role of SLP in treatment lesion etiology

1. -introduction to aphasia
-etiology
-treatment strategies and techniques

2.  Aphasia is an impairment of language. An
acquired communication disorder that
impairs a person’s ability to process
language, but does not affect intelligence.
 Impairs ability to speak and understand
others and most people with aphasia
experience difficulty reading and writing.

3. Different areas of the brain are specialized for different
functions. It is possible to divide the brain up into
different modules which can cooperate in performing the
functions of perception, movement, thought, and speech.
One important brain module is the language module.
We shall see that there our linguistic abilities really
require several modules that cooperate.

5. Dominant hemisphere
• Language lateralize to the dominant hemisphere:
o80% of people are right handed.
o 96-99% of right handed people in the left hemi
sphere.
o 60% of left handed people also lateralize to the
left
o 25% of left handed shows right dominancy.
o the remaining are mixed dominancy.

6.  Expressive aphasia was first
identified by the French
neurologist Paul Broca. By
examining the brains of
deceased individuals who
acquired expressive aphasia
in life, he concluded that
language ability was
localized in the
ventroposterior region of
the frontal lobe

7. Broca’s aphasia is a non-fluent type of
aphasia that is commonly associated with
verbal apraxia, relatively good auditory
comprehension, agrammatic speech, and
poor repetition

8.  Broca's area is one of the main language areas in the
cerebral cortex because it controls the motor aspects of
speech. Thus, other names for this disorder are 'expressive'
and 'motor' aphasia. Depending on the severity of the lesion
to Broca's area, the symptoms can range from the mildest
type (cortical dysarthria) with intact comprehension and the
ability to communicate through writing to a complete loss of
speaking out loud.

9. Expressive aphasia, known as
Broca's aphasia in clinical
neuropsychology and
agrammatic aphasia in
cognitive neuropsychology

10. – Traditional Broca Area” Brodmann’s 44&45”
– left frontoparietal lesions
– territory of the upper division of the left middle
cerebral artery
• Damage to Broca’s area alone is not enough to produce
Broca’s aphasia
• Usually involves Broca’s area + surrounding areas
including M1 & insula.

11. Distinct brain areas identified in terms of
anatomical structure
•So e.g. Broca’s area is
sometimes defined
as consisting of 44,45;
much of the literature
uses these numbers
because of their precise
definitions.

12.  Expressive aphasia differs from dysarthria,
which is characterized by a patient's inability
to properly move the muscles of the tongue
and mouth to produce speech. Expressive
aphasia contrasts with receptive aphasia,
which is characterized by a patient's inability
to comprehend language or speak with
appropriately meaningful words.

13. – Effortless
– excessively fluent (logorrhea).
– Paragrammatism:
• speaker of a foreign language would notice nothing
a miss, but a listener who shares the patient’s
language detects speech empty of meaning,
containing verbal paraphasias, neologisms, and
jargon productions.
 Individuals with Broca's aphasia frequently speak short,
meaningful phrases that are produced with great effort.
For them, speech is difficult to initiate, non-fluent,
labored, and halting. Affected people often omit small
words such as "is", "and", and "the"

14. Brocca

15.  ". For example, a person with Broca's aphasia
may say, "Walk dog" which could mean "I will
take the dog for a walk",

16.  Individuals with Broca's aphasia are able to
understand the speech of others to varying degrees.
Because of this, they are often aware of their
difficulties and can become easily frustrated by their
speaking problems.
 It is associated with right hemiparesis, meaning that
there can be paralysis of the patient's right face and
arm.
 Similarly, writing is difficult as well. Intonation and
stress patterns are deficient.
 Naming is deficient, often with bizarre, paraphasic
substitutions for the correct name
 patients show greater deficit in one modality than
in the other.

17. Pathogenesis and etiology of
aphasia

18. • Vascular lesions:
– Ischemic strokes, the most common cause of
aphasia.
– The clinical features of the aphasia are of crucial
importance to the vascular diagnosis.
– hemorrhagic strokes an important cause of
aphasia, most commonly the basal ganglionic
hemorrhages associated with hypertension.
– AVM, drugs, may cause hemorrhages
– amyloid angiopathy.
– cerebral vasculitis.

