Intensive Auditory Comprehension Treatment for People with Severe Aphasia:
Outcomes and Use of Self-Directed Strategies
A dissertation proposal submitted to the
Division of Graduate Education and Research
Of the University of Cincinnati
in partial fulfillment of the requirements of the degree of
DOCTOR OF PHILOSOPHY
In the Department of Communication Sciences and Disorders
In the College of Allied Health Sciences
Dissertation Committee: Aimee Dietz, Ph D., chair Lisa Kelchner, Ph.D. Robin Thomas, Ph.D. Pete Scheifele, Ph.D
2012 by
Kelly Knollman-Porter
Intensive Auditory Comprehension Treatment
Abstract
The purpose of this study was to determine the efficacy of an intensive (2 hours/day, 5 days/week for 3 weeks) treatment protocol on individuals with severe, chronic speech perception or auditory comprehension deficits associated with aphasia. Two experiments were implemented to examine this purpose. Experiment I: Single Word Comprehension Approach (SWCA) established the effectiveness of an intensive treatment protocol on single word auditory comprehension (n = 6). Alternatively, Experiment II: Speech Perception Approach (SPA) examined the outcomes of an intensive treatment protocol on speech perception in individuals with profound global aphasia (n = 2). The researcher employed an ABA single subject design for both experiments, and examined the following variables: (1) changes in single word comprehension (SWCA) or speech perception (SPA); (2) the number of self-initiated requests for repetition and lip-reading cues; (3) the effectiveness of repetition and lip-reading cues; (4) the indirect effects of the protocols on verbal expression (SWCA – naming; SPA – repetition; Both – narrative skills); (5) and generalization to functional communication environments. Results revealed that all participants enrolled in the SWCA or SPA exhibited a lack of awareness regarding their comprehension impairment at the onset of treatment. Despite this reduced awareness, 7 of the 8 demonstrated a large effect on either single word comprehension or speech perception. A generalization effect to untrained stimuli was also exhibited by these participants. The use of repetition successfully improved speech perception and single word comprehension in all participants; however lip-reading was beneficial in only 1 of the 8 participants. An indirect effect on verbal expression naming ability was demonstrated by 5 of the 6 SWCA participants; this effect was not observed in the SPA participants. Carryover of these skills to functional communication situations was reported by one of the eight caregivers. These finding suggest that
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individuals with severe to profound, deficits have the potential for continued improvements in speech perception or auditory comprehension, even in the chronic stages of recovery. However, caregiver involvement, use of personally relevant stimuli and rehabilitation protocols designed to increase self-awareness of speech perception and single word comprehension impairments may be a crucial link to generalization of communication gains to functional situations with this population.
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Acknowledgements
This work is dedicated to the men and women with aphasia who have willingly and openly allowed me to be a part of their lives. Without hesitation, they have been my true teachers. These individuals and their families have not only demonstrated to me the unique, complex world of aphasia, but more so, the true meaning of perseverance, dedication, and strength. They have and continue to inspire and challenge me as a clinician, researcher and as a human being.
I would also like to specifically thank my mentor, Dr. Lisa Kelchner, who has been and continues to be a role model for me in the field. Her passion and depth of knowledge are astounding. Even with these skills, she consistently displays humility and grace; never demeaning or critical. Words cannot thank her enough for the many years of training, advice, and guidance she has provided me over the past 15 years.
Three years ago, I had the pleasure of meeting Dr. Aimee Dietz. Little did I know at the time, she would play such a crucial role in the success of my program. Even through pregnancy and the birth of her beautiful son, she continued to challenge and encourage me to develop my skills as a clinical researcher. She supported me in my belief that clinical research, while time intensive, can make a difference in the lives of individuals with aphasia. My sincere thanks goes to her for the many hours of editing and guidance provided through this journey.
I will forever be indebted to my parents, Don and Doris Knollman. From a very young age, they instilled in me the importance of education, integrity, and hard work. During every stage in my life, they have been a constant source of assistance and encouragement. I thank them
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Intensive Auditory Comprehension Treatment
for standing in the gap while I chased yet another dream. I couldn’t ask for a better Mom and
Dad.
In addition, one of my greatest blessings are my children. Both Anna and Eric have been a constant support for me along this long journey. More than once, they used my own words against me when the more challenging phases of the Ph.D. program arose. It was a joy to watch them grow and mature through this process. It is my hope, that through my experiences they can realize that with persistence and dedication anything in life is possible.
Finally, over twenty years ago, God brought an amazing man into my life. Never have I known anyone as self-sacrificing and supportive as my husband, Randy Porter. He was my midnight tech support, statistics and excel tutor, my cheerleader and my counselor when the challenges of the program became overwhelming. Without hesitation, he is the best thing that ever happened to me. I love him very much and am forever grateful for his never ceasing, unconditional support.
This dissertation is truly not my own; and could not have been initiated or completed without the support of many other wonderful individuals. To the following I am also thankful: Dr. Pete Scheifele, Dr. Robin Thomas, Miami University Aphasia Support Group members and their families, my wonderful colleagues at Miami University, my students, and my church family.
