Pélagie M. Beeson, Ph.D., CCC-SLPDepartment of Speech, Language, and Hearing Sciences
Part 3: Medstar National Rehabilitation Hospital Workshop, March 2019
Consider aphasia rehabilitation as a sequence of treatments that can build upon one another
We have examined◦ Lexical, Phonological, and Interactive training sequence to
improve written language (with benefit to spoken language)◦ Lexical retrieval treatment capitalizing on rehabilitated
phonology and orthography.◦ Now we will look at text-level treatments
Lexical-Semantic Tx
Phonological Tx
Interactive Tx (words)
Perisylvian Aphasia with Global Agraphia
Perisylvian Aphasia with Phonological Agraphia
Treatment Sequence for Phonological Impairment
Lexical Retrieval Tx
Interactive Tx (sentences)
Sentence CART
Oral reading tx
Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level
Stimulate production of morphosyntax(inclusion of functors and morphological markers)
Problem-solving approach to spelling in sentence context
whole words
sound-letter
Phonologic Lexicon
Orthographic Lexicon
Phonemes Graphemes
Lexical
Sub-lexical
Lexical
Sub-lexicalletter-sound
Phonological alexia and agraphia
Semantics
Speech Motor Programs
Graphic Motor Programs
“dust?”
“dusp”
druffs Phonological Agraphia
Phonological Alexia
duspphonological impairment is evident by difficulty with nonwords
Chart1
Regular
Irregular
Nonwords
Column1
Percent Correct
85
87
25
Sheet1
Column1Series 2Series 3
Regular852.42
Irregular874.42
Nonwords251.83
Category 44.52.85
To resize chart data range, drag lower right corner of range.
“People had dinner out.”
Phonologic Lexicon
Orthographic Lexicon
The family was having dinner out at the restaurant.
Phonemes Graphemes
Semantics
Reading errors at sentence level
Impaired phonology is often associated with impaired reading accuracy for text
56 year-old, right-handed male◦ Stroke affecting left frontal,
parietal, and temporal lobes 12 years education 5 months post-stroke◦ WAB AQ: 64.4
Broca’s Aphasia 1.5 years post stroke◦ WAB AQ 77.6
Broca’s Borderline Fluent
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Reading Writing
Perc
ent
Corr
ect
WordsNonwords
At 3 years post-strokePhonological alexia + global agraphia
Chart1
ReadingReading
WritingWriting
Words
Nonwords
Percent Correct
96.65
10
12.5
5
Sheet1
ReadingWriting
Words96.6512.5
Nonwords105
Sheet2
Sheet3
“Lot on empty is … On the lot, on empty … On the empty lot … lot the .. On the empty lot near a park …the uh, many people were … hired to work.”
On an empty lot near the park many people were hard atwork.
Gray Oral Reading Test-IIILevel 3
Characterized by relatively good reading of single words in isolation, but marked impairment in reading words in text◦ Particular difficulty with functors and morphological markers
Seen in individuals with phonological alexia (and agraphia)◦ Lexicality effect (real words better than nonwords) Difficulty sounding out unfamiliar words due to impaired
sound-letter transcodingFriedman. R. (1996)
Slow, errorful text-level reading
Particular difficulty with functors and morphological markers
Part of speech effect◦ nouns > adjectives > verbs > functors
May paraphrase because they are perceiving the gist, but not reading every word
“Lot on empty is … On the lot, on empty … On the empty lot … lot the .. On the empty lot near a park …the uh, manypeople were … hired to work.”
On an empty lot near the park many people were hard atwork.
Background Oral reading treatment has the potential to improve reading
ability, as well as spoken language production◦ Cherney (1986) showed improved overall spoken language
performance with oral reading treatment ORLA = Oral Reading treatment for Language in Aphasia)
Our approach is similar: Supported Oral Reading Treatment Aim to maximize correct reading of all words in sentences Oral reading treatment serves to stimulate accurate sentence-
level productions Treatment should follow phonological/interactive treatment to strengthen phonological skills first
Treatment session◦ Clinician read sentence aloud while
pointing to each word◦ Read sentence with clinician using
choral reading and pointing to each word◦ Patient read sentence alone aloud,
pointing to each word◦ Incorrect productions corrected◦ Repeat until mastery achieved
The Romans were the first to make keys of iron.
described in Orjada and Beeson (2005).
