Presentation on theme: "Associate Professor Lyndsey Nickels"— Presentation transcript:
1Treatment of Word retrieval impairments: Do we know which tasks work for whom and why? Continued! Associate Professor Lyndsey NickelsNational Health and Medical Research CouncilSenior Research Fellow,Macquarie Centre for Cognitive Science (MACCS),Macquarie University, Sydney, Australia
2How do we decide which treatment? Remember….Therapy for word retrieval DOES NOT have to include word retrievalEach different level of breakdown in word production will be best remediated by a different type of treatment(e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991)impaired word meaning (semantics)→ treatment focusing on meaningimpaired retrieval of the phonological form from semantics→ treatment focusing on providing/accessing the phonological formimpaired phoneme level/phonological encodingtreatment focusing on phonemes
3How do we decide which treatment? Each different level of breakdown in word production will be best remediated by a different type of treatment(e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991)impaired word meaning (semantics)→ treatment focusing on meaningimpaired retrieval of the phonological form from semantics→ treatment focusing on providing/accessing the phonological formimpaired phoneme level/phonological encodingtreatment focusing on phonemes
4What treatment is appropriate? Semantic impairmentsThe most successful therapy seems to involve exploring the semantic attributes of a stimulus.e.g. Boyle & Coelho, 1995.Coelho, McHugh & Boyle, 2000.Hillis, 1991, 1998.Nickels & Best, 1996.LexicalSemanticsPhonological Output LexiconPhonological Output BufferSpeech
5Therapy for semantic impairments Exploring semantic attributes of a stimuluse.g. Semantic feature analysis (SFA)(Boyle & Coelho, 1995; Coelho, McHugh & Boyle, 2000)name a picturegenerate features relating to …..Can we be sure this is effective?Not entirely … they use very small numbers of items in the sets, and examine changes in performance using visual inspection with no statisticsGROUP: is an ANIMALUSE: is used for protectionACTION: does what? BarksLOCATION: is found at homeASSOCIATION: reminds me of a kennel
6Therapy for semantic impairments (cont) e.g. Nickels & Best (1996) AER“Relatedness judgements” (with feedback)Nickels & Best argue that feedback is critical to obtaining generalisation to untreated itemsStatistically significantly improved naming of treated and untreated stimuli
7Therapy for semantic impairments (cont) e.g. Hillis (1991, 1998) HG.LemonRed vs yellowRound vs ovalThin skin vs thick skinSweet vs sour
8Therapy for semantic impairments (cont) e.g. Hillis (1991, 1998) HG.name a picture,if and semantic error was produced,→ drawing of errorcompare drawing to the target picturediscuss semantic distinctionsSignificant improvement in written naming (treated)also in spoken naming and word comprehensionImprovement of treated items and untreated items in the same semantic category(but this may just be that untreated items appeared in therapy)Hillis (1991, 1998) used a similar technique to remediate the semantic impairment and improve (written) naming for HG. HG was asked to attempt to name a picture, if this attempt failed and a semantic error was produced, a drawing of her error was made. This drawing was compared to the target picture and semantic distinctions between the two were discussed. Both treatments are argued to be successful. In the case of HG, there is a clear demonstration that there is improvement not only in written naming, which was treated, but also in spoken naming and word comprehension (as would be predicted for a treatment targeting semantic processing).
9How does the treatment for semantic impairment work? If so what would the effects be?Doesn’t it improve the semantic impairment?
