From the book  "THE  BRAIN'S  WAY  OF  HEALING"  by  Norman  Doidge, M.D.


MEDICAL  WORLD  -  Keith Hunt

A Device That Resets the Brain

An Unusual Device

By coincidence, perhaps, a friend of Ron's from high school also developed MS and voice problems. Now a retired professor living in Madison, the friend told Ron that a laboratory there, at the University of Wisconsin, had invented a strange device that you put in your mouth to help MS symptoms. He had tried it as part of a study the lab was doing, and it had actually helped with his voice. The inventors were using the device to treat a range of MS symptoms, not only voice problems. The lab had a strange name, the Tactile Communication and Neurorehabilitation Laboratory, and it was run by three men: Yuri Danilov, a Russian neuroscientist (and former soldier of the Soviet army); Mitch Tyler, an American biomedical engineer (formerly of the U.S. Navy); and Kurt Kaczmarek, an electrical engineer.

The founder of the lab, Dr. Paul Bachy-Rita, had recruited them. Bachy-Rita, who had recently died, was a legendary figure, one of the first advocates of using brain plasticity in healing. A physician who worked as a neuroscientist, he was the first of his generation to argue that the brain is plastic from cradle to grave, and he used that understanding to develop devices that facilitated positive plastic change. Devices that he developed helped blind people see and helped restore balance lost after brain damage; they also included computer games for stroke patients to train their brains to restore lost functions.

When Ron arrived at the lab, he saw a small, modestly equipped room in an old building. It had a loading dock at its entrance, the hallway was under construction, and as one patient said, it "did not look like the home for scientific miracles." Ron's attitude was "This may work, this may not. What have I got to lose?" The team reviewed his medical records and did tests and recordings to determine his ability to walk and balance. They took him to the university's voice assessment department and recorded his speech, which was incomprehensible, broken up, and appeared as little dots on the monitor. When the baseline testing was complete, they took out the device he had heard about.

It was small, fitting into a shirt pocket. It had a cloth strap attached, and some of the scientists in the lab wore it hanging around their necks, like a pendant. The part that went into the mouth and rested on the tongue looked like a wide stick of chewing gum. This flat part had 144 electrodes on its underside, which fired off* electric pulses, in triplets, at frequencies designed to turn on as many of the tongues sensory neurons as possible, by generating a pattern of stimulation that roved across the underside of the device. This flat part was attached to a tiny electronics box, about the size of a matchbox, which sat outside the mouth and had some switches and lights on it. Yuri, Mitch, and Kurt called it the PoNS, named, tongue-in-cheek, for a part of the brain stem called the pons, one of the device's main targets. The acronym PoNS stands for Portable Neuromodulation Stimulator, because when it stimulates the neuroplastic brain, it modifies and corrects how the neurons are firing.

The team asked Ron to put the device in his mouth, while he stood as straight as he could. It painlessly stimulated his tongue and its sensory receptors with waves of gentle signals. Sometimes the stimulation tingled, and sometimes it became barely noticeable, and when it did, the team would adjust the dial, turning it up. After a while, they asked him to close his eyes.

After two twenty-minute sessions, Ron was able to hum a tune. After four, he was able to sing again. At the end of the week, he was belting out "Old Man River."

What was most remarkable was that Ron's improvement, after almost thirty years of steadily worsening symptoms, was so rapid. He still had MS, but now his brain circuits were functioning so much better. He stayed at the lab for two weeks, working Mondays through Fridays, practicing with the device in his mouth, resting, and practicing again. He did six sessions a day during the first week—-four in the lab, two at home. Electronic voice testing showed huge improvement, a steady stream of sound. His other MS symptoms started to improve. The day he left, the man who had come in wobbling on a cane, tap-danced for the team.

I spoke with Ron two months after he returned home to Los Angeles. He had brought the device home to practice with and reinforce his gains. Now that he had his voice back, he was gushing words—at times I had to ask him to talk more slowly, so I could get it all down.

