Aphasia Notes - A Guide to Treatment of Aphasia

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Aphasia Notes
Test III
Athena Hagerty
• 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 wasn’t 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 don’t have to give them a sticker.
• General Info about Treatment:
• Planning for treatment- don’t take
hours, do it easily and it’s cheap or free
for therapy. Free newspapers from
Dubois. Clinic has a laminator. Paper,
pencil and you can do therapy
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. Don’t do workbook stuff. If
they don’t need you, they shouldn’t be in therapy.
Computer programs are bad. Group therapy also
WORKS. Evidence behind it. More support by other
patients. Maintaining skills.
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 Wernicke’s, severe global,
after 3 months following injury. If nothing
changes after 3 months that’s bad.
• 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.
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- you’re 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.
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.
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.
Treatment of Auditory Comp.
• Task switching activities• Discourse comprehension – can they actually
answer questions?
– Familiar- if its familiar it will be easier.
– Length & redundancy-
Goal Writing
• Long term goal- 3 components to a goal- every
supervisor requires these 3 things.
• Performance=measure
• Condition- type of cues you are using
• Criteria –percentage or trials
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.
CUES
• Cues- extra help
•
•
•
•
•
•
•
Verbal- explaining or repeating
Phonemic- it’s a” K” for key.
Visual
Pointing
Gestures
Written
Tactile (touch)- holding their hand. Giving them
something to feel or touch.
Percentages
Maximum moderate minimum assistance. –
Dr Isaki doesn’t like these terms. Doesn’t 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.
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
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
Reading Comprehension Tx. (deficits)
• Reading glasses? Do they have glasses?
• Surface Dyslexia? Lost direct lexical route and
now dependent on phonological route. Exsound by sound or letter by letter.
• Deep dyslexia- you have lost phonological
route, now you’re dependent on whole word
recognition.
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
Anomic Tx.
• Anomia looks like…
•
•
•
•
Pauses
Fillers “uh, um”
I don’t know
Ineffective gestures (waving during
conversation)
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. Cup=”You use a _____ for drinking.”
• Synonyms- works for high functioning
• Antonyms- not every word has an antonym
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 can’t think of a word, can’t write it.
• Gestures- depends on person’s vocab, for high functioning
patient
• Drawing- depends on person’s vocab, for high functioning
patient
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.
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
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 you’re in is too noisy.
Resource Allocation
NAMING
AUDITORY COMP
CENTRAL
POOL
ORGANIZATION
PROBLEM SOLVING
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.
Preparing someone for
lifetime of Aphasia
• 1) remember to give fair assessments of
prognosis (don’t 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 person’s life and
relationship to others. Patients are unchanged
at the core.
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. We’ll 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
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. Shouldn’t be
weird. Listen to their family and friends and
ask what concerns they have.
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.
ADULTS
•
•
•
•
•
•
Easiest population.
Easiest prep time
No stickers & crafts
Don’t 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.
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 person’s 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.
A good clinician….
• Can adjust to changes- client will have good days
and bad. We should be constantly thinking of
hierarchy.
• Recognizes when therapy isn’t doing very much
• Laughter & crying is OK-sympathizing is OK.
• Therapy has an ending. If patient plateaus,
maybe it’s time to discharge them. You can say “
you can always come see me”.
• Speech = motor- damage to PMC causes
apraxia
• Language= syntax semantics etc.
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. Exwhen we see key, we know how to use it.
– Show them object and say “show me how to use
it”.
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, you’ll see struggle and searching
behaviors.
Speech Deficitstype of ideomotor apraxia
• 2) Limb Apraxia- inability to demonstrate volitional
movements of arm wrist and hand on command. Exwave 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 can’t. Kind of like they can’t pretend.
Speech Deficitstype 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.
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 client’s production because
eventually you will understand them after a
while.
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
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
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.
Severe Apraxia or Aphasia
Severe Dysarthria/or Apraxia-consider an AAC if can’t 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.
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
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 apraxiacomorbidity..the type of aphasia associated with severe apraxia is global
aphasia
• Other Indication see below
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
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
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.
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.
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 don’t 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)
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%.
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
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.
Broca’s aphasia has telegraphic speech, use of content
words like nouns and verbs.)
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 Broca’s 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.
Problem: if the client can not say the word “key” and over 5 trials, the client still can’t 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
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 clinic…at 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 don’t 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
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