Dr. Michael Lobatz discusses the neurological effects of mindfulness-based stress reduction.
Dr Michael Ovitz is the medical director emeritus of the rehabilitation center at Scripps Memorial Hospital and so Anita's and senior neurologist and co founder of the neurology center of southern California. Dr Michael Lomax has a degree in biomedical engineering that was a James scholar and graduate of the Abraham Lincoln School of Medicine at the University of of University of Illinois Chicago. Dr Lo bats completed his internship and neurology residency at the university of California at san Diego, where he also served as chief resident. He was on the voluntary clinical faculty for the san Diego Naval Medical Center and was a voluntary clinical assistant professor of neurology at the University of California at san Diego Medical center. Dr Lo bats is a board certified diplomat of the american board of psychiatry and neurology and past Chief of staff of Scripps Memorial Hospital and Sonatas. It has special specialized interests as a neurologist and the diagnosis, treatment and rehabilitation of brain injury, stroke neurodegenerative diseases such as Alzheimer's disease, chronic traumatic encephalopathy, API and Parkinson's disease. Dr low back provided direction and oversight for the entire rehabilitation program, including the brain injury program at the rehabilitation center at Scripps Memorial Hospital and Sonatas. For over 20 years. We'll begin with our thomas Chippendale memorial lecture soon. Uh, it's usually a very inspiring talk and one that you take away with you after the conference is over. But before I virtually hand over the microphone to duck low bats, I'll just say a couple more words if any of you have attended the scripts brain injury conference before or for any of you that work at scripts, you know, dr michael below bats. And it's also not a rare occurrence that I meet a patient or someone in the community and I find out that they know him either socially, professionally or they say something like he took care of me or he took care of my family member and without him, this whole conference wouldn't be, he was the long running medical director of the rehabilitation unit at scripts and the course director for this brain injury conference. And he's also the one who is responsible for bringing me back to San Diego. He stepped down from his position in 2019 and handed over the reins to me. And when when the planning committee started planning their first conference without Dr Lo bats. Mhm. One of my biggest concerns was getting someone who can truly honor Dr Chippendale, especially knowing that Dr Chippendale meant so much to Dr Lo bats. I thought who better to honor Dr Chippendale than Dr Lo bats himself. I'm really looking forward to this talk. And I got a sneak peek the other day. And uh I think you really enjoy it, that he's always teaching me something new. I don't know, I don't remember if I told him this, but I enjoy sharing an office with him. I've learned a lot over the last couple years and I enjoy having an encyclopedia next to me that I can ask questions too. I enjoy hearing about his travels and him showing me his photos and to those that don't know, he's a pretty good photographer as well. I want to please welcome Dr Michael Low bats, thank you very much Jihad. It's just a honor and privilege to speak to everybody today. And I thank you for your very, very kind words. I um I am humbled by the invitation from scripts to give this talk uh, When Dr. Chippendale passed away seven years ago, um we established this lecture as a memorial to him because he meant so much to so many people and I'm going to honor him a little bit at first but I want to make specific thank you's right now to you dr Jeff for to carry Bence and Sarah harding to the entire scripts team to MEREDITH and everybody that has participated and put together the conference this year in such difficult circumstances of the pandemic. The pandemic light is at the end of the tunnel or that the light is at the end of the tunnel for the pandemic fortunately and hopefully in the future we can be back together in the same room and enjoying each other's company and learning from each other. Um A day has not gone by my career when I haven't learned something new from somebody. Uh And that's been one of the joys of being in medicine is the constantly expanding ability to learn new things. And today the lecture is going to honor Dr Chippendale in several different ways. First of all, I want to honor him as a person uh and we'll get into that in just a minute. I want to honor him as a neuroscientist. Uh and I want to talk about our experiences together a little bit in backpacking and in terms of meditation and the mindfulness course that both he and his uh wife, julie Chippendale uh ran at scripts for um 18 years while tom was around and several more years after with Julie. So with that I want to first start off by saying I have no conflicts of interest of any kind. Nobody essentially gives me anything these days, so I have nothing to disclose. Um So, Dr. Chippendale was born in 1949, passed away seven years ago in 2014 prematurely At the age of 64. He was a gentle man, uh brilliant, thoughtful, a terrific listener, very kind and compassionate, uh dedicated to neuroscience, to rehabilitation services. He was very transparent in his communication, He was super committed to his patients. Um Both he and julie created the mindfulness based stress reduction chorus modeled after Jon Kabat Zinn's work at, I believe the University of massachusetts many years ago. Uh and they established it as scripts and notice. Uh and it served the community like I said for more than 20 years he loved the Sierras, He loved hiking on the muir trail. We did that a couple of times together. And uh just parenthetically, you can imagine two neurologists In a tent for 22 days hiking the trail together, cooking together, uh sleeping at night in the same tent uh and doing everything together for 22 solid days. Um for and what kind of conversation may have occurred, what kind of thinking um would have occurred during those long stretches on the trail when you're with yourself? He was devoted father, spouse, to julie partner and friend. So he had a bachelor of arts from University of California Irvine, a master's degree in pharmacology and therapeutics, a master's degree in psychology, a PhD in neuroscience from Princeton, a doctor of medicine from UC Irvine. Uh you know, I first met Doctor Chippendale when he uh yeah, applied for a residency, internship and residency position at our residency position at University of California san Diego, and I happened to be the chief resident when he came in and applied. And uh I sat down with him uh at UcsD in Hillcrest, outside at a picnic table or something for lunch and met him and realized at that point what a special human being he was. And that began a long career together. He went through his residency and I told him later to call me when he's done and he became first an associate and then a partner for the many years that we work together. So a little video here of Dr Chippendale that I put together some pictures that just might give you a little sense of the some of the things that he was that he did, and I hope this honors him correctly. Um by the way, you see him there, he's wearing a vest and he loved vests. I don't know if anybody remembers that from scripts that's listening in, but that's one of the things that he loved and this is him with julie at one of our many get togethers