Conference Presentation given at 3rd Annual Conference of Indian Federation of Neurorehabilitation IFNR 2015 at MET Mumbai, India in parallel worshop on Aphasia Rehabilitation

1. Cognitive-Linguistic Therapy
Strategies Across Different Aphasia
Types
Ms Sonal V Chitnis
Asst Professor in Speech Language Pathology BVDU SASLP
Coordinator of Memory Clinic ,Bharati Hospital Research
Centre &
BVDU School of Audiology &Speech Language Pathology
Bharati Vidyapeeth Deemed University, Pune 43
sonalc123@gmail.com
www.aphasiastrokeindia.com
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2. Perspective on Aphasia from Interdependence of language &
Cognition
Assessment of Cognition in Aphasia : Literature
From a Speech language pathologist’s
perspective, I aspire to cover...
Aphasia Rehabilitation : Goals, aims& Approaches
Cognitive linguistic Therapy CLT strategies
Case studies (PWA)
CLT vs Communicative treatment & clinical efficacy
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3. Modern Definition of Aphasia
• Aphasia is a multi‐modality disturbance of
speech, language, and memory caused by
neurological injury, particularly stroke (Small,
2010)
• There other principal aetiologies of aphasia
such as TBI, degenerative disorders, neoplastic
disorders, neuroinfectious disorders, etc.
• Each gives a rise to a different clinical picture.
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4. Language
LearningCognition LearningCognition
The term “cognitive linguistic disorder”
might have been used to acknowledge the
inseparability of cognition and language.
( Luria 1966, Sarno 1998, Chapeay 2001, Helm-Estabrooks 2002, Shapiro,2011,
Code 2012)
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5. Aphasia: Going beyond Language
'Language' is impossible without these 'horizontal' cognitive
functions ( Code 2012) :-
large range of aphasic symptoms can be
(partially?) explained in terms of impairments of
STM/working memory, Praxis impairmentsSTM/working memory,
executive deficits
(eg, inhibition, attention),
Praxis impairments
(eg, apraxia of speech,
spatial praxis),
Perceptual impairments
Dependence of language Info
processing on memory
(mainly STM/WM),
&executive functions.
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6. What to assess & address???
Primary elements of Cognitive processes- Attention, Memory,
language, Executive Functions, Visuospatial Skills
( Helm-Estabrooks, 2001)
Linguistic & Extra Linguistic skillsLinguistic & Extra Linguistic skills
VERBAL, SPATIAL & SOCIAL COGNITION
Metaphasia, Metacognition
*COGNITIVE LINGUISTIC ASSESSMENT
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7. LINGUISTIC
• Language
comprehensio
n
• Expressive
language skills
• Word retrieval
EXTRALINGUISTIC
•Literal Interpretations
•Social cognitive related-higher
pragmatic tasks
•Visuospatial skills
•Gestures, body language and
facial expressions
NONLINGUSTIC
• orientation
to Time
,Place, and
Direction
• Neglect
• Word retrieval
• Reading and
writing
• Calculation
EXTRALINGUISTIC
facial expressions
•Prosodic domain
• Time pressure management ,
reaction time ,
•problem solving & Reasoning
NONLINGUSTIC
• Attention
• Memory
WM/ STM
& LTM
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8. Cognitive neuropsychological
perspective from models of language
& Cognition
Many models provide an integrated account of
how cortical -subcortical structures might
influence language output through ainfluence language output through a
neuroregulatory mechanism that is consistent
with knowledge of cortical–subcortical
neurotransmitter systems and structural
features
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9. Divergent Semantic model
• Aphasia as a convergent semantic disorder based
on Guilford’s model 1966, Chapey 1977, Sarno
1998.
Chapey 2001 discussed assessment & treatment• Chapey 2001 discussed assessment & treatment
of Aphasia, that there are both semantic
convergent & divergent impairment ( the basis of
each individual's ability to recognize and
reproduce previously learned material and to
converge upon correct answer )
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10. The Multicomponent WM Model,
Baddeley 2003,Miyake & Shah 199908/03/2015 IFNR 2015,MET Mumbai India 10

11. 1] Global Aphasic Neuropsychologial battery
(GANBA) -- Van Mourik et al 1992
• Targeted non linguistic cognitive skills-
attention,
concentration,
memory & intelligence ( Raven’s progressivememory & intelligence ( Raven’s progressive
Matrices) ,
visual & nonverbal auditory recognition.
