546 Exam 2

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elz125
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243674
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546 Exam 2
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2013-10-29 21:57:06
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aphasia
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Aphasia exam 2
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  1. Features of Global Aphasia
    • Loss of language comprehension and verbal expression
    • No sex or age bias
    • Most lesions are cortical, extensive, left hemisphere, MCA, thrombosis
    • Clinical depression
    • Frequent facial and limb apraxia (right side)
    • Probably right hemiparesis too
    • Isolated areas of preserved comprehension for some clients
  2. Global Aphasia Expression
    • Stereotypic recurring utterances; real word or nonsense
    • Continuous syllable string with intonation changes
    • Unreliable or absent yes/no
    • Nonspecific gestures (looks like communication, but has no meaning)
  3. Recovery of Global Aphasia
    • Lowest recovery rate; variable
    • 50% do not evolve to less severe
    • Comprehension improves more than expression; nonverbal more than verbal
    • Improvement enhanced by treatment within first 12-18 months
  4. Prognostic Indicators of Global Aphasia
    • Age: no proof that younger is better
    • Imaging: findings are not reliable
    • Language scores: early yes/no response- better outcome at 1 year post stroke
  5. Treatment Approaches for Global Aphasia
    • Greater success when focus on residual skills (skills that were still intact after the stroke)
    • 1. Social approaches
    • 2. Functional approaches
  6. Social Approaches (Global Aphasia)
    • Partner training
    • Conversational coaching
  7. Functional Approaches (Global Aphasia)
    Communication boards
  8. Communication Boards
    • Begin highly structured: matching pictures prior to discrimination (point to) tasks
    • Provide high level of support- physical assistance
    • Alternative designated boards to keep categories separate
    • Train in natural environments
  9. Modest Goals for Short Term Treatment of Global Aphasia
    • Develop reliable yes/no response with speech of gestures
    • Develop set of basic messages via speech or gestures or pictures
    • Improve comprehension of basic 1 step commands in context with nonverbal cues
    • Encourage drawing as form of communication
  10. Types of Comprehension Processes
    • Bottom-up
    • Top-down
    • Knowledge-based or heuristic
  11. Bottom-up
    • We use only when necessary
    • Analysis using piece by piece approach (e.g. phonetic decoding of unfamiliar word)
  12. Top-down
    • Used more often than bottom-up
    • Knowledge-based or heuristic (e.g. guess at meaning using your experiences
    • Heuristic knowledge is preserved in most aphasic patients
  13. Knowledge-based or Heuristic
    • Used to understand spoken material
    • General knowledge
    • Expectations
    • Intuition
    • Guessing
    • Does not require continuous word-by-word lexical and syntactic analysis
    • Allows for use of SCRIPTS
  14. SCRIPTS
    • Pre-written dialogues between two people
    • Ex. social greetings, a waitress taking orders, etc.
  15. Use of Scripts in Therapy
    • Scripts: what we expect to hear based on experience
    • Preserved for many people with aphasia
    • Context facilitates comprehension
    • Appropriate for those with sentence level comprehension skills
  16. SCRIPTS: Spoken Sentence Comphrension
    • SLP modifies length and complexity of stimuli and responses required
    • Most daily life utterances are less than 5 words in length (hi, how are you, good to see you, etc.)
    • Employs "response switching"
    • More functional than working on following 2 and 3 step directions
    • No empirical evidence to show improvement in overall language comprehension
    • Scripts help people communicate within a public/social setting
  17. Response Switching
    • Deliberate changes in the form of stimulus sentences and required responses from trial to trial
    • Ask a question, person replies with statement, follow-up question, joke, etc.
