Aphasiology

ISSN: 0268-7038 (Print) 1464-5041 (Online) Journal homepage: https://www.tandfonline.com/loi/paph20

Intensive language-action therapy (ILAT): The

methods

Stephanie Difrancesco , Friedemann Pulvermüller & Bettina Mohr

To cite this article: Stephanie Difrancesco , Friedemann Pulvermüller & Bettina Mohr (2012)
Intensive language-action therapy (ILAT): The methods, Aphasiology, 26:11, 1317-1351, DOI:
10.1080/02687038.2012.705815

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APHASIOLOGY, 2012, 26 (11), 1317–1351

Intensive language-action therapy (ILAT): The methods

Stephanie Difrancesco1, Friedemann Pulvermüller2,3 ,

and Bettina Mohr1,3
1
Department of Psychology, Anglia Ruskin University, Cambridge, UK
2
Brain Language Laboratory, Department of Philosophy and Humanities, Freie
Universität Berlin, Berlin, Germany
3
Cognition and Brain Sciences Unit, Medical Research Council, Cambridge, UK

Background: Brain and language theories suggest the application of general

neuroscientific and linguistic principles in the neurorehabilitation of language. The inter-
woven nature of language and action has long been emphasised in linguistic pragmatics,
and recent neuroscience research has indeed demonstrated tight functional interactions
between language and action mechanisms of the human brain. This provides impor-
tant arguments in favour of practising language in communicative settings, rather than
with the sole purpose of producing linguistic structures. Intensive language-action ther-
apy (ILAT), including its most popular form called constraint-induced aphasia therapy
(CIAT), realises language-action embedding in synergy with the use of intensive training
and guidance by modelling, shaping, and explicit rules. ILAT leads to significant improve-
ment of language performance in chronic post-stroke aphasia within a short period of
time. A comprehensive description of its methods has thus far been missing.
Aims: We describe the methods of ILAT, illustrate its use, and outline methods for lin-
guistic-pragmatic evaluation of its effects.
Main Contribution: We explain the general principles and practical features of ILAT
methods and of language-action games (LAGs) constituting this method. The structure
of and materials for two LAGs, the REQUEST and PLANNING games, are highlighted
by discussing in detail their respective action-structure, materials, and rules. These LAGs
are employed to encourage the use of language in communicative contexts through inter-
active requests and the planning of joint activities. A main linguistic focus is on object
nouns in the REQUEST game and on action verbs in the PLANNING game. Focusing
and tailoring of LAGs to patients’ communicative needs by means of modelling, shaping,
and explicitly introduced communication rules are also explained. Finally the assessment
of communicative success is illustrated based on clinical measures, performance within
LAGs, and the Communicative Aphasia Log (CAL).
Conclusions: Different linguistic-pragmatic and social-interactive forms of communica-
tion can be translated into specific therapeutic LAGs in the context of ILAT to target
specific speech acts and parts of speech. Apart from clinical tests, methods for evaluating
communication performance are available for assessment of therapy success.
Keywords: Aphasia; Stroke; Neurorehabilitation; Intensive language therapy; Constraint-
induced aphasia therapy.

Address correspondence to: Friedemann Pulvermüller, Habelschwerdter Allee 45, 14195 Berlin,
Germany. E-mail: [email protected]
We thank Karen Harrington for help with delivering aphasia therapy and with patient recruitment.
Research was funded by Anglia Ruskin University and the Medical Research Council.
© 2012 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/aphasiology http://dx.doi.org/10.1080/02687038.2012.705815
1318 DIFRANCESCO, PULVERMÜLLER, MOHR

Intensive language-action therapy (ILAT) refers to a set of techniques for speech

and language therapy (SLT) that emphasise massed practice, action-embedded lan-
guage use relevant for daily life, and the focusing and tailoring of treatment to the
individual patients’ communicative abilities and needs. It has been shown that one
form of ILAT, called constraint-induced aphasia therapy (CIAT), is successful in
improving language in chronic post-stroke aphasia (PSA) within a short period of
time (Pulvermüller et al., 2001). The success of ILAT in the treatment of chronic
aphasia has been replicated by several studies (Berthier et al., 2009; Faroqi-Shah &
Virion, 2009; Goral & Kemplar, 2009; Kirmess & Maher, 2010; Kurland, Pulvermüller,
Silva, Burke, & Andrianopoulos, 2012; Maher et al., 2006; Meinzer, Djundja, Barthel,
Elbert, & Rockstroh, 2005; Szaflarski et al., 2008). Further research documented
neuroplastic changes in language-related brain activation brought about by ILAT.
Such cortical reorganisation of language was even manifest in chronic PSA (Breier
et al., 2009; Breier, Maher, Novak, & Papanicolaou, 2006; Breier, Maher, Schmadeke,
Hasan, & Papanicolaou, 2007; Meinzer et al., 2004, 2008; Pulvermüller, Hauk, Zohsel,
Neininger, & Mohr, 2005; Richter, Miltner, & Straube, 2008).
We here use a new term “intensive language-action therapy” instead of the old
term “constraint-induced aphasia (or language) therapy”. This is because the term
“constraint” has given rise to misunderstandings in the past. One type of concern
arose based on the (somewhat distant, but still possible) suppressive association of the
word “constraint”—occasionally leading to requests for friendlier methods. In fact,
as the method itself gives no reason for any concern of this sort, we chose to use
friendlier terminology, speaking, for example, about “guiding” patients instead of
“constraining” them, thus hoping to avoid the misunderstanding in future. A further
misunderstanding had arisen based on the relationship between constraint-induced
aphasia therapy and constraint-induced motor therapy of stroke-related lateralised
motor deficits. The latter includes putting the unaffected arm in a sling to constrain
its use and force use of the affected extremity. In analogy, constraint-induced language
therapy had been understood by some to prohibit any kind of non-verbal communi-
cation and gesturing although, as we discuss in detail below, its aim is to encourage
verbal communication, also if it is accompanied and supported by nonverbal action.
Nonverbal communication replacing verbal activity should be avoided, but the con-
cordant verbal communication and other body actions are in fact desirable—especially
given the background of the well-known evidence for synergistic effects between action
and language processes, see later.
The new term, ILAT, may not only help to overcome the above misunderstandings,
it is also informative as it highlights two important features of the new approach: first
that it is an intensive method, typically applied several hours per day, and second, that
language is being practised in action contexts. An additional advantage of the new
term is the fact that its use can be slightly wider. Whereas CIAT primarily covered
one specific type of communication, that is REQUEST1 interactions, a broader and
gradually increasing spectrum of communication types and speech acts is targeted in
the wider intensive language-action therapy context.
Despite the demonstrated success of ILAT’s most researched form, CIAT (also
called CILT, constraint-induced language therapy) in aphasia treatment, and despite
the increasing interest in this method from a neuroscientific point of view, there is

1 For convenience here we write speech act terms in capital letters.

 ILAT METHODS 1319

still a lack of detailed guidance on how to run the procedures practically in clinical
settings and how to adjust the method to the spectrum of deficits of individual patients.
Furthermore, the precise implementation of speech acts, their embedding in other
actions, and the choice of language materials has previously not been described in
much detail. This article will close this gap by highlighting the principles of this
type of SLT and by outlining the exemplary procedures involved in the intervention.
Special attention will be given to the rules and settings; practical samples of ther-
apy elements will capitalise on two types of language games. Finally, this article will
exemplify the measurement of communicative performance gains induced by ILAT.
By “communicative” performance we mean that a focus will be on the question of
how patients succeed in performing speech acts such as informing, requesting, making
suggestions etc. and how they succeed in understanding such linguistic actions.
One potential problem frequently suggested regarding ILAT relates to the high-
intensity aspect and a related practicability issue. As the therapy is so intense, being
delivered with a frequency of several hours per day (typically 3 hours), it has been
claimed that the clinical day-to-day practice cannot deal with such high demand. This
is a false argument. Randomised controlled trials have investigated the effectiveness
of the same amount of SLT delivered in a short time period, in an intensive language-
action setting, and stretched out over several weeks in a classical utterance training
regime. Such a study showed that the same amount of therapy was more efficient in the
intensive CIAT context than in the classic one (Pulvermüller et al., 2001). Therefore it
is not required to provide overall more treatment hours to make therapy more efficient,
but it is important to re-structure the delivery of therapy, so that the same patient can
receive treatment within a shorter time interval, ideally on a day-to-day basis in order
to enhance the learning effects.

PART I: NEUROSCIENTIFIC PRINCIPLES AND THEIR PRACTICAL

IMPLICATIONS
Intensive language-action therapy, ILAT, and constraint-induced aphasia therapy,
CIAT, developed from two major roots: communicative and pragmatic SLT (Aten,
Caligiuri, & Holland, 1982; Davis & Wilcox, 1985; Pulvermüller & Roth, 1991) and
constraint-induced therapy of motor deficits caused by stroke and other brain dis-
eases (constraint-induced motor therapy, CIMT, see Taub, Crago, & Uswatte, 1998;
Taub, Uswatte, & Pidikiti, 1999). Similar to CIMT, ILAT builds on three major prin-
ciples: (1) massed practise, (2) behavioural relevance, and (3) focusing of patients
by guidance provided by the training context, shaping, and other behavioural tech-
niques. Similar to pragmatic and communicative aphasia therapy, speech acts and
their sequences known from everyday dialogues constitute the frames for therapeutic
interaction, thus rendering these interactions behaviourally relevant. These speech act
sequences are embedded into therapeutic language games, which allow for repeated
practice of words, utterances, and sentence structures. Focusing is provided by the
structure of the training interactions inspired by Wittgenstein’s concept of language
games (Wittgenstein, 1953). Materials and action structures are applied in game-like
activities which connect speaking and writing with non-linguistic actions. These lan-
guage games allow the tailoring of SLT to the patients’ communicative needs. Further
guidance comes from communication partners (especially therapists) acting as role
models and from communicative success in the games.
1320 DIFRANCESCO, PULVERMÜLLER, MOHR

The neuroscience foundation of the three main principles constituting ILAT, inten-
sive practice, communicative and behavioural relevance, and focusing, will now be
explained one by one.

