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Exploiting Neuroplasticity in Aphasia Treatment & Recovery OSLHA October 5, 2019 This is your printable handout. It will provide the basic information and a format for taking notes. All of these slides have a slight grey background. The full ppt to be used during the workshop contains photos, videos and much color. It is too large for printing. The full ppt will be available here - https://www.aphasiatoolbox.com - after October 1, 2019
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Exploiting Neuroplasticity in Aphasia Treatment & Recovery Oklahoma Speech Language Hearing Association October 5, 2019 2
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OSLHA Annual Convention William Connors Financial relations: aphasiatoolbox® owner Telepracticecommunity.com owner EverythingSLP.com ; homeceuconnection.com vendor Non-Financial Relationships: The National Aphasia Association (representative; committee member) The Brain Recovery Crew (BRC) ASHA; state committees OH; PA 3
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I know who you are…. Hard working, Dedicated, Intellectually inquisitive SLPs, in the trenches helping people to talk; type; converse; interact; recover. 4
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Statement of the Problem: Upwards of 2 million people in the United States and Canada, (the Aphasia Institute, 2011) as well as millions more throughout the world, continue to suffer with hope-robbing, independence-depriving effects of aphasia-apraxia despite millions of dollars spent on research, treatment, and public awareness of the problem (Kelly, 2011, Stahl, 2011). The great majority of PWA and their caregivers find this state of affairs unacceptable (Worrall, 2011). They have a dissensus with our approach to research and clinical outcomes. The first step in solving a problem is realizing there is one. 5
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What should SLPs do? How can we offer a truly patient-driven clinical management that in fact takes advantage of neural plasticity and most efficiently and effectively maximizes patient recovery of communication and cognitive skills in a program that is effective and affordable? How do we best turn people with aphasia into people recovering from aphasia? How do we do this in the world of organizational and 3rd party barriers? How can we go beyond the significant limitations of traditional aphasia therapy? 6
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What will we be discussing that is different, new, controversial?
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There is no such thing as acquired apraxia of speech, rather a motor planning and execution problem that affects, voice, breath flow, tongue, lips, etc. How do I turn a thought into an acoustic event? There is no such thing as a circumscribed auditory comprehension problem in aphasia. It’s a catch-all term. Reflection and release can facilitate significant change. Since it’s all about change, especially neurophysiological, that’s essential. PRA need a program in which they are not bullied. They need mindful environments, not dissonance. Aphasia-stress free-not aphasia stress-full. 8
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Translating research-based EBP, that only generalizes to trained word lists, will not get people conversing again, at least not in my lifetime. Martin, et al. 2006 Errorless learning may have a place, but it’s not in aphasia recovery. Our clients cannot make a mistake for differing recovery reasons. What they are thinking is what they will say. We need to help him/her fix how he/she thinks. Fix thoughts not speech. Who’s doing the thinking and who’s doing the talking? It better be the client. 9
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It’s not about word recall. One cannot unblank, unblock, or get cued. Instead, we move thoughts and concepts. Aphasia recovery is all about movement, period. Bolte-Taylor, 2008 TED talks. We can do harm. “I experienced stimulation coming in through my sensory systems as chaos, and it felt like pure pain.” Bolte-Taylor, 2008; Small and Wineburgh, 2004 Carry every activity into a conversational dyad, or better yet triad. Aphasia recovery is not about speech or typing; it’s about neural pathways, activations, neural interactions, movement. 10
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How many repetitions do we need? It takes 0 repetitions. You just have to think through the next one. Propositional speech and language are always generative; created never imitated. Don’t waste time on things that come back on their own. Complexity training on steroids. We don’t fix aphasia by thinking about aphasia. We fix aphasia by thinking about and reconnecting normal and deliberate thought turned into movement. Sometimes we need to Blink It and sometimes we need to Think It. Too much info can cause problems. We need to prime better. 11
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“After the age of 30, I think the most insane, hopeless things I tried to do were drilling auditory comprehension tasks in PWA and implementing conventional speech therapy with people with a recent aphasia.” Bill Connors. We must address seriously the cognitive issues but not with apps or worksheets but rather folded into our treatment, practice and everyday activities. “Our findings suggest that individuals’ cognitive ability, specifically verbal short-term verbal memory, affects anomia treatment success.” JSLHR Digman. 12
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3 KEY THINGS TO ASK YOURSELF ON EACH ACTIVITY TODAY: How do I thread work on cognition into this? How do I analyze the client’s response to shape treatment and client practice via formative assessment? A rising tide lifts all boats. How do I facilitate reading comprehension and auditory processing into all that I do?
