4/10/2018

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What recollections in tranquility do to a promised topic

Talk about the probable best treatment packages for AoS and aphasia

Turns out that the condition-specific methods are limited ◦ Will discuss one for AOS and one for aphasia

Most of the aphasia programs function as potential retention activities for AoS

The Pittsburgh group has structured a number of traditional steps into a useful program

Name has come to be Sound Production Treatment (SPT)

This program can be used with a variety of severities by simply selecting appropriate stimuli

It is conceptually sound And the developers have done (and continue

to do) the hard work of research

Wambaugh et al JSHR, 41, 1998 (20 years old)

Five step program, from less to more cueing Built on minimal contrast pairs in words For example, p vs b (pad vs bad) In one experiment one sound was the target

◦ Logical because of frequent AoS error pattern of : Place, voicing, and plosion for frication errors

Data based on only fifteen treatment sessions

Modeling

Repetition

Minimal pair contrasts

Integral stimulation

Articulatory placement cueing

Feedback ◦ All sounds pretty familiar and it should

◦ We’ve known about txing speech problems for decades

Clinician produces both in pair and pt says both

If error, then each one of pair presented and produced separately

If both correct, repeat and on to next pair

Provide knowledge of results (good, okay, etc)

If not, step is repeated

If still not, went to next step

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Cl showed printed versions of the target

Says this is the sound you are working on

Then repeat step one

If BOTH okay go on to next pair

If not, go to next step

If only target was wrong earlier or if both were then only target was subjected to integral stimulation

Watch me, listen and say what I say If correct try to get two to four more

repetitions If correct go on to next pair If target is incorrect go to next step

Cl produced the target using silent juncture after the target and before the rest of word

If correct, went to next pair

If not, went to next step

Cl provided verbal description of sound and produced it in isolation

Correct or incorrect Cl then went on to next pair

Or in another version, simplify the context

Usually use 8 to 10 stimuli

In substitutions use sound that most frequently substitutes for the target (one of several emerging rules)

Try to work at word or phrase level

Try to use all stimuli in each session

Try to get through all at least 4 to 8 times per session

Trained and untrained items improved

Generalization was limited

As was maintenance

Subjects had aphasia and apraxia

Another problem was overgeneralization of the sound treated ◦ Started showing up where it was not appropriate

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This program uses all the traditional approaches

It is the time honored task continuum

The study itself is controlled in the traditional ways with generalization probes, baseline line and maintenance probes

Can do the treatment based on it ◦ So excellent for students and new clinicians

Some of our very first convincing data

Acquired Apraxia of Speech: Evidence-Based Intervention. ASHA Professional Development ASHA products sales 10801 Rockville Pike Rockville MD 20852-3279

Wambaugh et al (2006). Treatment guidelines for acquired apraxia of speech…JMS-LP, 2, xv-xxxiii

Overgeneralization is a huge problem for all of us in AoS tx sessions and with this program in original form ◦ Sound we emphasize comes to dominate others

Limited generalization to other sounds, environments and across time is also frequent

How the authors address these limitations Wambaugh et al (2012) Treatment of acquired apraxia of

speech: examination of treatment intensity and practice schedule. Epub

Wambaugh & Mauszycki (2010). Sound production treatment with severe apraxia of speech. Aphasiology, 24 (6-8), 814-825

Wambaugh & Nessler (2004). Modifications of SPT…Aphasiology, 18, 407-427

Wider variety of stimuli across manner, place and voicing, presented in unpredictable order, and including at least one “hard” one

Other cognitive, learning components ◦ Plan before you speak

◦ Pt self-evaluation and attempted self-correction

◦ Less frequent feedback

◦ Distractions

◦ Fewer, wider spaced responses

Step one: modeling/imitation ◦ Clinician produces both (for example, ban and pan) ◦ (could become ban, pan, Dan, ran {usually a hard

stimulus} in variable order)

◦ in pair ◦ (now four stimuli, or what ever number you and pt agree

on)

◦ and pt says both ◦ (or whatever number you have chosen) (and only after

active silence)

◦ In original clinician then provides feedback ◦ (instead patient evaluates each, clinician and patient

evaluate the adequacy of that evaluation and then patient tries to self-correct)

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Need some activity/participation steps

Way to approximate communication

Contrastive stress drill is a Q-A drill

Could be used even with single words

Idea is for cl to ask a variety of Qs about components of sentences already worked on in other ways

Stimulus: I got pie on my tie

Drill ◦ Cl: Did you get tooth paste on your tie?

