Finding a Voice

By Jesse Lee

A decade ago, people with aphasia faced a long and difficult road to recovery. With advances in neuroscientific treatment, the Intensive Aphasia Program at Marquette is revolutionizing aphasia care.

Ashley Stich is a typical 17-yearold who loves to do traditional teen activities — she was a two-time academic all-state golfer, and she played basketball and ran track at Tremper High School in Kenosha, Wisconsin, where she recently graduated. She was active in the school band, playing the flute, piccolo and bass flute.

Ashley also loves to talk about movies.

“Mom and I went to the movie theater,” Ashley tells Gina LaBarbera, the first-year graduate student in the Speech Pathology and Audiology program who acts as Ashley’s graduate clinician in the Speech and Hearing Clinic’s Intensive Aphasia Program. “My mom wants to see Incredibles 2, but I wanted to see a different movie.”

LaBarbera types the sentence into a computer, praises Ashley, then asks her to look at the screen and determine what might be wrong with the sentence she just spoke. After a few seconds of reading, Ashley realizes her mistake.

“Oh, no, my mom wanted to see Incredibles 2,” Ashley says.

Watching through one-way glass in a separate room, Ashley’s mom, Kim, is unfazed by the mistake but proud that her daughter caught it.

“Less than two years ago, Ashley could only say about five words,” Kim says.

In October of 2017 Ashley was diagnosed with Moyamoya disease, a rare, progressive brain disease caused by blocked arteries at the base of the brain, in the basal ganglia. These structures play a role in movement fluidity and are also thought to affect habitual behavior, emotion and cognition.

Moyamoya affects about 1 in 100,000 people. The disease gets its name from the blood vessels it affects — the word “moyamoya” means “puff of smoke” in Japanese, and it describes the tiny tangle of blood vessels in the basal ganglia that become damaged as they attempt to compensate for low blood flow to the brain. This results in reduced oxygen delivery to the brain, which can lead to headaches, seizures and often stroke. On December 1, 2017, three days before Ashley was scheduled to have surgery to attempt to treat the disease, she had a massive ischemic stroke.

“Ashley was medically sedated for nearly three weeks after she had the stroke,” Kim recalls. “When she awoke, she couldn’t talk.”

The stroke resulted in aphasia, damage to her brain’s language center. Ashley stayed at Children’s Hospital of Wisconsin and Froedtert Hospital for weeks, where she worked to recover from the stroke and to regain her language.

“At Children’s and then Froedtert, I couldn’t remember my name or my birthday,” Ashley says. “The only sentence I could really say was ‘out the door.’”

Kim knew that Ashley needed more help with the aphasia, but she and her husband were unsure where to begin.

“We found a program in Florida, but it was very expensive, and it would completely disrupt Ashley’s school,” Kim says. She continued looking and was happy to learn about Marquette’s Intensive Aphasia Program from Tina Puglisi-Creegan, the Intensive Aphasia Program coordinator.

“I remember when I talked to Tina for the first time,” Kim says. “She really took the time to explain all of the benefits of having Ashley here. She had Ashley come in and interview and Tina said, ‘We’re going to make this work.’ She was so positive.”

Puglisi-Creegan, Sp ’79, Grad ’80, clinical professor in the Speech Pathology and Audiology Department, along with Jackie Podewils, clinical assistant professor of speech pathology and audiology, had the idea for the Intensive Aphasia Program more than a decade ago.

“Eleven years ago I went to a conference,” Puglisi-Creegan says. “This is when they were just starting to talk about neuroplasticity in regard to speech rehabilitation. They were moving to that model, but no one was sure how to implement it.”

The key concept behind neuroplasticity is that the brain is constantly adapting in response to external stimuli; that through intensive, repetitive therapy, the brain can change to learn — or, in the case of aphasia, relearn — processes and tasks. However, the stimuli and the manner in which it is presented is crucial for laying a pathway. That includes regaining language skills lost through traumatic brain injury.

Puglisi-Creegan learned about new therapy models at the conference, including constraint therapy, shaping, modeling a program a level or more above where the patient is currently comfortable and using frustration as a teaching tool.

“This is the opposite of what we were taught,” Podewils says. “Everything we learned when we were in training to become speech pathologists was now negated.”

Podewils and Puglisi-Creegan decided they’d need to do some research into these new forms of therapy, but they hit roadblock after roadblock from fellow speech pathologists unwilling to share their secrets of this new model.

Puglisi-Creegan was frustrated, but given her tenacious nature, was undeterred. There was one name that she’d heard at the conference, and she kept hearing it repeated by other therapists: Friedemann Pulvermüller.

Pulvermüller is a German neuroscientist and speech-language pathologist who was at the forefront of the neuroplasticity movement as it relates to language. He was the leader of cognitive neuroscience of language at the Medical Research Cognition and Brain Science Unit at Cambridge University.

“I said to Jackie, ‘You know, I’m going to call this Pulvermüller myself,’” Puglisi-Creegan says.

She left a message with her email address, and a short time later, Pulvermüller sent her an email that would form the basis for the Intensive Aphasia Program.

“He sent me a language game — one that most people are already familiar with — called Go Fish,” she says.

The game was based on a key principle of neuroplasticity: saliency. Saliency means that, when you make someone talk, it should be as close to the communicative act as possible. The old model of drills on words and phrases was no longer the standard.

In the game, you say the person’s name, then request a card. “Tina, do you have a seven?” This simple act of forming a complete sentence in the context of the game makes the request, and thereby the act of communication, salient — it carries a specific meaning to the person making the request.

Podewils and Puglisi-Creegan decided to test the theory. They took their patient who was making the least amount of progress and who had a stubborn motor speech disorder along with a substantial aphasia disorder, and they did a trial therapy. The improvement in just a three-week timeframe was incredible.

“She went from a one-word mean length of utterance, meaning she could only say ‘book’ or ‘chair,’ to a 10-plus mean length of utterance,” Puglisi-Creegan says.

An even more amazing result was that the patient’s syntax — their word order — improved without being specifically targeted.

Based in large part on the trial’s success, Podewils and Puglisi-Creegan established the Intensive Aphasia Program. It’s a verbal-specific program in which the patient works three hours every day for three weeks and also has a home-based component. And the cost is far less than other programs of its kind around the country that can range in the thousands — Marquette charges just $2,500 for the three-week session.

In addition to the two professors, the program allows graduate students, like LaBarbera, to hone their skills in an on-site clinical setting.

“This program is the reason I came to Marquette,” LaBarbera says. “I wanted to work with people with aphasia, and here I knew I would have a lot of opportunities to work with people like Ashley. I love sitting with her and seeing her progress day to day.”

“Gina is — it’s almost like a family kind of,” Ashley says. She tries to continue, but emotion holds her back. As Ashley begins to cry, LaBarbera wipes her own tears and moves to hug Ashley. Soon the two are laughing.

Ashley graduated from high school this year and has been accepted at Carthage College, where she plans to study kinesiology and sports medicine. Kim attributes a lot of Ashley’s success to the Intensive Aphasia Program. “She would not be going to college if we didn’t have this program,” Kim says. “Now she’s got a better chance for taking the next step.”