Chapter 30 - Specific Approaches for Enhancing Expressive Language

Constraint-induced language therapy (CILT) or constraint-induced aphasia therapy (CIAT)

is modeled on approaches to constraint-induced therapy in areas of practice outside of communication (i.e., treatments involving neuromotor control). In this approach, people are restricted in their use of compensatory modalities. They are encouraged to use the modalities that are the most impaired. The approach has been developed to date primarily for people with aphasia.

is a restitutive approach. Maximizing reliance on impaired systems seemed to stimulate impaired abilities.Thus, the underlying rationale for CILT is that it is important to encourage people with language disabilities to use the language modalities that are most impaired.

On What Principles Is CILT Based?

• communication should be restricted to verbal expression (e.g., that nonverbal modality use should be discouraged), and

• practice should be intense.

How Is CILT Implemented?

The focus has been more on what participants with aphasia were not allowed to do. That is, they have been instructed primarily not to use nonlinguistic means to communicate and not to use the stronger of oral versus written modalities of communication.

Typically, tasks during CILT have been focused on spoken language production, often using a cueing hierarchy approach.

Treatment intensity has generally been about 3 to 4 hours per day for at least 5 days per week over 2 weeks or 10consecutive days.

One challenge with the state of CILT to date is that there is

little consistency across studies in terms of the actual treatment protocol implemented. Not only are the details about treatment intensity and duration lacking in some studies but so are the specific activities in which participants engaged.

What Is the Status of CILT in Terms of Evidence-Based Practice?

Maher et al. (2006) reported carryover of language gains. Johnson et al. (2014) reported positive outcomes following CILT with four people with chronic Broca’s aphasia. They noted a lack of statistical significance in language battery test scores but improved use of language in natural contexts

Kurland et al. (2012) found that treatment effects for CILT in addition to PACE treatment were greater than PACE treatment alone for two people with aphasia.

They reported “modest evidence” for greater effects from more intensive treatment.

“constraint treatments and multimodality treatments are equally efficacious, and there is limited support for constraining client responses to the spoken modality”

Regardless of the effectiveness of CILT, it is important to note that, overall, there is no clear evidence that using supported communication across all modalities impedes recovery of impaired modalities.

Most of the research on CILT to date has been done with people who had severe

Broca’s aphasia and apraxia of speech.

Script training

is a method in which the client practices using personally relevant conversational scripts that are written in collaboration with a speechlanguage pathologist (SLP).

It is intended for people with aphasia who have limited expressive language.

The goal is to produce relatively fluent speech and natural language production in socially meaningful contexts.

On What Principles Is Script Training Based?

Script training is based on evidence that repetitive practice of preestablished, personally relevant conversational text will decrease the amount of effort involved in speaking during conversation and increase spontaneous language generation (Bilda, 2011).

Although script training may be considered impairment focused, it also fits within a social and life participation model because it entails use of trained scripts in actual real-life communicative contexts.

How Is Script Training Implemented?

• Discuss the goals of script training with the client.

• Have them generate topics that are most relevant to themselves. The scripts may be monologues or dialogues to be initiated by the client in actual communicative situations.Scripts may include, for example, personal stories, general conversational topics, content to provide information, and descriptions of personal interests. It might help for you to propose a few specific topics based on what you know about their interests and communication needs.

• Use supported communication strategies to collaborate with in generating a written script for specific content the person wants to be able to convey.

• Practice reading the script aloud with the person, then have them read it alone,supporting them as needed.

• For homework, assign repeated reading aloud of the script several times a day.

• Have the client practice using the script in contexts where the content is socially appropriate.

• Have the client practice the script with new conversational partners.

What Is the Status of Script Training in Terms of Evidence-Based Practice?

Youmans et al. (2005) reported increased accuracy of production and good generalization to spontaneous use for two people with aphasia.

Goldberg et al. (2012) The authors noted that both participants improved in terms of grammatical morpheme production, rate of speech, syntax, and overall conversational success

Manheim et al. (2009) Outcomes, as indexed according to the Burden of Stroke Scale indicated significantly reduced communication difficulty.

