Neuroscience, neuroplasticity and stroke rehabilitation
by Ronald Shone, B.Sc., M.A., B.Sc (Psych), DCH
There are many new developments taking place in neuroscience that have important implications for the mind-body problem and hypnotherapy in particular. Some of these developments can, with some modification, be used in hypnotherapy. Here we give one illustration as to how neuroplasticity can be used in a hypnosis session to help with stroke rehabilitation. This example is chosen because there is little in the hypnosis literature on its use with stroke patients. Second, there is little in the neuroscience literature on the implications of neuroplasticity for therapy and bringing about beneficial change.
First we discuss some developments in neuroscience that shed light on the mind-body problem. In particular, we discuss neuroplasticity – what it means and how it applies to therapy. We then turn to a discussion of strokes and how neurogenesis and neuroplasticity can help in stroke rehabilitation. Attention, however, is focused on how hypnosis can be used to stimulate neuroplasticity for stroke patients.
There is still a mystery about how a thought can lead to a change in the body. Three developments in neuroscience may provide some explanation:
Here we shall provide a simple explanation of these developments and speculate on their implications for hypnotherapy.
Gene expression gives an explanation of how the environment can influence genes and so influence behaviour. In order to understand the link between the environment and genes it is important to understand that genes lead to the production of protein and it is proteins that influence the body. In simple terms, the environment can lead a gene to switch on or switch off a particular protein or to switch down or up a particular protein. It is this switching on/off - up/down that leads to a change in the body.
Chromosomes are composed of a double-stranded DNA molecule (deoxyribonucleic acid): the double helix linking just four nucleotide bases: adrenalin, cytosine, guanine and thymine – denoted A, C G and T respectively. Cell division occurs with the DNA unravelling and duplicating itself so that each strand forms a duplicate of the original chromosome. The chromosomes are composed of genes that provide the genetic code. Some genes (structural genes) contain information for the synthesis of a particular protein. Other genes (operator genes) control one or more structural genes and it is the operator gene that determines if and when a structural gene will synthesize a protein, i.e. whether the structural gene will be expressed and at what rate. Operator genes are basically like switches: some switch structural genes on or off; others turn the structural genes up or down (like dimmer switches). An important aspect of operator genes is that they are influenced by signals coming from the environment. This is how experience (and suggestion) interacts with genes to influence development and behaviour.
Gene expression involves DNA being converted into RNA (ribonucleic acid) which then leads to the production of a protein (a sequence of amino acids). There are two distinct phases to gene expression. First, DNA is converted into RNA, called the transcription phase. Second, RNA is used to produce a protein, called the translation phase. Such gene expression determines how a cell will develop and how it functions when it matures into a particular type of cell, such as a brain cell, bone cell, or a muscle cell. Gene expression gives rise to the phenotype (an organism’s observable characteristics and traits) from a particular genotype (an organism’s hereditary information contained in its genes).
From the perspective of gene expression, it could be argued that when a hypnotist makes suggestions, and if those suggestions are taken on board by the client, then some changes can take place at the neural level that allows change to take place. Some research indicates that gene expression varies in time. Some can activate changes within about an hour, others in around two hours, while others take around four hours. Early gene expression, for example, may be important in the way the immune system operates. Once activated, the effects may be within a few minutes and may continue for hours, weeks or even years. Gene expression may play a major role in stress related problems, especially post-traumatic stress disorder (PTSD). There is an important implication for therapeutic sessions, which often are no longer than one hour. This may be too short for certain genes to express themselves. However, the use of audio files may (just may) overcome this problem. Therapeutic suggestions are given in the hope of changing a client’s behaviour – whether to think differently, to do something active, or to problem-solve. At the end of the day, only the individual can initiate gene expression. The clinician can only change the environment, create novelty in order to facilitate gene expression, or provide a different perspective that allows internal reappraisal to take place.
