Aphasia Exam 1 – Flashcards

based heavily on significant auditory stimulation and repetition. Language competence has survived, but language performance was impaired and could be regained with the right kind of stimulation. Tx focused on facilitating and stimulating language use. (Stim and repetition remain important principles in present-day approaches) i. Joseph Wepman & Hildred Schuell (1940-1960)

age, educational background, time since onset of the damage, and severity of aphasia became important prognostic variables. RCTs were conducted, but were difficult to design and carry out b/c of heterogenous nature of aphasia and failure of researchers to specify and systematize tx appropriately. i. Frederick Darley and his students (1972)

aim to reteach language utilizing traditional and intuitive educational methods from child and foreign-language teaching i. Howard and Hatfield? (1987): classify most approaches into several main methodologies

repetition, imitation, modeling, prompting and cuing, used in some hierarchically organized therapy approaches for apraxia of speech. Designed for specific types of aphasia or impairment type, such as perseveration; organized into steps and levels. Melodic Intonation Therapy (MIT) aims to reestablish some speech in patients by reorganization of the speech production process using melodic intonation. Visual Action Therapy (VAT) is used for Broca's or global impairments. i. Nancy Helm-Estabrooks and Martin Albert and colleagues (1991)

intact functional subsystems could substitute for impaired subsystems. E.g., letters made of sandpaper could aid in reading impairment via the tactile system. Drawn "articulograms" of the lips producing particular combinations of speech sounds were developed for severe apraxia of speech, in which the speaker uses the intact visual route to the speech production mechanism. i. Luria (1970)

Assumed that components of cognition are organized in modules that are domain-specific (computations performed by a module are specific to that module only), associated with circumscribed brain structures, genetically determined and computationally autonomous, and independent of other cognitive processes. Model is well-known for box-and-arrow diagrams used to conceptualize processing and represent the stages and routes involved in activities. Focus on single-word processing (shared with Wernicke-Lichtheim model). Includes a model of assessment for treatment and an emphasis on the individual patient and his/her problems. Howard and Patterson outline 3 strategies for tx: reteaching of the missing info, missing rules, or procedures based on detailed testing; teaching a different way to do the same task; and facilitating the use of impaired access routes. *Main contribution in systematizing assessment, allowing a clearing identification of the location of impairments within a hypothetical model. Advocated the development of single-case designs for therapy research. i. (early 1980s) Coltherat (1983); Jerry Fodor (19830; Gall ii. Wernicke-Lichtheim model: Dejerine (1982)→Liepmann (1920)→Marshall and Newcombe (1973)→Ellis and Young (1988)→Howard and Patterson (1990)

movement away from the medical-model, classification-based treatments. Focus on everyday, functional communication. i. Martha Taylor-Sarno (1969) and Audrey Holland (1980)

the therapist and patient participate equally as sender and receiver of messages; interactions entail the exchange of new information; the aphasic person chooses the modality or method of communication; feedback is based on the aphasic's person success in communicating the message; the approach encourages writing, gesture, drawing, and pointing. Promoting Aphasics Communicative Effectiveness (PACE) emphasized successful communication, not precise oral naming or correct syntax. i. Davis and Wilcox (1985)

based on surviving right hemisphere (RH) processing. Include MIT, artificial languages made up of visual arbitrary shapes or symbols for use with globally impaired patients. There were also attempts to directly influence cognitive processing in the RH and stimulate latent RH language processes using lateralization techniques such has dichotic listening and hemi-field viewing. Tx were developed that were delivered by microcomputers using mainly behavioral methods utilized intense stimulation and feedback on performance and control of the pace and level of difficulty by the user. i. Code/Katz? (1980s and 90s)

designed to increase successful participation in authentic communication events, to focus on communication at the level of conversation, to provide communication support systems within the speaker's own community, and to increase community confidence and empower speakers with aphasia. Differs significantly from medical model, and social disability and social exclusion that accompany aphasia became increasingly acknowledged. Views the problem as society's failure to accommodate the different needs of persons with impairments, which lead to people with disabilities facing increased social barriers and oppression. i. World Health Organization (WHO) (1980)

a heterogenous entity with varied clinical manifestations caused by damage to the lesions of the white matter and the subcortical nuclei that do not affect the cortex. Includes deficits in comprehension, dysarthria, and motor impairments; or (w/ damage to the thalamus) nonfluent speech, severe reduction of spontaneous speech, and semantic paraphasias, but not comprehension deficits.

right-handed individuals suffering from aphasia after RH lesions

aphasia may be more frequent but less severe and with better prognosis in left-handed people because of a hemispheric specialization that remains less strong. Rasmussen and Milner (1977) found 70% left hemisphere dominance, 15% bilateral representation, and 15% right dominance in non-right-handed individuals (compared with 96% left hemisphere, 4% right hemisphere dominance in right-handed people).

selective perceptual deficits (e.g., erroneous perception of shapes, motion, colors); bizarre situations where the patient cannot recognize things that he/she readily recognized before. Visual agnosia, prosopagnosia, acoustic or auditory agnosia, auditory verbal agnosia, spatial agnosia

the patient finds it impossible to perform simple movements such as a military salute or waving goodbye

an acquired disorder of learned volitional actions associated with breakdown in the planning or programming of the movements needed for speech. The breakdown is likely at a stage of phonetic encoding or control.

difficulty executing a sequence of simple movements necessary to achieve a complex task, such as lighting a fire or addressing and mailing a letter

the two hemispheres are not responsible for the same functions

paralysis of one side of the body

loss of vision in the opposite half of the visual field

an inadequate blood supply to an organ or part of the body caused by constriction or obstruction of the blood vessels

fragment of fat, blood clot, air, etc. that travels in a blood vessel until it obstructs blood flow; causes occlusive CVA

patient denies, ignores, or is indifferent to his/her own paralysis

agnosia or indifference for the (left) half of the space

the zone surrounding the necrotic area (dead brain cells) where cells are still partially functioning. The edema developing around the lesion compresses small vessels and blocks local circulation, worsening the situation. The extent to which the penumbra zone survives and recovers normal function contributes to the final outcome of the stroke. Together, with the resorption of the edema, survival of these cells partially explains spontaneous recovery that occurs within a few days post stroke

paralysis of the four limbs

double vision

caused by a lesion in the upper part of the brain stem, characterized by complete paralysis, including the head, only with the possibility of vertical movement of the eyes and eyelids. Most salient feature is that, whereas consciousness and sensation may be intact, they pass unnoticed by all observers because of the pervasive paucity of all capacity for movement

(unilateral) absence of movement coordination of the limbs

loss of reading ability

blood vessels between the major arterial territories. Posterior boundary zones: between the territories of the middle cerebral artery and the posterior cerebral artery, in the conjunction of the parietal and the occipital cortex. Anterior boundary zones: between the territories of the middle cerebral artery and the anterior cerebral artery, in the frontal area close to the summit of the cerebral hemisphere

occurs because of rupture of connections between the brain centers, which, in theory, are specific for a particular function (e.g., Broca's area, the alleged speech center, as part of the perisylvian language network)

Wernicke-Geschwind model, based on the assumptions that specific brain centers are specific for a particular function. Geschwing (1967) suggested that semantic processing is mediated by a specific brain region, probably the inferior parietal cortex. Many theorists have questioned this model. Based on an anatomical disconnection model

swear words, poems, or prayers, supported by the RH

boundary zones between major arterial territories; border zones of irrigation of the arteries of the brain; infarction in this area may be caused by severe arterial hypotension

severe condition in which verbal output that is fluent, but characterized by the presence of phonemic and semantic paraphasias, neologisms, and empty speech, which rich content words are reduced in frequency

a. (the middle cerebral artery is the final branch of the internal carotid artery) and obstruction results in a severe clinical syndrome, sometimes including confusion or coma, with hemiplegia and hemianesthsia, hemianopia, and aphasia if the lesion is located in the dominant hemisphere for language. If ischemia involves the "minor" hemisphere, there may be agnosia of the opposite half of the body, hemispatial neglect. Anosognosia frequently results. i. If the superior branches of the artery are concerned, there may be central facial paralysis with insensitivity and numbness of the opposite lower half of the face (i.e., a central VII) and of the opposite upper limb, together with Broca's aphasia. ii. Ischemia in the territory of the inferior branches leads to contralateral hemianopia or superior quadrantanopia and to Wernicke's aphasia if the hemisphere dominant for language is affected. iii. Ischemia in the territory of the penetrating branches (basal ganglia and part of the internal capsule) is associated with hemiplegia affecting both the contralateral upper and lower limbs and lower face. This capsular hemiplegia may be accompanied by hemianopia, dysarthria, or aphasia.

