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.

Behavioural and eye-movement outcomes in response to text-based reading treatment for acquired alexia.

Text-based reading treatments, such as Multiple Oral Rereading (MOR) and Oral Reading for Language in Aphasia (ORLA) have been used successfully to remediate reading impairments in individuals with acquired alexia, but the mechanisms underlying such improvements are not well understood. In this study, an individual with acquired alexia who demonstrated reliance on a sub-lexical reading strategy (i.e., presence of spelling regularity effect and phonologically plausible errors) underwent 12 weeks of text-based reading treatment combining MOR and ORLA procedures. Behavioural assessments of single-word and text reading, along with eye-tracking assessments were conducted pre-treatment, post-treatment and at 5 month follow-up. Improved reading fluency (rate, accuracy) was observed for both trained and untrained passages. Evidence from behavioural and eye-tracking assessment suggested text-based reading treatment facilitated use of a lexical-semantic reading strategy. Increased frequency and lexicality effects, as well as a shift in initial landing position towards the centre of the word (the "optimal viewing position") were observed at post-treatment and follow-up assessments. These results demonstrate the potential utility of using eye movements as a parameter of interest in addition to traditional behavioural outcomes when investigating response to reading treatment.

Evaluation of use of reading comprehension strategies to improve reading comprehension of adult college students with acquired brain injury.

Adults with mild to moderate acquired brain injury (ABI) often pursue post-secondary or professional education after their injuries in order to enter or re-enter the job market. An increasing number of these adults report problems with reading-to-learn. The problem is particularly concerning given the growing population of adult survivors of ABI. Despite the rising need, empirical evaluation of reading comprehension interventions for adults with ABI is scarce. This study used a within-subject design to evaluate whether adult college students with ABI with no more than moderate cognitive impairments benefited from using reading comprehension strategies to improve comprehension of expository text. Integrating empirical support from the cognitive rehabilitation and special education literature, the researchers designed a multi-component reading comprehension strategy package. Participants read chapters from an introductory-level college anthropology textbook in two different conditions: strategy and no-strategy. The results indicated that reading comprehension strategy use was associated with recall of more correct information units in immediate and delayed free recall tasks; more efficient recall in the delayed free recall task; and increased accuracy recognising statements from a sentence verification task designed to reflect the local and global coherence of the text. The findings support further research into using reading comprehension strategies as an intervention approach for the adult ABI population. Future research needs include identifying how to match particular reading comprehension strategies to individuals, examining whether reading comprehension performance improves further through the incorporation of systematic training, and evaluating texts from a range of disciplines and genres.

Successful remote delivery of a treatment for phonological alexia via telerehab.

A growing body of literature supports the effectiveness of the remote delivery of rehabilitation services, i.e., telerehab. Aphasia treatment is particularly well suited for telerehab because of the verbal and visual nature of speech-language therapy, but scientific research investigating aphasia telerehab is in its infancy. No studies to date have evaluated whether treatment of acquired reading disorders by a live clinician can be feasibly, effectively, or efficiently conducted via telerehab. Here we address this gap in the literature by reporting our success remotely remediating the reading deficits of two participants with phonological alexia. We adapted for the telerehab setting a previously validated treatment for phonological alexia (Friedman, Sample, & Lott, 2002 ), which uses a paired-associate design to train reading of problematic words. Both telerehab participants significantly improved their reading of trained words in similar time frames as previous participants (Friedman et al., 2002 ; Kurland et al., 2008 ; Lott, Sample, Oliver, Lacey, & Friedman, 2008 ); furthermore, both participants reported high satisfaction with the telerehab setting. Although telerehab with alexic patients poses unique challenges, we conclude that treatment for alexia via telerehab is nevertheless feasible, may be equally effective as in-person treatment, and saves substantial resources for participants as well as clinicians.

An Exploratory Study of Reading Comprehension in College Students After Acquired Brain Injury.

