Techniques for Assessment and Treatment in an Inpatient Setting Carla J Maiolini MACCCSLP CBIS Learning Objectives Explore strategies and techniques related to the assessment of patients communication skills and distinguish the common deficits related to communication following B ID: 595242
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Slide1
Communication after brain injury
Techniques for Assessment and Treatment in an Inpatient
Setting
Carla J.
Maiolini
, MA/CCC-SLP, CBISSlide2
Learning Objectives
Explore
strategies and techniques related to the assessment of patients’ communication skills and distinguish the common deficits related to communication following Brain Injury
Identify
various modalities utilized for targeting expressive and receptive language and motor speech skills
Implement
techniques and rehabilitation approaches to address communication deficitsSlide3
The “numbers” of Brain Injury
According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled
. –
www.strokecenter.org
In 2010, about 2.5 million emergency department (ED) visits, hospitalizations, or deaths were associated with
TBI - either
alone
or in combination
with other
injuries - in
the United States.
-
www.cdc.gov
Aphasia
affects about two million Americans and is more common than Parkinson’s Disease, cerebral palsy or muscular dystrophy. Nearly 180,000 Americans acquire the disorder each year. However, most people have never heard of it
. –
www.aphasia.orgSlide4
The “Words” of Brain InjurySlide5
Communication and Cognitive Impairments After Brain Injury
Verbal Expression
Auditory Comprehension
Writing/Reading
Word Finding
Speech
s
ound production
Attention
Perception
Memory
Thought organization
Planning
Sequencing
(Lash, 2009)
Reasoning
Insight
Judgement
Problem Solving/Calculations
Orientation
Awareness
Perseverative Verbal/Motor Behaviors
Sensorimotor
Emotional LabilitySlide6
Case Study #1
The patient
is a 48 y/o female with
PMHx
significant
for gastritis
, hyperlipidemia, HTN, DM, and AKI who was admitted to
the hospital
with
Right-sided
weakness. CT head showed: Chronic distal L MCA superior frontal cortical/ subcortical ischemic infarct and a chronic lacunar infarct in the left caudate nucleus/ internal capsule
genu
Patient
had depression and bereavement issues due to recent passing away of her
husband
She was admitted to the facility for Acute RehabSlide7
Case Study #1- Assessment
Informal
assessments on initial evaluation revealed
:
Mild
Expressive
Aphasia
– hesitations,
impaired word
finding,
and semantic
paraphasias
Oral Apraxia with groping during oral mechanism exam
only
What is the difference between “speech” and “language”?Slide8
Case Study #1- Assessment
Formal assessments utilized:
Bedside Western Aphasia Battery
Boston Naming Test
Portions of Montreal Cognitive AssessmentSlide9
Case Study #1 - Treatment
Semantic Feature Analysis/Description
(Boyle and Coelho, 1995)Slide10
Case Study #1 - Treatment
Typicality Training
Generate semantic features
Train atypical items first
Sorting of like items
(Kiran, et al 2011)Slide11
Case Study # 1 – Additional Considerations
Depression
Cognition and
decision-making
– patient with frequent falls during hospital stay, refusing or hiding medications, resistant to techniques to increase safety
What other services can we provide to maximize recovery and increase participation?
Neuropsychology and Counseling
Recreation Therapy
Therapy sessions outsideSlide12
Case Study #1 - Outcomes
Improved communication at simple conversation level
Decreased
paraphasias
Reduced frequency and length of hesitations
Reduced patient frustration and improved participationSlide13
Case Study #2
The patient is an
81 year-old
male
who
admitted to the hospital after a
fall and was found to have a
right
subdural
hematoma. He was treated conservatively
because of prior
aspirin use and was
discharged home two days later.
Four days
after that
,
a follow-up
outpatient
head CT showed worsening
r
ight
subdural hematoma with midline shift.
He was
admitted
to the hospital and had a
right
craniotomy for subdural hematoma
evacuation.
