I’m sharing the amazing story of how an intensive home exercise program helped my patient talk again. He went from single words to full conversations!
This post is the follow-up to “Improve aphasia outcomes by creating intensive home exercise programs“, which was inspired by a fantastic seminar by Amanda Eaton and Carmen Russell, which I attended at the ASHA Convention in 2018.
Free DIRECT download: Response Elaboration Training (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Meet my patient “Ralph”.
- Ralph’s prior experience with speech therapy.
- Speech therapy now limited to once per week.
- The intensive home exercise program.
- Ralph was not going to follow this protocol.
- How I adapted the protocol to meet Ralph’s goal.
- Ralph’s amazing progress with intensive home exercise.
- Full extent of impairment became more obvious.
- Ralph’s language is good, now improving cognition.
- Related Eat, Speak, & Think posts.
- Have you tried an intensive home exercise program?
Meet my patient “Ralph”
Ralph is a 70-year-old man who was very healthy and active in the community until he had his stroke about a year before I met him. He had a wide circle of friends, volunteered weekly, and was always outdoors engaged in one sport or another.
When I met him after his stroke, his life was completely changed. He was paralyzed on his left side, wheelchair-bound, and home-bound. He rarely left the house, and in fact, rarely left the room that he now was confined to.
Most of his friends stopped coming by. When they did come by, conversation was stilted and visits were short. Ralph, who was gregarious by nature, now spoke only in single words or very short utterances. And usually only when asked a direct question.
Ralph was also confused about time, place, and events. He became upset when people said things he didn’t believe were true. He had left neglect, which means he often didn’t notice things on the left side of what he was looking at. And he didn’t seem to realize the extent of his impairment.
Ralph’s prior experience with speech therapy
Based on conversation with his wife, Ralph had had nearly continuous speech therapy since his stroke the year before. Previous therapy focused on attention, automatic sequences, answering yes-no questions, following one-step directions, confrontation naming, verbalizing personal facts, reading, and writing.
At my first meeting with Ralph and his wife, I was firmly told “no worksheets, no flashcards, and no technology”.
I think Ralph found worksheets and iPads frustrating due to his impaired ability to sustain attention to a task in addition to his left neglect.
Plus, they didn’t see how that was going to help with their main goal: teaching Ralph to have conversations again.
Speech therapy now limited to once per week
In addition to no worksheets, flashcards, or technology, they also limited me to once per week. Generally, I would start off at three times per week for someone who was so impaired.
Ordinarily, I would have felt very challenged by these restrictions.
Because I knew that Ralph was not likely to improve if his rehabilitation consisted solely of speech therapy once a week during which I provided conversation-based therapy.
Lucky for me (and Ralph), I had just come back from the ASHA Convention, where I had learned about intensive home exercise programs for people who have aphasia. And his wife was willing to work with Ralph every day.
The intensive home exercise program
Here are the highlights of what I learned from the ASHA Convention seminar “Creating Deliberate Independent Practice Programs for PWA: Insights from Intensive Therapies.”
- 60-90 minutes of daily practice requiring high effort.
- Break this up into two to three sessions across the day.
- Engage your patient in writing SMART goals.
- Plan three types of activities: journaling, practical tasks, and drill exercises.
- Choose personally-relevant materials and tasks at the Goldilocks level.
- Vary the context (here are 30 activity ideas).
- Set an intentional schedule targeting mini-goals.
Ralph was not going to follow this protocol
You may already realize that Ralph was not going to follow this recommended protocol. He would willingly engage in conversational tasks, but no reading or writing, and no drill work.
But he had four things going for him.
- He agreed that he wanted to talk more.
- His wife said she would do whatever I recommended (outside of the restrictions above).
- He responded well to Response Elaboration Training.
- His living space was full of interesting memorabilia.
What is Response Elaboration Training?
Response Elaboration Training is a way to help people with aphasia produce complete sentences.
Tactus Therapy has an article on Response Elaboration Training, which shares a link the original 1985 case study by Dr. Kevin Kearns and gives examples.
If you’re an ASHA member, you have free access to a 2019 meta-analysis of Response Elaboration Training. Analysis of nine studies shows that the training method is effective for many people with aphasia. Effect sizes varies from small to large, and applies to both treated and untreated items after treatment and at follow-up.
Basically, you find a small set of pictures showing some activity. Show the first picture to the person with aphasia and ask them to describe it.
However they answer, you reinforce it by repeating what they said and adding a few more words to make what they said more complete. (If they can’t say anything, offer them a choice.)
Ask them to repeat what you said.
Then you ask a “wh” question (or “how”) to elicit more information about the picture. They answer. You reinforce and ask them to repeat.
You continue talking about the picture in this way, asking questions, reinforcing, and adding information. In this way, the person with aphasia begins saying longer sentences.
