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Handbook of Cognitive Rehabilitation | www.austinpublishinggroup.com/ebooks
Gerry Leisman1,2,3 and Robert Melillo4
1The National Institute for Brain and Rehabilitation Sciences, Israel.
2Biomechanics Laboratory, O.R.T.-Braude College of Engineering, Israel.
3Universidad de Ciencias Médicas de la Habana, Facultad Manuel Fajardo, Cuba.
4Institute for Brain and Rehabilitation Sciences, USA.
*Corresponding author: Gerry Leisman, The National Institute for Brain and Rehabilitation
Sciences, Nazareth, Israel, Email: gerry.leisman@staff.nazareth.ac.il
Published Date: April 05, 2015
INTRODUCTION
Cognitive-Motor Development and Dysfunction
Little difference exists between the development of cognitive and motor function in childhood
and the relearning of cognitive and motor function post-trauma in adulthood. “Rehabilitation
recapitulates phylogeny.” In all cases, function must either be learned or re-learned. That
learning developmentally is associated with the formation and integration of motor and cognitive
milestones.
Motor and Cognitive Effects of Inhibition and Disinhibition as a Basis for
Cognitive Rehabilitation
It has been known that individuals who are markedly late in achieving developmental milestones
are at high risk for subsequent cognitive impairment [1,2]. The mechanisms underlying infant and
adult motor and cognitive associations remain poorly characterized. One possibility is that the
Cognitive Rehabilitation in Developmental
Disabilities
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neural systems that subserve motor development in infancy also contribute to the development
improved cognitive functions [3,4]. However, a number of questions remain concerning the
they could be answered, could shed light on the reasons behind the associations. For example,
function), or does it also apply to general intellectual function? Murray and colleagues [4] examined
these questions in a large British general population birth cohort in which measurements were
available for development in language and motor domains in infancy, general intellectual function
of executive/frontal lobe function) in adulthood. These authors noted that [4] noted that faster
attainment of motor developmental milestones is related to better adult cognitive performance in
some domains, such as executive function.
The developing infant is concerned with navigating to items of interest and exploring the
environment, ultimately to develop a sense of self, independent of the environment to which he
act’s outcome, and it is conjectured to prevail only if “consciousness” is present [6].
Because motivation relates to the self, while an act’s consequences can include environmental
components, consciousness is seen as lying at the operational interface between body movement
passive) transactions with its milieu. Only through those anatomical attributes can an individual
possess consciousness [7].
involved failed attempts, with attendant pain. What leads to discomfort will have been stored as
memory of possible sensory feedback resulting from certain self-paced movements. Likewise,
repertoire accessible unconsciously. Ultimately, the child hits upon the correct combination and
more complex motor pattern is temporarily deposited in explicit memory [8], and subsequently
transferred to long-term implicit memory [9], probably during the frequent periods of sleep
[10,11], characteristic in infancy. Soon, the toddler is able to walk without concentrating on every
step, and more complicated foot-related scenarios will enjoy brief sojourns at the center of the
explicit stage.
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The system conjures up a simulated probable outcome of the intended motor pattern, and
vetoes it if the prognosis is adverse. The simulated outcome lies below the threshold for actual
movement, and the mimicking requires two-way interaction between the nervous system and
the spindles [12,13] associated with the skeletal musculature, particularly when the muscles are
already in the process of doing something else. The interplay provides the basis of sensation, this
always being in the service of anticipation.
The bottleneck in sensory processing [14] arises because planning of movement is forced to
through our actual or simulated muscular movements, this is postulated to produce the unity
of conscious experience. Intelligence then becomes a measure of the facility for consolidating
the capacity for probing novel consolidations of motor responses.
We can think without acting, act without thinking, act while thinking about that act, and
act while thinking about something else. Our acts can be composite, several muscular patterns
being activated concurrently, though we appear not to be able to simultaneously maintain two
streams of thought. When we think about one thing while doing something else, it is always our
thoughts, which are the focus of attention. This suggests that there are least two thresholds, the
higher associated with overt movement and the lower with thought. Assuming that the signals
underlying competing potential thoughts must race each other to a threshold [15], it may be
earlier, the presence of strong loops could make overt movement too automatic. We can now add
a second possible penalty; thoughts might otherwise establish themselves by default. One should
note that overt movement and mere imagery-that is, covert preparations for movement, appear
to involve identical areas [17].
Thoughts, according to this scheme, are merely simulated interactions with the environment,
and their ultimate function is the addition of new implicit memories, new standard routes from
could well underlie the interplay between explicit and implicit in brain function.
A major problem confronting those who would explain consciousness is its apparently
walk.
more extensively reviewed elsewhere [18]. There has been a correlation shown between retained
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this was in the absence of any overt pathology in the brains of these children.
In another study [20] the relationship between extreme low birth weight infants, motor and
cognitive development at one and at 4 years was studied. The authors observed a relationship
between motor ability and cognitive performance. Their study investigated the association
between movement and cognitive performance at one and 4 years corrected age of children born
less than 1000g, and whether developmental testing of movement at one year was predictive of
cognitive performance at four years. Motor assessment at both ages was performed using the
year and cognitive performance at both one and at four years and between the subscales of each
cognitive performance at four years and this was independent of biological and social factors and
the presence of cerebral palsy.
In yet another study, [21] the relationship between a normal intact cerebellum and primitive
combination in the decerebrate cat before and after acute cerebellectomy. The investigators noted
seen in almost all children with neurobehavioral disorders and these factors are thought to play a
critical role in the development of normal coordination and synchronization of the motor system
and the brain [2,11].
Romeo and associates [22] examined the relationship between the acquisition of independent
walking. They noted that most of the infants they examined had a twostep development pattern.
The investigators observed, in those with incomplete pattern, a trend toward delayed acquisition
of independent walking.
Teitelbaum and associates [23] hypothesized that movement disturbances in infants can be
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noted may persist too long in autism. Head verticalization in response to body tilt they noted is a
be a markers for autism.
Recovery Recapitulating Phylogeny as a Basis for Therapeutic Strategy in
both Adults and Children
There are numerous consistencies between the successive developmental stages and recovery
locomotion and posture in rhesus monkeys passed through states similar to those seen during
stroke recovery. Teitelbaum et al. [24] found that the four stages of feeding behavior in normal
development re-emerged in rats recovering from a lateral hypothalamic injury. Other studies
from his laboratory determined that forelimb placing in the cat passed through the same stages
during normal development and during recovery from a focal lesion [25]. Morerecent studies in
humans lend further support to such a link, especially with regard to motor function. In other
cases, such as language, the case for a parallel between development and recovery might be less
compelling.
A major theme common to both childhood development and successful recovery from
with brain damage could no longer read but could write and not be able to read what he wrote.
The sequence of events after stroke was well described in the 1950s by Twitchell [27]. Initially,
movements consist of whole-arm synergistic events, then proximal movements predominate.
faster movements and shorter reaction times are seen as stroke recovery proceeds. This general
pattern is similar to motor changes during normal development. Newborn infants respond in a
generalized fashion to stimulation, with early responses showing much more movement of the
What are the changes in brain function that underlies these improvements in motor function
during stroke recovery, and how similar are they to the events of normal development? Brain-
mapping studies have provided some insights, and a number of similarities have emerged,
including those related to bilateral motor control and those related to plasticity of cortical
representational maps.
Bilateral Motor Control
Childhood is associated with bilateral motor control, in association with immaturity of the
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corticospinal connections essential for fractionated unilateral movements. In contrast, adulthood is
associated primarily with contralateral motor control, together with well-developed corticospinal
motor cortex induced bilateral responses in hand and arm muscles of most children, but only
contralateral responses from the age of ten. The frequency with which ipsilateral responses were
the movement of both hands during intended use of only one, a phenomenon known as mirror
movements. Mirror movements during hand motor tasks are normal in children, but decrease
in their prevalence and magnitude, then disappear in the early teenage years13. There are
limited data that describe functional brain activation in children. Studies using near-infrared
unilateral passive arm movements [30] in contrast to contralateral activation in response to the
same movements in adults [31].
hemisphere and in the right inferior frontal gyrus, when compared with adults. Bilateral motor
control has also been described in adults who have suffered a stroke. Neurophysiological features,
however, suggest two different patterns. One is found in individuals with poor motor status,
either soon after stroke or late after stroke in individuals with poor recovery. Neurophysiological
evaluation of these individuals discloses features in common with children. A second pattern of
bilateral motor control has been described in individuals with good recovery after stroke and has
more similarities with the normal adult motor physiology.
Soon after stroke, and in individuals with poor recovery long after stroke, studies have
demonstrated an increased degree of bilateral motor control that has similarities with normal
bilaterally increased sensorimotor cortex activation during passive movement of the paretic arm,
when compared with the same stimulus in controls [33]; this is the same stimulus that produced
bilateral sensorimotor cortex activation in infants and contralateral activation in healthy adults
[34]. In the stroke hemisphere, soon after stroke and in individuals with poor recovery from
ipsilateral responses to TMS are seen in children but not in adults. Furthermore, these ipsilateral
responses to TMS among individuals who have not recovered from a stroke are delayed by several
milliseconds compared with contralateral responses, similar to results in children. As with motor
behavior, neurophysiological characterization of individuals with poor motor status after stroke
has a number of similarities with early stages of development.
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Individuals with good recovery from a hemiparetic stroke also show increased bilateral motor
with good recovery after stroke have described bilateral activation in motor cortex regions
during performance of a hand motor task [35,36]. In contrast to individuals with poor recovery,
however, those who are well-recovered have normal central motor conduction times [37] and
do control subjects) [38,39]. Numerous studies have found that control subjects performing a
unilateral motor task recruit ipsilateral motor cortex, though to a smaller extent than stroke
subjects moving a recovered hand [35,36,40]. The site of ipsilateral motor cortex recruited by
stroke and control subjects is similar. In controls, the sites activated in a given hemisphere during
ipsilateral and during contralateral hand movements are spatially distinct. In the nonstroke
of separation in stroke is very similar to that seen in controls [41], suggesting that in stroke, a
cortical region normally used for movement is being recruited, but in an exaggerated way.
individuals who have suffered a stroke without good recovery, ipsilateral control of hand
[38,39]. The second pattern is seen in adults and in individuals with good recovery, suggesting
complexity of unilateral hand movements by normal adult subjects has been associated with
greater activation of the ipsilateral motor cortex [42].
Cortical-Map Plasticity
Brain-mapping studies have supported the idea that in humans, a number of cortical regions
contain orderly but overlapping representation of body regions [43]. In animal studies, these
studies [44]. The capacity to reorganize cortical representational maps might be maximal at
early time points in development. For example, hemispherectomy during early childhood can be
associated with remapping of motor, language and other functions to regions within the remaining
hemisphere [6,45].
