Perspective

A colleague recently dropped off one of the Magic Eye books. It is filled with stereograms. When focusing one’s vision in just the right way, heretofore “invisible” images are revealed in three dimensions. They are really cool to look at. If one practices divergent (parallel) viewing and focuses into the distance (through the page) the image seems to have 3-D depth that opens out away from the viewer. If one looks at the image cross-eyed (that is, focusing on a spot in front of the page), the image seems to come towards the viewer.

I have found viewing these images to be quite engaging. Not only does seeing them in 3-D require a steady visual and mental focus, it also exercises my left-side awareness.

After my stroke, I had a fair amount of left-side deprivation. I lost virtually all left-side tactile sensation. I also lost some auditory sensation. Early on, while rehabbing at Spaulding, I learned to shut out hospital noise by sleeping on my right side, so that my right ear was against the pillow. My left ear was open to the noise, but my brain mostly failed to perceive it.

Vision was also affected. While other stroke patients with whom I have spoken experience visual deficits much worse than my own, I did have difficulty seeing and making sense of (and also imagining) left-side images. It was nearly two years before I stopped smacking into door frames with my left side.

Seeing the stereogram hidden images is rewarding, but holding them for an extended length of time is more so. That’s because maintaining the image requires relaxed mental attention and clarity.

I have been playing with the book’s images (and ones I found on the internet) for about three weeks. I have also been paying increased attention to the way I focus on things in the “real” world. When on morning walks I work to notice not only the things upon which I am directly focusing, but also upon things in the foreground or in the distance. I sometimes feel like a photographer tinkering with depth of field.

Years ago, while I was studying kenpo, the teacher tried to get the class to spar without focusing our vision on any particular spot. He wanted us to scan our opponents with our minds so as to develop sensitivity to a range of depths and angles simultaneously. He wanted us to experience a broad depth of field, to be mentally focused without narrowly focusing our vision.

Similarly, in one of his Don Juan books (I don’t remember which one or the actual language used), Carlos Castaneda wrote about learning to perceive the “real” world through unfocused perception. Fictional character or not, Castaneda’s Don Juan offered some terrific insights.

Visual focus may bring clarity to a particular spot, but doing so may also interfere with other possibilities.

Right now, I am sitting at my desk in my third-floor office. If I look out the window, I see the house across the street. If I hold up a finger in front of the house, as long as I keep my focus on the house I seem to see right through the finger. The finger becomes solid only when I focus on it specifically, at which point I lose track of the house details.

How important is finding a proper focus/perspective in stroke recovery?

An Unexpected Return

Last weekend I made my post-stroke orchestral debut at the Wintergreen Music Festival, where I played one of the many percussion parts in Ginastera’s Estancia. Admittedly, I played instruments that could mostly be played with one hand and required no particular expertise.

That was perfect.

Hiking with Euclid

Sharan and I are in our second week at the Wintergreen Summer Music Festival. Yesterday we went for a half-day hike on the Appalachian Trail. Views into the Shenandoah Valley were magnificent.

Because the trail was rocky and uneven, for me walking was awkward and occasionally quite challenging. In the steepest parts I resorted to using all fours (not elegant, but effective). Every fifteen minutes or so, my swift trail mates waited for me to catch up.

Our hosts offered me a walking staff to use for the hike. I had never tried one before, but discovered a third “leg” was helpful in traversing uneven ground.

Early on, it was a fun toy. Initially, I held it in my strong right hand, but soon I practiced coordination skills by holding it in my (stroke-affected) left hand.

Challenging my disabled side always results in a change in consciousness, which opens doors to new insights and thinking projects. Yesterday I found myself playing a really quick game about triangles. I imagined my two feet and the tip of the walking stick as vertices. The triangle constantly shifted and inverted as I walked. And (because I was only conceptualizing in two dimensions) with each step the point momentarily become a line. It was difficult to follow the changes, especially if I tried too hard (in which case my thinking become labored, clumsy, and muddled).

I continue to do visualization exercises to strengthen my mental focus and imagination, often with color, sound, and shifting geometric figures. This game was new and fun. Since I could only hold the requisite attention for short periods of time, I played in installments.

As the hike progressed and I tired, my general coordination started to fade. I eventually came to realize that I was becoming overly reliant on the staff. So I stopped using it.

