(ASU) CD 5731 Neurogenic Disorders I
(FSU) Dysphagia
(LRC) OT 443 Physical Rehabilitation
(ASU) CD 5733 Neurogenic Disorders III
(UTK) ASP 539 Motor Speech Disorders

CASE SUMMARY #1

History: Charlena Fortune is a 67 year old woman with a ten year history of multiple mild strokes. Most recently, she suffered a more severe ischemic stroke involving the left MCA. MRI revealed an infarct in the L MCA watershed area as well as evidence of multiple infarcts throughout the cortex bilaterally.

Prior to this stroke, she was living independently and caring for her teenage grandson. She lives in an urban area and relies on state subsidies for income. She is 4 days post-onset and her physicians are considering discharge options from acute care.

ID of likely language limitations: The left MCA supplies blood to most of the lateral surfaces of the left hemisphere, as well as to portions of the subcortical areas. Possible language limitations include: auditory processing and comprehension difficulties, phonological storage problems, written language deficits, and reading comprehension difficulties. Visual deficits may also been seen, which may in turn affect the patients reading comprehension abilities.

Stephanie Beeson

ID of likely speech limitations: Based on the information given it seems as though damage to the cortex would definitely cause the patient to have difficulty with motor speech planning. Due to the fact that the MRI revealed an infarct in the left middle cerebral artery and multiple infarcts in the cortex bilaterally this suggests that the patient may exhibit spastic dysarthria. This type of dysarthria will usually occur when a stroke in one hemisphere is combined with previous cerebral damage in the other hemisphere and this seems to be the case. In general, the patient may exhibit weakness and slowness of the articulators, as well as a harsh vocal quality.

Stephanie Doucette and Melissa Carpenter

ID of likely swallowing limitations: Charlena Fortune may experience swallowing difficulties following her stroke which affected her left MCA. Her swallowing difficulties may be heightened due to her history of multiple strokes. Apraxia of swallow is common in patients who have suffered from left hemisphere ischemic strokes. Characteristics of apraxia of swallow involves a delay in the oral swallow. Other characteristics of apraxia of swallow include: no tongue movements when bolus is present or sporadic motions of the tongue to find the bolus in the oral cavity. Ms. Fortune should feed herself while no commands to swallow are given to exhibit a more appropriate swallow. Her oral transit will also be delayed due to her stroke. The chewed bolus could take over five seconds to travel through the mouth and reach where the pharyngeal phase is triggered. This time period was extended due to the number of multiple strokes Ms. Fortune has suffered. Her pharyngeal swallow will also be delayed for over five seconds. Once the pharyngeal swallow is triggered by the bolus a normal swallow will probably take place in patients who have suffered from one stroke. In this case, Ms. Fortune may experience further difficulties due to her multiple strokes including: reduced laryngeal elevation, reduced closure of the laryngeal vestibule, and unilateral weakness of the pharyngeal wall. Ms. Fortune will experience these difficulties if her normal swallow function had not returned after her previous strokes.

Lindsay Vaughn

ID of likely limitations in basic ADL's: Ms. Fortune’s history indicates that she has been living independently prior to this most recent stroke and therefore may have learned some compensation techniques that have allowed her to overcome deficits that were the result of previous strokes. However, this latest stroke is likely to have caused impairments much more extreme than in the past and she is likely to be experiencing difficulties in many of her basic ADL’s. Since unilateral neglect is probable and possibly even anosagnosia, she is likely to be experiencing deficits in grooming, oral hygiene, bathing/showering, and dressing. In addition, hemiplegia, which will have the greatest involvement in the areas of the arm, face, and tongue, will lead to difficulties with feeding and eating and possibly medication routines. Toilet hygiene is a potential problem due to perceptual difficulties and motor impairments. Cognitive and emotional impairments that result from this stroke may lead to complications in the areas of functional communication, emergency responses, socialization, and sexual expression. Ultimately, this stroke will potentially effect all of Ms. Fortune’s basic ADL’s and most of them for more than one reason. Given her age and previous role of providing care to a teenage grandson, all of the ADL’s addressed above are potentially important in Ms. Fortune’s life.

