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Treatment of Word retrieval impairments:
Do we know which tasks work
for whom and why?
Continued!
Associate Professor Lyndsey Nickels
National Health and Medical Research Council
Senior Research Fellow,
Macquarie Centre for Cognitive Science (MACCS),
Macquarie University, Sydney, Australia
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How do we decide which treatment?
Each different level of breakdown in word production will be best remediated by a different type of treatment
(e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991)
• impaired word meaning (semantics)
→ treatment focusing on meaning
• impaired retrieval of the phonological form from semantics
→ treatment focusing on providing/accessing the phonological form
• impaired phoneme level/phonological encoding→ treatment focusing on phonemes
Remember…. Therapy for word
retrieval DOES NOT have to include word retrieval
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How do we decide which treatment?
Each different level of breakdown in word production will be best remediated by a different type of treatment
(e.g. Hillis & Caramazza, 1994; Nettleton & Lesser, 1991)
• impaired word meaning (semantics)
→ treatment focusing on meaning
• impaired retrieval of the phonological form from semantics
→ treatment focusing on providing/accessing the phonological form
• impaired phoneme level/phonological encoding→ treatment focusing on phonemes
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What treatment is appropriate?
Semantic impairments
The most successful therapy seems to involve exploring the semantic attributes of a stimulus.
e.g. Boyle & Coelho, 1995.
Coelho, McHugh & Boyle, 2000.
Hillis, 1991, 1998.
Nickels & Best, 1996.
Phonological Output Buffer
Speech
Phonological Output Lexicon
Lexical Semantics
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Therapy for semantic impairments
e.g. Semantic feature analysis (SFA) (Boyle & Coelho, 1995; Coelho, McHugh & Boyle, 2000)
• name a picture• generate features relating to …..
Exploring semantic attributes of a stimulus
GROUP: is an ANIMAL
USE: is used for protection
ACTION: does what? Barks
LOCATION: is found at home
ASSOCIATION: reminds me of a kennel
Can we be sure this is effective?
Not entirely … they use very small numbers of items in
the sets, and examine changes in performance
using visual inspection with no statistics
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Therapy for semantic impairments (cont)
e.g. Nickels & Best (1996) AER
“Relatedness judgements” (with feedback)
Statistically significantly improved naming of treated and untreated stimuli
Nickels & Best argue that feedback is
critical to obtaining generalisation to untreated items
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Therapy for semantic impairments (cont)
e.g. Hillis (1991, 1998) HG.
Red vs yellowRound vs oval
Thin skin vs thick skinSweet vs sour
Lemon
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Therapy for semantic impairments (cont)
e.g. Hillis (1991, 1998) HG. • name a picture, • if and semantic error was produced, • → drawing of error • compare drawing to the target picture • discuss semantic distinctions
• Significant improvement in written naming (treated)• also in spoken naming and word comprehension • Improvement of treated items and untreated items in the
same semantic category(but this may just be that untreated items appeared in therapy)
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How does the treatment for
semantic impairment work?
Doesn’t it improve the
semantic impairment?
If so what would the effects be?
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Phonological Output Lexicon
Speech output
Phonological Output Buffer
Lexical Semantics
Writing
Heard SpeechPrint
Idea, Picture, or seen object
Lexical Semantics
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Phonological Output Lexicon
Speech output
Phonological Output Buffer
Lexical Semantics
Writing
Heard SpeechPrint
Idea, Picture, or seen object
Lexical Semantics
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Phonological Output Lexicon
Speech output
Phonological Output Buffer
Lexical Semantics
Writing
Heard SpeechPrint
Idea, Picture, or seen object
Lexical Semantics
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Phonological Output Lexicon
Speech output
Phonological Output Buffer
Lexical Semantics
Writing
Heard SpeechPrint
Idea, Picture, or seen object
Lexical Semantics
Semantic therapy for semantic
impairments should improve
all modalities
But although this was true for
Hillis’ study with HG, it was not
for AER.Improvement in all
modalities only occurs if treatment improves semantic
processing
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How did the authors think these treatments for semantic impairments were having their effects?
