Severe Wernickes Aphasia: Using Augmented Input Strategies to Improve Communication 8 8 8 8

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Severe Wernickes AphasiaUsing Augmented Input
Strategies to Improve Communication 8 8 8
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• Kathryn Garrett PhD?CCC-SLP
• Duquesne University, Pittsburgh, PA /
• Private Practice
• Ruth Mason Richman MS CCC-SLP
• Newton-Wellesley Hospital, Newton, MA

ASHA 2007 -- BOSTON 1 hour Seminar
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What is Wernickes aphasia?

• A fluent aphasia according to Geschwinds
  classification system
• A posterior aphasia syndrome caused by lesions to
  the superior temporal gyrus according to the
  Boston classification system
• A syndrome of aphasia that impacts the phonologic
  and semantic system and results in
• significantly reduced language comprehension
• reduced ability to produce intelligible speech
• Paraphasias and jargon
• NOT apraxia of speech

Courtesy Natl Aphasia Association
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Traditional neuroanatomic correlates of
Wernickes aphasia syndrome
Gray matter (cortical) frequent white matter
(subcortical) involvement
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Possible Etiologies

• Middle cerebral artery (posterior branches)
  thrombotic or embolic events
• Internal or common carotid artery occlusions
• Anterior branches of the posterior cerebral
  artery
• Anoxic events leading to infarcts in the
  watershed areas -- ends of the arterial
  distribution zones
• Tumors, abscesses
• Focal TBIs

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Facts about Wernickes aphasia syndrome

• Represent approximately 13 of all patients with
  aphasia (Brust et al., 1976 Wade et al., 1986)
• Older than average - compared with general
  population of stroke patients (Damasio, 1988
  Obler, 1978)
• physiologic basis for this phenomenon is not
  known
• Perform very poorly on standardized tests if
  willing to participate secondary to
• Linguistic Deficits
• Behavioral Rigidity
• Why are you doing this to me? I dont understand
  what you want from me! OR
• Impulsive responding
• Egocentric focus
• Clinician Are the lights on in this room
• Client Well, we always turn them on dont
  we?

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Expressive characteristics

• Unintelligible gibberish
• Jargon, paraphasias, and neologisms -- a random
  soup of sounds
• Perception of another language being spoken
• Grammatic utterances (subjects are identifiable,
  actions can be deduced)
• Phonological encoding breakdowns - jargon
• Lexical mapping difficulties - semantic
  paraphasias
• Occurs during generative speech and repetition
• Press of speech/logorrhea/uninhibited output
• Preserved intonation suggests ideation and
  communicative intent exist despite bizarreness of
  speech production

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Behavioral manifestations

• Limited insight into the cause of expressive
  communication breakdowns
• May demonstrate frustration when others do not
  understand
• May give up when encountering communication
  breakdowns (Marshall, 2001)
• And not persist, ask for clarification, or
  attempt to convey the message through other
  methods
• May retreat and seldom initiate (Marshall, 2001)

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Comprehension difficulties

• Wide range of impairment severity
• Pure word deafness intermittent
  comprehension
• Phonologic decoding problems
• Semantic decoding problems
• Auditory processing (nonlinguisic) problems also
  can interfere with successful comprehension
  (Brookshire, 1987)
• Initial attending and focus (slow rise time)
• Information capacity or memory
• Noise buildup / internal perseveration
• Intermittent imperceptions

Video Illustration MM Baseline
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Auditory information is transient

• Cannot be processed quickly or efficiently enough
  for meaning to be mapped onto the
  acoustic/phonologic signal
• People with Wernickes aphasia often miss
• general ideas and topics
• specific details
• nuances
• lost in a fog of sounds, words, and references
  that mean nothing

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Writing mirrors speech output
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Compounding the problem

• Cognition
• Confused and disoriented
• Externalize the problem (Why are you asking me
  this?)
• General lack of awareness regarding extent and
  impact of comprehension impairment
• At times seems to go beyond challenges attributed
  to comprehension deficit alone
• May need to see this speech written down to
  understand that their output is unintelligible to
  others
• Have difficulty thinking strategically to use
  other communication strategies

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Impairments often lead to

• Frustration
• Dependence on others to direct their daily
  schedule
• No viable means of communicating basic needs
• No means of engaging in social interaction
• Family frustration and sadness
• Misdiagnoses
• Inappropriate discharge plans or shortened
  rehabilitation stays

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Surprises -- competencies revealed in meaningful
contexts

• Intermittent, meaningful verbal output in some
  conversations
• E.g., It was a a furrilous time. The boys ser
  pin to them reference to Steelers football
  victory
• But never on demand
• Say football
• no response or darsimee

