Diane talks with Mary McCord, Legal Director at the Institute for Constitutional Advocacy and Protection and Visiting Professor of Law at Georgetown University Law Center.
Guest Host: Susan Page
Strokes kill an estimated 130,000 Americans a year, but fast access to medical treatment can and does save lives. Stroke survivors typically face a number of physical and cognitive disabilities including the inability to speak. For years doctors believed that if a patient could not regain language within a few months to a year after a stroke, prospects for further recovery were limited. But now it’s known that stroke victims, as with those who suffer other types of brain injuries, can continue to make progress years after the initial injury. Guest host Susan Page and stroke rehabilitation experts talk about the recovery process.
- Dr. Peter Turkeltaub Assistant professor of neurology and director, Cognitive Recovery Lab and medical director, Center for Aphasia Research and Rehabilitation, Georgetown University Medical Center.
- Dr Alex Dromerick Director, Neuroscience Research Center and director, Comprehensive Stroke Research Program, MedStar National Rehabilitation Network.
- Audrey Holland Professor of speech and hearing sciences, University of Arizona.
MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA Today sitting in for Diane Rehm. Strokes are the leading cause of disability in the United States today. While most strokes survivors are seniors, the number of people under 55 who suffer a stroke has been growing. Joining me to talk about the stroke rehabilitation and recovery process, Dr. Peter Turkeltaub, assistant professor of neurology at Georgetown University Medical Center, Dr. Alex Dromerick of Medstar National Rehabilitation Network and Audrey Holland, professor of Speech and Hearing Sciences at the University of Arizona.
MS. SUSAN PAGEWelcome to "The Diane Rehm Show."
DR. PETER TURKELTAUBThank you.
MS. AUDREY HOLLANDThank you.
DR. ALEX DROMERICKThanks.
PAGEWe're gonna invite our listeners to join our conversation later in this hour with your questions or to share your own experience with recovery from strokes and other brain traumas. You can call our toll free number, 1-800-433-8850, send us a email at firstname.lastname@example.org, or find us on Facebook or Twitter. So let's start at the beginning. Peter, explain to us exactly what a stroke is.
TURKELTAUBWell, there are two kinds of strokes. There is one kind which is a bleeding event in the brain so a blood vessel bursts and there is blood inside the brain which causes damage and then the more common kind is a blood clot that prevents blood flow to a portion of the brain. And so that portion of the brain doesn't get enough blood or oxygen and is damaged.
PAGEAnd we think of this as an issue for seniors, but younger people have strokes, too. Is that becoming more common?
TURKELTAUBWell, I'm not sure if it's becoming more common. Alex might be able to address that. But it does happen in young people, even babies.
PAGEAlex, what is happening in terms of age? Is it happening more often with younger people?
DROMERICKYes. So stroke is thought of as an old person's disease and certainly seniors are prone to it, but about half of all strokes occur in people who are of working age or younger and they can occur at the time of birth or even earlier, all through life. And then, as we get older, starting in our 40s and generally the rate of stroke starts increasing. And yes, stroke is increasing in the younger population.
PAGESo what are the risk factors for having a stroke?
DROMERICKSo they're very similar to the ones for heart disease, so things like high blood pressure, smoking, diabetes, high cholesterol, all of those things increase your risk of stroke. So does picking the wrong parents, meaning, you know, genetic causes. Some families have a tendency toward stroke and then, of course, age.
PAGEAnd happily, many people survive a stroke. So Peter, what helps people survive a stroke if they do have one?
TURKELTAUBWell, being young helps and having a lot of reserve. Having a small stroke clearly helps so the larger the stroke, the less likely you are to survive. In general, people who have the second kind of stroke that I described, a blot clot that causes lack of blood flow, are more likely to survive than people who have had a bleeding event in the brain.
PAGEAnd how much difference does it make how quickly you get medical attention after suffering a stroke?
TURKELTAUBWell, that's probably the most important thing, the faster you can get to the emergency room to get treatment for stroke, the more likely you'll be able to get one of the medications or interventions that can help prevent a stroke from getting worse or even help a stroke to get better.
PAGEAnd I wonder, Alex, how often do people have a stroke and don't realize it, don't identify what it is that's happening?
DROMERICKSo stroke is a complicated thing. Our brains are complicated and injuries to our brains, it can be sometimes hard to tell when you're having a stroke. And the American Heart Association has a very nice little approach to it. They have the acronym FAST, which stands for Face, Arm, Speech and Time, meaning if you have a drooping face that comes on all of a sudden or you have trouble talking that comes on all of a sudden or you have trouble moving your arm or leg that comes on all of a sudden, then the clock is ticking.
