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Aphasia:FunctionalCommunication

TherapeuticTechniquesandLife-BasedGoalSetting

3:15

CourseObjectives:• Attendees willbeable todiscusstraditionaltherapeutic techniques forPWA.

• Attendees willbeable toadapt traditionaltherapeutic techniques forPWAtoeffectivelypromote lifeparticipation.

• Attendees willbeable towrite patient-centeredgoals forPWAtoeffectively include functionalcommunication modes intocarestructures.

WHATDOWEALREADYKNOWABOUTAPHASIATHERAPY?

Pseudo Pre-testJ

TRUEorFALSE:

Itisalways easy todiagnose anaphasiasyndrome inour

clients.

TRUEorFALSE:

Wearefortunate tobeabletochoose anicelypackaged

treatmentplan forspecificaphasiasyndromes.

TRUE orFALSE:

Social considerationsarenot necessary to

consider whenformulating a

treatment plan forpersons with aphasia

(PWA).

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TRUEorFALSE:

Treatment shouldalways focus ontheclientfirstand thecaregiversecond.

TRUEorFALSE:

Thereisnobetterfeelingthatseeing aclientsuccessfullycommunicateforthefirsttime!

Whatisfunctionalcommunication?

h ttp ://www.ab cya.com/wo rd_cloud s.h tm

THERAPY

Whatarewearecurrently doing andhowitiseffective.

WhattherapyisNOT.

• Clean andeasy…• Aonesizefitsallapproach…• Prescribed…• Onesided…

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WhattherapyIS.

• Patient-centered…• Dynamic…• Need-based…• Inclusive…

Tried andTrue…

Therearemanythingsthatwe

alreadydothatarequiteeffectivewhentreating

PWA.

Someofwhichare:

WordFindingTreatment

Syntax Treatment

ReadingTreatment

WritingTreatment

MelodicIntonationTherapy

CommonAdjunctiveTherapies…

Likewise, therearemanythingsthatwecurrentlydotosupplementthesetraditionaltherapymethodsfora

PWA.

Someoftheseare:

Computer-basedTreatment

MultimodalTreatment

PartnerTraining

ScriptTraining

Pragmatic Treatment

AndStill More…Sometherapeuticmethodsaremore

situationdependentand

mustalignwiththevaluesofaPWAandtheirsupport

system.

Thesemaybe:

ConstraintInducedLanguageTherapy

ReciprocalScaffolding

VerbalNetworkStrengtheningTreatment

GroupTherapy

AugmentativeandAlternativeCommunication

WHENDOWEUSEWHAT?So,thequestion is…

Non-fluent

Fluent

Complex

• Melodic IntonationTherapy• Syntax treatment• WordFinding Treatment• AAC• CILT

• Verbal NetworkStrengthening

• WordFinding Treatment• Cognitive Approaches

• Computer-based• Multi-modal Approaches• Reading andWritingConsiderations

GENE

RALIZ

ATION

STRA

TEGIES

•Scrip

tTraining

•CaregiverTraining

•Grou

pTherapy

ASHA, n.d.; Brookshire, 2015; Helm-Estabrooks , et al.,2014

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Making theEBP frameworkworkforaphasia care…• Usewhathasbeen found

towork…• Recognize thepowerin

our ownrichexperiences…

• Incorporate theclient’svaluesasanEQUAL partof ourtx planning…

Client/Patient/Caregiver PerspectivesASHA,2005

Discussion BreakJ

CURRENTMETHODSMEETALIFEPARTICIPATIONMODEL.

Whyreinvent thewheel? ShiftingthefocusfromwhatIcan’tdotowhatICAN

do!

