20Q: Clinical Challenges in Aphasia Rehabilitation

From the Desk of Ann Kummer

If you work with individuals affected by aphasia, this article on aphasia management will be of great interest to you! Drs. Patrick Coppens and Janet Patterson, who are both experts in aphasia, have provided this 20Q article as an overview of aphasia characteristics and aphasia management. This article provides important practical information for the clinician in a very concise manner.

Dr. Patrick Coppens is a faculty member in the Communication Science and Disorders Department at SUNY Plattsburgh where he teaches graduate courses in neurogenic communication disorders. He has been a clinician, a teacher, and a researcher for over 25 years. He has recently published two textbooks in clinical aphasiology.

Dr. Janet Patterson is Chief of the Audiology and Speech-Language Pathology Service at the VA Northern California Health Care System. She is also a lecturer in the Communication Science and Disorders Department at California State University, East Bay. She has been a clinician, teacher, researcher, and administrator for over 30 years. She is an ASHA Fellow.

After reading this article, you may want more information. Well, you are in luck. Drs. Coppens and Patterson have recently published a comprehensive text called Aphasia Rehabilitation: Clinical Challenges, published by Jones & Bartlett Learning, 2018. This book has a strong clinical focus, but is based on current evidence. There are case illustrations to help the reader apply the information to real life. Part 1 covers the challenging symptoms of aphasia, including perseverations, paraphasias, jargonaphasia, agrammatisms, echophenomena, and neurogenic stuttering. Part 2 covers challenging treatment components, including patient motivation, generalization, multimodal strategies, and treatment intensity. This book can serve as a valuable handbook for clinicians who evaluate and treat patients with aphasia.

Now...read on, learn and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

20Q: Clinical Challenges in Aphasia Rehabilitation

Janet Patterson

Patrick Coppens

1. What are the clinical challenges in aphasia rehabilitation?

There are many important aspects of the clinical interaction that are only superficially treated or not addressed at all in aphasia therapy textbooks. Therefore, speech-language pathologists involved in the rehabilitation of individuals with aphasia are faced with significant clinical challenges. For example, certain aphasia symptoms such as paraphasias, perseverations, or agrammatism are very familiar to clinicians, but very challenging to address in therapy. Similarly, some issues such as treatment intensity or client motivation are intuitively perceived as important contributors to clinical outcome but are typically not well integrated in the development of clinical objectives, likely because clinicians do not know how to best apply these principles. We attempted to identify some of these “gaps” in clinical knowledge and compiled them in a recent book in the hope of assisting clinicians who face these issues in daily practice.

2. You mentioned perseverations. How do you best address these in clinic?

Think of perseverations as a combination of understimulation of the correct target and overstimulation of the incorrect one. So, you should consider a combination approach: focus on the underlying naming problems by providing the client with clues to maximize access to the appropriate response while at the same time encouraging the client to self-monitor to decrease the production of errors. The rehabilitation approaches for anomia tend to be very familiar to most clinicians but the strategies used to inhibit the perseveration may require some getting used to.

3. What kind of strategies can I use to limit perseverations?

For example, you should avoid using the perseveration yourself as this would be additional stimulation of the erroneous answer. Before providing the client with the next stimulus, make sure to use a preparatory set, such as “Here is the next word. I still want you to say just one word. Are you ready?” This has the advantage of distracting from the former productions and building some delay between stimulus presentations. Similarly, it is good practice to introduce a delay between stimulus and response. The literature recommends a time interval of 5 to 10 seconds. One approach called Reducing Aphasic Perseveration (Munoz, 2011) starts with a 20 second interval that progressively decreases.

4. My clients often produce the wrong word instead of a perseveration. How is that different?

It is similar and it is also definitely a clinical challenge. These errors are referred to as paraphasias, and there are several types of paraphasias: semantic paraphasias (e.g., saying “dog” for “cat”), phonemic paraphasias (e.g., saying “mat” or “lat” for “cat”), and neologisms (e.g., saying “stapoli” for “cat”). The theory teaches us that we produce words in roughly two stages. The purpose of the first stage is to select a lexical item. The selection process is based on the principle of spreading activation. When you are looking at a dog, the features related to the concept of dog (“has 4 legs,” “barks,” “wags tail,” etc.) combine to activate the lexical item. However, related items that may share some of these features are also somewhat activated. The most activated lexical item will be selected for further processing. An error at this stage may lead to a semantic paraphasia (saying “cat” for “dog”). This is why most semantic paraphasias are related in meaning to the target word. Once selected, the lexical item goes to stage two, during which the phonemic makeup of the lexical item is retrieved: phonemes are selected and ordered. An error in stage two may lead to a phonemic paraphasia (saying “log” for “dog”).

