Mirror Box Therapy - Part VI

or: Outlook - Possibilities - Thoughts

OK - our brains are built to predict the future - let's see if I can help that along. ;-)

Blakeslee - in her excellent book - has reported that there are preliminary results that viewed the problem of Anorexia from a body map disorder point of view. What if people with anorexia "just" have a different body map - one that is much much thinner than their real bodies.

Easy: they feel extremely uncomfortable in their own bodies. I imagine it like your whole body being numb (think of the effect you feel after you visited your dentist - now only include your whole body).

The only way to make the felt image and the actual image fit is to starve yourself - in 20% of cases even to death. That's how strong this urge is.

The thing we have to recognize about emotions and the urges they produce is that they are strong motivators - they "make us do things". And only when we have satisfied whatever the emotion tells us does the urge go away. Viewing pain as an emotion like hunger and so on makes it much easier to grasp what's it all about.

My best guess is that eventually all body dismorphic disorders will be recognized to really be "body map" disorders and be treated accordingly.

(I know that pain is not a real emotion - it's much more than that. But some of the effects it has on us and on our behavior are very similar which makes it easier to talk about it.)

Another very frequent condition where feedback therapy shows good results is tinnitus.
Again - peripheral thinking (i.e. in terms of damaged structures) hasn't amounted to much progress being made.

Now - thanks to brain imaging we can see that tinnitus is the same as phantom limb pain only for our sense of hearing. The auditory cortex where sounds are mapped becomes disorganized - creating random noise. By re-training the auditory cortex - as Herta Flor and Colleagues have done - having the patient distinguish different frequencies and so on - the symptoms can be markedly reduced.

Another treatment that is able to alleviate such symptoms is TMS (transcranial magnetic stimulation) which shows even better results.
One clinic in Germany at Regensburg University is working with this technique. And on a sad side note - largely unnoticed by the medical establishment as yet.

Migraines - with aura - are yet another field where neuroscience has found an identifiable cause - quickly spreading cortical depression. And the easiest way to describe treatment I have to think of the term "re-booting". It seems that a few neurons go haywire - causing others to join in. By zapping those neurons - which are located in the visual cortex - you can stop the effect from spreading.

A handheld device is currently undergoing final tests and should be on the market soon.

As for other frequent conditions:
focal dystonias, writers cramp, jips in golfers, RSI, .... are all due to some form or other of the map areas becoming deformed, fused or altered in some unintended way. Treatment as I stated before has to re-establish normal maps, creating congruence between the VR program and the actual sensory information.

If you don't suffer from any of these conditions count yourself lucky.

Not only was treatment unavailable till now - since no real cause could be found sooner or later people were accused of the symptoms being all in their heads - which in a way they were - but as real physiological manifestations - not some unexplained "psychological" phenomenon.

Don't get me started on the harm that was done to these people by so-called medical professionals who are too lazy to pick up a book or medical journal once in a while and are too arrogant to question their own knowledge.

A much more common problem everyone has to deal with sooner or later is aging and it's accompanying aches and pains.
The best term for this combination is sensori-motor amnesia - which - as far as I can tell - comes from Thomas Hanna who built on the work of Feldenkrais.

What do "old" people have in common?
Their posture, their way of walking, their difficulty in looking over their shoulders (which makes driving a car dangerous), and so on and so forth.

Yet - with a little hands on treatment - they are able to regain a lot of their mobility within minutes.

How come?
Well - I see daily life as a constant struggle between adaptive and (cumulative) maladaptive learning.

Babies learn all day long. They learn a language or two or three, they learn social norms and customs by imitation, they learn how to move their bodies in thousands of different ways. After a while they become school children - and learning takes on more of a purely "mental" form - the memorization of knowledge. "Body learning", i.e. different types of movement aren't explored any more.

Now you might say that during the teenage years most people pick up a sport - and you'd be right. But it is one sport - with one specialized way of moving - and not a great variety of things.

After that you have a job - and if you are really unlucky it either involves sitting or doing the same repetitive tasks over and over again.

What happens when you either have to little movement (sitting) or too much small movements is that your body maps change. Add to that that the tissue becomes hypoxic and you have a recipe for disaster:
this body map change is accelerated by the presence of pain.

