Final Manuscript Submitted to Journal. Reference for Published Version: Webster, J., Morris, J., Connor, C., Horner, R., McCormac, C., & Potts, A. (2013). Text level reading comprehension in aphasia: What do we know about therapy and what do we need to know? Aphasiology, 27(11), 1362-1380. Title: Text level reading comprehension in aphasia: What do we know about therapy and what do we need to know? Authors: Janet Webster1, Julie Morris1 Carli Connor2, Rachel Horner3, Ciara McCormac4, Amy Potts5 Addresses: 1 Speech and Language Sciences, School of Education, Communication and Language Sciences, King George VI Building, Newcastle University, Newcastle upon Tyne, NE1 7RU. 2
Darlington Learning Disability Service, Tees Esk and Wear Valleys NHS Foundation Trust,
Hundens Lane, Darlington, DL1 1DT 3
Lincolnshire Community Health Services, Assisted Discharge Stroke Service, Unit 7, The
Point, Lions Way, Sleaford NG34 8GG 4
Aberdeen City Speech and Language Therapy Department, Airyhall Clinic, Springfield
Road, Aberdeen, AB15 7RF. 5
Northumbria Healthcare NHS Foundation Trust, Speech and Language Therapy,
Northumberland Child Health Centre, Woodhorn Lane, Ashington, Northumberland, NE63 9JJ. Short Title: Reading in aphasia Corresponding Author: Janet Webster Contact Details: Speech and Language Sciences, School of Education, Communication and Language Sciences, King George VI Building, Newcastle University, Newcastle upon Tyne, NE1 7RU.
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0191 222 5235
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[email protected] Abstract Background: Reading comprehension difficulties are a common feature of aphasia, affecting the understanding of single words, sentences, paragraphs and extended text. Whilst there have been studies investigating treatment for single word reading, there are a limited number of studies of treatment methods targeting the reading of paragraphs and connected text. Aims: This paper will describe a series of single case studies, each investigating the effectiveness of a different therapy approach for paragraph level reading comprehension. The studies raise a number of issues regarding the assessment of reading, choice of therapy and measurement of outcome; these will be discussed in relation to the studies and the wider evidence base. Methods & Procedures: Four people with aphasia were involved in the studies. Participants presented with reading difficulties alongside other language difficulties. Each study involved a single case study, multiple baseline with control task design. Detailed assessment of reading comprehension was completed pre-therapy, post-therapy and at follow-up, approximately two to four weeks post-therapy. Participants were also asked about their premorbid reading abilities and preferences, their reading difficulties and their views about therapy and its impact. Outcomes & Results: All participants showed some improvement in the accuracy of reading comprehension but there was extensive variability in the significance of gains, when gains were seen and on which assessments. Post-therapy, three of the four participants read the assessment passages and answered the questions more quickly. All participants reported some positive change in their reading, either in reading ability, reading behaviour or
feelings about reading, but again individual variation was evident in the extent and type of change perceived. Conclusions: These studies raise a number of important issues regarding the assessment of reading, therapy choice and measuring the outcome of therapy. These issues are discussed in relation to current literature, with an aim of informing future research investigating the assessment of, and therapy for, reading comprehension difficulties in people with aphasia. Reading is fundamental to everyday activities and developing the evidence base is of crucial importance in supporting people with aphasia to maximise their reading ability.
