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Aphasiology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/paph20
Attentive Reading and Constrained Summarisation (ARCS) discourse treatment for chronic Wernicke's aphasia a
Yvonne Rogalski , Lisa A. Edmonds Melissa J. Gardner
b c
a
, Valerie R. Daly &
a
a
Department of Speech-Language Pathology and Audiology , Ithaca College , Ithaca , USA b
Research Health Scientist, Brain Rehabilitation and Research Center, Malcom Randall Veterans Affairs , Gainesville , USA c
Department of Speech , Language and Hearing Sciences, University of Florida , Gainesville , USA Published online: 23 Jul 2013.
To cite this article: Aphasiology (2013): Attentive Reading and Constrained Summarisation (ARCS) discourse treatment for chronic Wernicke's aphasia, Aphasiology, DOI: 10.1080/02687038.2013.810327 To link to this article: http://dx.doi.org/10.1080/02687038.2013.810327
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Aphasiology, 2013 http://dx.doi.org/10.1080/02687038.2013.810327
Attentive Reading and Constrained Summarisation (ARCS) discourse treatment for chronic Wernicke’s aphasia
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Yvonne Rogalski1 , Lisa A. Edmonds2,3, Valerie R. Daly1, and Melissa J. Gardner1 1 Department of Speech-Language Pathology and Audiology, Ithaca College, Ithaca, USA 2 Research Health Scientist, Brain Rehabilitation and Research Center, Malcom Randall Veterans Affairs, Gainesville, USA 3 Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, USA
Background: Emerging evidence suggests that discourse-level treatments can improve microlinguistic processes such as lexical retrieval. Attentive Reading and Constrained Summarisation (ARCS) is a cognitive-linguistic discourse treatment that focuses attention on reading aloud and orally summarising text while constraining from non-specific language use. Aims: The primary aim of the current study was to evaluate the effect of ARCS on improving lexical retrieval abilities in two participants with Wernicke’s aphasia. Methods & Procedures: Two women with chronic moderate and severe Wernicke’s aphasia were administered ARCS for this case study. The study design was comprised of pre-treatment testing followed by 18 times of 50-minute sessions of ARCS therapy over 10 weeks and post-treatment testing immediately after and 2 months after the completion of treatment. Treatment stimuli included abridged versions of news articles. Primary outcome measures of lexical retrieval were the Boston Naming Test 2nd edition and informativeness of words during picture description and untreated article retell tasks. Outcomes & Results: The participant with moderate Wernicke’s aphasia improved on all three primary outcome measures, and she reported that the treatment made a functional impact on her life. In contrast, the participant with severe Wernicke’s aphasia did not improve on any of the outcome measures. Individual differences between the participants likely account for the discrepancy in treatment outcomes. Conclusions: ARCS demonstrates potential as a therapy for improving lexical retrieval in discourse with the possibility of generalisation to confrontation naming in persons with moderate Wernicke’s aphasia. Keywords: Wernicke’s; Aphasia; Intervention; ARCS; Discourse; Anomia.
Address correspondence to: Yvonne Rogalski, 953 Danby Rd., Ithaca College, Ithaca, NY 14850, USA. E-mail:
[email protected] This work was supported in part by an American Speech-Language-Hearing Association Advancing Academic-Research Careers Award. The authors would like to thank “P1” and “P2” for their participation in the study. We would also like to thank Julianna VanMeter for assisting with reliability. © 2013 Taylor & Francis
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INTRODUCTION This case study evaluated the effect of Attentive Reading and Constrained Summarisation (ARCS) (Rogalski & Edmonds, 2008) on the proportion of informative words in discourse as well as single-word naming for two women with Wernicke’s aphasia. The ARCS treatment is a cognitive-linguistic treatment based on theories of attention and constraint. The protocol requires participants to read aloud and verbally summarise portions of a reading passage while constraining from using nonspecific language (e.g., pronouns, “thing,” “stuff”) or opinions. Attention is promoted by reading aloud with the intent to summarise (Rogalski & Edmonds, 2008), while summarising requires attention to only the most essential units of information (Adams, 1991; Ulatowska & Chapman, 1994). The “constraint” component of ARCS promotes effortful language use along the same principles that guide constraint-induced language or aphasia therapy (e.g., Meinzer, Rodriguez, & Gonzalez Rothi, 2012; Pulvermüller et al., 2001). However, instead of encouraging spoken language by constraining the use of gestures or drawings, ARCS promotes enhanced access to the targeted semantic system by encouraging the intentional use of linguistically specific words (e.g., “the pencil”) over general words (e.g., “the thing”). The original ARCS case study described a participant with primary progressive aphasia who exhibited cognitive declines in attention, macrolinguistic impairments in discourse coherence and cohesion (most pronounced in his excessive use of tangents) and microlinguistic impairments characterised by anomia, non-specific language use and paraphasias. Following an ARCS treatment, the participant demonstrated increases in global and local coherence (topic maintenance and inter-sentential maintenance), cohesion (the semantic relationship linking one word to another across utterances), and informativeness (the percentage of meaningful words compared to total words in discourse production) (Rogalski & Edmonds, 2008). Although the authors did not include a single-word outcome measure for naming, increases in the informativeness of discourse suggested improvement in this participant’s ability to use more specific language.
