Speech and communication are complex functions we take for granted until something goes amiss. After a stroke or brain injury, the level of impairment may range from minor to severe, and it is not uncommon for multiple aspects of communication to be impaired. Just 10% of people will fully recover, 25% will have a minor impairment, and 40% will have a moderate impairment—daunting statistics. To varying degrees, individuals can learn strategies to speak and communicate again. Matt was one of these statistics, but there was no way to predict where on the prognostic spectrum he would fall, and it didn’t look good. Most of his brain swelling had been in the region that controls language skills, and the permanent damage was unknown.

Establishing a means of communicating a yes/no response was essential. Despite best efforts, early attempts to encourage Matt to mouth the words, shake his head, or make thumbs-up and thumbs-down gestures proved unsuccessful. Not until early June did he occasionally select a yes/no card, once indicating yes that he wanted to go outside but no that he didn’t want to play the piano.

As time permitted and he was able, the speech therapists attended to Matt’s memory loss and cognitive deficits—it was a juggling act of priorities. In one session, she worked on object and word identification. When given pictures of two objects (e.g., a shirt and pants), he selected the requested item 75% of the time and did even better pointing to a desired number from 1 to 10.

The therapist continued to monitor and address Matt’s swallowing disorder. Eventually, when offered ice chips, Matt began to move them slowly around in his mouth, chew, and swallow them. A swallow study or videofluoroscopy was ordered to evaluate the anatomy and movement of food and liquids through the mouth, throat, and esophagus to assess if he was ready to eat actual food and what consistency was safe. Up to now, he was being fed through a tube inserted into his stomach. His first nourishment by mouth in seven weeks was three bites of applesauce. It didn’t come naturally. The therapist had to verbally encourage and externally massage his throat to trigger a swallow response. His progress was measured by the spoonful, the quality of movement of the applesauce in his mouth (no hard food or water yet), and the number of successful swallows. By degrees, he was able to sip thickened water without choking or worse. Finally, on June 13th, Matt greedily ate two graham crackers without choking, attesting to the old adage that slow and steady wins the race.

Having successfully eaten two graham crackers as a snack, the speech therapist developed a diet plan to introduce soft foods and liquids. Initially, she sat with him throughout lunch, closely monitoring his swallowing and frequency of choking to avoid aspiration, especially with liquids. A thickening agent was added to milk and juice because it was too risky otherwise. Once deemed safe, Matt progressed to three meals a day, and semi-solid foods were introduced cautiously. Matt ate SO slowly—ridiculously slow, slower than a snail’s pace—taking a whole hour to finish a meal. Time was consumed manipulating the fork, attempting to scoop a bite, raising it to his mouth—or maybe not. He’d lift the fork, with or without food on it, contemplate opening his mouth or not, lower and raise the fork again, or place it back down on the plate with the food untouched. It was mind-boggling—two or three cycles of this for every successful bite. Words of coaxing or encouragement had no effect. It was a tedious assignment to monitor him for the hour it took to finish his lunch, and it took away from my therapy time. Thank goodness, with practice, in a week, he did better and cleared his plate in 40 minutes and the following week in 30 minutes. Phew. The nurses anticipated that once Matt could take medicines crushed in applesauce, the feeding tube would be obsolete and removed—yet another milestone to check off a long to-do list.