“i know exactly where it is but i don’t know where it’s going…”
TRANSCRIPT
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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 [email protected]. 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?
REFLECTIONS
DO I RECOGNISE THAT STABLECAN FEEL STUCK?
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DO I EVER THINK ABOUTWRITING AN ARTICLE WITH ACLIENT?