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Childhood Motor Speech Disorders in a Child with 7q11.23 Duplication Syndrome

grammatical functions,7although their intonation is not yet adultlike even at age 3 years.

d is correct, but incomplete. Communicative gestures, facial expressions, and other body language (leading, mime, etc.) typically precede or coemerge with the onset of meaningful words. In fact, they appear to lay the groundwork not only for words

but also for two-word combinations.

For children with speech delay, nonoral signals are vital communication tools to supplement the spoken word. Children who lack communicative intent are at risk of social-pragmatic disorders, such as autism spectrum disorder.

2. Primary symptoms of CD include the following:

a) Poor transitions between consonants and vowels. b) Groping of articulators. c) Imprecise consonant closures. d) Phonotactic errors more predominant than phonetic

errors.

e) Mis-stressed multisyllabic words.

Answer: c is correct. The imprecision results from low muscle tone, which leads to diﬃculty achieving complete consonant closures and may result in frication of stops, for example.

a is incorrect. This is a symptom of CAS, resulting from

impaired motor planning and programming.

b is incorrect. This is a symptom of CAS, resulting from

impaired motor planning and programming.

d is incorrect. This is a symptom of CAS, resulting from

impaired motor planning and programming.

e is incorrect. This is a symptom of CAS, resulting from

impaired motor planning and programming.

3. Primary symptoms of CAS include the following:

a) Choppiness due to segregated syllables or words. b) Decreased volume. c) Frication of stops. d) Poor quality of phonation. e) Decreased ability to produce prolonged vowel sounds.

Answer: a is correct. This is a result of impaired motor planning and programming. It appears that each sound, syllable, or word (depending upon the degree of impairment) is planned individually, with inappropriate pauses between productions of the units, as the next chunk of speech is planned.

b is incorrect. This is a symptom of CD, resulting from low

muscle tone.

Of course, some children may speak quietly for

other reasons.

c is incorrect. This is a symptom of CD, resulting from low

muscle tone.

d is incorrect. This is a symptom of CD, resulting from poor

neural coordination of muscle contractions.

e is incorrect. This is a symptom of CD, resulting from low

muscle tone.

4. Therapy recommendations for speech–sound disorders,

including motor speech disorders, include all of the following except: a) Many trials per session. b) Nonspeech oral motor exercises. c) Delayed, inconsistent feedback to ensure skill mastery. d) Consistent feedback for new skills. e) Variable stimuli and random trials to ensure skill mastery.

Answer: b is correct. It is not a recommended approach for speech–sound intervention. Research has shown that neurological control for speech is distinct from neurological control for nonspeech functions, such as chewing and blowing. The developmental progressions of these two functions also diﬀer. There is no current research evidence supporting the use of nonspeech oral motor activities to improve speech production.

13,14

a is incorrect. It is a recommended strategy. More motor

practice yields more complete learning.

c is incorrect. It is a recommended strategy. Delayed, inconsistent feedback encourages the child to rely more and more on his/her own self-monitoring and feedback systems, which yields more complete learning.

d is incorrect. It is a recommended strategy. When a skill is initially being taught, the learner needs more consistent feedback until his/her own self-monitoring and feedback systems begin to develop.

e is incorrect. It is a recommended strategy. Real communication situations are varied and unpredictable. Therefore, to be able to generalize new skills functionally, we must practice them with variable stimuli and with trials of diﬀerent sorts intermixed.

17,18

40.5 Description of Disorder and Recommended Treatment

At the age of 2.2 years, DC’s speech disorder was profound. However, communicative intent was a relative strength. Intervention included modeling simple vocalizations, including emotion words (“ow, ooh, wow, haha”) and key words and phrases (“mine, no, stop it, more, go”) in predictable routines (book reading, songs, daily activities). Continued use of manual sign and the addition of picture communication were also encouraged to decrease frustration and increase conventional communication. Occupational therapy was recommended to determine the potential eﬃcacy of tactile cues such as those provided in the Prompts for Restructuring Oral Muscular Phonetic Targets

(PROMPT) approach

despite her tactile defensiveness.

