Cerebral conversations episode 4 - changing brains and minds

Episode 4 | Changing brains and minds | Iona Novak & Tracey Spicer on Neuroplasticity

Neuroplasticity is the secret ingredient for better brain power – and better outcomes for children with disability.

Professor Iona Novak, CPA’s Chair of Allied Health, co-founder of the CPA Research Institute and renowned journalist, author and broadcaster Tracey Spicer go deep into our grey (and white) matter to explore the brain’s ability to create new neural pathways and what that means for a child’s critical early years of neurological development. How can we rewire our brains by learning new skills? Why are some pathways a bit overgrown and others rather well-trodden? Can teenagers and adults harness neuroplasticity, and how is it relevant for people without disability?

Professor Iona Novak, CPA’s Chair of Allied Health, co-founder of the CPA Research Institute and a Fulbright Scholar. Her research aims to discover, test and translate new treatments that have the potential to make a real impact for people living with cerebral palsy. Learn more about Iona’s work at cerebralpalsy.org.au/research/

Author, journalist and broadcaster, Tracey Spicer is a passionate advocate for the causes that matter most. For her decades of work for social welfare and charitable groups (including as an ambassador of the Royal Hospital for Women’s newborn care unit), Tracey was awarded the Order of Australia in 2018. Learn more at traceyspicer.com.au 

Find out more about the incredible work by CPA’s research team

Sign the Window of Opportunity petition for national early screening of CP

Find out about Dr Hayley Smithers-Sheedy and her team’s work on preventing CMV in pregnancy

Find out about Dr Cathy Morgan and her team’s work on early detection of CP

Episode transcript 

Andy McLean: Hello and welcome to Cerebral Conversations. I’m Andy McLean.

Ben McAlary: and my name is Ben McAlary. Welcome to episode four. In today’s episode, we have returning guest Tracey Spicer, broadcast journalist and Order of Australian recipient. Speaking with Professor Iona Novak, now Professor Iona Novak is the Cerebral Palsy Alliance Chair of Allied Health and co-founder of the Cerebral Palsy Alliance Research Institute.

Andy McLean: This episode, I think it’s fair to say Ben really gets your grey matter working. This is where we get into the subject of neuroscience, neuroplasticity and just the ways in which brains can evolve and grow and how, how we can actually train our brains it’s said neurons that fire together wire together. That’s an expression that pops up during this conversation. It’s certainly got me thinking.

Ben McAlary: And it does get you thinking, Andy, because I would never have thought that some of the concepts regarding neuroplasticity we can use in our everyday lives. Professor Novak is a wonderful storyteller, and she uses some really practical examples to paint a picture about neuroplasticity and its impact on our everyday lives.

Andy McLean: It’s pretty mind blowing stuff. So, without further ado, let’s get into it.

Tracey Spicer: Professor Iona Novak, you’re a Fulbright scholar, a superstar of STEM, one of the 100 women of influence in a world leading researcher of people with cerebral palsy. I often find that high achievers like your good self become so because of their passion about the area that they work in. What initially sparked your interest in cerebral palsy?

Iona Novak: I met cerebral palsy when I was four years old. Her name was Louisa, and she was my best friend and we were hanging upside down in a tree at the time. And because we were upside down, gravity moved her jeans a little and I saw that she was wearing a boot with metal straps on the side, which I now know is called a caliper or an ankle foot orthosis. And Louisa, she was very sharp. She caught me looking it and staring at her foot and said, I’ve got cerebral palsy. Get over it. Let’s play. And at that moment, Louisa invited me to be her equal. She invited me to play, and I think we talk a lot about people with disabilities’ rights that they should be treated as equals. But in fact, she invited me to be her equal. And fast forward, I was eight years old. My mother had a strict ban on television. She was a teacher. She thought television would lower our intelligence. So the minute she left the house, my sisters and I had a little roster going . One person would watch to see when she was coming home and the other to watch television. And one day by surprise, I caught myself watching a film called Annie’s Coming Out, which is about a young woman with cerebral palsy. And at the time, she was living in an institution and she was assumed as well as her cerebral palsy to have an intellectual disability and a teacher came to the school and discovered, in fact, she was incredibly bright and adopted this young woman, and she went on to become a lawyer. And at that moment, I went on to decide how I was going to work with people with cerebral palsy. Still haven’t told my mom how it got to there, but it was a very important moment for me because I learned that by deeply listening to others, maybe it’s a small eye movement. Maybe it’s a smile that she can understand things about people, and everybody deserves to have someone in their corner and deserves to have someone listening to them. And that’s really what drives me.