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Visual Definition Of Aphasia “If you change the way you look at things, the things you look at change.” STEP 1 VISUAL APC Session 2: The Visual Definition of Aphasia - Visual 14
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VISUAL ACUITY PROBLEM TX ACTIVITIES “Tell me the name of this object” Misses info on one side or middle. Turns head; Moves page PWA: “I can’t see that.” Visual neglect and/or inattention Keyboarding Figure Ground Mazes Visual Apps 15
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Comprehension Processing (Auditory Comprehension) PROBLEM TX ACTIVITIES Clinician: “You write with it.” PWA (jargon output): “Huh?” “I don’t understand.” “What did she say?”. Say it  Understand it “A rising tide lifts all boats” Address learned inattention Clarify/verify Cognitive/attention tasks 16
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How to Treat & Manage Auditory Comprehension Problems in Aphasia 17 Available at EverythingSLP.com
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Aphasia: Factors That May Affect Auditory Comprehension Syntax complexity Length of sentence Speech sound decoding Sound processing Verbal working memory Semantic processing Short term memory Attention skills Depression Bad habits Lack of faith in listening skills Running start Learned helplessness Hearing loss Noisy background Speaker variables: mumbling; rapid rate; accent; eye contact; manner 18 www.EverythingSLP.com
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12 Smart Message Delivery Strategies to Facilitate Auditory Comprehension Manage background noise- maximize auditory signal. Use an alerting signals to get his/her attention. Use face to face communication – always use eye contact. Use a slow, yet natural, rate of speech – stretch vowels. Place key words at beginning. Pause before key word– use an inter-stimulus pause. Control message complexity - KISS it. Use a shorter sentence(s) to control message length. Use direct wording – say what you mean clearly Increase redundancy –straightforward language. Use supplementary cueing –gestures; print; photos. Train client to be assertive about fuzzy comprehension. 19 www.EverythingSLP.com
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12 Ways to treat Auditory Comprehension Problems (ACP) Improve the clients ability to attend. Probably most important. Effectively treat expressive aphasia – Arising tide lifts all boats. Recognize that ACP in aphasia as a circumscribed deficit does not exist – identify and treat the actual culprit. Eliminate apraxia or other contributing or masking factors. Overcome the apraxia that affects the head nod – shake for yes-no. Ensure that everyone involved exploits the 12 strategies. Work diligently to remediate underlying, contributing cognitive problems. Control message complexity - KISS it. For the person with a fluent type aphasia, be sure to address effectively any syllable structure processing issues. Clean up any residual motor issues such as apraxia or ataxic dysarthria. Study the history of treatment programs – what really works? Avoid falling into the trap that isolated drills facilitate recovery. 20 www.EverythingSLP.com
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Visual Recognition (Agnosia, Asymbolia) PROBLEM TX ACTIVITIES Clinician: “I brush my teeth with it.” PWA: “I have never seen one of those.” QOL Verify a selected symbol Visual Action Therapy (VAT) Promoting Aphasics’ Communication Effectiveness (PACE) 21
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Semantics [meaning]-Lexical Cognition PROBLEM TX ACTIVITIES Semantic knowledge Fuzzy semantic boundaries Semantic Boxing Semantic Feature Analysis (SFA) Verb Network Strengthening Treatment (VNEST) PWA: “I think it’s a thing.” “It’s writing... no booking.” “I can’t really think of that.” “Sounds familiar, I’m sure I knew it once.” 22
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Lexical [affect of field]- Semantic PROBLEM TX ACTIVITIES PWA: “That’s a door.” “I know it’s for writing, with a pencil, it’s a pen, no paperpen…” Lighting Up the Lemma Lemma Lit up? >raise hand Tribond game Nerbing 23
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Phonological Encoding -Word Form PWA: Phonological encoding “pent”, “benner”, “peen” (neologistic-jargon “des”; tindent”) “I know the word. I can see it in my head but I can’t get it out. PROBLEM TX ACTIVITIES Lexical-Semantic meltdown Phonological Assembly 24
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But butter butterfly = FA But butterfly butterfly = common; syllable structure But but but = syllables structure; phonological buffer Mutt mutter mutterfly = phonological encoding; Butterfly no no = imitation; awareness Butterfly butterfly = imitation; But but not butter = calm repair. no no butterfly “What?” = attention Moves lips while = attention; lack of faith listening imitation-bound; running start syndrome 25
