learning

The Maytor, the Shorpine and the Traigol

Helen McGrane introduced mythical creatures to people with aphasia to explore whether individualised optimal learning approaches might improve the effectiveness of aphasia therapy. Here, with Linda Armstrong, she discusses the outcomes of that research and the implications for practice.

peech and language therapists have a wide range of assessments available now to look at many different aspects of a persons aphasia. We also have a wide range of materials for and approaches to therapy. But how does therapy work? How does speech and language therapy affect the brain of a person with aphasia? Is the client re-accessing previously held linguistic information and / or are new neural pathways being laid down? Why does it work better with some people than others? Should we be using optimal learning approaches such as encouraging errorless learning so that the person does not rehearse errorful or maladaptive responses? These are questions to which we still have no robust answers. Helen set out to begin to answer them by exploring one possible cerebral mechanism by which people with aphasia might be able to benefit in therapy new linguistic learning using optimal learning approaches such as staggered learning and an errorless learning approach. Several people have already examined learning in people with aphasia, but none using a set of stimuli in which both the word forms and the word meanings were new. If people with aphasia were able to demonstrate new linguistic learning, then this might open up a new approach to therapy, in which even previously held words might be treated as new.

Creature creations

Helen created 20 creatures, each with a unique image, name, skill, food and habitat (figure 1). Twelve people under the age of 65 years (six female and six male) of varied age, years in education, employment and severity of aphasia particiFigure 1 Examples of creatures

pated in four individual daily and consecutive training sessions, in which five new words were taught per day. The training sessions Helen McGrane used a staggered and errorless learning approach and included independent learning time (up to a maximum of 30 minutes), in which the participants could try to learn as many details as they could about each creature (name, skill, habitat and food) alone and in whatever manner they chose. They were told they could use any manner of learning that they wished and were given the option of choosing any, all or none of the following tasks to aid their learning of the stimuli: listen to the details to be learned via a taperecording (name, skill, habitat and food) as many times as they wished look at the written and picture representations of the vocabulary practise writing the word forms and associated meanings / attributes through copying the above material practise semantic and syllable matching tasks that would be similar to assessments they would later complete. The participants attempted a hierarchy of tasks at the end of each session to assess their learning of that days five new words. Those unable to demonstrate their learning by saying or writing the words could do so in other ways, such as matching a written word to the image, matching the initial written syllable with its final syllable and indicating how many syllables each creatures name had. Full details of the screening, training and assessment procedure are available from Helen. All twelve participants learned some new linguistic information, even those with significant language impairment. Their scores ranged from 15 per cent to 99 per cent on the assessment of their learning. All participants were invited to participate in a delayed assessment session that took place 3-5 days following the final training session. Ten participants agreed. Their retention of original information learned ranged from 49 per cent to 83 per cent. One participant, with severe aphasia, illustrates the procedure.

Linda Armstrong

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June (pseudonym) June was a 60 year-old widow who lived alone, with carers visiting daily and regular contact from her family. She presented with upper and lower hemiparesis on her dominant side and mobilised with a wheelchair, following a left intra-cerebral haemorrhage 146 months prior to participating in the study. This was Junes second stroke. She had been a factory worker and had nine years of education. Before the training sessions began, Junes mood, language (single word processing and connected speech) and cognition were screened. On the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983), June scored 16 for both anxiety and depression. This is the highest possible abnormal score indicating high emotional status for both anxiety and depression, some of which may have been related to her relatively recent bereavement. The language screening consisted mainly of parts of the PALPA (Kay et al., 1992) and pictures from Snodgrass & Vanderwart (1980) as well as narration of the Cinderella story (spoken and written) and the Cognitive Linguistic Quick Test (CLQT) (HelmEstabrooks, 2001). Junes score profile on the language screening is shown in table 1 and plotted onto Ellis & Youngs (1996) cognitive neuropsychological model of language in figure 2, where the pale highlight indicates impairment.
Table 1

