If learning is not in your body, you haven’t learned it… Those who believe that the mind trains the body have it backwards, it is the body that trains the mind.
(Jensen E.) (Footnote: Jensen, E. (2000). Teaching with the body in mind. The Brain Sore, San Diego, CA. )

Ever since Alois Alzheimer first described the disorder that bears his name, researchers are on a quest to find the cure and stop the rampage of this decimating illness. The syndrome characteristic to Alzheimer's and other neurodegenerative diseases is commonly referred to as Dementia. Dementia is, therefore, a group of symptoms specific to illneses which cause irreversible decline of cognitive functions. These brain deseases can affect memory, language, orientation, visual-spatial processing, attention, judgement, planning, behaviour, emotional control and personality. Neurodegenerative diseases are also called “progressive diseases”, due to their irreversibility. Dementia is commonly associated with Alzheimer’s disease which is accounting for 50-75% of cases (ABS, 2015) and it occurs most commonly in the elderly. According to Australian Bureau of Statistics there are 342,800 people living with dementia (2015) in Australia and the number is expected to grow.

The causes of neurodegenerative diseases, including Alzheimer's, remain a mystery. Despite decades of research, Alzheimer’s disease remains largely untreatable and incurable; even with billions of dollars invested and more than 200 anti-Alzheimer’s drugs developed no major breakthrough in its treatment had been developed. All current drugs are oriented on treating symptoms and have only modest effects. The hope is that any breakthrough in understanding Alzheimer's will help us understand all other major neurodegenerative diseases.

What research tells us, so far, is that there are two toxic proteins involved in Alzheimer’s – amyloid and tau, with amyloid being the trigger and tau doing the most of the damage (Footnote: Vanderstichele, H., Bibl, M., Engelborghs, S., Le Bastard, N., Lewczuk, P., Molinuevo, J.L., Parnetti, L., Perret-Liaudet, A., Shaw, L. M.,Teunissen, C., Wouters, D., & Belnnow, K. (2012). Standardization of preanalytical aspects of cerebrospinal fluid biomarkertesting for Alzheimer’s disease diagnosis: A consensus paper from theAlzheimer’s Biomarkers Standardization Initiative. Alzheimer’s & Dementia, 8, (65–73.). ). Over time these proteins build up in the brain – initially in the medial temporal lobes and then in other brain regions. The human brain can tolerate a certain amount of amyloid, but once tau is activated the symptoms of Alzheimer’s start to appear. Presence of beta amyloid (markers for Alzheimers) in spinal fluid, in combination with mental status exam, may be used to increase the accuracy of a diagnosis. However, there are many factors that influence the onset and development of this disease. Research suggests that complex interactions take place, with many factors influencing its development; from relations between amyloids and the sleep disturbances (Footnote: Holth, J K., Fritschi, S. K., Wang, C., Pedersen, N. P., Cirrito, J. R., & Mahan, T. E. Finn, M. B. Manis, M., Geerling, J. C., Fuller, P. M., Lucey, B. P., & Holtzman, D. M. (2019). The sleep-wake cycle regulates brain interstitial fluid tau in mice and CSF tau in humans. Science, 363 (6429), 880-884.); Noble, W., & Spires-Jones, T.L. (2019) Sleep well to slow Alzheimer's progression? Science, 363 (6429), 813-814. ), to association between estrogen and dementia (Footnote: Lobo, R. A., Davis, S. R., De Villiers, T. J., Gompel, A., Henderson, V.W., Hodis, H. N., Lumsden, M. A., Mack, W. J., Shapiro, S., & Baber, R. J. (2013). Prevention of diseases after menopause. Climacteric, 17(5): 540-556. ) , or evidence of relation between metal toxicity and inflammation (Footnote: Huat, T. J., Camats-Perna, J., Newcombe, E. A., Valmas, N., Kitazawa, M., & Medeiros, R. (2019). Metal Toxicity Links to Alzheimer's Disease and Neuroinflammation. J Mol Biol, 431(9):1843-1868 ). Some research provide stronger evidence than others, and sometimes these studies could even be contradictory, as Maki and Henderson study show, contrary to belief, giving women estrogen with progestin (Prempo) would increase their risk of Alzheimer’s disease. (Footnote: Maki, P. M. & Henderson, V. W. (2012). Hormone therapy, dementia, and cognition: the Women's Health Initiative ten years on. Climacteric, 15(3): 256–262. )

