Evidence Based Aphasia Therapy
after 15 years
Now What?
MACDG
November 4, 2015
St. Louis, Missouri
Sharon M. Holloran M.A.CCC
Lead Speech Pathologist for the Evidence Based Aphasia Clinic
The Rehabilitation Institute of St. Louis
EBAC Patients (2001-2014)
(not including 25 extremely severe patients, and non-covered)
Characteristic
Male
Female
Number/316
Percentage
184
132
Age
58.2%
41.8%
57.2+15
(16-90)
Anomic
Global
Mixed nonfluent
Wernicke’s
Transcortical sensory
Broca’s
Transcortical motor
Conduction
Unclassifiable
101
66
27
23
17
16
8
3
27
32%
21%
8.5%
7.3%
5.4%
5.1%
2.5%
<1%
8.5%
Fluent
Non-fluent
191
125
60%
40%
Weeks post-event
(range)
38.1 + 118.3
(1-1248)
EBAC Patients (2001-2014)
Etiology
Number/316
Percentage
LMCA ischemic stroke
194
61%
Left hemorrhagic stroke
66
21%
Left subcortical only ischemic
stroke
16
5%
Left hemisphere tumor
13
4%
Left hemisphere traumatic
brain injury (TBI)
11
4%
Left ACA or PCA ischemic
stroke, or subarachnoid
hemorrhage
6
2%
Infectious, seizures or multiple 16
sclerosis
5%
EBAC Patients (2001-2014)
Baseline Measures
(pre-treatment)
BDAE Language Competency Index (LCI)
Mean (sd)
Possible range
37.9 (28)
0-100
38.3 (31)
0-100
37.4 (30)
0-100
Boston Naming Test (BNT)
19.5 (20)
0-60
Communication Activities of Daily Living
(CADL-2)
63.9 (26)
0-100
ASHA Quality of Communication Life
Scale
3.78 (0.7)
0-5
Communication Effectiveness Index
(CETI)
53.4 (23)
0-100
LCI-Expressive
LCI-Comprehension
Levels of Evaluation of Change
6-month
5-month
4-month
3-month
2-month
1-month
Baseline
Aphasia diagnostic exam
X
X
Nonverbal cognitive testing
X
X
Mood/QOL/functional comm.
X
X
Family rating of change
X
X
X
X
X
X
X
Discourse measurement
X
X
X
X
X
X
X
Treatment data-trained
X/X X/X X/X X/X X/X X/X X/X
Treatment probe-untrained
X/X X/X X/X X/X X/X X/X X/X
Treatment probe-control behavior
X/X X/X X/X X/X X/X X/X X/X
Measurement
• Neuropsychology Measures
– Boston Diagnostic Aphasia Evaluation
– Communication Activities of Daily Living-2
(CADL-2)
– Boston Naming Test
– ASHA Quality of Communication Life
– Visual Analog of Mood Scale
Speech-Language Measures
• Western Aphasia Battery (WAB)-Initial Evaluation
– Aphasia Quotient
• Communication Effectiveness Index (CETI)-monthly
– 16 items to rate client with aphasia
• Discourse Comprehension Test-monthly
– 2 stories , 8 y/n questions on each
• BDAE Discourse Production Measure (Aesop fable story
retelling)-monthly
– Story retelling task yields 3 scores
Scoring
• CETI - mark a line 10 cm long on 16 items and find
average
• DCT- read 2 stories, ask 8 y/n ?’s per story
• Discourse Production- retell Aesop’s fable & record
• Ideally linded SLP takes measures and transcribes &
scores
Discourse Production PROBE
• Video of Aesop’s Fables
Medical Record #
EVIDENCE-BASED APHASIA CLINIC TRACKING FORM
Client: _______________________________
D.O.B.: ________
Diagnosis: ____________________________
Age: ____
Onset: ______________________
Aphasia Subtype: _________________________________________________________
Lives with: _____________________________________________________________
Initial NP/AD Date: ______________________
6 month follow-up:_____________
BDAE-3 LCI: ___________ Aud Comp: _____
Expression: ______
CADL-2: ________________
CETI: ______________
WAB/ADP Date: ____________________
BNT: ____
ASHA QOC: ___________
Score: ___________
Goals: ________________________________________________________________
Current communicative behavior/ Communication Partner
_____________________________________________________________________________________
___________________________________________________________
Date
Date
Date
Date
Date
CETI Score
Client
Other
Discourse
Comprehension probe
M______
D______
x/16
Raw
score____%
Discourse Production
Probe
-folder #
-Time
Clauses/utterances
# content units/ total
Efficiency
cu / # seconds
Fable / Content units
fox/stork 23
lion/mouse 33
fox/crow 24
rabbit/turtle 20
Date
Development of an EBAC (2001)
• Development of treatment care paths
– Care paths for primary areas of language
competence
•
•
•
•
Verbal expression
