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How Tai Chi and Related Practices Can Prevent Both Falls and Cognitive Decline

Prof. Peter Wayne introduced the lecture by referring to the holistic approach offered by the Ancient Medical systems of healthcare as compared to Modern Medicine. The ancient systems  aimed at treating the whole person and enhancing the interconnection between physiological bodily systems. Tai Chi, takes an ecological view, as compared to the modern mechanistic view. Modern Medicine, though highly specialized, tends towards reductionism, perception of fragmentation of the body and healthcare, and the more recent Precision Medicine studies it at a molecular level, all these approaches sometimes ‘missing the forest for the trees’.

Tai Chi is an internal Chinese martial art practiced for defensive training, health benefits and meditation and has practitioners all over the world from Asia to the Americas. Tai Chi’s approach is to integrate mind–body function through multimodal interventions that  strengthen,  even as they relax  body and mind. It is the key to reduce muscle stress, improve motor coordination and create greater sensory awareness. The whole spread of these multimodal interventions include aerobic exercise, dynamic structural integration, active relaxation of mind and body, enhancing awareness, mindfulness and focused attention, consolidating intention, beliefs, expectations, natural free breathing, social and community interactions and  philosophical, spiritual and ritualistic outlook, all within a set time-frame – an integrative approach ‘with a smooth, sustained flow, like wading through water’. Qigong is an allied  system to Tai Chi  to cultivate and balance life energy for health and wellbeing.

Prof. Wayne stressed that cognitive decline and falls in the elderly constitute a major Public  Health concern.  Falls can result in irreversible health consequences and add substantially to the economic burden on health care system. In this scenario, traditional approaches to preserve cognitive function, delay cognitive decline and prevent falls in the elderly may have a  role to play. Towards this goal, Prof. Wayne presented  studies which provided evidence base to prove the efficacy of Tai Chi and Qigong.

1Tinetti’s (2003) was one of the early observational studies on ‘prevention of falls in the elderly’. She provides guidelines for management of elderly above 75 years with a history of a previous fall. She lists the conditions which have been shown to increase the subsequent risk of falling which need to be investigated : “arthritis; depressive symptoms; orthostasis; impairment in cognition, vision, balance, gait, or muscle strength; and the use of four or more prescription

medications”. An exercise regimen to improve gait balance and muscle strength have been suggested by her.

2Logghe et al (2010) conducted a meta-analysis  to study the effects of Tai Chi on fall prevention,    fear of falling and balance in older people. Randomized controlled trials published between 1988 and January 2009 were included and compared with non-exercise controls.  Nine trials (representing 2203 participants) were included in the analyses, where compared with exercise controls, Tai Chi participants showed notable improvement. Linking the cognitive and the affective, in elderly who have experienced a fall earlier, (sometimes with less serious sequelae), revealed that a lasting concern about falling, results in  an individual avoiding activities that he/she remains capable of performing. Ironically, this is a key factor that leads to falling in the future.

3Fuzhong Li  (2016) conducted a study with the objective of evaluating the impact a fall prevention intervention in the community senior centers in Oregon The method followed was a single-group design. It was to evaluate the Tai Chi and Quigong or Tai Ji Quan Moving for Better Balance (TJQMBB) program adopted, with population reach, implementation, effectiveness, and maintenance .The study population was from  36 senior centers in 4 Oregon counties between 2012 and 2016. The primary outcome measure, as part of the effectiveness evaluation, was number of falls as ascertained by self-report. Trained TJQMBB instructors delivered the program to community-dwelling older adults for 48 weeks, with a 6-month post-intervention follow-up. The program resulted in a 49% reduction in the total number of falls and improved physical performance, providing evidence base to conclude that TJQMBB is an effective public health program that can be broadly implemented  for primary prevention of falls among community-dwelling older adults.

As a follow up to the previous study, 4Fuzhong Li et al (2018) conducted a single-blind, 3-arm, parallel design, randomized clinical trial over a 3 year period in Oregon with the objective of studying the therapeutic efficacy of Tai Chi and Qigong  or Tai ji Quan (TJQ) intervention versus multimodal exercise routine among older adults at high risk of falling. ‘TJQ Moving for Better Balance’ (TJQMBB), developed on the classic concept of Tai Chi was studied against a multimodal exercise (MME) program and a stretching exercise routine in reducing falls, as an intention-to-treat assignment. 670 who had fallen in the preceding year, or had impaired mobility, consented and were enrolled. During the trial, there were 152 falls (85 individuals) in the TJQMBB group, 218 (112 individuals) in the MME group, and 363 (127 individuals) in the stretching exercise group. It was concluded that among community-dwelling older adults at high risk for falls, a therapeutically tailored Tai Chi Qigong balance training intervention was more effective than conventional exercise approaches for reducing the incidence of falls.

