SED6019-20-21 S2 STUDENT-intervention-of-Aphasia 20190225

Intervention and
Management
of Aphasia
SED6019, 2021
Lorinda KWAN, PhD
Different Approaches to Ax Aphasia
• Medical, connectionist model
• Cognitive neuro-psychological (CNP)
• Linguistic Model
• Functional Model
• Social Model
4/March/2019 2018 SED6019 1819 Tx Aphasia LK 2

Medical Model
• Localization Model
• Connectionist Model
• Syndrome Approach

Cognitive Neuro-
psychology Model
(CNP)
(Kay, Lesser &
Coltheart (1996)
Model)
Model of Linguistic
Processing/ Model
of Linguistic-
Information
Processing

Linguistic Model
• Components of language • Testing breakdowns in these

• Phonology elements
• Morphology
• Syntax • Applied to explain the
phenomenon of Agrammatism
• Lexical - Semantics
• Prosody
• Discourse
Courtesy: Prof S. Kiran

Functional –Social Model (ICIDH-2)
(International Classification of Functioning Disability and Health -2, WHO 1993)

Social Model
• Encompass more on “participation” of the WHO-ICIDH-2 model.
• Advocates for the disabled
• Focus on provision of a ‘ramp’ in communication for PWAs
• Policy and strategies for making the community ‘aphasia friendly’

What are the limitations of these models?

What would you do to assess the presence of
aphasia in this patient with stroke?

Study this case…
• XXX suffered from a left ischemic attack in YEAR. She was in coma for
one day at Acute A Hospital and was then transferred to Rehab B
Hospital.
• Post-stroke, she could only produce “yes” (係呀).
• Non-oral feeding was used at the beginning; normal diet has been
resumed in two weeks.

Tasks for initial assessment of a PWA
• Case History ( New info + Verification of Old info)
• Clinical Impression of Sp, Lang, Comm
• Ax of auditory language comprehension
• Ax of language production

o
Case History ok fully respect the pa

2020 6
• Priority of questions • Medical Hx

• Significant information • What, When, Where, How
• Verification of information, and • Sp, lang, Comm, Swallow
source of information What, How, When
• Informing assessment goals and • Choose the methods/tools of
tools assessment that can yield
outcomes to develop
• Use time as gold measurable intervention goals

Clinical Impression
• Forming a clinical impression using
• XXX was a cheerful and active models of aphasia
verbal communicator. She was non-
fluent in her expressive language • Inform goals, priority and tools to
very dependent to her husband for assess receptive and expressive
cues to participate in language.
communication with the clinician. • Some goals of Ax can be answers to
Her husband used gestural cue, these Qs:
syllabic cue, and semantic cue • Does this patient have any language
interchangeably… impairments? If yes, what is the
• Due to her referral reasons, XXX impairment and which are the areas
of impairments? How severe are
was assessed with a clinical these impairments?
criterion-based language • Do these impairments create barriers
assessment protocol in the for her communication, and
following order on DATE participation of her main roles? If yes,
why, and how? If no, why and how?
Now I have the Ax results, what can I do to form intervention
goals
Task Accuracy Trials Level
Confrontation Naming (common objects) 100% 6/6 Spontaneous

Photo-action naming (verb) 50% 3/6 Spontaneous
100% 3/3 Syllabic cue
Object function (verb) 50% 3/6 Spontaneous
100% 3/3 Syllabic cue
Responsive Naming 100% 3/3 Gestural cue
100% 1/1 Carrier of quantifier
100% 1/1 Manipulating objects
Divergent Naming (fruits and dim sum) 7 items Semantic Cue

Writing
Personal information (name, name of husband, address) 0% 0/3 Spontaneous
66.7% 2/3 Verbal cue (radical)
Dictation of monosyllabic common words 0% 0/3 Spontaneous

