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Anosognosia – Part II

Article by Moody Neuro

In Part I of this series I gave an introduction to anosognosia, a lack of awareness experienced regarding deficits which occur following a brain injury (http://tlcrehab.wordpress.com/2013/04/17/anosognosia-part-i/).  This lack of sufficient awareness of injury-caused deficits can be frustrating for both the brain injury survivor and the survivor’s family and can often lead the survivor to make poor decisions.  In this installment, I will address strategies by which a survivor can effect improvement of that awareness.

Anosognosia is particularly common when individuals who have suffered moderate to severe brain injuries are first coming out of their comas.  These individuals often suffer from Post-Traumatic Amnesia (PTA).  At this early stage, brain injury survivors are just beginning to heal.  They may walk or talk but will tend to say and do things stridently out of character, such as physically assaulting health care professionals and caretakers or making wild accusations (“You’ve poisoned my food”, etc.).  They also have a very poor understanding of the world around them and new memories established tend not to be very strong ones.  It can be argued that during PTA most brain injury survivors lack a full awareness of their injury.  After all, they are not really well enough connected to reality to allow for a full understanding of all that has happened and often cannot hold on to new memories for a long enough time in order to remember things they have been told.  Many brain injury survivors’ anosognosia simply improves as they gradually emerge out of PTA and attain a better understanding of their situation.

Anosognosia is improved by successfully teaching the brain injury survivor about his or her deficits.  Many people take it for granted that a patient in a wheelchair will automatically understand that he or she is unable to walk.  This is often not the case, particularly in the immediate aftermath of an injury.  Sometimes family and friends can forget that the brain injury survivor may not have all of the information about the injury to which they’ve been exposed.  After all, the survivor may have been unconscious or in PTA while doctors shared such information with the family and friends.  It is important that the brain injury survivor be taught, with rigorous repetition, about his or her brain injury and subsequent deficits.  It often helps to review medical records with the brain injury survivor so the survivor is able to see what happened laid out in an “official” form.  Since many survivors have deficits in memory and comprehension, it is generally helpful to review the information with the survivor on an excessively regular basis until he or she demonstrates a strong understanding of the injury and its consequences.

Brain injury survivors with anosognosia often benefit greatly from feedback on their performance during tasks.  This can aid in a very specific manner in efforts to teach them about their deficits.  For instance, a survivor with reading deficits may not believe he has a deficit until he attempts a reading test and learns that he got half the comprehension questions wrong.  Therapists may employ a method termed “guided failure.”  In this method, the patient is allowed to attempt a task (with safety precautions in place, as necessary) that the patient believes he or she is capable of completing but which the therapist knows will serve as a substantial obstacle.  This gives the patient an opportunity to try the task and learn from his or her struggles.  In some cases, the survivor may benefit from seeing a video which documents the attempted task and resultant poor performance.  Some survivors who minimize their difficulties quickly gain appreciation for their deficits when they see their difficulties on video.   The video provides objective evidence of performance.  Another method that therapists often use is asking patients to rate how they will do on a task prior to starting it and then comparing that rating with the actual results of the attempt.  This method allows the therapist to show patients the difference in performance between what those patients believe they are capable of achieving and what actually occurs.  As an example, a patient may estimate that he can walk 5 miles but when he tries to walk he is only able to accomplish 10 feet.  The therapist will then review with him the difference between his estimated performance and his actual performance.

Improvement in anosognosia, particularly for survivors with more serious injuries, can be a long, slow process.  Most survivors do show improvement over time.  Unfortunately, there are some cases in which a survivor does not make appreciable improvement in their anosognosia despite considerable effort.  In these cases, it is vital that the survivor’s family and treatment team develop a safety plan in order to minimize the impact anosognosia is allowed to have on the survivor’s general welfare and overall quality of life.

Learn about the Moody Neuro’s brain injury treatment services.

Strokes are medical conditions that affect millions globally. In the United States, more than 795,000 people have a stroke each year, with about 610,000 cases being first or new strokes. 

These can lead to a wide range of physical and cognitive impairments. Speech and language disorders are among the most common and most challenging consequences of strokes, occurring in about a third of stroke survivors. 