40.6 Outcome

DC was reevaluated at the age of 3.2 years following 1 year of intervention. On the Mullen Scales, visual reception (nonverbal reasoning) and receptive language T-scores continued in the average range and her expressive language T-score, although at the first percentile, was no longer at floor. Again, she was observed playing with her mother as well as in a diagnostic therapy session. DC’s lips were sometimes parted and sometimes closed as she chewed with a mostly rotary chew. She cleared a spoon full of pudding with her lips but did not lick oﬀ pudding from around her lips. She sipped juice from a straw with no leakage. She engaged in pretend and cause–eﬀect play and made excellent eye contact. DC’s linguistic progress was striking: she now produced approximately 40 diﬀerent recognizable imitated and spontaneous words. Many, but not lbreak/>all, vocalizations were whispered or quite quiet. She produced one two-word utterance, “baby hand.” DC’s consonant and vowel repertoires also had expanded considerably, as shown in ▶ Table 40.2.

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Childhood Motor Speech Disorders in a Child with 7q11.23 Duplication Syndrome

Table 40.2 Phonetic repertoires at age 3.2 years

Initial Medial Final

Consonants b, p, d, t, g, k

n w, j f, dʒ,tʃ

Vowels i, ɪ,e,ɛ,æ,u,ʊ,o,ɑ, ʌ

ɑɪ, ɑʊ

p, d, k, ʔ m, n f, s, ʃ

b, p, d, t, k, ʔ m, n f

However, she continued to demonstrate weak lip-rounding for [w] and word productions were inconsistent. Although her syllable shapes were predominantly CV (consonant + vowel), she produced quite a few final consonants (i.e., CVC syllable shapes) as well. Most of DC’s words were one to two syllables in length. Two-syllable words tended to be produced with a slight pause between syllables (e.g., [gɑ.di] for “doggie;” [bɑ.dɛ]for“bottle”). She produced one internal consonant sequence (CVCCVC) twice, in the word “backpack,” which appeared to be articulated with careful eﬀort. DC also demonstrated the ability to incorporate prosodic elements into one-word utterances to express communicative intent such as questions, comments, and commands.

DC’s symptoms suggested a combination of at least two motor speech disorders. Symptoms of CD included slow speech, low muscle tone in her lips, asymmetry of the lips and tongue, and some delays in feeding skills. Symptoms of CAS included a limited phonotactic repertoire, segregated syllables, inconsistency, and eﬀortful speech. However, due to her limited expressive vocabulary, neither diagnosis was made at age 3.2 years. DC’s social interaction and play skills, however, were strong.

At the age of 3.2 years, adults were encouraged to expand DC’s utterances, provide her fill-in-the-blank prompts (“The wheels on the bus go ___”), and model simple complete grammatical utterances in a repetitive manner (e.g., “Look, there’sa dog. He’s a big dog. The dog is running fast. Wow, he’s a fast dog!”). It was also suggested that DC be given choices between a desired object or activity and an undesirable one, ideally with the two objects held near the adult’s face to encourage her to take advantage of visual modeling of the correct word.

DC was next evaluated at the age of 4.2 years. The Verbal

Motor Production Assessment for Children (VMPAC)

was

attempted, but she was not compliant. Her score on the Assess-

ment of Phonological Patterns-3 (HAPP-3)

fell below the first percentile. DC spoke words and phrases in a slow and eﬀortful, but prosodically natural, manner. She demonstrated groping, inconsistency, vowel distortions, atypical error patterns, and poor control of voicing. Coarticulation and reduction across words within phrases were also noted (e.g., [tɜ˞nəigɑn] for “Turn the heaton;” [wʌ dɪʔnʌnʌms] for “Wantit num-nums”). Although she was resistant to tactile cues on her face, she responded well to gestural cues and to tactile cues performed on the examiner or in the air. A diagnosis of CAS, with symptoms of CD, was made.

At the age of 5.7 years, DC produced multisyllabic words with equalized stress and complete sentences with atypical pauses. Inconsistency, atypical patterns, vowel deviations, eﬀort, and groping all persisted, confirming the diagnosis of CAS. Symptoms of dysarthria also persisted, including immature chewing, imprecise consonant production, inability to move the tongue laterally, persistent breathiness, decreased pitch range, and

decreased velar control with nasal leakage. She completed the VMPAC with diﬃculty, scoring within the severe range in all areas: global motor control (general and specific movement systems supporting speech production), focal oral motor control (volitional movement control of the jaw, lips/face, and tongue), sequencing (nonspeech and speech movement sequencing), connected speech and language control (words, phrases, and sentences), and speech characteristics (pitch control, vocal resonance, vocal quality, loudness, prosody, and rate).

