3/23/2012

NEW CONCEPTS IN THE

MANAGEMENT OF APHASIA:
PRACTICAL APPLICATION

Written and Presented By:

Kara Kozub O’Dell, M.A. CCC-SLP, BIS
Allied Health Manager, Neurological Recovery Unit
The Rehabilitation Institute of Chicago

APHASIA

APHASIA TREATMENT TECHNIQUES

Verbal Expression
 Combined
Semantic/Phonological
Cueing Hierarchy
 Complexity of Treatment in
Syntactic Deficits
 Constraint Induced Language
Treatment (CILT)
 Conversational Scripting
 Mapping Treatment
 Melodic Intonation
Treatment (MIT)
 Multiple Oral Reading
 Naming Complexity
Treatment
 Oral Reading for Language in
Aphasia (ORLA)
 Promoting Aphasic
Communication Effectiveness
(PACE)
 Prompts for Restructuring
Oral Muscular Targets
(PROMPT)
 Reciprocal Scaffolding
 Response Elaboration
Treatment
 Schuell’s Stimulation
Approach
 Semantic Feature Analysis
 Semantic Cueing Hierarchy
 Sentence Production Program
for Aphasia (SPPA)-
 Supported Conversation for
Adults with Aphasia
 Thematic Language
Stimulation
 Treatment for Aphasic
Perseveration
 Treatment of Underlying
Forms
 Voluntary Control of
Involuntary Utterances

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APHASIA TREATMENT TECHNIQUES

 Auditory Comprehension
 Auditory Comprehension
Training
 Auditory Retention &
Comprehension Tasks
 Complexity of Treatment
in Syntactic Deficits
 Conversational Scripting
 Language Oriented
Treatment
 Mapping Treatment
 Reciprocal Scaffolding
 Schuell’s Stimulation
Approach
 Supported Conversation
for Adults with Aphasia
 Thematic Language
Stimulation
 Reading Comprehension
 Multiple Oral Reading
 Oral Reading for
Language in Aphasia
(ORLA)
 Schuell’s Stimulation
Approach
 Supported Conversation
for Adults with Aphasia
 Thematic Language
Stimulation

APHASIA TREATMENT TECHNIQUES

 Written Expression
 Agraphia Treatment
 Copy and Recall
Treatment (CART)
 Promoting Aphasic
Communication
Effectiveness (PACE)
 Reciprocal Scaffolding
 Schuell’s Stimulation
Approach
 Supported
Conversation for
Adults with Aphasia
 Thematic Language
Stimulation
 Non-Verbal
Communication
 Back to the Drawing
Board
 Promoting Aphasic
Communication
Effectiveness (PACE)
 Supported
Conversation for
Adults with Aphasia
 Visual Action Therapy

APHASIA TREATMENT TECHNIQUES

 Motor Speech
 Back to the Drawing
Board
 Dabul & Bollier
 Prompts for
Restructuring Oral
Muscular Targets
(PROMPT)
 Rosenbeck
 Sound Production
Treatment
 Techniques for
Speechless Apraxic
patient
 Wambaugh

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Research:
Evidence

Change in
Thinking: New
Concepts

Approaches to
Managing
Aphasia

Clinical Practice

“NEW” CONCEPTS
 Intensity

 Technology

 Life Participation

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BARRIERS TO APPROACHES
 Challenges to incorporating new
concepts and implementing new
approaches
 Time
 Patient population
 Setting
 Access to materials, CEUs, knowledge
 Payer requirements

EXPANDED DEFINITION OF
EVIDENCE BASED PRACTICE :
SACKETT, ET AL, 2000

Evidence
Based
Practice

Clinical Best Current

Client Values
Expertise Research

PRINCIPLES OF NEURAL PLASTICITY

1. Use it or lose it
2. Use it and improve it
3. Specificity
4. Repetition matters
5. Intensity matters
6. Time matters
7. Salience matters
8. Age matters
9. Transference
10. Interference

(Kleim & Jones, 2008)

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CLINICAL APHASIA EVIDENCE FOR

PRINCIPLES OF EXPERIENCE-
DEPENDENT PLASTICITY
1. Timing of treatment delivery
2. Use it or lose it
3. Generalization or transfer of treatment effects
4. Intensity of treatment