ARCS TREATMENT IN WERNICKE’S APHASIA Individuals with Wernicke’s aphasia have been shown to present with characteristics of empty speech, including paraphasias, pronouns, and non-specific words (Nicholas, Obler, Albert, & Helm-Estabrooks, 1985). Evidence in the aphasia literature suggests that macrolinguistic deficits such as excessive production of comments and irrelevant utterances are also found in the discourse of people with Wernicke’s aphasia (Christiansen, 1995; Nicholas et al., 1985). Given the focus of ARCS treatment to engage active retrieval of language through summarisation and promote meaningful and specific language by constraining the use of non-specific words or phrases, we considered ARCS would be appropriate for the non-specific and irrelevant output observed in Wernicke’s aphasia. The discourse-based tasks used in ARCS have the potential to promote generalisation to lexical retrieval abilities through systematic activation of the cognitive and linguistic components underlying the complex language processing involved in discourse. Specifically, ARCS engages an active retrieval of language through summarisation and promotes meaningful language by constraining the use of non-specific
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words or phrases. Both of these treatment components also have the potential to strengthen access to the semantic system, which can promote lexical retrieval of more meaningful words. We hypothesise that it works in the following ways: First, reading attentively with the intent to summarise primes the semantic system for activation by providing the context from which lexical items are activated (Ledoux, Camblin, Swaab, & Gordon, 2006), making it easier to retrieve the targeted information than if the information had not been primed. Second, lexical retrieval during summarisation may strengthen semantic access by acting as a secondary encoding (Brown & Craik, 2000) of the primary information activated through reading. Third, constraint may strengthen semantic access by forcing intentional use of specific rather than general language, just as constraint-induced language approaches promote neuroplasticity by enforcing the use of the affected linguistic modality (verbal rather than non-verbal language) (Meinzer et al., 2012). Evidence from the aphasia literature also suggests that discourse-based treatments (in contrast to single-word treatments) can result in improved word retrieval and informativeness of discourse in people with aphasia (for a review, see Boyle, 2011). For example, discourse-based treatments incorporating semantic feature analysis have resulted in increased communicative informativeness of discourse in a singleparticipant therapy (Peach & Reuter, 2010) and group therapy (Falconer & Antonucci, 2012), and have resulted in increased noun retrieval in group therapy (Antonucci, 2009). Given the emerging evidence that discourse-based therapies can enhance lexical retrieval in people with aphasia and that ARCS is a discourse-based therapy that promotes intentional use of linguistically specific words, we explored the use of ARCS in two participants with Wernicke’s aphasia who exhibited severe word-finding difficulty and “empty” discourse marked by paraphasias and non-specific word use as well as macrolinguistic impairments such as a tangential discourse. In the original case study (Rogalski & Edmonds, 2008), improvements in lexical retrieval were based on a measure of discourse informativeness for a picture description: the percent correct information unit (%CIU) as described in Nicholas and Brookshire (1993). Boyle (2011) notes there is little consistency as to how lexical retrieval is measured in the emerging discourse-based studies, and states that “stimuli to assess outcomes need not be constrained to include treated vocabulary items as long as measures that capture changes in the general process of word retrieval are used” (p. 1323). Because we were interested in exploring the generalisation effects of ARCS on lexical retrieval across tasks in the current study, we have included a test of confrontation naming, the second edition of the Boston Naming Test (BNT-2; Kaplan et al., 2001), in addition to %CIUs from untreated discourse stimuli. We have also added a secondary outcome measure, a questionnaire created for this study that allows the participants to rate how effectively they understand and communicate information prior to and after treatment. Given that the participant in the original case study (Rogalski & Edmonds, 2008) improved on discourse informativeness, we hypothesised post-ARCS treatment increases in discourse informativeness in the participants with Wernicke’s aphasia. Additionally, given that treatment at the discourse level has resulted in improvements on a number of lexical retrieval measures in previous studies (Boyle, 2011), we hypothesised that treatment with ARCS would yield increases in post-treatment BNT-2 scores.
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METHOD
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Participants At the time of the current study, P1 was a 63-year-old right-handed Caucasian woman with a 4-year history of chronic Wernicke’s aphasia resulting from a ruptured brain aneurysm and subsequent left middle cerebral artery (MCA) cerebrovascular accident (CVA). P1 reported normal vision and hearing and was a native English speaker. She reported having better reading comprehension than auditory comprehension and often required conversation partners to supplement with written communication. She was a retired registered nurse who lived independently in the community, led an active life, and frequently communicated with family and friends. P1 had been receiving speech-language therapy for 4 years prior to the treatment study. P2 was an 83-year old right-handed Caucasian woman who, at the time of the current study, had a 21-year history of chronic Wernicke’s aphasia as a result of a left MCA CVA in 1990 and a transient ischemic attack in 1995. She was a native English speaker with normal vision, but her pre-testing audiological examination revealed that she had a mild, sloping to severe sensorineural hearing loss for which she refused hearing aids. Given P2, similar to P1, reported better reading comprehension than auditory comprehension, it was determined that her hearing loss would not interfere with the reading-based ARCS treatment. Moreover, she conceded to using a personal frequency modulation (FM) system during treatment. P2 was a retired administrative assistant who lived in a residential senior retirement community. She reported that she infrequently participated in scheduled activities with fellow residents because of her aphasia, and preferred to watch subtitled television. P2 had received speech-language therapy off and on for 20 years prior to the onset of the treatment study. The participants were not receiving any additional language therapy services during the time of the study. This study was approved by the Ithaca College All-College Review Board for Human Subjects Research.
Pre-testing standardised and non-standardised measures P1 and P2 completed a number of standardised and non-standardised measures prior to beginning therapy (see Table 1). Standardised tests included the Boston Naming Test (BNT-2; Kaplan et al., 2001), the Western Aphasia Battery Revised (WAB-R; Kertesz, 2007) Aphasia Quotient (AQ) and Language Quotient (LQ) subtests, and the written version of the Pyramids and Palm Trees test (PPT; Howard & Patterson, 1992) to evaluate processing of written semantic associations between words. To assess the participants’ perception of their ability to understand and talk about information across a number of common scenarios, an informal, non-standardised 5-point Likert Scale termed the Comprehension and Communication Survey (CCS) was developed based on the kinds of communication situations the participants encounter. Participants rated 8 events on a scale of 1 (very hard) to 5 (very easy) for a maximum of 40 points. See Appendix A for a copy of the survey. P1 was diagnosed with moderate Wernicke’s aphasia according to the WAB-R, and demonstrated severe anomia, indicated by a score within the 20th percentile, on the BNT-2 (Kaplan et al., 2001) (see Table 1). Her anomia was characterised by semantic and phonemic paraphasias. On the BNT-2, 3/3 errors were semantic paraphasias and on the WAB-R naming subtest, 3/5 errors were semantic and 2/5 errors were phonemic. Her performance on the PPT (43/52), a test of semantic relatedness, was below
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TABLE 1 Pre-treatment results from standardised and non-standardised measures Test/measure
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BNT-2 (/60) WAB-R AQ (/100) WAB-R LQ (/100) WAB-R subtests Spontaneous speech (/100%)a Aud verb comprehension (/100%)a Repetition (/100%)a Naming and word finding (/100%)a Reading (/100%)b Writing (/100%)b PPT written words (/52) CCS (/40)c
P1
P2
7 63.7 67.4
11 41.2 38
85 68.5 33 47 83 60.5 43 24
55 29 6 30 62 26 51 19
BNT = Boston Naming Test 2nd edition, WAB-R = Western Aphasia Battery Revised (AQ = Aphasia Quotient, LQ = Language Quotient), Aud verb = Auditory Verbal, PPT = Pyramids and Palm Trees test, CCS = Comprehension and Communication Survey. a Subtests used to compute AQ; b Subtests used in conjunction with AQ subtests to compute LQ; and c Non-standardised 8 question, 5-point Likert scale created for the current study.
what is considered normal (47–52). Finally, her score on the CCS (24/40) was higher on pre-testing than P2’s score. P2’s test results indicated a severe Wernicke’s aphasia and severe anomia (see Table 1). Her WAB-R subtests revealed scores in all areas that were much lower than P1’s. In comparison to P1, P2 had a higher frequency of paraphasic errors that were predominantly semantic in nature. On the WAB-R naming subtest, 10/14 errors were semantic or mixed phonemic-semantic, and 4/14 were phonemic. On the BNT2, 4/4 errors were phonemic. However, P2’s performance on the PPT was within the normal range and higher than P1’s. P2’s score on the CCS (19/40) was lower than P1’s score.