On the Goldman–Fristoe Test of Articulation-2 (GFTA-2),

she achieved a standard score of 75, at the fourth percentile for her age. Her HAPP-3 score again fell below the first percentile. The Comprehensive Test of Phonological Processing-2 (CTOPP-2) was given to assess her reading readiness. She scored at the sixth percentile on phonological awareness and third percentile

24,25

on phonological memor y. Syllable control practice,

articula-

tory gesture practice (e.g., Moving across Syllables by Kirkpatrick

), and backward buildups in conjunction with explicit

et al. practice of word stress, sentence stress, and pausing within

sentences

were recommended.

DC was most recently reevaluated at the age of 8.9 years. Although she continued to progress in all areas, she had not caught up to her peers in most areas. Her General Conceptual Ability (GCA; similar to IQ) on the Diﬀerential Ability Scales-II

(DAS-II)

was in the borderline range, with nonverbal reasoning within the low average range and verbal skills in the borderline range. Her standard scores for receptive vocabulary as measured by the Peabody Picture Vocabulary Test-4 (PPVT-4) and expressive vocabulary as measured by the Expressive

Vocabulary Test-2 (EVT-2)

were in the low average range. On the Clinical Evaluation of Language Fundamentals-5 (CELF-5), DC’s performance varied widely as a function of the subtest; she scored in the average range on the formulated sentences and recall of sentences subtests, in the borderline range on sentence comprehension, and in the low range on word structure, linguistic concepts, and following directions. On the CTOPP-2, DC demonstrated some gains, with phonological awareness and phonological memory now both at the 14th percentile (low average range). On the Wechsler Individual Achievement Test-

III (WIAT-III),

DC’s single-word reading and passage reading accuracies were within the average to low average range for children her age. Her pseudoword decoding, oral reading rate, and reading comprehension were considerably weaker, with standard scores in the borderline range. On the VMPAC, DC continued to score in the severe range in all areas except speech control, on which she demonstrated improvement except for control of prosody, which aﬀected her intelligibility. DC now exhibited some inappropriate compensatory strategies for cueing her articulators; she self-cued her tongue to move using her left index finger on her teeth or her fist pressed into her cheekbone. She occasionally stabilized her jaw by biting her lip and speaking through this gesture, which resulted in distorted speech. Her eyes widened when her jaw moved in an apparently unplanned direction. Her sentences were longer and more grammatically appropriate than previously observed, but syntactic as well as speech–sound errors persisted. Her score on the GFTA-2 fell to below the first percentile relative to children her age. She continued to have diﬃculty contrasting front ([d] and [t]) with back consonants ([g] and [k]) and moving from continuant (e.g., [s], [f]) to stopping sounds (e.g., [t], [p]) and

150

Childhood Motor Speech Disorders in a Child with 7q11.23 Duplication Syndrome

back again in sentences. Given the severity and atypicality of her speech–sound disorder, it was recommended that DC continue to receive intensive speech-language therapy to improve consistency and accuracy of speech–sound production. Suggestions included achieving stable oral postures for speaking tasks without using overt compensatory self-cueing strategies by practicing simple repetitive sequences (e.g., [bababababa]) with smooth direct jaw-opening and jaw-closing movements, increasing her flexible use of prosodic features in conversation, and mastering consistent use of age-appropriate speech sounds in words. Intensive systematic phonics instruction with additional instruction focused on reading comprehension also was strongly advised.

40.7 Key Points

●

CAS and CD often co-occur, especially in children with neurodevelopmental syndromes.

●

Although progress in therapy is expected with appropriate intervention, CAS is a long-term disorder associated with language and literacy diﬃculties as well as oral motor, motor speech, and speech deficits.

●

Appropriate compensatory strategies must be taught as these children tend to develop inappropriate strategies that draw unfortunate attention to themselves.

40.8 Acknowledgments

This case is part of a larger dataset on 7q11.23 duplication syndrome research supported by the Simons Foundation (238896) and the National Institute of Child Health and Human Development (R37 HD29957). We acknowledge the child and her mother, as well as the current and former members of the Neurodevelopmental Sciences Laboratory at the University of Louisville for their participation in this project.

