Causes of Acquired BI

• Cerebrovascular Accident (CVA) - stroke

  • Embolus - a moving clot from another part of the body that lodges in the artery

  • Thrombosis - when an artery has gradually filled in with plaque

  • Both types result in the closing of an artery to the brain which lead to the deprivation of oxygen (anoxia)

• Transient Ischemic Attack (TIA) - a temporary closing of the artery with symptoms that disappear within 24 hours (may precede a stroke); may be a smaller stroke

• Hemorrhages - another type of stroke, bleeding in the brain

• Aneurysm - weakening of an artery that bulges and eventually breaks, interrupting blood flow to tissues fed by that artery

• Effects of a stroke are immediate

• Result of edema (swelling of brain tissue)

• Spontaneous recovery - recovery of function associated with a reduction in edema

• Recovery is better if the brain damage is small and the stroke occurs at a young age

Causes of Traumatic BI

• Open/closed brain injury

  • Open brain injury - skull is opened; ex. gunshot wound

  • Closed brain injury - brain movement; ex. whiplash

• Contusions - bruises on the surface of the brain

• Lacerations - tearing of structures and blood vessels

• Diffuse axonal injury - damage to nerve cells in the connecting fibers of the brain

• Intracerebral - damage within the brain

• Meninges - tissue covering the brain

• Hematoma - areas of encapsulated blood

• Range from mild to severe depending on the force of the impact and the amount of brain tissue affected

• Diffuse/localized

• Greater the damage, more cognitive/language/speech/swallowing skills will be affected

Causes of BI

• Neoplasms (new growths) and tumors can occur within the interior of the brain or on the surface within the tissue coverings

• Can cause destruction of brain tissue and increased pressure in the brain

• Tumors can be fast or slow growing

• Final cause of BI is progressive deterioration of brain functions, gradual loss of brain cells resulting in brain atrophy

• Alzheimer’s dementia makes up 70% of the cases of dementia

  • Degeneration of neurons

  • Accumulation of amyloid plaques

  • Tangles (twisted stands of proteins)

Aphasia

• Aphasia is a language disorder caused by left hemisphere damage, typically resulting from a stroke

  • Auditory comprehension

  • Verbal expression

  • Reading

  • Writing

Classifications of Aphasia

• Clinicians use the patterns of strengths and weaknesses in the areas of communication to classify the type of aphasia

• Evaluate the following skills:

  • Naming

  • Fluency

  • Auditory Comprehension

  • Repetition

  • Sentence Formation and Production

Naming

• Naming - is the process of knowing and retrieving the label for an object

  • Parts of naming: “BOOK”

    • Access the conceptual store that identifies the item as something with a cover, lots of pages, and that you read

    • Identify a semantic label (vocabulary word) that best fits the concept that you established, “book”

    • Develop a phonological form for the label /b/ /oo/  /k/

• Naming Errors:

  • Individual may have no awareness that it is not meaningful to the listener

  • Neologisms - are new words “gabot” for “table”

  • Semantic paraphasia - lion for tiger

  • Phonemic paraphasia - gable for cable

  • Circumlocutions - describe the characteristics of the item, how it is used, and in what circumstances, but cannot name it

• Failure to name does not provide information on why the task cannot be carried out

• Naming deficits are a universally expected feature of aphasia regardless of lesion site

Fluency

• Fluent aphasia: patients present with an overall ease of speaking, normal length and rate, and adequate melody (posterior brain lesions -- Wernicke’s Area)

• fluent aphasia Wernicke’s aphasia tactus

• Nonfluent aphasia: is characterized by effort, a slow rate, and abnormal pauses (anterior brain lesions -- Broca’s Area)

• Broca’s aphasia nonfluent aphasia tactus

Auditory Comprehension

• Is the ability to understand spoken language

• Includes:

  • Segmenting the sounds heard into meaningful phonemes

  • Understanding the meaning of the words within the sentence

  • Retaining the message in memory long enough to understand it and form a response

• Clinicians assess auditory comprehension by asking questions, making statements, or giving commands to which the individual must respond

• “Point to the door”

• “Does a stone float?”