A large portion of the perisylvian area, often caused by total occlusion of the left middle cerebral artery. Nonfluent. Impaired comprehension, repetition, and naming.

Posterior part of the inferior frontal gyrus, the insula, and the frontal operculum (i.e., Broca's area). Premotor and prefrontal areas of the cortex, subcortical regions, and parts of the basal ganglia may also be affected; Nonfluent. Comprehension maintained. Impaired repetition and naming.

Various sites: frontal region anterior or superior to Broca's area, at the supplementary motor area, or at the cingulated gyrus. Sometimes subcoritcal, affecting white matter beneath the frontal lobe. Nonfluent. Comprehension and repetition maintained. Naming impaired.

Watershed area. Nonfluent. Comprehension and naming impaired. Repetition maintained.

Posterior left perisylvian region, esp. posterior part of superior temporal region (i.e., Wernicke's area), and sometimes adjacent parietal and temporal areas. Fluent. Comprehension, repetition, naming impaired.

Posterior to the perisylvian region, in the parietal-occipital region. Fluent. Comprehension and naming impaired. Repetition maintained.

Left temporal-parietal junction, maybe including other structures such as the insula, primary auditory cortex, and supramarginal gyrus. Fluent. Comprehension maintained. Repetition and naming impaired.

Posterior language areas, including the angular gyrus or milddle temporal gyrus. Considered to have little or no localization value because several brain regions are involved in confrontation naming. Fluent. Comprehension and repetition maintained. Naming impaired.

There are specific regions throughout the left hemisphere and some regions in the right hemisphere that correspond with specific language functions. Damage to any single one of these regions results in well-defined aphasic symptoms.

i. Embolic: fragment of a blood clot or other materials travels in a blood vessel until it obstructs blood flow; causes occlusive CVA ii. Thrombolic: fixed clot in a blood vessel that usually results from buildup of plaque on vessel walls; causes occlusive CVA; most common in older patients. Ischemic stroke/infarct; inflammation of blood vessels. iii. Hemorrhagic: occurs when a weakened blood vessel ruptures. Potential of better prognosis in the long run; potential candidate for more tx later on. Two types of weakened blood vessels usually cause hemorrhagic stroke: aneurysms and arteriovenous malformations (AVMs). 1. Aneurysm: a ballooning of a weakened region of a blood vessel. If left untreated, the aneurysm continues to weaken until it ruptures and bleeds in the brain. 2. AVM: a cluster of abnormally formed blood vessels. Any one of these vessels can rupture, also causing bleeding in the brain.

i. Advanced age ii. Hypertension iii. Heart disease iv. Diabetes (metabolic syndrome) v. Transient ischemic attacks (TIAs) vi. Prior CVA

i. Cigarette smoking ii. Alcohol consumption iii. Oral contraceptive use iv. Mitral valve prolapse v. Obesity vi. Physical inactivity vii. Lupus diagnosis

i. Sudden weakness or numbness of the face, arm, or leg on one side of the body ii. Sudden dimness or loss of vision, particularly in one eye iii. Sudden difficulty speaking or trouble understanding speech iv. Sudden severe headache with no known cause v. Unexplained dizziness, unsteadiness, or sudden falls, especially with any of the other signs

i. Primary: good health habits and genetic health history ii. Secondary: early screening for risk factors iii. Tertiary: early identification and treatments

4 steps taken in the 3 hours of the onset of symptoms i. Rapid recognition and reaction to stroke warning signs ii. Call 9-1-1 immediately and tell the operator that you or the person you are with is having stroke warning signs iii. Rapid start of prehospital care. Receive early assessments and pre-hospital care by EMS personnel. iv. Rapid diagnosis and treatment at the hospital. Receive prompt evaluation of medical data and treatment to restore blood flow to the brain

