Speech and Language Therapy for Acquired Central Dysgraphia in Neurological Patients: A Systematic Review to Describe and Identify Trainings for Clinical Practice.

PURPOSE: Acquired central dysgraphia is a heterogeneous neurological disorder that usually co-occurs with other language disorders. Written language training is relevant to improve everyday skills and as a compensatory strategy to support limited oral communication. A systematic evaluation of existing writing treatments is thus needed. METHOD: We performed a systematic review of speech and language therapies for acquired dysgraphia in studies of neurological diseases (PROSPERO: CRD42018084221), following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist with a search on several databases for articles written in English and published until August 31, 2021. Only methodological well-designed studies were included. Further assessment of methodological quality was conducted by means of a modified version of the Downs and Black checklist. RESULTS: Eleven studies of 43 patients in total were included. For each study, we collected data on type of population, type of impairment, experimental design, type of treatment, and measured outcomes. The studies had a medium level of assessed methodological quality. An informative description of treatments and linkages to deficits is reported. CONCLUSIONS: Although there is a need for further experimental evidence, most treatments showed good applicability and improvement of written skills in patients with dysgraphia. Lexical treatments appear to be more frequently adopted and more flexible in improving dysgraphia and communication, especially when a multimodal approach is used. Finally, the reported description of treatment modalities for dysgraphia in relation to patients' deficits may be important for providing tailored therapies in clinical management.

Speech therapy and hyperbaric oxygen for aphasia after carbon monoxide intoxication.

Acute carbon monoxide (CO) intoxication may result in delayed neurological sequelae, which can include amnesia, ataxia, aphasia, emotional lability, disorientation, dysphagia, and other manifestations. A 27-year-old man reported symptoms of aphasia with agraphia and alexia in a review after CO intoxication. The patient received outpatient speech therapy, as well as repeated sessions of hyperbaric oxygen for 15 days, interspersing speech therapy with hyperbaric oxygen therapy for two months. After this period of combined treatment the aphasic symptomatology remitted, and oral and written language was normal. The complete disappearance of aphasia with agraphia and alexia confirms the efficacy of the combined intervention. More data from large clinical studies are needed to assess the outcomes of hyperbaric oxygen treatment in patients with delayed neurological sequelae after CO intoxication, but this case suggests it may be a good therapeutic option in combination with specific speech therapy.

Effects of Transcranial Direct Current Stimulation in writing: a case report of deep agraphia. / Efeitos da Estimulação Transcraniana por Corrente Contínua na escrita: um relato de caso de agrafia profunda.

We present the case report of a 61-year-old male participant with chronic conduction aphasia and deep agraphia after ischemic stroke who received training on writing under dictation associated with transcranial direct current stimulation. The treatment consisted of five 50-minute dictation sessions with the application of 2 mA of anodal transcranial direct current stimulation for 20 minutes over the left occipitotemporal cortex. The participant improved his written production of pseudowords and regular low-frequency words, via the phonological route, in addition to a small improvement in the production of irregular words, via the lexical route. After training, there was also a small improvement in writing for untrained stimuli, suggesting generalization. In the assessment carried out 5 months after the end of the treatment, the benefit was maintained for stimuli processed via the phonological route. The results are promising given the severity and chronicity of the case and suggest that transcranial direct current stimulation associated with writing therapy represents a possible clinical alternative for patients with deep agraphia.

Apresentamos o relato de caso de um participante do sexo masculino, 61 anos, com afasia de condução crônica e agrafia profunda após acidente vascular cerebral isquêmico que recebeu treinamento de escrita sob ditado associado à estimulação transcraniana por corrente contínua. O tratamento consistiu em cinco sessões de 50 minutos de escrita sob ditado com aplicação de 2 mA de estimulação transcraniana por corrente contínua anódica durante 20 minutos sobre o córtex occipitotemporal esquerdo. O participante apresentou melhora na produção escrita de pseudopalavras e de palavras regulares de baixa frequência, via rota fonológica, além de uma pequena melhora na produção de palavras irregulares, via rota lexical. Após o treinamento, houve também pequena melhora da escrita de estímulos não treinados, sugerindo generalização. Na avaliação realizada 5 meses após o término do tratamento, o benefício foi mantido para estímulos processados via rota fonológica. Os resultados são promissores dada a gravidade e cronicidade do caso e sugerem que a estimulação transcraniana por corrente contínua associada à terapia de escrita representa possível alternativa clínica para pacientes com agrafia profunda.

