Professional Documents
Culture Documents
21 (1988), 491-503
This study compared the effects of PACE and traditional stimulation therapy in the reme-
diation of naming deficits. The subject was a 66-year-old conduction aphasic. An ABCBC
time-series design was employed. Greater gains were evidenced during the PACE phases
of treatment on two types of probes-confrontation naming and picture description tasks.
INTRODUCTION
Word retrieval or naming problems occur in virtually all types of aphasic
patients. Thus, the treatment of naming deficits is an issue of special
concern to aphasiologists. A number of different approaches have been
employed for treating anomia. Some therapies such as Base-10 Pro-
grammed Stimulation (La Pointe, 1977) have emphasized a relearning
approach. When specified stimuli are established at a criterion level, the
vocabulary is changed and the patient practices until criterion is again
reached. Other approaches, such as that of Schuell et al. (1964), stress
that the goal of therapy is not to teach new material to the patient, but
rather to maximize the efficiency of an impaired language system. In
Schuell’s stimulation therapy, the clinician supplies a variety of auditory-
visual models and cues to elicit patient response. This latter approach,
which involves the stimulation of word retrieval processes rather than the
teaching of new vocabulary per se, is thought by some to be more effective
for the aphasic patient (Schuell et al., 1964; Howes and Geschwind, 1964;
Wiegel-Crump and Koenigsknecht , 1973).
Despite the strengths and widespread use of Schuell’s stimulation ap-
proach, there is a major limitation: This approach does not consider the
functional context of communication. Although a major objective in
aphasia treatment is to improve the patient’s ability to communicate in
natural conversation, the client-clinician interaction in a typical treatment
METHODOLOGY
Subject Description
The subject was a 66-year-old, right-handed female who had sustained a
left cerebrovascular accident (CVA) approximately two years prior to the
study. A computed tomography scan showed no definite infarct. The pa-
tient presented with right hemiplegia and severe fluent aphasia, charac-
terized by paraphasic speech and impaired comprehension. Following her
CVA, the patient received approximately one year of speech and language
therapy. Therapy was volitionally terminated by the patient prior to the
initiation of the present study.
At the time of the investigation the patient exhibited a residual right-
sided hemiparesis. She had passed audiometric screenings at 25 dB IS0
bilaterally at 500, 1000, and 2000 Hz. The subject was a native English
speaker with high school education. The Boston Diagnostic Aphasia Ex-
amination, BDAE, (Goodglass and Kaplan, 1983) was administered to the
subject two weeks prior to her participation in the study. The results are
consistent with the diagnosis of conduction aphasia. The BDAE rating
scale of speech characteristics was applied to the subject’s verbal per-
formance on both expository speech (description of the cookie theft pic-
EFFICACY OF PACE 493
ture) and conversational tasks. The ratings on the scale indicate fluent
paraphasic speech (see Figure 1). Poor repetition skills were exhibited in
the repetition of high-probability and low-probability phrases-the sub-
ject scored at the 30th and 40th percentiles, respectively, on these sub-
tests. Finally, mean performance on the auditory comprehension subtests
of the BDAE is also consistent with the diagnosis of conduction aphasia.
The mean percentile on the four auditory comprehension subtests was
50%.
Treatment Programs
The treatment program during traditional stimulation therapy followed
the format recommended by Schuell et al. (1964). Both auditory and visual
stimulation were used to elicit naming responses. In addition to the picture
stimuli, a host of auditory-verbal models were supplied. These included
use of carrier phrases, sentence completion, and associated words. The
Design
An ABCBC time-series design was utilized in which the treatment phases
(BCBC) included traditional stimulation therapy (B) and PACE therapy
(C). Three base-line measures were taken initially-these were identical
to the probes described below. Twenty treatment sessions followed, with
each treatment phase consisting of five sessions. Thus, the two therapy
approaches were alternated every five sessions. The same clinician per-
formed all treatment sessions. Sessions were conducted daily (Monday
through Friday).
Probe Description
Probe measures were taken after each therapy session. Two types of
naming measures were utilized as probes-a confrontation naming task
and a picture description task. The confrontation naming task was chosen
to provide a widely used, objective index of naming performance. The
EFFICACY OF PACE 495
manner as the confrontation naming task). Word length was also balanced
across sets. Stimulus words are listed in Appendix B.
Administration of Probes
For the confrontation naming probe, the subject was instructed to name
the pictures. For the picture description task, the subject was asked to
describe what was happening in each picture. If her description of any
picture failed to include an attempt to name the targeted stimulus words,
the prompt “Can you tell me anything else about the picture?” was offered
once by the clinician.
Scoring of Probes
All probe sessions were videotaped for scoring purposes. All naming re-
sponses were scored on a multidimensional scale based on communicative
effectiveness (see Table 1). Scores on this scale ranged from a maximum
score of 2 for responses that effectively communicate the target word to
a score of 0 for incorrect responses. On the confrontation naming task,
the maximum possible score was 30 points; on the picture description
task, the maximum score was 16 points. Naming efficacy on each task
was measured by a percentage score composed of the patient’s score
divided by the maximum possible score.
An independent observer restored 25% of the probes for reliability
purposes. Interjudge reliability was found to be 91%.
RESULTS
LO
90
a0
70
60
/"
50
40
30
20
10
0 0
^_ ,
> I tl 9 10 Ll 12 13 14 15-16 17 18 iY 20
SESSIONS
498 E. C. LI et al.
Category Percentage
IQ)
90
80
70
60
5o
40
30
LO
10
0 I
2 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PROBES
therapy). For instance, during Phase 4, the patient progressed from 25%
to 50% effective naming performance. Percentage scores on the probe
tasks are provided in Appendix C.
DISCUSSION
The patient demonstrated observable improvement during the PACE
phases of therapy-a trend absent during the traditional phases. Improve-
ment associated with PACE was evidenced on confrontation naming and
picture description tasks.
A stairstep effect was seen on the confrontation naming probes. The
individual response categories that consistently improved during PACE
therapy were effective circumlocution and effective multiple responses
(see Table 3). Following the introduction of PACE therapy, the subject
was able to apply these communicative strategies when she encountered
naming difficulties. Rather than “give up” when unable to name the tar-
get, the patient frequently described the object. For example, for the
target word “basket” she produced the following circumlocution: “some-
thing you put food in so you could go outside and go someplace to eat-
you could carry that, too.” The patient also learned to pair gestures with
her verbal circumlocutions (effective multiple responses). The develop-
ment of alternative strategies of communication were particularly helpful
to this patient since she was two years post-CVA. It is suspected that her
language performance had stabilized to such a degree that any improve-
EFFICACY OF PACE 501
High Frequency
Sets 1 2 3 4 5
Low Frequency
Sets 1 2 3 4 5
.-
1 accordion asparagus harmonica camel canoe
2 broom bench comb hanger mask
3 stilts scissors snail pelican wreath
4 toothbrush scrool hammock dart mushroom
5 pyramid pencil noose knocker volcano
High Frequency
Sets 1 2 3 4 5
Low Frequency
Sets 1 2 3 4 5
REFERENCES
Davis, A. (1980). A critical look at PACE therapy. In R. Brookshire (ed.) Clinical
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Davis. A. (1985). Adult Aphasia Rehabilitation: Applied Pragmatics. San Diego:
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Howes, D., and Geschwind, N. (1964). Quantitative studies of aphasic language.
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Kaplan, E., Goodglass, H., and Weintraub, S. (1983). Boston Naming Test. Phil-
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