HELP! Is it Aphasia, Apraxia, Dysarthria or ALL of

the Above??!!

Jamie L. Johnson, MA L/CCC-SLPUniversity of Kansas HospitalSeptember 24, 2015

During this session, participants will actively participate indiscussing:

Different types of aphasia and dysarthria.

Define dysarthria and apraxia.

Evaluation in the acute and outpatient settings will be identified.

The role of the SLP in education with family/friends for carryover into the home and community will briefly be discussed.

Aphasia

•National Aphasia Association

•www.aphasia.org

Aphasia Evidence Map

Standardized Evaluations

•Purpose:▫Assess 4 modalities▫Classification▫Prognostic statement▫Treatment

Fluency

•Non-fluent 0-5 words•Borderline fluent 6-8 words•Fluent 9+ words

Fluency

•Average of 3 longest phrases in response to▫What happened to you▫Description of picture (cookie theft)▫Response to emotional question-”Tell me

about your family.” “Do you remember what happened on 911?”

Standardized Evaluations• Classification

▫WAB▫BDAE

• Non-classification▫MTDDA▫PICA▫Functional Assessment of Communication

Skills for Adults (ASHA FACS)▫CADL▫Communication Effectiveness Index (CETI)-

caregiver

Screening Tests

•Frenchay Aphasia Screening Test (FAST)

•Ullevaal Aphasia Test (UAST)

Others:

•ADP•Boston Naming Test

SETTING DEPENDENT

ACUTE

INPATIENT REHAB

OUTPATIENT

SNF

LTACH

HOME HEALTH

Standardized Evaluations• What do you use??

HOW ABOUT YOU

Do you determine the type or classification of aphasia?

Type of Aphasia

Fluent or Nonfluent

Conversational Speech

Auditory comprehension

Repetition Naming Lesion Location

Anomic Aphasia

fluent Fluent, normal utterance length and well-formed sentences

Good for everyday conversation, difficulty with complex syntax

preserved Impairment is hallmark

Acute – outside perisylvian zona (angular gyrus or inferior temporal region), chronic- perisylvian area, posterior tempolateral region

Conduction Aphasia

fluent Fluent with normal utterance length but has paraphasias

Good for casual conversation, difficult with complex syntax

Impairment is hallmark, good spontaneous speech, paraphasias during repetition

Always impaired

Posterior perisylvian lesions affecting supramarginal gyrus in parietal lobe and arcuate fasciculus

Transcortical sensory aphasia (TcSA)

fluent Fluent with normal utterance length, but semantic paraphasias, anomia

Significantly impaired

Preserved Severely impaired

Extrasylvian regions involving POT junction region; posterior and deep to Wernicke’s area; sensory info doesn’t reach language areas

Wernicke’s aphasia

Fluent Fluent, easily articulated speech of normal utterance length, semantic and phonemic paraphasias, verbal output excessive and rapid but empty

Severely impaired at single-word level, difficulty with complex syntax and multi-step commands, unaware of inability to produce coherent speech

Significantly defective, cannot even repeat single words

Paraphasic and severe anomia

Large posterior perisylvian lesions encompassing Wernicke’s area and extending superiorly into inferior parietal region

Transcortical motor aphasia (TcMA)

Nonfluent Little attempt to produce spontaneous speech, mute, speech is reduced in length

Good for most conversational interaction, difficulty with complex syntax

Preserved, but absence of spontaneous speech

Relatively preserved

Extrasylvian regions of left frontal lobe; dorsolateral frontal lesions located anterior or superior to Broca’s area, supplementary motor areas, cingulate gyrus

Broca’s aphasia

Nonfluent

Slow, halting speech production, utterances are of reduced length with simple grammar

Good for conversational speech, difficulty with complex syntax

Limited to single words and short phrases

Impaired to some degree, especially for low frequency words

Broca’s area causes transient disruption of speech production and fluency; persistent Broca’s aphasia from larger perisylvian lesions encompassing more of the left frontal lobe