Now - before pain becomes "felt" there is already nociceptive information being sent to the brain which uses reflex responses to automatically adjust posture and such. Just watch people at the cinema - they are constantly shifting position to distribute the pressure from sitting over a wider area of the body.

Only when those mechanisms don't suffice to change the nociceptive input pain is produced.

These two examples give you an idea about what aging is:
it is the slow accumulation of changes in our body maps with the effect that we un-learn how to move bit by bit. This process is accelerated/aided by sub-conscious pain and automatic reflex responses (reflexes are stereotypical - that's why old people "all" have the same posture).

It's not because our bodies can't move freely anymore - the brain simply has forgotten how to send the appropriate motor commands.

The solution: life-long body learning. Feldenkrais, Somatics, Yoga, .... - all build on this.

It's a bit more difficult to incorporate this into daily life - but things like the Nike Free are a good way to start.

Those shoes really do help your feet to become alive again.

What are you waiting for?
Go do something now or I will send them after you: ;-)

Mirror Box Therapy - Part V

or: Resources

I love the Internet - plain and simple.
All my life I knew there was something missing - till broadband came along and changed everything. ;-)

This collection of links is an ongoing project - feel free to suggest additional links, blogs, websites, ... in the comments or by email to matthias.weinberger(at)gmail.com

Medical Databases and Search Engines:
- PubMed
- HubMed - a much better interface than PubMed
- Google Scholar

Recommended Journals:
- Pain
- Neuroscience Letters
- Experimental Brain Research
- Neurology
- Brain
- Journal of Applied Physiology
- Journal of Neurophysiology

Videos:
- YouTube
- SciVee

People:
- Ramachandran
- Herta Flor
- Lorimer Moseley
- Candy McCabe

Products:
- NOI
- Mirrorboxtherapy.com

Blogs:
- Diane Jacobs
- Neurotonics
- Howtocopewithpain - including a monthly pain blog carnival
- Psychology of Pain
- David Butler's blogs: one, two, three
- Michael Merzenich
- Deric Bownds`MindBlog
- BPS Research Digest
- MindHacks
- Mixing Memory
- The Frontal Cortex
- Healthskills
- Jeisea

Books:
- V.S. Ramachandran "Phantoms in the Brain"
- Sandra Blakeslee "The Body has a mind of it's own"
- Herta Flor "Psychobiologie des Schmerzes"
- David Butler, Lorimer Moseley "Explain Pain"
- Patrick Wall, Ronald Melzack "Textbook of Pain", "Pain"
- Alain Berthoz "The Brains Sense of Movement"
- Michael Gazzaniga "The Mind's Past"
- Jeffrey Schwartz "The Mind and the Brain"

Forums:
- NOI - the forum closed some time ago - but the archive is still there
- SomaSimple

Podcasts:
- Brain Science Podcast
- All in the Mind
- TED Talks

I thought about including a section about the most important scientific papers - but there simply are too many out there.
For those who want to dig into this stuff: start here.

Mirror Box Therapy - Part IV

Feedback.

That's what the treatment of chronic pain boils down to: you have to send feedback - be it visual, tactile, auditory, ... to the brain so it can update the VR model. Only if the model and the corresponding motor command generated by it and the information from the external sensors matches up will the pain stop - very rapidly as several studies have shown.

Now - the really great thing about any type of feedback therapy is that the corresponding map which was altered in a maladaptive way starts to get reorganized while doing the therapy. That's what the studies report: during the first few training sessions the pain diminishes very rapidly - but comes back after a short amount of time (15 minutes,...).

But after the 5th or 6th session most people are able to get more lasting pain relief - and after just 3 weeks of daily practice most people can stop doing mirror box therapy altogether because the pain doesn't return.

This is all due to the positive effects of brain plasticity: the brain is able to re-organize very very quickly - provided it has the right incentive to do so.

As yet there are no long terms studies out that show how people with phantom limb pain that were treated with mirror box therapy have done over the years - this method is simply to new. I expect the first big trials to show up in the next 5 years or so in the wake of the studies done now at Walter Reed Medical Hospital with Veterans of the Iraq War.
That should give us an even better picture about what causes the process of maladaption in the first place.