Lee et al. (2009) reported that greater intensity of use of prerecorded script practicing software led to better treatment gains for those w/ more severe language impairment.

Melodic Intonation Therapy (MIT)

an intervention method based on facilitating spoken language through the exaggeration of three elements of spoken language prosody: pitch, the tempo and rhythm of utterances, and stress for emphasis.

MIT is intended for people with severely limited oral expression, especially people with Broca’s aphasia (with or without apraxia of speech). The best candidates for treatment are said to be those with good auditory comprehension, the ability to self- monitor and self-correct, and willingness to participate actively.

The goal is to draw on the prosodic features of language to facilitate verbal output. MIT targets speech output at the impairment level.

MIT is restitutive in terms of the goal to foster brain changes to enhance speech output and prosody. It may also be considered compensatory in that a person may learn to use melody and rhythmic patterns to facilitate their own spoken language.

On What Principles Is MIT Based?

MIT was developed based on the hypothesis that “functions associated with the intact right hemisphere might be tapped to improve the language functions of a damaged left hemisphere”

• The right hemisphere mediates music and speech prosody in most people.

• The right hemisphere is typically preserved in individuals with aphasia such that singing abilities are spared in most individuals with left hemisphere lesions alone.

• Preserved musical and prosodic capabilities can be used to facilitate language production in people with aphasia.

How Is MIT Implemented? Original Method

is composed of clear steps organized in a hierarchy of increasing difficulty. Difficulty refers to an increased phrase length with each level and removal of melodic intonation and rhythmic tapping within later levels.

• pausing for 6 seconds between presenting a target stimulus and having the person respond, and between the completion of one targeted verbal item and the next to enable processing time

• avoiding excessive reinforcement for good responses

• avoiding incorporation of melodies similar to actual songs, which might stimulate memories of song lyrics. The recommended frequency of intervention is two 30-minute sessions daily, 5 days per week. The recommended criterion for progression from one level to the next is 90% or better accuracy for 10 consecutive therapy sessions.

intoning

means that instead of speaking, you sing the words in a melodious pattern that exaggerates the natural pitches corresponding to how a target sentence might be said.

sprechgesang

“spoken song,” refers to a blend of speaking and singing. Sparks (2008) described it as being similar to intoning in terms of the exaggerated tempo, rhythm, and stress but having a more constant pitch: “

MIT LV. 1

• Hum a melodic pattern twice holding the left hand of the client. Together, make hand-tapping movements in time with the humming, emphasizing rhythm, tempo, and stress.

• Motion for the client to join with you in humming the same melodic pattern. Continue repeating the same humming pattern.

• Gradually fade out your humming, while continuing the hand tapping. Use gesture to encourage the client to continue humming. Continue to do this until the client hums in away that matches what you have modeled.

MIT LV. 2: Step 1

• Think of a sentence that would be meaningful for the client to say. Examples might be: “I am hungry,” “I need help,” “I love you,” or “How are you?” Consider the intonation pattern with which the target sentence would be naturally said.

• Hum that intonation pattern while holding the client’s hand, tapping in rhythm to the humming.

• Intone the words of the sentence instead of humming, with the same melody, stress, and rhythm.

• Motion for the client to join with you; intone the sentence together. If the client cannot do this, wait for a few seconds, then move on to another sentence and start again at Level II, Step 1.

MIT LV. 2: Step 2

• Intone the same sentence along with tapping hands.

• Continue hand tapping but fade your intoning, and gesture to the client to continue intoning the sentence. If the client cannot do this, wait for a few seconds, then move on to another sentence and begin at the start of Level II, Step 1 again.

MIT LV. 2: Step 3

• Signal for the client to listen to you.

• Present the same intoned sentence again, accompanied by hand tapping with the client.

• Signal the client to repeat the sentence while you continue hand tapping, but stop intoning.

• If the client has trouble initiating the sentence, provide a phonemic cue.

• If the client cannot do this, wait for a few seconds, then move on to another sentence and begin at the start of Level II, Step 1 again.

MIT LV. 2: Step 4

• Without hand tapping, intone the question, “What did you say?”

