Using a digital spelling aid to improve writing in persons with post-stroke aphasia: An intervention study.

BACKGROUND: Intervention studies aimed to improve the written production of single words by persons with aphasia have yielded promising results and there is growing interest in interventions targeting text writing. The development of technical writing aids offers opportunities for persons with aphasia, and studies have shown that using them can have a positive impact on written output. AIMS: The aim was to investigate what impact training to use a computerised spell checker had on text writing in persons with aphasia. METHODS & PROCEDURES: The study had a multiple-baseline single-case experimental design replicated across six male Swedish participants with mild-to-moderate post-stroke aphasia. The participants received training twice a week during 8 weeks, learning how to use the spell checker. At baseline and before every session, the participants wrote two texts which were logged in a keystroke-logging tool. Dependent variables were continuously measured in the texts, and the participants performed tests of language function and answered questionnaires on reading and writing habits and health-related quality of life before and after the intervention. The participants were also interviewed about how they had experienced the training. The results were evaluated on individual and group level. RESULTS: The study showed that systematic individual training involving a spell checker was experienced as positive by the participants and that they all described their writing ability in more positive terms after the intervention. Evaluation showed statistically significant improvements on group level for the dependent variables of spelling accuracy, rated syntax, writing speed and proportion of unedited text during text writing when using the spell checker. The intervention also had a generalising effect on writing speed and editing during text writing without the spell checker and on spelling accuracy in a dictation test. The participants who had the greatest spelling problems were the ones who showed the most progress, but participants with only minor writing difficulties at baseline also improved. CONCLUSIONS & IMPLICATIONS: The study shows that a digital spelling aid constitutes effective support for people with aphasia and may also affect levels other than spelling. The training had a generalising positive effect on text writing and spelling in a test. Although writing difficulties is a persisting symptom in aphasia, it can be supported and improved through use of digital spelling aids. Hence, treatment of writing ability should always be included in the rehabilitation of people with aphasia. WHAT THIS PAPER ADDS: What is already known on this subject Use of a technical writing aid can have a positive impact on the written output of persons with aphasia. Using a digital spell checker may improve spelling as well as other levels of writing, but it has not been investigated using a keystroke-logging tool in combination with language-test scores and results from questionnaires. What this paper adds to existing knowledge Through analyses on both individual and group level, this study shows that a digital spelling aid constitutes effective support for people with aphasia and also affects levels other than spelling. The training had a generalising positive effect on text writing and spelling in a test. What are the potential or actual clinical implications of this work? Digital spelling support, which is a relatively simple and inexpensive technology, can support and improve text writing in persons with post-stroke aphasia.

Intervention for a lexical reading and spelling difficulty in two Greek-speaking primary age children.

An intervention study was carried out with two nine-year-old Greek-speaking dyslexic children. Both children were slow in reading single words and text and had difficulty in spelling irregularly spelled words. One child was also poor in non-word reading. Intervention focused on spelling in a whole-word training using a flashcard technique that had previously been found to be effective with English-speaking children. Post-intervention assessments conducted immediately at the end of the intervention, one month later and then five months later showed a significant improvement in spelling of treated words that was sustained over time. In addition, both children showed generalisation of improvement to untrained words and an increase in scores in a standardised spelling assessment. The findings support the effectiveness of theoretically based targeted intervention for literacy difficulties.

Re-learning to be different: Increased neural differentiation supports post-stroke language recovery.

Identifying the neural changes that support recovery of cognitive functions after a brain lesion is important to advance our understanding of human neuroplasticity, which, in turn, forms the basis for the development of effective treatments. To date, the preponderance of neuroimaging studies has focused on localizing changes in average brain activity associated with functional recovery. Here, we took a novel approach by evaluating whether cognitive recovery in chronic stroke is related to increases in the differentiation of local neural response patterns. This approach is supported by research indicating that, in the intact brain, local neural representations become more differentiated (dissimilar) with learning (Glezer et al., 2015). We acquired fMRI data before and after 21 individuals received approximately 12 weeks of behavioral treatment for written language impairment due to a left-hemisphere stroke. We used Local-Heterogeneity Regression Analysis (Purcell and Rapp, 2018) to measure local neural response differentiation associated with written language processing, assuming that greater heterogeneity in the pattern of activity across adjacent neural areas indicates more well-differentiated neural representations. First, we observed pre to post-treatment increases in local neural differentiation (Local-Hreg) in the ventral occipital-temporal cortex of the left hemisphere. Second, we found that, in this region, higher local neural response differentiation prior to treatment was associated with less severe written language impairment, and that it also predicted greater future responsiveness to treatment. Third, we observed that changes in neural differentiation were systematically related to performance changes for trained and untrained items. Fourth, we did not observe these brain-behavior relationships for mean BOLD responses, only for Local-Hreg. Thus, this is the first investigation to quantify changes in local neural differentiation in the recovery of a cognitive function and the first to demonstrate the clear behavioral relevance of these changes. We conclude that the findings provide strong support for the novel hypothesis that the local re-differentiation of neural representations can play a significant role in functional recovery after brain lesion.

