Aphasia center offers more therapy choices

Center takes multidisciplinary approach

Post-inpatient treatment for the more than 1 million Americans with aphasia often fails to provide them with hope of regaining their ability to communicate with others. Insurance carriers fail to recognize that aphasia is a chronic condition that sometimes requires lifetime treatment.

"The way we treat people with aphasia right now in this country is by giving them a week or two of [outpatient] therapy, and then saying that’s it. I believe there are many aphasia patients who need ongoing therapy for years," explains Steven Small, MD, PhD, director of the University of Chicago Comprehensive Aphasia Center at Schwab Rehabilitation Hospital & Care Network in Chicago. Small also is a professor of neurology at the University of Chicago.

Clinic provides assessment, therapy

The 125-bed rehab hospital’s new aphasia center provides a comprehensive program of assessment and therapy for aphasia patients with a goal of helping them make improvements beyond those possible if they were left to fend for themselves, as sometimes happens after discharge from an inpatient facility.

"What we do that’s most different from other places is we’ve instituted a multidisciplinary evaluation approach," Small explains. "Each patient is seen by three primary care providers."

Most of the aphasia center’s patients have had strokes, but patients with dementia, brain cancer, brain tumors, multiple sclerosis, and traumatic brain injuries also might qualify for the aphasia clinic.

Small, who is a cortical neurologist, is one of the three team members. The others are Amy Usher, MS, CC-SLP, a speech-language pathologist, and Elizabeth Pieroth, PsychD, a staff psychologist who specializes in neuropsychology.

The aphasia center opened earlier this year but has not yet collected specific outcomes data. Anecdotal evidence suggests that patients who are a few years post-stroke have improved in their communication skills because of the center’s treatment, Usher and Pieroth say.

"One way we’re seeing improvements is through family members coming in and letting us know they are very happy because the patient is initiating more speech at home and the patient is more intelligible and more verbal," Pieroth says.

Here are the main components of the center’s aphasia program:

  • Comprehensive evaluation: Small, Pieroth, and Usher evaluate patients referred to the center. Small assesses patients’ sensory problems, as well as cerebellar problems. The sensory problems include whether patients have the ability to feel their hands and legs and know where they are in space. These problems also encompass motor skills, weakness of the mouth or palate, weakness of hands, and coordination difficulties.

    Usher begins her evaluation by giving the patient a battery of tests, including the Boston Diagnostic Aphasia Examination, the Apraxia Battery for Adults, the ASHA-FACS, and the Boston Naming Test. "Those are in addition to some other informal testing measures," she says.

    Pieroth assesses patients’ cognitive abilities and their general emotional and affective states. She administers various neuropsychological tests, depending on a patient’s level of functioning. For example, a patient who has had a stroke on the left side of the brain, affecting the person’s right side of the body, may be unable to speak or use the dominant hand for writing or drawing. Pieroth wouldn’t give such a patient any tests that required writing or drawing.

    With some patients, the tests might be visual; with others, they are verbal. The assessment tools include a visual spatial processing test, a visual memory test, and a problem-solving test that has no verbal requirements.

  • Consensus meeting: Small, Pieroth, and Usher meet after completing their evaluations to discuss the patient’s deficits and potential outcomes. The roundtable discussion also may include the patient’s referring physician or other doctors.

    "We talk about the main problems the patient has and what sorts of things we might do to help the patient," Small says. "We don’t restrict our attention to the issues of getting the patient’s speech back, although communication is the most important thing, but we also look at the patient’s quality of life, including the patient’s ability to have a job, talk with family members, and feel comfortable at a party."

    The team decides whether the patient needs to be referred for vocational training, substance abuse counseling, or other therapies.

    "We then come up with modified goals and recommendations," Usher says.

    The consensus meeting is one of the big advantages to the aphasia center, Small says. Each member of the trio evaluates the patient differently, and together they come up with treatment strategies a one-sided evaluation would have missed.

    "We think that all sorts of cognitive skills can impact both the language disorder itself and possible treatments," Small says.

    That’s why Pieroth’s evaluation is important, he adds. "If someone has a good visual memory, for example, then the therapist might be able to use therapy that has visual aides or visual material."

    Pieroth also could highlight a patient’s problems with depression or other psychological problems stemming from the patient’s emotional reaction to the illness. "It’s known that patients who have depression after a stroke don’t have as good a rehab outcome as people who don’t," Small says.

