SPCH3112 EOS

speech pathology

number of routes for writing

spontaneous writing = 3 routes

dictation = 5 routes

routes for spontaneous writing

SS/GOL/GAB

SS/POL/GOL/GAB

SS/POL/PAB/PGC/GAB

routes for writing to dictation

lexical semantic - AA/PIL/SS/GOL/GAB

lexical semantic supplement 1 - AA/PIL/SS/POL/GOL/GAB

lexical semantic supplement 2 - AA/PIL/SS/POL/PAB/PGC/GAB

lexical non-semantic - AA/PIL/POL/GOL/GAB

non-lexical - AA/APC/PAB/PGC/GAB

central dysgaphias

deep dysgraphia

surface dysgraphia

phonological dysgraphia

semantic dysgraphia

deep dysgraphia

type - central

breakdowns - SS, POL, GOL, PGC

routes impaired - all routes are impaired (regular words, irregular words, non-words)

error types - semantic errors (e.g. go to write time and actually write clock)

psycholinguistic features - imageability, frequency, grammatical class

treatment - written word picture matching giving semantic information (e.g. pants are for the lower body, shirt is for the upper body)

surface dysgraphia

type - central

breakdowns - GOL

routes impaired - impairment in irregular words (lexical)

error types - regularization errors (e.g. write irregular words the way they sound), confusion when writing homophones

psycholinguistic features - frequency (more success in high frequency words)

assessment - 46 - homophone spelling (to dictation and definition)

treatment - training of pairs of homophones, anagram & copy treatment (ACT), copy and recall personally relevant words

phonological dysgraphia

type - central

breakdowns - PGC

routes impaired - impairment of non-words and unknown words

semantic dysgraphia

type - central

breakdowns - SS, PGC

routes impaired - spontaneous writing and written naming for all words/non-words. spelling from dictation is impaired for non-words only

routes spared - spelling to dictation for real words

error types - semantic errors (e.g. write time instead of clock)

psycholinguistic features - imageability

effect of impairment to PGC

difficulty with irregularly spelled words (because the PGC only converts phonemes into their corresponding graphemes, can only spell words the way they sound)

use for non-lexical routes

production of non-words or unknown words

psycholinguistic features

imageability (semantic system)

frequency (lexical systems)

letter length (analysis and assembly buffers)

peripheral dysgraphias

arise from impairment of the GAB and beyond

orthographic buffer breakdowns

physical-letter-code-dysgraphia

apraxic dysgraphia

transitional dysgraphia

spatial dysgraphia

orthographic buffer dysgraphia

type - peripheral

impairment level - orthographic buffer

error features - errors occur at the middle or end of the word

error types - omissions (jumpr for jumper), substitutions (peanul for peanut), transportations (jumepr for jumper), additions (jumpear for jumper)

physical letter code dysgraphias

type - peripheral

impairment level - pnysical letter CoDeS

features - mix upper and lower case

mix styles of writing (e.g. cursive and print)

inability to use a certain case or style

substitution and reversal of allographically similar letters (e.g. B and P, m and n)

apraxic dysgraphia

type - peripheral

impairment level - graphic motor programs

features - errors in letter formation but correct letter is selected

copying and oral spelling are better than writing to dictation

transitional dysgraphia

type - peripheral

impairment level - disconnect of alographic to motor planning

impaired - written spelling

spared - oral spelling and typing

errors are well formed but letters are incorrect

spatial dysgraphia

type - peripheral

impairment level - graphic details

spared - spelling and legibility

errors - over repetition of strokes and letters, incomplete letters, progressive widening of margin, deviation from horizontal