    • Purpose: prepare person for day to day conversations out in public
    • Requires: memory skills, comprehension
  18. SCRIPTS: Grammar and Syntax in Spoken Sentence Comprehension
    • A. Present tense is easier for clients to comprehend than past or future
    • B. Affirmative is easier than negative
    • C. Singular is easier than plural
    • D. Active voice is eatery than passive
    • Start with concrete language and then move to more complex language
    • Reducing sentence length may have undesirable consequence of increasing syntactic complexity (making something shorter doesn't necessarily make it better)
  19. SCRIPTS: Comprehension of Discourse
    • Word and sentence comprehension cannot predict comprehension of discourse
    • Discourse comprehension is often better than single-sentence comprehension (can use context cues)
    • Comprehension is aided by context, redundancy, predictability, extralinguistic cues (ex. salience or emphasis)
    • Try not to be condescending/patronizing like you are talking to a child
  20. Comprehension of Discourse
    • Conversational speech = how we communicate naturally
    • 1. Context
    • 2. Predictability/familiarity
    • 3. Redundancy
    • 4. Extralinguistic cues
  21. Context (Comprehension of Discourse)
    • Contextually relevant sentences that precede or follow a target sentence can improve processing of key information (e.g. identify topic, setting, or predict relationships)
    • Tap into general knowledge and experience
  22. Predictability/Familiarity (Comprehension of Discourse)
    • Use preexisting knowledge
    • Scripts organize knowledge of common situations
    • Can use overt scripts, then fade
  23. Redundancy (Comprehension of Discourse)
    • Begin treatment using repetition, paraphrasing and elaboration
    • Emphasize main ideas and direct information
    • Allows clients to use heuristic/knowledge based processes
  24. Extralinguistic Cues (Comprehension of Discourse)
    • Pauses
    • Word stress
    • Natural gestures
    • Facial expressions
    • Be careful with humor
  25. Treatment of Discourse
    • Stimulus manipulations
    • Patterns of auditory comprehension problems
  26. Stimulus Manipulations (treatment of discourse)
    • Familiarity
    • Length
    • Redundancy
    • Salience
    • Directness
    • Rate
    • Context
  27. Patterns of Auditory Comprehension Problems (treatment of discourse)
    • 1. Slow rise time: miss initial input
    • 2. Noise build up: errors increase over time
    • 3. Intermittent auditory imperception: comprehension fades in and out (shutter effect); unpredictable errors
    • 4. Retention deficit: deterioration with increased length
  28. Treatment of Auditory Comprehension Problems (treatment of discourse)
    • 1. Slow rise time: alerters; redundancy 
    • 2. Noise build up: insert silent intervals
    • 3. Intermittent auditory imperception: use redundancy
    • 4. Retention deficit: control stimuli for length; gradually increase message length
    • Teach significant others to use these strategies to benefit the client outside of therapy
  29. Treatment of Wernicke's Aphasia
    • Using context to facilitate communication
    • Marshall's Context-Based Approach
  30. Marshall's Context-Based Approach (Wernicke's)
    • Best with people who have sentence-level comprehension
    • Focuses on message comprehension and message exchange
    • Two stages of treatment related to time post onset; early and late
  31. Early C-B Treatment for Wernicke's Aphasia
    • Many patients don't know that they aren't being understood and aren't understanding
    • Emotional and behavior effects
    • Family confusion
    • SLP assumes role of "behavioral engineer" (educates and guides patient, family and treatment team; trains conversational partners)
    • Early assessment: patients do poorly on typical tasks
    • Marshall uses para-standardized testing, observation, and personal information about patient
  32. Early C-B Assessment: Para-standardized Testing
    • Spark Para-standardized Examination Guidelines for Adult Aphasia (PSE)
    • Indicates: 
    • Strengths/weaknesses
    • What facilitates comprehension and message exchange
    • Marshall modified PSE to include assessment of four communication features: Therapeutic Set, Pragmatics, Auditory Comprehension, Verbal Expression
    • Each feature includes: Areas of concern, Negative signs/behaviors, and Positive signs/behaviors
  33. Early C-B Assessment: Observation and Personal History
    • Observation: communication in different settings with different partners (add information to PSE)
    • Gather personal history: history, background, pre-morbid communication, style and habits (can use questionnaires)
  34. Early C-B Therapy: Goals
    • 1. Establish therapeutic set: positive attitude (if client has negative set, you can find a way to show how working with you is beneficial)
    • 2. Create different contexts for communication: need for communication (top-down model)
