CCC-SLP CBIS 2015 NJSHA

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Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 Learner Outcomes 1. Summarize five complex and unique case studies in adult rehabilitation. 2. Identify and define speech and language deficits in individuals with diagnoses ranging in severity related to acquired speech and language disorders. 3. Advance ability to facilitate meaningful treatment objectives in order to optimize functional independence and community reintegration of individuals with acquired communication disorders and co-morbid diagnoses. 4. Incorporate evidence-based practice during treatment planning for adult rehabilitation. Overview • Treating concomitant deficits • Four case studies • Overview of diagnosis and deficits • Video samples of assessment • Goal writing • Video samples of treatment • Treatment planning • Materials • Summary/Questions     

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Concomitant Deficits Identify and prioritize deficits Differential Diagnosis Strong clinical decision making Review of PMH Maximize independence: Pre-morbid level of Functioning Identify patient goals: Functional Create clinician goals Objective and Quantifiable Review funding and insurance guidelines

Case Studies • Aphasia  Mixed receptive/expressive  Fluent  Non-Fluent • Apraxia of speech • Dysarthria • Primary Progressive Aphasia Assessment • Boston Diagnostic Aphasia Evaluation (BDAE-4) • Boston Naming Test (BNT) • Western Aphasia Battery (WAB) • Expressive One Word Picture Vocabulary Test (EOWPVT-4) • Apraxia Battery for Adults (ABA-2) • Reading Comprehension Battery for Adults (RCBA-2) • Receptive One Word Picture Vocabulary Test (ROWPVT-4) • Ross Information Processing Assessment (RIPA-2) • Behavioural Assessment of the Dysexecutive Syndrome (BADS) • Measure of Cognitive Linguistic Abilities (MCLA) • Frenchay Dysarthria Assessment (FDA-2)

There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 Case Study #1- AF • 47-year-old male • Employed as parole counselor • Collapsed when boxing • Occlusion of the left carotid artery resulting in a left MCA infarct • Malignant edema s/p left hemicraniectomy • Resultant right hemiplegia and global aphasia • Dysphagia status post PEG tube placement • Course complicated by aspiration pneumonia • PMH of hypertension and obesity • Hospitalized at the acute stage for 3 weeks • Transferred to a rehabilitation setting and received inpatient therapy for 2.5 months • Discharged to home with close supervision • Home Care Services:  2-3 days/week for 4 weeks  Upgraded to regular solid diet with all liquids Case Study #1- Assessment BDAE- Cookie Theft Case Study #1- Assessment BNT-Short Form Case Study #1- Characteristics • Expressive Language  Severe non-fluent aphasia  Telegraphic utterances  Stereotypical Utterances/Overlearned Phrases  Word Retrieval Deficits  Poor syntax & grammar  Paraphasias- semantic & literal  Perseveration  Stimulable for phonemic and semantic cues  Expressive < Receptive • Receptive Language  Preserved self-monitoring  Auditory comprehension of basic information  Poor body part identification  Basic y/n reliability  1-Step Commands • Reading Comprehension: Basic phrase-sentence level • Written Expression: Basic Functional Level Case Study #1- Long-Term Goals • LTG #1: The patient will demonstrate basic functional expressive language skills at the sentence level 90% of the time given minimal cues for home, community, medical and safety needs. • LTG #2:The patient will demonstrate receptive language skills at the moderately complex conversation level with 90% accuracy given minimal cues for home, community, medical and safety needs. • LTG #3:The patient will demonstrate reading comprehension skills at the moderately complex multi-paragraph level with 90% accuracy given minimal cues for home, community, medical and safety needs. • LTG #4:The patient will demonstrate written expression skills at the basic sentence level with 90% accuracy given minimal cues for home, community, medical and safety needs. Case Study #1- Short-Term Goals

There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 • • • • • • •

STG #1: The patient will complete a variety of basic word retrieval tasks (e.g. phrase completions, concrete divergent naming, naming synonyms/antonyms, naming objects, etc.) with 75% accuracy given maximal visual, verbal, tactile cues. STG #2: The patient will complete basic phrase-sentence level production tasks (e.g. SVO picture description, conversational exchanges, etc.) with 75% accuracy given maximal visual, verbal, tactile cues. STG #3:The patient will complete basic-moderately complex y/n reliability questions with 90% accuracy given minimal cues. STG #4: The patient will follow basic 2-step auditory directions with 90% accuracy given moderate cues (e.g. Body part identification, object manipulation, etc.) STG #5: The patient will complete basic single word level written expression tasks (e.g. basic phonics and irregulars at the monosyllabic word level) with 90% accuracy given minimal cues. STG #6: The patient will complete basic sentence level reading comprehension tasks (e.g. sentence/picture matching, following written directions, etc.) with 90% accuracy given minimal cues. STG #7: The patient will implement 1 word retrieval strategy during basic structured word retrieval tasks (e.g. circumlocution, SFA, written expression, gesture, etc.) with 90% accuracy given minimal cues.

