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And, crucially, to work hard at their own care. "We have been habituated to a way of thinking," notes Doidge, which derives from what he calls the military metaphor of medicine, "the idea that the patient is merely the passive battleground where the two antagonists, the doctor and the disease, fight it out. The patient's job is to endure until the doctor comes up with something, or, these days, to become involved in a fundraising event that will send money to researchers so they or the drug companies can come up with the answer." But the plastic brain, capable of so much, still needs the help of mind and body to realize its possibilities.
Consider Dr. Michael Moskowitz, who knows pain both professionally and intimately. The co-operator of Bay Area Medical Associates in Sausalito, Calif., Moskowitz is a star in the treatment of pain, the man who sets the exams in pain medicine for aspiring American doctors. His clinic treats intractable cases, patients who have tried everything for their agony—all known drugs, nerve blocks, acupuncture—without result. "We are where people come to die with their pain," he told Doidge. By 2007, 13 years after a waterskiing accident, it looked like Moskowitz would be one of them. The acute pain from his neck injury had morphed into permanent, and growing, chronic pain.
It did so via the same mechanisms that create that transformation in anyone. "Chronic pain is plasticity gone wild," Doidge says. The injury to Moskowitz's neck had also affected his body's pain system, specifically the neurons in the brain associated with the neck area, causing them to fire repeated false alarms long after the neck had healed. What happened next illustrates core laws of neuroplasticity. Neurons that fire together, wire together: the more Moskowitz's pain signals flared, the better and quicker they became at it. Use it or lose it: the fight for brain territory is competitive. The more Moskowitz favoured his neck because of the pain, the less the neurons involved with it had to do, and the more vulnerable they become to hijacking by nearby areas, including the pain sensors now working overtime. Moskowitz was caught in a vicious circle. His pain, 3/10 on the standard scale at the best of times, and spiking frequently to 8/10, was only getting worse. "Plasticity is a blessing when you're listening to classical music and developing an appreciation for it," Doidge wryly notes, "but it's a curse when you are reinforcing pain."
As his quality of life inexorably eroded, Moskowitz sat down to read 15,000 pages of cutting-edge neurological research, seeking a way to make plasticity work for him. Moskowitz concentrated on two areas of the brain among the dozen that do at least some pain processing, the posterior cingulate and the posterior parietal lobe, areas whose primary purpose is to deal with visual information.
He knew already that when a brain area is processing pain it uses about five per cent of the neurons in the area, but the reinforcement involved in chronic pain means about 15 to 20 per cent of the neurons become involved. By concentrating on an image of his brain—an image in which it changed from being lit up by pain activity to being calm and pain-free—Moskowitz thought he could quiet the original pain receptors and force the hijacked neurons back to their day jobs as visual processors.
It required relentless dedication at first, a conscious response to every twinge. In three weeks, Moskowitz thought he detected slight improvement, enough to spur him on; by six weeks the pain that had spread to his back was gone; within a year he was almost always pain-free everywhere. He had turned the vicious circle virtuous. "Relentlessness was the most important factor, absolutely," Doidge agrees. "As a psychiatrist, I know that if you reframe a symptom attack as an opportunity, if instead of becoming crestfallen and pulling back, you treat every pain, anxiety or inhibition—reframe it as your moment—that's the route to altering that circuitry. That's what Moskowitz did. He didn't let a single twinge of pain go by."
Intense dedication is a hallmark of those who, all on their own, accomplish large-scale change in their brains. John Pepper, a South African now in his late seventies, was diagnosed in his thirties with the incurable, chronic, progressive neurodegenerative disease known as Parkinson's. By all odds he should be immobile, if not dead, by now, but Pepper has fought his symptoms to a standstill by vigorous exercise carried out with ferocious determination and conscientious attention to detail. "Even as his unconscious ability to walk unravelled," Doidge explains, "Pepper realized that if he analyzed how he walked and used his conscious mind to guide him, he could still do it. So he used a different part of his brain, the frontal lobes, and—like a child learning to walk—thought himself into efficient walking."
Pepper's case has fascinated everyone who has encountered it, partly because of his admirable bloody-mindedness, and partly for the way it demonstrates the importance, in recalibrating brain activity, of walking, the king of exercise. "It's our evolutionary history at work," Doidge argues. "When do animals do a lot a walking? When the environment they are in is being swarmed by predators or falls short of food. Moving to a new territory means entering a place where they have to do a lot of learning. When the brain takes note of a lot of walking, it and the body together secrete growth factors which put the brain into a super-plastic state, primed to learn."
People with Parkinson's have six times the dementia rate of those who do not, and Pepper is reaching what are the danger years for anyone, yet his mind is sharp. That, together with his mode of exercise and the first-the-right-heel-then-the-left-knee precision with which he pursues it, raise a question about Alzheimer's, a disease where both exercise and conscientiousness are proven factors in delaying onset. Is Alzheimer's a disease of plasticity, or rather of its absence? Doidge is cautious in response. "There are so many ways of looking at Alzheimer's. Most researchers analyze it chemically, because of the proteins involved, in hopes of finding alleviating drugs, but to look at Alzheimer's that way is to put it under the microscope at very high power—it is more holistic to think of an Alzheimer's brain as one that is losing plasticity."
Whether walking battles the onset of dementia through its link to plasticity or by its more general health benefits, it's one of the most potent anti-dementia forces known. "Now we have the Cardiff study looking at the British men over 30 years and it shows that if you did five things, including walking at least three kilometres a day," Doidge says, "the risk of dementia falls a staggering 60 per cent. If any medication did that, it would be the most talked-about drug in history."
Not that drugs have any role in the story Doidge tells. Moskowitz, who has switched the goal of his clinic from pain management to pain eradication, recognizes that he himself (and the likes of Pepper) is an outlier set apart by his iron determination. Not all his patients can follow him down his own relentless road. Even so, Moskowitz does not always seek to aid them with drug therapy—instead devoting considerable effort to weaning them from painkillers—but with touch, sound and vibration. It's a pattern Doidge sees everywhere. "Almost all the success stories involve a combination of mind and energy."
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