Current approaches to rehabilitation for acquired communication and swallowing problems

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Current approaches to rehabilitation for
acquired communication and swallowing problems

• Karen Bryan
• Professor of Clinical Practice, Speech and
  Language Therapist
• European Institute of Health and Medical
  Sciences, University of Surrey

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Differential diagnosisNon-progressive vs
Progressive

• Dysphasia- disorder of language processing.
• Dysarthria- neuromuscular disorder of speech.
• Dyspraxia- disorder of speech motor programming.
• Dementia- global impairment of intellect which is
  progressive.

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Illustrations

• From the Action for Dysphasic Adults (now
  Speakability) Dysphasia Matters pack.
• Allow people with dysphasia and other speech and
  language disorders to speak for themselves.

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Dysphasia- disorder of language processing
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What does aphasia mean to people who have it?

• social isolation and exclusion
• changed relationships
• changed sense of self
• loss of friends
• loss of work
• loss of leisure opportunities
• difficulty with speech / writing /reading

• lack of access to information
• loss of opportunities to participate
• loss of confidence
• bewilderment
• lack of understanding by other people
• possibly also difficulty swallowing

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Jasvinder
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The focus of aphasia therapy today

• Changes in language use
• Psychosocial adjustment
• Social participation
• Nina Simmons Mackie, 1998

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Intervention along a continuum
Impairment based therapies
Living with therapies
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Assessment

• Screening
• Processes within language taking knowledge
  derived from studies using neuro-imaging,
  neuro-linguistics and cognitive neuro psychlogy
• Aim to find out which part of a process such as
  single word naming is damaged.
• Then design a therapy programme for that
  individual to repair the damage, use another
  route or functionally compensate

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AUDITORY ANALYSIS INPUT LEXICON SEMANTIC
SYSTEM OUTPUT LEXICON SOUND ASSEMBLY MOTOR
PROGRAMME PRODUCTION

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Therapy

• Individually tailored
• Specific therapies mainly developed and validated
  by single case studies
• Functional approaches to therapy such as
  conversation analysis
• Living with Aphasia approaches increasingly via
  the voluntary sector eg Speakability and Connect
  networks
• Need to enhance the evidence base for aphasia
  therapy using quantitative and qualitative
  studies.

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Connie age 36CA example

• S Did you paint that thing today?
• C I Cant paintits lef hands
• S What hand?
• C Lef hands.
• S lefT
• C lef hands
• S youre saying lef youre not saying the T
• C I cant. (Sounds and looks upset)

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Work After Stroke

• Many different factors enable/hinder work
• Work is very important to stroke survivors
• Services vary geographically
• Rehabilitation needs to incorporate longer term
  goals such as work related issues
• Issues for government and society re particularly
  younger stroke survivors
• Employer issues

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Dysarthria- disorder of motor programming with no
language difficulties
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Dysarthria management

• Detailed assessment of the speech system and
  underlying pathology
• Individualised programme to maximise use of
  preserved skills and to compensate for
  difficulties
• Use of technology to augment or replace speech
• Functional communication issues

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Swallowing

• Assessment follows the same principles and may
  involve clinical examination, videofluoroscopy,
  functional swallowing and eating more widely
• Treatment aims to ensure swallow safety and
  increase swallow efficiency
• Individually tailored using a combination of
  approaches

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Management approaches

• Impairment based- working to alter the physiology
  of the swallow eg effortful swallow or
  supra-glottic swallow (close vocal folds before
  and during swallowing)
• Compensatory eg altering food consistency, and
  postural changes to facilitate the swallow,
  modifying sensory characteristics of the swallow,
  changing bolus size

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Alternatives to swallowing

• Naso-gastric tubes for shorter durations
• PEG tubes for longer term nutrition can be
  combined with minimal eating or tasting to
  promote better quality of life
• Research is looking at longer term use of PEG

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Wider management issues

• Training nursing and junior medical staff to make
  swallowing screening assessments
• Raising awareness of swallowing issues
• Working with dieticians to promote nutrition

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Wider Agenda re Communication Issues

• We all experience communication difficulties
• NSF older people emphasises good communication
  practice
• Measures to help people with aphasia will help
  those who have other problems such as sensory
  disturbances, limited command of English
• Much work to be done across all health and
  medical personnel, as well as staff on transport,
  in banks, benefit offices etc.

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Practitioner communication skills

• Awareness of their own communication skills
• Able to listen actively
• Able to use alternatives to direct questions
• Awareness of communication difficulty occurring.

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Facilitating Communication

• Dont rush- allow time.
• Make eye contact and listen carefully.
• Have pen and paper handy.
• Communicate using any means possible- speak,
  write, draw, gesture, point.
• Try another way if the message is not understood
• Check that information has been understood.

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Illustration
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The Way Forward

• Increase the evidence base for therapy
• Promote access to SLT for all people with
  acquired communication difficulties early
  access, sufficient treatment, re-assessment and
  review, appropriate linkage with supporting
  organisations
• More awareness of communication difficulty within
  healthcare systems and ultimately within society
  as a whole.

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More information

• www.UKConnect.org
• www.strokeassociation.org