PALPA for GAB

39 - letter length spelling

PALPA for SS for writing

40 - imageability and class

41 - grammatical class

42 - class with imageability controlled

43 - morphology

PALPA for phoneme/grapheme conversion

44 - regularity

23 - spoken letter/written letter matching

PALPA for lexical vs non-lexical routes

45 - non-word spelling

PALPA for lexical vs non-lexical SS-GOL

46 - homophone spelling (to dictation and definition)

difference between letter and syllable length effects

letter length effects - GAB

syllable length effects - PAB

the reading routes

lexical semantic - regular words + irregular + meaning

lexical non-semantic - regular words + irregular words + no access to meaning

non-lexical - regular words + no access to meaning + non-words

dyslexia types

peripheral - visual dyslexia, pure dyslexia

central - surface dyslexia, deep dyslexia, phonological dyslexia

visual dyslexia

type - peripheral

impairment level - VOA

routes impacted - lexical semantic, lexical non-semantic, non-lexical

features - read words as visually similar words (e.g. land for lend)

treatment - letter identification, letter naming (if severe to the point that the person struggles to identify a single letter)

pure dyslexia

type - peripheral

impairment level - connection between VOA and OIL

routes impacted - lexical semantic and lexical non-semantic

psycholinguistic features - word length as there are more letters to identify

features - letter by letter reading, able to read a word when they have identified enough letters in the word

treatment

• help patient identify full words by practicing reading the same essays over and over (homework important!). repeated practice until patient reaches 100wpm on that passage.

• use tactile-kinesthetic cueing + feedback → name letters while tracing them on the palm. also speed-read long strings of letters.

surface dyslexia

type - central

impairment level - OIL (most common) or POL (because forced to take non-lexical route when reading aloud)

routes impacted - lexical semantic, lexical non-semantic

psycholinguistic features - frequency effects because lexicon/s impaired, length effects because relying on non-lexical routes

features

• cannot read irregular words because they are using the non-lexical route.

• makes regularisation errors → may read real words the way they are spelled (e.g. diseased may be read as deceased because /s/ usually says its short sound), may read steak as steek, may read love as loave

• misidentifies pseudo-homophones when they sound like real words (e.g. identifies blud as a real word).

• visual and misapplication of rules appears sometimes.

• when making visual-lexical decisions, may rely on sounding out word and deciding if it sounds like a real word, therefore irregular (e.g. yacht) words may be classified as non-words.

treatment

• choose a set of words that have a highly irregular pronunciation (e.g. words that end in ‘ough’). using pictures, train the person on that set of words.

• 1 = sentence completion (cloze) → person needs to choose the correct word out of correct item, homophone, pseudo-homophone, similar items. person is encouraged to select the correct item as quickly as possible. 2 = sentence choice with correct and incorrect homophone.

deep dyslexia

type - central

impairment level - OIL, connection between OIL and SS, SS, connection between SS and POL, connection between OIL and POL, OPC, connection between OPC and PAB

routes impacted - lexical semantic, lexical non-semantic, non-lexical

psycholinguistic features - frequency, imageability, grammatical class

errors - main feature is semantic errors (e.g. reading apple as orange).This is because all routes are impaired, and the person usually relies on the impair lexical-semantic route, thereby producing semantic errors.

other errors include:

visual-semantic → synchrony = orchestra

morphological → walking = walked

functor substitution → between = until

visual → soup = soul

treatment

train person in letter-sound correspondence.

step 1) create code word for each sound (b = baby)

step 2) when they see the letter b, think of code word baby and segment the initial sound from the word baby

step 3) blend the segmented sound to the other sounds in the word

step 4) learn the contextual rules (e.g. c says ‘s’ when followed by i, e, or y or e+a says ‘ee’)

phonological dyslexia

type - central

impairment level - OPC, connection between OPC and PAB

routes impacted - non-lexical route

psycholinguistic features - length

features - non-words and new/unfamiliar words impaired (because they need to be sounded out). regular words and irregular words are spared.

can be seen when deep dyslexia is resolving.

