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Aphasia Classification and Assessment
Judith Robillard Shultz MSc. SLP(C)Speech-Language PathologistMGH-MUHC
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Purpose of Assessment
Determine if aphasia is present or absentDistinguish it from other related conditions
Motor speech disordersCognitive-communication disorders
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Lecture goals
Components of communication andnormal language processingSyndromes of aphasia
Features of related conditionsCommon assessment tools, diagnosticallyrelevant tasksHow to communicate with an aphasicpatient
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Definition of Aphasia
Disturbance of language caused by braindamage affecting:Comprehension
auditoryreading
Expressionspeakingwriting
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Important Distinctions
LanguageVocabulary, grammar..
SpeechMovement tongue, lips.
Cognition Attention, memory, problem solving.
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Theoretical Basis for Classification of Aphasia:
Boston Classification(Kertesz & Poole; Goodglass & Kaplan)
A contemporary localizationist viewLanguage localizable in the brain
Perisylvian region in the left hemisphereanterior language zone = left frontal lobeposterior language zone = lefttemporal/parietal lobes
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Boston Classification
Consists of cortical centers and connectingpathways Aphasia Syndromes
Broca, Wernicke, GlobalConduction, TC Motor, TC Sensory, Mixed TC
AnomicSupplied by left MCA
Anterior and posterior branches, main trunk
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How the Brain PerformsLanguage
Comprehension of LanguageHow is it accomplished?
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How the Brain PerformsLanguage
Comprehension of SpeechEars
Auditory Cortices
Wernickes areaConstructs an overall meaning
Assigns meaning to words/relation among words
Evaluates the context (literal vs figurativemeaning)
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How the Brain PerformsLanguage
Reading ComprehensionEyesVisual CorticesWernickes area
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How the Brain PerformsLanguage
Spontaneous Spoken Language?
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How the Brain PerformsLanguage
Spontaneous Spoken LanguageWernickes area retrieves words, sentencestructure
Sends it to Brocas area via the ArcuateFasciculusBroca formulates an action planSends plan to primary motor cortexPrimary motor cortex refines it and sends to thecranial nerves for speech muscles via thepyramidal system
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How the Brain PerformsLanguage
What single language task tests the entirecircuit?
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How the Brain PerformsLanguage
Repetition (tests the entire language circuit)Primary auditory cortexWernickeBroca via the AFBroca recodes into articulatory plan
Primary motor cortexPyramidal system to CNs
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How the Brain PerformsLanguage
Oral ReadingVisual Cortex to Wernicke and the sameprocesses as for repetition follows
WritingWernicke via AF to premotor cortex for
arm and hand, movement planned, sent tomotor cortex
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Boston Classification: KeyDiagnostic Distinctions
Fluent vs Nonfluent AphasiaSpeech fluency
Prosody, melody, rate, pauses
Subtypes further distinguished by:Repetition
Language ComprehensionParaphasia
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Boston Classification: KeyDiagnostic Distinctions
ParaphasiaLiteral/phonemic = shooshbruss/ toothbrush;tevilision/television
Verbal/semantic = table for chair, cranberryfor teapotNeologism = chantlast/refrigerator
Perseverative = comb, fork/toothbrush,comb/key
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Boston Classification: FluencyDimension
Nonfluent AphasiaLesions to anterior portion of language centerof dominant hemisphere
Slow, effortful, pauses, disturbed prosodyFluent AphasiaLesions to posterior language center of
dominant hemisphereEffortless with normal/fast rate, goodintonation and stress patterns
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Nonfluent aphasias: subtypes
Brocas aphasiaComprehension
Relatively preserved, some difficulty with complex syntaxReading comprehension relatively spared
ExpressionSlow & effortful productionLimited word outputFour words or less per utteranceFrequent perseverations
AgrammaticWriting usually parallels oral expression
Repetitionpoor
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1 2 3 4 5 6 7artic agility _________________________________________________________________________
unable sometimes clumsy never impaired
phrase length _________________________________________________________________________ 1 word 4 words 7 words
grammatical form _________________________________________________________________________ no syntactic word groupings simplified/incomplete normal range
melodic line _________________________________________________________________________ word by word limited to short phrases normal
paraphasias _________________________________________________________________________ present in every utterance 1-2 instances per minute absent
word finding __________________________________________________________________________ fluent but empty information prop to fluency primarily cont words
sentence repetition __________________________________________________________________________ 0-20 30 40 50 60 70-80 90-100
auditory comprehension ___________________________________________________________________________
0-20 30 40 50 60 70-80 90-100
Brocas Aphasia Rating Scale Profile of SpeechCharacteristics Boston Diagnostic Aphasia Examination
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Transcripts: Cookie TheftBrocas Aphasia
Water dripping. Boy. GirlOkay. Okay. MotherMother(Clinician prompt..Whats going
on?) No.
