Treating verb retrieval a clinical study

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Treating verb retrieval a clinical study

• S. Edwards1,2 K. Tucker1
• 1University of Reading, UK
• 2 University of Limerick, Ireland
• Seminar
• University of Reading 2006

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Verbs are necessary for sentences
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• Meaning
• Phonological form
• Syntactic information
• 1. the permitted and obligatory phrasal
  structure that can / may follow or precede
  the verb
• 2. distribution within a sentence
• 3. tense and agreement.

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Verbs and aphasia

• Verbs may be more vulnerable than nouns in
  Brocas aphasia
• (Berndt et al 1997 Miceli et al 1984 Zingeser
  Berndt 1990 Semenza, Luzzatti, and Carabelli
  1997)
• although not always (Berndt Haendiges 2000
  Caramazza Hillis 1991)

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And in some cases of fluent aphasia, verbs are
more vulnerable (Berndt et al 1997)

• Further verb production may be atypical.
• For example
• diversity of verb types may be reduced in fluent
  aphasia (eg. Edwards and Bastiaanse 1998)

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Treatment of verbs and sentence production

• Creating sentences may be aided by providing the
  verb (Berndt et al 1997 Webster, Morris and
  Franklin 2003)
• Or a sentence frame may elicit verb (Webster et
  al 2003)

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• 15 years of sentence treatment
• Jones 1986 Thompson et al 1993 Thompson et al
  1997 Ballard Thompson 1999 Thompson et al
  2003 Webster, Morris and Franklin 2003
• Evidence of a bi-directional effect
• Treatment of sentence structure associated with
  greater facility with verbs (Weinrich, Shelton,
  Cox and McCall 1997 Thompson, Shapiro, Kiran and
  Sobecks 2003)
• Treatment of verbs influences sentence structure
  (Mitchum and Berndt 1994 Raymer and Ellsworth
  2002 Schneider and Thompson 2003)

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• However..
• work on improving sentence structure and verb
  retrieval has almost exclusively been with
  agrammatic subjects
• although studies now beginning to look at fluent
  or mixed aphasia (Murray, Ballard and Karcher
  2004)

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Experimental vs clinical trials

• Constraints of clinical practice
• Resources
• Subject selection
• Subject / funders expectations
• Ethics
• Replication

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Experimental vs clinical trials cont.

• Differing aims and design
• Clinical looking for improvement in language
  behaviour that is sustained ( Howard, Best, et al
  Jane Marshall et al 1997)
• Experimental looking for evidence that the
  independent variable brings about change
  (Thompson , Shapiro et al 2003).

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Experimental vs clinical trials cont

• Design phase of treatment / non-treatment
• Choice of dependant variable.
• External validity
• experimental strength / communicative application

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The study

• A clinically based trial in a typical NHS setting
  
• Regular treatment focused on verb retrieval in
  fluent aphasia
• Aimed to increase proportion of well formed
  sentences and to answer theoretical questions

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Questions

• Can verb retrieval be facilitated by systematic
  and repeated exercises in fluent aphasia?
• Can speed as well as accuracy of retrieval be
  improved?
• Will enhanced verb retrieval generalise to
  untreated verbs i.e. response generalisation?
• Will improved verb retrieval in controlled tasks
  be associated with a greater proportion of
  well-formed sentences i.e. stimulus
  generalisation (Thompson in press)?

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• Can improvement be maintained?
• What effect does the type of assessment task have
  on performance?

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• Response generalisation changes in untrained
  language behaviour. For example a set of words
  is trained and improvement is found in the
  untrained set.
• Stimulus generalisation changes in untrained
  language conditions. For example when
  improvement in word retrieval impacts on ability
  to retrieve words in narratives. (Thompson in
  press)

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Our project

• Multiple single subject design using within
  subject comparisons to examine the effect of
  treatment on verb retrieval in fluent aphasia.
• Subjects with fluent aphasia (BDAE 2001)
• Regular and systematic treatment backed up by
  home practice over 2 - 4 months

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Subjects

• 3 subjects were recruited via local SLTs.
• All were diagnosed as having fluent aphasia (BDAE
  2001)
• Aphasia resulted from left-sided CVA
• At least 6 months post-onset.

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Table 1. Participant details
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Procedures

• Base line 3 assessments pre-treatment over a 3
  month period.
• treatment 2 x week 4 months (JD CB)
• 2 x week 3 months (JR)
• Follow-up testing
• Subjects JR CB
• immediately after treatment and 3 months post
  treatment
• Subject JD
• immediately after treatment and 2 months post
  treatment

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Assessments

• Initial sessions
• Shortened BDAE (Goodglass, Kaplan and Baresi
  2001)
• All testing times
• Production and comprehension of verbs
• Production and comprehension of sentences
• (VAST Bastiaanse, Edwards and Rispen 2002)
• 3. Object and action naming (Druks and Masterson
  2000)
• 4. Continuous speech samples

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• (VAST Bastiaanse, Edwards and Rispen 2002)
• Production and comprehension of verbs
• naming single action pictures (N40
• selecting 1 of 4 action pictures (N40)
• Production and comprehension of sentences
• creating a sentence picture (N20)
• Selecting 1 of 4 pictures (N40)

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• 3. Object (162) and action naming (100) black
  and white line drawings
• (Druks and Masterson 2000)

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Control tasks

• non-word repetition
• syllable length repetition
• spelling to dictation
• (PALPA Kay, Lesser and Coltheart 1992)

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Connected speech data

• Story retell
• Aesops tales (BDAE)
• Picture description (Cookie theft BDAE)
• Conversational data (aided by a video news clip)

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Treatment

• Structured and repeated exercises to elicit
  verbs drilling.
• Procedures
• sentence completion
• definition
• picture naming (Berndt et al 2002)

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Verbs for treatment

• 50 action pictures set A treatment
• 50 action pictures set B control
• Sets controlled for frequency, AOA, familiarity
  and argument structure.

