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Slide 1 - Supporting Persons With Chronic Communication Limitations: Head & Neck Cancer M. Sullivan, C. Gaebler, & L. Ball Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center Omaha, NE
Slide 2 - Objectives Upon completion, participants will be able to: determine when AAC is the best treatment option select appropriate AAC devices use AAC strategies to improve the communication of persons with head and neck cancer Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions Ch. 11: Head and Neck Cancer Purpose: to demonstrate usefulness of AAC strategies & devices to enhance and supplement communication of persons following surgery for Head and Neck Cancer The types of cancer & surgeries include: tongue (glossectomy) maxilla (maxillectomy) larynx (laryngectomy)
Slide 3 - Standard Speech Rehabilitation following Head & Neck Cancer Surgery Often involves use of a prosthesis Glossectomy: palatal augmentation or reverse palate Maxillectomy: speech obturator or surgical flap to cover defect & improve velopharyngeal closure Laryngectomy: tracheoesophageal voice prostheses, artificial larynges Rehabilitation also involves direct speech therapy for improved speech intelligibility and learning new methods of communication, such as esophageal speech
Slide 4 - Rehabilitation Outcome Many become excellent communicators following rehabilitation Success of speech rehabilitation varies with extent of surgery fit of prosthesis adaptability of patient successful use of the chosen method of communication Patient success (Perry et al, 2003) Of n = 65 with total laryngectomy @ 12 months 41% TEP 25% artificial larynges 17% TEP+ artificial larynx 10% gesturing & writing 4% esophageal speech
Slide 5 - WHY AAC? Not all persons achieve adequate communication with the more “standard” practices, therefore need additional strategies Even good communicators may have difficulty in some situations (e.g., noise, grocery deli) Not all individuals adapt to their lack of communication without instruction
Slide 6 - Needs Across the Lifespan Communication needs following surgery for head/neck cancer vary across the lifespan e.g., reduced hearing, new communication partners, illness or recurrence AAC strategies in rehabilitation add to arsenal of communication techniques & assist in a variety of communication situations
Slide 7 - Phases of AAC Intervention We will discuss these phases as they relate specifically to persons with head/neck cancer… I. Getting Ready Phase II. Immediate Post Surgical Phase III. Speech Restorative Phase IV. Long term AAC Phase V. Medical Instability Phase
Slide 8 - I. Getting Ready Phase Occurs prior to cancer surgery Inform regarding expected changes Assess natural speech & complete the preoperative checklist Educate on methods of communication that may serve immediate & long term needs following surgery
Slide 9 - Immediately after surgery, You may not be able to speak. Ask Yes/No questions Mouth words in a slow & overexaggerated fashion Point to the 1st letter of the word as you “mouth” it Write messages (note pad /dry erase board). Gesture or act out the item or action you need Use a picture communication board After several days, you may experience the following: Speaking may be more possible. Packing & sutures may be removed, making it more comfortable for you to move your mouth. Slow your speech and overexaggerate words Point to/spell the topic or keyword of what you’re discussing If you had a laryngectomy, short bursts of air trapped in your esophagus may escape, enabling sound to come out of your mouth (esophageal speech). Use your tongue to make clicking sounds to get attention. After hospitalization, … Speech Therapy may fine-tune your communication and/or teach other options. Some people use prerecorded messages for frequent messages or when interacting with unfamiliar listeners. Some people type messages into a AAC device that speaks. Many of these devices are available for trial use through Speech Pathology. Preoperative Checklist
Slide 10 - Personal Communication Needs Complete a communication needs assessment Gather names of family, friends, important places, etc. Create a communication board Offer chance to record their voice for voice mail, answering machine, or pre-record digitized messages on AAC device Emphasize that they WILL be able to communicate! Introduce some AAC dry erase board, markers or note pad, pens Technology: digitized pre-recorded devices, text-to-speech, palm pilot devices, etc GoTalk Attainment Co.
Slide 11 - Communication Needs Assessment Demographics Family Immediate family (names, relationship, etc.) Significant relatives (names, location, relationship) Which family are close in proximity? Distance? Recent family changes/events? (marriage, births, deaths) How often have family been present since surgery? Language spoken by family Personal Home & community Identify features, leisure interests, hobbies, home responsibilities, pets, community activities, how they move in community (walk, w/c), etc. Type of neighborhood (rural/urban, etc) Important people in the neighborhood (neighbors, friends, etc.) Trips/vacations Noisy environments frequented (restaurants, casinos, race tracks, sports events, etc) Employment Job, place, FT/PT, duties, retired?, etc. Phone Use Amount, who, etc.