Understanding Stroke-Induced Speech & Language Disorders

Stroke-induced speech and language disorders significantly impact communication abilities. Among these, aphasia, dysarthria, and apraxia of speech are prevalent. Understanding how they are diagnosed and their specific symptoms can aid in prompt and effective management.

Aphasia

Aphasia is a common outcome of stroke, manifesting as difficulty in speaking, understanding, reading, and writing. There are many different types of aphasia, depending on the affected brain area, and are categorized based on the symptoms present:

  • Expressive Aphasia (Broca’s Aphasia): Characterized by broken speech, limited vocabulary, and difficulty forming complete sentences. Patients often understand what is being said to them but struggle to verbalize responses.
  • Receptive Aphasia (Wernicke’s Aphasia): Patients can produce fluent speech but may lack meaning or include nonsensical words. They often have significant difficulty understanding spoken language.
  • Global Aphasia: A severe form of aphasia where individuals have extensive difficulties with both speech production and comprehension.
  • Anomic Aphasia: Individuals have difficulty finding words, particularly nouns and verbs, making their speech sound vague.

Dysarthria

Dysarthria is a speech disorder that affects 20-30% of stroke survivors. It occurs when stroke impacts the muscles responsible for speech, leading to slurred or slow speech that can be hard to understand. It is typically diagnosed through a physical examination and a series of speech evaluations conducted by a speech-language pathologist (SLP). 

It is characterized by the following symptoms:

  • Slurred or slow speech that can be difficult to understand
  • Monotone or robotic-sounding speech
  • Difficulty controlling the volume of speech, which may be too loud or too soft
  • Challenges with the rhythm and flow of speech, including rapid speech that’s hard to interrupt or slow, drawn-out speech
  • Respiratory issues affecting the ability to speak loudly or for extended periods

Apraxia of Speech (AOS)

Apraxia of speech is a neurological disorder characterized by difficulty sequencing the movements needed for speech. This is caused by the impact of the stroke on the brain’s pathways involved in producing speech. 

Patients with AOS know what they want to say but struggle to coordinate the muscle movements to articulate words correctly. This results in distorted speech, difficulty initiating speech, or the inability to accurately produce speech sounds or sequences of sounds. 

How Long Is the Stroke Speech & Language Recovery Time?

According to one study on post-stroke speech and language therapy, approximately one-third of stroke patients experience speech problems after a stroke. Many of these individuals begin to recover within a few months, with significant progress typically observed within three to six months.

In another study, 62% of subjects had speech challenges after suffering from a stroke. By six months post-stroke, 74% were able to completely recover their communication abilities. 

However, the figures above provide a general timeline for post-stroke speech and language recovery. Stroke speech recovery time is highly individualized and can vary depending on several factors. These can include the following:

  • Severity of the Stroke: More severe strokes often lead to extensive brain damage, resulting in longer and more challenging recovery periods for speech.
  • Location of the Brain Injury: The brain’s specific regions control different speech and language functions; damage to these areas directly impacts recovery complexity and duration.
  • Age and Overall Health of the Patient: Generally, younger patients with better overall health before the stroke tend to experience faster and more complete recoveries.
  • Pre-existing Conditions and Comorbidities: Conditions such as diabetes or hypertension can slow down recovery by complicating the overall health scenario and rehabilitation process.
  • Individual Variability and Resilience: Personal resilience, the support system’s strength, and the individual’s motivation significantly influence the pace and success of speech recovery efforts.

The first three months after a stroke is a crucial period for recovery, as a majority of stroke patients see the most significant improvement during this period. However, it’s also important to note that, although at a slower pace, recovery can continue well past the 6-month mark with continued therapy and practice. 

This underpins the importance of early intervention and ongoing rehabilitation efforts, including speech therapy, to maximize each patient’s recovery potential. 

What Does the Stroke Speech & Language Recovery Process Look Like?

The journey to regain speech and language after a stroke is multifaceted and varies significantly from one individual to another. Understanding the structured phases of recovery can provide insight into what patients and their families can expect during this challenging time. 

Here’s a closer examination of each phase in the stroke speech recovery process.

