1. Test III Athena Hagerty
Aphasia Notes
Test III
Athena Hagerty

2. General Info about Treatment:
Working with Adults: you can tell them what they are doing and why. You can provide concrete feedback to your patient. Telling the person what they are doing a great job at. You can provide feedback for errors. “That wasn’t a good way to say that, tell me again”. Progress is its own reward. Instead of planning for kiddos, adults are happy for therapy, you don’t have to give them a sticker.

3. General Info about Treatment:
Planning for treatment- don’t take hours, do it easily and it’s cheap or free for therapy. Free newspapers from Dubois. Clinic has a laminator. Paper, pencil and you can do therapy

4. Generalization:
Loose training- you should consider stimulus items that elicit a variety of acceptable responses. 1 cup for multiple things 
Sequential modification- treat in different environments and diff. contexts.
Does Treatment Work?
Aphasia therapy work? YES. But It needs very good guidance from the clinician. Don’t do workbook stuff. If they don’t need you, they shouldn’t be in therapy. Computer programs are bad. Group therapy also WORKS. Evidence behind it. More support by other patients. Maintaining skills.

5. Goals of Aphasia Therapy
Empowering the patient- you teach them skills that they can use.
Communicative Competence- the person can communicate in ANY context. If you can do this with patient you are a successful SLP. 
Who receives treatment?- Initially everyone who has aphasia should receive treatment.
Prognosis- there are some people with really poor prognosis= severe Wernicke’s, severe global, after 3 months following injury. If nothing changes after 3 months that’s bad.
Communication Competence-the end goal is to get them to discourse production.

6. Group therapy- if its available, patient should participate.
Evaluation of cognition- you can evaluate cognition as the person improves IF the neruopsych is good at evaluation.
Neuropsych needs to be experienced.

7. Treatment of Auditory Comp.
Bottom up model- patient is analyzing sounds to make sense of info. Repeating plate over and over again to make sense of it.
Top down model- begins with an expectation about the the speaker will say. Either confirm or change the action depending on the production. Ex- you’re walking and see a friend hows it going? They say not so good, you keep walking, see you later… then go back and ask them what up.
Goal: the client will repeat a targeted word 3x with a verbal cue (clinician verbally repeats the words) with visual cue (client reads a target word) with 100%.

8. Treatment of Auditory Comp.
Knowledge based/heuristic process-
general knowledge and intuition to deduce meaning of spoken information.
what to expect when you are ordering at a restaurant.
Goal: the client will listen and watch waiter during his presentation and will order a
Goal: the client
General knowledge about the resturant with world knowledge…

9. Treatment of Auditory Comp.
Point to/ show me
Y/N questions
Wh- questions/tell me (simple or complex) what is your name? where are you? Does it snow in July? Do you use an axe to cut the grass?
Following Directions (1-3) can increase up to three steps. (WM component)
Sentence verification- person has to listen to sentence and tell if its true or false. Can make it difficult my adding fake words.
Treatment Targets for Auditory Comp: Point to Yes.No and Wh questions, Follow Direction for Sentence Verfication, Task Switching and Discourse Production.

10. Treatment of Auditory Comp.
Task switching activities-
Discourse comprehension – can they actually answer questions?
Familiar- if its familiar it will be easier.
Length & redundancy-

11. Goal Writing
Long term goal- 3 components to a goal- every supervisor requires these 3 things.
Performance=measure
Condition- type of cues you are using
Criteria –percentage or trials

12. Treatment of Auditory Comp.
Aud comp long term goal- will vary from facility to facility. Determine goal by hierarchy. End point to whatever facility your in. where we want to get the patient eventually.
ST Goals- small steps to get to the long term goal. Baby step to get to long term goal. Point to show me/ y/n
Biggest LT goal- to comprehend conversation. Ask questions during conversation and keep track of answers.
Ex- patient. Moderate aud comp deficits. Are long term goal would be for academic year. ST- semester. Complex y/n questions.
You can add use methods:
LTG: the client will use discourse production within 6 months. Or the client will use discourse production within 3 months.
what can the client achieve within 6 months or 3 months?
LTG: The client will comprehend conversation with 100% accuracy with visual (by clinician gesturing), with verbal (by clinician repeating the last sentence) with tacticle (by client tapping his leg when the conversation does not continue)
Auditory Comprehension Treatment Targets for Global Aphasia
STG:
Auditory

