Aphasia-Apraxia Therapy: Exploiting Neuroplasticity MSHA Annual Convention – Duluth, MN April 13-14, 2012

Bill Connors,, M.A., CCC-SLP www.aphasiatoolbox.com Pittsburgh, PA 724-494-2534; [email protected] skype- aphasiatoolbox; oovoo- aphasia

Part 1:

The pressing clinical question for the treatment of aphasia and related disorders: How can we offer clinical management that truly takes advantage of neural plasticity and most efficiently maximizes patient recovery of communication skills?

Learner Outcomes: 1. Identify 10 techniques to simplify, adapt and maximize computers and information technology for aphasia, alexia, agraphia and cognitive therapy. 2. Identify 5 key cognitive/mental processes that underpin and support language and its rehabilitation and incorporate these into treatment protocol development and application. 3. Identify 5 evidence-based techniques for the treatment of alexia and agrapahia. 4. Identify 4 observation and analysis techniques of aphasic client behavior to use in applying evidence-based treatment, to maximize rehabilitation activities, and effectively train caregivers/coaches participation in the treatment process.

Basic Session Plan:  Present a clinical, visual definition so we have a useful, shared idea of what aphasia and the related disorders are.  Present, demonstrate and be involved in treatment concepts, ideas, techniques and tools for innovative aphasia rehabilitation.  Solicit shared ideas, questions, comments, and improvements.

11 Big Questions for Today?: •What is aphasia, really? •How can we make every activity and the client’s daily routines truly therapeutic? (Simmons-Mackie, 2009) •What does the best EBP for aphasia look like? (ASHA-EBP, 2012-b; Dollahan, 2004) •Why do we call ‘rehabilitation or treatment plateau’ a ‘patient plateau’ (Helm-Estabrooks, 2010)? •What do PWA actually want – acute phase vs. intermediate phase (Berger, 2002; Papathanasiou, 2003; Rosenbek, 1989; Small, 2004; Worrall, 2011)? •Can traditional, didactic treatment ever be effective for acquired aphasia (Master Clinician Network, 2010; Rosenbek, 1976; Speech Therapy on Video, 2006)? •What is the cost-benefit ratio for monthly, intensive aphasia treatment-monthly type programs (Speechways, 2011)? •What might smart treatment tools that take advantage of neural plasticity look like (Hamilton, 2011)? •Why do 1.25 million resident of Canada and the USA suffer chronic aphasia? •How do we best replace learned non-use and learned helplessness with independently generated, propositional communication (Connors, 2009-a; Kirkland, 2010; Page 2012; Pulvermüller, 2008)? Does a rising cognition tide really lift all aphasia boats (Cho, 20 Helm-Estabrooks, 2011-a) •Can worksheets grow dendrites?

“It is incumbent upon us to use activities that are truly therapeutic. These are tools and activities that facilitate and take advantage of neural plasticity for independent movement and propositional communication.” Bill Connors

Statement of the Problem: Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 1 MSHA Annual Convention – April 13-14, 2012 More than 1.2 million people in the United States and Canada (Brody, 1992; NAA, 2011; the Aphasia Institute, 2011) as well as millions more throughout the world, continue to suffer with hope-robbing, independence-depriving effects of aphasia despite millions of dollars spent on research, treatment, and public awareness of the problem (Kelly, 2011). The great majority of PWA and their caregivers find this state of affairs unacceptable (Worrall, 2011).

What is aphasia? : “Aphasia is different for each person with aphasia.” (Anguish, 1990) What is needed is a definition that truly offers insight into and understanding of aphasia and its related disorders.. Typical printed definitions are limited in their use for understanding the complexities, synergies and opportunities for aphasia recovery and treatment specifics. (Aphasia Institute, 2010; NAA, 2012). A Visual Definition of Aphasia and Apraxia (www.aphasiatoolbox.com).

What is traditional aphasia treatment?: Traditional aphasia therapy can be a nebulous term. Although it has not been well defined, traditional therapy is mentioned often in the literature. As early as 1979, Rosenbeck (1979) questioned the popular ‘point to’ paradigm.” in terms of its effectiveness yet the technique persists to this day. Its characteristics have been described as relatively rigid and asymmetric with the rigidity of structure limiting generalization to conversation and discourse (Silvast, 1991; Wilcox & Davis, 1977). Marshall (1977) advised against the use of structured aphasia treatment in the early post onset period after a CVA.

How have we failed these PWA?;  The treatment program has invested in approaches that either don't work or are too slow in achieving results.  The treatment program lacks faith and gives up too quickly on the patient.  The treatment program blames the patient with comments like, "You have reached a plateau.”(Helm-Estabrooks, 2010)  The treatment program fails to go beyond the clinical evidence and research.  The treatment program focuses treatment on data not mental processes.  The treatment program fails to collaborate causing the patient to lack resources at discharge.  The treatment program fails to recognize that "Aphasia is different for everybody." and therefore applies cookie- cutter activities.  The program fails to demand lots of client independent, coached and peer practice (Kelly, 2011).  The treatment program fails to provide for ongoing, self-help practice after discharge using innovative tools with caregiver training.  The treatment program fails to use innovative tools and materials.  The treatment program relies on imitation and external cueing.  The treatment program fails to revolve everything around conversation.  The treatment program fails to address the cognitive underpinnings of speech (Mayer, 2006).  The treatment is not aggressive and persistent.  The treatment fails to use formative assessment effectively. (Connors, 2009)

