Therapy for single word

problems
Christos Salis

christos.salis@ncl.ac.uk

1
 • Theoretical and practical background to aphasia
therapy
• Focus on aphasia after stroke
• Brief linguistic introduction
• Theories of aphasia and relevance to therapy
What we • The International Classification Framework
covered last (World Health Organisation)
• The person and therapy goals
time • Models of service delivery and how much
therapy (“dosage”)
• Generalisation
• Broad types of therapy

2
 Brief linguistic background

Speech -> sounds -> syllables Print -> letters -> syllables ->
-> words words

Words -> phrases -> sentences Words -> phrases -> sentences
-> discourse/conversation -> paragraphs

And typing

3
 Spoken word production
Therapy
approaches for Spoken word understanding
single word
problems Written word production
(production,
understanding) Written word understanding

4

Spoken word production
• Naming difficulties the most distinguishing
characteristic of aphasia
• Affects all people across different severities
(very mild to very severe)
• Picture naming and/or spontaneous speech
• Across all word classes
• Main focus today nouns
Factors that affect spoken word
production
• Frequent vs. non-frequent words
gata vs. hipopotamo
• Concrete (imageable) vs. abstract words
pera vs. amor
• Word length (in syllables or phonemes)
pera vs. manzana
• Word class
taza vs. conducer
Vary from person to person
• Motor speech disorders: apraxia of speech,
dysarthria (aphasia = language, not speech)

5
 Spoken word production

• Semantic system: responsible for meaning,

abstract meaning features but not word form

• Phonological output lexicon: spoken word form as

a unit

• Phonological assembly: order of individual

phonemes

• Articulatory programming: planning of (motor)

speech movements
/pera/

6
 What helps spoken word • Important to know if cues can help a person
production in people with produce words

aphasia? • Can be used as a therapy method

• Two examples

Cues & other ways

Howard & Harding (1998) – compensatory approach
• Phonological (first sound or syllable)
• Semantic (meaning relation)
Conroy et al. (2009) – impairment approach
• Graphemic (letter)

• Collocation – word combinations that occur

together (salt and … pepper)
• Describing the word (circumlocution)
• Repetition

7
• Use of alphabet board
• Extra time to produce word
• Other cues also examined

8

• 7 people with aphasia
• Most severe - KP - 0%
• Least severe – WE - 67%
Decreasing cue therapy
Increasing cue therapy
Findings
• No difference between the two cueing therapies
• Both speed and accuracy improved
• Faster speed for nouns than verbs
9
 Semantic Feature Analysis (SFA)
gato gatito
• A very popular treatment, with a lot of evidence
about its effectiveness + animal + animal
+ domestic + domestic
+ feline + feline
• Uses the concept of semantic features to help
+ adult - adult
person with aphasia produce a word and/or talk
about a word using semantic features so that the
Semantic features are stored in the semantic
communication partner can understand what the system (or semantic memory)
person wants to say when they have difficulties
finding the intended word

• Considered a semantic type of therapy

• Evidence of generalization beyond treated words

10
Semantic Feature Analysis (SFA)
Steps involved

1) Picture with target word shown to person

2) Person tries to name it
3) Whatever the response, you talk about the
word/picture’s semantic features using
questions about

Category
Function
Action • If person names the picture, you still ask all questions
Location
• Can be used with other word classes,
Association with different grids about semantic features
Properties

https://tactustherapy.com/semantic-feature-analysis-sfa-anomia/
11
 Phonological Components
Phonological components
Analysis (PCA)
• Similar to SFA but less popular, less evidence about Rhyme (final syllable pattern)
effectiveness Alliteration (first sound)
Final sound associate
• Uses phonological features (or components) of target
Number of syllables
word

• Some people with aphasia benefit less from semantic

features and more from phonological (speech sound)
features

• Considered a phonological type of therapy

• Evidence of generalization beyond treated words

12
 Phonological Components
Analysis (PCA)

• Similar to SFA but less popular, less evidence

crema k
about effectiveness,

• Uses phonological features

• Some people with aphasia benefit less from

semantic features and more from phonological
cactus a 2
(speech sound) features

• Considered a phonological type of therapy

13
Comparison between SFA and PCA
Method
• Participants 8 people with aphasia
• 12 treatment sessions
• In each session, half the time was spent on SFA, other half on
PCA

Findings
• 7 people improved with PCA
• 6 of these 7 “maintained” the therapy effect with PCA
• 4 people improved with SFA
• SFA did not benefit people with semantic problems
• PCA benefited most people

14
Severely disordered phonology
Paraphasias

Semantic gato -> perro

Phonemic gato -> gado
Neologism gato -> krili

• In conversation (connected speech) too

many neologisms are called “jargon”
(jargon aphasia)
• Awareness may vary
• Repeated attempts to self-correct words
may improve intelligibility (clarity) a little
in some people
• Limited therapy studies
• Experimental single-case
• PCA treatment
• Treated words improved and this was maintained
• Reduction of neologisms
• No generalization to untreated words
15
Spoken word
understanding problems

Three types of clinical patterns

1) Person has mainly or exclusively semantic

problems
2) Person has mainly phonological problems
3) Person has both problems

Most people will also have spoken word production

problems
Rarely, some people may have a more severe
problem understanding

16
Spoken word
understanding

17
Semantic problems in people with aphasia
Picture to picture matching
• Some people may have more problems with semantics
than phonology (speech sounds)
• Semantic problems often affect both understanding and
production of words
• Really extreme in semantic dementia (a type of primary
progressive aphasia); less so in aphasia after stroke
• Spoken and written word understanding will be diffcult

Spoken word to picture matching goat

Written word to picture matching

18
Improving semantics: Tasks from therapy studies

1. Spoken word to picture

matching
2. Written word to picture
matching

An issue to consider: “chance”

• Experimental single-case study
• Person had semantic problems
• Authors did not assess phonological processing in detail
• 13 words

“Does a bear have fur?