Kara Cantoni

ID of likely limitations in complex ADL's: According to the historical information received on Ms. Fortune’s current and previous status, a general idea of level of functioning in complex ADL’s (IADL’s) can be deduced. With Ms. Fortune’s previous history of multiple mild strokes, she may have not completed portions of or entire complex ADL tasks depending on the level of the previous complications. With the MCA currently being involved during her stroke, she is likely to exhibit many functional deficits that would impair her in her complex daily activities. She is likely to have deficits/limitations including, but not limited to: right hemiplegia, possible hemianopsia, apraxia, Broca’s and/or Wernicke’s aphasia, lack of judgment, impaired organization in behavior, depression, lability, and become easily frustrated. The later behavioral issues play an important role to safety in performing vital complex ADL tasks such as meal preparation and cooking, money management, driving, shopping, household maintenance and also importantly in her care of others. It is essential to be able to assist Ms. Fortune in remediation and compensation for many of the above deficits in order for her to move forward to safe completion of complex ADL’s.

Kimberly Elkins

ID of likely limitations in cognition: Considering Ms. Fortune's age, ten year history of multiple mild strokes, the recent stroke involving the left MCA, and the evidence of multiple infarcts throughout the cortex bilaterally, I think she could have vascular dementia or also known as MID (multi-infarct dementia). Multiple cortical infarcts can affect the anterior, middle, and/or posterior cerebral arteries. In their progression towards dementia, they can show symptoms of apraxia and aphasia.ID of likely limitations in cognition could include memory, attention, thinking, and learning. To be more specific, there could be cognitive deficits in the areas of executive functioning, memory, attention, visuoperception, and affect & emotions. Some of the deficits may include, but are not limited to poor judgment, reduced initiative and motivation, reduced self monitoring, impaired sequencing, impaired semantic/working memory, poor episodic memory, spatial disorientation, disinhibition, may exhibit emotional lability, disorientation for time, impaired selective attention, and decreases arousal/alertness.

Tiffani Bender

Assessment of swallowing: It would first be important to gather any additional information from the patient, or from his/her family, concerning symptoms that would indicate a potential swallowing disorder:

* Had she previously experienced swallowing difficulties following strokes?
* Had Ms. Fortune been on a regular diet prior to the stroke?
* Does the client have food allergies?
* Has she attempted to eat since this stroke?
* What happens when she tries to swallow? Does she cough and choke?

It is important to find out difficulty with a specific consistency if the patient does describe a swallowing problem. The clinician should then ask Ms. Fortune to demonstrate what she did when starting to swallow. From this demonstration, it could be concluded that she attempted too much material or did not position it appropriately in her mouth.

The clinician should be able to:

* localize the disorder (oral, pharyngeal, or both)
* easiest and most difficult types of food for Ms. Fortune to swallow
* nature of disorder

The Adult Bedside Dysphagia Examination should be used to evaluate the integrity of Ms. Fortune's oral mechanism. This assessment will look at not only Ms. Fortune's oral structure, but also specifically the behaviors that may alter her chewing and/or swallowing function. This will assess the range, rate, and accuracy of lip, tongue, velum, and pharyngeal movement during speech, reflex, and swallowing. It is important for the clinician to first consider the risk of attempting bedside swallows. If Ms. Fortune is able to follow directions, cough on command, has good pulmonary function, bedside swallows may be administered, and the following should be noted:

* reaction to food
* oral movements- bolus manipulation and mastication
* struggle (coughing, changes in breathing, etc) and when these behaviors are displayed
* secretion levels
* duration
* breathing/swallowing coordination (Logemann, 1998)

Videofluoroscopy should be administered to further examine functional abnormalities that are causing the patient's symptoms. The modified barium swallow will provide the clinician with information on the following:

* oral and pharyngeal transit times
* valve functioning
* peristalsis
* if and why aspiration occurs (Logemann, 1998)

This may not reveal additional information regarding oral and pharyngeal function. In Ms. Fortune's case, it may not be necessary to perform the MBS if bedside examination reveals that symptoms exist primarily in the pharynx.

