Language Difficulties (Aphasia)

Topic: Difficulty with language (aphasia) following brain injury

April, 2011

Dina Collins is a Speech-Language Pathologist with the Acquired Brain Injury Program, Outpatient Team at G. F. Strong Rehab Centre, in Vancouver, BC. She has been working with adults with traumatic injuries, including brain injury, since beginning at GF Strong in 1993. Providing assessment, diagnosis and treatment for people with communication difficulties, and working with a team of professionals to assist individuals in returning to the community - reintegration to home, school or work, have been the focus of her work. She is a clinical educator, supervising students from across Canada and the United States, and has provided workshops to community partners and family members. She has also given provincial and national presentations on subjects including the effects of brain injury on communication, communication strategies, and group therapy approaches. She has been a co-developer of teaching materials addressing the education of family members on the impact of stroke and brain injury on communication.

Dina completed her Bachelors of Arts degree in Linguistics in May 1981 at the University of British Columbia. She completed her Masters of Arts degree in Speech Language Pathology in August 1989 at Western Washington University in Washington, USA and holds dual certification (Canada/US). Dina has also worked for three years as a Speech Language Pathologist and Department Head at Stanton Yellowknife Hospital in Yellowknife, NWT. Dina received an Excellence in Clinical Education Award, from the University of British Columbia, in 2009. In 2010, Dina, along with a team of interdisciplinary colleagues, was awarded a William G. Fraser Research grant to explore communication strategies in stroke.
 

Mike Ruskin is a Speech-Language Pathologist with the Outpatient Team of the Acquired Brain Injury program at G.F. Strong Rehab Centre in Vancouver, B.C. He has worked for 23 years with adults with brain- injury having swallowing and communication difficulties. He began his career working in acute rehab at Shaughnessy and Vancouver General Hospitals. During the last 12 years his focus has been to collaborate with a team of rehab professionals to assist brain-injury survivors in reintegrating into their community, returning to work or school and in resuming some of the communication – related activities with which they have had difficulties since their injury. He also leads outpatient groups at G.F. Strong including the Aphasiaⁱ Group, the Reading Group, and the Language Skills Group. He has presented educational sessions to family and friends of brain injury survivors on the impact of a brain injury on communication and provided them with tips and strategies for maximizing communication.

Mike completed his Bachelor of Sciences Degree in Biochemistry in May, 1973 at the University of British Columbia. He completed his Masters of Sciences degree in Speech Language Pathology in August, 1989 at the University of British Columbia. Mike is a registered member with the College of Speech and Hearing Health Professionals of B.C. and is a certified member of the Canadian Association of Speech Language Pathologists and Audiologists.

Question: How are speech problems involving a tic, and stammer emanating from a brain injury treated and where does one obtain funding for treatment?

The cause of stuttering continues to be elusive for researchers and health care professionals alike. Stuttering, or stammering as some refer to it, is a communication disorder which disrupts the normal flow of speech. This disruption can appear as repetitions or prolongations of sounds, syllables or words or can, in some cases result in stoppages (no sound) of sounds and syllables. There may also be unusual facial and body movements such as “tics” that may accompany stuttering behaviour.

Stuttering can occur in childhood or adulthood. Childhood stuttering is commonly referred to as developmental stuttering while stuttering following years of normally fluent speech and occurring suddenly following a brain injury is referred to as neurogenic stuttering or acquired stuttering. This most commonly occurs in adulthood. Infrequently, individuals who have experienced developmental stuttering may also suffer a brain injury which may result in an exacerbation of symptoms or a reoccurrence of stuttering. In responding to this question, we will assume that there is no prior injury or developmental stutter.

The precise cause of stuttering is not known; however, researchers are actively seeking new information about this complex communication disorder. In neurogenic stuttering, it typically appears following some sort of injury or disease to the central nervous system i.e. spinal cord, including cortex, subcortex and cerebellar regions. These injuries or diseases can include:
• Cerebrovascular accident (stroke) with or without aphasia
• Head trauma
• Tumours, cysts
• Degenerative diseases such as Parkinson’s Disease or Multiple Sclerosis
• Other diseases such as meningitis, Guillain-Barre Syndrome, and AIDS
• Side effects from some medications

With neurogenic stuttering, it is thought that the brain has difficulty coordinating the different components involved in speaking because of signaling problems between the brain and nerves or muscles. The primary symptoms and severity of neurogenic stuttering result from a very diverse set of diseases, disorders or injuries, and consequently may vary widely among different individuals.

