WEBVTT 00:00:00.017 --> 00:00:05.837 So this is Paul for sure with Adrian Owen, one of the speakers in our BCWT summer school. 00:00:06.797 --> 00:00:13.017 And Adrian showed us his latest work, which actually is opening up a whole new 00:00:13.017 --> 00:00:16.537 way on how we think about different kinds of neurological disorders. 00:00:16.857 --> 00:00:22.577 So Adrian, maybe you want to give us the short version of that. Sure. Yeah. 00:00:23.457 --> 00:00:29.597 We've been using fMRI to look at patients who have so-called disorders of consciousness. 00:00:29.597 --> 00:00:33.557 These are things like coma, vegetative state, minimally conscious state. 00:00:34.117 --> 00:00:40.637 And really, our main aim has been to determine whether fMRI, 00:00:40.717 --> 00:00:45.817 and more recently EEG, can be used to detect residual awareness. 00:00:46.117 --> 00:00:51.637 So can we put a patient in a scanner and determine that in spite of the fact 00:00:51.637 --> 00:00:56.717 that they may appear to be vegetative behaviorally, they are in fact aware? 00:00:56.717 --> 00:00:59.337 Aware and we did that a couple of years 00:00:59.337 --> 00:01:02.377 ago now with our first patient we've seen 00:01:02.377 --> 00:01:05.337 four or five patients since then that are 00:01:05.337 --> 00:01:11.137 clearly aware or can be shown to be be aware in the scanner despite having no 00:01:11.137 --> 00:01:16.437 behavioral signs of awareness and i suppose our most recent big result if you 00:01:16.437 --> 00:01:21.837 like is is to to use this method to communicate with somebody who was incapable 00:01:21.837 --> 00:01:24.617 of any form of communication outside of the scanner. 00:01:25.297 --> 00:01:28.557 Technically, this person was in a minimally conscious state. 00:01:28.717 --> 00:01:32.457 It had been assumed for many years that he was in a vegetative state. 00:01:32.597 --> 00:01:38.137 But in the scanner, he was able to answer yes or no questions by modulating his brain activity. 00:01:39.352 --> 00:01:44.092 But now, this is an amazing outcome in some sense, right? 00:01:44.172 --> 00:01:46.172 Because it's also a scary outcome 00:01:46.172 --> 00:01:50.532 because it means we might have been misdiagnosing a lot of these patients. 00:01:50.812 --> 00:01:56.872 But now, in some sense, if you want criticism, which is also often fielded against 00:01:56.872 --> 00:02:01.612 these approaches, it's like, yeah, but I would not even know whether you're 00:02:01.612 --> 00:02:02.852 aware of what I'm just talking to you. 00:02:02.852 --> 00:02:05.752 Because it's a typical zombie argument right where okay at 00:02:05.752 --> 00:02:09.052 the surface it all might look like you're aware 00:02:09.052 --> 00:02:12.852 you're conscious but can i really be sure so so 00:02:12.852 --> 00:02:18.712 how can you really be sure that your patient is minimally aware in a way i think 00:02:18.712 --> 00:02:28.212 this sort of discussion um you know you could say this is held back um work 00:02:28.212 --> 00:02:32.392 in this area i mean what we have with these patients is it's a very simple, 00:02:32.892 --> 00:02:37.392 practical problem, which is that some of them might actually be conscious, 00:02:37.972 --> 00:02:39.652 but unable to tell us that they're conscious. 00:02:39.772 --> 00:02:42.852 Now, by that, I'm not trying to define what consciousness is. 00:02:43.132 --> 00:02:47.592 I'm really just trying to say, well, their world is rather like your world or 00:02:47.592 --> 00:02:50.512 my world, except they can't move. They can't speak. 00:02:50.772 --> 00:02:56.612 They can't blink an eye. So irrespective of what consciousness might be, 00:02:56.632 --> 00:02:58.752 either philosophically or psychologically. 00:02:59.612 --> 00:03:04.552 Their sense of the world, how they feel about themselves, how they feel about 00:03:04.552 --> 00:03:08.172 what they know about what's going on around them, might be similar to yours 00:03:08.172 --> 00:03:11.372 and mine, but they're incapable of demonstrating that fact. 00:03:11.692 --> 00:03:15.152 Now, we know a lot about the locked-in syndrome. 00:03:15.252 --> 00:03:21.112 These are the cases of patients who are able to blink an eye or to move an eyebrow despite being... 00:03:22.382 --> 00:03:28.582 Treatments and despite them being cognitively often perfectly intact. 00:03:29.302 --> 00:03:34.402 So I think it's very probable that there is a sub-population of patients, 00:03:34.542 --> 00:03:37.982 a minority of patients, who are sort of, if you like, totally locked in. 00:03:38.062 --> 00:03:44.062 Again, cognitively intact, conscious, if you like, but unable to blink an eye 00:03:44.062 --> 00:03:48.662 or move an eyebrow or indicate in any way that they're conscious. 00:03:48.662 --> 00:03:56.122 So my concern really is that until now, we have had no practical way of identifying these people. 00:03:56.502 --> 00:04:00.322 I mean, it seems logically certain that they exist, but how, 00:04:00.482 --> 00:04:04.862 if they cannot respond, if they cannot produce some sort of indication that 00:04:04.862 --> 00:04:06.662 they're conscious, how could you ever know they were there? 00:04:06.922 --> 00:04:09.802 So, and this is really what we're trying to find out. 00:04:10.002 --> 00:04:14.002 I think it's actually a next stage to go back to your question is to say, 00:04:14.022 --> 00:04:15.622 well, what is their consciousness like? 00:04:15.742 --> 00:04:19.802 Are they really conscious like we are? At the moment, all we know is, 00:04:19.802 --> 00:04:24.402 you know, what we know is already very surprising, which is that they're not unconscious. 00:04:24.642 --> 00:04:29.182 They're not vegetables. They are, in fact, in some senses, aware of where they 00:04:29.182 --> 00:04:32.722 are, what situation they're in, and perhaps, you know, how they got there. 00:04:32.782 --> 00:04:35.282 And I think, you know, we need to move on from there now. 00:04:37.562 --> 00:04:43.602 But doesn't that imply possibly that maybe the idea of really hanging this on 00:04:43.602 --> 00:04:46.202 this hook of consciousness is maybe a big distractor? 00:04:46.202 --> 00:04:52.042 Because if I listen to you, if I get it right, in some sense, 00:04:52.102 --> 00:04:55.162 you could also argue these are more deficits of, let's say, communication and 00:04:55.162 --> 00:04:59.702 interfacing to the world than necessarily of experience and consciousness. 00:05:00.102 --> 00:05:03.482 Is that a reasonable interpretation? That's absolutely correct. 00:05:03.702 --> 00:05:07.742 And the reason why this gets complicated is because, you know, 00:05:07.762 --> 00:05:09.642 it's not really an all-or-nothing condition. 