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Practice Guidelines: PACE Therapy
Origin/Background
When treating a client with aphasia, the primary goal of therapy is to
improve the individual’s ability to communicate in everyday life. To reach this
goal, clinicians may choose an impairment-based approach, which targets
discrete communication skills that present as difficult to the client. In regards to
language expression, naming deficits greatly impact a client’s ability to convey his
or her message. To target these errors, clinicians choose intervention approaches
proven to increase the individual’s ability to perform the discrete skill as well as
improve his or her overall communication.
Most impairment-based approaches lack a component that results in
generalization to natural communication (Carragher, 2012). Since transferability
is of utmost importance when choosing therapy techniques, clinicians often
hesitate to use approaches that do not possess this characteristic. For example,
generalization continues to be an area of weakness for traditional language
therapies due to its lack of a social component (Thompson, 2012).
PACE therapy, also referred to as Promoting Aphasics’ Communicative
Effectiveness, is an impairment-based approach to aphasia intervention that
incorporates traditional naming tasks with a conversational component. Jeanne
Wilcox and Albyn Davis first introduced the approach to the field of speech
language pathology in 1978 at the annual ASHA convention. Because PACE
combined elements of communication differently than any approach published at
the time, many clinicians and researchers became quickly interested in its
methodology (Davis, 1980). Like many new advancements in the field, confusion
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and controversy surfaced regarding the new approach. Wilcox and Davis
published many articles explaining PACE’s principles, followed by recording a
videotape of the approach’s implementation with 40 clients diagnosed with
aphasia (Davis, 2005).
When developing the approach, Davis and Wilcox structured the
framework of PACE upon the idea that most clients with aphasia have an ability
to communicate. Natural conversation provides these individuals with
opportunities to overcome their communication deficits (Davis, 2005). With
these two assumptions in mind, Davis and Wilcox carefully created a therapy
approach that targeted the discrete skill of word retrieval within structured
client-clinician interactions, which ideally encompassed all aspects of natural
conversation.
Candidacy
When choosing an intervention approach, it is imperative that clinicians
consider whether the client falls within the population the technique best serves.
In regards to PACE therapy, multiple reviews reveal evidence of which
individuals are considered as best candidates for its implementation; however,
much of the information proves as controversial in regards to aphasia severity
level, therapy structure, and client diagnosis based on the multidimensional
approach to aphasia classification.
Davis (2005) reported that PACE therapy is a useful approach because it
can be easily adapted for clients with different severity levels of aphasia due to its
compensatory and multimodal nature. Not all approaches possess this feature
because its stimuli may only range within particular levels of simplicity or
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complexity. With PACE therapy, clinicians can choose stimuli to best meet the
client’s needs, adjust the complexity of the targets, and use different modeling
strategies in conversation (Davis, 1980).
Although Davis (2005) suggests the approach’s flexibility in his published
literature, he also provides information regarding specific populations that would
and would not benefit from the approach. PACE has been used as a standard
treatment method for Broca’s, Anomic, and other mild to moderate aphasias;
however, individuals with Wernicke’s, Mixed, Global, or any severe aphasias
would not benefit from the approach due to its reliance on fairly intact
comprehension skills (Davis, 1980).
Technique
To implement PACE therapy, the clinician must follow the four principles
of implementation: equal participation, new information, free choice of channels,
and natural feedback (Davis, 1980). Equal participation entails that the client and
clinician equally play conversation roles as the message sender and receiver
throughout therapy. This represents typical conversational discourse, where each
communicator takes turns sending, processing, and interpreting information. It
also gives individuals with aphasia opportunities to become active participants in
conversation by using their expressive language abilities, rather than passively
listening to their conversation partner.
The new information principle establishes that neither client nor clinician
is aware of the other’s message prior to each target’s successful explanation. This
prevents the clinician from anticipating the client’s message (Davis, 1980). The
message receiver must base his or her understanding of the target solely on the
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client’s ability to successfully communicate his or her ideas. The clinician cannot
use inferences to comprehend the explanation until the client uses an effective
method to convey the message in conversation.
