Communication disorders and rehabilitation of persons with stroke.

Stroke or a cerebrovascular accident (CVA) is the most frequent cause of injury to the nervous system (Metter, 1986). According to the National Institute of Neurological Disorders and Stroke (NINDS, 1989), stroke is the nation's third leading killer with nearly half a million Americans stricken annually when blood flow to the brain is interrupted and nerve cells are damaged, with a resultant 150,000 deaths annually from stroke related courses. For the 2.5 million stroke survivors in America today rehabilitation means help and hope. It is estimated that 80 percent of those with stroke are candidates for a rehabilitation regime that may enhance communication abilities (Rao, 1993). A left CVA, right CVA, or a brain stem injury may result in an impairment in any of the following communication abilities: voice, speech, language, fluency, and cognition. The resultant communication disorder has a significant life-shattering impact on a person's quality of life. This article is intended to provide a brief overview of these various disorders and to describe the pivotal role of the speech-language pathologist (SLP) in the rehabilitation of stroke survivors.

Acute Rehabilitation

The SLP, along with the other members of the stroke rehabilitation team, are daily reminded that no two persons with stroke present the same profile of problems and potential, but each stroke person admitted for acute rehabilitation is provided an interdisciplinary rehabilitation plan tailored to optimize functional return of that person's abilities. For example, at the National Rehabilitation Hospital (NRH) in Washington, DC, the stroke person's average length of stay (LOS) is 4 weeks. The patient is evaluated by the entire team within the first 72 hours and a team conference is held during the first week of admission. In the first week, the SLP is responsible for conducting an indepth review of the patient's medical record, interviewing the patient and/or significant other (SO), completing a functional assessment of communication abilities, rating the person's initial functional communication status, projecting discharge communication status, and then reporting to the team. The SLP's team conference report typically includes a report of the patient's initial functional communication status; a brief description of the optimal method(s) for the team members to communicate with the patient; a recap of the patient's communication liabilities, assets, and complications; and, finally, an operational statement of at least two interdisciplinary goals that relate to communication.

Communication treatment, begun during the first week of admission, continues on a daily basis until discharge, when the SLP conducts a thorough, final assessment, rates the patient's functional communication status, and, if indicated, refers the stroke person for followup treatment. In addition to the SLP's initial and final assessments, participation in the weekly team conferences, and conduct of daily treatment, the SLP is also responsible for documenting the patient's progress towards goals and reporting test-retest results weekly. In addition, the SLP plays an integral role in participating in a scheduled family conference and in training the family on how to communicate with the stroke person and how to carry over the communication strategies into the patient's everyday life.

Functional Communication

The stroke survivor may experience a communication disorder defined as "any impairment in communication... and the focus is on the individual's capacity to exchange thoughts and information clearly and plausibly rather than on speech, language deficits" (Toner et al., 1990). Today's rehabilitation focus is on functional communication. If a stroke person is unable to tell you his phone number, he may be able to find it in his wallet and show you, or be able to write it, dial it, or even look it up in the phone book for you. The crux of the SLP's role with the person with a communication disorder is to first establish the primary problem, then problem solve with the patient attempting to determine the most effective, efficient, and reliable method(s) for breaking down the barriers to successful, functional communication. The first underlying assumption is that what is a barrier (handicap) for one person with stroke is not a barrier for another. A second premise is that communication wants and needs vary among individuals or for an individual in differing environments. Contrast the communication needs of a highly educated scientist with those of an individual with limited vocational and educational attainment. Consider the communication challenges at work or school versus those found in a home or a nursing home. For these reasons, functional communication must be individually defined for each stroke person and, as outlined by Aten (1986), "must consider the severity of the communicative disturbance, the pre-morbid lifestyle of the patient, and the setting in which that person will ultimately reside" (p. 226).

Assessment

The SLP evaluation of a person with stroke involves administering a comprehensive battery of tests to assist in determining the diagnosis, prognosis, and plan for the patient. The communication problems that are common after a left CVA are aphasia, apraxia, agnosia, and dysarthria; after a right CVA they are right hemisphere communication impairment (RHCI) and dysarthria; and after a brain stem stroke they are various types of dysarthria. The diagnostic search in this assessment is for the primary deficit, i.e., the communication problem that is chiefly responsible for disrupting the process of getting one's message across and/or getting a need met. The post-stroke communication disorders and the corresponding key concept for each is noted in Table 1.

Table 1

Disorder     Key Concept
Aphasia      language
Dysarthria   motor speech
Apraxia      volitional control
             of speech
Agnosia      recognition
RHCI         communication

The traditional clinical assessment considers neurological and neuroradiological data that identifies primary signs and symptoms consistent with the probable cause and site of lesion. Thus, if a right-handed person has suffered a single, left CVA to the frontal lobe with resultant right-sided paralysis, the diagnostician can rule out a number of adult neurogenic communication disorders (e.g., RHCI and dysarthria) and thereby conduct a further assessment to determine whether the underlying communication impairment is aphasia, apraxia, or both.

