Exam 2 Study Guide Flashcards
Do we know that treatment for aphasia makes a difference in the brain structure?
Yes.. Liepert in 2000 said: Noticeable changes in motor cortices after only 1.5 hrs.
Weiler & Rinjntjes (1999): Training correlated with changes in language-related areas in :
– Right Hemisphere:
- Middle superior temporal gyrus
- Supramarginal gyrus
Is neural plasticity a new idea in aphasiology?
No, Hughlings Jackson, Luria, Geschwind all suggested elements of plasticity
There were conflicting views originally and many of them thought the brain was hard-wired for specific functions but Hughlings Jackson, Luria, Geschwind all suggested elements of plasticity. Since 1990s, they have done some specific studies (think back to the article about the violinists, blind people, etc.)
What are the main mechanisms of repair?
Two Main Mechanisms
– 1. Recruitment of cortical areas in undamaged hemisphere
– 2. Extension of specialized areas adjacent to the lesioned site.
What happens in recovery? What are the dominant mechanisms in theory?
- Bilateral Redundancy in the neural representation of function- Redundancy for swallowing, speech
- Synaptic Neuronal Sprouting- nerves will sprout dendrites, nerves can/do regenerate
- Reinforcement of existing neuronal circuits- strengthening current circuits that are functioning
- Formation of new polysnaptic connections: Rebuild pathways around the damaged areas- new circuits and connections
- Resolution of initial edema- concussion caused from swelling of a brain in most cases
–>will often remove a piece of the skull to let the brain swell out
–>There are more people to die from swelling after stroke than from the actual stroke
–>Can take about 6 months for swelling to go down
– Release of inhibition
In Weiller’s study of Wernicke’s aphasics, what did he find regarding recruitment of the right hemisphere?
– Broca’s area – Left lateral prefrontal cortices – Right superior temporal gyrus – Right Inferior premotor – Right Lateral Prefrontal cortices – No activation in Left Superior Temporal Gyrus
His Hypothesis: Sensorimotor and language functions are represented in extended, variable, heavily parallel processing, and bilateral networks with several levels of representation. Reweighting of activity within and between the various levels of the preexisting network, rather than any more radical substitution of function, constitutes the dominant principle underlying recovery.
Weiller, et. al. (1995) Normal subjects – language tasks: left, of course, but right hemisphere also activated.
Damaged Cortices: Could be that right hemisphere activation relates to non-linguistic features and is irrelevant to the recovery of language (Liepert, 2000).
Which age group shows the most plasticity of the brain, children or adults?
- Children showed greater than normal language participation of the right hemisphere and atypical symmetry with early onset
- Children have greater language participation in the R hemi, so if they have damage, R hemi will develop lang.
Johanssen Article Info.:
What are 6 possible causes for training induced neurological changes after a stroke?
- Deafferentation
- Removal of inhibition
- Activity dependent synaptic changes
- Changes in membrane excitability
- Growth of new connections
- Unmasking of preexisting connections
Aphasiologists are enthusiastic about stem cell transplantation/implantation. What are the implications for stroke rehabilitation?
- Neural stem cells have been found to be as effective as fetal stem cells at proliferating and differentiating into neurons and glia in tissues.
– Transplanted cells interact with the host tissue by forming connections.
– The best improvements have been found in studies that combined stem cell transplants and housing in enriched environments post-transplant.
– The environmental signals work to promote stem cell differentiation.
What have been the effects of an enriched environment on brain plasticity? How does this translate to aphasia treatment?
- Research studies have shown that postoperative environments can affect the recovery of lesioned lab animals
- Rats with experimentally induced brain damaged were placed in different types of environments for recovery. The rats in the enriched environment performed considerably better than the rats housed in the standard laboratory environments.
- These results held true even for the rats that were postponed access to the environmentally enriched environment for 15 days post trauma.
– This study also compared social interaction to physical activity in the recovery process.
– It was found that rats with social interaction performed better than just rats with physical activity. However, the rats that were placed in environments with rich with social interaction and physical activity fared better overall.
What do you need to know about the location and size of the lesion before beginning treatment planning?
— Location and Size of the
Location and size of lesion predict treatment response.
– Subcortical structures- small lesion in thalamus can be detrimental. (relay station)
Helm Estabrooks says: lesion information is seldom used as a guide to aphasia therapy, although this information might inform treatment decisions.
Why are cognitive processes important to overall success of aphasia treatment?
- Attention
- Memory
- Executive Functions
- Visuospatial Skills
Hinckley, Carr & Patterson (2001)-study of 12 patients with aphasia: found not language scores but cognitive scores that made a difference.
