1. + Treatment of Aphasia Week 10 March 17 th, 2011

2. + Treatment of Aphasia II. General Approaches to Treatment B. Direct: Promoting Aphasic’s Communicative Effectiveness (PACE) (Davis & Wilcox) 1. Developed out of recognition that standard direct stimulation approaches do not coincide with structure of natural conversation 2. PACE focuses patient and clinician on ideas to be conveyed rather than on struggle for linguistic accuracy

3. + Treatment of Aphasia II. General Approaches to Treatment 3. Multiple modes of communication are encouraged 4. There is active participation of the listener in the speaker’s efforts to convey a message 5. Procedures are derived from 4 principles a) clinicians and patient participate equally as senders and receivers of message

4. + Treatment of Aphasia II. General Approaches to Treatment 5. Procedures are derived from 4 principles b) exchange of new information between clinician and patient c) patient has free choice as to which communicative channels he/she may use to convey new information d) feedback is presented by the clinician as receiver, in response to patient’s success in conveying a message

5. + Treatment of Aphasia II. General Approaches to Treatment 6. % point scoring system based on successfulness of communication 4 = message conveyed on first attempt 3 = message conveyed after general feedback indicating lack of understanding 2 = message conveyed after specific feedback (questioning etc.) 1 = message not completely understood 0 = message not understood

6. + Treatment task Typical therapy tasks contain: clinician’s stimulus, patient’s response, and clinician’s feedback Some basic tasks in treatment of aphasia Auditory comprehension Clinician’s stimulus: says a sentence while showing three pictures Patient’s response: points to one of the pictures

7. + Reading comprehension Clinician’s stimulus: says a sentence while showing three pictures Patient’s response: points to one of the pictures Spoken word finding Clinician’s stimulus: shows a picture of a common object Patient’s response: says name of the object Written word finding Clinician’s stimulus: shows a picture of a common object Patient’s response: writes name of the object

8. + Treatment task To improve patient’s performance, we may modify or supplement a stimulus or provide a informative feedback

9. + Treatment task Key feature of therapy task is the “number of items” presented to the patient. different stimuli at a comparable level of difficulty are presented to elicit responses E.G., YOU BUY A _____; YOU WRECK A ____; YOU FIX A _____ More than one response may be acceptable for one stimulus E.G., CAR, FORD, BUS SO ON.. As long as target process is being exercised, words or sentences presented or produced wouldn’t matter.

10. + Adequate stimulation and good response In the stimulation approach, the antecedent event is the driving force behind improving responses Maximizing the“arousal power”of a stimulus Stimulus selection, ordering, and presentation is important in eliciting responses from patients. Stimulation is largely via auditory modality (least impaired) From baseline auditory stimulation, the power of input is increased with “multi-modality stimulation”

11. + Adequate stimulation and good response For naming task, multimodality stimulation might be the first sound and first letter of a target word For comprehension, auditory and printed version of a single statement, or a drawing

12. + Naming

13. + Naming and Word-Retrieval Problems Anomia or word-retrieval difficulty Is one of the most common and persistent symptoms among individuals with aphasia These deficits vary substantially in their cognitive and neural underpinnings Assess distinct patterns of naming deficits Implement appropriate treatments to address individual’s naming dysfunction

14. + Semantic and phonological stages Lexical form is represented through modality- specific components separately for input and output processing Naming: Cognitive mechanisms

15. + Crosson (1999)

16. + Naming: Cognitive mechanisms E.g., picture confrontation naming: Primary input mechanism involves the visual object recognition system It then activates the semantic system (store of meanings and information that we have learned about words, objects, or actions) Semantic representations then activate modality- specific output lexicons for spoken and written words.

17. + Crosson (1999)

18. + Differentiating features of naming impairments When visual perceptual deficits are excluded, a failure to name an object could result from damage to the semantic system or phonological output lexicon In the case of a breakdown at the level of the semantic system: poor semantic or conceptual information failing to activate the required lexical form. Semantically based naming impairments are associated with difficulty in all lexical tasks Impairment is evident for all types of naming tasks regardless of input modality (i.e., picture naming, naming to spoken definitions) and output mode (oral and written naming) Difficulty in spoken and written word comprehension and in interpreting the meanings of viewed objects and gestures.

