Organized Stroke Strategy 4th Annual Conference The Face of Stroke Bingemans Wednesday October 25, 2

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Organized Stroke Strategy 4th Annual Conference
The Face of StrokeBingemans Wednesday October
25, 2006 Kitchener, Ontario Canada

• Techniques to Support Conversation with Clients
  with Aphasia

Presented by Michele B. AndersonSpeech-Language
Pathologist M.S.,
CCC-SLP(C), Reg. CASLPO
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At the conclusion of this seminar it is
anticipated that participants will

• Experience what it is like to have impaired/
  reduced ability to communicate
• Discuss/reflect on emotions experienced in
  response to being treated as a client with
  aphasia
• Increase awareness of the relationship between
  clients behaviours /or reactions which may occur
  in settings that require communication

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At the conclusion of this seminar it is
anticipated that participants will

• Learn about different modalities that may be
  impaired as a result of a stroke or acquired
  neurological incident
• Apply experiences acquired today to shape/direct
  future interactions with clients with aphasia
• Review and implement suggested techniques post
  session with clients in your setting

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The Role of the Speech/Language Clinician
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Brain Food

• Not being able to talk is not the same as having
  nothing to say.
• - Rosemary Crossley

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What is Communication?
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What is Communication?

• SENDER MESSAGE RECEIVER
• MESSAGE - Non-verbal MESSAGE
• OUT - Verbal IN

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Stroke/Neurological Incident

• Stroke occurs when a clogged or burst artery
  interrupts blood flow to the brain.
• This interruption of blood flow deprives the
  brain of needed oxygen and causes the affected
  brain cells to die.
• When brain cells die, function of the body parts
  they control is impaired or lost.

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Stroke/Neurological Incident

• A stroke can cause paralysis or muscle weakness,
  loss of feeling, speech and language problems,
  memory and reasoning problems, swallowing
  difficulties, problems of vision and visual
  perception, coma, and even death.
• NEXT STEPS

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Communication Assessment

• Assessment may include a review of the following
  skills
• Attention/Concentration
• Receptive Understanding of Language
• Expressive Language/Speech Gesture
• Pragmatics
• Reading/Literacy
• Writing/Literacy
• Functional Assessment
• Medication Review

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Communication-Related Effects of a Stroke The
A list

• AphasiaCommunication modalities/ receptive
  expressive language processes
• Apraxia of speech Verbal abilities
• Dysarthria Oral Motor Functioning
• DysphagiaSwallowing
• Source - American Speech-Language-Hearing
  Association

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Communication-Related Effects of a Stroke The
A list

• Aphasia
• Communication processes that encompass receptive
  expressive language modalities

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Aphasia language

• Message IN Message OUT
• Understanding - Talking
• Reading - Writing

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APHASIA (language)

• People with aphasia
• know more than they can say

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Characteristics ofRECEPTIVE Aphasia

• Common areas of difficulty
• Responding to questions with inappropriate or
  wrong answers
• Following commands /or instructions
• Listening skills
• Reading and understanding written words

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EXPRESSIVE Aphasia

• Definition
• The decreased ability to express oneself or
  communicate needs.
• There are two types of expressive aphasia
• FLUENT and NON-FLUENT

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Characteristics ofEXPRESSIVE Aphasia

• Common Areas of difficulty
• Fluent speech
• Lack of meaningful words non-specific/irrelevant
  
• Sound /or word substitutions
• Elimination of non-meaningful words due to the
  effort of speaking

• Difficulty writing
• Excessive talking
• Use of made-up words
• Difficulty repeating
• Decreased awareness of difficulties
• Putting words together that dont make sense
• Reduced ability to name pictures /or objects
• Searching for sounds with various mouth
  movements

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Communication-Related Effects of a Stroke The
A list

• Apraxia of Speech
• Relates to verbal abilities

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Apraxia of Speech VERBAL APRAXIA

• Wrong Sounds or No Sounds

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APRAXIA

• The decreased ability or inability to position
  the
• Lips
• Tongue
• Vocal Cords to
• produce various sounds of speech from the
  impaired motor aspect of producing sounds

• An individual with apraxia may know what they
  wish to communicate, but cannot produce the
  correct sounds for each word.