Pre-testing discourse and reading The participants also completed two measures of discourse (see Table 2). To evaluate the informativeness and efficiency of picture description, two Nicholas and Brookshire (1993) individual pictures (Cat in Tree, Birthday Party) and two sequential pictures (The Argument, Directions) were given. Measurements included the number of words, the number of correct information units (CIUs: the number of intelligible, relevant words), the percentage of CIUs (%CIUs: the total number of correct information units divided by the total number of words), the number of words per minute (WPM), and the number of CIUs per minute. The participants were also tested on the informativeness and efficiency of their retelling of four untreated articles (see stimuli section below for details) to characterise their summarisation abilities and to provide a comparison for post-treatment stimulus generalisation. Although the retelling task was created for the current study, and reliability has not been previously demonstrated, we used the Nicholas and Brookshire (1993) procedures for measuring the informativeness and efficiency because they have
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TABLE 2 Averaged pre-testing results from the Nicholas and Brookshire (1993) picture description task and the untrained article retell task Task
P1
P2
Picture Words CIUs %CIUs WPM CIUs/min
187.5 116 63.7 106.8 67.5
63.5 32.8 50.8 91.3 46.5
Untrained article retellsb Words CIUs %CIUs WPM CIUs/min % reading errors
218.5 99.5 45 95.5 42 8.83
26.3 8.8 30.6 78 23.6 17.3
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descriptiona
CIUs = correct information units, WPM = words per minute. a Averaged from four picture descriptions (two single and two sequential) and b Averaged from four untrained article retells.
been applied to a variety of discourse tasks, including story retell (e.g., Doyle et al., 2000; McNeil, Doyle, Fossett, Park, & Goda, 2001). It should be noted that in the Doyle et al. (2000) and McNeil et al. (2001) studies, story retell involved the presentation of pictured story frames accompanied by the oral story, followed by the participant’s verbal retell. During the retell, the participant had access to the complete set of pictured story frames. In the current study, however, the participants were instructed to read the article one time aloud and then to orally tell the clinician everything they remembered about the article, from memory. Clinicians did not provide corrections or feedback for reading or retelling errors during testing. P1 had notably higher pre-treatment scores on all measures of informativeness and efficiency compared to P2 (see Table 2). Her spoken discourse during conversation, the WAB-R picture description and the Nicholas and Brookshire picture description tasks, was characterised by anomia, omissions, phonemic paraphasias, non-informative and deictic language (e.g., overuse of pronouns, and “thing, there”), and tangents. In terms of reading, P1 exhibited paralexias that were predominantly phonemic (71.43%) compared to semantic (28.57%) on a sample reading passage. P1’s alexia was likely due to impairments in her phonological output lexicon, which would also account for the presence of phonemic paraphasias in her spoken output. On the picture description and untrained news article retell tasks, P2 scored below P1 on all measures (see Table 2). Her discourse characteristics were similar to P1’s but additionally included semantic paraphasias. In terms of reading errors, P2 showed a reverse pattern from P1, with predominantly semantic paralexias (83.53%) in comparison to phonemic (16.47%). P2 likely exhibited a deep alexia, characterised by errors that were semantic (dog –> tail), visual (then –> when) and morphological (found –> find). Additionally, P2 had approximately twice as many paralexias as P1 on pretesting. P2’s alexia type coupled with her error frequency indicate that her alexia was
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more severe than P1’s. Despite errors in oral reading, both participants had disproportionate impairments in auditory comprehension versus reading comprehension and thus reading was their preferred mode of comprehending.
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Stimuli The treatment articles used for the ARCS therapy and the untreated articles for pre-, post- and maintenance testing were randomly chosen abridged articles from the CNN news story archives (http://literacynet.org/cnnsf/archives.html). Abridged articles were used because they had been modified from the original articles to facilitate reading ease in populations with low comprehension, such as non-native English speakers. Articles used for testing had a mean word count of 213.25 (SD = 30.54, range = 208–276) and a mean grade level of 4.93 (SD = .95, range = 3.9–6.2). Articles used for treatment had a mean word count of 285.77 (SD = 67.19, range = 168–389) and a mean grade level of 5.81 (SD = 1.06, range = 3.8–7.2). The stimuli covered an array of news topics, including health, science and technology, and disasters. Both participants received the same set of untreated articles for testing and the same set of articles for treatment.
Testing and treatment frequency All the testing and treatment took place in a university clinic over the course of 3 months. The BNT-2, WAB-R, PPT and Nicholas and Brookshire picture description tasks were administered prior to and immediately after the completion of treatment. The reading and retelling of the untreated articles took place prior to treatment, immediately after treatment, and 2 months after treatment. P1 and P2 completed approximately 5 hours of pre-testing over several days, followed by 18, 50-minute ARCS treatment sessions approximately twice per week over 10 weeks. Two trained graduate clinicians (the third and fourth authors), supervised by the first author, administered the pre-treatment tests and treatment to their respective participants, P1 and P2. The first author conducted treatment reliability live on 50% of sessions; clinicians’ adherence to the protocol was greater than 95%. Post-testing was completed by two different graduate clinicians. Two months after the completion of treatment, the first author re-administered the four untreated article stimuli to assess treatment maintenance.
