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Thursday, October 13, 2011

Announcement of courses

traveling the pathway of aphasia recovery
Announcement of courses

 
Bill Connors will be presenting full day workshops titled: Aphasia and Apraxia: Clinical Decision-Making and Innovative Techniques.  The next two workshops will be October 28, 2011 in New Brunswick, Canada and November 4, 2011 in Virginia Beach, VA USA.   

Contact: email-bill@aphasiatoolbox.com  or phone-724.494.2534 for information 

This workshop will cover the innovative treatment tools, technology and activities of the Brain Compatible Aphasia Treatment Program (BCAT) and the Motor Reconnect Apraxia Program (MRAP).  These programs, using evidence-based elements, have been developed to take optimal advantage of neural plasticity to maximize recovery from aphasia and related disorders.  Course activities will include a primary focus on active learner participation with real-time distance therapy (telerehab), demonstration videos, and hands on use of tools and software, as well as lecture and discussion. 

FORMAL COURSE OBJECTIVES/LEARNER OUTCOMES
1. identify 10 techniques to simplify, adapt and maximize computers and information technology for aphasia, alexia, agraphia and cognitive therapy with a focus on apps and the internet.
2. identify 5 key cognitive/mental processes that underpin and support language and its rehabilitation and incorporate these into treatment protocol development and application.
3. identify 5 techniques for applying adult evidence-based rehabilitation techniques in working with adolescents and young adults with communication problems.
4. identify 4 observation and analysis techniques of aphasic client behavior to use in applying evidence-based treatment to maximize rehabilitation activities and effectively train caregivers/coaches participation in the treatment process.  

  


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Thursday, May 26, 2011

Motor Reconnect Apraxia Program 5/24/2011

 
Motor Reconnect Apraxia Program – Treatment Activities www.aphasiatoolbox.com 5/24/2011

traveling the pathway of aphasia recovery
We now offer both online and on-site CEU Apraxia Treatment programs for SLPs.  If you are interested in participating in or sponsoring a Motor Reconnect Apraxia Program CEU program, contact Bill Connors at 724.494.2534 or bill@aphasiatoolboxcom.

While this newsletter is primarily intended for speech pathologists, it should also useful be for people with apraxia and their caregivers/coaches. If you missed the previous newsletter, you may review it by visiting our website at www.aphasiatoolbox.com and clicking on Resources then Archived Newsletters.


SLP: If you would like to refer a client for online treatment or to consult with us in collaborative therapy, contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .


PERSON WITH APHASIA or CAREGIVER: if you would like to set up an online consultation or for more information contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

This is the third and final in a series of newsletters discussing a new, innovative approach to the treatment of acquired apraxia of speech (motor programming problems).   Speech/language pathologists (SLP), people with apraxia, and caregivers/practice coaches routinely share with us at aphasiatoolbox.com their disappointment with progress in apraxia treatment programs.   In response to this need, we have created the Motor Reconnect Apraxia Program.   Over 30 years in development, this program calls upon 21 key therapy and practice principles ( http://aphasiatoolbox.blogspot.com/2011/04/new-campaign-apr-17-2011-at-850-am.html ).   Finally there is a program that truly approaches apraxia as a movement disorder with a focus on motor skills ( Mass, 2008).


In our last newsletter, we discussed in more detail principles and techniques of this Motor Reconnect Apraxia Program. At a recent professional workshop, Nancy Helm-Estabrooks offered, “The fact is that we are beyond using just linguistic therapy with people with aphasia.” (Helm-Estabrooks, 2011). Likewise, we are beyond just doing speech therapy with over-reliance on motor learning theory when treating people with acquired apraxia.   In our first newsletter on this topic, we compared and contrasted the motor learning principles used routinely in treating childhood apraxia of speech (CAS) with our proposed motor reconnect principles for treating people who have already learned how to talk but have an acquired impairment.   The difference between treating CAS in children and acquired apraxia in adults is remarkable and all too often overlooked by treatment programs.