over the many years. Um and uh, Tom and Julie had three beautiful Children. Um This is uh on our second mirror hike where we're being set off by our spouses. That's Debbie, next to me and my wife. The picture here on the left is the essentially the original partnership of the neurology center. One of our get together is where we would talk about, you know what we're doing here. We are about to launch off into the unknown near trail all the way to um the not uh two having a word finding difficulty here, uh to the top of peaks and so forth. Tom was great hiker, very thoughtful, good companion to be with on the trail. So it was Mount Whitney that I was referring to a moment ago. Uh and uh he left starting fires in the morning and the evenings before we would uh shut down camp and cook our meals and so forth. Um staring into that fire was meditation uh in and of itself as you probably know if you've done that. Um it was hard work hiking uh sometimes exhausting and here we are resting inside of a stream and another start this one at the Golden trout Wilderness and off to A three Week Track. The impact that he had on a variety of individuals is untold. You know, at his memorial service after he passed. uh there were 800 people that attended at the quail gardens in Encinitas. So with that and uh with the knowledge that this is a neuroscientist who love the outdoors in nature and mindfulness, family person and extraordinary. I would like to now start to talk to you a little bit about the neuroscience that is behind uh some of the things that he uh was so enamored with and so interested in, namely mindfulness and we're going to ease our way into that. And start by talking about the brain, how it evolved, what we know about it, what we're learning about it yet. And hopefully give you some new concepts to think about when you are seeing your patients, when you are contemplating the death, the sits that they have in front of them and when you are strategizing how you're going to overcome them if you can, or how you're going to adjust to them. So about four billion years ago on Earth molecules combined to form intricate structures, organisms. And this story of organisms is called biology and this um idea along with the evolution to homo sapiens, I took from a book by Yuval Noah Harari called sapiens, which if you haven't read this book, uh it is very worthwhile getting. I believe Bill Gates thinks it's one of the most important books you should read uh and uh it may give you some background and information and understanding of the evolution of man to where we are today. About 150,000 years ago, our species emerged from East africa and look just like us. Homo sapiens. In about 70,000 years ago, organisms called Homo Sapiens formed elaborate structures and cultures and the development of these cultures and the study of these structures of cultures is called history. But there were three important revolutions that shaped the course of this history. The first one is called the cognitive revolution. About 70, 30 to 70,000 years ago. The Agricultural Revolution sped it up 12,000 years ago when we began to cultivate and be able to have the availability of food and nutrition on a much bigger global scale. And then finally, only 500 years ago the Scientific revolution, which interestingly as he puts it may yet, and history as we know it. So what about the brain, what happened along the way? Um The brain's got larger in this, through the study of skulls that were found in archaeological projects and so forth. The Neanderthal brains were probably the largest and early homo sapiens, probably about the same as neanderthals or maybe a little less. But the modern human brain is actually smaller than the Neanderthal brains. And so that's sort of interesting yet we're supposedly more sophisticated and intelligent and able to do more, but our brains are smaller. So what does that actually mean? And how do we reconcile that? So, the modern sapiens brain is about 73- 85 cubic inches. Um And that's tripled since the early hominids. And what's also interesting is that it only accounts for 2-3% of total body way, But at rest consumes 25% of the body's energy. So this cognitive revolution, what was it? It was the appearance of new ways of thinking and communicating 30 to 70,000 years ago. And what caused it, this sort of tree of knowledge of mutation? What is that? How did it change us? Was it accidental? Um The change was an inner wiring that changed. It certainly wasn't size, right? It allowed us to think in unprecedented ways. It allowed us to communicate amongst each other in a new type of language. And most scholars believe that um the inner wiring of the brain may have been the prominent change. Some change in the internal structure. Perhaps some small genetic mutation occurred that caused two parts of the brain that were previously unconnected to connect to each other. Uh that structures crossing the brain from one side to the other on this left sided picture, um are the corpus callosum large internal structure here that I'm showing you as well as what doesn't appear here on the brain is the anterior and the posterior commish yours, which also connect the left to the right side of the brain, and so and back and forth. These structures allowed for communication with each hemisphere, but the interior in the posterior commissioners in particular were structures that allowed for communication with the temporal lobes with the amygdala, which is one of those emotional structures with the hippocampus, which is the memory structures. And so perhaps those changes occurred, which allowed the internal wiring to become much more efficient and much more able to connect the different parts of the brain. We don't have a theory, a very clear theory about what the biological and the more logical factors were that led to that change. These are all conjectures and of course are being studied still to this day. The brain itself contains 1.1 trillion cells, the majority of which are support cells and 100 billion neurons. Excuse me. So, on this genetic level there are differences between the most um closely related primates to current homo SAPIEN brains. On a genetic level there are different genes. For instance, there's a fox po gene which is associated with speech and language development. There is a human variant of genes caused srg oppo and srg post c genes that produce greater dendritic spine density, greater neural connections, interestingly there is a type of cell in the brain called the Von Okan Imo neuron. These are more prevalent in humans than in other primates and their associated interestingly with empathy with social awareness and self control. On a circuitry level, Also, humans have a more complex what they call mirror neuron system um and go to the next slide and talk about mirror neurons for a moment. Mirror neurons are neurons that fire both when an animal or human acts when the animal or human observes the same action performed by another. In other words, your neurons activate when you're watching another individual do something that you're trying to learn or mimic and the same neurons are activating in that individual who is actually doing the task or doing a thing that you're observing and at the same time your neurons mirror that activation. These are found primarily in the pre motor cortex and other parts of the brain, Somatosensory cortex, parietal cortex and so they're important obviously in understanding the actions of other people and for learning new skills by imitation. It's also