+ Treatment of Aphasia Week 13 April 7 th, 2011. Treatment of Aphasia Treatment goals based on aphasia type I. Global aphasia A. Need to deal with prognosis

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Treatment of Aphasia

Week 13April 7th, 2011


Treatment goals based on aphasia type

I. Global aphasia A. Need to deal with prognosis of improvement (course of

recovery). 1. Sarno (1981, 1988) studied recovery pattern of

globally aphasic patients – all recovered to some extent – comprehension improved the most, propositional speech the least.

2. Largest amount of improvement occurred in period of 6 months to one year postonset stroke – at 6 months postonset, there was more spontaneous use of gestures.


I. Global aphasia B. Improve auditory comprehension

1. associations between words (nouns and verbs)

2. answering yes/no questions

3. following simple commands


I. Global aphasia C. Verbal expression:

1. words that are functionally relevant 2. words that are phonetically easy to articulate 3. imitation, cuing, looking at general responsiveness 4. programs such as Helm-Estabrooks Voluntary

Control over Involuntary Utterances a. you attempt to buildup core vocabulary based on

what the patient produces (use of emotionally laden words)

b. might be helpful because of the right hemisphere’s role in emotions.


I. Global aphasia D. Nonverbal expression http://teachinglearnerswithmultipleneeds.blogspot.com/2

010/06/ipossibilities-for-those-with.html

http://itunes.apple.com/us/app/proloquo2go/id308368164?mt=8

1. Language boards – will sometimes not work with global patients

2. Bliss symbols, use of Rebus symbols 3. Using gestural systems

A) programs such as Visual Action Therapy (VAT) – Helm Estabrooks

http://teachinglearnerswithmultipleneeds.blogspot.com/2010/06/ipossibilities-for-those-with.html







I. Global aphasia A) Visual Action Therapy (VAT) – Helm

Estabrooks Program capitalizes on existing verbal and

nonverbal behavior Program of graded tasks intended to develop

gesturing as substitute communicative channel Patients must be able to match pictures and

objectives as prerequisite skill 12 steps with first six used to train recognition

and production of gestures with objects and last six steps toward gesturing without objects


II. Broca’s Aphasia A. Goals in auditory comprehension are higher level than

those for global aphasia 1. focus on comprehension at sentence and paragraph

level 2. syntactic information should be manipulated – use of

context to circumvent syntactic comprehension problems


II. Broca’s Aphasia B. Work on verbal expression

1. specifically higher level thought organization skills and divergent tasks such as sequencing, categorizing, procedures, retelling of stories, high level word retrieval activities

2. writing goals should focus at the word and sentence level


II. Broca’s Aphasia C. Agrammatism

1. omit initial unstressed word in a sentence (pronouns, articles, prepositions). a) these patients start sentence without stressed

word that carries a lot of content (noun). 2. greater tendency to have verb and object

construction than subject and verb construction



4. difference in use of /s/ morpheme a) being most sensitive to plural /s/ (e.g., balls) in

which /s/ conveys much meaning

b) followed by possessive /s/ (e.g., John’s ball)

c) least sensitivity to third person singular (e.g., he runs).



5. use of adverb to mark things a) such as future tense (e.g., using modal “will”) –

agrammatic patient has difficulty with use of “will” (e.g., “he will work” becomes “He work again next week”).

b) comparatives (“He is taller” becomes “He is tall enough”).

c) patients simplify structure from a syntactic point of view – will spread out a syntactically condensed phrase



6. agrammatic patient looks at subject-verb-object (SVO) structure from cognitive viewpoint (using nonlinguistic strategies) a) what is the most salient noun (that is, they use

saliency when producing utterances with SVO structure)

b) what makes noun salient is animacy and size – they will then add a verb to mark the noun and then add a less salient noun


III. Wernicke’s aphasia A. Improve auditory comprehension, particularly at the

single word level (similar to global patients).

B. Increase patient’s awareness of paraphasic errors and attempts to modify and correct errors – as comprehension improves they will be able to deal better with paraphasic errors


III. Wernicke’s aphasia C. Emphasize the content of what they are trying to

communicate 1. content over structure 2. need to deal with patient’s listeners and work with

them to improve their listening skills in regard to patient

3. listener needs to become more active and fill in content

D. Investigate whether visual system is stronger than auditory – if so, these patients will respond better to the printed word.