Multiple rearrangements can occur after a single stroke, and an improved understanding of
cortical reorganization in this setting might come from studying patterns of change in multiple
systems. For example, compared with controls, an individual recovered from a small precentral
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to know. Gains in one aspect of function might arise at the cost of another; for example, this might
with improvement in the stroke-affected hand [35].
Evidence from animal and from human studies suggests that treatments targeting brain
example, a dramatic improvement in recovery is seen when rats with an experimental stroke are
given amphetamine; if the drug is not paired with physical activity, however, this improvement
was abolished [47]. Similarly, physical restraint can reduce post-stroke neuronal responses and
impede recovery [48]. Such a bi-directional relationship between behavioral experience and
brain structure during development has long been appreciated and might be of value in clarifying
physiotherapy in relation to post-stroke molecular therapies.
Localization, Optimization and Connectivities as a Basis for Cognitive
Rehabilitation
A neuroanatomical conceptualization based on localized function is largely an irrelevancy
for cognitive rehabilitation in developmental disabilities both in childhood and adulthood.
brain regions cooperate with each other. The reader is invited to review these concepts more
comprehensively elsewhere [18,45].
Figure 1 presents a traditional view of the localization of language function in the adult brain
and Figure 2 represents the nature of network processing of language not circumscribed to a
particular locale but rather to an organization of networks for optimized performance. Figure 3
then takes the understanding of network processing and demonstrates a non-localized view of
language processing.
Figure 1: Traditional understanding of localization of language in adults.
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Figure 2: Multiple stream models of receptive language functions organized into multiple self-
organizing simultaneously active networks [49].
Figure 3: Functional cortical networks measured by tractography [50].
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that is involved in that processing. Intuitively, we would expect higher performance to correlate
with more activity, for the cerebral cortex the contrary is the case. Higher performance in several
reduced consumption of energy in several cortical areas.
This phenomenon has also been studied with EEG techniques in different frequency bands.
The function of childhood neurological development is precisely to facilitate the creation of
localized function and it is dynamic. It can be changed and is therefore plastic. This localization of
of cognitive function is directly a consequence of the effectiveness of networks that now can be
measured. Fewer brain regions necessary to accomplish a single task in one individual compared
These networks, active during learning and problem solving of all kinds, are plastic and can
be changed as a direct consequence of experience and training. In attempting to apply graph
theory concepts to child and adolescent neurocognitive performance to create a fundamental
change in the educational training and evaluation paradigm, we can characterize the organization
& development of large-scale brain networks using graph-theoretical metrics as represented in
Figure 4 below.
Figure 4: Grounded meaning indicates that the meaning of words and sentences are “embodied”
[57].
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Rehabilitation
already-learned motor patterns into more complex composites, such consolidation sometimes
[18]. A normal child, lying on its back and wanting to roll over onto its front, soon learns that this
in the same direction. If the timing of this sequence is correct, the supine-prone transition requires
simple motor sequence. Indeed, the sequence does not even occur in their failed attempts. Instead,
they awkwardly arch their backs and ultimately fall into the desired position.
When a new motor pattern is being acquired, both the means and the ends will be coded
in currently active patterns of neuronal signals. And there must be interactions between these
is to be achieved. The prefrontal cortex probably dictates patterns of elementary muscular
sequences, but it must be borne in mind that the sophistication of the latter will depend upon
what the individual has already learned. A ballet dancer would regard as an elementary motor
feature to evolve thus far has been that seen in the mammals, and it permitted acquisition, during
of muscular movements. This mechanism makes heavy demands on the neural circuitry, because
it requires an attentional mechanism. As attention must be an active process, there must be
feedback from the muscles, carrying information about their current state, including their current
rate of change of state. Without such information, anticipation would be impossible, and without
anticipation there could be no meaningful adjudication and decision as to the most appropriate
The fascinating thing is that access to such on-line information mediates consciousness, the
gist of which is the ability to know that one knows. The ability to know that one knows is referred
knowing that one knows that one knows, merely depends upon the ability to hold things in
separate patches of neuronal activity in working memory. This manifests itself in a creature’s
intelligence, which also dictates its ability to consolidate existing schemata into a new schema.
When we know that we know, the muscular apparatus is not only monitoring its own state, it is
monitoring the monitoring.
It is precisely this absence of anticipation that impedes the ability of the brain injured to
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recover and why it is that the discussion of the early development and the discussion of primitive
early in life must be relearned.
“releasing the brakes” for motor actions and other functions.
THERAPEUTIC THEORY AND STRATEGY
increase stimulation and provide the proper fuel. The attempt should be to relearn the motor and
developing child and reappearing in the neurologically compromised adult. In practice, however,
it is not quite that straightforward. The purpose of this chapter is to provide the theoretical
rationale for therapeutic and intervention strategies currently available, but not to provide a
“how to” manual, the subject of a subsequent volume. We need now to consider how we increase
stimulation and what could be the best fuel.
Treatment Rationale
The current thinking is that only two options for treatment exist: one being medication and
physical interventions which makes up approximately 75 percent of recommendations and the
other being psychological or behavioral counseling including neuropsychology which makes
up the other 25 percent. Numerous alternative effective treatment options are available and
discussed in the context of recent brain, behavioral, pharmacological, biochemical, and genetic
research.
Behavioral Intervention Strategies
Cognitive behavioral therapy
This form of therapy has been used on adults for many fears or phobias, anxiety disorders,
panic attacks, and post traumatic stress disorder
physically approach, and ultimately experience the very things that terrify them. It is thought
that this particular form of therapy deliberately sets up a program of repeated programmed self-
awareness exercises to rewire connections in the brain and form helpful new memories, just as
repetitive practicing of the piano gradually creates a memory of motor skills. Common cognitive
distortions without a neurobehavioral disorder likely have adaptive evolutionary value. Cognitive
distortions are natural consequences of using fast track defensive algorithms that are sensitive
to threat. In various contexts, especially those of threat, humans have evolved to think adaptively
rather than logically. Hence, cognitive distortions are not strictly errors in brain functioning and
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neurobehavioral disorders in general most consistently points to dysfunction in cortical-striatal
implication, there may be functional disconnection between the anterior and posterior higher
these systems via cognitive interventions constitutes a logical remedial approach in the treatment
interventions.
Related to neurobehavioral disorders, however, studies have shown that CBT is just as effective
as drugs in many instances [58,59]. Rosenberg and colleagues [60] had studied the pathophysiology
of obsessive-compulsive disorder treated by CBT. They had reported increased thalamic volume
that decreased to levels comparable to control subjects after effective paroxetine therapy. No
result of a general treatment response or spontaneous improvement. However, recent research
of research supporting an involvement of neural circuitry connecting the orbitofrontal cortex,
reported [61] which expands upon previous work demonstrating effects of CBT on functional
relationships between cognitive choice, behavioral output and brain activity.
Cognitive behavioral therapy gradually stimulates the neocortex by increasingly having the
patients physically interact with their environment. We have seen that children exposed to violence
or neglect have similar symptoms as posttraumatic stress disorder, where the amygdala and
limbic system are overactive. In children, this results from a delayed development of the prefrontal
cortex and the amygdala remains the primary site of emotionally based information processing.
The rise of physical activity engages the muscle and joint receptors and the cerebellum, which is
the initiator of all human learning, cognitive or social. The cerebellum also is the largest source of
stimulation to the thalamus and the prefrontal cortex as well as the basal ganglia. As the person
physically interacts with the environment, it induces the cerebellum to promote developments
of the prefrontal cortex, which then inhibits the amygdala and limbic system, which reduces the
fear and stress responses. The prefrontal cortex now allows the individual to have perception
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that is more appropriate and awareness of the reaction of others to their actions as they learn
what is socially appropriate behavior. We also think that the recall the painful memories at the
same time helps to link these in time and space or synchronize these memories with other areas,
previously inhibited emotions. The individual would be theoretically forming new memories that
are less disturbing than the previous associations.
Wykes and colleagues [62] had performed an evaluation of the effects on the brain of cognitive
examined the effects on brain activity as a result of engaging in cognitive behavioral therapy. Three
by fMRI and a broad assessment of executive functioning was completed at baseline and post-
motion artifact. The fMRI analyses indicate that the control group shows decreased activation but
regions associated with working memory, particularly the frontal cortical areas. The results are
with schizophrenia can be associated clearly with psychological rather than pharmacological
therapy.
A study was performed in which the effects of citalopram and CBT on regional cerebral blood
rCBF was assessed in 18 previously untreated patients with social phobia during an anxiogenic
anxiety questionnaire data, and randomized to citalopram medication, CBT group therapy, or a
waiting-list control group. Scans were repeated after 9 weeks of treatment or waiting time. The
outcome was assessed by subjective and psychophysiological state anxiety measures and self-
report questionnaires. The questions were re-administered after one year. The results indicate
the waiting-list group remains unchanged. Within both treated groups, and in responders
regardless of treatment approach, improvement is accompanied by a decreased rCBF-response
to public speaking bilaterally in the amygdala, hippocampus, and the periamygdaloid, rhinal,
non-responders, particularly in the right hemisphere. The degree of amygdala-limbic attenuation
is associated with clinical improvement a year later. The authors conclude that common sites of
action for citalopram and CBT of social anxiety are observed in the amygdala, hippocampus, and
neighboring cortical areas that subserve bodily defense reactions to threat.
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CBT can be employed as a systematic effort to assist brain impaired individuals in developing
with acquired nervous system brain injury receiving biweekly CBT sessions for 20 weeks in a
school setting. Treatments were provided by trained schoolteachers under the supervision
of psychologists specializing in cognitive rehabilitation. Students were evaluated pre- and
posttreatment using neuropsychological tests. After treatment, the students demonstrated a
learning ability according to the authors. The theoretical rationale for CBT intervention has been
practically adapted to attempt to teach meta-cognitive executive thinking strategies to children
with disorders of executive function. The intervention is based on the notion that some children
with disorders of executive function have disorders of higher-level language, which predispose
them to the executive impairments demonstrated. The teaching and reinforcing of meta-cognitive
thinking strategies may well help advance verbal mediation of complex tasks and selfregulation
developmental executive disorders, little has been written about interventions that may enable
the children to acquire some of the requisite adaptive skills.