Hillis (1998) “improvement at the semantic level itself – perhaps through increased specificity of semantic representations of trained items”
Coelho et al (2000) - a strategy for word retrieval“by activating the semantic network surrounding the target word, that word may be activated above its threshold, thereby facilitating retrieval”
Nickels and Best (1996)
“the use of a strategy (which may be unconscious) of exploring the semantics of an item … which facilitates retrieval of that item (perhaps by increasing the semantic information addressing the output lexicon…)”
Consistent with improvement
across modalities
Consistent with improvement
restricted to speech production
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• Semantic tasks– Those tasks which involve focusing on word meanings
• Semantic tasks may be used to treat semantic impairments– Those tasks which seem to most often improve semantic
impairments involve reflecting on semantic features
– However even then they may NOT improve semantics itself but may instead provide a strategy for improving word retrieval.
Didn’t we contrast semantic impairments
and post-semantic word retrieval impairments?
Semantic tasks and semantic impairmentsHold on! How can
therapy for semantic impairments improve word retrieval without improving semantics
Yes, but semantic impairments cause word
retrieval impairments …
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Semantics
Object, picture or idea
purrs
cat dog rabbit fish
barksfur pet4-legs scales
houserobin
Phonological Lexicon
PhonologicalBuffer/
Phonemesæ td o gk
Post semantic word retrieval impairment
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Semantic impairment
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Sem impairment
Semantics
Object, picture or idea
purrs
cat dog rabbit fish
barksfur pet4-legs scales
houserobin
Phonological Lexicon
PhonologicalBuffer/
Phonemesæ td o gk
Semantic impairment
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Semantics
Object, picture or idea
purrs
cat dog rabbit fish
barksfur pet4-legs scales
houserobin
Phonological Lexicon
PhonologicalBuffer/
Phonemesæ td o gk
Semantic impairment also leads to a
reduction in activation at the word form level
Semantic impairment
Although, as we will see, this is usually
only the case in people with less severe semantic
impairments.So tasks can be
effective in improving word
retrieval WITHOUT improving the
semantic impairment
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SUMMARY: What treatment is appropriate?
Semantic impairments
The most successful therapy seems to involve exploring the semantic attributes of a stimulus.
e.g. Boyle & Coelho, 1995.
Coelho, McHugh & Boyle, 2000.
Hillis, 1991, 1998.
Nickels & Best, 1996.
Phonological Output Buffer
Speech
Phonological Output Lexicon
Lexical Semantics
Any questions?
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Therapy for semantic impairments or semantic tasks as therapy?
• Virtually all tasks involve semantic processing• Some focus on semantic processing to a greater extent
(we tend to refer to these as semantic tasks)
e.g.odd one out
(spoken or written) word to picture matching
These tasks are widely used in the remediation of word-retrieval impairments, however, their use is not restricted to those individuals with semantic impairments.
word-picture verification
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Semantic tasks for improving word retrieval
The use of semantic tasks is not restricted to individuals with semantic impairments…...
semantic tasks can improve word production even for those individuals with good semantic processing and even when the tasks are performed accurately
(e.g. Nickels & Best, 1996).
…. In fact they are probably more likely to improve word production for those with relatively less semantic impairment – those with ‘post-semantic lexical retrieval impairments’.
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What treatment is appropriate?
Word retrieval impairments
Tasks focusing on semantics and phonology
- improve word retrieval
e.g. Howard et al 1985
Nickels & Best 1996 Phonological Output Buffer
Speech
Phonological Output Lexicon
Lexical Semantics
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What treatment is appropriate?
Word retrieval impairments
Tasks involve activation of both semantics and phonology
But may focus more on semantics….
Phonological Output Buffer
Speech
Phonological Output Lexicon
Lexical Semantics
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What treatment is appropriate?
Word retrieval impairments
All the tasks involve activation of both semantics and phonology
But may focus more on semantics
or phonology
Phonological Output Buffer
Speech
Phonological Output Lexicon
Lexical Semantics
Repeat “kangaroo”
It starts with /k/
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What treatment is appropriate?
