Helping Clients With Aphasia Retrieve Words—On Their Own

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Eric Broder Van Dyke / Shutterstock.com

“I can’t hear it!” This was said by Mrs. A, a 67-year-old woman with aphasia, who actually hears fine. What she meant to say is that she can’t recall the sequence of sounds to express a particular word or idea. When we have that tip-of-the-tongue loss of a name, how do we try to remember it? What strategies are we using to get to that word that we can’t remember?

Our success depends on our ability to hunt and gather—and on the number of neural connections we can tap into to access the information. These skills are cognitive, not simply learned operantly.

In my last blog post, I talked about establishing cueing hierarchies and functional activities for our adult clients. This post looks at using the cueing hierarchy to stimulate the rewiring process. Sometimes I think that I am a sort of electrician rather than an SLP. I work on finding the connections based on observed behavior from evaluations or activities (like writing, gesturing or drawing) that require least intervention.

How do we develop these skills? How can we teach strategies for short and long-term functional success?

Sometimes, we spend the therapy session working on the most disabled aspects of the communication disorder: comprehension, word retrieval, writing and reading. But if we don’t tap clients’ best abilities to foster some success, and if we don’t address whether they are continuing to practice these skills outside the therapy room, how will compensatory skills, adaptive skills and new connections work for them?

Let’s look at Mrs. A, who said, “I can’t hear it.” She was telling me about the very connection that she lacks due to her aphasia: re-auditorization. She can’t hear the words or the phonemes that make up the words in what I call “her mind’s ear.” If given the first phoneme, or a carrier phrase, she almost always names the word. She is able to write the word about 75 percent of the time but can only read it aloud about 30 percent of the time. She will often be able to speak complex multisyllabic words or a short phrase when discussing a topic. Auditory and reading comprehension is 75 percent for paragraphs. She is very intact cognitively, but her affect varies emotionally from congenially engaged to depressed and angry.

She is about two years post-stroke and has an all-in-one AAC that she doesn’t use. Our goals must address her frustration by establishing immediate successful compensatory strategies for communication. Then we need to build skills that will help in the rewiring, so that she begins to cue herself. The rewiring will be difficult here because she doesn’t link the phoneme to the letters she is able to write. But if she can write the word and then read it aloud more often, she can develop a clear strategy for verbalization that will reduce her frustration.

We will begin by simply reviewing phonetic placement in monosyllabic words. I like to use real words—which have semantic value—rather than nonsense syllables. Consonant-vowels alone don’t work as well as consonant-vowel-consonants that mean something. Mrs. A started relearning that a /b/ means that the lips come together when starting a whole word like “beer.” We chose beer for the visceral, emotional connection it has for many people. We talked about when she might drink beer, such as at a baseball game, which lends itself to picture assistance to boost cognitive links. We initially used a mirror to model the placement while sitting next to her. We highlighted the first letter and said it with her. She saw the picture, then wrote the word.

Mrs. A can now produce the whole word “beer” after seeing a picture of it. Looking at the Cueing Hierarchy, we have moved from most clinician involvement to independent self-cueing for this phoneme. She is moving on to more phonemes rapidly so that we may not need to review every letter after a period of time. Mrs. A. is beginning to generalize the link to other sounds. New neuro-behavioral links and relinks are helping her associate the orthographic letter with a physical movement and the sound that is produced. New cognitive links and self-cueing has begun!

Next, she will need to use the strategy in controlled conversation and small groups to increase her comfort level and functional use outside of treatment. This is a big hurdle. Families and caregivers are crucial players and need to be instructed how to encourage communication without frustration. When possible, teach the caregivers and families how the strategy works. They will use it more readily at home and will see how it can work in a variety of situations, such as in restaurants.

Another client, Mrs. C, had a similar functional ability to write but not verbalize. With time, she was able to trace the first letter in the air to cue herself to say a word.

In both cases, skills that had been present were improved, then used to create a compensatory strategy for functional communication. We must teach our clients strategies for improving the scope of their communication without our cues, using their own strategies, thereby making them more independently functional. While available strategies are unique to each client, they usually take the form of low tech gesturing, drawing, writing, even circumlocution.

We want our clients to be learning and improving communication dynamically. If we always fill in all of the sentences or speak for them, they cannot make their own connections. When allowed to use strategies independently, they then blossom, not only communicatively but socially.

Betsy C. Schreiber, MMS, CCC-SLP, is a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

Speech Therapy and Aging: Brain Plasticity and Cueing Hierarchies

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(photo credit)

Given our knowledge of the plasticity of the brain, are we as clinicians or caregivers, able to help to develop new links with a behavioral model, by using gradated cueing hierarchies?  Could this low-tech and pharmaceutical-free form of treatment  have neurologically based implications for rehabilitation and adaptation in communicatively challenging settings?

