Lecture 4: Nonfluent Aphasias Flashcards
Other names for nonfluent aphasias:
expressive aphasia, motor aphasia, anterior aphasia
Major General symptoms of nonfluent aphasias:
Decreased rate of speech, decreased phrase length, decreased prosody, decreased initiation of speech, decreased talking in general, increased effort
4 Nonfluent Aphasias
Broca’s, global, transcortical motor, mixed
Broca’s Aphasia Background
first described in 1861
Associated with damage to the cerebral language areas surrounding the sylvian fissure but not extending to Wernicke’s area
Hallmark characteristic: fluency impairment
Broca’s Aphasia Neuroanatomical Bases
Posterior-inferior (3rd) frontal gyrus of the left hemisphere known as Broca’s area (44 and part of 45)
Area known as anterior language cortex
MCA blood supply
Lower part of the premotor cortex
General Characteristics of Broca’s Aphasia
More easily recognized than Wernicke’s
Typical present with contralateral hemiplegia or hemiparesis; weakness of (r) facial muscles
Most motor problems improve over time
Pts often very depressed; catastrophic reactions refusing to cooperate or continue testing
Language Characteristics of Broca’s Aphasia
Nonfluent and effortful speech Agrammatic speech Impaired repetition of words/sentences Impaired naming Questionable auditory comprehension Oral reading Writing problems
Broca’s Aphasia Site of Lesion
Posterior-inferior central gyrus of the left hemisphere
Verbal Expression in Broca’s Aphasia
Severely impaired; agrammatic; telegraphic; dysprosodic; possible AOS; minimal paraphasias
Auditory Comprehension in Broca’s Aphasia
Better than expression; some degree of deficiency in some pts; essentially intact for most
Naming in Broca’s Aphasia
Impaired
Repetition in Broca’s Aphasia
Impaired, especially for grammatical features
Oral Reading in Broca’s Aphasia
Impaired; similar to oral expression
Reading Comprehension in Broca’s Aphasia
Impaired to some extent
Writing in Broca’s Aphasia
Impaired
Transcortical Motor Aphasia Background
Extrasylvian aphasic syndrome; lies outside of perisylvian language zones
Nonfluent aphasia with good repetition skills
Hallmark characteristic: discrepancy between language production problems (impaired) & spared repetition skills
Neuroanatomical Bases in TMA
Anterior superior frontal lobe Usually above or below Broca's area Lesions often impact association pathways Impacts supplemental motor area Supplied by anterior cerebral artery
General Characteristics in TMA
Similar to Broca’s aphasia
Motor disorders: rigidity of UE, akinesia, bradykinesia
Hemiparesis
Pts may demonstrate apathy or behavioral withdrawal: exhibit little to no interest in using language
Language Characteristics of TMA
Muteness, echolalic, reduced spontaneous speech
Agrammatic speech, paraphasic
Impaired naming with intact repetition
Relatively intact serial speech
Intact knowledge of grammar/ meaningfulness
Limited naming; may use motor prompts (snapping, etc. to get going)
Better comprehension than production
TMA site of lesion
Deep portions of the left frontal lobe below or above Broca’s area
Verbal expression in TMA
Impaired; initially mute; paraphasic; agrammatic; telegraphic; limited word fluency; pt will have no apraxia of speech
Auditory Comprehension in TMA
Intact for simple; subtle problems with complex material
Naming in TMA
Mildly impaired; better for confrontational naming
Repetition in TMA
Intact; may demonstrate echolalic and perseverative speech
Oral Reading in TMA
Impaired
Reading Comprehension in TMA
Good except for syntactically complex material
Writing in TMA
Impaired
Mixed Transcortical Aphasia (MTA) Background
Rare nonfluent aphasia type
Combine TMA and TSA
Language impairment is severe and extensive
Pts retain repetition skills (Hallmark & distinguishing feature from global aphasia)
Has been labeled isolation aphasia
Neuroanatomical Bases of Mixed Transcortical Aphasia
Caused by various conditions that decrease blood flow throughout cerebral arteries: hypoxia of various origins, cardiac arrest, cerebral edema, multiple embolic strokes
