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P.A.C.E neuro evaluation
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46 views22 pagespace
P.A.C.E neuro evaluation
Uploaded by
laurenc.foucheCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
/ 22
is that any aphasic __
and that the way to
ieatment paradigm .
sonversation. |
indamental belief underlying this approac
‘The text explores the ways in which existing Winslow Press
Photographic packs can be used as stimulus materials in PACE
ISBN 0 86388 051 7
ING APHASICS’
UNICATIVE EFFECTIVENESS
[PL EDELMAN aoe
4 First published in 1987 by:
Winslow Press, Telford Road, Bicester, Oxon OX6 OTS.
Reprinted 1988, 1989, 1990, 1991, 193
ISBN 0 86388 051 7
eG ian, 1987
in any form or by any means, electr ,
photocopying, recording or otherwise, without prior
permission in writing from the copyright owner.
(01. 280/°RINTED BY RAVEN PRINT (OXON) LTD, BRACKLEY, NORTHANTS
Contents
Preface 7
Chapter 1: Introduction 11
Chapter 2: Principles of PACE _ 3
Chapter 3: Setting Goals 19
Chapter 4: ion of Stimuli 24
Chapter 5: Modelling __29
Chapter 6: Referents 31
Chapter 7: Evaluation 33
| Appendix I: Rating Scale for PACE Interaction 38
Appendix I: __ Record of PACE Session 40
Appendix It: Contents of Photographic Set 42
Bibliography 44
——_____Bibliography ad Gill Edelman is District Speech Therapist for the Hammersmith and Queen
Charlotte’s Special Health Authority, based at Hammersmith Hospital in
London. Also on the Hammersmith site are the Royal Postgraduate Medical
‘School and the Medical Research Council; the Speech Therapy Department
therefore not only provides a district service, but is also actively involved in
teaching, training and research,
‘The author graduated with a BA in English Language and Literature from
Birmingham University in 1977, and then undertook a two-year postgraduate
Course at the School for the Study of Disorders of Human Communication (now
the Centre for Clinical Communication Studies, City University), qualifying in
1979. Prior to her present appointment, Gill worked at Charing Cross Hospital
‘and Edgware General Hospital, Middlesex, during which time she began to
develop her special interests in aphasia and the management of patients with
head and neck cancer.
In 1982 and 1983 Gill travelled to the USA to visit a number of Aphasia
Research Centres and to attend the Clinical Aphasiology Conference. She is
particularly interested in the field of pragmatics and in the possible application
of pragmatic theory to the assessment and treatment of aphasia. This stimulated.
her interest in PACE; she is currently planning a research project which will
investigate the pragmatic skills retained by severely aphasic patients.
—— EDITOR’S NOTE —————_______
For the sake of clarity alone, in this text we have used ‘he? to refer to the patient
and ‘she? to refer to the therapist
Preface |
It was whilst I was an undergraduate student reading English Language
and Literature at Birmingham University that I first became interested in
speech therapy. A substantial part of my English degree was devoted to
the study of modern linguistics and it was through the course on psycho-
linguistics and applied linguistics that I first became fascinated by the
complexity of human language behaviour and aware of the existence of
speech and language pathology.
Although it was this academic background which gave me the first
push in the direction of speech therapy as a career, I did not expect to
find myself ten years later referring back to my old undergraduate notes
and essays. My Professor of Linguistics, Prof John Sinclair, was a
pioneer in the field of work which goes under the name of Discourse
Analysis, ie. the study of language as it is used in communicative
interactions. I found the lectures and seminars on this course particularly
interesting. Tutorial exercises included, for example, taping
‘Brummagem’ conversations at bus-stops and later analysing them in
tutorial sessions. We looked at turn-taking within conversations, the way
in which speakers conveyed their meaning through a variety of verbal
and non-verbal channels, strategies used to clarify misunderstandings,
etc. All these things I now realise would fall under the broad heading of
Pragmatics.
This background of analysing normal communicative behaviour has
think been invaluable to my thinking about communication in aphasia.
Having had a ‘traditional’ introduction to classification systems,
standardised test procedures and various approaches to treatment in my
speech therapy training, as a newly qualified speech therapist I became
PACE/7 increasingly frustrated at the shortcomings in many of these methods,
‘What appeared to be lacking was an awareness of normal communicative
behaviour and the means by which to assess aphasic performance against
this background and to plan appropriate treatment goals accordingly.
Although the recently developed emphasis on ‘functional
communication’ has gone some way towards this, functional
communication assessments are more geared to the goals of
communicative behaviour than the means whereby these goals are
achieved. Similarly, some functional communication therapies are
predominantly non-verbal and therefore do not reflect features of ‘normal
communication’.
Having thought through some ideas about alternative methods of
assessment and treatment on my own, I found myself reading a chapter
by Davis & Wilcox, Incorporating Parameters of Natural Conversation in
Aphasic Treatment (in Chapey (ed.) Language Intervention Strategies in
Adult Aphasia, Williams & Wilkins, Baltimore, 1981). This was my
introduction to pragmatic theory applied to the assessment and treatment
of aphasia. I found myself reading and nodding vigorously in agreement.
