Advanced cerebral gymnastics -spotter required

After attaining satisfactory progress with duration and quality of attention, the next phase of activities involved"forced" use of increasingly more challenging thought processes: memory, sequencing and a subtle but exciting discovery - learning! I later came to see these specific set of skills referred to as Executive Functioning- capacity to break a problem or task into discrete steps and to assign sequence or priority to steps. At an even higher level, executive functioning involves the capacity to process feedback to recognize, understand, and correct mistakes - activities that engage a stroke survivor in this latter "learning opportunity" addresses a tendency seen in the behavior of individuals with injury to areas in the right hemisphere of the brain: impulsivity.

Description of activities
The activities at this advanced stage of cognitive therapy involved a sequence of computer- driven exercises in reading, memorizing then executing multi-step directions to move shapes to new locations in a specific sequence. The software feature that "forces" memory: the instruction disappear once you begin by moving the first object. The software feature that "forces" learning and error correction: the software highlights an object if moved to the wrong location or if moved in incorrect sequence -also, a "start over" option is available to recover the instructions and to get a second or third glance at the instructions to get the details and sequence straight. My therapist would review my performance results - provided by the software in terms of both time taken to successfully complete a set of exercises and the number of attempts to complete through trial,error, correction. Trust me, you wouldn't want to try this one alone - your sanity and the computer would both be at risk.

Why this works
As I learned from my experience with physical and occupational therapies (and from the explanations provided by some highly trained, superbly skilled therapists), the strategy of "forced use" essentially puts the body through a process that coerces or inspires the brain to recruit and train healthy brain cells to perform work previously executed by cells now damaged -- and in most instances permanently-- (due to loss of oxygen during the stroke). As described in a posting re: use of an electronic stimulation device to recover movement of my fingers:" The therapy helps you train the healthy parts of the brain following a stroke to take over the EMG signals that once came from the areas of the brain now affected by stroke. Repetitive use may help achieve voluntary muscle contractions of the paralyzed muscles by causing the brain to assign new brain cells to obtain direct muscle movement, assisted by the device."

So, the cognitive therapy works in a fashion similar to that of the physical therapy. My cognitive therapy included the additional wrinkle of the therapist's interventions that introduced adaptive strategies like taking notes or verbalizing instructions to augment impaired memory or developing a written check list as a proxy for intuitive executive functioning.

The most exciting revelation of progress attributable to the cognitive therapy came months later during neuro psych testing when I witnessed a cognitive equivalent to the promises of the physical therapy:"Repetitive use may help achieve voluntary muscle contractions of the paralyzed muscles by causing the brain to assign new brain cells to obtain direct muscle movement." There were several instances in which I intuitively applied one of the "practiced" adaptive strategies to perform either more quickly or more accurately on a task required by a test.

For example, one section of a recent round of neuropsych testing involved repeating a list of seemingly random list of items read by the tester:" Holland, moss, towel, ivy, Poland, broom, wheat, blanket,Thailand" etc. This type of memory test was administered almost weekly during therapy or evaluations with neurologist - but on this day, I remembered and intuitively applied an adaptive memory technique suggested to me in the context of viewing and recalling items in a picture. At some point in cognitive therapy, when presented a page with dozens of items and asked to write down the items I had seen, the trick, I was told by my therapist, was to recognize the categories of the items and to use that insight to remember in one instance the modes of transportation( plane, bus, car, bike, roller skates) and the animals(birds, lion,elephant) and so forth - So, on the second round of neuropsych testing, I had a front-row seat to witness my brain demonstrate the capacity to learn! The random list of items was comprised of plant, countries and household objects and with this insight easier to memorize and recall.

Cerebral gymnastics: part two

To the best of my recollection, (I'm not kidding I don't recall exactly but) the second round of activities in speech (cognitive) therapy addressed issues of the quality of the attention- the first round having worked on quantity i.e. duration of attention. The activities in round two all involved tasks that demanded "active" listening and reading for comprehension with testing of recall as the measurement /"forced use" aspect of the therapy's design.

In comparing the strategies and tactics of my physical and cognitive therapies I now see parallels in the sense that as the prescribed physical activities presented movements choreographed to "force" the use of my weakened affected side, the mental gymnastics prescribed for speech (cognitive) therapy presented tasks orchestrated to "force" the use of the affected areas of my brain --or the use of thought processes conventionally associated with the right hemisphere of the brain where CT-Scans and MRI's indicated cell damage from the loss of oxygen for the period of time when the normal flow of oxygenated blood through my middle cerebral artery (MCA) was interrupted by the stroke.

A sample of tasks involved included something as simple as listening or reading a passage then repeating a summary of the pertinent details. More challenging exercises involved reading a passage rich in details such as names of people performing various tasks or in possession of various objects and then completing a grid that represented who was doing what--with the trick being that the passage would not provide a"linear" or "complete" inventory of who was doing or was holding what-- so completing the grid required "active" comprehension in reading and re-reading the passage to gather pertinent data and to record "known" items on the grid -The final phase for completing the grid was , then, using what was known to induce or deduce by process of elimination other pieces of the puzzle.

paying for attention deficit

One of the first goals of my speech (cognitive) therapy was simple but critical: to increase the length and quality of attention. The trauma of hospitalization and attending sleep deficit presented significant challenges in sustaining focused attention. After a week or so, once my physical condition had improved to a point where I showed signs of being well-rested, I began working with a speech therapist to address the impairments from damage of a stroke that according to physical evidence depicted by CT-Scans and MRI's caused injury to areas on the right side of my brain. As, an introductory course in cognitive neuroscience or an attempt to hold a brief conversation with me even four days after my stroke would reveal -my injuries on the right hemisphere of the brain had little or no impact on my speech at least in terms of generating words;-) written or verbal expression if anything tended towards too much not too little. So the preliminary work focused on cognitive vs speech therapy of a verbalization nature. The first exercises were appropriately "mind-numbing" to the extent that the assigned tasked required me to control a racing, wandering mind to acquire a state of focus we all know or describe as "paying attention." Not something as simple as awake -vs asleep. but a state of mind that demonstrates an awarenes of and ability to intelligently respond to external stimuli. The first exercises which were I surmise both diagnostic as well as therapeutic involed listening to a recorded voice that read a list of letters and or numbers and pressing a buzzer each time I heard a specific letter or number. This would go on for what appeared to me for 5-10 minute strethches over the course of an hour or so with small breaks for changes of instruction to listen for the number 4 or the letter N. The challenge for me was
(partially) physical like trying to stay focus on driving while extremely tired. The other challenge was allocating sufficient band-width to rember what letter I was waiting for and to press the buzzer when the voice finally spoke the target letter or number. I couldn't help but to feel that I was in a battle of wits with the drone on the tape, who dilligently read his script of random letters and numbers with the dispassion of a mid-western boy-scout brought in to call bingo at a nursing home in vegas recently scandalized by cheating scheme involving a bingo caller on the take. So, my attention available to hear and to respond correctly was in competitio with idle thoughts such as imagining the face or the setting behind the voice on the tape . I did not receive immediate scores or feedback on my performance on these attention deficit tests but recall that my weekly report on goals for the upcoming week and performance against goals for previous week. contiued to note progress with the duration and quality of my attention