Prevention & Recovery

Brain health: What women need to know

By: Mark Witten

Photo courtesy of Masterfile Author: Canadian Living Credits: Photo courtesy of Masterfile

Prevention & Recovery

Brain health: What women need to know

By: Mark Witten
In July 2009, 52-year-old Connie Cardoso was at home with pneumonia when her husband, Danny, realized something was very wrong. While they were watching TV together, he noticed she wasn't breathing properly and called 911.

By the time the ambulance arrived, she had lost consciousness. It was more than just a lung infection—Connie had suffered a stroke. She woke up the next morning at Toronto Western Hospital and realized she couldn't move her left arm. "It was devastating for me when the movement on my left side didn't come back on its own," she says. Her doctors also told her she had a clot in her brain, which is still there to this day.

But despite her scary prognosis, Connie's motivation was clear: She wanted to be healthy enough to attend her son's wedding later that summer. She reached her first milestone through intensive inpatient rehab immediately after the stroke. "I went to my son's wedding in a wheelchair on August 29 with a private nurse," says Connie, now 57.

Since 2010, Connie has benefited from the community-based exercise program Together in Movement and Exercise (TIME), which has enhanced her recovery after discharge from rehabilitation. "With certain exercises, I put weight on the weak side to get the muscles to connect back to the brain," says Connie. "I've gained better balance and confidence, and improved my walking. The more I exercise, the better I feel."

What is neuroplasticity
Connie's progress is not an exception to the rule. Scientists once believed the brain was hardwired in infancy and childhood, and that, after these critical years, no new brain cells could form. Damage to the brain from stroke or injury would have life-altering effects, and the brain would never work the same way.

Well, it turns out they were wrong. New research on the brain's capacity to continue to change and make new cells and connections is leading to promising and practical 
evidence-based strategies to improve, maintain or restore brain health. The concept is known as neuroplasticity, the brain's extraordinary ability to reorganize itself by sprouting new connections between nerve cells and giving birth to cells in critical brain regions, such as the hippocampus, which is involved in forming, organizing and storing memories. After 12 months of moderate-intensity aerobic exercise three times per week, the memory region of your brain (which normally shrinks with aging or a memory condition) may be amenable to change.

This new knowledge has huge implications for women's brain health. Women are more susceptible to disabling brain conditions such as Alzheimer's disease, and research suggests that women are vulnerable to memory loss during menopause. Small-vessel disease, which causes silent strokes and reduces blood supply in the brain, is also more prevalent among women. Finally, women seem to have more serotonin receptors  
in the brain (suggesting the possibility of less available serotonin, which impacts mood), and they are twice as likely to develop depression, a risk factor for stroke and dementia.

Neuroscientists aren't certain why women are more vulnerable to these brain-disabling conditions, but they have some theories. The loss of estrogen from the body in menopause may be a contributor to worsening memory and increased dementia risk.

Also, a number of stroke risk factors—such as high blood pressure, atrial fibrillation, migraine with aura, depression and emotional stress—tend to be stronger or more common in women than men. Some research suggests that lower lifetime levels of engagement in physical activity and greater frailty (a geriatric measure of overall health) in older women may be another factor.

A growing body of research now shows how the adult brain can and does change after exercise, cognitive and social engagement, electrical stimulation and dietary intervention. Women now have more options and opportunities to maximize brain health. These brain-nurturing strategies will allow women to work proactively with health-care professionals to reduce their risk of stroke or recover more fully from it, live effectively with mild cognitive impairment (MCI) to lessen dementia risk, and function better in daily life with cognitive changes that typically occur with aging.

"Brain plasticity exists, and there is a lot more neuroplasticity than we ever imagined. The brain appears to be changing itself all the time. We should never give up—even when there is severe impairment—in trying to give the best possible interventions and treatments," says Dr. Sandra Black, brain science program research director at Sunnybrook Research Institute and Brill chair in neurology at the University of Toronto.

Muscle-activation therapy
Connie's walking post-stroke has steadily improved, but she hasn't regained the use of her left arm, and her husband still needs to cut up her food and help her dress.

She recently enrolled in a research study at Toronto's Sunnybrook Health Sciences Centre that pairs the use of Botox with an experimental motor-training program called optimal muscle-activation therapy. The Botox treatment loosens and unlocks rigid muscles, so they can be more engaged in movement during muscle-activation therapy.