Pseudoword spelling ability predicts response to word spelling treatment in acquired dysgraphia.

Although rehabilitation of acquired dysgraphia can be quite effective, identifying predictors of responsiveness to treatment is useful for prognosis and individualization of treatment protocols. This study examined whether various features of treatment response were predicted by the integrity of one or more of the central cognitive components of spelling: orthographic long-term memory, orthographic working memory, and phoneme-grapheme conversion. Twenty dysgraphic individuals received 12 weeks of bi-weekly, individualized, lexically-based spelling rehabilitation using a spell-study-spell paradigm. Linear multiple regression modelling examined whether the type and severity of the dysgraphic deficit, assessed before rehabilitation, predicted the magnitude and rate of improvement, generalization to untrained items and maintenance of treatment gains. The results revealed that pseudoword spelling accuracy - indexing the integrity of the phoneme-grapheme conversion system - was the only factor examined that significantly predicted the rate of accuracy gains for trained words as well as the extent of generalization to untrained words. Pre-treatment pseudoword spelling accuracy also predicted retention of gains for trained and untrained words at 3-month follow-up. These findings reveal that the integrity of the phoneme-grapheme conversion system prior to dysgraphia rehabilitation may play a key role in rehabilitation-driven recovery, even when the treatment approach targets lexical rather than pseudoword spelling processes.

Transcranial direct current stimulation with multiple oral re-reading therapy for pure alexia without agraphia: a case report.

Pure alexia without agraphia is characterized by impaired reading due to damage to the occipitotemporal cortex with preserved writing skills. In this case report, we investigate the effect of multiple oral re-reading (MOR) therapy adjunct with transcranial direct current stimulation (tDCS) in improving reading recovery of a 64-year-old patient with pure alexia without agraphia following a stroke. His MRI revealed an area of infarct with microhemorrhages at the left occipitotemporal region. The patient was blinded to each therapy and underwent seven consecutive sessions of sham tDCS followed by seven consecutive sessions of real tDCS, coupled with 1-hour MOR therapy during each session. Western Aphasia Battery (WAB) was performed at baseline, before sham and real-tDCS, and 6 weeks after completing tDCS therapy. The patient showed improvement using both sham and real-tDCS with better reading comprehension, average reading time, and word per minute after real-tDCS. This study suggests that MOR, coupled with tDCS therapy may accelerate the reading recovery in patients with pure alexia.

Too harts, won sole: Using dysgraphia treatment to address homophone representation.

Previous spoken homophone treatment in aphasia found generalization to untreated homophones and interpreted this as evidence for shared phonological word form representations. Previous written treatment of non-homophones has attributed generalization to orthographic neighbours of treated items to feedback from graphemes to similarly spelled orthographic word forms. This feedback mechanism offers an alternative explanation for generalization found in treatment of spoken homophones. The aim of this study was to investigate the mechanism underpinning generalization (if any) from treatment of written homophones. To investigate this question a participant with acquired dysgraphia and impaired access to orthographic output representations undertook written spelling treatment. Generalization to untreated items with varying degrees of orthographic overlap was investigated. Three experimental sets included homographs (e.g., bank-bank), heterographs (e.g., sail-sale), and direct orthographic neighbours (e.g., bath-path). Treatment improved written picture naming of treated items. Generalization was limited to direct neighbours. Further investigation of generalization found that items with a greater number of close neighbours in the treated set showed greater generalization. This suggests that feedback from graphemes to orthographic word forms is the driving force of generalization. The lack of homograph generalization suggests homographs do not share a representation in the orthographic lexicon.

Agraphia with reversible splenial corpus callosum lesion caused by hypoglycemia.

BACKGROUND: Neurological manifestations caused by hypoglycemia range from reversible focal deficits and transient encephalopathy to irreversible coma or death. Recently, high signal intensity lesions in the splenium of the corpus callosum on diffusion-weighted magnetic resonance imaging were reported in adults experiencing hypoglycemia. However, patients presenting with agraphia are rare. SUBJECT AND METHODS: We examined a 17-year-old left-handed female patient with type 1 diabetes who exhibited transient left agraphia with a reversible splenium lesion of the corpus callosum on diffusion-weighted imaging caused by hypoglycemia, which was improved with blood glucose management alone. CONCLUSION: This rare case indicates that agraphia, a sign of callosal disconnection syndrome, can result from a reversible splenial lesion of the corpus callosum caused by hypoglycemia.

The nature and treatment of phonological text agraphia.

Phonological alexia and agraphia are written language disorders characterised by disproportionate difficulty reading and spelling nonwords in comparison to real words. In phonological alexia, it has been shown that, despite relatively accurate reading of words in isolation, text-level reading deficits are often marked and persistent. Specifically, some individuals demonstrate difficulty reading functors and affixes in sentences, a profile referred to as phonological text alexia. In this paper, we demonstrate an analogous manifestation of the phonological impairment on text-level writing and suggest the term "phonological text agraphia". We examined four individuals with phonological alexia/agraphia who also showed disproportionate difficulty writing well-formed sentences in comparison to their grammatical competence in spoken utterances. Implementation of a phonological treatment protocol resulted in significantly improved sublexical phonology skills as well as improvements in grammatical accuracy of written narratives. These findings support the notion of a common phonological impairment underlying nonword reading/spelling deficits and sentence-level difficulties.

Promoting linguistic complexity, greater message length and ease of engagement in email writing in people with aphasia: initial evidence from a study utilizing assistive writing software.

BACKGROUND: Improving email writing in people with aphasia could enhance their ability to communicate, promote interaction and reduce isolation. Spelling therapies have been effective in improving single-word writing. However, there has been limited evidence on how to achieve changes to everyday writing tasks such as email writing in people with aphasia. One potential area that has been largely unexplored in the literature is the potential use of assistive writing technologies, despite some initial evidence that assistive writing software use can lead to qualitative and quantitative improvements to spontaneous writing. AIMS: This within-participants case series design study aimed to investigate the effects of using assistive writing software to improve email writing in participants with dysgraphia related to aphasia. METHODS & PROCEDURES: Eight participants worked through a hierarchy of writing tasks of increasing complexity within broad topic areas that incorporate the spheres of writing need of the participants: writing for domestic needs, writing for social needs and writing for business/administrative needs. Through completing these tasks, participants had the opportunity to use the various functions of the software, such as predictive writing, word banks and text to speech. Therapy also included training and practice in basic computer and email skills to encourage increased independence. Outcome measures included email skills, keyboard skills, email writing and written picture description tasks, and a perception of disability assessment. OUTCOMES & RESULTS: Four of the eight participants showed statistically significant improvements to spelling accuracy within emails when using the software. At a group level there was a significant increase in word length with the software; while four participants showed noteworthy changes to the range of word classes used. Enhanced independence in email use and improvements in participants' perceptions of their writing skills were also noted. CONCLUSIONS & IMPLICATIONS: This study provided some initial evidence that assistive writing technologies can support people with aphasia in email writing across a range of important performance parameters. However, more research is needed to measure the effects of these technologies on the writing of people with aphasia, and to determine the optimal compensatory mechanisms for specific people given the linguistic-strategic resources they bring to the task of email writing.

Micrographia, much beyond the writer's hand.