Etiology of Aphasia i. Vascular, e.g., stroke ii. Infectious, e.g., encephalis, meningitis, HIV iii. Traumatic/Toxic, e.g., HIV, CO poisoning iv. Anoxia/Allergic, e.g., heart attack recovery v. Metabolic, e.g., metachromatic leukodystrophy (inherited disorder) vi. Idiopathic/Iatrogenic, e.g., chemotherapy vii. Neoplastic, e.g., tumor viii. Degenerative, e.g., Pick's disease (dementive disorder that has a proclivity for damaging language regions)

a. According to Kolb (1995), neuroplasticity is considered to be the brain's capacity to change either at the micro level (i.e., cellular/network level), known as neural plasticity, or at the macro level (i.e., behavioral/system level), known as behavioral plasticity, allowing the brain to respond to environmental changes or changes in the organism itself. Plasticity can be adaptive or maladaptive. Adaptive brain plasticity consists in efficient reorganizing, whereas maladaptive brain plasticity results in the persistence of aphasic signs and poor recovery resulting from inefficient rewiring b. Neuroplasticity is the brain's ability to change. The brain is able to change at two levels: either the cells and connections within the brain itself change, or the entire neural system changes, i.e., the entire brain and nerve connections. Changes in the entire system can result in learning of new behaviors, for example repeatedly performing therapy activities can cause the brain to form new connections, allowing the person to learn a new skill or technique.

a. There is a distinction between recovery and compensation, both of which can occur at the micro and macro levels, resulting in improvements. At the behavioral level, recovery refers to the capacity to perform a previously impaired task in the same manner as before an injury, but compensation refers to the use of a new strategy to perform that same task. At the micro level, recovery is the restoration of the function within an area of the cortex that was initially lost after the injury, while compensation occurs when a different neural tissue takes over the functions lost after injury. b. Three possible outcomes on the recovery timeline: (1) compensation may occur, which may reflect a change in strategy or represent the substitution of a new behavior for the lost one; (2) partial restitution of the original behavior, which could reflect the partial return of the function; (3) original behavior is completely restored because the structural properties of the brain allow plastic changes to take place, which allow recovery to occur.

a. Neurological factors: related to the etiology of the injury, size and site of lesion, and severity and type of aphasia i. Etiology of aphasia: hemorrhage is associated with more favorable outcomes than infarction/ischemic stroke. ii. Lesion size: may have a different effect on expressive versus receptive skills (negative correlation between lesion volume and comprehension recovery for larger lesions only; smaller lesion associated with significant recovery in oral and written expression and almost intact comprehension; medium lesions make good recovery in all language modalities except written expression). iii. Severity: initial severity may be a more important predictor of recovery than lesion size, as lesion size has an effect on initial severity iv. Lesion site/type of aphasia: Better recovery the less of the temporal lobe involved. In general, people with expressive or nonfluent aphasia tend to have a better prognosis than those with receptive or fluent aphasias do. The prognostic value of individual neurological factors still remains undetermined. 1. For people with Wernicke's aphasia, the integrity of the angular gyrus and anterior midtemproal gyrus seems important for language recovery; involvement of the supramarginal gyrus correlated with poor recovery. 2. Global aphasia: spontaneous speech recovery is related to the involvement of subcoritacl white matter areas; better prognosis when Wernicke's area is spared 3. For Broca's aphasia, best recovery is related to intactness of subcortical areas 4. Transcortical aphasias: good prognosis in general 5. Conduction aphasia: progress seems similar to that in Broca's b. Individual factors: characteristics such as age, education, handedness, health status, race, and SES. Personal and biographical factors appear to play a minor role in recovery from aphasia compared to the neurological factors. i. Age: younger patients are believed to have more favorable outcomes (age is related to etiology, aphasia type, and overall health) ii. Gender: females may have better prognosis than males (may be a very weak prognostic indicator of recovery) iii. Handedness: the prognostic value of handedness (left-handed and ambidextrous) for recovery is not strongly supported iv. Emotional and psychosocial changes that accompany aphasia may have an impact on prognosis (e.g., depression, motivation), but their influence has not been ascertained or quantified.