‘The next step was to select and try out the PACE approach with an
aphasic patient. I was particularly concerned at that time about a patient
of mine—let’s call her Mary. Mary was a 70-year-old lady who had
suffered two CVAs in successive years, which had left her with a
hemiplegia and with a severe non-fluent aphasia. Intensive therapy,
using 2 variety of ‘traditional’ treatment approaches, produced no
improvement in verbal skills, Attempts to introduce non-verbal systems
| including Makaron gesture met with disdain from Mary, and therapy
sessions became increasingly frustrating for both patient and therapist.
We started in a small way with PACE activities, finding
communicative goals that Mary could achieve with a significant measure
of success, gradually building on these, introducing new strategies as we
progressed. Mary spontaneously started to point to objects, gesture and
use facial expression in combination with isolated words and fragmentary
Phrases to get her message across. The only way to summarise her
progress from this point is to say that Mary ‘took off ! The point at which
I realised Mary had really made incredible progress was when she
attended her own case conference and through a variety of gesture, words
and facial expression conveyed to all the professionals assembled that she
had no intention of going into the home as they were planning, but that
| she was determined to stay in her own home with a home help, or else!
8/PACE
Mary had succeeded in getting across an extremely complex message
loud and clear. My interest in pragmatics and in PACE in particular was
kindled.
Perhaps I was lucky in that the patient I chose was particularly suited
to this approach and at the time it was introduced she was peculiarly
‘motivated because of her situation and communicative needs. However, 1
have tried PACE with many other patients now, and am convinced that it
‘may have a place in the rehabilitation of many more.
One thing I should point out: my enthusiasm for PACE does not
imply a disillusionment with other aphasia therapies; I believe that the
aphasia therapist's skill lies in selecting and combining these approaches
for her particular patient’s needs. I hope that the notes which follow and
the photographic materials provided will allow other clinicians to
understand the PACE approach and develop ew therapeutic
Programmes for their patients.
PACE/9 I should like to thank my American friends and colleagues for their
warmth and openness in sharing their knowledge and expertise. I would
particularly like to thank Dr G Albyn Davis and Dr Bob Brookshire for
their support and for their permission to reproduce certain materials in
the text
I would also like to thank the Department of Medical Ilustration of
the Royal Postgraduate Medical Schoo! for their technical expertise in
Producing the photographs (and in modelling for them!) And finally,
thanks to my mother for her unending patience in expertly typing and re.
typing numerous drafts of this manuscript,
10/ PACE
!
Introduction
PACE is an acronym for Promoting Aphasics’ Communicative
Effectiveness, Devised by two American speech pathologists, Dr G Albyn
Davis and Dr M Jeanne Wilcox, it was first presented in 1978 at the
annual ASHA convention. The following year an educational video was
made (Davis & Wilcox, 1979) which demonstrated the principles of the
PACE interaétion and showed a variety of patients undergoing therapy
using this technique. Since 1978 these and other authors have further
developed and evaluated the approach (Davis & Wilcox, 1980; Edelman,
1983) and PACE is now a treatment procedure with international
application.
PACE is not, however, a prescriptive treatment programme, Rather
it is ‘an approach to treatment” based on a belief that ‘any aphasic
individual can communicate in some way’ and that the way to encourage
and enhance these communicative strategies is via a treatment paradigm
which reflects the aims and structure of natural conversation, Nor is
PACE aan exclusive approsch. PACE activities may be usefully
incorporated into @ treatment programme which focuses on improving
specific linguistic skills through language drills and exercises, For some
Patients, therefore, PACE may simply provide an opportunity to practise
these verbal skills (and indeed other non-verbal strategies) in a quasi-
conversational setting in which the emphasis is on ‘getting the message
across’ rather than on linguistic perfection, For other patients, PACE
activities may be used more exclusively. This may be particularly
relevant in cases where further linguistic recovery is unlikely and the
emphasis therefore shifts to maximising the use of residual verbal and
non-verbal skills to improve overall functional communication.
PACE/1 Four fundamental principles guide and shape the PACE interaction.
Within this ‘framework’, the planning and selection of individual
therapeutic goals and tasks depends (as always) on the skill of the
clinician,
12/PACE
1
Principles of PACE
Principle 1
There should be an exchange of information
In natural conversation there is a high ratio of new to given information.
‘The extent to which conversational participants need to make their
message explicit is dependent on the amount of knowledge and
experience they already share.
This shared knowledge may affect vocabulary selection, For
example, people with the same professional background are able to use
terminology which is meaningless to those who are not similarly
qualified. In conversation with non-professionals, terminology must be
avoided and more accessible vocabulary needs to be carefully selected to
aid effective communication
Furthermore, the speaker's assumptions about what his listener
already knows may also influence his phrasing of an utterance, For
example, in the following extract, Speaker 1 mistakerly assumes that
Speaker 2 knows he has bought a new car:
Speaker 1: ‘Well, what do you think of it?”
Speaker 2: ‘Think of what?"
Speaker 1: ‘The car!”
Speaker 2: ‘What car?”
Speaker 1: ‘My new car, the red Mercedes parked outside!
Speaker 2: ‘Oh, I wondered whose it was . it’s fabulous!”
|
PACE/13, Speaker 1’s mistaken assumption leads him to be very non-speci
As he realises that his listener does not know what he is talking about, his
reference to the new car becomes increasingly explicit. What he had
assumed was ‘given’ (ie, shared knowledge) was in fact ‘new’ to his
listener.