Alexia and Agraphia Intervention Following Traumatic Brain Injury: A Single Case Study.

Purpose This case study documents the effectiveness of a multicomponent intervention for an adolescent with acquired alexia and agraphia following severe traumatic brain injury. Method Initial testing revealed severe central alexia and surface agraphia with concomitant anomic aphasia. Intervention components included sight word drills, modified Multiple Oral Reading (MOR) procedures, functional reading tasks, and modified Copy and Recall Treatment. Intervention spanned 2 months with sessions 5 days per week. Data collection and analysis involved monitoring sight word decoding, reading speed and decoding errors during MOR, and spelling accuracy of Copy and Recall Treatment words. Follow-up testing occurred at intervention conclusion. Results Sight word mastery for 315 words progressed from 66.35% to 100% over 5 weeks and was maintained thereafter. MOR materials progressed from Grade 1 to Grade 5. Initial reading speed was 31 words per minute with errors on 15% of words. At program completion, reading speed was 47 words per minute with 7% decoding errors despite increased difficulty of reading material. The participant demonstrated initial mastery of 15 spelling lists containing 15 words each and sustained mastery (2 additional consecutive weeks of 100% accuracy) of 8 lists. Follow-up assessment revealed improvements consistent with 3-4 grade levels but persistent impairment relative to premorbid functioning. Conclusion The multicomponent program was effective in promoting substantial improvement, although surface alexia and agraphia persisted after 2 months of treatment. The case provides an example of the type and extent of progress possible given minimal initial recovery but systematic intervention within the context of intensive postacute rehabilitation.

Multi-step treatment for acquired alexia and agraphia (Part I): efficacy, generalisation, and identification of beneficial treatment steps.

Reading and writing impairments are common in individuals with post-stroke aphasia. Treatment typically aims to improve the function of one of these modalities by strengthening aspects of either lexical or sublexical processing. In the present study, eight adults with acquired alexia and agraphia were administered a comprehensive treatment targeting specific lexical and sublexical processes underlying reading and/or writing. Two participants were trained in reading and six were trained in writing. Throughout treatment, reading and writing accuracy were monitored for trained items, as well as untrained but orthographically and semantically related items. Linear mixed effects models indicated that the most substantial gains were made on trained items in the trained modality; generalisation to trained items in the untrained modality and untrained but related items in both modalities was also observed. Participants improved significantly on a subset of treatment steps intended to address lexical access and representations, sublexical conversion mechanisms, and the graphemic and/or phonological buffer processes in both modalities. These results demonstrate the efficacy of a novel, comprehensive treatment protocol and suggest that targeting multiple reading and writing processes in conjunction may facilitate widespread generalisation.

Multi-step treatment for acquired alexia and agraphia (part II): a dual-route error scoring system.

Dual-route neuropsychological models posit two distinct but interrelated pathways for reading and writing: the lexical and the sublexical. Individuals with reading/writing deficits often rely on the combined power of the integrated system to perform print-processing tasks. The resultant errors reflect varying degrees of lexical and sublexical accuracy in a single production; however, no system presently exists to analyze errors robustly in both routes. The goal of this project was to develop a system that simultaneously, quantitatively, and qualitatively captures changes in lexical and sublexical errors following treatment. Errors are evaluated hierarchically in both routes according to proximity to a target. This dual-route error scoring (DRES) system was developed using data from a novel treatment study for eight patients with acquired alexia/agraphia; a computerised version of the system was also developed (ADRES). Repeated-measures multivariate analyses of variance and post hoc analyses revealed significant dual-route treatment effects. Qualitative analyses revealed unique patterns of change across participants, reflecting the benefits of error evaluation beyond a binary correct/incorrect judgment. Finally, categorical error shifts were observed via group-level analysis. The results of this study indicate that treatment-induced evolution of reading/writing can be meaningfully and comprehensively represented by this novel scoring system.