• Signal to the client to answer with the same intoned utterance.

• Provide hand tapping and a phonemic cue if the client is having trouble.

MIT LV. 3: Step 1

• Present the intoned sentence again with hand tapping and gesture for the client to do it in unison with you.

• Fade your intoning as the client continues, only joining in again if needed.

MIT LV. 3: Step 2

• Intone the sentence again with hand tapping.

• Give a hand signal to the client to request that they delay the response for a second or two.

• Gesture for the client to intone the sentence alone.

MIT LV. 3: Step 3

• Intone a question to elicit a response that is relevant to the sentence on which you have been working. The example that Sparks (2008) gives is as follows: if the target sentence in Step 2 was, “I want some pie,” then you might intone, “What kind of pie?” (p. 846).

• If the client does not respond accurately, back up to Level III, Step 2.

MIT LV. 4: Step 1

• Signal for the client to listen while you intone the sentence.

• Present the sentence twice in sprechesang while hand tapping with the client.

• Gesture for the client to join you in unison sprechesang while hand tapping together.

• If the client does not join in, model it again, and again gesture for the client to join in.

MIT LV. 4: Step 2

• Signal for the client to listen and not join in while you present the same sentence again in sprechesang with hand tapping.

• Wait for 2 or 3 seconds and gesture for the client to repeat the sentence in sprechesang with hand tapping.

• If the client cannot or does not do it, go back to Level IV, Step 1.

MIT LV. 4: Step 3

• Signal for the client to listen, and then present the same sentence using typical speech prosody and no hand tapping.

• Signal for the client to repeat the sentence using typical speech prosody.

MIT LV. 4: Step 4

• Ask questions relevant to the sentence just spoken in Step 3. For example, if the sentence was “I want to eat,” then you might ask, “What do you want to eat?” “What’s your favorite food?” and “Where would you go to get that?”

MIT treatment and outcome measurement

suggested that optimal treatment duration is no more than 8 weeks,although there is a great deal of variation in duration and intensity of treatment in the related research literature.

Outcomes indices directly tied to treatment may include scoring of responses for each level,repetition accuracy, and length, informativeness,and accuracy of responses to questions in Level IV.

Additional metrics reported in evaluating MIT outcomes include mean length of utterance, information content units, confrontational naming accuracy,effectiveness of communication with a partner, and self-initiation of MIT strategies.

What Is the Status of MIT in Terms of Evidence-Based Practice?

Conklyn et al., 2012) the treatment group showed significant improvements compared to the control group.

Van Der Meulen et al. (2016) found that MIT was only effective for repetition of trained materials. Repetition improvement did not transfer to untrained items, to word finding, or to spontaneous conversation, and it was not maintained 6 weeks after treatment.

Haro-Martinez et al. (2019), found no significant results according to standardized measures, although questionnaire responses from caregivers suggested some improvement.

Albert et al. (1973) reported After 1 to 2 months of MIT treatment, each person demonstrated increased expressive language abilities in propositional speech, including the ability to answer questions and converse with peers.

the best candidates for MIT are

those with lesions in Broca’s area but not in the temporal lobe or right hemisphere. Those with poor responses had bilateral lesions involving Wernicke’s area. Naeser and Helm-Estabrooks.

Those with with limited stereotypical jargon, paraphasias, and agrammatism. Sparks et al. (1974)

neurological evidence for the mechanisms of recovery associated with MIT.

Schlaug et al. (2008) reported significantly more fMRI activity in the right hemisphere following MIT.

Belin et al. (1996) Blood flow was measured via positron emission tomography while the participants listened to and repeated words with exaggerated melody and rhythm. Results indicated activation of Broca’s area and the left prefrontal cortex. This was in contrast to abnormal activation Importantly, their findings of left hemisphere reactivation called into question the notion that MIT leads to right hemisphere compensation.

discerning the elements of the overall treatment that may account for its effectiveness

Dunham and Newhoff (1979) found hand tapping as a prosodic cue was helpful. Hough (2010) found melodic cues w/o hand tapping but with verbal stimuli beneficial.