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But butter butterfly Bit better = vowel; phono-semantic butterfinger But cutter mothfly = lex-semantic; phonol encoding Beet beetly beetlyer = morphologic; vowel; But buTTER butterFLY = prosodic; But but…ter bu..tter….floo = mental resources alloc; phonol I can’t = learned helplessness; aphasic; “What? ‘Did you hear = attention anything? “Yes butter.” But butare buttarefly = syllabic issues “This is stupid.” = He’s got a point there. 26
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Motor Planning (Acquired Apraxia of Speech) Phonemic encoding: “(silence)” Struggle to phonate: “uh..hhuu; “bodee bodee boddee.” PROBLEM TX ACTIVITIES The Viking Motor Reconnect Apraxia Program Limb therapy Chunk a syllabary 27
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Physical Movements (Dysarthria) Physical execution: “shlen.” “ whisper pen” Tightness PROBLEM TX ACTIVITIES Speech Therapy: breath flow; relax; natural; eye contact; release; ataxic dysarthria 28
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Physical Movements (Coordination) Ataxic Dysarthria PROBLEM TX ACTIVITIES Oral Motor Coordination Program and Activities 29
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Syntactic – Semantic Creating sentences: “coffee; aphasiaisms – “drinking coffee”; noun bound; one word answers; agrammatism; morphology PROBLEM TX ACTIVITIES Sentence Patterning; Conjugation; Pronouns; Canonicalize; Fill in grammatical slots 30
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Cognitive Memory Working memory Attention Problem solving Cognitive flexibility Reasoning- Inferencing Perseveration ****** PWA: “Key….to the… I forgot.” Jerk head when addressed; look lost; act aphasic PROBLEM TX ACTIVITIES Verbal Working Memory Attention Training Attention tasks Metacognition 31
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Prosody Intonation (Aprosodia) Mental Resource Allocation Stress for syllables and words Blending ; Rhythm; Melody Intonation for sentences Phrasing Monotone Lack of word stress PROBLEM TX ACTIVITIES Sentence Intonation Patterning Heteronyms Viking with an Attitude 32
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Whole Person Recovery Fatigue Pain Medication Anxiety Depression: clinical - situational PROBLEM TX ACTIVITIES Schedule Work through it Develop faith Whole Person Recovery Alternative treatments 33
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Intent Intent, pragmatics; Why are you talking?: “Imitating; lack of topic introduction. “ PROBLEM TX ACTIVITIES What do you think of me? Say what you mean; Aphasia Quips Inferencing; Speaker Question Intent: 34
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Mental Resource Allocation-Cognitive Allocation of mental resources: PROBLEM TX ACTIVITIES metacognition; metaphasia; A rising tide lifts all boats, Keep treatment simple but program robust; formative assessment 35
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The notion that speech or language or word recall is located in one part of the brain is becoming increasingly difficult to support. Rather, expressive and receptive speech requires rhythmic and coordinated activations and interactions by numerous neural structures and processes for normal speech as well as for aphasia treatment and practice that truly exploits neuroplasticity. http://neurosciencenews.com/brain-activity-neurobiology-6224 Moore. 36
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OK, let's get this straight once and for all....."There is no center ( speech or language) but a network of interconnected areas, each with a slightly different specialization,...". Researchers from Northwestern University just published a paper in the journal Brain (Marek-Marsel Mesulam) wherein they demonstrate that Wernicke's area, thought to be the center of language comprehension, in fact is not. We have so very much to learn about how the brain processes and creates speech and language. The concept that there is a speech center leads to the idea that these are circumscribed aphasia disorders which leads to the idea that one method or exercise or approach or app can make a real difference. "Forget about it." Richmond, Ben, https://motherboard.vice.com/en_us/article/weve-been-wrong-about-where-the-brain-process-language-for-141-years, 2015 37
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Treatment Domains: Phonetic Encoding: motor knowledge; plan; execution Phonologic encoding; syllabary; prosody; sounds; coartic Semantic Cognition: word activation; meanings Syntactic Processing: syntax; verbs; sentences Conceptual: symbolic, idea; mental proposition Discourse: narrative; conversation; pragmatics Cognition: VWM; attention; episodic buffer; ProSolv Orthographic: spelling: keyboarding; reading Whole Person: safety, music, faith, family, exercise 38
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What is Neuroplasticity? Old science: Rita Marie Ryan Smoke a cigarette lose 50 brain cells> drink a beer lose 100 brain cells 39
