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Severe Wernickes Aphasia: Using Augmented Input Strategies to Improve Communication 8 8 8 8


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Title: Severe Wernickes Aphasia: Using Augmented Input Strategies to Improve Communication 8 8 8 8

Severe Wernickes AphasiaUsing Augmented Input
Strategies to Improve Communication 8 8 8
  • Kathryn Garrett PhD?CCC-SLP
  • Duquesne University, Pittsburgh, PA /
  • Private Practice
  • Ruth Mason Richman MS CCC-SLP
  • Newton-Wellesley Hospital, Newton, MA

ASHA 2007 -- BOSTON 1 hour Seminar
What is Wernickes aphasia?
  • A fluent aphasia according to Geschwinds
    classification system
  • A posterior aphasia syndrome caused by lesions to
    the superior temporal gyrus according to the
    Boston classification system
  • A syndrome of aphasia that impacts the phonologic
    and semantic system and results in
  • significantly reduced language comprehension
  • reduced ability to produce intelligible speech
  • Paraphasias and jargon
  • NOT apraxia of speech

Courtesy Natl Aphasia Association
Traditional neuroanatomic correlates of
Wernickes aphasia syndrome
Gray matter (cortical) frequent white matter
(subcortical) involvement
Possible Etiologies
  • Middle cerebral artery (posterior branches)
    thrombotic or embolic events
  • Internal or common carotid artery occlusions
  • Anterior branches of the posterior cerebral
  • Anoxic events leading to infarcts in the
    watershed areas -- ends of the arterial
    distribution zones
  • Tumors, abscesses
  • Focal TBIs

Facts about Wernickes aphasia syndrome
  • Represent approximately 13 of all patients with
    aphasia (Brust et al., 1976 Wade et al., 1986)
  • Older than average - compared with general
    population of stroke patients (Damasio, 1988
    Obler, 1978)
  • physiologic basis for this phenomenon is not
  • Perform very poorly on standardized tests if
    willing to participate secondary to
  • Linguistic Deficits
  • Behavioral Rigidity
  • Why are you doing this to me? I dont understand
    what you want from me! OR
  • Impulsive responding
  • Egocentric focus
  • Clinician Are the lights on in this room
  • Client Well, we always turn them on dont

Expressive characteristics
  • Unintelligible gibberish
  • Jargon, paraphasias, and neologisms -- a random
    soup of sounds
  • Perception of another language being spoken
  • Grammatic utterances (subjects are identifiable,
    actions can be deduced)
  • Phonological encoding breakdowns - jargon
  • Lexical mapping difficulties - semantic
  • Occurs during generative speech and repetition
  • Press of speech/logorrhea/uninhibited output
  • Preserved intonation suggests ideation and
    communicative intent exist despite bizarreness of
    speech production

Behavioral manifestations
  • Limited insight into the cause of expressive
    communication breakdowns
  • May demonstrate frustration when others do not
  • May give up when encountering communication
    breakdowns (Marshall, 2001)
  • And not persist, ask for clarification, or
    attempt to convey the message through other
  • May retreat and seldom initiate (Marshall, 2001)

Comprehension difficulties
  • Wide range of impairment severity
  • Pure word deafness intermittent
  • 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
  • Intermittent imperceptions

Video Illustration MM Baseline
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
  • specific details
  • nuances
  • lost in a fog of sounds, words, and references
    that mean nothing

Writing mirrors speech output
Compounding the problem
  • Cognition
  • Confused and disoriented
  • Externalize the problem (Why are you asking me
  • 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
  • Have difficulty thinking strategically to use
    other communication strategies

Impairments often lead to
  • Frustration
  • Dependence on others to direct their daily
  • No viable means of communicating basic needs
  • No means of engaging in social interaction
  • Family frustration and sadness
  • Misdiagnoses
  • Inappropriate discharge plans or shortened
    rehabilitation stays

Surprises -- competencies revealed in meaningful
  • Intermittent, meaningful verbal output in some
  • E.g., It was a a furrilous time. The boys ser
    pin to them reference to Steelers football
  • But never on demand
  • Say football
  • no response or darsimee

  • Intermittent, functional auditory comprehension
  • Clinician Here, why dont I get you your
    coatit looks like youll need it out there
  • Client No no, no problemwalks over to coat
    rack and retrieves jacket
  • But never on demand
  • Clinician Point to the coat rack
  • no response

