Week 1. 4 Stroke and aphasia assessment-Q.pdf

What is a stroke? Results when blood supply (bringing oxygen and nutrients) is diverted from a part of the brain Brain makes up 2% of the body’s mass but requires 25% of the body’s intake of oxygen hypoxia Stroke is a serious medical emergency Every minute 1.9 million neurons can die 5th most common...

What is a stroke? Results when blood supply (bringing oxygen and nutrients) is diverted from a part of the brain Brain makes up 2% of the body’s mass but requires 25% of the body’s intake of oxygen hypoxia Stroke is a serious medical emergency Every minute 1.9 million neurons can die 5th most common cause of death in the US, second in the world 1st leading cause of adult disability in the US and world Katan & Luft, 2018, Seminars in Neurology 1 What are the different kinds of strokes? 1. Ischemic 2. Hemorrhagic 3. TIA* Types of stroke Ischemic Hemorrhagic Thrombotic Intracerebral Embolic Subarachnoid Arterial blood supply to the brain 4 Types of strokes Ischemic strokes 80-85% Thrombosis: clot builds up along artery walls Embolism: clot is thrown from a distant location, usually the heart Causes: Damaged, aging vessels, high blood pressure, arteriovenous malformation (AVM) ‫عنوان المخطط‬ Hemorrhagic Hemorrhagic strokes 15-20% Intracerebral: more common; blood vessel within the brain bursts Subarachnoid: blood vessel in the space between the brain and skull bursts Risk Factors: high blood pressure, cigarette smoking, estrogen contraceptives, excessive alcohol intake, illicit drug use Ischemic Incidence in percent of different stroke types 6 What happens when there is a stroke? When blood supply is reduced to parts of the brain, there can be sudden loss of function As cells die, permanent brain damage is the result Interventions can help save brain function or the person’s life Ischemic Tissue Plasminogen Activator (clot busting drug) Endovascular Thrombectomy (Neurosurgery to retrieve clot) Hemorrhagic: Surgery to repair vessel or reduce swelling Craniectomy 7 Ischemic Core and Penumbra Diaschisis Due to damage of neural pathways, even remote areas of the brain may be impacted. Initially, this can make determining the long-term effects of a stroke difficult Resolution of diaschisis is an important step in post-stroke recovery and contributes to the observation of “spontaneous recovery” The evolution of the idea of diaschisis 9 Nature of Aphasia and Aphasia Assessment Aphasia: Overview (van der Lely & Pinker, 2014, Trend in Cognitive Sciences) Language disorder that results from damage to the language network in the brain  Hubs  Connections Etiologies:  Stroke  Traumatic Brain Injury  Neurodegenerative Disease  Brain Tumor Accounting for different aphasia types Stroke-induced aphasia profiles related to vascular system Development of classic stroke aphasia classification system  describe possible aphasia subtypes General Guide to Lesion Location More frontal and dorsal  Non-fluent (motor speech & linguistic) More posterior and ventral  Fluent speech production with phonemic paraphasias Temporal Pole (rare outside of dementia)  Semantic loss Signs of Aphasia: Naming Impairment Anomia = word retrieval difficulty Paraphasias = errors in naming  Semantic (verbal) paraphasia = errors in word choice  Phonemic (literal) paraphasia = errors in sound selection/sound substitution errors Characterizing Aphasia In general, the location and extent of lesion determine the characteristics of aphasia*  Site and size of lesion (or atrophy) Aphasia syndromes are based upon     Naming Fluency Auditory comprehension Repetition *Caveats regarding aphasia types Time Window 1.  Correlation between aphasia type and lesion location is best in first few months post onset Evolution 2.  Patients may evolve from one type to another over course of recovery and treatment One size does not fit all 3.   Not everyone with aphasia can be classified into one type Wertz (1981): only 76% of 92 patients were classifiable by aphasia type However, aphasia syndromes remain a useful way of describing aphasia characteristics. Fluency Adapted from Beeson & Rapcsak, 2006 Non-Fluent Fluent Global Broca’s Transcortical Motor Mixed Transcortical Wernicke’s Conduction Transcortical Sensory Anomic Auditory Comprehension Good Poor Global Mixed Trans. Broca’s Global Poor Trans. Motor Wernic. Repetition Repetition Poor Auditory Comprehension Good Poor Good Mixed Trans. Broca’s Trans. Motor Anterior Lesions Good Trans. Sens. Conduc. Repetition Repetition Poor Wenic. Good Trans. Sens. Anomic Poor Conduc. Posterior Lesions Good Anomic Aphasia Two individuals with aphasia: 1. What features of their language impairment do they have in common? 