Promoting Aphasics Communicative Effectiveness PACE

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Promoting Aphasics Communicative Effectiveness
(PACE)

• Elizabeth Bowman, Miaoling Huang, Leanne Goldberg
  and Karen Patti
• Dr. Froud
• Language Disorders in Adults
• 17 November 2004

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Promoting Aphasics Communicative Effectiveness
(PACE)

• 1978 by Jeanne Wilcox and G. Albyn Davis
• Developed on 2 assumptions
• Most aphasic individuals have some ability to
  communicate
• Natural conversation presents communicative
  difficulties that they have to overcome
• Developed from the recognition that traditional
  therapy techniques do not duplicate natural
  conversation  
• Intended to reshape structured interaction
  between clinician and patients
• Also improves communicative ability as much as
  possible within the limits imposed by brain damage

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• What is the Goal of PACE and How Does PACE Work?
• Main Goal - To provide the patient with
  strategies to communicate ideas instead of
  focusing on accurate linguistic structure or
  semantic ability and ultimately generalize these
  strategies into daily life.
• How it works - modified traditional picture
  naming task to approximate natural face to face
  conversation
• Based on the pragmatic rule of reciprocity, PACE
  includes the following pragmatic approaches
• Wide range of speech acts
• Turn-taking between participants
• Hint-and-guess sequences when communication
  breakdown occurs

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• Who is PACE used with?
• PACE is one of the few pragmatic therapies used
  with aphasics of many levels and types such as
  the following
• Anomic-one concern is in improving lexical
  retrieval in natural communicative situation.
  PACE provides opportunities for lexical retrieval
  for these patients in natural speaking situations
  which is imperative for generalization
• Brocas-Easily adapted for patients of different
  levels of severity because high level verbal
  skills are not necessary for participation
• Wernickes- PACE capitalizes on the verbal output
  of these patients which is generally
  characterized as fluent but empty speech. PACE
  imposes controls which help to shape their empty
  speech to more meaningful speech

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• The Four Principles of PACE
• The 4 principles are
• The Exchange of New Information
• Equal Participation
• Free Choice of Communicative Channels
• Functional Feedback
• Treatment must incorporate all 4 principles to be
  considered conventional PACE. There are many
  PACE-like treatments that are often referred to
  as PACE-lite

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Principle 1 The Exchange of New Information

• In PACE conversations, the messages that the
  therapist and patient send to one another must
  consist of new information.
• One method implements the use of cards which show
  line drawings and are used to initiate topics of
  conversation. Cards are presented face down
• The person sending the message draws a card and
  must somehow explain what appears on it to the
  other participant. During the first phase of
  therapy, cards depicting everyday objects are
  typically used.
• Verb cards are introduced next which are followed
  by story-sequence cards. In other words, the
  content of messages becomes more abstract as
  therapy progresses.

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• There are assumed conversational conventions in
  communication that exist between speakers when
  relating given or new information
• Communicators are assumed to understand these
  conventions (as they are underlying shared
  knowledge) when engaging in conversation.
• Example Two people are looking at a picture of
  a dog. There would be no reason for a person to
  say, Thats a dog, because that information is
  already available to the two people looking at
  the picture. More appropriate comments would be
  would be in the form of opinions (e.g. Thats a
  cute dog.) or feelings (e.g. I love dogs.) or
  informative statements (e.g. I have a two dogs
  at home.)

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• Problems that Non-PACE Treatment Protocols Have
  in Regards to the Exchange of New Information
• They do not consider the use of conversational
  rules governing given v. new information between
  communicative participants
• Example A clinician shows a patient a picture
  of a cat. The clinician asks the patient, What
  is this a picture of? or Can you describe this
  picture for me?
• The first problem with this example is that both
  the clinician and the patient can view the
  picture of the cat. Therefore, the verbalization
  made by the patient is not new information.
  Instead, it is information already shared by both
  communicative participants.

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• What are the Benefits of PACE with Regard to the
  Exchange of New Information?
• PACE avoids redundant situations such as in the
  previous example with the picture of the cat
• PACE creates an atmosphere where the rules
  governing given v. new information between
  communicative participants in conversation can be
  followed

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• How does PACE Accomplish the Exchange of New
  Information?
• The initiator or sender keeps his/her message
  stimulus out of view in order to relay a message
  to the receiver that is not known.
• Example There is a stack of stimuli between the
  clinician and the patient that are face down on a
  table. The clinician acts as the initiator and
  chooses a conversational stimulus and transmits a
  message to the patient/receiver.
• PACE promotes the exchange of new information by
  employing a method whereby the message stimulus
  is unknown to the receiver.

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• Problems to Consider with this Procedure for the
  Exchange of New Information in PACE
• The clinician will choose the conversational
  cards before a therapy session and will already
  know the nature of which the cards consist of
  especially if the same cards are used repeatedly
  in therapy sessions. This factor decreases the
  true exchange of new information.
• This may result in pretending by the clinician,
  as the clinician will have to fake not knowing
  what communicative cards the patient is
  conveying. This would create a very unnatural
  and unrealistic exchange of information.

