NV COnvention

Transcription

NV COnvention

4/24/2014
Aphasia-Apraxia Therapy:
Exploiting Neuroplasticity
Speech-Language & Audiology Canada
Orthophonie et Audiologie Canada
2014
Handout
“Traveling the Pathways of
Aphasia Recovery…”
…neural reconnect pathways
…aphasia recovery pathway
…life’s enduring pathway
“Life without passion is
unforgivable.” Sean John
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Aphasia Background
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Pitt 1974-75
RIT; NTID 1976
Private Practice 1976-current
PATREC 1999
UPMC 1999
aphasiatoolbox.com, The Aphasia Center of
Innovative Treatment, INC 2005• 30+ years
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aphasiatoolbox.com
The Aphasia Center of Innovative
Treatment, INC
William A. Connors, CCC-SLP
800 Vinial Street, B408
Pittsburgh, PA 15212
724.494.2534
[email protected]
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Mission Statement
Our vision is to educate, support and train
PWA, SLPs, and the public at large to act on
and believe in the endless possibilities of
recovery.
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Vision Statemnt
Help people with aphasia and the related
disorders of apraxia, alexia and agraphia
become pilots of their rehabilitation process
in order to maximize their recovery.
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Goals
• Internal Goals:
1. Define aphasia and related disorders in a
clinically useful ways
2. Present, demonstrate and be involved in
treatment concepts, ideas, techniques and tools
for innovative treatment and maximal recovery
3. Please: share ideas, questions, challenges,
and improvements (e.g., relate to
adolescents and young adults) * Ask Bill
Anything
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Objectives
1. Discuss aphasia and its related disorders
– A statement of the problem
– The pressing questions about aphasia treatment
– Evidence-based practice
– A clinically-useful visual definition of aphasia
2. Discuss specifics of exploiting neuroplasticity:
– General rehabilitation
– Communication disorders
– Evidence base
– Brain Compatible Aphasia Treatment
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–
Objectives
3. Present treatment ideas, materials and tools for an
aphasia treatment program designed to exploit
neuroplasticity:
– Philosophy – Materials – Protocols - Tools
– Software - Patient progress and recovery
– References for scientific support and underpinnings.
4. Relate these treatments to :
– Semantic-lexical impairment - Phonological
impairment
– Discourse impairment - Comprehension issues
– Cognitive skills that support speech and language
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– Acquired reading/writing problems
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Statement of the Problem:
More than 1.2 million (2 million?) people in the United
States and Canada, (Brody, 1992; NAA, 2011; the
Aphasia Institute, 2011) as well as millions more
throughout the world, continue to suffer with hoperobbing, independence-depriving effects of aphasia
despite millions of dollars spent on research,
treatment, and public awareness of the problem (Kelly,
2011, Stahl, 2011). The great majority of PWA and
their caregivers find this state of affairs unacceptable
(Worrall, 2011).
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What should SLPs do?
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12 Big Questions for Today:
• Can traditional, didactic treatment ever be
effective for acquired aphasia given what we are
learning about neuroplasticity (Master Clinician
Network, 2010; Rosenbek, 1976; Speech Therapy
on Video, 2006)?
• Is the cost-benefit ratio for monthly, intensive
aphasia treatment-monthly type programs value
added (Speechways, 2011)?
• What might smart treatment tools that take
advantage of neural plasticity look like (Hamilton,
2011)?
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• Why do at least 1.25 million residents of
Canada and the USA suffer from chronic
aphasia?
• Why do clinical trials fail to generalize?
• How do we do treatment with digital natives?
• What are the best practices and evidence for
turning people with aphasia into people
recovering from aphasia?
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• How do we best replace learned non-use, learned
non-attention and learned helplessness with
independently generated, propositional
communication (Connors, 2009-a; Kirkland, 2010;
Page 2012; Pulvermüller, 2008)?
• Does a rising cognition tide really lift all aphasia
boats? (Cho, 2008; Helm-Estabrooks, 2011-a)
• How can we best exploit neuroplasticity by making
every activity and the client’s daily routines truly
therapeutic? (Simmons-Mackie, 2009)
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• Why do we call “a rehabilitation plateau” or
“treatment plateau”- a “patient plateau” (HelmEstabrooks, 2010)?
• If you are doing a treatment activity or area of focus,
and you know it is clear it is helping the client, and is
essential for his/her recovery, yet there is not
research evidence, or there is conflicting or equivocal
evidence, is it ethical for you to withhold treatment?
• …and the big question of the day……?
• Can Worksheets grow dendrites? Make paper and
pencil activities truly therapeutic.
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What is aphasia?
“Aphasia is different for each person with aphasia,”
(Anguish, 1990). What is needed is a definition
that truly offers insight into and understanding of
aphasia and its related disorders. Typical printed
definitions are limited in their use for
understanding the complexities, synergies and
opportunities for aphasia recovery and treatment
specifics and lack of attention to the implications of
the cognitive underpinnings, (Vallila, 2013).
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National Aphasia Association
• Aphasia is an acquired communication
disorder that impairs a person's ability to
process language, but does not affect
intelligence. Aphasia impairs the ability to
speak and understand others, and most
people with aphasia experience difficulty
reading and writing.
• http://www.aphasia.org/Aphasia%20Facts/ap
hasia_faq.html
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What is aphasia?
What is needed is a definition that truly offers
insight into and understanding of aphasia and
its related disorders. Typical printed
definitions are limited in their use for
understanding the complexities, synergies and
opportunities for aphasia recovery and
treatment specifics, (Aphasia Institute, 2010;
NAA, 2012).
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Visual Definition of Aphasia
• http://www.aphasiaapps.com/visualdef1.html
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How have we failed these PWA?
• The treatment program has invested in approaches
that either don't work or are too slow in achieving
results, (Greener, 1998; 2000, Small, 2000)
• The treatment program lacks faith and gives up too
quickly on the patient.
• The treatment program blames the patient with
comments like, “You have reached a plateau,” (HelmEstabrooks, 2010, Rennhack, 2014).
• The treatment program fails to go beyond the clinical
evidence and research.
• The treatment program focuses treatment on data, not
mental processes.
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• The treatment program fails to collaborate causing the
patient to lack resources at discharge. (Martelli, 2012)
• The treatment program fails to recognize that aphasia is
different for everybody and therefore applies cookie-cutter
activities.
• The program fails to demand lots of client independent,
coached and peer practice (Kelly, 2011).
• The treatment program fails to provide for ongoing, selfhelp practice after discharge using innovative tools with
caregiver training.
• The treatment program fails to use innovative tools and
materials. It does not know what to do.
• The program fails to treat the whole person.
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• The treatment program relies on imitation and external
cueing. Imitation routine is a stagnant atrophy.
• The treatment program fails to revolve everything
around conversation .
• The treatment program fails to address the cognitive
underpinnings of speech (Helm-Estabrooks, 2009;
Mayer, 2006, Vallila, 2012).
• The treatment is not aggressive nor persistent.
• The treatment fails to use formative assessment
effectively, (CAPCSD, 2012; Connors, 2009)
• The program uses traditional materials and techniques
in telepractice (Connors, 2014).
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• The clinician becomes the frontal lobes of the
patient.
• “The prevailing paradigm for most rehabilitation
programs involves heavy queuing on the part of
the clinicians.” “…. The clinicians executive
functions and problem-solving skills….” do the
most work going treatment sessions.
Helms and Karow, Problem Solving Therapy
Program, 2010
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What is traditional aphasia
treatment?
Traditional aphasia therapy can be a nebulous term.
Although it has not been well defined, traditional therapy
is mentioned often in the literature. As early as 1979,
Rosenbeck (1979) questioned the popular ‘point to’
paradigm in terms of its effectiveness yet the technique
persists to this day. Its characteristics have been
described as relatively rigid and asymmetric with the
rigidity of structure limiting generalization to
conversation and discourse (Silvast, 1991; Wilcox & Davis,
1977). Marshall (1977) advised against the use of
structured aphasia treatment in the early post onset
period after a CVA.
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Traditional Treatment
• Depends on external cuing; encourages the clinician to
serve as the clients frontal lobes
• Overuse of responses using pointing; matching; initiating;
completing; copying
• Focuses on nouns and consonants - instead of verbs and
vowels
• Lacks use of formative assessment and a dynamic plan
• Treats naming, auditory comprehension; (HelmEstabrooks, (2010; 2011-a; 2011-b)
• Has a discharge date in mind
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Our job as part of EBP = extract the clinical and
intellectually useful information, knowledge
and tools from science and research to assist
the client in their pursuit of improvement
and/or recovery.
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EBP can come from many areas of study- published journal
reports, data that were collected in one area of science (or
social science) that are applicable to the case at hand, even an
SLP's own data collection. In spite of what many people believe, "evidence" is often
gleaned from an SLP's own caseload, and "trial-and-error"
methods are far from obsolete. Of course, we are treating
individuals, which is why generalized conclusions often do not
suit the bill. But my main point about research was that every
little piece of research, like a dot in a famous painting, simply
adds to the big picture, and should never be considered "the
big picture” itself.
(Dollahan, , 2004)
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Evidence based practice
• External Scientific Evidence
• Clinical expertise/Expert opinion
• Client/patient/caregiver perspectives
American Speech-Language-Hearing
Association, 2013 http://www.asha.org/members/ebp/
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What do people with aphasia and
apraxia really want?:
• Acute phase (Marshall, 1997)
• Intermediate phase (Berger, 2002)
• Chronic phase
• Cured
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What do people recovering from
aphasia and apraxia really want?
• To discuss politics with friends over coffee
• Read stories to their grandkids.
• Use normal technology: email; cell phone;
iPad; remote control
• Chat with their spouses about the day
• And in today’s new technology world, be
screen-literate such as video chatting with
their digitally-native grandkids
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What PWA do not want.
