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6/5/2006 Word Retrieval Treatments with Aphasia Holley J. Freyaldenhoven, M.S., & Kim McCullough, Ph.D., CCC-SLP, University of Central Arkansas, Conway, Arkansas | |
| Abstract: This single-subject study examined the effects of semantic and phonological cueing treatments on the word finding abilities of a sixty-four-year-old male with anomic aphasia, targeting the participant’s specific level of lexical processing impairment (i.e. predominantly lexical-semantic, predominantly lexical-phonological, or mixed semantic-phonological). This investigation was a modified replication of a study by Wambaugh and colleagues (2001) which compared the effects of semantic and phonological cueing treatments on individuals with aphasia with differing levels of deficit. The participant received both treatments at single-word and conversational levels. Each treatment consisted of a pre-stimulation phase and a treatment phase in which response-contingent hierarchical steps were applied. Results indicated that although the participant clinically appeared to benefit from both types of treatments, there was a more positive response to the phonological cueing treatment. Introduction: Aphasia is known to be a highly variable, heterogeneous disorder. Few patients with aphasia follow a specific spontaneous recovery pattern, and few receive the same specific treatment for their impairment. One common form of language impairment exhibited by patients with aphasia is naming deficits. Some naming deficits in individuals with aphasia respond better to phonological cueing treatments that utilize first sound, syllable or rhyming cues to facilitate naming of target words. However, some types of naming deficits respond better to semantic cueing treatments that utilize cues such as sentence completion, the function of the target word, the location of the target word, or a superordinate of the word. Based on these different types of naming deficits, two types of treatments are typically used to address these deficits; those that target lexical-semantic levels of processing (Drew & Thompson, 1999; Kiran & Thompson 2003) and those that target lexical-phonological levels of processing (Raymer, Thompson, Jacobs, & LeGrand, 1993; Miceli, Amitrano, Capasso, Caramazza, 1996). Treatments based on lexical processing models have been successful at facilitating generalization for patients with aphasia. If the clinician can identify the lexical level at which the breakdown occurs, specific treatment can be used to target that particular level of processing. For example, if an individual with aphasia-induced word retrieval deficits has a deficit at the lexical-semantic level of processing, semantic cueing treatments would best facilitate naming and generalization for the individual. Tasks used to target lexical-semantic levels of processing typically involve judging semantic relatedness of items, categorizing objects or pictures, matching words to pictures, describing semantic features and providing synonyms and antonyms (Wambaugh, Linebaugh, Doyle, Martinez, Kalinyak-Fliszar, & Spencer, 2001). Drew and Thompson (1999) examined the effects of a semantic treatment on the acquisition, generalization, and maintenance of picture naming tasks to improve discrimination of perceptual, functional, and associative attributes of the pictures. The effectiveness of excluding a target word to facilitate the naming of pictures in two semantic categories, the promotion of generalization within and across semantic categories, and maintenance of trained words were targeted to measure treatment effects. Also, the addition of a phonological component to improve naming abilities was targeted to measure the effects of the treatment. Drew and Thompson (1999) concluded that treatment plans should be specifically based on the impaired level of processing in the individual and demonstrate the rationale for specifically based treatment for impaired levels of processing. Kiran and Thompson (2003) examined whether atypical exemplars are more complex than typical exemplars within a category. The training of complex items to facilitate generalization to untrained simpler items was applied to the treatment of naming deficits in patients with aphasia. The semantic complexity was examined by controlling the typicality of category exemplars. Kiran and Thompson (2003) concluded that training of atypical items within a category and their semantic features resulted in the generalization to the naming of intermediate and typical examples of that category. Tasks utilized to target lexical-phonological levels of processing typically include performing rhyme judgments, using word-initial sound cues, repeating names of target items, and generating rhyming words (Wambaugh et al., 2001). Raymer, Thompson, Jacobs, and LeGrand (1993) implemented a phonologically based treatment to train oral picture naming in four individuals with aphasia who had severe word-retrieval deficits, but differing deficit patterns. Raymer and colleagues used two sets of 30 monosyllabic picturable nouns containing 10 target training words, 10 rhyming words, and 10 semantically related words. During baseline and generalization, three probe tasks - oral picture naming, oral word reading, and written picture naming - were administered during the baseline phase during four consecutive sessions. During the treatment phase, untrained words associated with each set were also presented to assess generalization. For the phonologically based treatment a picture was randomly selected and the participant was asked to spontaneously name the pictured item. If the naming attempt was unsuccessful, the participant was given a word that rhymed with the target word. If the naming attempt was again unsuccessful, the participant was given an initial phoneme cue. If the naming attempt was once again unsuccessful, the participant was given an auditory