Motor Reconnect Apraxia Program – The Program


Review of some key principles:

  1. Since acquired apraxia is different for each person, the techniques and activities may not all apply and/or may be initiated, suspended or reinitiated at various point in the treatment program.
  2. Disassociate jaw and vocal fold neural controls.
  3. Be aware this is errorful learning.  As with any motor re-training or conditioning program, we learn (reconnect) our muscle action and memory by attending to both our less accurate as well as inaccurate movement.  
  4. Increase metapraxia, the knowledge and awareness of apraxia and movement patterns  (Heilman, 2007).
  5. Improve deliberate control of vocal fold action (voicing, phonation).
  6. Establish effective use of proprioceptive feedback, the ability to focus on the sense of position, location and orientation and movement of the body and its parts  ( The Dana Guide, 2007).
  7. Establish presyllabic and preprosodic skills.
  8. Establish the effective production of vowels in primarily in relation to jaw position and as the building blocks for syllables.
  9. Simplify the client’s movement patterns.
  10. Establish syllables as the building blocks for speech motor programming.
  11. Simultaneously address any apraxia affecting arm/hand control.  This allows us: a) to begin to address keyboarding and screen literacy skills; b) work on any asymbolia (impairment in understanding and using symbols), facilitate the client’s metapraxia, and help the client improve independent therapeutic efforts by recognizing shared elements of the effects of apraxia on various motor functions of the body.

The specific elements of the Motor Reconnect Program for Apraxia – (targeted mental processes and skills):


  1. The Visual Definition of Aphasia – (metapraxia)
  2. Viking - concepts
  3. The basic Viking – pulsing syllables – (initiation; focused attention; vocal fold control; separating jaw-vocal fold neural controls)
  1. Modeled
  2. Independent on request – (initiation; dispersing speech perseveration; sound processing and working memory)
  3. Durational Viking – Stretching Vowels – (increase auditory and proprioceptive feedback)
  4. Intoned Viking – (pre-intonation and stress)
  5. Viking with an Attitude – (decoding and encoding prosody; sound processing; phonological and tonal working memory)
  6. Rhythmed Viking – (enhancing speech rhythm)
  • Scatpraxia:
    1. Scatpraxia: yes-no-delicious –(initiation; letting vocal variety happen)
    2. Scatpraxia: vowels
    3. Scatpraxia: varied vowels (letting vocal variety happen)
    4. Scatpraxia: bringing in the consonants – (syllablabification; syllable structure)
    5. Scatpraxia Group online – (vicarious learning; peer support)
  • Vowels
    1. Jaw positions – (the jaw as the platform for speech) production; establishing awareness of proprioceptive feedback)
    2. Around the Mouth – (vowel production using proprioceptive feedback; working memory for vowels; presyllabic)
    3. The Elevator: Alternating Vowels – (alternating attention; expandingr jaw neural controls)
    4. Long-Short vowels – (expanding the vowel inventory)
    5. Vowel Sequences From Memory -  (sound processing and working memory)
    6. Continuous Phonation – (introducing dipthongs)
    7. Blend Sounds into Words – (prosodic blending)
    8. V to VC words – (pre phonological assembly; syllabification)
    9. Alternate / h / -vowels –(enhancing laryngeal fine motor control)
  • Oral-Motor Coordination Program – (addressing naturalness of syllable structure and its supra-syllabic features)
  • Vowels Become Pronouns –(incorporating language elements; initiation)
  • Simple Conjugation- (transitions into canonical sentence structure)
  • Oral-Motor Coordination Program – (addressing naturalness of syllable structure and its supra-syllabic features)
  • Sound Embedded Verbs –(incorporating canonical sentence structure)
  • Sentence Intonation Patterning (prosody supports intent; )
  • GROUPS online ( http://www.aphasiatoolbox.com/?q=smallgroup ):
    1. Oral Motor Coordination
    2. Men’s Aphasia Bootcamp
    3. Coaches


    Heilman, Kenneth, and Gonzalez Rothi, Leslie, Apraxia – The Dana Guide, http://www.dana.org/news/brainhealth/detail.aspx?id=9772  
    Helm-Estabrooks, Nancy, Cognition and Aphasia: Clinical Implications, Pennsylvania Speech-Language-Hearing Association Convention, 4/7/2011, Pittsburgh, PA


    Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K. J., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17, 277-298.


