Preserved intonation suggests ideation and communicative intent exist despite bizarreness of speech production
7 Behavioral manifestations
Limited insight into the cause of expressive communication breakdowns
May demonstrate frustration when others do not understand
May give up when encountering communication breakdowns (Marshall 2001)
And not persist ask for clarification or attempt to convey the message through other methods
May retreat and seldom initiate (Marshall 2001)
8 Comprehension difficulties
Wide range of impairment severity
Pure word deafness intermittent comprehension
Phonologic decoding problems
Semantic decoding problems
Auditory processing (nonlinguisic) problems also can interfere with successful comprehension (Brookshire 1987)
Initial attending and focus (slow rise time)
Information capacity or memory
Noise buildup / internal perseveration
Video Illustration MM Baseline 9 Auditory information is transient
Cannot be processed quickly or efficiently enough for meaning to be mapped onto the acoustic/phonologic signal
People with Wernickes aphasia often miss
general ideas and topics
lost in a fog of sounds words and references that mean nothing
10 Writing mirrors speech output 11 Compounding the problem
Confused and disoriented
Externalize the problem (Why are you asking me this)
General lack of awareness regarding extent and impact of comprehension impairment
At times seems to go beyond challenges attributed to comprehension deficit alone
May need to see this speech written down to understand that their output is unintelligible to others
Have difficulty thinking strategically to use other communication strategies
12 Impairments often lead to
Dependence on others to direct their daily schedule
No viable means of communicating basic needs
No means of engaging in social interaction
Family frustration and sadness
Inappropriate discharge plans or shortened rehabilitation stays
13 Surprises -- competencies revealed in meaningful contexts
Intermittent meaningful verbal output in some conversations
E.g. It was a a furrilous time. The boys ser pin to them reference to Steelers football victory
But never on demand
no response or darsimee
Intermittent functional auditory comprehension
Clinician Here why dont I get you your coatit looks like youll need it out there today.
Client No no no problemwalks over to coat rack and retrieves jacket
But never on demand
Clinician Point to the coat rack
15 The Clinical Problem
Therapy is often difficult to implement
Success is difficult to achieve
Stimulation/repetition approaches are typically unsuccessful at improving speech intelligibility
No direct methods to effect change
Poor comprehension and limited awareness result in
Inability to benefit from feedback or instructions
Lack of forward movement within therapeutic process
16 A clinical wish list
Interrupt the cycle of unsuccessful communication as quickly as possible
Find a modality through which the individual can receive some meaningful input and make sense out of his/her world
Identify predictable contextual routines within which the individual can begin to express and comprehend successfully
Demonstrate success before an untimely discharge from therapy occurs
17 SLP treatment for Wernickes aphasia
Significantly less attention in the medical and SLP literature than for anterior or anomic aphasia syndromes
Seminar focus - management of auditory comprehension deficits
Impairment-based approaches to remediate auditory comprehension deficits appear to be the most commonly employed in adult therapy settings
Presentation of increasingly difficulty auditory tasks and stimuli (e.g. commands point to discrimination tasks) with
Hierarchy of cues
Marshalls Controlled Auditory Stimulation Program (Lexicon Press)
18 Partner-supported strategies
Kagan 1998 -- Supported Conversation
Implies that the focus of remediation extends beyond the communicator
Includes partners and environmental contexts
Strategies implemented by partners in real-life contexts aim to minimize or bypass the disability versus fix the impairment
Goal better communication and increased participation in relevant life activities
19 Augmented Input
Developed by Garrett Beukelman (1992 1998) and Garrett Lasker (2005) to improve the conversational comprehension of adults with aphasia
Definition Any visual-verbal strategy employed by the communication partner that increases the message comprehension of the communicator with aphasia
20 Partner provides
Written key words
Individual symbolic gestures
21 Partner presents graphic support in real time
Writes or draws while communicating key concepts to denote
topics and topic changes
questions and response choices
References text (point) to match auditory with visual input
Clinician Did you hear about the new mayor
Client nonverbally conveys limited comprehension
Clinician So the new mayor point to written key word mayor after it is written is that youngster Luke point to printed name then write 28 y.o.. Right
Clinician Its hard to believe isnt it
Client Well you know that...right there serty-tar points to 28 y.o.
Clinician Yes thats pretty young to run the city isnt it!
22 The partner should also
Stop periodically to check comprehension
Are you with me Did you get that
What do you think Is that right
Yes or no
23 Bonus - more intelligible spoken language may occur
Encourage expression of key word targets but dont force them
May emerge later in the session
Then bring clients attention to his/her intelligible productions
Clinician You said this word mayor - great! I understood it! point to previously written key word -- mayor
Client Thats right I did..layer..mardi..
Clinician Dont worry about ityoull say mayor againwell talk about Mayor Luke next time points to written key words
Client Mayor sukee thats right suke.