Word retrieval impairments
All the tasks involve activation of both semantics and phonology
They produce long lasting, item specific effects in the majority of individuals with impaired activation of the correct target in the phonological lexicon
Improves likelihood of the target being sufficiently activated to be retrieved successfully.
Phonological Output Buffer
Speech
Phonological Output Lexicon
Lexical Semantics
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Let’s explore these tasks that improve word retrieval in
more detail
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“Semantic” tasks as therapy
Word-picture matching
Word-picture verification
Widely effective (Howard et al, 1985; Marshall et al, 1989)
Long lasting effects (Pring et al., 1990)
Generally, lasting effects are item specific
These tasks typically don’t require word
production but improve naming at a later point
nevertheless
The tasks work best with people that can do them easily (people with
less of a semantic problem)
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Howard et al (2006)
Compared the efficacy of word-picture matching with related and unrelated distractors
(related distractors = deeper processing = more effective?)
How important is the emphasis on
semantic processing?
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Howard et al (2006)
Compared the efficacy of word-picture matching with related and unrelated distractors
All incorrect before word-picture matching
After word-picture matching
Related distractors: 45% correct
Unrelated distractors: 50% correct
Controls: 30% correct
How important is the emphasis on
semantic processing?
No evidence that deeper semantic processing
improves efficacy of word-picture matching
Not even for those with more severe
semantic impairments?
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Howard et al (2006)
Compared the efficacy of word-picture matching with related and unrelated distractors
All incorrect before word-picture matching
After word-picture matching
Less sem imp. More sem imp.
Related distractors: 50% 40%
Unrelated distractors: 60% 40%
Controls: 40% 23%
How important is the emphasis on
semantic processing?
No evidence that deeper semantic processing improves efficacy of
therapy: not even for those with more severe semantic impairments
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Martin, Laine et al (2000, 2003, 2004, 2005) ‘Contextual Priming’
Compared the efficacy of naming/repetition in the context of semantically related distractors and unrelated distractors.
How important is the emphasis on
semantic processing?
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Martin, Laine et al (2000, 2003, 2004, 2005) ‘Contextual Priming’
How important is the emphasis on
semantic processing?
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Martin, Laine et al (2000, 2003, 2004, 2005) ‘contextual priming’
Compared the efficacy of naming/repetition in the context of semantically related distractors and unrelated distractors.
- Naming is worse at the time with semantically related distractors.
- Naming is improved no more (at a later point) with semantically related distractors.
How important is the emphasis on
semantic processing?
No evidence that a semantic context
improves efficacy of therapy
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How important is the emphasis on
semantic processing?
Not as important as we thought!
• Tasks which have traditionally been labelled ‘semantic’, such as word-picture matching are equally effective with unrelated items.
• Adding a semantic context to a (naming/repetition) task does not make it more effective.
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Word form is usually provided.
e.g. Le Dorze et al (1994)
“Show me the octopus”
“Show me the mollusc with long legs”
How important is the phonological form in the semantic task?
Most probably critical to its effectiveness
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Therapy: The application of a
technique several times, over days, weeks
or months
Immediate Cueing effects: The effect of a technique at the time of
its application
Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments
What is a facilitation
experiment?
It looks at the effect of a task performed ONCE on
another task at a later point and contrasts with…
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Cueing, Facilitation, Therapy
“k”
kangaroo
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Cueing, Facilitation, Therapy
“k”
kangaroo
….later
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Cueing, Facilitation, Therapy
“k”“k”
“k”“k”
“k”“k”
“k”“k”
“k”
kangaroo
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Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments
Phonological
Repetition
“kangaroo”
Semantic without the word form
Feature verification
Does it hop?
