Exam 3 - Aphasia Classifications + Assess./Remediation

Arousal

Continuum in state of consciousness/awareness

Attention

Continuum in ability to focus consciousness/awareness

Perception

Recog. of relevant dimension of sensory stimuli

Memory

Ability to store/retrieve info over varying time periods

Reasoning

Ability to draw conclusions through logical thinking

Neurological basis of Speech, Lg, Cog.

1. Arousal

2. Attention

3. Perception

4. Memory

5. Reasoning

Listening/Aud comprehension

Area #40, 49; Hearing + understanding message

Speaking/Expressive lg.

• Retrieve concept idea + aud. image/word

• Connect circuit

• Program message + word

Neuro-Ling. Model

1. Listening/Aud comprehension

2. Speaking/expressive lg.

3. Speech circuit

Aphasia

Verbal comm + multi-modal disorder caused by cerebral damage

2 Major Aphasia approaches

1. Unidimensional

2. Multidimensional

Unidimensional Approach

• 1 lg. component

• Degree of severity

• 1 therapy type

Multidimensional Approach

• Multiple lg. components

• Dependent on lesion’s size + location

• Diff methods required for diff aphasia types

Alt. Approaches

1. Holistic

2. Localizationist

3. Connectionistic

Expressive aphasia

Damage anteriorly (#44) / Broca’s

• Non fluent

• Verbal difficultly

• Struggles + hesitancies

Receptive aphasia

Posterior lesions / Wernicke’s

• Fluent

• String of words

• Comprehension problems

Broca’s aphasia #44: Comprehension

• Better reception, but not normal

• Predominantly expressive

• Upper ½ of comprehension

Broca’s aphasia #44: Nonfluent

• Slower programming

• Affected, effortful stop + start

• Short sentences

Broca’s aphasia #44: AOS

• Slow initiation

• Slow rate

• Phoneme selection problems

• Poor transitions

Broca’s aphasia #44: Agrammatism

• Telegraphic speech

• Economy of effort

Broca’s aphasia #44: Reading/Writing

• Mirrors oral lg./speech

• Writing least used lg. modalities (and developed last)

• Reading is a translation from visual to aud modality

Broca’s aphasia #44: Poor repetition

• Better imitative behavior

• Apraxia shows with command + imitations

• Real objects improve naming

Broca’s aphasia: Associated problems

1. Emotions - depression

2. Motor - #4 unilateral lesion, arm paralysis

3. No visual problems

4. Oral apraxia #44

5. Limb apraxia #6

Wernicke’s aphasia #22: Description

• Secondary association area

• Linked more to sensory

• Incoming aud stimuli linked to other brain areas

Wernicke’s aphasia: Funcs.

• Fluent, not normal

• Poor comprehension

• Poor reading, writing

• 60+ yrs old

Area #22: Aud. Verbal Comprehension

• Integrated activity of many brain areas

• Semantic problem - can’t attach meaning to what they hear (not a perception problem)

Area #22: Aud. Image Retrieval

• Aka word retrieval problem

• Normal motor skills; fluent sentence length

• Inability to recall previous aud. experience (object/person name)

• Aud. pattern

• When they can’t think of a word, they tell about it

Word/Aud. Image retrieval problems

1. Circumlocution

2. Empty speech

3. Semantic paraphasia

4. Phonemic paraphasia

5. Neologism

6. Jargon(ism)

Circumlocution

Talking about/around a word; Legitimate words used, but never gets to the point

Empty speech

General words that don’t comm. info

Semantic paraphasia

Substituting word in same semantic category

Phonemic paraphasia

Substituting word that resembles target word but not part of our lg.

Neologism

Random/made-up word that doesn’t resemble target word

Jargon(ism)

Continuous sentences/stretches of neologisms

Area #22: Aud. Guidance/Self-monitoring

• Compromise area = speech cannot be regulated

• Unable to self-correct

Wernicke’s aphasia #22: Associated Issues

• No hemiplegia

• Unrealistically happy/euphoric (unaware they don’t make sense)

• Become belligerent, can tell things are wrong as they progress

Conduction aphasia

• Arcuate fasciculus + forwarding aud. image damage

• Less severe Wernicke’s, intact comprehension

• Problem: organizing output

Conduction aphasia: Funcs.

• Good comprehension

• Fluent

• No AOSS

• Difficult repetition

Conduction aphasia: Associated symptoms

• No hemiplegia

• Some bilateral limb apraxia (no hemiplegia to mask it)

• RVF deficit in both eyes

• Optic radiations run deep into cortext

Global aphasia

• Deep lesion in MCA

• Damage to Wernicke’s, Broca’s, AF

• Impairment across all modalities

Global aphasia: Funcs.

• Poor comprehension

• Severely non-fluent

• Poor repetition

• Poor reading, writing

• Concept of what they want to say

• Good non-verbal pragmatics

Transcortical motor aphasia

• Broca’s area cut off at prefrontal cortex

• Ok motor programming, but cut off from motivation/desire to talk

• No AOS

• Nonfluent

• Intact comprehension

• Perfect repetition

Transcortical sensory aphasia

• Wernicke’s area cut off from cortex except speech circuit

• Lesion borders region supplied by MCA + PCA

• Speech fluent, similar to Wernicke’s

• Poor comprehension

• Excellent repetition

Transcortical mixed aphasia

• Nonfluent (limited verbalizations, paraphasia, anomic)

• Poor comprehension

• Good repetition (Echolalic, but not perfect)

Primary progressive aphasia (PPA)

• Not specific diagnosed trauma

• Associated w progressive illness/dementia

• Gradual loss of ability to name objects

Anomic aphasia #39: Funcs.

