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This is seen in Wernicke's

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•Fluent aphasia •Sensory aphasia, receptive aphasia, posterior aphasia •Articles, prepositions, conjunctions are correct but content words may be paraphasias •Circumlocution •Press of speech (logorrhea) •Empty speech

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Wernicke's struggle with:

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• Unable to appreciate differences between words he/she his/ him •Dissociations between sight & meaning of word; and between sound & meaning of word •Loss of semantic typicality •Impaired short term retention & recall •Paraphasias (verbal usually, sometimes literal, and neologistic)

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Wernicke's •Mild

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aware of errors; follow conversational rules

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Wernicke's •Moderate

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rarely notice errors, are attentive and cooperative, but don't stay on task for therapy or testing; go off on "tangents" in conversation

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Wernicke's •Severe

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attentive; severe comprehension impairments, oblivious to errors & communication failure

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What else defines Wernicke's?

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•Not hemiparetic •Often have visual field cuts •Damage to aud cortex, 41-42 & 22, white matter •Hearing ok, but loss of com; hear music fine •Speech is rapid with preserved rhythm, articulatory agility, melodic line

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• What do I do with a comb? Well a comb is a utensil or some such thing that can be used for arranging and rearranging the hair on the head both by men and by women. One could also make music with it by putting a piece of paper behind it and blowing through it. Sometimes it could be used in art - in sculpture, for example, to make a series of lines in soft clay. It is usually made of soft plastic and usually black although it comes in other colors. It is carried in the pocket until its needed, when it is taken out and used, then put back in the pocket. Is that what you had in mind?

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Mild Wernicke's (press of speech)

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• This morning for - that meal - the first thing this morning - what I ate - I dined on - chickens, but little - and pig - pork - hen fruit and some bacon I guess.

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Moderate Wernicke's (circumlocution)

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•I went down to the thing to do the other one and she was only the last one that ever did it.

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•Moderate Wernicke's (empty speech)

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(asked what he had for breakfast) •"That's frinking the ambuviat binia the frigulator."

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Severe Wernicke's

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Management of Wernickes

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Early after stroke most aphasics don't talk. Wernicke's patients do! Earlier release from hospital. No rehab. Others don't recognize their errors as readily.

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Wernicke's patients

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•Seem confused, but aren't •Sometimes poorer prognosis than Brocas, because of comprehension problems. •IF blood restored to Wernicke's area, may resolve to anomic.

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Typical Aphasia Tests

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•Therapy seems less effective because tests don't capture improvements. •Wernicke's pt feels aphasia tests are annoying and does badly. •On in-context things, he does better. Things about his life, a current situation, relevant to them, etc. •(Think of when you are trying to come up with some word out to the blue... but if you've been involved with it, you can retrieve and understand it more quickly.)

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Strategies with pt with Wernicke's

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• Meet with the family •Get a functional measure •Establish a therapeutic set •Interview •(Test) •Interact

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Get a Functional Measure

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•Inpatient Functional Communication Interview (IFCI) - measure functional communication in a hospital. •Other functional measures - What are these? - CADL - ASHA-FACs - FCP - CETI - FIM: Functional Independence Measure

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Establish a Therapeutic Set

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•Pt must understand SLP is there to help him. •SLP must understand what is important to the patient.

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Assessment for Wernicke's

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•Standard tests give little info. •Personalize it. •Get background info and use it to engage pt in interview. •Interview; Para-Standardized testing (next page) •Be detective - how, what does he use, etc.

