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Published on January 23, 2008

Author: Paola

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Examining Communicative Participation in Community-Dwelling Adults with Neurologic Communication Disorders :  Examining Communicative Participation in Community-Dwelling Adults with Neurologic Communication Disorders Kathryn M. Yorkston, PhD, BCNCD Estelle R. Klasner, Ph.D., CCC-SLP Carolyn Baylor, MS, CCC-SLP University of Washington Acknowledgement:  Acknowledgement We gratefully acknowledge support from: NIH, grant # 1R21 HD 45882-01, a planning grant “Developing a Scale of Communication Participation” National Institute on Disability and Rehabilitation Research (NIDRR), grant #H133B031129, National Rehabilitation Research and Training Center on Multiple Sclerosis. Overview of Seminar:  Overview of Seminar (1)   What are we talking about? Definitions and models (2)   Where have we been? Paradigm shifts in measurement (3)  What we need to know? Report the results of in-depth interviews with community-dwelling adults with MS or SD (4)   What do we do now? Discuss current clinical procedures & future research directions Overview of Seminar:  Overview of Seminar (1)   What are we talking about? Definitions and models (2)   Where have we been? Paradigm shifts in measurement (3)  What we need to know? Report the results of in-depth interviews with community-dwelling adults with MS or SD (4)   What do we do now? Discuss current clinical procedures & future research directions Why communication?:  Why communication? “The ability to communicate is important for the development of personality, understanding of the world, self-esteem, etc. It is the medium through which people express, share, learn, inform, discover, that is, through which we define ourselves, and as such it has a closer inexplicable link to a person’s well-being than perhaps his/her physical health.” Cruice, Worrall, & Hickson, 2000 Why communication?:  Why communication? Communication is central to quality of life. Communicative activities form major domain that needs to be considered when evaluating participating in life situations. Client-Centered Measures:  Client-Centered Measures Quality of Life Health-Related Quality of Life Activity-Related Quality of Life Communication-Related Quality of Life Satisfaction with Communicative Participation Quality of Life: Definition:  Quality of Life: Definition An individual’s perception of his/her position in life in the context of the culture and value systems in which he/she lives and in relation to his/her goals, expectations, standards, and concerns. (WHO, 1993) Quality of Life: Characteristics:  Quality of Life: Characteristics Global – satisfaction with life as a whole Personal – must the perspective of the individual Multidimensional – represents the sum of many factors Health-Related QoL:  Health-Related QoL The extent to which one’s usual or expected physical, emotional and social well-being are affected by a medical condition or its treatment. (Cella, 1995; cited in Johnston & Miklos, 2002) Activity-Related QoL:  Activity-Related QoL Quality of everyday life – assessing both activities of persons and their feelings about or appraisals of them. (Johnston & Miklos, 2002) Communication-Related QoL:  Communication-Related QoL The quality of everyday life that assesses communicative activities (function, community participation, and behaviors) and persons’ feelings about or appraisal of them. Participation as involvement in life situations:  Participation as involvement in life situations . .a person’s myriad of activities performed within the context of their social environment. Some may be deliberately chosen to promote single tasks & overarching goals or to maintain a current value state Other activities such as self-care are less open to choice but still serve the goal of independence and survival. Herzog et al., 2002) Communicative Participation: A Definition:  Communicative Participation: A Definition To take part in life situations where knowledge, information, ideas or feelings are exchanged, may take the form of speaking, listening, reading, writing and non-verbal techniques. Components of the Definition:  Components of the Definition Activities performed in natural/social settings that have a goal or purpose Activities we want to do Things that have value Activities we have to do Necessary for survival Necessary for independence Relationship of Measures:  Relationship of Measures Quality of Life Health-Related Quality of Life Activity-Related Quality of Life Communication-Related QoL Satisfaction with Communicative Participation Participation Complex:  Skills Needed for Activities Participation Complex Personal Household Work/Ed. Leisure Relationships Community Domains of Participation Cognition Mobility Communication Manipulation Personal Involvement in situations related to self-care or medical care. :  Personal Involvement in situations