University of Paisley Multidisciplinary Stroke Management

NHS Greater Glasgow and Clyde

Advancing Skills in Stroke Care

Communication Issues

Content • Speech and language disorders of stroke: • Dysphasia • Dysarthria • Dyspraxia • SLT assessment • SLT therapy • SLT discharge

• Patterns of recovery • Alternative aids • Strategies for Multidisciplinary team

Speech and Language Disorders of Stroke

• Dysphasia

• Dyspraxia

• Dysarthria

• Right hemisphere syndrome

Dysphasia • Dysphasia is a disorder of language that can occur as a result of stroke • It can range from mild to severe. • It can affect:  Speech  Understanding speech  Reading  Writing

Fluent Dysphasia • • • •

Normal speed and intonation Nonsense words/jargon Poor self-monitoring and awareness of errors Understanding often poor

“Cookie Theft” Picture

Example of fluent speech (Based on description of cookie theft picture.) “Well this is…….mother is away here working her work out o’here to get her better, but when she’s looking, the two boys looking in the other part.”

Non-fluent dysphasia • • • •

Slow and hesitant Articulation errors mostly uses nouns Understanding is usually intact

Example of non-fluent speech (Based on a description of the cookie theft picture) “Cookie jar…fall over….chair…water…empty”

Fluent/non-fluent dysphasia • In reality, it is not always that clear cut. People do not always fall neatly into one type of dysphasia. • People can change from one to the other in the early days after a stroke. • Sometimes people have some of the symptoms of one type and some of the other eg. good comprehension but jargon words.

Swearing •People often swear when they have dysphasia. •This is because there is a lack of control in the brain over what is said. •Don’t be offended! They can’t help it.

Singing and automatic speech •People with dysphasia can often sing songs or recite days of week or other learned utterances. •These are stored in the person’s memory in a different part of the brain than the language centre for making up sentences.

Dysarthria • Dysarthria is a motor speech disorder. • Dysarthria affects the movement of the individual speech muscles. • It can vary from mild slurring to completely unintelligible speech

Dysarthria Dysarthria can affect: • Lip movements • Tongue movements • Jaw movements • Soft palate movement • Muscles of respiration • Muscles of voice production

Dysarthria v’s Dysphasia • Dysarthria is not a language problem. This means there is no difficulty finding the words to say or word choice errors. • Dysarthria purely affects how the words are uttered. E.g. how clear the sounds are articulated • Some people have both dysarthria and dysphasia as a result of a stroke.

Speech Dyspraxia • Speech Dyspraxia is another speech impairment which can occur after stroke.

• It rarely occurs on its own and usually occurs alongside Dysphasia or Dysarthria

Symptoms of Speech Dyspraxia • The person with speech dyspraxia has difficulty moving the speech muscles in the correct way. • The muscles are not weak as in dysarthria but the problem is that the message sent from the brain to move the speech muscles is impaired.

Symptoms of Speech Dyspraxia • The person usually tries again and again to say the word and may silently practise too. • Someone with speech dyspraxia knows what they want to say but the muscles do not make the correct sounds . • It is a very frustrating condition.

Right hemisphere syndrome (RHS) • Damage to the right hemisphere as a result of stroke can result in difficulties with understanding and use of some more complex areas of language.

Symptoms of RHS • • • • • •

Poor eye contact Difficulty staying on topic Easily distracted Lack of emotion in speech Interpret words literally Difficulty understanding humour

Example of RHS speech

“My husband and I like going out for a drink on a Friday night to The Talbert Arms in Milngavie. I once went to Jersey for my holidays and it was beautiful weather.”

Role of the SLT • • • •

Assessment Diagnosis Therapy/Support/AAC Discharge planning

Assessment of Dysphasia Informal

Formal

•Conversation based •Reading •Writing •Understanding •Speaking •Everyday abilities

•Several published tests •Baseline measurement •Informs treatment plan

Treatment for Dysphasia and Dysarthria 2 approaches:

• Impairment based model • Social model

Impairment based therapy • Traditional model looks at assessment results and targets areas where mistakes were made. • Eg. someone making sound errors in speech, therapy would work on sound order and awareness

“Tac” for “Cat”

Social model of therapy • Newer approach • Learning to cope with living with a speech problem. • Using aids/strategies to help improve communication • Re-establishing independence.

Pattern of therapy • 3 months is the casebook time given for recovery from stroke. • With speech and language problems recovery can continue for up to 2 years. • Ideally, therapy should be 3-4 times a week in the early stages and gradually scaled down as appropriate.

Factors affecting recovery of speech and language after stroke • Practicality of attending 3-4 times a week • Degree of brain damage from stroke(s) • Time since onset of stroke • Deaf/visual impairment • Motivation/Cooperation • Age • General health/mobility

Communication Aids • • • • • • •

Alphabet chart Picture Chart Communication book PABA Lightwriter Go talk Dynamo

Communication Aids and dysphasia • People with dysphasia can make use of aids depending on their comprehension. • They have to be able to identify/understand what a word or symbol means eg. If they are thirsty they must point to a ‘drink’ symbol.

Picture communication board

To help with understanding…. • Talk SLOWLY • Give the person plenty of TIME to take in what you are saying

• Use SIMPLE but ADULT language • Swap longer words for short simple words eg use pill instead of medication

• Don’t shout • Use GESTURE, WRITING and DRAWING • Rephrase if not understood

• Ask questions to check that you have been correctly understood and confirm what has been established • Emphasise key words e.g. “Take one pill in the morning” • REPEAT information as required • Leave a WRITTEN RECORD of any plans or decisions • Always have a notepad and pen handy • RECAP to check that the person has understood • REMEMBER Aphasia affects communication NOT intelligence

To help with expression…. • Give the person plenty of time to get their message across • Encourage the person to use any method to communicate eg speech, writing, drawing, facial expression, gesture, pointing to pictures • Don’t interrupt or “fill in” too soon. If you do have to guess what the person means, check that you have understood correctly. • Provide written words for the person to choose from e.g. Are you having difficulty walking? YES / NO Do you want TEA / COFFEE / JUICE?

• The person may get their message across, but may make errors. If you’ve understood the message, don’t push for a correct production of the word. • Don’t pretend to understand the person if you haven’t understood their message. Work together to try and establish what the person is trying to say. You won’t always be able to work it out, but the person with aphasia will appreciate that you’ve tried.