Aphasia - comps
Minnesota test for differential diagnosis
This test is not really used anymore. Purpose: comprehensive examination of strengths and weakness in all language modalities, as a guide to planning treatment - differential diagnosis of: - aphasia - perceptual disorders -apraxia -dysarthria - consequences of brain damage - predicting recovery
Boston diagnostic aphasia examination
- 1-2 hour administration time (variable depending on severity) - administration tells you: if there is aphasia, aphasia type/classification, inferences about localization, useful fro treatment planning and measurement of recovery (can admin again)
Transcortical motor
- Broca's area becomes disconnected from other parts of the brain, but it isn't internally damaged, so the ability to process grammar is retained - marked by the absence of spontaneous speech and writing - difficulty initiating and organizing responses (because of the increase effort level to do so), but once started expression is relatively-well articulated - will reply briefly to questions; confrontation naming is relatively intact - relatively preserved aspects: repetition, writing to dictation, reading
Tests for right hemisphere damage
- RICE (rehabilitative institute of Chicago examination of the right hemisphere) - Burns brief inventory of communication and cognition
Broca's aphasia
- Telegraphic expression - simplified grammar which results in speech with mostly content words (nouns and few verbs), function words are generally left out - severe writing difficulties
Fluent aphasias
- Wernicke's - Conduction - transcortical sensory - anomic
global aphasia
- a severe form of aphasia that reflects aspects of both Broca's and Wernicke's aphasia (entire language system affected and not usable) -reading and writing difficulties parallel those of the verbal linguistic domain
Initial assessment
- accurate care: issues of survival and medical stability are emphasized, and thus focus on swallowing, breathing, medical classifications. as a result, most problems are dealt with at the impairment level - rehabilitative: more attention can go to speech and language problems and recently also degree of independent functioning/functional communication and life participation quality/potentials. rehabilitation related assessment and intervention will include a strong consideration of activities. functions of daily living. Also quality of life participation is more important in theses settings.
Parietal lobe
- asterognosis: mention the task of recognizing shapes by touch when you don't see them - constructional apraxia: difficulty in coping geometrical forms from memory - left visual neglect: visuo-spatial disorientation and dressing apraxia
strategies for comprehension training
- attention training - listening and pointing (o action)
Non-fluent aphasias
- broca's - transcortical motor - global
classification types
- broca's - wernickes - conduction - anomic - transcortical motor - transcortical sensory - mixed transcortical sensory motor aphasia - global - PPA - Alexia with agraphia
sources of information
- case history - reported observations - personal history - medical information
Mechanical trauma
- closed head injuries - open head injuries
Motor speech evaluation
- conversation -picture description - vowel production - repetitions of mono syllables - repetitions of syllable sequences - multi-syllable words - words that increase in length - sentences
group therapy for aphasia
- creates unique opportunities and benefits that are hard to come by in individual therapies - provides opportunities to communicate and practice - great for psychosocial adjustment purposes - learning from the problems and experiences of others, learning "you are not alone" - as an addition to individual therapy, it adds opportunities for generalizing language skills learned into more natural and spontaneous contexts - types of groups: psychosocial, family counseling/support, speech/language treatment
looking at behavior profiles
- dependent on the client's communication skills such as they are measured in prevalent and comprehensive aphasia tests of our discipline - western aphasia battery - Boston diagnostic aphasia evaluation
TIA symptoms
- hemiparesis - hemisensory changes - transient aphasia - transient changes in vision
Stimulation approaches to aphasia therapy
- hildred's schuell's stimulation approach to achieve language rehabilitation - Resource allocation model for aphasia - analog to 'demands-capacity model'
risk factors for stroke (atherogenic)
- hypertension - coronary artery disease - TIA's - Carotid bruits - Diabetes mellitus - hyperlipidemia - smoking - prior strokes
environmental systems approach to adult aphasia: lubinski
