News

Stroke often causes major changes to someone’s identity and sense of self in a range of contexts, through changes to work, relationships and hobbies. 

This comes as a consequence of a range of factors, including the long-term impact of the stroke (to language, movement etc.), situational and psychological changes. However, according to the team, little is known about the extent to which stroke impacts identity, or what factors contribute.

The University of Surrey is now carrying out a research study into Cognitive Functioning and its Relationship with Identity and Mood in Stroke: please read on!

 About the Research

This study is about the impact of stroke on identity: assessing the relationship of changes in sense of self to other direct or indirect causes of stroke, such as mood, language and memory. For their analysis, the team are looking for a wide range of survivors, not only those with perceived difficulties with the above issues following stroke, but also for those without.

Taking part will allow them more insight to the psychological impact of stroke. The team emphasises that while this is unlikely to have personal benefit for the person taking part, the study will publish anonymised data in scientific journals, therefore increasing understanding and potentially improving psychological care.

Open to Recruitment

You may be able to take part if:

• You are over 18 and have had a stroke at least 6 months ago.
• You do not have any further neurological conditions, such as Alzheimer’s.
• You do not have a current psychiatric disorder that is not under effective management.
• You are able to provide informed consent.
• You are able to complete a questionnaire either independently or with help from a caregiver.

If you are unsure of whether you are able to take part, please contact us (h.thompson@surrey.ac.uk).

What You Will Need to Do

A team member will ask you to fill out an online survey, which will take approximately 30 minutes. These will ask questions about you, your stroke, your identity pre and post-stroke, and about your mood.

Then the team will follow this up with a virtual Zoom session also lasting approximately 30 minutes. Here, you will be asked to carry out some language and memory tests. The tests are similar to activities you may possibly have done with a speech therapist or psychologist.

For those who do not have access to a computer there is the option to complete the study by phone or post – this may just take a little longer.

What Happens Next

The results may be disseminated in undergraduate dissertations, at academic conferences and in journals, but your part will remain anonymous. The team aims to send you an overview of the findings of their study, along with any further implications, once the research is complete.

Please contact Dr Hannah Thompson at h.thompson@surrey.ac.uk  if you have any questions or require any further information.

If you do not have any further questions and would like to take part, please see the link to the online survey below. You can fill this out in your own time. 

The team will contact you shortly after you have completed the survey to arrange the second half of the study.

If you would prefer to complete the whole study over the phone or via Zoom. please contact Dr Hannah Thompson or one of the other members of the team:

Carmen Rumbold: cr00473@surrey.ac.uk

Chloe Christaki: cc01485@surrey.ac.uk

Chelsea Mathias: sm02350@surrey.ac.uk

For more Information on Cognition, you can get a copy of:

Had a Stroke? What Now? (2020)

Transcranial direct current stimulation (tDCS) uses a constant, low electrical current to stimulate a targeted region of your brain. This is performed via surface electrodes placed on the scalp.

A note for ARNI blog readers: this kind of neuromodulation technology is mostly only accessible during in-patient or out-patient rehabilitation. Clinicians don’t encourage ‘do-it-yourself’ use of tDCS. Even if you find it possible to gain access to similar devices with the intention of applying the stimulation design of published studies, this is inadvisable and dangerous because improper use might cause harm.

Clinically, there is moderate quality evidence of benefit on upper limb impairment, as compared to placebo or control, and there is high quality evidence that it’s not harmful. There exists strong evidence that it does not improve gait or balance when compared to sham stimulation.

Although tDCS could be provided for stroke patients (for example before or during upper limb task-practice to try to boost neuroplasticity, coupled with novel technologies like robot-assisted training), its added value to rehabilitation outcomes has been limited so far due to lack of adequately-powered research. 

So, our colleagues at the Institute of Neurology, UCL have been exploring the issue of tDCS to improve the evidence for potential for improved upper limb outcomes via their ReCAPS Study.

ReCAPS: Re-opening the critical period for plasticity after stroke. This study is funded by Brain Research UK (BRUK).

(ReCAPS is a research study at the moment, not a clinical trial or free therapy).

This study has now re-opened with extensive COVID-safety measures in place.

OPEN TO RECRUITMENT! You may be able to take part if:

• You have experienced a stroke which affected the movement of your arm or hand.
• You have not experienced a stroke.