PURPOSE: This exploratory study builds on the small body of existing research investigating reading comprehension deficits in college students with acquired brain injury (ABI). METHOD: Twenty-four community college students with ABI completed a battery of questionnaires and standardized tests to characterize self-perceptions of academic reading ability, performance on a standardized reading comprehension measure, and a variety of cognitive functions of this population. Half of the participants in the sample reported traumatic brain injury (n = 12) and half reported nontraumatic ABI (n = 12). RESULTS: College students with both traumatic and nontraumatic ABI cite problems with reading comprehension and academic performance postinjury. Mean performance on a standardized reading measure, the Nelson-Denny Reading Test (Brown, Fischo, & Hanna, 1993), was low to below average and was significantly correlated with performance on the Speed and Capacity of Language Processing Test (Baddeley, Emslie, & Nimmo-Smith, 1992). Injury status of traumatic versus nontraumatic ABI did not differentiate results. Regression analysis showed that measures of verbal attention and suppression obtained from the California Verbal Language Test-II (Delis, Kramer, Kaplan, & Ober, 2000) predicted total scores on the Nelson-Denny Reading Test. CONCLUSIONS: College students with ABI are vulnerable to reading comprehension problems. Results align with other research suggesting that verbal attention and suppression problems may be contributing factors.

An evaluation of reading comprehension of expository text in adults with traumatic brain injury.

PURPOSE: This project was conducted to obtain information about reading problems of adults with traumatic brain injury (TBI) with mild-to-moderate cognitive impairments and to investigate how these readers respond to reading comprehension strategy prompts integrated into digital versions of text. METHOD: Participants from 2 groups, adults with TBI (n = 15) and matched controls (n = 15), read 4 different 500-word expository science passages linked to either a strategy prompt condition or a no-strategy prompt condition. The participants' reading comprehension was evaluated using sentence verification and free recall tasks. RESULTS: The TBI and control groups exhibited significant differences on 2 of the 5 reading comprehension measures: paraphrase statements on a sentence verification task and communication units on a free recall task. Unexpected group differences were noted on the participants' prerequisite reading skills. For the within-group comparison, participants showed significantly higher reading comprehension scores on 2 free recall measures: words per communication unit and type-token ratio. There were no significant interactions. CONCLUSION: The results help to elucidate the nature of reading comprehension in adults with TBI with mild-to-moderate cognitive impairments and endorse further evaluation of reading comprehension strategies as a potential intervention option for these individuals. Future research is needed to better understand how individual differences influence a person's reading and response to intervention.

Overcoming the effect of letter confusability in letter-by-letter reading: a rehabilitation study.

Patients who read in a letter-by-letter manner can demonstrate effects of lexical variables when reading words comprised of low confusability letters, suggesting the capacity to process low-confusability words in parallel across the letters (Fiset, Arguin, & McCabe, 2006). Here a series of experiments is presented investigating letter confusability effects in MAH, a patient with expressive and receptive aphasia who shows reduced reading accuracy with longer words, and DM, a relatively "pure" alexic patient. Two rehabilitation studies were employed: (i) a word-level therapy and (ii) a letter-level therapy designed to improve discrimination of individual letters. The word-level treatment produced generalised improvement to low-confusability words only, but the serial processing treatment produced improvement on both high and low confusability words. The results add support to the hypothesis that letter confusability plays a key role in letter-by-letter reading, and suggest that a rehabilitation method aimed at reducing ambiguities in letter identification may be particularly effective for treating letter-by-letter reading.

Implicit learning in children with spelling disability: evidence from artificial grammar learning.

The development of reading and spelling skills seems to be influenced by both explicit and implicit learning processes. The aim of this study was to investigate whether children with spelling difficulties show a deficit in the implicit learning of frequent letter chunks. This was done by comparing the performance of children with good and poor spelling skills on an artificial grammar learning task. The results show that children with poor spelling skills have difficulties recognizing previously presented letter strings. Moreover, they show impaired implicit learning of frequent letter chunks, particularly in letter strings that can be processed phonologically. Comparing children's performance with chance performance revealed that poor spellers demonstrated some implicit learning, but a significant group difference showed that implicit learning was less efficient in poor spellers as compared to good spellers. These findings support the idea that implicit learning deficits play a role in the development of poor literacy skills.

