Lear Communication, Speech, Language, Voice and Cognitive Therapy

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April 2012 – How Many Words Should a 2-Year Old Know?

Parents often wonder about their toddlers’ speech and language development. A nice checklist is available on the Early Words website and an interesting article was in the Globe and Mail:

June 2011 – Never Say Never When it Comes to Rehabilitation After Brain Injury!
Read about an individual and his family who never gives up and keeps improving after a truly severe brain injury:

April 2011 – Speech-Language Pathology and Brain Injury – My “Speech” is Fine, So Why Do I Need an SLP?

February 2011 - What is Constraint-Induced Language Therapy? Does it work?

Constraint-induced language therapy has its underpinnings in physiotherapy and was initially developed for use with patients experiencing limb weakness. For example, the strong arm would be immobilized so that patients would be forced to try using the paralyzed arm.

Unlike traditional therapy techniques in aphasia therapy which promote the use of multiple forms of communication (i.e.: writing, drawing, gesturing, etc.), constraint-induced language therapy forces patients to use only verbal responses which are gradually shaped into longer and more complex responses over time. This is an intensive process (generally up to 3 hours of therapy per day, 5 days per week).

Recently, researchers have started to question whether the noted benefits are the result of forcing patients to utilize verbal communication or the high intensity of treatment or both. Recent research suggests that both factors may be involved. In a systematic research review completed by Cherney et al. (2008), researchers found positive outcomes for both constraint-induced language therapy and intensive therapy protocols for individuals with non-fluent, chronic aphasia. Taken together, the researchers concluded that the benefit of constraint-induced language therapy may be in part related to its intensity. In another study, Maher et al (2006) found a positive effect of the forced language use component as well.

Clearly, more research is needed. Nonetheless, evidence is mounting that the treatment technique once restricted to physical rehabilitation may serve well in the field of communication rehabilitation.

October 2010 – Research about the Effectiveness of the SpeechEasy Device on Stuttering

Pollard et al published a research article (Journal of Speech, Language and Hearing Research, April 2009) about SpeechEasy, an electronic device that you wear on your ear designed to assist people who stutter. Its appearance resembles a digital hearing aid and is therefore small and cosmetically appealing. The device plays back your own speech so you hear yourself at a slower rate and different pitch. This mimics the effect of speaking in unison with another person, which has shown to help increase fluency in people who stutter.

The effectiveness of using SpeechEasy to reduce stuttering varies. When the device was tested in laboratory settings it generally showed positive results, especially with reading out loud. But when tested in natural conversation situations, the results ranged. Some participants reported that even though the device helped them improve their fluency, they found wearing the device to be rather annoying. Other people who were not observed to have an actual objective decrease in their stuttering, reported feeling better about their speech while wearing it, experiencing less fear and anxiety.

The authors conclude that substantial training in active fluency techniques may be needed to optimize the effectiveness of the SpeechEasy device. Unfortunately, no conclusions could be drawn about what type of person is most likely to benefit from the device either through true reduction in stuttering or simply through feeling less anxious when wearing the device, even if stuttering isn’t reduced.

In another recent investigation (Lincoln et al, October 2010), researchers found that different people responded differently to varying delays or frequency alterations and it was difficult to predict which alteration and/or delay might be effective for any given individual.

May 2010 - TV Inhibits Language Development

We’ve known for a long time that increased television exposure during infancy (ages 2 months to 4 years) is associated with language delays and attentional problems, but we really haven’t known why. In this study, they discovered that when the television is on, there is reduced speech and communicative interaction in the home. Infants vocalize less and their caregivers also speak to them less. For each hour a child watched television or was near a television that was on, there were reduced vocalizations, reduced word use, and reduced conversational turns. The child also heard an average of 770 fewer adult words for each hour the TV was on compared to when it was off. The authors of the research study make some good recommendations for parents:

www.seattlechildrens.org/home/about_childrens/press_room

January 2009 - Neuroplasticity and Aphasia – therapy can rewire the brain!

Raymer, Maher, Patterson and Cherney (June 2007) completed a review of research studies related to Constraint Induced Language Therapy (CILT) and functional changes in brain physiology. CILT refers to intensive therapy (often at least 3 hours per day, at least 4 days per week) where individuals with aphasia are forced to communicate only verbally (compared to more common therapy approaches where all forms of communication [speaking, writing, drawing, gesturing] are encouraged). Results suggest that intensive therapy is very beneficial in all cases, and this has been documented on both speech-language testing as well as brain scans, but there seems to be some advantages to forced verbal language use. These advantages seem to be further expanded when CILT procedures were also carried out by family members at home in between therapy sessions. The authors are therefore optimistic on 2 counts – first, that therapy can improve actual brain function even in people with “chronic” aphasia and second, that CILT in particular seems to produce particularly strong gains. More research is needed of course, but these are promising signs!

October 2008 – Intensive Reading Therapy Can Rewire the Brain

In the August 2008 issue of Psychologia, researchers Meyler et al. discovered that poor readers in the 5^th grade who receive 100 hours of intensive reading therapy showed actual differences in their brain function on fMRI scans! These differences were observed immediately after the intensive remediation period and remained present one year later. Prior to instruction, poor readers showed significantly less activation in key reading areas of the brain. After instruction, these areas showed much greater activation and the activation continued to spread over the following year. After a year, activation in the previous poor readers was almost the same as the level of activation seen in the good readers. This is wonderful support for the importance of focused intervention for long term gains!

May 2008 – What It’s Like to Have Aphasia

CBC ran an incredible segment interviewing individuals with aphasia and their families. Please go to http://www.cbc.ca/sunday/2008/04/041308_5.html to watch the video.

March 2008 – The Impact of Language Skill on Independence in Teenagers

Excerpts from a recent article by Conti-Ramsden & Durkin (Feb 2008):

“The present study examined independent functioning in domains relevant to everyday living. These included self-care activities, traveling and meeting people, and managing finances, among others. Autonomy in these kinds of tasks is foremost in young people’s subjective sense of reaching adulthood…”

“…By the end of compulsory schooling (i.e., 16 years of age) most typically developing adolescents appeared competent in the areas of independence examined… In contrast, and as predicted, adolescents with specific language impairment fared significantly less well… This finding is consistent with the assumptions that language abilities are integral to a range of everyday personal competencies…”

“…the findings underscore the need for intensive intervention directed at improving oral language skills… The study also highlights the need to monitor and support not only the oral language skills of these children but their reading progress…”

October 2007 – Stroke Rehabilitation Standards

On April 30, 2007, the Heart and Stroke Foundation of Ontario published its “Consensus Panel on the Stroke Rehabilitation System.” This report was based on an extensive review of the research literature and included many references to the Canadian Stroke Strategy’s “Best Practice Recommendations for Stroke Care” (2006, updated in 2008). Key excerpts regarding rehabilitation are as follows:

“All patients admitted to hospital with acute stroke will have an early initial rehabilitation assessment by relevant rehabilitation professionals as soon as possible after admission within the first 24-48 hours. Weekends will not limit “time to assessment.””

“All stroke survivors (excluding TIAs) who are not admitted to hospital or who are discharged home from acute care will undergo an ambulatory or home-based screening assessment, which includes a medical, functional and cognitive assessment, by professionals with expertise in stroke, within two weeks.”

“The Blueprint concludes, based on recently published studies, that “greater intensities of rehabilitation therapies result in improved stroke outcomes. The combination of high-intensity therapies provided early in the course of the stroke recovery provides the greatest benefit.””

“Stroke survivors will receive the appropriate intensity and duration of clinically relevant therapies across the care continuum based on individual need and tolerance.

a) Mild stroke: Stroke survivors discharged to the community will be provided with ambulatory services for one hour of each appropriate therapy, two to five times per week, as tolerated by the patient and as indicated by patient need.

b) Moderate stroke: Survivors of a moderate stroke will receive a minimum of one hour of direct therapy time for each relevant core therapy, with an individualized treatment plan, for a minimum of five days per week, by the interprofessional stroke team based on individual need and tolerance.

c) Severe stroke: Survivors of a severe stroke who are Rehab Ready will receive the frequency and duration of therapy that can be tolerated; the interprofessional team will increase the frequency and duration as tolerance improves to a minimum target of one hour of direct therapy time for each relevant core therapy, with an individualized treatment plan, for a minimum of five days per week, by the interprofessional stroke team based on individual need and tolerance.”