Now I have the Ax results, what can I do to form
intervention goals
Task Accurac Trials Level
y
Single word-object pointing (real objects in choice 100% 6/6 Spontaneous
of 4)
Single word-object pointing (photos in choice of 4) 100% 4/4 Spontaneous
Yes-no questions (personal information) 100% 3/3 Spontaneous
Yes-no questions (environment) 100% 1/1 Spontaneous
Yes-no questions (world knowledge) 100% 2/2 Spontaneous
Simple sentence (choice of 4 photos) 85.7% 12/14 Spontaneous
Remarks: error was conducted for structures of relative clauses and double objects.
Complex or abstract relations in sentence 100% 4/4 Spontaneous
Wh-questions 75% 3/4 Spontaneous
100% 1/1 Choice of 3
Short discourse of 12 words, Wh-questions 100% 2/2 Spontaneous
Short discourse of 35 words, Wh-questions 0% 0/3 Spontaneous
33.3% 1/3 Choice of 4
Main Concept of short discourse 50% 1/2 Spontaneous
Reading
Written word-object matching (photos; choice of 3) 100% 3/3 Spontaneous
Spoken word-written word matching (choice of 3) 100% 2/2 Spontaneous
Oral reading of daily words (e.g. in, out, push, pull) 25% 1/4 Gestural cue.

Case study – Diagnosis and Prognosis
• Diagnosis and Prognosis
• XXX is diagnosed with moderate-severe non-fluent expressive aphasia and mild receptive
aphasia. (the severity: assessment task, task/ total number of task, <33% = severe; 33%-67% = moderate; <67% = mild, <89% = normal )
• Prognosis of XXX was good. The client suffered from recent stroke in three months, and
she has no comorbid disability. The CVA was in ischemic nature, and lesion area focused
on left inferior frontal cortex. The client was at younger age ( 50 years old) with general
good health premorbidly. She also received high education and is multilingual. The
client is very motivated to the therapy. She also had supportive caregiver to conduct
home therapy with her.
• Negative prognostic factors include the severity of aphasia is moderate-severe, and
cognition and memory impairment after stroke, which could affect her maintenance of
trained targets.
• Recommendations
• XXX is recommended to receive speech and language therapy on weekly basis, both face-
to-face and online. Treatment objective will focus on naming, production discourses,
reading and writing.

Case study -Long Term Goals
• Long term goal (to be completed in 1 year):
• The client will reduce communication barrier in familiar social
communication by oral and written language

Case study -Short term goals
• Short term goal (to be completed in 9 sessions):
• The client will be able to produce 10 two-word utterances upon
moderate cues with 70% accuracy.
• The client will be able to produce 3 frequently used scripts precisely
with 70% accuracy.

A Plan for Intervention of PWA
• Goal • Goal: The client will be able to name common
• Rationale verbs with semantic cues with 80% accuracy.
• IS: if client is above 80% success, the task will
• Method be changed to naming of same set of verbs
• Increasing Steps ( IS) without cues ( spontaneously)
• Decreasing Steps ( DS) • DS: If client is under 80% success, the task will
be changed to naming of same set of verbs
with gestural cues IN ADDITION TO the same
semantic cues.
• Operational
• Measurable
• Context
• Hierarchy

• Goal • Goal: The client will be able to name
• Rationale common verbs with semantic cues with
80% accuracy.
• Method
• Rationale: Language assessment of this
• Increasing Steps ( IS) client showed failure of production of two-
• Decreasing Steps ( DS) word utterances. As verb will be acted as
leverage for production of Verb-object
phrases ( two-word utterances), verbs that
are familiar to the client will be chosen as
initial treatment targets.

• Goal • Goal: The client will be able to name common verbs with semantic
• Rationale cues with 80% accuracy.
• Method:
• Method
• Increasing Steps ( IS) • Pre-treatment baseline measurement
• 4 familiar verbs and 4 unfamiliar verbs ( all are mono-syllabic targets)
• Decreasing Steps ( DS) will be presented by video clips to the client to elicit naming. The
clinician will provide semantic cues: the tools used with the target
verbs to aid the client. All 8 targets will be presented 1 time.
• 4-familiar verbs are: 帶，買，煮，開
• 4-unfamiliar verbs are: 推，玩，打，夾
• Accurate responses: correct naming
• Inaccurate responses: no response, paraphasia, partial/incomplete
naming, response time longer than 5 seconds.

