Part 3: Medstar National Rehabilitation Hospital Workshop, March 2019

Pélagie M. Beeson, Ph.D., CCC-SLP Department of Speech, , and Hearing Sciences  Consider 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 Treatment Sequence for Phonological Impairment Perisylvian Aphasia with Perisylvian Aphasia with Global Phonological Agraphia Oral reading tx Stimulate production of morphosyntax Lexical-Semantic Tx (inclusion of functors and morphological Phonological Tx markers) Interactive Tx (words) Interactive Tx (sentences) Problem-solving approach to spelling in sentence context

Sentence CART Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level

Lexical Retrieval Tx Phonological alexia and agraphia phonological “ ” dusp dusp impairment is evident by difficulty

Semantics with nonwords

Phonologic whole words Orthographic Lexical Lexicon Lexicon Lexical sound-letter Sub-lexical Phonemes Graphemes Sub-lexical letter-sound

Speech Motor Graphic Motor Programs Programs

“dust?” druffs Phonological Phonological Alexia Agraphia Impaired phonology is often associated with impaired reading accuracy for text The family was having dinner out at the restaurant.

Semantics

Phonologic Orthographic Lexicon Lexicon

Phonemes Graphemes

“People had dinner out.” Reading errors at sentence level  56 year-old, right-handed male ◦ 100 S troke affecting left frontal, 90 parietal, and temporal lobes 80 70  60 12 years education Words 50 Nonwords  5 months post- 40 30 ◦ WAB AQ: 64.4 PercentCorrect 20 10 Broca’s Aphasia 0  1.5 years post stroke Reading Writing ◦ WAB AQ 77.6 At 3 years post-stroke Phonological alexia + global agraphia Broca’s  Borderline Fluent On an empty lot near the park many people were hard at work.

“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 Gray Oral Reading Test-III people were … hired to work.” Level 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 transcoding Friedman. R. (1996) On an empty lot near the park  Slow, errorful text-level many people were hard at reading work.  Particular difficulty with “Lot on empty is … On the lot, functors and morphological on empty … On the empty lot … lot the .. On the empty lot markers near a park …the uh, many  Part of speech effect people were … hired to work.” ◦ nouns > adjectives > verbs > functors  May paraphrase because they are perceiving the gist, but not reading every word  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 The Romans were the first to make keys of iron. ◦ Incorrect productions corrected ◦ Repeat until mastery achieved 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 until accurate ◦ 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). Gray Oral Reading Test-3 Levels 1-5 GORT-3 Results 100% 60

80% 50 40 60% Accuracy 30 40% Rate 20 Reading Rate 20% 10 Reading Accuracy Reading 0% 0 Pre-Testing Post-Testing

Significant improvement in reading accuracy No significant change in reading rate Orjada and Beeson (2005)  Recall that written spelling was markedly impaired 100 Real Words Nonwords 90 80 summer flig 70 60 Words debt hoach 50 40 Nonwords enough 30

snite PercentCorrect 20 bake glope 10 0 worm boak Reading Writing blood cheed At 3 years post-stroke Phonological alexia + global maybe smode agraphia  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) Response to Copy and Recall Treatment (CART) implemented concurrent with oral reading treatment. 5 words/set 50 words mastered 10 weeks of treatment

Orjada and Beeson (2005) 100%

80%

60%

40% Accuracy 20%

0% Reading Writing Reading Writing Functors Functors Functors Functors Pre-Test Post-Test Significant improvement reading functors (p = .02) Significant improvement writing functors (p = .01)

described in Orjada and Beeson (2005). WAB picture description Conversation

Pre-Tx During Tx Post-Tx Post-Tx

MLU in 3.62 6.32 7.40 9.47 words One-word 30.8% 4.6% 8.3% 0% utterances  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 Full Treatment Sequence for BB (Broca’s aphasia with Phonological Alexia and Global Agraphia) Perisylvian Aphasia with Global Agraphia