2. What features are unique? Assessing Language Differential diagnosis of aphasia type requires examination of the various language domains Formal assessment: use of standardized assessments Modality Production Reception Speech Production Auditory Comprehension Writing Reading Informal assessment: testing using non-standardized measures 19 Formal Assessment in Aphasia Purposes of formal assessment are to: 1. Establish current level of functioning  2. Determine presence, profile (type, severity) and impact of aphasia Determine treatment plan    Establish baseline performance Prioritize treatment goals Assess progress in therapy program – continue, modify or discontinue tx Informal Assessment in Aphasia “a fluid exercise in critical thinking” determining the most appropriate clinical goals from analyzing abilities/behaviors at all levels of ICF Four guiding questions: 1. 2. 3. 4. What is the extent of the problem? Where does the behavior break down? What helps the behavior? What is/are the underlying mechanism/s for the behavior? Clinician Scientists Assessment = The Scientific Method! 1. Data Collection    2. Hypothesis Formation  3. obtaining information from formal and informal measures language strengths & weaknesses of patient, other cognitive/linguistic skills, impact of these impairments information from patient, family, caregivers, etc. interpret data, make decisions re: presence of aphasia, candidacy for tx, prognosis, appropriate tx goals Hypothesis Testing  ongoing assessment & analysis of treatment goals, patient progress Screening tests  Aphasia Screening Tests  Bedside versions of common aphasia batteries  e.g. WAB-R bedside version; BDAE-3 bedside version  Standalone screening tests  e.g. Bedside Evaluation and Screening Test (BEST-2) (Fitch-West & Sands, 1998)  Subtests of several standardized test batteries (ADP, WAB, etc.)  Key questions to consider:  Bedside Screening Document Comprehensive Aphasia Batteries  Designed to identify presence and type of aphasia  Typical components of language batteries  speech production  auditory comprehension  reading  writing  Tasks of varying difficulty  Vary type of input  visual (nonlinguistic vs linguistic)  Vary response modality gesture/action, spoken, written Standardized Aphasia Tests Advantages Disadvantages Does not easily allow for exploration of strengths and weaknesses Can interfere with the establishment of rapport Does not necessarily direct treatment Allows for classification and quantification of severity  compare over time  compare with other individuals  communicate profile with other professionals  research purposes Standardized “Impairment-based” Tests for Aphasia Boston Diagnostic Aphasia Exam (BDAE-3; Goodglass & Caplan, 2001)  Boston Naming Test (BNT) Western Aphasia Battery – Revised (WAB-R; Kertesz, 2006) Aphasia Diagnostic Profiles (ADP; Helm-Estabrooks, 1992) Boston Assessment of Severe Aphasia (BASA; Helm-Estabrooks et al. 1989) Activity: Speech Production Tasks Arrange in order from easiest to difficult        repeating phrases/sentences conversational speech counting high probability cloze phrases single word repetition picture description naming easy/automatic difficult/complex Speech Production Tasks sample tasks across continuum of difficulty difficult/complex easy/automatic counting cloze phrases naming high probability single word repetition phrase/ sentence repetition conversational speech picture description Activity: Auditory Comprehension Tasks Arrange in order from easiest to difficult        sentence comprehension Y/N questions (abstract) follow complex commands point to objects Y/N biographical questions discourse comprehension follow simple commands easy/automatic difficult/complex Auditory Comprehension Tasks sample tasks across continuum of difficulty difficult/complex easy/automatic point to objects follow simple commands Y/N biographical questions sentence comprehension Y/N questions (abstract) discourse comprehension follow complex commands Activity: Reading Tasks Arrange in order from easiest to difficult        sentence comprehension recognize word vs nonword comprehension of written text follow written commands read single words out loud read connected text out loud match picture to printed word easy/automatic difficult/complex Reading Tasks sample tasks across continuum of difficulty easy/automatic difficult/complex recognize read single follow read word vs words aloud written connected nonword commands text aloud match comprehension sentence picture to of written text comprehension printed word Activity: Writing Tasks Arrange in order from easiest to difficult        writing to dictation (words) copy words production of written discourse write own name writing to dictation (sentences) write sentences written naming easy/automatic difficult/complex Writing Tasks sample tasks across continuum of difficulty difficult/complex easy/automatic copy words write own name writing to dictation (words) writing to dictation (sentences) written naming production of written discourse write sentences