Stroke Patients: Who Benefits From Speech Therapy?

A stroke can be a life-altering event, and its effects can vary from temporary paralysis to permanent disabilities. One of the most common consequences of a stroke is speech impairment, often referred to as aphasia. Aphasia affects an individual's ability to speak, write, read, and communicate in general. It can range from mild cases, impacting only one form of communication, to severe cases, where multiple modes of communication are affected. The impact of a stroke on speech depends on which area of the brain is affected and the extent of the damage.

Speech therapy plays a crucial role in helping stroke patients recover their speech and communication skills. Speech-language pathologists (SLPs) assess, diagnose, and treat disorders related to speech, language, and cognitive functions. They work with patients and their caregivers to develop individualized treatment plans, focusing on neuromuscular re-education and cognitive language exercises.

Various exercises can be employed to improve tongue and mouth muscle strength and coordination, such as tongue stretches and tongue-to-side movements. Breathing exercises are also beneficial for regulating breathing during speech. Additionally, practicing speech sounds and repeating words and sentences can help improve speech formation and clarity.

While not all stroke patients require speech therapy, it can significantly aid in the recovery process for those facing speech and communication challenges.

Tongue exercises

Tongue In-and-Outs

Stick your tongue out as far as possible and hold it for 2 seconds, then pull it back in. Hold for another 2 seconds, and repeat. This exercise helps train the tongue to move in coordinated patterns, which will help improve speech production.

Side-to-Side Tongue Movements

Open your mouth and touch the right side of your mouth with your tongue. Hold it for a few seconds, then reach for the left side of your mouth and repeat the exercise. This exercise helps improve your tongue's range of motion and coordination.

Up-and-Down Tongue Movements

With your mouth open, stick out your tongue and then reach up toward your nose. Hold for 2 seconds, then reach down toward your chin. Hold again for 2 seconds and repeat. This exercise works the full range of motion for your tongue and helps improve control.

Tongue Curling

Extend your tongue as far as possible to the corner of your mouth and then curl it backward toward the back of your mouth as far as you can. Hold for a few seconds and then relax. Repeat this exercise 5 times. This helps improve the flexibility and range of motion of your tongue.

Tongue Resistance

Place a spoon or a flat object like a tongue depressor on your tongue and push against it. Hold for a couple of seconds, then relax. You can also do this exercise by placing the object under your tongue and pushing up against it. This helps strengthen the tongue and improve its ability to move against resistance.

These tongue exercises can be done in front of a mirror to help with accuracy and provide visual feedback. It is important to repeat these exercises regularly to promote neuroplasticity and recover the ability to produce speech effectively. Remember to always consult with a speech therapist to determine which exercises are most appropriate for your specific needs.

Communication strategies

Strategies for Stroke Survivors:

• Use alternative communication methods: If speaking is challenging, consider using other forms of communication such as picture boards, hand signals, or writing. These methods can help convey basic needs and thoughts until speech improves.
• Focus on one task at a time: Avoid multitasking and give your full attention to the conversation. This helps reduce distractions and improves comprehension.
• Write things down: Use short written notes, flashcards, or a pencil and paper to jot down thoughts before speaking. This can help organize thoughts and ensure clear communication.
• Use gestures and hand signals: When words are difficult to find, try using simple gestures, hand signals, or pointing to convey your message. This can be especially helpful for basic needs and daily tasks.
• Use technology: Computers and smartphones offer various apps and tools designed to aid individuals with aphasia. These technologies can facilitate communication and provide alternative ways to express thoughts.
• Look for environmental clues: If you're struggling to find the right words, try looking around your environment for clues or objects that can help convey your message.

Strategies for Family, Friends, and Caregivers:

• Get the person's attention: Before speaking, ensure you have their full attention to facilitate better comprehension.
• Speak slowly and clearly: Use a normal tone of voice, but speak slowly and clearly to aid understanding. Avoid shouting, as it may cause confusion or frustration.
• Keep it simple: Communicate one idea at a time and use short, simple sentences. Avoid complex or compound sentences that may be harder to understand.
• Ask yes or no questions: Use closed-ended questions whenever possible to make it easier for the person to respond. Avoid open-ended questions that require lengthy answers.
• Repeat and rephrase: If necessary, repeat or rephrase your sentences to ensure understanding. Use different words or simplify your language to enhance comprehension.
• Use written communication: When speaking is challenging, consider writing down your message with a black marker to make it easier to read. Written communication can be a helpful supplement to spoken words.
• Pay attention to body language: Non-verbal cues, such as facial expressions and gestures, can provide additional context and help you understand the person's thoughts and emotions.
• Provide ample time: Be patient and give the person enough time to process information and formulate a response. Avoid rushing or interrupting them.
• Encourage participation: Include the person in conversations and activities as much as possible. Encourage them to express themselves and provide opportunities for social interaction.

Aphasia-friendly formats

Aphasia is a language disorder that affects the ability to express and comprehend language, both spoken and written. It is typically caused by damage to the left hemisphere of the brain and can result in difficulties with word retrieval, sentence formation, and reading and writing comprehension. Aphasia can occur after a stroke, with an estimated 25-50% of stroke cases resulting in aphasia.

