September 21, 2021 • 27 mins
Neuroplasticity is the secret ingredient for better brain power – and better outcomes for children with disability. In this episode 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?
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Andy McLean (00:00):
-Hello and welcome to Cerebral Conversations. I'm Andy McLean.
Ben McAlary (00:04):
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
(00:24):
of Allied Health and co-founder of the Cerebral Palsy Alliance
Research Institute.
Andy McLean (00:30):
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, n europlasticity 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
(00:51):
together wire together. That's an expression that pops up during
this conversation. It's certainly got me thinking.
Ben McAlary (00:57):
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
(01:18):
our everyday lives.
Andy McLean (01:19):
It's pretty mind blowing stuff. So, without further ado, let's
get into it.
Tracey Spicer (01:28):
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 (01:52):
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
(02:13):
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,
(02:37):
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
(02:58):
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
(03:19):
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 (03:42):
You were fortunate to learn about it early weren't you, in childhood, b ecause 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 (03:57):
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 (04:19):
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 (04:34):
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,
(04:54):
that we were like, humans are on an autopilot or
a blueprint of development, and you couldn't really change things.
Tracey Spicer (05:01):
There's also this concept of pruning in neuroplasticity. Can you
explain that in layperson's terms?
Iona Novak (05:08):
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
(05:29):
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
(05:50):
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 (06:09):
So how could we all use the concept of neuroplasticity
in our everyday lives?
Iona Novak (06:14):
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.
(06:35):
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
(06:55):
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
(07:18):
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
(07:38):
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,
(07:59):
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
(08:21):
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 (08:38):
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 (08:50):
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
(09:12):
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,
(09:33):
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
(09:55):
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
(10:16):
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 (10:27):
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 (10:35):
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
(10:57):
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,
(11:20):
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 (11:29):
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 (11:39):
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,
(12:00):
you can connect with them are really important to this
bonding process.
Tracey Spicer (12:04):
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 (12:18):
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
(12:38):
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
(12:58):
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
(13:19):
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 it, going through the pain barrier and
working against the clock. But what Rohan did was got
(13:41):
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.
(14:05):
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 (14:16):
Oh, it's incredible. It's such an exciting area of research,
but it also has me wondering, I ona 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
(14:40):
the rest of the community?
Iona Novak (14:41):
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.
(15:02):
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
(15:24):
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
favorite all time stories in this area was an intervention
that I tested in cerebral palsy, which is the plasticity
(15:46):
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
(16:07):
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
(16:28):
the light on i n 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
(16:50):
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
(17:10):
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.
(17:31):
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 (17:49):
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 (18:03):
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
(18:23):
what the women in STEM program in Australia or superstars
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
(18:45):
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
(19:07):
another aspect of diverse thinking.
Tracey Spicer (19:09):
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 (19:20):
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
(19:41):
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.
(20:05):
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 color 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,
(20:27):
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 the 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 (20:59):
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 (21:10):
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,
(21:33):
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 (21:47):
What do you hope to see within your lifetime in
this area, particularly around neuroplasticity?
Iona Novak (21:53):
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,
(22:17):
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
(22:39):
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
(23:00):
very exciting, and I think it's not impossible that we
would see a cure for this condition.
Tracey Spicer (23:04):
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 (23:19):
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
(23:40):
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
(24:02):
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
(24:24):
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 (24:38):
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 (24:56):
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
(25:16):
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,
(25:37):
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.
(25:58):
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 (26:05):
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 (26:21):
Thank you very much.
Ben McAlary (26:26):
You've been listening to Cerebral Conversations, a podcast produced by
Cerebral Palsy Alliance.
Andy McLean (26:33):
To learn more, check out the show notes to this episode.
Over at cerebral palsy .org.au/cerebral conversations.
Ben McAlary (26:42):
And if you enjoyed the show, please rate or review on
your favourite podcast platform.
Andy McLean (26:48):
And to join the conversation, follow us on Facebook and Instagram.
Ben McAlary (26:52):
Thanks again for listening!