Intensive practice
Neuroscience research demonstrates that when networks of neurons in the brain are
frequently simultaneously active, they become strongly connected with each other.
In contrast, asynchronous firing weakens established synaptic links (Hebb, 1949;
Tsumoto, 1992). The correlation learning implied by the “fire together – wire together
rule” has implications for the representation and processing of language in the human
brain (Pulvermüller, 1999). In early language learning, babbling in human infants
becomes fine-tuned to specific speech sounds or phonemes they frequently hear. When
infants babble or speak their first words, connections between inferior frontal regions,
whose neurons control articulations, and the auditory areas in the superior temporal
regions, whose neurons are being sparked by the self-produced acoustic word forms,
become strengthened, thus leading, due to Hebbian learning, to action-perception cir-
cuits for phonemes and words (Pulvermüller & Fadiga, 2010). Correlation learning
may therefore be relevant for the basic mapping between articulations and speech sig-
nals. However, such learning may also play a role in acquiring semantic and linguistic-
pragmatic knowledge. As words are frequently used in the context of their referent
objects or actions, simultaneous activation of neuronal circuits, for example in the
visual or motor systems and in the language cortex, results. Hebbian learning princi-
ples therefore imply the formation of a connection and semantic linkage between word
form representations in the cortical language system (left-perisylvian cortex) and their
related concept representations in other parts of the cortex, including sensorimotor
and multimodal areas (Pulvermüller, Kiff, & Shtyrov, 2012). Similar correlation
learning may also occur for syntax (Pulvermüller, 2001; Pulvermüller & Fadiga, 2010).
Conversely, if connected neurons are frequently active independently from each
other, their connections undergo synaptic weakening. Such “anti-Hebb” learning
(Tsumoto, 1992) may become relevant to language in cases of brain injury, for example
when partial damage to the circuit connecting word form and concept does not allow
the conceptual circuit to spark the linguistic one, and vice versa. Use of an inappropri-
ate word may lead to further anti-Hebb learning, which could therefore imply further
weakening of the already damaged word-concept links (Berthier & Pulvermüller, 2011;
Pulvermüller & Berthier, 2008).
These considerations have clear implications for neurorehabilitation. As much as
co-activation of crucial neuronal circuits should be encouraged, the independent acti-
vation of circuit parts should be avoided. ILAT aims to re-strengthen links between
phonological, lexical, semantic, and conceptual circuits, which include action- and
perception-related circuits, by co-activating these neuronal ensembles (Berthier &
Pulvermüller, 2011). Regular, intensive practice may facilitate coincidence learning
to obtain rewiring of synaptic connections and behavioural (language) changes in
patients. Critically, increasing the frequency of daily practice and therefore reduc-
ing the time delay between therapy sessions should minimise the possibility that
circuit parts are activated in isolation and crucial connections degrade, for exam-
ple when words are used in an inappropriate context so that synaptic weakening of
word–concept links may result.
 ILAT METHODS 1321

It therefore appears useful to aim at practising language in an intensive training

regime, with many therapy hours applied in as short a time as possible. Over and
above the effect of intensity or therapy frequency, an increase of the amount of therapy
should always be beneficial (Bhogal, Teasell, & Speechley, 2003).

Behavioural and communicative relevance

The second theoretical principle on which ILAT is based addresses the communicative
and behavioural relevance of language use in the therapeutic settings. This princi-
ple builds on work in communicative and pragmatic SLT which aims to improve
patients’ abilities to communicate in everyday-life conversations (Aten et al., 1982;
Davis & Wilcox, 1985; Pulvermüller & Roth, 1991). In one form of communicative
therapy called PACE (promoting aphasics’ communicative effectiveness; Davis &
Wilcox, 1985), drawings, pictures, and other visually stimulating items are used to pro-
mote information dialogues and spontaneous communication including turn taking.
Building on PACE, communicative aphasia therapy was further developed to widen
the spectrum of speech acts and communication forms targeted in aphasia therapy
(Pulvermüller & Roth, 1991). To this end, Wittgenstein’s concept of language games
was systematically exploited and a range of therapeutic language action games were
created to approximate, and allow the practice of different communication forms,
including requesting, joint planning, storytelling, giving directions etc. (Pulvermüller,
1988, 1990; Pulvermüller & Roth, 1991). These language action games, or LAGs, form
the therapy frames of CIAT and ILAT (Pulvermüller & Berthier, 2008).
As discussed in the previous section, semantic links established during lan-
guage learning sometimes connect neuronal ensembles in left-perisylvian language
regions with sensorimotor areas. Inferior frontal and parietal sensorimotor areas are
strongly active during language perception and comprehension in general (Berthier
& Pulvermüller, 2011; Fadiga, Craighero, Buccino, & Rizzolatti, 2002; Pulvermüller,
2005; Pulvermüller & Fadiga, 2010; Pulvermüller et al., 2012; Pulvermüller, Shtyrov,
& Ilmoniemi, 2003; Watkins, Strafella, & Paus, 2003). Interestingly, specific seman-
tic relationships of words are also manifest in sensory and motor systems of the
brain. Reading or hearing the word “grasp” co-activates the specific motor areas
that would be active if the person actually performed the word-related action (i.e.,
grasping; Hauk, Johnsrude, & Pulvermüller, 2004). Semantic action links between
motor and linguistic regions appear to be bi-directional whereby stimulation (using
TMS) of topographical areas of the motor cortex such as the leg or arm area has
been shown to improve reaction time to the recognition of leg-related and arm-related
words, respectively (Pulvermüller, Hauk, Nikulin, & Ilmoniemi, 2005). Similarly, spe-
cific brain activation to semantic features occurs in visual, auditory, gustatory, and
olfactory brain areas when processing linguistic expressions relating to visual informa-
tion (about colour or form), tastes, odours, or sounds (Barrós-Loscertales et al., 2011;
González et al., 2006; Kiefer, Sim, Herrnberger, Grothe, & Hoenig, 2008; Pulvermüller
& Hauk, 2006).
What implications do these findings have for aphasia therapy? If language and
action systems of the brain are strongly interwoven, one of the two can help the other
to activate in case of focal lesion. Therefore practising language in interactions where
words appear in their natural context of non-linguistic actions and object perceptions
should be of utmost relevance to reactivate language circuits. One example for this
would be to pick up (a card depicting) an apple and hand over the apple (or card) when
1322 DIFRANCESCO, PULVERMÜLLER, MOHR

asked to by someone else. Or to verbally agree to join in playing tennis while simul-
taneously performing/mimicking the action of using a tennis racket. However, the
use of the word “tennis” in a context where one player PROPOSEs the activity and a
second one AGREEs to take part, already constitutes an important form of pragmatic
language-action embedding, as the word is used to reach relevant communicative
goals. In these cases neural activity may spread from sensorimotor areas to facilitate
processing in those parts of the language networks that are affected by brain damage
(Berthier & Pulvermüller, 2011; Pulvermüller & Berthier, 2008). The focus on linking
language with sensorimotor networks in ILAT differentiates this therapeutic approach
from SLT aiming purely at producing linguistic utterances or structures, with little
attention to action embedding and speech act features of the verbal output.
In essence the close functional links between language and action systems of the
brain, along with the well-known a priori knowledge about the pragmatic role of
language as a communicative tool in interaction between people, lead to the aim of
practising language structures in communication and action context.

Focusing
There is strong evidence that adaptation to stroke-related deficits is a major issue
in functional recovery and that it may hinder poststroke rehabilitation (Taub, 2004;
Taub et al., 1998, 1999; Taub, Uswatte, & Elbert, 2002). For example, a patient
who, following a stroke, is unable to move one arm might learn to avoid using the
affected limb. Similarly, patients with aphasia might quickly realise that, owing to
their disorder, they cannot speak properly. As a result these patients might resort to
strategies such as using simplified sentences (“telegraphic style”, agrammatism) to
communicate with others or, in extreme cases, might avoid verbal communication
altogether and limit themselves to gesturing (Kolk & Heeschen, 1990). Thus an
important feature of neurorehabilitation is to avoid such learned or strategic non-use
of potentially available capacities. To make patients with stroke-related motor deficits
use their affected limbs, Taub and colleagues developed constraint-induced motor
therapy (CIMT; Taub et al., 1998). In CIMT, constraints are employed that force
the patient to use their affected limb. Compensatory activity using the intact arm
and other adaptation to stroke-related deficits is prohibited by constraints in order
to facilitate rewiring and re-strengthening of neuronal connections supporting the
functionality of the affected limb.
In a similar manner, aphasia patients can be guided (or “constrained”) to use ver-
bal utterances that they would normally avoid due to lack of success in the past and
resultant avoidance behaviour (learned non-use). Due to practising of verbal com-
munication skills which are still available to stroke patients, they may regain some of
their lost language skills that would otherwise have remained unused. So ensuring that
patients with aphasia make use of the full range of their available verbal abilities is a
valuable aim of neurobehavioural rehabilitation (Taub, 2004; Taub et al., 1999).
How can learned non-use in patients with chronic aphasia be overcome or even be
prevented? Linguistic “constraints” cannot be applied in a similar fashion to the slings
and restraints applied to the unaffected arm, which are used in CIMT to guide the use
of the affected extremity. In ILAT it is the use of language games and related materials
that provides the guidance for patients to systematically explore, apply and elaborate
on a repertoire of verbal utterances and actions these patients might still be able to use,
but wouldn’t typically in their day-to-day behaviour because of lack of success in the
 ILAT METHODS 1323

past. Note that the focusing on the patients’ full range of verbal communication skills
does not imply that non-linguistic actions be prevented. As discussed in the previous
section, it is of importance to allow relevant non-linguistic actions in context of verbal
activities, including the use of gestures complementing verbal utterances. What should
be avoided is the isolated use of gestures in replacement of verbal communication,
which is a typical strategy of learned non-use.
In ILAT the most important therapeutic tools to provide guidance and focusing for
patients are:
(1) The action structure of the language game.
(2) The materials (typically specific sets of picture cards) used in the game and the
framing of the game (e.g., barriers between players, double card sets, impossibility
of seeing each other’s cards).
(3) Behavioural techniques such as modelling, shaping, and positive reinforcement.
(4) Explicit rule descriptions.
We will address these “focusing tools” one by one in subsequent sections of this
paper.
For more detailed explanation of the neuroscience foundations of ILAT and CIAT,
the reader is referred to recent reviews focusing on this issue (Berthier & Pulvermüller,
2011; Pulvermüller & Berthier, 2008).