DROMERICKAnd you have about three hours to get to the emergency room to get a treatment that we call TPA or tissue plasminogen activator, which can reduce the severity of the stroke and even reverse it in some cases.
PAGESo three hours is kind of the magic window to do something really effective.
DROMERICKYeah, it's even more than that so it's three hours, but the earlier in that window the better. And so it's better to be treated at one hour than two hours, two hours than three hours. We do sometimes extend out the treatment out to four and a half hours, but each minute means more brain is injured and therefore the outcome is not as good and the recovery is tougher.
PAGEAnd Audrey, we know that language is one of the things that's most identified with the consequences of having a stroke. Why is that?
HOLLANDI'm not sure it is the most identified. I think it's one of the least identified of the problems in terms of people's unawareness of the presence of aphasia partially because of the trauma of a paralysis or partially because of the fact that it's a silent problem when people are not talking. And I think there's another issue here, too, and that has to do with the very large variability in both the number of symptoms and the variety and severity of symptoms that occur following a stroke.
HOLLANDSo all of them play a factor in what is identified as the strongest -- what grandpa has is not necessarily what you will have as a stroke.
PAGEBut when people have a stroke, how often do they then end up having difficulty with language?
HOLLANDLanguage problems occur between 25 and 40 percent of people who have strokes and that's a hard number to pin down, but it's in that range.
PAGESo Peter, tell us, what are we learning now about what happens with a stroke and how you can deal with the consequences of a stroke that we didn't know before?
TURKELTAUBWell, we're learning a lot about how the brain responds to an injury, including a stroke. And so there's a lot of basic research going on to understand how the brain changes in response to a stroke and that includes both early changes, so what happens immediately after the stroke with restoration of blood flow and restoration of swelling and changes in the connections between parts of the brain and then the changes that occur later in the brain, so how the brain actually adapts to having had an injury and how the systems of the brain can change to rewire, hopefully to produce recovery.
PAGEHave we always known that the brain can kind of rewire itself after being injured? I mean, to what degree do we now realize the brain's ability to kind of recover in ways that we didn't understand before?
TURKELTAUBWell, if you think about it, we, as humans, are always learning. We're always acquiring new information. And in a way, that information has to be instantiated in the brain so if you think about it hard, we've always known that the brain has a capacity to change over our lifetimes. But what we're understanding now is to what degree the brain can change in response to injury and also what kind of changes are related to just simple biological effects and those that are related to the experience that we have after an injury.
PAGESo Alex, what have you found in treating patients about their ability to maybe make surprising recovery after the trauma of a stroke?
DROMERICKSo the thing I tell all of my patients is everybody improves.
PAGENow is that true?
DROMERICKIt pretty much is. It is pretty much true unless you have such a severe stroke that you are in a coma or you die. Everybody has some improvement. Now, not everybody has as much improvement as they want, but most everybody improves. And I will tell you that when I went to medical school, which was a few years before Peter, I was taught that the brain did not recover.
DROMERICKAnd it actually took the neuroscience research of the '90s, during the decade of the brain, to really nail down that, in fact, human adults have some ability to recover and that's called neuroplasticity. It's all over the radio and television these days, that that work that was done in the '90s is now being translated into treatments in the 2000s.
PAGEAnd what happened in the '90s to allow researchers to figure out what the brain was really capable of?
DROMERICKSo a decision was made by the U.S. federal government that they would declare the '90s the decade of the brain. There was a big investment on the part of the country, primarily through the National Institutes of Health and the National Science Foundation to invest in human neuroscience research. There was a lot of technology that came online in the '90s, things like magnetic resonance imaging that those kinds of things.
DROMERICKAnd the theme was picked up -- it was so popular, it was actually picked up all around the world. And the number one finding that came out of that when they kind of did a look back at the decade of the brain was this idea that, yes, the human brain, the adult human brain, has plasticity. We use it in recover from things like stroke, brain trauma, multiple sclerosis, brain tumors and that it seems open to manipulation in favor of patients so that by manipulating those recovery responses, people with all those conditions might have a better recovery than they would otherwise.
PAGESo what can you do, Peter, to encourage the brain to recover after its had the trauma of a stroke or some other kind of injury?
TURKELTAUBWell, I think the biggest thing that we know you can do is engage in experiences to relearn what you've lost and to learn new skills so in the medical field that includes therapy, so physical therapy, occupational therapy and speech therapy when you have aphasia or a loss of language. And beyond medicine, it involves engaging actively in your life, physical exercise, mental exercise, social exercise, getting out and engaging in the community and having experiences that would help your brain blossom.
PAGEAnd have you found, Audrey, that expectations for what can happen after a stroke have changed during your lifetime?
