COMMUNICATION PROBLEMS

COMMMUNICATION

Communication can be defined as the process by which

people share ideas, experience, knowledge and
feelings through the transmission of symbolic
messages.

 Communication are usually spoken or written words,

pictures or symbols.

 But we also give information through body language,

gestures, and looks, facial expressions can show how
we feel and what we think about an issue or another
person.
COMMON WAYS
 COMMUNICATION PROBLEMS
Communication problems vary, depending on an individual's personality, pre-
injury abilities, and the severity of the brain damage. Typical effects may
include:

Slow or slurred speech

Difficulty in swallowing
Drooling or a nasal tone
Problems with finding the right words
Trouble with understanding others

Communication problems can be a mixture of both receptive and expressive

problems, regardless of whether the cause was a brain tumour, traumatic
brain injury, encephalitis or other type of brain disorder.
SKILLS
RECEPTIVE SKILLS
- involve receiving and
understanding language. Typical
signs of this are:
 Poor recognition of vocabulary
 Continually asking for things to be
repeated
 Difficulty with the speed, complexity
or amount of spoken information
 Not paying attention in conversations
 Not understanding what is said
 Difficulty remembering instructions
given.
Remember that hearing loss can also
occur after a brain injury and have
the same effects. The ideal is a
hearing test by an audiologist before
assessing receptive skills.
EXPRESSIVE SKILLS
The ability to form sentences, find the
right words, and make the right
sounds may appear unaffected and
not be detected during rehabilitation,
Possible problems include
 Non-stop rapid talking
 Rambling explanations and switching to
unrelated topics
 Difficulty remembering certain words
 Incorrect use of language
 Poor spelling and difficulty learning new
words
 Saying the same thing over and over
(perseveration)
 Trouble with long sentences.
COMMUNICATION PATHOLOGY
 Direct- pathologic condition of a single organ influences other elements
of the communication process in ways that are predictable,considering
the integrated nature of speech & language (eg.,OAD,alterations in
vocal pitch&intensity and phrasing modifications through
compensations for impaired ability to sustain airflow)

 Indirect –pathological condition of organ can affect the final

communication product in more diffuse manner (hypothyroidism , can
influence voice quality as an isolated component of speech & also lead
to language confusion & impaired memory)
TYPES OF COMMUNICATIN PROBLEM
 Anomia means "can't name". Everyone has an occasional trouble with
remembering a word but it can be a severe problem after a brain injury.
Sometimes the wrong word is chosen e.g. "Pass me the noon" instead
of "Pass me the spoon

 " A speech/language pathologist can provide techniques to help, such as

circumlocution e.g. if you can't come up with the word "telephone" you
might say "you dial it to call people" so people will understand what
you are trying to say.
DYSARTHRIA
 Group of motor speech disorders characterized by
slow,weak,uncoordinated movements of speech musculature
 Lesion can be CNS/PNS /both including
cerebrum,cerebellum,brainstem &cranial nerves
 Differential diagnosis,CP,MS,parkinsonism,ALS,brainstem
stroke,traumatic brain injury
 Differential diagnosis,dysarthrai Vs apraxia as both are motor speech
disorder but c/f will vary
 Apraxia,automatic movements are intact(nonspeech) where as dysarthria
isn’t
 Apraxia,inconsistent errors(hallmark) where as dysarthria highly consistent
articulation errors
 Apraxia, respiratory or phonatory involvement is rare where as in dysarthria
inclusion of all speech subsystem(respiration&phonation)
 Types –flaccid
-spastic
-ataxic
-Hypokinetic
-hyperkinetic(quick,slow,tremors)
-mixed
Amyotrophic lateral sclerosis :
-combined spastic&flaccid dysrathria will cause detoriation of speech
- slow rate,low pitch,hoarse &strained quality
-highly defect articulation,marked hyprnasality

Parkinsonism :
-hypokinetic dysarthria
-vocal pitch &loudness are flattened
-monotony
-consonant articulation in contextual speech & syllable repetition is
blurred
Pseudobulbar palsy :
-Speech is slow &labored
-articulation is consistently imprecise
-pitch is low & monotonus
-voice quality is harsh & strained

