Nonfluent Aphasias

mixed transcortical aphasia

(transcortical sensory and motor) 1. rare nonfluent aphasia type 2. combines TMA and TSA 3. severe and extensive lang impairment 4. retain repetition skills 5. has been labeled "isolation aphasia"

what is the PACE approach?

-Prompting Aphasics' Communicative Effectiveness -by Pulvermuller and Volkbert, 1991 -uses compensatory strategies to facilitate communication *encourages the exchange of information *provide stimuli picture face down btwn pt and clinician and the pt must look at it an use any available means to communicate the message--like charades *SLP guesses and provides feedback *typically used with fluent, but can be used with nonfluent

neuroanatomical bases of transcortical motor aphasia (TCA, TMA)

-anterior superior frontal lobe, watershed areas -usually above or below Broca's area -lesions often impact association pathways -impacts supplemental motor area -supplied by anterior cerebral artery

neuroanatomical bases of mixed transcortical aphasia

-caused by various conditions that decrease bloodflow through the cerebral arteries (hypoxia of various origins, cardiac arrest, cerebral edema, multiple embolic strokes) -supplied by the MCA and the anterior/posterior cerebral arteries -broca's, wernicke's and the arcuate fascisculus are spared

gestural response therapy

-core vocabulary is chosen based upon pt needs (begin with 5-10 words) -SLP makes gesture while saying a word -clinician repeats the word with the pt -pt imitates the gesture immediately, then after a brief delay -pt gestures after the clinician says the word and writes the word -pt writes the word if possible when seeing the gesture

what are some other terms for the nonfluent aphasias?

-expressive aphasia -motor aphasia -anterior aphasia

card Tx (deck of cards)

-improve sequencing of numbers on cards by putting them in order -match cards by suit and number (use 2 decks) -respond to commands using cards (pick up the ace) can help with: -attention -language -matching -sorting -is meaningul

What is the Mapping Tx?

-mapping for agrammatism (Byng, 1988) -targets sentence structure and thematic roles by identifying the subject and object of sentences -uses pictures

neuroanatomical bases of global aphasia

-most likely involves entire perisylvian region affecting both broca's and wernicke's areas -subcortical areas may be impacted -more common sites are impacted by MCA -p. 148 has good picture -widespread destruction of the left fornto-temporo-parietal regions

what are the neuroanatomical bases of broca's?

-posterior-inferior (third) frontal gyrus of the left hemisphere (brodmann's 44 and part of 45) -area known as the anterior language cortex -lower part of the premotor cortex

what will it be like to work w/ a pt with TMA?

-single words will require coaxing on our part -we need to coax them to speak -as improvement continues, they become more echolalic (but early on they are mute)

general characteristics of global aphasia

-strong neurological symptoms: weakness, paralysis, sensory loss -apraxia including both verbal and oral types -hemi-neglect: left neglect common in right hemisphere damage

using AAC

-when introducing AAC device, assess the device's communicative capabilities and compare it with the client's needs (consider operational demands regarding client's motor, sensory and cognitive skills) -adapt device to client's situations and available support -train family and client how to use it -monitor its use for functional language

general characteristics of TMA

1. similar to Broca's aphasia, except that they can repeat 2. motor disorders: rigidity of UE, akinesia, bradykinesia (similar to parkinsonism) 3. hemiparesis 4. pts may demonstrate apathy or behavioral withdrawal -exhibit little to no interest in using language

writing hierarchy

1. trace a word 2. copy the word 3. say the word for the pt to identify in writing 4. ask the pt to write the word to dictation 5. ask the pt to write the word given a picture 6. ask the pt to write the word in response to a question

communication boards

1. use communication boards with pictures and words -alphabet and word boards are usually ineffective for individuals with global aphasia 2. include pictures of people and familiar objects 3. use pictures of real objects, actions, and places 4. teach the pt to use the communication board -point when an item is named (immediate then with a delay) -keep the board visually simple at first and then expose more items with time when success is achieved -consider a more high-tech AAC device if possible and financially feasible

general characteristics of mixed transcortical aphasia

1. varied clinical picture 2. bilateral UMN paralysis 3. severe spastic quadriparesis (weakness of all 4 limbs) 4. visual field deficits (typical problem is right hemianopia) 5. weakness in hip/shoulder area 6. severe brain damage

when was Broca's Aphasia first described?

1861

what is the blood supply for transcortical motor aphasia?

ACA

what is the blood supply of broca's area?

MCA

RET

Response Elaboration Training (RET) Kearns, 1991 -uses loose training with patient-initiated responses (without restrictions) -uses simple line drawn picture stimuli requiring personal interpretation -SLP scaffolds responses (does not provide correction to pt responses) -six steps: 1. elicit spontaneous response to picture 2. model and reinforce patient's response 3. provide 'wh' cues for patient to elaborate 4. reinforce elaboration and model the sentence 5. repeat and have patient repeat 6. reinforce and provide another model

what is transcortical motor aphasia?

