Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole, and we have a panel for you today with three Northwestern Medicine clinicians to highlight a case study at the Northwestern Medicine Aphasia Center at Marianjoy. Our case today involves a 77-year old patient who experienced a stroke resulting in aphasia. He began treatment as an inpatient at Marianjoy, and later transitioned to the Northwestern Medicine Aphasia Center at Marianjoy for continued support.

Joining me in this panel is Michelle Armor. she's a speech language pathologist and Program Manager and Founder of the Aphasia Center at Northwestern Medicine Mary and Joy Rehabilitation Hospital; Dr. Robin Cohen, she's a physical medicine and rehabilitation specialist at Northwestern Medicine Marianjoy Rehabilitation Hospital; and Shamun Mohammed, he's a speech-language pathologist as well at Northwestern Medicine Marianjoy Rehabilitation Hospital.

Thank you all for being with us today. And Dr. Cohen, I'd like to start with you. For providers that may not be as familiar with this topic, kind of set the table for us. What is aphasia, and what typically causes it?

Robin L. Cohen, MD: Aphasia is a language disorder that can affect a person's ability to speak, understand, read or write. Some people may experience difficulty in all of these language areas, while others, only a few areas can be impacted. The number one cause of aphasia is stroke. Approximately 30% of all strokes result in aphasia. Other etiologies can include brain injury, brain tumor, or other neurological diseases.

The classic model of aphasia was developed by Wernicke and Lichtheim in the 19th Century and was further redefined neuroanatomically by Geschwind in the 1960s, linking specific areas of the brain to specific syndromes. So, this is the model that we're all most familiar with. We've learned it in medical school. We studied it again in residency. However, with the advent of MRIs, there's been other ways of thinking about how aphasias form, which has led to other areas of thinking about how they could be treated.

So, I guess, the more current models such as Dell's model and these dual stream models look at more at networks, network involvement as opposed to specific areas of the brain.

Melanie Cole, MS: That's so interesting, and thank you for explaining that. So, Michelle, give us a little bit of an overview of the Northwestern Medicine Aphasia Center at Marianjoy, and what makes it so unique and different from other approaches.

Michelle Armour, MS, CCC-SLP: Sure. Yeah. So I mean, I think before I get into the aphasia center, I think it's important to talk about how Marianjoy just structures our various services as a hospital. So, Marianjoy is a freestanding rehabilitation hospital, and we have 125 inpatient rehabilitation beds. We have this full comprehensive outpatient program. But then, we have this group of specialty clinics, which provides post-acute services to anyone still experiencing any form of disability at any point in their recovery.

And the Northwestern Medicine Aphasia Center at Marianjoy kind of falls under that umbrella of our specialty clinics. Other specialty clinics that we offer include driver's rehabilitation, a balance and fall prevention program, an accessible fitness center. So, any service that someone might need at any point in their recovery.

So, the aphasia center specifically offers services to people who are living with aphasia, who are living in the community, and it's accessible to them at any point. No matter how far post onset they are or no matter how acute they are, they could access our services right away while they're even in outpatient concurrently.

So, the aphasia center's main goals, we want to provide opportunities for individuals with aphasia that are living in the community, just to continue to practice their functional communication and also to receive opportunities for socialization with other people who also have aphasia and just try to connect them, because it's a very isolating experience when someone's living with aphasia. And oftentimes, they're still learning what it even means to have aphasia.

So, the ultimate goals of our center are to connect them with one another to help reduce the risks of social isolation and just help improve their overall quality of life. We do that in a variety of ways. We offer an eight-week community aphasia group program where they would work together. And the groups are led by a speech-language pathologist to help facilitate those activities and those conversations. We do offer individual sessions for people who might not want the group experience, but want to kind of speak with more speech therapists to receive more guidance. We also offer virtual groups just to increase accessibility for those who might have trouble getting here in-person.

And then, most recently, in the last three years, we've developed an intensive comprehensive aphasia program, which we refer to as our ICAP for short. And the ICAP is much different than our other programming options in the aphasia center. The ICAP is a model that's used internationally, but the intent of an ICAP is a little different versus just quality of life, it's really meant to maximize on neuroplasticity. So, we work six hours a day, four days a week for four weeks in our ICAPs specifically, to try to help our clients with aphasia maximize on neuroplasticity by that high frequency, increased intensity, to try to make as much progress as possible with their aphasia in a relatively short amount of time of just four weeks. So with our kind of unique structure, we offer these different options to people to kind of meet them where they're at and help meet their needs along the course of their recovery.