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Functional Communication Therapy for Aphasia

+Overview

Aims to improve quality of life by addressing functional goals.

Goals are individualized for each patient and are based on pt’s specific interests.

Therapy usually occurs in real life context (or as close as possible).

Can be used with any type of aphasia, however it is more difficult with severe or global aphasia. These patients are likely to improve in auditory comprehension, but results

for verbal expression may be discouraging. Clinicians should try to establish or support any means of communication as soon as possible.

+Candidacy for Functional Communication Therapy

Brookshire (1997) identified four characteristics that indicate a patient may not have the ability to become a functional verbal communicator, if he/she has at least 2 of the following:

1. Stereotypic utterance along with severely impaired comprehension.

2. Inability to match objects.

3. Unreliable yes/no response to questions.

4. Semantic or neologistic jargon without awareness and self-correction.

+Goals of Functional Communication Therapy

Maximize use of residual linguistic capacities

Develop augmentative or alternative modes of communication

Improve the role of partners and settings in facilitating communication

Maximize psychological and emotional adjustment to language impairment

+Examples of Broad Functional Goals

The following goals would be acceptable to Medicare or any other third party payer:

1. The patient will communicate basic physical needs and emotional status.

2. The patient will engage in social communicative interactions with immediate family or friends.

3. The patient will carry out communicative interactions in the community.

+Topics to be Covered

The clinical-functional gap

Personally relevant content

Compensatory Behaviors

Different types of Interactive Therapies

Life Participation

+The Clinical-Functional Gap

In 1985, Jeffrey Metter, a neurologist, reported that documented clinical improvement did not necessitate generalization to everyday activities

One reason for this observation may be extreme differences between the standard treatment setting and real life communicative situations

+The Clinical-Functional Gap

Clinical setting: minimal distractions, interactions with people who understand aphasia, and repetitive drills are designed to reduce communicative deficits and encourage success

Real life presents many more communicative obstacles for someone with aphasia, such as: more distractions, interactions with people who are uninformed about aphasia, and lack of clinician support

This is known as the clinical-functional gap

Closing the clinical-functional gap is accomplished by bringing components of real life/natural situations into the clinic and by gradually moving the patients into situations that occur outside of the clinic.

+Personally Relevant Content

Important component of any functional therapy program

Often chosen the first day of treatment based on patient’s likes or dislikes (e.g. What does the patient like to talk about?; What are the patients hobbies?)

Research has found that material is better understood when it pertains to self and the immediate environment and facilitates generalization

Simmons-Mackie and Damico (1996) say clinicians should conduct “contextual inventories” to find out the content and interest in a patients life. Technique as been given a name: Thematic Language Stimulation

(TLS)

+Personally Relevant Content

Patients are more successful when they choose their own semantic cues for naming objectives (Freed, Celery, and Marshall, 2004).

Also, a functional analysis (which are revealed by the contextual inventories) of activities common in a patient’s life should be done to determine basic language functions the patient needs in everyday situations.

Therapy can be planned to correspond to specific communicative activities that are personally relevant for the client.

Example: If a patient enjoys baseball games, “What are the basic language functions used in these situations?” Pt needs to be able to read the scoreboard; be able to converse with family/friends attending

the game with he/she; how to order food at the game; be able to order tickets to the game. All of these aspects in regarding this situation is personally relevant to this patient Basically, the patient should be in control of the content of treatment, and it should not be

based on the clinician’s comfort.

+Compensatory Behaviors

An aphasic patient should try to make best use of his/her residual communicative resources (e.g. language abilities and nonverbal mechanisms used for conveying messages).

The various compensatory techniques can be divided into low-tech and high-tech strategies.

Types of low-tech compensatory behaviors include: communication boards, gesturing and drawing, and adaptive language strategies.

Types of high-tech compensatory behaviors include: the use of computers and other electronic devices.

+Interactive Therapies

Focus on clinician and patient interactions

More specifically the structure of conversation is a more natural way for the patient to apply communicative techniques and strategies that have been targeted in direct training.

Offers an opportunity for the patient to possibly increase their confidence in their communicative abilities in a natural conversation.

Teaches the patient that he/she is not solely responsible for the success of the communication.

