1. Language and Cognition Colombo 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. Written word Visual Analysis VIL Semantics POL Buffer Grapheme to Phoneme Conversion speech Spoken word Auditory Analysis AIL Object Recognition

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 Target Picture GROUPUSEACTION LOCATIONASSOCIATION (is a _____)(is used for _____) (does what?) PROPERTIES (Has/is ___) (Is found _____) (Reminds me of ___)

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

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 TargetResponse TOMATOCan’t pronounce it, don’t like them, its red SYRINGEA thing for pushing medicine 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