associated with social cognition. This is an area of social cognition. I'm going to get back into this in a little while. That's extremely interesting. And what's the neurologic basis of that? Of understanding empathy, emotion, anger and so forth in what we observe and how do we react to that And all of these things that we're talking about have their seat in certain parts of the brain but only come to be as a result of the connections that we have between the different parts. So with the cognitive revolution came symbolic thinking super crucial in this evolution. The ability to think about things or conjure up in your mind, things that do not exist like fiction, what we call fictions, these include legends, myths, gods if you want to believe that and religion and some of the earliest forms of art, we're just there like this stable cave lion man, which was obviously a thing that did not exist But for which an individual was able to conjure up in their mind and create art. And in this case a statue found in a cave in France that dates back to circa 32,000 years ago. So this evolution in the brain that took place at that point was evidenced by in archaeology, art and jewelry, there was obvious evidence of trade between different groups. There was complex societies that developed not just dozens of people, which was the typical family unit in early homo sapiens or in Neanderthal, but also much more complex societies comprising of hundreds and then later, even more huge societies developed around common thoughts, myths, religion or whatever was the needs of that time. Um, and with the ability of large numbers of strangers to cooperate successfully in common development came immense power and it was so immense that it enabled them to conquer the world and drive all other human species to extinction. So what do we know about the brain and what have we been taught about the brain more specifically? And I'm going to refer to myself as well as dr Chippendale. What we were taught was that there were different parts of the brain that did different things. You know, you had your motor area which produced motor movements, you had your primary sensory cortex which produced sensation. You had your visual cortex which produced in the occipital lobe which produced vision, your auditory cortex, your speech and language areas where Nikki's and Broca's areas, your prefrontal cortex, which may have been intelligence. And we were also talk that there was this left brain and the right brain. Left brain bringing the rational part of the brain, analytical for which language was the dominant feature, typically the left side, the right brain where you were abstract, holistic, creative, artistic intuitive. These are the these are the sort of basic tenants that when we learned neuro anatomy and function, this is while we were taught and the way this was learned originally was through focal brain lesions when people had strokes and they lost their ability to move the right side of their body. And we studied their brain and we found that the left motor cortex was involved. We made the connection that though that was where that function existed. And so most of the basis for localization of most neurologic symptoms and behaviour come from this, which is the focal brain lesion studies, and some of it also has to do with the white matter, the deeper part structures of the brain. And we're going to talk about that some more and about what we're learning about that now and how the science is changing and how hopefully when you come away from the lecture today, you'll have a realization and that it's much more complex than what we're talking about. So these neural networks probably developed over two million years and kept growing and growing and the cortex, like I said, was regarded by most neuroscientists as the major locus of cognitive function. But now we know the white matters of increasingly recognized importance critical for that cognition. So you know, the grey matter, the cortex is indispensable, but the white matter composes more than half of the brain and it's involved in these distributed neural networks that's observe these kinds of behavioral neural behavioral operations and they're essential connectivity by which everything is organized in concert with the gray matter and with the cortex that provide us with this repertoire of capabilities that we have. So there was in the last 35-40 years, a revolution in imaging that occurred with the advent first of CT scanning, but later most importantly of MRI scanning, I remember I gave a lecture at the university of California san Diego was a grand rounds to the medicine department uh in 1981 believe it or not, and uh I talked about this new technique called mari and what it was going to be like for the future for neurologists and little did I know, I thought it was pretty cool at the time, my background by the way, is in biomedical engineering. And so I was really automatically interested in this technology and how it worked and became more interested as it developed. And Only over the last 10 or 15 years though, as the technology evolved to allow us to see things in a different way. As the magnets involved in magnetic resonance imaging became more sophisticated and larger and more powerful. We began to see more things and using newer techniques for looking at the brain, not just the anatomy now, which is all we could do with early MRI and with CT scanning, but actually looking at physiology and function that you can now do with MRI technology. And one of the first things to come along was diffuse intense er tensor imaging, which is a technique that allowed for looking at water diffusion. But forget about that, what it does actually is that allows you to look at the tissue architecture in either normal or disease state. And this has been used extensively now to map the white matter tracts in the brain. Previously, we would section a brain at an autopsy and we would look at the white matter and we would go over these were these are all the connections. And we had an idea maybe for more sophisticated studies of where the connections went a little bit, but nowhere near the detail that we know now and nowhere near the detail that actually really exists. We're not there yet to know all of it. And what we know now is that the brain is electrical, biochemical, these rich connections. This is the cortex and how the cortex activates and the different lobes and maybe what their functions are. Uh and then how they're all being connected together and how they're all functioning from one side to the next, from front to back from top to bottom. And um these connections are extraordinarily rich uh and our important in the function of the brain in particular. And let's, and this is just um using function using defusing tension imaging and what we call track ta graffiti. We can now make maps of the different connections in the brain. And this is just a tiny tiny representation of what's actually there. But you can see that there are different parts being connected from one side to the next. So there are remember hoops, there are 5000 synapses per neuron And there are 100 billion neurons. And if I did my math correctly here, That's 500 trillion connections. 