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The four principles and essential procedures of
PACE
Principle Procedures
The clinician’s feedback as a The new information condition
receiver is based on the should make this inevitable
patient’s success in for both participants. Our
conveying the message. feedback should let the
client know if he or she got
the idea across. If we
already know the message,
we should respond as if we
did not know.
© J. J. Hinckley, 2013
PACE: Goals and measures
• Frequency of successfully communicated
message
• Number of attempts prior to success/% of
attempts with x number of attempts or fewer
• Improved efficiency measured by total time
required for each attempt (averaged); can be
reported as % faster
• Frequency/% of attempts using a particular
strategy
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PACE rating scale
5 – message conveyed at first attempt
4 – message conveyed after general feedback from
the clinician
3 – message conveyed after specific feedback from
the clinician
2 – message partially conveyed
1 – message not conveyed
0 – no attempt to convey message
Davis, G. (1980). A critical look at PACE therapy. In Brookshire, R. (ed), Clinical Aphasiology Conference
Proceedings. Minneapolis: BRK Publishers.
Edelman, G. (1987). P.A.C.E.: Promoting Aphasics’ Communicative Effectiveness. Oxon, UK: Winslow
Press.
© J. J. Hinckley, 2013
Task-specific training
This approach focuses on training responses and strategies in a
particular context that is highly relevant to the individual.
This should be training in a task that will be encountered
relatively frequently. Ideally, the trained task will have
elements within it that will also be used in other contexts.
For example, training that is focused on giving personal
information such as name, address, and phone number to
order something also transfers to giving the same
information to order a pizza (Hinckley, Patterson & Carr,
2001).
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Example: Catalog ordering
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Catalog-ordering - potential
measurements
• Response latency – time to respond
• Accuracy – communicative effectiveness
– Scoring system (adapted from CADL-2)
2 = fully communicative response
1 = some errors
0 = completely inaccurate/ineffective
• Total time/total duration of task
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Menu-ordering
1. Can I get you something to drink?
2. What would you like?
3. What sides would you like with that?
4. Would you like anything for dessert?
5. OK, thank you.
© J. J. Hinckley, 2013
Examples of near-transfer – highly
similar contexts
• Catalog-ordering/pizza ordering (personal
information)
• Pizza-ordering/menu ordering
• Requesting routines
– Requesting puzzle access/requesting dining or TV
access
• Role-playing examples you can use in your
setting?
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Errorful vs. errorless learning
• Errorful learning refers to learning that occurs
when a client attempts an item, fails, and then
receives feedback/correction
– Example: Typical cueing techniques
• Errorless learning refers to learning that
occurs when a client engages in positive
practice only; all trials are successful
– Example: fading cues
© J. J. Hinckley, 2013
Errorless learning
• Assumption of this approach is that errors
made during practice interfere with the
learning of the correct responses
• Incorrect responses are stored to some degree
in implicit memory
• Explicit memory processes usually “edit” or
revise these memories, but this cannot occur
in amnesic patients that have more impaired
explicit memory
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Task-specific training may be errorful
when…
• Role-playing is used
– Feedback, correction, or support is only offered
when there is a breakdown
– Client does not switch strategies or otherwise self-
correct until there is a breakdown
• How can we make task-specific training
errorless?
© J. J. Hinckley, 2013
Spaced Retrieval
Spaced retrieval training (SRT) (Brush & Camp, 1998; Camp,
2006) incorporates some elements of errorless learning. This
kind of practice is most powerful when the targeted task or
strategy is being learned in the context in which it will actually
be used. It maximizes retained procedural learning (Evans et
al, 2002). This training technique was originally used with
memory impaired patients, and it has been shown to be
effective with patients who have memory impairments due to
dementia, stroke, or other brain injury.
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Spaced Retrieval
A specific piece of information or a strategy is selected for
training. The information or strategy should be highly
relevant to the individual (something they actually need to
know and respond to in their daily routine). In addition, the
likely context in which the information will be needed should
be selected.
• Example: Client walks outside facility and needs to be able to tell address in case
he goes too far. Clinician targets address (or getting ID out of wallet with address
on it) as target. Clinician selects trigger as “Where do you live?”
The first step is for the clinician to provide the cue or
question that will serve as the trigger for the client’s
response. Ask the client to repeat the correct
information immediately.
© J. J. Hinckley, 2013
Spaced Retrieval
Clinician begins to increase delay between trials.
Initially, the target should be repeated again a
few seconds later.
“OK, let’s practice that again. If I say, ‘Where do you
live?’, you take out your ID.”
Delay between trials increased.
Two minutes later. “Where do you live?”
If client makes an error or fails to respond, shorten
the delay and continue positive practice. Then
return to increasing delays.