(Raymer, et al, 2008)

INTENSITY: NEW CONCEPTS

 There is conflicting evidence as to whether or not
speech and language therapy is efficacious in
treating aphasia
 Most positive studies provided intense therapy over a
short period of time
 Most negative studies provided less intense therapy
over a longer period of time

INTENSITY: THE EVIDENCE

Study N Methods Intensity of Therapy Outcome Result
Bakheit et al. 2007 97 Patients post first stroke were assigned to either 5  5 hours/week or 2 hours/week for  Overall , no significant differences noted in performance  ‐
one hour sessions/week or 2 one hour  12 weeks on WAB between standard and more intensive therapy.  
sessions/week; WAB given at 4, 8, 12 and 24 weeks None of the patients assigned to intensive group finished 
their course.

Brindley at al. 1989 10 Patients with Broca’s aphasia per BDAE without  5 hours over 5 days a week for 12  Significant improvement on FCP. +

predominate apraxia 1 year post stroke weeks

Lincoln, et al. 1984 327 Aphasic patients 10 weeks post stroke randomized  2 one hour sessions/week for 34  Both groups demonstrated improvement, but no  ‐

to either receive 2 one hour sessions for 34 weeks  weeks significant improvement between groups.
or no treatment

Marshall et al.  1989 121 Males 2‐12 weeks post onset from a single left  8‐10 hours/week for 12 weeks  At 12 weeks, the SLP group showed significantly more  +

hemisphere thrombosis infarct were randomized  improvement than the deferred therapy group, but home 
to home therapy by wife, friend or relative,  therapy group did not differ from SLP therapy group.  
therapy by SLP or therapy by SLP deferred for 12 
weeks.

Poeck et al. 1989 160 Aphasic patients with only L hemisphere  9 hours/week for 6‐8 weeks Gains were significant for both the treatments and  +/‐

involvement as shown by CT and beyond the acute  control groups.
stage.  Patients received intensive treatment for 9 
hours/week for 6‐8 weeks and results were 
compared with a previous study of 92 patients 
who did not receive therapy.

Wertz et al. 1986 121 Male veterans under age 75 years of age who were  8‐10 hours/week for 12 weeks Clinic patients performed significantly better on PICA  +

2‐4 weeks post onset of single thromboembolic  than those deferred.  No significant difference between 
stroke.  Patients demonstrated language severity  home and clinic groups.  No significant difference 
in the 10th‐80th percentiles on the PICA and were  between any group after 24 weeks.
randomized into 8‐10 hours therapy/week for 12 
weeks followed by 12 weeks of no treatment or 8‐
10 hours/week of treatment by a volunteer for 12 
weeks followed by no treatment for 12 weeks or 
treatment deferred for 12 weeks followed by 12 
weeks of treatment by an SLP

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INTENSITY : NEW CONCEPTS

 Intense therapy over a short amount of
time could improve outcomes for patients
with aphasia
 Positive treatment effects for a mean of 8.8 hours of
therapy/week for 11.2 weeks

VERSUS

 Negative studies that provided 2 hours/week for 22.9

weeks

(Bhogal et al., 2003)

INTENSITY : APPROACHES
 Oral Reading for Language in Aphasia (ORLA)
 Oral expression + reading comprehension + written
expression
 Conversational Scripting
 Oral expression + auditory comprehension
 Constraint Induced Aphasia or Language Therapy
(CIAT or CILT)
 Oral expression
 Copy and Recall Treatment (CART) With
Repetition of a Spoken Model
 Written expression + oral expression
 Anagram and Copy Therapy (ACT)
 Written expression

ORAL READING FOR LANGUAGE

IN APHASIA
 Initially developed based on neuropsychological
models of reading
 Improvements may occur in other modalities,
including oral and written expression
 Incorporates repetitive multimodality stimulation
and practice
 Strengthens lexical information, so that the benefit
extends to other modalities
 Technique may be efficacious in treating apraxia
because it incorporates three elements—rhythm,
pacing, and linguistic templates

(Cherney, 1995, 2004)

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ORAL READING FOR LANGUAGE IN APHASIA