Auditory comprehension
Reading
Written language
– Include treatments aimed at activity/participation level
EB Activity/Participation Treatments
Primarily Compensatory for Communication
Promoting Aphasics’ Communicative Effectiveness (PACE; Li et al., 1988)III
Supported Conversation for Adults with Aphasia (SCA; Kagan et al., 2001) I
Visual Action Therapy (VAT; Helm-Estabrooks et al., 1982)III
Formal drawing program (Lyon & Sims, 1986) III
Computerized Visual Communication System (C-ViC; Steele et al., 1989)III
Lingraphica system (Aftonomos et al., 1997) III
Training in gestural sign language (American Indian; Skelly, 1979)III
Partner training in facilitative behavior (Simmons et al., 1987) E
Conversational coaching (Holland, 1988) E
Sentence Production
Program (Helm-Estabrooks
& Ramsberger, 1986)III
Wh-interrogative
production treatment
(Thompson et al., 1993)II
Verbal cueing for sentence
production (Loverso et al.,
1998)III
Primarily Restorative for Communication
Constraint-induced aphasia therapy (CIT; Pulvermuller et al., 2001)I
Group therapy in functional situations (Aten et al., 1982)III
Voluntary Control of Involuntary Utterances (VCIU; Helm & Barresi, 1980) E
Treatment of Aphasic Perseveration Program (TAP; Helm-Estabrooks et al.,
1987) III
Conversational script training (Cherney et al., 2008) III
Mapping therapy (Byng et
al., 1994)III
Syntactic
EB Impairment-Level Treatments
Apraxia of
speech?
No
Yes
Is deficit
phonologic,
semantic or
syntactic?
Semantic
Semantic feature analysis
(Lowell et al., 1995)III
Feature-contrasting technique
(Hillis, 1998)III
Multistage semantic
treatment (Drew &
Thompson, 1999)III
Personalized cueing (Freed &
Marshall, 1995)III
Lexical-semantic therapy:
BOX (Doesborgh et al.,
1993)I
Word-picture matching
(Marshall et al., 1990)E
Gestural+verbal treatment
(Raymer st al., 2006)III
Phonologic
Melodic Intonation Therapy (MIT; Sparks
et al., 1974)III
Contrastive stress/imitation of contrasts
(Wambaugh et al., 1998)III
Response Elaboration Training (RET;
Kearns, 1985)III
PROMPT technique (Hayden, 1999)E
Phonologic naming therapy (Robson, 1998) III
Phonologic therapy (Nettleton & Lesser, 1991) III
Phonologic hierarchy (Greenwald et al., 1995) III
Retraining O-P/P-O conversion (Kiran et al.,
2001)III
Phonological components analysis (PCA) therapy
(Leonard et al., 2008)III
Word discrimination therapy (Fisher et al.,
2009)III
Verbal Expression Treatments
Primarily Compensatory for Communication
Promoting Aphasics’ Communicative Effectiveness (PACE; Li et al., 1988)III
Supported Conversation for Adults with Aphasia (SCA; Kagan et al., 2001)I
Visual Action Therapy (VAT; Helm-Estabrooks et al., 1982)III
Formal drawing program (Lyon & Sims, 1986)III
Computerized Visual Communication System (C-ViC; Steele et al., 1989)III
Lingraphica system (Aftonomos et al., 1997) III
Training in gestural sign language (American Indian; Skelly, 1979III , Simmons & Zorthian, 1979)
Partner training in facilitative behavior (Simmons et al., 1987) E
Conversational coaching (Holland, 1988) E
Back to the Drawing Board
Drawing to facilitate naming (Farias, Davis & Harrington, 2005)
Miscellaneous Restorative for Speech Production/Communication
Constraint-induced aphasia therapy (CIT; Pulvermuller et al., 2001)I
Group therapy in functional situations (Aten et al., 1982)III
Voluntary Control of Involuntary Utterances (VCIU; Helm & Barresi, 1980)E
Treatment of Aphasic Perseveration Program (TAP; Helm-Estabrooks et al., 1987) III
Conversational script training (Youmans et al., 2005, Cherney et al., 2008)III
Thematic Language Stimulation (Chapey, 2008)
Semantic/Lexical Retrieval Programs
Response Elaboration Training (Gaddie, Kearns, Yedor, 1991)
Semantic feature analysis (Lowell et al., 1995)III
Semantic feature analysis + Response Elaboration Training (Conley & Coelho, 2003)
Feature-contrasting technique (Hillis, 1998) III
Multistage semantic treatment (Drew & Thompson, 1999)III
Personalized cueing (Freed & Marshall, 1995)III
Lexical-semantic therapy: BOX (Doesborgh et al., 1993) I
Word-picture matching (Marshall et al., 1990) E