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Assessment severe non-fluentaphasia
48 year old maleReceived tPAInfarct = left frontal inferior and medial gyri andtemporal-parietal operculumYes/no only speech output
Accurate yes/no responses to personallyrelevant questionsGesturing to express himself Right arm weakness
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Nonfluent Aphasias
Global AphasiaSevere language deficits in all modalitiesResponds to personally relevant language
Responds to nonverbal cues Automatic speech may be preservedVerbal stereotypes commonExtensive (L) hemisphere lesion involvingBrocas and Wernickes area
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Neurophysiology of brain damage
and the neurological exam 16
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Nonfluent aphasia
Transcortical Aphasias (TCM nonfluent;TCS fluent)Preserved repetitionSpare central language areas,disconnects from rest of brain
Watershed, borderzones
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Nonfluent aphasiaTranscortical Motor:
Lesion= anterior and superior to Brocas areaReduced speech output, good auditorycomprehension, striking ability to repeat
Reduced speech outputFrontal lobe dysfunction (initiation, maintenance)Brief answers when highly structured (e.g., tell methe name of the hospital vs. tell me what you thinkof the hospital)Pathological inertia
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Fluent AphasiasWernickes aphasia
Comprehension (auditory & reading) impairedOral Expression:
fluent, well-articulated, good prosodyrapid rateincessant (logorrhea, press of speech)verbal and literal paraphasiasneologismsempty speech
paragrammaticRepetition poor Lack of awarenessLesion site: temporo-parietal region involving Wernickes
area and adjacent white matter
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1 2 3 4 5 6 7artic agility _________________________________________________________________________ unable sometimes clumsy never impaired
phrase length _________________________________________________________________________ 1 word 4 words 7 words
grammatical form _________________________________________________________________________ no syntactic word groupings simplified/incomplete normal range
melodic line _________________________________________________________________________ word by word limited to short phrases normal
paraphasias _________________________________________________________________________ present in every utterance 1-2 instances per minute absent
word finding __________________________________________________________________________ fluent but empty information prop to fluency primarily cont words
sentence repetition __________________________________________________________________________ 0-20 30 40 50 60 70-80 90-100
auditory comprehension ___________________________________________________________________________
0-20 30 40 50 60 70-80 90-100
Wernickes Aphasia BDAE
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Thats on fairble my own Clinician: yes your family
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That s on fairble my own. Clinician: yes, your family .Stuck at that feek already.. On the fff..starting to
goof uf already. Clinician: ok, do you have a largefamily? Do you have a big family? No, yes welltheres 3, 4-4 all told but we only see masically onceof a time at home and 2 of them occasionally athome..the other 3 rd well hes always away at ff foambut masically on on the boys always failinghesliving at home and belonging to the future show.
Clinician: There not all at home all at once? Justone at home all the time, he goes to goes toschool? ..its a high school , its like a hymn schoollike I dont know what you call itfffforgetting andKathys shes a married man and has a daughter athome.. a new daughter.. The other girl is seeing herboyfriend but going give a poy part with her parents.
And what does your wife do?
