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?

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.

 

Speechless

This blog recently received a bunch of hits from England. It turns out that four graduate students/speech and language therapists at City University London are doing a project titled, “Blog talk: the impact of aphasia on people’s lives.”

I have mixed feelings on being deservedly selected as one of their subjects.

That said, two days ago I pulled my dictaphone. When I tried to put some music on it, I discovered the flash drive was full.  So, I began erasing old stuff. But not without first listening to it. I came across material dictated while at Spaulding Rehabilitation Hospital in the first weeks after my stroke. It was shocking to hear how I struggled to speak.  Many multi-syllable words were landmines. They tended to explode halfway through and required multiple attempts to articulate.  If I tried to say a verb ending in ‘d’ in the past tense (‘tend’ to ‘tended’), the diction was either mush (‘tendehthh’) or expansive (‘tendededed’).

During the past few weeks, I have been visiting with some stroke patients who have lost all speech. I stay and talk as long as they seem interested, and a long as I can think of optimistic things to say.

Constraint-induced movement therapy

Constraint-induced movement therapy is a technique developed by behavioral neuroscientist Edward Taub. The idea is that, by forcing an attenuated limb to do real-world work, the brain will rewire itself to accomplish the task.

Taub was a center of controversy in the 1980s for his experiments on macaque monkeys during which he surgically cut the animals’ afferent (or sensory) nerve pathways so that information received by a limb could not reach the spinal cord and make its way to the brain. Taub observed that, despite the fact that the motor nerves had been left in tact, the monkeys would not use limbs they could not feel. Taub then came up with the idea of constraining the monkeys’ good limbs, thus leaving them little choice but to use their compromised ones, which they promptly did.

The monkeys’ actions disproved the long-standing theories developed by followers of Nobel laureate Sir Charles Sherrington (1857-1952), who held that all movement is a response to outside stimulus.  This idea dominated neuroscience for decades.

Though Taub’s monkey experiments were limited to afferent nerves, he also had the insight that individuals with traumatic brain injury (such as a stroke) might benefit from limb constraint.

That was a good idea, but it hardly required deafferenting monkeys. Every drummer and pianist knows the benefits of one-hand practice. It’s not that drummers and pianists constrain limbs, but they do work one hand at a time to focus on skill development. Such development (particularly hand independence) will occur much more slowly when only practicing both hands together.

I mentioned in an earlier post that just a few days after my stroke a physical therapy intern at Mass General Hospital had me try to comb my hair with my left hand. The effort was not very successful, but I understood her reasoning—force the arm to work and the brain will work to solve the task.

Was her attempt a good idea? Not for a patient with less determination, I suspect. Failure often leads to surrender. But for me, I mostly just thought the attempt was premature.  Too many skills were required to perform the requested task.

This was a lesson I had learned when trying to sight-read difficult music way over my head. (One sets off boldly, soon begins to sputter, then will either grind to a defeated halt or muddle through to the end for a dubious victory.) Performing is altogether different from sight reading, however. With sufficient tenacity one can generally learn to perform even fiercely difficult music (though not necessarily beautifully or gracefully), but the endeavor will take many months, or years.

Though the hair combing was a failure, I took it as just another difficult “sight reading” experience. A week or so later, while at Spaulding Rehabilitation Hospital, I began to eat my meals with left hand alone. Succeed or starve, I had decided.

It wasn’t pretty, especially with the liquids, but I am still alive. (When my night nurse brought in my meds and a glass of water she would cheerily announce, “Time for your evening bath.”) I have eaten every meal since with my left hand. (Often it is still not pretty.)

Stroke recovery is not “sight reading.” It requires tenacious practice with the goal of flawless performance

My own progress has been slow. At first, I compared my recovery to learning a 1964 percussion piece by Charles Wuorinen titled “Janissary Music,” which, come to think of it, I never did learn well enough to perform, despite a year working on it. (…perhaps that was a poor model upon which to base my recovery aspirations…)

Patients at Taub’s clinic undergo constraint-induced movement therapy for hours every day. Many patients experience considerable improvement. I have no interest in being a Taub patient, but I have considered constraining my right hand so as to force my left to do all the work all the time.  I don’t mind the frustration that could so easily be avoided (I wrote this post using only my left hand), but the time it takes to accomplish basic tasks (not to mention cleaning up the inevitable messes) is terrifically inefficient when trying to meet real-world expectations.

