Professional Statement Paper: “My Stroke of Insight” by Jill Bolte Taylor

Lifestyle & Disability Assignment

Professional Statement Paper:

 “My Stroke of Insight” by Jill Bolte Taylor

Katherine van den Heuvel

University of Maryland Baltimore

October 29, 2012

The book My Stroke of Insight by Dr. Jill Bolte Taylor¹ is a very accessible source for the general public to gain a better understanding of stroke.  In her book, Dr. Taylor outlines her work as a neuroanatomist prior to her stroke, the basics of anatomy and brain function, how her symptoms presented during her stroke, and the aftermath.  She goes on to elaborate about what approaches worked best for her own treatment, and spends some time talking about her choice to use more of the right side of her brain.  Dr. Taylor writes about her mother’s involvement in re-teaching her as if she was a young child, and highlights the warning signs of a stroke. 

Because she had a very specific and rare type of stroke, there is some risk that her portrayal of her own disability with stroke will be inappropriately generalized by the public. What Dr. Taylor experienced was a left hemisphere hemorrhage from a previously undiagnosed arteriovenous malformation (AVM).   According to the National Institute of Neurological Disorders and Stroke, AVM’s are the cause of only two to four percent of hemorrhagic strokes.² Dr. Taylor does an excellent job of presenting her disability and those involved with her treatment in a very fair and nonjudgmental way.  While Dr. Taylor’s autobiographical story is an accurate case study, there exists a definite risk of misconception by the general public that all persons with stroke may experience a similar level and type of disability. 

While her book does not dwell on the differences between left and right brain stroke, Dr. Taylor describes the differences between right and left-brain hemisphere functions with her discussion of brain anatomy and function.  As a future physical therapist, I can keep in mind the possible ramifications for a person who suffers a stroke in a particular hemisphere. Dr. Taylor experienced a deficit on her left cerebrum, including language, memory, and hearing. She highlights the blissful feeling she experienced when the analytical chatter of her left-brain was shut off.  She felt very expansive and connected to everything, describing the experience as finding Nirvana.  In contrast, patients who experience a right side stroke may become more detail oriented and more reliant on clear and rational verbal communication.  In that case, it may be important to reconnect them with the value of creativity and connection between people and things.  This is supported by a description of hemispheric lateralization of function in the book Basic Clinical Neuroanatomy. ³ According to that text, the left-brain is strong in analytical thinking, rationalizing, calculation, and verbalizing, while the right hemisphere is better at emotion, nonverbal thinking, artistic skills, and spatial perception.

Another way that Dr. Taylor’s book will have an impact on me as a Physical Therapist is through her captivating descriptions.  She writes vividly about her memories of how she felt and what she thought during all aspects of her treatment, explaining that although she was “mentally disabled,” she was not unconscious.  Her perception of people and their energy (and her desire for calm, quiet, and positive energy) is a great insight into the mind of a patient who may be unable to express their feelings and needs.  When she was awake in the first few days following her stroke, she felt pain in her body, lights were too bright, sounds were too loud, and the world was moving too quickly.  She discusses her need for sleep and how her skills became better integrated after periods of rest.  According to a study on fatigue levels in patients with stroke and end-stage heart failure published in 2008, the Fatigue Assessment Scale is a good way to measure fatigue after a stroke.⁴ They show the scale to have good face validity, test-retest reliability, and high construct validity.   Although Dr. Taylor did not have continuing motor deficits or qualify for Physical Therapy, professionals in any discipline can apply her descriptions and tips for treatment. 

One thing that I will choose to educate my patients and their families about is the recovery process.  This book demonstrates the importance of patience, not only of the therapist, but also of the patients for themselves.  Each task and concept that Dr. Taylor learned took a lot of time and effort.  I can expect my patients to need a lot of time to work on new things, and a lot of rest.  According to Taylor, she finally regained an understanding of mathematics four years after her stroke.  She did not consider herself to be fully revered until eight years had passed.  According to the National Stroke Association, progress is possible even twenty years after a stroke. ⁵

Another thing presented in the book that I feel is important for me to teach my patients and their families is the importance of breaking a task into smaller components.  Dr. Taylor provides example after example of how learning part of a task at a time helped her to achieve the whole skill, from learning to sit up in bed to completing a jigsaw puzzle and sorting laundry.  In the text Motor Control: Translating Research into Clinical Practice, this is also called “task analysis.” ^6(p.36) The idea is to not only break down components of the skill or movement, but also to be able to put them into the correct sequence.  Dr. Taylor could not afford to be disappointed by the failure to succeed with an entire skill all at once, and neither can my potential future patients.  While I know that a positive attitude is helpful, Dr. Taylor brings out the importance of celebrating each mini success along the way.