◦ Pt: No, I got PIE on my tie

◦ Cl: Did you get pie on your shoe?

◦ Pt: No, I got pie on my TIE

◦ And so on

Many, many more treatment packages for aphasia

Want to highlight one that seems particularly promising for aphasia of the Broca’s type

One of the newest and most intriguing (to me) therapies is

◦ VERB NETWORK STRENGTHENING TREATMENT

Edmonds, Nadeau, Kiran (2009). Aphasiology, 23, 402-424

Edmonds & Babb (2011). Effect of verb network strengthening treatment in moderate to severe aphasia. AJSLP, 131-145

Going to do rationale and method first, data second

Focus on “the predictive components of the distributed semantic representation of concepts, which are expressed linguistically as verbs” (p. 404).

These components can be called agents (old name subjects) and patients (old name objects)

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Cut as a verb

Agents (those who cut) include butcher, builder, budget controller

Patients (what is cut) meat, board, budget

Thus retrieval is for a wider range of concepts than in the usual naming therapy with emphasis on “What is this?”

Verb cards with one verb on each card

Prepare a bunch of agent and patients for each verb

Prepare five cards with one of these following words: who, what, where, when, why

Cuts Agent Patient

Who What Where When Why

12 sentences for semantic judgment ◦ Three correct

Carpenter cuts linoleum

◦ Inappropriate agent

Barber cuts linoleum

◦ Inappropriate patient

Carpenter cuts hair

◦ Thematic reversal

Linoleum cuts the carpenter

Cl says “tell me who or what can (verb) be verbed?) Puts out the who or what card and the card with a verb written on it

Each word generated is then written on a card and placed under the who/what

Minimum of three required before going on

Who cuts cuts what or

Carpenter

Seamstress

Barber

If pt can’t get three then cl provides several appropriate and inappropriate and pt chooses

Beanie

Barber

Spinach

The who and what are to be rotated so that both agents and patients are elicited ◦ The carpenter cuts what?

◦ Who cuts the linoleum?

May take some considerable cueing even with appropriate and inappropriate foils for some pts to get three of each

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Work toward complete utterance by providing the person’s previous Agent+verb and verb+patient

Carpenter cuts

And getting pt to produce an appropriate patient or agent depending on which piece is missing

What

Who cuts linoleum

If person cannot produce then cl provides three correct and incorrect

Person reads and selects or sorts both the correct and incorrect

Person chooses agent-patient pair

They are placed in front of person on cards

Then Cl has person answer where when why questions

Carpenter Cuts Board

where when why

No emphasis on complete sentence grammatically

carpenter cuts board work

building site

Requires semantic judgment of sentences

Cl reads 12 sentences for person judgment ◦ Sentences are agent verb patient

◦ 4 are correct

◦ 4 have incorrect agent

◦ 4 have incorrect patient

◦ 4 have agent and patient reversed

Return to first step

Person is told: “tell me who (or what) can verb (be verbed)

Cl aims for three responses

Again person is asked for three (who can verb) and three (what can be verbed)

No cards

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This is, of course, merely the bare bones of the tx

May have to do much more cueing and repetition

N=2, Nonfluent

Two, two hour sessions per week

Pt 1 got 45 hours-Pt 2 got 37.5

Outcomes: ◦ WAB

◦ Sentence production

◦ Discourse

◦ Proxy/pt report of functional outcome

Pt 1 AQ from 45.2 to 55.5

Pt 2 AQ from 36.4 to 48.1

Pt 1 Functional communication from 21.9 to 37.3

Pt 2 functional communication from 21.9 to 42.9 (CETI, Lomas, 1989) ◦ Visual analog scale of ability to communicate in

several situations

Pre post and maintenance sentence production, Pt 1

Generalization to noun and verb naming

Generalization to sentences using untreated verbs

On the Western Aphasia battery

And on production of complete utterances on connected speech samples

Edmonds & Babb, 2011

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Clinician and patient have to work harder

Errors may increase

Total responses in session may be reduced

But responses, once they arrive, are more likely to generalize or carryover to speaking outside the clinic

Treatment is tougher ◦ Thus may have to build up to these modifications

In these the target may differ, being movement in AoS and meaning in aphasia ◦ CILT

◦ SCRIPTS

◦ ALCS

Preceded by a bit of data for those of you who may not have time to read all the literature

“The accumulated scientific evidence warrants the assertion that, on average, treatment for aphasic persons is effective” Robey, JSHR, 1995

Large gains are achieved from therapy with severe aphasic persons ◦ Need not to hang the crepe on more severe folks

