From the desks of Teresa Goddard, M.S., Lead Consultant – Sensory Team and Beth Loy, Ph.D., Principal Consultant and Melanie Whetzel, M.A., CBIS, Lead Consultant – Cognitive/Neurological Team
May is American Stroke Month. Every 40 seconds someone has a stroke, and one out of six people will suffer a stroke in his or her lifetime (American Stroke Association, 2015). The limitations of a stroke depend on where the stroke occurred. For example, a stroke can affect vision when it happens in the back of the brain. Up to two thirds of people experience some change to their vision after a stroke (National Stroke Association, n.d.). Vision loss is typically visual field loss, such as blind spots and tunnel vision; or visual perception problems, such as double vision or depth perception; however, color vision deficiency and long-term blurriness are also common.
Accommodations for individuals who have had a stroke vary, but for those with vision loss, technologies are available to help them overcome these limitations. These technologies may help with reading printed material, accessing computer information, writing notes and completing forms, accessing a telephone, working with money, reading from an instrument, assembling parts, driving, working with light sensitivity, distinguishing colors, and being mobile. Examples of accommodations cover a wide range of industries:
- A customer service representative for a financial institution had long-term blurry vision from a stroke and could no longer read his computer screen. The employer provided screen reading software for his computer so that information present on the screen and information inputted into the system would be read back to him.
- An assistant manager for a nonprofit had complete loss of vision in one eye and low vision in the other due to a stroke. The individual was having problems reading printed paper copies. A portable magnifier, stand magnifier, and a closed-circuit television (CCTV) were used to magnify materials.
This month we put the spotlight on stroke and look at additional accommodations for communication, mood, and mobility. Please feel free to contact JAN and speak to a consultant if you have questions that might be a little complicated or are not effectively answered by this article.
Accommodations for Speech and Language Impairments Resulting from Stroke
Strokes can impact communication in a variety of ways depending on the part of the brain affected. Three typical speech and language impairments arising from stroke include dysarthria and apraxia, which impact one’s control over the movements of the muscles used in speaking; and aphasia, which causes difficulty understanding and using language. Some individuals who are recovering from stroke may have undergone evaluations to determine whether they would be helped by assistive technology such as augmentative and alternative communication (AAC) devices. This may be more likely for individuals with severe apraxia of speech that is not responding well to other treatments. They may also have learned or be in the process of learning compensatory techniques such as using a slower rate of speech or using other communication methods like typing, writing, drawing, or gesturing to support and enhance communication.
While there is no one best method to support individuals with speech and language impairments resulting from stroke, some tips for listeners and communication partners include:
- Give respectful attention;
- Avoid interrupting;
- Understand that more time may be needed for the person to process and respond to a question;
- Confirm your understanding, but do not attempt to complete sentences for the speaker;
- Be mindful of your own rate of speech;
- Avoid “talking down” but be prepared to rephrase using simpler sentence structures if needed;
- If responding to open ended questions is difficult, try asking yes or no questions;
- Minimize distractions;
- Minimize background noise;
- Allow the person to use methods that work for him and with which he is comfortable;
- Allow the use of assistive devices and know how to use them with a public address (PA) system or phone if needed;
- Have materials such as pen and paper available for writing or drawing if needed;
- Understand that some individuals may use more than one method of communication;
- Be prepared to make and receive telephone calls via the Speech-To-Speech Relay Service;
- Be open to suggestions from the individual and his medical provider/speech language pathologist; and
- Remember that a speech or language impairment does not in and of itself impact intelligence.
Some communication access technologies designed to facilitate communication between individuals who are deaf or hard of hearing and hearing communication partners may also be helpful to support communication with a person who has had a stroke, particularly if the person communicates more easily by typing and reading. Examples of two such devices that are designed with features to support public access include UbiDuo and Interpretype. For more information on these see information from JAN's SOAR. You can also learn more tips on communicating with individuals who have had a stroke on the website of the American Speech-Language-Hearing Association (ASHA).
Accommodations for Hemiparesis Resulting from Stroke
Hemiparesis, which is a weakness of one side of the body, is one of many residual effects of having a stroke that limit physical or motor functioning (National Stroke Association, 2014). According to the National Stroke Association, about 8 out of 10 individuals who survive a stroke will experience hemiparesis. Depending on the area of the brain where the stroke occurred, either the left or the right side of the body may experience a reduction in muscle strength. The degree to which motor functioning is limited depends on the individual and improvement in physical ability can be seen as a result of therapy and various forms of treatment.
Hemiparesis can also limit an individual’s ability to perform a job or parts of a job, and those planning or preparing to return to work following a stroke may need to explore accommodation options. An individual experiencing hemiparesis may have difficulty walking, standing, balancing, climbing, grasping, or gripping objects for precision or detailed work tasks, and could experience general muscle fatigue or a lack of coordination (National Stroke Association, 2014). Depending on the type of job and the essential functions of the position, one or more accommodations may be needed to ensure that a return to work is successful for an individual with hemiparesis.