Utilizing performance on intelligence testing spanning 20 years, Bellus and colleagues [65]
performed a study evaluating changes in cognitive functioning of a severely brain injured
individual, who had been placed in a long-term psychiatric hospital and treated in an intensive
improvement in overall verbal and nonverbal cognitive functioning during treatment. These
improvements were maintained for a 1-year period. The authors suggest that the use of ‘low tech’,
small group interventions, within intensive behavioral rehabilitation programs, may lead to the
in problem solving and social adjustment, Suzman and associates [66] provided case studies and
a series of multiple baseline experiments examining the effects of a multi-component CBT on
indicate that the training program resulted in a substantial decrease in errors on a computerized
problem-solving task used to monitor problem-solving performance during baseline and
of problem solving abilities.
Frolich and associates [67] have indicated that in the past, cognitive behavioral treatment
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of parent and teacher questionnaires. CBT was found effective in reducing the core symptoms
of the cited symptoms. These investigators conclude that CBT is an important component in the
to its effectiveness in situations where children still have problems of self-guidance.
poor motivation, poor organizational skills, impulsivity, reduced anger control, and low self-
both medicated and non-medicated were assigned to either CBT or a waiting list control. CBT
was delivered in an intensive format with eight two-hour, weekly sessions with support people
were maintained one year after the intervention. The study’s authors conclude that the CBT
randomly assigning them for 3 months of intensive treatment to a 5-day residential program or a
residential program demonstrate clinical deterioration and increased symptoms of anxiety
and depression. These investigators conclude that greater emphasis be placed on research
neuropsychological test performance.
Behavioral Therapeutic Intervention
Our eyes usually move in brief motions called saccades. Between the saccades, they focus on
the objects that we see [70]. Although our eyes move several times per second, we perceive the
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for us to notice the interval between the snapshots [70].
The saccadic eye movements, generated during a visual oddball task, of autistic children,
children were examined to determine whether autistic children differed from these other groups
in saccadic frequency [71]. Autistic children made more saccades during the presentation of
addition, unlike the normal and dyslexic groups, their saccadic frequency did not depend on
stimuli, and thereby learning processes.
Goldberg and colleagues [72] employed ocular-motor paradigms to examine whether or not
movements in patients with HFA and in normal adolescents on anti-saccade, memory-guided
saccade MGS, predictive saccade, and gap/overlap tasks. Compared with the normal subjects,
also showed longer latencies on a MGS task and for all conditions tested on a gap/null/overlap
appeared). When the latencies during the gap condition were subtracted from the latencies in
the overlap condition, there was no difference between patients and normals. These authors
conclude that abnormalities in ocular motor function in patients with HFA provide evidence for
the involvement of a number of brain regions in HFA including the dorsolateral prefrontal cortex,
It is known that autistic children demonstrate abnormal gaze behavior toward human faces
expression. The second study dealt with neutral faces presented either upright or upside-down.
upright faces, with or without an emotional expression. Furthermore, results of the second study
against the notion that the abnormal gaze behavior in everyday life is due to the presence of facial
stimuli per se. Furthermore, the absence of a face orientation effect in autistic children might be
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addressed by therapeutic intervention using eye movements.
processing social information and that that several studies on eye movements have indeed found
indications that children with autism show particularly abnormal gaze behavior in relation to
social stimuli even though previous studies did not allow for precise gaze analysis. In the their
study [75], the looking behavior of autistic children toward cartoon-like scenes that included a
behavior of autistic children was found to be similar to that of their age- and IQ-matched normal
indication for an abnormality in gaze behavior in relation to neutral objects. It is suggested that
the often-reported abnormal use of gaze in everyday life is not related to the nature of the visual
stimuli but that other factors, like social interaction. Therefore, intervention strategies employing
eye movements as a therapeutic vehicle are theoretically useful.
engagement and disengagement in 16 high-functioning autistic children of about 10 years of age
and 15 age- and IQmatched normal control children. Subjects were asked to make saccadic eye
off 200 msec. before the target appeared. Although no differences between the groups in either
overlap condition and the gap condition) was smaller in the autistic group than in the control
group. They concluded that autistic children show a lower level of attentional engagement.
Ruffman and colleagues [76] addressed these issues by studying social understanding in
autism employing eye gaze as a measure of core insights. Twentyeight children with autism
and 33 mentally handicapped children were given two tasks tapping social understanding and
a control task tapping probability understanding. For each task, there was a measure of eye gaze
at differentiating children with autism from children with other mental handicaps. Children with
autism did not look to the correct location in anticipation of the story character’s return in the
social tasks, but they did look to the correct location in the nonsocial probability task. These
investigators also found that within the autistic group, children who looked least to the correct
location were rated as having the most severe autistic characteristics. Further, they found that
whereas verbal performance correlated with general language ability in the autistic group, eye
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gaze did not. They argue that eye gaze probably taps unconscious but core insights into social
behavior and as such is better than verbal measures at differentiating children with autism from
mentally handicapped controls. Additionally, eye gaze taps either spontaneous processes of
simulation or rudimentary pattern recognition, both of which are less based in language, and
the social understanding of children with autism is probably based mostly on verbally mediated
theories whereas control children also possess more spontaneous insights indexed by eye gaze.
in explicit experimental tasks. To bring experimental measures in line with clinical observation,
Klin and associates [77] reported a novel method of quantifying atypical strategies of social
monitoring in a setting that simulate the demands of daily experience. While viewing social scenes,
social adjustment and less autistic social impairment, whereas more time on objects predicted
the opposite relationship. When viewing naturalistic social situations, individuals with autism
demonstrate abnormal patterns of social visual pursuit consistent with reduced salience of eyes
and increased salience of mouths, bodies, and objects. Fixation times on mouths and objects but
not on eyes are strong predictors of degree of social competence.
From an evolutionary standpoint gaze is an important component of social interaction. The
function, evolution, and neurobiology of gaze processing are therefore of interest in the context
of neurobehavioral disorders of childhood. The role of social gaze has changed considerably for
primates compared to other organisms. This change may have been driven by morphological
changes to the face and eyes of primates, limitations in the facial anatomy of other vertebrates,
changes in the ecology of the environment in which primates live, and a necessity to communicate
information about the environment, emotional and mental states. The eyes represent different
levels of signal value depending on the status, disposition, and emotional state of the sender and
receiver of such signals. There are regions in the monkey and human brain, which contain neurons,
that respond selectively to faces, bodies, and eye gaze. The ability to follow another individual’s
gaze direction is affected in individuals with autism and other neurobehavioral disorders as we
have seen, as well as following particular localized brain lesions. We can hypothesize that gaze
following is “hard-wired” in the brain, and may be localized within a circuit linking the superior
temporal sulcus, amygdala, and orbitofrontal cortex. A more complete review is provided by
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Emery [78]. This being the case the with developmental neurobehavioral disorders should clearly
be involved in intervention strategies employing eye gaze as a vehicle.
Supporting the notion of eye gaze involvement, Howard and colleagues [79] reported a
convergence of behavioral and neuroanatomical evidence in support of an amygdala hypothesis
characteristic of the effects of amygdala damage, in particular selective impairment in the
recognition of facial expressions of fear, perception of eye-gaze direction, and recognition
memory for faces. Using quantitative magnetic resonance imaging analysis techniques, they found
that the same individuals also show abnormalities of medial temporal lobe, notably bilaterally
enlarged amygdala volumes. These results combine to suggest that developmental malformation
of the amygdala may underlie the social-cognitive impairments characteristic of HFA. While they
support a primary underlying involvement of eye-gaze.
Eye movement dysfunction also is likely to occur after injury at several levels of the neuraxis.
Unilateral supranuclear disorders of gaze tend to be transient, but bilateral disorders more
enduring Nuclear disorders of gaze also tend to be enduring and are frequently present in
association with long tract signs and cranial nerve palsies on opposite sides of the body. Nystagmus
is a reliable sign of posterior fossa or peripheral eighth nerve pathology. Familiarity with these
concepts may help the clinician answer questions regarding localization and prognosis and their
remediation in post head injury insult or in developmental disorders is necessary.
In attempting to explain further why gaze-shift impairment is part of the clinical picture in
neurobehavioral disorders, we should recall that imaging and clinical studies have challenged the
concept that the functional role of the cerebellum is exclusively in the motor domain. Townsend
and associates [80] presented evidence of slowed covert orienting of visual-spatial attention
damage acquired from tumor or stroke. In spatial cuing tasks, normal control subjects across
a wide age range were able to orient attention within 100 msec. of an attentiondirecting cue.
msec. but did show the effects of attention orienting after 800-1200 msec. These effects were
demonstrated in a task in which results were independent of the motor response. In this task,
Although eye movements may also be disrupted in patients with cerebellar damage, abnormal
consistent with evidence from organism models that suggest damage to the cerebellum disrupts
both the spatial encoding of a location for an attentional shift and the subsequent gaze shift. These
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data are also consistent with a model of cerebellar function in which the cerebellum supports
of patients with lesions to this brain circuitry, a selective disturbance in the ability to suppress
commonly emerges during childhood or adolescence, few studies have examined psychotropic-
processes in this disorder. Ocular-motor tests were administered to 18 psychotropic medication-
comparison subjects to assess the following 3 well-delineated aspects of prefrontal cortical
function: the ability to suppress responses, the volitional execution of delayed responses, and
that may underlie the repetitive symptomatic behavior that characterizes the illness [81].
Mostofsky and colleagues [82] assessed saccadic eye movements in boys with Tourette’s
saccades) were used to examine functions necessary for the planning and execution of eye
movements, including motor response preparation, response inhibition, and working memory.
differences among the three groups in accuracy of memory-guided saccades. Mostofsky’s ocular-
response as evidenced by excessive latency on prosaccades. Signs of impaired response inhibition
it is hypothesized that these arise because of disruption to a behavioral inhibition system. In
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children and healthy adults. Executive functions were measured using a test of spatial working
functions were measured using an ocular motor paradigm that required individuals to use task
would appear at either of the two locations. In one block, targets appeared on 80 percent of trials.
In the other block, targets appeared on 20 percent of trials. The ability to control the release of
on the spatial working memory task than the healthy adults, there was no difference between
on the spatial working memory test than the healthy children, although spatial working memory
and this was due to their inability to voluntarily inhibit saccades when there was a low target
having found similar effects in both males and females.
Bergmann [85] speculated that the hippocampus and amygdala are involved in using eye
movements as a rehabilitation tool. He notes that it is thought that these two structures are
involved in much of the brains learning and remembering.
retains the dry facts.” He also notes that inhibition of the amygdala is thought to arise from the
left prefrontal cortex [86].
A second pathway from the thalamus projects to the neocortex; this arrangement allows the
amygdala to react before the neocortex. The neocortex processes the information through several
interventions resynchronizes the activity of the two hemispheres, by way of the alternating
stimulus which may mimic the activity of the pacemaker function within the cortex that may
gradually shifts the brain activity from amygdaline hyperactivity to activation of greater
neocortical function.”