11Heard Speech Print Idea, Picture, or seen object Lexical Semantics Phonological Output LexiconPhonological Output BufferSpeech outputWriting
12Heard Speech Print Idea, Picture, or seen object Lexical Semantics Phonological Output LexiconPhonological Output BufferSpeech outputWriting
13PrintHeard SpeechIdea, Picture, orseen objectBut although this was true for Hillis’ study with HG, it was not for AER.Improvement in all modalities only occurs if treatment improves semantic processingLexicalSemanticsLexical SemanticsPhonological Output LexiconSemantic therapy for semantic impairments should improve all modalitiesPhonological Output BufferSpeech outputWriting
14Coelho et al (2000) - a strategy for word retrieval Consistent with improvement across modalitiesHow did the authors think these treatments for semantic impairments were having their effects?Hillis (1998)“improvement at the semantic level itself – perhaps through increased specificity of semantic representations of trained items”Coelho et al (2000) - a strategy for word retrieval“by activating the semantic network surrounding the target word, that word may be activated above its threshold, thereby facilitating retrieval”Consistent with improvement restricted to speech productionHow might these semantic treatments be having their effects? Hillis is explicit that HG’s improvement was “improvement at the semantic level itself – perhaps through increased specificity of semantic representations of trained items” (Hillis, 1998, p654). Coelho et al (2000) do not appear to advocate a relearning of semantic distinctions, but instead focus on the facilitative effects of SFA “by activating the semantic network surrounding the target word, that word may be activated above its threshold, thereby facilitating retrieval” (p135).Indeed they are explicit in suggesting that SFA is a strategy for word retrieval, noting that the aphasic individual treated by Boyle & Coelho (1995) was “less able to internalise the SFA strategy to facilitate word retrieval” (Coelho et al, 2000, p140).Nickels and Best (1996b) discuss a similar account for a man with a semantic impairment, AER, following ‘relatedness’ judgements (and following ‘function’ judgements). They suggest that naming improvement showed generalisation by “the use of a strategy (which may be unconscious) of exploring the semantics of an item (when naming fails) which facilitates retrieval of that item (perhaps by increasing the semantic information addressing the output lexicon to a ‘critical’ level where retrieval can occur)” (p119).Hence, techniques promoting reflection on semantic properties may be better viewed as teaching a strategy , albeit an unconscious strategy, rather than remediating semantic processing, at least for some of the individuals targeted.Nickels and Best (1996)“the use of a strategy (which may be unconscious) of exploring the semantics of an item … which facilitates retrieval of that item (perhaps by increasing the semantic information addressing the output lexicon…)”
15Semantic tasks and semantic impairments Hold on! How can therapy for semantic impairments improve word retrieval without improving semanticsSemantic tasksThose tasks which involve focusing on word meaningsSemantic tasks may be used to treat semantic impairmentsThose tasks which seem to most often improve semantic impairments involve reflecting on semantic featuresHowever even then they may NOT improve semantics itself but may instead provide a strategy for improving word retrieval.Didn’t we contrast semantic impairments and post-semantic word retrieval impairments?Yes, but semantic impairments cause word retrieval impairments …
16Post semantic word retrieval impairment Object, picture or ideaSemanticspurrsbarks4-legsfurpetscalesPhonological LexiconrobincatdograbbitfishhousePhonologicalBuffer/ Phonemeskdæogt
18PhonologicalBuffer/ Phonemes Sem impairmentSemantic impairmentObject, picture or ideaSemanticsbarksfurpet4-legsscalespurrsPhonological LexiconrobincatdograbbitfishhousePhonologicalBuffer/ Phonemeskdæogt
19PhonologicalBuffer/ Phonemes Semantic impairmentAlthough, as we will see, this is usually only the case in people with less severe semantic impairments.Object, picture or ideaSo tasks can be effective in improving word retrieval WITHOUT improving the semantic impairmentSemanticspurrs4-legsfurbarkspetscalesPhonological LexiconrobincatdograbbitfishhouseSemantic impairment also leads to a reduction in activation at the word form levelPhonologicalBuffer/ Phonemeskdæogt
20SUMMARY: What treatment is appropriate? Any questions?Semantic impairmentsThe most successful therapy seems to involve exploring the semantic attributes of a stimulus.e.g. Boyle & Coelho, 1995.Coelho, McHugh & Boyle, 2000.Hillis, 1991, 1998.Nickels & Best, 1996.LexicalSemanticsPhonological Output LexiconPhonological Output BufferSpeech
21Therapy for semantic impairments or semantic tasks as therapy? These tasks are widely used in the remediation of word-retrieval impairments, however, their use is not restricted to those individuals with semantic impairments.Virtually all tasks involve semantic processingSome focus on semantic processing to a greater extent(we tend to refer to these as semantic tasks)e.g.odd one out(spoken or written) word to picture matchingword-picture verification
22Semantic tasks for improving word retrieval The use of semantic tasks is not restricted to individuals with semantic impairments…...semantic tasks can improve word production even for those individuals with good semantic processing and even when the tasks are performed accurately(e.g. Nickels & Best, 1996).…. In fact they are probably more likely to improve word production for those with relatively less semantic impairment – those with ‘post-semantic lexical retrieval impairments’.