500 trillion connections fucked up. You know, let's talk about artificial intelligence for just a moment and computers and you know, Watson and um the supercomputers that, you know, institutions and governments have now and this worry especially from Elon musk, that there is going to be this um mm hmm. Fear of artificial intelligence. And I have to laugh a little bit. Well, first of all it doesn't come anywhere near to the complexity of the brain. Uh and furthermore, if we're going to, if we're going to uh fear intelligence, it's the human brain that is much more feared than artificial intelligence. Right? So, but this is the intricacy of this and the seat of your ability to think, your ability to comprehend, your ability to express yourself. The emotions that you have, the executive function, the ability to plan, check your work, do your work, act upon it, evolve it and so forth. Are not only in those gray matter structured but mostly are in the connections, Those 500 trillion connections that we're trying to understand. So there is actually a science now of trying to understand these connections and it's called the human connect home. And there's actually a human connect on project and there's some literature out there on this and it's derived from this functional neuroimaging uh and mapping healthy brains is part of that. And most of it where they do functional neuroimaging of thousands of healthy persons and they provide maps using diffusion tensor imaging and other things. So let's talk about lesions again for just a moment uh and you may know this, but you may be also be surprised to learn that you can get the same stim pdam from a lesion in the brain that can occur in different parts of the brain. So in other words, lesions in different locations that cause the same symptoms. And you know, how is that? We always thought that the connections. I'm sorry, we always thought that the cortex was where this action was, or the immediate connection from that cortex, but now we know that there are commonly distributed networks that can produce the same symptom from a lesion in a different location. So when we look at this, when we take different patients who have symptoms and we map where there are lesions are located and we then try to connect it to a common network that we can see with diffusion tensor imaging. In the connect home we expose new targets that may involve complex neurologic symptoms, for instance, such as hallucinations, delusions, abnormal movements, pain, coma, cognitive and social dysfunction. There is a two patients here in this slide in the middle uh one that has a language uh I'm sorry, one that has a uh language difficulty in panel A uh and uh there are some common a neuron to neuron anatomical substrates in different locations, mostly in that frontal lobe. And then there's also another patient here with the same symptoms but with distributed lesions in different parts of the brain. So how do we reconcile that? We reconcile that through the commonly distributed internal networks? So the human connect um projects has resulted in normative maps of these anatomical and functional projects. And when we overlay these with these uh lesions uh using MRI and these cohorts of thousands of persons, we get an idea of how all of this fits together. So this is the human connect um project that looks at all of these normative maps. And then when we overlay these uh focal brain leave brain lesions from those two subjects that I showed you before, we can get an idea of what the connected networks are. And these connected networks are through these greener structures in the middle here. That amount landing there. Ah This is a complex subject and this is another one uh connect home localized for visual hallucinations. And what we found here was that there are connections between visual association areas and other central structures like the genic Hewlett ganglia and the thalamus and so forth. Many symptoms can be caused by different lesions in the brain. These include for instance, movements like Emmy Korea, um Delusions of familiarity, freezing of gait in criminality lesions, for instance, in criminality are associated with connections to the orbital frontal cortex, which is a region activated by moral decision making lesions that cause freezing of gait are connected to the cerebellum lesions of delusions of familiarity are connected to uh area in the back of the corpus callosum cause called the spleen. E. Um we're going to talk about that a lot more coming up what that area in a couple of other areas mean. And lesions with hemi Korea are connected to areas of the deeper brain structures such as the attainment. There is even more research going on now at ultra high field strength diffusion tensor imaging using seven Tesla scanners. These are incredibly powerful MRI scanners that are only used in research. Excuse me. And so for instance, in patients with trigeminal neuralgia, this particular slide, I want to first point yourself to the normal side which shows the homunculus over laid the area and you remember that, you know, your leg is in the middle, your face arm. Uh and I'm sorry, your face, eyes, lips, jaw are sort of over here in the lateral side. Uh And what you have here is a representation of the connections of the tracks that are occurring from the cortex down to the thalamus in the center and over here on this side, what you're seeing is a change in those tracks in an individual who has severe try general neurology and in this particular case there's a thinning of the tracks and this is a sort of what is thought to be an altered micro structure, which is a sort of physiologic response. two pain being generated in the trigeminal nerve, in the cortex, in the connections to the cortex to sort of reduce the pain. One would conjecture out of that. So this is sort of the clinical beginning of understanding how these tracks can be looked at and maybe then eventually how we can alter how we are approaching these things. There was another major development that occurred in 1990 and M. R. I. Which was the use of what we call functional M. R. I. This was invented and discovered essentially by Dr. Ogawa in 1990. Uh and he used he was the one that recognized that blood oxygen levels of as they varied in the brain could be detected on MRI. Using a technique called both blood oxygen level dependent contrast, or bold, He called it, and mind you that blood oxygen levels are directly related to the function uh and the physiology of what's going on in that particular brain structure. So in other words, when you're when you're moving your arm on your right arm, your left arm is going to your left brain is going to light up right, because it's using more oxygen, more glucose is being metabolized. And he was able to demonstrate this with this bold technique. And then this allowed the mapping of blood and hence functional activity in the brain. And that's why it's called functional MRI. So this particular case on the left side is a individual during speech and it shows a left lateralization uh in this right handed 17 year old patient who had some mental uh challenges mental retardation of some type. And then second case showed another area on the left side of the brain uh in a right handed 10 year old with A. D. H. D. Of note is that these parts of the brain are on the left side which is associated with speech speech areas. So this was a demonstration essentially that you can show areas of the brain lighting up when you have an individual performing a task and thus called functional MRI. Using functional MRI. A new type of thinking occurred which was called the default mode network. And we're going to talk about this in some degree at this point. And another new concept for many of you, I suspect default mode network is a large scale brain network composed of the medial