19. • Traumatic brain injury
– depressed skull fractures
– hematomas of the intracerebral, subdural, and
epidural spaces
– Gunshot wounds produce focal aphasic
syndromes
• Tumors of the left hemisphere
– The onset of the aphasia is gradual, and edema and
mass effect may result in other cognitive deficits.
– Enlarging tumor may be difficult to distinguish from
a diffuse encephalopathy or early dementia.

20. • Infections of the nervous system
– Brain abscesses can mimic tumors and
present with aphasia
– Chronic infections, such as tuberculosis or
syphilis, can result in focal abnormalities.
– Herpes simplex encephalitis has a
predilection for the temporal lobe and
orbital frontal cortex, and aphasia can
be an early manifestation, along
with headache, confusion, fever,
and seizures.
• Aphasia often is a permanent sequel in
survivors of herpes encephalitis.
– AIDS: either the AIDS dementia complex or
the opportunistic infections.

21. • degenerative central
nervous system
diseases
– Alzheimer’s disease may be
more common in familial
cases and may predict poor
prognosis.
– dialysis dementia
syndrome: started with
stuttering followed by
true aphasia and
dementia
• Seizures:
– Epileptic aphasia is important
to recognize because
anticonvulsant drug therapy
can prevent the episodes

22. • Get the person's attention before you start
speaking.
• Maintain eye contact and watch the person’s
body language and use of gesture.
• Minimize or eliminate background noise (TV,
radio, other people).
• Simplify your sentence structure and
emphasize key words.
• Reduce your rate of speech.

23. • Keep your voice at a normal level. Do not speak
loudly unless the person asks you to do so.
• Keep communication simple, but adult. Don't
"talk down" to the person with aphasia.
• Give the individual time to speak. Resist the
urge to finish sentences or offer words.
• Communicate with drawings, gestures, writing,
and facial expressions in addition to speech.
• Encourage the person to use drawings,
gestures, and writing.

24. •Use "yes" and "no" questions rather than
open-ended questions.
•Praise all attempts to speak and downplay
any errors. Avoid insisting that that each
word be produced perfectly.
•Engage in normal activities whenever
possible.
•Encourage independence and avoid being
overprotective.

25.  Impairment based therapies:
A person with aphasia initially wants to speak better and make sense
of language spoken by others. Therefore, speech-language
pathologists attempt to repair what is broken. Therapies focus an
individual's attention on tasks that allow him or her to comprehend
and speak as successfully as possible. A therapy session may be the
only time of the day in which the mental mechanics of language are
exercised with minimal frustration.
These include all _RESTORATIVE APPROACHES

26.  Communication based therapies:
Communication oriented treatments, in part, assist the person in
conveying messages and feelings with alternative means of communicating
.In addition, an individual is encouraged to use any remaining language
ability that succeeds in conveying messages. Therefore, communication-
based activities continue to be partly "language-based" and are likely to
incorporate impairment-based objectives simultaneously.
These accompanies
_COMENSATORY STRATEGIES

27.  Constraint-Induced Movement Therapy
 Constraint induced language therapy
 Melodic Intonation Therapy (MIT)
 Tele-rehabilitation

28.  This therapy is modeled
after a physical therapy for
paralysis in which a patient
is "forced," for example, to
use an impaired side of the
body, because the good
side has been restricted or
constrained.
 In applying this principle to
communication functions, a
person with aphasia may be
constrained in using intact
gesture in order to direct
the individual to use
impaired spoken language.

