Paul Conroy

Errorless and errorful therapy for verb and noun naming in aphasia

Background: The aphasiological literature has provided an extensive body of research on verb impairments but many fewer verb therapy studies. Verbs display particular complexity at various levels of linguistic analysis: phonological, morphological, semantic, and syntactic. Verb impairments can arise at any of these processing levels as well as from cognitive sources. Verb-naming therapies may therefore be relatively more vulnerable to errors, which could reduce their effectiveness. Errorless learning has been used with positive results for noun therapies. Aims: Given the high linguistic and cognitive demands of verb processing, this study investigated whether errorless therapy would be more effective for verb naming than more traditional hierarchical cueing (relatively errorful) therapy. Methods & Procedures: Nine participants with word-finding difficulties as a part of their chronic aphasia took part in the study. Outcomes & Results: For the dependent variable of naming accuracy, as in previous studies, we found that errorless therapy was as effective as errorful therapy for both verb and noun naming. Three participants with most severe aphasia showed significantly greater gains in noun as opposed to verb naming. The remaining participants exhibited comparable gains in both nouns and verb naming. There was no lasting generalisation from treated to untreated therapy items. The prediction that errorless therapy would be more effective for verb naming was not upheld; errorless and errorful approaches were as effective as one another. Conclusions: An errorless-learning approach to verb and noun naming was a time-efficient therapy, and one that was as effective as an errorful/hierarchical cueing method in improving naming accuracy, for a range of participants with varying naming skills and types of aphasia.

Towards theory‐driven therapies for aphasic verb impairments: A review of current theory and practice

Background: This review is intended for both theoretically and clinically motivated audiences with an interest in aphasic verb impairments. This work is supported by a Research Bursary from the Stroke Association (TSAB 2004/01). Aims: Building from previous reviews, our aim is to provide a concise summary of the relevant theoretical research and perspectives on verbs, and from this theoretical foundation to explore which aspects have been incorporated and tested in therapy studies. Main Contribution: In the theoretical domain, the review first considers the patterns of verb and noun impairments in aphasic syndromes. Second, an overview of the linguistic differences between verbs and nouns is provided, differences that occur at various levels of linguistic analysis: phonological, morphological, semantic, and syntactic. This is followed by a detailed account of the psycholinguistic perspective on verb–noun differences. Specifically, this section examines the role of variables such as imageability and frequency, and the issue of depiction of actions in static picture versus dynamic video format. Evidence from neuroimaging studies as well as neurodegenerative conditions such as semantic dementia is also reviewed. Finally, the psycholinguistic account further discusses the question of whether verbs (and nouns) serve as primary ordering principles in the cognitive architecture of language processing or whether they should be more accurately viewed as points on an overarching psycholinguistic continuum. Also within the psycholinguistic discussion, event perception is described as a theoretical account with implications for verb processing. Despite the importance of verbs in their pivotal role in connected speech, there is a very limited body of literature on verb therapies and only a small number of the theoretical issues/perspectives have penetrated approaches to treating verb impairments. Ten published papers are described. Two of these directly compare verb and noun therapies, reflecting the many comparisons of noun vs verb impairments in the theoretical literature. The remaining eight consist of purely verb‐focused therapies, which also examined the effects of increased verb retrieval skills on related sentence production (reflecting the pivotal role of verbs in connected speech). These eight studies are subdivided between four that targeted verb retrieval only and four that also investigated aspects of verb argument structure and sentence production. Conclusions: The general discussion notes possible new approaches to the treatment of verb deficits that arise from the many factors noted in the theoretical literature which are yet to be fully explored in therapy studies.

The effects of decreasing and increasing cue therapy on improving naming speed and accuracy for verbs and nouns in aphasia