• PWA do not want someone talking for them.
• They don’t want to point to pictures.
• They don’t want a machine talking for them
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What was the old science on
neuroplasticity?
• Rita Marie Ryan
• Smoke a cigarete lose 50 brain cells> drink a
beer lose 100 brain cells
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What is neuroplasticity?:
The human brain’s ability to continually grow, learn and
recover is well documented (Gage, 2002; Hamilton,
2011; Scientific Magazine, 2007; The Franklin Institute,
2011). Despite these remarkable scientific advances,
insufficient attention has been given to developing
innovative tools and techniques to take optimal
advantage of neural plasticity in efficient ways in the
treatment of aphasia (Helm-Estabrooks, 2011; Kirkland,
2004; Robbins, 2011; Varley, 2011). We need to
identify and utilize activities that result in, “…relevant
neural activations…” and subsequent “…neural
strengthening…” (Pulvermüller, 2008).
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Neural plasticity is the ability of the central
nervous system (CNS) to change and adapt in
response to environmental cues, experience,
behavior, injury, or disease, (Ludlow, et al. 2008)
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Neuroplasticity can be defined as the ability of
the nervous system to respond to intrinsic or
extrinsic stimuli by reorganizing its structure,
function and connections. Major advances in
the understanding of neuroplasticity have to
date yielded few established interventions,
(Cramer, S. et al. Harnessing Neuroplasticity For
Clinical Applications, Brain, Vol 134, 2012
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Neuroplasticity occurs with many variations, in
many forms, and in many contexts. However,
common themes in plasticity that emerge across
diverse central nervous system conditions
include experience dependence, time sensitivity
and the importance of motivation and attention,
(Cramer S, et al, 2012)
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Neuroplasticity and Aphasia
Recovery
A fundamental principle underlying the research
discussed in this review is that the brain,
regardless of age, is flexible and capable of
change; that is, it has the capacity for structural
and functional plasticity throughout the human
life span. Plasticity underlies normal processes
such as development, learning, and maintaining
performance while aging, as well as response to
brain injury, ( Raymer, 2008)
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Neuroplasticity and Aphasia
Recovery
• The human brain’s ability to continually grow, learn
and recover is well documented (Gage, 2002;
Hamilton, 2011; Scientific Magazine, 2007
• Despite these remarkable scientific advances,
insufficient attention has been given to developing
innovative tools and techniques to take optimal
advantage of neural plasticity in efficient ways in
the treatment of aphasia (Helm-Estabrooks, 2011;
Kirkland, 2004; Robbins, 2011; Varley, 2011)
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How do we exploit neuroplasticity?
“This is the evidence of intuitive heuristics:
when faced with a difficult question, we often
answer an easier one instead, usually without
noticing the differences,” Daniel Kahneman,
Thinking Fast and Slow.
(heuristics: problem solving by trial and error)
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How to exploit neuroplasticity to
maximize aphasia recovery-BCAT:
1. Recognize and appreciate the existence and
potential of neuroplasticity and then make the
necessary mental and professional perceptual shift
, (Raymer, 2008, Saur, 2012).
2. Believe in and act on the endless possibilities of
recovery. Turn your client from a PWA to a PRA.
3. Commit to using activities that are truly therapeutic
for exploiting neuroplasticity. Fold in fluency early.
(Gonzales-Rothi, 2008).
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maximize aphasia recovery:
4. Help clients aggressively overcome learned nonuse, helplessness, non-attention. Demand
independent practice. (Klein, 2008; Leigh, 2013,
Pulvermüller, 2008).
5. Use many, many neural flows, known as repetitions
in traditional format. Neurons that fire together,
wire together. Use it or lose it (Kleim, 2008).
6. Keep the basics simple and the environment
complex. Only say what to do. Since processing is
the goal there are no mistakes. (Raymer, 2008).
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7. Ensure that the client aggressively assumes
responsibility for his/her recovery plan. Demand
intensive coached and independent practice
outside of the clinic. Train the coaches. (Connors,
2014)
8. A rising tide lifts all boats. Address multiple
cognitive-linguistic skills and make sure that the
client is working from his/her own memory.
9. Ensure hours of daily practice. The client who
“..know what the target is can practice
independently.” (Rvachew, 2012)
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10. Prime the client for treatment and recovery.
(Kahneman, 2011). Ensure metapraxia. Tell the
client only what to do. Reconnect (or teach)
keyboarding skills and screen literacy. Blink it.
(Gladwell, 2005)
11. Identify and utilize activities that result in,
“…relevant neural activations…” and subsequent
“…neural strengthening…”. . Focus on normal
mental processes. (Pulvermüller , 2008)
12. Revolve everything around conversational speech
facilitated by faith and rhythm, (Stahl, 2014)
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13.Use a Whole Person Recovery approach:
 Nutrition; exercise; rest; spiritual; meditation;
medication; social; occupational; emotional
 We’re in it to win it. Stay the course.
 Be knowledgeable about alternative treatments:
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Embrel injections-etanercept. (Tobinick, 2011)
EEG
TMS-Transcranial Magnetic Stimulation
Pharmacology-Piracetram; levodopa; bromochriptine;
(Small, 2004)
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Kleim and Jones, Principles of experience-dependent neural
plasticity: implications for rehabilitation after BI, JSHR 51 2008
• Use it or lose it. If you do not drive specific brain
functions, functional loss will occur.
• Use it and improve it. Therapy that drives cortical
function enhances that particular function.
• Specificity. The therapy you choose determines the
resultant plasticity and function.
• Repetition matters. Plasticity that results in functional
change requires repetition.
• Intensity matters. Induction of plasticity requires the
appropriate amount of intensity.
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Kleim and Jones, Principles of experience-dependent neural
plasticity: implications for rehabilitation after BI, JSHR 51 2008
• Time matters. Different forms of plasticity take place at
different times during therapy.
• Salience matters. It has to be important to the
individual.
• Age matters. Plasticity is easier in a younger brain, but
is also possible in an adult brain.
• Transference. Neuroplasticity, and the change in
function that results from one therapy, can augment
the attainment of similar behaviors.
• Interference. Plasticity in response to one experience
can interfere with the acquisition of other behaviors.
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Brain Compatible Aphasia
Treatment Program (BCAT)
BCAT is a treatment program for aphasia and
related disorders that consists of 15 different
treatment modules that utilize 75
treatment/practice protocols each of which is
supported by hundreds of exercises on a
dedicated website with accompanying software.
This evidence-based practice emanates from
external scientific evidence shaped by clinical
expertise and experience and is driven by the
consumers goals and perspectives.
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Brain Compatible Aphasia
Treatment Program (BCAT)
BCAT is not a collection of unrelated, fragmented,
research protocols and drills that pigeonhole
clients into a truncated, non-operational
treatment program whose outcome is datadriven and data-defined. BCAT springs directly
from the ASHA definition of evidence-based
speech/language pathology practice
(http://www.asha.org/members/ebp/, 2012 ).
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Use all modalities to help people
speak again (Pulvermueller, 2008)
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Screen literacy; keyboarding
Reading – alexia; writing – agraphia
Listening – auditory comprehension; sound processing
Interpersonal communication – pragmatics; intent;
discourse
Cognitive underpinnings – verbal working memory,
attention, mental resource allocation, flexible thinking,
problem solving, sequencing, cognitive flexibility
Non verbal – gestural, facial, body language
Motor problems
Be cautious about limiting modalities, (Rose, 2012)
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BCAT Flowchart
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SLP assesses PWA with focus on client goals and values
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Select treatment module
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Select protocol
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Select exercise
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Treatment session
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Assign home practice - aphasiatoolbox.com: applications; materials;
coaching; groups
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Formative Assessment of competencies
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Tweak exercise
Tweak Practice Tweak protocol
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BCAT Treatment Modules
• AphasiaPhonics Module for phonological elements of
aphasia and phonological working memory (Buchwald,
2004, Christy, 2006)
• The Cognitive Underpinnings Module for memory,
attention and mental resource allocation (Helm-Estabrok,
2011, 2012)
• Conjugation Module for sentence building, neural
pathway flows and verbal working memory
• Discourse Building for syntax reconnection,
conversational skills and cognitive flexibility
– Intent; Conversation; Narrative; Question answer and
generate
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• Flash Spelling Module for acquired alexia, agraphia,
screen literacy, visuospatial skills and visual working
memory
• Keyboarding Module for apraxia, hand-eye
coordination, visuospatial skills and screen literacy
• Morphing Module for prefixes, suffixes, and elements
of grammar
• Numeracy Program for cardinal and ordinal numbers
and everyday number concepts
• Module for referencing, sustained attention skills and
getting speech started
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• Pure Alexia for addressing acquired alexia,
agraphia with a focus on letter-by-letter
• Semantic Cognition Module for self-generated
word recall and comprehension, vocabulary
building and cognitive flexibility
• Verbing Module for verb recall fluency, sentence
building and alternating attention (Boo, 2010,
Faroqui-Shah, 2007,2008)
• The PACEmatics Module for pragmatics and
language In action
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• Prosody Module for sentence intonation,
word stress and phrasal timing (Hargrove,
2009)
• The Online Group Module for peer
engagement, practice and support (Chapey,
2008; NAA, 2012; Ross, 2010)
• Functional Goals Module
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AphasiaPhonics Treatment Module
Benefits of this module
• It helps the client to think in sounds.
• It helps the client to reconnect normal mental processes for
decoding and encoding.
• It improves the client’s ability to develop phoneme
sequence knowledge.
• It provides a platform to address phonological
buffer/working memory problems.
• It improves the client’s syllabification skills and ability to say
words with more than two syllables.
