Transcript Communication after brain injury - Brain Injury Association Of

COMMUNICATION AFTER
BRAIN INJURY
Techniques for Assessment and Treatment
in an Inpatient Setting
Carla J. Maiolini, MA/CCC-SLP, CBIS
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 deficits
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.org
THE “WORDS” OF BRAIN INJURY
COMMUNICATION AND COGNITIVE
IMPAIRMENTS AFTER BRAIN INJURY

Verbal Expression

Reasoning

Auditory Comprehension

Insight

Writing/Reading

Judgement

Word Finding

Problem Solving/Calculations

Speech sound production

Orientation

Attention

Awareness

Perception


Memory
Perseverative Verbal/Motor
Behaviors

Thought organization

Sensorimotor

Planning

Emotional Lability

Sequencing
(Lash, 2009)
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 Rehab
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”?
CASE STUDY #1- ASSESSMENT
 Formal
assessments utilized:

Bedside Western Aphasia Battery

Boston Naming Test

Portions of Montreal Cognitive Assessment
CASE STUDY #1 - TREATMENT
 Semantic
Feature Analysis/Description
(Boyle and Coelho, 1995)
CASE STUDY #1 - TREATMENT
 Typicality Training

Generate semantic features

Train atypical items first

Sorting of like items
(Kiran, et al 2011)
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 outside
CASE STUDY #1 - OUTCOMES
 Improved
communication at simple conversation level
 Decreased
paraphasias
 Reduced
frequency and length of hesitations
 Reduced
patient frustration and improved participation
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 right 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.
CASE STUDY #2 - ASSESSMENT
 JFK
Coma Recover Scale – Revised
(Giacino, et al 2004)
CASE STUDY #2 - ASSESSMENT


Administration of the JFK CRS-R yielded the following:

Auditory Function Scale: Localization to Sound 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 processing
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

Cognitive-linguistic skills somewhat intact
So… Why use with this patient?
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)
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)
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 Stimulation
CASE STUDY #2 - TREATMENT
 Multi-modal
Sensory Stimulation

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 therapists
CASE STUDY #2 - TREATMENT
 Family
Involvement

Communication Partner Training*

Participation in treatment sessions

Carryover of techniques

ROM exercises
*(Simmons-Mackie, et al 2010)
CASE STUDY #2 - OUTCOMES

Final JFK CRS-R 23/23

Consistently follows simple commands both with and without objects.

Verbalizes basic wants and needs

Responds to simple “Wh-” and “Yes/No-”questions.

Intermittent confusion and poor recall

Continues with trach for medical reasons – tolerates PMSV

Tolerates ice chips without overt signs or symptoms of aspiration
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
Axonal 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.
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)
CASE STUDY #3 - ASSESSMENT
 Wessex
Head Injury Matrix (WHIM)
 Initially: High
Score of 26, Total 11 behaviors
(Shiel, et al 2000)
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 weeks
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 Schedule
CASE STUDY #3 - TREATMENT

Sensory stimulation techniques








Thermal/tactile/gustatory
Various liquids/flavors
Vibration
Massage
Fan
Cool compress
Preferred music
Familiar voices
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
 Use
with team approach to therapy
of Rancho Los Amigos Scale
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)
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)
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 schedule
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 questions
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/down
CASE STUDY #3 - TREATMENT
 Other
contributing factors

Family involvement/Caregiver needs

Psych issues – medication management

Behavioral challenges

Staff support and carry-over
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 comprehension
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 behaviors
CLOSING REMARKS
 Questions?
 Hands-on
Practice
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:10.1044/10580360.0404.94
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
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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/
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What is a Passy-Muir® Valve? (2016). Retrieved March 1, 2017, from http://www.passy-muir.com/what_is
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