In performing these assessments, the clinician will likely discover the following symptoms:

* initiation of oral phase is delayed
* swallowing more easily accomplished spontaneously rather than with verbal directions
* oral transit delay
* pharyngeal swallow delay

The clinician would conclude that Ms. Fortune's symptoms are indicative of swallow apraxia.

Logemann, Jeri A.(1998). Evaluation and treatment of swallowing disorders (2nd edition). Austin: Pro-Ed.

McAfee, Julie G. & Shipley, Kenneth G. (1998). Assessment in speech-language pathology: A resource manual (2nd edition). San Diego: Singular.

Heather Westall ASU

Assessment of language:When assessing language, you would need to look at their expressive and receptive language abilities. Aphasia batteries are most likely going to have the information you would need to look for in this patient. Areas of assessment include: (1) auditory comprehension- single word recognition, yes/no questions, and commands (2) expression- verbal and nonverbal, naming, repetition, connected speech, automatic speech (3) reading- single word recognition, sentence level, paragraph level, oral reading (4) writing- personal information, automatic information, writing to dictation. The Western Aphasia Battery (WAB) covers all of these things as well as non language skills. Other tests that would help assess language include the Test of Adult and Adolescent Word Finding, which is a naming test, and the Discourse comprehension test which measures discourse. The CADL-2 which is a test of a person's functional language could also be used in this case. Since the patient is four days post onset, you can use informal assessment while visiting her at bedside. Asking her questions about personal information and naming objects in the room will help you get a good idea of her language abilities.

Ashley Harvey

Assessment of speech: Because of Mrs. Fortune's recent onset it is unclear how much of a speech assessment can be obtained. Since she has had a recent L hemisphere CVA, her language may be affected. She may also be too weak to last through a full assessment.

1. The first step is to attempt to interview the patient. During this process, we will attempt to gain understanding of her speech status prior to
this last stroke. We will also try to determine Mrs. Fortune's perception and awareness of how severe her problem is. If she is unable to communicate due to language difficulties,the interview will be conducted with her family.

2. An oral motor exam will follow the interview in order to assess movement and symmetry of the lips, tongue, and velum (along with other areas of the oral cavity, voice, and AMRs). Because of possible auditory comprehension deficits, it is imperative to demonstrate the actions that Mrs. Fortune needs to perform.

3. Depending on Mrs. Fortune's cooperation and health status, we will attempt to formally assess for dysarthria. It is important to assess all of the
following subsystems of speech:
-respiration
-phonation
-resonation
-articulation
-intelligibility
-prosody.

The "Frenchay Dysarthria Assessment", "Dysarthria Profile", and "Dysarthria Examination Battery" all measure the above subsystems. In addition, the Frenchay also looks at cough and swallowing reflexes and drooling. There is also a section on the test form to note hearing, sight, language, mood, posture, sensation, and sight. The Dysarthria Profile assesses DDK, swallowing, and cough reflex. The Dysarthria Examination Battery formally assesses oral sensitivity to tactile stimulation. Ideally, we could pull from all three of these test in order to gain a more
complete picture of Mrs. Fortune, but due to her increased risk of reading difficulty, sight problems, and decreased stamina, we will administer the Frenchay. There is more reading required in the other two exams. There is still a risk of problems administering this test because of the possibility of decreased auditory comprehension.

If Mrs. Fortune does in fact present with spastic dysarthria, we expect the test to show some or all of the following: hypernasality, slow rate, reduced ROM of the articulators, chewing and swallowing problems, and decreased pitch variability. We will also expect to hear a harsh, strained-strangled voice quality.


