Final Exam- Study Guide Flashcards
Why does Rosenbek say that auditory comprehension is sometimes called the “veiled disorder” of aphasia?
“A deficiency in the ability to process or understand spoken language that cannot be accounted for by peripheral sensory deficit, generalized cognitive deficit, or primary disturbances in attention or arousal.”
Where on the cortex is auditory comprehension localized?
Posterior superior aspect of the left temporal lobe and its posterior extension
PST lesion =
Absence of PST lesion =
poor prognosis for aud. comp.
good prognosis (even if initially more severe)
The most severe have lesions in
PST extending into infrasylvian portion of the supramarginal gyrus
What are the key components of comprehension (according to Rosenbek?)
- Stimulus detection
- Discrimination of stimuli
- Retention
- Categorization
- Sequential retention
What are some specific tests for Auditory Comprehension?
The Proust-Lichtheim Test
Liepmann
Pierre Marie – Three Papers Test
Coin and Bowl Test, Hand, Eye, and Ear Test, Man, cat and Dog test.
Goldstein (1948) – contextual basis
1872: The Proust-Lichtheim Test:
Liepmann:
Pierre Marie:
Goldstein:
Raise Fingers, squeeze hands, blink, etc.
nodding agreement test
yes/no questions
“Here are three pieces of paper of different sizes, give the largest one to me, crumple the middle one and throw it on the floor and as for the smallest one- put it in your pocket.” Relies on MEMORY, PRODUCTION and EDUCATION to some extent
1st to stress context and pragmatics- everyday questions related to personal interests
What are some activities within general aphasia tests that assess auditory comprehension skills?
Minn. Test for the Differential Dx of Aphasia (MTDDA)
Token Test
Revised Token Test
Aud. Comp. Test for Sentences (ACTS)
Functional Auditory Comprehension Task (FACT)
Yes/no questions
1,2,&3 step commands
What are some of the basic tenets of the following treatment approaches that address auditory comprehension issues?
Linguistic Stimulation approach:
Pointing to objects by name
Following Commands
Answering questions
What are some of the basic tenets of the following treatment approaches that address auditory comprehension issues?
VAT:
VIC:
CAIAC:
PACE:
TWA:
CAIAC:
Goal: “To improve the understanding of spoken messages in natural settings and everyday situations.” (pg. 335)
Candidates: (Table 23.1, pg. 346)
Alert, little fatigue
Moderate to severe auditory comprehension deficits
Moderate non-linguistic cognitive problems
Good visual perceptual skills
Basic graphomotor skills
Ability to complete homework
Nonlinguistic variables can influence performance on tasks requiring comprehension of spoken messages.
Experience that employing drills of verbally presented linguistic stimuli have questionable effectiveness.
None of CAIAC tasks require obvious processing of verbal stimuli or any verbal output.
All tasks require attention and conceptual knowledge of shape and size.
Attention Tasks:
Abstract design cancellation (pg. 348-349)
Alternating graphomotor patterns (pg. 351)
Symbol trails task (pg. 352-353)
Conceptual Knowledge tasks:
Odd-man out designs (what doesn’t belong) (pg. 35)
Actual size/weight judgments(pg. 356)
Sorting semantically related pictured objects (pg. 357)
Odd man out pictured objects (pg. 358)
TWA:
Goal: “To improve ability of individuals with moderate to severe Wernicke’s aphasia to understand spoken messages in everyday settings and situations”
Candidates: Moderate to severe Wernicke’s aphasia
Severely-moderately impaired single word comprehension
Severely-moderately impaired repeating of single words, phrases and sentences
Relatively preserved single-word reading comprehension
Some ability to read aloud a few single words with high emotional value
Based upon theory of “re-auditorizaton”
Pre-test: must be able to read 4/15 single words from ADP.
Baseline Step
Treatment Steps:
Reading comprehension-match printed to pictorial
Oral Reading-read word aloud
Repetition-repeat with only picture
Auditory Comprehension-select from field of 6
Can sub-cortical lesions alone cause aphasia?
Yes, severe aphasia because everything goes through the thalamus
If damage to a sub-cortical structure causes aphasia, does that mean that these structures have language functions?