Normal gait depends not only on musculo-skeletal efficiency and co-ordination, but on cognitive stimulation of the prefrontal cortex, executive function, showing the interdependence of cognition and motor function which is more obvious with the process of ageing. 5 Verghese et al (2013) in their study ‘Motoric Cognitive Risk Syndrome (MCR) and the Risk of Dementia’   correlate gait speed and cognitive function, and the risk of future dementia. MCR syndrome is a more recently recognised predementia syndrome, characterized by cognitive complaints and slow gait in older individuals without dementia or prior history of mobility disability. MCR syndrome provide a clinical approach to identify individuals at high risk for dementia, (especially vascular dementia)  and offer the benefit of preventive  intervention. There is MRI evidence to show that after 40 weeks of Tai Chi training in non-demented individuals there is an increase in total brain volumewhich isreflected in an improvement in cognitive performance. 

6Wayne et al (2022) conducted a meta-analyses  of Tai Chi’s benefits to cognition observable in the brain. Studies included in the analyses had detailed cognitive testing records. The study supports small to moderate, but clinically relevant improvements in executive function following 10 weeks to 1 year of Tai Chi training in cognitively intact adults. The effect sizes were equivalent to those reported following other exercise and cognitive training.

To introduce a cognitive function accompanying gait, a dual task of thinking or talking while walking was studied. Walking with counting backward as a dual task was tested. With Tai Chi training, dual task walking improves more than with routine exercise regimen. This showed benefit when employed on patients with Parkinson’s disease. Prof. Wayne, as a matter of interest, pointed out that Boston Tai Chi experts have greater regular gait rhythm when challenged with dual cognitive task than those without such training.

 Tai Chi training can reduce both chronic pain and depression. In a study  7Quixadá (2022) showed that Qigong training positively impacts both posture and mood in breast cancer survivors (BCS) with persistent post-surgical pain (PPSP). Pain catastrophizing has been shown to increase the risk of developing PPSP in BCS. With a 12-week Qigong mind-body training program for BCS, most of the participants who improved in measures of fatigue also improved their vertical head angle. The severity of the pain decreased and the vertical spine angle improved. Qigong may be a promising intervention for addressing biopsychosocially complex interventions such as PPSP in BCS. This training could be applied to other chronic medical conditions with interdependence of posture, affect and complex interactions between trauma, pain, and impaired psychosocial function. Qigong enabled participants to reconnect mind and body and this is best brought out by quoting from an excerpt from a BCS participant of the study:  “How you feel about your body is a challenge after you’ve had breast cancer. … [But] mind and body have to be interconnected. All of it together [in Qigong] relaxes you and helps you stretch out a little bit, calm you down, help you think about your body in a different way, and trust your body to get inside yourself in a different way.”

Research toward an embodied cognition framework for mind-body has been suggested by 8Osypiuk, (2018). Contemporary and traditional mind-body practitioners describe their interventions (including Qigong) as enhancing interoceptive and proprioceptive bodily awareness, connecting body schema and body image and creating the sense of the minimal and implicit self. A unitary conceptualization of body and mind has been elaborated by  Shunrya Suzuki  9(Suzuki, 1970), a  Zen Buddhist teacher in  ‘Zen Mind, Beginner’s Mind’ and how the right posture in itself leads to attaining the right state of mind.  He suggests that if your mind is empty, it is always ready to receive anything; it is open to everything. In his all -encompassing wisdom  he states that in the beginner’s mind there are many possibilities; in the expert’s mind there are few.

Prof. Wayne summed up the efficacious role that Tai Chi and Qigong training can play in areas of cognition and gait in the elderly. Some of the references in the lecture have been provided below for easier accessibility.

