9/20/2014

1

The Critical Role of the Person with Aphasia in Speech Production Treatment

Katarina L. HaleyUniversity of North Carolina at Chapel Hill

NCSHLA Fall ConferenceSeptember 20, 1:45 pm – 4:45 pm

Acknowledgments and disclosure

• This research was supported by award number UL1RR025747 from the National Center for Research Resources.

• Additional funding was provided by the UNC Department of Allied Health Sciences

• The LIV Cards are sold by the University of North Carolina Department of Allied Health Sciences.

Presentation Overview• Current AOS treatment evidence and practice guidelines• Models for comprehensive goal setting

– ICF– A-FROM– An alternative model

• The L!V Cards: PWA and proxy

• Targeting Communicative Life Participation– Script training– Integration between AAC and speech practice– Self-administered practice

• “Auto-Speech” (autonomous speech production training)

• Conclusions

Current AOS treatment evidence and practice guidelines

AOS treatment guidelinesANCDS committee, 2006; update 2014/2015

Articulatory kinematic approaches - “probably effective”Rate/rhythm control approaches - “possibly effective”Intersystemic approaches - “possibly effective”AAC approaches - could not be rated for likelihood of benefit

Wambaugh, J.L., Duffy, J.R., McNeil, M.R., Robin, D.A., & Rogers, M.(2006). Treatment guidelines for acquired apraxia of speech: A synthesis and evaluation of the evidence. Journal of Medical Speech Language Pathology, 14(2), xv-xxxiii.

Wambaugh, J.L., Duffy, J.R., McNeil, M.R., Robin, D.A., & Rogers, M.(2006). Treatment guidelines for acquired apraxia of speech: Treatment descriptions and recommendations. Journal of Medical Speech Language Pathology, 14(2), xxxv-ixvii.

Wambaugh, J.L. (2006). Treatment guidelines for apraxia of speech: Lessons for future research. Journal of Medical Speech-Language Pathology, 14(4), 317-321.

www.ancds.org

American Academy of Neurology Classification system for clinical

practice guidelines

• Class I: Randomized controlled clinical trial (RCT) in a representative population (masked, objective, or independent outcome assessment)

• Class II: Cohort lacking in masked, objective, or independent outcome assessment, case-control

• Class III: Controlled within-participant designs (with masked, objective, or independent outcome assessment)

• Class IV: Uncontrolled studies

9/20/2014

2

Articulatory kinematic approaches

• Modeling• Integral stimulation (speech entrainment)• Articulatory placement cues• Shaping• Minimal contrast practice• Biofeedback

GOALS/OUTCOME: Improved accuracy of sound, syllable, sentence production based on probes and (less frequently ) articulation tests. Mixed results for generalization to untreated exemplars. No generalization to untreated targets.

Rate/rhythm approaches

• Metronomic pacing• Finger tapping/counting• Instructional feedback• Computerized pacing – oral reading• Pacing board

GOALS/OUTCOME: Mixed results for improved accuracy of sound production and increased fluency based on probes. Mixed results for generalization to untreated exemplars. No generalization to untreated targets.

Inter-systemic approaches

• Iconic gestures (e.g. Amerind)

• Rhythmic gestures (tapping, counting)

• Singing

GOALS/OUTCOME: Improved accuracy of sound production based on probes and (less frequently) articulation tests; increased use of iconic gestures. Mixed results for generalization to untreated exemplars. No generalization to untreated targets.

AAC approaches

• Gestures

• Communication boards/notebooks

• Speech generating devices

• Multiple communication systems – writing, drawing, notebooks, gestures

GOALS/OUTCOME: Increased use of AAC system/s, communicative success in the environment where training occurred, but unwillingness to use in typical communication settings

Models for comprehensive goal setting

ICFA-FROMAn alternative model

Almost all evidence supporting AOS tx is at the level of body

structures/functions

articulatory-kinematic and rate/rhythm approaches are promising, BUT….