INTRODUCTION: This review on micrographia aims to draw the clinician's attention to non-Parkinsonian etiologies, provide clues to differential diagnosis, and summarize current knowledge on the phenomenology, etiology, and mechanisms underlying micrographia. METHODS: A systematic review of the existing literature was performed. RESULTS: Micrographia, namely small sized handwriting has long been attributed to Parkinson's disease. However, it has often been observed as part of the clinical picture of additional neurodegenerative disorders, sometimes antedating the motor signs, or following focal basal ganglia lesions without any accompanying parkinsonism, suggesting that bradykinesia and rigidity are not sine-qua-non for the development of this phenomenon. Therefore, micrographia in a patient with no signs of parkinsonism may prompt the clinician to perform imaging in order to exclude a focal basal ganglia lesion. Dopaminergic etiology in this and other cases is doubtful, since levodopa ameliorates letter stroke size only partially, and only in some patients. Parkinsonian handwriting is often characterized by lack of fluency, slowness, and less frequently by micrographia. Deviations from kinematic laws of motion that govern normal movement, including the lack of movement smoothness and inability to scale movement amplitude to the desired size, may reflect impairments in motion planning, possible loss of automaticity and reduced movement vigor. CONCLUSIONS: The etiology, neuroanatomy, mechanisms and models of micrographia are discussed. Dysfunction of the basal ganglia circuitry induced by neurodegeneration or disruption by focal damage give rise to micrographia.

Treatment for Alexia With Agraphia Following Left Ventral Occipito-Temporal Damage: Strengthening Orthographic Representations Common to Reading and Spelling.

PURPOSE: Damage to left ventral occipito-temporal cortex can give rise to written language impairment characterized by pure alexia/letter-by-letter (LBL) reading, as well as surface alexia and agraphia. The purpose of this study was to examine the therapeutic effects of a combined treatment approach to address concurrent LBL reading with surface alexia/agraphia. METHOD: Simultaneous treatment to address slow reading and errorful spelling was administered to 3 individuals with reading and spelling impairments after left ventral occipito-temporal damage due to posterior cerebral artery stroke. Single-word reading/spelling accuracy, reading latencies, and text reading were monitored as outcome measures for the combined effects of multiple oral re-reading treatment and interactive spelling treatment. RESULTS: After treatment, participants demonstrated faster and more accurate single-word reading and improved text-reading rates. Spelling accuracy also improved, particularly for untrained irregular words, demonstrating generalization of the trained interactive spelling strategy. CONCLUSION: This case series characterizes concomitant LBL with surface alexia/agraphia and demonstrates a successful treatment approach to address both the reading and spelling impairment.

Generalisation after treatment of acquired spelling impairments: A review.

This paper provides a comprehensive review of treatment studies of acquired dysgraphia and the occurrence of generalisation after this treatment. The aim is to examine what determines the occurrence of generalisation by investigating the link between the level of impairment, the method of treatment, and the outcome of therapy. We present the outcomes of treatment with regard to generalisation in 40 treatment studies. We derive general principles of generalisation which provide us with a better understanding of the mechanism of generalisation: (1) Direct treatment effects on representations or processes; (2) interactive processing and summation of activation; and (3) strategies and compensatory skills. We discuss the implications of these findings for our understanding of the cognitive processes used for spelling. Finally, we provide suggestions for the direction of further research into this important area, as a better understanding of the mechanism of generalisation could maximise treatment effects for an individual with acquired dysgraphia.

The effect of computer-assisted therapeutic practice for children with handwriting deficit: a comparison with the effect of the traditional sensorimotor approach.

The objective of this study was to compare the effect of computer-assisted practice with the sensorimotor approach on the remediation of handwriting problems in children with dysgraphia. In a randomized controlled trial, experiments were conducted to verify the intervention effect. Forty two children with handwriting deficit were assigned to computer-assisted instruction, sensorimotor training, or a control group. Handwriting performance was measured using the elementary reading/writing test and computerized handwriting evaluation before and after 6 weeks of intervention. Repeated-measures ANOVA of changed scores were conducted to show whether statistically significant differences across the three groups were present. Significant differences in the elementary reading/writing test were found among the three groups. The computer group showed more significant improvements than the other two groups did. In the kinematic and kinetic analyses, the computer group showed promising results in the remediation of handwriting speed and fluency. This study provided clinical evidence for applying a computer-assisted handwriting program for children with dysgraphia. Clinicians and school teachers are provided with a systematic intervention for the improvement of handwriting difficulties.