Lexical-Semantic Tx Phonological Tx Interactive Tx Oral Reading Tx retrain spelling for specific words (and stimulate spoken retrain sound-letter production of targeted words) correspondences and train problem-solving phonological strategies to self-correct Stimulate production of manipulation skills spelling errors morphosyntax (inclusion of functors and morphological markers) at sentence level Lexical Retrieval Tx

train lexical retrieval strategies including semantic, orthographic, and phonological self-cuing

Postscript: Oral reading treatment followed by lexical retrieval treatment Boston Naming Test 27/60  36/60 Treatment Sequence for Phonological Impairment Perisylvian Aphasia with Perisylvian Aphasia with Global Agraphia Phonological Agraphia Oral reading tx Stimulate production of morphosyntax Lexical-Semantic Tx (inclusion of functors and morphological Phonological Tx markers) Interactive Tx (words) Interactive Tx (sentences) Problem-solving approach to spelling in sentence context

Sentence CART Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level

Lexical Retrieval Tx  Case Example ◦ 3 years post onset  WAB Aphasia Quotient = 74.3 Single Word Reading/Writing Pre-Tx 100  Phonological alexia 90 80  Relatively intact single word reading L 70  60 reg Severely impaired nonword reading 50 irreg 40  Global Agraphia correct % 30 non  Unable to spell real words or 20 10 nonwords 0 reading writing

 Previously received: Lexical spelling tx Phonological tx Interactive tx  Implement: Oral reading treatment (supported oral reading treatment) 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 and] when they left their buil, their homes.”  Slow, errorful text-level “In Greece, long ago [before], reading people had locks and keys. But  they had a hard time [giving] Particular difficulty with taking their keys with them [and functors and morphological then] when they left their markers homes.”  Part of speech effect ◦ nouns > adjectives > verbs > functors  May paraphrase because they are perceiving the gist, but not reading every word  Therapy 2 x week for 6 weeks  Daily homework: repeated oral reading of targeted text

P1 Practice Text

60 55 50 45  Target: 50 wpm for 40 Text 1 35 Text 2 practice texts 30 Text 3  <5 errors/ 100 words 25 Text 4 20 Text 5 15 Reading Reading Rate: WPM 10 5 0 1 2 3 4 5 6 7 8 9 10 11 Pre Tx 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.

Post Tx In 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. Locks and Keys Petra (2nd grade level) (12th grade level)

Error rate Error rate Rate (wpm) Rate (wpm) (per 100wd) (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 Treatment Sequence for Phonological Impairment Perisylvian Aphasia with Perisylvian Aphasia with Global Agraphia Phonological Agraphia Oral reading tx Stimulate production of morphosyntax Lexical-Semantic Tx (inclusion of functors and morphological Phonological Tx markers) Interactive Tx (words) Interactive Tx (sentences) Problem-solving approach to spelling in sentence context

Sentence CART Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level

Lexical Retrieval Tx  50 year-old male  16 years of education  5 years post large LMCA stroke due to carotid artery dissection  Broca’s evolved to ◦ WAB: 80.7 ◦ BNT: 50/60

WAB picture description (pre-treatment) Phonological Alexia with Global Agraphia Reading: Words Spelling: Words sister machine ST 100 sword head 90 laugh ENIT 80 chant kept 70 LANELY storm 60 Single Word island 50 Reading/Spelling 40 flig Reading: Nonwords Spelling: Nonwords 30 flop

20  hoach FID flig 10 soak 0 cheed hoach Reading Spelling OST cheddar Words Nonwords smode LIFN mofer smore Impaired Text Level Writing

Well-Formed and Complete Sentences 100 90 80 70 60 50 40 %Correct 30 20 “The boy has a book. 10 The Tree is LeTT. 0 And…he’s got a sandwich The CAR is iN ThE DivNe He Sentence Well Formed and complete somewhere. The girl has The MAN a BooK. Spoken Written some coffee. I don’t know The Women an a piNNeN BAD. what type of coffee, maybe THE is a FaLe. it’s Starbucks. There’s a car. THE is a BooM The Fise PoNe. But…you know, it’s off. Treatment Sequence for Phonological Impairment Perisylvian Aphasia with Global Agraphia

