Exploiting Neuroplasticity in Aphasia Treatment Recovery OSLHA October

Exploiting Neuroplasticity in Aphasia Treatment & Recovery OSLHA October 5, 2019 This is your printable handout. It will provide the basic information and a format for taking notes. All of these slides have a slight grey background. The full ppt to be used during the workshop contains photos, videos and much color. It is too large for printing. The full ppt will be available here - https: //www. aphasiatoolbox. com - after October 1, 2019

Exploiting Neuroplasticity in Aphasia Treatment & Recovery Oklahoma Speech Language Hearing Association October 5, 2019 2

OSLHA Annual Convention William Connors • Financial relations: • aphasiatoolbox® owner • Telepracticecommunity. com owner • Everything. SLP. com ; homeceuconnection. com vendor • Non-Financial Relationships: • The National Aphasia Association (representative; committee member) • The Brain Recovery Crew (BRC) • ASHA; state committees OH; PA 3

I know who you are…. • Hard working, • Dedicated, • Intellectually inquisitive SLPs, • in the trenches helping people to talk; type; converse; interact; recover. 4

Statement of the Problem: Upwards of 2 million people in the United States and Canada, (the Aphasia Institute, 2011) as well as millions more throughout the world, continue to suffer with hope-robbing, independence-depriving effects of aphasia-apraxia despite millions of dollars spent on research, treatment, and public awareness of the problem (Kelly, 2011, Stahl, 2011). The great majority of PWA and their caregivers find this state of affairs unacceptable (Worrall, 2011). They have a dissensus with our approach to research and clinical outcomes. The first step in solving a problem is realizing there is one. 5

What should SLPs do? How can we offer a truly patient-driven clinical management that in fact takes advantage of neural plasticity and most efficiently and effectively maximizes patient recovery of communication and cognitive skills in a program that is effective and affordable? How do we best turn people with aphasia into people recovering from aphasia? How do we do this in the world of organizational and 3 rd party barriers? How can we go beyond the significant limitations of traditional aphasia therapy? 6

What will we be discussing that is different, new, controversial?

• There is no such thing as acquired apraxia of speech, rather a motor planning and execution problem that affects, voice, breath flow, tongue, lips, etc. How do I turn a thought into an acoustic event? • There is no such thing as a circumscribed auditory comprehension problem in aphasia. It’s a catch-all term. • Reflection and release can facilitate significant change. Since it’s all about change, especially neurophysiological, that’s essential. • PRA need a program in which they are not bullied. They need mindful environments, not dissonance. Aphasia-stress free-not aphasia stress-full. 8

• Translating research-based EBP, that only generalizes to trained word lists, will not get people conversing again, at least not in my lifetime. Martin, et al. 2006 • Errorless learning may have a place, but it’s not in aphasia recovery. Our clients cannot make a mistake for differing recovery reasons. What they are thinking is what they will say. We need to help him/her fix how he/she thinks. Fix thoughts not speech. • Who’s doing the thinking and who’s doing the talking? It better be the client. 9

• It’s not about word recall. One cannot unblank, unblock, or get cued. Instead, we move thoughts and concepts. Aphasia recovery is all about movement, period. Bolte-Taylor, 2008 TED talks. • We can do harm. “I experienced stimulation coming in through my sensory systems as chaos, and it felt like pure pain. ” Bolte-Taylor, 2008; Small and Wineburgh, 2004 • Carry every activity into a conversational dyad, or better yet triad. • Aphasia recovery is not about speech or typing; it’s about neural pathways, activations, neural interactions, movement. 10

• How many repetitions do we need? It takes 0 repetitions. You just have to think through the next one. Propositional speech and language are always generative; created never imitated. • Don’t waste time on things that come back on their own. Complexity training on steroids. • We don’t fix aphasia by thinking about aphasia. We fix aphasia by thinking about and reconnecting normal and deliberate thought turned into movement. • Sometimes we need to Blink It and sometimes we need to Think It. Too much info can cause problems. We need to prime better. 11