GLOBAL APHASIA• VERBAL EXPRESSION

▫ NON-FLUENT▫ Severely Impaired▫ *Automatic speech may

be preserved• COMPREHENSION

▫ Severely Impaired• REPETITION

▫ Impaired• WRITING

▫ Impaired• READING

COMPREHENSION▫ Impaired

• LARGE LEFT DOMINANT LESION▫ Involving Broca’s and

Wernicke’s areas

BROCA’S APHASIA• VERBAL EXPRESSION:

▫ NON-FLUENT (4words or less)

▫ Slow effortful▫ Perseverations▫ “Telegraphic speech”

• COMPREHENSION:▫ Relatively preserved

• REPETITION▫ Poor

• WRITING ▫ Parallels expression

• READING COMPREHENSION▫ Relatively spared

• ANTERIOR PORTION OF THE LEFT

HEMISPHERE

TRANSCORTICAL MOTOR APHASIA• VERBAL EXPRESSION

▫ NON-FLUENT• AUDITORY

COMPREHENSION:▫ Intact

• REPETITION▫ Intact

• SIMILAR TO BROCA’S WITH ABILITY TO REPEAT

• Anterior and Superior to Broca’s area

• Watershed, borderzones

*MIXED NON-FLUENT• Resembles Broca’s but

auditory comprehension below 50 percentile.

• Auditory comprehension too good to be Global

WERNICKE’S APHASIA

• VERBAL EXPRESSION▫ FLUENT ▫ Jargon, non-sensical

words, rapid rate▫ Retain sentences but lack

meaning▫ May speak with no

insight into errors• COMPREHENSION

▫ poor• REPETITION

▫ poor

• Temporo-parietal involving Wernicke’s area and adjacent white matter

CONDUCTION APHASIA• VERBAL EXPRESSION

▫ FLUENT ▫ Word finding▫ Paraphasic errors

• COMPREHENISON ▫ Relatively intact

• REPETITION▫ Poor

• RARE

• ARCUATE FASCICULUS AND LEFT PARIETAL

TRANSCORTICAL SENSORY APHASIA• VERBAL EXPRESSION

▫ FLUENT▫ Echolalia

• COMPREHENSION▫ SIMILAR TO

WERNICKE’S-EXCEPT STRONG ABILITY TO REPEAT

REPETITION:▫ Intact

• Watershed PCA/MCA territories, borderzones

• Spares Wernicke’s area

*MIXED TRANSCORTICAL APHASIA

• COMBINATION OF THE TWO TRANSCORTICAL APHASIAS

• AUDITORY COMPREHENSION AND EXPRESSION SEVERELY IMPAIRED

• REPETITION INTACT

ANOMIC APHASIA• VERBAL EXPRESSION

▫ FLUENT▫ Word Finding problems▫ Circumlocutes

• COMPREHENSION ▫ Intact▫ USE OF NON-SPECIFIC

WORDS SUCH AS “THING”

• REPETITION ▫ Intact

• MILD FORM• +Awareness

CROSSED APHASIA• LANGUAGE CENTER NO

IN EXPECTED HEMISPHERE

• • EX. RIGHT-HANDED

PERSON WITH R CVA WITH APHASIA

Reading and Writing

Alexia

Alexia with Agraphia

Agraphia

Paraphasias▫ Literal/Phonemic▫ Verbal/Semantic

Neologism

Perseveration

Circumlocutions

SUBCORTICAL APHASIA• THALAMUS• INTERNAL CAPSULE• BASAL GANGLIA

• MIRROR CORTICAL LESION APHASIAS

• CAN CO-OCCUR WITH CORTICAL APHASIAS

PRIMARY PROGRESSIVE APHASIA• GRADUAL LOSS OF LANGUAGE-

PRESERVED MEMORY, VISUAL PROCESSING AND PERSONALITY-UNTIL THE END

• BEGINS WITH WORD FINDING PROGRESSES TO IMPAIRED GRAMMAR AND COMPREHENSION

• DYSARTHRIA AND APRAXIA MAY ACCOMPANY

• *STRUCTURAL & PHYSIOLOGICAL ABNORMALITIES IN LEFT HEMISPHERE (FRONTAL, PARIETAL AND TEMPORAL.