PART II: ILAT METHODS

ILAT procedures
Basic setting
As explained above, ILAT aims to implement three main guidelines for the
neurorehabilitation of language derived from neuroscience and linguistic sciences:
high frequency, language-action embedding, and focusing on the individuals’
communicative abilities and needs.
Although there is in principle no upper limit for the amount and frequency of
therapy, real-world limitations constrain the implementation of the high-frequency
therapy principle. A therapy frequency of 3 hours per day in 10 consecutive working
days represents a high therapeutic intensity which can be tolerated by many patients
and may even be applicable in clinical contexts.
In the ILAT context language-action embedding is realised through verbal com-
munication in the context of other communicative and non-linguistic overt actions.
Language use is a crucial component of card games with picture cards showing objects
or actions. These games include both non-communicative actions, such as showing,
handing over, or taking and putting aside a card, as well as verbal communicative
actions, such as asking for one of the cards, or objects depicted. As mentioned, we call
these communicative interactions language action games, or LAGs.
When specifying LAGs we will stick to the following terminology: a game, or LAG,
consists of several rounds characterised by a communicative goal (requesting and pass-
ing an object/card), which in turn consist of a sequence of moves or turns, that is speech
acts, nonverbal communicative actions, and other, not communicative action turns (e.g.,
the request, the handing-over of the requested item, or a clarifying question).
For performing LAGs participants typically sit around a table with barriers
between them (see Figure 1). Barriers ensure that participants cannot see each other’s
1324 DIFRANCESCO, PULVERMÜLLER, MOHR

Figure 1. Therapeutic setting for ILAT. Four players, usually three aphasic patients and one therapist sit
around a table, with a set of 12 matching pairs of cards distributed between them.

cards. In addition the barriers also make it more difficult for participants to efficiently
use and perceive any non-verbal communication, such as gestures or pointing. In par-
ticular, this set-up ensures that gestures cannot easily be used to replace verbal output
(see later section on gesturing), while still allowing participants to use them in addition
to their spoken output, if they wish.
At the start of the LAG each of the participants or “players” is given a set of picture
cards. Patients and the therapist act as players following the same rules for commu-
nicating in the LAG. Two copies of each picture card are used in the game, although
each with a different player. At the beginning of each “round” of the LAG, one player
selects one picture card from their set. The aim is to obtain the matching card from
a different participant. Note again that each player can only see his or her own cards
or objects, as the barriers prevent sight of any co-players’ cards. In one type of LAG,
the REQUEST game, the only tool for obtaining the matching card is making ver-
bal requests. In a different type of game, the PLANNING game, participants have to
propose activities to their co-players. The players can propose an activity, or agree to
participating in the activity, only if they have a corresponding action picture in their
set of cards. In these contexts patients have to perform a series of different speech acts
in interaction with other players to achieve success in the game.
All speech acts are embedded into sequences, although these sequences are, similar
to natural conversations, not necessarily linear. They are normally best represented
as action trees rather than action chains, because one speech act can be followed
by a range of other different, but well-defined, acts. For example, a REQUEST to
hand over an object (or a card depicting it) can be responded to by FOLLOWING
this request, that is handing over the object (card), but if the player does not have
 ILAT METHODS 1325

the object/card in his or her set, a REJECTION of the request must follow. If there
are understanding problems—because the speaker has not articulated clearly enough,
used an (in the context) ambiguous expression, or because the addressee did not
understand precisely enough—there is motivation to initiate a repair sequence to
CLARIFY what has been meant. Also each of these “second moves” has a range
of possible continuations. Similar sequences characterise other language games too.
We will address the specific action-sequence structure of different LAGs later.
Importantly, the action sequences allow patients to practise both speech produc-
tion and comprehension and (with minor modifications of the game) can also be
used to practise reading and writing. Note in this context that a standard procedure
applies to comparing the cards after they have been verbally identified. The speaker
would first select the card and make his or her request or proposal, the addressee
would then, ideally, respond by agreeing, selecting the corresponding card, and hand-
ing over the card. In turn, the speaker would then also show his/her card and, only if a
match between cards has been achieved, thus proving successful communicative inter-
action, the sequence finishes as successful. Feedback about successful speech acts and
successful comprehension, therefore, is given by way of the card-matching procedure.
Making requests or planning an activity with someone else are communicative
speech acts which often occur in everyday life situations. Such relevance to everyday
communication has long been emphasised to be highly relevant in aphasia ther-
apy (Davis & Wilcox, 1985; Elman & Bernstein-Ellis, 1999). Taking into account
behavioural-communicative relevance, different speech acts in everyday life, and
varying levels of patients’ language abilities, we have created materials for use in
ILAT which ensure that patients engage in different forms of communication in a
behaviourally relevant language-action context. One set of materials will be described
in more detail in a separate section below.

Gesturing in ILAT
Before addressing more specific features of ILAT, we would like to comment on the
role of non-verbal communication and gesturing in ILAT, a topic already mentioned
above. As emphasised, a common misunderstanding about the CIAT (and therefore
also ILAT) method had been that non-verbal communication of any sort always needs
to be “suppressed” when using this method.2 Note, however, that from the point of
view of brain science where language and action systems have been demonstrated to
be functionally connected and to interact synergistically, it would not be advisable
to forbid gesture in the context of verbal communication attempts, as facilitation of
linguistic brain systems by excitation from still intact action/gesture systems may be
one of the keys for the success of language-action embedding. On the other hand,
the focusing principle suggests not allowing patients to replace demanding actions,
which they have reason to practise, with easy ones. The solution is obviously to allow,
even encourage, gesturing and non-verbal activity, not in replacement but rather as
a complement of verbal communication. Therefore, to make it possible to efficiently
practise verbal language use, we typically discourage substitution of spoken language
by gesture. Note again that it is a side effect of the barriers on the table between players
that it is difficult to see each other’s hands and gestures. This is desirable in the context

2 The origin of this misunderstanding goes back to misleading formulation in Pulvermüller et al., 2001.

We have elaborated on this issue elsewhere (e.g., Pulvermüller & Berthier, 2008).
1326 DIFRANCESCO, PULVERMÜLLER, MOHR

of the non-use avoidance strategy: the aim is to practise verbal abilities, speaking and
writing, possibly accompanied and facilitated by gestures (e.g., saying “letter” plus
gesture of writing), but not to replace words by isolated gestures.

Speech acts and their sequential structure

Language games can be more or less complex. In everyday communication it is
sometimes advantageous to get as much done with one single utterance as possible,
while in other circumstances it is more advisable to move carefully and slowly, ascer-
taining at each step that addressees fully understand and one doesn’t request too much
from communicative partners. Correspondingly, the pragmatic structure of speech act
sequences can be more or less elaborate in LAGs too. We typically use a form of LAGs
in which one player addresses one other player with a REQUEST or a PROPOSAL.
This one-to-one mode requires selecting a partner, focusing attention on that partner,
and taking turns with that partner only. A more challenging version would be if one
player addresses all other players. In this one-to-all mode there is an increased demand
on divided attention and turn-taking abilities, as several participants may start to
speak at a time and therefore compete for attention. A further modification divides
the action structure into four sub-moves, whereby a QUESTION–ANSWER sequence
first aims at clarifying whether a given co-player is in possession of the required object
(or is able/willing to take part in the suggested activity) and the third move then is the
key speech act, REQUEST or ACTION PROPOSAL followed by its specific response
options for the fourth move. Also, this four-move version can be realised in the one-to-
one or one-to-all modes. In order to illustrate the different speech acts during a LAG,
we use so-called “action trees” which demonstrate the sequential structure of speech
acts. Several examples of action trees are outlined below.
Typical action sequences would thus be the following in three variants of the
REQUEST game:
r 2 move – specific – Player A REQUESTs object from player B – Player B follows
the request or rejects
r 2 move – general – Player A REQUESTs object from any co-player – Player B (who
has the matching card) follows the request while others reject
r 4 move – specific – Player A asks B whether s/he has a given object – Player B agrees
or denies – Player A REQUESTs the object from B – B follows the request
More details, as well as specific examples will be given below with regard to the
sequence structure of the REQUEST and PLANNING LAGs (see section on Specific
features of LAGs).

