Language and CognitionColombo 2011

Day 7Specific Issues in Aphasia –

Treatments for production impairments

Principals of Treatment• Restitutive strategies appropriate in early stages

when neurophysiologic changes maximal e.g. semantic/phonological treatment

• Substitutive strategies aimed at circumventing the naming impairment -beneficial during acute and chronic stages e.g. gesture, reading, self-cueing

Rothi (1995)

Restitutive Treatment

Written word

Visual Analysis

VIL

Semantics

POL

Buffer

Grapheme to Phoneme

Conversion

speech

Spoken word

Auditory Analysis

AIL

Object Recognition

Semantics

• Semantic deficits:– Naming impairments (spoken and written)– Deficits in all comprehension tasks (auditory

and written)

Semantic Comprehension Treatment

• Can treating comprehension have direct impact on expression?

• Byng et al (1990): – patient with severe semantic impairment– Therapy targeted picture categorisation of

related items, and spoken word to picture match with semantic distractors

– Post therapy, improved naming for trained words

Semantic Distinctions

• Hillis (1998)– Patient provided with semantic information

about pictures the patient could not name.– Contrasted those with another related object– Significant improvements in naming trained

pictures – ALSO: improved naming in untrained pictures,

and written word production

Semantic Feature Matrix/Analysis

Target Picture

GROUP USE ACTION

LOCATION ASSOCIATION

(is a _____) (is used for _____) (does what?)

PROPERTIES

(Has/is ___) (Is found _____) (Reminds me of ___)

Semantic Feature Analysis Training

• Boyle and Coelho (1995)– Patient with mild non-fluent aphasia demonstrated

improved naming of trained and some untrained pictures.

– No generalisation to connected speech

• Boyle and Coelho (2000)– Patient with moderate fluent aphasia from HI– Could SFA training be used with more severe

aphasia? Would it be generalised better if larger number of stimuli used?

Semantic Feature Analysis Training

• Improved confrontation naming in treated and untreated items

• “Modest improvements” in connected speech

• Generalisation to untreated items more substantial when fewer target items used

• Effects maintained at 2m after treatment

Semantic Feature Analysis• Conley and Coelho (2003)• 57yr old female, 8yrs post Left CVA. Severe anomia• Naming 30 pictures using SFA and Response

elaboration training (RET)– …”What are they for?”– “Call…”– “That’s it you can call people”– “Jimmy!– “That’s it, you can call Jimmy on the telephone”– “Call…Jimmy”– “Maybe jimmy will call and say what’s for dinner?”– “Nothing!”

Conley and Coelho (2003)

• Treatment 3hrs/week, 6 weeks• Improved naming of treated and untreated

pictures• Treatment effect maintained at higher level

for treated over control pictures

• ?Whether combined approach was necessary

Written word

Visual Analysis

VIL

Semantics

POL

Buffer

Grapheme to Phoneme

Conversion

speech

Spoken word

Auditory Analysis

AIL

Object Recognition

Phonological Treatment

• Impairments in:– Oral naming– Oral word reading– Oral word repetition

• But:– Good auditory and word comprehension– Good written naming and writing to dictation

Phonological treatments• All routes lead to POL. Therefore:

– Reading aloud sets of words– Repetition of sets of words

Can facilitate naming abilities (Capasso and Caramazza 1996)

• Ellsworth and Raymer (1998)– “Does this start with /k/?”– “Does it sound like book?”– Improvements in verb naming when used with a

semantic questions hierarchy

Phonological Cueing

• Raymer et al 1993:– Patient attempts to name picture– Initial phoneme cue: “it starts with /t/”– Rhyme cue: “it rhymes with fable”– Oral reading cue: [TABLE]– Repetition: “Say after me, table”

• Improvements seen in trained words.

Phonological Judgement Treatment

• Robson, Marshall, Pring and Chiat (1998)– Provided patient with tasks requiring judgements on

phonological aspects• Number of syllables• Initial phoneme

– Encouraged activation of phonological representations

– Improved naming in trained and some untrained pictures.

• N.B. Nickels and Best (1996): phon treatment facilitates naming but often short-lasting and does not generalise.

Substitutive Treatment

Circumlocution• Provision of semantic information to describe a

concept

Target Response

TOMATO Can’t pronounce it, don’t like them, its red

SYRINGE A thing for pushing medicine

May also allow for lexical representation to be accessed more easily (Whitworth, Webster and Howard 2005)

Graphemic self-cueing

• Despite impaired POL, patient may access spelling.

• Use grapheme-to-phoneme conversion to generate first letter and sound

DeDe, Parris and Waters (2003)

• 49yr male, Left MCA infarct with subsequent haemorrhage.

• 4yrs post onset• Moderate-severe non-fluent aphasia

affecting verbal and written modalities• Oral, verbal and limb apraxias• Highly motivated to speak! Resistant to

alternative methods of communication.

DeDe, Parris and Waters (2003)• Auditory comprehension: functional for one to

one conversation. Difficulty for long and syntactically complex sentences

• Severe anomia with no impact of frequency or word length.

• Unable to access phonological representations in a picture homophone matching task

• Poor comprehension of written word• Unable to write single words to dictation or

complete written naming. Was able to write first grapheme with 50-60% accuracy.

