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Title: Assessing Aphasia and Neurogenic CDs


1
Assessing Aphasia and Neurogenic CDs
2
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3
Localizationists
  • Franz Gall (early 1800s)
  • Paul Broca (1850s) a neurologist----articulate
    speech located in the posterior-inferior frontal
    lobe
  • Karl Wernicke (1874) a German neuropsychiatrist
    published work on sensory aphasia lesions in
    the posterior temporal lobe

4
Anti-localizationists
  • Marie Jean-Pierre Florens (colleague of Gall!)
    was the first
  • John Hughlings Jackson (NHNSND) a British
    neurologistearly 1900s
  • Henry HeadBritish neurologist---1920s
  • Equipotentialists
  • Lead to theories of cerebral dominance

5
Language and Cerebral Dominance
  • Left hemisphere dominance for sph/lang was
    Broca---early thoughts were that left and right
    halves of the brain were mirror images on one
    another
  • Symmetry notion lasted until Goodglass and
    Kaplan, Penfield and Roberts (1950s)!!
  • Confusion about function right handed people
    were left hemisphere dominant

6
Therefore,
  • Left handed people must be right hemisphere
    dominant?????
  • Only a theory based upon case studies
  • Maybe from an effort to equalize
    theories---make things symmetrical
  • Think of theories of phonation---honest!
  • (neurochronaxic theory!)

7
50s researchers noticed
  • Both left and right handed people had similar
    problems after brain injury
  • We learned from the early sodium amytal studies
    that a small of people are right hemisphere
    dominant
  • Most adults are left hemisphere dominant for
    sph/language
  • The question is how are we born?
  • Think cerebral plasticity

8
Implications of cerebral plasticity
  • Younger injuries have greater opportunity to
    improve
  • Older patients recover less language function
    than younger patients
  • The older the patient at the time of injury the
    more severe the persistent consequences of the
    injury

9
Connectionists
  • These theories focus on function of areas
    surrounding the injury in the case of language
    impairment
  • The periSylvian region of the left frontal lobe
    is sometimes called the anterior language zone
  • Important for planning and executing language
    speech, writing, and maybe gestures
  • The periSylvian region in the left temporal
    lobes is the posterior language zone
  • For comprehending and formulating linguistic
    messages with accurate syntax and semantic
    structures

10
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11
Anterior Language Zone
  • Posterior frontal lobe, just anterior to the
    motor strip
  • Holds the location of Brocas area the motor
    speech planning site
  • Brocas area responsible for planning
    organizing speech movements for the primary motor
    cortex
  • Injury here produces Brocas aphasia

12
Posterior Language Zone
  • Located in the posterior superior left temporal
    lobe
  • a.k.a. Wernickes area
  • Sometimes called the auditory association cortex
  • Important for storage and retrieval of mental
    representations for words, word meanings,
    grammatical and linguistic rules

13
Remember the connectionists?
  • Wernickes gets most of its input from the
    primary auditory cortex (Heschls Gyrus)
  • Function of the primary auditory cortex is
    perception and discrimination of auditory stimuli
  • If a tree falls in the woods and there is no one
    there to hear it.

14
More connectionists
  • Wernickes and Brocas are connected by a large
    bundle of nerve fibers (a fasciculus)
  • Runs between the mid temporal lobe and the
    frontal lobe via the parietal lobe
  • The arcuate fasciculus is the primary route by
    which linguistic messages formulated in
    Wernickes are transmitted forward to Brocas area

15
The angular gyrus
  • At the junction of the temporal, parietal and
    occipital lobes
  • Important for processes in reading and writing
  • Damage to the angular gyrus causes
  • Alexia reading impairment
  • Agraphia writing impairment

16
Language Functions
  • Comprehension of speech
  • Spontaneous speech
  • Repetition
  • Oral Reading
  • Writing
  • Gestural responses to spoken commands

17
Fluency
  • Important to understanding the connectionist
    model because connectionist aphasia syndromes are
    divided into fluent and non-fluent types.
  • Relationship between speech fluency,
    paraphasia, repetition and language comprehension.

18
Fluent (aphasic patients) have normal or near
normal speech rates and use a variety of
different grammatical constructions function
words and grammatical inflections are present,
and usually syntactically appropriate. Intonation
patterns are present and usually appropriate.
Nonfluent (aphasic patients) have slow and
labored speech. The variety of grammatical
constructions is often restricted and intonation
may be reduced or absent function words and
grammatical affixes may be omitted, and patients
may rely a lot on nouns (Howard Hatfield, 1987,
p. 147).
19
Connectionist Aphasia Syndromes
  • Fluent
  • Damage posterior to the Rolandic Fissure
  • Sph flows smoothly and effortlessly
  • Fluent aphasic spkrs. Usually manipulate rate,
    intonation, and stress
  • Non Fluent
  • Damage anterior to the Rolandic Fissure
  • Sph is halting and made with great effort
  • Rate is slower than normal, intonation is
    limited, stress is missing (diminished)

20
Paraphasias
  • errors in speaking produced by speakers with
    aphasia (Brookshire)
  • 2 forms literal and verbal paraphasia
  • Literal paraphasia phonologic (phonemic)
    errors----tootbrust for toothbrush
  • Verbal paraphasia semantic errors (usually
    related to the term) as in knife for fork
  • Sports talk play was admiral defense had
    pronouns
  • NOTE literal paraphasia vs. apraxia

21
Repetition
  • Variations in speech repetition and language
    comprehension are indicators of several fluent
    aphasia syndromes

22
Classical Aphasia Syndromes
  • Brocas aphasia
  • Wernickes aphasia
  • Global aphasia
  • Conduction aphasia
  • Transcortical motor aphasia
  • Transcortical sensory aphasia
  • Mixed aphasia
  • Disconnection syndromes

23
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24
Brocas aphasia
  • Expressive, motor or anterior aphasia
  • Because of proximity to the motor strip (face,
    hand and arm) and because descending pyramidal
    fiber tracts run alongside Brocas area pts
    with Brocas display right-sided hemiplegia or
    hemiparesis

25
Brocas area
  • Lower part of the premotor cortex just anterior
    to the primary motor cortex
  • Premotor cortex plans skilled voluntary
    movements for the motor cortex in both
    hemispheres
  • Brocas area is adjacent to motor cortex of the
    face thus it is the speech motor planner

26
Speech style
  • Slower rate, laborious movement, halting
  • Long pauses between words sometimes even within
    words
  • Lacking intonation
  • Misarticulations are common some consonants and
    vowels are distorted
  • Short phrases usually missing functor words I.e.,
    conjunctions, prepositions and articles

27
Speech style Brocas
  • Missing functor words causes the description of
    agrammatic sometimes called telegraphic
  • Next slide is from from a patient describing a
    picture from the Boston Diagnostic Aphasia
    Examination (BDAE). The Cookie Theft.

28
A sample of Broca-type speech
29
Brocas aphasia Writing
  • Pts. Write as they speak slowly and laboriously
  • Strings of content words sprinkled with
    misspellings, distortions/omissions of letters.
  • Poor form, maybe due to hemiplegia (forced to use
    non-dominant hand)
  • Usually print not cursive slanted writing

30
Brocas writing style
31
Brocas comprehension
  • Comprehension is better than speech or write
  • Although Brocas pts tend to be slow readers
    (careful testing will probably show both reading
    and listening impairments)
  • Repair strategy is usually preserved, e.g., they
    make attempts to correct errors in sph or writing

32
Brocas comprehension
  • Tend to be good tx candidates because they are
    usually cooperative
  • error awareness sometimes leads to emotional
    lability
  • Usually remember goals from day to day

33
Wernickes aphasia
  • Also has other names sensory aphasia, receptive
    aphasia and posterior aphasia
  • Salient feature impaired comprehension of
    spoken and printed verbal materials
  • If severe, pt may be unable to comprehend simple
    spoken or written material
  • Mild/moderate get the basic idea but tend to
    miss the details

34
Wernickes
  • Often dont associate sound (or sight) of words
    and their meanings
  • Difficulty with semantic distinctions e.g., know
    difference between small vs. tiny, good vs.
    wonderful, etc.
  • Often display problems with short term retention
    and recall for verbal material
  • Tend to do poorly on digit recall, recall lists,
    etc

35
Wernickes
  • Performance tends to deteriorate when
    instructions are longer, more verbal

36
Wernickes speech
  • Unlike Brocas, Wernickes patients speech is
    usually smooth, even well formed grammatically
  • Speech seems less effortful sometimes even long,
    syntactically correct utterances with proper
    prosody
  • May see some delay when there is difficulty with
    word recall

37
Speech sounds good, eh?
  • Not.
  • Speech is usually typified with verbal
    paraphasias (sometimes literal paraphasias, too)
  • Ferbus lalo! Neologisms
  • Strings of neologisms jargon
  • Essentially, Wernickes aphasics produce empty
    speech it lacks meaning
  • Usually filled with stuff or things or
    pronouns
  • Even circumlocute!

38
Wernickes speech style
39
Wernickes handwriting style
40
Logorrhea
  • Some Wernickes patients will talk copiously
    until you MUST interrupt them
  • Due to circumlocution and poor self monitoring
    skills

41
Wernickes writing
  • Yup, it resembles their speech writing is
    better in that the letters are well formed, they
    write with ease and it is legible
  • Most will use cursive
  • Handwriting is mechanically normal but ----it
    lacks content
  • Paraphasias in speech usually show up in writing,
    too
  • Yeah, logorrhea happens in writing, too.

42
Wernickes candidacy
  • Patients are usually alert, attentive and likely
    to stay on the task at hand
  • Mild forms usually know their errors
  • Moderate forms rarely notice errors nor attempt
    to repair errors
  • Cant stay on task in testing and tx procedures
  • Conversational speech is tangential

43
  • Auditory comprehension problems complicate all
    communication trials
  • Pragmatics/turn taking is usually preserved

44
Concommitants
  • Wernickes patients are not usually hemiplegic
    (unless there is involvement of the motor strip--
    global aphasia)
  • Lesions deep in the temporal lobe may destroy
    portions of the visual cortex
  • Causes contralateral visual field loss
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