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The Future of Integrative Medicine in India

Introduction:

On 11th May 2023, in a significant development, a Memorandum of Agreement (MoA) was signed between the Indian Council of Medical Research (ICMR), under the Union Ministry of Health and Family Welfare, and the Union Ministry of Ayush, (Ayush standing for Ayurveda, yoga, unani, siddha and homeopathy), to promote and collaborate on integrative health care and research. The MoA will enable both parties to jointly establish Ayush-ICMR Centres for Advanced Research in Integrative Health at the All India Institutes of Medical Sciences (AIIMS), in India. Inpatient and outpatient services will be established in the new Integrated Medicine departments of all 23 ‘functioning’ AIIMS which earlier served only as Ayush service departments. The studies will  extend to areas of public health as well. This initiative is planned to place integrative medicine  on a firmer footing  and for it to justifiably gain wider acceptance.

ICMR proposes to strengthen evidence-based research capacity of the team. Research methodology needs a face lift even at undergraduate levels in India. Establishing a working committee of experts and workshops and training programs across the centres will enhance the co-learning process and organizational stability. ICMR plans to update The National Ethical Guidelines for Biomedical and Health Research Involving Human Participants’ 2017 with a developed comprehensive section on Integrative Medicine ethics, based on research inputs from the newly established ICMR-Ayush centres.

Can an Integrated System of Medicine Work?

The Hindu Podcast  Can an Integrated System of Medicine Work?on 19th May,2023,(follow podcast link and write up given here), featured Dr.Cyriac Abby Philips, Senior Consultant and Clinical Scientist in Hepatology, Rajagiri Hospital, Kochi, opposing the move and Dr. Ennapadam S. Krishnamoorthy, Founder and Neuropsychiatric Consultant, Buddhi Clinic, Chennai, as the proponent. Buddhi Clinic offers Neuropsychiatric care and management by a multidisciplinary team following the modern medicine approach, and integrates it with some non-pharmacological therapies. The host, Ms. Zubeda Hamid, initiated the dialogue seeking  the two consultants’ views on the above Union Government initiative. They had diametrically opposite view in some areas of Integrative Medicine, but came together in one voice on  randomised controlled trials as gold standard and the standardisation of formulations critical to uniformity of dosage. Dr.Philip’s misgivings were based on the side effects of some Ayush medications, and the very rare hepatotoxicity with liver injury as an adverse event. The NIH, USA, has expressed concern over cases of heavy metal poisoning with Ayurvedic formulations.

The dramatic global growth of the Traditional Complementary and Alternative Medicine (T-CAM) movement during the last 3 decades is also a people’s movement to seek alternative therapies to relieve unrelenting pain or to have possible respite from the travails of chronic illness. It also comes with the realization that though modern medicine offers evidence-based healthcare, the latest technologies, and has no substitute in emergency care, it does not have all the answers and 20% of patients can be non-responders. CAM is a global phenomenon, WHO reporting that 80% of the global population have opted for it at some stage in their life. In this context, foreign governments and regulatory bodies also appear to have accepted the call for broader approaches to healthcare. The latest global collaborative move in this direction, is the signing of the MoU and  onsite launch of WHO Global Centre for Traditional Medicine, Jamnagar, India, which  took place between the Ministry of Ayush and WHO on 21st April 2022, to establish  WHO – GCTM, with India as the host country. It is planned to start functioning by mid-2024. This new ‘pluraristic approach’ to healthcare goes with the caveat that all new, potentially useful healthcare interventions, must establish their safety, quality and efficacy.

The overall aim of drug standardization is to ensure the quality, efficacy and uniformity of the products, in terms of their chemical and biological properties. Ayurvedic formulations are designed and manufactured based on unique principles of Ayurveda pharmacology, many of which exert a multi-drug-multi-target mode of action effect, due to the presence of several bioactive molecules in its natural form. This is different from the single-drug-single-target action of modern molecular drugs. This complicates evidence-based research in herbal formulations, and even standardization can be difficult. The active medicinal molecule may be isolated through chromatographic methods, but the identification and role of the other bioactive molecules may remain unknown.

There are several peer-reviewed international journals on Integrative Medicine. Two leading Indian online international journals, both open access, peer-reviewed, quarterly publications are:  Journal of Ayurveda and Integrative Medicine, established in 2010, (published jointly by The Institute of Trans-disciplinary Health Sciences and Technology and The World Ayurveda Foundation and published on Elsevier) and   Indian Journal of Integrative Medicinewhich started publication about 4 years back.

