Stroke

What is a stroke?

A stroke is when a clogged or burst artery interrupts blood flow to the brain. This interruption of blood flow deprives the brain of needed oxygen and causes the affected brain cells to die. When brain cells die, function of the body parts they control is impaired or lost.

A stroke can cause paralysis or muscle weakness, loss of feeling, speech and language problems, memory and reasoning problems, swallowing difficulties, problems of vision and visual perception, coma, and even death.

What physical and emotional problems occur after a stroke?

Common warning signs of a stroke include the following:

  • sudden numbness or weakness of the face, arm and/or leg
  • sudden confusion, trouble speaking, or difficulty understanding speech
  • sudden difficulty seeing in one or both eyes
  • sudden trouble walking, dizziness, loss of balance, or loss of coordination
  • sudden severe headache with no known cause

If you or anyone you know experiences any of the above warning signs, call your doctor or go to an emergency room immediately.

Because of the organization of our nervous system, an injury to one side of the brain affects the opposite side of the body. Often the person loses movement and/or feeling in the arm and/or leg opposite the side of the brain affected by the stroke. So, if a person has a stroke on the left side of the brain, he or she may have weakness or paralysis in the right arm and leg. This makes it difficult for the person to perform activities of daily living (e.g., dressing, feeding, bathing, tying shoes, etc.). It is also common for survivors of stroke to tire easily.

After a stroke, a person may be able to see objects in only certain parts of his or her field of vision. Visual perception of everyday objects may also change. Objects may look closer or farther away than they really are, causing the person to spill at the table or bump into things while walking. Some people may lose awareness of their weaker side and ignore or forget about it. As a result, they may have trouble reading because they only see half of the page. They may only dress one side of their body thinking they are fully dressed. This one-sided neglect is most common when there is damage to the right hemisphere of the brain.

Stroke survivors often show inappropriate emotions and extreme mood fluctuations. They may laugh when something isn’t funny or cry for no apparent reason. This is particularly common early on in the recovery process.

Persons who have had a stroke may seem very self-absorbed. They may demonstrate an intense need for a structured, unchanging routine. They may be very frustrated with their inability to communicate effectively, and this may lead to anger and depression.

What communication problems occur after a stroke?

After a stroke, some people experience language deficits (aphasia) that significantly impair their ability to communicate. These deficits vary depending on the extent and location of the damage.

Deficits in social communication skills (pragmatics) may result in the following:

  • Difficulty sequencing thoughts together to tell a story
  • Switching topics without warning, or seeming to “go off on tangents” without informing the listener
  • Difficulty taking turns in conversation
  • Problems maintaining a topic of conversation
  • Trouble using an appropriate tone of voice
  • Difficulties interpreting the subtleties of conversation (e.g., sarcasm, humor)
  • Problems “keeping up” with others in a fast-paced interaction
  • Reacting inappropriately; seeming overemotional (overreacting), impulsive, or “flat” (without emotional affect)
  • Having little to no self-awareness of inappropriate actions or responses

Oral motor functioning is sometimes affected by a stroke. The following problems may occur:

  • Muscles of the lips and tongue may be weaker (dysarthria) or less coordinated (apraxia).
  • Speech may not be clear.
  • Breathing muscles may be weaker, affecting the patient’s ability to speak loudly enough to be heard in conversation.

Muscles may be so weak that the person is unable to speak; consequently, he or she may need augmentative or alternative communication aids to help express ideas (e.g., a communication board).

Weak muscles may also limit the ability to chew and swallow effectively (dysphagia).

What cognitive problems occur after a stroke?

Cognition refers to thinking skills. Cognitive difficulties are common in people who have had a stroke on the right side of the brain, and they vary in seriousness depending on the location and severity of the damage. The following problems may occur:

  • Not being aware of one’s surroundings
  • Poor attention to tasks
  • Memory difficulties
  • Poor reasoning skills
  • Poor problem solving skills
  • Poor executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and evaluation, flexibility of thinking)
  • Trouble concentrating when there are internal and external distractions (e.g., carrying on a conversation in a noisy restaurant, dividing attention among multiple tasks/demands)
  • Slower processing of new information
  • Recent memory is affected in some people, making new learning difficult. For example, some people may have trouble learning the new things they are being taught, such as how to get in and out of their wheelchair safely.

How is a stroke diagnosed?

