Sara Henson CD 625

Practice Guidelines: PACE Therapy

Origin/Background

When treating a client with aphasia, the primary goal of therapy is to

improve the individual’s ability to communicate in everyday life. To reach this

goal, clinicians may choose an impairment-based approach, which targets

discrete communication skills that present as difficult to the client. In regards to

language expression, naming deficits greatly impact a client’s ability to convey his

or her message. To target these errors, clinicians choose intervention approaches

proven to increase the individual’s ability to perform the discrete skill as well as

improve his or her overall communication.

Most impairment-based approaches lack a component that results in

generalization to natural communication (Carragher, 2012). Since transferability

is of utmost importance when choosing therapy techniques, clinicians often

hesitate to use approaches that do not possess this characteristic. For example,

generalization continues to be an area of weakness for traditional language

therapies due to its lack of a social component (Thompson, 2012).

PACE therapy, also referred to as Promoting Aphasics’ Communicative

Effectiveness, is an impairment-based approach to aphasia intervention that

incorporates traditional naming tasks with a conversational component. Jeanne

Wilcox and Albyn Davis first introduced the approach to the field of speech

language pathology in 1978 at the annual ASHA convention. Because PACE

combined elements of communication differently than any approach published at

the time, many clinicians and researchers became quickly interested in its

methodology (Davis, 1980). Like many new advancements in the field, confusion
Sara Henson CD 625

and controversy surfaced regarding the new approach. Wilcox and Davis

published many articles explaining PACE’s principles, followed by recording a

videotape of the approach’s implementation with 40 clients diagnosed with

aphasia (Davis, 2005).

When developing the approach, Davis and Wilcox structured the

framework of PACE upon the idea that most clients with aphasia have an ability

to communicate. Natural conversation provides these individuals with

opportunities to overcome their communication deficits (Davis, 2005). With

these two assumptions in mind, Davis and Wilcox carefully created a therapy

approach that targeted the discrete skill of word retrieval within structured

client-clinician interactions, which ideally encompassed all aspects of natural

conversation.

Candidacy

When choosing an intervention approach, it is imperative that clinicians

consider whether the client falls within the population the technique best serves.

In regards to PACE therapy, multiple reviews reveal evidence of which

individuals are considered as best candidates for its implementation; however,

much of the information proves as controversial in regards to aphasia severity

level, therapy structure, and client diagnosis based on the multidimensional

approach to aphasia classification.

Davis (2005) reported that PACE therapy is a useful approach because it

can be easily adapted for clients with different severity levels of aphasia due to its

compensatory and multimodal nature. Not all approaches possess this feature

because its stimuli may only range within particular levels of simplicity or
Sara Henson CD 625

complexity. With PACE therapy, clinicians can choose stimuli to best meet the

client’s needs, adjust the complexity of the targets, and use different modeling

strategies in conversation (Davis, 1980).

Although Davis (2005) suggests the approach’s flexibility in his published

literature, he also provides information regarding specific populations that would

and would not benefit from the approach. PACE has been used as a standard

treatment method for Broca’s, Anomic, and other mild to moderate aphasias;

however, individuals with Wernicke’s, Mixed, Global, or any severe aphasias

would not benefit from the approach due to its reliance on fairly intact

comprehension skills (Davis, 1980).

Technique

To implement PACE therapy, the clinician must follow the four principles

of implementation: equal participation, new information, free choice of channels,

and natural feedback (Davis, 1980). Equal participation entails that the client and

clinician equally play conversation roles as the message sender and receiver

throughout therapy. This represents typical conversational discourse, where each

communicator takes turns sending, processing, and interpreting information. It

also gives individuals with aphasia opportunities to become active participants in

conversation by using their expressive language abilities, rather than passively

listening to their conversation partner.

The new information principle establishes that neither client nor clinician

is aware of the other’s message prior to each target’s successful explanation. This

prevents the clinician from anticipating the client’s message (Davis, 1980). The

message receiver must base his or her understanding of the target solely on the
Sara Henson CD 625

client’s ability to successfully communicate his or her ideas. The clinician cannot

use inferences to comprehend the explanation until the client uses an effective

method to convey the message in conversation.