Ginger Geldreich
Amanda Fry

Assessment of basic ADL's: To assess Ms. Fortune, I would complete a morning ADL. This would include a sponge bath, upper and lower body dressing, grooming, and oral hygiene. After watching her during oral hygiene, I could make some assumptions about feeding; however, it would be beneficial to watch Ms. Fortune during a meal. Finally, I would have Ms. Fortune in the ADL kitchen to see how she can maneuver. Knowing that she was independent prior to her last CVA, this basic assessment would allow me to see what level she is currently functioning on and whether or not she is safe to return home.

Katie Kaminska

Assessment of complex ADL's: The minimal I-ADL's (Instrumental ADL's) that are needed for a client to live alone independently include the ability to prepare or retrieve a simple meal, employ safety precautions and display good judgment, and the ability to take medication or get emergency assistance if needed (Pedretti 2001). The main location of the CVA is in the L MCA however with multiple infarcts occurring bilaterally it is likely that Ms. Fortune will have a variety of cognitive and visual perceptual difficulties as well as physical limitations. It is my opinion that her teenage grandson isn't in a position to take on adult responsibilities that include taking care of an elderly grandmother , therefore it is best to want the highest level of independence as if she was living alone. One standardized assessment that could be used
is the AMPS (Assessment of Motor and Process Skills) The subsets that are recorded are as follows:

Pedretti L.W., Early M.B. (2001), Occupational Therapy, Practice Skills for Physical Dysfunction 5th edition, (pp. 126-129, 644-656) Mosby

Unsworth C, (1999) Clinical Reasoning with Executive Functions Impairment, Cognitive and Perceptual Dysfunction, (pp. 215-232) Philadelphia F.A. Davis.

Holly Wagstaff

Assessment of cognition: To assess Ms. Fortune, the clinician could begin by informally assessing her through observation. For example, the clinician could orient her to person, place, time, and event to see if she is aware of the problem and her surroundings. ("Tell me your name." "Where are you?" "What is the date?" "Why are you here?") Next the clinician can ask Ms. Fortune about her family or career to assess her long term memory or short term memory. If there seems to be any problems with answering the questions, the clinician would need to find a test that measures cognitive functioning. One of the most commonly used tests of cognition is the Ross Information Processing Assessment (RIPA). It assesses: 1) memory, (including immediate, recent, temporal orientation-recent, temporal orientation-remote) 2) spatial orientation 3) orientation to environment, 4) recall of general information, 5) problem solving and abstract reasoning, 6) organization, and 7) auditory processing and retention. By using this test to assess Ms. Fortune's cognitive functioning, the clinician will be able to determine deficits in memory, orientation, executive functioning, and auditory processing. Other tests include the Galveston Orientation and Amnesia Test and the Rivermead Behavioral Memory Test. Because of Ms. Fortune's history of multiple strokes and damage to the L MCA, it is likely that she will have some deficits in cognition, including short term memory, recall of information, orientation to environment, problem solving, and organization.

Mandy Crow

Prognosis: Based off the historical information and description of deficits, prognosis is fair pending behavioral variables (type and severity of disorders), patient cooperation, family support, and medical stability for language, speech and swallowing. This prognosis is assuming the patient had normal-to-mild functioning prior to the most recent left MCA ischemic stroke. After discharge from acute care, Miss Fortune would benefit from 2-4 weeks in a rehab facility. Afterwards, depending on the amount of functioning gained, Miss Fortune may need to be referred to a skilled nursing facility (SNF), or nursing home.

Stacey Walter

Swallowing targets and activities: Based the probable diagnosis of apraxia of swallow resulting from multiple strokes, the following goals for Ms. Fortune are functionally appropriate:

1. Increase oral transit time and sensory awareness.
2. Increase the triggering mechanism of the pharyngeal swallow.

Compensatory activities include: postural changes, increasing sensory input, modifying bolus volume and transit speed of the bolus, changing food consistency or viscosity and introducing intraoral prosthetics.