Technology-enhanced writing therapy for people with aphasia: results of a quasi-randomized waitlist controlled study.

BACKGROUND: Acquired writing impairment, or dysgraphia, is common in aphasia. It affects both handwriting and typing, and may recover less well than other aphasic symptoms. Dysgraphia is an increasing priority for intervention, particularly for those wishing to participate in online written communication. Effective dysgraphia treatment studies have been reported, but many did not target, or did not achieve, improvements in functional writing. Functional outcomes might be promoted by therapies that exploit digital technologies, such as voice recognition and word prediction software. AIMS: This study evaluated the benefits of technology-enhanced writing therapy for people with acquired dysgraphia. It aimed to explore the impact of therapy on a functional writing activity, and to examine whether treatment remediated or compensated for the writing impairment. The primary question was: Does therapy improve performance on a functional assessment of writing; and, if so, do gains occur only when writing is assisted by technology? Secondary measures examined whether therapy improved unassisted written naming, functional communication, mood and quality of life. METHODS & PROCEDURES: The study employed a quasi-randomized waitlist controlled design. A total of 21 people with dysgraphia received 12 h of writing therapy either immediately or after a 6-week delay. The primary outcome measure was a functional assessment of writing, which was administered in handwriting and on a computer with assistive technology enabled. Secondary measures were: The Boston Naming Test (written version), Communication Activities of Daily Living-2, Visual Analogue Mood Scales (Sad question), and the Assessment of Living with Aphasia. Analyses of variance (ANOVA) were used to examine change on the outcome measures over two time points, between which the immediate group had received therapy but the delayed group had not. Pre-therapy, post-therapy and follow-up scores on the measures were also examined for all participants. OUTCOMES & RESULTS: Time × group interactions in the ANOVA analyses showed that therapy improved performance on the functional writing assessment. Further interactions with condition showed that gains occurred only when writing was assisted by technology. There were no significant interactions in the analyses of the secondary outcome measures. A treatment effect on these measures was therefore unconfirmed. CONCLUSIONS & IMPLICATIONS: This study showed that 21 people with dysgraphia improved on a functional writing measure following therapy using assistive technology. The results suggest that treatment compensated for, rather than remediated, the impairment, given that unassisted writing did not change. Further studies of technology-enhanced writing therapy are warranted.

Maximising recovery from aphasia with central and peripheral agraphia: The benefit of sequential treatments.

Maximal recovery from acquired language impairment may require progression from one behavioural treatment protocol to the next in order to build upon residual and relearned cognitive-linguistic and sensory-motor processes. We present a five-stage treatment sequence that was initiated at one year post stroke in a woman with acquired impairments of spoken and written language. As is typical of individuals with left perisylvian damage, she demonstrated marked impairment of phonological retrieval and sublexical phonology, but she also faced additional challenges due to impaired letter shape knowledge and visual attention. The treatment sequence included (1) written spelling of targeted words, (2) retraining sublexical sound-to-letter correspondences and phonological manipulation skills, (3) training strategic approaches to maximise interactive use of lexical, phonological, and orthographic knowledge, (4) lexical retrieval of spoken words, and finally (5) sentence-level stimulation to improve grammatical form of written narratives. This Phase II clinical study documented positive direct treatment outcomes along with evidence of a significant reduction in the underlying deficits and generalisation to untrained items and language tasks. Improvements on a comprehensive assessment battery were realised as functional gains in everyday written and spoken communication, including improved lexical retrieval and grammatical complexity of written narratives. This case provides a valuable example of the cumulative therapeutic benefit of sequential application of theoretically motivated treatment protocols.

The neural substrates of improved phonological processing following successful treatment in a case of phonological alexia and agraphia.

Phonological deficits are common in aphasia after left-hemisphere stroke, and can have significant functional consequences for spoken and written language. While many individuals improve through treatment, the neural substrates supporting improvements are poorly understood. We measured brain activation during pseudoword reading in an individual through two treatment phases. Improvements were associated with greater activation in residual left dorsal language regions and bilateral regions supporting attention and effort. Gains were maintained, while activation returned to pre-treatment levels. This case demonstrates the neural support for improved phonology after damage to critical regions and that improvements may be maintained without markedly increased effort.