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• Intermittent, functional auditory comprehension
• Clinician Here, why dont I get you your
  coatit looks like youll need it out there
  today.
• Client No no, no problemwalks over to coat
  rack and retrieves jacket
• But never on demand
• Clinician Point to the coat rack
• no response

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The Clinical Problem

• Therapy is often difficult to implement
• Success is difficult to achieve
• Stimulation/repetition approaches are typically
  unsuccessful at improving speech intelligibility
• No direct methods to effect change
• Poor comprehension and limited awareness result
  in
• Inability to benefit from feedback or
  instructions
• Lack of forward movement within therapeutic
  process

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A clinical wish list

• Interrupt the cycle of unsuccessful communication
  as quickly as possible
• Find a modality through which the individual can
  receive some meaningful input and make sense out
  of his/her world
• Identify predictable contextual routines within
  which the individual can begin to express and
  comprehend successfully
• Demonstrate success before an untimely discharge
  from therapy occurs

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SLP treatment for Wernickes aphasia

• Significantly less attention in the medical and
  SLP literature than for anterior or anomic
  aphasia syndromes
• Seminar focus - management of auditory
  comprehension deficits
• Impairment-based approaches to remediate
  auditory comprehension deficits appear to be the
  most commonly employed in adult therapy settings
• Stimulation therapy
• Presentation of increasingly difficulty auditory
  tasks and stimuli (e.g., commands, point to,
  discrimination tasks) with
• Repeated trials
• Feedback
• Hierarchy of cues
• Marshalls Controlled Auditory Stimulation
  Program (Lexicon Press)

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Partner-supported strategies

• Kagan, 1998 -- Supported Conversation
• Implies that the focus of remediation extends
  beyond the communicator
• Includes partners and environmental contexts
• Strategies implemented by partners in real-life
  contexts aim to minimize or bypass the disability
  versus fix the impairment
• Communication Ramp
• Goal better communication and increased
  participation in relevant life activities

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Augmented Input

• Developed by Garrett Beukelman (1992, 1998) and
  Garrett Lasker (2005) to improve the
  conversational comprehension of adults with
  aphasia
• Definition Any visual-verbal strategy, employed
  by the communication partner, that increases the
  message comprehension of the communicator with
  aphasia

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Partner provides

• Written key words
• Gestures
• Referential pointing
• Individual symbolic gestures
• Pantomime
• Referential graphics
• Maps
• Pictures
• Objects

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Partner presents graphic support in real time

• Writes or draws while communicating key concepts
  to denote
• topics and topic changes
• key ideas
• questions and response choices
• References text (point) to match auditory with
  visual input
• Clinician Did you hear about the new mayor?
• Client nonverbally conveys limited
  comprehension
• Clinician So, the new mayor point to written
  key word mayor after it is written is that
  youngster Luke point to printed name, then
  write 28 y.o.. Right?
• Client Yeah
• Clinician Its hard to believe isnt it?
• Client Well, you know, that...right there,
  serty-tar points to 28 y.o.
• Clinician Yes, thats pretty young to run the
  city, isnt it!

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The partner should also

• Stop periodically to check comprehension
• Are you with me? Did you get that?
• What do you think? Is that right?
• Yes or no?

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Bonus - more intelligible spoken language may
occur

• Encourage expression of key word targets but
  dont force them
• May emerge later in the session
• Then, bring clients attention to his/her
  intelligible productions
• Clinician You said this word mayor - great! I
  understood it! point to previously written key
  word -- mayor
• Client Thats right I did..layer..mardi..
• Clinician Dont worry about ityoull say
  mayor againwell talk about Mayor Luke next
  time points to written key words
• Client Mayor sukee, thats right, suke.

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Implementation - Augmented Input

• Teach partners to
• Observe communicator for receptive breakdowns
• Provide augmented input to resolve breakdowns as
  needed
• Intermittently (e.g., novel topics)
• Continuously (write while talking)
• Collect materials needed
• Notebooks and pens
• Referential items - scrapbooks, photos

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Theoretical Base

• Sevcik et al. (1991) -- partners real-time
  reference to graphic symbols can increase the
  comprehension, orientation, functional
  understanding and participation of individuals
  with severe intellectual disabilities in
  meaningful daily activities
• Symbols are selected based on the partners
  judgment regarding the communicators current
  referential interest
• Static visual symbols vs. transient auditory
  symbols
• PECS, schedule boxes, commenting boards, story
  boards, on-line drawings and gestures
• More fundamental level of meaning is conveyed in
  pictorial symbols than in auditory-verbal words

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Case Illustration Demographics

• Personal History
• 86 year-old retired mechanical engineer
• 3 years post onset at time of our intervention
• Married with 2 adult children
• Lives with wife at home (condominium)

