Evidence Based Aphasia Therapyafter 15 years

Now What?

MACDGNovember 4, 2015St. Louis, Missouri

Sharon M. Holloran M.A.CCCLead Speech Pathologist for the Evidence Based Aphasia Clinic

The Rehabilitation Institute of St. Louis

EBAC Patients (2001-2014)(not including 25 extremely severe patients, and non-covered)

Characteristic Number/316 Percentage

MaleFemale

184 132

58.2%41.8%

Age 57.2+15(16-90)

AnomicGlobalMixed nonfluentWernicke’sTranscortical sensoryBroca’sTranscortical motorConductionUnclassifiable

10166272317168327

32%21%8.5%7.3%5.4%5.1%2.5%<1%8.5%

FluentNon-fluent

191125

60%40%

Weeks post-event(range)

38.1 + 118.3(1-1248)

EBAC Patients (2001-2014)

Etiology Number/316 Percentage

LMCA ischemic stroke

Left hemorrhagic stroke

194

66

61%

21%

Left subcortical only ischemic stroke

16 5%

Left hemisphere tumor

Left hemisphere traumatic brain injury (TBI)

Left ACA or PCA ischemic stroke, or subarachnoid hemorrhage

13

11

6

4%

4%

2%

Infectious, seizures or multiple sclerosis

16 5%

EBAC Patients (2001-2014)Baseline Measures(pre-treatment)

Mean (sd) Possible range

BDAE Language Competency Index (LCI) LCI-Expressive

LCI-Comprehension

37.9 (28)

38.3 (31)

37.4 (30)

0-100

0-100

0-100

Boston Naming Test (BNT) 19.5 (20) 0-60

Communication Activities of Daily Living (CADL-2)

63.9 (26) 0-100

ASHA Quality of Communication Life Scale

3.78 (0.7) 0-5

Communication Effectiveness Index (CETI)

53.4 (23) 0-100

Levels of Evaluation of Change

Aphasia diagnostic exam

Nonverbal cognitive testing

Baseline

1-month

4-month

3-month

6-month

5-month

2-month

Mood/QOL/functional comm.

Family rating of change

Discourse measurement

Treatment probe-untrained

Treatment probe-control behavior

Treatment data-trained

X X

X X

X X

X X X X X X X

X X X X X X X

X/X X/X X/X X/X X/X X/X X/X

X/X X/X X/X X/X X/X X/X X/X

X/X X/X X/X X/X X/X X/X X/X

Measurement

• Neuropsychology Measures– Boston Diagnostic Aphasia Evaluation– Communication Activities of Daily Living-2 (CADL-2)– Boston Naming Test– ASHA Quality of Communication Life– Visual Analog of Mood Scale

Speech-Language Measures

• Western Aphasia Battery (WAB)-Initial Evaluation– Aphasia Quotient

• Communication Effectiveness Index (CETI)-monthly– 16 items to rate client with aphasia

• Discourse Comprehension Test-monthly– 2 stories , 8 y/n questions on each

• BDAE Discourse Production Measure (Aesop fable story retelling)-monthly– Story retelling task yields 3 scores

Scoring

• CETI - mark a line 10 cm long on 16 items and find average

• DCT- read 2 stories, ask 8 y/n ?’s per story• Discourse Production- retell Aesop’s fable & record• Ideally linded SLP takes measures and transcribes &

scores

Discourse Production PROBE

• Video of Aesop’s Fables

Medical Record #

EVIDENCE-BASED APHASIA CLINIC TRACKING FORM

Client: _______________________________ D.O.B.: ________ Age: ____ Diagnosis: ____________________________ Onset: ______________________ Aphasia Subtype: _________________________________________________________ Lives with: _____________________________________________________________ Initial NP/AD Date: ______________________ 6 month follow-up:_____________ BDAE-3 LCI: ___________ Aud Comp: _____ Expression: ______ BNT: ____ CADL-2: ________________ CETI: ______________ ASHA QOC: ___________ WAB/ADP Date: ____________________ Score: ___________ Goals: ________________________________________________________________ Current communicative behavior/ Communication Partner ________________________________________________________________________________________________________________________________________________ Date Date Date Date Date Date CETI Score Client Other

Discourse

Comprehension probe

M______ D______ x/16 Raw score____%

Discourse Production Probe -folder # -Time Clauses/utterances

# content units/ total

Efficiency

cu / # seconds

Fable / Content units fox/stork 23 lion/mouse 33 fox/crow 24 rabbit/turtle 20

Development of an EBAC (2001)

• Development of treatment care paths

– Care paths for primary areas of language competence

• Verbal expression• Auditory comprehension• Reading• Written language

– Include treatments aimed at activity/participation level

EB Activity/Participation Treatments

Syntactic

EB Impairment-Level Treatments

Semantic

No Yes Phonologic

Apraxia of speech?