ILAT materials
The materials described here are picture cards developed recently by our group specifi-
cally for English-speaking aphasic patients. All items are photographs of either objects
or people taking part in a range of activities/actions (n = 624) and presented in colour
on laminated cards sized 6 by 4 inches on a blank white background (see exam-
ples of pictures cards in Figure 2). Each object/activity depicted on the cards has a
best-matching single noun or verb, or more complex noun phrase or sentence. Cards
with best-matching single noun/verb were subdivided into frequency classes accord-
ing to the standardised lexical frequency of these items. To this end, Kučera-Francis
 ILAT METHODS 1327

Figure 2. Examples of materials from ILAT. Cards depicted from each of the eight categories: pictures
related to word with (a) high frequency (“bed”), (b) middle frequency (“cup”) and (c) low frequency
(“clock”); (d) objects whose names are phonological minimal pairs, i.e., objects that differ by one speech
sound or letter (“ball” and “wall”); (e) objects from the same semantic categories (animals); (f) multi-feature
objects whose identification requires at least two words (“circle biscuit” and “square biscuit”); (g) spatial
relationships requiring a phrase with preposition for unique identification (“cup on/next to saucer”); (h)
action pictures related to action verbs (“(horseback) riding”).

word frequencies were taken from the Medical Research Council’s Psycholinguistic
database (Coltheart, 1981). For therapeutic use, all picture cards were duplicated to
obtain matching pairs of cards.3
As mentioned before, choice of materials can be adjusted to patients’ needs, abili-
ties, and interests. The materials chosen may challenge patients and encourage them to
use language they might normally avoid. However, care must be taken that materials
are not too difficult, so that patients might become frustrated. With patients improv-
ing their performance, appropriate increase in difficulty of LAGs can be controlled by
material choice. At the same time it is useful to use some items as “repeat cards” so
as to monitor “trivial” therapy effects on the items practised, as well as “test cards”,
which have not been used before but are of comparable difficulty. These latter items

3 Examples of the cards are given in this paper. Publication of the full set of cards is under

preparation. An electronic version of a previous card set adopted in previous projects on CIAT and
ILAT in German (Neininger, 2002) can be accessed at: http://kops.ub.uni-konstanz.de/handle/comm-5/
browse?value=Neininger%2C+Bettina&type=author
1328 DIFRANCESCO, PULVERMÜLLER, MOHR

are matched for psycholinguistic features and are essential for assessing non-trivial
generalisation effects brought about by therapy.
Below, seven “categories” of picture cards are presented for the REQUEST
LAG. These are not meant to represent a linearly increasing difficulty ladder, but
rather different points in a multidimensional difficulty space, with some items (pic-
tures of objects with names of high lexical frequency) typically relatively easy to
process by patients, and others (minimal pairs, multi-feature objects, and object
sets) being experienced as more challenging. We only used one full set of cards in
the PLANNING LAG as not so many patients with specific difficulty in action
description were available. Below, the eight subcategories of materials are briefly
described:

Categories 1–3:Word frequency. (1) The simplest set of cards (n = 60 items) are
those depicting objects whose most characteristic verbal label has high lexical fre-
quency; these items, typically nouns, were used more than 100 times per million
words. These included words such as “table” and “door”. Higher-frequency words
are often easier for aphasic patients than words used less often in everyday language
(Pulvermüller & Berthier, 2008). Therefore difficulty of the LAG can be increased by
reducing the lexical frequency of typical names of the objects depicted. (2) Middle-
frequency items (n = 60) showed objects with a word frequency of their typical names
between 20 and 100 per million. Examples are “plate” and “key”. Once patients are
relatively confident making requests with middle-frequency items, it makes sense to
introduce (3) low-frequency items (n = 60); these are object cards with nouns of cor-
responding word frequency of 20 per million or below, such as “candle” and “vase”.
Along the frequency axis, the level of difficulty can therefore be adjusted to patients’
ability and progress throughout the therapy.

Category 4: Minimal pairs. Minimal pairs are words that only differ in one speech
sound or letter. The 30 picture cards of this set show pictures typically named by
English nouns that are only minimally different phonologically and/or orthograph-
ically. Examples are “ball” and “wall”; or “glass” and “grass”. Identifying these
items in the context of their minimal pair-objects requires rather precise pronuncia-
tion (or letter writing) and is thus especially appropriate for patients suffering from
apraxia of speech and pronounced speech production deficits (or writing deficits).
Corresponding difficulty in phonological discrimination in speech perception (and
letter discrimination in reading) can also be addressed using this set.

Category 5: Semantic categories. Difficulty in distinguishing between items can be

introduced by making them more and more similar. Distinguishing an animal from a
tool is relatively easy and can be done using many different words. However, if similar
animals need to be distinguished, such as different mammals, or even smaller sub-
categories such as cats, the demand on linguistic processing gets greater. A set of cards
include 84 items from different hierarchically organised semantic categories. Semantic
groups include pictures of animals, clothing, fruit and vegetables, furniture, tools, and
vehicles. Using this card set, and especially a specific sub-category set of cards, fine-
grained distinction and verbal description between items are needed, as it would not be
enough to simply ask for an “animal” or “animal with four legs”, for example, but the
species “cat” would need to be distinguished, and even a specific subtype such as the
“black cat” from the “white kitten”. Note, furthermore, that certain kinds of language
 ILAT METHODS 1329

deficits come with category-specific impairments so that tool or animal names may be
selectively impaired in individual patients (Gainotti, 2000).

Category 6: Multi feature objects and object arrangements. To further increase dif-
ficulty, card sets were created which required a more complex description for unique
identification of a given card; 180 cards include subsets differing by colour, shape, size,
or a mix of all of these. Note that the attributes of the objects and their size necessitate
more elaborate descriptions and therefore introduce a constraint to use more complex
linguistic forms in the game. For success in LAGs using this category of picture cards
it is necessary to uniquely specify the set of objects on a given card against the alterna-
tives in the set. This may require verbal explication of all information available, using
forms such as “four round biscuits” or “one green and one red pepper”. Thus this card
set can be used to focus communication on two and three word utterances along with
more complex constructions.

Category 7: Spatial relationships. A final set of object-related cards includes objects

in different spatial relationships thus requiring the use of prepositions (n = 60) in
order to uniquely identify the depicted scenarios. As the different cards can show the
same two or more objects but arranged in different ways, the players are required to
use spatially specific linguistic structures, such as “the cup on the saucer”; “the cup
under the saucer”; “the cup next to the saucer”, to perform a successful request. Note,
furthermore, that prepositions and spatial language are difficult to process in spe-
cific kinds of aphasia (Tranel & Kemmerer, 2004) and in dementia with predominant
posterior-parietal involvement.

Category 8: Action cards. In the PLANNING LAG the aim of the interaction is to
propose and agree on an activity that several players could perform together. Therefore
picture cards need to show actions, and typical actions are best “named” using verbs
or longer expressions including verbs. The 60 cards in this extended set depict a range
of everyday activities, either ones which can be performed alone such as “brushing
teeth” or “licking an envelope”, or group activities such as “hiking” or “playing a
board game”. This card set and game is especially appropriate for patients with deficits
in speaking about actions and using verbs. There is ample evidence for deficits in verb
and action processing in certain types of aphasia and specific dementias (Kemmerer,
Rudrauf, Manzel, & Tranel, 2012; Miceli, Silveri, Villa, & Caramazza, 1984).

Introducing the games and rules to patients: Modelling, shaping, and

reinforcement
The rules of the therapeutic language action games are typically introduced by playing
the games. As many patients suffer from severe comprehension deficits, a verbal expla-
nation might not always be effective. So, starting with the barriers, cards in front of
each of the participants, and the therapist making a request is typically the best pos-
sible strategy. In this introductory phase of the therapy it may help to have available
a co-therapist to demonstrate the interactive nature of the games. Aphasic patients
may just join in, as pictures and verbal actions provide relevant cues. Modelling and
shaping can also be used to encourage desirable activities by patients. Within the first
“rounds” of the game the therapist may also illustrate the different possibilities of
responding to the key speech act of the game (REQUESTING in the REQUEST
game and PROPOSING AN ACTION in the PLANNING game). It also makes good
1330 DIFRANCESCO, PULVERMÜLLER, MOHR

sense that the therapists demonstrate not only using the “best possible” match (the
word “house” for a card depicting a house), but also alternative expressions that may
function equally well in solving the communication problem. Note that, depending on
the cards from which the target object needs to be distinguished within the given con-
text, the expressions “home”, “to live in”, “thing with a roof”, may be sufficient and
equally functional, whereas more specificity may be needed in other contexts (“red
house with a long chimney” in case of a card set including several houses). In the
materials section above, we have already shown how the game can be tuned to control
utterance complexity by choosing the appropriate materials requiring more or less
complex and challenging utterances.
Patients will typically stick to sets of utterances which they know they can eas-
ily produce (e.g., single words, simple sentences). However, through modelling, new
utterance types and speech acts can be introduced easily and, by systematic positive
reinforcement, their application can be established (see example Transcript 3 below).
For example, it is our observation that if the therapist uses full sentences, polite-
ness formulae, or even specific grammatical constructions repeatedly, patients will
start making attempts towards mirroring such linguistic activity. Note that there are
neuroscience reasons for assuming that “syntactic priming” (Branigan, Pickering,
& Cleland, 1999; Pulvermüller, 2010) and “mirroring” (Pulvermüller & Fadiga,
2010; Rizzolatti & Sinigaglia, 2010) are automatic mechanisms built into the human
brain.

Explicit rule descriptions

As mentioned before, much of the burden of introducing the therapeutic language
games is through “learning-by-doing”. However, if patients have sufficient compre-
hension abilities, explicit rule descriptions may be important to adjust and fine-tune
the game to patients’ communicative abilities and needs. A problem that frequently
arises is that some participating patients do not have difficulty with a given type of
game, whereas others still struggle. In this case it is advisable to introduce additional
constraints by explicit rules that make the game more difficult for best performers.
Note that explicitly introduced rules can easily be adjusted to each patient depending
on ability levels. Different explicit rules can apply for each player, whereas the material
constraints, which serve similar purposes of adjusting difficulty level, always apply to
all players. To explicitly introduce a rule for one or more participants, the therapist
would request that they use utterances of specific types, for example:
Regarding the length of utterances:
r any utterance, including single words (“clock?”)
r two word expressions or longer utterances, including adjective–noun or noun–verb
minimum (“pass clock?”)
r full grammatical sentences (“Could you pass me the clock?”)
r grammatically complex forms (embedded sentences; “Could you pass the apple that
is red?”)