13. CUES Cues- extra help Verbal- explaining or repeating
Verbal- explaining or repeating
Phonemic- it’s a” K” for key.
Visual
Pointing
Gestures
Written
Tactile (touch)- holding their hand. Giving them something to feel or touch.
Visual cues:
Pointing:
Gestures
Written:
Tactile:
Drawing:
Verbal: explaining or repeating

14. Percentages Maximum moderate minimum assistance. –
Dr Isaki doesn’t like these terms. Doesn’t like 3 out of 4 trials. Likes percentages better.
Mild- 90% of time can do tasks.
Moderate-80% of time
Severe-70% of time
Try and shoot for 20% (increase) of time.
Global aphasia- 30% of time correct- yes you can get them to 50% of the time.
Normal is not 80% of the time. You can write a goal for 100% of time if you think you can do it. Because they were capable before the CVA.
If client hits goal 3 times, you then need to review to goals and revise them.

15. Goal for Auditory Comp.
GOAL for this client- client will answer complex yes/no question with 95% accuracy given verbal cues. In my methods verbal cues means repetition of questions.
Client will follow 3 step commands with 95% accuracy given visual cues. Visual cues may be pointing to item
Auditory Comprehension Treatment Targets for Aphasia requires assessment/evaluation information before selecting a target.
Point to/Show-1 step-point to the door
Goal: the client will point to familiar objects in field of 4 with 100% given visual and verbal cues
Goal: the client will point to unfamiliar objects in field of 4 with 100% accuracy given visual and verbal cues.
Goal: given a verbal model, the client will point to familiar/unfamiliar objects
Yes/No questions-is your name? orientation information
Goal: the client will answer 10 simple yes/no question about his family with 100% accuracy with verbal and visual cues.
Goal: the client will answer 10 simple yes/no questions about a read passage with 100% accuracy with verbal cues (verbally repeating the cues)
Goal: the client will answer 10 complex yes/no questions about his hobbies with 100% accuracy with verbal and visual cues.
Wh-question in conversations
Goal: the client will use wh-questions for auditory comprehension by asking wh-questions for clarifaction after reading a passage with 100% accuracy verbal cues.
Follow Directions-
Goal: the client will follow 1-3 step direction with 100% by performing the action given clinician verbal and visual cues.
Change the variables from 1 to 3 steps
Sentence Verifaction-client will listen to clinician statement and the client will say true or false.
Goal: the client will answer true or false with visual and verbal cues after given a clinician statement with fake words/length and complexity with 100% accuracy.
Goal: the client will answer true or false to 10 questions without verbal cues from the clinician after watching a 30-second video with 100% accuracy
Task-switching-use sentence verifaction and yes/no questions
Discourse comprehension-conversation (variable: familiarity, length)
Goal: during a familiar conversation about the client’s hobbies, the client will retell events about his hobbies for 3-5 minutes.
Goal: the client will answer 10-questions during a familiar 3-5 minute conversation with client and clinician with 100% accuracy.

16. Expressive language Treatment
Content Words (nouns more important for Global)
Enhance with nonverbal communication (can live w/out articles & adverbs)
Increase length & complexity- Sub, Verb, Obj
Picture Description- take a picture from the newspaper (Norman Rockwell pics)
Storytelling & retelling
Conversation- most difficult
If you improve anomia, you will improve expressive language
Expressive Treatment Targets require a Language Sample. Picture description/story retelling/ conversation can be prompt by type of pauses, filler, ineffective gestures, verbal cue will be “can you tell me more.”
Content words: Usually on a picture board, Picture board will have mostly Nouns.
Goal: the client will match a noun to a picture on his picture board given a verbal and visual model with 100% for all nouns on his picture board.
Goal: the client will use non-verbal communication for expressing their feeling/wants/needs given a verbal and visual cues with 100% accuracy
Goal: the client will use content words for expressive communication by matching a noun to a picture board given a verbal and visual model with 100% accuracy for all nouns on his communication board.
Increase Length and Complexity of Productions
Goal: the client will increase the length and complexity for expressive communication by add an action verb to a noun given a verbal model with verbal cues
Goal: the client will increase the length and complexity of syntax for expressive communication by add a content word to a action verb given a verbal cue with 100%
Picture description: Picture description plus statement “what is he doing?” For picture description, if the client is shown a picture, and you tell me what he is doing?
Goal: the client will describe a picture to increase expressive language by verbally describe objects and action in the picture given a verbal and visual cues.
Storytelling and retelling-clinician will find picture for the client. The client is shown a picture and ask to tell a story with a beginning middle and ending, if the client has difficulty, the clinician will explain how a story work and provide example of a story with beginning middle and ending. If more is needed, the clinician will draw or show pictures in a sequence.
Goal: the client will retell a story given a wordless picture book with 100% accuracy with visual and verbal cues.
5. Conversation-End goal
1. Goal: during conversation, the client will express his needs, wants, and feeling with 100% accuracy and no verbal cues to continue the conversation.
Special relationship: Anomic/Conduction aphasia, if you improve anomia, you will improve expressive language. Implies that we target anomia first before targeting expressive language.
Expressive Treatment Target for Global Aphasia
Goal: the client will use contents words by combining two content words to expressive want/needs/feeling
Expressive Treatment Target for Broca’s Aphasia-Patient can produce S-V-O-Adj.
Goal: the client will increase the length and complexity for expressive communication by adding additional verb to form S-V-V with given verbal models plus visual and verbal cues.

