Case Study 1 Aimee Burns, Stephanie Kramer, Courtney Scholl, Diona Ysaac

Transcription

1 Case Study 1 Aimee Burns, Stephanie Kramer, Courtney Scholl, Diona Ysaac Mrs. Jones is an 89-year-old right-handed female who presented with a severe fluent aphasia (Wernicke s) after a left parietal CVA 6 months ago. Initially, she was unintelligible and exhibited frequent use of neologisms and semantic and phonemic paraphasias. Mrs. Jones demonstrated press of speech. Her speech was difficult to understand and the content seemed unrelated to the topic of discussion. Mrs. Jones demonstrated significant auditory comprehension problems and severe wordretrieval deficits. Mrs. Jones was unable to point to body parts, objects, pictures or follow even single-step directions. She also demonstrated difficulty with responding to yes/no questions. Although reading comprehension was poor, Mrs. Jones was able to match written words to objects and pictures. She was able to write her name but had difficulty writing anything else. After several months of speech-language pathology services, Mrs. Jones currently demonstrates occasional neologisms, a moderate-severe degree of perseveration, moderate word-finding difficulties, and occasional semantic and phonemic paraphasias. Improvements were also noted in the area of auditory comprehension. Mrs. Jones is inconsistently able to follow single-step commands, identify objects named, and answer simple questions. 1. What would you target in therapy? Why? Since the client still presents with auditory comprehension and expressive difficulties after several months of speech therapy, the following goals will be targeted in next therapy sessions: To decrease neologistic, phonemic and semantic paraphasias during expressive tasks such as conversation and verbal explanation of pictures and objects. To decrease press of speech by incorporating comprehension of a stop gesture. To reduce perseveration reduce the client s frustration and improve word retrieval skills Word retrieval- To help the client communicate more effectively Follow commands with increasing complexity (e.g., varying canonical forms) To facilitate comprehension of functional tasks Identify and name objects- To facilitate improvements in word retrieval and auditory comprehension Answer questions with increasing complexity- To help the client communicate more effectively, facilitate comprehension of functional tasks 2. Discuss with detailed examples how you would use PACE and TAP with this case. In addition, describe 2 other therapy strategies that you would use with detailed examples that relate to the procedures. A. PACE Promoting Aphasics Communicative Effectiveness is a therapy strategy that can be used with clients with Wernicke s aphasia and with clients with auditory comprehension difficulties.

2 The purpose of PACE is to emphasize the use pragmatic aspect of communication and information that involves a range of communication intentions such as informing, requesting, questioning, negating. This approach relates to Schuell s traditional approach to aphasia therapy which is to stimulate or restore patient s language function across 4 modalities. The goal of this strategy is to through conversations and barrier activities using any mode of communication (e.g., visual, gestural, graphic, verbal). The clinician and the client take turns conveying information to each other participating equally as senders and receivers of messages in a variety of communication intentions. The clinician can model communication options.the advantage of PACE as therapy strategy is that it uses a natural communicative context to improve language. An activity that we can be done with the client would be using a newspaper in the session. The clinician will talk about the current events in the newspaper and can ask the client to name a picture. If the client has difficulty with this task then, different cues may be given to the client such as describing physical characteristics, function category, or associated concepts. If the client still continues to have difficulty given the description of the item, other modes of communication such as writing, drawing, or gestures will be used. An example of the activity is shown below: (Clinician points to a clock picture in the newspaper) Clinician: What do you see in this picture? Client: uummm eerr..tick.. Clinician: It is round, it tells time, it has 2 hands.. Client: umm.. (Clinician writes the word clock in a paper) Client: Clock! Feedback is simply the success of communicating, the characteristic of Normal Communication B. VISUAL ACTION THERAPY Visual Action Therapy is another therapy strategy that can be used for the client. It is a non-vocal treatment program for severely aphasic patients and was initially used for clients with global aphasia. There are three levels in this approach. Level 1 consists of 12 steps and levels 2 and 3 consist of steps 7-12 of the level 1. There is a hierarchy of difficulty, and the client must