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Nickels, McDonald, Makin, Moses & Taylor –Facilitation Experiments
Name 300 pictures until 95 failed (10 second limit)
Sort the failed items into 3 (frequency & length)matched sets
Facilitation Task 1 Facilitation Task 2 Control
Facilitation
Name all 3 sets of pictures+ 30 easy fillers
1 week later
10 mins later
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Comparing repetition and a semantic task with no word form
-0.20
-0.10
0.00
0.10
0.20
0.30
0.40
0.50F
ME
JNI
KC
C
PS
J
DR
S
JUE
SJS
JMM
DIP
MC
B
WV
K
FA
B
JOW
MF
T
SM
G
Gro
up
participant
ben
efit
co
mp
ared
to
co
ntr
ols semantic
phonological
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Comparing repetition and a semantic task with no word form
-0.20
-0.10
0.00
0.10
0.20
0.30
0.40
0.50F
ME
JNI
KC
C
PS
J
DR
S
JUE
SJS
JMM
DIP
MC
B
WV
K
FA
B
JOW
MF
T
SM
G
Gro
up
participant
ben
efit
co
mp
ared
to
co
ntr
ols semantic
phonological
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Comparing repetition and a semantic task with no word form
-0.20
-0.10
0.00
0.10
0.20
0.30
0.40
0.50F
ME
JNI
KC
C
PS
J
DR
S
JUE
SJS
JMM
DIP
MC
B
WV
K
FA
B
JOW
MF
T
SM
G
Gro
up
participant
be
ne
fit
co
mp
are
d t
o c
on
tro
l pic
ture
s
semanticphonological
Very little benefit from a semantic task without the word form for most
individuals
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Semantic tasks without the word form
We also looked at the same tasks used as therapy with 4 individuals with aphasia
… once again, semantic tasks without the word form had little benefit
…. for example….
DRS
8 sessions of semantic therapy (feature verification)
over 2-3 weeks
Before each therapy session named all those items that were to be treated, and a set of control pictures (50 items in each set).
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DRS - Semantic Therapy
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8
daily pretests
nu
mb
er c
orrect
( /5
0)
no. correct THERAPY
no. correct CONTROL
Linear no. correct THERAPY
Linear no. correct CONTROL
McNemar Day 1 vs Day 8
Wilcoxon 1 sample
Sem Treat ns 0.028773653
Sem control p= 0.0117 0.04377147
Sem treat vs sem control Wilcoxon 2 sample NS
No extra benefit from the
semantic task
But the untreated items seem to improve.....
Spontaneous recovery?Generalisation?
Benefits from repeated naming attempts?
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Treated (sem)
Naming control
Unseen
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Pre-test 1 Pre-test 2 Post sem 1 Post sem 2
Treated (sem)
Naming control
Unseen
Treated items and repeatedly named items
improve to the same degree – so there is no specific benefit from the
semantic task
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Pre-test 1 Pre-test 2 Post sem 1 Post sem 2
Treated (sem)
Naming control
Unseen
Treated items and repeatedly named items
improve to the same degree – so there is no specific benefit from the
semantic task
The improvement from naming controls isn’t
generalisation or spontaneous recovery (unseen controls don’t
improve) – but benefit from repeated attempts at
naming
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Summary: semantic tasks in word retrieval
• Degree/depth of semantic processing appears not to be critical (Howard et al)
• Presenting tasks in a semantic context can interfere short-term and mostly has no long term advantage over presentation in unrelated contexts (Martin, Laine et al)
• Presence of phonological form appears critical in most cases (Le Dorze et al; Nickels et al: facilitation studies, DRS therapy study)
…… and so to Phonological tasks
Any questions?
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“Phonological” tasks
• Repetition of target• Reading aloud• Phonological & orthographic cueing• Rhyme judgements • Syllable and phoneme counting• Phoneme segmentation• Anagrams
…….but nearly always in the presence of the picture.
Again we need to remember the distinction between the nature of
the task and the nature of the impairment…. Here we are talking about phonological tasks but NOT impairments to the phoneme level.
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Phonological tasks and word retrieval
• Widely argued to be the most appropriate for impairments in retrieval of (or damage to) the phonological form from the phonological output lexicon (e.g. Hillis & Caramazza, 1994; Miceli,et al, 1996; Nettleton & Lesser, 1991)
Miceli et al (1996): as these tasks focus at the level of activation of individual entries in the phonological output lexicon, their effects should be item specific
– a result of ‘priming’ retrieval of the phonological form.
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For many years ‘semantic’ tasks were thought to be
more effective than ‘phonological’ tasks in
improving word retrieval
How true is this?