00:05:09.642 --> 00:05:16.682 Condition, the vegetative state is part of a whole group of different conditions 00:05:16.682 --> 00:05:20.042 that are more or less non-communicative. 00:05:21.627 --> 00:05:24.667 Minimally conscious state these are patients who are perhaps one step 00:05:24.667 --> 00:05:27.667 up from vegetative they are able to at least on 00:05:27.667 --> 00:05:30.887 some occasions indicate that they are aware 00:05:30.887 --> 00:05:33.887 by perhaps moving an arm occasionally or 00:05:33.887 --> 00:05:36.687 moving an eye and but they are not able to 00:05:36.687 --> 00:05:39.907 turn that into any sort of functional communication if 00:05:39.907 --> 00:05:42.727 a patient were able to raise their left arm for 00:05:42.727 --> 00:05:45.947 a yes or their right arm for a no we would conclude they 00:05:45.947 --> 00:05:49.227 were severely disabled probably not minimally conscious 00:05:49.227 --> 00:05:52.727 and so on you have all these different sort of types of conditions and 00:05:52.727 --> 00:05:55.727 in any given clinical situation it's very very 00:05:55.727 --> 00:05:58.447 easy to mix them up you know 00:05:58.447 --> 00:06:01.427 a vegetative patient sorry a minimally conscious patient on 00:06:01.427 --> 00:06:06.207 a bad day might appear to be vegetative and maybe diagnosed as vegetative and 00:06:06.207 --> 00:06:10.267 this obviously can have an impact on their care and an impact on the way people 00:06:10.267 --> 00:06:17.427 respond to them and think about them sometimes for many years so you know it 00:06:17.427 --> 00:06:20.767 may well be that i mean the patients that we are identifying And I think, yes, 00:06:21.127 --> 00:06:22.887 you know, they are not vegetative. 00:06:22.927 --> 00:06:25.727 It's clearly not the right description of these people. 00:06:25.867 --> 00:06:31.527 They have some form of communication disorder, they are, or responsivity disorder, I suppose. 00:06:31.767 --> 00:06:36.667 And actually, sometimes we now describe them as non-responsive patients rather 00:06:36.667 --> 00:06:42.047 than vegetative patients, because that is an assumption that is, 00:06:42.087 --> 00:06:45.427 you know, I think, based on flawed logic. Right. 00:06:45.907 --> 00:06:51.967 So in some sense, this might also then explain some of the criticisms against, 00:06:52.067 --> 00:06:56.747 for instance, this 2007 science paper where this main result came out, 00:06:56.787 --> 00:06:57.927 where also people would argue, well. 00:06:58.607 --> 00:07:04.407 This could just be, let's say, reflex-like automatic responses in the absence of experience. 00:07:04.607 --> 00:07:07.807 But in some sense, you could not say yes, but in some... 00:07:08.510 --> 00:07:11.570 Maybe that doesn't actually really matter because what we want to provide are 00:07:11.570 --> 00:07:16.330 then these new communication channels to also improve quality of life and quality 00:07:16.330 --> 00:07:17.790 of care for these patients. 00:07:18.030 --> 00:07:23.550 And this whole question about now this additional phenomenon of consciousness is really secondary. 00:07:23.610 --> 00:07:26.430 Is that a reasonable way of summarizing your approach? 00:07:26.630 --> 00:07:30.690 Yeah, I mean, in that sense, I think you're right that worrying too much about 00:07:30.690 --> 00:07:33.670 what consciousness is can be a distraction in that context. 00:07:33.670 --> 00:07:39.310 For example, to be able to build a brain-computer interface that would allow 00:07:39.310 --> 00:07:44.550 a patient who everybody else thought was vegetative and behaviorally appears 00:07:44.550 --> 00:07:46.430 to be entirely non-responsive, 00:07:46.450 --> 00:07:51.130 if our brain-computer interface of the future would allow that person to have 00:07:51.130 --> 00:07:54.570 a normal interaction with their family members, 00:07:54.830 --> 00:07:59.810 honestly, I don't really care whether we believe that person is conscious or 00:07:59.810 --> 00:08:04.650 not, or whether I have the scientific evidence to prove that they are conscious or not. 00:08:04.750 --> 00:08:08.170 If they are able to communicate with their family, then that's good enough for me. 00:08:09.150 --> 00:08:14.310 Absolutely. Sure, I can see that. But now, right now, technically, 00:08:14.610 --> 00:08:18.710 it's a bit of cumbersome technology. This is not something you're going to do at home. 00:08:19.630 --> 00:08:23.550 So what's the future of this? Do you see this as a portable diagnostic system 00:08:23.550 --> 00:08:25.390 somewhere down the line? I do. 00:08:25.530 --> 00:08:30.270 And I think it's not as far down the line as we might all think. 00:08:31.190 --> 00:08:35.010 We have recently, and I didn't talk about this in my talk today, 00:08:35.110 --> 00:08:41.610 but we've recently been exploring ways of transferring the fMRI technology to 00:08:41.610 --> 00:08:45.130 EEG. Now, obviously, EEG is cheaper. It's more portable. 00:08:45.790 --> 00:08:51.690 In some senses, it's easier to do. It has many problems in this patient population. 00:08:52.330 --> 00:08:57.730 One of the problems is to do with the brain damage. EEG systems work very well 00:08:57.730 --> 00:08:59.830 with brain-shaped brains. 00:09:00.150 --> 00:09:04.170 As soon as your brain is not brain-shaped, and that is often the case in a patient 00:09:04.170 --> 00:09:07.410 who's had a traumatic brain injury, has been involved in a car accident, 00:09:07.470 --> 00:09:12.110 for example, EEG models have a lot of problems localizing signal. 00:09:12.670 --> 00:09:18.030 So that's a big problem. Also, for your EEG model to work effectively, 00:09:18.190 --> 00:09:20.170 you really need to have a skull. 00:09:20.290 --> 00:09:22.890 And many of our patients have parts of their skulls missing. 00:09:23.070 --> 00:09:28.170 This is part of the surgical procedure involved in saving their lives. 00:09:28.550 --> 00:09:31.770 And this can cause all sorts of artifacts on the EEG. 00:09:32.250 --> 00:09:38.590 The other thing that I think is powerful by its simplicity in the fMRI is that 00:09:38.930 --> 00:09:41.270 is to do with the anatomical localization. 00:09:41.330 --> 00:09:47.350 At the end of the day, one of the tasks that we use is to ask the patient to 00:09:47.350 --> 00:09:48.890 imagine playing a game of tennis. 00:09:49.070 --> 00:09:52.710 We look for the characteristic activation in the premotor. 00:09:53.909 --> 00:09:59.549 But really, it doesn't actually matter whether it is in the premotor cortex or not. 00:09:59.709 --> 00:10:03.209 It also doesn't really matter if the premotor cortex, due to the brain injury, 00:10:03.309 --> 00:10:06.149 has been shifted to somewhere that it wasn't previously. 