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All severe deficits are challenging unless physiologic improvement causes substantial improvement
Movement and meaning All severe neurologic speech language deficits are not same ◦ Here am excluding dysarthria
Severe or global aphasia-whatever term does not endanger compensation Usually pretty simple for the experienced ◦ Usually, but not inevitably, a combination of clinician to identify even with limited testing aphasia and AoS Severe non-fluent deficit that appears to be
neither AoS or aphasia alone or in combination Some cases are more difficult and will talk about a diagnostic therapy to help make Severe or profound AoS sense of these ◦ Often called apraxia of phonation
For years some clinicians have avoided the Severe deficits across all language modalities: speaking, reading, writing, listening term global aphasia for billing reasons Speaking often limited to one or more “recurring utterances” And-truth be known-the term may matter Reading limited perhaps to a few single words and these are often identified inconsistently less than the description Writing limited to inconsistent copying What is that description? Listening best preserved modality but very easy to overestimate Cognition-once acute brain damage resolved-is restored to near pre-morbid levels Social interaction and behavior similarly restored to normal or near normal pre-morbid
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Apraxia of speech often
Hemiplegia often as well as a variety of other limb deficits
Field cut often
Personality intact Both superior and inferior limbs of middle cerebral artery
Often significant frustration
May be much better treatment candidate at 6 mos than earlier
Psychologically this has always been the hardest clinical issue for me Only approximately 5% recover functional Family wants person with aphasia (PWA) to speech talk Patient wants same Prognosis especially dark if improvement Neither takes kindly to any but verbal does not occur in first few days post expressive emphasis And we have to be careful of self-fulfilling prophesies
Do not impress me as global No intelligible speech beyond a form of “yeah” ◦ Enough comprehension to recognize and try to correct Seem to have better language than speech errors or prevent them with silence and no cognitive deficit No hemiplegia, cognitive, or behavioral deficit Language impaired but not as severely as speech They look like apraxic speakers superficially Did the most basic motor speech training but
never learned even one word However, treat them motorically and they do not respond with improved speech But regained enough reading to enjoy paper Could write simple words functionally as in I have never gotten one to talk taking phone message and grocery list Comprehension not normal but functional
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Naeser et al Severe nonfluency in aphasia. Nancy Helms’s Visual Action Therapy Brain. 112:1-38, 1989 ◦ Program centers on learning gestures to ◦ Describes this group as having nearly no hope of communicate notions talking again ◦ Speech is inhibited ◦ She says need to identify so can begin an appropriate nonverbal treatment such as VAT or ◦ Publisher of this program is pro-ed, 1991 visual action therapy More of this in a moment and also some other treatment options
Such patients can be identified by localization Two critical areas BUT not in cortex on scan First is ◦ Of course many of us do not have scans to work ◦ Medial subcallosal fasciculus from
Thus clinically ◦ Lesion here disrupts connections of supplementary ◦ They are speechless or nearly so and remain that way despite increasing language competence motor area and striatum ◦ They are not globally aphasic in any traditional sense ◦ Seems to affect preparation and initiation of speech ◦ They do not regain speech even with treatment movements ◦ But communication is definitely possible And more possible than in traditional global aphasia
Medial one-third of PVWM or periventricular Aphasia doesn’t seem to be right white matter Language is too good This area is deep to the motor-sensory area AOS doesn’t seem right cause can’t teach to for mouth talk May affect sensory feedback and pathways Dysarthria is wrong necessary to motor execution Dementia is wrong
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What do we call a problem of initiation, Language intact or nearly so, especially execution, will to produce and sensory comprehension feedback May be mute If muteness lasts more than 14 or so days, some Abulia? other speech-language deficit is likely The clinical issue is to identify such patients Or there is a previously unreported co-morbidity so treatment planning can begin such as infection, multiple strokes have an influence Once muteness lifts effortful speech emerges with variable speed but often quickly ◦ Rosenbek (2004). In Kent (Ed.). MIT Encyclopedia of Communication Disorders. The MIT Press
Avoid wasting clinician and patient time doing things that won’t help ◦ In both global and severe, non-fluent speech is very unlikely This is not to say that no treatment is appropriate ◦ General stimulation is critical This brings us to pairing movement Person with severe, non-fluent much more tolerant of early focal treatment than is person and meaning with global Person with severe apraxia only one likely to respond to speech drills ◦ Of course can try speech drills with all in the beginning
But requires extreme clinical acumen in Use imitation, phonetic placement, integral practice stimulation, or combinations to elicit a verbal response Because interpretation of finding is likely to ◦ If patient has meaningful, recurring utterance can be TOUGH try starting with that If produced successfully then have person
select from an array Object is to elicit the most meaningful Do enough so you can determine difference utterances (two at a minimum) and then test between chance and understanding if person can consistently indicate understanding of the utterances’ meanings
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Because of severity I ◦ Try to start with short meaningful utterances I, bye, and etc Select from
◦ Eye ear nose throat (or any other appropriate May have to retreat to oral movements foils) written out More on this in a moment ◦ Or pointed to or
Represent the spoken utterance’s meaning in any and all possible ways Gestures, pictures, written, sung
Add one or more additional verbal stimuli Limb apraxia can be an influence
As can peripheral and more central auditory and Is a better test of meaning visual deficits such as the agnosias, and dementia, and on and on Frustrates perseveration which is usually a major challenge for these persons But sorting all these influences out is what makes us a profession and not just well-intentioned folks with patience and hearts of gold Then start going back and forth between ◦ And you don’t have to KNOW; an hypothesis is good verbal and meaning however most enough and usually all you muster regardless of years of successfully represented experience
A critical reference for going beyond this bare Clear that most of these movements do not bones discussion have easily represented meanings ◦ Kent (2015). Nonspeech oral movements and oral Thus first measure is motor disorders: A narrative review. Am J Sp-Lang ◦ Can person switch reliably from one movement to Path, 24, 763-789 another For our immediate clinical use ◦ Can person combine into sounds ◦ Use movements, if at all possible, that are part of ◦ Does person remember what was learned in one speech sounds session in the next session ◦ Try to integrate into sounds as quickly as possible
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To degree person cannot associate movement If hypothesis is severe aphasia or severe non- and meaning hypothesize severe aphasia fluency, continue a short bit of speech To degree person can make association therapy each session hypothesize severe non-verbal or AoS But move quickly to alternative To degree person cannot reliably produce the communicative procedures such as drawing movements hypothesize severe aphasia or and gesturing (to be reviewed) severe non-fluency ◦ Either alone or combined with speech To degree person can both learn movements If hypothesis is AoS, intensify the speech, and associate with meaning hypothesize AoS motor work
Long-range, perhaps idealized goals These goals are idealized-but why not? Of course, their attainment may depend in part on behaviors over which we have little control ◦ Restoration of best possible language and/or ◦ Field deficit speech performance ◦ Hemiplegia ◦ Emotional illness But much is IN our and our patient’s control ◦ The richest, best possible communication AND, if we enter rehab with more modest goals we will achieve only those ◦ The richest, best possible reengagement in life And, of course, the goals are different and the art and science of practice is to match goal and ◦ The most comfortable possible adjustment to patient at every stage of treatment with each residual communication deficit person
Regardless of severity it is important to patient and family are going to want to try remember speech The SLP does not cure, improve, or slow Tough intellectually cause you know success is unlikely decline of anyone No rule about how long to try Persons do that themselves with the My rule of thumb is to have a bit of speech clinician’s support guidance and methods work every session-duration varies with Doing so requires ◦ How much person and family want it ◦ WILLINGNESS ◦ How successful you are at helping them be realistic ◦ ABILITY TO CHANGE-this is the one that makes ◦ Whether generalization is occurring selecting the appropriate treatment target so And I try to move quickly to speech facilitated critical by alternative modality
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Gesture and speaking in the brain Linked in brain ◦ Sample treatment study and a simple tx program Can be of two general types ◦ Meaningful Discussions of simple programs using imitation Gesturing and the right hemisphere followed by more functional steps such as using ◦ Intention treatment gesture to answer question have been described Hux, Weissling, Wallace (2008). Communication-based interventions…In Chapey Language Intervention Strategies Drawing in Aphasia…, Fifth Edition, Wolters Kluwer814-36 Will describe a newer program of sis or seven steps depending on how you divide Writing ◦ Timing, limited meaning Will describe one of more interesting-intention therapy
Dipper et al (2015) The language-gesture Makes sense to try combining gesture and connection…Clin Ling Phon, 29, 748-763 speaking especially in severe Recognizing that both will doubtless require Make case for cortical interaction and say therapeutic attention But with hope that gesture can facilitate the “..gesture is both closely related to spoken verbal language deficit and compensatory…” Reference: Raymer et al (2012). Contrasting effects of errorless naming treatment and gestural facilitation for word retrieval in aphasia. Neuropsych Rehab, 22, 235-266
25 pictured items Step four: Cl models both and pt imitates Step one: Clinician models name and gesture both three times for each item Step five: After 5 sec pause, pt asked to Step two: Clinician models only the gesture, spontaneously name and gesture but only if pt imitates and clinician helps with shaping can successfully name pt’s hand. Pt repeats gesture three times Step six: If name forgotten, cl models both Step three: Cl models name and pt imitates and again gets three repetitions three times
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Step seven: CILT type barrier but only to No or very limited activity/participation steps block view of cards. Pt tries to name and but we will address in later section very gesture each card specifically ◦ If not able to name, card set aside ◦ At end of the complete set, the cards not named are As with most research the emphasis is on modeled (both gesture and name) and only one impairment repetition required Which is not bad its just incomplete for clinical ◦ purposes Results: generalization to standardized aphasia exam,
Intention- selection of one course of action Trained to initiate a naming through a over others in preparation to respond movement sequence with the left hand Stroke can cause a disconnection between Movement sequence used in the first two intentional and production mechanisms phases of treatment is nonsymbolic (button affecting language output press) Intention treatment primes right hemisphere Movement sequence in third phase of initiation mechanisms using the left hand treatment is more natural and can be ◦ See: Crosson (2008). Seminars in Sp & Language, generalized to situations outside the clinic 29, 188-194 10 sessions at each stage, tx 5 days per week
Most effective in patients with nonfluent Pt lifts lid off aphasia and moderate to severe anomia Reaches inside to press a button Patients with language initiation difficulties Then says name of may benefit from engaging right hemisphere item that pops up intention mechanisms prior to naming with button push If correct go to next If incorrect, imitate the cl while also making gesture
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Crosson et al (2007). JINS, 13, 582-594 ◦ 23 with moderate to severe naming deficits and nonfluent ◦ 11 with profound deficits ◦ Intention tx had positive effect in 89% ◦ And generalization occurred for 85% ◦ Assumption is that right hemisphere perhaps interacting with some intact posterior left hemisphere tissue is basis for treatment effect
N= 4 single-subject cross-over Simple gesture accompanied by “immediate Two txs: effects” for 2 but no generalization ◦ non-symbolic circular gesture and name Meaningful gesture accompanied by delayed ◦ Meaningful gesture and name naming improvement for two and immediate 10 sessions of each separated by 7 days effects on gesturing for 3 with carryover in Results are predictably complex one Milder improved most but one severe made substantial improvement in gesturing Suggestion: Use both forms of gesturing in treatment
Type of gesture Seems to Whether done with right or left hands ◦ Benjamin et al (2013). Submitted. Done in right or left hemispace or in the N=14, 7 intention group; 7 control midline The usual intention treatment compared to Whether done before during or after speaking same except no gesture or with no attendant speaking ◦ Phase 1 and 2 confrontation naming ◦ Phase 3 category member generation ◦ 10 sessions at each phase
Verbal and fMRI outcomes
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No difference between groups in naming In control group, the shift was to LEFT improvement hemisphere more posterior regions More generalization to untreated stimuli in the gesture (Intention) condition Taken together mere production seems to There was a lateral shift (to right hemisphere) build on left hemisphere mechanisms in the Intention group that correlated to improvement Adding gesture seems to “recruit” right ◦ Shift was to lateral posterior perisylvian regions posterior regions as explanation for ◦ Not to frontal (as in earlier study) improvement
Generalization to discourse as elicited by “Maintenance of a residual relationship picture description between hand movements and language seems like a (more) plausible explanation for ◦ Altmann et al (2015). JSLHR, 57, 439-454 the rightward laterality shift to intention treatment” A step closer to activity/participation
One of the few behavioral treatments created specifically to target areas of brain as basis There are formal programs that like most for improvement formal programs are heavy on follow the leader Preferably usually is introducing drawing into Now for the severe, non-fluent who unlike communication attempts more naturally the severely aphasic person can often learn to And there are (of course) combinations write
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One of the most misunderstood programs Lyon Sims.CAC Proceedings, 18:339-347, because people immediately think of art and 1994 talent Morgan, Helm-Estabrooks. CAC Proceedings. Principal developer: Dr. Jon Lyon 17:64-72 Read: Lyon, Drawing; Its value as a Ward-Louergan & Nicholas (1995). Drawing communication aid for adults with aphasia. to communicate…Eur J Dis Commun, 30, Aphasiology. 9:33-94, 1994 475-491 Farias et al (2006). Drawing: its contribution to naming. Brain & Lang, 97, 53-63
Drawing alone can communicate messages May augment verbal Drawing may be somewhat independent of Emphasis is not on art but on communication language symbols and rules Outcome is communication effectiveness May rely more on visuoconceptual forms of thinking May facilitate language in other modalities May access inner thought or speech May help to increase confidence to use other modalities May use more intact right hemisphere skills (Rosenbek)
Brain damage influences drawing Use traditional modeling and delay Drawing may not be acceptable methodology to establish or refine drawing of stick figures - May be disrupted by co-existing apraxia Describe a situation and have a person draw, for Drawing is not independent of cognitive example linguistic subsystems If not intelligible, provide a verbal cue, for example, where is the TV? Pr, provide a drawing cue such as adding the missing part yourself
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Or enlarge the area of the missing part and First make a guess about content have pt draw it in the box (now draw the TV If wrong, get oriented with Qs: in here) -Perspective -Setting Move the situation into a PACE context and -Main objects use another interactant -Who Be sure interactant is also trained in cueing -When Move from simple to more complex notions Ask that main part of drawing be highlighted
Ask that main part be enlarged 8-accurate, complete identification within Ask pt to show what to do with particular first minute element 7-accurate, complete identification after delay up to two minutes Systematically summarize and reformulate 6-same but within three minutes what is being communicated 5-same but longer than three minutes 4-inaccurate, related identification within three minutes
3-inaccurate, remotely related within three Takes work to make it communicative minutes Clinicians sometimes cannot give up on 2-inaccurate, unrelated despite interactive manipulating the speech structures attempt Anecdotally recorded that many patients speak more frequently and with greater 1-inaccurate unrelated with no interactive variety attempt By self is not complete therapy It must be pragmatic
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N=10 persons with severe aphasia, minimum Aim one was to have a person try to evoke a of one year of aphasia drawn representation of an idea 12 weeks of tx with one hour of individual Focus on efficiency so that what is and one hour of group per week portrayed is most critical to the Aim: promote use of drawing in communication communication Develop awareness of needs of interpreter Sacchett, et al. 1999. Int J Lang comm dis, 34, 265-289 and respond creatively to failed communication Improve the interpretive skills of others
Dependence on interactive drawing which is Drawings were “significantly” more to say the clinician draws as well recognizable after tx Minimized the use of pictures as they do not Drawings in context were more support generation of ideas recognizable than those in no context NO generalization to other modes of Emphasis on use of the drawings to communicate communication Results maintained 6 weeks later So a lot of PACE stuff and turn taking BUT some changes in communication reported by carers
Get improvement on trained items Functional MRI shows “strong bi-hemispheric Get reports of improved communication in activation of semnatic and phonological natural environments networks while drawing” No change in untreated modalities Farias, Davis, Harrington. (2006). Drawing: its contribution Usual conclusion is that the natural to naming in aphasia. Brain Lang, 97, 53-63 environment change is wishful thinking Maybe not
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Used most frequently for severe CART and T (texting)-CART No apparent relationship between ability to Beeson et al (2003). Writing treatment for draw from memory and severity of type of severe aphasia: Who benefits? JSLHR, 46, aphasia 1038-1060 Gainotti, et al (1983). Drawing objects from memory in CART=copy and recall therapy aphasia. Brain, 106, 613-622 Data are from 21 one hour sessions over 13 weeks ◦ Is that an intensity you can meet? ◦ Will be talking about this and what to do in lecture 3
Method is an example of using one modality One: clinician shows a written word (or not- to help another in this case writing to support may merely say it) and says it and urges pt to speaking imitate In ideal world has him imitate till correct ◦ M-MAT is acronym for any treatment doing this ◦ If never correct can just go with the written form as in this next step ◦ MOAT is acronym for tx that emphasizes tx of a Two: Clinician writes word (if not written out modality for its own sake in beginning) and has pt copy multiple times
If correct, then word is covered and pt is to write from memory Cue as necessary Will discuss the most data-supported method Also get them to write and say for AoS in afternoon
RESULTS: many severe pts learn both writing Reminder: Don’t worry about not knowing and saying for sure what your patient has Carry-over best for written as opposed to ◦ Careful attention to how each responds to what you texting using key board and phone are doing will tell you if you are doing right
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Thanks
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