Locked in syndrome case study

Diagnosis – multiple brainstem strokes due to basilar artery thrombosis

Presentation – Severe dysarthria and dysphonia (<10 % intelligible), severely limited body movements (only able to oppose fingers on his right hand inconsistently).

Diagnostic assessments – FEES + VF – moderate oro-pharyngeal dysphagia, reduced strength + coordination of oral manipulation, reduced base of tongue to posterior pharyngeal wall approximation. Decreased vocal fold approximation/adduction and some evidence of overcompensation.

Therapy in hospital – consistent yes/no response via head nodding/ no movement was established + use of an AEIOU alphabet chart (listener assisted) utilising the yes/no response.  The patient disliked the use of AAC and predominantly attempted to communicate via speech.

Communication Guidelines

Understanding

·   T can understand what you are saying.

·   T can find it harder to understand if he is tired or upset.

·   On these occasions you may need to slow down your speech/ repeat yourself.

Speaking

Following his stroke T has:

·   Dysphonia- a difficulty with using his voice and vocal cords effectively and consistently.

·   Dysarthria – a difficulty using his mouth, tongue and lips to articulate clearly.

T finds it difficult to speak loudly and clearly. You can use these tips to help him maximise his communication:

·   Listen carefully and watch T’s lips when he is talking.

·   Prompt T to break words up; if he says one word at a time it is easier to understand him.

·   Remind T to exaggerate sounds.

·   If you are stuck on a word ask T to spell it out aloud.

·   If you are really stuck ask T to take a break and try again in a while.

Communicating

T is able to use strategies to aid communication when speaking is too hard to understand.

·   Ask him yes/no questions and get him to shake or nod his head clearly.

Goals

To improve consistency of strategy use to increase intelligibility with mouthing. Strategies 1. Break up the words and syllables 2. Over-articulation 3. Respond to forced choices.

To improve reliability of low tech AAC use.

Tasks

·   Based around T’s interests and family in order to keep him motivated/engaged.

·   Practicing breaking family names into syllables, getting T to count the syllables. Breaking down short phrases into words.

·   Practice spelling of words using the alphabet board e.g. places he has visited

Goals

To improve timing, depth and consistency of in-breath and out-breath.

To increase the frequency of voicing. Within task and conversation.

Tasks:

1.     Head and neck mobilisation and relaxation

Ø  Head and neck stretches and relaxation exercises.

2.     Breathing

Ø  Support T to put a hand on his abdomen and upper chest for feedback. Practice diaphragmatic breathing exercises, blowing exercises (blowing tissue/ imaginary candle/ imaginary letters/ blow on a mirror).

3.     Voice

Ø  Yawn/sigh, ‘h’ words (turning voicing on and off).

Ø  Blah blah blah app on ipad – saying ah and maintaining the sound

4.     Conversation

Ø  Pracice strategies within a conversation about one of T’s interests. Aim is to understand 3 keywords/ phrases.

Outcomes

Ø  T became around 65 % intelligible at a single word level and 50% intelligible at a short phrase level.

Ø  Inconsistent voicing but consistent controlled exhalation for short phrases.

Ø  T was able to participate in conversations with his family.