Treatment protocol The ARCS protocol used in the present study is described in Appendix B. The original ARCS protocol (Rogalski & Edmonds, 2008) involved three steps: (1) Read two to three sentences aloud with the intent to summarise, (2) Re-read silently for comprehension, and (3) Summarise aloud the two to three sentences while maintaining the topic and using meaningful words (e.g., no non-informational words such as “thing” or “stuff,” no opinion, and no pronouns). Each of the three steps was then repeated until the article was completed. Several additions were made to the original ARCS protocol (Rogalski & Edmonds, 2008) that involve previewing, re-reading for feedback, and summarising the complete article in order to enhance activation of the semantic system and lexical access. Step 1 of the revised protocol now requires the participant
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first to read the entire article aloud once to preview the content so that the participant has a better indication of what to expect. The second addition (step 5) requires the participant to re-read each sentence aloud after summarisation in order to receive feedback about what he or she has just summarised from memory. Feedback can further consolidate the information (McDaniel & Fisher, 1991; McDaniel, Roediger III, & McDermott, 2007) and improve retention, particularly if responses were previously incorrect (Pashler, Cepeda, Wixted, & Rohrer, 2005). The final change was added to the end of the protocol. In the original protocol the participant reads and summarises section by section until the article is complete; the revised protocol requires oral summarisation of the entire article from memory in order to cohere and consolidate the information just studied. Both participants received the same set of written guidelines for completing the treatment (see Appendix A “Guidelines for participant”). Clinicians followed the same general written guidelines in order to maintain consistency across participants (see Appendix A “Guidelines for clinician”); however, some differences in cueing resulted to meet the participants’ individualised needs. Compared to P2, P1 required less clinician-directed feedback during reading aloud and more feedback during her summaries, such as reminders to adhere to the constraints. P2 required more cliniciandirected cueing and corrections for paralexias than P1 when reading aloud. When P2 encountered a reading error, the clinician instructed her to stop and look at the clinician’s lips and to say the word in unison with the clinician with clearly demarcated syllables. If after five attempts the word was not read correctly, P2 would continue reading the next word. This technique of concurrent lip-reading and listening has been associated with increased auditory comprehension in patients with word deafness (Shindo, Kaga, & Tanaka, 1991). P2 also used a personal FM system during therapy to increase the volume of the clinician’s voice to assist with following directions and reception of clinician’s cues for reading errors. All sessions were recorded using a Marantz PMD660 professional portable digital recorder.
Data analysis of pre- and post-treatment and maintenance discourse measures The third and fourth authors transcribed and coded all pre- and post-treatment Nicholas and Brookshire picture descriptions and pre- and post-treatment and maintenance untreated article retells into Microsoft Word to obtain and record a word count. Timing information (start and end time) was obtained from the digital files and recorded on the transcripts. Coding for Words and CIUs, which were used to calculate %CIUs, was conducted according to Nicholas and Brookshire procedures (1993). Inter- and intra-rater reliability for the percent reliability of point-by-point coding of CIUs was assessed by the third and fourth authors and an additional master’s level student. The first author randomly assigned about 20% of the transcripts (four each from P1 and P2) to the reliability raters who were blinded to whether the transcripts were from the pre-, post- or maintenance period. Intra-rater reliability was 90.7% and inter-rater reliability was 91.7%. Disagreements were discussed and re-coded according to consensus. Given that both participants presented with paralexias when reading aloud during pre-testing, additional descriptive data on reading errors was collected and then analysed post hoc to determine whether treatment had an effect on the reading errors. Reading errors were defined as phonemic, semantic or mixed errors. Coders counted
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the number of errors produced during the reading of each of the untreated article retells, then divided by the total number of words produced.
RESULTS
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It was hypothesised that the ARCS treatment would result in increases to three primary outcome measures: (1) the raw scores from the BNT-2, (2) the averaged %CIUs obtained from the four Nicholas and Brookshire (1993) picture descriptions, and (3) the averaged %CIUs from four untreated article retells. Also reported are changes observed in the secondary outcome measure, the CCS, and in the WAB-R LQ, the PPT, and the percentage of reading errors. The data are reported in Tables 3–5. For the BNT-2 and the picture descriptions, participant scores are reported and
TABLE 3 Pre- and post-treatment, and percent change (% change) results from standardised and non-standardised measures for both participants P1 Test/measure
P2
Pre-
Post-
% Change
Pre-
Post-
% Change
BNT-2 (/60) 7 WAB-R AQ (/100) 63.7 WAB-R LQ (/100) 67.4 WAB-R LQ subtests (/100% each) Spontaneous speech 17 Aud verb comprehension 137 Repetition 33 Naming and word finding 47 Reading 83 Writing 60.5 PPT written words (/52) 43 CCS (/40)a 24
16 66.2 74.7
128.57 3.93 10.83
11 41.2 38
11 44.4 52.1
0 3.20 37.12
18 146 30 48 91 80.5 47 34.5
5.9 6.6 −9.1 2.1 9.6 33.1 9.30 43.75
11 58 6 30 62 26 51 19
11 128 12 36 73 44.5 50 22
0 120.7 100 20 17.7 71.2 −1.96 15.79
BNT = Boston Naming Test 2nd edition, WAB-R = Western Aphasia Battery Revised (AQ = Aphasia Quotient, LQ = Language Quotient), Aud verb = Auditory Verbal, PPT = Pyramids and Palm Trees test, CCS = Comprehension and Communication Survey. a Non-standardised eight question, 5-point Likert scale created for the current study.
TABLE 4 Averaged pre-, post- and 2-months post-treatment results from four untrained article retells P1 Measure Words CIUs % CIUs WPM CIUs/min % reading errors
P2
Pre-
Post-
Two-months post-
Pre-
Post-
Two-months post-
218.5 99.5 45 95.5 42 8.83
239.5 135 55.9 78.2 50.2 4.3
221.8 133 56.5 75.8 42.6 5.7
26.3 8.8 30.6 78 23.6 17.3
44 12.5 32.3 33.52 11.1 16.3
34 11 32.2 48.9 15.5 19
CIUs = correct information units, WPM = words per minute.
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TABLE 5 Pre-post ARCS treatment averaged change scores and aphasia reliability (retest reliability change) from two single and two sequential Nicholas and Brookshire (1993) pictures P2
Words CIUs %CIUs WPM CIUs/min
P2
Pre-
Post-
Change
Pre-
Post-
Change
Retest reliability changea
187.5 116 63.7 106.8 67.5
276.5 205.5 74.6 92.6 68.9
89 89.5 10.9 −14.2 1.4
63.5 32.8 50.8 91.3 46.5
80 45 58.3 93.1 55.3
16.5 12.2 7.5 1.8 8.8
not available not available 9.88 15 15.25
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CIUs = correct information units, WPM = words per minute. a Estimated average absolute change scores for two single and two sequential pictures taken from figures used in Brookshire and Nicholas (1994).
interpreted in the context of test–retest reliability parameters. For the untreated article retells, a novel assessment, the percentage of change from one assessment period to the next is reported, as no reliability measures were available. The percentage of change between scores is also reported in some cases to more accurately capture the differences between the participants, whose scores were so dissimilar on pre-testing.
