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Lecture Notes April 14, 2010Severe Left Neglect: Determine the type of cues that are appropriateE.g. the client is hunched over to the right.The client will turn to the left during a conversation with verbal, visual and tactile cues with 100%Stimulus: the clinician will say to the client, “look to the left” Tactile cue: the clinician will turn their wheel chair. Verbal cue: Clinician will say “ I am turning your wheelchair” Verbal cue: the clinician will say “ look at me I am turning my head”The client will describe a picture.The client will complete a task. Mild Left Neglect: Determine the type of cues that are appropriate (e.g. The client will turn to the left during a conversation (pragmatics) given verbal and vision cues with 100%The client will look to the left during a conversation (pragmatics) given verbal and visual cues with 100%The client will look to the left during reading/writing (communication) given verbal and visual cues with 80%-100%.Stimulus: the clinician will say to the client, “look to the left”. Verbal cue: the clinician will explain to the patient about turn to the left during conversation. Visual cue: the clinician will put something bright and highlight something on the right and it the cue to turn to the left. Informal Extension of Attention1. Does the client complete task?2. Does the client maintain conversation for 5 minutes?The client will describe an object The client will complete a taskThe client will turn his head left with 100% accuracy because of Verbal means the clinician will tell the client to turn the headVisual means the clinician will the client will turn his head left with 100% given a verbal cue, visual cue The client will describe a object on their left side using reading, writingthe client will attend to the conversation partner (pragmatics)If we highlight, this is a visual cue.Attention by incorporate into goals by completing a conversation, completing tasks. Do leave room for argumentsProsodyMelodic contour and rthym of speech-song voiceConveys meaning-types of meaning, different example of prosodic-emotional content during conversation (e.g. client will sound low or high during conversation if they are expressing emotional content)Examples-state of speaker=how is the speaker feeling=emotional content-speaker’s attitude towards listener-if person being sarcastic, you can tell-sarcasm- can be picked up.RHD-monotone or euphoric (over the top happy)-Patient will never changeThe client will change contour during conversation (pragmatics)-over the top happy is rare-humor does not work with monotone:Example..with humor, you expect prosodic contour to convey laughter-people who have a lot of prosodyLinguistic effects-how prosody affects stress and syllable duration-change of stress will change the meaning of sentenceExample: The patient with montone will say “green house” without stressGoal: the client will add stress to spondee words during a conversation (pragmatics), reading (communication). the client will add stress to a word in a sentenceStimulus: Non-linguistic (emotion, humor, formality) how prosody affects emotions, humor and formality-changes the meaning of the sentence-emotions-with friends use prosody, with colleague don’t use emotional prosodyIf I am happy I will change my contours with my friendsIf I am serious, I will not change my contours?Mild RHD or Mild R CVATarget: Goal: the client will change contours in a conversation with 100% accuracy with verbal and visual cue.[Stimulus: the clinician will ask to change the contour of the sentence by raising the pitch, verbal cue: the clinician will model the contour in conversation, visual cue: the clinician will gesture the contour by raising his hand.Severe RHD or Severe R CVATarget:Goal: the client will use contours to change meaning in a sentence with 100% accuracy with verbal, visual, and tactile cues.[Stimulus: the clinician will ask the client to raise the contour at the end of sentence: Verbal cue: the clinician will model the contour. Visual cue: the clinician will trace the contour above the sentence. Tactile cue: the clinician will use finger over finger and trace the contour of the sentence with the client’s finger]]PATIENT WITH RHD, Patient with R CVAPitch is vulnerable in RHD-no vary pitch-A person with no pitch sounds monotoneLanguage is intact but prosody impaired (-high incidence of divorce)Counseling the Family-tell family that the pt’s prosody has changed. One of the symptoms of RHD, R CVA, is the patient will sound monotone. Typically, the patient will not be able to contours, pitch, or stress to convey emotional meaning. Emotional prosody most impaired with RHD-can produce or comprehend prosody (e.g. the patient spouse is having a bad day and the patient doesn’t get the emotional content from the patient) The patient is having a bad day and the spouse doesn’t get the Target: Production and Comprehension of Prosody-communication breakdown between Client will identify emotions and tell each otherMild RHD or Mild RCVATarget: AffectGoal: the client will verbalize his emotions with 100% accuracy with verbal andvisual cues[Stimulus: the clinician will teach the patient on how to tell others how they are feeling. “I am having a bad day, Verbal cue: the clinician will remind the client to state his feelings before beginning. Visual cue: the clinician will gesture Target-facial expressions (e.g. patient can not detect facial expression, crying face does not understand)Goal: the client will use facial expressions in conversation with 100% accuracy with verbal and visual cues.