Topic: Treatment
 
  1. Treatment planning
    1. Goal selection
      1. Level of focus
        1. Impairment
        2. Disability
        3. Handicap
      2. Prioritizing
        1. Functional communication
        2. Work with patient/family
    2. Setting
      1. Patient's room
      2. Clinic or office
      3. Day or recreation room
      4. Patient's home
    3. Time
      1. Duration of session
      2. Frequency
      3. Predicted duration of therapy
    4. Participants
      1. Family
      2. Nursing
      3. Individual versus group
  2. Treatment
    1. Variability issues
      1. Rise time and fatigue
      2. Medical issues
      3. Performance variability
      4. Emotional lability
    2. Principles of a functional approach (Hartley, 1995)
      1. philosophy
        1. valuing social roles
        2. empowerment
        3. normalization
        4. interdependent model of service
        5. consumer-driven
        6. ecological validity
      2. intervention strategies
        1. top-down processes
        2. outcome-oriented
        3. holistic
        4. natural environments
      3. content
        1. normal adult social roles
        2. personally meaningful tasks and content
        3. functional life skills
  3. Treatment Models (Table 6.1, Chapey Text; Holland, 1998)
    1. Neurological Models
      1. Derived from historical models of neurologic deficit
        1. "loss" of centers or connections
        2. goal is to restore function or reroute information
      2. Examples
        1. intersystemic
          1. utilizing a different modality to produce a response
            1. pair weak and strong modalities to "deblock"
          2. "minor hemisphere"
            1. use non-dominant hemisphere to compensate for impaired dominant hemisphere
            2. examples
              1. music
              2. humor
              3. imagery
              4. construction
          3. MIT (below)
        2. intrasystemic
          1. utilizing additional cues to stimulate the same system to respond
    2. Linguistic Models
      1. emphasizes attention to linguistic organization and complexity
      2. systematically target specific phonological, semantic and syntactic forms
    3. Cognitive Models
      1. Derived from conceptualization of language as process-driven
        1. language comprehension and production requires intact basic cognitive abilities which support linguistic processing
        2. attention, memory, executive functions
    4. Functional Models
      1. Derived from recognition that 1:1 correspondence between impairment and disability is not always observed
      2. Targets very specific tasks that contribute to improvement in functional situations, not necessarily on standardized measures
      3. focuses on effective communication of message rather than specific forms
  4. Treatment Strategies
    1. Auditory comprehension
      1. Comprehension patterns
        1. "Slow rise time"
        2. "Noise build-up"
      2. Speaker compensations
        1. alerting signals
          1. name
          2. "look at me"
          3. "listen"
          4. "ready"
        2. modifying content
          1. familiar content
          2. concrete content
          3. consistent content
        3. modifying form
          1. short and simple phrases
          2. reduced rate
            1. prosodics
            2. pauses
          3. stress important words
          4. nonverbal communication
            1. gestures
            2. facial expression
          5. maximize redundancy
        4. repetition
        5. rephrasing
        6. watch for signs of comprehension/confusion
      3. Environmental changes
        1. reduce background noise
        2. increase familiarity of surroundings
        3. increase familiarity of stimuli
      4. Task modifications
        1. single word recognition
          1. auditory bombardment
          2. matching
            1. picture to object
            2. object to object
            3. picture to picture
          3. forced choice
            1. two choices
            2. more than two choices
        2. yes/no questions
          1. Content
            1. personal information
              1. Is your name Joe?
              2. Are you a man?
            2. familiar information (answer in view)
              1. Are you in a bed?
              2. Is this your husband?
            3. familiar information (answer not in view)
              1. Do you have a car?
              2. Do you live in Boone?
            4. standard information (general)
              1. Is a horse larger than a dog?
              2. Does Christmas come in August?
            5. standard information (specific)
              1. Can you cut grass with an ax?
              2. Was Nixon president before Ford?
          2. Form
            1. stimulus
              1. verbal only
              2. nonverbal cues
            2. response
              1. verbal
              2. nonverbal
                1. nod /shake
                2. squeeze hand
                3. eye blink
                4. eye gaze
        3. commands
          1. assisted movements
          2. gestural model
          3. simple commands
          4. 2-3 step commands with same verb
          5. 2-3 step commands with different verbs
        4. discourse
          1. provide context
            1. pictures
            2. props
          2. nonverbal cues
          3. oral versus written discourse
          4. concrete versus abstract content
          5. previews and summaries
    2. Formulation & Expression
      1. General principles
        1. total communication
        2. allow increased response times
      2. Word retrieval
        1. Tasks
          1. Automatic tasks
          2. Confrontation naming
            1. objects
            2. pictures
            3. gestural cues ("Guesstures")
          3. function
            1. "What do you clean your teeth with?"
