Book Review: My Stroke of Insight

‘My Stroke of Insight’ is a New York Times bestseller, written by neuroanatomist Dr. Jill Bolte Taylor. This powerful story has made a resounding impact across the world, through the medium of this book and Jill’s TED talk, which has received over 17 million views to date. I wasn’t quite sure what to expect when a friend handed me this book having determined it would be something I would enjoy from the title. I’m hugely interested in recovery from stroke and so the subject matter, a brain scientist’s own personal experience of having a stroke and their path of recovery, was certainly something that I was keen to read.

The book opens with a description of Jill’s past life, pre-stroke. She was a trained neuroanatomist who traveled the USA, encouraging clinical populations to donate their brains to science post-mortem. She enjoyed her work immensely and brought an air of creativity and uniqueness to it, as she was dubbed the “Singin’ Scientist” for the jaunty jingle she had created to relieve tension in these meetings. Following our introduction to Jill, she provides a good overview of the mechanisms of the brain. These are laid out in layman’s terms and are easily accessible to the general population. This brief tour of neuroanatomy allows readers to understand the source of the problem, which I believe is a vital component for comprehending the difficult subject matter. The core of the book details the events of her actual stroke and her steps to recovery. This candid account of her experience is novel; allocentrically, the reader watches as piece-by-piece her neural function shuts down and with it, her motor functions collapse, her speech becomes incomprehensible, her fixated attention becomes a distant memory. We learn of her struggle in the days and weeks after: the constant exhaustion, the incapability to communicate her wants and needs, her regression back to infancy. Yet Jill accounts for all of this in straight-forward manner: she facilitated her recovery by creating small, attainable goals and came out the other side of it as an ebullient and jovial woman. The book ends on a positive note, highlighting Jill’s renewed passion for life, deeply appreciative of many aspects of living that are easily taken for granted, like the feeling of raindrops running across your skin or the sound of your favourite music.

Throughout the book, Jill raises some excellent points with respect to the clinical treatment and examination of stroke patients. Personally I felt that these small suggestions and observations from a stroke survivor reflects the true seminality of this work. In a frankly honest tone, Jill illustrates the absolute necessity of feeling safe in the medical staffs’ care and the impact this holds over the recovery of the patient. She reminds us that these patients are not some stupid creatures to be cast aside thoughtlessly. They are human beings full of emotional turbulence and frantic need – they are wounded and frightened. Thus, good bedside manner is imperative and the strength and range of their remaining abilities needs to be taken into careful consideration for any and all interaction – even if that simply means lifting the lid off a plate of food in order for them to eat. Jill recounts how the staffs’ treatment of her played a role in her recovery: she would co-operate only with those who were kind and attentive towards her, and would choose to ignore those with whom she felt treated her in an inconsiderate and discourteous manner. She also describes her deep confusion and unhappiness with hospital policies, such as being asked to sign consent forms when her cognitive damage was so severe that she could not even understand language. Such aberrant treatment clearly bred an environment of dissonance for Jill during such a trying time, and may similarly be affecting many more suffering survivors. It is clear that there is a need to revise the guidelines for interacting with these types of patients, and garnering advice from stroke survivors may be a very good place to begin this process.

As I said earlier, this book also elucidated to some very thought-provoking opinions on assessment post-stroke. Although such examinations may appear simple and untaxing to the ordinary observer, to a stroke patient they are often exhausting and arduous. Jill speculates that the methods for assessment are simply concerned with matching performance to a criteria based on “normal behaviour” and fail to provide a comprehensive insight into what may actually be happening in patients’ brains. For example, the doctor may test if a patient’s recall is fast or slow, but will not take into account the time-consuming thought process that must be undertaken in order to grasp the mere understanding of the instructions, before even trying to carry out the task. Jill proposes that such practices would benefit immensely from a cohesion of information provided by stroke patients themselves based on their experiences.

Additionally, Jill draws some attention to reasons why patients may fail to make a good recovery (or certainly a remarkable recovery like hers!). She believes that patients often fail to recognize their smaller achievements, such as managing to grasp a pen again for the first time post-stroke, as real victories and so their path to recovery becomes elongated by their lack of belief in themselves. She also emphasizes the importance of wanting to try to relearn previous skills – without this, patients lack the foundation to propel themselves into recovery. One last casual observation made during the account of Jill’s rehabilitation also struck a chord of interest in me. She postulates that while we take many learned skills as abstract and irrelevant, it is surprising to find how much we really need them to conduct our day-to-day lives. The example she uses amused me, largely due to my ardent resilience to math during my school years: the importance of algebra in the calculation of where to put plates on a dish-rack when washing up.

While much of this book both intrigued and enlightened me, I did find the final few chapters more difficult to swallow – my time spent reading them felt like wading through quicksand that I couldn’t pull myself out of fast enough. Here, Jill reveals a very spiritual and mystical side of herself. Given her traumatic experience, this is a fully understandable paradigm to undertake, and her elation for life is deeply admirable. However, this is just not an area that encapsulates my attention. Furthermore, throughout the book Jill shows a penchant to lean heavily on the concept of hemispheric differentiation – the constant chatter of “right-brained” and “left-brained” failed to impress me. I felt that in this regard, she relied too much on the retired myth of the left and the right brain, rather than any of the more empirical evidence that have been demonstrated in studies of hemispheric specialization.