Supplied by MCA, & anterior/posterior cerebral arteries
Broca’s, Wernicke’s, & arcuate fasciculus are spared
General Characteristics of Mixed Transcortical Aphasia
Varied clinical picture
Bilateral UMN paralysis
Severe spastic quadriparesis (weakness of all 4 limbs)
Visual field deficits (typical problems is right hemianopia)
Weakness in hip/shoulder muscles
Severe brain damage
Language Characteristics of Mixed Transcortical Aphasia
Extremely limited spontaneous verbal expression, echolalic Severely impaired fluency Severely impaired auditory comprehension Marked naming difficulty Unimpaired automatic speech Normal articulation Severe reading deficits Severe writing impairments
Lesion site: Mixed Transcortical Aphasia
watershed area (pg. 113)
Verbal expression: mixed transcortical aphasia
Often severely impaired; Agrammatic with paraphasias
Auditory Comprehension: Mixed Transcortical Aphasia
Often severely impaired
Naming: Mixed Transcortical Aphasia
Impaired
Repetition: Mixed Transcortical Aphasia
Good but parrot-like; nonfunctional repetition
Oral Reading: Mixed Transcortical Aphasia
Often severely impaired
Reading Comprehension: Mixed Transcortical Aphasia
Often severely impaired
Writing: Mixed Transcortical Aphasia
Impaired
Additional Info on Mixed Transcortical Aphasia
“Broca’s aphasia with decreased auditory comprehension
Global Aphasia Background
May account for 30-55% of pts with aphasia
Most severe form of aphasia; has a generalized effect on communication skills
Impacts all modes of communication & spares no particular skill (which is hallmark)
Possible for it to evolve into another type of aphasia
Be careful of prognosis
Neuroanatomical Bases of Global Aphasia
Lesion likely to involve entire perisylvian region affecting both Broca’s and Wernicke’s areas
Subcortical areas may even be impacted
More common sites are impacted by MCA
Widespread destruction of left fronto-temporo-parietal regions
General characteristics of global aphasia
Presence of strong neurological symptoms; weakness; paralysis; sensory loss
Apraxia including both verbal & oral types
Hemi-neglect
Hemi-neglect
left neglect is common in right hemisphere damage
Language Characteristics of Global Aphasia
Globally impaired communication skills
Severely impaired fluency
Impaired repetition, naming, reading, writing
Impaired auditory comprehension
Global Aphasia Site of Lesion
Widespread damage; left fronto-temporo-parietal regions
Verbal expression in global aphasia
Severely impaired; minimal vocalizations
Auditory comprehension in global aphasia
Impaired; maybe personally relevant info; some y/n ?s
Naming in global aphasia
Impaired
Repetition in global aphasia
Impaired
Oral reading in global aphasia
Impaired
Reading comprehension in global aphasia
Impaired
Writing in global aphasia
Impaired; no meaningful; may copy letters &/or write name
General Nonfluent Aphasia Treatment
Coarticulated speech; auditory comprehension; oral expression tasks; understanding written language/reading; writing strategies
Coarticulated speech
Build on level of success (syllables, words, phrases…)
Auditory comprehension strategies
Point, follow commands, understand complex material
Oral expression tasks may range from:
Oral-motor skills, automatic sequences, repetition, answering questions, naming, & word fluency to reading words & sentences aloud
Understanding written language (reading)
Identify letters, words, match words and pictures, read sentences and paragraphs
Writing Treatment
Improve mechanics for writing basic info, the alphabet, numbers, writing to dictation, writing names, & writing about a picture or event
Treatment Strategies: Consider spared abilities/functional levels:
Good writing: apply directly to communication
Some writing: consider a writing/spelling therapy program
No writing, some drawing: consider a communicative drawing therapy program
No writing, some gesturing: consider a communicative gesturing therapy program
Gestural-verbal training increases naming for some people with aphasia
PACE approach