My best guess is that initial pain (a painful limb that hurts before amputation) is the single most important factor - the brain learns the pain.
That's why amputations done where the limb was anaesthesized first show much better outcomes than traumatic amputations.

If you look at the case of CRPS - and to some extent after a stroke - you see another interesting thing:
the immobilization phase you have to go through after breaking a bone or suffering from a stroke tells your brain that - despite it sending motor commands to your limb - there is no proprioceptive feedback from the sensors in that limb.
If you can't move your hand because it's in a cast it can't send enough feedback to the brain.

So gradually over the weeks the hand map is adjusted - resulting in a limb that actually can't be moved even after the cast is removed. The brain has un-learned that the hand can move a great deal. And since the VR simulation in our brains is the basis for our actual perceptions and thoughts and feelings and everything else a lot of people describe their afflicted hand as no longer belonging to them.

An even more extreme example with different causes is the so called Alien Hand syndrome in which people don't recognize the hand being theirs at all.

What happens with the hand during CRPS - the swelling, osteoporosis and all the other stuff is secondary to the changes in the brain!

By using a mirror to give the brain visual feedback of an intact, healthy and freely movable limb re-organizes the map and symptoms vanish very quickly.
There are some preliminary results that show that even in stroke - at least part of the paralysis that results is not "real" paralysis - but learned paralysis - the brain just thinks that one side can't move any longer.

And even if that only accounts for say 20% - every bit of function you are able to regain after a stroke is better than nothing.

What sets CRPS apart from other chronic pain syndromes is that in addition to the hand map becoming distorted is that people aren't able to distinguish between a picture of a left hand and a right hand. They loose the sense of laterality.

This could be due to the fact that the brain uses the representations of the hands in it's internal model to construct laterality in the first place.

This would amount to the loosing of one of the models of the physical world that was established during childhood. Imagine yourself loosing your sense of gravity - one could no longer throw things accurately because you wouldn't be able to plan a parabolic trajectory - you would think that things always just fly in straight lines.

The NOIgroup Institute has developed a set of cards and a computer program with which you can re-learn this basic first step called Recognize.

If CRPS is in full swing however and sort of movement might aggravate pain.
That's why in severe cases you have to wait a little before you can do visual feedback therapy (mirror box).

The treatment in these cases starts by doing imaginary movements.
Those activate the same brain areas as actual movements - after all the brain does the same while running the VR program - the only thing that's missing is the actual motor command which is actively inhibited.

That way you can train the neuronal/mental circuitry which later will be activated for real.

As for areas of the body that have no limb like features - like the back:
you could have the patient lie down and point a video camera at his back and show him the image on a monitor.

But - as a few clever scientists have found out long ago - visual and tactile feedback are treated as equal in the brain.
Here finally the hands of the therapist come into play. ;-)

By touching the skin over the area you want the patient to move you can facilitate the whole process.
Once he has established motor control over that area again he is instructed to activate the muscles in that area every day so that the brain receives proprioceptive information from that area on a constant basis.
I advise some variation of primate grooming for home use: back rubs, brushes, whatever is available.

Regardless of which type of condition you have or want to treat:
the basis is always to send feedback about a limb or another part of the body to the brain (the comparator).

Feedback in daily life is important: remember how hard you had to hit the keys on an old typewriter?



Today's keyboards - especially the new one's from Apple are awesome!
Touch screens however are tricky because they don't provide any feedback. If the manufacturers were clever they'd introduce a very slight vibration - that would do the trick.

Mirror Box Therapy - Part III

or: the bad part

As I've tried to explain: the maps of the body are what the brain uses to run the virtual reality simulation. And maps are plastic - to some degree.

Genetically every body map has 2 hands and 2 feet. Even when - through some defect you are born with only one hand! The map still says that there have to be two - and that is what the VR simulation represents. That's why people with one limb missing from birth still are able to feel a second "phantom" limb.

The brain doesn't care about reality since it regards the VR simulation as being reality.
It may take a while to get your hand around this - but trust me - this is what happens.

Let's have a look at this visual illusion:



Your brain - based on the models it has built over the years insists on seeing different sized tabletops. It just does. Why? Because the internal VR simulation is built on a model that says that illusionary perspective (fake 3D so to speak) means depth - even when - like on the monitor you are looking at - only 2D is present.