Photo album with recording feature for each page One sentence per page with corresponding recording◦ Play recording and read silently◦ Read sentence aloud with recording untilaccurate◦ Read sentence aloud without recording until correct
Passages◦ Selected book passages◦ Shifted to use of personal scripts Orjada & Beeson (2005)
High School Reunion Script used for Oral Reading“We expect around 100 to 150 people to come.”“I graduated with about 350 other people in my class.”
Measuring improvement Read target paragraph aloud◦ Reading accuracy # words correct/total # of words
◦ Reading rate in words/minute Criterion for mastery◦ 90% reading accuracy
New paragraph assigned
described in Orjada and Beeson (2005).
GORT-3 Results
0%
20%
40%
60%
80%
100%
Pre-Testing Post-Testing
Read
ing
Accu
racy
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Read
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Rate
Significant improvement in reading accuracyNo significant change in reading rate
Gray Oral Reading Test-3 Levels 1-5
Orjada and Beeson (2005)
Recall that written spelling was markedly impaired
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Reading Writing
Perc
ent
Corr
ect
WordsNonwords
At 3 years post-strokePhonological alexia + global agraphia
Real Words Nonwords
flig
hoach
snite
glope
boak
cheed
smode
summer
debt
enough
bake
worm
blood
maybe
Chart1
ReadingReading
WritingWriting
Words
Nonwords
Percent Correct
96.65
10
12.5
5
Sheet1
ReadingWriting
Words96.6512.5
Nonwords105
Sheet2
Sheet3
Purpose◦ to strengthen specific orthographic representations (and
links to semantics and phonology) Goal◦ Re-learn spellings of specific words within personal scripts
Approach◦ Homework-based Copy and Recall Treatment
Copy and recall treatment (Beeson, 1999)◦ Homework based treatment◦ Targeted 5-word sets Copy each word 3-5 times Write words from memory Check spelling and make corrections Repeat until mastery achieved
I used to “hot-rod” cars years ago. I was a drag racer. I won a lot of races on the streets, but not as many on the drag strip. Gary was the one who souped up my cars. I used to own a ‘23 Ford, a ‘39 Ford, and a ‘56 Ford. The ‘39 was my favorite, although I also like the ‘56. I also had a ‘65 Corvette, but I only drove it once before I had to put a new engine in it. Racing is hard on cars. My friends Billy, Bryant, and many others raced cars, too.
Underlined words were also homework for spelling using Copy and Recall Treatment (CART)
5 words/set
50 words mastered
10 weeks of treatment
Orjada and Beeson (2005)
Response to Copy and Recall Treatment (CART) implemented concurrent with oral reading treatment.
Significant improvement reading functors (p = .02) Significant improvement writing functors (p = .01)
0%
20%
40%
60%
80%
100%
ReadingFunctors
WritingFunctors
ReadingFunctors
WritingFunctors
Pre-Test Post-Test
Acc
ura
cy
described in Orjada and Beeson (2005).