Complex Semantic Naming Program (Swathi-Kirin, 2003)
Gestural+verbal treatment (Raymer st al., 2006)III
Phonologic Programs
Phonologic naming therapy (Robson, 1998)III
Phonologic therapy (Nettleton & Lesser, 1991)III
Phonologic hierarchy (Greenwald et al., 1995)III
Retraining O-P/P-O conversion (Kiran et al., 2001)III
Phonological components analysis (PCA) therapy (Leonard et al., 2008)III
Word discrimination therapy (Fisher et al., 2009)III
Syntactic Programs
Sentence Production Program (Helm-Estabrooks & Ramsberger, 1986) III
Wh-interrogative production treatment (Thompson et al., 1993)II
Verbal cueing for sentence production (Loverso et al., 1998) III
Mapping therapy (Byng et al., 1994) III
Verb Network Strengthening Treatment (VNest) (Edmonds, Nadeau, Kiran, 2009)
Semantic feature analysis + Response Elaboration Training (Conley & Coelho, 2003)
Apraxia Programs- See Apraxia of Speech Decision Tree
Auditory Comprehension Treatments
Impaired Pre-Linguistic Processing
Attention Process Training (APT)E
Noise reduction
Pausing
Primarily Compensatory for Auditory Comprehension
Environmental support (patient and family training)
(written, pictorial, gestural cues)E
Formal drawing program (Lyon & Sims, 1986)III
Miscellaneous Restorative for Auditory Comprehension
Treatment for Wernicke’s Aphasia (TWA) (if word reading/pic match) E
Training in speech (lip) reading
Phonologic training
Amphetamine treatmentI
Training in speech (lip) reading
Schuell Auditory Comprehension Tasks (if word-level deficit)
Complex Semantic Naming Treatment (Swathi-Kirin, 2003)
Situational Therapy for Wernicke’s Aphasia (Altschuler et al., 2006)
Visual Action Therapy (VAT; Helm-Estabrooks et al., 1982)III
Sentence/Discourse Level Programs that Target Auditory Comprehension
Verb Network Strengthening Treatment (VNest) (Edmonds, Nadeau, Kiran, 2009)
Response Elaboration Training (Gaddie, Kearns, Yedor, 1991)
Script Training (Youmans et al., 2005)
Reading Treatment Programs
Primarily Compensatory for Communication
Phrase-formatted text (PFT) use (Beeson & Insalaco, 1998)III
Training in head turning for right visual field deficit (Daniel et al., 1992) E
Environmental support – noise reduction (Kilborn, 1991)E
Hyphenation by grapheme units (Harley & O’Mara, 2006)E
Primarily Restorative for Communication
Attentional training (Coelho, 2005)E
Computer-supported reading treatment (Katz & Wertz, 1997)III
Intensive stimulation approach with written input (Schuell) E
Letter Identification
Kinesthetic reading (Seki et al., 1995)III
Motor cross-cuing for reading (Maher et al., 1998) III
Semantic-Lexical Treatments for Pure Alexia (Letter-by-Letter Reading- impaired access to orthography)
Multiple oral re-reading (MOR; Moyer 1979III , Kim & Russo, 2010)
Rapid categorical judgments (Friedman & Lott, 2000)III
Rapid lexical judgments with corrective feedback (Hillis, 1993) III
Train word-picture matching with corrective feedback (Hillis & Carmazza, 1994) III
Phonological Treatments
Retraining grapheme to phoneme conversion (Kiran et al., 2001)III
Lindamood Phoneme Sequencing Program (Conway et al., 1998) III
Training bigraphs/orthographic-phonemic conversion (Friedman & Lott, 1996)
Training homophones in sentences (Scott & Byng, 1989)
Phonological Treatment Program (Beeson, 2010; Protocol)
Persistent reading impairment at word level or above
Oral reading for language in aphasia (ORLA; Cherney, 1995) III
Oral reading treatment (ORT; Orjada & Beeson, 2005)III
Mapping therapy (Schwartz et al., 1994)III
Hierarchical cued oral reading for corpus of words (Hillis & Carmazza, 1994)III
Conversational script training (Cherney et al., 2008)III
Written Language Treatments
Global Agraphia- retrain spellings for specific words
Anagram and Copy Treatment (ACT; Beeson, 1999)III
Copy and Recall Treatment (CART; Beeson et al., 2002, 2003)III
Phonological Agraphia- retrain sound-letter correspondences
Phonological Treatment Program (Beeson, 2010; Protocol)
Lindamood Phoneme Sequencing Program (Conway et al., 1998) III
Surface Agraphia- difficulty with irregular words
