a multi-disciplinary approach - pearson clinical files... · angela kinsella-ritter, sp 1 ......

Pearson Clinical Webinar: Regaining Independence Post-stroke

7th March 2016

© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and

Angela Kinsella-Ritter, SP 1

Presented by:Bridget Barnett

E: [email protected] Occupational Therapist

andAngela Kinsella-Ritter

E: [email protected] Speech Pathologist

9th March 2016

Regaining independence post-stroke: The impact of executive functioning and language skills on activities of daily

living (ADLs) after a neurological event.

A Multi-Disciplinary Approach

• Today’s webinar will highlight how OTs, Speech Pathologists

and Psychologists can work together to support clients in

regaining functional independence post-CVA.

• Through the use of case study examples, this webinar will

provide a brief overview of the BADs, WAB-R,CLQT and

Pyramids and Palm Trees to illustrate ways in which they can

be used clinically to:

• gain a clearer picture of clients’ abilities

• explore the influences of cognitive skills and language on

one another

• the impact this has on an adult's functional performance

and

• to guide intervention planning.


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Goals of Assessment

• To determine the presence of impairment

– Severity and type of impairment

– Determine the individual’s strengths and weaknesses

• To identify exacerbating factors

– Vision and hearing

– Agnosias (recognition deficits) in various modalities

– Deficits in proprioception or praxis

– Affective (mood) disorders

– Effects of medication

• To identify intervention goals

Treatment Considerations

Timing

• During spontaneous recovery period or wait?

• Vignolo (1964): treatment is only really effective if it begins when

physiologic recovery is most rapid

• Poeck et al (1989): time post-onset does not affect recovery of language,

but it does affect response to treatment

• Generally, delaying treatment has not been conclusively demonstrated to

have any effects on eventual outcome; but it might impact on the patient

and their family

Candidacy

• Some patients have very mild impairments and recover spontaneously

• Some are so severely impaired that they may note necessarily benefit

from intervention

• Some refuse, lack motivation, can’t travel


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Treatment Planning

What person can do

cannot do

does do

What person needs to do

wants to do

closing the gap

• Analyse and interpret the assessment results• Discuss with client (where possible) as well as with the

family• Set long and short term goals• Consider type of task, stimuli selected, modality of material,

type of facilitation given, duration and intensity of therapy (Byng and Black 1995)

Components of Language Function

Cognitive

Recognition, understanding,

memory, attention, reasoning ability

Linguistic

Auditory comprehension, language production (form and

content)

Communicative/Pragmatic

Turntaking, topic initiation and maintenance, repairs, speech acts

produced, nonverbal aspects


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Behavioural Assessment of the Dysexecutive Syndrome (BADS)

Utility in clinical practice

Clinical utility of the BADS12

Overview of the BADS

• A test battery aimed at predicting everyday

problems arising from Dysexecutive Syndrome

(frontal lobe impairment)

• Authors: Barbara A. Wilson, Nick Alderman,

Paul W. Burgess, Hazel Emslie, Jonathan J. Evans

• Published in 1996

• Administration time approx 40 mins

• Age range: 16-87 years

• Six subtests + DEX questionnaire


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Problems in assessing the Dysexecutive Syndrome

• Traditional neuropsych tests don’t always reflect real life demands of problem solving, planning and organising, setting priorities and adapting behaviour

• Tests might be sensitive to frontal lobe damage but may not reflect everyday situations, making functional correlations difficult


What does the BADS assess?

Subtests tap into executive functions including:

• The ability to initiate behaviour

• Inhibition of competing actions or stimuli

• Selecting relevant task goals

• Planning and organising a means to solve

complex problems

• Shifting problem-solving strategies flexibly

• Monitoring and evaluating behaviour


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BADS Subtests

• Rule Shift Cards Test

• Action Program Test

• Key Search Test

• Temporal Judgement Test

• Zoo Map Test

• Modified Six Elements Test


The Dysexecutive Questionnaire (DEX)

• A 20-item questionnaire. The items sample the

range of problems commonly associated with

the Dysexecutive Syndrome in four areas:

emotional or personality changes, motivational

changes, behavioural changes, and cognitive

changes

• Each item is rated on a 5 point scale

representing problem severity.