• Global aphasic with better scores responded
better for Language Oriented Treatment.
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12. 2] Cognitive linguistic Quick test (CLQT)
-- Helm-Estabrooks, 2002
Personal facts
Symbol cancellation
Confrontation naming
Clock drawing
Story retelling& paragraph comprehension
Linguistic
Story retelling& paragraph comprehension
Symbol trials
General naming
Design memory
Mazes score
Design generation
Non linguistic
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13. 3] Cognitive Linguistic Assessment protocol
-- Shyamala K.C. & Deepa, 2009.
• Domain i: Attention, Discrimination and
Perception
• Domain ii: Memory
• Domain iii : Problem Solving• Domain iii : Problem Solving
• Domain iv: Organization
4] Manipal Manual of Cognitive Linguistic
Abilities -- Mathew M , Bhat J 2014
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14. Focusing on Cognitive Neuropsychological
correlates in assessment & Rx of Aphasia
Right VS left Brain & Dominance , cerebral
Organization
Hemisphere specific Frontal, Temporal, Parietal ,
Occipital Lobar FunctionsOccipital Lobar Functions
Motor Vs Sensory impairment
Fluent vs. Nonfluent type of aphasia and other
Neurogenic communication disorders
Association pathways & Dissociated Cognitive
Linguistic networks
Multimodality based assessment
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15. REHABILITATION !!
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16. Person with Aphasia:
From Inner Self to Outer Self
What was it like Inside?
The Material ME The Social ME
The Spiritual ME
What was it like Inside?
• “When am I going to be me again? This is not
what I had in mind for ‘me.’ After some more
rehab will I be me again?”
mentioned by LaPointe in his preface in “Wings”,
Kopit A. ( 1978 ) & Viera E. (2005)
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17. INTERESTING CASE
STUDIESSTUDIES
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18. Case study 1
• 54 yrs, right handed, male came with c/o not able to
speak, read & write properly post stroke since 4 months.
• Subinspector by profession,
• Premorbid multilingual proficient in Urdu, Telugu, English,• Premorbid multilingual proficient in Urdu, Telugu, English,
Dakkhini
• MRI revealed Rt MCA infarct, massive frontoparietal
nonhaemorrhagic infarcts.
• Significant Lt Neglect, severe paraphasia, paralexic &
paragraphic errors noted.
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19. • He could answer in one to two word phrases, occasionally 3- 4 word
sentences observed.
• He couldn’t follow simple commands or express however he could
read words with paralexic errors, he couldn’t write except his name .
• Relatively preserved serial speech for numbers, days of week,
months of the year in Urdu, English & Telugu all three languages
• Interesting findings: initial phoneme deletion on reading, relativelyInteresting findings: initial phoneme deletion on reading, relatively
intact letter by letter spelled word recognition
• On Telugu Western Aphasia Battery : he could be categorized as
Transcortical Motor Aphasia
• Regressed Urdu & Telugu orthographical skills as compared to
English- L3
• On English WAB Pt showed significant regression on all.
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20. • Doctor : /octor/
• Nose : /ose/
• Table : /able/
• Economic Discrimination : /conomic
iscrimination/iscrimination/
• Similar pattern on L1, L2 was observed too.
Provisional Diagnosis:
Crossed Aphasia in Dextral with Neglect dyslexia
with dysgraphia
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21. Case 2
• 74yr/M, workaholic Ex managing director of Sugar Factory becoming
increasingly forgetful, since 6 months
• Difficulty recalling details of recent events , impairment to read, write,
discuss recent important information such as meetings ,payments,
appointments, luncheon engagements, etc. Poor verbal and spatial praxis
observed, and ideomotor apraxia. Poor learning , deficit in delayed recallobserved, and ideomotor apraxia. Poor learning , deficit in delayed recall
of the words on the Ray Auditory Verbal Learning Test
• Worried about his memory, Fluency- regressed Second language ( English)
, slow progression
• ADL well preserved.
