Fictional case study;
Isabella and her journey through stroke
Isabella enters the office of John, a neuropsychologist alongside her husband Pat. She is a 28-year-old primary school teacher in charge of the local school’s choir. Isabella also has a two-year-old son. Recently, Isabella had an ischemic stroke in the anterior speech area in the left hemisphere, resulting in Broca’s Aphasia (difficulty in speech production) and hemiparesis (mild to severe paralysis on one side of the body). John suspects hypertension (stress) and smoking caused the stroke.
First few days after stroke: Assessment
Neuroimaging
With the help of an MRI scan, John observed damage to
Broca's area, specifically the Pars opercularis (BA 44). The
MRI suggested no signs of damage in the pars triangularis
(Figure 1).
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A disconnect in the white matter tracts leading from the Pars
opercularis to the posterior language areas was also found
with diffusion weighted tractography.
John assessed Isabella using the following tests:
-
Cognitive-Linguistic Quick Test (CLQT)
(Helm-Estabrooks, 2018) -
Western Aphasia Battery-Revised (WAB-R)(Barfod, 2013)
-
Fugl-Meyer assessment for motor recovery after stroke
(Gladstone, Danells & Black,2002).
​
The CLQT assesses status of cognitive-linguistic functioning through
attention, memory, executive functions, language and visuospatial
skills. The measure is offered for English and Spanish-speaking adults
usually with a suspectedeurological dysfunction. The CLQT includes
clear cut scores for each cognitive domain, labeled Within Normal
Limits, Mild, Moderate and Severe (Helm-Estabrooks, 2018).
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The WAB-R is designed to examine linguistic skills such as information content and nonlinguistic skills in people with Aphasia. Linguistic skills include fluency,auditory comprehension, repetition, naming, word finding, reading and writing. Nonlinguistic skills, on the other hand, includes drawing, block design,calculation and praxis. Ultimately, the WAB-R is a tool used to help determine the location of the lesion as well as classifying what type of Aphasia the patient is experiencing. The eight different types of Aphasia are Global, Broca’s, Transcortical motor, Wernicke’s, Transcortical sensory, Mixed transcortical, Conduction and Anomic Aphasia (Barfod, 2013).
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The Fugl-Meyer assessment for motor recovery after a stroke, which is a quantitative evaluation instrument focused on measuring sensorimotor stroke recovery (Gladstone, Danells & Black, 2002). The assessment includes a 226-point multi-item Likert-scale used to evaluate recovery from stroke. The Fugl-Meyer contains five main domains which are motor function, sensory function, balance, joint range of motion and joint pain, whereas each of the domains are scored on a three-point scale from 0 being “cannot perform”, 1 being “performs partially” and 2 being “performs fully” (Gladstone, Danells & Black, 2002).
Based on Isabella’s scores from on the completed CLQT, WAB-R and the Fugl-Meyer assessment, John confirmed the diagnosis of hemiparesis with severe Broca’s Aphasia.​
​
Behavioural/Psychologic assessments
Fig. 1
Isabella's MRI scan showing damage to BA 44 (Pars opercularis)
Neuroanatomy
The human brain is an extremely complex organ, it is composed of many neurons which communicate with each other through neural activity and create parts which are responsible for various kinds of functions, hence the brain is categorized by the broader lobes and hemispheres within which we see histological (cell anatomy) and the functional sub categorizations of the cell clusters.
Broca’s area is one such categorization that is located in the left hemisphere of the frontal lobe of the brain and it is also called Brodmann’s areas 44 and 45, parts of the brain labeled as brodmann's areas are based on the anatomy of the cells in that cluster. functionally the broca's area is known to play a role in speech production.
Wernicke’s area is another categorization that is located in the posterior section of the upper temporal lobe and is also known as Brodmann’s area 22, it is usually found in the left hemisphere of the brain and functionally the part is known to play a role in speech comprehension.
