Mr. Johnson, a 45-year-old male and a successful attorney, is married and has no children. One day as he was walking up to the door of his apartment building, he became the victim of a drive-by shooting. He was injured, and his MRI shows left brain damage, which includes damage to his entire left perisylvian area, including the superior temporal gyrus, area triangularis, the inferior part of the parietal lobe, the arcuate fasciculus, and the inferior portion of the primary motor cortex. The shooting occurred a month ago, and he is now medically stable.
Johnson’s head trauma caused mainly damage to his left hemisphere, which is involved in executing most of the language components, including reading, writing comprehension, expressive and receptive (Brook, 2021). The left-brain lesion that involved damage with areas such as the perisylvian area and pars triangularis of the inferior frontal lobe resulted in Broca’s aphasia. Damage in the superior temporal gyrus may result in Wernicke’s or receptive aphasia (Rouse, 2020). Mr. Johnson’s medical report includes damage to the Arcuate fasciculus, which refers to a group of nerve transmitters that connect both areas of Broca’s and Wernicke (Rouse, 2020). These areas are responsible for speech production, clarity (e.g., intelligibility), and language understanding.
In addition, he experienced damage to the right parietal lobe, which can result in neglecting part of the body or space (contralateral neglect). This can impair many self-care skills, such as dressing and washing. Additionally, right-side damage can cause difficulty in fine motor skills (constructional apraxia), denial of deficits (anosognosia), and drawing ability (Hallowell, 2017). Despite the head trauma, Mr. Johnson is medically stable; however, he is unable to read and write due to the damage to the brain’s left hemisphere. The patient needed a speech-language pathologist (SLP) to complete a comprehensive speech language evaluation to determine his abilities and weaknesses for inpatient rehab.
The hearing test aims to identify if the client is at risk of having any hearing deficit or disorder due to stroke, head injuries, or aging. Johnson suffered from a head injury that might impact hearing ability, affecting adults’ communication and quality of life (“American speech-language-hearing association,” n.d.). The SLP will start the screening process by collecting information from Johnson’s wife. The SLP needs to verify from the wife if the client exhibits any concerns about his hearing ability. The wife will explain if she needs to speak louder so Johnson can listen. The SLP should learn if the client gets frustrated by noises. It is also vital to understand whether the client has reduced ability to listen to others in different settings (e.g., noise and quiet environments). Then the pathologist will conduct a hearing screening. Afterward, if the client shows hearing concern, the physician will refer Johnson to an audiologist to conduct a further hearing assessment to diagnose and set prevention action and intervention plans.
The SLP will ask Johnson and his wife if the patient has any concerns about his voice audibility and its impact on their communication. The pathologist would want to know whether Johnson’s voice when speaking is of low volume, which can cause his partner difficulty hearing. The SLP then will analyze Mr. Johnson’s voice to see if he exhibited changes in voice quality, such as hyponasality, hypernasality, or low and high pitch. In hyponasality, the patient’s voice sounds blocked, and the speech is generated by too little air getting through the nose. If any voice changes are evident, then the SLP will conduct further testing or make a referral for an SLP with voice experiences.
Fluency skills was found to be associated with activation more anterior-ventrally in left inferior frontal gyrus and Mr. (Shao al et., 2014). Johnson case history stated that the area was impacted from his head injury, so the SLP should conduct verbal fluency assessment. The SLP could be conducted using formal and informal assessments. The SLP could collect speech sample while interacting with the client and see if Mr. Johnson exhibits any disfluency characters such as using “um, repeated word, syllable and had blockages.” The SLP could also conduct a formal test such as fluency subtest within the CLOT. The subtest refers to as “generative naming”. The SLP asks the client to orally produce words beginning with a given letter, M in one minute. Also ask Mr. Johnson to say all the animals he knows in 1 minute. Some studies (Henry and Crawford (2004) suggested that verbal fluency performance reflected working memory and executive functioning. The patient has to exercise word retrieval, effortful self-initiation suppresses repetitions and control the time execution of the task (e.g., number of words produced in 1 minute)).