Layout of a session
• Subjective Observations
• Objective Measurements of tasks performance
• Analysis of patient performance
• Plan for the next session
• SOAP

SOAP notes
S Client came in with good mood on wheel chair for the first session, accompanied by husband and an Indonesian domestic-helper.
O1 Confrontational Naming of Verbs:

4-familiar verbs are: 帶，買，煮，開
4-unfamiliar verbs are: 推，玩，打，夾
Pre-treatment baseline: 帶(-)，買(+)，煮(-)，開(-), 推 (-)，玩(-)，打(-)，夾 (-) - 12.5%
Semantic Cues: 50%, failed all unfamiliar verbs [Errors were mainly no responses (75%), and partial naming (25%)]
DS: Semantic Cues + Gestural cues: 50%, failed all unfamiliar verbs [Errors were mainly no responses (50%), and partial naming (50%)]
A1 Client was not responsive to semantic cues when naming unfamiliar verbs. Although additional cue, gestural cues, was added during DS,
client remain inaccurate in naming推，玩，打，夾. It is suggested this task will be continued in the next session with only verbs familiar
to the client. After she adapts to the intervention method and gains more than 80% success on naming familiar verbs, unfamiliar verbs will
be introduced afterwards.
P1 Goal: The client will be able to name common verbs with semantic cues with 80% accuracy.
Rationale: Client was not able to name unfamiliar verbs in the last session although semantic cues and gestural cues were provided. This
task will be carried out with familiar verbs only to establish higher response accuracy in the client.
Method:
Pre-tx baseline will be measured
4 treated familiar verbs and 4 untreated familiar verbs ( all are mono-syllabic targets) will be presented by video clips to the client to elicit
naming. The clinician will provide semantic cues: the tools used with the target verbs to aid the client. All 8 targets will be presented 1
time.
4- treated familiar verbs are: 帶，買，煮，開
4-untreated, familiar verbs are: A, B, C, D
Accurate responses: correct naming
Inaccurate responses: no response, paraphasia, partial/incomplete naming, response time longer than 5 seconds.

Treatment of
Auditory Comprehension
Process-Oriented Treatment of Receptive Aphasia
Training of Auditory Comprehension
• Earliest work by Schuell, Jenkins, Jimenez-Pabon (1964).
• The main cause of aphasia:
• Impaired auditory comprehension,
• restricted auditory retention span
• Training by bottom-up approach word to sentence to discourse
• Training by top-down approach ( language

discourcelkjii1)
• Text-based processes
• Knowledge-based /heuristic processes
• Scripts
• Mental representations of familiar daily life situations in which
certain events typically occur and occur in a typical order.
• Mild-mod aphasic retain knowledge of scripts

Intervention of auditory comprehension
bottom-up approach
• Single word comprehension

• Comprehension of questions
• Comprehension of spoken instructions
• Comprehension of discourse

Single word comprehension tasks
bottom-up approach
• Tasks types • Performance of patients depend

• Show me X, point to Y mainly on these linguistic aspects
• Define X, • Length of target words
• Match Y to the pictures. • Lexical complexity
• Tell me another word that has the • Frequency
same meaning as X. • Imagineability
• “At work, John types with a Y. What is
Y?” • Now we also know patient’s
• “There are many people in the bank. performance based on these
Anne is at the bank too. She is trying aspects:
to get cash from her account. So she • Familiarity
went up to the__. Where would Anne • Functional load
go to get some cash?” • Syntactic role

Example: single word comprehension
•碗

Example: single word comprehension
• 眼鏡

Auditory Comprehension beyond single
words
• Sentence
• Semantics
• Syntactic unit
• Utterance length
• Word Order
• Types of sentences
• Declarative
• Interrogative
• Imperatives

Auditory comprehension beyond single words
• Yes-no Qs
• General Knowledge
• 你係唔係姓陳?
• Semantic
• Functions of objects
• 筆係唔係用嚟寫字?
• Super or sub-categorical
• 萍果係唔係生果?
• Synonyms or antonyms
• [開心]係唔係同[快樂]意思一樣?
• Syntax
• 筷子係唔係擺係碗底嘎?
• Open-ended Qs
• 點解有病要食藥?