prefrontal cortex, The poster your singular eight cortex and an area called the angular gyrus right over here, here's the sagittal view here is the exhale view and it's best known using functional MRI techniques, bold techniques, it's best known to be lighting up and be most active when a person is not focused on the outside world and the brain is at wakeful rest. So in other words, your brain is always active, it never stops. But there are times when if you're not moving your left arm, you're not moving your right arm or you're not thinking about something actively, let's say or you're not moving or walking or talking that this particular area is always there, it's always working and it may actually be what's actually there as a part of your inner self awareness. And it's the theory of mind comes down to potentially what's happening in this default mode network. And the default mode network is involved in remembering the past and thinking about the future. Self reflection, self reference. And as I had mentioned, the neurologic basis of self, it's potentially as well. And these connections that occur between the posterior cingulate than the prefrontal cortex, these are important connections that are always there, always working. But yet maybe they are different when something happens to you, to an individual, to a patient that has certain things to occur or maybe are born with certain things. So what about this? And this is interesting stuff and it gets in to be a little bit controversial uh between the links between brain connectivity and Demographics and behavior of an individual. And this is a human connect um project publication that came out of natural neuroscience from Smith of 461 patients ages 22-35 who had default mode network functional. MRI. They developed an average map of connectivity and they then correlated that to a variety of different behavioral aspects such as um age, history of drug use, socioeconomic status, personality traits, performance on tests and other features. I'm going to show this picture on the right here again in a moment. This is where I think it gets a little controversial because there is some subjective uh and potential racial issues that arise out of making such demographic and behavioral uh assumptions. So um that said, what they found, what they looked at was a variety of different what they call positive traits. Um and then a variety of different negative traits such as anger, uh smoking alcohol, use drug problems uh and so forth. Uh And uh they looked at this and they tried to correlate the uh default mode network functional MRI with these traits. And what they found was that on the right side here, the positive traits were associated with higher education, stronger physical endurance, above average performance and memory test verbal acuity, higher income levels, negative traits which had reduced connection as efficiencies. We're in poverty, lack of education, smoking alcoholism, poor sleep and so forth. And so this is is this nature versus nurture? Is this chicken or egg? I leave it to you to essentially think about that. I don't have an answer to that and I would like to think that were all born somehow the same and then then things change, but I'll leave that to others in the philosophical uh and other higher neuroscience realms to discuss this. But I will say this, there are differences that occur and whether they're a chicken or egg is one is the question maybe. But there are differences that are there that are between those positive. If you want to call them positive and negative, you want to call them negative. And I recognize how controversial that is. Whole brain white matter organization and intelligence and educational attainment. What about that? So the general cognitive ability, what we refer to as intelligence is associated with educational attainment throughout childhood into adult life. And um we know that white matter connect home efficiency is not as strongly efficient in those with lesser intelligence and educational attainment. And we know that the relationship between connect um efficiency and educational entertainment is there. So what is the importance of that distributed brain network property for that cognitive or educational ability in childhood and further how can we improve that if we so choose to by doing certain different things and in those that have potentially abnormalities or problems or are born with a different set of circumstances in the default mode network and with that within that connectivity, how are they affected and what happens with them? So one of the areas or many areas that we've now found differences in default mode networks includes of course traumatic brain injury, but also on attention, attention deficit hyperactivity disorder, autism patients in chronic pain have changes in default mode networks, depression, schizophrenia, post traumatic stress disorder and left one out here obsessive compulsive disorder. There are changes that occur. And here's one interesting study that looked at uh individuals who are having difficulty with self perception and autism or, I'm sorry, difficulties with perception of self. So in Children who do not have autism during self recognition, the default mode network lights up in a certain particular way when performing face processing tasks of either their own face, recognizing their own face, are recognizing the face of others. But in Children with autism only show this activation in these areas when recognizing their own faces, not in others. So there's a difference in the default note mode network, not necessarily what we would refer to as abnormal, but different. Then what, let's say another individual would have in a more mainstream a type of individual. So what about in TB changes in brain and in connections also occur. And when we look at neuropsychological measures of attention and working memory in both mild to all the way to very severe TBI versus control subjects, we see differences. We see when you control for age and the pre morbid intelligence, there's there is slower information processing in TB. Of course, we know this and it's found to be associated with track changes, particularly in the corpus callosum and in the superior longitudinal physical us, and in other areas of the occipital frontal connections, corona, radio to and generally in the cerebral white matter. But what we also know and and one of the things that I do when I evaluate a patient who has had a traumatic brain injury is I will get a diffusion tensor imaging scan and I will look at the corpus callosum particularly and I will look to see are there any changes that have occurred that could be related to that traumatic brain injury? And often we see this and often we find that patients are having these neuropsychological difficulties and we think that there in some way related and it gets complicated pretty quickly after that. But there are ways that we can currently look at this connectivity issue in a clinical way. So, um what about social cognition? I've mentioned that earlier. Uh there were um this one study by Genova looked at 42 individuals with moderate to severe TBI versus 23 healthy controls that looked at a facial affect recognition identification tests. I'd ask the question to our speech therapists out there. Do you ever use this test? Facial emotion identification test? Very interesting. And this was done to assess their ability to identify and discriminate happiness, sadness, anger, surprise, shame, fear. Um These individuals also underwent structural