Language and Cognition Colombo 2011

1. Language and CognitionColombo 2011 Day 7 Specific Issues in Aphasia – Treatments for production impairments

2. 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)

3. Restitutive Treatment

4. Spoken word Written word Visual Analysis Auditory Analysis Object Recognition AIL VIL Grapheme to Phoneme Conversion Semantics POL Buffer speech

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

6. 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

7. 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

8. Semantic Feature Matrix/Analysis GROUP USE ACTION (is a _____) (is used for _____) (does what?) Target Picture PROPERTIES LOCATION ASSOCIATION (Has/is ___) (Reminds me of ___) (Is found _____)

9. 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?

10. 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

11. 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!”

12. 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

13. Spoken word Written word Visual Analysis Auditory Analysis Object Recognition AIL VIL Grapheme to Phoneme Conversion Semantics POL Buffer speech

14. 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

15. 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

16. 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.

17. 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.

18. Substitutive Treatment

19. Circumlocution • Provision of semantic information to describe a concept May also allow for lexical representation to be accessed more easily (Whitworth, Webster and Howard 2005)

20. Graphemic self-cueing • Despite impaired POL, patient may access spelling. • Use grapheme-to-phoneme conversion to generate first letter and sound

21. 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.

22. 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.

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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.

29. 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

30. 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.

31. 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)

32. 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

33. 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

34. 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

35. 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

36. 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