Research has shown that rehabilitation does cause reorganization within the brain and behavioral changes even years post onset, especially with intensive therapy. However, due the differences of study methods and participants, not enough is known about which factors make a person a good candidate for a given therapy approach, i.e., "guided recovery" (where one specific therapy approach can be suggested for a particular individual to maximize recovery) is not possible at this time. Advocacy focuses on continued rehab beyond traditionally short therapies.

a. Principles and concepts are organized into categories of dependent (acquisition, generalization, interference, maintenance, and neural effects/plasticity) or independent variables (timing, intensity, quantity, salience of stimuli, any patient characteristics that could influence treatment outcome, neural conditions (e.g., lesion site and size), and treatment variables). Treatment variables refers to any of the behavioral and/or neural manipulations taking place during the tx to restore function (e.g., training a specific linguistic function w/ semantic feature analysis) or to compensate for impaired functions (e.g., using gestures). A 3rd dimension of the framework represents the variety of linguistic behaviors that can potentially be targeted during language treatment (phonology, syntax, etc.). b. Therapists observe, assess, and intervene at the behavioral level, while their knowledge of the neural mechanisms underlying behavioral changes remains theoretical. However, the evidence shows that behavioral manipulation can modify the neural organization. We still need to determine the type, intensity, and frequency of input required to trigger the neural mechanisms that will maximize functional recovery. Three important questions need to be answered: i. We need to understand why a function can be impaired by some lesions and not others. ii. We need to clearly determine the different recovery mechanisms that may contribute to the improvement of specific functional systems, in a specific individual, at a specific moment in the recovery process. iii. We need to associate particular behavioral interventions with specific recovery mechanisms to maximize functional outcome.

1. Use It or Lose It Failure to drive specific brain functions can lead to functional degradation 2. Use It and Improve It Training that drives a specific brain function can lead to an enhancement of that function 3. Specificity The nature of the training experience dictates the nature of the plasticity 4. Repetition Matters Induction of plasticity requires sufficient repetition 5. Intensity Matters Induction of plasticity requires sufficient training intensity 6. Time Matters Different forms of plasticity occur at different times during training 7. Salience Matters The training experience must be sufficiently salient to induce plasticity 8. Age Matters Training-induced plasticity occurs more readily in younger brains 9. Transference Plasticity Plasticity in response to one training experience can enhance the acquisition of similar behaviors 10. Interference Plasticity in response to one experience can interfere with the acquisition of other behaviors

a. Formal assessment: any published quantification tool. Typically, results are quantitative and provide little guidance for the development of specific treatment procedures. b. Informal assessment: the process of creating and manipulating stimuli for the purpose of making clinical decisions, usually by answering hypothesis questions. Also includes the essential process of gathering specific background info through record review and interviews.

a. Loss of Body Functions and Structures: impairments that are primary or secondary outcome of health condition, e.g., aphasia, cognitive deficits, hemiparesis, and visual field impairment. b. Limitations in Personal Activities: difficulties completing activities of daily living or functional tasks, e.g., difficulties with self-care, shopping, cooking, and phone use because of problems with reading, speaking, listening, and/or writing. c. Restrictions in Participation in Society: problems individuals encounter when attempting to maintain or reestablish life and societal activities and roles, e.g., difficulties returning to their premorbid occupation, sustaining their role or status in the family, or participating in previous or new leisure activities. d. Contextual Factors: personal (internal attributes) and environmental variables (external attributes) that may influence how individuals experience the consequences of their health condition, e.g., cultural and social background, age, gender, motivation level; physical (architectural barriers, climate), social (degree of family and community support), and attitudinal variables (societal attitude toward disability)

a. Keep abreast of advances in tests and procedures for quantifying and qualifying aphasia, and evaluate critically these advances in terms of their validity and applicability. i. Utilize aphasia test procedures with strong research evidence ii. Administer aphasia test procedures in manner in which they were empirically verified iii. Considering own clinical knowledge and skills, recommendations of other experts, and specific client's needs and preferences to guide selection of aphasia test procedures

