Characteristics and Management of a Classic Case of Broca Aphasia

Kathryn FichoDepartment of Communication Disorders and Sciences

Rush University, Chicago, ILCase Advisor: Mary Hoban, MS, CCC-SLP

Moderator: Dr. Richard Peach, PhD, CCC-SLP

Learning Objectives

• Examine a classic case of a patient with Broca Aphasia

• Review neuroanatomy and brain mapping relative to the regions for language comprehension and production

• Discuss the common features and language deficits seen in patients with Broca Aphasia

• Consider the recommended treatment approaches for patients with Broca Aphasia

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Patient A: History

Patient A is 37 y/o RIGHT handed African American male with a PMH of hypertension (HTN), hyperlipidemia, cardiomyopathy, deep vein thrombosis (DVT), and ETOH abuse. He was previously employed as an IT network systems administrator.

At an OSH in Fall 2013, Patient A was diagnosed with an acute ischemic CVA of the left middle cerebral artery (L-MCA) with a thrombus in M2 segment. He was immediately transferred to RUMC and received Transient Tissue Plasminogen Activator (tPA).

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Patient A: Medical Timeline

Patient A remained in acute care at RUMC for 31 days, receiving occupational therapy, physical therapy, and speech services for dysphagia and speech-language treatment.

No formal language assessment completed due to the severity of Patient A’s deficits.

Following his inpatient stay at RUMC, Patient A was discharged to an inpatient facility (RIC) for daily speech/language rehabilitation over a 2-week period. Following discharge, he received no further speech-language treatment until Spring 2015.

At this time, Patient A returned to RUMC for a speech/language evaluation at the outpatient clinic.

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Western Aphasia Battery – Revised (WAB-R)– Spontaneous Speech: 11/20– Auditory-Verbal comprehension: 7.7/10– Repetition: 5.8/10– Naming and Word Finding: 8.2/10– Aphasia Quotient: 65.4 *Cut-off for Aphasia= 93.8

ASHA Quality of Communication Life Scale (QCL)– 3.68 / 5

ASHA Functional Communication Measure (FCM)– Spoken language expression: 3 / 7– Spoken language comprehension: 4 / 7– Motor Speech: 4 / 7

Motor Evaluation – Unilateral RIGHT-sided weakness in UE and LE– No longer able to write with dominant RIGHT hand– Occasional RIGHT-sided drooling

Patient A: Evaluation 1 in Spring 2015

Kertesz, 1982; Paul et al., 2004; ASHA, 2003 5

SLP: I want you to tell me what’s happening in this picture and try to talk in sentences, okay?P.A.: Okay

The familySun Uh, dogThe wife Uh, the father Sixters... sixters [sIk stɚz]

SLP: What are they doing?P.A.: Uh, picnicSLP: Can you tell me what he’s doing in a

sentence?P.A.: ReadingSLP: What else do you see? What about back

here?P.A.: Fishing SLP: Anything else?P.A.: Yeah, like uh, a number, like uh,

Four hundred seventy Four hundred seventy The houseFlag

SLP: Anything else?P.A.: Yes, castle

Spring 2015 WAB-R Picture Description Task

Kertesz, 1982

Total # utterances 14

Grammatical utterances 0 0%

Agrammatic utterances 14 100%

Total # words 27

Verbs used 2 7%

Phonemic paraphasias 1 3.7%

All quantities and percentages exclude immediate repetitions and fillers (e.g. “uh,” “like”)

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Impressions: Moderate Broca Aphasia and Apraxia of Speech (AOS)– Language output characterized by agrammatism and telegraphic speech:

heavy in content words and lacking function words– Frequent perceived articulatory substitutions (e.g. krugriver for ‘screw

driver’)– Marked impairment in phrase repetition – Strengths: Comprehension of simple sentences and Y/N questions

Recommendations– Intensive speech-language treatment 2-3x/week for 2-3 months– Use Modified Response Elaboration Training (M-RET) to increase phrase

length, improve grammatical completeness, and reduce apraxic errors– Use of augmentative communication, as patient is comfortable with

technology and has smart phone accessPrognosis:

– Fair to good based on deficit severity, time post-onset, educational background, and motivation to improve

Patient A: Evaluation 1 in Spring 2015

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Review of Broca's area: Neuroanatomy

Anatomy•Vascularized by the left Middle Cerebral Artery (L-MCA)•BA 44, operculum: unimodal motor cortex•BA 45, pars triangularis: heteromodal cortex

Features •Motor planning for speech praxis•Serial or syntactic processing of input and output (speech comprehension and production)•Syntactic working memory computes dependency relations for verbs

Grodzinsky & Friederici, 2006; Wise, 2003 8

Damage to Broca's area may result in apraxia of speech, agrammatism, and/or deficits in syntactic processing

Common Features of Broca Aphasia•Agrammatic or telegraphic speech characterized by reliance on content words and omission of function words•Diminished processing and production of syntactically complex phrases•Reduced syntactic memory, in turn impairing thematic role assignment

Broca Aphasia is often accompanied by apraxia of speech (AOS) because the speech motor cortex (operculum) shares a vascular system with the rest of Broca's area.