- includes exploiting aspects of the environment for optimizing the potentials of language rehabilitation - main points - many environments where clients lives do not give much reason or motivation to communicate, or provide few opportunities to do so - many situations have little built-in need to communicate, as many of the needs are anticipated by the staff/procedures - there is lack of positive reinforcement for communication
Damage to frontal lobe
- losing initiative and judgement, emotional changes occur with a tendency to euphoria. Both inhibition and disinhibition take place. - broca's area
Degeneration
- may result in generalized intellectual impairment - alzheimers, MS, pick's disease, vascular dementia, depression, pseudo dementia
porch index of communicative ability
- measures communicative ability, degree of deficit, and amount of recovery (with repeated administration) - advantages: subtle scoring system, reliability and validity, standardized, has a composite severity measure - disadvantages: descriptive - no classification possible, rigidity, starts with hardest items first
Space occupying lesions
- neoplasms - cancer - non-maliganent tumors
medical treatment of strokes
- osmotherapy - anti-thrombotic - surgery
the Boston naming test
- part of BDAE package - 60 images to be named in order from easiest to most difficulty
Hildred schuell's stimulation approach to achieve language rehabilitation
- principles of remediation: - intensive auditory stimulation should be used - stimulus difficulty should start at an appropriate level (60 - 80% to begin) - use repetitive stimulation - each stimulus should elicit a response (responses should be elicited, not forced or corrected) - feedback about response accuracy should be provided when it appears beneficial, pt. should be shown their progress - use abundant and varied materials that are simple and relevant to the patient's deficits, new materials should be extension of familiar ones - sessions should start with easier 'warm-ups'
Anomic aphasia
- probably damage in the temporal/parietal/supra-margianal region - essential symptom: severe word finding difficulties - speech may sound empty in severe cases - does not have paraphasia's and neologisms like wernicke's does - intact auditory comprehension - compensatory behaviors are common (circumlocutions) - normal disfluencies are common because of word retrieval problems, and in relatively mild cases the client may complain about it being hard to talk or that they talk more slowly
ALPS: aphasia language performance scales
- screening tool for obtaining a profile of the language abilities following brain damage that is suspected to have led to aphasia - four subsections: listening, total talking, reading, total writing
Wernicke's aphasia
- seemingly normal, fluent speech when not listening to what the client is actually saying - speech characterized by paraphasia and neologisms (client unaware of these); rapid speech - Looks less physically impaired than those with Broca's - Less aware of condition but more disabled in communication - Comprehensive reading is often severely impaired, and writing is more impaired than verbal expression (making AAC limited and difficult)
acute symptoms associated with brain damage
- severe headache - nausea, vomiting - reduced consciousness (or even coma); come depth is usually determined with the Glasgow scale
ALPS: Aphasia language performance scales
- simple straightforward screening tool for obtaining a profile of the language abilities following brain damage that is suspected to have led to aphasia Four subsections: - listening - total talking - reading - total writing
temporal lobe damage
- slight bilateral loss, a loss of the ability to localize is notable - damage to the left association area: acoustic verbal agnosia - damage to angular gyrus: Alexia with agraphia - wernicke's area
Strategies to help improve expression
- start at lowest level of performance - agrammatism - managing "press for speech" - word retrieval
western aphasia battery
- strong parallel with structure and approach as the BDAE - measures spontaneous speech, comprehension, repetition, naming, reading and writing, praxis and rhythm, construction
Conduction
- the connection between Broca's and wernicke's is partially or entirely damaged and as a result, these areas cannot communicate, interact, or cooperate - Primary symptom: unique inability (or difficulty) to repeat linguistic stimuli - mostly expression is affected - circumlocutions - word finding problems, problems in sequencing phonemes - paraphasia's (but client is aware of them) - depressed tendency to communicate - severe writing problems - comprehension reading is intact but oral reading is difficult
ways to classify neurogenic communication disorders