To establish the current level of communicative and cognitive functioning in the individual with aphasia, including identifying the presence, type, and severity of aphasia and delineating specific language and cognitive strengths and weaknesses. Formal assessment findings can be used to: (1) establish the baseline performance level; (2) distinguishing and prioritizing treatment goals; and (3) inform decisions regarding the need to continue, modify, or discontinue treatment (when administered during the tx process).

a. Standardized: Standardization refers to the process of administering a test to an, ideally, extensive sample of individuals who represent the population segment with whom the test will be used. This process yields standardized test administration procedures that, in turn, minimize measurement error and permit comparing an individual client's performance to those in the normative sample. b. Normed:

a. Reliability: the pyschometric property that provides info pertaining to the degree with which a test yields similar data across repeated administrations in similar testing circumstances b. Validity: the degree of theoretical and empirical support a test has

a. Content: provides info regarding how well a test measures the skills or functions that it contends to measure b. Construct: the degree to which a test corresponds with other tests designed to measure the same function or construct c. Ecological: a type of criterion-related validity that indicates how well clients' test scores reflect their behavior in their typical environments during their daily activities and interactions d. Criterion-related (or predictive): reflects the accuracy with which a test determines a client has a deficit

a. WAB-R (Western Aphasia Battery-Revised): provides evaluation of the Body Structures and Functions ICF level, aiming to identify the presence and type of aphasia and language deficits. Only appropriate for monolingual English-speaking clients b. ASHA FACS (ASHA Functional Assessment of Communication Skills for Adults): focuses more on the Personal Activities level of ICF framework and aims to identify daily communication activities with which individuals with aphasia may have difficulty completing independently. c. Both are aphasia test batteries designed to assess difficulties the person with aphasia may be experiencing.

a. Aphasia battery: assess a number of linguistic skills (e.g., lexical-semantic retrieval, syntactic comprehension) and communication modalities (i.e., listening, speaking, reading, writing, and sometimes, gesturing) via tasks and stimuli that vary in complexity b. Aphasia screening test: designed for quickly ascertaining the presence or absence of aphasia, determining the need for further testing, and identifying initial treatment targets. Most screening tests have been adapted for bedside administration and for use by other healthcare professionals and are typically used in acute care facilities.

a. Connected speech or discourse is examined either minimally or not at all by most formal aphasia or language tests. b. Analysis of discourse provides information pertaining to Activity and Participation levels of the ICF model (which are often not assessed by most structured aphasia and language tests) c. Certain language skills (e.g., turn-taking, topic management) can be assessed only through discourse sampling and analysis

A growing literature has documented that not only do individuals with aphasia frequently have concomitant cognitive deficit, but also these cognitive deficits may negatively affect their language abilities, treatment outcomes, and level of burden in their caregivers. Furthermore, the cognitive test performance of individuals with aphasia cannot be predicted on the basis of their aphasia severity. Lastly, a formal cognitive assessment is necessary because research with the stroke patient population has found that informal evaluation alone will miss a significant number of cognitive symptoms. Cognitive test results may provide important info regarding prognosis and the length and type of treatment.

a. What is the extent of the problem? b. Where does the behavior break down? c. What helps the behavior? d. What is/are the underlying mechanisms for the behavior?

a. QoL: QOL measures are often utilized to examine the domain of Participation Restrictions (designed to evaluate feelings, experiences, attitudes, and believes that may positively or negatively influence an individual's ability to participate and take pleasure and satisfaction in life). b. Caregiver evaluation: considering the perspective of family, caregivers, and other daily communication partners is essential, particularly when attempting to determine the impact of aphasia on Participation in Society and Contextual Factor levels of the ICF model because these individuals are most familiar with the premorbid communication style and ability of the individual with aphasia.