• Two forms; a self-report and a carer/ relative

report


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Case study 1 – “Harry”

• 80 years old

• Admitted for inpatient rehab following right CVA

• Lives at home with daughter

• Independent with showering, dressing, toileting

• Has an IDC that will be required upon discharge

• Manages own medication

• Prepares light meals

• Drives an automatic car

• Previously managed finances independently

• Shows limited awareness of current abilities

• MMSE score 24/30Clinical utility of the BADS17


Rule Shift Cards

•Numerous errors in both versions

•Difficulty processing the test instructions; did not

seek clarification when instructions not

understood

Action Program Test

•“Why would you want me to

do that?”



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Key Search Test

•Unable to conceptualise

square as a field

•Took 7 minutes

•Evidence of attempt to cover

all ground but ineffective



Temporal Judgement

•Initially stated it was “impossible” to estimate

•Correctly answered question “how long do most

dogs live for”

•Unable to estimate question about window

cleaning

•Reported 10 minutes for time needed to blow up

a balloon

•Reported 30 minutes for dental check-up but

stated “it depends how many teeth you have”



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Zoo Map

•Difficulty conceptualising task

•When prompted, stated that he

needed to “visit places”

•Lack of scanning/searching skills when visually

locating places on map

•Distracted by certain details, e.g. perseverated on

cafe

•Stated “there are too many restrictions”

•Did not attempt to draw on either version map



• Age corrected standardised score – 24

• “Impaired” range

• Assessment highlighted depth of impairment

and shed light on issues managing IDC, e.g.

• Planning ahead

• Prospective memory

• Managing multiple cognitive demands

• Comprehending instructions

• Insight/error recognition

• Strategy generation



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Conclusion

• BADS can detect subtle cognitive impairments

that may be missed on MMSE and less complex

tasks

• BADS allows qualitative data gathering e.g.

impulsivity, flexibility of thought, self

monitoring

• BADS can highlight strengths as well as

weaknesses

• BADS can provide insight into potentially useful

strategies

• BADS can increase client/carer awarenessClinical utility of the BADS23

Cognitive Linguistic Quick Test(CLQT)


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Overview of the CLQT

• The purpose of the CLQT is to assess the

relative status of five cognitive domains in

adults with known or suspected neurological

dysfunction.

• Author: Nancy Helm-Estabrooks

• Published in 2001

• Administration time approx 15 to 30 mins

• Age range: 18-89 years


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CLQT Tasks & Cognitive Domains

Total Composite Severity Rating

• CLQT is criterion-referenced• Severity ratings for two age categories (ages 18-69 and 70-89)• Severity ratings are mild, moderate, several and WNL for each

of the 5 cognitive domains• A total Composite Severity Rating and a Clock Drawing Severity

Rating serve as a neurocognitive screener


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Personal Facts

Symbol Cancellation


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Symbol Cancellation Task Results

Confrontation Naming


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Clock Drawing

Story Retelling


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Auditory Comprehension

Symbol Trails –Trial Items


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Symbol Trails

Generative Naming


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Design Memory


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Mazes

Design Generation


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Case Study: CVA with extensive left hemisphere lesion and small right hemisphere lesion

• 64 year old, right handed man with a doctorate degree

• Referred for an evaluation 11 months post left-hemisphere stroke which resulted in a

� Dense right hemiplegia and aphasia

• He had received extensive rehabilitation and is still under the care of a speech-language pathologist (who requested a second opinion re therapy planning

• Assessments included:

� CLQT

� Boston Diagnostic Aphasia Examination, 3rd Ed (BDAE-III)

� Boston Assessment of Severe Aphasia, 2nd Ed (BASA-II)

� A comprehensive neuropsychological test

� MRI Scan

� Informal Assessment

CLQT Examiner’s Manual, p. 87


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Summary Scoring Worksheet



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Design Generation Task Results


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Symbol Cancellation Task Results

CLQT Results

• Moderate overall impairment

• Severely impaired language skills

• Moderately impaired attention and executive functions

• Mildly impaired visuospatial skills

• The Memory Severity Rating (MSR) was interpreted with caution as the client was unable to produce verbal responses

