Caring for an Aphasia Patient

 Around 1,000,000 individuals in America suffer from some form of aphasia, struggling to communicate as easily as they did pre-injury. The role of an aphasia patient's carer is to aid the recovery process in the hope that the patient will regain a level of normality to their speech. Throughout the recovery period there are a series of actions that a carer can take to aid in relearning language, or to help a patient to feel more confident in communicating.

Keeping it Simple

One key thing to remember when communicating with an aphasia patient is that, while they may understand everything you say it may take them longer to process it. Keeping background noise and distractions to a minimum can help their comprehension. Avoid talking to them like you would a child and use adult language, however, keep sentences shorter and simple so it is easier for them to reply. Instructions should be broken down into simple steps and, initially, questions should be yes-or-no ones. This will allow an aphasia patient to slowly regain their ability to retain information.

Learn to Listen

Depending on the manifestation of a patient's aphasia it may take them a longer time to respond to a question. In these circumstances it is important not to rush them to respond and simply to be patient until they have finished talking. Avoid putting words into their mouths otherwise they will not have the opportunity to relearn speech for themselves. If forming full sentences is a struggle for a patient try working out other ways of communicating, such as using hand gestures, picture charts, or writing. The inability to vocalize thoughts does not mean that they do not understand what you have said so ask them if they have and simply cannot say their response.

Boost Their Confidence

An important aspect of the recovery process is the patient feels that they are living a normal life, so encourage them to to participate in every-day activities and decisions. Try to encourage them to carry out more daily tasks independently and avoid the urge to overprotect them. Although it may seem counter-intuitive to engage a patient in conversations with larger groups of people, it may be beneficial to their recovery. In a one-on-one setting there is a lot of pressure on the patient to respond to questions and engage in the conversation but in a small group they are able to join in when they feel ready and no one is waiting on them to reply. As their speech improves try taking the patient out into more public settings so that they can practice their communication skills in real life situations.

The most important thing to remember when aiding the recovery of an aphasia patient is that each case is different. Rehabilitation methods that may have worked for one patient may not work for another so work with them to find the best exercises for their situation.  

Bringing Science to the Community – Introducing Dr. David Putrino

This month we introduce to you Dr. David Putrino, Director of Rehabilitation Innovation for the Mount Sinai Health System. Dr. Putrino's medical career began in Australia, where he completed an undergraduate degree in physiotherapy before carrying out a PhD in neuroscience at the University of Western Australia. On completion of his PhD, Dr. Putrino held teaching positions, both at Curtin University of Technology and Edith Cowan University in Perth in Western Australia, teaching neuroanatomy and neuropathology.

After working as a clinician in Australia Dr. Putrino moved to New York to study computational neuroscience at Harvard Medical School, MIT, and NYU. During his time at NYU he worked as a assistant in the School of Medicine, teaching neuroanatomy and clinical neuroscience. Currently he holds a position, not only as the Director of Rehabilitation Innovation, but also as an Assistant Professor of Rehabilitation Medicine at the Icahn School of Medicine at Mount Sinai. His work includes developing innovative technology solutions for patients who are in need of better healthcare accessibility. He also lends his technological expertise to the Red Bull High Performance athletics division, consulting with them and using state-of-the-art technologies to monitor, and improve, the performance of athletes.

As well as using his medical training within rehabilitation medicine, and the athletics field, Dr. Putrino believes that it is the responsibility of scientists and medical professionals to add to the education of the community. He believes scientists need to engage the public in science, technological advances, and current research, and to explain why these are such important fields. With this in mind, Dr. Putrino dedicated a portion of his time to co-founding the not-for-profit organization StreetSmart Science. This venture connects scientific mentors with local high schools to get students excited about working in the science sector. The organization currently works with three inner-city high schools in the Bronx and Harlem areas. This passion for community enrichment has also led to Dr. Putrino holding the position of “Chief Mad Scientist” at Not Impossible Labs, an organization that crowd-sources accessible technological solutions for high-impact humanitarian issues.