P1’s results P1 exhibited pre- to post-treatment increases on all the three primary outcome measures. She had a 9 point (128.6%) increase on her BNT-2 score (see Table 3), indicating a notable change, as retest reliability for the BNT-2 is high (r= 0.91, SEM= 1.02) with a gain of only about 1 point from first to second testing for non-brain-damaged older adults (Flanagan & Jackson, 1997). She also had a 24.2% increase in %CIUs on her untreated article retells, which she maintained 2 months past the completion of treatment (see Table 4). As for her picture description measures, P1 increased her raw %CIUs score by 10.9 points (17.11%) in post-treatment. After estimating the retest parameters for people with aphasia based on figures including the two single and two sequential pictures from Brookshire and Nicholas (1994), P1’s improvement on the picture description task was marginal (see Table 5). Nonetheless, in post-treatment, P1’s increases in %CIUs on picture description and article retells were within the context of increased information as demonstrated by a large increase in number of CIUs and words. P1’s decreases in WPM on both types of discourse measures resulted in increased efficiency (CIUs/minute) on the article retells but no changes in efficiency on picture description. For a sample of P1’s post-treatment discourse on the article retell task, please see Appendix C. Finally, P1 had a 43.8% increase in her self-reported ratings on the CCS (see Table 3). Her ratings suggest improvement in all communication scenarios, but her greatest reported changes were in “talking to a friend” and “talking to a stranger” (both increased from 3 to 4.5). Increases on the CCS suggest that she perceived positive changes in her ability to understand and communicate outside of therapy. Although not part of the primary outcome measures, some pre- to post-treatment testing changes occurred that deserve mention (see Table 3). First, P1 made notable improvements on her WAB-R LQ score, demonstrating a 7.3-point increase. Evaluation of the individual WAB-R LQ subtests indicated fairly evenly distributed and modest improvement (>5%) in spontaneous speech, auditory comprehension and
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reading, plus a notable (33%) increase in her writing ability. Second, P1’s PPT test score improved, elevating her from just below normal limits to within the normal range, where a score greater than 90% indicates no clinically significant impairment on the task (Howard & Patterson, 1992). Finally, with regard to reading aloud from the article retells, P1 had a 51.3% post-treatment reduction in reading errors and demonstrated some maintenance of the improved oral reading abilities at 2 months post-treatment (see Table 5).
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P2’s results P2’s results were somewhat different from P1’s. P2 did not exhibit any changes on her BNT-2 score (see Table 3), and although she had a 7.5-point increase in her raw %CIU score on the picture description tasks, this change was within the parameters of what would be expected on test–retest reliability for people with aphasia (Brookshire & Nicholas, 1994) (see Table 4). Like P1, P2 produced more informative discourse (i.e., increases in CIUs) post-treatment with a 37.2% increase in CIUs on picture description and a 42% increase in CIUs on article retells. Moreover, P2’s efficiency (CIUs/minute) increased by 18.9% on the picture description but decreased by 53% on the article retells, driven by a 57% decrease in WPM. Unlike P1, P2’s ratings on the CCS showed only a negligible increase (from 19 to 22 points), indicating that she perceived little change in her ability to understand and relay information in non-therapy-based contexts. Although not a primary outcome measure, P2’s WAB-R LQ score showed more improvement than P1’s, with an increase of 14.1 points (see Table 3). She demonstrated notable increases (17% to 121%) on all subtests except spontaneous speech, showing marked improvement in comprehension, repetition and writing. Unlike P1, P2’s reading errors showed little change (see Table 5).
DISCUSSION The purpose of this case study was to explore the effect of a cognitive-linguistic treatment, Attentive Reading and Constrained Summarisation (ARCS) (Rogalski & Edmonds, 2008), on single-word naming and discourse informativeness in two participants with moderate and severe Wernicke’s aphasia. Due to previous positive changes in discourse informativeness with ARCS treatment in a gentleman with a progressive aphasia, we hypothesised similar increases in informativeness in participants with chronic stroke-induced aphasia. Additionally, based on reports of discourse level treatments that have resulted in improved lexical retrieval on a variety of measures (Boyle, 2011), we hypothesised post-treatment increases in single word naming. Primary outcome measures were the BNT-2 (Kaplan et al., 2001), and the percent correct information units (%CIUs) obtained from four Nicholas and Brookshire pictures (1993) and four untreated article retells. The secondary outcome measure was the CCS, a survey created for the study in order to capture the participants’ subjective perceptions of change related to the treatment. Hypotheses were supported for P1, who improved on the BNT-2 and exhibited marginal change on %CIUs in both discourse tasks. Moreover, P1’s self-reported higher ratings on the CCS indicates that the treatment had a positive impact on functional communication in daily life. Hypotheses were not supported for P2, who showed no changes in single word naming or discourse informativeness, and whose CCS showed negligible change as a result of the treatment. The differences in treatment outcomes may be related to the differences between
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the participants themselves. Participant variability has been known to affect treatment response to anomia therapy (for a review, see Lambon Ralph, Snell, Fillingham, Conroy, & Sage, 2010). Accordingly, we will discuss each of the participants’ responses to the ARCS treatment separately, with consideration of how individual differences in the participants may have contributed to the differences in treatment outcomes.
