ISSN 88-097 (Online) Commun Sci Disord 06;():0- Original Article http://dx.doi.org/0.96/csd.6 Treatment Efficacy of Semantic eature Analyses for Persons with Aphasia: Evidence from eta-analyses Se Jin Oh, Bora Eom, Chaewon Park, Jee Eun Sung Department of Communication Disorders, Ewha Womans University, Seoul, Korea Correspondence: Jee Eun Sung, PhD Department of Communication Disorders, Ewha Womans University, 5 Ewhayeodae-gil, Seodaemun-gu, Seoul 0760, Korea Tel: +8--77-08 ax: +8--77- E-mail: jeesung@ewha.ac.kr Received: April 5, 06 Revised: ay 5, 06 Accepted: ay 0, 06 This work was supported by the BK Plus Project funded by the inistry of Education of Korea. Objectives: Semantic feature analysis (SA) is a treatment to improve word retrieval ability by strengthening impaired semantic networks. A large number of studies have reported the efficacy of SA treatment on trained items, but its generalization effects on untrained items, discourse production or standardized language measures are controversial. Through the use of meta-analyses, the current study aimed to provide a systematic review of the treatment and generalization effects of SA for individuals with aphasia. ethods: A systematic search based on 5 databases (DBPIA, RISS, EBSCOhost, ProQuest, Pubed) identified studies which met the inclusion criteria. Effect sizes were calculated using Cohen s d and robust improvement rate difference for naming and discourse production. We analyzed the standardized mean difference for standardized language measures. Results: Results demonstrated medium to large effect sizes for trained items, but small effect sizes for untrained items. or discourse production, effect sizes varied from small to large depending on the types of outcome measures. SA treatment approach contributed to improving overall language ability, but its generalization effects onto naming domains from standardized language tests seem to be limited. Conclusion: SA treatment was effective for improving naming ability on trained items and increasing overall language ability. However, its generalization effects were relatively limited for untrained items, discourse production and standardized naming tests. These results suggest that researchers and clinicians should consider several factors which may affect the treatment efficacy of a SA approach for individuals with aphasia. Keywords: Aphasia, Naming, Semantic feature analysis, eta-analysis 실어증은언어습득이후대뇌언어반구의손상으로인해발생하는언어장애이다 (cneil & Pratt, 00). 실어증의여러증상들중에서이름대기장애는중증도및실어증유형과상관없이실어증환자들에게서폭넓게, 지속적으로나타나는것으로보고되고있으며, 의사소통에미치는영향이크다는점에서실어증치료분야에서중요한이슈가되어왔다 (Boyle, 004; Coelho, chugh, & Boyle, 000; Goodglass & Baker, 976; Goodglass & Wingfield, 997). 이름대기장애는의미및음운등다양한네트워크의손상으로인해나타날수있으며 (Butterworth, 989; Caramazza, 997; Dell, Schwartz, artin, Saffran, & Gagnon, 997; oygel & Dell, 000; Goldrick & Rapp, 007; Levelt, Roelofs, & eyer, 999; Starreveld & La Heij, 996), 이에대한치료는크게의미네트워크를활 성화하는방법과음운치료에집중하는치료방법으로나뉘어져시행되어왔다. 본연구에서는이중에서도의미네트워크활성화에기반을둔치료방법을중점적으로살펴보고자한다. 이름대기장애의치료를위해의미네트워크의활성화에중점을두는치료접근법은의미네트워크가개념을구성하는자질들 (conceptual features) 로이루어져있으며, 단어를인출하기위해서는관련된의미자질들이활성화되어야하고 (Dell et al., 997), 이러한의미자질들을충분히활성화시키지못하거나인출하는데어려움이있을때이름대기장애가발생한다고본다 (Chapey, 008; Wilshire & Coslett, 000). 이러한점에서이름대기장애에대한치료는손상된의미네트워크를강화시켜, 단어인출능력을향상시키고이와더불어단어인출의어려움을대체할수있는의미적처 0 http://www.e-csd.org Copyright 06 Korean Academy of Speech-Language Pathology and Audiology This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
