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21 (1988), 491-503


California State University, Fullerton

This study compared the effects of PACE and traditional stimulation therapy in the reme-
diation of naming deficits. The subject was a 66-year-old conduction aphasic. An ABCBC
time-series design was employed. Greater gains were evidenced during the PACE phases
of treatment on two types of probes-confrontation naming and picture description tasks.

Word retrieval or naming problems occur in virtually all types of aphasic
patients. Thus, the treatment of naming deficits is an issue of special
concern to aphasiologists. A number of different approaches have been
employed for treating anomia. Some therapies such as Base-10 Pro-
grammed Stimulation (La Pointe, 1977) have emphasized a relearning
approach. When specified stimuli are established at a criterion level, the
vocabulary is changed and the patient practices until criterion is again
reached. Other approaches, such as that of Schuell et al. (1964), stress
that the goal of therapy is not to teach new material to the patient, but
rather to maximize the efficiency of an impaired language system. In
Schuell’s stimulation therapy, the clinician supplies a variety of auditory-
visual models and cues to elicit patient response. This latter approach,
which involves the stimulation of word retrieval processes rather than the
teaching of new vocabulary per se, is thought by some to be more effective
for the aphasic patient (Schuell et al., 1964; Howes and Geschwind, 1964;
Wiegel-Crump and Koenigsknecht , 1973).
Despite the strengths and widespread use of Schuell’s stimulation ap-
proach, there is a major limitation: This approach does not consider the
functional context of communication. Although a major objective in
aphasia treatment is to improve the patient’s ability to communicate in
natural conversation, the client-clinician interaction in a typical treatment

Address correspondence to Edith C. Li, Ph.D., Department of Speech Communication

(EC-199), California State University, Fullerton, Fullerton, CA 92634.

0 1988 by Elsevier Science Publishing Co., Inc. 491

655 Avenue of the Americas, New York, NY 10010 0021-9924BSB3.50
4% E. C. LI et al.

session does not correspond to the structure of normal conversation. The

patient does not participate in any meaningful exchange of information.
For example, during a standard confrontation naming task, the situation
is arranged such that the patient is not conveying any new information
to the clinician (pictures are fully visible to both parties). In addition, the
patient is primarily the speaker and the clinician is predominantly the
listener-there is no turn-taking involved. Finally, the expected behavior
involves specific target words rather than the communication of some
Recently, Davis (1980, 1985) has proposed a procedure termed PACE
(Promoting Aphasics’ Communicative Effectiveness), which reshapes
therapy into a form more closely resembling face-to-face conversation.
In PACE the client and clinician engage in natural interaction sequences,
alternating turns as senders and receivers of the message. In addition,
patients are encouraged to use multiple channels, including gestures to
communicate. Two formal studies (Davis, 1985) have found increased
communicative effectiveness when aphasic patients participated in PACE
as compared to direct stimulation therapy. However, there are no con-
trolled studies on the efficacy of PACE applied specifically to the treat-
ment of naming disturbances. The purpose of this study was to compare
the relative effectiveness of PACE and Schuell’s traditional stimulation
in an aphasic patient with naming deficits.

Subject Description
The subject was a 66-year-old, right-handed female who had sustained a
left cerebrovascular accident (CVA) approximately two years prior to the
study. A computed tomography scan showed no definite infarct. The pa-
tient presented with right hemiplegia and severe fluent aphasia, charac-
terized by paraphasic speech and impaired comprehension. Following her
CVA, the patient received approximately one year of speech and language
therapy. Therapy was volitionally terminated by the patient prior to the
initiation of the present study.
At the time of the investigation the patient exhibited a residual right-
sided hemiparesis. She had passed audiometric screenings at 25 dB IS0
bilaterally at 500, 1000, and 2000 Hz. The subject was a native English
speaker with high school education. The Boston Diagnostic Aphasia Ex-
amination, BDAE, (Goodglass and Kaplan, 1983) was administered to the
subject two weeks prior to her participation in the study. The results are
consistent with the diagnosis of conduction aphasia. The BDAE rating
scale of speech characteristics was applied to the subject’s verbal per-
formance on both expository speech (description of the cookie theft pic-