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• Wilcoxs (1980) Solution to Problems with the
  Procedure for the Exchange of New Information
• Change the stimuli frequently and use a large
  number of stimuli
• Instead of the clinician choosing the stimuli
  have the patients spouse or a family member
  choose the stimuli to avoid pretending on
  behalf of the clinician

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Principle 2 Equal Participation

• This principle sets the overall tone for PACE
• Participants are equal as senders and receivers
  of messages by taking turns or alternating in
  communicating messages about the stimulus items
  to each other
• Turn-taking is twofold
• Topic initiation and response sequences (global
  level)
• Several turns exchanged over the same topic
  (example)

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• Equal Participation Accomplishes Three Important
  Goals
• Allows Pt. experience with topic initiation
  (sender) as well as topic responses (receiver)
• Allows the clinician to serve as a model for
  initiation as well as responding and thereby
  provides opportunities for the clinician to
  emphasize or de-emphasize communicative channels
• Allows the Pt. to gain experience sustaining a
  communicative interaction for several turns over
  the same topic.

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• Patient as the Initiator
• Consider context and decide what does not need to
  be restated and what needs to be stated.
• Gain listener attention (verbal or nonverbal)
• Symbol selection (distinctions and intention)
• Repairing ambiguous messages - apply feedback and
  reformulate message through self-monitoring

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• Patient as respondent
• Decode the relevant contextual information and
  apply given and new conventions to the received
  message
• Provide feedback such as the following
• Message received
• Contingent query
• Clarification request

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• Clinician as the Model
• Modeling can strengthen desirable communicative
  behaviors and minimize or eliminate undesirable
  behaviors
• Functions
• Reinforce patient's communicative capabilities
• Demonstrate particular strategies
• Influence vs. direction (e.g. never directly
  instruct Pt. to use a particular channel)
• Role Specific Influence The clinician's
  initiating behavior influences the patient's
  initiating behavior and clinicians respondent
  behavior influence patients respondent behavior.
  (example)
• Three Examples (1) Press for speech" affects
  comprehension (2) Poor prognosis for verbal
  recovery yet still insists on primary use of
  verbal modality for sending message (3)Pretends
  to comprehend messages

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• The Patient Sustaining a Topic
• Miniturn sequence allows the Pt. to coordinate
  symbolic behaviors such as stress, use of
  indefinite or definite articles,
  pronominalization
• The Pt. also has the opportunity to make use of
  turn-taking conventions that are important for
  sustaining an interaction on a particular topic
  such as
• Relatedness of turns
• Confirmation
• Contingent queries
• Repair

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Tracking Progress

• Rating Scales Rate each message sent, based on
  number of miniturns before clinician comprehends
  the message
• Scale by Davis (1980), see handout

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Principle 3 Free Choice of Communicative
Channels

• The third principle of PACE therapy is free
  choice.
• In normal face to face interactions, people use
  different means of communication such as
  speaking, reading, and writing.
• PACE therapy attempts to keep the communication
  process as natural as possible by allowing the
  patient to chose which means of communication
  he/she wishes to use to convey the message.
• The aphasic patient may choose any means he/she
  has available.

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• How Does PACE Address Free Choice Better than
  Other Therapies?
• Other aphasia treatments frequently are more
  focused on symbolic or linguistic perfection
  rather than communicative adequacy.
• The free choice option of PACE is intended to
  allow patients the opportunity to use strategies
  to communicate that do not necessarily need to be
  verbal.
• However, PACE does not intended to minimize the
  importance of verbal expression. In many cases,
  verbalization will be the primary focus of
  treatment.
• Free choice allows patients to chose linguistic
  surface structure to express themselves. For
  example
• I go Wednesday again (expressing time with an
  adverb)
• She done? (questioning using intonation)
• While these structures are not grammatically
  correct, they successfully convey the message and
  are therefore acceptable.

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Implementation of Free Choice

• The patient should not be directly told which
  channel of communication to use.
• The clinician indirectly encourages effective
  channels through modeling as the sender.
• The client observes this model and then has
  option of incorporating the strategies into their
  communication.
• Allowing patients to decide on their own to use
  these strategies facilitates generalization.

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• Patients are more likely to use strategies that
  they have selected rather than one they have been
  told to use by a clinician.
• When giving PACE therapy, the clinician should
  make the following clear to the client
• The primary goal of treatment is to convey a
  message. NOT to focus on perfect transmission of
  the message
• The client has a choice as to how he/she can
  transmit the message
• Example Instructions
• We are going to take turns letting each
  other know what is on these cards. Our goal is
  going to be for each of us to guess what is on
  each others card. I would like for you to start
  by picking a card and not letting me see it.
  Then, let me know what is on the card in any way
  you can without actually showing it to me.

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•  Following such instructions, patients may still
  struggle to verbalize.
• If the clinician notices the patient is
  struggling to verbalize, an alternative means of
  communication should be modeled right away.
• For some patients it is best for the clinician to
  take the first 2 or 3 turns.

