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Broca's aphasia

Assessment

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Principles of Assessment (Johnson, 1998)

1. To describe language behaviors in terms of both strengths and weaknesses. 
2. To identify existing problems. 
3. To determine intervention goals.
4. To determine factors that facilitates the comprehension, production, and use of language.
 

Goals of Assessment for Aphasia (Website 1)

1. To determine if the patient presents with aphasia-are the patient’s language skills within normal limits when compared to others. 
1b.  To identify the existence of complicating conditions-such as auditory and visual sensitivity and motoric impairment. 
2. Analysis of cognitive abilities-Cognition refers to the way sensory input is transformed, reduced, stored, elaborated, recovered, and used. 
3. Analysis of the ability to comprehend language content.  This is the meaning, topic, or subject, matter of individual words, utterances, and conversation. 
4. Analysis of the ability to comprehend language form.  This goal analyses the patient’s understanding of morphology and syntax. 
5. Analysis of the ability to produce language content.  This goal analyses whether the patient can provide the spoken or written name of objects, actions, or attributes. 
6. Analysis of the ability to produce language form.  This includes morphology, syntax, and phonology. 
7. Analysis of pragmatic ability.  This includes the ability to convey message, understand discourse rules, and conversational skills. 
8. Determination of candidacy for progress in therapy.  Prognostic indicators include biographical variable, medical variable, and language/cognitive variables. 
9. Specification and prioritization of intervention goals.  Goals are formulated by and language and what areas are in most need of intervention.


Hallmarks of a Quality Assessment
The evaluation of a patient with aphasia must be very thorough, including the following characteristics: 

1. A current knowledge of the characteristics and patterns of the patient’s language impairment in aphasia as well as the restrictions to personal activities that it may induce. 
2. Comprehensive language samples of patients performing tasks at various levels. 
3. Repeated observation, abstraction of behavior patterns and formulation of hypotheses. 
4. A qualitative and quantitative description of performance to generate information regarding the course, extent, and scope of treatment. 
5. Respect for each and every patient, including that patient’s past history and accomplishments, as well as their future contributions. 
Assessment Processes (Brookshire, 2003)
The assessment of aphasia involves three interrelated components:  Data collection, hypothesis formation, and hypothesis testing.
1. Data Collection:  This is the process of obtaining information that is linked directly or indirectly to the patient’s strengths and weaknesses.  Data collection strategies include observation, screening tests, and comprehensive standardized tests. 
2. Hypothesis Formation:  This involves categorizing the data or forming taxonomies based of regularities or similarities observed in the collected information.  It also involves interpreting the data and making decisions regarding the presence of aphasia, candidacy for prognosis, and appropriate treatment goals.  Categorization examples are classification and severity. 
3. Hypothesis Testing:  This is the ongoing assessment of treatment goals, procedures, and patient progress.  It enables the clinician to continue to secure additional data about the language abilities and deficits of the patient in order to determine the validity, accuracy, and appropriateness of hypotheses that were formulated.  These results must be reported.
 
The assessment of aphasia begins when the referral lands on the speech-language pathologist’s desk (Brookshire, 2003).  Once it is determined that the patient has aphasia, the question of type becomes important (Johnson, 1998(.  Types of aphasia can be ascertained through analysis of the present language profile and history.  Cortical and sub cortical aphasias should be determined using their characteristic profiles of language behavior.  In addition to determining the type of aphasia, it is important to determine the level of functional impairment. A scale can be used that is directed at looking at communication use in the environment in which the patient typically communicates.  A more in depth test is needed if the screening does not provide adequate information or if the patient experiences difficulty.  The results of these tests indicate the severity of the aphasia and also provide information regarding the exact location of the brain damage (website 1).  This more extensive testing also provides more information necessary to design an intervention plan. 
Tasks to Assess for Broca’s Aphasia
As was previously stated, slow, confluent speech, limited output, sound distortions, impaired naming and repetition, difficulty understanding syntactic structures, and apracia of speech characterize Broca’s aphasia.  Auditory comprehension of spoken language is better than production.  Assessment of these target behaviors should be meaningful to the patient.  Some of the most commonly suggested assessment for these target behaviors is the following: 
1. Naming Responses:  Select names of actions, objects, or persons that are of immediate use to the patient.  Synonyms, antonyms, spelling words rhyming words, and completing sentences can also be used for assessment. 
2. Phrases and Sentences:  Simple phrases and sentences can also be used.  Adding functional units or sentence forms can expand these.  Morphological features can also be assessed. 
3. Writing:  Copying letters, words, and sentences, wring from dictation, and spontaneous writing can be assessed. 
4. Reading Skills:  Use isolated words, which are useful to the patient.  Also assess silent reading and comprehension using materials of interest and value. 
5. Repetition Skills:  Repetition of single words that are useful to the patient should be used as well as blends and multisyllable words.  Also used is repetition of sentences. 
6. Automated speech and Singing:  Such tasks, as recitation of the alphabet, singing of familiar songs, and humming a tune should be used. 
Assessment Batteries for Broca’s Aphasia
There are diagnostic tests and functional communication batteries for diagnosis of Broca’s aphasia. 
Three of the most widely used diagnostic tests are: 
1. Porch Index of Communication Ability PICA:  this test assesses the measurement of the level of performance over a wide range for both initial determination and detection of change over time (website 2)
Description:  the measurement of change is based on a multidimensional scoring system, which is intended to be sensitive to subtle differences among aphasia behaviors.  The PICA evaluates auditory comprehension, reading, oral expressive language, pantomime, visual matching, writing, and copying abstract forms.  It consists of eighteen subtests and requires intensive training to administer and score.

