20Q: Goal and Treatment Selection in Aphasia in 20 Sessions or Less

From the Desk of Ann Kummer

A few decades ago when I first starting practicing, speech-language pathologists had the luxury of being able to provide virtually an unlimited number of therapy sessions when treating patients, particularly those with acquired neurogenic disorders. Those days are over and they’re not coming back! With the advent of healthcare reform, we are being challenged to improve our outcomes and patient satisfaction, while at that same time, decrease our costs. Of course, the per capita cost of therapy is directly related to the number of sessions required to achieve desired outcomes. Because this is so important, I am particularly excited about this article by Jackie Hinckley, PhD, CCC-SLP, which focuses on effective treatment for aphasia with a limited number of treatment sessions.

Dr. Jackie Hinckley is currently Associate Professor at Nova Southeastern University and serves as Executive Director Emeritus of Voices of Hope for Aphasia. She is the Project Lead on the PCORI-funded project, “A National Research Incubator for Patient-Centered Outcomes Research in Communication Disabilities.” Her research focuses on treatment effects and the nature of treatment research, including replication and implementation science. Dr. Hinckley is the author of two books, Narrative-Based Practice in Speech-Language Pathology, and What Is It Like to Have a Communication Impairment?  Simulations for Family, Friends, and Caregivers. She is Board Certified in Neurogenic Communication Disorders (Academy of Neurologic Communication Disorders & Sciences) and serves on the Advisory Board of the National Aphasia Association.

In this article, Dr. Hinckley will discuss Goal Attainment Scaling and provide examples of activity-focused therapy goals. She will then describe characteristics of activity-focused therapy. Finally, she will talk about different types of assessments and how these lead to different types of goals. I think you will really like this article!

Now…read on, learn, and enjoy!

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

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Goal and Treatment Selection in Aphasia in 20 Sessions or Less

Jackie Hinckley

1. Where do I start with my client with aphasia?

First, let’s face the reality of how much treatment your client with aphasia is likely to receive. In many typical rehabilitation sessions, treatment may be delivered from 2 to 5 times a week, for 30-60 minutes per day, for 6-8 weeks. In some settings, the amount of treatment will be much less – over 50% of people with aphasia in skilled nursing facilities will receive 5 or fewer total therapy sessions focused on the aphasia (Mullen, 2016).

So, you may have between 2 and 40 hours total to make a difference in the life of a person with aphasia.  Think realistically about the total amount of time you have to make an impact. When you understand what the resource limitations are, you will be better able to think constructively and realistically about what you can accomplish.

2. What if I have a short amount of therapy time available – like 10 sessions or so?

The first step is making a small number of sessions count is to recognize that you will probably not be able to significantly change a whole language domain in a short amount of time. No matter how much you would like to improve a person’s word retrieval abilities enough to change all of their conversations, there is very little if any evidence to suggest that a significant amount of progress on a language domain or skill of this type can be accomplished in a very few numbers of treatment sessions.

Here is what you can do – you can significantly change the client’s ability to do something that is important to them. If you can help the person with aphasia do one daily activity that is highly meaningful and relevant, then you can significantly impact every day of that person’s future.

3.  I have to give a formal assessment – what do I choose?

Most formal aphasia assessments are focused on identifying domain-specific impairments, such as deficits in auditory comprehension, reading, writing, word-finding, or sentence production. Aphasia assessments in this category include tests like the Boston Diagnostic Aphasia Examination, the Western Aphasia Battery, and the Quick Aphasia Battery [link: https://aphasialab.org/qab/]

Fewer formal aphasia assessments measure functional abilities – but there are some. For example, the Communication Activities of Daily Living – Third Edition (CADL-3) assesses functional areas including using numbers, social interaction, contextual communication, and internet basics (Holland, Fromm & Wozniak, 2018). 

Another option to consider is an assessment that will also give you information about any concomitant cognitive impairments. An assessment like the Cognitive Linguistic Quick Test-Plus (CLQT+) (Helm-Estabrooks, 2017) offers a cognitive assessment path specific for those with aphasia. This may help you determine the kinds or numbers of different communication strategies that are most likely to be helpful for a person who also has attention, memory, and/or executive function impairments.

Both the CADL-3 and the CLQT+ can be administered in approximately 30 minutes, making them realistic options for many clinical settings.

4. If I use an impairment-focused assessment, what will my goals look like?

Most clinicians choose impairment-focused assessments most frequently (Wallace, Worrall, Rose, & LeDorze, 2017; Verna, Davidson & Rose, 2009). If an assessment is exclusively focused on impairments, then the clinician has little information to use to develop personally relevant goals.

