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Aphasia:FunctionalCommunication
TherapeuticTechniquesandLife-BasedGoalSetting
3:15
CourseObjectives:• Attendees willbeable todiscusstraditionaltherapeutic techniques forPWA.
• Attendees willbeable toadapt traditionaltherapeutic techniques forPWAtoeffectivelypromote lifeparticipation.
• Attendees willbeable towrite patient-centeredgoals forPWAtoeffectively include functionalcommunication modes intocarestructures.
WHATDOWEALREADYKNOWABOUTAPHASIATHERAPY?
Pseudo Pre-testJ
TRUEorFALSE:
Itisalways easy todiagnose anaphasiasyndrome inour
clients.
TRUEorFALSE:
Wearefortunate tobeabletochoose anicelypackaged
treatmentplan forspecificaphasiasyndromes.
TRUE orFALSE:
Social considerationsarenot necessary to
consider whenformulating a
treatment plan forpersons with aphasia
(PWA).
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TRUEorFALSE:
Treatment shouldalways focus ontheclientfirstand thecaregiversecond.
TRUEorFALSE:
Thereisnobetterfeelingthatseeing aclientsuccessfullycommunicateforthefirsttime!
Whatisfunctionalcommunication?
h ttp ://www.ab cya.com/wo rd_cloud s.h tm
THERAPY
Whatarewearecurrently doing andhowitiseffective.
WhattherapyisNOT.
• Clean andeasy…• Aonesizefitsallapproach…• Prescribed…• Onesided…
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WhattherapyIS.
• Patient-centered…• Dynamic…• Need-based…• Inclusive…
Tried andTrue…
Therearemanythingsthatwe
alreadydothatarequiteeffectivewhentreating
PWA.
Someofwhichare:
WordFindingTreatment
Syntax Treatment
ReadingTreatment
WritingTreatment
MelodicIntonationTherapy
CommonAdjunctiveTherapies…
Likewise, therearemanythingsthatwecurrentlydotosupplementthesetraditionaltherapymethodsfora
PWA.
Someoftheseare:
Computer-basedTreatment
MultimodalTreatment
PartnerTraining
ScriptTraining
Pragmatic Treatment
AndStill More…Sometherapeuticmethodsaremore
situationdependentand
mustalignwiththevaluesofaPWAandtheirsupport
system.
Thesemaybe:
ConstraintInducedLanguageTherapy
ReciprocalScaffolding
VerbalNetworkStrengtheningTreatment
GroupTherapy
AugmentativeandAlternativeCommunication
WHENDOWEUSEWHAT?So,thequestion is…
Non-fluent
Fluent
Complex
• Melodic IntonationTherapy• Syntax treatment• WordFinding Treatment• AAC• CILT
• Verbal NetworkStrengthening
• WordFinding Treatment• Cognitive Approaches
• Computer-based• Multi-modal Approaches• Reading andWritingConsiderations
GENE
RALIZ
ATION
STRA
TEGIES
•Scrip
tTraining
•CaregiverTraining
•Grou
pTherapy
ASHA, n.d.; Brookshire, 2015; Helm-Estabrooks , et al.,2014
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Making theEBP frameworkworkforaphasia care…• Usewhathasbeen found
towork…• Recognize thepowerin
our ownrichexperiences…
• Incorporate theclient’svaluesasanEQUAL partof ourtx planning…
Client/Patient/Caregiver PerspectivesASHA,2005
Discussion BreakJ
CURRENTMETHODSMEETALIFEPARTICIPATIONMODEL.
Whyreinvent thewheel? ShiftingthefocusfromwhatIcan’tdotowhatICAN
do!
