Stroke

Stroke occurs when a clogged or burst artery interrupts blood flow to the brain. This interruption of blood flow deprives the brain of needed oxygen and causes the affected brain cells to die. When brain cells die, function of the body parts they control is impaired or lost. A stroke can cause paralysis or muscle weakness, loss of feeling, speech and language problems, memory and reasoning problems, swallowing difficulties, problems of vision and visual perception, coma, and even death.

Symptoms

• Sudden numbness or weakness of the face, an arm and/or a leg
• Sudden confusion, trouble speaking, or difficulty understanding speech
• Sudden difficulty seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance, or loss of coordination
• Sudden severe headache with no known cause

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Causes

Blockage of blood vessels in the brain

• Clots can travel from the blood vessels of the heart or neck and lodge in the brain.
• Small vessels in the brain can become blocked, often due to high blood pressure or damage from diabetes.
• Clots can form in the blood vessels of the brain due to arteriosclerosis (hardening of the arteries).

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Bleeding into or around the brain

• Weak spots on brain arteries (aneurysms) burst, covering the brain with blood.
• Blood vessels in the brain break because they have been weakened by damage due to high blood pressure, diabetes, or aging.

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Effects Not Related to Communication

Because of the organization of our nervous systems, an injury to one side of the brain affects the opposite side of the body. Often the person loses movement and/or feeling in the arm and/or leg opposite the side of the brain affected by the stroke. This makes it difficult for him or her to perform activities of daily living (e.g., dressing, feeding, bathing, tying shoes, etc.). It is also common for survivors of stroke to tire easily.

A person may be able to see objects in only certain parts of his or her field of vision. Visual perception of everyday objects may also change. Objects may look closer or farther away than they really are, causing the person to spill at the table or bump into things while walking. Some people may lose awareness of their weaker side, and ignore or forget about it. As a result, they may have trouble reading, or they may only dress one side of their body thinking they are fully dressed. This one-sided neglect is most common when there is damage to the right hemisphere of the brain.

Stroke survivors often show inappropriate emotions and extreme mood fluctuations. They may laugh when something isn't funny or cry for no apparent reason. This is particularly common early on in the recovery process.

Persons with stroke may seem very self-absorbed. They may demonstrate an intense need for a structured, unchanging routine. They may be very frustrated with their inability to communicate effectively, and this may lead to anger and depression.

Communication-Related Effects

Communication is the ability to understand and convey a message orally, in writing, and with gestures, facial expressions and body language. After a stroke, some people experience language deficits (aphasia) that significantly impair their ability to communicate. These deficits vary depending on the extent and location of the damage. Read a detailed discussion of aphasia .

Cognition refers to thinking skills. Cognitive processes include an awareness of one's surroundings, sustained attention to tasks, memory, reasoning, problem solving, and executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and evaluation, flexibility of thinking). Cognitive difficulties are common in people with a stroke on the right side of the brain, and they vary in seriousness depending on the location and severity of the damage.

Some stroke patients have trouble concentrating when there are internal and external distractions (e.g., carrying on a conversation in a noisy restaurant, dividing attention among multiple tasks/demands). Their processing of new information is generally slower. Longer messages may have to be "chunked," or broken down into smaller pieces. The stroke survivor may have to repeat/rehearse incoming messages to make sure crucial information has been processed. Communication partners may have to slow down their rate of speech to accommodate these processing needs.

Recent memory is affected in some people, making new learning difficult. For example, some people may have trouble learning the new things they are being taught, such as how to get in and out of their wheelchair safely.

Impairments in executive functioning may diminish the ability to set long- and short-term goals. Planning and organizing tasks may be effortful, and it may be difficult to self-evaluate work. Consequently, these individuals may seem disorganized and unable to negotiate their lives without the assistance of families and friends.

The person's use of language may reflect this disorganization. He or she may have difficulty chaining a sequence of thoughts together to tell a story. He or she may switch topics without warning, or seem to "go off on tangents" without informing the listener.