Junes language screening data Language screening scores Word Non-word Listening lexical decision 8/8 7/8 Repetition 8/8 5/8 Reading lexical decision 5/8 7/8 Reading aloud 4/8 0/8 Spelling 0.5/6 0/6 15/15 10/15 12/15 (shapes) (pictures) (words) 9.5/12 18 (severe)

Categorisation Naming CLQT language

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

learning The CLQT language subtest indicated that June had severe language impairment. Her language screening data suggested that she had many language difficulties at single word level. June indicated that she could not read or spell very well prior to her stroke but the exact extent of her previous literacy was unclear. Her spontaneous speech was limited to three single words (ken [know], no, yes] and, as can be seen in figure 2, most of the modules and pathways were impaired to some degree. June had difficulty repeating non-words, reading aloud and spelling words and non-words and also naming. She had some difficulties categorising pictures (67 per cent correct) and words (80 per cent correct). June was unable to narrate the Cinderella story either in spoken or in written form. Despite evidence of comprehension difficulties it was evident that June understood all instructions, especially when given examples. We predicted that she would find it difficult to demonstrate the learning of new vocabulary in any format due to her severe language impairment. The cognitive sub-tests of the CLQT indicated that June had mild attention, executive function and visuospatial skill impairment and moderately impaired memory and clock drawing skills (table 2). However she demonstrated adequate visuospatial skills to engage in the training and assessment tasks by drawing detailed pictures of the creatures and copying the new words accurately. The severity of Junes memory impairment would predict a difficulty learning and recalling the new vocabulary. The scoring system of the CLQT only accepts verbal answers as valid responses to the tasks, which may underestimate the memory abilities of non-verbal participants with aphasia. However, June also had difficulty learning the non-linguistic task (stepping-stone route), only achieving 44 per cent on immediate recall and 22 per cent on delayed recall. This indicates a poor capacity to learn new information. Junes performance on each task designed to assess her learning is in table 3 with a summary of her ability to learn the new vocabulary for immediate recall assessments. June was unable to recall any of the new words spontaneously either in spoken or written form. She was also unable to recognise the words in listening or reading recognition tasks. June selected the correct number of syllables for three creatures and accurately completed the written syllable matching task for four words. She matched nine new spoken words with the correct picture and eight when reading the new words.
Table 3

All twelve participants learned some new linguistic information, even those with significant language impairment Guidance required
June was one of three participants who required guidance in organising her independent learning time (possibly relating to her cognitive impairment or limited experience of education). She listened to the audio recording of the creatures phonological representation and semantic features and practised some of the assessment tasks. This guidance was required for each of the four training sessions and, although June was offered the full 30 minutes for each session, she chose to utilise only 55 minutes (46 per cent) of the total allotted independent learning time.

Junes performance on learning new vocabulary Assessment task Score Name (spoken) Name (written) Skill (spoken or written) Habitat (spoken or written) Food (spoken or written) Auditory lexical decision Lexical decision (reading) Picture-syllable matching Syllable completion Reading aloud Word-picture matching (name) (spoken) Word-picture matching (name) (written) Word-picture matching (skill) (spoken) Word-picture matching (skill) (written) Categorisation (habitat, food) (picture) Categorisation (habitat, food) (written) Total (possible maximum score of 320) 0 0 0 4 5 0 0 3 4 0 9 8 7 1 6 3 50

Figure 2 Representation of Junes single word processing abilities SPOKEN WORD PICTURE WRITTEN WORD

Auditory Abstract Phonological Letter Analyses Identification

Visual/ Object Recognition Phonological Orthographic Input Input Lexicon Lexicon Semantic System Acoustic to Letter to Phonological Phonological conversion conversion Phonological Output Lexicon Orthographic Output Lexicon Copy Letters

Junes score represents 16 per cent of the potential total. In light of the low score, we considered the element of a chance performance on the tasks. However, the data indicated that June was able to word-picture match (both spoken and written) for five of the new words. She was also able to identify the skills for three of these new creatures and for two of them she also identified their habitat and food. Therefore we were confident that June demonstrated the ability to learn some information about the new words despite the severity of her aphasia, her mood and her cognitive impairments.