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Para-Standardized Testing -By Robert Marshall

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1.Therapeutic Set 2.Pragmatics 3.Auditory Comprehension 4.Verbal Expression Para-Standardized Testing

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Therapeutic Set

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NEG: hostility, distractibility,perseveration of tasks, rigidity of behavior POS: accepting, able to switch task, able to engage in task, role play and pretend; ease of establishing

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Pragmatics

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conversational rules NEG: limited turn-taking; violates social conventions; blames problems on outside forces; doesn't initiate, gives up POS: follows conversational conventions;understands he had a stroke; makes needs known; initiates; persists

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Auditory comprehension

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NEG:poor hearing; looking confused; difficulty pointing & identifying, can't follow commands, not helped by slower rate or topic alerts, press of speech, doesn't ask for repeats or verification; visual cues don't help comprehension; no awareness of errors POS: Good hearing; responds enthusiastically about personal interests; task oriented; follows simple commands; comprehension improves with cues, asks for verification; aware/upset by errors

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Verbal Expression

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NEG: Empty speech; rejects target word when presented; unrestricted verbal output; para-grammatical errors (him/he); neologisms; unaware of errors; continue with errors even if pointed out; has no alternative ways to convey POS: Aware of errors, errors are variable, strong grammatical structure; errors similar to target; improves when given model; conveys meaning by alternate means (description) or modality

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Treatments for Receptive and Expressive Aphasia

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•Context Based Approach by Robert Marshall •PACE •Cognitive Neuropsychological Approaches •(Social Approaches - we already talked about a bit) •Hybrid Approaches •General anomia approaches •Group Therapy - many

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About Context Based Treatment

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•Limited time, soon after stroke, short duration, helps family interact •Aphasic person performs better when stimuli is personally relevant •CBT -reduces stress of having drill, naming •Clinician is not the instructor, but the communicative partner •SLP must know the background of the patient and family situations •SLP must be flexible and try different approaches •What helps pt understand, what does pt use to communicate, what disrupts conversation, what increases it? Videotape if needed. Use items in pts room (flowers), children's names. •Role play situations

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Context Based Treatment consists of:

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A. COMPREHENSION 1.Make comprehension happen 2. Teach the patient to take responsibility for comprehension 3. Caregivers learn to talk to pt using demo and modeling B. IMPROVE INFORMATION EXCHANGE

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Rationale for context based treatment

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1. IF you make comprehension happen -it improves Identify and manipulate: 1) linguistic 2) temporal variables

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Linguistic changes (CBT)

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1.Annouce the topic, or alert to topic change 2. Add stress to key words 3. State info directly 4. Use repetition and synonyms 5.Rephrase, expand to create message redundancy

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Temporal variables (CBT)

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1. Use a slightly slower rate 2. Put pauses between clauses 3. Alert to incoming message

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C= Clinician P=Patient C: I would like to talk to you about your family. P: Oh boy. C: I know you have a large family [presents written word "FAMILY"]. P: Oh, my family, well it's a big one. C: I understand you have a quite a few children. How many do you have? P:Let me see, Tony ,Markee, Martee, Muckee-------Oh no. C: That's a hard word to say, but I'm interested in HOW MANY [stresses this word]: four, five six [gestures higher]. P: No more than that [holds up 10 fingers]. C: Wow, 10 kids. That must keep you busy. All boys? P: No way, no way. Lots of girls [holds up seven fingers]. C: Seven girls. That means you have three boys [holds up three fingers]. P: Yep, three of them. Example cont. C: I understand one of your boys is quite famous. P: Huh [looking quizzical] What did you say? C: I'm glad you asked me to repeat that question. Any time. I was asking about your FAMOUS son. P: Oh, you mean Buddig, Bodie, Booby. C: Right, Buddy, I understand he's a rather good football player? [Buddy is really a baseball player.] P: Not that one, the other one. Example cont. C: Sorry wrong sport. You mean golf? P: Nope. C: Tennis? P: Get out of here. C: Baseball? P: That would be one. He's a [gestures pitching motion] you know. C: Pitcher? Wow. Is he right or left handed? P: One of these [gestures with his left hand].