00:10:06.509 --> 00:10:11.849 As long as we can replicate it, and every time we ask the patient to imagine 00:10:11.849 --> 00:10:16.349 this task, that same area of the brain lights up, and it's robust and reliable. 00:10:16.769 --> 00:10:21.349 And we can use that as a communication signal. It's a little harder to do that 00:10:21.349 --> 00:10:26.169 with EEG because we don't have the same level of anatomical precision. 00:10:26.949 --> 00:10:28.569 Saying that, it's doable. 00:10:29.549 --> 00:10:33.729 And I have some people, some postdocs working with me in Cambridge at the moment. 00:10:33.829 --> 00:10:38.709 Damien Cruz presented data at a human brain mapping meeting here in Barcelona 00:10:38.709 --> 00:10:47.549 earlier this year, showing that it is doable with EEG in a patient who is presumed to be vegetative. 00:10:47.549 --> 00:10:50.949 Vegetative now there it doesn't we change the task slightly we don't have them 00:10:50.949 --> 00:10:55.169 imagining playing tennis we have them squeezing their imagine squeezing toes 00:10:55.169 --> 00:11:00.409 or imagine squeezing the right hand and this produces enough information to 00:11:00.409 --> 00:11:02.949 be able to decode the eg signal to. 00:11:04.169 --> 00:11:09.589 Determine whether the patient is signaling a yes or signaling a no now you know 00:11:09.589 --> 00:11:13.989 we still have some way to go it doesn't work in real time in fmri the patient 00:11:13.989 --> 00:11:16.629 is still in the scanner and we We know whether they're saying yes or no. 00:11:16.709 --> 00:11:21.689 With EEG, we have to take data away, analyze it, come back several hours later, 00:11:21.769 --> 00:11:25.969 and we can correctly deduce what the response was at the time. 00:11:26.209 --> 00:11:31.309 So some of the logistics, the technology still has to be worked out. 00:11:31.369 --> 00:11:37.989 But I'm quite confident that in a reasonably short time, we will have a portable 00:11:37.989 --> 00:11:42.629 system that will allow a patient who is behaviorally entirely non-responsive 00:11:42.629 --> 00:11:45.649 to be able to produce yes and no responses. 00:11:46.897 --> 00:11:52.657 That's very impressive. But now tell me, in some sense, this sounds a bit counterintuitive 00:11:52.657 --> 00:11:55.517 to me that this is right now so difficult. 00:11:55.597 --> 00:11:58.677 Because if you look at the existing brain-computer interface technology, 00:11:59.077 --> 00:12:03.437 essentially it's like, okay, you use a classifier to associate brain states 00:12:03.437 --> 00:12:06.737 to certain kinds of outcomes, certain kinds of behavioral outcomes. 00:12:06.737 --> 00:12:09.517 Comes so i would have imagined that you 00:12:09.517 --> 00:12:12.777 would exploit this kind of existing bci technology for your 00:12:12.777 --> 00:12:16.217 patients but apparently your patients have some special features 00:12:16.217 --> 00:12:19.217 that prevent you from doing that so what what makes 00:12:19.217 --> 00:12:22.337 them special it's interesting i mean we have um we have 00:12:22.337 --> 00:12:27.417 collaborations with some excellent bci people in europe now uh we have a grant 00:12:27.417 --> 00:12:32.857 so-called decoder grant for framework 7 grant specifically to try and integrate 00:12:32.857 --> 00:12:38.937 existing bti bci technology with is the experience that we have with vegetative 00:12:38.937 --> 00:12:40.377 and minimally conscious patients. 00:12:40.737 --> 00:12:47.957 But I tell you, I think the most difficult problem is more of a social one or a psychological one. 00:12:48.117 --> 00:12:50.277 And it's actually about training. 00:12:50.877 --> 00:12:55.897 If you look at the very best BCI systems, they involve some training. 00:12:56.057 --> 00:12:58.497 Now, you know, the best ones don't involve a lot of training, 00:12:58.617 --> 00:13:02.857 but it's some training. And that training invariably involves a social interaction 00:13:02.857 --> 00:13:07.517 between an experimenter, a scientist, a trainer, and a patient, 00:13:07.597 --> 00:13:10.997 perhaps a paraplegic patient or somebody who is incapable of moving. 00:13:11.057 --> 00:13:14.577 But almost always, that patient is capable of communication. 00:13:15.837 --> 00:13:18.637 And, you know, you imagine the scenario. You say to the person, 00:13:18.717 --> 00:13:21.397 well, what I want you to do is to, you know, imagine playing tennis. 00:13:21.477 --> 00:13:24.337 And when you do, the cursor is going to move on the screen. 00:13:24.377 --> 00:13:27.497 And I want you to make it go up with a bit more tennis or down with a bit less 00:13:27.497 --> 00:13:31.177 tennis. this. This involves a kind of a complex social interaction that's very 00:13:31.177 --> 00:13:38.517 hard to have with a patient that you do not necessarily know in advance is even conscious. 00:13:38.657 --> 00:13:40.617 And then this is the more difficult, 00:13:41.649 --> 00:13:46.109 situation that we're often faced with with these patients. It's not like having 00:13:46.109 --> 00:13:48.969 a normal interaction with somebody where they can say, hang on, 00:13:49.009 --> 00:13:53.409 tell me again, I didn't quite understand the instructions. Our patients can't do that. 00:13:53.729 --> 00:13:59.809 At the very best, our patients can imagine playing tennis in order to indicate 00:13:59.809 --> 00:14:04.629 yes over a five-minute period when we specifically ask them a question like, 00:14:04.789 --> 00:14:06.789 did you understand the instructions? 00:14:07.009 --> 00:14:10.889 And that whole, you know, just to ascertain that Somebody knew what you wanted 00:14:10.889 --> 00:14:16.189 them to do would require, you know, a little bit more effort than it would with 00:14:16.189 --> 00:14:18.309 somebody who could just tell you, stop, stop. 00:14:18.409 --> 00:14:22.209 I mean, I've lost the plot. Let's go through this again. How do I do it? 00:14:22.809 --> 00:14:27.489 And I think that's a, you know, it's a barrier to entry in this situation that 00:14:27.489 --> 00:14:31.269 you don't have normal channels of communication. Everything is much slower. 00:14:31.569 --> 00:14:36.569 So do you also find examples where you have patients who just don't get it? 00:14:37.349 --> 00:14:40.469 Yeah. Did you see they try to do something, but they do the wrong thing? 00:14:40.989 --> 00:14:45.809 Yeah. I mean, in many ways, well, yes, we do. I'm sure whether we know what 00:14:45.809 --> 00:14:47.749 they're doing or not is another matter. 