23What treatment is appropriate? Word retrieval impairmentsTasks focusing on semantics and phonology- improve word retrievale.g. Howard et al 1985Nickels & Best 1996LexicalSemanticsPhonological Output LexiconPhonological Output BufferSpeech
24What treatment is appropriate? Word retrieval impairmentsTasks involve activation of both semantics and phonologyBut may focus more on semantics….LexicalSemanticsPhonological Output LexiconPhonological Output BufferSpeech
25What treatment is appropriate? Word retrieval impairmentsAll the tasks involve activation of both semantics and phonologyBut may focus more on semanticsor phonologyLexicalSemanticsPhonological Output LexiconPhonological Output BufferSpeechRepeat “kangaroo”It starts with /k/
26What treatment is appropriate? Word retrieval impairmentsAll the tasks involve activation of both semantics and phonologyThey produce long lasting, item specific effects in the majority of individuals with impaired activation of the correct target in the phonological lexiconImproves likelihood of the target being sufficiently activated to be retrieved successfully.LexicalSemanticsPhonological Output LexiconPhonological Output BufferSpeech
27Let’s explore these tasks that improve word retrieval in more detail
28“Semantic” tasks as therapy Word-picture matchingWord-picture verificationThe tasks work best with people that can do them easily (people with less of a semantic problem)These tasks typically don’t require word production but improve naming at a later point neverthelessWidely effective (Howard et al, 1985; Marshall et al, 1989)Long lasting effects (Pring et al., 1990)Generally, lasting effects are item specific
29How important is the emphasis on semantic processing? Howard et al (2006)Compared the efficacy of word-picture matching with related and unrelated distractors(related distractors = deeper processing = more effective?)
30How important is the emphasis on semantic processing? Howard et al (2006)Compared the efficacy of word-picture matching with related and unrelated distractorsAll incorrect before word-picture matchingAfter word-picture matchingRelated distractors: 45% correctUnrelated distractors: 50% correctControls: 30% correctNot even for those with more severe semantic impairments?No evidence that deeper semantic processing improves efficacy of word-picture matching
31How important is the emphasis on semantic processing? Howard et al (2006)Compared the efficacy of word-picture matching with related and unrelated distractorsAll incorrect before word-picture matchingAfter word-picture matchingLess sem imp More sem imp.Related distractors: 50% 40%Unrelated distractors: 60% 40%Controls: 40% 23%No evidence that deeper semantic processing improves efficacy of therapy:not even for those with more severe semantic impairments
32How important is the emphasis on semantic processing? Martin, Laine et al (2000, 2003, 2004, 2005) ‘Contextual Priming’Compared the efficacy of naming/repetition in the context of semantically related distractors and unrelated distractors.
33How important is the emphasis on semantic processing? Martin, Laine et al (2000, 2003, 2004, 2005) ‘Contextual Priming’
34How important is the emphasis on semantic processing? Martin, Laine et al (2000, 2003, 2004, 2005) ‘contextual priming’Compared the efficacy of naming/repetition in the context of semantically related distractors and unrelated distractors.- Naming is worse at the time with semantically related distractors.Naming is improved no more (at a later point) with semantically related distractors.No evidence that a semantic context improves efficacy of therapy
35How important is the emphasis on semantic processing? Not as important as we thought!Tasks which have traditionally been labelled ‘semantic’, such as word-picture matching are equally effective with unrelated items.Adding a semantic context to a (naming/repetition) task does not make it more effective.