Introduction This paper describes a series of single case studies investigating therapy for paragraph level comprehension difficulties. Four therapy studies are discussed:Study 1, Participant AC: Attentive reading and constrained summarisation therapy (ARCS) Study 2, Participant CC: Proposition identification and constrained summarisation therapy (PICS) Study 3, Participant DB: Therapy involving three contextual strategies (3 strategy) Study 4, Participant EG: Oral reading for language in aphasia (ORLA) therapy Background Reading is fundamental to everyday social, leisure and employment opportunities; reading difficulties, therefore, have a dramatic impact on all aspects of a person’s life. In a study of long term needs after stroke by McKevitt and colleagues (2011), 23% of respondents reported a need around ‘reading difficulties’. Reading comprehension can be affected in many different ways, with difficulties understanding single words (e.g. on menus, signs), phrases and sentences (e.g. notes, instructions), paragraphs (e.g. letters, newspaper articles) or extended text (e.g. books). Mayer and Murray (2002, p728) state that, ‘although reading of connected text is often the ultimate treatment goal, few treatments have been developed to target reading at this level’. In contrast, a number of therapies have targeted single word reading (see reviews in Whitworth, Webster, & Howard, 2013). Whilst studies have shown treatment to be effective for reading of trained words (e.g. Lott & Friedman, 1999), with some generalisation to untrained words (e.g. Friedman & Lott, 2002), there is limited evidence of gains in everyday reading. In some studies, participants reported changes in reading frequency and their ability to understand particular stimuli (Friedman, Sample, & Lott, 2002; Lott & Friedman, 1999) and gains have been reported in reading comprehension at sentence and/or paragraph level (Lott & Friedman, 1999). At sentence
level, people with aphasia often have difficulties understanding grammatically complex, reversible sentences, when presented in either spoken or written form. There are no therapy studies specifically targeting reading comprehension at this level, although some therapy methods e.g. mapping therapy (Marshall, 1995) and Linguistic Specific Treatment (Thompson, 2001) use written stimuli. These therapy techniques aim to improve spoken production although gains in spoken and/or written comprehension are often also seen. There has been no consideration of the impact of any gains on everyday reading. At text level, the bulk of the therapy literature has focused on oral reading. A number of studies (reviewed in Kim & Russo, 2010) use Multiple Oral Rereading (MOR), where the same passage is read repeatedly, with the aim of improving reading speed. MOR is not focused on reading comprehension per se, and the majority of participants are reported to have good or functional comprehension prior to therapy; participants generally report slow reading speed which interferes with their everyday reading. These studies have demonstrated improved reading rate on trained passages and generalisation (of this improved rate) to untrained passages, particularly those with some overlap with the trained stimuli (Lacey, Lott, Snider, Sperling, & Friedman, 2010). In contrast, Oral Reading for Language in Aphasia (ORLA) therapy, initially described by Cherney, Merbitz and Grip (1986), was designed to improve comprehension. ORLA involves repetitive, assisted oral reading of sentences and short paragraphs, with an emphasis on rhythm and using visual cues. Cherney and colleagues suggested that by improving the fluency of reading, more resources can be allocated to understanding meaning, resulting in improved comprehension. Despite the stated aim of therapy, there is limited investigation of comprehension within the group studies (Cherney, 2010; Cherney et al., 1986) and minimal evidence of gains. In a single case study, participant VP did show some gains in paragraph comprehension (Cherney, 2004), but overall the evidence for the effectiveness of the approach (for comprehension) is limited.
