A Multi-Disciplinary Approach - Pearson Clinical Files... · Angela Kinsella-Ritter, SP 1 ......
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Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 1
Presented by:Bridget Barnett
E: [email protected] Occupational Therapist
andAngela Kinsella-Ritter
E: [email protected] Speech Pathologist
9th March 2016
Regaining independence post-stroke: The impact of executive functioning and language skills on activities of daily
living (ADLs) after a neurological event.
A Multi-Disciplinary Approach
• Today’s webinar will highlight how OTs, Speech Pathologists
and Psychologists can work together to support clients in
regaining functional independence post-CVA.
• Through the use of case study examples, this webinar will
provide a brief overview of the BADs, WAB-R,CLQT and
Pyramids and Palm Trees to illustrate ways in which they can
be used clinically to:
• gain a clearer picture of clients’ abilities
• explore the influences of cognitive skills and language on
one another
• the impact this has on an adult's functional performance
and
• to guide intervention planning.
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 2
Goals of Assessment
• To determine the presence of impairment
– Severity and type of impairment
– Determine the individual’s strengths and weaknesses
• To identify exacerbating factors
– Vision and hearing
– Agnosias (recognition deficits) in various modalities
– Deficits in proprioception or praxis
– Affective (mood) disorders
– Effects of medication
• To identify intervention goals
Treatment Considerations
Timing
• During spontaneous recovery period or wait?
• Vignolo (1964): treatment is only really effective if it begins when
physiologic recovery is most rapid
• Poeck et al (1989): time post-onset does not affect recovery of language,
but it does affect response to treatment
• Generally, delaying treatment has not been conclusively demonstrated to
have any effects on eventual outcome; but it might impact on the patient
and their family
Candidacy
• Some patients have very mild impairments and recover spontaneously
• Some are so severely impaired that they may note necessarily benefit
from intervention
• Some refuse, lack motivation, can’t travel
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 3
Treatment Planning
What person can do
cannot do
does do
What person needs to do
wants to do
closing the gap
• Analyse and interpret the assessment results• Discuss with client (where possible) as well as with the
family• Set long and short term goals• Consider type of task, stimuli selected, modality of material,
type of facilitation given, duration and intensity of therapy (Byng and Black 1995)
Components of Language Function
Cognitive
Recognition, understanding,
memory, attention, reasoning ability
Linguistic
Auditory comprehension, language production (form and
content)
Communicative/Pragmatic
Turntaking, topic initiation and maintenance, repairs, speech acts
produced, nonverbal aspects
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 4
Behavioural Assessment of the Dysexecutive Syndrome (BADS)
Utility in clinical practice
Clinical utility of the BADS12
Overview of the BADS
• A test battery aimed at predicting everyday
problems arising from Dysexecutive Syndrome
(frontal lobe impairment)
• Authors: Barbara A. Wilson, Nick Alderman,
Paul W. Burgess, Hazel Emslie, Jonathan J. Evans
• Published in 1996
• Administration time approx 40 mins
• Age range: 16-87 years
• Six subtests + DEX questionnaire
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 5
Clinical utility of the BADS13
Problems in assessing the Dysexecutive Syndrome
• Traditional neuropsych tests don’t always reflect real life demands of problem solving, planning and organising, setting priorities and adapting behaviour
• Tests might be sensitive to frontal lobe damage but may not reflect everyday situations, making functional correlations difficult
Clinical utility of the BADS14
What does the BADS assess?
Subtests tap into executive functions including:
• The ability to initiate behaviour
• Inhibition of competing actions or stimuli
• Selecting relevant task goals
• Planning and organising a means to solve
complex problems
• Shifting problem-solving strategies flexibly
• Monitoring and evaluating behaviour
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 6
Clinical utility of the BADS15
BADS Subtests
• Rule Shift Cards Test
• Action Program Test
• Key Search Test
• Temporal Judgement Test
• Zoo Map Test
• Modified Six Elements Test
Clinical utility of the BADS16
The Dysexecutive Questionnaire (DEX)
• A 20-item questionnaire. The items sample the
range of problems commonly associated with
the Dysexecutive Syndrome in four areas:
emotional or personality changes, motivational
changes, behavioural changes, and cognitive
changes
• Each item is rated on a 5 point scale
representing problem severity.
