COVER STORY: THERAPY

I know exactly wher but I dont know wh

READ THIS IF YOU ARE INTERESTED IN USING COMMUNICATION AIDS AS THERAPY TOOLS HOW IMPAIRMENT AND FUNCTIONAL THERAPY APPROACHES WORK TOGETHER DESIGNING THERAPY COLLABORATIVELY WITH CLIENTS Trevor Harley is also author of comprehensive psycholinguistic textbook 'The Psychology of Language'. For your chance to win a FREE copy of this book, see the Reader Offer on the inside front cover.

Photo: Paul Reid.

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

Photo: Paul Reid.

COVER STORY: THERAPY

re it is here its going

When Laorag Hunter offered Helen Gowland a high-tech aid as a communication strategy, neither suspected it would become a means of facilitating Helens use of multi-syllabic words in everyday speech. Here, with Siobhan MacAndrew and Trevor Harley, they discuss the use of images as signposts in therapy and the kind of service we need to provide to ensure such opportunities are not missed.
his article describes a specific component of therapy, a solution-focused approach that is simple to implement. This therapy evolved collaboratively when the introduction of a high-tech aid as a communication strategy opened up unplanned possibilities. We find it particularly exciting because it is having a measurable impact on a client with conduction aphasia seven years after onset. Our story starts seven years ago, when Helen Gowland settled down one evening to watch Jools Holland on TV. This was a moment of relaxation in a schedule involving many roles. Helen worked full-time as a specialist physiotherapist, researcher at an international level, Chair of the school Parent Teacher Association, wife, mother to three teenagers and daughter to an elderly father. She remembers wondering that evening why paramedics were in her house. Helens next memory is ten days later in neurosurgery finding herself with a large surgical wound in her skull, unable to speak or to understand what people were saying. It took a long time to fully grasp what had happened. Helen had suffered a sub-arachnoid haemorrhage from a large left middle cerebral artery aneurysm. An emergency craniotomy was required to clip the aneurysm. Two days later Helen experienced delayed ischaemia with seizures and severe aphasia.

Figure 2 Meta-linguistic awareness A print showing how Helen senses her aphasia. Reprinted by kind permission of Christine Kingsley.

Changing needs
Helens partnership with speech and language therapist Laorag has continued and developed over the seven years. Episodes of care have responded to her changing

needs and varied in type and length. Reasons for therapy have included assessment, rehabilitation, supporting and enabling (Malcolmess, 2001). Additionally, Helen has opted in to resources and projects including group work, computer classes and visual arts. Complicating factors affecting rehabilitation have included wound infections, removal of her temporal bone-flap with later cranioplasty to close the skull, and issues relating to epilepsy and side effects of medication. Helens communication profile resembles that of the syndrome of Conduction Aphasia (Goodglass & Kaplan, 1983). Key features are fluent and grammatical speech; difficulty in the sequential order of speech sounds in naming and repetition; greater difficulty with longer words; good awareness of errors; repeated attempts at error correction (a characteristic known as conduite dapproche) and relatively spared comprehension. Helen has excellent conversational skills and is exceptionally resourceful at getting her ideas across through total communication methods. When she is unable to express the full content of her message she will use drawing, fragmentary writing, pantomime, circumlocution and even singing. Helens speech is easy to understand and is fluent and grammatical. These strengths contrast with a history of severely impaired noun production in spontaneous speech, spoken naming, written naming and repetition. Helens understanding in everyday situations is good but vulnerable to errors in times, days and numbers. She notices increased difficulties understanding in groups where there are

rapid shifts of turn and when there is background noise. Formal assessment shows comprehension breakdown in sentences if the context does not assist in understanding the relationship between items. In terms of naming (figure 1), Helens assessment record shows a history of word form errors (literal paraphasias), many of which are non-words. Alternatively, attempts are aborted after inability to start the word or after producing only the initial phonemes. Helens errors increase with word length and she makes more deletions or substitutions towards the end of words. Less frequently, Helen makes semantic errors, such as substituting father for husband.
Figure 1 Naming examples