And so it decides to factor in this fake perspective and makes one tabletop seem bigger than the other.
This internal VR program can't be overridden (!) and is presented to you (your consciousness) - as being factual.
By the way: the tabletops have exactly the same shape and size - at least in"real" reality. ;-)

Or think back to a visit at the dentist when your cheek was anaesthesized: if felt bigger - much bigger - even when you looked at it in the mirror. Those sensory illusions are the results of the brain trying to make sense of conflicting information. It runs the data through the VR program and decides that the outcome - however ridiculous - has to be true.

Now for the really bad part:
if those maps - that form the basis for the VR program - are plastic - what about them running amok? What happens when something goes wrong and those maps change in a maladaptive way?
That's what happens in phantom limb pain, CRPS, chronic pain syndromes, anorexia, body image disorders, ...

Let's have a look at phantom limb pain:
here the real limb is amputated - but the map stays. It shrinks and adjacent map areas take over - but there is always a representation of the limb present. And the VR program is built on that. Watch someone who lost his arm slip - he still reaches out with his missing limb to steady himself.

Why? The VR program was built to save time - to enable us to react as fast as possible. If we didn't have something like it we could never regain balance. So it uses the basic blueprint (2 arms and 2 legs) when it comes to balance.
This invasion of adjacent areas has as an effect that people who lost an arm feel their arm being touched when you touch their cheeks - the area next to it.

A different thing happens in chronic LBP: the area starts expanding - probably as a way to increase spatial resolution as I suggested some time ago.
It invades other nearby area - that's why after a while - chronic pain start to spread. It doesn't do so by clear boundaries - there are no recognizable dermatomes affected - thereby making treatment more difficult.

This maladaptive plasticity is most probably driven by these factors:

1) lasting acute pain: pain demands attention and causes fear. Both are strong chemical reactions - probably accelerating learning in the map area (at a cost of course)

2) reducing of computational demand: the brain adapts to the pain - learns the pain to free up resources in the periphery. Hence learned pain. Herta Flor has done work in this direction.

3) favorable genetic disposition to develop chronic pain

So regardless of what happens behind the scene - either a shrinking of the map or it's expansion - pain is the result.
The most notable difference so far is that in conditions where no input exists the pain is often caused or ... by clenching or spasms whereas there is only pain and nothing else when the affected part is still there - as in LBP.

This is certainly a very interesting thing to go into - but has little to no effect on therapy as far as I know yet.

So why does pain occur?

Well - the brain does a good job with the VR program - an excellent job in fact; but there are times when it has to adjust the output that is produced by that program; this is especially true when we encounter new and unfamiliar situations.

Imagine yourself having lived in the desert all your life and then encountering snow and ice for the first time. Your brain can't anticipate what's going to happen when you step on that white surface - it has no experience what conditions it'll encounter - so it constructs a motor command anyway and checks the incoming sensory information on a regular basis to adjust the motor command accordingly.

That's why you are able to learn new stuff very quickly.
This is done by an area that we'll call the Comparator.

In the case of phantom limb pain however there is no feedback available. Not tactile, not visual, not kinesthetic. And since our brains can't just crash like a Computer it sends out a signal to a higher brain center to deal with the problem. It's similar to other emotions: they are produced by "lower" centers to inform the "higher" centers to please do something about them.

And that is it - the "secret" of chronic pain. It's a message from the Comparator saying "I can't make sense of this - the VR model is fine - but the feedback from the sensors doesn't match. Please deal with it - I don't care how and get back to me." (At least that's what I imagine is going on in a Woody Allen kind of way). ;-)

The solution: feedback therapy.

Mirror Box Therapy - Part II

or: the good part

A bit of Science - the "how does it really work" bit:
our brains build models of the external and internal world.
You could say that we have a virtual reality generator inside our heads that tries to anticipate the consequences of action (it's own and others).

Watch a puma or some other fast predator in the act of catching prey:
the puma's brain has to factor in speed (it's own and that of the prey), anticipate the course the prey is likely to take so it can plot an intercept course (this bit is like Star Trek) ;-), factor in the weight of the prey (!) - otherwise the moment the Puma catches it it is thrown off balance, open the jaws just so - not to wide or it takes to long to close them - nor too little or you catch nothing at all.
Pretty complex huh?!

