NOTE

REHABILITATION OF ALEXIA: A CASE STUDY

Sandra B. Moyer

(Purdue University)

There have been many reports over the years of patients with acquired alexia or dyslexia. Recovery of the ability to read in these cases appears to occur either spontaneously (Newcombe and Marshall, 1973) or not at all (e.g. Denckla and Bowen, 197 3 ). Successful rehabilitation programs for alexic patients have not, to this writer's knowledge, been developed. The present report describes a reading program which proved effective with a 30-year-old, male alexic patient with a transitory mild aphasia and persisting right homonymous hemianopsia. No agraphia was present. The most striking feature of his reading difficulty was extremely slow letter-by-letter "sounding out" of words and, at a later stage, painfully slow word-by-word reading. Some of this patient's symptoms, including slow visual­verbal processing, are shared by the patient with left occipitotemporal lobectomy reported by Denckla and Bowen (1973 ). They cite slowness in visual-verbal processing as a characteristic common to their patient and some developmental dyslexics. Others (e.g., Denckla and Rudel, 1974; Spring and Capps, 1974) have noted similar slowness in children with reading problems.

In the present case study a successful technique for increasing reading speed was developed by this writer for use in the later stages of the remedial reading program. This technique, subsequently labeled Multiple Oral Rereading (MOR), involves repeated oral reading of connected discourse. This procedure contrasts with the more usual method of repeated practice on isolated words to increase speed of word identification. The use of MOR with this patient resulted in a substantial gain in reading speed over a relatively short period of time. The effectiveness of MOR in increasing this patient's reading rate suggests that it may be useful for rehabilitation of other selected cases of acquired alexia. In addition, children with reading problems who demonstrate slow .visual-verbal processing might benefit from the use of MOR. Following the case report and a brief description of the early, more traditional, stages of remediation, the MOR technique will be presented.

CASE REPORT

This 30-year-old Spanish-American assistant bank manager developed cerebral embolic complications following surgery for mitral valve replacement at Presbyterian Hospital Center, Albuquerque, New Mexico, in May 1970. Im­mediate post-operative symptoms were a nominal dysphasia, right homonymous hemianopsia and increased reflexes on the right side with an extensor toe sign on

Cortex (1979) 15, 139-144.

140 5. B. Moyer

that same side. A right-sided hemiparesis was noted and cleared within 24 hours. Severe headaches were experienced during the two-week post-operative period. On discharge from the hospital one month later the cardiac status was excellent. The major disabilities were a dense right hemianopsia and alexia without agraphia.

Two months post-operatively, physical, neurological and psychological evaluations were performed. At this time, the patient was described as well adjusted and sociable. His judgement and insight appeared normal.

Neurological examination revealed normal functioning of the motor system, reflexes and sensory system. Cranial nerve examination showed a persistent right visual field loss and a mild right central type facial paresis. There was no evidence of hemiparesis, and the toe signs were both flexor plantar. The nominal dysphasia had disappeared and immediate recall for verbal material (repeating a sentence, retelling a fable) was good. The patient's immediate recall of a name, address and a flower were normal but difficulty was noted on delayed (5 minute) recall.

Intellectual status was assessed by the W AIS resulting in a verbal IQ of 121, a performance IQ of 80 and a full scale score of 103. Testing required an "inordinate amount of time". The right visual field loss presented a problem on several of the Performance subtests of the W AIS. For example, on the Digit Symbol subtest the patient ignored the last 11;2 inches on the right of each (71;2 inch) line. He was unaware of this omission until it was pointed out to him. Mild memory problems were reported for material acquired in the past as well as for more recent information (his customers' names and appointment times}.

Mild visual-perceptual-motor impairment was suggested by difficulty in drawing a cube, below-average performance on the Bender Gestalt and on the Ayres test. It is not clear to what degree the visual field loss affected performance on these tests.

Reading ability was described as "profoundly impaired". The patient had difficulty in identifying words, made frequent substitutions and found it necessary to spell some words aloud in order to identify them. He was able to compose and write a paragraph at normal to rapid speed and in a legible hand. Writing a paragraph dictated to him was performed with similar ease. He was unable to read these paragraphs on subsequent visits. The patient reported that on discharge from the hospital (one month post-operatively) he had been unable to read at all. He had begun to work independently on his reading problem using his son's 2nd grade reading textbook.

At this point, the patient was in a highly anxious state concerning his ability to function competently in his profession. As an assistant bank manager, the ability to read quickly and accurately seemed essential.

The patient was referred to the Manzanita Center Reading Program at the University of New Mexico in September, 1970, three months after his release from the hospital. He was tutored by a different graduate student instructor under faculty supervision for each of three academic semesters (Fall 1970, Spring 1971, and Fall 1971}.

Rehabilitation program: first year

Initial assessment of reading skills in September 1970 indicated that the patient had either retained or relearned through his own effort all the basic phoneme/grapheme relationships. He exhibited some confusion of visually similar letters such as b-d, h-n-r, p-q-g and m-w. He could, given time, read most common words presented in isolation (e.g., on "flash cards"} or in context. This reading was painfully slow with laborious "sounding out" of each word. It was apparent that little use could be made of surrounding context to facilitate word recognition.

