Pélagie M. Beeson, Ph.D., CCC-SLP Department of Speech, … · 2019. 3. 28. · Pélagie M. Beeson, Ph.D., CCC-SLP. Department of Speech, Language, and Hearing Sciences. Part 3:

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

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ent

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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

GORT-3 Results

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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

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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%

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100%

ReadingFunctors

WritingFunctors

ReadingFunctors

WritingFunctors

Pre-Test Post-Test

Acc

ura

cy


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


Full Treatment Sequence for BB (Broca’s aphasia with Phonological Alexia and Global Agraphia)


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







Sentence CART

Oral reading tx




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

0102030405060708090

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

1015202530354045505560

1 2 3 4 5 6 7 8 9 10 11

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







Sentence CART

Oral reading tx




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.

0102030405060708090

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



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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Pre Post With Speller

Response to Treatment Sequence

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Lexical (CART) Phonological Interactive Sentence CART

Before Tx

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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

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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




A sequential treatment approach can maximize recovery



Sentence CART

Oral reading tx




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

Documents

Pélagie M. Beeson, Ph.D., CCC-SLP Department of Speech, … · 2019. 3. 28. · Pélagie M. Beeson, Ph.D., CCC-SLP. Department of Speech, Language, and Hearing Sciences. Part 3: