cognitive linguistic therapy strategies in different aphasias ifnr 2015

Cognitive-Linguistic Therapy

Strategies Across Different Aphasia

Types

Ms Sonal V Chitnis

Asst Professor in Speech Language Pathology BVDU SASLP

Coordinator of Memory Clinic ,Bharati Hospital Research Centre &

BVDU School of Audiology &Speech Language Pathology

Bharati Vidyapeeth Deemed University, Pune 43

[email protected]

www.aphasiastrokeindia.com

08/03/2015 IFNR 2015,MET Mumbai India 1

Perspective on Aphasia from Interdependence of language &

Cognition

Assessment of Cognition in Aphasia : Literature

From a Speech language pathologist’s

perspective, I aspire to cover...

Aphasia Rehabilitation : Goals, aims& Approaches

Cognitive linguistic Therapy CLT strategies

Case studies (PWA)

CLT vs Communicative treatment & clinical efficacy08/03/2015 IFNR 2015,MET Mumbai India 2

Modern Definition of Aphasia

• Aphasia is a multi‐modality disturbance of speech, language, and memory caused by neurological injury, particularly stroke (Small, 2010)

• There other principal aetiologies of aphasia such as TBI, degenerative disorders, neoplastic disorders, neuroinfectious disorders, etc.

• Each gives a rise to a different clinical picture.


Language

LearningCognition LearningCognition

The term “cognitive linguistic disorder”

might have been used to acknowledge the inseparability of cognition and language.

( Luria 1966, Sarno 1998, Chapeay 2001, Helm-Estabrooks 2002, Shapiro,2011,

Code 2012)08/03/2015 IFNR 2015,MET Mumbai India 4

Aphasia: Going beyond Language

'Language' is impossible without these 'horizontal' cognitive

functions �� ( Code 2012) :-

large range of aphasic symptoms can be

(partially?) explained in terms of impairments of

STM/working memory, Praxis impairmentsSTM/working memory, executive deficits

(eg, inhibition, attention),

Praxis impairments

(eg, apraxia of speech, spatial praxis),

Perceptual impairments

Dependence of language Info processing on memory

(mainly STM/WM), &executive functions.


What to assess & address???

Primary elements of Cognitive processes- Attention, Memory, language, Executive Functions, Visuospatial Skills

( Helm-Estabrooks, 2001)

Linguistic & Extra Linguistic skills Linguistic & Extra Linguistic skills

VERBAL, SPATIAL & SOCIAL COGNITION

Metaphasia, Metacognition

*COGNITIVE LINGUISTIC ASSESSMENT


LIN

GU

IST

IC

• Language comprehension

• Expressive language skills

• Word retrieval E

XT

RA

LIN

GU

IST

IC • Literal Interpretations

• Social cognitive related-higher pragmatic tasks

• Visuospatial skills

• Gestures, body language and facial expressions

NO

N L

ING

US

TIC • orientation

to Time ,Place, and Direction

• Neglect• Word retrieval

• Reading and writing

• Calculation

EX

TR

A L

ING

UIS

TIC

facial expressions

• Prosodic domain

• Time pressure management , reaction time ,

• problem solving & Reasoning

NO

N L

ING

US

TIC

• Attention

• Memory WM/ STM & LTM


Cognitive neuropsychological

perspective from models of language

& Cognition

Many models provide an integrated account of

how cortical -subcortical structures might

influence language output through a influence language output through a

neuroregulatory mechanism that is consistent

with knowledge of cortical–subcortical

neurotransmitter systems and structural

features


Divergent Semantic model

• Aphasia as a convergent semantic disorder based on Guilford’s model 1966, Chapey 1977, Sarno1998.

Chapey 2001 discussed assessment & treatment • Chapey 2001 discussed assessment & treatment of Aphasia, that there are both semantic convergent & divergent impairment ( the basis of each individual's ability to recognize and reproduce previously learned material and to converge upon correct answer )


The Multicomponent WM Model,

Baddeley 2003,Miyake & Shah 1999 08/03/2015 IFNR 2015,MET Mumbai India 10

1] Global Aphasic Neuropsychologial battery

(GANBA) -- Van Mourik et al 1992

• Targeted non linguistic cognitive skills-

� attention,

� concentration,

� memory & intelligence ( Raven’s progressive � memory & intelligence ( Raven’s progressive Matrices) ,

� visual & nonverbal auditory recognition.