Phonologic problem solving for spelling- Interactive Spelling Treatment (Beeson et al., 2000; Protocol)
Primarily Compensatory for Communication
Environmental support – spell check, space, keyboard (X)E
Apraxia of Speech
Nondiscriminative
Primary
Clinical
Characteristics:
 slow speech rate
 sound distortions
 errors relatively
consistent in type
 prosodic abnormalities
Nondiscriminative Clinical
Characteristics
 articulatory groping
 perseverative errors
 Speech initiation difficulty
 awareness of errors
 automatic speech better
than propositional speech
 islands of error-free speech
Clinical Characteristics
that Cannot be used to
diagnose AOS
 anticipatory errors
 transposition errors
 limb or oral apraxia
 express-receptive
language gap
Treatment Approaches:
Articulatory Kinematic
 PROMPT (Bose, 2001)III
 Sound Production Treatment (Wambaugh, 1998)III
 Minimal pairs (Wambaugh, 1996)III
 Articulatory posture drawings,
modeling, self-initiated postural
cueing, mirror monitoring, practice
(Raymer, 2002)III
 Modified RET (Wambaugh &
Martinez, 2000)
 Script Training (Youmans, 2011)
AAC
 Instruction to use writing (Lustig,
2002)III
 Electrolarynx (Marshall, 1988)IV
 Training with communication books,
alphabet supplementation, voice
output aid (Yorkston, 1989)IV
 Blissymbols (Lane, 1981; Bailey,
1983)IV
 Total communication; signing
(Fawcus, 1990)IV
Rate and/or Rhythm
 Repeated Practice with rate/rhythm
control (Wambaugh, 2000)III;
(Wambaugh et al., 2012)
 Metronome with Hand-Tapping
(Mauszycki & Wambaugh, 2008)
 Training prolonged speech to reduce
rate via computer based program
(Southwood, 1987)III
 Stress patterning practice-modeling
and auditory feedback (Tjaden,
2000)IV
Intersystemic Reorganization





Production of gestures (Dowden,
1981)IV; Gestural-Verbal Treatment
(Raymer, 1991)III
Pairing verbalization with AmeriIndian production (Skelly, 1971)IV
Gestural reorganization (tapping)
with imitation of contrasts drills
(Wertz, 1984)III
Choral singing, phrase production in
song (Keith, 1975)IV
Melodic Intonation Therapy (Sparks
et al., 1974)III; (Hurkmans et al.,
2012)
Exlusionary
Characteristics:
 fast rate
 normal rate
 normal
prosody
Effect Size
• Effect size refers to a family of indices specific
to single subject design that establishes the
magnitude of gain from treatment.
• Effect size is defined as a “ quantity that
describes the degree to which a treatment
outcome differs from zero.( Beeson & Robey,
2006 )
Effect Sizes
• Small effect size = 0.2
• Medium effect size = 0.5
• Large effect size = 0.8
Effect Sizes (d)
Word-finding treatment for anomia in aphasia
1.66
Viagra (oral sildenafil) vs. placebo and self-reported
change from baseline in sexual functioning
1.60
Effect of low dose prednisone vs. placebo on number
of swollen joints in rheumatoid arthritis
1.05
Computerized cognitive rehabilitation post-stroke
0.54
Effect of donepezil on cognition in Alzheimer’s
0.51
Improvement in depression with paroxetine
vs. placebo
0.21
Wisenburn & Mahoney, 2009; Althoff et al., 2003; Katzman et al., 2007; Winblad et al.,
2009; Saag et al., 1996; Cha & Kim, 2013
Effect Sizes
• Wisenburn and Mahoney, 2009
• Completed a meta-analysis of 44 studies and
107 effect sizes that just came out this year
• Analysis of various approaches for word
finding deficits in people with aphasiasemantic, phonological, and mixed
• Revealed semantic therapy appeared to have
better generalization to untrained words
Aphasia Treatments
How to implement programs in
your setting.
MACDG
November 4, 2015
St. Louis, Missouri
Jacque Livingston M.A.CCC
Speech Therapist at The Rehabilitation Institute of St. Louis
The Rehabilitation Institute of St. Louis
EXPRESSIVE PROGRAMS
(In order of typical progression)
•
•
•
•
•
•
•
PROMPT
Gestural Verbal Treatment (GVT)
Script Training
Semantic Feature Analysis (SFA)
Phonological Component Analysis (PCA)
VNeST
Response Elaboration Treatment (RET)
Tactile treatment for motor speech
disorders
• PROMPTS for Restructuring Oral Muscular Phonetic Targets
• Used with patients 6 months of age onward.
