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

www.strokecamp.org

http://www.unitedstrokealliance.org/

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Stroke Support Group Finder Link

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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.
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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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Apraxia vs. Aphasia

information obtained from Marylee Nunley our Executive Director

This is a transcript of a video presentation by Dave Valiulis who comes to our camp in Rockford, Illinois. He has done some public speaking and is an all around nice guy. He helped us while we were at a stroke conference recently in San Diego since he lives there.

Dave presented a longer, somewhat different version in the “Communicative Disorders” class at a Program in Communicative Sciences and Disorders of Cal State, San Marcos, San Diego, 2012.

The video follows this text transcript version.

By Dave Valiulis

My name is David, and this is not how I sounded 4 years ago.

For no apparent reason, in 2008, a clot reached my brain, giving me a stroke. As a result...

My right side didn’t work and I couldn’t speak at all. Back then, I figured this wasn’t permanent, that soon I would snap out of it. I was right and also wrong. I can walk again and I can move my right hand again. And I can even talk again – sort of.

Back in ‘08, I had the following 3 speech conditions: 

     - I was unable to say words clearly or loudly enough. This is 
       calleddysarthria.

     - On top of my dysarthria, I had expressive aphasia -- knowing 
       what you want to say but you can’t think of the words to say it.

     - On top of my aphasia, I also had apraxia of speech -- not being 
       able to remember how to make your mouth say the words you 
       want to say.

   My dysarthria lasted about 6 months. My aphasia lasted about 2
   years. And my apraxia is 4 years and counting.

I have often wondered about which is worse – having aphasia or having apraxia.

Certainly, my aphasia was worse in the beginning because it prevented me from remembering the words for a thought. Aphasia also made me confuseyes with no, he with she, and will with would. It also made even the simplest email very hard without leaving out small words like the and of. But I am thankful I had a good kind of aphasia, one that left my comprehension and reading intact. In any case, it has gotten a lot better over the years.

But my apraxia is another story. It still plagues me with every word I speak. That is why I speak so slowly, so deliberately. That is why I must think about every word, every syllable, every sound.
All this, and no one has even heard of apraxia. Only 11% of stroke survivors even have it. No one can relate to apraxia or really understand it – unless they have it.

But everyone can relate to aphasia. After all, aphasia is like having a word stuck at the tip of your tongue … and everyone gets that from time to time. And lots of people have heard about aphasia since Gabby Giffords was shot. Why, aphasia even has its own month devoted to it (June).

But to explain apraxia, you have to give a detailed explanation of how speech happens. You have to say something like this…

     1. Speech begins with an idea of what you want to say.

     2. The words of what you want to say must be put in the right
         order and grammar.

     3. Then you have think about the sounds -- and the sequence of
         sounds -- that make up those words.

     4. All this information has to be translated into a series of highly
         coordinated motor movements of the lips, tongue, jaw, and 
         palate.

     5. The brain must tell the muscles the exact order and timing of 
         movements so that the words are properly said. In children, 
         once those words are spoken repeatedly, the speech motor act
         becomes automatic. These speech motor-plans are stored in 
         the brain to be easily accessed as muscle memories.

All this is my preamble to saying apraxia is the loss of these muscle memories. Stroke survivors like me who have apraxia have to slowly and with effort relearn these motor plans – in effect, our whole childhood’s speech process has to be relearned.

· So when I hesitate now, it’s not because I don’t know what to
   say; it’s because I have to think about how to make my mouth 
   move to say it.

· When I say a word over and over, it’s not because I am 
   perseverating; it’s because I am practicing – listening and making 
   adjustments.

· When I speak in a monotone, it’s not because I’m thinking like a
   robot; it’s because I’m struggling with every syllable.

· If I sound like I have a learning disability, it’s not because my 
   intelligence is faulty; it’s because my stroke reset my muscle
   memories to a child’s.

And that is why my voice has changed since my stroke. Stroke survivors all say that you never realize how many things you take for granted until they’re taken away. This is especially true of apraxia, since what it has taken away from you is so hard to explain and so hard to do without.

But I’m still working on my apraxia, making new pathways from my brain to my mouth that hopefully will last a lifetime this time!

Thank you.

Here's the video presentation given by David: 
http://www.youtube.com/watch?v=Gpz2ukhyy2I&feature=youtu.be

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Life is filled with a lot of "one liners"

By Monica Vest Wheeler

I've heard and seen enough at Retreat & Refresh Stroke Camps since the summer of 2008 to fill a couple dozen books just about camp and the amazing array of individuals who gather at these unique weekends.

The survivors, caregivers, volunteers and staff who gather at each of these weekend events were brought together for a reason. Executive Director Marylee Nunley often says everyone who is there was meant to be there, and that's why every camp is so different, even if a single theme is followed an entire year. It's all about the people.

I've scribbled countless notes through the years, and I have discovered an abundance of "one liners" within this collection. These are statements or simple observations that have been uttered or written at camps by anyone and have left a powerful impression upon me.

Yes, I'm ALWAYS listening and watching and absorbing. Revisit some of these moments with me …

• A volunteer wipes her eyes, tearful at the conclusion of a camp weekend and looks at the survivors: "My legs hurt, but you take a step forward every day. You’re all my heroes.”