36 How important is the phonological form in the semantic task? Most probably critical to its effectivenessWord form is usually provided.e.g. Le Dorze et al (1994)“Show me the octopus”“Show me the mollusc with long legs”
37Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments It looks at the effect of a task performed ONCE on another task at a later point and contrasts with…What is a facilitation experiment?Immediate Cueing effects: The effect of a technique at the time of its applicationAs I said earlier, we used two tasks which had been used in the earlier phase of the study - that is, (click) repetition with the picture present, in the phonological treatment component.In the semantic treatment component the person was asked a yes/no question about a feature of the picture. The picture was in front of them but the question didn’t include the target word (we’ll touch on why this was important in the discussion a bit later on).Therapy: The application of a technique several times, over days, weeks or months
41Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments Semantic without the word formFeature verificationDoes it hop?PhonologicalRepetition“kangaroo”
42Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments Name 300 pictures until 95 failed (10 second limit)Sort the failed items into 3 (frequency & length)matched setsFacilitation Task 1Facilitation Task 2Control1 week laterFacilitation10 mins laterName all 3 sets of pictures+ 30 easy fillers
43Comparing repetition and a semantic task with no word form
44Comparing repetition and a semantic task with no word form
45Comparing repetition and a semantic task with no word form Very little benefit from a semantic task without the word form for most individuals
46Semantic tasks without the word form We also looked at the same tasks used as therapy with 4 individuals with aphasia… once again, semantic tasks without the word form had little benefit…. for example….DRS8 sessions of semantic therapy (feature verification)over 2-3 weeksBefore each therapy session named all those items that were to be treated, and a set of control pictures (50 items in each set).
47DRS - Semantic Therapy No extra benefit from the semantic task But the untreated items seem to improve.....Spontaneous recovery?Generalisation?Benefits from repeated naming attempts?No extra benefit from the semantic task
49Treated items and repeatedly named items improve to the same degree – so there is no specific benefit from the semantic task
50The improvement from naming controls isn’t generalisation or spontaneous recovery (unseen controls don’t improve) – but benefit from repeated attempts at namingTreated items and repeatedly named items improve to the same degree – so there is no specific benefit from the semantic task
51Summary: semantic tasks in word retrieval Any questions?Degree/depth of semantic processing appears not to be critical (Howard et al)Presenting tasks in a semantic context can interfere short-term and mostly has no long term advantage over presentation in unrelated contexts (Martin, Laine et al)Presence of phonological form appears critical in most cases (Le Dorze et al; Nickels et al: facilitation studies, DRS therapy study)…… and so to Phonological tasks
52“Phonological” tasks Repetition of target Reading aloud Phonological & orthographic cueingRhyme judgementsSyllable and phoneme countingPhoneme segmentationAnagrams…….but nearly always in the presence of the picture.Again we need to remember the distinction between the nature of the task and the nature of the impairment…. Here we are talking about phonological tasks but NOT impairments to the phoneme level.They range from repetition of the target, phonological (and orthographic) cueing of picture naming, tasks involving phonological judgements such as rhyme judgements, syllable and phoneme counting, and phoneme segmentation to tasks combining orthography and phonology using reading, anagrams and scrabble tiles.In much the same way as with semantic tasks, many of these have been used to facilitate word retrieval and not exclusively in individuals with phonological impairments.
53Phonological tasks and word retrieval Widely argued to be the most appropriate for impairments in retrieval of (or damage to) the phonological form from the phonological output lexicon(e.g. Hillis & Caramazza, 1994; Miceli,et al, 1996; Nettleton & Lesser, 1991)Miceli et al (1996): as these tasks focus at the level of activation of individual entries in the phonological output lexicon, their effects should be item specific– a result of ‘priming’ retrieval of the phonological form.Phonological tasks have been widely argued to be the most appropriate for impairments in retrieval of (or damage to) the phonological form from the phonological output lexicon (e.g. Miceli, Amitrano, Capasso & Caramazza, 1996; Nettleton & Lesser, 1991). Miceli et al (1996) argue that as these tasks focus at the level of activation of individual entries in the phonological output lexicon, their effects should be item specific – a result of ‘priming’ retrieval of the phonological form. Indeed that is what has been found in several studies (e.g. Miceli et al., 1996; Hillis & Caramazza, 1994, HW; Nettleton & Lesser, 1991, DF).But as already mentioned – item specific effects are also what has been the most common outcome for so called semantic tasks when used to remediate word retrieval impairments.
