THE PLASTIC BRAIN (& THE IMPORTANCE OF EARLY INTERVENTION)

Did you know that the brain has the capacity to change throughout life –  to reorganise itself, sometimes to replace cells that die, and to create new connections?

This malleability of the brain, which is a relatively recent discovery, is called “plasticity” or more accurately “neuroplasticity”.  A neuroscientist called Norman Doidge in his fascinating book, The Brain that Changes Itself, calls it “one of the most extraordinary discoveries of the twentieth century”. 

Research is showing that the brain has the ability to change itself and form new pathways throughout life, even into old age.  This is powerful and very exciting stuff and much is still not known about exactly how it all works.  What they do know, is that where a child with brain damage is concerned, the critical years for neuroplasticity are the early ones. 

THE MEDICAL FRATERNITY HAS A TENDENCY TO DISCOURAGE HOPE

When your child has had a brain injury, the possibility that the brain can change is a very compelling idea.  It also means (in my opinion) that there is always space for hope.  In most cases, there are things you can do to help a child achieve their own best possible outcome. 

Alas, doctors often tend to err on the side of caution…  

When Lily was 36 weeks old (she was born at 27 weeks) a paediatric neurologist told us it was unlikely that Lily would walk, talk, hear, see or be able to connect with us emotionally (which was already inaccurate which he’d have known if he’d actually assessed the patient and not just her medical records… but I digress).   His was very much a wait-and-see attitude giving no hope for her future.  He kept warning us to “be prepared” and to not get our hopes up. 

We had a very different experience when she was 4 months old (1 month adjusted) at a checkup with her GP. This doctor said to us, you just never know, keep the faith, the brain is plastic.  I didn’t really know what that meant, which is why I began to do a lot of research on the topic, and, Reader, it gave me so much hope that there could be ways to help Lily “rewire” her brain, or help it to form new pathways.   It also made me very determined to do everything I could to help make this happen. 

One of the best illustrations I have seen of brain potential in cerebral palsy (“CP”) is given by Karen Pape.  

In this diagram she illustrates how brain damage that causes CP does not worsen as a child grows.  Initially the damage looks big compared to the rest of the brain, but as the child grows and their brain grows, relatively the child has “more normal brain real estate”.  What this means is that babies who suffer brain damage have a significant advantage over adults who suffer brain damage because their brain keeps growing and has potential for improving the functions (e.g. movement or speech) that have been affected.

HOW THE YOUNG BRAIN DEVELOPS[1]

Without getting too technical, when a baby is born, the young brain produces things called synapses. Effectively these are connections or signals between neurons (a type of brain cell).  In fact it produces thousands of synapses (until the age of about three and even beyond, the number of synapses increases from 2,500 to 15,000 per neuron… which is a whole lot of synapses, when you think that we are born with 100 billion neurons).  The most active period of forming synapses is during the first 12 months of life. 

This overproduction of synapses enables the infant to develop basic abilities. Synapses that are used often and strengthened, become faster and more efficient, but those that are not used will be removed or “pruned” away.  For children with CP, often these basic abilities do not develop on their own.  This is why the case is made for early intervention during the first two years of life, exposing the infant brain to different experiences and movements to help to strengthen these neural signals before synaptic pruning increases.

In addition to synapse development, during this period of the child’s life,  neurons are undergoing the most active phase of “myelination”, a process of insulation around the nerves which enables much faster transmission of neural messages.  

These two processes underlie neuroplasticity in the young brain, and imply that the damaged brain has the potential for change within the brain cells. 

These are also the reasons why early intervention is advocated, especially for children with CP. 

According to a paper[2] that reviews evidence on the impact of CP-specific early intervention, data suggest that this intervention can help to maximise neuroplasticity and function.   For example, the study cites results of randomised clinical trials showing that Constraint Induced Movement Therapy can help to improve hand function in the short and longer term for babies with hemiplegic CP.

WHAT IS EARLY INTERVENTION AND WHAT DOES IT AIM TO DO?

“In the most general sense, early intervention for CP refers to starting therapeutic approaches as early as possible to improve the development of a baby or young child with a delay or identified motor issue[3].” 

