Tls for oslha unit&vid 2 21-11

Morganstein & Certner-Smith, 2011

Shirley Morganstein, MA CCC-SLP

Marilyn Certner Smith, MA CCC-SLP

Speaking of Aphasia, LLC

Thematic Language Stimulation


Introduction: TLS Philosophy

W h a t ’s T L S ?


TLS Definition

Thematic language stimulation (TLS) is a systematic method of aphasia therapy that employs thematically-related vocabulary in multimodality stimulation, targeting changes in language processing for functional communication.

TLS Flow: A Process

Begins with a select group of words, related in meaning.

Places words in particular linguistic contexts.

Uses words in tasks that employ both input and output modes.

Targets improvement of underlying language processes for conversational success.


Role of the Therapist in TLS

Carries the burden of success.

Provides a link between what the PWA knows and what he shows.

The neurobiological catalyst.


The Therapist and the PWA

Stimulation: improved language performance.Observation during stimulation: reveals information about underlying processes.Awareness of processes: has value in conversational strategy development



TLS: Elements of the Definition

Thematic language stimulation (TLS) is a systematic method of aphasia therapy…


How is it systematic?

Presents material in hierarchical arrangement– Best modality first– Easiest S-R format first

The “Alice-in-Wonderland” phenomenon“Begin at the beginning, continue

through the middle, and stop when

you come to the end.”


…that employs thematically-related vocabulary in multimodality stimulation



Thematically-related vocabulary?

Meaningful content and personal relevance heighten therapeutic effect via contextual language elements.

Capitalizes on the organizational systems and elements already well-established within the brain, rather than creating new ones.


Multimodality stimulation?

Language involves speaking, understanding, reading, and writing. Schuell (1964)felt remediation should employ all of these modalities in order to enhance therapeutic effect.– At the right level in each modality– In every session– In a sensible progression of activity

and task requirements


… targeting changes in language processing for functional communication.



Changing processes for functional communication?

TLS hypothesis is that you are changing the way the brain is working, by “working the brain”.


Brain Work: Neurobiological Evidence


Animal studies

Jenkins et al (1990) found expansion of distal digit representation in monkey brains after sensory training.Kilgard and Merzenich (1998) found changes in the organization of monkey aud cortex with exposure to combination of sound exposure and administration of chemical neurotransmitters.


Research in Humans: “The Community of Brain Repair”

Constraint-induced therapy in affected upper extremities post CVA.

BWST in spinal cord injury


“What goes around comes around”1950’s: Schuell’s clinical neurobiology1960’s: Programmed instruction1970’s: Compensatory Techniques1980’s: Cognitive and Linguistic techniques1990’s: Social and Life Participation2000’s: Renewed neurobiological interest

The Next Decade: the Brain Redux

fMRI : does therapy change the brain?

Cortical stimulation: electrocortical stim in conjunction with therapy

Neurotransmitters in conjunction with tx



Schuell’s NeurobiologicalStimulation

Principle of maximal patient response, achieved by– Extending language and

materials– Emphasis on task

repetition, re-ordering, adaptation

– Meaningful context


Schuell’s Neurobiological Stimulation

Principle of stimulus adequacy, achieved via– Intensity– Focus– Linguistic bombardment– Multiple presentations– Varied context

S.Morganstein & M.Certner-Smith

Schuell’s Neurobiological Stimulation

Systematic and Intense Presentation– Organized– Programmed for success– Repetition



Building on Schuell’s model: The TLS advantage

Use of thematically-related vocabulary, rather than

isolated high-frequency words.– Provides a “hook” upon which to

hang language: natural context.– Provision of linguistic context allows transition to

meaningful conversation.


Building on Schuell’s model: The TLS advantage

Provides inherent redundancy, depth and breadth.

Fosters connection with language, with feelings, ideas, history.Educational/training component and metacognitive exploration for PWA and/or others


Research with TLS



TLS: Preliminary Research

Defining Success – finding a functional communication measure: content unit analysis proposed by Yorkston and Beukelman.

Design Choice – single subject, reversal.

Subject selection – no significant vision or hearing deficits; able to participate in a 3 week course of 5 day/week therapy.


TLS: Preliminary Research

Procedures– CU analysis (cookie theft picture)– One week in a randomly assigned module– Repeat CU analysis– Reversal of module– Repeat CU analysis– Reversal of module– Repeat CU analysis


Treatment Effects ofTLS

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1.8

0.9

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3.12.7

4.9

2.1

12

6.4

7.4

10.8

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14

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Test Intervals

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Beginning with TLS: Assessment



Assessment

The PWA’s preferences for treatment and goals is where is all begins.