54For many years ‘semantic’ tasks were thought to be more effective than ‘phonological’ tasks in improving word retrievalHow true is this?
55Comparing repetition and a semantic task with no word form
56Comparing repetition and a semantic task with no word form Very little benefit from a semantic task without the word form … repetition is almost always more beneficial
57DRS - Phonological Therapy Significant extra benefit from the repetition task
58For many years ‘semantic’ tasks were thought to be more effective than ‘phonological’ tasks in improving word retrievalThis seems NOT to be true in general, particularly if the semantic task does not include the word form
59Semantic & phonological treatments: an overstated distinction? BOTH have semantic and phonological componentsSemantic tasks without the phonological form are generally not effectiveHoward (2000)– tasks having the same effects in the same wayStrengthening the connections between semantics and phonological form when both are simultaneously activeequivalent effects for semantic and phonological tasks for most individualsHoward (2000) suggests that the difference between semantic and phonological tasks may well be overstated. In the majority of the studies with semantic treatments, the form of the word is provided (as a spoken or written word), and as we have already noted, in ‘phonological’ tasks, the picture is usually present (evoking semantic processing) and/or a word provided for repetition, which will also access word meaning. Hence in both tasks there is semantic and phonological information available.Howard (2000) argues that the difference between these tasks is indeed more apparent than real and that both tasks are indeed having their effects in exactly the same way – by strengthening mappings between semantics and phonological form when both are simultaneously active. This predicts equivalent effects for semantic and phonological tasks for most individuals.Unfortunately, there are few studies which examine this issue. Howard (2000), in a reanalysis of Howard et al. (1985b), found a very high correlation between the rate of improvement during the two types of therapy, and naming accuracy on items treated by the two methods.Moreover, a homogeneity test on the difference between the effects of the two treatments confirmed that there was no evidence that any patient benefited more from one treatment than the other.Nevertheless, one of the cases studied by Nickels & Best (1996b), PA, does seem to counter Howard’s prediction – she benefited from tasks providing the word form (in her case the written word) but failed to benefit from semantic tasks (including the word form). Clearly, once again, further investigation is warranted[ii].[ii] It is also probable that the choice of stimuli has an influence on the success of treatment. Martin, Laine & colleagues (Laine & Martin, 1996; Martin & Laine, 1997, 2000; Martin, Fink, Laine & Ayala, 2001) have recently observed that some individuals benefit from facilitation using sets of either phonologically or semantically related items, whereas others are impaired by these contexts.
60PhonologicalBuffer/ Phonemes Object, picture or ideaSemanticspurrsbarks4-legsfurpetscalesPhonological LexiconrobincatdograbbitfishhousePhonologicalBuffer/ Phonemeskdæogt
61PhonologicalBuffer/ Phonemes Object, picture or ideaSemanticspurrsbarks4-legsfurpetscalesPhonological LexiconrobincatdograbbitfishhousePhonologicalBuffer/ Phonemeskdæogt
62PhonologicalBuffer/ Phonemes Object, picture or ideaSemanticspurrsbarks4-legsfurpetscalesPhonological LexiconrobincatdograbbitfishhousePhonologicalBuffer/ Phonemeskdæogt
63‘Semantic’ and ‘phonological’ tasks are working in similar ways By strengthening the connections between semantics and word form by activating both semantics and phonology
65The role of effort and error How does amount of ‘effort’ or accuracy in a task affect the benefit for naming?Effortful >benefit than automatic?Greater semantic processingErrorless >benefit than errorful?