Regarding the way to address other players:

r no restriction (“Could you pass me the fork?)
r always use co-player’s name (“Joe, could you pass me the fork?”)
 ILAT METHODS 1331

Regarding politeness:
r no restrictions (“Pass the bread?”)
r use of politeness formula obligatory (“Please could you pass the bread?”)
Please note again that all of these rules can also be introduced by modelling,
although this is more difficult if rules are adjusted to individual patients. Note, further-
more, that some of these focusing tools only make sense for specific deficit patterns, for
example a constraint on complex linguistic forms primarily for patients with specific
grammatical impairments, especially agrammatism. It may be best not to overempha-
sise explicit rules and draw more heavily on material constraints, as described above.
If rules are established explicitly, success of the speech act should depend on adher-
ing to the rules. For example, a patient asked to follow the politeness and name-usage
rules should only receive a requested object card or be allowed to participate in any
proposed activity if, indeed, a politeness formula and the name of the addressee had
been used. This can be motivated by everyday communication, as in some contexts,
making a request or proposition in a polite way and speaking to the addressee by
using their name is of great importance for success.
Although it has been argued that the therapist function in CIAT can be taken on by
non-specialists (Meinzer, Streiftau, & Rockstroh, 2007), we wish to warn that the com-
plex role of the therapist in CIAT or ILAT is, according to our experience, difficult to
master for interested laypersons who have little background in language sciences and
pathology. Please consider that, in addition to serving as a communication partner
with the same function as any of the LAG-participating patients, the role of the ther-
apist includes modelling and shaping, adjustment, introduction and keeping track of
patient-specific rules, keeping track of communicative success and failure, possibly in
the form of a protocol, and most importantly, adjusting their own language activities
to most efficiently help patients who participate in the LAGs. We doubt that a layper-
son can take on such a demanding and complex task without substantial training
and experience. We do, however, believe that using language-action games at home,
between patients and their partners or friends, and in aphasia self-help/community
groups among patients, can be beneficial and motivating for patients suffering from
language difficulties (Pulvermüller, 1990; Pulvermüller & Roth, 1991; Roth, 1986).

Role of a co-therapist
The typical composition of participants in ILAT is one therapist and two or three
aphasic patients. In addition, a co-therapist can be present during all sessions. Whereas
the main therapist engages in language action games (LAGs) and models possible
speech acts for patients, the optional co-therapist—whose role can also be taken on by
experienced therapists, on top of their LAG-playing function—is responsible for:
r taking notes of communicative moves of each individual patient;
r keeping track of difficulties and improvements during each therapeutic session; and
r helping patients who have difficulties with a specific card or communicative move.

Patient selection
ILAT’s most researched form, CIAT, has been tested in randomised controlled tri-
als (RCTs) with patients suffering from chronic aphasia after stroke. It is reasonable
1332 DIFRANCESCO, PULVERMÜLLER, MOHR

to assume (but not proven) that patients with other aetiologies also profit from this
SLT method. Most studies so far prove effects at the chronic stage, although encour-
aging results also come from initial exploratory work at the acute post-stroke stage
(Kirmess & Maher, 2010). The group setting used in recent studies is most appropri-
ate for patients with moderate to mild forms of aphasia. Very severe language deficits,
as seen for example in global or mixed-transcortical aphasia, may be best treated in a
one-to-one or two-on-two fashion initially, with equal patient to therapist interaction
(Kurland et al., 2012; Pulvermüller & Schönle, 1993).
Many previous studies were all performed on pre-selected clinical populations,
some applying rather strict inclusion and exclusion criteria. In principle, intensive
forms of action-embedded language therapy should be applicable to most patients
able to partake in standard SLT. Other forms of SLT used in previous studies have,
for example, typically included an unconstrained (total communication) training
approach based on patient’s functional deficits involving exercises such as naming,
repetition and sentence completion (e.g., Pulvermüller et al., 2001); or SLT based
on PACE therapy (Kurland et al., 2012). However, the special demands related to
the intensity of delivery, the group setting, and the multiple simultaneous demands
on action, perception, interaction, and communication ability, limit to a degree the
range of patients who may be able to participate or who may benefit from this form
of SLT. Criteria that might lead the therapist, or possibly a consultant neurologist, to
discourage participation in ILAT, could include the following:

r Chronic heart disease or other illness that may make it difficult to participate in
engaging activity for several hours.
r Inability to understand the introduction to LAGs and related instructions.
r Presence of major perceptual, motor and neuropsychological impairments that
make it difficult to perform in LAGs, including severe forms of motor impairments
and apraxia,visual processing deficits, planning deficits, learning deficits, memory
deficits, or attentional deficits.

This said, it should be noted that a degree of memory, attention, and motor/apraxia
impairment can be tolerated in LAGs, and may even be worked upon in the settings
described. A patient with aphasia and neglect may not only learn to use words and
understand the LAGs, but also to retain an overview over a spectrum of picture cards
and co-players during a LAG. Apraxia of speech is certainly not hindering partic-
ipation but will indeed be a valuable target of SLT in ILAT context (see Kurland
et al., 2012), especially where emphasis is put on phonological minimal pairs or card
selection biasing verbal output towards consonant clusters and complex utterances
challenging the articulatory system. Verbal working memory training is provided, as
increasingly complex utterances need to be kept in mind while card sets are being
searched. Due to the high attention demands of ILAT, patients with low attention abil-
ities or with very severely impaired language may find it difficult to follow the intensive
schedule. On the other hand, the training of turn-taking provided by LAG partici-
pation also implies training of attending to communication partners, visual stimuli,
others intervening etc., so that both the focusing of attention as well as divided atten-
tion can be trained. Furthermore, a minimum level of comprehension is needed in
order to be able to participate in the language action games although, as explained, a
good deal of the explanation can be done by modelling and shaping. Although, ide-
ally, ILAT should be carried out in groups, it is also possible to deliver therapy on a
 ILAT METHODS 1333

one-to-one basis, which may be better suited for severely impaired patients, as
mentioned before.
Previous research has shown that patients with different forms of aphasia and dif-
ferent levels of language impairments participating in the same group can benefit
from ILAT. Note that ILAT offers possibilities of introducing rules to titrate differ-
ent difficulty levels for individual players in the same game. Therefore therapy groups
can indeed consist of patients with different abilities and impairments. Certainly it
will be easier and more efficient to conduct ILAT with a more homogeneous patient
group (e.g., with moderately impaired patients all suffering from agrammatism), if
this happens to be possible. Important complications of mixed-ability groups are the
possibilities that patients with more severe language problems may sometimes cause
less-severely impaired patients to become frustrated with the slow pace, whereas severe
patients in the context of much better performers might become unnecessarily frus-
trated with their comparatively low rate or level of success and progress. It is therefore
desirable to group patients with similar aphasia severity together, although there are
options for balancing demands.

Evaluation of progress in language-action games

When taking notes during LAGs it is important to focus on the evaluation of each
individual patient’s speech acts. In this context, it has proved to be useful to take
notes, in the form of a protocol, of:
(a) Date, number of game, round, and speech act/turn.
(b) Type of LAG (e.g. “request” or “planning”).
(c) Progression level imposed by materials (simple objects, coloured object arrange-
ments, actions etc.) and rules for each player (use of politeness form, full
sentences, etc.).
(d) Speech act (or attempt) type (requesting, rejecting, accepting, clarifying).
(e) Utterance type (full sentence, politeness, target word, description of target).
(f) Appropriateness of speech act: fully functional (3), functional but with minor
delay or error (2), minor functional contribution (1), not functional at all (0).
A scoring sheet can be used to systematically note the progression of games/levels
(as indicted under a–c) and to evaluate each patient’s performance (as indicated
under d–f), and in order to plan the next session. An example of how a speech act
would be scored using these criteria can be found in the Appendix. It has proven to
be very helpful to videotape or voice record sessions for the purpose of transcribing
and evaluating relevant communicative sequences later on, particularly when no
co-therapist is available during the therapy. The evaluation of communicative acts
after each therapy session will help to monitor the progress for each individual
patient and will help the therapist to adjust rules or materials for the next session (see
focusing section for more details). As the therapy proceeds, it is important for the
therapists to introduce new rules and constraints and to refine existing rules, referring
to notes and any recordings taken.

Specific features of language action games (LAGs)

In all LAGs exemplified here, two identical sets of cards are distributed evenly between
players, so that each player has 6 to 12 cards in front of her/him. As the first step
1334 DIFRANCESCO, PULVERMÜLLER, MOHR

of each round, one player selects a card from their set and holds it in their hand.
Please note again that the simultaneous use of motor and verbal action (holding the
card in the hand and speaking) is a crucial element of ILAT. Next, the player per-
forms the key speech act, or makes an attempt at performing it. This key speech act
can be REQUESTING the depicted object from one of the co-players. In a differ-
ent kind of game the key speech act is PROPOSING a joint activity depicted on the
picture card. A different participant can then respond to the initial verbal action, for
example by passing the picture with the requested object or by agreeing to participate
in the proposed action and passing the corresponding card. Note again that pass-
ing a card is a nonverbal action into which speech acts are embedded and that this
serves as a check for successful communication. After one successful round of com-
munication, the object-requesting or action-proposing player puts aside the matching
pair of picture cards. For each player, the aim of the game is to get rid of his or her
cards by having them put aside after participating in as many as possible successful
communications.
As discussed, ILAT can be used to practise different kinds of key speech acts,
for example REQUESTING AN OBJECT and PROPOSING AN ACTIVITY, as
well as parts of speech (nouns and verbs). In what follows, the rules of ILAT
will be illustrated through practical examples of the REQUEST and PLANNING
LAGs. The two games follow a similar language-action structure (see Figures 3
and 4), but importantly encompass different kinds of speech acts, both of which
are important for day-to-day communication. Therefore the therapeutic aims of
each game are explained to highlight the differences between the LAGs. Example
transcripts have been taken from therapy sessions with two non-fluent aphasic
patients (see later for more details). The example transcripts will be used to illus-
trate possible moves, including speech acts from the different players (PA, PB, etc.)
Please note numbers in brackets indicate the length of pauses (in seconds) during
speech.

Object request LAG

Therapeutic aim. To learn to participate in REQUEST dialogues, that is to reliably
make REQUESTS using a range of verbal utterances, to appropriately respond to
REQUESTS by HANDING OVER objects (cards), or by REJECTING the request,
or, in case of doubt and difficulty, to work towards CLARIFYING the request. Here
words, phrases, and syntactic structures of various degrees of difficulty are prac-
tised. The use of successful verbal requests results in acquiring pairs of cards with
the same objects depicted on them. Figure 3 illustrates the sequence structure of
the REQUEST LAG, indicating its possible moves and their possible successions in
the game.

Objective of the game for the players. To be the first player to have no cards left to
match, either by receiving or passing on matching cards.