related to self-care or medical care. Asking for help from a family member Giving instructions to a caregiver Asking questions about your medications Household Involvement in situations related to managing a household and those living together in it. :  Household Involvement in situations related to managing a household and those living together in it. Arranging for service or repairs (e.g. for home or car) Taking a phone message for someone in your household Interacting with a child about schedules and chores Work/Education Involvement in situations related to paid or unpaid (volunteer) employment or school work :  Work/Education Involvement in situations related to paid or unpaid (volunteer) employment or school work Reporting to your work supervisor Explaining your opinion or idea at work or school Using email at work Leisure: Involvement in situations related to discretionary activities not related work or other duties :  Leisure: Involvement in situations related to discretionary activities not related work or other duties Telling a joke Commenting while watching a television show with others Having a conversation about a book, movie, show or sports event Relationships: Involvement in situations related to social roles that connect or bind participants.:  Relationships: Involvement in situations related to social roles that connect or bind participants. Staying connected with family and friends Writing a personal note, letter or email Giving your opinion to family or friends Community: Situations related to community involvement (e.g. civil roles, communication within the community). :  Community: Situations related to community involvement (e.g. civil roles, communication within the community). Actively participating in a religious service Introducing yourself to a stranger Ordering a meal at a restaurant General:  General Making small talk Taking part in a group discussion Communicating on the telephone Situations crossing all domains Relationship of Measures:  Relationship of Measures Quality of Life Health-Related Quality of Life Activity-Related Quality of Life Communication-Related QoL Satisfaction with Communicative Participation Participation Complex:  Skills Needed for Activities Participation Complex Personal Household Work/Ed. Leisure Relationships Community Domains of Participation Cognition Mobility Communication Manipulation Overview of Seminar:  Overview of Seminar (1)   What are we talking about? Definitions and models (2)   Where have we been? Paradigm shifts in measurement (3)  What we need to know? Report the results of in-depth interviews with community-dwelling adults with MS or SD (4)   What do we do now? Discuss current clinical procedures & future research directions A Scenario: 40 y/o woman with MS:  A Scenario: 40 y/o woman with MS Situation: In the afternoon, She has difficulty making herself understood to co-workers She has stumbled & fallen at work A Scenario: 40 y/o woman with MS:  A Scenario: 40 y/o woman with MS Physician: Asks about: Leg weakness Coordination Management of fatigue Management of spasticity Possibilty of exacerberation Current regime of course altering drugs A Scenario: 40 y/o woman with MS:  A Scenario: 40 y/o woman with MS PT/OT/SLP: Ask about: Mobility function Upper extremity function (manipulation) Speech & cognitive-communication function Need for assistive devices to maintain independence A Scenario: 40 y/o woman with MS:  A Scenario: 40 y/o woman with MS Person with Disability Asks: What do my co-workers think? Should I really be working? How can I manage financially if can no longer work? What will I do if I can’t work? Questions are: Global Personal Shifting Paradigms :  Shifting Paradigms Prior to early ‘80s – Process Focused (Impairment) Assessment ‘80 – ‘95 – Assessment of Function Mid 1990s to present – Assessment from insider’s perspective (Client-Centered) Slide33:  Number of Quality of Life References Slide34:  PICA Pt-Place WAB Examine Impairment Slide35:  PICA Pt-Place WAB FIM Intell-Dys CADL CETI ASHA FACS Measure Function Communication Abilities in Daily Living - Revised (CADL-2):  Communication Abilities in Daily Living - Revised (CADL-2) Number of items: 68 Examples: (greeting, making an appointment) Rating: Performance scored for accuracy & efficacy Data Collection Method: Simulated situations Communicative Effectiveness Index (CETI):  Communicative Effectiveness Index (CETI) Number of items: 16 Examples: (getting someone’s attention, understanding writing) Rating: continuous linear scale “not at all able” to “as able as before stroke” Data Collection Method: Proxy rating (SLP or SO) ASHA Functional Assessment of Communication Skills (ASHA FACS) :  ASHA Functional Assessment of Communication Skills (ASHA FACS) Definition: The ability to receive or to convey a message, regardless of mode, to communicative effectively & independently in a given (natural) environment. ASHA Functional Assessment of Communication Skills (ASHA FACS) :  ASHA