“i know exactly where it is but i don’t know where it’s going…”

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COVER STORY: THERAPY

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 20076

I know exactly whebut I dont know w

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rapid shits o turn and when there is background noise.Formal assessment shows comprehension breakdown

in sentences i the context does not assist in understand-

ing the relationship between items.

In terms o naming (gure 1), Helens assessment

record shows a history o word orm errors (literal para-

phasias), many o which are non-words. Alternatively,

attempts are aborted ater inability to start the word or

ater producing only the initial phonemes. Helens errors

increase with word length and she makes more dele-

tions or substitutions towards the end o words. Less

requently, Helen makes semantic errors, such as substi-

tuting ather or husband.

Figure 1 Naming examples

Mug muck monk mugHoover hoolaCigarette sigarantSpeakability speakaleekieCognitive neuropsychological models o speech pro-

duction detail the component processes in speech pro-

duction (see or example Levelt, 1989). With reerence to

such models, Den Ouden & Bastiaanse (2005) conclude

that the symptoms o conduction dysphasia are associ-

ated with impaired phonological encoding. This stage -

between word orm selection and articulatory planning

- incorporates a slot-ller mechanism that maps the

sounds (llers) onto their position (slots) in a word rame

(Nickels, 1997). Den Ouden & Bastiaanse (2005) suggest

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007 7

COVER STORY: THERAPY

e it isere its going

When Laorag Hunter oferedHelen Gowland a high-tech aidas a communication strategy,neither suspected it wouldbecome a means o acilitating

Helens use o multi-syllabic wordsin everyday speech. Here, withSiobhan MacAndrew and TrevorHarley, they discuss the use oimages as signposts in therapy and the kind o service weneed to provide to ensure suchopportunities are not missed.

This article describes a specic component otherapy, a solution-ocused approach that is sim-

ple to implement. This therapy evolved collabo-

ratively when the introduction o a high-tech

aid as a communication strategy opened up unplanned

possibilities. We nd it particularly exciting because it is

having a measurable impact on a client with conduction

aphasia seven years ater onset.

Our story starts seven years ago, when Helen Gowland

settled down one evening to watch Jools Holland on TV. This

was a moment o relaxation in a schedule involving many

roles. Helen worked ull-time as a specialist physiotherapist,

researcher at an international level, Chair o the school Par-

ent Teacher Association, wie, mother to three teenagers and

daughter to an elderly ather. She remembers wondering

that evening why paramedics were in her house.

Helens next memory is ten days later in neurosurgery

nding hersel with a large surgical wound in her skull,

unable to speak or to understand what people were say-

ing. It took a long time to ully grasp what had happened.

Helen had sufered a sub-arachnoid haemorrhage rom

a large let middle cerebral artery aneurysm. An emer-

gency craniotomy was required to clip the aneurysm.

Two days later Helen experienced delayed ischaemia

with seizures and severe aphasia.

Changing needsHelens partnership with speech and language therapist

Laorag has continued and developed over the seven

years. Episodes o care have responded to her changing

needs and varied in type and length. Reasons or thera-py have included assessment, rehabilitation, supporting

and enabling (Malcolmess, 2001). Additionally, Helen

has opted in to resources and projects including group

work, computer classes and visual arts. Complicating

actors afecting rehabilitation have included wound

inections, removal o her temporal bone-ap with later

cranioplasty to close the skull, and issues relating to epi-

lepsy and side efects o medication.

Helens communication prole resembles that o the

syndrome o Conduction Aphasia (Goodglass & Kaplan,

1983). Key eatures are uent and grammatical speech;

di culty in the sequential order o speech sounds in

naming and repetition; greater di culty with longer

words; good awareness o errors; repeated attempts

at error correction (a characteristic known as conduite

dapproche) and relatively spared comprehension.

Helen has excellent conversational skills and is excep-

tionally resourceul at getting her ideas across through

total communication methods. When she is unable

to express the ull content o her message she will use

drawing, ragmentary writing, pantomime, circumlocu-

tion and even singing. Helens speech is easy to under-

stand and is uent and grammatical.

These strengths contrast with a history o severely im-

paired noun production in spontaneous speech, spoken

naming, written naming and repetition. Helens under-

standing in everyday situations is good but vulnerable to

errors in times, days and numbers. She notices increased

di culties understanding in groups where there are

Figure 2 Meta-linguistic awareness A print showing how Helen senses her aphasia. Reprinted by kind permission o Christine Kingsley.