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P1 discussion P1’s post-treatment increases on the BNT-2 and informativeness on the article retells and Nicholas and Brookshire (1993) picture descriptions suggest a positive response to ARCS therapy. Importantly, the results were not obtained from measures reflecting words or stimuli that had been explicitly trained during therapy, suggesting a beneficial effect on cognitive-linguistic processes that support confrontation naming, narrative production and the various demands required for the retell task (intention, attention, reading, memory, lexical retrieval). Additionally, P1’s reduced speech rate coupled with an increase in words and CIUs may indicate the use of a strategy. This finding is consistent with that in the original case study (Rogalski & Edmonds, 2008), where the authors proposed that the participant’s decrease in speech rate despite maintenance of %CIUs may have been attributed to a strategy of slowing down to carefully attend to constraints and use specific words (Rogalski & Edmonds, 2008). Thus, P1’s maintenance of discourse informativeness on the article retells of 2 months post-treatment supports the likelihood of enhanced cognitive-linguistic skills targeted in ARCS as well as the possibility of a continued effort to avoid general and non-specific words. Encounters with P1 after therapy completion suggest anecdotally that she was consciously attempting to refrain from using nonspecific words during communicative interactions. For example, she would stop herself in the middle of a sentence to state: “Now I know I’m not supposed to say that one, so let me try again.” P1’s post-treatment improvements on the PPT and the WAB-R writing subtest, and her reduction in reading errors compared to pre-treatment scores, may indicate generalisation beyond the primary outcome measures. Though these tasks encompass different language domains, their improvement is consistent with components of ARCS therapy. For the PPT, P1 may have been paying more attention to the written words and their semantic relationships, as the ARCS therapy encourages attention during reading for comprehension. Increases on the PPT may also reflect improvements in reading skills for written word comprehension, as demonstrated by modest increases on the reading subtest of her WAB-R LQ and her decrease in reading errors during the reading aloud portion of the article retell task. It is important to note, however, that P1’s shift on the PPT from just below normal to within the normal range may not be related to generalised therapy gains. P1’s decrease in reading errors may be attributed to the practice she received reading aloud during the ARCS therapy, which is consistent with the Oral Reading for Language in Aphasia approach (Cherney, 2004), where reading aloud promotes reading comprehension and accuracy. P1’s improvement in writing, her greatest improvement on the WAB-R LQ, was likely due to improved lexical access. ARCS required P1 to repeatedly access meaningful words from her semantic system, the same system from which words are accessed in speaking and writing (e.g., Kay, Lesser, & Coltheart, 1992), and improvements to semantic processing could have improved lexical access to spoken and written modalities, which has been observed previously (e.g., Edmonds & Babb, 2011). P1’s post-treatment self-ratings on the CCS suggest that she perceived some positive changes in activities relating to an understanding and relaying information outside of
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therapy. Thus, this provides preliminary evidence that ARCS may generalise beyond the clinic into functional communication, though we are cautious in this interpretation since the CCS has not undergone psychometric evaluation. However, previous research supports this possibility, as Best and colleagues reported that participants’ changes in word-finding as a result of anomia therapy related strongly to participants’ activity ratings on a psychosocial measure (Best, Greenwood, Grassly, & Hickin, 2008). P1’s positive response to the ARCS therapy may have been due to several factors. First, she had a moderate form of Wernicke’s aphasia and her auditory comprehension was less severely impaired than P2’s. Aphasia severity and auditory processing have been associated with treatment prognosis; people with less severe aphasia and people with fewer auditory processing impairments have better post-treatment outcomes (de Riesthal & Wertz, 2004). Second, P1’s error patterns in confrontation naming and reading aloud were predominantly phonological, suggesting greater retrieval interference from neighbouring phonemes than semantic competitors during lexical access. Given ARCS’ intention to strengthen the underlying semantic system via reading and retrieval of meaningful words, having less semantic competition would presumably result in less interference and greater access to the target. Third, P1’s alexia was less severe than P2’s at the initiation of therapy, and thus she was reading with fewer errors. Given ARCS requires reading with the intent to summarise in order to prime the semantic system, having fewer initial reading errors likely results in a more efficient priming of the semantic system.
P2 discussion P2’s response to the ARCS therapy was markedly different from P1’s. On the primary outcome measures, P2 did not show any improvement on the BNT-2, and she exhibited negligible changes in %CIUs on the article retell and picture description tasks. Regarding efficiency, WPM did not change on picture description, but there was a sharp decline in speech rate on the article retells. This finding suggests that P2, like P1, may have been attempting to use a strategy during retell, albeit ineffectively. Even though P2 did not improve on primary outcome measures, P2 made considerable progress on the WAB-R LQ auditory comprehension and repetition subtests. These changes are most likely due to the clinician-directed visual and spoken word cues given for reading breakdowns during a treatment. Improved auditory comprehension in individuals with auditory agnosia has been associated with paired written and auditory presentation of single words (Francis, Riddoch, & Humphreys, 2001) and concurrent lip-reading and listening treatments (Shindo et al., 1991), both of which involve a strong acoustic-phonological component. Recently, Robson and colleagues found a strong correlation between auditory comprehension and acousticphonological perception in Wernicke’s aphasia (Robson, Keidel, Lambon Ralph, & Sage, 2012), further supporting the notion that P2’s improvements in auditory comprehension were likely the result of verbal phonological cueing during treatment. Despite some notable improvement in comprehension on the WAB-R LQ, P2 reported virtually no change on the Comprehension and Communication Survey compared to P1. Pre-treatment differences between the participants may elucidate this result. In comparison to P1 at pre-treatment, P2 reported being more socially isolated as a result of her aphasia. To that end, the ARCS therapy approach may not have been an ideal fit for P2’s needs. P2 may have been better served by a treatment targeting a
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social-interaction approach to promote communicative success during social/group interaction. Several additional factors likely contribute to P2’s poor response to ARCS therapy. First, P2’s aphasia and alexia were more severe than P1’s prior to treatment. P2’s specific impairments in reading (she produced roughly twice as many reading errors as P1 during oral reading and needed more cueing during therapy) and repetition (6/100 on the WAB LQ) likely made her a less ideal candidate for ARCS therapy, which includes a heavy reading aloud component. In support, Lamdon Ralph and colleagues found that reading and word repetition loaded strongly onto a phonological factor that predicted outcomes for anomia therapy (Lambon Ralph et al., 2010). Second, P2 presented with reading errors marked by semantic, visual and morphological errors, suggestive of deep dyslexia. The type and severity of her alexia likely interfered with the priming of her semantic system during the “reading with the intent to summarise” component of ARCS. Additionally, the article-retell outcome measure also required reading aloud, thus, reading errors likely interfered with the processing of the content to be retold. In support of this, P2 performed more poorly on the article retell task than on the picture description tasks of pre- and posttherapy. On pre-testing, P2 produced fewer than half the number of words (on average, 26.3) on her article retells than on picture description (on average, 63.5). The differences between these numbers likely reflect the differences in task demands; retelling an article requires reading aloud, retaining subsequent information, then retelling, whereas the picture description task does not require reading nor does it have the additional cognitive demands of memory because the stimulus is available throughout the task. Finally, both participants received the same reading stimuli for therapy. It is possible that the materials were too complicated for P2, given the severity of her alexia.
Study limitations The current findings suggest potential use of ARCS as a therapy to aid meaningful lexical retrieval in discourse and confrontation naming in persons with moderate Wernicke’s aphasia. However, there are limitations that require cautious interpretation of the results. Because this is a case study with a pre-post design absent of a baseline phase, repeated exposure to the materials could have contributed to the improvements observed. Thus, to guard against over-interpretation of the picture description results, the current findings were interpreted within reported re-test parameters from Brookshire and Nicholas (1994) and from the BNT-2 (Flanagan & Jackson, 1997). There are no normative data for the articles used for the retell during pre-, postand maintenance testings, and as such the results must be considered conservatively. However, the results of the article retells are consistent with the overall improvement profiles for the participants such that larger gains were observed for P1. Although no control tasks were determined a priori, P2 did not improve on a number of tasks, providing some suggestion of internal validity. P1 did show more widespread improvement than P2, but she did not, for example, show improvement on a number of tasks that theoretically could have shown gains as a result of the treatment (e.g., speech rate on both picture description and article retell, repetition on the WAB-R). Finally, it may not have been optimal to pilot ARCS on P2 given her severity of aphasia, which was 21 years post onset (as compared to P1’s aphasia severity and time post onset).