Functional Assessment of Communication Skills (ASHA FACS) Number of items: 43 Examples: (requests help when necessary, understands simple signs) Rating: 7-pt scale defined by quality & independence Data Collection Method: Proxy rating (SLP) Slide40:  PICA Pt-Place WAB FIM Intell-Dys CADL CETI ASHA FACS VHI V-RQol BOSS QoCLS Insider Perspective Voice Handicap Index:  Voice Handicap Index 30 items 4-point scales Normal to Severe Domains Function Physical Emotions People seem irritated with my voice. I run out of air when I talk My voice difficulties restricts my person & social life. Jacobson et al, 1997 Voice-Related Quality of Life:  Voice-Related Quality of Life 10 items 5-point scales None to “As bad as can be” Domains Social-Emotional Physical Functioning I sometimes get depressed because of my voice I have to repeat myself to be understood. Hogikyan & Sethuraman, 1999 Burden of Stroke Scale:  Burden of Stroke Scale 7 com. Items (65 total) 5-point continuous scale “Not at all” to “Cannot do” Because of your stroke, how difficult is it for you to Be understood by others Write a letter Understand what you read Doyle, 2003 ASHA Quality of Com Life Scale:  ASHA Quality of Com Life Scale Paul-Brown & Frattali, 2003 Pilot Version: 35 items Scale on a 4 point pictograph Domains Relationship/Social life Interests & Leisure Vocational & School Life Autonomy/Well Being Slide45:  PICA Pt-Place WAB FIM Intell-Dys CADL CETI ASHA FACS VHI V-RQol BOSS QoCLS ICIHD ICIHD-2 ICF Continuum of Outcome Measures - ICF:  Continuum of Outcome Measures - ICF Impairment - Activity - Participation Focus Biologic Psycho-social Measurement Approaches Well- Recognized Less Agreement Environment/ Context Relatively Unimportant Critical Continuum of Outcome Measures:  Continuum of Outcome Measures Impairment - Activity - Participation Relatively Small Very Large Health Care Provider Client Primary Rater Where have we been?:  Where have we been? Shifting Paradigms Prior to early ‘80s – Process Focused Assessment ‘80 – ‘95 – Assessment of Function Mid 1990s to present – Assessment from insider’s perspective Overview of Seminar:  Overview of Seminar (1)   What are we talking about? Definitions and models (2)   Where have we been? Paradigm shifts in measurement (3)  What we need to know? Report the results of in-depth interviews with community-dwelling adults with MS or SD (4)   What do we do now? Discuss current clinical procedures & future research directions Research Update: Overview:  Research Update: Overview Introduction to qualitative methods Participation in Multiple Sclerosis (MS) Insiders’ Perspective on Participation The lived experience of Spasmodic Dysphonia (SD) Qualitative Research: An Overview:  Qualitative Research: An Overview A systematic way of exploring complex issues that are best understood in the context in which they occur Participant is the expert- shares information that he/she feels is vital for understanding Text rather than numbers serve as data Clinical vs. Qualitative Interview:  Clinical vs. Qualitative Interview Clinical Questions are specific Clinician is expert Written notes Purpose is assessment and treatment Qualitative Questions are broad Participant is expert Information is recorded Purpose is to understand lived experience Qualitative Data Analysis:  Qualitative Data Analysis Interviews are transcribed Read and re-read Interpreted and re-interpreted Validated and re-validated Participation and Multiple Sclerosis:  Participation and Multiple Sclerosis Purpose of Study to understand the experiences of people with MS as they engage in daily life activities and situations to understand the strategies that people with MS develop to maintain participation in life situations What is Multiple Sclerosis:  What is Multiple Sclerosis Inflammatory disease of the CNS (primarily white matter) Lesions result in demyelinization Unpredictable, variable course Some Symptoms of MS:  Some Symptoms of MS Visual changes Muscle changes Dysarthria (usually mixed type) Fatigue Cognitive changes (memory,executive functioning) Dysphagia Methods:  Methods Phenomenological inquiry Guided interviews focused on everyday activities and strategies Individuals participated in 1-3 interviews Methods-Data Analysis:  Methods-Data Analysis Interviews were transcribed Read several times Code system was developed and applied to sections of the transcripts that related to the research questions Ethnograph software used to index codes Themes were created and validated by participants Participants:  Participants Fourteen participants - 11 women, 3 men Age range 38 - 52 Mean time since diagnosis - 8 years Theme: Defining the activity:  Theme: Defining the activity Priorities: Seeing what is important Plans: Learning about resources Perspectives: Fixing it yourself Theme: Changing how things are done:  Theme: Changing how things are done Precipitating Factors Awareness Construction of Strategies Evaluation of Strategies Priorities: Seeing what is important:  Priorities: Seeing what is important “You learn that life is short and you quit worrying about stuff that doesn’t matter. You only have so much energy to fuss and fiddle with things that are not going to matter in the long run. So you learn to focus on what’s important.” Priorities: Seeing what is important:  Priorities: Seeing what is important “If you lose your interaction with people, your world is going to shrink. Having your peer base at work is really important.” Plans: Learning about Resources:  Plans: Learning about Resources “The house wasn’t getting cleaned enough, and it was stuff that I couldn’t do. What’s the solution? Let’s hire someone. I saw a 20/20 interview one time, where this couple was ready to divorce because of the house being a mess. All the money you are spending on counselors, good grief, get someone in to clean. I guess I have learned to look for solutions.” Perspectives: Fixing it yourself :  Perspectives: Fixing it yourself “ I am finding that I am strong. I feel like I can deal with anything that comes up now. I am finding new ways of viewing my life and if a problem comes up, I can find an answer to it. I don’t want anyone telling me what to do, I would rather uncover it myself.” Precipitating Factors:  Precipitating Factors “ When you get tired, there are cognitive problems and you just don’t think as clearly. I know I can do the job, but sometimes I fatigue and cognitive changes create a struggle for me to get it done the way I normally would.” Awareness:  Awareness “ I have to watch what I say all of the time. I can’t speak off the top of my head, the more fatigued I get, I might not think something through correctly and communicate something different.” Construction of Strategies:  Construction of Strategies “I can’t be scattered, everything has to have its place, I don’t want to waste energy looking for something and find it is not there.” Evaluation of Strategies:  Evaluation of Strategies “Why should I make myself crazy trying to remember this? that’s why I have it on a piece of paper. Don’t knock yourself out memorizing. It’s here and it will always be here. ” Components of Satisfaction with Communicative Participation:  Components of Satisfaction with Communicative Participation Measurement ideas were presented to participants Measurement of satisfaction was defined as an important measure of communicative participation Satisfaction was broken down into five different components Participants :  Participants 42 year old women with MS - mild communication deficits 48 year old man with ALS - moderate communication deficits 23 year old man with cerebral palsy since age 8 - severe communication deficits Slide72:  Satisfaction with Communication Participation Importance Frequency Ease of Performance Independence Personal definitions “doing my best” Importance:  Importance Importance: how important is the involvement in the situation to you? More of an internal feeling and personal judgment Importance:  Importance “Small talk is very important to me. It often acts as a bridge to make new friends that know me as I am now.” Frequency:  Frequency Frequency: a level of satisfaction with the number of times a person engages in an activity, if he/she is not doing the activity as often as he/she would like they may not be satisfied with his/her participation Frequency:  Frequency “Frequency is measured differently for me now. Slower is faster. If I take my time to do something like calling a friend, I will do it more often because I did it right. If I do it fast and can’t say what I want to, then my frequency will be less.” Ease of Performance:  Ease of Performance This can be viewed in two ways: if something is easy to do, you are satisfied with your performance if something was challenging and you did it, you can also be satisfied with your performance Ease of Performance:  Ease of Performance “Performance for me is to be comfortable with someone. If I am comfortable, then it is easy for me, even if I have trouble [talking].” Independence:  Independence If you are able to participate with a level of independence that is comfortable for you then you can be satisfied. Independence:  Independence “Independence is very different for me now. I used to think of it as being able to go and do whatever I wanted. Now, I see it as being able to learn new ways to hang on to what I can still do.” “Doing My Best” (Personal):  “Doing My Best” (Personal) If you feel that you gave the activity your best effort, regardless of the outcome you can still be satisfied with your participation. “Doing My Best” (Personal):  “Doing My Best” (Personal) “I have tried for 3 years to talk to my boss and tell him I can do more. He still looks at me and sees someone who can’t do much. I keep trying to talk to him. I try my best. I know the problem is his, but I am still going to do my best.” The Insider’s Perspective on SD: Communication-Related QoL:  The Insider’s Perspective on SD: Communication-Related