Integrative Health Research must aim at a transdisciplinary approach. ‘Transdisciplinary’ involves the integration and transformation of fields of knowledge from multiple perspectives in order to define, address, and resolve complex  problems, the integration transcending individual disciplines.  National Health Policy (2017) in ‘Mainstreaming the Potential of AYUSH’ puts focus on sensitizing practitioners of each system to respect the strengths of the other.

There is a wealth of wisdom and ancient traditions which can be incorporated  sensibly and safely, for the well­being of the human race. A systematic, goal-directed  approach, (within time frames), under the Union Government umbrella, with comfortable levels of funding, common training programs, pooling the multicentre data of clinical findings under intention to treat in  standard method against Ayush approaches, longitudinal studies, phytochemical analysis, all under a strong leadership and committed stakeholders, must yield results. The challenge is to ‘modernize’ Ayush and make it relevant and contextual and to  create a  robust  interface between Ayush and modern science. The strength of ancient systems lie in promotive and preventive health, treatment of NCDs,  regenerative medicine and mind-body science in mental health. Not to be forgotten is the in situ conservation of wild gene pools of medicinal herbs and the benefits of integrative research reaching the poor of our country.

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Dr. Krishnamoorthy Srinivas 90th Birthday Memorial Lecture

Introduction

The Dr. Krishnamoorthy Srinivas 90th Birthday Memorial Lecture Webinar was delivered on 15th  February, 2023 by Prof. Christopher Mathias, under the auspices of Buddhi Clinic, Chennai. Mrs. Krishnamoorthy Srinivas, Prof. ES Krishnamoorthy,  Founder-Director of Buddhi Clinic and his team were present at the clinic venue. It was fitting that Ms.Aparna Rajagopal, a lawyer by training, (with over a decade of dedication to her animal sanctuary and sustainable animal farm, Beejom in Noida), opened the proceedings with old, fond memories and a daughter’s perspective of a ‘good friend’ and a doctor father. For family and close friends, it was an event to honour the life of a loved one, and to professional colleagues, Srinivas’  legacy of  commitment and excellence in medical care.

Eminent senior members of the Indian Neuroscience fraternity participated in the Webinar to honour the memory of Prof. Krishnamorthy Srinivas – Prof. P. Satish Chandra, former Vice Chancellor of National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Prof. Man Mohan Mehndirattha, Former Director and Professor, Department of Neurology, Gobind Ballabh Pant Institute of Medical Education, New Delhi  and Prof. AV Srinivasan, Emeritus Professor, Tamil Nadu Dr MGR Medical University. AV Srinivasan, who was one of Dr. Srinivas’ earliest DM (Neurology) students and later associated closely as a professional colleague, spoke at some length about his guru. He traced  the professor’s   long years of training in the UK and later in Canada, the pioneering effort in establishing Neurology as a superspecialty in India, building a small  department of Neurology in the well served Community Medicine centre-Voluntary Health Services (VHS) Medical Centre, Chennai, (later a multispecialty hospital), bringing world Neurology to India through the endowment lectures and interaction with the Indian Neurology groups, medical students and the lay audience, and his distinguished national and international awards and honours. The note of appreciation  summed up the professor’s legacy- Dr. Srinivas, teacher, researcher, administrator, but always a clinician; a family man, with admiration for his devoted wife Padma and the achievements of his two children- Prof. ES Krishnamoorthy  and Ms. Aparna Rajagopal and their respective spouses. Prof. Krishnamoorthy Srinivas followed Prof. Christopher Mathias achievements in the UK in the field of ANS with interest and could not deny a sense of pride in his Indian origin. The  prestigious lectures he has delivered worldwide include (under the ‘Srinivas umbrella’) the 3rd Prof. K Srinivas lecture, Chennai (2005); K. Gopalakrishna lecture, Chennai (2006); and TS Sinivasan Conclave Lecture, NIMHANS, Bangalore (2015), 35th TS Srinivasan Gold Medal Award and Endowment Oration, Chennai (2015).