29. TIME
 A second, and perhaps more well-known,
component of this treatment is that it is more
intensive than typical therapy schedules and
it lasts for a relatively short duration. For
example, the therapy may be administered
for three hours daily for two weeks

30. ◦ Best candidates are patients whose Auditory
Comprehension is better than their verbal expression and
verbal expression is severely impaired
◦ Strategies:
 Intonation pattern uses a range of 3-4 notes
 Elements include an exaggerated melody line composed
of at least 2 syllables. The rhythm and point of stress
help to convey meaning
 MIT is slower, similar to Chant Talking
 Program Progresses to Longer syntactic units and to
Clinician Question, Client Answer using progressively
faster melodic patterns.

33.  Established procedures are provided over the
Internet with web cameras so that the
therapist and person with aphasia can see
and hear each other.

34.  Activities/Participation-Based
Treatment
• Augmentative and Alternative Communication (AAC)
Treatment involving the use of augmentative aids, such
as picture and symbol communication boards and electronic
devices, to help individuals with aphasia express themselves.

36. • Promoting Aphasics' Communication
Effectiveness (PACE)
A conversational treatment in which any
modality can be used to communicate ideas
from one partner to the other. The client
and clinician take equal turns in the sender
and receiver roles, and this promotes
conversational participation.

37. The clinician and patient exchange new
information.
Instead of having a picture of an object
or event
(called the message) in simultaneous
view of the
clinician and patient, a stack of
message stimuli is
placed face down to keep messages
from the view of
a message receiver. A client selects a
card and
attempts to convey the message on the
card. The
Brussels modification is to place a
screen about eight
inches high between the patient and
clinician, and the
message receiver chooses the message
from options.
Principle Details

38. The clinician and patient participate
equally as
senders and receivers of messages.
This principle puts the turn-taking
feature of
conversation into the interaction. The
clinician and
client simply alternate in drawing a
card and sending
messages.
The patient has a free choice as to the
communicative modes used to convey
a
message.
Contrary to training one modality such
as gesture or
drawing, the patient is left to choose
the mode that is
used for any message. We do not tell a
client to
perform in a particular way.
The clinician’s feedback as a receiver is
based
on the patient’s success in conveying
the
message.
The new information condition should
make this
inevitable for both participants. Our
feedback should
let the client know if he or she got the
idea across. If
we already know the message, we
should respond as
if we did not know.

39. • Oral Reading for Language in Aphasia
(ORLA)
treatment using auditory, visual, and written
cues to assist the person with aphasia in
reading sentences aloud.

40. • Constraint induced language therapy
In CILT, a small group of patients with aphasia take
part in language activities in which they are
constrained to verbal responses that are shaped
toward more expansive utterances over time. In
contrast to other aphasia treatment approaches
that promote the use of compensatory
communication modalities such as gesture,
drawing, or writing, in CILT no compensatory
nonverbal communication strategies are allowed
during the language activities. Improved verbal
responses are the goal of treatment. Furthermore,
treatment is provided on an intensive schedule, up
to three hours per day for five days per week.

42.  Partner Approaches
• Conversational Coaching
This strategy aims at increasing communicative
confidence through the practice of scripted conversations.
 Procedures:
1. Effective strategies for each partner (with and without
aphasia) are collaboratively identified. These could be
verbal or nonverbal communication strategies.
2. The couple selects the strategies that they are most
comfortable with and which ones they will work on
using.

43. 3.A communication situation is created, such as
viewing a short video clip. One partner views
the video and has the job of communicating
the information to the other partner.Both
partners should be using their identified
communication strategies to achieve a
collaborative result. Partners take turns
exchanging information in each conversational
role (sender and receiver).
4. The clinician acts as a coach to each of the
two partners as they exchange and build
information together.