A comparison of errorless and errorful therapies for dysgraphia after stroke.

Despite the increasing significance of written communication, there is limited research into spelling therapy for adults with acquired dysgraphia. Existing studies have typically measured spelling accuracy as an outcome, although speed may also be important for functional writing. As spelling is relatively slow, effortful and prone to errors in people with dysgraphia, minimising errors within therapy could be a factor in therapy success. This within-participant case-series study investigated whether errorless and errorful therapies would differ in their effects on spelling speed and accuracy for four participants with acquired dysgraphia. Matched sets of words were treated with errorless or errorful therapy or left untreated. Results were collated one week and five weeks after therapy. Both therapy approaches were successful in improving spelling accuracy. For three participants, equivalent gains were demonstrated following errorless and errorful therapy. One participant made significantly greater improvements in spelling accuracy following errorless therapy. The effects were maintained five weeks later. There was no significant difference in post-therapy spelling speed between the two therapy conditions. The results of this study suggest that both errorful and errorless therapies can be effective methods with which to treat spelling in adults with acquired dysgraphia.

Neural correlates of paediatric dysgraphia.

Writing is an important skill that is related both to school performance and to psychosocial outcomes such as the child's self-esteem. Deficits in handwriting performance are frequently encountered in children with developmental coordination disorder. This review focuses on what is known about the neural correlates of atypical handwriting in children. Knowledge of the neural correlates is derived from studies using clinical case designs (e.g. lesion studies), studies using neuroimaging, and assessment of minor neurological dysfunction. The two functional imaging studies suggest a contribution of cortical areas and the cerebellum. The largest study indicated that cortical areas in all regions of the brain are involved (frontal, temporal, parietal, and occipital). The two lesion studies confirmed cerebellar involvement. The findings of the study on minor neurological dysfunction in children with writing problems correspond to the imaging results. The limited data on the neural substrate of paediatric dysgraphia suggest that at least a subset of the children with dysgraphia have dysfunctions in extensive supraspinal networks. In others, dysfunction may be restricted to either the cerebellum or specific cortical sites.

[Role of pediatricians in the diagnosis and therapy of dyslexia, dysgraphia and dyscalculia]. / A családorvosok szerepe a dyslexia, dysgraphia és dyscalculia diagnosztikájában és terápiájában.

Pediatricians play an important role in the diagnosis and therapy of children with dyslexia, dysgraphia or dyscalculia. These syndromes strongly affect children's school performance. Children with dyslexia, dysgraphia or dyscalculia show a significant underachievement in reading, writing or counting and their failure to meet the school requirements undermines their self confidence and positive self-concept. As a result, children with learning problems often become aggressive, frustrated or play the clown in the classroom. According to the Hungarian law children with any learning difficulties have the right to get special education by their specific symptoms. In the realisation of the law and equity the pediatrician's expertise is essential and has an important role in the therapeutical procedures. However, the pediatrician's role is more complex than writing an opinion. Pediatricians can help by giving a detailed description about these syndromes and explain them how they can help their child, what are the main difficulties during the child's studies, what kind of therapies can be efficient and how they can make their child's school years easier. During the assessment most of the parents ask the following questions: What does dyslexia, dyscalculia or dysgraphia exactly mean? Is it a handicap or a learning difficulty? Could the child live a normal life? With the proper answer and with an inclusive attitude pediatricians can help both the parents and the children to create a liveable lifestyle and make their children's schoolwork more successful. The authors' opinions are to close the medical and the pedagogical view, because without the cooperation of these two scientific fields, the theme affected parents, children and teachers cannot get proper help to find better solution and support for their problems. In the survey the authors intend to give a complex view about the symptoms of these syndromes and try to give useful advice for pediatricians how they can support their patients emphasizing the key role of pediatricians and clinical expertises in the early recognition and therapy.