“We are like clay jars in which this treasure is stored. The real power comes from God and not from us.” 2 Corinthians 4:7
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Table of Contents
List of Tables List of Figures Chapter 1
xvii xx
- Introduction
- 1
- 5
- Purpose of the Investigation
Chapter 2
- Review of the Literature
- 7
- 7
- Normal Comprehension: The Process
Acoustic phonetic analysis Phonological processing Lexical semantic system
889
- Speech Perception/Auditory Comprehension Deficits Associated with Aphasia
- 10
The Influence of Short-Term Working Memory on Comprehension
Short-term working memory: Normal Comprehension Short-term working memory: Comprehension in aphasia
11 11 12
- Self-Awareness
- 13
- 14
- Self-Awareness in Aphasia
- Assessment of Comprehension Deficits in Aphasia
- 18
- 19
- Assessment of short-term working memory and comprehension
Therapeutic Management of Comprehension Deficits in Aphasia
Intensity of treatment
20 22 23 24
Utilization of repetition cues Utilization of lip-reading cues
- Research Questions and Research Hypothesis: Experiment I - SWCA
- 25
- 27
- Research Questions and Research Hypothesis: Experiment II – SPA
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Intensive Auditory Comprehension Treatment
Chapter 3
- Methods
- 29
- 31
- Participants
- Setting
- 34
34 34
Design Screening and Cognitive-Linguistic Assessment Materials
- Equipment
- 34
34 35
Audio and video equipment Audiometer
- Screening
- 35
35 35 35 36 36
Social and medical history survey Hearing screening Visual acuity screening Response screening Comprehension severity screening
Cognitive-Linguistic Assessment
Phonological processing
36 36 37 37 37
Semantic processing Working memory Non-linguistic cognitive assessment tools
Screening and Cognitive-Linguistic Assessment Procedures
Video recording protocol
38 38
- Screening
- 38
38 38 39 39 40 40
Medical and social history survey Hearing screening Visual acuity screening Response screening Comprehension severity screening Neuroimaging
- Cognitive-Linguistic Assessment
- 40
- 41
- Measurement of phonological processing and working memory
Measurement of semantic comprehension and working memory 43
- Non-linguistic cognitive assessment protocol
- 44
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Assessment of Experimental Complexity Stimuli Materials
Experiment I: SWCA assessment materials Experiment II: SPA assessment materials
Assessment of Experimental Stimuli Complexity Procedures
Experiment I: SWCA assessment procedures Experiment II: SPA assessment procedures
Experimental Materials
44 44 46 46 47 50 53
Experiment I: SWCA
Equipment
53 53 53 54
Single word comprehension stimuli Verbal naming stimuli
- Experiment II: SPA
- 54
54 55
Speech perception stimuli Verbal repetition stimuli
Common experimental materials
Audio and video equipment Picture description
55 55 55 55 55
Communication history survey Frustration/fatigue monitoring
- Experimental Procedures
- 55
Experiment I: SWCA
SWCA baseline phase
Single word comprehension Verbal naming measures
SWCA treatment phase SWCA probe data
56 56 56 56 56 59
- 59
- SWCA maintenance phase
Experiment II: SPA
SPA baseline phase
Speech perception
60 60 60 60 61 62
Verbal repetition measures
SPA treatment phase SPA probe data
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Intensive Auditory Comprehension Treatment
- SPA maintenance phase
- 62
Common experimental procedures
Picture description
62 62 63 63
Communication history survey Frustration/fatigue monitoring
- Independent and Dependent Variables
- 63
63 64 65 66 66
Experiment I: SWCA independent and dependent variables Experiment II: SPA independent and dependent variables
Research Fidelity Analyses Ethical Issues
Chapter 4
- Results
- 68
68 68
Single Word Comprehension Study
Participant T.G.
- Single word comprehension – Response to intervention
- 69
69 70 71
Trained stimuli Untrained stimuli Comprehension error patterns
Self-initiated requests for cues
Repetition
72 72
- 73
- Lip-reading
- Comprehension accuracy following cues
- 73
73 75
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
75 75 76 77
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Intensive Auditory Comprehension Treatment
- Generalization to functional communication environments
- 78
- 81
- Participant B.G.
- Single word comprehension – Response to intervention
- 81
82 82 83
Trained stimuli Untrained stimuli Comprehension error patterns
Self-initiated requests for cues
Repetition
84 84
- 85
- Lip-reading
- Comprehension accuracy following cues
- 86
86 87
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
88 88 89 91
- Generalization to functional communication environments
- 92
- 93
- Participant T.O.
Single word comprehension – Response to intervention
Trained stimuli
93 94 94 95
Untrained stimuli Comprehension error patterns
Self-initiated requests for cues
Repetition
96 96
- 97
- Lip-reading
- Comprehension accuracy following cues
- 98
98 99
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
99 99 100 102
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Generalization to functional communication environments
Participant B.D.
Single word comprehension – Response to intervention
103 105 105 105 106 107
Trained stimuli Untrained stimuli Comprehension error patterns
Self-initiated requests for cues
Repetition
108 108
- 109
- Lip-reading
- Comprehension accuracy following cues
- 110
110 111
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
112 112 114 115
- Generalization to functional communication environments
- 116
- 119
- Participant D.W.
