Monday, 24 January 2011

A Journey Through the Brain; - The Pons.

The pons, (which is a Latin word meaning ‘bridge’), is a small structure in the lower brainstem, just above the medulla oblongata and below the midbrain.  Behind it lies the cerebellum, with which it has many connections. Again we have another brain structure here whose size belies its importance.

The pons has been argued to be the seat of consciousness and there can be no doubt that it plays a large role in regulating our level of arousal.  Also, injuries to the pons can produce coma!  The main function of this structure is to pass information between the cerebellum and the cerebral cortex, in addition, it helps to send other messages to the brain, manage arousal feelings, and monitor respiration.  Some scientists believe that the pons is an important part of dreaming, since it is responsible for Rapid Eye Movement (REM) sleep, which is an essential part of any sleep cycle.

There are a few sets of nuclei (brain cells) in the pons which are of vital importance to our performance as human beings.

The Raphe Nuclei. -   These groups of cells in the middle of the pons are also sometimes classed as belonging to another brain structure called the ‘reticular formation.’  The reticular formation is a ‘net’ like structure which intertwines itself with many other structures in the lower brainstem and in higher structures too.  However, back to the raphe nuclei of the pons, which have widespread connections to other areas of the brain and would seem to be a major producer of serotonin in the brain.

Studies have shown that the levels of activity of serotonin-containing cells in the raphe nuclei varies directly with the overall level of motor activity or arousal of the child. There are also changes in pattern associated with drowsiness and sleep (cells slow down firing while entering sleep, and stop firing during REM sleep).

The serotonin produced by the raphe nuclei is involved in a range of physiological and pathological functions in the human body, such as helping to regulate the release of serotonin that controls sleep patterns, mood, pain response, and motor functions.  So when I am asking questions of parents in a consultation about their child’s development and those questions are centred on the child’s level of arousal, sleep pattern and mood, I am checking for injury here.  Also when parents see me ‘pinpricking’ their children, I am checking their pain response at the level of the pons.

The way in which the raphe nuclei of the pons are considered to influence sleep by many is through their connections with the suprachiasmatic brain cells in the hypothalamus.  This is where our ‘circadian clock’ is located, which regulates our sleep wake cycle.  Children who have injuries which prevent these connections from operating appropriately, either sleep too much or conversely they might have terrible problems sleeping at all.


Locus coeruleus -  These are a small collection of brain cells  located in the pons and they are the major source of noradrenaline in the forebrain.  Again it is arguable that the locus coeruleus belong to the reticular system, an area critical for arousal and wakefulness. Locus coeruleus neurons have extremely wide connections and they themselves are connected to by only a few brain stem nuclei and forebrain areas. The activity of these cells varies not only with arousal but also with specific cognitive processes, resulting in concerted release of noradrenaline in multiple target areas, with very complex effects.  This key neuromodulatory system is currently thought to be critical for numerous functions including our response to stress.  Therefore one might imagine how a child with a dysfunction of these neurons and their connections might experience high anxiety or even show symptoms of ADHD. 

The locus coeruleus connects to the entire cortex, the thalamus, limbic structures such as the amygdala and the hippocampus, the globus pallidum and the cerebellum, as well as other brain cells which control the release of dopamine.  In studies, activation of the locus coeruleus promotes high levels of vigilance and arousal. 

The locus coeruleus also plays a major role in attention and behavioural flexibility.  Indeed, when the activity of these cells is blocked, so that they cannot produce noradrenaline in the forebrain, we see problems in the ability to shift attention between different stimuli. Could injury here produce one of the phenomena which we see predominately in children with autism, but also in other neurodevelopmental disabilities, where the child becomes obsessed with certain objects, movements, sounds, tactile experiences, etc and focuses on that stimuli sometimes to the exclusion of all other stimuli?

On the other hand, enhancing noradrenergic function can facilitate shift of attention when the behavioral relevance of stimuli is varied experimentally, with resultant rapid behavioral adaptation.  This would be typical of the child with AD(H)D, who could not focus on one particular task / object appropriately.