Phonologic naming therapy (Robson, 1998)III Phonologic therapy (Nettleton & Lesser, 1991)III

Phonologic hierarchy (Greenwald et al., 1995) III

Retraining O-P/P-O conversion (Kiran et al., 2001)III

Phonological components analysis (PCA) therapy (Leonard et al., 2008)III Word discrimination therapy (Fisher et al., 2009)III

Is deficit phonologic, semantic or syntactic?

Semantic feature analysis (Lowell et al., 1995)III Feature-contrasting technique (Hillis, 1998)III

Multistage semantic treatment (Drew & Thompson, 1999)III Personalized cueing (Freed & Marshall, 1995)III

Lexical-semantic therapy: BOX (Doesborgh et al., 1993)I

Word-picture matching (Marshall et al., 1990)E

Gestural+verbal treatment (Raymer st al., 2006)III

Melodic Intonation Therapy (MIT; Sparks et al., 1974)III

Contrastive stress/imitation of contrasts (Wambaugh et al., 1998)III

Response Elaboration Training (RET; Kearns, 1985)III

PROMPT technique (Hayden, 1999)E

Sentence Production Program (Helm-Estabrooks & Ramsberger, 1986)III

Wh-interrogative production treatment

(Thompson et al., 1993)II

Verbal cueing for sentence production (Loverso et al., 1998)III

Mapping therapy (Byng et al., 1994)III

Primarily Compensatory for Communication Promoting Aphasics’ Communicative Effectiveness (PACE; Li et al., 1988)III

Supported Conversation for Adults with Aphasia (SCA; Kagan et al., 2001) I

Visual Action Therapy (VAT; Helm-Estabrooks et al., 1982)III

Formal drawing program (Lyon & Sims, 1986)III

Computerized Visual Communication System (C-ViC; Steele et al., 1989)III

Lingraphica system (Aftonomos et al., 1997)III

Training in gestural sign language (American Indian; Skelly, 1979)III

Partner training in facilitative behavior (Simmons et al., 1987)E

Conversational coaching (Holland, 1988)E

Primarily Restorative for Communication Constraint-induced aphasia therapy (CIT; Pulvermuller et al., 2001)I Group therapy in functional situations (Aten et al., 1982)III

Voluntary Control of Involuntary Utterances (VCIU; Helm & Barresi, 1980)E

Treatment of Aphasic Perseveration Program (TAP; Helm-Estabrooks et al., 1987) III

Conversational script training (Cherney et al., 2008) III

Verbal Expression Treatments Primarily Compensatory for Communication Promoting Aphasics’ Communicative Effectiveness (PACE; Li et al., 1988)III

Supported Conversation for Adults with Aphasia (SCA; Kagan et al., 2001)I

Visual Action Therapy (VAT; Helm-Estabrooks et al., 1982)III

Formal drawing program (Lyon & Sims, 1986)III

Computerized Visual Communication System (C-ViC; Steele et al., 1989)III

Lingraphica system (Aftonomos et al., 1997)III

Training in gestural sign language (American Indian; Skelly, 1979III , Simmons & Zorthian, 1979)

Partner training in facilitative behavior (Simmons et al., 1987)E

Conversational coaching (Holland, 1988)E

Back to the Drawing Board Drawing to facilitate naming (Farias, Davis & Harrington, 2005) Miscellaneous Restorative for Speech Production/Communication Constraint-induced aphasia therapy (CIT; Pulvermuller et al., 2001)I Group therapy in functional situations (Aten et al., 1982)III

Voluntary Control of Involuntary Utterances (VCIU; Helm & Barresi, 1980)E

Treatment of Aphasic Perseveration Program (TAP; Helm-Estabrooks et al., 1987) III Conversational script training (Youmans et al., 2005, Cherney et al., 2008)III

Thematic Language Stimulation (Chapey, 2008) Semantic/Lexical Retrieval Programs Response Elaboration Training (Gaddie, Kearns, Yedor, 1991) Semantic feature analysis (Lowell et al., 1995)III

