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APHASIA

Aphasia is an acquired communication disorder that impairs a person’s ability to process LANGUAGE, but DOES NOT AFFECT intelligence. Aphasia impairs the ability to speak and understand others.

-National Aphasia Association

LANGUAGELanguage is a system of communication that uses symbolism. K L U $ + M –Phonemes: perceptually distinct unit of soundsWords: sounds combined & given meaningSentences: combination of syntax (rules) and semantics (meaning).

• CLASSIFICATIONS OF APHASIAEXPRESSIVE VS. RECEPTIVEFLUENT VS. NON-FLUENT

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-NATIONAL APHASIA ASSOCIATION

-COURTESY OF MY-MS.ORG

MCA DISTRIBUTION -SLIDESHARE.NET

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BROCA’S APHASIA* short utterances* limited vocabulary* halting, effortful speech*mild comprehension deficits

Lesion* Inferior frontal gyrus

IdeaChoose Words

(Semantics)

Sentence Structure (Syntax)

Speech Sounds

(Phonology)Coordinate

Muscles Articulate Speak Fluently Pragmatics

SAMPLE OF BROCA’S THERAPY FROM TACTUS THERAPY

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WERNICKE’S APHASIA• Comprehension is poor (auditory &

reading)• Fluent, intact prosody• Logorrhea, press of speech• Neologisms, Paraphasias• Lack of awareness

LesionTemporo-Parietal, Posterior section of the superior temporalgyrus near the auditory cortex

Input Perception RecognitionAuditory

PhonologicalAnalysis

AttachMeaning

PreparationFor

Output

WERNICKE’S APHASIA FROM TACTUS THERAPY

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GLOBAL APHASIA* severe language deficit* responds to personally relevant language

* responds to non-verbal cues* some automatic speech

LesionBroca’s & Wernicke’s AreaPerisylvian region

WHAT DID THEY SAY?ANOMIA (Without Name)Tip of tongue, unable generate labelCommon with Many AphasiasAnomic Aphasia

PERSEVERATIONOverstimulation of the wrong targetthat occurred before question oractivityStereotypy

PARAPHASIAS * Language errors characterized by unintended syllables, words during speaking attemptsPhonemic/Literal-substitution of sound(s) for another,i.e., “thistle” for “whistle”

Verbal-substitution of real word for target word, i.e., cat/dog…chair/dog

* Agrammatism-difficulty with formulating grammatically correctsentences, telegraphic speech

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OTHER CONSIDERATIONS*APRAXIA (DIFFICULTY PLANNING AND EXECUTING VOLUNTARY MOVEMENTS) -WORDPRESS.COM

VERBAL* SOUND SUBSTITUTIONS, GROPING

FOR ARTICULATORY PLACEMENT* VOICE ONSETNON-VERBAL* DIFFICULTY WITH ORAL

COMMANDS, I.E. SMILE, STICKOUT YOUR TONGUE

* NODDING/SHAKING HEADFOR YES/NO INDICATION

CONSIDER MELODIC INTONATION

LIMB* DIFFICULTY EXECUTING BODY

MOVEMENTS FOR COMMANDS THAT WERE COMPREHENDED

* POINTING (COMMUNICATIONBOARDS)

* LESS SO WITH GROSS MOTOR, I.E.LEGS

IDEATIONAL* PLANNING ISSUES RELATED TO

USE OF OBJECTS

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HOLLAND AND FRIDIKSSON, 2001. INDICATING FORMAL TESTING AND IMPAIRMENT BASED APHASIA TX, MAY NOT BE APPROPRIATE IN THE ACUTE CARE PHASE OF STROKE.APHASIA MANAGEMENT DURING THE EARLY PHASES OF RECOVERY FOLLOWING STROKE

WHY? *SHORTENED HOSPITAL

STAY*FEAR, ANXIETY, FRUSTRATION*MAY NOT BE READY TO

RECEIVE OR BENEFIT FROM REMEDIATION/INSTRUCTION

* SPONTANEOUS RECOVERYWEBSTER, NEWHOFF (1981)

* POSTPONE FORMAL TESTING FOR A FEW DAYS

* CAN MIX FORMAL TESTING WITH INFORMAL INTERACTIONS.DOCUMENT STRENGTHS ANDWEAKNESSES

* EDUCATION/COUNSELING

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EDUCATION/COUNSELING* STAFFSHARE “TEST” RESULTS, STRENGTHS WITH NURSING

