Susan Nitzberg Lott

Multiple Oral Re-reading treatment for alexia: The parts may be greater than the whole

This study examines the reasons for the success of Multiple Oral Re-reading (MOR; Moyer, 1979), a non-invasive, easily administered alexia treatment that has been reported in the literature and is currently in clinical use. The treatment consists of reading text passages aloud multiple times a day. Findings that MOR improves reading speed on practised as well as novel text have been inconsistent, making MORs role in the rehabilitation of alexia unclear. We hypothesised that MORs treatment mechanism works through repetition of high frequency words (i.e., bottom-up processing). We designed and controlled our text passages to test the hypothesis that participants would not improve on all novel text but would improve on text that includes a critical mass of the words contained in the passages they were re-reading. We further hypothesised that the improvement would be at the level of their specific alexic deficit. We tested four participants with phonological alexia and two with pure alexia during 8 weeks of MOR treatment. Contrary to the conclusions of previous studies, our results indicate that improvements in top-down processing cannot explain generalisation in MOR and that much of the improvement in reading is through repetition of the practised words. However, most patients also showed improvement when specific phrases were re-used in novel passages, indicating that practice of difficult words in context may be crucial to reading improvement.

The role of level of representation in the use of paired associate learning for rehabilitation of alexia

Patients with phonological alexia (difficulty reading pseudowords) frequently have concomitant difficulty reading functor words and verbs compared with concrete nouns. The current study compares two techniques for helping two patients with phonological alexia regain the ability to read functors and verbs. One technique follows the approach of reorganization of function, while the other relies on the stimulation approach. Study 1, employing a reorganization approach, resulted in both patients increasing their reading accuracy from approximately 10 to 90% or greater. Study 2, using a stimulation approach, resulted in significant improvement, however neither patient was able to achieve accuracy greater than 59%. Study 3 reverted back to the reorganization approach using the same words from Study 2. Both patients demonstrated significant success, achieving 90% or greater accuracy. Whereas the reorganization approach meets with far greater success than the stimulation approach, both approaches can be seen as instances of paired associate learning. An explanation of the advantage of the reorganization approach is developed which focuses on the nature of the pairings in the paired associate learning paradigm: it is proposed that pairings within the same level of representation are easier to learn than pairings that cut across levels of representation.

Modality-specific phonological alexia

Abstract Following a stroke, patient TL presented with a pure alexia that also displayed the features of phonological alexia (poor pseudoword reading, part-of-speech effect). This pattern was absent, however, when words were spelled aloud to TL. We propose that, with visual input, orthographic word forms are only weakly activated in TL. This weak activation succeeds in activating strongly represented semantic code—such as concrete nouns—but not weakly represented semantic cod—such as functor words—resulting in a part-of-speech effect. When words are spelled aloud, the input is sufficient to activate the orthographic word form strongly, and all words are identified. Most pure alexia patients can spell written words aloud to themselves (hence they are often called letter-by-letter readers), and consequently do not show symptoms of semantic reading. TL, whose letter-naming abilities are poor, cannot resort to this alternative strategy, and so the consequences of a weakly activated orthographic word form are ...

Overt use of a tactile/kinaesthetic strategy shifts to covert processing in rehabilitation of letter-by-letter reading

Background: Letter-by-letter readers identify each letter of the word they are reading serially in left to right order before recognising the word. When their letter naming is also impaired, letter-by-letter reading is inaccurate and can render even single word reading very poor. Tactile and/or kinaesthetic strategies have been reported to improve reading in these patients, but only under certain conditions or for a limited set of stimuli. Aims: The primary aim of the current study was to determine whether a tactile/kinaesthetic treatment could significantly improve reading specifically under normal reading conditions, i.e., reading untrained words presented in free vision and read without overt use of the strategy. Methods & Procedures: Three chronic letter-by-letter readers participated in a tactile/kinaesthetic treatment aimed at first improving letter-naming accuracy (phase 1) and then letter-by-letter reading speed (phase 2). In a multiple case series design, accuracy and speed of reading untrained words without overt use of the trained tactile/kinaesthetic strategy was assessed before phase 1, after phase 1, and again after phase 2. Outcomes & Results: All three patients significantly improved both their speed and accuracy in reading untrained words without overt use of the trained tactile/kinaesthetic strategy. All three patients required the additional practice in phase 2 to achieve significant improvement. Treatment did not target sentence-level reading, yet two of the three patients became so adept that they could read entire sentences. Conclusions: This study replicates previous findings on the efficacy of tactile/kinaesthetic treatment for letter-by-letter readers with poor letter naming. It further demonstrates that this treatment can alter cognitive processing such that words never specifically trained can be read in free vision without overtly using the trained strategy. The data suggest that an important element in achieving this level of generalisation is continuing training beyond the point of initial mastery (i.e., accurate letter naming).

Repetition priming in oral text reading: A therapeutic strategy for phonologic text alexia

Background: Phonologic text alexia (PhTA) is a reading disorder in which reading of pseudowords is impaired, but reading of real words is impaired only when reading text. Oral reading accuracy remains well preserved when words are presented individually, but when presented in text the part‐of‐speech effect that is often seen in phonologic alexia (PhA) emerges. Aims: To determine whether repetition priming could strengthen and/or maintain the activation of words during text reading. Methods & Procedures: We trained NYR, a patient with PhTA, to use a strategy, sentence building, designed to improve accuracy of reading words in text. The strategy required NYR to first read the initial word, and then build up the sentence by adding on sequential words, in a step‐wise manner, utilising the benefits of repetition priming to enhance accuracy. Outcomes & Results: When using the strategy, NYR displayed improved accuracy not only for sentences she practised using the strategy, but unpractised sentences as well. Additionally, NYR performed better on a test of comprehension when using the strategy, as compared to without the strategy. Conclusions: In light of research linking repetition priming to increased neural processing efficiency, our results suggest that use of this compensatory strategy improves reading accuracy and comprehension by temporarily boosting phonologic activation levels.