Assessing at the Impairment Level

Determine the severity of the aphasic symptoms

The type of aphasia

The adequacy of conversation and communication



Assessment of Impairment begins..

Evaluates deficits on standardized measures.

Derives information about patient process during testing– Less emphasis on the

score– More emphasis on how

he got it



More Assessment

Probes strategies for task success

Derive information about functional communication and its enhancement.



Assessing the Impairment (Deficit)

BDAE

MTDDA

WAB

PICA



Process Assessment

Quality as well as quantity:– What is he doing?– How is he doing it?– Why is he doing it that way?– What is the time factor?– Is he using strategies that succeed? That fail?

“Batteries are for cars,Not for people.” Edith Kaplan



Assessment beyond language…

The assessment process parameters beyond language include:– Cognition: attention, abstract thinking, – Behavior: initiation, flexibility, problem solving, etc– Visual Considerations: hemianopsia, scanning

issues, acuity– Psychological considerations: sense of humor,

affect



Strategy probes for TLS

Aphasia testing using a TLS mindset requires strategy probes – Naming/word retrieval (what type of cuing helps,

phonemic or semantic?)– Repetition (does repetition increase linguistic

accuracy?)– Oral reading (does oral reading increase awareness

of errors & afford an opportunity for self correction?)– Etc……



Assessing conversational ability and style

Assess conversational ability, any way you can– Formal tool: FCP, CADL– Interview, questionnaire

Assess transactional process:– Circumlocution, self-correction, self-cueing

Assess interaction:– Drive, social connection, problem-solving, flexibility


Summary of Assessment

LanguagePatient processNon-language profileTask strategiesConversation

S.Morganstein & M.Certner-SmithMorganstein & Certner-Smith, 2011

Formulating a TLS Unit

A TLS Recipe



TLS: Creating and Using The TLS Unit

Following a culinary metaphor…


The TLS Unit: It’s About…

Knowing

Selecting

Developing

Delivering

Extending

Enhancing


TLS: Knowing

“Who am I dining with?”– Education– Talents & Interests– Family background– Insight about the nature of aphasia– Life priorities– Style (emotionally open or closed)


TLS: Selecting

Choosing the sandwich:– Topics that relate to the person’s

interest are always preferred:– Provides a natural and personal

connection for treatment.– Enhances the likelihood of linguistic success since

he has better access to information and ideas on “his turf.”


TLS: Creating

Assembling the sandwich– Select content vocabulary: 8-10 words related semantically,

preferably concrete nouns and verbs.– Select the exercises to be employed for a course of 5-7

sessions based upon assessment findings.– Establish a treatment hierarchy for the

exercises, progress easier to harder.– Create (or copy) those exercises

to be used.


TLS: Delivering

Introductory topical conversation on the theme

Manipulation of language in a series of multimodality tasks

Return to functional conversation on the theme.

Here’s a TLS Sandwich!


TLS: Extending

Serve more of the sandwich:– Extend the theme by adapting and adding exercises

as you go.– Extend the theme in real, related conversation. – Extend the theme in supplementary materials

(menus, ads, letters, internet articles)


TLS: Enhancing: Metalinguistic Process

What just happened here? (reflections on the meal)– SLP internally reflects upon what

worked, and modifies what she does next time.

– SLP offers observations to patient about performance in a general sense:

• Gives positive feedback• Leads toward insight about aphasia (prerequisite

for developing strategies)


TLS: Enhancing Metalinguistic Process

Critiquing the experience: continued– SLP offers more detailed observations about

performance and asks the patient for his discoveries– Gives positive feedback; transaction & interaction– Establishes a collaborative relationship in problem

solving the treatment outcome.– Encourages more responsibility and independence in

symptom management


TLS: Secrets of a Good Sandwich

Maintain a success rate of approximately 80-90% for each selected task.Present flexibly, shift and roll as needed.Recognize task order, decrease choices, change modes.Keep patient in the loop: ask for feedback, comments and insights.Use humor and emotion whenever feasible; the limbic system is a good stimulator.


TLS: Secrets of a Good Sandwich

Make small changes in some aspect of the task each time you repeat it (and do repeat it!)“Milk” the linguistic contexts in which the words appear.There are no “wrong” responses—merely more opportunities to stimulateInclude multi-modalities to reap the stimulation benefit.


TLS: Formatting the Unit

The ABC’s of Exercises

What to Include

Creative Composition

Building Layers of Language

Having Fun with Words


Your Turn


TLS: The Exercises

Supermarket UnitCore Vocabulary

Purpose: related vocabulary that will provide the core concepts and language of the chosen theme.

Description: nouns and verbs that are highly predictable and in some cases picturable.

aisle freezer

cashier squeeze


Repetition/Oral Reading

Purpose: controlled speech practice using auditory and/visual input.