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that, as well as a mapping decit, the error patterns o

some people with conduction aphasia are secondary

to a verbal memory decit. In these cases speech errors

result rom di culties retaining the activation o the

phonological plan.

Meta-linguistic awarenessHelens descriptions o her experience when naming sug-gest having word orm knowledge with inability to com-

plete the phonological orm. These descriptions show a

high level o meta-linguistic awareness (see gure 2, p.7):

I know the meaning o the word but I dont know what it

looks like.

I know exactly where it is but I dont know where its going.

Sometimes I can start it but I dont really know how to say

it properly.

Helens written naming ollows a similar pattern to

her speech in that she writes partial word orms. She re-

quently writes more letters o a word than sounds she

can say. When letters are omitted she can oten indicate

the correct number o letters or syllables.

Helens reading is slow and limited to short pieces.

She has great di culty recognising unction words such

as prepositions, conjunctions and determiners. This is

a symptom o phonological dyslexia. Impaired reading

by letter to sound conversion (grapheme to phoneme

route) orces reading via the semantic route (Harley,

2001). Words with poor semantic representations such

as unction words are thereore read poorly (Friedman et

al., 2002). Helen compensates or this di culty by using

text-to-speech sotware to aid reading comprehension.

Speech production stuckThrough semantic type therapy (Nickels, 2002) and practice

o specic word sets Helen slowly made modest gains in

naming. At the start o this therapy Helens speech produc-tion was stable; this could be re-phrased as stuck. Laorag

ofered a communication aid as a back-up to speech to help

transer o inormation such as address, phone number,

numbers, and commonly used amily details. Helen liked

the idea o using the aid to practise speech but using it in

interactions did not appeal. She elt the aid was too big, too

slow and di cult or people to read. She thought that peo-

ple would be too busy to attend to it and that it negatively

afected perception o her competence.

Helen wanted to say letter names as they requently

occur, or example, in addresses, clothing sizes, names o

companies and medication (or example, DD2, RAC, CPR).

Letter names cannot be read by letter to sound conver-

sion and are disadvantaged in reading via a semanticroute because they are low in semantic value. Friedman et

al. (2002) increased unction word reading in two people

with phonological dyslexia. Using paired associate learn-

ing Friedman improved reading o unction words (low

semantic value) by pairing with homophones high in se-

mantic value (not/knot, knows/nose). This is an example

o a reorganisation o unction where intact processes are

used to compensate or impaired processes.

We linked the alphabet with semantically rich homo-

phones and near homophones that Helen ound mean-

ingul (gure 3). Near homophones begin with a sound

that is the same as the letter name. These links were re-

inorced by storing a picture o the link word along with

a recording o the letter name in a Dynamo digitised

speech communication aid.

COVER STORY: THERAPY

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 20078

FunLaorag segments the target word into syllables and sug-

gests single syllable words that are homophones or near

homophones or each syllable. An image to represen

each single syllable word is selected rom the PictureCommunication Symbols set (Mayer-Johnson, 1981)

Where there is more than one possible image Helen se-

lects the one that is most meaningul to her. Associating

each syllable with a Picture Communication Symbol has

drawn upon Helens strengths in word meaning, oreign

languages, wide-ranging knowledge and creativity. It

has also been a un part o therapy or both o us!

We make a page or each target word on the Dynamo

Each syllable is represented by a picture o the associated

image rom the Picture Communication Symbols accom-

panied by the written orm o the word. The syllable is re-

corded so that when the picture is touched the syllable

is heard (gure 5). Initially, Laorag made the recordings

but ater two to three months o therapy Helen couldindependently say and record the single syllable words

By activating the pictures in sequence Helen hears her

recorded production o the whole word built up syllable

Figure 3 Alphabet links

Letter Link word Link Picture Homophone type

A eight Near homophone

B bee Homophone

C sea Homophone

D Delia Near homophone

Helen ound the discipline to practise challenging but

her ability to say letter names improved. Interestingly,

the method enabled Helen to say letter names in se-

quence (eg. MP). This suggested a potential to sequence

single syllables to produce multi-syllabic words i eachsyllable was associated with a picture cue. Helen was

enthusiastic and quickly identied long words she want-

ed to say such as aphasia, Glenrothes, Victoria. Laorag

was concerned that this was too ambitious as until now

work on spoken output had mainly been on single syl-

lable, picturable words.