“The wait time from when the stroke survivor is Rehab Ready and referred to rehabilitation services until the start of all appropriate rehabilitation services should be no more than:

Two business days for inpatient stroke rehabilitation, and
Five days for both ambulatory and home-based stroke rehabilitation."

July 2007 – I hear a lot of people with a “hoarse” or “breathy” sounding voice – is this normal?

No! A hoarse or breathy voice means that the vocal cords are not moving properly and/or that there is something structurally wrong (e.g., nodules growing on the vocal cords). It is true that there seem to be a lot of people out there with hoarse-sounding voices. While these may be considered “sexy” in the short term, as the disorder progresses, the voice becomes more gravelly sounding and, in some cases, the voice can even disappear altogether.

The good news is that most voice disorders are highly amenable to treatment. If caught early on, voice therapy alone may be sufficient to return the voice to normal structure and function. If left until later when vocal nodules may be permanent, surgery may be required followed by voice therapy.

If you are concerned about your voice, first go see an Ear, Nose and Throat specialist (we can recommend some if you’d like) to determine if there is anything structurally wrong with your vocal cords. The ENT will let you know what your diagnosis is and what your options are. If therapy is an option, contact a speech-language pathologist to get the process started as soon as possible!

September 2005 - How do I decide between a tutor and a speech-language pathologist when my child has a learning disability?

This is a difficult question! If the learning disability has a language basis (which many do), in the ideal world it would be optimal to have both a speech-language pathologist and a tutor working with your child.

A tutor we have worked with provided an excellent analogy. Speech-language pathologists teach students how to use all the tools in the kitchen (mixer, frying pan, stove, measuring cup, recipes, etc.) so that they know how to cook. Tutors ensure that students utilize these tools correctly in order to prepare meals.

So speech-language pathologists teach the broad skills to allow success in learning (both in school and out in the real world) and tutors help students make use of these skills in particular courses. Please see the handout about Language Based Learning Disabilities on the Our Services page of this website.

You will likely just need a tutor if your child:

is just struggling with a particular course (e.g., science, math, etc.),
seems to be doing relatively well, but just needs extra time or repetition,
just needs help with particular assignments.

You should involve a speech-language pathologist if your child has the following difficulties, regardless of the particular subject:

oral reading
reading comprehension (i.e., understanding novels or textbooks)
writing (i.e., writing stories or essays)
note-taking (i.e., listening to the teacher and efficiently translating the information into helpful notes)
studying for tests

You should also contact a speech-language pathologist if your child has previously been to a tutor or learning centre and has not experienced significant improvement. It may be that time and repetition aren't sufficient and your child may instead need a thorough analysis of his or her cognitive-language system in order to revamp how they learn.

March 2005 - Redesigning Canada's Health Care System

In the fall of 2004, Justine appeared on CHML's Roy Green show for a full hour to discuss her vision for health care in Canada. In March 2005, the Hamilton Spectator ran a full page article describing this new system. If you'd like to read Justine's essay entitled Health Care for More than Just One Generation, you may download it in PDF format. Click here

January 2004 - What is "cluttering"?

Cluttering is a syndrome characterized by a speech delivery rate which is abnormally fast, irregular or both. In addition, the person's speech is affected by 1) a failure to maintain normally expected sound, syllable, phrase, and pausing patterns and/or 2) greater than expected incidents of disfluency, the majority of which are unlike those typical of people who stutter (The ASHA Leader, November 18, 2003).