How I adapted the protocol to meet Ralph’s goal
I decided to fully lean into their goal of improving conversation by focusing solely on conversation, but using the evidence-based practices of Response Elaboration Training combined with an intensive home exercise program.
Remember, Ralph was not initiating conversation or doing anything to keep conversation going. He was speaking mostly in single word utterances, in direct response to prompting from the other person.
I educated Ralph and his wife that he needs to work hard at talking for 60 to 90 minutes a day. I gave them a month calendar with 3 boxes drawn for each day. Ralph’s wife was to check off a box when they completed 20-30 minutes of conversation practice.
Then I trained Ralph’s wife on Response Elaboration Training. This is what I told her:
- Pick out an interesting object from the display cases.
- Say “Tell me about this”.
- Repeat what he says and fill in any gaps, adding just a few words.
- Ask Ralph to repeat what you said.
- Continue asking questions about it, following the same steps.
That’s it. They started this during the last week of November.
Ralph’s amazing progress with intensive home exercise
By the end of December, Ralph was frequently initiating conversation, asking questions, and making comments. Within a month, he was speaking mostly in phrases with occasional sentences!
I told them what to do and how much time to spend on it each day, and they followed through. Not only was his wife using Response Elaboration Training with him, but she had various family members also doing it.
They were motivated because they were working directly on the specific outcome they wanted from speech therapy. And they were using very personal items and memories to achieve that outcome.
And now that Ralph could carry a conversation, his friends started visiting more often and staying longer.
Full extent of impairment became more obvious
Now that Ralph was talking more, his family could more easily recognize that he had significant language and cognitive-communication impairments beyond conversation.
Some of Ralph’s difficulties included:
- Frequent word choice errors.
- Difficulty forming full sentences.
- Often misunderstanding what he heard.
- Stopping talking mid-conversation for no apparent reason.
- Switching the topic of conversation inappropriately.
- Easily distracted by his environment.
- Mixing up family member’s names and relationships.
- Forgetting where he was, when it was, and recent events.
Ralph and his wife were thrilled at his progress (as was I!), and they were more than willing to try anything I suggested.
At this point, I began introducing activities and materials to address some of the above difficulties:
- Spaced retrieval with errorless learning for family names and relationships.
- Auditory comprehension exercises.
- Left neglect compensatory training.
- TalkPath Therapy for language and cognition (home exercise program).
- Tactus Therapy apps for language and cognition (during therapy only).
- Worksheets and verbal exercises to practice left attention strategies, reading comprehension, following directions, reasoning, and problem solving.
- Journaling.
Ralph loves the worksheets and verbal exercises. So far, the journaling hasn’t caught on. And he’s not doing the TalkPath Therapy because the internet reception is poor.
So Ralph’s home exercise program has been intensive daily practice with verbal exercises and worksheets. I know worksheets are a controversial topic. I think it comes down to how and why they are used. All I can say is that I try to be thoughtful about which worksheets I select and what skills and strategies I want him to practice.
The bottom line is that my job is to work with whatever modality my patient is willing to try and to do my best to make the activity relevant, meaningful, and effective.
Ralph’s language is good, now improving cognition
My patient is lucky in the sense that he has private insurance with no limits on rehab, as long as he’s making progress. I’m still working with him once a week, and we’ve accomplished a tremendous amount over the past seven months:
- Talking in full sentences with appropriate word choices.
- Speech is fluent and clear.
- Conversation skills are normal except for mild issues with relevance and appropriateness.
- Sense of humor is recovered.
- Auditory comprehension is adequate for everyday conversations.
- Use of left attention strategies is improving.
- Remembers family names and relationships.
- Memory for recent events is improved.
- Oriented to place and inconsistently to time.
Ralph has improved from a moderate-severe cognitive-communication impairment to a mild impairment. He’s made consistent progress with therapy, still has deficits that are impacting his daily interactions, and wants to continue. So we’ll continue, now with a focus on cognitive-communication skills.
Related Eat, Speak, & Think posts
- Improve aphasia outcomes by creating intensive home exercise programs.
- Free course to improve conversation skills in aphasia.
- How to assess pragmatic skills in adults with brain injury.
- Free multimedia resources for the SLP.
Have you tried an intensive home exercise program?
If you have, please share what you tried and how it went! You can leave a comment below or contact me privately.
Or, if you haven’t tried it yet, maybe consider it for your next patient with communication difficulties. I wasn’t able to follow the exact protocol with Ralph, but we still had remarkable gains.
Free DIRECT download: Response Elaboration Training (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Monika Rams on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
Thanks for this – super helpful . I love the way you break things down, too! Perfect for my organization-minded brain.
Thanks, Megan, I really appreciate that!
Thank you!!! Great summary of working around barriers and what actually worked!
You’re welcome, KMW! Everyone’s different, but maybe something in here will be helpful!