Effective communication depends to some extent on the speaker's
ability to signal new versus given information, and on the listener’s
ability to detect and interpret these signals. These facts, however, are
seldom reflected in many traditional aphasia therapy tasks where the
message to be conveyed is already known by both clinician and patient.
For example, in @ picture description task the clinician selects and
presents the picture to the patient. The patient's subsequent attempts to
describe the picture are communicatively redundant since both
participants already share the information which is being conveyed.
A fundamental change in the task is brought about by the simple
action of turning the set of stimulus pictures face down on the tabl
the clinician and not shown until the end of the exchange. Although the
clinician may have some knowledge about the set of stimuli (for example,
they may all be selected from the Winslow Press Verbs set), she has no
knowledge about the particular stimulus item which the patient is
attempting to describe. In this way, the ratio of new to given information
has beeen increased and the task contains an clement of real
communication.
| This notion of new and given information is central to the PACE
approach; and the relative ‘newness’ of the informaton and ‘naivety’ of
the participants are variables which can be manipulated to increase ot
decrease the difficulty of a given task. (See Selection of Stimuli, page 24.)
Principle 2
The patient should have a free choice of communicative channels
Tn natural conversation, a variety of communicative channels are used,
both singly and in combination, in order to send and receive messages.
Gesture, facial expression and pointing all combine to supplement (or
sometimes replace) the spoken and written word in everyday
communicative activities.
‘Many ‘traditional’ aphasia therapies have encouraged the clinician to
separate out systematically these components of natural communicative
14/PACE
Now, when the patient selects 2 picture, it is withheld from the view of |
behaviour and to focus primarily on verbal performance. Here, the
overriding aim has often been to increase verbal output and to facilitate
‘normal’ use of language. So, for example, in the picture description task,
@ patient is encouraged to produce 2 grammatical and meaningful
sentence deemed appropriate to the picture.
Frequently, however, the utterances clinicians most reward are those
that are least ‘natural’ in context. For example, it may be more natural
simply to say ‘shaving’ than to say ‘the man is shaving with a razor’, when
previous cards have shown the same man involved in a variety of other
activities, The fact that it is a man doing something is ‘given’, What is
‘new’ is what he is doing. The fact that he is using a razor is implied in the
word shaving and is evident in the picture. And yet we frequently
encourage this sort of full sentence production in an attempt to ‘perfect’
aphasic patients? verbal responses.
In addition to this primary focus of traditional therapy, namely
enhancing linguistic performance, there may also be a secondary
| focus~that of enhancing para-linguistic skills, such as gesture and facial
expression, This secondary focus is, however, often regarded as
augmentative or supplementary, rather than forming an integral part of
‘normal communicative behaviour.
PACE therapy encourages the clinician to make available as many
different channels of communication as possible throughout a
therapeutic interaction. These may include verbal responses, pointing to
the written word, pointing to objects or pictures, gesture, drawing,
writing, etc. The clinician has three ways of making such options
available and accessible to the patient:
i She can ‘model’, ie. demonstrate appropriate behaviours when
sending/receiving messages in an attempt to influence the
sending/receiving behaviour of the patient.
fi, She can provide physical clues or ‘referents’, ie. by making
available, for example, objects, pictures or printed words to which
the patient can point when sending or receiving messages.
fii, Pen and paper can be made available in order that spontaneous
writing or drawing can be used.
Whilst enlarging the communicative repertoire by making available
such @ wide range of potential channels of communication, the clinician
should not, however, be directive about the patient’s selection of
appropriate channels to convey his message.
PA\ ‘The PACE paradigm is designed ro enable the patient t0 discover for
‘himself which communicative channels, both singly and in combination,
are likely to be most effective. Frequently such channel combinations are
| the most effective way for aphasic patients to convey a message.
Although the language deficit prevents accurate message sending, verbal
Tesponses accompanied by gesture, pointing or drawing may help to
convey an idea both more accurately and more promptly.
Principle 3
Clinician and patient should participate equally
as receiver and sender of messages
In normal communicative exchanges, each conversational participant
functions as both receiver and sender of messages. It is part of normal
wuistic and social development that speakers learn to switch roles
in conversational exchanges. Davis & Wilcox point out that this
happens at two levels:
i. at the level of topic initiation~ when participants may function as
either topic initiator or topic respondent, and
ii, within each topic discourse-each participant taking turns to
listen and respond to the other.
Within such interactive sequences, participants have an opportunity
to practise a number of conversational skills, such as how to maintain and
change topics, interrupt, request information or repair communicative
errors, give feedback, etc. These conversational skills are essential to the
maintenance of an equal and meaningful dialogue.
Frequently, however, therapeutic exchanges do not reflect the
essential features of such conversational turn-taking, nor do they make
such a variety of demands on the participants. In many traditional
therapeutic tasks, the action is one-way. The clinician functions as sender
of messages and the patient as receiver, or vice versa. Furthermore, there
is little equality in topic selection~this is usually imposed by the
clinician,
In marked contrast to the above, the PACE interaction affords
clinician and patient an equal share in initiating topics. (This is achieved
by taking turns to select stimuli.) They can also function more
realistically as alternative receiver and sender of messages within topic
16/PACE
exchanges (by participating in a dialogue about a particular stimulus
item). This equal participation gives the clinician opportunities to model
appropriate sending and receiving behaviours and allows the patient to
practise those skills required for initiating and maintaining a mesningful
dialogue.