"You can imagine if you haven't sung for twenty-eight years, what it's like suddenly to sing again. The fact that I could carry a tune, and hook one note to another, after four twenty-minute sessions, was astounding and emotional—more than emotional—I broke down. They told me to hum and vocalize while the thing was in my mouth. I gradually realized my voice was getting stronger. The next day Yuri said, 'You don't need that cane.' That day I got rid of it. By the third day, I was able to stand without any support, and with my eyes closed. By the time I left, I could sing two octaves. I was a bass baritone, and I had a low E that I could sing in public, and when I did Annie Get Your Gun I got up to an F sharp. And ... I can be loud now! I was so loud in their lab, they had to put their fingers in their ears. And now when we walk our dog every night, I walk so fast my wife can hardly keep up with me."

Then he said to me, "Do you realize that we have been talking for a full hour?"

"I wasn't expecting you to sound younger than I do," I said finally. "Your voice sounds like that of a man decades younger."

He took a moment to think. "Well, maybe it should," he laughed. "I haven't used it for thirty years."

Why the Tongue Is the Royal Road to the Brain

The PoNS is in my mouth as I write these words, because the stimulation, in addition to promoting healing, seems to sharpen focus, and I want to get to know its potential. Its signals reach only 300 microns beneath my tongue's surface, turning on the sensory neurons that lie there. (A micron is a thousandth of a millimeter.) The device is providing the neurons just enough stimulation to fire their own electrical signals to the brain, as they would if I put some food on my tongue and felt it there. The team labored for years to use this mild electrical stimulation to create a firing pattern in the sensory neurons that would most closely approximate the way they fire in response to being touched, at 200 Hz, in a rhythm of three signals, pause, three signals.

But why stimulate the tongue? Because the tongue, the team has discovered, is a royal road to activating the entire human brain. The tongue is one of the most sensitive organs in the body. "When the carnivores started to move on the surface of the earth," Yuri points out, "the first points of contact with the earth were the tongue and the tip of the nose. Both are designed for exploring the environment—for close contact. A lot of animals, from insects to giraffes, use the tongue extensively, and it is capable of a highly precise movement, so the brain developed a strong connection to it." And human babies, in the oral phase, try to get to know the world by putting it in their mouths, sensing it with their tongues. There are forty-eight different kinds of sensory receptors on the tongue, fourteen on the tip alone, to sense touch, pain, taste, and so on. These sense receptors pass electrical signals to nerve fibers, then on to the brain. By Yuri's analysis, there are 15,000 to 50,000 nerve fibers on the tip of the tongue, which create a huge information highway. The device sits on the front two-thirds of the tongue, which is supplied by two nerves that receive sensory information from the tongue's receptors. The first, the lingual nerve, is for receiving touch sensation; the second, a branch of the facial nerve, is for receiving taste sensation.

These nerves are part of the cranial nerve system, which connects directly to the brain stem, which sits two inches behind the back of the tongue. The brain stem is where major nerves that enter and exit the brain converge. It is closely connected to the brain's processing areas for movement, sensation, mood, cognition, and balance. Thus, electrical signals that enter the brain stem can turn on much of the rest of the brain simultaneously. Brain scans and EEG recording studies that the Madison team has done on people using the device show that after 400 to 600 milliseconds, brain waves are stabilized, and all parts of the brain start to react, firing together. Many brain problems arise because the brain's networks are not firing together, or because some are underfiring. But often we don't know exactly which circuits are underperforming, even with brain scans. Owing to plasticity, each brain is wired somewhat differently at the microscopic level. So when brain scans show damage to an area in a given patient, we can't be 100 percent certain what goes on in that area. "But our tongue stimulation," says Yuri, "activates the whole brain, so even if I can't see where the damage is, I know the device is turning on the whole brain."

Once the team stimulates a patient's brain, they invent exercises to help a person regain whatever function was lost. The patient is always asked to use the device to stimulate the brain while doing an appropriate exercise. Ron was asked to hum; a person with balance problems would stand on a balance ball with eyes closed; someone with problems walking would try to walk, then run, on a treadmill.

There is something else intriguing about the tongue, of little interest to Western clinicians but of great interest to Yuri Danilov, the teams Russian member. For millennia, the tongue has been of central importance in Chinese and Eastern medicine for making diagnoses because it is an internal organ that can be seen from outside the body.