    Movement, Balance, and Coordination – the Dana Guide, Georgopoulos, Aposotlos,    http://www.dana.org/news/brainhealth/detail.aspx?id=10070 , November 2007

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    Motor Reconnect Apraxia Program – Principles
    www.aphasiatoolbox.com 

    While this newsletter is primarily intended for speech pathologists, it should also useful be for people with apraxia and their caregivers/coaches. If you missed the previous newsletter, you may review it by visiting our website at www.aphasiatoolbox.com and clicking on Resources then Archived Newsletters.  

    SLP: If you would like to refer a client for online treatment or to consult with us in collaborative therapy, contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

     

    PERSON WITH APHASIA or CAREGIVER: if you would like to set up an online consultation or for more information contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

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    We communicate with hundreds of speech language pathologists (SLP) who treat clients with acquired speech and language problems. The difficulties encountered treating acquired apraxia that impacts speech are a major concern for many SLPs, especially when the apraxic impairment is severe. Likewise, numerous people with residual apraxia have shared their frustration concerning how their unresolved apraxia limits their speech, independence and social life.  The large number of people with apraxia who continue to suffer is unacceptable to us. We have developed the Motor Reconnect Apraxia Program (MRAP)
    In our last newsletter, we compared and contrasted the motor learning principles used routinely in treating childhood apraxia of speech with our proposed motor reconnect principles for treating people who have already learned how to talk but have an acquired impairment. In this edition, we will discuss in more detail the principles and techniques of this Motor Reconnect Apraxia Program. At a recent presentation, Nancy Helm-Estabrooks offered that, “The fact is that we are beyond using just linguistic therapy with people with aphasia.” (Helm-Estabrooks, 2011). Likewise, we are beyond just doing speech therapy with people with apraxia.Motor Reconnect Apraxia Program – Principles 
    1. Recognize that, “Apraxia is different for everybody.”   Forget about using a cookie cutter or minimalistic treatment approach that stifles the opportunity for formative assessment and highly ‘responsive-to-change’ treatment.
    2. Be sure to consistently treat acquired apraxia truly as a movement disorder. Keep your focus on the clients’ knowledge of movements before, during and after execution. While placement cues may play a role treatment (Wambaugh, 2006), they are much less important than movement planning and implementation in MRAP.
    3. Ensure normal breath support. Have the client initiate each phonation or utterance with a ‘normal’ inhale as if he/she was going to say a few sentences. Keep this simple. Show the client how to ‘let the airflow turn on vocal your vocal folds” using normal body posture, action and inhalation. Minimize instructional details to compensate for the apraxia.
    4. Ensure metapraxia. This means that the client understands and knows what apraxia is. Help the client absolutely approach apraxia as a movement disorder. This is as much physical training as it is speech therapy http://www.armystudyguide.com/flashcards/flashcards.php?cat=19&qnum=14 .
    5. Get the patient to embrace his/her mistakes.   Movement and sound errors are basically irrelevant as long as intrinsic knowledge of proprioceptive feedback is guiding and monitoring the client’s attempts and later corrections or verifications.
    6. Be sure to work on the cognitive underpinnings for speech, language and communication early, often, and continually. We know that improving cognition can result in improvements in aphasia. The cognitive skills especially important to improving motor control include: working memory; sustained, selective, alternating and focused attention; cognitive flexibility; and selective mental resource allocation.
    7. THIS PRINCIPLE IS IMPORTANT. Be sure to have the client working from his/her own memory using the normal self-generated neural pathways for movement patterns. If it is necessary to provide a model, make sure the client pauses and allows your voice to die down in his/her head before responding. Add a distracter stimuli between the presentation and the response to facilitate this intrinsic mental focus. Emphasize that the patient needs to generate a movement pattern as opposed to an imitation. Do not allow the client to struggle, to subvocally rehearse, or try to ‘get a running start’ after your model.