Rehabilitation of alexia 141

As remedial techniques designed specifically for use with cases of acquired alexia were not available, procedures adapted from children's developmental and remedial programs were used during the first two semesters of the rehabilitation program. A summary of those which appeared to be effective follows.

The problem with visual discrimination of some similar letters was improved by the use of the Fernald ( 194 3) technique of finger tracing letters cut out of sandpaper. To increase accuracy of word identification paragraphs were dictated to the patient who wrote, then typed and read them aloud. To facilitate speed of word recognition, extensive practice was given in rapid response to a set of high frequency words (Dolch Basic Sight Words) printed on flash cards. Speed of recognition improved very rapidly on these words. A device which flashes words or phrases on a screen for a designated time interval (Controlled Reader) was also utilized. Words missed on the filmstrip were practiced at the end of each session. In addition, the patient was given contextual materials written for adults learning to read (Laubach Literacy Series). These were read as home assignments. It was noted during the second session (only three days after the first) that certain paragraphs in this material were being read with a considerable improvement in speed. The patient remarked that he had read that selection several times and had as a result almost committed it to memory. It is not known how extensively this strategy of repetitive practice was used during the first two semesters by the patient in his reading activities at home.

Multiple Oral Rereading

In September 1971, 16 months post-operatively, the third semester of remedial work had begun. It was during this semester that the Multiple Oral Rereading technique was developed for use with this patient. There were 12 ses­sions, one per week, each lasting 1 ~-2 hours.

Initial status

At this point, the patient's speed in reading the set of well-practiced high frequency words (Dolch Basic Sight Words) had reached the point where the rate at which the cards could be turned was the limiting factor. However, speed of reading unpracticed words and of contextual materials was still quite slow. A reading test (The Gray Oral Reading Test) had been administered in May 1971. The patient's performance on this test containing paragraphs ranging in difficulty from first to eleventh grade level indicated an average reading rate of 48 words per minute. By comparison, professional newscasters read at speeds of between 220 and 344 words per minute (as reported in Sticht, Beck, Hauke, Kleiman and James, 197 4 ). Most words encountered by the patient in simple context could be read accurately. However, the slow speed of word recognition appeared to interfere with processing of larger syntactic/ semantic structures. Two word phrases were the most common intonational grouping. Reading comprehension per se was not considered to be a problem. Emphasis during this fall, 1971 semester was placed almost totally on improving speed of reading contextual materials. Although comprehension was routinely evaluated as one measure of reading skill, it was not a direct instructional goal.

Procedure

Reading selections were taken from a children's encyclopedia (The Golden Book Encyclopedia) chosen for its short length of reading line, uniform readability

142 S. B. Moyer

level (5th to 6th grade level), high information content, variety of subject matter and easily legible print. Each week a new selection, roughly 600 words in length, was read aloud by the patient and timed. The assigned selection was then practiced daily at home over a period of one week. Practice averaged 30 minutes per day and consisted simply of repeated oral reading of the assigned selection to increase speed and fluency. At the following weekly session, the practiced selection was read once and timed. A new selection of similar difficulty was then read and timed. Initial and practiced reading rates were charted. To provide a more sensitive measure for assessing gain in reading speed, rate was recorded in syllables per minute rather than words per minute. A syllables-per-minute measure takes into account word length which tends to increase with more "difficult" material (Coke, 1974; Coleman, 1971 ). A comparison was made of initial reading rate on new (unpracticed) material over the three-month period. The patient was always aware of his progress.

Other procedures were assigned relatively little time and attention during this period. Practice on the high frequency words and use of the Controlled Reader were continued for only a short time. The patient reported some practice in visually tracking along the lines of print as his wife read to him at home.

Results

There was a steady increase in initial reading speed on new selections each week. Rate increased from an initial 66 syllables per minute in September to 94 syllables per minute in December, a gain of approximately 42%. In addition, a comparison of average rate of reading on the Gray Oral Reading Test (paragraphs 4 through 11) administered in May 1971 and the same test administered in December 1971 was made. Average reading speed on this test increased from 76 spm in May to 114 spm in December, a 50% gain in rate.'

The patient's subjective report supports the measured gain in reading speed. He announced at the end of the tutoring program in December 1971 that he could for the first time since his surgery read the newspaper fluently enough to enjoy that activity. He added that at that point he was able to read credit applications completed by his customers quickly enough that they remained unaware of his reading problem.

Discussion

With the MOR technique, reading speed appears to be increased by repetitive practice. However, it is not the element of repetition which distinguishes MOR from traditional reading approaches. All reading methods incorporate repetitive practice of some unit of the written language. The unit may be the phonogram (spelling pattern) smaller than the word (fat, cat, rat), the word (Run, run. See Bob run), or parts of phrases or short sentences (I see something blue. I see something big). Rarely however are units larger than the sentence systematically repeated. It is the inclusion of extended repetition of language units larger than the sentence which distinguishes the MOR technique. For this patient, selections repeated were about 600 words in length.