17. Reading Comprehension Tx. (deficits)
Reading glasses? Do they have glasses?
Surface Dyslexia? Lost direct lexical route and now dependent on phonological route. Ex- sound by sound or letter by letter.
Deep dyslexia- you have lost phonological route, now you’re dependent on whole word recognition.
First question to ask client: Do you use glasses to read? (e.g. patient must be able to see text)
Surface Dyslexia-because of CVA-the patient has lost direct lexical route and now dependent on phonological route
The patient will read letter by letter/sound by sound.
Goal: the patient will read out loud in unison with the clinician of written material in 1-5, 5-15, words in length with 100%
(e.g. boring teenager…try to decode each sound as they sound out…it does not work with all words)-used for low frequency words
Deep Dyslexia-Sight reading
The patient can not sound out the word, because the patient know words by sight-used for high frequency words
Goal: the patient will read out loud functional high frequency words in lengths of 1-30 in unison with the clinical from a given word list with 100% accuracy.

18. Reading Comprehension Tx. (deficits)
Letters- can they identify a letter?
Words to pics- matching words to pics
Phrase to pics
Sentence- written questions or matching to pics
Paragraph- written questions, 2 sentences, then 3, short stories
Survival Reading (6th grade level) menu, telephone book
Treatment Targets: reading comprehension verbal cue (meaning the clinician will repeat the letter, word, sentence to the client)
1. Letters. The Clinician will present letters to the patient.
1. Goal: the patient will identify letters from a letter sheet with verbal cues (meaning the clinician will repeat the letter to the client) with with visual cue (meaning the clinician will narrow the scope of letter to a field of 4) 100% accuracy
2. Words to pictures: the clinician will present a picture of objects and the client will match the word to the picture
1. Goal: the patient will match a written word to picture in field of 2/4 pictures with 100% accuracy (verbal cue meaning the clinician will repeat the word to the patient, visual cue meaning the clinician narrow the field of 4 to a field of 2, given a verbal model of each picture or given phonological or semantics cues
2. (example: dog, cat,elephant)
3. Phrase to pictures: the client will present a picture of object and the client will match a phrase to the picture
1. Goal; the patient will match a written phrase to a picture in a field of 4 given a verbal model of each picture plus semantic cues with % accuracy
4. Sentence-written questions vs. written sentences to pictures: The clinician will present two sentence (John went to the store. Who went to the store?), the patient will match a picture to the phrase.
1. Goal: the patient will match a written question to a picture in a field of 4 given a read passage by the clinician in length of words with 100% accuracy.
5. Paragraphs: the clinician will read a short paragraph and the client will match written questions, match 2 sentence, match 3 sentences to a picture
1. Goal: after reading a short paragraph, the patient will match a written question to a picture in a field of 4 with semantic cues from the pictures by the clinician with 100% accuracy.
If the client begins to fail at task, the clinician will need to back up…the functional communication approach is to read menus, advertisements, signs.
The patient may read out loud a passage and not understand…therefore, the word may be match to a picture and then give function for the key.
Write goals for Broca’s aphasia and Anomic aphasia:
Broca’s Aphasia is a type of expressive non-fluent aphasia characterized by word finding difficulty and articulation problems (poor word finding skills, poor articulation) with relatively good auditory comprehension and with telegraphic speech, abnormal prosodic, cooccuring with apraxia/dysarthria
Anomic Aphasia is a type of express fluent aphasia characterized by poor word finding skills with relatively good auditory comprehension

