COMMUNICATION AFTER BRAIN INJURY Techniques for Assessment and

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 Reasoning Verbal Expression Auditory Comprehension Insight Writing/Reading Judgement Word Finding Speech sound production Problem Solving/Calculations Attention Orientation Perception Awareness Memory Thought organization Perseverative Verbal/Motor Behaviors Planning Sensorimotor Sequencing Emotional Lability (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 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 O 2 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 with team approach to therapy Use 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 neuroopthamology 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. 0 b 013 e 3181 b 6 e 28 b 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). Boston. Naming 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. 0 b 013 e 318180 b 90 e Nasreddine, Z. S. , Phillips, N. A. , Bã©Dirian, V. , Charbonneau, S. , Whitehead, V. , Collin, I. , Chertkow, H. (2005). The Montreal Cognitive Assessment, Mo. CA: 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, Mc. Lellan 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/e 98