HOLLANDOh, absolutely. And I think one of the things that's happened is that early on, I believe most people felt that physical recovery of limb use was likely to be much more strong than recovery of language. And that's not the case anymore. I think we have learned that language recovery might go on longer, but it's strong.
PAGEWe're gonna take a short break. When we come back, we'll go to the phones. Our lines are open, 1-800-433-8850. We'll take your calls and questions and we'll continue our conversation about rehabilitation possibilities after a stroke. Stay with us.
PAGEWelcome back. I'm Susan Page of USA today sitting in for Diane Rehm. And with me in the studio, Alex Dromerick. He's director of the Neuroscience Research Center and director of the Comprehensive Stroke Research Program at MedStar National Rehabilitation Network. And Dr. Peter Turkeltaub, he's assistant professor of neurology and director of the Cognitive Recovery Lab, and medical director at the Center for Aphasia Research and Rehabilitation at Georgetown University Medical Center. And Audrey Holland, she's professor emeritus of speech and hearing sciences at the University of Arizona and research director at the Adler Aphasia Center at Maywood, New Jersey.
PAGELet's go to the phones and take some of our callers who are waiting. We'll go first to Kathleen who's calling us from here in Washington, D.C. Hi, Kathleen.
KATHLEENHi, how are you?
KATHLEENThank you for taking my call. I have experienced I think eight years ago a double stroke on the left side of my head. I was in a bicycle crash and I had a helmet on but I felt all these symptoms happening to me slowly. And I tried to get myself to a hospital but it took 48 hours or more 'til I could get to emergency room. And my whole right side got paralyzed. And I think I was in the trauma center for maybe three months. I can't remember but I ended up with what they told me is TBI, traumatic brain injury, permanent.
KATHLEENBut I used to be a singer before. And I've had my voice scoped I guess a few times now and my vocal chords, one isn't vibrating at the same time the other one is and it's preventing me from singing. And it's been eight years and I'm hoping that -- I don't know if it's something that I should expect to come back with more effort or if it's just a lost cause or...
PAGEOkay. Yeah, Kathleen, how interesting. Let's ask our panel. Thanks for your call and we're glad that you seem to be doing well in so many ways after your stroke. What about the act of singing? Does that get affected in some special way, Audrey?
HOLLANDSometimes singing can be a very strong adjunct for -- and there are forms of therapy that actually center on the use of singing or a form of singing in speech. But I think singing is probably controlled by a different part of the brain and that's one of the reasons that it can be recruited into working on language. And my advice would be for you to continue doing what you're doing if you seem to be getting some amount better from what's going on. It's never too late.
PAGEYou know, I wonder though, this message -- I’m sorry, did you want to add something, Alex?
DROMERICKYeah, I think the other thing that happens after a stroke is the -- what we call the motor system, the ability to move. You can develop a condition called spasticity or stiffness. And that motor system is involved in moving our vocal chords as well as our arms and legs. And sometimes it's worth consulting actually an ear, nose and throat doctor who can take a look at the vocal chords and see whether injection of Botulinum toxin or some such can help under those circumstances.
HOLLANDAbsolutely. Yes. I think that's very strongly in order.
PAGEAnd of course we know some other disorders like spasmodic dysphonia where they have that treatment. Diane Rehm herself has undergone that sort of treatment in the past. In having a stroke, given the kind of complex nature of the brain, do you ever find people affected in very particular and unusual ways? They lose one particular ability because of the stroke?
TURKELTAUBSure. Yeah, that actually happens very commonly so the different parts of the brain serve different functions. And although they're all related to each other, a particular stroke -- small parts of the brain or particular parts of the brain can cause specific functions. So one example of that is alexia. So that's a problem with reading after a stroke. And there's even a form of that called pure alexia where really the only problem is with reading. So speech and language are essentially normal.
TURKELTAUBBut the problem is that your visual system just can't access the visual word forms of words.
HOLLANDAnd in addition to that, sometimes people have that problem without even having any writing problems so that...
HOLLAND...the act of being able to write is preserved even though they can't read what they write.
PAGEAnd so what can you do in a situation like that?
TURKELTAUBWell, there are special kinds of therapy for that specific problem. So one of the ways that people have tried to approach it is to route around the visual system and help with kinesthetic feedback for instance. So you can teach people to trace letters on their hand and that helps them use their kinesthetic system, their sensory system to remind themselves of word forms and letter forms. And that helps to some degree.
HOLLANDAnd another is -- I think this is really important -- cases like this and problems like this inform generally how one might go about treatment and might give information that is more -- that is not just specific to that problem but can inform all of the areas -- all of the things we know about how the brain functions. So they're critical.