19. Anomic Tx. Anomia looks like… Pauses Fillers “uh, um” I don’t know
Ineffective gestures (waving during conversation)
Anomic aphasia is a type of expressive fluent aphasia characterized by word finding difficulty with relatively good comprehension and with pauses, fillers and ineffective gestures.
Broca’s Aphasia: After reading a phrase, the client will match a written phrase or written words to picture in a field of 4 with visual and verbal cues.
What are types of verbal cues? Can read out loud or silently (verbal cue meaning the clinician would give semantic descritpion, functional description of the object, visual cue meaning the clinician would demonstrate its functional use by gestures)
Issue: STG goals will be using the hierarchy. Functional goals like reading a menu, reading their credit card bills, phone bills be written as a long term goal.
LTG: the client will match
Anomic Aphasia: After reading a passage, the client will match a written question to pictures in a field of 4 with verbal and visual cues with 100% accuracy. (Goal is not good because anomic aphasia has more reading comprehension skills
Better Goal for Anomic Aphasia: After reading a paragraph, the client will answer 10 written questions verbally with verbal cues (good) .
Better Goal for Anomic Aphasia: After reading a paragraph, the client will underling answers to 5 written questions with verbal cues with 100%.
Anomic aphasia: the patient will take a long pause and difficulty for the clinician to interrupt
Clinician must know what natural speech looks like.

20. Anomic Tx. Suggestions for therapy
Naming (Rosenbek,Lapointe & Wertz) Choose at least 3 strategies
Semantic description- start describing its attributes, formulate descriptors to pull out. Cat= furry meow.
Embedding- (good for anomic aphasia) formulate your own sentence, embed the word within the sentence. Cup=”You use a _____ for drinking.”
Synonyms- works for high functioning
Antonyms- not every word has an antonym
Treatment Targets for Word Finding Difficulty: how are we going to reduce pause length, repetition of fillers, ineffective gestures.
Typically, a person in conversation will use semantic descriptors to help.
LTG: the client will use 3 or more compensatory strategies for word finding difficulties with 100%.
Semantic Descriptions: the client will formulate descriptors to pull out the word.
Goal: During a conversation, the client will give 3 semantic descriptors when having a word finding difficulties with 100% accuracy and
Goal: the client will give 3 or more semantic descriptors from a targeted word list with familiar and unfamiliar words with 100% accuracy with visual and verbal cues. (e.g. example: cat animal, cuddle)
Anomic aphasia is a type of expressive non-fluent aphasia characterized by word finding difficulties with relative good articulation and good auditory comprehension. Anomic aphasia can be high functioning…but they have long pauses repetition of fillers and ineffective gestures.
Embedding-formulate your own sentence, embed the word within the sentence. (internal strategy)
Goal: the client will formulate 10 sentences about the functional use of the 5 objects with 100% accuracy given a verbal cue
Goal: the client will formulate 1 sentence about the functional use of an object for 10 object with 100% accuracy given visual/verbal cues.
Goal: the client will use embedding strategies during a conversation when having word finding difficulties with 100% accuracy and (how do we measue internal strategies?)
Synonyms/Antonyms: Use for Anomic aphasia
Goal: the client will give 3 synonyms for a word with 100% accuracy with verbal cues.
Goal: the client will use synonym/antonym strategies during a conversation when having word finding difficulties with 100% accuracy.
Goal: During long pauses, repetition of filers, ineffective gestures, the client will use a synonym during a conversation with 100% accuracy.

21. Anomic Tx. Suggestions for therapy
Rhyming- “cat” “bat”- looking at things that rhyme to get word.
Sentence completion- high functioning= anomic, conduction. “You drink from a _____.”
Phonemic cues- weird strategy. Everyone around patient uses the prompt “You drink from a c____.”
Writing- if you can’t think of a word, can’t write it.
Gestures- depends on person’s vocab, for high functioning patient
Drawing- depends on person’s vocab, for high functioning patient
Treatment Targets: SESA RSP WGD, Auditory Point to Y/N/Wh Follow direction to SV, TS, Conversation, Reading Match letter, word, phrases, sentence, paragraph, functional reading. Anomia..SESA RSP WDG, Expressive, Content, Enhanced Non, Increase Length, Picture Description, Story Retelling, Discourse Production
Rhyming:
1. Goal: the client will give 3-5 rhyming words (internal strategies) for each targeted word with 100% with verbal cue (meaning clinician will give one of the rhyming word, “the target word (e.g. car) rhymes with this word (e.g. bar).
Sentence Completion
Goal: the client will complete 5 fill in the blanks about the semantic features/functional use of a targeted word with 100% accuracy given visual and verbal cues in 2-3 consecutive attempts (verbal cue meaning the clinician will read the fill in the blank statement to the client, visual cue if more than 1 sentence is on the paper, the clinician will highlight the sentence for the patient, visual cue will gesture the word.
Phonemic cues- only used in the clinic, people don’t use it.
Verbal cue (meaning 1. the clinician verbally provides a word that rhymes with the target word ‘it rhymes with …” 2. the clinician verbally provide a statement “it rhymes with ….and starts with /letter/….”
Verbal cue meaning 1. the clinician will ask “what is this?” 2. the clinician will give a verbal description of the object/action, 3. the clinician will create a fill in the blank statement 4. the clinician will provide the object name and ask the client to repeat it,
Visual cue meaning the clinician would write out the word or draw the object. In giving visual cues, the clinician will use dashes for the number of letters (e.g. _,_,_,) then increase visual cues by giving orthographic letters, until the words is spelled, or with picture description, the sentence what is he doing will be prompted with a picture and a written prompt, the sentence frame with written prompt and spoken prompt
Treatment Targets for people with anomic and conduction aphasia using other modalities sometimes work, but really you should other modalities for global aphasia
Do we create a mirror image of the session for the client with anomic aphasia?