Mug muck monk mug Hoover hoola Cigarette sigarant Speakability speakaleekie

Cognitive neuropsychological models of speech production detail the component processes in speech production (see for example Levelt, 1989). With reference to such models, Den Ouden & Bastiaanse (2005) conclude that the symptoms of conduction dysphasia are associated with impaired phonological encoding. This stage between word form selection and articulatory planning - incorporates a slot-filler mechanism that maps the sounds (fillers) onto their position (slots) in a word frame (Nickels, 1997). Den Ouden & Bastiaanse (2005) suggest
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Figure 5 Target word examples

that, as well as a mapping deficit, the error patterns of some people with conduction aphasia are secondary to a verbal memory deficit. In these cases speech errors result from difficulties retaining the activation of the phonological plan.

Figure 3 Alphabet links

Letter Link word Link Picture Homophone type A eight Near homophone

Meta-linguistic awareness
Helens descriptions of her experience when naming suggest having word form knowledge with inability to complete the phonological form. These descriptions show a high level of meta-linguistic awareness (see figure 2, p.7): I know the meaning of the word but I dont know what it looks like. I know exactly where it is but I dont know where its going. Sometimes I can start it but I dont really know how to say it properly. Helens written naming follows a similar pattern to her speech in that she writes partial word forms. She frequently writes more letters of a word than sounds she can say. When letters are omitted she can often indicate the correct number of letters or syllables. Helens reading is slow and limited to short pieces. She has great difficulty recognising function words such as prepositions, conjunctions and determiners. This is a symptom of phonological dyslexia. Impaired reading by letter to sound conversion (grapheme to phoneme route) forces reading via the semantic route (Harley, 2001). Words with poor semantic representations such as function words are therefore read poorly (Friedman et al., 2002). Helen compensates for this difficulty by using text-to-speech software to aid reading comprehension.

bee

Homophone

sea

Homophone

Delia

Near homophone

Speech production stuck

Through semantic type therapy (Nickels, 2002) and practice of specific word sets Helen slowly made modest gains in naming. At the start of this therapy Helens speech production was stable; this could be re-phrased as stuck. Laorag offered a communication aid as a back-up to speech to help transfer of information such as address, phone number, numbers, and commonly used family details. Helen liked the idea of using the aid to practise speech but using it in interactions did not appeal. She felt the aid was too big, too slow and difficult for people to read. She thought that people would be too busy to attend to it and that it negatively affected perception of her competence. Helen wanted to say letter names as they frequently occur, for example, in addresses, clothing sizes, names of companies and medication (for example, DD2, RAC, CPR). Letter names cannot be read by letter to sound conversion and are disadvantaged in reading via a semantic route because they are low in semantic value. Friedman et al. (2002) increased function word reading in two people with phonological dyslexia. Using paired associate learning Friedman improved reading of function words (low semantic value) by pairing with homophones high in semantic value (not/knot, knows/nose). This is an example of a reorganisation of function where intact processes are used to compensate for impaired processes. We linked the alphabet with semantically rich homophones and near homophones that Helen found meaningful (figure 3). Near homophones begin with a sound that is the same as the letter name. These links were reinforced by storing a picture of the link word along with a recording of the letter name in a Dynamo digitised speech communication aid.

Helen found the discipline to practise challenging but her ability to say letter names improved. Interestingly, the method enabled Helen to say letter names in sequence (eg. MP). This suggested a potential to sequence single syllables to produce multi-syllabic words if each syllable was associated with a picture cue. Helen was enthusiastic and quickly identified long words she wanted to say such as aphasia, Glenrothes, Victoria. Laorag was concerned that this was too ambitious as until now work on spoken output had mainly been on single syllable, picturable words. For our multi-syllabic words therapy, Helen makes lists of words that she wants to say and use but is unable to produce (target words). The lists typically consist of written fragments of each word (1-3 letters) accompanied by a drawing for picturable items. For more abstract words (eg. policy, resources) additional clues in the form of gestures or associated words are required from Helen before Laorag can identify the target word. Helens chosen vocabulary reflects personal, family and professional interests, needs, seasons and world events. Most items are 2-5 syllables in length (figure 4).
Figure 4 Target vocabulary (selected by Helen)