[Stimulus: the clinician will ask client to imitate clinician facial expressions. Verbal cue: the clinician will describe aspects of the facial expressions. Visual cue: the clinician will imitate the facial expression for the client.]]Target-content of story (e.g. clinician will have to pull out key components)Goal: the client will verbalize the emotional content of the story with 100% with visual and verbal cues.[Stimulus: the clinician will teach the patient on how to tell others about the emotional content of story by saying “this is a funny, sad, exciting story” Verbal cue: the clinician will remind the client to say ‘this is a funny story” Visual cue: Characteristic of Communication Breakdown in Patient with RHD, RCVACommunication breakdown because emotional are not conveyedRHD must identify feeling. model=feeling,RHD can not identify facial expression (goal) RHD will identify the content of the story through emotion/feelings.Clinician can pick out stories from newspaper and talk about the emotional contentTherapy approach and Targets for RHD, R CVA-match prosody to picture with emotions (pictures of sad, angry, mad)-mild to severe-monotone (teach changes in prosody for mild cases)-identify stress patterns on paper….draw the contour and see if they can raise their voice,Visual cue: draw a contour, elevate hand as contour goes up to signal raise the voiceVisual cue: draw the stress onto word, elevate hand to signal stress or how stress is equal.Tactile: use patient finger or tap with patientTarget-Exclamation!-clinician will teach the client to become louder.Goal: the client will use loudness to convey exclamations in a conversation with 100% accuracy with verbal, visual and tactile cues. [Stimulus: the clinician will ask the client to increase loudness on stressed exclamatory words: Verbal clinician: the clinician will say “make the word louder” Visual cue: the clinician will draw the stress on the word or gesture the stressed word. Tactile cue: the clinician will use hand over hand to tap the loudness]]Reliance of semantic information-literal Why? instead of prosodicPatient will look for meaning before prosody-must be literal. Patient will say “I am having a bad day, or Spouse saying “I having a bad day”difficulty understanding sarcasm-don’t target sarcasm or humor.Client will need to use literal meaning especially for severe RHD, RCVAKnowledge of the emotionDifficulty with compound nouns vs. noun phrases (e.g. light house) if the patient is monotone, we will lose meaningMinimal emphatic stress-can use loudness to substitute (e.g. monotone: she wore that dress-no meaning convey except the literal. emphatic stress: she wore THAT dress-conveys that it was something else).Clinician will teach the loudness, but difficult to teach prosody can’t correct prosodyWhat happening in the RHD? Differences between RH and LH.RH perceives non-linguistic and emotional prosodyLH contributes to linguistic prosody because LH is language based.AREAS AffectedProsody comprehension R. anterior and Posterior. cortical lesions…the amount of lesion determine severity affect Note: if the person has severe left neglect, the prosody will be worseLinguistic prosodic deficits-Multiple areas are involved including sub cortical area and cortical area-right. frontal temporal and parietal lobes caudate nucleus, internal capsule, and thalamus.Neglect will guide how much the deficit is. Designing a Screener!5 sentences that bring aboutI had a great cup of coffee this morning (happy)My dog died yesterday (sad)my dog ate my sandwich (anger)I can’t believe it (excited)Are you okay? (concerned)Statement How do we screen for prosody in language..How would we describeProsodic contourExclaimation!Change the prosody to have a question that will raise the intonation patterns. Make changes in prosodicLinguistic deficits for RHD, RCVA1. Performs normal on aphasia test (w/assistance for L neglect)a. language is okay for RHD, RCVA, but aphasia test are not sensitive enough to detect errors in prosody.2. Problems with convergent and divergent thinkingConverging on one idea (can’t put humor together)-patient will put bits and pieces but can’t put it all together.-converging all part into the wholeDivergent thinking: Single concepts with additional concepts (problems with humor, dual meaning with jokes). If you only have one meaning, you don’t get the humor.Divergent; give me three reasons for moving.Convergent: semantic description of objectWord with dual meaning are difficult for patient with RHD and R CVA. (don’t get humor)Difference between the hemispheresRH-holistic -important for single word processing (e.g. different from anomia..single words less frequently used -less frequent meanings-slower than LH and less selective than LH-added value to language, the subtleness of language-writing symbols of Chinese-sign language will be lostLH-language-strong semantic overlap-words with multiple meanings-highly selective-rapid in selections-language dominatesRHD-Assessment-problems with collective naming (e.g. furniture)-the client will become confabulate. -problems with abstract categories (e.g. liquids)-more left neglect=worse linguistic -problems with generative naming (e.g. FAS)-given a category, name as many in 1 minuteAbstract vs. ConcreteHow will