Post-op
the hematoma increased with a midline shift, so
he was
taken back to
the OR
. The patient had trach and
PEG placement.
Admitted to the facility for
medical and respiratory management
in conjunction with the
Recover Coma Emergence
Program
.Slide14
Case Study #2 - Assessment
JFK Coma Recover Scale – Revised
(
Giacino
, et al 2004)Slide15
Case Study #2 - Assessment
Administration of the JFK CRS-R yielded the following:
Auditory Function Scale:
Localization to S
ound 2
Visual
Function Scale: Fixation 2
Motor Function Scale: Flexion Withdrawal 2
Oromotor
/Verbal Function Scale:
Oral
Movements 2
Communication
Scale: None 0
Arousal
Scale:
Eye
Opening
with
Stimulation 1
Total:
9/23
Informal assessments also revealed:
impaired
expressive/receptive language, aphonic secondary to trach, impaired auditory processingSlide16
Case Study #2 - Treatment
Passy Muir Speaking
Valve
Indications/Stop Criteria
O2 Saturations 93% or higher
Stable Heart Rate
Respiratory Rate WNL
No visible distress or change in work of breathing
C
ognitive-linguistic skills somewhat intact
So… Why use with this patient?Slide17
Case Study #2 - Treatment
Passy Muir Speaking Valve
Benefits
Voice/speech production
Secretion management
Weaning/
decannulation
/improved respiratory mechanics
Restored upper airway facilitates olfactory response
Quality of life
Increased
subglottic pressure
assists
in trunk support for
mobilization
(www.passy-muir.com)Slide18
Case Study #2 - TREATMENT
Early Mobilization
Increased wakefulness
Reduced risk of aspiration
pneumonia
Increased timeliness of vent/trach
weaning*
Reduced
length of hospital stays**
*(
Brochard
and
Thillle
, 2009)
**(Morris, et al 2008)Slide19
Case Study #2 - Treatment
What did therapy sessions look like?
Interdisciplinary team treatment sessions
PMSV in place on hub of trach
Patient positioned upright at edge of bed to optimize wakefulness
Multi-modal Sensory StimulationSlide20
Case Study #2 - Treatment
Multi-modal Sensory
S
timulation
Thermal/tactile/deep pressure
Intraoral
stimulation
Cold/Sour
swabs
Auditory with preferred music
Presentation of
familiar
items
Simple commands, y/n- and
wh
-questions to encourage interaction with therapistsSlide21
Case Study #2 - Treatment
Family Involvement
Communication Partner
Training*
Participation in treatment sessions
Carryover of techniques
ROM
exercises
*(Simmons-Mackie, et al 2010)Slide22
Case Study #2 - Outcomes
Final JFK CRS-R 23/23
Consistently follows simple
commands both with and without objects.
Verbalizes
basic wants and needs
R
esponds
to simple
“
Wh
-” and “Yes/No-”questions
.
I
ntermittent confusion and poor recall
Continues with trach for medical reasons – tolerates PMSV
Tolerates ice chips without overt signs or symptoms of aspirationSlide23
Case Study #3
The patient is
a 33 y/o male who presented to the ED following
head
on
collision/MVA
with cardiac arrest at the scene, underwent 2 minutes CPR prior to return of spontaneous circulation. Intubated in the field.