Postural techniques:
1. Head back to assist inefficient oral transit time. Rationale; utilizes gravity to clear oral cavity.
2. Head, chin down to assist the trigger of the pharyngeal swallow. Rationale; widens valleculae to prevent bolus from entering the airway, narrows airway entrance, pushes epiglottis posteriorly.
3. Head rotated to damaged side to assist with unilateral pharyngeal paresis. Rationale; twists the pharynx to eliminate the damaged side from the bolus path.

Techniques to improve sensory awareness are compensatory activities that involve patient manipulation by the caregiver and do not change the motor control of the swallow. They are also considered therapeutic techniques because they may change the timing of the swallow by reducing both the oral onset time and delay in triggering the pharyngeal swallow.

1. Increase downward pressure of the spoon against the tongue when presenting food in the mouth to promote sensory awareness.
2. Present a sour bolus; 50% lemon juice, 50% barium to promote sensory awareness.
3. Present a cold bolus to promote sensory awareness.
4. Present a bolus that requires chewing so mastication will provide preliminary oral stimulation.
5. Present a bolus with a larger volume, 3 ml or more, a larger volume may help trigger a pharyngeal swallow.
6. Thermal-tactile stimulation with a cold laryngeal mirror rubbed for five seconds on the anterior faucial arches prior to the swallow to heighten oral awareness and alert a sensory stimulus.
7. Suck-swallow stimulation using increased vertical tongue-jaw movements with the lips closed to help facilitate the pharyngeal swallow.
8. Allow patient to feed themselves to initiate the sensorimotor act of swallowing.
9. Food consistency changes should the last compensatory strategy explored.
Thickened liquids: to assist with delayed pharyngeal swallow or oral tongue dysfunction. The level of thickness may vary. Some patients may need pureed foods, others will benefit from nectar or honey thickened liquids.
Purees or thick foods: to assist with a delayed pharyngeal swallow or reduced laryngeal closure at the vestibule.
10. Introduction of intraoral prosthetics to assist with swallowing.

Therapy techniques:

1. Oral motor exercises.
2. Range of tongue motion exercises.
3. Bolus control exercises.
4. Bolus propulsion exercises.

Jules Roberts

Basic ADL targets and activities: All the basic ADLs will be affected because of the multiple strokes Ms. Fortune has suffered. These include grooming, eating, dressing, toileting, and bathing.

Goals that would be appropriate for Ms. Fortune would be:
1) Pt will be modified independent with ADLs.
2) Pt will demonstrate use of adaptive equipment for functional performance of ADLs.

Activities to include:
*ROM arcs, any activity that will require reaching to pt's max AROM (active range of motion)
*strengthening program for increasing strength and endurance; ex: dowel rods with no weight at first then adding weight
*perceptual activities; ex: building with blocks by following design in 2-D and 3-D
*transfers to tub and practice bathing
*educate patient on use of adaptive equipment and have them practice to demonstrate their understanding

Holly Creeger

Complex ADL targets and activities: Goals for IADL's/Complex ADL's

1) Patient will prepare warm snack with modified independence.
2) Patient will make bed with modified independence.

Continuing with biomechanical rehabilitation will help improve her function in these areas (such as ROM, strength and endurance).

1) In order to prepare the warm snack (such as popcorn or pudding) it would be easiest and most likely safest to use the microwave. She should be able to mix with one hand while seated in a wheelchair if she has no use of her right side. However it would also be good, if she has movement, to have her use her right side in order to work on ROM, strength and endurance. If she is seated in a wheelchair she may need to use a reacher to gather materials.

