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Making Therapeutic Sense of Severe Deficit

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Making Therapeutic Sense of Severe Deficit 4/10/2018 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 1 4/10/2018 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 2 4/10/2018 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 3 4/10/2018 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 4 4/10/2018 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 5 4/10/2018 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 6 4/10/2018 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).
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