 Purpose
 Improve reading comprehension by providing practice in
grapheme-to-phoneme conversion
 Improve oral expression and auditory comprehension of
sentences by strengthening the lexical-semantic system
 Appropriate Patients
 Patients with various severity levels of fluent and non-
fluent aphasia
 Materials
 Sentences and paragraphs up to 100 words in length
 Procedures
 SLP sits across from patient
 SLP reads stimulus aloud pointing to each word as
he/she reads it

ORAL READING FOR LANGUAGE IN APHASIA

 Procedure (cont’d)
 SLP reads stimulus again with both SLP and patient
pointing to each word
 SLP and patient read stimulus aloud together with patient
pointing to each word; repeat, varying rate and volume
 For each line or sentence, SLP states word for patient to
identify
 For each line or sentence, SLP points to a word for patient
to read
 Patient reads stimulus aloud (SLP helps as needed)
 Resources
 Cherney, LR (2004)
 Cherney, L, Merbitz, C and Grip, J (1986)
 Cherney, LR (1995)

ORAL READING FOR LANGUAGE IN APHASIA

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ORAL READING FOR LANGUAGE IN APHASIA

 Sample Goals
 Severe aphasia: reading comprehension
 Moderate aphasia: oral expression
 Mild aphasia: written and oral expression

 Patient will achieve 80% accuracy reading

comprehension of 3-5 word sentences with moderate
cues.
 Patient will achieve 100% accuracy oral expression
while reading 3-5 word sentences aloud in unison
with SLP with maximal visual and verbal cues.
 Patient will write 3-5 word sentences to describe
pictures, actions or thoughts with 85% accuracy with
moderate cues.

ORAL READING FOR LANGUAGE IN APHASIA

ORAL READING FOR LANGUAGE IN APHASIA

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CONVERSATIONAL SCRIPTING
A “script” is a series of functional
sentences spoken in routine
communication situations
 Also utilized with patients with autism to
focus on “turn taking”
 Can be used with patients with AAC
devices
 Principle: generalization or transfer

CONVERSATIONAL SCRIPTING
 Purpose
 To facilitate communication and participation in
conversational exchanges specific to routine activities
 Patients can focus on speech initiation, turn-taking
and socialization once scripts become “automated”
 Appropriate Patients
 Patients with multiple levels of aphasia severity
 Materials
 Completed needs assessment to determine patient’s
communication needs and interests
 A script
 Procedures
 Mass practice with a specific script

CONVERSATIONAL SCRIPTING
Customer Service Rep (CSR): Hello, this is Comcast. How can I help you?
Patient (P): Yes, I need to pay my cable bill.

CSR: May I have your phone number?

P: Yes, it’s 555-1212.

CSR: Thank you. Can you verify your address, please?

P: It is 345 East Superior Street in Chicago, Illinois.

CSR: Your bill this month is $124. How do you wish to pay?
P: With my MasterCard on file, please.

CSR: Thank you. Can you verify the last 3 digits, please?
P: Yes, four seven two.

CSR: Thank you. Your card has been charged and your payment will be reflected
on your account. Is there anything else I can do for you today?
P: No, thank you.

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CONVERSATIONAL SCRIPTING
 Resources
 The Center for Spoken Language Research
http://cslr.colorado.edu/beginweb/skriptalk.html
 RIC: The Rehabilitation Research and Training
Center on Technology Promoting Integration for
Stroke Survivors: Overcoming Societal Barriers
http://www.rrtc-stroke.org/research/r3.php
 Cherney, Halper, Holland & Cole, (2008)
 Sample Goals
 Patient will use a specific script to take four
conversational turns at the sentence level, given
minimal cueing after one review.
 Patient will express three wants, needs or
preferences via use of a specific script at the word
level in 75% of trials with moderate cues after review
x3.

