Speech and Language Therapists (SLTs) work as an integral
part of the Multidisciplinary team (MDT) alongside other allied health
professions such as doctors, nurses, psychologists, physiotherapists and
occupational therapists. The team aim to provide a holistic care package to best
suit an individual’s needs.
are responsible for the assessment, diagnosis and management of disorders of
speech, language, communication and swallowing. They work with adults with brain
injury (ABIs) during the acute phase in hospital, throughout rehabilitation and
as outpatients or in the community. ABIs
(see stories link) may require speech and language therapy intervention in the
SLTs assess and treat speech and language
difficulties aiming to empower ABIs to communicate their needs and interact with
others. This not only increases their quality of life, but also promotes
independent living. Dysphasia is a language impairment which can result in an
individual having difficulties understanding and/or expressing themselves. For
example, AbIs may have difficulty understanding instructions and may have
trouble finding the right words in conversation.
Reading and writing are similarly affected.
Cognitive communication disorders are common in brain
injury as they affect more than just language function but a range of cognitive
functions such as memory, processing and attention. Cognitive communication
disorders can be mild or severe as in low awareness states where awareness of
environment and self is impaired and communication is limited and variable to
mild and minimally visible. ABIs may also experience speech difficulties such as
The terms dysarthria and dyspraxia may be used to
describe a motor speech disorder. This can be caused by muscle weakness and/or
impaired co-ordination between the brain and the muscles used for speech. SLT’s
may work on strengthening these muscles through exercise or consider
compensatory strategies such as Total Communication. SLTs work to improve
communication utilising a Total
Total Communication refers to the use of
gesture, drawing, pictures, writing and low and high tech communication aids to
assist with conveying a message. They will advise what strategies are most
effective with everyone involved in an individual’s care or treatment.
Communication difficulties can range in severity, from
profound difficulty with little or no ability to communicate or understand, to
mild impairment. The impact can affect many aspects of life including simple
tasks such as smiling to a relative, understanding questions to conversing with
friends. Later on it can affect an individual’s ability to participate in /
return to work or education.
For individual’s in a low awareness state SLTs aim to
assess and review their response to a range of different stimuli. These
assessments aim to establish if the individual has some awareness of themselves
and their environment and to identify any responses which could be used for
communication purposes. They will use a range of assessments to identify
communication behaviours such as the Wessex Head Injury Matrix.
They will often use everyday tasks such as
teeth cleaning or taste trials to work on assessment and development of
communication skills as these are more likely to elicit spontaneous responses in
SLTs need to take into account a number of
factors that may impact on communication such as vision, hearing, physical
ability and thinking known as cognition. Some of these are likely to be present
in a severe brain injury. As a result assessment and development of reliable and
functional responses for communication involves the whole team to identify the
optimum position and movement and how to help the individual to understand and
respond optimally. SLTs will wish to involve the families of individuals by
asking them for information about the individual’s lifestyle or to bring in
favourite things that are meaningful and may trigger a response.
The term dysphagia is used to describe swallowing
difficulties. Oral feeding difficulty is also used to describe wider issues than
just swallowing and includes difficulty in the following tasks:
· Initiating eating and drinking
· Recognition of food, drink, cup, spoon
· Getting the food or drink to the
· Opening the mouth
· Difficulty moving the food in the mouth to trigger
Often sensation can be affected after brain injury
and may affect the face and mouth leading to hypersensitivity where the
individual is extra sensitive to touch. This can affect ability to resume eating
and drinking again and can make it difficult to perform oral care which is very
important to reduce risk of infection.
You may see oro-facial hypersensitivity during
face washing, teeth cleaning and eating. It manifests itself in hypersensitive
responses such as: facial grimaces, lip pursing, biting, teeth grinding, or
turning away. It can even affect other parts of the body leading to spasms,
flexing or extending arms and legs. In extreme cases it can lead to gagging when
the spoon is placed in the mouth.
The SLT will set up a desensitisation programme
and include this prior to any oral activity in order to diminish the
hypersensitivity and encourage more normal responses. This why it is important
for individuals to be well supported and positioned in bed and their wheelchair.
For adults with brain injury SLTs assess
swallowing ability to establish a) whether they can swallow their saliva (see
next section on tracheostomy management) or b) begin to eat and drink something
by mouth. They often make modifications such as altering consistency of
food/fluids to increase safety when eating and drinking or changing position for
eating or teaching special swallowing exercises to improve swallowing function
If an individual is unsafe for oral intake they may receive their nutrition and
hydration via an alternative route such as a feeding
tube down the nose called a nasogastric
tube or in the stomach.
SLTs also make use of assessments such as nasendoscopy
using a tube through the nose into the throat and videofluoroscopy where food and drink is mixed with barium
contrast using x-ray conditions. Both
provide visual examinations of which help aid swallowing management. Individuals
may move from full tube feeding to a combination of food, drink and tube feeds
and full oral intake depending on how they progress in rehabilitation.
At times decisions are made about what is in the
individual’s best interests taking into account their quality of life. For
example, an individual may have tastes for pleasure even when the risks of this
have been acknowledged.
SLTs work with the medical team, nursing staff and
physiotherapists to determine if a patient is able to manage without a
tracheostomy and if tracheostomy removal is not possible either now or later, in
identifying the best tracheostomy tube for their needs. SLT’s take an active
role in saliva management and voicing.
Tracheostomies are not used solely because someone cannot
eat or drink and removing them will not necessarily enable someone to talk
SLTs are responsible for managing cuffed tracheostomy
tubes which are used for management of saliva and preventing this from entering
the lungs which can give rise to chest infections. SLTs will undertake swallowing assessments to
determine whether the individual can swallow their saliva and cough to protect
their airway (passage to the lungs). A cuff deflation programme may start and
eventually the tube can be changed for a cuff less tracheostomy tube. A one way
valve or cap is used next as part of the process towards removing the tube and
is particularly useful if the individual is trying to talk as it allows air to
flow through the voice box once more. If the person has the ability to speak
then with the tracheostomy tube capped they will be able to vocalise again.
Their speech may still be slurred and difficult to understand or they may have
difficulty speaking in full sentences.
Rehabilitation and management of communication and eating
and drinking in ABIs may extend over a long period and the type and amount of
intervention can vary accordingly. Most SLT is provided from within the NHS
particularly in the acute phase however other organisations provide
rehabilitation and care for ABIs including private and charitable organisations
and individual SLTs via the Association for Speech and Language Therapists in