WAB picture description Conversation
Pre-Tx During Tx Post-Tx Post-Tx
MLU in words
3.62 6.32 7.40 9.47
One-word utterances
30.8% 4.6% 8.3% 0%
Oral reading treatment resulted in improved reading accuracy (but not reading rate)
Written spelling accuracy improved for targeted words using Copy and Recall Treatment
Generalization◦ improved reading and spelling of functors◦ increased length and complexity of spoken utterances
WAB◦ AQ increased from 77.6 to 81.3◦ Improvements most notable in spoken language
production
Lexical-Semantic TxPhonological Tx
Interactive Tx
retrain spelling for specific words (and stimulate spoken production of targeted words)
retrain sound-letter correspondences and phonological manipulation skills
train problem-solving strategies to self-correct spelling errors
Perisylvian Aphasia with Global Agraphia
Full Treatment Sequence for BB (Broca’s aphasia with Phonological Alexia and Global Agraphia)
Lexical Retrieval Tx
train lexical retrieval strategies including semantic, orthographic, and phonological self-cuing
Oral Reading Tx
Stimulate production of morphosyntax (inclusion of functors and morphological markers) at sentence level
Boston Naming Test27/60 36/60
Postscript: Oral reading treatment followed by lexical retrieval treatment
Lexical-Semantic Tx
Phonological Tx
Interactive Tx (words)
Perisylvian Aphasia with Global Agraphia
Perisylvian Aphasia with Phonological Agraphia
Treatment Sequence for Phonological Impairment
Lexical Retrieval Tx
Interactive Tx (sentences)
Sentence CART
Oral reading tx
Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level
Stimulate production of morphosyntax(inclusion of functors and morphological markers)
Problem-solving approach to spelling in sentence context
Case Example◦ 3 years post onset WAB Aphasia Quotient = 74.3
Conduction aphasia Phonological alexia Relatively intact single word reading Severely impaired nonword reading
Global Agraphia Unable to spell real words or
nonwords
L
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100
reading writing
% c
orre
ct
Single Word Reading/Writing Pre-Tx
reg
irreg
non
Previously received: Lexical spelling tx Phonological tx Interactive tx Implement: Oral reading treatment (supported oral reading treatment)
“In Greece, long ago [before], people had locks and keys. But they had a hard time [giving] taking their keys with them [and then and] when they left their buil, their homes.”
In Greece, long ago people had locks and keys. But they had a hard time taking their keys with them when they left their homes.
“In Greece, long ago [before], people had locks and keys. But they had a hard time [giving] taking their keys with them [and then] when they left their homes.”
Slow, errorful text-level reading
Particular difficulty with functors and morphological markers
Part of speech effect◦ nouns > adjectives > verbs > functors
May paraphrase because they are perceiving the gist, but not reading every word
05
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Rea
ding
Rat
e: W
PM
P1 Practice Text
Text 1Text 2Text 3Text 4Text 5
Target: 50 wpm for practice texts
Pre Tx
Post TxIn Greece, long ago, people had locks and keys. But they had a hard time taking their keys with them [to] when they left their homes. That’s because the keys were too big.
In Greece, long ago [before], people had locks and keys. But they had a hard time [giving] taking their keys with them [and then] when they left their homes.
Locks and Keys(2nd grade level)
Petra(12th grade level)
Rate (wpm)Error rate (per 100wd)
Rate (wpm)Error rate
(per 100wd)
Pre-Tx 26.7 9 28.7 7
Post-Tx 41.3 7 29.4 16
Controls ~200 0 ~140 0
Improved rate and accuracy for untrained text at the trained grade level
Lexical-Semantic Tx
Phonological Tx
Interactive Tx (words)
Perisylvian Aphasia with Global Agraphia
Perisylvian Aphasia with Phonological Agraphia
Treatment Sequence for Phonological Impairment
Lexical Retrieval Tx
Interactive Tx (sentences)
Sentence CART
Oral reading tx
Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level
Stimulate production of morphosyntax(inclusion of functors and morphological markers)
Problem-solving approach to spelling in sentence context
50 year-old male 16 years of education 5 years post large LMCA
stroke due to carotid artery dissection
Broca’s evolved to anomic aphasia◦ WAB: 80.7◦ BNT: 50/60
WAB picture description(pre-treatment)
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Reading Spelling
Single Word Reading/Spelling
Words Nonwords
Phonological Alexia with Global Agraphiasistermachineheadlaugh keptstorm
fligflophoachsoakcheedcheddarsmodesmore
Reading: Words
Reading: Nonwords
Spelling: Words
Spelling: Nonwords
flig
hoach
mofer
sword
chant
island
ST
ENIT
LANELY
FID
OST
LIFN
Impaired Text Level Writing
“The boy has a book. And…he’s got a sandwich somewhere. The girl has some coffee. I don’t know what type of coffee, maybe it’s Starbucks. There’s a car. But…you know, it’s off.