Credits (26:53):
The music for this
podcast was kindly supplied by Ocean Alley. Check out the
band's music on Bandcamp or visit oceanalley .com.au
-Hello and welcome to Cerebral Conversations. I'm Andy McLean.
Ben McAlary (00:04):
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
(00:24):
of Allied Health and co-founder of the Cerebral Palsy Alliance
Research Institute.
Andy McLean (00:30):
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, n europlasticity 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
(00:51):
together wire together. That's an expression that pops up during
this conversation. It's certainly got me thinking.
Ben McAlary (00:57):
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
(01:18):
our everyday lives.
Andy McLean (01:19):
It's pretty mind blowing stuff. So, without further ado, let's
get into it.
Tracey Spicer (01:28):
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 (01:52):
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
(02:13):
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,
(02:37):
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
(02:58):
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
(03:19):
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 (03:42):
You were fortunate to learn about it early weren't you, in childhood, b ecause 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 (03:57):
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 (04:19):
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 (04:34):
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,
(04:54):
that we were like, humans are on an autopilot or
a blueprint of development, and you couldn't really change things.
Tracey Spicer (05:01):
There's also this concept of pruning in neuroplasticity. Can you
explain that in layperson's terms?
Iona Novak (05:08):
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
(05:29):
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
(05:50):
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 (06:09):
So how could we all use the concept of neuroplasticity
in our everyday lives?
Iona Novak (06:14):
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.
(06:35):
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
(06:55):
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
(07:18):
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
(07:38):
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,
(07:59):
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
(08:21):
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 (08:38):
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 (08:50):
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
(09:12):
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,
(09:33):
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
(09:55):
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
(10:16):
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 (10:27):
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 (10:35):
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
(10:57):
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,
(11:20):
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 (11:29):
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 (11:39):
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,
(12:00):
you can connect with them are really important to this
bonding process.
Tracey Spicer (12:04):
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 (12:18):
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
(12:38):
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
(12:58):
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
(13:19):
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 it, going through the pain barrier and
working against the clock. But what Rohan did was got
(13:41):
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.
(14:05):
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 (14:16):
Oh, it's incredible. It's such an exciting area of research,
but it also has me wondering, I ona 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
(14:40):
the rest of the community?
Iona Novak (14:41):
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.
(15:02):
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
(15:24):
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
favorite all time stories in this area was an intervention
that I tested in cerebral palsy, which is the plasticity
(15:46):
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
(16:07):
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
(16:28):
the light on i n 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
(16:50):
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
(17:10):
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.
(17:31):
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 (17:49):
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 (18:03):
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
(18:23):
what the women in STEM program in Australia or superstars
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
(18:45):
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
(19:07):
another aspect of diverse thinking.
Tracey Spicer (19:09):
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 (19:20):
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
(19:41):
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.
(20:05):
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 color 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,
(20:27):
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 the 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 (20:59):
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 (21:10):
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,
(21:33):
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 (21:47):
What do you hope to see within your lifetime in
this area, particularly around neuroplasticity?
Iona Novak (21:53):
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,
(22:17):
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
(22:39):
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
(23:00):
very exciting, and I think it's not impossible that we
would see a cure for this condition.
Tracey Spicer (23:04):
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 (23:19):
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
(23:40):
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
(24:02):
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
(24:24):
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 (24:38):
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 (24:56):
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
(25:16):
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,
(25:37):
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.
(25:58):
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 (26:05):
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 (26:21):
Thank you very much.
Ben McAlary (26:26):
You've been listening to Cerebral Conversations, a podcast produced by
Cerebral Palsy Alliance.
Andy McLean (26:33):
To learn more, check out the show notes to this episode.
Over at cerebral palsy .org.au/cerebral conversations.
Ben McAlary (26:42):
And if you enjoyed the show, please rate or review on
your favourite podcast platform.
Andy McLean (26:48):
And to join the conversation, follow us on Facebook and Instagram.
Ben McAlary (26:52):
Thanks again for listening!
Credits (26:53):
The music for this
podcast was kindly supplied by Ocean Alley. Check out the
band's music on Bandcamp or visit oceanalley .com.au
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