Anything I could do, they could do…

This post is not about music, though the current experience is unfolding because of my wife’s musical skills. We are at the Wintergreen Music Festival in Virginia. She is working like crazy; I am working out like crazy.

At the gym.

I have decided to try muscling my physical deficits into submission. A stupid idea, I know, but it offers a certain sense of accomplishment. (I am getting stronger, if not more adept.)

The pre-stroke me could occasionally power my way to success, even when skills were lacking. For a few years I played squash a couple times a week. All of my partners were more skilled than I, but every once in a while I could win a game on aggressiveness alone. No finesse, just muscle. The victories gained in this fashion were not particularly satisfying (because I knew I didn’t deserve to win). But least I didn’t lose.

Sometimes that’s enough.

Calling Dr. Doolittle

“Despite evidence that use of the impaired upper extremity has a positive effect on the neurophysiological consequences after stroke, recent studies in rats paint a very different picture. Restricting the unimpaired forelimb in rats with sensorimotor cortex lesions results in prevention of dendritic growth in the uninjured cortex, exaggeration of the neuronal injury, and more severe behavioral deficits.”

RJ Nudo. “Remodeling of cortical motor representations after stroke: implications for recovery from brain damage.”  Molecular Psychiatry (1997) 2, 188–191.

The observation above comes after the author’s brief discussion of Edward Taub’s “constraint-induced movement therapy,” a stroke rehabilitation technique that has proven quite successful in humans.

For the record, I am appalled by Taub’s research technique, which involved cutting afferent ganglia (transmitters of sensory information to the central nervous system) then forcing the monkeys to learn to use their disabled limbs.

Dante Alighieri would have found a spot for Taub.

Was all that cruelty necessary? Couldn’t any moderately impaired stroke patient have told Taub that affected limbs improve with use?

Time and again, I return to the “hard science” literature looking for insights about stroke recovery. I come away with models and brain maps, but little insight. Invariably, I retreat to experience.

How has my brain adapted to tissue loss? I suppose an MRI might tell me what neurons are firing where, but that information won’t help my penmanship or Frisbee toss. Effective rehabilitation requires writing and tossing. Lots of it.

Until someone can convince me that I am wrong, I will continue to understand the brain (and its attendant neural patterns) not as a thought creator, but (as rills left in a hillside’s soil provide evidence of a heavy rain) the result of thinking.

Tipping my hat to Taub, I have typed this post using only (well, almost only) my left (affected) hand.

Regarding this post’s title…  Dr. Doolittle talked to the animals. Dr. D was the original “dog whisperer.” When I was a child, he was also my favorite fictional character. Rather than monitoring the brains of maimed rats, Dr. D would have protected them. Had he arrived too late for that, he would have asked the poor critters how he might relieve their suffering.

Nurturing Nature

The 8-year-old juggling a soccer ball and the 48-year-old jogging by, with Japanese lessons ringing from her earbuds, have something fundamental in common: At some level, both are wondering whether their investment of time and effort is worth it.”
Benedict Carey, in “How Do You Get to Carnegie Hall? Talent,” NY Times, 7/14/14.

Really? If this is true, both are wondering about the wrong thing. I suspect, however, that the 8-year-old is simply having fun. To imagine dazzling like Lionel Messi is also fun. (Depending on the season, as a boy I imagined pitching like Warren Spahn or quarterbacking like Bart Starr, or being like my father.)

How could imagining greatness ever not be “worth it?” With imagination comes discovery. Children experience this. Adults don’t seem to get it.

There is always value in “doing.” If I practice stroke rehabilitation only because I want to get to “Carnegie Hall,” I am missing the point.

I taught percussion at the college level for a number of years. Not once did I tell my students to practice so they might “get to Carnegie Hall.” I taught them to focus and problem solve so they would become better musicians. I also tried to help them develop thinking skills, tenacity, coordination, and character.

A few of these students stayed in music. Most went into other professions: technology, business, law, etc. All brought insights gleaned from music to their respective occupations. (See Dr. Nimesh Nagarsheth’s thoughtful book Music and Cancer: A Prescription for Healing. Dr. Nagarseth and I studied with the same teacher at University of Wisconsin Madison.)