CONSTRAINT INDUCED
LANGUAGE THERAPY (CILT)
 Extended from traditional forced use
paradigms
 Patients with chronic aphasia use most
accessible communication channels
 Major components: forced use AND
massed practice
 Principle: Use it or lose it

CONSTRAINT INDUCED LANGUAGE

THERAPY(CILT)
 Purpose
 Create an environment that constrains patients to
systematically complete intensive practice of speech
acts with which they have difficulty
 Limit the use of writing, gesturing, drawing or giving
up on a message all together in order to promote oral
expression
 Appropriate Patients
 Patients with chronic aphasia
 Materials
 Routine therapy tasks (games, PACE, conversation)
 Procedures (Example: “Go Fish”)
 All communication must be spoken words

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CONSTRAINT INDUCED LANGUAGE

THERAPY(CILT)
 Procedure (cont’d)
 Each patient selects a card (dog) and requests the
object on the card without showing it to the other
players (clinician changes level of difficulty as
appropriate i.e. “dog” vs. “Do you have a dog?”)
 Other players respond verbally in the appropriate
manner (i.e. “here” vs. “I have a dog”)
 Treatment is provided on an intensive schedule that
varies by protocols (3 hours+ hours/day at least 5
days a week)
 Resources
 Cherney, L, et al. (2008)
 Maher, LM, Kendall, D, et al. (2006)

CONSTRAINT INDUCED LANGUAGE

THERAPY (CILT)
 EVIDENCE SUMMARY:

 Positive effects of CILT and intensive aphasia

treatment primarily for individuals with nonfluent
chronic aphasia
 CILT can result in improved language function and
everyday communication for those patients with
aphasia
 Need additional research, contrasting forced
language use and treatment intensity in individuals
with acute aphasia and those with fluent types of
aphasia

CONSTRAINT INDUCED LANGUAGE

THERAPY(CILT)
 Sample Goals
 80% accuracy verbal expression of single words
during a structured task following a model with
moderate cues.
 Patient will verbally express a sentence length
response to a question given minimal assist in 80% of
trials.

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COPY AND RECALL TREATMENT WITH

REPETITION OF A SPOKEN MODEL
(CART+REPETITION)

 Lexical retrieval difficulties affect written and

spoken language
 CART created to improve orthographic
representations in patients with aphasia
 Engages both phonological and orthographic
processing of lexical items

COPY AND RECALL TREATMENT WITH

REPETITION OF A SPOKEN MODEL
(CART+REPETITION)
 Purpose
 Pairs writing treatment with repeated oral naming
practice to improve written and oral naming of target
words
 Appropriate Patients
 Patients with moderate aphasia who have naming
deficits
 Materials (Word Level)
 List of 20 relevant common and proper nouns
 Recorder with pre-recorded productions of target
words with picture cards for each target

COPY AND RECALL TREATMENT WITH

REPETITION OF A SPOKEN MODEL
(CART+REPETITION)
 Procedure
 A line drawing of one of the 20 target words is presented;
the patient is cued to orally name and write the word
 A spoken or recorded model is presented and the patient is
cued to “listen, repeat and copy”
 Unsuccessful oral responses are followed by opportunities
for the patient to achieve correct production by prompting
verbalization three times (“It sounds like this. Coffee. Can
you say it? Say it again. One more time.”)
 Unsuccessful written responses are followed up by
presenting a handwritten model of the word and cueing the
patient to write it three times (“It looks like this. Coffee.
Can you copy it? Write it again. One more time, write
coffee.)

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COPY AND RECALL TREATMENT WITH

REPETITION OF A SPOKEN MODEL
(CART+REPETITION)
 Procedure (cont’d)
 Remove all examples of written words and prompt
patient to name a picture. Whether or not it is correctly
named, have the patient listen to the target word. Do
this three times.
 Next, have the patient write the target without a
written model. Have them write it three times, giving
feedback and covering their attempt after each.
 It is recommended that 10 targets are used each session
until 80% accuracy is achieved.
 Homework requiring patient to use an audio recording
to listen to word, name and then write 20 times is given
and should take 30-60 minutes to complete.

(CART+REPETITION)

(CART+REPETITION)

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COPY AND RECALL TREATMENT WITH

REPETITION OF A SPOKEN MODEL
(CART+REPETITION)

 Resources
 Beeson, PM, Rising, K & Volk, J (2003).
 Beeson, PM & Egnor, H (2006).