TURKELTAUBYeah, I think that's a very important point. And it's worth saying that historically speaking, people who have had strokes have probably contributed more than anyone else to our understanding of how the brain works. And it's specifically through this -- through when things like this happen where a stroke to a small part of the brain or a restricted part of the brain cause specific problems. And then we know that that part of the brain is involved in that kind of function.
PAGEAnd to what degree do we -- we've learned a lot about traumatic brain injury because of the wars in Iraq and Afghanistan. One said consequence of those wars has been the number of soldiers who have come back with traumatic brain injury. Has that helped with the treatment of strokes? Has that had an impact, the fact that that's gotten a lot of attention and that it is a -- the community affected is generally younger, healthier people who are in the armed forced.
DROMERICKSo it's actually in reverse as Audrey and Peter have mentioned. You know, people like us sort of -- when we're helping -- taking care of people with a stroke and we're doing our research, we're actually thinking on two tracks. One is the clinical issue in front of us, how to help that person, whatever's going on with them. The second is it's an opportunity to study how the brain works, and how the brain recovers in this case.
DROMERICKAnd because of the characteristics of stroke, it's actually much easier to study brain recovery in people with stroke than it is in people with traumatic brain injury. So the flow of ideas and information actually starts at stroke and then goes to things -- all those other conditions that can affect the brain specifically. You know, trauma, multiple sclerosis, et cetera.
PAGELet's talk to Vanessa. She's calling us from Oklahoma City, Okla. Vanessa, hi, you're on the air.
VANESSAHi. Thanks for taking my call. I just had a question about the child's ability for the brain to heal itself. I've heard them mention a few times about neuroplasticity for the young adults. And I just wondered how that differed with children.
PAGEYeah, Vanessa, that’s an interesting question. And Peter, you had said earlier that even infants can suffer strokes. So what do you find with kids when they have strokes?
TURKELTAUBWell, the general rule of thumb is that the earlier you have a stroke in childhood, the better off you are. And in fact, it is the case that young kids recover much better than adults. So it does happen that infants sometimes have strokes and sometimes they're very large strokes, right around the time of birth. And what happens with those kids is in many cases, even if they've lost most of the left hemisphere of their brain, they can actually recover fairly normal language.
TURKELTAUBAnd the way that we think that happens is that the language functions, which usually reside in the left side of the brain for most of us, shift over to the right side in those kids. And it seems that in adults, when they have a stroke, their brains are not as plastic as the young kids. And so that...
PAGEAs with every other part of the body, right?
DROMERICKYou got that right.
TURKELTAUBThat's right, yeah. So adults' brains try to make those kinds of shifts. And when we look at functional brain activity in people who have had strokes to the left hemisphere and have aphasia, the loss of language, we do see that the right hemisphere is trying to help. So the right hemisphere comes online more than in people who haven't had a stroke. But it just doesn't seem to do as good a job as the kids who have had a stroke.
PAGESo if you were able to do an MRI or look at the brain of a young child who suffered a stroke and who had that system work, had the right hemisphere of the brain kicks in to pick up where the left hemisphere can't do what it usually does, does it look very different? How does -- does the brain look very different than a brain that hasn't undergone that kind of trauma?
TURKELTAUBWell, interestingly the organization of the system looks pretty similar. So it's the same areas of the right hemisphere that become involved in language as the corresponding areas of the left hemisphere that would've been involved.
PAGEAudrey, when you have a child who has suffered a stroke, is the -- trying to deal with some of the language issues that come up, is it different than in adults?
HOLLANDNot really. It's -- one wants to work holistically on language, not just speech or not just comprehension or reading and writing, but reading and writing perhaps a little later. But the important thing I think is for a child to have as much language stimulation and as much environmental stimulation for his language as possible in treatment.
PAGEYou know, Peter, you talked about people who have suffered strokes, the need to have social interactions. You know, that makes some sense to try to engage. But you talked also about just exercise. What role can physical exercise play when you're trying to recover fully from a stroke?
HOLLANDI want to get into this, too, a little bit...
PAGEAudrey, go ahead.
TURKELTAUBWell, why don't you take it?
HOLLANDWell, first of all, I think that developing in both treatments that deal with the impairment of aphasia itself, the language problems and exercises and drills that deal with the language ones, is extremely important. But because as Alex and Peter have both mentioned, recovery has this very long trajectory and has a very long trajectory for adults particularly and language particularly. The need for ongoing services long after the health care providers can still provide services is just absolutely mandatory.
HOLLANDAnd at that point it isn't just so much the impairment-based drills and work specifically on language, but also how one brings in the environment. And this is a big new movement to deal with life participation long after stroke. And that's an exciting movement.
PAGESo what kind of things do you try to do now that perhaps we didn't realize were important before?