실어증환자를위한의미자질이름대기중재효과에관한메타분석 오세진외 리능력또한향상될수있도록하는데중점을둔다 (Raymer & Rothi, 00). 의미자질 (semantic feature analysis, SA) 중재는의미적접근의대표적인치료법중의하나로목표단어와관련된의미자질들을산출하도록함으로써목표단어주변에있는의미네트워크를활성화시켜손상된의미체계의회복을유도하고, 목표단어인출의가능성을증가시키는데목표를둔다 (Boyle & Coelho, 995; Coelho et al., 000; addy, Capilouto, & ccomas, 04). SA 중재를위해임상가는대상자에게목표단어를나타내는그림을제시하며이름대기를요청한후, 목표단어와의미적으로연관되어있는의미자질들을산출하도록유도한다. 이때사용되는의미자질들은목표단어가속한상위범주나용도, 행위, 물리적속성등으로목표단어가동일한의미범주에속한다른항목들과구별되게하는중요한자질들로구성된다. 이처럼목표단어와관련된의미자질을반복적으로산출하도록하는것은목표단어로의접근성을향상시키기위해서일뿐만아니라단어인출이어려운상황에서관련된의미자질로접근하게하는전략의사용을자동화시키기위함이다 (Boyle, 004). 관련된의미자질들을산출한후에는다시목표단어에대한이름대기를요청하여산출되는단어의정확도로중재효과를평가한다. SA 중재는원래외상성뇌손상환자들의인지및의사소통손상을치료하기위해제안되었으며 (Haarbauer-Krupa, oser, Smith, Sullivan, & Szekeres, 985), assaro와 Tompkins (994) 에서의미자질훈련에대한치료효과가보고되었다. 이후, SA 중재는실어증환자들의이름대기치료에도도입되어이름대기능력향상에효과가있음이보고되었다 (Boyle, 004; Boyle & Coelho, 995; Coelho et al., 000; Conley & Coelho, 00; DeLong, Nessler, Wright, & Wambaugh, 05; Hashimoto & rome, 0; Peach & Reuter, 00; Rider, Wright, arshall, & Page, 008; Wambaugh, auszycki, Cameron, Wright, & Nessler, 0; Wambaugh, auszycki, & Wright, 04). SA 중재의효과를입증하려고했던연구자들은중재명사에대한치료효과뿐만아니라일반화효과에도많은관심을보여왔다. 이는 SA 중재가의미네트워크를강화시키는것에목표를둔다는점에서이미여러연구에의해검증된중재항목에대한이름대기능력뿐만아니라비중재항목에대한이름대기능력이나담화 (discourse) 수준에서의어휘-의미정보처리능력을향상시키는데에도기여할수있다고판단했기때문이다 (DeLong et al., 05). 또한 SA 접근법이의사소통능력전반의향상에목표를두고개발되었고 (Haarbauer-Krupa et al., 985), 실어증중재의궁극적인목표가자연스러운맥락으로의일반화 (Thompson, 989) 라는점을 고려해볼때, SA 중재로인한일반화효과는분석될가치가있다고볼수있다. SA 중재의일반화효과를알아보기위해연구자들은비중재항목에대한이름대기능력이나담화수준에서의어휘- 의미정보산출능력, 또는전반적인언어능력에미치는영향에관심을기울여왔다. 그러나이러한일반화효과에대해서는상이한연구결과들이보고되어왔다 (Kiran, 008; Raymer & Rothi, 00). Boyle과 Coelho (995) 는경도의비유창실어증환자에게 SA 중재를실시하여중재및비중재이름대기과제에서나타난효과를분석하였고, 그결과로중재항목과비중재항목모두에서이름대기능력이향상되었음을밝히며중재하지않은항목에대한일반화효과를보고하였다. 이와유사하게 Coelho 등 (000), Conley 와 Coelho (00), Boyle (004) 연구들에서도 SA 중재를실시한후, 중재하지않은항목에대해서이름대기수행력이증가하는현상을보고하였다. 그러나 Rider 등 (008) 은 명의실어증환자들을대상으로대상자들에게익숙한상황으로부터중재항목들을설정하여 SA 중재를실시한후중재및비중재명사들에대한중재효과를알아보았다. 그결과, 중재명사의경우이름대기수행력이증가하는현상을보였으나, 비중재명사에대해서는 명의대상자모두에게서효과가전혀나타나지않았거나미미한효과만보이는것으로나타났다. Wambaugh와 erguson (007) 그리고 Kristensson, Behrns와 Saldert (05) 연구에서도비중재항목에대한일반화효과는제한적이었음을보고하였다. 담화수준에서의일반화효과는일상생활에서언어사용의향상을더직접적으로예측할수있다는점에서 SA 치료의효과를평가하는데중요하게다루어져야할요소라할수있다 (Peach & Reuter, 00). 담화수준에서의의미정보산출에미치는영향을다룬연구들은자발화과제에서의단어및유효정보단위 (correct information unit, CIU) 산출능력에중점을두었으며측정항목의종류에따라서상이한결과들을제시해왔다. Boyle (004) 은명칭실어증환자와베르니케실어증환자에게 SA 중재를실시한후, 자발화과제 (Brookshire & Nicholas, 994) 에서의일반화효과를분석하였다. 분석결과, 대상자에따라지연되어산출되는단어의수가감소하여분당산출되는 CIU 수가증가하거나총 CIU 수가증가하는효과가나타났으나, 그외의항목에대해서는변화가없어담화수준에서의 SA 중재로인한일반화효과는제한이있음을보고하였다. Antonucci (009) 및 alconer와 Antonucci (0) 연구에서는 SA 그룹중재를실시하여자발화과제 (Nicholas & Brookshire, 99) 에서의단어및 CIU 산출의정확도와효율성을평가하였다. 자발화과제에서의단어산출수, CIU 총수, 분당산출된 CIU 수, 전체정보당 CIU 비율, 명사및동사산출비율을분 http://dx.doi.org/0.96/csd.6 http://www.e-csd.org
Se Jin Oh, et al. Treatment Efficacy of Semantic eature Analyses 석한결과, 대상자에따라서수행의향상을보인항목은달랐으며, 몇몇항목에대해서만향상이나타났다. 이러한결과를통해연구자들은 SA 중재가개별대상자에게미치는효과의정도는다르지만목표어휘의의미적지식에접근하는정확도나효율성에기여하는바가있음을제안하였다. Rider 등 (008) 연구에서는자발화과제에서산출된중재단어의수가중재전에비해증가하였으나이러한현상이이야기다시말하기나절차묘사하기와같은과제수행에서는나타나지않았다고주장하며담화수준으로의일반화효과는제한이있음을보고하였다. SA 중재가표준화검사의수행에미친일반화효과에대해서도문헌들은다양한결과를보고하였다. 표준화검사점수상에향상이있었다고보고한문헌들이많았으나실시된검사의종류에따라상이한결과들이보고되었다. Rider 등 (008) 은 SA 중재후웨스턴실어증검사 (Western Aphasia Battery, WAB; Kertesz, 98), 보스톤이름대기검사 (Boston Naming Test, BNT; Kaplan, Gooodglass, & Weinstaub, 00) 등의표준화검사의수행력변화를살펴보았는데, 전반적인점수상의변화는크지않았으나일부대상자들의 WAB 실어증지수 (Aphasia Quotient, AQ) 와 BNT 점수에서약간의향상이있었음을제안하였다. Antonucci (009) 에서는대상자모두에게서 WAB AQ 점수가소폭증가하는경향을보였고, BNT 점수의경우에는점수상의변화는크게없었으나의미적접근의향상을보여주는오류패턴상의질적인변화를보고하기도하였다. 