Sunday, September 28, 2014

Uncontrollable Laughter or Crying from Stroke Survivors

This article by David Wasielewski was posted in the September StrokeNet Newsletter the same time as Walt Kilcullen's article on "Dealing with Five Disabilities After Stroke" article in July 2014.

The StrokeNet site is an excellent source of information. 

Go to: www.strokenetwork.org

To contact David email to: newsletter@strokenetwork.org


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By David Wasielewski

Pseudo Bulbar Affect Disorder and Stroke Survivors

Many stroke survivors deal with the obvious challenges that stroke presents. Loosing physical use of one or more body parts, the ability to speak and or understand language. These losses are all readily apparent to caregivers and social contacts. But there are also a number of less obvious challenges that confront some survivors. One of those is Pseudo Bulbar Affect Disorder (PBA).

The symptoms of PBA are inappropriate outward or physical responses to emotions that the individual experiences. An affect is the physical manifestation of an emotion. The error in the affect defines the disorder. PBA has a range of effects and each survivor has their own experience. In its most severe case the survivor will display an affect that is opposite of the emotion experienced. A person hearing a funny joke may begin to cry, or a death in the family will bring the survivor to a hearty laugh.

In other cases the physical display varies in degree to what is appropriate or normal. The accidental breaking of a dinner plate might cause the survivor to cry uncontrollably or a slightly funny comment might cause prolonged loud laughter. The degree of the response is not appropriate. There is no difference between being slightly sad and uncontrollable crying. The response is always extreme. The inability to manage one’s emotional responses in day to day activities can be quite challenging for the survivor.

Not knowing what may cause an outbreak of crying or laughter may cause the survivor to isolate themselves to avoid embarrassment. In some extreme cases the survivor might even lack the personal insight to recognize that this is happening. It is also uncomfortable for caregivers and other social contacts. Others who do not fully understand the situation will tend to avoid the survivor in order to eliminate the uncomfortable situations. There is the perception that the survivor is mentally unbalanced. In any case, this invisible disability tends to isolate the survivor and make care and support more difficult than it already is.

I was stunned when I initially experienced this disorder. When I woke up in the hospital after my stroke I found myself crying uncontrollably when speaking to my family. As I expressed my concerns to the nurse she carefully explained that the overly emotional response was a result of the stroke. While this explained why I was so emotional she offered no advice as to how I might deal with the condition. I needed to develop some strategies on my own.

Over time (years) I have learned how to partially manage my reactions to events. If I’m aware that my emotional responses might be inappropriate in certain situations I will simply withdraw. I find myself leaving funerals when overcome. I often avoid telling funny stories or jokes as my laughter prevents me from completing the tale. If a situation is unavoidable I will try to explain the condition so others can understand.

The condition is particularly frustrating when I am involved in serious discussions. In situations where I should be mildly angry or upset my body reacts with laughter. This makes such discussions difficult for me, the person I’m dealing with and continuing on almost impossible. Often I need to withdraw instead of continuing on, leaving the topic unresolved.

So what is the survivor with PBA to do? Fortunately, there are some strategies to practice. When one feels an event coming on the survivor needs to find thoughts to distract him/herself from the topic. Imagining oneself in a calm place can be effective. Counting slowly to ten can distract the survivor from an emotional response. Deep, slow breathing often helps alleviate one’s reaction. Recently, several medications have come to the markets that are designed to manage PBA. Nuedexta is marketed for the condition. More information is available at: http://www.stroke.org/site/PageServer?pagename=PBA

It is most important for the survivor to identify the condition and explain it to friends, family and caregivers. This may not prevent the uncontrolled emotional response but it will allow others to recognize this somewhat unusual behavior as part of the effects of the stroke. Recognizing this as a condition and helping the survivor deal with it can help them overcome the stigma of PBA as they work to maintain their social relationships during their recovery.

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Sunday, September 21, 2014

Emotions - Dealing with the Five Disabilities Resulting from Stroke Part II

In last week's article written by Walt Kilcullen you read about two more of the five disabilities caused by a stroke. This week's article concludes the series and deals with the remaining disability: emotion. Part 2 was originally posted in its entirety in the September issue of the StrokeNet Newsletter at:
http://www.strokenetwork.org/newsletter/articles/disability02.htm

If you wish to contact Walt, he may be reached at:
newsletter@strokenetwork.org

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by Walt Kilcullen

Part 2.

V. Problems with Emotion


V. Problems with Emotion: Many people experience a range of emotional changes after a stroke. These changes can cause the person’s personality to change and can be disruptive and problematic.

Depression is a common condition after a stroke. It can be mild or it can be all consuming. Although depression is a normal part of grief after a stroke, if it continues for the long run, professional help is
called for.

Anger is also common after a stroke. In my support group, once every two months we split into two groups; one for survivors and one for caregivers. Many times I have heard a caregiver complain about fits of anger from their loved one for no apparent reason.

Emotional Lability is a condition of the brain that causes sudden, uncontrollable crying or inappropriate laughter. Of course this can result in embarrassing situations for both the survivor and the caregiver.