Case Study #1- Treatment: Picture Description “What’s Wrong” Case Study #1- Treatment: Feature Identification Case Study #1- Treatment: Anagram and Copy Case Study #1- Evidence Based Practice “Using CART with two clinical sessions per week and daily homework, an individual with severe Broca’s aphasia relearned written spelling for 46 words over 3 months.” (Beeson et al, 2002) “Writing should be considered an alternative modality for individuals who are unable to recover spoken language.” (Beeson et al, 2003) “More people with aphasia gestured as compared to typical controls, and that for many people with aphasia, the gestures produced were iconic.” (Sekine & Rose, 2013) “Importantly, aphasia type appeared to have an impact on the types of gesture the people with aphasia produced. Whereas concrete deictic gestures and emblems were used by individuals with all types of aphasia, significantly higher proportions of individuals with Broca’s and Wernicke’s aphasia produced concrete deictic gestures; significantly higher proportions of individuals with Broca’s and conduction aphasia produced iconic CVPT gestures; and, consistent with the second hypothesis, a significantly higher proportion of individuals with Broca’s aphasia produced pantomime and number gestures.” (Sekine & Rose, 2013) “Results of this study show that improvements in gesture and naming can be achieved (a) by people with severe and chronic aphasia and (b) in response to a limited therapy dose.” (Marshall et al, 2012) “Multimodality therapies take advantage of other mechanisms to support verbal production and provide multimodality communication skills for social interaction when word production fails. Taken together, it seems that multimodality treatments are a valid option for rehabilitation of individuals with chronic aphasia, and that constraining participant responses to the verbal modality is not strongly supported by current evidence.” (Rose, 2013) “When utilized as early stroke intervention in patients with non-fluent aphasia, MMIT demonstrates significant positive results in patients’ overall ability to verbally respond following one session and continued improved verbal output after twenty-four hours.” (Conklyn et al, 2012) “Results from this study suggest that a copy and recall methodology can be effective for training single-word spelling using the texting function on a cell phone in a manner similar to that with pen and paper. The time required to train words and the accuracy immediately after treatment were comparable for both modalities, but for this participant, long-term retention was stronger for words trained with pencil and paper compared with those trained with the cell phone.” (Beeson et al, 2013)

“Script training intervention is effective in improving dialogic discourse on a chosen topic for people with aphasia. The result of generalization probes indicates that people with aphasia are able to use learned scripts in similar functional situations. Furthermore, There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 this study highlighted how people with aphasia focus on different aspects of script training, relative to their impairments and goals. Strong self-cuing abilities appear to facilitate script learning. This study also suggests that videoconferencing may be a useful avenue for script training, as a supplement to in-person interaction with a clinician.” (Goldberg et al, 2012) “Results indicated that participants evinced some improvement for naming accuracy for treated words but not untrained words, and produced more target words from trained lists on the discourse tasks from the initial testing session to the post-treatment and maintenance sessions.” (Rider et al, 2008) Case Study #1- Treatment Planning • Script training: Initiating basic conversational turn-taking • Training AAC (e.g. picture boards-speech generating application) • Naming tasks (responsive/convergent/divergent) • Object/picture naming & description • Body part identification • Moderately complex y/n reliability • Inclusion of language applications for HEP • E.g. TherAppy, Lingraphica, etc. • Multimodal training- gestural, written expression, etc. • Incorporating writing & reading across all tasks • Functional Tasks- Restaurant simulation/MD appointments Case Study #2- RM • 52 year old female • Full time sales associate in retail • Found to have slurred speech and right facial droop and right-sided weakness • MRI revealed left MCA territory infarct with hemorrhagic transformation • Intraparenchymal hemorrhage • Left frontoparietal lobe Case Study #2-RM • Slight midline shift from left to right • Dysphagia and initially NPO but upgraded to regular diet with thin liquids • Course complicated by malignant hypertension • Past Medical History • Dyslipidemia • Hypertension Case Study #2- RM • Acute Hospitalization for 6 days • Inpatient Rehabilitation for 3 weeks • Discharged to home with close supervision • Immediately transitioned to outpatient rehabilitation Case Study #2 Assessment: Diadochokinesis Case Study #2 Assessment: Repetition (ABA-2) Case Study #2-Assessment: BDAE-4 Cookie Theft Case Study #2-Assessment: BNT-Short Form Case Study #2- Characteristics • Severe non-fluent aphasia • Severe apraxia of speech • Poor initiation There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 • • • • • • • • • • • • • •