 Sample Goals:
 Patient will name and write a set of 5 pictures/objects
on the 4th trial following 3 verbal and 3 written
productions of each target word with 80% accuracy
with minimal cues.
 Patient will name and write a set of 5 pictures/objects
following guided copy practice with 80% accuracy and
moderate cues.

ANAGRAM AND COPY TREATMENT (ACT)

 Purpose
 Provides patients with a core set of specific written words
to communicate basic wants and needs
 Improves link between graphemic representations and
semantics (spelling)
 Principle: Timing of treatment delivery
 Appropriate Patients
 Non-verbal patients with severe aphasia
 Materials
 A core set of approximately 20 words, 3-9 letters in length
 Procedure
 Patient is asked to write a word and is shown a picture of
the target; a semantic cue may also be provided

ANAGRAM AND COPY TREATMENT (ACT)

 Procedure (cont’d)
 If the target is correctly written, move to the next item.
If it is NOT correct see the steps below
 Present component letters in random order and ask the
patient to manipulate them to spell the word
 Once the word has been correctly spelled, the patient
copies it 3 times
 After copying 3 times, the written copies are removed
and the spelling is assessed 3 times
 Reference
 Beeson, PM, Hirsch, FM & Rewega, MA (2002)
 Sample Goals
 Patient will achieve 80% accuracy of spelling (as a
precursor to written expression ) of a core set of 10
words when presented with component letters in
random order with moderate cues.

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ANAGRAM AND COPY TREATMENT (ACT)

ANAGRAM AND COPY TREATMENT (ACT)

ANAGRAM AND COPY TREATMENT (ACT)

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ANAGRAM AND COPY TREATMENT (ACT)

ANAGRAM AND COPY TREATMENT (ACT)

TECHNOLOGY
 Provide limitless opportunities for
interactive language activities
 Computers
 Programs
 Internet
 E-Mail

 Mobile Phones
 E-Readers

 AAC

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TECHNOLOGY: COMPUTERS

Considerations
 Accessibility
 Voice recognition software
 Enlarged keyboards
 ABCDEF vs. QWERTY

 Instruction
 Range of programs
 Therapeutic programs, photo programs, greeting
cards, games, e-mail, etc.
 Features of programs
 Spell check / thesaurus

TECHNOLOGY: COMPUTERS
 Computer based aphasia therapy
 Provides a means for massed practice and increased
intensity
 Minimizes therapist time and resources
 Computerized programs
 AphasiaScripts™ (The Rehabilitation Institute of Chicago, 2007)
 ORLA™ (The Rehabilitation Institute of Chicago)
 Parrot (Parrot Software, West Bloomfield, Michigan)
 Bungalow (Bungalow Software, Inc., Blacksburg, Virginia)
 SentenceShaper ® (SentenceShaper Software; Psycholinguistic
Technologies, Inc., Elkins Park, Pennsylvania)

 Evidence
 Computer based interventions can improve language
skills at the impairment level, but there is limited
evidence that improvements generalize to functional
communication

ORLA™ (The Rehabilitation Institute of Chicago)

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ORLA™ (The Rehabilitation Institute of Chicago)

AphasiaScripts™ (The Rehabilitation Institute of Chicago, 2007)

TECHNOLOGY: MOBILE PHONES

 84% of individuals with disabilities surveyed own
or have regular access to a mobile phone
 6 semi-structured interviews with individuals
with aphasia; 3 semi-structured observations of
individuals with phones in key scenarios
 18 barriers to mobile phone use

 Device design
 Small phone buttons, small screen, use of unclear
symbols in menus, too many features
 Written support and training
 Unclear user manuals, inadequate training in use
 Other
 Unique language used with texting, complexity of use

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TECHNOLOGY: MOBILE PHONES

 9 factors that may help
 Design
 Labels on all controls
 Keyboards arranged in alphabetical order (not
QWERTY)
 Use of texting vs. voice communication
 Word prediction software
 Preprogrammed numbers
 Flip open handsets
 Written support and training
 Adequate support and training
 Written cues and images in instructions
 Familiar communication partner
(Morris and Mueller, 2010)

TECHNOLOGY: MOBILE PHONES

 Smart Phone and Tablet Apps
 Lingraphica®
 SmallTalk Aphasia
 SmallTalk Phonemes
 Small Talk Conversational

