Vol. 18 •Issue 14 • Page 6
Emerging role of technology
While there's little evidence indicating an advantage of one aphasia treatment over another, researchers agree that practice and repetition benefit patients. And one of the most cost-effective ways patients can get practice and repetition is through technology, stated Leora Cherney, PhD, CCC-SLP, BC-ANCDS, director of the Center for Aphasia Research at the Rehabilitation Institute of Chicago in Illinois.
Current research at the center is focusing on the efficacy of three computer programs she helped develop: Oral Reading for Language in Aphasia (ORLA), AphasiaScripts, and a Web-based version of ORLA. If the programs prove successful, they could augment speech-language pathology treatment for people with aphasia, she told ADVANCE. The studies are supported by the National Institute on Disability and Rehabilitation Research.
Contributors to the development and assessment of the computer programs include Sarel van Vuuren, PhD, and Nattawut Ngampatipatpong, of the University of Colorado in Boulder; Ronald Cole, PhD, of Mentor Interactive Inc., in Boulder; Edie Babbitt, MEd, CCC-SLP; Anita Halper, MA, CCC-SLP, BC-CD; Rosalind Hurwitz, MS, CCC-SLP; Jaime Lee, MS, CCC-SLP, of the Rehabilitation Institute of Chicago; and Audrey Holland, PhD, of the University of Arizona in Tucson.
ORLA involves clinicians and patients reading sentences and paragraphs aloud simultaneously. Patients can see and hear the sentences, point to
words, and receive support from the speech-language pathologist.
ORLA originally was developed in the 1980s to improve reading comprehension in individuals with aphasia.
"As it became easier to decode words while reading aloud with the therapist, they would also start to understand and comprehend what they were reading. That was the original basis," said Dr. Cherney, associate professor of physical medicine and rehabilitation at Northwestern University, Feinberg School of Medicine, in Chicago.
Subsequent studies showed that patients experienced cross-model generalization when using ORLA. While she and her colleagues observed changes in reading comprehension, they also noticed changes in oral and written expression and auditory comprehension in some participants.
"It's hard to know exactly what the mechanism is in terms of what's happening with oral reading," she said. "There's the multimodality stimulation and the repetitive practice and intensity of therapy."
Intensity of treatment-or the amount of treatment a patient receives in a specific interval of time-is a key issue in aphasia recovery. According to research on the recovery and rehabilitation of the motor system following stroke, the more intense the treatment, the more effective it may be.1
"We're starting to see the same kind of information in speech-language therapy research," said Dr. Cherney.
But could treatment that is "too" intense turn out to be detrimental? "We don't know what an optimum dosage of therapy is going to be," she said.
The amount of therapy that is optimum for a patient depends on many factors, including the type of treatment and certain patient characteristics, such as how much time has passed since the stroke, the size and location of the lesion, and other neurological and motivational factors.
"We don't have that information yet. We do know from animal studies that if the intensity of the treatment is too great early on, it may increase the size of the lesion," she said. "We also know that individuals with chronic aphasia respond positively to intensive language therapy. Intense treatment may be appropriate for some cases, while lighter, more distributed practice schedules may be warranted for others."2
In one study on ORLA, half of the participants received therapy using an early version of the computer program, and half received ORLA from a speech-language pathologist. Both groups improved, but the group that worked with the therapist actually showed greater improvement. Dr. Cherney and her fellow researchers hypothesized that one reason was because the group that used the program simply didn't have access to a speech-language pathologist for support.
"When you work with a therapist, the patient can look at the oral-motor movements of the therapist and get some additional clues from watching the movements of the therapist's mouth, particularly if they have apraxia of speech," she pointed out.
The researchers worked with the Center for Spoken Language Research (CSLR), in Boulder, CO, to develop a new computer program that would include an animated avatar in the shape of a speech-language pathologist's face. "The mouth movements [of the avatar] are relatively good but not perfect. It produces movements that are fairly similar to what a person would produce if they were saying these sentences," said Dr. Cherney.
The researchers then put the new ORLA program to the test. Subjects were randomized to receive either four or 10 hours of ORLA therapy a week, and the researchers are now analyzing these results.
In a second computer program, AphasiaScripts, the virtual therapist was designed to engage patients in scripted conversations.3 The rationale of the program is to improve the automatic production of larger units of language in natural conversation.
For example, an individual could learn to use the phrase "So, what's new with you?" as a way to initiate conversations at a gym or in other social situations. "His aphasia hasn't gotten any better," she said, "but he now has the tools that make him a better communicator. He can initiate the conversation."
"We don't necessarily expect that it will change language skills so they will improve a certain number of points on a formal aphasia language test but instead give individuals a way to be better communicators by having them produce chunks of conversation so automatically that it will come out very easily and fluidly in a variety of situations," she said.
The skills promoted in AphasiaScripts are not automatic speech, like counting, reciting the days of the week, or singing "Happy Birthday." Rather, the program provides practice with conversation that is not yet automatic to the individual. "It's taking things that are important for them to talk about and, with repeated practice, helps them produce segments of their conversations more automatically," she said. For example, a real estate agent who wanted to return to work learned scripts that focused on showing houses and dealing with the closing process.
Dr. Cherney and her colleagues also are evaluating the potential for providing aphasia treatment over the Internet. They are recruiting individuals from around the country to test a Web-based version of the ORLA program. Patients will be able to log in to the program on their home computer while clinicians monitor their progress from a host computer. The program allows for real-time interaction and for making necessary changes such as adjusting the level of difficulty. One individual has completed the six-week program so far.
Dr. Cherney plans to conduct a randomized study involving 25 individuals with aphasia. Some participants will receive treatment through the computer version, and others will act as the control group and complete a non-language-based computer program. Researchers will use Web cams to check in on the individuals.
"We want to compare the oral reading therapy with just doing something on the computer," she explained. "We've progressed with the oral reading, going from a straightforward program to one with the avatar, to looking at issues related to intensity of treatment, and then to the Web-based version."
During the six-week program, participants will practice nine hours a week. They will participate in three 30-minute sessions or two 45-minute sessions a day for six days a week.
"We are looking to see if aphasia treatments using specific technology work," she said. "We know that practice and repetition are important. Current methods of delivering aphasia treatment have to change if we want to provide high-intensity treatment. As technology improves, why not make use of it?"
1. Kleim, J.E., Jones, T.A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech-Language-Hearing Research, 51: S225-39.
2. Humm, J.L., Kozlowski, D.A., James, D.C., et al. (1998). Use-dependent exacerbation of brain damage occurs during an early post-lesion vulnerable period. Brain Research, 783: 286-92.
3. Cherney, L.R., Halper, A.S., Holland, A.L., et al. (2008). Computerized script training for aphasia: Preliminary results. American Journal of Speech-Language Pathology, 17: 19-34.
For More Information
Leora Cherney, PhD, e-mail: email@example.com
Jason Mosheim is an Associate Editor at ADVANCE. He can be contacted at firstname.lastname@example.org.