A stroke is diagnosed by medical professionals. Special tests that allow doctors to look at the person’s brain (CT scan, MRI) are often used to determine where the stroke occurred and how severe it is.

A speech-language pathologist (SLP) works with other rehabilitation and medical professionals and families to provide a comprehensive evaluation and treatment plan for stroke survivors. The team may include:

  • doctors
  • nurses
  • neuropsychologists
  • occupational therapists
  • physical therapists
  • social workers
  • employers/teachers (when applicable)

What causes a stroke?

Blockage of blood vessels in the brain

  • Clots can travel from the blood vessels of the heart or neck and lodge in the brain.
  • Small vessels in the brain can become blocked, often due to high blood pressure or damage from diabetes.
  • Clots can form in the blood vessels of the brain due to arteriosclerosis (hardening of the arteries).

Bleeding into or around the brain

  • Weak spots on brain arteries (aneurysms) burst, covering the brain with blood.
  • Blood vessels in the brain break because they have been weakened by damage due to high blood pressure, diabetes, or aging.

How common is stroke?

What does a speech-language pathologist do when working with individuals with a stroke?

The treatment program focuses on improving the skills that have been affected by the stroke, depending on what the areas are affected.

For expressive and/or receptive language skills , the SLP will work on specific drills and strategies to improve them, such as the following:

  • Participating in group therapy sessions to practice conversational skills with other stroke survivors
  • Holding structured discussions, focusing on improving initiation of conversation, turn-taking, clarification of ideas, and repairing of conversational breakdowns
  • Role-playing common communication situations that take place in the community and at home, such as talking on the telephone, ordering a meal in a restaurant, and talking to a salesperson at a store

If cognitive skills are affected, some activities may include:

  • Using a memory log to keep track of daily happenings to help with memory
  • Using an organizer to plan tasks
  • Using checklists
  • Increasing awareness of deficits in order to help self-monitoring in the hospital, home, and community

Eventually, persons are taken on individual and group community outings to practice their use of compensatory strategies outside of the hospital. They are asked to plan, organize, and carry out these trips using the compensatory strategies they have learned. For example, persons may practice using daily planners and checklists to plan the outing. They may practice functional reading and writing skills by using a telephone book to find the phone number of a restaurant and to writing it down. They may practice telephone skills by calling the restaurant and making a reservation. They may practice reading maps, taking public transportation to the restaurant, and counting the change needed to purchase a ticket. They may practice their functional conversational skills by ordering their food in the restaurant.

Later on in the recovery, the SLP may work with a vocational specialist to help transition the person back into work or school, if applicable. The SLP may also work with employers and/or educational specialists to implement the use of compensatory strategies in these settings. The SLP may work with them to modify the patient’s work/school environment to meet language and/or cognitive needs.

If speech muscles are weak, the SLP may teach exercises to strengthen these muscles. The person will practice the exercises at home and in therapy. The person may also be taught strategies to make speech more intelligible and to compensate for the muscle weakness.

If swallowing is a problem, the SLP may teach exercises to strengthen or improve the coordination of swallowing muscles, or strategies to compensate for muscle weakness and improve the safety of swallowing. The SLP works closely with doctors, nurses, and the dietitian to recommend the food consistencies that are safest and most appropriate for the patient’s needs. As the person gains more strength and coordination in swallowing muscles, the SLP works with these professionals to “upgrade” the person’s diet. For example, the SLP may recommend upgrading the diet from a pureed/blended consistency to a chunky consistency.

If the person is learning how to use an augmentative or alternative communication aid, treatment will focus on teaching use of the aid in structured conversation, with other stroke survivors, with family, and eventually in the community.

Videofluoroscopic Swallowing Study (VFSS)

Do you have problems swallowing?

You may have already had a swallowing test with a speech-language pathologist, also called an SLP. During this test you may have tried different foods and liquids. The SLP may have checked how well you can move the muscles of your mouth and how clearly you talk.

Sometimes the SLP needs even more information about how you swallow. You may need another swallowing test – this time in the radiology, or x-ray, department.

You may hear different names for this test. What it is called depends on your SLP and the place where you have the test done.

Some names you might hear are:

  • videofluoroscopic swallowing study, or videofluoroscopy
  • modified barium swallow, or MBS
  • esophagram
  • cookie swallow

The American Speech-Language-Hearing Association (ASHA) uses the term videofluoroscopic swallowing study, or VFSS.

Why have a VFSS?