• It helps the client to take advantage of residual abilities
with the letter-sound relationship.
• it introduces prosodic skills into the treatment process.
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AphasiaPhonics Treatment Module
Module objectives
The client will be able to:
• explain the relationship between sounds and letters
and syllables and words.
• transcribe and spell individual consonants, vowels and
words using the keyboard and BCATPA
• say aloud, using working memory, 3 words that
increase in length from 1 to 3 syllables.
• incorporate semantic information into lexical decision
making.
• utilize word stress to vary meaning and intent.
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Recipe for Reconnecting
AphasiaPhonic Skills
• Reconnect syllabification skills
• Establish competency in the production,
recognition and phonetic transcription of
vowels
• Thread work done on flash spelling and
keyboarding throughout efforts to reconnect
aphasia phonics
• Emphasize the letter-sound relationship.
Phoneme < > grapheme conversion skills.
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• Utilize vowel closure spelling task. D_g;
H_ s_w h_m.
• Think it > say it > it say > type it > say it >
remember it.
• Advance into 2-3 and 4 syllable words.
• Reestablish syllabification skills.
• Blend with work on the morphing modules
focusing on root words plus prefixes/suffixes
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• Blend into semantic cognition activities
including rhyming, sounding out words,
irregular spelling, etc.
• Spell baby, spell. Improve spelling results in
improved speaking when worked together in a
coordinated plan.
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• Increasing Syllable Protocol
– Diagnostic
– Knowledge of syllable structure
– Combine with spelling
– Forward and backward
– Easy > more complex
– Advance to 1-2-3-4
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•
•
•
•
Lay
Please
Six
A
lady
pleasing
sixty
a man
ladybug
pleasingly
sixty one
Amanda
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AphasiaPhonics Module
• Syllabification, Aichert, 2010
• Phoneticizing – The client will be able to phonetically
transcribe (encode<>decode) 2-syllable words using the
aphasiatoolbox phonetic alphabet.
• Lettersounds
• Syllabification, Aichert, 2010
• Phoneticizing – The client will be able to phonetically
transcribe (encode<>decode) 2-syllable words using the
aphasiatoolbox phonetic alphabet.
• Lettersounds
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•
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VOWELS
/ EE / eat,
/ i/
it
/A/
ate, eight; /e/
ebb
/ ae /
at
/u/
us
/a/
ought
/O/
oat
/ OO / ooze;
/ oo /
put
Dipthongs
/ a EE / I, eye
/ u EE / oy!
/ a OO / owl
/ EE OO / you, U, ewe
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•
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Oral Reading Treatment (ORT)
Copy and Recall Treatment (CART)
• http://www.aphasia.webhost.uits.arizona.edu
/sites/default/files/BeesonRisingASHA2011_H
andouts.pdf
• http://www.clinicalaphasiology.org/2004_pdf/
Orjada%20_CAC_poster.pdf
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Oral Reading Treatment (ORT)
• SLP read sentence aloud pointing to each word
• Patient and SLP read sentence aloud pointing to each
word
• Patient and SLP read sentence aloud pointing to each
word:
– Correct errors on-line
– Repeat until mastered
Home practice = yes
Generalization = yes
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Copy each word 3-5 times
Write words from memory
Check spelling and make corrections
Repeat procedure until recall without error
Home practice = yes; home based
Generalization = yes
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Phoneme Based Rehabilitation of
Anomia in Aphasia, Kendall, 2008
• Form concepts of phonemes (Lindamood)
• Master recognizing, distinguishing and
manipulating phonemes in words and
nonwords.
• > isolation > CV / VC > CVC / VCC / CCV > 2 and
3 syllable words
• Home practice - No ; all in clinic
• Generalization = yes
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Treatment of Phonological Output,
Peach, 1996
• Printed word to read aloud presented
• If error > write the word (increased salience)
• Cue failed > pair with another consistent word
with target phoneme in initial position
• Imitation when other cues failed this provided
a direct auditory model)
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Conjugation Treatment Module
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It helps the client to generate rhythmic, neural flows.
It helps the client to re-familiarize canonical sentences.
It reconnects the client’s use of subjective pronouns.
It facilitates initiation skills.
It assists in reconnecting verb recall and production.
It helps the client improve working memory and
sustained and alternating attention skills.
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Conjugation Treatment Module
Module objectives
• The client will be able to:
• Using verbal working memory and alternating
attention fluently generate SVO sentences in
conjugated sequence.
• Expand conjugated sentence by R branching.
• Expand conjugated sentence by L branching.
• Expand conjugated sentences by varied R
branching.
• Reverse word order conjugate questions.
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Conjugation
• Subjective pronouns ( later-objective;
possessive; interrogative; in determinates)
• Conjugate SP + V > Canonical > R branching
• Modaling: basic SP+M > R branch S+M+V
• Reverse word order conjugation
• Add Objective Pronoun: I know me. I know
you. etc. (like;love;see;saw;sat;helped)
• >> Pronouned chiasmus.
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Discourse Building Treatment Module
• It helps the client to engage in conversation.
• It reconnects the client’s ability to ask,
answer and clarify questions.
• It assists the client in appreciating and utilizing
communicative intent.
• It assists the client in utilizing inferencing in
communicative interaction.
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Discourse Building Treatment Module
Module objectives
• Engage in conversation.
• Identify intent and say and type a sentence
using that intent on a sentence.
• Generate an inference given a situational,
semantic context.
• Produce a short narrative speaking and
typing.
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“My experience has been that no amount of
imitation, singing, matching items, good
intentions, pointing to pictures, playing with
apps, completing sentences, confrontation
naming, or repetition will maximize a PWA's
recovery toward independently generated,
propositional conversational speech. “
Bill Connors
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Sentence Patterning
I asked a question>> the client answers it
scaffolding by my words.
Do you eat? > “ I eat.”
Do you like dinner? > “ I like dinner.”
Did Bob eat? > “He ate.”
Do you like coffee or tea? > “ I like coffee.”
How do you feel? > “I feel fine?”
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Sentence Patterning
• Q & A format.
• Facilitate less contrived and more real
conversational feel.
• Encourage coaches and family to do this in
real situations.
• Achieve a rhythm and flow in cumulative
practice. Q>A>Q>A>Q>A
76
Discourse
• Supported Conversation: PACE; Marshall:
Scripting; SC
• Narrative
• Intent: Say What you mean; Inferencing;
Reading the Newspaper;
• Question skills (exp-rec): Interrogative Color
Coded;
• Protocols:
77
Promoting Aphasics
Communicative Effectiveness
PACE therapy: Four key components
1. New Information
2. Open modality use
3. Take turns
4. Feedback on effectiveness not manner
• Davis, 1981
78
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cepcepting Module
• Reconnect interrogative pronouns:
– Who; what; when; where; why; how
– Add: which; how many; how much;
• Speaker’s Intent Protocol
– Say or type the question intent of a speaker's
utterance.
– Say or type the question intent of a speaker's
utterance then give the answer.
– Great for group work
79
2.2 DI - Questions: Speaker's Intent
•
•
•
•
•
•
•
•
•
How old are you? >
“number”
Where do you live? ?
“address”
Do you have children? >
“yes or no”
What is your middle name? >
“ a name”
Do you prefer tea or coffee? > “either /or”
How many cars do you own? > “a number”
Why are we working together? > “reason”
What time did you eat breakfast? > “a time”
Who is your favorite friend? >
“a name”
Return to productivity
Work
College
High School
Volunteer
Start a business
Aphasiatoolbox.com, 2014, Armstrong, 2013,
AARP, 2013
81
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Morphing Treatment Module
• It helps the client reconnect semantic-syntactic
awareness and knowledge of morphological
concepts.
• It helps the client use prefixes and suffixes in
recovering speech, language and conversation
skills.
• It improves the client’s syllabification and
unstressed syllable production skills.
• It assists the client’s semantic specification
skills.
82
Morphing Treatment Module
Module objectives
• say aloud, using working memory, 3 words
that increase in length, based on morphosyntactic elements, from 1 to 3 syllables.
• identify the semantic variants of
morphological elements.
• say morphologically marked words with
appropriate stress patterns.
83
Morphing
• Reconnecting clients ability to inflect root
words.
• Morph Increasing Syllables
• Phoneticize
• Heteronyms-intonation morphing; (words;
phrasals)
• Distal and internal constructs
Nault, 2009
84
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Helm-Elicited Language Program
for Syntax Stimulation (HELPS
•
•
•
•
•
•
•
•
•
•
•
Imperative – Sit down
Imperative Transitive – Mow the lawn.
WH interrogative - Where is my car?
Declarative transitive – I drink coffee. (canonical)
Declarative intransitive – I sit.
Comparative – This is harder.
Passive – He was hit by me.
Yes/no question - Is it here?
Direct and indirect objects – She served Bob dinner.
Embedded sentences – I want you to be safe.
Future - I will drink coffee.
85
BCAT Sentence Type Hierarchy
• Canonical
– Present>past>future>present continuous>modals
•
•
•
•
Intransitives
Reverse question asking
Imperatives
Complex-compound
– Subjects or verbs or object phrases
– Sentences
86
Thompson's treatment of
underlying forms
1. Train comprehension of underlying form
focusing on argument structure-Given forms
on cards identify-point to work cards for the
action? “Hugs”
2. Move words or phrases to form a target
sentence given words-move cards to form “I
it was the boy who the girl hugs. ”
3. Produce the target sentence by reading-”It
was the boy the girl hugged.”