Phrases
 Small Talk Daily Activites

 MyVoice™: Communication
Aid
 Tactus Therapy Solutions:
TherAppy
 Comprehension
 Naming
 Reading

 Writing

TECHNOLOGY: MOBILE PHONES

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LIFE PARTICIPATION
 Internal Classification of Functioning, Disability,
and Health (ICF) Framework
 Implementation in 2001 with unanimous
endorsement of the classification by the 54th World
Health Assembly
 Healthcare classification framework for describing
and measuring health and disability
 Used for functional status assessment, goal setting &
treatment planning and monitoring, as well as
outcome measurement in clinical setting
 Takes into account the social aspects of disability

ICF: DEFINITIONS
 Impairments: problems in body function or
structure such as a significant deviation or loss.
 Activity: the execution of a task or action by an
individual.
 Participation: involvement in a life situation.

 Activity Limitations: difficulties an individual may

have in executing activities.
 Participation Restrictions: problems an individual
may experience in involvement in life situations.
 Environmental Factors: make up the physical,
social and attitudinal environment in which
people live and conduct their lives.

LIFE PARTICIPATION APPROACH

TO APHASIA (LPAA)
 Call for a broadening and refocusing of clinical
practice and research on the consequences of
aphasia
 Focus on re-engagement in life

 Places life concerns of those affected by aphasia

at the center of all decision making
 Empowerment and collaboration on interventions
may lead to more rapid return to active life and
reduce the consequences that lead to long-term
health costs

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LIFE PARTICIPATION APPROACH

TO APHASIA (LPAA)
 Assessment includes determining relevant life
participation needs
 In addition to assessing communication and
deficits, clinicians should be equally interested in
how the patient does with support
 Clinicians take on take on roles in addition to
doing therapy, such as “communication partner”,
“coach” or “problem solver”
 Clinicians evaluate and document on:
 Life activities and satisfaction
 Social connections and satisfaction
 Emotional well-being
(Chapey, et al, 2010)

SOCIAL PARTICIPATION OF STROKE

SURVIVORS WITH APHASIA
 Impact of stroke – Are survivors with aphasia
different from those without?
 126 participant divided into two groups (aphasia and
no aphasia) and surveyed at 2 weeks, 3 months and 6
months post onset
 Outcomes improved significantly over time
 Scores comparable for:
 Physical abilities
 Well being
 Social support

 Scores for people with aphasia significantly lower

than those for people without aphasia on:
 Participation in activities
 Quality of life
(Hilari, 2011)

SOCIAL PARTICIPATION OF STROKE

SURVIVORS WITH APHASIA
 Interviews (adapted to communication needs of
the individuals) of 150 stroke survivors with
aphasia
 Variation in social participation
 Low home integration scores (finances, childcare,
housework, meals, etc.)
 Low productivity scores (work, retirement, education,
volunteer, etc.)
 Age, gender, performance on ADLs and aphasia
severity related to social participation

(Dalemans, et al. 2010)

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LIFE PARTICIPATION
 Severity of aphasia
 Environment
 Activity participation

 Person, identity, attitude and feelings

versus

 Traditional language domains

 Functional communication abilities

LIFE PARTICIPATION
 Communication Disability Profile - CDP (Swinburn &
Byng, 2006)

 The Stroke and Aphasia Quality of Life Scale-

SAQUL-39 (Hilari et al, 2003)
 The Burden of Stroke Scale – BOSS (Doyle et al., 2002)

 The ASHA Quality of Communication Life -

ASHA-QCL (Paul et al, 2003)
 The only tool that assesses communication confidence
 “I am confident that I can communicate”

 Confidence: “a feeling or consciousness of one’s

powers” (Miriam Webster Online)

LIFE PARTICIPATION
 Supported Conversation for Adults
with Aphasia (SCA)
 Group Therapy: Book clubs,
conversation groups

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SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
 An emphasis on the social unit of dyad
incorporating the conversation partner, rather
than sole focus on the person with aphasia.
 Interaction/social connection is given as much
weight as transaction/exchange.
 The person with aphasia is treated as a
competent person capable of making decisions, if
appropriate support is provided.
 Social & societal barriers to conversation &
participation in daily life are taken into account
with a commitment to providing the support
necessary to decrease these barriers.
 Principle: Use it or lose it; generalization