Boucher (2001) suggested that melodic contour is not as important as rhythm and pacing. They reported that an emphasis on tonal conditions during treatment did not facilitate repetition gains; the emphasis on rhythm and pacing of words did.

Stahl et al. (2013) compared singing versus rhythmic speech in seven people with Broca’s aphasia and eight with global aphasia. They concluded that both may be effective in eliciting formulaic expressions in people with “nonfluent” aphasia.

Laughlin et al. (1979) reported that syllable duration is an important parameter in MIT administration. 2 s per syll was best.

In sum outcomes are mixed, and the overall quality of the supportive research is not strong.

A challenge in summarizing and interpreting the evidence base for MIT is the

lack of treatment fidelity across many studies and the great variability in treatment outcomes measures.

A weakness of MIT is that the

main areas targeted are accurate progression through the prescribed tasks and a focus on linguistic form rather than true communication. Measures of social validation and generalization to naturalistic communication (effects beyond the impairment level) are needed

Voluntary Control of Involuntary Utterances (VCIU)

is a treatment approach designed to improve expressive, propositional communication in people with severe nonfluent aphasia whose speech is limited to automatic production of few words.

The purpose is to stimulate the use of propositional language in individuals who mainly use involuntary utterances but who are able to read and comprehend at least one word at a time.

Goda (1962) and Vignolo (1964) suggested that clinicians could effectively use correct automatic or involuntary utterances to facilitate production of voluntary utterances

An inherent benefit is that using the person’s spontaneous productions may help to increase the likelihood that treatment materials are relevant to the individual.

On What Principles Is VCIU Treatment Based?

The assumption behind VCIU is that spontaneously produced, automatic speech can be used to facilitate the production and intentional use of real words in conversation.

A supposition that complements the approach is that using words uniquely tailored to each individual, with stimuli based on actual prior productions, will help ensure personal relevance.

How Is VCIU Implemented?

• Create a list of all the words that the client is known to have produced spontaneously, and write each on a separate card.

• Ask the client to read one card at a time aloud.For each card, if the client reads it correctly,keep the card; if not, discard it.

• Present pictures of the target words and ask the client to name each one. If the client cannot name it, show the corresponding written word and ask the client to read it aloud.

• Any time the client produces a different real word, discard the former target word and replace it with the new word.

• Provide the target word card to the client to practice at home.

• Through supported communication,encourage progression from oral reading and confrontation naming to use in natural conversation.

Family members and friends can be involved in the VCIU approach by identifying new target words (based on utterances they hear the client say outside of the clinical setting) and by practicing voluntary use of target words in meaningful social contexts.

What Is the Status of VCIU in Terms of Evidence-Based Practice?

Very limited research has been done on the efficacy of VCIU. Helm and Barresi (1980) reported that three participants with limited automatic speech but relatively intact reading and auditory comprehension skills showed improvement in confrontation naming. One demonstrated significant improvement in the number of words used in natural conversation. A great deal more research must be done to support the evidence base for this approach.

Response Elaboration Training (RET)

was developed by Kearns (1985) as a means of increasing the length and improving the information content of oral language of people with Broca’s or “nonfluent”aphasia.

In contrast to more formalized methods, during RET, the client is seen as the primary communicator, and client-initiated topics are encouraged. Successful communication of novel ideas is encouraged rather than accuracy of production.

In RET, people with aphasia are shown picture stimuli. Instead of having them describe the pictures, the clinician encourages them to elaborate on whatever thoughts they associate with the picture.

In RET, a forward-chaining technique is implemented.

That is, the clinician responds directly to anything the client says and models and reinforces longer utterances based on client-initiated utterances.

On What Principles Is RET Based?

RET is considered an interactive loose training program geared toward lengthening of utterances and increasing variety in linguistic formulations.

Loose

training programs

are those that reduce clinician control over stimuli, responses, and feedback during treatment.

How Is RET Implemented?

• Show a stimulus picture depicting an everyday activity and elicit an initial verbal response to the picture. Encourage the client to elaborate on whatever the client is reminded of when looking at the picture. Avoid having the client describe the picture or name items depicted.

