Efficacy of Language
Games as Therapy for
Post-Stroke Aphasia
Louise Lander
Moor Green Outpatient Brain Injury UnitBirmingham Community Healthcare NHS Foundation Trust
 A novel, clinically relevant intervention
 Collaboration between public healthcare provider and
universities
 Funded by the National Institute for Health Research
Dr Andrew Olson
Dr Cristina Romani
Samantha Tyler
Iman Idrees
Louise Lander
The context:
 Rising demand for healthcare, with limited resources
 An urgent need for new and productive ways of delivering aphasia therapy
 Focus on word-retrieval: an extremely common and distressing symptom,
which is extensively treated with cued picture-naming therapies (eg
Wisenburn & Mahony, 2009)
Word retrieval therapy:
We used:
• Clinically effective
• at impairment and functional levels
• deliver improvement in quality of
life, reduce social isolation
• Cost effective
• delivered efficiently to enable
increased intensity
• Acceptable to patients
• be motivating and engaging
• Impairment based cued wordretrieval
• Group therapy
• A game mode
Design:
Language game therapy
 Charade-like games
 Picture cards: 90 nouns 90 verbs
 3 matched word groups for 3 games
 Game P- phonemic cueing
 Game G- phonemic+gesture cueing
 Game S- phonemic+semantic cueing
 Each game played for 18 hours over 2 weeks
 Two teams of 3 patients, with mod-severe, expressive
chronic aphasia
Assessment
 Assessment specific to game
therapy:
 Picture-naming of 180 treated words
 Description of 9 pictured scenarios
 Assessment of general language
function:
 Comprehensive Aphasia Test
 Boston Naming Test
 Cinderella Story Re-tell
 Subjective assessment:
 Participant Satisfaction Questionnaire
Picture naming: Gains by treatment order
Group scores for each word set
60
Interaction
between word set
and game type:
p<0.001
50
Percent correct
40
Word set P
Word set G
30
Word set S
20
10
0
Time 1
Time 2-After Time 3-After Time 4-After Time 5-After
Game P
Game G
Game S
standard
therapy
Treatment order
Scenario description: Gains by treatment order
Group scores for each word set
35
Interaction
between word set
and game type:
p<0.001
Percent targets achieved
30
25
20
Word set P
Word set G
15
Word set S
10
5
0
Time 1
Time 2- after Time 3- after Time 4- after Time 5- after
game P
game G
game S
standard
therapy
Treatment order
Picture naming:
Gains by participants
Participant data combined across game type
90
Main effect of
therapy phase:
p<0.001
80
Percent correct
70
60
P1
50
P2
P3
40
P4
P5
30
P6
20
mean
10
0
Baseline
After game
therapy
Maintenance
Therapy phase
After standard
therapy
Scenario description: Gains by participants
Participant data combined across game type
50
Main effect of
therapy phase:
p<0.001
Percent targets achieved
45
40
35
P1
P2
P3
P4
P5
P6
mean
30
25
20
15
10
5
0
Baseline
After game
therapy
Maintenance
Therapy phase
After standard
therapy
% change in average score
Summary of all language testing
120
*
100
*
*
80
60
40
20
0
*
Participant satisfaction with therapy
40
Number of responses
35
30
Example statements:
Standard therapy
-The therapy improved
my talking
Game therapy
-The therapy was suited
to me
25
20
-The therapy helped me
achieve my goals
15
-I am satisfied with the
therapy
10
-I did not get tired
5
0
Strongly Disagree Neither
disagree
agree nor
disagree
Agree
Strongly
agree
Summary
 Picture-naming score almost doubled: sits favourably with other
studies (eg Ramsberger & Marie 2007, Rider et al 2008, Best et al
2013, Raymer et al 2006)
 This therapy is distinguished from others in that it is delivered
intensively and efficiently to a group in a game format
 The improvements were largely item-specific, similar for types of
cueing
 Gains were largely long-lasting and generalised to a connected
speech context
 This supports the validity of our game therapy for improving wordretrieval in connected speech.
 Some participants improved content of unsupported narrative.
 It was clinically effective, cost effective and had strong patient
acceptability
References
Best, W., Greenwood, A., Grassly, J., Herbert, R., Hickin, J. & Howard, D. 2013, "Aphasia
rehabilitation: does generalisation from anomia therapy occur and is it predictable? A case
series study.", Cortex, vol. 49, no. 9, pp. 2345-2357.
Carragher, M., Conroy, P., Sage, K. & Wilkinson, R. 2012, "Can impairment-focused therapy
change the everyday conversations of people with aphasia? A review of the literature and
future directions", Aphasiology, vol. 26, no. 7, pp. 895-916.
Conroy, P., Sage, K. & Lambon Ralph, M. 2009a, "The effects of decreasing and increasing
cue therapy on improving naming speed and accuracy for verbs and nouns in aphasia",
Aphasiology, vol. 23, no. 6, pp. 707-730.
Conroy, P., Sage, K. & Lambon Ralph, M. 2009b, "Improved vocabulary production after
naming therapy in aphasia: can gains in picture naming generalize to connected speech?.",
International Journal of Language & Communication Disorders, vol. 44, no. 6, pp. 1036-1062.
Enderby, P., Pickstone, C., John, A., Fryer, K., Cantrell, A. & Papaioannou, D. 2009,
"Resource manual for commissioning and planning services for SLCN", .
Lanyon, L.E., Rose, M.L. & Worrall, L. 2013, "The efficacy of outpatient and communitybased aphasia group interventions: a systematic review", International Journal of
Speechlanguage Pathology, vol. 15, no. 4, pp. 359-374.
McKevitt, C., Fudge, N., Redfern, J., Sheldenkar, A., Crichton, S., Rudd, A., Forster, A.,
Young, J., Nazareth, I., Silver, L., Rothwell, P. & Wolfe, C. 2011, "Self-reported long-term
needs after stroke", Stroke, vol. 42, pp. 1398-1403.
References
Nickels, L. 2002, "Therapy for naming disorders: Revisiting, revising, and reviewing",
Aphasiology, vol. 16, no. 10-11, pp. 935-979.
Pert, S. 2010, "Supporting Staff to Balance Caseloads" in Embedding Evidence-Based
Practice in Speech and Language Therapy: International Examples, eds. H. Roddam & J.
Skeat, 1st edn, John Wiley & Sons Ltd, Chichester, pp. 72-78.
Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P. & Taub, E.
2001, "Constraint-induced therapy for chronic aphasia after stroke", Stroke (00392499), vol.
32, no. 7, pp. 1621-1626.
Ramsberger, G. & Marie, B. 2007, "Self-administered cued naming therapy: a singleparticipant investigation of a computer-based therapy program replicated in four cases",
American Journal of Speech-Language Pathology, vol. 16, no. 4, pp. 343-358.
Raymer, A., Singletary, F., Rodriguez, A., Ciampitti, M., Heilman, K. & Rothi, L. 2006, "Effects
of gesture+verbal treatment for noun and verb retrieval in aphasia.", Journal of the
International Neuropsychological Society, vol. 12, no. 6, pp. 867-882.
Rider, J.D., Wright, H.H., Marshall, R.C. & Page, J.L. 2008, "Using semantic feature analysis
to improve contextual discourse in adults with aphasia", American Journal of SpeechLanguage Pathology, vol. 17, no. 2, pp. 161-172.
Wisenburn, B. & Mahoney, K. 2009, "A meta-analysis of word-finding treatments for aphasia",
Aphasiology, vol. 23, no. 11, pp. 1338-1352.