When you have a swallowing test in the SLP’s office or in your hospital room, the SLP can’t see what is happening inside your mouth and throat. The VFSS lets the SLP see:

  • if food is going into your airway instead of your stomach, called aspiration
  • which parts of your mouth and throat may not be working well
  • what kinds of food are safest for you to swallow
  • if certain positions or strategies help you swallow better

Babies and young children can also have this test done. Your SLP can tell you more about what to expect for your child.

How is the VFSS done?

This study is done in the radiology, or x-ray, department. You will meet the SLP there. There may also be a doctor there, called a radiologist. A radiology technician will be there to help you get ready and set up the equipment.

You will sit or stand next to an x-ray machine. Your SLP will give you different foods and drinks mixed with barium. The barium makes the food and liquid show up on the x-ray. Barium is not harmful and won’t stay in your body for too long. The x-ray machine is only turned on while you swallow so you don’t get too much radiation.

The SLP will ask you to do different things during the test. You may try soft foods and hard foods, and thin liquids and thick liquids. You may take small amounts and large amounts. You may be asked to move your head in different positions. You may also try things like swallowing hard. The test may be recorded so it can be watched again later.

If your child is having a VFSS, you may be asked to hold him in your lap. You will be given protection from x-rays, like lead vests and cover ups. You may feed your baby from a bottle if that is how he eats. Barium is not dangerous for babies or young children. You may see it in the baby’s diaper for a few days after the study.

You should not have this test done if you think you may be pregnant. It is not safe to have x-rays while pregnant.

What happens after the test?

Your SLP and doctor will talk about what they saw during the study. You and your family will be told the results. The SLP may show you the video of the test so you can see what happens yourself. Your SLP will use the test results to decide what treatment will help your swallowing. You and the SLP will discuss what foods and liquids are safest, and how to eat them. You may start swallowing therapy soon after the study.

Feeding and Swallowing Disorders (Dysphagia) in Children

What are feeding and swallowing disorders?

Feeding disorders include problems gathering food and getting ready to suck, chew, or swallow it. For example, a child who cannot pick up food and get it to her mouth or cannot completely close her lips to keep food from falling out of her mouth may have a feeding disorder.

Swallowing disorders, also called dysphagia (dis-FAY-juh), can occur at different stages in the swallowing process:

  • Oral phase – sucking, chewing, and moving food or liquid into the throat
  • Pharyngeal phase – starting the swallow, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking
  • Esophageal phase – relaxing and tightening the openings at the top and bottom of the feeding tube in the throat (esophagus) and squeezing food through the esophagus into the stomach

What are some signs or symptoms of feeding and swallowing disorders in children?

Children with feeding and swallowing problems have a wide variety of symptoms. Not all signs and symptoms are present in every child.

The following are signs and symptoms of feeding and swallowing problems in very young children:

  • arching or stiffening of the body during feeding
  • irritability or lack of alertness during feeding
  • refusing food or liquid
  • failure to accept different textures of food (e.g., only pureed foods or crunchy cereals)
  • long feeding times (e.g., more than 30 minutes)
  • difficulty chewing
  • difficulty breast feeding
  • coughing or gagging during meals
  • excessive drooling or food/liquid coming out of the mouth or nose
  • difficulty coordinating breathing with eating and drinking
  • increased stuffiness during meals
  • gurgly, hoarse, or breathy voice quality
  • frequent spitting up or vomiting
  • recurring pneumonia or respiratory infections
  • less than normal weight gain or growth

As a result, children may be at risk for:

  • dehydration or poor nutrition
  • aspiration (food or liquid entering the airway) or penetration
  • pneumonia or repeated upper respiratory infections that can lead to chronic lung disease
  • embarrassment or isolation in social situations involving eating

How are feeding and swallowing disorders diagnosed?

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your pediatrician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. A speech-language pathologist (SLP) who specializes in treating children with feeding and swallowing disorders can evaluate your child and will:

  • ask questions about your child’s medical history, development, and symptoms
  • look at the strength and movement of the muscles involved in swallowing
  • observe feeding to see your child’ s posture, behavior, and oral movements during eating and drinking
  • perform special tests, if necessary, to evaluate swallowing, such as:
    • modified barium swallow child eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on an X-ray.
    • endoscopic assessment a lighted scope is inserted through the nose, and the child’s swallow can be observed on a screen.