    8. Disassociate jaw and vocal fold neural controls. Most clients with apraxia seem to present with a concentrated, struggled neural control pattern.   Maintain normal head/body posture having the client keep his/her eyes open while paying careful attention to sounds produced and the feel of the movements. Facilitate the client’s use of normal, self generated neural controls.
    9. The client focuses on finishing the proprioceptive feedback loop. “Your brain sends a message to move – you move – your jaw sends a message back –‘ I moved, here I am, what do I do next’?” - the brain tells then where to go next.” Focus on intrinsic, proprioceptive feedback is the key. Eliminate distracters that require the patient to externally focus (e.g., mirrors, tape recorders, photographs).
    10. Build in laryngeal pulsing; rhythm and flow (Wambaugh, 2006).  Establish presyllabic and preprosodic skills. Reestablish syllable structure use and knowledge early (Zeigler, 2010).
    11. Introduce vowels as jaw positions with neutral controls separate from the laryngeal musculature.  Pay less attention to lips and even less attention to tongue position at first but more as treatment progresses.   Increasing accuracy of vowel production tends to come along as reconnection of controls and awareness improves.
    12. Minimize work on consonants early. If the phonatory apraxia (mental resource demands lessened) and ease in production of the vowels is facilitated (reconnected control), we have found that most consonants come along for free as the program progresses. Ignore cognate pair errors until later in treatment as these often improve as the other skills improve.
    13. Rely heavily on formative assessment and treatment adjustments. Minute-by-minute, day-by-day stay on top of the opportunities to grow the program and to make adjustments. Be prepared to revisit some activities that client progress would now make therapeutic. It is important to realize that there is no rigid sequencing of treatment activities in the motor reconnect apraxia program. The clinician, in concert with the clients, uses his/her clinical experience, knowledge and intuition in designing and constantly growing the treatment program. The client as an individual will require different activities at different stages of his/her treatment. This is the art of apraxia therapy.
    14. Move into production of syllables As Soon As Possible (ASAP).   Move syllables into words ASAP (e.g., pronouns) and words into canonical sentences ASAP.
    15. Thread into linguistic contexts when appropriate but make it as early as possible.
    16. Challenge the client’s system; (e.g., scatpraxia group http://www.aphasiatoolbox.com/?q=smallgroup ). Set up apraxia treatment groups as clients gain much from observing peers. This is where subvocal rehearsing is facilitatory to reconnecting.
    17. Train like the Navy Seals: Have your client so prepared to move so that it’s not how to do it something (how to phonate; move jaw; speak), it’s what and when to do it (content and intent). He/she needs to be consistently able to phonate and articulate with minimal demands on mental resource allocation. Think automaticity.
    18. We have found that most of these principles also apply to dysarthria, especially ataxic dysarthria.
    19. It is our opinion that singing does not directly help the recovery of speech affected by apraxia. By all means, we do recommend that clients who enjoy singing do so for the enjoyment and to get the vocal folds active. In over 30 years of experience, however, including hundreds of hours attempting to utilize music/singing in treatment, we have seen little success in applying singing as a treatment technique.
    20. Simultaneously address any apraxia affecting arm/hand control. This allows us to: begin to address keyboarding and screen literacy skills, work on any asymbolia (impairment in understanding and using symbols), facilitate the client’s metapraxia, and help the client improve independent therapeutic efforts by recognizing shared elements of the effects of apraxia on various motor functions of the body
    21. Practice. Practice. Practice. On average, our clients practice about 2.5 hours per day outside of any treatment sessions. The importance of this dedication to practice cannot be overstated. This also means that the client practices both independently and with a practice coach. It is not difficult to train a caregiver to help the client practice. A few treatment sessions a week will not do the trick. Overcoming a moderate-severe apraxia is a daunting task that requires a tremendous amount of therapeutic time on task participating in smart activities.  

    Stay tuned : - ) . Our next newsletter will describe and discuss in more detail the actual activities involved in our treatment Motor Reconnect Apraxia Treatment program.    