• Strengths• Successes• Promotion ofHealth

WHO, 2001

WhatistheLifeParticipationApproachtoAphasia?(ASHA, 2000)• Developedin2000byASHAsLPAAprojectgroup

(Chapey,Duchan,Elman,Garcia,Kagan,Lyon,Simmons-Mackie)

• FocusesonTHECLIENT’Swantsandneeds• GoalsaretobemeaningfultothePWAandaidinlife/communityreintegrationtotheirhighestlevelofpotential

• Aimstoreducenegative lifeconsequencesthataphasiamaycause

LPAA Values: (ASHA, 2000)1) Enhance lifeparticipation2) AllPWAareentitledtoservice3) Documented life-enhancement

changes areincluded asmeasures of success

4) Personal andenvironmentalfactors aretx targets

5) ServicesareavailableasneededatALLstagesof aphasia

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LivingwithAphasia:FrameworkforOutcomeMeasurement(Kagan,et al., 2007)

LPAA Adult LearningTheory

Kimbarow,2007ASHA, 2000

AdultLearningTheory1) LifeExperience asaresource2) Responsibility =Greater Outcomes3) TheneedtoknowWHY?4) Internal motivation toward quality liferoles

Kimbarow,2007

UnderstandingtheseprinciplesallowsthePWAto…• Equalizethe socialrelations ofservicedelivery• Create authentic therapeutic experience• Create experiences that areengaging• Establish usercontrol• Become accountable toother partnersKimbarow,2007

Thisallmakessense…

Sonowwhat???

1:00

GOALS,GOALS,GOALS…Howour goalsdriveour care.

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www.careerro cketee r.com

Earlydecisionsinourpatient’scaredrivethedurationofourinteraction

withthem…

Patient-CenteredOutcomesConsider:• HowdoIcreate thegoalsformypatient?• Howdothe goalsIcreate affectthecareIprovide?

• Doesmypatient andhis/her familyknowthegoalsIhavedetermined?

MoreonthislaterJ

Whatdoyounoticeaboutthequestionsonthepreviousslide?

I

TheVALUESelementofEBP…

Client/Patient/Caregiver Perspectives

ASHA,2005

üDoweknowwhattherapeutictechniqueshaveresearchtobackuptheiruseforthisPWA?ü Dowehaveexperiencetoguideourclinicaldecisionmakingtowardappropriatetx measures?ü HAVEWEASKEDTHECLIENTWHATHIS/HERGOALSARE?

Recognizingourrole…

WhenLPAAandtheA-FROMmodelarethefoundationforourpracticeinaphasiacare,theclientwillalwaysbe

atthecenterofourdecisions…

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Patient-CenteredOutcomesNow, consider:• Howdid thepatient arriveatthis goal?• Howcanthecareprovided beshaped tomeettheneedsofaPWA?

• Doesthepatient andhis/her familyunderstand howthesegoalscanbeachieved?

MoreonthislaterJ

Patient-CenteredOutcomeswilldriveproductivecarethatourclientsaremoreinvested in,thereby

increasingmotivation…

Tippett(2012);Kennedy,etal.(2012)

Impairment BasedTherapy• WordFindingTreatment• SyntaxTreatment• MelodicIntonationTherapy• ConstraintInduced

LanguageTherapy• TreatmentofUnderlying

Forms• ReadingandWriting

Treatment

Non-ImpairmentBasedTherapy• Multi-modalTreatments• ScriptTraining• PartnerTraining• ReciprocalScaffolding• AAC• GroupTherapy

Brooksh ire,2 0 1 5 ;Helm-Estab rooks etal . , 2 0 1 4

WHEREISOURHAPPYPLACE???

Howmuchdowedoofwhat???

• Impairment BasedTreatment Strategies

• Non-ImpairmentBasedTreatmentStrategies

• Counseling andEducation

• ProfessionalCollaboration onthebehalf ofthe PWA

Beginningwiththeendinmind(sortof)…• Weareallaware thatthecombinationoftreatmentmodalitiesisanindividualizedpuzzle,notaneatequation…

• Patient-CenteredGoalcreationdoneincollaborationwiththePWAwillhelpustoseewhattheywantoutoftherapy…

• Theywewillbeable toclearlyseehowmuchofwhatisnecessary!

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FUNCTIONALOUTCOMES!

Thiswill giveusMeasurable andAttainable…

Well-writtenLTGs PoorlywrittenLTGs Whythere’saproblem…

ThePWAwill respondtospokenyes-noquestionsviaheadnodsand/orverbalyesandnowithatleast80%accuracyinstructuredconversationsontopicsofpersonal relevance.

ThePWAwill improveauditorycomprehension.

No specificbehavioristargeted;improvementcan’tbedirectlymeasured;nocriterionis set.

The PWAwill respondtoyes-noquestions relatedtobiographicalinfo(e.g.name,familynames,address,occupation)with60%accuracy.