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Future directions The difference in response to ARCS across participants raises some interesting questions about contributing individual differences to treatment outcomes. The protocols of the present and previous ARCS study required participants to read aloud prior to summarisation to ensure that the participants were not producing any reading errors that might interfere with comprehension and thus subsequent production of summaries. Reading aloud can have a positive impact, as in the case of P1 whose reading errors decreased post-treatment. However, reading aloud can also have a negative impact, as with P2 whose time spent correcting paralexias may have interfered with the original aim of ARCS, making it instead an exercise in auditory perception for phonological corrections. Future studies should compare silent reading versus reading aloud in ARCS to determine if there are any differences in treatment outcomes between the two modalities. Future studies should also consider an a priori minimum phrase-level reading proficiency, so that individuals can focus more on the treatment itself, than on reading. Future studies should consider the type of alexia present, if any, and be cautious about using ARCS therapy with someone who presents with a deep alexia. Future studies should consider tailoring the ARCS treatment materials to individual’s needs, starting with shorter reading passages that increase with complexity and length as treatment progresses. Finally, more research is warranted on the effect of ARCS on participants with severe aphasia.
CONCLUSIONS Though more research is needed, ARCS may be particularly useful in Wernicke’s aphasia because the treatment targets attention to self-monitoring during reading aloud and reading comprehension, both of which could be impaired due to compromised comprehension. Additionally, the characteristic empty speech in Wernicke’s aphasia is addressed through constraint of general words (also a form of selfmonitoring) and promotion of more semantically informative words, which aids lexical retrieval. Thus, because of the complex, yet systematic and integrated treatment components in ARCS, a generalisation to component tasks is possible, as was observed with P1. Manuscript received 20 January 2013 Manuscript accepted 28 May 2013 First published 19 July 2013
REFERENCES Adams, C. (1991). Qualitative age differences in memory for text: A life-span developmental perspective. Psychology and Aging, 6, 323–336. Antonucci, S. (2009). Use of semantic feature analysis in group aphasia treatment. Aphasiology, 7, 854–866. Best, W., Greenwood, A., Grassly, J., & Hickin, J. (2008). Bridging the gap: Can impairment-based therapy for anomia have an impact at the psycho-social level? International Journal of Language and Communication Disorders, 43, 390–407. Boyle, M. (2011). Discourse treatment for word retrieval impairment in aphasia: The story so far. Aphasiology, 25, 1308–1326. Brookshire, R. H., & Nicholas, L. E. (1994). Test-retest stability of measures of connected speech in aphasia. Clinical Aphasiology, 22, 119–133. Brown, S. C., & Craik, F. I. (2000). Encoding and retrieval of information. In E. Tulving & F. I. Craik (Eds.), The Oxford handbook of memory (pp. 93–107). New York, NY: Oxford University Press.
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Cherney, L. (2004). Aphasia, alexia, and oral reading. Topics in Stroke Rehabilitation, 11, 22–36. Christiansen, J. A. (1995). Coherence violations and propositional usage in the narratives of fluent aphasics. Brain and Language, 51, 291–317. de Riesthal, M., & Wertz, R. T. (2004). Prognosis for aphasia: Relationship between selected biographical and behavioural variables and outcome and improvement. Aphasiology, 18, 899–915. Doyle, P. J., McNeil, M. R., Park, G., Goda, A., Rubenstein, E., Spencer, K., . . . Szwarc, L. (2000). Linguistic validation of four parallel forms of a story retelling procedure. Aphasiology, 14, 537–549. Edmonds, L., & Babb, M. (2011). The effect of verb network strengthening treatment (VNeST) on persons with moderate-severe aphasia. American Journal of Speech-Language Pathology, 20, 131–145. Falconer, C., & Antonucci, S. M. (2012). Use of semantic feature analysis in group discourse treatment for aphasia: Extension and expansion. Aphasiology, 26, 64–82. Flanagan, J. L., & Jackson, S. T. (1997). Test-retest reliability of three aphasia tests: Performance on nonbrain-damaged older adults. Journal of Communication Disorders, 30, 33–43. Francis, D. R., Riddoch, M. J., & Humphreys, G. W. (2001). Cognitive rehabilitation of word meaning deafness. Aphasiology, 15, 749–766. Howard, D., & Patterson, K. (1992). Pyramids and palm trees: A test of semantic access from pictures and words. Bury St. Edmunds: Thames Valley. Kaplan, E., Goodglass, H., & Weintraub, S. (2001). The Boston naming test (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Kay, J., Lesser, R., & Coltheart, M. (1992). Psycholinguistic assessment of language processing in aphasia. Hove: Lawrence Erlbaum Associates. Kertesz, A. (2007). The western aphasia battery revised. San Antonio, TX: Psychological Corporation. Lambon Ralph, M. A., Snell, C., Fillingham, J. K., Conroy, P., & Sage, K. (2010). Predicting the outcome of anomia therapy for people with aphasia post CVA: Both language and cognitive status are key predictors. Neuropsychological Rehabilitation, 20, 289–305. Ledoux, K., Camblin, C. C., Swaab, T. Y., & Gordon, P.C. (2006). Reading words in discourse: The modulation of lexical priming effects by message-level context. Behavioral and Cognitive Neuroscience Reviews, 5, 107–127. McDaniel, M. A., & Fisher, R. P. (1991). Tests and test feedback as learning sources. Contemporary Educational Psychology, 16, 192–201. McDaniel, M. A., Roediger III, H. L., & McDermott, K. B. (2007). Generalizing test-enhanced learning from the laboratory to the classroom. Psychonomic Bulletin and Review, 14, 200–206. McNeil, M. R., Doyle, P. J., Fossett, T. R. D., Park, G. H., & Goda, A.J. (2001). Reliability and concurrent validity of the information unit scoring metric for the story retelling procedure. Aphasiology, 15, 991–1006. Meinzer, M., Rodriguez, A. D., & Gonzalez Rothi, L. J. (2012). First decade of research on constrained-induced treatment approaches for aphasia rehabilitation. Archives of Physical Medicine and Rehabilitation, 93, S35–S45. Nicholas, L. E., & Brookshire, R. H. (1993). A system for quantifying the informativeness and efficiency of the connected speech of adults with aphasia. Journal of Speech, Language and Hearing Research, 36, 338–350. Nicholas, M., Obler, L. K., Albert, M. L., & Helm-Estabrooks, N. (1985). Empty speech in Alzheimer’s disease and fluent aphasia. Journal of Speech and Hearing Research, 28, 405–410. Pashler, H., Cepeda, N. J., Wixted, J. T., & Rohrer, D. (2005). When does feedback facilitate learning of words? Journal of Experimental Psychology: Learning, Memory, and Cognition, 31, 3–8. Peach, R. K., & Reuter, K. A. (2010). A discourse-based approach to semantic feature analysis for the treatment of aphasic word retrieval failures. Aphasiology, 24, 971–990. Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P., & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32, 1621–1626. Robson, H., Keidel, J., Lambon Ralph, M. A., & Sage, K. (2012). Revealing and quantifying the impaired phonological analysis underpinning impaired comprehension in Wernicke’s aphasia. Neuropsychologia, 50, 276–288. Rogalski, Y., & Edmonds, L. A. (2008). Attentive Reading and Constrained Summarisation (ARCS) treatment in primary progressive aphasia: A case study. Aphasiology, 22, 763–775. Shindo, M., Kaga, K., & Tanaka, Y. (1991). Speech discrimination and lip reading in patients with word deafness or auditory agnosia. Brain and Language, 40, 153–161. Ulatowska, H. K., & Chapman, S. B. (1994). Discourse macrostructure in aphasia. In R. L. Bloom, L. K. Obler, S. De Santi, & J. S. Ehrlich (Eds.), Discourse analysis and applications: Studies in adult clinical populations (pp. 29–46). Hillsdale, NJ: Lawrence Erlbaum Associates.