PALPA for VOA

18 - mirror reversal

19 - upper/lower case matching

20 - lower/upper case matching

21 - words and non-words

PALPA for OIL

24 - illegal non-words

25 - imageability and frequency

26 - morphology

27 - pseudo-homophones

PALPA for SS for reading

31 - imageability & frequency (also tests OIL)

32 - grammatical class

33 - class & imageability

34 - morphology

Access to SS

38 - homophone define-then-read

PALPA for OPC

22 - letter naming and sounding

PALPA for PAB

30 - syllable length reading

PALPA for lexical vs non-lexical reading

28 - homophone decision

29 - letter length reading

35 - spelling/sound regularity and reading

PALPA for non-lexical reading

36 - non-word reading

general principles of dyslexia treatment

• Restitutive vs substitutive treatment

• Which processors is task targeting?

• What parameters are to be manipulated e.g., input vs output, modality, items?

• Does patient understand treatment rationale?

• Begin at level of approx 20% errors

• Minimal cueing

• Correction via judgement strategies

• Upgrade at 90% correct + no delay → make task more difficult

• Measure effects of treatment

assessments including sentence comprehension

WAB - Western Aphasia Battery

BDAE - Boston Diagnostic Aphasia Examination

CAT - Comprehensive Aphasia Test

VAST - Verb and Sentence Test

NAVS - Northwestern Assessment of Verbs and Sentences

Sentence Processing Resource Pack

PALPA - subtests 55, 56, 57, 58, 59, 60

TROG - Test for Reception of Grammar

Object Manipulation Test

Wiig-Semel Linguistic Relations

Informal grammatical task

factors that influence sentence comprehension in aphasia

verb comprehension in isolation

non-canonical sentences

reversible sentences

complex syntax, relative clauses, passive voice

longer sentences

sentences containing verbs with more arguments

sentences with more than one verb

variables measured on CAT sentence comprehension

manipulates a lot of variables so you can see which ones influence the pwa’s ability to comprehend the sentence. CAT = highly comprehensive, as the name suggests.

• PAS/number of arguments

• passive vs active voice/canonicity

• reversibility

• types of phrases

(small number of tests, followed up by further testing such as PALPA subtests)

variables measured on the VAST

four pictures are presented to the patient. one correct, one incorrect verb but correct roles, one correct verb but reversed roles, one incorrect role and incorrect verb.

subtests:

• verb comprehension (with verb and noun distractors)

• canonical vs non-canonical sentences

• grammaticality judgement (note: you can still have a grammatical sentence that doesn’t make semantic sense)

variables measured on the NAVS

• verb comprehension test (verbs with 1, 2, or 3 arguments) [note: verbs with optional arguments are more difficult than verbs with only compulsory arguments]

• canonical and non-canonical sentences

• more vs less complex structures

language based treatments for sentence comprehension

Mapping Therapy

Verb - semantic therapies

Treatment of Underlying Forms (linguistic/noncanonical treatment)

effective sentence comprehension therapy approaches

semantic reactivation approaches

functional argument structure approaches

note: these therapies have evidence for generalisation

must do:

verb therapy —> verb-argument therapy and/or verb semantic therapy when doing TUF or mapping therapy

semantic reactivation approaches

most evidence based approach to increasing verb comprehension in sentences

semantic networks with choice

semantic networks without choice

role semantic network without choice

verb-picture matching

odd-ones-out

probe questioning: visualization

semantic feature analysis

cued naming (SS-POL)

semantic phonological verb Tx

mapping approaches to comprehension therapy

targets the functional level of comprehension (thematic roles - who is doing what to whom?)

targets relating verb arguments to thematic roles

generalises to production

seven stages of sentence query

1) identify the verb in the sentence

2) identify the agent in the sentence

3) identify the patient

4) identify the prepositional phrase

5) identify the ‘why’ ‘when’ and ‘how’ phrases

6) rearrange segments to match a picture

7) increase sentence complexity (e.g. passive/non-canonical, reversibility controlled)

note: change the position of each of the syntactic elements so that you can be sure that the person is able to correctly identify the phrase, not just remember the location.