19. + Differentiating features of naming impairments Naming errors take number of forms Incorrect responses would be expressed as semantic related words (e.g., hammer for screwdriver) Semantically empty naming errors (e.g., a thing you use) Perseverations (e.g., repeated use of the word “eggs” for all naming attempts). Confusion in comprehension tasks Performance in oral word reading and writing to dictation may not be affected

20. + Differentiating features of naming impairments Naming and comprehension impairments- according to specific semantic categories such as living and nonliving things, fruits and vegetables, tools and animals (Best, 2000) This probably relates to the loss of specific neural networks that mediate critical aspects of semantic information shared by several members of a given semantic category (Caramazza & Shelton, 1998)

21. + If the breakdown occurs at the level of the phonological output lexicon, the incorrect responses 1) adequate semantic or conceptual information not being able to access the required lexical representation or 2) failing to activate unavailable lexical representations resulting in omissions or semantic errors

22. + Differentiating features of naming impairments Impairments affecting the phonological output lexicon lead to difficulty in all tasks requiring the use of stored phonologic representation Comprehension abilities are typically preserved Difficulty is evident in all oral naming tasks (e.g., oral picture naming, oral naming to spoken definitions) and in oral word reading

23. +  Errors may take variety of forms  Semantic or no response errors  Some may produce neologistic errors (if servere) or phonemic paraphasias (if representations are partially preserved)  Selective impairment for phonologic output – written word production may be preserved.

24. + For example, damage to the lexical form 'scissors' would prevent its adequate semantic representation (made of metal, long, inanimate, used to cut objects, sharp edge, etc.) from activating the correct response. However, because the lexical entries related in meaning to 'scissors' are activated, the semantic representation of 'scissors' could still activate semantically related forms such as knife, blade, plies, etc. and produce semantically incorrect responses. Therefore, a breakdown at the level of the semantic system or the phonological output lexicon could result in semantically related errors.

25. + Impaired oral and written word naming & intact comprehension abilities: Concurrent dysfunction of both phonologic and orthographic output lexicon Access failure from semantic to phonologic & orthographic Intact oral reading abilities –- in individuals with semantic-phonologic impairments

26. + Identification of these different forms of anomia through evaluation in the context of a cognitive model has led to the development of treatment programs on proposed sources of breakdown within the model.

27. + Assessment The purpose is to specify the mechanisms that are responsible for naming impairment as well as those that are spared. A) Lexical task comparisons B) Stimulus characteristics C) Error analyses

28. + Assessment Lexical Task Comparisons: The naming assessment should include a variety of single word processing tasks in which the clinician systematically varies input and output modalities, and analyzes patterns of performance across tasks sharing processing modalities.

29. + Output ModalityInput Modality SpeechViewed Object SpeechOral name to speechOral picture name WritingWritten name to definitionWritten picture name Gesture/PointingPantomime to named object Word-to-picture matching Word-to-picture yes/no verification Associated pictures match Category sort Picture rhyme judgment Pantomime to viewed object Assessment of Naming

30. + Assessment Naming to pictures versus definitions can be contrasted: visual-semantic access dysfunction to naming failure To distinguish semantic versus phonologic bases of naming breakdown, Performance can be examined semantic processing tasks category sorting for closely related semantic categories (e.g., summer versus winter clothing) Matching associated pictures according to semantic relationships (e.g., rabbit: carrot)

31. + Assessment To distinguish impairments that preferentially affect the phonologic output lexicon: Contrast performance across modalities: Oral Vs Written naming Rhyme judgments for picture pairs (e.g., do the names of these pictures rhyme?: whale-nail)

32. + Assessment Stimulus Characteristics: Grammatical categories (e.g., nouns versus verbs) and semantic categories (living versus nonliving) need to be systematically evaluated. A number of other psycholinguistic variables affect the ability to retrieve words. E.g., frequency, length, familiarity, etc. 3.) error analyses analyze

33. + Treatment for Anomia Word Finding Cue Responsiveness Cues are used to elicit words automatically or without training Semantic cue: provide information about the target word’s meaning Semantic cue may be said to activate an area in semantic memory Lexical or phonological cue: provide information about a word (i.e., first sound or syllable) Lexical cues point to a form in the mental lexicon Either type of cue is more effective in eliciting names than a picture alone.