Cluttering is a fluency disorder that is often confused with stuttering. Although the two disorders frequently co-occur, cluttering is actually very different from stuttering:

Cluttering	Stuttering
Disfluencies characterized by unfinished words, interjections and revisions	Disfluencies characterized by sound, syllable or word repetitions, sound prolongations and blocks
Low awareness of disfluencies	High awareness of disfluencies
Few secondary behaviours	Many secondary behaviours (e.g., eye blinking, nostril flaring)
Disorganized speech with some grammatical errors	Well organized speech, but fear and anxiety limit output
Reading and writing difficulties	Strength in language arts

Cluttering is usually assessed by a Speech Language Pathologist in conjunction with other professionals such as classroom teachers or psychologists. Treatment can be very effective and usually includes slowing the rate of speech, increasing awareness, improving speech sound precision, improving organization of speech and reducing excessive disfluencies.

November 2002 - Does reflux/heartburn contribute to voice disorders?

Yes. Voice disorders, such as hoarse, strained or gravely voice quality, may be due in part to the reflux. This condition, termed Gastroesophageal Reflux Disease (GERD), can cause severe inflammation and heartburn-type pain, or it may not cause any symptoms beyond poor voice quality. Reflux occurs because of damage or weakening of the lower esophageal sphincter (valve), allowing acid and other digestive fluids to escape from the stomach and enter the esophagus and larynx where it may cause irritation and inflammation.

GERD is now recognized as a major contributing factor in many voice disorders. This means that some voice disorders could be caused by reflux, and others could fail to heal due to the chronic irritation of acid reflux on the tissue of the vocal folds. It is also common for people to develop certain behaviors, such as chronically clearing the throat or coughing, in an attempt help relieve reflux symptoms. Unfortunately, such behaviors are vocally abusive, and often have negative effects on the vocal folds, further worsening voice quality.

The goal of voice therapy is to assess and treat the contributing factors of each individual's voice disorder, and to teach and provide education, strategies and techniques to improve and maintain voice quality. When GERD is involved or suspected to play a role in the voice disorder, education and strategies to improve the reflux symptoms are incorporated into treatment.Combined with possible medical intervention from the ENT and/or family physician, therapy is typically effective in improving GERD, and resolving its negative effect on the voice.

December 2001 - Interesting Facts about Swallowing

Swallowing is something we all take for granted. We eat and drink with little thought as to how food and fluids pass from our mouth to our stomach. In fact, swallowing is one of the most complex actions we perform, but the entire process takes only 17-23 seconds to complete. The average person swallows approximately 600 times per day - about 350 times while awake, 200 times while eating, and around 50 times while asleep. It requires the coordination of 26 muscles in the mouth, plus the throat and esophagus.

Many diseases and injuries, such as stroke, brain injury, Parkinsons, Multiple Sclerosis and others, can affect the swallowing muscles. Weak swallowing muscles can allow food and drink to get into the lungs and cause chest infections like pneumonia. Common signs of swallowing problems include: coughing, choking, throat clearing, "wet, gurgly" voice during and after meals, and food left in the mouth. Sometimes there are no signs at all, until a chest infection occurs.

If you know someone who may have swallowing difficulties, have them assessed by a speech-language pathologist and dietitian. There are many things that can be done to maximize swallowing safety and enjoyment.

September 2001 - Frequently Asked Questions

Does OHIP cover speech-language pathology?

No. OHIP has never paid for speech-language pathology. Check with your insurance provider, because you may be covered for speech pathology through work, or through your car insurance if you've had a car accident.

Do I need a doctor referral to obtain the services of a speech therapist?

No, a doctor's referral is not needed for private SLP services. However, occasionally insurance companies require a doctor's referral, so check with your insurer if you plan on using insurance to pay for your private SLP services. A doctor's referral is likely needed for publicly funded services.

Are speech-language pathologists regulated in any way?

Yes. Much like doctors or dentists, speech-language pathologists must belong to the College of Speech-Language Pathologists and Audiologists of Ontario (www.caslpo.com), their regulating body, in order to practice.

Can I hire a private speech-language pathologist to work with me while I am still in hospital or if I am in a nursing home?

Yes.

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