2) In order to make her bed, if she is in a wheelchair, she need to make sure that she is able to reach all areas of the bed (make sure the w/c can fit on both sides of the bed), if not she would need to use a reacher. To reduce fatigue, she could make up one side of the bed and then wheel to the other side so she isn't going back and forth. Once again if she has movement in her right side it would be good to incorporate it wherever possible.

stacy mccraw

Language targets and activities: 1. Ms. Fortune will increase her auditory comprehension to better understand and communicate with her family.
a. Clinician should begin with a picture/object and give a single word stimulus, such as a drink. The clinician can identify it by pointing
to the picture/object and naming it several times. Next, the clinician says "drink," or "Point to the drink," indicating to the patient to
respond by pointing to the picture/object of the drink. If a family member asks Ms. Fortune if she wants a drink, she will understand what
they are asking. A communication board may be used to aid her understanding. Ms. Fortune, or family members, may point to the
objects for verification.

b. After the connection has been made that the picture/objects is represented by a word, another stimulus should be discussed as in part
a. Once the new stimulus has been successfully identified, the two stimuli should be placed together. Then the clinician would ask the
patient to point to which ever picture/object the clinician said. If the patient was correct an additional stimuli would be added in
the same fashion as b. However, if the patient was not correct, the clinician should return to the single stimuli word. The clinician
should continue to add on/move back as needed. This method can be used in various ways. For example, pointing to body parts, clothing, answering yes/no questions, following directions, etc. Each portion can be made more and more complex to better serve the patient in her increasing auditory comprehension.

2. Ms. Fortune will increase her oral expression to indicate her wants (i.e. watching tv, etc) and needs (i.e. food, toilet, etc.).
The clinician will provide stimuli in varying conditions for the patient to respond to orally, which will continue to increase in complexity. To build vocabulary and use of language to better communicate Ms. Fortune?s wants and needs, stimuli will include tasks such as: repeating after the clinician (C: I'm hungry; F: I'm hungry), completing a phrase/sentence (let's watch __), naming pictures/objects, answering wh- questions, etc. A communication board may be used if Ms. Fortune needs to expressively communicate and cannot find the proper words.

Missy Jones

Long Term Goal: Miss Fortune will increase her auditory comprehension abilities to a level of 90% accuracy.

Short Term Goals:
1. Miss Fortune will correctly answer yes/no questions about pictures with 90% accuracy.
2.Miss Fortune will correctly follow verbal commands to open, close, show, give, pat, etc. with 90% accuracy.

Speaker compensations of using alerting signals, modifying content and form, repetition, rephrasing, and watching for signs of comprehension
and confusion will be implemented. During therapy, Miss Fortune will be presented with action pictures. The clinician will then ask Miss Fortune a yes/no question pertaining to the presented picture, and she will be expected to respond with the appropriate answer. For example, the clinician will show Miss fortune a picture of a man running, and then ask "Is the man skiing in this picture?" In addition, the
clinician will give Miss Fortune a verbal command and she will be expected to execute the given command. For example, the clinician will
say ?Put your hand on your head.?

Long Term Goal: Miss Fortune will increase formulation and expression of words with 90% accuracy.

Short Term Goals:
1.Miss Fortune will increase word retrieval to 90%.
2.Miss Fortune will decrease perseveration during speech by 90%.

Listener compensation strategies of allowing increased response time for Miss Fortune will be implemented. The clinician will use confrontation naming to increase Miss Fortune's word retrieval abilities. The clinician will present a familiar object to Miss Fortune (a toothbrush) and ask her "What's this?" The clinician will then ask her " What do you do with this?" Miss Fortune's perseveration issues will be addressed by breaking the pattern. The clinician will either change the topic or change the task when Miss Fortune begins to perseverate.

Laticia Peck

Speech targets and activities: Since Miss Fortune has multiple infarcts bilaterally, various components of the motor system have been affected. Therefore, it is possible that she is demonstrating a mixed dysarthria. If the dysarthria is a pure dysarthria,the most likely type is spastic since there is bilateral damage to the UMNs. Therefore, these goals were written with spastic dysarthria in mind.

Long Term Goal:
Miss Fortune will improve vocal quality in connected speech by reducing increased muscle tone in laryngeal muscles.