Free choice of channels allows both conversational partners to choose any

modality to convey his or her message including speech, gestures, drawing, and

writing (Davis, 1980). This principle shifts the focus from verbal output to any

means of communication the individual selects. Clients are encouraged to use

multiple modalities to convey messages, including gestures and verbal

circumlocutions. The clinician’s role is to model effective communication through

various modalities and behaviors (Chin Li, 1988)

Natural feedback provides the client with aphasia the opportunity to

experience an authentic means of gathering information regarding his or her

conversation partner’s ability to comprehend the message (Davis, 2005). This

principle helps structure PACE therapy to emulate natural conversation. When

utilizing natural feedback, the clinician provides responses only found in

conversation, such as facial expressions, body language, and responses that

indicate the message was not effectively sent for clear comprehension (Davis,

2005). This presents the individual with an environment to make errors without

corrective feedback, which imitates typical comprehension cues found in

everyday conversation.

When combining these four principles, authentic PACE therapy occurs.

Each principle of PACE must be implemented to model its conversational

structure, which requires the client to serve both conversation roles as the

message sender and receiver. The intention behind this framework is that the
Sara Henson CD 625

clinician will have the opportunity to observe how the individual participates in

conversational discourse with other conversation partners (Davis, 1980).

The client and clinician both partake in conversation based on picture or

word stimuli. Each partner will alternate serving as the message receiver and

sender. Each turn, the conversation partner draws from a stack of stimuli

unknown to his or her partner. Then, the message sender uses the

communication modality of his or her choice to explain the stimuli to the

receiver. When the message is conveyed successfully, the receiver will correctly

identify the stimuli. The clinician records data regarding the frequency of

modalities used when conveying messages and the client’s competence as a

communicator (Davis, 1980).

Like any published treatment for aphasia, PACE contains both strengths

and limitations. Many strengths of the therapy technique lie within its

fundamental principles of implementation. For example, PACE’s multimodal

approach gives the client freedom to choose the communication strategy or

combination of strategies that help them communicate best. Incorporating

gestures with verbal output, for example, supports language recovery and

communication because the client is less restricted to relying solely on speech

(Rose, 2013).

Another strength of PACE therapy is its absence of deeming

communicative attempts as correct or incorrect as well as highlighting the roles

of each conversation partner. This provides individuals with aphasia a better idea

of progress and leads them to making executive decisions regarding their

methods of communication. Its design increases clients’ confidence and provides

Sara Henson CD 625

comfort in knowing that communication is both the responsibility of the listener

and the speaker (Davis, 2005). Because aphasia encompasses all aspects of an

individual’s life, the fact that PACE takes those psychological aspects into

consideration strongly supports its use.

In a single-subject case study published by Chin Li (1988), he discusses the

effectiveness and transferability of the PACE approach. He states that his patient

showed significant improvements when performing naming tasks after

participation in PACE therapy. The client also demonstrated increased mood and

responsiveness to communication. Chin Li also claimes that clients can apply

communication strategies used in therapy sessions when encountering naming

deficits in natural discourse.

In regards to elapsed time after stroke, Chin Li (1988) hypothesizes that

individuals who have surpassed the window of recovery post-diagnosis will

benefit from PACE therapy because the approach provides alternative strategies

to compensate for naming difficulties. Although all of these assertions derive

from one client’s rehabilitation experience in particular, it stands to reason that

similar results may occur in other clients who demonstrate similar aphasic

behaviors related to naming impairments.

Limitations of PACE therapy reflect the same principles noted as strengths

by some researchers and clinicians. For example, although the principle of new

information stands as one of PACE therapy’s strongest aspect, clinicians often

present difficulty with remaining unaware of the client’s targets (Davis, 1980).

This is due to the fact that the clinicians most likely created the stimuli used in

therapy and can remember what pictures or words represented on the cards.
Sara Henson CD 625

Once the client begins to describe the stimuli, the clinician can make quick

inferences instead of relying solely on the individual’s multimodal language.