• Speech Pathologists are the only professionals with the
prerequisite knowledge to apply PROMPT
• To become fully trained in PROMPT, a clinician must complete
four essential steps to be able to fully understand the
PROMPT technique and apply it appropriately to patients
• Introduction to PROMPT, Bridging PROMPT to intervention,
The PROMPT technique self study, PROMPT Certification: A
Self-Study Project
• Website: promptinstitute.com
Using Tactile Prompts in Therapy
•
•
•
•
•
Voicing/Breath
Labial
Jaw Height
Lingual
Valving
Voicing
• Start here in the non verbal patient
• May need oral stimulation (e.g. tactile,
thermal, gustatory) before treatment to prime
articulators
• Tactile prompt to diaphragm, chest, and larynx
• Teach inhale then voicing on exhale
• Prompt mouth open to initiate voicing
Labial placement
• Video labial closure/labial retraction
• Video labial rounding
•
•
•
•
Labial opening (voicing)
Labial closure (bilabials)
Labial retraction (/i/)
Labial rounding (/o/ /oo/)
Lingual Placement
• Video for velar placement
• Use verbal cue for lingual placement and
position
o Front, middle, back
• Use modeling for visual and phonemic cues
• Decrease cueing hierarchy, tactile→verbal
→visual →independent
Nasals
•
•
•
•
•
•
Video for nasal sound
Prompts for valving on /m/ /n/
Prompt for air through nose
Prompt for lingual postion of /n/
Prompt for labial positions of /m/
Use with minimal pairs, ex mom vs mop
teaching pt to redirect air from nasal cavity to
oral cavity
Putting it together
• Video of Prompt workshop
Gestural Verbal Treatment
GVT
Gestural Verbal Treatment
• Targets verbal production
• Pt population typically non fluent with mild to
severe aphasia/apraxia of speech
• Pair intact gesture to facilitate production of
verbal expression
• Target gestures should be functional
• May increase from word to phrase length
verbalizations
• Use gesture which best illustrates target word
Gestural Verbal Treatment
1. Target pic placed in front of subject and a model of
the verbal and gestural target provided
2. Gesture elicited in isolation following a model
3. Verbal production elicited in isolation following a
model
4. Verbal and gestural responses are modeled together
while client produces simultaneously
5. Verbal and gestural response elicited together
without a model
6. Each training item is presented two to three times per
treatment session.
Gestural Verbal Treatment Video
• Video of GVT
Script Training
Script training
• Script Training was initially developed to promote verbal
communication on client-selected topics (Holland, Milman, Munoz,
& Bays, 2002)Goal is for individuals for whom speech is no longer
automatic to produce islands of fluent speech in conversation
• Previously used as a treatment approach to improve automatic
language production in adults with aphasia
• To become automatic, scripts must be practiced as phrase or
sentence-length units vs. syllable or ‘one word at a time’ approach
(Youmans, Holland, Munoz, & Bourgeois, 2005)
• For individuals with expressive speech difficulties repeated practice
of phrases and sentences can lead to automatic and effortless
speech productions
Script Training
•
Work with patient to create 3 scripts. Each script should consist of 3-4 relatively
short sentences.
– Example: Conversation Starters:
•
•
•
•
•
How are your grandchildren?
Good morning.
I’ll see you later.
What’s new?
Utilize cuing hierarchy to introduce scripts.
– Phrase repetition
– Choral reading with clinician
– Independent production
•
•
•
When the client can produce a newly trained phrase independently at least 20
consecutive times a new script is added or more information is added to mastered
script.
Patient’s are expected to practice scripts at home for 15 minutes per day.
Once a script is mastered, generalization training is initiated.
– Clinician purposefully varies response and comments to help the participant make scripts
more resilient and more flexible.
Script Training Data Collection
DATE 6/14/12
Script 1
Time
Script 2
Time
Script3
Time
6/4/12 6/19/12 6/21/12 6/28/12 7/2/12 7/5/12 7/10/12 7/12/12 7/17/12 7/19/12
40
60
70
90
96
90
93
94
96
96
3:00
2:45
1:56
1:35
1:13
1:13
1:10
1:27
1:02
1:00
39
38
81
86
95
95
99
5:00
2:25
2:05
2:10
1:11
1:20
1:01
78
2:47
Semantic Feature Analysis
Theory of SFA
• There are strong neural connections between related
concepts
• There is better access to word-finding within categories
• SFA allows pt’s to self cue by activating these neural
connections
• The 2009 study by Antonucci
– pts treated with SFA during discourse production tasks
showed improvements in general communication efficiency
• 2010 Peach and Rueter
– showed that targeting word finding behaviors in connected
speech generalized to naming of untrained object and
action pictures
Model for SFA
• SFA model involves description of a target item
(picture in the center of the template) which
enables the pt. to generate features including:
–
–
–
–
–
–
Group
Use
Action
Properties
Location
Association
Semantic Feature Analysis (Nouns)
Semantic Feature Analysis
Semantic Feature Analysis Video
• Video of SFA
Phonological Component Analysis
• The Phonological Component Analysis was modeled after
SFA through spreading activation (Boyle and Coehlo, 1995)
• The PCA protocol (Coehlo, 2008) followed the protocol of a
target picture presented in the center of the chart with the
pt asked to identify 5 phonological components related to
the target:
-rhyming
-identify the first sound of the word
-first sound association
-final sound
-number of syllables
PCA TEMPLATE
Visual Network Stregthening
Treatment
VNeST
VNEST
• Verb Network Strengthening Treatment (VNeST)
(Edmonds et al., 2009)
• Semantic treatment - to improve lexical retrieval of
content words in sentence context
• Promotes systematic retrieval of verbs and their
thematic roles
• Treatment uses co-activation of verbs and their
thematic roles so that a verb primes its agents
(arresting/policeman), patients (arresting/criminal) and
instruments (cutting/scissors) and vice versa.