Perhaps more testing with fMRI scans may be necessary to really prove the theory. Therapy approaches using cueing models have been well documented in the literature in speech therapy treatment for aphasia.  However, the way we use clinician originated cues can help create new links and expedite a broad area of cognitive and linguistic improvement, or maintain the functional status quo, unless we analyze the kinds of cues we are using and the amount of independence we are carefully eliciting from the client.

By looking at each task and cue needed on a continuum from simple to complex, concrete to abstract, you can construct a grid of where on the continuum the client functions and how you can provide a cue or help them provide their own cues for success.

The idea that the damaged axons and dendrites in the brain are looking for connections and stay active when the brain is activated, prompted me to want to create a cueing continuum (see http://carmichaellab.neurology.ucla.edu/integrated-view-neural-repair-after-stroke.) On the theory that the client can develop new pathways , if we always fill in the missing word or provide the first phoneme, then the client will never have to learn where to get it, via their own written word, for example.  But how do we get from writing the word for the client to having the client write the word in the air and say it? It all depends on the residual abilities, but the concept can be applied to everyone.

We have a 60 year old gentleman with TBI who is learning how to semantically cue himself to find a word. Initially, he had severe speech and cognitive impairments. Now, in conversation, he often uses circumlocution to get his point across. However, sometimes specific words are warranted, and this is difficult for him. He can sometimes spell the word aloud even though he cannot speak it. We had him do this several times with great success. Our next task was to remind him that he could do this to help himself.  Later we only asked him what he would like to do.  We are helping him build those dendritic links ( and learn to use a skill) by carefully reducing the amount of clinician prompting or cueing during the sessions and writing down the strategies for him to practice at home. Although there are many approaches to cueing, none of them seem to describe cueing in a continuum from most invasive to most independent. Many clinicians describe the cues as semantic or phonemic.  I found that there were nuances in cueing that I had learned over the years to allow the client to gradually become independent. When I had difficulty transmitting these ideas to my students, I created a loose continuum to mark where our clients fell given specific objectives, and how we could get their neurons to get closer together behaviorally if not actually by breaking the cues down.

Along with the goals we establish for our clients, no matter their abilities, we must always be evaluating their behavior and trying new materials and varied activities to facilitate language.

As we converse with others, we derive cues from the environment and from the people with whom we are speaking (that is part of the reason why conversation amongst the adult neurologically language-impaired looks better than when we test them by looking for specific words and longer utterances).

Our goal with cueing is to develop self-cues and elicit more language. A self-cue can be as basic as a gesture or a drawing, but if the client is doing it and communicating to me what he did for the weekend, then he has been successful. Often when the stress is lower or the focus is away from speaking, the words and incidental phrases flow more freely. The best reward is to see the expression on our client’s face when he says a few words effortlessly because he was engaged in the activity. But this is not we what we are trying to do. We are trying to give him real tools for those times he cannot utter a word.

When the client leaves the therapy room, we want him or her to be able to use their own skills, rather than rely on others. Since they may not be able to develop their own means of self-cueing, we include self-cue skill development as part of the therapy plan.  The client may or may not have the ability to provide his or her own cues, yet. But throughout the therapy and rehabilitation process, we work toward the skills of self-cuing no matter the level, such as writing, gesturing, drawing pictures, and talking about the item or activity with words that are available.

The Cueing Hierarchy Continuum is by no means linear, but will generally go from simple and most dependent to complex and independent. They follow the behavioral branches that may be used in clinic therapy logs. They are separated on my behavior grid in 3 categories: Clinician Assisted Cues, Clinician prompting (or reminding the client to use a strategy) and Self Correcting. This approach requires that the client learn about his strengths and how to implement them to improve what we would consider weaknesses. By identifying which cues are more dependent, we can be cognizant of allowing the client to work at a documented realistic level achieve the objective.

It is well documented that there is enough plasticity in almost any brain to stimulate, heal and renew brain function after a stroke or TBI. For cognitive loss during normal aging, the dementias and the progressive dementias, there is less clear documentation for which approaches are the most effective and pragmatic for our clients. However, similar principles can be used to establish functional objectives along with the family and caregivers.

How to develop skills? How to develop strategies for short and long-term functional success?  Sometimes, we spend the therapy session working on comprehension, word finding, writing and reading using a variety of materials.  But, if we don’t address what they are learning outside the therapy room, which they may visit one or two times a week, how will compensatory skills, adaptive skills and  new connections be utilized?   That will be the topic for next month’s post.