The SLP may work as part of a feeding team. Other team members may include:

  • an occupational therapist
  • a physical therapist
  • a physician or nurse
  • a dietitian or nutritionist
  • a developmental specialist

Your child’s posture, self-feeding abilities, medical status, and nutritional intake will be examined by the team. The team will then make recommendations on how to improve your child’s feeding and swallowing.

What treatments are available for children with feeding and swallowing disorders?

Treatment varies greatly depending on the cause and symptoms of the swallowing problem.

Based on the results of the feeding and swallowing evaluation, the SLP or feeding team may recommend any of the following:

  • medical intervention (e.g., medicine for reflux)
  • direct feeding therapy designed to meet individual needs
  • nutritional changes (e.g., different foods, adding calories to food)
  • increasing acceptance of new foods or textures
  • food temperature and texture changes
  • postural or positioning changes (e.g., different seating)
  • behavior management techniques
  • referral to other professionals, such as a psychologist or dentist

If feeding therapy with an SLP is recommended, the focus on intervention may include the following:

  • making the muscles of the mouth stronger
  • increasing tongue movement
  • improving chewing
  • increasing acceptance of different foods and liquids
  • improving sucking and/or drinking ability
  • coordinating the suck-swallow-breath pattern (for infants)
  • altering food textures and liquid thickness to ensure safe swallowing

After the evaluation, family members or caregivers can

  • ask questions to understand problems in feeding and swallowing
  • make sure they understand the treatment plan
  • go to treatment plans
  • follow recommended techniques at home and school
  • talk with everyone who works with the child about the feeding and swallowing issues and treatment plan
  • provide feedback to the SLP or feeding team about what is or is not working at

What causes feeding and swallowing disorders?

The following are some causes of feeding and swallowing disorders in children:

  • nervous system disorders (e.g., cerebral palsy, meningitis, encephalopathy)
  • gastrointestinal conditions (e.g., reflux, “short gut” syndrome)
  • prematurity and/or low birth weight
  • heart disease
  • cleft lip and/or palate
  • conditions affecting the airway
  • autism
  • head and neck abnormalities
  • muscle weakness in the face and neck
  • multiple medical problems
  • respiratory difficulties
  • medications that may cause lethargy or decreased appetite
  • problems with parent-child interactions at meal times

Orofacial Myofunctional Disorders (OMD)

What are orofacial myofunctional disorders (OMD)?

With OMD, the tongue moves forward in an exaggerated way during speech and/or swallowing. The tongue may lie too far forward during rest or may protrude between the upper and lower teeth during speech and swallowing, and at rest.

What are some signs or symptoms of OMD?

Although a “tongue thrust” swallow is normal in infancy, it usually decreases and disappears as a child grows. If the tongue thrust continues, a child may look, speak, and swallow differently than other children of the same age. Older children may become self-conscious about their appearance.

What effect does OMD have on speech?

Some children produce sounds incorrectly as a result of OMD. OMD most often causes sounds like /s/,/z/, “sh”, “zh”, “ch” and “j” to sound differently. For example, the child may say “thumb” instead of “some” if they produce an /s/ like a “th”. Also, the sounds /t/, /d/, /n/, and /l/ may be produced incorrectly because of weak tongue tip muscles. Sometimes speech may not be affected at all.

How is OMD diagnosed?

OMD is often diagnosed by a team of professionals. In addition to the child and his or her family or caregivers, the team may include:

  • a dentist
  • an orthodontist
  • a physician
  • a speech-language pathologist (SLP)

Both dentists and orthodontists may be involved when constant, continued tongue pressure against the teeth interferes with normal tooth eruption and alignment of the teeth and jaws. Physicians rule out the presence of a blocked airway (e.g., from enlarged tonsils or adenoids or from allergies) that may cause forward tongue posture. SLPs assess and treat the effects of OMD on speech, rest postures, and swallowing.

What treatment is available for individuals with OMD?

A speech-language pathologist (SLP) with experience and training in the treatment of OMD will evaluate and treat the following:

SLPs develop a treatment plan to help a child change his or her oral posture and articulation, when indicated. If tongue movement during swallowing is a problem, the SLP will address this as well.

Treatment techniques to help both speech and swallowing problems caused by OMD may include the following:

  • increasing awareness of mouth and facial muscles
  • increasing awareness of mouth and tongue postures
  • improving muscle strength and coordination
  • improving speech sound productions
  • improving swallowing patterns

If airways are blocked due to enlarged tonsils and adenoids or allergies, speech treatment may be postponed until medical treatment for these conditions is completed. If a child has unwanted oral habits (e.g., thumb/finger sucking, lip biting), speech treatment may first focus on eliminating these behaviors.