VNeST Procedure
• VNeST: Procedure (Edmonds et al., 2009)
• 1.Generation of three agents or patients for verb (using
who/what & verb cards; if cannot produce 3 words,
then can select cards from choice of target plus 3 foils)
• 2.Generation of corresponding agent or patient to
complete agent–patient pairs; reads word pair aloud
• 3.Answer wh-questions about agent–patient pair
(when, where, why)
• 4.Semantic judgement of sentences read aloud by
clinician
Vnest Template
Response Elaboration Treatment
RET
Response Elaboration Treatment
•
Targets increase the length and information content of verbal responses
•
The goal of this therapy is to reinforce and elaborating on the language of
the aphasic patient.
•
A typical session involves a six step training sequence.
•
The patient is presented with a picture stimulus and responds with a
spontaneous description.
•
The clinician then expands and reinforces the patient’s response. After
cueing and repetition requests, the patient will ideally be able to lengthen
the understanding of the stimuli and number of words used to describe it.
Response Elaboration Treatment (RET)
Procedure
1. Stimulus presented (e.g. personal picture, magazine photo, etc.
Must be action on photo)
• Clinician: “What is happening here?”
• Patient: “Crying.”
2. Expansion/reinforcement
• Clinician: “Good! The boy is crying.”
3. “Why” cue
• Clinician: “Why is the boy crying?”
• Patient: “Hit head.”
4. Combining patients response, modeling
• Clinician: “Great! The boy is crying because he hit his head.”
Response Elaboration Patient Data
Date
11/15 11/19 11/19 11/26
Content Units
10
Efficiency 0.11
12/3
12/6
12/10 12/13 12/17 12/27
1/7
1/14
1/17
1/21
1/28
1/31
1/28
12
17
17
10.5
12.1
9
13
15
15
14
13
16
18
23
17
18
0.08
0.11
0.11
0.09
0.1
0.13
0.125
0.11
0.165
0.13
0.13
0.14
0.17
0.17
0.14
0.14
Content Units= information (nouns, verbs, adjectives relevant to topic)
Efficiency= content units/time
Date
LCI
# clauses
2/9/11
2/22/11
3/2/11
3/9/11
3/24/11
3/30/11
4/20/11
5/18/11
6/18/11
0.6
1
0.75
1
1.2
1
0.6
1
1
2
3.0
3.0
5.0
6.0
5.0
2.0
7.0
8.0
Response Elaboration Video
• Video of RET
Receptive Programs
• Treatment for Wernicke’s Aphasia (TWA)
• Complex Semantic Naming
Treatment for Wernicke’s Aphasia
• Developed by Helm-Estabrooks and Fitzpatrick
• Based on the evidence that the ability to repeat
orally presented stimuli may be linked to the
ability to process or understand these stimuli
• Appropriate for moderate to severe Wernicke’s
Aphasia
• Pt. must demonstrate good ability to understand
written stimuli at the single word level and some
ability to correctly read single words aloud
TWA
• Treatment Steps
– Step 1: Reading Comprehension: match a printed, lowercase
word to its pictorial representation with 6 pictures (one correct
and five foils)
– Step 2: Oral Reading: read the target word aloud (with no
pictures out)
– Step 3: Repetition: repeat the word as presented by the clinician
with only the picture present (no printed stimuli)
– Step 4: Auditory Comprehension: correctly select the pictorial
representation of the word from a group of 6 upon hearing the
word spoken by the clinician (no printed stimulus)
– Incorrect spoken responses that are real words are used as
future stimuli.
TWA Treatment Data
Base
line
10/28/13
10/30/13
11/4/13
11/6/13
11/13/13
11/22/13
12/16/13
12/20/13
12/23/13
1/3/14
1/10/14
Match
written
word to
pic
100%
100%
100%
87%
100%
85%
95%
100%
95%
100%
100%
100%
Read
word
aloud
67%
67%
67%
37%
45%
43%
55%
85%
65%
75%
85%
85%
Repeat
word
83%
83%
83%
81%
43%
78%
100%
100%
100%
95%
100%
95%
Aud.
