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.
SLTs 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 following areas;
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 slurred speech.
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 Communication approach.
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 natural situations.
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 etc.
· Getting the food or drink to the mouth
· Opening the mouth
· Difficulty moving the food in the mouth to trigger a swallow.
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 again.
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 Private Practice.