Generally though, we really value what's called the life participation approach to aphasia, which is just a kind of blanket statement of values that says we ultimately want to help our clients with aphasia live successfully and participate fully in life. And that involves talking to them about what those participation activities are and how we can help them get there.

Melanie Cole, MS: Wow. It's such a comprehensive approach. Michelle, thank you so much for explaining all that. Now, Dr. Cohen, in this case that we're discussing today, what medical factors contributed to the patient's condition? You mentioned stroke before. Were there other symptoms or complications you had to manage? What about the comorbid situations that go along with stroke? Because there are many.

Robin L. Cohen, MD: So, this 77-year old patient was ultimately diagnosed with a left temporal hemorrhagic stroke. Other medical issues that impacted the development of his stroke was he had quite a number of cardiovascular comorbidities, particularly atrial fib and flutter. He had preserved heart failure. He of course had hypertension, which is the number one cause of stroke. But the issue that I would say that really most impacted his ability to communicate, which is the topic today, was that he has oral motor apraxia, which is the inability to volitionally sequence oral movements of speech or non-speech tasks. And this really did impact his recovery, and added a layer of complexity to his ability to communicate. And I know my colleagues will discuss this in much greater detail.

The other thing is that also we'll talk about in more detail that he had a type of aphasia called a fluent aphasia. And that actually led to him presenting to be at a much higher level ability to communicate and understand information told to him than he truly had. So, he had a lot more challenges than he presented when you first walked into the room to meet him.

Shamun Mohammed, MS, CCC-SLP: Yeah. And I think when thinking about like language challenges, especially with this patient, it was just kind of narrowing down what type of communication would work best for him and trialing different modalities. He definitely had challenges, but he was able to communicate when given the right strategies and the right tools. Honestly, it was a pretty big misconception when he first got here was that he was confused, he couldn't understand what we were saying, which he couldn't understand what we were saying, and it was because it was all auditory. Once we figured out a way for his comprehension to improve with different strategies, it helped immensely. And I think that's what's important about this case, is the fact that we did try multiple ways to help improve comprehension as well as expression of language.

Melanie Cole, MS: Well, Shamun, I'd like to stick with you for a minute. So, tell us a little bit about that initial approach once you discovered these challenges being auditory, and tell us the strategies you used. How did you adapt the therapy to his needs? That's so interesting.

Shamun Mohammed, MS, CCC-SLP: Yeah, I think, you know, it's interesting in general, because whenever we're reading the case history or the history in general for a patient, we're only given the region of the brain that was impacted. So, you don't really have a full idea of what you're going to walk into. And with that in mind, you kind of just have to have an open-mind approach to interacting with your patients.

In this case, I walked in, asked him how he was doing, how his day's going, open-ended questions. And honestly, he was able to say, "Good, I'm doing well." But then, once we started to ask kind of deeper questions, that's kind of where we unlocked some of those language challenges, even with just simple yes-no questions, open-ended questions, so then it comes down to what type of formal assessment I'm going to use, and here we use the Western aphasia battery bedside. It's a quick assessment that allows us to look at a patient's fluency, their word finding, their auditory comprehension, their verbal repetition. There's also an apraxia battery on the back and confrontation naming.

And honestly, in this case, this patient had such a severe case of Wernicke’s aphasia that it was kind of difficult to get through that assessment because, in my mind, that assessment doesn't necessarily paint the best picture of the patient. And I knew going through it that it wasn't going to go too well. But that also allowed me to know, "Okay, in this formal setting, I can only follow these instructions, so I'll do that. But after I'm done with this assessment, I'll trial some different modalities of communication." Writing keywords down, that was super helpful. Using a yes-no picture board, that was helpful as well. And having these visuals in front of this patient increased his comprehension substantially. It was night and day. And it was almost comedic at times, because I would ask him a question and he would get a little confused. But the second I would write a keyword down for him. He was like, "Oh yes, yes, yes, yes. That's what I'm talking about," and that light bulb kind of turned on. And it helped so much to just be able to trial and error all of that.

Another approach that we like to use in our inpatient is allowing the family to fill out patient questionnaires so that we can make the treatment a lot more personal and elicit language that is potentially more familiar to them as well.

Robin L. Cohen, MD: That's really interesting. Can you give an example of that?