Rules of the game: Requesting an object. A round of the game begins with the first
player, whom we label A here for convenience. A selects a card and REQUESTS the
corresponding item from a different player, B. Verbal utterances that could be used for
 ILAT METHODS 1335

Figure 3. Request-an-object game. This decision tree illustrates the possible moves and relevant speech acts
during the REQUEST game.

successfully making a request range from single words to whole sentences and even
more complex forms, for example:
Strawberry, red little thing. Would you pass me a strawberry, please?

Responding to the request. Typically, a request is followed by:

r B FOLLOWING the request by handing over the card with the corresponding
object on it,
r B REJECTING the request by mentioning the unavailability of the requested
object card in their set,
r CLARIFICATION attempts in case of communication problems.

Following the request. If Player B has identified the requested object and found the
corresponding picture card, Players A and B show their cards to each other and to
all other players to confirm that the cards match. Player A, who requested the card
and received the matching one, may thank B and puts both cards to the side. Player
B, the addressee of the previous round, then begins a new round by requesting an
item depicted on one of his/her cards. The LAG continues until all cards are matched.
We illustrate this sequence of moves by example Transcript 1.

Transcript Example 1 – following a request

A REQ A: (Picks up card) Have you a plant, please?

B FOL
B: Sure, I can certainly give you a plant. (Offers and shows card with plant)
A: Thank you. (Shows his/her card with plant and takes Player B’s card
B REQ after matching check)

Rejecting the request. If Player B does not have the matching card, they must deny
the request (“no”; “sorry, no” or “I do not have this card”). Player A can then address
1336 DIFRANCESCO, PULVERMÜLLER, MOHR

another player with the same request. Note that this feature of the game leads to fre-
quent repetition of successful speech acts and thus contributes to the desirable massing
of practice.

Transcript Example 2 – rejecting a request

A (to player B): May I please have one large white bottle and two green
A REQ
small bottles?
B REJ
B: I’d love to give that, but I haven’t got it. I’m sorry.
A REQ A: Thank you very much.
B: That’s OK.

A: (to Player C) Would you have one large white bottle and two small green
bottles please?

Clarifying the request. During a specific move there may be times when players
either cannot find a suitable target word or phrase to perform the intended speech
act, or when more information is needed for making a successful request. In addition,
a perfect utterance and unambiguous speech act may be produced by A, but B may
not understand appropriately due to comprehension deficits. In these cases Player B
or C (which may be another co-player or the therapist) can query the request; ask
Player A to repeat; or encourage Player A to think of alternative ways to communi-
cate what he or she wants B to do. As explained in the section on ILAT materials, at
times different expressions may be equally well suited to achieve communicative suc-
cess in a particular LAG, whereas at other times more specialisation may be needed in
a LAG, for example one presenting several different forms of the same item, (e.g., small
bulldogs, ones of different colours). Therapists and players ask and inspire Player
A to use alternate expressions and even descriptions of colour, shape, or what the
object is used for. Clarifications are based on the strategy of systematically exploring
the search space based on players’ own cards (i.e. “I have two bulldogs, one is big
and one is small”). In general any verbal communication which leads to successful
identification of the requested card is actively encouraged and positively reinforced
by the therapists’ verbal comments and through receiving the pair of matching
cards. Unsuccessful attempts should neither be positively rewarded nor punished in
any way.
Transcript Example 3 illustrates a complex clarification (or “repair”) sequence.
Here A first makes an unsuccessful attempt to request a drill, then clarification
questions follow and new attempts at requests are made by A. Later on a revised
description of the desired object “crow hammer . . . for making holes” leads to
the correct assumption on B’s side. Then B performs another set of clarification
moves, asking back whether “power tool” and “drill” is the target of the request
and, after agreement on A’s part, hands over the correct card. This sequence pro-
vides a quite dramatic demonstration of how the (only partially appropriate) input
from different communication partners together with the constraints provided by
the LAG can lead to communicative success, even in the absence of canonical
utterances.
 ILAT METHODS 1337

Example Transcript 3 – Clarifying the request

A REQ A: Right, err, do you- err (2s) crow- (3s) crow something, err right,
B: What colour is it Player A?
B CLA
A: Its blue, blue on one side and red at the back and red at the front, and
its clo- crow hammer, crow hammer, (2s) hammer. Have you got it?
A REQ
B: Does it have one handle or two handles?
B CLA A: Err no-not really. Not really a handle.
B: It hasn’t got a handle?
A REQ A: Well (1s) err (1s) it’s red on one side and red at the back and the front
and call-It’s called something like a crow hammer. Do you have it (3s)
B CLA for making holes?
B: Hold on, is it a power tool?
A CLA
A: Yes, yes.
B FOL B: Oh I think I have it. I think I know. A drill? (Player shows card)
A: Yes a drill. Thank you (Player shows card and takes it after matching
check)

Detection of failure: (a) Unsuccessful request. At times in a specific move it may

become clear that an unsuccessful request has occurred. The primary diagnostic here
is the mismatch between cards shown by Players A and B. Upon comparing their
cards, A, B, and the other players will realise the problem. In this situation A and B
take back their own card. After the unsuccessful round A has lost the right to initiate
a new round; Player B goes on to start a new round by selecting a new card and by
requesting the depicted object.

Example Transcript 4 – detection of failure

A REQ A: Chair with umm a, a (7s) in front of it, it’s right, it’s in front of it
B: Sorry?
B CLA A: Chair with an apple, oh, no, a cushion (6s) in front of it,
in front of it, under- underneath it
FAIL
B: Underneath the chair? (B shows card with cushion on the floor but in
front of the chair)
B REQ
A: No, no, that’s the front one, the one benea- beneath it (A shows card
with cushion directly under chair. Card mismatch and A and B each
take back their own cards and Player B begins new round)

(b) Unsuccessful comprehension. Communication failure is very obvious in this

kind of LAG when all players reject a given request. The transcript below illustrates
such a “general” failure, followed, however, by a repair sequence initiated by A, who
interestingly adds new information thus making a redundant request. He/she now
specifies the requested objects by two attributes “brown bottle” and “with white label”,
which leads to success. The new round will be initiated by Player B, who has handed
over the requested item.
1338 DIFRANCESCO, PULVERMÜLLER, MOHR

Example Transcript 5 – detection of failure

A REQ A: Could I have one brown bottle please?

B: One bro-own bottle. I’m afraid I can’t give you any brown bottle
B REJ
A: OK, Player C would you have one brown bottle please?
A REQ C: No, I’m afraid I haven’t got one.

C REJ A: Oh, Player D would you have one brown bottle please?
D: I’m afraid to say it but I don’t have it either.
A REQ
A: OK, somebody has the brown bottle with a label – I’ll just do a general
D REJ
one then. One brown bottle with a white label on it.
B: Ah, I have that
A CLA
A: May I have it please?
B FOL B: Yes, thank you (Player B shows card)
A: Yes, thank you very much. (Player A shows card and takes the pair after
B REQ
confirming that they match)

Action planning LAG

Therapeutic aim. To learn to participate in interactive PLANNING of future
activities, by PROPOSING joint activities, and by responding to such proposals by
ACCEPTING them, by REJECTING them, or by CLARIFYING the proposal. This
game is played with cards depicting actions; these define the activities to be proposed
and the activities a player can agree to participate in. The use of successful speech acts
(activity planning with a co-player) results in acquiring, and putting aside, pairs of
these action cards. Figure 4 illustrates the possible moves and subsequent steps of the
game.

Objective of the game for the players. To be the first player to have no cards left,
either by receiving or passing on cards.

Rules of the Game: Proposing an activity. A round begins with A picking up a

card and proposing the depicted action as a joint activity. Examples of the range of
utterances which can be used are: Hiking; play chess; why don’t we watch TV; you know
what? We should rent a boat.

Responding to the proposal. Typically the proposal is followed by:

r B ACCEPTING to join the proposed activity and handing over the corresponding
card,
r B REJECTING the proposal by mentioning that the he/she is not able to
participate (owing to unavailability of the matching card),
r CLARIFICATION attempt in case of communication problems.
 ILAT METHODS 1339

Figure 4. Planning-an-activity game. This decision tree illustrates the possible moves and subsequent speech
acts during the PLANNING game.

Accepting the proposal to join an activity. If Player B has the corresponding action
picture card, s/he agrees to join the proposed joint activity. Upon checking that the
cards match, Player A then takes both cards and puts them aside. Player B then
begins a new round by selecting a card from his/her set and by proposing the depicted
action as a joint activity. Transcript Example 6 illustrates a successful round of the
PLANNING game, which, however, starts with an unsuccessful attempt at making a
request, followed by a repair sequence over which relevant information (that “stick”,
“hole”, and “ball” are part of the activity) is produced step by step, to incrementally
frame the to-be-proposed target activity (playing golf).

Transcript Example 6 – accepting proposal to join activity

A PRO A: Can you help me with umm, would you like to play umm. I’ve lost it
B: You can describe it, A.
B ACC A: (4s) long stick with two people and a hole and a stick with a hole on the
end of it. Umm (2s) I can’t see what else is there?
B PRO
B: So maybe you could tell me what we could do with the stick?
A: Umm it’s two sticks with a ball and long, a long stick and ball; and a
long, umm a ball that you hit?
B: So you hit a ball?
A: Yes, with the long (1s) stick
B: I think I know. Would you like me to play golf with you? (Player A offers
card and B also shows card, which matches)
A: Oh, yes. (Player A takes both cards upon confirmation of match).

Rejecting the proposal. If Player B does not have the matching card, he/she should
deny the proposal to participate in the activity. Player A then makes the same proposal
to a different player.
1340 DIFRANCESCO, PULVERMÜLLER, MOHR

Example Transcript 7 – rejecting proposal

A PRO A: B, would you like to join me walking the dog tomorrow?

B REJ
B: No, I think my dog just want to stay in-indoors
A: Ah, OK. Well then C would you like to join me walking the dog?
A PRO

Clarifying the proposal. If clarification is needed during a move, Player B can

request more information or ask A to repeat the proposal. Again, clarification moves
are made based on players’ own cards. Note that, in example Transcript 8, the target
activity is “sending out a letter, with a stamp on it”. Due to word-finding difficulties,
the proposal to “lick a stamp” is made initially. Only when A specifies further that the
proposed activity relates to an “envelope” can the target activity be selected uniquely
among its alternatives in the game.

