Aphasia Notes

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Aphasia Notes

• Test III
• Athena Hagerty

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• General Info about Treatment
• Working with Adults you can tell them what they
  are doing and why. You can provide concrete
  feedback to your patient. Telling the person what
  they are doing a great job at. You can provide
  feedback for errors. That wasnt a good way to
  say that, tell me again. Progress is its own
  reward. Instead of planning for kiddos, adults
  are happy for therapy, you dont have to give
  them a sticker.

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• General Info about Treatment
• Planning for treatment- dont take hours, do it
  easily and its cheap or free for therapy. Free
  newspapers from Dubois. Clinic has a laminator.
  Paper, pencil and you can do therapy

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Generalization

• Loose training- you should consider stimulus
  items that elicit a variety of acceptable
  responses. 1 cup for multiple things 
• Sequential modification- treat in different
  environments and diff. contexts.
• Does Treatment Work?
• Aphasia therapy work? YES. But It needs very good
  guidance from the clinician. Dont do workbook
  stuff. If they dont need you, they shouldnt be
  in therapy. Computer programs are bad. Group
  therapy also WORKS. Evidence behind it. More
  support by other patients. Maintaining skills.

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Goals of Aphasia Therapy

• Empowering the patient- you teach them skills
  that they can use.
• Communicative Competence- the person can
  communicate in ANY context. If you can do this
  with patient you are a successful SLP. 
• Who receives treatment?- Initially everyone who
  has aphasia should receive treatment.
• Prognosis- there are some people with really poor
  prognosis severe Wernickes, severe global,
  after 3 months following injury. If nothing
  changes after 3 months thats bad.

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• Group therapy- if its available, patient should
  participate.
• Evaluation of cognition- you can evaluate
  cognition as the person improves IF the
  neruopsych is good at evaluation.
• Neuropsych needs to be experienced.

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Treatment of Auditory Comp.

• Bottom up model- patient is analyzing sounds to
  make sense of info. Repeating plate over and over
  again to make sense of it.
• Top down model- begins with an expectation about
  the the speaker will say. Either confirm or
  change the action depending on the production.
  Ex- youre walking and see a friend hows it
  going? They say not so good, you keep walking,
  see you later then go back and ask them what up.

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Treatment of Auditory Comp.

• Knowledge based/heuristic process-
• general knowledge and intuition to deduce meaning
  of spoken information.
• what to expect when you are ordering at a
  restaurant.

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Treatment of Auditory Comp.

• Point to/ show me
• Y/N questions
• Wh- questions/tell me (simple or complex) what is
  your name? where are you? Does it snow in July?
  Do you use an axe to cut the grass?
• Following Directions (1-3) can increase up to
  three steps. (WM component)
• Sentence verification- person has to listen to
  sentence and tell if its true or false. Can make
  it difficult my adding fake words.

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Treatment of Auditory Comp.

• Task switching activities-
• Discourse comprehension can they actually
  answer questions?
• Familiar- if its familiar it will be easier.
• Length redundancy-

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Goal Writing

• Long term goal- 3 components to a goal- every
  supervisor requires these 3 things.
• Performancemeasure
• Condition- type of cues you are using
• Criteria percentage or trials

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Treatment of Auditory Comp.

• Aud comp long term goal- will vary from facility
  to facility. Determine goal by hierarchy. End
  point to whatever facility your in. where we want
  to get the patient eventually.
• ST Goals- small steps to get to the long term
  goal. Baby step to get to long term goal. Point
  to show me/ y/n
• Biggest LT goal- to comprehend conversation. Ask
  questions during conversation and keep track of
  answers.
• Ex- patient. Moderate aud comp deficits. Are long
  term goal would be for academic year. ST-
  semester. Complex y/n questions.

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CUES

• Cues- extra help
•  
• Verbal- explaining or repeating
• Phonemic- its a K for key.
• Visual
• Pointing
• Gestures
• Written
• Tactile (touch)- holding their hand. Giving them
  something to feel or touch.

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Percentages

• Maximum moderate minimum assistance.
• Dr Isaki doesnt like these terms. Doesnt like
  3 out of 4 trials. Likes percentages better.
• Mild- 90 of time can do tasks.
• Moderate-80 of time
• Severe-70 of time
• Try and shoot for 20 (increase) of time.
• Global aphasia- 30 of time correct- yes you can
  get them to 50 of the time.
• Normal is not 80 of the time. You can write a
  goal for 100 of time if you think you can do it.
  Because they were capable before the CVA.
• If client hits goal 3 times, you then need to
  review to goals and revise them.