Prof. Christopher Mathias MBBS, LRCP&S, DPhil, DSc, FRCP, FMedSci

Institute of Neurology, University College London ,
National Hospital for Neurology and Neurosurgery, Queen Square, London, UK

Neurovascular and Autonomic Medicine, The Lindo Wing,
Imperial College NHS Healthcare Medicine at St. Mary’s Hospital, London, UK

Graduating with a record of academic excellence from St. John’s Medical College, Bangalore, India, in 1972 and receiving the State Award for Academic Distinction, Mathias set foot in the UK with a Rhodes scholarship to Oxford University. What followed was his trail-blazing career trajectory in the field of Neurovascular and Autonomic Medicine. In 1987 he was awarded the Fellowship of the Royal College of Physicians, London, in 1995 the Doctorate of Science (DSc) in the Faculty of Science at London University and In 2001 he was elected to the Academy of Medical Sciences (FMedSci). In 1991 he founded Clinical Autonomic Research, the first medical journal dedicated to clinical autonomic neuroscience. He is Senior Co-Editor, with Sir Roger Bannister, of Autonomic Failure: a Textbook of Clinical Disorders of the Autonomic Nervous System, which is in its 5th edition in 2014.

Prof. Mathias was Clinical Service and Research Director of two leading NHS and academic departments in London, the Pickering (Neurovascular Medicine) Unit at St. Mary’s Hospital, and the Autonomic Unit at the National Hospital for Neurology and Neurosurgery, Queen Square. The centers were amalgamated in 2014, and are now based at Queen Square. He is Emeritus Professor of the Institute of Neurology since 2014. In 2014 he founded the Autonomic & Neurovascular Medicine Centre at the Hospital of St. John & St. Elizabeth, incorporating the latest techniques and with experienced autonomic personnel.
Prof. Mathias has served on many national and international committees. He was a founding member of the Clinical Autonomic Research Society of Great Britain (Secretary, 1982-1986, Chairman, 1987-1990). He was Foundation President of the European Federation of Autonomic Societies (1998 to 2004). He has served on international task forces (EFNS, American Spinal Injuries Association) and on consensus groups (such as the American Autonomic Society 1996 and American Academy of Neurology, Boston 2007). He was a Trustee of Stoke Mandeville in the Spinal Research (2017-2019).He has been Chair of the Autonomic Group of the Ehlers-Danlos International Consortium, the Ehlers-Danlos Society from 2018.
In the Dr Krishnamoorthy 90th Birthday Memorial Lecture, Prof. Christopher Mathias recollected the warm welcome he had received from Prof. Srinivas when he visited India and discussions on the luminaries Srinivas trained with while in the UK.

Prof. Christopher Mathias traced the history of the development in the field of ANS in the UK, much of which he had witnessed in a key central position as clinician-researcher with the most eminent pioneers in this then somewhat neglected field (Prof. Sir John Spalding, Prof. Stanley Peart and Prof Roger Bannister, to name a few) and in the best UK centres with focus on ANS studies. He took the audience through his professional journey, with fascinating historical references interwoven with the scientific details of his 5 decade long contribution in the ANS field.

Falling Humans, Failing Neurons: Meeting the Challenge of Autonomic Dysfunction

“Faints, falls, fits, flutter, funny turns” was the intriguing list presented by Prof. Christopher Mathias at the outset of his lecture, indicating clinical presentations of autonomic dysfunction with its challenge of falling humans, often pointing to failing neurons. Central to the lecture was the neurovascular and neurohormonal aspects of ANS, stretching from basic knowledge to ‘new millennium disorders’ in this burgeoning field.

Mathias referred to the sympathetic and parasympathetic components of the Autonomic Nervous System (ANS) and the wide range of involuntary control exerted by these components on visceral body functions, often working in opposite directions in their role of homeostatic regulation. Signs and symptoms of autonomic involvement may be related to impairment of cardiovascular, gastrointestinal, urogenital, thermo-regulatory, sudomotor, and pupillomotor autonomic functions.

 Postural  hypotension or orthostatic hypotension (OH) ranging from ‘dizziness’ to syncope , may have multiple causes which  may  be related to  the  heart, brain or    ANS. It may be fixed, as in autonomic failure, or intermittent, as in autonomic-mediated syncope or postural tachycardia syndrome (PoTS). Autonomic –mediated syncope may occur in even superfit persons, such as in vaso-vagal syncope which is the ‘more common form’ of fainting episodes.