Turning to brain plasticity, it must be appreciated that there was a view held in science about the brain for a long time. This view was that after initial development of the nervous system there was no further growth of nerve cells: that neurogenesis was not possible. The implication of this is that the brain, which is at the heart of the neural network, is fixed. The neural network is a network of nerves all linked by axons (long stems on the nerve) and dendrites (small-like tentacles). By means of these axons and dendrites nerves connected with each other to form a network – a neural net. Electrical impulses pass through the network and pass from one nerve to another at the synapse (the gap between a dendrite or axon and another nerve cell) by means of chemicals. If there was no growth in neurons then the number of such nerves and their connections would be fixed. In simple terms this implies we are hard wired. But some neuroscientists began to question this view, and considered the possibility that new nerves can grow in the neural network: that neurogenesis is possible. Others also argued that the brain could adapt, making new connections with dendrites that did not exist before: that neuroplasticity is possible. Such new connections could change the firing patterns of existing neurons. Brain plasticity refers to the existence of neurogenesis and neuroplasticity. Neurogenesis is a longer term change in the neural net than neuroplasticity, and usually takes place in the hippocampus. Neuroplasticity has led to the view of the brain of what fires together is wired together. These developments have important implications, most especially for therapy – and not just hypnotherapy.
It now appears that experience can lead to neuroplasticity. Experience leads to changes in the cortical map, especially the motor cortex. Such change can also arise in the case of damage to the nervous system. Neuroplasticity can take two forms. One is a strengthening of existing connections; the other is the creation of new connections. Since experience can lead to neuroplasticity, it is fair to postulate that repeated hypnosis (or meditation) can lead to changes in the neural network. Going into trance is a skill, which becomes easier with practice. I made this point in my review of The Chicago Paradigm. Repeated hypnosis leads to a habit formation, which arises when new spindle cells (a particular type of nerve cell) form in the hippocampus. Such a development of new nerve cells (neurogenesis) arises when we learn something new.
An interesting question is, ‘If neuroplasticity is possibly, what holds it back?’ A probable partial answer to this question is our limited beliefs. Such limited beliefs arise from past experiences and culture. Limited beliefs lead to negative thinking, e.g. ‘I can’t do such and such’. Another aspect of the answer is that for certain new connections to occur, the experience needs to be intense, or repeated often enough. There is circumstantial evidence for this. Something becomes a habit if it is repeated often enough (constant firing together of nerves) and once it has been taken over by the unconscious mind it becomes a habit (it becomes wired). But not just repeated often enough there needs to be an emotional element which gives it intensity, and so strengthens the firing and wiring.
When an animal performs an act then certain neurons in the brain fire. However, it has recently (early 1990s) been noted that when an animal observes the same action performed by another then the same neurons fire. It is though the neurons are ‘mirroring’ the behaviour carried out by the other animal, i.e. they are acting as if they were them self carrying out the act. Such firing was first observed in the macaque monkey, but has subsequently been found in the human brain. Humans are complex animals and the mirror neurons found in humans appear more extensive than in monkeys. The mirror neuron system, if it exists (and not all accept it yet), provides a neurological foundation for empathy. Certain brain regions are active when certain emotions are being experienced: emotions such as disgust, happiness, pride, shame, embarrassment and lust. But they are also active when observing others in situations in which these emotions are prevalent: ‘we feel the other person’s pain’.
The mirror neuron system has been used to explain the importance of mimicry. This has important implications for language and learning in children. But from the point of view of hypnosis, it has important implications for rapport, transference and counter transference, some NLP techniques, hypnotic depth, and creative visualisation – to name but a few. For example, it is well known that difficult subjects can more readily enter hypnosis when they observe others doing so. They are unconsciously mirroring the other person. Note too that mirror neurons fire with no conscious involvement: it is an unconscious act. This example highlights another issue found to be important with regard to mirror neurons. The mirror neurons fire more when observing another who is in close proximity. There are two points relevant in this statement. First, the one being observed is an actual animal or person. It is not a video or something being observed on TV. It is true that mirror neurons fire if the person who is being observed is (say) on a video, but it is not as strong. Second, the proximity of the person being observed is important. The mirror neurons fire more when the proximity is closer. It appears that this has important implications for humans as social animals, e.g. deducing the intension of others and for cooperative behaviour.
Mirror neurons enable us to see and feel others in an intentional way, i.e. I can see you as having purpose and intention because I mirror what you are doing. Mirror neurons allow us to engage in pretend play; it allows me to put myself in your shoes in order to empathise with you and understand your intention. Such pretend play has many uses in clinical hypnotherapy. Much of creative visualisation is utilising mimicry. Even the simple induction and following an instruction that the arm is getting lighter and starting to rise is invoking (mimicking) what a person does and feels when their arm gets light. Similarly, the golfer who in his or her mind’s eye does the perfect put is invoking the mirror neuron system and doing (in the mind’s eye) the perfect put. It has often been stated that children are excellent hypnotic subjects. Could this simply be a reflection of the fact that they mimic so readily? It is the way they learn and learn to become social animals.
