विवरण
Stroke is one of the leading causes of death and disability in India. Speech and Swallowing disorders are common after stroke. The onset time of swallowing rehabilitation following stroke has an important role in the recovery of dysphagia and preventing complications. A stroke can also affect the muscles in the mouth and throat, making it a challenge to talk clearly. These side effects can make speaking, and reading more difficult. Therefore rehabilitation post stroke is an important skill to be owned by doctors, physios and nurses.
सारांश
- Stroke, defined as acute neurological dysfunction caused by ischemia or hemorrhage, can result in various disabilities, with aphasia affecting 35-40% of stroke patients upon hospital discharge. Aphasia is an acquired language disorder stemming from brain injury, typically in the left hemisphere. It impacts various aspects of language, including expression through speech, gestures, and writing, as well as comprehension. Effective communication is a complex process involving impulse reception, interpretation, retention, recall, visualization, and appropriate response formulation.
- Language comprehension operates on three levels: arrival (noticing a symbol), knowing (recognizing the symbol), and association (connecting the symbol with past experiences and current context to form an answer). In contrast, motor speech function, the output side of language, has three levels: emotional language (automatic responses to stimuli), automatic level (routine responses), and propositional/volitional level (conscious thought processing and articulation).
- Neuroanatomically, language functions are widely distributed in both hemispheres, centered around the perisylvian area of the dominant hemisphere, perfused by the middle cerebral artery (MCA). Key areas include Broca's area (inferior frontal gyrus), Wernicke's area (superior temporal gyrus), and the arcuate fasciculus connecting them. MCA infarcts in the left hemisphere are frequently associated with aphasia.
- Bedside assessment of aphasia involves evaluating spontaneous speech, comprehension, repetition, naming, writing, and reading. Scales like the Boston Diagnostic Aphasia Examination and Functional Communication Profile offer comprehensive assessments. Aphasia classifications include expressive vs. receptive, fluent vs. non-fluent, and central vs. para-central, with the Wernicke-Geschwind model categorizing eight aphasic syndromes under fluent and non-fluent types.
- Non-fluent aphasias (Broca's, transcortical motor, global) exhibit effortful speech production, syntax errors, and limited vocabulary. Fluent aphasias (Wernicke's, transcortical sensory, conduction, anomic) feature connected speech but may lack meaning or involve repetition. Each aphasic syndrome correlates with specific brain regions and manifests uniquely in spontaneous speech, comprehension, repetition, naming, reading, and writing abilities.
- Apraxia is the inability to perform purposeful movements despite intact motor power, sensation, and coordination, often due to motor planning and sequencing difficulties. Types include verbal apraxia (difficulty forming intelligible words), ideomotor apraxia (inability to perform tasks on command but can do so automatically), ideational apraxia (lack of understanding of task concept), constructional apraxia (impairment in producing designs), and dressing apraxia (inability to dress oneself).
- Early diagnosis and treatment of aphasia and apraxia are critical for maximizing recovery, typically within the first 2-3 months post-stroke. Recognizing these conditions is essential for therapists to plan and execute effective therapeutic goals, coordinating with speech therapists and adapting interventions based on the patient's specific deficits (e.g., using visual or kinesthetic stimuli when auditory comprehension is impaired).
- Dysarthria is a motor speech impairment where language comprehension remains intact. It affects articulation and other speech subsystems. Flaccid dysarthria involves hypanasality and breathy voice, while spastic dysarthria presents strained voice quality. Unilateral upper motor neuron dysarthria often co-occurs with Broca's aphasia. Ataxic dysarthria results in "drunken speech", and hypokinetic dysarthria, associated with Parkinsonism symptoms, causes reduced loudness. Management strategies include restorative and compensatory approaches.
- Aphasia therapy aims to restore language abilities or compensate for language problems using methods such as music, gestures, drawing, and sign language. Communication boards can facilitate communication for patients with severe aphasia, and the use of technology is increasing with mobile apps and dedicated devices. Therapists need to communicate with patients effectively through clear questions, eye contact, and understanding gestures.
- Dysphagia is difficulty in swallowing, potentially leading to aspiration. It involves oral, pharyngeal, and esophageal phases, with oral and pharyngeal stages handled by speech therapists. Signs include coughing, choking, food sticking, and wet voice. Swallow screening is essential, even with no evident symptoms. Management includes swallowing exercises, thermal stimulation, electrical stimulation, dietary changes, and, if needed, tube feeding.
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