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APPENDIX A Comprehension and Communication Survey Please rate your current level of difficulty on the following: 1. Reading aloud to others Very Hard 1
Very Easy 2
3
4
5
2. Reading by yourself Very Hard 1
Very Easy 2
3
4
5
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3. Talking to a friend Very Hard 1
Very Easy 2
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5
4. Talking to a stranger Very Hard 1
Very Easy 2
3
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5. Reading the newspaper Very Hard 1
Very Easy 2
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6. Talking about the newspaper Very Hard 1
Very Easy 2
3
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7. Watching the TV news Very Hard 1
Very Easy 2
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8. Talking about the TV news Very Hard 1
Very Easy 2
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APPENDIX B TABLE A1 Revised Attentive Reading and Constrained Summarisation (ARCS) treatment protocol Step 1. 2.
3.
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4.
Guidelines for participanta
Guidelines for clinicianb
Read the entire passage one time a loud Read a sentence one time a loud with intent to summarisec Re-read sentence silently for comprehension (if necessary) Summarise the sentence a loud from memory using meaningful words: a. No pronouns (he, she, it) b. No non-specific words (thing, stuff) c. No opinions or unrelated words
Correct any reading errors
5.
Re-read the sentence a loud
6.
Continue reading a loud, summarising a loud, and re-reading the rest of the sentences
7.
Summarise the entire passage a loud from memory
Correct any reading errors
Give verbal/written prompts and redirection to written rules for constraint violations. Encourage participant to circumlocute if word-finding difficulties arise
Continue correcting and redirecting. Participant should complete Steps 2–5 for all sentences before proceeding to Step 7 After the participant has finished summarising, ask for his/her opinion/feedback about the passage
Rationale Provides a preview of the content Primes the semantic system for activation Ledoux et al. (2006) Enhances comprehension for any missed content during reading a loud Lexical retrieval strengthens semantic access by acting as a secondary encoding Brown and Craik (2000). Constraint strengthens semantic access by forcing intentional use of specific language Meinzer et al. (2012) Provides feedback to further consolidate information McDaniel and Fisher (1991)
Enhances activation of semantic system and lexical access
a Guidelines
were typed and placed in view of the participant during treatment; b Guidelines were typed and placed in view of the clinician during treatment and c Number of sentences read and summarised at one time should be tailored to the participant.
APPENDIX C Pre- and post-treatment sample of P1’s untrained article retell Article: Nurse Tracking Technology: Abridged Version, by Hattori, J. (2003, August). Cable News Network. Article can be found at: http://www.literacynet.org/cnnsf/nursetech/ abridged/home.html
P1 pre-treatment retell (after reading the article once) Well the s-, I know which on the S. E. T. O. N. That X they were talking about the nurses wearing the new um what they call, the their names and the newer kind of things.
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So they had their names on it. And they can talk on the thing, badges there could talk to where they’re at and what there uh with the patients they’re working. And where they’re at and what they have to do. And so this way they’ll know exactly what they’re doing. And um and the patients that they’re looking, and the number and everything. So they were doing that for 2 years with the S. E. T. O. N., at that one. And they have done very good for them.
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And the othen- the eda- eda- E. D. A. N., they um at first had a lot of it was hard for them to wear the patient their names. And um but there were, I think it was eight hundred and fifty people had that on. And it was a good thing to have it. It was hard but it’s something they should, the nurses should know where they’re at.
P1 post-treatment retell (after reading the article once) This is um, amazing because th- this is about nurses wearing new badges on for the nurse. What you wear on your eight, and fifty people use this for at Seton hospital. And also the Eden hospital wore it. And what they did, they put XX the uh it’s a called a tracking madige- padige- badagebadge. And they put it on. And what they do um, especially {pause 0:04} I think it’s in Jersey city. Maybe I’m wrong with that, hospital for me. That wasn’t on that, but. Um what they did is they wanted to see how it was. Because it was old, especially Eden was very old. And what they would put that on, um they would know how the patient was. And they put it on they could know what hospital they were the hospital was in. And where were they were going, and when they were talking to the patient. And they would know what they were saying and everything. And what number they were doing. And um it was amazing that they could know what they were doing, what they doing. And some people didn’t like it at all. So some of the nurse took it off and threw it off of them.
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And pa- you know finally some people found where it was. Because they hated what all that it did. But um, after using that the um {pause 0:03} they saw that it was a meanIt was {pause 0:04} amazing that they have it on. And how it did for where they, what they doing. An- and the nurses were doing much much better. And not just you know sitting down and doing much stuff. And here they were really working and doing um.
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And the Seton medical and the Eden Eden Eden hospital are um medical are doing much better. Both of them. It’s much better.