In my professional opinion, this book is a very valuable resource for the general public.  It is extremely accessible to the layperson with its two early chapters on anatomy with simple hand drawn pictures, basic description of stroke types, and overview of left and right brain function.  There may be some risk of misconception by the general public that what Dr. Taylor experienced with her left brain stroke is something experienced by all patients who have a stroke.  I would still recommend this book to the general public for stroke awareness and warning signs and to healthcare professionals for treatment of patients.  This book did not change my viewpoint on patients with stroke, but rather reinforced and enhanced my pre-professional learning.  

Reference List

1. Taylor JB. My Stroke of Insight. New York: Plume; 2009.

2. National Institute of Neurological Disorders and Stroke.
NINDS Arteriovenous Malformation Information Page. Available at: http://www.ninds.nih.gov/disorders/avms/avms.htm. Accessed October, 2012.

3. Young PA, Young PH. The cerebral cortex: Hemispheric lateralization of function. In: Basic Clinical Neuroanatomy. Baltimore, MD: Williams and Wilkins; 1997:195.

4. Smith ORF. Comparison of fatigue levels in patients with stroke and patients with end-stage heart failure: application of the Fatigue Assessment Scale. J Am Geriatr Soc. 2008;56:1915.

5. National Stroke Association. After Stroke. Available at: http://www.stroke.org/site/PageServer?pagename=afterstroke. Accessed October, 2012.

6. Shumway-Cook A, Woollacott M. Motor learning and recovery of function: Whole versus part training. In: Motor Control: Translating Research into Clinical Practice. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2012:36. 

Ibuprofen, water will help my headaches

Are you dependent on pain medication to treat a headache? Why? Some people experience migraines, and really need some sort of chemical help. My theory is that most people take too much medicine because they grew up using pain pills for every little thing, and so have built up a tolerance to normal amounts of medication.

I usually ignore a small headache. When it get's bad though, I need to get to a quiet place. Sometimes that alone can alleviate the headache. I'll also try giving myself a bit of a neck and shoulder massage if I feel tight.

Medicine is a last resort. I take one ibuprofen with cold water. It's under the adult dose, but it is effective for me- probably because I avoid medicine unless it it really necessary! The cold water itself seems to help reduce my pain as well.

If I go to sleep with a headache at night, I lose it by the time I wake up in the morning. Therefore, I often don't take medicine if I am at home in the evening- I just try to get to bed a bit earlier.

Osteoporosis

Can you fracture a bone by sneezing?  If you have advanced osteoporosis, then the answer is yes.  Simply put, osteoporosis is bone loss, and low bone mass can lead to fractures, especially of the hip and vertebral column.            

Let’s take a closer look at the anatomy of osteoporosis.  A cross section of bone is usually comprised of a ring thick, strong, cortical, or compact bone, and the lighter trabecular, or spongy, bone that is essentially a collection of struts and arches.  The spongy bone normally provides strenth without adding a lot of weight.  Osteoporosis affects both types of bone, opening and connecting the spaces in spongy bone until it lacks mechanical strength, and eating into the normally dense compact bone.  In severe cases the outer ring of compact bone is breached. 

While there are no simple symptoms of porous bones, there can be disastrous results from this disease.  The risk factors are often simple things, such as being a woman, or being Caucasian, Asian, or Hispanic/Latino, although African Americans are also at risk. Women are more prone to fractures than men in general, because they tend to have lighter bones to begin with. Older age, family history of osteoporosis, self-history of broken bones (especially hip fractures), being small and thin, and men and women having low levels of estrogen or testosterone may be risk factors you cannot control. Young women athletes with irregular menses may be at elevated risk as well. The sex hormone estrogen normally inhibits the activity of bone reducing osteoclasts. Menopause reduces estrogen levels, allowing the osteoclasts to kick into dangerous overdrive.

Risk factors you can change include: poor diets that lack calcium and vitamin D or have excessive amounts of protein, sodium and caffeine (including that found in soda); being inactive; smoking, which also reduces estrogen levels; drinking alcoholic beverages to excess, and taking certain medications such as steroid medications, some anticonvulsants and others.  Certain diseases and conditions such as anorexia nervosa, rheumatoid arthritis, gastrointestinal diseases and others can also lead to an increased risk of osteoporosis. 

