2. THE NEUROLOGICALLY ACQUIRED SPEECH LANGUAGE AND SWALLOWING DISORDERS ASSOCIATED WITH CVA AND TRAUMATIC BRAIN INJURY BY: JOANNE IMRIE SPEECH LANGUAGE PATHOLOGIST

3. INTRODUCTION TO SLP Speech Language Pathologists (SLP’s) assess and manage any disorders that affect a persons ability to communicate (listening, speaking, reading, writing) Due to in depth knowledge of head and neck anatomy and physiology, swallowing disorders are also an area of expertise for SLP’S

4. INTRODUCTION TO COMMUNICATION Language Cognitive aspect of communication i.e. words and sentences (spoken or written). Language requires the adequate comprehension and expression of vocabulary (mental dictionary), grammar (sentence structure, tenses) and social skills Speech Physical aspect of communication. i.e. co- ordination between the physical processes of respiration, phonation, articulation and resonance. Speech requires adequate oral peripheral muscle function and tone. Oral- Motor planning. Swallowing requires similar muscle groups as speech. Swallowing requires the co-ordination and adequate functioning of oral and pharyngeal structures.

5. The disorders that affect one’s ability to communicate or to swallow encompass a wide range of disorders. An SLP would assess and manage people with the following conditions:

6. WHO DO SLP’S ASSESS AND TREAT?  Neonates at risk for devt.al delay (i.e.prem, low APGAR, Jaundice, hypoxia, asphyxia) or with devt.al delay (premature, talked late, walked late, “babyish” speech)  Infants with cleft lip or palate  Infants, toddlers and children who have feeding/sucking difficulties  Children with speech/articulation/ pronunciation/language problems, or who stutter

7. CONTINUED.. Children with reading, writing and spelling difficulties Children with diagnosed learning disabilities (auditory processing, ADHD, Specific Language Impairment). These children generally present with reading writing and spelling difficulties co-occurring with their diagnosis. (A SLP assessment and report/opinion is a vital part of the process in diagnosing learning disability ADHD etc). SLP’s and audiologists are the only professionals trained to assess and manage Auditory processing disorders, phonics difficulties, Language comprehension and expression difficulties. Children and adults with vocal nodules/ or hoarse voice caused by overuse and misuse of the voice. Before surgery

8. CONTINUED.. Individuals with degenerative disorders that cause weak breathing muscles or weak muscles used for speech, voice and feeding e.g. Multiple sclerosis, Parkinson’s, Huntington’s, Muscular dystrophy, Cerebral palsy Individuals with Dementia or Alzheimer’s with resulting speech, language, feeding or interaction difficulties. Individuals who have suffered stroke or head injury resulting in speech language or feeding problems

9. THE NEUROLOGICAL DAMAGE CAUSED BY TRAUMATIC BRAIN INJURY (TBI) OR CVA (STROKE) COULD CAUSE IMPAIRMENT IN ANY OF THE COMMUNICATIVE FUNCTIONS. SPEECH, LANGUAGE OR SWALLOWING

10. NATURE OF COMMUNICATIVE IMPAIRMENTS Aphasia Language skills impaired - Aphasia. Patient may lose all language, may substitute words with similar meaning, have word-finding or comprehension difficulties. Dysarthria Speech impaired/ slurred - Dysarthria. Speech is quiet, slurred, voice may be impaired, nasal resonance. Apraxia Speech impaired in terms of oral motor planning - Apraxia. Groping for correct mouth/tongue/lip placement. Difficulty moving mouth voluntarily/on command. Dysphagia When feeding or swallowing is impaired -Dysphagia.

11. THE PREVIOUSLY MENTIONED IMPAIRMENTS COULD OCCUR CONCURRENTLY IN ANY COMBINATION, OR THEY COULD OCCUR IN ISOLATION. AN SLP IS THE ONLY HEALTH PROFESSIONAL TRAINED TO ASSESS AND TREAT THESE DISORDERS.

12. APHASIA There are different types and severities of Aphasia. Basic Breakdown. Global Aphasia- Reception and expression impaired. Receptive Aphasia- comprehension impaired, but expression fairly intact Expressive Aphasia - expression impaired but reception fairly intact In the hospital it would benefit the Aphasic patient if nurses and doctor would stimulate them verbally as much as possible, to reinforce the Language Therapy.

13. DYSARTHRIA Encompasses impairment in any/all aspects of Speech: Respiration (inhalation and exhalation, respiratory reservoire, respiratory capacity for speech) Phonation (production of voice, approximation of vocal folds) Articulation (co-ordination, range of movement, strength and tone of articulators, clarity of speech, intelligibility) Resonance (placement of the voice in the vocal tract, hypernasality, hyponasality, placement of the tongue affecting resonance) Prosody (rate and rhythm of speech, stressing of syllables) In the hospital it would benefit the Dysarthric patient if they could be encouraged to do mouth movements like sucking, blowing, puffing out cheeks, smiling, kissing movements to strengthen the articulators.

14. APRAXIA A patient might be able to move his mouth correctly or lick his lips while eating, as this is automatic and unplanned. However, the oral motor planning difficulties seen in Apraxia would inhibit him from being able to lick his lips (or any other mouth movement) on command. Since the patient would have difficulty moving his mouth voluntarily, this would severely affect speech which requires rapid mouth movements and much planning to produce a word. In the hospital, a patient would benefit from copying others mouth movements (or using a mirror) to relearn each sound and letter used for speech, and to relearn to make voluntary mouth movements.

15. DYSPHAGIA Often people with Dysphagia also present with Dysarthria. 3 stages of swallowing: oral phase1(biting and chewing, without spillage), oral phase 2 (propelling bolus backwards towards root of tongue), and pharyngeal phase (swallow reflex is triggered in oropharynx/root of tongue, epiglottis closes and bolus is propelled into esophagus. Involves co-ordination between lips, cheeks, tongue, velopharynx, pharynx, epiglottis, esophagus. If a patient is coughing during feeding or has gurgly voice quality after swallowing, he may be aspirating or having difficulty swallowing. He should be referred to SLP for a swallowing assessment. It would be best to insert an NG tuge immediately and give all liquids through NG especially water. Water is the most difficult to swallow. Please inform SLP of Barium swallow. Best is Videofluoroscopy but modified Barium swallow (three textures) is adequate.

16. CONCLUSION SLP’s and Audiologists provide a health service to people from diverse language, cultural and socio- economic background and to individuals with multiple disabilities. The SLP will equip them with the communication skills that they lack, to allow them to be able to be re-integrated into and participate in their community, at school and with their family. Remember: Communication (listening, speaking, reading and writing) is a basic human right, which allows the individual to seek and receive basic needs, to receive an education, to build relationships, to sustain relationships and to achieve the vital social closeness that a person needs for mental and emotional well being.