As a result, clinicians begin using some of their precious therapy time to remediate one or more language domains, often the most severe as measured by the impairment-based assessment. Therapy goals that are chosen this way are typically linked directly to the original, impairment-focused assessment. For example, if a client achieved a score of 2/10 on the Reading Sentences and Paragraphs subtest of the Boston Diagnostic Aphasia Examination, and his spouse tells you that he “always loved to read”, you are likely to set a goal about comprehension of written sentences at a performance level that is somewhat higher than the initial test performance.  

5. How will my therapy choices be driven by these goals?

In this example, a treatment that focuses on reading sentence might be selected. Strategies such as underlining key words, using text-to-speech on a device, or other supports may be selected and practiced.

In this situation, clinicians often use an “additive model” to thinking about therapy (Hinckley, 2018). We select and use an impairment-focused treatment for a portion of the total therapy time, and then we add on a functional practice that is intended to apply or generalize what is being worked on in the impairment-focused portion of therapy. So, in a typical 45-minute treatment session, you may work on the impairment for 20 minutes and then practice the skill in a functional activity for another 20 minutes.

Is this the best use of limited treatment time? In a scenario where you have 10 treatment sessions available, you would be using 200 minutes total (about 3 ½ hours) on improving the reading impairment, and 200 minutes total (about 3 ½ hours) working on how the individual will apply these reading strategies or techniques to activities they will actually be doing after therapy ends. Can you realistically make an impact using this approach?

6. How else can I conduct an assessment?

When treatment time is going to be limited, focus your efforts on a particular activity that the client will engage in daily to make the biggest impact.

In order to do this, you will need to put your focus on the client’s typical activities. Most clients with aphasia spend their time watching TV, doing little else, and socializing very little with family after therapy discharge. Our job, especially when treatment time is limited, is to zoom in on one activity that you can help to change, that can realistically be added to the person’s daily life.

Would it be worth 10 treatment sessions to help someone learn how to call or text a family member? Request help with an activity?

One of my favorite clinical anecdotes is the case of an individual with aphasia and dementia living in a long-term care facility. Every day his wife came to visit him, but he never remembered her name, which made his wife very sad on a daily basis. Using spaced retrieval and a photo of the client’s wife, 100% of his speech treatment time was used practicing the response, “That’s my wife, Sarah!” Both client and wife had tears of joy the first day he called his wife’s name when he saw her coming down the hall. Was that worth 10 hours of therapy? I think so. It was probably the most meaningful thing in the daily life of these two individuals that I had the power to change.

7. How do I conduct an assessment that is focused on the client’s preferred activity?

To ensure the client’s preferred activity is the focus of your goals, start your evaluation by determining client priorities. After that, you can select some assessments – formal or informal, as needed – that specifically inform the activity that is important to the client. This is a patient-centered approach to goal-setting (Leach, Cornwell, Fleming & Haines, 2010).

For example, let’s say a young adult with aphasia who is the parent of young children comes to you. Let’s also imagine that, for this person, being able to say important things to the children (like, “Stop that!” Get down from there!”, or “I love you”) is critical, along with being able to read a bedtime story. If we know this first, before we even given any standardized assessment, we can tailor our tests to those that will very specifically relate to those personal priorities. Can the person express imperatives in any form – gesture, intonation, some words? Can the person read single words or short phrases aloud – specifically, those with children’s level vocabulary? Or, can the person repeat single words of the type that come from children’s stories? These are the things we need to know. The Oral Reading score on a standardized aphasia battery says a little about this, but doesn’t really give you everything you need to move quickly into personally relevant goals and therapy planning.

Our goal here is to make every minute of contact time contribute to the achievement of one or more personally relevant priority goals.

8. Is there any other way to set a therapy goal?

The typical way we set treatment goals is to administer a standardized battery, identify the language impairments that are most affected, and set goals that relate to the batter we administered. That usually leads us to creating goals like “The client will follow 3-step directions with XX% accuracy”, or “The client will name pictures of common objects with XX % accuracy”. While these goals may eventually support the client’s ability to do the functional activity that is important to them, it will probably take more therapy time to get there than you might have.

9.  What is Goal Attainment Scaling?

Goal Attainment Scaling (GAS) is an evidence-based approach to ensuring that a client is fully engaged in setting their rehabilitation goals. It is a collaborative approach in which the client and clinician agree to a goal – such as being able to read a simple Dr. Seuss book to their child. Then, together, the client and clinician establish criteria levels for what the outcome of working on this goal might look like, and both client and clinician select a pre-treatment rating level. After a pre-determined amount of treatment time, both client and clinician assess the outcome level, using the same criterion scale.