3 achieve a level of mastery of each step before proceeding to the succeeding step. Listed below are the materials needed for this approach and steps for level 1 that will be targeted in the session: A. 8 objects (razor, telephone, cup, toy pistol, saw, hammer, screwdriver, and blackboard eraser) and their contextual prompts if indicated (block of wood, block of wood with protruding nail, block of wood with protruding screw, and slate) B. 8 colored, large line drawings C. 8 colored, small line drawings of these objects (object picture cards) D. 8 drawings depicting the objects being manipulated by a stick figure (action picture cards) LEVEL 1: Step 1: Tracing Step 2: Large Picture Matching Step 3: Small Picture Matching Step 4: Manipulating Objects Step 5: Action Picture Command Instruction Step 6: Following Action Picture Commands Step 7: Pantomimed Gesture Demonstration Step 8: Recognizing Pantomimed Gestures Step 9: Pantomime Gesture Instruction Step 10: Producing Pantomime Gestures Step 11: Pantomimed Gesture for Absent Object Demons Step 12: Producing Pantomimed Gestures for Absent Object Since the client inconsistently follows single-step commands, identifies objects named, and answers simple questions, steps 1-6 may be used during the therapy session. Matching pictures will assist the client in identifying objects named and follow instructions. Listed below are the activities that will be done in the session: Step 1: The clinician will guide the client in tracing objects in a paper then will ask the client to trace different pictures. Step 2: The clinician will administer the following procedures using 8 objects and 8 pictures.

4 Object to Picture Matching- 8 picture cards lined up in front of patient; give patient objects and have him place objects on matching picture. Leave objects on pictures as you go. Picture to Object Matching- 8 lined up in front of patient; randomly give large picture cards to patient and have him match them to objects. Leave cards on objects as you go. Picture to Object Pointing- 8 objects lined up in front of patient; hold up a large picture card and nonverbally get patient to point to the matching. No picking up the object. Object to Picture Pointing- 8 large picture cards lined up in front of patient; hold up each object and nonverbally get patient to point to the matching picture. No picking up the card. Step 3: The clinician will administer the 4 parts of step 2 using the small picture cards instead of the large ones. Step 4: The clinician will model the function of each object using nonverbal actions (called a contextual prompt) and will put object in front of the client so that the client can correctly show object s function. Step 5: The clinician will put object (with contextual prompting) and action picture card in front of client and point to the card, pick up the object, and model the function. The clinician will then put the object before the patient, point to the card, and have client gesture the object s function. Step 6: The clinician will put 8 objects and contextual prompts in front of patient and will show the action picture card and ask the client to find object that goes with it and demonstrate its function. C. Treatment of Aphasic Perseveration (TAP) TAP would be beneficial to the client because the client presents with moderate-severe perseveration. TAP is the only therapy program that specifically aims to reduce or treat

5 perseveration by bringing it to the awareness of the client and helping them suppress their perseverative responses. The final goal of TAP is to help clients produce correct, nonperseverative responses. A good candidate for TAP would be someone who is alert and with some preserved comprehension and memory skills. The client described has retained the ability to match, which means she presents with some intact comprehension. Prior to starting TAP; the clinician needs to determine which specific strategies work best for the client, based on their performance on the BDAE. Helm-Estabrooks & Albert (2004) outlined 10 different strategies that are ranked from minimal to maximal assistance that can be used for the client. The clinician must choose 3 strategies from the list, and these strategies can change per session, depending on what seems to work best for the client. The strategies are: 1. Time interval (wait time) 2. Gestural Cue 3. Drawing 4. Descriptive Sentences 5. Sentence Completion 6. Graphic Cue 7. Phonemic Cue 8. Oral Reading 9. Repetition 10. Unison speech or singing Afterwards, The TAP program includes a list of 38 stimuli, which falls into the categories of objects, actions, colors, letters, numbers, body parts and geometric forms. The clinician can choose to present it by category or by item. Before beginning the program, it s important that the clinician explains to the client why she is participating in this program, because they believe that awareness of the problem is a key factor for success. Perseveration is explained, and the client is told that instead of perseverating, they can ask for help or give no response instead. A 5-second wait time must be employed before presenting a new stimuli, and when a client perseverates, TAP recommends desensitizing the client by writing the word on a piece of paper and tearing it up and leaving it in their field of vision so that it can serve as a reminder to the client not to perseverate. The scoring system is as follows: Confrontation naming- 0-4 range with 4 as the client responding correctly without a cue, and 0 as the client responding incorrectly after receiving three cues Perseverative Responses- 0-4 range with 0 as no perseveration and 4 as perseverative response after the third cue.

