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XX1APHASIA
| Question | Answer |
|---|---|
| Aphasia can affect many aspects of language including | speaking, listening, reading, and writing. Most common is for ALL FOUR to be impacted but to differing degrees. |
| Is Aphasia an access issue or a loss issue? | Current belief is that it is more of an access issue - right after a stroke the pt cannot access, but after therapy can improve. Pt is still aware of difference in function though (have to type up lectures in advance for example.) |
| Aphasic pts. have some cognitive issues at some level that affect performance to some degree... | possibly attention, possibly working memory, words they just spoke may disappear... |
| Aphasia is an ACQUIRED disorder. The definition as it relates to this is: | Skills must be DEVELOPED before the loss occured; for example, a 10 year old child that had a stroke, well, they didn't have language fully developed yet, so it isn't Aphasia. No specific age, just when fully developed - maybe 18-25... |
| Any domain of language could be impacted by Aphasia. What are some of the DOMAINS that could be impacted? | Phonology Morphology Lexical/Semantics Syntax and Pragmatics (but just for the record, Pragmatics is not typically impacted because it relates more to right hemisphere.) |
| Aphasia results from brain damage and is thus acquired. As it affects language and not speech per se, it is more likely an access problem. Probably some cognitive impairments as well. | Aphasia results in the disruption of language in particular ways suggesting that the ares of the brain that are damaged are involved in language function... they are disrupted. This can apply to any language system including sign. |
| Parts of the brain that are damaged in Aphasia should be viewed as a | language SYSTEM - not just small parts of the brain - they all work TOGETHER. |
| Early in the 19th century, when doctors knew of someone with strange behaviors, they would wait around till that person died eventually and then study their brain via autopsy... | They would see how the brain was damaged and then start hypothesizing about it. This was the beginning of locationist theory. |
| Franz Gall | Phrenology Phrenology Mapping feeling people's heads for more pronounced parts and thinking about how diff parts of the brain had diff functions. Phrenology was beginning of locationist theory. He got a bad rap from charlatans trying to copy him & make $ |
| Bouillard | From casebooks he thought anterior to posterior was speech relevant. Frontal = speech impacted. 1/2 correct that there is a breakdown between the motor component and an amnesia for words - diff aphasic syndromes. One of earliest writers about this. |
| Dax | Found that the distinction isn't anterior and posterior, but rather left to right. His son published this after Dax's death 27 yrs later but Broca got all the credit in the same year. |
| Broca | Broca's Area 1861 studied some pt who could only say 'tan' - not a clear cut case cause the guy had gangrene. His comprehension and 'reason' were good, but he couldn't find words. Broca gave lang test and was involved in autopsy - big damage in left hemi |
| "Tan"'s brain had a huge hole in left hemisphere (now known as Broca's Area) and the right side was just fine. | Broca determined that area was dominate for language and language function was in the frontal lobe. |
| How was Broca's finding 'not quite true' with regard to left brain language dominance? | Most people are left hemi dominant for language, but not ALL. 97% of right-handed are left language dominant. Right hemi is 19% of left handers. Rest are left or both. |
| How else was Broca's finding 'not quite true' with regard to location of language center? | Language is not solely localized in the frontal lobe... Broca's area IS still implicated for language processing, but white matter is too. |
| Wernicke wrote a famous paper when he was only 27 years old. He believed in location but also in connections in the brain and what might happen if those connections broke. | If connection is broken, must be Conduction Aphasia - can speak, and kinda understand, but when they try to imitate the speech of others it gets lost in the middle, and pts unaware of problems! |
| Wernicke made an association between what is now known as Wernicke's Area and the Primary Auditory Cortex - there is more than ONE language area... diff infarctions in diff areas =. | diff types of aphasia. |
| Wernicke-Lichtheim Schema | cool map thing that shows what kind of aphasia someone might have depending on the location of brain damage. |
| Dejerine: | Alexia without agraphia The Supramarginal Gyrus and Angular Gyrus were his areas - one of pioneers in localization of function. Any lesion in Perisylvian region has impact on multiple language abilities. |