No concern was given in the case history; however, the SLP will conduct the bedside screening from the WAB to see if the client had any issues in this matter. The client will follow the instruction of the SLP while drinking or eating some food. The pathologist will ask the client to drip 30 ml of water to hold in five seconds, then swallow and cough after consuming. Also, the SLP should ask the client and the caregiver if the client exhibits any concern with swallowing behaviors. If a situation is noted, the SLP will conduct future testing, such as FEES.
Since Mr. Johnson’s lesion occurs in the left brain and impacts both areas of language, including Broca’s and Wernicke, I would conduct a modality assessment for several reasons. If Johnson exhibits apraxia with Broca’s, the speech might exhibit low intelligibility, affecting his life quality. Studies show that adults with apraxia and Broca’s experience emotional stress and frustration due to limited ability to communicate about their needs. They feel the terms are in their mind and mouth but not coming out due to anomia, and when words come out, they are incorrect due to the brain condition. The client might want to say “give me,” so he will say “hef me,” “hep me,” or “hed me,” repeating the phrase until they finally get it right after five or six trials of speaking. This will cause them frustration. Therefore, an AAC device will be recommended to allow the patient to communicate his needs and adapt to the community. The assessment will include testing three devices to select the best fit for Johnson’s positioning and needs.
The SLP starts this assessment using an informal subtest from the WAB, or the SLPs generate their own. During the bedside screening, it is administered in 5-10 minutes, and the SLP investigates if the client exhibits cognitive challenges to conduct further exploration. The SLP will help with formal testing of the Cognitive Language Quality Test (CLQT) to examine the impact of brain injury on cognitive skills. The test investigates the cognitive abilities of attention, executive functions, logical reasoning, visual-spatial ability, memory, and auditory recognition. The integrity of these components does not require verbal responses. It is suitable for patients with all aphasia, including severe aphasia (Conti, 2017). The test includes nonverbal tasks such as design generation, symbol trails, mazes, clock drawing, and symbol cancellation.
During the attention subtest, the client completes the symbol cancellation task. The patient will look at one image and then find and mark them from scattered images. Executive functioning is conducted using maze design generation by connecting dots to form different designs (Henry & Crawford, 2004). Johnson has a brain injury and damage on the left side, leading to language challenges. The damage on the right side causes problems with memory, attention, etc. (Conti, 2017). The pathologist needs to investigate which cognitive domain is impacted after the injury to determine therapy plans.
The Western Aphasia Battery (WAB) tests language and nonlinguistic abilities most commonly impaired by aphasia in adults. It examines linguistic skills, including information content, fluency, auditory comprehension, repetition, naming and word-finding, reading, and writing. The expressive language includes spontaneous speech that is collected by introducing six questions. The speech sample intends to examine grammar and sentence structures (syntax). Additionally, the client will describe given images using phrases and sentences that the SLP will analyze later. During the receptive subtest, the patient will look at pictured objects, letters, and numbers and point to what the examiner says. The test takes thirty to sixty minutes to administer, based on the degree of the client’s aphasia and any accompanying abnormalities such as apraxia or dysarthria using the repetition subtest.
The SLP asks the patient to repeat words, phrases, and sentences of increasing difficulty with 15 items. The SLP selects this test to identify what type of aphasia the patient had and the location of the lesion causing aphasia. The case history indicated that the client had injured the left side of the brain; however, it does not affirm that only his left side was impacted. Thus, it is recommended to identify what type of aphasia (e.g., Global, Broca’s, Transcortical motor, Wernicke’s, Transcortical sensory, Mixed transcortical, Conduction, and Anomic) he has. Brain injury impacts speaking and may make it hard for the patient to understand spoken language, so it is vital to conduct the assessment.Additionally, it provides informal testing for the severity of the expressive and receptive language to select appropriate therapy plans.