Tracey Spicer: You were fortunate to learn about it early weren’t you, in childhood, because one of the defining aspects of cerebral palsy historically is that it is widely misunderstood for those who don’t know what it is, what is cerebral palsy and what causes it?

Iona Novak: Cerebral palsy is a physical disability. It’s the most common physical disability of childhood in Australia. It occurs from a brain injury that affects movement, and it can be as mild as a fist ed hand right through to someone that might use a wheelchair and need help from their parents to get dressed or to even eat. So it’s a very common condition, but it’s often misunderstood.

Tracey Spicer: Why focus on neuroplasticity, which is your specialisation in this area? I remember reading a little more than 10 years ago that bestselling book, The Brain That Changes Itself. How does this help particularly children with cerebral palsy?

Iona Novak: Neuroplasticity means simply neuro, meaning brain and plasticity, meaning changeable or adaptable. It’s the idea that the brain can change itself, and you’ve referred to that very important book about the brain that could change itself and that was really revolutionary at the time, because people thought that the brain couldn’t change, that we were like, humans are on an autopilot or a blueprint of development, and you couldn’t really change things.

Tracey Spicer: There’s also this concept of pruning in neuroplasticity. Can you explain that in layperson’s terms?

Iona Novak: Yes, pruning is a little bit like you mentioned for a rose garden. So in a rose garden, you might turn out all the extra branches and you do that to let in extra light and let the rose focus on producing more roses next time. And it’s it’s sort of a decluttering process to allow success in that we also have pruning that happens in our brain. So when we’re born, we’re not born to speak English, we’re not born able to walk. Those are things we learn. All of the possibilities of connection are there, but how those connections happen based on what you practice in your environment. So after a while, you move these gravel driveways through the freeways and you prune off all the gravel driveways that you’re not using. And that’s to make space and focus on things that you do well. And that’s how people get really good at doing things because they practice and they improve the connectivity to these pathways. And that’s the process of plasticity. So pruning is about moving, removing things that you aren’t using.

Tracey Spicer: So how could we all use the concept of neuroplasticity in our everyday lives?

Iona Novak: Well, neuroplasticity is the way that we learn a skill or the way that we refine a skill, and it has several features to it that make it work. So the first thing is it works best when it’s something that’s important to you that you want to learn to do. We’re all motivated by things we enjoy and same with children with a brain injury like cerebral palsy. It’s best to pick things that they want to learn to do. It’s more exciting to learn to ride a skateboard than perhaps to use a knife and fork, and we can understand motivation, increases plasticity and there are a couple other important principles. So use it or lose it. So the brain is a very efficient organ. It doesn’t really waste any real estate. It dedicates real estate to things you do often. And if you don’t do it, it fades that space and dedicates it to something else. We also have this principle called use it and improve it. So the more you practice something, the more size of tissue that the brain dedicates to that task and the more efficiency dedicated to the pathways to that task. So it’s a little bit like when you’re learning something, it starts out as a gravel driveway and the more you practice, it becomes like a six lane freeway because of efficiency. It’s also really important to have repetition and intensity of practice. There’s another book out there called the 10000 hour rule, which suggests that that’s a critical amount. It does, of course, vary between tasks what the actual dose is. But this idea that repetition is really important for the brain, it’s also important that things are really specific when you’re learning. So if you thought about a child learning to ride a bike, it’s actually a really complex skill. You’ve got to get on and off, you’ve got to maintain balance, you’ve got a steer, you’ve got to navigate, you’ve got to work out how not to fall off. You’ve got to stop and these types of things. And that’s why we see, you know, there was a shift in the way bikes are manufactured for children. So originally, you know, we all learnt that they had training wheels on them. And then of course, you’re only doing part of the task when you’re riding with training wheels here. Of course, your steering and your pedalling and you’re getting on and off, but you’re not actually balancing, the training wheels are doing that piece. And so we saw this shift in the bike manufacturer to these little wooden bikes where the children’s feet are on the floor. And that’s because they’re actually doing the balancing task. So children that learn to ride a bike using one of those balance bikes actually learn a lot faster then than riding with training wheels because it’s much more specific and brains like really specific practice.