• A survivor announces, "I’m adjusting to the new life.”
Another reminds him, “Don’t regret the old life.”

• One survivor tells another, “One of these days, you’ll get those fingers moving. Sometimes it hurts, but you get used to the pain.”

• A survivor with aphasia writes on a whiteboard, “Where would we be without our mouthpieces (caregivers)?”

• A caregiver says, "I'm reinventing my dream in a new way."

• A survivor says, "My stroke made me stronger. I have a list of things I get to do, even if have to find a new way."

• A survivor reflects, "If I did one step every day, imagine how far I would get in six months."

• A survivor tells her fellow survivors, "Everybody has a choice. God has work for us, so get to it. No time for a pity party. We have a life to live."

• A caregiver says, "He doesn’t know where he’s coming from. I should have had video. I would have shown that to him to show his progress. He doesn’t know the difference."

• A caregiver explains, "I came across people who know how to see through you and read you. It was surprising when I'd find people who 'get it.' Hang onto that to get you through until you meet the next person to carry you through the next step."

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Music Therapy - Enhancing Stroke Recovery

I have published music therapy articles on this blog before but I think this one is also worth passing on. This caught the eye of Marylee, our Executive Director, in the StrokeNet Newsletter web site she subscribes to. The article touches on some of the music and drum circle benefits we've noticed at our camps.  

This article was originally submitted in their February newsletter by David Wasielewski, a member of the StrokeNet Newsletter staff:

At a recent stroke group meeting a member with significant aphasia described his experience in joining a singing group, how his ability to sing was almost unaffected by his aphasia and that he had noticed some improvement in his normal speech that may have resulted from the singing. Some investigation and an email from Avi Golden, a Stroke Network member, brought to light some interesting information that demonstrates that singing and Music Therapy can help recovery from stroke in a variety of unexpected ways.

Music therapy research has demonstrated that this is an appropriate treatment for brain trauma recovery such as stroke. ‘Music therapy programs provide opportunities for clients to learn alternative means for undertaking daily tasks to accommodate for the neurological impairments that inhibit brain and physical function.’ It helps clients develop capabilities to recover what has been lost. Music Therapists can use music as a planning and memory tool.

Complex tasks are incorporated into a ‘song lyric’ to help survivors remember and organize all aspects of a complex task such as making a sandwich or getting dressed. Occupational and physical therapists have found that exercising to music helps survivors enhance recovery of physical functions, much the same as music helps healthy folks with ‘normal’ exercise routines. As we survivors often hear, much of the recovery from the trauma of stroke is dependent on neuroplasticity or the ability of the brain to rebuild function by developing new neural connections.

All Therapies encourage the rebuilding and of lost skills (recovery) or finding another brain function that allows the survivor to accomplish a task in a different way (compensation). Research in Music Therapy focuses on the ‘perception and production of music’ and its ‘effects on brain and behavior’. These effects on the brain can be categorized. One area of research focuses on how music and auditory stimulation relates to the synchronization of rhythmic physical movement.

Dance and jazzercise are examples of how music facilitates movement and physical memory. Does music enhance the brain’s ability to learn new motor skills? This research touches on the notion that music and its rhythmic character promote the synchronization of many related brain activities and that the simultaneous firing of these multiple groups of neurons helps promote recovery from the trauma of a stroke.

This follows the popular notion that neurons that fire together, wire together, creating effective new circuits. Repeating an experience utilizing musical rhythm enhances development of these new circuits and recovery of brain function. Music therapy is effectively administered according to the Neurologic Music Therapy (NMT) model. Researchers have demonstrated that gait training, walking with auditory stimulation, music, is more effective than without that stimulation.

The same favorable effect has been demonstrated in non-physical functions. One researcher describes a client who could not accomplish the complex task of getting dressed in the morning. After learning a song that described the task, the patient became much better at completing the task independently. The stimulation of rhythm and language improved the client’s memory, motor planning and proper sequencing of dressing activities. Song lyrics supplemented with a melody and tempo helped overcome his deficits.

Aphasic patients see similar benefits. Survivors who undergo intense musical therapy are able to better generate phrases in ‘out of therapy’ situations. Aphasic survivors who have difficulty with word retrieval are able to self- generate learned auditory cues to help with word recovery. Music therapy and singing have been successful with increasing vocal range, breath control and rate of speech.

The demonstration of successful new music therapy interventions offers survivors alternatives and supplements to traditional PT and OT therapies. The added variety of brain stimulation provided through Music Therapy is not only effective in enhancing speech therapy but has also proven to be effective in non-speech related tasks like gait training and recovery of other physical functions.

Based on this research survivors might explore Music Therapy to supplement their current traditional treatments. A conversation with your therapist might lead to some additional progress in recovery

Thanks to Avi Golden and my stroke support group for suggesting this topic.

Reference: Neuroplasticity and Functional Recovery: Training Models and Compensatory Strategies in Music Therapy  Baker, Felicity: Roth, Edward A. Nordic Journal of Music Therapy, 13(1) 2004, pp. 20-32.

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If you are interested in subscribing to the StrokeNet Newsletter go to:

http://www.strokenetwork.org/ 

It's free and there are many good articles on stroke related issues.

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