HOLLANDWell, one of the things that's become increasingly more important is psychosocial interaction in aphasia. And there has been this movement in the last ten to fifteen years -- it's interesting how it parallels the era of the brain has been to develop programs actually called life participation approaches. Where it's effective long term treatment involving other people with aphasia, a lot of group interaction, a lot of opportunity for people with aphasia to begin the process of participating in life again. And being able to do the same kinds of things that other people who do not have strokes do. this is a very important movement in aphasia.
PAGEAnd, you know, I wonder if you have any advice for -- you know, all of us have interacted with people who have survived strokes.
PAGEAnd sometimes they have great difficulty in talking. And they either can't talk or they can't make sentences or they use the wrong word, not the word they meant. And what advice do you have for people who are talking to them and want to help them get better and want to have them participate in life? What can we do to make that work better?
HOLLANDThere are a lot of things you can do to make it work better. One is to listen. I mean, and to be prepared for someone with aphasia to take longer to get his thoughts in order and to say what he wants to say. And to communicate that you need to know whether this person wants you to help or doesn't want you to help. There's a whole rubric called supported communication where we can make someone who is aphasic actually sound like he speaks better than he really does because we know how to support his efforts. And that's part of this movement. It's very important.
PAGEI'm Susan Page and you're listening to "The Diane Rehm Show." We're taking your calls, 1-800-433-8850. Peter.
TURKELTAUBI just wanted to add that if you're interested in finding out about these sorts of things, how to help people with aphasia or people who have aphasia, if you're looking for resources like the kind that Audrey mentioned, there's a great organization called the National Aphasia Association. And their website is aphasia.org, that's A-P-H-A-S-I-A dot org. And they have a lot of great information on how to communicate with people with aphasia and how to help people with aphasia find the resources that they need.
PAGEBesides listening, should you try to help them find the right word if they're obviously struggling for a word, or should you just listen?
HOLLANDOkay. Well, one of the best tricks, and it's a kind of simple one is to say to somebody, do you want me to help you or do you want to do it? Many times we can fill in the word for somebody who has trouble with that. But some people like to have that and some people don't like to have that. And people with aphasia, you know, don't have -- they don't have a problem thinking. They have problems talking. And so they have -- they can guide the kind of things you can do that are helpful as well.
PAGENow, how often though is the loss of language associated with the loss of cognition, of an inability to think? They're not connected at all?
HOLLANDThey're not disconnected but people with aphasia are -- it's an irony that one of the things that is true of most people with aphasia is that they all think better than they talk. And that is -- that's a terrific pain to be able to have thoughts and understand the world around you and not be able to put it into words.
PAGEAlex, is it sometimes hard though as a doctor to tell where the problem with language begins and where a problem with cognition begins?
DROMERICKYeah, it really can be. And, you know, the language -- first of all you have to remember when working with a person with aphasia that they're not stupid, that that is an adult...
DROMERICK...or, you know, an otherwise intact child who has a language problem. That being said, they can have subtle problems with cognition, with memory, with other things that can look even like somebody who's had a mild traumatic brain injury or concussion. That there are subtle things that may not even show up on testing but can be there, problems with concentration and those sorts of things.
HOLLANDBut if you're going to err I think the way to do it is toward being -- thinking more positively about the person with aphasia. One of the complaints that we hear over and over again is with interactions with physicians that -- sorry about this, guys.
PAGENothing personal, guys.
HOLLANDNo, don't take this personal. But that if you go in for your evaluation, you're not talked to. You're ignored. The person who is talked to is your spouse or the person who accompanies you. And that is -- that is a constant complaint of people who have strokes and aphasia.
TURKELTAUBYeah, I think -- and it's also, you know, a difficulty being a physician, having the time pressure of seeing patients. So there's a pressure to not give enough time to communicate appropriately with people with aphasia. And, you know, people with aphasia, for instance, tells us all the time that they have words that they can hear in their head, they know what they want to say. They can say it in their head and it just won't come out of their mouth. And a lot of times physicians especially -- sometimes speech pathologists too, but really more physicians ignore those kinds of statements.
HOLLANDYou're right, you're right.
TURKELTAUBBut the truth is we're starting to do some research on this and we're finding that to some degree they're right. Those words are in their heads and they just won't come out.
HOLLANDAnd the other -- the point you make about speaking, you don't have time to speak, even the rate of speech matters so that if you speak a little more slowly to people who have aphasia, you're very much more likely to help them understand what's being said.
PAGEWe're going to take a short break and when we come back we'll go back to the phones. We'll take some of your calls and we're going to read your emails. You can email us at email@example.com or find us on Facebook or Twitter. Stay with us.
