Visual Action Therapy (Helm-Estabrooks, Albert, Nicholas) – Flashcards
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Visual Action Therapy (VAT)
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a hierarchically organized, nonverbal program designed to train people with severely restricted spoken and written expression AND oral ideomotor apraxia to produce symbolic gestures for the purpose of communication
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Purpose of VAT
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1. to reduce apraxia 2. increase ability to gesturally represent common objects from memory 3. generalize those skills purposes of communication in everyday settings
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Candidacy for VAT
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1. Experience of a left-hemisphere stroke 2. Severe aphasia w/ inability to produce spoken or written language & limited ability to communicate using self-generated, representational gestures 3. moderate to severe ideomotor limb and oral apraxia 4. ability to produce some spontaneous, overlearned gestures in everyday communication 5. At least moderately able to perform nonverbal cognitive tasks of visual perception, attention, and memory 6. Alert, cooperative, and motivated with attention span sufficient for at least 30 minute treatment sessions
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Operational Framework
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bridges the gap between very poor ability to transmit concepts through any means AND the need and desire to communicate information; works outside of the modality of speech
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Gardner, Zurif, Berry, and Baker (1976)
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Used a visual communication system (VIC) consisting of real objects and a series of index cards containing simple, arbitrary, or representational drawings illustrating meaningful units; participants were trained to follow commands, answer questions, and describe events using the objects and cards Outcome: People w/ global aphasia reatain a rich conceptual system and at least some of the cognitive operations necessary for natural language; 5/8 showed significant gains in auditory comprehension despite tx being carried out in silence
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Helm and Benson (1978)
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explored the use of non-linguistic visual and gestural approach of individuals with global aphasia and severe oral ideomotor apraxia Outcome: research led to the development of the VAT therapy method which trains persons w/ aphasia to represent items w/ hand and arm gestures
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Helm-Estabrooks, Ramsberger, Brownell and Albert (1985)
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found that it was relatively easier to train people w/ global aphasia and severe ideomotor apraxia to gesturally represent object involving movements of the proximal motor systems vs. distal motor systems Outcome: VAT procedures require movement of proximal movements before the introduction of those incorporating distal movement
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Ramsberger and Helm-Estabooks (1989)
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designed a bucco-facial VAT program that used stimuli requiring facial and oral movements for gestural representation Outcome: 6 individuals t showed significant post-therapy improvement on the following PICA subtests: verbal repetition, pantomime, auditory comprehension, reading comprehension, and graphic copying: Led to development of 3rd phase to VAT program that makes use of items requiring oral movements
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Establishing Appropriate candidacy
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1. Use of the BASA to obtain a diagnosis of severe aphasia and failure to compensate for restricted verbal output through gestures 2. Test of Limb and Oral Apraxia: to confirm ideomotor apraxia and its severity 3. Communication Questionnaire: determine extent of gestural communication in everyday settings 4. Nonvocal Communication Scale (NCS): assesses gestural communication in natural settings Additional Purpose: to measure response to treatment at the conclusion of VAT
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Essential Items for a VAT session
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1. 15 real objects (NOT toys) taken from the home or bought at a hardware or other store 2. 15 shaded line drawings of these objects 3. 15 action pictures of a simple figure using these objects
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VAT Objects
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1. Proximal-limb gestures: flag, paint stirrer, gavel, saw, & iron 2. Distal-limb gestures: screwdriver, teaspoon, cell phone, artist's fine paintbrush, & tea bag 3. Oral gestures: whistle, artificial flower, lollipop, drinking straw, lip moisturizer Objects do not need to be fully functional: Client will be pretending to use objects
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Contextual Props
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1. Proximal-limb gestures: empty gallon paint can 2. Distal-limb gestures: block of wood containing large screw, coffee mug, paint-by-number outline of picture 3. Oral gestures: soft drink bottle, floral essence or perfume
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VAT Levels
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Level 1: real objects, pictures of the object, and action pictures. ALL 12 steps must be competed at this level Level 2: NO real objects: action pictures are substituted for objects. Begin at step 6 Level 3: ONLY the object pictures. Begin at step 6 Move onto distal items when the scoring criterion has been reached for the final step of Level 3 of the proximal VAT
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VAT Scoring
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1 point = fully correct performance with no hesitation 0.5 points = notably delayed or self-corrected speech 0 points = all other attempts A perfect score = 5 (each phase uses 5 objects) Criterion to move onto next step = 4.5 (allows 1 self-correction)
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VAT Scoring (2)
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Client fails to reach criterion on multiple trials of a step: modifications are made to improve performance *Recommended that you describe errors in the score-sheet margins & record scores for ALL responses
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Types of errors frequently made
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1. Paramimias: substitution of one gesture for another 2. Perseverations: inappropriate repetition of a previous response
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VAT Steps
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1-4: establish that the participant has the visuospatial and symbolic skills necessary for matching objects w/ the line drawing of these objects If unsuccessful: a trial of tracing is implemented
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Step 1: Matching Pictures and Objects (Placing objects on pictures)
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1. Sit across from the client & place all 5 line drawings of the objects on the table 2. Hand each object to the person & Silently indicate that he/she is to lay the object on the line drawing 3. Do not remove the objects until all 5 are in place
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Step 2: Picture-object matching (placing pictures on objects)
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1. arrange all 5 objects randomly before the client 2. hand the pictures to him/her in a different random order 3. silently encourage the person to lay the pictures on the objects they represent