The study by Iona Novak and colleagues (2017) recommends that the purpose for early intervention for children with CP ought to address the following (I quote from the study):

One. To optimise motor, cognition and communication skills (to promote learning and neuroplasticity inter alia through physical and occupational therapy, and speech therapy);

Two. To prevent secondary impairments and minimise complications that worsen function or interfere with learning (various issues including pain management, orthopaedics, sleep assessment, opthalmology etc); and

Three. To promote parent or caregiver coping and mental health to reduce stress, anxiety and depression

In countries that provide early intervention services, usually they comprise at the minimum: physiotherapy (physio), occupational therapy (OT) and speech therapy. 

Whilst there are different schools of thought in the realm of physiotherapy, I think it would be fair to say broadly that physiotherapy interventions aim to help a child with CP strengthen the pathways and connections in their brains, through practicing movement and helping the child to develop efficient and variable movement patterns, better motor planning and control, and to work on muscle stiffness and joint flexibility. 

In Lily’s case, in the past year, I have seen how her regular physio and OT sessions and every day practice at home have helped her to get stronger, and are helping her to figure out how to move her body and how to put all those movements together.   I am also learning so much about communication and how speech develops. 

As a mother, it has been so heartening to see all the work begin to come together.  From an academic perspective, it has been fascinating to learn about how the human body works and how powerful and complex the brain really is. 

HOW DO YOU KNOW IF YOUR CHILD NEEDS EARLY INTERVENTION & HOW TO ACCESS IT

In most countries, access to publically-provided early intervention services will first require a diagnosis.  This can be a very bureaucratic process, with many hurdles to cross.  It is likely to require an element of parental persistence, so brace yourselves!!  

Preemie?  Don’t Wait for Diagnosis!

My advice for parents of preemies (based on maternal gut instinct) is to speak to a physiotherapist about possible early intervention as soon as you can, whether or not your child turns out to have any developmental delay. As we have discovered, the earlier you can start, the better.

How to get a diagnosis?

The diagnosis of CP is becoming possible before 6 months corrected age (Novak et al, 2017), but in most cases, it is still usually made in the first two years of life.   If your baby is born preterm you will be on the lookout for developmental delay, but parents of term babies with no initial apparent difficulties may only notice it later. 

If you do worry about delay then waste no time in raising your concerns with your GP or paediatrician.  They will be able to guide you and may refer your child to specialist doctors such as a paediatric neurologist

Diagnosis for CP will likely involve a series of tests to evaluate the child’s motor skills and potentially a brain scan to enable the doctor to detect any abnormalities that may indicate possible movement disorder.

In Lily’s case she suffered brain injury at birth and CP was therefore indicated or anticipated as she grew.  She was 5 months old (adjusted) when her paediatrician confirmed everyone’s suspicions.  Children with a less stormy start may need to be evaluated over time to rule out other disorders that may cause similar symptoms. 

HELPFUL FURTHER READING
  • For a truly helpful and parent-friendly source of information about symptoms, diagnosis, treatments and interventions, I highly recommend the CP Foundation’s “CP Resources” website.  
  • Check out SuperLily’s Useful Resources page, especially Karen Pape’s blog and the the State of the Evidence Traffic Light study, which discusses research showing which types of intervention seem to be making the biggest impact.
DIFFERENT INSIGHTS AND TIPS FROM AROUND THE WORLD?

As ever, I am hopeful that SuperLily will begin to find traction in a broader audience and am keen to promote the platform as a parents’ information sharing hub.  So please do share your experiences and recommendations for diagnosis and early intervention around the world!

There are a few different ways you can do this:

  • Leave your comments after this blog
  • Comment on SuperLily’s Facebook page
  • Send me an email – robyn@super-lily.org
  • Write a guest post for SuperLily!
COMING UP NEXT

I am hoping to interview Lily’s amazing physiotherapist for her insights on physiotherapy and early intervention.   


[1] https://physio-pedia.com/Early_Intervention_and_the_Importance_of_Early_Identification_of_Cerebral_Palsy?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal

[2] Novak, I. et al (2017), Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment. Jama Pediatrics, 71(9): 897-907.

[3] https://cpresource.org/topic/early-intervention

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