22. Anomic Tx. Suggestions for therapy
Once you DO get word:
practice for a couple of trials (recommend 3).
Also practice at the end of session.
Do we create a mirror image of the session for the client with aphasia?
Answer: anomia is not consistent
Global Aphasia and Anomic Aphasia.
Global Aphasia is a type of expressive non-fluent aphasia characterized by word finding difficulties, articulation problems, and relatively poor auditory problems coccurring with linguistic and language problems, dysarthria and apraxia.
Anomia Treatment Target for Global aphasia:
Goal: the client will identify 1 synonym accurately given
Goal: the client will use gestures for word finding difficulties by showing the correct gestures verbal cues with 100%
Goal: the client will use drawing for word finding difficulties given hand-over-hand cues with 100% accuracy.
Goal: the client will use writing for word finding difficulties given a verbal reminder to use writing strategies with 100% accuracy.
Why can’t I describe the verbal/visual/tactile cues? Or do we generalize to just verbal/visual/tacticle cueing.
Goal: the client will use a communication book.
Anomic Aphasia is a type of expressive fluent aphasia characterized by word finding difficulties, but with relatively good auditory comprehension.
Anomia Treatment Target for Anomic Aphasia.
Goal: the client will complete 5 fill in the blank about semantic descriptor for a targeted word given a verbal cue.
Goal: the client will use semantic descriptors given verbal and visual cues.
Goal: the client will use sentence completion for word finding difficulty given visual/verbal cues with 100% accuracy
Issue: How do we teach strategies to client when they are anomic? Is this part of our goal? Do we need an outcome? So, if I am teaching the client how to use sentence completion or semantic description…I can write out how to do it? Clinician will teach strategies, and hopefully the client will use the strategy. We first teach the strategy and then we test in conversation. (e.g. during conversation, the client will use word finding strategies to resolve word finding difficulties)

23. Format (Brookshire)
Hello- (only 5 minutes) where you catch up with your patient. How was your week? Etc.
Accommodation- we are going to work on easier tasks first.
Work- where you concentrate on more difficult tasks.
Cool down- more easier tasks so they can feel good about their performance.
Goodbye- reviewing entire session and progress they were able to show. Summarize abilities

24. Resource Allocation
Central Pool- a way to think about how your therapy is affecting your client, analyze performance. Can pull out all sorts of language abilities and cognitive processes.
Depends on the demands of the task, you can pull out too many processes from the central pool. If this happens, the client will fail.
Reduce processes if client fails.
Environment can affect performance (noisy, busy, etc.) SIMPLIFY environment
Dr Isaki said to change rooms if the room you’re in is too noisy.

25. Resource Allocation CENTRAL POOL NAMING AUDITORY COMP ORGANIZATION
PROBLEM SOLVING

26. Goals of Aphasia Therapy
1) want patient to regain as much comm as possible as much as their injury allows and their needs drive them.
2) teach them to compensate for the skills that they lack.
3) teach them to be in harmony with their lives.

27. Preparing someone for lifetime of Aphasia
1) remember to give fair assessments of prognosis (don’t use word normal)
2) stress the importance of what remains. (everyone has skills)
3) Aphasia is a human disorder meaning it not only affects language, but a person’s life and relationship to others. Patients are unchanged at the core.