• “After the age of 30, I think the most insane, hopeless things I tried to do were drilling auditory comprehension tasks in PWA and implementing conventional speech therapy with people with a recent aphasia. ” Bill Connors. • We must address seriously the cognitive issues but not with apps or worksheets but rather folded into our treatment, practice and everyday activities. “Our findings suggest that individuals’ cognitive ability, specifically verbal short-term verbal memory, affects anomia treatment success. ” JSLHR Digman. 12

3 KEY THINGS TO ASK YOURSELF ON EACH ACTIVITY TODAY: 1. How do I thread work on cognition into this? 2. How do I analyze the client’s response to shape treatment and client practice via formative assessment? 3. A rising tide lifts all boats. How do I facilitate reading comprehension and auditory processing into all that I do?

Visual Definition Of Aphasia “If you change the way you look at things, the things you look at change. ” STEP 1 VISUAL APC Session 2: The Visual Definition of Aphasia - Visual 14

“Tell me the name of this object” VISUAL ACUITY PROBLEM Misses info on one side or middle. Turns head; Moves page PWA: “I can’t see that. ” Visual neglect and/or inattention TX ACTIVITIES Keyboarding Figure Ground Mazes Visual Apps 15

PROBLEM Comprehension Processing (Auditory Comprehension) Clinician: “You write with it. ” PWA (jargon output): “Huh? ” “I don’t understand. ” “What did she say? ”. TX ACTIVITIES Say it Understand it “A rising tide lifts all boats” Address learned inattention Clarify/verify Cognitive/attention tasks 16

How to Treat & Manage Auditory Comprehension Problems in Aphasia Available at Everything. SLP. com 17

Aphasia: Factors That May Affect Auditory Comprehension Syntax complexity Speech sound decoding Verbal working memory Short term memory Depression Lack of faith in listening skills Learned helplessness Noisy background Length of sentence Sound processing Semantic processing Attention skills Bad habits Running start Hearing loss Speaker variables: mumbling; rapid rate; accent; eye contact; manner www. Everything. SLP. com 18

12 Smart Message Delivery Strategies to Facilitate Auditory Comprehension 1. Manage background noise- maximize auditory signal. 2. Use an alerting signals to get his/her attention. 3. Use face to face communication – always use eye contact. 4. Use a slow, yet natural, rate of speech – stretch vowels. 5. Place key words at beginning. 6. Pause before key word– use an inter-stimulus pause. 7. Control message complexity - KISS it. 8. Use a shorter sentence(s) to control message length. 9. Use direct wording – say what you mean clearly 10. Increase redundancy –straightforward language. 11. Use supplementary cueing –gestures; print; photos. 12. Train client to be assertive about fuzzy comprehension. www. Everything. SLP. com 19

12 Ways to treat Auditory Comprehension Problems (ACP) 1. 2. 3. Improve the clients ability to attend. Probably most important. Effectively treat expressive aphasia – Arising tide lifts all boats. Recognize that ACP in aphasia as a circumscribed deficit does not exist – identify and treat the actual culprit. 4. Eliminate apraxia or other contributing or masking factors. 5. Overcome the apraxia that affects the head nod – shake for yes-no. 6. Ensure that everyone involved exploits the 12 strategies. 7. Work diligently to remediate underlying, contributing cognitive problems. 8. Control message complexity - KISS it. 9. For the person with a fluent type aphasia, be sure to address effectively any syllable structure processing issues. 10. Clean up any residual motor issues such as apraxia or ataxic dysarthria. 11. Study the history of treatment programs – what really works? 12. Avoid falling into the trap that isolated drills facilitate recovery. www. Everything. SLP. com 20

PROBLEM Visual Recognition (Agnosia, Clinician: “I brush my teeth with it. ” PWA: “I have never seen one of those. ” QOL Asymbolia) TX ACTIVITIES Verify a selected symbol Visual Action Therapy (VAT) Promoting Aphasics’ Communication Effectiveness (PACE) 21