Meta analysis is high level evidence

Holland et al, JSHR, 1996

“There is both experimental and clinical evidence that individuals with aphasia benefit from services of speech-language pathologists”

Contains a complete review of the literature TO THAT TIME ◦ Systematic review also strong evidence

Kelly et al (2010). Speech and language therapy for aphasia following stroke. Cochrane Database Systematic Review, Issue 5, CD000425. DOI:10,1002/14651858 CD 000425

SLT vs No SLT 14 studies 1064 participants SLT vs stimulation or social support: 6

studies 279 participants SLT method vs another 21 studies 732

participants

“some indication of the effectiveness of SLT”

Results “favored intensive SLT over conventional”

Treatment provided by a “therapist-trained and supervised volunteer appears to be as effective as the provision of SLT by a professional”

Insufficient evidence in favor of any one treatment over any other

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Brady et al. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2012. CD 000425

Identified 39 RCTs with 2418 participants ◦ 19 with 1414 compared SLT (all treatment

procedures combined) with no SLT

Results: SLT producing significant benefits on expressive and receptive language

7 RCTs comparing SLT and social support ◦ Result: No differences in functional communication

25 “randomized comparisons” (they had trouble with many of the designs) of SLTs of two different types ◦ Results: No indications of superiority of any

individual approach

“Some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language”

“Insufficient evidence to draw any conclusions regarding the effectiveness of any one specific SLT approach over another”

Greener et al. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev. 2000(2). CD 000425 ◦ N=12 RCTs

◦ “Speech and language treatment on people with aphasia after stroke has not been shown either to be clearly effective or clearly ineffective within an RCT”

Suggest using other forms of evidence

• Single subject and small group data GENERALLY are accumulating showing treatment effects even in severe, several years post

• Case study • Kendall showed functional change in a person with

aphasia 40+ years post

• MRI on pt shows large chronic lesion

• Used LiPS or the phonetically based program initially developed to teach reading to children

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These were all developed for aphasia

But by changing stimuli can put them in a continuum of functional steps for AoS

Several levels of task difficulty

Stimuli are manipulated to increase or decrease difficulty:

Characteristics of items (e.g. word+color) Good “vegetable” Yellow, red or green?

Requirements of the response during the therapy games (longer or shorter)

Cueing provided if necessary to reduce error responses

Card matching task

First pt and then cl asked (without showing as barrier between) for a matching card

When pt turn cl cued with phonemic, description and other traditional cues

Goal was for the listener to produce the appropriate card ◦ And for patient to produce the right word or

approximation to allow clinician to select and hand over the correct card

Up to three patients and one clinician seated with barriers

Pairs of cards distributed so that no one has both copies of a card

Cards can be ◦ Objects, written words, drawings or photos of

complex daily activities

Also called Language Action Therapy

Turn taking with one person asking in whatever way possible who has a card similar to the one he/she has selected from individual stack

Person who has the other copy turns it over and takes a turn

Another clinician can provide cueing and encouragement

Some clinicians require only talking

Others allow gesturing ◦ And other turn it into a supported communication

task and allow/encourage any form of communication

Object is to progressively make the stimuli more difficult conceptually and linguistically

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LEVEL MATERIAL DESCRIPTION EXPECTED REQUEST

EXPECTED RESPONSE

1 Pairs of cards Single wd naming using Q inflection

Naming with Q –Bread?

Yes/no +naming

2 Pairs of cards Address player by name and us Q naming

Persons’ name-do you have (name)

Yes/no (name) I do/don’t have Name

3 Pairs displayed in 2 versions

As above but add modifier to distinguish among the two

(Name) do you have a (descriptor, eg toasted) name (bread)

Yes/no I don’t have a (descriptor) name

4 Pairs in two versions and two amounts

Add amount Name do you have amount of descriptor object

Yes/no and etc

Effect of the method continues to be demonstrated in many studies

However, ◦ Read Rose (2014) Am JSLP ◦ Loose the restraints and get same or even broader

effects

Or Wilssens et al (2015) Am JSLP showing its intensity and not program ◦ Doesn’t matter (within limits of course) what we do

as long as we do a lot of it

This program is an approximation of a functional program

And it seems few people are using the rigid constraint these days

Holland (2002). Scripts in the management of aphasia. Paper presented to the world Federation of Neurology. Villefranche, FR

Holland et al (2010). Tell me your story: analysis of script topics selected by persons with aphasia. AJSLP, 19, 198-203

More recent pubs folded into upcoming slides

Notion is simply that pt (when possible) and pt and cl when necessary create discussions of an appropriate length and difficulty ◦ Can even be for the patient single words: salmon, Kiwi, smelt ◦ Need to be relevant to pt’s life and passions ◦ Written out ◦ Parts for both Cl and Pt are typical ◦ But may be a short script for pt only to tell of an interest or

happening or wish

Then practice begins with written script in front of both persons ◦ And Cl and Pt take turns ◦ In the beginning the Cl can do the asking and cl the answering

Can be practiced first with clinician then with communication partner

Cl: Lets go eat

Pt: OK CL: Where do you want to go Panera or Satchel’s?

