The Strands of Speech and Language Therapy

Weaving Plan for Neurorehabilitation

Katy James

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000154016
• Edition: 1
• Topic: Computer Science
• Subtopic: Computer Science General
• Index: Computer Science

This book is written by a team of speech and language therapists from The Wolfson Neurorehabilitation Centre. It is intended for practitioners working with patients who have acquired communication disorders resulting from brain injury: aphasia, cognitive-communication disorder, dysarthria, apraxia. The authors believe that a therapeutic programme should have it's foundations in the linguistic, non-verbal, neurological and neurospsychological perspective of the patient's difficulties. The approach the team has developed consists of several different strangs of therapy, with each strand representing an element of the rehabilitation process: assessment; goal planning; specific individualised treatment; education; friends and family; and psychosocial adjustment. This book describes these strands, illustrates in a user-friendly way how each one relates to therapy, and fives some practical ideas of how practitioners might work within them. Each chapter begins with the guiding principles and evidence bases that underlie the rationale for one particular strand of therapy. They then follow examples of practice and case studies of a real-life example of each strand. This book describes a speech and language therapy service that aims to be responsive to patients' needs and develops tailor-made intervention programmes that arer unique to each individual. It includes downloadable resources containing assessments and practical tools.

1 Assessment and feedback

For patients admitted to the multidisciplinary rehabilitation unit, assessment should be multidimensional and wide-ranging to enable appropriate planning. Assessment is an important dimension to guide differential diagnosis and determine the needs level of the patient, and is a core aspect of specific individualised treatment planning. Done thoroughly, it enables us to formulate initial hypotheses and establish the process of collecting evidence for change. Assessment is also an essential strand of the service within an expert centre; the role of assessment may be as much to inform others (for example the patient, community team colleagues) as to inform those working in the centre.

Guiding principles

Underpinned by theory and keeping abreast of new learning

Theoretical models, neurological and linguistic, are seen to underpin assessment. At the Wolfson we have a philosophy of not ‘throwing the baby out with the bathwater’ and so make use of access to our neurology colleagues and brain scans to guide us in the initial stages of information gathering. We make reference to the specific neurology, that is, the site and location of the individual’s brain injury, to guide us as to the expected communication breakdown. For example, when presented with a diagnosis of brainstem injury we might expect dysarthria; with anoxic brain injury we would perhaps expect a diffuse cognitive-communication disorder; with a right middle cerebral artery infarct we might expect both of those plus more specific problems with affect and non-verbal abilities. However, we must be aware that lesion site is only ground-clearing information and will not give us the full picture of communication breakdown; considering the neurology alone is insufficient to formulate our hypotheses about the details of communication breakdown. The limitations of attempting to diagnose and describe communication disorders based on lesion site alone can be seen from the emerging evidence that lesions in diverse brain areas can result in similar communication impairments. Thalamic aphasia has long been described, and other subcortical linguistic impairments have been identified more recently. In a review paper written in 1994, Kennedy & Murdoch challenge the fact that language is only represented in the cortex. They discuss the extralinguistic functions of the thalamus and suggest that intervention programmes could be devised on the basis of a detailed description of the patient’s communication abilities. Paquier & Mariёn (2005) have discussed evidence that implicates the cerebellum in diverse higher cognitive functions such as language. As our understanding of brain injury and communication difficulties increases, it seems that damage to any part of the brain may result in communication changes related to linguistics, cognition or information processing.

It is very important then for speech and language therapists to have a means of assessing and diagnosing communication impairment. It has been identified that in some areas these disorders are currently going untreated (Brady et al, 2003). Appropriate treatment is reliant on an accurate understanding of the cause of a client’s difficulties. This is well understood in aphasia where models of language processing can identify exactly where in the word retrieval system there is a breakdown (Ellis & Young, 1988). In the context of a cognitive-communication disorder these models are not helpful since word-finding difficulties in these cases may be linked to higher-level skills such as initiation or attention control.

Viewing aphasia as primarily a language disorder has, for many years, informed our assessment and consequential therapy, but more recently recognition, as described above, of the co-occurrence of other cognitive disorders has impacted on the approach we take. This has led us to recognise the need to assess the cognitive linguistic breakdown. Published assessment tools such as Mount Wilga High Level Language Assessment and the Measure of Cognitive-Linguistic Abilities (MCLA) are available (see the Appendix for details of formal and informal assessment tools), but with this recognition has come a burgeoning of new kinds of cognitive-communication disorder and links to traditional views of communication breakdown following brain injury. Frankel et al (2007) provide a useful illustration of a woman with aphasia and executive difficulties and endeavour to describe what the therapist needs to consider in the assessment and treatment. Evidence of this broadening clinical focus was discussed at the American Speech and Hearing Association annual conference (2005, quoted in Milman et al, 2008). It was stated that clinicians working in rehabilitation in the USA reported that a larger proportion of SLT services were directed towards cognitive-communication disorder (32 per cent) than to aphasia (22 per cent). Current ongoing research suggests that approximately 50 per cent of all stroke unit admissions present with some features of cognitive-communication disorder (McIntosh et al, 2010).

However, theory must also consider the information the patient brings. When we assess, we need to consider that established models offer some help with assessment, but patients inform the models too. The symptoms and behaviour do not always fit the models. So, at the Wolfson we believe it is paramount to continue to be holistic in our assessment and thinking, and use the patient and their specific injury to enlighten us on the nature and consequences of the breakdown for them.