Bulbarpalsy :
-hypernasality(nasal emission of air during speech)
-inhalation is often audible &exhalation is breathy
-articulation is often imprecise( due to insufficient intraoral breath pressure
or immobility of the tongue & lips due to impairment of
hypoglossal&fascial nerves which prevent normal production of vowels
&consonants)
Dystonia:
-involuntary body &fascial movements cause unpredictable voice
stoppages
-disintegration of articulation
-excessive variation of loudness & distortion of vowels
- slow in rate and reduce loudness &pitch,prolongation of interword
intervals
Choreoathetosis :
- involuntary movememts that alter normal breath cycle result in sudden
exhalatory gusts of breath
-burst of loudness,elevation of pitch &disintegration of articulation
-overall loudness level may increased
-prolong pause and equalizing stress on all syllables &words
 ASSESSMENT FOR DYSARTHRIA
 Based on impairment and functional limitation
IMPAIRMENT:
- focus on speech production process
ie.,weakness,slowness,discoordination/abnormal tone of speech
-speech mechanism,includes respiratory,phonatory,velopharyngeal,or oral
articulation subsystem
-assessing respiratory subsystem begins with perceptual measures
ie., ratings of no.of words produced per breath
Instrumental approach;
-includes acoustic measures of vocal intensity & utterance durations
-aerodynamically,respiratory performance assessed by estimating the subglottal air
pressure generated by the speaker
-respiratory inductive plethysmography,information about the movement of ribcage
and abdomen during breathing and speech
Assessment of phonatory/laryngeal subsystem
-begins with perceptual ratings of pitch charateistics (eg.,pitch level,pitch
breaks,monopitch,voice tremor)
loudness (eg.,monoloudness,excess loudness,variation of volumes)
voice quality (harsh voice,hoarseness,wet voice,strained voice)

Istrumental approach;
-acoustically,vocal fundamental frequency &intensity can be measured
-aerodynamically,measure of laryngeal resistance
Assessment of velopharyngeal
-this mechanism can be measured with perceptual judgments of
hypernasality
-nasalization can be measured acoustically
- precise interferences can be made about timing of velopharyngeal
closure by obtaining simultaneous aerodynamic measures of air pressure
and airflow during selected speech sample
-movement of velopharyngeal mechanism can be observed through
cineradiographic techniques
Assessment of oral articulation
-can be made perceptually by rating consonant and vowel precision
-movement can also be interfered using cineradiographic technique
&myoelectric activity with EMG technique

Assessing the functional limitation:

- measures,speech intelligibility (measures speak rate useful index of
severity of disorder)
TREATMENT
Fix the goal(vary according to the severity of disability &disorder)
Severly affected:
-intelligibility is poor,that they are unable to communicate verbally
-goal,involves establishing functional means of communication using
augmentative approaches
-communication augmentation refers to any device designed to
augment,supplement or replace verbal communication
- system ranges from communication boards &books to computer based
speech synthesis system
-selection of appropriate augmentation system is needed to evaluate
person communication needs
-other test,cognition,language,memory,physical control,vision and
hearing
Moderately involved:
-who are unable to use speech as their sole means of communication but
are not completely intelligible

-goal involves maximizing intelligibility

-training include establish appropriate speech rate also involve

prosthetically managing severly impaired velophryngeal mechanism
through use of palatal lift,which is dental retainer with a shelf attached to
elevate soft palate necessary to reduce hypernasalation &nasal air
emmision,better speech sounds

-other way is to control the no.of words per breath and to stress important
words in sentence
Mild involvment:
-characterized as intelligible but less efficient and less natural than normal
-treatment planning must first determined whether there is handicap
-goal should be fixed whether treatment is needed or not
Other:
-treatment approach for other clinical condition will vary
-initially the patients are encouraged to maximize the functional
communication level by paying specific attention to clarity and consonant
emphasis and reducing no.of words per breath
 LARYNGECTOME REHABILITATION
- Cancer of the larynx,treated by surgery,irradiation &chemotherapy
- Extent of tumor,presence of diseased lympnodes,selection of specific surgical
procedure is needed
- eg.,if any laryngeal tumor is removed yet voice is maintained,
post.op rehabilitation is needed for compensation of swallowing than voice
restoration
Rehab:
-total laryngectomy remains a common procedure for the treatment of
laryngeal cancer
-goal is to obtain speech rehabilitaion,tracheostoma care,&adjustment to
tracheostoma breathing
-ie.,patient must adjust to relatively dry air entering the lungs without
benefit of mucosal humidification from the nose,mouth &pharynx
-they are in need of humidifiers and moist stomal covers to prevent
crusting,prevent formation of mucosal plug,especially few months of post-
op
SPEECH OPTIONS
 Several options available for speaking
 Which is electrolarynxes and pneumatic external reeds offer most
patients an opportunities to speak within days after surgery
 Tracheal esophageal puncture(TEP)with insertion of small one-way
valved prosthesis enable some laryngectomes to produce an esophageal
vibratory voice
 Final option is to learn esophageal speech
ELECTROLARYNX

