Complexity in Aphasia Therapy:

the case of sentence & discourse production

Paul Conroy,

Marcella Carragher, Anne Hesketh

Rotterdam, March 30th 2012

Om te beginnen:

Het spijt me niet in staat zijn om deze lezing te geven in het Nederlands.

Helaas, de monlingual tendensen van het Verenigd Koninkrijk ook uitstrekken naar Ierland.

Hoewel ik spreek sommige Ierse Gaelic en school jongen Frans, ik betwijfel of deze zou veel gebruiken om u.

Dus nu terug naar Engels ...

Plan:

A literature review The conclusions from this review Too much complexity!? Towards simplicity: Developing a

hybrid intervention for expressive

language in non-fluent aphasia Results Discussion

Why focus on sentence & discourse production?

• ‘verbal therapies’ literature - single word production - highly imageable object names (Nickels, 2002)

• Evidence that this level of therapy can benefit e.g., conversation (Carragher et al., 2012)

• But often need for ‘bridging’ therapy – e.g. Greenwood et al. (2010)

• Also, no relationship between action naming skills and verb diversity in connected speech (Bastiaanse & Jonkers, 1998)

• Sentence & discourse measures more ecological (Armstrong, 2000)

Therapy Cognition

LinguisticTheory

Search Method for literature review

(with Dr Anne Hesketh):

Web of Knowledge searches using two search terms were conducted.

• ‘aphasia + sentence + therapy’ (yielding 320 studies)

• ‘aphasia + discourse + therapy’ (120 studies).

• By-hand searches were also carried out for relevant therapy studies between January 2000 and December 2010.

Criteria:

• therapy/intervention studies with participants with aphasia

• Focus on expressive language, beyond single word naming, of the person with aphasia, and with baseline and post-intervention analyses.

90 studies in 7 sub-categories:

1) Training production of

morphological markers

1) Mapping therapies

2) Event perception

3) Sentence building therapy

4) Speech processing prosthesis

5) Therapy for complex structures

6) Discourse therapy

90 studies in 7 sub-categories:

Training production of morphological markers (Weinrich, et al., 1997; Faroqi-Shah,

2008)

Mapping therapies (Marshall et al., 1997; Edmonds, Nadeau et al. 2008)

Event perception (Marshall et al., 1993; Marshall & Cairns, 2005)

Sentence building therapy (Links et al., 2010; Ruiter et al.,2010)

Speech processing prosthesis (Linebarger et al., 2001; Linebarger & Schwartz,

2005)

Therapy for complex structures (Thompson et al., 1996;

Thompson et al. 2010)

Discourse therapy (Peach and Wong, 2004; Whitworth, 2010)

90 studies in 7 sub-categories:

Training production of morphological markers (Weinrich, et al., 1997; Faroqi-Shah,

2008)

Mapping therapies (Marshall et al., 1997; Edmonds, Nadeau et al. 2008)

Event perception (Marshall et al., 1993; Marshall & Cairns, 2005)

Sentence building therapy (Links et al., 2010; Ruiter et al.,2010)

Speech processing prosthesis (Linebarger et al., 2001; Linebarger & Schwartz, 2005)

Therapy for complex structures (Thompson et al., 1996;

Thompson et al. 2010)

Discourse therapy (Peach and Wong, 2004; Whitworth, 2010)

C-VIC Weinrich, Shelton, Cox and McCall (1997)

• 3 participants

• Therapy to improve tense morphology

• C-VIV: icons represent object and action words which can be ordered into sentence frames

• 10 verbs trained (4 reg; 6 irreg)

• Picture stimuli – about to steal, stealing, having just stolen…

• Verbal/written production of sentence with tense markings…

• Training up to 15 sessions or until success criterion reached

Tense Morphology Training Results

Pre-therapy Post-therapy

0% 48%

6% 67%

12% 68%

Verb retrieval

(trained & untrained)

Tense production

Pre-therapy Post-therapy

36% 89%

43% 85%

53% 83%

Tense Morphology Training Results

Patterns of generalistion: Strong for regular verbs (comb, combed),

not for irregulars (go, went)

Comprehension of verbs & sentences

(word/sentence picture matching) improved

The authors speculated their findings were consistent with a restricted processing account in which, in the interaction between lexical and syntactic processing, the ‘authomisation’ of the tense morphology production process allowed reallocation of resources to other processes, such as verb retrieval and comprehension.

Verb Network Strengthening Treatment (VNeST):a semantic treatment focusing on strengthening the connections between verbs (e.g., measure) and their typical thematic roles (e.g., chef, sugar).