According to Rao (1993), a comprehensive diagnostic test protocol should consist of the following areas of assessment:

* subjective complaint/reason for referral;

* background information including medical biographical and behavioral history;

* sensory motor screens, e.g., hearing and vision;

* oral motor examination of structures and function of the speech/swallowing mechanisms;

* standard voice and speech evaluation: examining pitch, quality, and intensity of voice and speech intelligibility at the word, phrase, and sentence level, noting sound distortions, omissions, and substitutions;

* standard language evaluation examining spontaneous speech, auditory and reading comprehension, repetition, naming, and writing;

* standard cognitive screen examining orientation, memory, writing, and calculation;

* functional status assessment of communication;

* patient and family participation/contribution;

* environmental prosthetic/device inventory; and

* pragmatic performance and potential: examining the use of language in context and reviewing patient's use of substitution/compensation strategies.

Upon completion of the comprehensive assessment, the clinician is expected to arrive at a communication diagnosis and prognosis. The challenge is to estimate the potency of the many prognostic factors, such as cause and severity of the stroke, and make the best clinical estimate as to what is the patient's overall prognosis. In formulating a prognosis, the SLP asks the following three questions:

1. Prognosis for what?

2. Which factors are positive?

3. Which factors are negative?

Although the correspondence is not 1:1, the SLP does get an impression as to what are the best odds. Once a determination is made that the patient's overall prognosis is either good, fair, or poor for a given level of functional communication, the clinician must then estimate the patient's response to treatment:

1. Will treatment help?

2. If so, what modalities should be treated, and in what order?

3. What type of treatment should be used?

Diagnostic Therapy: At NRH, the average length of stay for stroke has declined steadily from a high of 48 days (1985) to a current low of 28 days (1992). Acute medical rehabilitation continues to be ratcheted down on a continuing basis, so that it is very likely to assume that the average length of stay for stroke in a rehabilitation facility will continue to decline. Even a 3-week period does not leave the treatment team sufficient time for a comprehensive evaluation. Today's inpatient SLP must hit the ground running on day 2 of a stroke person's admission. The team must already have determined from pre-admission and medical record data the subjective complaint and rehabilitation goals of the patient; the pertinent biographical, medical, and behavioral information concerning the stroke person's candidacy for rehabilitation; and the necessary neurological findings that permit the assigned therapist to be eclectic in the tests and diagnostic approaches to be used.

Five years ago, the treatment team had the luxury of at least a week to complete a thorough, even scholarly, diagnostic workup. Today, one must short-circuit the comprehensive approach and determine on line the most pressing communication problems and the most promising approaches to functional remediation. Thus, the results of a yes/no battery do not just provide the clinician with a percentage of yes/no reliability, but diagnostic therapy data as well, such as:

* the best input channel or combination of channels;

* the variables that optimize success and minimize failure; and

* the most stimulable content and methodology.

Hence, diagnostic therapy does not only tell the clinician that Mr. Jones scored 45/60 on a given yes/no subtest, but also that given more time and a repeated stimulus, accuracy was enhanced. In addition, although several errors were noted due to impulsivity, the patient did self-correct at least once. This type of data will help the team at the initial team conference to decide on the most effective means of getting the message across so that the patient and significant other can follow the critical training in self-care, ambulation, etc. In summary, diagnostic therapy is the clinician's followup effort at finding immediate, practical application for the test results. This information is invaluable to the team, the patient, and the significant other as they together move towards achieving the rehabilitation goals.

The diagnostic instrument and diagnostic therapy should not just label behavior but assist the team, the patient, and the family to immediately reap benefit from the prognostic and prescriptive elements. A sound diagnostician does not only attempt to find what the stroke survivor can or cannot do, but, more importantly, attempts to discover what approach is the most fruitful for enhancing functional communication and achieving the best possible outcome.

Treatment

A simple definition of handicap is that "it is a limitation of choice." The impairment (aphasia) results in a disability (language disorder) which causes the stroke person to experience a handicap (prevents the person from resuming his pre-trauma familial, vocational, or avocational status). The prescription for stroke rehabilitation is to attempt to maximize the stroke person's options--provide the handicapped person with more societal choices. In the context of a post-stroke communication disorder, there are three rehabilitation approaches that can be employed to minimize the handicap by maximizing options:

* Enhance functional capacity, by helping the person with aphasia change behavior through rehabilitation strategies.

* Reduce demands of the environment, by minimizing the penalty on the person with aphasia, such as removing competing signals (turning off the TV) and optimizing transmission of signals (having pencil and paper available).