1 There is of course the possibility here of a test-retest effect, but it rna)! be added that a comparison of rate on the same test administered in January 1971 and the May 1971 test shows only an 18% increase.

Rehabilitation of alexia 143

The question arises as to why MOR should facilitate reading speed. It has long been known that words can be read faster in context than in random lists (Cattell, 1885; Biemiller, 1974). Presumably the syntactic/semantic constraints available in context permit faster processing of the component words. In other words, the structure provided by the whole facilitates processing of the parts. A whole-to-part view of reading is exemplified by the theoretical approaches taken by Smith (1971) and Goodman (1967). Generally, these approaches emphasize the larger syntactic/ semantic aspects of language. Accurate word identification is not deemed necessary as long as the meaning is retained. By contrast, in the MOR technique, a high level of word identification accuracy is encouraged.

A part-to-whole view of reading would require that a sufficient number of words be recognized quickly and "automatically" enough to permit them to be "chunked" into a syntactic/semantic unit within the limits of short term memory capacity (cf Smith, 1971; Laberge and Samuels, 1974). In the earlier stages of the remedial program for this patient, the focus was placed on repetitive practice of individual high frequency words in isolation from context. The part-to-whole viewpoint is implicit in this strategy.

These two contrasting views (part-to-whole versus whole-to-part) are not necessarily mutually exclusive. It seems likely that both processes must occur simultaneously and interactively for efficient fluent reading. Rumelhart (197 6) has developed a parallel interactive model of reading which seems more nearly representative of the reading process viewed in this way. Such a model would permit facilitation to occur in more than one direction, between word identification, syntactic structure and the semantic component, for example. With MOR, the parts (words, at this level) are being practiced to the point of fluency within the structure of the whole (syntactic/semantic organization). The MOR technique may owe its success to the fact that all components of written language structure are simultaneously maintained over practice. Repeated processing of the same structural organization may be necessary to establish (or reestablish) the optimal relationship between the various levels of that organization.

Over the past several years, the MOR technique has been carried out with three selected clinical cases of dyslexia. These young patients had in common the characteristic of unusually slow visual-verbal processing in the face of normal measured intelligence. The technique has proven successful in all three cases, producing an increase in reading speed comparable to that achieved by the patient reported here.

SuMMARY

This case study described the success of a technique labeled Multiple Oral Rereading (MOR) in the remediation of a case of acquired alexia in an adult male. Unusually slow visual-verbal processing characteristic of this patient is sometimes noted in dyslexic children. The possibility that MOR might prove effective for other selected cases of acquired alexia and "developmental" dyslexia is considered.

REFERENCES

BIEMILLER, A. (1974) Relationships between oral reading rates for letters, woras, ana stmple text, and the development of reading ability, ERIC, ED 092 911.

CATTELL, ]. (1885) Vber die Zeit de Erkennung und Benennung von Schreiftzeichen, Bildern,

144 S. B. Moyer

und Farben, Philosophische Studien, 2, 635-650 (translated by R. Woodworth in ]ames McKeen Cattell, Man of Science, Science Press, Lancaster, Pa., 1947.)

CoKE, E. (1974) The effects of readability on oral and silent reading rates, Educat. Psycho!., 66' 406-409.

CoLEMAN, E. (1971) Developing a technology of written instruction. Some determiners of the complexity of prose, in Verbal Learning Research and Technology of Written Instruction, ed. by E. Rothkopf and P. E. Johnson, Teachers College Press, Columbia University, New York.

DENCKLA, M., and BoWEN, F. ( 1973} Dyslexia after left occipitotemporal lobectomy: a case report, Cortex, 9, 321-332.

-, and RuDEL, R. (1974) Rapid "automatized" naming of pictured objects, colors, letters,

and numbers by normal children, Cortex, 10, 186-202. FERNALD, G. (1943) Remedial Techniques in Basic School Subjects, McGraw-Hill, New York, GooDMAN, K. (1967) Reading: A psycholinguistic guessing game, ]. Read. Spec., 6, 126-135. LABERGE, D., and SAMUELS, S. (1974) Toward a theory of automatic information processing

in reading, Cogn. Psycho!., 79, 835-844. NEWCOMBE, F., and MARSHALL, ]. (1973) Stages in recovery from dyslexia following a left

cerebral absces, Cortex, 9, 329-332. RuMELHART, D. (1976) Toward an interactive model of reading, technical report No. 56,

Center for Human Information Processing, University of California at San Diego, San Diego, California.

SHALLICE, T., and WARRINGTON, E. (1975) Word recognition in a phonemic dyslexic patient, Quart. J. Exper. Psycho!., 27, 187-199.

SMITH, F. (1971) Understanding Reading, Holt, Rinehart and Winston, New York. SPRING, C., and CAPPS, C. (1974) Encoding speed, rehearsal, and probed recall of dyslexic

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Human Resources Research Organization, Alexandria, Virginia.

Sandra B. Moyer, Assistant Professor of Education, South Campus Courts, Building E, Purdue University, West

Lafayette, Indiana 47907, USA.