• Strengths• Successes• Promotion ofHealth
WHO, 2001
WhatistheLifeParticipationApproachtoAphasia?(ASHA, 2000)• Developedin2000byASHAsLPAAprojectgroup
(Chapey,Duchan,Elman,Garcia,Kagan,Lyon,Simmons-Mackie)
• FocusesonTHECLIENT’Swantsandneeds• GoalsaretobemeaningfultothePWAandaidinlife/communityreintegrationtotheirhighestlevelofpotential
• Aimstoreducenegative lifeconsequencesthataphasiamaycause
LPAA Values: (ASHA, 2000)1) Enhance lifeparticipation2) AllPWAareentitledtoservice3) Documented life-enhancement
changes areincluded asmeasures of success
4) Personal andenvironmentalfactors aretx targets
5) ServicesareavailableasneededatALLstagesof aphasia
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LivingwithAphasia:FrameworkforOutcomeMeasurement(Kagan,et al., 2007)
LPAA Adult LearningTheory
Kimbarow,2007ASHA, 2000
AdultLearningTheory1) LifeExperience asaresource2) Responsibility =Greater Outcomes3) TheneedtoknowWHY?4) Internal motivation toward quality liferoles
Kimbarow,2007
UnderstandingtheseprinciplesallowsthePWAto…• Equalizethe socialrelations ofservicedelivery• Create authentic therapeutic experience• Create experiences that areengaging• Establish usercontrol• Become accountable toother partnersKimbarow,2007
Thisallmakessense…
Sonowwhat???
1:00
GOALS,GOALS,GOALS…Howour goalsdriveour care.
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www.careerro cketee r.com
Earlydecisionsinourpatient’scaredrivethedurationofourinteraction
withthem…
Patient-CenteredOutcomesConsider:• HowdoIcreate thegoalsformypatient?• Howdothe goalsIcreate affectthecareIprovide?
• Doesmypatient andhis/her familyknowthegoalsIhavedetermined?
MoreonthislaterJ
Whatdoyounoticeaboutthequestionsonthepreviousslide?
I
TheVALUESelementofEBP…
Client/Patient/Caregiver Perspectives
ASHA,2005
üDoweknowwhattherapeutictechniqueshaveresearchtobackuptheiruseforthisPWA?ü Dowehaveexperiencetoguideourclinicaldecisionmakingtowardappropriatetx measures?ü HAVEWEASKEDTHECLIENTWHATHIS/HERGOALSARE?
Recognizingourrole…
WhenLPAAandtheA-FROMmodelarethefoundationforourpracticeinaphasiacare,theclientwillalwaysbe
atthecenterofourdecisions…
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Patient-CenteredOutcomesNow, consider:• Howdid thepatient arriveatthis goal?• Howcanthecareprovided beshaped tomeettheneedsofaPWA?
• Doesthepatient andhis/her familyunderstand howthesegoalscanbeachieved?
MoreonthislaterJ
Patient-CenteredOutcomeswilldriveproductivecarethatourclientsaremoreinvested in,thereby
increasingmotivation…
Tippett(2012);Kennedy,etal.(2012)
Impairment BasedTherapy• WordFindingTreatment• SyntaxTreatment• MelodicIntonationTherapy• ConstraintInduced
LanguageTherapy• TreatmentofUnderlying
Forms• ReadingandWriting
Treatment
Non-ImpairmentBasedTherapy• Multi-modalTreatments• ScriptTraining• PartnerTraining• ReciprocalScaffolding• AAC• GroupTherapy
Brooksh ire,2 0 1 5 ;Helm-Estab rooks etal . , 2 0 1 4
WHEREISOURHAPPYPLACE???
Howmuchdowedoofwhat???
• Impairment BasedTreatment Strategies
• Non-ImpairmentBasedTreatmentStrategies
• Counseling andEducation
• ProfessionalCollaboration onthebehalf ofthe PWA
Beginningwiththeendinmind(sortof)…• Weareallaware thatthecombinationoftreatmentmodalitiesisanindividualizedpuzzle,notaneatequation…
• Patient-CenteredGoalcreationdoneincollaborationwiththePWAwillhelpustoseewhattheywantoutoftherapy…
• Theywewillbeable toclearlyseehowmuchofwhatisnecessary!
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FUNCTIONALOUTCOMES!
Thiswill giveusMeasurable andAttainable…
Well-writtenLTGs PoorlywrittenLTGs Whythere’saproblem…
ThePWAwill respondtospokenyes-noquestionsviaheadnodsand/orverbalyesandnowithatleast80%accuracyinstructuredconversationsontopicsofpersonal relevance.
ThePWAwill improveauditorycomprehension.
No specificbehavioristargeted;improvementcan’tbedirectlymeasured;nocriterionis set.
The PWAwill respondtoyes-noquestions relatedtobiographicalinfo(e.g.name,familynames,address,occupation)with60%accuracy.