Initial Assessment and Diagnosis

Before recovery can begin, a thorough evaluation is conducted by a team of healthcare professionals led by an SLP. This assessment aims to identify the type and severity of the speech and language disorder, be it aphasia, dysarthria, or AOS. The evaluation may include cognitive-linguistic assessments, comprehension tests, speech production analysis, and functional communication measures. 

Based on this assessment, a personalized therapy plan is crafted to address the patient’s specific needs.

Acute Phase

The acute phase typically occurs within the first days to weeks following a stroke. During this period, medical stabilization is the primary focus, with healthcare teams working to manage the immediate effects of the stroke. 

Speech therapy may begin with simple exercises or assessments to gauge the patient’s abilities. However, intensive therapy usually does not start until the patient is medically stable. During the acute phase, the goal is to support overall recovery and prevent complications immediately after the stroke.

Subacute Phase

The subacute phase generally spans from two weeks to three months post-stroke and is characterized by more intensive speech therapy interventions. As the patient’s medical condition stabilizes, the focus shifts to active rehabilitation. Therapy during this phase is tailored to the individual’s specific speech and language deficits and may include:

  • Exercises to improve articulation, fluency, and voice control for those with dysarthria.
  • Language therapy to enhance understanding, speaking, reading, and writing skills in patients with aphasia.
  • Motor speech exercises and strategies to improve speech planning and production in apraxia of speech.

The subacute phase is crucial for taking advantage of the brain’s natural recovery processes and neuroplasticity, where the brain begins reorganizing and adapting to the loss of function.

Chronic Phase

The chronic phase of recovery extends from several months to years after the stroke. It focuses on long-term rehabilitation and adjustment to any residual speech deficits. During this time, patients may continue to see gradual improvements in their speech and language abilities, although the rate of recovery may slow. Therapy in the chronic phase often includes:

  • Advanced communication strategies to cope with ongoing challenges in daily life.
  • Maintenance exercises to preserve and enhance speech gains achieved in earlier phases.
  • Supportive technologies and aids, such as communication devices, to assist in effective communication.
  • Community reintegration activities to help patients return to as normal a life as possible, engaging in social, vocational, or recreational activities.

What Is the Role of Neuroplasticity in Speech & Language Recovery?

Neuroplasticity refers to the brain’s fundamental property to change and adapt its responses to new experiences, learning, and environmental changes. This adaptive capacity enables the brain to reorganize itself by forming new neural connections.

When the brain, or a part of the brain, is damaged after a stroke, neuroplasticity is what allows the other parts of the brain to take over the functions of the damaged area. Through targeted rehabilitation and therapy, such as speech therapy for stroke survivors, patients can retrain other brain areas to perform the lost functions and facilitate recovery.

Enhancing Stroke Speech & Language Recovery Time

Adopting a comprehensive approach involving several key strategies is vital to enhance the stroke speech and language recovery time. This multifaceted approach can maximize the chances of regaining speech and communication abilities.

This comprehensive approach must incorporate the following strategies:

  • Early intervention to leverage the brain’s highest potential for neuroplasticity in the initial period following a stroke, significantly improving the chances for recovery.
  • Alternative communication strategies, such as gestures, writing, and visual aids, to help maintain communication during the recovery process. 
  • Adopting technology, including speech-generating devices and software applications designed for speech rehabilitation, for personalized exercises and continuous practice, which is vital for progress.
  • Providing continuous support from psychologists, support groups, and therapy to help manage feelings of frustration, depression, and anxiety, fostering a positive mindset essential for rehabilitation.
  • A healthy diet and lifestyle to supply essential nutrients that support brain function, along with regular physical activity, adequate sleep, and management of medical conditions.

Begin Your Post-Stroke Recovery Journey With Moody Neurorehabilitation

Moody Neurorehabilitation understands the complexities and challenges that come with post-stroke rehabilitation. We are dedicated to supporting patients and their families through this critical time with specialized care and personalized treatment plans.

Since our inception in 1982, Moody Neurorehabilitation has been a leader in brain injury rehabilitation. Our approach centers on providing comprehensive care tailored to each patient’s needs and goals. We believe in treating the whole person, not just the symptoms, to improve overall quality of life.

We invite you to start your recovery journey with us. Contact Moody Neurorehabilitation today to schedule a consultation with our experts. Let us help you navigate the path to recovery with care, compassion, and expertise.

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