6 Example: After presenting body part stimuli to the client, the client perseverates on the word nose. Clinician: If you feel that you are about to say nose, how about try to take a deep breath instead, or you can say Help which will signal me to cue you to the right word. Let s try it again. What is this? Client: Nose Clinician: Not quite. Look at what I m about to do. I am ripping up the word nose and placing it here so that it can remind you that we will try to avoid saying that word. Okay, what is this picture? It s a part of our body that we use to see. Client: Eyes D. Treating the Equivocal Response I believe that this program would be beneficial for the client because the client still presents with difficulty answering questions. The client is inconsistent with her responses, and this program aims to help PWA develop clear and correct responses in order to establish effective communication interaction. To begin this program, you must first shape the response by making clear to the client what is required. For example, you can tell the client that you will be working on the responses Yes and No. 1. Clinician: Today we will be working on the words yes and no. Watch and listen to me as I say the words, okay? YES NO - Point to the word and repeat 5 times, with a 5-second wait time between each utterance - Point to the word and repeat 5 times, with a 5-second wait time between each utterance 2. Next, you must physically assist the client with 5 repetitions of one response, and then the other response

7 3. Present 4, then 3, then 2 yes-no stimuli while saying word ensuring that you are providing a 5- second wait time in between each presentation. It s important not to move on until the correct response produced 4. Request gestured yes responses to 2 simple unambiguous questions while continually assisting the client. Repeat this procedure for the no response 5. Request 5 repetitions of gestured yes then no. Facilitate with physical or verbal cues, if necessary 6. Once the client is able to say the words consistently, alternate the requests for yes and no making sure 5-second wait time is provided. 7. Afterwards, the clinician must stabilize and maintain this by playing a game or embedding this activity in a therapy activity, making sure the client now uses these responses appropriately.

8 Case Study 2 Aimee Burns, Stephanie Kramer, Courtney Scholl, Diona Ysaac Mr. Raymer is a 65 year-old right-handed male who presents with global aphasia and right hemiplegia after a left CVA that resulted in extensive damage to the pre- and postrolandic areas 9 months ago. At this time, Mr. Raymer demonstrates severe deficits in language comprehension and expression across all modalities. He demonstrates the ability to understand simple yes/no questions, such as, Is your name Marshall? and is able to inconsistently identify body parts named. He is not able to follow simple one-step verbal commands. He relies heavily on nonverbal modes of communication such as facial expressions and head nods to communicate yes/no responses. His verbal output is characterized by stereotypic utterances and neologisms. Mr. Raymer has severe difficulty with reading and is unable to read even familiar single words. He does demonstrate the ability to copy written words but is unable to write spontaneously. Mr. Raymer appears to be frustrated by his inability to communicate but appears to be alert and attentive. 1. What would you target in therapy? Why? This client presents with substantial deficits in both expressive and receptive language abilities across multiple modalities. It is of utmost importance for the client to understand multiple yes/no questions and to be able to execute basic receptive tasks in order to hone the ability to increase expressive task accuracies. The following goals will be targeted in next therapy sessions: To improve auditory comprehension as evidenced by consistent execution of one-step commands in well-controlled situations, as well as consistent answering of more difficult yes and no questions. To improve receptive language ability by identifying basic sight words, as well as relevant names and locations. To consistently elicit relevant words with minimal neologisms/stereotypic utterances. To improve writing, drawing and gestures as compensatory communication strategies to deliver simple messages. To incorporate a picture communication board as another communication strategies to convey messages in an effective and efficient manner. 2. Discuss 3 therapy strategies that you would use with this case. Provide detailed examples that relate to the procedures you discuss. A. VISUAL ACTION THERAPY (VAT) Visual Action Therapy is a non-vocal treatment program for severely aphasic patients and was initially used for clients with global aphasia. There are three levels in this approach. Level 1 consists of 12 steps and levels 2 and 3 consist of steps 7-12 of level 1. The first 6 levels will be targeted for this particular client to most closely align with targeted goal areas:

