Slide 1

Thematic Language
Stimulation
Megan Brey & Nicole Compty

We researched and implemented a therapeutic approach to aphasia intervention called

Thematic Language Stimulation.

Slide 2

Thematic Language Stimulation (TLS)- What is it?

A systematic method of therapy for aphasia that
uses vocabulary centered around a functional theme
for the client
Uses multimodality stimulation
Targets changes in language processing for
functional communication outcomes
Purpose: To change the way the brain is working by
working the brain
Morganstein & Certner-Smith, 2008, p. 451

Thematic language stimulation is a therapy that is systematic using thematically related

vocabulary in multimodality stimulation (visual and aural), targeting changes in language
processing for functional communication.
Language restoration comes about through carefully controlled stimulation
o overall improved understanding, speaking, reading, and writing

Slide 3

Theory/Rationale for Use

The organization of the approach reflects the organization
of the brain
Looks more closely at the person with aphasia, rather than
the disorder of aphasia
Links what the person with aphasia knows and what the
person with aphasia can produce to increase language
proficiency in comprehension, production, reading, and
writing
Provides meaningful content in a more natural context

Morganstein & Certner-Smith, 2008

Influenced by the process approach in intervention of understanding the why as well as the
what about aphasia
Studies done with monkeys have shown data suggesting that with systematic motor stimulation,
the brain is able to change, including changes in the organization of the monkeys auditory
cortex
The speech-language pathologist is the link between what they know and what they can
produce and therefore the burden of success lies in our hands
In doing so, this allows us to reveal information about the clients underlying processes which is
valuable in the development of strategies for success, especially at the conversational level
Talk about comfort levels

Slide 4

Who is TLS designed for?

Clients with fluent or non-fluent aphasia
No marked perseveration or semantic
confusion
Visual preservation

Morganstein & Certner-Smith, 2008

Authors feel you can use TLS with both fluent and non-fluent aphasia
Patients with moderate to severe difficulties appear most to profit
o some research has said otherwise
Candidates for TLS include:
o no marked perseveration or semantic confusion in task performance
it has been found that because the words are all thematically related, it
can make individuals who perseverate struggle even more.
o good ability to understand the purpose of therapy
o stable emotional status
o visual language preservation
Have to have some preserved visual abilities to be a good candidate for TLS

Slide 5

Cognitive & Behavioral Considerations

1. Patient Involvement
2. Specific Symptom Awareness
3. Task Orientation and Retention
4. Perseveration
5. Visual Perception

Morganstein & Certner-Smith, 2008

There are a few cognitive and behavioral attributes that should be considered by the SLP to
determine if the client would benefit from TLS.
Patient Involvement: TLS works best with insightful, motivated clients who get it
Examining their ability to connect with the disorder, comment on the patients own
internal processes or performance for such behavior on task, and consider other types
of metalinguistic analyses
However, given its structure, TLS can be used to improve metalinguistic ability and lack
thereof should not entirely this treatment out for a client
Specific symptom awareness: Clients with specific symptom awareness tend to achieve more
progress and do better overall
Task Orientation and Retention: saves time because we do not have to take the time to
completely re-explain the directions of the task every time
Perseveration: Given the semantic relatedness of the words used in TLS, perseveration can
become exacerbated. Therefore, individuals who present with perseveration are not considered
good candidates for this approach
Visual Perception: TLS relies heavily on multimodality input. As a result, it will be crucial for us
to know ahead of time if there are any visual problems. If severe, TLS will most likely not be
effective.

Slide 6

Pre-Assessment/Baseline
Need specific information on language abilities to
develop an appropriate program
Need to determine:
which cerebral processes are impaired
the level at which performance breaks down in
each modality
the reason why performance breaks down when
it does
Process oriented examination using formal tests,
informal tests, and observations to get adequate data
Morganstein & Certner-Smith, 2008

Programs are so individualized, that clinicians must obtain specific information on the
language abilities of clients
o
determine:

which cerebra processes are impaired

level at which they break down

the reason why they are breaking down

Clinicians obtain this information through both formal and informal testing
Formal testing:
o
Determine:

repetition abilities

sentence construction abilities

automatic language

picture description

ability to follow directions

yes/no reliability

reading comprehension

oral reading

graphic expression
o
You can use:

BDAE

MTDDA

WAB

PICA
Observations:
o
Determine:

level of participation in conversational exchanges

relative use of alternatives to speech when they appear in the natural

course of an exchange

present level of comprehension

o
Quality as well as quantity:

What is he doing?