Single word comprehension – Response to intervention
Trained stimuli
120 120 120 121
Untrained stimuli Comprehension error patterns
Self-initiated requests for cues
Repetition
122 122
- 123
- Lip-reading
- Comprehension accuracy following cues
- 124
124 125
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
126 126 128 129
- 130
- Generalization to functional communication environments
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Intensive Auditory Comprehension Treatment
- Participant R.K.
- 133
- Single word comprehension – Response to intervention
- 133
134 134 135
Trained stimuli Untrained stimuli Comprehension error patterns
Self-initiated requests for cues
Repetition
136 136
- 137
- Lip-reading
- Comprehension accuracy following cues
- 138
138 139
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Naming of trained comprehension stimuli Naming of untrained comprehension stimuli Picture description
140 140 141 142
- Generalization to functional communication environments
- 143
- 146
- Experiment I: SWCA – Summary of results
Research Question 1 Research Question 2 Research Question 3 Research Question 4 Research Question 5 Research Question 6 Research Question 7 Research Question 8
146 147 148 148 149 150 151 151
Speech Perception Study
Participant T.L.
Speech perception – Response to intervention
152 152 153 153 153 154
Trained stimuli Untrained stimuli Speech perception error patterns
Self-initiated requests for cues
Repetition
156 156
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Intensive Auditory Comprehension Treatment
- Lip-reading
- 156
- Speech perception accuracy following cues
- 157
157 158
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Repetition of trained speech perception stimuli Repetition of untrained speech perception stimuli Picture description
158 158 159 160
- Generalization to functional communication environments
- 161
- 164
- Participant E.R.
Speech perception – Response to intervention
Trained stimuli
165 165 165 166
Untrained stimuli Speech perception error patterns
Self-initiated requests for cues
Repetition
167 167
- 168
- Lip-reading
- Speech perception accuracy following cues
- 169
169 170
Repetition Lip-reading
Verbal Expression – Indirect treatment effects
Repetition of trained speech perception stimuli Repetition of untrained speech perception stimuli Picture description
171 171 172 173
- Generalization to functional communication environments
- 174
- 177
- Experiment I: SPA – Summary of results
Research Question 1 Research Question 2 Research Question 3 Research Question 4 Research Question 5 Research Question 6 Research Question 7 Research Question 8
177 178 178 178 179 179 180 180
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Chapter 5
- Discussion
- 181
- 181
- Experiment I: SWCA – Major Outcomes
- Response to intervention
- 182
185 185 188 191 192
Effectiveness of self-initiated requests for cues
Repetition Lip-reading
Verbal expression: Indirect treatment effects Generalization to functional communication environments
- Experiment II: SPA – Major Outcomes
- 195
- Response to intervention
- 196
197 200 201
Effectiveness of self-initiated requests for cues Verbal expression: Indirect treatment effects Generalization to functional communication environments
- Limitations and Direction for Future Research
- 202
Intensity of the treatment protocol Neurologic correlates Utilization of lip-reading cues Indirect impact on verbal expression Functional relevance of treatment stimuli Functional communication
202 203 204 205 206 206
- 208
- Were the outcomes worth the effort?
- Conclusions
- 210
211 225 228 229 230 231
References
Appendix A. Inclusion/Exclusion Criteria Appendix B. Hearing Screening Appendix C. Visual Acuity Screening Appendix D. Response Screening Appendix E. Lexical Analysis SWCA
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- Appendix F. Experimental Stimuli Complexity Assessment SWCA High Frequency
- 233
Appendix G. Experimental Stimuli Complexity Assessment SWCA Medium Frequency 235 Appendix H. Experimental Stimuli Complexity Assessment SWCA Low Frequency Appendix I. Experimental Stimuli Complexity Assessment SPA CV Appendix J. Experimental Stimuli Complexity Assessment SPA CVC Appendix K. Experimental Stimuli Complexity Assessment SPA CCVC Appendix L. Baseline and Probe SWCA High Frequency Version A Appendix M. Baseline and Probe SWCA High Frequency Version B Appendix N. Baseline and Probe SWCA Medium Frequency Version A Appendix O. Baseline and Probe SWCA Medium Frequency Version B Appendix P. Baseline and Probe SWCA Low Frequency Version A Appendix Q. Baseline and Probe SWCA Low Frequency Version B Appendix R. Treatment SWCA High Frequency
237 239 242 244 246 248 250 252 254 256 258 263 267 271 273 275 277 279 283 287 288
Appendix S. Treatment SWCA Medium Frequency Appendix T. Treatment SWCA Low Frequency Appendix U. Baseline and Probe SPA - CV Version A Appendix V. Baseline and Probe SPA - CV Version B Appendix W. Baseline and Probe SPA - CVC Version A Appendix X. Baseline and Probe SPA - CVC Version B Appendix Y. Treatment SPA – CV Stimuli Appendix Z. Communication History Survey Appendix AA. Fatigue/Frustration Scale Appendix BB. Frustration Form