The Neuroscience on the Web Series:
CMSD 636 Neuropathologies of Language and Cognition

CSU, Chico, Patrick McCaffrey, Ph.D.


Chapter 10. Aphasia: Therapy


Several different therapeutic approaches, including behavior modification, cognitive therapy, combinations of behavioral and cognitive methods, and pragmatic approaches have been used to improve the language of aphasic patients.

Pharmacotherapy

In (2008-sabbatical) I researchd the literature on the use of medicine in intervention. I came across an article on pharmacotherapy for intervention where Albert, et al. 1987 treated a patient who had a two-and-a-half-year history of transcortical motor aphasia from a left frontal intracerebral hemorrhage. Dr. Albert and his colleagues gave the patient the drug bromocryptine, a dopamine agonist. Improvement was noted in aphasia characterized by improved word finding, decreases in response latency, and fewer paraphasias. Since this was given to just one patient, conclusions cannot be drawn, Nevertheless it is quite intriguing. Dr. Joel Rothfeld, a Chico, California neurologist, in an e-mail to me said "I am familiar with the use of bromocriptine in such settings. Dopamine agonists of which bromocriptine is one, are sometimes helpfull in improving arousal. Typically don't use bromocriptine anymore, but rather one of the new agonists (mirapex, requip)." According to Love and Webb (2001) L-dopa has improved phrase structure, volume, timing and syntax. Lack of cholinergic agents may result in memory impairment in some patients, Cholinergic networks using acetycholine may help patients with fluent aphasias (such as Wernicke's) (Love and Webb 2001). Pharmacotherapy and traditional aphasia therapy together may be more effective than either used alone.

Fitz Gerald,1996 looked at neural plasticity in recovery from brain injury. He described neural plasticity in monkeys and lower mammals after lesions in the motor cortex. Recovery was attributed to a change in allegiance of cell columns near the lesion. These cells took on the motor function of the damaged neurons. According to Fitz Gerald. P. 235 "it is possible to enlarge the motor territory of a patch of cortex merely by injecting a GABA antagonist drug locally into the cortex."

Operant conditioning, a form of behavior modification was the first type of therapy used to remediate aphasia. This approach involves shaping language behavior by helping patients progress through a series of tasks presented in fixed order, from least to most difficult.

Schuell was the first to take a cognitive approach to aphasia therapy. She proposed that an extended period of intensive stimulation would improve the quality of the aphasic's language behavior. Because it was believed at the time that language was naturally learned through the auditory modality alone, Schuell emphasized the use of auditory stimuli. More recently, Joseph Duffy and Carl Coelho, in Chapey, 2001, have written an excellent chapter that modifies and improves upon Schuell's approach. As it is now known that input from all modalities contributes to language learning, Duffy and Coelho suggest a multi-modality approach to rehabilitation for the aphasic patient. Chapey (2001) recommends among other things, the use of divergent thinking in aphasia therapy. (In a divergent thinking task, a patient is required to produce several creative responses to every stimulus. For example, the patient might be asked to think of several unusual ways to make use of an everyday object.)

LaPointe's (1990) Programmed stimulation approach to aphasia therapy combines behavioral and cognitive methods. He advocated the use of a hierarchy of therapy tasks based on level of difficulty employed by behaviorists, but uses the kinds of stimuli employed by therapists with a cognitive orientation.

Several types of programmed stimulation for aphasics have been developed by other therapists. Among these are melodic intonation therapy (Sparks & Holland, in Chapey, 1994) and visual action therapy VAT (Fitzpatrick & Baresi, 1982). Melodic intonation therapy, or MIT, uses music to involve the non-dominant hemisphere in language production. Visual Action Therapy involves the use of everyday tools, like hammers and screwdrivers, in therapy. Both of these programs were developed for use with severely impaired patients. MIT was designed specifically for those with non-fluent aphasia, but is currently being used with individuals with apraxia also. I wasnot very effective using VAT.

Pragmatic approaches use social interaction to improve the communicating abilities of aphasic patients. Many different pragmatic approaches exist. For example, teaching language in a naturalistic setting by taking an aphasic out to a restaurant and helping him/her order a meal could be considered a form of pragmatic therapy.