Many people who have not had a brain injury may experience a degree of “normal dysfluency” such as mild interruptions in their speech. Examples of this may be interjections of words such as “um” “like” and repetitions, pauses or revisions of words during their speech. These typically do not interfere with the communication process. However, with neurogenic stuttering, there are some specific symptoms which disrupt communication in a more significant manner. These may include:
• Hesitations and pauses in unusual locations in an utterance.
• Stoppage of speech during the production of a word without finishing the word.
• Additional sounds during speech production may occur within words or between words.
• Rapid bursts of speech which may be unintelligible.
• Extra movements of lips, jaw, or tongue while attempting to speak.

Individual’s reactions to the disruptions in their speech vary. Some people are relatively unconcerned or less aware of their disruptions while others demonstrate increased awareness and anxiety and occasionally depression over their difficulties with speaking. Earlier, we referred to accompanying behaviours that occasionally arise when stuttering occurs. These secondary or associated behaviours such as “tics” or other distracting body movements may occur prior to or during a stutter. These behaviours occur less commonly with neurogenic stuttering The individual may also begin to avoid words that they have difficulty with or situations that they feel will increase the likelihood of stuttering. These behaviours may arise out of the speaker’s attempts to overcome or force their way through the dysfluency. They may also result from attempts to hide or disguise the fact that they are having difficulty producing normal sounding speech. As you might expect emotional stress or trauma may exacerbate symptoms.

It is not uncommon for individuals with neurogenic stuttering to experience several other communication impairments such as:
• Aphasia – a complete or partial impairment in language comprehension and expression.
• Dysarthria – errors in the production of the speech sounds such as slurring of sounds and words that affect the intelligibility of the individual’s speech.
• Apraxiaⁱ of speech – irregularities in the timing and inaccuracies in the movement of the muscles used in speech production
• Anomiaⁱ – difficulty in finding the appropriate word to use

Before getting treatment, it is advisable that someone suspected of having neurogenic stuttering is assessed and diagnosed by a speech-language pathologist. The diagnosis should determine whether the dysfluency is neurogenic in origin and whether any other communication impairments are affecting fluency.

There is no single treatment approach that will alleviate symptoms in all individuals who experience stuttering. Therapy techniques that can reduce the symptoms of stuttering include:
• Slowing the rate of speech by increasing the duration of sounds and words.
• A gentle “easy onset” of the start of a phrase as characterized by an easy initiation of exhalation and gentle onset of the first sound of a word.
• Breathing exercises, an important element in therapy.
• Emphasis of a smooth flow of speech production and use of relaxed body posture and speech production musculature.

Additional strategies provided to family members and friends can assist in reducing the concerns of the person who stutters and improve their communication. Simplifying one’s speech, allowing more time for the individual to respond, modeling slow easy speech, and in general, reducing communication demands and expectations may provide extra support.

Generally the goals for therapy are to reduce the frequency of stuttering, decrease the tension, struggle and anxiety of stuttering and decrease word or situation avoidances. Education of individuals about stuttering and coping strategies concerning attitudes and perceptions is also a very important part of the therapy plan as is the implementation of effective communication skills. Goals are individualized dependent upon the symptoms, severity and circumstance of the person who stutters.

Funding for speech-language pathology services may be available through individual insurance plans. Extended health benefits may provide limited funding. Financial assistance for individuals to obtain stuttering therapy may be available through BCAPS (BC Association for People Who Stutter). In addition, speech-language pathologists who specialize in stuttering are listed on this site as well as on the BCASLPA website (listed below). Further funding options and information may be available through individual speech-language pathology service providers.

To learn more about neurogenic stuttering, there are numerous websites and references dedicated to this subject. Parts of the information provided have been gathered from some of the sources sited in references below.

BC Association for People Who Stutter (BCAPS) www.bcaps.bc.ca
BCASLPA (British Columbia Association of Speech-Language Pathologists and Audiologists) www.bcaslpa.ca
ASHA (American Speech-Language-Hearing Association) www.asha.org
www.stutteringhelp.org
www.stammering.org (UK site)
www.westutter.org
www.nsastutter.org
www.nidcd.nih.gov/health/voice/stuttering