- using definitions - location of damage - etiology of damage - starting from prevailing thinking models of speech and language functioning - looking at behavior profiles - starting from prevailing thinking models of speech and language functioning
bedside screening
- view medical history before interacting with patients - will allow you to see damage as neurologist sees it as well as medications or other medical issues that could be important for how you do speech and language therapy - should last approximately 15 minutes. Duration depends on tolerance of the client, and typically only materials in the direct environment are used. BEST - 2
transcortical sensory
- werincke's area loses the ability to communicate with much of the rest of the brain, but it does remain intact by itself and is still connected to the other language areas - comprehension is impaired - articulation may be good, but paraphasia's and neologisms are common - reading and writing are severely impaired - good repetitions of even long sentences (major difference with wernicke's) and does not readily initiate speech
Risk factors for stroke (other)
-age -familial tendencies - polycythemia (increase in red blood cells) - alcohol (if excessive) - physical inactivity - obesity - oral contraceptives
Western aphasia battery (WAB)
-strong parallel with structure and approach of the BDAE - looks at: - spontaneous speech - comprehension - repeition - naming - reading and writing - praxis and rhythm - construction - considered not be as comprehensive as BDAE
open head injury
Are more likely to lead to aphasia than with the opposite, because the damage tends to be more localized. This is considered a penetration injury, can produce extensive contusions and lacerations of brain tissue
PICA: Porch Index of Communicative Ability
Purpose: to measure communicative ability, sensitive/reliable measurement of degree of deficit and amount of recover (repeated administration is possible) (this test is considered outdated)
- language formulation - language comprehension (listening to a speaker) - writing - comprehensive reading BDAE or WAB may be helpful
Did brain damage actually result in a deficit using language for communication? in other words, did the damage that occurred result in symptoms that are related to any or several of the following related dimensions or channels of using language?
- TBI: brain damage that results in "language of confusion" - Dementia or language of generalization intellectual impairment - mental conditions: psychosis or other psychiatric conditions - malingering tests that would be helpful: informal questions from clinician, nonverbal intelligence test, raven, nonverbal subtets of WAB or BDAE, alzhiemer's quick test
Establish that language differences are not a result of brain damage that extends beyond the language areas, or even aren't related to areas to begin with
- apraxia of speech - dysarthria - hearing and visual problems tests would include a motor speech evaluation
Establish that language related symptoms are not primarily a result fo some sensory-motor speech disorder
questions to be answered; full diagnostic
Establish that language related symptoms are not primarily a result of some sensory-motor disorder (AOS, dysarthria, hearing/visual problems)
mild aphasia
They are relatively aware of the mistakes that they make, and they react to them with frustration and concern. The impact of their communication problem is relative to: - personal needs, expectations - social needs and typical daily communication situations vocational needs/educational needs/recreational needs
dysarthria
a family of motor speech disorders due to the inability to execute or coordinate the execution of movement related to speech examples: spasticity, flaccidity, ataxia, hyper and hypokinetic dysarthria - some brain damage that involves changes in the motor systems may involve neurogenic language disorders to some degrees as well. Mostly typical damage to the motor cortex is close to Broca's area and so easily also produces symptoms that originate in the latter.
Mild aphasia
a mild impairment in language use; client's with this share more features with normal language use than they deviate.
apraxia of speech
a motor speech disorder characterized by inability to effectively (and efficiently) plan/program speech movements. There is no inability to effectively (and efficiently) plan/program speech movements. There is no inability in using motor nerves or muscle per se, but rather it represents a loss in knowing how (manner) to move the speech structures for certain speech sounds, or where (place) for example in place, manner, or in controlling the voicing characteristics (mostly timing) of these sounds. Currently, the main characteristic (meaning always there) is considered speech that is slow and labored.