PAGEHere's an email from we've gotten from Mary who writes us from Woods Hole, Mass. She said, "How about strokes while sleeping?" Can you get a stroke while you're asleep and I wonder how that affects the whole idea that you need to get treatment within three hours of a stroke. It must make it harder. Alex, can you have a stroke while sleeping?
DROMERICKYou bet you can. And this often raises treatment difficulties. You know, I mentioned before that four and a half hour time window for TPA, the clot busting drug. And what we look for is the time when the person was last known to be normal. So if somebody wakes up with a stroke and they went to bed at 11:00 at night and they wake up at 7:00 in the morning having had a stroke, well, we don't know what time they had it and they would be beyond the window for that treatment. Now we're doing studies to try and identify who might be safe to treat under those circumstances, but it's an issue and there's a substantial number of strokes that fall in that category.
PAGEWhen you talked about this idea that it's important to get treatment within three hours if possible...
PAGE...After a stroke is that because the treatment just works better or can you actually not do that treatment if too much time has passed?
DROMERICKSo what happens is the treatment is less effective as each minute passes. And the very best stroke services will have that drug running in your arm -- it's an intravenous drug -- running in your arm within 30 or 45 minutes of the time you present to the emergency room. And that's one of the marks that we use for the quality of acute stroke treatment. What happens after four and a half hours is that the complication rate goes up beyond the treatment effectiveness. And so what happens is -- it's a clot busting drug. You have hemorrhages, you have bleeding in the brain and so the side effects of the drugs at that point outweigh the benefits.
PAGEYeah, but I wonder what triggers you to have a stroke. Maybe this is a myth, but I think of somebody getting very upset and you say don't do that you're going to have a stroke. I mean does that trigger a stroke or is that just -- is that just a myth, Peter?
TURKELTAUBYeah. Well, I think it's a myth in that if you just get stressed out it's very unlikely that you're going to have a stroke because you're stressed out on a given day. There's actually ongoing research about the relationship between stress and strokes, but, you know, the cause of the stroke, if we're talking about an ischemic stroke, the blood clot kind of stroke, is an occlusion of blood flow. And that happens either because there's a blood clot that forms in the heart that goes up to the brain or because of atherosclerosis and hardening of the arteries in the neck or in the head. And so I wouldn't say that stress causes a stroke.
PAGEAnd so you're just as -- if those are the causes then you're just as likely to have a stroke while sleeping as awake. I mean it's not more likely to happen when you're awake?
DROMERICKGood question. I don't think it's anymore likely to happen when you're asleep than awake. I bet somebody's done that study, though.
PAGEHere's another emailer, John, who writes us from Dallas. He writes, "I drink a lot of energy drinks like Red Bull. I am 34 years old and my friends warn me that I'm going to have a stroke because of the caffeine." True?
TURKELTAUBWell, it is the case that if you drink a huge amount of caffeine or stimulants that there's -- that you can cause a spasm of the blood vessels in the body that can result in stroke. It's very unusual and so I wouldn't want to give any specific advice on exactly how much Red Bull to drink or not to drink, I'd say.
DROMERICKBut to extend this idea a little bit further there are also street drugs that have the same kind of effect. So cocaine, methamphetamine can also cause the spasm of the blood vessels and that's actually a significant contributor to stroke in young people.
PAGESo we know that young people, for reasons beyond not having a stroke, shouldn't be using cocaine and meth, but do you think John should maybe limit his intake of Red Bull?
DROMERICKYou know, everything in moderation.
TURKELTAUBAnd we don't know how much he drinks.
PAGEHere's an -- I'm sorry, go ahead.
TURKELTAUBI would just say if there's one thing that he shouldn't do to prevent a stroke risk it's smoke. So smoking cigarettes clearly increases your lifetime risk of stroke.
PAGEAnd if we're talking about risk factors, women are much more likely to have strokes than men, right? No?
DROMERICKNo. It's roughly equal. It really is driven by the amount of cardiovascular risk factors that an individual has so...
PAGEAnd I've also read that African Americans are more likely to suffer strokes than whites. Is that true?
TURKELTAUBThis is true.
PAGEAnd why is that?
DROMERICKA couple of reasons one is genetic. There are different racial and ethnic groups around the world that are more prone to either stroke or hypertension. The second is in a -- it also has to do with socioeconomic status. So people who are lower education levels may be -- may not want to trust the healthcare system in the same way that other groups do, may not take blood pressure medicines and so a very common thing we see, particularly in the larger cities, is young people, particularly men, in their 30's and 40's who knew they had high blood pressure, but didn't take blood pressure medicines and they have the hemorrhagic stroke that Peter was referring to and so it's a very common syndrome.
PAGEAnd you also talked about being overweight can be a risk factor for a stroke. Is that -- you're -- not so much. You're shaking your head.