Slide 12 - II. Immediate Post Surgical Phase Usually in ICU for 1-3 days and then moved to medical/surgical floor. Often has tracheostomy tube & nasogastric tube; so speech attempts may be difficult and painful. Maxillectomy: will have surgical packing and/or obturator in place Glossectomy: may have sutures that limit movement of remaining oral structures
Slide 13 - Establishing & Facilitating Basic Communication Glossectomy & Maxillectomy Focus on non-vocal communication Head nods, gestures, writing, alphabet boards and picture communication boards Laryngectomy oral adapted alaryngeal device Illegible handwriting Text-to-speech AAC device e.g., Light WRITER or DynaWRITE Illiterate Symbol-to-speech AAC device e.g. Dynavox V or ATI mini-Mercury Loan Programs Some hospital units will purchase AAC devices if they will be dedicated for use on that unit for billable rental
Slide 14 - Low or No Technology AAC Alphabet supplementation Topic boards Voice amplifier Writing Sample Voice Amplifier
Slide 15 - III. Speech Restorative Phase May transition out of hospital to outpatient or rehabilitation setting Medically stable, with interim obturator or prosthesis in place (as indicated) Likely interacting with larger group of communication partners e.g. neighbors, roommates in rehabilitation, receptionists, medical personnel
Slide 16 - Oral Communication Breakdowns Repair Strategies/ Cueing Hierarchy Repeat slowly Repeat with gesture Provide the key or topic word Provide the 1st letter Rephrase the utterance Tap one time for each word Write
Slide 17 - Goal: Independent Use of Strategies Track use of each strategy in structured & conversational speech Cue as needed, particularly if not moving from one strategy to another when breakdowns persist Instruct caregiver/staff to cue patient in similar ways
Slide 18 - IV. Long Term AAC Phase May begin at any point during recovery when it is determined that oral speech is not yielding functional communication. Evaluate to determine the AAC device which most closely meets the communication needs of that individual Match features of device with identified communication needs Provide training in programming & use of the AAC device.
Slide 19 - Assess Levels of Communication 1. Intelligibility 2. Supplemented Comprehension 3. Communication Efficiency 4. Communication Effectiveness 5. Communication Interest Level 6. Communication Needs 7. Literacy Level 8. Co-occurring Conditions
Slide 20 - 1. Intelligibility Speech Intelligibility Test (SIT)- record person reading sentences of increasing length, which are decontextualized. Consider use of AAC technology if sentence intelligibility is less than 80% Be sure to measure objectively, don’t estimate! Yorkston, Beukelman, Hakel, & Dorsey (2007) SIT sentence subtest, sample report
Slide 21 - 2. Supplemented Comprehension How understandable is the speech when all available strategies/techniques are used? e.g. using any or all of: gestures, slowed & exaggerated articulation, topic established, 1st letter cue Videotape person discussing topics introduced by SLP while using strategies. “Tell me about your favorite vacation.” Consider AAC technology if comprehensibility is less than 90%
Slide 22 - 3. Communication Efficiency Divide the overall intelligibility of speech in sentences by the speaking rate in words per minute Intelligibility/words per minute = efficiency If the speaker has to slow speech (less than 100 wpm) in order to be intelligible, then speech is no longer efficient. Consider AAC technology if communication efficiency ratio is 0.70 or less.
Slide 23 - 4. Communication Effectiveness Communication Effectiveness Index (CETI) CETI was developed as a rating scale for persons with aphasia and their communication partners. (Lomas, et al 1989) It was adapted for use with persons following head and neck cancer surgery (Sullivan, Beukelman, & Mathy-Laikko, 1993) If reductions in communication effectiveness are reported in specific daily tasks, AAC technology may be appropriate
Slide 24 - Communication Effectiveness Index Adapted from Lomas, et al How effectively do you communicate when…. 1………………………2………………………3………………………4………………………5 Not understood Effectively understood Talking at home? Talking on the telephone? Talking with strangers? Talking in the car? Talking in front of a group? Talking when excited or upset? Talking with people who are hearing impaired? Talking over intercoms (drive-up windows)? Talking over background noise?
