Ch. 8 Neurologically Based Communicative Disorders and Dysphagia (aphasia, AOS, dysarthria)

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How are non-fluent aphasias generally characterized?
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Even though two or more languages may be controlled largely by same regions of the cortex, some specific regions might be more concerned with one language or the other.

For this reason, this "amalgamated hypothesis" better accounts for the differential recovery of language following strokes in bilingual speakers.
T/F: Prognosis for treatment is not necessarily better in the case of patients with aphasia whose treatment is initiated soon after onset.False; Prognosis for treatment is better in patients whose treatment is initiated soon after onsetWhen treating auditory comprehension in persons with aphasia, what words should be targeted?Words that are functional and frequently used. In addition, at the beginning, shorter sentences and syntactically simpler sentences could also be targetedWhat is agnosia?Agnosia is impaired understanding of the meaning of certain stimuli, even though there's no peripheral sensory impairment. Patients can see, feel, hear stimuli but can't understand their meaning. Therefore, agnosia can be defined as the disorder of recognition.If a patient has impaired understanding of the meaning of certain words, has difficulty in matching objects with their sound with normal visual recognition of objects, what is the name of their clinical condition called?auditory agnosia.This is a rare disorder often associated with bilateral occipital lobe damage or posterior parietal lobe damage.visual agnosiaIf a patient had impaired understanding of spoken words but has normal peripheral hearing, normal recognition of nonverbal sounds, normal recognition of printed words, and normal verbal expression and reading, what is this clinical condition called?auditory verbal agnosia (pure word deafness)What is tactile agnosia?Impaired tactile recognition of objects when visual feedback is blocked. Impaired naming of objects (or impaired description of objects) clients can feel in their hands.You orally ask the patient point to the word "read" in a list of words. What are you testing the patient for?auditory comprehension as well as reading ability.You give a patient a ball, scissors, a pencil to hold while blindfolding them. You then ask them to tell you what they are holding or to describe what they're holding. What are you testing for?Tactile agnosia.What is the area of lesion in Transcortical motor aphasia?anterior superior frontal lobe, often below or above Broca's which isn't affected.What is agrammatic or telegraphic speech? Where would you typically see this kind of speech?Agrammatic or telegraphic speech is limited to only nouns and verbs. Conjunction, articles, prepositions omitted You would usually see this type of speech in patients with Broca's aphasia.Can patients generally write well when they have Transcortical motor aphasia?No. They have serious impaired writing skills.When patients have parrotlike repetition, almost echolalic but they cannot comprehend what is being heard, what kind of aphasia is this?Mixed Transcortical aphasiaWhat area of lesion is involved in mixed transcortical aphasia?lesions in the watershed area or the arterial border zone of the brain (between the areas supplied by the middle cerebral arteries and the anterior and posterior arteries).What is the most severe form of nonfluent aphasia?Global aphasia.What area of lesion is involved in global aphasia?Global aphasia affects all language areas (the Perisylvian zone/region).What branch of artery/blood vessel is the Wernicke's area supplied by?The left middle cerebral arteryWhat's empty speech?substitution of general words (this, that, stuff, thing)What area of lesion is involved in the transcortical sensory aphasia?temporoparietal region of the brain. Especially in the posterior portion of the middle temporal gyrus. Broca's, Wernicke's, and arcuate fasciculus may be largely unaffected.What aphasia (according to the Advanced Review SLP Book) has normal automatic speech such as counting?Transcortical sensory aphasiaWhat is the hallmark of conduction aphasia?Fluent language, good comprehension, but poor repetition skills.What area of lesion is involved in conduction aphasia?Lesions are in the region between Broca's and Wernicke's, especially in the supramarginal gyrus in the inferior parietal lobe and the arcuate fasciculus. (But the AF has been challenged based on neuroimaging studies)What is neologism?Creation of meaningless words. More than 50% of the word is substituted.Give a general description of anomic aphasia.Anomic aphasia is a pervasive word-finding difficulty problem. Anomia is naming difficulty. - There's no impairment of pointing to named objects - Generally fluent speech, normal syntax - Use of vague and nonspecific words, resulting in empty speech - Circumlocution - Verbal paraphasia (word substitutions) - Intact