Reading comprehension, particularly at text level, is a complex skill involving linguistic processing alongside cognitive skills, for example, working memory and attention. Some therapy studies have targeted deficits in these cognitive skills, with a view to improving reading comprehension. Mayer and Murray (2002) used a modified version of MOR, including a comprehension component, alongside sequenced exercises for working memory. Following therapy, participant WS reported no improvement in his everyday reading but some gains were seen in comprehension of complex passages on the Gray Oral Reading Test (GORT: Wiederholt & Bryant, 2001). The therapy gains were not as extensive as the authors had predicted; they conclude that WS may have had attentional dyslexia and that focusing on attention may have been more beneficial. Coelho (2005) evaluated the effects of an attention training programme designed to develop sustained attention and then alternative, selective and divided attention. The participant in the study, MH, had text level reading comprehension difficulties alongside attention deficits. Training resulted in gains on assessments of paragraph comprehension and MH reported functional changes as she resumed reading the paper, short novels and attending a book club. In addition to the approaches described, the literature on text level comprehension would suggest there are alternative therapy approaches which could be developed. There are many factors known to influence normal text comprehension, and there is also evidence about strategies used to improve reading ability in poor readers. Relevant information, in the form of a title, written context or picture, provided prior to reading the text has been shown to facilitate text comprehension; these are known as ‘advance organisers’ and, for normal readers, are particularly effective in facilitating the understanding of complex text (e.g. Bransford & Johnson, 1973). Advance organisers can activate schema about previous events and experiences (Ellis, 1993) and the reader can then use this prior knowledge to aid understanding. There may be the potential to exploit advance organisers in therapy so people with aphasia make maximum use of the information. Anderson (2000) suggests that to improve reading ability, people should preview, frame questions and then read. Following
reading, there is a process of reflection, reciting to recall information and then review to go over the main points. Using elements of this, Rogalski and Edmonds (2008) described a therapy with a participant with primary progressive aphasia. Therapy used ‘Attentive Reading and Constrained Summarisation’ (ARCS) of newspaper articles. ARCS was initially designed to improve discourse production, topic maintenance and semantic specificity, but with a focus on reading and identifying important information in passages, it may offer an approach to improving reading comprehension. There is also the potential to use strategies aiming to identify propositions or main ideas in the text, by underlining key words, annotating texts etc. The theoretical basis for the use of main ideas by people with aphasia is not particularly strong, but there is some evidence in the literature and certainly use of the concept in clinical practice. Brookshire and Nicholas (1984) conducted a study exploring the comprehension of main ideas (defined as central information in the story) and found that, like control subjects, people with aphasia understood main ideas better than detail when questioned. (This study used spoken discourse). This concept of main idea has been used both within assessment (Brookshire & Nicholas, 1993) and within aphasia therapy materials (Martinoff, Martinoff, & Stokke, 1981). It may relate to understanding of gist and/or propositions. Meteyard and colleagues (2010) describe a single case study (DV), where everyday reading was accurate but slow. They worked with DV to develop a range of strategies, including phrase marking (rather than individual word reading), summarising, annotation of text and checking comprehension. Post therapy, there was an increase in reading speed and an increase in self rating of confidence and reading ability. Cocks et al. (2010) describe four single cases of adults with reading difficulties following traumatic brain injury. In each case, therapy aimed to improve functional reading and involved strategy development (key word identification and prompt sheets). As Cocks and colleagues acknowledge, the studies are not carefully controlled, but suggest that improvement in reading comprehension and reading confidence can be seen some time post onset, with relatively minimal amounts of therapy input.
Within clinical practice, the authors of this paper were working with people with aphasia who identified reading for meaning as a therapeutic goal. The evidence base, as described, is limited; the authors therefore decided to trial a range of different treatment methods, with approaches based on the literature (when available) but also on approaches used in practice and/or suggested from the wider reading literature. Participants presented with everyday reading comprehension difficulties alongside other language difficulties. Whilst the aim was to determine whether any particular approach led to improvement and was worthy of replication, the studies highlighted a range of issues which need careful consideration in order to advance the evidence base. Aim This paper will describe a series of single case studies, each investigating the effectiveness of a different therapy approach for paragraph level reading comprehension. These raise a set of issues which will be discussed in relation to the studies and the wider evidence base, including the assessment of reading, choice of therapy and measuring outcome. Method Each study involved a multiple baseline with control task design. Prior to a period of therapy, background assessments of language, reading and cognitive skills were carried out. Detailed assessment of reading comprehension, considering both time taken and accuracy, was completed pre-therapy, post-therapy and at follow-up (between two and four weeks post-therapy) to monitor the effects of therapy. The control task was selected for each participant depending on profile of language performance. Pre-therapy, all participants were asked about their reading abilities and preferences and their reading difficulties in an informal interview. Post-therapy, the interview was repeated with a focus on any change in their reading abilities/difficulties, their views about therapy and its impact. In some cases, rating scales of reading ability were used alongside the interviews.
