“What’s Next?” How to Keep Challenging Your to Maximize Recovery

KERRI SUTLEY M.S., CCC-SLP LEAD PATHOLOGIST ENCOMPASS HEALTH REHABILITATION [email protected]

 1. Provide a brief overview of common cognitive, communication, and swallowing difficulties that survivors and caregiver's can Learning encounter.

Objectives  2. Offer tips, techniques, and technology based resources to help facilitate continued recovery

What is a Speech- Pathologist and how can we help? What is a Speech-Language Pathologist and how can we help?

 A Speech-Language Pathologist is an individual trained in the assessment and management of difficulties with communication, cognition (thinking skills), voice, and swallowing.

 A Speech-Language Pathologist is trained to treat children and adults, however my specialty is adult rehabilitation therefore that will be the area of focus during this presentation. Common diagnosis that I see are those with Stroke, brain injury, Parkinson's and other neurologic conditions.

Communication skills include: listening, The most common types speaking, reading, of communication writing, conversation, disorders are , and non-verbal Apraxia, and . communication skills

Communication Aphasia

 Aphasia is a disorder that results from damage to portions of the brain responsible for language. Aphasia can develop suddenly as the result of a stroke or head injury, or gradually as the result of a brain tumor or infection. It can also be a symptom of a degenerative dementing illness such as Alzheimer's. It is estimated that 18-38% of stroke survivors have aphasia. According to the America Heart Association in 2017 Aphasia Approximately 795,000 occurred in the U.S. each year and about 1/3 of those result in aphasia.

There are many types of . We will discuss three of the most common:

Wernicke’s Broca’s Global.

Wernicke’s FLUENT/ Wernicke’s area in the brain Fluent/Receptive

 Wernicke's aphasia occurs when there is damage in the posterior region of the in an individual’s dominant hemisphere of the brain.  In fluent aphasia, an individual may be able to speak with normal rate and intonation but speech may have little or no real meaning because the individual’s sentences are lacking content words or may contain "made up" words (). Types:

Semantic Phonemic Neologisms

The person may The person may The person may have substitute one word for substitute one sound or speech characterized another. For example, syllable for another. For as “jargon.” For example an individual may say example, an individual an individual may use “watch” for “clock” may say “dock” for words that are “made “clock” up.” For example saying “smire” for “clock.” Individuals with fluent aphasia are often unaware of their mistakes and can have some degree of difficulty with comprehension.

They tend to lose focus when background noise is present or Fluent/Receptive when more than one person is speaking.

Reading can also be impacted. The individual may be able to read a headline but not comprehend the text in the body of an article. Broca’s NON-FLUENT/ Broca’s area in the brain Non-Fluent/Expressive Aphasia

 Broca's aphasia is the most common type of non-fluent aphasia. In this type of aphasia, damage is primarily in the dominant inferior of the left hemisphere (Broca’s Area).  When there is a in Broca’s Area, there can be a breakdown between one’s thoughts and one’s language abilities. Thus individuals will report they know what they want to say but are unable to produce the words.  Speech is often produced in short phrases and with great effort.  The individual may have difficulty Non- producing the right sounds or finding Fluent/Expressive the right words to communicate. Aphasia  Sentence structures are typically simplified and often missing linking words or conjunctions: "drink water" for "I want a drink of water.” Non-Fluent/Expressive Aphasia

 Those with Broca’s aphasia generally comprehend fairly well, however understanding may break down with more complicated sentence structures. For example: "Joe gave Cindy a flower" may be easy for the individual to interpret, however "The flower was given to Cindy by John" may result in a breakdown in comprehension.  Those with Broca's aphasia may be able to read but have limited writing ability. Global RECEPTIVE/EXPRESSIVE APHASIA

 Global aphasia is the most severe form of aphasia. It results from damage to multiple language-processing areas of the brain. In global aphasia, individuals can typically produce little to no or the language they can produce may be incomprehensible.  Comprehension skills are impaired even with very simplified sentence structures.  These individuals are also often not able to read or write.  While we have only covered three of the more common types of aphasia, Other Types more types do exist. Other types of aphasia include: mixed transcortical, of Aphasia transcortical motor, transcortical sensory, conduction, and . Additional types of Aphasia Apps for Aphasia

Apraxia MOTOR SPEECH DISORDER Apraxia

 Apraxia is a motor speech disorder that affects the brain pathways involved in planning the sequence of movements for producing speech.