(Agent: carpenter) (V: measure) (Patient: stairs)

“The carpenter is measuring the stairs.”

:

“carpenter”

The carpenter is measuring the stairs.

Surveyor

Land

Chef

Sugar

Designer Room

Measure

Surveyor

Land

Chef

Sugar

Carpenter Lumber

Designer Room

Weigh

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Lexical selection(among competitors)CarpenterPlumberMeasureWeighStairsWall

Function assignment:

Lexical retrieval:

“measure”

“stairs”

Constituent assembly:S

NP VP NP

aux /V/ det /N/

S

NP VP NP

det/N/ det /N/

Surveyor

Land

Chef

Designer Room

Surveyor

Land

Chef

Designer Room

Surveyor

Land

Chef

Designer Room

Surveyor

Land

Chef

Designer Room

VERB THEMATIC NETWORKS

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Positional LevelLexical Retrieval Constituent Assembly

Message Level

Functional LevelLexical Selection Function Assignment

Grammatical Component

Phonological Level

Output

Adapted from Bock & Levelt, 1994

SENTENCE PRODUCTION MODEL

(Agent: carpenter) (V: measure) (Patient: stairs)

“The carpenter is measuring the stairs.”

:

“carpenter”

The carpenter is measuring the stairs.

Surveyor

Land

Chef

Sugar

Designer Room

Measure

Surveyor

Land

Chef

Sugar

Carpenter Lumber

Designer Room

Weigh

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Lexical selection(among competitors)CarpenterPlumberMeasureWeighStairsWall

Function assignment:

Lexical retrieval:

“measure”

“stairs”

Constituent assembly:S

NP VP NP

aux /V/ det /N/

S

NP VP NP

det/N/ det /N/

Surveyor

Land

Chef

Designer Room

Surveyor

Land

Chef

Designer Room

Surveyor

Land

Chef

Designer Room

Surveyor

Land

Chef

Designer Room

VERB THEMATIC NETWORKS

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Jeweler

Gold

Cashier

Produce

Butcher Meat

Nurse Patient

Positional LevelLexical Retrieval Constituent Assembly

Message Level

Functional LevelLexical Selection Function Assignment

Grammatical Component

Phonological Level

Output

Adapted from Bock & Levelt, 1994

SENTENCE PRODUCTION MODEL

VNeST/ ‘Verb Network Strengthening Treatment’ (Edmonds, Nadeau et al. 2008)

o Verbs prime typical agents (e.g., pray–nun) and patients (arrest–criminal)

o Treatment: 10 verbs, 3-4 possible agents, 3-4 possible patients

o Results demonstrated generalisation to lexical retrieval of content

words in sentences with trained and untrained verbs across participants.

o Pre- to post-treatment generalisation was observed on single verb and noun naming and lexical retrieval in sentences across a variety of tasks across participants.

o Generalisation to connected speech was observed for three of four participants.

A theory of generalisation:

“centring a semantic therapy on verbs provides the basis for engaging large expanses of semantic networks during treatment and through Hebbian learning, strengthening the neural basis for a large variety of concept representations, and increasing the probability that those representations can elicit corresponding word production.”

Edmonds, Nadeau et al. 2008, p.420

SentenceShaper® Linebarger and Schwartz (2005)

‘turning off the clock’ on sentence production;

uses intact comprehension of sentences to allow trial and error sentence production aided by coloured symbols

Method:

• The communication system (CS) derived from observations by Linebarger and colleagues

• recording sentence parts produced by the participant and then storing them under a shape such as a square, star or triangle

• sentence part stored in a shape is spoken as many times as necessary by touching the shape on the screen

• the shapes can be moved digitally around the computer screen so they can be lined up and the sentence parts built up into longer phrases or whole sentences

• high frequency verbs are listed on the right side of the screen and propositions on the left side

Speech Processing Prosthesis:

Treatment effects:

• aided and treatment effects (on unaided spontaneous speech) of CS supported performance based accounts of aphasic speech production.

• linguistic knowledge is largely preserved in aphasia but cannot be used effectively in real time due to performance factors: difficulties in accessing, retaining, or selecting linguistic information under the temporal constraints that normally obtain in spoken language production

• enlarging the (temporal) planning window (‘turning off the clock’), as well as allowing for lexical association and enhanced lexical retrieval through a cloze effect (offering semantic, syntactic and prosodic retrieval cues) achieved through re-playing of sentence fragments

Conclusions from literature review:

• Options for sentence/discourse production therapy are varied: wide choice of theoretically-plausible, clinically defined interventions.

• They offer the opportunity for generalisation of trained skills, optimising the likelihood of functional change in everyday expressive communication skills.