The Chinese believe that our bodies have energy pathways, called meridians, that convey an energy called chi or qi through them. Two of these key meridians, "the governing vessel" and "the central vessel," meet at the tongue. Martial artists, tai chi practitioners, and qigong meditators, to improve their performance, often place the tongue on the roof of the mouth, to link those two energy channels. Meridians emerge on the skin surface at acupuncture points. The acupuncture points used by Chinese medicine haven't changed in several thousand years, but as Yuri points out, it has recently been claimed that several points are on the tongue. These tongue points are now being used in Hong Kong to treat traumatic brain injuries, Parkinsons, cerebral palsy, stroke, visual problems, and other neurological problems. Acupuncturists frequently use electrical stimulation (electroacupuncture) instead of needles; possibly the device also functions as a form of electroacupuncture.

Meeting Yuri, Mitch, and Kurt

Yuri Danilov stands six feet six, has a shaved head and the high cheekbones of a Mongolian, and is huge and powerful. He was born in Irkutsk, one of the oldest cities in Siberia. He spent ten years of his childhood north of the Arctic Circle, when his parents, polar geologists, moved the family to Norilsk, a gulag city built by Stalin. Half the people there had been in the gulag, and 100,000 prisoners are buried nearby. Norilsk is the northernmost industrial city in the world, and so cold that when you spit, your saliva turns to ice by the time it hits the ground. Yuri's personal record for standing outside was in weather that was less than minus 65 Celsius, the lowest point on the thermometer. The day after he graduated from university, at twenty-two, the Soviet army stationed him for two years in Murmansk, also north of the Arctic Circle. At times his unit was sent out on exercises opposite NATO Arctic forces, just over the border.

Yuri's scientific interest in Eastern medicine began early. As he was growing up in Siberia, "there were Chinese people everywhere, and teas and Chinese herbs, and we used Chinese medicines and acupuncture in everyday life." As a young man, he created an electrical machine to locate acupuncture points on the skin by detecting the changes in electrical activity over them. He used acupuncture to treat his toothaches and headaches.

Yuri became an accomplished neuroscientist, working in the country's leading lab for visual neuroscience, the famous Pavlov Institute of Physiology, which was part of the Soviet Academy of Sciences. He earned one degree in biophysics (which enables him today to work with engineers), and a Ph.D. at the Pavlov Institute, in neuroscience. His area of greatest expertise is visual neuroscience. He did his research on the neuroplastic properties of the brain's visual system long before it was widely recognized that the brain is plastic. By coincidence, the first article he translated, in 1975, into Russian was by Dr. Paul Bachy-Rita, the man who set up the lab in Madison where he now works. He also became quite familiar with the use of electrical stimulation to treat sleep and other problems. Electrical sleep machines, unknown in the West, were used in hundreds of clinics throughout the USSR.

When he started at the Pavlov Institute, two thousand people were there, including five hundred scientists, and it was a place of great intellectual rigor, but the economic chaos following the transition from Communism led to thirty rounds of cuts and caused the august institute almost to collapse: there was no longer money for experiments, equipment, electricity, lab animals, drugs, or salaries. In the early 1990s he left the lab to do a sixteen-university tour lecturing about neuroplasticity in the United States and briefly working there. Afterward he returned to Russia to find his lab empty. The equipment that had taken him twelve years to set up, the animals he worked with, the money for experiments, were all gone.

When Yuri arrived in America in 1992, there was no one like him. He was an accomplished, hard-boiled neuroscientist with a long pony-tail, well versed in Eastern movement practices such as yoga, meditation, tai chi, and the Russian martial arts, including the system perfected by Russian special forces and Stalin's bodyguards. Fifteen years later he found that aspects of these practices, in combination with the PoNS, could be extremely useful for helping neurologically ill and brain-injured patients to "reset" their brains.

At the Madison lab, Yuri works with patients, and as he discovers strengths and weaknesses in the device, he feeds that information to his codevelopers, Mitch and Kurt.

Mitch is the team's biomedical engineer and study coordinator. He is the interface between Yuri and other collaborating clinicians, and he handles the scientific and technical facets of the research. His task has been to understand how to get information across the skin.

Mitch also practices Eastern martial arts and is a second-degree black belt and an instructor in tae kwon do and a daily mindfulness meditator. He participated in the Cold War, for the United States: when the Soviets launched Sputnik, he was chosen as one of the brightest American kids, to be fast-tracked into a special stream studying math and science. Ultimately he served in the U.S. Navy, tracking Russian convoys, submarines, destroyers, and communications. 