ThePWAwill increaseauditorycomprehensionforsimpleyes-noquestions.

Nospecificbehavioristargeted;thereisnoincreaseindicated;nocriterion is set.

Adapted from Helm-Estabrooks et al.,2014Table 16.1

STGConsiderations…Inwhatwayswillthegoalsbeimplementedtoenhancelifeparticipation?Are life-enhancementchangesincludedasmeasuresofsuccess?Are theSTGs abletobequantifiedorqualifiedforappropriatedocumentationneeds?Are there personalandenvironmentalfactorsincluded as tx targets?

Isthe serviceplanappropriateforthePWAbasedonhis/herneedrelative tothestageofaphasiatheyareexperiencing?DothegoalslendthemselvestomotivationandresponsibilityforthePWA?

ASHA,2000;Kimbarow,2007;Brookshire,2015

THEFACEOFAPHASIATHERAPY

Thebigpicture ofwhatmaychange…

WhattherapyIS…(again)

• Patient-centered…• Dynamic…• Need-based…• Inclusive…

Usingwhatworksinthemosteffectiveway…Context…• Relevantmaterials• Client accountability fortransference/generalization

• Community reintegration goals

L.P.A.A.ASHA,2000

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Tryingsomethingnew(ormaybejustlookingatitmoreobjectively)…• Impairment Based Treatment techniques for PWAare

good!– MassedPractice/Neuroplasticity Raymeretal.,2008

• Non-Impairment Based Treatment techniques mayservetobridgethe gapbetweenstructured tx andgeneralization!Helm-Estrabrooks etal.,2014

• Therapeutic Conversation and DailyGoalCreation…Rosenbeck,2016

L.P.A.A.ASHA,2000

Family, family,family…Inclusion becoming broadscope!• ConversationalPartnerTraining…– Shouldbeadirectgoalofaphasiatherapy!

• ScriptTraining…– Expectcommunityrehearsalatamoreprescribedlevel!

• ReciprocalScaffolding…– Trainfamily/caregivershowtosettheirlovedoneupforsuccess!

L.P.A.A.ASHA,2000

Sometimesit’swhatwedon’t seethatmakesthebiggestdifference…

2:00

L.P.A.A

←TREATMENTMETHODS

←SOCIALANDCOMMUNITYREINTEGRATIONSTRATEGIES

DiscussionBreakandTimetoStretchJ

JOHNSTANDISH

CaseStudyTime:Alookatpatient-centeredcare,treatmentplanning,andintegrationofLPAAprinciples…

Mr.Standish– WVSHA2016

Mr.Standishisa62-year-oldmaleadmittedtothehospitalforwhichyouwork.HesufferedaCVAtotheleftinferiorlateralfrontallobe.Hewaspleasant,howeverfrustratedthroughoutyourassessment.YougaveMr.StandishtheShortformoftheBostonDiagnosticAphasiaExamination,aswellasconductedinformalmeasurestopredictstimulabilityanddetermineappropriatetreatmentmethods.

0:50

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ACHANGE INFOUNDATIONAL IDEALSPROVIDING BETTER FUNCTIONALOUTCOMES…

Fromtable, tohome,tocommunity,andbeyond!

WhattherapyIS…(again)

• Patient-centered…• Dynamic…• Need-based…• Inclusive…• Ongoing…

“…ITISNOTTHEPERSON WITHAPHASIA WHOHASREACHEDAPLATEAU; ITISTHECLINICIAN.”

NancyHelm-Estabrooks

TheMYTHoftheaphasiaplateau…• Whatdoesputtinga timeline on recovery do forourpatientswith Aphasia?

• Howwouldyou feel if youwere intheir shoes?• Whatwould youwant tohear ifyouora lovedonewere thePWA?

• Howcanwemediate thedesiresandneeds ofourpatientswith delivering honest informationregarding prognosisandexpectations?

Helm-Estabrooks et al.,2014

“COULDAGREATERMIRACLETAKEPLACETHANFORUSTOLOOKTHROUGHEACHOTHER’SEYESFORANINSTANT?”

HenryDavidThoreau

The complexity of whatwe do…Combiningscience,experience,andempathyWe mustbe highly aware of all three of these things at all times…

Psychosocial considerations…• Therehasbeenmovement inourfield asawhole tomovefrom abiomedical frameworktoaBIOPSYCHOSOCIALframeworkofcare.