What causes OMD?

The following may cause OMD:

  • allergies
  • enlarged tonsils and adenoids
  • excessive thumb or finger sucking, lip and fingernail biting, lip picking, and teeth clenching and grinding
  • family heredity

Allergies can cause problems with the functioning of the mouth or face muscles. For children with allergies, it is often hard to breath normally through the nose because of nasal airway blockage. They often breath with their mouths open, tongues lying flat on the bottom of their mouths. Lip muscles may lose their strength and tone if an open-mouth posture continues for a long time.

Enlarged tonsils and adenoids can block airways, causing an open-mouth breathing pattern. This pattern can become habit forming and continue even after medical treatment for the blocked airway is received.

Excessive thumb or finger sucking, lip and fingernail biting, lip picking, and teeth clenching and grinding can result in OMD. Constant thumb sucking in particular may change the shape of the child’s upper and lower jaw and teeth, requiring speech, dental, and orthodontic intervention. The effect of the problem depends on how often and how long the oral habit is practiced.

Family heredity can be involved in determining the size of a child’s mouth, the arrangement and number of teeth, and the strength of the lip, tongue, mouth, and facial muscles.

The Importance of Play

Stages of play is a theory and classification of children’s participation in play developed by Mildred Parten in 1932.

Parten recognized six different types of play:

  • Unoccupied (play) – when the child is not playing, just observing. A child may be standing in one spot or performing random movements.
  • Solitary (independent) play – when the child is alone and maintains this status by being focused on its activity. Such a child is uninterested in or is unaware of what others are doing. More common in younger children (age 2–3) as opposed to older ones.
  • Onlooker play (behavior) – when the child watches others at play but does not engage in it.[2] The child may engage in forms of social interaction, such as conversation about the play, without actually joining in the activity.This type of activity is also more common in younger children.
  • Parallel play (adjacent play, social coaction) – when the child plays separately from others but close to them and mimicking their actions.  This type of play is seen as a transitory stage from a socially immature solitary and onlooker type of play, to a more socially mature associative and cooperative type of play.
  • Associative play – when the child is interested in the people playing but not in the activity they are doing, or when there is no organized activity at all. There is a substantial amount of interaction involved, but the activities are not coordinated.
  • Cooperative play – when a child is interested both in the people playing and in the activity they are doing. In cooperative play, the activity is organized, and participants have assigned roles. There is also increased self-identification with a group, and a group identity may emerge. Relatively uncommon in the preschool years because it requires the most social maturity and more advanced organization skills. An example would be a game of freeze tag.

According to Parten, as children became older, improving their communication skills, and as opportunities for peer interaction become more common, the nonsocial (solitary and parallel) types of play become less common, and the social (associative and cooperative) types of play become more common

Treating speech subsystems in Childhood Apraxia of Speech with tactual input: The PROMPT approach

Philip S. Dale University of New Mexico

Deborah A. Hayden PROMPT Institute, Santa Fe, New Mexico

Purpose: PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) is a treatment approach for the improvement of speech sound disorders in children, which uses tactile cues to support and shape movements of the oral articulators. No research to date has systematically examined the efficacy of PROMPT for children with Childhood Apraxia of Speech (CAS).

Methods: Four children (3.6–4.8), all meeting the ASHA (2007) criteria for CAS were treated. All children received 8 weeks, 2x/week of treatment including at least 4 weeks of full PROMPT treatment, including tactile cues. During the first four weeks, two of the four children received treatment which included all PROMPT components except tactile information. This design permitted both between-subject and within-subject comparisons to evaluate the effect of tactile cues. Gains in treatment were measured by standardized tests and by criterion referenced measures based on the production of untreated probe words, reflecting change in speech movements and auditory perceptual accuracy.

Results: All children made significant gains during treatment, but measures of motor speech control and untreated word probes provided evidence for more gain when tactile cues were included.

Conclusions: PROMPT as a whole appears to be effective for treatment of children with CAS, and the inclusion of tactile cues appears to facilitate greater effect.

Child Speech and Language

Below is a link to a website that fully describes speech and language disorders.

http://www.asha.org/public/speech/disorders/ChildSandL.htm

Speech Disorders

Language Disorders

Medical and Developmental Conditions

Communication Options

Frequently Asked Questions