Semantic feature analysis + Response Elaboration Training (Conley & Coelho, 2003)

Feature-contrasting technique (Hillis, 1998)III

Multistage semantic treatment (Drew & Thompson, 1999)III Personalized cueing (Freed & Marshall, 1995)III

Lexical-semantic therapy: BOX (Doesborgh et al., 1993)I

Word-picture matching (Marshall et al., 1990)E

Complex Semantic Naming Program (Swathi-Kirin, 2003)

Gestural+verbal treatment (Raymer st al., 2006)III

Phonologic Programs Phonologic naming therapy (Robson, 1998)III Phonologic therapy (Nettleton & Lesser, 1991)III

Phonologic hierarchy (Greenwald et al., 1995)III

Retraining O-P/P-O conversion (Kiran et al., 2001)III

Phonological components analysis (PCA) therapy (Leonard et al., 2008)III Word discrimination therapy (Fisher et al., 2009)III

Syntactic Programs Sentence Production Program (Helm-Estabrooks & Ramsberger, 1986)III

Wh-interrogative production treatment (Thompson et al., 1993)II

Verbal cueing for sentence production (Loverso et al., 1998)III

Mapping therapy (Byng et al., 1994)III

Verb Network Strengthening Treatment (VNest) (Edmonds, Nadeau, Kiran, 2009) Semantic feature analysis + Response Elaboration Training (Conley & Coelho, 2003)

Apraxia Programs- See Apraxia of Speech Decision Tree

Auditory Comprehension Treatments Impaired Pre-Linguistic Processing Attention Process Training (APT)E Noise reduction Pausing Primarily Compensatory for Auditory Comprehension Environmental support (patient and family training) (written, pictorial, gestural cues)E Formal drawing program (Lyon & Sims, 1986)III

Miscellaneous Restorative for Auditory Comprehension Treatment for Wernicke’s Aphasia (TWA) (if word reading/pic match)E Training in speech (lip) reading Phonologic training Amphetamine treatmentI Training in speech (lip) reading Schuell Auditory Comprehension Tasks (if word-level deficit) Complex Semantic Naming Treatment (Swathi-Kirin, 2003) Situational Therapy for Wernicke’s Aphasia (Altschuler et al., 2006) Visual Action Therapy (VAT; Helm-Estabrooks et al., 1982)III

Sentence/Discourse Level Programs that Target Auditory Comprehension Verb Network Strengthening Treatment (VNest) (Edmonds, Nadeau, Kiran, 2009) Response Elaboration Training (Gaddie, Kearns, Yedor, 1991) Script Training (Youmans et al., 2005)

Reading Treatment Programs Primarily Compensatory for Communication Phrase-formatted text (PFT) use (Beeson & Insalaco, 1998)III

Training in head turning for right visual field deficit (Daniel et al., 1992)E Environmental support – noise reduction (Kilborn, 1991)E

Hyphenation by grapheme units (Harley & O’Mara, 2006)E

Primarily Restorative for Communication Attentional training (Coelho, 2005)E

Computer-supported reading treatment (Katz & Wertz, 1997)III Intensive stimulation approach with written input (Schuell)E

Letter Identification Kinesthetic reading (Seki et al., 1995)III

Motor cross-cuing for reading (Maher et al., 1998)III Semantic-Lexical Treatments for Pure Alexia (Letter-by-Letter Reading- impaired access to orthography)

Multiple oral re-reading (MOR; Moyer 1979III , Kim & Russo, 2010)

Rapid categorical judgments (Friedman & Lott, 2000)III

Rapid lexical judgments with corrective feedback (Hillis, 1993)III

Train word-picture matching with corrective feedback (Hillis & Carmazza, 1994)III

Phonological Treatments Retraining grapheme to phoneme conversion (Kiran et al., 2001)III

Lindamood Phoneme Sequencing Program (Conway et al., 1998)III Training bigraphs/orthographic-phonemic conversion (Friedman & Lott, 1996) Training homophones in sentences (Scott & Byng, 1989) Phonological Treatment Program (Beeson, 2010; Protocol) Persistent reading impairment at word level or above Oral reading for language in aphasia (ORLA; Cherney, 1995)III

Oral reading treatment (ORT; Orjada & Beeson, 2005)III

Mapping therapy (Schwartz et al., 1994)III

Hierarchical cued oral reading for corpus of words (Hillis & Carmazza, 1994)III

Conversational script training (Cherney et al., 2008)III

Written Language Treatments Global Agraphia- retrain spellings for specific words Anagram and Copy Treatment (ACT; Beeson, 1999)III