ture) and conversational tasks. The ratings on the scale indicate fluent
paraphasic speech (see Figure 1). Poor repetition skills were exhibited in
the repetition of high-probability and low-probability phrases-the sub-
ject scored at the 30th and 40th percentiles, respectively, on these sub-
tests. Finally, mean performance on the auditory comprehension subtests
of the BDAE is also consistent with the diagnosis of conduction aphasia.
The mean percentile on the four auditory comprehension subtests was

Treatment Programs
The treatment program during traditional stimulation therapy followed
the format recommended by Schuell et al. (1964). Both auditory and visual
stimulation were used to elicit naming responses. In addition to the picture
stimuli, a host of auditory-verbal models were supplied. These included
use of carrier phrases, sentence completion, and associated words. The


Figure 1. Pretreatment speech characteristics profile of subject (Boston Diag-

nostic Aphasia Examination).
494 E. C. LI et al.

frequency of occurrence of the target words across sessions was controlled.

Of the target words, 67% were high-frequency words (defined as the first
and second most frequently used words according to the Thorndike-
Lorge Word Count, 1944) and 33% were low-frequency words (defined
as the third thousand most frequently used or beyond). Target words were
selected from six categories judged to be functional to the patient, in-
cluding food, personal items, and clothing.
If the patient did not succeed in naming the specific target words, cor-
rective feedback and cuing techniques were employed. The cues most
facilitating were presentation of the initial phoneme of the target and use
of the printed word.
The protocol for PACE therapy involved natural interaction sequences
in which the client and clinician alternated turns communicating the iden-
tity of the object depicted on a card (Davis, 1985). Only the sender of the
message knew the identity of the object. During the patient’s “turn” as
sender, she was encouraged to use any effective means of communication
including gestures and verbal circumlocutions. Her task was to enable
the clinician as receiver to guess the object name from whatever infor-
mation she could provide. During the clinician’s turn as sender, she mod-
eled the use of effective channels and types of communicative behaviors.
Both object and action pictures were used during PACE therapy. Target
words were chosen from the same functional categories utilized in tra-
ditional therapy. However, the specific target words differed from those
trained during the traditional phase. Frequency of occurrence was con-
trolled in the manner described above-67% of the target words were
high frequency and 33% were low frequency.

An ABCBC time-series design was utilized in which the treatment phases
(BCBC) included traditional stimulation therapy (B) and PACE therapy
(C). Three base-line measures were taken initially-these were identical
to the probes described below. Twenty treatment sessions followed, with
each treatment phase consisting of five sessions. Thus, the two therapy
approaches were alternated every five sessions. The same clinician per-
formed all treatment sessions. Sessions were conducted daily (Monday
through Friday).

Probe Description
Probe measures were taken after each therapy session. Two types of
naming measures were utilized as probes-a confrontation naming task
and a picture description task. The confrontation naming task was chosen
to provide a widely used, objective index of naming performance. The

picture description task was selected to provide an indication of naming

performance in a context more closely resembling natural, conversational
speech. Each confrontation naming task consisted of 15 target nouns and
each picture description task consisted of 8 target words depicted in the
context of action pictures.
Five different sets of picture stimuli were assembled in order to elimi-
nate the possibility of a learning effect in the subject. During the treatment
phases, each of the tive stimulus sets were presented once during each
phase. The stimulus sets were randomized for each base-line and treat-
ment phase. In addition, the order of administration of confrontation nam-
ing and picture description tasks within each session was counter-