Shamun Mohammed, MS, CCC-SLP: Yeah, sure. One of the big challenges that we had was, at the beginning when this patient was admitted, he was trying to elope, he was trying to leave the room. And due to the communication challenges, this patient did get mislabeled with cognitive communication deficits. But in this case, that wasn't the challenge. The main challenge was the auditory comprehension aspect of things. And once we were able to narrow down that using certain strategies, whether it was related to the context of the conversation or even an unfamiliar topic in that moment, if we wrote down a certain keyword, it helped him to improve his comprehension and know that like, "Okay, we understand that you're having a hard time communicating, so let's work together to figure out what you're trying to tell us." And in that moment, he was upset, he was frustrated, and it took a lot of trial and error to figure that out. And he was frustrated and upset because he wasn't able to communicate with his family. He wasn't able to talk to his wife. He wasn't able to make a phone call. And that was causing this frustration, which led him to elope in this case. And when we were trying to guide him back and inform him like, 'Look, we are trying to assist you in this moment," it caused more confusion, especially with so many people talking to him at once. It was a perfect recipe for disaster, unfortunately.

And one of the things that I strongly recommended after those situations happened was that it should be one-on-one communication using these certain strategies, and it made a world of difference.

Michelle Armour, MS, CCC-SLP: And I'll just piggyback off of what Shamun is saying it, I think with a person who has fluent aphasia with these significant auditory comprehension impairments, because they're having trouble understanding, oftentimes they don't understand that what they're saying isn't making sense. Because a person with aphasia, they know exactly what they want to say. They're saying it in their head. And if they're having trouble comprehending, oftentimes they're having trouble comprehending the fact that the words they're saying are not matching the words that they're thinking, and that is really frustrating. It's hard to hear yourself. And so, sometimes, especially in the acute phase of aphasia, it takes a while to have that person understand that they're having the difficulty with communication. Oftentimes, they'll look at their family or the healthcare provider, like, "What's wrong with you? I'm saying it. Why aren't you understanding it?" And it takes some time for them to learn what the change is in their language and how we're hearing it. So, I think that's just always an extra challenge, and I think that was a piece of what this gentleman was also experiencing in those early days in the hospital.

Shamun Mohammed, MS, CCC-SLP: Yeah. And going off of that, a way that we helped to build his awareness or insight into his expressive language challenges was writing down what he was saying so that he could read what he was attempting to say, and I would present it to him. He would read these neologisms or jargon that he would come up with. He would read it off the piece of paper and he himself goes, "That's not what I meant." And that helped to improve his language in general.

Robin L. Cohen, MD: One challenge, at least for providers, is often we are seeing these patients in such a short time period that we get a chance to interact with them, that we ask them, fire off questions at folks, and we don't pick up so fast or don't want to realize that they may not be understanding what is being asked. And it takes time to try other modes of communication. But it's absolutely critical, as we have alluded to, because the treatment team did not quickly pick up that the patient was having trouble with understanding words that were being spoken to him, led to an elopement event or a near-elopement event. And had we realized when he was first admitted to the floor that he was having difficulty with understanding spoken language, and we proceeded to write things down for him, which he clearly understood much better, we would've avoided that elopement event.

Shamun Mohammed, MS, CCC-SLP: Yeah. And I think that's why it's so important to get these types of assessments and interactions so early in a person's care so that we can establish modalities of communication so that they can talk to the doctor, they can understand what the doctor's saying, they can even talk to the care tech that's working with them. And better yet, even just call their family and say hi, because sometimes even that's like very difficult for them. So, starting as soon as possible is probably what everyone's target should be when it comes to communication, especially with aphasia.

Melanie Cole, MS: Shamun, were there any turning points that you want to mention during his rehabilitation journey? Anything that was really exciting? I mean, you've mentioned so many and you all have really expanded on this, but was there something that got you really excited where you went, "Yeah, this is it"?