PROBLEM Semantics [meaning]Lexical Cognition Semantic knowledge Fuzzy semantic boundaries Semantic Boxing TX ACTIVITIES Semantic Feature Analysis (SFA) Verb Network Strengthening Treatment (VNEST) PWA: “I think it’s a thing. ” “It’s writing. . . no booking. ” “I can’t really think of that. ” “Sounds familiar, I’m sure I knew it once. ” 22

PROBLEM PWA: “That’s a door. ” “I know it’s for writing, with a pencil, it’s a pen, no paperpen…” Lexical [affect of field]Semantic TX ACTIVITIES Lighting Up the Lemma Lit up? >raise hand Tribond game Nerbing 23

PROBLEM Phonological Encoding Word Form PWA: Phonological encoding “pent”, “benner”, “peen” (neologistic-jargon “des”; tindent”) “I know the word. I can see it in my head but I can’t get it out. TX ACTIVITIES Lexical-Semantic meltdown Phonological Assembly 24

But butterfly = FA • But butterfly • But but Mutt mutterfly Butterfly no no Butterfly butterfly But but not butter no no butterfly • “What? ” • Moves lips while listening • • = common; syllable structure = syllables structure; phonological buffer = phonological encoding; = imitation; awareness = imitation; = calm repair. = attention; lack of faith imitation-bound; running start syndrome 25

But butterfly • Bit better butterfinger • But cutter mothfly encoding • Beet beetlyer • But bu. TTER butter. FLY • But but…ter bu. . tter…. floo • I can’t • “What? ‘Did you hear anything? “Yes butter. ” • But butare buttarefly • “This is stupid. ” = vowel; phono-semantic = lex-semantic; phonol = morphologic; vowel; = prosodic; = mental resources alloc; phonol = learned helplessness; aphasic; = attention = syllabic issues = He’s got a point there. 26

PROBLEM Motor Planning (Acquired Apraxia of Speech) Phonemic encoding: “(silence)” Struggle to phonate: “uh. . hhuu; “bodee boddee. ” TX ACTIVITIES The Viking Motor Reconnect Apraxia Program Limb therapy Chunk a syllabary 27

PROBLEM Physical Movements (Dysarthria) Physical execution: “shlen. ” “ whisper pen” Tightness TX ACTIVITIES Speech Therapy: breath flow; relax; natural; eye contact; release; ataxic dysarthria 28

PROBLEM Ataxic Dysarthria Physical Movements (Coordination) TX ACTIVITIES Oral Motor Coordination Program and Activities 29

PROBLEM Creating sentences: “coffee; aphasiaisms – “drinking coffee”; noun bound; one word answers; agrammatism; morphology Syntactic – Semantic TX ACTIVITIES Sentence Patterning; Conjugation; Pronouns; Canonicalize; Fill in grammatical slots 30

PROBLEM Cognitive Memory Working memory Attention Problem solving Cognitive flexibility Reasoning- Inferencing Perseveration ****** PWA: “Key…. to the… I forgot. ” Jerk head when addressed; look lost; act aphasic TX ACTIVITIES Verbal Working Memory Attention Training Attention tasks Metacognition 31

PROBLEM Prosody Intonation (Aprosodia) Mental Resource Allocation Stress for syllables and words Blending ; Rhythm; Melody Intonation for sentences Phrasing Monotone Lack of word stress TX ACTIVITIES Sentence Intonation Patterning Heteronyms Viking with an Attitude 32

PROBLEM Whole Person Recovery Fatigue Pain Medication Anxiety Depression: clinical situational TX ACTIVITIES Schedule Work through it Develop faith Whole Person Recovery Alternative treatments 33

PROBLEM Intent, pragmatics; Why are you talking? : “Imitating; lack of topic introduction. “ Intent TX ACTIVITIES What do you think of me? Say what you mean; Aphasia Quips Inferencing; Speaker Question Intent: 34

PROBLEM Allocation of mental resources: Mental Resource Allocation. Cognitive TX ACTIVITIES metacognition; metaphasia; A rising tide lifts all boats, Keep treatment simple but program robust; formative assessment 35

