We are pleased to welcome Stacie Raymer, Ph.D., CCC-SLP, as our guest 
host for the SLP chat tonight, Monday, December 6, 2004.  Dr. Raymer will
be addressing the topic of Aphasia Therapy Word Finding/Word Retrieval.

Dr. Stacie Raymer is an associate professor in the Department of Early
Childhood, Speech Pathology, and Special Education at Old Dominion
University. She is also an investigator affiliated with the Brain
Rehabilitation Research Center at the VA Medical Center in Gainesville,
Florida. She completed her undergraduate work at the University of
Wisconsin and masters and doctoral studies at the University of Florida.
Her research interests for the past  years have examined neural and
cognitive mechanisms as well as most effective treatments for disorders
of word retrieval, reading, writing, and limb praxis. Her recent studies
of aphasia rehabilitation have been supported by a Clinical Research Center
grant from the NIH (National Institute of Deafness and other Communication
Disorders). She has more than  publications and has presented her work
nationally and internationally. Dr Raymer is currently coordinator of
ASHA Special Interest Division  Neurophysiology and Neurogenic Speech
and Language Disorders.

Dr. Raymer has provided additional resources which may be found below
the chat transcript.

<Robin > Welcome!  We are chatting tonight about the topic of Aphasia Therapy: Word Finding/Word Retrieval
          with guest host Stacie Raymer, Ph.D., CCC-SLP.
<Robin > Dr. Raymer, please give us some background information about this topic.
<Stacie Raymer> As you all know, word retrieval impairments are very common among patients with aphasia.
          Therefore we spend quite a bit of time addressing these problems in clinical practice.
<Stacie Raymer> I thought we'd spend some time tonight discussing some issues in assessment and then in treatment.
<Robin> Please define word retrieval impairment.
<Stacie Raymer> To me word retrieval impairment is a pretty broad category and means any difficulty thinking
          of words - This problem occurs primarily in conversation arise in association with just about any type of
          damage affecting the left cerebral hemisphere.
<Lander> Is it synonymous with anomia and/or dysnomia?
<Stacie Raymer> I tend to use the terms word retrieval and anomia interchangeably.
<Stacie Raymer> We primarily test anomia through picture naming tasks, so sometimes people use the phrase
          naming impairments as well.
<Robin > Tell us about more assessment please
<Stacie Raymer> Some people distinguish word retrieval impairments from naming impairments - with naming
          impairments specifically referring to the tip of the tongue phenomenon.
<Stacie Raymer> Just about every aphasia test battery has subtests for word retrieval. But tests like the
          Boston Naming Test(BNT) and the Object and Action Naming Battery can be very useful.
<Stacie Raymer> The other interesting thing is that naming impairments can vary. Some individuals have have
          more trouble with nouns than verbs and vice versa.
<Stacie Raymer> Others can have trouble with selective semantic categories like animals or fruits and vegetables.
<Robin > How do you distinguish word retrieval from naming impairments?
<Stacie Raymer> Some people think word retrieval has to do with the semantic stage of processing while
          naming impairments arise in the stage beyond semantics when activating the retrieval stage. I don't
          usually make that distinction. I use the terms interchangeably.
<Stacie Raymer> I have a chapter in Chick LaPointe's revised book just out. It might be a useful resource.
<Lander> In assessment of word retrieval impairment is consideration given to an individual's ability to
          compensate for lack of word retrieval in other ways that are effective?
<Stacie Raymer> Lander, definitely... we look at all options to communicate an idea.
<Stacie Raymer> Lander's question makes me think about treatment options, where we might address treatment
          to specifically attempt to restore vocabulary or we might teach strategies to circumvent the problem.
<Stacie Raymer> Do people have time during assessment to do additional naming testing? Or is an aphasia
          battery all you get?
<AdrienneFSU> Let's be generous and say we have time to probe for naming deficits beyond standard battery...
          what do you suggest?
<Stacie Raymer> I like to include some kind of testing that allows for a direct comparison of comprehension
          and production.
<Stacie Raymer> So for example, the revised BNT also has a comprehension subtest. That allows a direct
          comparison to determine whether impairment is semantically-based - impaired comprehension plus production,
          or primarily phonologically-based - intact comprehension but poor naming.
<Stacie Raymer> I'd certainly also encourage folks to probe more for differences in naming for grammatical
          (nouns vs verbs) and semantic categories. Treatment could be targeted in more efficient directions
          if our assessment has given us an opportunity to understand the impairment a little more thoroughly.
<Stacie Raymer> We also tend to use some informal test batteries.
<Stacie Raymer> Certainly, word retrieval impairments can be tapped in rating scales like those on the ASHA-FACS
          or the CETI.
<masha> What do FACS and CETI stand for?
<Stacie Raymer> ASHA FACS is Functional Assessment of Communication Skills for Adults.