With some patients, clinicians may feel it unnecessary to take turns
themselves in selecting stimuli. Indeed, this element can be dropped
without compromising the fundamental principle of equal participation
as patient and clinician will in any event take turns to send and receive
‘messages within each exchange about an individual stimulus item, as
indicated above.
Principle 4
Clinician feedback should be based on communicative adequacy
In a natural setting, feedback between conversational participants is
usually based on whether or not a message has been understood and
whether or‘not it is in accordance with the listener’s expectations.
Respondents may often therefore seek clarification or check their own
interpretation (for example, ‘Do you mean... . ”). Similarly, participants
rarely praise or criticise each other’s choice of vocabulary or grammatical
construction.
In therapeutic exchanges, however, the focus on linguistic adequacy
leads to an emphasis on this latter type of feedback feom the clinician.
Responses such as ‘good’, ‘fine’, ‘okay’ tend to be used liberally when the
patient’s verbal responses are judged eppropriate and acceptable.
Attempts to draw attention to erroneous verbal responses, via
questioning, repetition or offering alternatives, are equally common
features of clinician feedback. Judgements about the ‘appropriateness
and acceptability” of patients’ responses are frequently subjective and (as
noted before) often made without due consideration of relevant
contextual variables.
In PACE exchanges, the clinician must significantly adjust her
habitual responses. The primary goal of each interaction is to ‘get the
‘message across’. Therefore the clinician must provide feedback on the
communicative rather than the linguistic adequacy of the patient's
message. If she has understood, responses should either be of the kind
‘Oh, I see’ or they should seek clarification/corroboration (for example,
PACE NT ‘You mean it’s a... ?') or they may offer additional comment. It is
‘unnecessary to ‘reward’ the patient for communicating effectively in this
type of exchange for the rewards are intrinsic to the activity; effective
communication continues, whereas unsuccessful communication breaks
down,
Again it must be stressed that PACE is not a therapy programme in
itself, but a philosophy or approach to treatment. Through the
application of the four basic principles outlined above, the clinician is
able to select, plan and structure appropriate therapeutic tasks. A new
perspective on overall treatment goals inevitably influences the planning
of hierarchical steps towards those goals. The shift in emphasis from
linguistic to communicative adequacy requires that clinicians take into
account new parameters in their treatment programmes.
18/PACE
3
Setting Goals
The ultimate goal of PACE activites is to extend the scope for success
beyond that attainable during therapeutic activities, ie. the effects of
therapy should be generalisable to other communicative contexts. In
establishing short and long-term aims for PACE therapy, conventional
measures of linguistic skills may need to be modified or indeed
abandoned. Variables such as word-finding ability and complexity of
grammatical structure may not now be appropriate in this context. New
goals may be restated as follows:
> To convey an increasingly complex range of material. It is
neither practical nor constructive to propose a hierarchy which will be
applicable to all patients. The hierarchies which clinicians develop
within PACE may be unique to an individual patient for whom they have
been constructed, taking into account the communicative contexts within
| which he needs to function,
A number of variables can be identified which may affect the
difficulty of tasks for individual patients, and therefore influence
planning of hierarchical steps in therapy. |
The linguistic and communicative strengths and coeaknesses of the
patient have a bearing on performance. For example, if a patient has
retained skills, eg. gesture, which he is not using maximally in
communicative exchanges, increasing the effective use of gesture may
need to become a specific therapeutic goal, In contrast, if a patient
experiences frequent failures in his attempts to initiace a conversation,
“topic initiation’ and ‘conversational starters’ may be noted as therapeutic
poals.
PACE/19 The functional needs of the patient (both physical an.. .ommunicative)
should influence priorities in therapy. For example, a very severely
impaired patient might begin by focusing on sending and receiving
messages related to basic everyday needs, such as toileting and meals. As
the patient progresses, therapeutic activities can reflect increases in
physical and communicative independence, later focusing perhaps on
activities outside the home.
‘The familiarity of the material is significant. The frequency with
which the patient might come into contact with these objects/activities in
his everyday life, or the personal relevance of materials selected as
stimulus items, will influence his response.
‘The relative concreteness versus abstractness of the material may affect
his performance. Concrete nouns and verbs may be more readily named,
pictured or gestured than their more abstract counterparts.
‘The need for specificity will make additional demands on the patient.
Where more detailed communication is needed to convey @ particular
stimulus item effectively, this is rated higher than a generalised response.
The mumber of concepts to be conveyed in any single stimulus in turn
affects the difficulty of the task, To indicate a single object or action will
in most instances prove easier than to ‘describe’ a composite picture, or 2
sequence of activities.
> To extend the patient’s range of communicative channels. The
clinician may seek to improve her patient's skills within various
channels. For example, many patients are so determined to express
themselves verbally that they neglect other communicative modalities
available to them which may be equally effective in getting the message
across. By pitching tasks at the appropriate levels and modelling
communicative channels not currently being used by the patient, she
‘may encourage him to extend his repertoire of communicative options.