For our multi-syllabic words therapy, Helen makes

lists o words that she wants to say and use but is unable

to produce (target words). The lists typically consist o

written ragments o each word (1-3 letters) accompa-

nied by a drawing or picturable items. For more abstract

words (eg. policy, resources) additional clues in the orm

o gestures or associated words are required rom Helen

beore Laorag can identiy the target word. Helens cho-sen vocabulary reects personal, amily and proessional

interests, needs, seasons and world events. Most items

are 2-5 syllables in length (gure 4).

Figure 4 Target vocabulary (selected by Helen)

Figure 5 Target word examples

Aphasia

Glenrothes

Victoria

Hospital

Manchester

Inverness

AmbulancePharmacist

Greece

Management

International

Marks and Spencer

St Andrews

Hideko

Japan

Mackinlay

Egypt

Relations

Continence

Chlamydia

University

Paddington

Psychology

BudapestCommunication

Australia

Thorburn

Ipswich

Cambridge

First Aid

Africa

Sudan

Switzerland

Umbrella

Antique

America

Islam

Computer

Politics

Czech Republic

GraduateExam

Leaflet

CBIR

Aneurysm

Internet

Sociology

Pakistan

Tsunami

Neurology

Stollen

Sandwich

Sainsbury

Age Concern

Address

Stepney

Anatomy

HRTTheatre

Courgette

Broccoli

Coleslaw

SR flour

Statement

Parliament

Bric-a-brac

DVD

Strathearn

Human Resources

Cathedral

Elephant

Animal

Policy

MSP

NovelConcert

Ozone

Lebanon

South

Columbia

Falkland

Prescription

1955

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We agree with Nickels (2002) that or the clinician

understanding how the therapy worked is a luxury and

would add that given the complex variables in typical

therapy this can eel like impossibility!

However, our method draws upon several therapy ap-proaches, unctional, re-organisation and stimulation:

The goal is unctionalto allow Helen to say the words

she wants to use and is driven by Helens require-

ments and aspirations.

We achieve production o previously errorul words

through an alternative route (re-organisation). The pictures

in sequence give Helen su cient inormation to allow

phonetic encoding. This may be a direct efect o improved

phonological assembly. Alternatively, improved production

could be a consequence o improved monitoring. Each pic-

ture allows Helen to know the one syllable target which she

can check and correct at a pre-speech production stage.

Once production o the multi-syllabic word is enabled,

Helen can go on to practise in a stimulus-responsemanner (stimulation). This strengthens the connec-

tions between semantic and phonological processing

giving the possibility o the therapy being efective

through rehabilitation o impaired processes.

Helen has rated eatures rom most to least important

or her. (The comments are in Helens own words.)

The picture is most important. I dont look at the let-

ters at all. The picture opens it (the word) up or me.

Quick results.

The words are always there or me to check i Im not

sure. Thats reassuring.

The words are the ones I really need and want to

have.

I can practise on my own, even in my bed. It (the Dy-

namo) is easy to carry around in my bag.Its interesting to show others what Im doing in thera-

py and I can explain that its about pictures.

Im not bothered whether its my own speech or not,

but I am glad that it s not American.

Our success illustrates that therapy to improve a production

disorder can be efective many years post-onset. Although

we dont know i this would have worked earlier or Helen, it

has prompted Laorag to earlier and more creative trialling o

stimulability in speech production with other clients.

Flexible serviceAspects o our organisation and management have been

vital in enabling this work. Our service is exible to deliver

therapy according to client need and potential or change

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rather than within set time boundaries. The method devel-

oped through dedicated time or continuing proessional

development activities, particularly Laorags attendance

at British Aphasiology Society conerences. O equal im-

portance is a management commitment to provide andmaintain communication aids or clients.

Client need, therapist knowledge and the availability o

technology changes over time. In this therapy these vari-

ables came together to give a rewarding outcome. Giving

people with aphasia the opportunity to review therapy

options could be o benet long ater their initial period

o rehabilitation.