DROMERICKIt's not nailed down in the way that smoking and high blood pressure and diabetes is.
HOLLANDAnd how about diet?
DROMERICKI think it's driven by the cholesterol level.
TURKELTAUBYeah, it's all related. I'd say that, you know, being overweight is a risk factor for diabetes, which is a risk factor for a stroke.
PAGEHow about the importance of being physically active? You know, we're urged to exercise more for any number of reasons. Does it also help protect you from having a stroke?
TURKELTAUBWell, in the same way that regular aerobic exercise is good for your heart it's good for the blood vessels of the body and reduces the risk of atherosclerosis which leads to stroke. You know, and then another interesting area is the relationship between physical exercise, aerobic exercise and recovery.
PAGEAnd what's the relationship there?
TURKELTAUBAlex, you want to...
DROMERICKOkay, so there is a gathering body of evidence that increasing the aerobic fitness and strength of individuals can improve cognition and it certainly can improve mobility. So when people have a stroke they may be clumsy on one side of their body. It increases what we call the energy cost of ambulation meaning it's harder to walk from, you know, say a block. You have to consume more calories. The way people cope with that is they actually slow down their walking.
DROMERICKSo they walk slower than everybody else in their family and then the family, when they're in a hurry and needs to get to the -- you know, to the mall or to the grocery store or something tend not to take that person along because they walk too slowly. If they're in better aerobic condition they can tolerate that increased energy cost, can walk faster and have more full participation in the community.
HOLLANDAnd I would add that many forms of physical activity involve social interaction. I think that's for people who have had strokes is an important part of the recovery process, too. I mean I think that people with aphasia who go to gyms and have an opportunity just to sit and talk to other people while they're on their exercise bikes are getting a form of language therapy along with their physical activity at the same time. So, I mean, there's a big interaction here.
PAGEThat's the life participation aspect...
PAGE...of it that you were talking about.
HOLLANDWell, that's part of it, yeah. I mean it's -- I think one of the most exciting and fascinating things that's been going on in this field has been concern with the long term -- what are we going to do after we run out of healthcare benefits? What kind of things are we going to do? And I would -- I need to point out that the National Aphasia Association can put people in touch with the many, many programs that are operating now in the United States which focus, not necessarily totally, but largely on psychosocial benefits of being with other people who have had strokes, worrying about the other members of the family who are also having difficulties because of stroke, family support groups, so forth and so on.
HOLLANDSo there are lots of things going on in this arena. Right here in Washington there's Stroke Comeback Center. There are many, many programs that deal and look toward this long term solution to many of the healthcare -- long term healthcare problems with people with stroke.
PAGEYou know, you've talked about the importance of constantly improving. You say anybody can improve after you have a stroke and that improvement can happen for a much longer period of time than we once thought, but I wonder if you ever have patients who are tired of working on recovery. You know, they work on recovery and they make some progress, but it's got to be hard. It's got to take effort. And is there a point where a stroke survivor could make more improvement, but just -- it's just, for that person or their family it's just too hard?
HOLLANDI think that's -- I think that's in human nature. I mean I think we've already established that people who have strokes are pretty -- pretty capable of -- very capable of making many of the life decisions that any of us might make. And if you say I'm tired of doing something -- I'm tired of doing something there's no reason to, sort of, push them beyond that limit. And I have some kind of strong feelings that when people who have had stroke say I've done enough to get better. I'd just rather sit and fish and enjoy the rest of my life that it's time for the rest of us to back off.
PAGEWell is that hard for doctors sometimes, though, I mean, to say, okay, you could get better if you kept working on it, but they just feel like they've reached their limit?
DROMERICKSo almost everybody -- so the way many of us think about this is that the stroke itself, the injury to the brain so it's a biological limit to how much recovery there can be, but very few people actually get close to that limit and that usually they can improve more. There's now, more lately, a financial limit that Medicare has established pretty severe therapy caps, the amount of outpatient therapy you can get each year. And it's been pretty severely reduced and so while, you know, the research of people like us says that it takes hundreds or even thousands of hours to regain certain kinds of skills, the therapy that's available is actually going down and that's a result of, you know, healthcare payments systems and those kinds of things.
TURKELTAUBYeah, so I just wanted to say that I think, you know, probably the most profitable thing that could happen is for us to increase the benefits for therapy, but a lot of the push in research lately has been to figure out how to make the best use of the time that we have in therapy and so some of the new clinical research in aphasia and in physical recovery from stroke has revolved around technologies that might boost the effect of therapy. And that might include medications in some cases or it might include forms of electrical or magnetic brain stimulation.