 

Alternative communication tools explored

  • Individual therapy: Usher typically meets individually with patients once a week. She works on some of the speech goals that are specific to that patient, with the ultimate goal of improving functional communication. "We work on the basics and provide stepping stones," she says. "I may train a patient how to use an alternative form of communication, like a communication board."

    She also teaches patients specific communication skills, using gestures, and works with them on their ability to name objects and develop increasingly complex speech.

  • Group therapy: Usher leads an aphasia communication group once a week. The group’s goal is to improve functional communication based on verbal skills, gestures, and pictures. "We encourage any sort of successful communication skills so it’s a more natural environment for patients, as opposed to working with them one-on-one," she explains. "And they can also assist each other, asking other participants to repeat things, and asking questions, and helping other people to convey their message."

  • Psychological treatment and education: Small estimates that more than half of the stroke patients also suffer from depression. "It’s a very big problem, and we do have a very comprehensive evaluation of that issue, and we recommend to patients’ physicians that they consider drug therapy for depression when we think it would be helpful," Small says.

    Some patients and/or their families are referred to Pieroth for therapy to help them with depression and other emotional problems related to their illness and difficulty in communicating with others. However, for patients with language difficulties, therapy for depression sometimes is impractical.

    Pieroth also educates family members about aphasia, stroke, and brain injury. "I explain why it effects their language, and I talk a lot about behavioral issues because some of the behavioral problems are related to neurological insult, and some are related to affective reaction to injury, such as frustration in not being able to communicate. Family members don’t understand how that plays out and how it really affects the person," she explains.

    Pieroth may begin by meeting with the patient’s caregiver and asking about the caregiver’s concerns about changes in the patient. "We don’t know the patient before the stroke, so it’s important to get the family’s understanding of the changes they’ve noticed, both affective and personality changes," she notes.

    Sometimes family members will say the patient is being stubborn and not behaving as expected. The true problem is that the patient has difficulty understanding what is being said and may have indicated a "yes" answer to a caregiver’s question, when the truth is the patient doesn’t have a clue about what has been asked.

    "People can falsely believe the patient understands them, and so it becomes very frustrating for the patient and family member if things don’t work out as expected or if the patient doesn’t respond as the family member desires," she says.

    Occasionally, family members will respond to their frustration by becoming verbally abusive, yelling at the patient, and arguing. Pieroth teaches them better coping strategies.

    She also shows families how to identify the signs and symptoms of depression in the patient. For example, patients may tend to isolate themselves because of their inability to clearly communicate, and Pieroth explains that this is a common sign of depression in aphasic patients.

    "They may sit in a room and watch TV and avoid other people," she adds. "Look for warning signs of depression, such as sleep disturbance, appetite disturbance, and other indicators."

  • Reimbursement: The medical and speech pathology treatment typically is covered by insurance companies and Medicare, but the psychological evaluation and treatments usually are not reimbursed. Even so, Small says this component is an essential part of the overall program.

    "It’s very frustrating, and we need to educate insurance companies," Pieroth says.

    The aphasia center started outcomes research on its comprehensive treatment approach, looking at patients’ quality of life, language improvement, and cognitive improvement, she says.

    Ultimately, a body of research that shows improvements among aphasia patients through a multidisciplinary approach could help convince payers to reimburse for this type of treatment. 

 

Executive Summary

Subject:

Schwab Rehab in Chicago opened an aphasia center that treats patients with a multidisciplinary team and comprehensive approach.

Essential points:

  • The aphasia team consists of a neurologist, a neuropsychologist, and a speech-language pathologist.
  • Team members hold consensus meetings to discuss each patient’s case and set treatment goals particular to a patient’s deficits and strengths.

  • Patients are treated in individual and group therapy sessions, and their family members are educated about aphasia and the reasons behind the patient’s behavioral problems.

Need More Information?

  • Elizabeth Pieroth, PsychD, Staff Psychologist, Schwab Rehabilitation Hospital, 1401 S. California Ave., Chicago, IL 60608. Telephone: (773) 522-2010, ext. 5167.

  • Steven Small, MD, PhD, Director, University of Chicago Comprehensive Aphasia Center at Schwab Rehabilitation Hospital, 1401 S. California Ave., Chicago, IL 60608.

  • Amy Usher, MS, CC-SLP, Speech-Language Pathologist, Schwab Rehabilitation Hospital, 1401 S. California Ave., Chicago, IL 60608. Telephone: (773) 522-2010, ext. 5039.