Developmental writing disorders: assess to rehabilitate.

BACKGROUND: Writing ability requires to use and control several processes of visual and phonological information processing and an adequate programming and coordination of motor sequences. We studied a writing precursor gesture in children with developmental dysorthography and/or developmental dysgraphia in order to point out anomalies to be treated with specific rehabilitative interventions. METHODS: Twenty-five children affected by developmental dysortography (ICD 9 CM: 315.09; ICD 10: F81.1) and/or developmental dysgraphia (ICD 9 CM: 315.2; ICD 10: F81.8) (mean age 9.1 years [range: 6.3-11.4 years]) ran a maze, project in front of them, using a wireless mouse. Data regarding angular excursions, execution times and gesture accuracy were collected and elaborated using Dartfish 6.0 software and the labyrinth generating program (PRINC), and compared with normative data previously obtained from a sample of 226 healthy children of the same age and grade. RESULTS: The comparison did not evidence significant differences regarding gesture structure (trajectories of arm segments and angular excursions of interested joints). Angular and temporal execution patterns were reached in delay in these children. No correlation was found with general cognitive and visuomotor integration skills; a deficit of visual attention was associated with an abnormal elbow range of motion. CONCLUSIONS: Although these findings need to be confirmed in larger studies, data obtained evidence that children with developmental writing disorders have a time delay in the acquisition of writing motor patterns and not an alteration of gesture structure itself. This has relevant implications for the rehabilitative approach.

Improving the Historical Knowledge and Writing of Students With or At Risk for LD.

In this study, we explored the potential of two forms of discussion (disciplinary vs. traditional) for 39 sixth- and seventh-grade students with or at risk for learning disabilities (LD), before writing historical arguments. Nine teachers who led small group discussions in six heterogeneous social studies classrooms implemented the intervention. Students who were involved in disciplinary discussions ( n = 19) scored statistically higher than their peers who engaged in traditional discussions ( n = 20) on a measure of historical knowledge (partial η2 = .23); they also wrote essays with better persuasive quality (partial η2 = .43) and greater evidence of historical thinking (partial η2 = .40). A delayed posttest delivered 8 weeks after instruction ended revealed that students in the experimental condition continued to write in more historically sophisticated ways than did students in the comparison condition (partial η2 = .19). Challenges, however, remain for struggling learners who must now meet basic and advanced disciplinary literacy goals.

Impaired Retention of Motor Learning of Writing Skills in Patients with Parkinson's Disease with Freezing of Gait.

BACKGROUND: Patients with Parkinson's disease (PD) and freezing of gait (FOG) suffer from more impaired motor and cognitive functioning than their non-freezing counterparts. This underlies an even higher need for targeted rehabilitation programs in this group. However, so far it is unclear whether FOG affects the ability for consolidation and generalization of motor learning and thus the efficacy of rehabilitation. OBJECTIVE: To investigate the hallmarks of motor learning in people with FOG compared to those without by comparing the effects of an intensive motor learning program to improve handwriting. METHODS: Thirty five patients with PD, including 19 without and 16 with FOG received six weeks of handwriting training consisting of exercises provided on paper and on a touch-sensitive writing tablet. Writing training was based on single- and dual-task writing and was supported by means of visual target zones. To investigate automatization, generalization and retention of learning, writing performance was assessed before and after training in the presence and absence of cues and dual tasking and after a six-week retention period. Writing amplitude was measured as primary outcome measure and variability of writing and dual-task accuracy as secondary outcomes. RESULTS: Significant learning effects were present on all outcome measures in both groups, both for writing under single- and dual-task conditions. However, the gains in writing amplitude were not retained after a retention period of six weeks without training in the patient group without FOG. Furthermore, patients with FOG were highly dependent on the visual target zones, reflecting reduced generalization of learning in this group. CONCLUSIONS: Although short-term learning effects were present in both groups, generalization and retention of motor learning were specifically impaired in patients with PD and FOG. The results of this study underscore the importance of individualized rehabilitation protocols.

The role of learning in improving functional writing in stroke aphasia.

