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From idealism to realism, step by step

Evidence shows that impairment based treatment for people with chronic aphasia can make a difference but is it a realistic proposition for everyday clinical practice? With the help of Simon, his wife Lesley and information and communication technology, Jane Mortley and Rebecca Palmer chart the effectiveness and time efficiency of the StepByStep program.
t is our impression that people with chronic aphasia rarely receive impairment based therapy from speech and language therapists, and that long-term input often focuses on compensatory techniques to assist the individual to communicate. However, many people with aphasia still report the motivation to improve several years post stroke, their goal being to use more language (Mortley et al., 2004). It is generally accepted that approximately 250,000 people are living with aphasia at any one time in the UK alone (RCSLT, 2009) and national guidelines support the provision of speech and language therapy for as long as these people are benefiting from and able to tolerate it (NICE, 2010). Recent evidence challenges our traditionally held beliefs by showing that improvement in long-standing chronic aphasia is possible (Meinzer et al., 2005; Raymer et al., 2008; Kurland et al., 2010). Neuroscience research has identified that the brain has the capacity for structural and functional plasticity throughout the human lifespan, with imaging studies showing a significant relationship between neuro-plastic changes and language recovery (Raymer et al., 2008). A key principle of neuro-plasticity is that intensity matters, and systematic reviews support the idea that the greater the intensity of language treatment, the greater its effectiveness (Robey, 1998; Bhogal et al., 2003). A further important principle is use it or lose it. Compensatory communication techniques of gesture, writing and picture charts are essential for most people with aphasia. However, it is important that this is complemented by effective impairment based therapy, as the active avoidance of words or phrases that are difficult may lead to learned non use of these words and grammatical structures. Language action therapies in aphasia encourage the use of residual language skills, even when the vocabulary and grammatical structures are difficult to produce, to promote the READ THIS IF YOU BELIEVE IN USING THE EVIDENCE BASE LISTENING TO CLIENTS WISHES ONGOING CAPACITY FOR CHANGE

How I offer impairment therapy (2):

reactivation and strengthening of language circuits that have survived the brain lesion (Pulvermuller & Berthier, 2008). Constraint Induced Aphasia Therapy (CIAT) is a form of language action therapy in which constraint refers to the principle of focusing clients on their remaining language abilities, especially those they avoid using. Constraint induced aphasia therapy involves pairs games, encouraging use of language by constructing barriers between players to prevent pointing or gesturing. This therapy is carried out intensively for 30 hours over 2 weeks using the principle of massed practice. The target words, phrases or sentences are shaped to increase the level of difficulty as the client improves (Pulvermuller et al., 2001; Meinzer et al., 2005; Pulvermuller & Berthier, 2008). Pulvermuller et al. first demonstrated evidence for the effectiveness of this technique in aphasia treatment in 2001, and a preliminary systematic review of 10 studies conducted over the decade concluded that the evidence for intensive and constraint induced therapies for aphasia is favourable (Cherney et al., 2008). Learning theory suggests that the personal relevance or salience of language material being practised is also of importance (Raymer et al., 2008). Meinzer et al. (2005) recognised the need to promote lost language functions repeatedly in real life situations for people with chronic aphasia, so introduced CIAT plus. This combined written materials and photographs of everyday scenarios with a training module including a clients relative in daily communication exercises, which provided an additional valuable element to the therapy. The behavioural relevance principle, based on experiments which show cortical links between actions and words, also states that it is advantageous to practise language in relevant action contexts (Pulvermuller & Berthier, 2008). Structured therapy tailored to the individuals difficulties is another important aspect. Barthel et al. (2008) found effects of

Lesley and Simon

Model Oriented Aphasia Therapy - which tailors treatment according to individual symptoms - were comparable to CIAT when delivered at similar intensity. High intensity of treatment is common to many effective therapies. Unfortunately the resources required to achieve this through face-to-face speech and language therapy sessions are often prohibitive, particularly in the long term. The use of volunteers has been recognised as a potential way to enable intensive practice. Meinzer et al. (2005), suggested volunteer assistance in carrying out CIAT, and Fink et al. (2005) proposed trained volunteers to support computer practice. There is a growing body of evidence that computer software can be used effectively to enable clients to practise language based exercises independently from their therapist, consequently increasing the intensity of practice that can be achieved with face-toface contact only (Katz & Wertz, 1997; Lee et al., 2009). Case series studies have shown the use of computers to support varying levels of independent practice. Fink et al. (2002) demonstrated the effectiveness of computers to increase intensity of word finding treatment by using them to offer treatment between face-to-face sessions with a therapist, whereas Ramsberger & Marie (2007) report improvements in word finding