Helm-Estabrooks, Bayles, Ramage, & Bryant (1995)-Therapists must screen for cognition
-Often the assumption is that aphasia is an isolated language disorder, and other domains of cognition are not affected by the stroke. Not true. Say it’s difficult to predict the extent to which other domains of cognition will be spared or impaired in patients with aphasia.
What meta-cognitive skills must be intact for effective learning/treatment?
Self-awareness Insight Motivation Self-Monitoring Self-Initiation Goal-oriented Behavior
What are some considerations of aphasia therapy that are unique (i.e. differ from treatment with children)?
Teach compensatory strategies-access the vocab you used to have.
– Not teaching/re-learning
– Not necessarily shooting for 100% recovery
– Goal might be for functional not back to original
Prognosis issues for the family and client
Repeated practice, more intensive and massed
– A lot of repetition. Intensive massed practiced
Client-specific goals
Co-treatment issues
– Likely to work with PT or OT
Funding issues: Insurance companies only give 12-20 sessions after stroke
– The Center for Individuals with Physical Disabilities
Discharge decisions
– When do you stop?
What does Rosenbek say is the most important goal of aphasia therapy?
prepare the client for a lifetime of aphasia
– get them to a point where they can live with their disabilities
– Mild strokes may get back to 100%
What are some of his other suggestions for effective treatment?
Be open to trying new approaches
Aphasics are often unchanged in all ways except communication-treat the person not the aphasia
– Remember they are the same person, just cannot communicate in the same way
Aphasiology has its limits
Treatment is not limited to Communication
Individual treatment is essential
Testing is crucial
Listening is the most important part of testing
Therapy must be structured
No single set of procedures is adequate
Concentrate on antecedent versus consequent events; success is its own reward
Exploit strengths
– Figure out what they can do and focus on that
Work toward generalization
Make the client his/her own clinician
– Self-monitoring: only with them 1 hour a day a couple times a week.
Involve others
Avoid treatments that make them feel abnormal
– Abnormal- may be things you don’t think are weird. Comm notebook, signing, etc
Beginnings and endings are awful!!
Recognize when improvement may not be worth the cost
Modern technological advances
Gaiety has its place in treatment of aphasics
What is spontaneous recovery?
Spontaneous recovery is the recovery made without any treatment. “Separating spontaneous improvement from treatment effects has been a challenge for clinical scientists.”
The body healing itself without any therapy, most likely due to a reduction of edema or swelling in the damaged hemisphere, a return to normal blood flow or circulation in the undamaged hemisphere, and collateral or compensatory blood circulation in the damaged hemisphere.
Does aphasia therapy work? What does the Robey article tell us about treatment in general?
Meta-analysis of treatments of aphasia.
Conclusion: Aphasia treatments are effective and all patients should be offered
Holland article information:
Explain the terms:
Effectiveness
Efficacy- defined as the individual’s improved communicative behaviors that were reached through speech and language therapeutic interventions
Efficiency
Effect
Stroke is the _______leading cause of death in the USA, according to this article (Holland)
_3rd _
Holland article information:
What are the effects of a stroke and aphasia on the individual, the family and the role in society?
Aphasia is an acquired language disorder meaning it is not present since birth. Therefore, when one acquires aphasia, it affects their social aspects of their lives as well. People with aphasia often become socially isolated due to their difficulties communicating with others.
Individuals with aphasia often experience a loss of income, loss of safety due to their inability to communicate their needs for help, an increased dependency on others for tasks including reading schedules, going shopping, making appointments, etc.
Individuals with aphasia often find they cannot function in a society where they cannot communicate.
The individual’s spouse may also experience social isolation.
o There is a common misperception by family members that their loved one is not the same. Aphasia is a loss of language, not a loss of cognition and intellect
o Family member often have to take on new roles such as caregiver, primary income provider, etc.
Holland article information:
What standards comprise a Class I study, a Class II study and a Class III study?
“Class I: Evidence provided by one or more well-designed randomized controlled clinical trials”
“Class II: Evidence provided by one or more well-designed randomized clinical studies such as case-control, cohort studies, and so forth”
“Class III: Evidence provided by expert opinion, nonrandomized historical controls, or one or more case reports”
According to Holland, most aphasia studies are _________ studies.
Class_III_
What are some potential problems with this?