PURPOSE: Improving writing in people with aphasia could improve ability to communicate, reduce isolation and increase access to information. One area that has not been sufficiently explored is the effect of impairment based spelling therapies on functional writing. A multiple case study was conducted with eight participants with aphasia subsequent to stroke. This aimed to measure the effects of spelling therapy on functional writing and perception of disability. METHOD: Participants engaged in 10 sessions of copy and recall spelling therapy. Outcome measures included spelling to dictation of trained and untrained words, written picture description, spelling accuracy within emails, a disability questionnaire and a writing frequency diary. RESULTS: All participants made significant gains on treated words and six demonstrated improvements to untreated words. Group analyses showed significant improvements to written picture description, but not email writing, writing frequency or perceptions of disability. CONCLUSIONS: These results show that small doses of writing therapy can lead to large gains in specific types of writing. These gains did not extend to improvements in frequency of writing in daily living, nor ecological measures of email writing. There is a need to develop bridging interventions between experimental tasks towards more multi-faceted and ecological everyday writing tasks. Implications for Rehabilitation Acquired dysgraphia can restrict people from participating in social, educational and professional life. This study has shown that copy and recall spelling therapies can improve the spelling of treated words, untreated words and written picture description in people with a range of types and severities of dysgraphia following stroke. The results of this study suggest that more specific additional training is required for other writing activities such as email writing.

Comparing uni-modal and multi-modal therapies for improving writing in acquired dysgraphia after stroke.

Writing therapy studies have been predominantly uni-modal in nature; i.e., their central therapy task has typically been either writing to dictation or copying and recalling words. There has not yet been a study that has compared the effects of a uni-modal to a multi-modal writing therapy in terms of improvements to spelling accuracy. A multiple-case study with eight participants aimed to compare the effects of a uni-modal and a multi-modal therapy on the spelling accuracy of treated and untreated target words at immediate and follow-up assessment points. A cross-over design was used and within each therapy a matched set of words was targeted. These words and a matched control set were assessed before as well as immediately after each therapy and six weeks following therapy. The two approaches did not differ in their effects on spelling accuracy of treated or untreated items or degree of maintenance. All participants made significant improvements on treated and control items; however, not all improvements were maintained at follow-up. The findings suggested that multi-modal therapy did not have an advantage over uni-modal therapy for the participants in this study. Performance differences were instead driven by participant variables.

Neurorehabilitation applied to specific learning disability: Study of a single case.

BACKGROUND: Specific Learning Disorders (SLD) therefore represent chronic, not temporary disorders with varying degrees of expression throughout life. The beginning of imaging, anatomy and genetics studies have made it possible to investigate the brain organization of individuals suffering from SLD (Deheane, 2009). OBJECTIVES: The purpose of this paper is to describe a treatment method for reading and writing disorders through an intervention based on the integration of a sublexical method and a neuropsychological approach, with assistive technologies in the study of a single case. METHODS: The protocol is based on the modularization theory (Karmiloff-Smith, 1990). The data presented in this paper with a A-B-A basic experimental drawing. RESULTS: This study confirms the degree of effectiveness of the treatments based on the automated identification of syllables and words together with the integrated enhancement of neuropsychological aspects such as visual attention and phonological loop (Benso, 2008), although in the follow-up condition only some abilities maintain the progress achieved. CONCLUSIONS: As previously mentioned, the SLD represents a chronic disorder, consequently the treatment does not solve the root cause of the problem, but can grant a use of the process decidedly more instrumental to everyday life.

[Dystypia after ischemic stroke: a disturbance of linguistic processing for Romaji (Romanized Japanese)?].

"Dystypia", characterized by an impairment of typing on a keyboard, is a unique neurobehavioral syndrome. A 77-year-old right-handed woman developed a relatively selective impairment of typing after ischemic stroke. The MRI documented new scattered ischemic lesions in the middle cerebral artery territory of the left hemisphere and an old infarct lesion in the frontal area of the right hemisphere. The standard neuropsychological tests showed no aphasia, normal praxis, intact visuospatial ability, and a mild visual memory disturbance. The detailed analysis documented severe impairment of writing and reading abilities for Romaji (Romanized Japanese), spelled by alphabet letters and the most common way to input Japanese into computers. The writing and reading abilities for other Japanese linguistic modalities such as kanji (morphogram: Chinese character), kana (syllabogram: Japanese proper character), and alphabet letters, were not or minimally impaired. A disturbance of linguistic processing for Romaji may be the main underlying neural mechanism for dystypia in this patient.

Efficacy of a task-based training approach in the rehabilitation of three children with poor handwriting quality: a pilot study.