What do people with aphasia and apraxia really want?:  Acute phase (Marshall, 1997)  Intermediate phase  Chronic phase

What is neurolasticty?: The human brain’s ability to continually grow, learn and recover is well documented (Gage, 2002; Hamilton, 2011; Scientific Magazine, 2007; The Franklin Institute, 2011). Despite these remarkable scientific advances, insufficient attention has been given to developing innovative tools and techniques to take optimal advantage of neural plasticity in efficient ways in the treatment of aphasia (Helm-Estabrooks, 2011; Kirkland, 2004; Robbins, 2011; Varley, 2011). We need to identify and utilize activities that result in, “…relevant neural activations…” and subsequent “… neural strengthening…” (Pulvermüller , 2008).

What can be done?: Find a program that blends aphasia research and current best clinical evidence with neuroscience, learning theory, technology and SLP clinical expertise while emphasizing the values, needs and goals of the PWA (Connors, 2010).

Aphasia Treatment Comparison: Traditional vs. Brain Compatible

Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 2 MSHA Annual Convention – April 13-14, 2012 Traditional Aphasia Treatment Brain Compatible Aphasia Treatment GOAL: To change speech and language performance. GOAL: to help the brain reorganize itself primarily with Often utilizes imitative pathways. renewed and new neural connections. Utilizes propositional pathways for self-generation. Heavy emphasis on the cognitive underpinnings and supports for communication. A. Utilization of external cues: imitate; “Watch me.”; repeat A. Utilizes a focus on normal, internal mental processes. this; Label. Point to. “Create a sentence.”; “Build a ?”; Focus on establishing independence while overcoming learned non-use. B. Utilization of closure tasks: “ You write with a ___?. B. Focus on getting started at the beginning. Focuses on finishing. C. Use of point to tasks. Confrontation naming. Matching. C. Reliance on phoneme-grapheme connection. “Say it, say Deblocking. it, type it, say it.” D. Utilization of external PWA focus of attention. External D. Internal PWA focus of Attention. prompting. E. Emphasizing of - adapt, accommodate, relearn. E. Recover, reconnect, reconnect, normalize. F. Incorporates errorless learning; goal of increasing PWA F. Embrace and learn from your mistakes. response accuracy. G. Measures data to reflect progress mostly in the clinical G. Behavior and performance in the real world reflects setting. progress. H. Clinic focused PWA practice. Limited Time On Task H. Independent, home-based focused PWA practice. Practice. Ongoing, intensive treatment practice (Pulvermüller, 2008). I. Revolves around targeted behaviors. Utilizes passive I. Revolves around always comes back to self generated, discourse. independent conversational speech. J. Utilize tactile and proprioceptive feedback. J. Minimize tactile and maximize proprioceptive feedback. K. Think and respond. K. Blink it (Gladwell, 2005); Work both fast and slow thinking (Kahneman, 2011). L. Focus on nouns. L. Focus on verbs, especially in canonical sentences. M. Focus on consonants. M. Focus on vowels and syllabification. N. Facilitate repetitions. N. Facilitate neural flows. (Kahneman, 2011) O. Tends to be didactic. Rigid structure. O. Focuses in metaphasia. Highly interactive. P. Changes based on formal, periodic probes and testing. P. Changes based on formative assessment, minute-by- minute, day-by-day. Q. Narrow focus on speech and language performance. Q. Heavy reliance on cognitive underpinnings (Helms- Estabrook, 2011-a). R. Improve writing skills. R. Normalize screen literacy and keyboard competence. S. SLP serves as frontal lobes of PWA. S. PWA uses his/her own frontal lobes. T. Client may reach a plateau. T. Rehabilitation program or therapist may reach a plateau. U. Communicative intent minimized or absent. U. Communicative intent critical. V. Little or no attention to the phonological elements of V. Major attention paid to the phonological elements of aphasia. aphasia. AphasiaPhonics Program. W. Rehabilitation program and/or insurance usually drives W. Consumer-driven discharge. discharge. X. Addresses accepting, accommodating; prepares client X. Prepares client for the future; for change, thinking based. for the past and current. (Prensky, 2008). Y. Drills auditory comprehension Y. If they can say/type it; they can understand/hear it Cho new ; ensure adequate metaphasia and attention.

Helping people speak again: Everything should revolve around and emanate from efforts to reconnect the client’s ability to engage in conversation.

Use all modalities to help people speak again  Screen literacy; keyboarding  Reading – alexia; writing – agraphia  Listening – auditory comprehension; sound processing Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 3 MSHA Annual Convention – April 13-14, 2012  Interpersonal communication – pragmatics; intent; discourse  Cognitive underpinnings – verbal working memory, attention, mental resource allocation, flexible thinking, problem solving, sequencing  Non verbal – gestural, facial, body language  Motor problems

Brain Compatible Aphasia Treatment Program: Brain Compatible Aphasia Treatment (BCAT) is designed to exploit the powerful recovery and reconnective potential of brain plasticity (Friston, 2011). The brain’s ability to continually grow, learn and recover is well documented ( http://www.fi.edu/learn/brain/exercise.html ). This evidence-based program blends aphasia research and clinical evidence with neuroscience, learning theory, technology and SLP clinical expertise while emphasizing the values, needs and goals of the person with aphasia (PWA). Utilizing formative assessment techniques, the BCAT clinician assesses the client’s performance on an ongoing basis in order to continually respond to progress and grow the scope of the program accordingly. The client uses his/her improved speech and conversational skills improve in fully functional ways by participating in online small support, conversation and activity groups (http://www.aphasiatoolbox.com/?q=smallgroup). In addition, any successful program such as BCAT should contain some key elements including: evidence of effectiveness; a personalized plan; lots of daily client practice (http://aphasiatoolbox.blogspot.com/2009/09/practice-makes- perfect.html ); affordable cost; high accessibility; and finally either no expiration date or careful provision of resources at discharge.