Vibratory sounds either directly into the oral cavity

via catheter or indirectly via neck tissues
PNEUMATIC REEDS

-Type of external voice prosthesis

-This device placed over tracheastoma

to allow exhaled air to pass across reed to
produce tone

-Inexpensive and produce a pleasant

quality of voice
TRACHEAL-ESOPHAGEAL PUNCTURE

Tracheo Esophageal Speech is

accomplished by the
presence of a
Tracheo Esophageal
Prosthesis which
is inserted through the
TracheoEsophageal Puncture
(TEP).
APHASIA
 Is a disorder of both the expression &reception of propositional
language secondary to cortical or subcortical disease,usually in left
hemisphere

 Symptoms may be part of diffuse pathologic condition,

ie.,there will be disruption in their ability to manipulate lingustic
symbols,such as disorientation
 CLASSIFICATION OF APHASIC SYNDROME
FLUENT:
ANOMIA - word finding difficulty without other serious linguistic deficits
CONDUCTION- good comprehension;deficits in repetition of low
probability phrases
WERNICKE- phonemic &semantic paraphasias;poor comprehension
TRANSCORTICAL SENSORY – fluent neologistic language,poor
comprehension,intact repetition
Nonfluent type
BROCA
-telegraphic,agrammatic expression often associated with apraxia
TRANSCORTICAL MOTOR
-limited language output,intact repetition,fair comprehension
GLOBAL
-severe expressive&receptive,reduction in language
MIXED TRANSCORTICAL
-severe reduction in expression &reception,repetition intact
 DIFFERENTIAL DIAGNOSIS
AGNOSIA
-inability to interpret or recognize information when end organ is intact
-eg.,pt with auditory agnosia would have normal hearing threshold but cant
interpret speech signals at the cortical level
-hence there will be impairment in only one modality
APRAXIA
-speech is characterized by labored &dysprosodic productions resulting in
errors of ommision,substitution & repetition
-have difficulty programming the positioning of the speech musculature
&sequencing the movement for speech
DEMENTIA
-syndrome of progressive cognitive deterioration that affects ability to
communicate
-expressive &receptive language deficit will be present
CONFUSION
-is characterized by reduced recognition,reduced understanding &
responsiveness to environment,faulty memory,unclear thinking
&disorientation
-often associated with head trauma
TEST FOR APPHASIA
Minnesota test
-differential diagnosis of aphasia
-is most comprehensive test battery
- it has 47 subtest,need 3hr to administer
-particularly useful fore recognising &classifying deficits of auditory
comprehension
BOSTON
-boston diagnostic aphasia examination(BDAE)
-27 subtests &additional group of non-language based subtests as a part
of battery to evaluate parietal lobe dysfunction
-useful in assessing the deficiencies in language consistent
WESTERN APHASIA BATTERY
-is modification &expansion of BDAE
-auditory&expressive modality scores yeid a aphasia quotient(score below
93 is consistent with aphasia)
-Performance quotient on basis of
reading,writing,drawing,calculation,block design
-summary ofcognitive function combines AQ&PQ scores(useful after
traumatic injury)
PORCH INDEX OF COMMUNICATIVE ABILITY
-contain 18 subset
-Need 40hr
-uniqueness has its 16 pt scoring scale,every response on each subtest is score
from 1 to 16
TOKEN TEST:
-design to detect auditory comprehension disorders
-pt given 20 tokens with two shapes,two size&five color &asked to
manipulate them in their known language

