1. Exploiting Neuroplasticity in Aphasia Treatment & Recovery OSLHA October 5, 2019
This is your printable handout. It will provide the basic information and a format for taking notes. All of these slides have a slight grey background. The full ppt to be used during the workshop contains photos, videos and much color. It is too large for printing. The full ppt will be available here after October 1, 2019

2. Exploiting Neuroplasticity in Aphasia Treatment & Recovery Oklahoma Speech Language Hearing Association October 5, 2019

3. OSLHA Annual Convention William Connors Financial relations:
aphasiatoolbox® owner
Telepracticecommunity.com owner
EverythingSLP.com ; homeceuconnection.com vendor
Non-Financial Relationships:
The National Aphasia Association (representative; committee member)
The Brain Recovery Crew (BRC)
ASHA; state committees OH; PA

4. I know who you are…. Hard working, Dedicated,
Intellectually inquisitive SLPs,
in the trenches helping people to talk; type; converse; interact; recover.

5. Statement of the Problem:
Upwards of 2 million people in the United States and Canada, (the Aphasia Institute, 2011) as well as millions more throughout the world, continue to suffer with hope-robbing, independence-depriving effects of aphasia-apraxia despite millions of dollars spent on research, treatment, and public awareness of the problem (Kelly, 2011, Stahl, 2011). The great majority of PWA and their caregivers find this state of affairs unacceptable (Worrall, 2011). They have a dissensus with our approach to research and clinical outcomes. The first step in solving a problem is realizing there is one.
Probably more like 2 million.

6. What should SLPs do?
How can we offer a truly patient-driven clinical management that in fact takes advantage of neural plasticity and most efficiently and effectively maximizes patient recovery of communication and cognitive skills in a program that is effective and affordable?
How do we best turn people with aphasia into people recovering from aphasia?
How do we do this in the world of organizational and 3rd party barriers?
How can we go beyond the significant limitations of traditional aphasia therapy?

7. What will we be discussing that is different, new, controversial?

8. There is no such thing as acquired apraxia of speech, rather a motor planning and execution problem that affects, voice, breath flow, tongue, lips, etc. How do I turn a thought into an acoustic event?
There is no such thing as a circumscribed auditory comprehension problem in aphasia. It’s a catch-all term.
Reflection and release can facilitate significant change. Since it’s all about change, especially neurophysiological, that’s essential.
PRA need a program in which they are not bullied. They need mindful environments, not dissonance. Aphasia-stress free-not aphasia stress-full.

9. Translating research-based EBP, that only generalizes to trained word lists, will not get people conversing again, at least not in my lifetime. Martin, et al. 2006
Errorless learning may have a place, but it’s not in aphasia recovery. Our clients cannot make a mistake for differing recovery reasons. What they are thinking is what they will say. We need to help him/her fix how he/she thinks. Fix thoughts not speech.
Who’s doing the thinking and who’s doing the talking? It better be the client.

10. It’s not about word recall. One cannot unblank, unblock, or get cued
It’s not about word recall. One cannot unblank, unblock, or get cued. Instead, we move thoughts and concepts. Aphasia recovery is all about movement, period. Bolte-Taylor, 2008 TED talks.
We can do harm. “I experienced stimulation coming in through my sensory systems as chaos, and it felt like pure pain.” Bolte-Taylor, 2008; Small and Wineburgh, 2004
Carry every activity into a conversational dyad, or better yet triad.
Aphasia recovery is not about speech or typing; it’s about neural pathways, activations, neural interactions, movement.

11. How many repetitions do we need. It takes 0 repetitions
How many repetitions do we need? It takes 0 repetitions. You just have to think through the next one. Propositional speech and language are always generative; created never imitated.
Don’t waste time on things that come back on their own. Complexity training on steroids.
We don’t fix aphasia by thinking about aphasia. We fix aphasia by thinking about and reconnecting normal and deliberate thought turned into movement.
Sometimes we need to Blink It and sometimes we need to Think It. Too much info can cause problems. We need to prime better.