ThePWAwill increaseauditorycomprehensionforsimpleyes-noquestions.
Nospecificbehavioristargeted;thereisnoincreaseindicated;nocriterion is set.
Adapted from Helm-Estabrooks et al.,2014Table 16.1
STGConsiderations…Inwhatwayswillthegoalsbeimplementedtoenhancelifeparticipation?Are life-enhancementchangesincludedasmeasuresofsuccess?Are theSTGs abletobequantifiedorqualifiedforappropriatedocumentationneeds?Are there personalandenvironmentalfactorsincluded as tx targets?
Isthe serviceplanappropriateforthePWAbasedonhis/herneedrelative tothestageofaphasiatheyareexperiencing?DothegoalslendthemselvestomotivationandresponsibilityforthePWA?
ASHA,2000;Kimbarow,2007;Brookshire,2015
THEFACEOFAPHASIATHERAPY
Thebigpicture ofwhatmaychange…
WhattherapyIS…(again)
• Patient-centered…• Dynamic…• Need-based…• Inclusive…
Usingwhatworksinthemosteffectiveway…Context…• Relevantmaterials• Client accountability fortransference/generalization
• Community reintegration goals
L.P.A.A.ASHA,2000
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Tryingsomethingnew(ormaybejustlookingatitmoreobjectively)…• Impairment Based Treatment techniques for PWAare
good!– MassedPractice/Neuroplasticity Raymeretal.,2008
• Non-Impairment Based Treatment techniques mayservetobridgethe gapbetweenstructured tx andgeneralization!Helm-Estrabrooks etal.,2014
• Therapeutic Conversation and DailyGoalCreation…Rosenbeck,2016
L.P.A.A.ASHA,2000
Family, family,family…Inclusion becoming broadscope!• ConversationalPartnerTraining…– Shouldbeadirectgoalofaphasiatherapy!
• ScriptTraining…– Expectcommunityrehearsalatamoreprescribedlevel!
• ReciprocalScaffolding…– Trainfamily/caregivershowtosettheirlovedoneupforsuccess!
L.P.A.A.ASHA,2000
Sometimesit’swhatwedon’t seethatmakesthebiggestdifference…
2:00
L.P.A.A
←TREATMENTMETHODS
←SOCIALANDCOMMUNITYREINTEGRATIONSTRATEGIES
DiscussionBreakandTimetoStretchJ
JOHNSTANDISH
CaseStudyTime:Alookatpatient-centeredcare,treatmentplanning,andintegrationofLPAAprinciples…
Mr.Standish– WVSHA2016
Mr.Standishisa62-year-oldmaleadmittedtothehospitalforwhichyouwork.HesufferedaCVAtotheleftinferiorlateralfrontallobe.Hewaspleasant,howeverfrustratedthroughoutyourassessment.YougaveMr.StandishtheShortformoftheBostonDiagnosticAphasiaExamination,aswellasconductedinformalmeasurestopredictstimulabilityanddetermineappropriatetreatmentmethods.
0:50
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ACHANGE INFOUNDATIONAL IDEALSPROVIDING BETTER FUNCTIONALOUTCOMES…
Fromtable, tohome,tocommunity,andbeyond!
WhattherapyIS…(again)
• Patient-centered…• Dynamic…• Need-based…• Inclusive…• Ongoing…
“…ITISNOTTHEPERSON WITHAPHASIA WHOHASREACHEDAPLATEAU; ITISTHECLINICIAN.”
NancyHelm-Estabrooks
TheMYTHoftheaphasiaplateau…• Whatdoesputtinga timeline on recovery do forourpatientswith Aphasia?
• Howwouldyou feel if youwere intheir shoes?• Whatwould youwant tohear ifyouora lovedonewere thePWA?
• Howcanwemediate thedesiresandneeds ofourpatientswith delivering honest informationregarding prognosisandexpectations?
Helm-Estabrooks et al.,2014
“COULDAGREATERMIRACLETAKEPLACETHANFORUSTOLOOKTHROUGHEACHOTHER’SEYESFORANINSTANT?”