* FAMILY/PATIENTWHAT IS APHASIATIPS FOR COMMUNICATIONDIAGRAMSSPONTANEOUS RECOVERY

INFORMAL ASSESSMENT* ESTABLISH MEANS OF YES/NO* USE ITEMS IN ROOM TO MAKE

CHOICES, PROBE AUDITORY DISCRIMINATION, COMMANDS

* USE GREETING CARDS, MENUFOR READING

* WRITE FAMILIAR FAMILY NAMES* PROBE NAMING WITH ITEMS IN ROOM,

FAMILY PICTURES

15 MINUTE SEGMENTS (FATIGUE)

BOSTON DIAGNOSTIC APHASIA EXAMINATION (BDAE)-NORMED TEST-%TILE RANKS-USED FOR NIH STROKE SCALE, COMMON “LANGUAGE” WITH NURSING –GOODGLASS & KAPLAN

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A WORD ABOUT YES/NO* BIOGRAPHICAL INFORMATION* 50% RULE* EYE BLINKS, EYE GAZE, NOD/

SHAKE, THUMBS UP/DOWN* VERTICAL VS. HORIZONTAL* ASK “NO” RESPONSE ?’S* POINTING, FACILITATE ARM MOTION,

PLACE PENCIL/PEN IN HAND* ASK NURSING, FAMILY WHAT WORKS* POST WHAT WORKS, ALL DOING

THE SAME THING

MAY BE LOW TECH, BUT…COLOR CUESYMBOL CUEEXPRESSION CUE

EXPLORE FREE APPSLET ME TALK YES/NOAPPNOTICE UG UTOPIA PROGRAMMING, LLC

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TEXTING, USE OF WORD PREDICTION

AUGMENTATIVE COMMUNICATION BOARDS -VIDATAK, CHILDREN’S HOSPITAL BOSTON

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ORIENTATION

EDUCATION“INFORMATION ABOUT APHASIA, STROKE, AVAILABLE RESOURCES”, WORRALL, ET AL 2011

LOW TECH

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SPONTANEOUS RECOVERY* EARLY IMPROVEMENT MAY REFLECT

RETURN TO FUNCTION OF COMPROMISED BRAIN AREAS

* TURKELTAUB ET AL. (2001) EVIDENCEOF LANGUAGE REORGANIZATION TO HOMOTOPIC REGION IN RIGHT HEMISPHERE

* ROBSON ET AL. (2014) RECRUITMENT OF THE ANTERIOR TEMPORAL LOBES FOR COMPREHENSION IN WERNICKE’SAPHASICS

TIPS FOR COMMUNICATING WITH PWA

* EYE CONTACT (EDUCATE RE: NEGLECT)* USE SHORTER SENTENCES* DON’T TALK DOWN* LIMIT NOISE, DISTRACTION* GIVE CHOICES* ASK YES/NO QUESTIONS* OFFER GESTURE, DRAWING, WRITINGASHA.ORG (AMERICAN SPEECH, HEARING ASSOCIATION)NATIONAL APHASIA ASSOCIATIONAMERICAN STROKE ASSOCIATION

OTHER RESOURCESFree or Low Cost AppsStroke Support GroupsMissouri State University Speech-Language Hearing Clinic

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PRICE VARIES $5 - $25EVIDENCE BASED FREE LITE VERSIONS FREE

Tactus Therapy Lingraphica’s Talk Path

CONSTANT THERAPYTabletSmart phone$25 monthly$250 yearly- The Language Corp.

-AMERICAN SPEECH HEARING ASSOCIATION

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INTELLIGENCE: ONE’S CAPACITY FOR LOGIC, PROBLEM SOLVING, CREATIVITY, PLANNING, SELF AWARENESS, LEARNING….