5: How do you treat paraphasias?

There are several ways to treat paraphasias clinically. One is to develop a cueing hierarchy that orders the cues from less to more help for the client. Such a hierarchy could include semantic cues, phonological cues, or both depending on the specific client’s naming error pattern. It could also include multimodality clues, such as a request to draw the target object. A second approach focuses on stimulating the target item by activating semantic links. Semantic feature analysis (Boyle & Coelho, 1995) is the best known example of this approach. Interestingly, there is a phonological equivalent to this approach called Phonological Components Analysis (Leonard, Rochon & Laird, 2007) that relies more on phonemic and orthographic cues to stimulate the target response. Finally, therapy for paraphasia could also include the use of other modalities, such as writing, drawing, or gesturing. If paraphasias dominate the client’s verbal output, this could lead to jargon aphasia.

6: What is jargon aphasia?

Jargon aphasia is when a client with fluent aphasia is mostly unintelligible, most likely because of the predominance of paraphasias or neologisms. Three types of jargon are identified: semantic (the output contains real words but utterances do not make sense), neologistic (presence of neologisms), and phonemic (very few recognizable words). Jargon aphasia is not a separate type of aphasia per se, but rather a subtype associated with Wernicke’s aphasia. It is usually paired with poor comprehension, anosognosia (i.e., lack of insight into the impairment), poor self-monitoring, and logorrhea (i.e., press of speech). This clinical picture is challenging to treat.

7: How do you treat jargon aphasia?

The therapy approach for jargon aphasia should target comprehension skills and self-monitoring (i.e., anosognosia). For example, after any comprehension task, the client could be asked systematically to judge his or her response. This will emphasize the importance of constant self-monitoring and you can gather data on comprehension and self-monitoring within the same task. If your client also has logorrhea (i.e., press for speech), it may be wise to develop tasks that do not require a verbal answer, at least at the outset. In some cases, it may be appropriate to ask the client to judge their recorded oral productions. This may be easier for your client, particularly if the underlying problem involves the amount of processing resources. Judging one’s own output indeed requires two simultaneous tasks: paying attention to the output at the same time as it is being produced. Expressive language can be treated by targeting word finding and the underlying semantic and phonemic paraphasias. In a number of cases, these processes can be facilitated by relying on other modalities, and many of these clients have shown relatively better preserved writing skills.

8: What are the clinical challenges with clients who are non-fluent?

With clients with non-fluent aphasia, one of the biggest challenges is agrammatism. This refers to the tendency of a client with Broca’s aphasia to use mainly nouns and very few verbs and hardly any grammatical functors and morphological markers. There is disagreement in the literature as to the underlying cause of agrammatism. Some authors argue that there is a specific syntactic deficit preventing the client from assigning roles to sentence elements. This leads to the typical reversal errors exhibited by these clients. Other authors see the source of the difficulty in the transition between the deep structure to the surface structure within the framework of Chomsky’s Transformational Grammar. For example, these clients are often unable to understand a sentence in the passive voice. And yet other authors argue for an impairment in resource allocation as evidenced by better receptive than expressive syntactic processing in some cases. This lack of agreement about the underlying mechanism of the symptom renders therapy for agrammatism particularly challenging.

9: How can I address agrammatism in therapy?

Because these clients use few verbs, it is a good idea to focus therapy specifically on verbs. Another reason is that verbs are the central hinge of a sentence and carry with them a prescribed sentence structure (i.e., the Verb Argument Structure). For example, “swim” or “sleep” only requires an agent (“John is sleeping”), whereas “give” requires three arguments (“John gives the ball to the boy”). To maximize the impact on agrammatism, the therapy should not only focus on verbs but on verbs in a sentence context rather than in isolation. For example, the Verb Network Strengthening Treatment (VNeST; Edmonds, Nadeau & Kiran, 2009) is an excellent example of such an approach. If your client has particular trouble with reversible sentences, another useful approach is mapping therapy (Schwartz, Saffran, Fink, Myers & Martin, 1994). In mapping therapy, the client is essentially taught to associate thematic roles to sentence elements and how these roles get modified, for example to generate questions. Throughout this type of therapy, visual supports are used as concrete illustration of the roles and sentence modifications. For clients with milder agrammatic disorders, the Treatment of Underlying Form (TUF; Thompson & Shapiro, 2005) focuses on more complex syntactic structures. Finally, if your client has specific problems with morphological markers (e.g., plurals, past tense, etc.), it may be necessary to train these separately. The literature confirms that there is no cross generalization between these three approaches and you should consider targeting them separately.

