Assessment & Intervention

Front 1

Purposes of Assessment (4)

Back 1

1. To identify specific problems- whether or not aphasia exists
2. To describe language behaviors- address all modalities (aud comp, verbal language, reading and writing)
3.To determine intervention goals- predict factors that will make them successful or unsuccessful in therapy (prognosis). Make a long-term goal.
4.To identify factors that facilitate the retrieval of language- visual support, repetition, reduced rate, etc…

Front 2

Parts of Assessment (4)

Back 2

1. Patient Hx- get infro from chart
2. Speech & Language Testing- each modality, low functioning vs. high functioning
3. Informal Observation
4. Additional Testing- hearing, swallowing, cognition, motor-speech

Front 3

Components of Aphasia Assessment/ Modalities (4)

Back 3

1. Auditory Comprehension
2. Verbal Expression
3. Reading Comprehension
4. Written Expression

Front 4

Auditory Comprehension Assessment- Description of the nature of impairment

Back 4

-Difficulty assigning meaning to incoming words
-Difficulty understanding word relationships
-May be confounded by a memory impairment

Front 5

Auditory Comprehension Assessment- Assessment tasks

Back 5

-Single word comprehension
-Comprehend objects by function
-Follow 1,2,3 step directions
-Comprehend yes/no
-Comprehend Wh-?
-Comprehend narratives
-Understand simple conversation

Front 6

Auditory Comprehension Assessment
1. Low Functioning
2. High Functioning

Back 6

1. Responds to name, identifies personal belongings, 1 step directions in context, use of common objects
2. Increase length/complexity of narratives, task specific assessment

Front 7

Auditory Comprehension Assessment- Associated Memory Deficits

Back 7

-Slow rise time
-Noise buildup
-Retention deficit
-Information Capacity Deficit

Front 8

Conditions that modify or facilitate auditory comprehension

Back 8

-less complexity, abstractness, slower rate of presentation, shorter length
-word frequency
-imageability
-context
-personal interest

Front 9

Verbal Expression Assessment- Description of the nature of the impairment

Back 9

• Deficiencies in word finding including some paraphasic errors – such as wrong word or related word, jargon or word may be absent
• Syntactic impairment- being able to use complex syntactic structures, trouble with function words (prepositions, articles, conjunctions), lose some morphological markers
• Motor speech production impairment- dysarthria or apraxia of speech

Front 10

Verbal Expression Assessment- Assessment tasks

Back 10

• Repeating single words and phrases
• Completing automatic speech tasks (counting, Days Of Week, Months Of Year)
• Closure naming
• Confrontational naming- various categories (nouns, verbs, body parts, colors, numbers, letters)
• Provide single word answers to questions about self/family (name, age, occupation)
• Provide short answers to Wh questions
• Express basic needs and wants
• Describe an action picture
• Describe procedure/daily event
• Participate in conversation
• Ask questions
• Retell a story

Front 11

Verbal Expression Assessment-
1. Low functioning
2. High functioning

Back 11

1. • Informal observation to note gestures or improved performance with familiar people
• Attempt first six tasks but with verbal prompts, gesture and semantic cueing
2. • Spontaneous language sample- analyze with Shewan Spontaneous Language Analysis System (see handout)
• Informal assessment with more complex tasks
Explaining idioms
Providing multiple meanings of words
Making inferences (Norman Rockwell pictures are good for this)
Drawing conclusions

Front 12

Conditions that facilitate verbal expression

Back 12

• Prediction: Number of words that could possibly complete the sentence.
• Ex: “I drove a ___” is more predictable than “I ate a _____” because there are a fewer # of things you can drive
• Expectation: Extent to which word was the expected response
• Ex: “I drove my ___” (“car” has higher expectation than “bus” because it’s more likely that you would drive a car.)
Specific task: closure is easier than confrontational naming
Presence/absence of context

Front 13

Reading Comprehension Assessment- Description of the nature of impairment

Back 13

• Process is slowed and more effortful
• Difficulty understanding syntax
• Difficulty understanding words
• Visual problems
• May be associated with memory deficit

