President’s forum on International Health.
07 October 2009
Slavically Speaking:
Treating Communication Disorders in
Poland
by
James Dembowski
TTUHSC Department of Speech Language
Hearing Sciences
Goal:
“What I did on my summer non-vacation.”
• Report on a series of visits to…
• Clinics and clinicians specializing in the
treatment of adult communication
disorders
• Poland, July 2009
Acknowledgements
• Emilia Sitek
Medical University of Gdansk, Dpt. of Neurological and Psychiatric Nursing, Gdansk
St. Adalbert Hospital, Dpt.of Neurology, Gdansk
• Joanna Seniow, Ph. D.
Institute of Psychiatry and Neurology, Warsaw
• Agata Szkielkowska, MD, Ph.D.
• Joanna Ratynska, MD, Ph.D.
• Kinga Wolujewicz
Institute of Physiology & Pathology of Hearing, Audiology and Phoniatrics Clinic, Warsaw
• Danuta Kadzielawa, Ph. D.
University of Warsaw
• Hanna Ulatowska
University of Texas at Dallas
About Poland…
Eastern Europe, bordered by Russia, Lithuania, Belarus, Ukraine,
Slovakia, Czech Republic, Germany
312,000 sq. kilometers (121,000 sq. miles)
Texas: 696,000 sq. kilometers (269,000 sq. miles)
Presentation outline:
• Division of labor in Polish treatment of
communication disorders
• Studying stroke and related disorders
• Two model rehabilitation institutes
(language & cognition; speech & voice)
• Provocative questions & issues
Division of Labor
Division of labor: Logopedists
• In the U.S.,communication disorders in
adults and children are treated by the
speech-language pathologist (SLP).
• In Poland, the correlate of the SLP is the
“logopedist”…
– Treats childhood speech disorders
(articulation, stuttering)
– Works in schools, associated w/ special ed.
– Brief post-undergrad evening/weekend
training
– New 5-year post-H.S. academic program
Division of labor: neuropsychologists
• Neuropsychologists
• Treat adults w/ neurogenic
disorders
• Assessment & treatment of
language & cognition
• Generally not involved in motor
speech disorders
Division of labor: neuropsychologists
• Neuropsychologists
• Training:
–5 years college
–Minimum 1 year clinical patient
contact
–5 years post-graduate study
–Summative exam
–Thesis
Division of labor: otolaryngologists (ENTs)
• Otolaryngologists (ENTs)
• Treat adult speech & voice
disorders (vocal nodules,
stuttering, dysarthria and other
motor speech disorders)
• Do behavioral therapy (e.g., vocal
hygiene) in addition to surgery,
pharmacological therapy
Stroke and Related
Neurological Disorders
Stroke
• POLKARD Neurologia
• Polish National Stroke Prevention
and Treatment Registry
• Associated with
–National Program for Prevention
of Cardiovascular Disease
Stroke
• POLKARD Neurologia
• Modeled on…
– Swedish Stroke Registry
– European Union “Heart Plan for Europe”
– WHO 2006 Helsingborg Declaration on stroke
management
• 85 Medical centers
– Contribute data
– Provide education
Stroke
• POLKARD
• Established in response to
dramatic increase in
cardiovascular disease, late 20th
century
• Among highest stroke mortality
rates in Europe
Stroke
• POLKARD
• Katowice
–Major mining center of Poland
–“miners were the aristocracy of
the workers”
–Highest prevalence of
cardiovascular disease
–Chief center of heart transplants
Stroke
• POLKARD
• Tracks
Stroke related….
–Hospital admissions
–Morbidity & mortality rates
–Risk factors
–Treatment types
–Outcomes
Stroke
2001
2007
Risk factors
Blood pressure 69%
Smoking
21%
73%
13%
Treatments
Statins
Anticoagulants
Hospitalization
Mortality
11.6%
9.5%
36.4%
10.8%
13.4 days
12.1 days
15.2%
12.5%
“Poor
outcome”
57.5%
56.9%
Outcomes
Model Rehabilitation Institutes
Institute of Psychiatry &
Neurology (Warsaw)
Institute of the Physiology and
Pathology of Hearing (Warsaw)
Inst. Psychiatry and Neurology
• Institute of Psychiatry & Neurology
• Major institute for study and treatment of
psychiatric and neurologic diseases
• Inpatient & outpatient
• Addresses stroke, trauma, stable focal
infarcts
• Does NOT address (generally)
– Degenerative diseases
– Speech motor control disorders
Inst. Psychiatry & Neurology
• Nine person neuro- team
• Dr. Joanna Seniow (head;
neuropsychologist)
• 2 additional neuropsychologists
• 1 MD neurologist
• 1 (atypical) logopedist (w/ advanced
training)
• Graduate students, technicians
Inst. Psychiatry & neurology
• Combined rehabilitation facility
and laboratory
Inst. Psychiatry & neurology
• Laboratory focus
–Attention deficits in language
impairment (aphasia)
–Differential attention deficits
(focused, divided, sustained…)
–Differentially influence
communication
–Differentially treatable
Inst. Psychiatry & neurology
• Laboratory focus
• Hypothesis:
– Attention (a psychological condition), along
with neurologic post-stroke repair processes,
may be related to degree of arousal (a
neurophysiologic condition)
Inst. Psychiatry & neurology
•
•
•
•
Laboratory focus
Large N
Double blind study of…
Non-invasive transcranial magnetic
stimulation
• To increase arousal and attention
• And facilitate natural self-repair processes
Inst. Psychiatry & neurology
• Treatment focus
–Language (aphasia),
cognition, attention deficits,
memory, executive function,
general programming and
control
Inst. Psychiatry & neurology
• Aphasia treatment in Poland…
• Derives from the work of Alexander Luria
(1902 – 1977)
– Soviet neuropsychologist
– Socio-political connection to Poland (’40s –
80s)
– Luria’s approach to language analysis &
disorder well suited to highly inflected Slavic
languages (?)