The UCL team wants to know:

• How brain activity changes after someone has a stroke.
• If weak, non-invasive brain stimulation could encourage the brain into a pattern of activity which is useful for upper limb rehabilitation.

You will need to have an MRI scan and attend 2 study sessions at the UCL institute of Neurology.

During sessions, you will watch a nature documentary while having very weak brain stimulation. Brain stimulation feels like a warm, tingling sensation on your head.

Please contact one of the team for more information:

Kirsten Thomas: kirsten.thomas.19@ucl.ac.uk

 Jenny Lee: Jenny.lee@ucl.ac.uk

 Carys Evans: Carys.evans@ucl.ac.uk

—————————————

Tel: 0203 4488 774

Website: https://recapsstudy.wixsite.com/research/

Stroke survivors commonly experience fatigue, which can have a major impact on their ability to self-manage and be as independent as possible again. A major survey has shown that the pandemic has made the condition more difficult to cope with. It can greatly impact upon quality of life, making everyday tasks feel overwhelming and unachievable, or just plain exhausting. Furthermore, post-stroke fatigue doesn’t always improve with rest and isn’t necessarily related to recent activity. So, it’s not like typical tiredness. Up to 70% of survivors experience fatigue that includes overwhelming physical and/or mental tiredness and exhaustion. 50% find this kind of particular tiredness to be their main problem.

The Stroke Association reported in September the results of their survey of 1,546 stroke survivors and 403 carers and family members. This includes 110 people who had their stroke this year, and 69 people whose stroke has happened during the Covid-19 pandemic (since March 2020). Their comments showed that the pandemic has caused recoveries to stall, or in some cases actually contribute to making the effects of their stroke – including fatigue – worse or more difficult to deal with. A large proportion reported also reported that the pandemic has had a negative effect on their progress.

Nottingham University have started a research study (Principal Investigator: Professor Avril Drummond ) to shed new light on the way people seek to manage it. To do this they need to interview as many people who have suffered a stroke and have what they think is fatigue AND/OR interview people who care for stroke survivors coping with fatigue (often a family member or members).

Recent research  indicates that there may potentially be a common pathway linking fatigue to everything from poor-quality sleep and physical inactivity to a bad diet. If this is correct, then a handful of potential lifestyle changes could go a long way to fighting everyday fatigue.

Nottingham University want to find out about you and your daily experiences in order potentially to help you via the outcome(s) of their study. For instance, how much you can actually do in a day without exhaustion? Has your fatigue got better/worse/stayed the same? Have you learned to ‘listen’ to your body and your reactions to activities as well as to your rest periods? Do you keep some kind of activity diary? Have you tried any drug or cognitive behavioural therapy? 

Please note: this is NOT a sample of questions you may be asked but simply informs the issue for this invitation. Please email the Study Co-ordinator, Joanne Ablewhite and her team at the address above…

Also, as noted above, the team very much need the input of carers. The research team will ask you to be as specific and thoughtful as you can within the short interview timeframe, and will most appreciate your involvement in the study.

If this is you, what do you find helps the person you care for? Have you noticed that it has become less of an issue as time has gone on? Do you, for instance, try to advise the person you care for to try and pace him/herself before, during and after any activity? What seems to work/have worked for the person? What doesn’t/hasn’t?

Again, please note that this is NOT a sample of questions you may be asked but simply informs the issue for this invitation post. Please email the Study Co-ordinator, Joanne Ablewhite and her team at the address above…

The UCL World Stroke Day Forum is a FREE annual event (26th to 30th October) which invites stroke survivors, carers and loved ones to contribute to and influence the future of stroke research and rehabilitation.

This year, the Forum will be entirely digital (Zoom-based) in response to the COVID-19 pandemic.

VISIT THE UK WORLD STROKE DAY FORUM SITE TO FIND OUT ABOUT THE EVENT ASAP AND BOOK YOUR PLACE.

There will be Live Q&As and workshops with UCL researchers and charity partners, and ‘meet and greets’, where you can informally chat to all contributors. You can also watch pre-recorded talks to hear the latest about stroke research and rehabilitation.

The event takes place over a whole week: it’s going to be superb!

The Zoom-based Forum aims to empower stroke survivors to contribute to stroke research and rehabilitation at UCL. It will host over 30 live events including Q&As, workshops and informal meet & greets with leading researchers, clinicians and charities.