한편, Kiran (008) 연구에서는중재항목의수행력변화와비중재항목및 WAB AQ, BNT, Psycholinguistic Assessment of Language Processing in Aphasia (PALPA; Kay, Lesser, & Coltheart, 99), Pyramids and Palm Tree (PAPT; Howard & Patterson, 99) 점수간의상관관계를분석하였다. 분석결과, 한명의대상자에게서중재항목의이름대기점수와 PALPA 및 PAPT 검사점수간에유의한상관관계가있었음을제시하며, SA 중재가표준화검사수행력향상에기여할수있지만그효과가제한적임을보고하였다. 이처럼 SA 중재효과에관한연구들은중재항목에대해서는효과가있다는비교적일관성있는결과를보여주고있으나, 중재하지않은과제및표준화검사의수행에미치는효과에있어서는상이한결과를제시하고있다. 따라서 SA 중재가실어증환자들의어휘-의미정보처리능력의향상에어느정도기여하는지에대한종합적결론을도출하기에는제한이있다. 또한이러한 SA 중재의효과를보고한연구들은대부분단일대상연구설계로진행되었고연구간실험조건이다르다는점에서개별연구결과를종합한효과정도를파악하기가어려운점이있다. addy 등 (04) 은 SA 중재에대한체계적문헌연구를실시하였는데, 신경학적손상을동 반한환자들에게 SA 중재를적용한 편의연구들을분석한결과, SA 중재가중재받은항목에대한대면이름대기능력을향상시키는데효과적인중재법임을보고하였다. 그러나 addy 등 (04) 의연구에서는실어증뿐만아니라외상성뇌손상대상자들을포함하였으며, 중재하지않은과제및표준화검사에서의일반화효과는분석하지않았다. 또한효과크기를측정하는방식에있어서기초선단계에서의이상치의영향을많이받고효과크기가과대평가될우려가있는비중복비율 (percentage of non-overlapping data, PND; Scruggs, astropieri, & Casto, 987) 방식을이용하여분석결과를제시하였다 (Parker, Vannest, & Brown, 009). 따라서본연구에서는지금까지실어증환자들을대상으로 SA 중재효과를보고한문헌들을종합하여 SA 중재의치료효과를살펴보고, 비중재명사이름대기, 담화과제및표준화검사수행에미치는일반화효과를분석하고자하였다. 또한이상치의영향을최소화할수있는효과크기측정법인개선율차이 (improvement rate difference, IRD; Parker, Vannest, & Davis, 0) 방식을보다개선한형태인 robust IRD 방식을적용하여메타분석을실시하였다. 본연구의연구질문은다음과같다. 첫째, SA 중재가실어증환자의중재명사이름대기에미치는효과는어떠한가? 둘째, SA 중재가실어증환자의비중재명사이름대기에미치는일반화효과는어떠한가? 셋째, SA 중재가실어증환자의담화수준에서의단어및의미정보산출에미치는일반화효과는어떠한가? 넷째, SA 중재가실어증환자의표준화검사수행에미치는일반화효과는어떠한가? 연구방법문헌검색및선정실어증환자들을대상으로 SA 중재효과를살펴보기위하여 06년 월에국내외데이터베이스를통해관련연구들을수집하였다. 문헌선정기준은실어증환자를대상으로명사자극을사용하여 SA 중재를실시한단일대상연구만을분석문헌으로선정하되분석대상자는뇌졸중발병후 6개월이상이경과한단일언어사용자로발병전손잡이가오른손잡이며좌반구뇌졸중으로인한실어증환자만을포함하였다. 문헌검색을위해국외 (EBSCOhost, ProQuest, Pubed) 개, 국내 (DBPIA, RISS) 개, 총 5개의데이터베이스를활용하였다. 문헌검색조건은학술지문헌으로제한하였으며검색어는국외데이터베이스는 aphasia and semantic http://www.e-csd.org http://dx.doi.org/0.96/csd.6
실어증환자를위한의미자질이름대기중재효과에관한메타분석 오세진외 feature analysis or SA treatment or SA therapy or SA intervention 으로국내데이터베이스는 aphasia and semantic feature analysis 으로입력하여문헌을수집하였다. 문헌검색을통해 Pubed에서 8편, ProQuest에서 88편, EB- SCOhost에서 7편, RISS에서 0편, DBPIA에서 0편, 총 5편의연구가검색되었다. 이중중복된문헌 48편을제외한나머지연구 05편의제목과초록을통해 SA 중재와관련성이없는연구 74 편을추가로제외하였다. 또한연구대상이실어증환자가아닌문헌 편과단일대상연구외실험설계방법을사용한문헌 편을분석에서제외하였으며출판형태가리뷰에해당하는 편, 대상자가단일언어사용자가아닌 편을제외하였다. 이후, 나머지 편의연구전문확인을통해 SA 중재외다른중재가복합적으로실시된연구 6편, 중재자극이명사가아닌경우 ( 예 : 동사 ) 4편을제외하였다. 또한 SA 중재효과를살펴보았지만언어평가를실시하지않은경우또는그값을제시하지않은연구 편이제외되었다. 최종적으로실어증환자를대상으로 SA 중재를실시한단일대상연구중중재에따른언어효과를살펴본총 편의문헌이선정되었다. 문헌선정및제외기준은 Table 에제시하였고선정과정과흐름도는 igure 과같다. 연구의질평가선정된문헌의질적평가를위해 Tate 등 (008) 의단일대상연구 (single case experimental design, SCED) 평가척도를사용하였다. 평가항목으로연구대상자병력, 목표행동에대한정확한정의, 효 과적인실험디자인, 안정적인기초선및중재효과측정, 자료기록 Table. Criteria for inclusion and exclusion Inclusion criteria Research design Single-subject design Exclusion criteria Group design Qualitative research Pre-post case study Participant Aphasia due to stroke Sensory deficits Severe dysarthria or apraxia History of neurological disease TBI Right-hemisphere stroke Left-handed ultilingual Less than 6 months since stroke onset Intervention approach SA, modified SA Stimuli Noun Verb Dependent measures WAB AQ BNT Confrontation naming Percentage of nouns retrieved Percentage of verbs retrieved Number of CIUs (average) CIUs per minute Percentage of CIUs SA with other intervention approaches Other measures TBI= traumatic brain injury; SA= semantic feature analysis; WAB= Western Aphasia Battery (Kertesz, 98, 006); AQ= Aphasia Quotient; BNT= Boston Naming Test (Kaplan, Goodglass, & Weintraub, 98, 00); CIUs= correct information