Transcript HELP! - Kansas Speech-Language

HELP!
Is it Aphasia, Apraxia, Dysarthria or ALL of
the Above??!!
Jamie L. Johnson, MA L/CCC-SLP
University of Kansas Hospital
September 24, 2015
During this session, participants
will actively participate in
discussing:
Different types of aphasia and
dysarthria.
Define dysarthria and apraxia.
Evaluation in the acute and
outpatient settings will be
identified.
The role of the SLP in education
with family/friends for carryover
into the home and community will
briefly be discussed.
Aphasia
• National Aphasia Association
• www.aphasia.org
Aphasia Evidence Map
Standardized Evaluations
• Purpose:
▫
▫
▫
▫
Assess 4 modalities
Classification
Prognostic statement
Treatment
Fluency
• Non-fluent
• Borderline fluent
• Fluent
0-5 words
6-8 words
9+ words
Fluency
• Average of 3 longest phrases in response to
▫ What happened to you
▫ Description of picture (cookie theft)
▫ Response to emotional question-”Tell me about
your family.” “Do you remember what happened
on 911?”
Standardized Evaluations
• Classification
▫ WAB
▫ BDAE
• Non-classification
▫ MTDDA
▫ PICA
▫ Functional Assessment of Communication Skills for
Adults (ASHA FACS)
▫ CADL
▫ Communication Effectiveness Index (CETI)-caregiver
Screening Tests
• Frenchay Aphasia Screening Test (FAST)
• Ullevaal Aphasia Test (UAST)
Others:
• ADP
• Boston Naming Test
SETTING DEPENDENT
ACUTE
INPATIENT REHAB
OUTPATIENT
SNF
LTACH
HOME HEALTH
Standardized Evaluations
• What do you use??
HOW ABOUT YOU
Do you determine the type or
classification of aphasia?
Type of
Aphasia
Fluent or
Nonfluent
Conversational
Speech
Auditory
comprehension
Repetition
Naming
Lesion Location
Anomic
Aphasia
fluent
Fluent, normal
utterance length and
well-formed sentences
Good for everyday
conversation,
difficulty with
complex syntax
preserved
Impairment
is hallmark
Conduction
Aphasia
fluent
Fluent with normal
utterance length but
has paraphasias
Good for casual
conversation, difficult
with complex syntax
Always
impaired
Transcortical
sensory
aphasia
(TcSA)
fluent
Fluent with normal
utterance length, but
semantic paraphasias,
anomia
Significantly
impaired
Impairment is
hallmark, good
spontaneous
speech,
paraphasias
during
repetition
Preserved
Acute – outside perisylvian
zona (angular gyrus or
inferior temporal region),
chronic- perisylvian area,
posterior tempolateral
region
Posterior perisylvian lesions
affecting supramarginal
gyrus in parietal lobe and
arcuate fasciculus
Wernicke’s
aphasia
Fluent
Fluent, easily
articulated speech of
normal utterance
length, semantic and
phonemic paraphasias,
verbal output excessive
and rapid but empty
Significantly
defective,
cannot even
repeat single
words
Paraphasic
and severe
anomia
Transcortical
motor aphasia
(TcMA)
Nonfluent
Little attempt to
produce spontaneous
speech, mute, speech is
reduced in length
Severely impaired at
single-word level,
difficulty with
complex syntax and
multi-step
commands, unaware
of inability to produce
coherent speech
Good for most
conversational
interaction, difficulty
with complex syntax
Preserved, but
absence of
spontaneous
speech
Relatively
preserved
Broca’s
aphasia
Nonfluent
Slow, halting speech
production,
utterances are of
reduced length with
simple grammar
Good for
conversational
speech, difficulty
with complex
syntax
Limited to
single words
and short
phrases
Impaired
to some
degree,
especially