Fridriksson et al., 2013; Richardson et al., 2012

Broca Aphasia: Common Features

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Question for the Audience

What areas might be targeted in the speech-language treatment of a patient with Broca Aphasia?

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Question for the Audience

What areas might be targeted in the speech-language treatment of a patient with Broca Aphasia?

• Thematic role assignment or mapping• Production and comprehension of sentences

with complex syntax• Verb retrieval• Sentence generation and completion• Agrammatism or telegraphic speech• Movement of noun phrases in non-canonical

sentences

Kiran & Sandberg, 2012 11

Follow-Up Question for the Audience

What treatment techniques might be used to target these areas?

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What treatment techniques might be used to target these areas?

• Melodic Intonation Therapy (MIT)• Semantic Feature Analysis (SFA)• Treatment of Underlying Forms (TUF)• Stimulation Approach• Sentence Production Program for Aphasia

(SPPA)• Verb Network Strengthening Treatment (VNST)• Modified Response Elaboration Training (M-RET)• Cueing Verb Treatment• Mapping Therapy

Follow-Up Question for the Audience

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What treatment techniques might be used to target these areas?

• Melodic Intonation Therapy (MIT)• Semantic Feature Analysis (SFA)• Treatment of Underlying Forms (TUF)• Stimulation Approach• Sentence Production Program for Aphasia

(SPPA)• Verb Network Strengthening Treatment (VNST)• Modified Response Elaboration Training (M-RET)• Cueing Verb Treatment• Mapping Therapy

Follow-Up Question for the Audience

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Review of SFA, M-RET, and SPPA

Semantic Feature Analysis (SFA): patients are cued to provide six different features for a target object or action; based on spreading-activation models

Response Elaboration Training (RET)-Modified RET (M-RET)

Sentence Production Program for Aphasia (SPPA)

Boyle & Coelho, 1995; Peach & Shapiro, 2012 15

Peach & Reuter, 2010

An example of action-word SFA

Moving at a speed faster than walking

To move about quickly, to exercise

Jog, sprint, speed, race, dash, hurry

Move legs faster than you would to walk

Treadmill, sidewalk, track, outside, field

Hurrying, working out, exercise, rushing, racing

*Patient shown picture of person running*

Run

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Peach, R. K., & Reuter, K. A. (2010). A discourse-based approach to semantic feature analysis for the treatment of aphasic word retrieval failures. Aphasiology, 24(9), 971-990.

• Clinicians often employ SFA treatment during picture description tasks. However, carryover effects are not well-demonstrated. The purpose of this study was to assess the effectiveness of discourse-based SFA versus SFA for picture description in treating word retrieval deficits in connected speech

• Participants: 2 bilingual (primary: English, native: Serbian, Filipino) females with mild-moderate anomic aphasia from a single left hemisphere stroke

• Methods: Object and action word targets were treated with SFA during discourse in treatment. Researchers then investigated generalizations of lexical retrieval improvements to participants’ discourse and untrained picture descriptions.

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Peach, R. K., & Reuter, K. A. (2010). A discourse-based approach to semantic feature analysis for the treatment of aphasic word retrieval failures. Aphasiology, 24(9), 971-990.

Outcomes: • Both participants improved in both verbal productivity and

number of correct informational units (CIUs).• Generalization to untrained items occurred for both objects

and actions.• Frequency of word-finding behaviors did not change

significantly. This may be due to increased quantity of output (i.e. verbal productivity)

Conclusions:• Similar improvements noted in discourse-based SFA

treatment as in picture description-based SFA treatment.• However, some argue that discourse-based SFA has higher

ecological validity than SFA for picture description. Further research to compare outcomes is ongoing.

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Semantic Feature Analysis (SFA)

Response Elaboration Training (RET): patient’s utterances are re-modeled and forward-chained by the SLP to stimulate longer and more informative utterances•Modified RET (M-RET): Various revisions to protocol

• The clinician may provide response options in the absence of patient initiation (AOS)

• Clinician may use integral stimulation of expanded responses

• Clinician and patient may repeatedly practice expanded responses

Sentence Production Program for Aphasia (SPPA)Wambaugh, Wright, & Nessler, 2012

Review of SFA, M-RET, and SPPA

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Example of RET vs. M-RET

Kearns, 1985

If no patient response, clinician: “/k/, /kr/”

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Wambaugh, J. L., Wright, S., & Nessler, C. (2012). Modified Response Elaboration Training: A systematic extension with replications. Aphasiology,26(12), 1407-1

RET has consistently resulted in increased production in discourse in people with aphasia. It has been modified (i.e. M-RET) to address treatment of patients who also present with AOS. The purpose of the present study was to measure the generalization effects of M-RET.