Stroke and stroke rehabilitation
What is a stroke?
There are two types of stroke, both of which result in brain damage: (1) ischemic stroke (ischemia means starved of oxygen), and (2) haemorrhage stroke. The former, and most common, results from a thrombosis or embolism that blocks or narrows a blood vessel that carries oxygen to the brain. The latter occurs when a blood vessel bursts so causing a haemorrhaging into the brain tissue. Whatever stroke occurs, the symptoms that occur depend on the area of the brain that is damaged. Damage to the left hemisphere results in problems on the right side of the body; while damage to the right hemisphere results in problems on the left side of the body. The typical symptoms that result involve reduced functionality, reduced activity and fatigue, muscle wastage along with partial paralysis and issues with balance and walking. There are also associated symptoms, such as memory loss, depression and anxiety. Of the symptoms the most common is paralysis. Such paralysis can result in one of two types of muscle tone: (1) reduced muscle tone (flabby muscles) or (2) high muscle tone (spastic and tight muscles). The most common paralysis is that affecting one side of the body (hemiplegia). This can affect the face, arm, leg or the entire side of the body. Where damage occurs in the cerebellum difficulties can occur in the coordination of movement that leads to problems with posture, walking and balance. Many more specific problems occur depending on the location of the stroke.
Rehabilitation therapy begins in hospital, followed by therapy as an out-patient or by a visiting physiotherapist at home. Unfortunately rehabilitation is an on-going process that can often take many years. The most common therapy is physiotherapy with very focused and repetitive practice. These days hospital stay has been reduced and an early discharge is the norm. This means rehabilitation outside of the hospital is more important in the rehabilitation process.
Neuroplasticity/neurogenesis and stroke rehabilitation
Neuroplasticity following a stroke involves encouraging new nerve connections in undamaged nerve cells (usually close to those that have been damaged), encouraging other connections to become stronger, and removing those that no longer function. Therapy for rehabilitation of whatever type involves changing a person’s brain structure and functional organisation. In other words, with appropriate training it is possible for the brain to reorganise itself. The aim is to encourage the brain to seek out other routes that will re-establish motor control. Neuroplasticity allows the brain to change function and structure that compensates for damaged neural pathways either by strengthening existing ones or re-routing along alternative pathways.
It is also possible to encourage the growth of new nerve cells (neurogenesis). The cells involved in this process are spindle cells located in the hippocampus. When new learning takes place new spindle cells grow in the hippocampus. These cells are specially designed for forming new memories. Such neurogenesis requires effort, concentration and repetition so that what is being learned becomes habituated. If these are not engaged in sufficiently then such new spindle cells die. This is an important observation for stroke rehabilitation.
A crucial element in the success of neuroplasticity and neurogenesis in relation to stroke rehabilitation is specific and repetitive inputs until these become a habit. Such movements can actually be carried out, but they also can be imagined to be carried out. (An aspect important for the use of hypnosis.) It is known that there are two barriers to the success of neuroplasticity and neurogenesis. (1) Too little motor activity to start the focused repetitive motor activity. (2) Psychological ones, such as depression and a lack of a positive attitude. Both lead to reduced or even no practice in the tasks that need to be performed.
Most therapy for stroke is work done by someone else for the person concerned, most typically a physiotherapist. The stroke victim becomes reliant on others and not work done by their own brain. In general, stroke survivors have not been shown effectively how to rehabilitate themselves. Once rehabilitation with special therapists has finished, survivors of strokes simply do not know how best then to proceed. Here is where hypnosis and self-hypnosis can be employed in the rehabilitation process.
Hypnosis to aid neuroplasticity and neurogenesis
Even if neuroplasticity and neurogenesis are accepted, the issue is how to bring these about. As pointed out already, focused repetitive actions can be employed. Constraint Induced Movement Therapy encourages this by constraining the good motor movements, so forcing the stroke victim to use their weak motor muscles. The use of hypnosis rests on the observation that creative imagery can fire appropriate neurons in the brain as they would if the functions were actually performed. A hypnotherapist can help a client to repeat focused motor movements in their imagination. These can replicate what a client would be doing in real life. It is also possible to suggest time distortion so that 30 minutes of exercise can be done in just 5 minutes. Furthermore, suggestions to encourage motivation, effort and concentration can be employed in order to ensure that the spindle cells live long enough to create habituation and for new dendrites to form in existing nerve cells so encouraging neuroplasticity.