No, its function is to relay the information from the cortex. The relay station is damaged, therefore aphasia is likely to occur
Are all deep structures sub-cortical and not cortical? What about the insula?
No, the insula has lead us to believe it is more of a cortical structure
What are the characteristics of cortical versus sub-cortical aphasias?
“Characteristics have not been defined yet.”
They have a greater variability in number of words/breath
Great variability in number of words uttered in one breath unit
Hypophonia or low speech volume distinguishes subcortical from cortical aphasia.
What does Help-Estabrooks call sub-cortical aphasics?
Borderline fluent
What are the symptoms of thalamic lesions?
Auditory Comprehension skills:
Highly variable
Repetition skills
Good
What are more symptoms of thalamic lesions?
Hemiplegia, hemisensory loss, right-visual field problems, maybe coma
Mutism initially or hypophonic (low volume)
Eventually variable phrase length and paraphasic and perseverative with bizarre word choices
Severe anomia (naming problems)
Variable auditory comprehension for conversational speech but poor for complex material
Relatively good repetition
Decreased paraphasia while repeating
Impaired reading and writing
What are the symptoms of anterior damage to the internal capsule and putamen of the basal ganglia?
Auditory Comprehension skills:Relatively good
Repetition Skills: Good
Dysarthria, hypophonia, imprecise articulation
Variable phrase length from 4-6 word phrases to nearly normal
Semantic & phonemic paraphasias with a range of grammatical constructions.
Mild or no repetition problems
Anomia: Moderate naming or word-finding problems
Mild auditory comprehension problems Moderate reading problems Severe writing problems
What are the symptoms of damage to the posterior capsular-putamenal lesions?
Auditory Comprehension skills: Poor
Repetition Skills: Poor
Hypophonic, well-articulated, grammatical speech
Semantic, phonemic and neologistic paraphasias Fluent speech, variable phrase length Severe auditory comprehension deficits Anomia: severe naming and word-finding problems Poor repetition problems Moderate reading problems Moderate writing problems
What happens if both anterior and posterior areas are damaged?
Global aphasia Non-fluent and extremely limited spontaneous speech Stereotyped monosyllabic utterances or single-word productions Severely dysarthric Severely impaired Auditory comprehension Significant naming and repetition Serious reading and writing problems.
How does Helm-Estabrooks recommend addressing sub-cortical lesions?
Mirrors the symptoms of other aphasias at this time
Is it common to have a bi-lateral lesion?
Rare to have simultaneous lesions Rare to have simultaneous lesions
(16 reported cases or 0.3% of CVAs)
Where are they usually located?
Usually due to aneurysm of Anterior Communicating Artery and subarachnoid hemorrhage
Do bilateral CVAs generally have a positive outcome?
Often poor outcome if not fatal
What is meant by “alexia”?
Suffer from reading problems while other language-related skills such as naming, oral repetition, auditory comprehension or writing may still be intact.
What type of reading tasks should be the function of early aphasia therapy?
Target survival reading skills
Reading letters, menus, checkbooks, bank statements, medicine labels, phone books calendars, maps, product labels, emergency signs, etc.
List some treatment considerations for working with reading with a moderate to severe aphasic.
Functional Verbal Expression is the Priority for severe aphasics
Basic/Functional Reading skills may be important for mild-moderate aphasics
“The first step in designing a reading treatment program is to assess the premorbid level of literacy and the current need for and interest in reading.”
Silent reading comprehension more important than oral reading
How do writing problems differ in anterior versus posterior left hemisphere CVAs?
Anterior left: structurally poor writing: misspelling, poor letter formation
Posterior left: Word order, word omission, letters formed OK
How do writing problems differ between left hemisphere CVAs and right hemisphere CVAs?
Left Hemisphere: More pronounced structural and syntactic writing problems than right hemi
Right Hemisphere: Spatial aspects, Left neglect, Margin errors
What are the main types of agraphia ?
Pure Agraphia
Deep Dysgraphia
Phonological Dysgraphia
Surface Dysgraphia
Pure Agraphia-
unusual syndrome
agraphia without anything else going on
Deep Dysgraphia-
Route between word meaning and written form impaired.