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more coordinated with their eye movements, there usually is improvement in learning and
behavior. A direct neurological connection exists between the neck and extra-ocular muscles;
examining for weakness and fatigability of eye muscles can test weakness of neck muscles. It has
adduct one eye and not the other, this usually represents a unilateral weakness or neurological
imbalance, and the weakness is often found on the same side as a neocortical decrease in
Saccadic dysmetria with the child looking up to the right or down and left is usually associated
with right cerebellar lesions, whereas up and left and down and right dysmetria is associated
There are currently some interesting studies examining eye movement intervention strategies in
neurobehaviorally involved children using functional imaging techniques that should reveal or
Biofeedback
Biofeedback training provides a tool to consciously control the autonomic nervous system using
biofeedback devices in order to alleviate stress, migraine headaches, asthma, high blood pressure,
and a host of other health conditions including epilepsy. Neurofeedback or EEG biofeedback is the
form of biofeedback typically used on children with epilepsy and neurobehavioral conditions like
cognitive means. It is thought that neurofeedback seems to work by interacting in the area of
frequency of signal transmission. Frequency in this context is the rate at which electrical activity
is a component of a bounded continuum ranging from death through various states of sleep and
ultimately to excitement and seizures. These are described in Table 1 and Figure 5 below:
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Table 1: EEG Frequency Ranges
Figure 5:
levels including those associated with an awake excited person, the alpha rhythm associated
with relaxation with eyes closed, the slowing in frequency associated with a drowsy condition,
the slow high amplitude waves of sleep, the larger slow waves associated with deep sleep, and
the further slowing of EEG waves associated with coma.
With decreasing states of consciousness, the EEG frequency slows and the amplitude increases.
Waveform Frequency Range (in Hz) Amplitude (in μV) Occurrence
Gamma rhythm 30-50 Excitement
Beta rhythm 18-30 < 10 Alert/eyes open, arousal,
anterior scalp
Alpha rhythm 8-13 0-40
Adults, older children, relaxed
wakefulness/eye closed,
parietal, occipital temporal
regions
Mu rhythm 7-11 0-20
Asymmetric, asynchronous
between 2 sides at times
unilateral, central parietal,
attenuates with contralateral
extremity movement, thought of
movement, or tactile stimulation;
no reaction to eye opening and
closing
Theta rhythm 4-7 40-60 Childhood, light sleep, temporal
areas through adolescence
Delta rhythm 0.5-4 40-200 Sleep
Delta rhythm 0.5-3 40-200 Infancy, deep sleep, coma
Lambda & K complex & sleep
spindles Not dened solely in terms of
rhythm Deep sleep
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of brain weight and the average frequency of EEG background activity from posterior regions of
Figure 6:
[88,89].
Even though these measures of frequency by EEG are now considered relatively crude, they
do provide a window into excitability within the brain. Researchers thought that problems arise
speculation that arousal levels may be the major component in a whole host of disorders. The goal
of neurofeedback therefore is said to be to stabilize the brain and nervous system so that it does
returns us to some original theories of arousal that were popular in the 1950s. It was then thought
that two main states existed, stability and arousal [90]. According to this theory, optimal idling
speed for the human brain is about 14 Hz. Therefore, if the brain’s major activities of speed
lower than that 8-13 Hz, an individual may feel tired and might seek stimulation from coffee
disorder. Alternatively, over-arousal might provoke an individual to feel unsettled and might then
seek out alcohol to decrease arousal level or need medication to calm down, the situations being
akin to depression versus mania or left versus right hemisphere dysfunction. Anxiety, hyper-
vigilant stress, and obsessive behavior are thought to be all symptoms of over-arousal.
In the 1960s, neurofeedback was considered a revolutionary way to examine the mind and
its capabilities. One of the early pioneers of biofeedback was M.B. Sterman, who was one of the
This rhythm is associated with inhibition of motor activity [91-93]. It was labeled sensory-motor
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in humans. An increase in SMR in the EEG of cats by operant conditioning was subsequently
demonstrated [94].
to increase the incidence and duration of Rolandic sleep spindles, which occur in the identical
more sustained periods of quiet sleep in both normal subjects and insomniacs [95]. It was also
noted that paraplegics and quadriplegics exhibit larger than normal amounts of sleep spindles
cord injuries exhibit a relative dearth of epileptic behavior. Additionally, cats with cervical dorsal
column transection exhibit a heightened threshold for druginduced seizures. In one case it was
noted in an epileptic patient who experienced upper cervical cord compression, following the
between the incidence of SMR rhythm and of motor induced seizures. Reduction of activity in the
4-7 Hz frequency band has also been demonstrated in monkeys during sleep, after administration
of four anticonvulsant drugs. This suggests that excessive low frequency amplitude is indicative
Following this postulation, it was found in 1969 that after training for enhanced SMR rhythm
in cats, threshold for seizure onset was increased for chemically induced seizures [97]. Following
this, EEG feedback training in poorly controlled epileptics showed reports of seizure reduction.
Sterman achieved an average 66 percent reduction in seizure incidence in four epileptics using
SMR enhancement training in combination with inhibition of excessive slow activity in 6-9 Hz
region. Wyler and associates [98] showed that enhancement of EEG activity above 14 Hz and
suppression of activity below 10 Hz was effective in seizure reduction. Synchronization of the EEG
worsened seizure incidents where a desynchronization of EEG improved it [98].
Lubar and Bahler [99] took Sterman’s work even further and in a different direction. He had
noticed that hyperactivity decreased in patients treated for epilepsy and based on this created
observables are similar in general to interictal epileptiform activity consisting of a relative
their absence of seizure history was reported by Lubar and Shouse [100]. A number of behaviors
of 13 behavioral categories. The EEG training was shown to be more effective than the use of
A study by Lubar and Lubar [101] extends the technique to attentional defects and learning
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disabilities. The appropriateness of doing this is based on long standing observations that
more than 60 percent of the cases of learning disabilities exhibit EEG abnormalities [102]. The
experimental protocol was complimented with training in the 15-18 Hz region associated with
EEG activation in general and with arousal and focus. Changes in EEG were documented with
power spectral density measurements, which were compared with those of normal subjects. The
EEG biofeedback was also accompanied by academic training. Acquisition of the desired EEG
have a strong neurological basis with increased beta activity occurring over central and frontal
portions of the cortex and decreased beta activity occurring centrally, posteriorly, and sometimes
even frontally. Beta activity has been associated with daydreaming and a lack of beta activity with
poor ability to concentrate and to complete task.
sessions initially carried out 2-3 times a week and then phased out over a period. A session may
information based on our previously described neurological model, we can see that consistent
with these EEG studies, decreased activity or arousal of the brain, especially over somatosensory
conditions. EEG activity is produced by the ascending activation system from the thalamus.
Synchronization results from decreased thalamic activity and decreased desynchronization from
increased thalamic activity. These studies also show that there is a relationship with activity from
input from the dorsal column, its effect on EEG activity, and with the production of abnormal EEG
activity.
In addition, the dorsal column projections to the cerebellum and thalamus and subsequently
to the somatosensory cortex and frontal lobe seem to be the basis of gamma oscillations and
with decreased stability and function of the brain pathways and their processing capability. EEG
may be an effective remediation tool because cognitive activation of frontal lobe will activate
ascending pathways from the cerebellum and thalamus, as well as descending frontal projections
to the brainstem reticular formation, basal ganglia, and will increase muscle tone with subsequent
feedback through spine cerebellar and dorsal column pathways to cerebellar-thalamic and
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exceed the metabolic rate of neuronal pathways. However, neurofeedback therapists do not
In addition, if the problem arises from the musculoskeletal system and its lack of feedback as
in a neck injury, this intervention strategy will not be effective in effecting change in the region
of primary involvement. Whereas stimulating motor activity may be more specialized to a
Sensory-Motor Intervention Strategies
Therapeutic use of light
Levitan and associates [103] reported that evidence exists from clinical, epidemiological, and
similar latitudes.
include forms of depression, anxiety, learning disabilities, and sleep disorders, etc. One of the most
recognized disorders that have been treated with the use of light is seasonal affective disorder or
as well as other similar disorders are due to the affect that light has on regulating of biological or
circadian clocks.
could respond directly to light. He later traced this affect to the minnows’ pineal gland, which
we now know to be the source of melatonin. In the brain, a group of cells known as the supra-
chiasmatic nucleus of the hypothalamus or SCN is thought to be the basis of biological clocks [105].
In mammals, it appears to be remarkably reliable. Even when removed from an experimental
organism and placed in a dish, it continues to keep time on its own for approximately a day. The
SCN is divided into two structures. One is the right hemisphere and one is in the left, just below
and behind the eyes. Each part of the SCN is made up of approximately 10,000 densely packs
neurons. Recent research in mice suggests that mammals have a set of special photoreceptors in
their eyes, which react to light signals and carry them directly to the SCN. These photoreceptors
are thought to be different from the rods and cones used to perceive light stimulating the retina. It
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is thought that light helps to reset the biological clocks. Light in the morning is thought to set the
clock ahead and in the evening, backwards. Whether the running of these biological clocks is an
innate quality of cells or a product of some unseen force, like gravity, is not known. Nevertheless,
disruption of light stimuli can disrupt these clocks.
Many other areas of the brain are affected by light. We can recall our earlier discussion of the
intricacies of the development and function of the ventral and dorsal visual systems and their
role in cognitive perception and limbic system function. We recall that the dorsal visual system
is associated more with right hemisphere function, which is involved in global or low frequency
for a local visual function or higher frequency stimulation. These systems are powerfully
connected to cognitive and emotional functions.
brain as a whole. However, different frequencies of the same stimulus may have asymmetric
affects on the brain. Modulating the frequency of stimulus also takes into account the metabolic
rate of brain cells. Interestingly, it has been noted that red, which is a low frequency source, would
be expected to slow down the neocortex and affect more of the right brain, increasing sympathetic
to left brain and in fact, has been shown to increase parasympathetic functions [106]. It has also
been noted that a pale light blue paint on the walls of schools appears to decrease hyperactivity
in children, where pale yellow on the walls of schools appears to improve concentration and
learning abilities.