87
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Verb networked strengthening (VNeST)
1. Verb networked strengthening (VNeST)
2. Generate three pairs of agents and themes for a given
verb-who can measure? And what can be measured?Carpenter Chef Taylor would sugar cloth
3. Answer 12 WH questions about one agent theme pairwhere does a chef measure sugar?-In the kitchen
4. Make judgments about goodness of fit of agents and
themes and 12 sentences-the sugar measures the chefinappropriate reversed thematic rolls
5. Generate three pairs of agents and themes for a given
verb-who can measure? What can be measured?-Cup
Carpenter Chef Taylor would sugar clock
(Edmonds, L, 2011)
88
Numeracy Treatment Module
• It helps the client to reconnect the ability to use numbers
and number concepts in everyday life.
• It helps the client to improve his/her ability to type digits
and spell the names of numbers.
• It helps the client to identify and incorporate number
concepts into communication.
• Performance objective - The client will be able to:
• identify a number concept
• type from memory the digit and spell the number of a
numerical concept.
• use a finger count to represent a number concept.
• use numbers in everyday conversation and communication.
89
Numeracy
•
•
•
•
•
Combine with Limb Apraxia activities.
Number Concept Coaching: phoneticize; spell;
Supported conversation; PACE;
Longer numbers
Apps; websites
90
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Pronouns Treatment Module
• It will help the client get started.
• It will help he client improve pronoun usage and
comprehension.
• It will help the client initiate speech and sentences.
• It will help the client utilize referencing and narrative
cohesiveness to discourse.
• It will refamiliarize the client with canonical sentence
structure.
• It will help the client reconnect elements of gender,
number and morphological markers.
• It will help the client to understand and ask questions 57
91
Pronouns Treatment Module
Module objectives
• identify subjective, objective, possessive,
interrogative and indefinites pronouns.
• say and type from memory these pronouns.
• say and type the pronoun given the
corresponding concept.
• clarify ambiguous comments or questions using
interrogative.
• say and type a pronoun for a preceding person,
place, thing or concept.
92
Recipe for Reconnecting Pronouns
1. Begin work on vowels
2. Start with Subjective: I you he she it we you they
– Say and type in sequence from memory
– Add concepts: PPC; anaphors
– Add to conjugation
– Later add indeterminate: this that these those
3. Add objective: me you him her it us you them
– As above
– Add to conjugation; : advanced referential work; anaphors
– Add to pronouned canonical sentence work (like show love
hate see saw found lost hold held dress dressed dress help
hinder carried supported move encouraged drove transport
seated hug kiss tell told annoy)
93
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Recipe for Reconnecting Pronouns
4. Add possessive: my your his her its our your their
– Add concepts: advanced referential work; anaphors
– Add to pronouned canonical sentence work
5. Add indefinites: someone; somebody; anyone; everyone;
6. Add question pronouns: who what when where why how
– Add concepts: PPC; Headlining
– Add to pronouned canonical sentence work
– Add to the paragraph level of use:
94
Pronouns
• Subjective>objective >possessive> indeterminates
• Subjective pronouns; Personalized Pronoun Concept
coaching
• Referencing: basic forward; catapors ( Because _ _ , Bob ate
dinner.)
• Question words: speaker’s intent;
• Canonical Sentence work:
• Chiasmus:I like him. > He likes me.
• She sees them. > They see her.
• Verbs: Greet; Meet; see; saw; hit; kiss; want; See; hit; kiss;
miss; want; love; know; knew
95
Pronouns-Fill-in
When Bob proposed to Rose, _ _ _ excited and accepted
_ _ _ proposal. _ _ _ _ began to make plans for _ _ _
_ _ wedding. _ _ _ called her mother and Bob called
_ _ _ father. His father asked, “_ _ _ _ _ will the event
take place?”
_ _ _ _ held hands and promised
_ _ _ _ _ _ eternal love.
I have a sister. _ _ sister is a dentist. _ _ _ practice is
in Boston and I visit
_ _ _ often. She treats _ _ _
staff well and expects much from _ _ _ _ . I told her, "_
am proud of you for the way you treat _ _ _ _ staff
and patients. " She asked, _ _ _ _ are you coming back
again.”
96
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Semantic Cognition Treatment Module
• It will help the client to improve fluent and divergent
word recall.
• It will facilitate use of normal prosody in word and
sentence production.
• It will help the client with semantic specification.
• It will improve fluent sentence production.
• The client will acquire metacognition of the lemma
activation and use.
97
Semantic Cognition Treatment Module
Module objectives
• say and type words that represent various
meaning of a given word.
• vary word stress and prosodic features to change
word meaning and form.
• make accurate lexical decisions differentiating
real from non-words.
• The client will be able to activate a lemma;
decide if she can activate the
lexeme/grapheme/gesteme; utilize available
neural pathway
98
Semantic Cognition
• Protocols: Lighting Up the Lemma; Multiple
Meanings; Heteronyms (prosody);
• Apps; Websites: Hinky Pinks;
• Semantic Webs
• Semantic Scaling:
• Semantic Figure Ground
99
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Semantic Figure Ground
• Present to client a photo or image of a canonical nature
(subject- verb- object; agent-action-argument)
• Have the client specify the 3 elements (point to; circle;
underline; highlight; say)
• Have the client say and then type each element in a
canonical sentence.
• Relate this ( metaphasia) for lexical- semantic- syntactic
issues and elements.
• Use formative assessment to grow this activity: use more
complex visual images ( more agents and actions); use
semantically equal elements ( a dog and cat sleeping with
each other)
100
Semantic Figure Ground
• Given a photograph of a simple scene, D will be able to select
and focus on a semantic figure and communicate that to the
therapist.
• FA - Increase the visual complexity of the photograph
– Increase the semantic complexity of the photograph
– Present a photograph with a number of different scenes.
• For scaffolding purposeless, discuss or suggest.
• To add work on cognitive skills, present the image for a limited
time. Scaffold by re- exposing the image but make client work
from memory. ( visual processing; orthographic decoding;
working memory).
Wambaugh, 2013
Semantic Scaling
1. Present two words that are exemplars of a semantic
category yet differ significantly in terms of quality, quantity
or characteristics.
2. Have the client say and then type exemplars that meaning
wise fall between the two.
1.
2.
3.
4.
5.
6.
Hot
.
.
.
.
Cold
1. First
2. .
3. .
4. .
5. .
6. . SIxth
102
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Sematic Scaling
•
•
•
•
•
•
•
•
First- last (second, third, etc. , next)
Hot-cold (warm, tepid, luke-warm, cool)
Young-old (middle-aged, )
Beginning-end (middle)
Light-dark (medium ?? ?? ??
Morning-night (afternoon, evening)
Near –far ( close, next to, distance)
Never-always (seldom, sometimes, often)
103
Semantic Feature Analysis (Boyle)
• Offers tremendous value and potential for
word finding practice.
• Concern relative to generalization has been
addressed.
“ Treatment using SFA resulted in improved naming of
treated typical and atypical responses…. Training in a
mediated strategy also resulted in improved retrieval of
experimental words. Regardless of intervention approach,
generalization to untreated items was limited. Wambaugh,
2012 (a)
Group SFA ideas: Antonucci, 2009
104
Treatment of proper name retrieval deficits in an
individual with temporal lobe epilepsy
• Offered by RA massed practice 2 hrs / day for 5 days.
• Stimuli presented on a computer.
• Can you name this person? > Respond only if
confident. > response or not >
• RA gave semantic features > 2 other pictures of
target > RA gave # of syllables + first phoneme > RA
gave total # of sounds in 1st and last name > RA gave
printed name > client wrote name 3 times then
repeated the name 3 times with print in view.
Minkina, 2012
105
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Constraint-Induced Aphasia Therapy
There may be times to limit/constraint modality
interactions during word recall and verbal
production, but there are significant limitations.
The art of aphasia treatment is to know when.
“together, these data suggest that constraint
treatments and multi modality treatments are
equally efficacious, and there is limited support
for constraining client responses to the spoken
modality. Rose, 2012
106
Verbing Treatment Module
• It will help the client reconnect his/her ability to produce and
comprehend verbs while reconnecting the semanticphonological-motor centers in the brain.
• It will refamiliarize the client with the canonical sentence
structure and fill the verb grammatical slot.
• It will help to facilitate sentence flows by facilitating the
argument and right branching
• rhythmically and fluently say and type a verb given a
corresponding argument/object.
• offer alternative verbs for concepts and arguments and fluently
say conjugated canonical sentences given a specific verb.
• say and type a verb to fill a grammatical slot.
• incorporate prepositions into phrasal verb forms.
• use prosody to modify sentence meaning and intent.
107
Recipe for Reconnecting Verbing and
Sentence Formulation
1. Be able to activate, say then type an
argument:
2. Be sure to address pronouns and
conjugation.
3. Gain competence in canonical construct and
usage. Know how to fill the grammar slots.
4. Build verbal working memory and attention
5. Coordinate with discourse work.
108
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6.1 DI Canonical Sentence Framework
• Behavioral Objective:
• S – when shown a photo, will identify the Subject – Verb –
Object slots, and then say a full canonical sentence.
Mental Processes:
• Increased awareness of semantic-syntactic elements of
sentences, grammar, sentence and question generation;
lexical access; "lighting up" a lexeme; aphasiaphonics;
grapheme to phoneme mental conversion; lexeme activation;
lexical to semantic area interaction; reading; verification
strategy.
• Baseline: Feb 2012
Disambiguating Sentences Protocol
• Present to client a canonical sentence with ambiguous meanings. (Bob
beat his boxing opponent.)
• Have the client discuss 2 (or more) possible meanings for the sentence).
• Have the client say and then type each meaning in a canonical sentence.
• Relate to ( metaphasia) lexical- semantic- syntactic issues and elements
relative to multiple meanings.
• Use formative assessment to grow this activity: use more complex
sentences; use newspaper headlines.
• For scaffolding purposeless, discuss or suggest verb or word alternative
meanings.