 Just as in aphasia, apraxia can be mild to severe. Apraxia however, can happen in conjunction with other Apraxia speech and language problems (such as aphasia or dysarthria).

In apraxia errors are often inconsistent and speech may be slow and halting or the individual may “grope” for sounds.

An individual may be able to say everyday phrases and greetings with little effort especially when relaxed, Apraxia however longer and more complex sentences are difficult.

An individual may also struggle more when asked to repeat a word or phrase vs. spontaneous production. Apps for Apraxia Tips for Improving Communication Interactions

 Have the individual keep a card they can show Improving or someone in case of emergency explaining that Compensating they have aphasia and/or apraxia and how that impacts their communication and for Aphasia understanding.  Keep pertinent emergency contact and Apraxia information accessible or with the individual at all times. Improving or Compensating for Aphasia and Apraxia

 Do not “talk around” the person with aphasia/apraxia. Include them in the conversation. Many people with aphasia/apraxia feel that family, friends, doctors, etc., bypass them and communicate directly with the caregiver. While this may be necessary to a point to ensure that important information gets conveyed accurately, it is also important for the individual to feel included in these interactions. Improving or Compensating for Aphasia and Apraxia

 Do not talk FOR the person with aphasia/apraxia. Although word finding may be difficult for an individual, it's important for you to be patient when they are attempting to speak or communicate.  Ask permission before you help or speak for them. Sometimes interrupting an individuals train of thought can actually make it harder and more frustrating for them to communicate. Improving or Compensating for Aphasia and Apraxia

 Minimize distractions and noise level. Turn off the TV or radio or other background noise and move to a quieter location if you can. This can help the person focus on the conversation at hand. Improving or  Slow down YOUR rate of speech and make eye contact when Compensating speaking whenever possible. This for Aphasia can help the person with aphasia/apraxia better understand and Apraxia what you are saying. Improving or Compensating for Aphasia and Apraxia

 When you ask the individual questions use simple yes/no for basic needs and preferences.

 Try to limit open-ended questions: "What would you like for dinner?" Instead ask the question and provide simple/clear choices: "Would you like steak or chicken for dinner?" Improving or Compensating for Aphasia and Apraxia

 When giving instructions, break them down into simple steps and gesture if necessary. Allow plenty of time for the individual to process and respond. Improving or Compensating for Aphasia and Apraxia

 If the individual is struggling, try to encourage them to say their message another way or rephrase it.  Also break down longer, more complex words into shorter segments.  Try singing. Using melody can often make it easier to articulate words. Try tapping out the syllables in a word or tap your finger for each word in a sentence.

Improving or Compensating for Aphasia and Apraxia

BEST APPROACH: Use multimodal communication strategies. An individual will have much greater success when communicating by using a combination of speaking, gesturing, writing, sketching and/or the use of either low or high tech augmentative communication systems.

Augmentative Communication

Low Tech High Tech  Does NOT require electronics of  DOES use electronics to any kind and can include supplement communication. things such as picture boards , These can include the use of letter boards, word boards and computer programs, tablet any combination of the three. computers with APPS, and specially designed augmentative devices that can not only assist with communication but can be accessed multiple ways (pointing, vocalizing, eye gaze) Improving or compensating for aphasia and apraxia

 SOCIALIZE!!! This is often a scary one for those struggling with aphasia/apraxia but it is likely one of the most important things for brain recovery. Individuals with aphasia can feel very isolated and this can limit their desire to attempt to communicate.  Try to get involved regularly with friends or family. Get involved in your church or other organization. Join a stoke survivors support group. How can you expect language and communication skills to recover if you don't USE them? Dysarthria MOTOR SPEECH DISORDER Dysarthria is weakness in the muscles used for speech including those of the lips, tongue, throat, and muscles for breathing. Dysarthria differs from aphasia. The individual with aphasia may have difficulty understanding speech Dysarthria (comprehension), using the right words or poor sentence structure. With dysarthria the individual has more problems with the execution of speech (moving the articulators in a coordinated manner for clear speech). Dysarthria