neuroimaging, including DT and examination of white matter integrity. And what they found was that the this facial, this ability to recognize these emotional states was reduced what was impaired and associated with reduced white matter integrity, particularly in a variety of different regions. But the inferior longitudinal physical us, inferior frontal occipital physical us. And I've mentioned this word twice now, fitz. I'm sorry I'm going backwards here. The inferior frontal occipital physical US. This is a tract that goes from the occipital lobe to the frontal lobe and back. So the occipital lobe visual the frontal lobe intellect potentially. Of course. Also all of the different white matter tracks in between. But um memory, emotion, spontaneity and so forth, frontal lobe. This is a connection between the two. One activates the other and how they are a bill. How are they are involved in? Social cognition is of interest. Here they are affect. Social cognition is affected by the integrity of this tract, the ability to respond to emotional um appearance of another individual. So we think that the white matter and grey matter uh in traumatic brain injury play a significant role in emotionally processing impairments. What about aggression? We've all seen patients with TB that have aggressive tendencies that lose their filter. A lot of the times we refer to this as a frontal lobe problem. Uh That's what it's typically thought. But here's A. D. T. I. Study that looked at in mild traumatic brain injury, uh neural mechanisms associated with aggression in chronic recovery stage. And in these individuals had greater radial diffuse acidity, which means that the corpus callosum had reduced fiber integrity, reduce structural integrity and there was a significant association between this particular white matter integrity in the corpus callosum and greater aggression. So again the white matter tracks are mediating all of this different areas and the gray matter are central computers are all being connected together and when they are disrupted in one way or another, a variety of behaviors may emerge and it's not just all about the cortex. So that begs the question then how do we manage this? And how do we modulate it? Can we modulate this default mode network? Can we change the way the function and even the anatomy of the brain is? And there is some evidence that this can occur. And there have been a variety of studies looking at the default mode network in acupuncture meditation, which I'm going to go into shortly sleep using psychedelic drugs, psychotherapy, antidepressants, physical activity. Just a word about the psychedelic drugs. Um, just most recently, there was an indication that excuse me, post traumatic stress disorder can be um in some way modulated with the use of psychedelic drugs such as psilocybin or magic mushrooms. And there's some thought that this may be approved as an ultimate treatment of PTSD. What happens with that to our default mode network? There may be changes that occur as a result of that, but how can we also change the default mode network in other ways? So one of those ways is likely to be mindfulness meditation training and there are different areas of the brain that have been shown to now change this default mode network, particularly in this uh dorsal lateral prefrontal cortex for this one blue circle, this other one in a association cortex uh and another one here in the singular eight areas. Um So the structural changes um uh are the, I'm sorry the functional activation changes and reduce functional connectivity has been shown to occur in long term practitioners of mindfulness meditation training. And there are others that, such as transcendent transcendental meditation that have been found to actually activate the default mode network. So this may have some basis in how we can change our ways of reactivity and so forth. And this is well known of course amongst meditators and in the mindfulness space meditation um community. Uh but eight weeks of mindfulness meditation training alters that functional connectivity in ways that are thought to indicate consistent attentional focus, enhanced processing of sensory information and a better awareness of your own sensory experience. And what we see is that there is an increase in arresting connectivity between these prick Eunice areas endorse a lateral prefrontal cortex in nBR participants and that this actually on DT studies looking at structure, showed increased micro structural connectivity of white matter tracks in these regions and this was associated with self reported improvements in attention. So what about backpacking? We're coming to the sort of end of the talk here, uh and how does all this fit together? And how do we um Honor Dr Chippendale, his memory and his uh the effect that he's had on all of us and particularly upon me and so picture this, you're away from your desk, you're out in nature, dirt crunches under your feet with each step you take each one step closer to a scenic vista, your heart's pumping, your whole body is working. And it may be hard all around you. Nature trees, flowers, birds, sun shining, a blanket of warmth on you. Wind blowing at all the right times. This is backpacking. You're backpacking sounds pretty nice. It's even better in real life if you haven't tried it. Yeah. So what about backpacking and meditation in my way of thinking about that is that it's one and the same. Mindfulness. Meditation is typically described um by my buddhist friends and practitioners as non judgmental attention to experiences in the present moment. And this embraces the concept of not only mindfulness but also equanimity, and it requires regulation of attention in order to keep your focus on immediate experiences right then? What's happening right at the moment? Your thoughts, your most in your body, posture, your sensations among other things. Mhm. So hiking is meditation for me and I can't express that adequately in words. You know when you're out there Um carrying your backpack and you're trying to make uh 10 or 15 miles in a day up and down some pretty steep hills. Uh You are working on your breath, you're working on each step. Um You are focused on your sensations in your body. This is exactly the same as meditating in some respects. And on a long walk you're with another person as I was with dr Chippendale, but also alone with your mind. So backpacking is a study on being present in the moment, every bear and stealing some a few words from staying in the police. Every breath breath you take, every step you take, you'll be watching you okay? And I end with this quote from Bill bryson, a walk in the woods. Uh, I was worry of the trail, but still strangely in its thrall found the endless slog hideous, but irresistible, grew tired of the boundless woods, but admired their boundless, boundless nous, enjoyed the escape from civilization and act for its comforts. I wanted to quit and to do this forever. Sleep in a bed and in a tent, see what was over the next hill and never see a hill again. So, thank you so much. I hope you have a little bit of new learning and insight into what's happening. Excuse me. What's happening in neuroscience today? Uh in terms of this study of brain function, how it's evolved since the beginning of time, how it's affecting our civilization, how it's uh, affected all of us and our learning of what we do and how we treat patients, uh, and how we tie this together with meditation and with backpacking in particular in my case, uh and in honoring Tom Chippendale, thank