Certainly musical facility is essential for a successful career in music, but careers are built on many additional factors, including: imagination and creativity, sensitivity, social grace, ability to perform well under pressure, risk tolerance, health (both physical and emotional), tenacity, likeability, patience, luck, and more.

Constructive engagement takes discipline, organization, and imagination. This is a lesson I first digested through musical practice. When I thoughtfully engage (through writing, listening, drumming, moving, imagining, teaching, laughing), I move toward wholeness.

P.S. For what it’s worth, I did make to Carnegie Hall (but only because the ensembles with which I was performing happened to be booked there). Frankly, it took me a few minutes to remember the various performances, and I’m not sure I remember them all. At any rate, being there was far less important than the process undertaken to get there. Those concerts were moments in a life. Who I have become (the good and the bad) through thinking and doing represents life’s events distilled.

Bee here now

We have a beautiful garden, rich with flowers (and weeds) from early spring until late fall. Admittedly, it is more exuberant than neatly organized, but it is fragrant and lovely to behold. Although we have a compost pile, throughout of the spring and summer we often liquefy fruit and vegetable remains in a blender, then dig the stuff directly into the soil. We use neither pesticides nor fertilizers. Every year the soil is more friable and more productive.

We also maintain our garden for the insects, especially the bees and butterflies. This year there have been very few of either. It’s heartbreaking. In yesterday’s New York Times there was a thoughtful and troubling editorial by Mark Winston titled, “Our Bees, Ourselves: Bees and Colony Collapse.” Colony collapse is a very serious problem.

What does all this have to do with stroke and music? A lot. Winston writes, “Honeybee collapse has been particularly vexing because there is no one cause, but rather a thousand little cuts.” I am sure this is also true for conditions leading up to stroke. I am not currently concerned with prevention, however. I am focused on recovery.

People often ask me if therapy was helpful, and if I am still involved with it.  My answer is, “Yes and yes. Constantly.” But I stopped working with therapists about six months after my stroke. To paraphrase Winston, “Stroke recovery is slow. The process is particularly vexing because there is no single solution, but rather thousands of potential curative approaches and tactics.”

Finding and making productive use of the possibilities has been up to me. I quickly realized that I have the ability to engage in therapy every time I breathe. This is the case not because breathing is particularly therapeutic (though well advised), but because the perceptions, mental attitudes, and physical exercises with which I might engage while breathing are therapeutic.

I will try to provide a useful example from recent morning walks in a nearby woods. I have been becoming increasingly troubled by the way I tend to lean forward while walking, even while standing. This has been the physical characteristic ever since my stroke. It’s also a habit from which I need release. Adhering to the old adage, “chest out, shoulders back, stomach in” is not going to mitigate the problem. Paying close attention to my breathing, and regulating it appropriately does, however.

As a walk, I breathe normally, but take care to breathe low into my diaphragm while being attentive to the way the muscles across my lower stomach and groin release and contract.  By focusing on inhalation and allowing muscular release, my center of gravity feels lower and my upper body is freed. This mysterious “downward settling” enables me to hold a more natural and upright posture. Moments later, when focusing on exhalation, I gently pull my hips forward into better alignment over my feet. This also serves to free my upper body. All this is done with the greatest possible level of relaxation.

[Diaphragmatic breathing is often used for stress relief. Singers find the technique essential to generate breath support. Diaphragmatic breathing also requires practice. I suggest first practicing by lying down or sitting/standing still. After my stroke, I breathed only through the chest. My breathing was so shallow I often ran out of breath partway through a sentence.]

As with nearly all of my exercises, I begin this one by working with my left-side deficit, which in this case means, inhaling while pushing off with the left foot. Once I get a feel for the task, I integrate it bi-laterally, side to side, so as to ensure that I work the muscles (and my brain) in a balanced way, I undertake one breath cycle across an odd number of steps (three, five, or seven depending on my pace).  For example, in a three-step breath cycle first I inhale while pushing off with my right foot. The next inhalation occurs four steps later while pushing off with my left foot. As you become comfortable with the exercise, you will notice that with steady and even breathing, exhalations are initiated between steps.  This is a great example of integrating the rhythm two against three throughout your entire body. If you breath more slowly or walk more quickly, regulate inhalations to every five steps (begin exhalation on step/beat 3.5 to create the ratio two against five.