UNRAVELING NONVERBAL COGNITIVE PERFORMANCE IN ACQUIRED APHASIA ROBERT FUCETOLA, ET AL 2009

“IMPAIRMENT IN NON-VERBAL COGNITIVEABILITY IS NOT FULLY EXPLAINED BY LANGUAGECOMPETENCE IN PERSONS WITH APHASIA”

ATTENTION AND OTHER COGNITIVE DEFICITS IN APHASIA: PRESENCE & RELATIONSHIP TO LANGUAGE & COMMON MEASURES, LAURA MURRAY, 2012

“GROUP WITH APHASIA PERFORMED SIGNIFICANTLY MORE POORLY ONCOGNITIVE MEASURES, BUT DISPLAYEDVARIABILITY IN PRESENCE, TYPES, SEVERITY OF THEIR ATTENTION & OTHER DEFICITS”,

SYMBOL CANCELLATION (COGNITIVE LINGUISTIC QUICK TEST) HELM-ESTABROOKS, 2011

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TRAILS-CLQT, HELMS-ESTABROOKS, 2011

DIVIDED ATTENTION

EXECUTIVE FUNCTIONSRange of Cognitive Abilities including goal formulation, planning, carrying out goal directed plans, and monitoring effects of actions (quality control)

THE RELATION BETWEEN LANGUAGE, NON-VERBAL COGNITION AND QUALITY OF LIFE IN PEOPLE WITH APHASIA ( NICHOLS, ET AL 2017)

• 28 PWA, Chronic phase• Language battery, non-verbal

cognitive battery, quality of life battery (aphasia friendly)

• NVC impairment predicted 3x the variance on a measure of QOL than Language impairment

• Emerged predictors: Trails task, Visual Memory task & Maze

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C-SPEAK APHASIASTUDY(NICHOLAS, SINOTTE & HELM-ESTABROOKS, 2011)

C-SPEAK APHASIA STUDY(NICHOLAS, ET AL 2011)

• 10 PWA, chronic aphasia• Severe, non-fluent aphasia• 6 months training using C-Speak• Carry-over to functional communication

(making phone calls, answering biographical questions, describing person-action pictures, describing a short video, writing a card and grocery list)

• 4 out of 10 communicated more information with computer than without

• Baseline non-linguistic executive function skills, pictorial semantic knowledge and auditory comprehension

• Only non-linguistic executive function skills correlated with treatment response

WAIS R: WECHSLER ADULT INTELLIGENCE SCALE (THE PSYCHOLOGICAL CORPORATION) AND PYRAMID AND PALM TREES TEST (HOWARD & PATTERSON)

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RAVEN’S PROGRESSIVE MATRICES -JOHN RAVEN 1936

WISCONSIN CARD SORT-DAVID GRANT, ESTA BERG

TIC TAC MAZESCLQT, NANCY-HELM ESTABROOKS, 2011

PROMOTE COMMUNICATIONFor Our Severe Clients - Supported Communication

- Melodic Intonation- Visual Action Therapy- Scripting; Aphasia- Personalized Vocabularies- Multi-modality communication

(Famous People Protocol)- Technology!!

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NON-PROPOSITIONAL LANGUAGEOVER-LEARNED, ROTE* COUNTING, DAYS OF WEEK* PRAYERS* WELL KNOWN SONGS* CURSING

LIMBIC SYSTEM, BASAL GANGLIA,RIGHT HEMISPHERE STRUCTURES

-EXPLETIVES: NEUROLINGUISTIC AND NEUROBEHAVIORAL PERSPECTIVES ON SWEARING, VAN LANKKER, CUMMINGS, OCTOBER 1999.

MELODIC INTONATION (MIT)Uses musical elements of speech (melody, rhythm, stress) to improve language (apraxia)Intoning simple 2-3 syllable phrases – 5+ syllable phrases3 levels (elementary, intermediate, advanced)

MELODIC INTONATION CONT.

Uses 2 pitches. Stressed syllables have upward pitch, unaccented syllables have downward pitchLeft hand taps each syllable (paces speaker and may involve right hemispheric sensorimotor network)Elementary level: Humming, Unison Intoning, Unison Intoning with Fading, Repetition, Response to a probe question

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PERSONALIZED VOCABULARY“YOU WANT TO GO FOR A WALK?” “GO, JOHN, GO!”

SHIRLEY RYAN ABILITY LAB-FORMERLY RICPERSONAL ANIMATED THERAPIST (PAT), 20 SCRIPTS, EDITOR OPTION TO CREATE OWN SCRIPTS, REPEATED PRACTICE, REQUIRES WINDOWS

FAMOUS PERSON PROTOCOL

*APHASIA BANK*PROMOTES MULTI-MODALITY COMMUNICATION

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WORD FINDING TREATMENT• Common to have Confrontation

Naming Goals• Boston Naming Test• Spreading Activation from M. R.

Quilllan’s (1967) theory of semantic memory search

• The search process is initiated by labeling a set of source nodes (concepts in a semantic network) with “weights” of activation then spreading that activation to other nodes linked to the source

SPREADING ACTIVATION THEORY

SEMANTIC FEATURE ANALYSIS

1) PATIENT TO NAME PICTURE

2) ASKED TO GENERATE FEATURES

3) PATIENT TO NAME PICTURE AGAIN

ACTIVATION OF SHARED FEATURES RESULTS IN SPREADING ACTIVATION TO OTHER CATEGORY MEMBERS

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SEMANTIC FEATURE ANALYSIS: TRAINING ATYPICAL EXEMPLARS

“Training atypical items within a category and their semantic features results in generalization to naming of intermediate and typical exemplars of the category selected for training.” –Kiran & Thompson, 2003

TRAIN ATYPICAL EXEMPLARS TO PROMOTE GENERALIZATION (SFA) (KIRAN & THOMPSON, 2003)

VNEST PROTOCOL: VERB NETWORK STRENGTHENING PROGRAM, EDMONDS, 2014• Takes SFA a step further,

focusing primarily on verbs• Focuses on Agrammatism

(strengthens sentence structure, S+V+O)

• Same verb, but promotes semantic variety

• Pictures not used, promoting mental flexibility

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10 VERBS (TRANSITIVE, AVOID OVERLAP)

3-5 HRS. A WEEK/10 WEEKS

3 X 5 CARDS

3 PAIRS SUBJECTS/OBJECT“WHO”, “WHAT”

CLIENT READS EACH TRIAD

CHOOSE ONE TRIAD

EXPAND TO “WHERE”, “WHY”, “WHEN”

CLIENT READS ALOUD

CLEAR TABLE, ASK 12 QUESTIONS ABOUT VERB, CLIENT DECIDES CORRECT/INCORRECT

RECALL VERB

REPEAT FIRST STEP WITHOUT CUES

VNEST PROTOCOL -EDMONDS, 2014

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WHEN IT COMES TO MEDICATIONS• Reduce Polypharmacy• Avoid topiramate (can worsen

anomia) –Mula, 2012

• Many single case studies that wouldindicate benefit for Aphasia

• Address neurotransmitter systems disrupted by stroke

• Medication enhancing plasticity• Cholinesterase Inhibitors

A RANDOMIZED PLACEBO-CONTROLLED STUDY OF DONEPEZIL IN POST STROKE APHASIA• Berthier, et al 2006• 26 participants, 70 y/o or younger, chronic aphasia (1yr. or greater) • Computer randomized, well matched baseline variables• Western Aphasia Battery (WAB), Communication Activity Log (CAL),

Psycholinguistic Assessments of Language Processing in Aphasia (PALPA)

• 5mg/daily or placebo during a 4 week titration followed by 12 weekmaintenance (10mg/daily), followed by 4 week wash out phase

• Testing at 0, 4, 16 (endpoint), 20 (washout) week(s)• Concurrent Speech Language Therapy, 2 hrs. per week

“Syndrome specific standard approach”

RESULTS:• Statistically significant changes in

Aphasia Quotient (AQ) on the WABIncreased picture Naming on the (PALPA)

• Between group differences no longer significant at week 20. Suggests continued usage needed for benefit

• Adverse events higher for Donepezil group than placebo (Irritability (4), Insomnia (2) only during titration. 2 with recurrence of post stroke seizure without relapse after dose adjustment

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GALANTAMINE ADMINISTRATION IN CHRONIC POST-STROKE APHASIA,HONG, 2012

• 45 patients, 75 y/o or less, 1 year or greater post stroke

• Week 0 – Week 16• 8 mg/day for 4 weeks, 16 mg/day for

following 12 weeks• Spontaneous speech, comprehension,

repetition, naming• AQ on WAB

RESULTS• Statistically significant increase in total

AQ WAB score in Galantamine group• In Galantamine group, “good” vs.

“poor” responders. “Good” responders had higher level education, higher baseline Mini-Mental Status Exams

• Beneficial effect more prominent in subcortical dominant lesions

AUDITORY TRAINING CHANGES TEMPORAL LOBE CONNECTIVITY IN WERNICKE’S APHASIA: A RANDOMIZED TRIAL – WOODHEAD ET AL. (2017)

• 20 patients, 2 concurrent treatments• 5 week blocks• Drug only (5 mg. Donepezil)• Drug (10 mg.) + Earobics (two 40 min Tx)• Placebo• Placebo + Earobics

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RESULTS: • Statistically significant (but small) improvement

in speech comprehension with Phonological training (Earobics)

• Improvements including Generalization,improved written comprehension

• Worse comprehension with medication than placebo

• Both effects stronger in more severely impaired patients

• Take away: Donepezil may be better suited for speech expression vs. comprehension

REFERENCES IN ORDER OF OCCURRENCE Holland, A., and Fridiksson. (2001). Aphasia Management During Early Phases of Recovery Following Stroke. American Journal of Speech-Language Pathology, 10 (1): 19-28. Webster, E. & Newhoff, M. (1981). Intervention with families of communicatively impaired adults. In D.S. Beasley & G.A. Davis (Eds). Aging: Communication processes and disorders. Orlando, Fl : Grune & StrattonWorrall, L., Sherratt, S., Rogers, P., Howe, T., Hersh, D., Ferguson, A. (2010). What people with aphasia want: Their goals according to the ICF. Journal of Aphasiology, pages 309-322Turkeltaub, P.E., Messing, S., Norise, C., & Hamilton, R.H. (2011). Are networks for residual language function and recovery consistent across aphasic patients? Neurology, 76, 1726-1734.Robson, H., Zahn, R., Keidel, J.L., Binney, R. J., Sage, K., & Ralph, M.L. (2014). The anterior temporal lobes support comprehension in Wernicke’s aphasia. Brain, 137, 931-943.Robert Fucetola, Lisa T. Connor, Michael J. Strube & Maurizio Corbetta (2009.)Unraveling nonverbal cognitive performance in acquired aphasia, Aphasiology, 23:12, 1418 – 1426Murray, L. (2012). Attention and Other Cognitive Deficits in Aphasia: Presence and Relation to Language and Communication Measures. American Journal of Speech-Language Pathology. Vol 21, 51-64.

REFERENCES CONTINUED:Nicholas, M., Hunsaker, E., & A.J. Guarino. The relation between language, non-verbal cognition and quality of life in people with aphasia (2015)Journal of Aphasiology Volume 3, 688-702Nicholas, M., Sinote, Michelle P., Helm-Estabrooks, N. (2011) C-Speak Aphasia alternate communication program for people with severe aphasia: Importance of executive functioning and semantic knowledge, Neuropsychological Rehabilitation, 21:3, 322-366.Van Lancker, D., Cummings, J.L. Expletives: Neurolinguistic and neurobehavioral perspectives on swearing. (1999). Brain Research Reviews (1): 83-104Kiran, S. & Thompson, C. The Role of Semantic Complexity in Treatment of Naming Deficits: Training Semantic Categories in Fluent Aphasia by Controlling Exemplar Typicality (2003)Journal of Speech, Language and Hearing Research. Volume 46, 608-622Edmonds, L.A. (2014). Tutorial of Verb Network Strengthening Treatment (VNEST): Detailed description of the treatment protocol with corresponding theoretical rationale. SIG 2 Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 24(3), 78-88

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REFERENCES CONTINUED

Mula, M. Topitamate and cognitive impairment: evidence and clinical implications. (2012)Therapeutic Advances in Drug Safety. Dec 3(6):279-289

Berthier, M., Green, C., Higueras, C., Martin, M.C.,(2006) A randomized, placebo-controlled study of donepezil aphasia. Neurology 67(9):1687-9

Hong, J., Lee, J., Lim, T., Shin, D. Galantamine administration in chronic post-stroke aphasia (2012)Journal of Neurology. 83(7):675-80

Woodhead, Crinion, Teki (2017)Auditory training changes temporal lobe connectivity in Wernicke’s aphasia: a randomized trial. Journal of Neurology/Neurosurgery Psychiatry

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