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100
Sentence Well Formed andcomplete
%Cor
rect
Well-Formed and Complete Sentences
Spoken Written
The Tree is LeTT.The CAR is iN ThE DivNe HeThe MAN a BooK.The Women an a piNNeN BAD.THE is a FaLe.THE is a BooM The Fise PoNe.
Lexical-Semantic TxPhonological Tx
Interactive Tx
retrain spelling for specific words retrain sound-letter
correspondences and phonological manipulation skills train problem-solving
strategies to self-correct spelling errors
Perisylvian Aphasia with Global Agraphia
Treatment Sequence for Phonological Impairment
12 weeksVowels: 3 weeksBlending: 10 weeks Sentence Writing Tx
12 weeks
Stimulate written sentences with copy and recall treatment.
4 weeks
41 weeks of treatment total (over 1 year)
Purpose◦ Improve speed and accuracy of written sentence production
Goal◦ Increase rate and decrease errors in production of written
personal narratives◦ Generalize to untrained sentence-level writing
Approach◦ Repeated copy and recall of sentences in the context of
personal narratives◦ Sentence Copy and Recall Treatment (Sentence CART)
5 personal, written narratives◦ Developed with patient/family
input◦ Each passage of similar length and
complexity 4-6 sentences 5-10 words per sentence Complexity will vary by patient
◦ Topics of personal relevance Work history Favorite vacation Hobbies Personal anecdotes
I did a bodybuilding contest.I exercised for months.I was a stroke survivor.It was my proudest moment.
When I was 28 I lived in Antarctica.The weather was 70 degrees below zero.I had to pass physical and mental exams.I worked at the Byrd Station for 18 months.I collected data to study the atmosphere.
Gardening is one of my favorite things to do.My house sits on a one acre lot.My husband and I landscaped the whole yard ourselves.Our yard has a fountain and a covered patio.I love flowers and making the garden beautiful.
5 Example Passages from 3 different participants
Baseline◦ Write each passage to dictation 3 times
Treatment◦ Writing to dictation, sentence by sentence. ◦ Interactive approach to spelling: Detect and correct errors in each
sentence. Use spell checker as needed.◦ Copy corrected sentence 3-5 times.
Homework◦ Copy each sentence in target
passage 5 times.
1. Generate sentence using target spelling word.2. Read sentence aloud.3. Identify spelling errors and missing words.4. Correct spelling errors using problem solving
(sound out, examine for errors, use spell checker).5. Note: grammatical/morphemic errors may also be
detected/corrected. Wrote: My surgean approve me for surgery. Read as, “My surgeon approved me for surgery.” Patient corrected surgeon using the spell checker, and
sounded out and identified the missing /d/ in approved.
Franklin Spell Checker
Phone
Homework
I did a body building contest.I exercised for months.I was a stroke survivor.It was my proudest moment.
I DID BODY CONTIC.
I EXRSEZ FOR MONS.
I WAS A STORK SUREVER
IT WAS MY PROUDET MOMINT
I DID A BODY BUILDING CONTEST.
I EXERCISED FOR MONTHS.
I WAS A STROKE SURVIVOR
IT WAS MY PROUDEST MOMENT.
Target
Pre-Tx
Post-Tx
Treatment ◦ 1 hour sessions, 2 times per week◦ Criterion: 80% accuracy writing
passage to dictation over 2 consecutive sessions ◦ Length of Treatment: 5-12 weeks
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Reading Words ReadingNonwords
Spelling Words SpellingNonwords
Single Word Reading/Spelling
Pre Post With Speller
Response to Treatment Sequence
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Lexical (CART) Phonological Interactive Sentence CART
Before Tx
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Pre PostInteractive
Post CARTSentences
Well-formed and Complete Sentences
The Tree is LeTT.The CAR is iN ThE DivNe HeThe MAN a BooK.The Women an a piNNeN BAD.THE is a FaLe.THE is a BooM The Fise PoNe.
02468
10
Pre Post Interactive Post CARTSentences
Mean Sentence LengthTHE is A FiSHiNG BOAT THAT HAS A BOY ON BOARD.THE BOY IS FLYiNG A KITE AN HE THIS PULLING A SiRiNG.HE PUT HiS GLASSING ON AND HAD A BOOK IN IS HAND.THERE IS A TREE THAT IS BLOOMING.THERE IS A RADiO THAT IS SOOTHiNG.