          4. properties
            1. "Name something red"
          5. Sentence completion
          6. Categories
            1. Identifying category from exemplars
            2. identifying exemplars from category name
            3. identifying addition exemplars when given prototypical exemplars
        2. Cuing
          1. phonemic
            1. "It's a sh____"
          2. semantic
            1. "You wear it on your foot"
          3. Sentence completion
            1. "Put on your sock and ____"
        3. Principles
          1. concrete to abstract
          2. familiar (personal) to general
          3. low emotionality
          4. ALLOW INCREASED RESPONSE TIME
        4. Perseveration
          1. "break" pattern
            1. change topic
            2. change task
          2. PAT (below)
      3. Grammatical Complexity
        1. Clarification strategies
        2. Model appropriate grammatical forms
        3. Total communication
        4. Increasing grammatical complexity
          1. direct linguistic treatment
            1. plurals
            2. locatives
            3. wh questions
        5. HELPSS (below)
      4. Logorrhea/Empty speech
        1. issues
          1. auditory comprehension deficits often co-exist
          2. self-monitoring often poor
        2. strategies
          1. turn-taking signals
          2. contextual cues
            1. scenario boards
            2. pictures
          3. clarification strategies
            1. may need to interrupt
            2. utilize auditory comprehension strategies (see above)
          4. encourage self-monitoring
      5. Paraphasias
        1. use word-retrieval strategies to elicit correct word
        2. model intended word
        3. use clarification strategies to identify intended word
        4. develop paraphasia dictionary (beware of stereotypical utterances)
        5. VCIU (below)
    3. Pragmatics (Hartley, 1995)
      1. Modular approach (Ehrlich & Sipes, 1985)
        1. nonverbal
          1. paralinguistic features
          2. facial expression
          3. posture
          4. eye gaze
        2. communication in context
          1. topic initiation and and maintenence
          2. turn taking
          3. awareness of social context
        3. message repair
          1. identification of communication breakdown
          2. awareness of listener needs
          3. repair strategies
        4. cohesiveness
          1. sequencing of information
          2. use of spatial and temporal concepts
      2. Best addressed in group settings
  5. Specific Aphasia Treatment Programs (Helm-Estabrooks & Albert, 1991)
    1. Visual Action Therapy (VAT)
      1. Overview
        1. developed to promote functional communication in patients with severe aphasia
        2. utilizes gestures to represent objects
      2. General sequence
        1. matching pictures with objects
        2. matching action pictures with objects
        3. producing/recognizing pantomimes as representing objects
    2. Back to the Drawing Board
      1. Overview
        1. developed to promote functional communication in patients with severe aphasia
        2. utilizes drawings to represent feelings, needs, and events
      2. General sequence
        1. drawing cartoon sequences from memory
          1. assess presence of main theme
          2. inclusion of important details
        2. drawing cartoon sequences to relate events or concepts
    3. Voluntary control of involuntary utterances (VCIU)
      1. Overview
        1. designed to promote verbal output of severely nonfluent patients who produce a limited number of stereotypical utterances
        2. targets using stereotyped utterances in the appropriate contexts under volitional control
      2. General sequence
        1. stimuli selected from patient's spontaneous vocabulary
          1. spontaneous speech
          2. naming
          3. reading
        2. additional stimuli added as they emerge
        3. confrontation naming of spontaneously produced words
    4. Melodic Intonation Therapy (MIT)
      1. Overview
        1. designed to promote verbal output of severely nonfluent patients
        2. utilizes "sung" sequences to facilitate speech output
      2. Candidacy
        1. nonfluent
        2. intact RH function
        3. good auditory comprehension
      3. General sequence
        1. matching of tapped rhythm
        2. matching of hummed melody
        3. unison singing
        4. repetition of singing
        5. response to probe question
        6. transition to sprechsgesang
    5. Helm Elicited Program for Syntax Stimulation (HELPSS)
      1. Overview
        1. designed to promote grammaticality of spoken discourse in patients who are agrammatic or paragrammatic
        2. uses story completion to elicit sentence structures
      2. General sequence
        1. read introductory probe "Rob's grandchild is bored. Rob gets a book, and he reads his grandchild a story. What does he do?"