Mitch and Yuri understand each other, though the understated, gracious, mellow-voiced, California-raised Mitch and the no-nonsense Arctic Yuri are like polar opposites attracting. Mitch has been learning bits of Russian since grad school, when he started reading abstracts of articles not available in English.

Mitch originally trained as a high-tech engineer of electrical machines—he never took a biology course. "I was a bit arrogant," he recalls. "Who needs that soft science, cells and squishy stuff? I am an engineer! We are going to conquer the world!" After a 1981 car accident fractured his spine and left him paralyzed from the navel down, that attitude changed. "Lying in the hospital room, not able to feel my legs, I was terrified. I didn't know how nerves worked." He got a copy of Gray's Anatomy from his nurse, and "it became my bible and launched my interest in how I could apply my technical knowledge of circuits to biological systems."

By 1987 he had fully recovered and was working in Paul Bachy-Rita's lab. Paul was a big-picture thinker who came up with far-out ideas, and Mitch's job was to implement them. His first task with Paul was working on one of his sensory plasticity projects, a condom for paraplegics with spinal cord injuries who had lost all penile sensation. The condom had "tactile pressure sensors" that detected friction in intercourse and transferred the stimulation it detected to electrodes that tickled a part of the body that could feel. This stimulation in turn sent signals to the man's brain. They hoped it might help the demoralized subjects, robbed of the pleasures of intercourse, become sexually excited. It worked.

Kurt Kaczmarek, Ph.D., the third member of the team, is an electrical engineer. Of the three, he worked longest with Dr. Bachy-Rita, whom he met in 1983 as a student. He is now a senior scientist in the University of Wisconsin's department of biomedical engineering. Slim, Kurt is in his early fifties and has dark blond hair and an earnest, conscientious air. As a boy, growing up north of Chicago, he loved to design, build, repair, and improve electrical devices. He worked for years in a TV repair shop. Even today his hobby is repairing old electronic devices.

Kurt spent twenty-five years learning how to produce synthetic electrical signals that can carry complex information that can be inputted into the skin's touch receptors, then relayed to the brain. Working with Bachy-Rita, Mitch, and the team, he constructed a device that supplied visual information from a camera to the tongue, then to the brain, allowing blind people to see (described in The Brain That Changes Itself). They learned to present the information on the tongue using an array of 144 electrodes and found ways to coordinate the firing sequences of electrodes in wavelike patterns. The team has learned that some wave patterns will put people to sleep, as do the Russian sleep machines; others stimulate them to be more alert, as occurs when people take amphetamines or Ritalin-like drugs.*

Kurt is the teams calculation grinder and deep analytic thinker. He is a genius at taking a concept and translating it into a working physical device. He is probably the world's leading expert on how to use electrical stimulation to speak to the brain through the human skin, a process he calls "electro-tactile stimulation." His long-term project is to use all he's learned to develop guidelines for making electro-tactile devices. But that larger task is always being interrupted now that they have invented the PoNS, because he is constantly redesigning and improving it. "I mean," he says, "people are coming in here with a cane and then walking out without one."

The Early History of the Device

Against the wall of Yuri's small office sits the one cane they have kept, the first that was left behind in this tiny lab. It belonged to Cheryl Schiltz, who came to the lab after being disabled for five years and went home actually dancing. Yuri's office once belonged to the group's founder, Dr. Paul Bachy-Rita. The story of how Cheryl recovered, and of Bachy-Rita's own realization that the brain is plastic, was driven by a very personal experience, which I told in detail in The Brain That Changes Itself.

In 1959 Paul's sixty-five-year-old father, Pedro, had a stroke that paralyzed his face and half his body and left him unable to speak. The doctors told Paul's brother George that Pedro had no hope of recovery. George, a medical student, was still too early in his medical studies to have learned the doctrine of the unchanging brain. So he began treating his father without preconceived ideas. After two years of daily, intensive, incremental brain and movement exercises, Pedro underwent a complete recovery. After he died (mountain climbing at the age of

* Cranial electrotherapy stimulation (CES) devices, such as the Fisher Wallace device or the Alpha-Stim device, apply the stimulation to the head. They are modifications of the Russian sleep machines, and the FDA is proposing they be approved as safe for insomnia, anxiety, and depression. They have been on the market since 1991.

seventy-two!), Paul had an autopsy performed on Pedro and discovered that 97 percent of the nerves in a key pathway in his brain stem were destroyed. Paul had an epiphany: the exercises that Pedro had done had reorganized and rewired his brain and built new processing areas and connections that worked around the stroke damage. It meant that even the brain of an old man was plastic.