model. At whatever level the word was correctly elicited, the participant was requested to repeat the word five times and a spontaneous naming of the item was re-attempted. Results indicated that each participant was successful in the acquisition of trained target items, but that response generalization varied, depending on each participant’s level of breakdown. Raymer and colleagues’ investigation demonstrated the use of a cognitive model of lexical processing that focused on phonological treatments to guide the treatment strategies for individuals with word-finding deficits. While utilizing the theory of cognitive models of lexical-semantic processing, Miceli, Amitrano, Capasso, Caramazza (1996) analyzed the treatment outcomes of two individuals with aphasia to examine if generalization occurred with all untreated items, untreated but semantically related items, or if no generalization to untreated items occurred. Miceli and colleagues (1996) also examined the duration of treatment effects in each participant. Treatment tasks required each participant to name a picture item and the written word, written word only, and picture item only. If the item could not be named, the participant was given phonemic cues in a hierarchical manner until the correct response was produced by the participant. Miceli and colleagues (1996) concluded that when the lexical-phonological component is damaged but the lexical-semantic component is spared, improvement does not generalize to untreated words. Miceli and colleagues (1996) also concluded that response accuracy of treated items decreased over time. Although the longitudinal study conducted with one of the participants did not show his naming of treated items below baseline, Miceli and colleagues cautioned that, with time, it could. Generalization and maintenance of treated words is an important aspect of treatment. Sentence production can often be hindered by word-retrieval deficits in persons with aphasia. The production of sentences in meaningful speech is necessary for the patient to communicate functionally in conversation. Generalization and maintenance of treated words should be carried outside of therapy into the patient’s everyday life, allowing the patient the full benefit of implementing word retrieval skills learned in therapy. Treatment should include using the patient’s social surroundings to facilitate generalization and maintenance of treated words. Eales and Pring (1998) suggested the use of individual therapy sessions followed by group therapy sessions as a means of generalization, maintenance of treated words, and reducing the cost of therapy. For the current study an attempt was made to examine the effects of two lexical retrieval treatments in an individual with anomia. This study was an attempt to replicate Wambaugh and colleagues (2001). Their research was based on the idea that a person with aphasia would respond better if treatment (semantically based or phonologically based) was focused on the specific level of lexical processing deficit. It was hypothesized that by targeting the participant’s specific lexical pathway, one treatment would facilitate a more positive outcome with regard to remediation of the subject’s word finding difficulties and generalization to untreated items. The semantic cueing treatment (SCT) and the phonological cueing treatment (PCT) used by Wambaugh and colleagues (2001) and used in the present study, paralleled each other with regard to number of hierarchical cueing steps, relative difficulty of steps, and general application of steps. Neither lexical retrieval treatments were developed specifically for a person with naming deficits. Instead, each treatment was developed to target specific lexical pathways associated with specific lexical retrieval errors. Methods: The participant was recruited from the University Speech-Language Hearing Clinic in Conway, Arkansas. He was a native-English speaking, 64-year-old male Caucasian. The participant had obtained a high school diploma and had some college experience. He was a retired preacher and resided at home with his wife. He was less than 1 year post CVA and exhibited naming deficits. The participant was administered the Test of Adult Word Finding (TAWF) (German, 1990), the Western Aphasia Battery (WAB) ( Kertesz, 1982), subtests of the Minnesota Test of Differential Diagnosis of Aphasia (MTDDA) (Schuell, 1973), and the Apraxia Battery for Adults (ABA) (Dabul,1979). The participant obtained an aphasia quotient on the WAB of 90.6. TAWF scores indicated a mild naming impairment. The ABA indicated no presence of apraxia of speech. The MTDDA indicated impairments in the following subtests: matching printed to spoken words; reading comprehension, paragraph; reading comprehension, sentences; retelling paragraph, written spelling; oral spelling; producing written sentences; writing sentences to dictation; and writing a paragraph. Each of the participant’s lexical retrieval errors were categorized, prior to treatment, as either lexical-semantic, lexical-phonological, or mixed. Based on criteria set forth by Wambaugh and colleagues (2001), the preliminary evaluation indicated the participant might respond better to the PCT due to a more evident lexical-phonological impairment than a lexical-semantic impairment, although both types of errors were found. Wambaugh and colleagues' criteria included assessment measures such as the ones listed in Table 1. Additionally, the participants naming performance on a set of 260 line drawings (Snodgrass and Vanderwart, 1980) was analyzed. Based on the above, Wambaugh and colleagues (2001) examined areas of performance including picture and word semantics, rhyming, picture naming, phonemic cueing responsiveness, oral reading and repetition. Typically, participants would demonstrate either a predominately semantic or predominately phonological deficit. However, in some cases participants would present with a “mixed deficit” which included difficulty with both semantic and phonological processing. Table 1. Pretreatment Test Results.  