In general, accommodations could include the purchasing of equipment or assistive technology for an individual who uses a computer or performs detail-oriented assembly work. If an individual uses a mobility aid such as a scooter or wheelchair, worksite and/or workstation modifications may need to be made. A restructuring of a job, either to perform essential functions in a different way or reallocate marginal functions, flexibility in breaks, and leave to seek treatment may be potential accommodations to explore. Reassignment to a vacant position may be necessary if accommodations cannot be made in the current job or if an accommodation would pose an undue hardship.
Below are a few accommodation examples for individuals with hemiparesis:
- A medical receptionist was returning to work following a stroke resulting in hemiparesis of her non-dominant left side. She had difficulty holding the phone while taking notes and typing information into a computer. Her employer provided a wireless headset and a one-handed keyboard as accommodations.
- An automobile parts assembler had hoped to regain strength in his dominant right side following a stroke resulting in hemiparesis. He had exhausted FMLA leave and decided to request reassignment. He was placed in a vacant stock clerk position that was less physically demanding. He was also provided a scooter to access the facility and a tablet device was mounted to the handlebars, which allowed him to access purchasing and receiving documents with one hand.
- A teacher had been released to return to work following a stroke resulting in hemiparesis of her dominant left side. The individual had undergone treatment and rehabilitation, but had trouble balancing, standing, walking, and grasping small items, such as a pen. Accommodations provided included a stand/lean stool, a height-adjustable laptop tray with a laptop connected to the classroom smart board, low-tech grip aids for writing, and grab bars placed along the walls of the class and in the hallways for assistance with balancing.
If an employee requests an accommodation related to hemiparesis, the employer should work to find a solution that suits the needs of everyone.
Accommodations for Mood Disorders Resulting from Stroke
A stroke is a life-changing event that can affect an individual’s emotional well-being as much as his/her physical function. Many of us know and understand the physical (weakness, paralysis), cognitive (memory, processing), and communication (speech, language) challenges stoke survivors face, but we may not be aware of the challenges faced when mood disorders occur as result of a stroke.
Although stroke effects are unpredictable, mood disorders such as depression, anxiety, and pseudo-bulbar affect (PBA) are common. According to neuropsychologist Dawn Giuffre, Ph.D., of Medstar National Rehabilitation Hospital, researchers are seriously evaluating whether certain types of strokes or strokes in certain areas of the brain produce mood disorders. So far, studies suggest that simply having a stroke increases the risk of either anxiety or depression, or having both. Research also indicates that PBA is more common in survivors of brainstem stroke, but it can occur in strokes in other areas (Caswell, 2014).
Depression affects between one- and two-thirds of stroke survivors. It is characterized by feelings of overarching sadness, lack of pleasure in activities that were previously enjoyed, or changes in eating and sleeping patterns. By contrast, anxiety occurs when a survivor focuses on worries and concerns, without the ability to resolve those concerns. Anxiety affects about one-fifth of survivors (Caswell, 2014).
PBA symptoms are frequent, incontrollable outbursts of crying or laughing. The episodes are inappropriate to the situation, such as laughing at a funeral or crying at a joke. Another characteristic of PBA episodes is that even in an appropriate situation, the reactions are exaggerated. PBA has not been as thoroughly investigated as depression or anxiety, but it is not uncommon. It impacts 28 to 52 percent of stroke survivors, according to studies (Caswell, 2014).
If you or someone you know has had a stroke and is experiencing a mood disorder as a result, consider job accommodations that can be provided to assist with the return to work. The following real-life situations and accommodation solutions may be helpful:
- Situation A: A court employee was having difficulty with emotions after returning to work following an acquired brain injury due to a stroke. She was diagnosed with PBA that caused outbursts of uncontrollable laughter at seemingly inappropriate times.
- Accommodation A: The employee asked that her co-workers be educated on PBA so they would better understand what could be viewed as inappropriate behavior. The employee agreed to talk to her neurologist about the training. She was also accommodated with extra breaks to help manage her stress, a temporary lightening of her workload, and a flexible schedule to allow her time for counseling and doctor appointments.
- Situation B: An employee returning to work after a stroke was dealing with depression. As a result, the employee’s performance was impaired and the previous supervisory method was no longer effective.
- Accommodation B: The supervisor agreed to meet with the employee weekly to discuss performance and conduct issues that were becoming problematic, as well as put accommodations into place. Among the accommodations: a flexible schedule for health care appointments, a diagram to help with the flow of duties, templates to assist in report writing, and a move to an area with more natural lighting.
For additional information, accommodation ideas, and resources related to limitations resulting from stroke see JAN's A to Z: Stroke.
- American Stroke Association (2014). Effects of Stroke. Retrieved April 15, 2015 from http://www.strokeassociation.org
- Caswell, J. (2014, Summer). Post-stroke mood disorders. Stroke Connection, 16-17.
- National Stroke Association (2014). Hemiparesis. Retrieved April 27, 2015, from http://www.stroke.org
- National Stroke Association (n.d.). Vision. Retrieved April 27, 2015, from http://www.stroke.org