BCAT Flowchart

SLP Assesses PWA   Select treatment module   Select protocol   Select exercise  Treatment session   Assign home practice - aphasiatoolbox.com: applications; materials; coaching; groups   Formative Assessment    Tweak exercise Tweak Practice Tweak protocol  

BCAT Client Core Competencies Client core competencies represent the skills and knowledge base that clients advance through and reconnect when using the BCAT program. From the results of an assessment, target competencies can be identified for a treatment plan or practice assignment. Formative assessment allows for careful, ongoing growth and/or modification of target competencies.

i. Metaphasia i. Visual definition of aphasia ii. Lighting up the lemma (O’Donnell, 2012) iii. Anchoring the lemma iv. Distributing the lemma; accessing the lexicon and the praxicon (Ochipa, 2002) v. Semantic cognition ii. Pronouns i. Subjective Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 4 MSHA Annual Convention – April 13-14, 2012 ii. Objective iii. Possessive iv. Interrogative v. Indeterminate vi. Personalized pronoun concepts vii. Canonical sentence pronoun identification viii. Sentence patterned pronouning iii. Conjugation (includes spelling/typing) i. Pronoun ii. Pronoun + Verb iii. Pronoun + Verb + Object (Canonical Sentence) iv. Pronoun + Verb + Objective pronoun (Canonical Sentence) v. Copula vi. Reverse word order vii. Sentence Patterning 1. S-V (affirmative) 2. S-V-O (canonical) 3. S-V-O (consistent verb-random object) 4. S-V-O (either-or verb choice) 5. S-V-O clause 6. Propositional Q&A iv. Verb Tensing- Sentence Structure v. Prosody: coarticulate; anchor then demand; heteronyms; increasing syllables; Viking; scatpraxia; sentence intonation patterning; reconnect reverse word order) i. build in ii. ignore/omit  blend in vi. AphasiaPhonics i. Sound-letter correspondence ii. Syllable structure iii. Syllabification iv. Phoneticizing v. Vowels 1. 10 vowels 2. Jaw positions 3. Around the mouth 4. /VC/ verbs 5. /CV/ verbs 6. /CVC/ verbs (canonical syllable) 7. Irregular past tense verbs vi. Increasing Syllables vii. Compound words; tripounds; quadrapounds vii. Numeracy i. Overcoming limb apraxia ii. Number Conversions iii. Number Concept Coaching 1. Simple 2. Advanced 3. Time concepts iv. Basic math 1. Visual 2. Mental 3. Attentional viii. Verbing i. Verb identification 1. Recognition 2. Anchoring ii. Arguments Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 5 MSHA Annual Convention – April 13-14, 2012 1. Single 2. Alternating 3. Fluent 4. Divergent 5. Initial closure iii. Irregular past tense iv. Phrasal verbs (sneaking up on prepositions) v. Verb Tensing (Faroqui-Shah, 2007; Faroqui-Shah, 2008) ix. Semantic cognition i. Homonyms ii. Compound words iii. Heteronyms iv. Prepositions v. Holynomy vi. Semantic scaling vii. HinkPinks viii. Nerbing 1. Words 2. Phrasal nerbs x. Morphology i. Lexical 1. Inflectional word building 2. derivational word building 3. compound word building ii. adjective comparative, superlative iii. prepositions iv. conjunctions v. prefixes vi. suffixes vii. Irregular past tense verbs . xi. Discourse building i. PACEmatics (pragmatics) 1. Equal partners: turn-taking 2. New information exchange 3. Open modality use a. Gestures b. Numbers c. Printing; writing d. Technology i. Cell phones ii. iPads iii. computers iv. internet e. Speech f. Drawing g. Environmental 4. Feedback building 5. Responsiveness to efforts 6. Gestures 7. Verification 8. Clarification 9. Repair 10. Expansion 11. VAT 12. PACE ii. Question recognition and knowledge 1. Identification of question type Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 6 MSHA Annual Convention – April 13-14, 2012 a. Yes-no b. Yes-no –I don’t know c. Either-or d. Closed ended: specific; convergent e. Open ended 2. Accurate answer iii. Interrogative answering 1. Sentence 2. New headline 3. Paragraph iv. Complex sentences v. Compound sentences vi. Inferencing xii. Narrative Building i. Linking thoughts; linking words ii. Paragraphs iii. Sequencing iv. Ordinal concepts xiii. Group interaction and interpersonal engagement (Chapey, 2000) i. Conversational skills ii. Social thinking; perspective talking iii. Online group participation 1. Cafes 2. Treatment groups 3. Conversation groups iv. Local support groups (NAA, 2012) v. Local aphasia centers vi. Advanced group work 1. Online public speaking and leadership training 2. Facilitating a group online 3. Simulated work practice xiv. Screen literacy i. Keyboarding ii. Flash Spelling iii. Transitioning to propositional spelling iv. www.aphasiatoolbox.com navigation 1. homepage 2. applications a. load b. use c. select d. summary page print and email 3. protocols and materials v. email 1. send 2. download 3. attach 4. photo 5. purchases vi. document management 1. open 2. edit 3. save 4. email vii. Cell phone 1. Send and receive calls 2. Texting Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 7 MSHA Annual Convention – April 13-14, 2012 3. Voice mail 4. Photos 5. Features: apps; alarm; timer; etc. viii. facebook ix. twitter x. internet 1. search; google 2. links xi. ATM; remote controls; credit card use; gps; gas pump; etc xv. Cognitive- supportive; interactive; supplemental i. Working Memory ii. Attention: (focused; sustained; selective; alternating; [divided?] ) iii. Cognitive flexibility: divergent thought iv. Executive functions v. Mental resource allocation vi. Inference vii. Metacognition