10: Some clients show echolalic behavior; how can I treat that?

Echolalia is the automatic and noncommunicative repetition of a word or utterance without understanding its meaning. Echolalia is a syndrome of echophenomena, or imitation behavior, which is an act of social dependence when a client repeats something without instruction. There are several types of echolalia, differentiated by factors such a timing and format of the utterance. Echolalia is more common in clients with a fluent aphasia than nonfluent, and individuals with aphasia may also show echopraxia (repetition of actions) or echographia (translating visual stimuli into writing) however these forms of echophenomena are infrequent. In planning treatment, consider whether the echolalic behavior has negative or positive consequences on communication. A negative consequence would appear when the echolalia interferes with successful communication, perhaps for a person with a fluent aphasia. In this case individualized treatment strategies would aim to inhibit the echolalia, perhaps by introducing a pause point during speaking. In contrast, for a person with a nonfluent aphasia, creating a treatment strategy that redirects repetition into overlearned phrases or meaningful communication can have a positive consequence on the interaction, that is, the echolalic repetition can be used as a therapeutic tool.

11: I have heard about neurogenic stuttering that results in dysfluent speech; what are its symptoms?

Many clients who have a neurologic disorder experience acquired neurogenic stuttering (ANS), which is the stuttering-like dysfluencies resulting from damage to the nervous system. More specifically, stroke-related neurogenic stuttering (SRNS) describes the dysfluent behavior observed in clients who experienced a stroke. ANS and SRNS are different from developmental stuttering even though they have elements in common, and distinct from psychogenic stuttering which arises from psychogenic disorders. Most individuals diagnosed with stroke-related neurogenic stuttering do not have a history of development or psychogenic stuttering. Most clients with SRNS show a combination of the three core stuttering behaviors – repetitions, prolongation, and blocks – more frequently in the initial position of words than the medial or final positions. However, they are a heterogeneous population with a great deal of variability in their stuttering behavior in communication contexts. The ability to adapt to stuttering has been observed in about 50% of persons with SRNS, which may be predictive of treatment success.

12: How can I assess and treat clients with SRNS?

Assessment should be multifaceted and include tasks and questions to differentiate developmental, neurogenic, stroke-related and psychogenic stuttering. The Assessment Battery for Acquired Stuttering in Adults (DeNil, Jokel & Rochon, 2007) is a useful tool that includes tasks in four sections: case history; general functions such as language, speech production, and cognition; speech fluency assessment; and self-assessment of attitudes. Treatment is best designed from the careful assessment using this battery. Many of the techniques successfully used to treat SRNS are similar to those used for persons with developmental stuttering, such as decreasing speech rate, increasing loudness, cognitive restructuring, fluency shaping, and breathing exercises. Most common is a combination of behavioral and relaxation or cognitive restructuring techniques. The relationship between change in stuttering behavior and parallel change in language behavior following aphasia treatment is not clear, but likely they are independent, suggesting that a treatment program should focus on both language and fluency disorder.

13: A challenge for clinicians who treat clients with aphasia, including clients with complex disorders is facilitating generalization of learned behavior; how can I achieve generalization?

Generalizing a learned behavior to a new or different context is optimal, yet often left to chance as we assume that clients will figure out on their own how to apply learned behavior in new contexts. That is, generalization has been approached as a passive process using strategies such as “train and hope” (Stokes & Baer, 1977) or “fishing for evidence of change” (Webster & Whitworth, 2015). As clinicians we can do better by recognizing that generalization is not a unitary process but should be viewed as two processes, and by actively planning for generalization from the beginning of our treatment. The two types of generalization are response generalization and stimulus generalization. Response generalization is the appearance of a different, but similar, response in an untrained situation, for example applying a syntactic structure that was trained with one set of words to a different set of words. Successful generalization would occur if the trained syntactic structure is used correctly with the untrained items. Stimulus generalization occurs when a behavior learned in one context is repeated in a different and untrained context, for example, when a script of greeting behavior learned with one communication partner is used successfully with a different communication partner. Psycholinguistic or linguistic process that facilitate one type of generalization may not facilitate the other. Although it is an optimal treatment outcome, generalization cannot be expected if treatment itself is unsuccessful, and it must be actively planned as part of the treatment protocol.