* Provide assistive devices, e.g., by determining a menu of core needs and then fabricating a communication board that pictures or lists these same needs for the adult with a communication disorder to be able to convey wants and needs.

Thus, the SLP joins the patient, significant other, and the treatment team in arriving at the most pragmatic plan to achieve functional communication goals in an efficient and effective manner.

Coaching

Ylvisaker and Holland (1985) chose a sports analogy to clarify the executive functions to clinicians and head injured young adults. Specifically, they employed the image of an internalized coach to represent to patients their role in governing their own actions. Ylvisaker and Holland have found that understanding the functions of a coach enables many patients to use the concrete goal of becoming a good self-coach in their own rehabilitation. The executive or coaching functions they considered in the treatment of cognitive-communicative disorders are shown in Table 2.

Table 2

  1. Self-awareness: Being cognizant of one's own strengths and
weaknesses
and factors that affect ones functioning.
  2. Goal Setting: Setting goals that are realistic, meaningful,
and challenging.
  3. Planning-Preparing-Training: Putting oneself in a position
to complete a
task effectively.
  4. Self-Instruction: Giving oneself specific appropriate
directions about
how to carry out a task effectively.
  5. Self-Motivation: "Getting going" and "shutting down" when
appropriate.
  6. Self-Monitoring: Attending to one's performance and factors
that
interfere with success.
  7. Problem-Solving and Practical Reasoning: Taking stock of
one's
performance and modifying goals, plans, or strategies in
response to obstacles.
  (Ylvisaker and Holland, 1985, p. 244)

This coaching analogy is also quite applicable to many in the stroke population where goal setting, self-monitoring, and problem solving are crucial components in effectively getting a message across or getting a problem solved. Thus, the clinician serves as a coach and mentor to the stroke person who is engaged in a game of life. One example follows:

"C.R.", a 37-year-old stroke person with aphasia, is nearly 1 year post onset. His stroke recovery has been surprising in its breadth and depth. His initial status was severe in all vital spheres. He couldn't walk, talk, or bathe and toilet. The prognosis was fairly grim for such a bright young man with a wife and two young children. He desperately wanted to get better and at the onset was assertively a part of the team's planning and implementation process. He moved from yes/no questions and a single communication book, then later to an alphabet board and finally to where C.R., an avid sports fan, employs internal coaching to arrive at his message and intent in a complete, coherent, and cogent manner. Four days per week, he puts into practice the above mentioned seven-step coaching model in his work re-entry as a customer service agent for a major U.S. airline. One day per week he attends a vocationally driven rehabilitation program, where the physical therapist, occupational therapist, and SLP review and refine the prior week's successes and debrief and detail the failures to ultimately ensure success so C.R. can resume his prior highly competitive job. (Refer to the final section of this article for C.R.' s own testimony on post-stroke rehabilitation.)

An initial period of diagnostic therapy provides the team and the patient additional "coaching intelligence" to strategically plan how to attack a problem and how to win at getting a need met. According to Ylvisaker and Holland (1985), diagnostic treatment involves the systematic exploration of the effects on learning and general adaptation behavior of the following:

1. Learning Environment: What is the level and pace of activities?

2. Patient Endurance, Persistence and Initiative: Does the patient attempt to communicate with strategies?

3. Alternate Cueing Systems: Do gestures facilitate verbalization?

4. Type of Task Presented: (This includes processing difficulty as well as interest factor.) Does avocational interest (sports, politics) foster enhanced communication?

5. Types of Reinforcement, Density of Success, Explicitness of Rules and Instruction: Does the patient go through an established routine (self-cueing hierarchy) when confronted with a communication breakdown?

6. Use of Compensatory Strategies and the Ability to Generalize and Maintain the Use of Strategies: Does the patient use a pacing board to slow the rate of his dysarthric speech?

7. Adaptability to Revised Educational or Vocational Goals: Following a pilot regime at work, is the patient amenable to retraining for another position? (Adapted from Ylvisaker and Holland, 1985, p. 248.)

In summary, the philosophy of stroke treatment promoted in managing communicatively impaired adults is to empower the patient to become more involved in his own care: to foster in the patient the desire to increasingly become his own case manager. Once the patient is apprised of this rehabilitation charge and agrees to be involved, the patient may then enroll in a rehabilitation regime. Of particular import in this training program is the engagement of the patient as a planner. What is it he wants to accomplish and how can he get to that end? An array of executive functions are systematically tapped by the coaching team to enhance outcome. The initial phase of training and self-coaching is preoccupied with diagnostic therapy or exploring the candidate's strengths and weaknesses, liabilities and assets, with an eye towards teaching the most effective strategy to communicate and/or determining from the patient what works best under different circumstances. Whatever the post-stroke disorder, the above philosophy and approaches can provide the framework for ameliorating or compensating for the communication disability.