• To add work on cognitive skills, present the sentence for a limited time.
Scaffold by re- exposing the sentence but make client work from
memory. ( visual processing; orthographic decoding; working memory).
110
Canonacalizing Complex Sentences
• Present to client a complex sentence with 3
key semantic-syntactic elements in temporal
order: Bob cooked, then he ate dinner and
cleaned the table.
• Have the client specify the 3 elements (point
to; underline; highlight; say): cook, eat, clean
• Have the client say and then type each
element in a canonical sentence.
• Relate this (metaphasia) to narration, story
telling, giving directions.
111
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Canonacalizing Complex Sentences
• Use formative assessment to grow this activity: mixed
temporal order ( Before Bob ate and cleaned the table, he
cooked dinner.); use more sophisticated conjunctions and
constructs (Because he [anaphor] cooked dinner early,
Bob was able to eat early and clean up leisurely. For
scaffolding purposeless, this can be made into a sentence
anagram task using tile or cards for manual sequencing.
• To add work on cognitive skills, present the complex
sentence only aloud (auditory processing; verbal working
memory) or only flash the printed sentence ( visual
processing; orthographic decoding; working memory).
112
Verbing
• Traditional: Verb Network Strengthening (memory
structure-verb heard or read>genralized situational
knowledge activated) generate specific explicit
thematic roles to verb network representing relevant
event schemas[chef-sugar; carpentar-lumber+wh?];
HELPPS; Thomkins and Shapiro;
• Verbing: Arguments; Mental State Verbs; Irregular
Past Tense;
• Phrasal Verbs (sneaking up on prepositions): Phrasal
Nerbing;
113
Response elaboration training (RET)
• This is a loose training procedure that attempts to
approximate natural conditions. The clinical process
then revolves around the client self generated
productions ( contrast with didactic targeting a desired
response.
• Use pictures with minimal contacts to promote a patient
presenting a topic independently > use this as a starting
point > help the client expand on the utterance using
reinforcement; modeling; additional prompts; and
forward changing.
(Kearns, 1985)
114
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Modified response elaboration training:
application to procedural discourse and
personal recounts (M-RET)
• Applied RET to procedural discourse and personal
recounts rather than narrative discourse.
• SLP facilitates an initial production “ Tell me in detail
how you would go about……”(PD); “tell me
something about anything that you would like to talk
about.” (PR) > SLP reinforces and facilitates
elaboration on the response. > SLP reinforces and
then combines the responses to create a lengthier
response. > client practices the new response.
Wambaugh, 2012 (b)
115
Cognitive Skills Support Treatment
Module
• It will improve the client’s cognitive skills
•
•
•
•
•
•
•
•
Working memory
Attention: focused; sustained; alternating
Cognitive flexibility
Reasoning
Problem solving
Mental resource allocation
Generative ideas and word flow
Inferencing
116
Non-linguistic learning in individuals with Aphasia:
effects of training method and stimulus characteristics
“Although aphasia is a deficit that is characterized
primarily by impairments and language, an increasing
body of research has recently been dedicated to
understanding the contribution of cognitive deficits of
attention, concept knowledge, executive function, and
memory on language construction, use in rehabilitation
in people with aphasia.”
For that matter, “Researchers have identified learning
ability as a central factor in rehabilitation…”
Vallila-Rother, 2013
117
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Cognitive Skill Support
•
•
•
•
Everyday attention examples: van light; ??
Thread through all activities
Traditional: Solberg and Mateer; Helms new book;
Verbal Working Memory and Attention Training;
Alternating numbers;
• Aphasia Sight Reader: Reading the Newspaper;
Stroop; Rock, Paper, Scissors; Disambiguate;
Orientation; Pronoun Cataphors;
• Apps, websites: Brain Party; Stroop; Luminosity
118
1.2 CS – Verbal Working Memory
• S will say aloud a sentence with the words in
varying order based upon a command that
requires changing word order:
• Put the sentence in alphabetical order;
• Put the sentence in reverse alphabetical order;
• Say the sentence in reverse word order.
• Say the words in order of word letter length.
• Say every other word.
(Sohlberg and Mateer, 2001)
1.3 CS - Cards – Yes - No
• Activity: cards-yes-no
• Behavioral Objective:
• Given a deck of cards turned over one at a time, the client will say :
• 1. “yes” when the coach turns over one of three specified cards ( jack, 7 ;
3 = YES);
• 2. “no” when any other number or picture card is turned
over (1,2,4,5,6,8,9,10, queen, king = NO); and
• 3. “maybe” when the back of a card or a joker is displayed (joker =
MAYBE).
• Modify: increase # of cards; vary according to suit;
• Mental Processes:
• Focused, sustained and alternating attention; verbal working
memory; narrative; number recognition; visual processing and
attention; task focus task shift; cognitive flexibility.
• Date/Baseline: September 2011
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My Advice to PWA
•
•
•
•
Become the pilot of your own recovery.
It does not matter how long ago you had your stroke.
It is about faith and rhythm.
A rising tide lifts all boats. Fix everything you can and
learn and do new things and skills.
• Find something you want to do better than before your
stroke.
• Practice requires thousands of neural flows but it must
be smart practice. Allow no busy work or detrimental
drills in your treatment or recovery programs.
121
My Advice to PWA
• Work from your own memory. Cut the therapy
umbilical cord. Act as your own frontal lobe. NO
IMITATION.
• Know where to put your attention, act on that then
move to the next area of focus.
• The better you spell the better you will talk.
Reconnect your keyboarding, reconnect your spelling
skills and normalize your ability to use screens.
• When we improve your cognitive skills like memory,
attention and cognitive flexibility your aphasia gets
better.
122
My Advice to PWA
• Keep simple yet aggressive and innovative recovery
program.
• Be aggressive and tenacious doing only smart
therapy that truly exploits your neuroplasticity and
reconnects your speech and language.
• Join a support group for support and engagement
and an conversation-treatment group for aggressive
progress.
• Never,ever ever give up. If someone talks about an
aphasia plateau, don't walk away, RUN AWAY
123
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PPA
My husband, age 73, was diagnosed last year at
Mayo Clinic with PPA. However, they did not
recommend any speech or other therapy. I have
noticed a worsening of his ability to remember
& say words as well as his ability to
comprehend. We live in Western PA.
I would like to help him but I don't know how.
Can you help us? Any help you could give would
be greatly appreciated.
124
Session 2:
• The second pressing clinical question for the
treatment of apraxia and related disorders
(abulia: asymbolia; etc.): how can we offer
clinical management that truly takes
advantage of neural plasticity and most
efficiently maximizes patient recovery of the
motor aspects of communication skills?
• Just treating symptoms of ATAS does not
exploit neuroplasticity.
125
Aphasia Background
• Basketball Team, University of Pittsburgh,
1965-55
• National Technical Institute for the Deaf, 1976,
basketball coach and ASL
• Boxing training and coaching
• aphasiatoolbox.com 2005- current
• 38+ years experience in aphasia therpay
126
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Objectives
1. Discuss acquired apraxia and related disorders
– A statement of the problem
– Defining acquired apraxia for clinical purposes
2. Treatment philosophy and rationale while keeping
in mind the optimal exploitation of neural plasticity
Present traditional treatment programs
a. VAT
b. 8 Step Continuum
c. Integral Stimulation - Watch, listen, imitate
d. Interactive
127
Objectives
3. Discuss the treatment modules the Motor Reconnect
Apraxia Program (MRAP) and keyboarding, alexia and
agraphia
– The Viking
– Keyboarding> Flash spelling >Propositional Spelling
4. Discuss problems that may coexist or accompany the
apraxia that affects movement of articulators; vocal folds
and limbs
– Asymbolia
-Abulia
– Keyboard agnosia
-Initiation impairment
– Ataxic dysarthria
128
Objectives
5. Alexia and agraphia:
Discuss nature of acquired alexia and agraphia.
Discuss traditional programs.
Present techniques and tools for the treatment
and practice for:
keyboard agnosia
keyboarding skills
flash spelling
propositional spelling
129
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4/24/2014
More than 1.2 million (2 million?) people in the United
States and Canada, (Brody, 1992; NAA, 2011; the Aphasia
Institute, 2011) as well as millions more throughout the
world, continue to suffer with hope-robbing,
independence-depriving effects of aphasia despite
millions of dollars spent on research, treatment, and
public awareness of the problem (Kelly, 2011).
Many of these PWA experience impairment in the motor
skills of planning and execution of movement patterns
necessary for speech production. In this author’s
experience, this condition is always accompanied by a
significant phonological aphasia.
130
Session 1
131
What do people recovering from aphasia
and apraxia really want?
• To discuss politics with friends over coffee
• Read stories to their grandkids.
• Use normal technology: email; cell phone;
iPad; remote control
• Chat with their spouses about the day
• And in today’s new technology world, be
screen-literate such as video chatting with
their digitally-native grandkids
132
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What PWA do not want.
• People Talking for them
• Machines talking for them
• Pointing
133
The pressing clinical question for the treatment
of apraxia and related disorders: How can
we offer clinical management that truly takes
advantage of neural plasticity and most
efficiently and effectively maximizes patient
recovery of motor skill? How do we best turn
people with apraxia affecting speech (AAS)
into people recovering from apraxia?
134
Motor Problems
•
•
•
•
Apraxia that affects speech
Apaxia that affects other body movements
Agraphia and alexia
As time permits:
– Dyarthria
– Ataxia
– Abulia
– Asymbolia
– Telepractice
135
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What is apraxia?
“Aphasia (apraxia) is different for each person with
aphasia,” (Anguish, 1990). What is needed is a
definition that truly offers insight into and
understanding of acquired apraxia and its related
disorders. Typical printed definitions are limited in
their use for understanding the complexities,
synergies and opportunities for apraxia recovery
and treatment specifics, (Aphasia Institute, 2010;
NAA, 2012).