“Does a bear have gills?”

Therapist pointed to each written semantic feature as it was spoken

Feedback: Person’s response was acknowledged as either correct or
incorrect and the correct response was either restated or explained.
Example: “Yes, the bear has fur” or “No, the bear has fur

20
Phonological (auditory processing) problems

Heard Word


AUDITORY PHONOLOGICAL ANALYSIS
Identify speech sounds by analysing the string of sounds
heard


AUDITORY OR PHONOLOGICAL INPUT LEXICON
A store of auditory (spoken) word recognition units;
recognising the word as a familiar one


SEMANTIC SYSTEM
A store of word meanings activated in response to word
recognition
 Identifying problems with phonological (auditory)
processing
Need to consider:
1. Hearing ability
2. Person’s (or spouse’s)
3. Phonological processing
4. Semantics
Phonological processing assessment
Auditory discrimination of real words – do
these words sound the same?
pero – perro (minimal pairs)
palta – piel (maximal pairs)
Auditory lexical decision – are pairs of words
real words or not?
palta – tilpi
Important: lip reading!
Improving input phonology (auditory processing):
Tasks from therapy studies
Same as in assessment but with Similar tasks as for semantic problems
feedback

Auditory discrimination of real words –

do these words sound the same? Spoken word to picture matching
pero – perro (minimal pairs)
palta – piel (maximal pairs) Word-picture verification (will describe
later)
Auditory lexical decision – are pairs of
words real words or not?
palta - tilpi
Improving input phonology (auditory processing):
Tasks from therapy studies
Same as in assessment but with Other auditory tasks
feedback

Pairs of words that rhyme

Auditory discrimination of real words –
do these words sound the same?
pero – perro (minimal pairs) Pairs of words that start with the same
palta – piel (maximal pairs) sound

Auditory lexical decision – are pairs of Specific phoneme discrimination from

words real words or not? spoken words
palta - tilpi Example: raise your hand when you hear
words that start with /t/
Writing (and reading) in
aphasia therapy

• Person’s therapy goals to improve writing (and

or reading)

• Digital communication (text, e-mail, internet)

• Alternative way of communication when

speech fails or speech is too severely affected

• More of that in our last session (4th)

25
Written
word
production
 Factors affecting written word production
• Level of education of person, English - /f/
familiarity with writing

• Similar factors (as in spoken) fish, tough

• Sound-letter correspondence
(less of an issue in transparent
example of non-transparent
orthography languages) sound-letter

English vs. Spanish, Italian, Greek

(sound-letter correspondence)

27
Copy And Recall Therapy (CART) – Beeson et al.

https://aphasia.sites.arizona.edu/content/9

• Experimental single-case
• Very severe aphasia (including non-verbal
reasoning)
• Person had his own mobile phone
• 15 hours of therapist
• 15 hours of homework
• CART and T-CART (T = texting)
• 15 words per therapy
Findings
Improvements in spelling and spoken naming
trained in either modality
Stronger maintenance for handwriting than
mobile phone typing
Functional use of texting that continued 2 years
later

29
Some thoughts
• Writing therapy includes very repetitive tasks over a long period of
time
• Beeson (2002) – ST learned 17 words to 80% correct after 10,
twice weekly sessions & additional homework
• Robson et al. (1998) – RMM learned about 60 words after 59
sessions of 45 minutes
• Rapp & Kane (2002) – MMD learned 10 words in 25 sessions
• Direct therapy often supported self-directed home practice
• Need to think about client’s level of independence/skills when
deciding on tasks for home practice
• Using technology in writing therapy raises additional challenges
Written word
understanding
 Seen Word • Similar processes as in spoken word understanding


• However, unlike spoken word understanding, there are
VISUAL ORTHOGRAPHIC ANALYSIS no two types of therapy (semantics – phonological /
Identify a visual stimulus as a string of letter orthographic), at least at clinical level

 • Clinical therapies for single word understanding are

ORTHOGRAPHIC INPUT LEXICON typically semantic – similar tasks (for spoken word
understanding)
A store of written words recognition units; recognising the
word as a familiar one


SEMANTIC SYSTEM
A store of word meanings activated in response to word
recognition

32
Written word to picture matching

• Person point to the picture that matches the

written word

• Typical feedback if wrong: “This was not correct.

You showed me “palta” (therapist points to “palta”)

• Person tries again. If wrong, similar feedback to

above

• Person may also read word aloud. This may help

understanding and/or learning

pera
Written word to picture verification

• Person needs to indicate “yes” or “no”

• If written word matches picture -> “yes”

• If not -> “no”

• Issues: “chance”, “yes” or “no” bias, more complex

instructions for person, “disagreement” more
difficult
pera manzana

• Can use the same task for spoken word agreement disagreement
understanding
 Summary
• Semantic, phonological therapies for spoken word production with some similarities
between them

• Semantic problems tend to affect spoken and written (understanding and production)

• Therapy tasks are similar to assessment tasks. BUT, in therapy we provide feedback to
person and many ways to attempt to get it right. We don’t do that in assessments (usually)

• Most therapy tasks are based on pictures but need to think about generalization. This means
we need to vary tasks and situations of practice.

35
 Summary
• According to studies, most therapy effects (progress) are not retained long-term. Once
person stops practicing, performance deteriorates

• Most studies use small number of words. This is often the case in clinical practice because of
the severity of the aphasia and “model of service delivery”.

• Need to discuss with person and other relevant people (family, friends, partners) about their
involvement in therapy.

• Aphasia being a communication problem, affects not only the person but also people close
to that person

36
Alnwick Castle

/anik/

Thank you

37