Participants: Six persons with chronic aphasia (2 Female; 5 Nonfluent)

Methods: M-RET was applied as treatment for two picture card sets and a personal recount condition. Performance was measured by production of correct informational units (CIUs) during probes with trained and untrained pictures, home conversations, and structured discourse tasks.

Wambaugh, Wright, & Nessler, 2012 21

Outcomes:•Increase in CIU for trained and untrained picture sets but no significant gains for personal recounts•Significant improvements in structured discourse and functional communication measures (FCMs) for the majority of the participants•Poor compliance limited the home conversation performance as an outcome measure; was not used for analysis

Conclusions:•M-RET improved CIUs for picture conditions to a similar degree as RET•The high demand and amount of time required for this treatment and its limited effects should be considered before selecting M-RET or RET for treatment

Wambaugh, J. L., Wright, S., & Nessler, C. (2012). Modified Response Elaboration Training: A systematic extension with replications. Aphasiology,26(12), 1407-1

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Review of SFA, M-RET, and SPPA

Semantic Feature Analysis (SFA)

Response Elaboration Training (RET)-Modified RET (M-RET)

Sentence Production Program for Aphasia (SPPA): a hierarchical approach to treat agrammatism in patients with nonfluent aphasia; the patient is presented with a picture and brief story and is cued to produce a target sentence.

Helm-Estabrooks, Nicholas, & Helm, 2000 23

In the earlier version of SPPA, called the Helm Elicited Language Program for Syntax Stimulation (HELPSS), patients were probed to use 14 different syntactic structures to answer questions about stories.

SPPA, an update of HELPSS, included the following changes:•Stories in the program describe everyday activities that patients can relate to (e.g. include phrases like “call the doctor”)•6 sentence types eliminated from HELPSS: SPPA includes only the 8 most functional syntactic structures•Sentence types more useful in functional communication are trained first (e.g. wh- interrogatives, imperatives)•Greater variety of sentence-initial words to eliminate likelihood of overgeneralization of linguistic forms•Patient population limited to those with agrammatism•Facilitated administration and general housekeeping

Helm-Estabrooks, Nicholas, & Helm, 2000

Helm-Estabrooks, N., Nicholas, M., & Helm, S. A. (2000). Sentence production program for aphasia. Pro-ed.

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Helm-Estabrooks, N., Nicholas, M., & Helm, S. A. (2000). Sentence production program for aphasia. Pro-ed.

Helm-Estabrooks, Nicholas, & Helm, 2000 25

Patient A: Treatment

Patient A participated in 3.5 months of biweekly speech/language treatment sessions at RUMC outpatient clinic in Fall 2015-Winter 2016.

Treatment primarily utilized SFA, M-RET, and SPPA to target…•Improved use of action and function words•Improved syntactic processing of input and output•Increased phrase length •Omission of apraxic errors

Patient A demonstrated high levels of motivation and compliance with his treatment program and completed homework assignments independently.

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Patient A: Evaluation 2 in Winter 2016

After these 24 sessions of outpatient treatment using the previously described techniques (SFA, SPPA, M-RET), Patient A was reevaluated using the WAB-R with the following results:

•Spontaneous Speech: 12 / 20Improvement of +1

•Auditory-Verbal Comprehension: 9.45 / 10Improvement of +1.75

•Repetition: 6.7 / 10Improvement of +0.9

•Naming and Word Finding: 8.2 / 10No change

• Aphasia Quotient: 72.7 / 100 *Cut-off for Aphasia: 93.8Improvement of +7.3

Kertesz, 1982 27

SLP: Tell me what you see happening.P.A.: It’s a picnic

Summer homeThe… the kidsTwo kidsThe wife and father, like uhThe boy is flying a kiteThe daughter is, uh, the

sand castle

What’s the name?Sand cancelUh, I don’t knowI don’t knowUh the the stranger is

fishingBoatThe boat uhFour seventy-oneUm, summer homeI think so The doll, He like it The doll, He like it

Kertesz, 1982

Winter 2016 WAB-R Picture Description Task

Total # utterances 17

Grammatical utterances 7 41%

Agrammatic utterances 10 59%

Total # words 59

Verbs used 11 18.65%

Phonemic paraphasias 1 1.69%

All quantities and percentages exclude immediate repetitions and fillers (e.g. “uh,” “like”)

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At this time, Patient A was approved for continuation of skilled speech/language treatment 2x/week for 3 weeks.