    • 3. Increase comprehension in established context
    • 4. Maintain flow of communication in context
  35. Marshall's Use of Communicative Context
    • "Prime the patient" for context
    • Use visual stimuli
    • Reinforce and encourage patient's requests for repetition
    • Use concrete humor and descriptive language
    • Alert patient to topic change
    • Maximize redundancy
    • Use paralinguistic cues
    • Manipulate response for short answers
    • Fill in necessary words to keep patient focused (very different from traditional therapy)
    • Slow rate of speech and pauses at natural intervals
  36. Early C-B Therapy: Excessive or Restricted Speech Flow
    • Excessive flow: "press of speech"
    • Defective utterances fed back into impaired auditory comprehension system- lack of comprehension of what is said to them and lack of comprehension of what they are saying ("garbage in, garbage out")
    • Stop Strategy: teach the client that when a sign that signals 'stop' is used, the client must stop talking
    • Paraphrase, model, reinforce: help the client understand that they don't need to keep talking to get their point across, they can say what they want to say in a more succinct way
  37. Early C-B Therapy: Restricted Speech Flow
    • Patient begins to comprehend problems
    • Severe interference of communication of basic needs
    • Fill in
    • Keep trying
    • Acceptance
    • Reinforce persistence
    • Variability
  38. Early C-B Therapy: Support and Guidance for Caregivers
    • SLP demonstrates how to: increase comprehension, restrict or promote speech flow, create communication opportunities (make sure the caregivers know that they can't restrict communication opportunities)
    • Have family members/communication partners observe so they can try using the strategies with the client at home
  39. Marshall's Later Context-Based Therapy for Wernicke's Aphasia
    • ~2-3 months post onset
    • Persistent word-finding problems or is considered to have anomic aphasia; less severe comprehension problems; good response to early C-B tx (tend to use circumlocution or interjections as fillers)
    • Comprehensive assessment and family completes rating scales (what still seems to be the problem with communication?)- can write therapy goals using this
  40. Later C-B Therapy: Residual Auditory Comprehension Problems
    • 1. Attention deficits- sustained attention, shifting attention from one task to another, multi-tasking is not encouraged
    • 2. Perseveration- when a response that was appropriate is repeated when it is no longer appropriate (usually stops after a while, if it perseveres, that is not a good prognostic indicator)
    • 3. Impaired understanding single words- can't understand a word without context
    • 4. Retention deficits- have to work on understanding each part of the utterance and may forget the beginning of it
  41. Later C-B Therapy: Attention Deficits
    • 1. Use alerters (verbal or nonverbal)
    • 2. Specify topic change (verbal or nonverbal)
    • 3. Teach to alternate tasks (break long activities up by interjecting other activities in the middle, like watching a movie)
  42. Later C-B Therapy: Perseveration
    • No agreement on how to treat
    • a. Allow time to integrate and consolidate
    • b. Treatment of Aphasic Perseveration (recommend communicating clearly to the client that the perseverating response is not appropriate)
    • Change the activity (move to a nonverbal activity) or take a break
  43. Later C-B Therapy: Problem Understanding Single Words
    • Behavioral Indicators:
    • 1. More trouble identifying by name than by function
    • 2. Repetition of word; perplexed
    • When interference with communication occurs, SLP:
    • a. Increases redundancy
    • b. Increases contextual support
  44. Later C-B Therapy: Retention Deficits
    • Can further restrict comprehension of contextual situations and isolated tasks
    • Teach behavioral and compensatory strategies:
    • Asking for repetition
    • Rehearsal (doesn't usually help)
    • Personal cuing (try to related a name to someone they know)
    • Memory aid (external)- writing notes
  45. Later C-B Therapy: Improving Discourse Comprehension
    • 1. Rest/Withdraw- let the clients know it's okay to rest after a conversation or visit with a friend
    • 2. Pre-stimulation- give information before a situation so the person can start imagining and guessing what the conversation topics may contain
    • 3. Supplementary input- closed captioning, reading a description of a movie
  46. Reading Comprehension Problems in Aphasia
    • Slow rate (reduced mental resources)
    • Misperceptions
    • Word by word decoding (easy to lose meaning)
    • Poor retention
    • Loss of overall meaning (since it takes so long to get through, cohesion is decreased)
  47. Assess Reading at Sentence and Paragraph Levels
    • Subtests: WAB-R, BDAE (matching word to picture, picture to word, letter to letter, etc.)