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• What are the Channels of Communication?
• Channels can include speaking, writing,
  gestures, pointing to printed words, drawing
  pictures, or pointing to related pictures.
• Materials such as paper, pen, pictures, alphabet
  cards, word lists should be available to the
  client.
• The types of communicative channels made
  available to patients will vary based on
  individual needs and capabilities.
• Communication devices are used by some aphasic
  patients to aid in expression. Such devices
  should be used during therapy as well.
• If the patient uses a device during therapy, the
  goal should be to make the device practical and
  functional in the clients daily life.

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Principle 4 Functional Feedback

• The fourth and final principle of PACE is that
  the therapist gives feedback to the patient based
  on his or her success in communicating a
  message.  The main emphasis is not on trying to
  improve the patients verbalization but it is on
  effectively conveying messages
• Feedback needs to be realistic, functional and
  focus on conveying/comprehending the message
• If the clinician comprehends the message, no
  matter how the client conveyed the message, it
  was successfully communicated
• Feedback is given immediately
•    

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• How Can Functional Feedback be Given?
• Rather than telling the patient if they were
  correct or not, tell them whether the message was
  understood or not.
• Clinician should ask for more information, guess
  or use 20 questions for example, when they dont
  understand the patients message. This will help
  the patient send a more comprehendible message.
• Cueing (initial sound, carrier phrases, printed
  or spoken word) can be used to improve the
  patients response.
• Clinician must respond to what they understand as
  it will resemble reciprocal interactions in
  natural conversations.
•     

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• Feedback by clinician will relate to the degree
  of comprehension (the function of the patients
  message adequacy)
• Clinician needs to provide information with why
  the message is ambiguous. For example, I dont
  understand, tell me more only conveys the
  message was not comprehended but Youre looking
  at something? gives the patient more insight)
• Clinicians should guess when provided with
  ambiguous information because a guess may help
  the patient repair the message adequately
• The Painting /Shaving Example
• The patient is trying to convey shaving and
  clinician guesses painting. The patient then has
  some information to use rather than if clinician
  just said  I dont know
• When possible, the clinician should initially
  respond with same channel used by the patient so
  that the patient can evaluate effectiveness of
  the channel selected

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•  When patient says, Youre right, when in fact,
  you are not, it is important to let the patient
  know that you didnt understand by saying, Oh, I
  thought you meant .hes really .. Do not use
  an instructional element.
• The clinician must discipline themselves to
  maintain objectivity because the goal is to
  generalize the patients conversational skills.
• Some aphasics are hard on themselves and feel it
  is more important to verbalize perfectly.
  However, PACE, is based on the communicative
  adequacy, rather than grammatically perfect
  verbalizations
• It is also helpful to conduct a PACE session with
  a client and his/her family members

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PROS of PACE Therapy

• Can be carefully adjusted for many different
  levels of impairment
• Proven effective in enhancing communicative
  abilities
• PACE can have a positive impact on a patients
  motivation to try and use the communication
  methods they have available. If the patient
  rejects one method of communication, PACE
  supports other methods that the patient is
  willing to use.
• The tasks done in PACE are continuously changing
  to ensure that the patient does not lose focus
  which will increase motivation
• Dual involvement of patient and clinician adds to
  patient confidence and comfort and allows the
  patient to realize that conveying messages is not
  solely his/her responsibility.

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Pros (continued)

• The patient can practice PACE with family members
• Can be used as a late generalization stage in
  other treatment programs
• It has contributed to shaping group treatments
• Powerful for training strategies as the clinician
  demonstrates communicative and socially
  acceptable modalities while the Pt. makes
  decision whether to use them.

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CONS of PACE Therapy

• Efficacy
• Pt. improved in referential communicative
  ability, but not on standard language test
• A lot of studies done were not conducted with
  conventional PACE, but PACE-lite
• Few studies of PACE meet the criterion for
  efficacy exceed what can be expected from
  spontaneous recovery (Holland, Fromm, Deruyter
  and Stein, 1996)
• Need more extensive formal research but results
  of limited research is promising.
• Is PACE a treatment program or a component of a
  treatment program?

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Cons (continued)

• Not applicable for all patients and all
  severities of aphasia especially opposed to
  patients who have a severe type of aphasia
  because these patients might not learn from
  indirect methods of therapy.   
•   
• It tends to be less natural and pragmatic then
  authors tend to make it sound.
• Quality of the patients message may not be
  adequate for listeners comprehension.
• Scoring is difficult when clinician is trying to
  understand patient simultaneously
• Therapy is unrealistically long-term to obtain
  quality of results (Europe vs.US Belgium 2 yrs)

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• PACE Revisited by Davis, G. A. 2004 a must-
• read for better understanding of PACE.
• References
• Davis, G. A. Wilcox, M. J. (1985). Adult
  aphasia rehabilitation- applied pragmatics. San
  Diego, CA College-Hill Press, Inc.
• Davis, G. G. (2004). PACE revisited. Aphasiology.
  To be published.
• LaPointe, L. L. (1997) (Ed.) Aphasia and related
  neurogenic language disorders (2nd edition). New
  York Thieme Medical Publishers.