Thematic Language Stimulation - USHA

Thematic Language Stimulation 

Shirley Morganstein, MA CCC-SLP 

Marilyn Certner Smith, MA CCC-SLP 

Speaking of Aphasia, LLC 

Morganstein & Certner-Smith, 2011 

TLS Definition 

Thematic language stimulation (TLS) is a 

systematic method of aphasia therapy that 

employs thematically-related vocabulary in 

multimodality stimulation, targeting changes 

in language processing for functional 

communication. 


Role of the Therapist in TLS 

! Carries the burden of 

success. 

! Provides a link between 

what the PWA knows 

and what he shows. 

! The neurobiological 

catalyst. 


Introduction: TLS Philosophy 

What’s TLS? 


TLS Flow: A Process 

! Begins with a select group of words, related in 

meaning. 

! Places words in particular linguistic contexts. 

! Uses words in tasks that employ both input and 

output modes. 

! Targets improvement of underlying language 

processes for conversational success. 


The Therapist and the PWA 


! Stimulation: improved 

language performance. 

! Observation during 

stimulation: reveals 

information about 

underlying processes. 

! Awareness of processes: 

has value in 

conversational strategy 

development 

1

TLS: Elements of the Definition 

Thematic language stimulation (TLS) is 

a systematic method of aphasia 

therapy… 



! …that employs thematically-related 

vocabulary in multimodality 

stimulation 

How is it systematic? 

! Presents material in hierarchical arrangement 

– Best modality first 

– Easiest S-R format first 

! The “Alice-in-Wonderland” phenomenon 

“Begin at the beginning, continue 

through the middle, and stop when 

you come to the end.” 


Morganstein & Certner-Smith, 2011 Morganstein & Certner-Smith, 2011 

Multimodality stimulation? 

! Language involves speaking, understanding, 

reading, and writing. Schuell (1964)felt 

remediation should employ all of these 

modalities in order to enhance therapeutic effect. 

– At the right level in each modality 

– In every session 

– In a sensible progression of activity 

and task requirements 


Thematically-related vocabulary? 

! Meaningful content and personal relevance 

heighten therapeutic effect via contextual 

language elements. 

! Capitalizes on the organizational systems and 

elements already well-established within the 

brain, rather than creating new ones. 


! … targeting changes in language 

processing for functional 

communication. 


2

Changing processes for 

functional communication? 

! TLS hypothesis is that you are changing the 

way the brain is working, by “working the brain”. 


Animal studies 


! Jenkins et al (1990) found 

expansion of distal digit 

representation in monkey 

brains after sensory training. 

! Kilgard and Merzenich (1998) 

found changes in the 

organization of monkey aud 

cortex with exposure to 

combination of sound 

exposure and administration 

of chemical 

neurotransmitters. 

“What goes around comes around” 


! 1950’s: Schuell’s clinical 

neurobiology 

! 1960’s: Programmed 

instruction 

! 1970’s: Compensatory 

Techniques 

! 1980’s: Cognitive and 

Linguistic techniques 

! 1990’s: Social and Life 

Participation 

! 2000’s: Renewed 

neurobiological interest 

Brain Work: Neurobiological 

Evidence 


Research in Humans: “The 

Community of Brain Repair” 


! Constraint-induced 

therapy in affected upper 

extremities post CVA. 

! BWST in spinal cord 

injury 

The Next Decade: the Brain Redux 


! fMRI : does therapy 

change the brain? 

! Cortical stimulation: 

electrocortical stim in 

conjunction with 

therapy 

! Neurotransmitters in 

conjunction with tx 

3

! Principle of maximal 

patient response, 

achieved by 

– Extending language and 

materials 

– Emphasis on task 

repetition, re-ordering, 

adaptation 

– Meaningful context 

Schuell’s Neurobiological 

Stimulation 




! Systematic and Intense 

Presentation 

– Organized 

– Programmed for success 

– Repetition 



! Principle of stimulus 

adequacy, achieved via 

– Intensity 

– Focus 

– Linguistic bombardment 

– Multiple presentations 

– Varied context 


Building on Schuell’s model: 

The TLS advantage 

! Use of thematically-related 

vocabulary, rather than 

isolated high-frequency words. 

– Provides a “hook” upon which to 

hang language: natural context. 

– Provision of linguistic context allows transition to 

meaningful conversation. 

Morganstein S.Morganstein & Certner-Smith, & M.Certner-Smith 2011 Morganstein & Certner-Smith, 2011 

Building on Schuell’s model: 

The TLS advantage 

! Provides inherent redundancy, depth 

and breadth. 

! Fosters connection with language, with feelings, 

ideas, history. 

! Educational/training component and 

metacognitive exploration for PWA and/or others 

Morganstein S.Morganstein & Certner-Smith, & M.Certner-Smith 2011 

Research with TLS 


4

TLS: Preliminary Research 

! Defining Success – finding a functional 

communication measure: content unit analysis 

proposed by Yorkston and Beukelman. 

! Design Choice – single subject, reversal. 

! Subject selection – no significant vision or 

hearing deficits; able to participate in a 3 week 

course of 5 day/week therapy. 

Communicative Efficiency 

14 

12 

10 

8 

6 

4 

2 

0 

12 

3.1 

0.9 


Treatment Effects ofTLS 

6.4 

2.7 

1.8 

1 2 3 4 


Test Intervals 

7.4 

4.9 

0.9 

Assessment 

! The PWA’s preferences for treatment and goals 

is where is all begins. 


