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Movement and meaning

All severe deficits are challenging unless physiologic improvement causes substantial improvement

All severe neurologic speech language deficits are not same ◦ Here am excluding dysarthria

Severe or global aphasia-whatever term does not endanger compensation ◦ Usually, but not inevitably, a combination of

aphasia and AoS

Severe non-fluent deficit that appears to be neither AoS or aphasia alone or in combination

Severe or profound AoS ◦ Often called apraxia of phonation

Usually pretty simple for the experienced clinician to identify even with limited testing

Some cases are more difficult and will talk about a diagnostic therapy to help make sense of these

For years some clinicians have avoided the term global aphasia for billing reasons

And-truth be known-the term may matter less than the description

What is that description?

Severe deficits across all language modalities: speaking, reading, writing, listening

Speaking often limited to one or more “recurring utterances”

Reading limited perhaps to a few single words and these are often identified inconsistently

Writing limited to inconsistent copying Listening best preserved modality but very easy

to overestimate Cognition-once acute brain damage resolved-is

restored to near pre-morbid levels Social interaction and behavior similarly restored

to normal or near normal pre-morbid

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Apraxia of speech often

Hemiplegia often as well as a variety of other limb deficits

Field cut often

Personality intact

Often significant frustration May be much better treatment candidate at 6 mos

than earlier

Both superior and inferior limbs of middle cerebral artery

Only approximately 5% recover functional speech

Prognosis especially dark if improvement does not occur in first few days post

Psychologically this has always been the hardest clinical issue for me

Family wants person with aphasia (PWA) to talk

Patient wants same

Neither takes kindly to any but verbal expressive emphasis

And we have to be careful of self-fulfilling prophesies

Do not impress me as global Seem to have better language than speech

and no cognitive deficit They look like apraxic speakers superficially However, treat them motorically and they do

not respond with improved speech I have never gotten one to talk

No intelligible speech beyond a form of “yeah” ◦ Enough comprehension to recognize and try to correct

errors or prevent them with silence

No hemiplegia, cognitive, or behavioral deficit

Language impaired but not as severely as speech

Did the most basic motor speech training but never learned even one word

But regained enough reading to enjoy paper

Could write simple words functionally as in taking phone message and grocery list

Comprehension not normal but functional

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Naeser et al Severe nonfluency in aphasia. Brain. 112:1-38, 1989 ◦ Describes this group as having nearly no hope of

talking again

◦ She says need to identify so can begin an appropriate nonverbal treatment such as VAT or visual action therapy

Nancy Helms’s Visual Action Therapy ◦ Program centers on learning gestures to

communicate notions

◦ Speech is inhibited

◦ Publisher of this program is pro-ed, 1991

More of this in a moment and also some other treatment options

Such patients can be identified by localization on scan ◦ Of course many of us do not have scans to work

from

Thus clinically ◦ They are speechless or nearly so and remain that

way despite increasing language competence ◦ They are not globally aphasic in any traditional

sense ◦ They do not regain speech even with treatment ◦ But communication is definitely possible And more possible than in traditional global aphasia

Two critical areas BUT not in cortex

First is ◦ Medial subcallosal fasciculus

◦ Lesion here disrupts connections of supplementary motor area and striatum

◦ Seems to affect preparation and initiation of speech movements

Medial one-third of PVWM or periventricular white matter

This area is deep to the motor-sensory area for mouth

May affect sensory feedback and pathways necessary to motor execution

Aphasia doesn’t seem to be right

Language is too good

AOS doesn’t seem right cause can’t teach to talk

Dysarthria is wrong

Dementia is wrong

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What do we call a problem of initiation, execution, will to produce and sensory feedback

Abulia?

The clinical issue is to identify such patients so treatment planning can begin

Language intact or nearly so, especially comprehension

May be mute If muteness lasts more than 14 or so days, some

other speech-language deficit is likely

Or there is a previously unreported co-morbidity such as infection, multiple strokes have an influence

Once muteness lifts effortful speech emerges with variable speed but often quickly ◦ Rosenbek (2004). In Kent (Ed.). MIT Encyclopedia of

Communication Disorders. The MIT Press

Avoid wasting clinician and patient time doing things that won’t help ◦ In both global and severe, non-fluent speech is very

unlikely

This is not to say that no treatment is appropriate ◦ General stimulation is critical

Person with severe, non-fluent much more tolerant of early focal treatment than is person with global

Person with severe apraxia only one likely to respond to speech drills ◦ Of course can try speech drills with all in the beginning