Deficits in social communication skills may alter the ability to take turns in conversation, maintain a topic of conversation, use an appropriate tone of voice, interpret the subtleties of conversation, "keep up" with others in a fast-paced interaction. Persons after stroke may seem over-emotional (overreacting), impulsive, or "flat" (without emotional affect). They may say or do inappropriate things in conversation. Most frustrating to families and friends, there may be little to no self-awareness of just how inappropriate actions are.

Oral motor functioning is sometimes affected by a stroke. Muscles of the lips and tongue may be weaker or less coordinated ( dysarthria ). Speech may not be clear. Breathing muscles may be weaker, affecting the patient' s ability to speak loud enough to be heard in conversation. Muscles may be so weak that the person is unable to speak; consequently, he or she may need augmentative or alternative communication aids to help express ideas (e.g., communication board). For a detailed discussion of augmentative and alternative communication, click here.

Weak muscles may also limit the ability to chew and swallow effectively ( dysphagia ). Read a detailed discussion of swallowing problems .

Speech-Language Pathologist

The speech-language pathologist works with other rehabilitation and medical professionals (doctors, nurses, neuropsychologists, occupational therapists, physical therapists, social workers, employers/teachers when applicable) and families to provide a comprehensive evaluation and treatment plan for stroke survivors.

Speech-Language Assessment:

• The speech-language pathologist completes an assessment of speech and language skills.
• Social communication skills ( pragmatic language ) are evaluated with formal tests and the role-playing of various communication scenarios. The person may be asked to interpret/explain jokes, sarcastic comments, absurdities in stories/pictures (e.g., What is strange about a person using an umbrella on a sunny day?). During informal conversation, the speech-language pathologist will observe proficiency with initiating conversation and conversational topics, taking turns during a discussion, expressing thoughts clearly using a variety of words and grammatical constructions, maintaining a topic of conversation, and alerting the listener when topics are changed. The speech-language pathologist will assess the ability to clarify communication intentions if the conversational partner does not understand.
• If problems are observed, the speech-language pathologist will evaluate swallowing , and make recommendations regarding management and treatment. The focus of this evaluation will be to ensure that the person is able to swallow safely, and receive adequate nutrition. Additional swallowing tests may be recommended by the speech-language pathologist as a result of this evaluation.
• If necessary, the speech-language pathologist may evaluate the ability to use an augmentative or alternative communication aid to help express basic needs and ideas.

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Speech-Language Treatment

The treatment program focuses on improving the skills that have been affected by the stroke:

• If expressive and/or receptive language skills are affected, the speech-language pathologist will work on specific drills and strategies to improve them.
• The person may participate in group therapy sessions to practice conversational skills with other stroke survivors. The speech-language pathologist may lead the group through structured discussions, focusing on improving initiation of conversation, turn-taking, clarification of ideas, and repairing of conversational breakdowns. Group members may role-play common communication situations that take place in the community and at home, such as talking on the telephone, ordering a meal in a restaurant, and talking to a salesperson at a store.
• If cognitive skills are affected, the person will learn to compensate for difficulties remembering (e.g., using a memory log to keep track of daily happenings) and organizing (e.g., using an organizer to plan tasks, using checklists). Treatment always focuses on increasing awareness of deficits in order to help self-monitoring in the hospital, home, and community.
• Eventually persons are taken on individual and group community outings to practice their use of compensatory strategies outside of the hospital. They are asked to plan, organize, and carry out these trips using the compensatory strategies they have learned. For example, persons may practice using daily planners and checklists to plan the outing. They may practice functional reading and writing skills by using a telephone book to find the phone number of a restaurant and to write it down. They may practice telephone skills by calling the restaurant and making a reservation. They may practice reading maps, taking public transportation to the restaurant, and counting the change needed to purchase a ticket. They may practice their functional conversational skills by ordering their food in the restaurant.
• Later on in the recovery, the speech-language pathologist may work with a vocational specialist to help transition back into work or school, if applicable. The speech-language pathologist may also work with employers and/or educational specialists to implement the use of compensatory strategies in these settings. The speech-language pathologist may work with them to modify the patient' s work/school environment to meet language and/or cognitive needs.
• If speech muscles are weak, the speech-language pathologist may teach exercises to strengthen these muscles. The person practices the exercises at home and in therapy. The person may also be taught strategies to make speech more intelligible and to compensate for the muscle weakness.
• If swallowing is a problem, the speech-language pathologist may teach exercises to strengthen or improve the coordination of swallowing muscles, or may teach strategies to compensate for muscle weakness and improve the safety of swallowing. The speech-language pathologist works closely with doctors, nurses, and the dietitian to recommend the food consistencies that are safest and most appropriate for the patient' s needs. As the person gains more strength and coordination in swallowing muscles, the speech-language pathologist works with these professionals to "upgrade" diet. For example, he or she may recommend upgrading diet from a pureed/blended consistency to a chunky consistency.
• If the person is learning how to use an augmentative or alternative communication aid, treatment will focus on teaching use of the aid in structured conversation, with other stroke survivors, with family, and eventually in the community.