Laorag Hunter is a speech and language therapist at the Centre

or Brain Injury Rehabilitiation, Royal Victoria Hospital, Dundee,

DD2 1SP, e-mail laorag.hunter@nhs.net. Helen Gowland is Chair

o Tayside Speakability and a member o the Aphasia Scotland

project steering group. Siobhan MacAndrew is a psychologist

in the division o psychology at Aber tay University and Trevor

Harley is Dean o School and Chair o Cognitive Psychologyat Dundee University and the author o The Psychology o

Language (see reader ofer on inside ront cover).

ReerencesDen Ouden, D.B. and Bastiaanse, R. (2005) Phonologicalencoding and conduction aphasia, in Hartsuiker, R.J., Bas-tiaanse, R., Postma, A. and Wijnen, F. (eds.) Phonological

Encoding and Monitoring in Normal and Pathological Speech .Hove: Psychology Press, pp 86-101.Friedman, R.B., Sample, D.M. & Nitzberg Lott, S. (2002) The roleo representation in the use o paired associate learning or re-habilitation o alexia, Neuropsychologia 40, pp.223-234.

Goodglass, H. and Kaplan, E. (1983) The assessment o aphasiaand related disorders. 2nd edn. Philadelphia: Lea and Febiger.Harley, T.A. (2001) The psychology o language. 2nd edn.

Hove: Psychology Press.Levelt, W.J.M. (1989) Speaking: From intention to articulation.Cambridge MA: HIT Press.

Malcomess, K. (2001) The Reason or Care, Bulletin o the Royal Col-lege o Speech and Language Therapists595 (November), pp.12-14.Mayer-Johnson (1981) Picture Communication Index. SolanaBeach CA.Nickels, L. (1997) Spoken word production and its breakdownin aphasia. Hove: Psychology Press.

Nickels, L. (2002) Therapy or naming disorders: Revisiting,

revising and reviewing,Aphasiology, 16(10/11), pp. 935-979.

ResourcesThe British Aphasiology Society, www.bas.org.ukThe Dynamo Communication Aid is available rom Dynavox

Systems Ltd, Sunrise Medical Building, High Street, Wollas-

ton, West Midlands, DY8 4PS (www.dynavox.co.uk)

COVER STORY: THERAPY

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007 9

SLTP

by syllable. Ater listening a ew times and considering

the image associated with each syllable Helen is usually

able within the session to record the target word as a

whole item on the Dynamo page. At this point, her pro-

duction oten automatically alters to accommodate thenormal stress pattern o the target word. It is as i Helens

memory or production o the word is reactivated.

When Helen eels condent that she has captured the

production she practises and celebrates by playing with

the word. Around Christmas time she delighted in exclaim-

ing Have a piece o Stollen, Do you like Stollen?, Would

you care or some Stollen? She also conesses to continu-

ing this practice by talking to hersel on the bus ride home.

Helen is comortable to delete words rom the Dynamo

once she is satised that she can independently recall the

graphic or the single syllables which subsequently cue

her spoken production o the whole multi-syllabic word.

When a previously used syllable occurs in a new target

word Helen sometimes eels the addition o the graphicin the Dynamo is unnecessary and the written orm o the

syllable appears alone. Occasionally Helen requests that a

Picture Communication Symbol is changed, i she nds it

doesnt mean anything. For example trail to represent

the second syllable in Australia was changed rom a path

to a child trailing a pull-along toy.

Therapy sessions are approximately bimonthly and no

preparation is required by the therapist secondary to ses-

sions. Helen eels this schedule is appropriate to establish

new vocabulary and it also accommodates Helens ac-

tivities including volunteer work, committee work, amily

commitments and holidays. Four to six target words are

added each session and in 17 months Helen has mastered

the production o over 70 target multi-syllabic words.

Helen is now occasionally able to generate images or twosyllable words independently o therapy sessions.

Sel-generated cuesHelens ability to say target words and use these in real com-

municative situations shows notable increase. Additionally,

there are signs o carryover in her use o sel-generated

cues. Within sessions Helen has become aster at produc-

ing target words. Qualitative changes are also apparent in

Helens reections. Helen has a sense o achievement and

eeling o progression as opposed to previously eeling

stuck. The positive outcome or Helen is also clear as she

describes imagined ears, or example, what i we hadnt

tried this?, what i you had discharged me?, what i you

have to take the Dynamo away?

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