Training Item of your own:
• 加冰

Training item of your own
• 買一盒

Training item of your own
• 深色同白色分開

Auditory Comprehension of Discourse
Process-Oriented Treatment of Receptive Aphasia

Auditory comprehension of Discourse Top-Down approach
• Bottom-Up vs Top-Down Processing • Example Treatment :

• Sample discourses read by ST, or played
from recordings
• Top-Down strategies are still • Patients answer Yes-no questions, close-
maintained in people with mild- end questions, or sentence-completion
moderate level of aphasia tasks.
• ( c.f. Discourse Comprehension Test,
Brookeshire & Nicolas, 1993)
• Patients at higher levers can be trained
• They are still able to get main ideas, by answering open-ended questions, and
and major inferences from daily re-tell of the discourse sample.
conversations.

What strategies can be trained for better
discourse comprehension?
• Script knowledge can be more predictable
• Patient can practice identification of scripts that underlie the

discourse
• Ask the patients to predict what would happen next in the sample
scripts

Intervention of Reading
For people with aphasia
Training for Reading
• Whole word reading
• Part-of word reading (morpheme, grapheme or radicals in

Chinese)
• Sentence reading ( less redundant than spoken language)
• Semantic Mapping
• Top down, Heuristic Process is much preferred over text- based
process

Training Reading for Survival (reading for text reading )
- reading for survival
• Literacy history (Webb, 1990) -> help he to location the important info
• Most Want to Read + Want to Read but could Do Without

(Rosenbek, La Pointe, & Wertz 1989)
• Mail, chequebook, medicine labels, calendar, product labels
• Messages, signs, newspaper, magazines, tv guides, menu, bible
• Everyday Reading and Writing Practices (Parr, 1992)

• Personal letters, bills, forms, official letters, advertisements, phone
numbers, newspaper, tv guides, books, bank statements, dosage
instructions for medications, menus.
• Sight Reading
• [開], [危險], 1 -10
• Read in isolation vs Read in Natural contexts
• Software for Sight words (Katz & Nagy, 1983; Major & Wilson, 1985; Weiner, 1983; and
others)

Intervention of Expressive language
Process-Oriented Treatment of Expressive Aphasia
Language productions are commonly trained
in these levels
• Volitional speech
• Connected Speech
• Picture Descriptions

Why is naming a common treatment in PWA?
• Naming deficit is the most prominent symptoms of aphasia (Laine & Martin,
2006)
• Expressive aphasia features

• Anomia, neologism, jargons, perseverations, semantic paraphasia, phonemic
paraphasia, circumlocution, empty words, agrammatism
• Picture naming, confrontation naming are the most popular

treatment for aphasia (Kiran & Bassetto, 2008; Nickels, 2002)

Cued naming ( volitional speech) semantic cues: __( )
• Sentence Completion Tasks
• Lend on patients residual language knowledge of automatic and
stereotypic utterances (general and personal)
• Can be used to facilitate confrontation naming but efficacy is in

questions
• Highly-constrained sentence completion facilitation in confrontation naming is less
maintained than less-constrained sentence completion (Kremin,1993)

Cued naming ( volitional speech)
• How do we do Sentence Completion Tasks?
• ST supply highly constrained sentences with final few words missing; patients supply the
missing words.
• Treatment move from highly-constrained to less-constrained

• English: a cup of ___ vs Today, Joe bought a __
• Cantonese: with highly-constrained classifiers
• 擺多一對_____
• Cantonese: with less-constrained classifiers.
• 擺一個___

Naming task that is based on CNP model
Process-oriented treatment of expressive aphasia

Semantic Feature Analysis ( SFA)
• Using Semantic Features to improve naming
• Haarbauer-Krupa, et al 1985; Massaro& Thompkins, 1994; Boyle, 2001; Boyle & Coelho, 1995, Rider et al 2008).
• Semantic Features: group category, use, action, properties, location,

and semantic association

Naming by describing semantic features

Rider, Wright, Marshall, Page(2008). Using Semantic Feature Analysis to Improve Contextual Discourse
in Adults With Aphasia. AJSLP, 17(2):161-172.
• The picture of the target word was placed in the centre of the chart, and the participant was prompted to produce the target word and then
produce the semantic features of the target word.
• Features included the target word’s group category, use, action, properties, location, and semantic association. Responses that had a clear
relationship to the attribute in question were judged to be appropriate
• If a participant did not provide an appropriate attribute within 10–15 s, then the examiner provided an appropriate attribute
• Additionally, if a participant gave an inappropriate attribute as a response, the examiner corrected the participant and provided an
appropriate attribute.
• After the semantic features were given, the examiner wrote them in the correct place on the chart.
• All features for the target word were produced in order to encourage use of the SFA chart, even if the participant was able to name the
target word initially or during production of the semantic features. Once the chart was complete, the examiner reviewed the features one
time with the participant, and then moved on to the next item.