67Method Name 300 pictures until 95 failed (10 second limit) Sort the failed items into 3 (frequency & length)matched sets1 week laterFacilitation Task 1Facilitation Task 2ControlFacilitation10 mins laterName all 3 sets of pictures+ 30 easy fillers
68Facilitation effect compared to control pictures: Errorless/Automatic (Repetition) vs Errorful /Effortful (Phonemic cues)********
69Facilitation effect compared to control pictures: Errorless/Automatic (Repetition) vs Errorful /Effortful (Phonemic cues)********
70Comparing Phonological Tasks >benefit thanRepetitionEffortless, ‘shallow’ processing, error reducingWell, repetition is better and it does improve more BUT the proper comparison is within a task ….Phonemic cueingEffortful, deeper processing, errorful“kangaroo”“k”Is errorless (or error reducing) better than errorful?No need for it to be effortful to be helpful – FOR MOST PEOPLE
71Fewer errors means greater benefit? Repetition is more error-free than cueing… but the proper comparison is within a taskCueingDo the people who are more accurate with cueing (at the time) have more benefit for naming (later)?
72Errorless items benefit more? Repetition is more error-free than cueing… but the proper comparison is within a taskCueingno significant correlation between success of the cue during facilitation and benefit of cueing for subsequent naming.i.e. errorless is not better than errorful for cueing.Why did we think errorless might be better in the first place?
73Errorless learning Hypothesis Remediation is more effective if errors are prevented- the act of producing an error may strengthen the incorrect association, and make the correct response less likely to occur.HistoryAnimal learning (Terrace, 1963)Children with developmental learning difficulties(e.g. Sidman & Stoddard, 1967).Acquired memory impairments (amnesia)(e.g. Baddeley & Wilson, 1994)
74Errorless learning and anomia treatment Fillingham et al (2003)“error reducing techniques do have positive effects for patients with word finding difficulties. As yet there is limited information on which to judge whether this technique is significantly advantageous over errorful approaches” (p358).Fillingham et al (2005, 2006)No significant difference between errorless (repetition) and errorful (cueing) tasks.Abel et al (2005)No significant difference between increasing and vanishing cues methods (errorful vs error reducing).BUT nonetheless repetition may be more beneficial than phonemic cueing for many peopleRemember that this will all depend on the processing strengths and weaknesses of the aphasic individualThere appears to be no difference between errorful and errorless techniques in aphasia
75How semantic & phonological tasks work Any questions?How semantic & phonological tasks workError & Effort
76Generalisation in the treatment of word retrieval. the most successful treatment is one which effects improvement not only for the items used in therapy but also for any other item, in any other context.many treatments produce clear long lasting effects on the treated items, generalisation to untreated items is less common, and when obtained, often less robust (e.g. Nickels and Best, 1996b)
77When perceived generalisation is actually an effect of (assessment during) treatment! DRS
78When perceived generalisation is actually an effect of (assessment during) treatment! DRS
79When perceived generalisation is actually an effect of (assessment during) treatment! Howard et al (1985) “Naming controls”naming daily but NOT treatedImproved significantlyWidely interpreted as generalisation of treatment effects– more probably the result of repeated attempts at naming (Howard, 2000)Nickels (2002) JAWRepeatedly attempted to name a set of pictures (daily for a week)Significantly improved naming
80Practice makes (closer to) perfect: trying to name helps naming! But it could have important implicationsUse it or lose it(Attempts at) conversation might improve word retrieval- (Trying to) talk about the same topics may be betterHOW?some names will be successfully retrieved on one occasion but not on another.When, by chance, an individual produces a picture name successfully, both the semantic representation and the phonological representation for that item are simultaneously active.This will then strengthen the mapping for that item, making it more likely that the word will be produced correctly on a subsequent occasion (which will again strengthen the mapping).Over time, more items will have strong enough mappings to be produced accurately on every occasionOr perhaps just partially activating the phonological representation when trying to name is enough to strengthen the mappingsMore work needs to be done to determine who this works for, how close together naming attempts have to be etc etc