[Visual rehabilitation training for homonymous field defects]. / Visuelles Rehabilitationstraining bei homonymen Gesichtsfeldausfällen.

Homonymous field defects cause reading and orientation disorders. The reading disorder depends on the size of the macular sparing, the side of the field defect (unfavorable in reading direction) and spontaneous adaptive mechanisms. Methods which support compensation strategies should be recommended as evidence-based training procedures: optokinetic training with scrolled text for reading disorders and saccade training for orientation disorders. By optimized utilization of the total field of gaze, general exploration of the environment, reaction times during search tasks and quality of life can be improved.

Development of a theoretically based treatment for sentence comprehension deficits in individuals with aphasia.

PURPOSE: Two new treatments, 1 based on sentence to picture matching (SPM) and the other on object manipulation (OM), that train participants on the thematic roles of sentences using pictures or by manipulating objects were piloted. METHOD: Using a single-subject multiple-baseline design, sentence comprehension was trained on the affected sentence type in 1 task-related protocol in 15 participants with aphasia. The 2 tasks were SPM and OM; the treatment stimuli were object relatives, object clefts, passives, and unaccusatives, as well as two control structures-object relatives with a complex noun phrase (NP) and active sentences with three NPs. RESULTS: The criteria for efficacious treatment was an increase in the level of performance from the pretreatment probes to the posttreatment probes for the treated structure such that accuracy rose from at or below chance to above chance and either (a) accuracy rose by 33% or (b) the effect size was 2.6. Based on these criteria, the success rate for training the target structure was 2/6 participants in the SPM condition and 4/7 participants in the OM condition. CONCLUSION: The outcome of this study illustrates the utility of this theoretically motivated and efficacious treatment for sentence comprehension deficits in individuals with aphasia.

Reading difficulty after stroke: ocular and non ocular causes.

BACKGROUND: Ocular causes of reading impairment following stroke include visual field loss, eye movement impairment and poor central vision. Non ocular causes may include cognitive errors or language impairment. AIM: The purpose of this study was to identify all patients referred with suspected visual impairment who had reported reading difficulty to establish the prevalence of ocular and non ocular causes. METHODS: Prospective, multicentre, observation study with standardised referral and assessment forms across 21 sites. Visual assessment included visual acuity measurement, visual field assessment, ocular alignment, and movement and visual inattention assessment. Multicentre ethical approval and informed patient consent were obtained. RESULTS: A total of 915 patients were recruited, with a mean age of 69·18 years (standard deviation 14·19). Reading difficulties were reported by 177 patients (19·3%), with reading difficulty as the only symptom in 39 patients. Fifteen patients had normal visual assessment but with a diagnosis of expressive or receptive aphasia. Eight patients had alexia. One hundred and nine patients had visual field loss, 85 with eye movement abnormality, 27 with low vision and 39 patients with visual perceptual impairment. Eighty-seven patients had multiple ocular diagnoses with combined visual field, eye movement, low vision or inattention problems. All patients with visual impairment were given targeted treatment and/or advice including prisms, occlusion, refraction, low vision aids and scanning exercises. CONCLUSIONS: Patients complaining of reading difficulty were mostly found to have visual impairment relating to low vision, eye movement or visual field loss. A small number were found to have non ocular causes of reading difficulty. Treatment or advice was possible for all patients with visual impairment.

The rehabilitation of hemianopic dyslexia.

Hemianopic dyslexia is a frequent and disabling functional impairment following brain injury. This form of dyslexia is an acquired reading disorder whereby patients with homonymous visual field defects have persistent and severe reading difficulties, despite having intact language functions. Hemianopic dyslexia has received little attention from researchers and clinicians, and this article is the first to review the rehabilitation of patients with the condition. In light of advances in our knowledge about the nature and causes of hemianopic dyslexia, I critically examine the available treatment methods for visual field disorders and evaluate their efficiency in alleviating hemianopic dyslexia. On the basis of the reviewed evidence, I suggest that compensatory therapies, which attempt to reorganize eye-movement control, are superior to restorative therapies, which aim at visual field restitution. For the rehabilitation of hemianopic dyslexia, I recommend a treatment protocol that involves the systematic and repetitive practice of specific eye movements for reading. Despite increasing evidence for the effectiveness of this treatment protocol, which has clinically relevant long-term benefits, the underlying mechanism of the therapeutic effect is still unclear. Indeed, more research is required to further improve the efficiency of rehabilitation in patients with hemianopic dyslexia.