12. “After the age of 30, I think the most insane, hopeless things I tried to do were drilling auditory comprehension tasks in PWA and implementing conventional speech therapy with people with a recent aphasia.” Bill Connors.
We must address seriously the cognitive issues but not with apps or worksheets but rather folded into our treatment, practice and everyday activities. “Our findings suggest that individuals’ cognitive ability, specifically verbal short-term verbal memory, affects anomia treatment success.” JSLHR Digman.

13. 3 KEY THINGS TO ASK YOURSELF ON EACH ACTIVITY TODAY:
How do I thread work on cognition into this?
How do I analyze the client’s response to shape treatment and client practice via formative assessment?
A rising tide lifts all boats. How do I facilitate reading comprehension and auditory processing into all that I do?

14. Visual Definition Of Aphasia
“If you change the way you look at things, the things you look at change.”
STEP 1 VISUAL
APC Session 2: The Visual Definition of Aphasia - Visual

15. “Tell me the name of this object”
PROBLEM
Misses info on one side or middle.
Turns head; Moves page
PWA: “I can’t see that.”
Visual neglect and/or inattention
VISUAL ACUITY
TX ACTIVITIES
Keyboarding
Figure Ground
Mazes
Visual Apps

16. Say it  Understand it “A rising tide lifts all boats”
PROBLEM
Clinician: “You write with it.”
PWA (jargon output):
“Huh?”
“I don’t understand.”
“What did she say?”.
Comprehension
Processing
(Auditory
Comprehension)
TX ACTIVITIES
Say it  Understand it “A rising tide lifts all boats”
Address learned inattention
Clarify/verify
Cognitive/attention tasks

17. How to Treat & Manage Auditory Comprehension Problems in Aphasia
Available at EverythingSLP.com

18. Aphasia: Factors That May Affect Auditory Comprehension
Syntax complexity Length of sentence
Speech sound decoding Sound processing
Verbal working memory Semantic processing
Short term memory Attention skills
Depression Bad habits
Lack of faith in listening skills Running start
Learned helplessness Hearing loss
Noisy background
Speaker variables: mumbling; rapid rate; accent; eye contact; manner

19. 12 Smart Message Delivery Strategies to Facilitate Auditory Comprehension
Manage background noise- maximize auditory signal.
Use an alerting signals to get his/her attention.
Use face to face communication – always use eye contact.
Use a slow, yet natural, rate of speech – stretch vowels.
Place key words at beginning.
Pause before key word– use an inter-stimulus pause.
Control message complexity - KISS it.
Use a shorter sentence(s) to control message length.
Use direct wording – say what you mean clearly
Increase redundancy –straightforward language.
Use supplementary cueing –gestures; print; photos.
Train client to be assertive about fuzzy comprehension.

20. 12 Ways to treat Auditory Comprehension Problems (ACP)
Improve the clients ability to attend. Probably most important.
Effectively treat expressive aphasia – Arising tide lifts all boats.
Recognize that ACP in aphasia as a circumscribed deficit does not exist – identify and treat the actual culprit.
Eliminate apraxia or other contributing or masking factors.
Overcome the apraxia that affects the head nod – shake for yes-no.
Ensure that everyone involved exploits the 12 strategies.
Work diligently to remediate underlying, contributing cognitive problems.
Control message complexity - KISS it.
For the person with a fluent type aphasia, be sure to address effectively any syllable structure processing issues.
Clean up any residual motor issues such as apraxia or ataxic dysarthria.
Study the history of treatment programs – what really works?
Avoid falling into the trap that isolated drills facilitate recovery.

21. Clinician: “I brush my teeth with it.”
PROBLEM
Clinician: “I brush my teeth with it.”
PWA: “I have never seen one of those.”
QOL
Visual
Recognition
(Agnosia, Asymbolia)
TX ACTIVITIES
Verify a selected symbol
Visual Action Therapy (VAT)
Promoting Aphasics’
Communication Effectiveness (PACE)

22. Semantics [meaning]-Lexical
PROBLEM
Semantic knowledge
Fuzzy semantic boundaries
Semantic Boxing
Semantics [meaning]-Lexical
Cognition
TX ACTIVITIES
Semantic Feature Analysis (SFA)
Verb Network Strengthening Treatment (VNEST)
PWA: “I think it’s a thing.” “It’s writing... no booking.” “I can’t really think of that.” “Sounds familiar, I’m sure I knew it once.”