Pt: Satchel’s

Cl: What time shall we go?

Pt: 5:30

CL: You going to eat your usual pizza? Pt: No

Cl: So what are you going to have?

Pt: Pasta

And etc

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Clinician can do lots of cueing ◦ Highlighting key words

◦ Choral reading of pt’s part

◦ With visual and auditory cues

◦ Or delayed reading with v-a cues

Then begin fading cues

And with questions clinician can help the pt move beyond the script to related content

This is a formal way to move toward more functional communication

N=2

Script training done via videoconferencing

3 weeks of three times per week tx

Results: ◦ Both improved in scripts and functional

conversation

Accuracy

Grammatical productivity

Rate of speech

Articulatory fluency

Goldberg et al (2012). AJSLP, on line

N=3, 1 Broca, 1 Wernicke, 1 anomic

9 weeks of home treatment via computer

All improved on ◦ Content

◦ Grammatical productivity

◦ Rate of production

◦ On every script

Increased verbal communication

Increased performance in other modalities

Changes recognized by others

Increased confidence

Satisfaction with software

Cherney et al (2008). Am J SLP, 17, 19-34

Especially if they are somewhat more complex

The hard work has been done for us ◦ Kaye & Cherney (2016). Script templates: A practical

approach to Script training in aphasia. Top Lang Disord, 36, 136=153

BTW this article reviews all the articles and data until 2016.

Templates at five levels of difficulty for ◦ Ordering pizza

◦ Planning to buy groceries

Written to include 10 turns of communicator

Five levels of difficulty ◦ Give criteria for choosing as reading ability

◦ Difficulty determined by data based decisions on

Readability, grammatical and semantic complexity

Go to original article-templates are available on line

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Cherney and colleagues (2014) experimented with more and less cueing Cherney et al (2014). Acquisition and maintenance of

scripts in aphasia…AJSLP, 23, S343-S360

◦ Cues in high

Highlighting key words or even sentence

Careful modeling of mouth movements

Visual and auditory cueing and choral reading

◦ The more severe the more cueing necessary

◦ This was done via computer BTW

Aphasiascripts is trademarked computer program

A crisp little program worked out by

Dr. Yvonne Rogalski For mild moderate aphasia-usually more

posterior or fluent

Pubs: Rogalski & Edmonds (2008). Attentive Reading and Constrained Summarisation (ARCS) treatment in primary progressive aphasia: a case study. Aphasiology, 22, 763-775

Rogalski et al (2012) CAC annual convention

AR piece ◦ Read appropriately long and interesting text aloud

◦ With understanding that summarization will be the goal

◦ Can be short and easy or longer and more difficult depending on pt ability and interest

◦ Cl helps with errors in the aloud reading and does all the other traditional cueing

CS PIECE ◦ Summary is constrained by pt specific laws

◦ Laws or restraints are written down and reviewed

◦ Exs:

No general words such as stuff or thing

No extraneous info (a big one for most aphasic people)

Sometimes no pronouns so that person is required to provide names

Can cue

Can get repetition of the summary

Shape language at discourse level

The aphasic brain loses some degree of ability to select and order-in other words impaired attention

This little program structures the shaping

Seems especially useful for those with more fluent aphasias

Single patient with PPA

18 treatments of one hour in 17 weeks

Stimuli: current news of interest to pt from http://www.the week daily.com

Tested pre-post and after 2 months

Measured a number of variables including ◦ Coherence: coherent organization of main ideas

and details

◦ Cohesion: appropriate relationships of words and sentences

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No opinions

No pronouns

No non-specific words such as stuff

Written out and presented to him any time one was violated

Increased coherence

Increased cohesion

Increased words per minute and correct information units=number of information units/total number of words

Results maintained

Increased lexical retrieval

Decreased number of reading errors

In one of two patients with moderate-severe Wernicke’s aphasia

That’s all right

Evidence-based practice also gives equal status to clinical intuition

And the data will arrive