Betsy C. Schreiber, MMS, CCC-SLP, received a BA in Psychology and MMS Master of Medical Science in Speech Pathology from Emory University in Atlanta, Georgia. Her CCC was earned during the 3 years she worked at Hitchcock Rehabilitation Center in Aiken, South Carolina where she had the opportunity to learn about NDT and Sensory Integration with the original, Jane Ayres, working with LD and CP children and neurologically impaired adults. She is currently a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She has also served as an ASHA Mentor and hopes to participate in ASHA’s  Political Action Committee in the coming year. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.

“After Words”: The Story Behind the Film

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(photo credit - Aphasia Community Group) 

In 2000 I produced a program called “Faces of Aphasia,” which was held at Boston University. It aimed a spotlight on aphasia and the Aphasia Community Group of Boston. Now beginning its 24th year, the Group is one of the oldest support groups of its kind.

“Faces of Aphasia” introduced aphasia to the community through the performing arts. It featured the first public performance by acclaimed mezzo soprano Jan Curtis following her stroke. Actor/playwright Joseph Chaikin performed “Struck Dumb,” a monologue on the inner thoughts of an aphasic individual. “The Other Voices of Aphasia,” an original piece by group co-founder Judy Blatt, was performed by family members. A staged reading of “Night Sky” by Susan Yankowitz, a play about aphasia, was performed by individuals living with aphasia. It was filmed and used as a teaching tool in communication disorders graduate programs.

Inspired by “Faces of Aphasia,” Emmy Award winning filmmaker Vincent Straggas and I created the documentary “after words 2003,” which premiered in Boston in June, 2003. It featured vivid portraits of members of the Aphasia Community Group as well as internationally acclaimed celebrities such as Tony Award winner Julie Harris, Academy Award winner Patricia Neal, Grammy Award winner Bobby McFerrin, Robert McFerrin, and Annie Glenn Award winner Jan Curtis, all of whose lives were touched by aphasia and related disorders. “after words 2003” opened to wide acclaim and was embraced by the public and in academic, rehabilitation, community, and medical settings.

A new documentary, based on the original film, and comprised of new portraits and interviews has been produced and is currently airing on public television stations around the country. Co-produced by me, Vincent Straggas, ASHA fellow and executive director of the National Aphasia Association Ellayne Ganzfried, the new “after words” features neurologists, authors and clinicians including Nancy Helm Estabrooks, Ellayne Ganzfried, Jerome Kaplan, Howard Kirshner, Marjorie Nicholas, Oliver Sacks, Martha Sarno, and Gottfried Schlaug. It profiles individuals living successfully with aphasia, presents different types and severities of aphasia, including primary progressive aphasia, explores aphasia’s impact on families, discusses legal implications of aphasia, and explores the life participation approach to aphasia.

“After Words” is currently being distributed to public television stations nationwide. However, it is up to each individual station to include it in their schedule. While it has already aired in a number of cities, it has not yet aired on the majority of public television stations. Therefore, the producers of “After Words” encourage the aphasia communityspeech-language pathologists, state and local speech-language hearing associations, aphasia support groups, rehabilitation centers, individuals touched by aphasia—to contact their local public television stations and urge them to air “After Words.” We anticipate a new wave of airings to occur in the months to come, following the program’s re-distribution to public television in mid-January. Thus, contacting local stations, and in particular, program managers at these stations, when the film is re-distributed, would be especially timely.

We hope to bring this important program to the widest possible audience.  Take a look at the trailer:

Jerome Kaplan is an SLP and founder of the Aphasia Community Group of Boston.  Working with artists, actors, musicians, filmmakers, and members of the aphasia community, he has developed projects to raise aphasia awareness and understanding by illuminating the world of aphasia and promoting the life participation approach to aphasia.  His latest project, “after words,” a documentary about aphasia, is currently airing on public television. 

Apps targeting Adults with Aphasia

On this episode, I have decided to focus on a few apps I know that target skills which have been impacted by a stroke leading to Aphasia. Individuals with aphasia experience difficulties in one or more modalities such as reading, writing, as well as speaking and auditory comprehension.

Many SLPs working in the hospital  or at the skilled nursing facility settings complain that the majority of the applications were designed for small children. While this is in fact true, today I will do a basic demo of a few apps I know were designed with the adult population in mind.

I believe Tactus is the starting point for those of you looking for apps for adults. Their website is www.tactustherapy.com.

 

 

Here is a list of the apps demonstrated on this episode:

Naming Therappy by Tactus Therappy

iName it by Smarty Ears

Language Therappy by Tactus Therapy

Small Talk by Lingraphica

 

(This post originally appeared on GeekSLP)

 

Barbara Fernandes is a trilingual Speech- Language pathologist, a geek  and an app developer. She is the founder and CEO of Smarty Ears Apps , a company that creates apps for speech therapy. Barbara is also the face behind GeekSLP TV, a blog and video podcast focusing on the use of technology in speech therapy. Barbara has also been a practicing speech therapist both in Brazil and in the United States. Barbara has created over 21 applications for the mobile devices for speech therapists.

