1. Speech and Language Therapy: Stroke Services
Sheena Borthwick
Speech and Language Therapist: Clinical Specialist in Stroke
MOE presentation 26th May 2011

2. Content of Presentation
What can the speech and language therapist contribute to stroke care?
Incidence and impact of communication and swallowing problems after stroke
What is included in assessment?
What are the treatment options?
Key messages for the overall management of communication and swallowing disorders post stroke.
MOE presentation 26th May 2011

3. MOE presentation 26th May 2011
What does SALT mean?
Speech and language therapist
The SALT lady!
Swallowing assessment
Swallow screening or the “mini salt”
MOE presentation 26th May 2011

4. Dysphagia in stroke: Incidence
Wide discrepancies in studies detailing the incidence of dysphagia post stroke due to:
patient selection methods
evaluation methods
Time post onset
Definition of dysphagia
Up to 75% have dysphagia immediately post stroke (Martino R., Foley N., Bhogsal S., Diamant N., Speechley M., Teasell R. (2005) Dysphagia after stroke: Incidence, diagnosis and pulmonary complications. Stroke 36 (12) )
MOE presentation 26th May 2011

5. MOE presentation 26th May 2011
Impact of dysphagia
Of those who initially present with dysphagia:
76% will have moderate to severe presentation
15% will have persisting dysphagia (Mann G., et al. (1999) Swallowing function after stroke: Prognosis and prognostic factors at 6 months. Stroke 30 (4) )
Length of stay longer
Twice as likely to go to nursing home ( Odderson I et al. (1995) Swallow management in patients on an acute stroke pathway: Quality is cost effective. Archives of Physical Medicine and Rehabilitation, 76 (12)
Higher risk of post stroke pneumonia ( Sellars et al. (2007) Rislk factors of chest infection in acute stroke. Stroke 2007
Psychosocial issues : QOL
MOE presentation 26th May 2011

6. MOE presentation 26th May 2011
SIGN 119 –Management of patients with stroke
The identification and management of dysphagia
June 2010
MOE presentation 26th May 2011

7. MOE presentation 26th May 2011
NHS QIS Clinical Standards for Stroke Services 2009: All patients are screened by a standardized assessment method to identify any difficulties in swallowing safely due to low conscious level and/or the presence of signs of dysphagia.
Identifies presence or absence of symptoms
Determines only short term plan
NBM or oral diet
Need for referral to SLT
Insufficient to probe pattern of problem or rehabilitation planning
MOE presentation 26th May 2011

8. MOE presentation 26th May 2011
Screening tests
Screening
What should a screening tool include?
Sensitivity and specificity
Graduated water swallow + cough /voice
Sensitivity 76%
Specificity 67% Perry L.(2001). Screening swallowing function of patients with acute stroke. Part two: detailed evaluation of the tool used by nurses. Journal of Clinical Nursing. 2001; 10(4), )
Silent aspiration
15-39% individuals following stroke (Leder S., Suiter D., Greene B. Silent aspiration risk is volume-dependent.. Dysphagia (published online 10th November 2010))
MOE presentation 26th May 2011

9. MOE presentation 26th May 2011
Training
Available on the intranet:
Healthcare>
A-Z>
Dietetics> screening for dysphagia
MOE presentation 26th May 2011

10. SLT swallowing assessment
Clinical Bedside assessment
Blend and balance information from
Cognitive assessment
Respiratory assessment
Posture /positioning
Oral mechanism
Inferring of physiology of pharyngeal swallow
Assessment of oral intake
Oral phase
Make a realistic interpretation of the pharyngeal phase
Consider adaptation to different compensations
MOE presentation 26th May 2011

11. Example of inferring physiology
X cranial nerve
Changed vocal quality
Volitional cough – coup
This would therefore suggest:
Reduced laryngeal closure
Intra-swallow aspiration
Decreased cough in response
Sensory – silent aspiration
Reduced upper sphincter opening
Consequently expect pharyngeal residue on thicker consistency and possible post swallow aspiration
MOE presentation 26th May 2011

12. SLT swallowing assessments: Instrumental
FEES: Fibreoptic endoscopic examination of swallowing
Videofluoroscopy
MOE presentation 26th May 2011

13. Physical and perceptual
Carer skill
/availability
Distraction
Food choices available
Swallowing
Physical and perceptual
Additional variables
Bolus control, preparation and propulsion
Airway closure
Pharyngeal clearance
Posture
Head and neck control
Vision /neglect
Insight / motivation
Following directions
Fatigue / conscious levels
dentition
Foundation of bulbar function
Respiratory function
Co-ordination of breathing with swallow
Cough and upper airway reflexes
MOE presentation 26th May 2011