Development of Probe Materials

Stimulus pictures were required for both the confrontation naming and
picture description tasks. The confrontation naming task consisted of line
drawings of objects, which had been prepared for a prior research project.
Stimuli were selected from the Boston Naming Test (Kaplan, Goodglass,
and Weintraub, 1983) and the Basic Set of Word Making Curds (Medlin,
1975). Picture stimuli were enlarged if necessary so that line drawings
were of uniform size on &in. by 11-in. sheets. In order to ensure that
the pictures were visually unambiguous and likely to elicit consistent re-
sponses, they were presented to 16 normal subjects prior to the study.
For a stimulus picture to be included in the study, at least 90% of the
normal subjects had to provide either the anticipated target word or an
acceptable synonym. From the pool of available words that fulfilled the
foregoing criteria, 5 sets of 15 words were constructed. The stimuli were
assembled such that each set contained 67% high-frequency words and
33% low-frequency words. High-frequency words were defined as the first
and second thousand most frequently occurring on the Thorndike-Lorge
Word Count (1944) and low-frequency words were defined as the third
thousand most frequent or beyond. The occurrence of single- and mul-
tisyllabic words was also balanced across sets. Stimulus words are pro-
vided in Appendix A.
The picture description task consisted of eight target nouns depicted
within action picture contexts. Each individual picture contained two key
nouns to be named in the context of running speech. The pictures were
screened with 10 normal subjects prior to the study. In order for the
stimulus picture to be included in the study, 80% of the subjects had to
provide the anticipated target word during their description of the picture.
From the pool of available stimulus pictures, five sets were constructed.
The sets were assembled such that each list contained 50% high- and 50%
low-frequency words (frequency of occurrence was defined in the same
496 E. C. LI et al.

manner as the confrontation naming task). Word length was also balanced
across sets. Stimulus words are listed in Appendix B.

Administration of Probes
For the confrontation naming probe, the subject was instructed to name
the pictures. For the picture description task, the subject was asked to
describe what was happening in each picture. If her description of any
picture failed to include an attempt to name the targeted stimulus words,
the prompt “Can you tell me anything else about the picture?” was offered
once by the clinician.

Table 1. Scoring Scale for Confrontation Naming and Picture

Description Probes”
Responses Scoring 2 Poinrs
2-a Effective single word-word that is accurate. delayed, distorted, or self-
2-b Effective circumlocution-specific description of target word that allows target
to be identified with context unknown.
2-c Effective gesture-accurate and precise gesture judged to be intelligible to all
2-d Effective written word-target word spelled correctly and written intelligibly.
2-e Effective written phrase-phrase spelled correctly and written intelligibly that
specifically describes target.
2-f Effective drawing-accurate and recognizable drawing of the target-
recognizable to all viewers.
2-g Effective multiple responses-response that combines one or more categories
to ultimately produce an accurate and intelligible response.

Responses Scoring 1 Point

l-a Semantic paraphasia-word in the same semantic category as the target.
l-b Phonemic paraphasia-attempt contains sound substitutions; however, it bears
a phonetic resemblance to the target word.
I-C Weak circumlocution-phrase that provides a general description of the target;
however, target cannot be identified with context unknown.
l-d Weak gesture-gesture is imprecise; judged to be intelligible to some viewers.
l-e Weak written word-target word is misspelled or intelligibility is impaired.
l-f Weak written phrase-phrase is misspelled or intelligibility is impaired.
1-g Weak drawing-drawing is imprecise; judged to be recognizable to some
l-h Weak multiple responses-response that combines one or more categories to
produce an approximation of the target word.

Responses Scoring 0 Points

0 Incorrect responses--these include unrelated words, neologisms, perseverative
responses, and echoed responses. Unintelligible responses-spoken,
gestural, written, or drawn-are also included.

a The number represents the point credit assigned to the response.


Scoring of Probes
All probe sessions were videotaped for scoring purposes. All naming re-
sponses were scored on a multidimensional scale based on communicative
effectiveness (see Table 1). Scores on this scale ranged from a maximum
score of 2 for responses that effectively communicate the target word to
a score of 0 for incorrect responses. On the confrontation naming task,
the maximum possible score was 30 points; on the picture description
task, the maximum score was 16 points. Naming efficacy on each task
was measured by a percentage score composed of the patient’s score
divided by the maximum possible score.
An independent observer restored 25% of the probes for reliability
purposes. Interjudge reliability was found to be 91%.