Front 14

Reading Comprehension Assessment- Assessment tasks

Back 14

• Match letters, words
• Match words to pictures
• Recognizing and reading letters
• Read and demonstrate comprehension of directions of increasing length
• Read and demonstrate comprehension of sentences of increasing syntax
• Read and demonstrate comprehension of sentences with less frequency of occurrence
• Comprehend the main point of paragraphs of increasing length
• Comprehend detail questions of paragraphs of increasing length
• Comprehension of daily life materials (Bible, menu, telephone directory, newspaper)

Front 15

Reading Comprehension-
1. Low Functioning
2. High Functioning

Back 15

1. • Attempt only the beginning levels
• Attempt even with most impaired patients
2. • Give RCBA-2
• Alternative tests (p. 144)
• Informal assessment with functional reading material and task analysis

Front 16

Reading Comprehension Assessment- oral reading v. comprehension

Back 16

• Oral reading-
i. We are likely to hear paraphasic errors
ii. Can use it to help you judge comprehension
iii. Words that are semantically related have more paraphasic errors because they are more closely connected. Semantically unrelated words are easier to read.
iv. For semantically unrelated choices their performance decreases just because the number of choices when there are 7 or 8 choices

Front 17

Conditions that facilitate reading comprehension

Back 17

• Word frequency of occurrence
• Imageabililty, concreteness, familiarity of words
• Size of answer choice arrays
• Semantic relatedness of answer choices
• Syntactic complexity
• Presence/absence of context
• Predictiveness
• Length & reading level of paragraph
• Types of comprehension questions (MP vs. detail)
• World knowledge

Front 18

Written Expression Assessment- Description of the nature of impairment

Back 18

• Paresis or nondominant hand- mechanical errors
• Literal, verbal neologistic paragraphias (paraphasias that are written down) in writing
• Complete agraphia

Front 19

Written Expression Assessment- Assessment Tasks

Back 19

• Copying letters/words
• Writing to dictation letters/words
• Automatic writing tasks (name, address, numbers)
• Writing 1 word/short phrase answers to questions
• Writing a picture/object description

Front 20

Written Expression
1. Low Function
2. High Function

Back 20

1. Word processing
2. Task specific assessment

Front 21

Factors that facilitate written expression

Back 21

• Mechanical
• Word finding & paraphasic errors
• Priority of writing/using as a cue

Front 22

WHO (2001), ICF

Back 22

World Health Organization, International Classification of Functioning, Disability, and Health

Front 23

WHO (2001), ICF: Primary Classification Areas

Back 23

1. Body structure/function/impairment
2. Activities/ participation/ disability/ handicap
3. Environmental Factors

Front 24

Supplemental Testing

Back 24

1. Cognitive Assessment- memory, thinking & reasoning
2. Hearing Screening- age, reports of sensory loss post-stroke
3. Swallowing- has a separate set of orders
4. Motor Speech
5. Functional Assessment/ life participation

Front 25

Stimulation Approach to Aphasia Therapy
1. Def'n of Aphasia
2. Principles

Back 25

(Hildred Schuell)
1. Affecting language across all modalities unilaterally
2. o words, language is not lost, language system still working just not as efficient. Faulty connections. Asynchronous chaos of language processes.
o trying to draw out better production or comprehension by the way we stimulate the patient
o if we provide controlled intensive stimulation, we’re going to help reorganize the language system
o primarily auditory stimulation

Front 26

Stimulation Approach to Aphasia Therapy: Specific Techniques

Back 26

-Do not talk louder
-Decrease the signal:noise ratio
-Provide larger font
-Reduce # of answer choices
-Use multi-modal stim.
-Slow rate, increase pauses
-Control length of sentences
-Self-cuing very successful
-Less complex syntactical structures

Front 27

Spontaneous Recovery
1-30 days:
3-6 months:
6-12 months:
12+ months:

Back 27

1. Greatest amount of change in the first 30 days after the stroke
2. pace of recovery slows down
3. spontaneous recovery can continue occurring for one year post-stroke
4. insurance stops paying for services
• Progress after this point becomes slow
• Can sometimes be picked up for therapy under a different diagnosis

Front 28

Acute phase

Back 28

0-3 days post stroke
o No evidence that we can physiologically impact the brain with our traditional therapy
o During this time, the role of the SLP is more as a counselor
• Talk with family, answer questions about communication, explain the healing process