The therapy is designed to retrain Connie's "awakened" muscles to perform specific tasks. Through repeated use, her muscles learn new activation patterns and her brain forms new connections.

"We're trying to take advantage of the looseness in the muscles from the Botox injections to retrain the muscles of the affected limbs, and changes in the electrical activity patterns in the brain and muscles as a result of the muscle-activation treatment," explains study leader George Mochizuki, a doctor of neuroscience.

One of Connie's training tasks, which are broken into building blocks, is to reach for a coffee cup: lifting her arm off the table, straightening her elbow, opening her hand and unfolding her fingers. She has already noticed more movement in her fingers.

"The Botox is trying to relax muscles that can't function," says Connie. "We're trying to make my triceps work so my arms can reach. If I could do that, I would be able to pick up my grandchildren and play with them. 
I could also crochet, garden and help my husband cook."

As a result of pairing Botox with muscle-activation therapy, Connie was able to gain some movement in her left hand.

Post-stroke exercise training

One morning in May 2008, Sharron Carter wasn't feeling well, so her husband drove her to Toronto's Sunnybrook Hospital. Though she was only 40 years old at the time, she had suffered two previous strokes in her 30s. When she went to sleep at the hospital that night, she felt exhausted. She woke up the next morning to find something had happened overnight.

"I couldn't move my arms and legs. It was very frightening," she says. She'd suffered a stroke that severely affected the left side of her body and caused major weakness in her arm and leg. She could no longer walk.

Like many stroke patients, Sharron underwent standard physical rehabilitation for the first three months post-stroke. She improved somewhat through standard care and was able to walk very slowly with a cane, but had almost no energy.

Luckily, a nurse friend told her about an innovative exercise-based stroke recovery program at the Toronto Rehabilitation Institute/University Health Network. As a participant in the six-month Toronto Rehabilitation Institute-Risk Factor Modification and Exercise Program Following Stroke (or TRI-REPS) program, she followed an exercise prescription 
that included 60 minutes of aerobic 
training and 30 minutes of resistance training five times per week.

Although Sharron began intensive exercise training 
10 months after her stroke, she made big strides forward rather than hitting a plateau after the standard three months of rehab, a traditional time frame given for spontaneous recovery (and when people generally stop improving). "My legs got much stronger, my balance improved and I could eventually walk without a cane," she says.

Along with mobility gains, Sharron also experienced significant cognitive improvements and enjoyed a better quality of life. "After the exercise training, 
I was more alert, had more energy and could think more clearly," she says. 
"I could remember things better when reading a book or talking with my husband and friends. I also had more motivation to go out with my husband on a Saturday night for dinner and have a good conversation with him."

Sharron, now 46, has continued to follow the same daily aerobic- and exercise-training prescription at her local gym.

The neuroscience behind exercise
Throughout rehabilitation, Sharron has contributed to exciting new research findings through her participation in two studies by Susan Marzolini, TRI researcher and exercise physiologist. The studies showed that intensive aerobic  
and resistance training confer a wide range of cognitive, motor and other brain health benefits for patients months and years after a stroke. A 2013 study of 41 patients found that after six months of exercise, the proportion of stroke patients with MCI dropped from 66 percent to 37 percent.

"These results provide compelling evidence that by improving cardiovascular fitness through aerobic exercise and increasing muscle mass through resistance training, stroke survivors can improve their brain health," says Marzolini. "Overall cognition improved, but the specific parameters that improved the most were attention, concentration and executive function."

Marzolini says exercise boosts brain health in several ways. "Aerobic exercise increases blood flow to the brain and a growth factor called BDNF, which supports the growth of new brain cells and connections. Weight training increases a growth factor in the blood called IGF-1, which improves the survival of brain cells. Exercise also has a protective effect by decreasing inflammation in the brain, which causes tissue damage."

In the second study, Marzolini found that after six months of exercise, 120 stroke patients with brain damage, including Sharron, made rapid gains. The participants showed improvement in the strength and range of motion of weakened limbs (22 percent), range of motion of affected/weakened limbs (11 percent), walking speed (19 percent) and the distance they could walk (16 percent). They also reported big social gains and began to attend more activities in their communities. The participants were, on average, two years post-stroke, but the study included people who had experienced a stroke from three months to five years prior to starting the program.

