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.