| Reading and writing difficulties after a stroke without involvement of spoken language = | Alexia with agraphia - Dejerine - suspected damage to angular gyrus and white matter below it - impacts reading and writing - angular gyrus is thought to be the GATEWAY to the Language System. |
| Alexia withOUT agraphia | inability to recognize words and letters especially with low frequency words. Person can WRITE, but can not read what they have written later! This is left occipital cortex and splenus of the corpus callosum damage. |
| Alexia withOUT agraphia results from damate to the left occipital cortex and splenus of the corpus callosum and results in | info from the right cannot cross over to the left angular gyrus. |
| Geshwind | Connectionism. Interested in fluent versus non-fluent aphasia and developed these ideas as categories. |
| When a word is heard, what brain centers? | Primary auditory cortex, Wernicke's Area |
| When a word is to be spoken what happens? | Broca's area, Wernicke's area, motor cortex |
| When a heard word is to be spelled? | Primary auditory cortex, Wernicke's area, angular gyrus, motor area. |
| When a word is read? | Occipital lobe, Wernicke's area, Broca's area Motor Cortex Frontal Lobe |
| Pierre Marie | Global Model: reinterpretation of primary aphasias. Wernicke's is the only true aphasia. Other things REVOLVE around Wernicke's area. Wernicke's is the only true linguistic area. |
| Most common cause of aphasia is stroke. | CVA is a sudden disruption in blood supply to the brain that deprives it of nutrients and oxygen and the brain is damaged. |
| Diaschisis | when there is no input to the undamaged side except for the loss of input - well, this is still an impact after an ischemic stroke. Initially diffuse symptoms, then more focal symptoms remain. |
| Know names of meninges in brain | subarchnoid and other terms. Look them up. |
| Hemorrhagic Strokes are much more fatal | 40% fatality rate |
| Must know recovery pattern from stoke | KASA standard and warning signs too! |
| Before you go in to assess a pt in a hospital, do these things: | read the chart, the neurology report, the doctor's notes, talk to the nurse, go visit the patient and informally observe him/her |
| What kinds of things can you ask the nurse about a patient before you go in to assess them? | Can you talk to him? Can he follow instructions? When is a good time to see him? When does he take medication? When is he the most alert? Does he fall asleep after meals? |
| Stop in to say 'hi' to the patient before you assess him | it is a good time to get a 'snapshot' on him as to how easy it will be to establish rapport do this as part of initial information gathering. |
| Altered reponsiveness can occur after a stroke | everything slows down and everything requires more concentration |
| Perseveration | repeating the same thing over and over again |
| Diminished Response Flexibility | diff kinds of responses to diff ?'s |
| Impaired self-monitoring | use a very structured task instead of alternating tasks |
| What is the general purpose of assessment for Aphasia? | to diagnose communicative impairments, their nature, and their severity To arrive at a prognosis for communicative recovery To make decisions about the appropriateness and the focus of treatment |
| Why do another assessment at the end of treatment for Aphasia patients? | To measure the pt's communicative abilities again; to measure the efficacy of treatment |
| What are the general PROCEDURES for assessment with a pt? What kind of info is gathered and analyzed? | Info gathered, subjective report, objective data = try to determine the cognitive and/or language deficits, their impact on daily function, the necessity and nature of treatment, and give any recommendations to pt and caregiver. |
| What are some syntactic factors involved in comprehension? | Semantic reversibility and non-syntactic routes to comprehension (lexico-pragmatic processing) * Word Order *Animacy |
| Word Order and Animacy relate to what? | Nonsyntactic routes to comprehension a.k.a. Lexico-pragmatic Processing |
| What is Lexico-pragmatic Processing? | Word Order and Animacy as a nonsyntactic route to comprehension. |
| The apple the boy is eating is red. The dog the boy is patting is tall. The girl the boy is chasing is tall. The boy is eating a red apple. These are examples of: | Semantic Reversibility which is a Syntactic Factor involved in Comprehension |
| There are 3 categories of Aphasia Tests. What are they? | Screening Tests Standardized Aphasia Batteries Supplementary Aphasia Tests |