This brings us to pairing movement and meaning

But requires extreme clinical acumen in practice

Because interpretation of finding is likely to be TOUGH

Object is to elicit the most meaningful utterances (two at a minimum) and then test if person can consistently indicate understanding of the utterances’ meanings

Use imitation, phonetic placement, integral stimulation, or combinations to elicit a verbal response ◦ If patient has meaningful, recurring utterance can

try starting with that

If produced successfully then have person select from an array

Do enough so you can determine difference between chance and understanding

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Because of severity ◦ Try to start with short meaningful utterances

I, bye, and etc

May have to retreat to oral movements

More on this in a moment

Represent the spoken utterance’s meaning in any and all possible ways

Gestures, pictures, written, sung

I

Select from ◦ Eye ear nose throat (or any other appropriate

foils) written out

◦ Or pointed to or

Add one or more additional verbal stimuli

Is a better test of meaning

Frustrates perseveration which is usually a major challenge for these persons

Then start going back and forth between verbal and meaning however most successfully represented

Limb apraxia can be an influence

As can peripheral and more central auditory and

visual deficits such as the agnosias, and dementia, and on and on

But sorting all these influences out is what makes us a profession and not just well-intentioned folks with patience and hearts of gold ◦ And you don’t have to KNOW; an hypothesis is good

enough and usually all you muster regardless of years of experience

A critical reference for going beyond this bare bones discussion ◦ Kent (2015). Nonspeech oral movements and oral

motor disorders: A narrative review. Am J Sp-Lang Path, 24, 763-789

For our immediate clinical use ◦ Use movements, if at all possible, that are part of

speech sounds

◦ Try to integrate into sounds as quickly as possible

Clear that most of these movements do not have easily represented meanings

Thus first measure is ◦ Can person switch reliably from one movement to

another

◦ Can person combine into sounds

◦ Does person remember what was learned in one session in the next session

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To degree person cannot associate movement and meaning hypothesize severe aphasia

To degree person can make association hypothesize severe non-verbal or AoS

To degree person cannot reliably produce the movements hypothesize severe aphasia or severe non-fluency

To degree person can both learn movements and associate with meaning hypothesize AoS

If hypothesis is severe aphasia or severe non-fluency, continue a short bit of speech therapy each session

But move quickly to alternative communicative procedures such as drawing and gesturing (to be reviewed) ◦ Either alone or combined with speech

If hypothesis is AoS, intensify the speech, motor work

Long-range, perhaps idealized goals

◦ Restoration of best possible language and/or

speech performance

◦ The richest, best possible communication

◦ The richest, best possible reengagement in life

◦ The most comfortable possible adjustment to residual communication deficit

These goals are idealized-but why not? Of course, their attainment may depend in part

on behaviors over which we have little control ◦ Field deficit ◦ Hemiplegia ◦ Emotional illness

But much is IN our and our patient’s control AND, if we enter rehab with more modest goals

we will achieve only those And, of course, the goals are different and the art

and science of practice is to match goal and patient at every stage of treatment with each person

Regardless of severity it is important to remember

The SLP does not cure, improve, or slow decline of anyone

Persons do that themselves with the clinician’s support guidance and methods

Doing so requires ◦ WILLINGNESS ◦ ABILITY TO CHANGE-this is the one that makes

selecting the appropriate treatment target so critical

patient and family are going to want to try speech Tough intellectually cause you know success is unlikely

No rule about how long to try My rule of thumb is to have a bit of speech

work every session-duration varies with ◦ How much person and family want it ◦ How successful you are at helping them be realistic ◦ Whether generalization is occurring

And I try to move quickly to speech facilitated by alternative modality

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Gesture and speaking in the brain ◦ Sample treatment study and a simple tx program

Gesturing and the right hemisphere ◦ Intention treatment

Drawing

Writing

Linked in brain Can be of two general types ◦ Meaningful Discussions of simple programs using imitation

followed by more functional steps such as using gesture to answer question have been described Hux, Weissling, Wallace (2008). Communication-based

interventions…In Chapey Language Intervention Strategies in Aphasia…, Fifth Edition, Wolters Kluwer814-36

Will describe a newer program of sis or seven steps depending on how you divide

◦ Timing, limited meaning Will describe one of more interesting-intention therapy

Dipper et al (2015) The language-gesture connection…Clin Ling Phon, 29, 748-763

Make case for cortical interaction and say

“..gesture is both closely related to spoken language deficit and compensatory…”

Makes sense to try combining gesture and speaking especially in severe

Recognizing that both will doubtless require therapeutic attention

But with hope that gesture can facilitate the verbal

Reference: Raymer et al (2012). Contrasting effects of errorless naming treatment and gestural facilitation for word retrieval in aphasia. Neuropsych Rehab, 22, 235-266