S.Morganstein & M.Certner-‐Smith 

10.8 

2.1 

1.6 

LS 

RE 

JS 

TLS: Preliminary Research 

! Procedures 

– CU analysis (cookie theft picture) 

– One week in a randomly assigned module 

– Repeat CU analysis 

– Reversal of module 


– Reversal of module 



Beginning with TLS: Assessment 


Assessing at the Impairment Level 

! Determine the severity of the aphasic symptoms 

! The type of aphasia 

! The adequacy of conversation and 

communication 



5

Assessment of Impairment begins.. 

! Evaluates deficits on 

standardized measures. 

! Derives information 

about patient process 

during testing 

– Less emphasis on the 

score 

– More emphasis on how 

he got it 



Assessing the Impairment (Deficit) 

! BDAE 

! MTDDA 

! WAB 

! PICA 



Assessment beyond 

language… 

! The assessment process parameters beyond 

language include: 

– Cognition: attention, abstract thinking, 

– Behavior: initiation, flexibility, problem solving, etc 

– Visual Considerations: hemianopsia, scanning 

issues, acuity 

– Psychological considerations: sense of humor, 

affect 



! Probes strategies for 

task success 

! Derive information about 

functional 

communication and its 

enhancement. 

More Assessment 



Process Assessment 

! 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? 

“Batteries are for cars, 

Not for people.” Edith Kaplan 



Strategy probes for TLS 

! Aphasia testing using a TLS mindset requires 

strategy probes 

– Naming/word retrieval (what type of cuing helps, 

phonemic or semantic?) 

– Repetition (does repetition increase linguistic 

accuracy?) 

– Oral reading (does oral reading increase awareness 

of errors & afford an opportunity for self correction?) 

– Etc…… 



6

Assessing conversational 

ability and style 

! Assess conversational ability, any way you can 

– Formal tool: FCP, CADL 

– Interview, questionnaire 

! Assess transactional process: 

– Circumlocution, self-correction, self-cueing 

! Assess interaction: 

– Drive, social connection, problem-solving, flexibility 

! Knowing 

! Selecting 

! Developing 

! Delivering 

! Extending 

! Enhancing 



Formulating a TLS Unit 

! A TLS Recipe 

Summary of Assessment 



Morganstein & Certner-Smith, 2011 Morganstein & Certner-Smith, 2011 

The TLS Unit: It’s About… 


! Language 

! Patient process 

! Non-language profile 

! Task strategies 

! Conversation 

TLS: Creating and Using The 

TLS Unit 

! Following a 

culinary 

metaphor… 

TLS: Knowing 

! “Who am I dining with?” 

– Education 

– Talents & Interests 

– Family background 

– Insight about the nature of aphasia 

– Life priorities 

– Style (emotionally open or closed) 


7

TLS: Selecting 

! Choosing the sandwich: 

– Topics that relate to the person’s 

interest are always preferred: 

– Provides a natural and personal 

connection for treatment. 

– Enhances the likelihood of linguistic success since 

he has better access to information and ideas on 

“his turf.” 

Here’s a TLS Sandwich! 


TLS: Delivering 


! Introductory topical 

conversation on the 

theme 

! Manipulation of language 

in a series of 

multimodality tasks 

! Return to functional 

conversation on the 

theme. 

TLS: Enhancing: 

Metalinguistic Process 

! What just happened here? (reflections on the meal) 

– SLP internally reflects upon what 

worked, and modifies what she 

does next time. 

– SLP offers observations to patient 

about performance in a general sense: 

• Gives positive feedback 

• Leads toward insight about aphasia (prerequisite 

for developing strategies) 


TLS: Creating 

! Assembling the sandwich 

– Select content vocabulary: 8-10 words related semantically, 

preferably concrete nouns and verbs. 

– Select the exercises to be employed for a course of 5-7 

sessions based upon assessment findings. 

– Establish a treatment hierarchy for the 

exercises, progress easier to harder. 

– Create (or copy) those exercises 

to be used. 


TLS: Extending 

! Serve more of the sandwich: 

– Extend the theme by adapting and adding exercises 

as you go. 

– Extend the theme in real, related conversation. 

– Extend the theme in supplementary materials 

(menus, ads, letters, internet articles) 


TLS: Enhancing 

Metalinguistic Process 

! Critiquing the experience: continued 

– SLP offers more detailed observations about 

performance and asks the patient for his discoveries 

– Gives positive feedback; transaction & interaction 

– Establishes a collaborative relationship in problem 

solving the treatment outcome. 

– Encourages more responsibility and independence 

in symptom management 


8

TLS: Secrets of a Good Sandwich 

! Maintain a success rate of approximately 80-90% for 

each selected task. 

! Present flexibly, shift and roll as needed. 

! Recognize task order, decrease choices, change 

modes. 

! Keep patient in the loop: ask for feedback, comments 

and insights. 

! Use humor and emotion whenever feasible; the limbic 

system is a good stimulator. 


TLS: Formatting the Unit 


! The ABC’s of Exercises 

! What to Include 

! Creative Composition 

! Building Layers of 

Language 

! Having Fun with Words 

TLS: The Exercises 


TLS: Secrets of a Good Sandwich 

! Make small changes in some aspect of the task 

each time you repeat it (and do repeat it!) 

! “Milk” the linguistic contexts in which the words 

appear. 

! There are no “wrong” responses—merely more 

opportunities to stimulate 

! Include multi-modalities to reap the stimulation 

benefit. 


Your Turn 


Thank you ! 


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Thematic Language Stimulation - USHA

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