartments of a cat’s calf, and its different behavior depending if it is jumping or just walking.
Going back to these arguments, and in our specific case, what we see as an elbow bending, we do not see that the same muscle gets activated, and in the same manner if this elbow bending is to take a glass to the mouth in order to drink, or to take the fingers to the forehead in order to scratch it. Then, to think, that intensely asking the elbow to bend could not be one of those definible “correct”orders.
I think that at this point, you would want to know which is the correct order, what do you need to do in order to recover the possibility of moving and have a relation with our own selves, and the most favorable movement. I obviously cannot go to a patient and tell him:
“Look at this time, you are obliged to conceptual metaphors of your body, which are not the most propitious for your recovery”, because I would be risking to be taken to a psychiatric ward. What I usually do with my patients, in the first months, is to let him familiarize with his body, reaching him how to feel, perceive and gather information with his surroundings, meaning proposing simple perception exercises, that involves the whole body, contextualizing them in the daily activities that the patient does. I give some practical examples in the road, that as we know, in many cases see the hemiplegic patient getting to the floor with the tip of the foot or with the lateral side and most rarely with the heel. In this case one of the possible exercises to improve this phase of the gait is to recognize and discriminate some consistencies with the heel.
Let us stop for just a moment on the fact that the heel is the first part of our foot which comes in contact with the floor and as such, it is that part that help us to gather much information about the characteristics of the floor, not only from the point of view of its consistency, or its inclination, but reasoning in logical terms, maybe nature would have predisposed that the heel, and the areas of the brain involved in the analysis of the information gathered by it, in order to take the function of the trip or on the contrary maybe it was not the first arriving to the floor.
The rehabilitation role is to facilitate this gathering of information and help the patient to recover the possession of this information, since it is through it that he could build the movement.
Remember the Anochin outline that we saw before, our movement program is made based on the information that we gathered with the surroundings and the same information that we can gather and process only through the movement.
Before concluding, since we have talked about the gait, walking, the information, the feet and the floor, I am going to show you this small apparatus which you will get to know very well, and that I ask you to reflect about your role in this perception and movement process. A rigid and thick sole which clearly has the task of avoiding falls,but that gets with arrogance in the dialogue between the floor and the foot. In another article, I specifically speak about the Codeville’s rubber band , so I only limit myself to this provocation. that should
Obviously in the first months where we work with the patients with these a bit technical perception exercises, I always invite the patients to discover and understand the new sensations which come from the new condition. In fact only those who live inside a hemiplegic situation know what it feels and that there are different sensations which we had never had felt before and above the ones he should learn to guide himself, for example, control over the hypertonia or the irradiation. r y son sensaciones diferentes que nunca antes había sentido y sobre las cuales debe aprender a orientarse para obtener, por ejemplo, control sobre la hipertonía o la irradiación.
Unfortunately, since it is true that only the people who live a hemiplegia, can know how you feel having a spastic side of your body, it is also true that a hemiplegic patient can experiment the same sensations that others, because it is a unique experience of life.
Therefore if we unmask the conceptual metaphors which up to date we have adjusted our behavior to, even if we offer the most favorable alternatives, and away from the Kubrick and Tarantino examples, and maybe closer to lines above read about the movement as a continuous dialogue between the surroundings and us, the learning and the choreography between our body and the space around us, we will always have to incorporate new concepts and ideas through direct experiences, those that we define as exercises.
When we talk about the Perfetti method, we try to not only see the surface made up by perception technical exercises, that for a fact are constantly done and on time will be sufficient to avoid most of the spasticity problems, and would place us on the road to recovery, but we are also going to see all the mediation work of the therapist who works to help the patient to understand and handle himself.