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No. correct Cognition screen Line bisection Semantic memory Word fluency Recognition memory Gesture object use Arithmetic Part 1: Language comprehension Comprehension of spoken language Comp. of spoken words Comp. of spoken sentences Comp. of spoken paragraphs Section TOTAL Comprehension of written language Comp. of written words Comp. of written sentences Section TOTAL 14/15 8/16 28/30 18/32 46/62 55 51 53 15/15 6/16 30/30 12/32 4/4 46/66 65 44 60 49 0.5 10/10 10 10/10 12/12 2/6 59 60 54 59 98 44

Score

T-score

T-scores explained: T-scores put scores from different subtests onto a common scale of difficulty showing relative strengths and weaknesses across different tasks. The CAT (Comprehensive Aphasia Test) T-scores are based on the results from 266 people with aphasia. A T-score of 50 represents the mean score within the sample of people with aphasia; 96 per cent of scores from people with aphasia will fall between 30 and 70.

Figure 1a Comprehensive Aphasia Test - Cognition and Language comprehension sections No. correct Part 2: Expressive Language Repetition Repetition of words Repetition of complex words Repetition on non words Repetition of digit strings Repetition of sentences Repetition TOTAL Spoken Language Production Naming objects Naming actions Word fluency Naming TOTAL Reading Aloud Reading words Reading complex words Reading function words Reading non words Reading TOTAL Writing Writing copying Writing picture names Writing to dictation Writing TOTAL 11/24 0/3 3/3 0/5 16/33 12/24 2/5 16/16 3/3 4/5 3/14 3/12 29/50 Pre-therapy 32/32 6/6 9/10 6/14 6/12 59/74 Pre-therapy 22/48 4/10 3 29 Pre-therapy 22/24 0/6 6/6 0/10 33/70 Pre-therapy 27/27 6/21 5/28 38/76 61 46 46 48 44 40 62 40 47 16/24 1/3 3/3 0/5 20/33 50 50 47 49 20/24 2/5 65 62 62 46 48 55 16/16 3/3 5/5 3/14 3/12 30/50 Post-therapy 32/32 6/6 10/10 6/14 6/12 60/74 Post-therapy 42/48 4/10 10 56 Post-therapy 34/48 2/6 6/6 0/10 42/70 Post-therapy 27/27 16/21 7/28 50/76 61 55 47 51 47 40 62 40 51 61 50 54 57 65 62 67 46 48 56 Score T-score No. correct Score T-score

when the speech and language therapists role was only to set up and monitor the use of computer exercises. Advances in information and communication technology have made it feasible to monitor therapy from a different location through the use of the internet (Mortley et al., 2004), in keeping with the growing recognition of the crucial role of telehealth in delivering health services efficiently. The Department of Health (2006) prioritises self management of long term conditions using such technical innovations. The StepByStep treatment approach incorporates these key elements of successful impairment focused aphasia therapies in the resource efficient manner required to achieve the necessary levels of intensity. It uses a computer program through which the therapist can tailor therapy exercises to each clients language needs and select personally relevant vocabulary. It is designed to be easy for an individual to use independently for self managed intensive (daily) practice, with the support of a relative or volunteer where possible. It also follows the principle of errorless learning (Fillingham, 2006), starting with tasks that the individual can achieve with ease. This limits the struggle to produce words and increases confidence by promoting faster, easier retrieval.

Simons therapy

Figure 1b - Comprehensive Aphasia Test - Expressive language sections pre and post therapy % words named correctly pre-therapy 42 16 % words named correctly post-therapy 70 18