Testing: To be discussed

Treatment Planning: To be discussed (Papathanasiou, 2003, Worrall, 2012)

Brain Compatible Aphasia Program (BCAT) Treatment Modules (first 10 modules in alphabetical order aligning with Aphasia Sight Reader list)

1. AphasiaPhonics Module for phonological elements of aphasia and phonological working memory 2. Conjugation Module for sentence building, neural pathway flows and verbal working memory 3. Discourse Building for syntax reconnection, conversational skills and cognitive flexibility. a. Intent b. Conversation c. Narrative 4. Flash Spelling Module for acquired alexia, agraphia, screen literacy, visuospatial skills and visual working memory 5. Keyboarding Module for apraxia, hand-eye coordination, visuospatial skills and screen literacy 6. Morphing Module for prefixes, suffixes, and elements of grammar 7. Numeracy Program for cardinal and ordinal numbers and everyday number concepts 8. Pronouns Module for referencing, sustained attention skills and getting speech started 9. Semantic Cognition Module for self generated word recall and comprehension, vocabulary building and cognitive flexibility 10. Verbing Module for verb recall fluency, sentence building and alternating attention 11. The PACEmatics Module for pragmatics and language In action 12. Prosody Module for sentence intonation, word stress and phrasal timing 13. The Online Group Module for peer engagement, practice and support 14. The Cognitive Underpinnings Module for memory, attention and mental resource allocation 15. The Alexia-Apraxia Module for acquired reading and writing problems