Regardless of my quandaries, I would recommend this book as a light and easy read. With less than 200 pages, it makes for an excellent companion on a long journey and provides a fascinating account of a brain scientist’s interpretation of the neural and cognitive events of her own stroke. Lastly, it is truly inspiring to read about such an exceptional recovery in the face of such extreme neurological catastrophe – and plants a seed of hope that such progress will become the norm in the future.

My Stroke of Insight is available to buy on Amazon here: http://www.amazon.co.uk/Stroke-Insight-Jill-Bolte-Taylor/dp/0340980508

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Stroke Rehabilitation: Paving New Pathways To Improvement

I came across a very interesting article today with regards to stroke, and the impact cerebral plasticity has on rehabilitative techniques (see http://www.theguardian.com/science/2015/feb/08/robert-mccrum-lucky-survivor-stroke-treatment-revolution?CMP=twt_gu). It’s an area that I have read quite a bit on, and so this blog will aspire to give a brief overview of different forms of rehabilitation, and the reasoning behind them. The focus will be on motor function, rather than the cognitive impairments that can accompany a stroke.

Firstly, a stroke occurs when the blood flow to a particular brain area is disrupted (Murphy & Corbett, 2009). This allows cells to die off, which negatively affects the functioning of that cerebral region, i.e. an infarct to the hand knob of the motor cortex could lead to an impairment of hand movement. Strokes can be caused by a burst aneurysm or a blood clot blocking a blood vessel. This website (http://www.stroke.org/) will answer a wide range of questions regarding the causes and consequences of stroke. This blog will be discussing one of the most notable and debilitating effects of stroke: motor impairment.

Robert McCrum speaks of the difference in the rehabilitation environment between today and 30 years ago, when he first came into contact with it. He uses words like “dynamic” to describe the attitudes and approaches of stroke recovery nowadays. He attributes the growing knowledge surrounding cerebral plasticity to this new optimism. Cerebral plasticity refers to the structural change of the brain in order to accommodate changing demands (Lövdén, Wenger, Märtensson, Lindenberger & Bäckman, 2013). This is often depicted as the “rewiring” of neural connections, and appears to be fundamental for learning and re-learning, in the case of rehabilitation (Kleim & Jones, 2008). Although the concept can seem complex and daunting, it is actually a simple enough idea; the brain creates a compensatory pathway or method to carry out a task to the best of the individual’s (new) ability. It’s the same principle as finding an obstruction preventing you from taking the easy route on the highway to your destination, and choosing to drive down the smaller, less-taken roads to reach it.

Physical rehabilitation has been employed in cases of stroke for quite a long time. One might believe that this is simply to strengthen the muscles that have wasted away, and has nothing to do with the neural mechanisms of motor function. But why have the muscles diminished in the first place? In the majority of cases, lesions to the motor cortex destroy the motor neurons responsible for stimulating said muscles which leads to a gradual depletion of tone and strength. Physical rehabilitation attempts to stimulate the motor regions, in order to excite the motor areas responsible for the impairment in functioning (Liepert, Miltner, Bauder, Sommer, Dettmers, Taub & Weiller,1998). This will allow a reorganization of the (now) redundant anatomical circuits and allow neuronal populations to change their physiological relationships with other neuronal ensembles (Linazasoro, 2006). Physical rehabilitation for stroke is largely concerned with muscle strengthening and physical conditioning, with advancements in technology introducing us to an era of robot-assisted movement training (Teixeira-Salmela, Olney, Nadeau & Brouwer, 1999; Lum, Burgar, Shor, Majmunder & Van der Loos, 2002). Imaging studies have demonstrated plastic changes to the neural networks involved in movement, coinciding with marked motor improvement (Hodics, Cohen & Cramer, 2006).

While neural plasticity’s place in physical rehabilitation is interesting, even more fascinating is it’s role in rehabilitative interventions which employ mental/motor imagery to aid recovery. Mental imagery can be defined as a process in which individuals can actively relive sensations (visual, auditory, tactile, etc) without the need for external stimuli (Jackson, Lafleur, Malouin, Richards & Doyon, 2001). Motor imagery is described as the internal reproduction of the representation of a specific action, without the execution of movement (Jackson et al., 2001). A notable example of the reasoning behind the use of mental imagery in motor rehabilitation comes from Pascaul-Leone and colleagues (1995) study. This investigation incorporated three groups: (i). the physical group, which involved physically practicing playing a piano piece over a period of time, (ii). the mental group, which involved mentally imagining playing the same piano piece over the same period of time, and (iii). a control group. The results revealed that both the mental and physical group showed a marked improvement in their fine finger motor skills, when compared to controls. It also demonstrated that structural changes to the motor cortex pertaining to the fingers, in both the physical and mental group. This suggests that these neural networks were recruited for the learning of the motor task, and that mental practice can appropriately access and modulate those connections (Pascaul-Leone et al., 1995). This study recruited healthy individuals, but it lays a foundation for the use of mental/motor imagery in stroke rehabilitation.

