MODULE 6: PRINCIPLES OF INTERVENTION FOR APHASIA AND COGNITIVE CONDITIONS

RECOVERY

→ spontaneous recovery (decelerating curve) 

→ late or long-term recovery may still take place 

→ type of aphasia → evolve over time 

→ degree of recovery → varies from px to px 

NEUROANATOMICAL FACTORS	PERSONAL FACTORS
Lesion size and site (extent of involvement within specific structures that affect recovery)	Age, psychosocial factors, gender, handedness

NEUROANATOMICAL FACTORS

Lesion size and site (extent of involvement within specific structures that affect recovery)

PERSONAL FACTORS

Age, psychosocial factors, gender, handedness

PSYCHOSOCIAL/FUNCTIONAL APPROACHES TO INTERVENTION

SOCIAL APPROACH

LIFE-PARTICIPATION APPROACH TO APHASIA (LPAA)

ENVIRONMENTAL APPROACH

SOCIAL APPROACH

• Goal: promote membership in a communicating society and participation in personally relevant activities

• Consistent with the philosophy of LPAA

• Aphasia is addressed as an element of social system and communication → social act

• Acknowledges that the meaning of aphasia to the person with aphasia and to those around him or her is greater than the linguistic deficit alone

• Aphasia is a diagnosis, but also aphasia is a socially constructed way of being that is created through the experiences of the PWA

PRINCIPLES OF SOCIAL APPROACH

1. Dual goals of transaction and interaction

2. Address communication within an authentic context

3. Communication as dynamic, flexible, and multidimensional

4. Communication is collaborative

5. Focus on natural interaction: conversation

6. Focus on adaptations and enablement rather than impairment and disability

7. Focus on personal and social consequences

8. Embrace the perspective of those affected by aphasia

9. Qualitative as well as quantitative measures — ex of scale: stroke and aphasia QoL scale - 39

INTERVENTION WITHIN A SOCIAL MODEL

Expanding skill and confidence in conversation

Conversation therapy

Enhanced compensatory strategy training

Conversational coaching

Group therapy

Scaffolded and supported conversations

Partner training

Conversation therapy

Focuses not only on message exchange but also on appropriate social communication skill, arguing, jokes, stories, gossiping, paralinguistic, nonlinguistic, contextual cues

Enhanced compensatory strategy training

Gesture, writing, asking for repeats, using augmentative aids, creativiy, generativity, and interactivity

Conversational coaching

Practice of communicative scenarios

Group therapy

→ ideal context for conversation therapy 

→ focus on interaction than practicing discrete skills

Scaffolded and supported conversations

→ follow communicative contributions rather than controlling or directing discourse

→ clinician expands and facilitates but avoids taking over

LIFE-PARTICIPATION APPROACH TO APHASIA (LPAA)

A consumer-driven service delivery approach that supports individuals with aphasia and others affected by it in achieving their immediate and long term life goals

Life concerns of those affected by aphasia is at the center of all decision making

FOCUSES ON

→ consequences of aphasia

→ reengagement in life

→ selection and participation in the recovery process

→ collaboration on the design of intervention

Considers dual function of communication

→ transmitting and receiving messages

→ establishing and maintaining social links

Focus on the real-life goals of people affected by aphasia

Initial stages = effective communication with nurses

Later stages = return to employment

LPAA CORE VALUES

• The explicit goal is enhancement of life participation

• All those affected by aphasia are entitles to service

• Measures of success include dociumented life-enhancement changes

• Both personal and environmental factors are targets of intervention

• Emphasis is on availability of services as needed at all stages of aphasia

ENVIRONMENTAL APPROACH

Takes into consideration the interrelatedness of individuals, communication abilities, effectiveness of communication partners to facilitate communication and physical and social environment

Goal: create a positive communication environment

→ access to communication

→ valued as meaningful communication partners

SCHEULL’S STIMULATION APPROACH

Employs the manipulation and control of stimulus dimensions to aid the px in making maximal responses

DESIGN OF INTERVENTION — STRUCTURE OF STIMULATION

VOLUME AND NOISE

DIMENSIONALITY, SIZE, COLOR, CONTEXT, AMBIGUITY, & OPERATIVITY

SIZE AND FORM

METHOD OF DELIVERY OF AUDITORY STIMULATION

DISCRIMINABILITY (SEMANTIC, AUDITORY, VISUAL)