• Two forms; a self-report and a carer/ relative
report
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 7
Case study 1 – “Harry”
• 80 years old
• Admitted for inpatient rehab following right CVA
• Lives at home with daughter
• Independent with showering, dressing, toileting
• Has an IDC that will be required upon discharge
• Manages own medication
• Prepares light meals
• Drives an automatic car
• Previously managed finances independently
• Shows limited awareness of current abilities
• MMSE score 24/30Clinical utility of the BADS17
Case study 1 – “Harry”
Rule Shift Cards
•Numerous errors in both versions
•Difficulty processing the test instructions; did not
seek clarification when instructions not
understood
Action Program Test
•“Why would you want me to
do that?”
Clinical utility of the BADS18
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 8
Case study 1 – “Harry”
Key Search Test
•Unable to conceptualise
square as a field
•Took 7 minutes
•Evidence of attempt to cover
all ground but ineffective
Clinical utility of the BADS19
Case study 1 – “Harry”
Temporal Judgement
•Initially stated it was “impossible” to estimate
•Correctly answered question “how long do most
dogs live for”
•Unable to estimate question about window
cleaning
•Reported 10 minutes for time needed to blow up
a balloon
•Reported 30 minutes for dental check-up but
stated “it depends how many teeth you have”
Clinical utility of the BADS20
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 9
Case study 1 – “Harry”
Zoo Map
•Difficulty conceptualising task
•When prompted, stated that he
needed to “visit places”
•Lack of scanning/searching skills when visually
locating places on map
•Distracted by certain details, e.g. perseverated on
cafe
•Stated “there are too many restrictions”
•Did not attempt to draw on either version map
Clinical utility of the BADS21
Case study 1 – “Harry”
• Age corrected standardised score – 24
• “Impaired” range
• Assessment highlighted depth of impairment
and shed light on issues managing IDC, e.g.
• Planning ahead
• Prospective memory
• Managing multiple cognitive demands
• Comprehending instructions
• Insight/error recognition
• Strategy generation
Clinical utility of the BADS22
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 10
Conclusion
• BADS can detect subtle cognitive impairments
that may be missed on MMSE and less complex
tasks
• BADS allows qualitative data gathering e.g.
impulsivity, flexibility of thought, self
monitoring
• BADS can highlight strengths as well as
weaknesses
• BADS can provide insight into potentially useful
strategies
• BADS can increase client/carer awarenessClinical utility of the BADS23
Cognitive Linguistic Quick Test(CLQT)
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 11
Clinical utility of the BADS25
Overview of the CLQT
• The purpose of the CLQT is to assess the
relative status of five cognitive domains in
adults with known or suspected neurological
dysfunction.
• Author: Nancy Helm-Estabrooks
• Published in 2001
• Administration time approx 15 to 30 mins
• Age range: 18-89 years
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 12
CLQT Tasks & Cognitive Domains
Total Composite Severity Rating
• CLQT is criterion-referenced• Severity ratings for two age categories (ages 18-69 and 70-89)• Severity ratings are mild, moderate, several and WNL for each
of the 5 cognitive domains• A total Composite Severity Rating and a Clock Drawing Severity
Rating serve as a neurocognitive screener
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 13
Personal Facts
Symbol Cancellation
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 14
Symbol Cancellation Task Results
Confrontation Naming
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 15
Clock Drawing
Story Retelling
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 16
Auditory Comprehension
Symbol Trails –Trial Items
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 17
Symbol Trails
Generative Naming
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 18
Design Memory
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 19
Mazes
Design Generation
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 20
Case Study: CVA with extensive left hemisphere lesion and small right hemisphere lesion
• 64 year old, right handed man with a doctorate degree
• Referred for an evaluation 11 months post left-hemisphere stroke which resulted in a
� Dense right hemiplegia and aphasia
• He had received extensive rehabilitation and is still under the care of a speech-language pathologist (who requested a second opinion re therapy planning
• Assessments included:
� CLQT
� Boston Diagnostic Aphasia Examination, 3rd Ed (BDAE-III)
� Boston Assessment of Severe Aphasia, 2nd Ed (BASA-II)
� A comprehensive neuropsychological test
� MRI Scan
� Informal Assessment
CLQT Examiner’s Manual, p. 87
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 21
Summary Scoring Worksheet
Summary Scoring Worksheet
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 22
Summary Scoring Worksheet
Design Generation Task Results
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 23
Symbol Cancellation Task Results
CLQT Results
• Moderate overall impairment
• Severely impaired language skills
• Moderately impaired attention and executive functions
• Mildly impaired visuospatial skills
• The Memory Severity Rating (MSR) was interpreted with caution as the client was unable to produce verbal responses
• Although the MSR was in the severe range, his score (5 points out of a possible 6) for the non-verbal task of Design Memory was at the normal Criterion Cut Score for his age (5 points)
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 24