The notion that speech or language or word recall is located in one part of the brain is becoming increasingly difficult to support. Rather, expressive and receptive speech requires rhythmic and coordinated activations and interactions by numerous neural structures and processes for normal speech as well as for aphasia treatment and practice that truly exploits neuroplasticity. http: //neurosciencenews. com/brain-activityneurobiology-6224 Moore. 36

OK, let's get this straight once and for all. . . "There is no center ( speech or language) but a network of interconnected areas, each with a slightly different specialization, . . . ". Researchers from Northwestern University just published a paper in the journal Brain (Marek-Marsel Mesulam) wherein they demonstrate that Wernicke's area, thought to be the center of language comprehension, in fact is not. We have so very much to learn about how the brain processes and creates speech and language. The concept that there is a speech center leads to the idea that these are circumscribed aphasia disorders which leads to the idea that one method or exercise or approach or app can make a real difference. "Forget about it. " Richmond, Ben, https: //motherboard. vice. com/en_us/article/weve-beenwrong-about-where-the-brain-process-language-for-141 -years, 2015 37

• Treatment Domains: - Phonetic Encoding: motor knowledge; plan; execution - Phonologic encoding; syllabary; prosody; sounds; coartic - Semantic Cognition: word activation; meanings - Syntactic Processing: syntax; verbs; sentences - Conceptual: symbolic, idea; mental proposition - Discourse: narrative; conversation; pragmatics - Cognition: VWM; attention; episodic buffer; Pro. Solv - Orthographic: spelling: keyboarding; reading - Whole Person: safety, music, faith, family, exercise 38

What is Neuroplasticity? Old science: Rita Marie Ryan Smoke a cigarette lose 50 brain cells> drink a beer lose 100 brain cells 39

What is Neuroplasticity? Neural plasticity is the ability of the central nervous system (CNS) to change and adapt in response to environmental cues, experience, behavior, injury, or disease, (Ludlow, et al. 2008) http: //www. cnn. com/2016/08/16/health/language-in-the-humanbrain/index. html 40

Neuroplasticity and Aphasia Recovery • The human brain’s ability to continually grow, learn and recover is well documented (Gage, 2002; Hamilton, 2011; Scientific Magazine, 2007 • 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) 41

Why AAC devices fail to interest PWA/PRA • • • Asymbolia Abulia Aphasia Apraxia – motor planning Embarrassment Not natural Too slow and cumbersome Keyboard agnosia Cognitive issues Figure ground Fear of abandoning speech 42

Hopefully we are beyond the idea that drilling cognitive skills in contexts that are far removed from the actual speech-language skills to which they are expected to apply. Research is refuting the idea that we should spend much treatment or practice time in training programs. “… that assume transfer of general skills to language processing. ” Be prepared to justify the use of apps, worksheets and drills that isolate memory or attention skills. Peach and others, Seminars in Speech and Language; Feb, 2017. 43

Motor- How to Treat Acquired Apraxia That Affects Phonation - It’s all about moving air. Phonetic encoding 1. Viking 1. 2. 3. 4. Basic Perfect Viking 1 Durational Viking – stretching the vowels Pulsed Viking - presyllabic Viking with and Attitude – preprosodic – decoding prosody 1. 2. # of syllables add stress pattern 1. 2. 3. 4. 5. 6. 7. 8. 9. Jaw positions 3: up - middle - down long vowels 7 ( / i e ae ^ a O U / mix the order short vowels (shorten the long vowels) diphthongs – maintain voicing as jaw moves Vowels become pronouns / h / & /a/ / h / & long vowels - /hh > /a/ > /h/ > /OO/ > /h/ > /ae/ > /h/ / h / & short vowels - /h/ > /a/ > /h/ > /OO/ > /h/ > /ae/ > /h/ & /m/ - /h/ > /m > /h/ > /m/ > /h/ 5. The / h / Viking 6. The varied Viking: / m / ; /vowels/ 7. Vowels around the mouth – It’s all about moving the jaw