<Stacie Raymer> ASHA FACS is ASHA's CETI is Communicative Effectiveness Index and it comes from a paper in JSHD
          (Lomas et al., 1989).           
<Stacie Raymer> Some rating scales allow us to consider the impact of naming impairments for real life
          communication consequences.
<Stacie Raymer> The other idea I should mention draws upon the WHO perspective.
<masha> What is the WHO perspective.
<Stacie Raymer> WHO stands for the World Health Organization.
<Stacie Raymer> Much of our thinking these days is driven by the WHO Model of Functioniong Disability and Health
          (2001, WWW3.WHO.INT/ICF).
<Stacie Raymer> In this perspective, aphasia has to do with impairment of language functions. But we must always
          consider the impact of aphasia on communication activities and participation.
<Stacie Raymer> I try to teach my students to have a balance between assessment at the language function level
          (e.g., aphasia batteries, BNT) and communication activities/participation (e.g., ASHA FACS).
<Lander> Since damage to the brain may be either temporary or permanent, what differences in treatment
          approaches are there for each?
<Stacie Raymer> Actually, once the brain is damaged, those cells are lost.
<Stacie Raymer> There is certainly evidence that we can recruit regions during treatment including perilesional
          cortex or contralesional cortex. But I don't usually think of brain damage as temporary.
<Robin> Very good points.  Please tell us how you set up your treatment program following assessment.          
<Stacie Raymer> I admit that I am a researcher, so my treatment programs tend to be rather selective.
<Stacie Raymer> What I would do clinically would be broader.
<Stacie Raymer> Anyhow, there are several treatment options that people might implement. Most commonly people
          think about use of cueing hierarchies.
<Stacie Raymer> Establish a set of cues of increasing potency and go through naming exercises in which you
          practice a set of appropriate vocabulary.
<Robin> What type of cueing do you suggest?
<Stacie Raymer> Different people might respond differently to some cues but usually a sentence completion,
          initial sounds, rhyming words, number of syllables - clues like this help people get to a target word.
<Stacie Raymer> With practice over time, people will need fewer and fewer cues as their vocabulary is improved.
<masha> Do you recommend a certain hierarchy--ie, start with semantic cueing and then phonologic cueing, etc.?
<Stacie Raymer> I don't recommend a specific hierarchy. You determine what works best for that individual and
          start with least effective and move toward most effective. It's individualized.
<Stacie Raymer> Another nice alternative is something called Semantic Feature Analysis (SFA) training.
<Robin> Tell us about Semantic Feature Analysis (SFA).
<Stacie Raymer> Mary Boyle has written a few papers in SFA, most recently in AJSLP (2004).
<jka> I have used semantic feature analysis and really like it.
<Stacie Raymer> In Semantic Feature Analysis (SFA), a target picture is set out on a grid surrounded by some
          key words.
<Stacie Raymer> Each key word helps the patient elicit a piece of semantic info about that target.
<Stacie Raymer> e.g. apple - category - fruit; action - pick it ; where found - on a tree - attributes - red
<jka> You can use if with all levels
<Stacie Raymer> What do you mean by all levels?
<jka> Mild to moderate aphasics
<Stacie Raymer> You're right. Mary Boyle and colleagues have used SFA with a number of patients - moderate -
          mild - Wernicke's to Broca's to anomic aphasia.
<Stacie Raymer> SFA may be teaching the patients a strategy to think of any information they can about the
          target - that way in real life when they can't think of a word, they try this strategy to express all
          they can - sometimes leading to correct retrieval.
<AdrienneFSU> Can you talk about generalization to words not trained?
<Stacie Raymer> Generalization is an important issue.
<Stacie Raymer> Most of our word retrieval treatment literature is not very encouraging as to generalization.
<Stacie Raymer> Some people think that as we retrain vocabulary, we are training fairly specific representations
          and not rules. Therefore generalization may be more limited.
<Stacie Raymer> The more that our treatments can teach a strategy, like SFA, the more they are likely to generalize.
<Linda> Would you select vocabulary in categories?
<Stacie Raymer> As for training a category - I don't think we have good evidence to answer that yet.
<Stacie Raymer> Maybe some of you are familiar with a paper by Kiran and Thompson in JSHR (2003).
<Stacie Raymer> In the JSHR paper, Kiran trained people within a category. She showed that training most typical
          words did not generalize to other category members - but training atypical words ended up generalizing
          to other category members that were more typical.
<Stacie Raymer> The Kiran paper has not yet been replicated, but it is interesting and surprising.
<Stacie Raymer> Sometimes patients get a little confused if you spend too much time within one category.
<Stacie Raymer> e.g. within one category we might cause patients to make more semantic errors - they just get
          confused with other words within the category. But we really don't know if it's better to train within a
          category or to train a random set of words from many categories.