Just these two parts do not give us a complete understanding of how speech is represented in the brain, both of these parts are connected by a bunch of axons, which is the fibre like body of the neuron, when we look at the brain we can see some parts of it are grey while the other parts of it are white, this color difference is determined by whether the axons are coated in myelin, a sort of insulation for the wiring that is the axons, this coat of myelin changes the way in which signals are transmitted from one neuron to another. The bunch of axons which connect the broca's area and the wernicke’s area are known as the arcuate fasciculus,these axons are heavily myelinated and hence referred to as, white matter tracts. This wiring moves from the temporal cortex through the parietal cortex and reaches the frontal cortex. (Catani, M., & Schotten, M. T. de. 2008)
In the case of Isabella there is a disconnect in these white matter tracts as well as some damage in the pars opercularis (BA 45). which gives us a complete neuroanatomical view of the damage which in turn will help us
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Use the widget below to play with a 3D model of the brain
This page was created as part of a neuropsychology group project for an MSc in Cognitive Science at University College Dublin.
Munster Music Therapy would like to extend it's gratitude to the co-authors of this page -
Avasare, P., Dineen, D., Lindstad, S., Longo, L. A.
The treatment plan
For the improvement of the impairments due to hemiparesis, rehabilitative therapies focused on activating neural plasticity mechanisms will be crucial for helping Isabela to regain independence in daily activities. Several clinical studies point at the efficacy of rhythmic entrainment for upper extremity and full body coordination motor rehabilitation (Altenmueller et al., 2009; Grau-Sanchez et al., 2013), and for speech and language functions recovery in hemiparetic stroke patients (Thaut & McIntosh, 2014). Moreover, music holds a strong emotional value for Isabela, relevant for the acceptance of the treatment program and its success.
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Among the treatment techniques in neurologic music therapy (NMT) relying on entrainment concepts, the following neural modulation non-invasive protocols will be offered, with length of sessions gradually increasing.
Initial to medium term
Motor rehabilitation
The Patterned sensory enhancement (PSE) technique uses the elements of music, such as meter, tempo, pitch, dynamics, duration, and harmony, to create sound patterns that mirror, elicit and guide functional movements of daily activities or the motor patterns underlying these activities. PSE is aimed at increasing physical strength, endurance, balance, posture and other functional motor skills of upper and lower limbs (Thaut & McIntosh, 2014).
For instance, if the music therapist wants to work on Isabela’s hand to mouth arm motion (relevant for eating and drinking), they may use a crescendo for the upward movement and a decrescendo for the release of the movement creating a multi-sensory environment to help the brain to cue relevant movements.
See PSE in action here
Speech rehabilitation
·Musical speech stimulation (MUSTIM) technique helps patients with severe expressive aphasia in spontaneous non-propositional speech production by the association of melody and text in long term memory (familiar melodies and songs) (Straube et al., 2008). Depending on the goals and on the functioning of the patient, MUSTIM presents progressive levels of application (Thaut & McIntosh, 2014). For Isabela’s initial speech rehabilitation:
- At the first level of complexity, the therapist may use a familiar song living out first words, and then phrases for Isabela to fill in, and progressively improve, and eventually end up singing the entire song with musical accompaniment.
- At the second level of complexity, the therapist may use common incomplete sentences musically cued, and ask Isabella to independently complete them, such as “Thank you very….” “Much”. ​
See MUSTIM in action here
Medium to long term
Motor rehabilitation
Rhythmic auditory stimulation (RAS) is the application of rhythmical auditory stimuli associated with the intention and ongoing facilitation of gait and gait related activities (Dreu et al, 2014).
This means something akin to marching in time with the music, though it can get slightly more compliacted than that!
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RAS was developed to help people with Parkinsons disease improve their gait speed (walking speed), balance, fall risk and stride length although in recent years multiple studies have indicated it's use as an effective tool for stroke rehabilitation (Mainka et al, 2018, Suh et al, 2014)
By using an instruments (such as a guitar or autoharp) at a regular rhythm in time with a metronome an internal sense of rhythm is created which synchronizes the movement and sensory areas of the brain (Thaut et al, 2009).
Various different approaches (some examples presented in the videos below) exist to target walking speed, stride length, balance etc but all share the same key principle - moving the legs and shifting weight in time with the beat.