repetition, unimpaired articulation - normal oral reading skills, good reading comprehension, normal writing skills.What area of lesion is involved in anomic aphasia?It's caused by lesions in different regions of the brain, including the angular gyrus, the second temporal gyrus, and the juncture of the temporoparietal lobes.Which standardized diagnostic battery (as mentioned in the Review book) includes a subtest with musical skills?Boston Diagnostic Aphasia Examination (BDAE-3)Which standardized test requires intensive training to administer and score among the standardized aphasia tests?The Porch Index of Communicative Ability-Revised (PICA).Describe the difference between responsive naming and confrontational naming in regards to assessment of aphasiaResponsive naming is naming with contextual cues. For example, clinician may ask, "What color is snow?" Confrontational naming is naming while showing a picture.Define word fluency in terms of assessing naming skill in the assessment of aphasia.Word fluency is recalling names that belong to a specific category.Are there any tests available for bilingual speakers with aphasia?Yes. There's the Bilingual Aphasia Test that has been used frequently and researched. There's also the Multilingual Aphasia Examination-Revised Edition, that helps evaluate aphasia in English, French, German, Italian, and Spanish.Describe in as much detail as you can the difference between aphasia and dysarthria.Aphasia is a neurologically based language disorder affecting areas of language. Unlike aphasia AND APRAXIA, dysarthria is pervasive. It can affect all aspects of speech production, including resonance, articulation, phonation, prosody, respiration.What is neglect syndrome?Neglect syndrome refers to a set of attention problems in which patients are slow/inaccurate at seeking out stimuli presented contralateral to side of brain damage.The loci of brain damage that produces flaccid dysarthria includes:cranial nerve nuclei in the brainstem, the peripheral nerves, some cervical/thoracic nerves, and neuromuscular junctionsWhat happens with progressive use of the muscles in patients with Myasthenia Gravis in terms of the field of dysarthria?Classic symptoms of Myasthenia Gravis is the progressive dysarthria during longer conversations or progressive dysphagia during a meal. Muscle weakness improvess with reset.What is Guillain-Barre Syndrome?It is a demylenating disease that affects CN's and PN's. The onset is acute with full progression of the disease. however, there is a recovery pattern for the disease. A few individuals never fully recover.What is Bell's Palsy? Do patients recover? If so, how long?It is an acute, unilateral, peripheral lower motor neuron CN VII (facial nerve) paralysis. It affects the facial nerve root as opposed to the cranial nerve nucleus. Prognosis for improvement is generally good and most individuals show recovery in 2-3 weeks.In what cortical areas does motor speech programming occur?Broca's area, supplementary motor area, primary sensory cortex, supramarginal gyrus, basal ganglia, insulaT/F: AOS is caused by muscle weakness or neuromuscular slownessFalseDefine Primary Progressive Apraxia of SpeechA fronto-temporal dementia that recently is recognized as the only or dominant symptom.What are the key features of AOS?distortions, intersegment transitionalization difficulties consistent in location/place within an utterance, groping articulatory postures, initiation difficulties, substitutions, additionsWhat is oral apraxia or nonverbal oral apraxia?Difficulty with imitation or with volitional non-speech movements of oral structures. It accompanies AOS about 70% of the time.Order the types of errors in terms of place, manner, voicing by severity in AOS.More errors of place, then manner, then voicingT/F: In AOS, affricates and fricatives are more difficult to produce than stops.TrueWhat are the 3 types of speech sound sequencing errors that occur in AOS.Anticipatory or Regressive errors - a sound from the latter part of a word is substituted earlier in the word. ex: 'grappoper' for grasshopper Reiterative or Preservative errors - a sound from early in the word is substituted for a sound later in the word. ex: 'dred' for dress Transposition or Metathesis erros - sounds switch positions in a word ex: 'tefelone' for telephoneAre prosodic deficits a key feature of AOS?include decreased rate of speech, prolongation of consonants/vowels, syllable segmentation, tendency to equalize stress across syllables or wordsWhen AOS occurs in conjunction with dysarthria, what kind of dysarthria is it that we usually see?Unilateral upper motor neuron dysarthriaDescribe the simplified psycholinguistic model for speech production during a naming task.Semantic Activation/Semantic Lexicon (lexical/word comprehension) - probs at this level are revealed as auditory comprehension errors during aphasia testing for single word comprehension. Phonologic Lexicon/Word Form Activation (word form selected)- probs at this level result in SEMANTIC