However, what we now do understand is that our gene-inherited tendencies may reveal our vulnerability towards certain diseases but it is the gene-environment interactions which determines their onset. Beneficial factors, such as mental and social involvement when integrated with physical activity can decrease the rate of cognitive decline in someone with dementia and improve their quality of life dramatically. Our brains are so plastic that even everyday same practices produce slightly different neural connections. This brain’s ability to change itself through creation of new and strengthening of already existing neural pathways is called neuroplasticity. In rehabilitation after stroke procedure, it is demonstrated that environmental influences (CI Therapy) can cause plastic change in the injured brain (Footnote: Taub E., Uswatte G., Pidikiti R. (1999). Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation—a clinical review. Journal of Rehabilitation Research and Development, 36: 237–251. ) It seems that the best cure may be achieved by prevention. Deseases that cause dementia begin many years before any symptoms become apparent. We do know that being aware and attentive, active, mentally and socially engaged helps with the prevention of many neurodegenerative diseases and may even slow their progression.

Art as a way of retaining cognitive capabilities

Nowadays some of the more successful artists do not even produce their own work themselves. They have an army of elves doing the "production”. In history of Western metaphysics concept was traditionally separated from physical action. By following same tradition contemporary fine art students are, even at universities, encouraged to write about what they would do in "conceptual" terms where the planning is often the end in itself. However, what would be the point of artistic endeavour when a mounting research, from different scientific fields, demonstrates that the real benefits of artistic activity come from the artistic creative process defined by the physical action itself? (Footnote: Tyler, C. W., & Likova, L. T. (2012); Cheney, 2017; Schlegelet al., 2014; Marois & Fougnile, 2009; Cisek & Kalaska, 2005.)

Here, however, we shall not dwell on the mysterious depths of art, nor shall we discuss the fundamentals of what constitutes art. In this instance, we shall consider the benefits of an artistic process from a neurological point of view. More specifically, the benefits of what is considered as a traditional, representative visual art practice - drawing, in relation to therapeutical treatments of many neurodegenerative diseases.

In our time many would argue that, due to the fact that representational art is concerned with appearances it, apparently, lacks the depth of modern art which is concerned with ideas. As such it is habitually diminished in the eyes of the artworld due to its imperative of copying reality or relation to "just" gaining the skill of copying reality. The popular assumption is that representational art is forever entrapped into competing battle with photography, while, in fact, anyone who has ever drawn or painted anything knows that the process of art, even the one we call representative art, has nothing to do with the ability to recreate more or less accurate illusions of reality.

Drawing as Neuroplastic Awareness Drawing Therapy

In his famous 1871 lecture, Helmholtz, a German physicist, emphasised two capabilities of artists: advanced observational capabilities and enhanced memory for the observed images. While the ?rst part of his claim is often mentioned, the second, memory related, has been widely neglected.

Drawing, nowadays almost forgotten as an artistic medium, may seem simple but is an extremely complex activity that requires harmonisation of multiple brain mechanisms, such as perceptual processing, memory, precise motor planning and motor control, spatial transformations, emotion control, and involvement, among many other high cognitive functions (Footnote: Schlegel, A., Alexander, P., Fogelson, S. V., Li, X., Lu, Z., Kohler, P. J., Riley, E., Tse, U., & Meng, M. (2014). The artist emerges: Visual art learning alters neural structure and function. NeuroImage, 105: 410-451.) We know that to learn a language we need to follow and adopt certain rules to acquire it; It is similar with music and visual arts. By learning how to draw we are learning the rules of the medium and aquiring specific skills. Working memory and attention are two central pillars of cognition. Drawing reveals concurrent visual-motor selections, as it engages visual and motor brain areas at the same time. Items in visual working memory can invoke multiple, item-specific, action plans to be accessed while visual representations is assuring the guided behaviour. Praxis is the ability to perform meaningful or coordinated movements under voluntary control, which involves left parietal lobe, the one which is often effected by Alzheimer’s disease. (Footnote: Arbib, M. A. (2006). Aphasia, apraxia and the evolution of the language-ready brain. Aphasiology, 20(9-11): 1125-1155.). Patients can understand what they should do but are not able to initiate action (Kawai, Y., Midorikawa, A., Sugimoto, A., Futamura, A., Sobue, G., & Kawamura, M. A. (2013). A new disorder of praxis in neurodegenerative disease that may be part of Alzheimer's disease. Neurocase, 19(4): 408-15.)