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Supported Conversation for Aphasia™
(SCA)
www.aphasia.ca
Supported conversation for adults with aphasia
based on the idea that reduced ability and
opportunity to engage in conversation affects the
way that adults with aphasia are perceived. The less
opportunity there is to engage in genuine
conversation the less opportunity there is to reveal
competence. (Kagan et al., 1995)
© J. J. Hinckley, 2013
Supported Conversation for Adults
with Aphasia (SCA™): Two principles
Acknowledge Competence
Techniques to help PWA feel
competent
Reveal Competence
Techniques to give and receive
accurate information from PWA
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Acknowledging competence
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Revealing competence
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www,aphasia,ca
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www,aphasia,ca
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Kagan et al, 2004
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Kagan et al, 2004
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For the person with aphasia…
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For the person with aphasia…
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Communication partner training with
other therapists/nurses as targets
• Documentation issues
– How client improves communication ability when
in the presence of a good/poor partner
© J. J. Hinckley, 2013
Conversational Coaching1
Conversational coaching is a method for training the individual
with aphasia to use effective communication strategies – such
as gesture, drawing, or writing – similar to PACE. However, in
conversational coaching the training also includes the primary
communication partner, such as a spouse or other family
member (Holland, Hopper & Rewega, 2002). The clinician
serves in the role of coach to both parties.
Effective communication strategies for both the person with
aphasia and the primary communication partner are targeted.
The clinician acts as a communication strategy coach for both
partners (with and without aphasia). The primary
communication partner plays an equal role in improving
conversation.
1 = Evidence is strong for communication partner training
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Conversational Coaching
• Candidacy: Effective for a variety of types and
severities of aphasia. Best outcome will be achieved
when there is a primary communication partner who
is willing and able to learn and maintain
communication strategies.
• Goals & Expected Outcomes: The desired outcome is
the implementation of effective communication
strategies in conversation by both the person with
aphasia and the primary communication partner.
© J. J. Hinckley, 2013
Conversational Coaching
Step 1. Determine a hierarchical list of strategies for each
partner. This should be based on the needs of the
person with aphasia and what will work within that
dyad.
Examples of strategies could include: drawing or writing to
aid expression; drawing or writing to aid comprehension;
longer pauses; slower speech rate; learning a gesture to
request more time
Step 2. The clinician presents a short narrative or story to
one member of the dyad while the other is out of the
room. This could be a short video clip (e.g., America’s
Funniest Videos)
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Conversational Coaching
Step 3. The other partner comes into the room. The first
partner explains the clip or story to the second partner using
the targeted strategies.
The clinician should direct each member to their strategies
as needed, or coach one member or the other on more
effective ways to achieve success while they are
engaged in this transaction. Positive feedback should
also be provided.
Step 4. This can be repeated as needed to master strategy use
and practice in a variety of contexts.
© J. J. Hinckley, 2013
Discussion
• Do the cognitive requirements for these
treatments differ? (Task-specific training,
spaced retrieval, PACE, CPT)?
• Discuss the language or cognitive
characteristics of a client that would lead you
to select either task-specific training, MIT, or
SFA.
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Aphasia treatments that meet these
criteria
(Hinckley, 2011; Salter et al, 2012; Allen et al, 2012)
Reading/writing focus Multi-modality
• Multiple Oral Re- • PACE
reading/ORLA • Task-specific training
• Anagram Copy and Recall • Communication Partner
Treatment Training
• Spaced retrieval
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Anagram Copy and Recall Treatment
(ACRT)
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Multiple Oral Re-reading
• Reading aloud a passage 3 times during
training session – with feedback
• Reading same passage aloud 5-6 more times
at home each day
• Daily practice during the week on the same
passage
• Passage is changed at end of week
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Oral Reading for Language in Aphasia
(ORLA)
• ORLA has four levels of treatment based on
length and reading level:
– Level 1. Simple 3-5 word sentences at a first grade reading
level;
– Level 2. 8-12 words that may be single sentences or two
short sentences, at a third grade reading level;
– Level 3. 15-30 words, divided into 2-3 sentences, at a sixth
grade reading level;
– Level 4. 50-100 words comprising a 4-6 sentence simple
paragraph, also at a sixth grade reading level
© J. J. Hinckley, 2013
Both ORLA and MOR target semantic
and phonological routes for reading
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Which of these require MORE
cognitive abilities for success?
Oral expression focus
• Phonological/semantic • Constraint-induced aphasia
cueing tx
• Task-specific training • Melodic Intonation Training
(phonological/semantic
cueing) • Semantic Feature Analysis
• PACE • Script training
• Verb Network
Strengthening Treatment
• Response Elaboration
Training
© J. J. Hinckley, 2013
Which of these require MORE
cognitive abilities for success?
Reading/writing focus Multi-modality
• Multiple Oral Re- • PACE
reading/ORLA • Task-specific training
• Anagram Copy and Recall • Communication Partner
Treatment Training
• Spaced retrieval
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How to select among the treatments?
1. Functional/personal goals
– LIV cards, Key Life Activities, ICF Checklist, Goal
Attainment Scaling
2. Cognitive abilities/specific language
processes
– Break down tasks and goals that are personally
relevant using Cognitive Task Analysis
© J. J. Hinckley, 2013
3. Select from among evidence-supported
treatments, matching cognitive and language
characteristics to treatments that target
needed skills for personally relevant goals
– Ordering in a restaurant
– Shopping for clothes
– Filling out a written form
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Thank you!
Contact me with
questions or comments
[email protected]
Bloom Where Planted by David Dow,
stroke survivor
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