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What is Neuroplasticity? Neural plasticity is the ability of the central nervous system (CNS) to change and adapt in response to environmental cues, experience, behavior, injury, or disease, (Ludlow, et al. 2008) http://www.cnn.com/2016/08/16/health/language-in-the-human-brain/index.html 40
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Neuroplasticity and Aphasia Recovery The human brain’s ability to continually grow, learn and recover is well documented (Gage, 2002; Hamilton, 2011; Scientific Magazine, 2007 Despite these remarkable scientific advances, insufficient attention has been given to developing innovative tools and techniques to take optimal advantage of neural plasticity in efficient ways in the treatment of aphasia (Helm-Estabrooks, 2011; Kirkland, 2004; Robbins, 2011; Varley, 2011) 41
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Why AAC devices fail to interest PWA/PRA Asymbolia Abulia Aphasia Apraxia – motor planning Embarrassment Not natural Too slow and cumbersome Keyboard agnosia Cognitive issues Figure ground Fear of abandoning speech 42
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Hopefully we are beyond the idea that drilling cognitive skills in contexts that are far removed from the actual speech-language skills to which they are expected to apply. Research is refuting the idea that we should spend much treatment or practice time in training programs. “… that assume transfer of general skills to language processing.” Be prepared to justify the use of apps, worksheets and drills that isolate memory or attention skills. Peach and others, Seminars in Speech and Language; Feb, 2017. 43
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Motor- How to Treat Acquired Apraxia That Affects Phonation - It’s all about moving air. Phonetic encoding Viking Basic Perfect Viking 1 Durational Viking – stretching the vowels Pulsed Viking - presyllabic Viking with and Attitude – preprosodic – decoding prosody # of syllables add stress pattern The / h / Viking The varied Viking: / m / ; /vowels/ Vowels around the mouth – It’s all about moving the jaw Jaw positions 3: up - middle - down long vowels 7 ( / i e ae ^ a O U / mix the order short vowels (shorten the long vowels) diphthongs – maintain voicing as jaw moves Vowels become pronouns / h / & /a/ / h / & long vowels - /hh > /a/ > /h/ > /OO/ > /h/ > /ae/ > /h/ / h / & short vowels - /h/ > /a/ > /h/ > /OO/ > /h/ > /ae/ > /h/ /h/ & /m/ - /h/ > /m > /h/ > /m/ > /h/ > /m/ > /h/
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How To Treat Acquired Apraxia That Affects Articulation – It begins to be about moving the articulators Begin to add a consonant Vowels around the mouth > / VC / > a /C/ eat /EEt /; it / it / ; ate /At / Vowels around the mouth > / CV / > a /C/ eat /EEt /; it / it / ; ate /At / Accept features first The elevator for vowels: Long vowels - /EE/ > /a/ > /EE/ > /OO/ > /EE/ > /ae/ > /EE/ Long & short vowels - /EE/ > /a/ > /EE/ > /i/ > /EE/ > /ae/ > /EE/ > /o/ > /EE/ > /OO/ > /EE/ subjective pronouns leading to conjugation Co-articulation-anticipatory – It’s all about loading up the syllabary syllabification; Schwa initiated increasing syllables Contractions Phoneticize Scatpraxia : vowels > vary vowels > add consonants
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How to Treat Acquired Apraxia That Affects Symbolic Gesture - It’s all about loading up the gesturbary moving the hand and arm symbolically Canonical Gestures How To Treat Yes-No Acquired Apraxia: Yes/No apraxia for head nod/shake: MMMHHHH > head shake < > nod ?Yes-No-Delicious Number Concept Coaching Basic answers Complex answers Morra (Rock-Paper-Scissors) Recognize question intent Forced point to either < > or question Point to answer for question type : yes/no ; either-or; closed ended; Oral Motor Coordination Program How To Treat Stereotypes / Recurrent Utterances How To Treat Acquired Ataxic Dysarthria Traditional Approaches 8-Step Continuum - Melodic Intonation Therapy - Visual Action Therapy
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Phonological: How to Treat Phonological Aphasia – AphasiaPhonics Phonological encoding Phonological Aphasia: Syllable Count and Syllable Structure. Vowels around the mouth Elevator Vowels > Liquids > plosives > fricatives Increasing syllables Basic (one-syllables; frequency effect; simple sound structure) More complex (mutli-syllabic; less frequent) Schwa initiated Vary 1st word (one > one rain > one rainbow > Phoneticize: sound-letter correspondence
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Phonological: How to Treat Phonological Aphasia – AphasiaPhonics Compound words Basic 1st or 2nd word remains the same Cognitive assembly after individual meaning ( dog > house > doghouse) Tripounds > quadrapounds Anagrams Lexical decision Semantic decisions Lexical – Semantic Meltdowns Phonological Assembly Sound embedded verbs Traditional Approaches: Phonomotor by Kendall