They are collected from formal testing such as the WAB and retelling the story section from CLOT. The client will listen to a short story and retell it using his words and whatever he could recall from the details. In the WAB test, the client needs to answer six questions using sentences. It explains what type of sentences, phrases, and words the client produced to communicate. The testing explains if the client uses more nouns and fewer verbs or vice versa. Some clients might have no articles and substitute letters or nouns within the same categories. For example, the client will say cat for dog and “mat” for “pat.” The case study does not specify the client’s errors in the language, so a language sample will allow the SLP to find out about that.
The medical history shows that Johnson has damage within the inferior part of the parietal lobe within the left hemisphere. Damage in this area can result in what is called “Gerstmann’s Syndrome.” It includes right-left confusion, difficulty with writing (agraphia), difficulty with mathematics and the inability to perceive objects normally (agnosia) (Hallowell, 2017). Mr. Johnson is a lawyer and writing is a major component of his daily career. Then the SLP should conduct a writing assessment to evaluate the strength and weakness of this skills in order to help the client to adapt into the community and maintain independency. This assessment also will help in selecting goals and treatment plans. Thus, reading assessment is recommended to examine the severity rate of this skills. Mr. Johnson is a lawyer, and his job requires to read claims, reports, email and resources, so it is important to evaluate his reading for selecting goals and intervention plans as well.
The case study stated that Mr. Johnson experienced right-side brain damage that might cause difficulty making things such as (constructional apraxia), denial of deficits (anosognosia) and drawing ability (Hallowell, 2017). The assessment was conducted using formal and informal testing. The SLP will informally show Mr. Jonson some written sentences and asks him to copy them. Formally the SLP will test the writing skills using the WAB subtest. It is administered for his age and medical condition. The writing assessment is essential to determine if Mr. Johnson can write his messages during his daily routines, such as medication notes, doctor appointments, etc. He is a lawyer, so he might continue to work, so he needs to enhance his writing skills impacted by aphasia. Additionally, writing is considered a strategy to communicate about the needs and wants. Mr. Johnson is a lawyer and will benefit from enhancing his writing skills if his aphasia impacts staying involved in the community and maintaining his quality of life.
No concern was given in the case history. However, the SLP will conduct the bedside screening from the WAB to see if the client has any issues in this matter. The client will follow the instruction of the SLP while drinking or eating some food. The SLP will ask the client to drip 30 ml of water to hold in five second then swallow and cough after the swallowing (Marinelli et all, 2017). Also, the SLP should ask the client and the caregiver if the client exhibits any concern with swallowing behaviors. If a concern is noted the SLP will conduct a future testing such as FEES.
The brain injury includes Hampshire, impacting Johnson’s communication skills and job. The traumatic brain injury (TBI) that Mr. Johnson experienced is extensive and might impact his cognitive/linguistic and motor speech disorders. His lesion occurred in the left part of the brain, the area affecting the functioning of both expressive languages with Broca’s aphasia. Broca’s aphasia refers to effortful speech with few expressive words. Thus, the brain injury exhibited changes in his language, including expressively, reading, and writing. His speech displayed reduced intelligibility. He has word-finding difficulties, which cause frustration and breakdown in communication. Mr. Johnson is a lawyer, and his job requires him to present reports in court using fluent and accurate speech. He cannot be standing in the court trying to find words to express his thoughts. Due to all these reasons, using the AAC device will assist him in delivering an accurate and fluent speech promptly.
Additionally, he is a successful lawyer, and it is important to support him to stay independent and active in the community. Using an AAC voice generator device will be helpful to express his need in a word and with his spouse. The AAC will deliver his message clearly. The usage of AAC device does not imply that he is not intelligent or cognitively diable (“American speech-language-hearing association,” n.d.). The SLP will select a mobile AAC device providing a speaking voice. The device can be software that the client accesses through any smart device (e.g., phones and laptops) and a high-technology AAC (Beukelman et al., 2007). It provides compensatory communication strategies such as voice, drawing, and writing to support the understanding of communication messages by individuals with TBI and their communication partners.