aphasia
an acquired communication disorder caused by brain damage, characterized by an impairment evident in language modalities: speaking, listening, reading, and writing. (it is not the result of a sensory or motor deficit, a general intellectual deficit, or a psychiatric/psychological deficit essential elements: - neurogenic - acquired - affects language - is not primarily sensory, motor, or cognitive/psychological
Boston Diagnostic Aphasia Examination (BDAE)
answers these questions: - is there aphasia - what type of aphasia are we dealing with? (classification) - inferences about localization are possible (however, this is not ethical without the help of a neurologist or MD) - useful for treatment planning and measurement of recovery
TBI
aphasia may be the result of this if the damage involves language centers known to take part in linguistic processing; there may also be other differences in language use than aphasia, known as language of confusion -clinical relevance for aphasia: in assessment, the clinician needs to be able to separate out language differences that are caused by damage directly, or those that are indirect result from changes in cognitive performance.
moderately severe aphasia
client still has a "broad language repertoire" to rely on, which argues against a loss of linguistic form and content". Language is fundamentally altered from normal with regard to: - its specificity - complexity - organization
questions to be answered; full diagnostic
determine severity level of aphasia (mild, moderate, severe)
Questions to be answered; full diagnostic
did the brain damage result in deficit using language for communication? language formulation and expression, comprehension, writing, reading
constructional aphasia
difficulty in coping geometrical forms from memory - parietal lobe
Questions to be answered; full diagnostic
establish that language differences are not a result of brain damage that extends beyond the language areas, or even aren't related to language ares to begin with
questions to be answered; full diagnostic
establish the aphasia classification type
atherosclerosis
hardening of the arterial walls. Which can lead to developmental stenosis, a structural narrowing of the arteries
anti-thrombotic
improvement of blood circulation
Moderately severe aphasia
in addition to language changes, there usually are also some changes in: memory, attention, and (a reduced) level of awareness of response accuracy
neoplasms
initially there is compensation for pressure from growths through lessening the cerebrospinal fluid around the brain. Later, there may be a disturbance of the blood/CSF circulation. It in turn restricts blood/CSF and makes the damage worse
Infectious/metabolic
intoxication - use of certain hard-drugs - may lead to localized and/or wide-spread damage to the CNS such as associated with various cognitive disorder including aphasia and language of confusion
thrombosis
is a condition associated with an obstruction that consists of cholesterol and fatty substance (contains cholesterol) in an artery.
CADL: communicative abilities of daily living
is a functional approach to assessing the patient's communicative impairment. It assesses not only linguistic abilities, but also how the client taking benefit of the context, nonverbal cues in real life. tests: - reading, writing, and using numbers - social interaction - divergent communication - contextual communication - nonverbal communication - sequential relationships - humor/metaphor/absurdity This test can be used on people with aphasia, TBI, MR, or individuals who are deaf.
questions to ask with bedside screening
is there a problem with communication? could it be aphasia? cognitive issues? sensory-motor? are there swallowing issues? if it is aphasia, what could be the primary type/classification? are there coexisting medical or other conditions that are known to interact with aphasia therapy, or langauge functions in general?