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Goal for Auditory Comp.

• GOAL for this client- client will answer complex
  yes/no question with 95 accuracy given verbal
  cues. In my methods verbal cues means repetition
  of questions.
• Client will follow 3 step commands with 95
  accuracy given visual cues. Visual cues may be
  pointing to item

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Expressive language Treatment

• Content Words (nouns more important for Global)
• Enhance with nonverbal communication (can live
  w/out articles adverbs)
• Increase length complexity- Sub, Verb, Obj
• Picture Description- take a picture from the
  newspaper (Norman Rockwell pics)
• Storytelling retelling
• Conversation- most difficult
• If you improve anomia, you will improve
  expressive language

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Reading Comprehension Tx. (deficits)

• Reading glasses? Do they have glasses?
• Surface Dyslexia? Lost direct lexical route and
  now dependent on phonological route. Ex- sound by
  sound or letter by letter.
• Deep dyslexia- you have lost phonological route,
  now youre dependent on whole word recognition.

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Reading Comprehension Tx. (deficits)

• Letters- can they identify a letter?
• Words to pics- matching words to pics
• Phrase to pics
• Sentence- written questions or matching to pics
• Paragraph- written questions, 2 sentences, then
  3, short stories
• Survival Reading (6th grade level) menu,
  telephone book

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Anomic Tx.

• Anomia looks like
• Pauses
• Fillers uh, um
• I dont know
• Ineffective gestures (waving during conversation)

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Anomic Tx. Suggestions for therapy

• Naming (Rosenbek,Lapointe Wertz) Choose at
  least 3 strategies
• Semantic description- start describing its
  attributes, formulate descriptors to pull out.
  Cat furry meow.
• Embedding- (good for anomic aphasia) formulate
  your own sentence, embed the word within the
  sentence. CupYou use a _____ for drinking.
• Synonyms- works for high functioning
• Antonyms- not every word has an antonym

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Anomic Tx. Suggestions for therapy

• Rhyming- cat bat- looking at things that
  rhyme to get word.
• Sentence completion- high functioning anomic,
  conduction. You drink from a _____.
• Phonemic cues- weird strategy. Everyone around
  patient uses the prompt You drink from a c____.
• Writing- if you cant think of a word, cant
  write it.
• Gestures- depends on persons vocab, for high
  functioning patient
• Drawing- depends on persons vocab, for high
  functioning patient

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Anomic Tx. Suggestions for therapy

• Once you DO get word
• practice for a couple of trials (recommend 3).
• Also practice at the end of session.

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Format (Brookshire)

• Hello- (only 5 minutes) where you catch up with
  your patient. How was your week? Etc.
• Accommodation- we are going to work on easier
  tasks first.
• Work- where you concentrate on more difficult
  tasks.
• Cool down- more easier tasks so they can feel
  good about their performance.
• Goodbye- reviewing entire session and progress
  they were able to show. Summarize abilities

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Resource Allocation

• Central Pool- a way to think about how your
  therapy is affecting your client, analyze
  performance. Can pull out all sorts of language
  abilities and cognitive processes.
• Depends on the demands of the task, you can pull
  out too many processes from the central pool. If
  this happens, the client will fail.
• Reduce processes if client fails.
• Environment can affect performance (noisy, busy,
  etc.) SIMPLIFY environment
• Dr Isaki said to change rooms if the room youre
  in is too noisy.

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Resource Allocation
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Goals of Aphasia Therapy

• 1) want patient to regain as much comm as
  possible as much as their injury allows and their
  needs drive them.
• 2) teach them to compensate for the skills that
  they lack.
• 3) teach them to be in harmony with their lives.

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Preparing someone for lifetime of Aphasia

• 1) remember to give fair assessments of prognosis
  (dont use word normal)
• 2) stress the importance of what remains.
  (everyone has skills)
• 3) Aphasia is a human disorder meaning it not
  only affects language, but a persons life and
  relationship to others. Patients are unchanged at
  the core.