• Global aphasic with better scores responded better for Language Oriented Treatment.


2] Cognitive linguistic Quick test (CLQT)

-- Helm-Estabrooks, 2002

� Personal facts

� Symbol cancellation

� Confrontation naming

� Clock drawing

� Story retelling& paragraph comprehension

Linguistic

� Story retelling& paragraph comprehension

� Symbol trials

� General naming

� Design memory

� Mazes score

� Design generation

Non linguistic


3] Cognitive Linguistic Assessment protocol

-- Shyamala K.C. & Deepa, 2009.

• Domain i: Attention, Discrimination and Perception

• Domain ii: Memory

• Domain iii : Problem Solving• Domain iii : Problem Solving

• Domain iv: Organization

4] Manipal Manual of Cognitive Linguistic Abilities -- Mathew M , Bhat J 2014


Focusing on Cognitive Neuropsychological

correlates in assessment & Rx of Aphasia

�Right VS left Brain & Dominance , cerebral Organization

�Hemisphere specific Frontal, Temporal, Parietal , Occipital Lobar Functions Occipital Lobar Functions

�Motor Vs Sensory impairment

�Fluent vs. Nonfluent type of aphasia and other Neurogenic communication disorders

�Association pathways & Dissociated Cognitive Linguistic networks

�Multimodality based assessment08/03/2015 IFNR 2015,MET Mumbai India 14

REHABILITATION !!


Person with Aphasia:

From Inner Self to Outer Self

What was it like Inside?

The Material ME The Social ME The Spiritual ME

What was it like Inside?

• “When am I going to be me again? This is not

what I had in mind for ‘me.’ After some more

rehab will I be me again?”

mentioned by LaPointe in his preface in “Wings”,

Kopit A. ( 1978 ) & Viera E. (2005)


INTERESTING CASE

STUDIESSTUDIES


Case study 1

• 54 yrs, right handed, male came with c/o not able to speak, read & write properly post stroke since 4 months.

• Subinspector by profession,

• Premorbid multilingual proficient in Urdu, Telugu, English, • Premorbid multilingual proficient in Urdu, Telugu, English, Dakkhini

• MRI revealed Rt MCA infarct, massive frontoparietalnonhaemorrhagic infarcts.

• Significant Lt Neglect, severe paraphasia, paralexic & paragraphic errors noted.


• He could answer in one to two word phrases, occasionally 3- 4 word

sentences observed.

• He couldn’t follow simple commands or express however he could

read words with paralexic errors, he couldn’t write except his name .

• Relatively preserved serial speech for numbers, days of week,

months of the year in Urdu, English & Telugu all three languages

• Interesting findings: initial phoneme deletion on reading, relatively Interesting findings: initial phoneme deletion on reading, relatively

intact letter by letter spelled word recognition

• On Telugu Western Aphasia Battery : he could be categorized as

Transcortical Motor Aphasia

• Regressed Urdu & Telugu orthographical skills as compared to

English- L3

• On English WAB � Pt showed significant regression on all.


• Doctor : /octor/

• Nose : /ose/

• Table : /able/

• Economic Discrimination : /conomiciscrimination/iscrimination/

• Similar pattern on L1, L2 was observed too.

Provisional Diagnosis:

Crossed Aphasia in Dextral with Neglect dyslexia

with dysgraphia


Case 2• 74yr/M, workaholic Ex managing director of Sugar Factory becoming

increasingly forgetful, since 6 months

• Difficulty recalling details of recent events , impairment to read, write,

discuss recent important information such as meetings ,payments,

appointments, luncheon engagements, etc. Poor verbal and spatial praxis

observed, and ideomotor apraxia. Poor learning , deficit in delayed recall observed, and ideomotor apraxia. Poor learning , deficit in delayed recall

of the words on the Ray Auditory Verbal Learning Test

• Worried about his memory, Fluency- regressed Second language ( English)

, slow progression

• ADL well preserved.

• h/o bilingualism, premorbidly proficient in Marathi & English08/03/2015 IFNR 2015,MET Mumbai India 21

• MMSE � 26/30,

• ACE-R � 52/100,

• CDR= 0.7

• The remainder of his neurologic examination is normal excluding mild slowed gait

• No sig clinical history noted in Neuropsychiatric • No sig clinical history noted in Neuropsychiatric inventory ( NPI) except mild anxiety

• GP had treated him as early PD, no sig improvement on Syndopa plus since 3 months

• He is concerned but not depressed


Naming – 4/12Circumlocution,

semantic paraphasias observed


Dictation

Spont writing +

Copying words


Spont Writing sample

Visuospatial abilities


Reaction Time- 65 seconds, he could name

only yellow & Red, profound errors in stroop

taskShendkar K,& Chitnis S 2014


• MRI reveals �

Mild cerebral atrophy, medial

temporal atrophy noted, Lt parietal occipital

lobe> Rt Parieto occipital atrophy noted, lobe> Rt Parieto occipital atrophy noted,

lacunar ischemic infarcts noted bilateral

whitematter pathways


DIAGNOSIS ???????????????

PNFA with CBSPNFA with CBS( Progressive Nonfluent Aphasia with Cortico

basal Syndrome)


APHASIA REHABILITATIONAPHASIA REHABILITATIONAPHASIA REHABILITATIONAPHASIA REHABILITATION

Primary goal of rehabilitation is to reduce disability and help individuals attain a level of functional independence (Sarno, 2004, Becker, 1994)

The Key Elements of Aphasia Therapy – Faith and Rhythm.

Faith in memory - we converse from our own thoughts and memory Conscience mind ( Friston 2011)


Approaches in Aphasia rehabilitation

• General vs Specific treatment approaches

• Linguistic & Communicative aphasia therapy approaches

• Stimulus response approaches such as MIT• Stimulus response approaches such as MIT

• Functional/ Pragmatic approaches & AAC

• Cognitive approaches : CLT

• Pharmacological therapy

• Computer-based interventions as an adjunct to clinician guided treatment


Aims of aphasia therapy approaches

� Reactivation

� Relearning

� Brain reorganization� Brain reorganization

� Cognitive-relay

� Substitution

� Compensation


• The ultimate goal – to make PWA communicate

in everyday settings with unpredictable demands

& fluctuating conditions

Goal oriented behaviour & flexible problem solving

� hall mark of Executive Functions.� hall mark of Executive Functions.

Thus there comes need to consider INTEGRATION

of all domains of cognition for better Rx outcome

in Aphasia Rehabilitation (Helm Estabrookes,

2002)


Renowned Aphasiologist � Holland A. 1994, promptly

raised few of empirical questions.

1. Should the Rx of Aphasia be the language that is preserved?

2. Should the focus of Rx of Aphasia be the Missing Language ( Semantic& Phonological routes) ?

3. Should the focus of Rx of Aphasia be the tasks that are used in treatment?


4. should the focus of Rx of Aphasia be on the interaction of PWA and his/her environment?

5.should the broader deficits than language problems such as Attention deficits, working

5.should the broader deficits than language problems such as Attention deficits, working memory, perseveration, be the focus of treatment?

Or above all??


COGNITIVECOGNITIVECOGNITIVECOGNITIVE---- OR NEUROOR NEUROOR NEUROOR NEURO----LINGUISTIC LINGUISTIC LINGUISTIC LINGUISTIC

ORIENTED TREATMENTORIENTED TREATMENTORIENTED TREATMENTORIENTED TREATMENT

Concentrates on Cognitive processess & language-specific

impairment in an individual with aphasia .

The treatment involves specific tasks such as naming, semantic or The treatment involves specific tasks such as naming, semantic or

phonological training, sentence production, writing and reading

(Chappey, 1977).

Other approaches include multimodal treatment or computer-

based aphasia treatment.

These interventions are based on psycholinguistic or cognitive

neuropsychological models.08/03/2015 IFNR 2015,MET Mumbai India 35

Cognitive approaches to Aphasia

• Cognitive linguistic Therapy ( CLT) Chapey R 1977

• Brain Compatible Aphasia Treatment Program

(Connors 2010 ,Friston 2011,)

• Language Oriented Treatment : psycholinguistic • Language Oriented Treatment : psycholinguistic

approach ( Shewan & Bandur 1986)

• Thematic Language Stimulation ( Wepman 1972,

Based on Shwell 1964)

• Non linguistic training ( computerized aided task

oriented program) & Impairment based

Individualized treatment Computer aided iPad based

program in PWA) Kiran et al 201408/03/2015 IFNR 2015,MET Mumbai India 36

Foundation for CLT

Cognitive-linguistic therapies are recommended as a practice standard post stroke rehabilitation - American Congress of Rehabilitation Medicine ( Cicerone 2011)

They Aim to improve overall functional communication through stimulating cognitive processes, such as

� awareness/attention,

� immediate discovery,

� recognition, comprehension

� memory, Executive functions

� convergent thinking & divergent thinking,

� & evaluative thinking

LANGUAGE & COMMUNICATION


Cognitive Linguistic Therapy

Vs

Communicative Treatment

CLT

aims at restoring the

CT

aims at optimizing aims at restoring the

linguistic levels affected, semantics, phonology or syntax & enhancing overall cognitive abilities e.gCLT ,LOT, Divergent

model Rx,BCAT

aims at optimizing information transfer by training compensatory strategies and use of residual language skills Communication facilitation e.g ILAT, specific language Aphasia intervention


Determining factors for CLT strategies:

1 Fluency : Agramatism & paragrammatism

2. Auditory comprehension : good vs poor

3. Severity of aphasia : mild/ mod/ severe

4. Aphasia with good cognition vs aphasia with poor cognitionpoor cognition

5. Lesion : focal vs diffuse

Cortical vs Subcortical/Mixed

5. Etiological factors

6. Language modalities & Recovery pattern

7. Mono vs bi/ multilingualism aphasia


Aphasia with MCI

Anomia / Specific Anomia

Alexia with /without agraphia

Acalculia

Crossed aphasia Crossed aphasia

Post TBI

Tumor based Aphasia

Degeneration based aphasia APHENTIA or Language based Dementia


ACCESS

DECISION MAKING!!!

Aphasia with good

cognition Vs ACCESS VS

STORAGE

cognition Vs Aphasia with

poor cognition


• Semantic & Phonological treatment based on Semantic Divergent model - Cognitive Linguistic Therapy ( Chapey 1977)

• Language & Cognitive therapy tasks ( Kiran at al 2005, Ranvell et al 2007 )

• BCA T (Brain Compatible Aphasia Treatment Program)

(Connors 2010 ,Friston 2011,)


Cognitive tasks for CL therapy

strategies ( Kiran et al 2014)

Visuospatial Processing

Symbol

Memory

Visuospatialpicture/word

memory

Attention

Response

Problem solving

Analytical reasoning

Executive function

Symbol cancellatio

n

Telling time/analo

g clock

memory matching

Visuospatialauditory memory

Voicemail task

Response inhibition

Symbol cancellatio

n

reasoning

Arithmetic

Quantitative reasoning

Sequencing a set of

steps/instructions


Naming

Rhyme judgment

Syllable identificatio

n

Picture naming

Kiran et al.2014

Naming Therapy

Phoneme–sounId

Identification

Category matching

Feature

Matching, Sorting,

Recalling


Reading Therapy

Spoken word–to–written

word identification

Written word category

identification

Reading maps

Reading Therapy

Reading passages

Long passage

Reading comprehensi

on


Writing

Word copy completion,

Multisensory tasks

Word spelling completion

Letter-to-sound

matching

Writing Therapy Oral Word

spelling

Recognition & Discrimination

Picture spelling

completion

Picture spelling

Sound-to-letter

matching


Clinical Efficacy of CLT

Cognitive-linguistic therapies are recommended as a practice standard and found to be effective during the acute and postacute rehabilitation for language in post stroke aphasia.