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Comparing repetition and a semantic task with no word form
-0.20
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ME
JNI
KC
C
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SJS
JMM
DIP
MC
B
WV
K
FA
B
JOW
MF
T
SM
G
Gro
up
participant
ben
efit
co
mp
ared
to
co
ntr
ols semantic
phonological
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Comparing repetition and a semantic task with no word form
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0.00
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ME
JNI
KC
C
PS
J
DR
S
JUE
SJS
JMM
DIP
MC
B
WV
K
FA
B
JOW
MF
T
SM
G
Gro
up
participant
be
ne
fit
co
mp
are
d t
o c
on
tro
l pic
ture
s
semanticphonological
Very little benefit from a semantic task without
the word form … repetition is almost
always more beneficial
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DRS - Phonological Therapy
0
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1 2 3 4 5 6 7 8
daily pretests
nu
mb
er c
orrect (
/50)
No. correctTHERAPY
no. correctCONTROL
Linear no.correctTHERAPY
Linear no.correctCONTROL
McNemar Day 1 vs Day 8
Wilcoxon 1 sample
Phon Treat p= 0.0001 < .0001Phon control p= 0.0042 0.002304428
Phon treat vs phon control
Wilcoxon 2 sample
p(1 tail) =.048
Significant extra benefit from the repetition task
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For many years ‘semantic’ tasks were thought to be
more effective than ‘phonological’ tasks in
improving word retrieval
This seems NOT to be true in general, particularly if
the semantic task does not include the word form
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Semantic & phonological treatments: an overstated distinction?
• BOTH have semantic and phonological components– Semantic tasks without the phonological form are generally
not effective
• Howard (2000)
– tasks having the same effects in the same way
• Strengthening the connections between semantics and phonological form when both are simultaneously active
• equivalent effects for semantic and phonological tasks for most individuals
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Semantics
Object, picture or idea
purrs
cat dog rabbit fish
barksfur pet4-legs scales
houserobin
Phonological Lexicon
PhonologicalBuffer/
Phonemesæ td o gk
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Semantics
Object, picture or idea
purrs
cat dog rabbit fish
barksfur pet4-legs scales
houserobin
Phonological Lexicon
PhonologicalBuffer/
Phonemesæ td o gk
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Semantics
Object, picture or idea
purrs
cat dog rabbit fish
barksfur pet4-legs scales
houserobin
Phonological Lexicon
PhonologicalBuffer/
Phonemesæ td o gk
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‘Semantic’ and ‘phonological’ tasks are working in similar ways
By strengthening the connections between
semantics and word form by activating both
semantics and phonology
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The role of effort and error
• Effortful >benefit than automatic? – Greater semantic processing
• Errorless >benefit than errorful?
How does amount of ‘effort’ or accuracy in
a task affect the benefit for naming?
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Comparing Phonological Tasks
“kangaroo”
Repetition
Effortless, ‘shallow’ processing,
error reducing
“k”
Phonemic cueing
Effortful, deeper processing,
errorful
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Method
Name 300 pictures until 95 failed (10 second limit)
Sort the failed items into 3 (frequency & length)matched sets
Facilitation Task 1 Facilitation Task 2 Control
Facilitation
Name all 3 sets of pictures+ 30 easy fillers
1 week later
10 mins later
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FM
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Mea
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Phon Cues
Repetition
*
*
*
*
*
**
*
Facilitation effect compared to control pictures:Errorless/Automatic (Repetition) vs Errorful /Effortful (Phonemic cues)
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MF
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SM
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Mea
n
Phon Cues
Repetition
Facilitation effect compared to control pictures:Errorless/Automatic (Repetition) vs Errorful /Effortful (Phonemic cues)
*
*
*
*
*
**
*
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Comparing Phonological Tasks
“kangaroo”
Repetition
Effortless, ‘shallow’ processing,
error reducing
“k”
Phonemic cueing
Effortful, deeper processing,
errorful
> benefit than
No need for it to be effortful to be
helpful – FOR MOST PEOPLE
Well, repetition is better and it does improve more BUT
the proper comparison is within
a task ….
Is errorless (or error reducing) better than errorful?
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Fewer errors means greater benefit?
