ManagementofWernickesAphasia:AContext

BasedApproach
RobertC.Marshall,Ph.D.,Professor,Departmentof
RehabilitationSciences,UniversityofKentuckyand
ResearchConsultant,UniversityofMichiganAphasia
Program

WernickesAphasia
WernickesaphasiaisassociatedwiththeGerman
neurologist,CarlWernicke.
PierreMarie,theFrenchneurologistconsidered
Wernickesaphasiatheonlytrueaphasia.
JosephWepman,usedthetermthetalking
aphasicswhenreferringtoindividualswith
Wernickesaphasia

CausativelesionsinWernickesaphasia
Blockagesinsmaller,posteriorbranchesof
LMCA(emboli)
Damagetoprimaryauditorycortex(41,42),
Wernickesarea(22),secondtemporaland
angulargyri(39,40),whitematterextension.
Damageofareasvitaltolanguageprocessing
butnotmotorareas

SymptomsofWernickesAphasia
Speech&Language
Severecomprehension
deficits
Attentiondeficits
Fluent,butseverely
disruptedspeech
Severeimpairmentof
readingandwriting
Poorselfmonitoring

Physical
None
Individualisusually
independentinselfcare
shortlyaftertheirstroke
Strokeoftendoesnotresult
inlossofconsciousnessfor
someindividuals

WernickesQuiz
Therearemanytreatmentprogramsandavailable
treatmentoutcomestudiesforWernickesaphasia.T/F
Wernickesaphasiahasapoorerprognosisfor
improvement.T/F
Wernickesclientsdisplaylesscognitiveflexibility.T/F
Clinicianthatliketocontrolthetreatmentsessionenjoy
workingwiththeWernickesclient.T/F

AdvantagesofaContextBasedApproachto
Management
Fitswiththewaythistypeofpatientistreatedinthemanagedcare
system(earlydischarge)
Helpsthepatientcopewithimmediatedemandstocommunicateina
reallifecontext(athome)
Capitalizesonthepatientsstrengths(speaking,preservedsyntax,
pragmatics,mobility,speedofresponsiveness)
Promotescompensation(usingallmodalitiesofcommunication)and
providesascaffoldforcaregivereducation
Providesimmediatesuccessincommunicationandsetsthepatientup
forlaterdeficitspecifictreatment

Vern
Vernhadalefthemisphereembolicstroke
withresultingWernickesaphasia.Hedidnot
loseconsciousness,buthisspeechwas
severelydisrupted.Infactitwassodisrupted,
andVernwassoupsethewastakentothe
policestationbeforehewastakentoa
hospital.

VernsHospitalCourse
Onceinthehospital,Vernwasdeterminedto
havehadastroke.Hewasfinephysically,but
hewasveryfrustratedhecouldnotmakehis
needsandwantsknown.
Heseemedtobetryingtotellussomething
important.Hebecomesoupsetwithhis
failureshehadtobeplacedinrestraints.

VernsSpeechEvaluation
Vernsspeechandlanguageevaluationwent
poorly.Hegavefewmeaningfulresponsesto
testitems,butheneverrelentedintryingto
getanimportantmessageacrosstome.
Ultimately,Iabandonedmyattemptstotest
Vern,andconcentratedonwhathewastrying
totellme.

TheBirthofaContextBasedApproach
WhenIstoppedtryingtogetVerntopointtopicturesandnamethings
andjustconcentratedoninterpretingwhathewastryingtotellme,I
learnedthatthecauseofhisagitationwashiswifesdrinkingproblemand
thefearthatshewouldsquandertheirsmallsavings.
Vernwassoondischarged,butwehadformedabondthatledtolater
treatmentsuccess.
Hetaughtmethatcontextualcommunicationwasthewaytogointhe
earlystagesofmanagementwithclientswithWernickesaphasia,andIve
neverstrayedfromthat.

ContextBasedManagement
Thegoalofthecontextbasedapproachisto
improvelisteningcomprehensionand
informationexchangeinauthentic
communicativecontexts.