9 Step 1: Tracing - The clinician will guide the client in tracing objects in a paper then will ask the client to trace different pictures. Step 2: Picture Matching/ Pointing - 8 picture cards lined up in front of patient; give patient objects and have him place objects on matching picture. Leave objects on pictures as you go. This exercise will then transition from matching exercises to pointing exercises. Step 3: Smaller Picture Matching/ Pointing -The clinician will administer the 4 parts of step 2 using the small picture cards instead of the large ones. Step 4: Manipulating Objects - The clinician will model the function of each object using nonverbal actions (called a contextual prompt) and will put object in front of the client so that the client can correctly show object s function. Step 5: Action Picture Command Instruction - The clinician will put object (with contextual prompting) and action picture card in front of client and point to the card, pick up the object, and model the function. The clinician will then put the object before the patient, point to the card, and have client gesture the object s function. Step 6: Following Action Picture Commands - The clinician will put 8 objects and contextual prompts in front of patient and will show the action picture card and ask the client to find object that goes with it and demonstrate its function. Once Mr. Raymer is able to complete the first 6 steps, he may be able to move on to Level 2 of VAT. B. SHAPING Shaping is a form of therapy that mimics classical conditioning with the intentions of increasing the patient s ability to comprehend the target response and then work towards appropriately expressing it. Shaping begins with simpler objectives and gradually builds toward increased complexity in respect to the patient s performance throughout each level of treatment. Since Mr. Raymer frequently communicates using gestural responses, the focus of therapy will be to incorporate yes/no questions requiring head nods as responses and one step directions to assess his comprehension abilities. Shaping is utilized to assist Mr. Raymer with associating the target word with the appropriate card choice. 1.) Initially, the clinician will explain to the client the instructions for the first task using both gestures and verbalizations to determine if he is able to comprehend the concept introduced. Visual aids can also be utilized to increase his success with the task and reduce some of the cognitive demands. During the first level, the clinician will say the following, We are going to be working on the words, yes and no. The clinician will model the target word (i.e., yes) and have the client attend to what she is saying. The clinician will present yes and no cards and point to them when she is producing the correct word accompanied by the appropriate gesture. After 5 seconds, the target word (i.e., yes) and gestures will be repeated. Five repetitions of the stimulus will occur to familiarize the client with the appropriate response (i.e., yes). 2.) At this level, the clinician will now focus on the no card and provide the same directions as previously stated. The same procedure is utilized to allow for elaborated

10 exposure of the stimulus and to encourage the desired response. Since the client s primary mode of communication is gestures, the clinician will assist the client with shaking his head up and down for yes, along with left to right for no. The cards will act as visual cues to increase the client s ability to associate the colors (i.e., red, purple) with the correct word response. Practice will consist of 5 repetitions of yes and 5 repetitions of no using head nods. 3.) The clinician will increase the complexity of the task by presenting 4, then 3, then 2 yesno stimuli while saying the word. There will be a latency time of 5 seconds between these responses. The clinician won t move on until the correct response is elicited from the client. An exposure to direction following incorporated into this task will strengthen his cognitive abilities and facilitate an improvement in expressive language skills across sessions. 4.) If the client has achieved mastery at the previous levels, the next level can be introduced to challenge comprehension abilities. The clinician will choose two unambiguous questions to elicit a response such as Am I a girl? and Is the sky blue? The client will be required to nod his head for either yes or no in response to these questions. Similar unambiguous questions will be asked by the clinician to target the no response. ( Does it snow in the summer? and Are cows green? ) 5.) The clinician will intensify the task by requesting the client to provide 5 repetitions of gestured yes and then 5 repetitions of gestured no. Verbal or gestural cues from the clinician will be exhibited if difficulty is noted. 6.) At this level, the clinician will alternate requests for both yes and no gestural responses at 5 second intervals to assess comprehension skills based on these response times. C. COMMUNICATION BOARD IMPLEMENTATION Communication boards are an excellent way for clients with severe communication difficulties to more effectively. Since Mr. Raymer is able to answer basic yes/no questions, this may be a great way for him to interact with familiar as well as unfamiliar communication partners. To meet Mr. Raymer s specific needs, the communication board will have basic functions/ needs implemented for use on the board. The client is already able use gestures, and is able to answer yes/no questions. As such, a binary choice or spontaneous pointing approach may be utilized to facilitate communication. First, Mr. Raymer will have to determine which icons on a board will best suit his needs. These can be presented to him as yes/no questions, of which he will have to accurately answer two consecutive times. As he identifies needs for his communication board, the speech-language pathologist can add them in appropriate areas of the board.

11 Sample communication needs: I want I need More Bathroom Wife Body Parts Yes No Greeting The picture communication board can be utilized in multiple ways: Practice writing key words from the communication board Receptive tasks using pictures on the communication board Practicing expressive output/ repetition of constantly used words from the communication board Patient-initiated communication by pointing to desired outcomes on the communication board

12 Sample communication board: Another sample communication board: