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Flashcards in Treatment & Related Issues Deck (48):
1

Treatment Related Issues

Medical environment (cost benefit issue)

third party regulation (private insurance)

medicare limitations

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Medicare Part A Limitations

20 days of care in hospitals

100 days in skilled nursing facilities

home health care

hospice care

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Medicare Part B

Outpatient service over age 65, including doctor visits, outpatient hospital care, hospitalization beyond Part A coverage

80% of charges after annual deductible

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Treatment Team - PT

Dx of muscle strength and range of movement for functional independence

Strengthen muscles

muscle atrophy and contracture prevention

5

Treatment Team - OT

Motor abilities for skilled activities of daily living

compensatory strategies for visual-spatial deficits

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Treatment Team - Recreational Therapist

Programming activities to keep patients purposefully occupied

7

Treatment Team - Social Worker

Medical communication to patients/families

Discharge plans

Post-discharge care with suggestions for nursing facilities, state and social services

Medical directive follow ups: wheel chair, prosthetic needs

Coordination of competence evaluation

8

Treatment Team - Clinical Psychologist

Emotional and personality issues

treatment for psychoses and depression

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Treatment Team - Dietician

Nutritive needs and delivery types

10

Treatment Team - SLP

Acute phase:
importance of communication
family reorientation
minimization of regression

Subacute phase (limited treatment)

Chronic phase:
Prevention of communicative regression
Promotion of restitution,
Progress monitoring
Planning long term treatment
Family participation)

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Effects of Brain Damage

Diminished response flexibility

Task-related anomalies:
impulsive responses
excessive caution

Perseveration

Reduced self-monitoring:
posterior lesion cases
Wrenches' aphasics are bad at self-monitoring, doesn't happen with an anterior lesion

Recognition with no anticipation of errors

Information processing deficit:
- Slow rise time : takes the person time to start listening/only gets last part of the phrase

- Noise build up : after first few words there is too much "build up" in the system, can't process later words in the phrase

- Retention deficit : memory

- Intermittent imperceptions : variable performance, scattered

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Two Types of Perseveration

Recurrent: repetition of a response after other subsequent verbal attempts

Continuous: inappropriate uninterrupted prolongation of verbal attempt; have to change task

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Poor Prognostic Indicators

Bilateral or large lesions

Multiple strokes

Verbal stereotypes ("let me tell you")

Perseveration

No matching of common objects and pictures

Unreliable yes/no responses

Jargon

Lack of self-correction

Medical complications

Depression

Malingering

Negative attitude

Poor family support

Etiology:
- occlusive lesions: good early recovery
- hemorrhage: best in 2nd or 3rd month
- traumatic: better and slower over a long time

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Positive Prognostic Indicators

Self-correction

Awareness

Younger age

Short time post-onset

Good health

Motivation

Family support

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Treatment Procedural Info. - Linguistic Processes to be Attended

Recognition

Discrimination

Comprehension (visual and auditory)

Productive (verbal and graphic)

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Treatment Procedural Info. - Response Modes

Pointing

Gestures

Nodding

Writing

Verbalizing

Augmentative Modes

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Treatment Procedural Info. - Response Delay

Greatest response increment in 3-5 seconds with most in 10 seconds

Responsiveness better with meaningful/novel stimuli

Natural contexts: greater accurate responses

Unison or delayed recall: unison better with severely involved patients

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Treatment Procedural Info. - Method of Facilitation

Repetition

Cue

Combining Stimulus modes

Number of alternatives

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Treatment Procedural Info. - Treatment Methods

Imitation

Matching

Selection

Completion

Comprehension

Spontaneous Production

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Treatment Procedural Info. - Stimuli Construction

Meaningfulness

Length (short length of word)

Complexity (causes serious problems, avoid excessive complexity)

Frequency

Relatedness (semantically related is good)

Concrete image

Size

Modality of ease

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Facilitation Procedures - Cueing Hierarchy

What is this called?

Direction to state the object function

Direction to demonstrate the use

Statement of the function by clinician

Sentence completion

Sentence completion + silent articulated 1st phoneme

Sentence completion + vocalized 1st phoneme

Sentence completion + verbalized 1st 2 phonemes

Say "....."

22

What to Treat - Relative Impairment Approach

Identification of communicative peaks and valleys

Tx to lower points to try to reduce the depth of the valley

Tx on peaks only if a smaller gap between peaks and valleys

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What to Treat - Fundamental Ability Approach

Focusing on impaired processes/components

Focus on cognitive process underlying the deficit, not output behaviors like comprehension

In anomia: word production, sentence construction

Improve auditory comprehension

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What to Treat - Functional Ability Approach

Focus on competencies needed in daily life

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Goal Setting

Realistic and definitive short and long-term goals that are beneficial to patients, meet their communicative needs, and relevant to demonstrable outcome

Practical

Adequacy not perfection

Patience with recovery

Rationale for each step and activity

Ask why for each Tx step

No teaching or retraining - only facilitation

Elicitation rather than forcing a response

Focus on measurable aspect of communication

26

Treatment Planning - Stimulation Approach

Stimulate rather than teaching words

The antecedent event - the driving force in improving responses, rather than the consequent event in behavioral therapy

Maximizing 'arousal power' of the stimulus

Auditory perceptual system

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Difficulty of Tasks in Treatment

Difficulty at 40-50% level

no more than 40-50% error responses

increase complexity with performance stabilization (90-95% in consecutive sessions)

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Session Organization

General activity

Consolidation

East tasks

Difficult tasks

Consolidation

Cooling off

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Base 10 Response Form

Form that includes list of stimuli and scores for a series of sessions, as well as a graph where progress can be charted

easy, brief, provides visual feedback, retention of stimuli, provides a basis for termination

30

Measuring Generalization

Treatment task performance charting

standardized test repetition

probing of goal-related task independent of treatment

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Generalization

Applications of acquired knowledge to:
- tasks with shared features
-situations that allow the knowledge application
-enable conversation at home

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Ways to Promote Generalization

Natural contingencies targeting behaviors related to patient's life

training of sufficient exemplars - train a behavior into enough different settings for generalization

loose training - stimulus conditions and response requireemtns vary to increase generalization
- across responses
- within a response class
- one environment to other environment

elicitation of responses by other means like mnemonics or mental imagery

matrix training of distanced items (table of distances between words)

33

Measuring Communicative Effectiveness

Total number of words or utterances

Number of content units

Number of correct words in content units

Number of bound morphemes

Ratio index of lexical efficacy (number of words divided by content words)

Index of grammatical support (average number of grammatical words in each content unit)

Complexity index (clauses per utterance)

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Discourse Analysis

Empty utterances (don't express content, "oh boy")

Sub-clausal utterance (content words only)

Single clause utterance (subject/verb only)

Multi-clause utterances

Agrammatic deletions (omission of grammatical markers)

35

Measuring the Effects of Treatment - Single Treatment Effects

Pre- and Post- treatment

ABA a minimum of 3 phases

Tx usually withdrawn but measurement continues

Design: comparison of results from 2 phases

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Measuring the Effects of Treatment - Multiple Baseline

Best way to demonstrate the effects of tx.

A single tx to study:
different behaviors within a patient
the same behavior in several patients
or the same behavior across different environments

37

Medical Treatment

Preservation of life by treating:
- Myocardial infarct
- BP
- Edema
- Cardia Thromboembolism (blood thinning with anticoagulants)
- TIAs (platelet-inhibators - platelets with a source of growth factors lead to the formation of blood clots)
- Thromboembolic strokes (vasodilators, tPA (tissue plasmogenic activator))
- Limiting infarct by decreasing metabolism (barbiturates)
- Reperfusion (endarterectomy (done with external carotid artery) and stent and umbrella (for collecting broken parts of the plaque))

38

Pro-Activation (Brookshire)

Exposure to difficult-to-name objects interferes with subsequent easy-to-name items

easy to name items facilitates subsequently difficult to name items

priming: exposure to a stimulus to influence a response on a later stimulus

39

Importance of Contexts (Barten)

Open-ended conversation is the most effective in naming

VCN to picture is less effective

Naming from verbal description is the least effective

40

Traditional Treatment

Based on stimulus and response - not the most productive

Targeted areas and components

One or multiple modalities

Incorporation of stimulation-response

Performance measurement in %

Pros
- good training
- focused exercises

Cons:
- poor generalization
- limited practical value

41

Language Reorganization

Transfer intact functions to disrupted functions for promoting language reorganization

2 types:
Intra-systemic
Inter-systemic

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Intra-Systemic Language Reorganization

Improving a communicative system by transferring downward or upward (eg verbal singing, controlled by the right brain)

43

Inter-Systemic Language Reorganization

Using unrelated functional system to reorganize an impaired system (eg gestures with verbalizations)

44

Deblocking (Bierwisch)

Removal of a masking effect on impaired function by an intact one

ex. auditory mode to deblock reading, semantic description to deblock naming

45

MRI & Recovery

Measuring Tx Effects:
- post-stroke right activation
- successful training leading to a left shift
- over learning leading to a shifted left activation in peri-lesion area

Optimal recover = LH peri-lesion reactivation

Time:
- Increased RH activation w/in 2 wks after stroke and a return to baseline levels after 1 year
- Increased LH activity gradually from acute to chronic stage
- A temporary contribution of RH in the early post-stroke phase, but absent in chronic stages

46

Schuell's Auditory Stimulation Approach

Controlled intensive auditory stimulation to maximize reorganization of the brain

includes controlled speech rate, meaningful stimuli, incorporation of graded complexity, control of stimulus length, monitoring loudness level (20 dB higher), combining sensory modalities, promoting face to face conversation

47

Family Support Group

Forum for meeting other survivors and caregivers, seeking help with adjustments, expressing feelings, social network

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Benefits of Group Therapy

Communication in natural environments

Opportunity for spontaneous conversation

Generalization of learned skills

Development of self-confidence

Emotional support