a. ICF/biopsychosocial approach/A-FROM (parts of ICF that are particularly relevant to aphasia): Living with aphasia involves all of the following: i. Participation in life situations: 1. Activities 2. Communication and conversation 3. Roles and responsibilities 4. Relationships ii. Personal identity, attitudes, and feelings: 1. The future 2. Your view of yourself 3. Aphasia and who you are 4. Feelings iii. Severity of aphasia: 1. Understanding other people 2. Speaking 3. Reading 4. Writing iv. Communication and language environment: 1. Services, systems, and policies 2. Attitudes of others to you and the aphasia 3. Help with communication and conversation

a. Step 1: Info gathering and sharing b. Step 2: Collaborative goal-setting c. Step 3: Pretherapy assessment (i.e., baselining) d. Step 4: Therapy e. Step 5: Reassessment

a. Step 1: Info gathering and sharing: review charts, interview client and family, inform client and family about aphasia, stroke, and potential services. Some SLPs like to baseline using standardized measures during this stage. b. Step 2: Collaborative goal-setting: discuss with the client and family the stroke, affects of aphasia, long-term goals. Actively listen and have a shared understanding of the problem before collaboratively setting long-term goals, and sorter-term goals. c. Step 3: Pretherapy assessment (i.e., baselining): Establish a baseline for each goal-oriented task in order to provide the client and therapist with test scores that can measure progress over time. Some SLPs complete a standardized assessment at this stage to explore the language capabilities of the person with aphasia to determine the level of breakdown in the language processing system. d. Step 4: Therapy: can be structured/direct or indirect, but should be client-focused, goal-directed, outcome-oriented. General treatment sequence: i. Identify change required in performance of the client ii. Discuss the nature of the change required of the person iii. The person with aphasia produces the desired target spontaneously or with the help of the clinician through the use of a cueing hierarchy or prompts to facilitate a response iv. Repetition stabilization, first immediately and then by delay v. The person with aphasia transitions to volitional control (laddering: changing instructions; increasing length, complexity, and/or naturalness) vi. Check that the target is being performed in the clinic and then in real life e. Step 5: Reassessment: Either progress measurement or baselining; provides evidence of progress and may lead the clinician and client to negotiate a new goal either because the original goal has been achieved or because the client wants to set a different goal.

a. Step 1: Info gathering and sharing: Provide information to the family as well as the client, and include the family in the interview process b. Step 2: Collaborative goal-setting: actively listen to the client and his/her family, allow plenty of time in a quiet, private environment c. Step 3: Pretherapy assessment (i.e., baselining): consider the family members' communication styles, care-giving demands, activity and participation limitations, and QOL as baseline measures d. Step 4: Therapy: Indirect therapy may involve teaching skills to communication partners. The therapist communicates to the client and family clear objectives to achieve the short- and long-term goals with the overriding objective of facilitating maximum return of the communication abilities of the person with aphasia and subsequently his/her ability to participate in everyday life activities. e. Step 5: Reassessment: share and translate baseline/progress results for the client and his/her family. Include family members in decisions to negotiate new goals

a. Begin: Once person is alert and medically stable, program of intervention that aims to rehabilitate the communicative functions that have been lost can begin. Any added communicative deficits brought about the aphasia can complicate discharge, especially ability of the person to seek help in an emergency (this should be prioritized for tx). SLP can support transition home by providing info about available services, establishing links with the community, and helping the patient and family maintain a sense of hope and well-being. Treatment started during the acute period (3 months) has been found to increase spontaneous and long-term recovery. The following caveats may affect an early start to tx: i. The patient and family should want language therapy ii. The patient should be able to participate in and learn from language tasks iii. Health and well-being matter (e.g., depression) and should take precedence over language therapy iv. Language therapy should be presented using a positive but realist approach b. End: hospital discharge or health service funding restraints may require discharge from therapy when leaving the hospital or after 6 to 12 months postonset, but therapists should provide information about other services available in the community. Ideally, clients with aphasia will self-discharge from community-based rehab. The person with aphasia will have returned to former roles or will accept new roles and activities and will continue satisfying relationships or form new ones as well as accept the new language system they have worked hard to achieve.

a. Provides important communication opportunities b. Allows for discussion of barriers and facilitators c. Provides support, hope, social connections (decrease susceptibility to depression

A discrete brain lesion can disrupt the functioning of distant brain regions that are structurally intact