Copy and Recall Treatment (CART; Beeson et al., 2002, 2003)III

Phonological Agraphia- retrain sound-letter correspondences Phonological Treatment Program (Beeson, 2010; Protocol) Lindamood Phoneme Sequencing Program (Conway et al., 1998)III Surface Agraphia- difficulty with irregular words Phonologic problem solving for spelling- Interactive Spelling Treatment (Beeson et al., 2000; Protocol) Primarily Compensatory for Communication Environmental support – spell check, space, keyboard (X)E

Apraxia of Speech

Nondiscriminative

Treatment Approaches:

Primary Clinical Characteristics: slow speech rate sound distortions errors relatively

consistent in type prosodic abnormalities

Nondiscriminative Clinical Characteristics articulatory groping perseverative errors Speech initiation difficulty awareness of errors automatic speech better

than propositional speech islands of error-free speech

Clinical Characteristics that Cannot be used to diagnose AOS anticipatory errors transposition errors limb or oral apraxia express-receptive

language gap

Exlusionary Characteristics: fast rate normal rate normal

prosody

Articulatory Kinematic PROMPT (Bose, 2001)III Sound Production Treatment -

(Wambaugh, 1998)III Minimal pairs (Wambaugh, 1996)III Articulatory posture drawings,

modeling, self-initiated postural cueing, mirror monitoring, practice (Raymer, 2002)III

Modified RET (Wambaugh & Martinez, 2000)

Script Training (Youmans, 2011)

Rate and/or Rhythm Repeated Practice with rate/rhythm

control (Wambaugh, 2000)III; (Wambaugh et al., 2012)

Metronome with Hand-Tapping (Mauszycki & Wambaugh, 2008)

Training prolonged speech to reduce rate via computer based program (Southwood, 1987)III

Stress patterning practice-modeling and auditory feedback (Tjaden, 2000)IV

AAC Instruction to use writing (Lustig,

2002)III Electrolarynx (Marshall, 1988)IV Training with communication books,

alphabet supplementation, voice output aid (Yorkston, 1989)IV

Blissymbols (Lane, 1981; Bailey, 1983)IV

Total communication; signing (Fawcus, 1990)IV

Intersystemic Reorganization

Production of gestures (Dowden, 1981)IV; Gestural-Verbal Treatment (Raymer, 1991)III

Pairing verbalization with Ameri-Indian production (Skelly, 1971)IV

Gestural reorganization (tapping) with imitation of contrasts drills (Wertz, 1984)III

Choral singing, phrase production in song (Keith, 1975)IV

Melodic Intonation Therapy (Sparks et al., 1974)III; (Hurkmans et al., 2012)

Effect Size

• Effect size refers to a family of indices specific to single subject design that establishes the magnitude of gain from treatment.

• Effect size is defined as a “ quantity that describes the degree to which a treatment outcome differs from zero.( Beeson & Robey, 2006 )

Effect Sizes

• Small effect size = 0.2

• Medium effect size = 0.5

• Large effect size = 0.8

Effect Sizes (d)

Word-finding treatment for anomia in aphasia 1.66

Viagra (oral sildenafil) vs. placebo and self-reported 1.60change from baseline in sexual functioning

Effect of low dose prednisone vs. placebo on number 1.05of swollen joints in rheumatoid arthritis

Computerized cognitive rehabilitation post-stroke 0.54

Effect of donepezil on cognition in Alzheimer’s 0.51

Improvement in depression with paroxetine 0.21 vs. placebo

Wisenburn & Mahoney, 2009; Althoff et al., 2003; Katzman et al., 2007; Winblad et al., 2009; Saag et al., 1996; Cha & Kim, 2013

Effect Sizes

• Wisenburn and Mahoney, 2009• Completed a meta-analysis of 44 studies and

107 effect sizes that just came out this year• Analysis of various approaches for word

finding deficits in people with aphasia- semantic, phonological, and mixed

• Revealed semantic therapy appeared to have better generalization to untrained words

Aphasia TreatmentsHow to implement programs in

your setting.MACDG

November 4, 2015St. Louis, Missouri

Jacque Livingston M.A.CCCSpeech Therapist at The Rehabilitation Institute of St. Louis