| What are some examples of 'supplemental' tests that you can use for Aphasia???? | Supplemental Aphasia Tests may include: Naming Sentence Comprehension Spontaneous Speech (sentence production) Reading/Writing Motor Speech Functional Communication |
| To use a Standardized Battery is must have these things: | Standard test instruction Standard scoring procedure Normative data Other Psychometric Data Range of item difficulty |
| To be an effective standardized battery to test for Aphasia, besides needing to have standard test instruction, standard scoring procedure, normative data, other psychometric data and a range of item difficulty, a battery should: | Lead to classification of aphasia or deficit Provide Severity Index Show general Strengths and Weaknesses of pt Be free of cultural bias |
| According to Brookshire in 1973, there are PATTERNS of Auditory Comprehension Deficits. What are they? | Slow Rise Time Noise Build-up Retention Deficit |
| Slow Rise Time, Noise Build-up and Retention Deficit are | patterns of auditory comprehension deficit. |
| What are some miscellaneous factors that may influence sentence comprehension? | Stimulus length, context, rate of stimulus presentation, and stress/intonational contour |
| Stimulus length, context, rate of stimulus presentation, and stress/intonational contour are examples of what? | some miscellaneous factors that may influcne sentence comprehension. Figure, if someone said something a brief something to you, in a readable context, said it slowly enough you could follow, and said it with an interesting stress, you'd understand them! |
| What are some SEMANTIC factors involved in comprehension??? | FREQUENCY of Occurrence = high? low? Semantic CATEGORIES REDUNDANCY |
| Using High frequency of occurrence, semantic Categories, and Redundancy all help with what? | Comprehension for Aphasics |
| What is meant by Semantic Categories as it relates to comprehension for Aphasics? | Semantic Categories such as object, actions, colors, numbers, letters (all aphasic groups) and also Free Standing Morphemes or Bound Morphemes - Categories... The Free Standing and Bound Morpheme categories are for fluent and agrammatic aphasics.) |
| What is meant by Redundancy as it relates to comprehension for Aphasics? | Semantic redundancy and slow rate facilitate all aphasic groups comprehension. Apple is good or apple is good today is not as redundant in meaning as 'apple is good to eat.' |
| What are some general principles for testing brain damaged patients? | Prepare materials based on your knowledge of pt. Next, choose an appropriate place for testing. Make sure you schedule the testing to maximize the patient's performance! |
| What are some of the Behavioral, Cognitive, and Emotional Effects of Brain Damage? | Altered Responsiveness slower Perseveration repeats Diminished response flexibility diff resp to diff ?'s Impaired self-monitoring (use highly Impaired self-monitoring: use structured tasks not alternating) Diff w/ attn Disturb of personality/emotion |
| What does Auditory Comprehension Deficits in Aphasia present like??? | Inability to understand linguistic utterances that has nothing to do with sensory input, nothing to do with generalized cognitive deficits, and nothing to do with attention deficits... Crosses all aphasic groups. Not sensory, not cognitive and not attentn |
| Who was the Phrenologist? | Gall |
| Localizationists??? (there are 3 localizationists) | Bouillaud Broca and Dax |
| Connectionists? (there are 4 Connectionists) | Wernicke, Lichtheim, Dejerine, and Geshwind |
| Who is the most MODERN? | Geshwind |
| Who is the Global Modelist? | Pierre Marie |
| Gall's contribution to Aphasiology? | Phrenology was like a precursory principle to functionism. Thought he could detect personality, talents from size of brain centers by feeling skull. |
| Who said that when the frontal lobes are affected, speech is affected, and when the frontal lobes are spared, speech is spared? (Not quite true btw.) | Bouillard - he was a localizationist. He was only part right because the most IMPORTANT dichotomy is btw the Left and Right Hemispheres of the brain, not btw the anterior and posterior areas. |
| Marc Dax was another localizationist - what did he figure out? | Dax figured out that the left hemisphere of the brain had some control over language but Bouillard was unaware of the Dax research. |
| What was Bouillard's real contribution then if he wasn't right about the frontal lobe comment??? | Bouillard distinguished btw aphasic syndromes in that there could be a breakdown of motor speech mechanisms and that type where there is more of an amnesia for words. He just had the directionality/areas wrong. |
| What was 'Tan's real name? | Leborgne = 'Tan' because that was all he could say, maybe they called him 'tan' since he was leborn. |