PARAPHASIAS and at rare times unrelated word substitutions. (bus for car) Phonologic Buffer/Syllabic Assembly (phonemes held in short term memory) - probs at this level result in phonemic paraphasias (tamp for lamp) or neologisms (rantu for truck) Motor Planning/programming - probs at this level result in AOS Motor Execution/Speech Produced - probs at this level result in dysarthriaWhat test/batteries can we use to assess AOS?Specific articulation testing designed to identify various factors Cookie Theft picture Rote tasks Apraxia of Speech Rating scale to identify presence of AOS and various characteristicsWhat is the difference between phonemic paraphasia and AOS errors?Phonemic paraphasias have clear speech but substitutions, while AOS has distortions on their sounds.An important article, Maas, et al (2008) Principles of Motor Learning in treatment of motor speech disorders discusses treatment for AOS. Discuss the priciples1st Principle: Whether to use large or small amount of drill work 2nd Principle: How frequently to treat the patient. 3rd Consideration: Use Constant (Blocked) or Variable (Random) Presentation of Tx stimuli. 4th Consideration: Frequency/timing of feedback given to the patient as to the accuracy of their production of a given stimuli. 5th Consideration: What level (sound/syllable/word/phrase) to begin treatmentBriefly describe one of the most widely used approaches of Tx for mild, moderate, and moderately severe AOS.Integral Stimulation/8 Step Task Continuum of Rosenbek Step 1: unison production Step 2: clinician mouths stimulus, unison Step 3: immediate repetition w/ integral stimulation Step 4: successive productions Step 5: patient reads aloud stimulus Step 6: reads after removal of stimulus Step 7: target stimulus elicited w/ question Step 8: target stimulus elicited in role-playing situationsWhat's the Sound Production Treatment?It's a treatment method for AOS that incorporates portions of the integral stimulation techniques into a more structured hierarchy while targeting specific sounds contained in words.What's PROMPT?PROMPT therapy in AOS uses tactile-kinesthetic cues to facilitate correct production. Highly structured finger placements on patient's face/neck are used to signal articulatory targets. It shapes non-speech oral movements into speech production.What's Melodic Intonation Therapy?It's a technique that uses a singing-like quality for phrase production combined with hand-tapping, then gradual fading of the singing/tapping quality so that productions more closely approximate natural speech productions.If a patient has moderate to severely impaired auditory comprehension, limited verbal output, unawareness of errors, and demonstrates stimulability for success with MIT over a treatment session or 2, will this patient be a good candidate for MIT for AOS?No. The patient must have - good to mildly impaired auditory comprehension - limited verbal output - good error awareness - demonstrates stimulability success with MIT in a tx session or twoWhat treatment type is used for severely apraxic speakers as mentioned in Aker's text for AOS?Multiple Input Phoneme therapy. It's used with severely apraxic speakers who produce primarily verbal stereotypies. It shapes the stereotypic utterance into various alternative utterances (e.g. two-two-two shaped into two-tea-tie shaped into two-one shaped into two-one-two-three)If a patient has a lot of stereotypy in their speech, what treatment method would you use? a) Melodic Intonation Therapy b) Voluntary Control of Involuntary Utterances c) Multiple Input Phoneme TherapyC) Multiple Input Phoneme TherapyWhat severity of AOS patients (characteristics) would be best for Voluntary Control of Involuntary Utterances?Patients with mild to moderate auditory comprehension deficits, who have severely nonfluent speech, but who also produces an occasional to moderate number of recognizable automatic utterances.Describe the Voluntary Control of Involuntary Utterances treatment method.This technique requires clinician to write down any intelligible word or phrases that the patient produces spontaneously. The clinician then determines if patient can read them aloud. If patient can't correct read it aloud, then card is set aside. Words that patient can successfully read aloud are drilled via repeated oral reading and speech repetition.What are low level apraxic speakers? What would you do for treatment?Low level apraxic speakers are those with little to no speech output. You would use techniques such as rote speech tasks with prior massive modeling by the clinician.What is palilalia? What's the cause?Palilalia is a rare acquired 'disorder of speech characterized by compulsive repetition of a word/phrase which the patient reiterates with increasing rate and decreasing volume. It's most likely caused by a bilateral basal ganglia pathology.Are patients aware of the reiterations/repetitions in palilalia?Yes.What are some of the speech evaluations of AOS?Diadochokinetic testing; specific articulation tests; spontaneous