The Rehabilitation Institute of St. Louis

EXPRESSIVE PROGRAMS(In order of typical progression)

• PROMPT• Gestural Verbal Treatment (GVT)• Script Training• Semantic Feature Analysis (SFA)• Phonological Component Analysis (PCA)• VNeST• Response Elaboration Treatment (RET)

Tactile treatment for motor speech disorders

• PROMPTS for Restructuring Oral Muscular Phonetic Targets• Used with patients 6 months of age onward.• Speech Pathologists are the only professionals with the

prerequisite knowledge to apply PROMPT• To become fully trained in PROMPT, a clinician must complete

four essential steps to be able to fully understand the PROMPT technique and apply it appropriately to patients

• Introduction to PROMPT, Bridging PROMPT to intervention, The PROMPT technique self study, PROMPT Certification: A Self-Study Project

• Website: promptinstitute.com

Using Tactile Prompts in Therapy

• Voicing/Breath• Labial• Jaw Height• Lingual• Valving

Voicing

• Start here in the non verbal patient• May need oral stimulation (e.g. tactile,

thermal, gustatory) before treatment to prime articulators

• Tactile prompt to diaphragm, chest, and larynx• Teach inhale then voicing on exhale• Prompt mouth open to initiate voicing

Labial placement

• Video labial closure/labial retraction• Video labial rounding

• Labial opening (voicing)• Labial closure (bilabials)• Labial retraction (/i/)• Labial rounding (/o/ /oo/)

Lingual Placement

• Video for velar placement• Use verbal cue for lingual placement and

positiono Front, middle, back

• Use modeling for visual and phonemic cues• Decrease cueing hierarchy, tactile→verbal

→visual →independent

Nasals

• Video for nasal sound• Prompts for valving on /m/ /n/• Prompt for air through nose• Prompt for lingual postion of /n/• Prompt for labial positions of /m/• Use with minimal pairs, ex mom vs mop

teaching pt to redirect air from nasal cavity to oral cavity

Putting it together

• Video of Prompt workshop

Gestural Verbal TreatmentGVT

Gestural Verbal Treatment

• Targets verbal production• Pt population typically non fluent with mild to

severe aphasia/apraxia of speech• Pair intact gesture to facilitate production of

verbal expression• Target gestures should be functional• May increase from word to phrase length

verbalizations• Use gesture which best illustrates target word

Gestural Verbal Treatment

1. Target pic placed in front of subject and a model of the verbal and gestural target provided

2. Gesture elicited in isolation following a model3. Verbal production elicited in isolation following a model4. Verbal and gestural responses are modeled together

while client produces simultaneously5. Verbal and gestural response elicited together without

a model6. Each training item is presented two to three times per

treatment session.

Gestural Verbal Treatment Video

• Video of GVT

Script Training

Script training• Script Training was initially developed to promote verbal communication

on client-selected topics (Holland, Milman, Munoz, & Bays, 2002)Goal is for individuals for whom speech is no longer automatic to produce islands of fluent speech in conversation

• Previously used as a treatment approach to improve automatic language production in adults with aphasia

• To become automatic, scripts must be practiced as phrase or sentence-length units vs. syllable or ‘one word at a time’ approach (Youmans, Holland, Munoz, & Bourgeois, 2005)

• For individuals with expressive speech difficulties repeated practice of phrases and sentences can lead to automatic and effortless speech productions

Script Training• Work with patient to create 3 scripts. Each script should consist of 3-4 relatively short

sentences.– Example: Conversation Starters:

• How are your grandchildren?• Good morning.• I’ll see you later.• What’s new?

• Utilize cuing hierarchy to introduce scripts.– Phrase repetition– Choral reading with clinician– Independent production

• When the client can produce a newly trained phrase independently at least 20 consecutive times a new script is added or more information is added to mastered script.

• Patient’s are expected to practice scripts at home for 15 minutes per day.• Once a script is mastered, generalization training is initiated.

– Clinician purposefully varies response and comments to help the participant make scripts more resilient and more flexible.