• h/o bilingualism, premorbidly proficient in Marathi & English08/03/2015 IFNR 2015,MET Mumbai India 21

22. • MMSE 26/30,
• ACE-R 52/100,
• CDR= 0.7
• The remainder of his neurologic examination is
normal excluding mild slowed gait
• No sig clinical history noted in Neuropsychiatric• No sig clinical history noted in Neuropsychiatric
inventory ( NPI) except mild anxiety
• GP had treated him as early PD, no sig
improvement on Syndopa plus since 3 months
• He is concerned but not depressed
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23. Naming – 4/12
Circumlocution,
semantic paraphasias observed
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24. Dictation
Spont writing +
Copying words
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Spont Writing sample

25. Visuospatial abilities
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26. Reaction Time- 65 seconds, he could name
only yellow & Red, profound errors in stroop
taskShendkar K,& Chitnis S 2014
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27. • MRI reveals
Mild cerebral atrophy, medial
temporal atrophy noted, Lt parietal occipital
lobe> Rt Parieto occipital atrophy noted,lobe> Rt Parieto occipital atrophy noted,
lacunar ischemic infarcts noted bilateral
whitematter pathways
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28. DIAGNOSIS ???????????????
PNFA with CBSPNFA with CBS
( Progressive Nonfluent Aphasia with Cortico
basal Syndrome)
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29. APHASIA REHABILITATIONAPHASIA REHABILITATIONAPHASIA REHABILITATIONAPHASIA REHABILITATION
Primary goal of rehabilitation is to reduce disability and
help individuals attain a level of functional
independence (Sarno, 2004, Becker, 1994)
The Key Elements of Aphasia Therapy – Faith and
Rhythm.
Faith in memory - we converse from our own thoughts
and memory Conscience mind ( Friston 2011)
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30. Approaches in Aphasia rehabilitation
• General vs Specific treatment approaches
• Linguistic & Communicative aphasia therapy
approaches
• Stimulus response approaches such as MIT• Stimulus response approaches such as MIT
• Functional/ Pragmatic approaches & AAC
• Cognitive approaches : CLT
• Pharmacological therapy
• Computer-based interventions as an adjunct to
clinician guided treatment
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31. Aims of aphasia therapy approaches
Reactivation
Relearning
Brain reorganizationBrain reorganization
Cognitive-relay
Substitution
Compensation
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32. • The ultimate goal – to make PWA communicate
in everyday settings with unpredictable demands
& fluctuating conditions
Goal oriented behaviour & flexible problem solving
hall mark of Executive Functions.hall mark of Executive Functions.
Thus there comes need to consider INTEGRATION
of all domains of cognition for better Rx outcome
in Aphasia Rehabilitation (Helm Estabrookes,
2002)
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33. Renowned Aphasiologist Holland A. 1994, promptly
raised few of empirical questions.
1. Should the Rx of Aphasia be the language that is
preserved?
2. Should the focus of Rx of Aphasia be the Missing
Language ( Semantic& Phonological routes) ?
3. Should the focus of Rx of Aphasia be the tasks
that are used in treatment?
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34. 4. should the focus of Rx of Aphasia be on the
interaction of PWA and his/her environment?
5.should the broader deficits than language
problems such as Attention deficits, working
5.should the broader deficits than language
problems such as Attention deficits, working
memory, perseveration, be the focus of
treatment?
Or above all??
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35. COGNITIVECOGNITIVECOGNITIVECOGNITIVE---- OR NEUROOR NEUROOR NEUROOR NEURO----LINGUISTICLINGUISTICLINGUISTICLINGUISTIC
ORIENTED TREATMENTORIENTED TREATMENTORIENTED TREATMENTORIENTED TREATMENT
Concentrates on Cognitive processess & language-specific
impairment in an individual with aphasia .
The treatment involves specific tasks such as naming, semantic orThe treatment involves specific tasks such as naming, semantic or
phonological training, sentence production, writing and reading
(Chappey, 1977).
Other approaches include multimodal treatment or computer-
based aphasia treatment.
These interventions are based on psycholinguistic or cognitive
neuropsychological models.