Primary progressive aphasia
language specific degeneration occurs because of relatively rare form of dementia (frontotemporal dementia)
moderately severe aphasia
language use differences may be characterized specific to the following linguistic dimensions: - lexical/semantic - morpho-syntactic - phonologic disruption - pragmatic disruption (this dimension actually may also provide useful strengths)
severe aphasia
marked reduction in the repertoire of language forms such as reduced lexicon, and a strongly simplified linguistic rule system
infection, intoxication, and use of (certain) hard drugs
may lead to localized and/or wide-spread damage to the CNS such as associated with various cognitive disorders including aphasia and language of confusion; anoxia would lead to similar affects
degenerative diseases and dementias
may result in generalized intellectual impairment (Alzheimers, MS, pick's disease; multiple infarcts (MID, or vascular dementia); depression or "pseudo-dementia"
astereognosis
mention the task of recognizing shapes by touch when you don't see them. - parietal lobe
closed head injuries
non-penetrating - can produce mild to severe loss of consciousness. - often produce diffuse, multiple, and widespread effects such as contra-coup
closed head injury
non-penetrating injuries: can produce mild or severe loss of consciousness. They often produce diffuse, multiple and wide-spread effects. contra-coup may occur (which is damage on the opposite side of the brain when it rebounds) some of the defects may disappear in weeks
medical treatment of strokes
osmotherapy (reduction of blood volume, reduces blood pressure. Reduction of edema) - anti-thrombotic (improvement of the blood circulation (perfusion) - surgery
open head injury
penetration - can produce extensive contusions and lacerations of brain tissues - more likely to lead to aphasia than the opposite injury due to damage being more localized
Cancer
problems can be results of 1. metastasis, 2. pressure to the brain
osomotherpy
reduction of blood volume, reduction of edema
TIA
represents a warning that a more severe stroke may be immanent. It usually lasts for about an hour, but could last up to 24 hours.
Alexia with agraphia
some clients have predominant problems in reading and writing domains. If Alexia occurs without agraphia, this would point to more posterior location of damage, while the simultaneous presence of symbolic reading and writing abilities point to an area affected around the angular gyrus and supra-marginal gyrus
review of location of neuro centers for speech and language
speech production: located in Broca's area, on the lower left frontal lobe of the cortex. Specific instructions for speech related movements go to appropriate points on the sensory motor strips that have to do with executing these movements - language formulation: wernicke's area
long term therapy
starts when a client is medically stable. Goals are rehabilitative in nature: if still necessary continued word on swallowing, word on walking/ambulation communication and be able to carry out ADLs.
non-malignant tumors
still a problem with pressure (benign and malignant tumors, extra or subdural hematoma, abscess, edema
mild aphasia
strengths: - preserve nearly normal discourse abilities (even though language may be slightly simpler and less efficient than before) - may benefit from context in natural situations and interactions - may benefit from nonverbal behaviors displayed by the speaker
CVA/stroke
sudden disruption of blood flow or bleeding in portions of the brain resulting in permanent damage and clinical signs that last beyond 24 hours (if less than 24 hours considered a TIA)
severe aphasia
the client is no longer able to use primary (verbal expression and comprehension) or secondary (writing and reading comprehension) language modality for successful communication
dementia
the medical term for a family of most "degenerative type" disease processes that affect brain functioning. The effects on language performance compared to language of confusion are at the same time overlapping and distinctly different.
location of damage
the most dominant viewpoint today is that neurogenic communication disorders should be classified based on information regarding location and size of damage
moderately severe aphasia
therapy: would be based on the profile of the linguistic abilities that need attention, or that are preserved and may serve as assets in helping to overcome weaker ones (compensation)
The Minnesota test for differential diagnosis of aphasia
this is an older test that isn't used as often anymore
apraxia
this is considered a condition that is commonly associated with Broca's. it is often difficult to separate the consequences of both and commonly the apraxia masks the extent of the coexisting aphasia.
mild aphasia
tx in general: - awareness and emotional reactions to the difficulties need attention - probably some level of word retrieval therapy may be needed - a focus on reading and writing in relatively important - learn to tolerate distractions - counseling
Severe aphasia
tx: - AAC - Inter-systemic organization - may need to work on cognitive prerequisites for being able to re(develop) language - start with comprehension first - nearly all burden of communication is on you
mild aphasia
typical (remaining) problems in the population are: - anomia - disfluency susceptibility to distractions - reduced efficiency overall
left visual neglect
visuo-spatial disorientation and dressing apraxia - parietal lobe
acute therapy
whatever it take to protect the patient's life and preventing further disability.
Boston naming test
you simply show pictures and the client is expected to give you the name. If no response is forthcoming, prompts may be. given (stimulus cue, which is of a semantic nature), or id that doesn't work, a phonemic cue