Transient beneficial effects of excitatory theta burst stimulation in a patient with phonological agraphia after left supramarginal gyrus infarction.

We report a patient showing isolated phonological agraphia after an ischemic stroke involving the left supramarginal gyrus (SMG). In this patient, we investigated the effects of focal repetitive transcranial magnetic stimulation (rTMS) given as theta burst stimulation (TBS) over the left SMG, corresponding to the Brodmann area (BA) 40. The patient and ten control subjects performed a dictational words and nonwords writing task before, and 5 and 30 min after they received excitatory intermittent TBS (iTBS) over the left BA 40, the right hemisphere homologous to BA 40, the Wernicke's area, or the primary visual cortex. ITBS over the left SMG lead to a brief facilitation of phonological non-words writing to dictation. This case study report illustrates that rTMS is able to influence, among other language functions, the phonological loading processes during the written language production in stroke patients.

Evidence-based diagnosis and treatment for specific learning disabilities involving impairments in written and/or oral language.

Programmatic, multidisciplinary research provided converging brain, genetic, and developmental support for evidence-based diagnoses of three specific learning disabilities based on hallmark phenotypes (behavioral expression of underlying genotypes) with treatment relevance: dysgraphia (impaired legible automatic letter writing, orthographic coding, and finger sequencing), dyslexia (impaired pseudoword reading, spelling, phonological and orthographic coding, rapid automatic naming, and executive functions; inhibition and rapid automatic switching), and oral and written language learning disability (same impairments as dyslexia plus morphological and syntactic coding and comprehension). Two case studies illustrate how these differential diagnoses can be made within a conceptual framework of a working memory architecture and generate treatment plans that transformed treatment nonresponders into treatment responders. Findings are discussed in reference to the importance of (a) considering individual differences (diagnosis of impaired hallmark phenotypes) in planning and evaluating response to instruction and modifying instruction when a student is not responding; (b) recognizing that teaching may change epigenetic gene expression at one stage of schooling, but not the underlying gene sequences that render individuals still vulnerable as curriculum requirements increase in nature, complexity, and volume in the upper grades; and (c) using evidence-based diagnoses of specific learning disabilities that are consistent across states for free and appropriate education K to 12 and for accommodations throughout higher education and professional credentialing.

A treatment sequence for phonological alexia/agraphia.

PURPOSE: Damage to left perisylvian cortex often results in impaired phonological processing abilities with written language profiles consistent with phonological alexia and phonological agraphia. The purpose of this article was to examine a behavioral treatment sequence for such individuals intended to strengthen phonological processing and links between phonology and orthography, as well as train a means to maximize use of residual orthographic and phonological knowledge for spelling. METHOD: Two women with persistent impairments of written language and phonological processing following damage to left perisylvian cortical regions participated in this study. Both exhibited characteristic features of phonological alexia and agraphia in that reading and spelling performance for real words was better preserved than nonwords (lexicality effect). A 2-stage treatment protocol was administered to strengthen sublexical skills (phonological treatment) and to train interactive use of lexical and sublexical information to maximize spelling performance (interactive treatment). RESULTS: Both participants improved phonological processing abilities and reading/spelling via the sublexical route. They also improved spelling of real words and were able to detect and correct most residual errors using an electronic spelling aid. CONCLUSIONS: Behavioral treatment served to strengthen phonological skills supporting reading and spelling, and provided a functional compensatory strategy to overcome residual weaknesses.

Developmental dysgraphia with profound hearing impairment: intervention by auditory methods enabled by cochlear implant.

Learning disability combined with hearing impairment (LDHI) is a poor prognostic factor for the language development of hearing impaired children after educational intervention. A typical example of a child with LDHI and effective interventions provided by cochlear implants are presented in this report. A case of congenital cytomegaloviral infection that showed dysgraphia as well as profound deafness was reported and an underlying visual processing problem diagnosed in the present case caused the patient's dysgraphia. The dysgraphia could be circumvented by the use of auditory memory fairly established by a cochlear implant.