• Respond to the client’s initial response with your own comments, and encourage the client to expand on the initial response. Continue to make additional comments in response to the client’s comments as appropriate.

• Ask Wh- questions regarding the client’s own responses.

• Model sentences that combine the client’s initial and subsequent responses. Ask the client to repeat your combined sentences.

• Do not directly correct the client’s responses;instead, provide natural feedback through conversational modeling.

What Is the Status of RET in Terms of Evidence-Based Practice?

Research studies to date, primarily case studies and single-participant studies, have shown increases in the amount of verbal information provided by people with Broca’s aphasia in response to picture stimuli.

Treatment outcomes have been indexed in terms of number of words, length of utterances, sentence completeness, and grammatical accuracy. RET effects have been shown to generalize to other conversational partners, picture stimuli, and social settings

Limitations of RET studies to date are the lack of consistent metrics used to demonstrate outcomes, small sample sizes, and a lack of randomization and control groups.

Treatment of Aphasic Perseveration (TAP)

is an approach originally designed by Helm-Estabrooks et al. (1987) for people with aphasia who tend to perseverate on speech sounds, words, and utterances they have already said. People with neurogenic communication disorders tend to perseverate in a variety of ways.

TAP is an impairment-level approach. The goals are to reduce perseverations and enhance naming. Optimal candidates for TAP are people with aphasia who have at least moderately intact comprehension, good memory, and moderate to severe recurrent perseveration.

General categories of perseveration are

recurrent, continuous, and stuck-in-set perseveration

On What Principles Is TAP Based?

Given how pervasive recurrent perseveration is in chronic aphasia, and given how it tends to persist regardless of time post-onset  addressing it head-on may be especially helpful for many people with aphasia. The underlying principle is that by helping people become aware of their perseverations, we may help them suppress them

How Is TAP Implemented?

• Establish a baseline by calculating the percentage of words perseverated during the confrontation naming portion of the Boston Diagnostic Aphasia Examination-3

• Explain to the client what perseveration is and give examples. Ask that the client pay particular attention to their perseverations to try to avoid them. Of course, do this with a gentle and friendly, not corrective, tone.

• Engage in a confrontation naming activity,with 5-second intervals between items.Arrange the stimuli according to the severity of perseveration the person has exhibited on the confrontation naming task. The intent is to start where the client will have the greatest success and then to move to more difficult items in a hierarchical fashion. Although the earlier descriptions of TAP recommended use of preestablished picture sets, more recent versions have acknowledged that it is important to use pictures that are most personally relevant to each individual’s daily use of language.

• Continue to draw attention to moments of perseveration. Write the incorrect utterance that was spoken and then rip it up in front of the client. If the client perseverates on the same word again, point to the ripped paper as a reminder. As you have the client name one picture at a time, track:

• the number of items (pictures) named correctly (providing up to three cues for each), and

• the number and type of words on which the person perseverates (regardless of the number of times the client perseverated on each word).

TAP scoring

Cues may be gestures, drawings, spoken descriptions, graphic cues (initial letters, syllables, or the whole word), phonemic cues, requests for repetition, or requests to speak or sing the word in unison.

If you choose to work on sets of words within semantic categories (e.g., kitchen items, foods, transportation, letters, numbers), it may help to mention that the category is about to change, to avoid stuck-in-set types of perseverations based on the task.

It is important to test for treatment effects not only with trained but also untrained items.

BDAE-3 confrontation naming scores

minimal: 0% to 5%

mild: 5% to 19%

moderate: 20% to 49%

severe: 49% and higher

What Is the Status of TAP in Terms of Evidence-Based Practice?

Helm-Estabrooks et al. (1987) reported results of a single-case design study with alternating types of treatment for three people with aphasia. They reported substantial reduction in perseverations for all three participants. They did not report results according to generalization to untrained naming stimuli or tasks. No other empirical reports on the effectiveness of the approach appear to have been published to date. Thus, the evidence base is weak.

Given the pervasiveness of perseveration in acute and chronic aphasia, further research on treatment methods to address it is important. Contextualizing such research in a life participation framework will be important.