Individuals accept AAC devices to communicate their needs and allow them to engage in activities in which they perceive themselves as competent, and that promote their self-esteem & self-satisfaction. Mr. Johnson should maintain his participation in the community despite his disability. Additionally, the AAC device will help communicate between Mr. Johnson and his spouse to avoid breaking down communication or withdrawing socially and maintain quality of life (Shao et al., 2014). Some clients with aphasia intend to stop talking and interacting with caregivers and others in the community. He will benefit from the AAC device to maintain his participation in the community and enhance his quality of life.
One of the new speech-generating devices allows smartphones to provide a more robust language system. Such an option of the speech-generating device is more flexible and can be used in various conditions. The smartphone-like operational system can be adjusted to different events and practices by downloading particular semantic word groups.
The Western Aphasia Battery (WAB) is a diagnosing test that evaluates persons with aphasia’s language and nonlinguistic abilities. This data aids in identifying the kind of aphasia and the position of the aphasia-causing lesion. It provides a baseline for detecting changes during treatment by measuring how the patient did on the test. This also helps assess the patient’s linguistic skills and weaknesses. The WAB is aimed toward English-speaking grownups and patients between 18 and 89 who have neurological diseases (Barfod, 2013). Speech, fluency, auditory processing, reading, and writing are among the evaluated language abilities. Drawing, mathematics, block design, and apraxia are among the assessed nonlinguistic skills.
The aphasia quotient (AQ) is the statistics representing the total degree of language impairment. The WAB, a whole battery of eight subtests, keeps the present measure’s structure, general content, and clinical relevance while making several enhancements. The therapist will be aided in discriminating among surface, deep (phonological), and visual dyslexia by two novel extra measures (reading and writing of unusual and non-words). A quick check of the patient’s performance is provided by reviewing around 15 elements and a bedside WAB–R. The WAB subtest includes an examiner’s guide with knowledge regarding analytical or psychometric attributes, a test explanation applicable to aphasic communities, a historical indication of validity and reliability, and details about the distinctive elements of evaluating the linguistic competence of people with dementia (Barfod, 2013). Spiral-bound stimulus book replacing loose stimulus cards changed administering directions to a more accessible with guidance to the examinee for all subtests, extended scoring rules for clarity, and it aids in the categorization of aphasia into several forms are among the WAB subtypes. The time which is required for completing particular action is within one-minute period.
The rationale for WAB is selected because it aims to identify what type of aphasia the client has. The SLP will determine if the patient has expressive, receptive aphasia or mix and the severity. The case history indicated that the client had an injury on the left brain, but that does not affirm that the impact completely damages only his left side. Thus, it is recommended to identify what type of aphasia the client is experiencing. The patients with the left hemisphere damage have more severe problems with the language than people with right hemisphere contractions. “Left hemisphere (LHD) patients with aphasia on traditional measures (WAB) performed worse than controls and non-aphasic LHD patients on all neuropsychological domains suggesting that aphasia affects other aspects of cognition” (Kertesz, 2020).
It assessed adults ages 18–80 with communication or cognitive deficits due to a neurological injury (TBI traumatic brain injury). The test is criterion-referenced to identify moderate-level impairments, and the obtained scores are also criterion-referenced. This test’s results help with selecting treatment targets and functional treatment goals (Boone et al., 2020). It takes 30 minutes, so it will not exhaust clients during the process of administering the test (Marinelli et al., 2017). According to his medical record, Mr. Johnson has a brain injury that impacts both left and right hemisphere The SLP will select this assessment because his age is within the testing age range (e.g., 45 years old). He also had a medical diagnosis (TBI) that supported the selection. In addition, the test could help the SLP identify the impairment locations, such as left and right hemispheres versus mixed neurological deficit. The client had an injury that mainly occurred in the left hemisphere, but the right side might be impacted due to the severity of the injury.