One of the best-known pragmatic therapies for aphasia is PACE, or therapy for promoting aphasics' communicative effectiveness which was developed by G. Albyn Davis. I knew Albyn when he and I were doctoral students at Ohio University. PACE is based on the pragmatic rule of reciprocity; the therapist and the patient participate in a conversation as equals, each taking turns sending and receiving messages.

I particularly like PACE because it is more natural than other approaches. Diane Jones, a speech pathologist, and the director of rehabilitation at Enloe Rehabilitation Hospital in Chico has modified PACE, replacing the cards with real objects.

According to Davis and Wilcox (1981),and Davis (2000) PACE is based on the following four principles:

1. The Exchange of New Information

In PACE conversations, the messages that the therapist and patient send to one another must consist of new information. Usually, cards showing line drawings are used to provide the subjects for messages. Cards are presented face down, The Brussles modification employs an eight inch screen between the clinician and patient. The person sending the message draws a card and must somehow explain what appears on it to the other participant. Cards showing everyday objects are typically used during the first phase of therapy. Verb cards are introduced next, followed by story-sequence cards. In other words, the content of messages becomes more abstract as therapy progresses.

2. Equal Participation

In PACE, the therapist does not overtly direct the interaction. Instead, he/she and the patient participate in dialogues as equals, taking turns as both the senders and receivers of messages. Thus, both are responsible for accurately conveying information and for giving feedback indicating whether or not messages sent by the other person are sufficiently clear. The egalitarian nature of PACE interactions may in itself be very therapeutic for patients who often spend most of their time receiving directions from others.

3. Free Choice of Communicative Channels

The patient's ability to communicate effectively is stressed in PACE, not the use of a particular communication system. Participants in PACE conversations may convey their messages by speaking, writing, drawing, pointing at object, gesturing, pantomime or any other mode of communication available to them. The existence of so many options improves the chances that the therapist will understand the patient's messages and thus reinforce his/her attempts at communication

Of course, the therapist can subtly encourage the patient to use a mode of communication by using it. For example, if a clinician wanted a patient to practice using gestures, he/she could utilize gestures when sending messages.

4. Functional Feedback

The feedback provided by the therapist in PACE conversations is realistic and functional. Rather than telling the client that a response was correct or incorrect, he/she tells him whether the message was understood, as any listener would do in an everyday interaction.

When the patient sends an unintelligible message, the therapist should do more than indicate that he/she does not understand the communication. He/she should ask for more information, guess, or try some other technique to help the patient send the message in an understandable manner. With very impaired patients, a "twenty question" approach may be effective. If necessary, the therapist can "stack the deck" in the patient's favor so that he/she knows which cards the client is drawing. This will enable him/her to ask the right questions when the patient fails to communicate the information on the first try.

Therapy for Anomia

Most, if not all aphasias are accompanied with word finding difficulty. Many approaches have been used to help the patient with word retrieval. Most use prompting or cueing. Providing the initial phoneme is one way to prompt. Other cues and prompts include using printed cards containing the target word, or clinician's use of synonyms and verbal descriptions of activities or characteristics regarding the target word. According to Patterson et. al. 1985 the facilitatory effects of semantic cues/prompts were shown to last longer than those of phonologically based cues/prompts. Some of the semantic cues/prompts used were saying the target word while pointing to a picture of it, and matching a printed word to a picture, prior to naming it, and making semantic judgments about a target word such as (Is a lizard a reptile?). Linebaugh, 1990. According to Vitevitch, (2008) information about graph theory, a mathamatical construct, can help explain how words are stored in memory and retrieved. He used a computer science program called Pajek to construct a database of more than 20,000 lexical items. While this research cannot provide an immediate theraputic panacea for word retrieval, it may result in additional research that could help us create remedial tools for word finding problems.

 
 


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Other courses in the Neuroscience on the Web series:
CMSD 620 Neuroanatomy | CMSD 642 Neuropathologies of Swallowing and Speech

Copyright, 1998-2008. Patrick McCaffrey, Ph.D. This page is freely distributable.