Tom Balchin from ARNI will be speaking on Monday 26th and Wednesday 28th October about:

How to Approach Functional Recovery at any Stage after Stroke

Please sign up asap – limited tickets now.

Full programme is downloadable from here.

Well-being may be adversely affected following stroke. Approximately 33% report depressive symptoms and 20% report anxiety during the first months or years and general psychological distress and social isolation amongst other factors are prevalent. So, what can be done about this? If you’re a stroke survivor, how can you help yourself to regain well-being, and what exactly is it anyway? 

A study being completed by Tom Oliani as part of his doctorate in Clinical Psychology at the University of Sheffield concerns well-being after stroke.

Well-being is basically a combination of how satisfied a person is with their life, and how positive or negative they generally feel. People who have had a stroke can experience decreases in their general well-being. Evidence suggests that people in the general population who report more psychological flexibility and ‘self-compassion’, also often report an increased in well-being. However, there is not much research about whether this is the case for people who have had a stroke.

As such, Tom’s study aims to investigate if those stroke survivors who have do show higher levels of psychological flexibility and ‘self-compassion’ ALSO prove to report feeling more positive towards their circumstances and rehabilitation/recovery than those who report a lesser degree of self-compassion or psychological flexibility. And whether this traits and states change depending on how severe their stroke was and the recovery they make.

Do consider helping Tom with his study if you’ve had a stroke, or know someone who has! It won’t take a few moments…

Can I take part?

You can take part if:

• You have experienced a stroke or multiple strokes.
• You are an English speaker.
• You are over 18 years of age.
• You do not have difficulty reading or understanding words.
• You are not currently either in hospital or living as an inpatient in a residential service.

What will I have to do?

You will be asked to complete an online questionnaire about your stroke, thinking styles, and well-being. This will take 15-20 minutes.

You can find more information about the study by clicking this link: Well-being after stroke study

Then just email Tom at t.oliani@sheffield.ac.uk

Do you have difficulty sleeping after stroke? If so, you’re not alone.

Sleep gives you the base you need to have the energy for all your daily activities such as working, home life, driving and communication. But is it something about the quality of sleep you get or the quantity that you get that helps? And how does this knowledge help stroke survivors?

Although you may have had problems sleeping pre-stroke, you may have extra difficulties post-stroke. You may have trouble falling asleep or staying asleep. You might wake up several times during the night or wake up early and can’t go back to sleep. Or you may still feel tired after waking up and find it hard to nap during the day, even though you’re tired. You may find it difficult to concentrate or feel irritable during the day. Some people develop sleep apnoea (a sleep disorder characterised by pauses in breathing or periods of shallow breathing during sleep), teeth grinding or restless leg syndrome.

It is known that lack of sleep can affect your concentration, mood, overall health and how alert you are.

Researchers from the University of Oxford, led by Professor Heidi Johansen-Berg, together with the Oxford Centre for Enablement and the Oxfordshire Stroke Rehabilitation unit, have been investigating sleep in people with stroke and brain injury. Their study, funded by the Wellcome Trust, has just been published in the journal of Neurorehabilitation and Neural Repair.

They assessed 59 people with stroke and brain injury, who were staying in a hospital rehabilitation unit, as well as a control group of 55 people who had not had a brain injury and were at home. They report that people who had experienced brain injury rated their sleep quality as lower than the control group.

Furthermore, using sleep monitoring wrist watches they showed that, on average, people with brain injury had more disrupted sleep and spent more time awake overnight.

The researchers also wanted to know how sleep quality related to recovery.

They found that upon discharge from the rehabilitation unit, people with stroke and brain injury who had better sleep:

1. Scored higher on the tests of arm/hand function
2. Showed less overall movement impairment in their affected arm and legs
3. Were more mobile.

When looking at recovery of functional independence over the time spent in the rehabilitation unit, people with brain injury who had more consistent, less disrupted sleep recovered more quickly than those who had more disrupted sleep.

 What does this mean?

Dr Fleming reports: “As we anticipated, people in hospital following brain injury generally don’t sleep as well as people who haven’t had a brain injury and are at home. What is really interesting is that people who sleep better seem to recovery more quickly and have better outcomes from their rehabilitation.”

If you have any questions about the results of this published study, please get in contact with Dr Melanie Fleming on melanie.fleming@ndcn.ox.ac.uk

What next?