Required mechanical ventilation. He
was found to have
a TBI, later defined as Diffuse
A
xonal Injury,
and multiple orthopedic
complications. He
stayed in the surgical ICU almost one
month. Underwent
trach and
PEG. Patient
also demonstrated frequent restlessness and agitation and was eventually diagnosed with Paroxysmal Sympathetic Hyperactivity. Slide24
Case Study #3 - Assessment
Initially admitted to the Recover Coma Emergence
Program – Administration of the JFK CRS-R yielded the following:
Auditory Function Scale: Auditory Startle(brief
delay <1 second)
1
Visual Function Scale: Visual Startle 1
Motor Function Scale:
Automatic
Movements 5
Oromotor
/Verbal Function Scale:
Oral
movement
2
Communication Scale:
None
0
Arousal
Scale:
Eyes
Open
without
Stimulation
2
Total: 11/23
(
Giacino
, et al 2004)Slide25
Case Study #3 - Assessment
Wessex
Head Injury Matrix (
WHIM)
Initially: High Score of 26, Total 11 behaviors
(
Shiel
, et al 2000)Slide26
Case Study #3 - Treatment
Initially with trach, Passy Muir Speaking Valve utilized and tolerated without difficulty – allowed patient to vocalize
Capped and
decannulated
in less than 3 weeksSlide27
Case Study #3 - Treatment
Continued neuro storming and agitation
Thrashing in bed, restless, concern for vertigo
Bed bound due to confusion
Sensory reintegration/desensitization approach to treatment
Deep
pressure/weighted blanket
Enclosed bed
Tactile stimulation with various textures
Low lighting
Reduced auditory stimuli
White noise and relaxation
music
Visiting ScheduleSlide28
Case Study #3 - Treatment
Sensory stimulation techniques
Thermal/tactile/gustatory
Various liquids/flavors
Vibration
Massage
Fan
Cool compress
Preferred music
Familiar voicesSlide29
Case Study #3 – Treatment/ongoing assessment
Highest JFK CRS-R score achieved was 14/23 over course of 3.5 months
Eventually discharged from Recover
Coma Emergence Program
due to not meeting requirements of scoring
Visual and Auditory deficits impacted score
Continued with team approach to therapy
Use of Rancho Los Amigos ScaleSlide30
Case Study #3 – Treatment/Ongoing Assessment
Rancho Los Amigos Scale Level 4 – Confused/Agitated
Alert
and in heightened state of
activity
Purposeful
attempts to remove restraints or tubes or crawl out of
bed
May
perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another's
request
Very
brief and usually non-purposeful moments of sustained
alternative
and divided
attention
Absent
short-term
memory
(www.neuroskills.com)Slide31
Case Study #3 – Treatment/Ongoing Assessment
Rancho Los Amigos Scale level 4 – Confused/Agitated
May cry out or scream out of proportion to stimulus even after its removal
May exhibit aggressive or flight behavior
Mood may swing from euphoric to hostile with no apparent relationship to environmental events
Unable to cooperate with treatment efforts
Verbalizations are frequently incoherent and/or inappropriate to activity or
environment
Staff Education/Team support
(www.neuroskills.com)Slide32
Case Study #3 - Treatment
Impaired task recognition
Set-up of realistic situations
Seated at table for meals
Allowed to self-feed
Placed in front of sink for hygiene tasks
Return to “normal” tasks
Perspective-taking for patient – enclosed bed/confusion/fear
Out of bed scheduleSlide33
Case Study#3 – Treatment
Communication
Intermittent verbalizations with semantic/phonemic
paraphasias
Neologistic
speech
Repetitive verbalizations
No command following
Inconsistent response to
wh
- or y/n questionsSlide34
Case Study #3 - Treatment
Communication – Alternative means
Writing on paper with hand-over-hand
Drawing letters and numbers on hand/chest
Counting out alphabet/spelling
Foam/plastic letters/tracing
Tactile cueing for ADLs
Thumbs up/downSlide35
Case Study #3 - Treatment
Other contributing factors
Family involvement/Caregiver needs
Psych issues – medication management
Behavioral challenges
Staff support and carry-overSlide36
Case Study #3 – Outcomes
Vision – Profoundly Impaired – pending neuro-
opthamology
consult
Expression
Expressed basic wants/needs intermittently at sentence level
Asked questions about environment/situation
Intact linguistic awareness given spelling of words
Auditory Comprehension/Hearing
Continued poor auditory comprehension – pending
Aud
consult
Concern for Pure Word Deafness/Auditory Verbal Agnosia
Rare instances of auditory comprehensionSlide37
Case Study #3 - Outcomes
Cognition
Poor orientation
Severe impaired short term recall
Intact sustained attention
Intact mental manipulation
Discharge WHIM
Highest behavior 52; Total 27 behaviorsSlide38
Closing Remarks
Questions?