[Visually based reading disorders after brain damage. Standardised assessment and treatment with READ]. / Erworbene, visuell bedingte Lesestörungen. Standardisierte Diagnostik und Therapie mit READ.

Visually based reading disorders are frequently encountered in patients with acquired brain damage. Homonymous visual field defects, impaired elementary visual capacities (acuity, contrast sensitivity, convergent fusion, ocular motor disorders), visual neglect or Balint-Holmes syndrome are the most frequent causes of such reading disorders. Reading is not only an important prerequisite for vocational and private life, but is also indispensable for subsequent cognitive abilities such as verbal working memory and long-term memory. Despite this importance no comprehensive system exists for the standardised assessment and treatment of visually based reading capacities in the German-speaking area. Here, we describe the basic properties of such a system (READ). After a short survey of the main causes of visually based reading disorders after brain damage, the anamnesis, diagnostic facilities, normative data as well as a variety of treatment techniques of the novel system are described. Selected results from ongoing clinical group studies as well as case examples highlight the diagnostic sensitivity and therapeutic efficiency of the new system for better management of visually based reading disorders after brain damage.

Treatment of reading impairment after stroke.

PURPOSE OF REVIEW: Reading impairments after left or right hemisphere stroke are common yet receive little attention from clinicians and therapists. In this review, we focus on the classification of acquired alexia and the current theory and practice underlying the rehabilitation of this diverse set of disorders. RECENT FINDINGS: The underlying behavioural impairments that dictate reading ability in the acquired alexias are becoming better understood; this, in turn, has led to targeted therapies being undertaken, mainly on a single subject basis. In hemianopic alexia, the most 'peripheral' of the acquired alexias, where text reading speed is determined largely by damage to the visual field, therapies have been directed at improving reading eye movements. In 'pure' alexia, techniques are usually aimed at improving whole-word recognition. In central alexic syndromes, where other language functions are also involved, the emphasis has been on strengthening connections between lexical and semantic representations, strengthening phonological representations, or both, and their association with lexical/semantic knowledge. SUMMARY: Despite targeted approaches to the rehabilitation of patients with alexia caused by stroke, there is still a preponderance of largely descriptive, single-case studies in the literature. In some syndromes, small trials have been attempted and the hope is that, in the future, more systematic investigations will be carried out so rehabilitation efforts can be built on a strong theoretical and empirical foundation. Well designed, single-case studies continue to play an important role in informing therapy, as these disorders are, by nature, heterogeneous.

Rehabilitation of hemianopic dyslexia: are words necessary for re-learning oculomotor control?

Unilateral homonymous visual field disorders after brain damage are frequently associated with a severe impairment of reading, called hemianopic dyslexia. A specific treatment method has been developed which allows patients to regain sufficient reading performance by re-learning eye-movement control in reading through systematic oculomotor practice. However, it is still unclear whether the treatment effect associated with this training procedure critically depends on using text material. We therefore evaluated the effectiveness of systematic oculomotor training with non-text material (Arabic digits) in comparison with conventional oculomotor training using text material (words) in 40 patients with unilateral homonymous visual field disorders and hemianopic dyslexia. Non-text training was found to be as effective as conventional text training in improving reading performance and associated eye-movements in these patients. Our results suggest that using words is not critical to the treatment effect of this training procedure. Thus, lexical-semantic processes seem not to be necessary for re-learning eye-movement control in hemianopic dyslexia.

Acquired dyslexia after stroke in the prereading stage: a single case treatment study with f MRI.