you. Right. Yeah, yeah, well, thank you very much, Doctor Loeb, that's a lot of fascinating uh information. Um one of the things that you got me thinking, talking about the, the connect, um um I'll have to admit that it was never really uh interested in art much when I was younger, but one of the things that I think struck me as I got, you know, got older was this difference of how, you know, somebody can look at a painting or a sculpture or something and see something and somebody else looked at it and you know, now doesn't doesn't bring much to them. And I was thinking, you know, with a lot of, you know, I feel like artists tying into kind of our emotions and some deeper connections in the brain that possibly if I matched if I have some of these connections in my brain that's similar to the artists that developed it, that I can create this connection to it, that maybe somebody else can't. And I'm wondering things like, you know, uh music therapy and not just you know, music therapy that just listen to music, but when people are actually doing music therapy and art therapy and things that I wonder how much the, you know, the connect um plays a role in this. Do you have any uh thought to that? I think that's a very interesting question. I do think that there is evidence that music therapy does alter uh functional connectivity in some respects. Um it would be um um probably intuitive to think so, given what we already know, but also um that we are going to be um studying that even in deeper ways. Um There was in years past a lecture at our conference by Michael Tout uh from the universe from colorado state, I think in um colorado Springs who is an expert at music therapy and I believe he has data that shows that there are functional connective changes. Also, what's really interesting for me, also on another level different, but I've seen this both in a traumatic brain injury patient and I've also seen it in Alzheimer patients, which as when they were injured, they became more artistic um overnight. And I have a couple of examples of that. I have one young girl who had an anoxic brain injury at age 16 who prior to that was a stick figure drawer and after that became an amazing artist and who had some deep white matter involvement in her T. B. I. I'm sorry in her anoxic brain injury. And then in Alzheimer's disease or in other forms of dementia like frontotemporal dementia. There are published studies that show people becoming also exquisite artists as their disease progresses, presumably initially thought to maybe unmasked by dis inhibiting certain areas but also potentially by making other connections more preferential such as that orbital frontal cortex connection where what you see and how you interpret it and how you react to. It may have something to do with the connection between those two centers. So thank you. There was one chat question I see here, do you want to take do you want me to answer that? Uh huh. Yeah. So uh yeah. So do you expect functional MRI use in guiding neuroma, rehabilitative therapies? I do I do think that that is a that's the frontier for us as rehabilitation professionals is that we are going to be looking at all this new data and we're going to be thinking about how we're going to strengthen the connections between one area and another that we can demonstrate to be weak on our functional MRI. Um one of the things that I think we already do uh is boxing. Boxing for me is not just about hitting, but it's about sequencing, right? Our therapists taught me this by the way. Um and uh when you start sequencing what's happening there, you are connecting your motor to your frontal lobe, to your visual, you're strengthening these connections between these two things, You're not building new neurons, you're strengthening connections. So I think as we learn about which connections have different functions and as we learn about which connections are involved in certain aspects of brain injury, we are going to alter our rehabilitation strategies in the future. So um We have another question says a wonderful tribute to Dr. Chippendale and two wonders of our brain into the great book Sapiens uh and to the joys of backpacking. So the question is, do you think that that should be used more routinely? Just as structural scan such as alright mris. And CT scans are now in the diagnosis of concussion and white matter changes in auto immune diseases including those associated with covid. Um Good question. Yes. I do think that every one of my brain injury patients gets a D. T. I. Image as part of the M. R. I. Work up. This means that they have to be referred to a three T. MRI. So wherever you're located listening in on this lecture, whether it's um here or you're in India or someplace else, um you need to find a three tm re that is doing it scripts has won uh, imaging healthcare specialists has one here in town, University of California san Diego has one as well, But other locations may not have them. They may have 1.5 TMris, the smaller magnets and those are not going to be able to do adequate DT I imaging. So you'll be careful about how you're going to refer your patient into what you're asking for. Um, so yeah, I I had a patient a while back who had a stroke and he ended up with an expressive aphasia. And when he was attempt to speak, he used the word school a lot and nobody knew why he kept saying school and it didn't mean the same thing every time. Um, and you know, we would have to try to figure out what he meant by using context clues. But, you know, I feel like if he was using a random word, then it wouldn't be the same word over and over and over again. And, you know, I wonder so in my mind, I'm thinking there's gotta be a reason why he used that word. And I think, um you know, we have a number of speech therapists who are registered for the course, and I think they, you know, are probably looking at a lot of stuff like that. And I'm thinking, if we could tie into some of that, you know, as you kind of mentioned, as far as, you know, guiding the neural rehabilitative process, if we can tie into some of those connections, you know, what are we able to do with rehabilitation in the future? Certainly. Uh I think that that's very interesting. It'll be really interesting to do a functional MRI on that individual uh and look and see what the default mode network looks like. And that would be worthy of the paper. I don't know if you can still find that patient but uh that would be worthy of a paper to forward the knowledge and all of this. But maybe there's some aspect of that that we can learn from. Yeah. Now um with the uh these the default network and our connect them, uh I'm wondering how standard or how variable from person to person these connections are um as far as uh inherently genetically versus obviously as we go through different um it experiences through life that you would think that different connections would form. But I wonder how standard it is I guess, you know, going back to your nature versus nurture um you know that is the that is a big question and we don't know the answer to that. We just can work with thousands of patients and develop what we think are norms like we have a norm for your hemoglobin. You know, when you do a cbc, it's developed over thousands of patients, so we know that and when we would say something is different, we would typically say it's two standard deviations from the norm or more, more than two standard deviations out and uh so but there's going to be individual variability and that's why I really want