Word type Objects Actions

Figure 2 Object and Action Naming Battery pre- and post- therapy

Jane, an independent specialist speech and language therapist, developed the StepByStep program. She used it with Simon, a 52 year old man who suffered a stroke 9 years ago. Simon and his wife Lesley have agreed to their story being shared. Simon is right handed and English is his first language. Prior to his stroke he ran his own haulage business. In 2002, at the age of 43, Simon had an infarct located in the inferior frontal gyrus area of the left hemisphere, resulting in severe aphasia. After 6 years he still wished to improve his ability to use language, and his wife Lesley assisted him in finding options for impairment based speech and language therapy. At this stage Simon was frustrated and withdrawn, showing little initiation of speech. According to Lesley he would use about 10 words a day, a few recurrent phrases such as too true or yes I know, and no sentences. He communicated through gesture, drawing and sky writing the first letter, and had a Say-it! SAM communication aid. Simons pre-intervention Comprehensive Aphasia Test (Swinburn et al., 2004) scores are in figures 1a and b. They show that comprehension of both spoken and written single words was good, but impaired at the sentence level. Simons aphasia affected all areas of expression including repetition, spoken language production, reading aloud and writing. Jane also administered the Object and Action Naming Battery (Druks & Masterson, 2000) to assess Simons naming ability further (figure 2). He scored 42 per cent correct on objects and 18 per cent correct on actions. His errors were mixed in terms of

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semantic paraphasias, phonological errors and no response. His word retrieval was helped by phonemic cueing. Intervention was offered in four steps over a 6 month period: Step 1: Computer therapy at single word level a) Spoken naming The target word was shown with a succession of cues to facilitate word retrieval as shown in figure 3. Simon would attempt to say the word but if he was not able to he could choose from a number of different cues to facilitate the word. Simon was encouraged firstly to say the word without help. If he was unable to do this he would try to type the initial letter for selfphonemic cueing. If this did not trigger the word then he would listen to the first phoneme. If this did not cue him then he would click to hear the whole word spoken which he was able to repeat. It was important that he was able to say the word with or without cues for each picture to ensure the connections were being made in the brain. b) Written confrontation naming The target words were also put into a range of spelling exercises from initial letter spelling, copying the whole word, anagram solving, and flash where the word is shown and then disappears when he started to type the target word (figure 4). Only correct responses were accepted and help was given in the form of the on-screen keyboard which reduced the number of letters displayed to ensure that he could progress through each question. The exercises were presented in levels of difficulty and the next exercise in the sequence was presented when he achieved 85 per cent on two occasions, shaping the therapy tasks in response to improvement. Step 2: Computer therapy at sentence level Sentence based tasks (figure 5) incorporated the target word within the context of a meaningful functional sentence based on I would like a [target word] please. In a level 1 task the sentence was shown. When Simon clicked on the blue button he would hear the whole sentence spoken. He was also able to click on each word within the sentence to hear it spoken and try to repeat the whole sentence. When he felt confident in producing the sentence, he would move up to level 2 which showed him the target picture and the question only. He was required to try to say the sentence without the written prompt. If he found it difficult he could again click on the blue button to see the written sentence and hear it spoken. Step 3: Language action therapy game Simon and his wife were shown how to do the language action therapy tasks, incorporating the concept of use it or lose it. Two copies of the word sets were printed out, and a wooden partition was positioned on the table between them, low enough to see their faces, but high enough to avoid use of gesture or pointing instead of language. Jane, who was

Click to see video giving first sound of word Click to type initial letter Click on dictionary to see written word Click to see video showing mouth movements

Figure 3 Cues to facilitate word retrieval

Figure 4 Screenshots of an anagram and flash

Figure 5 Sentence level tasks

monitoring the therapy remotely, asked them to play a pairs game. This involved them each having four cards, with Simon required to say I would like the [target picture] please in order to win pairs. The winner was the person with the most pairs. When Lesley asked Simon for a card, his response was either here it is or no, I havent got it. The constraint aspect to this task was that Simon had to produce a sentence containing the correct target word, otherwise Lesley would not give him the card. Imposing such constraint can be difficult and risk exposing the language weaknesses of the person with aphasia. The StepByStep approach reduces such discomfort by ensuring that the person with aphasia can retrieve the target words in sentences in step 2 with the computer before moving on to the barrier games. In addition, the language action therapy is introduced very much as a game to be enjoyed by the person with aphasia and communication partner. Step 4: Using scenarios in every day speech This step follows the behavioural relevance principle and the notion of using language functionally with relatives and communication

partners. Lesley encouraged Simon to use the new language in everyday contexts to promote generalisation. So instead of saying would you like a coffee? to which he would respond yes or no, she would say what would you like to drink? or she would give him his breakfast or cup of tea without sugar so he would practise I would like some sugar please. A key element of StepByStep is remote support. Jane reviewed progress every 6 weeks by teleconferencing with Simon and Lesley through Skype, using webcams so they could see each others faces. A commercially available program called TeamViewer enabled Jane to connect to Simons computer remotely in order to control the StepByStep software. Jane adjusted the computer exercises if needed and offered instruction to Simon and Lesley when he was ready to start practising the new vocabulary in phrases using the pairs game (Step 3). Jane shaped the use of the words in the game during the sessions to encourage more complete phrases and sentences. Once sentences were being used easily in the pairs game, she guided the practice of the new vocabulary and sentences into everyday situations.