28. Preparing someone for lifetime of Aphasia
4. Never forget you are treating a PERSON w/ Aphasia. Try to resist being everything to the patient.
5. Learn to be a good listener. We’ll hear all types of info. We have boundaries in our profession, refer out as needed.
6. Have to trust our patients that they are going to survive and cope and life

29. Preparing someone for lifetime of Aphasia
7. We are going to be counseling for comm disorders (not depression). Teach them about Aphasia and words we use. National Aphasia Assoc. has great paperwork.
LISTENING IS IMPORTANT. Silence is OK. Wait for them to say something. Shouldn’t be weird. Listen to their family and friends and ask what concerns they have.

30. Preparing someone for lifetime of Aphasia
Rosenbeck states “that clinicians that are adequate, treat all people more or less equally. A superior clinicians finds out what each patient wants and needs and determines what is possible.

31. ADULTS Easiest population. Easiest prep time No stickers & crafts
Don’t need to applaud
Comm is its own reward
If you have superior clinician, will see amazing things in therapy.
Patient will try harder and they continue treatment.
Difficult for them to let you go.

32. ADULTS cont. You can point out errors and how to change those errors.
You have built this relationship on trust, support and respect.
It is acceptable to exploit a person’s strengths.
Prepare for generalization- client needs to be on their own. Take client out of therapy and let client do their own thing. Then go back in clinic and talk about it.

33. A good clinician….
Can adjust to changes- client will have good days and bad. We should be constantly thinking of hierarchy.
Recognizes when therapy isn’t doing very much
Laughter & crying is OK-sympathizing is OK.
Therapy has an ending. If patient plateaus, maybe it’s time to discharge them. You can say “ you can always come see me”.

34. Speech = motor- damage to PMC causes apraxia
Language= syntax semantics etc.

35. Speech Deficits
Apraxia- the disturbed ability to reproduce purposeful learned movement, despite intact mobility. NO weakness of the musculature.
Ideational Apraxia- the disruption of ideas needed to understand the use of objects. Ex- when we see key, we know how to use it.
Show them object and say “show me how to use it”.

36. Speech Deficits
Ideomotor Apraxia- requires motor movement. Types of ideomotor:
1) Buccofacial/nonverbal/oral apraxia- the inability to demonstrate volitional oral movements on command. Exercises on oral mech exam. If you have this apraxia, you’ll see struggle and searching behaviors.

37. Speech Deficits- type of ideomotor apraxia
2) Limb Apraxia- inability to demonstrate volitional movements of arm wrist and hand on command. Ex- wave goodbye (they have problems with that). Look for whether they can do movements closer to the body or further away. Assess: if you give them an object they can do movement, take away object, they can’t. Kind of like they can’t pretend.

38. Speech Deficits- type of ideomotor apraxia
3) Apraxia of speech- where patient has problems programming the position and sequence of speech musculature, for the production of volitional speech (Darley Def.)
Characteristics:
No weakness or paralysis or sensory loss
Automatic speech is easier than planned speech
Artic consistancies in/of errors. When they make errors it WILL be consistent.
Struggle and searching behavior.

39. Dysarthrias
Dysarthrias- weakness, paralysis, incoordination of the muscles, required for speech.
Descriptors: speech sounds slurred, unclear, imprecise.
Tx- make sure you have unfamiliar listeners come is to check client’s production because eventually you will understand them after a while.

40. Indirect and direct approach
General Suggestions: different approaches
1. Indirect approach-SLP is not working on any system specifically
1. Assisting the motor function (e.g. palatal lift, abdominal binders, surgery)
Palatal Lift are done by dentist, teach person how to use

41. Direct Approach
Direct approach (SLP will work on the area affected; phonation, intensity, breathe support)
Goal for the SLP: SLP will listen, determine what area needs to be remediated
See below
a. listen and determine what area needs to be remediated (e.g . SLP will provide exercises to specific areas where the client needs it the most) Implication is SLP will use drill exercises
(e.g. Direct approach can be useful for flaccid dysarthria. The SLP will over-articulate speech.)
b. Mantra, if you can’t model it, you can’t use it in therapy. (SLP will extragrate the movements of each word. Goal the SLP will hit their targets with each articulator but not loss the prosody and this is resolved by the SLP slowing the rate of speech…talking large and hit the sounds, but will sound good to the listener) Avoiding sounding telegraphic, monotone, slower speech rate.
d. Dysarthric patients should not slow rate of speech down because the sounds will become slurred! Goal for the SLP: the client will talk to the clinician and the clinician can identify which systems are impaired. If the client works on articulation and breathing, the client will become a “good” speaker

42. General Strategies The clinician and the client will:
a. Speak in a quiet environment implies that there is no competing noise.
b. Speak face to face implies visual cues
c. Teach client when to repeat, when to simplify and when to paraphrase.