In the future the researchers are hoping to investigate ways of improving sleep quality for people in the hospital, and to see whether this can help boost recovery.

First though, they are investigating whether an online sleep improvement programme can help to improve sleep quality in stroke survivors who have already been discharged from hospital. If you have had a stroke and experience poor sleep, then you may be able to take part in this research. Would you like to take part? 

ARNI INSTITUTE NOTES: DO PLEASE GET IN TOUCH WITH DR FLEMING AT THE UNIVERSITY OF OXFORD ASAP IF APPROPRIATE – WHO KNOWS WHAT COULD EMERGE IN TERMS OF OPTIMISING FUNCTIONAL RECOVERY AS RESULT OF IMPROVING SLEEP?

‘HAD A STROKE? NOW WHAT? FROM HOSPITAL TO REHABILITATION AND BEYOND’.

With a revealing Foreword by broadcaster Andrew Marr, himself a stroke survivor, this seriously practical book reveals everything you need to know about for real-life, evidence-based recovery from limitations caused by stroke, that you can actually understand, use and apply successfully for yourself.

PUBLICATION DATE 01/06/20.

(PLEASE DO FORWARD THIS POST TO OTHER PEOPLE YOU MAY KNOW, AS APPROPRIATE)

With 244 Royal book size pages of new information and material, it’s the first book Dr Balchin has presented since the 2011 best-selling ‘Successful Stroke Survivor’, so you can imagine that it’s stacked with new thoughts and revelations for you based on experience, the neurorehabilitation evidence-base and help from the numerous experts in stroke in the UK and globally who he is lucky enough to be supported by/linked with.

This book, with photos and illustrations, is a one-stop ‘go-to’ to give to a family going through the painful process of having a loved one suffer stroke – or for the stroke survivor to get for themselves to add to their ‘ammo’.

Here you will find out how to cope with stroke, and recover from it optimally. It takes you through the full process; from arriving at hospital onward. Suitable therefore also for someone many years after stroke, this book reveals many hundreds of clever tips concerning how to rehabilitate effectively and self-manage at home over the long term in a relatively cost-free way.

Every stroke results in different outcomes, dependent on thousands of variables. A clear-cut background to stroke and the problems it may cause is presented. The author is a stroke survivor who has created and refined over the last 20 years, via his Charity, The ARNI Institute, the innovative ARNI approach to stroke rehabilitation. Here he shows you exactly:

• How to get through the acute hospital time and what family, carers and friends can best do to help.
• How to dramatically extend your ‘time window’ for potential recovery by taking advantage of your brain’s capacity for neuroplasticity.
• How to recover lower and upper limb action control balance, stability, arm and hand recovery as well as regaining strength and cardiovascular health over time. 
• How to develop creative physical coping strategies and how to self-manage using evidence-based strategies and smart tricks of the trade.
• How to find which practical aids are shown in the evidence to be most likely to work for you, and those which will not, from aphasia to vision.
• How to secure the appropriate rehabilitation assistance and financial assistance to suit your needs in the community and how to save significant amounts of money and time while doing so.
• How to gain an excellent quality of life after stroke, and get back to work if appropriate.
• How to ensure that successful familial relationships and intimate partner relationships can be achieved after stroke.

Many hundreds of other questions are answered with reference to the clinical experts and latest evidence base. He shows you that nothing in your recovery should be too complex. On the contrary, he shows you how you can make your rehab a fun commitment/hobby. And therefore, easing pressure from your loved ones and supporters.

This book will be of major assistance to anyone who has had the misfortune to have had a stroke and is entering the recovery phase. And essential too, for their families and supporters.

Endorsed with the Stroke Specific Framework Quality Mark (Reg. No 19755) by the United Kingdom Forum for Stroke Training and Education (UKSF).

Andrew Marr notes: ‘This book gives you in one place, so far as I’m concerned for the first time, everything that a stroke survivor in modern Britain really needs to know. It tells you what happened, and probably why, and what can be done about it. It doesn’t shirk the grim bits. It explains the jargon. But, while Tom Balchin doesn’t sugar-coat the assault on the brain and its effects, on almost every page he gives the reader reasons for optimism and essential information’. 

