Treatment & Related Issues Flashcards
Treatment Related Issues
Medical environment (cost benefit issue)
third party regulation (private insurance)
medicare limitations
Medicare Part A Limitations
20 days of care in hospitals
100 days in skilled nursing facilities
home health care
hospice care
Medicare Part B
Outpatient service over age 65, including doctor visits, outpatient hospital care, hospitalization beyond Part A coverage
80% of charges after annual deductible
Treatment Team - PT
Dx of muscle strength and range of movement for functional independence
Strengthen muscles
muscle atrophy and contracture prevention
Treatment Team - OT
Motor abilities for skilled activities of daily living
compensatory strategies for visual-spatial deficits
Treatment Team - Recreational Therapist
Programming activities to keep patients purposefully occupied
Treatment Team - Social Worker
Medical communication to patients/families
Discharge plans
Post-discharge care with suggestions for nursing facilities, state and social services
Medical directive follow ups: wheel chair, prosthetic needs
Coordination of competence evaluation
Treatment Team - Clinical Psychologist
Emotional and personality issues
treatment for psychoses and depression
Treatment Team - Dietician
Nutritive needs and delivery types
Treatment Team - SLP
Acute phase:
importance of communication
family reorientation
minimization of regression
Subacute phase (limited treatment)
Chronic phase: Prevention of communicative regression Promotion of restitution, Progress monitoring Planning long term treatment Family participation)
Effects of Brain Damage
Diminished response flexibility
Task-related anomalies:
impulsive responses
excessive caution
Perseveration
Reduced self-monitoring:
posterior lesion cases
Wrenches’ aphasics are bad at self-monitoring, doesn’t happen with an anterior lesion
Recognition with no anticipation of errors
Information processing deficit:
- Slow rise time : takes the person time to start listening/only gets last part of the phrase
- Noise build up : after first few words there is too much “build up” in the system, can’t process later words in the phrase
- Retention deficit : memory
- Intermittent imperceptions : variable performance, scattered
Two Types of Perseveration
Recurrent: repetition of a response after other subsequent verbal attempts
Continuous: inappropriate uninterrupted prolongation of verbal attempt; have to change task
Poor Prognostic Indicators
Bilateral or large lesions
Multiple strokes
Verbal stereotypes (“let me tell you”)
Perseveration
No matching of common objects and pictures
Unreliable yes/no responses
Jargon
Lack of self-correction
Medical complications
Depression
Malingering
Negative attitude
Poor family support
Etiology:
- occlusive lesions: good early recovery
- hemorrhage: best in 2nd or 3rd month
- traumatic: better and slower over a long time
Positive Prognostic Indicators
Self-correction
Awareness
Younger age
Short time post-onset
Good health
Motivation
Family support
Treatment Procedural Info. - Linguistic Processes to be Attended
Recognition
Discrimination
Comprehension (visual and auditory)
Productive (verbal and graphic)
Treatment Procedural Info. - Response Modes
Pointing
Gestures
Nodding
Writing
Verbalizing
Augmentative Modes
Treatment Procedural Info. - Response Delay
Greatest response increment in 3-5 seconds with most in 10 seconds
Responsiveness better with meaningful/novel stimuli
Natural contexts: greater accurate responses
Unison or delayed recall: unison better with severely involved patients
Treatment Procedural Info. - Method of Facilitation
Repetition
Cue
Combining Stimulus modes
Number of alternatives
Treatment Procedural Info. - Treatment Methods
Imitation
Matching
Selection
Completion
Comprehension
Spontaneous Production
Treatment Procedural Info. - Stimuli Construction
Meaningfulness
Length (short length of word)
Complexity (causes serious problems, avoid excessive complexity)
Frequency
Relatedness (semantically related is good)
Concrete image
Size
Modality of ease
Facilitation Procedures - Cueing Hierarchy
What is this called?
Direction to state the object function
Direction to demonstrate the use
Statement of the function by clinician
Sentence completion
Sentence completion + silent articulated 1st phoneme
Sentence completion + vocalized 1st phoneme
Sentence completion + verbalized 1st 2 phonemes
Say “…..”