After Tx
Positive self-ratings after treatment for writing and general communication skills.
Wrote and presented his first Toastmaster’s speech soon after treatment
Aspires to give a TED talk.
4 individuals with perisylvian aphasia◦ 1 Broca’s with severe apraxia of speech◦ 3 evolved anomic aphasia◦ All with impaired phonological skills at the outset◦ Completed treatment sequence to strengthen phonological and
orthographic skills, and detect and self-correct written errors
Lexical-Semantic Tx
Phonological Tx
Interactive Tx
Sentence Writing Tx
22
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Pre-Tx Post-Phon Post-Int Post-CARTSent
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Mean Written Sentence Length
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The most common perisylvian aphasias have a persistent, marked impairment of phonological skills◦ Broca’s, Wernicke’s, Conduction, and Global aphasia, as well
as those who have evolved to anomic aphasia from perisylvian damage The impairment may be more evident in written language, especially
when spoken language is relatively recovered. Common profiles include Single word level: Phonological or global alexia and agraphia Text level: Phonological Text Alexia and Phonological Text Agraphia characterized by difficulty with functors and affixes (morphological
markers) in text level reading and writing writing is nearly always more impaired than reading
Lexical-Semantic Tx
Phonological Tx
Interactive Tx (words)
Perisylvian Aphasia with Global Agraphia
Perisylvian Aphasia with Phonological Agraphia
A sequential treatment approach can maximize recovery
Lexical Retrieval Tx
Interactive Tx (sentences)
Sentence CART
Oral reading tx
Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level
Stimulate production of morphosyntax(inclusion of functors and morphological markers)
Problem-solving approach to spelling in sentence context
Beeson, P.M. & Insalaco, D. (1998). Acquired alexia: Lessons from successful treatment. Journal of the International Neuropsychological Society, 4, 621-635.
Beeson, P.M., Rising, K, DeMarco, A., Foley, T.H., & Rapcsak, S.Z. (2016). The nature and treatment of phonological text agraphia. Neuropsychological Rehabilitation, 26, 1-21.
Cherney, L., Merbitz, C., & Grip, J. (1986). Efficacy of oral reading in aphasia treatment outcome. Rehabilitation Literature, 47(5-6), 112-118.
Friedman, R. B. (1996). Phonological text alexia: Poor pseudoword reading plus difficulty reading functors and affixes in text. Cognitive Neuropsychology, 13(6), 869-885.
Orjada, S. & Beeson, P.M. (2005). Concurrent treatment for reading and spelling in aphasia. Aphasiology, 19, 341-351.
Sentence-Level Treatments for Aphasia, Alexia, AgraphiaAphasia Treatment SequencesSlide Number 3Slide Number 4Phonological Text AlexiaExample: BBPhonological Text AlexiaPhonological Text AlexiaPhonological Text AlexiaTreatment for Phonological Text AlexiaSupported Oral Reading TreatmentOral Reading HomeworkOral Reading HomeworkReading Accuracy and Rate for Practiced TextGeneralization: Oral Reading AccuracyExample: BBLexical Spelling Treatment implemented Concurrent with Oral Reading TreatmentPersonal Script (for oral reading treatment)Spelling Accuracy: Trained WordsGeneralization: Improved Reading & Spelling of Untrained FunctorsImprovements in Spoken languageBB Summary Slide Number 23Slide Number 24Phonological Text AlexiaPhonological Text AlexiaPhonological Text AlexiaOral Reading TreatmentResponse to Tx: Phonological Text AlexiaGeneralized Improvement to Untrained TextSlide Number 31Learning from another caseSlide Number 33Slide Number 34Slide Number 35Sentence Writing TreatmentSentence CART StimuliSentence CART ProcedureProblem Solving at Sentence LevelSentence-Level Interactive TreatmentSentence CARTSlide Number 43Text-level writing after treatmentSlide Number 45Evidence from other cases: �Sentence Copy and Recall TreatmentResponse to Treatment: �Generalization to untrained writingTake away pointsSlide Number 49References