Script Training Data Collection

DATE 6/14/12 6/4/12 6/19/12 6/21/12 6/28/12 7/2/12 7/5/12 7/10/12 7/12/12 7/17/12 7/19/12

Script 1 40 60 70 90 96 90 93 94 96 96

Time 3:00 2:45 1:56 1:35 1:13 1:13 1:10 1:27 1:02 1:00

Script 2 39 38 81 86 95 95 99

Time 5:00 2:25 2:05 2:10 1:11 1:20 1:01

Script3 78

Time 2:47

Semantic Feature Analysis

Theory of SFA

• There are strong neural connections between related concepts

• There is better access to word-finding within categories• SFA allows pt’s to self cue by activating these neural

connections• The 2009 study by Antonucci

– pts treated with SFA during discourse production tasks showed improvements in general communication efficiency

• 2010 Peach and Rueter– showed that targeting word finding behaviors in connected

speech generalized to naming of untrained object and action pictures

Model for SFA

• SFA model involves description of a target item (picture in the center of the template) which enables the pt. to generate features including:– Group– Use– Action– Properties– Location– Association

Semantic Feature Analysis (Nouns)

Semantic Feature Analysis

Semantic Feature Analysis Video

• Video of SFA

Phonological Component Analysis

• The Phonological Component Analysis was modeled after SFA through spreading activation (Boyle and Coehlo, 1995)

• The PCA protocol (Coehlo, 2008) followed the protocol of a target picture presented in the center of the chart with the pt asked to identify 5 phonological components related to the target:

-rhyming-identify the first sound of the word-first sound association-final sound-number of syllables

PCA TEMPLATE

Visual Network Stregthening Treatment

VNeST

VNEST

• Verb Network Strengthening Treatment (VNeST) (Edmonds et al., 2009)

• Semantic treatment - to improve lexical retrieval of content words in sentence context

• Promotes systematic retrieval of verbs and their thematic roles

• Treatment uses co-activation of verbs and their thematic roles so that a verb primes its agents (arresting/policeman), patients (arresting/criminal) and instruments (cutting/scissors) and vice versa.

VNeST Procedure

• VNeST: Procedure (Edmonds et al., 2009) • 1.Generation of three agents or patients for verb (using

who/what & verb cards; if cannot produce 3 words, then can select cards from choice of target plus 3 foils)

• 2.Generation of corresponding agent or patient to complete agent–patient pairs; reads word pair aloud

• 3.Answer wh-questions about agent–patient pair (when, where, why)

• 4.Semantic judgement of sentences read aloud by clinician

Vnest Template

Response Elaboration TreatmentRET

Response Elaboration Treatment

• Targets increase the length and information content of verbal responses

• The goal of this therapy is to reinforce and elaborating on the language of the aphasic patient. 

• A typical session involves a six step training sequence.

• The patient is presented with a picture stimulus and responds with a spontaneous description.

• The clinician then expands and reinforces the patient’s response. After cueing and repetition requests, the patient will ideally be able to lengthen the understanding of the stimuli and number of words used to describe it.

Response Elaboration Treatment (RET)

Procedure1. Stimulus presented (e.g. personal picture, magazine photo, etc.

Must be action on photo)• Clinician: “What is happening here?”• Patient: “Crying.”2. Expansion/reinforcement• Clinician: “Good! The boy is crying.”3. “Why” cue• Clinician: “Why is the boy crying?”• Patient: “Hit head.”4. Combining patients response, modeling• Clinician: “Great! The boy is crying because he hit his head.”

Response Elaboration Patient Data

11/15 11/19 11/19 11/26 12/3 12/6 12/10 12/13 12/17 12/27 1/7 1/14 1/17 1/21 1/28 1/31 1/28

10 12 17 17 10.5 12.1 9 13 15 15 14 13 16 18 23 17 18

0.11 0.08 0.11 0.11 0.09 0.1 0.13 0.125 0.11 0.165 0.13 0.13 0.14 0.17 0.17 0.14 0.14

Content Units

Efficiency

Date

Content Units= information (nouns, verbs, adjectives relevant to topic)Efficiency= content units/time

2/9/11 2/22/11 3/2/11 3/9/11 3/24/11 3/30/11 4/20/11 5/18/11 6/18/11

LCI 0.6 1 0.75 1 1.2 1 0.6 1 1

# clauses 2 3.0 3.0 5.0 6.0 5.0 2.0 7.0 8.0

Date

Response Elaboration Video

• Video of RET

Receptive Programs

• Treatment for Wernicke’s Aphasia (TWA)• Complex Semantic Naming

Treatment for Wernicke’s Aphasia

• Developed by Helm-Estabrooks and Fitzpatrick• Based on the evidence that the ability to repeat

orally presented stimuli may be linked to the ability to process or understand these stimuli