Listening 1

Some three weeks after the stroke, while still at Spaulding Rehabilitation Hospital, I was visited by two of my bosses from Boston University’s College of Fine Arts. Spying an mp3 player, one asked about my playlist.

Prokofiev most recently, I responded.

“Wonderful music,” he said.

Yes, I agreed. But the truth of the matter was that I hadn’t found listening to Prokofiev wonderful at all. Or any music on my playlist. Music (at the least cold digital sound that comes from an mp3 player) was now just a sterile collection of tones and rhythms. Prokofiev’s portrayal of the lissome Juliet failed to generate an emotional response. I fared no better with Aretha. No matter what I tried—classical, jazz, or favorites from my 1960s teens—music left me cold.

How come? It didn’t feel like depression. Indeed, I felt fine. I liked my therapists and caretakers, had regular visitors, and mostly enjoyed my fellow patients. For the first time in decades, I had no professional pressures and plenty of sleep.

Something was different.

Since I was a child, I had been attracted to music’s physicality. Music’s sensual presence, and especially its rhythmic flow, moved me, both literally and figuratively. When I listened, I listened with full body. I entrained to music’s currents and eddies, and felt most whole when swimming among them.

But now, with my left side physically and emotionally comatose, I couldn’t engage. I heard, but didn’t connect.

Polio

In 1930, when my mother (1922-2007) was 8 years old, she went to bed feverish, then fell into a coma. When she finally awoke, her left shoulder and upper arm were paralyzed. She was infected with poliomyelitis.

Though her parents found her the best medical care, including extended stays at Georgia’s Roosevelt Warm Springs Institute for Rehabilitation, my mother never regained use of her arm.

She lived with paralysis for 77 years.

Even so, she considered herself lucky. Many of her young friends from Warm Springs had afflictions that were much worse. She could hardly speak about the life-saving horrors of the iron lungs to which some of them were confined.

Shortly after being transferred to Spaulding Rehabilitation Hospital, I had a “visitation” from Mom. She let me know, and in no uncertain terms, that I had better not start feeling sorry for myself. Others had suffered through things much worse and for much longer. (No names were mentioned.)

And anyhow, I was going to recover.

BILATERAL INTEGRATION

The following is an except from a presentation I gave at the Inaugural Interdisciplinary Symposium on Quantitative Research in Music and Medicine. Ogden, Utah. June 3, 2011. The presentation will be published in its entirety in the 2011 Proceedings of the Interdisciplinary Society for Quantitative Measurement in Music and Medicine. Precise publication information will follow when it  becomes available. Many thanks to the conference board for allowing publication of this material in my blog.

My first post-stroke memories begin around four days after the event. Subjectively, my thinking seemed dazed, but relatively normal. I just felt very tired. It was not until I tried to act in the world—perform simple addition or subtraction, read, tell time, speak, or tried to do just about anything—that the fractures in my mind became apparent. So too with my body. At rest, it felt normal, completely pain free. Until I tried to act, I had no idea I could not chew and swallow normally, walk, or move my left arm and fingers. Indeed, I had no left side sensation whatsoever.

On the fifth day after the stroke, I found I could move my left wrist. Earlier in the day, a neurologist had asked if the stroke had affected my music cognition. I had no idea. I had not thought about music at all; mostly my mind was silent. The neurologist sang some pitch intervals and I identified them without difficulty. How about rhythm, he wondered. I tapped a clave pattern with my right hand, also with no apparent problem.

Alone again, with my left arm lying on the bed, I moved the wrist to tap a beat with my left hand fingers . . . 1, 2, 3, 4. Movement was slow, and difficult to maintain, but a far as I could tell, the tempo was even. Next, I tried to alternate left and right hands. That was not successful, initially at least. Right-side activity overwhelmed and masked the weak directions my damaged brain was sending to my left wrist, which abruptly stopped moving. Not until I focused nearly all my attention on moving the left wrist could I sustain the two sides together.  Even so, I succeeded only for a few repetitions.

