STROKE: How We Communicate and Recover After a Stroke

by Amy Phariss

Women experience more stroke than men and are more likely to die from stroke than from breast cancer. In the United States, for example, the lifetime risk of stroke for women is approximately 21%. For men, the risk of stroke is lower, at 1417%.

While these statistics are sobering, there is good news. According to the CDC, 4 in 5 strokes are preventable. We can take action to prevent stroke. Lifestyle changes can have big preventative impacts including limiting alcohol, stopping (or avoiding) smoking, eating a healthy diet, getting plenty of exercise and controlling chronic illness such as diabetes, high cholesterol, high blood pressure and others. In addition to stroke prevention, treatment and support post-stroke can greatly improve recovery and quality of life.

As we gain awareness of this important health issue, ONC is grateful to speak with Speech

Language Pathologist (SLP) Abbe Simon, who works regularly with people recovering from and impacted by stroke. Simon answers our questions about how stroke affects communication, how to treat stroke-related neurological language disorders and how care partners and loved ones can best help those recovering from stroke. We are thankful for Simon’s 26-years of experience in the field, allowing us a window into how consistent skilled therapy can impact not only stroke survivors but their families and loved ones, too.

ONC: One of the most common neurological communication issues faced by those who’ve had strokes is aphasia. Can you explain aphasia and how it relates to stroke?

Abbe Simon: Aphasia is an acquired language disorder that can impact a person’s ability to comprehend language, read, write and speak. Aphasia is a 7-letter word most Americans have never heard of unless it shows up in their life. About 25 to 40% of strokes cause aphasia, and stroke is the leading cause of aphasia.

Aphasia is strictly a disruption in a person’s ability to access their language. Aphasia does not affect one’s intellect. All of the information and knowledge they had before the stroke is completely intact. Aphasia presents itself differently depending on where in the brain a stroke occurred. This location in the left hemisphere of the brain, determines what type of language impairment a person might have. Language includes speaking, understanding, reading and writing. Someone with aphasia could have impairments in all or some of these areas. And depending on the location of a stroke, a person can have impaired speech production that results from a motor speech disorder or muscle weakness. This refers to conditions known as apraxia or dysarthria that impact articulation from being produced clearly. Communication results from a person’s ability to use language and when there is damage to part of the brain responsible for language, successful communication can be challenging. With the guidance of a skilled SLP, a person with aphasia can improve and effective communication can be achieved. Without the proper types of communication tools or supports, a person with aphasia is without their communication right. Just because a person is unable to speak like they once were, it does not mean they have nothing to say or ask. It’s a disservice if anyone attempts to speak to someone with aphasia and determines that they’re not competent or capable because they’re not able to communicate, if they haven’t offered them different options of communication.

AS: The primary symptom is the feeling of a word being on the “tip of your tongue” and not being able to say the word in the moment you want to say it. It’s called “word finding difficulty,” which a lot of people can experience if they haven’t had a stroke. It’s like knowing you know a person’s name, but you can’t say it at that moment

There are different kinds of aphasia that are present differently depending on the location, size, and severity of a stroke. Sometimes people produce words that are effortful and faulty, so speech comes across as choppy and not as smooth as a regular conversation. This is called non-fluent aphasia. Fluent aphasia can be described as connected sentences that do not necessarily contain real or intended words. This type of language pattern can be tricky to decipher and often includes comprehension deficits so a person may be less aware of their errors. A trained SLP will be able to know the type of aphasia one has and the therapies needed. Another thing about aphasia is how isolated people can feel. When you add a communication disorder on top of any kind of physical symptoms that might result from a stroke, other people may not know how to respond. They can feel intimidated or scared or turned off by these new communication symptoms. Unconsciously they may avoid the person who has had the stroke or not allow the time and space for them to express their new communication needs. And that most importantly, they are still the same person.

ONC: What is the biggest myth about aphasia?

AS: That it can never improve, that there is a plateau to one’s ability to improve their aphasia. This is completely untrue. The brain benefits from neuroplasticity and can continuously make changes given the proper input. When a person is motivated to make a change, you are never, ever too old to make changes.

ONC: What other communication problems can affect someone after a stroke, besides aphasia?

AS: When a stroke happens on the right side of the brain, you might have cognitive or cognitive linguistic issues, which include skills of higherlevel thinking such as insight, problem solving, and reasoning. These impairments can affect your ability to communicate. And as I mentioned before, some strokes can affect the production and intelligibility of speech. Lastly and location dependent, swallow function can be altered.

ONC: Which treatments can help with speech and communication issues following a stroke?

AS: So, working with a skilled speech therapist who understands acquired language disorders in adults, who can recognize that all treatment needs to prioritize the individual person’s goals, will be able to incorporate evidenced-based therapies that target the communication strengths and weaknesses. These are determined by the therapist and assessed all the time.

What they do in speech therapy must be done 10x more outside of the therapy environment. So, having the support of communication partners is essential to maximizing recovery.