Stroke is the leading cause of long-term neurological disability in Canada. But traditional stroke rehabilitation hasn't included intensive aerobic and resistance training as a supplement, in part due to concerns about patients' physical limitations and safety.

Marzolini has found that in these and earlier studies, exercise-based outpatient cardiac rehab programs can be modified and adapted to safely provide sufficient intensity to benefit patients who have suffered mild or moderate strokes. Because of the disabling effects of stroke, people like Sharron are highly motivated to stick with an exercise-based regimen.

"More than 90 percent of stroke patients complete the program, compared to about 70 percent of cardiac patients," says Marzolini. "They are driven because stroke affects their lives more. They want to get better, and even small gains have a big effect on their lives."

Dealing with memory loss
Anne McAndrew, a retired Seneca College nursing instructor in Toronto, became alarmed when she realized she would turn on the hose in the garden and leave it running overnight. "I was having memory problems and became quite depressed and concerned," says Anne, who started noticing these changes in her mid- to late 70s.

Her husband, Bob, a retired engineering professor, tried to help and correct her when she got her facts confused. "I never let the truth interfere with a good story," says Anne. 
"I made things up, so my husband started correcting me."

Anne was eventually diagnosed with MCI and was referred to Learning the Ropes for Mild Cognitive Impairment, a program at Baycrest Health Sciences in Toronto. There she learned strategies to help improve her memory in everyday life, and Bob found helpful ways to 
support her.

"I have a little notebook, and I write down my impressions of the places I've been and the friends I've met. It's like a personal diary," says Anne, who refers to the notes when she meets with those friends to make socializing and conversing easier.

Anne also regularly uses a memory technique she learned called "see it and say it," designed to help with prospective memory—remembering to do something in the future. The idea is to focus attention on a task by visualizing it, then saying the task out loud, which helps focus Anne's attention even better than saying the words silently to herself. To help remember a planned task, like going to prepare salad in the kitchen, Anne will picture a salad in her mind and then say "salad" aloud. That way she can more easily recall what to do when she arrives in the kitchen.

Anne, along with the 650 other MCI patients who have participated in this innovative program, has received information on the benefits of exercise, social and mental engagement, stress management and a nutritious diet to promote brain health and reduce the risk of dementia. Now 87, she and Bob (who tries hard not to correct her) maintain an active social life. "We enjoy going to live theatre and concerts regularly," says Anne. "At one time, it was just entertainment. Now this is part of my lifestyle and maintaining health."

Dr. Kelly Murphy, a clinical neuropsychologist who leads the program at Baycrest, emphasizes that people with MCI are capable of acquiring new knowledge in order to improve their memory skills. "When people experience success in learning and applying these strategies, they report feeling better about the situation and more in control of their lives," she says. "These people are actively learning, and we know that learning experiences benefit the brain."

Training the brain
The exercise and cognitive strategy prescriptions that are helping women like Sharron, Connie and Anne improve, maintain or restore brain health also offer new hope for women with small-vessel disease in the brain, which happens six to 10 times more often than an acute stroke. There are no proven therapies for this common condition, also known as covert stroke vascular disease (CSVD), which often causes problems in planning, decision-making and speed of thinking, and carries a substantial risk for acute stroke and dementia.

Brad MacIntosh, an imaging scientist at Sunnybrook Health Sciences Centre and at the Canadian Partnership for Stroke Recovery, is leading a new study, Recovery Improved in Covert Stroke With Exercise, to determine whether intensive aerobic exercise can improve the cognitive health and performance in the daily life of people with CSVD.

"My goal is to get covert stroke patients to experience runner's high," says MacIntosh. "We hope to show that, with the increased blood flow from exercise, 
people will be able to use their brains more efficiently, and that exercise treatment will buy them time so that they remain cognitively fit and maintain brain health longer."

Researchers still have a lot to learn about the complexities of the human brain, and how and why it functions the way it does when it comes to both aging and brain injuries. But with every ground-breaking study and innovation, scientific advances are steering medicine off the traditional course when it comes to recovery and rehabilitation—and showing us that the capacity of the mind to change and adapt to its surroundings may have more impact than we could have ever imagined. 

Keep your mind sharp with these seven free ways to boost your brain power.
                                               
This story was originally titled "Brain Changer" in the September 2014 issue.
           
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Prevention & Recovery

Brain health: What women need to know

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