23. Lexical [affect of field]- Semantic
PROBLEM
PWA: “That’s a door.”
“I know it’s for writing, with a pencil, it’s a pen, no paperpen…”
Lexical [affect of field]- Semantic
TX ACTIVITIES
Lighting Up the Lemma
Lemma Lit up? >raise hand
Tribond game
Nerbing

24. Lexical-Semantic meltdown Phonological Assembly
PROBLEM
PWA: Phonological encoding “pent”, “benner”, “peen” (neologistic-jargon “des”; tindent”) “I know the word. I can see it in my head but I can’t get it out.
Phonological
Encoding -Word Form
TX ACTIVITIES
Lexical-Semantic meltdown
Phonological Assembly

25. But butter butterfly = FA
But butterfly butterfly = common; syllable structure
But but but = syllables structure;
phonological buffer
Mutt mutter mutterfly = phonological encoding;
Butterfly no no = imitation; awareness
Butterfly butterfly = imitation;
But but not butter = calm repair.
no no butterfly
“What?” = attention
Moves lips while = attention; lack of faith
listening imitation-bound; running start syndrome

26. But butter butterfly Bit better = vowel; phono-semantic butterfinger
But cutter mothfly = lex-semantic; phonol encoding
Beet beetly beetlyer = morphologic; vowel;
But buTTER butterFLY = prosodic;
But but…ter bu..tter….floo = mental resources alloc;
phonol
I can’t = learned helplessness; aphasic;
“What? ‘Did you hear = attention
anything? “Yes butter.”
But butare buttarefly = syllabic issues
“This is stupid.” = He’s got a point there.

27. (Acquired Apraxia of Speech)
PROBLEM
Phonemic encoding: “(silence)”
Struggle to phonate: “uh..hhuu; “bodee bodee boddee.”
Motor Planning
(Acquired Apraxia of Speech)
TX ACTIVITIES
The Viking
Motor Reconnect Apraxia Program
Limb therapy
Chunk a syllabary

28. Physical execution: “shlen.” “ whisper pen”
PROBLEM
Physical execution: “shlen.” “ whisper pen”
Tightness
Physical Movements
(Dysarthria)
TX ACTIVITIES
Speech Therapy: breath flow; relax; natural; eye contact; release; ataxic dysarthria

29. Oral Motor Coordination Program and Activities
PROBLEM
Ataxic Dysarthria
Physical Movements
(Coordination)
TX ACTIVITIES
Oral Motor Coordination Program and Activities

30. Syntactic – Semantic PROBLEM
Creating sentences: “coffee; aphasiaisms – “drinking coffee”; noun bound; one word answers; agrammatism; morphology
Syntactic –
Semantic
TX ACTIVITIES
Sentence Patterning; Conjugation; Pronouns; Canonicalize; Fill in grammatical slots

31. Cognitive Verbal Working Memory Attention Training Attention tasks
PROBLEM
Memory
Working memory
Attention
Problem solving
Cognitive flexibility
Reasoning- Inferencing
Perseveration ****** PWA: “Key….to the… I forgot.” Jerk head when addressed; look lost; act aphasic
Cognitive
TX ACTIVITIES
Verbal Working Memory
Attention Training
Attention tasks
Metacognition

32. Mental Resource Allocation Stress for syllables and words
PROBLEM
Mental Resource Allocation
Stress for syllables and words
Blending ; Rhythm; Melody
Intonation for sentences
Phrasing
Monotone
Lack of word stress
Prosody Intonation
(Aprosodia)
TX ACTIVITIES
Sentence Intonation Patterning
Heteronyms
Viking with an Attitude

33. Depression: clinical - situational
PROBLEM
Fatigue
Pain
Medication
Anxiety
Depression: clinical - situational
Whole Person Recovery
TX ACTIVITIES
Schedule
Work through it
Develop faith
Whole Person Recovery
Alternative treatments