Apathy is not the same as depression even though the behavior is similar. The survivor, who is apathetic, cannot seem to get motivated. He stays in bed too long, sits or lies on the couch for hours, and often will not leave the house.

Anxiety is an unpleasant feeling which often includes nervous behavior such as wringing the hands or pacing about. It is a feeling of fear or distress over something that is unlikely to occur such as a heart attack or car accident.

Treatment options for problems with emotion:

● Antidepressants, drugs that control mood, psychological counseling, and psychiatric therapy are treatments for depression, anxiety, and anger management.

● Apathy is more difficult to treat because there are no drugs available to treat it. However, therapists and counselors have had success by developing a routine for the patient to follow. This includes getting up every day at the same time and scheduling events or activities at certain times each day. The focus is on action which will later lead to motivation toward everyday life.

● I could not find any treatment for emotional lability, but fortunately after a few months, it usually (but not always) fades away.

I wrote an article in the September, 2012 issue of strokenetwork.org on anger and aggressive behavior. There are drugs that are sometimes successful in treating this problem, but there is much the caregiver can do to lessen anger.

● Remember that anger and aggressive behavior are a result of the stroke. Your loved one cannot always control this behavior.

● Stay calm. Do not over react to your loved one’s outbursts. Speak slowly and softly without raising your voice until your loved one calms down.

● Avoid arguing or confrontation with your loved one. Redirect her attention to something else.

● After you identify things that create anger in your loved one, avoid them as much as possible. For example, if you observe that being around a large group of people sets her off, avoid that environment.

● If you as a caregiver become angry or frustrated, back off and cool down. Chances are she will also calm down after you step back and remain calm.

● Stay safe. If your loved one becomes violent, back away keeping a safe distance, and seek help if need be. 
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Sunday, September 14, 2014

Language and Memory - Dealing with the Five Disabilities Resulting from Stroke Part II

In last week's article written by Walt Kilcullen you read about two of the five disabilities caused by a stroke. This week's article deals with two more of the remaining disabilities he addressed, and next week I will conclude the series with what Walt wrote about emotions. Part 2 was originally posted in the September issue of the StrokeNet Newsletter at:
http://www.strokenetwork.org/newsletter/articles/disability02.htm

If you wish to contact Walt, he may be reached at:
newsletter@strokenetwork.org

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by Walt Kilcullen

Part 2.

III. Problems with language
IV. Problems with Memory and Reasoning

III. Problems with language: Language difficulties include the ability to speak, understand, write, read, add and subtract. All of these problems occur as a result of a left brain stroke.

Aphasia, which has many components, can be simplified by using just two terms. Expressive aphasia is the lack of ability to verbally express thoughts. The survivor can understand what is said, but response can be one word, or just a few words. Sometimes speech can be extremely slow, while other patients speak so rapidly, it is difficult to understand them. The second category is receptive aphasia. Sounds are heard but the patient cannot understand what was said.

Alexia simply means the lack of the ability to read. My experience is that both expressive and receptive aphasia patients experience difficulty in reading.

Agraphia simply means the lack of ability to write. This usually, but not always, goes along with Alexia.

Acalculia is the loss of mathematical ability including addition, subtraction, division, and multiplication.

Treatment options for problems with language:

An article that I wrote for the June, 2009 issue of the Strokenetwork.org newsletter deals extensively with aphasia. I recommend the following:

● Join an aphasia support group. Check www.aphasia.org to find one in a location near you.

● Investigate the use of computer software and speech devices to see if they can help you with speech therapy on your own.

Bungalow software, Parrot software, Communication Script Inc, and Lingraphica are examples.

● Investigate clinics and community groups that specialize in aphasia. Again visit www.aphasia.org to see what is available in your state. Be sure to get details such as cost, and success rate before you invest your time and money.

I also wrote an article for the July, 2011 issue of the StrokeNet dealing with alexia. Although there are numerous exercises available, none to date have a high success rate.

Hope for the future

● Pharmaceutical companies are testing drugs such as Piracetam, amphetamines, and Bromocriptine to improve speech for aphasia patients.

● Neural Regeneration has also shown promise. Researchers have used cell transplantation which is designed to restore brain tissue after a brain injury.

● Constraint Induced Aphasia Therapy has also shown positive results. During CIAT, the speech therapist spends three hours per day, five days per week, for three weeks giving intensive speech therapy targeting the patient’s specific weaknesses.

IV. Problems with Memory and Reasoning: Stroke can result in problems with short term memory, judgment, and also the ability to plan, comprehend meaning, learn new tasks, and solve problems.

Apraxia is the impairment or loss of ability to carry out learned movements despite having the desire and the physical ability to perform the movements.

Anosognosia is a deficit of unawareness. The patient seems unaware of the existence of his or her disability.

Treatment options for problems with memory and reasoning:

● Most stroke survivors recognize their short term memory loss and are able to adjust to it. Cognitive therapists develop strategies such as keeping a daily planner which focuses on organizing activities one day at a time.