This approach is a great way to incorporate person-centered care with pre/post treatment measures, and would be easy to include in many documentation requirements. Get all the details here: https://www.sralab.org/rehabilitation-measures/goal-attainment-scale

10. Where can I find a menu of evidence-based aphasia treatments to choose from?

If you haven’t checked out the ASHA Practice Portal, please do: https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934663&section=Treatment. This is a great source of peer-reviewed, evidence-supported aphasia treatments, including background evidence. In most cases, you will be able to seek out more details about any given treatment within the ASHA Journals. There is some evidence that therapy that is focused on a particular task, like ordering items from a catalog, is the most effective use of a limited number of sessions. This kind of therapy may have indirect, downstream effects on other general skills, like word-finding (Hinckley & Carr, 2005).

11. Shouldn’t I start with basic skills and then work on applying those skills and strategies later?

Not necessarily, although of course it depends on several factors. How much treatment time do you have? What are the client’s impairments, and how severe are they? What is likely to happen to the client down the road – what is the discharge plan? Remember that many of our clients may be discharged after a short amount of therapy with limited support in their living environment for continued practice and improvement. You’ll want to build success and transfer to real life contexts as quickly as possible in most cases. Not only does it maximize the effect of your treatment time, but it will help foster your client’s motivation and perseverance.

12. How do I choose therapies that focus on the client’s preferred activity?

Have you ever done one of those optical illusions where the more you stare at things, the more obvious aspects of the original image disappear? Sometimes I think this is what happens to use clinically. We keep looking at the same lists of treatments in the same categories. This one is for word-finding, this one is for memory…

So let’s shake it up a bit. Let’s look at the same list of treatments, but think about them differently. What kind of speech act does this treatment focus on? What is the client accomplishing with their words when they do this treatment? This will help us focus on treatments that are matched to the client’s preferred activity, rather than focused on a particular impairment.

For example, if our client wants to be able to request their own food choices independently, a treatment approach like PACE (Promoting Aphasics’ Communicative Effectiveness, Davis, 2005) that is predicated on successful communication, often in a barrier game format, is really a way to practice requesting the items that you want or are looking for. Although this treatment can have other outcomes as well, it is more likely to be related to what the client wants to do (successfully request things), than something like a picture naming task. In a picture-naming task, even if the pictured items are preferred food items, the client is labeling, not requesting. When treatment time is limited, it will behoove us to get as close to all of the aspects of the target activity as possible.

13. What if the person has a severe aphasia?

When aphasia is severe, we are even more tempted to step back to the most basic skills we can think of – things like matching objects to pictures, for example. While this might be an effective approach, especially with adequate treatment time, it is a contrived context that does not capitalize on the likely preserved social skills of the person with severe aphasia.

Focus on a social interaction in which you can insert the supports that will help the person with aphasia participate. I’ll never forget one of the first cases of severe jargon aphasia that I had as a young clinician. A young man in his 20s had a severe TBI in a car accident, and when he started to talk it was a non-stop stream of jargon. The first skill that emerged was turn-taking. Although I don’t believe he understood what I said, he began to stop talking when I spoke, and then start again with jargon when I stopped. Social interaction skills are powerful and have been laid down neurologically since birth. Try to embed any gestures, Melodic Intonation Therapy, use of pictures, or other into a social context to capitalize on treatment time and effort.

14. What if the person has some cognitive impairments along with the aphasia?

The neural insult that leads to aphasia is likely to have affected some of the circuitry that is used for other cognitive functions as well, to different degrees. One of the most important to know about, perhaps, is executive function. Executive functions are needed for communication strategy use, and also are necessary for learning how to switch from one strategy to another (for example, try gesture when speech is not working). The two most “aphasia-friendly” assessments in this area are the Executive Function tasks on the CLQT (mentioned earlier), and the Raven’s Progressive Colored Matrices, which has been a part of the Western Aphasia Battery for decades. Higher executive function scores might suggest that your client will be a wiz at learning a strategy and using it in different situations. Lower executive function scores might mean that you will need to train the strategies that are going to work for this client in the context in which they are going to be used, because the client may not have the executive function ability to support untrained transfer across settings.

15. How can aphasia best be addressed in the acute setting?

A person in the acute setting is likely to be trying to figure out what is going on, what happened to them, and what is going to happen next. Here are a few of the best things we can do for our clients with aphasia in the acute setting.

1. Diagnose the aphasia.
2. Make sure other health care providers including physicians, and the client and family know and understand the diagnosis.
3. Facilitate communication between the patient and the acute care staff, so that the patient can better communicate needs, or request information and help. A tool like the Inpatient Functional Communication Interview (O’Halloran, Worrall, Toffalo & Code, 2020) can help (https://www.pluralpublishing.com/publications/inpatient-functional-communication-interview-screening-assessment-and-intervention).

16. What are realistic goals for chronic aphasia in the long-term care setting?

As some of my previous examples suggest, we have to keep in mind the context in which the person lives. What is realistic? What is something that has the possibility of changing that person’s daily life? If the target of our intervention is not something that occurs daily, or almost daily, it is likely to get lost in the shuffle and our efforts for naught. What about being able to respond to or independently request activities – rather than being wheeled into one without a choice? Requesting the alternate menu item? Requesting help to make a phone call? These activities are realistic given the care setting, and the ones that are most relevant to the client will make the best goals.