Prognosis and Recovery: PICA has been used extensively as an objective measure of recovery.  The end score can be treated as a statistic to represent changes in single subtest related functions, response categories, and overall language function.  Mean scores are used to predict later levels of functioning.  The overall score is a single indication as to the amount of recovery made by a patient with aphasia. 

Treatment Planning:  Patterns of performance indicate the areas of language function, which are successful but challenging to the patient.  By having the patient do tasks in which his responses are slow but correct. The clinician can maintain the probability that the patient is working on tasks which are not are not beyond his capability, but are of a level of difficulty which forces him to work at near capacity.  Tasks which require the patient to use his language processing system at near capacity seem to be more effective and efficient in restoring the function of the system. 
2. Minnesota Test for Differential Diagnosis of Aphasia MTDDA:  This test is a comprehensive assessment of the assets and liabilities of the patient in all language areas as a guide to therapy.  It also predicts differential diagnosis of and recovery. 
 
Description: 
MTDDA is the most comprehensive of all aphasia tests. It takes form two to six hours to administer and consists of forty six subtests divided into five sections:  auditory disturbances, visual and reading disturbances, speech and language disturbances, visuomotor and writing disturbances, and disturbances of numerical relateions and arithmetic processes. 

Differential Diagnosis: 
This test is geared to differential aphasia from nirmal levels of language function with the aid of the normative data. 

Treatment Planning: 
This test provides many circumstances for task and item comparisons so that the clinician is able to make inferences about the basic problems to be treated.  The MTDDA provides a wide sampling of potentially adequate types of stimuli, of situations in which responses can be elicited, and of the kinds of circumstances in which a patient is able to use language successfully. 
3. Boston Diagnostic Aphasia Examination BDAE:  Description:  This test is geared towards diagnosis of the presence and type of aphasia, leading to inferences concerning the location of brain damage (website 2). 
It is primarily designed for the sampling of language behaviors, which have been demonstrated to be discriminative in the identification of aphasia syndromes. 
It evaluates particularity fluency, word finding, repetition, serial speech, grammar, paraphasias, auditory comprehension, oral reading, reading comprehension, and musical skills.
Differential Diagnisis: The BDEA provides an objective basis for the identification of aphasia syndromes and for pinpointing deviations from those syndromes in patients who do not fit the classification model.  They include profiles of a prototypical case and a range of performance for Broca’s, Wernicke’s, conduction, and anomic aphasia. 
Functional Assessment:
Functional communication assessments are useful in evaluating daily communication in in everyday settings (Roseberry-McKibbin, 2000).  These tests may be more biased than standardized tests in evaluating clients from linguistically and culturally diverse backgrounds.  Changes in functional communication may be measured.  Most tools require the clinician to make extensive and systematic observation of the clients and rate them on variable being measured.  Three commonly used functional communication assessments are: 
1. Communicative Abilities in Daily Living:  This test emphasizes daily communication in everyday situations.  Such skills as reading, writing, estimation of time, use of verbal a nonverbal contexts in communication, role-playing, social conventions, humor, and metaphor are rated. 
2. Functional Assessment of Communication Skills for Adults:  This test helps rate social communication, communication of basic needs, reading, writing, and number concepts, and daily planning. 
3. Communication Profile:  A functional skills survey.  An advantage of this test is that its sample includes patients from different cultural backgrounds.  It uses a rive point scale to rate the importance of selected skills of daily living.
 

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