It is unknown how outcomes affect life with AOS (and aphasia)

9/20/2014

3

What people with aphasia want:

1. Return to pre-stroke life. Be normal and enjoy life.

2. Recover ability to communicate about interesting things

3. Learn more about aphasia, stroke, and prognosis

4. SLP tx that meet their life participation needs

5. Control and independence

6. Dignity and respect

7. Engage in social, leisure, and work activities

8. Contribute to society

9. Good physical function and health

Worrall, L., Sherratt, S., Robers, P., Howe, T., Hersh, D., Ferguson, A., & Davidson, B. (2011). What people with aphasia want: Their goals according to the ICF. Aphasiology, 25, 309-322.

International Classification of Functioning, Disability and Health (2001). World Health Organization

Living with Aphasia: Framework for Outcome Measurement (A-FROM)

Participation

Personal

Language

Environ-ment

Kagan, A., Simmons-Mackie, N., Rowland, A., Huijbregts, M., & Shumway, E., McEwen, S., …..Sharp, S. (2008). Counting what counts: A framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 22, 258-280.

Communicative Life

Participation

BRAIN FUNCTION

PERSONAL FACTORS

ENVIRON-MENTAL FACTORS

• Community• Loved ones• Settings• Opportunity• Augmentative tools

• Spoken language• Speech productionAn Alternative

Model….

• Confidence• Mood• Knowledge• Connectedness• Self-determination

Could aspects of our tx be iatrogenic?

• Are we unintentionally strengthening negative personal factors by suppressing autonomy and revealing lack of competence?

• Does our avoidance of environmental factors promote “resistance to AAC” or a feeling of “failure”?

• How much of a partner are PWA in goal setting?

• What does it feel like to “take” the treatment?

• Does the plan include living with AOS and aphasia?

Beyond motivation as tx candidacy:Self-Determination Theory

• Innate psychological needs:

– Autonomy: the experience of initiating and regulating one’s actions

– Competence: the desire to act proficiently in our surroundings

– Relatedness: the importance of feeling supported and connected with others

Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist. 2000;55(1):68-78.

Deci EL, Ryan RM. The 'What' and 'Why' of Goal Pursuits: Human Needs and the Self-Determination of Behavior. Psychological Inquiry. 2000;11(4):227.

9/20/2014

4

Do you embrace client-centered care?• Occupational therapists indicated in interviews that they embraced

principles of client-centered care, but clients interviewed by the same investigators indicated they were unaware of attempts described by the therapists to engage them actively in the rehabilitation process

• When the same therapists were informed of the clients’ perspectives, they cited barriers to enacting client-centered care– inability to engage clients with impaired language/cognition– interference of high productivity demands– difficulty with clients who are passive and unmotivated,– work climates where the clients’ personal goals are not the priority of

the health-care team.

Maitra, K. K., & Erway, F. (2006). Perceptions of client-centered practice in occupational therapists and their clients. American Journal of Occupational Therapy, 60(3), 298–310.

Client-centered tx in aphasia• Aphasia is often perceived as an overwhelming barrier• Family members and friends give important input, but

relying on them introduces other problems for psychosocial well-being, motivation, and information accuracy.

• Using family members or friends present for support and supplemental input also affects autonomy of the PWA.

Croteau, C., Dorze, G. L., & Baril, G. (2007). Development of a procedure to evaluate the contributions of persons with aphasia and their spouses in an interview situation. Aphasiology, 21(6-8), 791–801.

Croteau, C., Le Dorze, G., & Morin, C. (2008). The influence of aphasia severity on how both members of a couple participate in an interview situation. Aphasiology, 22(7-8), 802–812.

Croteau, C., Vychytil, A. M., Larfeuil, C., & Le Dorze, G. (2004). “Speaking for” behaviours in spouses of people with aphasia: A descriptive study of six couples in an interview situation. Aphasiology, 18(4), 291–312.

Leach, E., Cornwell, P., Fleming, J., & Haines, T. (2010). Patient centered goal-setting in a subacute rehabilitation setting. Disability and Rehabilitation, 32(2), 159–172.

The L!V Cards: PWA and proxy

Do you know what I want out of my SLP/OT/PT therapy?

The Life Interests and Values Cards (L!V Cards)

What do you want to do morein your life?

Study 1: Mean agreement between PWA and family member/friend proxy: 71%

Haley, K L, Womack, J L, Helm-Estabrooks, N, Lovette, B, Goff, R (2013). Supporting Autonomy for People with Aphasia: Use of the Life Interests and Values (LIV) Cards. Topics in Stroke Rehabilitation, 20 (1), 22-35.

9/20/2014

5

What does “disagreement” mean?

Is it the presence of aphasia that causes limited agreement?

Mean agreement:72%.

Study 2: Mean agreement between seniors and family members/friend proxy: 72%

Haley, K. L., & Wangerman, T. (2012). Using family members or close friends as informants about participation goals for older adults with and without aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 22 (1), 12-17.

Study 3*: Mean agreement between PWA and family member/friend proxy: 70%

*Haley et al. (in progress). Life Activity Choices by People with Aphasia: Repeated Interviews and Proxy Agreement

Proxy agreement was significantly lower than test-retest agreement for PWA (78%)

So…

• PWA know what Life Activities they want

• Family members and close friends are not so good at speaking for them

Haley, K L, Womack, J L, Helm-Estabrooks, N, Lovette, B, Goff, R (2013). Supporting Autonomy for People with Aphasia: Use of the Life Interests and Values (LIV) Cards. Topics in Stroke Rehabilitation, 20 (1), 22-35.

PWA want to do more home/community, relaxing/creative, physical, AND social activities

PWA want to do more home/community, relaxing/creative, physical, AND social activities

Haley et al. (in progress). Life Activity Choices by People with Aphasia: Repeated Interviews and Proxy Agreement

9/20/2014

6

Valued communicative life participation as goals for speech

production treatment

Communicative Life Participation

Targeting Communicative Life Participationin AOS treatment

A. Script trainingB. Integration between AAC and speech practiceC. Self-administered practice

Communicative Life Participation

A. Script Training for aphasia• Goal is to achieve “islands of automatic speech” that can be produced

fluently that are available for use in real-life discourse

• Automaticity is achieved via repetition, choral reading, and independent production– Similarities with articulatory kinematic and rate/rhythm approaches for AOS

• Scripts are highly personalized and situation-specific– Topic is selected by PWA and lines are developed jointly by SLP and PWA

• Outcomes are primarily situation-specific, but generalization has also been observed– Script phrases occur observed in everyday conversation and in conversations

with novel partners

Bilda, K. (2011). Video-based conversational script training for aphasia: A therapy study. Aphasiology, 25(2), 191–201.Cherney, L. R., Halper, A. S., & Kaye, R. C. (2011). Computer based script training for aphasia: Emerging themes from posttreatment interviews. Journal of Communication Disorders 44, 493–501.Youmans, G., Holland, A., Muñoz, M., & Bourgeois, M. (2005). Script training and automaticity in two individuals with aphasia. Aphasiology, 19, 435–450.

Example of a script

Goldberg, S., Haley, K.L., & Jacks, A. (2012). Script training and generalization for people with aphasia. American Journal of Speech-Language Pathology, 21(3), 19– 34.

Speech outcomes of script training

• Words from the target script

• Increased speaking rate

• Improved sound production accuracy

• Increased fluency

Cherney, L., Halper, A., Holland, A., & Cole, R. (2008). Computerized script training for aphasia: Preliminary results.American Journal of Speech-Language Pathology, 17, 19–34.

Goldberg, S., Haley, K.L., & Jacks, A. (2012). Script training and generalization for people with aphasia. American Journal of Speech-Language Pathology, 21(3), 19– 34.

Holland, A., Milman, L., Muñoz, M., & Bays, G. (2002, June). Scripts in the management of aphasia. Paper presented at the World Federation of Neurology, Aphasia and CognitiveDisorders Section Meeting, Villefranche, France.

Youmans, G., Youmans, S. R., & Hancock, A. B. (2011). Script training treatment for adults with apraxia of speech. American Journal of Speech-Language Pathology, 20(1), 23–37.

9/20/2014

7

Goldberg, S., Haley, K.L., & Jacks, A. (2012). Script training and generalization for people with aphasia. American Journal of Speech-Language Pathology, 21(3), 19– 34.

Script Training with modification*

*As needed: Gradual progression of target length, Personalized cues

Goldberg, S., Haley, K.L., & Jacks, A. (2012). Script training and generalization for people with aphasia. American Journal of Speech-Language Pathology, 21(3), 19– 34.