If the brain of a predator had to start from scratch every time the hunt is on it wouldn't be able to catch anything at all.
Decisions have to be made instantaneously - speed is of the essence. The same goes for the prey by the way - without the jaw thing of course. ;-)



So how does a brain build a model of the world and the body?

Well - watch any toddler sitting at a desk - there comes a time during development when they start throwing things off the table - over and over again. They aren't called little scientists for nothing - throwing things is their way of learning about gravity. By throwing something off the table and hear it hit the floor beneath they learn that gravity is a constant and they are able to measure it's effect because the relation between the time it takes to hit the floor they can estimate the speed an object has.

There are literally hundreds of different experiments you can see going on during the first year of life - the visual tracking of objects for example. Infants - even when just a month old - learn that things in motion usually follow a steady course. That's why they are able to follow a point of light or an object on it's path even when the object is hidden from view for a short time. This truly is amazing stuff!

Again nature and nurture are at work here: the neuronal structures are laid down automatically - it's hardwired into our genome to develop these skills - but nurture "exercises" and strengthens these connections.

If you don't have the right environment present at the right time severe deficits turn up - as in the case of cats who couldn't move and were thus blind. Vision is dependent on movement - otherwise the brain can't make sense of the electrical signals coming in from the retina.

Not only does our brain contain models of the external world (physics, gravity, acceleration, ...) - but it also contains a body schema by having maps of the body surface all over the place.

The most important (and accessible) maps of the body are in an area called S1 - the Somatosensory Cortex - which is the funky way of saying "piece of brain that receives input from the outer body shell - skin".

And it is these maps that other parts of the brain use to run the virtual reality program - they are the basic building block of our sensory perceptions - or pre-perceptions as it were.

Say your brain wants to know how it would feel if you were to lift the arm straight up.
It doesn't send an actual motor command to do this - it runs an internal virtual reality simulation of you lifting the arm. It even anticipates the sensory feedback it would get from the receptors in your joints and muscles about you lifting your arm. These anticipatory sensory events are called pre-sensations.

The brain relies so much on these pre-sensations that it often acts on them instead on what really is happening. "Online" sensory feedback is only checked once in a while as it were. I will do a series on this some other time because it's such an important concept in treating chronic pain.

That way the brain can do every movement possible without you actually having to do anything in real life. This saves huge amounts of energy and time. Like in the example of the predator catching prey, saving time is a key function of our brains.

Again - nature and nurture: maps are hardwired - experience during childhood refine the maps (think babies sticking their feet into their mouths).

The big finding over the past decade or so has been that these maps are plastic and change constantly (within certain genetic boundaries).
If you use one part of your body more often the part of the map that corresponds is getting bigger - think violinists. One of their hand maps is huge.
If they stop playing the maps shrink again.
This has been shown for other forms of practiced movements too - juggling for example.
We have finally found one physical correlate of the motor skill learning process.

Even meditation - "just thinking" - is able to change your brain. Specific areas show remarkable differences between trained and untrained persons. This should convince even the greatest skeptics that the virtual reality simulation inside our brains is much more than a simple simulation - it actually is what the brain sees as being the real thing - a weakness that we can - among others - exploit in treating chronic pain.

Mirror Box Therapy - Part I

As stated in this posting Mirror Box Treatment was first described by V.S. Ramachandran and colleagues in 1995.

As always in the Sciences he built on the work that was done before him - he just happened to connect the dots. ;-)
There are some indications that even back in the 1920's or 1930's there was a German scientist who thought along these lines - but never followed through. Imagine how different the treatment of chronic pain syndromes would've been during the past 70 years if they'd started back then!

So how does it work?
Say you have one affected limb - be it that the limb was amputated or you are suffering from CRPS.
You put a mirror in front of you - put the affected limb behind the mirror so that it is hidden from view - the other one goes on front - and you start moving both in the same fashion.

>

You of course know that the limb that you see in the mirror is just a reflection of the healthy one - but your brain can't.
Vision is a very useful but notoriously unreliable sense. Just look at any visual illusion to see how easy it is to fool the eyes/brain.
This is one of the best illusions ever: rotating spiral.