Shamun Mohammed, MS, CCC-SLP: Yeah. I would have to say about halfway through the patient stay, we eliminated the use of thumbs up, thumbs down, yes-no cards. And it was like we cleared the fog all of a sudden. And this patient was able to understand these simple yes-no questions and complex yes-no questions, and it made it so much easier for them to communicate with us. And it also showed us that his comprehension was getting so much better. So, we were able to push the limits a little bit more and introduce, in this case, a communication book, which was great. And we were able to trial different formats of the communication book. And I think that turning point was so pivotal, and having his family involved with that-- his family was incredibly involved. They wanted to know the best ways to communicate. because it was just him and his wife at home and his kids lived on the other side of the country on the east coast. And being able to just say like, "Okay, you can use yes-no questions. And we can potentially use this communication book to help you guys communicate." That was huge. And having his family involved and willing to do as much as they wanted to do made a really big difference. The second I mentioned the ICAP program, his family was like, "We will do it. We want to do it. Give us the information." And when I told them about the aphasia center, in general, they were amazed. The look on their face when it was like there are other individuals with this exact same challenge that you can work with and hang out with and talk with and build a community with-- they got so excited because they didn't feel as though this was something they had to do on their own.

Melanie Cole, MS: I would love to give you each a chance for some final thoughts. Before we do that, Michelle, speak a little bit about how you all measure success for participants in these programs. What kind of criteria do you use? I mean, there's certainly quality of life, as Shamun was just saying, but speak about specific measurements for success for these participants.

Michelle Armour, MS, CCC-SLP: Yeah, absolutely. So, I think it depends on which part of our aphasia center they're accessing. So like I mentioned, we have this group program that this individual did first. He joined us in this eight-week community program. And it connected him with all these other individuals. And it was eyeopening, like, "I'm not the only one living with this condition." And for that kind of program, there's no way to assess it. It is the introduction. It's getting them involved and it's helping them build the community, as Shamun said.

Now, with the ICAP program that he did participate in, that's much different because our goal is different. Our goal is to really change the aphasia, to improve the condition, and to have him improve his ability to communicate. So for that program specifically, we do a series of standardized assessments. One, really looking at impairment-based measure. It's the Western aphasia battery, but the full version. Shamun alluded to the bedside version that we use in inpatient. We do a participation-based measure looking at communication and activities of daily living. We do a cognitive measure because sometimes there is a cognitive impairment in conjunction with the aphasia. It is different, but there is an aphasia-friendly way to evaluate cognition, so we do that as part of admission into the ICAP. And then, we do a series of patient-reported outcome measures so that we can really have a better understanding of how our clients are feeling, how their confidence is in terms of their communication, and how their quality of life is in their eyes at that moment in time.

We also do just functional language samples. So, we have them talk, we have them tell us a story. And we analyze that for all aspects of language to really see are they a better communicator? Are they finding their words? Are they building adequate sentences? How is their language expression for a functional conversation or for telling stories?

And so, with this patient specifically, he did wonderful. I mean, by the time he was finished with our ICAP, and we did all of those assessments I mentioned before admission into the ICAP and then immediately after, he was scoring much higher. He actually changed the severity of his aphasia following participation in the ICAP from a moderate fluent aphasia at admission to a mild aphasia after the ICAP was said and done. He went from scoring mild on cognitive impairment measures to within normal limits. He jumped an entire 12 points on percentile ranking in terms of his participation measures. So, the difference was substantial. And then, we do focus groups. And we ask them all about their participation in life activities. Because standardized assessments like that, they're great, they're informative, but no matter what a standardized test may show, if their time with us is allowing them to participate more fully in life, interact more effectively with their family and friends and just overall positively impact their psychosocial wellbeing, then we know we're doing our job right.

And for this gentleman, that is exactly what we heard from him and his family. He got back to being independent, fully independent with his independent activities of daily living. He started to read for pleasure again, which was such a huge, huge progress for him. His auditory comprehension improved, where he started listening to podcasts again. He started listening to TED Talks. He was doing these things that he enjoyed doing prior to his stroke. And he wasn't able to do that because of the aphasia previously. He was ordering for himself in restaurants. He was going and doing more social engagements that otherwise he was kind of refraining from because they were hard. It was difficult to do social things that he would've done previously. And he got back to doing those. He got back to driving. He did our driver's rehabilitation program. And he is now an independent driver. So, the progress was just substantial, both on paper but in real life. And I think for all of us here at Marianjoy, that's what we value and that's what we really measure as success.

Melanie Cole, MS: Wow. That's so cool. I love to hear that. And Dr. Cohen, what should other clinicians keep in mind when treating and first seeing these complex aphasia cases like this?

Robin L. Cohen, MD: Thank you for the question. I think it's an important one. I think there's a lot of take-home points that we have hit upon. I'm going to try to summarize some of them. So, I think most important, or one of the most important things, is to lean on your speech therapists to develop a strategy to communicate with the patients, as soon as possible. I think that is so important. And I think we should recognize then aphasia changes over time. So, the strategy that works on day one, it may not be the same strategy that works on day 10.