When communicating with individuals with aphasia, it is important to use aphasia-friendly formats to facilitate understanding and expression. Here are some strategies to create aphasia-friendly formats:

• Use simple and short sentences: Avoid long and complex sentences as they may be difficult to understand. Keep your sentences concise and straightforward.
• Speak clearly and slowly: Avoid raising your voice, as it can be overwhelming. Instead, speak at a normal volume and pace to give the person adequate time to process the information.
• Reduce distractions: Choose a quiet place to speak, as background noise can make it challenging for individuals with aphasia to focus on the conversation. Ensure you have their full attention before you start speaking.
• Use gestures and visual aids: Supplement your verbal communication with gestures, pictures, or digital communication apps. Visual supports can help convey your message more effectively.
• Encourage writing: Some individuals with aphasia may find it easier to express themselves through writing. Provide pen and paper, or a whiteboard, to facilitate communication.
• Ask yes or no questions: Phrase your questions in a way that allows the person to respond with a simple "yes" or "no." This simplifies their task and reduces the pressure of formulating a lengthy response.
• Rephrase and confirm: If the person doesn't understand your words, try using different ones. There are often multiple ways to convey the same message. Repeat what you think they said to confirm your understanding.
• Be patient and allow time: Understand that communication may take longer, and be patient with the person. Allow ample time for them to respond and avoid rushing them, as it can be frustrating when they are trying to speak.

These strategies can be applied in various formats, such as written materials, conversations, or technology-based solutions, to create aphasia-friendly formats. For example:

• Written materials: When creating written materials for individuals with aphasia, use simple language, short sentences, and clear formatting. Break down complex information into smaller chunks and provide visual aids, such as pictures or diagrams, to support comprehension. Use bullet points or numbered lists to enhance clarity and make the content more digestible.
• Conversations: In conversations with individuals with aphasia, speak clearly and slowly. Use gestures and visual aids to support your verbal communication. Encourage them to use writing or drawing as a supplement to speaking if needed. Be patient and give them time to express themselves.
• Technology-based solutions: Utilize technology tools, such as communication apps or software, to facilitate communication. These tools can provide text-to-speech capabilities, picture communication options, or predictive text to assist individuals with aphasia in expressing themselves.

By implementing these strategies and creating aphasia-friendly formats, we can improve communication and understanding for individuals with aphasia, empowering them to participate more effectively in their daily lives.

Swallowing management

Screening and Diagnosis:

• Screening for dysphagia is recommended within 24 hours of a stroke to identify any swallowing difficulties.
• Various screening tools are available, such as the Burke Dysphagia Screening Test, Toronto Bedside Swallowing Screening Test (TOR-BSST), and Modified Mann Assessment of Swallowing Ability (MMASA). These assessments consider factors such as dysphonia, dysarthria, abnormal gag reflex, and cough after swallowing.
• If dysphagia is suspected, a more comprehensive clinical bedside evaluation is performed by a speech-language pathologist (SLP). This includes an oral examination, assessment of facial and tongue weakness, and evaluation of the patient's ability to cough and swallow.
• Further instrumental assessments, such as videofluoroscopic examination (modified barium swallow) or fiberendoscopic examination of swallowing (FEES), may be conducted to visualize the swallowing process and identify any abnormalities.

Treatment and Rehabilitation:

• Once dysphagia is identified, a swallowing management plan is developed by the SLP in collaboration with a multidisciplinary team. This plan may include dietary modifications, such as altering the consistency and volume of food.
• Intensive swallowing therapy is often recommended, which may include a range of exercises such as the Shaker exercise, Mendelsohn maneuvers, tongue-holding exercises, and effortful swallow. These exercises aim to improve the strength and coordination of swallowing muscles.
• Other compensatory strategies may be employed, such as postural adjustments, increasing volitional control, and sensory input techniques.
• In severe cases, a feeding tube may be necessary to ensure adequate nutrition until swallowing function improves.
• Regular reassessments are conducted to monitor the patient's progress and adjust the management plan accordingly.

Cognitive-communication

Communication screening should be conducted within 48 hours of hospital admission for all stroke survivors. The most commonly used screening test is the Frenchay Aphasia Screening Test (FAST), which is designed to identify receptive and expressive language impairments in the domains of speaking, listening, reading, and writing. However, FAST may fail to identify patients with cognitive communication disorders or mild motor speech disorders. As such, communication screening is often viewed as part of a more comprehensive cognitive screen. The Functional Impairment Battery, which includes screening for memory, neglect, aphasia, anomia, hearing, visual acuity, and depression, is more effective in identifying stroke survivors with communication deficits.

For those identified with communication disorders, a comprehensive communication assessment is conducted by a speech-language pathologist. This assessment considers the impact of the impairment on the individual's activity and participation within specific contexts, as well as the influence of their communication environment. The assessment covers areas such as the ability to understand spoken and written material, communicate ideas effectively through speech or gestures, and the intelligibility of speech.

Intervention and rehabilitation strategies are then implemented based on the assessment results. For individuals with aphasia, useful strategies may include writing or drawing, gesturing and pointing, introducing the topic of conversation beforehand, and using communication charts or devices. For those with speech impairments, recommended strategies include the use of pen and paper, letter pointing boards, electronic communication devices, reducing the speed of speech, and using iconic gestures. Environmental adaptations, such as providing a nurse call button that is easily recognizable or developing a communication diary, may also be considered.

The intensity of aphasia therapy has been found to impact recovery, with higher intensities (approximately 3-8 hours/week) leading to better outcomes. Additionally, rehabilitation for communication impairments should be initiated as soon as possible post-stroke and delivered intensively.

Frequently asked questions