COMBINING SENSORY MODALITIES

STIMULUS REPETITION

RATE AND PAUSE

LENGTH AND REDUNDANCY

CUES, PROMPTS, AND PRESTIMULATION

FREQUENCY AND MEANINGFULNESS

ABSTRACTNESS

VOLUME AND NOISE

Reducing noise > increasing volume

DIMENSIONALITY, SIZE, COLOR, CONTEXT, AMBIGUITY, & OPERATIVITY

→ use realistic stimuli

→ Potent visual stimuli appear to be characterized by 3-dimensionality:

• Color,

• redundant physical properties, 

• operability, 

• & lack of ambiguity

SIZE AND FORM

→ large print > small print 

→ consider preferences for uppercase, lowercase, cursive, manuscript

METHOD OF DELIVERY OF AUDITORY STIMULATION

→ direct presentation > earphones 

→ binaural stimulation > selective stimulation of one ear/hemisphere

DISCRIMINABILITY (SEMANTIC, AUDITORY, VISUAL)

→ more semantically related >> increased difficulty 

→ words with minimal phonemic differences (difficult) 

→ high-uncertainty pictures (more difficult) 

COMBINING SENSORY MODALITIES

 use of several modalities in combination is often recommended

STIMULUS REPETITION

→ repetition of stimuli subsequent to errors appear to increase adequate responses, with max benefits derived from 1st or 2nd rep

→ constraint-induced language therapy

RATE AND PAUSE

 slowing rate and lengthening pauses can have a facilitatory effect  

LENGTH AND REDUNDANCY

 reducing length and increasing redundancy facilitate comprehension

CUES, PROMPTS, AND PRESTIMULATION

→ even the mos widely used facilitators may not be effective for every patient 

→ analyses of the level of breakdown and px stimulability are important

FREQUENCY AND MEANINGFULNESS

→ decreased word frequency >> increased difficulty 

→ word frequency for individuals is determined by their unique experiences, needs, occupation, culture, & numerous other factors

→ objects/actions with emotional connotations & contextually relevant and related tasks are easier

ABSTRACTNESS

abstract words are more difficult than concrete words

PATTERNS OF AUDITORY DEFICIT

SLOW RISE TIME

NOISE BUILDUP

RETENTION DEFICIT

INFORMATION CAPACITY DEFICIT

INTERMITTENT AUDITORY IMPERCEPTION

SLOW RISE TIME

→ tend to miss initial portion and coprehend only last part 

→ use warning signals 

NOISE BUILDUP

→ tend to respond more accurately to initial portion and make more errors progressively 

→ more complex materials produce noise more rapidly 

→ use messages with gradually increasing length and complexity with gradually decreasing intervals of silence

RETENTION DEFICIT

→ deteriorate as length increases but not as susceptible to complexity factors; breakdowns occur at the same point regardless of complexity 

→ gradually increase message length

INFORMATION CAPACITY DEFICIT

→ difficulty receiving and processing information at the same time 

→ may be able to repeat the beginning and end but not the middle

INTERMITTENT AUDITORY IMPERCEPTION

Fades inand out randomly

CONSTRAINT INDUCED LANGUAGE THERAPY (CILT)

An intensive therapy model based on the forced use of verbal oral language as the sole channel of communication

Client is required to practice for several hours on a daily basis

CIILT KEY PRINCIPLES

Forced use of spoken language through the application of visual barriers

Constraint of other communication modalities (e.g., gestures, writing, circumlocution)

Massed practice in an enriched, therapeutic, and communicatively relevant environment

ERRORLESS LEARNING

People may remember their mistakes but not the correction

A person learns by saying or doing it, rather than being told or shown by someone

The person is not given the opportunit to make a mistake (i.e., no mistake to be remembered) by providing cues or support

Fillingham et al., 2010

→ errorful and errorless learning appear to be equally likely to produce a positive outcome

KEY PRINCIPLES

PROVIDING CORRECT ANSWER IMMEDIATELY

BACKWARD CHAINING (FOR MULTISTEP TASKS)

FORWARD CHAINING (FOR MULTISTEP TASKS)

COMBINED IMAGERY WITH ERORRLESS LEARNING

PROVIDING CORRECT ANSWER IMMEDIATELY

What is this person’s name? His name begins with M; his name is Michael”

BACKWARD CHAINING (FOR MULTISTEP TASKS)

Show all of the steps → all steps except las one → gradually withdraw prompts after each trial until all steps are learned

FORWARD CHAINING (FOR MULTISTEP TASKS)

Demonstrate the first step on the first trial → first 2 steps on the second trial → continue until whole sequence is remembered

COMBINED IMAGERY WITH ERORRLESS LEARNING

Associations between objects were taught by creating mental images