34. Inferencing; Speaker Question Intent:
PROBLEM
Intent, pragmatics; Why are you talking?: “Imitating; lack of topic introduction. “
Intent
TX ACTIVITIES
What do you think of me?
Say what you mean;
Aphasia Quips
Inferencing; Speaker Question Intent:

35. Mental Resource Allocation-Cognitive
PROBLEM
Allocation of mental resources:
Mental Resource Allocation-Cognitive
TX ACTIVITIES
metacognition; metaphasia; A rising tide lifts all boats, Keep treatment simple but program robust; formative assessment

36. The notion that speech or language or word recall is located in one part of the brain is becoming increasingly difficult to support. Rather, expressive and receptive speech requires rhythmic and coordinated activations and interactions by numerous neural structures and processes for normal speech as well as for aphasia treatment and practice that truly exploits neuroplasticity. neurobiology-6224 Moore.

37. OK, let's get this straight once and for all
OK, let's get this straight once and for all....."There is no center ( speech or language) but a network of interconnected areas, each with a slightly different specialization,...". Researchers from Northwestern University just published a paper in the journal Brain (Marek-Marsel Mesulam) wherein they demonstrate that Wernicke's area, thought to be the center of language comprehension, in fact is not. We have so very much to learn about how the brain processes and creates speech and language. The concept that there is a speech center leads to the idea that these are circumscribed aphasia disorders which leads to the idea that one method or exercise or approach or app can make a real difference. "Forget about it."
Richmond, Ben, wrong-about-where-the-brain-process-language-for-141-years, 2015

38. Treatment Domains: Phonetic Encoding: motor knowledge; plan; execution
Phonologic encoding; syllabary; prosody; sounds; coartic
Semantic Cognition: word activation; meanings
Syntactic Processing: syntax; verbs; sentences
Conceptual: symbolic, idea; mental proposition
Discourse: narrative; conversation; pragmatics
Cognition: VWM; attention; episodic buffer; ProSolv
Orthographic: spelling: keyboarding; reading
Whole Person: safety, music, faith, family, exercise

39. What is Neuroplasticity
What is Neuroplasticity? Old science: Rita Marie Ryan Smoke a cigarette lose 50 brain cells> drink a beer lose 100 brain cells

40. What is Neuroplasticity?
Neural plasticity is the ability of the central nervous system (CNS) to change and adapt in response to environmental cues, experience, behavior, injury, or disease, (Ludlow, et al. 2008)
brain/index.html

41. Neuroplasticity and Aphasia Recovery
The human brain’s ability to continually grow, learn and recover is well documented (Gage, 2002; Hamilton, 2011; Scientific Magazine, 2007
Despite these remarkable scientific advances, insufficient attention has been given to developing innovative tools and techniques to take optimal advantage of neural plasticity in efficient ways in the treatment of aphasia (Helm-Estabrooks, 2011; Kirkland, 2004; Robbins, 2011; Varley, 2011)

42. Why AAC devices fail to interest PWA/PRA
Asymbolia
Abulia
Aphasia
Apraxia – motor planning
Embarrassment
Not natural
Too slow and cumbersome
Keyboard agnosia
Cognitive issues
Figure ground
Fear of abandoning speech

43. Hopefully we are beyond the idea that drilling cognitive skills in contexts that are far removed from the actual speech-language skills to which they are expected to apply. Research is refuting the idea that we should spend much treatment or practice time in training programs. “… that assume transfer of general skills to language processing.” Be prepared to justify the use of apps, worksheets and drills that isolate memory or attention skills.
Peach and others, Seminars in Speech and Language; Feb, 2017.

