Challenging Case

by Lisa
(MA)

I am an SLP in home care and I have a question about a specific patient.

He is 43 yo with L CVA in May of 2011 )frontotemporal and basal ganglia infarct). He is non-verbal, but NOT APHASIC.

He is unable to communicate verbally d/t profound oral apraxia, verbal apraxia and dysarthria. He relies on written language, iPad and texting to communicate.

Cognition is WNLs. Oral-motor functions are significantly impaired with poor saliva mgmt (wears Transcop patch), decreased jaw ROM, sig lingual and labial flaccidity with tongue thrust and anterior tongue position @ rest and very limited palatal elevation Clearly, NPO with Gtube.

Last MBS showed a markedly delayed and disorganized oral phase, with limited ability to manipulate pureed bolus and no sig bolus propulsion.

I've tried everything I can think of with him, including Debra Beckman Techniques, proprioceptive neuromuscualr facilitation, and he has been seeing a chiropractor for microcurrent tx for the past month and a half.

His progress has been painfully slow and inconsistent, suspectedly secondary to the apraxic component.

He has made some gains, as his mandibular ROM/opening has improved, some volitional lingual movement, tried sour/sweet/icing. He is only able to produce nasal vocal grunt on command. Interesting, when he yawns or other automatic responses, he shows the ability to move his tongue.

He is only able to close his mouth with tactile stim of tissue to his mouth, which I've tried to shape. Pt very motivated to progress, tries to complete exercises ALL day long every day.

I've been working with him for 3 months and sadly, am considering discharging him d/t lack of progress.

He is desperate to improve. Any suggestions of other things I could try?

Any suggestions would be greatly appreciated!!!!

Lisa