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Preparing someone for lifetime of Aphasia

• 4. Never forget you are treating a PERSON w/
  Aphasia. Try to resist being everything to the
  patient.
• 5. Learn to be a good listener. Well hear all
  types of info. We have boundaries in our
  profession, refer out as needed.
• 6. Have to trust our patients that they are going
  to survive and cope and life

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Preparing someone for lifetime of Aphasia

• 7. We are going to be counseling for comm
  disorders (not depression). Teach them about
  Aphasia and words we use. National Aphasia Assoc.
  has great paperwork.
• LISTENING IS IMPORTANT. Silence is OK. Wait for
  them to say something. Shouldnt be weird. Listen
  to their family and friends and ask what concerns
  they have.

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Preparing someone for lifetime of Aphasia

• Rosenbeck states that clinicians that are
  adequate, treat all people more or less equally.
  A superior clinicians finds out what each patient
  wants and needs and determines what is possible.

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ADULTS

• Easiest population.
• Easiest prep time
• No stickers crafts
• Dont need to applaud
• Comm is its own reward
• If you have superior clinician, will see amazing
  things in therapy.

• Patient will try harder and they continue
  treatment.
• Difficult for them to let you go.

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ADULTS cont.

• You can point out errors and how to change those
  errors.
• You have built this relationship on trust,
  support and respect.
• It is acceptable to exploit a persons strengths.
• Prepare for generalization- client needs to be on
  their own. Take client out of therapy and let
  client do their own thing. Then go back in clinic
  and talk about it.

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A good clinician.

• Can adjust to changes- client will have good days
  and bad. We should be constantly thinking of
  hierarchy.
• Recognizes when therapy isnt doing very much
• Laughter crying is OK-sympathizing is OK.
• Therapy has an ending. If patient plateaus, maybe
  its time to discharge them. You can say you
  can always come see me.

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• Speech motor- damage to PMC causes apraxia
• Language syntax semantics etc.

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Speech Deficits

• Apraxia- the disturbed ability to reproduce
  purposeful learned movement, despite intact
  mobility. NO weakness of the musculature.
• Ideational Apraxia- the disruption of ideas
  needed to understand the use of objects. Ex- when
  we see key, we know how to use it.
• Show them object and say show me how to use it.

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Speech Deficits

• Ideomotor Apraxia- requires motor movement. Types
  of ideomotor
• 1) Buccofacial/nonverbal/oral apraxia- the
  inability to demonstrate volitional oral
  movements on command. Exercises on oral mech
  exam. If you have this apraxia, youll see
  struggle and searching behaviors.

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Speech Deficits- type of ideomotor apraxia

• 2) Limb Apraxia- inability to demonstrate
  volitional movements of arm wrist and hand on
  command. Ex- wave goodbye (they have problems
  with that). Look for whether they can do
  movements closer to the body or further away.
  Assess if you give them an object they can do
  movement, take away object, they cant. Kind of
  like they cant pretend.

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Speech Deficits- type of ideomotor apraxia

• 3) Apraxia of speech- where patient has problems
  programming the position and sequence of speech
  musculature, for the production of volitional
  speech (Darley Def.)
• Characteristics
• No weakness or paralysis or sensory loss
• Automatic speech is easier than planned speech
• Artic consistancies in/of errors. When they make
  errors it WILL be consistent.
• Struggle and searching behavior.

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Dysarthrias

• Dysarthrias- weakness, paralysis, incoordination
  of the muscles, required for speech.
• Descriptors speech sounds slurred, unclear,
  imprecise.
• Tx- make sure you have unfamiliar listeners come
  is to check clients production because
  eventually you will understand them after a while.

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Indirect and direct approach

• General Suggestions different approaches
• 1. Indirect approach-SLP is not working on any
  system specifically
• 1. Assisting the motor function (e.g. palatal
  lift, abdominal binders, surgery)
• Palatal Lift are done by dentist, teach
  person how to use

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Direct Approach

• Direct approach (SLP will work on the area
  affected phonation, intensity, breathe support)
• Goal for the SLP SLP will listen, determine
  what area needs to be remediated
• See below

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General Strategies

• The clinician and the client will
• a. Speak in a quiet environment implies that
  there is no competing noise.
• b. Speak face to face implies visual cues
• c. Teach client when to repeat, when to simplify
  and when to paraphrase.