00:14:47.889 --> 00:14:52.289 And I think that's really the problem. I'm like a patient that could talk to 00:14:52.289 --> 00:14:56.289 you and say, well, when you said play tennis, did you mean I'm supposed to be 00:14:56.289 --> 00:14:58.949 serving from the baseline or should I be up near the net? 00:14:59.289 --> 00:15:02.569 We can't have that sort of dialogue. We have to be very prescriptive. 00:15:02.569 --> 00:15:07.129 We have to tell people precisely what we want them to do in a way that we hope 00:15:07.129 --> 00:15:08.749 they always understand. 00:15:08.929 --> 00:15:12.589 And of course, inevitably, some of them won't because we all have different 00:15:12.589 --> 00:15:16.089 worldviews of how one plays tennis, for example. 00:15:16.369 --> 00:15:20.989 But how quickly do you understand from your average patient that they got it? 00:15:21.189 --> 00:15:24.089 Yeah, so this is the great thing about the tennis task, which, 00:15:24.149 --> 00:15:28.749 you know, in some senses, it's a bit strange, especially being English. 00:15:28.749 --> 00:15:32.889 I'm slightly sensitive having come up with this tennis playing task. 00:15:33.189 --> 00:15:37.149 It's a slightly odd thing to do, and perhaps it seems very English. 00:15:38.795 --> 00:15:43.955 And, but it could have been cricket, you know, it could have been cricket, but there you go. 00:15:44.015 --> 00:15:47.615 We, I think cricket probably would never have worked as well. 00:15:47.675 --> 00:15:51.695 And the reason is there are many more degrees of freedom with cricket than there are with tennis. 00:15:51.795 --> 00:15:54.935 The, the reason we ended up with tennis is because essentially we're trying 00:15:54.935 --> 00:15:57.315 to get people to imagine moving their arms. 00:15:57.455 --> 00:16:02.355 That's really all it takes. If you imagine moving your arms in a big gestural 00:16:02.355 --> 00:16:05.455 way, you know, waving your arms in the air, like you were waving a flag, 00:16:05.675 --> 00:16:08.835 that produces beautiful pre-motor activity. 00:16:09.095 --> 00:16:13.155 And I tell you, it works in every single person. This is not something that, 00:16:13.175 --> 00:16:16.495 you know, sometimes doesn't work. Absolutely everybody works. 00:16:16.735 --> 00:16:20.015 If you say to people, imagine playing cricket, to use your example, 00:16:20.095 --> 00:16:22.115 we have actually tried football, soccer before. 00:16:22.735 --> 00:16:26.955 What happens in healthy volunteers is typically they choose different things. 00:16:27.095 --> 00:16:31.455 I mean, in soccer, somebody might favor playing in goal. So they'll imagine 00:16:31.455 --> 00:16:35.595 standing still with a little bit of hand movement, or they might be a striker, 00:16:35.615 --> 00:16:40.255 in which case they'll imagine a lot of sprinting up and down the pitch. 00:16:40.455 --> 00:16:42.875 Similarly with cricket, are you in bat? Are you bowling? 00:16:43.095 --> 00:16:46.675 Are you fielding? It has many degrees of freedom. freedom tennis basically 00:16:46.675 --> 00:16:49.675 whichever role you choose to play in 00:16:49.675 --> 00:16:52.735 a game of tennis it's going to involve waving your arms around 00:16:52.735 --> 00:16:58.015 in the air like you're waving a flag and you know i'm joking aside i think it's 00:16:58.015 --> 00:17:04.375 that sort of relative invariance in how people imagine doing the task that makes 00:17:04.375 --> 00:17:08.855 it so reliable in the scanner and it means we don't do any training we really 00:17:08.855 --> 00:17:12.335 do not tell people or when I say, you know, play tennis, 00:17:12.415 --> 00:17:15.895 do it in this way or do it in that way, we are able to just put people in the 00:17:15.895 --> 00:17:18.635 scanner and say, the idea is play tennis. 00:17:18.735 --> 00:17:22.815 And most we will say, please don't run around too much because that tends to 00:17:22.815 --> 00:17:25.975 activate spatial navigation networks as well. 00:17:26.095 --> 00:17:29.535 So we tend to say, well, stand still when you're playing tennis and imagine 00:17:29.535 --> 00:17:32.315 you're serving or you're receiving on the baseline. 00:17:32.455 --> 00:17:36.075 But there's no great training involved and it works every time. 00:17:36.075 --> 00:17:42.375 But is it helping you in this case that you are exploiting. 00:17:43.305 --> 00:17:46.085 The asymmetries in the body representation here, for instance, 00:17:46.105 --> 00:17:49.625 now you involve the hand that will have a larger representation in these body 00:17:49.625 --> 00:17:51.645 maps than, for instance, the foot. 00:17:52.205 --> 00:17:56.705 Is that helping you? Yeah, we've had a lot more success with hands, 00:17:56.845 --> 00:17:59.285 as you say, than with feet. 00:18:01.525 --> 00:18:07.265 Which, given that feet are represented more medially than the hands, 00:18:07.365 --> 00:18:08.565 perhaps not surprising. 00:18:08.785 --> 00:18:13.465 Perhaps that is a good thing. although it tends to be a bilateral activity across 00:18:13.465 --> 00:18:17.525 the midline in the premotor cortex that we see when people you know imagine 00:18:17.525 --> 00:18:21.105 playing tennis so it's not a lateralization actually it's not a lateralization 00:18:21.105 --> 00:18:24.145 people will typically produce bilateral activity, 00:18:24.745 --> 00:18:30.785 also controls controls exactly yes but you know again we're quite non-prescriptive 00:18:30.785 --> 00:18:34.805 about how people play tennis and people will often move the you know imagine 00:18:34.805 --> 00:18:39.425 moving the racket to the other hand we don't say only move your right hand we say you know 00:18:39.805 --> 00:18:42.345 We'll try to move your hands around like you're playing tennis. 00:18:42.505 --> 00:18:47.645 So, you know, we haven't done sort of fine-tuned the experiment to try and generate 00:18:47.645 --> 00:18:52.925 a specific lateralized activity, but in part because it just works so well. 00:18:52.985 --> 00:18:56.525 I mean, we've had to fine-tune this experiment in some ways, 00:18:56.665 --> 00:19:03.825 but not to a great extent because from very early on, it proved itself to be very reliable. 00:19:03.885 --> 00:19:07.865 Whereas other things like we tried imagining swimming, for example, 00:19:07.865 --> 00:19:11.445 it just tended to be less reliable. Imagine singing a song in your head. 00:19:11.565 --> 00:19:13.305 Again, it was less reliable. 00:19:14.525 --> 00:19:18.625 But given the organization of the body representation, then you would expect 00:19:18.625 --> 00:19:21.925 if you would take a task that would involve parts of the face, 00:19:21.965 --> 00:19:24.185 like the lips, for which you know you have a huge representation, 00:19:24.605 --> 00:19:26.085 it might be very effective. 