On a recent neurology prac I was working with a lovely patient who had a L MCA stroke rendering him expressively aphasic among other things. At first there was some receptive aphasia too, but that quickly resolved so he could understand perfectly well but speech was minimal. Initially he was unable to verbalize at all, but could phonate to command (ie repeat kaka, gaga...) After 2 weeks he was still unable to form sentences but could respond to questions where options were given, and occasionally when they weren't. Having to spend 2hrs a day for 3 weeks with someone who can't speak, I had to employ some strategies to enhance assessment and communication. I thought these might come in handy for anyone who encounters a similar patient.

• Patience, patience, patience. If you get frustrated (or can't hide frustration) the patient would become more frustrated or self conscious. These emotions detract from the task making speech harder... similar to us in an OSPE if an examiner fired questions at you faster than you can respond.
• Open questions are a waste of time. If someone can't form a sentence, closed questions are the only option when an answer is required eg during Ax (as opposed to speech exercises)
• No stroke patient would like being talked to as though they're stupid. It is possible to simplify language &/or talk slower without sounding condescending if you consciously try. In this example, 'dumbed down' speech would have been totally inappropriate and annoying for the patient (once the receptive aphasia disappeared).
• Extra checks can help you determine whether aphasia is influencing the Ax results eg for light touch localisation, practise with eyes open first.
• Non-verbal response options to Ax questions include: thumbs up/down (good for joint position sense); smile/frown (good for sharp blunt or shoulder pain screening)
• Try not to feel awkward with silence. Occasional silent times give the patient a chance to relax and is probably as important for cognitive rest as sitting down after gait retraining.
• Think about what you say before it comes out to ensure that there's an easy way for the patient to answer it
• Ask one question at a time
• Everything requires more concentration post-stroke so don't attempt multi-tasking when both tasks are hard eg UL facilitation + conversation
• Minimize background noise and distraction
• Put in as much effort to develop rapport as you would with any other patient. After 3 weeks I actually felt like I knew this guy quite well. I was surprised at how few words are needed for quality conversation.
• Liaison with the speech therapist equipped me with lots more tactics that I wasn't aware of before, eg
• Practising automatic language like the alphabet, counting, days of the week...
  
• Finishing doubles eg hot and... (cold), light and... (dark)
  
• Naming objects nearby
  
• Giving options in closed questions eg are you from Australia or overseas? rather than 'what country are you from?'
• These were useful to practice during breaks from physical tasks. As the speech therapist was unable to see the patient everyday, our input in this area could be invaluable.

I'm sure lots of these ideas were already common sense to everyone, but hopefully there are some new ones too.