• Anecdotal evidence suggests these interventions are not represented within standard clinical practice (at least in the UK) to the extent we might predict, given the outcomes reported (Marshall 2008)

The complexity conundrum:

• The challenge of accessing and understanding

this literature

• Legacy of the negative syntax drilling tradition?

• Detailed and distinct assessment and treatment procedures

• Investment required for specific software

• Interventions based on small sample sizes

MRC framework for complex interventions to improve health (2000)

Ways forward: simplification?

Extraction and combination of active ingredients

Reduce to a rich sauce

Towards a

hybrid therapy for

non-fluent aphasia

Improving the conversations of speakers with non-fluent aphasia: Evaluating the combination of impairment-focused therapy and interaction-focused therapy

Impairment focused therapy for non-fluent aphasia

• Orientated towards conversation as the main therapy outcome – everyday functional goals

• Wide remit to review the relevant literature in a ‘quest for the best’

• 2 phase hierarchical therapy plan, with lexical phase and structural phase

Participants:

Case series

9 participants

Non-fluent aphasia

Men/women ratio 7:2

Age range: 34 – 68 years of age

Range of time post-onset: 10 months – 15 years

Assessment Data:

– Boston Diagnostic Aphasia Evaluation (BDAE)

– Pyramids & Palm Trees

– Kissing & Dancing Test

– PALPA 9 (repetition of words and nonwords)

– PALPA 31 (reading aloud)

– Object Action Naming Battery (actions only)

– Verb And Sentence Test (VAST)

– Cinderella re-tell

– Conversation sampling

– Cognitive assessments

765432

Phrase length

Melodic line

Word finding relativeto fluency

Sentence repetition

Grammatical form

0-2030 90-10040 50 60 70-80

1

Articulatory agility

Percentile scores

Paraphasias in speech

Performance of speakers with non-fluent aphasia

BL KKPM JH PG DMGL DC AT

Auditory comprehension

Lexical therapy stimuli:

• Object Action Naming battery

• Personally relevant verbs

• Light Verb Elicitation Test

(Conroy, unpublished)

• International Picture Naming Project

Lexical therapy

Consistent failure of retrieval across two test administrations

Therapy set = 40 Control set = 40

Frequency Imageability Age of acquisition Length Number of arguments

Lexical therapy

o Semantic feature analysis (SFA)

o boost activation within a semantic network (Coelho, McHugh & Boyle, 2000)

o spreading activation theory of semantic processing (Collins & Loftus, 1975)

o Wambaugh & Ferguson (2007): modified SFA procedure to accommodate verbs

o Facilitative effect of gesture on lexical retrieval (Lanyon & Rose, 2009)

o Increasing phonemic cues (Nickels, 2002)

who

where

VERB

what

how

gesture

why

Example of picture stimuli

SFA diagram

(some) Results from lexical therapy:

Post-therapy assessment x2:

Treated verbs

Control verbs

Sentence production (VAST)

Connected speech

Does verb therapy impact on naming

treated and untreated verbs?

Context: naming assessmentTime: 1 week after therapy

Are gains in verb naming maintained

after therapy has ended?

Context: naming assessmentTime: 1 month after therapy

Do participants generalise improvements in verb naming to sentence production?

Context: unrelated task of sentence production (VAST)

0

10

20

30

40

50

60

70

baseline post-therapy

Time

Acc

ura

cy o

f se

nte

nce

pro

du

ctio

n

PM

BL

JH

KK

PG

GL

DM

DC

AT*

*

Elicited sentence production:

• Sentences scored out of 3 (intransitive) or 4 (transitive)

• 1 point for production of agent, 1 for verb, (optionally 1 for patient), 1 for word order

• Sample improvement:

- pre-therapy: “down… the boy”

- Post-therapy: “boy sliding”

Summary of results of lexical therapy phase:

• Significant direct therapy effects for 8/9 participants

• Significant indirect therapy effects for 5/9 participants (less severe)

• These gains were maintained

• Changes in elicited sentence production for 2/9 (both ends of severity range)

• A promising start!

Structural therapy phase:

• Again, a hybrid therapy, trying to extract the most promising ingredients and combine them in a novel way

• designed to facilitate a range of non-fluent speakers in producing a variety of syntactic constructions, guided by a production hierarchy (Mapping: Marshall, 1995; Action: Links et al., 2010)

• aim to target and develop simplified syntactic constructions (REST: Ruiter et al., 2010), with the aim of generalising therapy effects to withstand increased processing demands.

Innovative features: Task flexibility: intervention levels mean that participants with a

range of non-fluent severity can work within the same therapy programme.