44. Motor- How to Treat Acquired Apraxia That Affects Phonation - It’s all about moving air. Phonetic encoding
Viking
Basic Perfect Viking 1
Durational Viking – stretching the vowels
Pulsed Viking - presyllabic
Viking with and Attitude – preprosodic – decoding prosody
# of syllables
add stress pattern
The / h / Viking
The varied Viking: / m / ; /vowels/
Vowels around the mouth – It’s all about moving the jaw
Jaw positions 3: up - middle - down
long vowels 7 ( / i e ae ^ a O U / mix the order
short vowels (shorten the long vowels)
diphthongs – maintain voicing as jaw moves
Vowels become pronouns
/ h / & /a/
/ h / & long vowels - /hh > /a/ > /h/ > /OO/ > /h/ > /ae/ > /h/
/ h / & short vowels - /h/ > /a/ > /h/ > /OO/ > /h/ > /ae/ > /h/
/h/ & /m/ /h/ > /m > /h/ > /m/ > /h/ > /m/ > /h/

45. How To Treat Acquired Apraxia That Affects Articulation – It begins to be about moving the articulators
Begin to add a consonant
Vowels around the mouth > / VC / > a /C/ eat /EEt /; it / it / ; ate /At /
Vowels around the mouth > / CV / > a /C/ eat /EEt /; it / it / ; ate /At /
Accept features first
The elevator for vowels:
Long vowels - /EE/ > /a/ > /EE/ > /OO/ > /EE/ > /ae/ > /EE/
Long & short vowels - /EE/ > /a/ > /EE/ > /i/ > /EE/ > /ae/ > /EE/ > /o/ > /EE/ > /OO/ > /EE/
subjective pronouns leading to conjugation
Co-articulation-anticipatory – It’s all about loading up the syllabary
syllabification;
Schwa initiated increasing syllables
Contractions
Phoneticize
Scatpraxia : vowels > vary vowels > add consonants

46. Oral Motor Coordination Program
How to Treat Acquired Apraxia That Affects Symbolic Gesture - It’s all about loading up the gesturbary moving the hand and arm symbolically
Canonical Gestures
How To Treat Yes-No Acquired Apraxia: Yes/No apraxia for head nod/shake:
MMMHHHH > head shake < > nod ?Yes-No-Delicious
Number Concept Coaching
Basic answers
Complex answers
Morra (Rock-Paper-Scissors)
Recognize question intent
Forced point to either < > or question
Point to answer for question type : yes/no ; either-or; closed ended;
Oral Motor Coordination Program
How To Treat Stereotypes / Recurrent Utterances
How To Treat Acquired Ataxic Dysarthria
Traditional Approaches
8-Step Continuum - Melodic Intonation Therapy - Visual Action Therapy

47. Phonological Aphasia: Syllable Count and Syllable Structure.
Phonological: How to Treat Phonological Aphasia – AphasiaPhonics Phonological encoding
Phonological Aphasia: Syllable Count and Syllable Structure.
Vowels around the mouth
Elevator
Vowels > Liquids > plosives > fricatives
Increasing syllables
Basic (one-syllables; frequency effect; simple sound structure)
More complex (mutli-syllabic; less frequent)
Schwa initiated
Vary 1st word (one > one rain > one rainbow >
Phoneticize: sound-letter correspondence

48. Phonological: How to Treat Phonological Aphasia – AphasiaPhonics
Compound words
Basic
1st or 2nd word remains the same
Cognitive assembly after individual meaning ( dog > house > doghouse)
Tripounds > quadrapounds
Anagrams
Lexical decision
Semantic decisions
Lexical – Semantic Meltdowns
Phonological Assembly
Sound embedded verbs
Traditional Approaches: Phonomotor by Kendall

49. Light Up the Lemma: build a sentence to work from client’s thoughts.
Semantic Cognition: How to Treat Word Activation & Spreading (Word Recall)
Pronouns
Subjective
Objective
Possessive
Question concepting
Personalized Pronoun Coaching Concept Coaching
Question - Interrogative
Drill
Clarify a mumble
Reading Headlines with Comprehension
Cataphors – Anaphors
Indefinites
Light Up the Lemma: build a sentence to work from client’s thoughts.
Semantic Feature Stimulation ( SFS)
Semantic Figure Ground
Attention to detail

50. Semantic Cognition: How to Treat Word Recall – Activation
Verbing – Argument fluency
Phrasal verbs
Nerbing
Mental state verbs
Flip the subject
Numeracy
Number concept coaching
Number conversions
Number Concept Coaching
Reflect feeling > reflect content = connotation vs. denotation