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Fluent aphasias
Conduction aphasiaRepetitiondisproportionately severeworsens with length of stimuli
Comprehension: relatively goodExpression:
word finding errors and produce literal/phonemicparaphasiasconduite dapproche (lumpily, lutikly)
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Fluent aphasias
Awareness:Self correction, disturbed prosody
Lesion site: Arcuate fasciculusDisconnects Wernickes area from Brocas area
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1 2 3 4 5 6 7artic agility _________________________________________________________________________ unable sometimes clumsy never impaired
phrase length _________________________________________________________________________ 1 word 4 words 7 words
grammatical form _________________________________________________________________________ no syntactic word groupings simplified/incomplete normal range
melodic line _________________________________________________________________________ word by word limited to short phrases normal
paraphasias _________________________________________________________________________ present in every utterance 1-2 instances per minute absent
word finding __________________________________________________________________________ fluent but empty information prop to fluency primarily cont words
sentence repetition __________________________________________________________________________ 0-20 30 40 50 60 70-80 90-100
auditory comprehension ___________________________________________________________________________
0-20 30 40 50 60 70-80 90-100
Conduction Aphasia
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Cest la cuisine.uh cest la cuisine.. uh..lvier uh
qui avec leau okleau, teau puis elle lalan.lela lanche..lanche..ok..elle essuie les fisisse essuieles siesse avecokavec.puisuhouiok.okok..nonok.non il y a dautre choseuh.. il y a dautrechose la..il y a leau qui le vayeau, qui le plancher bon ok cest le garf, le garf et la feuille, la fillette, puisla elle est, elle tambor, le tam, le tambourin, letambourin le tambourin va va banche, va bancher entout cas..cest effrayant!.cest effrayant! Oui legaron, ben la, lui aussi il veut il veut ga gatter gatter les gteaux uh.. puis cest a.
Abricot
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Abricot
Escalier ChampignonHlicoptre
HippopotameTchcoslovaquieRfrigrateur Vous savez bienIl tombe par terre
Les cls sont jetesJe vais au travailNe lui dites pas
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Fluent aphasias
Anomic aphasiaComprehension: goodExpression:
Word finding problemsEmptyFew substantivesCircumlocutions
Repetition: good Awareness of deficits
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1 2 3 4 5 6 7artic agility _________________________________________________________________________
unable sometimes clumsy never impaired
phrase length _________________________________________________________________________ 1 word 4 words 7 words
grammatical form _________________________________________________________________________
no syntactic word groupings simplified/incomplete normal range
melodic line _________________________________________________________________________ word by word limited to short phrases normal
paraphasias _________________________________________________________________________ present in every utterance 1-2 instances per minute absent
word finding __________________________________________________________________________ fluent but empty information prop to fluency primarily cont words
sentence repetition __________________________________________________________________________ 0-20 30 40 50 60 70-80 90-100
auditory comprehension ___________________________________________________________________________
0-20 30 40 50 60 70-80 90-100
Anomic Aphasia
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Fluent aphasias
Transcortical SensoryLesion in the watershed area of junction PCAand MCA territory of the hemisphereSpares Wernickes area but isolates it fromrest of brainResemble severe Wernickes aphasia butwith preserved repetitionRepetition characterized by echolalia repeats without understanding
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Mixed transcortical aphasia
Some consider fluent; some non-fluentSimilar to global but repetition better Multiple lesions in anterior and posteriorborder zones
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Subcortical aphasias
May cause language disturbancesbecause alter the physiology of theoverlying cortex and not due to subcortical
structures per seResearchers divide into thalamic and non-thalamic
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Alexia with Agraphia
Lesion = angular gyrusSurface and deep alexia/agraphiaIf speech affected = anomic aphasiaMay be accompanied by non-languageparietal lobe signs (calculation, clock
setting, finger id, r-l discrim)
Pure Alexia (pure word blindness;
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Pure Alexia (pure word blindness;
alexia without agraphia)Writes but cannot read (words, letters)Usually hemianopic in the right visual fieldTwo critical lesions
Lesion destroys visual cortex of lefthemisphere and damages splenium of thecorpus callosum
Wernickes area is intact but isolated fromvisual input from both hemispheres
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Pure Agraphia
Severe disorder of writing with little or noinvolvement of readingDamage to the left angular gyrus
Limitations of Classical
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Limitations of Classical
Explanations of AphasiaDamage confined to Brocas Area orWernickes area does not produce chronicaphasia
Aphasia from damage deep in the brainSyndromes better for groups thanindividuals
Center for reading the AG? At best only 50% can be classified
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Contemporary Theoretical
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Contemporary Theoretical
Orientations
Cognitive NeuropsychologyModel normal cognitive processing Analyze performance of brain damaged
against normal modelLess concerned with localizationError analysis
Single case studies
Reading
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Reading
Figure 25-1. Schematic representation of the component representations and processes for single-word reading and writing.