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Patient A: Evaluation 3 in Spring 2016

After 12 sessions of outpatient treatment (36 total), Patient A was reevaluated using the WAB-R with the following results:

•Spontaneous Speech: 12 / 20No change

•Auditory-Verbal Comprehension: 8.4 / 10Decrease of -1.05

•Repetition: 7.8 / 10Improvement of +1

•Naming and Word Finding: 8.8 / 10Improvement of 0.6

• Aphasia Quotient: 74 / 100 *Cut-off for Aphasia: 93.8Improvement of +1.3

Patient A approved to continue treatment with SLP for an additional 10 weeks.

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Patient A Outcomes: Performance on the WAB-R

WAB-R Subscore Spring 2015 Winter 2016 Spring 2016Spontaneous Speech (out of 20)

11 12 12

Auditory-Verbal Comprehension (out of 10)

7.7 9.45 8.4

Repetition (out of 10)

5.8 6.7 8.4

Naming and Word-Finding (out of 10)

8.2 8.2 8.8

Aphasia Quotient (out of 100) *Cut-off for Aphasia = 93.8

65.4 72.7 74

+1

+0.7

+3

+0.6

+8.6

Question for the audience: Why do you suppose Patient A’s most substantial improvement was in the area of repetition?

Kertesz, 1982 31

Patient A Outcomes: Patient-Specific Goals

The following improvements were made from initiation of treatment in Fall 2015 to Spring 2016.

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Patient A Outcomes: Performance on the WAB-R Picture Description

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Patient A Outcomes: Performance on the ASHA FCM’s

ASHA, in conjunction with the National Outcomes Measurement System (NOMS), created the Functional Communication Measures (FCM) to “describe the change in an individual’s functional communication and/or swallowing ability over time” (ASHA, 2003).

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• Patients with Broca Aphasia classically present with agrammatism and difficulty processing complex syntax

• Choosing an intervention method based on the areas of patient deficits is crucial

• Semantic Feature Analysis (SFA) can be used with nouns or verbs, based on the patient’s area of difficulty, and may be particularly useful in patient’s with Broca aphasia due to their specific difficulty with verb retrieval

• Modified Response Elaboration Training (M-RET) is an efficient treatment for increasing sentence length and reducing use of telegraphic sentences, particularly for patients with an accompanying AOS.

• Importance of evaluating a patient on more than one outcome measure

Take Home Points

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References

1. American Speech-Language-Hearing Association. (2003). National Outcomes Measurement System (NOMS): Adult speech-language pathology user’s guide. Rockville, MD: ASHA.

2. Boyle, M., & Coelho, C. A. (1995). Application of semantic feature analysis as a treatment for aphasic dysnomia. American Journal of Speech-Language Pathology, 4(4), 

3. Fridriksson, J., Guo, D., Fillmore, P., Holland, A., & Rorden, C. (2013). Damage to the anterior arcuate fasciculus predicts non-fluent speech production in aphasia. Brain, 136(11), 3451-3460.

4. Grodzinsky, Y., & Friederici, A. D. (2006). Neuroimaging of syntax and syntactic processing. Current opinion in neurobiology, 16(2), 240-246.

5. Helm-Estabrooks, N., Nicholas, M., & Helm, S. A. (2000). Sentence production program for aphasia. Pro-ed.6. Kertesz, A. (1982). Western aphasia battery test manual. Psychological Corp.7. Kiran,S. & Sandberg, C. (2012). Treating Communication Problems in Individuals with Disordered Language. In R.

K. Peach & L. P. Shapiro (Eds.), Cognition and Acquired Language Disorders: An Information Processing Approach (298-322). St. Louis, MO: Elsevier Health Sciences.

8. Paul, D. R., Frattali, C. M., Holland, A. L., Thompson, C. K., Caperton, C. J., & Slater, S. C. (2004). Quality of communication life scale (ASHA QCL).American Speech-Language-Hearing Association, Rockville, MD, USA.

9. Peach, R. K., & Reuter, K. A. (2010). A discourse-based approach to semantic feature analysis for the treatment of aphasic word retrieval failures. Aphasiology, 24(9), 971-990.

10. Peach, R. K., & Shapiro, L. P. (2012). Cognition and Acquired Language Disorders: An Information Processing Approach. Elsevier Health Sciences.

11. Richardson, J. D., Fillmore, P., Rorden, C., LaPointe, L. L., & Fridriksson, J. (2012). Re-establishing Broca’s initial findings. Brain and language, 123(2), 125-130.

12. Wambaugh, J. L., Wright, S., & Nessler, C. (2012). Modified Response Elaboration Training: A systematic extension with replications. Aphasiology, 26(12), 1407-1

13. Wise, R. J. (2003). Language systems in normal and aphasic human subjects: functional imaging studies and inferences from animal studies. British Medical Bulletin, 65(1), 95-119.

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