Evaluating the patient Scientific Method Identify the problem

Evaluating the patient

Scientific Method • • • Identify the problem Propose a solution: formulate a hypothesis Develop procedures to test eh hypothesis Collect data relevant to the hypothesis Analyze the data Modify the hypothesis, formulate a new one or reach a conclusion based upon the analysis

Scientific method as a clinical method • Gather information about the patients impairment; referral, hx. , examination • Evaluate the subjective reports (“symptoms”) and objective test results (“signs”) for which are actually relevant • Decide if a collection of symptoms and signs exists: syndrome

• Seek relationships among symptoms and signs so as to know the involvement of the body or the mental status • If the symptoms are a syndrome that has a known course and outcome, state a prognosis for eventual recovery • From the hs, examination and facts, formulate a decision on how the patient’s condition will affect daily life

Things to remember about clinical methods • Data collection and analysis is basically using the scientific method to solve a specific problem: finding a clinical solution • Learn from experiences: the process repeats itself! • The process is ongoing; constant changes occur, therefore routinely re-evaluate • Missing “data” leads to flaws in diagnosis

Referrals • • Personal information Pts. location at the time of the referral Short description of current status Referral source

Reviewing medical records • Patient ID • Personal history: occupation, marital status, children, residence, hobbies, employment and educational history • Medical Hx. : previous illnesses, injuries, medical conditions, current disabilities, complaints.

• Communication issues: previous CVAs, disorientation, confusion, distorted sph, loss of consciousness, seizures, chronic medical conditions – e. g. , diabetes, vascular disease, heart disease, pulmonary disease, hearing loss, visual problems

Neurologic Examination • Cranial nerves • Motor system: – Muscle tone and range of movement: • Hypertonia: increased resistance to passive movement---2 forms – Spacticity (increased stretch reflex causes muscles to be hard and tense)---motor cortex or corticspinal tract---UMN – Rigidity (relaxed limb evenly resists movement in any direction » Extrapyramidal system lesions---LMN

• Decreased resistance to passive movement: – Hypotonia (flaccidity)—”rag doll phenomena”

Muscle Strength 4 Active movement against resistance or gravity 3 Active movement against gravity but not resistance 2 Active movement only when gravity is eliminated 1 Flicker or trace of contraction 2 0 No contraction

Reflexes • Deep (tendon) – patellar • Superficial – Pathological (primititive) • Gag • Swallow • Corneal 0 Absent 1+ Diminished 2+ Normal 3+ Brisk (faster, greater amplitude) 4+ Clonus (rhythmic contraction and relaxation

Motor exam: common terms • Athetosis: slow, writing movements; involuntary & purposeless—basal ganglia/ex-pyr. Sys. • Dystonia: abnormal, involuntary contractions or postures • Myoclonus: short bursts; cause abrupt, brief movements; cerebellar • Fasciculations (muscle) & Fibrillations (muscle fiber) • Both are LMN indicators

Common terms • Gait: walk – Festinating gait: running, tiny shuffling walk—Parkinson’s – Steppage gait – Waddling – Dancing gait

Sensory system examination • Evaluation to somesthetic (bodily) senses: pain, numbness or abnormal sensations • Hyperesthesia: abnormal sensitivity to stimulation – Paresthesia: disturbance in peripheral nerves – Anesthesia: complete loss of sensation

Sensory system exam • Pain, pressure, touch – Deep sensation: muscles, tendons and joints • Body position and vibration – Superficial sensation: skin • Light touch, pinprick, and temperature

Sensory: Equilibrium • Dizziness: Vertigo – VIII nerve lesions (acoustic neuroma) – Vascular problems of brainstem or cerebellum – Meniere’s disease (increased pressure in the inner ear: Vestibular system) • Evaluated by stance, gait, and nystagmus

Consciousness and Mentation • Confusion: lowered overall level of consciousness • Lethargy: drowsy, may fall asleep at inappropriate times • Amnesia: complete loss of memory for a time. Note Post Traumatic Amnesia (PTA)

Seizures • Note frequency, duration, precipitating events, and changes in sensation or mentation (“aura”), NOTE: physical status AFTER the seizure • General causes: alcohol or drug withdrawal, CNS infections, hypoglycemia, and other diseases

Types of seizures • Gran Mal: “convulsion” – Massive discharge of neurons in brain causes contraction of all muscles in the body – Last about 1 -3 minutes – Petit mal = brief loss of consciousness < 1 min. – Bilateral brain dysfunction • Partial Seizures “Focal seizures” - localize discharge on neurons - Partial loss of consciousness - Fleeting duration - Clonic movements of individual muscle groups - Localized brain dysfunction

MMSE Scoring (Folstein, Folstein & Mc. Hugh, 1975) 25 -30 Normal Adult X < 25 = indication of compromised mental status (MMSE was on Judging Amy last week!)

Personal history: Mr. Shaw is a 55 -y/o accountant (college grad). Married, with two children; son 28, daughter neither living at home. Wife (Florence) is a secondary-school teacher. Nonsmoker x 10 yrs. Occasional social ETOH nonabuser. Both parents deceased (mid-80 s), apparently of natural causes. Employed at time of apparent neurologic incident. Medical history: Past medical history includes adult-onset diabetes mellitus diagnosed in 1991, hypertension diagnosed 1993, and a possible TIA in March of last year. The patient's wife reports that at the time of the apparent TIA they were watching television when the patient became confused, did not answer questions, and seemed not to understand. The patient's symptoms apparently cleared in an hour or two, and they did not seek medical advice or assistance. Medications on admission include tolbutamide 500 mg twice a day, chlorothiazide 500 mg twice a day, which apparently control the patient's hypertension and diabetes, and occasionally aspirin. Background: The patient was accompanied to this medical center by his wife, who provided this information. The patient apparently was in good health until this apparent neurologic event, which occurred at approximately 0815 hrs this day. The patient was getting dressed for work when he experienced a sudden onset of speech difficulties and leg weakness. The patient did not vomit, lose consciousness, or report double vision, nausea or vertigo. He arrived at the emergency room ( medical center at 0905 hrs. The neurologic examination began at approximately 0920 hrs. Habits: The patient is an ex smoker (0. 5 ppd x 10 years) and has not smoked for approximately the past 10 years. The patient apparently drinks three or four glasses of wine per week and other alcoholic drinks occasionally, but his wife reports that he has never been a heavy drinker. Physical examination: The patient looks his stated age and is in no apparent distress. He appears alert and is oriented x 3. Vital signs: Blood pressure 162/89, pulse 72, temperature 98. 6, respiration 18. HEENT exam: No signs trauma or deformation. Moist mucous membranes. Neck negative for lymphadenopathy or thyromegaly. No carotid bruit. Cardiovascular exam: Normal S 1, 52, without gallop or murmurs. Lungs: Clear to auscultation. Abdomen soft land nontender. No organomegaly or palpable masses. Lower extremities: No pedal edema. Neurologic examination: The patient is globally aphasic. Listening comprehension evaluation showed that he is able to follow very simple commands like "close your eyes" or "open your mouth. " He is unable to give yes-no answers to questions. He is a little bit confused as to right/left commands. He is unable to do complex commands. Reading evaluation showed the patient unable to to identify a letter. He had paraphasic errors in single-word identification (e. g. , "wrisp" for "wrist"). The patient was unable to follow commands on reading because of inability to comprehend. Expression evaluation showed that the patient unable to read a narrative. He was unable to repeat "no ifs, ands, or buts. " He was also unable to name objects like watch or pin. Cranial nerve examination: It was difficult to examine the patient's visual acuity because of his aphasia. Acuity appears within normal limits, but the patient exhibits a questionable right-sided field cut. Funduscopic examination showed no evidence of papilledema. His pupils are 3 mm to 4 mm bilaterally, round, equal, and reactive to light and accommodation. He had intact extraocular movements. His corneal relexes are present bilaterally. His jaw jerk was + 1. He had symmetrical nasolabial folds and wrinkles. His tongue is midline and so is his uvula. He has symmetrical gag reflex bilaterally. He has symmetrical strength in his shoulders bilaterally. Motor examination: The patient has no pronator drift and no involuntary movements. His muscle tone is normal bilaterally. His strength appears 5/5 on the left and 4/5 in the right upper extremity and 3/5 in the right lower extremity. Grasp reflex on right. He had external rotation in his right lower extremity. His coordination exam was unremarkable for dysmetria. Deep tendon reflexes are +2 on the left and +3 on the right, + 1 in both ankles. Plantar reflex on right. Sensory examination: Impossible to establish accurately because of patient’s aphasia. However, the patient withdraws both lower and upper extremities to pinprick stimuli. Gait: The patient walks slowly, but with symmetrical arm swings bilaterally. Mild dragging of right foot. Problem list: 1. Probable LH stroke 2. Aphasia 3. Hypertension 4. A~-onset diabetes mellitus