Background: Verb impairments in aphasia have generated considerable theoretical interest in the literature (Druks, 2002; Druks & Masterson, 2003; Marshall, 2003) but this is not reflected in the number of studies investigating therapies for verb impairments (Conroy, Sage, & Lambon Ralph, 2006). Recent anomia therapy studies have compared errorless and errorful techniques (Abel, Schultz, Radermacher, Willmes, & Huber, 2005; Fillingham, Hodgson, Sage, & Lambon Ralph, 2003; Fillingham, Sage, & Lambon Ralph, 2005a, 2005b, 2006). Decreasing cues have been proposed as the optimal interaction of low error and sustained effort in therapy in the amnesia literature (Komatsu, Mimura, Kato, Wakamatsu, & Kashima, 2000). Following on from Conroy, Sage, and Lambon Ralph (2008), we predicted that decreasing cue therapy would result in greater effects in terms of both naming accuracy and speed relative to increasing cues. Aims: The present study aimed to answer the following questions: (1) Would naming therapy consisting of decreasing cues result in greater naming accuracy for verb and noun targets than therapy consisting of increasing cues? (2) Would decreasing cues result in speedier naming responses to verb and noun targets than increasing cues? Methods & Procedures: A case‐series study that utilised decreasing versus increasing cues as naming therapy for verbs and nouns was implemented with seven participants with aphasia of various sub‐types and degrees of severity. A total of 120 target words were collated for each participant, divided into three sets, each consisting of 20 verbs and 20 nouns. Set A was used in decreasing cues therapy, set B in increasing cues therapy, and set C served as control items. Ten sessions of therapy were delivered to each therapy set concurrently. The speed of post‐therapy naming responses as well as accuracy was recorded. Outcomes & Results: All participants showed significant therapy gains after both decreasing and increasing cue therapies, with little or no change in naming of control sets. The two therapies were equivalent in the degree to which participants improved in naming accuracy and yielded almost identical overall speed of naming responses. Naming speeds for successfully named items, post‐therapy, were faster for nouns than verbs (perhaps reflecting their shorter length), and faster at immediate than follow‐up assessment. Conclusions: Decreasing cues are as effective in naming therapy as increasing cues, in terms of both accuracy and speed of naming for verbs and nouns.

Can impairment-focused therapy change the everyday conversations of people with aphasia? A review of the literature and future directions

Background: The ultimate goal in any programme of aphasia rehabilitation is that behaviours targeted in therapy will generalise to everyday use for people with aphasia (PWA). The pervasiveness of conversation in everyday life has undoubtedly contributed to the recent interest in aphasiology regarding how we facilitate, and capture evidence of, change in conversation following therapy. Given the rich nature of conversation data, various analytical approaches have been utilised within impairment-focused therapy studies; however, much of this work has been carried out in isolation from other methodologies such as conversation analysis (CA)—a field which has historically concerned itself with conversation data. The result is a growing literature base which is dispersed in nature. For clinicians who are faced with the daily challenge of therapeutic management for a diverse population of PWA the literature on generalising therapy gains to everyday conversation may be too unwieldy to be of benefit to current clinical practice. Aims: This paper aims to synthesise and critically review key papers from impairment-focused studies which have investigated the impact of therapy on the conversations of PWA. For the purposes of this review, conversation is defined as a dialogue between the person with aphasia and a conversation partner. Main Contribution: First, the motivation to investigate conversation within aphasia assessment is discussed, with consideration of how conversation differs from, but ultimately complements, other forms of language assessment. Following this, five impairment therapy studies will provide a platform for discussion of methodological issues and analytical approaches relating to conversation data. Finally, consideration is given to how researchers and clinicians may build on current literature to develop the use of conversation as an outcome measure in aphasia intervention. Where appropriate, insights are drawn from interaction-focused therapy studies regarding the collection and analysis of conversation data. Conclusions: There is emerging evidence that impairment-focused therapy can impact on the conversations of PWA. While these early findings are promising, investigations have been limited to naming therapies and the methods of data collection used have implications for ecological validity. Incorporating particular elements of interaction-focused approaches may help to inform data collection, investigations of therapy outcome, and issues of candidacy for specific treatments. Furthermore, combining therapeutic and analytical approaches is likely to be more closely akin to the clinical reality of aphasia intervention, where clinicians are likely to use all resources at their disposal in the rehabilitation of a speaker with aphasia.