Word
ID to
pic
100%
100%
83%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
83%
81%
50%
71%
75%
90%
95%
100%
95%
90%
Name
Picture
TWA Video
• Video of TWA
Complex Semantic Naming
• Can be used as an expressive or receptive
program
• Study suggests patients trained on naming of
atypical exemplars demonstrated generalization
to naming of intermediate and typical items, but
pt. trained on typical items demonstrated no
generalized naming effect to intermediate or
atypical examples (Kiran and Thompson 2003)
• When using as a receptive treatment program
you can target understanding of complex yes/no
questions and semantic sorting
Complex Semantic Naming
• Treatment Steps
Step 1: pt. names the picture
Step 2: pt. is given 2 written choices of a category and is
asked to identify which category the picture belongs
in
Step 3: pt. is given 6 written semantic features (3 yes
and 3 no) and then asked to identify which semantic
features are yes and which are no
Step 4: pt. answers 15 yes/no questions pertaining to
the semantic features of the target
Step 5: pt. names the picture again
Complex Semantic Naming Treatment Data
Set 2
Select
semantic
feature
Set 2
Set 2
Set 2
Set 3
Set 2
Set 3
91%
100%
100%
100%
100%
91%
Answer
y/n
ques.
91%
90%
93%
91%
90%
Name
typical
picture
80%
50%
70%
40%
10%
70%
Mod A
Mod A
Mod A
Ind.
Ind.
Min
70%
60%
80%
90%
90%
100%
90%
Mod A
Mod A
Mod A
Ind.
Ind.
Min
Min
Name
atypical
picture
Aphasia Treatments
and the chronic patient
MACDG
November 4, 2015
St. Louis, Missouri
Karen Blank M.A.CCC
Senior Speech Therapist at The Rehabilitation Institute of St. Louis
The Rehabilitation Institute of St. Louis
Treating the Chronic Patient
• Past research studies ,from 1982(Holland) to present , have cited
improvements made with the chronic aphasic patient.
• Moss and Nicholas (2006) describe chronic patients as 1 year post
stroke. They showed that improvements made in treatment can be
made up to years post stroke.
• Meinzer et al (2004) showed after intensive therapy with patients
with chronic aphasia, there were positive changes in brain activity
correlated to positive changes in language functions . They
concluding that reorganization of the brain occurs even years after
stroke.
• Basso and Macis(2011) showed 9/13 chronic patients improved in
oral and written nouns and action naming, and oral and written
sentence production. Again, intensive therapy ,including 2-3 hours
of homework ,aided in gains made.
Treatment Progression of the
Nonfluent patient
1. Gestural verbal treatment /Prompt or TactileKinesthetic treatments: Treating apraxia of
speech with trained words and phrases
↓
2. Script training/RET training: To elicit more
information and increase fluency/length of
utterance.
↓
3. Promote generalization through use with family
and friends, use of “wh” questions to elicit
conversationally relevant speech.
Treatment progression of the Fluent
Patient
1. Treatment for Wernicke’s Aphasia (TWA)
Speech Reading/Lindamood Phonological Program
↓
2. Phonological Component (PCA)Analysis/ Semantic
Feature Analysis (SFA)/ Complex Semantic Feature
Analysis (Kiran)
↓
3. VNESST/ Script training/ and RET training
↓
4. Generalization: Wh-questions in conversation and
continue to track LCI, content units, and efficiency.
Analysis of Treatment of Chronic
Patients in the EBAC
•
•
•
•
•
•
•
•
From 20 chronic patients seen over the last few years in the EBAC the following were
results of evidenced-based treatment. Significant change on WAB 5 points, Significant
change of CETI 11 points.
Pre
Post
Significance
WAB
43.94
65.11
<.001*
LCI
.25
.91
.002*
Content Unit 2.82
4.09
.165
Efficacy
1.50
3.27
.078
CETI-Self
56.16
66.81
.064
CETI-Other
45.73
57.13
.017*
Changes in WAB scores were: average of 21.17 points the range was -13 to 61.3 pts
Changes in LCI scores were: average .65
Changes in Content Units were: average 1.27
Changes in CETI were from significant other were: average 11.4
Changes in CETI from pt. were: average 10.7
Average time of treatment from onset was: average 488 days (310-842)
Average time of treatment was: average 21 months (15-25)
Statistically significant changes in the
chronic patient
• 85% of chronic patients showed statistically
significant increase in WAB from admit to
discharge
• 54% of chronic patients family members had
statistically significant increase in CETI
Increasing Content Units
Pt’s who increased content units by 15% or higher
Aphasia subtypes and treatments: n=6
•
•
•
•
•
Global: GVT
Broca’s : Lindamood → RET
Non fluent : RET
Non-fluent: Script training →PCA →RET
Wernike’s: RET
• Conclusion
o Increases in content units improved greatest with our
non-fluent patients receiving RET.
Increasing Efficiency
Pt’s whose efficiency increased by at least four content units per
minute.
Aphasia subtypes and treatments: n=5
•
•
•
•
•
Anomic: PCA
Broca’s: Lindamood→RET
Mixed non fluent: RET
Mixed Nonfluent: TWA/Complex Semantic Naming/SFA/RET
Wernikes: RET
• Conclusion:
o RET worked best with this pt population to improve
efficiency (4/5 received RET).
o Efficiency changes seen with both fluent and nonfluent
patients with both receptive and /or expressive aphasias.