Slide 25 - 5. Communication Interest Level Ask the person whether they wish to communicate over the phone in social situations Ask whether they have family/caregiver support for AAC technology. AAC technology is recommended for those expressing interest in communicating in contexts which require voice output AND when there is family/caregiver support
Slide 26 - 6. Communication Needs Revisit the communication needs assessment to determine new or modified needs in this phase. e.g. has returned to work, needs to speak with family member long distance AAC is appropriate when these needs cannot be met using natural speech
Slide 27 - 7. Literacy Level Establish a measure of literacy and fluency in their native language. Do they speak English as a second language? Literate? Nonliterate? Text-to-speech devices symbol sets Qwerty vs. Alphabetic LightWRITER Dynavox Technologies Boardmaker Mayer-Johnson
Slide 28 - 8. Co-occurring Conditions Vision Hearing Mobility Cognition Folstein Mini-Mental State Examination
Slide 29 - What Next? Assessment items 1-5 indicate whether person will likely benefit from AAC Assessment items 6-8 will generate a list of AAC device features necessary for that individual SLP then matches features and together with person, selects from all devices providing necessary features, begin trial When most appropriate device is identified, work with person on funding to acquire device and then initiate training
Slide 30 - Necessary/Helpful AAC Features Persons with Head & Neck Cancer Alphabet input (text) Text-to-speech voice output Lightweight & easily portable Unless in wheelchair, which then can be mounted High quality display Need good visibility in multiple environments Direct access Most likely with hands Message formulation ability Ability to preprogram and store messages Rate acceleration features to increase rate of message formulation Word & phrase prediction
Slide 31 - Some High Tech AAC Ideas (FYI: Medicare calls them speech generating devices – SGD’s) Check out these devices & more in the exhibit hall! LightWRITER Dynavox Technologies Mini-Mercury Assistive Technology LinkCLASSIC Assistive Technology DynaWRITE Dynavox Technologies Say-it! SAM Words+ V Dynavox Technologies Palmtop Dynavox Technologies Cyrano Communicator One Write Company TalkingAid Wireless Zygo Spok21 Zygo
Slide 32 - V. Medical Instability Recurrence of cancer Additional surgery Additional adjunctive treatments Temporary compromise pneumonia Permanent compromise metastasis to brain hearing loss in family member
Slide 33 - Goal: Maintain Communication & Modify System As Necessary Revisit communication needs assessment add or modify communication system to address any new issues Reintroduce AAC options which may have been previously declined Re-train staff & caregivers regarding most efficient methods for communication
Slide 34 - References Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The communication effectiveness index: Development and psychometric evaluation of a functional communication measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113-124. Perry, AR., Shaw, MA., & Cotton, S. (2003). An evaluation of functional outcomes (speech and swallowing) in patients attending speech pathology after head and neck cancer treatment(s): Results and analysis at 12 months post-intervention. Journal of Laryngology & Oncology, 117, 368-381. Sullivan, MD., Gaebler, CB., & Ball, LJ. (2007). AAC for people with head and neck cancer. In (Beukelman, Garrett, & Yorkston, Eds.) Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions, Baltimore: Paul H. Brookes, pp. 347-367. Sullivan, MD., Beukelman, DR., Mathy-Laikko, P. (1993). Situational communicative effectiveness of rehabilitated individuals with total laryngectomies. Journal of Medical Speech-Language Pathology, 1, 73-80. Yorkston, K., Beukelman, DR., Hakel, M., & Dorsey, M. (2007). Speech Intelligibility Test. Lincoln, NE: Madonna Rehabilitation. Available from: email or
Slide 35 - Table of Contents 1. An Introduction to AAC Services for Adults with Chronic Medical Conditions: Who, What, When, Where, and Why David R. Beukelman, Kathryn M. Yorkston, & Kathryn L. Garrett 2. AAC in the Intensive Care Unit Kathryn L. Garrett, Mary Beth Happ, John M. Costello, & Melanie B. Fried-Oken 3. Brainstem Impairment Delva Culp, David R. Beukelman, & Susan K. Fager 4. Spinal Cord Injury Deanna Britton & Ross Baarslag-Benson 5. Traumatic Brain Injury Susan K. Fager, Molly Doyle, & Renee Karantounis 6. Severe Aphasia Joanne P. Lasker, Kathryn L. Garrett, & Lynn E. Fox 7. Primary Progressive Aphasia Julia M. King, Nancy Alarcon, & Margaret A. Rogers 8. Dementia Michelle S. Bourgeois & Ellen M. Hickey 9. Amyotrophic Lateral Sclerosis Laura J. Ball, David R. Beukelman, & Lisa Bardach 10. AAC Intervention for Progressive Conditions: Multiple Sclerosis, Parkinson's Disease, and Huntington's Disease Kathryn M. Yorkston and David R. Beukelman 11. AAC for People with Head and Neck Cancer Marsha D. Sullivan, Carol Gaebler, & Laura J. Ball 12. AAC Decision-Making Teams: Achieving Change and Maintaining Social Support David R. Beukelman, Kathryn M. Yorkston, & Kathryn L. Garrett
Slide 36 - Websites Information on Medicare reports and billing codes for SGDs: Information on AAC and manufacturer links:
Slide 37 - Contacts Marsha D. Sullivan, M.S., CCC Carol Gaebler, M.S., CCC Laura J. Ball, Ph.D., CCC Phone: 402-559-6460 Fax: 402-559-5753 Address: 985450 Nebraska Medical Center Omaha, NE 68198-5450