43. Severe Apraxia or Aphasia
Severe Dysarthria/or Apraxia-consider an AAC if can’t understand the person a. communication board-picture board: picture of things that they need/feel/want b. communication book (e.g. C-book has section/or tabs like a food section, activity section and the patient turns to that page to express their needs/wants). The client will use his communication book to express his wants and needs. The client will point to a picutre c. electronic device (6 pictures to laptop to). The goal is for the client to produce S-V/S-V-0 sentences using his electronic device with 60%-100% with no cues.
Goal: The client will make 1-2 graphics symbol sentences using his communication board/book/electronic devices.
Goal: The client will match the correct graphic symbol to word in % accuracy given access to his communication board.
based on patient needs…Beside AAC use other modalities to communicate (writing, and drawing and gestures)

44. 5 factors for AAC List of AAC objects-Patient needs plus:
1. Cost of system-low functional-high functional ($1-$8000)
a. not everyone has good insurance
2. Amount of training to use device (e.g. client and clinician training)
a. SLP may needs hours of training before using the device, implement techniques
3. How does the system interfere with other activities? (e.g. person can not bring AAC to beach
4. Intelligibility of output (e.g. electronic voice on telephone)
a. women voice, hanging up on electronic devices
5. Acceptability of system (everyone needs to accept the fact there is a device and give the client time to use the AAC device

45. General Guidelines for Dysarthria
Treatment of Severely Impaired Apraxia of speech-motor programing
1. Poor prognosis for apraxia of speech –
a. one month with no volitional speech only stereo typical utterances
(e.g. stereotypical utterances- patient says wiki wiki wiki wiki and can not get anything out.)
b. after treatment for 1 month, the patient has not improved and every area for communication is severely impaired.
2. Poor prognosis-if patient has severe aphasia as well as severe apraxia-comorbidity..the type of aphasia associated with severe apraxia is global aphasia
Other Indication see below
Another indication for sever apraxia, the patient will have multiple types of apraxia Severe apraxia-any of the speech deficits (multi-type of apraxia includes speech and/or limb) characterized by:
0. Severe apraxia will have multiple apraxia
1. Severe apraxia will always have hemiplegic or hemipareies
2. Severe apraxia does not necessarily mean severe aphasia, a client with severe apraxia from severe to moderate aphasia.

46. Treatment for Severe Apraxia
1. AAC device
2. multi- modalities communication
3. Single functional words
4. The SLP will educated family about what is speech apraxia and aphasia
See notes below
Dr. Isaki suggests using a Modified MIT (Melodic Intonation Therapy)-(e.g. bath-tap, room-tap)
In teaching words to the client, the words must be functional like bathroom..in severe cases, the SLP will target 10 functional words.
Goal: the client will say 10 functional words using melodic intonation techniques with % in unison with the clinician (verbal prompts).

47. Characteristic of Moderate Apraxia
Prognosis Indicators:
1. Poor prognosis-if patient has some volitional speech within one month
Characterized by:
1. Moderate apraxia will have mild forms of other types of apraxia like limb
2. Moderate apraxia will have hemiplegia and hemipareis
3. Moderate apraxia will have a mild to moderate degrees of aphasia

48. Treatment for Moderate Apraxia
1. SLP will use drill format to produce sounds
Goal: the client will say functional words given from a functional word list with 80% accuracy given verbal and visual cues. the client will say a functional phrase given a verbal model from the clinician with 80% accuracy. the client will say a functional sentence without a verbal model.)
2. clinician will direct client to use words, phrase, to sentences
3. work-entry is possible with AAC. Some moderate aphasiacs will return to work and the SLP may suggest the use of an AAC device.
Goal: the client will access his device, the client will produce a 2-3 word phrase using his AAC device with 80% given a clinician verbal prompt.
Length and complexity of sentence with an AAC are possible goals

49. Characteristic of Mild Aphasia
Prognosis Indicators:
1. Mild apraxia have volitional speech, Dr. Isaki calls them functional speakers
Characterized by:
1. Mild apraxia will have only mild aphasia
2. Mild apraxia will struggle with words and make errors, but they are cognitively aware of their problems with speech. If they are aware of the speech errors, they will correct it.
Goal: the client will self-repair speech by repeating the word/phrase/sentence to the listener.