units. Records identified through database search (N=5) Inclusion criteria Subject: aphasia Intervention: SA Design: single-subject design Outcomes: WAB AQ, BNT, confrontation naming, # words (average), % nouns retrieved, % verbs retrieved, # CIUs (average), CIUs/min, %CIUs Pubed (N=8) ProQuest (N=88) EBSCOhost (N=7) RISS (N=0) DBPIA (N=0) Records removed if duplicated (N=05) Records after on basis of title and abstract (N=) ull-text available (N=) Studies included in meta analysis (N=) Records exluded Non-relevant SA (N=74) Non-relevant aphasia (N=) Not a single-subject design (N=) Review research (N=) Not a monolingual (N=) Ab stract, poster, thesis, conference paper (N=0) Records excluded SA with other intervention approaches (N=6) Verb treatment (N=4) Language test scores not provided (N=) igure. lowchart of studies included from database search. SA= semantic feature analysis; WAB= Western Aphasia Battery (Kertesz, 98, 006); AQ = Aphasia Quotient; BNT= Boston Naming Test (Kaplan, Goodglass, & Weintraub, 98, 00); CIUs= correct information units. http://dx.doi.org/0.96/csd.6 http://www.e-csd.org
Se Jin Oh, et al. Treatment Efficacy of Semantic eature Analyses Table. Assessment of methodological quality of single-case experimental designs No. Title SCED quality score Antonucci (009) 8.5 Boyle (004) 0.5 Conley & Coelho (00) 8 4 DeLong et al. (05) 0 5 alconer & Antonucci (0) 8 6 Hashimoto & rome (0) 9.5 7 Kiran (008) 0.5 8 Kiran & Thompson (00) 0.5 9 Kristensson et al. (05) 0.5 0 Rider et al. (008) 0 Wambaugh et al. (0) 0.5 SCED= single-case experimental design. 의정확성, 평가자간신뢰도실시, 독립된평가자의유무, 통계분석 실시, 반복측정가능여부, 일반화효과등의 개의항목을분석하 였다. 각항목에대해 0 점 ( 부적절 ) 에서 점 ( 적절 ) 으로판별을하고 각연구별로총점을산출하였다. 분석결과분석된연구들의점수 범위는 8 점에서 0.5 점, 평균점수는 9.7 점으로나타나, 종합적인분 석논문의대상으로적합한것으로평가되었다 (Lock & Amstrong, 997). 각문헌별결과는 Table 에제시하였다. 코딩및자료분석 본연구에서는선정된연구 편의 SA 중재효과를살펴보기 위해각문헌에서제시한중재및비중재명사이름대기결과와담 화수준에서자발화산출결과값 ( 평균단어산출수, 명사및동사 산출비율, 평균 CIU 수, 분당 CIU 수, CIU 비율 ) 을종속변인으로 살펴보았다. 각과제에따른대상자별효과크기는선정된연구에서 Cohen s d (Beeson & Robey, 006) 값이제시된경우그값을사용 하였고, 그값이제시되지않았거나계산할수없는경우 robust IRD 를계산하여분석하였다. Cohen s d 는중재단계의평균값에 서기초선단계의평균값을뺀값을기초선평균표준편차 SD 로나 눈값을말한다. Robust IRD 는더욱신뢰성있는결과를얻기위하 여 IRD 를보완하여변형한것으로기초선과중재단계의중복된 자료점들을각단계에동일하게나눠준후, 중재단계에서기초선 단계보다향상된정도로계산된값을말한다 (Parker et al., 0). 효과크기의해석을위해 Cohen s d 의경우 Beeson 과 Robey (006) 의기준을적용하여치료효과크기를높은 (large, d 0.), 중간 (medium, 7.0 d 0.0), 낮은 (small, 4.0 d 6.9) 으로구분하였 다. Robust IRD 의경우 Parker 등 (009) 의기준을적용하여점수가.5 미만은효과크기가의심스럽거나낮은효과로,.5-.7 미만은중간 효과크기로,.7 이상은높은효과크기로구분하였다. SA 중재가표준화언어검사수행력에미치는효과를분석하기위하여선정된문헌에서실어증환자의전반적인언어능력을측정한 WAB의 AQ와명사대면이름대기능력을측정한 BNT의중재전 후점수를종속변인으로사용하였다. 효과크기는통계프로그램인 CA (Comprehensive eta-analysis ver. ) 를사용하여분석하였다. 각문헌의연구자, 출판년도, 독립변인 (SA 중재 ) 및종속변인 (WAB AQ, BNT 점수 ) 의통계적수치 ( 중재전 후평균, 표준편차, 표본크기, r값 ) 를입력하여분석하였다. 각과제에따른연구결과별효과크기는표준화된평균차이 (standardized mean difference, SD) 를산출하였으며, 95% 신뢰수준 (confidence intervals) 을계산하였다. 선정된문헌의연구방법, 표본등이다양하다는점을인정하여무선효과모형 (random-effects model) 을적용하여결과를산출하였다 (Borenstein, Hedges, Higgins, & Rothstein, 009). 신뢰도평가중재및중재일반화효과크기를 robust IRD로계산한경우제 연구자와제연구자간의평가자간신뢰도를산출하였다. 전체문헌대상자의 robust IRD를 명의저자가개별적으로계산하였을때일치율은 00% 였다. CA를사용하여효과크기를산출한전반적인언어검사의경우총 명의저자가전체 편의연구를개별적으로코딩후효과크기를산출한결과일치율은 00% 였다. 연구결과선정된연구의특성본연구에서분석된논문은총 편이었으며, 각연구별대상자의수는 명에서 9명으로총 6명의실어증환자들의중재결과가본연구에서분석되었다. 대상자의연령은 0세에서 80세까지다양했으며, 실어증발병기간또한 7개월부터 84개월까지다양한분포를보였다. 대상자들의실어증유형은명칭실어증, 브로카, 베르니케, 전도실어증, 연결피질운동실어증등으로다양한유형의대상자들이참여하였다. SA 중재를실시한기간은평균 주 ( 범위 : 5-8주 ), 중재회기수는평균 0회 ( 범위 : 9-8회 ), 한회기의시간은평균 75분 ( 범위 : 45-0분 ) 이었다. SA 중재의효과를측정하기위하여본연구주제와관련하여사용된과제는다음과같다. 중재및비중재항목에대한효과분석을위해서대면이름대기과제가사용되었으며, 종속변수는반응의정확도였다. 담화수준에서의일반화효과측정을위해서는그림자극을보고설명하는과제 (Brookshire & Nicholas, 994; Da- 4 http://www.e-csd.org http://dx.doi.org/0.96/csd.6