Find a speech-language pathologist near you.

Who Is Affected?

Stroke is a leading cause of death in the United States, and a major cause of serious, long-term disability in adults. Estimates of stroke incidence in the medical and allied health literature range from 500,000 to 760,000 in the United States annually. However, these figures are based on symptomatic strokes and most likely do not reflect the incidence of non-symptomatic infarcts (tissue death resulting from insufficient blood supply) and hemorrhages (massive internal bleeding) (1-3). There are few studies that analyze stroke in women, taking into account the vascular risk factors, cause of stroke, clinical picture, and outcome. According to one study, sex determines some clear differences in patients suffering a first-ever stroke (4). Stroke is a major cause of death and disability among African Americans (5, 6). Yet research on stroke knowledge and barriers to stroke prevention among African Americans is limited (5). Despite recent advances in treatment for stroke, there has been limited improvement in the public’s knowledge of stroke signs and symptoms, initiation of stroke-risk-reduction behaviors, and the importance of early treatment-seeking actions (3).

The number of patients affected by stroke will increase as an effect of aging (7). Stroke in the young is rather rare. The proportion of juvenile stroke is strongly linked to the structure of the population (8). Individuals 15-44 years of age are generally considered young adults and have many risk factors mentioned that may include drug use, alcohol abuse, pregnancy, head and neck injuries, heart disease or heart malformations, and infections. Some other causes of stroke in the young are linked to genetic diseases (9).

Apraxia in Adults

Apraxia (also referred to as apraxia of speech, verbal apraxia, or dyspraxia) is a motor speech disorder caused by damage to the parts of the nervous system related to speaking. It is characterized by problems sequencing the sounds in syllables and words and varies in severity depending on the nature of the nervous system damage. People with apraxia know what words they want to say, but their brains have difficulty coordinating the muscle movements necessary to say those words and they may say something completely different, even nonsensical. For example, a person may try to say "kitchen", but it may come out "bipem". The person will recognize the error and try again, sometimes getting it right, but sometimes saying something else entirely. This can become quite frustrating for the person.
 

Characteristics of Apraxia

• Difficulty imitating speech sounds
• Possible difficulty imitating non-speech movements, such as sticking out their tongue (oral apraxia)
• Groping for sounds
• In severe cases, an inability to produce sound at all
• Inconsistent errors
• Slow rate of speech
• Somewhat preserved ability to produce "automatic speech", such as greetings like "How are you?"
• Can occur in conjunction with dysarthria (muscle weakness affecting speech production) or aphasia (language difficulties related to neurological damage)

Treatment

A speech-language pathologist works with people with apraxia to improve speech abilities and overall communication skills. The muscles of speech often need to be "retrained" to produce sounds correctly and sequence sounds into words. This occurs through exercises designed to allow the person to repeat sounds over and over and practice correct mouth movements for sounds. The person with apraxia may need to slow their speech rate down or work on "pacing" their speech so that they can produce all of the sounds necessary for their message. In severe cases, alternative means of communication may be necessary, such as the use of simple gestures or more sophisticated electronic equipment.