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Participation Assessment

• Pre-stroke levels of activity
• World traveler
• Member of multiple social clubs and organizations
• Extensive circle of friends (though diminishing
  in recent years due to deaths of friends)
• Enjoyed conversing, storytelling, debating
• Frequent phone conversations with friends, family
• Life of the party

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The Stroke

• Medical History
• Ischemic left CVA at age 83 (November, 2003)
• Left frontotemporalparietal insula basal
  ganglia CVA with concomitant atrial fibrillation
  
• Respiratory distress and intubation
• Severe dysphagia/G-tube (4 mos)
• Initial diagnosis -- Global aphasia
• Confused and minimally responsive -- 1st month

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Therapy History

• Acute inpatient rehab
• 1 week then DCs to
• Subacute inpatient rehab
• December 2003 -- February 2004
• Home health therapy for 2 months
• February 2004 -- April 2004
• Outpatient at a Rehab facility
• May 2004 -- July 2004
• Compensatory tx focus to enhance expression
• Gestures, drawing, pointing, picture recognition
• Copying, matching names to pictures
• Functional game-playing
• Limited success with regard to reestablishing
  functional communication negative prognosis for
  return of functional speech
• DCd secondary to poor prognosis for return of
  functional speech
• Referred to Duquesne aphasia therapy group

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Participation Assessment

• Post-stroke / Before Augmented Input
• Had not traveled since his stroke at time of
  intervention
• Limited social interaction despite residence in
  same community and condominium
• Some participation in a social group for men with
  cognitive impairments
• Restaurant and library outings with his wife
• Participated minimally in phone conversations
• Watched a lot of T.V.
• Frequent communication difficulties and arguments
  with his wife (primary caretaker and
  communication partner)
• Also retreated and did not persevere to
  understand or convey a message

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Results of Formal Assessment

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Cognitive Task - Trailmaking (CLQT)
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Spontaneous Speech

• How are you today? unintelligible
• What is your name? FFirs
• What was your job? OK. There unint
  well way back unintell
• Tell mepicnic picture pointed to
  items fence and then this
  part
• PLUS
• Phonemic paraphasiasperseverative jargon

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Spontaneous Writing Sample
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Structured Writing/Drawing Sample --Favorite
Vacation
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Visual Scanning Task

• No field cuts
• Sustained concentration
• Overall fair-good comprehension of task given
  initial model/cues
• 0 omissions (100)
• 5 additions (38 additions)
• http//aac.unl.edu

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Phase I Intervention -- Outpatient Clinic

• Types of Therapy
• Individual Therapy -- 2 semesters (1X weekly)
• Introduction to augmented input
• Inhibition and conscious control of perseverative
  or jargon (nonfunctional) output
• Helm-Estabrooks Albert stop strategy
• Oral reading approach (Cherney, et al)
• Phrase-picture matching
• Yes-no response training (tagged yes-no
  technique Garrett Lasker, 2005)
• Group therapy -- Scaffolded Disourse Model
  (Garrett Ellis, 1998 Garrett, Staltari Moir,
  2006)
• Props, supported conversation, and thematically
  relevant activities

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Phase I Intervention -- Outpatient
ClinicJanuary, 2005

• Therapy Strategies
• Augmented Input
• Continuous written key word input generated by
  partner to supplement spoken output
• Additional partner gestures and use of graphic
  materials
• Referential (pointing - to speaker, to referent)
• Symbolic gestures
• Pantomime
• Pocket Talker portable personal amplifier
• Used during group for approximately 3 semesters
• Recently rejected
• appeared to have triggered ongoing engagement and
  attention to spoken output of others
• Photo Album - topic setter
• Introduced 3 years post onset (Summer, 2007)
• Currently used during group reminiscing or
  conversational activities only opportunities

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Examples of augmented input to enhance MMs
comprehension

• Topic -- explaining wifes unexpected heart
  surgery and related events

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Examples of augmented input to enhance MMs
comprehension

• Topic -- daughter-in-law suggesting a lunch
  location

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Clinical Outcomes -- Phase I

• Immediate acceptance of augmented input
• Frequent pointing to tablet to request input from
  partner
• General impression of more intelligible, on-topic
  verbal speech that corresponded (somewhat) with
  printed key words
• Could also point to written word choices to
  answer specific wh-questions
• Increased attempts to draw some concepts (though
  not a primary strategy)
• Better shifting of attention to speakers in group
• Became a true participant in group activities
• Began to pantomime and gesture to add information
• Limited his perseverative jargon output in
  response to Stop cues
• In general, Manny understood that he needed to
• Convey meaning as understandably as possible
• Follow what others have said