Tracey Spicer: It’s a terrific analogy. So, drilling down then on children with cerebral palsy, what are they capable of that no one before thought was possible?

Iona Novak: All humans are capable of learning, especially when it’s moving and motivating to a person, and that’s the really the important part of rehabilitation to ask the person what it is that they want to learn to do. Depending on the size and the location of the brain injury might dictate the upper limits of what you can learn to do. But important with this idea of capturing motivation, capturing amount of practice and capturing specificity of practice, you can actually, even with a brain injury, learn a new movement. So we have this concept in plasticity called nerves that fire together wire together. And what we mean is things that fire and send a message they actually make new connections. They wired together. And so for people with cerebral palsy, often because of their physical disability, there might be quite stationary. But actually moving and towards a target or activity they want to do actually is making firing, which is making new connectivity, and that new connectivity can be right around an injury. The brain is very creative. It might make a new pathway. So it’s really important that they do get to practice. For example, if you thought about an average baby learning to walk, they fall 17 times an hour when they’re learning to walk. Now, there’s no way you’d let a child with a physical disability fall 17 times a week because you’d want to protect them, when in fact, they probably need to fall more than 17 times an hour to practice the art of getting up off the floor and back onto their feet. So this idea of plasticity is important for all of us. But when you have a brain injury, you need an even bigger dose of practice to rewire around an injury. But it is possible to do it in many cases when you can make the movements that are important to you.

Tracey Spicer: How do you work with infants though? That must be incredibly difficult. It’s hard enough to read their reactions and responses anyway.

Iona Novak: Yes, working with infants is really an art. I can, as someone with a background in rehabilitation, can tell an adult to do a really boring repetition of 50 repetitions of an exercise in order to strengthen their shoulder or to to practice mobility. But you can’t negotiate with an infant. They often can’t understand the instructions, so you have to be a lot more creative. So we usually do two things that are important. The first one is find toys that are really motivating to them that make them want to repeat an action or a movement over and over again. So the toy has to be the just right challenge that it’s difficult enough they want to do it, but it’s not so hard they give up. And the other thing that we also do is work with parents because parents are the ultimate toy to children and moving towards their parents, for example, might really motivate a child to make those hours of practice. So you have to really think about what is the enticement or what would evoke an infant to make the movements.

Tracey Spicer: When you’re training both the parents and the infant, I imagine that even deepens the relationship within that own that that that family unit.

Iona Novak: Yes, it’s very important for all of us to be attached and connected to one another, and I think COVID has shown us that. But if you have a child with a disability, of course, there’s an enormous grief. It’s not the child that you planned on having. There’s a sorrow that goes along with that. But of course, you’re in love with this child as well and finding ways that as a parent that you can help with them, you can connect with them are really important to this bonding process.

Tracey Spicer: Oh, it’s just fascinating. Honestly, I could talk to you all day about this. Can neuroplasticity help people with disabilities in adulthood as well as it can help them in childhood? Or is it better off starting younger?