This is a type of mapping therapy

locative maps therapy

provide a set of 20 reversible sentences

provide two pictures (one correct and one incorrect) that the person has to match the sentence to

colour code the agent and the patient

provide two cues - one written and one visual to assist the person to understand which is the agent and which is the patient

gradually fade cues

spoken picture description assessments

WAB - Western Aphasia Battery

CAT - Comprehensive Aphasia Test

BDAE - Boston Diagnostic Aphasia Examination

note: choose a test with more interrelated images. WAB images less interrelated.

assessments for sentence production

language sample (picture description - CAT, WAB, BDAE)

TRIP - Thematic Roles In Production

(uses delayed repetition with picture cards to assess the patient’s ability to retrieve words with 1, 2, or 3 argument structures. results can show a) no difference between words and sentences b) words better than sentences c) sentences better than words)

VAST - Verb And Sentence Test

(single word retrieval, sentence production. subtests a) action naming name the verb that describes what is happening in the picture b) cloze - therapist says sentence without verb, patient produces full sentence with verb c) construction - describe what is happening in the picture in one sentence d) sentence anagram with pictures e) sentence anagram without pictures f) ‘wh’ anagrams)

NAVS - Northwestern Assessment of Verbs and Sentences

(pays attention to argument structure (1, 2, 3 and optional/obligatory) and canonicty a) verb naming b) argument structure production test c) sentence production priming test)

NAT - Northwestern Anagram Test

(uses word cards to describe a picture. targets non-verbal production of canonical and non-canonical sentences)

BAPPA-F - Battery for the Assessment of Plural Processing in Aphasia (Frequency)

(available free online for download. assesses the ability to verbally produce plurals correctly. a) spoken and written picture naming b) reading aloud c) repetition d) written word picture verification)

BAPPA-R - Battery for the Assessment of Plural Processing in Aphasia (Regularity)

(examines the effect of regularity of plural form on spoken production [e.g. king-kings = regular, foot-feet = irregular]. a) spoken and written picture naming b) reading aloud c) repetition d) written word picture verification)

support generalization of verb production to sentence production

targeting thematic grids

targeting predicate argument structure (PAS)

verb therapy for sentence production

Target the functional level of Garret’s Model

Webster et al. 2005

involves presenting the pwa w/ a verb and getting them to choose ‘who’ is most likely to do the verb and ‘who’ is likely to be the recipient of the verb. uses teaching on error with additional semantic information. (improve verb retrieval, improve awareness between verbs and nouns in sentences [e.g. PAS], improve production with 1, 2, 3 argument structures)

Schneider & Thompson 2003

describing and understanding the PAS of the sentence (e.g. who is doing what to whom). (trained on verb meaning and argument structure and retested on narrative task)

Bastianaase et al. 2006

fill in the verb in the sentence structure. (four levels: action naming, infinitive retrieval, verb tense agreement [morphosyntactic], sentence construction)

mapping therapies for sentence production

Target the functional level of Garret’s Model

used for clients with moderate-severe agrammatic aphasia

Byng et al.

(targets PAS. similar to shape coding/colourful semantics. client identifies the thematic roles within the sentence. start with non-reversible sentences. can use pictures from daily life to increase saliency.)

Whitworth et al. 2015

(focus on developing argument structure in non-reversible sentences. patient asked to identify ‘who’ and ‘what’ and identify other words that could fit those roles in the sentence. this increases semantic activation and association with the verb. can be used to help constrain output to plausible structure).

treatment of underlying forms therapy for sentence production

who is it for?: used for clients with mild-moderate agrammatic aphasia

theory: theory is that if you train the client on a more complex structure, it will generalise to less complex structures

• focus on reversible sentence structures (more complex)

• can use non-canonical structures (more complex)

• patient is provided with pictures showing the correct and incorrect structures and must choose which one matches the sentence

remediating production of verb tense morphology

purpose: designed to help patients identify the matching and correct auxiliary and main verb in a sentence (e.g. the man was washing the dishes) to produce a sentence with the correct tense.

doesn’t rely on verbal output (the patient arranges word cards to match the stimulus)

the levels of Garret’s Sentence Production Model

message (pre-linguistic)

functional

positional

phonetic

articulatory

the functional level of Garret’s model

• semantic retrieval

• determination of argument structure (e.g. is the sentence passive or active?)