Hands-on PracticeSlide39
References
Aphasia FAQs. (
n.d.
). Retrieved March 07, 2017, from https://www.aphasia.org/aphasia-faqs/
Boyle
, M., & Coelho, C. A. (1995). Application of Semantic Feature Analysis as a Treatment for Aphasic
Dysnomia
.
American Journal of Speech-Language Pathology,4
, 94-98. doi:10.1044/1058-0360.0404.94
Brochard
, L., &
Thille
, A. W. (2009). What is the proper approach to liberating the weak from mechanical ventilation?
Critical Care Medicine,37
. doi:10.1097/ccm.0b013e3181b6e28b
Giacino
JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med
Rehabil
. 2004; 85:2020–9.
Goodglass
, H., Kaplan, E., & Weintraub, S. (1983).
BostonNaming
Test. Philadelphia, PA: Lea &
Febiger
.
Kertesz
, A. (1982). The Western Aphasia Battery.
Philadelphia,PA
:
Grune
and Stratton
Kiran
, S., Sandberg, C., & Sebastian, R. (2011). Treatment of Category Generation and Retrieval in Aphasia: Effect of Typicality of Category Items.
Journal of Speech, Language, and Hearing Research,
54
, 1101-1117. doi:10.1044/1092-4388(2010/10-0117
)
Lash, M. (2009). The essential brain injury guide. Vienna, VA: Academy of Certified Brain Injury Specialists, Brain Injury Association of America.
Morris, P. E., Goad, A., Thompson, C., Taylor, K., & Harry, B. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure.
Critical Care Medicine,
36
(8), 2238-2243.
doi:10.1097/ccm.0b013e318180b90e
Nasreddine
, Z. S., Phillips, N. A.,
Bã©Dirian
, V., Charbonneau, S., Whitehead, V., Collin, I.,
Chertkow
, H. (2005). The Montreal Cognitive Assessment,
MoCA
: A Brief Screening Tool For Mild Cognitive Impairment. Journal of the American Geriatrics Society, 53(4), 695-699. doi:10.1111/j.1532-5415.2005.53221
.
Rancho
Los Amigos - Revised. (
n.d.
). Retrieved February 20, 2017, from
http://
www.neuroskills.com/resources/rancho-los-amigos-revised.php
Shiel
A, Wilson B, McLellan DL. WHIM.
Wessex
Head Injury Matrix - Manual. London: Harcourt Assessment, 2000
Simmons-Mackie, N., Raymer, A., Armstrong, E., Holland, A., &
Cherney
, L., R. (2010).Communication partner training in aphasia: a systematic review.
Archives of Physical Medicine and
Rehabiliation
, 91
(12), 1814-1837.
The Internet Stroke Center. (
n.d.
). Retrieved March 07, 2017, from
http://www.strokecenter.org/patients/about-stroke/stroke-statistics
/
Traumatic Brain Injury and Concussion. (2016, September 20). Retrieved March 07, 2017, from https://www.cdc.gov/traumaticbraininjury/get_the_facts.html
What
is a Passy-Muir® Valve? (2016). Retrieved March 1, 2017, from
http://www.passy-muir.com/what_is
Winstein
, C. J., Stein, J., Arena, R., Bates, B.,
Cherney
, L. R., Cramer, S. C.,
Zorowitz
, R. D. (2016, June 01). Guidelines for Adult Stroke Rehabilitation and Recovery. Retrieved March 06, 2017, from
http://stroke.ahajournals.org/content/47/6/e98Slide40