• Appropriate for moderate to severe Wernicke’s Aphasia

• Pt. must demonstrate good ability to understand written stimuli at the single word level and some ability to correctly read single words aloud

TWA

• Treatment Steps– Step 1: Reading Comprehension: match a printed, lowercase word

to its pictorial representation with 6 pictures (one correct and five foils)

– Step 2: Oral Reading: read the target word aloud (with no pictures out)

– Step 3: Repetition: repeat the word as presented by the clinician with only the picture present (no printed stimuli)

– Step 4: Auditory Comprehension: correctly select the pictorial representation of the word from a group of 6 upon hearing the word spoken by the clinician (no printed stimulus)

– Incorrect spoken responses that are real words are used as future stimuli.

TWA Treatment DataBaseline

10/28/13 10/30/13 11/4/13 11/6/13 11/13/13 11/22/13 12/16/13 12/20/13 12/23/13 1/3/14 1/10/14

Match written word to pic

100% 100% 100% 87% 100% 85% 95% 100% 95% 100% 100% 100%

Read word aloud

67% 67% 67% 37% 45% 43% 55% 85% 65% 75% 85% 85%

Repeat word

83% 83% 83% 81% 43% 78% 100% 100% 100% 95% 100% 95%

Aud. Word ID to pic

100% 100% 83% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Name Picture

100% 83% 81% 50% 71% 75% 90% 95% 100% 95% 90%

TWA Video

• Video of TWA

Complex Semantic Naming

• Can be used as an expressive or receptive program• Study suggests patients trained on naming of

atypical exemplars demonstrated generalization to naming of intermediate and typical items, but pt. trained on typical items demonstrated no generalized naming effect to intermediate or atypical examples (Kiran and Thompson 2003)

• When using as a receptive treatment program you can target understanding of complex yes/no questions and semantic sorting

Complex Semantic Naming

• Treatment StepsStep 1: pt. names the pictureStep 2: pt. is given 2 written choices of a category and is

asked to identify which category the picture belongs inStep 3: pt. is given 6 written semantic features (3 yes and

3 no) and then asked to identify which semantic features are yes and which are no

Step 4: pt. answers 15 yes/no questions pertaining to the semantic features of the target

Step 5: pt. names the picture again

Complex Semantic Naming Treatment DataSet 2 Set 2 Set 2 Set 2 Set 3 Set 2 Set 3

Select semantic feature

91% 100% 100% 100% 100%

Answer y/n ques.

91% 90% 93% 91% 90% 91%

Name typical picture

80% 50% 70% 40% 10% 70%

Mod A Mod A Mod A Ind. Ind. MinName atypical picture

70% 60% 80% 90% 90% 100% 90%

Mod A Mod A Mod A Ind. Ind. Min Min

Aphasia Treatmentsand the chronic patient

MACDGNovember 4, 2015St. Louis, Missouri

Karen Blank M.A.CCCSenior Speech Therapist at The Rehabilitation Institute of St. Louis

The Rehabilitation Institute of St. Louis

Treating the Chronic Patient• Past research studies ,from 1982(Holland) to present , have cited

improvements made with the chronic aphasic patient. • Moss and Nicholas (2006) describe chronic patients as 1 year post

stroke. They showed that improvements made in treatment can be made up to years post stroke.

• Meinzer et al (2004) showed after intensive therapy with patients with chronic aphasia, there were positive changes in brain activity correlated to positive changes in language functions . They concluding that reorganization of the brain occurs even years after stroke.

• Basso and Macis(2011) showed 9/13 chronic patients improved in oral and written nouns and action naming, and oral and written sentence production. Again, intensive therapy ,including 2-3 hours of homework ,aided in gains made.

Treatment Progression of the Nonfluent patient

1. Gestural verbal treatment /Prompt or Tactile-Kinesthetic treatments: Treating apraxia of speech with trained words and phrases

↓2. Script training/RET training: To elicit more

information and increase fluency/length of utterance.↓

3. Promote generalization through use with family and friends, use of “wh” questions to elicit conversationally relevant speech.

Treatment progression of the Fluent Patient

1. Treatment for Wernicke’s Aphasia (TWA) Speech Reading/Lindamood Phonological Program

↓2. Phonological Component (PCA)Analysis/ Semantic

Feature Analysis (SFA)/ Complex Semantic Feature Analysis (Kiran)

↓3. VNESST/ Script training/ and RET training

↓4. Generalization: Wh-questions in conversation and

continue to track LCI, content units, and efficiency.