• assignment of lexical items to PAS

the positional level of Garret’s model

• phonological retrieval

• syntactic planning

• insertion

considerations for working in critical care

high level of medical fragility

fluctuation in medical stability

one on one care from a nurse

highly medicalized environment

limited access to friends and family

noisy environment with constant light

frequent use of mechanical ventilation

frequent use of enteral feeding

role of the SLP in critical care

understanding the impact of intubation/ventilation, ICU management, insertion trauma, and disease leading to ICU admission on…

swallowing
communication…

function, assessment, and management

AND

weaning from ETT

medical decision making - can the patient manage secretions/swallowing enough to be weaned from the tube?

factors influencing recovery from critical care

disease causing admission to the ICU

intubation or tracheostomy tubes

sedation/medication/confusion/disease effecting state of consciousness

when is the SLP involved in critical care?

• when patient has been intubated/ventilated for more than 48 hours - swallow and voice Ax

• when patient changed to tracheostomy

• commencement of weaning from ventilation

• weaned from ventilation

• commencement of cuff deflation trails

• decannulation consultation of comm/swal/voice

time span of artificial airway types

ETT - up to two weeks

tracheostomy - time exceeding 2 weeks on ventilation

indications for artificial airways

patient unable to use respiratory system effectively enough on their own (e.g. stroke, paralysis, infection etc.)

patient’s upper airway is obstructed (e.g. swollen tongue/larynx, tumor, laryngeal surgery, etc.)

swallowing management post-extubation

food/fluid modification

supraglottic swallow (breath hold swallow), effortful swallow, controlled swallow

communication management post-extubation

often see mild and/or transient dysphonia

often see spontaneous recovery

encourage voicing to build strength

if dysphonia persists for 5 days, refer to ENT

advantages of tracheostomy vs ETT

• avoid glottic trauma

• reduce need for sedation

• oral intake/communication is possible (with assistance of specialised tubes, part of advanced practice)

• easier management of secretions

• easier to wean patient from ventilation

• patient able to be cared for outside ICU

• minimises aspiration risk with cuff

• ETT can cause laryngeal eodema quickly (within 2 days)

• ETT can cause contact granuloma quickly (within 2 days)

• glottic trauma from ETT = highly increased risk of voice and swallowing difficulties

parts of tracheostomy tube

obturator

inner cannula

decannulation plug/button

outer cannula

cuff (cuffless sometimes if upper airway obstruction only)

inflation line

pilot balloon

spring valve

flange

port/hub + speaking valve

role of SLP in suctioning

step 1) suctioning mouth (SLP or nurse) - can trigger gag reflex

step 2) suctioning below the cuff (PT, nurse, SLP w/ site specific training + nurse) - can trigger cough reflex, reduces oxygen saturation + increases distress

step 3) suctioning pooled above the cuff (trained SLP/PT + nurse) - deflate cuff and allow secretions to fall, or use suction aid w/out deflation

role of SLP in cuff deflation

use syringe to adjust the cuff before/after sessions - attach syringe to spring valve and withdraw air from cuff. pilot balloon will be flat when cuff is deflated and vice versa.

deflate before comm/swall evaluation - note volume of air removed from cuff

re-inflate cuff after comm/swall evaluation - insert same amount of air into cuff (cannot be too much or too little). If the pt. can no longer produce voice, then the cuff is adequately inflated. use manometre to check cuff is in the green zone for pressure.

allow time for patient adjustment to deflation/inflation

impacts of a tracheostomy tube

impacts of critical care management

• medications

• trauma/stress

• prolonged illness

consequences of illness that lead that person to need a tracheostomy

• stroke?