for low
frequency
words
Severely
impaired
Extrasylvian regions
involving POT junction
region; posterior and deep
to Wernicke’s area; sensory
info doesn’t reach language
areas
Large posterior perisylvian
lesions encompassing
Wernicke’s area and
extending superiorly into
inferior parietal region
Extrasylvian regions of left
frontal lobe; dorsolateral
frontal lesions located
anterior or superior to
Broca’s area, supplementary
motor areas, cingulate gyrus
Broca’s area causes
transient disruption of
speech production and
fluency; persistent Broca’s
aphasia from larger
perisylvian lesions
encompassing more of the
left frontal lobe
GLOBAL APHASIA
• VERBAL EXPRESSION
▫ NON-FLUENT
▫ Severely Impaired
▫ *Automatic speech may be
preserved
• COMPREHENSION
▫ Severely Impaired
• REPETITION
▫ Impaired
• WRITING
▫ Impaired
• READING
COMPREHENSION
▫ Impaired
• LARGE LEFT DOMINANT
LESION
▫ Involving Broca’s and
Wernicke’s areas
BROCA’S APHASIA
• VERBAL EXPRESSION:
▫
▫
▫
▫
NON-FLUENT (4words or less)
Slow effortful
Perseverations
“Telegraphic speech”
• COMPREHENSION:
▫ Relatively preserved
• REPETITION
▫ Poor
• WRITING
▫ Parallels expression
• READING COMPREHENSION
▫ Relatively spared
• ANTERIOR PORTION OF
THE LEFT
HEMISPHERE
TRANSCORTICAL MOTOR APHASIA
• VERBAL EXPRESSION
▫ NON-FLUENT
• AUDITORY
COMPREHENSION:
▫ Intact
• REPETITION
▫ Intact
• SIMILAR TO BROCA’S WITH
ABILITY TO REPEAT
• Anterior and Superior to
Broca’s area
• Watershed, borderzones
*MIXED NON-FLUENT
• Resembles Broca’s but
auditory comprehension below
50 percentile.
• Auditory comprehension too
good to be Global
WERNICKE’S APHASIA
• VERBAL EXPRESSION
▫ FLUENT
▫ Jargon, non-sensical words,
rapid rate
▫ Retain sentences but lack
meaning
▫ May speak with no insight
into errors
• COMPREHENSION
▫ poor
• REPETITION
▫ poor
• Temporo-parietal involving
Wernicke’s area and adjacent
white matter
CONDUCTION APHASIA
• VERBAL EXPRESSION
▫ FLUENT
▫ Word finding
▫ Paraphasic errors
• COMPREHENISON
▫ Relatively intact
• REPETITION
▫ Poor
• RARE
• ARCUATE FASCICULUS AND
LEFT PARIETAL
TRANSCORTICAL SENSORY APHASIA
• VERBAL EXPRESSION
▫ FLUENT
▫ Echolalia
• Watershed PCA/MCA
territories, borderzones
• Spares Wernicke’s area
• COMPREHENSION
▫ SIMILAR TO WERNICKE’SEXCEPT STRONG ABILITY
TO REPEAT
REPETITION:
▫ Intact
*MIXED TRANSCORTICAL APHASIA
• COMBINATION OF THE
TWO TRANSCORTICAL
APHASIAS
• AUDITORY
COMPREHENSION AND
EXPRESSION SEVERELY
IMPAIRED
• REPETITION INTACT
ANOMIC APHASIA
• VERBAL EXPRESSION
▫ FLUENT
▫ Word Finding problems
▫ Circumlocutes
• COMPREHENSION
▫ Intact
▫ USE OF NON-SPECIFIC
WORDS SUCH AS “THING”
• REPETITION
▫ Intact
• MILD FORM
• +Awareness
CROSSED APHASIA
• LANGUAGE CENTER NO IN
EXPECTED HEMISPHERE
•
• EX. RIGHT-HANDED
PERSON WITH R CVA WITH
APHASIA
Reading and Writing
Alexia
Alexia with Agraphia
Agraphia
Paraphasias
▫ Literal/Phonemic
▫ Verbal/Semantic
Neologism
Perseveration
Circumlocutions
SUBCORTICAL APHASIA
• THALAMUS
• INTERNAL CAPSULE
• BASAL GANGLIA
• MIRROR CORTICAL LESION
APHASIAS
• CAN CO-OCCUR WITH
CORTICAL APHASIAS
PRIMARY PROGRESSIVE APHASIA
•
GRADUAL LOSS OF LANGUAGEPRESERVED MEMORY, VISUAL
PROCESSING AND PERSONALITYUNTIL THE END
•
BEGINS WITH WORD FINDING
PROGRESSES TO IMPAIRED
GRAMMAR AND COMPREHENSION
•
DYSARTHRIA AND APRAXIA MAY
ACCOMPANY
•
*STRUCTURAL & PHYSIOLOGICAL
ABNORMALITIES IN LEFT
HEMISPHERE (FRONTAL,
PARIETAL AND TEMPORAL.