Winston later states, “Bees also provide some clues to how we may build a more collaborative relationship with the services that ecosystems can provide.” So too with an integrated approach to therapy. Therapy should not be something that only happens in 30 or 60 minute sessions. It should be ongoing, and undertaken in full collaboration with the ecosystem in which we live our creative lives.

A movie about honeybees

Motives

I have been reading stroke blogs lately. Many offer practical advice. More than a few are inspirational. There are also posts expressing resignation, frustration, or anger. I witnessed all of these emotions among fellow patients during my stay (and later as a volunteer peer facilitator) at Spaulding Rehabilitation Hospital in Boston.

For me, the effects of stroke have been humbling and occasionally humiliating, but also profoundly educational. Without question, my stroke has stimulated my thought life. Although too often it doesn’t show, in working through my various disabilities I am slowly becoming a better person

I undertook rehabilitation with a sense of urgency. For me, recovery was a matter of social obligation and personal pride. I have met other stroke patients who pursued rehabilitation with equal tenacity. I have met others who put forth very little effort at all.

Why do some people work hard on their recovery and others do not?  And why do some who work equally hard achieve less success than others? I suspect that answers to these questions have to do with a great variety of factors, including: age and general physical health, current life responsibilities and future possibilities, emotional state, and the nature of one’s stroke (the part of the brain that has been damaged).  I was blessed that my own stroke, which initially left me physically and cognitively impaired in a great variety of ways, did not diminish my desire to return to wholeness.

Because recovery is always on my mind, I was particularly struck by some ideas in a New York Times (July 4, 2014) article titled, “The Secret of Effective Motivation.” It begins as follows:

There are two kinds of motive for engaging in any activity: internal and instrumental. If a scientist conducts research because she wants to discover important facts about the world, that’s an internal motive, since discovering facts is inherently related to the activity of research. If she conducts research because she wants to achieve scholarly renown, that’s an instrumental motive, since the relation between fame and research is not so inherent. Often, people have both internal and instrumental motives for doing what they do.

Acting from internal motives is the key to success, the authors contend. They go on to write that, “efforts should be made to structure activities so that instrumental consequences do not become motives. Helping people focus on the meaning and impact of their work, rather than on, say, the financial returns it will bring, may be the best way” to attain success.

I wonder. Aren’t all the above motives instrumental?  Don’t they all refer to outcomes external (to varying degrees, of course) to the activity? I suggest a different approach. The real key to success (the authors never defined that term, so I won’t either) is something else: perceptive, thoughtful, and imaginative engagement through the activity itself.

Over a decade ago, my wife decided to purchase a new (old) violin.  I became involved for a range of “internal/instrumental” motives. Initially, I did not have a particular interest in violins themselves.  As that process unfolded, however, I became increasing intrigued by the various instruments we were accumulating. By paying close attention I developed more discerning eyes and ears, and richer intuitions, I heard and saw previously unnoticed qualities. Each instrument had a unique personality. Many spoke; a few sang. As I studied them and read about their luthiers, I came to see the instruments as living works of art tied to (yet transcending) time and place. As works of art, they embodied the past. As professional tools, they could facilitate the present. And as vehicles for expanding the powers of musical imagination, they suggested future possibilities. After the purchase, with my instrumental motives satisfied, other tasks occupied my time (though my new-found appreciation for violins remains undiminished).

I told this story to suggest that “motives” are instrumental by nature, and that success in any particular endeavor may have less to do with the motives that one brings to an activity than the level of engagement brought to bear. I find my professional work inherently stimulating. That is why I have pursued it for so many years, not because research is what scholars do or because I was hoping to get ahead in the profession. (Not surprisingly, following my intuitions and curiosities has taken me away from a standard professional trajectory.)

Surely, mental and physical facility is the direct goal of rehabilitation therapy (which, if I understand correctly, the authors would term an internal motive, not an instrumental one). Even so, many stroke patients fail to maintain an active rehabilitation regimen.