Cranial Nerves and the pons.
There are many cranial nerves which enter the brain at the level of the pons, they are as follows…

The trigeminal nerve. (Cranial nerve 5). - The trigeminal nerve is one of the main nerves of the face. There is one on each side. It comes through the skull from the brain in front of the ear. It is called trigeminal as it splits into three main branches. Each branch divides into many smaller nerves.

The nerves from the first branch go to your scalp, forehead and around your eye. The nerves from second branch go to the area around your cheek. The nerves from the third branch go to the area around your jaw.

The branches of the trigeminal nerve take sensations of touch and pain to the brain from your face, teeth and mouth. The trigeminal nerve also controls the muscles used in chewing, and the production of saliva and tears.  So when we see a child who does not seem to feel sensation in his face, mouth, teeth, or has trouble chewing, produces too much or not enough saliva, or has watery or dry eyes, we have to consider that there may be injury to this nerve or its connections in the pons.

The abducens nucleus (Cranial nerve 6 ). – This nerve and it’s connections with the pons seem to control our ability to move our eyes.  damage to the abducens nucleus causes loss of the ability to move the eye which is on the same side of the body as the injury, outward.  It can also result in lateral gaze paralysis: loss of the ability to move either eye in the direction of the side with the lesion.

Facial nerve nucleus. (Cranial nerve 7).  Lower down in the pons we find the facial nerve.  The facial nerve, or cranial nerve (CN) VII, is the nerve of facial expression. So when parents see me gazing into the face of their child for prolonged periods, I am checking out even the most minute fluctuations in facial expression in order to ascertain if there is injury at this point.

Vestibulocochlear nuclei (vestibular nuclei and cochlear nuclei – Cranial nerve 8).  - The vestibulocochlear nerve is a sensory nerve that conducts two special senses: hearing (audition) and balance (vestibular). It cannot be coincidental that these two senses travel into the brain together and the fact that so often I see children who have vestibular problems, who also have auditory processing disturbances. This is a common feature of autism and I postulate that the reason why so many children who have autism are so keen on vestibular stimulation is that it calms their auditory processing problems.

The eighth nerve enters the brain stem at the junction of the pons and medulla. The auditory component of the eighth nerve terminates in a sensory nucleus called the cochlear nucleus which is located at the junction of the pons and medulla. The vestibular part of the eight nerve ends in the vestibular nuclear complex located in the floor of the fourth ventricle.

The main connections from the vestibular cells are to the spinal cord (controlling head and body position), to the three, extraocular motor cells which play a part in controlling eye movements, to the thalamus where they are directed to the appropriate area of cortex for processing.  They also go to the cerebellum which controls the coordination of postural adjustments.

The lateral vestibular tract starts in the lateral vestibular nucleus and descends the length of the spinal cord on the same side. This pathway helps us walk upright. The medial vestibular tract starts in the medial vestibular nucleus and extends bilaterally through mid-thoracic levels of the spinal cord in the MLF. This tract affects head movements and helps integrate head and eye movements.

Many interconnections are found between the vestibular nuclei and the cerebellum, which coordinate the postural adjustments.  So you can see why vestibular stimulation of one form or another is a vital part of all Snowdrop rehabilitation programmes.

I think I have shown that the pons, although only a small structure in the lower brainstem, is of vital importance.

Friday, 21 January 2011

A Journey Through the Brain; - The Medulla Oblongata.

We will begin at the bottom of the brainstem, with the tiny, unimportant looking medulla oblongata.


However, the medulla is not unimportant at all as it is responsible for many of our vital functions and organs.  It controls several basic autonomic functions including respiration. It is situated on the lowest part of the brainstem and looks like an extension of the spinal chord which is swollen. It serves as the main pathway for nerve impulses which enter and leave the higher neural systems, indeed nerve fibres from both cortical hemispheres cross over here so that the right cortex controls the left side limbs and the left cortex controls the right side limbs.