The estimation of the life quality of the patients with aphasia is vital to understanding their needs. It can be performed through the Stroke and Aphasia quality of life scale, including the self-reports regarding the patient’s physical, moral, and emotional state. Assessing the health-related quality of life, especially self-reported, can be helpful in rationally identifying the needs of the client and enhancing the particular conditions (Ross, 2005) to increase motivation and prevent social and communication withdraw. The treatment outcomes directly depend on how the progress or regress is estimated.
Aphasia therapy is very diverse and tailored to meet the patient’s requirements. This is an essential issue in therapeutic interventions if abilities and tactics can be extended to the majority, if not all, communicative settings. Physical and occupational therapists are experts that might assist Mr. Johnson since they are focused on the patient’s requirements and goals. Each professional brings their clinical experience and judgment to the table. Each profession’s diagnostic and treatment approaches are founded on core ideas validated by external scientific data.
The patient should also consult other clinicians in order to check the general condition and get further instructions. First, visiting radiologist can be rational to identify which additional assessments should be held. Second, consulting an ACC specialist is vital for the efficient evaluation and planning the future interventions. The client also should visit a neurologist to define the extent to which the Johnson brain functions are distorted. The psychologist can also help the client overcome mental problems by accepting the current state. As far as Johnson has difficulties working as a lawyer after his leisure, the occupational therapist should direct the patient and find the possible working alternatives. ACC device affects the general quality of life from physiological and psychological perspectives. However, visiting mentioned specialists can significantly decrease the negative consequences.
Client with aphasia experienced difficulty finding words (e.g., nouns), so the therapeutic approach of Semantic Feature Analysis (SFA) is recommended. The process will enhance his semantic vocabulary and reduce communication breakdowns. SFA concentrates on identifying and expressing the significant features of nouns during a communication breakdown with the support of a graphic chart. The patient can use the chart to identify different categories of items (e.g., food, office supply, vehicle, tools etc), describe color, function, use, and association. In other words, the patient identifies an object or the attempted word using series of questions. For example, if a patient struggles with the term “medication container” , SLP helps them identify the color of the container, its location, use and other possible associations As a result, the patient is able to say, “I need the red plastic box that is located in the refrigerator, and used for my heart pain.” During the process, patients memorize vocabulary based on cognitive associations or semantic features. Such an approach helps to make the client’s speech more fluent and accurate. Additionally, SFA has been demonstrated to generalize or enhance word-finding for new terms.
The Communicative Drawing Program (CDP) concentrates on the utilization of drawing as a form of communicating when words are not available. It is designed for individuals with acute aphasia who have difficulty expressing themselves verbally and in writing. Drawing is essentially nonlinguistic approach; therefore, this might be effective even in patients with severe aphasia, according to one basic premise of CDP. In any event, CDP was created largely as a means of communication compensation (Hallowell, 2017). In the treatment of aphasia using CDP, ten steps are carried out.
The first step of CDP requires the patient to recognize and identify the different categories of objects by circling elements that belong to the same set. The second procedure is to provide the client with a set of twelve color markers and instruct the patient to draw clear black and white lines on the objects correctly. Thirdly, the physician should let the patient to trace along the contour of the drawn line as it enables the client acknowledge items. The patient is then asked to copy some geometric shapes to aid in drawing images of correct shape and sizes. The fifth step requires the caregiver to provide object pictures with parts missing and let the patient fill the parts using black pen (Hallowell, 2017). The sixth step requires clients to sketch a picture that was introduced to them and then taken away. The next procedure instructs the patient to sketch a recognizable and appropriate drawing of any object that the caregiver will describe to them (Hallowell, 2017). The client is told ten category names and the patient asked to draw any item in the group until it is recognizable. The ninth step requires clients to draw many items in any category without presented examples. The final step needs patients to draw and illustrate cartoon story that enables anybody to understand and interpret it.