| Leborgne / Tan could comprehend. His reasoning was fine. Tan could produce no meaningful speech though, except for the word 'tan.' He was also getting progressively worse... | Tan was in the hospital with Gangrene and Broca visited him... when Tan died, Broca autopsied his brain and discovered Broca's area - an area of special articulated language function in LEFT FRONTAL LOBE. Discovered term aphemia (aphasia) |
| Why might Broca not have known that the brain is actually way more interconnected and that language isn't wholly encased in Broca's area? | Because when he did the brain autopsy, he didn't look at slices, just looked at the whole thing. |
| Then there was this guy named Lelong in 1861 who had a sudden loss of speech after a probably stroke. He had good comprehension at bedside testing but couldnt produce more than a few words and a few numbers... He died and Broca sat in on autopsy again: | Whole brain, no slices again, but strengthened his hypothesese: 1) left hemi is dominant for language 2) language function is in the frontal lobe. |
| Today, we know more than Broca did about language function and where it occurs in the brain. | language is indeed lateralized to the left hemi, but only in 97% of right handed people. The RIGHT hemisphere controls language in 19% of people who are LEFT handed. The rest of the people? Well, they are either left hemisphere dominant, or bi-dominant |
| Today we also know that language is not solely localized in the frontal lobe, and that other brain lesions sites could result in Broca-like symptoms. | Broca's area is still implicated as being involved in language processing, but someone named Signoret performed CD scans on the old LeBorgne's brain and found the lesion was more extensive (remember, Broca didn't do slices.) |
| Wernicke discovered a new language problem - one where the pts didn't even realize they were having a problem at all. It was the beginning of connectionist school... | There were two case studies where the pts showed Marked deficits in comprehension, speech sounds were normal, speech didn't convey much information, speech contained word substitutions, and the pt didn't realize it. |
| Postmortem autopsies of the Wernicke cases indicated that there was an infarction in the POSTERIOR SUPERIOR TEMPORAL GYRUS... that is RIGHT NEXT TO THE PRIMARY AUDITORY CORTEX... | Became known as Wernicke's Area. Wernicke believe that destruction of auditory language processing was responsible for erroneous speech output and the pt being unaware of their errors. |
| Wernicke postulated that more than one area in the brain was responsible or language, that there were actually multiple areas, and infarctions in diff areas result in diff types of aphasia. He also thought about Conduction Aphasia which is: | the fact that there are connections between language centers in the brain and that this is vital for information processing. He came up with the concept of Conduction Aphasia. |
| Remember that thing called the Arcuate (Superior Longitudinal) Fasciculous? | It connects the frontal lobe to the parietal, occipital and temporal lobes... |
| Wernicke and Lichtheim laid out the Wernicke-Lichtheim model of language centers. It is this cool map looking thing that STILL serves as the basis of traditional aphasia classification. | It looks like a HOUSE. It predicts the possibility of conduction aphasia too. |
| Jules Dejerine Localization of FUNCTION | Jules Dejerine came up with the idea of the Language Zone. It's like the whole interconnected language areas of the brain. |
| Dejerine, the father of Function (localization of function that is) said that any lesion in this region has some impact on multiple langauge modalities: | Perisylvian Region - the Language Zone - Dejerine - any lesion here could have multiple language impact, but some particular channel might be more greatly impacted. |
| Dejerine also was responsible for the concepts of Alexia with Agraphia and Alexia withOUT Agraphia. | He reported Reading and Writing difficulties after a stroke. |
| Dejerine: Alexia with Agraphia | Inability to read, Inability to write, but spoken language is just fine. |
| Dejerine: Alexia withOUT Agraphia | Can't read, spoken language is fine, but CANNOT READ WHAT THEY JUST WROTE. Could write spontaneously and to dictation, but couldn't read it afterward. |
| If person can't read, and can't write, but their spoken language is just fine, what do you call this and what part of the brain might be implicated? | Alexia with Agraphia. Part of the brain that is the Gateway for Graphic Material is the Angular Gyrus and the white matter above it. (Think 'Angles' and Drawing.) |