The particular orientation of PACE activities, with emphasis on
communicative rather than linguistic adequacy, increases a patient's
awareness of the ways in which a variety and combination of channels
may facilitate effective sending and receiving of messages. Some patients,
previously resistant to work on gesture, have been more motivated to use
this modality when they found i
sending during a PACE activity.
eased their success in message-
> To extend the patient’s skills as a conversational participant.
‘The clinician can plan graded activities which help to increase the
20/PACE
patient’s cox..yetence in handling the following aspects of conversational
interaction:
The method of presentation of stimulus material provides experience
of topic initiation and maintenance. Each new stimulus item may
introduce a new ‘topic for discussion’. Therefore eah PACE session
affords both participants the opportunity to initiate new topics and
maintain discussion about a given topic. It is possible to ‘rig the pack’ of
stimulus cards in such a way as to increase or reduce demands for topic
tion by adjusting the order of stimulus cards, ie. by clustering or
separating out those cards relating to a similar topic.
As descibed under Principle 3, this approach to treatment capitalises
on the natural process of turn-taking in conversation, ie. clinician and
patient are expected to participate equally as receiver and sender of
messages.
Participants are encouraged throughout PACE activities to bring
each communicative exchange to a successful conclusicn, by “getting the
message across’. When planning and structuring activities, the clinician
should pitch tasks appropriately. These should be neither so casy that
successful cémmunication always takes place at the first attempt, nor so
hhard that the message is unsuccessfully or only partly relayed. To be
effective, the activity should produce occasions when clarification is
needed, thus placing demands on both participants. The following
conversational extract illustrates requests for clarification of ambiguous
‘messages and the revisions attempted in order to maintain an effective
communicative exchange:
Patient: ‘Food’
(gestures a saroing motion.) |
Clinician: ‘Are you cutting something?”
Patient: ‘Yes, knife.’
Clinician: ‘Oh, you're cutting something with a knife. Is that it?
Patient: ‘Yes, but knife and...”
(lifts hemiplegic hand to show two hands involved.)
Cli ‘Oh, knife and fork.”
Patient: ‘Yes, that’s it ... knife and fork.”
In this extract it can be seen that the patient wes monitoring the
response of the clinician, realised where his message was deficient and
was able to provide enough clues to correct it. Similarly, the clinician, in
PACE /2t the receiver role, was able to signal that she had not understood and to
ask questions which contributed towards clarifying the message.
Both these skills are important to develop in the aphasic person who
will necessarily encounter frequent break-downs in communication in
the course of his everyday activities. He needs help in learning how to
deal with communicative failure. When tackled within a therapeutic
environment, practice in recognising when miscommunication has
occurred, and in employing a range of skills required to restore an
effective communication, can help to increase confidence and reduce
frustration. The patient is then more likely to employ these coping
strategies in real-life situations.
> To increase the patient’s independence and confidence as
effective communicator. PACE encourages patients to become more
independent communicators through a variety of means, including the
use of a wider variety of communicative channels, the use of referents (see
‘page 31) and practice of skills required in conversational exchanges. All of
| these strategies encourage a greater resourcefulness and self-reliance.
| Clinicians will be familiar with the aphasic patient who typically fails to
initiate conversations or who gives up all too easily when he fails to get
his message across, becoming the passive respondent to a ‘twenty
questions’ barrage. The PACE approach to therapy aims to reduce these
potential problems by encouraging patients to harness all the skills and
strategies they possess, in order to become more active conversational
participants.
Even in the more severely impaired aphasic patients, PACE methods
may produce greater independence. The use of referents is particularly
relevant in this respect, Many clinicians will have been approached by
carers requesting ‘communication charts’ so that the aphasic person can
point to what he needs. The paradox about these charts is that those who
need them are rarely able to use them successfully. Several authors,
however, give anecdotal reports of greater success with communication
charts through their introduction and gradual assembly via PACE
activities. In a therapeutic situation where pictures are used to represent
objects or actions and to send messages, there may be greater chance of
carry-over to realtife situations.
| Another advantage of the PACE approach is that it encourages
patients to evaluate their own performance. In some drills, where
linguistic accuracy is the goal, it may be difficult for the patient to know
whether or not he has performed successfully. In a PACE session, the
2/PACE
success of each task is self-evident if the message has been conveyed. The |
Patient is less dependent on feedback from the clinician as to whether his
performance is satisfactory.
> To increase the patient's ability to function with a range of
conversational participants in varying communicative contexts.
As patients develop effective strategies for sending messages within the
therapeutic situation, there is a danger that an idiosyncratic code may be
developed between the patient and the clinician, Patterns of
communicative behaviour such as word/gesture combinations may be
more readily interpreted by a participant who is familiar with these
strategies. The individual clinician may also be skilled at drawing
inferences about the message.
Therefore it is important and advantageous that others act as
participants in the PACE exchange. For example, a ‘carer’ may be shown
how to function as the other participant. Such a therapy session provides
@ very useful, controlled context within which the patient can explore
strategies which may help him cope better when similar communication
difficulties arise in real life.