Lexical-Semantic Tx 4 weeks Phonological Tx Vowels: 3 weeks Interactive Tx Blending: 10 12 weeks Sentence Writing Tx retrain spelling for weeks specific words retrain sound-letter 12 weeks correspondences and phonological manipulation skills train problem-solving Stimulate written strategies to self- sentences with copy correct spelling errors and recall treatment. 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 Example Passages from 3 different participants  5 personal, written narratives I did a bodybuilding contest. ◦ Developed with patient/family I exercised for months. input I was a stroke survivor. ◦ Each passage of similar length and It was my proudest moment. complexity When I was 28 I lived in Antarctica.  4-6 sentences The weather was 70 degrees below zero.  5-10 words per sentence I had to pass physical and mental exams.  Complexity will vary by patient I worked at the Byrd Station for 18 months. ◦ Topics of personal relevance I collected data to study the atmosphere.  Work history Gardening is one of my favorite things to do.  Favorite vacation My house sits on a one acre lot.  Hobbies My husband and I landscaped the whole yard ourselves.  Personal anecdotes Our yard has a fountain and a covered patio. I love flowers and making the garden beautiful.  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 Target I did a body building contest. I exercised for months. I was a stroke survivor.  Treatment It was my proudest moment. ◦ 1 hour sessions, 2 times per week Pre-Tx ◦ Criterion: 80% accuracy writing I DID BODY CONTIC. passage to dictation over 2 I EXRSEZ FOR MONS. consecutive sessions ◦ Length of Treatment: 5-12 weeks I WAS A STORK SUREVER

Trained Passages 100 5 IT WAS MY PROUDET MOMINT Post-Tx 80 4 I DID A BODY BUILDING CONTEST. 60 3 40 2 I EXERCISED FOR MONTHS. % Correct

20 1 Rate: WPM I WAS A STROKE SURVIVOR 0 0 Baseline Treatment Maintenance Accuracy Rate IT WAS MY PROUDEST MOMENT. Response to Treatment Sequence Lexical (CART)  Phonological  Interactive  Sentence CART

Phonological Skills 100 Single Word Reading/Spelling 90 100 80 90

70 80 70 60 Phonological 60 50 Manipulation 50 Phonology- 40 40 Orthography 30 30 20 20 10 10 0 0 Reading Words Reading Spelling Words Spelling Pre Post Nonwords Nonwords Pre Post With Speller Well-formed and Complete Before Tx Sentences The Tree is LeTT. 100 The CAR is iN ThE DivNe He 80 The MAN a BooK. 60 The Women an a piNNeN BAD. 40 THE is a FaLe. 20 0 THE is a BooM The Fise PoNe. After Tx Pre Post Post CART Interactive Sentences THE is A FiSHiNG BOAT THAT HAS A BOY ON BOARD. Mean Sentence Length 10 THE BOY IS FLYiNG A KITE AN HE THIS PULLING 8 A SiRiNG. 6 HE PUT HiS GLASSING ON AND HAD A BOOK IN 4 IS HAND. 2 0 THERE IS A TREE THAT IS BLOOMING. Pre Post Interactive Post CART THERE IS A RADiO THAT IS SOOTHiNG. Sentences  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 2 2 Sentences Well Formed and Complete Mean Written Sentence Length 100 90 12 80 P1 P1 70 10 P2 P2 60 8 50 Percent P3 P3 40 6 P4 Number of words 30 P4 4 20 10 2 0 Pre-Tx Post-Phon Post-Int Post-CART 0 Sent Pre-Tx Post-Phon Post-Int Post-CART Sent  The most common perisylvian have a persistent, marked impairment of phonological skills ◦ Broca’s, Wernicke’s, Conduction, and , 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 A sequential treatment approach can maximize recovery

Perisylvian Aphasia with Perisylvian Aphasia with Global Agraphia Phonological Agraphia Oral reading tx Stimulate production of morphosyntax Lexical-Semantic Tx (inclusion of functors and morphological Phonological Tx markers) Interactive Tx (words) Interactive Tx (sentences) Problem-solving approach to spelling in sentence context

Sentence CART Improve accuracy and speed of sentence writing with copy and recall treatment (CART) at the sentence level

Lexical Retrieval 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.