    • Reading Comprehension Battery for Aphasia-2 (good for people who already have reading comprehension at sentence level)
    • Gray Oral Reading Test-3 (requires person to read aloud, gives you grade-level equivalent, this may not really be testing comprehension because the person may just be able to express it)
  48. 2 Types of Reading Comprehension Problems
    • 1. Deep or Phonologic Alexia:
    • Errors when "decode"
    • Can recognize whole words
    • Poor bottom-up approach
    • Good with familiar, meaningful words
    • 2. Surface or Semantic Alexia:
    • Poor whole word reading
    • Have to sound words out (at a deficit with unusual spellings)
    • Depend on decode approach
  49. Alexia
    Acquired reading comprehension deficit due to brain damage
  50. Deep/Phonological Alexia
    • 1. Can read high frequency concrete nouns
    • 2. Whole-word recognition intact
    • 3. Problems with function words
    • 4. Poor grapheme-to-phoneme (better off to teach them combinations of sounds- syllable approach)
    • Some success: biograph-syllable /pa/ vs. /p/ + /a/
    • Some success: phrase-formatted text and multiple oral rereadings
  51. Surface/Semantic Alexia
    • 1. Impaired whole-word reading:
    • Case studies suggest success with improving WWR
    • Teach through memorization and repetition
    • 2. Depend on grapheme-to-phoneme (word length effect is problem)
    • 3. Irregularly spelled words are mispronounced (teach to use context)
  52. Impaired Processes for Reading
    • Lost or impaired whole word reading
    • Lost or impaired phonemic analysis
  53. Occular Causes of reading Impairment
    • 1. Visual field loss
    • 2. Eye movement problem
    • 3. Poor central vision
    • Check brain imaging report
    • Question vision history
  54. Treating Neurogenic Reading Impairments
    • 1. Obtain literacy history:
    • Level of education
    • Reading preferences prior to stroke
    • How much they read prior to stroke
    • How much reading was involved in their job
    • 2. Determine current skills
    • 3. Determine importance to client
    • Best prognosis: sentence level comprehension of written material, intact vision, motivation to read/rich reading history, responsiveness to trial therapy, attending and memory skills
  55. Treating Severe Reading Comprehension Disorders
    • Survival Reading Skills (client indicates list of reading materials- most wanted to wanted but can do without)
    • Develop and teach core sight-reading vocabulary
    • Depends on discharge plan and who the person will have around them
  56. Treating Mild to Moderate Reading Comprehension Disorders
    • Teach clients to use context to establish topic and deduce word meaning
    • Taps heuristic knowledge
  57. Treatment of Reading: Stimulus Manipulations
    • Familiarity
    • Length
    • Redundancy
    • Salience/Directness
    • Vocabulary
    • Syntactic Complexity
  58. Reading Programs Based on Grade Level and Specific Skills
    • Identifying main ideas
    • Locating details
    • Homework assignments used in treatment sessions
    • Make sure reading selection is not demeaning
  59. Agraphia vs. Dysgraphia
    Agraphia is acquired
  60. Deep Agraphia/Sublexical Agraphia
    • Presence of written semantic errors, effects of frequency, imagery, and class
    • Word frequency is very important
    • They can write something that they can picture better than something they can't picture (ex. jogging)
    • Semantic paraphasia (ex. can visualize jogging, but may write down run)
  61. Surface Agraphia/Lexical Agraphia
    • Over reliance on sound to letter conversion; regularization of irregularly spelled words
    • Don't think about whole word units, think about decoding
    • Frequency and imagery do not help
    • Irregularly spelled words will be spelled the way they sound ("you" instead of "yacht")