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Over the 6 months, Simon completed 49 hours of computer therapy independently at home and received 6 hours of therapy from Jane. This consisted of 2 face to face sessions (3 hours) and 3 videoconferencing sessions (3 hours). We do not have a record of how much time Simon and Lesley spent doing the language action therapy tasks. Intensive, massed practice is a key component but, although StepByStep is 20 minutes per day, this approach is less intensive than CIAT (30 hours over 2 weeks) and is delivered over a longer period of time. This may be more manageable for some people with aphasia, particularly those still experiencing the effects of fatigue post stroke. Simons Comprehensive Aphasia Test results in figure 1b (p.30) indicate an improvement in naming objects with a change in T-score from 50-61 and writing picture names with a change in T-score of 46 to 55. The Object and Action Naming battery (figure 2, p.30) shows an improvement in naming objects but similar scores for action naming. Lesley also reported functional use of sentences in everyday conversation. The StepByStep approach to aphasia treatment was effective for Simon, as naming of nouns improved and generalised to non treated words, and was maintained up to 3 months post treatment. The change in Simons use of language lends further support to findings that people with chronic aphasia can improve with treatment. For Simon as the client, Lesley as his wife and Jane as the speech and language therapist, the StepbyStep package made evidence based, intensive treatment for aphasia a manageable, realistic and acceptable option. Simon and Lesley reported that practising individual words and sentences with the computer built confidence to use the language in the CIAT activities. It empowered Simon to practise independently and have control over his progress in therapy. The approach also included his wife as the main communication partner, involving her in a supportive role and enabling joint responsibility for use of the new language in contexts that were functionally relevant to them.
behavioural relevance real life massed practice Lee, J,B., Kaye, R.C. & Cherney L.R. (2009) Conversational script performance in adults with non-fluent aphasia: Treatment intensity and aphasia severity, Aphasiology 23(7-8), pp.885-897. Meinzer, M., Djundja, D., Barthel, G., Elbert, T. & Rockstroh, B. (2005) Long term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy, Stroke 36, pp.1462-1466. Mortley, J., Wade, J. & Enderby, P. (2004) Superhighway to promoting a client-therapist partnership: Using the Internet to deliver wordretrieval computer therapy monitored remotely with minimal speech and language therapy input, Aphasiology 18(3), pp.193-211. NICE (2010) Stroke quality standard: Ongoing rehabilitation. Available at: http://www.nice. org.uk/guidance/qualit ystandards/stroke/ ongoingrehabilitation.jsp (Accessed: 27 October 2011). Pulvermuller, F. & Berthier, M.L. (2008) Aphasia therapy on a neuroscience basis, Aphasiology 22(6), pp.563-599. Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P. & Taub, E. (2001) Constraint induced therapy of chronic aphasia after stroke, Stroke 32, pp.1621-1626. Ramsberger, G. & Marie, B. (2007) Self-administered cued naming therapy: a single-participant investigation of a computer-based therapy program replicated in four cases, American Journal of SpeechLanguage Pathology 16, pp.343-358. Raymer, A., Beeson, P., Holland, A., Kendall, D., Maher, L.M., Martin, N., Murray, L., Rose, M., Thompson, C.K., Turkstra, L., Altmann, L., Boyle, M., Conway, T., Hula, W., Kearns, K., Rapp, B., Simmons-Mackie, N. & Gonzalez-Rothi, L.J. (2008) Translational Research in Aphasia: From Neuroscience to Neurorehabilitation, Journal of Speech, Language and Hearing Research 51(1), pp.259-275. Robey, R.R. (1998) A meta-analysis of clinical outcomes in the treatment of aphasia, Journal of Speech, Language and Hearing Research 41, pp.172-187. RCSLT (2009) RCSLT Resource Manual for Commissioning and Planning Services for SLCN: Aphasia. Available at: http://www.rcslt.org/speech_ and_language_therapy/commissioning/aphasia (Accessed: 27 October 2011). Swinburn, K., Porter, G. & Howard, D. (2004) Comprehensive Aphasia Test. London: Psychology Press. Resources Say-it! SAM, www.words-plus.com Skype, www.skype.com StepByStep, www.aphasia-software.com TeamViewer, www.teamviewer.com

