Speech Rehabilitation

I'm a speech pathologist and as a speech-language pathologist in a rehab center I play two roles my first role is the traditional role of a speech pathologist working with communicative ly impaired patients stroke patients most oftenly have a communication disorder called aphasia APH a si a the Ephesian aphasia is a language problem that's secondary to left hemisphere brain injury if a person has a stroke on the left side of the brain most often they have a condition called aphasia aphasia isn't difficult to understand once you understand the complexity of it it affects your ability to understand language you hear to think of words that you want to say to even gesture the communication intent that you have your reading and your writing I think one possible analogy that helps me understand aphasia is if you think about English as a second language or learning French as another language when you're learning that language you have difficulty understanding what people are saying you certainly have difficulty speaking it you tire really rapidly that it's fatiguing to try to keep up that's just how patients perform who have left hemisphere damage resulting in aphasia aphasia is characterized by several components and one of them is called word finding problems you and I have had word finding problems it's that awful experience when you're trying to think of someone's name and you know it and you say it's just on the tip of my tongue wait just a second and you can't think of it and you're standing there looking at the mem barest thinking is this a neighbor someone from the church past patient and you can't remember who the person is and hour and a half later you think of the name now we all have had that kind of problem but aphasic patients have that problem in an exaggerated fashion they can't sometimes think of just common words for example they might say I need a clean you know it's um it's got the with the brandy um oh it's a I can't think a shirt a word finding problem they search and struggle all day long to find the words they want to express a meaning another characteristic of a stroke patient with left hemisphere damage resulting in aphasia would be what's called perseveration and perseveration is a fancy word for getting stuck in a rut when you thought of something and it's correct and it can't seem to leave your mind and you just keep saying that same thing over and over again or you keep doing the same thing over and over again and you don't want to now we don't have brain injury you and I haven't had a stroke and so one of the things that you and I experienced it's similar but not exactly is when we say oh I heard a song and it wasn't Whitney Houston just a minute it was um you know not Whitney Houston all I can think of is Whitney Houston and I know it's not Whitney Houston but I can't stop it from coming into my head that's what happens to stroke patients with aphasia is they might say this is a piece of paper and this is a piece of paper no no no no these aren't this isn't a piece of paper let's see it's a piece of no no not a piece of it's a they know they don't want to call this a piece of paper and they're stuck in a rut it's called perseveration another characteristic of this kind of patient is what's called automatic speech automatic speech has it's good side in it's bad side the good side is that lots of times patients who have trouble saying anything can automatically say a greeting a friend comes in and they say hi how are you but for the life of them when they want to do it again they can't automatic speech also might be the ability to say the days of the week or to count things that are automatic or memorized or wrote but you don't spend very much time thinking about now the flip side the more annoying side of automatic speech is swearing and lots of stroke patients where even if they didn't swear before and even if they don't want to I think it's a combination of several things certainly frustration moans when you can't say what you want to say you get frustrated but also there is a neurological component which is automatic sweet speech that's weary it's part of the brain injury and so people might swear when otherwise they would have inhibited that behavior sometimes when patients hear themselves doing this it's so upsetting to them that they would prefer to be quiet and they'll stop talking altogether my advice to you as you're working with this kind of patient is win that automatic swearing occurs you go ahead as though it isn't you look directly at the patient you go about your business another characteristic of this kind of patient is called emotional lability emotional lability and what that is is an exaggerated expression of emotional release it's usually expressed by crying stroke patients cry very easily it might cry when family comes and they cry when family goes and they cry when you say nice job and they might cry even over things that you don't think are emotionally leading topics you might come in to do a menu selection they've come to talk about your menu and the thought that now they're going to have to select something and they're gonna have to visit with somebody they don't know it's frightening and it triggers off this emotional ability and the patient cries as the brain injury subsides as some healing improves emotional ability reduces but it is important to realize that for the stroke patient emotional ability is a persistent situation and will probably carry through life long my advice to you when you're dealing with a patient who demonstrates emotional lability is to show some sign of compassion and a Kleenex or put your hand on the shoulder but also go about your business if you start to acknowledge the emotional ability as truly a clear expression of dissatisfaction or of depression you'll open the floodgates if you say oh I'm just so sorry I don't mean to make you unhappy over this and perhaps I what will happen is the person will have an outpouring that's almost uncontrollable it's not therapeutically sound so show your interest show your concern and move along stroke patients often have in addition or separate from aphasia a communication disorder called dysarthria and this r3 is slurred speech imprecise articulation it's caused by muscle in coordination and muscle weakness the tongue and the lips the soft palate the jaw just doesn't move rapidly enough it isn't precise enough so you'll get speech that's kind of slurred and run together sometimes it's hard to hear sometimes it's nasal sounding you'll need to listen with a third ear you'll need to watch the person carefully and then say to them what you believe you heard them say it validates the answer it validates what they're saying I do want to caution you about validating with yes and no most stroke patients have some yes and no confusion when you think about yes and no it really is nothing tangible you can't say this is a yes doesn't have a color or a shape you know buy it in a particular store it's an abstract concept it just means an affirmance affirmative reaction