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Characteristics of Apraxia

• Effortful Speech
• Telegraphic Speech
• Preservative Speech
• Sound substitutions
• Automatic speech

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Communication-Related Effects of a Stroke The
A list

• Dysarthria
• Oral Motor Functioning
• Source - American Speech-Language-Hearing
  Association

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Dysarthria Oral Motor Functioning/Speech

• Slurred Speech

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Dysarthria

• Neurological impairments created by dysarthria
  affect the following physical processes involved
  in speech
• Respiration
• Phonation
• Articulation
• Resonation
• Prosody

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Characteristics of Dysarthria

• Shortness of breath
• Breathy voice/whispering
• Decreased loudness of voice
• Monotone speaking
• Drooling
• Muscle weakness of the face, lips tongue
• Air escaping from the nose nasality
• Slow mouth movements
• Impaired chewing swallowing skills

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Communication-Related Effects of a Stroke The
A list

• Dysphagia
• Swallowing
• Source - American Speech-Language-Hearing
  Association

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Dysphagia Swallowing

• Swallowing disorder

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Characteristics of Dysphagia

• coughing during or right after eating or drinking
  
• wet or gurgly sounding voice during or after
  eating or drinking
• extra effort or time needed to chew or swallow
• food or liquid leaking from the mouth or getting
  stuck in the mouth
• recurring pneumonia or chest congestion after
  eating
• weight loss or dehydration from not being able to
  eat enough

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Characteristics of Dysphagia

• poor nutrition or dehydration
• risk of aspiration (food or liquid entering the
  airway) which can lead to pneumonia and chronic
  lung disease
• less enjoyment of eating or drinking
• embarrassment or isolation in social situations
  involving eating

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Communication-Related Effects of a Stroke The
On list

• Cognitive-Communication Skills
• Cognition thinking skills
• Attention Concentration
• Processing of Information
• Executive Functioning
• Recent Memory

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Communication-Related Effects of a Stroke The
On list

• Cognitive-Communication Skills
• Source - American Speech-Language-Hearing
  Association

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Cognitive-Communication Skills thinking disorder
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Characteristics of a COGNITIVE COMMUNICATION
DISORDER (thinking disorder)

• Thinking about Talking
• Problems having CONVERSATIONS
• Problems UNDERSTANDING and REMEMBERING
• Problems ORGANIZING their thoughts when speaking

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Communication-Related Effects of a Stroke The
S list

• Social Skills
• Pragmatics/ Social
  Communication
• Awareness of self/
  Self-regulation
• Source - American Speech-Language-Hearing
  Association

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Social Communication Skills
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SLP Treatment

• The SLP works on drills and exercises to improve
  specific language skills affected by damage to
  the brain.
• The SLP teaches the client ways to make use of
  stronger language skills to compensate for weaker
  language skills

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SLP Treatment

• Later on in recovery, the SLP may work with a
  vocational specialist to help the person return
  to work or school, if appropriate.
• If there is weakness of speech muscles, the SLP
  teaches exercises to strengthen these muscles

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Learning by Experience

• From this point on you are the individual with
  aphasia.
• The following experiences are intended to help
  you
• Experience what it is like to have impaired/
  reduced ability to communicate.
• Understand the deficits and feelings of the
  client with aphasia more fully.
• Acquire a working point of reference and
  heightened sensitivity to the communication needs
  of the client with aphasia.

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Learning by Experience Goals

• Individuals with aphasia may experience
  challenges impacting five general areas of
  functioning that are required to be a competent
  communicator.
• As of this moment you are an individual currently
  experiencing communication related effects of a
  stroke.

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Learning by Experience Goals

• Today you will experience deficits in the
  following areas
• Receptive Understanding/ Comprehension
• Expressive Language/Use of Speech Gesture
• Reading
• Writing
• Attention

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Experience 1

• Focus Comprehension Tasks
• Picture identification
• Answering questions
• Following directions

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Task Analysis Experience 1

• Activity 2
• Comprehension problems associated with auditory
  discrimination
• Activity 3
• Comprehension problems associated with missing
  information.
• Activity 4
• Auditory processing difficulties associates with
  rapid rate and complex information.

• Challenges You have experienced components of
  the
• A List
• On list
• S list
• Activity 1
• Receptive language deficits at word level.

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Skills used in Receptive Language Tasks

• Information Processing
• Sequencing
• Categorization
• Association
• Language Reasoning

• Discrimination
• Verbal Memory
• Hearing Acuity
• Attention Span
• Attention Focus

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Situations Requiring Receptive Language

• Group discussions
• Conversation
• Verbal directions
• Reading
• Writing
• Budget management
• Telephone communication
• Social gatherings
• Noisy environments

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Experience 2

• Focus Expressive Communication
• You are currently in your room and a member of
  you health care team walks in. You want to
  express and idea to this individual.