Treatment cueing hierarchy

• Writing the word/given a choice of 3 first letters/therapist writes and patient copies

• Tactile cues for placement of first grapheme. Attempted independently. If unsuccessful, therapist assisted.

• Provision of phonological cue (first sound/syllable) and repetition of word

• Video for home practice to help enforce self cues

Results• Baseline Naming:

– Control targets: 4.2% correct– Treatment targets: 6.8%

• Post treatment naming:– Control targets: 12.1%– Treatment targets: 55.5%– Able to write all of target items with 100% accuracy– Required fewer prompts over treatment phase (1x

week for 13weeks)– But: was not maintained at 6 weeks & did not

generalise

Gestural training

• Close relationship between gesture and language processing.

• Gestural pantomime paired with spoken production of words can improve word retrieval in aphasia

• Gestural training may be as effective as phonological/semantic cueing

Raymer and Rothi (2008) in Chapey.

Lanyon and Rose (2009)• 18 participants with chronic aphasia• 20mins conversation samples (video)• Each transcribed and gestural markers added

Evaluation:• Spontaneous gesture signif. higher during word

retrieval difficulties• Resolution of WFD signif. Higher with gesture

present• 5 subjects produced 50% more gesture during

resolved WFD than in unresolved WFD

Lanyon and Rose (2009)

• Conclusions:– Mild aphasics likely to benefit from gesture

production as linguistic abilities largely available

– Severe aphasics can produce communicative gestures. Worth exploring gesture as part of a total communication approach

Drawing Together Therapy Project Sacchett and Lindsay (2007)

• A 1 year project. Aimed to:– Develop and Evaluate therapy to promote

communicative drawing in chronic, severe aphasia

– Examine generalisation to functional use in real-life settings

– 2 Benefits of drawing: uses visual channel, permanent record of exchange.

Patient: FM• 47yr male, left SAH 2 years earlier.• Well known musician, travelled widely,

previously extremely articulate.• Spoken word to picture match 39/40• Written word to picture match 38/40• Pyramids and Palm trees 47/52• Spoken picture naming 0/40• Written picture naming 0/40• Limb apraxia affecting gesture

FM: Drawing abilities• FM could:

– Copy drawings– Draw to command but recognisability compromised– Self generation 18/120 recognisable due to manual

dyspraxia and inclusion of unecessary detail

• 12 week therapy period, 1 hr individual therapy (wife present) , 2 hours group therapy per week.

• Positive factors for therapy: highly motivated, involvement of wife, FM already exposed to concept to non-verbal comm., good comprehension.

Therapy Schedule

• Weeks 1&2: Improving awareness of need for useful distinctive features only– Adding details to a base shape e.g. circle into

coin, ring, plate– PACE task with visually similar objects

• Weeks 3-7: Drawing into conversation– Drawing to convey actions/events through

PACE task drawing elements separately rather than simultaneously (e.g. woman, tablets, boy)

Therapy Schedule

• Weeks 7-12: Giving Complex Messages– Drawing a verbally presented problem or

situation to his wife, in a cartoon strip format to clearly define events

Goal Outcomes• FM will use drawing with other modalities to convey

novel information in real life.– Achieved

• FM will include only important details in his drawings– Out of context still difficult to recognise, but in context

recognisability rating higher.• FM will demonstrate improved awareness of his

communication partner by responding to attempts at interpretation– FM improved clarification skills, allowing interpreter time,

listening and responding to questions, adding info with gesture

Drawing• 6 key principals

– Have paper and pencil always to hand– Do not begin interactions with requests the person

with aphasia draw– Embed drawing in your own communication– Take the first turn by drawing a context and then

encourage mutual turn taking– Do not expect drawings to be distinguishable or

complete– Use what is distinguishable as a way of interacting

further.Lyon 2000

Summary• A variety of treatment approaches• No clear relationship between type of

impairment and most effective treatment (Hillis 2002)

• Some patients with semantic impairments benefit from phonological treatment and vice versa. A combination of both most effective.

• Restitutive approaches short-lived with little generalisation. Substitutive approaches may be more effective in real-life contexts

References• Raymer and Rothi (2002) Clinical Diagnosis and Treatment of naming Disorders (chp

9) in Hillis, The Handbook of Adult Language disorders: Integrating Cognitive Neuropsychology, Neurology and Rehabilitation

• Conley and Coelho (2003) Treatment of word retrieval impairment in chronic Broca’s aphasia. Aphasiology 17(3) 203-11

• DeDe, Parris and Waters (2003) Teaching self-cues: A treatment approach for verbal naming. Aphasiology 17(5) 465-480

• Nickles and Best (1996) Therapy for naming disorders (part 1): Principals, puzzles and progress. Aphasiology 10(1) 21-47

• Raymer and Rothi (2008) Impairments of Word Comprehension and Production in Chapey, Language Intervention Strategies in Aphasia and Related Neurogenic Communication disorders Wolters Kluwer, Lippincot, Williams and Wilkins

• Lyon (2000) Finding, Defining and Refining functionality. In Worrell and Frattali, Chp 9 in Neurongenic Communication Disorders: A Functional Approach

• Lanyon and Rose (2009) Do the hands have it? The facilitation effects of arm and hand gesture on word retrieval in aphasia. In Aphasiology 23(7-8) 809-822