Review 1: ‘Who better to write a guide to stroke recovery than someone who has had one? And of those, there can be none better than Tom. He is smart, and studied the science to find ways to go beyond the usual. No quackery, this, but an inspirational and practical evidence and experienced-based recipe for recovery. I strongly commend it’. Review by Professor Hugh Montgomery, Professor of Intensive Care Medicine, UCL, Consultant Intensivist at the Whittington Hospital, Head of Centre at the Human Health and Performance, UCL Division of Medicine, Director of Research at The Institute for Sport, Exercise and Health, London. 

Review 2: ‘This comprehensive and empowering book is a must-read for stroke survivors and their families. The book uses Tom Balchin’s own experience of stroke, his knowledge of stroke as well as his work with others over the past two decades. It is highly readable and provides clear explanations of every step of the stroke journey as well as no-nonsense practical steps that everyone can take to improve their quality of life after stroke’. Review by Professor Heidi Johansen-Berg, Professor of Cognitive Neuroscience, Director, Wellcome Centre for Integrative Neuroimaging & Director, Plasticity Group at Oxford Centre for Functional MRI of the Brain, Oxford University.

Review 3: ‘Combining his academic expertise and clinical learning, Dr Balchin delivers an exceptional high quality text book for a wide target audience. In this wonderful guide, patients and families will find the essential knowledge they need to help maximise recovery potential after a stroke (or for that matter any injury of the nervous system). He also shows the rehabilitation professional the critical importance of empowering the patient to master their own rehabilitation’. Review by Professor Anand Pandyan, Professor of Rehabilitation Technology, Keele University & Associate Non-Executive Director of the Royal Wolverhampton NHS Trust.

Review 4: ‘This is an engaging, easy to read book, suitable for anyone on their journey following a stroke as well as for their family, friends and carers. It focuses on how to personally tailor the retraining of mind and body to optimise recovery from stroke. The messages contained here from Tom instil hope and confidence, and a desire to try yet harder and achieve great things that matter to the individual; yet the book is also written with compassion and kindness to accept limitations that may remain. Thank you, Tom, for putting together this road-map to recovery for stroke survivors’. Review by Professor Sarah Dean, Professor of Psychology Applied to Rehabilitation and Health, University of Exeter Medical School.

Review 5: ‘The book is an excellent guide for stroke survivors. It provides essential information about multidimensional aspects of stroke, from its impacts on the body to rehabilitation strategies. The illustration of fundamental exercises and explanation of evidence-based practice models make it highly appropriate for readers’. Review by Dr Mohsen Shafizadeh, Senior Lecturer in Clinical Motor Control and Movement Analysis, Sheffield Hallam University.

Review 6: ‘Rehabilitation after stroke remains a big health and social challenge in the UK and world wide. Thousands of stroke survivors and their carers/ families/ friends are constantly searching for up to date support and information on how to live a fulfilling life after stroke. Dr Balchin’s new book is a comprehensive document; an essential read for all individuals personally affected by stroke as well as healthcare professionals caring for stroke survivors. Covering various stages of stroke recovery in depth in addition to recommending specific evidence-based rehabilitation strategies, the book offers great insight and practical approaches into commonly encountered consequences of stroke. The book describes elegantly how stroke-related impairments can be managed early on before they result in permanent disabilities’. Review by Dr Khalid Ali, Senior Lecturer in Geriatrics and Stroke Medicine, Brighton and Sussex Medical School & Consultant Geriatrician at Princess Royal Hospital, Haywards Heath.

Neuromodulatory non-invasive brain stimulation (NIBS) techniques are experimental therapies for improving motor function after stroke. The aim of neuromodulation is to enhance adaptive or suppress maladaptive processes of post-stroke reorganisation. However, results on the effectiveness of these methods, which include transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are mixed. It’s posited that recent developments in NIBS technology will likely contribute to individualised therapy. Moving beyond single-area stimulation, targeting specific muscle groups that play different roles in post-stroke motor recovery (for example, finger flexors vs. extensors) may well be possible using multi-locus TMS. NIBS in stroke faces a challenge reminiscent of the development of other stroke therapies, such as thrombolysis and mechanical thrombectomy, where early studies were largely mixed before patient selection and individualising protocols were refined to determine its therapeutic potential.

So, researchers at UCL want to find out:

• How brain activity changes after someone has a stroke.
• If weak, non-invasive brain stimulation could encourage the brain into a pattern of brain activity which is useful for upper limb rehabilitation.