Spelling errors semantically related. Better at concrete nouns, greater difficulty with abstract nouns.
Functor words VERY difficult.
Connective pathway disorder
Phonological Dysgraphia-
impaired phoneme to grapheme conversion rules. Preserved ability to write real words, inability to write pseudo words.
Sounding out words and thinking of the associated grapheme that goes with it
Surface Dysgraphia-
Phonetic errors but able to write pseudowords
MOTORIC ORIGINS:
Apraxic Agraphia
Motor Agraphia
Micrographia
Hyperkinetic agraphia
Apraxic Agraphia-
Inability to use a writing tool to form symbols even with a model. Could be a component of ideomotor apraxia. Better ability with anagrams or typewriter or spelling aloud
Motor Agraphia-
paralysis of writing hand
Micrographia-
hypokinetic- writing is unusually small
Hyperkinetic agraphia-
hyperkinetic motor issues
Explain the basic processes that Beeson outlined in the CART and the ACRT programs.
ACRT: Purpose:
TO improve spelling to use writing as a means of communication.
Improve skills for everyday use.
Candidates:
Severely impaired writing
Good grapho-motor skills
Good single-word reading comprehension
Some knowledge of word forms
Good visual memory
Agnosias usually are due to damage to
the sensory areas: Posterior central gyrus
What does “agnosia” mean?
a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss
What is prosopagnosia?
Also known as ‘'’faceblindness’’’ and ‘'’facial agnosia’’’:
Patients cannot consciously recognize familiar faces, sometimes even including their own. This is often misperceived as an inability to remember names.
What is Anosonosia?
This is the inability to gain feedback about one’s own condition and can be confused with lack of insight but is caused by problems in the feedback mechanisms in the brain.
Those with Anosognosia with multiple impairments may even be aware of some of their impairments but completely unable to perceive others.
What is Autotopagnosia?
Is associated with the inability to orient parts of the body, and is often caused by a lesion in the parietal lobe of the posterior thalamic radiations.
What is auditory agnosia?
With Auditory Agnosia there is difficulty distinguishing environmental and non-verbal auditory cues including difficulty distinguishing speech from non-speech sounds even though hearing is usually normal
What is phonagnosia?
Is the inability to recognize familiar voices, even though the hearer can understand the words used.
What is simultanagnosia?
Patients can recognize objects or details in their visual field, but only one at a time. They cannot make out the scene they belong to or make out a whole image out of the details. They literally “cannot see the forest for the trees.”
Simultanagnosia is a common symptom of Balint’s syndrome.
What is asteriognosia?
Or ‘'’Somatosensory agnosia’’’ is connected to tactile sense - that is, touch. Patient finds it difficult to recognize objects by touch based on its texture, size and weight. However, they may be able to describe it verbally or recognize same kind of objects from pictures or draw pictures of them. Thought to be connected to lesions or damage in somatosensory cortex.
What are the general functions of the right hemisphere vs. the left hemisphere?
Arousal, orientation, vigilance and selective attention
Visual perception: holistic gestault-like stimuli, geometric and spatial information,
facial recognition, body image
Emotional experience and expressions:
angry and happy emotions
Perception of temporal order
Perception of musical harmony
Other aspects of communication…..
B. What are some aspects of communication attributable to the right hemisphere?
Discourse comprehension and production
Complex inferences implied in verbal
Communicative efficiency and specificity
Understanding alternative/ambiguous meanings
Understanding and expressing emotional tone
Understanding and expressing prosodic aspects
Prosody: intonation, rate, rhythm, pitch, intensity, etc
Persons with RHD usually exhibit what difficulties in these areas?
Comprehending 2-way conversation: may not take turns properly or not explain thing properly, go on and on
Complex inferences implied in verbal
Communicative efficiency and specificity
Not specific enough or too specific
Subtle inferences; overriding issues they don’t understanding
Flat emotional tone when speaking; sometimes they try and miss it. They have too much emotion.
R inferior frontal gyrus
R posterior temporo-parietal region for understanding prosody
Prosody: intonation, rate, rhythm, pitch, intensity, etc
C.What are some causes of communication problems in the right hemisphere?