81When generalisation is a reflection of (strategic When generalisation is a reflection of (strategic?) changes in processingSemantic tasks (with semantic disorders)Techniques promoting reflection on semantic properties may be better viewed as teaching a strategy, albeit an unconscious strategy.Phonological tasksBest (2006) examined who showed generalisation using a cueing treatment – it was those individuals with relatively more of a phonological impairment (and less semantic impairment)Self-cueingE.g. phonologically mediated orthographic cueing
82Mostly generalisation is limited… Therefore the emphasis is on the clinician to ensure that all items used in therapy are functionally relevant and chosen in collaboration with the person with aphasia.Nickels et al – in progress‘Home Programme’Using the most successful task (repetition)items chosen by the person with aphasia as being words they wanted to be able to say.Therapy presented by computer in powerpoint‘Structured’ conversation used to evaluate carry-over from naming to conversation
85Treatments aimed at remediating word production impairments Tasks can beeffective (e.g. Hillis & Caramazza, 1994; Howard et al, 1985b),produce durable effects (e.g. Pring et al, 1990),be administered by clinician &/or computer (e.g. Fink et al, 2002)be obtained on verbs & nouns (e.g. Murray & Karcher, 2000; Raymer and Ellsworth, 2002).carry-over into connected speech & conversation (e.g. Hickin et al, 2002),BUTtreatment tasks are not invariably effective
86Do impairment-based treatments impact on functional skills and increase activity & participation? word retrieval/production underlies every attempt at verbal communication hence improving word retrieval impairments is of course functionally relevantSimplistic and/or fundamentally misguidedBUTthe importance of an increased ability to name treated items following therapy should not be underestimatedHillis (1998) HG- small change in impairment – significant gains in activity & participation with the use of functionally relevant personal items (Bacardi & Coke!)
87Do impairment-based treatments impact on functional skills and increase activity & participation? Yes …. (functional gains can be achieved)but…. (they are by no means guaranteed)few studies that have formally evaluated the effects on disability of impairment-based remediation.It seems particularly important given the prevalence of item specific effects that remediation should include personally relevant stimuli.
88Any questions? Generalisation Effects of repeated naming Functional relevance
89Lets take another look at cueing So far we’ve talked about tasks that aim to improve the underlying word retrieval impairment – some tasks may work in other ways tooLets take another look at cueing
99? How does this work? Phonologically-mediated self-cueing T -> /t/?How does this work?Phonologically-mediated self-cueing(e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)
100Phonologically-mediated self-cueing T -> /t/Requires access to the written form when the spoken form is unavailabletomatoRequires an ability to convert letters into soundsRequires phonological cueabilityPhonologically-mediated self-cueing(e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)
101Phonologically-mediated self-cueing Can be retaughtCan use a computer cueing aid to do the conversionRequires access to the written form when the spoken form is unavailableRequires an ability to convert letters into soundsRequires phonological cueabilityPhonologically-mediated self-cueing(e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)
102Generating phonemic cues from the initial letter Nickels (1992) TC1. Spoken naming 2. Written naming 3. Convert letters to sounds dog
103Generating phonemic cues from the initial letter Nickels (1992)retaught letter-sound correspondencesThis improved TCs spoken naming to almost the same level as his written naming.He used this spontaneously in conversation.Could be (and was) used for any word he was trying to retrieve(only fails for words with irregular initial letters e.g. onion, Cinderella)1. Spoken naming 2. Visualise written word 3. Sound out initial letter& cue word production dogddog
104Using a computer to generate phonemic cues from the initial letter e.g. Bruce & Howard (1987); Best et al. (1997)1. Spoken naming d2. Visualise first letter 3. Press letter /d/4. Computer produces phoneme dog5. Cue word production
105Generating phonemic cues When spoken naming IF individuals can identify initial letter convert letters to sounds and are phonemically cueable Then they can generate their own cues.If unable to convert letters to soundsCan be retaughtCan use computer generated cues- may be able to use the letters without converting to sounds – Direct orthographic cueing.