실어증환자를위한의미자질이름대기중재효과에관한메타분석 오세진외 Table. The effects of SA on confrontation naming for treated and untreated items Study Participant Aphasia type Effect size for treated items Effect size for untreated items Cohen s d a Robust IRD b agnitude of effect Cohen s d a Robust IRD b agnitude of effect Boyle (004) Wernicke.9 Conley & Coelho (00).8.79 DeLong et al. (05) 4. 6.8 Wernicke.88 5.6 p 0.74.8 arginally small p4.97 4.44 Hashimoto & rome (0).94. Kiran (008).86.54 p.6.9 p4.67.5 p5.4 -.4 - Kiran & Thompson (00) luent.78.65 luent.96 p luent.84 -.8 - p4 luent.9.77 Kristensson et al. (05) Wernicke. -.5 - ixed non-fluent.47 -.7 - p.47.09 Rider et al. (008) Transcortical motor.86 arginally small -.88 - Transcortical motor 5.54 small. arginally small p.97 arginally small arginally small Wambaugh et al. (0) 5. 7.95 edium p 9.8 edium p4 7.48 edium p5.6 arginally small p6 5.0 p7 7.79 edium p8 7. edium p9 Wernicke 9.6 edium SA= semantic feature analysis; IRD= improvement rate difference. a effect, 4.0 d 6.9; medium effect, 7.0 d 0.0; large effect, d 0.. b effect, IRD <.5; moderate effect,.5 IRD <.7; large effect, IRD.7. vis, 005; Nicholas & Brookshire, 99) 가사용되었으며, 종속변수는평균단어산출수, 명사및동사산출비율, 평균 CIU 수, 분당산출된 CIU 수, CIU 비율이었다. 표준화검사에서의일반화효과측정을위해서는언어의전반적인능력을측정하는 WAB (Kertesz, 98, 006) 과 BNT (Kaplan, Goodglass, & Weintraub, 98, 00) 가사용되었으며 WAB AQ 와 BNT의점수를종속변수로사용하였다. 개별연구에대한정보는 Appendix 에제시하였다. SA 중재의효과크기분석 SA 중재가중재명사이름대기에미치는영향 SA 중재가중재명사의이름대기에미치는평균효과크기를분석한결과, 개별연구에서제시된 Cohen s d 점수를기준으로 d= 7.76 (SD = 4.94, N=6) 의중간정도의효과크기를보이는것으로나타났으며, 효과크기가제시되지않은연구의경우 robust IRD 점수를분석한결과.76 (SD =., N=6) 으로높은효과크기를보이는것으로나타났다 (Table ). SA 중재가비중재명사이름대기에미치는영향중재하지않은명사에대한일반화효과를분석한결과, Cohen s d 점수기준 d=.0 (SD =.65, N= 7) 로낮은효과크기를보이는것으로나타났고, robust IRD 점수또한.4 (SD =.49, N=6) 로낮은효과크기를보이는것으로나타났다. 이름대기수행에대한각연구의대상자별효과크기는 Table 에제시하였다. http://dx.doi.org/0.96/csd.6 http://www.e-csd.org 5
Se Jin Oh, et al. Treatment Efficacy of Semantic eature Analyses SA 중재가담화수준에서의단어및의미정보산출에미치는영향 SA 중재가담화수준에서의자발화산출과제에서단어산출수에미치는영향을분석한결과, 총단어산출의경우 robust IRD 점수가.48 (SD =.4, N= 4) 로낮은효과크기를나타낸반면, 산출된명사및동사의비율은모두.75 (SD noun =.7, N = 4; SD verb =., N= 4) 로높은효과크기를보이는것으로나타났다. CIU 관련변인의경우, 자발화에서산출된의미정보중평균 CIU 수에대한 robust IRD 점수는.6 (SD =.4, N= 6) 으로중간정도의효과크기를보였으나, 분당 CIU 수및전체의미정보에대한 CIU 비율의점수는각각.48 (SD =.44, N= 6) 과.44 (SD =.7, N = 6) 로낮은효과 Table 4. The effectiveness of SA on number of words, percentage of nouns retrieved, percentage of verbs retrieved Study Participant Aphasia type Antonucci (009) alconer & Antonucci (0) Transcortical motor Number of words (average) Percentage of nouns retrieved Percentage of verbs retrieved Robust IRD a 0..58 agnitude of effect - Robust IRD a.67.67.67 agnitude of effect Robust IRD a.67. agnitude of effect SA= semantic feature analysis; IRD= improvement rate difference. a effect, IRD <.5; moderate effect,.5 IRD <.7; large effect, IRD.7. Table 5. The effectiveness of SA on number of CIUs (average), CIUs per minute, percentage of CIUs Study Participant Aphasia type Antonucci (009) Boyle (004) alconer & Antonucci (0) Wernicke Transcortical motor Number of CIUs (average) CIUs per minute Percentage of CIUs Robust IRD a 0.4. agnitude of effect - Robust IRD a 0.7.54.7 agnitude of effect - Robust IRD a 0..54.67. agnitude of effect - SA= semantic feature analysis; CIUs= correct information units; IRD= improvement rate difference. a effect, IRD <.5; moderate effect,.5 IRD <.7; large effect, IRD.7. Study name Outcome Statistics for each study Std diff in means and 95% CI Std diff Lower Upper in means limit limit Z-Value p-value Antonucci(009) BNT 0.05-0.07 0.087 0.794 0.47 Antonucci(009) WAB_AQ 0. 