Reimagining Stroke Care
/When I had a concussion, the physician wagged her finger at me with a prescription for sensory isolation for 3 days - no screen time, no reading, no bright lights, no music. I had brought 5 books with me to work on a syllabus that weekend, which I did diligently for 5 hours.
Having been trained in working with people with brain injuries, I yielded immediately to that wagging finger. I knew what she meant and how important it would be to give my brain a rest.
Why don’t we offer these same prescriptions for people who have had strokes? Or are in a disordered state of consciousness (vegetative or minimally conscious)? Why is it that concussions get the sensory isolation? We learned through Haldelise Als’ work at Children’s Hospital in Boston. Her life’s work and research was changing the sensory experiences of Neonatal Intensive Care Units from being loud beehives of activities and alarms to one that is more sensorially appropriate for the immature nervous system.
People who have had strokes or other kinds of serious brain injuries also need those considerations of light and sound. The brain needs to be internally focused on repairing itself, on sorting itself out. The brain need not be aggravated by external sources of sound and light.
Consider this description by Jill Bolte Taylor, a neuroanatomist who had a massive brain hemorrhage. When she finally got help and got to a neurologic intensive care, she wrote:
Paying attention to what someone was saying took an enormous amount of effort, and I found it to be tiring. First, I had to pay attention with my eyes and ears, neither of which were working normally. (Bolte Taylor 2006, p. 76)
Normally we only need to use our ears to understand language. In times of compromised function, we have to use other modalities in support of that function.
My brain had to capture the sound (auditory signal) and then match that sound up with a specific lip movement (compensation with the visual system).
Then, it had to search and see if there was any meaning for these combinations of sounds stored anywhere in my wounded brain (this is matching what you hear with what you know).
Once I got one word figured out then I had to search for a combination of words, and with an impaired mind, that took hours! (Think about this last sentence, it contains 24 words and yet you had no problem understanding it. A person with a stroke is greatly challenged to understand one word at a time.)
In those initial days and perhaps weeks, people should be taught to signal or say, “I need a break.” When they do, they should rest. Sleep refreshes brain functions like restarting a malfunctioning computer. Let sleep do its work. And when the person is awake, it’s time to work, woven throughout the day, embedding work in functional contexts with much repetition. These are the keys to helping the brain repair itself.
The repairs have to happen in two important directions. That is because there are two primary aspects of the brain, one is the older brain that we share with other mammals and the second is the higher functioning brain that makes us the unique, creative, innovative, problem solving species that we are. The old part of the brain is known as the limbic system and is very much informed by sensory systems like sight and sound. We have to be able to hear properly in order to make sense of auditory stimuli. In order to do that, music is strongly indicated but dosed properly.
A study done in Finland by one of my favorite labs (Särkämö, et al. 2008) showed that listening to music improved recovery in the domains of verbal memory and focused attention. This contrasted with groups of patients who were listening to audiobooks and those who were in a control group.The music group also experienced less depression and confusion than the control group which is key to having the motivation to work hard in neurorehabilitation.
So, let people rest when they are tired.
Let’s make them tired for really good reasons by working them throughout the day, not just 30 minute or 1 hour blocks. It can be too exhausting.
Give them time to absorb the directions, the prompts, the schedule, medications.
Let’s give the brain what it needs to repair itself which is a controlled sensory diet.
Let’s rebuild the brain in the way that it was built in the first place - through sound.
Music is the ideal auditory stimulation because of the repeated patterns and emotional content. It is familiar, personal and welcomed during hospitalizations and should be considered an asset to recovery, resilience and well-being.
Bibliography and Resources
Bolte Taylor, J. (2006). My stroke of insight: A Brain Scientist's Personal Journey. New York: Penguin
Jill Bolte Taylor’s most excellent TED talk seen by over 26 million viewers
The research of Haidelise All: http://www.childrenshospital.org/research/researchers/a/heidelise-als