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151

Prioritizing Clinical Decisions in a Complex Medical Case

41 Prioritizing Clinical Decisions in a Complex Medical Case

Erin Embry

41.1 Introduction

Often in clinical practice, speech-language pathologists are faced with individuals who present with multiple cooccurring impairments, complicating the process related to diﬀerential diagnosis and the selection of priority intervention goals. This case report highlights the challenges of that process for a 65-year-old woman who experienced a left middle cerebral artery cerebrovascular accident (MCA CVA) (▶ Fig. 41.1) and provides systematic, clinical decision-making guidelines based on evidence-based approaches.

41.2 Clinical History and Description

BR was a 65-year-old woman admitted to an urban center emergency department with bilateral pleural eﬀusion. She was treated with diuretics and Coumadin on admission. The following day, she was found unresponsive with aphasia, left gaze preference, right facial droop, and right-sided posturing upon noxious stimulation. A computed tomography of the head showed no bleed but an early left MCA CVA. BR was within the appropriate time window for tissue plasminogen activator, a protein used to break down blood clots. However, due to her high National Institutes of Health Stroke Scale (NIHSS) score of 28 (▶ Fig. 41.2), she was deemed to not be a candidate.

A percutaneous endoscopic gastrostomy (PEG) tube, as opposed to a nasogastric tube, was placed to deliver nutrition due to inconsistent alertness. Magnetic resonance imaging revealed a patchy subacute hemorrhage and peripheral laminar necrosis in the parietal and frontal lobe white matter within an evolving large left MCA infarct with midline shift . After 2 weeks in acute care, BR was medically stable. Following a fiberoptic endoscopic evaluation of swallow (FEES) at bedside, she was advanced to a soft chewable diet with thin liquids. Her impairments were primarily associated with the oral preparatory and oral phases of the swallow. She was still largely nonverbal with a dense right hemiparesis. BR was then transferred to the inpa-

tient rehabilitation unit for intensive speech, occupational, and physical therapy.

Prior to admission, BR’s past medical history included newly diagnosed atrial fibrillation and congestive heart failure as well as a history of mild depression, smoking, and social alcohol use. Her discharge plan was to return home with her husband and continued care, as needed.

41.3 Clinical Testing

Given the size of the CVA, in conjunction with premorbid diffuse white matter necrosis, BR presented with multiple issues related to communication, cognition, and swallowing. Even though BR was reportedly tolerating a soft diet with thin liquids safely, overall oral intake was limited and a subsequent clinical swallowing evaluation was performed upon admission to the rehabilitation unit to assess any potential change in swallow function. An oral motor examination was discontinued as BR was unable to follow basic commands. Evidence of oral motor apraxia was observed for nonspeech tasks. At rest, BR presented with significant right-sided facial/labial asymmetry. Dentition was natural and complete. Intake of food/liquids was more spontaneous; BR was trialed with pureed and soft chewable solids only due to oral motor weakness and reduced range of motion. Labial containment was adequate; mild delays noted in bolus formation and propulsion and improved in timeliness with an increased number of trials; a seemingly timely reflexive swallow and adequate hyolaryngeal rise with all textures. Minimal oral residue with soft solids was noted in the right lateral sulci post swallow, likely due to sensory impairment. It was recommended that BR remain on her current diet with a calorie count and continued tube feed supplements as needed.

Comprehensive evaluation of speech, language, and cognition was performed to establish baseline measures and to implement a basic system for communication. Given BR’s limited responses to single-step commands and reduced verbal output, nonstandardized measures were used to evaluate basic expressive and receptive language skills in lieu of formal testing.

Fig. 41.1 Motor cortex and sensory cortex of the brain and surrounding areas.

152

Prioritizing Clinical Decisions in a Complex Medical Case

Fig. 41.2 National Institutes of Health Stroke Scale.

153

Prioritizing Clinical Decisions in a Complex Medical Case

154

The following baseline data were obtained for receptive lan-

guage skills: responses to simple yes/no questions pertaining to self/environment (via pointing to written word or head nod)= 2/10 (20%); following simple one-step directions =3/10 (30% with visual cue only); identification of body parts = 0/5; and identification of real, functional objects in field of two= 1/ 10 (10%). The following baseline data were obtained for expressive language skills: automatized sequences (e.g., days of week, ABCs, Happy Birthday, etc.) = 0/5, although evidence of melody to support songs and rhythm was emerging; patient spontaneously responded “Oh God” in response to failed attempts at various tasks; repetition of CV/CVC words with visual prompt = 0/ 5; and required hand-over-hand assist to initiate pointing of picture representations of basic wants and needs.