    References:

    Helm-Estabrooks, Nancy, Cognition and Aphasia: Clinical Implications, Pennsylvania Speech-Language-Hearing Association Convention, 4/7/2011, Pittsburgh, PA

    Wambaugh J., Duffy J., McNeil M, Robin D., and Rogers M., Treatment Guidelines for Acquired Apraxia of Speech: Treatment Desriptions and Recommendations, Journal of Medical Speech-Language Pathology, Vol. 14, Number 2, 2006

    Ziegler, Wolfram, Aichert, Ingrid, and Staiger, Anja, Syllable- and Rhythm Based Approaches to Apraxia of Speech, Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20 59-66 October 2010

     

     

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    Announcing - The Motor Reconnect Principles for Treating Acquired Apraxia 

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    This is an exciting newsletter for the staff at www.aphasiatoolbox.com as we are introducing our new, innovative program for treating acquired apraxia that utilizes motor reconnect principles (MRP). These MRP take advantage of the powerful potential of brain plasticity. We are experiencing excellent success using these motor reconnect principles to help our clients speak and converse again, even those with severe speech impairments related to apraxia.

    Traditionally, speech pathologists have used motor learning principles (MLP) in working with apraxia of speech due to stroke or brain injury.   We do know that these principles play a key role in the successful treatment of childhood apraxia of speech (CAS) in children who have not acquired the motor speech skill necessary for speaking ( McGlothlin, 2011, Strand, 2005.   While MLP provide valuable guidance and information, it may well, however, be a misguided interpretation to strictly apply MLP to clients with acquired apraxia.

     

    It is important to remember that MLP have emerged from studies that involved, “…nonspeech motor tasks largely performed by individuals with intact motor systems.” ( Mass, et al, 2008). The literature on how motor learning principles apply to impaired motor systems is unsettled at this time. This raises a number of issues related to using motor learning principles to drive treatment for acquired apraxia:

     

    1. First it is unknown whether speech motor control is sensitive to the same principles as nonspeech motor control.  In other words, should we teach people to use rapid, rhythmic movements of the articulators in spoken syllables in the same manner as teaching them to juggle 3 balls? Do the same learning principles apply?
    2. Secondly, we have not defined clearly how the principles of motor learning affect speech versus nonspeech learning.   Is it safe to assume that MLP apply equally to speech and nonspeech treatment?
    3. Thirdly, if clients do already know how to talk, shouldn’t we be taking advantage of neuroplasticity by utilizing activities that facilitate reconnection of the established, albeit damaged, neural pathways?
    4. Since, “…motor control impairment of AOS extends beyond speech and is manifest in nonspeech movements of the oral structures.” (Ballard, 2000) and the vocal folds, separation of the neural controls for the larynx, jaw and tongue/lips is a necessity for successful acquired apraxia treatment.
    5. Nearly all people with acquired apraxia that limits their voice and speech control, also experience phonemic and linguistic and most probably cognitive (e.g., attention; working memory; mental resource allocation) problems (Ballard, 2000, Burns, 2011). This would not be true of non-impaired subjects used in MLP studies. 

     

    It is clear that critical differences exist between learning a new motor skill and reacquiring or re-accessing previously mastered motor skills. For example, if a one takes a 5 year hiatus from golfing, he/she still knows how to golf; how to swing and grip a club, the rules of play, etc. He/she does not need to learn to golf; he/she just need to get reoriented and to reactivate motor memory of movement patterns.   He/she may want to take his/her golf swing apart and learn new skills but the basic motor pattern knowledge remains.  

     

    Given this, we have developed the motor reconnect principles for acquired apraxia that affects speech and voice. We incorporate these into our Viking Program for Apraxia (VPA). VPA uses both those components MLP that apply to the expanded MRP. This program not only separates and truly treats acquired apraxia as a movement disorder, but also then effectively threads the phonological and language components into practice (Burns, 2011, Hicks, 2010). Carryover into conversation happens naturally as our clients simultaneously engage other clients in group activities such as the Aphasia Communication Cafe (http://www.aphasiatoolbox.com/?q=smallgroup ). 

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    Table comparing and contrasting MLP with MRP

     

    Motor Learning Principles for CAS                        Motor Reconnect Principles for acquired apraxia

    GOAL: to help brain reorganize itself with new neural connections

    GOAL: to help brain reorganize itself with renewed and new neural connections

    A. Exploiting neuroplasticity: 1. Increase sensory input; 2. Provide many opportunities for specific input; 3. Modulate in lifelike contexts; 4. “Watch my face.”