<Ali> I think it depends on how you define a category. If you create a functional category - things in the
          patient's kitchen, room, etc., it seems to work better, than general categories such as furniture.
          Things that are personally more relevent seem to work better,
<Robin> Good point Ali.
<Stacie Raymer> Ali, absolutely personnally relevant is best.
<Stacie Raymer> SFA is a great technique and Mary Boyle is doing more studies to increase the evidence for that
<Robin> The SFA approach sounds very practical.
<jka> I found this technique stimulates self cueing.
<asherman_mckinley> The more evidence we have the better for reimbursement issues too.
<Stacie Raymer> Absolutely.
<Stacie Raymer> We are really trying to improve our evidence-based perspective. It is desperately needed.
<Stacie Raymer> I hope many of you are familiar with the ANCDS.org website.
<Stacie Raymer> ANCDS stands for Academy of Neurologic Communication Disorders and Sciences.
<Stacie Raymer> They are working on evidence based practice guidelines across the neurogenic disorders.
          Eventually there will be some guidelines for aphasia treatment.
<Stacie Raymer> ASHA is infusing evidence based practice perspectives.
<Stacie Raymer> Bob Marshall and his colleagues have written about using personally relevant cues during
          cueing hierarchies.
<Robin> can you give us an example?
<Stacie Raymer> Patients do better if they help in the process of identifying cues for themselves and the
          cues are more effective for improving their word retrieval.
<Stacie Raymer> I'd say that patients should be involved in selecting their vocabulary as well.
<Ali> good point, absolutely!
<Stacie Raymer> An example of a personally relevant cue might be - target word coffee - Starbucks.
<Stacie Raymer> Usually we would cue with co....
<Lander> How does the patient select vocabulary?
<Ali> I would involve both the family (caregivers) and the patient together, it may be difficult just for
          the patient, at least in the beginning.
<Stacie Raymer> Working with the patient and the family directly we should be able to identify the most
          necessary vocabulary.
<Lander> That makes sense.
<Stacie Raymer> With more severe patients, just about any vocabulary is necessary. So I just start with
          most relevant daily vocabulary.
<Lander> How do you determine how many words to target per session?
<Ali> Good question, Lander. I think that's determined by the severity of the patient.
<Stacie Raymer> We tend to work on subsets at a time -20  or so - though some even go to 50 at a time.
<Stacie Raymer> I think too many gets a bit confusing. Establish a core vocabulary and keep going from there.
<masha> Seems like SFA would not only improve production but also comprehension.
<Stacie Raymer> We've done some work using gestures to facilitate word retrieval.
<Ali> How are the gestures working?
<Stacie Raymer> We have shown that gestures can be useful for improving retrieval for both nouns and verbs.
<Stacie Raymer> Patients pair a pantomime with a spoken word and are required to produce them together repeatedly.
<Lander> Do you find that some patients naturally used gestures?
<Stacie Raymer> The premise is that the gesture will ultimately help retrieve the words like we all do sometimes.
<Stacie Raymer> Some patients spontaneously use whatever gestures they can think of.
<jka> Do you have a good source for a standard gestural system or do you recommend Amerind?
<Stacie Raymer> But some patients have some gesture difficulties because of limb apraxia, so they may not gesture
          as much as you would think unless they specifically work on gestures.
<masha> I have found that gestures really do help to elicit verbs.
<Ali> Does the patient develop his own gesture system that's reinforced or are they agreed upon mutually?
<Stacie Raymer> Usually we can agree on what would be a reasonable gesture.
<Ali> To what degree are the pantomimes iconic?
<Stacie Raymer> We tend to select any natural pantomimes - usually pretty iconic.
<Ali> OK, good.
<jka> I have also used patients' gestures if they use them consistently.
<Stacie Raymer> Some interesting work is being done by my colleagues Crosson et al at the University of Florida
          (Richards et al., 2002).
          They just use movements of the left hand - not pantomimes.
<Lander> I've observed patients who use hand tapping on tabletops instead of iconic gesturing.
<Stacie Raymer> These movements are intended to engage premotor cortext to help 'turn on' the word retrieval
          system. They practice naming objects in the context of making these limb movements and improve naming.
<Stacie Raymer> I think your hand tapping is definitely in the direction of what Crosson is doing.
<Stacie Raymer> What's especially nice about hand movements is that they can be used with all vocabulary -
          some words just don't have appropriate pantomimes.
<Stacie Raymer> Think about Melodic Intonation Therapy. Perhaps it's the hand tapping element moreso than the
          intonation element that leads to improvements with that technique.
<jka> So for example for cup they just pretend to hold a cup or do they perform the action of drinking?
<Stacie Raymer> The perform the action.
<Stacie Raymer> But in the Crosson work, they would reach out with their left hand and make a movement and
          try to say cup.
<AdrienneFSU> How do they get "cup" (noun) instead of "drink" (verb)?