• Although the MSR was in the severe range, his score (5 points out of a possible 6) for the non-verbal task of Design Memory was at the normal Criterion Cut Score for his age (5 points)


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• To assess potential for future recovery

(prognosis)

• To monitor change – e.g. spontaneous recovery,

treatment efficacy

• To evaluate maintenance of treatment gains

• To define factors that facilitate comprehension,

production and use of language

• To establish a working relationship with client

and significant others

Goals of Communicative Assessment

To determine the presence of aphasia*, and severity and type of aphasia, and to profile the client’s strengths and weaknesses

Goals of Communicative Assessment

• Organised, goal directed evaluation of the components of communication

• Evaluation of person’s QOL• Evaluation of communicative interactions within family/social unit

• Their role in society• Carried out to determine how strengths fortified and weaknesses modified Chapey 2008

*Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.


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Assessment of Communicative Functioning

• Not language per se – performance, pragmatics, communication skills in everyday life CALDs• reading timetables and menus• going to the doctor and shopping• making a phone call• writing a shopping list

Aphasia Recovery

Spontaneous recovery: decelerating curve

• Maximum recovery 1-3m

• Flattening out 6-7m

• Little/no spontaneous recovery after 1yr – plateau

Basso 1992 Benson and Ardila 1996 in Chapey 2008

Prognosis: TBI better than stroke, haemorrhagic better

than infarction

Lesser and Milroy 1993


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Neural Mechanisms for Recovery

• Reduction of cerebral oedema/improvement of

local circulation: Spontaneous recovery

• Brain plasticity: cortical reorganisation to

engage pre-existing but functionally depressed

pathways. Called upon when dominant

system fails

• Lesion size = negative influence on recovery

Aphasia Treatment

Efficacy: does aphasia treatment result in a significant improvement on one or more tests of language functioning?

Yes, provided that:• Treatment is delivered by qualified professionals• Content, intensity, duration and timing of treatment are appropriate

• Sensitive and reliable measures are used to track changes

Effectiveness: does aphasia treatment result in meaningful improvements in communicative functioning in daily life?


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Therapy Approaches and Models

• Approaches that assume the brain can relearn what has been

lost/skills can be re-accessed

• Approaches that assume lost language functions not recoverable.

• Therapy aimed at compensatory strategies

• WHO International classification of Functioning, Disability and

Health (2002)

• Body functions and structures i.e. impairments of brain

• Activity i.e. ability to make a phone call, read a menu

• Participation i.e. pursuit and enjoyment of real life goals e.g.

volunteering/getting a job

Western Aphasia Battery Revised(WAB-R)

Author: Andrew Kertesz | Published: 2007


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Western Aphasia Battery-Revised

Purpose:a screening and diagnostic test battery for evaluating language function in adults with acquired neurological disorders

Age Range:18 to 89 years

Administration Time: � Bedside Screening: 15 minutes� Diagnostic assessment: 30-45 minutes� Reading, writing, praxis, construction: 45-60 minutes

Scores:Research-based criterion scores; Aphasia Quotient, Language Quotient, Cortical Quotient

Applications

• Determine the presence, severity, and type of aphasia

• Obtain a baseline of patient abilities

• Document changes in abilities over time

• Guide treatment and management recommendations

• Infer the location and etiology of the lesion causing aphasia


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Bedside Screening: a quick look at functioning in 15 minutes

Bedside Screening: Areas Tested

• Spontaneous Speech: Content

• Spontaneous Speech: Fluency

• Auditory Verbal Comprehension: Yes/No Questions

• Sequential Commands

• Repetition

• Object Naming

• Reading

• Writing

• Apraxia


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Bedside Screening: Scores

Bedside Aphasia Score

� Content, Fluency, Auditory Verbal Comprehension, Sequential Commands, Repetition, and Object Naming

Bedside Language Score

� Content, Fluency, Auditory Verbal Comprehension, Sequential Commands, Repetition, Object Naming, Reading, Writing

Bedside Aphasia Classification

� Global, Broca’s Isolation, Transcortical Motor, Wernicke’s Transcortical Sensory, Conduction, Anomic