OH cuts across several neurovascular ANS conditions. In the normal upright position adopted by the human, the cardiovascular system comes under the influence of gravitational forces, with a fall in pressure above heart level. This exposes the brain to impaired perfusion if adequate adaptive mechanisms are not in place. The heart is unable to achieve adequate perfusion pressure independently and that is where the ANS come to the aid, by monitoring the BP and heart rate. Afferents from the heart, lungs, large vessels and baroreceptors feed information to the brain. The parasympathetic regulation of heart rate (HR) is through the vagus to the heart. There is a parallel sympathetic outflow. Sympathetic output also stimulates release of noradrenaline, which hormone constricts the blood vessels. OH occurs when mechanisms for the regulation of orthostatic (standing) BP control fails. Standing, in normal subjects, results in a fall in blood pressure and this fall is sensed by baroreceptors.  The initial fall in BP is corrected by an increase in heart rate and total systemic resistance with noradrenaline release causing vasoconstriction. Regulation by baroreceptors is also dependent on normal blood volume, and defenses against excessive venous pooling.

Mathias arrived at Worcester College in 1972 with a Rhodes scholarship from Oxford, and as graduate awardee, was offered work on animals in basic sciences. But he had hoped to be engaged in human studies, and preferably in Cardiology. When he showed his disappointment, John Walker, the college tutor suggested that he approach Prof. John Spalding in the Department of Neurology at  Churchill Hospital, who was engaged in research on humans on cardiovascular control linked with ANS.

Prof John Spalding took Dr. Mathias on as supervisor in 1973 at Churchill Hospital   Prof. Spalding was an active member of the Oxford team in the early 1950s that developed the East Radcliffe ventilator following a visit to Copenhagen at the epicentre of one of the world’s most devastating polio epidemics. He was convinced that in the acute phase of severe polio, other than the respiratory distress, the autonomic dysfunction was serious and called for urgent attention. Prof. Spalding wished to expand the scope of understanding the ANS role with similar studies on tetanus on the ventilator. Dr. John Corbett, after being awarded his doctorate, was on the verge of leaving for Ibadan and Lagos, Nigeria for this study. As there were not many cases available in the UK, Mathias hoped to get the required cohort for the study by joining the team. Marked autonomic instability with violent autonomic disturbances, severe hypertension and tachycardia, alternating with hypotension and bradycardia was the clinical picture in severe tetanus. Though “it was an amazing experience, it was difficult to record results in an organized manner” said Mathias.  Back in the UK, he got Prof. Spalding’s nod to continue similar ANS studies in tetraplegics and quadriplegics. Prof. Hans Frankel had taken  over from Prof. Ludwig Guttmann as Director, National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury. Dr. Mathias worked alongside with Prof. Frankel on several significant studies with the crucial clinical approach, taking into account the site and completeness of the spinal lesion.

In his lecture Mathias touched on Sir Ludwig Guttmann’s committed pioneering work at Stoke Mandeville from 1944, with several war casualties with spinal injuries being admitted. He had converted Stoke Mandeville into a centre for comprehensive care in spinal injury patients, and to this day it is run as a national centre of unmatched excellence. Today’s world Paralympics Games (which follows the Olympics in the same arena since 1960), had its humble beginnings as ‘Stoke Mandeville Games’ for Guttmann’s patients and he was the initiator of this and saw it reach such heights of recognition.

In one of the studies at Stoke Mandeville, in head up tilt on control subjects, the upright position produced a normal response. However, in high spinal cord lesion patients, (with no sympathetic outflow) the BP fell markedly, as there was no noradrenaline release.  There was a rise in the HR as the vagus was intact, but did not succeed in bringing up the BP. Were there other substances involved in BP control was the question that researchers faced – perhaps  prostaglandins, acetylcholine or renin-angiotensin. Prof. Stanley Peart was the expert on the renin-angiotensin-aldosterone system, from its clinical role to laboratory isolation and purification of angiotensin. Mathias approached him and through Christiansen (in a specialized Denmark laboratory), levels of a range of relevant substances was measured. Renin levels went up and rolled back, and aldosterone a little later, as it is dependent on angiotensin II. This suggested that the sympathetic nervous system was not the sole factor in BP control. Renin release and other mechanisms were involved, perhaps with the kidney as the source. Suprapubic tap resulted in BP rise and renin release. The conclusion drawn was that in tetraplegic patients, renin release during head-up tilt may occur independently of sympathetic nervous activity and is probably largely dependent on activation of renal vascular receptors. The renin-angiotensin-aldosterone system plays an important role in regulating blood volume and systemic vascular resistance, which together influence cardiac output and arterial pressure. For the first time this saw linking of the pathophydsiological lesion with the substances involved.