( Warrell et al 2011, Helm Estabrookes,2002,Pulvermullar et al, 2002)2002)

However recent RCT on efficiency Early Cognitive linguistic treatment vs communicative treatment showed equal improvement in the subjects & no conclusive difference but results yiels important clinical findings aiding in Aphasia rehab.

(de Jong Haqelstein et al 2011, Nauwens et al 2013)


Raising concerns & clinical issues in

PWA � ?

• Poor referral & ? timely follow up‐ chronic aphasia with less role of spontaneous recovery , Reorganization & neural plasticity,

• Fluent/ non fluent / Mixed fluency

• Degree & severity & Levels of Aphasia Rx at different modalitiesdifferent modalities

• Higher incidence of CVA and recurrent CVA , various other Neurocognitive Disorders etc

• Aging+ Aphasia : Can we call them PURE APHASIA ?????

Mild –Mod Cognitive Impairment ( Amnestic /or Non amnestic) & Aphentias

• Poor working memory � poor relearning � poor outcome & relapse

• Bi/ & Cognition : executive function


FUTURE DIRECTION

• Development of cross culturally valid tools & Protocols for assessment and intervention of cognitive linguistic abilities in Aphasia & related neurogenic communication disorders .

• RCT -Objective aphasia intervention program e.g. non invasive repetitive transcranial magnetic stimulation ( rTMS ) with and without CLT & other subjective approaches.without CLT & other subjective approaches.

• Large sample longitudinal intervention studies on cognitive linguistic perspective correlating neurophysiological, behavioural and different etiological aspects in stroke aphasia, degenerative aphasia , trauma based language disorders, NCD etc.


NEED OF THE HOUR

• Cognizant Clinicians to provide holistic

Intervention which aims to restore life

participation in PWA participation in PWA

• e.g LPAA- Life Participation Approach in

Aphasia ( Chapey 2012)


Being Pragmatic!

Cognitive - Improves Cognitive -Communicative

Intervention

Improves quality of life in

PWA


References1. Schuell H. Aphasia Theory and Therapy: Selected Lectures and Papers of Hildred

Schuell. Baltimore, Md: University Park Press; 1974

2. Kiran, S, Roches C, Balachandran I, & Elsa Ascenso, M .Development of an Impairment-Based Individualized Treatment Workflow Using an iPad-Based Software Platform. Semin Speech Lang 2014;35:38–50

3. Chapey R .A Divergent Semantic Model Of Intervention in Aphasia

4. Chapey R, Duchan JF, Elman RJ, Garcia LJ, Kagan A, Lyon JG, et al. Life-participation Approach to Aphasia: A Statement of Values for the Future. In: Roberta C, editor. Language Intervention Strategies and Related Neurogenic Communication Disorders 5th ed. Baltimore: Lippincott Williams & Wilkins; 2008. p. 279–84. Williams & Wilkins; 2008. p. 279–84.

5. Holland A. Cognitive Neuropsychological Theory & Treatmet for Aphasia :Explaning Strength & Limitation. Clinical Aphasiology.1994 ,22:275-282

6. Renvall K, Laine M, Martin N. Treatment of anomia with contextual priming: exploration of a modified procedure with additional semantic and phonological tasks. Aphasiology2007;21(5):499–527

7. Helm-Estabrooks N. Cognitive Linguistic Quick Test. London, England: Harcourt Assessment; 2001

8. Pulvermüller F, Roth VM. Communicative aphasia treatment as a further development of PACE therapy. Aphasiology. 1991;5:39–50

9. Shewan CM, Kertesz A. Effects of speech and language treatment on recovery of aphasia. Brain Lang. 1984;23:272–299.

10. Holland AL, Fromm DS, DeRuyter F, Stein M. Treatment efficacy: aphasia. J Speech Hear Res. 1996;39:27–36

11. Vieira E. Nakano.,Published dissertation. Changes In The Sense And Perception Of Self In Individuals With Aphasia: An ethnographic study. 2005 University of South Florida


Cognitive Neuro-Rehabilitation : A team Rehabilitation : A team Approach


cognitive linguistic therapy strategies in different aphasias ifnr 2015

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