Altering the balance of light or vision from one hemisphere to the other has also been shown
to have powerful psychological affects. Frederick Schiffer has found that using a pair of glasses
that block vision to either the right or left hemispheres can help alleviate anxiety or depression
[107,108]. Schiffer thinks that these glasses that work to relieve anxiety and distresses is
remarkable testimony to the link between the eyes and the two sides of the brain and a variety
of psychological problems. Schiffer attempted a simple experiment on himself. When he covered
one eye and part of the other, he detected a slight difference in his clarity of thought. Schiffer then
made safety glasses that covered one eye completely and half of the other. He had seventy patients
suffering from severe anxiety wear the glasses and measured the affect on a one to ten scale, by
on the scale) and 23 percent had a 2-point difference. Schiffer also had the patients wear glasses
that covered the other eye. In interviews, 40 of the patients said they felt more anxiety when they
wore the glasses. A study of a control group of college students, who were not in therapy, also
found measurable changes in their feelings of anxiety and changes in brain wave patterns with
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the remediation of neurobehavioral disorders of childhood, the existing theory supports it further
investigation.
performance, and behavior. Guided imagery is one form of visualization. Guided imagery has
the subject create internal scenarios and mental pictures that evoke positive physical responses.
Imagery is reported to improve the immune system [109] and reduce stress [110].
Leiner and associates [111] have noted that several studies of ideation or mental imaging
increases in different areas of the cerebellum and neocortex. On the other hand, it has been shown
that those who imagine shooting a basketball display as much improvement in that skill after a
week as those who actually physically practice shooting a basketball. This would lead us to think
that whether imagined or actually done, motor acts must activate similar area of the cerebellum
that create functional improvement in motor control.
In the last decade, there has been a dramatic increase in research effectively integrating
cognitive psychology, functional neuroimaging, and behavioral neurology. This new work is
one study the authors employed object recognition, mental motor imagery, and mental rotation
paradigms, to clarify the nature of a cognitive process, imagined spatial transformations used
in shape recognition. Among other implications of the study was that recognizing a hand’s
handedness or imagining one’s body movement depends on cerebrally lateralized sensory-
In a second study, using cutaneous, tactile, and auditory pitch discrimination paradigms, it was
suggested that the cerebellum has non-motor sensory support functions upon which optimally
mental representations in the absence of sensory stimulation, is a core element of numerous
cognitive processes. Numerous investigators have recently investigated the cortical mechanisms
underlying imagery and spatial analysis in the visual domain using event-related functional
magnetic resonance imaging during the mental clock task [113] and fMRI [114]. The timeresolved
analysis of cortical activation from auditory perception to motor response reveals a sequential
activation of the left and right posterior parietal cortex, suggesting that these regions perform
distinct functions in imagery tasks.
Knauff and colleagues found that in the absence of any correlated visual input, reasoning
inspect spatially organized mental models to solve deductive inference problems, we do have a
basis for concluded that imagery has the capacity for effecting change in brain state. In one of
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the view imaging studies to date on clinical applications of imagery as a therapeutic tool, Marks
and associates [115] investigated subjective imagery in obsessive-compulsive disorder before
and after exposure therapy using fMRI. A small randomized study was performed, with controls
a computer or by a therapist, or relaxation guided by audio-tape). Before and after treatment,
during fMRI scanning, patients imagined previously rehearsed scenarios that evoked an urge to
discomfort.
Therapeutic use of sound
Music has a unique capacity to reorganize cerebral function where it has been damaged
[7,116]. “There’s an overlap in brain mechanisms in the neurons used to process music, language,
mathematics and abstract reasoning,” Mark Tramo, a neuroscientist at Harvard Medical School
has stated, [117]. “We think a hand full of neuronal codes is used by the brain, so exercising the
brain through music strengthens other cognitive skills. It’s a lot like saying if you exercise your
body by running, you enhance your ability not only to run but also to play soccer or basketball.”
have reportedly been affective for children with learning disabilities and behavioral problems.
There are those who think that sound and music can effects dysfunction in the nervous system
through both its calming and energizing affects on the brain and CNS. As a clinical therapy it is
used in hospitals, schools and psychological treatment programs to reduce stress or lower blood
pressure, alleviate pain, overcome various learning disabilities, improve movement and balance,
and promote endurance and strength.
Campbell, author of the book The Mozart Effect, has researched the affect of music and its
43,000 – 82,000 years ago, humans knew that music created special effects. He suggests that music
the higher music frequency’s 13,000 – 20,000 hertz. To indicate that the application of the so-
called Mozart Effect is without controversy would be an understatement especially considering
there have been numerous reports of an inability to replicate the effect [119].
Hughes and Fino [120] had performed a study reported in Clinical Electroencephalography
The goal of this study was to determine distinctive aspects of Mozart music that may explain the
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Mozart, but also 67 of J.C. Bach, 67 of J.S. Bach, 39 of Chopin and 148 from 55 other composers were
computer analyzed to quantify the music in search of any distinctive aspect and later to determine
10-60 sec, mean and median of 30 sec), was found often in Mozart music but also that of the two
music that had no effect on epileptic activity in previous studies. Short-term periodicities were
is that one distinctive aspect of Mozart music is long-term periodicity that may well resonate
within the cerebral cortex and also may be related to coding within the brain.
Thompson and Andrews [121] in reporting on the Mozart effect in which they claim was made
that people perform better on tests of spatial abilities after listening to music composed by Mozart,
examined whether the Mozart Effect is a consequence of between-condition differences in arousal
condition but only for participants who heard Mozart. The two music selections also induced
differential responding on the enjoyment, arousal, and mood measures. Moreover, when such
differences were held constant by statistical means, the Mozart Effect disappeared. Thompson’s
We are here less concerned about Mozart as a composer and more about the effects of sound in
effecting change in brain and cognitive function.
Thompson and Andrews [121] in their paper provide an overview of the theoretical
underpinnings of the Tomatis Method, along with a commentary on other forms of sound/music
training and the need for research. A public debate was sparked over the Mozart Effect. This debate
has turned out to be unfortunate because the real story is being missed. The real story starts with
the rich interconnections between the ear and the nervous system to integrate aspects of human
development and behavior. The originating theories behind the Tomatis Method are reviewed by
Thomson and Andrews to describe the ear’s clear connection to the brain and the nervous system.
The neuropsychology of sound training describes how and what the Tomatis Method affects. The
50 years of clinical experience and anecdotal evidence amassed by Tomatis, shows that sound
stimulation can provide a valuable remediation and developmental training tool for individuals
with neurobehavioral disorders.
In Norway, in the 1980’s, educators used music therapy for children with severe physical and
mental disabilities. They found that music reduced muscle contraction in patients’ with severe
spastic conditions, increased range of motion in their spines, arms, hips, and legs. These effects
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would suggest effects not only on the neocortex, but the brainstem reticular formation as well as
the cerebellum. Since music has powerful effects on the hair cells in the vestibular apparatus, it
would also be expected to have effects on the olivary complex and the cerebellum. This, in fact,
may be its primary effect.
studies on music’s emotional impact on the brain. They employed positron emission tomography
volunteers were scanned while listening to six versions of a novel musical passage varying
systematically in degree of dissonance. Reciprocal CBF covariations were observed in several
distinct paralimbic and neocortical regions as a function of dissonance and of perceived
similar to those previously associated with pleasant/unpleasant emotional states, but different
from those underlying other components of music perception, and other emotions such as fear. In
in response to subject-selected music that elicited the highly pleasurable experience of “shivers-
down-the-spine” or “chills.” Subjective reports of chills were accompanied by changes in heart
rate, electromyogram, and respiration. As intensity of these chills increased, cerebral blood
motivation, emotion, and arousal, including ventral striatum, midbrain, amygdala, orbitofrontal
cortex, and ventral medial prefrontal cortex. These brain structures are known to be active in
links music with biologically relevant, survival-related stimuli via their common recruitment of
brain circuitry involved in pleasure and reward.
studies that examine the neuroanatomy of expert musicians as they listen to music. It has been
children have been shown to pay attention more acutely to stimuli with a harmonic structure,
and it seems that they learn music in the same way as language, with one note exponentially
acquiring new ones [126]. In the past few years, researchers have begun to map areas of the brain
involved in performing music or while silently reading scores. However, no previous studies have
examined the emotions elicited during a musical piece. A more complete review can be found in
[116].
Blood and her colleagues, decided to target the emotional response to music, by studying ten
adults from ages 19-43, as they listened to musical notes that either clashed or had a harmonic
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tone. They designed the experiment using a single melody and adding on six versions from a very
pleasant sounding piece to something that a two-year-old would bang out on the piano. They
According to Blood, the discordant notes triggered activity in the parahippocampal gyrus, an area
near the temporal lobe that plays an important role in processing sensory memory. When the
of the frontal lobe. Responses were primarily found on the right side of the brain. Blood and
colleagues think this activation as an indication of the emotional responses to music. These brain
regions were also different from the region activated when musicians read a score, or were asked
to pick out mistakes in musical pieces. In 1992, researchers at the Montreal Neurological Institute
late Justine Sergent and her colleagues studied musicians as they read scores or performed, and
tasks called upon during the musical experience rely on different areas of the brain. In one study,
subjects were eight right-handed faculty conductors. The conductors were instructed to focus on
errors in melody, harmony, or rhythm in a Bach Choral. The errors appeared one to every two
beats and the musicians were instructed to take notice but not to perform any motor responses.
Each task was shown to produce very different patterns of brain activity. Melody activated both
the left and right hemispheres in the temporal lobe, while harmony and rhythm triggered activity
more in the left hemisphere. Harmony did not activate the temporal lobe at all. Each of the tasks
also activated right fusiform gyrus. This same area in the left hemisphere has been linked to
visual processing of words. Researchers suspect that the right fusiform gyrus may have evolved
to regulate information on musical notes and passages. It has been noted that stroke patients
who have lost language function may be able to gain some verbal improvement, by singing
harmony, melody, and rhythm also activate the cerebellum even though the conductors were not
moving, indicating the cerebellum’s involvement in cognition.
Schlaug [125] reported that skilled male musicians he studied have larger cerebella than
average. He employed CT scans to compare 32 right-handed male musicians with 24 right-
handed men with no musical training. Schlaug and his colleagues [127] have previously reported
that male musicians have larger corpus callosa and larger primary motor cortices in the frontal
lobe. They have not found similar differences in the cerebellar volumes between male musicians
and nonmusicians. Other studies have shown functional brain changes in individuals who have
changes in the brain that are associated with a learned skill. This indicates that the cerebellum is
involved in both motor and cognitive function and in the processing and the production of music.
An interesting parallel exists between brain changes associated with the acquisition of a
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musical skill [125] and languages acquisition [111]. Leiner and associates have noted that the
lateral areas of the cerebellum are activated during the cognitive aspects of speech production,
whereas, the medial cerebellar cortex is activated during the motor function of speech. If music
music and language processing in the cerebellum, thalamus, and frontal lobe. It is also interesting
to note that musicians have been found to demonstrate structural changes in the cerebellum,
association cortex external to the neocortex, especially between the dorsal and ventral language
areas, it may assist in integrating function of the hemispheres. This being the case, we may expect
to see an enlargement in the corpus callosum associated with hemispheric integration. Since
both the corpus callosum and the cerebellum may be involved in the temporal synchronization of
multiple areas, this may be the reason for the observed enlargement.