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As the sessions progress, the beats per minute will gradually increase leading to an increase in walking speed and control with the aim of normalizing the gait pattern over the long term
See RAS in action here
Speech rehabilitation
Melodic Intonation Therapy (MIT) is the technique most used in stroke rehabilitation and Broca’s aphasia treatment (Thaut & McIntosh, 2014). Converging evidence show that MIT induces neuroplasticity by rerouting speech pathways from the damaged left hemisphere to the language-capable regions of the right hemisphere (Breier et al., 2010; Schlaug et al., 2009).
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Intoned melodies are first used to assist in the production of phrases mechanically repeated and the melodic aspect is gradually phased out to lead to greater ease with spontaneous utterances. These melodies are initially accompanied by hand movement, with tapping of the patient’s hands to emphasize beats and phrase structure. Language and motor learning converge during the combined tapping and intoning of melodies (Wortman-Jutt, S, 2019). Isabella’s MIT sessions are divided into the following stages:
- The therapist hums the target phrase while hand tapping with Isabella.
- The therapist sings the intoned statement while hand tapping with Isabella.
- The therapist asks Isabella to join in unison repetitions of the targeted phrase with hand-tapping.
- The therapist starts fading the singing but continues the hand-tapping.
- The therapist sings alone with hand-tapping and the cues Isabella to intonate the target phrase independently with hand-tapping.
- The therapist intones a question about the information in the target phrase and Isabella can respond with the assistance of hand-tapping, if needed.
*Source: TactusTherapy website, 2021.
See MIT in action here
Long term prognosis
Leaving the hospital and returning to life at home
Isabella will have to change her lifestyle, quit smoking, and monitor her diet and blood pressure, to reduce the likelihood of a future stroke beyond entering rehabilitation for both hemiparesis and Broca’s aphasia. Due to her impairments in the production of speech sounds and her overall communication, Isabella won’t be able to return to teaching or her position as school choir director. Isabella may experience frustration, loneliness, isolation, and feel challenged in her family and social relationships with severe implications for her general mental health as it has been noted that depression is often co-morbid with Broca’s aphasia (Laska et al, 2007, Mohr et al, 2017).
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Isabella will likely recover a good portion of her speech and motor functionality over time though it is imperative that she keeps up her rehabilitation regime at home once her initial rehabilitation plan has been completed. Over the long term she may wish to take blocks of music psychotherapy focused on coming to terms with her new life circumstances as well as neurologic music therapy blocks to refresh and update her home plan (Alternative types of psychotherapy such as classic talk therapies or other creative arts therapies like art therapy would also help Isabella to adjust). With some hard work, dedication and support from her loved ones, Isabella will have the opportunity to live a happy and fulfilling life post-stroke.
This page was created as part of a neuropsychology group project for an MSc in Cognitive Science at University College Dublin.
Munster Music Therapy would like to extend it's gratitude to the co-authors of this page -
Avasare, P., Dineen, D., Lindstad, S., Longo, L. A.
This page was created as part of a neuropsychology group project for an MSc in Cognitive Science at University College Dublin.
Munster Music Therapy would like to extend it's gratitude to the co-authors of this page -
Avasare, P., Dineen, D., Lindstad, S., Longo, L. A.
References;
Altenmueller, E., Marco-Pallares, J., Muente, T. F., and Schneider, S. (2009). Neural reorganization underlies improvement in stroke-induced motor dysfunction by music-supported therapy. Ann. N. Y. Acad. Sci. 1169, 395–405. doi: 10.1111/j.1749-6632.2009.04580.x
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Barfod, V. (2013) Western Aphasia Battery (WAB). Stroke engine https://strokengine.ca/en/assessments/western-aphasia-battery-wab/(accessed October 11, 2021)
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Breier, J. I., Randle, S., Maher, L. M., & Papanicolaou, A. C. (2010). Changes in maps of language activity activation following melodic intonation therapy using magnetoencephalography: two case studies. Journal of clinical and experimental neuropsychology, 32(3), 309–314. https://doi.org/10.1080/13803390903029293
Dreu, M., Kwakkel, G., & vanWegen E., (2014) (Chap.) Rhythmic auditory stimulation (RAS) for Gaot rehabilitation for patients with Parkinsons disease: A research perspective in Thaut, M., & Hoemberg, V. (Eds.). (2014). Handbook of neurologic music therapy. Oxford University Press (UK).