Front 29

Sub-Acute phase

Back 29

3-21 days post stroke
o Perhaps on a subacute rehab floor or center, stay for about three weeks
o PT, OT, Speech 2x/day

Front 30

Chronic phase

Back 30

anything beyond 30 days
o Probably at a nursing home or rehab center

Front 31

Auditory Comprehension Intervention: "Treatment for Wernicke's Aphasia" (TWA)

Back 31

o Improves auditory comprehension for patients with some reading comprehension and repetition skills
o 1) Match written words to pictures
o 2) Reauditorization step to improve auditory comprehension.
• Reauditorization- improved comprehension as aresult of saying the word.
• Read aloud the words from step 1, then repeat aloud the words with a spoken model and visual stimulus
o 3) Complete spoken word to picture matching task
o If they get it wrong, you don’t need to explain why that answer is wrong, etc…, simply state the correct answer paired with the correct picture.

Front 32

Auditory Comprehension Intervention: Stimulation Approach

Back 32

o Pointing tasks- point to the picture or object that represents to the spoken, written, and/or gestured word stimulus.
• Point to the written word that represents the spoken, written, and or gestured word stimulus.
• Point to the picture, object or written word that represents the spoken definition (point to the color of bananas)

o Following Directions- point to pictures or objects in the sequence specified by a spoken and/or written command.

o Answering Questions- answer spoken and/or written yes/no questions about general information (“Is Canada south of the United States?”)

o Sentence Verification
• Determine if a spoken and/or written sentence makes sense

Front 33

Semantic Features Analysis
1. Developer
2. Principle

Back 33

1. Cara Mazza
2. • Attempts to target comprehension and expression simultaneously
o Semantic system (input and output) are linked and impaired across the board

Front 34

Semantic Feature Analysis: Tasks

Back 34

o Sorting words or picture by semantic category: known vs. created categories
o Spoken or written word to picture matching tasks with semantically related distraction items
o Spoken or written naming tasks which include providing and or identifying relations
o Spoken or written phrase or sentence completion tasks- expand to simple Family Fued Game
o Answering questions about target items (yes/no or wh)
o Matching pictures or written words to spoken definitions
o Odd-one-out tasks

Front 35

Mild Comprehension Deficit Intervention

Back 35

• Help people who have had a stroke become their own self advocate
o It’s all right to say “could you repeat that” or “can you slow down” etc
• Teach them to control their environment
o Low noise, let family know ahead of time about the person’s deficits and strategies

Front 36

Functional Goal

Back 36

What skills does the patient need to participate in the same activities as they did before the stroke?

Front 37

Verbal Expression Intervention: Therapist Factors

Back 37

1. Controlling loggorhea- interrupt. Identify "it's my turn" and "it's your turn."
2. Decrease rate, increase pause time. The patient will repeat what's modeled for them.

Front 38

Semantically Based Cues

Back 38

Superordinate- it's an animal
Coordinate- it's like a cow
Associate- it eats hay
Function- you can ride it
Phrase or sentence completion- "The jockey fell off the ___"
Definition/Description- An animal you can find on a farm that you can ride.

Front 39

Phonologically Based Cues

Back 39

**Initial phoneme or syllable
Number of syllables
Rhyme
Repetition
Unison speech

Front 40

Orthographically Based Cues

Back 40

• Initial grapheme
• Number of letters
• Word shape
• Letter anagrams
• Copying
• Reading aloud

Front 41

ACT (Anagram, Copy Treatment)

Back 41

Therapy: Pick 10 words
• Show the picture with the word printed underneath it, and tell the client to “write the word for this” or “write the word ___”
• If correct, move on to next word.
• If incorrect, present them with the letters that make the word. Tell them “Make these letters spell ___.”
• If correct, ask them to copy the word 3x.
o Then present 2 foil letters.
• If incorrect, arrange them in the correct order, and ask them to copy the word 3 times.

Front 42

CART (Copy and Recall Treatment)

Back 42

Homework program
-Take target words that the patient was relatively successful at in therapy and ask them to practice writing the words daily.
-Put a folder with the pictures in it, and ask them to write it a minimum of 5 times.