Consonant and vowel distortions Unsuccessful attempts to self-correct High error rate for volitional/purposeful utterances vs. automatic/reactive utterances Limited to a few meaningful or unintelligible utterances Sequential Motion Rateconsonants – Omissions of consonants in all but two opportunities » E.g /owuh” for Totowa and /i-o-ei/ for Chipotle • In absence of context 0% intelligibility – Respiration-Phonation • Incoodination for inhalation/exhalation with short, rushed utterances • Phonatory incoordination versus paresis of VF (unable to voice target phonemes) – MPT 3s avg Concomitant profound dysphagia and apparent cognitive linguistic deficits – Absent initiation of swallow – Copious anterior loss of secretions – Poor comprehension of verbal instruction – Verbosity/tangential/perseverative – Episodic memory impairments – Reduced sustained attention – Avoidance behaviors –



Case Study #4- Long-Term Goals • LTG 1: Pt will utilize external aids such as simple text to speech or letter board supports in home and community for improved intelligibility across settings and listeners. • LTG 2: Pt will utilize internal strategies for intelligibility including slow rate and overarticulation for improved intelligibility across settings and listeners. • LTG 3: Pt. will convey simple biographical information and requests/verifications at phoneme-word level with 80% accuracy to a familiar listener. • LTG 4: Pt will tolerate at least one solid and one liquid consistency for pleasure intake. Case Study #1- Short-Term Goals • STG 1: Pt will utilize simple text to speech and letter board supports in structured therapy tasks for improved intelligibility across settings and listeners with maximal prompts for identification of communication breakdown and cues technique for use. • STG 2: Pt will utilize overarticulation and slow rate for phoneme, CV, and CVC level productions for vowels and bilabials with max cues/models and tactile sensory cue with 75% accuracy. • STG 3: Pt will achieve approximations for up to 5 target functional word to phrase level output with max cues/models for use of trained strategies for increased communication with familiar listeners. • STG 4: Pt will complete repetitions of bilabial, lingualveolar, and velar stops in CV and CVC environments with max tactile cues and models. • STG 5: Pt will complete oral sensory and oral placement therapy exercises for mandibular stability, mandibular ROM, labial closure, and lingual dissociation in sets of 5x4 with max cues/models for technique • STG 6: Pt will achieve increased mandibular ROM for more appropriate articulation via passive and active stretch as measured by production of open vowel /a/ in prompted output/drill in 4/5 trials. • STG 7: Pt will exhibit increased reflexive oral sensory behaviors in stimulation for increased oral awareness. • STG 8: Pt will exhibit increased secretion management/initiation of swallow with maximum multimodal cues as measured by successful initiation of swallow at least 5 times in a treatment session. There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 •

STG 9: Pt will sustain phonation for at least 5s (n=20s) with max cues/models.