Iona Novak: Plasticity can help us at all ages. There’s always hope. I like to think in the early years you can learn a lot of things because your brain is open to possibility, but you can learn later. It just takes longer. And actually, what you better at doing is refining. So maybe a good example, I think a lot of us probably would have been watching the Tokyo Olympics. And if you watched those gymnasts and you think, my goodness, how did they do all those maneuvers? Well, those people started at three or four, so I could start gymnastics now. Would I ever be Simone Biles? I don’t think so, because I would be scared of making some of those moves. My thinking process would cut in, it wouldn’t matter how much practice I did now, I would not have the flexibility, nor would I have the mental tenacity to do some of those things , there’s a complex process that happens from all that wiring and practice. But a great example of the Olympics I think was an athlete called Rohan Dennis, and I don’t know if people saw him win the bronze medal for the men’s road race in the time trial. So it’s where they get out on the bike and there’s a circuit and they have to make the fastest time. Now, Rohan actually did something very unique to plasticity, and there are a lot of specialist riders that came across from the Tour de France that were tipped to win all three medals in that and they had their specific time trial specialists. They’re good at going through the pain barrier and working against the clock. But what Rohan did was got there a couple of weeks early. He ran a film crew around the track and then he loaded it up onto a cycle trainer and he actually watched the terrain and cycled against that terrain for the two weeks leading into the race. So he knew every corner, every maneuver, how to increase his fitness, how to increase his angles into those corners. It’s a beautiful example of refinement from plasticity. Of course, he’s as good a rider as the others, but because he’d done that extra training and that specificity of practice, he won the bronze medal and beat people that didn’t seem possible that he could beat.

Tracey Spicer: Oh, it’s incredible. It’s such an exciting area of research, but it also has me wondering, Iona about how many barriers you face with people pushing back either consciously or subconsciously because of bias and discrimination and saying, oh no those people with cerebral palsy aren’t capable of that. You know, this misconception that people with CP have lower intelligence and the rest of the community?

Iona Novak: Yes, cerebral palsy field has had a lot of dogma to it and a lot of misunderstanding. So I mean, probably the best known one is everybody assumed it was an obstetric injury, but in fact, 80 per cent of cerebral palsy is caused during the pregnancy. It’s got nothing to do with the obstetrician. And so once you get around that hurdle, you can start thinking about prevention differently. So people say this was an unpreventable condition, but it turns out in Australia, we’ve been able to prevent 30 per cent of cases, which is really a staggering medical breakthrough. And if you’re born in Australia with cerebral palsy, you have a milder form of cerebral palsy. So we’ve made some extraordinary breakthroughs against what has been the dogma of this condition. And so people have also faced the dogma that their brains couldn’t change. But in fact, they can. People with cerebral palsy like anyone are motivated to do things that matter to them, and we just need to ask them what those things are and we need to pick rehabilitation techniques that harness that. So one of my favourite all time stories in this area was an intervention that I tested in cerebral palsy, which is the plasticity intervention called CO-OP, which stands for Cognitive Orientation to Occupational Performance and what it’s about. It’s a problem-solving approach. So a young girl with cerebral palsy, normal intelligence, she’s like an adult with a stroke, her one arm didn’t work and the other one did work really well. So she wanted to after school to be able to make a sandwich so she could have a snack. And we used this technique called CO-OP with her to actually see what she could do. And of course, nobody had let her in the kitchen really too much for her own safety. So when I started asking, she could see that the butter was dragging big holes into the brain. And I said, you know, we started 20 questions trying to get her to turn the light on in her room, rather than me solve it for her, and this is this key piece to plasticity, so she says, Oh well, you know, I need to change the butter , so how could you make the butter different? She says, Oh, we could put it in the fridge. I said, OK, let’s try that plan. So we put it in the fridge and of course, we get it out and no change in the results. So she starts thinking about it and she realises the texture needs to be different. She’s like, we can put it in the dishwasher. And I said, OK, let’s give that plan to try. And of course, people at the university now thinking, I’m not even qualified to practice, but what I’m trying to get her to do here is to solve the problem. So we put the butter in the dishwasher. And of course, you can only imagine what happened. And she said, No, that plan doesn’t work, you know? So I kept going and eventually she said the microwave. And she she she solved it. And that was her light bulb moment. And when I said before in in plasticity that neurons that fire together wire together because she solved that problem, there was a fire in me that created a new pathway and within minutes she could make a sandwich independently. And that’s because we initiated that process of her solving the problem. And then, of course, doing the plasticity component of practice s he actually got really good at it. But that’s why we need to apply these principles to someone with cerebral palsy rather than doing tasks for them and taking away opportunities for independence.

