Encountering a patient with severe aphasia can be daunting for new or recent clinicians.  Even seasoned speech pathologists who have had few cases of aphasia face difficulty executing communication goals.   I have spoken to hundreds of speech pathologists  aphasia treatment.  Many stated feelings of insecurity about treating severe aphasia.  Having been a speech pathologists and clinical supervisor, I have thoughts on what clinicians should consider if they have this concern.

For starters, it is wonderful to practice in a time when there is a plethora of accessible on-line clinical resources for treatment approaches.   They are helpful reminders, reviews and even sharing latest techniques for various communication disorders. 

Despite an enormous amount of information at our fingertips, application of therapeutic approaches require skill-level abilities that can only be solidified by therapist-patient engagement and case understanding. 

Confide in fundamentals.  Rely on use of fundamentals of evaluation of aphasia.  That requires us to start with case history.  Aphasia requires a neurological insult. Review hospital or facility records to verify results of imaging (CT and/or MRI).  Document the components of the radiological report that includes type and location of abnormal findings. Typically the type, size and location of therein injury will correlate to language behaviors or deficits.  Obtain the patient’s level of language, function and their medical background, and whether they are bi-lingual.

Capture the communication in present time.  At initial screening and later assessment of the patient observe the patient’s communication in spontaneous and structured context.   For patient’s who are severely impaired we should look for non-verbal attempts at communication.  Are there gestures, initiation of gestures, eye contact and tracking, and general responses to stimuli?

Are there spontaneous or responsive communication attempts?  Use a series of presentations of formal or informal assessment tasks to consider, identify and characterize whether the patient presents with common characteristics of aphasia including

impaired auditory comprehension, impaired verbal expression, existence of paraphasia, perseveration, impaired reading, confluent speech, fluent speech without meaning, differences between languages in a bilingual speaker, pragmatic problems and difficulty repeating words, phrases, and/or sentences.

Course a pathway to improved language that utilizes the patient’s re-emerging skill or most accessible language skill.  Write or modify your therapy goals based on your findings.  Strengthen that skill so that it can help facilitate re-learning of deficient language skills.  For example if a patient shows attention to task, clinician and stimuli, but poor comprehension, choose tasks that utilize the patient’s attention skills to facilitate increased comprehension. Likely you have to provide maximum support to push the patient through to meet this objective.

Often patients with aphasia have underlying cognitive deficits that are barriers to therapy.   I encourage clinicians to work through this because the action of therapy can help ease those deficits.  Documentation of the patient’s responses, even those small steps forward are confirmation that you are moving in the right directions.   As for my patient’s course, I set my sights on what direction I want for the patient.  I have seen some of the most language debilitated patients perform a skill that seemed out of reach.  This experience is why I created a language tool that helps aphasia patients.   I encourage every clinician to step into aphasia treatment and embrace the beauty of the complexity it may bring. It is very rewarding

 Please share through the comments your experiences working with patients who have severe aphasia.  

Ayana Webb

Speech-Language Pathologist

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