Treatment Flashcards
Treatment of Aphasia
Stages of Recovery
Early Stages: 1-3 months-coincides with the period of spontaneous recovery
Late Stages: months to years after injury
Service Delivery Contexts
Acute Care Hospitals Acute Rehabilitation Centers Skilled Nursing Facilities Long-term Care Centers Home Outpatient Centers
Prognosis for Recovery
Initial aphasia severity is the most important factor for predicting recovery
Not lesion size but the extent of involvement in specific areas that best predicts recovery
Age and recovery-probably health is most predictive
Gender-no evidence strongly favoring either
Handedness-no evidence strongly favoring either
Team intervention with a patient (and family) centered emphasis
Physician Nurse Case Managers Pharmacists Dieticians Neuropsychologists Occupational Therapists Physical Therapists Speech-Language Pathologists Support Personnel (COTA, PTAs SLP-A, Nursing Assistants)
Traditional Intervention Approaches
1. Stimulation Approach
Most widely used treatment approach
Hildred Schuell 1964
Stimulation approach that employs strong, controlled, and intensive auditory stimulation to maximize the reorganization and recovery of language
Use of controlled Auditory Stimulation
Therapist is NOT retraining BUT stimulating currently inaccessible language centers
The purpose is not to convey new learning but to stimulate old learning-attempt to reorganize a system that has been reorganized by brain damage (Wepman)
Activities for Auditory Abilities, Verbal Abilities, Reading & Writing
Potential Tasks emphasizing Auditory abilities
Point to Tasks
Following Directions/Commands
Yes/no Questions
Sentence or phrase completion
Attend to (stimulation approach)
the clarity of the auditory signal the clarity of the visual materials combining sensory modalities repetitive stimulation rate and pause length and redundancy cues, prompts and prestimulation frequency and meaningfulness syntax order of difficulty patterns of auditory deficits (slow rise time, auditory buildup)
Potential Tasks emphasizing
Auditory abilities Point to Tasks Following Directions/Commands Yes/no Questions Sentence or phrase completion
Thematic Language Stimulation
A systematic approach to aphasia treatment that employs thematically related vocabulary in multimodal stimulation for functional communication.
Firmly rooted in the Schuell model
More person-centered
“changing the way the brain is working by working the brain” (Chapey, p.451)
Focus on functional communication
Melodic Intonation Therapy (Albert, Sparks, & Helm, 1973)
A hierarchically structured program divided into THREE levels aimed at increasing the verbal expression of persons with nonfluent aphasia (Broca’s).
Uses musical elements of rhythm and tone to improve verbal expression
Designed to lead patients from intoning (singing) simple 2-3 syllable phrases to speaking 5 or more syllables.
Best candidates
Severely impaired verbal expression
Auditory Comprehension is better than their verbal expression
Unilateral, left hemisphere stroke
Produces real or accurate words when singing
Poor repetition (even for single words)
Motivation, good attention, and emotionally stable
Intonation based on three elements of spoken prosody
Variation of pitch
Tempo and rhythm
Points of stress
Melodic Intonation Therapy
Each level has 20 high-probability words (e.g. water) and social phrases (e.g. good morning)
Intonation pattern uses a range of 3-4 notes
Elements include an exaggerated melody of at least 2 syllables
MIT is slower, similar to Chant Talking
Progression to longer sentences and questions
Level 1 MIT
Establishing understanding of procedures (e.g. handholding; humming
Level 2 MIT
Humming Unison Intoning Unison intoning with fading Immediate repetition Response to probe question
Level 3 MIT
Phrase introduction
Unison fading
Delayed repetition
Response to probe question
Level 4 MIT
Delayed repetition Sprechgesang (spoken singing) Sprechgesang with fading Delayed spoken repetition Response to questions
C-Speak Aphasia Nicholas & Elliott (1999)
Picture based AAC program (non verbal communication) that allows users to select and combine pictures to make novel messages
Stimulate verbal communication
What’s included: c-speak
training manual 85 Speaking Dynamically boards screening test with 15 boards 28 stimulus cards score sheet
Best Candidates c-speak
Mod-Severe Broca’s Aphasia
Preserved auditory comprehension
Little or no reading comprehension or spelling
Unilateral brain damage
Absence of Hemi-neglect & Visual field cuts