Tracey Spicer: Iona, you’re a tremendous role model for girls and young women thinking about a career in STEM. What’s your best advice to them based upon the fact that as a child, you learned the importance of asking questions?

Iona Novak: Now, women are very underrepresented in the STEM fields in Australia, but that isn’t about talent, that’s about possibility. So when we ask young children to draw a picture of a scientist, they always draw a male. So where did they learn that from? They were inculturated in some way. So it’s about time working with school students to find opportunities, and that’s a lot about what the women in STEM program in Australia or superstar s of STEM is about; educating young children about possibilities of careers in STEM. And I think you can see from these stories from cerebral palsy that by asking questions, you really can make a difference. I really think that women asking questions and to wrestling with what is considered dogma is it is it really conventional wisdom or is it just a way of thinking, actually, if we look hard enough and we think outside the box, would there actually be other solutions for people? And when we co-design things with people with cerebral palsy, who of course have the most to gain, then they have the best ideas about how to change the field. So I think working with people with the condition as well is incredibly important, and that’s another aspect of diverse thinking.

Tracey Spicer: I know you’ve done such tremendous work in this area. You also invented a traffic light system, which which has been implemented into clinical practice in 24 countries. How does that work?

Iona Novak: Yes. So we invented a simple traffic code so that parents, clinicians, researchers, policymakers could all have the same language. That’s pretty simple. Green means that the treatment that you’re thinking about has been proven to work in a clinical trial. Red is, of course, the exact opposite. It’s been proven in the clinical trial to either make no difference or actually to have a side effect that causes a harm to children. And yellow is everything else, yellow might be that it’s a promising treatment, but more research would give us confidence. Yellow might be because we’re just not sure. Maybe it’s being sold on the internet, but we don’t really know whether it works or doesn’t work. It’s just never been tested in research before. Well, maybe it’s trending towards red and we call that a negative. Probably don’t do it. And this simple, common language has given us a way to split up one hundred and eighty two different intervention choices for families into these colour codes, which allows people to then start to think about. Now, if I want to improve the chance of making a sandwich, which is the most effective treatment and we can look through what we call a bubble chart, so this green bubbles, yellow bubbles and red bubbles, it’s a little bit like a glass of champagne, the higher up t he bubbles are rising, the better t he treatment is, so it allows parents to actually select interventions that are most likely to work to help their child choose that goal. And that’s really important for parents because they often feel like they should try everything for their child. And of course, a child needs a childhood as well. They need time to play and to be with friends. You can’t spend your whole life doing rehabilitation, so this tool is really good for cutting through the volume and telling you which things might work

Tracey Spicer: make it easier for the whole family. I also understand that we’ve come a long way around early diagnosis, and there are some more clinical trials underway at the moment.

Iona Novak: We’ve moved the needle on diagnosis. Diagnosis for cerebral palsy used to be at 24 months of age or two years of age. We’ve moved it right back to three months of age. So if you were to have a stroke after this interview and you waited in an Australian hospital for two years to get a diagnosis. Then to have any rehabilitation, you’d be very frustrated with the hospital system, but in fact, that’s what things were like for children with cerebral palsy. But by now having an early diagnosis of three months of age, we’ve been able to stop early intervention at that time. So the key of diagnosis is the access to early intervention.

Tracey Spicer: What do you hope to see within your lifetime in this area, particularly around neuroplasticity?