0.049 0.74.59 0.000 alconer & Antonucci(0) BNT 0.0-0.09 0.08.4 0. alconer & Antonucci(0) WAB_AQ 0.05-0.05 0.076 0.985 0.5 Kiran & Thompson (00) BNT.4-0.64.456.68 0.7 Kiran & Thompson (00) WAB_AQ 0.655 0..098.90 0.004 Kiran(008) BNT 0.960 0.46.575.065 0.00 Kiran(008) WAB_AQ 0.677 0.8 0.97 4.50 0.000 Rider(008) BNT 0.0 0.00 0.65.0 0.04 Rider(008) WAB_AQ 0.07-0.089 0. 0.87 0.8 0.4 0.05 0.5. 0.00 -.00 -.00 0.00.00.00 pre post igure. orest plot of the effects of semantic feature analysis on standardized language tests for aphasia. 6 http://www.e-csd.org http://dx.doi.org/0.96/csd.6
실어증환자를위한의미자질이름대기중재효과에관한메타분석 오세진외 Table 6. The effectiveness of SA on standardized language tests for aphasia Type SD 95% CI [LL, UL] p-value Overall.4.05,.5.00 WAB AQ.88.05,.5.007 BNT.098 -.0,.6.07 SA=semantic feature analysis; SD=standardized mean difference; CI=confidence interval; LL=lower limit; UL=upper limit; WAB=Western Aphasia Battery (Kertesz, 98, 006); AQ=Aphasia Quotient; BNT=Boston Naming Test (Kaplan, Goodglass, & Weintraub, 98, 00). 크기를보이는것으로나타났다. 담화수준에서의단어및의미정 보산출과관련된각연구의대상자별효과크기는 Tables 4 와 5 에 제시하였다. SA 중재가표준화검사수행에미치는영향 SA 중재가전반적인언어능력의변화에미치는영향을알아보 기위해대상자들의사전 - 사후차이의평균, 상관계수, 표본크기를 이용하여표준화된평균차이를산출한결과를 forest plot 으로제 시하였다 (igure ). 분석결과, 효과크기 SD =.4, p<.0, 95% 신뢰구간 [.05,.5] 으로 SA 중재가표준화검사의수행에미치는 효과가유의한것으로나타났다. 분석에포함된검사의유형별로 분석한결과, WAB AQ 점수에미치는효과는효과크기 SD =.88, p<.0, 95% 신뢰구간 [.05,.5] 으로유의한것으로나타났으나, BNT 점수에미치는효과는효과크기 SD =.098, p>.05, 95% 신 뢰구간 [-.0,.6] 으로유의하지않은것으로나타났다 (Table 6). 논의및결론 본연구는메타분석방법을사용하여실어증환자들에게실시 된 SA 중재가이름대기에미치는치료효과를살펴보고, 중재하 지않은과제및표준화검사의수행에미치는일반화효과를검증 하고자하였다. 문헌연구포함기준에따라 개의연구를분석한 결과, 종속변수에따라상이한효과크기가산출되었다. 중재항목 에대한치료효과는중간 - 높은수준의효과크기를보인반면, 일 반화효과에대해서는분석된측정치에따라다양한결과가도출 되었다. SA 중재가중재항목의이름대기수행력에미치는효과가높다 는결과는 SA 중재가이름대기향상에효과가있다는기존의연 구결과및이에대한체계적문헌분석을실시한 addy 등 (04) 의연구와일치한다. 이러한결과는목표단어와관련이있는의미 자질들을반복해서산출하도록하여목표단어주변의의미네트 워크를활성화시키는 SA 중재방법이이름대기치료에유용하다 는것을뒷받침한다 (Boyle, 004). 반면, 비중재항목의이름대기에관해서는일반화효과가낮은것으로나타났다. 이는비중재명사에대한일반화효과를보고한연구 (Boyle, 004; Boyle & Coelho, 995; Coelho et al., 000) 와일반화효과가제한적이었음을보고한연구 (Pring, Hamilton, Harwood, & acbride, 99; Rider et al., 008) 가혼재된양상을반영한결과로보인다. 비중재항목에대한일반화효과가일어나지않은부분에대해서는다양한요인들로설명될수있다. DeLong 등 (05) 은프로브 (probe) 동안비중재명사에노출된횟수가많을수록, 목표단어들이속한범주가다양할수록비중재명사에대한일반화가더촉진된다고하였다. 또한 Kiran과 Thompson (00) 은중재항목과비중재항목의의미적연관성이높을수록일반화가잘일어난다고주장하였고, Coelho 등 (000) 은대상자의언어적인특성이일반화에영향을미칠수있음을제안하였다. 본연구에서분석된문헌들의경우, 연구에따라비중재명사에노출된횟수나중재범주가다양하였고, 중재항목과비중재항목의의미적연관성또한연구들마다상이하였다. 또한대상자들의실어증유형이다양했다는점에서이들의언어적특성및개인차 (individual variability) 가일반화효과에영향을주었을것으로생각된다. 이러한여러가지변수들이일반화효과에영향을미쳐비일관적인효과크기가도출되었을가능성이있다. 담화수준으로의일반화효과에대해서는분석된항목별로다양하게나타났으나, 효과크기가크지않은경향을보였다. 명사와동사의산출비율은대체로향상된결과를보였지만, 단어산출수나유효정보단위관련변수에있어서는효과크기가비교적작았다. 본연구에서분석된문헌들중담화맥락에서의일반화효과를다룬문헌은단어산출의경우 편, CIU 산출의경우에는 편에불과하여본연구의결과만으로이에대한일반화효과를단정짓기는어렵지만, 개별단어중재를통해담화수준에서의수행력향상을기대하기어렵다는것은여러선행연구들을통해제안된바있다 (De- Long et al., 005). Goodglass (998) 는대면이름대기또는정의하기과제가자발화에서의단어인출을촉진하기에적합하지않다는제안을하였다. 또한 Ledoux, Camblin, Swaab 그리고 Gordon (006) 에따르면, 그림설명하기와같은담화수준과제에서는문맥을통해유추가능한단서들을활용할수있는반면, 대면이름대기와같은단어수준의과제에서는문맥에서오는의미점화 (semantic priming in context) 와같은관련정보가매우제한적이다. 따라서, 담화수준으로의일반화효과를기대하기위해서는의미맥락이있는과제를활용한중재가필요하다고주장하였다. 실제로 ayer 와 urray (00) 및 Peach와 Reuter (00) 는담화수준에서 SA 중재 http://dx.doi.org/0.96/csd.6 http://www.e-csd.org 7