<Stacie Raymer> That's an interesting question Adrienne. We thought in our studies that pantomimes would be
          better for verbs - as the action is depicted.
<Stacie Raymer> But our results seem to be showing that gestures are at least as effective for nouns, and
          perhaps moreso than for verbs.
<AdrienneFSU> interesting!
<Ali> It maybe interesting to use a combination of pantomimes for verbs and SFA for nouns. this way the two
          classes could be more separate and maybe easier to use.
<Stacie Raymer> I think it just depends what target vocabulary you practice with the pantomime. If we
          practice cup, they improve cup. If they practice drink, they improve drink.
<Stacie Raymer> We still get pretty much an item specific training effect with gestures, though their use
          of gesturing definitely improves to increase their communication abilities.          
<jka> What exactly is the hand movement?  Is it just a gross movement or are you trying to have the patient
          imitate the gesture that you model?
<Stacie Raymer> In the Crosson studies they start with a complex movement - reaching out and turning a lever -
          but eventually moving toward just a circular motion of the hand - like many of us would use when talking.
<Stacie Raymer> In our studies, we've used actual pantomimes - which again are very natural as many of us use
          pantomimes when we can't think of a word.
<jka> Do you have a reference for that study?  It sounds useful.
<masha> Where can we find the Crosson studies?
<Stacie Raymer> The Crosson study is actually Richards et al in Journal of Rehabilitation Research & Development.
<Stacie Raymer> The JRRD is available online - it's a VA journal so you can access it. The year was 2002.
<Lander> Do you find that even many of us use non-specific sort of repetitive movements to prompt word retrieval?
<Stacie Raymer> Sure, we all use these kinds of nonspecific movements.
<Stacie Raymer> The fancy word for nonspecific movements was Luria's Intersystemic gestural reorganization.
          It's an idea that has been talked about in apraxia of speech research as well.
<Lander> Do patients include facial expression -- when possible -- with hand movements?
<Stacie Raymer> No one really mentions facial expression.
<Stacie Raymer> I don't know what to predict about implications for facial expression during word retrieval.
<Stacie Raymer> That does remind me of some work though that shows emotional words may be retrieval somewhat
          better by the left hemispere patients.
<Stacie Raymer> Presumably the effect is because the right hemiphere's emotion abilities may promote retrieval.
<Robin> Dr. Raymer, Do you have any strategies for those "tip of the tongue" word retrieval problems that many
          of us have?!
<Stacie Raymer> When we all have that tip of the tongue problem, circumlocute! We need to teach patients to
          circumlocute as a strategy - with a specific goal. This is very functional. Once they provide more
          information, the listener can often figure out the missing information.
<Stacie Raymer> All of us do this.
<Stacie Raymer> Sometimes when we circumlocute, the word pops out.
<masha> We do this at my hospital--we call it Multi Modal Communication or MMC.
<masha> Teach the patient to circumlocute, use gestures, etc.
<Lander> So, the strategy works regardless of the mode of language -- oral or manual?
<Linda> Stacie, Did you mention using a grid/chart for SFA?  Would that be a good way to teach patients to
<Stacie Raymer> Yes, the SFA grid, as a by product teaches circumlocution
<Robin> Do you find more word retrieval difficulties with bilingual patients?
<Stacie Raymer> I don't know that answer to the bilingual question.
<Stacie Raymer> There are a variety of patterns that can be seen in bilingual patients.
<Stacie Raymer> Some patients say they have more trouble in their first language, others have trouble with the
          second language.
<Robin> Thank you...was curious.
<Stacie Raymer> Interestingly, imaging studies in bilinguals show that vocabulary for both language draws
          upon similar cortex.
<jka> I have a patient now who speaks only in Italian but when asked to name pictures she gets every one!
<Stacie Raymer> So the trouble is in conversation but not in picture naming?
<jka> Correct and motivation is low.
<jka> When asked to put words in sentences she has a hard time.
<Stacie Raymer> Some people talk about semantic impairments in the context of the ability to naming pictures
          using some direct visual/phonologic pathways.
<Robin > We have been chatting for an hour now......are there any more questions for Dr. Raymer?
<Lander> Is there a website where I can access info regarding your research?
<Stacie Raymer> I'm afraid I'm not organized on my website.
<Stacie Raymer> But I can recommend my recent chapters.
<masha> Dr. Raymer...you were very informative!!
<Ela> Thank you very much, Dr. Raymer,- good information
<jka> Thanks this was informative
<Robin > Thank you, Dr. Raymer, for sharing your expertise with us.  We will add the exact references you
          cited in this chat to the transcript when it is posted in our online archive.
<AdrienneFSU> Great chat! Thanks!!
<Robin > Thank you all for being here...great questions!
<Lander> Thank you for all of the information!
<Evelyn> Thank you
<Stacie Raymer> Thank you all for asking great questions. The hour flew by!
<Linda> Thanks for sharing your expertise!
<Ela> Thank you.
<Robin> Goodnight!

