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Cognitive Rehab Offers Hope for Stroke Sufferers
Concerns about her ability to retrieve words following a stroke led Gwen Keillor to Baycrest neurologist Dr. Jon Ween, and a new lease on life.
Gwen Keillor knew that as she grew older, she was bound to start slowing down but the 73 year old says it happened much sooner than she anticipated.
Active and healthy, Mrs. Keillor retired from teaching 10 years ago and moved from Toronto to her horse farm near Cobourg, Ontario where lifting 50-pound bales of hay and working the large vegetable and flower gardens were routine chores. In the winter, she loved to cross-country ski and take vacations, including hiking trips to New Mexico and Arizona in an Airstream trailer.
It was on one of these hiking trips in March 2005 that Mrs. Keillor felt more tired than usual and her left leg was weak. She attributed it to sitting too long while driving so she and her partner stopped to have lunch. When her hand began to tingle, they went to the local hospital.
“The nurse said I’d had a mild stroke, a TIA[Transient Ischemic Attack], that I’d be fine in 24 hours and I should go home and rest,” Mrs. Keillor explains. A neurologist confirmed this and told her to rest for a few days and then start heading for home.
But Mrs. Keillor says her speech started to get funny, her mobility worsened and it felt like there were electrical shocks going through her left side. Her daughter, a neuropsychologist in Toronto, told her to get to a stroke centre immediately so they drove to the Mayo Clinic Hospital in Scottsdale, Arizona. She spent 48 hours in intensive care and stayed for a week of speech and physical therapy before being flown home by air ambulance. She then spent six weeks in a rehabilitation hospital followed by six weeks of outpatient care and on-going physiotherapy.
The subcortical stroke she suffered – caused when blood flow through the small arteries in the brain is blocked – left her with mobility and cognitive difficulties. She was physically unbalanced and weak, and had trouble finding words and completing tasks.
Concerns about her word retrieval and attention problems led to a referral to neurologist Dr. Jon Ween, director of the Louis and Leah Posluns Stroke and Cognition Clinic at Baycrest. The stroke clinic, one of three out-patient programs in the Brain Health Centre (BHC), offers assessment, and diagnostic and rehabilitation services for both physical and cognitive deficits. The BHC also includes the Sam and Ida Ross Memory Clinic and the Mood and Related Disorders Clinic.
After a battery of cognitive testing, Mrs. Keillor was asked if she would like to take part in a 12- week pilot program offering cognitive rehabilitation strategies for people who have had a stroke. Despite having to travel from Cobourg to Toronto once a week, she jumped at the chance to do “anything that helps.”
She completed the program in August and says, “It was absolutely wonderful. I zeroed in on all kinds of strategies that work for me. I had terrible word retrieval problems and it was hard for me to get things done if people were talking to me. Now my ability to converse has improved, I can communicate faster and I feel more competent. I have much less anxiety, I learned how to clear my head and focus, and I’m even sleeping better.”
The significance of the pilot program and its promising outcomes is that it is an example of Baycrest research being put into action. Last January, scientists from Baycrest’s Rotman Research Institute and the Kunin-Lunenfeld Applied Research Unit published five papers on a large-scale clinical research study they conducted to evaluate a comprehensive approach to rehabilitating a wide range of cognitive functions that older adults typically use every day.
The study showed that the program can improve memory and cognitive function by between 15 to 40 per cent in healthy, older adults with normal cognitive decline. The next step was to see if the program also worked for people with brain damage caused by stroke. This study was funded by the JSF Mc- Donnell Foundation in the United States, and was developed under the auspices of the Heart and Stroke Foundation Centre for Stroke Recovery (CSR). The CSR is a virtual centre, bringing together scientists from three institutions: Ottawa Health Research Institute, Sunnybrook Health Sciences Centre, and Baycrest.
Scientists and clinicians from the stroke clinic worked together to adapt the cognitive rehabilitation program for this population. “Part of our mandate in the Brain Health Centre is to work with scientists to look at what evidence is being built in research and how we can apply it clinically,” explains Bianca Stern, co-director of the BHC and director of occupational therapy.
The challenge was taking the rigorous methodology necessary for research and making it clinically relevant for the real-life needs of stroke clients with varying degrees of difficulty with memory, concentration, attention, planning and organizing.
“We had leeway with certain content but we had to trial it in a standardized way to measure its effectiveness,” adds Baycrest neuropsychologist Dr. Dmytro Rewilak, who was in charge of the implementation. “Eventually, it will be up to the clinical staff to use our judgement to adapt the training based on the individual needs of the clients, and that’s what I see as its biggest value,” he says.
The pilot program was delivered in a group format to four participants once a week for three hours and consisted of three modules: memory training, goal management training and psychosocial training.
Memory training involved understanding how memory works, identifying and understanding memory slips, and using internal and external strategies to learn, retain and recover information.
“If someone was forgetting appointments, for example, we taught them internal strategies such as spaced repetition, which involves repeating information to yourself at increasing intervals of time until you remember it, and external strategies like using a planner, making lists or setting a timer,” explains occupational therapist Iona Yim who led the group sessions. “The important thing is for each person to understand their memory slips, learn to use the strategy that works best for them in different situations and capitalize on their strengths,” she adds.
Goal management training emphasized attention control to reduce every day memory slips, such as learning to stop and think to see if you’re on track; monitoring goal attainment; and, simplifying cognitively demanding life tasks.
Psychosocial training was designed to enhance psychological well-being and build participants’ confidence in their cognitive abilities.
A month after the group ended, participants were invited back to provide feedback. “Everyone said they benefited in some way, especially in achieving their goals,” says Ms. Yim. Now the clinicians are taking this feedback and their own recommendations back to the scientists who developed the program so that the modules can be modified and refined to best suit the needs of stroke clients with varying levels of impairment. Once the modifications are made, the group will be offered on a permanent basis and continually evaluated.
“It’s a work in progress and it ce
rtainly has potential,” adds Dr. Rewilak. “With some adjustments, I think it can be applied to different populations including people who have cognitive difficulties on the basis of an emotional disturbance such as depression. They would likely benefit from these techniques which instil a sense of confidence and self-mastery.”
Gwen Keillor says maintaining a positive attitude is half the battle. “It may take me longer to do things, but I know if I put my mind to it I will continue to improve.”
For more information on the Louis and Leah Posluns Stroke and Cognition Clinic, please call 416-785-4359 or visit www.baycrest.org/poslunsclinic.
Related Links
- More about Stroke at Baycrest
- Stroke - Signs, Prevention and Treatments
- MOST: Moving On after Stroke Program
- Stroke Recovery Group
- Healthy Living and Health Maintenance Programs
- Stroke Survivors get the MOST out of program
- Client no longer lost for words, thanks to stroke clinic team