‘PACE/# 4
Selection of Stimuli
A variety of stimuli can be used according to the
individual patient.
and needs of the
Real objects may be useful with patients who are visually or
perceptually impaired. Handling of the object may guarantee recognition
of the stimulus item. Similarly, for patients with limb apraxia, handling
of real objects may facilitate appropriate use of gesture. If real objects are
used, however, a small screen will need to be used to ensure that the
stimulus item is withheld from the view of the other participant during
the activity.
Line drawings, pictures or photographs may be used as stimuli where
visual recognition is not a problem. The use of pictured stimuli greatly
increases the range of topics which can be covered. The complexity of
these stimuli can be increased by picturing more then one object/activity,
reducing the familiarity of the material, etc. Experience suggests that
photographic materials are the most suitable for adult aphasics because
| they are more adult, more lifelike and more visually appealing.
| Printed words, sentences may also be used with patients whose reading
skills are at an appropriate level. This allows the clinician to select more
abstract concepts as stimuli which cannot readily be pictured but can be
represented by a written word or phrase.
As has already been explained, there are a number of ways in which
selection of stimuli may be manipulated in order to influence the difficulty
of the task, For example, one of the areas highlighted on page 20 was ‘the
need for specificity’. The relative importance of supplying detailed
24/PACE
information avout certain stimuli will depend upon two key factors:
i. the set from which the stimulus materials have been selected;
ii, the ‘naivety’ of the other participant.
If the stimulus materials consist of photographs taken from the
Winslow Press Objects pack, the clinician is likely to be very familiar with
the objects depicted in the set. Therefore, if the patient sends an
ambiguous message like ‘Booze... with ic yes, please!’, the
clinician is unlikely to guess ‘I’s a gin and tonic!’ for she will know that
such an object is not included in that pack. She is most likely to infer the
identity of the object through her knowledge of the contents of the set,
guessing ‘A bottle of whisky? A more detailed message would be
required ifthe same set of stimulus items were used by the same patient
but with a new and ‘naive’ participant, who lacked knowledge of this
particular set of materials
Using a circumscribed set of materials, such as the Winslow Press
packs, can also be useful in another way. Existing sets may already
provide materials for building a hierarchical programme. For example,
an early PACE session might involve using Winslow Press Verbs as
stimulus materials and providing photos from the Photo Library pack as
referents, as in the following extract:
6 Verb cards selected as stimuli are lying face down in a pile. 6
cards from the Photo Library pack are arranged as referents.
Patient: (takes card)
‘Oh yes...
(points 20 toothbrush)
Clinician: “The toothbrush, it’s someone brushing his teeth.”
(gestures brushing)
Patient: (copies gesture)
“Brushing.”
(shows card)
Clinician: ‘Okay, my turn’
(selects card)
(gestures drinking)
(points to cup)
Patient: (copies gesture)
Clinician: ‘Yes, she’s drinking a cup of tea.”
PACE 25 In this way, the continued use of referents and clinician modelling of
gesture leads to a successful sending and receiving of messages.
‘The Winslow Press sets can also be used to increase the need for
greater specificity. In the example just cited there is not a great likelihood
of confusion between pictures, given a minimal clue to the content of the
picture. However, ifthe Winslow Press Sequence pack were used instead,
this would greatly increase the potential for confusion. There are a
number of closely related activities portrayed, and an unspecific
communication would be insufficient to pin down the precise message,
unless further clarification were forthcoming as illustrated by the
following extract:
Patient: (selects card)
‘Letter,’
Clinician: ‘Something to do with a letcer.’
Patient: ‘Finish . .. letter”
Clinician: ‘He's finished writing the letter?” |
Patient: ‘No. |
(points 10 envelope, eoritten referent)
Clinician: ‘He's putting it in an envelope?”
Patient: ‘Yes... . envelope.”
‘"Naivety’ also relates to the degree of shared experience that exists
between the patient and the other participant. For example, if the
stimulus item portrays or refers to an object/activity of which they have
shared experience, it may greatly facilitate effective message-sending.
‘The following extract taken ftom a therapy session with a non-fluent
patient illustrates this:
(picks up picture of a camera)
‘Oh yes... very nice...
(makes vague hand movement to head)
Clinician: ‘Making your hair nice? . . . a hairbrush?”
Patient: ‘Ohno... me!”
(points to self)
(repeats hand movement)
Wife: (interrupts:)
‘A camera ... he used to be a keen photographer.’
Patient:
26/PACE
In this latter example, the tables are turned and it is the clinician who is
the naive participant requiring a more specific description, while for the
patient’s wife, shared experience makes a general reference quite
sufficient. For her, the patient's vague hand gesture is adequate to
represent the hand posture of holding a camera. |
‘The new sets of PACE photographs have been selected in order to |
increase the flexibility of Winslow Press packs, and their potential for use _ |
in PACE activities. They offer a broader range of objects and everyday
activities for use 2s stimulus materials and have been selected with the |
‘need for specificity’ in mind. When using these photographs, there is
greater potential for ambiguous messages unless communications are
quite specific. Ambiguities may be related to visual confusion (je. some
activities look similar) or to verbal confusion (ie. activities may share
similar vocabulary)
Listed below are some items included in one set. They are arranged
in sets of four. Each set comprises four activities related to one concept,
eg, cutting. There is the potential for confusion within and between sets
as a number: of objects are pictured in more than one activity, eg.
cleaning glastes, putting on glasses. It can be seen that simply identifying,
appropriate objects or actions may not be sufficient to convey the
complete message:
Cleaning shoes
Cleaning glasses
Polishing silver
Polishing table
‘Trimming moustache
Cutting nails
Cutting a cake
Cutting out a sewing pattern
Putting on a hat
Putting on glasses
Putting on lipstick
Putting on gloves.