                                        RESOURCES PROVIDED BY DR. RAYMER:

Boyle, M. (2004). Semantic feature analysis treatment for anomia in two fluent aphasia
syndromes. American Journal of Speech-Language Pathology, 13, 236-249.

Kiran, S., & Thompson, C.K. (2003). The role of semantic complexity in treatment of naming
deficits: Training semantic categories in fluent aphasia by controlling exemplar typicality.
Journal of Speech-Language-Hearing Reseaerch, 46, 608-622.

Marshall, R.C., Karow, C.M., Freed, D.B., & Babcock, P. (2002). Effects of personalized cue
form on the learning of subordinate category names by aphasic and non-brain-damaged subjects.
Aphasiology, 16, 763-771.

Raymer, A.M. (2005). Naming and word-retrieval problems. In L.L. LaPointe (Ed.), Aphasia and
related neurogenic language disorders (3rd ed., pp. 68-82). New York: Thieme.

Raymer, A.M., & Rothi, L.J.G. (2001). Cognitive approaches to impairments of word comprehension
and production. In R. Chapey (Ed.), Language intervention strategies in aphasia and related
neurogenic communication disorders (45h ed., pp. 524-550). Philadelphia: Lippincott Williams & Wilkins.

Richards, K., Singletary, F., Koehler, S., Crosson, B., & Rothi, L.J.G. (2002). Treatment of
nonfluent aphasia through the pairing of a non-symbolic movement sequence and naming. Journal
of Rehabilitation Research & Development, 39, 7-16.