GLOBAL APHASIA

AND MANAGEMENT
 Global Aphasia

 Global aphasia is a type of Aphasia that

is commonly associated with a large
lesion in the area of the frontal, temporal
and parietal lobes of the brain causing an
almost total reduction of all aspects of
spoken and written language.
Damage so MCA infarct Or ICA
widespread is usually caused by
Proximal
PRESENTATION
 The presentation of global aphasia are those of
severe Expressive Aphasia and Receptive aphasia
combined.

•Broca’s (BA 44, 45): Inf. prefrontal

gyrus
• Wernicke’s (BA 22): Post sup temporal
gyrus
• Arcuate fasciculus
• Connecting Broca’s with Wernicke’s
Speech and language characteristics
of globally aphasic patient :

 The presentation of global aphasia are those

of severe Expressive Aphasia and Receptive
aphasia combined.

 Studies show that spontaneous improvement,

if it happens, occurs within six months, but
complete recovery is rare.
Signs
 Initially the pt appears MUTE OR USES REPETITIVE
vocalization
 Expressive language remains limited
 No repetition
 Confrontation naming is severely or completely
impaired
 Reading and writing are also totally or severely
impaired
 Many of the dysfunctions are irreversible with
treatment
Symptoms
 The symptoms of global aphasia are impairments in all
aspects of word-based communication:
 Reading, writing, speaking, and understanding speech.
 The exact symptoms vary from individual to individual.
For example, some globally aphasic persons do not
understand speech at all, while others recognize familiar
personal names and are able to follow whole-body
commands. Similarly, some individuals are mute, while
others can produce a few sounds (e.g., "ta, ta")
 While no aspect of language is functional, certain aspects
may be more impaired than others.
 Global Aphasia
Clinical Feature Observation
Speech Mute or nonfluent
Comprehension Impaired
(auditory/written)

Repetition Impaired
Naming Impaired
Reading Impaired
Writing Impaired
Localization of lesion Typically associated with separate lesions in the
frontal and temporoparietal regions, including
both Broca’s area and Wernicke’s area.

Typical Pathology Stroke of internal carotid artery or proximal

middle cerebral artery
PROGNOSIS
 Persons with a large injury to the left perisylvian areas of
the brain, often initially show signs of global aphasia in
the first 1–2 days due to brain swelling (cerebral edema).

 With some recovery, impairment presentation may

progress into Broca's or Wernicke's aphasia

 Improvement may occur in one or both areas (expressive

and receptive language) over time.
MANAGEMENT
 Attempts to rehabilitate globally aphasic patients
utilizing traditional language therapies were largely
futile (marks, Taylor, Rusk 1957.Godfery and
Douglass 1959.Jenkins, Jimenez 1964)
TRADITIONAL APHASIA THERAPY

 Operant conditioning
 Cognitive approach to aphasia therapy
 Programmed stimulation for aphasics
 Pragmatic approaches
 PACE, or therapy for promoting aphasics'
communicative effectiveness which was
developed by G. Albyn Davis.
Operant conditioning,
 A form of behavior modification was the first type
of therapy used to remediate aphasia. This
approach involves shaping language behavior by
helping patients progress through a series of tasks
presented in fixed order, from least to most
difficult.
Cognitive Approach
 Cognitive approach proposed that an extended
period of intensive stimulation would improve the
quality of the aphasic's language behavior. Because
it was believed that language was naturally learned
through the auditory modality alone, it emphasized
the use of auditory stimuli.
Programmed Stimulation
 This approach to aphasia therapy combines
behavioral and cognitive methods. The use of a
hierarchy of therapy tasks based on level of
difficulty employed by behaviorists, but uses the
kinds of stimuli employed by therapists with a
cognitive orientation.
 Several types of programmed stimulation for
aphasics have been developed :
 Melodic intonation therapy
 Visual action therapy VAT
Pragmatic Approach:
 Pragmatic approaches use social interaction to
improve the communicating abilities of aphasic
patients. Many different pragmatic approaches
exist. For example, teaching language in a
naturalistic setting by taking an aphasic out to a
restaurant and helping him/her order a meal could
be considered a form of pragmatic therapy.
Training Approach
 Nine areas seen as an important communication competence
for global aphasia :
Cont…

establishing a good communication

speaker may be unintelligible.
Four Specific Non-Verbal Behavior:

1. Eye Contact:
 Maintain eye contact is important in keeping the

communication.
 Lack of eye contact show poor self image and

rejection of the patient.

 It is useful observation to determine if patient is

accepting interaction at given moment.

need.
VISUAL ACTION THERAPY
 It is non verbal structured treatment plan for
globally aphasic patients .The method employs
I. Eight real objects.
II. Eight large Pictures of the eight objects
III. Eight small Pictures of the eight objects

IV. Pictures in which the eight pictures are being

used.
LEVELS OF PROGRAMME
 Level 1
 Level2
 Level3
Level 1
Step 1. LARGE PICTURE MATCHING
 Object to picture matching

 Picture to object matching

 Object to picture pointing

 Picture to object pointing

Level 1 Cont…
Step 2. SMALL PICTURE MATCHING
 Object to picture matching

 Picture to object matching

 Object to picture pointing

 Picture to object pointing

 Level 1 Cont…
 Step 3. Object Use Training.
 Step4. Action picture taking.
 Step5. Following action picture command.
 Step6. Pantomimed gesture demonstration.
 Step7. Pantomimed gesture recognition.
 Step8. Pantomimed gesture training.
 Step9.Pantomime gesture production.
 Step10. Representational gesture for absent object training.
 Step11. Representational gesture for absent object
PROGRAMME HIERARCHY
Step 1. LARGE PICTURE MATCHING
 Object to picture matching
 The eight large objects card are arranged randomly
in a line in front of patient. The object are handed to
the patient, who places them on the corresponding
picture.
 Picture to object matching
 The eight objects are arranged randomly in a line,
and the objects card are given for placement on the
object.
AAC
 Treatment for adults with global aphasia has
typically involved the use of verbal treatment
methods or alternative communication
techniques including communication boards, word
lists and notebooks.
 However, many adults with aphasia are unable to
communicate verbally and alternative
communication techniques can be limited, as a
result of the restricted number and type of concepts
that can be adequately depicted and expressed.
PROVIDE EARLY COMMUNICATION
SYSTEM

