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Home , Anomic aphasia, Aphasia, Aphasiology

12/7/2018

APHASIA

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

-National Aphasia Association

LANGUAGE Language is a system of communication that uses symbolism. K L U $ + M – : perceptually distinct unit of sounds Words: sounds combined & given meaning Sentences: combination of (rules) and (meaning).

• CLASSIFICATIONS OF APHASIA EXPRESSIVE VS. RECEPTIVE FLUENT 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 *mild comprehension deficits Lesion *

Choose Sentence Speech Coordinate Speak Idea Words Structure Sounds Articulate Pragmatics Muscles Fluently (Semantics) (Syntax) (Phonology)

SAMPLE OF BROCA’S THERAPY FROM TACTUS THERAPY

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WERNICKE’S APHASIA • Comprehension is poor (auditory & ) • Fluent, intact • , press of speech • , • Lack of awareness Lesion Temporo-Parietal, Posterior section of the near the

Auditory Preparation Attach Input Perception Recognition Phonological For Meaning Analysis 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 Lesion Broca’s & Wernicke’s Area Perisylvian region

WHAT DID THEY SAY? ANOMIA (Without Name) Tip of tongue, unable generate label Common with Many PERSEVERATION Overstimulation of the wrong target that occurred before question or activity Stereotypy

PARAPHASIAS * Language characterized by unintended syllables, words during speaking attempts Phonemic/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 * -difficulty with formulating grammatically correct sentences, telegraphic speech

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

VERBAL * SOUND SUBSTITUTIONS, GROPING FOR ARTICULATORY PLACEMENT * VOICE ONSET NON-VERBAL * DIFFICULTY WITH ORAL COMMANDS, I.E. SMILE, STICK OUT YOUR TONGUE * NODDING/SHAKING HEAD FOR YES/NO INDICATION CONSIDER MELODIC INTONATION

LIMB * DIFFICULTY EXECUTING BODY MOVEMENTS FOR COMMANDS THAT WERE COMPREHENDED * POINTING (COMMUNICATION BOARDS) * 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 . 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 * WEBSTER, NEWHOFF (1981)

* POSTPONE FORMAL TESTING FOR A FEW DAYS * CAN MIX FORMAL TESTING WITH INFORMAL INTERACTIONS. DOCUMENT STRENGTHS AND WEAKNESSES * EDUCATION/COUNSELING

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EDUCATION/COUNSELING * STAFF SHARE “TEST” RESULTS, STRENGTHS WITH NURSING * FAMILY/PATIENT WHAT IS APHASIA TIPS FOR COMMUNICATION DIAGRAMS SPONTANEOUS RECOVERY

INFORMAL ASSESSMENT * ESTABLISH MEANS OF YES/NO * USE ITEMS IN ROOM TO MAKE CHOICES, PROBE AUDITORY DISCRIMINATION, COMMANDS * USE GREETING CARDS, MENU FOR 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 CUE SYMBOL CUE EXPRESSION CUE

EXPLORE FREE APPS LET ME TALK YES/NO APPNOTICE 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 AREAS * TURKELTAUB ET AL. (2001) EVIDENCE OF LANGUAGE REORGANIZATION TO HOMOTOPIC REGION IN RIGHT HEMISPHERE * ROBSON ET AL. (2014) RECRUITMENT OF THE ANTERIOR TEMPORAL LOBES FOR COMPREHENSION IN WERNICKE’S APHASICS

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, ASHA.ORG (AMERICAN SPEECH, HEARING ASSOCIATION) NATIONAL APHASIA ASSOCIATION AMERICAN STROKE ASSOCIATION

OTHER RESOURCES Free or Low Cost Apps Stroke Support Groups Missouri State University Speech- Language Hearing Clinic

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Tactus Therapy Lingraphica’s Talk Path

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

CONSTANT THERAPY Tablet Smart 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 COGNITIVE ABILITY IS NOT FULLY EXPLAINED BY LANGUAGE COMPETENCE 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 ON COGNITIVE MEASURES, BUT DISPLAYED VARIABILITY 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 FUNCTIONS

Range 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 task & Maze

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C-SPEAK APHASIA STUDY(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 MAZES CLQT, NANCY-HELM ESTABROOKS, 2011

PROMOTE COMMUNICATION For 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 LANGUAGE OVER-LEARNED, ROTE * COUNTING, DAYS OF WEEK * PRAYERS * WELL KNOWN SONGS * CURSING LIMBIC SYSTEM, , 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 phrases 3 levels (elementary, intermediate, advanced)

MELODIC INTONATION CONT.

Uses 2 pitches. Stressed syllables have upward pitch, unaccented syllables have downward pitch Left 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 RIC PERSONAL 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 • • 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 would indicate 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 week maintenance (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 “ specific standard approach”

RESULTS: • Statistically significant changes in Aphasia Quotient (AQ) on the WAB Increased 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 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 & Stratton Worrall, 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 , pages 309-322 Turkeltaub, P.E., Messing, S., Norise, C., & Hamilton, R.H. (2011). Are networks for residual language function and recovery consistent across aphasic patients? , 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 – 1426 Murray, 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, 688-702 Nicholas, 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): 83-104 Kiran, 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, 608-622 Edmonds, 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

THANK YOU

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