Lexical flexibility: specific lexical items (e.g. action verbs such as running, driving) are treated as structurally equal with pro-forms (including pronouns, deictic expressions – this, that, those-) and light verbs… participants are presented with choices as to which lexical items they want to insert within a structure.

Structural flexibility: in line with REST etc., the programme allows for targeting of reduced structures which may not be technically grammatically correct.

Increasing processing demands: at each level of intervention, participants are facilitated to generalise structures to contexts of increased processing demand.

Structural stimuli:

• 50 transitive action pictures

(some recycled from lexical phase)

• Baseline sentence production measures

(max 4 points system)

• 2 sets of matched stimuli (treatment, control)

• Baseline scores between 25-50% - working on structural production is viable (as opposed to lexical retrieval more simply) and yet clinically needed

Therapy materials:

• Black and white line drawings from the OANB/IPNP

• a written list of light verbs: participants will be reminded that they can use a light verb to substitute another (heavy) verb

• a written sentence frame with colour-coding to differentiate between the agent, verb and object

• a number of personal photographs to act as potential agents

Therapy method:

Participants will be asked to produce syntactic constructions three times in direct response to each picture stimulus,

and then identify and produce three alternative viable words: agent and patient labels (including pronouns and personal agents such as the names of family members),

and consider a lighter or ‘heavier’ verb to the first one they accessed.

Working on sentence production & alternatives to given sentences.

• Step 1a: focus on metalinguistic knowledge - identifying the written verb, agent and patient/theme in active and passive sentences.

• Step 1b: 2-part production - . participant asked to produce a simplified syntactic construction e.g., ‘ ‘agent+verb’ or ‘verb+patient’ construction

• Correct production: repeat a total of 3 times.

• Incorrect production: increased phonological cueing with written support.

• Generalisation task for all participants: The participant is asked to produce another 3 constructions, inserting alternative agent/ verb/ patient.

• Homework: practising exemplars of 2-part structures for the stimulus pictures.

The case was dragged by the boy

Next level:

Criterion for progress to next level: 60% success

• Step 2a: mapping 3-part structures – colour coding verb, agent, patient

• Step 2b: 3-part structures

• Correct production: repeat a total of 3 times.

• Incorrect production: increased phonological cueing with written support.

• Generalisation task for all participants: The participant is asked to produce another 3 constructions, inserting alternative agent/ verb/ patient.

• Homework: practising exemplars of 3-part structures for the stimulus pictures.

Higher levels:

• Step 3: expanding the syntactic construction. The participant is shown a picture and asked to produce a simplified syntactic structure with information added through adverbs or adjectives (HOW) or prepositions (WHERE).

• Homework: practising 2- and 3-part structures for everyday situations, e.g., emptying the dishwasher, emptying the bin, watering the garden, preparing a snack, etc.

• Step 4: targeting fluency, speed of delivery and prosody.

• Homework: practising 2- and 3-part structures for everyday situations with an emphasis on fluency, speed and prosody.

(some) Results from structural therapy:

Comparison of treated syntactic constructions before and after Phase 2 intervention

0102030405060708090

100

Baseline baseline 1 week post-therapy

1 monthpost-therapy

Time points

Accu

racy o

f syn

tacti

c

co

nstr

ucti

on

(%

) PM

BL

JH

KK

PG

GL

DM

DC

AT

Comparison of treated syntactic constructions averaged before and after Phase 2 intervention

** * *

*

* *

*

0

20

40

60

80

100

120

KK GL BL DC JH AT PM PG DM

Participants

Acc

ura

cy o

f sy

nta

ctic

co

nst

ruct

ion

(%

)

Baseline average

Post-therapy average

Comparison of untreated syntactic constructions before and after Phase 2 inter

0102030405060708090

100

Baseline 1 Baseline 2 1 week post-therapy

1 monthpost-therapy

Time points

Accu

racy o

f syn

tacti

c

co

nstr

ucti

on

(%

)

KK

GL

BL

DC

JH

AT

PM

PG

DM

Comparison of untreated syntactic constructions averaged before and after Phase 2 intervention

**

* *

* *

*

*

0

20

40

60

80

100

KK GL BL DC JH AT PM PG DM

Participants

Acc

urac

y of

syn

tact

ic

cons

truc

tion

(%)

Average basline

Average post-therapy

Conclusions:

Aphasia & aphasia therapy are complex

Sentence & discourse production particularly

theoretically (and practically) rich

Challenge of limited funds with which to develop flexible therapies

Hybrid therapy: borrowing, combining and adding to existing research

May be route to higher level evidence

MRC framework for complex interventions to improve health (2000)

• In order to develop specific interventions towards higher levels of evidence, we need to define the intervention, ensuring the optimal synthesis of the most active ingredients.