•
NOT DUE TO NEOPLASTIC,
VASCULAR OR METABOLIC
ETIOLOGIES NOR INFECTION
• Semantic variant
• Logopenic variant
• Non-fluent Agrammatic
variant
INSULA
“The Role of the insula in Speech and
Language Production”
Oh, A. et al.
• Responsible for articulatory control
Brain and Language 135 (2014) 96103.
• Higher order cognitive aspects of
speech-language
• Direct connections to Broca’s area
• fMRI-exp/rec and production/
perception=Bilateral ant insula
•
“Prime real estate”
Speech perception Left dorsal midinsula
• Expressive language tasks activated
left ventral mid=insula
• Mid Insula plays different roles in
S/L processing
MANY FACES OF APHASIA
Differential Diagnosis
• Motor Speech Disorders:
• Dysarthria
▫ Weakness/paralysis, incoordination, rigidity,
involuntary movement
• Apraxia
▫ Motor planning problem
▫ Absence of weakness
▫ Initiation, groping, revisions, inconsistent
Apraxia of Speech
• Messages from the brain to the mouth are disrupted,
and the person cannot move his or her lips or tongue
to the right place to say sounds correctly, even
though the muscles are not weak.
• Apraxia can occur in conjunction with dysarthria or
aphasia
• Caused by damage to the parts of the brain that
control coordinated muscle movement
Signs or Symptoms of Apraxia of Speech
Know what words they want to say, but their brains have difficulty
coordinating the muscle movements necessary to say all the sounds in
the words.
Individuals with apraxia may demonstrate:
• Difficulty imitating and producing speech sounds
• Sound distortions, substitutions, and/or omissions
• Inconsistent speech errors
• Groping of the tongue and lips to make specific sounds and words
• Slow speech rate
• Impaired rhythm and prosody (intonation) of speech
• Better automatic speech than purposeful speech
• Inability to produce any sound at all in severe cases.
• Frustrating
The faces of…dysarthria?......apraxia?
Modifier
•
•
•
•
•
•
•
0%
1-20%
20-40
40-60%
60-80%
80-99%
100%
G CODES
Impairment
WNL
MIN
MILD
MILD-MOD
MODERATE
MOD-SEVERE
SEVERE
NOMS
7
6
5
4
3
2
1
NOMS
MOTOR SPEECH
•
LEVEL 1: The individual attempts to speak, but speech cannot be understood by
•
familiar or unfamiliar listeners at any time.
•
LEVEL 2: The individual attempts to speak. The communication partner must assume
•
responsibility for interpreting the message, and with consistent and maximal cues,
•
the patient can produce short consonant-vowel combinations or automatic words
•
that are rarely intelligible in context.
•
LEVEL 3: The communication partner must assume primary responsibility for interpreting
•
the communication exchange, however, the individual is able to produce short
•
consonant-vowel combinations or automatic words intelligibly. With consistent and
•
moderate cueing, the individual can produce simple words and phrases intelligibly,
•
although accuracy may vary.
•
LEVEL 4: In simple structured conversation with familiar communication partners,
•
the individual can produce simple words and phrases intelligibly. The individual
•
usually requires moderate cueing in order to produce simple sentences intelligibly,
•
although accuracy may vary.
•
LEVEL 5: The individual is able to speak intelligibly using simple sentences in daily routine
•
activities with both familiar and unfamiliar communication partners. The individual
•
occasionally requires minimal cueing to produce more complex
•
sentences/messages in routine activities, although accuracy may vary and the
•
individual may occasionally use compensatory strategies.
•
LEVEL 6: The individual is successfully able to communicate intelligibly in most activities,
•
but some limitations in intelligibility are still apparent in vocational, avocational,
•
and social activities. The individual rarely requires minimal cueing to produce
•
complex sentences/messages intelligibly. The individual usually uses
•
compensatory strategies when encountering difficulty.
•
LEVEL 7: The individual’s ability to successfully and independently participate in
•
vocational, avocational, or social activities is not limited by speech production.