14: What are some of the strategies that facilitate response generalization or stimulus generalization for persons with aphasia?

Even though studies in the aphasia treatment literature have included measures of generalization in their reported outcomes, it may be challenging to confidently ascribe behavior changes to true generalization. This is likely due to factors such as client variability, the amount and type of exposure to items in the treatment process, and the linguistic processes underlying the target items. While generalization cannot be guaranteed, ten strategies that have been shown to have a possible facilitative effect for response generalization. The strategies are internalize the strategy by having the client take ownership of using it independently; train enough exemplars, although it is not clear how many exemplars that would be; use loose training such as Response Elaboration Training (Kearns, 1985); consider client variables such as aphasia severity or cognitive skills; include semantic processing although the evidence for this strategy is minimal; treat complex items using for example the Complexity Account of Treatment Efficacy (CATE, Thompson, Shapiro, Kiran & Sobeks, 2003); train verbs although it is not clear that this facilitates response generalization better than training nouns; train in a sentence context such as in VNeST (Edmonds, Nadeau & Kiran, 2009); train the underlying mechanism perhaps focusing on phonological knowledge or syntactic structure; and combine modalities as a compensatory strategy. It is important to remember that none of these strategies has a strong body of evidence to support it and selection for use in a treatment protocol must be made carefully and with regard to client factors and previous studies using the strategy. Several strategies that may facilitate response generalization also may facilitate stimulus generalization: use loose training, train in a sentence context, train verbs, treat complex items, train the underlying mechanism, internalize the strategy, and combine modalities. Three additional strategies may also facilitate stimulus generalization: add discourse training or some level of connected speech; add home practice through telehealth, a communication partner or a practice schedule for the client; and use functional items. Strategies that are related may be combined to facilitate stimulus generalization, such as combining loose training, many exemplars, and internalize the strategy. As with response generalization, the evidence in support of each of these strategies is not robust and therefore the clinician is cautioned to select carefully, whether using one strategy or combining them.

15: Lately we hear a lot about intensive treatment and dosage. How are these terms different?

Treatment intensity and dosage are ways of describing or quantifying how a treatment protocol is delivered. Intensity has multiple meanings. A treatment can be intensive if it is concentrated on only one task, or delivered several hours a day for a short period of time. Intensity has variously been quantified as low-medium-high according to number of hours per week (from 1.5 to more than 5) or at least 8 hours per week for 2 to 3 months. Thus the term intensity has been used casually without clear definition or agreement on its meaning. It has been intermingled with the concept of massed vs. distributed practice; cited as an important principle of neural plasticity (Kleim & Jones, 2008); and used to explain treatment effects without supporting data. Treatment intensity is an important factor to consider when deciding how to deliver treatment to a client but must match the client need and not assumed as the preferred practice. Dosage is a way of measuring intensity, much like the familiar terms of frequency and duration to describe how often a client is seen each week and for how many weeks. Several factors contribute to determine what Warren, Fey and Yoder (2007) call the cumulative intervention intensity. They are dose or the number of specific treatment teaching episodes in one session; dose frequency or the number of doses in a unit of time, say a 30-minute session; and total intervention duration or the period of time for treatment. Multiply these terms to achieve a dosage value, or cumulative intervention intensity (CII).

16: It seems easy to calculate cumulative intervention intensity, but how do I use it in treatment?