But a hypnotherapist can be more creative. Consider, for example, the problem of balance. A hypnotherapist, after inducing hypnosis, can suggest to their client that they are balancing on a plank that is resting on a ball. That they keep adjusting their balance so remaining on the plank. Constantly maintaining balance would be suggested as the creative image is elaborated on. Such a creative image will reinforce the client’s proprioceptors (those receptors that constantly maintain balance). The hypnotherapist can utilise any of the interests of their client that involve motor activity, e.g. golf or swimming. Ideally, the client can be taught self-hypnosis so that they can do this themselves and so take some responsibility for their own rehabilitation.
Affirmations to encourage neuroplasticity
Consider for a moment a woman who has just conceived. From then on the body and mind gets to work over the coming months to produce a baby. There is no conscious effort involved in this process. The body and mind takes over control. It involves a myriad of changes in muscles, nerves hormones etc. on the part of the mother and growth of all kinds on the part of the baby. A basic tenant of hypnotherapy is that the unconscious mind knows everything about a person and knows best how to accomplish change – and change is the essence of most therapy. It is possible then to give clients affirmations (suggestions) that encourages the brain to undertake neuroplasticity.
There is a major gap in both neuroplasticity literature and in hypnotherapy of providing such suggestions. Because of this we provide here a list of 25 affirmations that can be repeated with or without hypnosis. Of course they work best when given during a trance state and part of a therapy session for stroke rehabilitation.
As indicated already, the purpose of neuroplasticity is to create a habit, and this applies equally to creating new motor connections. So these affirmations should be repeated constantly. Ideally, stroke victims should learn self-hypnosis.
The list of affirmations are:
Your brain’s neural network can change.
It is possible to adapt your neural network.
The unconscious knows how to adapt your brain’s nerves.
Your unconscious can adapt healthy nerve cells to do the work of damaged nerves.
Healthy nerve cells close to the damaged ones can take over control of those nerves that were damaged.
Healthy nerves can grow new connections to allow motor control of muscles.
New electrical routes through the neural network can be found to replace those that no longer function.
Re-routing electrical signals is possible.
Your muscles that have difficulty responding can send messages back to the brain along new neural pathways.
New dendrites can grow on healthy nerves close to those that were damaged which allows new motor control of muscles.
New pathways in the motor neurons reduces muscle fatigue.
New pathways in your neural network decreases excessive muscle tone.
New pathways forming in the neural network, that compensate for pathways no longer working, increase limb control.
New pathways forming in the neural network improves your balance.
Your neural network is recovering as is your speech.
Your balance is improving day by day as your neural network re-wires itself.
Your motor muscles improve day by day as your neural network re-wires itself.
Your brain’s re-wiring improves at an ever increasing rate.
Your unconscious uses its knowledge of muscle memory to determine the best way to re-rout nerve impulses to all muscles.
Your unconscious is working day by day to establish new routes for electrical impulses to your motor muscles on the effected side of your body.
Changes in your brain can occur even within a few hours.
Your unconscious mind can turn on new genes in your nerves that can allow new pathways to be formed to your motor muscles.
The brain changes when there is a need for it to do so; and so it is time for your brain to make changes … NOW.
New neural pathways are now being strengthened that improves your sense of balance.
When you undergo constraint therapy you are encouraging the brain to form new neural pathways to the affected muscles and so encouraging them to function as they once did.
Audio files for Stroke Rehabilitation
Stroke patients go through a long period of rehabilitation, which sometimes can last many years. Since neuroplasticity and, in particular, neurogenesis, requires constant repetition so as to create habituation, then providing these affirmations as part of an audio file would provide the stroke-client with a means of undertaking the necessary repetition. Hypnotherapists can use the provided affirmations to create such audio files. My own web site provides two such audio files. (1) A file that can be downloaded by a client for their own use. (2) A file that a hypnotherapist can download and use with clients. These 20-minutes audio files involve the 25 affirmations repeated in random order, but also with ambient music to relax the person playing them. The files are located at the following address: www.shoners3.co.uk. Once the web site is opened up, follow the sequence: Self Improvement/TKR and Stroke/Stroke Rehabilitation/Stroke audio files
A final point to make is that neuroplasticity can be applied to a number of medical problems and not just for strokes.
Ronald Shone B.Sc., M.A., B.Sc (Psych), DCH is a Clinical Hypnotherapist based in the UK more information at: www.shoners3.co.uk