How To Treat Acquired Apraxia That Affects Articulation – It begins to be about moving the articulators 2. Begin to add a consonant 2. Vowels around the mouth > / VC / > a /C/ eat /EEt /; it / ; ate /At / 3. Vowels around the mouth > / CV / > a /C/ eat /EEt /; it / ; ate /At / 4. Accept features first 3. The elevator for vowels: 2. Long vowels - /EE/ > /a/ > /EE/ > /OO/ > /EE/ > /ae/ > /EE/ 3. Long & short vowels - /EE/ > /a/ > /EE/ > /i/ > /EE/ > /ae/ > /EE/ > /o/ > /EE/ > /OO/ > /EE/ 4. subjective pronouns leading to conjugation 5. Co-articulation-anticipatory – It’s all about loading up the syllabary 2. 3. 4. 5. syllabification; Schwa initiated increasing syllables Contractions Phoneticize 6. Scatpraxia : vowels > vary vowels > add consonants

3. How to Treat Acquired Apraxia That Affects Symbolic Gesture - It’s all about loading up the gesturbary moving the hand arm symbolically 3. Canonical Gestures 4. How To Treat Yes-No Acquired Apraxia: Yes/No apraxia for head nod/shake: 3. MMMHHHH > head shake < > nod ? Yes-No-Delicious 3. 4. 5. Basic answers Complex answers Morra (Rock-Paper-Scissors) 3. 4. Forced point to either < > or question Point to answer for question type : yes/no ; either-or; closed ended; 5. Number Concept Coaching 6. Recognize question intent 4. 5. 6. 7. Oral Motor Coordination Program How To Treat Stereotypes / Recurrent Utterances How To Treat Acquired Ataxic Dysarthria Traditional Approaches 3. 8 -Step Continuum - Melodic Intonation Therapy - Visual Action Therapy

Phonological: How to Treat Phonological Aphasia – Aphasia. Phonics Phonological encoding 1. Phonological Aphasia: Syllable Count and Syllable Structure. 2. Vowels around the mouth 3. Elevator 1. Vowels > Liquids > plosives > fricatives 4. Increasing syllables 1. 2. 3. 4. Basic (one-syllables; frequency effect; simple sound structure) More complex (mutli-syllabic; less frequent) Schwa initiated Vary 1 st word (one > one rainbow > 5. Phoneticize: sound-letter correspondence

Phonological: How to Treat Phonological Aphasia – Aphasia. Phonics 6. Compound words 6. 7. 8. 9. Basic 1 st or 2 nd word remains the same Cognitive assembly after individual meaning ( dog > house > doghouse) Tripounds > quadrapounds 7. Anagrams 6. Lexical decision 7. Semantic decisions 8. Lexical – Semantic Meltdowns 9. Phonological Assembly 10. Sound embedded verbs 11. Traditional Approaches: Phonomotor by Kendall

Semantic Cognition: How to Treat Word Activation & Spreading (Word Recall) 1. Pronouns 1. 2. 3. 4. 5. 6. Subjective Objective Possessive Question concepting Personalized Pronoun Coaching Concept Coaching Question - Interrogative 1. 2. 3. Drill Clarify a mumble Reading Headlines with Comprehension 7. Cataphors – Anaphors 8. Indefinites 2. Light Up the Lemma: build a sentence to work from client’s thoughts. 3. Semantic Feature Stimulation ( SFS) 1. Semantic Figure Ground 2. Attention to detail

Semantic Cognition: How to Treat Word Recall – Activation 4. Verbing – Argument fluency 5. Phrasal verbs 6. Nerbing 7. Mental state verbs 8. Flip the subject 9. Numeracy 4. Number concept coaching 5. Number conversions 10. Number Concept Coaching 11. Reflect feeling > reflect content = connotation vs. denotation

Semantic Cognition: How to Treat Word Recall – Activation 12. Word Forms 12. Homonyms – antonyms-synonyms 13. Heteronyms 14. Multiple meaning: Nouns-Verbs-Phrasal Verbs 13. Hinky Pinkys 14. Rhyme, Antonym, Synonym 15. Same-Different 12. 3 with no foil > 3 with one foil > 4 ? 13. 3 with two foils > 4 with 2 foils 14. Provide 3 words > create a sentence 15. Sematic scaling 16. Traditional Approaches 12. Semantic Feature Analysis