QoL Carolyn Baylor, M.S. Kathryn Yorkston, Ph.D. Tanya Eadie, Ph.D. Introduction to Spasmodic Dysphonia:  Introduction to Spasmodic Dysphonia Neurologic voice disorder of unknown etiology Type of focal dystonia Adult onset More prevalent in women than men Affects 50,000 people in North America (National Spasmodic Dysphonia Association, http://www.dysphonia.org, 2004) SD introduction (continued):  SD introduction (continued) Types of SD and voice characteristics: ADSD: intermittent tight voice breaks ABSD: intermittent breathy voice breaks Tremor Mixed (combinations of symptoms) Physical effort and fatigue with speaking Treatment with botox injections Symptomatic Cyclic Purpose of study:  Purpose of study To explore the psychosocial consequences of SD by examining the lived experiences of persons with SD from the insider’s perspective. Methods:  Methods Phenomenological inquiry Guided face-to-face interviews Research questions Tell us about your history with SD, for example when and how did your symptoms start and how did that affect you? What impact has SD had on your life? (These were two questions as part of a larger study.) Self-rated voice quality on day of interview Slide88:  Participants Slide89:  Communication -Related QoL Coping Strategies Changes in Self-View Affective Responses Participation in Social Roles Other People Physical Environment Physiologic Personal Social Connections are important:  Connections are important When I was hearing all the tremor and breaks, and to me it was a nervous voice. A voice that didn’t have confidence. A voice that was scared. RN Slide91:  Communication -Related QoL Coping Strategies Changes in Self-View Affective Responses Participation in Social Roles Other People Physical Environment Physiologic Personal Social Connections are important:  Connections are important It’s draining. I am really exhausted at the end of teaching. I said can this be my voice? AT Slide93:  Communication -Related QoL Coping Strategies Changes in Self-View Affective Responses Participation in Social Roles Other People Physical Environment Physiologic Personal Social Some Clinical Important Issues:  Some Clinical Important Issues Effort and Fatigue Dependability Spontaneity Voice as a representative Reaction of others Satisfaction with participation That we don’t measure well Effort and Fatigue:  Effort and Fatigue It just feels like you’re having to grab onto a word and push it out from your throat. It’s a definite physical effort. And you come home and you think you’ve been running a race all day long ‘cause you are tired. MA Dependability:  Dependability I just get tired of guessing where my voice might be on that day that you schedule your social thing…so I just don’t socialize. BW Spontaneity:  Spontaneity Speech lost its spontaneity and I had to preplan what I was going to say. RN Voice as a Representative:  Voice as a Representative I felt like I couldn’t really be myself. IP Reaction of Others:  Reaction of Others People become condescending like you’re not capable anymore because you don’t speak well. AT Satisfaction with Participation:  Satisfaction with Participation My participation is not what I would like….I go but I don’t participate. HT Overview of Seminar:  Overview of Seminar (1)   What are we talking about? Definitions and models (2)   Where have we been? Paradigm shifts in measurement (3)  What we need to know? Report the results of in-depth interviews with community-dwelling adults with MS or SD (4)   What do we do now? Discuss current clinical procedures & future research directions The Problem:  The Problem Many investigators bypass the difficulty of defining what QoL means and go right ahead with developing a measure or selecting a published measure to use in their research. Many of these instruments offer a minimal expansion beyond “function” or “health status” measures – the favorites of the 1970s and 1980s. Dijkers, 2003 Problems with current scales:  Problems with current scales Shifting terms and models Activity prevalence rates do not take into account the meaning & importance of the activity Lack of focus on communication in general rehabilitation scales Lack of focus on communication partners Proxy ratings don’t reflect PWD perspective Problems with current scales:  Problems with current scales Pool is biased with “easy” item, thus doesn’t capture mild disability Little emphasis on physical or social environment, i.e. communication partners Item may not reflect authentic communication situations Created by expert panels/health professionals Observational studies suggest scales do not contain frequently observed activities Goal: To develop a measure of communicative participation:  Goal: To develop a measure of communicative participation Reflective of participant’s perspective items generative via examination of their experiences scored in a self-report format Tapping multiple domains Acceptable to participant content administration time reading level