As I have already suggested, it regulates some of the more basic functions required for life. These include the involuntary processes of swallowing and digestion as well as breathing. It also regulates the heartbeat and the diameter of certain blood vessels-thus controlling blood flow. One could consider it the master control centre for the autonomic nervous system.  Partnered with the cerebellum it has some input to controlling movement and along with other structures, it also has some input to regulating states of arousal and sleep.


Several cranial nerves, (A cranial nerve carries sensory and other information from the outside world into the brain) enter the brain in the medulla.



The Glossopharyngeal Nerve.  This is counted as the ninth of twelve cranial nerves.   The glossopharyngeal nerve supplies the tongue, throat, and one of the salivary glands (the parotid gland). Problems with the glossopharyngeal nerve result in trouble taste and swallowing and also with an under or overproduction of saliva.
The Vagus Nerve. The vagus nerves carry a wide assortment of signals to and from the brain, and they are responsible for a number of instinctive responses in the body. You may also hear the vagus nerve called Cranial Nerve 10, or the wandering nerve. A great deal of research has been carried out on the vagus nerve, as it is a rather fascinating cranial nerve.
The vagus nerve carries information both to and from the brain.  It emerges at the back of the skull and meanders in a leisurely way through the abdomen, with a number of branching nerves coming into contact with the heart, lungs, voicebox, stomach, and ears, among other body parts. The vagus nerve carries incoming information from the nervous system to the medulla, providing information about what the body is doing, and it also transmits outgoing information which governs a range of reflex responses.

The vagus nerve helps to regulate the heart beat, control muscle movement, keep a person breathing, and to transmit a variety of chemicals through the body. It is also responsible for keeping the digestive tract in working order, contracting the muscles of the stomach and intestines to help process food, and sending back information about what is being digested and what the body is getting out of it.

When the vagus nerve is stimulated, the response is often a reduction in heart-rate or breathing. In some cases, excessive stimulation can cause someone to have what is known as a vaso-vagal response, appearing to fall into a faint or coma because his or her heart rate and blood pressure drop so much. Selective stimulation of this nerve is also used in some medical treatment; vagus stimulation appears to benefit people who suffer from depression, for example, and it is also sometimes used to treat epilepsy.

The Spinal Accessory Nerve.  The accessory nerve is the eleventh of the twelve cranial nerves.   Traditional descriptions distinguish two parts to the accessory nerve:
  • spinal part, that innervates the muscles around the neck
  • cranial part, made of rootlets that quickly combine with the vagus nerve.

The hypoglossal nerve is the twelfth cranial nerve. The twelve cranial nerves, the hypoglossal nerve included, emerge from or enter the skull (the cranium), as opposed to the spinal nerves which emerge from the vertebral column.
The hypoglossal nerve supplies the muscles of the tongue. (The Greek "hypo-", under and "-glossal" from A"glossa", the tongue = under the tongue).
Paralysis of the hypoglossal nerve affects the tongue. It impairs speech (it sounds thick) and causes the tongue to deviate toward the paralyzed side. In time, the tongue diminishes in size (atrophies).
Injuries to the medulla can be fatal, although at Snowdrop I have seen and treated children with impairments which obviously involve one or more of the above cranial nerves, who have survived.

Thursday, 20 January 2011

Treatment for Cerebral Palsy. - Physiotherapy.

In this post, I am going to give an overview of the form of treatment for cerebral palsy which we know as physiotherapy. I shall explain to the best of my ability the theoretical principles behind this form of therapy and review what evidence is available to support its use as a developmental tool.
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When a child is diagnosed as suffering from cerebral palsy, the diagnosing doctor automatically refers that child to a physiotherapist. This seems the logical and natural course of action; - the child after all, will have problems with muscle tone and with his joints. But is it the correct course of action? We will review the evidence to discover the truth!

In the UK, as in most other European countries, physiotherapy is based upon one of two systems of treatment, - the Bobath method, (sometimes known as ‘neurodevelopment therapy), or the Vojta method. The most common method and one which was employed upon my son for a short time was the Bobath method. Let us briefly summarise the theoretical underpinnings of each system, before moving on to assess their effectiveness.