How is he doing it?

Why is he doing it that way?
What is the time factor?
Is he using strategies that succeed? That fail?

Slide 7

Client Information

Initials: RI
DOB: 10/26/1955
Age: 59
Medical History: Left cerebral vascular accident in June of 2005

RI presents with a moderate non-fluent aphasia and moderate apraxia of speech.

Verbal expression is characterized by agrammatism (omissions of verbs and
functor words and predominance of content words) and word finding difficulties
(latencies)
Apraxia of speech is characterized by groping during volitional speech,
inconsistent articulatory errors, and difficulty producing multisyllabic words
Groping, eye blinking and facial grimacing during volitional speech
Uses hand signals to self-regulate speech production and to cue
conversational partners to give him time to think

Morganstein & Certner-Smith, 2008

Our clients initials are RI. He is a 59-year-old male who had a left cerebral vascular accident 9
1/2 years ago. He presents with nonfluent aphasia and moderate apraxia of speech
Some characteristics include agrammatism and word finding difficulties as well as groping
during volitional speech, inconsistent articulatory errors, and difficulty producing multisyllabic
words.
He does have the ability to self-regulate his speech production and is able to cue his
conversational partners to give him time to think

Slide 8

Goal
We chose TLS as an intervention method
for RI because TLS targets increasing
phrase length in functional
communication.
Mr. I will increase his average phrase length to 5
words across all communication settings (e.g.,
conversation, script).

Overall goals for TLS can include goals focusing on comprehension, production,
reading, and writing.
Research studies have used the cookie theft to collect baseline and measure progress
of production with the TLS program
We specifically chose TLS as an intervention method for RI because it targets increasing
his phrase length across multiple modalities and gives him multiple opportunities to
practice.
The goal listed is RIs goal from this semester, targeting his phrase length.

If we wrote his goal, we would modify across which settings he would increase his
phrase length. It is hard to measure his success in all settings. We would most likely pick
one.

Slide 9

Content and Delivery

TLS unit consists of 8-10 vocabulary words
Primarily nouns and verbs
Highly related to a specific topic
Presents tasks in a hierarchical arrangement
Best modality first
Allows the clinician and person w/ aphasia to
move back and forth between structured
clinical tasks and functional conversation
Metalinguistic dialogue
Environmental material
Morganstein & Certner-Smith, 2008

TLS is comprised of a unit of 8-10 vocabulary words, primarily nouns and verbs, that are all
highly related to a specific topic. For our client, we chose the movie theater because this was
something that we knew he enjoyed doing and would therefore be motivating.
Tasks are presented in a hierarchical manner in order to obtain the greatest success. The
progression starts with introductory topic material and moves to identification of the theme
vocabulary, manipulation of language in carefully adapted and sequenced multimodality tasks
and a return to conversational format...all within one session. This ensures an adequate
stimulus. One that is high in relevance and allows for multiple opportunities for both input and
output of the vocabulary in order to create a neurobiologic effect or a change in the brainmediated language performance
The order is also determined by using the clients best modality first. For instance, we knew our
client has a more difficult time writing, so we did not start with a writing task.
Another important component is the use of metalinguistic dialogue or someones ability to talk
about language and its use. This usually occurs at the end of the session. So the typical flow of
the session is from TLS activities to functional communication and then metalinguistic dialogue.
For example:
SLP: I noticed...
Client: Yes...

Use of metalinguistic dialogue also reinforces our collaborative relationship.

Finally, it is encouraged to use environmental materials. So, for a movie theater theme, one of
our words was popcorn. We might actually consider bringing in a popcorn container.