51. Semantic Cognition: How to Treat Word Recall – Activation Word Forms
Homonyms – antonyms-synonyms
Heteronyms
Multiple meaning: Nouns-Verbs-Phrasal Verbs
Hinky Pinkys
Rhyme, Antonym, Synonym
Same-Different
3 with no foil > 3 with one foil > 4 ?
3 with two foils > 4 with 2 foils
Provide 3 words > create a sentence
Sematic scaling
Traditional Approaches
Semantic Feature Analysis

52. Syntactic Domain: How To Treat Agrammatism Verbing
Common 5 > 10 ; reverse ; add alternates ;
Real-time concrete verbs
Group
Lighting up Broca’s area – BA more than just expressive
Conjugation
Build to Canonical
Right branch to extend verbal working memory
Left Branch time concept
Complex & compound sentences: conjunctions
Contractions

53. Syntactic Domain: How To Treat Agrammatism Sentence Patterning
Subject Verb > Canonical
Vary pronoun
Take to a Conversational Dyad
Use in all activities Slotting (Fitzgerald Key)
Phrasal Verbs
Tensing
Recursion –
Create 1 complex or compound sentence for 2 or 3 shorter ones
Conjunctions

54. Syntactic Domain: How To Treat Agrammatism Modals
Modal Conjugation “Conversational dyad
Modal Chiasmus: Reverse question asking: attention (#s; letters; S-V; +verbs)
Modal Increasing Syllables
Morphologic
Derivational switching
Prefixes > suffixes > internal
Irregular past tense verbs
Inflectional word building: grammatical category does not change
Derivational word building: change in word form
Prepositions
Phrasal verbs
Active – Passive Sentence Meltdowns
Contractions
Traditional Approaches: Mapping; TUFTS

55. Conceptual Domain: Where it all begins.
Thoughts
Ideas
Concepts
Intent
Semantic activation
If you don’t start from here it is not real. Least contrived
Light p the Lemma Sentence

56. Discourse: How To Facilitate Conversation and Narrative
Reflection
Reflect-Release-Create
Take Everything to a Conversational dyads
Question asking
Clarify > Verify
WordSmithing
Pacematics:
Exploiting Spontaneous Utterances in Aphasia

57. Discourse: How To Facilitate Conversation and Narrative Groups
Build a story
Intent Speech Acts – Say what you mean
Garbage can inferencing
AphasiaQuips
Create a Headline
Toastmasters
Traditional Approaches
PACE

58. Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language
Blend these into all that you do with deliberation: metacognition (metaphasia; metapraxia)
How To Treat Perseveration
Mental Resource Allocation
Problem Solving
Cognitive Flexibility
Divergent thought

59. Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language
Executive functions
Verbal Working Memory and Attention Training
AphasiaDoKu
Rhyme, Antonym, Synonym with an Attitude
Verbing with an Attitude
Forced choice: 2 ; 3

60. Garbage Can inferencing Attention tasks: Constant Therapy
Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language
Manipulating numbers
Strooping
Garbage Can inferencing
Attention tasks:
Constant Therapy
Proactive memory: Word of the Day
Traditional Approaches
1. Constant Therapy

61. Thread throughout daily work Paragraphs Group work
Orthographic
Keyboarding
Flash Spelling
Elision: vowels; abbreviations; acronyms
#of letters
# of words
Types of words
Phrases and sentences
Thread throughout daily work
Paragraphs
Group work

62. Whole Person Recovery Plan
Nutrition
Rest
Exercise: transition from patient (Ptherapy) to person (Ptraining)
Music
Spirituality
Drugs
Alternative treatments: hyperbaric; Embrel; injections; acupuncture; transcranial direct current stimulation; stem cells;
Relationships

63. Related
PPA
Right Hemisphere Stoke
Apps
Assessment
Formative Assessment

64. How do we exploit this type of program….
….in the real world of:
limited visits?
3rd party payments?
organizational barriers and obstacles?
???

65. We…. refer to experts. commit to change and effectiveness.
organize efforts.
collaborate – telepractice.
????