Prompting Aphasics’ Communicative Effectiveness; Pulvermuller & Volkbert, 1991
Uses compensatory strategies to facilitate communication: encourages exchange of information; provide a stimuli pic face down b/t pt & clinician & the pt must look at it & use any available means to communicate the message (charades with all modalities)
SLP guesses and provides feedback
Mapping Treatment
For agrammatism
Targets sentence structure & thematic roles by identifying subject & object of sentences
Uses pictures
Sentence Production Program for Aphasia (SPPA)
Helm-Estabrooks & Nicholas 2000
Used to improve conversation with pts who have nonfluent aphasia & who are agrammatic speakers
Attempts to increase phrase length, content, & grammar
Focuses on 8 sentence types using a thematic base
Melodic Intonation Therapy (MIT)
Sparks & Deck 1986
Approach that uses melodies & intonation patterns of the intact right hemisphere
4 levels: 1: intoning a melodic line; 2: hand tapping saying syllables; 3: answering questions; 4: practice with drilled phrases & sentences
Pictures used initially & later program cues reduced
Response Elaboration Training (RET); Kearns 1991
Program using loose training w/ pt-initiated responses (without restrictions)
Uses simple line-drawn picture stimuli requiring personal interpretation
SLP scaffolds responses (doesn’t provide corrections to pt responses)
6 steps: 1: Elicit spontaneous response to pic; 2: Model & reinforce pt’s response; 3: Provide ‘wh’ cues for pt to elaborate; 4: reinforce elaboration & model sentence; 5: repeat & have pt repeat; 6: reinforce & provide another model
Equivocal Responses
Vague, confusion, ambiguous
Treatment for Equivocal Responses
use 2 notecards w/ “yes” on 1 & “no” on other; pt repeats words 5 times each while looking at cards; assist the pt to say word & nod “yes” & then “no” when given a cue; present yes/no ?s for pt responses (request responses to simple ?s)
Establish a baseline & begin treatment with personal, environmental, informational ?s
Use pics to help understand ?s; chart responses
Gestural Response Therapy
Core vocab chosen based on pt needs (begin w/ 5-10 words); Clinician makes gesture while saying a word; clinician repeats word with pt; pt imitates gesture immediately then after brief delay; pt gestures after clinician says and writes the word; pt writes word if possible when seeing gesture
Card Therapy/Treatment (Deck of Cards)
Improve sequencing of #s on cards by putting them in order
Match cards according to suit & number (use 2 decks)
Respond to commands using cards (pick up the ace)
Writing Hierarchy
Trace word–>copy word–>say word for pt to identify in writing–>ask pt to write word to dictation–>ask pt to write word given a picture–>ask pt to write word in response to a ?
Communication Boards
use communication boards w/ pics & words: alphabet & word boards usually ineffective for individuals w/ global aphasia
Include pics of people & familiar objects
Use pics of real objects, actions, places
Teaching Pts to Use Communication Boards
Point when an item is named (immediate then with a delay)
Keep board visually simple at 1st & then expose more items with time when success is achieved
Consider a more high-tech AAC device if possible and financially feasible
Using AAC
When introducing a device, assess device’s communicative capabilities & compare it with client’s needs; consider operational demands regarding client’s motor, sensory, cognitive skills
Adapt device to the client’s situations & available support
Train client & family how to use device
Monitor its use for functional language
Functional AAC Considerations: How functionally can the patient:
Get someone’s attention, give yes/no answers, call for help, indicate understanding of what’s being said, respond without words, say the name of person nearby, communicate needs, wants, pain (if any), have social times with friends and family, understand written communication, communicate their emotions, describe something, have 1-on-1 convo, get involved in group talk about self, participate in group convo