(Aphasia Institute, 2004)

SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
 Purpose
 Provide an “assistive device” for communication by
emphasis on incorporating the conversational partner
 Technique is not just used in therapy, but in daily
interactions
 Appropriate Patients
 Patients with all types and severities of aphasia
 Materials
 BLACK marker
 Unlined paper
 Pictures, photos, drawings

SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
 Procedures
Step 1: Acknowledge Partner’s Competence
 Strive for feel / flow of natural adult conversation
 Use appropriate tone and sense of humor
 Handle incorrect / unclear responses respectfully
 Encourage partner when appropriate
 Acknowledge competence when partner is
upset/frustrated
 “I know you know what you want to say”
 Take on communicative burden as appropriate to
help partner to feel comfortable

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SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
Step 2: Reveal Competence
 Ensures that the adult with aphasia understands

 How much support is provided relative to what’s

needed?
 Verbal – short, simple sentences, redundancy /
repetition, verbal adaptation
 Nonverbal – gesture, writing, pictures /
resources, drawing
 Response to communicative cues – reacting to
facial expressions that indicate lack of
comprehension

SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
Step 2: Reveal Competence (cont’d)
 Ensures that the adult with aphasia has a means
of responding
 Verbal – fixed choice, yes/no
 Nonverbal – gesture, writing, resources, drawing
 Response to communicative cues – giving enough time
to respond

SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
Step 3: Verification
 Accuracy of adult with aphasia’s response not
automatically assumed
 Verbal – “So let’s see if I’ve got this right…”
 Nonverbal – gesture, writing, resources, drawing
 Response to communicative cues – appropriate
handling of inconsistent yes/no responses

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SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)
 Resources
 Kagan, A (2004)
 Kagan, A (2001)
 Sample Goals
 Patient will express 3 wants, needs or ideas during a
5 minute supported conversation via total
communication with maximal assist
 Patient will comprehend and express a variety of
topics during a 5 minute supported conversation with
no more than 2 communication breakdowns with
moderate assist

WHY SCA WORKS

 Aphasia can be defined as an acquired
neurogenic language disorder that may mask
competence normally revealed in conversation.
 There is an interactive relationship between
perceived competence & opportunity for
conversation.
 The ability & opportunity to engage in
conversation & reveal competence lie at the heart
of “communicative access” to participation in
daily life.
 Competence of people with aphasia can be
revealed through the skill of the conversation
partner who provides a “communication ramp”
for increasing communicative access.
(Aphasia Institute, 2004)

SCA MATERIALS
AVAILABLE FOR PURCHASE FROM NATIONAL APHASIA
INSTITUTE

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SUPPORTED CONVERSATION FOR

ADULTS WITH APHASIA (SCA)

GROUP THERAPY
 Different methods and types of groups
 Engagement is critical in order to be maximally
successful
 Process by which people establish, maintain and
terminate collaborative interactions
 Clinician facilitates and monitors to prevent an
individual session with observers
 Appropriate support should be provided
 Cue for strategies and total communication: gestures,
scripts, picture choices, etc.
 Principle: Use it or lose it and generalization

GROUP THERAPY
 Rules of Engagement
 Structure seating to promote engagement
 Clinicians as participants
 Monitor signals of engagement
 Gaze
 Body language/position
 Shared laughter, frustration, other emotions

 Gesture

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GROUP THERAPY
 Purpose
 Cost effective way to maximize limited language
therapy resources
 Provide opportunity for and encourage social
interactions, practicing of communication strategies
and peer support
 Evidence
 There is moderate evidence that group intervention
results in improvements on communication and
linguistic measures among individuals with chronic
aphasia.
 There is limited evidence that group therapy results
in improved communication.

Research:
Evidence

Change in
Thinking: New
Concepts

Approaches to
Managing
Aphasia

Clinical Practice

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 Thank you to Kathryn Miller, MS, CCC-SLP and Lisa Naylor, MA CCC-SLP for
their assistance with videotaping examples for this presentation.

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