Analysis of Treatment of Chronic Patients in the EBAC

• From 20 chronic patients seen over the last few years in the EBAC the following were results of evidenced-based treatment. Significant change on WAB 5 points, Significant change of CETI 11 points.

• Changes in WAB scores were: average of 21.17 points the range was -13 to 61.3 pts• Changes in LCI scores were: average .65• Changes in Content Units were: average 1.27• Changes in CETI were from significant other were: average 11.4• Changes in CETI from pt. were: average 10.7• Average time of treatment from onset was: average 488 days (310-842)• Average time of treatment was: average 21 months (15-25)

Pre Post Significance

WAB 43.94 65.11 <.001*

LCI .25 .91 .002*

Content Unit 2.82 4.09 .165

Efficacy 1.50 3.27 .078

CETI-Self 56.16 66.81 .064

CETI-Other 45.73 57.13 .017*

Statistically significant changes in the chronic patient

• 85% of chronic patients showed statistically significant increase in WAB from admit to discharge

• 54% of chronic patients family members had statistically significant increase in CETI

Increasing Content Units

Pt’s who increased content units by 15% or higher

Aphasia subtypes and treatments: n=6 • Global: GVT• Broca’s : Lindamood → RET• Non fluent : RET• Non-fluent: Script training →PCA →RET• Wernike’s: RET

• Conclusiono Increases in content units improved greatest with our non-

fluent patients receiving RET.

Increasing EfficiencyPt’s whose efficiency increased by at least four content units per minute.

Aphasia subtypes and treatments: n=5 • Anomic: PCA• Broca’s: Lindamood→RET • Mixed non fluent: RET• Mixed Nonfluent: TWA/Complex Semantic Naming/SFA/RET• Wernikes: RET

• Conclusion: o RET worked best with this pt population to improve efficiency (4/5

received RET). o Efficiency changes seen with both fluent and nonfluent patients

with both receptive and /or expressive aphasias.

Increasing LCIPt’s increasing LCI by .5 or higher

Aphasia subtypes and treatment N=8• Non-fluent: GVT→Script → VNeSST → RET• Mixed nonfluent: VNeSST• Broca’s: Lindamood →RET• Nonfluent: PROMPT →RET →VNeSST• Anomic: Script training →PCA →RET• Nonfluent: TWA →Complex Semantic Naming →SFA →RET• Transcortical Motor: RET• Mixed non fluent: Script training → RET

• Conclusion:o Biggest LCI improvements were seen in the chronic patients with non

fluent aphasia who were treated with RET and/or VNeSST.

Case Study of a EBAC Pt. with Chronic Aphasia

• Pt is a 54 year old male that suffered a left CVA with severe AOS in with onset on 2012

• Pt began therapy in 12/18/13 with Prompt therapy and was trained on 40 functional phrases with pt achieving 80% accuracy over 2-3 weeks. Video PROMPT Pt used these phrases in therapy and some use at home with wife and family and employees.

• WH questions to assist with functional carryover video to generalize trained phrases.• Pt proceeded with RET therapy that aided use of content units in functional,

everyday speech but did not improve in his LCI scores. RET video• Then pt advanced to VNESST which improved his LCI scores from 0.0 in beginning of

therapy to .5 in monthly probes, and then .8-1.0 when using wh questions for relevant topics he was interested in. Video of VNeST

• Pts WAB scores at 6 month intervals were : 36.8 (4/14); 51.5 (10/2014); and 64.7 (6/2015). Significant change each time after spontaneous recovery.

• CETI scores by wife were lowered from 60%-50% but CETI scores by pt. went from 64 to 81% in which pt kept indicating that he continued to speak better in home and work situations.

Conclusions of Presentation1. How are we going to find ways to deliver evidenced-based therapies in an intensive

manner to chronic patients when 3rd party payers stop funding the therapy?2. SLP’s should be aware of current evidence based aphasia treatments in order to

determine which treatment would be most effective for their clients aphasia subtype.

3. Furthermore, SLP’s need a protocol (e.g. interval probes) to measure whether the treatment is improving their pt’s language.

4 . Need to set up criteria for discharge, including what goals patients want to achieve, and length of therapy.

5. Tune ups may be needed with chronic patients post discharge (e.g. every 6 months) to encourage ongoing recovery.

6. More research needed to predict language recovery post stroke and determine best care path.

Questions

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