Long-Term Recovery After Stroke

After a stroke, an individual may experience physical difficulties, particularly in the arm, leg and face on one side of the body, cognitive problems, and speech and language deficits. The individual can expect some degree of "spontaneous recovery" in the days, weeks, and months immediately following the stroke. During this time, physical, cognitive, and communication deficits may diminish on their own as the brain heals, although intervention such as physical therapy, occupational therapy, and speech-language pathology services can enhance this spontaneous recovery.

Speech-language pathologists are trained to work with individuals with a variety of speech and language disorders, including aphasia, dysarthria, and apraxia. An SLP can help the affected individual improve communication skills beyond what will naturally occur after the stroke and teach compensatory strategies to overcome communication deficits.

The person who experiences a stroke can expect some degree of spontaneous recovery in the first 6 months or so after the stroke, although recovery may continue for over a year. The degree of recovery is highly dependent on the severity and location of the stroke and is very difficult to predict. Many times, improvements in physical abilities occur more rapidly than in communicative ability and cannot be used as a predictor for future speech and language improvements.

Many people with aphasia and their families have written about living with aphasia and note that maintaining a positive attitude and learning from others' experiences are keys to success in life after stroke. Reading personal accounts, using the Internet for information, and joining support groups are some ways that a person with aphasia and their family can learn about life with aphasia. Realizing that depression often follows a stroke, and knowing how to handle this depression, is also very important.

Aphasia is often a chronic problem and learning to live with it gracefully is possible and can lead to a fulfilling and satisfying life after stroke

Damage to the right hemisphere of the brain can lead to cognitive-communication problems, such as impaired memory, attention problems and poor reasoning. In many cases, the individual with right brain damage is not aware of the cognitive difficulties or communication problems that they are experiencing.
 

Causes

The causes of right hemisphere damage include:

• Stroke
• Traumatic Brain Injury
• Surgery
• Infection/Illness
• Tumor

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Characteristics

People with right hemisphere damage experience communication problems that are more subtle in nature than those that occur from left hemisphere damage. This is due in part to the fact that, in most of the population, the language centers are in the left hemisphere, while cognitive functioning is often housed in the right hemisphere. Cognitive-communication problems that can occur from right hemisphere damage include difficulty with:

• Attention
• Memory
• Organization
• Reasoning
• Problem-solving
• Orientation
• Left-side neglect
• Social judgment/pragmatics

Attention problems from right hemisphere damage include difficulty concentrating on a task amid distractions and paying attention for more than a few minutes at a time. Also, performing more than one task at once may be difficult or impossible.

A person's memory may be affected, as well. They may have difficulty recalling already learned information, such as street names or important dates, and may not be able to learn new information easily.

Organization problems include being able to correctly sequence events when telling a story or giving directions or maintaining a topic while conversing with others. Reasoning may also be impaired and the person may not be able to interpret abstract language, such as metaphors, or respond to humor appropriately.

The individual may not react appropriately when presented with a common occurrence, such as a car breakdown or overflowing sink. This is due to impaired problem-solving abilities. Leaving the individual unsupervised may be dangerous in such cases, as they could cause injury to themselves or others.

A person who has difficulty recalling the date, time, or place is said to have orientation problems. The individual may also be disoriented to self, meaning that they cannot correctly recall personal information, such as birthdate, age, or family names.

Left-side neglect is a form of attention deficit that may occur from right hemisphere damage. Essentially, the individual no longer acknowledges the left side of their body or space. They will not brush the left side of their hair, for example, or eat food on the left side of their plate, as they do not see them or look for them. Reading is also affected as they do not read the words on the left side of the page, starting only from midline.