Goal: Continued :  Goal: Continued Small floor and ceiling effects Psychometric adequacy reliability validity Responsive to treatment effects Clinically useful Initial populations: Why MS or TBI?:  Initial populations: Why MS or TBI? Restrictions in Com. Participation are likely Motor Speech disorders in half of MS & 1/3 of TBI Cog-Com disorders in half of MS and majority of TBI Many associated symptoms represented Represent a wide range of types of communication disorders age employment & education SES Good access to population Participation: Domains:  Participation: Domains Involvement in life situations: Personal Management Household Management Work/Education Recreation/Leisure Relationship/Intimacy Community Involvement Summary of Need for Tool:  Summary of Need for Tool ICF identified gaps in knowledge Communication in important - most everyday situations require it Double jeopardy for social isolation Current scales of communication are inadequate Slide110:  Health Condition Body Functions Activity Participation Environmental Factors Personal Factors Slide111:  Health Condition Body Functions Activity Participation Environmental Factors Personal Factors Examine Impairment Assess Severity of Functional Limitations Slide112:  Health Condition Body Functions Activity Participation Environmental Factors Personal Factors Communication-Related Quality of Life Importance of Participation (For the Insider Perspective):  Importance of Participation (For the Insider Perspective) “Isolation of disabled persons . . can have a very dramatic impact on their general improvement; it can prevent the development of mental capacities to the full and thus hold back their rehabilitation process.” (Syed, 2004) Client-Centered Intervention:  Client-Centered Intervention “The work of the therapist is similar to an artistic creation. The role of the therapist is to stimulate ideas, arouse emotions, and encourage activity on the patient’s part so that the patient, and not the therapist, tries to solve the problems he or she is confronting.” (Syed, 2004) Assessing Satisfaction with Communicative Participation:  Assessing Satisfaction with Communicative Participation Grand Tour Question (Westby, 1990) Identify Activities in Important Domains Personal Household Work/School Leisure Relationships Community Understand what contributes to satisfaction with the activity Slide116:  Participation Limitation in Activity Personal Factors Function & Disability Environmental Factors Problems: body function Depression Fatigue Pain Social support Financial factors Healthcare utilization Self efficacy Hope Mood & Coping Health Promoting Behaviors Personal/ Household Management Leisure Community Activities Relationships Work Future Research:  Future Research Developing a bank of items Evaluated by people with communication disability Evaluated by clinicians Interested? Contact: yorkston@u.washington.edu References:  References Cruice, M., Worrall, L., & Hickson, L. (2000). Quality of life measurement in speech pathology and audiology. Asia Pacific Journal of Speech Language Hearing, 5(1), 1-20. Doyle, P. J., McNeil, M. R., Hula, W. D., & Mikolic, J. M. (2003). The burden of stroke scale (BOSS): Validating patient-reproted communication difficulty and associated psychological distress in stroke survivors. Aphasiology, 17(3), 291-304. Frattali, C. M., Thompson, C. K., Holland, A. L., Wohl, C. B., & Ferketic, M. M. (1995). The Amercian Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS).Rockville, MD: ASHA. Herzog, A. R., Ofstedal, M. B., & Wheeler, L. M. (2002). Social engagement and its relationship to health. Clinical Geriatric Medicine, 18(3), 593-609, ix. Johnston, M. V., & Miklos, C. S. (2002). Activity-related quality of life in rehabilitation and traumatic brain injury. Archives of Physical Medicine & Rehabilitation, 83(Suppl 2), S26-38. References Continued:  References Continued Hogikyan, N. D., & Sethuraman, G. (1999). Validation of an instrument to measure voice-related quality of life (V-RQOL). Journal of Voice, 13(4), 557-569. Holland, A. (1980). Communicative abilities in daily living.Austin, TX: ProEd. Jacobson, B. H., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, G., Benninger, M. S., et al. (1997). The Voice Handicap Index (VHI): Development and Validation. American Journal of Speech-Language Pathology, 6(3), 66-70. Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Soghaib, C. (1989). The Communicative Effectiveness Index: Development and psychometrics evaluation of a functional communication measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113-124. Paul-Brown, D., & Frattali, C. (2003). ASHA Quality of Communication Life Scale. Paper presented at the ASHA Annual Meeting, Chicago Syed, Z. (2004). Brain damage: Its manifestions on the body and mind and the scope of rehabilitation from the perspective of a patient. Topics in Stroke Rehabilitation, 11(1), 92-97.

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