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Example - CBT (Marshall)

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2) pt takes responsibility for comprehension (CBT)

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Pretends to understand (socially acceptable). Clinicial should model: • ask for repetition (tell me again) • quizzical look • verify -You said she was late. Is she here? • ask a rhetorical question • ask/take a break when aud overload

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3) caregivers learn to talk to pt using demo and modeling (CBT)

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a) explain, show, model to family b) train staff - Program by Marshall and English -talking to Physical Therapist

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Context Based Treatment B. Improving Information Exchange

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• Break cycle of defective utterances (keeps talking), by inserting context ("I see you are a chef"). (Offer visual - magazine). • Use gentle STOP strategy • At first, SLP signals stop. "listen to self, correct." • If pt can't, slp models correctly • Treating perseveration -pt has shut out the new question. • SLP should take time to integrate one response before asking for another.

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About PACE

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• Promoting Aphasics' Communicative Effectiveness • PACE • PACE - is not a therapy program - it's a philosophy. • 4 principals - Exchange of information - Free choice of communication channels - SLP & Pt are equal senders and receivers of messages - Feedback is based on communicative adequacy

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PACE Principal 1)

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*There should be an exchange of information • Specificity depends on presuppositions. • If both see a picture - no communication is needed. If one does - must communicate. • Newness of information is key. Real communication.

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PACE Principal 2)

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* The patient should have a free choice of communicative channels • Reward communication: drawing, gesturing, facial expression • (SLP can help by modeling, make word banks, etc available & have paper available)

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PACE Principal 3)

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*SLP & therapist should participate equally as receiver and sender of messages. • Pace Principals

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PACE Principal 4)

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* Clinician feedback should be based on communicative adequacy • Traditional - correct grammar, ask for extended sentence • PACE -Did they get the message across? Oh, I see. Or, did you mean________

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Pace Materials

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• Pictures • Objects • Actions • Stories • Topics or Themes can be written out • New stimuli every session

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C: Tell me what's on your slide P: Bo C: You said "boy" - so there's a boy in that picture. What's he doing? P: Ahing C: Sorry, didn't get that. Did you say he's ironing? P: No. wat C: Oh - he's waiting Picture P: These people are sitting. C: Ok; somebody's sitting. Why? P: MMMMM draws picture of eyes shut C: OH - they must be tired. Do you mean_ The people are sitting down because they're tired.

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PACE picture example 1

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P: mmnlloeh C: Can you show me? (hands pencil) P: draws C: is this something about a book? P: Book. (writes R) C: OH - they're reading a book. Who's reading?

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PACE picture example 2

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•Scoring for PACE

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4 - message conveyed on first attempt 3 - message conveyed after general feedback (tell me more) 2 - Message conveyed following specific questions 1 - message only partially understood 0- receiver has no idea of the message

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About Cognitive Neuropsychological Approaches:

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•Cognitive Neuropsychological Approaches VS. Traditional •Traditional - don't distinguish the mechanisms of lexical failure that occur in different aphasias •CN - tries to characterize diverse lexical impairments (You really, really analyze). •Example - Analyze what is supposed to happen & where the problem is Activation of sensory structures trigger cognitive mechanisms in the CNS. Peripheral motor processes allow planning and executing of responses Recognition = stimuli is identified as familiar Agnosia = receive the stimuli but don't recognize it May affect different input systems (Vis vs Aud) Is it phonological or semantic?

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CNP: How do you know which part is impaired?

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• Compare modalities - Spoken word - Feel object - Written word • Control the stimuli and the task length - Common vs uncommon - Early learned etc. • Verification tasks MUST reject foils and verify correct • Sometimes better than pointing to one of array - May not know the word, but knows it's not the other one • Include semantic foils - Is this a house? Is this a tiger? • Include phonological foils - Is this a sprouse? Is this a house?