AS: Anybody who has a relationship with the person who has a communication problem – your hairdresser, your doctor, your neighbor. Anyone with whom you need to communicate is a partner. Since partnerships are didactic, a partner needs to understand and learn how a person with a communication impairment can be successful expressing themselves. It’s like someone who has crutches or is in a wheelchair, they need a ramp, maybe or someone to help them up. Communication partners help someone who needs assistance to be able to understand and express themselves successfully, whether that means verbally or alternatively. When a communication partner is made aware of another person’s communication needs, they have to adapt the style of communication. It’s kind of like, if you are talking to someone who is hard of hearing and they tell you that when there is a lot of background noise, it’s hard to hear, you’d go in another room or ask others to be quiet. Someone who has a communication problem, if you write down the words that are key or salient to the context, it will help them better understand the information. Facial expressions can also help. A communication partner needs to know how best to support someone with a struggle. All communication does not have to be verbal.

ONC: What does “recovered” look like for most patients? Can someone fully recover speech and communication skills after a stroke? Do people return to pre-stroke ability?

AS: That’s the million-dollar question. There’s definitely not a clear-cut answer to that. We know the brain has an ongoing ability to change. When we think of “recovering” we think of two things: rehabilitation (restore a lost function or compensate for something you can’t do anymore). So, you might try to regain vocal quality, for example, to restore your ability to be heard better. But if something is just really impaired, we have to think of ways to compensate for the loss. So, if pronouncing complicated words like celebration or philosophy is hard for somebody to say, we might have these words written down (if they use them frequently) or we’d ask a person if they’re capable of writing them or offer them written choices. So, we have back up means when spoken language is not available. When we are working on speech therapy, we’re working with neuroplasticity, so we’re building new neural pathways in the brain. We can’t get back what was lost, so we’re working with the healthy brain tissue. It takes a lot of time and work, a lot of redundancy and persistence, but it really does work. The brain’s ability to regain doesn’t only happen in a short period of time. There are so many factors. People can make progress and change years later, no matter how long it’s been. But this doesn’t mean every single person is going to achieve the same level of progress.

Again, it’s so important to mention one of the principles of neuroplasticity: “use it or lose it.” So, when you learn new things, you have to apply them and use them, or the brain won’t be able to do them consistently.

ONC: As caregivers and loved ones, what do we misunderstand about speech after a stroke? What are we missing?

AS: The biggest myth is that in the absence of prestroke speech, the person is a different person and shouldn’t be included in conversation. Just because a person’s speech is different doesn’t mean they don’t have anything to say.

At the same time, it’s okay for a care partner to be frustrated. There is validity to those feelings. Being open and honest about that can’t be ignored. Being open about feelings and frustrations is really important. Care partners need support too. They need help and education. But when the “patient” is discharged with a list of prescriptions and referrals, there is no prescription for the care partner. You’ll notice I use the word care partner instead of care giver. That is because of how strongly I feel about relationships being a partnership and that even after a stroke, that person can still find ways to give and take and that none of us should “only” give.

As a health coach for care partners, I realize they need support too. There can be feelings of resentment, frustration, overwhelm and even fear. Care and communication partners may not prioritize their own needs while nurturing and supporting someone after a stroke. Once a new routine has been established and a new sense of “normal” is felt, care partners’ health, wellness, and self-care may need attention. And even though the stroke didn’t occur in their brain, care partners’ lives are impacted, in often a pretty big way. Coaching sessions allow care partners to discover ways to address their own needs without feeling guilty.

ONC: Can you talk about the frustration caregivers feel in not being able to communicate? I imagine the frustration is on both sides, for the person who survived the stroke as well as for loved ones and caregivers.

AS: I think that when things happen in our life that we weren’t expecting or can’t control, we don’t know how to respond. When a stroke shows up in someone’s life, they can be 27 or 72 years old, the reaction is often a sudden, drastic, traumatic experience. People tend to rise to the occasion and do whatever they can for the person who’s had the stroke. They try to do anything they can to prevent another one. All the focus happens on the stroke survivor. If the needs of the family members and care partners are not met or even acknowledged, the relationship can become resentful and frustrated. And like in any relationship, communication is key. So now in the setting of relationship strain, we add a communication impairment, what do you imagine happens? More resentment and frustration for sure. To alleviate and improve this, counseling and supportive communication environments can allow these issues to be addressed. I feel so lucky that my dual role as SLP and health coach allows me to be an integral person in this process. I love watching progress unfold.

ONC: Finally, what advice would you give for someone who is struggling to communicate after a stroke? Any words of wisdom from someone who works in the field and has supported many people in recovery?

AS: Believe that you can communicate. Accept that it doesn’t only have to be spoken. Be sure to advocate for your communication needs.

Communication goes two ways. It’s not only your responsibility to communicate effectively. The other person has a responsibility as well that might include learning something new or different. And any time any of us are learning something new, we are doing good things for our brain’s longevity!