Inst. Psychiatry & neurology
• Aphasia treatment…
• Influence shift from Russia to…
– Great Britain, Scandinavia, Germany, Austria
• U.S. influence…
– Not theoretical
– Limited to selected psychometric testing
procedures
– Boston Diagnostic Aphasia Exam has been
translated into Polish; WAB has not.
Inst. Psychiatry & neurology
• Aphasia treatment (and related neurocognitive disorders, e.g. TBI)…
• Increasingly incorporate commercially
produced computer programs
• Developed with help from POLKARD
• Justification…
– Allows more patients to be treated, because…
– Patients can work independently
– (Not everyone agrees… see E.S.)
Inst. of physiology & pathology of hearing
• Instytutu Fizjologii I Pathologii Sluchu
• Institute of the physiology and pathology of
hearing
• International center of hearing and speech
• State of the art medical facility for hearing
and speech
• Specializes in cochlear implants
• Bioimaging Reseach Center includes fMRI
and electro-phys data collection
Inst phys & path of hearing
• Institute of physiology & pathology of
hearing
• Staffed primarily with ENTs
• 40 – 50 surgical procedures per day
• 40 – 60 cochlear implants per month
• Approx 500 pts implanted in 2008
• Over 12000 admissions yearly
• Onsite & offsite support & follow-up
Inst physiology & pathology of hearing
• Institute of physiology and pathology of
hearing
• Funding chiefly through national health
system
• Pts eligible and appropriate for CI are
covered by national health plan
• Includes inpatient and outpatient hospital
facilities… and…
• Classroom facilities for rehab with CI
children
Inst physiology and pathology of hearing
• Institute of physiology and pathology of
hearing
• Chief focus is hearing and CI… but…
• Staff also treats the range of voice &
speech disorders…
• Including functional and organic
disorders…
• Treatments include behavioral, surgical
and pharmacological approaches
summary
Summary
Contrasts between U.S. and Polish
(European) approaches to
communication disorders.
summary
• Summary:
• Developmental speech disorders are
treated by logopedists (speech therapists),
trained according to an educational model.
summary
• Summary
• Language & cognition disorders in adults
are treated by neuropsychologists
• Speech & voice disorders in adults are
treated by ENTs
• Training for both follows a medical model
• Training substantially exceeds that of
logopedists
summary
• Summary
• Treatment for adult disorders is delivered
by personnel whose training closely
matches that of physicians
summary
• “The person who treats neurogenically
involved adults should know a lot about
the diseases which cause speechlanguage disorders. They should know
etiology. If you do not understand these
diseases, you cannot be a partner to
physicians. You must be good enough to
be accepted and respected by physicians.”
(J. Seniow)
Provocative questions and
issues
Questions & issues
• Dr. Seniow does not support rehabilitation
efforts for degenerative diseases (e.g.,
progressive aphasia in Pick’s Disease).
• “When degeneration is faster than
behavioral therapeutic success, what’s the
point? We cannot ignore biological reality.”
• Support may be appropriate; rehab is not,
and support is not the job of the rehab
specialist
Questions & issues
• What is the role of treatment intensity in
delivery of therapeutic services?
• In Poland, treatment is often delivered on
an almost daily basis until goals are met,
or pt. is unable to make further progress.
• Treatment of, say, 1 hr/weekly is
considered not efficacious, and an
inappropriate use of resources.
Questions & issues
• Hospital departments are often paid (by
the national health plan or by private
insurers) according to diagnostic and
assessment procedures they perform.
• Thus…”choices are determined by which
procedures are most profitable for the
hospital.” (E. Sitek)
• Sound familiar?
Questions & issues
• “Activists and policy makers spend an inordinate
amount of time arguing about whether the
solution to high medical costs is to have
government or private insurance companies
write the checks… These arguments miss the
main issue. When it comes to making care
better and cheaper, changing who pays the
doctor will make no… difference[.] The lesson of
the high-quality, low-cost communities is that
someone has to be accountable for the quality of
care.” (Atul Gawande, New Yorker, June 1,
2009)
Questions & issues
• “Now, around the world, health
care is a product to be sold to
those best able to afford it. In this
sense, the distribution of health
care can never be fair. Is there
any way to change this? I don’t
think so.” (J. Seniow)
Thank You!