Front 43

VCIU (Voluntary Control of Involuntary Utterances)

Back 43

• Create- a list of the real words that anyone has heard the person say since the stroke
• Write- each word on a card. If they get it right, keep it. If they get it wrong, put it in a “try again later” pile
• Then for target words from step 2 provide pictures of the words and ask to name. If pt can not name the picture, show the written word and ask them to read word aloud.
• Next step is to ask questions requiring using target words to answer with picture cue and eventually without picture cue.
• After they successfully complete this therapy, you have a core vocabulary of 10-20 words. Next pick new functional words, or move to another strategy.

Front 44

RET (Response Elaboration Training)

Back 44

• Verbal Instruction & Stimulus presentation
 Cover of sports illustrated magazine
 Cl: Tell me about this picture, as completely as you can.
 Pt: He took it right to that sucker. To the hole, to the hole.
• Elaboration, Model, Reinforce
 Cl: Bill Walton dunks the ball over Kareem- Good
 Pt: No response
• “wh” cue
 Cl: What’s going on here?
 Pt: Playing in the Western Conference finals. Wowie. Gonna beat the Lakers four straight. Wait and see.
• Combine Patient Responses, Model, Reinforce
 Cl: Bill Walton dunks the ball over Kareem in the Western Converence finals against the Lakers- Great
 Pt: No response
• Request repetition and model
 Cl: You try to say the whole thing. Bill Walton dunks the ball over Kareem in the Western Conference finals against the Lakers.
 Pt: Walton dunks on Kareem in the finals with the Lakers.
• Reinforce, Model
 Cl: Good work. Bill Walton dunks the ball over Kareem in the Western Conference against the Lakers.

Front 45

Semantic Feature Analysis

Back 45

o Put the target word and picture and put it in the middle (pizza)
o Add information like:
• Category
• What is it made of
• Location
• What does it look like?
o Build an entire sentence based on the information

Front 46

SPPA (Sentence Production Program for Aphasia)

Back 46

• Present a picture and a brief story
• Level A: Elicit target sentence type using delayed repetition
• Level B: Elicit target sentence type without repetition
• When 15 correct responses, move to next sentence type.

Front 47

Mapping

Back 47

• Present a scene and spoken/written model of target stimulus. Ask them to identify the action.
• Ask the patient to identify who was doing the action by pointing, underlining, or saying the appropriate word from the stimulus sentence
• Ask the patient to identify who the action was done to by pointing, underlining or saying the appropriate word
• Ask the patient to say the target sentence by viewing the picture

Front 48

• PACE (Promoting Aphasics Communicative Effectiveness)

Back 48

o Structure therapy so that communication interactions share characteristics with everyday/ typical communication
o Classic PACE activity- you and the patient to sit across from each other. You each have a stack of cards and you don’t know what’s on the cards (pictures, words, sentences, etc). (You gather the materials, so get enough that you won’t be able to guess theirs right away). Take turns picking up a card and communicating to the partner what’s on the card.
• Success= when your partner understands what you’re talking about.

Front 49

Training Conversation Partners

Back 49

o One approach= identify disruptive behaviors and work to eliminate (video tape and analysis) (interruption and yes/no?)
o Provide structured training on specific strategies (table p 364)
o Supportive Conversation for Adults with Aphasia
http://www.aphasia.ca/trainingresources.html

Front 50

Treatment of Paraphasic Errors

Back 50

• Paraphasic errors= result of word-finding impairment
o Strengthen the semantic representation to get a better activation of the phonological lexicon
o Using Semantic Feature Analysis (see previous notes)
o A hierarchy of cuing is likely to activate the correct semantic representation

Front 51

Reading Comprehension Intervention

Back 51

• Before they even read, establish questions that they have to be able to answer when they’re done
• Re-teach them to use headings and subheadings to increase comprehension
• KWL
 Know
 Want to Know
 Learned
• Tell them ahead of time that when they’re done reading, they will put it into their own words (summarize)

Front 52

Written Expression Intervention

Back 52

o Pre-writing
• Graphic organizer to brainstorm for a weekly update (the patient can blog)
 What’s going on in PT, OT, ST, Family
 Take the listed information and turn them into complete sentences.
o Writing
• Graphic Organizer
 Have the patient fill in, or make more complete, his thoughts
• Telling about a weekly event (sequencing, or topic introduction)