CVA
Tumors
Head Trauma
Alzheimer’s, Parkinson’s, other neurological diseases
What are some of the pragmatic problems seen in right hemisphere CVA?
turn-taking,
topic maintenance,
social appropriateness,
eye contact
What is left neglect?
Failure to recognize stimuli in the left visual field
“Ipsilateral”
Left Neglect
Damage to any lobe in either hemisphere can lead to neglect
More severe and consistent, resistant to therapy
People with damage to either hemi can have neglect, it is ipsilateral.
Neglect can be of varying degrees.
Can affect vision or can see but neglect the left side
What are the characteristics of left-neglect?
Right focus, don’t notice left
Difficulty shifting attention from right to left
Failure to perceive left-sided tactile or perceptual stimuli
Failure to copy the left side of a picture of design
Painting only right half of a face-ignore left
Extreme right-centered attention to an array of stimuli
Paying attention only to the right side of a space described from memory
Bumping into things on the left
Using only right-sided objects
Disownership of the left side of the body Denying illness (anosagnosia)
Auditory neglect
Motor neglect
Left-neglect in reading
Left neglect in writing
Which is more commonly seen left neglect or right neglect?
Left brain damage: right-neglect = 2-15%
Right brain damage: left-neglect = 31-90%
What attentional deficits are seen in R CVA?
Reduced state of arousal
Difficulty in sustaining attention
Difficulty in paying selective attention
Disorientation:
Topographic disorientation
Geographic disorientation
Reduplicative paramnesia (rare condition)-belief in the existence of multiple and identical persons, places and body parts
What is meant by disorientation?
Inability to recognize person, place, time, or self
What does “affect” mean in the context of R CVA?
expression/emotions
What are some affective deficits of R CVA?
Difficulty understanding emotions
Difficulty stating the emotions depicted in pictures stories
Problems recognizing emotions in sentences
Problems understanding emotional tone of voice
Difficulty in emotional expressions
What is “prosody”?
stress patterns, intonation rhythm, and melodious qualities of speech that convey meaning
How can it be impaired in R CVA?
aprosodia, auditory affective agnosia, dysprosodia
Speech sounds monotonous
Lacks variation: Impaired stress patterns
Reduced rate
Devoid of emotion
Impaired in prosodic comprehension
Imopaired stress patterns
Devoid of emotion
What semantic or discourse problems are often seen in R CVA?
Semantic:
Difficulty with implied, alternative or abstract meanings
Failure to grasp overall meaning
Difficulty with proverbs, idioms, metaphors
Problems with abstract categories
Difficulty with irony, humor, sarcasm
Problems with logical errors in sentences
Discourse definition:
social communication skills, involves descriptions of events, objects, and performance, extended talk on a given topic, conversations.
Discourse problems:
Distinguishing significant from irrelevant info.
Use tangential, inconsequential aspects of topics
Conversational speech-irrelevant or tangential
Understanding implied meanings, abstract words, metaphors, irony, and humor
Premature incorrect inferences (jumping to conclusions)
Confabulation and excessive speech
Unelaborated narratives
Evaluation of R CVA:
What behaviors should be assessed particularly in R CVA?
Discourse
Pragmatic Behavior
Prosody
Neglect
Attention
Affective Processing
Also: Dysarthria & Dysphagia
What are some of the instruments available for evaluation of communication and cognitive problems in R CVA?
Know the basic uses for:
Rehab. Institute of Chicago Evaluation of communication Problems in Right Hemisphere Dysfunction (RICE)
Mini –Inventory of Right Brain Injury (MIRBI), Pimental & Kinsbury, (1989)
Burns Brief Inventory of Communication and Cognition, Burns (1995)
Rivermead Behavioral Memory Test, Wilson, Cockburn, & Baddeley, (1991)
Ross Information Processing Assessment, 2nd Ed. (RIPA-2), Ross-Swain, (1995)
Woodcock-Johnson Psychoeducational Battery Revised, Woodcock & Johnson, (1989)
What are some published tests for visual neglect?
Test of Visual Field Attention, Coolspring software
What does the Stroop Test assess?
?
What does the Prutting Protocol assess?