Repetition is more error-free than cueing… but the proper comparison is within a task
Cueing
Do the people who are more accurate with cueing (at the time) have more benefit for naming (later)?
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0
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MFT
DRSFAB
FME
KCCSJS DIP JN
IJM
MM
CBPSJ
JUE
WVK
SMG
JOW
Phon Cue - Facilitationaccuracy
Phon Cue naming benefit
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Errorless items benefit more?
Repetition is more error-free than cueing… but the proper comparison is within a task
Cueing• no significant correlation between success of
the cue during facilitation and benefit of cueing for subsequent naming.
• i.e. errorless is not better than errorful for cueing.Why did we think errorless might be better in the first
place?
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Errorless learningHypothesis• Remediation is more effective if errors are prevented
- the act of producing an error may strengthen the incorrect association, and make the correct response less likely to occur.
History• Animal learning (Terrace, 1963)
• Children with developmental learning difficulties (e.g. Sidman & Stoddard, 1967).
• Acquired memory impairments (amnesia) (e.g. Baddeley & Wilson, 1994)
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Errorless learning and anomia treatment
• Fillingham et al (2003)“error reducing techniques do have positive effects for patients with
word finding difficulties. As yet there is limited information on which to judge whether this technique is significantly advantageous over errorful approaches” (p358).
• Fillingham et al (2005, 2006)– No significant difference between errorless (repetition) and errorful
(cueing) tasks.
• Abel et al (2005)– No significant difference between increasing and vanishing cues
methods (errorful vs error reducing).
BUT nonetheless repetition may be more
beneficial than phonemic cueing for
many people
There appears to be no difference between
errorful and errorless techniques in aphasia
Remember that this will all depend on the processing strengths and weaknesses of
the aphasic individual
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Any questions?
•How semantic & phonological tasks
work
•Error & Effort
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Generalisation in the treatment of word retrieval.
• the most successful treatment is one which effects improvement not only for the items used in therapy but also for any other item, in any other context.
• many treatments produce clear long lasting effects on the treated items, generalisation to untreated items is
less common, and when obtained, often less robust (e.g. Nickels and Best, 1996b)
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When perceived generalisation is actually an effect of (assessment during) treatment!
DRS
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Pre-test 1 Pre-test 2 Post sem 1 Post sem 2
Treated (sem)
Naming control
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When perceived generalisation is actually an effect of (assessment during) treatment!
DRS
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Pre-test 1 Pre-test 2 Post sem 1 Post sem 2
Treated (sem)
Naming control
Unseen
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When perceived generalisation is actually an effect of (assessment during) treatment!
Howard et al (1985) “Naming controls”• naming daily but NOT treated• Improved significantly
• Widely interpreted as generalisation of treatment effects– more probably the result of repeated attempts at naming (Howard, 2000)
Nickels (2002) JAW- Repeatedly attempted to name a set of pictures (daily for a
week)- Significantly improved naming
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Practice makes (closer to) perfect:trying to name helps naming!
HOW?- some names will be successfully retrieved on one occasion but not on
another.
- When, by chance, an individual produces a picture name successfully, both the semantic representation and the phonological representation for that item are simultaneously active.
- This will then strengthen the mapping for that item, making it more likely that the word will be produced correctly on a subsequent occasion (which will again strengthen the mapping).
- Over time, more items will have strong enough mappings to be produced accurately on every occasion
Or perhaps just partially activating the phonological
representation when trying to name is enough to strengthen
the mappings
More work needs to be done to determine who
this works for, how close together naming
attempts have to be etc etc
But it could have important
implications-Use it or lose it- (Attempts at)
conversation might improve word retrieval- (Trying to) talk about the same topics may be
better
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When generalisation is a reflection of (strategic?) changes in processing
• Semantic tasks (with semantic disorders) Techniques promoting reflection on semantic properties may be better
viewed as teaching a strategy, albeit an unconscious strategy.
• Phonological tasks– Best (2006) examined who showed generalisation using a cueing
treatment – it was those individuals with relatively more of a phonological impairment (and less semantic impairment)
• Self-cueing– E.g. phonologically mediated orthographic cueing
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Mostly generalisation is limited…
Therefore the emphasis is on the clinician to ensure that all items used in therapy are functionally relevant and chosen in collaboration with the person with aphasia.