25 pictured items

Step one: Clinician models name and gesture for each item

Step two: Clinician models only the gesture, pt imitates and clinician helps with shaping pt’s hand. Pt repeats gesture three times

Step three: Cl models name and pt imitates three times

Step four: Cl models both and pt imitates both three times

Step five: After 5 sec pause, pt asked to spontaneously name and gesture but only if can successfully name

Step six: If name forgotten, cl models both and again gets three repetitions

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Step seven: CILT type barrier but only to block view of cards. Pt tries to name and gesture each card ◦ If not able to name, card set aside

◦ At end of the complete set, the cards not named are modeled (both gesture and name) and only one repetition required

Results: generalization to standardized aphasia exam,

No or very limited activity/participation steps but we will address in later section very specifically

As with most research the emphasis is on impairment ◦ Which is not bad its just incomplete for clinical

purposes

Intention- selection of one course of action over others in preparation to respond

Stroke can cause a disconnection between intentional and production mechanisms affecting language output

Intention treatment primes right hemisphere initiation mechanisms using the left hand ◦ See: Crosson (2008). Seminars in Sp & Language,

29, 188-194

Trained to initiate a naming through a movement sequence with the left hand

Movement sequence used in the first two phases of treatment is nonsymbolic (button press)

Movement sequence in third phase of treatment is more natural and can be generalized to situations outside the clinic

10 sessions at each stage, tx 5 days per week

Pt lifts lid off

Reaches inside to press a button

Then says name of item that pops up with button push

If correct go to next

If incorrect, imitate the cl while also making gesture

Most effective in patients with nonfluent aphasia and moderate to severe anomia

Patients with language initiation difficulties may benefit from engaging right hemisphere intention mechanisms prior to naming

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Crosson et al (2007). JINS, 13, 582-594 ◦ 23 with moderate to severe naming deficits and

nonfluent

◦ 11 with profound deficits

◦ Intention tx had positive effect in 89%

◦ And generalization occurred for 85%

◦ Assumption is that right hemisphere perhaps interacting with some intact posterior left hemisphere tissue is basis for treatment effect

N= 4 single-subject cross-over

Two txs: ◦ non-symbolic circular gesture and name

◦ Meaningful gesture and name

10 sessions of each separated by 7 days

Results are predictably complex

Simple gesture accompanied by “immediate effects” for 2 but no generalization

Meaningful gesture accompanied by delayed naming improvement for two and immediate effects on gesturing for 3 with carryover in one

Milder improved most but one severe made substantial improvement in gesturing

Suggestion: Use both forms of gesturing in treatment

Type of gesture

Whether done with right or left hands

Done in right or left hemispace or in the midline

Whether done before during or after speaking or with no attendant speaking

Seems to ◦ Benjamin et al (2013). Submitted.

N=14, 7 intention group; 7 control

The usual intention treatment compared to same except no gesture ◦ Phase 1 and 2 confrontation naming

◦ Phase 3 category member generation

◦ 10 sessions at each phase

Verbal and fMRI outcomes

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No difference between groups in naming improvement

More generalization to untreated stimuli in the gesture (Intention) condition

There was a lateral shift (to right hemisphere) in the Intention group that correlated to improvement ◦ Shift was to lateral posterior perisylvian regions

◦ Not to frontal (as in earlier study)

In control group, the shift was to LEFT hemisphere more posterior regions

Taken together mere production seems to build on left hemisphere mechanisms

Adding gesture seems to “recruit” right posterior regions as explanation for improvement

Generalization to discourse as elicited by picture description

◦ Altmann et al (2015). JSLHR, 57, 439-454

A step closer to activity/participation

“Maintenance of a residual relationship between hand movements and language seems like a (more) plausible explanation for the rightward laterality shift to intention treatment”

One of the few behavioral treatments created specifically to target areas of brain as basis for improvement

Now for the severe, non-fluent who unlike the severely aphasic person can often learn to write

There are formal programs that like most formal programs are heavy on follow the leader

Preferably usually is introducing drawing into communication attempts more naturally

And there are (of course) combinations

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One of the most misunderstood programs because people immediately think of art and talent

Principal developer: Dr. Jon Lyon

Read: Lyon, Drawing; Its value as a communication aid for adults with aphasia. Aphasiology. 9:33-94, 1994

Lyon Sims.CAC Proceedings, 18:339-347, 1994

Morgan, Helm-Estabrooks. CAC Proceedings. 17:64-72

Ward-Louergan & Nicholas (1995). Drawing to communicate…Eur J Dis Commun, 30, 475-491