This may also explain the results of a study by Chan and her colleagues [128] and others
[116,129], that indicate that children who spend a few years learning to play a musical instrument,
seem to be consistent with the brain scans that have shown the left planum temporale to be larger
in musicians than in individuals without extensive training in instrumental music. Chan and
associates [128] studied 60 female college students from the University of Hong Kong, of whom
30 had at least 6 years of training with western musical instruments before the age of twelve and
the other 30 had no formal training. The students were tested for verbal memory by attempts to
remember lists of words. The researchers stated, “We found that adults with music training learn
images such as words written on paper.
According to Evan Balaban, “There has been a long tradition of researchers trying to segregate
and speech), may have more to do with each other than was previously thought.” If musically
that non-musicians do not have, the main differences in ability between them would be the motor
acts associated with playing music and possibly the breathing associated with wind instruments
[130,131]. Both of these differences in ability and the functional changes associated with them can
be attributed to the effects of the cerebellum. This would also demonstrate that motor activities
have a carry-over effect on cognitive function of the frontal lobe, such as in the case of verbal
memory.
Musically trained brains respond to randomly heard musical tones in fundamentally different
ways than those who are untrained. This effect is apparently more pronounced among those
who take music lessons before the age of six. Recent studies suggest [125,132-134] that when a
piano tone is played, either more neurons are activated or the neurons are responding in a more
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synchronized fashion. No change occurs in those without musical training. In one study, German
researchers asked 20 musicians from a local conservatory were asked to watch a cartoon, while
either pure non-musical tones or piano tunes were presented. They measured electrical activity in
the brain during the activity. A control group of non-musicians heard the same tones. The results
showed about 25 percent more activity than non-musicians. What was also interesting is that
are not musical, had no apparent effect. In addition, those who began lessons before their sixth
birthday seemed to have the strongest response. It was also noted that the brains of musicians
respond differently to piano tones [133].
and a minor note). The recorded activity differences were noted in the left frontal cortex in those
with perfect pitch. When those with relative pitch were asked to choose between a major and
minor note, this region in the frontal lobe also became active. The authors concluded that those
motor speech area connected with activation of the right cerebellum. With this recent increase in
research showing the effects of music on the brain, music as therapy has gained wider acceptance
in more mainstream centers.
Therapeutic use of olfaction
The sense of smell can be used as a powerful stimulus to the brain. A number of recent
cognition, mood, and social behavior. These orthodox investigations have a common, if uneasy,
relationship with the holistic practice of so-called aromatherapy. In children and adults, various
studies have shown improvement in learning abilities and emotional disturbances, as well as affects
on blood pressure and stress responses. One study using peppermint oil has shown improvement
in cognitive function on children as compared to controls [136]. In their study Soussignan and
associates examined the facial responsiveness of ten mutic children with pervasive developmental
covertly videotaped while presented with a set of odors contrasted in hedonic valence. Hedonic
ratings of the stimuli were obtained from both the group of normal subjects and a panel of adults.
consisted in an analysis of facial movements with the Facial Action Coding System. Results
normal subjects showed more smiles. With the second method, a panel of observers rated odor-
elicited facial behavior. The observers were asked to judge whether the subjects were exposed a
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developmentally disordered subjects.
in inhibition, interference control, nonverbal working memory, and other facets of attention
serve as a basis for therapeutic intervention in this modality as well as others.
Further support for the use of olfactory stimulation as part of an overall intervention strategy
in neurobehavioral disorders of childhood comes from the study of Levy and colleagues [139] who
noted that memory for odors induces brain activation as measured by functional MRI. fMRI brain
scans were obtained in 21 normal male and female subjects and in in two patients with hyposmia
or diminished sense of smell in response to the imagination of odors of banana and peppermint
and to the actual smells of the corresponding odors of amyl acetate and menthone, respectively.
than that in response to the actual smell of these odors, and activation following imagination of
amyl acetate. The ratio of brain activation by imagination of banana to activation by actual amyl
acetate odor was about twice as high in women as in men. Before treatment, in patients with
hyposmia, brain activation in response to odor imagination was greater than after presentation of
the actual odor itself. After treatment, in patients with hyposmia in whom smell acuity returned to
quantitatively from that before treatment; however, brain activation in response to the actual
Brain regions activated by both odor imagination and actual corresponding odor were similar
be imagined and similar brain regions are activated by both imagined and corresponding actual
is greater than in women for some odors, but on a relative basis, the ratio for odor imagination
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experienced, is present, recallable, and capable of inducing a relatively constant degree of brain
activation even in the absence of the ability to recognize an actual corresponding odor.
Henkin and Levy [141] looked further at the nature of the lateralization of brain activation to
and right hemispheric localization of unpleasant odors. fMRI brain scans were obtained in 24
normal subjects in response to imagination of banana and peppermint odors and in response to
smell of corresponding odors of amyl acetate and menthone, respectively, and of pyridine. The
smell of corresponding odors of amyl acetate and menthone. There are no overall hemispheric
differences for pyridine odor. Localization of all lateralized responses indicates that anterior
frontal and temporal cortices are brain regions most involved with imagination and smell of odors.
Imagination and smell of odors perceived as pleasant generally activate the dominant or L to R
brain hemisphere. Smell of odors perceived as unpleasant generally activates the contralateral or
R to L brain hemisphere. According to these authors, predominant L to R hemispheric differences
in brain activation in normal subjects occur in the order amyl acetate > menthone > pyridine,
consistent with the hypothesis that pleasant odors are more appreciated in left hemisphere
and unpleasant odors more in right hemisphere. Anterior frontal and temporal cortex regions
previously found activated by imagination and smell of odors accounted for most hemispheric
differences.
hyposmia as they responded to odors of amyl acetate, menthone, and pyridine, to imagination
scans were compared with those in normal subjects and patients with acquired hyposmia. The
authors found that brain activation in response to odors was present in patients with congenital
acquired hyposmia Regional activation localization was in anterior frontal and temporal cortex
similar to that in normal subjects and patients with acquired hyposmia. Activation in response to
presented odors was diverse, with a larger group exhibiting little or no activation with localization
only in anterior frontal and temporal cortex and a smaller group exhibiting greater activation with
localization extending to more complex olfactory integration sites. “Memory” of odors and tastes
elicited activation in the same central nervous system regions in which activation in response to
patients with acquired hyposmia and did not lateralize. Odors induced CNS activation in patients
with congenital hyposmia, which distinguishes olfaction from vision and audition since neither
light nor acoustic stimuli induce CNS activation.
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Henkin and Levy concluded that odor activation localized to anterior frontal and temporal
cortex is consistent with the hypothesis that olfactory pathways are hard-wired into the CNS
and that further pathways are undeveloped with primary olfactory system CNS connections but
lack of secondary connections. However, some patients exhibited greater odor activation with
response localization extending to cingulate and opercular cortex, indicating some olfactory
signals impinge on and maintain secondary connections consistent with similar functions in
vision and audition. Activation localization of taste “memory” to anterior frontal and temporal
cortex is consistent with CNS plasticity and cross-modal CNS reorganization as described for
vision and audition. Thus, there are differences and similarities between olfaction, vision, and
audition; the differences are dependent on the unique qualities of olfaction, perhaps due to its
diffuse, primitive, fundamental role in survival. These studies add further support in employing
odor intervention strategies in neurobehaviorally-involved children in programs of differential
hemispheric activation.
The effect of the olfactory system on the limbic system is profound especially when we
consider the evolutionary development of the brain. The limbic system is intimately connected
to the rhinencephalon or primitive “nose brain.” Therefore, we would expect that odors or
pheremonal activity would have direct affect on emotions, autonomic regulations, and through
effects on the parahippocampal complex, on memory acquisition. Although it has been generally
accepted that the sense of smell is the only sense that is not related to the thalamus, there has
on eye and head movement [142]. Through this mechanism, pheremonal activity is thought
to regulate attentional mechanisms. Risold and Swanson used a method for simultaneous
characterize in the rat a hypothalamicthalamo- cortical pathway ending in a region thought to
regulate attentional mechanisms by way of eye and head movement.
The investigators thought that the relevant medial hypothalamic nuclei receive pheremonal
posterior thalamic nucleus and projects to the superior colliculus. In addition, bi-directional
by previous experience. They further note that there are striking parallels with basal ganglia
circuitry. In discussion of their results, they note that their evidence suggests that the rostral
medial zone nuclei of the hypothalamus participate in a thalamo-limbic projection similar to the
classic mammillo-thalamic limbic projections from the caudal medial zone and that the former
receives olfactory information and modulates well established attention mechanisms involving
eye and head movement.
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In regard to intra-cortical projections of the retro-splenial area, these are divided into three
streams. One major stream extends rostrally to end in the anterior cingulate caudal pre-limbic
two areas project back to the retrosplenial area. This is of interest because in the rat, anterior and
along with the adjacent secondary motor areas mainly because they project to several brainstem
regions involved in ocular motor control including the superior colliculus [143]. It is also noted
that the anterior cingulate and the secondary motor areas receive inputs from the lateral posterior
thalamic nuclei [142] and the medial dorsal nucleus No. 17 [144]. The anterior cingulate area
receives input from the lateral dorsal nucleus No. 20 [145] and the rostral nucleus reuniens.
Risold and Swanson [142] suggest that information arriving at the rostral medial hypothalamus
by descending pathways, as well as to parts of the cerebral cortex involved in regulating eye and
head movements by ascending pathways to the rostral nucleus reuniens and ventral intermedial
nucleus. They note that the hippocampal formation participates in conceptually similar circuitry
the mammillo-thalamic and mammillo-tegmental tracks. Iso-cortical regions project to the basal
ganglia, which in turn generate descending projections to mid-brain motor regions and ascending
projections to secondary motor cortical regions by way of the ventral anterior thalamic nucleus.
In summary Risold and Swanson [142] state that their model predicts that the rostral nucleus
reunions and ventral anterior medial nucleus projecting to the retrosplenial area pathway,
conducts pheremonal information to a polymodal cortical mid-brain pathway eliciting attentional
motor responses involved in the procurement phase of appropriate motivated or goal directed
behavior. We know that goal directed behavior is a function of the prefrontal cortex and approach
and avoidance behavior. Olfactory stimulation therefore would be expected to increase frontal
motor cortex. Olfactory stimulation affects limbic structures like the amygdala and hypothalamus,
which regulate emotional and autonomic responses and which are inhibited by frontal cortical
and intra-hippocampal circuit. The intra-hippocampal circuit plays a critical role in short-term
episodic or declarative memory [142].