The authors report a treatment study of a child (CK) who suffered a left-hemisphere stroke at age 6.3 years, a few months before beginning school. Despite complete recovery of spoken language abilities, CK failed to acquire written language abilities. Neurolinguistic assessment 2 years after the stroke revealed marked impairments in working memory, deficits in acquiring a sublexical reading strategy, and a very rudimentary orthographic network. Functional imaging demonstrated activation in posterior language areas during reading of familiar words while the attempt to read unfamiliar words activated peri- and contralesional structures of the anterior language areas. It was assumed that despite sufficient neural plasticity, the acquisition of a sublexical reading strategy was prevented by severe working memory deficits. Therefore, a specific treatment intervention was developed, choosing a compensatory strategy for reading remediation. Reading development was monitored over three months before and three months after an intensive training was conducted. Data showed significant gains in reading performance only after the specific intervention. These gains remained stable in a catamnesis 2 years later.

Reading-related oculomotor testing and training protocols for acquired brain injury in humans.

Many individuals with acquired brain injury (ABI) report reading problems of oculomotor origin. These may include frequent loss of place, skipping of lines and difficulty shifting to the next line of print. We describe two protocols for the testing and training of reading-related eye movements in adult individuals with ABI (traumatic brain injury [TBI] and stroke with hemianopia), who experience oculomotor-based symptoms when reading. These protocols use objective eye movement recording techniques and computer-based stimulus presentation and analysis. One protocol tests and the other trains basic horizontal and vertical versional eye movements (fixation, saccades and pursuit), as well as reading eye movements using simulated single and multiple line dynamic arrays. In addition, a reading rating-scale questionnaire is administered before and after completion of training to assess subjective reading improvement. In all paradigms, the target consists of a 0.5 degrees luminous square, which is displayed on a computer monitor positioned 40 cm from the subject along the midline. All testing and training are conducted under binocular viewing conditions with optical correction in place. There are two modes of training: normal internal oculomotor visual feedback either alone (4 weeks) or in conjunction with external oculomotor auditory feedback (4 weeks) administered in a counterbalanced manner within each diagnostic group. Training is performed 1 h, twice weekly for the 8 weeks. Oculomotor testing is conducted before, midway and after training. Following training, reading-related eye movements and reading ability improved as assessed both subjectively and objectively. These protocols provide a systematic approach to the quantitative and comprehensive testing and training of reading-related eye movement skills and behaviors in the ABI population manifesting oculomotor-based reading dysfunctions. Furthermore, the training protocol results in the rapid remediation of the eye movement deficits, which appear to transfer to activities of daily living.

Recovery of oculo-motor bias in neglect patients after prism adaptation.

Patients with "neglect dyslexia" usually make errors in reading the left part of words and non-words. It has been shown that "neglect dyslexia" can improve following a short period of adaptation to wedge prisms [Neuropsychologia 40 (2002) 718], however the mechanisms underlying this amelioration are still unknown. The present study evaluated the effect of prism adaptation (PA) on ocular scanning behaviour of neglect dyslexia patients by investigating: (a) the first saccade landing position during reading a letter string and (b) the distribution of fixation time as a function of the side of oculo-motor exploration of words and non-words. This in order to assess whether possible changes (in reading performance) after the adaptation might be attributed to a resetting of the oculo-motor system. Eye movements' performances were recorded before and after a single prismatic exposure on right brain-damaged patients with left hemispatial neglect and "neglect dyslexia". The results obtained in Experimental neglect patients before and after PA were then compared to that of control neglect patients, who were wearing goggles with neutral lenses. Moreover, in order to provide normative data on ocular scanning behaviour during letter string reading, neurologically healthy subjects were also studied. Following a single session of prism adaptation, the results showed, in the Experimental neglect patients, an improvement of neglect dyslexia, an increased left-sided exploration of the letter string and an increased amplitude of the first left-sided saccade. In contrast, in the Control neglect patients, neglect dyslexia as well as the oculo-motor system behaviour, remained the same after the use of goggles with neutral lenses. These findings demonstrate that the beneficial effect induced by a single prismatic adaptation may be conceived as a complex interaction between sensory stimulation and a resetting of oculo-motor system.