● There is little consensus on assessing apraxia but treatment includes speech, occupational and physical therapy. Some patients show significant improvement while others do not. Unfortunately, those patients that do not respond to therapy may not be able to function independently. There is no drug available to treat apraxia.

● No long term treatment is known to help anosognosia, however, the condition usually disappears in time.
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Next week, I will post what Walt wrote about emotions. I thought emotions deserved a posting by itself. Stroke survivors can experience very strong emotions such as anger and depression and they and their caregiver must learn how to own these emotions rather than let the emotions own them. I would also like survivors know that they are not alone with these emotions and that other survivors are dealing with them also. The survivor and caregiver must come to realize that these feelings are the result of the stroke and not always under the control of the survivor yet they can be dealt with to some degree with medication and therapy. Walt addresses these issues next week. 
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Sunday, September 7, 2014

Dealing with the Five Disabilities Resulting from Stroke Part I

By Walt Kilcullen

The following is Part 1 of a 2 part series titled Dealing With Five Disabilities Resulting from Stroke by Walt Kilcullen.  Part 1 deals with two of the five disabilities. 

Part 1 was originally posted in the July issue of the StrokeNet Newsletter at: http://www.strokenet.info/newsletter/2014/july.htm

If you wish to contact Walt, he may be reached at: newsletter@strokenetwork.org

Part 1.
I. Movement dysfunction and paralysis
II. Sensory dysfunction

The degree of motor damage and cognitive damage as a result of a stroke varies greatly from patient to patient because of the part of the brain affected or damaged and how badly the brain was damaged. In this article, I have examined the first two of five categories of disabilities and how a survivor can deal with each. The other three will be discussed in September.

I. Movement dysfunction and paralysis: If a stroke happens on the left side of the brain, it will affect the right side of the body. A left brain stroke will affect the right side of the body.

Paralysis can be on either side of the body. It can be of the foot and leg, the arm and hand, or both. If there is total paralysis, there is no treatment to improve or reverse that condition.

Dysphagia, or difficulty swallowing, occurs in some patients but is usually greatly reduced or cured early on by a speech therapist.

Ataxia affects the body’s ability to coordinate movement which leads to difficulties with body posture, balance, and walking.

Spasticity or tone “is a condition where muscles are stiff and resist being stretched. It can be found throughout the body but may be most common in the arms, fingers or legs. Depending on where it occurs, it can result in an arm being pressed against the chest, a stiff knee or a pointed foot that interferes with walking. It can also be accompanied by painful spasms.” (Stroke: A Stroke Recovery Guide, a publication of the National Stroke Association, p. 52).


Treatment Options for partial paralysis, ataxia, and spasticity

● A combination of physical therapy, occupational therapy, and medication is standard treatment.

● Exercises for strength, balance, coordination, stretching, or range of motion can be helpful.

● A brace on the affected leg to provide support and to correct foot drop is often prescribed.

● Injection of Botox into the affected area to relax the muscles by blocking the nerve activity that creates the stiffness has proven to be helpful in some patients.

● Baclofen Therapy has been successful for some patients in treating severe spasticity. Baclofen is injected into the spinal fluid using a surgically places pump.

Constraint Induced Movement Therapy has been under experiment and has shown great promise. It is designed for patients who have arm weakness and spasticity, but the patient must have some ability to move the hand. If you are interested in this research, Google: CIMT Edward Taub.

● Research is in progress using stem cells, and transcranial magnetic stimulation with the goal of reversing at least some of physical damage done by stroke



II. Sensory dysfunction: In some stroke patients, pathways for sensation are damaged resulting in pain in the side or the limb being blocked. Decreased feeling in the limbs, numbness or burning in the limbs and pain are examples of sensory dysfunction.

Decreased feeling usually in the limbs can occur but is not common.

Tingling, numbness, or burning usually in the limbs can occur but is not common.

Pain is the most troubling sensory problem because it is more frequent than the other sensory problems and it is usually more debilitating. Pain is often caused by nerve damage, or sometimes from lack of movement.

Treatment options for sensory dysfunction:

●  Decreased feeling, tingling, and burning in the limbs is very difficult to treat especially because what works for one patient may not work for another. Some patients report that continuous light exercise brings relief. Acupuncture, heat application, meditation, and prescribed medications are also reported by some to give relief.

● Pain is also difficult to treat because pain after a stroke can occur in various parts of the body. I wrote an article in the July, 2013 issue of the strokenetwork.org newsletter where I give tips on reducing pain. Yoga and meditation can help relax and teach the patient to breathe properly.

● Progressive Muscle Relaxation (PMR) is a step-by-step technique that helps the patient become aware of muscle tension and reduces the tension through a systematic approach that reduces pain. You can look at the PMR web-site to see visuals that will walk you through the PMR exercises.

● The Trigger Point Therapy Workbook: Your Treatment Guide For Pain Relief by Clare Davies has received nothing but good reviews on Amazon. Readers should give this a try.

● Chronic pain deserves treatment by a pain management specialist, and/or acupuncturist.
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Part 2 of this article will be published later in the September.

Areas covered will be:

III. Problems with Language
IV. Problems with Memory and Reasoning
V. Problems with Emotion

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