Slide 10

TLS Unit
1. Repetition
2. Speech Stimulation/Production
3. Copying
4. Categorization
5. Sentence Fill-Ins, Multiple Choice
6. Yes/No Questions
7. Answering Questions, Multiple Choice
8. Sentence Arrangement
9. Sentence Construction
10.Sentence Correction
11.Paragraph Reading, Multiple Choice Questions
12.Conversational Questions
Morganstein & Certner-Smith, 2008

Each unit consists of the 8-10 vocabulary words that are targeted in the functional theme
(mainly nouns and verbs)

Repetition tasks, fill-ins, multiple choice selection, and more.

o
These tasks are set up hierarchically, moving from simple to more complex

Clinician prepares units before intervention

TLS begins at the simplest level of repetition.

o
Units also increase by systematic complexity as well

Example: repetition unit

word

phrase

sentence

There are specific guidelines for how each unit should be designed.
o
For example, in the repetition unit, the vocabulary word is supposed to be at the
end of the phrase or sentence whenever semantically possible.

TLS is designed to use exercises over the course of 5-7 sessions

Here is our TLS program, organized into 12 units with 8 functional vocabulary words
related to the theme of going to the movie
*Show our binder

Slide 11

Cueing
Want client to stay between 80-90%
successful
Client must reach 80-90% success
before moving on to the next unit

Morganstein & Certner-Smith, 2008

TLST is designed to systematically deliver the greatest number of accurate responses.

Must scaffold them as needed to complete the task with 80-90% success before moving
to the next unit
If the client is above 90% accuracy, the activity is not stimulating the brain -- it is not a
therapeutic activity.
Clinicians must know client and determine what cues and prompts aid in their success -when a client is below 80% accuracy, clinician must be able to use scaffolds to aid in
succes. But, when a client is above 90% clinician must take away scaffolds or increase
the level of difficulty in the activity to ensure the brain of the client is being challenged!
o
the art of aphasia therapy

Slide 12

Feedback
Use cueing hierarchy to ensure they
are at least above 80% accurate
Provide verbal feedback when
necessary

Explicit

Morganstein & Certner-Smith, 2008

The cueing hierarchy is used to ensure that the client is at least above 80% accuracy. As a
result, we need to ensure we are using explicit and salient language. Feedback is mostly
embedded in natural conversation. As with many approaches, the moment to moment
adjustments are key going to be key.

Slide 13

Data Collection/Scoring
Binary
*Denote whether cueing was used and what type of
cue

Morganstein & Certner-Smith, 2008

TLST uses a binary data collection method

o remember to keep track of successful responses with and without cues.
collecting data during therapy session is quite easy if you use ten different stimuli
o score of 8/10 and 9/10 is the goal

Slide 14

Pros of TLS
Incorporation of all modalities to affect
change
Themes provide a highly meaningful
and motivational context
Organization reflects organization of
the brain
Morganstein & Certner-Smith, 2008

We felt like TLS did a great job of incorporating all modalities into a therapy session, which can
be really beneficial to effect change. The themes are designed to be highly motivated and
meaningful by centering them around a topic of interest for the client. Lastly, we also thought it
was good that this approach is based on the organization of the brain and therefore may
encourage better connections?

Slide 15

Cons of TLS
Can be time consuming to plan and
execute
May feel rushed at times
Difficulty in even one modality may
affect ability to move up the hierarchy
Not effective for individuals with
perseveration or visual impairments
Morganstein & Certner-Smith, 2008

On the other hand, there were some cons related to this approach. It can be time consuming to
create these themes for the SLP. At times, we did feel rushed to get through the exercises. As
we mentioned before, you have to take into consideration the clients capabilities. If the client
has a lot of difficulty in a specific domain, this can very easily affect their ability to benefit from
TLS. Finally, while this is not something that can be changed, because TLS is not considered
effective for individuals with perseveration or severe visual impairments, we felt this could be
limiting.

Slide 16

Video Demonstration(s)
Exercise 1: Repetition

Exercise 8 : Sentence Arrangement

Exercise 4: Categorization

Exercise 9: Sentence Construction

Exercise 5: Sentence Fill-In, Multiple

Choice

Exercise 12: Conversational Questions

During our therapy session, we completed all 12 tasks with RI.

We included 6 of the 12 video clips.
o 1. repetition
o 4. categorization
o 5. sentence fill-in, multiple choice
o 8. sentence arrangement
o 9. sentence construction
o 12. conversational questions
Pick two or three (depending on time) clips you would like to watch.