AuthenticCommunication
Contexts?
Topics/issuesthepatientwants,needs,orcan
communicateabout;problemsthepatient
wantstosolve
Vern:Fearsandconcernsover$
Marie:Goinghome
Pat:Childcustody
Celia:TuningintotherightBiblepassage

CreatingCommunicativeContexts
AllpatientsarenotlikeVern.Sometimestheclinicianhasto
createacontext.Shecandothisbyconnectingtothe
patientspersonalinterests:
Reviewingmedicalchart
Observing
Askthefamilyaboutthepatientspremorbidinterests
Biographies

ForExample

CubFan
Humor/sarcasm:Theyblewitagain
Emotion:Couldthisreallybetheyear?
Sharedknowledge:ImabigCubfantoo.
Availableprops:Whatsgoingonwiththe
Cubstoday?

StrengtheningtheContextualConnection
Writteninformationdetailingthetopic,key
words,orotherinformation
Facialexpression,gesture,bodyposition,tone
ofvoice
Relevantpictures
Personalartifactsofthepatient

OnceConnected
Capitalizeon:
Abilitytoconverse(fluency)
Preservedsyntax(abilityto
shifttenses)
Preservedpragmatics
(humor,nuance,sarcasm)
Speedofresponsiveness

Minimizeneedfor:
Bottomupandoffline
comprehension
Retrievalofspecificwords
Repetitionortorespondto
cues

SupportforContextBased
Treatment
Severalclinicalpapersinyourreferencelistprovide
therapeuticsuggestionsthatarerelevanttoacontextbased
approach.
Fromthesecomeanumberofsuggestionsforenhancing
comprehensionandimprovinginformationexchangeforthe
patientwithWernickesaphasiaintheearlypostonset
period.

Comprehensioncomesfirst:Findtheholeinthe
screen
Imagineyouhaveawiremesh
screenandyouthrowgooey,
stickymudatthescreen.
Someholesinthemeshwillbe
filledwithmud;otherswillbe
open.
Fortheclienttocomprehend,
youhavetohitanopenhole

Contextprimestheclientfor
listening
Throughtrialanderror,and
bylearningfrompast
experience,theclinicianfinds
aholeinthescreen.
Oncetheclientcomprehends
amessage,shemoveson
fromtherebycontinuingthe
conversation.

SuggestionsfromtheAuditoryComprehensionLiteratureon
ImprovingContextualComprehension

Highlightmainideas
Emphaticstresstoimportantwords
Usedirectwording
Userepetitionandparaphrasing
Speakalittleslowerandgettheclients
attention
Cohesiveties

MaintainingtheContext
Reinforceandencouragetheclienttoaskfor
repeats;askforrepeatsyourself
Verifyandrephrasewhattheclienthassaid;
askrhetoricalquestions
Clearlyalerttheclienttotopicswitchesand
reorienttothetopic
Givetheclientalisteningbreak

DemonstrateHowtoMaximize
Comprehension
Inacontextualsituationwherethetopicis
knowntoallthetherapistcan:
Demonstratehowtotalktotheclientto
maximizecomprehension
Revealtheclientscompetence
Familymembersandstafftuneinbetterto
topicsofmutualinterest

StopversusGoStrategies
Originally,itwasbelievedthatthebestwayto
workwiththeWernickesclientwastostop
thepatientformtalkingandhavehim/her
listenandtuneintotheirerrors.
Martin(1981a,b)questionedstoppingthe
bestthingthepatientdidandofferedan
alternativegostrategy

ImplementingaGoStrategy
Identifyatopicofinteresttotheclientthat
youknowsomethingaboutandletthepatient
teachyouaboutit
Becauseyouhaveaprioriknowledgeofthe
topic,youcanbeagoodinterpreterofthe
clientsdefectiveutterances

BreakingtheCycle
Paraphraseandrephrasetheclients
defectiveutterancessothattheyarefed
backtotheclientasagoodmodel
Thisbreaksagarbageoutgarbageincycleand
maintainscommunicationandinformation
exchange
Itprovidetheclientwithsuccess

TakingYourCuefromtheClient
Fillingintheblanksandprovidingtheclientwiththe
missingwordinafacesavingmanner
Encouragingtheclienttokeeptrying
Forgettingaboutthewordfindingproblemand
movingonbecausetheclienthasconveyedthe
meaning
Admitifyoudontgetit moveoninafacesaving
manner