Relatively preserved executive functioning, attention, and memory
—because they have to be able to navigate software of program
Training focus c-speak
General conversational interchanges
Telephone communication
Writing or email communication
Training considerations c-speak
May take 2-3 months 2x/week to master
Laptops and handheld devices required
Responses are agrammatic
Lingraphica1990
Computer Assisted Visual
Communication (C-ViC) based
Visual Action Therapy
Helm & Benson (1978)
Non-verbal hierarchical program used to increase production of gestures for use in functional communication
30 minute sessions 2x/week to accelerate progress
Best Candidates VAT
Boston alpha for bostob participant)
Left CVA
Severe aphasia (Global)
Inability to produce spoken or written language
Alert & Cooperative
Preserved spontaneous gesture production (e.g. pointing)
Preserved nonlinguistic visuospatial and memory skills
Ideomotor limb apraxia
Can produce some overlearned gestures
Three phases VAT
Proximal limb (shoulder and arm)VAT Distal limb (hand and finger) VAT
Materials VAT
15 real objects
15 shaded line drawings of objects
Action pictures of a simple figure using these objects
Contextual props (e.g. screw in a block of wood for use of screwdriver)
- objects varied depending on the type of gesture (proximal, distal, or oral).
Three levels at each phase (for those with severe global)
Level 1
Use of real objects, pictures and action pictures
Step 1: Matching pictures and objects
Step 2: Object use Training
Step 3: Action picture demonstration
Step 4: Following action picture commands
Step 5: Pantomimed gesture demonstration
Step 6: Pantomimed gesture recognition
Step 7: Pantomimed gesture production
Step 8: Representation of hidden objects demonstration
Step 9: Production of gestures for hidden objects
Level 2
Action pictures substituted for real objects
Level 3
Use of object pictures only (because pictures are more realistic than words)
* Both Level 2 & 3 begin with Step 5
Step 5: Pantomimed gesture demonstration
Step 6: Pantomimed gesture recognition
Step 7: Pantomimed gesture production
Step 8: Representation of hidden objects demonstration
Step 9: Production of gestures for hidden objects
Voluntary control of involuntary utterances
Program to improve speech output in individuals with severe non fluent aphasia
Can read single words
Occasionally produces single words
Can orally read single words produced
Pragmatic Therapy
PACE & Thematic Language Therapy
Promoting Aphasics’ Communicative Effectiveness
PACE, Wilcox & Davis (1985)
An approach that emphasizes the pragmatic aspect of communication and information involving a range of communicative intentions, such as informing, requesting, questioning, negating.
Goals are written to address Activities of Daily Living using communication, not the motor skills of performing the tasks
Principles PACE
- Exchange of new information in a conversational setting
- Encouraged to use any expressive modality: speech, signing, gestures, writing
- Both therapist and client are senders and receivers engaging in a conversational exchanges.
- Feedback is simply the success of communicating, the characteristic of normal communication
Goals of PACE
What do persons with aphasia gain in this process?
Clinician as a model for appropriate communication
Experience with topic and turn initiation
Experience with sustaining an interaction with several turns on the same topic
Best Candidates PACE
May be used with all persons with aphasia regardless of severity type.
Roles
Speaker PACE
Develop an appropriate message Consider context e.g New vs. Old info. Gain attention of addressee/listener Self-monitor and reformulate if a lack of understanding is relayed from addressee/listener
Addressee PACE
Decode the message (receptive)
Evaluate comprehension of message
Respond (expressive)
Request for clarification
Conversational Partner Training
Type of intervention rooted in a social model
There is a primary focus on conversation
Interaction between the PWA and his/her significant others
Interaction between the PWA and the community
Wave of the future:Traditional treatment and medical intervention
Transcranial magnet stimulation
Noninvasive procedure
Magnet fields
Creates electrical currents in discrete brain areas
Current is discharged through coil of wire
Current generates a rapidly pulsing magnetic field
Induces a changing electrical field in the cortex below the coil
Multiple stimuli (trains) can lead to ↑ or ↓ in excitability of the effected cortex
The effects can last beyond the duration of the trains