Some studies suggest that a simple tool use, such as a stick as an extension of limb movements, involves sensorimotor integration in the dorsal stream of visual processing for action control (Footnote: Arbib, M., Bonaiuto, J., Jacobs, S., & Frey, S. (2009). Tool use and the distalization of the end-effector. Psychological Research, 73(4): 441-62.)On the other hand, complex tool use involves a modification of hand movements into new motor actions; therefore, requiring the semantic knowledge about the tool and its function, which implies the role of ventral stream, mostly neural networks in the left temporal, frontal and parietal cortices (Footnote: Hodges, J. R., Bozeat, S., Lambon Ralph, M. A., & Patterson, K. (2000). The role of conceptual knowledge in object use - Evidence from semantic dementia. Brain 123(9): 1913-25.) Hodges and collegues demonstrated that patients with semantic dementia function well in everyday life and sometimes show striking preservation of the ability to use objects suggesting the interconnectivity between gesture, movement planning and semantic knowledge. Furthermore, many studies that combine visual or gesture (drawing) with verbal treatment showed significant effectiveness (Footnote: Farias, D., Davis, C., & Harrington, G. S. (2006). Drawing: Its contribution to naming in aphasia, Brain and Language, 97(1): 53-63.)

Drawing is not just any physical activity, even though any physical activity has been proven to be beneficial in treatments for many diseases. To use a pencil as a tool and to engage in drawing demands: awareness of movements, direction, concentration, planning and implementation and so much more. The process of sensory analysis of the world involves mental processing and presents available action opportunities. Decision-making, underlying voluntary behaviour, can then be viewed as the process of selection of motor options that will be executed (Fig.2.).

As Cisek and Kalaska note, eye connects perceptual, decisional, and motor processes, and we can assume similar association exist for the arm, whose main role is physical interaction with the world (Footnote: Cisek, P. & Kalaska, J. F. (2010), Neural Mechanisms for Interacting with a World Full of Action Choices. The Annual Review of Neuroscience, 3: 269–98) Studies of tactile perceptual decisions suggest a similar functional architecture for the limb motor system (Footnote: Romo, R., Hernández, A., & Zainos, A. (2004). Neuronal correlates of a perceptual decision in ventral premotor cortex. Neuron, 41(1): 165-73) Schelegel and colleagues (2014) conducted a study in which they investigated differences between art students and students who did not study art in relation to creative cognition, perception and perception to action. They found that art students’ creativity was proliferated through the reorganisation of prefrontal white matter. Furthermore, sketching from observation involved multivariate patterns of cortical and cerebellar activity in art students most prominently (Fig.3.). Plasticity in neural pathways that enable creative cognition and mediate perceptuomotor integration supported and was highly correlated with the appearance of these visual artistic skills.

From Visual Imput to Affirming Neural Pathways

As optic nerve leaves the eyeball, it carries the information to the various sites in the brain. Most of the fibres go first to lateral geniculate nucleus (LGN) in the thalamus, and from there information is transmitted to the primary projection area for vision, in the occipital lobe. Most astonishingly, the cells that link retina to the brain are already involved in the process of analysing the visual input. Further, LGN reaches to other parts of the brain, such as many areas of the occipital lobe (V1,V2,V3,V4, PO and MT) but also parietal cortex and inferotemporal cortex, with each of them having their own differentiated functions. This brain specialisation allows parallel processing (different steps of visual processing going at the same time). Within optic nerve itself, two types of cells are distinguished, - P cells and M cells. P cells are specialised for spatial analysis and detailed analysis of form. M cells – for detection of motion and perception of depth. From the occipital lobe signal is transmitted to the cortex of the temporal lobe. This pathway (referred to as - What system) is used for identification of objects. Second pathway carries information to the parietal cortex (Where system) and guides our action based on our perception.