And then, the other important thing is communication is a human right. And patients with aphasia can communicate. The challenge that the treatment team has is unlocking what strategy works best for them. And that may take a little bit of time, a little bit of trial and error, but it is absolutely critical in terms of their recovery from their stroke.

The other thing is family involvement is absolutely critical. And in this particular case, his family was so supportive and was a great comfort and resource for him. So, they have to be involved in the communication strategies and practicing those strategies. Safety planning is important too. You need to think about that as well. It's also very important to include all members of the treatment team in the communication strategy, because they'll be communicating and having FaceTime with the patient alone and everyone has to use the same successful strategies.

As we've alluded to, patients with aphasia can be decisional. And you cannot assume that if someone has aphasia, they're not decisional. Aphasia is different than cognitive deficits And we need to take the time to separate the two. And like I said, aphasia evolves over time, and people can recover and improve their communication with proper treatment.

Melanie Cole, MS: Shamun, next to you. I'd like you to speak about the patient himself. It seems like you had a lot of interaction, and you were critical to his rehabilitation. What would you like other clinicians to know about what you all accomplish together with this patient to increase that quality of life so much.

Shamun Mohammed, MS, CCC-SLP: Working with this patient was unbelievable in many different ways. Mainly the fact that, like Dr. Cohen mentioned, having the family involvement, I think that was a huge factor. And then, having the interdisciplinary team also join in on that and utilize these strategies and everything. He himself is just a great guy. Great personality, really funny, good sense of humor. He was somebody that I would clearly be friends with outside of the hospital. And knowing that his family was motivated and he was motivated to get back to everything that he was enjoying before, it made such a big difference.

And it's actually funny that Michelle brought up that he was able to get back to driving. I remember we were in the hospital and talking about return to driving and things like that, and how his wife doesn't really drive that often. And that day, I asked his wife, "Hey, how was the drive here?" And she's like, "Oh, I clipped the tire on the curb and the rim broke." And he was like, "What? What just happened?" And so, it was just seeing that he was kind of-- you could tell he was a little bit more motivated to get back to driving in that sense. But it was just funny because the wife was like, "Yeah, we rely on him. You know, without him doing these things, it's kind of tough at home to get by, especially when we don't have the support so close to us."

One thing that we really didn't touch on too much was family education in general. And this family was coming in like the last three or four days of his stay every day for hour-long speech therapy sessions and willing to get involved and learn how to communicate with the patient. And I think that is super important. Because a lot of the times, we'll see patients and there isn't that much family involvement due to whatever variables there are. And that does make it a lot more challenging for the individuals to communicate. So, we've talked a lot about different ways to help those with aphasia. It's just finding what works best, I guess, or what they're most comfortable with.

Melanie Cole, MS: Well, it's certainly very personalized. And Michelle, last word to you. As the families are helping, contributing, supporting, getting educated, you're working with these patients, how is Marianjoy uniquely able to support this patient's recovery and all the patient's at your aphasia center.

Michelle Armour, MS, CCC-SLP: All patients, no matter where they live, they have access to hopefully inpatient care, outpatient programs. But eventually, those levels of care, they come to an end. And, you know, as a speech therapist, I've worked in those levels of care and I know that feeling of being like, "Well, outpatient, your insurance isn't going to cover anymore. So unfortunately, we have to discharge at this time." But the person's looking at you like, "Well, but I still have aphasia. I still can't communicate. I'm still struggling so much."

And so, I think with Marianjoy, with these specialty clinics and the aphasia center offerings that we have, it gives someone that next step. Their formal episode of care may have come to an end, but we are here to continue to help them to move forward. And I think that is how we're uniquely positioned. And I think if more places had that, had support groups even, you know, had more community type of programming to help people after those formal episodes of care come to an end, then people will feel more supported, their families will feel more supported. And ultimately, they can continue on this journey and make more progress.

Melanie Cole, MS: Thank you all so much. This was absolutely enlightening and eyeopening and so interesting. Really an upbeat, uplifting case study. And thank you so much for telling us all about the aphasia center at Marianjoy. For more information about the Northwestern Medicine Aphasia Center at Marianjoy, please visit nm.org/aphasiarehab. Or for more information, you can always go to breakthroughsforphysicians.mm.org/rehabilitation to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.