    A. Exploiting neuroplasticity: 1. Moderate/reduce sensory input; 2. Provide more opportunities for intrinsic focus; 3. Modulate in phrase and sentence contexts; 4. “feel- think”

    B. Acquisition of performance is not a good index of retention

    B. Reacquisition of performance is a good index of retention

    C. Random practice is superior to blocked practice. Avoid repetitive trials with a predictable time pattern.

    C. Blocked practice can play a bigger role. Utilize repeated rhythmic flows of a self-generated nature (not repetitious)

    D. Intent to improve movement is critical.

    D. Intent to improve movement is critical. Intent is thought.

    E. Focus on individual phonemes should not be in the treatment plan.

    E. Focus on individual vowel phonemes should be the treatment plan with early transition to syllable stimuli structure.

    F. Focus on vowels a great deal.

    F. Focus on vowels a great deal especially to reestablish jaw control.

    G. Ongoing practice: blocked early for accuracy toward more random practice.

    G. Ongoing practice: blocked early for accuracy toward more random practice.

    H. Ongoing practice: lots and lots in context it will be used.

    H. Ongoing practice: lots and lots combined with work on phonological, lexical and semantic as appropriate. (Hicks, 2010)

    I. Make the ‘feel’ of the movement salient.

    I. Make the ‘feel’ of the movement salient, salient, salient.

    J. Utilize tactile and proprioceptive feedback.

    J. Minimize tactile and maximize proprioceptive feedback.

    K. Focus on function, core vocabulary.

    K. Reconnect to vocabulary. (sub, pronouns, conjugate)

    L. Segment syllables, not phonemes

    L. Segment syllables, not phonemes (compounds, tripounds; increasing syllable words)

    M. Fold in prosody early.

    M. Fold in prosody early. (scatpraxia; OMC)

    N. Focus on extrinsic feedback encourage visual and tactile feedback moving toward more intrinsic.

    N. Minimize extrinsic feedback; focus on intrinsic feedback.

    (adapted from McGlothlin, 2011, Strand, 2005)

     

     

     

    Stay tuned : - ) . Our next newsletter will describe and discuss in more detail our treatment program for acquired apraxia.    

     

     

    References:

    Ballard, Kirrie, Granier, Jay and Robin, Donald, Understanding the nature of apraxia of speech: Theory, analysis, and treatment, APHASIOLOGY, 2000, VOL. 14, NO. 10

     

    Burns, Martha, Apraxia of Speech in Children and Adolescents: Applications of Neuroscience to Differential Diagnosis and Intervention, Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders 21 15-32 April 2011

     

    Hickok, GregoryThe role of mirror neurons in speech perception and action word semantics, Language and Cognitive Processes, 25: 6, 749 — 776, First published on: 29 March 2010 (iFirst)

     

    Mass, Edwin, Robin, Donald, Austermann, Sharon, Wulf, Gabrile, Ballard, Kirie, Schmidt, Principles of Motor Learning in Treatment of Motor Speech Disorders, American Journal of Speech-Language Pathology • Vol. 17 • 277–298 • August 2008 • A American Speech-Language-Hearing Association

     

    McGlothlin, Jenny, Utilizing Motor Learning Principles in Treatment of Childhood Apraxia of Speech, Advance Magazine Presentation, http://speech-language-pathology-audiology.advanceweb.com/ 2011

     

    Strand, Edith, The Relationship of Practice and Repetition to Motor Learning for Speech in Children with Apraxia, http://www.apraxia-kids.org/site/apps/nl/content3.asp?c=chKMI0PIIsE&b=788447&ct=464503 , 2005

    SLP: If you would like to refer a client for online treatment or to consult with us in collaborative therapy, contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

     

    PERSON WITH APHASIA or CAREGIVER: if you would like to set up an online consutation or for more information contact Bill Connors at bill@aphasiatoolbox.com or 724.494.2534 .

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