The traumatic brain injury (TBI) that Mr. Johnson experienced is extensive and will impact his cognitive/linguistic and motor speech disorders. His lesion occurred in the left brain, and that area will affect the function of both expressive languages with Broca’s and might include apraxia with speech. Broca’s aphasia refers to effortful speech with few expressive words. Mr. Johnson is a lawyer, and his job requires him to present a report in the court using fluent and accurate discourse. He cannot be standing in the court trying to find his words because he has to express his words in time manners, so using an AAC device will assist him in delivering his speech accurately and promptly. If he had apraxia of speech, he would speak incorrect words he might produce “fan for man.” Apraxia causes patients to produce inadequate speech production due to coordination between motor planning and speech production, so AAC device is recommended to prevent miscommunication and communication breakdown.
Additionally, if he exhibits Wiencek’s aphasia, he will also benefit from using AAC to deliver correct words and sentences related to the given topic. The use of AAC will allow Mr. Johnson to maintain his participation in the community despite his disability. Moreover, the AAC device will help communicate between Mr. Johnson and his spouse to avoid breaking down communication or withdrawing socially and maintain quality of life. Some clients with aphasia intend to stop talking and interacting with caregivers and others in the community. He will benefit from an AAC device to maintain his community participation and enhance his quality of life.
In order to improve the quality of life of people with aphasia, different AAC devices can be used (Ross, 2005). Considering the fact that the patient is a lawyer, he needs the storage for files and quick search. SLP might recommend generic tablets with smartphone operating systems in such a situation. In other words, the non-dedicated devices with specific AAC applications may be relevant in such cases.
I would recommend Johnson and his spouse to join aphasia support forums. Participation gives them a chance to communicate with both each other and people with the same medical condition. Existence of a shared community helps the couple adjust to a life with aphasia. Such activities also allow them to share their feelings, and learn different coping strategies. Group aphasia therapy, compared to a hospital stay contributes to a more organic and healthy educational experience. Every individual in the group can discuss their own experiences, talk about potential strategies they used and assist those facing similar problems. Johnson, for instance, can obtain more information about using AAC devices, different communication approaches (supported conversation for adults with aphasia (SCA)).
Discussing other problems and recommendations, it is necessary to cover spousal challenges. Spouses also experience difficulty assisting their partners with limited communication and during communication breakdowns. The spouse is recommended to attend and be an active member in the aphasia support group.The spouse also could benefit from learning about SCA (Support conversation with adult) where the SLP will observe their interaction and provide them with strategies to enhance their interactions. Among the strategies, speaking slowly, using a smaller vocabulary a more friendly tone, asking open-ended questions can be beneficial. It is recommended to use questions such as “tell me what upsets you or what you like to eat”? Rather than asking the patient “why did you do that? What are you looking for.” The spouse could also summarize what the patient did using parallel talk. For example, “Today John decided to help me with the dinner and he was helpful because he did such and such”, etc. Finally, during group session the spouse gets support to allow him/her stay motivated and engaged with their partner. Recommended strategies for partners to use to increase the communication with the patient and support the spouse
The spouse is an essential component in having Johnson achieve his communication goals and enhance their joined quality of life. He will learn to use different communication modalities such as speaking, drawing and writing. ( Brook, 2021). Among the strategies, using simple yes/no questions to confirm understanding can also be utilized. Acknowledging communication breakdown and trying to fix it is an important part of change. Even when the patient cannot communicate verbally, their partner could learn about what he is trying to say or ask for clarification.
The caregiver helps the patient to point at an intended object or words they are struggling with. Additionally, the SLP and communication partner could collaborate to support the patient using SCI strategies. The role of the SLP is to observe the communication between the patient and the spouse and provide them with suggestions to support them and enhance their communication. For example, patient and caregiver can communicate throughout the day, as well as during each routine activity such as driving, shopping, gardening, shopping and watching TV. The more the couple communicate, the easier it is for a patient to communicate their needs. Communication slowly merges to be a normal daily practice. All of these strategies will increase opportunities for social connection.
References
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