Se Jin Oh, et al. Treatment Efficacy of Semantic eature Analyses 를실시했을때, 단어수준에서의중재에비해담화수준에서의단어인출능력이훨씬더향상되었다는결과를보고하였다. 표준화검사에대한일반화효과는언어전반적인능력부분이나실어증지수에서유의한향상이관찰되었으나, 이름대기과제에서는유의한효과가나타나지않았다. SA 중재후표준화검사에서의향상을보고한연구들은이러한일반화효과가 SA 중재과정에서반복적으로이루어지는의미정보의처리및의미자질의판단을통해전반적인의미처리능력이향상된것에기인한다고주장하였다 (Kiran, 008; Kiran & Thompson, 00). 실제로 Kiran (008) 은표준화검사하위영역들중향상을보인영역들은의미자질이나항목간의관계를판단하는검사들이었음을보고하면서, SA 중재가전반적인의미처리능력의향상에기여하는유용한중재법임을제안하였다. 중재를통해향상된이름대기능력이표준화된대면이름대기검사의항목으로일반화되지못한결과와관련하여 Kiran과 Thompson (00) 은 SA 중재의중재된범주외의항목으로의일반화효과는제한이있다고주장하였다. SA 중재의특성상특정범주의단어에집중하여중재가진행되기때문에대상자들은해당범주의단어에만노출이되어다양한범주가제공되는이름대기과제에서는일반화효과를기대하기어렵다는것이다. 본연구는 SA 중재의치료효과및일반화효과를보고한연구들을체계적으로분석하여 SA 중재가실어증환자들을대상으로중재명사의이름대기능력을향상시키는데높은효과를보이는중재법임을보여주었다. 그러나비중재명사에대한일반화효과는낮은것으로나타났으며, 담화수준및표준화검사에관해서는항목별로효과크기가상이하다는통합된결론을도출하였다. 담화수준에서결과분석에포함된연구가 -편으로상대적으로제한적임을고려할때, 이에대한일반화된결과해석에는제한점이있다. 또한본연구에서종속변수로본여러영역들의연구수가달라영역별효과크기에대한정확한비교에는한계가있다. 본연구에포함된대상자들은 명을제외하고는모국어가영어인실어증환자들이었기때문에언어적다양성이반영된일반화된결과를도출하지못하였다. 본연구의결과는영어라는언어적특수성이반영된결과일수있다는점에서한국어실어증환자들에게본연구의결과를적용시키는데에는주의가필요하다. 그럼에도불구하고본연구는실어증치료에서큰비중을차지하고있는이름대기중재법중, SA의치료효과크기에대한기초자료를제시하였다는점에서근거기반치료 (evidence-based practice) 확립에기여할수있을것으로기대된다. 또한본연구에서제시된 SA 중재의제한된일반화효과에대한결과는시간과비용의제약이따르는치료환경에서중요하게고려되어야할요소라고판단 된다. 예컨대, 이름대기능력의향상을넘어선일반화효과를목표로 SA 중재를적용하는것에는신중한고려가필요할것이다. SA 중재의효과를분석할때, 본연구에서제시하였던일반화에미치는여러요인들, 즉, 대상자의특성, 중재및비중재항목의의미범주, 비중재항목에노출되는횟수등을고려한통합적인판단도필요할것으로보인다. 또한 SA 중재의종합적인일반화효과에대해신뢰도높은결과를얻기위해서는이러한요인들이치료및일반화효과에미치는구체적인영향들에대한추가적인연구가진행되어야할것이다. REERENCES Antonucci, S.. (009). Use of semantic feature analysis in group aphasia treatment. Aphasiology,, 854-866. Beeson, P.., & Robey, R. R. (006). Evaluating single-subject treatment research: lessons learned from the aphasia literature. Neuropsychology Review, 6, 6-69. Borenstein,., Hedges, L. V., Higgins, J., & Rothstein, H. R. (009). Introduction to meta-analysis. Chichester, UK: John Wiley & Sons Ltd. Boyle,. (004). Semantic feature analysis treatment for anomia in two fluent aphasia syndromes. American Journal of Speech-Language Pathology,, 6-49. Boyle,., & Coelho, C. A. (995). Application of semantic feature analysis as a treatment for aphasic dysnomia. American Journal of Speech-Language Pathology, 4, 94-98. Brookshire, R. H., & Nicholas, L. E. (994). Test-retest stability of measures of connected speech in aphasia. Clinical Aphasiology,, 9-. Butterworth, B. (989). Lexical access in speech production. In W. arslen- Wilson (Ed.), Lexical representation and process (pp. 08-5). Cambridge, A: IT Press. Caramazza, A. (997). How many levels of processing are there in lexical access? Cognitive Neuropsychology, 4, 77-08. Chapey, R. (008). Language intervention strategies in aphasia and related neurogenic communication disorders (5th ed.). Baltimore, D: Lippincott Williams & Wilkins. Coelho, C. A., chugh, R. E., & Boyle,. (000). Semantic feature analysis as a treatment for aphasic dysnomia: a replication. Aphasiology, 4, - 4. Comprehensive eta-analysis (Version ) [Computer software]. Englewood, NJ: Biostat. 8 http://www.e-csd.org http://dx.doi.org/0.96/csd.6