Short term goal:
1.Miss Fortune will decrease hyperadduction of vocal folds to improve strained-strangled quality as judged by clinician. The following techniques
will be used:
a. head and neck relaxation and gentle massage
b. easy onset of phonation
c. yawn-sigh exercises
d. biofeedback

Long Term Goal:
Miss Fortune will improve her overall intelligibility to 75% as judged by clinician when context/topic is known.

Short Term Goals:
1. To increase ROM of articulators through:
a. passive and active tongue stretching exercises
b. passive and active lip stretching exercises
2. To improve phonemic precision by:
a. fully articulating all consonant phonemes
b. producing consonants while being provided with phonetic placement cueing from the clinician
c. participating in intelligibility and minimal contrast drills
* During these activities it will be important to practice functional words such as family names, needs vocabulary (ex: bathroom, hungry, etc.), and
vocabulary related to Miss Fortune's interests.

Kaylan Linder and Stephanie McCall

Cognitive targets and activities: Based on the fact that Mrs. Fortune has multiple infarcts throughout the context bilaterally ..... these episodes have most likely caused...MID (multi-infarct dementia). Depending on the severity of her condition... therapeutic strategies may not be an option due to the fact that we may not be able to change the damage that has happened...compensatory strategies may be the best bet in tx goals.

1. Assist Mrs. Fortune's memory for people that she comes in contact regularly.... one could create a photo album which has individual's faces and names in it... to help her remember who she is talking to. If the loss of her memory is only subtle... in which she has a hard time keeping track of appointments on a daily basis.... assist her in maintaining a date book... in which she can put appointments in.

2. Another goal that may be needed is to help her impaired selective attention.The family can be involved in helping with this goal. The SLP can help counsel with them to learn strategies that are useful in promoting selective attention... such as individuals should talk when there is no distractions taking place such as playing of the radio... or talking with the tv on.... individual's should also try to talk one-person-at -a-time.. in order to keep distractions down. The family should also remember to speak in short sentences that are easier to attend to and understand

Amy Harter

Review and question:

Identification of Likely Limitations

One thing that was not thought of in these was the possibility of aphasia, as well as apraxia of speech. In the swallowing ideas, the possibility of swallowing apraxia was brought up, which is very likely. Also, under the basic ADLs, socialization was listed, when it is generally thought of as a complex ADL. Overall, I think that these ideas are on point, bring up some great areas to assess, and are well explained.

Assessment Of Different Areas

Overall, I believe that some great protocols/tests were noted. The ideas and questions brought up in this section were on target and would fulfill an entire assessment battery. Given the amount of time since onset, the Dysarthria Examination Battery may be too much, unless given in multiple sessions. While it is a good test to use in an ideal setting, the reality is that it is rather lengthy, and the disorder area could be thoroughly covered using a shorter battery, leaving time for other areas in need of assessment.In the prognosis section of the cognition assessment, it was
stated that Ms Fortune would benefit from 2-4 weeks of rehabilitation. I absolutely agree. At the same time, depending on the amount of
health care the state will provide, the maximum amount of time in the rehabilitation setting would be Ms. Fortune optimal. Focusing on the areas of disability were great, but very little was said in accordance to actual participation in every day activities in all areas of assessment. This is the overall goal, bar none. The ideas and areas of assessment look great.

Targets/Activities

Overall the goals look great. Ms. Fortune would completely benefit from such a rigorous and in-depth treatment schedule. The activities are very appropriate for client presenting with this problem. In the basic ADLs, the one point that was left out that should be added to the protocol, is that of specific mobilization targets, such as brushing teeth, feeding, and washing herself. The short-term goals do look good in adding weight and endurance to the protocol. Ways to reduce fatigue were absolutely great, especially when it came to the ADL of making her own bed.
In the area of language, my only concern is the target of 90% for the formulation and expression of words. I feel that this may be a little high, considering the fact that she has had more than just this one stroke. Concerning speech targets: is over articulation what you meant when you said "fully articulate"? Also, another treatment method that should be added to the protocol is that of speaking louder. Using this treatment, many possible problematic areas could be targeted at once, such as sitting up straight, proper breath support, opening the mouth more fully, etc.
In the cognitive target areas, concerning the memory book, it may be helpful to also add objects and words that are in everyday speech and that tend to be problematic. The addition of these may be helpful in learning recall again.