Ability to learn

Phonological Output Buffer

Table 2

Phonological to Letter Conversion

Graphemic Output Buffer

Speech

Writing

Junes cognitive screening data Cognitive sub-test scores on CLQT Stepping-stone Route Attention Memory Executive Visuospatial Clock Non-linguistic function skills drawing learning 126 117 23 72 8 6 Mild Moderate Mild Mild Moderate 33%

This investigation of new learning in aphasia demonstrated that people with varying degrees of aphasia severity, cognitive ability and mood can learn new linguistic material. Those participants unable to speak or write effectively had the opportunity to show what they had learned through a range of tasks and response types. The main findings indicate that people with impaired language systems can demonstrate the ability to learn new language representations. The process of aphasia rehabilitation may therefore involve both the facilitation of already held information, inaccessible as a result of the stroke, as well as the process of new learning perhaps of previously known but now forgotten words. These results have several implications for aphasia therapy, some of which highlight the potential for speech and language therapists to make much more use of principles for theories of learning within their aphasia therapy programmes. Errorless learning asserts that people learn more successfully if they are prevented from 9

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

learning making and reinforcing their own errors (Fillingham et al., 2003) thus reducing the likelihood of incorrect memory traces being laid down. The concept which has been successfully used in the rehabilitation of people with memory impairments (Kessels & de Haan, 2003) looks as if it will find a very useful home in aphasia rehabilitation. It suggests that we should learn in a fashion that minimises guessing and maximises the trials where there is a strong chance of achieving the correct answer. Such approaches may contradict some therapeutic approaches where clients are encouraged to guess correct responses. However, the danger of creating and strengthening maladaptive connections through repetition and rehearsal of incorrect responses can only serve to reduce the functional impact of therapy and the creation of patterns of accurate responses. We cannot be certain that the participants in this investigation entirely employed an errorless learning approach to their independent learning time, but this was used during the training sessions and encouraged during the independent learning time. Mckissock & Ward (2007) showed that their errorless condition was most beneficial, while it did not require the participants to name the picture. Although further exploration is needed in this area speech and language therapists need to consider this in planning therapy tasks. The provision of adequate time for repetition and consolidation of therapeutic stimuli appears to be an essential component for therapy. Statistical correlation suggested that the longer participants spent consolidating the new vocabulary the more successful they were in learning the new words and retrieving them from long-term memory. Therefore, ensuring that consolidation time is planned into therapy is important for our clients. The once weekly speech and language therapy session, with ideas and / or tasks left for the client to undertake until the next session however may be of no benefit to clients like June, who are unable to structure their independent learning time. For them, discussion of learning strategies pre-therapy and during the therapy programme may increase the effectiveness of the face-to-face contact as well as time spent by the client on speech and language therapy in between contacts. In terms of appropriate referrals for aphasia rehabilitation, the study highlights that participants both in the acute and chronic stages of recovery demonstrated the ability to learn the new vocabulary. These findings are consistent with those studies that demonstrate the restitution of language by people in the chronic stages of aphasia and refute the idea that language rehabilitation for those in the chronic stages of stroke should only incorporate compensation strategies rather than facilitation of further restitution of language. Therefore, we as speech and language therapists need to consider this when referred people in the chronic stages of stroke. ing by rote, yet others used writing and drawing to help their learning and some people preferred to carry out the tasks. Could this explain why people with apparently similar characteristics of language impairment respond differently to rehabilitation efforts? Although the same stimuli might be used in therapy, could the differing approaches to learning provide an explanation for the differences found in the recovery of aphasia? This information could be fundamental to the success of language rehabilitation in that problems in facilitating the restitution of language may not be caused by the particular tasks we are employing but rather the manner in which they are presented to individuals. Perhaps discovering the optimum learning strategy for each client before embarking on the therapeutic process would identify the best methods and processes to use during their customised rehabilitation process. Speech and language therapists may therefore find it helpful to include an evaluation of the individuals learning style in their initial assessment before deciding on what type of therapy to offer. Currently there is no method of assessing the learning preferences of people with aphasia. Helen is working on developing such a tool. Helen McGrane completed this investigation while undertaking her PhD at Queen Margaret University College. She is now Clinical Research Fellow at Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, FK9 4LA. Linda Armstrong was her Director of Studies and is a speech and language therapist at Perth Royal Infirmary, Perth, PH1 1NX. Helens QMUC SSRC Theses Online version of her PhD thesis is available at http://www.roundtable.ac.uk/ ssrc/pubs/McGrane2006PhD.pdf.