If so, the Institute of Neurology at UCL invites you to join in with the ReCAPS study.

PLEASE TAKE ADVANTAGE OF THIS INVITATION IF IT’S APPROPRIATE FOR YOU!

ReCAPS: Re-opening the Critical period for Plasticity After Stroke. The study is funded by Brain Research UK (BRUK). ReCAPS is just a research study at the moment, not a clinical trial or therapy.

If you would like to attend:

You will need to have an MRI scan and attend 2 study sessions at the UCL institute of Neurology. Travel can be contributed to.

During sessions, you will watch a nature documentary while having very weak brain stimulation. Brain stimulation feels like a warm, tingling sensation on your head.

Please have a look at the flyer from the Institute of Neurology:

Or contact the researchers for more information:

Ms. Jenny Lee

jenny.lee@ucl.ac.uk

Tel: 0203 4488 774

 Dr. Carys Evans

carys.evans@ucl.ac.uk

Tel: 0203 4488 774

Website: https://recapsstudy.wixsite.com/research/

Neurofeedback is a brain scanning (MRI) technique that shows an individual a representation of their own brain activity while doing a task, so they can observe their brain activity and try to adapt it.

Over the past two years, a group of researchers at the Wellcome Centre for Integrative Neuroimaging at the University of Oxford have been conducting research into whether this technique  can help improve recovery of movement after stroke.

In this particular study, stroke survivors are asked to use different movements and strategies to activate the part of their brain that controls their more-affected hand/arm during an MRI scan. This is with the aim of teaching participants to engage particular parts of the brain – in order to increase the amount of movement they have in their more-affected hand/ arm.

Feedback of brain activity as seen by the participants.

“Try to increase the height of the red bar while keeping the blue bar low”

Professor Heidi Johansen-Berg, Director of the Centre, lead for the study, has mentioned to ARNI that the Centre is about half way through this study, and that they are still looking for more volunteers to take part in the study.

So, any stroke survivors out there – do look at this!! 

STROKE SURVIVORS ARE INVITED TO COME TO THE WELLCOME CENTRE FOR INTEGRATIVE NEUROIMAGING AT THE UNIVERSITY OF OXFORD

Here are some of the experiences of the participants who have taken part already.

Upon interviewing those who have taken part already, participants’ responses have been overwhelmingly positive, specifying both the enjoyment and fulfilment involved with taking part as well as a benefit to their motor recovery.

“You will certainly learn a lot from the experience and for me the study was transformational in further understanding the effects of my stroke and to learn how I could self-train further.”

“It is hard work, but is very worthwhile, not only for the research, but for self-awareness of the progress that can be maintained post stroke.”

Participants expressed that they felt others would benefit from taking part in the same way that they did.

Thomas Smejka, a researcher on this study, has noted that ‘…as researchers it is very important to us that our participants feel comfortable while taking part and we are incredibly grateful for the contribution they have made to our research’.

If you have any questions about this research, or would like more information about the study, please contact the researchers directly:

thomas.smejka@ndcn.ox.ac.uk or melanie.fleming@ndcn.ox.ac.uk

Or call one of the research team on 01865 611461 today.

It is the view of ARNI that being part of a clinical research study can ALWAYS push/point you towards new directions that you may not have ever thought about. You MUST take the opportunity to attend this world-class facility!

The Successful Stroke Survivor is one of the most popular and useful resources on the market at the moment for stroke survivors. Now the full manual, updated in 2017, is available on e-book (including Amazon Kindle) at HALF-PRICE of the printed version!!

With 175 five-star reviews on Amazon.co.uk, this book and techniques/strategies manual by ARNI Founder Tom Balchin is acknowledged to be very comprehensive. Because of this necessity, in order to present the evidence, approach, tips, hints and ‘tricks of the trade’, it is also quite heavy for some stroke survivors to fully use during self-rehab if upper limb limitations are present.

So, it is now available in one complete edition on ebook (1480 pages of real-deal advice of ‘skip-to’ sections), making it MUCH easier to use. 

Although essentially unchanged, there are also some updates to the text from the first, printed volume that are worthwhile reading/getting to grips with.

• Text-to-Speech: Enabled 
• Word Wise: Enabled
• Screen Reader: Enabled
• Enhanced Typesetting: Enabled