In a subsequent study, noradrenaline was infused through an intrarterial line in the arm or lower limb, an invasive procedure, to make it possible to monitor BP and HR continuously. Circulating noradrenaline during infusion did not significantly differ between the tetraplegics and the controls. However, over a wide range of doses by infusion, the blood pressure rose much more in the tetraplegics than in the controls. The findings indicate that tetraplegic subjects have an enhanced pressor response, as seen in the supersensitivity to the infused noradrenaline.

 Mathias did a stint in General Medicine between 1976 to 1979 at London and Portsmouth, paving the way to his MRCP, which was awarded in 1978. Following this period, Prof. Sir Stanley Peart suggested that Mathias continue in the ANS field. In 1978 he was awarded the Wellcome Trust Senior Clinical Research Fellowship. He had the honorary post as clinical assistant to work with Sir Stanley Peart at St. Mary’s Hospital and Medical School, University of London near Paddington, (the hospital where Sir Alexander Fleming discovered penicillin).

The Medical Unit at St. Mary’s was the hub of activity then, and a major study that Mathias was involved in, was ‘Neurogenic and renovascular hypertension-central and peripheral mechanisms in renal artery stenosis’ The underlying mechanism in renovascular hypertension involves decreased perfusion to the kidney and activation of the renin-angiotensin-aldosterone (RAAS) pathways to  elevate blood pressure by direct peripheral effects ( from increased afferent renal nerve activity) and probably through stimulation of sympathetic activity, which may  result from the central effects of angiotensin-II. The chronic ischemia produced by the obstruction of renal blood flow leads to changes in the kidney and  secretion of renin, the renin angiotensin –aldosterone system playing  a role.  Angiotensin  is responsible for vasoconstriction and release of aldosterone which causes sodium and water retention, thus resulting in secondary hypertension or renovascular hypertension as demonstrated experimentally  in patients with renal artery stenosis. The neurogenic components maintaining hypertension in renal artery stenosis are largely dependent on renal ischaemia, as revascularization by surgery, ameliorates or cures the hypertension in the majority of the patients studied. Denervation of the peripheral blood vessels by ablation demonstrated marked reductions in blood pressure in patients with resistant hypertension and elevated renal sympathetic nerve activity.

In 1984 Mathias was awarded a Wellcome Trust Senior Lectureship in Medicine, held jointly between St. Mary’s and the Institute of Neurology, working with Professor Sir Stanley Peart and Sir Roger Bannister till 1992. The  collaborative  study was on disorders with progressive autonomic failure –Parkinson’s disease, Multiple System Atrophy and Lewy Body disease, with cohorts for each one of these conditions.  Pure autonomic failure (PAF) which often presents with orthostatic hypotension, reduced heart rate variability, anhydrosis, erectile dysfunction, and constipation, without motor or cognitive impairment, was also studied.

In 1987 Prof. Mathias was awarded the Fellowship of the Royal College of Physicians, London (FRCP). Interdisciplinary studies in nocturnal polyuria, post prandial hypotension, exercise-induced hypotension and Dopamine beta hydroxylase deficiency were the studies that followed.

 In May 1991 the University of London conferred on Prof. Mathias the title of Professor of Neurovascular Medicine, held between St. Mary’s Hospital Medical School and the Institute of Neurology, British Postgraduate Medical Federation, London. He was Clinical Service and Research Director of two leading NHS and academic departments in London, the Pickering (Neurovascular Medicine) Unit at St. Mary’s Hospital, and the Autonomic Unit at the National Hospital for Neurology and Neurosurgery, Queen Square. These were tertiary referral centres serving the entire United Kingdom, also with international referrals. He pioneered the creation of clinical autonomic scientists, developments in laboratory autonomic testing, and with autonomic nurses, developed and streamlined autonomic diagnosis, investigation and treatment of many autonomic conditions.

That same year, Prof. Mathias founded the first medical journal dedicated to clinical autonomic neuroscience and served as editor till 1995, and continued as co-editor till 2013.  Another important publication in Dec. 2001 was, of Autonomic Failure: a Textbook of Clinical Disorders of the Autonomic Nervous System, as Senior Editor, with Sir Roger Bannister.