PAGEI'm Susan Page and you're listening to "The Diane Rehm Show." Here's an email we've gotten from Cheryl. She says, "After my mother had a stroke and became aphasic I looked for technology to help her recover her voice. Perhaps your guests can talk about the revolution in tech. For example, there is an app for iPads called proloquo2go that cost a couple hundred dollars versus the thousands of dollars that specialized devices cost." Audrey, can you talk about that?
HOLLANDI sure can. There are literally at this point hundreds of apps that are useful for people with aphasia. And the whole general -- and the whole general ability of aphasic people to take advantage of the more native technologies to say Google and email and a group called Aphasia Recovery Connection, which is a group of young people who are really -- who have had strokes who center on social media. There's tons of stuff out there and it's possibly the most exciting thing that's going on in treatment and a lot of that happens in these stroke centers and stroke programs.
PAGELet's go back to the phones and talk to Catherine. She's calling us from Concord, N.H. Hi, Catherine.
PAGEPlease go ahead. Do you have a question or a comment?6
CATHERINEOh, I have a comment. I suffered a stroke back in 2012 while I was sleeping, as a matter of fact. I woke up to my arm being numb and thought that it was just I had slept on it funny and pinched the nerve.
CATHERINEAnd I went to sit up to turn on the light and fell over or, you know, flopped back over on the bed and I kept trying to sit up and kept flopping over onto the bed again and realized something was not quite right. And I eventually, kind of, tossed myself gently off the bed and was trying to crawl around and find a way to leverage myself to sit up and couldn't find a way to do that. And my mother was sleeping in the room below and so I started knocking on the floor and calling for her as best I could and she heard me, fortunately. She came up and she had one of those buttons, 911 buttons.
CATHERINEAnd she was trying to sit me up and at that point we became aware that my left leg was numb. It was my right arm that was numb initially, that woke me up, but we realized as she was trying to sit me up, but that was -- my right leg was numb as well. I mean my left leg. And she pushed her button at that point and talking to 911. And they said, oh -- and she said I think you're having a stroke. And I said, I think you're right.5
CATHERINEAnd I had absolutely no pre-existing conditions that should have precipitated a stroke and worked out regularly twice a week doing cardiovascular, walked every day, no diabetes, no high cholesterol, no nothing so it was literally out of the blue. And I could not talk for the first little bit and I was, in fact, when I went and had -- I ended up having a double craniectomy because of the swelling in my head and they took out the frontal -- the right frontal lobe, temporal lobe, took out the front part of it.
CATHERINEAnd I've only just recently had that refurbished just two weeks ago. So I'm still recovering and as I was saying to the person taking the calls initially that it's funny because even now as I'm continuing -- you know, it's been over a year. As I'm continuing to learn and do things it's funny I use my old brain as I say and my left -- my old brain and my new brain. So I try to function as I would have previously, like, standing in front of the dishwasher to open it and not thinking much about that or in front of the fridge whereas now I have to learn how to stand more off to the side to open it to load it or do something or get something out.
CATHERINEAnd it's just kind of a funny thing that the old brain and the new brain -- and one day a little bit early on I was making my way to the bathroom and my husband was helping me. And I said I really want to hop. I was standing on my right leg -- my right side is fine. My left side has (unintelligible) and spasticity. I said to my husband I said I really want to try and hop and he said go ahead. And I said, OK. So I was standing on my right leg and I made the effort to hop and I hopped. Fortunately he was holding onto me so nothing happened. I didn't fall or anything, but it's funny how you -- it's this funny thing, but your brain goes from old brain to new brain, but then it's also funny still in just learning new skills.
PAGEUm-hum, right. Well, Catherine, you know, I have to say that it sounds like you've had a terrible ordeal, but you sound great. And it sounds like a pretty remarkable recovery. What do you think, Alex?
DROMERICKSo Catherine is, sort of, an example of what can happen with, what sounds like, a catastrophic brain injury and yet over time she improves and you can hear that she's moving and talking and doing things around the house and probably doing things in the community as well. And, you know, notice the other thing that she said is that she's still improving a year out from her injury.
DROMERICKAnd if you go and read the textbooks and if many patients go to talk to their, say, their neurologist, who often function as a stroke doctor, they will say that your recovery is done at six months. And that's what -- actually what a lot of the epidemiological studies say, but in fact when you do more detailed studies of specific kinds of recovery there's now cumulating evidence that people recover for a long, long time.
PAGEAnd what an inspirational story that is and what a great way to think about it using your old brain and your new brain, Catherine, thanks so much for calling us. And I want to thank our panel for being with us this hour, Alex Dromerick, Peter Turkeltaub and Audrey Holland. Thanks so much for joining us on "The Diane Rehm Show."
PAGEI'm Susan Page of USA Today sitting in for Diane Rehm. Thanks for listening.
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