The math to compute CII is straightforward, however careful planning is required to identify the components of the treatment that lend themselves to clear definition and quantification in order to do the math. Active ingredients are the clinician input and the client acts; the teaching episode is the framework for the treatment interaction; and individual variables are characteristics that relate to the client, clinician, or service delivery and that support or inhibit delivering a treatment in an optimum manner. View CII as the cost or resource requirement to deliver a treatment and compare it to the outcome or benefit from the treatment, as measured by formal and informal assessment. Speaking of optimum, our knowledge base does not yet provide evidence for the optimum treatment dosage or intensity for a particular client or treatment technique. The best way then to use CII to help think about treatment intensity is to consider your client’s needs and identify the contributing factors that may facilitate or inhibit successful treatment (e.g. teaching episode, dose frequency, client variables) and calculate the CII that you anticipate delivering. Then compare your CII to the CII from the treatment evidence on which you base your treatment selection. That is, look to the literature for a paper describing the treatment you propose to do and to the best of your ability, calculate a CII for that treatment exemplar; sometimes all the information to calculate CII will not be available but do the best you can. Then compare the two CII values and the treatment outcome from the published study. This will help you and the client set expectations for the amount of change you might expect (the benefit) given the resources in time devoted to treatment (the cost). Because individual client factors were considered in setting the CII, expectations may be adjusted from those in the exemplar study.

17: I would like to deliver treatment in an intensive manner, several days per week, but how can I do that if I can’t see a client every day?

Much of the literature in support of an intensive schedule of treatment delivery reports clinic-based treatment, however a few studies report home-based practice with a lay person, telehealth delivery, or computer-based treatment. These are excellent options to increase CII. Baker (2012) suggests calculating overall CII in two parts: one for clinic-based treatment and one for home-based treatment. As you consider using home-based treatment as part of an intensive treatment schedule you must be confident that as a clinician you can meet the preparation and timing requirements, that the client and family member or lay person are committed to the process and able to carry out the treatment tasks you design, and that the person with aphasia feels invested in the treatment program.

18: How can I determine if a client is invested in a treatment program or motivated to participate in treatment?

Motivation has many definitions. Common to almost all definitions are the ideas of motivation as a force or drive or energy, which is directed in a specific way toward a goal. Often when clinicians think about motivation it is in a general sense and used to explain why a client does not make the anticipated progress in treatment. A different way to think about motivation stems from self-determination theory, which qualifies types of motivation depending largely upon the reasons that cause people to act in ways they do. Autonomous motivation is a desirable state characterized by choice, volition, belief in the ability to achieve a goal, and self-selected reasons for acting. Opposite to that is amotivation when an individual does not believe he or she is able to complete the actions required to achieve a goal. In between these two states is controlled motivation where the motivation to act comes from outside the individual. Applied to clinical treatment, a client who shows autonomous motivation is invested in the treatment process and actively engaged in it. A client showing controlled motivation may engage in treatment but it is out of a sense of obligation or self-imposed demands to improve. A client in an amotivational state may attend treatment sessions but make limited progress because he or she is not engaged in the process and doesn’t believe treatment will result in change. A client’s state of motivation can fluctuate and may not be easily identified. As clinicians our role is to recognize the states of motivation and encourage and support a client’s autonomy in communication to the highest level possible.

19: What strategies support a client’s autonomy?

Approaches to treatment that are client-centered, such as a social model, the Life Participation Approach to Aphasia, and goal attainment scaling, select treatment goals and techniques based on a client’s stated communication needs and desires. A treatment technique may be selected to improve a specific communication behavior and in conjunction the clinician can use strategies to improve the client’s self-efficacy or belief in the ability to achieve the goal. These strategies fall into one of four sources that build self-efficacy: mastery experience when the client experiences success, perhaps through tasks of gradually increasing difficulty; vicarious experience when the client sees someone else successfully completing the behavior such as in group treatment; verbal persuasion through genuine and objective feedback and encouragement from the clinician; and affective experience when we help the client consider their physiological and affective states and how they might support improved performance or present barriers.

20: There are a lot of clinical challenges in aphasia rehabilitation. How do I know where to start to design a treatment program that includes evidence-based techniques, plans for generalization, the optimum service delivery model, and activities that encourage engagement?

The best place to start is with dynamic, client-centered, contextualized, informal assessment using a model such as the A-FROM (Aphasia: Framework for Outcome Measurement; Kagan, Simmons-Mackie, Rowland et al., 2008) or the informal assessment model (Coppens & Simmons-Mackie, 2018). Through the questioning and testing processes, and considering the parameters within which rehabilitation will occur, decisions can be made that lead the clinician and client to a mutually agreeable treatment plan. This of course, is the best-case scenario, but even when things do not go as well as hoped the resulting treatment plan has a better chance of success than a plan that is solely clinician-driven.