• The Visual Definition of Aphasia and Apraxia
(www.aphasiatoolbox.com )
136
What is Apraxia?
• We are not teaching the acquisition of a new
language or motor skill in an unsophisticated
context in which repetition plays a key role
(Corrigan, 1980; Strand, 2005).
• Since we are working on reconnecting the
neural pathways for a process that generates
speech and language, we need to facilitate
thousands of self-generated neural flows.
137
What is Apraxia?
“The problem in the relation of brain structure
to function is that we think of function as
active and dynamic and structure as fixed and
stable. The result is that mental activity is
artificially stabilized in compartments that can
be localized,…”
“…what is needed is an enlivened concept of
structure in terms of process,” (Brown, 2003)
138
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Overview
Where we stand in our profession on apraxia of
speech (AOS)
139
Darley, 2005
“..phonetic-motoric disorder of speech
production caused by inefficiencies in the
translation of well-formed and filled
phonological frame to previously learned
kinematic parameters assembled for
carrying out the intended movement,
resulting in intra-and interarticulator
temporal and spatial segmental and
prosodic distortions.’
140
Darley translated
Speech problem caused by a mental
difficulty in turning an accurate
lexeme into an efficient and effective
motor plan resulting in impaired
articulation and prosody.
141
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Acquired apraxia that affects speech
• a poor or inability to produce previously
learned skilled motor actions
Acquired apraxia that affects speech
• a poor or inability to produce previously
learned skilled motor actions due to motor
planning that fails to utilize well-formed
phonological representations.
142
What does apraxia that affects
speech look and sound like?
• Kendall and others, Influence of intensive
phono motor rehabilitation on apraxia of
speech, Journal of Rehabilitation Research and
Development, volume 43, 2006
143
What does apraxia that affects
speech look and sound like?
1.
difficulty in articulatory aspects of speech:
substitutions, distortions, distorted substitutions,
repetitions
2. Difficulty in rate and prosody aspects of speech:
slow utterances, prolonged consonants and vowels,
silent pauses, equalized stress, restricted pitch
3. Difficulty in fluency aspects of speech: false starts,
restart, visible and audible trial-and-error groping,
sound and syllable repetitions
144
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Good and bad news
• Experienced SLPs experienced difficulty in
diagnosing and differently diagnosing apraxia
of speech when compared to instrumental
measures.
Smith, A. ed., Apraxia of Speech: Concepts and
Contrversies, ASHA, 2012
145
3 perspectives on apraxia that
affects speech:
1. Disconnection: the mental phonological
representations of the words are retained but
they'd cannot be be translated into movement
patterns for speech output. "I know what I
want to say (and can hear it) but cannot speak
it.”
Smith, A. ed., Apraxia of Speech: Concepts and
Contrversies, ASHA, 2012
146
affects speech:
2. Motor memory: a corruption of the
knowledge of the acquired and stored
procedural knowledge of each word of a
language is generated by appropriate
movements of the articulators.
147
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affects speech:
3. Fine motor skills: this emphasizes the high
fine motor coordination demands required for
speaking. Moves the syndrome from a motor
programming problem more toward issues
with the execution of movements in light of
the fine motor requirements for connected
speech output.
148
Traditional treatment for AOS
seems to fall into 3 categories:
• 1. Articulatory positioning:
interval simulation, repeated
practice, articulatory placement
cuing, sound-contrast practice,
oral muscular phonetic-target
restructuring prompts.
149
Traditional treatment for AOS
seems to fall into 3 categories:
• 2. prosodic metronomic pacing,
finger tapping, contrastive stress
• 3. Augmentative: gestures,
writing, computerized systems,
communication boards
150
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These have in common?
They seem to spring from treatment models
that address the symptoms of the impairment
rather that the underlying mental processes
that cause the symptoms. We need to treat
and work with the symptoms and movements
but that does not preclude working on the
mental processes that produce the
movements.
151
Diagnosing apraxia that affects speech
• Does it matter?
• How accurate are clinical, non-instrumental
assessments?
• How does it differ from phonological aphasia?
• Are there different types of apraxia that affect
speech?
• What else does the apraxia affect?
• Does a rising apraxia recovery lift all boats?
152
Important read
• Anne Smith, editor, Apraxia of Speech:concepts and
Controversies, ASHA, 2012
• 100 pages > 1 on clinical opportunities
• Definitely not a field manual
How do we treat ATAS/AOS?
• There just is very little out there.
• There is very little empirical studies that can help
clinicians get the job done.
• Recent ASHA book
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Constantly…
Know > think > plan >
do > feel-hear >
REMEMBER
154
This is about …
• THIS IS ABOUT….reconnecting - not learning
• THINK…. gestures-not sounds
• ADDRESS…. vowels-consonants only if needed
• WORK IN…. syllables – later sentences
155
Recipe for Reconnecting Praxis Skills
1. Begin by reconnecting separate neural
controls for the vocal folds/laryngeal
musculature and the jaw/tongue.
a.
b.
c.
d.
The Viking Basic
Metapraxia: VDOAA;
Know-plan-do-feel-REMEMBER
Scatpraxia
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2. Focus on Fine Motor Control of the vocal
folds and laryngeal musculature
a.
b.
c.
d.
The Intoned Viking
Heteronyms
Sentence Intonation Patterning
3. Lettersounds
157
4. Address effects of apraxia on limbs; fingers;
yes/no-head;
a.
b.
c.
d.
e.
f.
Yes-no-delicious
Keyboarding Module
Morra
Visual Action Therapy
Physical Training for Life
158
5. Address aysmbolia or abulia;
a.
b.
c.
d.
Pragmatics
Metacognition
Sentence Intonation Patterning
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6. Blend in work on aphasia and the BCAT
program
a. Aphasiaphonics: vowels; unsressed syllables;
increasing syllables
b. Heteronyms
c. Know-plan-do-feel-REMEMBER
d. Sentence Intonation Patterning; Sentence
Patterining
160
7. Blend in work on aprosodia
a. Viking with an atitude
b. aphasiaphonics: vowels; unsressed syllables;
increasing syllables
c. Heteronyms
d. Sentence Intonation Patterning
e. Multisyllabic work (Hugg)
161
MRAP module steps
–Metapraxia – concepts of MRAP and
motor planning and execution.
Overcoming learned non-use. Paying
attention and appreciating progress
and mistakes. Feeling/hearing and
processing. Work from your own
memory and generate movements.
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MRAP module steps
–The basic Viking – pulsing syllables
(Max, 2011; Society for Neuroscience,
2007)
• Modeled
• Independent on request
–Durational Viking – Stretching Vowels
–Intoned Viking
163
The Motor Reconnect Apraxia
Program (MRAP) Treatment Modules
• Viking Module for reconnecting: separate
neural controls for the jaw and laryngeal
muscles; control over voice onset; preprosodic skills; and varied phonation
• ****
• Divide and Conquer
• Divide Attention and Conquer the Reconnection
164
MRAP module steps
–Viking with an Attitude – decoding
prosody (Hargrove, 2009)
• Number of syllables
• Number of syllables + stress pattern
–Rhythmic Viking
–Viking the Vowels for Motor Planning,
Anticipatory Co-articulation
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MRAP module steps
–Viking with an Attitude – decoding
prosody (Hargrove, 2009)
• Number of syllables
• Number of syllables + stress pattern
–Rhythmic Viking
–Viking the Vowels for Motor Planning,
Anticipatory Co-articulation
166
MRAP module steps
• Think-Plan-Do/hear-Feel-Remember
• “Mental practice, or thinking about
an activity, has been shown to
increase learning.” Kendall, 2006)
• Transitioning from the Viking
167
MRAP module steps
–YES-NO-IDK-Delicious (headshake /
head nod with phonation)
• Task oriented
• Simple
• Incorporating complex tasks
• Everyday usage
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MRAP module steps
–Blend with BCAT work – speech;
language, discourse; symbolic
representation.
169
The Motor Reconnect Apraxia Program
(MRAP) Treatment Modules
• Scatpraxia Module: for vocal fold pulsing, rhythm,
and flow (Baker, 2005, Umanski, 2010)
• Scatpraxia (Max, 2011; Umanski, 2010)
• Scatpraxia: vowels > varied vowels
• Scatpraxia: >consonants > apraxia work
Jaw/lips; voice onset; rhythm; phrasing; breath
control; melody; articulation; enunciation;
Singing: MIT
170
MRAP module steps
–Scatpraxia (Max, 2011; Umanski, 2010)
• Scatpraxia: vowels
• Scatpraxia: varied vowels
• Scatpraxia: bringing in the
consonants
• Scatpraxia: Fold in apraxia work
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MRAP module steps
1. The basic Viking
1. Drop jaw relaxed
2. Turn on voice
3. Turn off voice > 1 second
4. Jaw up gently
172
MRAP module steps
–Vowels
• 3 Jaw positions (tense-less tense-lax)
• 4-corner vowels
• Around the Mouth – be right behind
me; coarticulation
• The Elevator: Alternating Vowels
• Vowel Sequences From Memory
173
MRAP module steps
–Vowels
• Continuous Phonation – Diphthongs
• Blend Sounds into Words
• V to VC words
• Alternate / h / -vowels
• Alternate voiceless consonants vowels
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MRAP module steps
– Syllable structure work
• Vowels Become Pronouns
• Oral-Motor Coordination Program
• Sound Embedded Verbs
• Increasing Syllables
• Sentence Intonation Patterning
175
MRAP module steps
–GROUPS:
• Oral Motor Coordination - Apraxia
• Scatpraxia
• Coaches
176
MRAP module steps
– MRAP for Limb apraxia
• Praxis for number digits
• Morrapraxia (http://www.morrasociety.com/)
–Single number Morra
–Simple math Morra
–Morra
• Digital number concepting with keyboarding
• Rock, Paper, Scissors (ASR)
• Show me one higher; L/R; throw: 2 at a time
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MRAP module steps
–MRAP for Limb apraxia – Visual Action
Therapy (VAT)
• Gestural representation of present
objects (VAT)
• Gestural representation of missing
objects (VAT)
• In conversation-verification
178
MRAP module steps
- MRAP for Limb apraxia
•Keyboarding
–Typing
–Touch screen
–Touch pad
–Hovering
179
MRAP module steps
• Physical Fitness for Life Program
• A rising apraxia rehabilitation tide lifts all
boats.