 

Twitter Chat with Nancy Helm-Estabrooks

In recognition of National Aphasia Awareness Month, ASHA hosted a Twitter chat with Nancy Helm-Estabrooks, the SLP coordinating supplemental home speech-language services for Gabby Giffords. The chat took place on Twitter on Monday, June 25. Participants used the hashtag #aphasiachat and asked some great questions of Nancy. You can read the full transcript of the chat here (transcript goes in reverse chronological order), but here are just some of the questions/answers from the chat:

 

Here are a few additional resources related to aphasia:

Thanks to AARP and the National Aphasia Association for helping us spread the word about the chat!

This Twitter chat was a first for ASHA–what other topics would you like to see us address for potential future chats?

 

Maggie McGary is the online community & social media manager at ASHA, and manages ASHAsphere.

Loss, Grief, and the Longing for Human Connection

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Photo by RonAlmog

(This post originally appeared on Living Successfully With Aphasia)

About a month ago, driving in the early morning madness that is New Jersey traffic, I listened to this piece on NPR.  With the death of Osama Bin Laden has come a plethora of articles, photos, blogposts:  people’s emotional holding places have been disturbed, and everything is raw again.

This podcast was made by Beverly Eckert, who lost her husband, Sean on 911.  She recorded the podcast four years after his death, but the words sounded new and the feelings full as I drove the highway in muted sunlight.  Loss, grief, the longing for human connection.  These are what I heard, what I hear in the conversations I have with people living with aphasia.  And, like Beverly, the time that passes does not really soften the pain.

 Vision blurred, I pulled over to the side of the road, and wept.  It will not be the last time I am able to share in another’s longing for the return of what was.

Shirley Morganstein and Marilyn Certner Smith co-founded Speaking of Aphasia, a Life Participation practice in Montclair, NJ where people with aphasia instruct her daily in their journey. Recently, Shirley began a blog focused more on her personal thoughts about the people she has met and her own process as a therapist

The King’s Speech

(This post originally appeared on the Living Successfully With Aphasia blog)

You must see this film.

Period.

Years ago, I met Jung on lower Broadway in NYC. Not actually, of course. What I mean is that the concept of syncronicity rose up and hit me in the face that day. Details are not very important. What is important is that I had to acknowledge that things sometimes conspire to connect you to a larger truth, for which you may not even be aware you are searching.

Having seen The King’s Speech this week, I am struck by the relational and reflective aspect of the practice of speech therapy – the very thing we are now exploring in a deeper and more meaningful way. The character of Lionel Logue, played adeptly by Geoffrey Rush, succeeds with The King only because he establishes the relationship that forms a bond of trust and respect between them. And so it is in our therapy as well.

I am so happy to find a film like this that supports my own personal journey, and confirms what I know to be true.

Shirley Morganstein and Marilyn Certner Smith co-founded Speaking of Aphasia, a Life Participation practice in Montclair, NJ where people with aphasia instruct her daily in their journey. Recently, Shirley began a blog focused more on her personal thoughts about the people she has met and her own process as a therapist.

A Million Rubber Bands

(This post originally appeared on Living Successfully With Aphasia)

Alan K. Simpson, former senator from Wyoming, described resilience as being like “a million rubber bands.” People with aphasia are stretched there and back again as the weeks, months, and years slowly define who they are and will be. The aphasia literature of the fifties described people with aphasia as essentially unchanged in persona. I think not. This rubber band business moves people into and out of places they have never been, and changes do occur. What is obvious to me as I accompany them on part of this bouncing around, is that those who are resilient experience the lows and highs differently, constantly rededicating themselves to the next piece of what lies ahead. PBS hosted a wonderful series recently called, “This Emotional Life; ” one of the shows was dedicated to resilience.

“People who are resilient draw on strengths in themselves, their relationships, and their communities to help them overcome adversity. Resilient people often find meaning even in times of trouble and gain confidence from overcoming adversity. In this way, resilience can contribute to a deeply satisfying life.”

Some of you may remember Bob Shumaker, a former POW in Vietnam. In this video, he describes how he created a communication system: a tap code between prisoners that he believes permitted them all to survive three years in solitary confinement.

In a way, that is what people with aphasia do: create a new code for maintaining the connection between themselves and the world they inhabited before it, or laying down new pathways for the new life they are creating. And aphasia therapists? We are the interpreters, making a bridge between there and back again.

Shirley Morganstein and Marilyn Certner Smith co-founded Speaking of Aphasia, a Life Participation practice in Montclair, NJ where people with aphasia instruct her daily in their journey. Recently, Shirley began a blog focused more on her personal thoughts about the people she has met and her own process as a therapist