00:19:26.345 --> 00:19:30.985 Have you considered that? We have. Now, I think these things probably would 00:19:30.985 --> 00:19:34.245 be effective if you were actually doing the thing. 00:19:34.285 --> 00:19:37.385 But the important thing here is it's about imagery. 00:19:37.865 --> 00:19:43.345 I've been very surprised at how, in the early days when we were developing these 00:19:43.345 --> 00:19:49.465 tasks, how unreliable many imagery tasks that I thought would be very reliable would be. 00:19:49.865 --> 00:19:54.145 For example, one of the early studies we did with Melanie Boley, 00:19:54.225 --> 00:19:58.005 who is also speaking here today, looking at different types of imagery tasks, 00:19:58.185 --> 00:20:01.245 we came up with face imagery. We got people to imagine faces. 00:20:02.201 --> 00:20:05.561 You know, I naively thought, well, this is going to work in everybody. 00:20:05.721 --> 00:20:07.481 We've all got a fusiform face area. 00:20:07.881 --> 00:20:12.121 It's in the right fusiform gyrus for all of us. We'll all activate faces. 00:20:12.281 --> 00:20:14.401 Now, it turns out it's not true. 00:20:14.701 --> 00:20:18.981 You know, some of us will activate our FFA some of the time when we imagine 00:20:18.981 --> 00:20:22.981 faces, but a lot of us won't, which makes it clinically useless. 00:20:23.181 --> 00:20:25.281 It's not reliable enough to use. 00:20:25.841 --> 00:20:28.781 And, you know, when I went back and I questioned people after, 00:20:28.821 --> 00:20:32.901 you know, after finding this out, I question people that have done a lot of face work. 00:20:33.041 --> 00:20:38.981 Actually, even perceiving faces is not as reliable as we might expect it to 00:20:38.981 --> 00:20:42.001 be on an individual subject basis. 00:20:42.141 --> 00:20:49.381 If you pull apart those fabulous studies of face perception where people are 00:20:49.381 --> 00:20:53.521 actually seeing a face and you look at every individual subject, 00:20:53.901 --> 00:20:56.661 I can tell you that not 00:20:56.661 --> 00:21:01.081 every subject typically produces significant activity in their fusible face 00:21:01.081 --> 00:21:05.981 area you know every time they actually see a face so to expect it to activate 00:21:05.981 --> 00:21:10.461 during an imagery task i think it's probably asking too much it's not true of 00:21:10.461 --> 00:21:15.341 tennis imagine motor you know it's again it's not it's nothing magical about tennis but imagining, 00:21:15.901 --> 00:21:21.821 waving your hands around in the air i'm willing to wage you um it's hard to 00:21:21.821 --> 00:21:25.661 find a subject that but that does not produce activity in the premotor cortex. 00:21:25.961 --> 00:21:27.201 Yeah, we could want to test. 00:21:27.921 --> 00:21:33.921 Then on top of this, in some sense, it's very worrisome, what you're saying 00:21:33.921 --> 00:21:37.561 now, because you also showed in your talk that actually if you just look at 00:21:37.561 --> 00:21:41.921 activation maps in fMRI, you also cannot distinguish whether you look at a conscious subject, 00:21:42.781 --> 00:21:46.301 or an unconscious subject, a patient. 00:21:47.261 --> 00:21:52.081 On top of this now, you're saying in my control subjects, I cannot necessarily 00:21:52.081 --> 00:21:59.861 have a highly reliable replication of activity when people imagine different kinds of tasks. 00:22:00.161 --> 00:22:04.561 However, on the case of tennis, this is effective. 00:22:04.921 --> 00:22:07.181 There's high repeatability there. 00:22:07.861 --> 00:22:10.841 So how do you account for that? I think it's a sensitivity issue. 00:22:10.841 --> 00:22:16.961 I mean, I think every person has a fusiform face area, and I think that area 00:22:16.961 --> 00:22:24.261 is perceiving faces in every person when they see faces, and perhaps even when they imagine faces. 00:22:26.301 --> 00:22:32.981 But the sensitivity of fMRI is not such that in every participant we will detect 00:22:32.981 --> 00:22:35.761 activity in that region when they're doing the task. 00:22:35.961 --> 00:22:41.001 But could it also not mean that, let's say, in the fusiform cortex, 00:22:41.261 --> 00:22:46.761 the representation of phases is more distributed than the movement of tendons 00:22:46.761 --> 00:22:48.161 in your motor cortex, and therefore 00:22:48.161 --> 00:22:52.641 it's more difficult to pick it up reliably over different trials? 00:22:52.881 --> 00:22:55.981 Would that be a reasonable interpretation? Yeah, I think that's quite possibly true. 00:22:56.301 --> 00:23:00.681 Um i think there are many many reasons that could account for the variability you know i think. 00:23:01.381 --> 00:23:04.221 Pure imagery reasons too i mean it may well be that 00:23:04.221 --> 00:23:07.021 it's easier to imagine waving your hand 00:23:07.021 --> 00:23:10.001 around than it is to imagine a face do you imagine the 00:23:10.001 --> 00:23:12.861 face of your wife or your child or your dog or 00:23:12.861 --> 00:23:15.541 you know i don't know there are many 00:23:15.541 --> 00:23:18.201 reasons why this may be um you know 00:23:18.201 --> 00:23:21.081 i i know that empirically it's true that face 00:23:21.081 --> 00:23:25.101 imagery is less reliable than motor 00:23:25.101 --> 00:23:28.981 imagery in the context of imagining playing tennis similarly imagining 00:23:28.981 --> 00:23:31.881 i mean we thought for a long time you know sub 00:23:31.881 --> 00:23:36.181 vocal rehearsal might be a very good one we're all used to the idea of singing 00:23:36.181 --> 00:23:41.101 a song in our heads um in one of our early experiments we had uh participants 00:23:41.101 --> 00:23:45.361 singing christmas carols and we were probably doing our scanning in december 00:23:45.361 --> 00:23:49.901 or something we had participants imagining christmas carols, singing a carol. 00:23:49.961 --> 00:23:54.961 And again, a lot of people, a lot of the time will activate broker's area when 00:23:54.961 --> 00:23:58.721 they're singing Jingle Bells, but not everybody all the time. 00:23:58.941 --> 00:24:02.901 And the problem is, you need it to be everybody all the time. 00:24:02.921 --> 00:24:05.741 If you're going to make a reverse inference, if you're going to look at it and 00:24:05.741 --> 00:24:10.241 say, ah, yes, this person is doing what I asked them to do, they're imagining 00:24:10.241 --> 00:24:13.021 singing a carol or they're imagining playing tennis. 00:24:13.421 --> 00:24:17.881 It's essentially a reverse inference, and you don't have a lot of power in reverse 00:24:17.881 --> 00:24:24.701 inferences, unless you have a very reliable and robust result. Right. 