This interest in community education has brought Dr. Putrino's work into the public eye. He has appeared as a scientific expert on the American Heroes Network as well as having his research featured in a whole range of media, from the ABC, to the LA Times, to the Wall Street Journal, BuzzFeed to name but a few. It is his strong passion for using science to help his community, alongside his extensive background in neuroscience and technology, that have led to Dr Putrino becoming an integral part of the Mount Sinai Rehabilitation Innovation team.

Regaining Language in Aphasia Patients

 The outcome of aphasiac brain damage can seem debilitating to patients as their range of communication abilities is reduced. Depending on the extent of damage, and the area affected, there are treatments that can be employed to restore language abilities, either partially or completely.

The most commonly employed treatment process is speech and language therapy (SLT) and involves the patient working with a therapist on a series of exercises specially tailored to the type of aphasia damage. For patients who struggle to understand the meaning of words, activities, such as pairing words to pictures, or sorting words into groups based on their meaning, may be suggested, to redevelop word association knowledge and definition memory. If the trouble stems from a difficulty in expressing oneself coherently, a therapist may employ tasks in which the patient must name what they see in a picture, or judge whether or not words rhyme with one another. On top of working in one-on-one sessions with a speech therapist, often specially-designed computer programmes are used, alongside group speech sessions in order to improve conversational abilities.

Under circumstances where speech abilities are not restored to a functional level, speech therapists may work with the patient to develop alternative methods of communication. These may be in the form of gestural language, drawing or writing, or communication charts, where the patient has a grid of words or letters and can point to them to convey what they want to say.

While SLT is the most common form of therapy, research is also ongoing into medications and brain stimulation therapies. Certain drugs are being analyzed for their affects on aphasia symptoms, such as bifemelane, which has been noted for its abilities to increase circulation of blood in the brain, while others are being tested for increasing the brain's ability to recover and repair itself, and to help raise levels of depleted chemicals in the brain. Transcranial magnetic stimulation also holds promise, a technique that involves placing an electromagnet on the scalp and briefly sending an electromagnetic current through it to affected areas of the brain to re-stimulate activity in them.

Many of these alternative theories are still in the trial phase and so, currently, SLT is the most effective and widely used treatment. The prognosis of aphasia treatments can be difficult to predict, as it is heavily influenced by how severe the damage was, and also how healthy the brain was pre-injury. Recovery attempts are more likely to be successful in younger patients and are more effective the sooner they are started. Improvements in language and communication are most prominent in the first six months after the injury, however, this does not mean that recovery is impossible after this stage, with improvements still possible after several years in some cases.  

Stroke-Related Language Complications

 Conditions resulting from stroke damage can vary depending on which area of the brain was affected. Certain areas of the brain are responsible for the production, and synthesis, of language information and if these are damaged as a result of a stroke, the consequent communication problems are referred to as aphasia. There are four main types of aphasia – anomic aphasia, Broca's aphasia, Wernicke's aphasia, and global aphasia - each caused by damage to a different area of the brain.

Anomic Aphasia

Anomia is a condition in which a patient suffers a deficit of expressive language and is the most common, and also least severe form, of aphasia. While a patient with anomic aphasia may struggle to find the right word to describe something, especially nouns and verbs, they have no trouble understanding the speech of others and are able to read adequately, though writing may come with more difficulty.

Broca's Aphasia

Also known as expressive aphasia, this form is the result of damage in the frontal area of the left hemisphere of the brain. This area, known as Broca's area, is thought to be involved in the production of speech and damage to it can result in problems with forming full sentences. Though sufferers of expressive aphasia may be able to produce basic words to convey their message they struggle to form full sentences, often missing out important words, such as prepositions. As well as being unable to produce fluid speech they may also struggle to understand the speech of others.

Wernicke's Aphasia

On the other side of possible aphasic manifestations is Wernicke's, or receptive, aphasia. Occurring when the back section of the left brain hemisphere is affected, Wernicke's aphasia is characterized by difficulty understanding the meaning of written or spoken words. Patients still produce fluent, connected sentences, yet they unknowingly use nonsensical, made up words. They may still understand the flow of another person's speech and can work out from the rhythm of it whether they are asking a question or conveying an emotion, but have no understanding of the meaning of the words used. This is because the affected area, known as Wernicke's area, is thought to be the locus of human language comprehension.