24 Implementation - Augmented Input
Teach partners to
Observe communicator for receptive breakdowns
Provide augmented input to resolve breakdowns as needed
Intermittently (e.g. novel topics)
Continuously (write while talking)
Collect materials needed
Notebooks and pens
Referential items - scrapbooks photos
25 Theoretical Base
Sevcik et al. (1991) -- partners real-time reference to graphic symbols can increase the comprehension orientation functional understanding and participation of individuals with severe intellectual disabilities in meaningful daily activities
Symbols are selected based on the partners judgment regarding the communicators current referential interest
Static visual symbols vs. transient auditory symbols
PECS schedule boxes commenting boards story boards on-line drawings and gestures
More fundamental level of meaning is conveyed in pictorial symbols than in auditory-verbal words
26 Case Illustration Demographics
86 year-old retired mechanical engineer
3 years post onset at time of our intervention
Married with 2 adult children
Lives with wife at home (condominium)
27 Participation Assessment
Pre-stroke levels of activity
Member of multiple social clubs and organizations
Extensive circle of friends (though diminishing in recent years due to deaths of friends)
Enjoyed conversing storytelling debating
Frequent phone conversations with friends family
Life of the party
28 The Stroke
Ischemic left CVA at age 83 (November 2003)
Left frontotemporalparietal insula basal ganglia CVA with concomitant atrial fibrillation
Respiratory distress and intubation
Severe dysphagia/G-tube (4 mos)
Initial diagnosis -- Global aphasia
Confused and minimally responsive -- 1st month
29 Therapy History
Acute inpatient rehab
1 week then DCs to
Subacute inpatient rehab
December 2003 -- February 2004
Home health therapy for 2 months
February 2004 -- April 2004
Outpatient at a Rehab facility
May 2004 -- July 2004
Compensatory tx focus to enhance expression
Gestures drawing pointing picture recognition
Copying matching names to pictures
Limited success with regard to reestablishing functional communication negative prognosis for return of functional speech
DCd secondary to poor prognosis for return of functional speech
Referred to Duquesne aphasia therapy group
30 Participation Assessment
Post-stroke / Before Augmented Input
Had not traveled since his stroke at time of intervention
Limited social interaction despite residence in same community and condominium
Some participation in a social group for men with cognitive impairments
Restaurant and library outings with his wife
Participated minimally in phone conversations
Watched a lot of T.V.
Frequent communication difficulties and arguments with his wife (primary caretaker and communication partner)
Also retreated and did not persevere to understand or convey a message
Can be implemented with acute patients and outpatients
Can be taught quickly to partners (although may take longer to habituate)
Augmented Input complements other contextual strategies
Contextual group or individual therapy
Picture Symbol strategies (e.g. topic setters)
Response Elaboration Therapy (Kearns et al)
Thought-centered Therapy (Wepman)
Assists in meeting Marshalls (2001) challenge of reestablishing a successful communication connection as quickly as possible 50 Selected References
Brust JCM Shafer SQ Richter RW Bruun B (1976). Aphasia in acute stroke. Stroke 7 167-174.
Damasio H Tranel D Spradling S Alliger R. (1988). Aphasia in men and women. in Galaburda A (ed) Neurons to Reading. Cambridge Mass MIT Press pp 1-20.
Dronkers N. F. Wilkins D. P. Van Valin R. D. Redfern B. B. Jaeger J.J. (2004). Lesion analysis of the brain areas involved in language comprehension. Cognition 92(1-2) 145-177.
Eslinger PJ Damasio AR Age and type of aphasia in patients with stroke. (1981). Neurol Neurosurg Psychiatry 44 377-381.
Garrett K. Lasker J. (2005) Adults with severe aphasia. In D. Beukelman P. Mirenda (Eds.) Augmentative communication Management of severe communication disorders in children and adults 3rd edition (pp. 467-504). Baltimore Brookes Publishing Co.
Garrett K. Ellis G. (1999) Group communication therapy for persons with long-term aphasia Scaffolded thematic discourse activities. In Elman R. (Ed.) Group treatment of neurogenic communication disorders The expert clinicians approach (pp. 85-96). Boston Butterworth-Heinemann
Kagan A. (1998). Supported conversation for adults with aphasia methods and resources for training conversation partners. Aphasiology 12 816-830.
Knepper L.E. Biller J. Tranel D. Adams H.P. Jr Marsh E.E. (1989). Etiology of stroke in patients with Wernickes aphasia. Stroke 20 1730-1732.
Lasker J. Garrett K. Fox L. (2007) Severe aphasia. In D. Beukelman K. Garrett K. Yorkston (Eds). Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions. Baltimore Brookes Publishing Company. Pp. 163-206.
Marshall R. (2001) Management of Wernickes aphasia A context-based approach. (Chapter 18) In R. Chapey (Ed.) Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders 4th ed. Philadelphia Lippincott Williams Wilkins. Pp. 435-456.
Obler LK Martin AL Goodglass H Benson F. (1978). Aphasia types and aging. Brain Lang 6 318-322.
Peach R. (1995) Treating the fluent aphasias. Topics in Stroke Rehabilitation 21-14.
Sevcik R. A. Romski M. A. Wilkonson K. M. (1991). Roles of graphic symbols in the language acquisition process for individuals with severe cognitive disabilities. Augmentative and Alternative Communication 7 161-170.
Wade DT Hewer RL David RM Enderby PM (1986). Aphasia after stroke Natural history and associated deficits. J Neurol Neurosurg Psychiatry 49 11-16.
Wood L. A. Lasker J. Siegel-Causey E Beukelman D. R. Ball L. (1998). Input framework for augmentative and alternative communication. Augmentative and Alternative Communication 14 261-267.
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