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36. Cognitive approaches to Aphasia
• Cognitive linguistic Therapy ( CLT) Chapey R 1977
• Brain Compatible Aphasia Treatment Program
(Connors 2010 ,Friston 2011,)
• Language Oriented Treatment : psycholinguistic• Language Oriented Treatment : psycholinguistic
approach ( Shewan & Bandur 1986)
• Thematic Language Stimulation ( Wepman 1972,
Based on Shwell 1964)
• Non linguistic training ( computerized aided task
oriented program) & Impairment based
Individualized treatment Computer aided iPad based
program in PWA) Kiran et al 201408/03/2015 IFNR 2015,MET Mumbai India 36

37. Foundation for CLT
Cognitive-linguistic therapies are recommended as a practice standard post
stroke rehabilitation - American Congress of Rehabilitation Medicine (
Cicerone 2011)
They Aim to improve overall functional communication through stimulating
cognitive processes, such as
awareness/attention,
immediate discovery,
recognition, comprehension
memory, Executive functions
convergent thinking & divergent thinking,
& evaluative thinking
LANGUAGE & COMMUNICATION
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38. Cognitive Linguistic Therapy
Vs
Communicative Treatment
CLT
aims at restoring the
CT
aims at optimizing
aims at restoring the
linguistic levels
affected, semantics,
phonology or syntax
& enhancing overall
cognitive abilities e.g
CLT ,LOT, Divergent
model Rx,BCAT
aims at optimizing
information transfer by
training compensatory
strategies and use of
residual language skills
Communication facilitation
e.g ILAT, specific language
Aphasia intervention
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39. Determining factors for CLT strategies:
1 Fluency : Agramatism & paragrammatism
2. Auditory comprehension : good vs poor
3. Severity of aphasia : mild/ mod/ severe
4. Aphasia with good cognition vs aphasia with
poor cognitionpoor cognition
5. Lesion : focal vs diffuse
Cortical vs Subcortical/Mixed
5. Etiological factors
6. Language modalities & Recovery pattern
7. Mono vs bi/ multilingualism aphasia
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40. Aphasia with MCI
Anomia / Specific Anomia
Alexia with /without agraphia
Acalculia
Crossed aphasiaCrossed aphasia
Post TBI
Tumor based Aphasia
Degeneration based aphasia APHENTIA or
Language based Dementia
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41. ACCESS
DECISION
MAKING!!!
Aphasia with
good
cognition VsACCESS
VS
STORAGE
cognition Vs
Aphasia with
poor
cognition
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42. • Semantic & Phonological treatment based on
Semantic Divergent model - Cognitive
Linguistic Therapy ( Chapey 1977)
• Language & Cognitive therapy tasks ( Kiran at
al 2005, Ranvell et al 2007 )
• BCA T (Brain Compatible Aphasia Treatment
Program)
(Connors 2010 ,Friston 2011,)
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43. Cognitive tasks for CL therapy
strategies ( Kiran et al 2014)
Visuospatial
Processing
Symbol
Memory
Visuospatial
picture/word
memory
Attention
Response
Problem
solving
Analytical
reasoning
Executive
function
Symbol
cancellatio
n
Telling
time/analo
g clock
memory
matching
Visuospatial
auditory
memory
Voicemail
task
Response
inhibition
Symbol
cancellatio
n
reasoning
Arithmetic
Quantitativ
e reasoning
Sequencing
a set of
steps/instr
uctions
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44. Naming
Rhyme judgment
Syllable
identificatio
n
Picture
naming
Kiran et al.2014
Naming
Therapy Phoneme–
sounId
Identification
Category
matching
Feature
Matching,
Sorting,
Recalling
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45. Reading
Therapy
Spoken word–
to–written
word
identification
Written word
category
identification
Reading
maps
Reading
Therapy
Reading
passages
Long
passage
Reading
comprehensi
on
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46. Writing
Word copy
completion,
Multisensory
tasks
Word spelling
completion
Letter-to-
sound
matching
Writing
Therapy Oral Word
spelling
Recognition &
Discrimination
Picture
spelling
completion
Picture
spelling
Sound-to-
letter
matching
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47. Clinical Efficacy of CLT
Cognitive-linguistic therapies are recommended as a practice
standard and found to be effective during the acute and
postacute rehabilitation for language in post stroke aphasia.