| If the person can't read but CAN write but CANNOT READ what they JUST WROTE, this is called what? | If someone cannot read, speaks just fine, and can write from dictation or spontaneously but then CANNOT READ what they JUST WROTE, that is called Alexia withOUT Agraphia. |
| Alexia withOUT Agraphia brain damage is WHERE? | Alexia withOUT Agraphia is from damage in the Left Occipital Cortex (vision) the splenium of the corpus callosum (pathway) and info from the right hemi can't cross to the left to get to the angular gyrus which is above Wernickes' Area. |
| Angular Gyrus is thought to be the Gateway for what? | Gateway to the Language System for Graphic Material is the Angular Gyrus. |
| Geshwind = Modern Connectionism | Reintroduced the Wernicke-Lichtheim model - very interested in disruption of transmission of information btw motor and sensory (Conduction Aphasia) introduced the terms Fluent and Disfluent (non-fluent) |
| Broca's Area - gross localization language info? | articulatory form of words. |
| Wernicke's Area - gross localization language info? | Auditory form of words. |
| Angular Gyrus - gross localization language info? | Graphemic form of words. |
| Pierre Marie - | Global Model |
| Pierre Marie's Global Model of Aphasia? | Non-fluent aphasia is really MOTOR, is really DYSARTHRIA. Viewed Wernicke's Aphasia as an intellectual disorder ('lame' in thinking.) Viewed Wernicke's Area as only true Linguistic/Cognitive Area. 'There is only one basic aphasia.' |
| Peach's definition of Aphasia | general impairment affects all language activities to varying degrees / impairment in REAL TIME processes access versus loss / involves information processing in attention memory linguistic and executive levels of cognitive system for processing language. |
| Aphasia is acquired, relates to language (phonology, morphology, lexical/semantical, syntax, pragmatics) and a cognitive deficit could also be present. | Aphasia is a disturbance in processing of language symbols resulting from brain damage. It is acquired, occurs after language has been acquired, affects language (NOT SPEECH) prob an access problem, some cognitive impairment disruption relevant to damage |
| What are the PRIMARY NEUROLOGICAL CAUSES OF APHASIA? | Stroke or Tumor |
| What kinds of Strokes cause Aphasia? | A stroke is a CVA - a Cardiovascular Accident. There are two types of strokes: Ischemic and Hemorrahagic. |
| What are the two types of stroke that can cause Aphasia (they are both CVAs) | Ischemic and Hemorrhagic |
| Ischemic Strokes - tell me everything you know about them... | Ischemic Strokes: Brain tissue death due to blood supply deprivation Accounts for 80% of strokes! Thrombotic / Embolic / TIA |
| What is a Thrombotic Ischemic Stroke? | A Thrombotic Ischemic Stroke is caused by occlusion of an artery by the formation of artherosclerotic plaque on the arterial wall due to the accumulation of fibrous materials and lipids. SOMETIMES a Throbotic Ischemic Stroke can be PRECEEDED by a TIA. |
| What is an Embolic Ischemic Stroke? | An Embolic Ischemic Stroke is when a fragment of material from the occlusion of an artery breaks free (an emboli)and travels through the arterial system and then gets lodged somewhere. It causes a sudden blockage of an artery. |
| What is a Transient Ischemic Attack? | Temporary occlusion of blood vessel Deficits persist for only a few minutes to hours Followed by a complete recovery (questionable…) – Often caused by minute emboli which become broken down |
| What are the General Effects of an Ischemic Stroke? | During first hours and days, symptoms generated by diffuse impairments and focal impairments are caused by death of tissue at the site of stroke. Once spontaneous physiologic repairs take place, diffuse symptoms subside and focal symptoms remain. |
| Remaining focal symptoms after spontaneous physiologic repairs equate with what? | Permanent damage due to permanent loss of neurons in the infarcted area. |
| What causes diffuse impairments after a stroke? | Diffuse impairments result from swelling of brain tissue, increased intracranial pressure, release of neurotransmitters, transneural degeneration and diaschisis |
| Hemorrhagic Strokes are caused by what? | Hemorrhagic Strokes are caused by rupture of a cerebral blood vessel. They are 40% fatal. The are extracerebral. The rupture occurs in the blood vessels of the meninges or on the surface of the brain. Subarachnoid, subdural, epidural... |
| Subarachnoid Hemorrhages often are caused by what? | Aneurysms or arteriovenous malformations (AVMs) |
| What is an AVM? | An AVM could be a cause of a subarachnoid hemorrhagic stroke because they are abnormal coupling of the arterial and venous system, a congenital malformation that can cause a hemorrhage to occur. |
| Hemorrhagic Strokes COULD ALSO BE INTRAcerebral | not just EXTRAcerebral |
