1. HELP! Is it Aphasia, Apraxia, Dysarthria or ALL of the Above??!!
Jamie L. Johnson, MA L/CCC-SLP
University of Kansas Hospital
September 24, 2015

2. During this session, participants will actively participate in discussing:
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.

3. Aphasia
National Aphasia Association

4. Aphasia Evidence Map

5. Standardized Evaluations
Purpose:
Assess 4 modalities
Classification
Prognostic statement
Treatment

6. Fluency Non-fluent 0-5 words Borderline fluent 6-8 words

7. 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?”

8. Standardized Evaluations
Classification
WAB
BDAE
Non-classification
MTDDA
PICA
Functional Assessment of Communication Skills for Adults (ASHA FACS)
CADL
Communication Effectiveness Index (CETI)-caregiver

9. Screening Tests Frenchay Aphasia Screening Test (FAST)
Ullevaal Aphasia Test (UAST)

10. Others:
ADP
Boston Naming Test

11. SETTING DEPENDENT ACUTE INPATIENT REHAB OUTPATIENT SNF LTACH
HOME HEALTH

12. Standardized Evaluations
What do you use??

13. HOW ABOUT YOU Do you determine the type or classification of aphasia?

14. 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 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 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
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

19. GLOBAL APHASIA VERBAL EXPRESSION COMPREHENSION REPETITION WRITING
NON-FLUENT
Severely Impaired
*Automatic speech may be preserved
COMPREHENSION
REPETITION
Impaired
WRITING
READING COMPREHENSION
LARGE LEFT DOMINANT LESION
Involving Broca’s and Wernicke’s areas

20. BROCA’S APHASIA VERBAL EXPRESSION: COMPREHENSION: REPETITION WRITING
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

21. TRANSCORTICAL MOTOR APHASIA
VERBAL EXPRESSION
NON-FLUENT
AUDITORY COMPREHENSION:
Intact
REPETITION
SIMILAR TO BROCA’S WITH ABILITY TO REPEAT
Anterior and Superior to Broca’s area
Watershed, borderzones

22. *MIXED NON-FLUENT
Resembles Broca’s but auditory comprehension below 50 percentile.
Auditory comprehension too good to be Global

23. WERNICKE’S APHASIA VERBAL EXPRESSION COMPREHENSION REPETITION
FLUENT
Jargon, non-sensical words, rapid rate
Retain sentences but lack meaning
May speak with no insight into errors
COMPREHENSION
poor
REPETITION
Temporo-parietal involving Wernicke’s area and adjacent white matter

24. CONDUCTION APHASIA VERBAL EXPRESSION COMPREHENISON REPETITION RARE
FLUENT
Word finding
Paraphasic errors
COMPREHENISON
Relatively intact
REPETITION
Poor
RARE
ARCUATE FASCICULUS AND LEFT PARIETAL

25. 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

26. *MIXED TRANSCORTICAL APHASIA
COMBINATION OF THE TWO TRANSCORTICAL APHASIAS
AUDITORY COMPREHENSION AND EXPRESSION SEVERELY IMPAIRED
REPETITION INTACT

27. ANOMIC APHASIA VERBAL EXPRESSION COMPREHENSION REPETITION MILD FORM
FLUENT
Word Finding problems
Circumlocutes
COMPREHENSION
Intact
USE OF NON-SPECIFIC WORDS SUCH AS “THING”
REPETITION
MILD FORM
+Awareness

28. CROSSED APHASIA LANGUAGE CENTER NO IN EXPECTED HEMISPHERE
EX. RIGHT-HANDED PERSON WITH R CVA WITH APHASIA

29. Reading and Writing
Alexia
Alexia with Agraphia
Agraphia

30. Paraphasias Neologism Perseveration Circumlocutions Literal/Phonemic
Verbal/Semantic
Neologism
Perseveration
Circumlocutions

31. SUBCORTICAL APHASIA THALAMUS INTERNAL CAPSULE BASAL GANGLIA
MIRROR CORTICAL LESION APHASIAS
CAN CO-OCCUR WITH CORTICAL APHASIAS

32. 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

33. INSULA
“The Role of the insula in Speech and Language Production” Oh, A. et al. Brain and Language 135 (2014) “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

34. MANY FACES OF APHASIA

36. Differential Diagnosis
Motor Speech Disorders:
Dysarthria
Weakness/paralysis, incoordination, rigidity, involuntary movement
Apraxia
Motor planning problem
Absence of weakness
Initiation, groping, revisions, inconsistent

40. 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

41. 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

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

44. G CODES Modifier Impairment NOMS
0% WNL 7
1-20% MIN 6
MILD 5
40-60% MILD-MOD 4
60-80% MODERATE 3
80-99% MOD-SEVERE 2
100% SEVERE 1

45. 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,
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

46. 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

47. 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.

48. NOMS
READING
WRITING

49. Education Family Training Staff Training Education materials Websites
Apps
Home Programs
Family/Caregiver’s role in Therapy in any setting

50. QUESTIONS???

51. REFERENCES
Davis, G. (2007) Aphasiology: Disorders and Clinical Practice. pages
Helm-Estabrooks, N. Albert, M.L., 1991, 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,