• Holistic treatment
• Abulia; adynamia; asymbolia; alien arm
• Exercise; physical trainer; yoga; religion
• Ideas?
180
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The Motor Reconnect Apraxia Program
(MRAP) Treatment Modules
• The Aphasia Communication Café for peer
engagement, practice and support
• ARC group online
• Treatment Groups
181
MRAP module steps
–GROUPS:
• Oral Motor Coordination - Apraxia
• Scatpraxia
• Coaches
182
MRAP module steps
• Whole person apraxia recovery module:
183
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Visual Action Therapy (VAT)
• Work on handshapes and gestures
• Gestural representation of present
objects (VAT)
• Gestural representation of missing
objects (VAT)
184
Promoting Aphasics
Communicative Effectiveness
PACE therapy: Four key components
1. New Information
2. Open modality use
3. Take turns
4. Feedback on effectiveness not manner
• Davis, 1981
185
Gestures …
• are a permanent companion of everyday
speech and communication.
• are used to verify; clarify; complement and
emphasize.
• can be used to compensate for limited speech
output.
• usually require treatment for PWA.
186
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• Therapy to improve gestural expression in aphasia:
a controlled clinical trial. Daumuller, 2009
• GOAL: To improve the production of communicative
gestures in clients with aphasia – apraxia
• Treatment:
– 24 gestures in 3 sets
– SLPs helped clients practice the making the
gestures
– the presentation sequence of the 3 sets of
gestures were revered intermittently
– clients were familiarized with the functions of
gestures (metacognition)
187
• Therapy to improve gestural expression in
aphasia: a controlled clinical trial. Daumuller,
2009
– Clients practiced actual use of the objects
– Client mimed use of the object on request; on
sight of object; then a picture
– Clients used the gesture in in communicative
exchanges
• Progress noted for trained and untrained
gestures
188
8-Step Continuum
1. Watch and listen- say the word
simultaneously; attend to auditory/visual cues
2. Client imitates the target utterance with SLP
mouthing it.
3. Client imitates no cue provided.
4. Client imitates several repetitions.
5. Client reads aloud the target word.
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8-Step Continuum
6. As per step 5 but client says after the card is
removed.
7. Client say the target word in response to a
question from the SLP.
8. Client says the word in a role-playing context.
Rosenbek, 1972
190
Syllable- and Rhythm-Based Approaches in the
Treatment of Apraxia of Speech, Zielger, 2010
• 24 target sounds were selected. These were
simplified monosyllabic nouns and verbs from
a list of those with a complex syllable
structure. These were ordered from
phonologically most simple to most complex.
• Treatment: the client repeated the syllables
after the therapist provided a verbal model.
191
• Therapeutic training techniques included articulatory
pattern, articulatory placement, and to grow
stimulation.
• Feedback was provided regarding regarding
suprasegmental failure encouraging the patients to
speak more fluently or faster.
• All four subjects with apraxia speech showed specific
generalization effects from phonologically simple to
more complex target syllables.
192
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• Therapeutic training techniques included
articulatory pattern, articulatory placement,
and to grow stimulation.
• Feedback was provided regarding regarding
suprasegmental failure encouraging the
patients to speak more fluently or faster.
193
Melodic Intonation Therapy (MIT)
Intersystemic: hand gesture coupled with word
production
Intrasystemic: intoned speech rather than
conversational spoken speech
Nonfluent speakers > intone simple phrases > 5+
syllable phrases
Many interpretations of the original program
194
Elementary level
1. Humming > Unison Intoning > Unison intoning with fading >
Immediate repetition
2. Response to a probe question
Advanced level
1. Delayed repetition >Introducing Sprechgesang >
Sprechgesang with fading
2. Delayed spoken repetition > Response to a probe question
Norton (2009) added:
1. Inner rehearsal
2. Auditory-motor feedback training
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“….caution should be used relative to
conclusions about the effectiveness of
treatments that incorporate components of
music with Sarah logically impaired individuals.”
“Therapy methods using different musical
elements like melody, rhythm, dynamics, tempo
and metre, to regain speech production need not
automatically contain music therapy.”
Hurkmans, J, 2011
196
Can singing be decisive for speech production
for people with nonfluent aphasia?
Or, is rhythm the crucial component?
“…benefits typically attributed to melodic
intoning in the past could actually have their
roots in rhythm.”
Stahl, 2011
197
Review of treatment tenets:
• Ensure normal breath support. Let the air turn
the vocal folds on.
• Minimize details. Keep the practice simple and
the program complex.
• Ensure metapraxia. Help the client understand
movement planning and execution.
• Always push the client to work from his/her
own memory motor.
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• Establish separate neural controls for the
voice and the articulation of sound.
• Focus on proprioceptive feedback and
movement memory.
• Introduce vowels as jaw positions and then
movements.
• Rely heavily on formative assessment and
treatment adjustment
• As soon as possible, move into syllables then
words then sentences Challenge the client
• As soon as possible, move into syllables then
words then sentences.
• Challenge the client. Make sure he/she
practices out loud by him/herself.
Differentiating…
• phonological encoding from phonetic
encoding appears to be a clinical impossibility.
• Do it anyway then blend.
• Pure AOS ????
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Alexia and Agraphia
“Recent research suggests that nearly one third
of all individuals with damage to the left
perisylvian cortex have severely impaired
reading and spelling abilities.
(Rapcsak, 2009)
202
The majority of these PWA experience
impairment in reading (alexia) and writing
(agraphia). Moreover, many PWA lose their
familiarity with a keyboard and screen. In
today’s world of touch screens, ATM, emails
and texts, etc, this places an additional,
imposing communication barrier for PWA.
203
What do PWA/A want?
•
•
•
•
•
•
•
Use everyday technology; send emails
Read text messages from grandchildren
Get cash from an ATM
Pump gas
Read the newspaper and stories to grandkids
Use the touch screen on their iPad and Kindle
Play “Words With Friends”
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Agraphia-Statement of the Problem:
Writing is one expressive communication
modality that is parallel, rather than
subordinate, to speaking.
McNeil, 2005
However, there are numerous neural
communicative and idiosyncratic connections
which offers great rehabilitation and reconnective potential.
205
What is Agraphia?
The inability and the loss of the ability to write
and spell (when writing), is referred to as
"agraphia" i.e. an inability to form graphemes.
Agraphia is a neurological disorder involving
the loss of the ability to write.
http://brainmind.com/Agraphia.html
206
Subtypes of Dyslexia: Greenwald, 2000
Deep: Primary features: Poor non-word reading/worse
than word reading.
Word reading performance: commonly visual
errors/many semantic errors; high image better than
low image; high-frequency better than lowfrequency words; content better than function
words; nouns better than verbs.
Neglect: Primary features: impaired reading of all
words/nonwords; visual errors with positional bias
toward retention of letters on the left or right sides.
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Phonological: Primary features: poor non-word
reading/worse than word reading.
Word reading performance: visual/derivational error;
only infrequently semantic errors. Sometimes
content better than function words; word reading
less impaired overall then deep dyslexia.
Attentional Primary features; impaired text reading
but preserved single word reading. "Migration
errors” are typical. Difficulty reading single letters
within a word.
208
Surface: Primary features: fairly intact nonword
reading/poor word reading performance with
regularly spelled better than irregularly spelled
words. Errors are often attempts to "regularize” the
pronunciation of irregular words.
Letter by letter: Primary features: all word types are
read one letter at a time. Reading latency increases
as the word length increases. Typical strategy
observed in patients with Pure Alexia
209
Traditional Approaches
Despite the fact that, “ …the functional
consequences of reading and writing
impairments can be quite significant.”, there
has been, “…limited attention…” to their
rehabilitation.
(Beeson, 2001)
210
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Examples of A/A Treatment Approaches
LaPointe, 2011
Global:
lexical followed with phonological
Deep:
lexical followed with phonological
Phonological: phonological followed with interactive
Surface:
interactive
Letter by letter: multiple oral reading (MOR) (Lacey, 2007)
Allographic :
lexical; alphabet board
Apraxic agraphia: feedback dependent copying
211
Anagram and Copy Treatment (ACT)
• 1. “write the word for this.” (picture of a pen) > new
word
• OR if error > “make these letter tiles spell pen (epn)
> “copy the word 3 times”
• > “Make this spell pen + add foils (nkpel) “copy the
word 3 times”
• “Write the word pen (elicit 3 correct words.
• Next item
(Beeson, 1999)
212
GOAL: To reestablish orthographic representation for specific
words to build a functional vocabulary for communicative use.
• In collaborative fashion with the client and family, determine
personally relevant words.
• Start with 20-24 pictures- train in sets of 5 > Given printed
word, clients says the name then copies each personally
relevant word 3-5 times > Client writes words from memory >
Check spelling and make corrections > Repeat procedure until
recall without error > Daily homework > Complimentary
procedures: Talking photo album; practice imitating the
spoken name.