READING COMPREHENSION BATTERY

-10 subtest used to assess reading skills
-Subtest includes comprehension of morphosyntactic structure,functional
reading,sentence &paragraph comprehension
 TREATMENT
 Focus of aphasic remediation has been on stimulation-facilitation
approach,which pt&clinician interact within stimulus-response framework
 Speech pathologist must analyze the pt communicative strengths&weakness
 Training in communicative interaction must focus on following:
-appropriate rates of auditory presentation&importance of pause times
-differences between concrete&abstract language
-use of redundancy to improve comprehension
-utilization of contextual cues to comprehend what pt may
communicating
-ways to verify message from the pt
-ways to combine gesture &oral language to facilitate communication
-allowing appropriate amount of time for pt to formulate response before
restimultion( questioning&repeating)
 SWALLOWING & ITS IMPAIRMENT
 Is process in which the substances pass from mouth to pharynx into
esophagous by closing epiglottis
 Is important for eating &drinking
 Source of hydration &aligmentation
 Crucial role in maintaining airway integrity
 Abnormal swallowing(dysphagia) may lead to
dehydration,starvation,aspiration,pneumonia,or airway obstruction
 Dysphagia is frequently associated with CVA, TBI,head &neck
cancer.,,
 PHASES OF SWALLOWING
Dysphagia, can occur at any of the three stages in the swallowing process.
 Oral phase: Sucking, chewing and moving food/liquid into the throat
 Pharyngeal phase: Starting the swallowing reflex, 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 of the openings at the top
and bottom of the esophagus and squeezing food through the esophagus
into the stomach
 EVALUATION OF SWALLOWING
 It includes medical history
 Description of complaint
 Physical examination of peripheral deglutitory motor and sensory
system, including trial swallows under observation
 Diagnostic studies including video fluorography, manometry, EMG and
fiberoptic endoscopy
 HISTORY
 Neurologic History
 Stroke, headtrauma, parkinsonism or central demyelinating
diseases which may cause dyspthagia
 Prior operation should be noted (head and neck)
 Side effects (Sedation, muscle weakness, drying of mucous
membranes, dyskinesia) may contribute dyspthagia
 Anticholinergic and psychoactive medication are specially noted
 Psychosocial factors
 Elderly individual who lives alone
DESCRIPTION OF COMPLAINTS
 Data include
 Sensation of food sticking in the throat / chest

 Difficulty initiating swallowing

 Occurrence of coughing or choking associated with eating, drooling

 Wt loss, change in diet or eating habits, episodes of aspiration

pneumonia

 Symptoms of GERS

 Difficulties swallowing solids and liquids should be compared

 Pt with neurogenic swallowing impairment (coughing or choking
during drinking)
 Foodway obstruciton (food sticking in throat or chest) bulbar palsy,
tumor usually associated with disease of the escophagus or GES
 GES (Pharyngeal dysphagia), Nasal regurgitation with is associated
with weakness of palatopharyngeal mechanism
 Cancer of esophagus (pain on swallowing, odynophagia), heartburn,
acid regurgitation
 Aspiration pneumonia (reflux of stomach contents especially at night)
 Other factor weightloss of change in eating habits reflect with problem
in swallowing
 CLINICAL EXAMINATION
 CP, GI or Neurologic disease that may impair swallowing
 Assessment of mental status and pt cooperation
 Screening of language function (e.g. following spoken commands,
expressing thoughts), memory and visual-moto-perceptual function is
helpful
 Cranial nerves should be assessed carefully
 RS, examination of obstruction or restriction (tachypnea, stridor, use of
accessory muscles, paradoxic motion of chest wall or labored breathing
 Speech is examined (evidence of dysarthria)
 Head and neck are inspected and palpated (structural lesions)
 Hyoid bone and laryngeal cartilages are palpated carefully and
gently mobilized
 Facial sensations is checked bilaterally
 Facial expression is noted (muscles of face, mouth and neck)
 Masseter and temporalis can be palpated (patient bites and
chews)
 Movements of lower jaw are assessed
 Intraoral mucosa is examined (careful attention of lesions, oral
debris, abnormal movement and dryness)
 Assessment of Tongue Strength (resistance)
 Inspection of Palate (symmetry at rest and during phonation), each side
of palate is stimulated and gag reflexes are observed
 Soft palate and pharyngeal walls should contract briskly and
symmetrically, but gag reflexes may be difficult to elicit in some
normal individuals
 Presence of primitive reflexes associated with chewing and swallowing
(sucking, biting or snout reflexes) should be noted
 These pathologic reflexes are often found in pt with B/L hemispheric or
frontal lobe damage and may indicate impairments of oral motor
control
 COMPREHENSIVE EXAMINATION
 Observation include while pt eating and drinking

 The examiner observes for the promptness of the swallow and palpate
the anterior neck to assess the adequacy of laryngeal elevation

 Behaviors should noted (drooling, slow rate of eating, residual food in

the mouth after swallowing, frequent throat clearing, change in voice
quality and posturing of head and neck with swallowing)

 Spoonful of crushed ice, soft solid food laryngeal elevation

adequate protective cough mouth retention after swallowing
 DIAGNOSTIC STUDIES
 Videoflurography swallowing study(to have the patient eat &inspect for
any modification)
 Empirical approach,identify variables such as safe & unsafe
swallowing such as physical consistency of food,posture of pt(position
of head&neck)
 Variables are altered systemically during VFSS
INDICATIONS FOR VFSS
 Frequent choking episodes
 Difficulty managing secretions
 Wet-hoarse voice quality
 Respiratory complications
 Unexplained weight loss