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
  • Inability to benefit from feedback or
  • Lack of forward movement within therapeutic

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

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
  • Stimulation therapy
  • Presentation of increasingly difficulty auditory
    tasks and stimuli (e.g., commands, point to,
    discrimination tasks) with
  • Repeated trials
  • Feedback
  • Hierarchy of cues
  • Marshalls Controlled Auditory Stimulation
    Program (Lexicon Press)

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
  • Communication Ramp
  • Goal better communication and increased
    participation in relevant life activities

Augmented Input
  • Developed by Garrett Beukelman (1992, 1998) and
    Garrett Lasker (2005) to improve the
    conversational comprehension of adults with
  • Definition Any visual-verbal strategy, employed
    by the communication partner, that increases the
    message comprehension of the communicator with

Partner provides
  • Written key words
  • Gestures
  • Referential pointing
  • Individual symbolic gestures
  • Pantomime
  • Referential graphics
  • Maps
  • Pictures
  • Objects

Partner presents graphic support in real time
  • Writes or draws while communicating key concepts
    to denote
  • topics and topic changes
  • key ideas
  • 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
  • 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?
  • Client Yeah
  • 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!

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?

Bonus - more intelligible spoken language may
  • 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.

Implementation - Augmented Input
  • Teach partners to
  • Observe communicator for receptive breakdowns
  • Provide augmented input to resolve breakdowns as
  • Intermittently (e.g., novel topics)
  • Continuously (write while talking)
  • Collect materials needed
  • Notebooks and pens
  • Referential items - scrapbooks, photos

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
  • 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

Case Illustration Demographics
  • Personal History
  • 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)

Participation Assessment
  • Pre-stroke levels of activity
  • World traveler
  • 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

The Stroke
  • Medical History
  • 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

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
  • Functional game-playing
  • 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

Participation Assessment
  • Post-stroke / Before Augmented Input
  • Had not traveled since his stroke at time of
  • 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

Results of Formal Assessment

Cognitive Task - Trailmaking (CLQT)
Spontaneous Speech
  • How are you today? unintelligible
  • What is your name? FFirs
  • What was your job? OK. There unint
    well way back unintell
  • Tell mepicnic picture pointed to
    items fence and then this
  • PLUS
  • Phonemic paraphasiasperseverative jargon

Spontaneous Writing Sample
Structured Writing/Drawing Sample --Favorite
Visual Scanning Task
  • No field cuts
  • Sustained concentration
  • Overall fair-good comprehension of task given
    initial model/cues
  • 0 omissions (100)
  • 5 additions (38 additions)
  • http//

Phase I Intervention -- Outpatient Clinic
  • Types of Therapy
  • Individual Therapy -- 2 semesters (1X weekly)
  • Introduction to augmented input
  • Inhibition and conscious control of perseverative
    or jargon (nonfunctional) output
  • Helm-Estabrooks Albert stop strategy
  • Oral reading approach (Cherney, et al)
  • Phrase-picture matching
  • Yes-no response training (tagged yes-no
    technique Garrett Lasker, 2005)
  • Group therapy -- Scaffolded Disourse Model
    (Garrett Ellis, 1998 Garrett, Staltari Moir,
  • Props, supported conversation, and thematically
    relevant activities

Phase I Intervention -- Outpatient
ClinicJanuary, 2005
  • Therapy Strategies
  • Augmented Input
  • Continuous written key word input generated by
    partner to supplement spoken output
  • Additional partner gestures and use of graphic
  • Referential (pointing - to speaker, to referent)
  • Symbolic gestures
  • Pantomime
  • Pocket Talker portable personal amplifier
  • Used during group for approximately 3 semesters
  • Recently rejected
  • appeared to have triggered ongoing engagement and
    attention to spoken output of others
  • Photo Album - topic setter
  • Introduced 3 years post onset (Summer, 2007)
  • Currently used during group reminiscing or
    conversational activities only opportunities

Examples of augmented input to enhance MMs
  • Topic -- explaining wifes unexpected heart
    surgery and related events

Examples of augmented input to enhance MMs
  • Topic -- daughter-in-law suggesting a lunch