Participants Background information about the participants can be found in Table 1. Participants were adults with aphasia resulting from a single left hemisphere CVA at least six months prior to the study and were monolingual English speakers. All participants reported reading difficulties and were motivated to work on this. Participants had adequate or corrected vision and hearing, no evidence of hemianopia and adequate auditory comprehension to understand instructions. Participants selected for ARCS, PICS and 3 strategy therapies needed adequate spoken or written output to produce short summaries or generate information for mind maps. Participants were recruited via an aphasia support centre. All participants had received previous speech and language therapy which had, in some cases, involved reading activities but were no longer involved in active therapy. Participants continued to attend the support centre activities during the period of the study. Insert Table 1 about here Background assessments were carried out using sub-tests of the Comprehensive Aphasia Test (CAT: Swinburn, Porter, & Howard, 2004) and word reading stimuli from experiment one in Strain et al (1995). The results of these assessments are presented in Table 2. It can be seen that all participants have other aphasia symptoms, with some degree of difficulty with spoken production alongside their reading difficulties. In contrast, all were within normal range on the cognitive screen used. In word reading, all participants had some ability. EG’s performance was close to ceiling. DB made primarily phonological errors across word types. AC and CC showed a significant frequency effect, making a range of errors across stimuli. None of the participants showed a significant regularity effect. Reading comprehension was assessed using selected sub-tests of the Reading Comprehension Battery for Aphasia-2 (RCBA-2: Lapointe & Horner, 1998) and the Discourse Comprehension Test (DCT: Brookshire & Nicholas, 1993) (see table 2). Both tests assess silent reading and the overall time taken to read the stimuli and answer the questions was
recorded. Times were recorded using a stop watch and were rounded to the nearest minute. The RCBA-2 allows comparison of an individual’s performance, in terms of speed and accuracy, across sub tests. No control data is available in the assessment; it is suggested that control performance should be at ceiling. This suggestion is reinforced by an earlier study examining performance on the RCBA, where the mean score for non-aphasic adults was 97/100 (Pasternak & LaPointe, 1982). The DCT involves reading five stories and answering eight yes/no questions. The questions tap into different types of information: stated main ideas, implied main ideas, stated details and implied details. Two matched sets of stories are provided and these sets were rotated across assessment periods (with exception of DB). On the DCT, 20 adults without brain damage scored close to ceiling (set A stories, mean 37.2, range 34-40, set B stories, mean 36.9, range 34-40); control participants made most errors on implied detail questions. No information is available on the time taken to read and answer the questions. Insert Table 2 about here All of the participants showed some reading comprehension difficulties on both the RCBA-2 and DCT. AC and CC had the most severe reading comprehension deficits. Due to the limited number of items, it was difficult to identify significant patterns of performance within participants. On the DCT, AC and CC showed a similar pattern of performance across question types. EG and DB showed a tendency for better comprehension of main ideas and stated information. All of the participants took a long time to read the passages and answer the questions, with AC reading very slowly. Therapy All of the therapies aimed to improve reading comprehension at paragraph level. Within therapy, reading stimuli were articles from local newspapers or news websites (e.g. www.bbc.co.uk, www.chroniclelive.co.uk ). Reading difficulty was considered in relation to the Flesch Kincaid reading level (Kincaid, Fishburne, Rogers, & Chissom, 1975), with some
variation in readability grade across studies depending on the participants’ initial level of reading comprehension. Study 1, AC: ARCS therapy was based on the technique described by Rogalski and Edmonds (2008). Within therapy, AC was asked to read a whole passage aloud, read it again silently in two to three sentence chunks (attentive reading) before producing a short oral summary (constrained summarisation). AC completed 12, 45 minute to one hour sessions over six weeks. Study 2, CC: PICS therapy involved identification of propositions and key words as a strategy. In this therapy, CC was encouraged to read the article as many times as necessary, before identifying ‘key messages’, writing down the key words and providing an oral summary. CC completed eight sessions, with hourly sessions twice weekly for four weeks. Study 3, DB: The 3 strategy therapy used a combination of three