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Home Outcomes -- Phase I

• Encouraged Mannys spouse to implement the
  strategy at home
• Sylvia expressed an interest
• Technique was modeled
• Formal instruction delivered on multiple
  occasions
• Coaching and practice - multiple occasions
• Initial Outcome
• Commented on immediate and beneficial effect on
  participation
• But voiced confusion regarding its purpose
  (wanted him to say the words)
• Intrapersonal barrier (Acceptance?)
• Did not buy tablets
• Said she did not use the technique at home
• he understands pretty well
• I had him try to copy some words

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But

• What good is a clinical, partner-dependent
  strategy if real-life partners dont use it?
• Therapy has done no lasting good

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Phase 2 Intervention The End Run 1 year later

• Mannys Spouse -- Medical Emergency
• Family (dau, dau-in-law) in town for an extended
  stay
• Frequent observations of group therapy
• Immediate acceptance of strategies
• Made requests to implement strategy at home
• Ganging up
• Bought 5 tablets and pens
• Placed them in all rooms of Mannys residence
  while spouse was in the hospital
• Upon her discharge to home, daughters used
  strategy at every opportunity to model it
• Encouraged spouse to implement augmented input
  and gave her feedback

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3 Video Clips from interview

• 1. KG modeling Augmented Input
• Topic -- resuming their winter visits to Florida
• Swimming suits
• 2. Interview with Daughter
• 3. On with life!

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Behavioral Changes

• Increased orientation
• Increased on topic verbal and gestural comments
• Increased verbal intelligibility
• Increased ability to shift attention across
  multiple speakers (especially in group)
• Increased ability to indicate comprehension level
  and conceptual focus by referencing (pointing) to
  key words written by partners
• Less frustration about communication
• Sylvia has decreased her attempts to have Manny
  repeat words
• More satisfying and communicative phone calls
• Manny is happier (except for boredom)

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Conclusions

• Augmented input, when implemented habitually and
  strategically by trained conversational partners,
  changed Mannys ability to participate
• in daily communication with spouse/family members
• in aphasia therapy/interactions with other peers
  with aphasia

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Future research

• Identify a means of measuring message
  comprehension in response to augmented input
  before conducting systematic research
• Indirect -- how do we know they understood?
• Perceptual ratings
• Quantify nonverbal behaviors
• Compare participation, communicative success, and
  changes in comprehension with and without
  augmented input
• Across severity levels
• Types of partners
• Types of settings
• Measure factors affecting implementation among
  communication partners
• Training type and intensity
• Attitudinal - Is augmented input a style or a
  technique that can be learned by all?

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Final Thoughts

• Easy to implement (at a technical level)
• Materials Notebooks, whiteboards, markers,
  calendars, maps, natural gestures
• Can be implemented with acute patients and
  outpatients
• Can be taught quickly to partners (although may
  take longer to habituate)
• Augmented Input complements other contextual
  strategies
• Contextual group or individual therapy
• Picture Symbol strategies (e.g., topic setters)
• Response Elaboration Therapy (Kearns, et al)
• Thought-centered Therapy (Wepman)

Assists in meeting Marshalls (2001) challenge of
reestablishing a successful communication
connection as quickly as possible
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Selected References

• Brust, JCM, Shafer, SQ, Richter, RW, Bruun, B
  (1976). Aphasia in acute stroke. Stroke, 7,
  167-174.
• Damasio H, Tranel D, Spradling S, Alliger R.
  (1988). Aphasia in men and women. in Galaburda A
  (ed), Neurons to Reading. Cambridge, Mass, MIT
  Press, pp 1-20.
• Dronkers, N. F., Wilkins, D. P., Van Valin, R.
  D., Redfern, B. B., Jaeger, J.J. (2004).
  Lesion analysis of the brain areas involved in
  language comprehension. Cognition, 92(1-2),
  145-177.
• Eslinger PJ, Damasio AR Age and type of aphasia
  in patients with stroke. (1981). Neurol Neurosurg
  Psychiatry 44, 377-381.
• Garrett, K., Lasker, J. (2005) Adults with
  severe aphasia. In D. Beukelman P. Mirenda
  (Eds.) Augmentative communication Management of
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  adults, 3rd edition (pp. 467-504). Baltimore
  Brookes Publishing Co.
• Garrett, K., Ellis, G. (1999) Group
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  aphasia Scaffolded thematic discourse
  activities. In Elman, R. (Ed.), Group treatment
  of neurogenic communication disorders The expert
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• Kagan, A. (1998). Supported conversation for
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• Knepper, L.E., Biller, J., Tranel, D., Adams,
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• Lasker, J., Garrett, K., Fox, L. (2007)
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• Marshall, R. (2001) Management of Wernickes
  aphasia A context-based approach. (Chapter 18)
  In R. Chapey (Ed.), Language Intervention
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• Obler LK, Martin AL, Goodglass H, Benson F.
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