Stroke research has used the evidence of mental/motor imagery recruiting the same cortical motor areas in order to function, as an argument for its place in rehabilitation. Researchers have suggested that imagery of movement can stimulate the redistribution of active connections between parallel motor regions, and thus, improve recovery of motor function (Dijkerman, Ietswaart, Johnson & MacWalter, 2004). This form of rehabilitation involves techniques such as mentally rehearsing an action over a set period of time, and mentally practicing an action just prior to actually engaging in said movement. However, these methods have been met with mixed results. It should be noted that these studies can be confounded by a number of factors, that could lead to results determining whether the rehabilitation is effective or not. These include patients’ inability to engage in mental imagery (as lesions may disrupt neural networks involved in these processes), small sample sizes, heterogeneity in participants’ characteristics and outcome measures (Sharma, Pomeroy & Baron, 2006). Within the number of studies that provide evidence for mental/motor imagery’s positive impact on motor recovery, there have been reports that improvement in motor function is specific to the mentally rehearsed tasks (Dijkerman et al., 2004). This is less than optimal, as treatment generalizability is exceedingly important within rehabilitative techniques. Nonetheless, mental/motor imagery as a form of rehabilitation is an area that researchers should strive to engage in; even to use it as a complimentary add-on to physical rehabilitation. This type of intervention is ideal, as it requires little supervision, is cost-effective and easily accessible (Braun, Kleynen, Schols, Beurskens & Wade, 2008).

Stroke is a highly prevalent and disabling event, and thus, it is no surprise that there is a variety of rehabilitation programmes being researched and developed to combat it’s harsh impact on motor performance. It is important to be aware of cerebral plasticity’s role in these rehabilitative interventions, as it is the reorganization of neural connections  that stroke researchers are targeting. It should also be noted that due to the nature of stroke, the research into stroke rehabilitation has wider implications for other neurological disorders; these often provide a basis for treatments for neurodegenerative disorders affecting the motor system, such as Parkinson’s Disease, or for motor impairments resulting from traumatic brain injuries. In addition to the research’s practical significance, neural plasticity is a fascinating concept; the ability of the brain to pave new pathways and build new bridges in order to engage in learning or re-learning processes. It’s certainly an area worth keeping an eye on, and hopefully, the coming years will find these rehabilitative techniques to make progress in leaps and bounds.

References

Braun, S., Kleynen, M., Schols, J., Schack, T., Beurskens, A., & Wade, D. (2008). Using mental practice in stroke rehabilitation: a framework. Clinical Rehabilitation22(7), 579-591.

Dijkerman, H. C., Ietswaart, M., Johnston, M., & MacWalter, R. S. (2004). Does   motor imagery training improve hand function in chronic stroke patients? A pilot study. Clinical rehabilitation18(5), 538-549.

Hodics, T., Cohen, L. G., & Cramer, S. C. (2006). Functional imaging of intervention effects in stroke motor rehabilitation. Archives of physical medicine and rehabilitation, 87(12), 36-42.

Jackson, P. L., Lafleur, M. F., Malouin, F., Richards, C., & Doyon, J. (2001). Potential role of mental practice using motor imagery in neurologic    rehabilitation. Archives of physical medicine and rehabilitation82(8), 1133-    1141.

Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51(1), S225-S239.

Liepert, J., Miltner, W. H. R., Bauder, H., Sommer, M., Dettmers, C., Taub, E., & Weiller, C. (1998). Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neuroscience letters, 250(1), 5-8.

Linazasoro, G. (2006). Plasticity in PD: from compensatory usefulness to negative aberrant             behaviours. Focus Parkinson Dis18, 5-9.

Lövdén, M., Wenger, E., Mårtensson, J., Lindenberger, U., & Bäckman, L. (2013).            Structural brain plasticity in adult learning and development. Neuroscience &          Biobehavioral Reviews37(9), 2296-2310.

Lum, P. S., Burgar, C. G., Shor, P. C., Majmundar, M., & Van der Loos, M. (2002). Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke.Archives of physical medicine and rehabilitation, 83(7), 952-959.

Murphy, T. H., & Corbett, D. (2009). Plasticity during stroke recovery: from synapse to behaviour. Nature Reviews Neuroscience, 10(12), 861-872.

Pascual-Leone, A., Dang, N., Cohen, L. G., Brasil-Neto, J. P., Cammarota, A., & Hallett, M. (1995). Modulation of muscle responses evoked by transcranial magnetic stimulation during the acquisition of new fine motor skills. Journal of neurophysiology74, 1037-1037.

Sharma, N., Pomeroy, V. M., & Baron, J. C. (2006). Motor imagery a backdoor to the motor system after stroke?. Stroke, 37(7), 1941-1952.

Teixeira-Salmela, L. F., Olney, S. J., Nadeau, S., & Brouwer, B. (1999). Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Archives of physical medicine and rehabilitation, 80(10), 1211-1218.