Olfactory stimulation also affects the anterior and posterior cingulate areas, which have been
implicated in several aspects of spatial memory [146]. By affecting attentional mechanisms of eye
either through affects on ocular-motor or brainstem motor nuclei. Therefore, the use of olfactory
therapy or pheremonal activity has a neurophysiological basis for affecting both learning abilities
and behavioral and emotional disorders.
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Integrated Sensory-Motor Intervention Strategies
According to practitioners, Occupational Therapy is a health profession concerned with
improving a person’s occupational performance. In a pediatric setting, the Occupational Therapist
deals with children whose occupations are usually players, preschoolers, or students. The
Occupational Therapist evaluates a child’s performance in relation to what is developmentally
expected for that age group. If there is a discrepancy between developmental expectations and
function.
sensory input effectively. It is thought that sensory integrated dysfunction may be present in
motor, learning, social, emotional, speech, language, or attention disorders. Ayres thought that
proprioceptive input is extremely important to the function of the sensory system and the
because of its constancy of input. She thought that the primary source of this proprioceptive and
gravitational input was from the vestibular apparatus of the inner ear and the vestibular system.
She called this the cerebellar vestibular system. She thought that this system was a primary force
in brain development. This was insightful considering the paucity of research to then support
her theories of the development and function of the brain. Her observations and results were
impressive enough that now Occupational Therapy with its developmental early intervention
focus is universally adopted.
directly. The balance and sensitivity of the apparatus is set by the function of the cerebellum and
developing child and the vestibular and visual systems are relatively constant, the proprioceptive
system is by far the most important to the cerebellum and its effects on the thalamus and the
neocortex.
Ayres observed that children with learning and neurobehavioral problems exhibit what she
termed sensory defensiveness. It was thought that this sensory defensiveness was the result of
an over-activation of our protective senses. It was noticed that some children had decreased
responses to sensory stimuli and some appeared to have increased sensitivity to sensory input.
We now have a better way of understanding and explaining these observations and realize that
both are the product of decreased sensory input to the cerebellum, thalamus, and neocortex. The
cerebellum has two halves as does the cerebrum. These two halves must be balanced in their
activation. If they are not, the hemisphere with decreased activity may initially be less sensitive to
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incoming sensory stimuli with an increased threshold of activation because the neurons are less
active. However, over time, this decreased activation causes the cells to shift closer to threshold
as a compensatory mechanism. This makes the child more sensitive to stimuli that affect the
dysfunctional half of the cerebellum. Tactile, proprioceptive, extra-ocular, and vestibular input
movement of the head, neck, or body expressed as motion sickness, disordered eye movements,
or visual perceptual disturbances. Cerebral activity associated with cognition or emotion also can
this input, may cause these cells to produce free radicals and result in oxidative stress injury to
these same cells. In the basal ganglia this may produce hyperkinetic and/or hypokinetic behavior
through the same process. In the cerebrum, we recognize this as epilepsy, epileptiform activity, or
Ayres observed the symptoms of this process and described several types of sensory
defensiveness.
1. Tactile defensiveness: Children with tactile defensiveness avoid letting others touch them
and would rather touch others. They frequently fuss or resist hair washing or cutting. They may
act as if their life is being threatened when being bathed or having clothes changed. Some types of
clothes, clothing labels, or new clothes often irritate these children. They may dislike being close
not like to get their hands or feet dirty. They may seem unnecessarily rough to people. Some may
bump or crash into things on purpose as a way of seeking sensation or seen under responsiveness
to certain sensations or pain.
2. Oral defensiveness: Some children dislike or avoid certain textures or types of foods. They
may be over or under sensitive to spicy or hot foods, avoid putting objects in their mouth and/or
intensely dislike teeth brushing or face washing. Sometimes have a variety of feeding problems
since infancy.
3. Gravitational insecurity: This appears to be an irrational fear of change in position or
movement. These children are often fearful of having their feet leave the ground or having their
head tip backwards.
4. Postural insecurity: This is a fear and avoidance of certain movement activities due to poor
postural mechanisms.
5. Visual defensiveness: This may involve an over sensitivity to light and visual distractibility.
With this problem, children may avoid going outside in certain light and/or need to wear hats
or sunglasses to block out light. They may startle more easily and/or overt their eyes or seem to
avoid eye contact.
6. Auditory defensiveness:
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sometimes make excessive amounts of noise to block out sounds [148]. Other symptoms can
When we understand how the cerebellum functions and how it affects the thalamus and
cerebral cortex, we will then be able to explain more fully all of the symptoms of autistic spectrum
output nuclei. The cerebellum also controls motor coordination, balance, postural stability, and
extraocular eye movements. It also activates the thalamus, which relays all sensory input to the
be more sensitive to input and may cause decreased stability of thalamus and cerebrum, even
though the overall level of stimulation is decreased. This decreased threshold or increased signal-
This increased sensitivity is a product of decreased activation and is perceived as unpleasant by
the child. This explains why a child with the same problem can present differently with one being
over-reactive to certain stimuli and another being under-reactive. The underlying problem is the
same, a lack of the central nervous system being properly activated. The same lack of stimulation
can produce hyperkinetic behavior, while another may present with hypokinetic behavior.
Ayres devised a number of ways of treating these problems of sensory defensiveness. In
Occupational Therapy, the approach to treatment primarily involves vestibular, proprioceptive,
treatments for particular problems are:
1. Tactile defensiveness:
touch to arms, hands, back, legs, and feet with a non-scratching brush with many bristles. The
This treatment is recommended because the results are effective for short periods. Occupational
Therapists note that if these procedures are applied consistently over time, the defensiveness is
joints and heavy muscle action together is a special combination to reduce or eliminate sensory
a large body space).
2. Oral defensiveness: OT treatment of applying heavy pressure across the roof of the mouth
and giving input to the temporo-mandibular joint. Oral motor activities are also used that involve
biting or resistive sucking use with a knot on the end, fruit roll-ups, beef jerky, etc. to bite and pull
on. Occupational Therapists use small straws, sports bottles, plastic tubes, etc. for sucking as well
as mouth toys that involve sucking and blowing.
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3. Gravitational and postural insecurity: In which treatment includes jumping on bouncing
swinging on suspended tire inner tubes, “frog” sling swings, wet hammocks, platform swings,
and “bungy” cords. Climbing and crawling over an under large pillows, beanbag chairs, jungle
gyms, rocks, trees, up stairs, on hands and knees through obstacle courses made of furniture,
handwriting, and peg board drawing.
to treatment along with support of Ayers [149] concept of sensory defensiveness [150-152]. In
Theories of Physical-Mechanical Interventions
The effects of physical exercise on cognitive performance
If there is one activity that seems to be the “magic bullet” against almost every disease or
disorders, it is exercise, especially aerobic exercise. It seems almost every day a new study shows
exercise to reduce the risk and severity of a new disease from cancer to the common cold to
depression, exercise seems to be the one thing that prevents or cures them all. There have been
because of its affect on heart and cardiovascular system. Some think because of its affect on the
endocrine system, while others think it affects the immune system. The fact is that it affects all of
system. When one modality affects all of the systems of the body, it must be because of a primary
affect on the brain. As we have seen, autonomic, immune, endocrine, cognitive, emotional, and
sensory systems are all asymmetrically distributed in the brain. Exercise therefore must have a
generalized affect on all brain functions. As we know, the primary source of activation of the brain
is through the motor system, therefore, high frequency low intensity activity of the motor system
will have powerful affects on the global activation, arousal, and attention of the cerebellum,
thalamus, basal ganglia and cerebrum. Aerobic exercise affects all muscles of the body including
the involuntary postural antigravity muscles, as well as the voluntary muscles of the extremities
to the brain, and increases the capacity of the lungs to take in oxygen. We would expect, therefore,
that exercise would be helpful in improving a child’s ability to learn and control behavior and to
focus attention. Lack of physical activity would be expected to cause the opposite affect.
It has been demonstrated that mice who regularly exercise on running wheels had twice the
number of new brain cells compared to sedentary mice. One of the study’s authors, Fred Gage, has
said that, “More people in my lab have started running since we found this result.” The studies
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[153,154] are remarkable in several ways. Gauge’s laboratory demonstrated that humans along
with mice and non-human primates do grow new brain cells after birth. In a previous study, the Salk
researchers had found that those mice who had “enriched environment” with a tunnel, toys and
an exercise wheel grew more cells than those in regular lab cages [155]. What’s more, in the area
of new brain cell growth, the hippocampus is associated with learning and memory. Researchers
thought that it might not just be running per se, but exercise in general that causes the growth of
environment” mice showed that they perform better on learning tasks. Exercise has been shown
to enhance cognitive function and to help stroke victims recover from brain injury [156,157].
The type of exercise is important and the combination of physical activity and mental focus
or “purposeful” activity at the same time or close together, appear to yield the greatest changes.
Nudo and associates [158] documented plastic changes in the functional topography of primary
investigators employed intra-cortical micro-stimulation mapping techniques to derive detailed
maps of the representation of movements in the distal forelimb zone of M1 of squirrel monkeys,
sets of forelimb movements. After training on a small-object retrieval task, which required skilled
use of the digits, their evoked-movement digit representations expanded, whereas their evoked-
movement wrist/forearm representational zones contracted. These changes were progressive
and reversible. In a second motor skill exercise, a monkey pronated and supinated the forearm in
digit representational zones contracted. Their results show that M1 is alterable by use throughout
the life of an organism.
These studies also reveal that after digit training there was a real expansion of dual-response
representations, that is, cortical sectors over which stimulation produced movements about
two or more joints. Movement combinations that were used more frequently after training
indicates that a neurophysiological correlate of a motor skill resides in M1 for at least several days
together in the cortex argues that, as in sensory cortices, temporal correlations drive emergent
changes in distributed motor cortex representations.
Tantillo and associates [159] had performed a study examining the effects of exercise on
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in their study ceased methylphenidate medication 24 hours before and during each of three
decreased ASER latency, and decreased motor impersistence after maximal exercise. Girls with
support the employment of vigorous exercise programs as adjuvant in the management of the
Elliot and associates [160] examined the effects of antecedent exercise conditions on
maladaptive and stereotypic behaviors in 6 adults with both autism and moderate to profound
mental retardation. The behaviors were observed in a controlled environment before and after
exercise and non-exercise conditions. From the original group of participants, two were selected
subsequently to participate in aerobic exercise immediately before performing a community-
and stereotypic behaviors in the controlled setting. Neither of the less vigorous antecedent
conditions did. When aerobic exercise preceded the vocational task, similar reductions were
observed. There were individual differences in response to antecedent exercise. These authors
note that the use of antecedent aerobic exercise to reduce maladaptive and stereotypic behaviors
of adults with both autism and mental retardation is supported.