Efficacy of SFA
• Overall, naming therapy for PWA has little generalization from trained to
untrained items, efficacy is low (Thompson, 2006), except…
• SFA, generalization to untrained nouns have been observed in several studies
(Boyle, 2004; Boyle and Coelho, 1995; Edmonds and Kiran, 2006; Kiran & Thompson, 2003; Law, Wong, Sung, Hon, 2006).
• However, SFA generalization beyond word level is insignificant (Nickels, 2002;Rider,

Wright, Marshall & Page, 2008; Bolye 2009)
• SFA + PACE yield good word retrieval in discourse level (Antonucci, 2009)

Treatment of production of verbs?
Example of treatment and testing treatment
efficacy

From: Effect of Verb Network Strengthening Treatment (VNeST) in Persons With Aphasia: Extension and
Replication of Previous Findings
Am J Speech Lang Pathol. 2014;23(2):S312-S329. doi:10.1044/2014_AJSLP-13-0098
Legend:
Example of card layout for VNeST steps 1 and 3.
Copyright © American Speech-Language-

4/March/2019Date of download: 3/17/2015 2018 SED6019
Hearing 1819 Tx Aphasia LK
Association 54
Thematic graphs for VNeST
(Edmonds & Babb, 2011)

Case study with multiple baselines

Treatment of discourses
Process-Oriented Treatment of Expressive aphasia
Production of discourse is trained through
these tasks
• Monologues ( cued, elicited, partial)
• Story Telling ( experience, fictional)
• Procedures ( expository, familiar, or new)
• Conversations ( supported vs non-supported)

Conversation
• Conversation • Example of scripted conversation
• Topics training
• Turns • Enabling fluent speech in non-
• Grice Maxims of Conversation fluent aphasia: Dr. Julius
• Scripts Fridriksson at TEDxColumbiaSC
• Fixed Topics • https://www.youtube.com/watc
• Adjusted to Personal Experience h?v=Cy6S7aMmUYo

• Script Intervention
• https://www.youtube.com/watch?v=jdX2fdY5dLg
Script
• Script Template
• https://www.youtube.com/watch?v=GsCQvuNRij0
Intervention • Audio-Visual Articulatory mouth shape
• https://www.youtube.com/watch?v=gNkBzuwdlSU

Script Intervention
• Videod Intervention of Script
• Script Template

Promising Results found in
Scripts as Treatment Tool
• Holland, A., Halper, A., & Cherney, L. (2010). Tell me your story: analysis of script topics selected by persons
with aphasia. AJSLP
• Goldberg, S., Haley, K., & Jacks, A. (2012). Script Training and Generalization for People with aphasia. AJSLP
• …There is evidence that script training intervention can improve accuracy, grammatical productivity, speaking rate, and articulatory
fluency in script production tasks as well as in more functional conversational tasks..

Intervention of Writing
for survival
Writing for Survival
• Shopping lists
• Cheques
• Emails
• Texting
• Appointments

Writing treatment
• Discourse
• Sentence level ( syntax and semantic information), fill in the blanks
• Words
• Divergent name writing
• Dictation
• Partial word completion
• Stroke completion
• Find the correct word
• Error corrections

Functional and Social
Approaches
to Intervention of aphasia
Moving away from Process-Oriented Treatment of aphasia

Functional and Social Approach
• Focus on Communicative competence in daily life situations
• Enhance success in communication in daily life rather than linguistic

performance
• WHO ICIDH-2 : broaden notion of participation
• Social Model: Importance of transactional function, and interactional

function

Intervention of conversation
for person with aphasia
Social Functional Treatment of aphasia
Promoting aphasic’s Communicative Effectiveness (PACE:
Davis & Wilcox, 1985; Carlomagno, 1994; Davis, 2000;)
• Intervention targeting functional communication in situations that simulate

daily life communicative interactions
• PACE Four general principles (Davis, 2000)

• The clinician and the patient exchange new information
• The clinician and the patient participate equally as senders and receivers of
messages
• The patient has free choice of communicative modes used to convey a message
• The clinician’s feedback is based on the patient’s success in conveying messages.

