Frequently Asked Questions:
What are some obstacles in communication after brain injury and/or stroke?
A common language disorder following brain injury and stroke is aphasia. Aphasia is an acquired communication disorder that impairs a person’s ability to process language (comprehension and generating language) but does not necessarily affect intelligence. Patients with aphasia may also have related disorders that may complicate diagnosis, including visual field blindness, apraxia (inability to perform a task or sequence with the absence of motor weakness or aphasia), agnosia (difficulty recognizing or identifying stimuli; sensory, visual, auditory). Patients with any of the previously mentioned disorders can have more complicated aphasia.
How can providers determine the exact difficulty?
The speech-language pathologist must carefully choose evaluation materials and vary the mode of stimuli presentation to obtain an accurate picture of a person’s language skills.
For example, a person with apraxia may initially appear to have comprehension difficulties because of the inability to follow directions. It may be necessary to vary the question and response format (yes/no, pointing to pictures/words) to more correctly identify comprehension ability. Patients with visual field deficits may present as having reading comprehension deficits because they may not perceive all other written material in a given field of vision. The use of visual anchors may assist patients in scanning written material more accurately. It is essential for the speech-language pathologist to identify the most consistent mode of response for each individual patient and the vary the complexity of tasks using that mode.
What approach is taken once a specific deficit is identified?
Treatment approaches fall into three categories:
- Approaches that attempt to restore language ability
- Approaches that are compensatory in nature
- Approaches that support communication
How can we improve difficulties in language secondary to aphasia?
Restorative treatment involves activities aimed at directly improving speech and language skills. An example of this melodic intonation therapy (MIT) is a structured program in which multisyllabic words, phrases, and sentences are melodically intoned to teach patients speech. Patients for MIT should also have preserved auditory, repetition, and comprehension skills. Constraint-induced language therapy is another form of direct treatment in which individuals with aphasia are forced to use verbal communication by suppressing other means of communication such as gestures, drawing, and writing. Another form of restorative treatment is using drills to increase auditory comprehension of word, sentence, and paragraph-level material. Patients are required to make judgments about the relationship of a sentence to multiple pictures.
What types of compensatory programs are used in patients with aphasia?
Compensatory treatments facilitate communication by supplementing preserved language skills. Approaches include the use of augmentative systems such as communication boards and devices, gestural systems, and writing and drawing. Patients are taught to use such techniques to “get around” breakdowns in communication. An essential part of compensatory strategy is an insight into one’s deficits. Patients must be aware of their communication breakdown to attempt compensation actively.
How do supportive language treatment plans work with aphasic patients?
Supportive language treatment uses a multimodal approach that emphasizes the role of the listener or conversation partner. Certain programs teach listeners to use cognitive and communicative abilities preserved in patients with aphasia to maximize communication. Training conversation partners in this approach produced a positive change in ratings of social and message exchange skills of individuals with aphasia. For more information for such programs, one can look into “Supported Conversations for Adults with Aphasia,”
What is dysarthria?
Dysarthria is a disorder of oral communication due to paralysis, weakness, or incoordination of the speech musculature. An assessment of dysarthria often begins with an oral motor examination to evaluate the strength and coordination of the speech mechanism. This includes checking for facial symmetry and evaluating the tone, sensation, and strength of the lips, tongue, cheeks, jaw, and velum. Assessment of the perceptual characteristics of speech includes evaluating articulation, phonation (ability to produce sounds of speech), resonation, prosody, and respiration during speech and non-speech tasks.
How are motor language disorders like dysarthria rehabilitated?
Restorative treatment for dysarthria, as with any neurological communication impairment, should be individualized based upon a person’s specific needs. Oral motor exercises are one of the most widely used restorative treatment options for the articulation system. Exercises for the tongue, lips, and jaw can be performed with or without resistance to strengthen weakened muscles. When a patient’s phonation system has been affected, commonly used techniques include biofeedback (voice recording of the patient with playback), Teflon injections to strengthen vocal cord closure if there is vocal cord paresis, surgical remediation, posture, and laryngeal relaxation. Compensatory strategies can improve functional communication in patients with dysarthria. Patients with dysarthria commonly slur sounds or words together, omit sounds, speak with an increased rate of speech, and have difficulty sustaining adequate breath for speech, making it difficult for a communication partner to comprehend. Patients can be taught to exaggerate the production of sounds within a speech. Although this technique will lessen the naturalness of speech, a patient’s ability to communicate basic needs and wants is the initial goal in therapy. Various other compensatory strategies such as alphabet board, single breath word count exercises, computer technology/software to assist in language can be employed.
How can providers determine who can safely swallow food and liquids?
Evaluation of dysphagia (difficulty with swallowing) involves a thorough case history (understanding cause of the dysarthria and prior difficulty swallowing) and a comprehensive oral motor exam.
Indicators of dysphagia include drooling or spillage, pocketing of food in the oral cavity, delay in triggering swallow, coughing or choking before or after the swallow, and wet gurgly or hoarse vocal quality following the swallow. The Modified Barium Swallow Study and the Fiberoptic Endoscopic Evaluation of Swallowing provide objective information about whether the patient is aspirating (allowing food and/or saliva to enter the lungs instead of the esophagus) and the risk of aspiration. These tests also help to determine whether modifying food texture or using a compensatory technique such as changing the patient’s posture will improve swallow function.
How can dysphagia be treated?
Restorative treatment approaches include oral motor exercises targeting the musculature weakened by the neurological event (either orally or pharyngeal). Methods such as the McNeill Dysphagia Therapy Program, the Mendelsohn maneuvers, the Supraglottic Swallowing technique, the Masako techniques are all methods to improve swallow, prevent aspiration, and advance diet, the details of which are beyond the scope of this discussion. Compensatory techniques for patients with dysphagia include altering positions, altering diet consistency, and modifying mealtime behaviors. Altering head and trunk posture during swallowing may redirect food and liquid flow and change pharyngeal dimensions to prevent aspiration. Thickened liquids tend to move more slowly, allowing a patient with a delayed swallow time to prepare the bolus and protect the airway. Pureed or ground meats are more easily manipulated, requiring less mastication and manipulation than firm or regular solids.
Compensatory behavioral techniques during meals like alternating solids/liquids, different utensils (e.g., straws), swallowing multiple times per bolus, decreasing rate of eating, finger or tongue sweep to clear the buccal cavity of pocketed material, decreasing environmental distractions, and providing supervision can be used for safer swallowing.
For patients with aphasia, dysarthria, apraxia, dysphagia, therapy techniques are selected based upon the individual’s needs and abilities. At Cortlandt Healthcare, we are dedicated to tailoring each patient’s needs regimen. We understand the neurological, logistical, and psychological detriment a central nervous system injury can cause to a patient, his/her loved ones, and the disruption it can cause in his/her daily life. We want to serve our community with the scientific fund of knowledge in this dynamic field, with compassion, with hope.