• NOT DUE TO NEOPLASTIC, VASCULAR OR METABOLIC ETIOLOGIES NOR INFECTION

• Semantic variant

• Logopenic variant

• Non-fluent Agrammatic variant

INSULA“The Role of the insula in Speech and Language Production”

Oh, A. et al.

Brain and Language 135 (2014) 96-103.

“Prime real estate”

• Responsible for articulatory control

• Direct connections to Broca’s area

• Higher order cognitive aspects of speech-language

• fMRI-exp/rec and production/ perception=Bilateral ant insula

• Speech perception Left dorsal mid-insula

• Expressive language tasks activated left ventral mid=insula

• Mid Insula plays different roles in S/L processing

MANY FACES OF APHASIA

Differential Diagnosis

•Motor Speech Disorders:•Dysarthria

▫Weakness/paralysis, incoordination, rigidity, involuntary movement

•Apraxia▫Motor planning problem▫Absence of weakness▫Initiation, groping, revisions, inconsistent

Apraxia of Speech

• Messages from the brain to the mouth are disrupted, and the person cannot move his or her lips or tongue to the right place to say sounds correctly, even though the muscles are not weak.

• Apraxia can occur in conjunction with dysarthria or aphasia

• Caused by damage to the parts of the brain that control coordinated muscle movement

Signs or Symptoms of Apraxia of Speech

Know what words they want to say, but their brains have difficulty coordinating the muscle movements necessary to say all the sounds in the words.

Individuals with apraxia may demonstrate: • Difficulty imitating and producing speech sounds• Sound distortions, substitutions, and/or omissions• Inconsistent speech errors• Groping of the tongue and lips to make specific sounds and

words• Slow speech rate• Impaired rhythm and prosody (intonation) of speech• Better automatic speech than purposeful speech• Inability to produce any sound at all in severe cases. • Frustrating

The faces of…dysarthria?......apraxia?

G CODESModifier Impairment NOMS

•0% WNL 7•1-20% MIN 6•20-40 MILD 5•40-60% MILD-MOD 4•60-80% MODERATE 3•80-99% MOD-SEVERE 2•100% SEVERE 1

NOMS MOTOR SPEECH• LEVEL 1: The individual attempts to speak, but speech cannot be understood by

• familiar or unfamiliar listeners at any time.

• LEVEL 2: The individual attempts to speak. The communication partner must assume

• responsibility for interpreting the message, and with consistent and maximal cues,

• the patient can produce short consonant-vowel combinations or automatic words

• that are rarely intelligible in context.

• LEVEL 3: The communication partner must assume primary responsibility for interpreting

• the communication exchange, however, the individual is able to produce short

• consonant-vowel combinations or automatic words intelligibly. With consistent and

• moderate cueing, the individual can produce simple words and phrases intelligibly,

• although accuracy may vary.

• LEVEL 4: In simple structured conversation with familiar communication partners,

• the individual can produce simple words and phrases intelligibly. The individual

• usually requires moderate cueing in order to produce simple sentences intelligibly,

• although accuracy may vary.

• LEVEL 5: The individual is able to speak intelligibly using simple sentences in daily routine

• activities with both familiar and unfamiliar communication partners. The individual

• occasionally requires minimal cueing to produce more complex

• sentences/messages in routine activities, although accuracy may vary and the

• individual may occasionally use compensatory strategies.

• LEVEL 6: The individual is successfully able to communicate intelligibly in most activities,

• but some limitations in intelligibility are still apparent in vocational, avocational,

• and social activities. The individual rarely requires minimal cueing to produce

• complex sentences/messages intelligibly. The individual usually uses

• compensatory strategies when encountering difficulty.

• LEVEL 7: The individual’s ability to successfully and independently participate in

• vocational, avocational, or social activities is not limited by speech production.

• Independent functioning

NOMS SPOKEN LANGUAGE COMPREHENSION • LEVEL 1: The individual is alert, but unable to follow simple directions or respond to yes/no

• questions, even with cues.

