1. Communication after brain injury
Techniques for Assessment and Treatment in an Inpatient Setting
Carla J. Maiolini, MA/CCC-SLP, CBIS

2. 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

3. 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. –
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. -
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. –

4. The “Words” of Brain Injury

5. 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
Perseverative Verbal/Motor Behaviors
Memory
Sensorimotor
Thought organization
Emotional Lability
Planning
Sequencing
(Lash, 2009)

6. 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

7. 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”?

8. Case Study #1- Assessment
Formal assessments utilized:
Bedside Western Aphasia Battery
Boston Naming Test
Portions of Montreal Cognitive Assessment

9. Case Study #1 - Treatment
Semantic Feature Analysis/Description
(Boyle and Coelho, 1995)

10. Case Study #1 - Treatment
Typicality Training
Generate semantic features
Train atypical items first
Sorting of like items
(Kiran, et al 2011)

11. 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

12. Case Study #1 - Outcomes
Improved communication at simple conversation level
Decreased paraphasias
Reduced frequency and length of hesitations
Reduced patient frustration and improved participation

13. 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.

14. Case Study #2 - Assessment
JFK Coma Recover Scale – Revised
(Giacino, et al 2004)

15. 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

16. 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?

17. 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 (

18. 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)

19. 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

20. 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

21. Case Study #2 - Treatment
Family Involvement
Communication Partner Training*
Participation in treatment sessions
Carryover of techniques
ROM exercises
*(Simmons-Mackie, et al 2010)

22. 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

23. 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.

24. 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)

25. Case Study #3 - Assessment
Wessex Head Injury Matrix (WHIM)
Initially: High Score of 26, Total 11 behaviors
(Shiel, et al 2000)

26. 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

27. 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

28. Case Study #3 - Treatment
Sensory stimulation techniques
Thermal/tactile/gustatory
Various liquids/flavors
Vibration
Massage
Fan
Cool compress
Preferred music
Familiar voices

29. 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 Scale

30. 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 (

31. 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 (

32. 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

33. 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

34. 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

35. Case Study #3 - Treatment
Other contributing factors
Family involvement/Caregiver needs
Psych issues – medication management
Behavioral challenges
Staff support and carry-over

36. 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

37. Case Study #3 - Outcomes Cognition Discharge WHIM Poor orientation
Severe impaired short term recall
Intact sustained attention
Intact mental manipulation
Discharge WHIM
Highest behavior 52; Total 27 behaviors

38. Closing Remarks
Questions?
Hands-on Practice

39. References
Aphasia FAQs. (n.d.). Retrieved March 07, 2017, from
Boyle, M., & Coelho, C. A. (1995). Application of Semantic Feature Analysis as a Treatment for Aphasic Dysnomia. American Journal of Speech-Language Pathology,4, doi: /
Brochard, L., & Thille, A. W. (2009). What is the proper approach to liberating the weak from mechanical ventilation? Critical Care Medicine,37. doi: /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, doi: / (2010/ )
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), doi: /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), doi: /j
Rancho Los Amigos - Revised. (n.d.). Retrieved February 20, 2017, from
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),  
The Internet Stroke Center. (n.d.). Retrieved March 07, 2017, from
Traumatic Brain Injury and Concussion. (2016, September 20). Retrieved March 07, 2017, from
What is a Passy-Muir® Valve? (2016). Retrieved March 1, 2017, from
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