34. + Cuing Hierarchies Target picture: Blouse 1. It’s clothing 2. you can button it 3. It starts with /bl/ 4. It sounds like mouse 5. Written word: Here is the word, blouse 6. Say blouse Treatment for Anomia

35. + Word Finding Cue Responsiveness Cues are more effective as the severity of naming deficit decreases Phonological cue is more effective than semantic or other lexical cues such as printed or rhyming word Some believe that phonemic cues are more useful for cases of Broca’s aphasia that have most difficulty in naming Cues are more effective for conduction aphasia than the other fluent syndromes

36. + Treatment for Anomia Word Finding Self-Cueing Training a patient to write the first letter, sound it out, and generate his own carrier phrase Use the sound as a cue It was not very useful method

37. + Treatment for Anomia Word Finding Theory-Driven Naming Therapy The arousal power of cues indicate that aphasic impairment lies in lexical retrieval instead of being a loss of lexical storage (Howard et al., 1985) Another finding that phonological cues are superior to semantic cues could be because the stimulus object already activates semantic memory through the object recognition capacity. Semantic cues may be redundant One impression that a stroke raises the thresholds for lexical activation and that form-related cues lower the threshold or raise the activation level

38. + Treatment for Anomia Word Finding Theory-Driven Naming Therapy Treatments have been designed to repair the semantic system, the phonological output lexicon, or the route between semantic and lexical systems. The therapies have been broadly classified as Phonological (or lexical) treatment Semantic treatment

39. + Treatment for Anomia Word Finding Semantic treatments Emphasis on activating concepts associated with words Patients are not required to produce a word during the therapy One version of semantic treatment centers around word comprehension (i.e., picture-word matching) Progress in naming, especially for untreated items has been mixed.

40. + Treatment for Anomia Word Finding Semantic treatments Another version of semantic therapy is called “semantic feature analysis” Object in a naming task is accompanied by various cues An object is placed in the center of a feature analysis chart containing cues to various types of conceptual associations E.g., is used for ___, has_____, reminds me of ____ Patient has to complete the phrases and write answers in boxes surrounding the object

41. + Treatment for Anomia Word Finding Phonological treatments Phonological treatment focuses on sound structure, whereas orthographic treatment focuses on written structure or spelling.

42. + Treatment for Anomia Word Finding One study showed that both semantic and phonological impairments to be equally effective but with limited generalization Drew and Thompson (1999) were more impressed with combined treatments than with semantic treatment alone

43. + Treatment for Anomia Word Finding Results from case studies revealed that Patients with the same diagnosis do not respond well to the same treatment Too often, the treatments fail to generalize to other items and other tasks (Hillis, 2001) Basso (2005) suggested that increased frequency and longer duration of direct language treatment results in better communicative improvement The effectiveness of theory-driven naming procedures is not known for the subacute phase of recovery.

44. + Treatment for Anomia Other Naming Treatments The most common form of cueing treatment is to combine both phonological or semantic treatments Some clinicians have applied a mixed semantic- lexical procedure to the treatment of proper and common nouns. Contextual priming: Naming was preceded by repetition, which was intended to facilitate naming The treatment occurred in the following order: Spoken word-picture matching, repetition of the name, independent naming (delayed repetition)

45. + Treatment for Anomia Other Naming Treatments The most common form of cueing treatment is to combine both phonological or semantic treatments Some clinicians have applied a mixed semantic- lexical procedure to the treatment of proper and common nouns. Contextual priming: Naming was preceded by repetition, which was intended to facilitate naming The treatment occurred in the following order: Spoken word-picture matching, repetition of the name, independent naming (delayed repetition)

46. + Treatment for Anomia Computer-Assisted Treatment Computer programs provide automated presentation of stimulus “frames” and feedback upon response. Parrot Software have developed sophisticated programs for work on reading comprehension, semantic categorization, visual attention, short-term memory, and reasoning. The software is capable of providing hints to correct response and data on performance over time.

47. + Treatment for Anomia Computer-Assisted Treatment MossTalk Words: it provides auditory and written cues for naming and is clinician assisted or self-guided Multicue, a program in the Netherlands for naming therapy in which the patient selects his or her best cueing hierarchy