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Task Analysis Experience 2

• Challenges You have experienced components of
  the
• A List
• On list
• S list

• Some of you could
• Comprehend but not speak/articulate.
• Unable to use gestures to supplement your
  messages
• Felt pressures due to time constraints.

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Skills used in Expressive Language Tasks

• Memory
• Speech efficiency
• Attention span
• Comprehension

• Discrimination
• Word retrieval
• Sequencing
• Self monitoring

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Situations Requiring Expressive Language

• Lectures
• Conversation
• Giving directions
• Writing
• Explanations

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Experience 3

• Focus Reading
• Today you will engage in a simple exercise of
  reading and providing responses to associated
  questions

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Task Analysis Experience 3

• Decoding deficits will occur when a client has
  visual perceptual challenges
• Requires ability to decode and interpret complex
  concepts and information
• You are able to read and comprehend but cannot
  see all of the text, reducing your ability to
  understand

• Challenges You have experienced are components
  of the
• A List
• On list
• S list

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Skills used in Reading Tasks

• Tracking
• Memory
• Spatial orientation
• Vocabulary
• Word configuration
• Sequencing
• Comprehension

• Attention span
• Sound-symbol relationships
• Sound blending
• Symbol recognition
• Discrimination
• Visual acuity

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Situations That Requiring Reading Skills

• Reading books, magazines and newspapers
• Using a telephone book
• Following maps
• Reading directions

• Playing games
• Doing math computations
• Reading medication labels and dosage schedules
• Filling out job applications

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Experience 4

• Focus Writing
• Today you are in occupational therapy and will
  work on managing your finances.

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Task Analysis Experience 4

• Challenges You have experienced are components
  of the
• A List
• On list
• S list

• Understanding a problem does not change the
  performance difficulties you experienced
• Challenges - trying to write a cheque when it is
  not held down.

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Skills used in Writing Tasks

• Laterality
• Tracking
• Spatial organization
• Memory
• Fine Motor Control

• Discrimination
• Integration
• Attention span
• Attention focus
• Visual acuity

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Situations Requiring Writing Skills

• Balancing a checkbook
• Arts and Crafts
• Writing letters
• Report writing
• Games

• Leaving messages/notices
• Completing job applications
• Making lists

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Debriefing Some Questions

• Are you tired?
• What do you think it would be like to have these
  problems for the rest of your life?
• How do you feel about being dependant o others?
• How did you feel about not being able to
  understand or communicate simple ideas?

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Debriefing Some Questions

• What were your behaviours like? What about the
  others round you?
• After completing this simulation, will you alter
  your interaction style with your clients? How?
• What can you do, or not do, to help clients feel
  less frustrated?

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What Can Happen After A Stroke?

• Why is it Called an Invisible Barrier?

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Strategies for Communicating With Clients With
Aphasia
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Communication Techniques/Strategies

• Treat the Client with RESPECT

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Sensory Processing

• A large portion of information we experience and
  interpret is processed via non-verbal sensory
  modalities.

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Adaptations for Sensory Needs Hearing

• Reduce or eliminate background noise
• Establish face-to-face orientation with
• Adapt appropriate distance and body position in
  relation to the client
• Assume the same eye-level as the client
• Touch the client after visual contact has been
  made

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Adaptations for Sensory Needs Visual

• Adjust lighting to a level that will allow the
  client to use available vision with less strain
• Position the client to prevent glare or light in
  the face
• Assume an appropriate position and distance
• Touch the client appropriately only after verbal
  identification
• Verbalize any change of position in relation to
  the client

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Visual/Spatial/Constructional

• Cue the client to make eye contact with the
  person who is speaking
• Decrease clutter
• Keep items in the same place to make it easier to
  remember where an item is
• Stand/place objects in the clients good visual
  field
• Use pictures/simple signs to label items

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Environmental Assessment

• Distractions
• Distance/Proximity
• Lighting
• Seating
• Sensory/Physical Challenges
• Supports
• Tasks

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Techniques/Strategies for Getting the Message IN

• Help the Client To UNDERSTAND You

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Attention

• Decrease distractions
• Perform one task at a time
• Provide verbal reminders to stay on task
• Give simple one-step directions or make simple
  statements
• Ask the client to repeat information back to you