IncreaseDegreesofFreedom
Increasethenumberofoptionsforconveyinga
specificthought(relatedwords,descriptions,direct
referencetoitems)
DramaticallyreducetheuseofWhquestions
Askopenendedquestions makeopenended
statementsfortheclienttopickupon

Compensations
Reinforcingtheclientforbeingcognitively
flexibleandsuccessfullyusingdrawing,
writing,gesture,andpointingtoconvey
information
Discouragingtheuseofineffective
compensations,byfillinginthemissingword
fortheclientandtellinghim/herwhen
somethingdoesnothelp

Selfcorrection
Reinforceerrorawarenessandanyeffortto
selfcorrectwhethersuccessfulor
unsuccessful

Variability
Wernickesclientsareundulyconcernedthat
theirabilitytocommunicatespecificsvaries
fromdaytoday
Sometimescounselingisneeded

Successes
Summarizethingsfortheclientwhen
informationhasbeensuccessfullytransmitted
Theimmediatesuccessinsendingand
understandingmessagespreparestheclient
forlaterdeficitspecificwork

Mary
65yearoldwomanhadalefthemisphere
ischemicstrokewhileathome.
NoLOC;nophysicaldeficits;completeloss
abilitytocommunicate
Maryrealizedshecouldnotdrive;shewalked
twomilestoabrothershouseforhelp

MarysStory

Wernickesaphasia severe
Earlyrehabilitationunsuccessful
Marylivingathomealone,butsuccessfully
MaryenrolledinUniversityclinic
Unresponsivetodeficitspecifictreatment
Responsivetocontextbasedtreatment

FunctionalTests
Direct
CADLII
Everydaylanguagetest
AphasiaFunctional
LanguageAssessment
InpatientFunctional
AssessmentInterview

Indirect
ASHAFACS
FAQA
CETI
OxenhamQuestionnaire

Summary
No
Drill
Repetition
Tasksrequiringbottomup
processing
Cues/prompts
Acontextualmaterial

Yes
Personallyrelevantmaterial
Givingtheclientoptions
Increasingdegreesoffreedom
forwordchoices
Takingresponsibilityfor
comprehensionand
correction

AtmosphereofDelight
Aphasiarepresentsaproblemaccessinga
learnedcode.
Thepersonwithaphasiaiscompetent
Languagewaslearnedinanatmosphereof
delightwhichwasalwaysacontext
Itmakessensetorestoreitinasimilarvenue

References
Cochrane,M.(1983).Languageandtheatmosphereofdelight.InWinitz,H.(Ed.).TreatingLanguageDisorders:
forCliniciansbyClinicians,(pp.143162).Baltimore:UniversityParkPress.
Golper,LA,Rau,MT(1983).Systematicanalysisofcueingstrategiesinaphasia:takingyourcuefromthe
patient.InBrookshireR(ed.),Clinicalaphasiology:Conferenceproceedings,http://aphasiology.pitt.edu
Marshall,RC(2008).EarlymanagementofWernickesaphasia:Acontextbasedapproach.InChapeyR(ed.),
Languageinterventionsstrategiesinaphasiaandrelatedneurogeniccommunicationdisorders(5th ed.),
507529,Baltimore:Lippincott,Williams&Wilkins.
Marshall,R.C.(1983).Communicationstylesoffluentaphasicclients.InWinitz,H.(Ed.).TreatingLanguage
Disorders:forCliniciansbyClinicians,(pp.146180.Baltimore:UniversityParkPress.

References
Martin,AD(1981a).Therapywiththejargonaphasic.InBrownJ(ed.),Jargonaphasia,(pp.305326).NewYork:
AcademicPress.
Martin,AD(1981b).AnexaminationofWepmansthoughtcenteredtherapy.InInChapeyR(ed.),Language
interventionsstrategiesinaphasiaandrelatedneurogeniccommunicationdisorders(pp.141154,
Baltimore:Williams&Wilkins.
Wepman,JM(1972).Aphasiatherapy:anewlook.JournalofSpeechandHearingDisorders,37,203214.