• LaPointe, 2011
213
(
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Interactive Treatment
GOAL: To promote interactive use of residual
orthographic knowledge and phoneme-grapheme
conversion skills for improved detection and
correction of spelling errors.
• Obtain electronic spell checker for patient use.
• Generate a list of irregularly spelled words.
• Train in use of spell checker.
214
Interactive Treatment
• Say aloud an irregularly spelled word: sound word
and write it down; read carefully; input best attempt;
look and listen to possible answers; copy correct
spelling of the word.
• Can also include writing sentences to dictation and
checking spelling.
• HOMEWORK: As above. Can advance to topicdriven paragraphs.
(Beeson, 2000; LaPointe, 2011)
215
Multiple Oral Reading (MOR)
A. Initial Treatment Session(s)
a. select reading passage; b. calculate reading rate
1. determine a reading rate of accuracy for text
2. establish multiple oral reading procedures
a. client rereads the practice text; b. set up homework
program
B. Subsequent therapy sessions
1. review the patient's log for homework
2. determine rate and accuracy for reading for practiced text
3. determine target rate for practice text
4. determine reading rate and accuracy for new text (not
practiced)
(Beeson, 1998; LaPointe, 2011)
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BCAT-Agraphia
Keyboarding
∨
∨
Flash Spelling
∨
∨
Propositional Spelling
Keyboard agnosia
SLP question: " I have a client who at times
seems to be able to spell words but has
difficulty typing or using a keyboard. He often
just won't hit a key or he hovers over a key
without hitting it even though it is usually the
correct key?"
Keyboarding Treatment Module
Need for this module
This module is designed for clients who need to be
reintroduced to the keyboard. Some people with
aphasia, TBI and agraphia lose their previous skill
in recognizing and stroking a keyboard or screen.
The keyboarding activity helps the client to refamiliarize him/herself with keyboard knowledge
and skill in typing. This activity is also useful in
helping the client overcoming learned nonattention, inattention, and to accommodate
visual field loss.
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Defining keyboarding
Keyboarding refers to a person’s ability to comfortably
and efficiently use a keyboard or a touch screen in
order to interact with a technological tool such as a
computer, iPad, tablet, cell phone, ATM machine or
remote control.
( http://www.aphasiaapps.com/terms#K , 2013)
The need: This keyboarding skill may be impaired after
a stroke or head injury. Reconnecting keyboarding
skills is critical in maximizing aphasia recovery and in
the PWA/A’s returning to engagement in this world
full of technology.
Need
The program must take into account learned,
visual inattention (often masking his visual
field loss), learned helplessness, and fear of
failure parentheses (right/wrong phobia)
among other confounding variables. This
allows the client to then move on to spelling
from memory and propositional spelling.
(aphasiatoolbox newsletter, 2012)
• It helps the client to reconnect his/her ability to use
a keyboard.
• It helps the client learn, expand and/or reconnect
screen literacy skills.
• It facilitates the client’s ability to integrate right
and/or left visual field into normal keyboarding
activities: * Hicks story; Dr. Ivy outcome.
Performance Objective: The client will be able to type
from memory with normal keystrokes the letter keys
on the computer keyboard.
(Connors, 2013)
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• Open the Keyboarding Module on the
Aphasia Sight Reader software
• Select L 4 letter exercise set time to 3. sec
• Tell the client to "watch the top box and pay
attention to the letter that appears" ( make
sure the client only watches the letter with
hands flat, no extraneous movements, and
encourage him/her to have faith in letter
memory memory)
223
• When letter disappears tell client “Now find
the key with your eyes (no physical searching
or hovering with fingers)
• Say, “now type the letter that you saw with a
normal key stroke. It will be one of these 4
letters” (again, allow no physical struggle or
search behaviors; make sure the the client
strokes the key normally)
224
• Proceed to the next screen and letter (Do not
correct the letter typed yet. Only focus on the
visual and stroking behaviors)
• Continue as above > Summary page.
• Review the client’s performance on the
summary page.
• Repeat this exercise > 90-95% accuracy level.
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• When criterion is reached advance:
– > left keyboard 6 letters
– >right keyboard 4 letters
– >right keyboard 6 letters
226
– >right keyboard 6 letters….etc
• When the entire keyboard is exposed >
advance to the Flash Spelling module
227
Keyboarding
• Keyboard cutout > watch the letter> remember the
letter>find key with your eyes> stroke the key like normal.
Strict adherence-no extraneous, confounding movements or
mental processes
• L: 4 letter words > 6 > 9 > 12 (gradually expand cutout = GEC)
• R: 4 letter words > 6 > 9 > 12 (GEC)
• L: 4 letter words > 6 > 9 > 12
• R: 4 letter words > 6 > 9 > 12
• That’s it, Fort Pitt
• * Visual search for index card
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Keyboarding
• Watch the client’s eyes
• Monitor hand movements
• Formative Assessment – field cut or
inattention
– Sit across form client; flash index cards with letters
printed in various part of the visual field.
– Work with client to start at middle field of view
and view from there.
BCAT A/A Techniques
• The good news:
– Good success with most alexia-agraphia types
when used with attentive formative assessment.
– Fix the Agraphia and the alexia will improve.
– Example: Phonological treatment results in
improved reading and spelling skills.
(LaPointe, 2011)
Agraphia-Statement of the Problem:
“ ….effective writing [keyboarding; typing;
texting] can be performed only with a large
ensemble of intact subset skills: limb and hand
sensorimotor control (calligraphy),
orthography, visual-perceptual organization,
and a cascade of linguistic capacities
(McNeil, 2005)
Add cognitive underpinnings (Connors, 2013)
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BCAT Alexia Techniques
The good news:
Since the BCAT treatment for alexia and
agraphia is threaded through a robust,
comprehensive recovery program, the speech
language pathologist can adapt it and it can be
effective with, not only both alexia and
agraphia, but with most subtypes of agraphia
and alexia.
BCAT Alexia Techniques
More good news:
A rising tide lifts all boats. Improvements in
spelling can likewise facilitate progress in
other areas such as semantic and phonological
aphasia. Moreover, addressing cognitive
problems can facilitate improvements in
spelling and reading.
Flash Spelling Treatment Module
• It will help the client to be able to spell, by typing, words from
memory.
• It will help the client abbreviate.
• It will help the client recognize and type acronyms.
• It will help the client read words and sentences.
• It will help the client learn or reconnect emailing and texting
skills.
• Work on all types similarly
Performance objective - The client will be able to:
• Type long and multisyllabic words from memory.
• Recognize, by sight reading, words and concepts.
• Type abbreviations and reverse abbreviations.
• Recognize and type semantic relationships.
234
•
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Flash Spelling
1. Client: Watch word until disappears > store in
memory loop > find keys with your eyes>
stroke keys from memory in normal fashion.
2. SLP: Formative adjustments: time exposure;
length of word (letters; syllables); spelling
regularity; type of word (verb; morphological
complexity; grammatical load); frequency;
Rothi and Moss, 1992: a model assisted therapy
235
Recipe for Reconnecting Spelling
from Memory
1. Keyboarding competent for all letters > be able
to type from memory (<.6 sec) words of 3-5
letters
2. Be able to type from memory (<.6 sec) words of
6-7 letters
3. Be able to type from memory (<.6 sec) longer
variable length words: compounds; phrasal
verbs; Reverse clips;
4. Blend in oral (phoneme) > typed (grapheme)
work
1. Say aloud the letter (word) > client types
236
Recipe for Reconnecting Spelling
from Memory
5. Type from memory propositional transition
words and phrases: vowel closure;
abbreviations; acronyms; irregular spelling;
6. Propositional Spelling:
1. Words
2. Sentences
3. Paragraphs
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Recipe for Propositional Spelling
7. Gradually move to longer phrases and
sentences.
8. Scaffolded with missing vowels:
– W_ s_w h_m.
9. Spelling Increasing Syllables
– In > increase > increasingly
– One per screen > all three in grapheme buffer
– Morphology: reCALL > reCALLing
10 Have the client email, even if in a basic way.
11. Exercise: Canonicalize complex sentences:
– As the rice cooked, I set the table and poured
wine.
– The rice cooked. I set the table. I poured wine.
12. Blend with work on phonological;
morphological and numeracy activities.
13. Hundreds of hours of practice may be
needed.
14. Thread throughout the client’s entire
program.
15. Say it; Say it; think it; type it; remember it;
say it.
16. Continue to work on the cognitive skills that
support speech, language, reading and
spelling.
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17. Incorporate technology with texting; touch
screens; text chats.
18. Take advantage of popular technologies and
content: facebook; pinerest; Words with
Friends; the Visual Thesaurus;apps
Pure Alexia Treatment Module
Benefits of this module:
• It will help the client with letter by-letter alexia sight read
words and sentences.
• It will help clients reconnect the ability to e-mail and use
texting features.
• It can support the reacquisition of keyboarding skills.
• Objective: The client will be able to:
• sight read words when flashed briefly on the screen
monitor.
• sight read phrases when flashed briefly on the screen
monitor.
• sight read short sentences when flashed briefly on the
screen monitor
242
Pure Alexia
• Keyboarding and Flash Spelling Competent.
Competent.
• Use the Aphasia Sight Reader and then other
modules as formative assessment and
progress dictate. All may be done with index
cards.
243
81
4/24/2014
Track pad VS mouse
Fitt’s Law: predict how long it will take a user to
point to (and click on) an object using a specific
pointing device – mouse; trackball; trackpad;
finger. Assist in user interface selection.
http://fww.few.vu.nl/hci/interactive/fitts/
Therapy Fun Zone, 2014
http://www.yourtherapysource.com
244
Question; comments; discussions
Bill Connors
[email protected]
724.494.2534
www.aphasiatoolbox.com
82

NV COnvention

Transcription

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