Another potential limitation for using the PACE approach includes its

natural feedback principle. Because of the approach’s fixed framework, clinicians

cannot provide corrective feedback until the client confirms his or her message

has been successfully received; therefore, the clinician cannot direct the client

toward using a more effective modality for communication (Davis, 2005). This

presents as problematic because the client may need more explicit information

due to his or her lack of awareness that the modality chosen is not sufficiently

and effectively transmitting the message to the clinician.

Although the ultimate goal of aphasia treatment is to improve the person

with aphasia’s ability to communicate in everyday life, the interactions between

the client and clinician during PACE therapy do not reflect typical discourse

(Chin Li, 1988). The rigid, symmetrical structure used for conversation limits

targeting various aspects of communication, such as requesting, questioning, and

story telling. Additionally, the absence of conversation repair and use of a variety

of conversational partners classify PACE as an impairment-based approach

despite its theoretical social connotations (Davis, 2005).

In attempts to improve the conventional PACE methodology, clinicians

and researchers develop alternative versions of the approach. Davis (2005)

provides multiple published modifications to his original approach. For example,

clinicians often eliminate a principle of PACE to provide the client with

additional expressive communication opportunities during each session. Davis

also explains the Brussels modification, which places a barrier between the client
Sara Henson CD 625

and the clinician. Each conversation partner is given the same set of stimuli, and

the clinician can choose which target the client describes. Another modification

of PACE limits the client to only using speech as the modality for communication

to encourage the use of verbal circumlocutions as a compensatory strategy in

conversation.

In a study conducted by Newhoff (1981), the modifications suggested

incorporate a more meaningful component to imitate conversations the client

with aphasia will participate in everyday. Clinicians train an individual’s spouse

to use the principles of PACE in therapy sessions as well as at home to facilitate

additional conversation. Using caregivers as conversational partners in the

approach provides a meaningful context for the individual to practice multimodal

communication strategies. This change in the PACE approach potentially results

in higher success rates regarding generalization and transferability of word

retrieval improvements (Davis, 2005).

Despite the approach’s strengths and suggested modifications, further

research is needed to determine whether PACE is effective in treating word-

finding impairments. The clinical bottom line suggests that PACE is an

impairment-based treatment approach best used for clients who display mild-to-

moderate content errors, specifically naming deficits. Its use of multimodal

communication allows the person with aphasia to use any form of

communication to convey a message to others. Although PACE is described as a

discrete therapy approach, the task and materials used suggest it is only a useful

method of applying other therapy techniques. Due to mixed reviews and success
Sara Henson CD 625

rates, PACE may be classified as an experimental approach to aphasia therapy

(Davis, 2005).

References

Carragher, M., Conroy, P., Sage, K., & Wilkinson, R. (2012). Can impairment-focused

therapy change the everyday conversations of people with aphasia? A review

of the literature and future directions. Aphasiology, 26(7), 895-916.

Chin Li, E., Kiteselman, K., Dusatko, D., & Spinelli, C. (1988). The efficacy of

PACE in the remediation of naming deficits. Journal of Communication

Disorders, 21(6), 491-503.

Davis, G.A. (1980). A critical look at PACE therapy. In R. Brookshire (Ed.)

Clinical Aphasiology Conference Proceedings. Minneapolis: BRK

Publishers.

Davis, G.A. (2005). PACE revisited. Aphasiology, 19(1), 21-38.

Newhoff, M., Bugbee, J., & Ferreira, A. (1981). A change of PACE: Spouses as

treatment targets. In R. Brookshire (Ed.), Clinical Aphasiology conference

proceedings (pp. 234-243). Minneapolis: BRK Publishers.

Rose, M.L. (2013). Releasing the constraints on aphasia therapy: The positive

impact of gesture and multimodality treatments. American Journal of

Speech-Language Pathology, 22, 227-239.

Thompson, C. K., Kearns, K. P., & Edmonds, L. A. (2006). An experimental

analysis of acquisition, generalisation, and maintenance of naming

behaviour in a patient with anomia. Aphasiology, 20(12), 1226-1244.