The basic goals of Bobath physiotherapy are: -
(i). The prevention of postural deformity
(ii). The stimulation of normal developmental processes through the facilitation of normal patterns of movement.

These goals are operationalised by utilising several principles.
The first principle involves the inhibition of abnormal reflex patterns in the child. According to Bobath, as the child grows older and his central nervous system matures, the activity within the system falls into well worn patterns. A good example of this can apparently be seen in the child with a stiff muscle tone. The pattern of activity, with which the brain responds to any external stimulation, has the effect of further increasing the child’s muscle tone. It is claimed that this occurs because, due to the child’s brain injuries, there will only be a limited number of synaptic chains available to register a response. (Bobath, 1980. P. 79)

The techniques used by the proponents of Bobath therapy, apparently serve to inhibit these abnormal motor responses, by handling the child in such a way as to prevent a state of hypertonus occurring. In inhibiting these abnormal patterns of movement, the opportunity is apparently created for more normal movement patterns to occur, which are the remit of higher levels of the brain, and which have been prevented from occurring by the static state of the child’s muscle tone. (Bobath, 1980. p. 79)

The principle which underlies the ‘inhibition’ theory is that , -It is the body musculature, which determines the state of the central nervous system. It is the body musculature which controls the opening and closing of synaptic connections within the central nervous system and determines the subsequent outflow.” (Bobath, 1980, p. 83).

Does the musculature really exert influence and control over the state of the central nervous system? Surely this cannot be the case? Has the cart not been placed before the horse here? Surely it is the brain which controls the status of the body musculature?

Bobath cites as evidence for this view, the experiments of Van Uxwell, who studied the response to stimulation of primitive organisms such as Starfish. Briefly stated, he concluded that the “results of any stimulation can be predicted by looking at the body musculature.” (In Bobath, 1980. p. 83).

Bobath appears to be drawing a false interpretation from Van Uxwell’s experiments by implying that stimulation is directly affecting the status of the body musculature, which in turn is influencing the activity within the central nervous system. Such an interpretation does seem to be the wrong way around. Surely what is actually happening is that stimulation of the muscles is being transmitted into the brain by afferent nerve fibres; - the stimulus is then registered and interpreted within the brain and it is the brain which organises a response from the muscles via it’s efferent nerve pathways.

Although the state of the musculature reflects the pattern of activity within the central nervous system, to state on the basis of this evidence that it is the musculature which is influencing the brain is clearly a mistake!

The second major principle underpinning this approach involves the stimulation of higher mechanisms of control in the child with cerebral palsy. Such mechanisms comprise ‘righting reactions’ and ‘equilibrium reactions.’ (Bobath, 1980. p. 8)

These two sets of reactions are highly integrated and automatic responses to changes in posture or movement, aimed to restore disturbed balance.

The problem here is that children who suffer brain injury, especially children whose muscle tone is stiff, (spasticity), invariably have suffered considerable injury to the cortex. Equilibrium reactions in particular require cortical contribution. (Bobath, 1980. p. 8)

As for righting reactions, which are organised at the level of the thalamus, again a considerable percentage of children who suffer brain injury have thalamic injuries. (Beaumont, 1983. p. 83).

So, the relevance of the implementation of a programme of Bobath physiotherapy for the treatment of brain injury must be called into question.

It is now appropriate to quickly describe the other physiotherapeutic approach, although this is mostly used in some European countries and is known as ‘Vojta’ physiotherapy. In the Vojta system normal patterns of movement, for example, reaching and grasping, standing and walking, are not explicitly taught as such.  Vojta therapy rather claims to arouse the brain, triggering ‘intrinsic, stored movement patterns’ which can then be “exported” as synchronized movements linking the musculature of the body and extremities. 

It is claimed that frequent activation of these reflex-like movements, produces new ‘networking’ within the functionally blocked network of nerves between the brain and the spinal cord. For Vojta therapy to be successful it is claimed it must be carried out several times a day. A treatment lasts between 5-20 minutes.