Behavioral and Cognitive Changes of Brain Damage • Presence of these changes are dependent upon: – Previous Personality and Intellect – Location and extent of injury – Psychosocial support system • Such complications can compound the evaluation process

Responsiveness • Hyperresponsive – nonresponsive • Increased impulsivity – Lacking of impulse • Cognitive style: – Reflective: proceed slowly, fewer errors – Impulsive style: respond quickly; more errors

Perseveration • Repetition of responses that are no longer appropriate • Frequency and persistence of the behavious depends on the severity of the BD • May be seen in: – – Unilateral injury to either hemiphere Generalized damage due to TBI Middle stages of dementia Usually occurs in the first few days/weeks following the injury

Cognitive Changes • Concreteness and abstraction difficulties • Concrete: “loss of abstract attitude” – Unable to understand literal meanings • Difficulty with metaphors and idioms • Difficulty with humor, sarcasm, proverbs • May contribute to BD pts. Egocentrism--can’t accept another point of view

• Concreteness leads to difficulties with problem-solving---only see the simplest solution!

Impaired Self-Monitoring • Pt’s have difficulty recognizing their own performance in structured or unstructured circumstances – May fail to recognize errors in treatment, inappropriate behavior in social situations • Usually in pts with diffuse BD than those with focal lesions – More often infrontal or temporal lobe lesions

Impaired Error Anticipation • Some pts. Recognize their errors but cant’ anticipate or prevent them – Posterior lesions: usually find it funny – Anterior lesions: usually dismayed by the error

Impaired Focus and Concentration • Slow to focus implies pt performance improves with time • Difficulty holding concentration implies performance will deteriorate over time • Note pattern for when an activity changes

Impaired Sequencing • Difficulty perceiving, retaining, reporting and reproducing sequential information – Temporal sequencing? ? ? – Pointing, in order to a series of objects or pictures • Often found in frontal lobe damage in the language dominant hemisphere

Disturbances of Personality and Emotion • Emotional Lability: BD maylead to exaggerated swings in emotional expression – The emotion is correct but the magnitude of the reaction is disproportionate to the stimulus • May be expressed as uncontrolled crying • Pseudobulbar affect: failure to suppress a primitive reflex • May be expressed as excessive laughter---especially if pt feels stressed or threatened

Irritability and Low Frustration Tolerances • Pt may be prone to emotional outburst, probably due to low frustration tolerance • Different from emotional lability

Intolerance vs. Lability • Frustration has visible early signs • Progressive state of agitation • Reaction can be diverted if one recognized the signs • Lability happens rapidly • Dissipates rapidly • A reaction to one event

SLP: Interviewing the patient • • Find a quiet spot with few distractions Include a family member, if possible Tell the patient who you are!!! Make the patient physically comfortable Get the patient’s side of the story Be patient; listen carefully Talk at the level of the patient; avoid jargon

More on interviewing • Do your homework ahead of time! • Treat the patient as an adult; treat with respect • Prepare the patient for what is going to happen

Ok, it’s time for testing…. . • Explain the purpose of the testing • Describe the type of tests to be administered • Explain how the information will be analyzed and how it will be protected • Explain the test procedures • ASK the patient how he/she feels about taking ANY test

Testing Brain Injured Patients: • Increased levels of: – Patience – Empathy – Understanding • Expertise (experience) with test administration and interpretation • Observation rules for clinicians

General guidelines for testing • Do your homework • Choose an appropriate location for testing • Schedule testing at a time to maximize the patient’s performance • Make the testing process collaborative • Select appropriate tests