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Gladstone, D. J., Danells, C.J. & Black, S. E. (2002). The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabilitation and neural repair, 16(3), 232–240. https://doi.org/10.1177/154596802401105171
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Grau-Sanchez, J., Armengual, J. L., Rojo, N., Vecian de Las heras, M., Rubio, F., Altenmueller, E.,et al. (2013). Plasticity in the sensorimotor cortex induced by music-supported therapy in stroke patients: a TMS-study. Front. Hum. Neurosci. 7:494. doi: 10.3389/fnhum.2013.00494
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Helm-Estabrooks, N. (2018). Cognitive Linguistic Quick Test. In J. Kreutzer, J. DeLuca, & B. Caplan (Eds.), Encyclopedia of Clinical Neuropsychology (pp. 1–4). Springer International Publishing. https://doi.org/10.1007/978-3-319-56782-2_9082-2
Laska, A. C., Mårtensson, B., Kahan, T., von Arbin, M., & Murray, V. (2007). Recognition of depression in aphasic stroke patients. Cerebrovascular diseases (Basel, Switzerland), 24(1), 74–79. https://doi.org/10.1159/000103119
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Maier, M., Ballester, B. R., & Verschure, P. (2019). Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms. Frontiers in systems neuroscience, 13, 74. https://doi.org/10.3389/fnsys.2019.00074
Mainka, S., Wissel, J., Völler, H., & Evers, S. (2018). The use of rhythmic auditory stimulation to optimize treadmill training for stroke patients: a randomized controlled trial. Frontiers in neurology, 9, 755.
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Mohr, B., Stahl, B., Berthier, M. L., & Pulvermüller, F. (2017). Intensive Communicative Therapy Reduces Symptoms of Depression in Chronic Nonfluent Aphasia. Neurorehabilitation and neural repair, 31(12), 1053–1062. https://doi.org/10.1177/154596831774427
Straube, T., Schulz, A., Geipel, K., Mentzel, H. J., & Miltner, W. H. (2008). Dissociation between singing and speaking in expressive aphasia: the role of song familiarity. Neuropsychologia, 46(5), 1505–1512. https://doi.org/10.1016/j.neuropsychologia.2008.01.008
Suh, J. H., Han, S. J., Jeon, S. Y., Kim, H. J., Lee, J. E., Yoon, T. S., & Chong, H. J. (2014). Effect of rhythmic auditory stimulation on gait and balance in hemiplegic stroke patients. NeuroRehabilitation, 34(1), 193-199.
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Thaut, M. H., & Hoemberg, V. (Eds.). (2014). Handbook of neurologic music therapy. Oxford University Press.
Thaut, M. H., & McIntosh, G. C. (2014). Neurologic music therapy in stroke rehabilitation. Current Physical Medicine and Rehabilitation Reports, 2(2), 106-113.
https://doi.org/10.1007/s40141-014-0049-y
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Thaut, M. H., Stephan, K. M., Wunderlich, G., Schicks, W., Tellmann, L., Herzog, H., McIntosh, G. C., Seitz, R. J., & Homberg, V. (2009). Distinct cortico-cerebellar activations in rhythmic auditory motor synchronization. Cereb Cortex, 45, 44-53.
Wortman-Jutt, S., & Edwards, D. (2019). Poststroke Aphasia Rehabilitation: Why All Talk and No Action?. Neurorehabilitation and neural repair, 33(4), 235–244. https://doi.org/10.1177/1545968319834901
Catani, M., & Schotten, M. T. de. (2008, May 23). A diffusion tensor imaging tractography atlas for virtual in vivo dissections. Cortex. Retrieved December 8, 2021, from https://www.sciencedirect.com/science/article/pii/S0010945208001238.