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Severe Apraxia or Aphasia

• Severe Dysarthria/or Apraxia-consider an AAC if
  cant understand the person
• a. communication board-picture board picture of
  things that they need/feel/want
• b. communication book (e.g. C-book has
  section/or tabs like a food section, activity
  section and the patient turns to that page to
  express their needs/wants). The client will use
  his communication book to express his wants and
  needs. The client will point to a picutre
• c. electronic device (6 pictures to laptop to).
  The goal is for the client to produce S-V/S-V-0
  sentences using his electronic device with
  60-100 with no cues.

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5 factors for AAC

• List of AAC objects-Patient needs plus
• 1. Cost of system-low functional-high functional
  (1-8000)
• a. not everyone has good insurance
• 2. Amount of training to use device (e.g. client
  and clinician training)
• a. SLP may needs hours of training before using
  the device, implement techniques
• 3. How does the system interfere with other
  activities? (e.g. person can not bring AAC to
  beach
• 4. Intelligibility of output (e.g. electronic
  voice on telephone)
• a. women voice, hanging up on electronic
  devices
• 5. Acceptability of system (everyone needs to
  accept the fact there is a device and give the
  client time to use the AAC device

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General Guidelines for Dysarthria

• Treatment of Severely Impaired Apraxia of
  speech-motor programing
• 1. Poor prognosis for apraxia of speech
• a. one month with no volitional speech only
  stereo typical utterances
• (e.g. stereotypical utterances- patient says
  wiki wiki wiki wiki and can not get anything
  out.)
• b. after treatment for 1 month, the patient has
  not improved and every area for communication is
  severely impaired.
• 2. Poor prognosis-if patient has severe aphasia
  as well as severe apraxia-comorbidity..the type
  of aphasia associated with severe apraxia is
  global aphasia
• Other Indication see below

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Treatment for Severe Apraxia

• 1. AAC device
• 2. multi- modalities communication
• 3. Single functional words
• 4. The SLP will educated family about what is
  speech apraxia and aphasia
• See notes below

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Characteristic of Moderate Apraxia

• Prognosis Indicators
• 1. Poor prognosis-if patient has some volitional
  speech within one month
• Characterized by
• 1. Moderate apraxia will have mild forms of
  other types of apraxia like limb
• 2. Moderate apraxia will have hemiplegia and
  hemipareis
• 3. Moderate apraxia will have a mild to moderate
  degrees of aphasia

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Treatment for Moderate Apraxia

• 1. SLP will use drill format to produce sounds
• Goal the client will say functional words
  given from a functional word list with 80
  accuracy given verbal and visual cues. the
  client will say a functional phrase given a
  verbal model from the clinician with 80
  accuracy. the client will say a functional
  sentence without a verbal model.)
• 2. clinician will direct client to use words,
  phrase, to sentences
• 3. work-entry is possible with AAC. Some
  moderate aphasiacs will return to work and the
  SLP may suggest the use of an AAC device.
• Goal the client will access his device, the
  client will produce a 2-3 word phrase using his
  AAC device with 80 given a clinician verbal
  prompt.

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Characteristic of Mild Aphasia

• Prognosis Indicators
• 1. Mild apraxia have volitional speech, Dr.
  Isaki calls them functional speakers
• Characterized by
• 1. Mild apraxia will have only mild aphasia
• 2. Mild apraxia will struggle with words and
  make errors, but they are cognitively aware of
  their problems with speech. If they are aware of
  the speech errors, they will correct it.
• Goal the client will self-repair speech by
  repeating the word/phrase/sentence to the
  listener.

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Treatment Suggestions

• Treatment suggestions
• 1.SLP will target multi-syllabic word, phrases
  and sentences.
• 2. SLP wants the client to overcome speech
  apraxia The goal is work reentry.work-entry is a
  goal, clinician sets up therapy. (e.g.
  articulation therapy with children, you must
  model the sound. You dont need to describe where
  the articulation need to go. The clinician will
  need a verbal model for them and they will repair
  the speech using their own skills. The clinician
  will give a verbal and visual model to show the
  client.
• 3. SLP should use Melodic Intonation Therapy
  (e.g. modeling)

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General Suggestion for Apraxia

• 1. SLP will make movements visible, short and
  simple. (e.g. substitute dad for father)
• 2. SLP will begin with functional items, instead
  of made-up words. SLP need to have functional
  and meaningful for adults. SLP should use
  functional
• 3.SLP will use Melodic Intonation Therapy
  watch and listen.
• Goal The client will watch and listen to the
  clinician use melodic intonation techniques and
  then the client will use melodic techniques to
  use produce/say a functional phrase, functional
  sentence with 100.

