4/4/2016
Working with cognitive
communication disorders after
right hemisphere stroke:
The speech pathologist's role in
identification and management
A/Prof Petrea Cornwell
The Prince Charles Hospital, MNHHS
School of Allied Health Sciences, Griffith University
School of Applied Psychology, Griffith University
Speech Pathology and Stroke
Credit: Chris Bjornberg/Shutterstock.com
Dysphagia
Communication
Right Hemisphere Brain Functions
Left Hemisphere
Right hand control
Language skills
Writing
Scientific skills
Mathematics
Analytic thought
Logic
Right Hemisphere
Left hand control
Emotion expression
Spatial awareness
Music
Creativity
Insight
Holistic thought
Picture Source: http://neurosciencestuff.tumblr.com/post/111562039553/recovering-attention-after-a-stroke-brains-right. Downloaded 02/04/2016.
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Cognitive Communication
Disorder Defined
Cognitive Communication Disorder (CCD): Right
Hemisphere Stroke
Definition:
◦ communication impairment resulting from underlying
cognitive deficits due to neurological impairment1
COGNITIVE DEFICITS
COMMUNICATION
DEFICITS
◦ reflects an inability to create a “communication gestalt”
◦ i.e. difficulty integrating linguistic, paralinguistic &
extralinguistic components2
1. CASLPO (2002). Preferred practice guideline for cognitive-communication disorders.
http://www.caslpo.com/sites/default/uploads/files/PPG_EN_Cog_Communication_Disorders.pdf
2. Abusamra, V., et al.(2009). Communication impairments in patients with right hemisphere damage. Life span and disability, 1, 67 - 82.
Cognitive Communication Disorder (CCD): Right
Hemisphere Stroke
Definition:
◦ communication impairment resulting from underlying
cognitive deficits due to neurological impairment1
COGNITIVE DEFICITS
COMMUNICATION
DEFICITS
1. CASLPO (2002). Preferred practice guideline for cognitive-communication disorders.
http://www.caslpo.com/sites/default/uploads/files/PPG_EN_Cog_Communication_Disorders.pdf
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Cognition – Communication Interplay
Social Cognition
Extralinguistic
Features
Metacognition
Pragmatics
Executive Functions
Discourse
Memory
Sentences
Perception
Words
Attention
Sounds
The what?
Incidence and Nature of
Cognitive Communication
Disorder
Incidence of CCD
Remains unclear in literature due to methodological variations
range from 50% to 80%7-9
96% of people with RH stroke have at least 1 cognitive or
communication deficit10
Local data based on chart audit: 66% diagnosed with CCD
7. Benton & Bryan (1996). International Journal of Rehabilitation Research, 19(1), 47-54 .
8. Joanette & Goulet (1994). Clinical Aphasiology, 22, 1-23
9. Ferre et al (2009), Revista Neuropsicologia Latinoamericana, 1(1), 32-40
10. Blake (2002). Aphasiology, 16(4-6), 537-547
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Areas of Communication Impairment
Lexical-Semantics
Prosody
Discourse
Pragmatics
• ↓ ability to understand or use abstract or figurative language
• ↓ ability to comprehend complex sentence structures
• Aprosodia + ↓ comprehension of prosody
• Emotional & linguistic prosody
• ↓ understanding or producƟon of all forms of discourse
• hypo- or hyper-affective discourse production
• Impaired interpretion & use of language in social context
• non-verbal cues, social rules / conventions
Clinical Profiles of CCD
Preliminary taxonomy of 3 clinical profiles proposed11
Profile 1: significant impairments across all domains
global lexical semantic deficits, conversational discourse, & prosody
Profile 2: mixed presentation of impairments, ↓ severity of impairment
isolated lexical semantic deficit, conversational & narrative discourse, & linguistic
prosody
Profile 3: restricted areas of impairment
conversational discourse & emotional prosody
11. Ferre et al. (2012). Folio Phoniatrica et Logopaedica, 64, 199-207.
The why?
Department name (Edit in View > Header and Footer)
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How does CCD affect the individual and
their family?