Evidence suggests that task-based training approaches can improve the performance of children with handwriting difficulties. The present case study tests the efficacy of the Handwriting Task Program (HTP). Three male children (9-10 yr. old) with poor handwriting skills and different developmental disorders participated in the HTP, twice per week, for 13 wk. Handwriting legibility was assessed through the Concise Evaluation Scale for Children's Handwriting, and fine motor performance and handwriting speed were evaluated at pre- and post-treatment with the Visual Motor Integration Test and the Battery for the assessment of writing skills of children from 7 to 13 yr. old. The results showed that motor efficiency and global handwriting quality improved in all the children, although some handwriting difficulties still persisted in one child with Developmental Coordination Disorder (DCD). Further study may confirm on a larger sample that a visual-spatially based training may improve the handwriting legibility of children with DCD.

Breaking down number syntax: spared comprehension of multi-digit numbers in a patient with impaired digit-to-word conversion.

Can the meaning of two-digit Arabic numbers be accessed independently of their verbal-phonological representations? To answer this question we explored the number processing of ZN, an aphasic patient with a syntactic deficit in digit-to-verbal transcoding, who could hardly read aloud two-digit numbers, but could read them as single digits ("four, two"). Neuropsychological examination showed that ZN's deficit was neither in the digit input nor in the phonological output processes, as he could copy and repeat two-digit numbers. His deficit thus lied in a central process that converts digits to abstract number words and sends this information to phonological retrieval processes. Crucially, in spite of this deficit in number transcoding, ZN's two-digit comprehension was spared in several ways: (1) he could calculate two-digit additions; (2) he showed good performance in a two-digit comparison task, and a continuous distance effect; and (3) his performance in a task of mapping numbers to positions on an unmarked number line showed a logarithmic (nonlinear) factor, indicating that he represented two-digit Arabic numbers as holistic two-digit quantities. Thus, at least these aspects of number comprehension can be performed without converting the two-digit number from digits to verbal representation.

Training a new generation of speech-language pathologists with competences in the management of literacy disorders and learning disabilities in Hong Kong.

One of the recent developments in the education of speech-language pathology is to include literacy disorders and learning disabilities as key training components in the training curriculum. Disorders in reading and writing are interwoven with disorders in speaking and listening, which should be managed holistically, particularly in children and adolescents. With extensive training in clinical linguistics, language disorders, and other theoretical knowledge and clinical skills, speech-language pathologists (SLPs) are the best equipped and most competent professionals to screen, identify, diagnose, and manage individuals with literacy disorders. To tackle the challenges of and the huge demand for services in literacy as well as language and learning disorders, the Hong Kong Institute of Education has recently developed the Master of Science Programme in Educational Speech-Language Pathology and Learning Disabilities, which is one of the very first speech-language pathology training programmes in Asia to blend training components of learning disabilities, literacy disorders, and social-emotional-behavioural-developmental disabilities into a developmentally and medically oriented speech-language pathology training programme. This new training programme aims to prepare a new generation of SLPs to be able to offer comprehensive support to individuals with speech, language, literacy, learning, communication, and swallowing disorders of different developmental or neurogenic origins, particularly to infants and adolescents as well as to their family and educational team.

Rehabilitation of spelling in a participant with a graphemic buffer impairment: the role of orthographic neighbourhood in remediating the serial position effect.

Graphemic Output Buffer (GOB) disorder is defined as difficulty with the serial output of a sequence of letters in the output stage of the spelling process. In their rehabilitation study with a GOB patient, Sage and Ellis ( 2006 ) found that improvement on treated words generalised to untreated words from the same orthographic neighbourhoods as treated items, but not to other unrelated words. GOB patients frequently show a bow-shaped accuracy curve across letter positions, where letters at the middle positions are most error-prone. It may be that consistent letters at these middle letter positions across neighbourhoods modulate this effect. Spelling was treated using an Anagram and Copy Treatment (ACT) and generalisation to three untreated sets was examined: (1) neighbours of treated words with shared middle letters (e.g., clock-block), (2) neighbours with different medial position letters (e.g., clock-click), and (3) unrelated words (e.g., clock-puppy). Improvement was found for untreated neighbours with shared middle letters. There was no effect of training on the unrelated word set, and a negative impact on untreated neighbours with changed middle letters after the treatment. We attribute these results to top-down support from learned lexical representations, which facilitate spelling of untreated neighbours with shared middle letters but impede neighbours with changed middle letters. This latter result is attributed to interference from neighbours in the trained set strengthening competing letter representations at middle positions.