Paul's research was in vision. One of his first applications of neuro-plasticity was to develop a device to help the blind see. "We see with our brain, not with our eyes," he said, arguing that the eyes are merely a "data port"; its receptor, the retina, converts information from the electromagnetic spectrum that surrounds us—in this case, light—into electrical discharge patterns, which are sent down the nerves. There are no images or pictures in the brain (just as there are no sounds, smells, or tastes), just patterns of electrical-chemical signals. Based on a comparative analysis of the retina and the skin, Paul determined that the skin, too, could detect images, as it does, for instance, when we teach a child the letter A by tracing it on his skin. The skins touch receptors convert that information into electrical discharge patterns, which are then sent to the brain.

So Paul developed a device consisting of a camera, which sent pictures to a computer, which converted them to pixels (little dots like those that make up the picture on a computer screen), and sent that information to a small plate of electrodes that fits on the tongue—the prototype of the device Ron Husmann used. He called it the "tactile-vision device." Each electrode functioned like a pixel. When the subject aimed the camera at an image, some of the electrodes would fire tiny pulses of controlled electrical stimulation to represent light and slightly fewer to represent gray, while some remained off, to represent darkness. The same image that appeared before the camera appeared on the subjects tongue. Paul and the team decided to use the tongue as the "data port" because it has no layer of dead skin and is moist, so it is a great conductor. And it has so many nerves that Paul thought it would deliver a high-resolution image to the brain.

Subjects who had been blind since birth and used the device were able, with some training, to detect moving and looming objects; they could differentiate the faces of "Betty" and "Twiggy," and they could "see" complex images, such as a vase in front of a telephone. A blind man was able to use the tactile-vision device to detect perspective and even sink a basketball. Paul called this process "sensory substitution." It was a brilliant example of brain plasticity, because circuits in the brain that processed touch reconfigured themselves to connect to the brains visual cortex.

But the tactile-vision device was doing more than providing a new way to help a blind person see. It showed that, in principle, the brain could be rewired by a sensory experience. The senses provided direct avenues to rewire the brain.

In January 2000, team member Mitch came down with a serious infection that affected his balance apparatus, making him dizzy and unable to stand. He wondered whether the vision device might be adapted for balance problems. Paul agreed it might. Instead of using a camera, they used an accelerometer, a device like a gyroscope that can detect movement and position in space. They put it into a hat that fed information about position to a computer, then fed it to the tongue device, giving Mitch, the subject, information about where he was in space. If he leaned forward, the electrodes would give him gentle stimulation, and he would get a sensation of champagne bubbles rolling forward on his tongue; if he leaned sideways, the bubbles went to the side.

Their first patient was Cheryl Schiltz. Five years earlier, an antibiotic had damaged 97.5 percent of her vestibular apparatus (the balance organ in the ear), seriously disabling her. She was constantly disoriented and needed support to stay upright. Though she was only in her early thirties, she came to the lab with a cane.

When Cheryl inserted the device into her mouth, she was immediately oriented and calmed. The information on her tongue, which went directly to the areas of the brain stem that process touch, then found its way to another part of the brain stem, the vestibular nuclei, which process balance. The first time she wore the device, it was just for a minute, and after she took it out she was still able to stand for a few seconds and felt great. The next time she tried the device for two minutes, and the residual effect lasted forty seconds. The residual effect grew with training and practice, stretching into days, then months, until, after two and a half years of use, she no longer needed to wear the device at all. With training, Cheryl's brain was developing new circuits. She was completely cured. At this point, the account in The Brain That Changes Itself ended.

But Cheryl's story did not end there. She was so moved by her recovery that she decided to go back to school to become a rehabilitation professional. She did her internship at the Bachy-Rita lab. Her job was to train people to use the device that had helped her. She never dreamed who her first patient would be. Shortly after Cheryl was cured, I received an awful e-mail from Paul. He had received devastating personal news. |