Example Transcript 8 – clarification of proposal

A PRO A: Err, please lick (2s) a stamp for me

B CLA B: Stamp for you?

A: Mmm-
A PRO
B: I’ve got something licking-
B ACC A: Yes? What sort of licking is that?
B: (4s) umm
A: Envelope?
B: Ah yes, lick an envelope (Player B shows card)
A: Great, thanks. (Player A shows card then receives both cards, which
match)

Detection of failure: (a) Unsuccessful proposal. The unsuccessful outcome of a

round is evident when, upon comparing cards, players realise they do not match. Here
Player A and B each take back their own card and Player B begins a new round by
proposing an activity depicted on a card in his/her set.

Example Transcript 9 - unsuccessful proposal

A PRO A: Umm (2s) right (2s) umm I have here a (3s) hmm a (2s) big long rope
and attached to that I’ve got some err (3s) climbing frame, climbing
B CLA frame and I’d like to know would you like to please (1s) the (2s) the
climbing frame, the (2s) rope and me
FAIL
B: So you’re planning a climbing activity tomorrow and are asking if
B PRO
I would like to join you climbing a wall? Yes?
A: Yes, yes that’s right
 ILAT METHODS 1341

B: I’m very happy to join in (shows card depicting the activity “climbing
indoors”)
A: Oh, no. (Shows card depicting the activity “abseiling down a building”)

PART III. EVIDENCE FOR THE EFFICACY OF ILAT

Previous RCTs
Previous research applying a randomised clinical trial has demonstrated improve-
ments of language and communication performance in patients with chronic PSA
due to intensive daily practice, with several hours per day using the CIAT method
(Pulvermüller et al., 2001). Notably, all chronic PSA patients included in this trial
had shown no change in language performance for years prior to the commencement
of CIAT. Other studies have also reported beneficial effects of intensive SLT regimes
for acute as well as chronic aphasia patients, which, in several studies, remained
stable over weeks and up to 6 months (Bhogal et al., 2003; Cherney et al., 2008;
Faroqi-Shah & Virion, 2009; Goral & Kemplar, 2009; Kelly, Brady, & Enderby,
2010; Kirmess & Maher, 2010; Maher et al., 2006; Meinzer et al., 2005; Szaflarski
et al., 2008). Additional drug therapy has led to a further increase of therapy suc-
cess (Berthier et al., 2009). Thus intensive (daily) practice using ILAT methods leads
to clinical improvements of language functions, possibly because it entails re-learning
of word–concept links and rewiring of neuronal connections in language networks.
Improvement in language and communicative performance over 2 weeks of ILAT
therapy could be demonstrated using clinical aphasia tests, communication screenings,
and questionnaires.

Evaluation of language and communication in J.R. and L.S.

We evaluated the communicative performance of two patients, J.R. and L.S., (see
Table 1 for demographic and neurological data) who underwent 2 weeks of ILAT
with the LAGs and materials described above, as part of an ongoing study. Informed
consent was obtained from each participant. The study was approved by the NHS
Cambridgeshire 1 Research Ethics Committee.
Ten sessions of therapy were delivered and three of these sessions (on days 2,
5, and 10) were chosen for evaluation (“test sessions”). For evaluation of treat-
ment success we chose parts of the Boston Diagnostic Aphasia Examination (BDAE;
Goodglass & Kaplan, 1972) as clinical measures, the Communicative Activity Log

TABLE 1
Clinical and sociodemographic data of Patients J.R. and L.S
Months
Age, Native after Aphasia
Patient years Sex Handedness language onset Origin Lesion site Type Severity

L.S. 40 Female Right English 26 Aneurysm- Left Posterior Non-fluent Mild

subarachnoid Communicating
haemorrhage Artery Left
Sylvian fissure
J.R. 73 Female Right English 57 CVA Left middle Non-fluent Mild
cerebral artery
1342 DIFRANCESCO, PULVERMÜLLER, MOHR

(CAL; Pulvermüller et al., 2001) completed by both patients and clinicians as commu-
nication rating scales, and changes in performance and understanding of speech acts
within the LAGs, as revealed by conversation analysis techniques (for similar methods,
see Pulvermüller & Roth, 1991; Pulvermüller & Schönle, 1993).
Each of the three “test sessions” was video-recorded and later analysed in order for
speech and comprehension performance to be scored as described earlier. Response
times (RT) for speech acts were also measured. The following criteria for evaluating
speech acts were applied.

Speech production
Spoken output was evaluated as to whether it was sufficient to uniquely iden-
tify the target object in the context of the given LAG. Such unique identification
could be provided by a best-fit target word, a multi-word expression, a suboptimal
description leading to communicative success, or a full sentence. If a player used a
misleading object or action name or description, the speech act was counted as unsuc-
cessful. In addition the rules and constraints of each round had to be followed in
order for a speech act to be considered functional. This applied for the type of LAG
(REQUESTING or PLANNING) and other linguistic constraints such as the use of
politeness forms. In each round, i.e., for each card selected, only the first key speech
act, e.g., the REQUEST to the first-addressed co-player, was included. If a patient
self-corrected their speech act, this was accepted as a successful response. However,
if a therapist or other player initiated a repair sequence and only after this sequence
communicative success was achieved, this was scored as unsuccessful. Reaction times
(RTs) were measured from the point in time when a patient picked up the card to
when they started to pronounce a critical word or phrase which led to communicative
success, i.e., to their card being identified by co-players.

Speech comprehension
Passing the correct card or accurately rejecting a request was taken as criteria for
successful comprehension. Unsuccessful comprehension was scored if a player passed
an incorrect card or rejected a card they held in their set. (Although this information
is not always available in the LAG, video recordings allowed for accessing it.) All com-
prehension events were scored as successful or unsuccessful except the last request of
the game, as there was only a single card left. RTs were measured from the onset of the
critical word (object or action) to when the patients selected the correct card from their
set or explicitly rejected the request. For the evaluation of RTs, only comprehension
of the first request in each move was included.

Results
Boston Diagnostic Aphasia Examination. Performance of the subsections “con-
versational and expository speech”, including the picture description and narrative
discourse subtests; “auditory comprehension”, including the word comprehension,
word comprehension by categories, and the semantic probe subtests; “syntactic pro-
cessing”, including the touching A with B, reversible possessives, and the embedded
sentences subtests; and “naming” (Boston Naming Test, BNT) were analysed before
 ILAT METHODS 1343

TABLE 2
Boston Diagnostic Aphasia Examination results for patient L.S. and J.R.

L.S. J.R.

Before After Before After

Conversational and Expository Picture description 0.5 0.5 1 0.85

Speech (complexity index)
Narrative Discourse 1.16 1.2 0.91 0.67
(Complexity Index)
Average 0.83 0.85 0.955 0.76
Auditory Comprehension Word Comprehension/37 33 34 35 35.5
Word Comprehension by 30 30 29 30
Categories/30
Semantic Probe/60 56.00 57 57 56
Complex Ideational 3.00 4 2 2
Material/4
Composite score 122.00 125.00 123.00 123.50
Syntactic Processing Touching A with B/12 7.00 7 4 7
Reversible Possessives/10 4.00 8 7 7
Embedded Sentences/10 7.00 6 9 9
Composite Score 18.00 21.00 20.00 23.00
Boston Naming Test 26 39 27 37

BDAE; Goodglass and Kaplan (1972).

and directly after the 10-day therapy interval. Chi-square tests were calculated individ-
ually for each patient. There were no significant differences in the “conversational“,
“auditory comprehension”, or “syntactic processing” sections before and after the
treatment (see Table 2). In line with previous literature (Maher et al., 2006), where a
change of ≥2 SD (from the gender, age, and education adjusted mean normal perfor-
mance) was used to indicate a critical change in scores, results from the BNT revealed
significant improvement in naming performance for both LS and JR over therapy
(Figure 5, lower row).

Discourse analysis. The total number of trials evaluated from the three sessions
was 506. There were 188 speech production trials (93 for J.R. and 95 for L.S.) and
318 speech comprehension trials (171 for J.R. and 147 for L.S.). During the 10 days
of ILAT, L.S.’s and J.R.’s speech production appeared to improve both in terms of
reaction times and communication success on first attempt (see Figure 5, upper row).
In terms of L.S.’s and J.R.’s comprehension abilities (Figure 5, middle row), both
patients accurately understood nearly all speech acts directed at them throughout
therapy, thus performing at ceiling in terms of correctness of comprehension.

Error rates. Despite the fact that there was a numerical increase in the number of
successful speech outputs for both patients after therapy, chi-squared tests conducted
on the proportion of correct responses for overall speech output failed to confirm
significant changes across the three sessions analysed separately for patient J.R. and
patient L.S. (Figure 5, top right).
1344 DIFRANCESCO, PULVERMÜLLER, MOHR

Figure 5. Behavioural changes in L.S. and J.R. Performance is shown at the beginning (Day 2), middle
(Day 5) and end (Day 10) of the therapy. Top row: mean reaction times for speech acts (REQUESTs and
PROPOSALs; left) and proportion of correct speech acts on first requests (right). Middle row: mean reac-
tion times of actions giving evidence of correct comprehension of previous speech acts (REQUESTs and
PROPOSALs; left) and proportion of such actions providing evidence for correct comprehension (right).
Bottom row: Raw results from the BNT before and after therapy displayed for each patient.

When analysing comprehension of speech acts, a slight increase in the number of

correct responses was noticeable. A chi-squared test analysing the number of errors
again failed statistical significance for both patients (Figure 5, middle right).

