As speech language pathologists, we can sometimes get in the habit of doing the same tasks, in much the same way, without considering other angles or approaches to our therapy techniques. I’m hoping this blog helps us to "rethink" our traditional way of thinking, and encourages you to consider incorporating two of the most important “V-words” out there when it comes to Aphasia rehabilitation.
The first “V-word” - the HEART and CORE of our SENTENCES
“Dinner…uh…yea dinner. Beach….water….Oh yes, sun.” Although it depends on severity level, it is not uncommon for one’s verbal output to consist of single words when he/she has Aphasia. Nouns are usually some of the more common words expressed by individuals with Aphasia, which is why their verbal output may sometimes be described as “telegraphic.” For example, when describing a picture scene, an individual with Aphasia may say “man…the car….dog…..boat…kite…” and so on. There may be a lack of any sort of sentence structure or syntax present, and often, verbs are either completely omitted or quite scarce. So herein lies our first V-word - VERBS!
Verbs are truly the core of our sentences, and without them, our sentences are nonexistent, leaving a lot of room for interpretation. It may also be that by saying a noun, we’ve STARTED at the END of our sentence. For example, “kite,” instead of “The girl is flying a kite,” or “dinner” instead of “We ordered dinner.” Although the production of that single noun might allow a communication partner (the listener) to get in the ballpark, a lot of unknowns remain, leading to potential communication breakdowns. “Dinner…uh…yea dinner.” What about dinner? Did you EAT dinner? Did you ORDER dinner? Are you COOKING dinner? Is someone DELIVERING dinner? There are a lot of options, and without our verbs, the verbal message is incomplete and leaves room for misinterpretation.
How do we work on verbs?
A key start is to make sure we’re not simply working on naming pictures or objects during home practice or speech therapy sessions. There needs to be a heavy focus on VERBS and their related concepts. One of the more well-known evidence-based treatments developed for people with Aphasia is known as VNeST (Verb Network Strengthening Treatment), created by Lisa Edmonds and her colleagues. The idea behind this treatment is that by generating people (agents) and objects (patients) associated with specific verbs, the semantic network associated with that verb will be strengthened, and thus that verb
will become easier to access. For example, take the verb “FIX.” Who fixes? These are your people associated with the verb – Plumber, Electrician, Carpenter, Mechanic etc. Then we discuss and generate the objects associated with these people (i.e. What does a plumber fix? Toilet; what does a Mechanic fix? – Brakes) and so on. However, person with Aphasia wants to be able to access more verbs than just a small targeted subset – so how does that work?
The idea behind this verb strengthening treatment is that by targeting a verb like “fix,” and retrieving words associated with the verb, then related verbs like “repair” and “rebuild” will also become easier to access, because they are RELATED concepts.
The remaining challenge (at least one of them):
What about those verbs that are less imageable and concrete? Those words that used to very much be a part of one’s vocabulary, but are now difficult to access and seem difficult to target in therapy. For example, verbs like design, counsel, produce, formulate, etc. These verbs may be less common or familiar, and often are less imageable, making them more challenging to include in conversation, and should therefore also be addressed and included in one’s treatment. Consider a VNeST approach, and simply start with generating people associated with these verbs. Who designs? An artist designs. Who ELSE designs? An architect designs. Then build on that concept and ensure to come up with a variety of
possibilities, as this improves cognitive flexibility and word retrieval abilities.
The “other” V-word - the HEART and CORE of our WORDS
Just like verbs are the core of our sentences, VOWELS are the core of our words. When an individual presents with Apraxia, the motor speech disorder that often accompanies Aphasia, targeting vowels can be much more valuable and crucial than targeting consonants. For example., take a phrase like “How are you?” Nearly all of the sounds in that question are made up of vowels (i.e. ahOO –ah – EEOO). If someone is ONLY able to produce the vowels alone, the phrase becomes quite comprehensible when spoken, even without filling in the consonants. Additionally, it may just so happen that by targeting the vowels, the consonants start to fill themselves in.
How do we work on vowels?
I like to start with the 3 vowels EE (as in BEET), OO (as in BOOT), ah (as in HOT) for a few reasons. They are the most DIFFERENT from one another, and can therefore serve as your anchor vowels before addressing the others. They also may be easier to learn since the mouth postures for them are more visibly specific, and can be modeled more easily than some of the others.
Vowels can be something that are simply drilled, perhaps starting with them in isolation and then branching off into vowel + consonant and consonant + vowel combinations. Additionally, pronouns are primarily made up of vowels, AND are a great way to start a sentence, so I like heading in the direction of targeting subjective pronouns as soon as possible. I use the pronouns: I, You, He, She, We and They – and again, simply start by targeting the vowels.
I (a-EE)
You (EE-OO)
He (EE)
She (EE)
We (EE)
They (A)
Since most of the pronouns are made up of those 3 anchor vowels, this is a great place to start. Once the vowels are established during pronoun production, see if consonants can be added in. If not, stick with the vowels. Try conjugating the pronouns with a verb to start building a subject + verb sentence, and consider selecting a verb that also contains one of the 3 anchor vowels (i.e. I eat – a EE, EE). You can continue to build on this task, creating sentences with Subjects (pronouns), Verbs, and Objects. Stay focused on accurate vowel production without spending too much time on the consonants.
The remaining challenge (at least one of them):
Those consonants that we were hoping would “fall into place” have not, and are still challenging for my patient with Apraxia to produce. Once at least the 3 anchor vowels have been established and you are ready to integrate consonants, consider targeting JUST the FIRST consonant in a word (in addition to the vowel). Initial sound accuracy really helps to improve overall speech intelligibility (comprehensibility). Start with the consonants that
are easiest for your patient to imitate, and target words or short phrases (preferably one-syllable words) that have a heavy focus on using those sounds in the initial position. You may even get some of the remaining consonants in the word to fill-in without having to target them.
To sum it up:
So in conclusion, I hope some of these thoughts and ideas encourage you to re-evaluate and maybe re-consider your current approach, focusing more on the middle men of our words and sentences…our VOWELS and VERBS. They are truly such a valuable component of our speech and language, and shouldn’t be overlooked or underappreciated when we are treating individuals with Aphasia and Apraxia. They serve as the anchors to clearer speech, more language content, and overall improved communicative abilities.