45. • Supported Communication Intervention (SCI)
Supported communication intervention (SCI) is an approach to
aphasia rehabilitation that emphasizes the need for
multimodality communication, partner training, and
opportunities for social interaction
 LIFE PARTICIPATION APPROACH TO APHASIA (LPAA)
Call for a broadening and refocusing of clinical
practice and research on the consequences of
aphasia
Focus on re-engagement in life
Places life concerns of those affected by aphasia
at the center of all decision making
Empowerment and collaboration on interventions
may lead to more rapid return to active life and
reduce the consequences that lead to long-term
health costs

46.  Assessment includes determining relevant life participation
needs
 In addition to assessing communication and deficits, clinicians
should be equally interested in how the patient does with
support
 Clinicians take on take on roles in addition to doing therapy,
such as “communication partner”, “coach” or “problem solver”
 Clinicians evaluate and document on:
 Life activities and satisfaction
 Social connections and satisfaction
 Emotional well-being

47.  Word Finding Treatment
• Response Elaboration Training (RET)
A type of “loose training” which works to improve
lexical retrieval and the number of content words
produced by an individual with aphasia (Conley &
Coelho, 2003).Forward chaining, or elaboration, of the
client’s utterances is used.
•

48. RET Steps Clinician’s
stimulus
Patient’s
response
Clinician
feedback
1) Elicit initial
verbal
response to
picture
Line drawing of
simple
event (man with a
broom) “Tell me
what’s
happening in this
picture.”
“Man…sweeping”
2) Reinforce,
model,
and shape initial
response
Great. The man
is sweeping
3) Wh- cue to
elicit
elaboration of
initial response
Why is he
sweeping?”
“Wife…mad!”
4) Reinforce,
model,
and shape the two
patient responses
combined
“Way to go! The
man is sweeping
the floor because
his wife is mad.”

49. 5) Second model
and
request repetition
“Try and say the
whole
thing after me. Say
‘The
man is sweeping
the
floor because his
wife is
mad.’”
“Man…sweeping…
wife…mad.”
Good job!”
6) After
reinforcement
elicit delayed
initiation of the
combined
response.
“Now, try to say it
one
more time.”
“The
man…sweeping
because
his wife…mad.”

50. • Opposites Exercise
This exercise helps with repairing
word-finding abilities and
articulation, as well as expanding
limited concepts. For this
exercise, write down ten words,
such as "up," "mad" and "bright."
Then, ask for the opposite of the
word. For instance, you would
ask, "What is the opposite of up?"
You would then reply with
"down." This exercise can
increase in difficulty, with
concepts increasing in complexity
as the sufferer's tolerance
strengthens. For instance, try
"frustration" and "joy."

53. • Preposition Exercise
This exercise uses two spoons
and a box, and helps firm the
concept of prepositions. To
start, place the box on a
surface and place both
spoons anywhere relative to
the box, such as on the box
and beside it. These spoons
would not be in the same
location. Then ask, "Which
spoon is on the box?" He
would then reply by picking
up or pointing at the spoon.
You can increase the difficulty
by using multiple spoons.

56. • Semantic Feature Analysis Treatment
SFA is used to improve word-retrieval abilities in clients with
aphasia. This is done via spoken production of a target,
most usually prompted through a picture stimulus,
alongside structured elicitation of a series of semantic
features that are associated with the target. This
combination of elicitation of a target and semantic
features is hypothesised to strengthen (or reactivate) the
semantic network around the target and thereby
facilitating improved word retrieval on subsequent
attempts. As the client is also encouraged to verbally
produce the target, phonological representations of the
target are also accessed and may therefore also improve
the activation pathways between semantic and
phonological representations.

57. SFA is generally carried out with the aid of a ‘worksheet’ that may be
presented on paper or via computer screen. The worksheet generally
presents single-word or sentence prompts to elicit the semantic features
(e.g. Location/Where would you find it?). When the client provides an
appropriate response, these are generally written in the relevant space
by the clinician.
 Present target picture and ask client to name the picture (i.e. apple)
 Regardless of whether client correctly names the target picture, ask the
client to provide a verbal response for each of the semantic features
(e.g. fruit, grows on a tree, round, eat it, respectively)
 Once client provides a response for all semantic features, prompt client
to again name the picture
 Review the completed worksheet
◦ Clinician may provide review by integrating all information within a description (e.g.
an apple is a fruit that grows on trees. It is round and you eat it)
◦ Client may be encouraged to again verbally produce the target and semantic features
from the responses that have been written on the worksheet.

59. THANKYOU