Exploiting Neuroplasticity in Aphasia Treatment Tenet: 1. The BIG IDEA in Aphasia Therapy - Everything revolves around and comes back to propositional speech and conversation (Sidtis, 2004; . With determination, effective techniques and tools and lots of patient time on task, success is being made at getting clients, even with severe impairments, to talk least in some basic conversational way. (: Activity-Communicative Intent; Exercise-Speech Acts) Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 8 MSHA Annual Convention – April 13-14, 2012 2. The Essence of Aphasia Therapy - • Get the patient skilled at: a. knowing where to focus his/her mental attention b. acting on that point of focus c. efficiently shift to next point of focus. d. Have nothing to do with competing stimuli being introduced. ( : Activity-AphasiaPhonics; Exercise-Increasing Syllables) 3. The Key Elements of Aphasia Therapy – Faith and Rhythm. Faith in memory - we converse from our own thoughts and memory. Speech is rhythmic needing lots of neural flows, not repetitions. Online telespeech: Activity-Conjugation; exercise-subjective pronouns to conjugation) 4. The Missing Ingredient in Aphasia Therapy - A tremendous amount of smart, effective independent, patient practice. It is all about therapeutic time on task in a variety of situations including a therapeutic social network. (Outliers: The Story of Success by Malcolm Gladwell, 2008). Those whom we may think achieved by luck or talent or being in right place at right time: Beetles; Steve Jobs; athletes actually did >20,000 hours practice. Practice should be 2-3 hours a day minimum; focus is the key with technical and personal support; it should be highly responsive to change in client’s status. Why work with a client who doesn’t work harder than you? 5. Work on reconnecting neural pathways that are used for propositional, generative, conversational speech. Can using imitation or external cueing or closure tasks lead to independently self-generated speech output? Overuse of imitation and external cueing appears to be detrimental (Stephen Small, 2004) for clients in the long run as it results in mental focus on imitating not own thoughts. Do we do harm when using most traditional activities? We want to reconnect the propositional not the passive pathways that contribute to perseveration and learned helplessness (Sidtis, 2004. (: Activity-Discourse Building; exercise-Speech Patterning) 6. Keep your eye on the outcomes that truly matter. Focus on conversational interaction and discourse. Outcomes: back to work; converse with wife; read stories to grandkids; shoot the breeze over coffee in Starbucks; to lead a productive life. (website builder; , Dr Ivy, Nancy, aphasiatoolbox.com groups) 7. Use lots of SMART neural flows. This means avoiding, whenever possible, use of imitation, external cuing, and/or copying which may exacerbate perseveration and the inability to use real communication and speech in everyday life. The client should bombard the session with sentence flows ASAP (Brown, 2004). 8. Go after the new normal. Use all possible angles to reconnect the neural pathways. Prosody – definitely address the early and ongoing; Reading / Writing; Gestures, facial expression, body language; Pragmatics; Cognitive exercises – procedural memory; Social interaction. 9. Treatment Planning-Listen to the client to identify where to go next in treatment. (video,CH 3/8/12; 2011316) 10. Phonological to lexical neural interaction: Say it, say it, say it, type it, say it again then make it natural. At Montreal international aphasia conference 2010 a study was presented that discussed importance of activating the lexical and phonological areas of the brain to be most effective. 11. Establish skills in saying subjective pronouns early. Often activity where pure memorization encouraged. These start a great majority of everyday conversational sentences along with demonstrative, interrogative and indefinite pronouns. (: Activity-Pronouns; Exercise-Personalized Pronoun Concept Coaching) 12. Move into conjugation – Pronoun + verb. The art is to gradually get the client to do this from his/her own memory. (: Activity Conjugation) 13. Right branch conjugated sentences into longer utterances. Again building the client’s verbal working memory. (Build Canonical Sentences from AphasiaPhonics: Sound Embedded Verbs) 14. Expand into reverse word order question asking conjugation. Begin to address transforming sentence forms and making derivational changes – also works phonological skills. pronouns  conjugation right branching  reverse word order conjugation (Reverse Word Order Conjugation) 15. Be a master of stimuli. I am a stickler about this. If I were dean for a day in a graduate program I would have a course solely on stimulus creation and management. Kiran and Johnson (2008) offered that there was equivocal support for manipulating typicality within well-defined categories [encouraging loose training] and clinicians should be sensitive to other issues such word usage and individual variability. I see that as supporting complexity training. (Flash Spelling; Morphing) 16. Challenge the patient. He/she wants you to be aggressive. (Discourse Building; Narrative skills; Question Processing; Conjunction Junction; Online Group Public Speaking and Leadership Training for PWA) 17. Activity for 14. – Complexity Training - treatment relies on stringent selection criteria, “…therefore, a treatment that overtly and repeatedly consolidates activation of target semantic attributes as well as activation of related (but untrained) neighbors has a higher likelihood of promoting generalization to untrained items (Kiran, 2009). 18. Guide the patient toward being his/her own speech therapist. Use software and activities designed for not only SLP and coaches but also for client independent practice. 19. Make every activity truly therapeutic. (See .ppt on website) Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 9 MSHA Annual Convention – April 13-14, 2012 20. Focus early on Verbs. Nouns are easy but verbs are the essence of a sentence and we talk in sentences. (Raymer, 2006) (: Activity-Verbing; Exercise-Verbing Arguments) 21. Work ASAP in sentences starting with canonical sentence pattern ( Activity :Canonical Sentences) 22. Incorporate work on cognition (Helm-Estrabrook, 2010; Murray, 2002; Wright, 2004). (Inferencing; Activity Cognitive; Exercise-Verbal Working Memory) 23. Blend cognitive work with speech and language tasks. (Activity-Verbing; Verbing with Attitude). (Activity-Verbing; Verbing with Attitude). 24. Incorporate time concepts. Like American Sign Language, left branch time concept words to begin sentences including conjugated sentences. (Activity-Conjugation; Exercise-Left branched conjugation) 25. Verbing sentences transformed into the 3 basic time concepts. 26. Use all possible angles to reconnect the neural pathways: vision; use technology; screen literacy; internet 27. Software for Aphasia should: SHEAR - •Simple to use •Human touch remains (SLP; practice coach) •Effective for clients •Affordable •Responsive to change and client growth 28. Aphasia Sight Reader demonstration - STIMULI may be manipulated by: time displayed complexity ; word-sentence format; semantic category 29. Incorporate a natural learning cycle –transition through direct treatment, structured practice, independent drill, coached practice, and social, conversational usage. In the long, only the client can speak for him/herself 30. When possible, take advantage of technology: Sentence Shaper – www.sentenceshaper.com ; AAC – Lingraphica – www.aphasia.com ; Simplify email – Coglink - http://www.coglink.com/ (Green, 2007) 31. Deal effectively with the effects of apraxia. We are starting to make some decent strides by treating apraxia as a movement disorder using a cognitive focus. My suggestion is to be careful not to confuse issues of apraxia with phonological aphasia. Understand the difference and the implications for treatment and client conversation. 32. Focus on conversational interaction and discourse, even at the beginning. (Activity-Discourse Building; Exercise-Sentence Patterning) 33. – Sentence Patterning 1.8 includes question asking and turn taking but not imitation or external clinician cueing. 34. What would the perfect, complete treatment protocol look like? 35. Protocol – Self-help exercise guideline: Sentence Patterning – 1.8 Use the Sentence Patterning practice materials and basic demonstration video with this protocol. 36. Peer group interaction is essential: a. It provides the social support inherent in human interaction especially with those who share a life- changing event such as stroke or head injury. b. It offers the opportunity to learn both directly and vicariously from others by observing, listening and watching; c. It provides the speech therapist the chance to do formative assessment with his/her client, assessing progress and growing the individual treatment plan by direct observation of the patient in action with others; d. The social work involved in groups demands communicative engagement, collaboration and reciprocal action. All of these are critical for maximizing aphasia recovery. (Simmons-Mackie, 2009; (www.aphasiatoolbox.com archived newsletters) 37. Online treatment, conversation and support groups ; The Aphasia Communication Cafés at www.aphasiatoolbox.com; (Ross, 2010; Handout from International Aphasia Conference) 38. The National Aphasia Association – www.aphasia.org ; - Peer organized aphasia groups 39. www.strokesurvivor.com - Paul Berger’s consumer website, free newsletter. 40. Have the patient regain faith in and work from his/her own memory or thoughts. 41. Get rid of picture stimuli and mirrors and tape recorders if you want to stabilize intrinsic attention. We need real- time thought formulation, word recall and sentence flow. 42. Auditory Comprehension problems: Overcome bad habits of listening and response; solidify attention and communicative alertness; what a client can process effectively he/she can say. (Build a Story; Interrogative Answering; Inferencing; Interrogative answering); 43. Maintain eye contact whenever possible. Get client to feel, think and act ‘normal’ 44. Have the client BLINK IT! (Blink: The Power of Thinking without Thinking, (Gladwell, 2005). 45. Recognize that there is no such thing as a patient plateau. 46. Recognize that your client is not a data point or a statistic. Statistics do not apply to an individual person. 47. Put the client’s values, needs and goals into the driver’s seat for evidence-based practice. EBP is a framework and set of tools to improve treatment and includes clinical expertise and patient values in addition to current best

Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 10 MSHA Annual Convention – April 13-14, 2012 evidence. “EBP offers us a framework and a set of tools by which we can systematically improve in our efforts to be better clinicians, colleagues, advocates, and investigators.” (Dollahan, 2004). 48. Never, ever, ever give up. However, if you must discharge, have a list of quality resources and referral sources for that client (Connors, 2010).

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Sample BCAT Module:

AphasiaPhonics Treatment Module

Early in childhood, children learn to talk acquiring skills in recognizing (decoding) and saying (encoding) speech sounds. They also learn to read (decode) and write (encode) in letters incorporating their knowledge of and skill in producing speech sounds. This learning experience creates a very strong relationship between speaking and reading that lasts a lifetime. It is this powerful bond, forged by phonics, between sounds and letters that we utilize in the AphasiaPhonics Module as we help people with aphasia (PWA) read, write, and most importantly, talk again. Moreover, this phonics connection from childhood is the reason why we have made use of the many treatment techniques used by speech pathologists who work with phonological disorders in children in development of the AphasiaPhonics module.

The AphasiaPhonics Module takes advantage of this residual sound-letter connection that PWA still have. The clinician uses dozens of innovative treatment protocols and hundreds of stimuli lists on the Aphasia Sight Reader software program to make a therapeutic learning environment that takes full advantage of this phonics connection. The PWA’s ability to transcribe these sounds into phonetic symbols complement his/her efforts.

Phonics involves teaching how to connect the sounds of spoken English with letters or groups of letters and teaching learners how to blend the sounds of letters to pronounce unknown or unfamiliar words. The goal of AphasiaPhonics is to help the client reconnect the sounds of spoken English with letters or groups of letters and to blend the sounds of letters to pronounce words left unfamiliar due to phonological aphasia. Reconnecting word familiarity is a core building block in the AphasiaPhonics module. The AphasiaPhonics aphasia rehabilitation module uses multiple approaches including reading, writing, keyboarding, spelling, talking, gesturing, listening, and thinking.

The benefits of this module are:  It helps the client to think in sounds.  It helps the client to reconnect normal mental processes for decoding and encoding.  It improves the client’s ability to develop phoneme sequence knowledge.  It improves the client’s phonological working memory.  It provides a platform to address phonological working memory problems.  It improves the client’s ability to say words with more than two syllables.  It helps the client to take advantage of residual abilities with the letter-sound relationship.

Some the short-term objectives for the AphasiaPhonics module are: The client will be able to:  explain the relationship between sounds and letters and words.  say aloud, using short term working memory, two words with different spellings but the same sounds (homonyms protocol).  say aloud, using short term working memory, 3 words that increase in length from 1 to 3 syllables (increasing syllables protocol).  using working memory, decide it a string of letters is a real word, then type word and a brief definition (Verbal Working Memory application, Phonological Assembly protocol ).  using verbal working memory and alternating attention, think of a rhyming word given a semantic cue(Lexical- Semantic Meltdown protocol; Aphasia Sight Reader application.  type the phonetic symbols for a printed word, then type the spelling of its homonym (Phoneticize protocol).  using verbal working memory, provide a synonym, antonym and rhyming word for a target word.

Sample Alexia-Agraphia Module: Pure Alexia Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 11 MSHA Annual Convention – April 13-14, 2012 1. Letter by Letter Reading; also know by many other names in the literature: letter by letter, spelling dyslexia, alexia without agraphia, verbal dyslexia, word blindness, letter-by-letter dyslexia 2. Three reading pathways: 1. Sound out phonological; 2. Letter by letter; 3. Sight Read; The pure alexic has difficulty sight reading and defaults to the letter by letter pathway. 3. Multiple paragraph readings. Read a paragraph repeatedly encouraging and coaching toward sight reading. Memorization is ok since that is what sight-reading is? (Lacey, 2007). 4. Flash cards with selected stimuli; •Gradually expand stimuli length and complexity; Force sight reading; Deal with visual field loss 5. Read and listen simultaneously; Previous Tapes for visually impaired using unabridged books and tapes; Can now use text readers 6. Have faith and sound out the words; Blink it and then say the words immediately; Do not spell; Length of words in letters; sight read given category; adapt for R visual loss- all words end in ‘e’; everyday words -days, months, family names; Read the word then type 7. Do conjugation; Do letter naming in order then random. Sight Read and identify the category only; Exposed are birds and fruits; Flash “banana”; Which category does it belong? (Ska, 2003) 8. Manipulate stimuli- 1.Pair problem functor words and verbs with homophonous nouns (be/bee; in/inn); 2. Pair with relays that share initial phonemes but vary with final (apart/apartment; I’ve/ivy (Nitzberg, 2008); 9. The Aphasia Sight Reader: (Work with the AphasiaPhonics Activities; Increasing Syllables; Elision; Phonological Assembly) 10. Build Phonological Working Memory (Christy, 2006) •Build sight recognition of functor and grammatical words (Sperling, 2006). Use the captioning feature on the television to simultaneously work on reading and listening 11. Typos are you best friend. Embrace your mistakes