The preliminary evaluation indicated the participant might respond better to the PCT due to a more evident lexical-phonological impairment than a lexical-semantic impairment, although both types of impairments were found. These preliminary findings were based on criteria set forth by Wambaugh and colleagues. These criteria included assessment measures such as the ones listed in Table 1. Additionally, the participants naming performance on a set of 260 line drawings (Snodgrass and Vanderwart, 1980) was analyzed. Based on the above, Wambaugh and colleagues (2001) examined areas of performance including picture and word semantics, rhyming, picture naming, phonemic cueing responsiveness, oral reading and repetition. Typically, participants would demonstrate either a predominately semantic or predominately phonological deficit. However, in some cases participants would present with a “mixed deficit” which included difficulty with both semantic and phonological processing. Initial observation of the participant involved the identification of specific word targets from a selection based on the participant’s ability to verbally name a set of 260 line drawings (Snodgrass and Vanderwart, 1980). Each line drawing was presented twice to the participant. Of these 260 line drawings, targets in which the participant gave an incorrect response were randomly divided into four sets of stimuli: those used for SCT, those used for PCT, a response generalization set, and control items. Information was also obtained regarding the environment and context in which the participant had the most word finding difficulties. The participant’s goals for word retrieval in his natural environment were also identified. During the SCT, tasks involved judging semantic relationships. The SCT treatment was used to strengthen semantic associations such as categories of fruit, clothing and transportation. The pre-stimulation phase required the participant to select from two semantically related items and one unrelated item after a phrase verbally describing the target item was provided by the researcher. Treatment at the single-word level immediately followed the pre-stimulation phase. Response-contingent steps of the semantic cueing hierarchy were applied with each picture presentation. Verbal feedback was provided for correct/incorrect responses after each hierarchical step. A 3-5 second response time was allowed and was applied to each of the hierarchical steps. The response-contingent steps of the hierarchy were as follows (Wambaugh et al., 2001): Table 2. Cueing Hierarchy for Semantic Cueing Treatment.  During the PCT, tasks involved performing rhyme judgments and using word initial sound cues (i.e. for the word “book,” it starts with a /b/.). The pre-stimulation phase required the participant to select from two word-initial sound related items and one unrelated item after the target was verbally given by the researcher. Treatment at the single-word level immediately followed the pre-stimulation phase. Response-contingent steps of the phonological cueing hierarchy were applied with each picture presentation. Verbal feedback was provided for correct/incorrect responses after each hierarchical step. A 3-5 second response time was allowed and was applied to each of the hierarchical steps. The response-contingent steps of the hierarchy were as follows (Wambaugh et al., 2001): Table 3. Cueing Hierarchy for Phonological Cueing Treatment.  Using the selected picture cards, the single-word level of SCT and the PCT each were conducted separately during three, 30 minute sessions. Each pre-selected target word was exposed one time per session. Exposure control items were randomly presented with the selected treatment items, but did not receive treatment. Within both the SCT and PCT at the single-word level, the participant was given approximately 3-5 seconds to respond. If an incorrect response was given, response-dependent steps of the cueing hierarchy were administered until a correct response was given or a verbal model was provided. Post-observation probes were conducted on all treated and untreated items at two and six weeks following the completion of the SCT and PCT. It was determined during the study that the participant also would benefit from the SCT and PCT at the conversational level. After completing the word level phase, the conversational level phase was initiated. Using current events, pop culture news stories, and life experiences as conversation, SCT and PCT each were conducted at the conversation level during three, 30 minute sessions. Within both the SCT and PCT at the conversation level, the researcher determined the word the participant was attempting to produce and began cueing hierarchical steps. For both the single-word level and the conversation level, each session was audio recorded. The researcher also conversed with the participant regarding generalization of each treatment outside the therapy setting. Results: The highest level of the hierarchy that was required during each session of the SCT is shown in Figure 1. Figure 1. Results using SCT.  The baseline phase was the pre-stimulation phase and only required a single presentation of stimulus items in which the participant correctly named. Therefore, a level one cue is shown. During the SCT single-word treatment phase, during session one, only a level one cue was required. However, in sessions two and three, a level two was required. At the single-word two week probe, the participant reported he was “having a bad day.” He had difficulty naming the picture stimuli and required a level five cue. At the six week probe, the participant only required a level one cue. Because of the participant’s relative level of success the SCT was then implemented at the conversation level. In all three sessions, a level three cue was required. This increase in cues at the conversation level is probably due to the unstructured production of conversation being more difficult than single-word production in persons with aphasia. The highest level of the hierarchy required during each session of the PCT is shown in Figure 2. Figure 2. Results using PCT.  