However, there may be dangers in the use of this type of physiotherapy. During forced active rotation and head retraction, one child suffered from bleeding into the adventitia of both her vertebral arteries, which prompted ischemia of the caudal brainstem with subarachnoid haemorrhage. One wonders if comparable cases have arisen, but have not been registered? There may be a delay involving the performance of physiotherapy and the beginning of such neurological indicators. (Jacobi G, et al, 2001).

Is there any evidence for the effectiveness of any physiotherapeutic approach, regardless from which school of though it may derive? The answer has to be that down the decades, there have been various studies, although most of them poorly designed, most of which have indicated that children who have brain inuries do not benefit developmentally from physiotherapy.

In one of the earliest studies on record, children suffering from cerebral palsy were divided into three groups as follows: -

Children who received physiotherapy for twelve months.
Children who received no physiotherapy for six months, followed by six months of physiotherapy.
Children who received no physiotherapy at all.

At the end of the study, no significant differences were found between treated and untreated children in any of the criteria under observation. The concluding remarks were telling!
“It is felt that advice on the skilled handling of the severely handicapped child, initially in a therapy situation, imparts confidence to the child and the parents and that this is perhaps the major contribution of therapy.” (Wright, 1973).

The second major study in the seventies also produced discouraging indications for the efficacy of physiotherapy. Twenty four children under the age of eighteen months, with an initial diagnosis of cerebral palsy were divided into two groups, an experiemental group and a control group. The experimental group of children received physiotherapy for six months, whilst the control group received no therapy at all. At the end of the six month period it was found that there was very little differences between the groups, with the children who had been exposed to less physiotherapy showing slightly better results. For the more severely handicapped children, there was no difference at all. (Sherzer et al, 1976).

So, as early as the mid 1970’s the evidence pointed to the lack of success of physiotherapy as a treatment tool for brain injury. We now move to the 1980’s, where a further two studies shed light upon the approach. In the first study, 48 infants, with moderate to severe spastic diplegia, aged between twelve and nineteen months of age were randomly assigned to one of two groups. The first group received twelve months of physiotherapy. The second group however received a six month period of infant stimulation, (consisting of sensory, cognitive and language stimulation), followed by only six months of physiotherapy.

Assessment was performed after both 6 and 12 months of therapy to evaluate motor quotient, motor ability, and mental quotient. It was found that the children who had received the stimulation programme and less physiotherapy performed better on all measurements. Another nail in the coffin of the physiotherapist. (Palmer, 1988).

The other major study in the 1980’s was a review of all previous studies and was severely critical of the methodologies employed by all of them. However it too concluded that; “Evidence for the usefulness of this therapy has yet to be demonstrated.” (Tirosh et al, 1989).

We now move to the year 2000 and to a study in which 55 children with mild or moderate cerebral palsy were assigned to two groups, one a group which received physiotherapy and one which did not. The children were tested on a range of measures at six, twelve and eighteen months. At the end of this time the researchers found no difference between the two groups in any of the functional skills under scrutiny. (Ketelaar, M. et al. 2001).

A clear picture is emerging is it not?

In the last forty years, despite all of the research which has been carried out, only one study demonstrates any meaningful improvement in brain injured children who underwent a regime of physiotherapy and that single study was carried out by an employee of the Bobath centre!  These results hardly come from an independent source and therefore must be discounted.

Despite the evidence, the medical profession continue to tout physiotherapy as a developmental tool, with which to treat brain injured children. The evidence states that this is definitely not the case. 

Having set aside physiotherapy as a useful developmental tool, allow me to summarise why it does not work.

The focus of physiotherapy, despite what it’s proponents might claim, is upon the symptoms of brain injury. Those symptoms include the muscle tone of the child, whether stiff or floppy, scoliosis, fixed deformities, tremors etc. Never is any attention paid to the cause of those problems, - the injured brain.