a person with RHD, RCVA perform on abstract naming vs. concrete naming?Affect vs. Emotion-affect how you appear outside (outward expression of emotion for patient with RHD will have a flat affect) or show the right feelingEmotion-subjective mood state: internal experiences-relies on internal experience..why is there a disconnect between emotions and affect for patient with RH. The person does not show the emotion…How do we judge a person emotions?. Clinician must be able to judge the patient emotion (e.g. patient will appear flat) and teach both the client and spouse how emotional meaning can be conveyed through communication.RH dominance theory (3 components are housed in RH)perception-in RHcomprehension-in RHexpression of emotion-RHIf the RH is impaired, all 3 components are effected. If the person have left neglect, then these components will be effected.How do write a screener?How do we describe affect…emotional liability…constantly crying constantly laughing…With Affect-Patient must identify emotions1. Problems with facial expression (both comprehension and production)-pt looks bored-if person can not produce or comprehend facial expressions, then the affect creates social isolation-if the person has mild left neglect, the person with RHD can comprehend gestures and postures-if the person has RH, RCVA, the person will have problems with verbalizing emotions (stories, conversation). Person will not be able to tell good stories or have good conversations. NO EMOTION-better identifying emotion when interested in story (in written text, not in conversation)-reduced prosody for emotional memories (just can’t change the prosody). Person with RHD and is monotone cannot change prosody even if it is a childhood memory. Person with poor pragmatic skills. RHD is difficulty to have conversation with.Clinician must do a good job on describe and evaluate client with RH and LHDepression (DSMR-IV)-30-60% of RHD have depression2 or more of the following :-poor appetitie or over eating-insomnia or hypersomnia-low energy or fatigue-low self-esteem-poor concentration or difficulty making decisions-feelings of hopelessnessDepression and RHD-organic effects-changes in serotoin because of R CVA-reactive effects-response to deficits because I can’t read a book.-refer to neuropsy…won’t do their best. Can’t do effective therapy when pt is depressedClinician must ask the patient if they are sad. Delusions and Confusions with RHD: forming new connection, healing processAgitated and confusion (with TBI or with RHD, acute stages of recovery, healing)-incoherent thoughts-similar to jargon-easily distractable-implicature of left neglect, not distractable if you don’t see left-restlessness-can’t open eyes is typical R CVA and don’t participant-violent outbursts-can occur with RHD but rare-anterior frontal and temporal damage-similar to TBIMisidentification syndromes (confused about person, place and body parts)-pt will conflabute…Patient will make up information. Patient thinks that they are at restaurantor not my armReduplicative para-amnesia (place and person) Disorder-imposter (e.g. you look like my SLP, but you are not my SLP)-bifrontal(TBI) or right hemisphere frontal and/or parietal lesions-korsakoff’s syndrome (paranoid, confused)-looks like wernicke’s aphasialong-term alcoholismlack of thiamineprolonged alcoholismtype of reduplicative para-amnesiaClinician will have work on cognitive-communicationCapgras Syndrome is a type of Delusion and Confusion-imposters psychiatric component-psy should work with this populationProsopagnosia-visual agnosia (sensory disturbance) of faces-bilateral posterior lesions-no recall of familiar face-recognize voice, recognize picturesSomatoparaphrenia (common with RH damage)-misidentification of won’t body parts-confabulation-left neglectRH disrupts the feeling of being connected and united.Cognitively they can tell what is wrongWhat would you do if you were working with an individual REVIEW IN CLASS AssignmentThe client will identify the emotion state prior to beginning conversation. Be descriptive…if can identify that they are fine and move onto therapy..Sorry, its part of my stroke. Example: the patient is constantly crying. Target:GOAL: the clinician will ask client “how they are feeling?”2. What would you do with RHD. How do we convince. Show examples of deficits and give feedback by and give information about deficit through charts. 1. Make the therapy function and ignore response2. show the person the data collect. show the person a video of himself3. show the person’s what strengths and weakness from their chart3. ask the patient how they are feeling and refer to psy. Patient with RHD are competent with languageTherapy treatment with misidentifications1. how to convince someone who I am? Put into a memory book a picture.2. use a secret code.Have the patient follow the midline and cross overPatient will describe the misidentification.How do convince who we are How do we identify imposters? Identify features with proof with picturesIdentify places….identify and compare two pictures what constitutes a hospital and constitutes a restaurant. Identify body parts…they are able to describe move to areas from what they can see to what they can’t see and vice verse..They know that they have a right and left. How do avoid confabulation? Use sensation as a task to id body parts and avoid visual+ ................
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