The effects of verb retrieval therapy for people with non-fluent aphasia: Evidence from assessment tasks and conversation

Despite often impressive improvements on linguistic assessments, there is a lack of evidence of significant generalisation from impairment-focused aphasia therapy to everyday communication. The aim of the current study was to investigate the effect of a verb retrieval therapy across a range of levels of language production. Nine participants with chronic non-fluent stroke aphasia were recruited into this case series. Baseline assessment included naming a range of verbs (i.e., action verbs, semantically light verbs and personally relevant verbs) and sentence production. Multiple samples of conversation were collected from each participant and his/her partner. Consecutively failed verbs were divided across treatment and control sets; these sets were matched for salient psycholinguistic variables such as frequency, imageability and argument structure. A multi-component verb retrieval therapy was delivered, consisting of semantic feature analysis, gesture production and phonemic cueing. Following therapy, participants demonstrated significant and sustained gains in naming treated verbs; more modest effects were seen in untreated verbs. Mixed patterns of generalisation were evident in assessment of sentence production. In conversation, while group analysis suggested a lack of change, individual analyses indicated increased verb retrieval for three participants and qualitative changes related to the syntactic contexts of verbs retrieved.

A comparison of word versus sentence cues as therapy for verb naming in aphasia.

Background: Improving verb naming in people with aphasia should enable expession of a wider range of sentence types and meanings, and may have wider benefits for connected speech. Estableshing the optimal therapy methods for improving verb naming is, therefore, of substantial clinical importance. Aims: This study investigated whether cueing sentence production would improve verb‐naming accuracy to a greater extent than the more typical, single‐word verb‐cueing therapies. A second aim was to examine the extent to which verb picture naming improvements would generalise to naming of the same items in dynamic videos. Methods & Procedures: Seven participants with chronic aphasia including word retrieval impairment took part in a case‐series study. Decreasing cues were used to devise two therapies to improve verb naming: word cue therapy and sentence cue therapy. A total of 60 verbs that had not been named accurately in baseline testing on three presentations were collated for each participant. These were split into three sets of 20 verbs: set A was used in word cue therapy, set B in sentence cue therapy, and set C served as control items undergoing no therapy. The sets were matched for significant psycholinguistic variables such as word frequency, imageability, length, and number of noun arguments. Therapy consisted of 10 sessions over 5 weeks. Post‐therapy assessments consisted of an immediate naming assessment (1 week following therapy) and a follow‐up assessment 5 weeks later. Naming of the target verbs in set A for each participant was also assessed using a dynamic video presentation. Outcomes & Results: Both therapies resulted in highly significant gains in naming accuracy for treated verbs with little, if any, carry‐over to untreated verbs. There were no significant differences between the therapies for individual participants. At the group level there was a significantly greater benefit for word cue over sentence cue therapy at the follow‐up naming assessment. The gains in verb naming post therapy generalised from the static depictions used in therapy to naming of the same items in the dynamic video presentation format. Conclusions: Both word and sentence cue therapy for verb naming were effective in improving naming accuracy. Gains from word cue therapy can generalise to naming of very different exemplars of the same verb targets. Word cue therapy resulted in significantly greater gains than sentence cues at the level of the group, but the difference was not substantial enough to be significant at the individual participant level. Generalisation, as an effect following intervention, can be examined in terms of naming different exemplars of a word, as well as its more typical meaning of generalisation from treated to untreated items in therapy.

Decreasing cues for a dynamic list of noun and verb naming targets: A case-series aphasia therapy study

Errorless learning has had positive reports across both clinical and non-clinical domains. Within aphasia therapy studies, decreasing cue methods have been proposed as the optimal combination of low error and high effort. This study aimed to evaluate a modification to the decreasing cue method in which the set size of target nouns and verbs for training was extended dependant on participant progress in naming therapy. Four participants with word retrieval symptoms as part of their aphasia took part in a case-series study in which a decreasing cue hierarchy was applied to a dynamic list of noun and verb targets. An assessment probe at the start of each session determined how many new items were to be taken on in therapy, dependant on participant responsiveness to that point. All participants made significant improvements in naming accuracy for treated items from baseline and compared to control items. Two participants continued to take on new items which reflected consistent trajectories of improving naming accuracy, while two participants reached saturation points at which the frequency of errors in naming accuracy limited their set sizes. The varying trajectories of the participants were evaluated in relation to their baseline language and cognitive skills. Clinical implications from the findings and themes for further research were also considered.

Preliminary analysis from a novel treatment targeting the exchange of new information within storytelling for people with non-fluent aphasia and their partners.

