Meeting Recap from Dr. Biel

Thank you to everyone who made to our last meeting of the school year with Dr. Biel.

Here are the notes from the meeting:

Michael Biel CScD, CCC-SLP
05/10/11
Intensive Aphasia Treatment: Case of Non-Lexical Recurrent Utterances

• This is a case about a gentleman in a program called Pirate (Pittsburgh Intensive Registration Aphasia and Treatment Evaluation) in Pittsburgh.
• Why did this program become established? Aphasia is a complex disorder to treat and several veterans at the time had Aphasia.
• History: 61 y/o male, with left MCA (Middle Cerebral Artery) CVA (Cerebrovascular Accident) in 2005, global aphasia and severe AOS (Apraxia of Speech)
• He had nonlexical speech where he only said, “Ba ma ma ma, huh, ba bum bum ma ma.”
• treatment Hx:
• had 1-year inpatient rehab
• 2 years outpatient treatment (tx)
• group treatment
• various experimental txs
• despite tx, his speech did not improve; he was unable to repeat sounds.

• In PIRATE:
• tx for 6 hours a day for 6 days a week for 4 weeks.
• 4 hours of treatment were individual tx and the other two hours were in a group setting.
• COGNITION:
• he scored WNL on the Raven’s colored Progressive Matrices (assesses problem solving) and scored WNL on the pyramids and Palm Trees Test (assesses semantics)
• MOTOR SPEECH
• no cranial nerve signs
• motor speech testing was difficult- did show signs of nonverbal oral apraxia (NVOA)
• could imitate a “Uh” and /h/ via a PROMPT
• could manipulate rate and prosody of recurrent utterance when given a model
• AUDITORY COMPREHENSION
• Comprehensive Aphasia Test (CAT)
• he scored 21%ile for single word
• VERBAL OUTPUT
• all tasks resulted in production of the recurrent utterance
• chance level performance on a pictured rhyme judgement task from the PALPA; the PALPA is used supplemental to other Aphasia tests.
• a picture rhyme subtest is used: a picture of a fan and van are showed and the person has to indicate whether or not the words rhymed or not (yes or no)

• On PALPA’s picture-rhyme test he scored in the low percentile level; this means that his apraxia of speech could be and issue of something else.
• READING
• he had good visual lexical decision making (58/60); this means that for reading, he has some comprehension. He had poor with written rhyme judgment (31/60)
• perhaps he had impaired phonological processing?
• or impaired subvocalization or verbal working memory

• WRITING
• he was able to write 6/40 written items on PALPA; this suggests something that we can work with; he was also abel for write by dictation 5/6 3 letter words.
• WHY CAN’T SJ (client) REPEAT?
• Apraxia of Speech?
• He did show non-lexical recurrent utterances; he had some Nonverbal Oral Apraxia; in tx, he demonstrated overgeneralization during articulatory tx.

• TX GOALS

• 1) improve ability to repeat 2) use social greetings 3) improve ability to use writing to communicate
• TX PLANNING
• Dr. Biel looked up research articles that focused on treatment for individuals with recurrent utterances and studies with individuals with global aphasia and significant AOS. Most of the articles he found were antedotal. One article he found dealt with PROMPT.
• Dr. Biel used PROMPT since it was likely that SJ had AOL.
• INITIAL GOALS with PROMPT
• 1) control voicing during production of /h/ and “uh” contrasts
• 2) control jaw opening in /m/ and “uh” contrasts

• PROMPT RESULTS
• both goals were not met; he overgeneralized /h/ for “uh”
• NOW WHAT?
• Do we abandon goal to work on speech?
• Try antedotal txs like VCIU or MIPT (multiple input phoneme tx)?
• Try melodic intonation therapy?
• Dr. Biel tried MIPT after several attempts to contact the author of the research paper about MIPT.
• MIPT:
• How does this work?
• Step 1: gain control of involuntary utterance
• Step 2: use sounds in the recurrent utterance to generate new words to practice/probe (if the person says “ma ma” get them to say “ma mom”
• CONTROL
• Multiple inputs of the target phrase before production attempt.
• Integral stimulation (look, listen)
• Rhythmic tapping on the ipsilesional arm
• Choral repetition with the clinician being louder.

• EARLY MIPT RESULTS
• SJ controlled production of his recurrent utterances, BUT was unable to produce words generated from the recurrent utterance.
• MIPT MODIFICATIONS
• Include PROMPT cuing
• Try and create unique errors, i.e. errors that contained new sounds or sound combinations; this helped diversify SJ’s phonetic inventory.
• After a word was taught, SJ was immediately taught to generalize these words, such as “Hi.”
• RESULTS
• By the end of tx, he could produce 60 words, mostly one syllable with anterior, visible consonants.
• 50/60 repeated on post-testing with integral stimulation
• On the Syllable Length Repetition subtest (PALPA), he scored he got 6/24 by the end of treatment; initially he scored 0/24. By the end of treatment, he did not use “Ma bum bum.”
• By the 4th week of treatment, he was able to produce, “Hi,” “Fine,” and “Bye,” for social greetings.
• By the 4th week of treatment, he made improvement with writing but only with specific items which did not generalize.
• WHAT CAUSES NON-LEXICAL RECURRENT UTTERANCES?
• There is a damaged phonological system that is cut off from other systems in a loop.