Description: Use a word, phrase, sentence sequence in which core vocabulary items appear as the last word. Patient repeats or reads aloud.

aisle

in this aisle

Sugar is in this aisle.

squeeze

squeeze the fruit

Please don’t squeeze the fruit.


Speech Stimulation/Production

Purpose: language stimulation that transitions from cued contexts to generating novel language

Description: connected sentences for repetition. fill-ins, and answering questions.

The flour is down this aisle.

The flour is down this ____.

Where is the flour?

What else is in the baking aisle?


Copying

Purpose: writing and spelling practice at a basic level

Description: core vocabulary formatted for several writing trials with and without a model.

aisle freezer

__________ _________

__________ _________

__________ _________

__________ _________


Categorization

Purpose: Identification of the core vocabulary

Description: vocabulary are randomized in a list with foils provided of varying degrees of complexity.

aisle elephant

freedom freezer

squeeze SUV

student cashier


Sentence Fill-ins

Purpose: reading comprehension and oral recitation

Description: open ended sentences using target vocabulary and foils in a multiple choice format.

ink aisle over

I found sugar in the third _________

freezer salad butcher

Get the waffles from the__________


Yes/No Questions

Purpose: Stimulate comprehension visually and/or auditorally.

Description: Questions are formulated with target vocabulary designed to elicit a yes/no response.

Yes No

Is the freezer hot? ___ ___

Yes No

Do you squeeze ice cream? ___ ___


Answering questions- multiple choice

Purpose: Facilitates answering simple questions, reading comprehension and oral reading.

Description: Questions with responses in a mult. choice grouping of at least four items.

squeeze cashier freezer aisle

Where do you store ice cream? _____

What do you do with a melon? ______


Sentence Arrangement

Purpose: Syntactic practice

Description: Scrambled sentences are created for each core vocabulary item. Patient re-orders them.

I found:

aisle sugar in this the

____________________________

Give the money: the cashier to

____________________________


Sentence Construction

Purpose: Stimulates generating information and grammar.

Description: word pairs and word phrases are provided to create statements.

aisle -narrow down the aisle

cashier-money a quick cashier

freezer-turkey in the freezer

squeeze-Charmin squeeze a little


Sentence Correction

Purpose: Error identification and correction

Description: Statements containing core vocabulary item with two errors.

Errors can be in grammar, misspellings, or incorrect word choice.

The cashier if very slowy

______________________

The manager seem me squeeze the plumps?

______________________


Reading Paragraphs

• Purpose: Improve reading comprehension.

• Description: Humorous paragraphs which have the target vocabulary embedded within. Three of four questions are provided pertinent to content.

I wandered down the organic food aisle

searching for something interesting and

healthy. What would I chose, a soybean scone

or a tofu tamale? I wound up in the freezer

section where I squeezed a few packages.

Finally, I chose a pepperoni pizza with pork

rind crust. The cashier remarked, Dr. Atkins

would only approve of the pork rinds.”

1. What was his final choice?

j. A soy bean scone c. pepperoni pizza

k. A tofu tamale d. Dr. Atkin’s bar


Conversational Questions

• Purpose: Stimulate language that is more functionally based.

• Description: Questions designed to elicit conversational responses using core vocabulary items, and related semantic contexts.

Why shouldn’t you squeeze the fruit?

Describe which aisle in the supermarket is your favorite?


TLS: Baseball• Excerpt from

a full session, illustrating use and flow of TLS.

• Is the client’s conversation better at the end of the session?



Early Recovery

Clinical Functional Psycho/Social EducationManipulate Basic communication Support coping with Define Aphasia

symptoms processes the Trauma How it impacts

Life Participation

Psycho-social

Clinical

Functional

Education

Evolution of Recovery Dialogues


Middle Recovery

Clinical Functional Psycho/Social EducationFinesse the Transaction/Interaction Support coping with Problem solve

symptoms Enhance conversation life changes impact aphasia

Life Participation

Psycho- Psycho- socialsocial

Clinical

EducationFunctional



Late Recovery

Clinical Functional Psycho/Social EducationIntermittent Transaction/Interaction Promotes living well with aphasia Self-management explorations community focused Identity & engagement of LPAA goals

Life Participation

Clinical

FunctionalPsycho-social

Education



Participation in Life Situations

Severity of Aphasia

Communication and language environment

Personal identity, attitudes, and feelings

LIVING WITH APHASIA

Living with Aphasia: Framework for Outcome Measurement

(A-FROM)

Topics in Language Disorders, Volume 27, No. 4, Dec. 2007

Aura Kagan, The Aphasia Institute


Thank you !

Health & Medicine

Tls for oslha unit&vid 2 21-11