Verbal Expression and Discourse

Challenges Post ABI

  • Difficulties include participating in a conversation (retrieving or finding the right word to express oneself), or talking at length about any given topic, formulating sentences, and naming objects or people (MacDonald and Wiseman-Hakes, 2010).

Clinicians would be well acquainted with the presentation of word finding difficulties in the ABI population.  Despite the variety and availability of treatment materials and strategies aimed at addressing anomia, there is unfortunately a real paucity of studies with strong evidence that meet the inclusion criteria for the ERABI project.

Due to impairments in cognitive abilities following an ABI or TBI, difficulties in producing proficient discourse is commonplace. Previous treatments have focused on improving narrative and structured conversations post injury (Kilov et al., 2009). Established treatments often focus on the individual’s ability to communicate with a clinician or researcher but not in the presence of a friend or family member (Jorgensen & Togher, 2009). Whether an individual communicates with a friend, a family member or community member rather than a trained clinician post brain injury, has had an effect on the language choices made by both partners (Jorgensen & Togher, 2009).

Goals of Treatment

  • To have individuals post ABI focus on having their basic needs met
  • To improve word fluency, word usage and word finding
  • Organizing ideas in conversation

Treatment Strategies

  • The use of a yes/no response system
  • Encouraging individuals to speak clearly, with vocal effort and with proper breath support

Materials and Devices(related to articles reviewed and selected for inclusion based on evidence)

  • Lee Silverman Voice treatment (LSVT®)

Treatment of Verbal Expression and Discourse

Lee Silverman Voice Treatment(LSVT®)

The LSVT has traditionally been used to address reduced speech intelligibility in patients with hypokinetic dysarthria from Parkinson’s Disease. LSVT is an intensive treatment program that requires four one-hour treatment sessions per week for four weeks. The primary goal is to increase effort during phonation by frequently encouraging the patients to “speak loudly” or “shout”.  “Critical to the treatment’s success is the calibration of higher vocal effort and loudness as normal” (Solomon et al., 2001). Ramig et al. (1995) concluded that the focus on increased laryngeal adduction in LSVT is essential to maintaining increased vocal loudness and therefore to the effectiveness of the treatment program.

Several studies have been found in literature that examined LSVT as a treatment for dysarthria specifically within the ABI population (Wenke et al., 2008; Solomon et al., 2001; Solomon et al., 2004). Wenke et al. (2008) concluded “positive effects that LSVT appears to have on speech and communication with non-progressive dysarthria”. Further research using a control group was recommended by these authors and would advance the current evidence that, at this time, suggests LSVT has potential as a treatment for dysarthria post ABI.

Solomon et al. (2001; 2004) conducted two studies investigating the effectiveness of LSVT. In the initial study, Solomon et al. (2001) evaluated the effect of Combination Treatment incorporating LSVT-type exercises, direct respiration treatment and physiotherapy exercises that targeted the upper chest wall on a patient diagnosed with mixed hypokinetic-spastic dysarthria, upper body hypertonicity and cognitive and memory impairments secondary to ABI.

In the second study following Breathing for Speech Treatment, speech breathing approached normal levels and after LSVT speech breathing improved further and intelligibility markedly (Solomon et al., 2004). Gains were maintained up to 4 months, but were limited by the spastic characteristics of dysarthria and sporadic medical complications.

In a current study, Wenke et al. (2011), randomly assigned a group of ABI individuals to either the LSVT group, or the traditional dysarthria therapy (TRAD) group. Both interventions were administered 1 hour each day/4 days/4 weeks. During the LSVT sessions, participants repeated daily variables using a loud and clear voice multiple times. The TRAD program included strategies to increase intelligibility by “restoring lost function or promoting the use of residual function(pg 9). Speech abilities were assessed using the Assessment of Intelligibility of Dysarthric Speech (AIDS). Both groups improved in work intelligibility following treatment but this improvement was not seen at the post follow up assessment.  Those in the LSVT had a significantly greater number of words spoken per minute than those in the TRAD group (p<0.015). Study results suggest that LSVT is comparable to TRAD.

Yes/No Response

The establishment of a consistent yes/no response is desirable when working with patients following severe brain injury, to facilitate communication between patient and care providers. It has been argued that the establishment of a yes/no response is important in differentiating between patients in a vegetative state versus those in a minimally responsive condition (Andrews, 1996; Childs et. al., 1993; Giacino & Zasler, 1995; Grossman & Hagel, 1996).

Barreca et al. (2003) attempted to better define the severity of the patient population with regard to functional communication. Barreca et al. (2003) compared two rehabilitation approaches that attempted to establish correct responses to yes/no questions. Subjects in Group A received treatment utilizing an enriched stimulus environment (e.g. Mozart sonatas played for up to 4 hours/day, decorated hospital room with personal mementos suspended from a mobile above the bed), collaborative multi-disciplinary intervention and additional yes/no training by the Communicative Disorders Assistant (CDA), 3 times/week for 30 minutes. In addition, the CDA trained healthcare team members and families to follow scripted procedures to increase arousal/attention and to elicit yes/no responses. Group B received a standard hospital environment (e.g. personal mementos on a bulletin board or on the wall, patient's own music) and typical team interventions.

A trend towards statistical significance for treatment A over B was found despite the lower numbers. These findings offer evidence that some patients with severe head injuries improve their ability to communicate “yes/no” responses when undergoing consistent training and environmental enrichments (treatment A) (Barreca et al., 2003). Increased interactions between patients and nursing were informally observed. As well, families reported on a satisfaction questionnaire that they were better able to communication with their loved one.

The reader is encouraged to review the aforementioned studies within Table 7.3 at the end of this module for further details

Conclusions

There is Level 2 evidence from one RCT suggesting the LSVT and TRAD programs work equally well in improving the intelligibility and everyday communication of individuals with non-progressive dysarthria (Wenke et al., 2011).

Based on a single RCT by Barreca et al. (2003), there is Level 1b evidence that some patients with severe head injuries may improve their ability to communicate “yes/no” responses after undergoing consistent training and environmental enrichments.

 

Although the LSVT was found to improve the total number of words spoken per minute, overall the TRAD program was just as effective in improving the speech of those with non-progressive dysarthria.

Patients with severe head injuries may improve their ability to communicate “yes/no” responses with consistent training and environmental enrichments.