also known as extrasylvian aphasic syndrome b/c it lies outside of the perisylvian language zones -is a nonfluent aphasia with good repetition skills

global aphasia

common, may account for 30-55% of pts with aphasia -is most severe form of aphasia; has a generalized effect on communication skills -impacts all mode of communication and spares no particular skill -possible for global aphasia to evolve into another type (you do not see this with mixed transcortical) -be careful of prognosis

tx for equivocal responses

equivocal=vague, ambiguous confusing -use two 3x5 cards with yes and no on them -pt repeats each word 5 times while looking at the cards -assist the pt to say the word and nod yes and then no when given a cue -present yes-no questions for the pts responses -request responses to simple questions: 1. is your name _____? 2. did you have a stroke? -establish a baseline and begin treatment with personal, environmental and informational questions -use pictures to help the pt understand questions -chart responses

functional AAC considerations

get someone's attention give yes/no answers call for help indicate understanding of what is being said respond without words say the name of a person nearby communicate their needs, wants, pain (if any) have social time with friends and family understand written communication communicate their emotions describe something have a one-on-one conversation get involved in group talk about self participate in a group conversation

MIT

melodic intonation therapy by Sparks & Deck, 1986 -uses melodies and intonation patterns of the intact right hemisphere -four levels: 1. intoning a melodic line 2. hand tapping saying syllables 3. answering questions 4. practice with drilled phrases and sentences -pictures are used initially and later program cues are reduced

SPPA

sentence production program for aphasia -by Helm-Estabrooks &Nicholas, 2000 -used to improve conversation w/pts who have nonfluent aphasia and who are agrammatic speakers -attempts to increase phrase length, content and grammar -ocuses on 8 sentence types using a thematic base

how can we differentiate TMA from Broca's?

the discrepancy btwn lang production problems and repetition skills

what are the 4 nonfluent aphasias?

1. broca's 2. global 3. transcortical motor (TCM or TMA) 4. mixed (mixed transcortical)

general nonfluent aphasia Tx

1. coarticulated speech (build on level of success in syllables, words, phrases...) 2. auditory comprehension (point, follow commands, understand complex material) 3. oral expression tasks may range from: [oral-motor skills, automatic sequences (days of week, etc.), answering questions, naming, word fluency, reading words and sentences aloud] 4. understanding written language (reading) (identify letters, words, match words and pictures, read sentences and paragraphs) 5. writing improve mechanics for writing basic information, the alphabet, numbers, writing to dictation, writing names, and writing about a picture or event 5. consider spared abilities and functional levels -good writing: apply directly to communication -some writing: consider a writing/spelling therapy program -no writing, some drawing: consider a communicative drawing therapy program -no writing, some gesturing: consider a communicative gesturing therapy program -gestural-verbal training increases naming for some people with aphasia (pair approaches)

what are the major symptoms characteristic of the nonfluent syndromes of aphasia?

1. decreased rate of speech 2. decreased phrase length 3. decreased prosody 4. decreased initiation of speech (and AOS) 5. decreased talking in general 6. increased effort (and AOS) *many of these symptoms overlap w/symptoms of AOS

language characteristics of mixed transcortical aphasia

1. extremely limited spontaneous verbal expression, echolalic (some have no spontaneous speech, some have parrotlike repetition) 2. severely impaired fluency 3. severely impaired auditory comprehension 4. marked naming difficulty (often neologistic, or don't respond to naming tasks) 5. unimpaired automatic speech (but once you interrupt them they have to start over) 6. normal articulation (no dysarthria, no apraxia) 7. severe reading deficits (oral reading and comprehension of reading are totally impaired) 8. severe writing impairments (total impairment) 9. show little recovery (may have to discharge for lack of progress)(AAC isn't helpful) 9. severe reading

language characteristics of global aphasia

1. globally impaired communication skills 2. severely impaired fluency 3. impaired repetition, naming, reading and writing 4. impaired auditory comprehension (may understand some personal information, but this is rare) -minimal vocalizations -might be able to copy a letter or number (writing)

general characteristics of broca's aphasia

1. more easily recognized than wernicke's 2. typically present w/contralateral hemiplegia or hemiparesis 3. weakness of [r] side facial muscles 4. most motor problems improve over time (but communication issues persist) 5. pts are very often depressed; catastrophic reactions refusing to cooperate or continue testing (pseudobulbar affect)

language characteristics of TMA

1. muteness (especially early on), echolalic (repeat you), reduced spontaneous speech 2. agrammatic speech, paraphasic 3. impaired naming w/intact repetition (poor confrontation naming--sometimes cues are helpful) 4. intact serial speech (relatively) 5. intact knowledge of grammar/meaningfulness (if they make grammatical mistakes, they may fix them spontaneously) 6. limited naming; may use motor prompts (like a handclap to initiate speech) 7. better comprehension than production 8. poor speech intonation 9. no AOS 10. oral reading and writing are impaired 11. reading comprehension: good except for synactically complex material

what are the language characteristics of broca's aphasia?

1. nonfluent and effortful speech (pauses, revisions, repetition and prolongations)(they know this is wrong since receptive lang is usually intact)(may have AOS and poor suprasegmental use) 2. agrammatic speech (telegraphic speech; have content words; omit articles and grammatical morphemes) 3. impaired repetition of words and sentences (unable to or reduced ability to imitate SLP prompts, especially for grammatical features) 4. impaired naming (difficulties with naming; cues are sometimes helpful; phonemic cues can be the sound or the actual letter; naming difficulties could be b/c of AOS) 5. questionable auditory comprehension (broca's area is also related to comprehension; comprehension is usually intact, but not always) 6. oral reading (is effortful, nonfluent; often mirrors verbal expression; may have difficulty comprehending what is read 7. writing problems (write slowly, labor intensive, will mirror verbal expression) *agrammatic writing, oral reading, and verbal expression