( Warrell et al 2011, Helm Estabrookes,2002,Pulvermullar et al,
2002)2002)
However recent RCT on efficiency Early Cognitive linguistic
treatment vs communicative treatment showed equal
improvement in the subjects & no conclusive difference but
results yiels important clinical findings aiding in Aphasia rehab.
(de Jong Haqelstein et al 2011, Nauwens et al 2013)
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48. Raising concerns & clinical issues in
PWA ?
• Poor referral & ? timely follow up‐ chronic aphasia with less role of
spontaneous recovery , Reorganization & neural plasticity,
• Fluent/ non fluent / Mixed fluency
• Degree & severity & Levels of Aphasia Rx at
different modalitiesdifferent modalities
• Higher incidence of CVA and recurrent CVA , various other Neurocognitive
Disorders etc
• Aging+ Aphasia : Can we call them PURE APHASIA ?????
Mild –Mod Cognitive Impairment ( Amnestic /or Non amnestic) &
Aphentias
• Poor working memory poor relearning poor outcome & relapse
• Bi/ & Cognition : executive function
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49. FUTURE DIRECTION
• Development of cross culturally valid tools & Protocols for
assessment and intervention of cognitive linguistic abilities in
Aphasia & related neurogenic communication disorders .
• RCT -Objective aphasia intervention program e.g. non invasive
repetitive transcranial magnetic stimulation ( rTMS ) with and
without CLT & other subjective approaches.without CLT & other subjective approaches.
• Large sample longitudinal intervention studies on cognitive
linguistic perspective correlating neurophysiological, behavioural
and different etiological aspects in stroke aphasia, degenerative
aphasia , trauma based language disorders, NCD etc.
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50. NEED OF THE HOUR
• Cognizant Clinicians to provide holistic
Intervention which aims to restore life
participation in PWAparticipation in PWA
• e.g LPAA- Life Participation Approach in
Aphasia ( Chapey 2012)
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51. Being Pragmatic!
Cognitive - ImprovesCognitive -
Communicative
Intervention
Improves
quality of life in
PWA
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52. References
1. Schuell H. Aphasia Theory and Therapy: Selected Lectures and Papers of Hildred
Schuell. Baltimore, Md: University Park Press; 1974
2. Kiran, S, Roches C, Balachandran I, & Elsa Ascenso, M .Development of an Impairment-Based
Individualized Treatment Workflow Using an iPad-Based Software Platform. Semin Speech Lang
2014;35:38–50
3. Chapey R .A Divergent Semantic Model Of Intervention in Aphasia
4. Chapey R, Duchan JF, Elman RJ, Garcia LJ, Kagan A, Lyon JG, et al. Life-participation Approach
to Aphasia: A Statement of Values for the Future. In: Roberta C, editor. Language Intervention
Strategies and Related Neurogenic Communication Disorders 5th ed. Baltimore: Lippincott
Williams & Wilkins; 2008. p. 279–84.Williams & Wilkins; 2008. p. 279–84.
5. Holland A. Cognitive Neuropsychological Theory & Treatmet for Aphasia :Explaning Strength &
Limitation. Clinical Aphasiology.1994 ,22:275-282
6. Renvall K, Laine M, Martin N. Treatment of anomia with contextual priming: exploration of a
modified procedure with additional semantic and phonological tasks. Aphasiology
2007;21(5):499–527
7. Helm-Estabrooks N. Cognitive Linguistic Quick Test. London, England: Harcourt Assessment;
2001
8. Pulvermüller F, Roth VM. Communicative aphasia treatment as a further development of PACE
therapy. Aphasiology. 1991;5:39–50
9. Shewan CM, Kertesz A. Effects of speech and language treatment on recovery of aphasia. Brain
Lang. 1984;23:272–299.
10. Holland AL, Fromm DS, DeRuyter F, Stein M. Treatment efficacy: aphasia. J Speech Hear
Res. 1996;39:27–36
11. Vieira E. Nakano.,Published dissertation. Changes In The Sense And Perception Of Self In
Individuals With Aphasia: An ethnographic study. 2005 University of South Florida
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53. Cognitive Neuro-
Rehabilitation : A teamRehabilitation : A team
Approach
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