The effect of home computer practice on naming in individuals with nonfluent aphasia and verbal apraxia.(Clinical report)

This study investigated the impact of daily home computer practice on oral naming of pictures by comparing performance with two other conditions: weekly clinician-only therapy sessions (with no computer) and no treatment. The four participants were diagnosed with nonfluent aphasia and verbal apraxia. For 13 weeks, the participants practiced naming three sets of 10 drawings. Each set was assigned to one of three conditions: independent use of a home computer program (Computer Practice), weekly therapy sessions with a clinician and no computer progr am (Weekly Practice), or no practice (Control). Performance on the stimuli was assessed at the beginning of the study (Baseline), during treatment, at the end of the treatment (Assessment 3), and 5 weeks posttreatment (Maintenance). With Computer Practice, two participants improved statistically (and one approached significance) from Baseline to Assessment 3. From Baseline to Maintenance, three participants maintained statistically significant gains. With Weekly Practice, only one participant improved statistically from Baseline to Assessment 3, and there were no significant improvements from Baseline to Maintenance. The Control condition resulted in no significant improvements in any participant. The results suggest that computer programs are a practical way to provide practice that is relatively independent and appropriate for individuals with aphasia and apraxia.

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As anomia is a consistent feature of aphasia (Davis, 2000), numerous studies have focused on the use of computerized programs in facilitating word retrieval (Adrian, Gonzalez, & Buiza, 2003; Bruce, & Howard, 1987; Colby et al., 1981; Doesborgh et al., 2004; Fink, Brecher, Schwartz, & Robey, 2002; Laganaro, Pietro, & Schnider, 2003; Mortley, Wade, & Enderby, 2004; Pedersen, Vinter, & Olsen, 2001). The results of these studies demonstrate that computer use can yield significant naming improvements across different practice settings (e.g., out-patient vs. in-patient) and different degrees of guidance (e.g., full guidance vs. part-time guidance) (Laganaro et al., 2003; Fink et al., 2002). Even a remotely monitored intervention that was updated over the Internet yielded significant improvements (Mortley et al., 2004)

Overall, the results of these studies show that computerized practice programs have great potential for treating individuals with aphasia. However, a downside to several programs is that patients with aphasia may not be able to operate a computer independently due to knowledge or motor limitations. For example, many elderly adults do not have premorbid exposure to computers. With no background knowledge, they may have difficulty learning basic computer skills due to cognitive deficits related to aphasia or associated brain damage. In addition, if there is right-sided paresis (or paralysis) or limb apraxia, patients may have trouble learning skills requiring fine motor control, such as using a computer mouse. When such limitations are present, there must be a person who can actively assist in the computer therapy. For example, in Adrian et al.'s study (2003), a speech therapist was present throughout the practice to direct the computer program for auditory and written cues as well as to provide feedback on the responses. Having the computer practice dependent on another person may limit opportunities for practice by the patient. The present study was designed to promote independent patient-initiated practice in a home. Participants were provided with a computer program that utilized an automatic presentation of cues and words and required minimal computer skills. Giving patients the ability to practice independently not only increases the opportunities for practice but potentially gives them a stronger sense of control over their own treatment.

The cueing provided in the computer practice program was based on the many studies showing the benefits of semantic, orthographic, and phonological cueing in individuals with nonfluent aphasia. Although previous studies have shown facilitating effects of cueing, the relative effectiveness of different cues has been disputed. For example, Love and Webb (1977) measured the relative power of various cues and found that for severely aphasic patients, modeling was the most effective cue; phonemic cues were the second most effective; and semantic (sentence completion) and orthographic cues were the third most effective. In contrast, Howard et al. (1985) observed that the facilitative effect of semantic treatment was more enduring than that of phonological treatment. Miceli, Amitrano, Capasso, and Caramazza (1996) reported a single case of anomia intervention where phonological treatment yielded significant gains in verbal naming that were maintained 17 months posttreatment. Hickin et al. (2002) argue that a possible reason for the long-lasting effect from semantic treatment is the extent of processing required for the patients. In semantic tasks, patients are usually asked to make choices or match items, whereas in phonological tasks they are passively given phonemic cues. When Hickin et al. provided phonological and orthographic cues in a format of choice making (e.g., "The word begins with either [TEXT NOT REPRODUCIBLE IN ASCII] or [TEXT NOT REPRODUCIBLE IN ASCII]") rather than as direct support (e.g., "The word begins with [TEXT NOT REPRODUCIBLE IN ASCII]"), they found that phonological treatment and orthographic treatment are equally effective. Similarly, Doesborgh et al. (2004) randomly assigned 46 patients with semantic and phonological deficits to either a semantic or a phonological treatment group. The results revealed equivalent significant improvements for both groups: the semantic group improved in semantic measures and the phonologic group improved in phonologic measures. Jokel, Rochon, and Leonard's (2004) studied a patient who made predominantly semantic paraphasias. After receiving phonologically based treatment, the patient showed a decrease in both semantic and formal paraphasias.

Although previous studies have attempted to elucidate the relative power of semantic and phonological treatment, it is often impractical to implement purely semantic or phonologic approaches in word-retrieval tasks. A purely semantic treatment would not allow the patient to say, or hear, target words. A purely phonological treatment would not allow the presentation of picture stimuli to the patient (Wambaugh et al., 2001). After reviewing the anomia intervention research, Nickels (2002) concluded that treatment approaches that integrate various components (e.g., phonological and semantic) would be the most beneficial in many cases, even if the relative strength of each component varies. Thus, an effective practice treatment should include a variety of cues, including semantic, phonological, and orthographic cues. Indeed, several computer treatments include cueing as a critical component (e.g., Katz & Nagy, 1984; Loverso, Prescott, & Selinger, 1992; Van Mourik & Van de Sandt-Koenderman, 1992).

Cueing is also commonly used in the treatment of individuals with verbal apraxia. Darley, Aronson, and Brown (1975) differentiate verbal apraxia, a motor speech disorder, from aphasia, a linguistic disorder. They propose that verbal apraxia results from damage in the motor speech programmer (MSP), which converts linguistic information into neuromuscular commands. The high computational load on the MSP to select the right muscles in the correct sequence and timing requires the system to be highly efficient. Therefore, it is assumed that the MSP largely depends on "preprogrammed chains of neural output" (p. 258), which develop during the process of speech/language acquisition. In individuals with verbal apraxia, there is a disruption in the efficient ...