Global Aphasia

Both Broca's and Wernicke's aphasias can vary in degree of severity but the most serious form, global aphasia, occurs when there is widespread language impairment. When both language areas of the left brain hemisphere are damaged, patients lose all language abilities, both in terms of comprehension and production and this form of aphasia most commonly occurs immediately after a stroke.

Often global aphasia is caused by swelling around the brain and may improve as this goes down. Similarly, area-specific language problems may decrease during the post-stroke recovery period. However, in instances where full language abilities are not regained speech and language therapies may be use to try and restore speech or, in extreme cases, to develop alternative ways of communicating.

Age-Related Musculoskeletal Changes

As we get older our bodies become more fragile, as bone and muscle densities reduce, increasing the likelihood of broken bones and body instability. Movement may become slower, and walking gait may become shorter, more unsteady, and with less swinging of the arms. Older individuals may become tired more easily and perform tasks less energetically, but what are the internal processes that drive these changes in musculoskeletal function?

From around the age of thirty bone mass begins to decrease in both men and women, increasing in rate in women after the onset of menopause. As a result, the risk of bone fractures increases. One common feature of ageing is a gradual shrinking in size. This is due to fluid loss in the spinal disks. Between the vertebral bones in the back are the gel-like cushions which serve to absorb shocks between the vertebrae. With age these discs begin to lose fluid, meaning the spinal bones grow closer together and the spine shrinks. Furthermore, the actual bones begin to lose mineral content, becoming thinner. Being less rigid the spinal column becomes curved, adding to the appearance of height loss.

As with the spinal disks, lubricating fluid between joints may also be lost during the ageing process, reducing protection against cartilage rubbing together and wearing away. As a result, the joints may become stiffer and less flexible, increasing the risk of developing arthritis. As bone wears away the minerals may be deposited around joints and calcify, causing extra joint stiffness.

In tandem with skeletal wear, the muscular system is also affected by age. As bone density decreases around one's 30s so does muscle mass. The result of this muscle loss, known as sarcopenia, is that the muscles are less able to support the bones, and stress on certain joints, such as the knees or back, increases. Deterioration is not universal throughout all types of muscle, and the muscle fibres that contract faster are more susceptible to damage than the slower contracting fibres. This translates into overall slower contraction of the muscles in old age and affects physical mobility, muscular strength, and grip. Around 7% of people over 70 are affected by functional sarcopenia - age-related muscle loss – and this figure increases to around 20% of the elderly over 80. As muscles lose function people become less able to move autonomously and this may translate into the development of muscle contractures, where the muscles shorten and harden.

While it is a natural process of ageing to lose both muscular and skeletal mass, the process can be slowed and prevented to a certain degree by maintaining a healthy lifestyle, with regular exercise to promote strength, balance, and flexibility. Keeping fit can also help the bones to stay strong, to reduce the risk of shrinking or breaking. To further support the maintenance of sturdy bones diet control is crucial, being well-balanced and high in calcium. Particularly women need to be aware of getting enough calcium and vitamin D in their diet as they age to lessen the risk of developing arthritis or osteoporosis. 

Living With Osteoarthritis – Managing the Symptoms

 As we get older the cartilage covering our joints become worn, resulting osteoarthritis. This condition manifests itself in the form of joint pain and stiffness and, while there is no cure for this chronic disease, there are treatments and measures that can be taken to reduce suffering.

It may seem counter-intuitive to reduce joint pain by increasing your movement, however, exercise is proven to be incredibly beneficial in reducing osteoarthritis symptoms. Rather than wearing down the cartilage further, strengthening exercises will alleviate pain, through building up the surrounding muscles, reducing strain put on the joints. Exercises that focus on range of motion are also excellent for improving the condition, as they encourage flexibility of the joints and reduce stiffness. Choose exercises that work the joints but that aren't too strenuous. Taking a brisk walk, or joining a relaxing class such as yoga or tai chi, that gently uses your muscles, will keep your body working to support your bones and joints. For less impact while working out, swimming or water aerobics both engage muscles while avoiding putting force on the joints.