50. Treatment Suggestions
1.SLP will target multi-syllabic word, phrases and sentences.
2. SLP wants the client to overcome speech apraxia The goal is work reentry.work-entry is a goal, clinician sets up therapy. (e.g. articulation therapy with children, you must model the sound. You don’t need to describe where the articulation need to go. The clinician will need a verbal model for them and they will repair the speech using their own skills. The clinician will give a verbal and visual model to show the client.
3. SLP should use Melodic Intonation Therapy (e.g. modeling)

51. General Suggestion for Apraxia
1. SLP will make movements visible, short and simple. (e.g. substitute dad for father)
2. SLP will begin with functional items, instead of made-up words. SLP need to have functional and meaningful for adults. SLP should use functional
3.SLP will use Melodic Intonation Therapy: watch and listen.
Goal: The client will watch and listen to the clinician use melodic intonation techniques and then the client will use melodic techniques to use produce/say a functional phrase, functional sentence with 100%.

52. Functional Outcome Measures
1. implement outcome measures (e.g. rating scales by the end of therapy and we will fill out the same measure.)
2. Measuring the gains of the client by rating
a. rating scale is subjective
b. areas of concerns are broad-(e.g. communication-will not show gains)functional independence measure (FIM score)
c. interreliability rating with family, client and clinician

53. What Do We Need to DO?
Step 1. Determine what type of aphasia the client has from the data below?
1. Expressive Non-fluent (global, brocas, transcortical) vs. Expressive Fluent (Wernickes/Transcortical Sensory, Conduction/Anomic).
Step 1a. Name the characteristic of the Aphasia. (e.g. Broca’s aphasia has telegraphic speech, use of content words like nouns and verbs.)

54. Step 2
Step 2: Determine what to target for the patient? Determine the target that will make the most gains from the data). Determine the area that will make the most changes in the area of communication?
0. SLP will need to teach the client a specific skill in a short amount of time. (by targeting drawing, writing, and gestures, you are teaching strategies). The client will use sentence completion for anomia. The client will complete 5 fill in the blanks sentences about a semantic description of a functional targeted word , about procedural task with 60%-100% accuracy given a read passage.
1. If we work on word finding difficulties (anomia), we will improve communication.
2. How would sentence completion generalize to outside environments. A mild Brocas will need to come up strategies to repair the anomia. A strategy might be a phrase to remember that word, but it is all internal. Why do we use cues for the severely impaired aphasiacs? Not for mildly impaired, we can teach the strategies and the mild Broca’s can generalize to other environments.
a. the 10+ strategies are not tasks. The client will use the strategy to complete a task.
b. Mild/Moderate/Severe Aphasia, the clinician will use cues. What type of cues is the clinician using. Why do we use cues in STG? Because we are teaching them a new skill. What skills does the SLP teach to mild/moderate/severe Brocas? The clinician will explain/show the client by modeling, by explaining how.

55. Problem: if the client can not say the word “key” and over 5 trials, the client still can’t say the word “key”. The clinician will need to find strategies to say the word “key”. A bad goal is simple to name the object over and over. A good goal will name a strategy to help say the word ‘key’. Goal; the client will use semantic descriptors/synomyms. The client will give 5 semantic descriptors for the functional targeted word with 60%-100% accuracy given verbal/visual cues.
The strategies are specific, you must be able to count the strategies..5 synomyms, antonyms, hypernyms, hyponyms, meronyms.
Strategies are incorporated in the tasks to help the person name! During a conversation, you may use the 10+ strategies to find a word if you are mildly impaired. However, during a conversation with moderate or severe, the conversation will be impaired. Strategies will help the listener move onto the next steps of the conversations. In a completing a fill in a blank, you can use any of the strategies. The strategy will help the listener continue the conversation
Issues: using on different modalities, you can make it higher or lower
Issues: what is a verbal cue? You must be able to describe the cuing. implies what kind of assistance you are given. be able to describe to your partner.
Issue: how does the patient communicate?

56. Step 3
Step 3: Write a goal for the client. Determine what type of cuing that will be used in therapy (target strengths) Goals should generalize to environments outside the clinic…at the store. Must write out Verbal, Visual,
The client will decrease neolgism by substituting a real word in 70% accuracy with visual cue by drawing, verbal cue by repeating, tactile cue by tapping.
confrontational naming: 70%-bad-compared to 100% before
repetition of words: 60 %-bad-grade
Auditory comprehension: Focus on 80% to 100%. Hospital setting, we only work on short term goals. We don’t know the affect of one-part onto two-part. Focusing on one-part and take baseline data.
What is the hierarchy? targeting the goal is important. Generalization, how do we approach therapy through goals. Your therapy goals are on or off.
one part: 80%-fair
two part: 40%-bad..if the patient has master 2 part directions, you can move onto wh-questions, answer questions, or answer two questions. THINK of the HIERARCHY