• TBI?

• upper airway obstruction?

consequences of re-direction of airflow

• loss of/impact to smell and therefore taste

• loss of humidification of air entering lungs

• increased secretions

• aphonia

• inability to cough (higher risk of aspiration)

• reduced laryngeal sensation (assists coughing reflex)

consequences of location of tube

• tracheal trauma

• tracheal necrosis

• tracheal granuloma

• scarring and stenosis (can lead to narrowing of the trachea)

• tracheal-esophageal fistula (NG tube = higher risk) - LONG TERM ISSUE

• tracheomalacia (softening of upper airway cartilages) - LONG TERM ISSUE

management of verbal communication with a tracheostomy tube

early management

reestablishment of communication early is essential for reducing distress/trauma

communication boards used in ICU by nurses

finger occlusion

verbal communication by allowing airflow around the deflated cuff using finger occlusion after secretions removed and cuff deflated

exhalation only = easier

inhalation and exhalation = requires more strength

monitor oxygen saturation during

one-way speaking valves

cuff deflated + suctioned

valve closes on exhalation

speaking valve cannot be attached when cuff inflated!!! PREVENTS EXHALATION!!!

assessment of swallowing with a tracheostomy tube

assessment

clinical evaluation of alertness etc.

oromotor

FEES (bedside)

CSE w/ cuff deflated to reestablish phonation and cuff w/ coloured foods that will be visible on suctioning (suction after 2-3 mouthfulls)

observe signs of aspiration (wet phonation? watering eyes?)

trial one food/fluid texture at a time

pass on recommendations to appropriate staff

SLP management of decannulation

• clinical decision making - do we think the patient can have the tracheostomy tube removed? work with team (nurse, doctors, PTs)

• tracheostomy no longer indicated - patient tolerating longer periods of time w/ cuff deflated w/out aspiration (24-48hrs w/ no negative signs)

• roughly 1 week of trials unless dysphagia is very severe

• patient does not change diet for 24 post decannulation → then re-establish dysphagia rehabilitation

• patient encouraged to cover approximated stoma wound with hand when coughing or exessively phonating for the initial recovery period (10 days to heal)

management of cognitive-communication in critical care

• once the patient is able to communicate verbally, you can commence screening of their expressive/receptive language

• the patient will be fully assessed when they move to the ward/acute/rehab

• consider the reason the person ended up in ICU

considerations for swallowing management in critical care

causes of unsafe swallowing in critical care

impact of disease that led to their admission to ICU

neurological involvement

impact of weakness and critical illness

ICU acquired weakness contributes to swallowing function

impact of medications

impact of re-directed airflow

loss of sensitivity and reflexes

impact of tube

incorrectly inserted tube impacts bolus transition

rehabilitation of swallowing in critical care

EMST —> expiratory muscle strength training

oromotor exercises

compensatory = food/fluid modification, body and head positioning

direct swallowing techniques (efficiency = effortful swallow, airway closure = supraglottic swallow)

role of SLP in cancer care

involved from the point of diagnosis → recovery/palliative care

swallowing management

speech management

advocacy

assessment of function

rehabilitation

populations SLPs work with in oncology

head and neck cancer (w/in a specialist cancer service team)

brain tumors → metastatic [other cancer has spread to the brain - end stage cancer journey], menigiomas [in meninges, typically benign], glioblastomas [common, aggressive primary tumor associated with sudden neurological signs], astrocytomas [malignant, less aggressive than glioblastomas]

lung cancer, breast cancer, etc. (address impacts of cancer treatment on swallowing/voice)

role of the SLP in tumor management continuum

diagnosis - patient education + advocacy (counselling and advice on comm/swal) →

on-treatment - monitoring + support + pre-habilitation (may be present to monitor speech and language function during awake craniotomies + manage impacts of surgery (assessment of function during recovery of swelling) →

post treatment rehabilitation + support + adjustment →

late effects detection + management (ongoing assessment and management of deficits + introduction of compensatory strategies for comm./swal) →

palliation - support + care

head and neck cancer types and causes

Type 1 → older onset, caused by smoking and/or moderate - heavy drinking

Type 2 → younger onset, HPV/viral causes

TNM classification

T = identifies location of tumor (0 = no evidence, 4 = massive tumor in structure)