Farias et al (2006). Drawing: its contribution to naming. Brain & Lang, 97, 53-63

Drawing alone can communicate messages Drawing may be somewhat independent of

language symbols and rules May rely more on visuoconceptual forms of

thinking May access inner thought or speech May use more intact right hemisphere skills

(Rosenbek)

May augment verbal

Emphasis is not on art but on communication

Outcome is communication effectiveness

May facilitate language in other modalities

May help to increase confidence to use other modalities

Brain damage influences drawing

Drawing may not be acceptable

May be disrupted by co-existing apraxia

Drawing is not independent of cognitive linguistic subsystems

Use traditional modeling and delay methodology to establish or refine drawing of stick figures -Describe a situation and have a person draw, for example

If not intelligible, provide a verbal cue, for example, where is the TV?

Pr, provide a drawing cue such as adding the missing part yourself

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Or enlarge the area of the missing part and have pt draw it in the box (now draw the TV in here)

Move the situation into a PACE context and use another interactant

Be sure interactant is also trained in cueing

Move from simple to more complex notions

First make a guess about content If wrong, get oriented with Qs:

-Perspective -Setting -Main objects -Who -When

Ask that main part of drawing be highlighted

Ask that main part be enlarged

Ask pt to show what to do with particular element

Systematically summarize and reformulate what is being communicated

8-accurate, complete identification within first minute

7-accurate, complete identification after delay up to two minutes

6-same but within three minutes 5-same but longer than three minutes 4-inaccurate, related identification within

three minutes

3-inaccurate, remotely related within three minutes

2-inaccurate, unrelated despite interactive attempt

1-inaccurate unrelated with no interactive attempt

Takes work to make it communicative Clinicians sometimes cannot give up on

manipulating the speech structures Anecdotally recorded that many patients

speak more frequently and with greater variety

By self is not complete therapy It must be pragmatic

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N=10 persons with severe aphasia, minimum of one year of aphasia

12 weeks of tx with one hour of individual and one hour of group per week

Aim: promote use of drawing in communication

Sacchett, et al. 1999. Int J Lang comm dis, 34, 265-289

Aim one was to have a person try to evoke a drawn representation of an idea

Focus on efficiency so that what is portrayed is most critical to the communication

Develop awareness of needs of interpreter and respond creatively to failed communication

Improve the interpretive skills of others

Dependence on interactive drawing which is to say the clinician draws as well

Minimized the use of pictures as they do not support generation of ideas

Emphasis on use of the drawings to communicate

So a lot of PACE stuff and turn taking

Drawings were “significantly” more recognizable after tx

Drawings in context were more recognizable than those in no context

NO generalization to other modes of communication

Results maintained 6 weeks later

BUT some changes in communication reported by carers

Get improvement on trained items

Get reports of improved communication in natural environments

No change in untreated modalities

Usual conclusion is that the natural environment change is wishful thinking

Maybe not

Functional MRI shows “strong bi-hemispheric activation of semnatic and phonological networks while drawing”

Farias, Davis, Harrington. (2006). Drawing: its contribution

to naming in aphasia. Brain Lang, 97, 53-63

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Used most frequently for severe

No apparent relationship between ability to draw from memory and severity of type of aphasia

Gainotti, et al (1983). Drawing objects from memory in aphasia. Brain, 106, 613-622

CART and T (texting)-CART

Beeson et al (2003). Writing treatment for severe aphasia: Who benefits? JSLHR, 46, 1038-1060

CART=copy and recall therapy

Data are from 21 one hour sessions over 13 weeks ◦ Is that an intensity you can meet?

◦ Will be talking about this and what to do in lecture 3

Method is an example of using one modality to help another in this case writing to support speaking

◦ M-MAT is acronym for any treatment doing this

◦ MOAT is acronym for tx that emphasizes tx of a modality for its own sake

One: clinician shows a written word (or not-may merely say it) and says it and urges pt to imitate

In ideal world has him imitate till correct ◦ If never correct can just go with the written form as

in this next step

Two: Clinician writes word (if not written out in beginning) and has pt copy multiple times

If correct, then word is covered and pt is to write from memory

Cue as necessary

Also get them to write and say

RESULTS: many severe pts learn both writing and saying

Carry-over best for written as opposed to texting using key board and phone

Will discuss the most data-supported method for AoS in afternoon

Reminder: Don’t worry about not knowing for sure what your patient has ◦ Careful attention to how each responds to what you

are doing will tell you if you are doing right

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Thanks