CONTRAINDICAITONS
• Severe respiratory dysfunction and in-cooperate pt
 X-ray films, detect morphologic changes in pharynx or esophagus (not
useful in studying dynamics of swallowing)
 Fiberoptic endoscopic examination of swallowing (FEES), to detect
aspiration in patients for whom radiographic studies are difficult,
benefit of direct visualization of pharynx and larynx to inspect for
mucosa lesions or motion impairment of vocal folds
 Esophagoscopy is essential for detecting a variety of esophageal and
GES disorders
 Electrodiagnostic studies, detect motor unit dysfunction of larynx,
pharynx and oral musculature
 MANAGEMENT OF SWALLOWING
IMPAIRMENT
TECHNIQUE
Flex neck
Turn head to once side
Hold breath before swallowing
Thicken liquids (avoid thin)
Thin liquids (avoid thick)
Slow rate of eating
Mendelsohn maneuver
Glottic adduciton exercise
Use glossectomy spoon
DESIRED EFFECT
Reduce aspiration
Direct bolus to ipsliateral side (away from
side of weakness)
Seal larynx, reduce aspiration
Reduce aspiration, improve bolus control
Reduce pharyngeal retention
Improve oral bolus control, avoid
overloading pharynx
Prolong PE spincter opening, improve
pharyngeal clearance
Improve airway protection, reduce
aspiraiton
Bypass anterior mouth, place food directly
into posterior oral cavity
 TECHNIQUE DESIRED EFFECT
Stimulate soft palate with cold Increase sensitivity for eliciting swallow
Feeding gastrostomy Bypass oral cavity and pharynx

Glossectomy spoon
STIMULATION OF SOFT PALATE WITH COLD
MENDELSOHN MANEUVER
GLOTTIC ADDUCTION EXERCISE

 Sit on a chair and grip the sides of the seat with both hands.
 While saying each number from one to 10 out loud, pull up firmly on
both sides of the seat, then relax and inhale naturally before saying the
next number.(valsalva maneuver)
 Repeat this exercise for a total of two sets in both the morning and
evening, for a total of four sets per day.
 Each set takes about 30 seconds to perform, requiring only two minutes
of daily exercise.
 It is possible to prevent contraction of the pharyngeal cavity and of
supraglottal structures
HEARING LOSS
 According to WHO hearing
impairment refers to
complete or partial loss of
ability to hear of one or both
ears.
 Level of impairment could be
mild,moderate,severe
 DEAFNESS,refers to
complete loss of ability to
hear from one or both ears
AUDITORY & ITS IMPAIRMENT
 DEFINITION OF AUDITORY REHABILITATION:
is an ecological,interactive process that facilitates one’s
ability to minimize or prevent the limitations& restrictions
that auditory dysfuction can impose on well being
&communication,including
interpersonal,psychosocial,educational,&vocational
functioning
CLASSIFICATION OF DEAFNESS
 According to
CLINICAL
0 to 25dB : normal for all
Other:
26-40dB : mild deafness
41-55dB : moderate deafness
56-70dB :moderately severe deafness
71-90dB :severe deafness
Above 90dB :profound deafness
CLASSIFICATION OF HEARING LOSS
HEARING LOSS

acquired congenital

Organic functional conductive mixed

sensoneural
 Conductive hearing loss:
-the conduction of the sound to the cochlea is impaired
-caused by external&middle ear disease
• Sensorineural hearing loss :
-due to defect in the conversation of sound into hearing loss
or transmission of those signal into cortex
-can be caused by disease of cochlea,acoustic nerve,brainstem
or cortex
• Mixed hearing loss :
-conduction of the sound to the cochlea is impaired
IMPACT OF HEARING LOSS ON QOL
 Physical health
 Emotional &mental health
 Social skills
 Family relationship
 Self-esteem
 Work&school performance
TRADITIONAL VARIABLES
 Time of onset
 Degree of loss
 Type of loss
 etiology
HISTORY
 Onset(sudden/gradual)
 Duration
 Uni/bilateral
 Continuous/intermittent
 h/o of exposure to noise
 Head trauma/surgeries
 Associated symptoms(pain,discharge,tinnitus,vertigo)
SERVICES INCLUDE:
 Diagnosis &qualification of hearing loss
 Hearing assistance technologies
 Auditory training
 Communication strategies training
 Information/educational counselling
 Personal adjustment counselling
 Psychological support
 Communication partner training
 Speechreading training
 Speech language therapy
 Inservice training