Case Study #4- Treatment: Letter Board/AAC supplement and pacing strategy Case Study #4- Treatment: Mandibular ROM Case Study #4- Treatment: Bilabial Drills and Oral placement therapy Case Study #4- Treatment: TTOS and Swallow Initiation Case Study #1- Evidence Based Practice “Furthermore, there is evidence that changes in rate alone, even when listeners cannot see the alphabet cues, result in increased intelligibility when speakers implement AS” (Beukelman, D., Yorkston, K., 1977). “Research suggests that alphabet cues improve intelligibility by an average of approximately 25% (range = 5%–69%)” (Buekelman et. al 2002) “This study was designed to examine the effects of rate control treatment on the accuracy of sound production and total utterance duration of multisyllabic words, phrases, and sentences with an individual with AOS and aphasia. Findings revealed that treatment resulted in an improvement in sound production accuracy…” (Mauszycki & Wambaugh, 2008) ‘”Mandible may place leading role in not only normal articulatory development but also in the origin and persistence of certain abnormal speech behaviors” (Green & Reilly 2003) “…the mandibular operating system assumes dominant responsibilities in early normal speech development.” (Green & Reilly 2003) “Slow stretching, in contrast, causes an inhibition of the stretch reflex and may decrease tone.” (Clark 2012) “Nonetheless, given unique physiology, particularly with respect to muscle spindles, there is reason to believe that tone disruptions may manifest differently in the orofacial musculature compared to the limbs. Only one muscle group in the orofacial system has a high density of muscle spindles and exhibits clear stretch reflexes: the jaw-closing musculature.” (Clark, 2012) “Icing is a therapeutic modality intended to decrease both nerve conduction velocity and muscle contraction speed, thus resulting in an overall decrease in tone” Gracies, 2001; Katz, 1988; Michlovitz, 1986) “superficial heating, thermotherapy, has been reported to decreased muscle tone, reduce muscle spasm…” (Smania et. al, 2010) “passive stretching with prior heat treatment significantly increased hamstring extensibility” (Smania et. al, 2010) “Response generalization to untrained exemplars paralleled trained productions and significant increases were seen incorrect productions of untrained sounds.” (Wambaugh and Cort, 1998) “Insufficient evidence to support or refute the use of OME’s to produce effects on speech was found in the literature” (McCauley, Strand, Lof, & Frymark, 2009) “Recent work suggests that an important signal is a sensory prediction error, which is the difference between the brain’s predicted outcome of the movement and the observed outcome. Note that this is different than an error in target accuracy – it instead reflects whether the body moved in the way that the brain thought it would. Sensory prediction errors can be used to calibrate the internal representations of body dynamics and the environment and recalibrate for changes in either. Well calibrated internal representations are important because they allow us to decrease reliance on time-delayed feedback from body sensors.” (Bastian 2008) “While there may not be a one-to-one correspondence between the oral sensory-motor skills for feeding and the oral sensory-motor skills for speech, there is an overlay of one system to another” (Rosen field-Johnson 2014)

There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 “OPT activities are used in conjunction with traditional speech therapy and do not replace direct work on speech sound production. However, working on the isolated muscle skills will facilitate standard movements for speech. All of the activities teach speech-like movements and are not NSOME (Non-Speech Oral Motor Exercises). Research in the area of dysphagia suggests that improving lingual strength through a sensory-motor exercise approach not only aids in swallow rehabilitation, it may also improve dysarthric speech indirectly” (Rosenfeld-Johnson 2014) Case Study #4- Treatment Tasks  Heat & Passive Stretch (mandible)  Oral Sensory inputs (tactile, temperature)  Thermal Tactile Stimulation  OME’s o Lingual strength and ROM o Labial seal o Mandibular ROM  Oral Placement Therapy o Horns 1-3 o Bite Tube o Bubbles  Letter board and pacing training in structured conversation o Revisions  Phonemic Placement and Drill  PROMPTs for Re-structuring Oral Muscular Phonetic Targets Case Study #5- JB  69 year old female  Gradual onset of challenges in “getting words out”  3 year decline with multiple diagnosis o Ultimately PPA  Prior speech therapy intervention at another site o Communication strategies  Pacing  Writing  Reducing communicative press  PMH significant for HTN, parotid tumor, question of TIA  NPE 2014 with strengths across domains of cognition  Functional ADL participation with use of prior trained strategies however “strain” increasing o Managing her own finances, medication, schedule o Caring for grandchildren  Strong caregiver support and familiar involvement o Perceivable strain between patient and spouse Case Study #5- Assessment BDAE- Cookie Theft Case Study #5- Assessment BNT-Short Form Case Study #5- Characteristics • Expressive Language  Moderate non-fluent aphasia with suspected apraxic overlay  Phonemic paraphasias  Groping/halting prosody in connected speech  Awareness of errors and over frustration  Mild reduction in syntactic construction  Expressive writing fair-good (1-2 letter omissions infrequently but generally discernable) There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015  



Stimulable for pacing and “deep breathing” or cancellation technique Receptive < Expressive Receptive Language  Preserved self-monitoring  Auditory comprehension of information in clinical interview and per caregiver report in ADLs • Reading Comprehension independent sentence paragraph level intact however did not test further