• To assess potential for future recovery
(prognosis)
• To monitor change – e.g. spontaneous recovery,
treatment efficacy
• To evaluate maintenance of treatment gains
• To define factors that facilitate comprehension,
production and use of language
• To establish a working relationship with client
and significant others
Goals of Communicative Assessment
To determine the presence of aphasia*, and severity and type of aphasia, and to profile the client’s strengths and weaknesses
Goals of Communicative Assessment
• Organised, goal directed evaluation of the components of communication
• Evaluation of person’s QOL• Evaluation of communicative interactions within family/social unit
• Their role in society• Carried out to determine how strengths fortified and weaknesses modified Chapey 2008
*Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 25
Assessment of Communicative Functioning
• Not language per se – performance, pragmatics, communication skills in everyday life CALDs• reading timetables and menus• going to the doctor and shopping• making a phone call• writing a shopping list
Aphasia Recovery
Spontaneous recovery: decelerating curve
• Maximum recovery 1-3m
• Flattening out 6-7m
• Little/no spontaneous recovery after 1yr – plateau
Basso 1992 Benson and Ardila 1996 in Chapey 2008
Prognosis: TBI better than stroke, haemorrhagic better
than infarction
Lesser and Milroy 1993
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 26
Neural Mechanisms for Recovery
• Reduction of cerebral oedema/improvement of
local circulation: Spontaneous recovery
• Brain plasticity: cortical reorganisation to
engage pre-existing but functionally depressed
pathways. Called upon when dominant
system fails
• Lesion size = negative influence on recovery
Aphasia Treatment
Efficacy: does aphasia treatment result in a significant improvement on one or more tests of language functioning?
Yes, provided that:• Treatment is delivered by qualified professionals• Content, intensity, duration and timing of treatment are appropriate
• Sensitive and reliable measures are used to track changes
Effectiveness: does aphasia treatment result in meaningful improvements in communicative functioning in daily life?
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 27
Therapy Approaches and Models
• Approaches that assume the brain can relearn what has been
lost/skills can be re-accessed
• Approaches that assume lost language functions not recoverable.
• Therapy aimed at compensatory strategies
• WHO International classification of Functioning, Disability and
Health (2002)
• Body functions and structures i.e. impairments of brain
• Activity i.e. ability to make a phone call, read a menu
• Participation i.e. pursuit and enjoyment of real life goals e.g.
volunteering/getting a job
Western Aphasia Battery Revised(WAB-R)
Author: Andrew Kertesz | Published: 2007
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 28
Western Aphasia Battery-Revised
Purpose:a screening and diagnostic test battery for evaluating language function in adults with acquired neurological disorders
Age Range:18 to 89 years
Administration Time: � Bedside Screening: 15 minutes� Diagnostic assessment: 30-45 minutes� Reading, writing, praxis, construction: 45-60 minutes
Scores:Research-based criterion scores; Aphasia Quotient, Language Quotient, Cortical Quotient
Applications
• Determine the presence, severity, and type of aphasia
• Obtain a baseline of patient abilities
• Document changes in abilities over time
• Guide treatment and management recommendations
• Infer the location and etiology of the lesion causing aphasia
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 29
Bedside Screening: a quick look at functioning in 15 minutes
Bedside Screening: Areas Tested
• Spontaneous Speech: Content
• Spontaneous Speech: Fluency
• Auditory Verbal Comprehension: Yes/No Questions
• Sequential Commands
• Repetition
• Object Naming
• Reading
• Writing
• Apraxia
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 30
Bedside Screening: Scores
Bedside Aphasia Score
� Content, Fluency, Auditory Verbal Comprehension, Sequential Commands, Repetition, and Object Naming
Bedside Language Score
� Content, Fluency, Auditory Verbal Comprehension, Sequential Commands, Repetition, Object Naming, Reading, Writing
Bedside Aphasia Classification
� Global, Broca’s Isolation, Transcortical Motor, Wernicke’s Transcortical Sensory, Conduction, Anomic
WAB-R Test Battery
Comprehensive Assessment� 10 receptive and expressive language tasks� 16 reading and writing tasks� 1 apraxia task� 4 nonlinguistic skills tasks
Scores� Aphasia Quotient (AQ)
o Spontaneous Speech | Auditory Verbal Comprehension | Repetition | Naming and Word Finding
� Language Quotient (LQ)o AQ subtests + Reading and Writing Score
� Cortical Quotiento AQ + LQ subtests + Apraxia Score and Constructional, Visuospatial and Calculation Scores
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 31
Spontaneous Speech
Spontaneous Speech Scoring
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 32
Auditory Verbal Comprehension
Auditory Verbal Comprehension
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 33
Auditory Verbal Comprehension
Repetition
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 34
Naming and Word Finding
Naming and Word Finding
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 35
Naming and Word Finding
Score Summary
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 36
Language & Cortical Quotients
Goals for Treatment
• “The primary objective in treatment of aphasia is to increase communication. What the aphasic patient wants is to recover enough language to get on with his life.” (Schuell et al 1964, 333.)