With all these risk factors, and a lack of symptoms until something breaks, how can you know in advance if you are at risk for fractures from osteoporosis?  You can see your primary care physician for a Bone Mineral Density (BMD) test. Studies indicate that there is a strong correlation between low bone density and risk for a fracture in the near future.  BMD tests can be performed a few different ways, but there is some risk of getting a false positive with this type of test.   A more detailed osteoporosis test lab workup would include a variety of tests including blood and urine tests for several hormones, phosphate, and calcium levels.  These tests determine whether osteoporosis may be caused by a secondary disorder such as renal or hepatic failure, anemia, acidosis, hypercalciuria, or abnormal calcium or phosphate levels.  Another test can check levels of bone building osteoblasts.  Tests for vitamin D deficiency may also be recommended. 

Your test results may indicate that you have a normal bone density, or that you are suffering from lower bone density that can fall in a range from the milder osteopenia to full blown osteoporosis.  By itself, osteopenia does not indicate a loss of bone density.  Rather, you may simply have always had less dense bones!  Like osteoporosis, osteopenia is lower than peak bone density.  Osteopenia may be caused by a variety of medical conditions.  If you are diagnosed with osteopenia, your doctor may recommend that you start taking precautions to inhibit the onset of osteoporosis.  These are often the same things you would do to combat the effects of osteoporosis, discussed next. 

While no cure for osteoporosis exists, the good news is that there are treatments available.  Most are for postmenopausal women, or for men.  Women who are no more than ten years beyond menopause may choose to take estrogen supplements.  Anyone undergoing treatment for osteoporosis should get additional testing annually to check progress.  A better idea is to prevent osteoporosis early in life.  A brief scan of the risk factors will indicate a few suggestions: get plenty of calcium and vitamin D; do not smoke; do not drink to excess.  Regular weight bearing exercises will increase your bone density, and muscle-strengthening exercises will help, too.  Drinking fluoridated water can help strengthen your bones.  Preventative steps are especially important for children and people under thirty years old, because the bones are still developing quite a bit until then.  If you get a BMD test early on, you will be in a better position to determine if you need to change your habits or begin taking medication. 

Calcium plays a strong role in the remodeling of bone structure.  Its presence inhibits the release of parathyroid hormone, or PTH.  PTH is released when blood calcium levels are low, which stimulates osteoclasts to break down bone and release stored calcium.  (Calcium levels must remain high enough in the body to participate in muscular contractions and nerve impulses.)  Calcium is readily available in a variety of food sources, from dairy products and vegetables to nuts and grains.  While calcium supplements are available, not all are off sufficient quality to be beneficial.  If you are trying to add more calcium to your diet, it is best to take in calcium at more than once time during the day, because the body immediately discards surplus calcium.  Dietary protein and caffeine can negligibly increase the loss of calcium through urination. People with kidney problems must be careful of their calcium intake, however, as excess calcium can lead to the development of kidney stones. 

Vitamin D is paired with calcium in the recommendations as it enhances adsorption.  One of the best ways to get an adequate intake of vitamin D is to spend some time in the sun without sun block every day.  In cases where this is not practical for medical or geographic reasons, vitamin D fortified foods or vitamin D supplements can be consumed. 

What sort of weight bearing exercise is required to have an impact on bone health?  It can be as simple as walking!  A walking program can be instated at almost any age, and is useful before and after diagnosis of osteopenia or osteoporosis.  Lifting weights and participating in Tai Chi are also recommended activities. Our bone structure is constantly changing in response to stimuli.  Thus, weight-bearing exercises tell your bones that you need stronger bones to resist the effects of gravity. When your workout includes muscle-strengthening exercises, the bones respond to bulkier muscles by becoming stronger themselves. 

In general, you can prevent the onset of osteopenia or osteoporosis by eating well, maintaining healthy habits, and getting load-bearing exercise such as walking from a young age.  Lacking things that inhibit osteoblasts from working or having too many things that encourage osteoclasts causes an overall loss of bone density over time.  Risk factors for osteoporosis are well known, and there are a variety of tests to diagnose the condition.  There are various things you can do to treat osteoporosis.  Treatment included lifestyle changes as well as medicinal approaches.  Osteoporosis prevention and testing should become a part of your complete medical checkup. 