In addition to diﬃculty with CV/CVC word repetition, BR could not imitate more reflexive vocalizations such as coughing, sighing, or throat clearing. Further, significant articulatory groping was observed when attempting to produce speech. Although assessment of BR’s cognitive functioning was limited due to language and speech impairments, overall sustained attention to structured tasks was reduced and BR required cues for redirection after an average of 25 seconds. Significant inattention to the left visual field was also observed. Insight into current impairments was beginning to emerge as BR exhibited a high level of frustration with failed attempts to communicate.

41.4 Questions and Answers for the Reader

1. What is the significance of a score of 28 on the NIHSS? What

does this mean in terms of prognosis?

Answer: The NIHSS is a standardized protocol used by physicians to quantify the severity and functional impacts of stroke. The score integrates components of the neurologic exam including cranial nerves (visual), motor, sensory, cerebellar, inattention, language, and loss of consciousness. Scores greater than 15 to 20 are considered more severe and are associated with less than 20% good or excellent outcome.

2. BR presents with multiple cooccurring impairments. How

would you determine the priority for evaluation and t reatment for a patient who presents with deficits in swallowing and all modalities of communication?

Answer: Safety is a priority in patient care and guides both the evaluation and treatment process. In the acute care stages, if swallowing is compromised and puts him/her at risk for either aspiration or inadequate nutrition and/or hydration, the most immediate need is to determine the cause of the problem and implement a plan of care that allows the patient to safely tolerate the least restrictive textures while meeting hydration and nutrition needs. If the patient is medically stable, the next step in the process shifts to establishing the most eﬀective method for the patient to communicate basic wants and needs to his/ her caregivers and hospital staﬀ. Approaches are highly variable and based on individual patient needs. More often than not, both the evaluation and treatment processes typically address individual and overlapping skills simultaneously in an attempt

Prioritizing Clinical Decisions in a Complex Medical Case

Fig. 41.3 Assessment and treatment hierarchy for complex patients.

to obtain a diﬀerential diagnosis, keeping in mind that the clinical presentation at this stage may rapidly evolve. For a patient who is essentially nonverbal with limited communicative intent, the clinician must proceed with an awareness of the underlying cognitive processes that support each domain. Remediation of these skills will be based on a hierarchal approach, beginning with comprehension (written and/or reading) and progressing to a focus on motor speech production and language expression (spoken and/or written) (▶ Fig. 41.3).

3. A swallow study (FEES) was initially performed while BR was on the acute care unit, but not repeated on the rehabilitation unit. Why was instrumental assessment of swallowing not repeated?

a) A minimum of 2 weeks in between testing is required. b) BR’s swallow diﬃculties were primarily limited to the oral

preparatory/oral phase and decisions to advance her diet could be safely determined based on clinical findings.

c) It was unlikely that the patient made any functional gains

in 2 weeks.

d) BR could not tolerate a follow-up FEES secondary to

decreased alertness and/or arousal.

Answer: b is correct. Per the FEES performed while on the acute care unit, BR’s primary impairments were associated with the oral preparatory and oral phases of swallow, while the pharyngeal phase was determined to be within functional limits with no observed penetration or aspiration. The risk for aspiration with more viscous textures is significantly reduced and, as a result, the clinician can proceed with a certain level of confidence that any dietary advancement can be safely recommended without additional instrumental assessment.

a is incorrect. Although a clinician should always consider patient safety and endurance levels and then carefully determine the actual need and/or benefits for a follow-up examination within that time frame, there is no contraindication to performing a second FEES within 2 weeks (like there may be for videofluoroscopy).

c is incorrect. BR was medically stable and transferred to the inpatient rehabilitation unit. Prog ress was slow due to the size and location of the stroke, but im provement in swallow function was repor ted and BR remained in the acute phase when spontaneous neurological gains were a st rong possibility.

155

Prioritizing Clinical Decisions in a Complex Medical Case

d is incorrect. This information was not explicitly reported, although a transfer from the acute care unit to an inpatient rehabilitation unit typically requires patients to be able to tolerate a minimum of 3 hours of therapy daily.

4. Based on BR’s presentation, what recommendation(s) would

you provide to the team and caregivers as the most eﬀective

approach to facilitate communication? a) Alternative/augmentative communication. b) Framing questions in yes/no format. c) Framing questions in choice format. d) Gestures and/or visual choices. e) Writing information down.