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Step 3: picture-object matching (pointing to objects)
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1. Collect the pictures and rearrange the objects 2. Hold up the pictures one at a time and indicate that the person must point to the object represented by the picture Modifications:If person cannot isolate and extend the index finger to point: 1. place a red sticker of a red dot on the objects and pictures & model the pointing behavior by helping the person to extend his index finger and touching the dot 2. wrap tape around the person's index finger to stiffen it for pointing *remove the stickers and/or the tape and confirm that the participant can complete this step without these aids before progressing to step 4
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Step 4: picture-object matching (pointing to pictures)
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1. Arrange all 5 cards before the client 2. Hold up the objects one by one & indicate that the client must point to the picture representing the object
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Step 5: object use training
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Goal: ensure that the participant has the necessary praxis skills for appropriate manipulation of real items 1. Present each object and contextual prop separately and demonstrate its use 2. place the object on the table in front of the individual and encourage him or her to pick it up and demonstrate its use (May initially require some modeling and shaping) * to receive credit: the client must properly manipulate the item w/o assistance
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Step 6: Action picture demonstration
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Demonstration only: NOT scored 1. randomly choose an object and the action picture of the figure manipulating that object 2. place the object in front of the person and the corresponding action picture slightly to his/her left 3. point to the picture and then pick up the object and demonstrate its use Goal: for the client to appreciate that each action picture represents a command
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Step 7: following action picture commands
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1. place all 5 objects w/ props in front of the person 2. Hold up an action picture and show it to the participant until he/she has correctly selected & manipulated the corresponding object If shaping/modeling/score less than 4.5: Give subsequent trials of this step until the criterion for advancement is achieved
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Step 8: Pantomimed gesture demonstration
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Goal: demonstrate that pantomimed gestures can stand for or represent objects 1. place each item on the table w/o contextual props 2. Produce the gesture that best represents the object *Proceed slowly so that the participant can cognitively link the gesture w/ the object Demonstration only: NO score
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Step 9: Pantomimed gesture recognition
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Goal: Client will demonstrate that he/she associates pantomimed gestures w/ the objects they represent 1. Place all 5 objects in random order on the table 2. Produce a pantomimed gesture representing one of the objects 3. silently encourage the individual to locate or point to the corresponding object
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Step 10: Pantomimed gesture production
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Goal: Client will produce appropriate, representational gestures for each of the 5 objects 1. show each of the 5 objects to the person, 2. Encouraging him/her to produce a correct gesture w/o touching the object (may require modeling an imitation) May need to manipulate the object: while slowly withdrawing the object, encourage the individual to continue the gesture without the object *Must produce a correct pantomimed gesture upon looking at the object
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Step 11: Representation of hidden objects demonstration
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Goal: the client will understand that a gestural message can convey a concept that is not visually present 1. Choose 2 objects and place them on the table while producing a gesture for each 2. Hide the 2 objects under a box 3. Remove on object and produce a gesture to represent the remaining hidden item while you point to the box with your other hand 4. Each object will take its turn remaining under the box to be represented with a gesture Demonstration only: NO score
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Step 12: Production of gestures for hidden objects
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Goal: the client will convey a message about something that cannot be seen 1. Place 2 randomly selected objects on the table and encourage the person to produce gestures for each 2. Hide the objects under the box 3. After 6 seconds, remove one object and indicating that he/she should produce a gesture representing the object still under the box Do this w/ all possible pairs until each has remained under the box to be represented with a gesture
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Measuring Response to VAT
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Pre- and Post-VAT measures: 1. The BASA, 2. The Communication Questionnaire, 3. the Nonvocal Communication Scale (NCS) Are re-administered @ the end of the program to measure treatment response
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Treatment After Completing VAT: Amer-Ind Code
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Following VTA, clinicians first use a program of the Amer-Ind code based on a modified version of American Indian Sign Language or "hand-talk" Train 30 Amer-Ind gestures chosen for their functionality
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Treatment After Completing VAT: PACE
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Promoting Aphasics' Communicative Effectiveness (PACE) Using the PACE photo cards, adults with aphasia are trained 2 gesture combinations often used w/ functional communication games (Ex. Go fish) Two important principles: 1. each member of the "conversation" takes turns as both senders and receivers of messages 2. New information is exchanged
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Treatment After Completing VAT: Use of Communication Partner
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The client is shown unseen pictured items and concepts (including useful objects, common activities, famous people, and news events) and must gesturally convey each concept to the interactant. The interactant must correctly identify the items being conveyed. - Interactant may need to be trained to improve his/her ability to attend to gestured messages and to ask for expansions or modifications of ideas not understood *Burden of communication is placed equally on the person w/ aphasia and interactant
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Sample Long-Term Goal for Improving Functional Gestural Communication
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1. The PWA will produce meaningful sequences of at least two manual gestures to communicate novel information in four of five structured short conversations.
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Sample Short-Term Goal for VAT and Gestural Communication
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1. Level1: The PWA will produce the correct gesture to represent hidden object in 9 of 10 trials (Level 2 and 3 examples on p.375)