Part 2:

Advances in the Treatment of Acquired Apraxia affecting speech, voice and limb

The second pressing clinical question for the treatment of apraxia and related disorders (abulia: asymbolia; etc.) How can we offer clinical management that truly takes advantage of neural plasticity and most efficiently maximizes patient recovery of communication skills?

1. identify 5 techniques for the treatment of apraxia of speech and limb apraxia.

2. identify 4 observation and analysis techniques of client behavior to use in applying evidence-based treatment to maximize rehabilitation activities and effectively train caregivers/coaches participation in the treatment process for apraxia.

3. identify 5 techniques for applying adult evidence-based rehabilitation techniques in working with adolescents and young adults with communication problems.

4. identify 10 issues with related solutions to effective telepractice for the treatment of aphasia and related disorders.

Motor Learning Principle Motor Reconnect Principle GOAL: to help bran reorganize itself with new neural GOAL: to help bran reorganize itself with renewed and new connections neural connections A. Exploiting neuroplasticity: 1. Increase sensory input; 2. A. Exploiting neuroplasticity: 1. Moderate/reduce sensory Provide many opportunities for specific input; 3. Modulate in input; 2. Provide more opportunities for intrinsic focus; 3. lifelike contexts; 4. “Watch my face.” Modulate in phrase and sentence contexts; 4. “feel- think” B. Acquisition of performance is not good index of retention B. Reacquisition of performance is good index of retention C. Random practice is superior to blocked practice. Avoid C. Blocked practice can play a bigger role. Utilize repeated repetitive trials with a predictable time pattern. rhythmic flows of a self-generated nature (not repetitious)

Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 12 MSHA Annual Convention – April 13-14, 2012 D. Intent to improve movement is critical. D. Intent to improve movement is critical. Intent is thought. E. Focus on individual phoneme should not be in the E. Focus on individual vowel phonemes should not be the treatment plan. treatment plan. F. Focus on vowels a great deal. F. Focus on vowels a great deal especially to reestablish jaw control. G. Ongoing practice: blocked early for accuracy toward G. Ongoing practice: blocked early for accuracy toward more random practice. more random practice. H. Ongoing practice: lots and lots in context it will be used. H. Ongoing practice: lots and lots combined with work on phonological, lexical and semantic as appropriate. I. Make the ‘feel’ of the movement salient. I. Make the ‘feel’ of the movement salient, salient, salient. J. Utilize tactile and proprioceptive feedback. J. Minimize tactile and maximize proprioceptive feedback. K. Focus on function, core vocabulary. K. Reconnect to vocabulary. (sub, pronouns, conjugate) L. Segment syllables, not phonemes L. Segment syllables, not phonemes (compounds, tripounds; increasing syllable words) M. Fold in prosody early M. Fold in prosody early; scatpraxia; OMC. (Baker, 2005) N. Attentional focus on extrinsic feedback encourage visual N. Minimize extrinsic feedback; attentional focus on intrinsic and tactile feedback moving toward more intrinsic feedback; focus on reinforcement of knowledge of (Freedman, 2005) movement.

The Motor Reconnect Apraxia Program (MRAP)

The Motor Reconnect Apraxia Program (MRAP) Treatment Modules

1. Viking Module for reconnecting: separate neural controls for the jaw and laryngeal muscles; control over voice onset; pre-prosodic skills; and varied phonation 2. Blending with BCAT work to: fold in linguistic areas of focus; work in phrases and sentences; address link to prosodic skills 3. Scatpraxia Module for vocal fold pulsing, rhythm, and flow (Baker, 2005) 4. Vowel Module for introduction and coordination of vowels with BCAT activities 5. Syllabification Module for vowel and syllable pulsing; pre-syllabic work 6. Limb Module for addressing: limb apraxia; keyboarding skills; 7. The Online Group Module for peer engagement, practice and support