Reaction times. Independent samples t-tests were conducted first on the RTs for
individual speech acts. The time it took from selecting the card to producing the crit-
ical word during all speech acts was significantly less on Day 10 than Day 2 for both
J.R., t(48) = 2.65, p = .011, and L.S., t(37) = 3.51, p = .001; (see Figure 5, top left).
Furthermore, independent samples t-tests were conducted on the RTs for comprehen-
sion. The average time it took to comprehend the requests significantly decreased from
Day 2 to Day 10 for both J.R., t(64) = 3.16, p = .002, and L.S., t(54) = 2.63, p = .011;
(see Figure 5, middle left).
 ILAT METHODS 1345

The results demonstrated improvements of communication performance within

LAGs in both patients over the therapy interval. Improvements were equally apparent
in production and comprehension. Note that performance was on “test sets” of cards
depicting objects and actions not previously trained in the therapy sessions. Therefore
a “trivial” therapy effect on practised materials can be excluded. Whereas the accuracy
analysis did not yield any significant results, probably due to patients’ performance
at ceiling level, the latency analysis revealed significantly quicker responses for both
patients after therapy.

Communicative Activity Log

The CAL (Pulvermüller & Berthier, 2008) was completed by both J.R. and L.S.,
as well as by an independent SLT therapist. All ratings showed improvements in
patients’ quality and amount of communication after therapy (see Figure 6). The
CAL questionnaire provides information on communication in everyday life situa-
tions. Higher ratings reflect increased frequency and better quality of communication.
Scores for the 18 questions for each of the subtests of the CAL were compared
before and after therapy. Paired samples t-tests were conducted on the self-ratings.
The self-ratings showed a significant increase in the amount and quality of commu-
nication after therapy for patient L.S., t(17) = 2.39, p = 0.028; t(17) = 2.95, p =
.009, respectively, but no significant improvement for patient J.R. The improvements
in these scores also appear to be reflected in the therapist-rating of communication
using the same rating scales (Figure 6). Paired sample t-tests showed that therapist
ratings of amount and quality of communication were not significantly higher after
therapy for patient L.S., but they were significantly higher for patient J.R., t(17) =
3.55, p = .002; t(17) = 7.09, p < .001, respectively. This is the reverse pattern of
significant effect seen in the patients’ self-ratings. Interestingly, a Pearson’s corre-
lation showed a significant positive correlation between the CAL therapist ratings
and the self-ratings for patients, J.R., r(70) = .421, p < .001, and L.S., r(70) = .338;
p = .001.

Figure 6. CAL scores for L.S. and J.R. Self- and therapist-rated scores on the amount and quality of
communication scales of the CAL, recorded before and after the therapy.
1346 DIFRANCESCO, PULVERMÜLLER, MOHR

Discussion of therapy outcomes

Over 10 days of ILAT the “naming” subsection of the BDAE, used as a standard-
ised clinical measure, yielded significant improvements in naming in both patients.
Over and above this improvement on a clinical language test, the detailed evaluation
of communication performance provided evidence for more efficient use of differ-
ent speech acts in the LAGs as well as an increase in comprehension success over
the treatment interval. Critically, communicative improvement could be shown when
novel items (pictures and words) not previously trained were used, thus demonstrating
a non-trivial, generalising effect of treatment. This demonstrates objective evidence
for communicative improvements after ILAT for both patients. In this evaluation,
latencies of crucial speech act production and comprehension during LAGs seemed
to be particularly sensitive to detecting therapy-related changes. In addition, CAL
self-ratings and therapist-ratings indicated the beneficial effect of ILAT for L.S. and
for J.R., respectively. The significance criterion was reached for the self-ratings in
one patient but on therapist ratings for the other, although a numerical improve-
ment was visible on all ratings obtained. We do not interpret the role of raters here,
as significant correlations confirmed consistencies across these raters. Together, and
in line with previous research, these results indicate that ILAT can lead to signifi-
cant improvements of language and communication on different measures, ranging
from clinical tests to evaluation of communication in therapy to ratings of everyday
communication.
We believe the lack of effects shown across all but the Boston Naming Subtest of the
BDAE should not be over-interpreted. First, we used only a subset of the test included
in this battery. Second, our patients had moderate to mild aphasia and many clinical
tests lack sensitivity in the upper range of aphasic performance. Third, also in previous
ILAT studies, the improvements over the 10-day treatment period were sometimes not
significant at the single-participant evaluation level, although ANOVAs performed at
the group level typically demonstrated an improvement. The lack of significant effects
here may therefore be due to test sensitivity and small sample size issues.
Whereas analysis of the latency of speech acts showed significant improvements
towards the end of therapy as compared with before, analysis of accuracy of speech
acts and comprehension did not. The lack of an accuracy effect for comprehen-
sion is explained by the ceiling effect resulting from the mild impairment of both
patients.
The fact that both L.S. and J.R. got faster at producing and comprehending speech
acts, despite the lack of significant improvements in speech act accuracy and auditory
comprehension measured with the BDAE, shows the importance of detailed analysis
of speech acts for detecting improvements over therapy. Similarly detailed analysis of
speech production and comprehension in a single patient with severe chronic post-
stroke aphasia, who underwent less-intensive communicative aphasia therapy with
LAGs, documented improvements on both accuracy and response time measures
over a therapy interval of several weeks (Pulvermüller & Schönle, 1993). One may
argue that, compared with an effect significant on both accuracy and response times,
the reaction time measure alone can only provide weaker evidence as, for example,
speeding could be due to the learning of LAG rules and may not necessarily reflect
increased communicative skills. However an effect due only to learning LAGs is pre-
dicted to be strong during the first sessions, but reduced or absent as soon as patients
became used to the interaction games. The patients of the present study picked up
 ILAT METHODS 1347

the LAG rules quickly and were already well familiar with the methods after three
sessions, so that any LAG familiarisation effect should be specific to the initial ther-
apy segment. However, as Figure 5 (top left) shows, speech act production latencies
improved constantly over the training interval, even with a tendency towards greater
improvement in the second half of the therapy period than in the first. This pattern
argues against the LAG learning possibility. Only the improvement on speech act
comprehension might be open to this interpretation.
Ratings of communication effectiveness and amount, assessed by the self-rated
and therapist-rated communicative activity log (CAL), tended to show improvements
after therapy for both patients, L.S. and J.R. However, significant differences were
only shown in the self-rated scale for patient L.S., but not the therapist rating. The
reverse was found for patient J.R.’s performance; while the self-rated scale showed
no significant improvements, the therapist rating demonstrated higher quality and
more communication after therapy. Taking a positive attitude, we see evidence for
improvement in both patients, along with significant correlation between self- and
therapist ratings. Importantly, the communicative improvement suggested by CAL
results is consistent with the positive outcome of conversation analysis, and is even
paralleled by the Boston Naming Test results, thus providing some cross-validation of
the improvements over testing procedures.
Although our present results do not unambiguously demonstrate dramatic effects,
they add to a growing body of reports on therapy-related improvements over ILAT
application. These results also indicate that, when assessing the effect of ILAT,
it is advisable for clinicians not only to assess language functions with clinical
tests, but to use communicative rating scales and if possible, more detailed analy-
sis of communicative and comprehension performance (Pulvermüller & Roth, 1991;
Pulvermüller & Schönle, 1993). Particularly the latter not only provides a vast amount
of information about changes in communication due to treatment, but is also helpful,
or possibly indeed necessary, for planning and delivering the most appropriate LAGs
with materials most relevant for a specific patient.

SUMMARY AND OUTLOOK

In this paper we have focused on the practical procedures involved in intensive
language-action therapy (ILAT), and its main variant, called constraint-induced
aphasia therapy. The underlying principles of ILAT include the use of an inten-
sive schedule, language-action contexts for communication, and the employment of
a range of modelling, focusing, and shaping techniques along with explicit rule intro-
duction. Whereas CIAT had exploited one form of communicative interaction, the
REQUEST LAG, one additional LAG, focusing on PROPOSING ACTIONS, has
been highlighted. Approximating a range of different communication types with an
increasingly elaborate set of LAGs firmly rooted in established neuroscience princi-
ples may point to a fruitful perspective for future neurorehabilitation research and
practice. For assessing the outcome of ILAT, it may be advantageous to exploit not
only clinical measures, but also conversation screening and analysis.

Manuscript received 29 March 2012

Manuscript accepted 19 June 2012
First published online 3 August 2012
1348 DIFRANCESCO, PULVERMÜLLER, MOHR

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APPENDIX: EXAMPLE OF THERAPY SCORING SHEET

As described in the main text, the progression of the LAG protocol can be organised
in the following way:
(a) Date/Number of Game/Round/Speech act/turn: Therapy Day 2/Game 3.
(b) Type of LAG: Planning.
(c) Progression level/Materials: Action set, Materials set 8
Progression level/Rules: J.R.: no politeness, full sentences
L.S.: no politeness, no full sentences.

In addition to keeping track of the type of game played, each move a player makes
can also be recorded and scored. These scores are then used to guide therapists in
determining further rules and progression for players. As an example, we will illustrate
how a speech act could be scored using example transcript 4 from the main text. In this
LAG the production of explicit action description had been defined as a specific goal
for participant A:
A: “Umm (2s) right (2s) umm I have here a (3s) hmm a (2s) big long rope and attached
to that I’ve got some err (3s) climbing frame, climbing frame and I’d like to know
would you like to please (1s) the (2s) the climbing frame, the (2s) rope and me
Co-player: So you’re planning a climbing activity tomorrow and are asking if I would
like to join you climbing a wall? Yes?
A: Yes, yes that’s right

(d) Speech Act (or attempt) type: A provides the background knowledge for an action
proposal by informing B about the availability of climbing tools by saying “I have
 ILAT METHODS 1351

here a big long rope and attached to that I’ve got some climbing frame”. A makes
an attempt to propose joint climbing by uttering the string “I’d like to know
would you like to please the climbing frame, the rope and me”.
(e) Utterance Type: full sentence to describe climbing tools; string with syntactic
deviance and politeness formula for making the proposal.
(f) Appropriateness of Speech Act: fully functional (3), functional but with minor
delay or error (2), minor functional contribution (1), not functional at all (0):
Appropriate performance for providing background knowledge. Nonstandard
utterance missing an action-descriptive term used for making a proposal. This is
ambiguous and requires clarification. As explicit action descriptors were defined
as target of the LAG, the score is 1 (without such a constraint, the score would be
2, as communicative success is reached).