After staring at the spiral for about 20-30 seconds look at the back of your hand!
Even if you know that there cannot possibly be movement there you will still see something crawling under your skin - your brain gives you the illusion of movement.
There is no way you can override this illusion. Consciousness - like it or not - is just a bag of tricks.

The brain thinks that the limb in the mirror is perfectly alright (even when in reality you lost it through an amputation) - sensory-motor congruence is re-established and the brain stops sending warning messages to higher centers of the brain - what we call "pain".
Somatosensory maps are re-modeled (which happens very quickly) - and the pain is gone (forever).
This is one the key points of this type of treatment: it actually changes the very structure of your brain! (Flor, H.; M. Diers & C. Christmann et al. (2006), "Mirror illusions of phantom hand movements. Brain activity mapped by fMRI", NeuroImage 31: S159)

This type of treatment has been tested over and over again - most recently at the Walter Reed Medical Hospital - and success rates are well beyond 80% - some even report numbers as high as 95%.
All that with a treatment method that costs a maximum of 20 Dollars and only takes a few weeks.
There simply is no easier way to treat these conditions.
And the best thing: you can do it yourself!

There are a few commercial suppliers of so called mirror boxes - all favor a different approach: some are collapsible, one here in Germany favors an occupational therapy approach so you can do more difficult hand functions, ....
Fact is: it's the basic principle behind the treatment thats key - by providing (visual) feedback.

How about bilateral problems?
Well - back in March of 2003 I proposed (on the Yahoo Group Supertraining, Message 29357) that the same principle could be applied to paraplegics who often suffer from central pain. The part of the body below the spinal lesion is often felt as being very painful. I proposed to put a mirror on top of a TV set so that the brain sees the reflection of the upper body - and have a video tape show a couple of legs walking. That way the brain might be fooled into thinking that the legs are able to move and the pain should be gone.

I didn't have the resources back then to do this experiment myself - so I described it to Dr. Mel Siff whose wife is paraplegic. Unfortunately before I could describe to them how to set up the experiment Dr. Siff died and the whole enterprise came to a stop.

Enter Lorimer Moseley - the genius from Australia and one the most incredible thinkers and teachers you can imagine - and his study he published in "Pain" in 2007. He actually did what I was thinking about in 2003.
And it gives me great pleasure to say: of course it worked!

This is what I want you to recognize: don't ever ever ever - not in your job, in life or - as in my case physiotherapy (and photography) - let yourself become stuck in thinking in techniques and applications - start thinking in principles.
That way you are able to adjust what you know according to the circumstances.

The same here: it doesn't matter if you have chronic pain in a limb or in the lower back - feedback is the key. You can't see your lower back - visual feedback is out of the question - so use tactile feedback which works just as well as Herta Flor (another genius) has proven.
If you become stuck in specifics you can't treat LBP because you are thinking that is has to be visual; thinking in principles of "just give feedback" enables you to do so much more.

As for the how to - here are a few pointers:

1) concentrate - by paying attention to what you see and feel you tell the brain that something important is going on

2) 10-15 minutes at a time: you really can't concentrate any longer. Try several sessions a day.

3) Vary the movements - pick up objects, do meaningful stuff

4) take your time - there's no advantage in rushing this

5) one session before bed-time. Sleeping helps with memory consolidation and learning new things (in this case it might "only" be re-learning old things) ;-)

6) and please change your thinking about what medicine is supposed to be and have a close look at what you expect from the medical services - by doing this we'll all be better off in the future.

7) don't let yourself be discouraged to give this type of treatment a try even when "medical professionals" tell you differently. The problems here are that a) most don't know about it and it is easier to say no to a new type of treatment than to take the time to learn about it and b) we medical professionals have shaped our own expectations of what constitutes treatment based on high-tech and other modalities and have often lost sight of what else is possible. We have to realize that it isn't we that heal a person - we are often only there to help a person heal himself - just managing the whole process. The medical field needs to acknowledge this more often I think.

8) at last: try it and share your experiences. Email and comments are always welcome because they provide me with important feedback (see!) ;-) so that I can update my thinking, learn and share it with others to help even more people.

9) be playful. Understand the principle (by reading this series) ;-) and find out how it works best for you.