Questions of my own for everyone:

1. Why is only apraxia of swallow considered and not apraxia of speech in combination of aphasia? (Many people stated that aphasia could be a possible problem, but apraxia of speech was not brought up.)
2. Would grouping faces/objects/words into different, appropriate categories (ex. home things, work things) help with memory "cataloging"
and eventually help with recall and retrieval?

GOOD WORK EVERYONE!!!!!

Shaun Key, ASU

Review and Questions:
It seems to me that everyone involved in this case study put a great deal of thought and effort into their responses. The areas of deficit that were discussed were very probable and likely to have accured due to site of her lesion and previous history.
Likely limitations:
The areas that were discussed in regard to language deficits were accurate, but many of those deficits could be categorized as an aphasia. The speech limitations were also accurate, but the idea of UUMN dysartria, mixed dysarthria and apraxia of speech were also possiblities. These and the other areas discussed were clearly explained and well thought out. I thought that overall they were very strong responses.

Assessment:
The assessment of the swallowing disorders was strong response that went into detail that all of us can use in our future work with dysphagia. Assessment of language was very comprehensive and will help to answer the questions needed to determine a possible aphasia. The assessment of speech that was discussed is also very appropriate and well planned, and the inclusion of the characteristics that she may present with was a nice addition to the section. The assessment of ADL's both basic and complex was also very good. I agreed the prognosis discussed and the time frame of intervention seemed very appropriate.

Treatment/activities:
The goals seem appropriate for the deficits previously discussed. The swallowing goals/treatment could be narrowed down by the use of the MBS. The study may help to determine the most appropriate form of intervention, of the ones that were discussed. ADL targets were also appropriate and activities were very well planned. Due to the fact that she has been also caring for her grandson, I felt that some of the ADL activities/goals should also be directed towards giving her the skills to continue taking care of her grandson, if she is able. The language targets seemed very accurate and on target with what the client may need. The speech and cognitive goals were also on target.

Questions:
*Should the clients pre-stroke life of taking care of her grandson, be considered when planning her ADL activities?
*How would the planning for activities for speech change if the client did have apraxia of speech, along with or instead of a dysarthria.
*Would the techniques for swallowing intervention have changed if the results from the Videofluroscopy or MBS were discussed?

I thought that all of the responses were very well written.

Mary Katherine Shay

Dr. Clark's Comments:

First, we missed a couple submissions (specifically, assessment of complex ADL's and cognition, and one review & question), but these might turn up in the next day or two. Please be sure to check your assignment and timeline so we have a complete discussion of each case.

Shaun & Mary Katherine did a nice job of reviewing the case and I want to echo and reinforce Shaun's observation that most of the ideas submitted focused on disability/activity level behaviors. This is the level where therapists seem to feel the most comfortable. Several postings referred to body structure/function impairments, which is helpful, but then we need to be careful to make sure our impairment-level treatments match up with the impairments we hypothesize are present (e.g., which specific oral motor exercises relate to spastic dysarthria and/or apraxia of speech/swallow).

But, as Shaun mentioned, I think we failed to consider Mrs. Fortune's life responsibilities and resources (participation issues). Can she return home to care for her teenage grandson? Is it reasonable to expect the grandson to care for her? What social/financial resources are needed? Is it likely these are available? How would SLPs and OTs contribute to the discussion of these issues? What other professionals are likely serving on Mrs. Fortune's care team?

Let me also echo Shaun's other comment: GOOD WORK EVERYONE!