HenryDavidThoreau
The complexity of whatwe do…Combiningscience,experience,andempathyWe mustbe highly aware of all three of these things at all times…
Psychosocial considerations…• Therehasbeenmovement inourfield asawhole tomovefrom abiomedical frameworktoaBIOPSYCHOSOCIALframeworkofcare.
Rosenbeck, 2016
WHY???
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VisionofthelifepathforPersonsWithAphasia…Hinckley, 2016;Shadden,2007
0:25
FinalQuestionandAnswerSessionJ
THANKYOUSOMUCHFORTHEOPPORTUNITYTOSHARETHISINFORMATIONWITHYOU!
Kelly Rutherford M.S.,[email protected]
References:• AmericanSpeech-Language-HearingAssociation.(2000).LifeParticipationApproachtoAphasia:A
Statementof ValuesfortheFuture.TheASHALeader:15February2000,pp.4-6.• AmericanSpeech-Language-HearingAssociation.(2005).Evidence-basedpracticein
communicationdisorders[PositionStatement].Availablefromwww.asha.org/policy.• AmericanSpeech-Language-HearingAssociation.(n.d.) .AphasiaPracticePortal.Retrievedfrom
http://www.asha.org/PRPSpecif icTopic.aspx?folderid=8589934663§ion=Treatment• Brookshire,R.H.(2015).Introductiontoneurogeniccommunicationdisorders(8thed).St.Louis,
MO:Mosby.• Helm-Estabrooks,N.,Albert,M.L.,Nicholas,M.(2014).Manualof aphasiaandaphasiatherapy(3rd
ed) .Austin,TX:Pro-ed.• Kagan,A.,Simmons-Mackie,N.,Rowland,A.,Huijbregts,M.,Shumway,E.,Mcewen,S.,Threats,T.,
Sharp,S.(2008,03) .Countingwhatcounts:Aframeworkforcapturingreal- lifeoutcomesofaphasiaintervention.Aphasiology,22(3),258-280.doi:10.1080/02687030701282595
• Kennedy,M.R.T.,Obrien,K.H.,Krause,M.O.2012,December.Bridgingperson-CenteredOutcomesandTherapeuticProcessesforCollegeStudentswithTraumaticBrainInjury.SIG2PerspectivesonNeurophysiologyandNeurogenicSpeechandLanguageDisorders.Vol22,143-151.AmericanSpeech-Language-HearingAssociation.
References:• Kimbarow,M.L.(2007).IntegratingLifeParticipationApproachestoAphasiaTreatmentWithAdult
LearningTheory.TopicsinLanguageDisorders,27(4) ,318-323.RetrievedJanuary14,2016,fromhttps://libids.marshall.edu/illiad.dll?Action=10&Form=75&Value=204012.
• Raymer,A.M.,Beeson,P.,Holland,A.,Kendall,D.,Maher,L.M.,Martin,N.,Murray,L.,Rose,M.,Thompson,C.K.,Turkstra,L.,Altmann,L.,Boyle,M.,Conway,T.,Hula,W.,Kearns,K.,Rapp,B.,Simmons-Mackie,N.,GonzalezRothi,L.J.(2008).TranslationalResearchinAphasia:FromNeurosciencetoNeurorehabilitation.JournalofSpeech,Language,andHearingResearch.Vol51,S259-S275.February2008.AmericanSpeech-Language-HearingAssociation.1092-4388/08/5101-S295.
• Rosenbeck,J.,Hinckley,J.,SantoPietro,M.J.(22March2016).Aphasia:WhatIKnowNowThatIWishIKnewThen–theArtof influence.AphasiaAccess:Webinarseries.
• Shadden,B.B.(2007).TheRoleof NarrativeintheLifeParticipationApprach toAphasia.TopicsinLanguageDisorders.Vol.27,4.p.324-338.
• Tippett,D.C.2012,January.CurrentConceptsinTreatmentPlanning:patientCenteredandEvidence-BasedPracticeinSpeech-LanguagePathology.SIG15perspectivesonGerontology.Vol17,27-33.AmericanSpeech-Language- HearingAssociation.
• WordCloud.(n.d.) .Createdathttp://www.abcya.com/word_clouds.htmon08Feb2016.• WorldHealthOrganization,InternationalClassificationof Functioning,DisabilityandHealth( ICF) .
(2001).Retrievedfromhttp://www.who.int/classif ications/icf/en/