Iona Novak: So I think it’s possible inside of my career that we might see a cure for cerebral palsy. There are many things under research. For example, a number of stem cells are being investigated for cerebral palsy, and we already know if we use them in later childhood at small doses that we can see that stem cells produce improvements in movement even bigger than rehabilitation, standard rehabilitation. So of course, that leads a person like me to ask more questions, which is what would happen if we tried them earlier. What would happen if we tried them in bigger doses? And what would happen if we tried multiple doses? And that work is currently underway and I think will deliver bigger results than we’ve already seen. And there are many other drugs that are under investigation as well for eliciting brain repair. And I think that these things are going to work hand-in-hand with neuroplasticity intervention . So some of these drug trials are going to create better opportunities and environments for the brain to thrive. And then with plasticity based interventions, you will be able to learn better because the brain’s in a better environment to actually repair itself and to rewire. And so I think the future is very exciting, and I think it’s not impossible that we would see a cure for this condition.

Tracey Spicer: What do we need to achieve this? Is it simply a matter of more money or is it attitudinal change as well, around perhaps a fixed mindset that not only the broader community has, but also some scientists and medical professionals?

Iona Novak: Money and mindsets to make a very big difference in the search. You’re three times more likely to have cerebral palsy than childhood cancer, but in fact, you’re more likely to die now from cerebral palsy in childhood than you are from cancer. And that’s because so much money and effort has been put into childhood cancer. People have done an extraordinary job in this country that survival is up into the high 90s so we can do something different for cerebral palsy by thinking differently, by putting Australia’s most talented people in this field. And that’s something that Cerebral Palsy Alliance is doing is been investing in young researchers and mid-career researchers to expand the capacity in the field so that we can actually do these paradigm changing kinds of questions that will actually change the future. So the public’s money is incredibly important. Cerebral Palsy Alliance is now actually the largest philanthropic source of funds for research and cerebral palsy in the world. And that seems extraordinary for a not for profit in the Allambie Heights in Sydney, which not even everybody in Sydney would know when that suburb is. It’s an extraordinary effort of courage and working with the public. And if we can do that and we’ve made this much change on and that sort of fundraising effort, we can do a lot more with people’s generosity and also with applying the best, the best minds to this problem.

Tracey Spicer: You really have achieved so much, both individually and also Cerebral Palsy Alliance. Are you concerned that the fact we’re living through a global pandemic might mean that it’s two steps forward or one step back as everyone focuses on vaccines of the coronavirus right now?

Iona Novak: There’s no doubt that the COVID pandemic has changed the trajectory of research. We’ve seen it two directions. So first of all, by quickly putting a lot of money into vaccines, you can quickly generate a vaccine and make medical breakthroughs. So that confirms that money into the right scientists makes a very big difference to people’s health and futures. But we’ve also seen a lot of damage done from the redirecting of money to away from existing work. So in addition, the COVID environment changes the work for clinical trials. So many people in their community are now experiencing changes in their mental health, which will change their response to a treatment, for example. But I like to look at the glass half full side of it and say that the vaccine story tells me that how on earth did we get so many vaccines together so quickly in testing thousands and thousands of people that are changing futures? That that this is the power of medical research and actually funding the right people to do the right work and having a focused effort. And I think if we maintain a focused effort on things that matter and matter, the patients, we really are going to have breakthroughs.

Tracey Spicer: Professor Iona Novak, it’s been an absolute pleasure to chat with you. Thank you for your incredible hard work, your kindness and your determination to change the lives of children and adults with cerebral palsy. You are amazing. Thank you.

Iona Novak: Thank you very much.

Ben McAlary: You’ve been listening to Cerebral Conversations, a podcast produced by Cerebral Palsy Alliance.

Andy McLean: To learn more, check out the show notes to this episode. Over at cerebralpalsy.org.au/cerebral conversations.

Ben McAlary: And if you enjoyed the show, please rate or review on your favourite podcast platform.

Andy McLean: And to join the conversation, follow us on Facebook and Instagram.

Ben McAlary: Thanks again for listening!

The music for this podcast was kindly supplied by Ocean Alley. Check out the band’s music on Bandcamp or visit Ocean Alley.

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