Nickels et al – in progress
‘Home Programme’
• Using the most successful task (repetition)
• 60-100 items chosen by the person with aphasia as being words they wanted to be able to say.
• Therapy presented by computer in powerpoint
• ‘Structured’ conversation used to evaluate carry-over from naming to conversation
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Treatments aimed at remediating word production impairments
Tasks can be • effective (e.g. Hillis & Caramazza, 1994; Howard et al, 1985b),
• produce durable effects (e.g. Pring et al, 1990),
• be administered by clinician &/or computer (e.g. Fink et al, 2002)
• be obtained on verbs & nouns (e.g. Murray & Karcher, 2000; Raymer and Ellsworth, 2002).
• carry-over into connected speech & conversation (e.g. Hickin et al, 2002),
BUT
treatment tasks are not invariably effective
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Do impairment-based treatments impact on functional skills and increase activity &
participation?• word retrieval/production underlies every attempt at verbal
communication hence improving word retrieval impairments is of course functionally relevant
Simplistic and/or fundamentally misguided
BUT
the importance of an increased ability to name treated items following therapy should not be underestimated
Hillis (1998) HG
- small change in impairment – significant gains in activity & participation with the use of functionally relevant personal items (Bacardi & Coke!)
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Do impairment-based treatments impact on functional skills and increase activity &
participation?• Yes …. (functional gains can be achieved)• but…. (they are by no means guaranteed)
• few studies that have formally evaluated the effects on disability of impairment-based remediation.
• It seems particularly important given the prevalence of item specific effects that remediation should include personally relevant stimuli.
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Any questions?
•Generalisation•Effects of repeated naming•Functional relevance
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So far we’ve talked about tasks that aim to improve the underlying
word retrieval impairment – some
tasks may work in other ways too
Lets take another look
at cueing
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?
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?
/t/
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tomato
/t/
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?
T
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tomato
TLetter cueing has been found to have the same effects as phonemic cues
– both immediate and longer term benefits for naming for some individuals
(Best et al. 2002)
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?
Some individuals can generate their own orthographic
cues
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?
TOMATO
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tomato
TOMATO
How does this work?
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?
T -> /t/
How does this work?
Phonologically-mediated self-cueing (e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)
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tomato
T -> /t/
Phonologically-mediated self-cueing (e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)
Requires phonological
cueability
Requires access to the written
form when the spoken form is
unavailable Requires an ability to convert
letters into sounds
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Phonologically-mediated self-cueing (e.g. Bachy-Langedock & DePartz, 1986; Nickels, 1992)
Requires phonological
cueability
Requires access to the written
form when the spoken form is
unavailable Requires an ability to convert
letters into sounds
Can use a computer
cueing aid to do the conversion
Can be retaught
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Generating phonemic cues from the initial letter
1. Spoken naming
2. Written naming
3. Convert letters to sounds
dog
Nickels (1992) TC
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Generating phonemic cues from the initial letter
1. Spoken naming
2. Visualise written word
3. Sound out initial letter
& cue word production
Nickels (1992)
retaught letter-sound correspondences
ddog
dog
• This improved TCs spoken naming to almost the same level as his written naming. • He used this spontaneously in conversation.• Could be (and was) used for any word he was trying to retrieve (only fails for words with irregular initial letters e.g. onion, Cinderella)
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Using a computer to generate phonemic cues from the initial letter
e.g. Bruce & Howard (1987); Best et al. (1997)
/d/
dog
d
3. Press letter 2. Visualise first letter
4. Computer produces phoneme
5. Cue word production
1. Spoken naming
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Generating phonemic cues
When spoken naming
IF individuals can identify initial letter
convert letters to sounds
and are phonemically cueable
Then they can generate their own cues.
If unable to convert letters to sounds
- Can be retaught
- Can use computer generated cues
- may be able to use the letters without converting to sounds – Direct orthographic cueing.