| An INTRAcerebral hemorrhagic stroke is when there is a rupture... | Intracerebral hemorrhagic stroke is when there is a rupture within the brain or brainstem, usually occurs with pts with hypertension and most are NOT surgically repairable. |
| What is the Recovery Pattern for Strokes? | Depends on the Type of stroke and the amount/location of brain tissue destroyed. |
| Ischemic stroke patients tend to recover early post-stroke, while hemmorhagic stroke pts tend to show recovery 4 - 8 weeks post onset. | Hemorrhagic stroke pts tend to show better recovery than ischemic stroke pts if their initial deficit was comparable. |
| What are the warning signs of stroke? | sudden weakness or numbness of the face, arm, leg on one side sudden dimness or loss of vision particularly in one eye loss or difficulty speaking or comprehending sudden severe headache with no apparent cause sudden difficulty swallowing |
| Prevention of stroke relates to lifestyle changes! | Control blood pressure Stop smoking Exercise regularly Eat a healthy diet Control diabetes |
| Medical Interventions - Prevention of Stroke | taking antiplatlet agents such as aspirin as recommended by dr. taking anticoagulants (blood thinners such as warfarin)if the pt has an atrial fibrillation Carotid endarterectomy if have carotid artery disease |
| Ischemic Stroke pts recover 'early' past stroke but timing is individualized. | Hemorrhagic Stroke pts tend to 'start' to show recovery 4 - 8 WEEKS post onset. |
| Why do hemorrhagic stroke patients take longer for them to start to show recovery, why 4 - 8 WEEKS later???? | Hemorrhagic stroke has a greater impact on brain tissue - brains don't like blood. There is bleeding in the brain, blood goes where it shouldn't go, there is swelling, there is debris, they need surgery, that causes more swelling... |
| Why if Hemorrhagic strokes are so traumatic both in the blood everywhere and the swelling caused by blood and by surgery and the 40% change of death so these patient have better recovery? | Because when a hemorrhagic pt has the blood, debris and swelling diminished, there may be actually less brain tissue damaged and therefore a better overall recovery closer to prior level of function, this if initial deficit was comparable. |
| What does it mean to say 'if initial deficit was comparable?' | meaning that after assessing with assessment tools that the scores for two pts with 2 diff stroke types (ischemic and hemorrhagic) were comparable. |
| Why might a Hemorrhagic Stroke pt recover more fully than an Ischemic Stroke pt? | An Ischemic Stroke pt may have hypothetically lost more brain tissue through blood deprivation to a larger area of brain tissue - the tissue didn't get any blood/oxygen/nutrients arriving at ALL. After diffuse symptoms abate, signif damage may remain. |
| In a Hemorrhagic Stroke, there may be less overall loss of brain tissue, less tissue may have actually died - provided the patient survives. There may have been more trauma with blood, swelling surgery, but less tissue death. | Hemorrhagic Stroke often occurs as the result of hypertension and patients are put on meds to combat this; sadly the meds often cause physiologic changes to arterial walls and make them more brittle and more susceptible to burst in subsequent strokes. |
| Spontaneous recovery is recovery that happens of its own accord. When a pt's brain starts to recover on it's own, that is spontaneous recovery. | Life was preserved, no rehab, no treatment, just spontaneous recovery from their weak state as a result of physiological repair process. Swelling abates. |
| Hypotheses about restoration of brain functions from spontaneous recovery after a stroke? | Hypothetically, the brain function if it restores may relate to nearby areas of the brain with similar function 'taking over' or possibly the contralateral brain hemisphere taking over some functions from the damaged area. |
| Pts look 'completely out of it' when in diffuse symptom state. During this time they may diminished response flexibility. What does that mean? | Diminished response flexibility is when they may have a hard time switching from one type of response to another. Some assessment tasks may have pt. respond, other tasks they may point, etc. If pt has difficulty do more practice example for understanding |
| If diminished response flexibility in diffuse state post stroke, do more practice examples to ensure pt understand before doing assessment | Use a lot of practice as they are not as mentally 'flexible.' |
| What is meant by a 'subjective report?' | Subjective report is simply the answers to 'Why are you here?' 'What can we help you with today?' |
| Must know about Stoke Recovery and also | Stroke Prevention |
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