Prognostic indicators
•Age of patient
•Premorbid language skills and literacy
•Education and occupation
•Extent and location of lesion(s)
•Presence of past neurological disorders
•Presence of past medical or behavioral disorders
•Current medical, neurological, behavioral disorders
•Current hearing ability
•Current visual status
•Current motor performance
•Current language performance
•Severity of aphasia
Prognostic indicators, continued
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Time of treatment initiation
Treatment technique
Accuracy of treatment application
Length of treatment
Intensity of treatment
Family involvement
Improvement/deterioration in general health during
course of treatment
• Improvement/deterioration in language performance
during course of treatment or trial period;
• Spontaneous recovery;
• Patient motivation, enthusiasm, attitude toward learning.
Limitations of research data
• Lack of control of variables that affect
treatment outcomes
• Questionable internal validity
• Poor description of patients
• Poor description of treatment procedures
and protocols
Negative indicators
(Brookshire, 1992)
Patients who have neurologically recovered
but still exhibit the following characteristics
may not benefit from treatment:
• Severe auditory comprehension problems
coupled with verbal stereotypes;
• Failure to match identical stimuli;
• Indiscriminate “Yes-No” responses;
• Jargon and empty speech without selfcorrection.
General principles of treatment
• Select client-specific target behaviors that provide the
greatest improvement in functional communication;
• Start treatment at a simpler level and move to
progressively more complex tasks;
• Target behaviors that signal the system is just beginning
to breakdown;
• Provide maximum amount of stimulus control in the
beginning, including modeling, pictures, objects and
events that help establish the behaviors;
• Reduce the clinically manipulated stimulus control in
gradual steps so that the target behaviors are produced
in response to more natural stimulus events;
General principles (continued)
• Provide immediate, response-contingent feedback to
increase desirable behaviors and decrease undesirable
behaviors (therefore you must keep score!!);
• Train self-monitoring skills
• Train significant others to evoke, prompt, support,
reinforce and maintain appropriate communicative
behaviors in the client;
• Elicit a large number of responses per session;
• Begin sessions with familiar items/tasks;
• Introduce new materials and procedures as extensions
of familiar materials and procedures.
General principles, continued
• Work in a quiet environment;
• Use multi-modality stimulation, but do not
overload the system;
• Give the patient plenty of time;
• Avoid precipitous repetitions;
• Use extralinguistic cues;
• Work in realistic contexts;
• Use alerting stimuli;
• Be positive, encouraging, success-oriented;
Philosophical statements:
“Most clinicians and investigators agree that aphasia is not
a loss of vocabulary or linguistic rules – instead it is the
result of impairments in processes necessary for
comprehending, formulating and producing spoken and
written language.”
“Clinicians who believe that aphasia represents a reduction
in the speed and efficacy of processes underlying
language, rather than loss of language, focus treatment
on reactivating or restimulating language processes,
rather than on teaching specific responses.”
“…there is no strong empirical evidence that functional
approaches to treatment are more successful than
traditional approaches in improving daily life
communication…the skills (or processes) targeted for
treatment (must be) relevant to daily life communication.”
Cognitive stimulation
(Martin, 1979)
Aphasia is a “reduction of the efficiency of action
and interaction of the cognitive processes which
support language behavior…(Therapy is) the
attempt to manipulate and to excite the action
and interaction of the cognitive processes which
support language behavior within and by the
organism so as to maximize their effective
usage…therapy is directed toward the
subsystems which process language (e.g.,
cognition, memory, convergent thinking,
divergent thinking and evaluation).”
Cognitive stimulation:
general therapy objectives
• To stimulate ability to recognize and comprehend
language;
• To stimulate ability to fix new information in memory in
order to improve communication;
• To stimulation ability to generate logical information or
conclusions during communication;
• To stimulate ability to generate logical alternatives to
given information, to produce a quantity and variety of
responses during communication, and to be able to
elaborate on ideas and plans during communication;
Cognitive stimulation:
general objectives (continued)
• To stimulate ability to make judgments or appraisals or to
formulate evaluations in terms of criteria such as
correctness, completeness, identity, relevance,
adequacy, utility, safety, consistency, feasibility, social
custom, and so forth in order to communicate more
effectively and efficiently;
• To stimulate the integration of all cognitive operations
through the use of problem-solving, decision-making,
and planning tasks and through conversational discourse
in order to communicate more effectively and efficiently.
Cognitive stimulation: treatment principles:
Begin with………and move toward………:
Tangible ………representational
Concrete……… abstract
Simple………complex
Real………complex
Actions………verbalizations
Simple classifications……….multiple classifications
Exaggerated sensory stimulation………decreased
exaggeration
Short stimuli/responses………longer stimuli/responses
Continuous reinforcement………intermittent reinforcement
Clinician reinforcement………self-reinforcement.
Treatment variables…
…that may affect single word
comprehension:
Frequency of occurrence;
Semantic or acoustic similarity
between target words and foils;
Part of speech;
Referent ambiguity
Fidelity
…that may affect sentence
comprehension:
Length and syntactic complexity;
Reversibility and plausibility;
Predictability
Personal reference;
Semantic similarity;
Reasoning and inferences;
Rate;
Redundancy;
Number, similarity and nature of
response choices.
Treatment variables…
…that may affect compre-
hension of spoken
discourse:
Same as above + world
knowledge;
Salience;
Directness;
Redundancy;
Cohesion and coherence;
Speech rate and emphatic
stress.
…that may affect naming
accuracy:
Frequency of occurrence;
Length;
Abstractness;
Phonological complexity;
Semantic category;
Form of visual stimuli;
Context.
Visual stimuli variables
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Real objects or 3-dimensional drawings;
Color;
Redundancy;
Operativity and imageability;
Physical properties;
Lack of ambiguity in perceptual
characteristics and context (e.g., flower in
vase versus flower in computer).