Free choice of channels allows both conversational partners to choose any
modality to convey his or her message including speech, gestures, drawing, and
writing (Davis, 1980). This principle shifts the focus from verbal output to any
means of communication the individual selects. Clients are encouraged to use
multiple modalities to convey messages, including gestures and verbal
circumlocutions. The clinician’s role is to model effective communication through
various modalities and behaviors (Chin Li, 1988)
Natural feedback provides the client with aphasia the opportunity to
experience an authentic means of gathering information regarding his or her
conversation partner’s ability to comprehend the message (Davis, 2005). This
principle helps structure PACE therapy to emulate natural conversation. When
utilizing natural feedback, the clinician provides responses only found in
conversation, such as facial expressions, body language, and responses that
indicate the message was not effectively sent for clear comprehension (Davis,
2005). This presents the individual with an environment to make errors without
corrective feedback, which imitates typical comprehension cues found in
everyday conversation.
When combining these four principles, authentic PACE therapy occurs.
Each principle of PACE must be implemented to model its conversational
structure, which requires the client to serve both conversation roles as the
message sender and receiver. The intention behind this framework is that the
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clinician will have the opportunity to observe how the individual participates in
conversational discourse with other conversation partners (Davis, 1980).
The client and clinician both partake in conversation based on picture or
word stimuli. Each partner will alternate serving as the message receiver and
sender. Each turn, the conversation partner draws from a stack of stimuli
unknown to his or her partner. Then, the message sender uses the
communication modality of his or her choice to explain the stimuli to the
receiver. When the message is conveyed successfully, the receiver will correctly
identify the stimuli. The clinician records data regarding the frequency of
modalities used when conveying messages and the client’s competence as a
communicator (Davis, 1980).
Like any published treatment for aphasia, PACE contains both strengths
and limitations. Many strengths of the therapy technique lie within its
fundamental principles of implementation. For example, PACE’s multimodal
approach gives the client freedom to choose the communication strategy or
combination of strategies that help them communicate best. Incorporating
gestures with verbal output, for example, supports language recovery and
communication because the client is less restricted to relying solely on speech
(Rose, 2013).
Another strength of PACE therapy is its absence of deeming
communicative attempts as correct or incorrect as well as highlighting the roles
of each conversation partner. This provides individuals with aphasia a better idea
of progress and leads them to making executive decisions regarding their
methods of communication. Its design increases clients’ confidence and provides
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comfort in knowing that communication is both the responsibility of the listener
and the speaker (Davis, 2005). Because aphasia encompasses all aspects of an
individual’s life, the fact that PACE takes those psychological aspects into
consideration strongly supports its use.
In a single-subject case study published by Chin Li (1988), he discusses the
effectiveness and transferability of the PACE approach. He states that his patient
showed significant improvements when performing naming tasks after
participation in PACE therapy. The client also demonstrated increased mood and
responsiveness to communication. Chin Li also claimes that clients can apply
communication strategies used in therapy sessions when encountering naming
deficits in natural discourse.
In regards to elapsed time after stroke, Chin Li (1988) hypothesizes that
individuals who have surpassed the window of recovery post-diagnosis will
benefit from PACE therapy because the approach provides alternative strategies
to compensate for naming difficulties. Although all of these assertions derive
from one client’s rehabilitation experience in particular, it stands to reason that
similar results may occur in other clients who demonstrate similar aphasic
behaviors related to naming impairments.
Limitations of PACE therapy reflect the same principles noted as strengths
by some researchers and clinicians. For example, although the principle of new
information stands as one of PACE therapy’s strongest aspect, clinicians often
present difficulty with remaining unaware of the client’s targets (Davis, 1980).
This is due to the fact that the clinicians most likely created the stimuli used in
therapy and can remember what pictures or words represented on the cards.
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Once the client begins to describe the stimuli, the clinician can make quick
inferences instead of relying solely on the individual’s multimodal language.