speech sample; oral reading of a passage; rote speech tasks (counting); test oral apraxia (stick out tongue)phonemic, graphemic, or literal paraphasia - contains substitutions, additions, omissions, and/or rearrangements of target word phonemes semantic paraphasias - substitution of a word that is semantically related to targt word random paraphasia - substitution of a word that lacks apparent semantic relations to the target word circumlocution- involves use of a description or definition for target word neologism - involves use of nonsense vs. target word indefinite substitutions - involves use of a nonspecific word or description for target word stereotypy- restricted form, single word, or phrase that may be produced involuntarily, may/may not be propositional, and appears frequently in patient's speech (for Aphasia) Patients w/ severe anomia may produce entire sentences in which all content words - jargonmemorize these termsWhy would we do an oral-facial exam for AOS?To rule out significant muscle weakness, incoordination, or sensory loss as seen in dysarthric patients.Define intention tremora tremor that begins during a visually guided target-directed mov't and that increases in amplitude/becomes more pronounced towards the end of movementDefine dysmetriapast-pointing, inability to control the range/trajectory of a movement. (ex: undershoot/overshoot a target)Define nystagmusrapid back/forth/jerky eye movementsWhat are Parkinson's Plus syndromes?a group of diseases that include some signs of PD as well as additional symptomsWhat's Progressive supranuclear palsy?a common Parkinson's plus syndrome. A hallmark feature of this disease is vertical gaze paresis.What's a hallmark of Multiple systems atrophy?involvement of autonomic functions such as blood pressure, heart rate, bladder control.Give the basic aspects or facets you would test when assessing dysarthria.Use a variety of speech tasks, including imitation and sustained phonation. Obtain a speech sample. Assess the diadochokinetic rate of AMRs and SMRs. Oral-facial exam. Assess respiratory, phonatory, articulation, prosodic, resonance, speech intelligibility, muscle strength-speed-range-accuracy. Standardized test: Frenchay Dysarthria Assessment; Assessment of Intelligibility of Dysarthric Speakers. ALS Speech Severity Scale Make a differential diagnosis based on a careful analysis of neurologic and speech symptoms predominant in specific types of dysarthrias.T/F: Unilateral brainstem damage above the decussation of the pyramids will always produce limb paresis AND facial paresis on the contralateral side of lesion.False. Unilateral brainstem damage above the decussation of the pyramids may produce limb paresis on one side of the body and facial paresis on the other side of the body.What are some ways we could check respiration of the speech system in dysarthric patients?To see if diaphragm is working, put hand on patient's stomach and it should distend on vigorous sniff. Also, the clinician should observe the type of breathing pattern (clavicular, thoracic, or abdominal-thoracic).When do we (usually) use alternate and sequential motion rates? What are they? What are they important for?We use them on dysarthric patients. These tests are good to look at speed of production, preciseness of production, and irregular breakdowns in articulation/phrasing. AMRs are conducted using repetitive production of (puh) for lips, (tuh) for tongue, (kuh) for back of tongue. SMRs are puh-tuh-kuh. (Buttercup, pee-tee-kay)What sort of treatment would you use in dysarthria with articulation problems?Motor learning principle, which is similar to AOS treatment. Brief periods of frequent practice are probably better than longer periods of infrequent practice. Blocked practice is best w/ severe patients.What's the treatment protocol for respiration or loudness?Some techniques are: 1) producing sustained airflow/subglottic air pressure of 5 cm of water for 5 secs 2) Vowel prolongation 3) Instructions to breathe deeper before speech attempts 4) Limiting no. of words/syllables uttered per breath to insure loudness is maintained over the entire utterance 5) Use of pressure on abdomen to aid in expelling more air during speech attempts 6) Expiratory Muscle Strength Training. (EMST device) -- has shown in various studies to not only strengthen such RESPIRATORY MUSCLES, but ALSO to IMPROVE LOUDNESS and SWALLOWING in patients. LEE SILVERMAN VOICE TREATMENT - has been used extensively for the treatment of the loudness/phonation/articulatory deficits of Parkinson's patientsWhat can we do if a dysarthric patient is hypernasal?Management of hypernasality includes: 1) Prosthetic appliances 2) Surgery 3) Behavioral techniquesT/F: Behavioral management techniques such as blowing/sucking exercises can be used to strengthen velopharyngeal muscles.FalseWhat technique could you use to improve hypernasality?CPAP Continuous Positive Airway Pressure therapy may be beneficial. It's an exercise program that uses an equipment with a nasal mask.