Test Selection • A sample of a large # of performances at different levels of difficulty • Test should locate a performance that is error-free, an area of complete breakdown and several intervening levels • Standardized test: so that results are reliable from test to test

Test Selection, cont. • Test should consistently input modalities, cognitive processes used, and output modalities needed to complete the test instructions • Test responses should be recorded in terms of quality and correctness • Test items should be sufficient to permit reliable estimates of performance

Test Selection, cont. • Test should suggest reasons for patient performance • Test should permit predictions about recovery

Guidelines, cont. • Use patient’s performance as a guide for what and how you test. • Use standardized tests and test procedures if you want to generalize the patient’s behavior to others or to other test administrations – Evaluate the normative sample of the test – Evaluate the normative statistics of the test

Considerations for Standardized Testing • Reliability: can it be • Validity repeated with the same – Content validity: how well does the content result? – Inter-rater reliability – Intra-rater reliability of a test related to known theory, models or concepts; – Construct validity: are the content and test procedures relevant to theory, etc.

Guidelines, cont. • Get a large enough sample of patient’s overall communicative behavior to allow for test-retest comparisons – Read the manual; consider the norm group and sample size • Generally: bigger sample size is better—why?

Reasons for SLP testing • To diagnose a communication disorder • To determine a prognosis for the CD • To make decisions on management and focus of the CD • To measure either the recovery process or the efficacy of the treatment process

Differential Diagnosis • To “differentiate” among other communicative disorders • To label or not to label……….

Establishing a prognosis • “Prognosis” is a prediction about the course of the recovery and about the extent of the recovery-----must consider: – Neurologic findings: stroke recovery patterns – Associated conditions: general vs. Impaired health, sensory and motor involvement – Patient variables: age, gender, education, occupation, premorbid intellingence, handedness, personality and emotional state

Prognosis, cont. • Nature and severity of the communication impairment(s) – For example, Broca type aphasics are better predictors of recovery than Wernicke’s---why? • Consider the predictive validity of some standardized tests. – Minnesota Test for Differential Diagnosis of Aphasia (MDTTA) uses a “patient profile approach”

Predictive validity, cont. • Porch Index of Communicative Ability (PICA) uses a statistical prediction method – Uses statistical analyses to determine the “relative” contributions of some variables – HOAP slope: High-overall prediction)---uses the 9 highest scores of the 18 subtests as a predictor of recovery • Prognostic treatment as a precursor to stating a prognosis

Treatment Efficacy • Single subject design is an excellent means of establishing baseline performance levels -for measuring patients’ response to treatment – For cues to the clinician to change tx. Procedures – For evaluating generalization of behaviors – For contributing to our knowledge base on neurogenic communication disorders

Efficacy and Functional Outcome • Efficacy: whether treatment has a positive effect – As measured on a standardized test • Outcome: whether tx. provided meaningful benefit • Functional outcome: tx improves patient’s daily life competences or personal wellbeing

Therefore, • In SLP, functional communication is an “approach to assessment and treatment that focuses on the patients’ daily life communicative success or lack thereof. ” (Brookshire) – Communication is not dependent on precise messages (linguistic) but upon the exchange of ideas despite errors in phonlogy, syntax, word choice, etc. -----function of language, not form

• Promoting Aphasics’ Communicative Effectiveness (PACE) – Davis and Wilcox, 1985) – Focuses on daily-life communications and on socially relevant aspects of communication • In health care, “functional communication” means: able to communicate basic needs and wants---what does that mean to you?

Situations rated by the Communicative Effectiveness Index (CETI) Situation Item 1. Getting someone’s attention 2. Getting involved in group conversations about him/her 3. Giving “yes” and “ no” answers appropriately 4. Communicating his/her emotions 5. Indicating he/she understands what is being said to him/her 6. Having coffee, time visits and conversations with friends and neighbors 7. Having a one-to-one conversation 8. Saying the name of someone whose face is in front of him/her 9. Communicating physical needs such as aches and pains 10. Having a spontaneous conversation 11. Responding to or communicating anything (including “yes” or “no”) without words 12. Starting a conversation with people who are not close family 13. Understanding writing 14. Being a part of a conversation when it is fast and there a number of people involved 15. Participating in a conversation with strangers 16. Describing or discussing something at length