•
Independent functioning
NOMS
SPOKEN LANGUAGE COMPREHENSION
•
LEVEL 1: The individual is alert, but unable to follow simple directions or respond to yes/no
•
questions, even with cues.
•
LEVEL 2: With consistent, maximal cues, the individual is able to follow simple
•
directions, respond to simple yes/no questions in context, and respond to simple
•
words or phrases related to personal needs.
•
LEVEL 3: The individual usually responds accurately to simple yes/no questions. The
•
individual is able to follow simple directions out of context, although moderate
•
cueing is consistently needed. Accurate comprehension of more complex
•
directions/messages is infrequent.
•
LEVEL 4: The individual consistently responds accurately to simple yes/no questions and
•
occasionally follows simple directions without cues. Moderate contextual support is
•
usually needed to understand complex sentences/messages. The individual is able to
•
understand limited conversations about routine daily activities with familiar
•
communication partners.
•
LEVEL 5: The individual is able to understand communication in structured conversations
•
with both familiar and unfamiliar communication partners. The individual
•
occasionally requires minimal cueing to understand more complex
•
sentences/messages. The individual occasionally initiates the use of
•
compensatory strategies when encountering difficulty.
•
LEVEL 6: The individual is able to understand communication in most activities, but some
•
limitations in comprehension are still apparent in vocational, avocational, and
•
social activities. The individual rarely requires minimal cueing to understand complex
•
sentences. The individual usually uses compensatory strategies when encountering
•
difficulty.
•
LEVEL 7: The individual’s ability to independently participate in vocational, avocational,
•
and social activities are not limited by spoken language comprehension. When
difficulty with comprehension
NOMS
SPOKEN LANGUAGE EXPRESSION
•
•
LEVEL 1: The individual attempts to speak, but verbalizations are not meaningful to familiar or
unfamiliar communication partners at any time.
•
•
•
•
•
LEVEL 2: The individual attempts to speak, although few attempts are accurate or appropriate.
The communication partner must assume responsibility for structuring the
communication exchange, and with consistent and maximal cueing, the individual can
only occasionally produce automatic and/or imitative words and phrases that are rarely
meaningful in context.
•
•
•
LEVEL 3 The communication partner must assume responsibility for structuring the
communication exchange, and with consistent and moderate cueing, the individual can
produce words and phrases that are appropriate and meaningful in context.
•
•
•
•
•
LEVEL 4: The individual is successfully able to initiate communication using spoken language
in simple, structured conversations in routine daily activities with familiar
communication partners. The individual usually requires moderate cueing, but is able to
demonstrate use of simple sentences (i.e., semantics, syntax, and morphology) and
rarely uses complex sentences/messages.
•
•
•
•
LEVEL 5: The individual is successfully able to initiate communication using spoken language
in structured conversations with both familiar and unfamiliar communication partners.
The individual occasionally requires minimal cueing to frame more complex sentences
in messages. The individual occasionally self-cues when encountering difficulty.
•
•
•
•
LEVEL 6: The individual is successfully able to communicate in most activities, but some
limitations in spoken language are still apparent in vocational, avocational, and social
activities. The individual rarely requires minimal cueing to frame complex sentences.
The individual usually self-cues when encountering difficulty.
•
•
•
LEVEL 7: The individual’s ability to successfully and independently participate in vocational,
avocational, and social activities is not limited by spoken language skills. Independent
functioning may occasionally include use of self-cueing.
NOMS
• READING
• WRITING
Education
•
•
•
•
•
•
Family Training
Staff Training
Education materials
Websites
Apps
Home Programs
• Family/Caregiver’s role in Therapy in any setting
QUESTIONS???
REFERENCES
• Davis, G. (2007) Aphasiology: Disorders and Clinical Practice. pages
33-39.
• Helm-Estabrooks, N. Albert, M.L., 1991, 2004. Manual of Aphasia and
Aphasia Therapy. 2nd edition, Pro-Ed, Austin Texas.
• Johnson, A., Jacobson, B,(2006) Medical Speech Pathology: A
Practitioner's Guide. Thieme Medical Publishers, New York, NY
• LaPointe, L. (2001 ) Aphasia and related Neurogenic Language
Disorders. Thieme Medical Publishers, New York, NY
• Oh, A. et al. (2014) The Role of the Insula in Speech and Language
Production Brain and Language. 135, 96-103.
• www.ASHA.org