The solid lines depict lexical-semantic routes and the dashed lines indicate sublexical routes.
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Differential DiagnosisMotor Speech Disorders:
DysarthriasWeakness/paralysis, incoordination, rigidity,involuntary movementConsistent errors
Apraxia of SpeechMotor planning problem
Absence of weakness etcInitiation, groping, revisions, inconsistent
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Case Example
He said I'd never bake again
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Apraxia of Speech
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Language of Confusion
Not a primary disorder of languageIrrelevant, confabulated contentNot usually focal brain damageIn confusion, language is better than theability to communicate
In aphasia, language is worse than theability to communicate
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Differential Diagnosis
Cognitive-Communication Disorders:Right Hemisphere Deficits
He can talk but hes not the same person
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Wab004.jpg
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1 2 3 4 5 6 7artic agility _________________________________________________________________________
unable sometimes clumsy never impaired
phrase length _________________________________________________________________________ 1 word 4 words 7 words
grammatical form _________________________________________________________________________
no syntactic word groupings simplified/incomplete normal range
melodic line _________________________________________________________________________ word by word limited to short phrases normal
paraphasias _________________________________________________________________________ present in every utterance 1-2 instances per minute absent
word finding __________________________________________________________________________ fluent but empty information prop to fluency primarily cont words
sentence repetition __________________________________________________________________________ 0-20 30 40 50 60 70-80 90-100
auditory comprehension ___________________________________________________________________________
0-20 30 40 50 60 70-80 90-100
Brocas Aphasia Rating Scale Profile of SpeechCharacteristics Boston Diagnostic Aphasia Examination
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Getting Your Message Across
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Adapted from: Simmons-Mackie, 2001; Brookshire, 1993; The Aphasia Institute(http://www.aphasia.ca/training/tips.html)
Modify Your Speech:One idea at a timePause between ideasSimple sentencesMain ideas
State your point directlyUse tone of voice/emphasis to highlight key pointsUse alerting strategies (persons name, touch)Key information at end
Signal new topic (Lets talk about.)Signal end of topic (Thats the end of that)Be redundant (Mary, your sister)
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Getting your message acrossRepeat, rephrase, verify, summarize
Avoid pronouns (Jim vs. he)Supplement Speech:
Gestures/pantomime/facial expressionWrite down key words, draw as you talkUse pictures, magazines, photos as props
Make use of the surroundings (talk about apicture/photo in the room)
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Encourage writing or drawingEncourage pointingIdentify general topic first, then details
Ask yes/no questionsUse a written yes/noIf you dont have time, say when you will return
Encourage the person to use your written words
To Help the Aphasic Person Get Messages Across
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Questions about aphasia An aphasic patient who cant answer questions about
person, place and time is disoriented An aphasic patient who is having difficulty speaking hasan expressive aphasiaIf an aphasic patient does not respond to a question orfollow instructions, it is because he/she does notunderstand
An aphasic patient who laughs and smiles at the righttime during a conversation understands everything
An aphasic patient should be able to benefit from analphabet or picture board
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