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Relearning to Speak, One Word at a Time

July 22, 2008
BCBR Article Relearning to speak, one word at a time By Rebecca Cole July 7, 2008 -- When people hear that someone has incurred speech loss due to a stroke, most usually think the patient cannot physically talk. In reality, a stroke patient can exhibit any number of language impairments. In the brain language functioning is stored in the left side - the side that controls abstract reasoning. When a patient has a traumatic incident such as a stroke, blood supply that is cut off can damage that area of the brain or hinder the connection to it. Within 24 hours of stroke onset, speech language pathologists are at the patient's bedside. After determining the patient can safely swallow and maintain nutrition, they immediately tackle the complex task of restoring his or her language functionality. Using a battery of tests and cues, the therapist works with the patient to pinpoint the problem, which can range from slurred speech to an inability to think of a correct word. Erin Watson, a speech language therapist at Exempla Good Samaritan Medial Center in Lafayette, said when a patient has a stroke affecting the language operation of the brain, it's the whole system that's affected, not just talking. "We have to break down what they understand and what they are able to tell us so we can treat the person as a whole," she said. "If you think of it as only their speech then you miss several parts of their communication abilities." JoAnne Domko, a speech language pathologist at Avista Adventist Hospital in Louisville, said although every individual's recovery is different, a speech therapist can tell within the first three days how the patient will recover. "It can take up to a year to find out how far they will progress, but those first three days are critical to start the rehab process," Domko said. "And how soon they are hospitalized at the first signs of a stroke is also a determining factor." Domko said speech therapy starts with the basics and moves patients to the highest functionality they have. "Our focus is to get them back into life, to get them functional to go home," she said. While in the hospital, a patient typically will see a speech language pathologist an hour a day, seven days a week. Once discharged the patient can either receive in-home care or outpatient services, typically consisting of 50-minute sessions three days a week, depending on the severity of impairment. Most therapists say the first three months are an optimal "window of opportunity" for intensive therapy and recovery, although positive progress can continue for up to a year or more. "With early intensive speech therapy services, patient outcomes are better," Watson said. "Although the amount of success a patient achieves in language recovery is dependent on the individual, early intervention is important." Costs for speech therapy range from about $50 to $150 per session and usually is bundled with other inpatient services. Most insurance policies cover the cost for both inpatient and outpatient treatment but typically limit the number of sessions an outpatient can have per year. The two main types of aphasia - or language impairment - are Broca's aphasia and Wernicke's aphasia. With Wernicke's aphasia, patients have problems understanding and expressing language - meaning they can talk but may speak nonsense or out-of-context words. Patients with Broca's aphasia are more locked-in: They can understand language but struggle to find the right word and get it out correctly. One of the first questions Juli Pearson, a speech language pathologist at Boulder Community Hospital, asks family members of stroke patients who suffer speech loss is about the patient's personality prior to the stroke. "We look at who they were before and try to modify different testing approaches to test their skill levels." Some initial tests include confrontational naming, where the therapist might ask a patient what they would use to cut a steak or to name the letters of the alphabet or the right word for a certain object. Higher-level language rehabilitation and testing would include problem solving, balancing a checkbook or counting money. After that the therapist works with the patient to help them return to normal life, whether it's understanding algebra functions for a former math teacher or how to use PowerPoint for a former executive. "Our goal is to provide them with day-to-day living skills," Pearson said. "They need to know how to function in the real world." For patients who suffer Broca's aphasia, Ann Galloway, speech language pathologist for Longmont United Hospital, said the words aren't necessarily lost forever. "It's almost like the patient can't find them in the brain. Everyone has had that feeling of a word being on the tip of their tongue; this is just way more so." Galloway uses cues such as associated words, the first sound or letter of a word or asks the patient to write the first few letters to help recall speech. "We use all the strengths left in the language functioning to stimulate the problem areas," Galloway said. "We send people home with practice sheets so the patient can work between sessions. Crossword puzzles or word games also help. But sometimes just being home and talking is the best practice."