Repetition

• Repetition of words and phrases assesses the integrity of connecting pathways (Arcuate fasciculus) between Wernicke’s area and Broca’s area

• Asked to repeat:

  • Hear the phrase (Wernicke’s area)

  • Organize the output for repetition (Broca’s area)

  • Arcuate fasciculus has damage an individual will have marked difficulty repeating words, but minimal difficulty with auditory comprehension, or fluency

Sentence Formulation and Production

• Impairments in sentence production vary from omission of verbs, incorrect ordering of words, or omission of function words such as articles, prepositions, and conjunctions

• These errors in sentence production are called agrammatism

• Telegraphic communication - Mom. Boy. Fall. Water. Uh-oh. Floor.

Classification of Aphasia

A significant portion of the aphasic population (25%) cannot be reliably assigned to a specific category because their disorder includes patterns that are indicative of more than one type of aphasia

Broca’s Aphasia

• Damage to Broca’s area

• Nonfluent, effortful speech and agrammatism

• Oral expression is slow with short sentences that contain mostly content words (subjects/verbs)

• Function words are omitted (in, on, the, is)

• Aware of their struggle to speak

• Repeated efforts to correct their errors

• Auditory comprehension is relative intact, although not entirely spared

Wernicke’s Aphasia

• Damage to Wernicke’s area

• Deficits in auditory comprehension

• Fluent oral expression

• Speech output has normal intonation and stress

• Speech production is filled with verbal paraphasias (mixing up sounds in words) and neologisms (making up new words)

• Speech sounds like jargon

• “empty” - lots of words, no clear meaning

• Show little obvious concern

• Reading and writing abilities are significantly impaired

• Repetition is impaired

• May have automatic sentence starters “in my opinion” but struggle with content words

Conduction Aphasia

• Damage to the pathways (arcuate fasciculus) that connect Broca’s area to Wernicke’s area

• Decreased repetition (most cannot)

• Oral expression is fluent but includes frequent paraphasias (take-cake)

• Oral and written language is a relative strength

• Often tries to correct their phonemic errors by saying the word repeatedly

• REEL- Example Conduction Aphasia 1

Anomic Aphasia

• Anomia = “without words”

• Difficulty in retrieving the names of objects, pictures, and concepts

• Auditory comprehension, verbal expression, and repetition are otherwise relatively unimpaired

• Marked absence of nouns in conversation

• Produce paraphasias, and circumlocutions

Global Aphasia

• All parts of language processing are severely impaired

• Nonfluent verbal expression

• Poor auditory comprehension

• Difficulty repeating words

• Nonmeaningful gestures

• May repeat the same word/syllable over and over - Perseverative speech

• Mom May 27, 2017 (global aphasia)

Assessment and Diagnosis of Aphasia

• Recovery from brain damage

• “spontaneous recovery” significant changes which occur from day to day as the nervous system recovers

• Communication during spontaneous recovery is variable and affected by fatigue, medical complications, and medication

Recovery from Brain Damage

• Comprehensive Aphasia Batteries

  • Boston Diagnostic Aphasia Examination - several hour examination for research

  • Porch Index of Communicative Ability (PICA) - functional communication and abilities

  • Western Aphasia Battery - most used in clinics

    • Classifies the type of aphasia; looks at content, fluency, auditory comprehension, repetition and naming, reading, writing; may do some drawing, basic math, block design, and praxis tests

• Each contain batteries that assess reading, writing, auditory comprehension, naming, and other language tasks

• Also assess functional communication skills or the ability to communicate meaning in familiar contexts regardless of the quality of the spoken language

• Functional Communication Profile - Used to estimate the individual’s ability to communicate in everyday situations; 6-9 months post injury with communication difficulties

• Communicative Abilities in Daily Living (CADL) - Used to estimate the individual’s ability to communicate in everyday situations; 6-9 months post injury with communication difficulties

• Hemiplegia - Muscle weakness or paralysis on the opposite side of the body than the brain damage

• Visual difficulties - may just need glasses; visual field cuts (black areas); visual neglect (will know the other side is there but do not see/perceive it)

• Cognitive deficits - decreased attention and decreased memory

The Treatment of Aphasia

• Initial goal is to provide the patient with a reliable communication system

• This may be single words/gestures/AAC (verbally app, touch chat (learn to generate sentences), or one symbol = one sentence, etc.)