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Semantic Cognition: How to Treat Word Activation & Spreading (Word Recall) Pronouns Subjective Objective Possessive Question concepting Personalized Pronoun Coaching Concept Coaching Question - Interrogative Drill Clarify a mumble Reading Headlines with Comprehension Cataphors – Anaphors Indefinites Light Up the Lemma: build a sentence to work from client’s thoughts. Semantic Feature Stimulation ( SFS) Semantic Figure Ground Attention to detail
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Semantic Cognition: How to Treat Word Recall – Activation Verbing – Argument fluency Phrasal verbs Nerbing Mental state verbs Flip the subject Numeracy Number concept coaching Number conversions Number Concept Coaching Reflect feeling > reflect content = connotation vs. denotation
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Semantic Cognition: How to Treat Word Recall – Activation Word Forms Homonyms – antonyms-synonyms Heteronyms Multiple meaning: Nouns-Verbs-Phrasal Verbs Hinky Pinkys Rhyme, Antonym, Synonym Same-Different 3 with no foil > 3 with one foil > 4 ? 3 with two foils > 4 with 2 foils Provide 3 words > create a sentence Sematic scaling Traditional Approaches Semantic Feature Analysis
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Syntactic Domain: How To Treat Agrammatism Verbing Common 5 > 10 ; reverse ; add alternates ; Real-time concrete verbs Group Lighting up Broca’s area – BA more than just expressive Conjugation Build to Canonical Right branch to extend verbal working memory Left Branch time concept Complex & compound sentences: conjunctions Contractions
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Syntactic Domain: How To Treat Agrammatism Sentence Patterning Subject Verb > Canonical Vary pronoun Take to a Conversational Dyad Use in all activities Slotting (Fitzgerald Key) Phrasal Verbs Tensing Recursion – Create 1 complex or compound sentence for 2 or 3 shorter ones Conjunctions
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Syntactic Domain: How To Treat Agrammatism Modals Modal Conjugation “Conversational dyad Modal Chiasmus: Reverse question asking: attention (#s; letters; S-V; +verbs) Modal Increasing Syllables Morphologic Derivational switching Prefixes > suffixes > internal Irregular past tense verbs Inflectional word building: grammatical category does not change Derivational word building: change in word form Prepositions Phrasal verbs Active – Passive Sentence Meltdowns Irregular past tense verbs Contractions Traditional Approaches: Mapping; TUFTS
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Conceptual Domain: Where it all begins. Thoughts Ideas Concepts Intent Semantic activation If you don’t start from here it is not real. Least contrived Light p the Lemma Sentence
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Discourse: How To Facilitate Conversation and Narrative Reflection Reflect-Release-Create Take Everything to a Conversational dyads Question asking Clarify > Verify WordSmithing Pacematics: Exploiting Spontaneous Utterances in Aphasia
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Discourse: How To Facilitate Conversation and Narrative Groups Build a story Intent Speech Acts – Say what you mean Garbage can inferencing AphasiaQuips Create a Headline Toastmasters Traditional Approaches PACE
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Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language Blend these into all that you do with deliberation: metacognition (metaphasia; metapraxia) How To Treat Perseveration Mental Resource Allocation Problem Solving Cognitive Flexibility Divergent thought
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Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language Executive functions Verbal Working Memory and Attention Training AphasiaDoKu Rhyme, Antonym, Synonym with an Attitude Verbing with an Attitude Forced choice: 2 ; 3
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Cognitive: How To Strengthen the Cognitive Underpinnings for Speech & Language Manipulating numbers Strooping Garbage Can inferencing Attention tasks: Constant Therapy Proactive memory: Word of the Day Traditional Approaches 1. Constant Therapy
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Orthographic Keyboarding Flash Spelling Elision: vowels; abbreviations; acronyms #of letters # of words Types of words Phrases and sentences Thread throughout daily work Paragraphs Group work
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Whole Person Recovery Plan Whole Person Recovery Plan Nutrition Rest Exercise: transition from patient (Ptherapy) to person (Ptraining) Music Spirituality Drugs Alternative treatments: hyperbaric; Embrel; injections; acupuncture; transcranial direct current stimulation; stem cells; Relationships
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Related PPA Right Hemisphere Stoke Apps Assessment Formative Assessment
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How do we exploit this type of program…. ….in the real world of: limited visits? 3rd party payments? organizational barriers and obstacles? ???
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We…. refer to experts. commit to change and effectiveness. organize efforts. collaborate – telepractice. ????