 Speech may be "slurred" or "mumbled" and hard to understand. An individual may speak too slow or fast and have difficulty coordinating respiration and phonation. Changes in a person's voice can also occur.  Traditional therapy and home Dysarthria exercises programs for dysarthria focus on strengthening the musculature if needed, learning how to coordinate breathing and phonation, and learning compensatory strategies to use when speaking such as controlling speaking rate, over-articulation, and controlling volume. Compensatory strategies include:  Making sure you are using good posture when speaking  Look at the individual you are talking to  Practice over-articulation  Pace yourself Dysarthria  Make sure you have adequate breath support when speaking A speech therapist trained in dysarthria rehabilitation can also provide further individualized techniques or suggestions for improving intelligibility

Neuroplasticity is our hope!

 Years ago researchers believed that our had little capacity to change once we reached adulthood. Researchers now know that is simply not the case. Our brain continues to change as we learn and have new experiences across our lifetime. The core of neuroplasticity is essentially our brain’s ability to adapt and change itself. Neuroplasticity

 When we learn new skills or re-learn old ones we are forming new pathways in the brain. Not all learning is created equal however. Each human being is unique, therefore there is great variability between how each of us learn. Rehabilitation from an injury must be individualized to meet each person's unique learning needs.  One of the most important driving forces behind the concept of neuroplasticity is behavior. The individual has to put in the work and in most cases LOTS of it, to give their brain the opportunity to learn and change after an injury. Cognition THINKING SKILLS Cognition is defined as the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. Simply put, cognition is our "thinking skills." Cognition

Changes in cognition can occur as a result of a stroke, brain injury, brain tumor, Alzheimer’s, or other neurological condition. Cognition

An individual with cognitive changes may experience difficulties with:  Memory  Attention and concentration  Problem solving, reasoning, and safety awareness  Organization and planning  Decreased processing and comprehension

How to compensate for changes in cognition Memory

 Structure and routine can be a great help with memory. Stick to a predictable daily routine as much as possible.  Stay organized and have a set locations for important items  Get in the habit of using memory aids such as calendars, keeping a daily schedule or planner, making lists, using the computer or your phone to provide daily reminders, or use smart home features (Alexa, Google home, etc.). Memory (cont’d)

 Devote time and attention to review and practice (review you schedule for the day each morning, set aside time to work on cognitive tasks daily).  Get enough rest! When we are tired everything is harder!  Speak to your doctor about how medications can affect memory or if you might be a candidate for a medication that can help with memory (Aricept or Namenda).  Reduce distractions and background noise Attention and  Take breaks when you get tired Concentration  Focus on one task at a time

 Practice on improving your attention by doing tasks such as reading, completing basic math problems, or puzzles. Start simply and increase the difficulty of the task. Start by reading a paragraph and work up to a short story.  Complete basic math facts and work up to Attention and balancing a checkbook or managing monthly Concentration bills.  You can also challenge your brain further by starting basic tasks in a quiet room and then transitioning to a more noisy environment (work with the radio or TV on in the background, move to an area where more family are gathered). Problem solving, Reasoning and Safety Awareness

 Remember that an individual can have difficulty recognizing that there is a problem, analyzing the problem at hand, and trouble deciding on a solution.  An individual may get stuck on a single solution and have a hard time considering other potential options. Work on finding a step by step strategy Problem for approaching problems.  Discuss or write the potential problem or safety Solving , concern.  Brainstorm possible solutions to the problem at hand. It is often a good idea to list the pros Reasoning, and cons of each potential solution. Review your list, choose a solution, and then attempt and Safety it.  Evaluate if the chosen solution was a success Awareness and if not, why?  Finally, if the first solution did not work, try another from the list and follow the same process. Problem Solving, Reasoning, and Safety Awareness

 If safety awareness is a concern, modifications to the environment may also need to be made such as locks on cabinets or doors, keeping tripping hazards picked up, using a monitoring device such as a camera, or having family or friends check in regularly. Break Break down activities into a step by step approach (Make down a written list if necessary)

Organization Think about the end goal of an activity. This can help you Set Goal work backwards when thinking about the steps that need and to occur in order to accomplish that end goal. Planning

Make lists of task steps in order of importance and cross Evaluate off tasks when completed.  Reduce background distractions whenever able to allow for better concentration.  Allow the individual more time to think about what was said or asked before moving on. Be patient!  An individual may need to get in the habit of Decreased re-reading information or summarizing/clarifying what has been said to Processing them to ensure they understood.  To exercise your processing skills, think about working on tasks with some sort of time pressure involved. Start slow and work your speed up (i.e. computer games, Apps, etc. ).