aspects (prior knowledge, advance organisers and salient features). Firstly, DB was given an article and asked to identify the main topic, with the therapist and participant then producing a mind map about the topic. He was then asked to identify advance organisers; these included titles, diagrams and pictures which could orientate the reader to the meaning of the article. Finally, he read the passage, underlining the salient features (similar to the key messages in study 2), before answering a series of yes/no and multiple choice questions. Therapy consisted of eight, one hour therapy sessions given across two blocks, with a break of three weeks in the middle (dictated by a holiday period). Study 4, EG: ORLA involved repetitive assisted oral reading of sentences and short paragraphs and replicated the procedure described by Cherney (2004). EG completed 12 sessions, with two, one hour sessions each week for six weeks. Outcome
All participants were assessed on the DCT pre-therapy, immediately post-therapy and at follow-up two to four weeks later. Figure 1 shows the results for overall accuracy of comprehension. Some participants were also reassessed on the RCBA-2. Performance on the DCT, RCBA-2 and the control task is summarised in table 3 and discussed below. No participant showed significant change on the selected control task. Insert Figure 1 about here Insert Table 3 about here Study 1: Participant AC (ARCS) Within therapy sessions, AC was very engaged and became more confident over time. During sessions, as reading passages became more complex, AC’s oral reading rate reduced. As therapy progressed, she showed an increasing ability to accurately report both main ideas (the focus of therapy) and details. ARCS therapy resulted in a non-significant increase in comprehension scores on the DCT post-therapy (Wilcoxon matched pairs test, z=1.66, p=0.098 two tailed). The change in score was a consequence of significantly improved comprehension of main ideas (main ideas, pre-therapy 11/20, post-therapy 19/20, chi-square (1) = 6.53, p=0.008, details, pre-therapy 10/20, post-therapy 11/20). Posttherapy, there was a reduction in the time taken which approached significance (Wilcoxon matched pairs test, z=1.89, p=0.059, two tailed). At follow-up, reading comprehension continued to improve. The difference between post-therapy and follow-up was not significant (Wilcoxon matched pairs test, z=0.56, p=0.577 two tailed). The difference between pretherapy performance and follow-up approached significance (Wilcoxon matched pairs test, z=1.90, p=0.058). At follow-up, reading was slightly slower than immediately post-therapy but the change was not significant (Wilcoxon matched pairs test, z=1.35, p=0.178). AC’s views about her reading (alongside other language difficulties) were obtained via the CAT Disability questionnaire and an informal interview. Table 4 shows the results of the CAT questionnaire; a reduction in score is indicative of less perceived disability. Pre-
therapy, AC reported most difficulties reading a piece in the paper or a letter, although talking and writing were considered more problematic than reading. Post-therapy, there was a small change in perceived difficulty in reading with simultaneous improvement in talking and understanding. It is not clear whether these widespread changes (in reported difficulty) are due to variability, a non-specific therapy effect or the fact that the therapy involved listening and spoken production of summaries as well as reading. In the post-therapy interview, AC reported she felt more confident about reading, was finding it easier to read and understand passages that had previously frustrated her and was now attempting to read short stories from magazines and newspapers each day. Insert Table 4 about here Study 2: Participant CC (PICS) Within therapy, due to CC’s spoken output difficulties, it was difficult for her to produce summaries independently and so written summaries were produced in collaboration with the therapist. Summaries were scored on the basis of whether CC had included all the important information contained in the beginning, middle and end of the story. CC often failed to include the relevant information and there was no trend for improved information as therapy progressed. CC found assessment of her reading very stressful and testing was kept to a minimum. CC repeated one sub-test of the RCBA-2, showing a numerical increase in comprehension accuracy from pre-therapy, to post-therapy and follow-up. On the DCT, reading comprehension showed a numerical increase (Wilcoxon matched pairs test, z=1.50, p=0.134, two tailed), with a general improvement across question types. At follow-up, two weeks later, there was a non-significant decrease in performance (Wilcoxon matched pairs test, z=1.38, p=0.168, two tailed). On the DCT, the time taken showed a non-significant (but substantial) increase, i.e. it took her longer to read the passage and answer the questions (Wilcoxon matched pairs test, z=1.89, p=0.059). This was maintained at follow-up.