00:24:25.761 --> 00:24:30.201 So the other aspect of the question had to do with the fact that if you would 00:24:30.201 --> 00:24:33.901 just look at the imaging result, you would not be able to say whether that person 00:24:33.901 --> 00:24:34.921 was conscious or unconscious. 00:24:37.861 --> 00:24:41.641 So how do you interpret that with respect to our understanding now of consciousness 00:24:41.641 --> 00:24:46.701 and its expression in the kind of activity, metabolic activity, 00:24:46.881 --> 00:24:49.021 that we can actually image with this kind of technology? 00:24:49.021 --> 00:24:52.581 Well, I think you have to make a very clear division between, 00:24:52.701 --> 00:24:57.381 let's say, what we'll call passive paradigms and active paradigms. 00:24:57.401 --> 00:25:02.061 And a passive paradigm is something that the brain will automatically do, 00:25:02.221 --> 00:25:05.181 irrespective of whether you are conscious or not. 00:25:05.301 --> 00:25:10.221 And that will include speech perception, face perception, all of these things. 00:25:10.221 --> 00:25:14.261 Now, if your fusiform face area lights up when you see a face, 00:25:14.441 --> 00:25:18.601 if your auditory cortex lights up, activates when you hear speech, 00:25:18.961 --> 00:25:24.541 you may well be conscious when that happens, but it will also likely happen 00:25:24.541 --> 00:25:29.061 if you are unconscious, even if you are healthy and unconscious, for example. 00:25:29.830 --> 00:25:33.210 Anesthetized and therefore we can't 00:25:33.210 --> 00:25:36.230 use it as a vehicle for determining that 00:25:36.230 --> 00:25:40.370 somebody is conscious you know even if it's highly correlated with consciousness 00:25:40.370 --> 00:25:44.790 you know it's it's it's not good enough the other types of paradigms the things 00:25:44.790 --> 00:25:48.730 we've been exploring are not dependent on external stimulation and these are 00:25:48.730 --> 00:25:54.410 i'll call them active paradigms um because what you're doing is you are 00:25:54.490 --> 00:25:57.890 asking somebody to generate a response with their brain. 00:25:58.150 --> 00:26:02.450 And this, for me, is analogous to asking somebody to raise their left hand. 00:26:02.570 --> 00:26:06.870 It's the same thing. You're saying, activate your premotor cortex when I ask you to. 00:26:07.670 --> 00:26:12.230 Now, you're not playing them a sound that you know will automatically activate it. 00:26:12.290 --> 00:26:15.890 And we know from the various experiments that we've done over the years usually 00:26:15.890 --> 00:26:21.750 to satisfy skeptical reviewers that people are capable of not generating these 00:26:21.750 --> 00:26:23.590 responses even when you ask them to. 00:26:23.650 --> 00:26:26.510 And the tennis example is a great example. If you say to somebody, 00:26:26.650 --> 00:26:30.290 I'm going to ask you to do something and I want you not to do it. 00:26:30.530 --> 00:26:34.050 In the ephemera scan, if you say, now imagine playing tennis, 00:26:34.250 --> 00:26:37.290 you will not see activation in the premotor cortex. 00:26:37.390 --> 00:26:40.410 People are perfectly capable of not generating this. 00:26:40.470 --> 00:26:46.150 And it's because it is an active or a willed volitional task. You have to want to do it. 00:26:46.630 --> 00:26:51.590 And it's that sort of want that we are using, I suppose, as our marker of consciousness. 00:26:51.750 --> 00:26:59.210 Our notion is that, you know, if somebody has the mental capacity to decide 00:26:59.210 --> 00:27:04.010 not to do something in spite of being told that they have to do it. 00:27:04.790 --> 00:27:09.210 Then we think that's a reasonable marker that they are conscious, 00:27:09.310 --> 00:27:12.390 or at least as conscious as you or I am. 00:27:12.470 --> 00:27:15.530 And, you know, I think distinguishing between those different fMRI tasks 00:27:15.530 --> 00:27:18.530 is really fundamental to this work because it's very very 00:27:18.530 --> 00:27:21.470 important that one doesn't think that all fmri means 00:27:21.470 --> 00:27:24.610 um you know any fmri activation means 00:27:24.610 --> 00:27:28.490 that you're conscious and similarly it isn't true that activation 00:27:28.490 --> 00:27:31.550 could just be an automatic thing there are certain types of 00:27:31.550 --> 00:27:39.370 activation that simply cannot be automatic okay so then uh if we now take take 00:27:39.370 --> 00:27:42.830 that interpretation of what this means for consciousness and we look at the 00:27:42.830 --> 00:27:48.370 kind of order that people try to give to the different states of consciousness 00:27:48.370 --> 00:27:49.670 you might find a person in, 00:27:49.730 --> 00:27:52.190 from let's say coma to fully aware. 00:27:54.073 --> 00:27:59.113 Is that structure that we assign to different forms of consciousness actually 00:27:59.113 --> 00:28:03.373 helping us or is it more of a hindrance, right, where you would go from coma 00:28:03.373 --> 00:28:06.813 to, let's say, minimally aware, et cetera? Yeah. 00:28:08.053 --> 00:28:12.433 Actually, I don't know the answer to that. There have been many surprises in 00:28:12.433 --> 00:28:15.813 this area over the last 10 or 12 years, and I'm very happy. 00:28:16.133 --> 00:28:21.873 I'll be very happy to be, you know, mostly to continue to be surprised. 00:28:21.873 --> 00:28:27.273 You know, it may be, for example, that the temporal aspect turns out to be more 00:28:27.273 --> 00:28:30.033 important than the depth aspect. 00:28:30.293 --> 00:28:33.213 You know, it may be that a lot of minimally conscious patients, 00:28:33.353 --> 00:28:38.833 it's not that they're in some intermediate state of consciousness between where 00:28:38.833 --> 00:28:41.593 you and I are and between a vegetative patient. 00:28:41.693 --> 00:28:43.833 It may be that they are intermittently conscious. 00:28:44.053 --> 00:28:48.373 They come in and out of consciousness. I don't find that, you know, 00:28:48.373 --> 00:28:49.933 very hard to believe. leave. 00:28:50.753 --> 00:28:54.113 I think that's something we can now explore because we, you know, 00:28:54.113 --> 00:28:59.973 we have a tool that we can use to more or less say that this person is conscious at this point in time. 00:29:00.053 --> 00:29:04.433 And obviously with longitudinal scanning, one could follow this in a minimally 00:29:04.433 --> 00:29:08.813 conscious patient and work out, you know, whether it is a temporal rather than a depth thing. 