When human beings converse, they rely not only on words to convey messages, but also on body language, facial expressions, and intonation (how the voice rises and falls while speaking). Right hemisphere damage can cause problems with pragmatics , leading the individual to ignore or misinterpret such nonverbal cues and lose the meaning of the message. They may also lack facial expression when speaking ("flat affect") or speak in monotone or too rapidly. Social judgment is also impaired and the person may laugh at inappropriate times or say inappropriate things without realizing that they have done so.

Treatment

A speech-language pathologist (SLP) is a person trained in working with people with communication disorders. When a person experiences right hemisphere brain damage with resulting cognitive-communication problems, a referral to a speech-language pathologist may be warranted. The SLP will work with the individual and develop a treatment plan designed to improve the individual's cognitive-communication abilities.
 

What you can do

• Provide a consistent routine every day
• Use calendars, clocks, and notepads to remind the person of important information
• Decrease distractions when communicating
• Stand to the person's right side and place objects to the person's right if they are experiencing left side neglect
• Break down instructions to small steps and repeat directions as needed
• Ask questions and use reminders to keep the individual on topic
• Avoid sarcasm, metaphors, etc. when speaking to the individual
• Provide appropriate supervision to ensure the person's safety

Selective mutism, formally known as elective mutism, is a disorder of childhood that is characterized by the peristent lack of speech in at least one social situation, despite the ability to speak in other situations.. Onset of selective mutism typically occurs before a child is 5-years-old. However, it is usually first noticed when the child enters school. Specific features of this disorder are described in the 2000 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (pp.125-127) as follows:

• Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g., at school) despite speaking in other siturations.
• The disturbance interferes with educational or occupational achievement or with social communication.
• The duration of the disturbance is at least 1 month (not limited to the first month of school).
• The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
• The disturbance is not better accounted for by a Communication Disorder (e.g., Stuttering) and does not occur exlusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or othe Psychotic Disorder.

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Associated Features and Disorders

A number of different psychological and personality features have been associated with selective mutism (e.g., excessive shyness, fear of social embarrassment, social isolation and withdrawal). Different studies identify different features. Even when a group of children with selective mutism in a particular study shows a tendency toward a particular feature, there are still children in the group who do not display that behavior. It is the persistent failure to speak in particular social situations that is the hallmark of selective mutism. There are different degrees of severity for both verbal and nonverbal communication. The severity also may vary from setting to setting. Children with selective mutism usually do not have speech or language problems; however, an associated communication disorder (e.g., articulation or phonological disorder, receptive or expressive language disorder) may occur. These communication problems though are not the main reason for the mutism.

According to the DSM-IV, children with selective mutism are “almost always given an additional diagnosis of an Anxiety Disorder (especially Social Phobia)” (p. 126).

Assessment

The speech-language pathologist works as part of a collaborative, interdisciplinary team consisting of the pediatrician, a psychologist or psychiatrist, the teacher(s), and the family. The speech-language pathologist will conduct a thorough parental interview , as most children who are selectively mute will not talk to the clinician. Use Find a Professional to locate a speech-language pathologist near you.

This interview seeks information on:

• the child's symptom history, especially focusing on the onset of the behaviors. The majority of children with selective mutism do not have a sudden onset of symptoms
• the degree to which the child is verbally and non-verbally inhibited, which may vary from setting to setting . Parents may be asked to provide information about the child's relationships with friends or to describe how the child communicates in social situations outside of school (e.g., interacting with other children and adults on the playground or talking on the telephone).
• associated problems (e.g., schizophrenia, pervasive developmental disorder) that could be contributing to the failure to speak. It is possible to rule out selective mutism if one of these are present.
• the child's speech and language development, as well as current use and comprehension of language. Does the child understand what people say to him or her? Does the child understand questions and follow directions? Is the child able to find the words needed to express ideas? The parent may be asked to describe the child's speech production (i.e., pronunciation of words, quality/tone/pitch of voice, fluency of speech) to help rule out any other speech and language disabilities that could be causing or exacerbating the mutism. Current studies show that 20-30 percent of children with selective mutism have other speech and language disabilities; however, these are not the cause of the mutism. It is important to address these speech and langaugedifficulties so the child can become more comfortable with communication.
• any environmental influences (i.e., learning more than one language at a time or not having adequate language stimulation) that may affect the child's comfort and confidence with the language.
• family history of psychiatric (e.g., social phobia, obsessive-compulsive disorder, or other anxiety disorders) and personality (e.g., extreme shyness) diagnoses that may be predisposing the child to mutism. The clinician reviews the child's medical history to rule out physical problems (e.g., neurological delay) underlying the mutism.

The speech-language pathologist will also review educational history via academic reports, parent/teacher comments, and standardized testing. Do these reports indicate concern about the child's communication skills with peers or adults in the classroom? Are teachers concerned about the child's academic achievement? The clinician reviews the reports of any previous testing (e.g., psychological) to assess whether other diagnosed disabilities could be causing or exacerbating the mutism.

The speech-language pathologist will then conduct a speech and language evaluation . The child’s anxiety level should be taken into account. Accommodations should be considered in order to evaluate the child in comfortable surroundings and with familiar people. A parent might be present to help facilitate communication. If any evaluation procedures are too anxiety provoking they should be discontinued.

• The clinician interviews the child to observe the quality of verbal and non-verbal communication . This is done through informal play activities (e.g., playing together with a dollhouse and using the dolls and accessories to stimulate dialogue and social interaction). If the child is having difficulty participating in these play activities, the clinician should try another type of activitiy. Drawing may be used as a means to explore non-verbal communication skills.
• Comprehension of language is evaluated using standardized tests (e.g., the child is shown a set of four pictures and is told to point to one of the pictures) and informal observation.
• The parent may be asked to do structured communication activities with the child (e.g., have the child retell the plot of a story or describe a picture) to create an informative videotape. The parent may also be asked to provide a videotape of the child's speech at home during regular conversation. These samples enable the speech-language pathologist to evaluate expressive language abilities (word knowledge, use of grammar, ability to sequence a set of ideas, social communication skills). The speech-language pathologist may attempt to conduct an oral-motor examination to evaluate the strength and coordination of the muscles in the child's lips, jaw, and tongue. Muscle weakness or incoordination may signify a neurological impairment that is may lead to a diagnosis other than selective mutism.
• S creening test for hearing and middle ear function should also be part of the evaluation.

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Treatment

The speech-language pathologist may coordinate a behavioral treatment program to increase verbalizations. Behavioral treatment is based on the premise that the child who is selectively mute is using the behavior in response to anxiety in social situations. The focus of the speech-language pathologist’s intervention is to reinforce communication with a gradual progression from non-verbal to verbal. This may be accomplished through stimulus fading, in which the speech-language pathologist sets simple goals (e.g., using a gesture to communicate) and gradually increases expectations until speech is achieved. Another behavioral treatment technique called shaping reinforces mouth movements that approximate speech (e.g., whispering) until true speech is achieved. Another technique sometimes used, when the child is willing, isthe self-modeling technique where the child watches videotapes of himself or herself performing the desired behavior (e.g., communicating effectively at home) to facilitate self-confidence and carry-over of this behavior into the classroom. The speech-language pathologist should collaborate with the psychologist, whose primary focus will be to help reduce the child’s anxiety.

The speech-language pathologist may also work with specific speech and language problems that are making the mute behavior worse. For example, some children with selective mutism are afraid to speak because they feel they may say the wrong thing. The speech-language pathologist may use role-playing activities to lessen the child's anxiety and increase confidence with speaking to different listeners in a variety of settings. Other children with selective mutism may not want to speak because they feel their voice "sounds funny." If necessary, the speech-language pathologist may work on speech pronun