MRAP module steps

a. Metapraxia – concepts of MRAP and motor planning and execution b. The basic Viking – pulsing syllables (Max, 2011; Society for Neuroscience, 2007): i. Modeled – ii. Independent on request c. Durational Viking – Stretching Vowels d. Intoned Viking e. Viking with an Attitude – decoding prosody i. Number of syllables ii. Number of syllables + stress pattern f. Rhythmic Viking g. Viking the Vowels for Motor Planning, Anticipatory Co-articulation h. YES-NO-IDK-Delicious (headshake / head nod with phonation) i. Task oriented ii. Simple iii. Incorporating complex tasks iv. Everyday usage i. Blend with BCAT work j. Scatpraxia (Max, 2011; Umanski, 2010) i. Scatpraxia: vowels ii. Scatpraxia: varied vowels Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 13 MSHA Annual Convention – April 13-14, 2012 iii. Scatpraxia: bringing in the consonants k. Vowels i. 3 - Jaw positions ii. 4-corner vowels iii. Add middle vowels iv. Add short vowels v. Around the Mouth – be right behind me; coarticulation vi. The Elevator: Alternating Vowels vii. Vowel Sequences From Memory viii. Continuous Phonation – Diphthongs ix. Blend Sounds into Words x. V to VC words xi. Alternate / h / -vowels xii. Alternate voiceless consonants -vowels l. Syllable structure work i. Vowels Become Pronouns ii. Oral-Motor Coordination Program iii. Sound Embedded Verbs iv. Increasing Syllables v. Sentence Intonation Patterning m. GROUPS: i. Oral Motor Coordination - Apraxia ii. Scatpraxia iii. Coaches n. Abulia; adynamia; asymbolia o. MRAP for Limb apraxia i. Praxis for number digits ii. Morrapraxia (http://www.morrasociety.com/) 1. Single number Morra 2. Simple math Morra 3. Morra iii. Digital number concepting with keyboarding iv. Gestural representation of present objects v. Gestural representation of missing objects vi. In conversation-verification vii. Keyboarding 1. Typing 2. Touch screen 3. Touch pad p. Physical Fitness for Life Program

MRAP – Principles  “If you can plan it you can say it; if you can remember doing it you can plan and do it independently the next time.”  Recognize apraxia as a true motor programming disorder and treat it as such initially (McNeil, 2000). o Allow for normal breath support; let air turn on vocal folds; normal posture, action and inhalation; minimize details. o Ensure metapraxia; absolutely approach apraxia as a movement disorder. o Provide the client with movement and sound productions that incompatible with recurrent utterances; enforce their use in the clinic and the everyday environment. o Address movement initiation issues as identified. o Reestablish separate neural controls for laryngeal and jaw/tongue; keep normal head/body posture; keep eyes open; pay careful attention to sound and the feel.  Use differential diagnosis and clinical observations as basis for treatment targets and activities not severity.  Get patient to embrace mistakes; movement and sound errors are irrelevant as long as intrinsic knowledge is guiding and monitoring attempts.  Intensive, frequent practice is critical (McNeil, 2000).

Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 14 MSHA Annual Convention – April 13-14, 2012  Always push for client working from his/her own memory. Maintain a client focus on internal proprioceptive feedback avoiding external mental focus. Minimize or eliminate: imitation; repetition; focus on external visual, auditory or tactile stimuli. o Your brain activates an plan, sends a message to move – you move – your jaw sends a message “ I moved, here I am, what do I do next?” ,the brain tells where to go next. o Build in laryngeal pulsing; rhythm and flow. o Since the normal planned unit is usually several words long (McNeil, 2000), work on increasing buffer capacity is critical.  Make vowels the early treatment targets (Haley, 2004); work on vowels early introducing vowels as jaw positions; usually tongue and lips movements come along for free. o Minimize work on consonants early; most come along for free as the program progresses; minimize attention to cognate pair errors. o Select targets on an individual basis not on level of severity (Square, 2001)  Fold in prosodic work when appropriate and as early as possible (Baker, 2005).  Rely heavily on formative assessment and treatment adjustments.  Address syllabification skills early.  Move into syllables ASAP; move syllables into words ASAP (e.g., pronouns); move words into sentences ASAP. o Thread the reconnected motor planning and programming skills into work on phonological aphasia ASAP. o Exploit anticipatory co- articulation to facilitate normal patterns. o Thread into linguistic contexts when appropriate but make it as early as possible.  Challenge the client’s system; (e.g., scatpraxia).  Train like the Navy Seals: It’s not how to do it, it’s what and when to do it.  Recognize what significant positive effects mean for both trained and untrained items and for efficacy as it applies to conversational speech. Do not burn your clinical bridges. (Gordon, 1997; Kelly, 2010).  Blend your apraxia motor work with your Physical Fitness for Life work.

Outcomes:  Use backward chaining technique o Relevance: Who care about what? (Berger, 2002; Connors, 2011; Hersch, 2010; Holland, 2006; Rosenbek, 1989; Worrall, 2011) o Start with the Incomes to get to the Outcomes o Goals o Objectives o Outcomes  Treatment Planning o “I do my best teaching when I don’t plan.” Anonymous by request o “A good plan is like a roadmap: it shows the final destination and usually the best way.” H. Stanley Judd  Testing o Formative Assessment (ASHA, 2001; Hill, 2001)  Measurement o Client o Research o Tools o Outcome of outcomes

Telerehabilitation:  Professional Issues (Brown, 2012; ASHA-telepractice, 2012)  Conferencing services  EBP  Privacy-HIPAA  Practical aspects (Berger, 2010; Gould 2012)  Advantages  Disadvantages; glitches Aphasia-Apraxia Therapy: Exploiting Neuroplasticity 15 MSHA Annual Convention – April 13-14, 2012  Human factor  Type of disorder  Group possibilities  Get used to it: digital natives-digital immigrants

Apps, applications and websites: To be discussed

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