I suspect this is the case in part because if one is not fully engaged, therapy can be both painfully boring and excruciatingly frustrating. Compounding the problem is the fact that recovery is difficult to visualize. Retaining that vision may be even harder. Rehabilitation is a long process, and full recovery is the exception rather than the norm. (Perhaps the goal of “recovery” is so amorphous/distant that it becomes an instrumental, rather than internal motive.  If that is the case, choosing a goal that is easily visualized [hand writing a letter or ambulating 20 feet] might provide a stronger motive than “recovery”).  But in any case, I suspect that reliance on any motive (at least “motive” as defined by the authors) is not the most efficacious rehabilitation strategy. Sooner or later, the motive’s psychic energy will diminish, if not be spent.

For me, the greatest successes seem to come when focusing on the activity itself (including paying close attention to one’s thoughts, and both emotional and bodily experience). I pay attention not because focus helps me attain my recovery goal (although it does), but because attentive and conceptually rich engagement is rewarding in its own right.  Engaging in this fashion builds psychic energy, rather than expends it.  By paying attention, each rehabilitation activity builds more awareness and clarity, which is plenty satisfying in its own right (especially when physical progress appears to stagnate).  Like my recently posted visualization and listening exercises, each activity holds potential for new and unexpected insights. Doing becomes its own reward.

 

Focal Dystonia

 

Focal dystonia is a neurological disorder that causes involuntary muscle contractions. It has affected a number of famous musicians, including pianist Leon Fleisher. Although focal dystonia is experienced in the muscles, the problem is rooted in the brain.

Brain mapping shows that individuals affected with focal dystonia present abnormal somatosensory reorganization. With a pianist, for example, normally separate representational areas for the fingers may become overlapped or fused. Apparently, command areas in the brain overlap not because of physical proximity in the body, but from task-oriented proximity. Theresa Lie-Nemeth, in “Focal Dystonia in Musicians,” cites a study in which wind/brass players who have embouchure dystonia show a blurring between brain regions dedicated to the fingers and lips.

Eckart  Altenmüller, in a chapter titled, “The Musician’s Brain as a Model for Adaptive and Maladaptive Plasticity,” writes that focal dystonia may have begun for musicians in the 19^th century, along with the increased technical demands (and requisite long hours of practice) of performing virtuosic music. (Altenmüller posits that Robert Schumann may have suffered from focal dystonia).  It is well established that extreme usage levels can contribute to focal dystonia, but for three reasons I find the timeline unconvincing.  First, an initial documentation does not mean a first occurrence.  Second, there was plenty of virtuosic music and existence before the 19^th century. (There was an article last month in The New Yorker discussing golfers with the yips, golf lingo for focal dystonia.  If putting a golf ball is “virtuosic” in the same way as performing a caprice by Paganini, perhaps we need to define the term more carefully.) Third, in addition to extreme usage, researchers have found other factors that trigger focal dystonia, including: tension, performance anxiety, and nervousness in general, as well as genetic disorders, disease, and stroke.

As a result of my stroke, I have dystonia.  I arrived at my dystonia from the opposite direction as did Mr. Fleisher, of course.  For Fleischer, once separate, and extraordinarily developed, brain areas apparently became fused.  My problem stems not from overdevelopment, but from underdevelopment.  My struggle is not with specialized areas merging, but from lack of “brain fences.” Directions sent to my stroke-affected left side are received with flashlight-beam width, rather than laser precision. For example, if I imagine moving my left-hand ring finger, all of the fingers, even my entire arm, will begin to tingle. (Imagine a flock of birds. One takes to flight and the rest follow.) These effects resonate across my entire left side.  If I think about to raising my big toe, my index finger will tingle in sympathy, perhaps even move.  If I curl my little toe, my pinky wants to curl right along with it.  Although they are less insistent, similar reflections also move in the opposite direction, from hand to foot.

To a great extent our life in the world is a result of what and how we think. It is possible that through inattention I have augmented my dystonia problem.  By “accepting” these connections, I may have strengthened the wiring between them. (I expected these tendencies to disappear automatically as I regained facility.  Perhaps they still will. In the first months after my stroke, when I began practicing drum rudiments, the left hand’s [or stick’s] impact would cause my entire left side to tremor. No longer.)

Unfortunately, I cannot report that I have an efficient strategy to mitigate the problem. (Suggestions are welcome!) The simple act of thinking about my left-hand thumb still triggers my entire arm to tingle. As with Mr. Fleisher, fingers curl unbeckoned.

