1. ADULT LANGUAGE EVIDENCE BASED PRACTICE GROUP Extravaganza 2007 Anika Hobbs and Kate Schuj Group Co-Leaders

2. The Group The adult group divided into 3 this year – with new terms of reference and new members We started with a brainstorming session…

3. Clinical Question We asked – “What areas related to your clinical practice do you have a burning desire to find out more about?” We realised that therapy for word- finding was an area of interest….

4. The Question We had a brainstorming discussion and came up with: Is repetition therapy effective in improving lexical access/word finding difficulties (in people with aphasia)?

5. Search Terms Speech and language therapy Repetition Aphasia Word-finding We searched all the usual suspects (OVID, Medline, PsychInfo, Google Scholar)

6. CAPping the Articles 7 possible articles were found Only 4 actually answered our clinical question and were included in our CAT

7. Article 1 - Article 1 - Fillingham, Sage and Ralph (2005) This article examined repetition in the context of errorful versus errorless learning Errorful learning allows the patient to make mistakes clinician uses a cueing hierarchy to assist correct response Errorless learning aims to set the patient up to make no errors by providing maximal support prior to attempting a task.

8. Fillingham Participants: 7 people with aphasia who displayed significant word finding difficulties at 6 months post-stroke Design Multiple crossover case series design Clinical Bottom Line Overall 5 of the 7 participants showed long term benefits from repetition therapy

9. Fillingham Limitations Other factors may be influencing participants’ success Participants’ executive skills may be related to improvement It’s not possible to dissociate whether for some participants reading rather than repetition might have been the active ingredient to the success of the therapy

10. Fillingham NH&MRC level of evidence: IV (Evidence obtained from case series, either post-test or pre-test and post-test)

11. Article 2 – Article 2 – Basso et al, 2001 This article compared multiple cueing strategies: Repetition Orthographic cueing Reading aloud

12. Basso Participants: 30 right handed volunteers and 2 right handed males who had left temporal lobe lesions Design ABA – single case design Clinical Bottom Line Repetition therapy did not result in long term improvement in naming for these patients with word finding difficulties

13. Basso Limitations: Small number of subjects and no matching between controls and subjects In addition: Orthographic cueing resulted in long term benefit (>5 weeks) for naming for both subjects Level of Evidence NH&MRC IV

14. Article 3 – Article 3 – Sugushita et al, 1993 This study examined repetition of picture names with provision of orthographic cues on failure

15. Sugushita Participants: 22 people with aphasia who had a left sided stroke Design: Modified AB, each group was its own control Clinical Bottom Line: In this study few people with aphasia benefited from attempted naming followed by repetition for oral naming. The written naming of more individuals was improved by attempted written naming followed by copying.

16. Sugushita Limitations: There was data for only a small subject group due to exclusions and drop outs There was a variation in length of time that maintenance was evaluated at Statistics only compared across groups of items, not within a set There was no control group of untreated items Level of Evidence – NH&MRC IV

17. Article 4 – Article 4 – Martin et al, 2004 This study looks at the immediate and short term effects of contextual priming on word retrieval in aphasia.

18. Martin et al (2004) Participants 11 people with chronic aphasia Design 11 single case studies with pre and post data Clinical Bottom Line The data suggests that there is a benefit that lasts at least 5 minutes on naming from repetition, for many (7/11) people with word retrieval impairments

19. Martin et al (2004) Limitations Results suggested patterns only, not cause and effect It was unclear how subjects or picture sets were “constructed” and treatment items “selected” In addition There is no evidence that repeating words in the context of other semantically or phonologically similar words increases the benefits. In fact it can temporarily interfere with word retrieval. Level of evidence – NH&MRC IV

20. CAT Clinical bottom line: Repetition therapy improves word finding difficulties for some people with aphasia but not all.

21. Discussion Effectiveness of repetition therapy depends on the person’s co-occurring impairments, severity and whether impairment is acute or chronic The method of repetition (ie errorless or errorful) may also have an impact on the effectiveness of repetition therapy Evidence from the CATs suggests that it is possible to gain some long term benefit (5-12 weeks) from repetition therapy Further research is needed regarding effectiveness of repetition therapy

22. Application to practice Repetition therapy has traditionally been dismissed as not being beneficial It is difficult to determine who repetition therapy will work for Some group members incorporated repetition therapy into their practice with varying results, further strengthening the conclusion that it is difficult to determine who “repetition therapy” will work for

23. Application to practice It is not clear from the studies we found what the exact impact of personality and learning style has on the responsiveness to, or what the possible outcomes are from repetition therapy This CAT raised a discussion around whether repetition therapy was actually teaching words or assisting with lexical retrieval – further research needed!

24. Future Directions This CAT has raised more questions related to our clinical practice The topic for next year is yet to be decided, however it is likely to follow on directly from this year’s CAT Possible areas include orthographic cueing and word finding, or errorless versus errorful learning

25. Acknowledgements All the Adult Language EBP group members for all their hard work, dedication and contributions Lyndsey Nickels, our academic link whose expertise has been invaluable!

26. References Fillingham JK, Sage K, Ralph MAL (2005). Further expolrations and an overview of errorless and errorful therapy for aphasic word- finding difficulties: The number of naming attempts during therapy affects outcome. Aphasiology. 19(7): 597-614 Basso A, Marangola P, Piras F and Galluzi C (2001). Acquisition of new “words” in normal subjects: A suggestion for the treatment of anomia. Brain and Language. 77, 45-49. Sugushita M, Seki K, Kabe S, Yunoki K (1993). A material-control single-case study of the efficacy of treatment for written and oral naming difficulties, Neuropsychologica. 31(6):559-569. Martin N, Fink R, Laine M and Ayala J (2004). Immediate and short term effects of contextual priming on word retrieval in aphasia. Aphasiology. 18(10), 867-898.