Here's a short video - kind of a case study so that you can see the effect mirror therapy can have on improving range of motion:

Thanks

I was invited to do a posting for the monthly pain blog carnival over at howtocopewithpain.org - the topic being thankfulness.
What better way to do this than with this great video:



First of all I want to thank all the scientists who ever lived who allowed themselves to think about things creatively and who didn't care what others thought at the time.

This goes back hundreds of years - among many others to Dr. John Snow who charted the deaths caused by Cholera in London in the 19th century and was able to solve the problem by identifying the causes, to James Lind who found the cure for scurvy - even if no one believed him, to Ignaz Semmelweis who found that washing your hands before childbirth saved lives.

There are hundreds more that should be included in this list - heroes that often nobody has heard of - forgotten by history. But it was they who enabled us to live the way we do - and we should never forget that.

You have to realize that a lot of these people suffered enormously during their lifetime because what they said didn't happen to be the accepted wisdom of the day.
Some went crazy, some killed themselves - but despite that they never stopped telling the truth.

One guy - Werner Forssmann - who later got a Nobel - was fired because he proved (on himself as a guinea pig) that you could put a catheter into your own heart. This technique has saved hundreds of thousands of lives! Imagine people like him keeping quiet about it and watching out for their own welfare - imagine where we would be now - still living in caves waiting for lightning to strike a tree so we could have fire. ;-)

"Big Science" is like Big business - a tough world to live and work in.
And only the courage of creative individuals keeps us going.
My heartfelt thanks to them.

My second round of thanks goes to the Organizers of the TED conferences for putting the amazing talks online.
Never before in my life have I seen so much talent gathered in one place. Every talk is a piece of art. I have no idea about marine biology - but when I watched the talk by Tierney Thys i was deeply moved. I just love watching poeple being passionate about what they do - it reminds me of myself. ;-)

Is there a thing more beautiful than watching someone talk about his or her work - in the process inspiring others?

I don't think so. You just can feel that these people want to do what they do - even if they weren't paid to do so. I wish everyone could experience the satisfaction you can have if you really love your job or your hobby.

Other great - must watch talks are:
- Sir Ken Robinson on education
- Hans Rosling on the developing world
- Dan Gilbert on Happiness
- Robert Fischell on Migraines
- Dean Kamen: watch a genius at work

My thanks also goes to BMW for sponsoring the talks - Bandwidth ain't cheap. ;-)

And now for some special thanks to the person who has influenced my work and my thinking more than anyone else on the planet:
V.S. Ramachandran.

He wrote a book (actually Sandra Blakeslee did - a gifted science writer) - called Phantoms in the Brain - that is still one of the best books about neuroscience out there.

After reading that book in about 2000/2001 I was hooked. The cases he described were just too weird to be true - but as it turned out it's even weirder than we can imagine.

In this talk he gives the example of Capgras Syndrome, Phantom Limb Pain and Synaesthesia.

You can also listen to his 2003 Reith Lectures covering much of the same material.
That's one the things I like about his talk: it's the same stuff he has covered over the past few years - there really is not much new material - but it is also the most succinct version of the issues involved that you can imagine.

Everything you need to know about the neuroscience of the self and pain is contained in that talk. It is the best starting point for your own exploration imaginable.

Starting at 13 minutes into the talk he introduces the biggest breakthrough in treating chronic pain syndromes ever: mirror box therapy.
I especially like the way that he clearly states that it doesn't have to be "high-tech" or expensive to work - but that the treatment is based on solid science. If you are able to exploit the weaknesses of our brain and our senses - go for it any way you like.
I cannot stress enough how important this is!

The medical establishment has - knowingly or unknowingly - created the expectation that big problems require big (and expensive) solutions. An MRI scanner costs millions of dollars and quite a bit of space. It's impressive just to look at - but don't let that fool you into thinking it'll help you one bit.

Yet this exaggerated reliance on for example imaging technology has created expectations that the health care providers are not able to keep up with - costs are going through the roof as more and more people get older and older.
We need to tone treatment down a little - find a new balance between too much and too little.

Mirror Box Therapy has none of the trappings of high tech medicine - yet it is incredibly effective.

And what's even better - it puts treatment back into the hands of the patients!
That's right - you are finally able to treat yourself again.