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Figure 6 Key vocabulary

Research for Benefit Programme is underway to evaluate the effectiveness and cost effectiveness of using this approach more widely as a method of service delivery for aphasia in the long term. Kirmess & Maher (2010) used Language Action Therapy principles in the earlier stages, one to two months post onset of aphasia, with positive results. In a similar way it would be useful to investigate the effect of using the StepByStep approach to investigate whether an earlier start helps to avoid learned non use of language experienced by those SLTP with chronic aphasia. Dr Jane Mortley is an independent speech and language therapist, and clinical director of Steps Consulting, www.aphasia-software.com/. Dr Rebecca Palmer is a speech and language therapist in Health Services Research at the University of Sheffield, email r.l.palmer@sheffield.ac.uk.
References Barthel , G., Meinzer, M., Djundja, D. & Rockstroh, B. (2008) Intensive language therapy in chronic aphasia: Which aspects contribute most?, Aphasiology 22(4), pp.408-421. Bhogal, S.K., Teasell, R. & Speechley, M. (2003) Intensity of aphasia therapy, impact on recovery, Stroke 34(4), pp.987-993. Cherney, L.R., Patterson, J.P., Raymer, A., Frymark, T. & Schooling, T. (2008) Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia, Journal of Speech, Language and Hearing Research 51, pp.1282-1299. Department of Health (2006) Our health, our care, our say: a new direction for community services. Crown copyright. Available at: http://www.officialdocuments.gov.uk/document/cm67/6737/6737.pdf (Accessed 20 September 2011). Druks, J. & Masterson, J. (2000) An Object and Action Naming Battery. London: Psychology Press. Fillingham, J.K., Sage, K. & Lambon Ralph, M.A. (2006) The treatment of anomia using errorless learning, Neuropsychological Rehabilitation 16(2), pp.129-154. Fink, R., Breecher, A., Schwarz, M. & Robey, R. (2002) A computer-implemented protocol for treatment of naming disorders: evaluation of clinician-guided and partially self guided instruction Aphasiology 16(10/11), pp.1061-1086. Fink, R., Brecher, A., Sobel, P. & Schwartz, M. (2005) Computer assisted treatment of word retrieval deficits in aphasia, Aphasiology 19(10-11), pp.943-954. Katz, R.C. & Wertz, R.T. (1997) The efficacy of computer-provided reading treatment for chronic aphasic adults, Journal of Speech, Language and Hearing Research 40(3), pp.493-507. Kirmess, M. & Maher, L.M. (2010) Constraint induced language therapy in early aphasia rehabilitation, Aphasiology 24(6-8), pp.725-736. Kurland, J., Baldwin, K. & Tauer, C. (2010) Treatmentinduced neuroplasticity following intensive naming therapy in a case of chronic Wernickes aphasia, Aphasiology 24(6-8), pp.737-751.

Ready and motivated

At the age of 52 years, Simon is now a more confident communicator who wishes to continue to use more language. This approach lends itself well to continuing treatment in the long term as relevant vocabulary can be included and changed as the persons daily needs change over time. As improvement can be made with treatment several years after onset of aphasia, the approach can be used whenever an individual is ready and motivated to work at the required intensity. Although Simons experience suggests the StepByStep approach is practical and offers people with chronic aphasia renewed opportunity for improvement, we cannot assume this will be the same for everyone. A pilot randomised controlled trial funded by the National Institute for Health Researchs

REFLECTIONS DO I REALISE WHEN MY BELIEFS ABOUT WHAT IS POSSIBLE LIMIT WHAT I OFFER? DO I UNDERSTAND THE VOCABULARY AND CONCEPTS OF IMPAIRMENT FOCUSED THERAPIES (FIGURE 6)? DO I EXPLOIT TECHNOLOGY TO INCREASE THE INTENSITY OF PRACTICE?
How has this article changed your thinking? Let us know see information about Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

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