In what manner do stroke victims struggle with language?
DAVID ALEXANDER, MD: Language problems involve having difficulties understanding what a word means or saying a word. The patient may know what they want to say, but simply can't get their brain to connect that word and they can't say it, or they may have trouble understanding how sentences are put together. Those I would consider to be language problems.

Speech problems have more to do with actual articulation. These are motor deficits. They can't coordinate their talking as well as they used to. They simply have trouble speaking and their speech is slurred or somehow difficult to understand.

When do these speech and language problems first make themselves apparent after a stroke?
DAVID ALEXANDER, MD: Immediately. They occur right at the onset of the stroke, and patients can look confused or dazed, even before it's identified as a language problem, or they can have immediate slurred speech, which is more recognizable. But they occur right at the time of the stroke.

When should rehabilitation start?
RICHARD ZOROWITZ, MD: Rehabilitation for speech problems should begin immediately, and the reason for that is because you want to be able to have that patient be able to express their needs and wants and hopefully be able to have them understand what's going on around them. This actually should occur with speech therapy, but even somewhat before that with nursing, so that the patient can participate in their care as much as possible.

Is speech therapy a given in most hospitals, for newly diagnosed stroke patients?
DAVID ALEXANDER, MD: In our hospital, yes. We have speech therapists who see the patient quite early, not simply for the speech problem, but because speech and language problems often lead to trouble swallowing, and that's one of the first things we evaluate. Generally, we have the speech therapist see the patients within 24 to 36 hours to help the other clinicians determine whether the patient can take in food or whether there should be intravenous feedings, or even tube feedings, through the nose, for example.

How fast do speech and language problems get better?
RICHARD ZOROWITZ, MD: Like recovery with movement, usually it will happen within the first few months. And like movement recovery, sometimes improvement is slow. It can take months or years even. But usually we're looking in the first several months after the stroke for the majority of recovery to occur.

If a person has not improved within six months, should they change their expectations, and indeed, should they just learn to live with whatever they have at that point?
DAVID ALEXANDER, MD: I think that people do change their expectations as they recover. At six months people can still make some incremental gains, but it's not going to have the same accelerated pace as earlier. I think, realistically, people do have to realize that recovery can have limitations.

How long should a person continue to receive language or speech therapy?
RICHARD ZOROWITZ, MD: Speech therapy for inpatients can occur for at least several months. If it is appropriate, therapy can occur on an outpatient basis. Like other therapies, what we also want to do is to try to train them to be able to do various exercises on their own so that they can continue doing things independently once therapy stops, because insurance will not pay for this indefinitely.

Is there evidence that therapy works, or can progress be associated with passing time?
DAVID ALEXANDER, MD: The good thing about stroke in general is that people do recover gradually. The brain does recover to some extent, so most people recover with time. Most professionals believe that acute speed or language therapy can speed up recovery. It's a hard thing to prove, however, because you have to compare it to the normal recovery that would have occurred anyway just simply with the family members talking to the patient, and the patient trying to do things themselves. It's difficult to get objective data.