WAB-R Test Battery

Comprehensive Assessment� 10 receptive and expressive language tasks� 16 reading and writing tasks� 1 apraxia task� 4 nonlinguistic skills tasks

Scores� Aphasia Quotient (AQ)

o Spontaneous Speech | Auditory Verbal Comprehension | Repetition | Naming and Word Finding

� Language Quotient (LQ)o AQ subtests + Reading and Writing Score

� Cortical Quotiento AQ + LQ subtests + Apraxia Score and Constructional, Visuospatial and Calculation Scores


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Spontaneous Speech

Spontaneous Speech Scoring


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Auditory Verbal Comprehension



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Repetition


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Naming and Word Finding



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Score Summary


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Language & Cortical Quotients

Goals for Treatment

• “The primary objective in treatment of aphasia is to increase communication. What the aphasic patient wants is to recover enough language to get on with his life.” (Schuell et al 1964, 333.)

• There may not be a complete recovery of language and communicative function

• Treatment may enhance recovery, but recovery will stop• Identify strengths and weaknesses; use the strengths to compensate for the weaknesses; help the client with aphasia to be an effective communicator in spite of their language deficits

• Generalisation – recovery must not be limited to the treatment room

• Generalisation does not just happen – it must be planned for, worked towards, tested for


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Example – treatment planningMr Z’s assessments show:

� Strengths:

o Good lexical comprehension

o Good comprehension of basic sentence structure

o Can draw and gesture to convey some aspects of meaning

o Semantic cueing facilitates naming

o Written support facilitates comprehension

� Weaknesses:

o Poor complex auditory sentence comprehension

o Spoken confrontation naming difficulties

o Difficulties in written confrontation naming when word frequency decreases

o Drawings and gestures may not be recognisable outside context as tend not to be well defined

• Mr Z’s wish: to talk/communicate better with family and friends

Pyramids and Palm Trees

A test of semantic access from words and pictures

• Authors: David Howard and Karalyn Patterson• Published: 1992• Age Range: 18 to 80 years• Administration Time:


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Six different versions of the test can be administered:

1. Three pictures

2. Three written words

3. Written word as given item, pictures as choices

4. Picture as given item, written words as choices

5. Spoken word as given item, two pictures as choices

6. Spoken word as given item, written words as choices


Pyramids & Palm Trees

Here are three pictures. You have to decide which one of these two at the bottom goes with the one at the top. Is it this one or this one?


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Pyramids & Palm Trees

Here are three words. You have to decide which one of these two at the bottom goes with the one at the top. Is it this one or this one?

• The two choices – the target and the distractor - are always

semantic coordinates whereas the given (top) item is

usually from a different category.

• The choice must always be made on the basis of some

property or association that is shared by the given item and

the target.

• Each triad can be answered on the basis of partial

information from the three stimulus items.

• Because the different triads tap a variety of kinds of

knowledge, clients are only able to perform with consistent

accuracy if they can retrieve complete and correct semantic

information from the three items in each of the triads.



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• Poor performance could indicate difficulty in

• Item recognition

• Semantics, or in the

• Decision process /word retrieval

• Determining the type of difficulty depends on the pattern of

performance:

• Score = total number of responses (+ 0.5 for refusals)

• A score of 26/52 is expected by chance

• A score of 33 is better than chance at p < 0.05

• 35 at p < 0.01

• 38+ at p < 0.001

Pyramids and Palm Trees: Interpretation

Summary• Multi-disciplinary approach

� Working in a multi-disciplinary team enables clinicians easy access expertise from other allied health professional when assessing and planning intervention for your patients.

• The assessments discussed today demonstrated that although we work in specific disciplines there is overlap in the information being sought and they highlight how each discipline supports and complements the other.


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sAngela Kinsella-Ritter

Consultant Speech Pathologist

[email protected]

M: 0408 511 110

Client Services:

1800 882 385

We’re here to help

Pearson Clinical AssessmentBridget Barnett

Consultant Occupational Therapist

[email protected]

M: 0407 259 317

Client Services:

1800 882 385www.pearsonclinical.com.au

a multi-disciplinary approach - pearson clinical files... · angela kinsella-ritter, sp 1 ......

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