        2. evaluate response
        3. utilize general sequence to elicit a variety of syntactical forms
    6. Treatment of Aphasic Perseveration (TAP)
      1. Overview
        1. designed to reduce perseverative aphasic errors
        2. utilizes a variety of cues and strategies to reduce perseveration
      2. Strategies
        1. time interval (5-10 seconds between S/R)
        2. gestural cue
        3. tactile cue
        4. drawing
        5. descriptive sentence
        6. sentence completion
        7. graphic cue
        8. phonemic cue
        9. oral reading
        10. repetition
        11. unison speech or singing
      3. Response to perseverations
        1. call attention to perseveration
        2. write perseverative response so patient can see it
        3. rip up the paper with the word on it
    7. Promoting Aphasics' Communicative Effectiveness (PACE)
      1. Overview
        1. promotes functional communication by focusing on effectiveness, rather than form, of messages
        2. therapist and client participate equally as receivers and senders of messages
      2. General sequences
        1. therapist/client take turns sending messages
        2. each tries to communicate new information
        3. patient can choose any mode to communicate information
        4. typical activities
          1. barrier games
          2. story retelling
  6. Treating cognition
    1. Arousal / coma stimulation
      1. multisensory
        1. tactile (shapes, textures, cold)
        2. kinesthesia (ROM, head elevation)
        3. auditory (environmental sounds, voice, music)
        4. olfactory (extracts, spices, familiar)
        5. visual (favorite items, bright or moving objects)
        6. gustatory (extracts, favorites)
      2. familiar routines
        1. simulates normal routine
        2. sensory and motor experiences
      3. structured stimulation
        1. begins with primitive senses
          1. movement
          2. smell
          3. touch
        2. progresses from unisensory to multisensory
    2. Orientation
      1. Response stimulation
      2. Facilitation
        1. name tag
        2. clock
        3. calendar
        4. map
        5. discussions about family
        6. logbook (journal, memory book)
          1. record daily activities
          2. may also include orientation information
    3. Attention
      1. grading of stimuli complexity
      2. grading of response complexity
      3. aspects of attention
        1. focused
        2. sustained
        3. selective
        4. alternating/shifting
        5. divided
      4. Incorporate spatial attention for patients with neglect
    4. Visual and spatial perception
      1. Work closely with OT
      2. SLP focuses on impact of perceptual impairments on communication
      3. Sample activities
        1. simple discrimination or matching
        2. closure
        3. figure-ground differentiation
        4. visual integration
      4. Goal progression
        1. increasing speed
        2. increasing accuracy
        3. increasing complexity
    5. Memory
      1. Stimulation using memory activities
      2. Compensatory techniques
        1. memory notebooks
          1. acquisition
          2. application
          3. adaptation
        2. rehearsal
        3. mnemonics
        4. augmentative devices
    6. Problem-solving
      1. components (Ben-Yishay et al)
        1. formulation of the problem
        2. analysis of the conditions
        3. formulation of strategy or plan
        4. choosing tactics to employ
        5. comparison of the solution with the problem
      2. activities
        1. hypothetical scenarios
        2. puzzles or other nonverbal tasks
        3. real-life situations
    7. Executive functions
      1. initiation
        1. optimize natural environmental cues
        2. external cues or signal systems
      2. planning
        1. sequencing tasks
        2. incorporate self-evaluation and self-monitoring
  7. Caregiver training
    1. essential to facilitate a decrease in handicap
    2. issues to address
      1. facilitating auditory comprehension of patient
      2. facilitating expression
        1. cues
        2. clarification strategies
        3. modelling
      3. "REALITY"
      4. total communication
      5. Lyon Handout