The role of effort in errorless and errorful learning

The technique of errorless learning (EL) has recently been applied to studies of the rehabilitation of anomia. In EL, the situation surrounding the performance of the desired task is controlled to prevent errors, sometimes through the use of descending cueing hierarchies. Another approach used in anomia treatments is ascending cueing hierarchies, in which errors are allowed. This is an example of errorful learning (EF). While both EL and EF paradigms have been used in anomia rehabilitation research, these approaches have never been directly compared (Fillingham, Hodgson, Sage, Lambon, & Ralph, et al., 2003). To address this issue, Treatment Comparison 1 (TC1) was designed to compare EL and EF treatments in training picture-naming with an anomic patient. The treatments were designed to be parallel in every way except that one was designed to prevent errors while the other allowed errors to occur. Treatment Comparison 2 (TC2) was designed to examine the role of effort in these same two treatment paradigms. The EL treatment was made more difficult but kept relatively errorfree so that it required more effort from the patient. The same manipulation was made to the EF treatment, enabling us to directly compare the two paradigms.

Functional reorganization supporting learning and maintenance in a case of phonologic alexia

There were no statistically significant di!erences in accuracy between the sets of to-be-trained (13% correct) or untrained (10%) words at T1/ pre-treatment. McNemar tests between trained/overlearned words and untrained words were statistically significant (p < .001) at T2/post-treatment (54% vs. 19%); T3/post-overlearning (89% vs. 9%); and T4/maintenance (83% vs. 14%). There were no statistically significant di!erences in BOLD signal between to-be-trained and untrained words pre-treatment. Post-treatment, in contrasting trained vs. untrained words, three clusters of activation were centered in left and right inferior frontal cortex and in the left lingual gyrus (cluster FWE-corrected p < .05), with the greatest spatial extent and degree of activation in the cluster centered in right homologous Broca’s area (BA45). Post-overlearning, greater activation was observed in left hemisphere structures, including perilesional activation in left (L) superior and inferior parietal cortex and precuneus, and L middle and anterior

Learning and maintenance in aphasia rehabilitation

An important issue in rehabilitation research is maintenance or retention of that which is learned during treatment. Studies that have measured maintenance rarely report 100% retention over time. That is, even if accuracy levels remain above baseline levels weeks or months after cessation of treatment, accuracy rarely remains at the level that had been reached by the end of treatment; some items are invariably lost. Understanding which items are likely to be lost, and why, would contribute to improvements in the design and implementation of treatment paradigms. In one common aphasia rehabilitation paradigm, a group of items are trained together until accurate performance is achieved on a predetermined percentage of the items. Training then proceeds to the next set of items. As a set is being trained to criterion, accurate performance is achieved for some of the individual items before others. One question that can be asked is whether the number of trials required to learn a word predicts the degree to which that word will be retained after treatment ceases. Three possibilities present themselves. One is that words that take longer to learn are more likely to be lost, perhaps because they are inherently more difficult. A second possibility is that words that take longer to learn are likely to be more tenacious; the hard work involved in learning helps to create a stronger representation. The third possibility is that this variable is not relevant to maintenance; once an item is learned, it is just as likely to be retained as any other learned items. To explore these alternatives, we compared number of errors on training with number of errors at maintenance for two patients who had successfully completed treatment for phonologic alexia.

Using repetition priming to improve oral reading in phonological text alexia

In Phonological Text Alexia (PhTA), pseudoword reading is poor, as is functor and affix reading in text. Reading of real words in isolation remains well preserved (Friedman, 1996). The syndrome may result from the phonological representations of functors being activated incompletely or at reduced speed. An alternate explanation is that while functors/affixes are activated normally, their activation levels decay at a pathologically rapid rate. If activation is either incomplete/slowed or if it decays rapidly, single functor reading should be unaffected, while functor reading in text would be impeded by interference from surrounding words. PhTA patients would therefore benefit from therapies that strengthen or prolong functor activation. One such technique that provides an immediate and transitory boost to word activation levels is repetition priming (Dean and Young, 1996). We hypothesized that repetition priming could be utilized to strengthen and/or maintain activation of functors during text reading. We created a treatment program to train a strategy, ‘Sentence Building’, in which the patient learns to read sentences by building them in steps. The repetition of the words as the sentences are built is predicted to help speed and maintain activation of the words on subsequent steps. We predict improved accuracy when the patient applies the mastered strategy to novel sentences.

Speeded functor reading: A new treatment program for phonological text alexia

In phonological text alexia (PhTA), a variant of phonological alexia, single word oral reading, including function word (functor) reading is intact, while oral text reading, particularly functors in text, is impaired (Friedman, 1996; Friedman & Lott, 1995). Patients with PhTA have decreased digit and word spans, impaired pseudoword repetition, and poor performance on tasks using rapid serial visual presentation. These findings suggest a decreased ability to hold multiple phonological codes in short-term memory (STM), resulting in increased retroactive inhibition or some form of phonological interference. Increased inhibition might have a stronger impact on functors than on content words, as content words’ semantic activation strengthens their overall activation levels, while functors cannot rely on such strong semantic activation. Moreover, the phonological representations of functors may not be activated completely or at normal speed, a hypothesis for which there is some evidence (Beeson & Insalaco, 1998). If functor activation is slowed but not impaired, accuracy of single functor reading would be unaffected, while functor reading in text would be impeded by interference from surrounding words. We designed a treatment to strengthen and speed the activation of the phonological representations of functors in a patient with PhTA that uses repeated exposure to functors and practice with rapid reading of these words.