N = number of nodes involved (0 = no nodal involvement, 4 = 4 nodes have metastases)

M = extent of tumor metastases (M0 = no metasteses, M1 = distant metastasis)

treatments for head and neck cancers

surgery - most common, reducing/de-bulking size of tumor/removal of surrounding tissues in ‘safe margins’.

radiation therapy - with surgery (pre or post op) or without surgery. directly targets the tumor

note: doses of radiation therapy higher than in other cancers b/c less responsive to radio therapy. higher dose = higher toxicity

chemotherapy - taken orally or intravenously, can kill cancer cells that have spread to other parts of the body, good when metastatic spread is present. used in conjunction with radiation therapy (+- surgery).

immunotherapies - helps the body to target the cancer cells and attack them w/ T-cells. can be used to extend the life of the patient in later stages. effects salivary glands, so SLP sees immunotherapy clients from all kinds of cancer.

impacts of toxicity on patients with cancer

fatigue

loss of appetite (esp. w/ chemo)

loss of taste/changes in taste (metalic)

mucositis (sores in the mouth and throat - esp. w/ rt)

eodema of oral/laryngeal tissues

lymphodema - later stages of therapy

strictures of oral/laryngeal tissues - more common w/ rt of eosophagus

xerostomia - rt can destroy salivary glands permanently + reduced/altered taste

loss of teeth/damage to teeth

trismus - reduced/impaired jaw opening

neuropathy - damage to cranial nerves

post surgical complications

slow/poor wound healing (diabetes = high risk)

fistulae

necrosis of tissue/bone + tissue graft failure

aesthetic changes (+psychological impacts)

interruption of normal communication and swallowing function

swelling - impacting voice, swallowing, airways

oversized tissue grafts

sensation loss - large areas of insensate tissue = high risk of pocketing foods + sutures and flaps create pockets that trap food/fluids

tethering impacts range of motion

combined effects of surgery + chemo/rt

role of SLP in diagnosis stage of cancer treatment

(advocacy + education)

surgical →

• assessment of functioning

• counselling for pt. + family

• advocacy

• assuring the client that you will be there for them throughout their journey

• answer any questions that the person has

• laryngectomy support visitor (if applicable, the lsv is another patient with direct experience)

non-surgical → same as surgical

role of SLP in on-treatment stage of cancer treatment

(monitoring + support + prehab)

surgical →

• patient treated in hospital for at least a few days depending on extent of surgery

• pt. often has tracheostomy

• pt. may be NBM depending on surgery, must wait for medical direction to start oral intake.

• determine swallow function w/ CSE as pt. recovers. compensatory management provided through multiple assessments.

• CSE for layngectomy not using barium, making sure bolus travels down eosophagus.

non-surgical →

• preparing clients for increasing deficits

• constant assessment of functioning

• support management of oral intake as toxicity increases

• coach to manage modified diet

• exercises at home for 7 weeks

• compensatory management of comfort with consideration to pain/fatigue/reduced appetite

• pain from mucositis is a major barrier, pharmaceutical management needed, soft/wet/liquid diet usually indicated

role of SLP in post-treatment stage of cancer treatment

(rehabilitation + support + adjustment)

surgical →

• function begins to recover

• pt. often goes back on-treatment for non-surgical treatments (may lead to psychological distress, so make sure the person is well informed on their prognosis for swallowing etc.)