What to Treat - Relative Impairment Approach
Identification of communicative peaks and valleys
Tx to lower points to try to reduce the depth of the valley
Tx on peaks only if a smaller gap between peaks and valleys
What to Treat - Fundamental Ability Approach
Focusing on impaired processes/components
Focus on cognitive process underlying the deficit, not output behaviors like comprehension
In anomia: word production, sentence construction
Improve auditory comprehension
What to Treat - Functional Ability Approach
Focus on competencies needed in daily life
Goal Setting
Realistic and definitive short and long-term goals that are beneficial to patients, meet their communicative needs, and relevant to demonstrable outcome
Practical
Adequacy not perfection
Patience with recovery
Rationale for each step and activity
Ask why for each Tx step
No teaching or retraining - only facilitation
Elicitation rather than forcing a response
Focus on measurable aspect of communication
Treatment Planning - Stimulation Approach
Stimulate rather than teaching words
The antecedent event - the driving force in improving responses, rather than the consequent event in behavioral therapy
Maximizing ‘arousal power’ of the stimulus
Auditory perceptual system
Difficulty of Tasks in Treatment
Difficulty at 40-50% level
no more than 40-50% error responses
increase complexity with performance stabilization (90-95% in consecutive sessions)
Session Organization
General activity
Consolidation
East tasks
Difficult tasks
Consolidation
Cooling off
Base 10 Response Form
Form that includes list of stimuli and scores for a series of sessions, as well as a graph where progress can be charted
easy, brief, provides visual feedback, retention of stimuli, provides a basis for termination
Measuring Generalization
Treatment task performance charting
standardized test repetition
probing of goal-related task independent of treatment
Generalization
Applications of acquired knowledge to:
- tasks with shared features
- situations that allow the knowledge application
- enable conversation at home
Ways to Promote Generalization
Natural contingencies targeting behaviors related to patient’s life
training of sufficient exemplars - train a behavior into enough different settings for generalization
loose training - stimulus conditions and response requireemtns vary to increase generalization
- across responses
- within a response class
- one environment to other environment
elicitation of responses by other means like mnemonics or mental imagery
matrix training of distanced items (table of distances between words)
Measuring Communicative Effectiveness
Total number of words or utterances
Number of content units
Number of correct words in content units
Number of bound morphemes
Ratio index of lexical efficacy (number of words divided by content words)
Index of grammatical support (average number of grammatical words in each content unit)
Complexity index (clauses per utterance)
Discourse Analysis
Empty utterances (don’t express content, “oh boy”)
Sub-clausal utterance (content words only)
Single clause utterance (subject/verb only)
Multi-clause utterances
Agrammatic deletions (omission of grammatical markers)
Measuring the Effects of Treatment - Single Treatment Effects
Pre- and Post- treatment
ABA a minimum of 3 phases
Tx usually withdrawn but measurement continues
Design: comparison of results from 2 phases
Measuring the Effects of Treatment - Multiple Baseline
Best way to demonstrate the effects of tx.
A single tx to study:
different behaviors within a patient
the same behavior in several patients
or the same behavior across different environments
Medical Treatment
Preservation of life by treating:
- Myocardial infarct
- BP
- Edema
- Cardia Thromboembolism (blood thinning with anticoagulants)
- TIAs (platelet-inhibators - platelets with a source of growth factors lead to the formation of blood clots)
- Thromboembolic strokes (vasodilators, tPA (tissue plasmogenic activator))
- Limiting infarct by decreasing metabolism (barbiturates)
- Reperfusion (endarterectomy (done with external carotid artery) and stent and umbrella (for collecting broken parts of the plaque))
Pro-Activation (Brookshire)
Exposure to difficult-to-name objects interferes with subsequent easy-to-name items
easy to name items facilitates subsequently difficult to name items
priming: exposure to a stimulus to influence a response on a later stimulus
Importance of Contexts (Barten)
Open-ended conversation is the most effective in naming
VCN to picture is less effective
Naming from verbal description is the least effective
Traditional Treatment
Based on stimulus and response - not the most productive
Targeted areas and components
One or multiple modalities
Incorporation of stimulation-response
Performance measurement in %
Pros
- good training
- focused exercises
Cons:
- poor generalization
- limited practical value
Language Reorganization
Transfer intact functions to disrupted functions for promoting language reorganization
2 types:
Intra-systemic
Inter-systemic
Intra-Systemic Language Reorganization
Improving a communicative system by transferring downward or upward (eg verbal singing, controlled by the right brain)
Inter-Systemic Language Reorganization
Using unrelated functional system to reorganize an impaired system (eg gestures with verbalizations)
Deblocking (Bierwisch)
Removal of a masking effect on impaired function by an intact one
ex. auditory mode to deblock reading, semantic description to deblock naming
MRI & Recovery
Measuring Tx Effects:
- post-stroke right activation
- successful training leading to a left shift
- over learning leading to a shifted left activation in peri-lesion area
Optimal recover = LH peri-lesion reactivation
Time:
- Increased RH activation w/in 2 wks after stroke and a return to baseline levels after 1 year
- Increased LH activity gradually from acute to chronic stage
- A temporary contribution of RH in the early post-stroke phase, but absent in chronic stages
Schuell’s Auditory Stimulation Approach
Controlled intensive auditory stimulation to maximize reorganization of the brain
includes controlled speech rate, meaningful stimuli, incorporation of graded complexity, control of stimulus length, monitoring loudness level (20 dB higher), combining sensory modalities, promoting face to face conversation
Family Support Group
Forum for meeting other survivors and caregivers, seeking help with adjustments, expressing feelings, social network
Benefits of Group Therapy
Communication in natural environments
Opportunity for spontaneous conversation
Generalization of learned skills
Development of self-confidence
Emotional support