106Direct Orthographic Cueing SD: Howard & Harding (1998)impaired access to the phonological output lexicon (good semantics)Unable to form lettersGiven an alphabet board– naming improved dramaticallyWas not using phonological mediationunable to convert letters to soundsunaffected by initial letter regularity (e.g. onion; eye)
107Self-generated orthographic cues Any questions?Self-generated cuesWhen spoken naming IF individuals can identify initial letter They may be able to use direct orthographic cueingIf they are phonemically cueable They may be able to use a computer to generate the cuesIf they can (or be taught to) convert letters to sounds They may be able to generate their own phonological cues.
109Using a cueing aid as therapy – who benefits? Best, Howard, Bruce & Gatehouse (1997)13 individuals treated with the cueing aidpredicted benefit only for those whowhen spoken naming can identify initial letter & are phonemically cueable They should be better at naming with the aid than without it (this is providing the cues).Only two individuals had both skillsAfter treatment:Only 1 individual had better naming with the aid than without.BUT 12 showed significant improvement in naming.WHY???
110Repetition in the presence of the picture Why does treatment with a cueing aid help individuals who are not predicted to benefit?Treatment tasks can work in different ways for different individualsMulticomponent treatmentorthographyphonologysemantics (presentation of the picture and attempted naming).Only one individual was helped by the aid providing the cue - for many others this was a standard word retrieval therapyPhonemic cueingRepetition in the presence of the picture
111Cueing aid reorganising the naming system: JOW (Best et al, 1997) Substantial and long-lasting effects of treatmentImprovement in treated and untreated itemstreatment drew attention to the relationship between orthography and phonologyaltered automatic (not strategic) processes in his word retrievalA direct orthographic cueing mechanism
112How tasks actually work may not be how you planned them to! Why does treatment with a cueing aid help individuals who are not predicted to benefit?Treatment tasks can work in different ways for different individuals…. especially when they are multicomponentHow tasks actually work may not be how you planned them to!And sometimes they don’t work even though you would predict they should!
113RECAPBEFORE THE BREAKAssessment of level of breakdown in word productionMethodological issues in evaluating treatment
114RECAP (continued) AFTER THE BREAK Improving naming when there are semantic impairmentsExploring semantic featuresIt may work by providing a strategy to improve naming rather than improving semantics itself.Word retrieval impairmentsSemantic vs phonological tasksSemantic tasks require the word form, depth of semantic processing is not importantPhonological tasks are also effectiveTasks are working in the same wayEffort & errorTasks do not need to be effortfulThere is no additional benefit from errorless performance
115RECAP (continued) Generalisation Self-generated Cues Treatment for Word retrieval impairments usually result in item specific improvementsbut may generalise to conversation, and can produce effects on participation/quality of lifeUse of functionally relevant items is a priorityRepeated attempts at naming may improve word retrieval for some individualsGeneralisation can result from strategic/compensatory approachesSelf-generated CuesPhonologically mediated/computer generated/direct orthographicTasks may not always work the way you expectALL OF THE ABOVE ARE GENERALISATIONS– every person with aphasia is different and could be the exception to these general principles
116Relationship between task, impairment and efficacy Therapist’s dream = Prescription guide“to unambiguously pair a particular functional impairment with a treatment task that has guaranteed success for that impairment”
117Clinicians need to know what to do NOW!!! choose a therapy that has the best chance of succeedingChoose a task that has successfully improved naming for a wide variety of people with spoken word retrieval impairments- multicomponent approaches (e.g. cueing hierarchies or multimodality/multi-task therapies – see e.g. Best et al, 1997; Hickin et al, 2002)Use pilot studies using different tasks for short periods (e.g. 1 week) to establish which tasks seem effective and which do not prior to continuing with the most effective therapies over longer period.
118Prove that it works!ensure that it is possible to establish whether or not a particular therapy is effective by using a sound methodology.We have a duty to be able to demonstrate that a therapy is effective to the individuals with aphasia, their families/friends/carers, those funding the treatment and not least to ourselves.