Further sets of photographic materials may be developed in this way in
order to extend the range and complexity of tasks. There is the potential
for selecting cards either from one set or from more than one set, thus
increasing the demand for specificity.
PACE/27 Note
It should be reiterated, however, that stimuli for PACE activities need
not be confined to photographic materials. Depending on the skills of the
patient, pictures, line drawings, symbols (eg. Bliss) or the written word
can all be used as stimuli. Conversely, the PACE photographic materials
need not be used solely for PACE activities. They are equally useful as
stimulus cards for a wide variety of speech, language and communication
exercises and can be used with individuals or groups of patients other
than aphasics (eg. mentally handicapped adults).
28/ PACE
Modelling |
‘Modelling has already been described as ‘demonstrating appropriate
bbchaviour in an attempt to influence the sending/receiving behaviour of
the patient’. Davis & Wilcox (1985) suggest that ‘clinicians’ sending
behaviour influences that same behaviour in clients, while clinicians’
respondent behaviour influences responding behaviour in clients’.
Whilst they acknowledge that further research is needed to corroborate
this clinical observation, this may be a variable worth considering when
planning and implementing PACE sessions.
Clinicians may choose to model particular channels because they are
not being used spontaneously by certain patients. For example, where
patients tend to rely solely on non-verbal communication, modelling of
gesture/word combinations and the use of referents which can be read
aloud may encourage greater verbal output. Other patients, described as
‘fixated’ in their attempts to communicate either verbally or through use
of a picture or word chart, need to'be encouraged to use other channels.
This can be achieved through the provision of referents and the use of
clinician modelling.
Note
This technique of modelling may, to some clinicians, appear rather
artificial since it involves the use of utterances or behaviours which are
not wholly spontaneous. For example, in order to demonstrate the value
of using other channels, verbal output may be consciously restricted.
Some might consider this unacceptable, feeling that itis like ‘pretending
to be aphasic’.
PACE /29 Alternatively, it may be advantageous to reduce verbal input with
some patients eg. those with severely impaired comprehension and fluent
speech output, and in any event the extent to which the clinician limits
hher own verbal output is dependent upon the patient’s impairments in
auditory comprehension and expressive language. Therefore, modelling
need not always imply a marked reduction in verbal expression.
30/PACE
Referents
Referents have been defined as ‘physical cues .. . objects, pictures, words.
etc... to which the patient can point’ in order to send messages or
demonstrate understanding of the clinician's message, Careful selection
of referents is necessary, different types being chosen in order to pitch.
each task at the appropriate level.
‘A particalar set of items may be too difficult for an individual patient
to respond to without the provision of referents. For example, an aphi
patient who is unable to make appropriate representational gestures may
be helped by the presence of real objects which he can use to demonstrate |
actions. Articulograms or initial letter cues might also be made available |
for a patient with articulatory apraxia where such cues might facilitate
verbal expression in real situations.
To enable generalisation, patients might be encouraged to scan the
room in order to find everyday items in their own environment which
ccan act as referents. Alternatively, the clinician may choose to introduce
additional referents as the patient’s overall communicative skills
improve. For example, written referents, such as word cards, may be
provided for a patient who shows improvement in written language
skills. A pen and paper may also be provided.
The number of referents provided must be limited. If too many are
available, the patient may be unable to scan all of them, or the time taken
to do so may be too great. Efficiency in sending and receiving messages
depends on both accuracy and speed. Furthermore, the extent to which
aphasic petients become independent communicators may depend on
how readily they learn to communicate using such referents. However,
there are two obvious problems with dependence on such material cues:
PACE/3 i. The cues themselves may not always be available in natural con-
versation.
ii, Ifthey are, overdependence on the cues can result in underdevel-
opment of other communicative skills (for example, if the patient
carries a communication chart).
‘These factors need to be taken into account when planning PACE
activities, and the use of referents modified accordingly.
52/PACE
i
Evaluanon
In order to evaluate the effectiveness of particular therapeutic
approaches, regular assessments need to be carried out. PACE activities
are no exception and several methods of evaluation are recommended:
1 Within sessions
Davis (1980) proposed @ rating scale for scoring the effectiveness of each
communication in a PACE exchange (see Appendix 1), ‘The five-point
scale reflects a patient's speed, accuracy and independence in sending
messages. The author suggests a sample of 15 consecutive attempts at
message-sending should be recorded and scored in this way in every
fourth session, in order that a check on progress can be made. By rating a
sample set of stimulus items from a PACE session in this way, useful
information can be obtainedindicating whether or not the task is
pitched appropriately.