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Language Level

• Choices provide choices when asking simple
  questions
• Do not pretend to understand when you dont.
• Emphasize key words
• Focused use of questions
• KISS Keep It Short and use Simple/basic
  vocabulary language
• Limit Questions If cooperation is challenging
  use simple statements instead of questions.
• Practice, practice, practice simplifying our
  language takes practice

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Memory

• Provide orientation information repeat
  information frequently or write it down so it can
  be easily seen
• Have the client repeat information/directions
  back to you or write it down
• Follow a routine perform the same tasks in the
  same order every day
• Repeat information/instructions to the client as
  needed

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Non-Verbal Communication

• Avoid speaking too quickly / too slowly
• Be Patient. It is okay if you do not understand
  every communication attempt. Assure the patient
  that you want to understand, maybe you can try
  again later.
• Facial Expression/Body Language observe these
  domains, this may give you insight into the
  clients feelings or needs.
• Other Methods of Expression Should a client
  become frustrated with speech, encourage other
  methods, such as pointing or gesturing to get
  messages across, to take a rest and try again
  later.

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Non-verbal Communication

• Silence is golden
• Stress - decrease or eliminate stress of
  communication. When talking or listening make
  every attempt to sit down and act calm.
• Supplement Your Verbal Language use multi-modal
  means to get the information across
• Talk normally - Speak to the client as you would
  speak to colleague or friend using your normal
  tone of voice or mannerisms.

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Problem Solving

• Perform one task at a time
• Repeat safety information frequently
• Provide written steps to complete a task
• Talk about how to solve a problem before
  attempting it
• Verbally or physically help the client begin a
  task

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Routines

• Choices provide choices when asking simple
  questions.
• Routine engage in daily activities that
  stimulate meaningful speech, activities may allow
  the client to speak in a relaxed situation.
• Keep a consistent routine.

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Carer Communication Strategies

• Clarify when needed. If you are unsure whether
  you have understood the client correctly, restate
  or rephrase the message.
• Facial Expression/Body Language observe these
  domains, this may give you insight into the
  clients feelings or needs.
• Provide feedback. Let the client know when you
  dont understand so he/she can attempt to say it
  again. Do not allow the client to continue if you
  have no idea what is being said.
• 20 Questions This can be frustrating to the
  client as well as to you.

VERIFY Am I on the right track?
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Techniques/Strategies for Helping Clients Get the
Message OUT

• Help the Client To Get Their POINT Across
•  

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Techniques/Strategies for Helping Clients Get the
Message OUT

• Be flexible and creative in how you assist the
  clients responses
• Be patient. It is okay if you do not understand
  every communication attempt. Assure the client
  that you want to understand, maybe you can try
  again later.
• Dont talk for the client. Avoid answering for
  the client. Allow the patient to communicate as
  much he/she desires.
• Feelings and Concerns validate, but avoid
  conversing about unreal events.

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Techniques/Strategies for Helping Clients Get the
Message OUT

• Limit Questions If cooperation is challenging
  use simple statements instead of questions.
• Monitor visitors Speech is usually better or
  clearer when the client is rested. You may want
  visitors to see the patient after the patient has
  had some rest. Some clients may feel embarrassed
  about their speech.
• Slowly loudly The client should be directed to
  speak slowly and loudly pause frequently.

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Client Communication Strategies
VERIFY Am I on the right track?
Clients should check with listeners make sure
they understand you. Fatigue Clients should
limit conversations when they are tired, as their
speech will become more difficult to understand.
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Questions? Comments?
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References

• American Speech-Language Hearing Association
  Website - Fact Sheets Aphasia Apraxia
  Dysarthria Dysphagia Stroke Swallowing
  www.asha.org
• Canadian Association of Speech-Language
  Pathologists and Audiologists Website - Fact
  Sheets Adult Communication Disorders
  Communication Disorders and Aging Swallowing
  Disorders www.caslpa.ca
• Knauss, S.D. Apraxia Cognition Dementia
  Dysarthria Dysphagia, San Antonio, TX,
  Communication Skill Builders, 1998
• Lum, N., Sutton, S. Living With Stroke
  Communication Kitchener, ON, Presentation, 2005
• Neuvlud, G.N., Jones, R.E.M. Experiencing
  Aphasia Tucson, AZ, Communication Skill
  Builders, 1989

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Brain Food

• Seek not to be understood but understand
• St.Francis of Assisi

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Thank You!