?
In an initial screening with a person with an RHD diagnosis, what activities could you use in an initial screening?
Interview
Scene Interpretation
Neglect:
Cancellation
Drawing
Line Bisection
Neglect: what percentages of L Brain-damaged individuals have R neglect compared to R Brain damaged individuals with L neglect?
Left brain damage: right-neglect = 2-15%
Right brain damage: left-neglect = 31-90%
What are some facial recognition deficits found in individuals with R Hemisphere CVAs?
Difficulty recognizing familiar faces
Difficulty choosing pictures of faces just shown
Problems naming the pictures of faces of famous persons
Capgras syndrome
Capgras syndrome:
: delusional belief that their friends and family members are not their real selves but imposters or doubles
Possible sensory issues associated with RHD that could impact treatment goals:
Achromatopsia
Simultagnosia
Pallinopsia
Reduplicative Paramnesia
Achromatopsia:
Loss of Color vision
Simultagnosia:
inability to perceive simultaneously the multiple details of a visual display.
Pallinopsia:
variant of hallucination, major feature is abnormal persistence or recurrence of visual images after the stimulus has been removed.
Reduplicative Paramnesia:
belief in the existence of multiple and identical persons, places and body parts
Major Treatment Targets
Hegde, 2008
Denial and indifference issues
Impaired attention
Visual neglect
Impulsive behavior
Pragmatic language skills
Impaired recognition of absurdities
Impaired comprehension of metaphors and proverbs
Prosody
Pragmatics
Affective language/emotional expression
Discourse aspects: Macrostructure
Agnosias: impaired facial recognition
Treatment of Attention Deficits Task
Simple Reaction Time Tasks:
Complex Reaction time Tasks:
Serial tasks:
Visual matching Tasks:
Arousal and sustained attention
Selective attention, vigilance
Arousal, vigilance
Selective attention
Stroop-type tasks:
Cancellation tasks:
Alternating responses during cancellation:
Dual tasks:
Vigilance, selective attention
Selective attention
Selective attention, flexibility, vigilance
Sustained attention, flexibility
Treatment of Visual Neglect
Strategy
Verbal Reminders
Salient visual and tactile cues
Restructure Environment
Tasks to encourage leftward search
Use of contiguous stimuli
Tell them “look left”…
Red line, highlighter, ruler, or Velcro strips on margins
Self-care items to the left
Items that encourage search
More sensitive to sets
Treatment of Affective Deficits
Comprehension of nonverbal emotional expression- scene discussion
Production of nonverbal affective expression: - not responsive to Speech Tx.
May need counseling.
Could use discourse treatment
Treatment of Prosodic Deficits
Comprehension:
ID emotional prosody in sentences
ID emphatic stress
ID sentence stress
Discriminate sentence types
Treatment of Prosodic Deficits
Production Tasks:
Produce emotional prosody in sentences
Produce emphatic stress in words
Produce emphatic stress in sentences
Treatment of Discourse Deficits
Inference Generation Tasks
Picture/story interpretation
Guided inference generation
Picture titles/ story headlines
Story continuations
Individual inferences
Treatment of Semantic Deficits
Alternative meanings:
Activation tasks- stimulate activation of alternate meanings
Homographs, word associations
Resolving ambiguities, inference revision
Suppression Tasks-Improve awareness and conscious control or suppression of
inappropriate alternate meanings
Homographs, semantic relations
Sentence interpretation
Treatment of Pragmatic Deficits
No known treatment to address affective components
Conversational Conventions:
Increased conversational promoters
Decreased conversational blockers
Theory of Mind tasks
Management of reduced sensitivity to listener needs
Denial and Indifference
Some consider this the most difficult aspect to treat!
If in denial- less motivated to work
May require delaying treatment until reduction of denial.
Increase awareness of the problems
Give immediate, systematic, and response-contingent corrective feedback
Videotaping/audio taping
Positive reinforcement of appropriate behaviors should accompany corrective feedback.
Encourage self-correction- have the client chart or count errors
Work closely with family or caregivers to give corrective feedback.
Treatment of Impaired Facial Recognition
Very little information available on tx
Focus on part to whole association