Dysphagia DIFFICULTY SWALLOWING Dysphagia

 Dysphagia is defined as difficulty or discomfort with swallowing.  Dysphagia can occur as a result of various neurological disorders such as stroke, brain injury, Parkinson's, multiple sclerosis, Amyotrophic lateral sclerosis(ALS or Lou Gehrig's disease), muscular dystrophy, cerebral palsy, and Alzheimer's. Dysphagia can also be the result of head and neck cancers, neck injuries, and mouth or neck surgery.  Dysphagia severity can range from very mild to profound and in some cases to the point of an individual needing an alternate means of nutrition/hydration such as a feeding tube. Dysphagia

 Incidence of dysphagia numbers vary from diagnosis to diagnosis and from study to study. The primary goal of dysphagia treatment is to rehabilitate the swallowing musculature and/or train strategies that can help an individual compensate for their swallowing difficulties and improve quality of life.  Potential consequences of dysphagia are: aspiration pneumonia, weight loss, poor nutrition, dehydration, compromised general health, chronic lung diseases, choking, and in extreme cases, death.  Coughing during or right after eating or drinking  Wet sounding voice during or after eating or drinking Signs and  Extra effort or time needed to chew or swallow  Complaints of difficulty with food or liquid Symptoms of leaking from your mouth Dysphagia  Food getting stuck in your mouth or throat  Unplanned weight loss  Difficulty taking medications

Signs and symptoms of potential swallowing problems

 If you notice any of these symptoms you need to speak with your doctor about them. You may need to be evaluated by a speech therapist to determine the best plan of care for rehabilitating your swallow. tactustherapy.com QUESTIONS? References

 1. Jose Carlos Castillo, Diego Alvarez-Fernandez, Fernando Alonso-Martin, Sara Marques- Villarroya, and Miguel A. Salichs, "Social Robotics in Therapy of ", Journal of Healthcare Engineering, vol. 2018, article ID 7075290. https://doi.org/10.1155.2018/7075290

 2. Dobkin BH. Rehbilitation and recovery of the patient with stroke. In: Grotta JC, Albers GW, Broderick JP, et al, eds. Stroke: Pathophysiology, Diagnosis, and Management. 6th ed. Philadelphia, PA: Elsevier; 2016: chap 58.

 3. Kischner HS. Language and speech disorders: aphasia and aphasic syndromes. In : Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SK, eds. Bradley's in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016: chap 13.

 4. Page S. Guide to living with aphasia. Arch Phys Med Rehabil. 2013;94(8): 1643-1644. PMID: 24049797 www.ncbi.nlm.nih.gov/pubmed/24049797

 5. National Institute on Deafness and Other Communication Disorders (NIDCD) and U.S. Department of Health & Human Servies, Aphasia, December 2015, NIH Pub. No. 97-4257, https://www.nidcd.nih.gov.

 6. National Aphasia Association. Aphasia Statistics, 2016, https://apahsia.org/2016- aphasia-awareness-survey/

References

 7. Charles Ellis, Rose Y. Hardy, Richard C Londrooth, & Richard K. Peach, "Rate of aphasia among stroke patients discharged from hospitals in the United States", Journal of , https://doi.org/10.1080/0287038.2017/1385052

 8. Aninda B. Acharya, Scott Dulebohn, Wernicke Aphasia, NCBI Booshelf, November 2018. https://www.ncbi.nom.gov/books/NBK441951/

 9. Aninda B. Acharya, Scott Dulebohn, Brocas Aphasia, NCBI Bookshelf, November 2018. https://www.ncbi.nlm.nih/gov/books/NBK436010

 10. American Speech-Language-Hearing Association, Aphasia, https://www.asha.org/public/speech/disorders/aphasia/

 11. American Speech-Language-Hearing Association, Adult Dysphagia, https://www.asha.org/public/swalloing/disorders/dysphagia