Case Study #5- Long-Term Goals • LTG #1: The patient will utilize low tech strategies for enhanced expressive communication in episodes of non fluent revisions with unfamiliar listeners given modified independence-minimum cues. • LTG #2:The patient will effectively navigate to target information in trained SGD dynamic display with 80% accuracy and min cues. • LTG #3: The patient and a caregiver will demonstrate increased understanding of medical diagnosis and aphasia symptoms in adjustment related counseling based discussions. • LTG #4: The patient and family will exhibit independent abilities for SGD programming and management. Case Study #5- Short-Term Goals • STG #1: The pt will utilize low tech strategies for enhanced expressive communication including deep breathing, pacing, and expressive writing in structured tasks of connected speech output at sentence to multi sentence level in 8/10 opportunities with min prompts for use and cues for technique. • STG #2: The patient will navigate to appropriate sub-categorical pages for biographical and medical information in dynamic display of Lingraphica SGD device with 80% accuracy and min-mod supports. • STG #3:The patient will utilize pacing strategy to complete “voice banking” and photo banking of target phrases within SGD dynamic display with max cues for device programming. • STG #4: The patient and caregiver/spouse will participate in verbal and written education regarding nature of primary progressive aphasia and progressive impact on communication. • STG #5: The patient and caregiver will demonstrate modified independence for simple SGD management (e.g. on/off, charging, trouble shooting). Case Study #5- Treatment: SGD navigation Case Study #5- Treatment: Voice Banking Case Study #5- Evidence Based Practice “For persons with PPA and their families, there is a need for education and counseling that emphasizes the progressive nature of the disorder and the fact that behavioral treatment to maximize communication ability cannot be expected to retard or reverse progression of the disease” (McNeil & Duffy 2001) “Think of speech supplementation as the “augmentative” part of AAC. It is a way to add to the speech to increase intelligibility.” (Hanson 2014) “Keep in mind that this treatment progression from unassisted to assisted treatment resembles the hierarchy that is the standard for individuals with neuromuscular disease such as ALS.” (Fried-Oken, 2008) “Operationally…three treatment goals: 1. To compensate for progression of language loss (not stimulate the language system to regain skills) 2. To start early. Begin compensatory treatment as soon as possible. Be proactive so the person with PPA can learn to use communication strategies and tools. 3. To include primary communication partners in all aspects of training, with outreach to multiple partners.” (Fried-Oken, 2008) “The role of partners should not be underestimated for the person with PPA. As an individual loses skills, the partner assumes more responsibility for interaction and message co-construction” (Fried-Oken, 2008) “Prediction and anticipation are cornerstones of proactive management… individuals with PPA become less successful at learning and incorporating augmentative means of communication to their daily lives” (Rogers & Alaron, 1999) There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015

Case Study #5- Treatment Planning • Connected speech output/structured conversation with training for low tech strategies • Naming tasks (responsive/convergent/divergent) with aims of strategy rehearsal • Training AAC (e.g. iPhone application for text to speech, Lingraphica) • Training for SGD programming including icon creation, photo storage, and voice banking • Programming collaboration- designation of target functional phrases for SGD • Rehearsal for SGD navigation in simulated social and ADL based “scripts” • SGD HEP training • Adjustment related counseling and resource/referral education • Support groups • Written materials • Psychological support for all stakeholders Summary • Differential diagnosis • Concomitant cognitive deficits • Strong clinical decision making • Functional Tasks • Consider Motivation: Work, Social, etc. • Group Therapy • Well-rounded tasks/sessions • Think “outside the box”

Contact Information: [email protected] [email protected] References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

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There are no financial or non‐financial relationships to disclose for this presentation.

Adult Speech and Language Disorders: Evidence-Based Practice, Goal Writing, and Treatment Planning Gabrielle Zimmer, M.S., CCC-SLP, CBIS Caryn Graboski, M.S., CCC-SLP CBIS 2015 NJSHA Convention April 30, 2015 Augmentative and Alternative Communication, Vol 17, 99-104. 17. Hanson, E., (2014), My Client Talks! Do I Still Need to Consider AAC in my Treatment Planning? Speech Supplementation Strategies: AAC for Clients Who Talk!, SIG 12 Perspectives on Augmentative and Alternative Communication, vol. 23, pp. 124-131. (DOI: doi:10.1044/aac23.3.124) 18. Gideon, D.A. (2009). Cognitive-social strategies for neurobehavioral rehabilitation: case analyses. NeuroRehabilitation, 25 (2), 93-100. 19. Gil, M., Cohen, M., & Groswasser, Z. (1996). Vocational outcome of aphasic patients following severe traumatic brain injury. Brain Injury,10 (1), 39-46. 20. Goldberg, S., Haley, K.L., & Jacks, A. (2012). Script Training and Generalization for People With Aphasia. 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