00:29:10.193 --> 00:29:13.773 Similarly with coma, you know, we don't, I mean, coma and vegetative state, 00:29:13.793 --> 00:29:16.333 they're often mixed up. Coma patients really are quite different. 00:29:16.473 --> 00:29:20.533 These are patients who appear to be asleep most of the time, 00:29:20.593 --> 00:29:24.993 whereas vegetative patients open their eyes and have sleep-wake cycles and to 00:29:24.993 --> 00:29:27.833 some extent appear to be animate. 00:29:28.993 --> 00:29:34.793 We've done very little research using these types of imaging approaches with coma patients. 00:29:35.093 --> 00:29:40.513 And it may be that we find that a lot of patients who are comatose or appear 00:29:40.513 --> 00:29:47.493 to be comatose do in fact have residual cognitive capabilities and perhaps even consciousness. 00:29:47.653 --> 00:29:51.933 I hesitate to predict that will be the case, but as I say, many things have 00:29:51.933 --> 00:29:58.173 surprised me and to some extent, it wouldn't surprise me if that turned out to be the case. 00:29:58.353 --> 00:30:04.653 So I don't think these things are not useful because up until now, 00:30:04.713 --> 00:30:09.413 we have to go on what we know and what we know is what we can measure and what 00:30:09.413 --> 00:30:12.153 we can measure up until now has been the behavior. 00:30:12.433 --> 00:30:16.853 And behaviorally, these are distinct conditions, coma, vegetative state, 00:30:16.973 --> 00:30:18.073 minimally conscious state. 00:30:18.973 --> 00:30:22.953 And, you know, they can be differentiated based on, you know, 00:30:22.973 --> 00:30:28.413 on behavior, whether it turns out that those are useless concepts in terms of 00:30:28.413 --> 00:30:29.413 levels of consciousness. 00:30:29.853 --> 00:30:35.533 I hope we now have the tools that will help us to answer that question. 00:30:36.474 --> 00:30:42.854 That's fantastic. But then, what's the working model of consciousness that you then apply to this? 00:30:42.934 --> 00:30:49.294 Like, for instance, also in the discussion this morning, one view is that you would say, well, 00:30:49.374 --> 00:30:56.814 you have these particular areas of the neocortex that have to be combined in, 00:30:56.854 --> 00:30:59.694 let's say, something you might call a global workspace or have to be massively 00:30:59.694 --> 00:31:02.674 integrated in order to be conscious. 00:31:02.674 --> 00:31:07.374 An alternative view could be that you say, no, they're actually very primitive 00:31:07.374 --> 00:31:11.974 subcortical structures that provide consciousness, while these higher areas 00:31:11.974 --> 00:31:17.214 of the cerebral cortex provide content to that ovarian complexity. 00:31:18.414 --> 00:31:22.494 It's rather decisive which of these two camps you step into if you now look 00:31:22.494 --> 00:31:24.594 at your vegetative state patient. 00:31:24.894 --> 00:31:29.714 Yeah. So what's your working hypothesis between these two extremes? 00:31:30.334 --> 00:31:32.514 Well, really, I think it's only, 00:31:32.814 --> 00:31:36.874 and this goes back to your question this morning, is that you can test it. 00:31:36.934 --> 00:31:41.494 I think that the problem until now has been, it's been very hard to come up 00:31:41.494 --> 00:31:42.774 with any corroborative evidence. 00:31:42.774 --> 00:31:47.434 You know, you can come up with something like a global workspace model of consciousness 00:31:47.434 --> 00:31:53.594 and we can say, well, you know, these people, healthy participants that we know 00:31:53.594 --> 00:31:57.114 are conscious produce this pattern of activity in their brains. 00:31:58.814 --> 00:32:06.274 These machines, animals, vegetative patients that we know are unconscious produce something else. 00:32:06.314 --> 00:32:09.454 But you don't really have, in the case of the vegetative patients, 00:32:09.494 --> 00:32:14.274 you don't have corroborative evidence. You can't say, we know they are not conscious 00:32:14.274 --> 00:32:18.794 and they have this model of consciousness fits. 00:32:19.794 --> 00:32:24.014 Now, I think you can. I think we could use the activation paradigm. 00:32:24.054 --> 00:32:26.894 As I say, it doesn't answer the question of what is consciousness, 00:32:27.054 --> 00:32:31.634 but I think it does allow you to have some sort of corroborative evidence and say, well, 00:32:31.754 --> 00:32:36.794 we can test whether these people who appear to be unconscious are actually conscious 00:32:36.794 --> 00:32:40.594 and then test these types of models to see whether they stand up. 00:32:40.594 --> 00:32:43.074 And, you know, honestly, I don't know whether they will. 00:32:43.354 --> 00:32:48.154 I think that's, you know, that's a suggestion that you made this morning. 00:32:48.214 --> 00:32:49.374 And I think it's a very good suggestion. 00:32:49.514 --> 00:32:51.754 This provides us with a mechanism for testing that. 00:32:51.954 --> 00:32:58.494 But if we look at the classics, right, the giants that inspire us like Penfield. 00:33:00.734 --> 00:33:04.914 He, at some point in his career, got convinced that there were much more these 00:33:04.914 --> 00:33:10.954 subcortical or central encephalic cores course, that would provide the key ingredients 00:33:10.954 --> 00:33:12.974 of, let's say, cognition and consciousness, 00:33:13.154 --> 00:33:21.474 because lesions to subcortical structures had a way more devastating impact on a patient than, 00:33:22.434 --> 00:33:23.714 lesions to the neocortex. 00:33:23.894 --> 00:33:26.834 And that then was an argument for him to say, well, we should look more at the 00:33:26.834 --> 00:33:27.734 subcortical structures. 00:33:27.994 --> 00:33:30.454 Do you also find that in the patients that you look at? 00:33:32.595 --> 00:33:34.935 Do we find whether the instruments tend to be… The similar core, 00:33:34.955 --> 00:33:41.615 exactly. Well, again, the problem is all, well, all patients are different. That's the problem. 00:33:41.755 --> 00:33:46.515 And, you know, I couldn't possibly say, yes, we generally find that's the way 00:33:46.515 --> 00:33:51.575 in patients because, you know, in part because there's so much variability in 00:33:51.575 --> 00:33:53.095 the site of the damage of the patients. 00:33:53.295 --> 00:33:57.755 And in part because, you know, often it's difficult to work out exactly what 00:33:57.755 --> 00:34:00.975 the damage is. If you've had a very traumatic brain injury, you know, 00:34:00.995 --> 00:34:03.255 this is not a measurable quantity. 00:34:03.475 --> 00:34:07.655 You know, you've got a bit of, well, you know, diffuse axonal injury is the 00:34:07.655 --> 00:34:11.055 perfect, you know, this is the perfect example where, you know, 00:34:11.075 --> 00:34:14.235 you're basically saying it's, you know, it's damage all over the place. 