Health
Making Headway
Is it possible for stroke victims to regain the ability to read, write, and speak? Dallas researchers are racking their brains.
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For more than a week following the stroke, Carol lay hopelessly mute in her hospital bed. “The only thing alive about her was her eyes,” Karl says. “She couldn’t talk, and I couldn’t tell what she understood. But I could see the lights were on behind her eyes.” Then, on the twelfth day, Carol made her first sounds: They were mere utterances, baby noises like eee and ooh, but “they had the melody and inflection of language,” Karl says. “It was like she thought they were words.” Today Carol confirms with a vigorous nod that she believed she was saying words and sentences and was miffed that Karl and their two children didn’t understand what she was “saying.” This is what aphasiologists like Walker-Batson mean when they say the “inner voice” of aphasic patients can be just fine, even as the “outer voice” is spouting gibberish.
Carol’s apraxia of speech was so extreme, in fact, that she had great difficulty making the most basic consonant and vowel sounds. “She had trouble with her own name and mine,” says Karl. “She couldn’t do a hard c or k sound.” At TWU speech therapist Sandra Curtis first attacked her pronunciation problems with mind-numbing daily drills. Viewing a videotape of Carol’s therapy, one can’t help but be struck by the cruelty of the affliction: Here’s a middle-aged college graduate and mother of two, once an avid reader and accomplished pianist, struggling harder than a child might to make simple hard c, p, and th sounds.
Still, her progress exceeded her doctors’ rather bleak expectations. Aided by the experimental dextroamphetamine dosing in her physical therapy at the Baylor Institute for Rehabilitation, Carol was able to stand in a little more than a month and walk with a cane shortly thereafter, though doctors had initially warned Karl that she might be confined to a wheelchair for a long time. And certain aspects of her aphasia seemed to recede: Even as her ability to express language remained infantile, her comprehension returned, and her writing skills showed themselves to be even more intact than her aural language skills.
Researchers are confounded by such contradictions and anomalies, which are typical in people with aphasia. For one thing, neurologists have known for some time that a certain percentage of damaged neurons “rebound” naturally, having been merely “stunned” by the swelling after a stroke or head trauma rather than destroyed. But which neurons relating to which links in the complex language comprehension and production chain can’t be predicted. Although age and attitude are the critical factors in recovery, aphasia experts are beginning to realize that the extent of a patient’s facility with language before a brain injury can play a role in his rehabilitation. Carol, for one, was unable to name various parts of her body for months, even though she could explain the function of, say, her hand. “If you had several numbers up on a board and asked her to point to the number three, she could do it right off,” Karl says. “But if you reversed the process, and you pointed to the number three and asked what it was, she’d draw a blank.”
To combat problems of this sort, Walker-Batson and her colleagues at TWU have rethought the way they treat aphasia. In the days when language was thought to be the product of a single center in the brain—the hard disk—a stroke or head trauma was believed to more or less delete the disk, so speech therapists literally retaught aphasic patients pronunciation, vocabulary, grammar, syntax, connotation, and denotation. But since researchers discovered that language comprehension and expression are, in fact, a complex collaboration of many regions of the brain, they’ve focused on retrieving them from an unknown number of alternative circuits. The guiding principle of aphasia therapy has thus become reaccessing and reconnecting, not just reeducation; the goal is to restore enough fluency for the patient to lead a productive existence. If such circuits are brought forward and cobbled together, a person with aphasia can regain his language skills more quickly and completely. “You have to think of language as an orchestra,” says Walker-Batson. “If the first violins get knocked out for some reason, the second violins still know the melody.” As a tool in this process, the results of the drug studies are promising, she adds: “They suggest that redundant circuits can be manipulated forward using medications along with therapy.”
Even though the dextroamphetamine accelerates the recovery rate—Walker-Batson’s study has shown that it increased the speed with which aphasic patients reach certain levels of verbal ability by up to three months—aphasia rehabilitation is long, arduous, and expensive. Carol receives thirteen hours of speech therapy a week at TWU and at the University of Texas at Dallas. The TWU sessions are inexpensive because they are experimental and therapy is mostly led by graduate students, but private speech therapy can run as much as $180 an hour—with no guarantee that insurance will cover it. “All in all, my insurance policy did us pretty well,” says Karl, who is an American Airlines pilot. “It covered all the major hospital charges and her initial physical and speech therapy. But there’s a cap on it, and they want to see improvement. That’s not always easy to show with aphasia.” And, of course, like most chronic disabilities, the infirmity exacts a toll that goes far beyond dollars and cents. “Carol needs someone with her nearly all the time,” Karl says. When he is unable to be there, Carol’s chief nurse is their 24-year-old daughter, Courtney, who has become so involved with her mother’s rehabilitation that she has entered the TWU graduate program in speech therapy and wants to be an aphasia therapist. “I regard that as one of the silver linings,” Karl says.
These days, the Koschaks will take good news wherever they can find it. Like most aphasic patients, Carol will never completely reacquire her facility with language; the goal of her therapy is to reconstruct enough of it that she can resume an independent, productive life. But from what I saw, she’s well on her way. Late in our interview, I asked her if, given her improvement from functional mute to merely “language challenged,” she had more hope for the future. She furrowed her brow in consternation. Finally, that look of joyous, childlike surprise filled her eyes. My use of the word “hope” had inadvertently triggered something deep in the hardware.
“I—am—open!” she said emphatically.
“Open?” I asked.
“Op-ing,” her speech therapist interjected. “Now, Carol, give us the h sound that’s there. That’s the word you mean.”
Carol took a deep breath and with great labor, but obvious enthusiasm, repeated, “I—am—hhh—oping!”
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