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Trialing materials and procedures

• All sentence frames for completion and definition
  questions were trialled on 20 non-aphasic
  speakers.
• Materials were adjusted until gt 85 agreement for
  each target verb (McCann 2005 Kemmerer and
  Tranel 2000)

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Order verbs were presented in the treatment tasks

• transitive verbs (kick)
• unergative (sing)
• optional transitive / unergative (eat)
• optional transitive / unaccusative (melt)
• (Shapiro et al 1987 Thompson et al 1995 Lee and
  Thompson 2002)

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Tasks for elicitation

• Built in cueing in the tasks
• Sentence completion (syntactic semantic)
• Definition (semantic)
• Picture naming

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Error free learning

• Additional cueing used to promote accurate
  responses
• semantic knot your shoe laces
• initial phoneme /t/
• part word /tei/
• multiple choice with semantic and phonemic
  distractors
• repeat target tie

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Task requirements

• Accurate and prompt response adjusted for each
  individual based on maximum time taken to respond
  in VAST.
• Any form of the target verb was accepted
• Needed to achieve 85 in two out of three trials
  of same task before moving to next level max. 2
  weeks

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Feedback

• Scores recorded on-line and participants were
  aware of their performances.
• Changes in scores were discussed.
• Aimed for a collaborative working sessions.

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Home practice

• Explicit work sheets for home-practice.
• Ten minutes twice a day, every day, except
  treatment days when one practice was required.
• Exercises were repeated even when 100 achieved.
• Practice partner attended sessions when new task
  was introduced.

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Results

• Subjects had greater difficulty naming actions
  than objects (p lt0.05).
• at each time point for JD and JR
• at T2 and T4 for CB.

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• Was verb retrieval facilitated by systematic
  treatment?
• Verb retrieval was facilitated.

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Table 2. verbs correct before and after
treatment
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• Can speed as well as accuracy of retrieval be
  improved?
• Verbs were retrieved faster after treatment

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Table 3. Time taken to name verb list A
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• Will enhanced verb retrieval generalise to
  untreated verbs?
• There was some limited generalisation to
  untreated verbs for all subjects, the trend for
  improvement continued in the follow-up stage.

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• There was no significant change in performance on
  the control tasks.
• Some evidence of response generalisation but only
  retrieving verbs as single words.

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• Was there an improvement in well-formed sentences
  associated with facilitated verb retrieval ?
• Scores on the sentence production task (VAST)
  improved for all subjects. CB maintained and
  continued to improve.

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Table 4. Sentence production (VAST)
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• There was some limited evidence of improvement in
  continuous speech
• evidence of stimulus generalisation

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Continuous speech
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• On the Cookie Theft
• JD showed an increase in well-formed sentences at
  T4
• CB did not show an improvement
• JR showed an increased proportion of well-formed
  sentences in final follow-up assessment T5

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JR Cookie theft
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• Was there an increase only in the verbs used in
  treatment?
• No but.
• No significant generalisation across verb sets
  for 3 subjects but more verbs in conversation
  data for JR

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• Can improvement be maintained?
• Maintenance varied across subjects but also
  across measures

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Table 5. Maintenance of improved performance
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Task effect

• Different types of connected speech samples
  showed different effects (Berndt et al 2002)
• For JR improvement was shown in the picture
  description (Cookie theft) and the conversational
  data

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JR Cookie theft
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JR story re-tell
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JR conversation sample
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• For JD there was improvement at T4 in the picture
  description and the conversational data
  improvement not maintained in follow-up testing.
• Performance fell for the story re-tell.

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• For CB NS increase in the number of grammatical
  utterances only in the story re-tell. There were
  lower or equal proportions of grammatical
  utterances in picture description and
  conversational data.

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Conclusions and discussion

• Systematic treatment can be effective
• significantly more verbs produced after
  treatment and there was an increase in
  grammatical utterances in some tasks
• Although there was some diminishing of
  performance post treatment for 2 participants
  (also found in L2 learning)

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• Regular, systematic treatment was effective for
  treated verbs as measured at T4 for all
  participants

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• Will improved verb retrieval in controlled tasks
  be associated with a greater proportion of
  well-formed sentences in connected speech?
• Limited success.
• Not all subjects improved in all continuous
  speech conditions.

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Implications for clinical practice

• Increased scores dont equate with improvement
• Difficulty of establishing base lines
• Connected speech data are tricky

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on the other hand

• Deficit-based treatment can be effective
• Effects may last
• Deficit-based treatment can be offered as part of
  the intervention package

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• Transfer of agrammatic treatment to fluent
  aphasia may be effective.

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• The end
• Thank you

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Acknowledgements

• University of Reading Research Endowment Fund
• University of Reading Health Research Fellowship
• Wokingham Primary Care NHS Trust
• Phillip Mannion
• Debbie Begent
• Lizet Van Ewijk
• Clare McCann

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Verbs list A list B Vast
where the verb occurs also in list A or B, is
indicated in brackets (9 from A, 9 from B!)
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