Patients with damaged occipital- temporal pathway often manifest visual agnosia – inability to recognise visually presented objects but have no problem in recognising visual orientation; while those who suffer from damage to occipital-parietal pathway have difficulty in detecting motion but not in identifying objects. Visual attention is a process of selection and is significantly related to memory. Early hypothesis suggests that things we do not consider important we fail to process from the start. Late hypothesis, on the hand, indicates that all input is analysed but just attended is remembered. Some research demonstrate that attended input was privileged from the very start (Footnote: Carrasco, M., Ling, S., & Reed, S. (2004). Attention alters appearance. Nature Neuroscience, 7(3): 308-13.) Furthermore, attention and awareness modulates neural pathways even as early as it reaches LGN, hence, attention changes our memory but it also literally changes our perception (Footnote: Yantis, S. (2008). The Neural Basis of Selective Attention: Cortical Sources and Targets of Attentional Modulation. Sage Journal, 17(2): 86-90.)

Body Knowledge - Cognitive Kinaesthetic Therapy, CI (Constraint Induced Movement) Therapy

In recent years, there has been a push to understand how movement affects cognitive functioning. Jensen presented multiple reasons for why movement has an influence on cognitive function. (Footnote: Jensen, E. (2005). Teaching with the Brain in Mind, (2nd Ed), Ch 4, Nov 2. 2015. Alexandria: ASCD2005.) As we have mentioned before, brain regions are extremely interrelated. Areas of the brain that control both gross and fine motor skills include the cerebral cortex, basal ganglia, and cerebellum. The cerebral cortex controls the movements of the muscles, while the basal ganglia control position and voluntary movement. Anatomically, the area of the brain associated with motor coordination is the cerebellum. It monitors muscles during movement but is also involved in memory, attention, and spatial perception suggesting a link between cognitive functioning and movement.

Jensen (2005) demonstrated that there is a functional evidence which shows improvement of cognitive functioning through movement. Enhanced blood flow due to increased movement escalates the amount of oxygen being delivered to the brain, influencing higher cognitive abilities and affecting attention. Furthemore, Eliassen, Souza and Sanes demonstrated an increased activation in the brain during movement while investigating explicit learning mechanism. (Footnote: Eliassen, J. C., Souza, T., & Sanez, J. N. (2001). Human Brain Activation accompanying explicitly directed movement sequence learning. Experimental Brain Research, 141: 269-280.) As Jensen has eloquently summarised: “ If learning is not in your body, you haven’t learned it… Those who believe that the mind trains the body have it backwards, it is the body that trains the mind” (Footnote: Jensen, E. (2000). Teaching with the body in mind. The Brain Sore, San Diego, CA.)

Having the object in front of your eyes or in your thoughts alone will not improve your memory. Learning is not a passive process. Our visual memory, motor skills and cognition are dependent on interrelation of different brain regions. Awareness, the intention to memorise, activity we chose in order to personalise the information, together with rehearsal, leads to deep processing. Visual memory evolves through connections between nerve cells and builds memory connections that serve as retrieval paths, which in return helps us improve memory in general and retain brain plasticity well into old age.

Therefore, drawing presents a unique activity that integrates different brain regions and enhances perceptual, cognitive, and motor abilities. It may look like a passive activity but its physicality is very specific. Life drawing is particularly demanding. It involves looking at objects in the world and then presenting them graphically (visual realism or view-based depiction). Furthermore, drawing strengthens the resolve and feelings of achievement, as its exercises do not only rely upon “enjoyment of creative action” alone, where everything is “equally beautiful”, although it may be true. The emphasis is on achieving a certain set of skills, which are not easy to gain, and on awareness of each movement presented as a possibility. Planning, implementation, coordination, memory and focus are, among many, important factors, which make these drawing extremely useful activity in the fight against cognitive decline.

People who suffer from neurodegenerative diseases are often not willing to engage with their environment. They feel ostracised and with little hope to ever contribute to community. There are not enough places for them to challenge themselves or have any possibility of improvement. Equaly, there are not enough places for their carers or those who are willing to do all they can to prevent the onset of neurodegenerative diseases. Therefore, there is a growing interest in developing tailored non-pharmacological strategies.

Our aim is to help individuals in delaying and preventing the onset of neurodegenerative diseases by devising appropriate treatments and doing lifestyle interventions which may reduce the impact (and delay the onset), but also those who are already affected to continue to actively participate in their living environments.