Phase 1- Initial choice making(y/n)

Phase 2- Pointing

Phase 3- Multipurpose Electronic AAC device

Emerging Communicator
CHALLENGES
 Poor comprehension without visual or personal context
 Inconsistent or nonexistent signal for “yes” or “no”
 No functional speech or gestures

Intervention Strategies for Emerging Communicators

 Low-tech AAC devices can be used to help the emerging communicator
comprehend and control their environment
•Treatment is focused on foundational communication
skills: turn-taking, choice-making ability with tangible
objects or photographs, referential skills, and clear signals
of agreement or rejection
•Conversation partner training should focus on how to
provide choice-making opportunities throughout daily
routines and reinforce communicator’s responses
Contextual Choice Communicator

Characteristics
 More capable than emerging communicators, but do not
initiate or add to conversations on their own – socially
isolated
 Can participate in conversations when provided written
choices on a turn-by-turn basis
 Can clearly indicate an answer or preference by pointing
to a choice of objects, pictures, or large print written
words.
 May benefit from Augmented Input Techniques
INTERVENTION STRATEGIES FOR CONTEXTUAL
CHOICE COMMUNICATOR

 AAC interventions should be embedded

within conversations about familiar topics
 Primary expressive goal is to teach the
communicator to consistently reference what
he or she is talking about, understand the
meaning of graphic symbols, make choices to
answer questions, and begin to ask questions
by pointing
Transitional Communicators
 Characteristics
 Have strategies to convey their message when they are unable to
speak, such as search through their communication notebooks or
gesturing.
 Biggest challenge is communicating successfully in spontaneous
conversations without contextual cues
 Intervention Strategies for Transitional Communicators
 Focus is on initiating conversations with as little cueing as
possible
 Storytelling can be used as a content-rich communication
activity
Independent Communicator
 Can comprehend most of what is said to them
without contextual support; use both natural
speech and augmented strategies

High tech electronic devices can be used with

them
Drawing to communicate
 Another variable means of communication for the
globally aphasic adult is drawing. However, few
individuals with severe aphasia initiate
communication through this modality without
specific training
Promoting Aphasics' Communicative Effectiveness (PACE)

 The therapist will use a picture or drawing to

stimulate a conversation, while the person with
aphasia is encouraged to use any means of
communication to respond.
 Early PACE sessions will focus on relatively
simple topics of conversation, such as where the
person was born. As the sessions progress, the
topics of conversation become more complex and
abstract, including, for example, the person’s
favourite film and why they like it.
1. The Exchange of New Information

 In PACE conversations, the messages that the therapist

and patient send to one another must consist of new
information. Usually, cards showing line drawings are
used to provide the subjects for messages.
 The person sending the message describe a card and
must somehow explain what appears on it to the other
participant.
SEQUENCE OF CARD PRESENTATION

 Cards showing everyday objects are typically used during the

first phase of therapy.
 Verb cards are introduced next
 Followed by story-sequence cards
 In other words, the content of messages becomes more
abstract as therapy progresses
2. Equal Participation

 In PACE, the therapist does not overtly direct the

interaction. Instead, he/she and the patient participate
in dialogues as equals, taking turns as both the senders
and receivers of messages. Thus, both are responsible
for accurately conveying information and for giving
feedback indicating whether or not messages sent by
the other person are sufficiently clear
3. Free Choice of Communicative Channels

 The patient's ability to communicate effectively is

stressed in PACE, not the use of a particular
communication system.
 Participants in PACE conversations may convey their
messages by speaking, writing, drawing, pointing
at object, gesturing or any other mode of
communication available to them.
 The existence of so many options improves the chances
that the therapist will understand the patient's messages
and thus reinforce his/her attempts at communication
 The therapist can subtly encourage the patient to use a
mode of communication by using it. For example, if a
clinician wanted a patient to practice using gestures,
he/she could utilize gestures when sending messages.
4. Functional Feedback

 The feedback provided by the therapist in PACE

conversations is realistic and functional. Rather
than telling the client that a response was
correct or incorrect, he/she tells him whether the
message was understood, as any listener would do
in an everyday interaction
 When the patient sends an unintelligible message,
the therapist should do more than indicate that
he/she does not understand the communication
 He/she should ask for more information, guess, or
try some other technique to help the patient send the
message in an understandable manner.
Treatment of underlying forms (TUF)
 It is the linguistic approach to the treatment of expressive
aphasia, treatment begins by emphasizing and educating
patients on the Thematic roles of words within sentences.
 Sentences that are usually problematic will be re worded
into active-voiced and declarative phrasings
 The simpler sentence phrasings are then transformed into
variations that are more difficult to interpret.
 For example, many sufferers of expressive aphasia struggle
with Wh- sentences. “What” and “who” questions are
problematic sentences that this treatment method attempts
to improve.
Contd…………
Training of Wh- sentences has lead improvements in
three main areas of discourse for aphasics:
 increased average length of utterances,

 higher proportions of grammatical sentences, and

 larger ratios of numbers of verbs to nouns

produced.