Oxford University Press, USA
A Book Review by: Paul Harris, O.D.
I know, I know, I can hear you saying, “A book on the brain that is more than 10 years old. Why should I read something that old about a field of science that is expanding so fast that this must be out of date?” Well, the simple truth is, this book was way ahead of its time. Many of the insights that these authors have had are ideas to which the field is just beginning to warm.
In many ways they are looking not so much at the brain as this hunk of tissue to be admired, but Stein, Brailowsky, and Will are looking at how we, as humans, use our brains to do the things we do and how we are affected when it is damaged. But rather then stop there, they seem to really be more clinically minded, as they have sown much hope in these pages as to the mechanisms and processes that allow for brain repair to occur.
Emergency personnel all around the world respond to the most critical things first; but as soon as the person is stable, they do little to assure the long-term preservation of brain function. There are times that the initial life saving treatment may even have an adverse effect on the health of the brain.
The financial priorities of our society surface very early and often in the care of the brain injured patient. The realities are often very difficult for the affected, their family and loved ones to understand.
Extensive and often expensive testing is done, but for what purpose? In some instances it may be done primarily to educate the doctor, to build their level of experience. In many instances testing results in the patient being classified in ways that block access to resources, because they are thought to be too affected. However, some of the most massively affected can and do make remarkable recoveries. Brain Repair takes time. These patients often heal slowly, and the healing times are typically longer than the physicians or health care systems care to wait.
Much new information is coming to light that the neat images we get from PET, MRI, and fMRI scans may be misleading. We see the old concepts of specific functions being tagged to specific areas of the brain emerging over and over again in ways that may not be correct. Does the area of increased oxygen intake during the picture always mean that the area that lights up is critical to what is being done at that moment? More and more, the answer is no, or at least not necessarily.
“PET scans demonstrate that many different brain areas, some quite distant from one another, work together to produce complex patterns of nerve activation and blood flow that are associated with behavior.” Pg. 29
Medicine is only now beginning to learn that brain injury in focal places can have secondary and sometimes devastating effects as the tissues of the brain respond to the injury. It is these types of changes that, once understood, should lead to new ways to save both people and their brains for the future. Studies dealing with peptide neurotransmitters and glial cells are discussed in depth. The biochemistry of brain recovery is fascinating. For example, some of the drugs used to calm a patient after an injury may actually exacerbate the problems associated with the brain injury. Commonly used medications such as anticonvulsants and tranquilizers may actually worsen the effects of the injury and delay or prevent subsequent recovery.
A key aspect of what we, as clinicians, have to offer is hope. Not false hope, but hope. A clinician who takes the time to listen to the patient, to hear for the very first time, many of their symptoms and to be able to relate them behaviorally to the injury, is invaluable to the brain injured patient. Many times patients are told this symptom or that symptom has no explanation and they learn to keep things to themselves, for fear that others will think them to be crazy in addition to having a brain injury. We help to restore a patient’s hope that they may get some restoration of function and often they are immediately raised up by their first encounter.
Here, the authors comment on aspects of the visual process that we take for granted, but which much of the medical establishment does not understand. An interesting discussion of field loss and “blind sight” is undertaken by Stein.
“The importance of training and rehabilitation is even more clearly demonstrated in the restoration of visual perception after extensive injury to the occipital cortex-the part of the brain thought to be essential for visual functions. Researchers now realize that the visual system is very complex and extensive, so that many cortical, as well as sub-cortical structures, are needed to create a visual experience. For example, it has been known for quite some time that adult monkeys with complete removal of the visual cortex bilaterally (in both hemispheres) can make pattern and brightness discriminations, and can even recognize the orientation of lines, if they are given extensive, very careful training and experience to overcome their cortical blindness. What is particularly interesting about this type of brain damage is that patients with cortical injuries can, in fact, locate visual targets that fall within their blindspot, even though they report that they cannot ‘see’ the targets.” Pg. 123
The authors seek to raise the reader’s awareness of the need for research so that it is possible to combat some of the forces pushing against brain injured patient getting proper care. In the future we may not have the luxury to claim to be only clinicians. We may each have to be part of multi-centered studies to pool our data and methods so that they can become more accepted and accessible to those in need.
I believe that in this next quote you will see where I believe we who provide behavioral vision care shine.
“At a more holistic level, there is growing awareness on the part of caregivers that hopes, beliefs, and attitudes can affect prognosis following cerebral injury-not just those of the patients themselves, but of the physicians and health-care workers who must treat them. If the attitude and belief of the treating physician are that no recovery of function is possible, what influence does that attitude have on the patient and on his or her family? Is it beyond possibility that a strongly stated ‘expert’ opinion that no recovery is likely will have important motivational and emotional consequences for long-term neural activity?” Pg. 138
There is so much more in this book that is worthy of your time. I look forward to hearing about the additional insights you got from this excellent book that I believe should be on the shelf of every health care practitioner who works with brain injured patients.
Thanks to Chuck Ferrin, O.D. for bringing this book to my attention.