Answer: All of the above are correct. Continuing to provide BR with a multimodal approach to communication in the acute care phase is beneficial as it oﬀers a variety of opportunities that may not have initially been successful during the evaluation, but have the potential to evolve as her status becomes more stable. It is important to note that while each of these approaches has merit, they should be based on her strengths and introduced systematically. Based on the initial evaluation, BR would likely achieve the highest level of success responding to structured yes/no questions followed by choice questions to indicate her basic wants and needs. These responses would be strengthened if coupled with visual cues such as gestures and the use of real/pictured objects. Written supports might also be beneficial, although her level of comprehension of written words has yet to be determined and, therefore, cannot be used in isolation. However, alternative forms of communication such as a basic picture board would be another potential supplemental approach until verbal expression improves. Independence with this approach would be challenging due to the coexisting ideational and motor apraxia that limits accuracy with pointing.

41.5 Diagnosis and Recommended Treatment

BR presented with multiple impairments: mild oropharyngeal dysphagia characterized by diﬃculty managing hard solids due to oral motor weakness and oral apraxia and global aphasia with a cooccurring severe verbal apraxia. Evidence of cognitive impairments in the area of attention and executive functioning was also noted. Diﬀerential diagnosis of speech versus language versus cognitive impairments proved diﬃcult in the initial stages, although given reported ideational and motor apraxia by physical and occupational therapy, it was suspected that motor impairments were greater than language impairments, which were likely more impaired than cognition. In addition, due to oral motor weakness, dysarthria was likely present, although it could not yet be determined secondary to limited verbal output. BR consistently exhibited frustration with unsuccessful attempts to communicate, spontaneously responding with “Oh God” in these instances. Given BR’s presentation, all basic wants and needs were to be anticipated and facilitated by staﬀ and family.

Since BR was safely tolerating a solid diet with thin liquids

and receiving supplemental nutrition/hydration via PEG tube as

needed, the focus of treatment shifted to attempting to establish a basic system of communication between her and her family and hospital staﬀ. The presence of cognitive impairments coupled with severe motor apraxia impacted BR’s initiation and coordination for both speech production and pointing and limited BR’s candidacy for a basic picture board to independently communicate. Therefore, a multimodal approach that focused first on improving auditory comprehension using functional pictures and stimulus items representing target sound classes in the initial position of words was implemented while simultaneously training with a basic picture and yes/no communication board for daily interactions. Treatment for improved speech production was based on principles of motor learning infused with traditional apraxia remediation approaches with the intended consequence that oral sensorimotor swallow function would also improve. Training of compensatory, postural, and/or therapeutic swallow techniques was not an option.

Patient and family education, counseling, and training were ongoing as the discharge plan was to return home with family support and additional hired care and therapy as needed.

41.6 Outcome

By the end of her 4-week stay in acute inpatient rehabilitation, BR was tolerating a mechanical soft diet with thin liquids and her feeding tube was removed. Comprehension of verbal direction, object identification, and social conversation in highly contextual situations had improved but was still impaired for noncontextual situations and abstrac t information. Verbal output minimally increased but was limited to single words that were imprecise due to both altered speech rate and precision. Repetition of CV/CVC words was inconsistent at 20% and accuracy of yes/no responses doubled to 40% using a combination of verbal, gestural, and written responses.

The most salient barrier to therapeutic progress, however, was depression resulting in a lack of motivation and reduced participation in all therapies. Cotreatments were scheduled to maximize therapy and to promote more opportunities for positive social interactions. BR was resistant to using a communication board other than a laminated yes/no response board. Her family was trained on modification of communication approaches to simultaneously promote yes/no responses while reducing frustration levels. BR was an avid dog lover and pet therapy was incorporated in therapy sessions when possible. Despite all eﬀorts, the entire team agreed that BR did not meet her full potential for success while in rehab and she was discharged home with her family. Additional hired supports and continued therapy were provided by both a home care agency and private therapists.

41.7 Key Points

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Individuals who experience a stroke present diﬀerently depending on their health history, activity level, educational background, and severity of the infarct.

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When faced with a patient with multiple therapeutic needs with regard to cognitive-communication and swallow function, as with any evaluation and treatment plan, safety is the primary target for intervention.

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Prioritizing Clinical Decisions in a Complex Medical Case

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Progress for individuals who present with cooccurring impairments is often slow. The frequency and structure of treatment sessions, types of stimulus items selected, the nature of the feedback, and patient motivation are key prognostic indicators to help patients regain and/or compensate for deficits.