• Is this reducing complexity?

• Preferable to see as ‘zipping’ complexity?

Bedankt voor het luisteren

References: • Armstrong, E. (2000). "Aphasic Discourse: the story so far." Aphasiology 14: 875-892.• Bastiaanse, R. and R. Jonkers (1998). "Verb retrieval in action naming and spontaneous speech in

agrammatic and anomic aphasia." Aphasiology 12(11): 951-969.• Carragher, M., P. Conroy, et al. (2012). "Can impairment-focused therapy change the everyday

conversations of people with aphasia? A review of the literature and future directions." Aphasiology in press.

• Coelho, C.A., McHugh, R.E. & Boyle, M. (2000). Semantic feature analysis as a treatment for aphasic dysnomia: A replication. Aphasiology, 14, 2, 133-142

• Collins, A.M. & Loftus, E.F. (1975). A spreading activation theory of semantic processing. Psychological Review, 52, 407-428.

• Edmonds, L. A., S. E. Nadeau, et al. (2008). "Effect of Verb Network Strengthening Treatment (VNeST) on lexical retrieval of content words in sentences in persons with aphasia." Aphasiology 23(3): 402-424.

• Faroqi-Shah, Y. (2008). "A comparison of two theoretically driven treatments for verb inflection deficits in aphasia." Neuropsychologia 46: 3088-3100.

• Greenwood, A., Grassly, J., Hickin, J., & Best, W. (2010). Phonological and orthographic cueing therapy: A case of generalised improvement Aphasiology, 24(9), 991 - 1016.

• Lanyon, L. & Rose, M.L. (2009). 'Do the hands have it? The facilitation effects of arm and hand gesture on word retrieval in aphasia. Aphasiology, 23, 7, 809-822.

• Linebarger, M. C., S. M.F., et al. (2001). "Computer-based training of language production: An exploratory study " Neuropsychological Rehabilitation 11(1): 57-96.

• Linebarger, M. C. and M. F. Schwartz (2005). "AAC for hypothesis testing and treatment of aphasic language production: Lessons from a "processing prosthesis" " Aphasiology 19(10/11): 930-942.

• Links, P., J. Hurkmans, et al. (2010). "Training verb and sentence production in agrammatic Broca's aphasia." Aphasiology 24(11): 1303-1325.

• Marshall, J., T. Pring, et al. (1993). "Sentence processing therapy: working at the level of the event." Aphasiology 7(2): 177-199.

• Marshall, J., S. Chiat, et al. (1997). "An impairment in processing verbs' thematic roles: a therapy study." Aphasiology 11(9): 855-876.

• Marshall, J. and D. Cairns (2005). "Therapy for sentence processing problems in aphasia: Working on thinking for speaking." Aphasiology 19(10/11): 1009-1020.Marshall, J. (2008). Aphasia Therapy and Cognitive Neuropsychology: A Promise still to be Fulfilled? Language Disorders in Children and Adults: New Issues in Research and Practice. V. Joffe, M. Cruice and S. Chiat. London, Wiley.

• Nickels, L. (2002). "Therapy for naming disorders: revisiting, revising and reviewing." Aphasiology 16: 935-79.

• Peach, R. and P. Wong (2004). "Integrating the message level into treatment for agrammatism using story retelling " Aphasiology 18(5-7): 429 - 441

• Ruiter, M. B., H. H. J. Kolk, et al. (2010). "Speaking in ellipses: The effect of a compensatory style of speech on functional communication in chronic agrammatism." Neuropsychological Rehabilitation 20(3): 423 — 458.

• Thompson, C. K., L. P. Shapiro, et al. (1996). "Training wh-question production in agrammatic aphasia: analysis of argument and adjunct movement." Brain and Language 52: 175-228.

• Thompson, C. K., J. J. Choy, et al. (2010). "Sentactics®: Computer-automated treatment of underlying forms." Aphasiology 24(10): 1242 — 1266.

• Wambaugh, J.L. & Ferguson, M. (2007). Application of semantic feature analysis to retrieval of action names in aphasia. Journal of Rehabilitation Research & Development, 44, 3, 381-394. Weinrich, M., J. R. Shelton, et al. (1997). "Remediating Production of Tense Morphology Improves Verb Retrieval in Chronic Aphasia." Brain and Language 58: 23-45.

• Whitworth, A. (2010). "Using Narrative as a Bridge: Linking Language Processing Models with Real-Life Communication." Seminars in Speech and Language 31(1): 64-75.