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Title: Aphasia Notes


1
Aphasia Notes
  • Test III
  • Athena Hagerty

2
  • 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.

3
  • 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

4
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.

5
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.

6
  • 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.

7
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.

8
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.

9
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.

10
Treatment of Auditory Comp.
  • Task switching activities-
  • Discourse comprehension can they actually
    answer questions?
  • Familiar- if its familiar it will be easier.
  • Length redundancy-

11
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

12
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.

13
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.

14
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.

15
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

16
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

17
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.

18
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

19
Anomic Tx.
  • Anomia looks like
  • Pauses
  • Fillers uh, um
  • I dont know
  • Ineffective gestures (waving during conversation)

20
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

21
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

22
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.

23
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

24
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.

25
Resource Allocation
26
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.

27
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.

28
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

29
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.

30
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.

31
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.

32
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.

33
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.

34
  • Speech motor- damage to PMC causes apraxia
  • Language syntax semantics etc.

35
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.

36
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.

37
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.

38
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.

39
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.

40
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

41
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

42
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.

43
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.

44
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

45
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

46
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

47
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

48
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.

49
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.

50
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)

51
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.

52
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

53
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.)

54
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.

55
  • 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

56
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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