Clinical Outcomes -- Phase I
  • Immediate acceptance of augmented input
  • Frequent pointing to tablet to request input from
  • General impression of more intelligible, on-topic
    verbal speech that corresponded (somewhat) with
    printed key words
  • Could also point to written word choices to
    answer specific wh-questions
  • Increased attempts to draw some concepts (though
    not a primary strategy)
  • Better shifting of attention to speakers in group
  • Became a true participant in group activities
  • Began to pantomime and gesture to add information
  • Limited his perseverative jargon output in
    response to Stop cues
  • In general, Manny understood that he needed to
  • Convey meaning as understandably as possible
  • Follow what others have said

Home Outcomes -- Phase I
  • Encouraged Mannys spouse to implement the
    strategy at home
  • Sylvia expressed an interest
  • Technique was modeled
  • Formal instruction delivered on multiple
  • Coaching and practice - multiple occasions
  • Initial Outcome
  • Commented on immediate and beneficial effect on
  • But voiced confusion regarding its purpose
    (wanted him to say the words)
  • Intrapersonal barrier (Acceptance?)
  • Did not buy tablets
  • Said she did not use the technique at home
  • he understands pretty well
  • I had him try to copy some words

  • What good is a clinical, partner-dependent
    strategy if real-life partners dont use it?
  • Therapy has done no lasting good

Phase 2 Intervention The End Run 1 year later
  • Mannys Spouse -- Medical Emergency
  • Family (dau, dau-in-law) in town for an extended
  • Frequent observations of group therapy
  • Immediate acceptance of strategies
  • Made requests to implement strategy at home
  • Ganging up
  • Bought 5 tablets and pens
  • Placed them in all rooms of Mannys residence
    while spouse was in the hospital
  • Upon her discharge to home, daughters used
    strategy at every opportunity to model it
  • Encouraged spouse to implement augmented input
    and gave her feedback

3 Video Clips from interview
  • 1. KG modeling Augmented Input
  • Topic -- resuming their winter visits to Florida
  • Swimming suits
  • 2. Interview with Daughter
  • 3. On with life!

Behavioral Changes
  • Increased orientation
  • Increased on topic verbal and gestural comments
  • Increased verbal intelligibility
  • Increased ability to shift attention across
    multiple speakers (especially in group)
  • Increased ability to indicate comprehension level
    and conceptual focus by referencing (pointing) to
    key words written by partners
  • Less frustration about communication
  • Sylvia has decreased her attempts to have Manny
    repeat words
  • More satisfying and communicative phone calls
  • Manny is happier (except for boredom)

  • Augmented input, when implemented habitually and
    strategically by trained conversational partners,
    changed Mannys ability to participate
  • in daily communication with spouse/family members
  • in aphasia therapy/interactions with other peers
    with aphasia

Future research
  • Identify a means of measuring message
    comprehension in response to augmented input
    before conducting systematic research
  • Indirect -- how do we know they understood?
  • Perceptual ratings
  • Quantify nonverbal behaviors
  • Compare participation, communicative success, and
    changes in comprehension with and without
    augmented input
  • Across severity levels
  • Types of partners
  • Types of settings
  • Measure factors affecting implementation among
    communication partners
  • Training type and intensity
  • Attitudinal - Is augmented input a style or a
    technique that can be learned by all?

Final Thoughts
  • Easy to implement (at a technical level)
  • Materials Notebooks, whiteboards, markers,
    calendars, maps, natural gestures
  • Can be implemented with acute patients and
  • Can be taught quickly to partners (although may
    take longer to habituate)
  • Augmented Input complements other contextual
  • 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
Selected References
  • Brust, JCM, Shafer, SQ, Richter, RW, Bruun, B
    (1976). Aphasia in acute stroke. Stroke, 7,
  • 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),
  • 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
  • Kagan, A. (1998). Supported conversation for
    adults with aphasia methods and resources for
    training conversation partners. Aphasiology, 12,
  • Knepper, L.E., Biller, J., Tranel, D., Adams,
    H.P. Jr Marsh, E.E. (1989). Etiology of stroke
    in patients with Wernicke's aphasia. Stroke, 20,
  • 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,
  • Peach, R. (1995) Treating the fluent aphasias.
    Topics in Stroke Rehabilitation, 2,1-14.
  • 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.