How can we predict who will improve and who will not improve? (Porch article, and PICA predictive mechanisms)
Factors to consider: site and extent of lesion & availability of treatment
High-Overall Prediction Slopes (HOAP slope) from PICA (Porch, 1981)
Intra subtest variability
Aten and Lynn (1978) Intra-subject Variability on the PICA not a predictor of progress
o People with not a lot of variability between subtests yield a better prognosis than those who subtest scores are varied
HOAP: High Overall Prediction
Highest individual item scores=overestimation of ability
Broader range of sampling needed for prediction
Represents several levels of processing across gestural, verbal, graphic subtests
Use Appendix D only at 1-month post-onset
More than 1 month-use HOAP Slopes
Factors such as: Age, Education, Auditory Comprehension, reading, speaking, writing
PICA most predictive power: Number of treatment sessions, Months post onset, Age
BDAE most predictive power: Confrontational naming, body part identification, complex ideational material
WAB: Age (younger), length of hospitalization (shorter), gender (male), type of stroke (hemorrhage), side of lesion (right)
What are some of Rosenbek’s recommendations regarding optimal vocabulary selection?
Understanding words- body parts, objects, food items, action pictures
Understanding descriptions- pictures of objects, objects, products and advertisements
Understanding shorter yes/no questions- yes/no (factual, absurdities)
Understanding sentences- yes/no
Understanding questions- point to
Understanding shorter directions (objects, body parts, etc)
Response switching
Imposed delays
Sequential assembly
What is meant by the term “agrammatism” in reference to non-fluent aphasia?
A pattern of sentence production that reflects an absence of grammatical structure.
Often Convey adequate messages-”structurally impoverished strings of content words” (Thompson, 2001)
Short, simple S-V and SVO structures that are often ill formed.
Cannot produce complex sentences
– Use content words not function words
– Can usually get their points across
What are the essential goals of treatment for Broca’s aphasia?
Add to the repertoire of agrammatic responses (more chronic cases)
– Rosenbek(1989) “believes that a greater number of agrammatic utterances communicates more than a lesser number of grammatic ones.” (pg. 220) Emphasize communication rather than correctness
Expand the complexity and/or length of utterances (acute cases)
In the HELPSS program, Helm-Estabrooks gives a hierarchy of sentence structure. Be able to sort out the order of presentation.
One sentence type is trained at a time, easiest first. Efficacy studies- improve on those trained but limited generalization.
- Imperative Intransitive Sit down.
- Imperative transitive Drink your milk.
- Wh-Interrogative
Where are my shoes? - Declarative transitive He teaches school.
- Declarative intransitive He swims.
- Comparative He’s taller.
- Passive
The car was towed. - Yes-no questions
Did you watch the news? - Direct and indirect object
He brings his mother flowers. - Embedded sentences She wanted him to be rich.
- Future
He will sleep.
How would you administer Rosenbek’s changing criteria method with a Broca’s aphasic?
Criterion 1: reinforcing 1-2 word utterances,
Criterion 2: 3-5 word utterances,
Criterion 3: 6-8 word utterances.
Criterion 4: more than 9 words.
Series of questions and answers using pictures as stimuli
Start at higher level for less severe clients.
Language stimulation cards
Changing Criteria Program Questions: Select two per picture
1. How many people, animals, objects do you see?
2. What is/are the person(s) wearing?
3. What is/are the person(s) holding?
4. What color are the clothes, sky, objects?
5. What is around the neck, waist, write?
6. How old is the person, animal, object?
7. Where is the person, animal object?
8. What time is it?
9. What are they(________)? add a verb
10. What are they doing?
Define “global aphasia.”
“All aspects of language are so severely impaired that there is no longer a distinctive pattern of preserved versus impaired components.”
Global aphasia is a severe, acquired impairment of communicative ability across all language modalities; no single communicative modality is preserved. Visual nonverbal problem-solving abilities are often severely depressed as well and are usually compatible with language performance. Patients often have a profound volitional performance deficit as well. Usually results from extensive damage to the language zones of the left hemisphere.
Is the diagnosis of global aphasia considered to be rare?
30-55% of Aphasics
Higher in the acute stages
Global aphasia often evolves to _ (which syndromes)_____________aphasia syndromes.
May evolve to Broca’s, Wernicke’s, anomic, or conduction aphasia (Peach, 2001)
o More likely in younger patients
o If they receive treatment early
According to Peach, how many global aphasic clients will evolve to less severe syndromes?
¼ to ¾ will recover to a less severe syndrome
Localization: Global aphasia is usually caused by damage to what areas of the cortex?
Lesions in the entire perisylvian region
– Broca’s Area
– Wernicke’s Area
– Deeper white matter of the brain
– Basal ganglia, internal capsule, thalamus
Middle Cerebral Artery Lesions
Which artery is often involved in a diagnosis of Global Aphasia?
Middle Cerebral Artery Lesions