Fun
Laorag segments the target word into syllables and suggests single syllable words that are homophones or near homophones for each syllable. An image to represent each single syllable word is selected from the Picture Communication Symbols set (Mayer-Johnson, 1981). Where there is more than one possible image Helen selects the one that is most meaningful to her. Associating each syllable with a Picture Communication Symbol has drawn upon Helens strengths in word meaning, foreign languages, wide-ranging knowledge and creativity. It has also been a fun part of therapy for both of us! We make a page for each target word on the Dynamo. Each syllable is represented by a picture of the associated image from the Picture Communication Symbols accompanied by the written form of the word. The syllable is recorded so that when the picture is touched the syllable is heard (figure 5). Initially, Laorag made the recordings but after two to three months of therapy Helen could independently say and record the single syllable words. By activating the pictures in sequence Helen hears her recorded production of the whole word built up syllable

Aphasia Glenrothes Victoria Hospital Manchester Inverness Ambulance Pharmacist Greece Management International Marks and Spencer St Andrews Hideko Japan Mackinlay Egypt

Relations Continence Chlamydia University Paddington Psychology Budapest Communication Australia Thorburn Ipswich Cambridge First Aid Africa Sudan Switzerland Umbrella

Antique America Islam Computer Politics Czech Republic Graduate Exam Leaflet CBIR Aneurysm Internet Sociology Pakistan Tsunami Neurology Stollen

Sandwich Sainsbury Age Concern Address Stepney Anatomy HRT Theatre Courgette Broccoli Coleslaw SR flour Statement Parliament Bric-a-brac DVD Strathearn

Human Resources Cathedral Elephant Animal Policy MSP Novel Concert Ozone Lebanon South Columbia Falkland Prescription 1955

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REFLECTIONS DO I RECOGNISE THAT STABLE CAN FEEL STUCK? DO I OFFER A SERVICE BOUND BY ARBITRARY TIME LIMITS OR FLEXIBLE TO A CLIENTS CHANGING NEED? DO I EVER THINK ABOUT WRITING AN ARTICLE WITH A CLIENT?

by syllable. After listening a few times and considering the image associated with each syllable Helen is usually able within the session to record the target word as a whole item on the Dynamo page. At this point, her production often automatically alters to accommodate the normal stress pattern of the target word. It is as if Helens memory for production of the word is reactivated. When Helen feels confident that she has captured the production she practises and celebrates by playing with the word. Around Christmas time she delighted in exclaiming Have a piece of Stollen, Do you like Stollen?, Would you care for some Stollen? She also confesses to continuing this practice by talking to herself on the bus ride home. Helen is comfortable to delete words from the Dynamo once she is satisfied that she can independently recall the graphic for the single syllables which subsequently cue her spoken production of the whole multi-syllabic word. When a previously used syllable occurs in a new target word Helen sometimes feels the addition of the graphic in the Dynamo is unnecessary and the written form of the syllable appears alone. Occasionally Helen requests that a Picture Communication Symbol is changed, if she finds it doesnt mean anything. For example trail to represent the second syllable in Australia was changed from a path to a child trailing a pull-along toy. Therapy sessions are approximately bimonthly and no preparation is required by the therapist secondary to sessions. Helen feels this schedule is appropriate to establish new vocabulary and it also accommodates Helens activities including volunteer work, committee work, family commitments and holidays. Four to six target words are added each session and in 17 months Helen has mastered the production of over 70 target multi-syllabic words. Helen is now occasionally able to generate images for two syllable words independently of therapy sessions.

Self-generated cues
Helens ability to say target words and use these in real communicative situations shows notable increase. Additionally, there are signs of carryover in her use of self-generated cues. Within sessions Helen has become faster at producing target words. Qualitative changes are also apparent in Helens reflections. Helen has a sense of achievement and feeling of progression as opposed to previously feeling stuck. The positive outcome for Helen is also clear as she describes imagined fears, for example, what if we hadnt tried this?, what if you had discharged me?, what if you have to take the Dynamo away?