The baseline phase was the pre-stimulation phase and only required a single presentation of stimulus items named correctly by the participant. Therefore, a level one cue is shown. Through the PCT single-word treatment phase, during sessions one, two, and three, a level two cue was the highest level of cue required. At the single-word two and six week probes, the participant required only a level one cue. Due to the participant’s level of deficit, the PCT was then implemented at the conversation level. In session one, a level four cue was required. In sessions two and three, a level two cue was required. The number of error occurrences using SCT during each session is shown in Figure 3. Figure 3. Number of error occurrences using SCT.  The baseline phase was the pre-stimulation phase and only required a single presentation of stimulus items, which the participant correctly named. Therefore, there were no errors that occurred. During the SCT single-word treatment phase, all three sessions had one error each. The two week probe revealed one error while the six week probe had no errors. As expected, more errors occurred at the conversation level than at the single-word level. The number of error occurrences using PCT during each session is shown in Figure 4. Figure 4. Number of error occurrences using PCT.  The baseline phase was the pre-stimulation phase and only required a single presentation of stimulus items, which the participant correctly named. Therefore, there were no errors. During the PCT single-word treatment phase, all three sessions had one error each. The two week probe revealed one error while the six week probe had no errors. As expected, more errors occurred at the conversation level than at the single-word level. Discussion: Results indicate a trend toward more improvement with the PCT for this participant. This is based on the actual data points as well as observations made by the clinician during the treatment sessions. The participant appeared to respond more quickly and confidently at both the word and conversation level when given phonological cuing. This participant’s pattern of performance is similar to that of a comparable participant in the study conducted by Wambaugh and colleagues (2001). At the end of the treatment phase, the participant was more comfortable and was able to move on more quickly in conversation during the PCT treatment at the conversation level. The participant reported the PCT assisted him during word finding difficulties more than the SCT. Additionally, the participant’s wife reported that she was more likely to use phonological cuing rather than semantic cuing when attempting to assist her husband in word-finding. Future research should explore a larger sample size, participants with more severe impairment, and increased generalization opportunities. In keeping with Wambaugh and colleagues’ study (2001), the participant appeared to benefit from both treatments. Acknowledgements: The presentation of this research at the 2004 Arkansas Speech and Hearing and the 2004 ASHA Convention in Philadelphia was funded by at the University of Central Arkansas and the UCA Speech-Language Pathology Department. References: Dabul, B. (1979). Apraxia Battery for Adults. Tigard, OR: C.C. Publications. Drew, R.L., & Thompson, C.K. (1999). Model-based semantic treatment for naming deficits in aphasia. Journal of Speech, Language, and Hearing Research, 42, 972-989. Eales, C., & Pring, T. (1998). Using individual and group therapy to remediate word finding difficulties. Aphasiology, 12, 913-918. German, D. J. (1990). Test of Adult Word Finding. Austin, TX: PRO-ED. Kertesz, A. (1982). The Western Aphasia Battery. New York: Grune & Stratton. Kiran, S., & Thompson, C.K. (2003). The role of semantic complexity in treatment of naming deficits: Training semantic categories in fluent aphasia by controlling exemplar typicality. Journal of Speech, Language, and Hearing Research, 46, 773-786. Miceli, G., Amitrano, A., Capasso, R., & Caramazza, A. (1996). The treatment of anomia resulting from output lexical damage: Analyses of two cases. Brain and Language, 52, 150-174. Raymer, A. M., Thompson, C. K., Jacobs, B., & LeGrand, H. R. (1993). Phonological treatment of naming deficits in aphasia: Model-based generalization analysis. Aphasiology, 7, 27-53. Schuell, H. (1973). The Minnesota Test for Differential Diagnosis of Aphasia. Minneapolis, MN: University of Minnesota Press Snodgrass, J. G. & Vanderwart, M. (1980). A standardized set of 260 pictures: norms for name agreement, image agreement, familiarity, and visual complexity. Journal of Experimental Psychology: Human Learning and Memory, 6, 2, 174-215. Wambaugh, J.L., Linebaugh, C.W., Doyle, P.J., Martinez, A.L., Kalinyak-Flisar, M., & Spencer, K.A. (2001). Effects of two cueing treatments on lexical retrieval treatments in aphasic speakers with different levels of deficit. Aphasiology, 15, 933-950. Biography: Kim McCullough is an Assistant Professor at the University of Central Arkansas in the Speech Language Pathology Department. She has over ten years experience working with the adult population. Her research and teaching focus is in the areas of normal aging processes and neurogenic communication disorders. Holley Freyaldenhoven is a speech pathologist at Johnson Regional Medical Center in Clarksville, Arkansas. She is currently working with the adult population with a focus on neurogenic communication disorders. This research was completed during her graduate course of study at the University of Central Arkansas in the Speech Language Pathology Department. | |