00:34:15.475 --> 00:34:18.535 So, you know, I don't think I can really say. I mean, I think we learn a lot 00:34:18.535 --> 00:34:22.055 from disorders like the locked-in syndrome where you, 00:34:22.135 --> 00:34:27.835 you know, you very often do have a very specific brainstem injury that has resulted 00:34:27.835 --> 00:34:33.715 in a situation where a patient is ostensibly cognitively normal but is nevertheless 00:34:33.715 --> 00:34:40.355 motorically almost entirely impaired perhaps only able to blink an eye or you know move an eyebrow. 00:34:41.395 --> 00:34:45.655 This produces I think the logical certainty that there are likely to be other 00:34:45.655 --> 00:34:52.975 patients that are entirely cognitively preserved yet unable to even blink an eye or move an eyebrow. 00:34:53.155 --> 00:34:56.815 As a scientist, it's inconceivable to me that the moment, you know, 00:34:56.815 --> 00:35:01.475 the lesion that knocks out eye movements also happens to knock out the whole of cognition. 00:35:01.795 --> 00:35:06.615 And of course, this is what we're looking at here is some kind of disconnection syndrome. 00:35:06.855 --> 00:35:13.795 You know, it's a lesion of a subcortical structure that is essentially disconnecting 00:35:13.795 --> 00:35:16.395 an and otherwise intact cortex. 00:35:16.515 --> 00:35:21.435 Now, that's why I would be reluctant to... 00:35:23.250 --> 00:35:29.150 To accept a view that this therefore makes the subcortical structures more important, 00:35:30.070 --> 00:35:35.110 because it could just be that you've cut off the water supply, 00:35:35.350 --> 00:35:39.510 you've disconnected the really important stuff up top. 00:35:39.630 --> 00:35:43.330 In a sense, it's going back to your comment about communication disorders. 00:35:43.510 --> 00:35:47.610 In a sense, what you've done is you've disconnected, you've 00:35:47.610 --> 00:35:52.010 severed a channel of communication between the 00:35:52.010 --> 00:35:56.090 brain and i say that in quotes that you know the conscious brain and the external 00:35:56.090 --> 00:36:02.310 world preventing either external stimulation coming in or um you know or the 00:36:02.310 --> 00:36:10.070 will going out you know or in some cases both very good so to to finish up i have two questions, 00:36:11.390 --> 00:36:17.590 um so on the one hand i'm you've been around for quite some time um making this 00:36:17.590 --> 00:36:24.110 incredible progress as using these really modern advances in imaging technology. 00:36:24.490 --> 00:36:29.550 So give me your experience in the way we approach studying the brain and understanding consciousness. 00:36:30.350 --> 00:36:34.170 What's the law of Adrian Owen that we should all adhere to? 00:36:37.630 --> 00:36:41.750 That's a very unfair question. I don't have a law. I just follow my nose. 00:36:41.970 --> 00:36:43.530 You know, I don't have a law. That could be a law. 00:36:43.950 --> 00:36:46.770 Follow your nose. I follow my hunches for sure. 00:36:46.950 --> 00:36:49.710 There you go. you've told me what my law is. I follow my hunches. 00:36:49.850 --> 00:36:55.890 I've had a lot of very strange ideas over the years, and some of them have worked out very well. 00:36:55.950 --> 00:36:59.290 Some of them have worked out to be, you know, complete blind alleys. 00:37:00.330 --> 00:37:05.990 I think, I mean, in the context of the work I've done in this particular patient 00:37:05.990 --> 00:37:09.130 population, what I have learned is very often that, 00:37:10.017 --> 00:37:13.237 the prevailing view um you know 00:37:13.237 --> 00:37:15.897 is not necessarily the right view and if you have a 00:37:15.897 --> 00:37:19.197 hunch however bizarre it might seem then follow 00:37:19.197 --> 00:37:23.337 that hunch so yep follow your nose um i you know i don't think 12 years ago 00:37:23.337 --> 00:37:28.097 at least i i know that 12 years ago and when we started to talk about these 00:37:28.097 --> 00:37:31.537 patients having residual cognitive function there was a tremendous amount of 00:37:31.537 --> 00:37:35.057 resistance to this idea because it just didn't seem like it could be at all 00:37:35.057 --> 00:37:38.177 likely and we've gradually worked our way through, 00:37:38.377 --> 00:37:40.477 you know, through this hierarchy. 00:37:40.657 --> 00:37:45.877 And, you know, I think if I maybe followed my nose even earlier than I did, 00:37:46.057 --> 00:37:49.937 we would have probably got to where we are today much more quickly than we have. 00:37:50.097 --> 00:37:55.277 I think, you know, the idea that somebody could actually be conscious and even 00:37:55.277 --> 00:37:59.677 able to communicate met with a tremendous amount of resistance, 00:37:59.877 --> 00:38:04.217 even at a time when I think myself So often people working with me, 00:38:04.257 --> 00:38:07.017 you know, are pretty sure that this must be the case. 00:38:07.097 --> 00:38:11.197 So follow your nose and follow it fast, I would say. Very good. 00:38:11.897 --> 00:38:16.077 Last one is, what's the one prediction which you really want to stick your neck out today? 00:38:16.197 --> 00:38:18.617 So I can come back to you five years from now and say, Adrian, 00:38:18.777 --> 00:38:20.917 show me, were you right or wrong? 00:38:20.917 --> 00:38:28.277 I predict that we will have a patient within five years who is entirely behaviorally 00:38:28.277 --> 00:38:32.617 incapable of demonstrating any evidence of consciousness awareness, 00:38:32.977 --> 00:38:39.417 yet is nevertheless capable of having a normal, and I put that in quotes, 00:38:39.617 --> 00:38:45.397 a normal conversation via some form of machinery, be it a brain computer interface 00:38:45.397 --> 00:38:51.037 or an fMRI scan with somebody in the outside world. 00:38:51.237 --> 00:38:55.017 So this has to be the absolute nightmare scenario, a patient who, 00:38:55.117 --> 00:39:00.297 under any form of clinical investigation, any form of behavioral testing, 00:39:00.637 --> 00:39:04.197 can exhibit no signs of conscious awareness whatsoever, 00:39:04.557 --> 00:39:11.737 yet in some technologically driven situation is able to have a conversation 00:39:11.737 --> 00:39:14.857 that most of us would consider to be perfectly normal. 00:39:14.957 --> 00:39:18.837 Not just yes, no questions. It's expressing opinions about the world, 00:39:18.977 --> 00:39:21.157 about themselves, and about the situation they're in. 00:39:21.257 --> 00:39:25.797 I predict we will have that scenario within five years. 00:39:26.257 --> 00:39:29.657 Fantastic. Aidan Nolan, thank you very much for this conversation. Thank you.