References

Arnheim, Daniel D., and William E. Prentice. Principles of Athletic Training, 10th ed.. New York: McGraw-Hill Higher Education, 2000.

"Bone anatomy in osteoporosis". Up to Date Inc.. November 2, 2009 .

Marieb, Elaine N., and Katja Hoehn. Human Anatomy and Physiology, 7th ed.. New York: Pearson Education, Inc, 2007.

"Ossification: An Introduction to Bone Formation, Growth, and Repair". Province of British Columbia Ministry of Advanced Education, Training and Technology . November 2, 2009 .

"Osteopenia - Overview". Web MD, Healthwise, Incorporated. November 3, 2009 .

Ott, Dr. Susan. "Osteoporosis and bone physiology". University of Washington Department of Medicine. November 2, 2009 .

"Osteoporosis Fast Facts". National Osteoporosis Foundation. November 2, 2009 .

Thomasen, Eivind, and Rachel-Anne Rist. Anatomy and Kinesiology for Ballet Teachers. Alton, Hampshire: Dance Books, Ltd, 2005.

xkcd: Lego

 

This xkcd webcomic reminded my of my April 2009 whole body/ organ donation blog!

Botox, Baby!

So here is the deal with not giving honey to a baby under 1 year old. It is not an allergy precaution, so don't think that you can give it to them just because no one in your family has an allergy!  Honey contains Botulism endospores; bees pick it up from dust when they are collecting pollen.  Babies are susceptible, as well as people who have had a long course of antibiotics, so they need to avoid eating honey as well.  (Unpasteurized corn syrup is also being named as a source of botulism, so follow the same precautions.)

The diagnostic symptoms of Botulism include dizziness, dry mouth, blurred vision, and paralysis.  There are additional unpleasant symptoms that also occur between 8 and 36 hours after eating contaminated food.

Clostridium botulinum, the causative agent, is an anaerobic bacteria; it needs an airless environment to thrive, which is why canned foods carry a danger of botulism.  It has endospores, which are essentially really, REALLY tough little cells that can survive where normal bacteria would be killed.  C. botulinum produces a toxin, and that is what makes us sick.  The toxin is called Botox.  Yes, the same stuff rich people pay to have injected into their faces.  They use the paralytic function of the toxin to paralyze the muscles in their faces, which stretches out the skin above the muscle and smooths out their wrinkles.  (The cosmetic use was discovered by accident when they started using Botox to treat people with muscle spasms in the late 1980's.)

So you might be wondering if Botulism is dangerous after all.  Yes!  Botox is one of the most powerful neurotoxins!  It takes as little as 90 nanograms to kill a 90 kg (200 pound) person.  That is far less than one ounce.  (90 nanograms = 3.17465658 × 10^-9 ounces)  Once ingested, Botulism toxin binds to your nervous system, then attacks your motor nerves by blocking neurotransmitter function.  That's the cause of the paralysis.  Their are also risks of complications from using injected Botox, up to and including death.

C. botulinum is naturally found in soils and aquatic sediments (beware of drinking untreated water), as well as non-acidic canned foods, honey, and corn syrup.  Contaminated canned foods tend to bulge, or may smell bad.  Don't eat it if you suspect it may be contaminated, and don't give even a tiny bit of honey to a baby or someone who has been on antibiotics for a long time.

Make no mistake, honey IS good for us- if we have a normal, healthy immune system and digestive tract.  We have normal flora (think GOOD bacteria) which protect us.  Babies don't develop their normal flora until they are 6 months to a year old.  People on antibiotics kill off their normal, good bacteria along with whatever bacterial disease they are trying to rid themselves of.  So the tiny amount of spores and Botox in honey and corn syrup is enough to make these groups very sick.  The comparatively larger doses of Botulism toxin in contaminated canned foods is enough to make a healthy adult sick, even with our protective normal flora.

You can prevent adult cases of Botulism by properly sterilizing and sealing canned foods, and heating foods to 100 degrees Fahrenheit for 15 minutes during normal cooking.  If you suspect a case of botulism, call 9-1-1 and get to the hospital emergency room!

Treatment includes getting an IV antitoxin as soon as possible.  This helps to neutralize the toxin circulating in your bloodstream.  Gastric washing may be required, as well as surgical tissue removal.  This helps to remove any unabsorbed toxin.  If the paralysis has moved into your respiratory system, you may need an artificial respirator.  Recovery from botulism is a very slow process.