Confrontation Naming Task

Figure 2 displays the subject’s percentage of correct responses on the
confrontation naming probes. Visual examination of Figure 2 reveals a
stairstep effect, with greater improvement reflected on the PACE phases
of treatment. Following a low rate of correct responses under base-line
conditions, the subject did not demonstrate observable improvement on
Phase l-the initial phase of traditional therapy. She did exhibit steady
improvement (from 57% to 70% correct) on Phase 2-the initial phase of
PACE therapy. After a plateau in performance during. Phase 3 (traditional

Figure 2. Percentage of responses correct on confrontation naming probes.

BL%X?lllX Tradltlona PACE Tradltlonal PACE










0 0
^_ ,
> I tl 9 10 Ll 12 13 14 15-16 17 18 iY 20

498 E. C. LI et al.

therapy) the patient improved during Phase 4 (PACE therapy) to achieve

80% correct at the conclusion of the experimental sessions. Percentage
scores on probe tests are provided in Appendix C.
In order to provide more information on the types of responses that
contributed to the confrontation naming results, individual response cate-
gories were analyzed on the confrontation naming task. Responses on all
confrontation naming tests were totaled and the proportion of responses
within each response category was tallied (see Table 2). Only percentages
greater than 2% were listed. Seventy percent of the responses fell into
three response categories: effective single-word responses, circumlocu-
tions, and incorrect responses.
To examine how individual response categories changed during the
treatment sequence, the proportion of individual responses in each re-
sponse category was calculated (see Table 3). Table 3 reveals several
trends. First, the number of effective single-word responses did not
change appreciably during the four phases of treatment. However, the
proportion of incorrect responses declined during the first PACE phase
(Phase 2) as the subject showed greater frequencies of effective and weak
circumlocution, effective multiple responses, and semantic paraphasias.
During the second PACE phase (Phase 4), increases in effective circum-
locution and in effective multiple responses were seen. Thus, the two
response categories that consistently increased during PACE therapy
were effective circumlocution and effective multiple responses. Appar-
ently, the patient’s increased use of these two communicative strategies
accounted for her decrease in naming failures.

Picture Description Task

Figure 3 displays the subject’s percentage of correct responses on the
picture description probes. Both Phase 1 and Phase 3 (traditional therapy)
reflected the relatively low levels of performance shown on base-line mea-
sures. Steady improvement was demonstrated on Phases 2 and 4 (PACE

Table 2. Percentage of Subject

Responses in Each Category

Category Percentage

Effective single word 25%

Effective circumlocution 7%
Effective multiple response 7%
Semantic paraphasia 7%
Phonemic paraphasia 5%
Weak circumlocution 28%
Incorrect response 17%
Table 3. Percentage of Responses in Each Response Category per Treatment Phase
Effective Effective multiple Semantic Phonemic Weak Incorrect
single word circumlocution response paraphasia paraphasia circumlocution response

Phase 1 24% 0% 0% 9% 7% 20% 39%

Phase 2 25% 3% 9% 11% 3% 32% 9%
Phase 3 28% 9% 5% 3% 7% 32% 15%
Phase 4 i3% 15% 12% 4% 3% 28% 4%

_. _~I -. _ ..> >~ _ - I - .a _ *._ -> - . c . .

500 E. C. LI et al.

Baselln~ Tradltiona PACE Traditional











0 I
2 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


Figure 3. Percentage of responses correct on picture description probes.

therapy). For instance, during Phase 4, the patient progressed from 25%
to 50% effective naming performance. Percentage scores on the probe
tasks are provided in Appendix C.