• LEVEL 2: With consistent, maximal cues, the individual is able to follow simple

• directions, respond to simple yes/no questions in context, and respond to simple

• words or phrases related to personal needs.

• LEVEL 3: The individual usually responds accurately to simple yes/no questions. The

• individual is able to follow simple directions out of context, although moderate

• cueing is consistently needed. Accurate comprehension of more complex

• directions/messages is infrequent.

• LEVEL 4: The individual consistently responds accurately to simple yes/no questions and

• occasionally follows simple directions without cues. Moderate contextual support is

• usually needed to understand complex sentences/messages. The individual is able to

• understand limited conversations about routine daily activities with familiar

• communication partners.

• LEVEL 5: The individual is able to understand communication in structured conversations

• with both familiar and unfamiliar communication partners. The individual

• occasionally requires minimal cueing to understand more complex

• sentences/messages. The individual occasionally initiates the use of

• compensatory strategies when encountering difficulty.

• LEVEL 6: The individual is able to understand communication in most activities, but some

• limitations in comprehension are still apparent in vocational, avocational, and

• social activities. The individual rarely requires minimal cueing to understand complex

• sentences. The individual usually uses compensatory strategies when encountering

• difficulty.

• LEVEL 7: The individual’s ability to independently participate in vocational, avocational,

• and social activities are not limited by spoken language comprehension. When

difficulty with comprehension

NOMS SPOKEN LANGUAGE EXPRESSION • LEVEL 1: The individual attempts to speak, but verbalizations are not meaningful to familiar or• unfamiliar communication partners at any time.

• LEVEL 2: The individual attempts to speak, although few attempts are accurate or appropriate.• The communication partner must assume responsibility for structuring the• communication exchange, and with consistent and maximal cueing, the individual can• only occasionally produce automatic and/or imitative words and phrases that are rarely• meaningful in context.

• LEVEL 3 The communication partner must assume responsibility for structuring the• communication exchange, and with consistent and moderate cueing, the individual can• produce words and phrases that are appropriate and meaningful in context.

• LEVEL 4: The individual is successfully able to initiate communication using spoken language• in simple, structured conversations in routine daily activities with familiar• communication partners. The individual usually requires moderate cueing, but is able to• demonstrate use of simple sentences (i.e., semantics, syntax, and morphology) and• rarely uses complex sentences/messages.

• LEVEL 5: The individual is successfully able to initiate communication using spoken language• in structured conversations with both familiar and unfamiliar communication partners.• The individual occasionally requires minimal cueing to frame more complex sentences• in messages. The individual occasionally self-cues when encountering difficulty.

• LEVEL 6: The individual is successfully able to communicate in most activities, but some• limitations in spoken language are still apparent in vocational, avocational, and social• activities. The individual rarely requires minimal cueing to frame complex sentences.• The individual usually self-cues when encountering difficulty.

• LEVEL 7: The individual’s ability to successfully and independently participate in vocational,• avocational, and social activities is not limited by spoken language skills. Independent• functioning may occasionally include use of self-cueing.

NOMS

•READING

•WRITING

Education

•Family Training•Staff Training•Education materials•Websites•Apps•Home Programs

•Family/Caregiver’s role in Therapy in any setting

QUESTIONS???

REFERENCES• Davis, G. (2007) Aphasiology: Disorders and Clinical Practice.

pages 33-39.• Helm-Estabrooks, N. Albert, M.L., 1991, 2004. Manual of

Aphasia and Aphasia Therapy. 2nd edition, Pro-Ed, Austin Texas.• Johnson, A., Jacobson, B,(2006) Medical Speech Pathology: A

Practitioner's Guide. Thieme Medical Publishers, New York, NY• LaPointe, L. (2001 ) Aphasia and related Neurogenic Language

Disorders. Thieme Medical Publishers, New York, NY• Oh, A. et al. (2014) The Role of the Insula in Speech and

Language Production Brain and Language. 135, 96-103.• www.ASHA.org