That confession made, I will share some large-scale body movements I practice to weaken limb reflection. For me, virtually every movement exercise involving limb independence has proven beneficial, if not completely restorative.

• Tai-chi movements (and all martial art movements when done slowly and with mental presence).
• Mirrored, opposite, and contrasting movements, either bilateral or affected side only (between the weakened arm and leg, hand and foot, fingers and toes). Practice simple exercises slowly.
• Walking sideways or backwards, dancing, swimming, and virtually any exercise.

And of course there are drumming exercises.  To strengthen limb independence, I like to play patterns not only between both hands but also between hand and foot. (When working with hand and foot, I mostly focus on my weakened side, but I also perform the patterns between all four limbs.) I will suggest exercises in a future post.

Tonal Exercises

I practice piano nearly every day. After my stroke, I initially used the instrument mechanistically, as a vehicle for regaining left-hand movement and dexterity.  I still use the piano in that fashion, but my focus has shifted. Rather than trying to achieve technical expertise (a quixotic dream, to be sure), I work to experience tone’s possibilities. The great majority of my piano “practice” time is spent listening to and conceptualizing pitch.

I have a practice routine, but because it revolves around unfolding musical intuition rather than technical studies, every practice session is different. Exercises are constantly evolving as I gain new insights and understandings.

Observing my practice sessions from the outside, it might appear as if I were doing nothing more than plunking out a tone or two every now and then.  But I am listening intensely, then conceptualizing to the best of my growing ability. This is hard work. Depending on the particular goal, it may require several minutes to digest of the implications enfolded within a single pitch.

I generally begin my practice sessions by pressing and holding down a single key, so as to listen to its rich overtone structure (and part II).

Through this exercise, I have learned to identify nuances that previously went unnoticed, even though my ears were younger and far more sensitive. (I could write at length about this experience, but it is most valuable to do the exercise oneself.)

Instead, I will describe an open-ended exercise that, by engaging the same material from multiple perspectives, strengthens my ability to conceptualize pitch relationships. Again, I begin by playing a single tone on the piano. But now, rather than focusing on the overtone structure, I infuse the tone with function by imagining it as one of the seven pitches that make up a major scale. Contextualizing in this way gives the tone a certain character, stability or movement tendency, and emotional quality.

A scale’s first degree (“do,” also known as the tonic) is the home tone, and is generally considered to be the most stable. That is where I usually begin. (Various music theory treatises describe scale-degree characteristics, but it is best to discover them by intuitive listening.)

The major scale has seven tones (do – re – mi – fa – sol – la – ti – do). After establishing my sounded tone as the tonic, I conceptualize the tone through the other six degrees. (Depending on your musical background, this may take some time and tenacity.) With each conceptual shift in scale degree, the sounded tone will be imbued with a different complexion.  Also with each shift in scale degree, the collection of imagined scale tones that make up the tonal palette will change. With practice, one can switch back and forth between different scale degrees, their characteristics, and their attendant tonal palettes with the same ease one inverts a Necker Cube (see “Ambiguity,” posted on July 3, 2014). In this case, however, there are many more possibilities and the effects are more subtle.

This is already a lot to conceptualize, but it’s only the beginning. There are endless possibilities to develop exercises in tone-based perspective.  One can follow the same procedure with minor scales and modes, for example.

Like a skilled juggler, one can also put lots of objects into play.  Here are two additional exercises. Both require considerable mental energy.

1. Go through the above progressions while sounding two pitches simultaneously, each representing a different (or perhaps the same!) scale degree.

2.  Sound a single pitch, but conceptualize it as simultaneously representing multiple scale degrees.

Of course, all of these exercises might be done without the aid of a piano, with the mind alone. I need the piano to keep me on track, to keep my undisciplined mind from wandering, and to provide a stable foundation for listening. The piano also allows me to “correct” my conceptualizations and to sound the combinations I cannot hear without assistance.

For me, these exercises provide a matrix to develop aural perception. Importantly, they can be undertaken by anyone who is recovering from a stroke, almost no matter what the extent of physical disability.

Finally, innate musicality may be irrelevant. Many of my musical colleagues (I suspect most), have aural skills superior to my own. I will never learn to hear like Art Tatum, but by following my intuitions I am learning to hear in a manner that is uniquely my own. I am learning to create a “symphony” in my mind.

Could one ask for more?