The patient demonstrated observable improvement during the PACE
phases of therapy-a trend absent during the traditional phases. Improve-
ment associated with PACE was evidenced on confrontation naming and
picture description tasks.
A stairstep effect was seen on the confrontation naming probes. The
individual response categories that consistently improved during PACE
therapy were effective circumlocution and effective multiple responses
(see Table 3). Following the introduction of PACE therapy, the subject
was able to apply these communicative strategies when she encountered
naming difficulties. Rather than “give up” when unable to name the tar-
get, the patient frequently described the object. For example, for the
target word “basket” she produced the following circumlocution: “some-
thing you put food in so you could go outside and go someplace to eat-
you could carry that, too.” The patient also learned to pair gestures with
her verbal circumlocutions (effective multiple responses). The develop-
ment of alternative strategies of communication were particularly helpful
to this patient since she was two years post-CVA. It is suspected that her
language performance had stabilized to such a degree that any improve-

ment in communicative skills was due largely to the ability to compensate

for her naming impairment.
Aside from specific communicative behaviors, the patient’s mood and
responsiveness to communication also improved during PACE therapy.
She tended to relax and exhibit more spontaneity when she was encour-
aged to focus on “getting the message across,” rather than supplying
specific target words. She genuinely enjoyed alternating roles as speaker
and listener during the interaction sequences.
In comparing confrontation naming to pictures description tasks, the
stairstep effect exhibited during confrontation naming probes was not
evident on the picture description probes. The subject’s performance on
Phases 3 and 4 mirrored her performance on Phases 1 and 2. Why did
the subject not register additional gains during the latter experimental
phases? A possible explanation lies in the nature of the picture description
task-picture description resembles natural conversation more closely
than confrontation naming. Consequently, greater linguistic demands
(e.g., sentence formulation) are placed on the speaker during the picture
description situation. The concentrated schedule of the treatment sessions
(daily basis for four weeks) may not have allowed the patient sufficient
time to generalize her improved naming abilities to the picture description
task. Thus, the later experimental sessions did not improve over the ear-
lier sessions.
In summary, this study provides evidence for the effectiveness of PACE
therapy when compared to traditional stimulation therapy. Although there
is a need for replication of these results on additional subjects, the current
data suggest that PACE therapy is effective when applied to naming dis-
orders. When this patient was encouraged to utilize her unique strengths
in a meaningful communication context, she developed effective strate-
gies to compensate for her naming deficits.



High Frequency
Sets 1 2 3 4 5

basket bed bell bone book

church car cup door feet
flag hat horse house lion
pie pipe rope ring safe
tent tree watch whistle CU

cow bear cloud bread cake

chain dog desk window fence
8 goat flower hand horn key
9 IamP leg tire suit rain
10 tie train wagon phone table
E. C. LI et al.

Low Frequency
Sets 1 2 3 4 5
1 accordion asparagus harmonica camel canoe
2 broom bench comb hanger mask
3 stilts scissors snail pelican wreath
4 toothbrush scrool hammock dart mushroom
5 pyramid pencil noose knocker volcano



High Frequency
Sets 1 2 3 4 5

1 band keys flower fish nail

2 teacher money girl doctor stairs
3 apple horse table nurse ball
4 letter tree farm tire tire

Low Frequency
Sets 1 2 3 4 5

1 clown towel rabbit hook hammer

2 bus bathroom carrot dinosaur flashlight
3 luggage cowboy picnic museum pond
4 umbrella monkey barn bike fireman


Session Session Session Session Session
1 2 3 4 5

Base-line 37% 47% 40%

Phase 1: Traditional 47% 40% 37% 43% 47%
Phase 2: PACE 57% 60% 67% 70% 70%
Phase 3: Traditional 70% 63% 67% 60% 63%
Phase 4: PACE 70% 73% 77% 77% 80%


Session Session Session Session Session
1 2 3 4 5

Base-line 25% 31% 25%

Phase 1: Traditional 25% 25% 38% 25% 38%

Session Session Session Session Session

1 2 3 4 5

Phase 2: PACE 38% 38% 38% 50% 56%

Phase 3: Traditional 31% 25% 38% 31% 31%
Phase 4: PACE 25% 38% 44% 50% 50%

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