Allow me to highlight this attitude by recalling a conversation I had with a paediatric physiotherapist. She stated that my son had very severe physical problems (symptom). I responded by confirming that yes, his brain injuries are very serious. Her response to this was to say, “Yes, his brain injuries are bad, but he also has terrible physical problems.” She could not see that the physical difficulties my son faced were caused by his brain injuries and that were the brain injuries not present, neither would be the physical problems, because one was a symptom and the other was the cause of that symptom.

Please do not misinterpret what I am saying. I am not saying that symptoms have to be ignored. Indeed it could be dangerous to ignore some symptoms, such as epilepsy! Yes, symptoms need to be controlled and indeed physiotherapy has a very important role in the prevention of dislocations, contractures etc,  but the symptoms that physiotherapy treats should not be treated in isolation. If we are to succeed in treating brain injury then we also have to develop cause centred approaches. Physiotherapy is not one of them, - we can prove it is not one of them and it would behove health professionals well, to stop touting physiotherapy as a developmental solution to brain injury. In doing so, they are misleading parents in just the same way as they accuse alternative treatments.

At Snowdrop we believe we do provide programmes of neuro-developmental stimulation which are aimed at the cause and not the symptoms, - the injured brain itself.  Call me radical, but I believe brain injury is in the brain, not in the arms and legs!

If you require more information on Snowdrop's work, please contact us at snowdrop_cdc@btinternet.com or visit our website.

Friday, 14 January 2011

Musical chills: Why they give us thrills

This is important and it demonstrates why music is an integral part of the life of a child on a Snowdrop programme. Music releases dopamine. Now dopamine isn't just involved in the 'reward / desire circuitry in the brain, it is the one neurotransmitter which it is necessary to be present in order for brain plasticity to occur! Dopamine is also released in the child's brain when we praise him!  Read here - http://www.eurekalert.org/pub_releases/2011-01/mu-mcw011211.php

Saturday, 8 January 2011

A Case Study. - Adriano. - A Case of Autism.

I thought it might be interesting for readers of this blog, if every now and then I included a case study of a child on the Snowdrop programme, (obviously with parental consent).  Names have been changed to protect identities, but here we go.

Adriano and his family are from the United States and first came to see me just over two years ago.  Adriano has a diagnosis of autism.

Adriano was 3 years old when I first saw him and didn't acknowledge me at all, indeed he didn't acknowledge anyone including his parents.  He made no eye-contact and tended to look to the side of the person who was trying to communicate with him, if he looked anywhere near them at all.  I quickly realised that he found it more comfortable to use his peripheral vision than his direct vision and was visually hypersensitive.  He also seemed to be auditorially hypersensitive, particularly if the sound was high pitched.  Conversely, his tactile discrimination was very poor and his parents reported that he was consequently clumsy, frequently bumping into things, but that when he did bump into things, he didn't seem to feel pain, even if he was quite badly bruised.

Adriano also displayed some unusual behaviour in that he was obsessed with lining his toys up.  His toys were the focus of what little language he had and he would talk to them rather than speak to his parents.  In fact he preferred to direct his language towards any inanimate object rather than speak to a human being.  This was a source of immense distress to his parents who dearly wanted to communicate with their son and wanted to here him address them as 'Mummy' and 'Daddy.'

I knew if we could get a handle on Adriano's sensory problems we would go a long way to improving his developmental prospects and so I set about constructing a programme.  The primary focus of the programme was the creation of a sensory / vestibular environment, which was constructed in his bedroom, where we could give the offending brain structures the opportunity process sensory information in a more controlled and organised way, -  to effectively retune themselves and their activity.  I knew this would be a long drawn out process requiring patience and perseverance and explained this to his parents, who were only too happy to hear that there was some hope.

Two years and three months down the line, Adriano still has many problems, but he is a different child.  It brought tears to my eyes when mum emailed me to say that not only had her son looked her in the eyes, but that he had called her 'mommy.'  He no longer talks to his toys, he talks to his parents; he no longer bumps into furniture, he now feels the pain that such bumps cause; he now longer looks around people he looks at their faces and his language development has improved immeasurably to the point where he now speaks in short sentences.

As I say, he still has many problems, but he is a very different little boy - the work goes on.