• There may not be a complete recovery of language and communicative function
• Treatment may enhance recovery, but recovery will stop• Identify strengths and weaknesses; use the strengths to compensate for the weaknesses; help the client with aphasia to be an effective communicator in spite of their language deficits
• Generalisation – recovery must not be limited to the treatment room
• Generalisation does not just happen – it must be planned for, worked towards, tested for
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 37
Example – treatment planningMr Z’s assessments show:
� Strengths:
o Good lexical comprehension
o Good comprehension of basic sentence structure
o Can draw and gesture to convey some aspects of meaning
o Semantic cueing facilitates naming
o Written support facilitates comprehension
� Weaknesses:
o Poor complex auditory sentence comprehension
o Spoken confrontation naming difficulties
o Difficulties in written confrontation naming when word frequency decreases
o Drawings and gestures may not be recognisable outside context as tend not to be well defined
• Mr Z’s wish: to talk/communicate better with family and friends
Pyramids and Palm Trees
A test of semantic access from words and pictures
• Authors: David Howard and Karalyn Patterson• Published: 1992• Age Range: 18 to 80 years• Administration Time:
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 38
Six different versions of the test can be administered:
1. Three pictures
2. Three written words
3. Written word as given item, pictures as choices
4. Picture as given item, written words as choices
5. Spoken word as given item, two pictures as choices
6. Spoken word as given item, written words as choices
Pyramids and Palm Trees
Pyramids & Palm Trees
Here are three pictures. You have to decide which one of these two at the bottom goes with the one at the top. Is it this one or this one?
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 39
Pyramids & Palm Trees
Here are three words. You have to decide which one of these two at the bottom goes with the one at the top. Is it this one or this one?
• The two choices – the target and the distractor - are always
semantic coordinates whereas the given (top) item is
usually from a different category.
• The choice must always be made on the basis of some
property or association that is shared by the given item and
the target.
• Each triad can be answered on the basis of partial
information from the three stimulus items.
• Because the different triads tap a variety of kinds of
knowledge, clients are only able to perform with consistent
accuracy if they can retrieve complete and correct semantic
information from the three items in each of the triads.
Pyramids and Palm Trees
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 40
• Poor performance could indicate difficulty in
• Item recognition
• Semantics, or in the
• Decision process /word retrieval
• Determining the type of difficulty depends on the pattern of
performance:
• Score = total number of responses (+ 0.5 for refusals)
• A score of 26/52 is expected by chance
• A score of 33 is better than chance at p < 0.05
• 35 at p < 0.01
• 38+ at p < 0.001
Pyramids and Palm Trees: Interpretation
Summary• Multi-disciplinary approach
� Working in a multi-disciplinary team enables clinicians easy access expertise from other allied health professional when assessing and planning intervention for your patients.
• The assessments discussed today demonstrated that although we work in specific disciplines there is overlap in the information being sought and they highlight how each discipline supports and complements the other.
Pearson Clinical Webinar: Regaining Independence Post-stroke
7th March 2016
© 2015 Pearson Clinical AssessmentPresented by Bridget Barnett, OT and
Angela Kinsella-Ritter, SP 41
sAngela Kinsella-Ritter
Consultant Speech Pathologist
M: 0408 511 110
Client Services:
1800 882 385
We’re here to help
Pearson Clinical AssessmentBridget Barnett
Consultant Occupational Therapist
M: 0407 259 317
Client Services:
1800 882 385www.pearsonclinical.com.au