Rosenthal-Malek and Mitchell [161] reported similar results. They investigated the reduction
self-stimulatory behaviors in adolescents with autism after vigorous exercise. Celiberti and
colleagues [162] in a detailed case study of an autistic boy also examined the differential and
stimulatory behavior. The exercise conditions were applied immediately before periods of
academic programming. Maladaptive self-stimulatory behaviors were separately tracked,
stimulation). Examination of temporal effects indicated a decrease in physical self-stimulation
and “out of seat” behavior, but only for the jogging condition. In addition, sharp reductions in
these behaviors were observed immediately following the jogging intervention and gradually
increased but did not return to baseline levels over a 40-minute period.
Recent studies using organism models have been directed towards understanding the
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increase resistance to brain insult, and improve learning and mental performance. Recently, high-
density oligonucleotide microarray analysis has demonstrated that, in addition to increasing
brain plasticity processes. Thus, exercise can provide a simple means to maintain brain function
and promote brain plasticity [163].
Lieberman and colleagues [164] reporting in the American Journal of Clinical Nutrition note that
peripheral glucose requirements increase and carbohydrate supplementation improves physical
performance. The brain’s utilization of glucose also increases during aerobic exercise. However,
the effects of energy supplementation on cognitive function during sustained aerobic exercise
are not well characterized. The investigators examined the effects of energy supplementation, as
the subjects performed physically demanding tasks, including a 19.3-km road march and two
4.8-km runs, interspersed with rest and other activities. Wrist-worn vigilance monitors, which
standardized self-report mood questionnaire were used to assess cognitive function. These
investigators found that vigilance consistently improved with supplemental carbohydrates in a
dose-related manner; the 12 percent carbohydrate group performed the best and the placebo
group, the worst. Moodquestionnaire results corroborated the results from the monitors; the
subjects who received carbohydrates reported less confusion, and greater vigor than did those
who received the placebo. Supplemental carbohydrate beverages enhance vigilance and mood
during sustained physical activity and interspersed rest. In addition, ambulatory monitoring
devices can continuously assess the effects of nutritional factors on cognition as individuals
conduct their daily activities or participate in experiments. These approaches have not been
employed in studying neurobiological involved children.
command’ during imagination of exercise under hypnosis, in order to uncouple central command
from peripheral feedback. Three cognitive conditions were used: imagination of freewheeling
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prefrontal cortex, and the cerebellum are concerned with volitional motor control, including
component of the respiratory response to ‘exercise’, in the absence of both movement feedback
and an increase in CO2 production, can be generated by what appears to be a behavioral response.
eyes open/closed conditions to assess baseline differences between these groups. Spectral power
was less for the exercise compared to the control group in the delta band, but greater in all other
bands. Mean band frequency was higher for the exercise compared to controls in the delta, theta,
and beta bands. Some differences in scalp distribution for power and frequency between the
affects resting EEG and again supports the effects of exercise on brain function.
Traditionally the view has been that there is a separation between motor skills and cognitive
ability. However, the same pathways and same global increase activation of the areas involved
with motor skill also underlie the areas that form the foundation of cognitive ability. However,
the brain is activity dependent, therefore even though the potential to learn is enhanced through
Humans speak, they type, they sign, they write each and intricate motor skill. In the domain
other organisms and suggest that motor capabilities are related to other intellectual capabilities.
Indeed some psychologists such as Jerome Bruner have suggested that even human language
capability is an outgrowth of capabilities involved to create new motor sequences.”
“Extensive evidence suggests that knowledge is acquired as a result of extensive practice,
thousands of hours of highly dedicated practice is key in separating the most successful people
in various motor and non-motor skill domains from the rest of us. This perspective grew initially
out of analysis of chess expertise, but also has been found to apply to muscle performance and
basketball.” Keele concluded, “…The surprising idea that stands out in the expertise literature is
that the extraordinary motor capabilities of humans are best understood as an extension of their
extraordinary cognitive abilities.” When we examine “geniuses” through out history, we can see
geniuses not only in their cognitive ability but also in their motor skill as well, to paint or play
music.”
The question is, does the constant practice of developing a motor skill like painting, or playing
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then they will not perform well in other areas of life. However, if motor skill is used as a tool to
develop brain areas, and then academic and social pursuits are diligently taught, the child will
learn those activities better and faster. The key is balance and in an otherwise normal child who
is behind, and in a child who is developmentally delayed, the fastest and most effective way to
increase the rate of development of their brain function may be through motor activity and motor
development. If there is a delay in motor skill development, then there will be a subsequent delay
in their cognitive and emotional development as well.
Occupational Therapists think that hyperactive children often have persistent tonic neck
uncomfortable for the child to sit normally. OT’s note that many children who are hyperactive are
for support. They may tend to stand when eating or doing homework and they may experience
fatigue of their neck and postural muscles, which becomes painful and affects the child’s ability
to concentrate. Occupational Therapists have designed a series of crawling exercises and claim
academic performance and behavior. These techniques emphasize the importance of the motor
system to effect the neurological development of a child’s brain and a subsequent improvement in
learning and behavior. While the theory does not take into the cerebellum, differential hemispheric
activation, and their effects on developing brain function into consideration, the theory does
emphasize the role of postural muscles in the manifestation of the observed symptoms. Most
thalamic and frontal lobe dysfunction. Therefore, any activity emphasizing proximal and postural
to right brain development and therefore would be expected to improve symptoms of right brain
Therapeutic Relations Between Musculoskeletal and Cognitive Function
The majority of all sensory input arises from somatosensory receptors of the musculoskeletal
system and the largest percentage of that amount comes from the receptors of the spinal muscles
and joints located in the upper cervical spine receptors [167]. Through the ability of these spinal
receptors and based on their upright orientation and transduction of gravitational forces into
electrochemical impulses that constantly bombard the brain by way of the dorsal column and
of perception, cognition, and emotional behavior, especially in the frontal lobe.
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However, with manifestation of symptoms, especially musculoskeletal symptoms, which make
up the vast majority of health complaints of humans, they are primarily symptoms of neurological
dysfunction and are best treated by effecting the nervous system directly. This can be achieved
by use of spinal manipulation, joint mobilization, exercise and by stimulating the brain through
a variety of environmental stimuli, such as sound, light, heat, cold, odors, tactile sensation,
demonstrate dysfunction of their motor-sensory system. Either this dysfunction of the motor-
sensory system may in fact be a primary cause of the brain dysfunction or the brain dysfunction
may be the primary cause of the motor-sensory dysfunction. Either way, the motor-sensory
systems, which include the postural muscles and joints of the spine and neck are dysfunctional.
Therefore, no matter what the primary source, an intervention strategy for the motor-sensory
dysfunction ought to result in an improvement of brain function and vice versa. This is especially
true in the frontal lobe where we have seen that both motor and non-motor functions can be
improvement of frontal lobe motor function associated with an improvement in a child’s motor
function capacities, such as muscle tone, coordination, mobility, strength, and endurance, should
emotional, and behavioral. By directing and including diagnosis and treatment of musculoskeletal
system function, we develop tools of measuring and affecting central nervous system status.
Luoto et al., [168] examined the relationship between musculoskeletal complaints relating to
higher brain function. The authors examined the mechanisms explaining the association between
and depression has been associated with impaired cognitive functions and slow reaction times.
in motor tasks. The authors hypothesize that chronic low back pain hampers the functioning
of short-term memory in a way that leads the preferred hand to loose its advantage over the
non-preferred hand, but that the advantage would be restored during rehabilitation. Reaction
times for the preferred and non-preferred upper limbs were tested in 61 healthy control and
68 low back pain patients. A multi way analysis of covariance was used to examine the group,
handedness, and rehabilitation was found. At the beginning, the reaction times for the preferred
hand were faster among the control subjects, but not among the patients with low back pain.
After the rehabilitation, the preferred hand was faster among both the control subjects and the
results support the hypothesis that chronic low back pain and disability impedes the functioning
of short-term memory, resulting in decreased speed of information processing among patients
with chronic low back symptoms.
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Numerous studies [169,170] report on a theory that suggests that a dysfunction in the way of
the brain receives and processes information from the body, may trigger so called writer’s and
musician’s cramps. Researchers have found that the debilitating disorder also called focal dystonia
of the hands stems from pushing the brain past its ability to learn quick repetitive movements.
When the brain signals become “jumbled” these researchers think the muscles spasm and stiffen.
Byl and Merzenich [171] based their studies on previous research that explains the mechanism
of how messages are wired to the brain. Studies explain how tactile receptors or nerves on the
skin speed signals to sensory maps, which undergo rewiring or plasticity with each learning
According to ongoing studies conducted by Byl, Merzenich, and colleagues [171] on monkeys,
rapid repetitive movements result in degeneration of the brain’s sensory map that leads to muscle
spasm and impaired muscle tone. They suggested that during successive movements, the brain
is forced to process too numerous sensations and muscle commands. This gives rise to faulty
may be inappropriate. Instead, they suggest retraining therapy that consists of exercises to help
maps so they can discriminate sensations better.
Byl noted that after 12 weeks of retraining therapy, 14 of 16 patients with severe focal dystonia
of the hand who were not helped by standard therapies reported improvement in function and
were able to return to work. A brain scan taken on one of the patients showed that the sensory
maps appeared more neatly arranged. Although many think that there are primary biomechanical
factors that produce repetitive strain type injuries, Byl thinks that focal dystonia of the hand
is more likely to occur if a person is exposed to biomechanical risk factors like a high level of
dystonia is a disorganization of the sensory maps adding that Botox and other treatments simply
“quiet symptoms.” She further states, “The nervous system is responsive to repetitive behaviors
movements would have a positive outcome, that it would make one smarter and be able to test
the sensory brain that seems to be associated with the disability disorder negative outcome.”
Focal dystonia, as described by Byl and associates, can be considered a primary dysfunction in the
motor system, including the basal ganglia, thalamus, cerebellum, and frontal lobe. Focal dystonia
or hypokinetic behaviors may be isolated to the sensory-motor cortices. Lower back and neck
pain are also oftentimes considered repetitive strain injuries and the same mechanism may apply.
Hypermobility of the spinal joints may also produce improper repetitive sensory input that may
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rewire sensory maps to produce fatigability or oxidative stress to brain cells. This may result in
a focal dystonia of the spinal muscles with effects on the sensory- motor cortices. These painful
muscle spasms either may be a product of the central nervous system irregular activation or may
also result in abnormal repetitive feedback to the cortex.
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