• Good comprehension

• Fluent

• No neologisms

• Few paraphasias

• Circumlocutions mostly

• No AOS

• Good repetition

• Poor naming word finding in isolation

• Poor cross modal funcs (reading + writing)

Nonfluent aphasias

1. Broca’s

2. Global

3. Transcortical motor

4. Transcortical mixed

Fluent aphasias

1. Wernicke’s

2. Conduction

3. Anomic

4. Transcortical sensory

Nonfluent, Good Comp.

1. Broca’s

2. Transcortical motor

Nonfluent, Bad Comp.

1. Global

2. Transcortical mixed

Nonfluent, Good Comp., +Rep

1. Transcortical motor

Nonfluent, Good Comp., -Rep

1. Broca’s

Nonfluent, Bad Comp., +Rep

1. Transcortical mixed

Nonfluent, Bad Comp., -Rep

1. Global

Fluent, Good Comp.

1. Conduction

2. Anomic

Fluent, Good Comp., +Rep

1. Anomic

Fluent, Good Comp., -Rep

1. Conduction

Fluent, Bad Comp.

1. Wernicke’s

2. Transcortical sensory

Fluent, Bad Comp., +Rep

1. Transcortical sensory

Fluent, Bad Comp., -Rep

1. Wernicke’s

Basic skills in assessment

1. Fluency

2. Aud. Comprehension

3. Repetition

4. Naming

Basic skills in assessment: Fluency

• Spontaneous, pic description

• Speech rate

• Utter length

• Artic. ease

Basic skills in assessment: Aud. Comprehension

• Single words

• Commands

• Paragraph length info

Basic skills in assessment: Repetition

• Word

• Sentence

Basic skills in assessment: Naming

• Confrontation

• Responsive

Prognosis depends on…

• Age of onset (the younger the better)

• Location/lesion size

• Time post onset

• Overall health

• Single vs mult. lesions (mult. strokes = poorer)

• Emotional well-being

• Undetermined factors

Purpose of assessment

1. Diagnosis of presence/syndrome

2. Determine performance level + change

3. Assess assets/liabilities

Assessment areas

1. Receptive lg.

2. Expressive lg.

3. Reading

4. Writing

5. Cog.

Assessment areas: Receptive lg.

• Isolated words (pointing tasks)

• Connected lg. (commands, y/n q’s, complex)

Assessment areas: Expressive lg.

• Naming

  • Obj., confrontational w time, sentence completion

• Repetition

  • Phon., words, phrases, sentences

• Fluency

  • Convo speech, story retell, pic description, procedural discourse

Assessment areas: Reading/Writing

Testing a patient’s:

• Letters

• Words, phrases, sentences

• Simple + complex paragraphs

• Functional

Assessment areas: Cognition

Testing patient’s:

1. LTM - personal q’s, y/n tasks, delayed recall

2. STM - digit/sentence/word repetition, commands

3. Executive func. - generate/plan/monitor goals, problem solving

4. Attention - focused, divided?

Western Aphasia Battery

Tests:

*Reading/writing on separate test

1. Spontaneous speech - convo, pic description

2. Aud. Verbal comp. - y/n q’s, aud word recog., sequential commands

3. Repetition

4. Name/word finding - obj naming, word fluency, sentence completion, responsive

Boston Diagnostic Aphasia Examination (BDAE)

Created by Goodglass + Kaplan; 3 goals:

1. Diagnosis of presence/syndrome

2. Measurement of performance level for baseline

3. Assets/liabilities as therapy guide

BDAE 5 major sections

Tests:

1. Convo speech

2. Aud. Comp.

3. Oral expression

4. Understanding written lg.

5. Writing (includes reading/writing, not separate)

BDAE interpretations

• Severity rating scale analysis

• Rating scale profile of speech characteristics

• Subtest/modalities performance patterns

BDAE strengths

• Comprehensive

• Includes reading, writing, oral apraxia as main body of test

• Standardized

• Scales for measuring qual. speech output

• For neuropsych/neurologists

Other formal assessments

• Boston Naming test

• CADL

• MTDDA

• Burns Right Hemisphere

• Apraxia Battery

• MIT

• AAC

• Cog. Ling. Quick test

Informal assessments

• Lg. Sample

• Vocabulary

• Topic maintenance (prag.)

• Fluency

• Suprasegmentals (intonation, prosody)

• Paraphasias, neologisms

• Voice qual.

• Breath support

• O/M func.

• Hearing

Key Remediation Principles

• Direct to person’s (dis)abilities

• Struct. therapy programs

• Provide feedback

• Show progress

• Direct therapy to “key” deficit areas

Direct treatment approach

Stimulus-Response-Consequence; Focused on specific lg. process

Indirect treatment approach

Unstructured, conversational (prag., word-finding)

Treatment hierarchies

1. Length + complexity

2. Cuing levels

3. Items

Treatment hierarchies: Length + complexity

• Simple → complex

• Concrete (literal) → Ideas (abstract)

Treatment hierarchies: Cuing levels

Verbal, visual, tactile

Treatment hierarchies: Items

Expressive + receptive

Struct. Evidence Based Treatment Protocols

• Semantic Feature Analysis

• Verbal Network Strengthening Treatment for Aphasia

• Phonomotor therapy

• Rosenbeck’s 8 Step Continuum of Apraxia

• MIT

Setting for Assessment/Remediation

• Functional

• 3-5 sessions/wk depending on severity + needs

• 30-60min sessions

• Warm up, introduce new tasks, cool down

• Timing (find good time for therapy)

• Plan for progression (where do I want them to be before discharge?)