14. MOE presentation 26th May 2011
Decision making
Swallowing mechanism
Metabolic consequences M
Ethics E
Achievable goals A
Law L
Team issues T
Inform /information I
Monitoring
End of life
Presented by Dr T. Hughes at UKSRG conference 2010
MOE presentation 26th May 2011

15. End of life and ethical considerations
Morag
Publication from the Royal College of Physicians produced in conjunction with the British Society of Gastroenterology and in response to continuing unease about the lack of consensus, including among doctors, about when artificial nutrition and hydration is appropriate.
The aim of the report is to improve care by providing healthcare professionals, patients, their families and carers with practical advice that has a sound legal and ethical basis, and to prevent distressing and complicated disagreements.
For example staff will comments that repeated tube removal, rather than being attributable to confusion, indicated the patients‟ choice to refuse
hydration and nutrition. Many stroke patients are incapacitated and unable to communicate their wishes, making verbal consent to NG insertion impossible; but is the action of voluntary tube removal the patient's way of expressing their right to refuse treatment?
End of life care
Nutrition and hydration
1 Staff understand that provision of oral fluid and nutrition is part of core care and is not to be withdrawn unless the patient refuses or is unable to participate. Nurses have a key role in nutritional and swallowing screening.
2 Staff understand that clinically assisted nutrition and hydration are considered medical treatments within law and therefore can be withheld or withdrawn if considered to be of no benefit for the patient. Where there is doubt or lack of consensus surrounding the benefit of supporting nutrition or hydration a time limited trial of clinically assisted nutrition or hydration is considered.
3 Staff understand that in patients with problems with oral feeding, decisions regarding supporting nutrition and hydration are often made in tandem with the recognition that the patient is entering end of life care. Nurses contribute to the decision-making within a multidisciplinary context.
4 Nutrition and hydration where appropriate are provided according to the individualised care plan. Nurses have a key role in the provision and monitoring of oral and clinically assisted nutrition and hydration.
MOE presentation 26th May 2011

16. Conservative approach to dysphagia management
Compensatory interventions
Eliminate food textures and fluid consistencies from menu
Utilise non-oral approaches
Wait and see (% patients improve in first week)
Compensatory feeding approaches
Bolus size
Speed
Placement
Positioning e.g. head postures
Specialist feeding utensils e.g. adapted cups
MOE presentation 26th May 2011

17. MOE presentation 26th May 2011

18. Evidence for therapeutic approach
Carnaby G., Hankey G., Pizzi J. (2006). Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet neurology. 2006; 5, 31-37
usual care – supervised feeding with precautions
Low intensity treatment – compensatory strategies and direct intervention
High intensity treatment – compensations and direct swallowing exercises
Outcome:
% patient s returning to normal diet by 6 months post stroke
Usual care 56%
Low intensity 64%
High intensity 70%
MOE presentation 26th May 2011

19. Facilitation exercises
Active therapeutic approaches which aim to have a direct and lasting effect on the swallowing physiology
Muscle strengthening
Tongue
Suprahyoid muscles
Direct swallowing
Supra-glottic swallowing
Effortful swallowing
Mendolsohn manoeuvre
MOE presentation 26th May 2011

20. Communication after stroke
Incidence – there are no official figures as estimates vary (RCSLT 2006)
Confusion with diagnostic labels
Lack of agreement in diagnostic labels
Lack of a verifiable diagnostic process
Poor recognition of the more subtle communication difficulties
Severity and impact are not directly related
O’ Halloran R., Worrall L., Hickson L The number of patients with communication related impairments in acute hospital stroke units. International Journal of Speech –Language Pathology, Vol.11, No. 6, pp
MOE presentation 26th May 2011

21. MOE presentation 26th May 2011
Diagnostic labels
Motor speech disorders
Dysarthria (UMN, LMN, extrapyramidal, cerebellar)
Language disorders
Aphasia
Cognitive disorders : orientation, memory, executive functions, attention
Cognitive –communication disorder
Impairments of pragmatics / discourse / social communication
Right hemisphere communication deficits
Motor planning disorders
Apraxia of speech
Visual perceptual disorders
Inattention
Visual field deficits affecting eye contact, scanning, reading, writing
MOE presentation 26th May 2011

22. MOE presentation 26th May 2011
Written words
Spoken words
Pictures /Objects
Auditory sound
analysis
Feature analysis
of written symbols
Visual
Recognition
system
Input lexicon
Word forms
Input lexicon
Written form
Acoustic to
phonological
conversion
( ability
to repeat)
Semantic System
(meanings)
Letter to
sound
conversion
(sound out
word)
Output
lexicon
Written
word
form lexicon
Sound to
letter
conversion
Phonological
assembly
Graphic assembly
Writing
Speech
MOE presentation 26th May 2011

23. Interpreting your observations
Reliability of yes/ no response
Biographical
Contextual
Abstract
Consistency of response
One step/ two step and three step commands
What conclusion can you make?
Test of auditory retention
Controlled for the complexity of the response required
Controlled for the linguistic complexity
Appears to be reading / saving face
MOE presentation 26th May 2011