PACE therapy
• Clinician and client take turn to tell a selected, unseen card
• Micmick most natural turn-taking in daily conversation
• The client will take up both the functional roles of speaker and
listener
• The client and the clinician share equal responsibility in the
conversation
• The client and clinician make use of verbal and non verbal
communication strategies to communicate over a natural context.
• C.f. Davis, G. A. (2005). PACE revisited. Aphasiology, 19(1), 21-38

Conversational Coaching
( Holland, 1991; Hopper, Holland & Rewega, 2002)v ( Text 376-377)
• Teaches conversation partners to use verbal or non-verbal strategies to

improve conversation interactions
• Use Scripts
• Use Short video
• The person with aphasia has to convey content of either the written scripts
or the video to communication partner
• The clinician coach the most effective conversation strategies for both
patients and communication partners

Training of
Communicative Partner of person with aphasia
Social-Functional Treatment of Aphasia
Train the Conversation
Partners
• Kagan & Gailey, (1993). Aphasia Treatment.
• Supported Conversation (SCA)

• Acknowledge reception of message;
• Supported message sent
• Verification

Supporting Conversation partner with
Aphasia (SCA)

Being Aphasia-Friendly

Being Aphasia Friendly in HK contexts
• aphasia friendly prints, that is:
• 1) supplement with Pictures, reduce Text ( use short phrases)
• 2) larger font size, as large as font 36
• 3) more inter-word space than inter-character space.
• For example
• 我有個朋友需要幫忙 à
• 我有個朋友需要幫忙

Augmentative and Alternative
Communication Strategies for PWA
• Gestures
• Drawings
• Communication Book

Examples of AAC useful for PWA
• Multimodal communication
Screening Task
• ( Garrett & Lasker, 2005)

Other non-oral communication for PWA
• Gestures
• Coverbal gestures
• Drawing
• Drawing with graded semantic meanings

Drawings in PWA
• Lyon, J. G. (1995). Drawing: Its value as a communication aid for
adults with aphasia. Aphasiology, 9(1), 33-50.
• Lyon, J. G., & Helm-Estabrooks, N. (1987). Drawing: Its communicative

significance for expressively restricted aphasic adults. Topics in
language disorders, 8(1), 61-71.

Drawing in PWA
• Focus on Semantic Features • Semantic Features
rather than artistic skills
• May use steps similar to training • 1 Semantic Feature:
writing
• Copy
• Finish a partially-presented picture • 2 Semantic Features: a spoon
• Corrections of a wrongly-drawn
picture
• Dictation • 3 Semantic Features : a clock
• Composition

A support to children with stroke Parents (2015)
• AAC for children with stroke
parents ( Kwan, 2015)
• A family story
• Addressing issues beyond
language impairments
• The psycho social impact of
living with aphasia

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Intervention and

4/March/2019 2018 SED6019 1819 Tx Aphasia LK 2

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• Components of language • Testing breakdowns in these

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Case History ok fully respect the pa

• Priority of questions • Medical Hx

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Task Accuracy Trials Level

Confrontation Naming (common objects) 100% 6/6 Spontaneous

100% 1/1 Manipulating objects

Divergent Naming (fruits and dim sum) 7 items Semantic Cue

66.7% 2/3 Verbal cue (radical)

Dictation of monosyllabic common words 0% 0/3 Spontaneous

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O1 Confrontational Naming of Verbs:

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• Training by bottom-up approach word to sentence to discourse

• Training by top-down approach ( language

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• Single word comprehension

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• Tasks types • Performance of patients depend

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• Bottom-Up vs Top-Down Processing • Example Treatment :

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• Patient can practice identification of scripts that underlie the

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• Part-of word reading (morpheme, grapheme or radicals in

• Sentence reading ( less redundant than spoken language)

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• Most Want to Read + Want to Read but could Do Without

• Everyday Reading and Writing Practices (Parr, 1992)

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• Expressive aphasia features

• Picture naming, confrontation naming are the most popular

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• Can be used to facilitate confrontation naming but efficacy is in

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