Communication is….the “currency of relationships”13 (pg. 44)
enables interpersonal interactions and social participation
Communication underpins so many aspects of our lives
work, hobbies, independent living
participation in healthcare & rehabilitation services
Limited research detailing the long term impact of CCD on individuals and
family
13. Parr et al. (1997). Talking about aphasia: Living with loss of language after stroke.
Buckingham: Open University Press
“…I was lucky with a mild stroke. The doctor said I was doing very well and I
only stayed at the hospital for two days. I came back to my own house without
needing help. But when I got home I started to realise that I wasn’t the same. I
thought I could understand what I heard and read pretty well. But put me in a
group of people and I struggle to follow the conversation which was a big surprise
for me as everyone said that I was fine. I am much better now with reading but I
got very tired initially, so I would just put the book down, I realised on my own that
I wasn’t quite the same. And that made me feel vulnerable, but I didn't want to
tell people close to me, they were worried enough already.”
Independent living
I worked state-wide as a manager. I could walk in
anywhere and call the shots When I had the stroke I
wouldn’t even have been able to buy a train ticket, I
could walk right up to the station but I wouldn’t have
known how to pay or even what ticket to ask for….
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Work
Everything changed for him, he could not return to work
even if he wanted. It was not just his physical difficulties,
his way of thinking through problems is shocking and of
course the way he views a situation is strange to say the
least. This is so different to the way he was….
Interpersonal relationships
His emotions and communication definitely changed, it was like living
with a toddler who didn't understand human emotions and how to
respond. I remember sitting on the couch crying one day and he just
looked at me and changed the subject, as if he didn’t even realise that I
was sad, and this is still hard. I still have to remind him not to cut people
off in conversations - he never used to be rude.
Interpersonal relationships
His speech was always clear and he could understand what he heard and
read and could write but his communication was completely different does that make sense? He would just go quiet in a group of people. Oneto-one is fine but 3 or 4 people together and he cannot participate. This
is why he lost contact with some of his friends. They couldn’t do the
same activities together anymore and then there was nothing left for him
to talk about. He doesn’t seem able to come up with new topics. Like I
will say to him, why don’t you just talk about this if you can’t talk about
last weekend, but it is hard for him.
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“What annoys me most these days is that I think they should have spent
more time on other things in rehab. I know they wanted him to get
stronger in his arm and better with his balance but it is as if they didn’t
pick up on all the other stuff because they were so busy with physio.
When he came home I would cringe … on the very first day leaving the
hospital a lady got into a waiting taxi ahead of us and he said 'god she is
fat' out loud and I could just hide somewhere for the embarrassment. So I
had to warn all our friends about this but he is so reluctant to socialise
now, not really reluctant I mean he would go along but he looks so bored,
and conversations just passes him by.”
So who should we see?
And how?
How do we determine who to see?
Do we follow the NSF Clinical Stroke guidelines?14
Sections 2.4.1 and 2.3.4
+ve screen for
cognitive
impairment
check
communication
abilities
comprehensively
assess
communication
14. NSF (2010). Clinical Stroke Management Guidelines, 2010. National Stroke Foundation, Australia.
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How do we determine who to see?
Should all patients with stroke (RH) be screened for communication
deficits using a screening tool?
potential sensitivity of prosodic tasks as screening tool alone
use of screening tool incorporating all domains of communication
self-report and significant other checklists / questionnaires
informal observation
When do we see this group?
Recovery
Outpatient / community
rehabilitation
Inpatient
rehabilitation
Acute Care
Comprehensive Assessment of CCD
What options are available to speech pathologists?
Standardised comprehensive assessment batteries
Standardised assessment tasks / tools
Self-report or significant other report questionnaires
Informal observation tasks
Enlist you neuropsychologist or occupational therapist for cognitive assessments an
necessary.