24. MOE presentation 26th May 2011
Factors manipulated
Word frequency
Impact on word store level
Imageability
Impact on semantic processing
Word length
Impact on phonological processing
Word regularity e.g. mint regular/ pint irregular
May be reliant on sub-lexical routes
Grammatical complexity
Comparison across modalities e.g. Visual v’s auditory
Use of distractors to analyse error type
MOE presentation 26th May 2011

25. MOE presentation 26th May 2011
Point to the boot
MOE presentation 26th May 2011

26. MOE presentation 26th May 2011
Patient views
Aphasia In Scotland Project
findings highlighted the need to:
Reduce the impact of the communication disorder
Apply communication support
Improve information provision
Social and emotional support for both patients and carers
Improve integration and co-ordination of services
Improve both professional and public awareness
Increase research
NHS Quality Improvement Scotland (NHS QIS)(2007). Aphasia in Scotland: Summary of key Findings. Edinburgh: NHS QIS.
NHS Quality Improvement Scotland(NHS QIS) (2008). The Road to Recovery; Aphasia in Scotland. NHS QIS Response to the Aphasia in Scotland Research. Edinburgh: NHS QIS.
MOE presentation 26th May 2011

27. Information Provision
“There is information, advice and support from the MD team for patients in a variety of formats, taking account of each patients’ communication ability” NHS QIS Clinical Standards for stoke 2009
Overall patients and families are dissatisfied with the information provision.
Smith J., Forester A., House A., Knapp P., Wright JJ., Young J. (2008). Information provision for stroke patients and their caregivers. Cochrane Database of Systematic Reviews 2008; Issue 2. Art.No CD001919
Aphasia friendly formatting – caution is needed in the use of illustrations. However appropriate use can increase comprehension by approx. 11%.Worral L., Rose T., Howe T., Brennan A., Egan J., Oxenham D., McKenna K.(2005). Access to written information for people with aphasia. Aphasiology 2005;19(10/11),
MOE presentation 26th May 2011

28. Supporting communication
“All people interacting regularly with a person who has aphasia should be taught the most effective communication techniques for that person” Royal College of Physicians Intercollegiate Stroke Working Party. (2008). National Clinical Guidelines for Stroke 3rd Edition. London: Royal College of Physicians.
MOE presentation 26th May 2011

29. MOE presentation 26th May 2011
SLT Clinical outcomes
MOE presentation 26th May 2011

30. International classification of functioning for aphasia
ICF
Therapy
Impairment
Target specific processes
Maximise potential brain plasticity
Retraining functions in language areas
Activity
Compensatory strategies
Alternative methods of communication
Environmental modifications
Work with communication partners to maximise communication
Participation
Treatment to support short and longer term goals
Lifestyle and identity changes
Facilitate access to employment, services
Well being
Providing information to both patients and family
Support for adjustment
MOE presentation 26th May 2011

31. Outcome with dysphagia
Bio-medical model
Reducing number of chest infections
Number of patients retuning to normal oral diet
Provision of good nutrition and hydration
Patient centred goals
Balance of risks – what is the patients priority?
Pulmonary system
Nutritional system
Psychological wellbeing
Compliance – Dissatisfaction with foods offered highly related in lack of compliance (Colodny N 2005)
Predictors of aspiration pneumonia– dysphagia although poses some risk is often not sufficient unless other risk factors as well. (Langmore 1998)
MOE presentation 26th May 2011

32. MOE presentation 26th May 2011
Key messages
Communication is complex and there are many different disorders with even more varied presentations
Impact is not related to severity
Communication disorders have an impact on both the individual and their families.
Communication disorders affect their engagement with all aspects of life in the longer term
Your skills as an effective communicator can help to overcome these barriers
MOE presentation 26th May 2011

33. MOE presentation 26th May 2011
Key messages
Screening for dysphagia is important to reduce risk but insufficient to evaluate or manage any suspected dysphagia
Dysphagia, under nutrition and dehydration are a high frequency and high impact consequences of stroke
Dysphagia management requires a whole system, coordinated interdisciplinary approach.
Evidence to support SLT interventions for dysphagia post stroke
MOE presentation 26th May 2011

34. MOE presentation 26th May 2011
SLT Role in stroke care
Diagnostic service
Ensuring patient safety (reducing aspiration), whilst balancing factors such as quality of life
Identify and deliver therapy programme based on detailed assessment.
Rehabilitation of specific processes
Compensation
Supportive
Focus on achieving goals taking into account individual preferences and beliefs
Provide information and training to patients & others
Working with the team to optimise positive outcomes
MOE presentation 26th May 2011

35. Thank you for Listening.
Any Questions?
MOE presentation 26th May 2011