  62. Global Agraphia
    • Impaired lexical and sub lexical spelling processes (will not functionally write in future)
    • Trace name over and over so they know the motor movements to sign their name
  63. Writing Deficits in Aphasia
    • Most aphasic adults write less well than they speak
    • Writing resembles speech in nature of errors:
    • Fluent aphasia: Fluent cursive, neat, empty content, paraphasic errors
    • Nonfluent aphasia: Distorted printing, uneven spaces and lines, confluent, agrammatic (often writing with left/non-dominant hand)
  64. Assessment of Single Word Writing
    • Use controlled word list for evaluation of lexical features (frequency, imagery, class, spelling regularity, word length, morphological complexity)
    • Johns Hopkins University Dysgraphia Battery (used for deficits with spelling)
  65. Writing Impairments: Damage to Processes?
    • Semantic system
    • Graphemic output lexicon
    • Graphemic buffer than temporarily holds graphemic information for writing
    • Conversation processes necessary to select and form (converting a word into writing)
    • Graphic motor processes (referral to occupational therapist)
    • Working memory
  66. Survival Writing Skills in Aphasia
    • Elicit client and family input to generate list of what client would most like to write, extract core vocabulary and basic syntax
    • Some clients are happy with writing phonemically (they write words the way they sound)
  67. Treating Mild Writing Deficits
    • Recent returned focus on writing: email
    • If informal, tolerance for telegraphic form
    • Formal messages require more complex syntax than spoken messages with accurate vocabulary (academic, vocational, professional)
    • Use spell check, style check, word prediction (word prediction requires good editing/self-correction skills)
  68. SLP Plus Neuroplasticity
    • Functional reorganization of language in aphasia
    • a. Recruitment of residual left hemisphere structures
    • b. Recruitment of right hemisphere regions, typically homologous to left hemisphere language areas (right hemisphere contributions may reflect attention, executive function, memory)
    • Cognitive reorganization
  69. What Do We Need to Express a Message?
    • Mental Lexicon: Store of information
    • Semantic Network: Connected representation of word meanings
  70. Mental Lexicon
    • Semantic and syntactic knowledge
    • Word forms knowledge (how spelled, what is sound pattern)
    • Orthographic (vision based)
    • Phonologic (sound based)
  71. Semantic Network
    • Connection strength or distance determined by associative relations
    • Model assumes that activation spreads from 1 conceptual node to others
    • Nodes closer together will benefit more from spreading activation
    • Activation spreads- where we store certain categories
  72. Message Formulation
    • Conceptual message grammatically encoded
    • Syntactic representation
    • LEMMA
    • Conceptual message activates encoding process, appropriate lemmas are
    • retrieved: Lexical selection
  73. LEMMA
    • Contains information about a word's syntactic properties and semantic specifications
    • Abstract conceptual form that has been mentally selected for utterance, but before any sounds are attached to it
    • Knowledge of a word
  74. Phonological encoding
    • Selected lemma activates the lexeme (sound form of words)
    • Move from intent to lemma to lexeme
  75. What Causes Word Retrieval Problems in Aphasia?
    • Phonologic access impairment- can client recognize words and pictures but cannot assign phonologic rules?
    • Semantic access impairment- mental lexicon; can client recognize words and pictures?
    • Combination of both impairments

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