Rosenbeck, 2016

WHY???

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VisionofthelifepathforPersonsWithAphasia…Hinckley, 2016;Shadden,2007

0:25

FinalQuestionandAnswerSessionJ

THANKYOUSOMUCHFORTHEOPPORTUNITYTOSHARETHISINFORMATIONWITHYOU!

Kelly Rutherford M.S.,CCC-SLPdavis139@marshall.edu

References:• AmericanSpeech-Language-HearingAssociation.(2000).LifeParticipationApproachtoAphasia:A

Statementof ValuesfortheFuture.TheASHALeader:15February2000,pp.4-6.• AmericanSpeech-Language-HearingAssociation.(2005).Evidence-basedpracticein

communicationdisorders[PositionStatement].Availablefromwww.asha.org/policy.• AmericanSpeech-Language-HearingAssociation.(n.d.) .AphasiaPracticePortal.Retrievedfrom

http://www.asha.org/PRPSpecif icTopic.aspx?folderid=8589934663&section=Treatment• Brookshire,R.H.(2015).Introductiontoneurogeniccommunicationdisorders(8thed).St.Louis,

MO:Mosby.• Helm-Estabrooks,N.,Albert,M.L.,Nicholas,M.(2014).Manualof aphasiaandaphasiatherapy(3rd

ed) .Austin,TX:Pro-ed.• Kagan,A.,Simmons-Mackie,N.,Rowland,A.,Huijbregts,M.,Shumway,E.,Mcewen,S.,Threats,T.,

Sharp,S.(2008,03) .Countingwhatcounts:Aframeworkforcapturingreal- lifeoutcomesofaphasiaintervention.Aphasiology,22(3),258-280.doi:10.1080/02687030701282595

• Kennedy,M.R.T.,Obrien,K.H.,Krause,M.O.2012,December.Bridgingperson-CenteredOutcomesandTherapeuticProcessesforCollegeStudentswithTraumaticBrainInjury.SIG2PerspectivesonNeurophysiologyandNeurogenicSpeechandLanguageDisorders.Vol22,143-151.AmericanSpeech-Language-HearingAssociation.

References:• Kimbarow,M.L.(2007).IntegratingLifeParticipationApproachestoAphasiaTreatmentWithAdult

LearningTheory.TopicsinLanguageDisorders,27(4) ,318-323.RetrievedJanuary14,2016,fromhttps://libids.marshall.edu/illiad.dll?Action=10&Form=75&Value=204012.

• Raymer,A.M.,Beeson,P.,Holland,A.,Kendall,D.,Maher,L.M.,Martin,N.,Murray,L.,Rose,M.,Thompson,C.K.,Turkstra,L.,Altmann,L.,Boyle,M.,Conway,T.,Hula,W.,Kearns,K.,Rapp,B.,Simmons-Mackie,N.,GonzalezRothi,L.J.(2008).TranslationalResearchinAphasia:FromNeurosciencetoNeurorehabilitation.JournalofSpeech,Language,andHearingResearch.Vol51,S259-S275.February2008.AmericanSpeech-Language-HearingAssociation.1092-4388/08/5101-S295.

• Rosenbeck,J.,Hinckley,J.,SantoPietro,M.J.(22March2016).Aphasia:WhatIKnowNowThatIWishIKnewThen–theArtof influence.AphasiaAccess:Webinarseries.

• Shadden,B.B.(2007).TheRoleof NarrativeintheLifeParticipationApprach toAphasia.TopicsinLanguageDisorders.Vol.27,4.p.324-338.

• Tippett,D.C.2012,January.CurrentConceptsinTreatmentPlanning:patientCenteredandEvidence-BasedPracticeinSpeech-LanguagePathology.SIG15perspectivesonGerontology.Vol17,27-33.AmericanSpeech-Language- HearingAssociation.

• WordCloud.(n.d.) .Createdathttp://www.abcya.com/word_clouds.htmon08Feb2016.• WorldHealthOrganization,InternationalClassificationof Functioning,DisabilityandHealth( ICF) .

(2001).Retrievedfromhttp://www.who.int/classif ications/icf/en/