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실어증환자를위한의미자질이름대기중재효과에관한메타분석 오세진외 Appendix. Study characteristics Study Experimental design Participant Age (yr) Gender Language PO (mo) Aphasia type Session Antonucci (009) ultiple-baseline design Boyle (004) ultiple-baseline design across behaviors and conditions 5 59 70 80 8 5 4 Wernicke 4 4 4 Time (min) 60-90 60-90 50 75 Duration (wk) 7 7 Session/ week Outcome measurement WAB a AQ BNT a # words (average) % nouns retrieved % verbs retrieved # CIUs (average) CIUs/min % CIUs Confrontation naming (treatment) Confrontation naming (probe) # CIUs (average) CIUs/min % CIUs Conley & Coelho (00) ABA single subject design 57 96 8 60 6 Confrontation naming (treatment) confrontation naming (probe) DeLong et al. (05) ultiple-baseline design across behaviors and participants alconer & Antonucci (0) Hashimoto & rome (0) p p4 ultiple-baseline design ultiple-baseline design across behaviors Kiran (008) ultiple-baseline design across participants and behaviors Kiran & Thompson (00) ultiple-baseline design across participants and behaviors Kristensson et al. (05) ultiple-baseline ABA design across participants 6 54 0 5 55 6 0 84 56 4 Wernicke Transcortical motor 8 4 4 50 50 50 50 90-0 90-0 7 7 Confrontation naming (treatment) Confrontation naming (probe) WAB b AQ BNT a # words (average) % nouns retrieved % verbs retrieved # CIUs (average) CIUs/min % CIUs 7 5 60 Confrontation naming (treatment) Confrontation naming (probe) p p4 p5 p p4 p 55 77 6 47 50 64 6 7 75 7 54 64 0 7 9 8 7 9 8 0 0 0 0 0 4 Swedish Swedish Swedish 99 9 4 6 60 4 luent luent luent luent Wernicke ixed non-fluent 4 7 0 7 0 0 0 0 0 0 0 60 60 60 7 8 5 5-6 5-6 5-6 - - - - -5-5 -5 WAB a AQ BNT a Confrontation naming (treatment) Confrontation naming (probe) WAB a AQ BNT a Confrontation naming (treatment) confrontation naming (probe) Confrontation naming (treatment) Confrontation naming (probe) (Continued to the next page) http://dx.doi.org/0.96/csd.6 http://www.e-csd.org
Se Jin Oh, et al. Treatment Efficacy of Semantic eature Analyses Appendix. Continued Study Experimental design Participant Age (yr) Gender Language PO (mo) Aphasia type Session Rider et al. (008) odified multiple-probe design across behaviors Wambaugh et al. (0) ultiple-baseline design across behaviors and subjects p p p4 p5 p6 p7 p8 p9 7 55 6 58 59 6 47 59 5 66 64 54 6 45 6 6 4 87 65 65 8 9 Transcortical motor Transcortical motor Wernicke 8 0 74 7 4 8 40 80 40 5 8 Time (min) 60 60 60 Duration (wk) Session/ week - - - Outcome measurement WAB a AQ BNT b Confrontation naming (treatment) Confrontation naming (probe) Confrontation naming (treatment) PO = month post onset; session N = number of sessions during intervention; WAB = Western Aphasia Battery (Kertesz, 98 a, 006 b ); AQ = Aphasia Quotient; BNT = Boston Naming Test (Kaplan, Goodglass, & Weintraub, 98 a, 00 b ); CIUs = correct information units; = not available. http://www.e-csd.org http://dx.doi.org/0.96/csd.6
실어증환자를위한의미자질이름대기중재효과에관한메타분석 오세진외 국문초록 실어증환자를위한의미자질이름대기중재효과에관한메타분석오세진 엄보라 박채원 성지은 이화여자대학교언어병리학과배경및목적 : 의미자질 (semantic feature analysis, SA) 중재는의미네트워크를강화시켜단어인출능력을향상시키는실어증이름대기중재법으로중재명사에있어서는비교적일관적인치료효과가보고되고있으나, 일반화효과에대해서는상이한결과가보고되고있다. 따라서본연구는 SA 중재를실시한문헌들을체계적으로분석하여치료및일반화효과에대한종합적인결과를도출하고자하였다. 방법 : 5개의국내외데이터베이스에서기준에적합한 개의논문을선정하여중재및비중재명사와자발화에대해서는 Cohen s d와개선율차이 (improvement rate difference) 를, 표준화언어검사에대해서는표준화된평균차이 (standardized mean difference) 를사용하여효과크기를산출하였다. 결과 : 중재명사에서는중간에서높은수준의효과크기가산출되어 SA 중재가이름대기치료에효과가있는것으로나타났으나비중재명사에서는낮은효과크기가, 자발화에서는측정치에따라다양한효과크기가산출되어일반화효과는제한적인것으로나타났다. 또한표준화검사에서는전반적인언어능력향상에는유의한효과가있었으나이름대기검사에미치는효과는유의하지않았다. 논의및결론 : 본연구는 SA 중재가이름대기및전반적인언어능력향상에긍정적인영향을미치는치료법이나비중재자극으로의일반화는제한적임을검증하였다. 이는치료및일반화에개입될수있는다양한변인들에대한추가적연구와더불어임상적차원에서의고려가필요함을시사한다. 핵심어 : 실어증, 이름대기, 의미자질중재, 메타분석본연구는 BK Plus 사업의지원을받았음. http://dx.doi.org/0.96/csd.6 http://www.e-csd.org