Because I had no sensation in my hand, it was necessary to watch the wrist move or to tap hard enough to hear my fingers make contact with the bed. Both were difficult. I tied tapping my left leg, but could not feel the contact. Next, I lifted my left arm over and tried tapping on the right side of my body. That was no better. The confusion resulting from registering right-side sensation when I moved my left hand made the task conceptually impossible.

Even so, I found the movement challenges highly engaging. Next, I tried a similar tapping exercise with my left foot, which I could now slowly rock back and forth. As with my hands, initially my left leg stopped moving when I attempted to alternate movements between both legs. Drum set-style, over the next few days and weeks I developed bilateral tapping exercises, organized both horizontally and vertically, for example:

1. Left hand—right hand—left hand—right foot.

2. Right hand—right foot—right hand—left foot.

3. Right hand—left foot—right foot—left hand.

4. Et cetera.

These exercises weren’t about developing quickness or fluidity of movement (that would only come months later), but about finding left-side muscles from different vantage points (or approaches) and with bilateral integration. There were distinct levels of difficulty. Crossing from left to right was far more difficult than alternating left hand with left foot. Crossing laterally and alternating hands and feet (see #3 above) was most difficult of all.

To keep me on task, I eventually attempted to maintain a steady rhythm. I continue to perform these exercises on a daily basis; they remain challenging. Concentrating locally (that is, entering deeply and solely into the experience of each particular movement event, rather than maintaining a broad overview perspective from which I sought to retain full-body awareness) made the task of moving from one limb to the next both more difficult and more productive. Such was the case for two reasons. First, paying close attention to each individual movement helped me understand the physical and mental mechanics of achieving the desired movement. Second, losing left-side focus resulted in left-side “invisibility.” It required considerable mental effort to rediscover the missing limb. I found that by having to search anew time and again, I began to learn where to look.

In the weeks that followed, my therapists gave me a variety of left-hand tasks. At first I picked up wooden blocks; later, I tried to stack them. Some two weeks after the stroke, and about a week after being relocated to Boston’s Spaulding Rehabilitation Hospital, I decided it was time to relearn to eat with my left hand. That first meal took almost an hour to consume and I looked like I had been in food fight, but my tray was cleared and a fair amount of the food had made it into my mouth. I was accomplishing tasks, but the work lacked a methodology upon which to scaffold undertakings from simple to difficult.

After all, imagine the muscle control involved in the “simple” act of picking up a block or getting food from plate to fork to mouth. The arm and hand must move through three-dimensional space; muscle groups must interact and work together. And with almost no sensation, I had to rely almost exclusively on visual cues. I cooperated with my therapists, but on my own I decided to break movement down to the basics, to create simple graduated exercises.

There is a piano in the common room of Spaulding’s stroke ward. At night, when the room was free, I went in to “play.” With my right arm I held my left hand over the keyboard and pushed down the keys one finger after another. Seconds would pass as I tried to locate neighboring digits, then move them forcefully enough into the keys so as to activate the hammers. When I learned to hold my left hand in place without assistance, I tied adding my right hand so as to play in octaves. The attempt was premature, however. When I used my right hand, I lost track of my left, which would simply fall to my side.

Some five weeks after the stroke, I was allowed to go home. We didn’t then own a piano, so I returned to the bilateral rhythmic exercises I had begun while still in intensive care.  My goal was to play a drum. It was nearly 6 months before I could hold sticks and hit what I was aiming for. I began with slow motion, maintaining a grip as I turned my wrist to bring the tip of the stick up and down, up and down. I quickly realized left-side pathways were fused together; my left leg moved reflexively in response to my brain’s muddled left-arm directions. As my left wrist turned, my left foot twisted with toes clenched inward. Nerves along my left side tingled, sometimes burned like a vicious case of hives.  While these effects have gradually lessened over time, they have yet to disappear.