Preparing for The Future of Post-Stroke Rehabilitation

The Agency for Health Care Policy and Research (AHCPR) has as its mission to promote improvement in clinical practice and patient outcomes through more appropriate and effective healthcare services; engender improvements in the financing, organization, and delivery of healthcare services; and increase access to quality care. On June 12, 1992, its expert panel held a hearing on

clinical practice guidelines on post-stroke rehabilitation. The only consumer (person with stroke) to address the panel was C.R., whose poignant and prophetic testimony was as follows:

"My name is C.R. I am 37 years old and had a stroke in June of 1991 which left me with a right sided paralysis and severe aphasia. I am here today during national Aphasia Awareness Week to talk about stroke after the fact, particularly for those folks with aphasia who might be unable to talk. The National Aphasia Association has asked me to talk to you about my stroke and continued recovery nearly 1 year later. Last year, I could not say a word. Today, I'd like to say a word about stroke.

"The biggest problems for me after the stroke were not the physical, but the stroke's impact on me and my family, on me and my friends, on me and my job--it struck all of us and I'm still 'recoiling'... Stroke actually is a life-long recoiling, not a couple of weeks, or months, or years--a lifetime of recoiling with my family, friends, and co-workers. Everday I am trying to realign my relationship with all comers--my wife, my two boys, my friends, my employer. I will try to outline for you three of the major problems that have happened to me this past year and what I have learned from these experiences.

"First, the emotional and psychological toll stroke takes on me and my family is even more devastating than the financial toll. The fear, the anxiety, the anger, all weigh heavily in the equation of rehabilitation. The necessary support, understanding, and therapy is at best uneven for many people with stroke. United, we tell all, that this is a major concern--life daily requires persons with stroke to pay a penalty because of their handicap. Some stroke persons have more resources (rehababilitation team, family, community) than others. Policy must recognize these areas of need and not limit or ration therapy to weeks or months. Policy must regard potential for quality of life and the ripple effect this will have on the family and the community at large.

"The second problem was work reentry. I am in my 30's and I want to work. As I see it, the person with a stroke has four options: he can return to his old job; he can return to his old company in a different job; he can start a whole new job; or he can't or won't work.

"None of these options are easy or attractive. All, except the latter, may come after much work, money, and frustration has been expended. It seems that many road blocks are in my way to becoming a gainfully employed taxpayer again. The Americans with Disabilities Act is not a solution but a tool. There must be a safety net that we can cling to in this regard. Hope is my only hope.

"The third problem is financial shock. The costs of stroke can be said to be the cause of another stroke. They are very high in terms of direct costs (healthcare dollars) and in terms of indirect cost (my not working). Typically a stroke survivor does not have the financial resources to go it alone. To recoil from the stroke, government must provide additional spring--to cushion our fall and push us back into the mainstream. I'm told that a dollar spent on rehab saves $9.00. We must afford to invest in the potential of 2 million stroke survivors--a million of whom have aphasia. The U.S. policy must be to strike back at stroke by supporting its survivors and preventing such a trauma from happening to others.

"Thank you for considering my testimony."

C.R. has not only returned to work, but, hopefully, his testimony has helped to bring the discussion of the clinical practice of post-stroke rehabilitation to a more personal level. C.R. and his remarkable continuing recovery of his communication skills is certainly testimony to the resilience of the human spirit and the effectiveness of rehabilitation today.

Bibliography

1. Aten, J. (1986). Functional communication treatment. In R. Chapey (Ed.): Language Intervention Strategies in Adult Aphasia, ed 2, Baltimore, MD, Williams & Wilkins.

2. Metter, E.J. (1986). Medical aspects of stroke rehabilitation. In R. Chapey (Ed.): Language Intervention Strategies in Adult Aphasia, Baltimore, MD, Williams.

3. National Institutes of Neurological Disorders and Stroke: Stroke (1989), U.S. Department of Health and Human Services, Bethesda, MD.

4. Rao, P.(1993). Current concepts in managing communication disorders in persons with stroke: In M. Ozer (Ed.): Management of Persons with Stroke, New York, Moseby.

5. Toner, J., Gurland, B., Leung, M. (1990). Chronic mental illness and functional communication disorders in the elderly. In E. Cherow (Ed.). Proceedings of the Research Symposium on Communication Sciences and Disorders, American Speech-Language Hearing Association, MD.

6. Ylvisaker, M., and Holland, A. (1985). Coaching, self-coaching and rehabilitation of head injury. In D. Johns (Ed.): Clinical Management of Neurogenic Communication Disorders, ed 2, Boston, Massachusetts, Little Brown & Co.