For example, if a patient consistently scores below three on each
stimulus item, the task probably needs to be modified, eg. different
stimuli chosen or additional referents provided. If the patient shows a
great spread of scores, ie. scoring five on some stimuli and less than three
on others, analysis of the lower scoring items may highlight the need for
training new communicative strategies, eg. if the patient has written
language skills which he is not using in communicative attempts, a pen
and paper might be provided to encourage spontaneous use of writing to
id message-sending. The therapist would model writing accordingly.
This author advocates using the Davis scale in conjunction with a
more detailed analysis of the channels of communication preferred by the
PACE/ SS patient. This involves making a written transcription of the dialogue. An
appropriate form has been devised for this purpose in order to provide a
complete record of the sample (see Appendix 1),
On this assessment sheet, the clinician specifies the therapeutic
goals, the stimuli to be used, referents selected and indicates the
appropriate communicative strategies to be modelled. The session can
then be transcribed by an observer or can be transcribed by the clinician
following the session if video recording is available. (It is not impossible
for the clinician to score the session whilst itis in progress, but this tends
to be disruptive and inevitably some detail is lost in such a speedy
transcription.)
The completed assessment form provides the clinician with a clear
analysis of the channels of communication used; what is said, written or
gestured; whether or not there is a clinician feedback indicating the need
for further clarification; and finally, the rating based on the Davis scale.
The following description of a PACE session and its analysis on the
sample assessment form (Appendix IN) serves to illustrate the approach
described above,
‘The patient is a 69-year-old man with a non-fluent aphasia. In
previous PACE activities he has been encouraged to point to pictures
(provided as referents) in order to identify the topic when sending
messages. However, he rarely uses gesture as a means of clarifying his
message and when gestures are used, they are often vague and non-
specific.
In this session, the clinician has selected the Winslow Press PACE
photographs as stimulus items. Because of the construction of this set
and the potential for ambiguity, the patient will have to convey more
specific messages in order to get the complete message across.
Real objects, depicted in the photographs, are provided as referents
to encourage the patient to demonstrate their use. The therapist will also
‘model their use. (This stage of object manipulation can be regarded as an
interim stage on the way to the elicitation of spontaneous
| representational gestures.)
Here is a sample of the exchange between the clinician and patiei
‘/PACE
Clinician:
Patient:
Clinician:
Patient:
Clinician:
Patient:
Clinician:
Patient:
ician:
a
Patient:
Clinician:
Patient:
Clinician:
Patient:
(looks at first photograph, places it face down on rable)
‘Wes a man writing.”
(points 10 envelope)
“Envelope.”
(takes envelope)
“Yes, that’s right—he’s writing an address.”
(mimes eeriting)
‘Address.’
(mimes coriting on the envelope)
“Yes, he’s writing out the address.”
(shows PL photograph)
(elects next photograph, places it face down etc.)
‘Same... stamp.”
‘He's sticking the stamp.’
(Picks up stamp and mimes licking and sticking stamp)
“Yes, sticking . . . stamp.’
(hous clinician photograph)
‘Okay, it’s my turn.”
(selects next photograph, etc; points 1 glasses)
“He's got a cloth.”
(mimes cleaning glasses)
‘Dirty?
“Yes, s0 he’s
Oh
(takes out own handkerchief and cleans glasses
meticulously)
(laughs)
“That's right~they’re clean now!
(shows photograph)
(selects next photograph, etc.)
“Tip, tip ... tip tip...” (rapidly)
(small rapid gesture with finger and thumb)
‘I don’t know . . . what more can you tell me?”
(Points t0 scissors)
ip... tip... tip
(looks questioningly)
“Cutting something?”
“Yes... yes. Cutting nails”
tip
PACE /35 (takes scissors, mimes cutting nails)
Clinician: ‘Oh, someone trimming their nai
(hows photograph)
Clinician: (selects next photogaph, etc:)
‘Oh, we've had this one . .. the spectacles.”
(mimes putting glasses on)
Patient: (picks up glasses from among objects; puts them on)
“Glasses.”
Clinician: ‘Yes, he’s putting on his glasses.’
| (shotos photograph)
Patient: (selects next photograph, etc.)
‘Case . .. suitcase ... no, no.’
‘Is it a case? Can you tell me anything more?”
“Man.”
(vague hand gesture)
Clinician: ‘Can you show me using these?”
Patient: (picks up key)
(mimes locking)
‘Lock it up.’
‘Lunderstand . . . He’s locking something . . . I think
"5 a briefcase.’
"Yes, yes . .. locking
(shores photograph)
As this extract illustrates, the patient is being made more aware of
strategies which will help him communicate his message, and is
gradually beginning to use the referents. Once more the patient has
become more proficient at this level and is able to send messages more
accurately and quickly and the objects may be withdrawn, encouraging
the patient to gesture spontaneously. It is interesting to note how, on two
occasions, an appropriate gesture spontaneously elicited appropriate
vocabulary from the patient, when he had been unable to find the right
words before,
In this way, analysis of each stimulus turn builds up a profile of the
session and allows the clinician to look at the strategies being used by the
patient, Individual ratings scores can be averaged to provide an overall
‘measure of communicative effectiveness within a session. In this way the
inician can assess whether or not all available channels are being used
effectively, evaluate the appropriateness of the task and plan further