Syntactic Domain: How To Treat Agrammatism 1. Verbing 1. 2. 3. 4. Common 5 > 10 ; reverse ; add alternates ; Real-time concrete verbs Group Lighting up Broca’s area – BA more than just expressive 2. Conjugation 1. 2. 3. 4. 5. Build to Canonical Right branch to extend verbal working memory Left Branch time concept Complex & compound sentences: conjunctions Contractions

Syntactic Domain: How To Treat Agrammatism 3. Sentence Patterning 3. Subject Verb > Canonical 4. Vary pronoun 5. Take to a Conversational Dyad 4. 5. 6. 7. Use in all activities Slotting (Fitzgerald Key) Phrasal Verbs Tensing Recursion – 3. Create 1 complex or compound sentence for 2 or 3 shorter ones 4. Conjunctions

Syntactic Domain: How To Treat Agrammatism 8. Modals 8. Modal Conjugation “Conversational dyad 9. Modal Chiasmus: Reverse question asking: attention (#s; letters; S-V; +verbs) 10. Modal Increasing Syllables 9. Morphologic 8. 9. 10. 11. 12. Derivational switching Prefixes > suffixes > internal Irregular past tense verbs Inflectional word building: grammatical category does not change Derivational word building: change in word form 10. Prepositions 8. Phrasal verbs 11. 12. 13. 14. Active – Passive Sentence Meltdowns Irregular past tense verbs Contractions Traditional Approaches: Mapping; TUFTS

Conceptual Domain: Where it all begins. 1. Thoughts 2. Ideas 3. Concepts 4. Intent 5. Semantic activation 6. If you don’t start from here it is not real. Least contrived 7. Light p the Lemma Sentence

Discourse: How To Facilitate Conversation and Narrative 1. Reflection 2. Reflect-Release-Create 3. Take Everything to a Conversational dyads 4. Question asking 5. Clarify > Verify 6. Word. Smithing 7. Pacematics: 8. Exploiting Spontaneous Utterances in Aphasia

Discourse: How To Facilitate Conversation and Narrative 1. Groups 1. Build a story 2. 3. 4. 5. 6. 7. Intent Speech Acts – Say what you mean Garbage can inferencing Aphasia. Quips Create a Headline Toastmasters Traditional Approaches 1. PACE

Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language 1. Blend these into all that you do with deliberation: metacognition (metaphasia; metapraxia) 2. How To Treat Perseveration 3. Mental Resource Allocation 4. Problem Solving 5. Cognitive Flexibility 6. Divergent thought

Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language 7. Executive functions 8. Verbal Working Memory and Attention Training 9. Aphasia. Do. Ku 10. Rhyme, Antonym, Synonym with an Attitude 11. Verbing with an Attitude 12. Forced choice: 2 ; 3

Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language 13. Manipulating numbers 14. Strooping 15. Garbage Can inferencing 16. Attention tasks: 17. Constant Therapy 18. Proactive memory: Word of the Day 19. Traditional Approaches 1. Constant Therapy

Orthographic 1. Keyboarding 2. Flash Spelling 1. 2. 3. 4. 5. Elision: vowels; abbreviations; acronyms #of letters # of words Types of words Phrases and sentences 3. Thread throughout daily work 4. Paragraphs 5. Group work

Whole Person Recovery Plan 1. Whole Person Recovery Plan 2. Nutrition 3. Rest 4. Exercise: transition from patient (Ptherapy) to person (Ptraining) 5. Music 6. Spirituality 7. Drugs 8. Alternative treatments: hyperbaric; Embrel; injections; acupuncture; transcranial direct current stimulation; stem cells; 9. Relationships

Related 1. PPA 2. Right Hemisphere Stoke 3. Apps 4. Assessment 5. Formative Assessment

How do we exploit this type of program…. …. in the real world of: • limited visits? • 3 rd party payments? • organizational barriers and obstacles? • ? ? ?

We…. • refer to experts. • commit to change and effectiveness. • organize efforts. • collaborate – telepractice. • ? ?