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Functional Outcome Measures

• Functional Outcome measures
• 1. implement outcome measures (e.g. rating
  scales by the end of therapy and we will fill out
  the same measure.)
• 2. Measuring the gains of the client by rating
• a. rating scale is subjective
• b. areas of concerns are broad-(e.g.
  communication-will not show gains)functional
  independence measure (FIM score)
• c. interreliability rating with family, client
  and clinician

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What Do We Need to DO?

• Step 1. Determine what type of aphasia the client
  has from the data below?
• 1. Expressive Non-fluent (global, brocas,
  transcortical) vs. Expressive Fluent
  (Wernickes/Transcortical Sensory,
  Conduction/Anomic).
• Step 1a. Name the characteristic of the Aphasia.
  (e.g. Brocas aphasia has telegraphic speech, use
  of content words like nouns and verbs.)

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Step 2

• Step 2 Determine what to target for the patient?
  Determine the target that will make the most
  gains from the data). Determine the area that
  will make the most changes in the area of
  communication?
• 0. SLP will need to teach the client a specific
  skill in a short amount of time. (by targeting
  drawing, writing, and gestures, you are teaching
  strategies). The client will use sentence
  completion for anomia. The client will complete 5
  fill in the blanks sentences about a semantic
  description of a functional targeted word ,
  about procedural task with 60-100 accuracy
  given a read passage.
• 1. If we work on word finding difficulties
  (anomia), we will improve communication.
• 2. How would sentence completion generalize to
  outside environments. A mild Brocas will need to
  come up strategies to repair the anomia. A
  strategy might be a phrase to remember that word,
  but it is all internal. Why do we use cues for
  the severely impaired aphasiacs? Not for mildly
  impaired, we can teach the strategies and the
  mild Brocas can generalize to other
  environments.
• a. the 10 strategies are not tasks. The client
  will use the strategy to complete a task.
• b. Mild/Moderate/Severe Aphasia, the clinician
  will use cues. What type of cues is the clinician
  using. Why do we use cues in STG? Because we are
  teaching them a new skill. What skills does the
  SLP teach to mild/moderate/severe Brocas? The
  clinician will explain/show the client by
  modeling, by explaining how.

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• Problem if the client can not say the word key
  and over 5 trials, the client still cant say the
  word key. The clinician will need to find
  strategies to say the word key. A bad goal is
  simple to name the object over and over. A good
  goal will name a strategy to help say the word
  key. Goal the client will use semantic
  descriptors/synomyms. The client will give 5
  semantic descriptors for the functional targeted
  word with 60-100 accuracy given verbal/visual
  cues.
• The strategies are specific, you must be able to
  count the strategies..5 synomyms, antonyms,
  hypernyms, hyponyms, meronyms.
• Strategies are incorporated in the tasks to help
  the person name! During a conversation, you may
  use the 10 strategies to find a word if you are
  mildly impaired. However, during a conversation
  with moderate or severe, the conversation will be
  impaired. Strategies will help the listener move
  onto the next steps of the conversations. In a
  completing a fill in a blank, you can use any of
  the strategies. The strategy will help the
  listener continue the conversation

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Step 3

• Step 3 Write a goal for the client. Determine
  what type of cuing that will be used in therapy
  (target strengths) Goals should generalize to
  environments outside the clinicat the store.
  Must write out Verbal, Visual,
• The client will decrease neolgism by substituting
  a real word in 70 accuracy with visual cue by
  drawing, verbal cue by repeating, tactile cue by
  tapping.
• confrontational naming 70-bad-compared to 100
  before
• repetition of words 60 -bad-grade
• Auditory comprehension Focus on 80 to 100.
  Hospital setting, we only work on short term
  goals. We dont know the affect of one-part onto
  two-part. Focusing on one-part and take baseline
  data.
• What is the hierarchy? targeting the goal is
  important. Generalization, how do we approach
  therapy through goals. Your therapy goals are on
  or off.
• one part 80-fair
• two part 40-bad..if the patient has master 2
  part directions, you can move onto wh-questions,
  answer questions, or answer two questions. THINK
  of the HIERARCHY

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