so they're easy to confuse when you say to a person do you like coffee and they say yes then a little bit later in the same conversation I would say do you hate coffee and if they say yes you realize that this person has a yes/no confusion that you might not always get valid answers with yes and no watch for head nod head shake facial expression it'll probably be more valid than what's actually verbalized there is one more condition I want you to know about and that's called apraxia Prak c is more difficult to understand apraxia is a neurological condition that comes secondary to stroke and it has nothing to do with muscle weakness or muscle in coordination in fact the musculature works fine the problem is the patient can't make the muscles work fine when they want to here's how its demonstrated communicatively a person might be able to stick out their tongue to lick their lips to wet their mouth but if the speech pathologist says now stick out your tongue they can't they might open their mouth or grimace do all other kinds of muscle movement and they can't get their tongue to come out they might automatically greet someone and say hello if you say say it again they can't a proxy is the inability for voluntary control of the oral musculature they can do automatic tasks automatic function because there isn't paralysis they can't do it on purpose speech is purposeful speech communicates what we want to say and what we believe what we wish for it controls our environment so the patient with apraxia very often is not going to be a verbal speaker and will need to use some kind of an augmentative communication device the speech pathologist helps the patient find that device make it functional and then use it with other people now let me move on to dysphasia dysphasia is the other role the speech pathologist plays dysphasia is difficulty chewing or sucking or swallowing it might be something very minor like food pocketing in the cheek or food falling out the corner of your mouth still eat you're just messy it can be as simple as being able to eat and drink but you joke when you take your pills your capsules your medications you just dread taking your medicine sometimes even you forget doing it because it's such a hassle but dysphasia can be much more serious it can run the gamut all the way to the person who can't swallow their own saliva whose MPO can take nothing orally has to be sustained nutrition and hydration through some other means it's a natural role for the speech pathologist to work on dysphasia because we're talking about the same set of musculature lips tongue larynx soft palate the same anatomical structures are used for swallow as are used for speech production so the speech pathologist plays a central role in the dysphasia management program here one of the things that we focus on our oral phase dysphasia oral phase disorders let me be specific oral phase of the swallow is voluntary if the patient controls it it's the ability to close your lips chew move the food around in your mouth enjoy the flavor enjoy the taste you can chew as long as you want or you can swallow as rapidly as you want it's purely voluntary it's the preparation for the swallow it's mixing it with saliva it's masticating it and then it's moving it to the back of the mouth to initiate a swallow reflex now the second phase of the swallow is not voluntary it's reflexive when the food hits the back of the mouth it triggers a swallow reflex and very quickly in almost a single motion the food is moved down the pharyngeal wall the soft palate that's the back of the roof of your mouth raises up and closes off the passage to your nose and it must do that or you'll have food and liquid going up in your nose now all of us have had a time when we've taken something carbonated and it fizzes up in your nose and it doesn't feel good it's because your soft palate didn't race fast enough to close off the passage to your nose for many of our patients the neurologically impaired patient the muscles of the soft palate are either weakened or slow and velar pharyngeal closure that's closing off the soft palate doesn't occur and the patient gets food and liquid going up into the nasal passage it's unpleasant and they don't want to eat also in the forensics phase of the swallow is the movement of the epiglottis now the epiglottis is a small almost finger like or tongue like projection that sits on the anterior wall of the pharynx right above the level of the larynx now you remember your larynx is your Adam's apples right here the epiglottis is right at the top of it on the anterior wall now the purpose of the epiglottis is when the food comes by the epiglottis ever so rapidly flips down and covers over the opening to the trachea and that's what helps reduce the risk of aspiration it actually directs the food into the esophagus now just for a moment think we have a single tube called the pharynx coming down from the mouth until you get to the voice box voice box Adam's apple larynx all words for the same thing then right there at the larynx is the bifurcation or the separation of the trachea and the esophagus the trachea is the airway the esophagus is the food - the only thing that can go in the airway is air and when people aspirate it means that right at the bifurcation of the trachea and the esophagus some of the food or liquid is going in the trachea that can't continue the speech pathologist job is to come up with kinds of strategies and compensations in cooperation with the dietician we change the bolus of food the liquid to make it accommodate whatever neurological impairment is demonstrated additionally we teach the patient compensations strategies postural adjustments holding their breath turning their head doing something different at the time of the swallow to help protect the airway the third phase of the swallow is the esophageal phase there are only three phases oral pharyngeal esophageal the esophageal phase is that phase of the swallow where the food is transported from the larynx below the larynx to the stomach usually we can't see that clinically as we're sitting beside and feeding a patient we can only see that through video fluoroscopy or x-ray technique but a symptom of esophageal dysfunction esophageal stage or third stage dysphasia is when the patient reflexes lots of patients have weak peristaltic motion not just going down but keeping the food down so if they lie down to rest if they bend over the food backs up causes all kinds of problems they're at risk for strictures they're at risk for peptic ulcers a condition called esophagitis stomach acid is not meant to be in your throat so we don't want reflux disorders often the speech pathologist works with a dietitian as well working on foods that are less reflux stimulating it's also a medical issue that the doctor handles pharmacologically you can see that the speech pathologist and the diet and work in tandem yes that I feel as though in dysphasia management I can't do my job effectively without the dietician it's a synergistic relationship in a team approach