people with impaired language systems can demonstrate the ability to learn new language representations
Speech and language therapists are well aware of the impact of cognitive impairments on the rehabilitation of aphasia and the difficulty of measuring the level of impairment with assessments that rely on speech and language, the very responses that are impaired by aphasia. In such clients the reduction of the cognitive load may help, for example through the use of a staggered learning approach where they are gradually presented with targeted words for rehabilitation.

Preferred method

Finally, qualitative observations in this study suggested that although participants were all given the same optional tasks to help learn the new vocabulary in their independent learning time, they tended to employ a preferred method of learning consistently across the four training sessions. For example, some people listened to the tape-recording a number of times, others read the list of words aloud repeatedly as if learn-

References

Ellis, A.W. & Young, A.W. (1996) Human Cognitive Neuropsychology. Hove: Psychology Press. Fillingham, J. K., Hodgson, C., Sage, K. & Lambon Ralph, M. A. (2003) The application of errorless learning to aphasic disorders: a review of theory and practice, Neuropsychological Rehabilitation 13(3), pp.337-363. Helm-Estabrooks, N. (2001) Cognitive Linguistic Quick Test. USA: The Psychological Corporation. Kay, J., Lesser, R. & Coltheart, M. (1992) PALPA: Psycholinguistic Assessments of Language Processing in Aphasia. Hove: Erlbaum. Kessels, R.P.C. & de Haan, H.F. (2003) Implicit learning in memory rehabilitation: a metaanalysis on errorless learning and vanishing cues methods, Journal of Clinical and Experimental Neuropsychology 25, pp.805-814. Mckissock, S. & Ward, J. (2007) Do errors matter? Errorless and errorful learning in anomic picture naming, Neuropsychological Rehabilitation 17, pp.355-373. Snodgrass, J. G. & Vanderwart, M. (1980) A standardized set of 260 pictures: norms for name agreement, image agreement, familiarity, and visual complexity, Journal of Experimental Psychology: Human Learning and Memory 6(2), pp.174-215. Zigmond, A.S. & Snaith, R.P. (1983) The hospital anxiety and depression scale, Acta Psychiatrica Scandinavica 67, pp. 361-370. 10
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

REFLECTIONS DO I ASK ABOUT INDIVIDUAL LEARNING PREFERENCES DURING ASSESSMENT AND USE THAT INFORMATION WHEN PLANNING THERAPY? DO I SCHEDULE APPOINTMENTS FLEXIBLY ACCORDING TO INDIVIDUAL NEED AND AVAILABLE EVIDENCE? DO I REDUCE COGNITIVE LOAD, GIVE SUFFICIENT TIME FOR REPETITION AND CONSOLIDATION AND SUPPORT A CLIENTS INDEPENDENT LEARNING TIME?
How has this article been helpful to you? What theories of learning are you using in your work? Let us know via the Summer 08 forum at http://members. speechmag.com/forum/.