Background: Therapy for people with aphasia (PWA) can encompass a wide range of aims and methodologies from targeting the linguistic impairment to strategic compensation to optimise communication, interaction, and vocational rehabilitation. Aphasia rehabilitation ultimately has a social goal of optimising the communication of PWA within their typical environment. Therefore, across treatment type, one unifying area of interest relates to the generalisation of behaviours targeted in therapy to untrained tasks and contexts, particularly those related to everyday communication. Two important aspects of everyday communication relate to conveying new information and telling anecdotes/stories. Measures of transactional success in storytelling have previously demonstrated reliability and validity as an analytical method. Aims: The study aimed to extend previous work on transactional success in storytelling to a programme of therapy targeting both the PWA and the communication partner (CP). The effects of therapy were measured in untrained novel storytelling tasks. Methods & Procedures: Four participants with chronic nonfluent aphasia and their CPs were recruited and a novel dual-focus treatment was administered. For the PWA, therapy targeted storytelling using the principles of “thinking for speaking” and story grammar. For the CP, therapy drew on the principles of conversation coaching to increase facilitative behaviours within storytelling to aid coconstruction of the story. Outcomes & Results: Outcomes were influenced by the complexity of the target stimuli: following therapy, three PWA demonstrated increased transfer of new information within untrained simple storytelling. For the untrained complex storytelling stimuli, improvements were limited to two PWA. There were also changes in how PWA produced stories (i.e., the order of events within the story), with simple stories becoming more inline with the sequence used by control participants. Regarding the CPs, again there was an effect of complexity: for the untrained simple story, three CPs improved the accuracy of their understanding while for the untrained complex story, two CPs improved. Interestingly, one CP consistently demonstrated a decrease in the amount of information successfully understood following therapy, despite improved information exchange by her partner with aphasia. Conclusions: The preliminary findings of this dual-focused therapy offer promise in terms of targeting a range of skills relating to both the PWA and CP, whilst the context of information exchange and storytelling promotes likelihood of generalisation of targeted behaviours to untrained tasks.

A comparison of errorless and errorful therapies for dysgraphia after stroke

Despite the increasing significance of written communication, there is limited research into spelling therapy for adults with acquired dysgraphia. Existing studies have typically measured spelling accuracy as an outcome, although speed may also be important for functional writing. As spelling is relatively slow, effortful and prone to errors in people with dysgraphia, minimising errors within therapy could be a factor in therapy success. This within-participant case-series study investigated whether errorless and errorful therapies would differ in their effects on spelling speed and accuracy for four participants with acquired dysgraphia. Matched sets of words were treated with errorless or errorful therapy or left untreated. Results were collated one week and five weeks after therapy. Both therapy approaches were successful in improving spelling accuracy. For three participants, equivalent gains were demonstrated following errorless and errorful therapy. One participant made significantly greater improvements in spelling accuracy following errorless therapy. The effects were maintained five weeks later. There was no significant difference in post-therapy spelling speed between the two therapy conditions. The results of this study suggest that both errorful and errorless therapies can be effective methods with which to treat spelling in adults with acquired dysgraphia.

Using phonemic cueing of spontaneous naming to predict item responsiveness to therapy for anomia in aphasia.

BACKGROUND Anomia refers to difficulties retrieving words and is 1 of the most common symptoms of aphasia and hence often the target of therapy. The principal aim of the present study was to explore, for the first time, whether it is possible to predict the responsiveness of individual words to naming therapy from the psycholinguistic properties of those words and from the length of the phonemic cue required to name them. The relationship between this form of cueing and the outcome of naming therapy is of particular interest given that cueing is an established research and clinical tool within aphasiology, and is commonly used to probe naming performance. METHOD By amalgamating data from 3 previous studies, we were able to analyze data from 22 participants with chronic aphasia, yielding cueing and therapy data for 1080 target words. Cross-session changes in cueing and naming accuracy were collated for 298 target words. RESULTS The results demonstrated that items which were accurately named after therapy (both at 1 wk and 5 wk later) required a significantly shorter phonemic cue to prompt correct naming in assessments prior to therapy. Imageability was a significant predictor of the required cue level, whereas word age of acquisition and word frequency were not. Highly imageable words required less cueing and were more likely to be accurately named posttherapy. A novel analysis of cross-session accuracy revealed that, even though the required cue length reduced across the first 6 of 10 therapy sessions, the relationship between the required cue length and final posttherapy accuracy was present throughout therapy. DISCUSSION The findings are discussed in the context of their clinical implications for intervention, specifically for therapies that focus on accurate production of specific word targets. Themes for future related research are also considered.