Another potential limitation for using the PACE approach includes its
natural feedback principle. Because of the approach’s fixed framework, clinicians
cannot provide corrective feedback until the client confirms his or her message
has been successfully received; therefore, the clinician cannot direct the client
toward using a more effective modality for communication (Davis, 2005). This
presents as problematic because the client may need more explicit information
due to his or her lack of awareness that the modality chosen is not sufficiently
and effectively transmitting the message to the clinician.
Although the ultimate goal of aphasia treatment is to improve the person
with aphasia’s ability to communicate in everyday life, the interactions between
the client and clinician during PACE therapy do not reflect typical discourse
(Chin Li, 1988). The rigid, symmetrical structure used for conversation limits
targeting various aspects of communication, such as requesting, questioning, and
story telling. Additionally, the absence of conversation repair and use of a variety
of conversational partners classify PACE as an impairment-based approach
despite its theoretical social connotations (Davis, 2005).
In attempts to improve the conventional PACE methodology, clinicians
and researchers develop alternative versions of the approach. Davis (2005)
provides multiple published modifications to his original approach. For example,
clinicians often eliminate a principle of PACE to provide the client with
additional expressive communication opportunities during each session. Davis
also explains the Brussels modification, which places a barrier between the client
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and the clinician. Each conversation partner is given the same set of stimuli, and
the clinician can choose which target the client describes. Another modification
of PACE limits the client to only using speech as the modality for communication
to encourage the use of verbal circumlocutions as a compensatory strategy in
conversation.
In a study conducted by Newhoff (1981), the modifications suggested
incorporate a more meaningful component to imitate conversations the client
with aphasia will participate in everyday. Clinicians train an individual’s spouse
to use the principles of PACE in therapy sessions as well as at home to facilitate
additional conversation. Using caregivers as conversational partners in the
approach provides a meaningful context for the individual to practice multimodal
communication strategies. This change in the PACE approach potentially results
in higher success rates regarding generalization and transferability of word
retrieval improvements (Davis, 2005).
Despite the approach’s strengths and suggested modifications, further
research is needed to determine whether PACE is effective in treating wordfinding impairments. The clinical bottom line suggests that PACE is an
impairment-based treatment approach best used for clients who display mild-tomoderate content errors, specifically naming deficits. Its use of multimodal
communication allows the person with aphasia to use any form of
communication to convey a message to others. Although PACE is described as a
discrete therapy approach, the task and materials used suggest it is only a useful
method of applying other therapy techniques. Due to mixed reviews and success
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rates, PACE may be classified as an experimental approach to aphasia therapy
(Davis, 2005).
References
Carragher, M., Conroy, P., Sage, K., & Wilkinson, R. (2012). Can impairment-focused
therapy change the everyday conversations of people with aphasia? A review
of the literature and future directions. Aphasiology, 26(7), 895-916.
Chin Li, E., Kiteselman, K., Dusatko, D., & Spinelli, C. (1988). The efficacy of
PACE in the remediation of naming deficits. Journal of Communication
Disorders, 21(6), 491-503.
Davis, G.A. (1980). A critical look at PACE therapy. In R. Brookshire (Ed.)
Clinical Aphasiology Conference Proceedings. Minneapolis: BRK
Publishers.
Davis, G.A. (2005). PACE revisited. Aphasiology, 19(1), 21-38.
Newhoff, M., Bugbee, J., & Ferreira, A. (1981). A change of PACE: Spouses as
treatment targets. In R. Brookshire (Ed.), Clinical Aphasiology conference
proceedings (pp. 234-243). Minneapolis: BRK Publishers.
Rose, M.L. (2013). Releasing the constraints on aphasia therapy: The positive
impact of gesture and multimodality treatments. American Journal of
Speech-Language Pathology, 22, 227-239.
Thompson, C. K., Kearns, K. P., & Edmonds, L. A. (2006). An experimental
analysis of acquisition, generalisation, and maintenance of naming
behaviour in a patient with anomia. Aphasiology, 20(12), 1226-1244.