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Standardised comprehensive assessment
batteries
MIRBI (Mini Inventory of Right Brain Injury)15
RIPA (Ross Information Processing Assessment)16
RICE-3 (RIC Evaluation of Communication Problems in Right Hemisphere
Dysfunction 3)17
RHLB (Right Hemisphere Language Battery)18
MCLA (Measure of Cognitive Linguistic Abilities)19
15. Pimental & Knight (2nd E). MIRBI. Pro-Ed, USA.
16. Ross-Swain, RIPA. Pro-Ed, USA.
17. Halper, Cherney & Burns. RICE-3. Rehabilitation Institute of Chicago, USA.
18. Bryan (1994). RHLB. John Wiley & Son Ltd, USA.
19. Ellmo (1995). MCLA. Vero Beach, USA.
Standardised assessment tasks / tools
Lexical semantic tasks
COWAT, Sentence Comprehension tasks (PALPA or CAT), Inferential
language (SCATBI)
Discourse Comprehension Test20
Florida Affect Battery21
The Awareness of Social Inferencing Test22
Functional Assessment of Verbal Reasoning and Executive Strategies23
20. Brookshire & Nicholas (1997). Discourse Comprehension Test. Alburquerque, NM: PICA Programs.
21. Bowers, Blonder & Heilman (1999). Florida Affect Battery. University of Florida, USA
22. McDonald, Flannagan & Rollins (2010). TASIT. Pearson Clinical, Australia.
23. MacDonald. FAVRES. CCD Publishing, Canada
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Checklists and Questionnaires
Latrobe Communication Questionnaire24
self-report and significant other forms
Social Communication Skills Questionnaire25
Cognitive-Communication Checklist for Acquired Brain Injury
(CCCABI)26
referral tool / checklist
24. Douglas, Bracy & Snow (2002). La Trobe Communication Questionnaire. Melbourne, Vic: La Trobe University.
25. McGann W, Werven G, & Douglas MM. Social competence and head injury: A practical approach. Brain Injury. 1997; 11:621-628
26. MacDonald. (2015). Cognitive-Communication Checklist for Acquired Brain Injury (CCCABi). Sheila MacDonald Associates, Canada.
Informal observational tasks
Tasks
Impairments
Person
Goals
Environment
Identification √
Now for management…
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Now for management…
Rehabilitation should27:
Consider pre-morbid communication status
Be individualized to the persons needs, goals and skills
Include training of communication partners
Occur in context to support generalization
27. Mateer & Sohlberg. (2003). Cognitive rehabilitation revisited. Brain Impairment, 4(1), 17-24.
Treatment Frameworks
Traditional
Context-sensitive
Process-specific approach
i.e. impairment or activity
focused
Assumes: discrete components of
cognition that enable acquisition &
use of information
premised by:
• cognitive +/- communicative
functions are inter-connected
• a link exists between cognitive
functioning and our goals,
emotions, knowledge, & context
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Current evidence for treatment of CCD in
RH stroke
small number of studies provide evidence for communication specific
treatment approaches
Treatments for aprosodia28,29
Cognitive-linguistic or motor-imitative approaches
Lexical-semantic treatments based on theoretical underpinnings
Focus: coarse coding or suppression deficit hypotheses30.31
28. Rosenbek et al. (2006) The effects of two treatments for aprosodia secondary to acquired brain injury. J Rehabil Res Dev 43:379-90. 41.
29. Leon & Rodriguez (2008). Aprosodia and its treatment. Perspect Neurophysiol Neurogenic Speech Lang Disord 18:66-72.
30. Blake et al. (2015). Contextual Constraint Treatment for coarse coding deficit in adults with right hemisphere brain damage: generalisation to narrative
discourse comprehension. Neuropsych Rehabi, 25(1), 15-52.
31. Blake, M. (2007). Perspectives on treatment for communication deficits associated with right hemisphere brain damage. Am J Speech-Lang Path, 16, 331-342.
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Treatments for CCD in RH stroke
Communication partner training32
Education about impact of RH stroke on communication
Draw knowledge from evidence base for similar disorders
e.g. treatment for CCD after TBI32
32. Tompkins (2012). Rehabilitation for cognitive-communication disorders in right hemisphere brain damage. Arch Phys Med Rehab, 31, 1 Suppl, S61-69)
Summary
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In summary
CCD after right hemisphere stroke is highly prevalent
CCD has the potential to impact may aspects of an individual’s life
that could lead to social isolation & ↓ emotional well-being
relationships, independent living, work, hobbies
Impact of CCD may be less noticeable in some environments
Identification and management of CCD after RH stroke should be part
of the speech pathologist’s role
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Questions?
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