to be careful in in talking about what's normal and what's abnormal because and and really, in autism in particular, I don't necessarily look at that as being abnormal. I look at that as being different and um the connectivity is different and that facial connect facial recognition connectivity is different. And so does that mean it's abnormal? No. And obviously patients with people with autism may have many other talents that far surpass others. Uh so uh we need to be careful about what we're labeling uh and but nature versus nurture is certainly going to have some uh that's a big debate, but there's probably some truth to both sides of that uh because we see functional connectivity changes in PTSD in traumatic brain injury and so forth. So just saying it's all nature is um probably not correct and but there's probably some truth to that, what you're born with versus what other people are born with, it would be quite amazing. I understand Einstein's brain is sitting in somebody's lab somewhere. I wonder if we could do a a functional and Marion On a brain that's been informal and for uh you know, 50 years. So it would be really interesting to see what his functional connections were imagined. They were pretty good. I have another question here uh says thank you for this insightful presentation. What would be a good reference to site to encourage the powers that be to allow me to send my patients to a three T. M. R. I. As opposed to 1.5 T. Available at my facility. Um why don't you submit your email address to me or through the through the course? And I will get you some references that will be helpful to you and um stating your case. One of the one of the things about evaluating patients, particularly with mild traumatic brain injury, it's less less of an issue and more severe TBI, where CT and conventional MRI are already abnormal and, you know, there's injury. But in mild traumatic brain injury where Cts and typical mris are normal. You have the task of trying to decide is what you're seeing something that is psychological or psychiatric in relation to the injury and you know and what happened to the individual Or are you seeing an individual who is really truly injured But you can't prove it with functional? I'm sorry. With a conventional MRI or with CT then you need absolutely three tm re because the three D. MRI allows I didn't talk about this but it allows for one additional sequence other than the TT it allows for a type of sequence called susceptibility weighted imaging. And what susceptibility weighted imaging is is a Type of sequence that's done in the three D. MRI. That looks for iron deposited in the brain. An iron is a byproduct of hemoglobin that has been broken down and removed after bleeding in the brain. Okay. So it turns out that the poor foreign structure of hemoglobin can be removed with normal brain healing but the iron no way to remove it for the body. It remains there forever and in shearing injury in the brain, which is typically, you know what happens in mild traumatic brain injury. You may get tiny little micro hemorrhages that are not visible on CT or conventional MRI but are visible on susceptibility weighted imaging. And the reason it's a visible on susceptibility weighted imaging is that iron is susceptible to the magnetic field of the MRI and it can be detected in that magnetic field because it is susceptible to the magnet. That's why we call it susceptibility weighted imaging. It's also called swan in some radiology, you know, reports or so forth. But you definitely need that if you're evaluating a mild traumatic brain injury case where CT and MRI are not going to help you and that should be pretty obvious too. Most people that are in the tv field okay. You mentioned about uh you know, for example, an autism different. Um it doesn't mean that it's abnormal. Uh sometimes I use the example of a car, you know, well, which car is better, you know, is of is a Mercedes better than A Ford F150. Well not if you're a construction worker and you're bringing, you know, I need to pick up stuff, right? So just because it's different, doesn't necessarily mean that this one's worse than this one. It depends on what the uses are. And so, you know, thinking there are there are people that might be different. It might be better at different things. You know, somebody who's who might be better at something than I am and something that I might be better at at somebody else at doing something else. And so I'm wondering it, you know, as part of the discovering these these connections and how they impact our ability to process information, how that may help guide people into something that they are good at would be an aptitude things, you know when they're younger or you know, helping us in a career. Who knows? That's a that's a little bit of a loaded question their doctor do for. I mean you know, um I wouldn't it's a little bit of brave new world I think uh that we would maybe scan somebody and figure out what they're good at uh because you do I I would truly believe you do have your opportunities to change your connect um and to enhance your connections or to make them more efficient and by doing different things and certainly we know that for mindfulness meditation and that we can do that. Yeah. Yeah. I think part of the reason for the loaded questions, I think sometimes when we see something new, we think about the possibilities with it. And then other times we think about, well what are the negative implications of it? You know? Like they talk about doing genetic studies to see that someone is predisposed to cancer. And does that mean that they're going to get cancer? And what does that, you know exactly the same for like Alzheimer's disease? We know there's a gene out there, but you might have the gene but never get Alzheimer's disease. So we don't recommend testing for that either. We did have 11 comment that said uh I guess referring to uh one of my earlier comments regarding to the person using the word school over and over. My idea is that it just it's just something that comes easy to that person. So they rely on it. I had a patient quite a number of years ago, They could only say one word. It was kind of like a combination between the word batter and butter, but she would use it uh with so much inflection in her voice and expression on her face that you would often understand what she was saying and never felt like she was using it to mean certain things. Yeah, that's very well said in that ability to express that emotion, there must be a pathway there from that, you know, language center uh and pathway to that facial expression that that patient was talking through their expression. It's really great. Thanks for bringing that up. Well, thank you very much. Again, I think um what if there's no other questions uh or dr Lopez if you have no more comments, but we could uh do is go to break a little bit earlier than then start up the next session a little bit earlier, I'll just make one final comment here. And as uh I would like hopefully everybody to have come away with, you know, some expanded knowledge about what's going on, like I said, but get out there and hike and backpack, and when it's hardest, that's when you'll be meditating the most, and and also meditate if you can, and take up mindfulness based stress reduction. There are multiple courses in SAn Diego and around the country. Uh and uh I would really encourage you, I know Dr Chippendale would absolutely encourage you to do these things as well. Thank you. Thank you. I appreciate it.