17. What if my client is not motivated?

Motivation comes from the interaction of a person with others and the environment. It is not something that a client either has, or doesn’t have; it can be modified little by little like other skills and abilities. To help our clients persist, we need to make sure that what we are asking them to do in therapy is clearly applicable to their preferences. Goal Attainment Scaling is a starting point that helps to ensure that clients will be engaged in the goal-setting process. Clients have the right to understand why each activity that they are being asked to perform is relevant to them. People also persist when they are encouraged, when they see success in others, or see success (no matter how small) in themselves, and find that the activity reduces – not increases – their stress or anxiety levels. This is a time-tested formula for task perseverance (Biel, Nitta, & Jackson, 2018).

18. When will a person with aphasia stop making progress?

An otherwise healthy person with aphasia can keep improving their communication skills and their abilities to engage in activities throughout their lifetime – just like the rest of us. The real issue, perhaps, is when does a person stop “getting therapy” and start “living life”? This is not a decision that a clinician can make on behalf of the client. It is a decision that needs to be made collaboratively with the client. Discharge from therapy is often misperceived by clients as being given up on, when in fact the end of therapy is coming about due to the end of financial or payment resources. Make this clear to your client. Your client deserves to know that they can still improve if they stay socially and communicatively active.

19. How do I make sure that I am doing the best aphasia treatment possible?

Did you know that there are International Best Practices for how to help people with aphasia? There are 10 practices that carry the weight of evidence from around the English-speaking world. You can find them, including an aphasia-friendly version of them, here: http://www.aphasiaunited.org/best-practice-recommendations/

20. How can I best help my clients beyond their last session with me?

If you’ve started with your client by co-determining preferred activities and goals, then a home program that follows up on those goals is going to be a breeze. Ditch the Xeroxed homework sheets that don’t accomplish any functional change and probably end up in a desk drawer or trash bin, anyway. Co-create a daily schedule for your client that includes times when the client will deploy the strategies or activities that you’ve worked on. If you’ve also had the opportunity to engage in partner training from the outset, then much of planning your home program will be set up for you. Your client will be able to do something differently – hopefully every day – because of you. Great job!

References

Biel, M., Nitta, L., & Jackson, C. (2018). Understanding motivation in aphasia rehabilitation. Chapter in Coppens, P. & Patterson, J. Aphasia Rehabilitation: Clinical Challenges. Jones & Bartlett Learning.

Davis, G. A. (2005). PACE revisited. Aphasiology, 19, 21-38.

Foster, A. M., Worrall, L. E., Rose, M. L.  & O’Halloran, R.(2013) Turning the tide: Putting acute aphasia management back on the agenda through evidence-based practice, Aphasiology, 27: 420-443, DOI: 10.1080/02687038.2013.770818

Helm-Estabrooks, N. (2017). Cognitive-Linguistic Quick Test – Plus. Pearson Assessments.

Hinckley, J. (2014). Facilitating life participation in severe aphasia with limited treatment time. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 24, 89-99.

Hinckley, J. J. (2018). Selecting, combining, and bundling different therapy approaches. Chapter in Coppens, P. & Patterson, J. Aphasia Rehabilitation: Clinical Challenges. Jones & Bartlett Learning.

Hinckley, J. J. & Carr, T. H. (2005).  Comparing the outcomes of intensive and nonintensive aphasia treatment.  Aphasiology. 19, 965-974.

Holland, A., Fromm, D. & Wozniak, L. (2018). Communication Activities in Daily Living. Third edition. Pro-Ed Inc.

Leach, E., Cornwell, P., Fleming, J., & Haines, T. (2010). Patient-centered goal setting in a subacute rehabilitation setting. Disability and Rehabilitation, 32, 159-172.

Mullen, R. (2016). How long will treatment for aphasia last? The ASHA Leader. https://doi-org.ezproxy.lib.usf.edu/10.1044/leader.OTP.21102016.38

O’Halloran, R. Worrall, L. Toffalo, D. & Code, C. (2020). Inpatient Functional Communication Interview: Screening, Assessment, and Intervention. San Diego: Plural Publishing.

Verna, A., Davidson, B., & Rose, T. (2009). Speech-language pathology services for people with aphasia: A survey of current practice in Australia. International Journal of Speech-Language Pathology, 11(3), 191.

Wallace, S. J., Worrall, L., Rose, T., & Le Dorze, G. (2017). Which treatment outcomes are most important to aphasia clinicians and managers? An international e-Delphi consensus study. Aphasiology, 31(6), 643.