Treatment Approaches for Aphasia

• 2 primary goals:

  • Reducing language deficits

  • Developing compensatory strategies

• Constraint Induced Language Therapy (CILT)

  • Focus on verbal expression (3-4 hours of treatment for several weeks) through a series of word games and activities coupled with restrictions on alternative modalities of expression

  • CIAT_aphasia.mov

• Supported Communication for Aphasia (SCA)

  • Focuses on training conversational partners

  • Trained partners act as a ramp to access participation in daily interactions for individuals with aphasia

• Group Therapy

  • Practicing communication skills in a nonthreatening and supportive community

Right Hemisphere Communication Deficits

• Left hemisphere: form (grammar, syntax) and content (vocabulary, semantics)

• Right hemisphere: use (pragmatics, social communication)

• Social communication includes:

  • Interpret emotion

  • Facial expressions

  • Changes in intonation (prosody)

• Right hemisphere seems to be involved in the ability to produce the “big picture” from the details

• People with right hemisphere damage see the details but are unable to understand the broader meaning they represent

  • Sees the tree and kite over the man flying it and family eating under it

• Difficulty understanding figurative language and humor

  • Thinks people are laughing at them because they do not understand the joke

• Narration and discourse are marked by an overabundance of detailed information, with some not being relevant to the topic

• “Talks too much”

• Stories are poorly organized, inability to isolate the most important facts

• Decreased topic maintenance

• Deficits in turn taking

• There are multiple cognitive, motor, and sensory problems following right hemisphere damage

• Lack of awareness (anosognosia)

  • May not believe that their left leg isn’t working and try to get up then fall

• Reduced insight into how deficits affect everyday life

  • More likely to accept and understand physical deficits over cognitive deficits

• Poor navigational abilities (gets lost)

• Sensory neglect: reduced responsiveness to visual, auditory, and tactile information presented from the left side

• Difficulty recognizing faces

• Assessment:

  • Attention

  • Memory

  • Spatial orientation

  • Emotional processing

  • Prosody

  • Inference

  • Discourse comprehension

    • Discourse - multiple sentences put together

  • Naming

  • Production

• Right Hemisphere Language Battery

Brain Trauma

• Neurological damage caused by injury to the brain from motor vehicle accidents (MVA), falls, blast trauma, etc.

• Damage to multiple areas of the brain as well as connecting fibers within the brain

• Damage is diffuse (multiple parts of the brain is effected), multiple motor, speech, language, and cognitive functions may be impaired

• Majority of symptoms are related to disrupted cognitive processes

• Effects of BI disrupts

  • Orientation - Who you are? Where are you? What time is it? Why are you here?

  • Attention

  • Memory

  • Processing - how quickly someone understands

  • Executive function - planning, initiation, etc.

• Over time, these problems resolve, but even with rehabilitation, there are often lasting deficits

• Range: mild-severe

Assessment

• Scales of Cognitive Abilities for TBI (SCATBI)

• Assesses orientation, reasoning, organization, recall and perception

• Treatment for TBI focuses on the deficits revealed from the assessment

• External memory aids, problem solving strategies

Special Issues in TBI

• Improvised explosive devices (IEDs) used in Iraq and Afghanistan have resulted in TBI to soldiers

• Large atmospheric pressure changes from the explosive blast

• Pressure waves move through body tissues

• PTSD

• Problems: chronic headache, emotional and behavioral changes, disorganization, deficits in memory, judgement, and attention

Sports Concussion

• Concussion are short term periods of confusion and loss of memory following injury to the head

• Symptoms resolve after a period of rest when sensory stimulation is minimized

• Repeated exposure may result in progressive degenerative disease

• Baseline cognitive behavior, monitor changes resulting from concussions

• Advising athletes when to return to practice

Dementia

• Dementia is a deterioration of cognitive and language abilities resulting from progressive degeneration of the brain

• Causes: heredity, vascular disease, viruses, unknown factors

• Symptoms include: memory deficits, changes in personality, orientation (person, place, time, situation) problems, episodes of confusion

• Early stages: word finding difficulties, reduced ability to comprehend new information, drift from the topic, grammar is intact

• Middle stages: vocabulary is noticeably diminished, difficulty comprehending grammatically complex sentences, express ideas with little sensitivity to the communication partner, fail to correct errors

• Late stages: severe anomia (no word finding), jargon, sentence fragments, meaningless content, dependent on assistance for most self-help skills

• Arizona Battery for Communication Disorders in Dementia (ABCD)

• Naming, oral description of objects

• Normative data for normal older individuals and individuals with dementia

• Intervention:

  • Changing communication environments, counseling caregivers, and group therapy

  • Reminiscence therapy

  • Spaced retrieval training

• Goal:

  • Strengthen residual cognitive abilities

  • Reduce demand on impaired functions

    • ex. putting a picture of their home door over their hospital door

  • Increase life satisfaction for the patient