In summary then, SLT assessment is the investigation of the consequences of brain injury in terms of motor, linguistic and cognitive-communication problems, but additionally it needs to consider the consequences of these for the person and their family. We must also use assessment results to develop our theory of communication disability, particularly in relation to cognitive-communication disorder, and have a duty to share our learning and expertise with our colleagues.

Rationale

Assessment can serve a number of purposes for a number of people (for example therapist, patient, family, multidisciplinary team), but it is important for both therapist and patient that the rationale for why and what the therapist is assessing is explicit. Choice of assessment may not be guided solely by a therapist’s clinical reasoning (for example, about neurology and expected difficulty) or observation, but by comments made by a patient’s wife who has noticed that her husband does not pick up on the nuances of interaction and subtleties of language as he did prior to the onset of his aphasia. Traditionally, we would expect to complete a language assessment for someone presenting with aphasia. However, in this case use of The Awareness of Social Inference Test (TASIT) may be indicated and justified in addition.

Furthermore, not to assess must be based on rationale; it may not be appropriate to go through a battery of communication assessments with someone who has been admitted from an acute bed and only recently completed assessment, or someone who is coming into the unit for a short stay. In such cases it may be appropriate to focus on informal, indirect assessment and information gathering from other sources. Clear documentation of rationale is important for all cases.

Liaison and use of qualitative and quantitative assessments

Information gathering from previous SLT, the multidisciplinary team, relatives and nursing staff plays an important role as do questioning and exploring with the patients themselves. Parr et al (2001) discuss the qualitative interview and how it guides the therapists to the meaning of the disorder to the person. It offers the chance to explore whether assessments are a true reflection of communication behaviour in all situations. We must take the information we glean from traditional assessment and use it alongside the qualitative information we can obtain from a variety of sources in order to build a comprehensive and true picture of the communication disability that person experiences. This will help to ensure that the rehabilitation setting is a reflection of the real world, as far as possible. Within this process, key areas to explore are consistency, variety of needs, ability to express self with new people and getting needs met.

Baseline and outcome measures

The SLT department at the Wolfson has found it useful to establish a set of assessments from which we choose the most appropriate tools. This ensures a core, consistent and equitable approach for our patients and provides us with outcome measures that we can audit and use to analyse our service more closely. This approach follows the theory of assessment, therapy and reassessment to evaluate progress, but also considers qualitative information. We use a variety of assessment tools and patient-specific outcome measures to demonstrate treatment efficacy. Goal planning is integral to the patient’s journey and a useful outcome measure. However, in order to ensure consistency and equity of input, minimum standards for pre and post therapy assessment have been devised, to be used in addition to goal planning. These are tailored to the individual according to the underlying impairment.

Outcome measures in the form of communication tables and scores are used to document outcomes of therapy from pre and post therapy assessment, in addition to goal attainment. The outcome measures in use by the SLT department aim to demonstrate the outcome of therapy at all levels, from impairment through to wellbeing, as outlined by Enderby et al (2006, see Table 1).

Table 1 Levels of therapy and example approaches

Level of therapy	Examples
‘Improve/remediate’	Tackling the underlying communication impairment, eg cognitive-communication disorder, phonological, semantic, syntactic, pragmatic, motor, sensory disorders
‘Extend functional activity relating to performance’	Communicating ideas, relating stories, use of total communication strategies/augmentative communication systems/aids
‘Develop strategies to accommodate the personal social disadvantage of the deficit’	Educating others and modifying attitudes, providing strategies for patients and caregivers, attending social events, sustaining a work role, maximising independence in communication situations
‘Support the patient and caregivers during the adjustment phase’	Identifying upset or concern, providing counselling, encouragement and support

Adapted from Enderby et al, 2006

It is important for the measurement to be meaningful, that is, not to be focused on ticking boxes but on generating information that, when looked at altogether, can give an idea about whether progress has occurred in different areas. A key requirement of the outcome measurement system is for it to be clinically applicable; it has proved possible to integrate this system into regular clinical practice for use with a variety of patients with differing therapeutic goals and diagnoses. Therefore clinical viability of such a system is indicated.

A recent study (McIntosh et al, in press) has found that outcome measures are needed to measure patients’ perception of change and to measure functional change. Objective and subjective measures are therefore vitally important.

Aid to planning and prioritisation: use of skill mix

The process of assessment aids the Wolfson SLT department in prioritising and managing its caseload and staffing allocation. A systematic, equitable approach is used to identify and establish an individual’s needs level in terms of input. This is discussed in more depth in Chapter 3 ‘Specific individualised treatment’.

Interrater reliability

Interrater reliability is very important regardless of the work setting. However, in the specialist and fairly newly recognised field where we work (that is, cognitive-communication disorder) it is particularly important that we strive for reliability within our department and approach. This relates to scoring and interpretation of assessment results, and to the terminology we are using to describe our patients’ presentation. While we recognise its importance, we admit that this is an area where we find it difficult to ensure that reliability is achieved at best practice level. Carrying out research and developing the area of specialist neurorehabilitation can only serv...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Introduction
• 1 Assessment and feedback
• 2 Goal planning
• 3 Specific individualised treatment
• 4 Education
• 5 Friends and family
• 6 Psychosocial adjustment
• 7 Conclusions
• Appendix
• References