We agree with Nickels (2002) that for the clinician understanding how the therapy worked is a luxury and would add that given the complex variables in typical therapy this can feel like impossibility! However, our method draws upon several therapy approaches, functional, re-organisation and stimulation: 1. The goal is functional to allow Helen to say the words she wants to use and is driven by Helens requirements and aspirations. 2. We achieve production of previously errorful words through an alternative route (re-organisation). The pictures in sequence give Helen sufficient information to allow phonetic encoding. This may be a direct effect of improved phonological assembly. Alternatively, improved production could be a consequence of improved monitoring. Each picture allows Helen to know the one syllable target which she can check and correct at a pre-speech production stage. 3. Once production of the multi-syllabic word is enabled, Helen can go on to practise in a stimulus-response manner (stimulation). This strengthens the connections between semantic and phonological processing giving the possibility of the therapy being effective through rehabilitation of impaired processes. Helen has rated features from most to least important for her. (The comments are in Helens own words.) 1. The picture is most important. I dont look at the letters at all. The picture opens it (the word) up for me. 2. Quick results. 3. The words are always there for me to check if Im not sure. Thats reassuring. 4. The words are the ones I really need and want to have. 5. I can practise on my own, even in my bed. It (the Dynamo) is easy to carry around in my bag. 6. Its interesting to show others what Im doing in therapy and I can explain that its about pictures. 7. Im not bothered whether its my own speech or not, but I am glad that its not American. Our success illustrates that therapy to improve a production disorder can be effective many years post-onset. Although we dont know if this would have worked earlier for Helen, it has prompted Laorag to earlier and more creative trialling of stimulability in speech production with other clients.

rather than within set time boundaries. The method developed through dedicated time for continuing professional development activities, particularly Laorags attendance at British Aphasiology Society conferences. Of equal importance is a management commitment to provide and maintain communication aids for clients. Client need, therapist knowledge and the availability of technology changes over time. In this therapy these variables came together to give a rewarding outcome. Giving people with aphasia the opportunity to review therapy options could be of benefit long after their initial period of rehabilitation. Laorag Hunter is a speech and language therapist at the Centre for Brain Injury Rehabilitiation, Royal Victoria Hospital, Dundee, DD2 1SP, e-mail laorag.hunter@nhs.net. Helen Gowland is Chair of Tayside Speakability and a member of the Aphasia Scotland project steering group. Siobhan MacAndrew is a psychologist in the division of psychology at Abertay University and Trevor Harley is Dean of School and Chair of Cognitive Psychology at Dundee University and the author of The Psychology of Language (see reader offer on inside front cover).

References
Den Ouden, D.B. and Bastiaanse, R. (2005) Phonological encoding and conduction aphasia, in Hartsuiker, R.J., Bastiaanse, R., Postma, A. and Wijnen, F. (eds.) Phonological Encoding and Monitoring in Normal and Pathological Speech. Hove: Psychology Press, pp 86-101. Friedman, R.B., Sample, D.M. & Nitzberg Lott, S. (2002) The role of representation in the use of paired associate learning for rehabilitation of alexia, Neuropsychologia 40, pp.223-234. Goodglass, H. and Kaplan, E. (1983) The assessment of aphasia and related disorders. 2nd edn. Philadelphia: Lea and Febiger. Harley, T.A. (2001) The psychology of language. 2nd edn. Hove: Psychology Press. Levelt, W.J.M. (1989) Speaking: From intention to articulation. Cambridge MA: HIT Press. Malcomess, K. (2001) The Reason for Care, Bulletin of the Royal College of Speech and Language Therapists 595 (November), pp.12-14. Mayer-Johnson (1981) Picture Communication Index. Solana Beach CA. Nickels, L. (1997) Spoken word production and its breakdown in aphasia. Hove: Psychology Press. Nickels, L. (2002) Therapy for naming disorders: Revisiting, revising and reviewing, Aphasiology, 16(10/11), pp. 935-979.

Flexible service
Aspects of our organisation and management have been vital in enabling this work. Our service is flexible to deliver therapy according to client need and potential for change

Resources
The British Aphasiology Society, www.bas.org.uk The Dynamo Communication Aid is available from Dynavox Systems Ltd, Sunrise Medical Building, High Street, WollasSLTP ton, West Midlands, DY8 4PS (www.dynavox.co.uk)
SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007