Increasing LCI
Pt’s increasing LCI by .5 or higher
Aphasia subtypes and treatment N=8
•
•
•
•
•
•
•
•
•
Non-fluent: GVT→Script → VNeSST → RET
Mixed nonfluent: VNeSST
Broca’s: Lindamood →RET
Nonfluent: PROMPT →RET →VNeSST
Anomic: Script training →PCA →RET
Nonfluent: TWA →Complex Semantic Naming →SFA →RET
Transcortical Motor: RET
Mixed non fluent: Script training → RET
Conclusion:
o
Biggest LCI improvements were seen in the chronic patients with
non fluent aphasia who were treated with RET and/or VNeSST.
Case Study of a EBAC Pt. with Chronic
Aphasia
•
•
•
•
•
•
•
Pt is a 54 year old male that suffered a left CVA with severe AOS in with onset on
2012
Pt began therapy in 12/18/13 with Prompt therapy and was trained on 40
functional phrases with pt achieving 80% accuracy over 2-3 weeks. Video PROMPT
Pt used these phrases in therapy and some use at home with wife and family and
employees.
WH questions to assist with functional carryover video to generalize trained
phrases.
Pt proceeded with RET therapy that aided use of content units in functional,
everyday speech but did not improve in his LCI scores. RET video
Then pt advanced to VNESST which improved his LCI scores from 0.0 in beginning
of therapy to .5 in monthly probes, and then .8-1.0 when using wh questions for
relevant topics he was interested in. Video of VNeST
Pts WAB scores at 6 month intervals were : 36.8 (4/14); 51.5 (10/2014); and 64.7
(6/2015). Significant change each time after spontaneous recovery.
CETI scores by wife were lowered from 60%-50% but CETI scores by pt. went from
64 to 81% in which pt kept indicating that he continued to speak better in home
and work situations.
Conclusions of Presentation
1.
2.
3.
4.
5.
6.
How are we going to find ways to deliver evidenced-based
therapies in an intensive manner to chronic patients when 3rd
party payers stop funding the therapy?
SLP’s should be aware of current evidence based aphasia
treatments in order to determine which treatment would be most
effective for their clients aphasia subtype.
Furthermore, SLP’s need a protocol (e.g. interval probes) to
measure whether the treatment is improving their pt’s language.
Need to set up criteria for discharge, including what goals patients
want to achieve, and length of therapy.
Tune ups may be needed with chronic patients post discharge
(e.g. every 6 months) to encourage ongoing recovery.
More research needed to predict language recovery post stroke
and determine best care path.
Questions
References
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•
Antonucci, S.M. (2009). Use of semantic feature analysis in group aphasia treatment.
Aphasiology, 23 (7-8), 854-866.
Bose, A., Square, P. A., Schlosser, R., & van Lieshout, P. (2001).Effects of PROMPT therapy on
speech motor function in a person with aphasia and apraxia of speech. Aphasiology, 15(8),
767–785.
Basso, A; Macis, M.;Therapy Efficacy in Chronic Aphasia. Behavioral Neurology; 2011
Boyle, M. (2004). Semantic feature analysis treatment for anomia in two fluent syndromes.
American Journal of Speech-Language Pathology, 13, 236-249.
Boyle, M., & Coelho, C.A. (1995). Application of semantic feature analysis as a treatment for
aphasic dystonia. American Journal of Speech-Language Pathology, 4, 94-98.
Conley, A., & Coelho, C. (2003). Treatment of word retrieval impairment in chronic Broca’s
aphasia. Aphasiology, 17(3), 203-211.
Helm-Estabrooks, N., Fitzpatrick, P., & Barresi, B. (1982). Visual Action Therapy for Global
Aphasia. Journal of Speech and Hearing Disorders, 47, 385-389.
Holland, A, ; Aten, James L.;Caliguiri, M.; The Efficacy of Functional Communication Therapy
for Chronic Aphasia Patients. Journal of Speech and Hearing Disorders, Feb. 1982, Vol 47, 9396
Leonard, C., Rochon, E., and Laird, L. (2008). Treating naming impairments in aphasia:
Findings from a phonological components analysis treatment. Aphasiology, 22(9), 923-947.
References
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Lowell, S., Beeson, P.M., & Holland, A.L. (1995). The efficacy of a semantic cueing procedure on naming abilities
of adults with aphasia. American Journal of Speech-Language Pathology, 4, 109-114.
Meiner, M.; Elbert, T. Weinbruch, C; Dundja, D., Barthal, G.; Rockstroh, B.; Intensive Language Training Enhances
Brain Plasticity in Chronic Aphasia. BMC Biology, 2004.
Moss, A. Nicholas, M. Language Rehabilitation in Chronic Aphasia and Time Postonset. Stroke 2006
Naeser, M; Martin, P; Nicholas, M; Baker, E.; Improved Picture Naming in Chronic Aphasia after TMS (transcranial
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