• education on comm/swall on how to function with the anatomy they now have post-surgery

• in laryngectomy, VP must be replaced regularly and tested to see if functional. Make sure that the surgical incisions remain open/need to be stretched open.

non-surgical →

• focus = active rehabilitation

• occurs after approximately 7 weeks of non-surgical treatment

• active rehabilitation to tackle swallowing safety and efficiency

• management of trismus (e.g. jaw stretching)

• instrumental assessment of swallowing functioning over time

role of SLP in late/remission effects stage of cancer treatment

(detection + management)

surgical → pt. returns to medical care roughly 1 x per year (don’t often see SLP right now), review swallowing, instrumental assessment

non-surgical → same as above

role of SLP in palliation stage of cancer treatment

(supportive care)

surgical →

• focus on maintaining quality of life in the final stages

• manage swallowing - compensatory

• manage communication (AAC may be indicated)

• manage documentation of wishes.

• be supportive as they transition into palliative management

• manage signs and symptoms in a functional way

• consider impacts of metastatic cancers

• consider impact on airways

• consider impact of neurological signs

• consider impacts of fragile immune system.

non-surgical → as above

role of SLP in glossectomy speech rehabilitation

pre-surgery voice-banking

partial glossectomy → rehabilitate articulatory precision, articulation drills, assessment of what sounds can/can’t be made with remaining tissue

total glossectomy → work w/ MDT to augment through prosthetics to enhance articulation potential, non-verbal enhancement (AAC, etc.)

role of SLP in glossectomy swallowing rehabilitation

[focus on bolus control + propulsion]

bolus propulsion → head tilt/toss backwards, use adaptive spoon to place bolus further back

airway protection → supraglottic swallow

role of SLP in maxillectomy

[prosthedontist creates obturator to compensate for loss of palate tissue]

swallowing - initially NBM, then modified (soft diet), then able to be upgraded once the obturator is in place

speech - address impacts to resonance, and specific articulation deficits depending on the location of the loss

role of SLP in swallowing in post total laryngectomy rehabilitation

[larynx removed + airway replaced with stoma (can contain a voice prosthesis)]

swallowing

• 50% on modified diet long term due to poor bolus propulsion (have to rely on gravity and strong bolus propulsion to swallow)

• management of the consequences of flaps (e.g. pocketing foods, lingual or digital sweep, sipping water between bites)

• modified diet may be required (usually extra sauces, avoiding dry foods)

• teaching head-toss maneuver to help move bolus back

• impacts of xerostomia - difficult to clear dry bolus

• monitoring the closure of the stoma

• monitoring cleaning of stoma

where are cancer services provided?

specialist cancer centres

the phonological retrieval level of Garret’s Model

• phonological retrieval - phonological word forms need to be retrieved for each lexical item that was selected in the previous step, e.g., the phonemes [m], [a], and [n] that make up the word man.

errors = phonological errors (e.g. saying ‘spool’ for ‘stool’)

level of model = the positional level

the syntactic planning level of Garret’s Model

• syntactic planning - a syntactic structure needs to be built. In this example, the speaker has chosen to produce an active (canonical) sentence structure. Notice how the inflection -ing and the function words is and the are built into the syntactic structure, not retrieved from the lexicon. Functional morphemes like -ing and function words like the are fundamentally different to open class lexical items.
errors = evident by simplicity of syntactic constructions used

level of model = the positional level

the insertion level of Garret’s Model

• insertion - lexical items and function words are inserted.
errors = missing function words (e.g. the, is), incorrect tense markers (e.g. dropped instead of dropping), incorrect auxiliary (e.g. aren’t instead of isn’t)

level of model = the positional level

The semantic retrieval level of Garret’s model

• semantic retrieval - lexical items are selected for the event (kiss) and the entities involved in the event (man, computer).

errors = incorrect word, nominalization (e.g. using a noun as a verb → the sink is sinking), omission of word (e.g. the lady is the dishes), semantic paraphasia (e.g. chair for stool), non-specific verb (e.g. getting the cookies rather than stealing, grabbing, etc.)

level of model = functional level