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Direct Orthographic Cueing
SD: Howard & Harding (1998)
• impaired access to the phonological output lexicon (good semantics)• Unable to form letters
• Given an alphabet board – naming improved dramatically
• Was not using phonological mediation• unable to convert letters to sounds• unaffected by initial letter regularity (e.g. onion; eye)
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Self-generated orthographic cues
When spoken naming
IF individuals can identify initial letter
They may be able to use direct orthographic cueing
• If they are phonemically cueable
They may be able to use a computer to generate the cues
• If they can (or be taught to) convert letters to sounds
They may be able to generate their own phonological cues.
Any questions?
•Self-generated cues
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When things don’t go the way you
planned!
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Using a cueing aid as therapy – who benefits?
Best, Howard, Bruce & Gatehouse (1997)• 13 individuals treated with the cueing aid
• predicted benefit only for those who when spoken naming
can identify initial letter & are phonemically cueable
•They should be better at naming with the aid than without it (this is providing the cues).
• Only two individuals had both skills
After treatment:
Only 1 individual had better naming with the aid than without.
BUT 12 showed significant improvement in naming.
WHY???
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Why does treatment with a cueing aid help individuals who are not predicted to benefit?
Treatment tasks can work in different ways for different individuals
Multicomponent treatment • orthography • phonology • semantics (presentation of the picture and
attempted naming).Only one individual was
helped by the aid providing the cue - for many others this was a standard word
retrieval therapy
Phonemic cueingRepetition in the presence of the
picture
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Cueing aid reorganising the naming system: JOW (Best et al, 1997)
• Substantial and long-lasting effects of treatment• Improvement in treated and untreated items
• treatment drew attention to the relationship between orthography and phonology
• altered automatic (not strategic) processes in his word retrieval
• A direct orthographic cueing mechanism
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Why does treatment with a cueing aid help individuals who are not predicted to benefit?
Treatment tasks can work in different ways for different individuals
…. especially when they are multicomponentHow tasks actually work may not be
how you planned them
to!And sometimes they don’t work
even though you would
predict they should!
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RECAP
BEFORE THE BREAK• Assessment of level of breakdown in word production• Methodological issues in evaluating treatment
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RECAP (continued)
AFTER THE BREAK• Improving naming when there are semantic impairments
– Exploring semantic features – It may work by providing a strategy to improve naming rather than
improving semantics itself.
• Word retrieval impairments– Semantic vs phonological tasks– Semantic tasks require the word form, depth of semantic
processing is not important– Phonological tasks are also effective– Tasks are working in the same way
• Effort & error– Tasks do not need to be effortful– There is no additional benefit from errorless performance
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RECAP (continued)• Generalisation
– Treatment for Word retrieval impairments usually result in item specific improvements
– but may generalise to conversation, and can produce effects on participation/quality of life
– Use of functionally relevant items is a priority– Repeated attempts at naming may improve word retrieval for some
individuals– Generalisation can result from strategic/compensatory approaches
• Self-generated Cues– Phonologically mediated/computer generated/direct orthographic
• Tasks may not always work the way you expect
• ALL OF THE ABOVE ARE GENERALISATIONS
– every person with aphasia is different and could be the exception to these general principles
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Relationship between task, impairment and efficacy
Therapist’s dream = Prescription guide
“to unambiguously pair a particular functional impairment with a treatment task that has guaranteed success for that impairment”
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Clinicians need to know what to do NOW!!!
• choose a therapy that has the best chance of succeeding
• Choose a task that has successfully improved naming for a wide variety of people with spoken word retrieval impairments
- multicomponent approaches (e.g. cueing hierarchies or multimodality/multi-task therapies – see e.g. Best et al, 1997; Hickin et al, 2002)
• Use pilot studies using different tasks for short periods (e.g. 1 week) to establish which tasks seem effective and which do not prior to continuing with the most effective therapies over longer period.
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Prove that it works!
• ensure that it is possible to establish whether or not a particular therapy is effective by using a sound methodology.
We have a duty to be able to demonstrate that a therapy is effective to the individuals with aphasia, their families/friends/carers, those funding the treatment and not least to ourselves.
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Thank you!
Any questions
or comments?
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