Practice of target scripts increases speaking rate/target word use and reduces disfluency

for communicative life participation

B. Integration between AAC and speech practice

• Home speech practice using a speech generating device (SGD) and motor learning guided (MLG) therapy resulted in improved production of trained items– What about AAC use?

• …in probes– What about in conversation? Communicative Life Participation?

Lasker, J. P., Hagemen, C. F., LaPointe, L. L., & Stierwalt, J. A. G. (2008). Using motor learning guided theory and augmentative and alternative communication to improve speech production in profound apraxia: A case example. Journal of Medical Speech-Language Pathology, 16 (4), 225-

Lasker, J. P., Stierwalt, J. A. G., Spence, M., & Cavin-Root, C. (2010). Using webcam interactive technology to implement treatment for severe apraxia: A case example. Journal of Medical Speech-Language Pathology, 18(4), 71-76.

C. Self-administered computerized practice

• Multimodality sensory stimulation – auditory, visual, orthographic– “Imagined production” followed by actual production– What about personalized cues?

• Outcomes– Increased fluency for trained targets… in probes– What about communicative life participation?

Whiteside, S. P., Inglis, A. L., Dyson, L., Roper, A., Harbottle, A., Ryder, J., …. Varley, R. A. (2012). Error reduction therapy in reducing struggle and grope behaviors in apraxia of speech. Neuropsychological Rehabilitation, 22 (2), 267-294

How to support autonomous practice

Use multiple modalities and presentation choices (→ multimedia)

Use intuitive (and low-cost) interface (→ digital photo/video album)

Build gradually (→ simple access to cameras, deleting, reordering)

THE CHALLENGE IS TO KEEP IT SIMPLE, YET FLEXIBLE

3 PWA24 sessions20 words phonological cues, 20 words personalized cues (top 2 graphs)20 untreated words (bottom 2 graphs)SUPERIOR RETENTION FOR PERSONALIZED CUES

Personalized cueing

Freed, D. B., Celery, K., & Marshall, R. C. (2004). Effectiveness of personalized and phonological cueing on long-term naming performance by aphasic subjects: A clinical investigation. Aphasiology, 18, 743-757.

9/20/2014

8

Marshall, R. C., & Freed, D. B. (2006). The personalized cueing method: From the laboratory to the clinic. American Journal of Speech-Language Pathology, 15, 103-111.

Personalized cueing

Communicative Life

Participation

BRAIN FUNCTION

PERSONAL FACTORS

ENVIRON-MENTAL FACTORS

• Community• Loved ones• Settings• Opportunity• Augmentative tools

• Spoken language• Speech productionAddressing all 3

domains to improve speech production in AOS…

• Confidence• Mood• Knowledge• Connectedness• Self-determination

“Auto-Speech” (autonomous speech production training)

PRINCIPLES of Auto-Speech for AOS• Speech practice targets Communicative Life Participation

– Target words and phrases are common or anticipated conversation topics determined by the PWA

– Content grows gradually

– When the PWA gains fluency, targets are practiced in context

• Dynamic environmental factors are modified– Practice in real settings becomes less taxing

– AAC is introduced implicitly and naturally, because practice items are convenient alternatives to talking

• Dynamic personal factors (self-determination) are supported– The PWA determines what to say and when to say it

– The PWA selects personal cues and evaluates effectiveness

• Intense practice is feasible– Practice could take place most anywhere and most anytime

Auto-Speech Demonstration

Conclusions

• AOS responds to various articulatory kinematic and rate/rhythm approaches, but intensity is important

• Almost all AOS treatments address only body structures/functions and not communicative life participation—which is the most important goal for people with aphasia (and AOS).

• PWA know what kind of life participation they want—their friends or family members can only infer

• Communicative Life Participation can be addressed by targeting speech production via script training, integration with AAC, and by providing opportunity to practice independently.

• “Auto-Speech” (autonomous speech production training) may be a useful approach.

9/20/2014

9

The Critical Role of the Person with Aphasia in Speech Production Treatment

• Functional goal setting– Communicative Life Participation

• Motivation to learn and practice– Personal factors tx at any level

• Application of strategies and skills– Environmental factors must be modified, so PWA can

learn to “generalize”

• Continued (life-long) learning and growth– Communicative needs are dynamic and persistent

Thank You!

khaley@med.unc.edu