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CNP Consider the Pattern of the Error production

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• This will tell you where the breakdown occurs And what are the types of production errors - Visual - Semantic • Superordinate • Coordinate • Associate • Circumlocution • Phonemic breakdown Assess Spared skills

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TX for Comprehension Impairments

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•Restitutive & Substitutive

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Restitutive

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* "fix" mechanisms - Sound to letter matching - Nonsense syllable discrimination - Auditory word to picture

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Substitutive

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*use other processes to accomplish comprehension - Lip reading - Writing words - Teaching partner to use strategies - AUD + WRITTEN WORDS= most effective

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CNP tx for Production Impairments (word retrieval problems)

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• Phonological Part and Semantic Part • Restitutive • Substitutive • Print to sound conversion

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CNP tx for Production Impairments (word retrieval problems)-Restitutive

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- Using comprehension tasks - Picture categorization - Spoken - written words to picture - Y/N ?s - Rehearsal of target words in comprehension task - Semantic cues - Contextual priming, etc.

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CNP tx for Production Impairments (word retrieval problems)- Print to sound conversion

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- Oral reading - Phonetic spelling - Gestural system training - Learn to circumlocute

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Treatment for Anomia

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...

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Treatment for Anomia- Example of a Specific Hybrid Approach

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• For word retrieval • To improve both semantic and phonological access to words • Uses semantic features matrix as a strategy • Patient uses enough semantic features that the partner will recognize the word • Hybrid Approach

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Example of a Specific Hybrid Approach DAY 1

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- 3 categories with 5-8 words per category

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Example of Specific Hybrid Approach DAY 2

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same categories but different words Bring: data sheet; category names; written words, Visual Semantic Feature Matrix

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Example of Specific Hybrid Approach Probe

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present all pictures for naming

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Example of Specific Hybrid Approach-Treatment

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- Present Category Name card - Pt places shuffled cards into correct category - Remove Category Name - Present Visual Semantic Matrix - Present target words & elicit features using questions on matrix - Pt write the word (you model if needed) - Write all words, then collect them - Pt reads words (model as needed) - Take away visuals; give description and client names

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Example of Categories

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• FEELINGS • DISHES • TOOLS

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OTHER research

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Semantic Typicality • Research supports idea of HARDER or more ABSTRACT words first, which allows easier words to fill in • Remind you of anything??? Great Dane.....Dog Petunia.......... Flower

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Anomia •Indirect approaches

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*minimize the anomia and focus on communication. • Say it for them, wait & encourage, let it go • Compensations -draw, write, point, word banks • Direct approaches -circumlocution -induced naming, personalized cueing, semantic feature analysis • Promoting self correction

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Anomia Other Treatment Therapies

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• PACE • RESPONSE ELABORATION TRAINING • GAMES • REMINISCENSE THERAPY • PROBLEM FOCUSED TX- problem solving activities (credit card problem) • (SLP can use Scale of Interaction Competence)

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Group Therapy

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• Group Therapy-has been found to be very effective for some. 1) Life Participation Approach to Aphasia (LPAA) 2) Interactional Aphasiology 3) Supported Conversation for Adults (SCA)

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Life Participation Approach to Aphasia (LPAA)

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- Re-engagement in life - Short & life long goals - Supports PWA and others affected by it

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Interactional Aphasiology

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- Focus on remediation of conversation

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Supported Conversation for Adults (SCA)

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- PWA and partner - Utterance adjustments - Gestural supports - Graphic supports - Line drawings pictographs - Photograph groupings

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Group Therapy Possible Materials

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• Personal photo albums, memorabilia • Board games • Magazines, newspaper articles • Photos/jokes from the internet • Movie/TV Clips • Songs/Song Clips • Atlases and maps • Restaurant menus

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Dr. Melinda Corwin TTHSC

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• Chatterboxes • Incredibles • Minds of the Round Table • Wise Guys • Comeback Kids • Wired Women • Happy Faces • Caregivers Network (More on groups when we get to dementia)

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There are many other programs and therapies!!

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• Gestural • Drawing - Visual Action Therapy • Musical • Structured • Linguistic • Stimulation • Communication • Support

Wernicke’s: Assessment & Treatment; Additional Therapies – Flashcards

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