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Promoting Aphasics’ Communicative Effectiveness (PACE)

Based on the following four principles:

1. The clinician and patient exchange new information.

2. The clinician and patient participate equally as senders and receivers of messages.

3. The patient has a free choice as to the communicative modes used to convey a message.

4. The clinician’s feedback as a receiver is based on the patient’s success in conveying the message.

+Stories and Scripts

Rehearsed stories and scripts provide a sense of comfort because of repetition.

Provide predictable verbal responses in interactional routines

Using these is a beneficial and confidence-building strategy for the patient

This is considered whole task training in that importance is on practicing the use of all required skills within a targeted context. Most other aphasia treatments are considered to be part task

training in that they teach specific skills in no certain context.

+Scripts

+Conversation as Therapy

Clinician’s goal is to help a patient transfer compensatory techniques like drawing and gesturing to natural conversation.

Scaffolded conversations is a technique used during conversation as therapy in which the exchange of messages is supported by offering cues or facilitators during the conversation e.g. Clinician may write a word that the patient was gesturing. Cues may also be used to remind and initiate a conversational

turn or initiate conveying a message.

+Conversation as Therapy

Conversation with aphasic patients is often studied by interviewing patients.

Holland (1998) described the “interview models” as stressing a receiver function over a participant function. Ex: Interview model: “Today we are going to talk about the most

embarrassing thing that ever happened to us. Why not begin, Joe?” Conversation: “You’re not gonna believe what happened to me

yesterday….Can you top this?”

• Clinicians should strive to utilize the conversational model during treatment in order to make the setting as naturalistic as possible.

+Situation Specific Therapy

Role playing provides the patient with an opportunity to stimulate the use of a variety of speech acts such as advising, warning, and arguing.

Environment is an important component and should reflect a real life situation. Example: When checking out at a store one is expected to do so

quickly and move on.

Family members can be a part of settings, but other partners such as a waiter, cashier, teller, etc. are also integral parts of the environment. These therapy partners are not knowledgeable about aphasia and

thus the clinician can anticipate communicative breakdowns the patient is likely to face.

•Real life situations can be categorized as non-stressful situations (e.g. planning a picnic), pleasant stressful situations (e.g. going out to dinner) or unpleasant stressful situations (e.g. dealing with an emergency).

+Group Therapy

Previous research has shown that group therapy provides increases in spontaneous communication for patients with aphasia (Elman & Bernstein-Ellis, 1999). Although results from this study where compelling, some

participants in the study were receiving outside therapy which could skew the results.

Can occur in many settings: subacute hospital rehabilitation, university clinics, and aphasia centers.

Usually small with about 3-4 patients; maybe up to 6.

Group therapy is also cost-effective when compared to individual treatment.

+Benefits of Aphasia Groups

Builds sense of empowerment by providing a safe interactive environment.

Combats social isolation.

Encourages conversations.

Can be used as a foundation for promoting resilience and leading to more complex social interactions.

+Life Participation

With all functional communication therapies, the person with aphasia is the central decision maker in determining clinical activities that allow he/she to reengage in desired life activities.

The primary goal is for the patient to once again be functional in his/her world.

SLP’s must document changes in language and communication, as well as life activities, life satisfaction, social connections, and overall emotional well-being.

+Life Participation

To facilitate the patient’s transition back to his/her normal routine, community involvement is essential

Volunteers from the local community serve as communication partners They have been trained by the SLP as how to be an effective

communicator with a person with aphasia. Rayner & Marshall (2003) found that training volunteers as

communication partners increases conversational participation of aphasic patients. However, this study had a limited number of participants with varying severity.

+Strengths

Functional Communication Therapy prepares aphasic patients for returning to their normal daily lives.

Promotes generalization to real life settings outside the clinic.

Engages patient’s because it is based solely on their interests.

Compelling research evidence to support functional communication therapy.

+Weaknesses

One can’t always account for what will happen in real life situations making it impossible to rehearse everything that could happen in therapy.

Unavailabilty of clinicians to provide cueing and support in the real world, as was provided in therapy.

Worrall (2006) suggests that a proportion of speech-language pathologists are not truly listening and responding to their clients' needs. This leads to a mismatch between the therapists' and clients' goals in therapy.

+Conclusion

“A great deal of functional or pragmatic treatment does not repair damaged language processes or teach something new. Instead, it reduces fear associated with communicative tasks in daily life.”

Documents

+ Treatment of Aphasia Week 13 April 7 th, 2011. Treatment of Aphasia Treatment goals based on aphasia type I. Global aphasia A. Need to deal with prognosis