Linked to exercise, maintaining a healthy weight is integral to relieving osteoarthritic symptoms. Excess weight can add additional pressure to weight-bearing joints such as the hips, knees, feet and back bone. Losing this extra weight, and then maintaining a healthy one, will reduce pain and restrict further damage to cartilage. Combined with living an active and healthy lifestyle, medications are available that can reduce symptoms, such as pain and inflammation around the joints, making it more manageable.

Physical, or occupational, therapists can teach osteoarthritis patients the best ways to use, and move, joints to prevent further wear and tear of the cartilage. As well as introducing range of motion and flexibility exercises, thermotherapy treatments may be suggested to mediate symptoms. Cold treatments are effective at numbing pain, decreasing swelling, and blocking nerve impulses to the joints while heat therapy will improve blood circulation and relax muscles, removing tension. Often a combination of the two techniques are used, applying heat in the morning to loosen up joints, followed by cold treatment later in the day to reducing any swelling that builds up.

Although steps can be taken to reduce osteoarthritic suffering, assistive devices may become necessary. These can range from walking aids, such as walking sticks or specially modified shoes, to devices that help in carrying out everyday activities. Kneelers for gardening, extenders for door knobs and taps, and clothing that is easier to fasten are all available so that patients can keep their everyday lives as normal as possible.  

World-Class Care – Introducing Dr. Donald Kastenbaum

This week we introduce one of our senior faculty members in orthopaedic surgery, Physician-In-Chief Dr. Donald Kastenbaum. Having performed over 5,000 primary and revision total hip and total knee replacements Dr. Kastenbaum has certainly earned the position of authority he holds in the field of orthopaedics. An expert in hip and knee surgeries, he has helped to develop several prosthetics for hips and knees that are being used worldwide in replacement surgeries.

Dr. Kastenbaum's journey to his current position of prestige began with studying for a medical degree at the University of Health Sciences – the Chicago Medical School. On completion of this he began an internship in general surgery at the Lenox Hill Hospital, followed by a residency in orthopaedic surgery at the Hospital for Joint Diseases Orthopaedic Institute. His specialisation into the field of hip and knee surgeries was further honed with a fellowship in Sports Medicine at New York University Hospital Medical Center before crossing the pond to complete another in Total Hip and Knee Replacement Surgery/ Arthritis at the London Hospital Medical Center.

His medical work on an international scale continued after his British fellowship, and over the past decade he has both lectured and worked worldwide. Having trained over 30 Chinese orthopaedic fellows, Dr. Kastenbaum returns to China every quarter in order to carry out, and teach, advanced surgical techniques, including minimally invasive and revision hip and knee surgery. Closer to home, he created Mount Sinai's first Comprehensive Arthritis Center, a facility designed to provide complete orthopaedic and rheumatological care, and physical therapy services. Dr. Kastenbaum holds positions within this institution as both Co-Director and Surgeon-In-Chief.

That, however, does not complete his list of medical contributions. In 2002 he was invited to be a part of the Insall Scott Kelly Institute for Orthopaedic and Sports Medicine, and was given the position of Associate Chairman of the Department of Orthopaedic Surgery, before becoming the Vice President in 2005. To add to his already-full career Dr. Kastenbaum also holds the position of President of the Mount Sinai Beth Israel Medical Board and Chairman of the Surgical Chairs. He is renowned as an expert in Hospital Perioperative Management, Safety/ Efficiency/ Outcome Analysis and aids hospitals across the world in developing their models of “best practice”.

All of Dr. Kastenbaum's involvements in different institutions are predicated on his great knowledge and expertise in the field of orthopaedic surgery. For more information on the medical procedures this world-class doctor can provide call 212-241-6335 to book a consultation.