In1995 Prof. Mathias was awarded the Doctorate of Science (DSc) in the Faculty of Science at London University. In2001 he was elected to the Academy of Medical Sciences (FMedSci). It was in recognition of Prof. Mathias’ contribution to ‘information of enormous value to both physiology and medicine in his work on supposedly rare disorders’.

In Feb. 2001, the analysis of 641 patients between 1992-1998, with recurrent syncope and presyncope, after cardiac, neurological, and metabolic causes were  excluded, was published. Autonomic aetiology was diagnosed in 310 cases on the basis of clinical features and screening autonomic tests. Orthostatic hypotension and confirmed chronic autonomic failure was the diagnosis in 31 (4·8%) patients; neurally-mediated syncope was diagnosed in 279 (43·5%).  Most of this group had vasovagal syncope (227 [35%]); other causes including carotid sinus hypersensitivity (37 [5·8%]), and a group of 15 (2·3%) were associated with rarer causes such as micturition syncope. 331 cases were of a miscellaneous, non autonomic group, rare cardiovascular causes like systemic hypotension, arrhythmias, or drugs, contributing to syncope in 53 cases; vestibular dysfunction in 32 and epilepsy in 11 cases of non-autonomic neurological causes. In 56 a psychiatric cause was thought to be contributory and in 179, the syncope was of unknown cause.

Progressively, there was an exponential rise in clinical referrals to the Neurovascular and Autonomic unit from 500 cases earlier to about  5000 cases and the various factors responsible for this increase was analysed. The above study brought to focus the significant role of autonomic testing in syncope and presyncope for evidence-based diagnosis, and management. Autonomic testing equipment and specialised laboratory tests had progressively improved and expanded their scope. Aside from this, the journal Clinical Autonomic Research, started in 1991, had gained in recognition and had established itself as the official international journal of the American Autonomic Society, the Clinical Autonomic Research Society of Great Britain, and the European Federation of Autonomic Societies and this led to referrals from outside the country as well. ‘New millennium autonomic disorders’, like PoTS required specialty diagnosis and management and new innovative approaches were employed. Prof. Stanley Peart’s leadership and expertise,- “His uncanny prescience about new millennium autonomic disorders” as Prof. Mathias put it, contributed immensely to the progress in the field.

PoTS, a rare clinical syndrome characterized by an increase in heart rate of at least 30 beats per minute on standing, and orthostatic intolerance, In PoTS, standing brings on symptoms such as palpitations, lightheadedness, brain fogging, and fatigue. It is a  major cause of orthostatic intolerance  especially in the young. 13-40 years, with greater prevalence in the female sex. Symptoms are often exacerbated after food ingestion, exertion and heat. The onset of PoTS often is linked to a triggering stressful event, followed by a long period of bed rest. Patients with PoTS are trained to live with the condition and avoid precipitating factors. The most common associated condition is the joint hypermobile form of Ehlers-Danlos syndrome.

 Prof. Mathias was involved in functional autonomic brain imaging studies with Prof. Hugo Critchley at the Wellcome Neuroimaging Lab at Queen Square from 2002.  Dr Critchley’s  research focused primarily on mind-body-brain interactions and he had published widely on emotion, autonomic psychophysiology, and interoception. Many autistic and  ADHD individuals struggle with awareness and response to interoceptive signalling of the  state of the inside body and the  ability to identify, understand and respond to them, which is so crucial  to survival.

The coupling of cognitive and emotional behaviour with sympathetic arousal was studied. with Prof. Criitley. One such .fMRI study to examine regional brain activity associated with autonomic cardiovascular control was during performance of effortful cognitive and motor tasks (which involves stress). 3 patients with focal damage of the anterior cingulate cortex (ACC), while they performed these tasks, had abnormal autonomic cardiovascular responses and blunted autonomic arousal to the mental stress, unlike in the 147 normal subjects tested in identical fashion, where the ACC supports generation of associated autonomic states of cardiovascular arousal.

Prof. Christopher Mathias is Emeritus Professor of the Institute of Neurology  since  2014. He founded the Autonomic & Neurovascular Medicine Centre at the Hospital of St. John & St. Elizabeth incorporating the latest techniques and with experienced autonomic personnel.