In an informal post-therapy interview, CC reported gains in confidence, that she was reading more often and enjoying reading again, despite the fact reading was still more difficult and time consuming than prior to the stroke. Following therapy she reported enjoying and engaging in reading more frequently and had begun to read novels designed for adult readers with literacy problems. She found that she was able to access these books in her local library and was very pleased to be able to return to her local library regularly. Study 3: Participant DB (3 strategy) Within therapy, DB needed constant encouragement to use the strategies. With prompts, he was consistently able to identify the advance organisers and identified the salient features at around 90% accuracy. His comprehension of the questions following the passage also averaged at around 90% accuracy. Following therapy, DB showed a small numerical, but non-significant, increase in comprehension accuracy on the RCBA-2 (McNemar’s exact test, p=0.424, two tailed) and DCT (Wilcoxon matched pairs test, z=0.54, p=0.586). There was a numerical reduction in the time taken to complete the RCBA-2 but this was also not significant. DB’s views on reading were obtained via an informal interview, supported by relevant sections/rating scales from the Communication Disability Profile (CDP: Swinburn & Byng, 2006). During the study, he was asked to keep a reading log. The log consisted of a series of tick boxes, recording what he had read (single words, titles, sentences, paragraphs), the strategies used (topic, visual cues, underlining) and how he felt about reading (happy, confused, sad). In the reading log, DB reported that he was using the strategies and there was evidence that he was underlining text in the newspaper articles he had submitted with the log. In the post-therapy interview, DB rated his overall reading ability slightly more negatively (from zero to one, good to worse), saying he sought more help from his wife. Despite this, he reported he was more able to read food labels (a concern prior to therapy), could now read varying lengths of text and would attempt reading a novel. Study 4: Participant EG (ORLA)
Within therapy with EG, the complexity of passages increased from headlines of 3-5 words through to articles of 50 to 100 words. He found the therapy very challenging, with the focus on oral reading quite tiring and frustrating when he was unable to read particular words. Despite this, he progressed through the levels maintaining at least 80% accuracy in reading aloud and consistently identifying the required word in the text. Following therapy, EG showed no change in reading comprehension scores on either the RCBA-2 or DCT. The time taken to read the passages and answer the questions reduced, with the change on the DCT approaching significance (Wilcoxon Matched Pairs Test, z=1.89, p=0.059, two tailed); similar reading times were seen at follow-up. At follow-up, there was significant improvement on the RCBA-2 (McNemar’s exact test, p=0.016, two tailed) compared to post-therapy scores, with EG only making one comprehension error. EG’s perceptions of his reading were discussed in an interview. He also completed the Communication Outcome after Stroke questionnaire (COAST: Long, Hesketh, Paszek, Booth, & Bowen, 2008), with six supplementary questions focused on functional reading. He was asked to rate ability on a scale of 0 to 4 (with 0 the worst possible and 4 the best possible). Pre-therapy, EG reported significant reading difficulties, rating overall reading as one on the scale, with bus timetables, cooking instructions and books being the most difficult (all rated one); food labels, newspapers and menus were each rated as two. He said that he only understood some of what he read which he found very frustrating. Post-therapy, he reported better reading overall (rated two), with a mixed pattern of responses in the individual categories (with some items staying the same, some being rated less difficult and some more difficult). His scores on the other parameters on the COAST were stable, with only a one point change on feeling more confident talking to familiar people and strangers. In the post-therapy interview, EG reported that he experienced the same level of frustration and that the amount and type of reading he did had not changed following therapy. Summary of Results
All of the participants showed some improvement in the accuracy of reading comprehension but the extent to which these improvements reached statistical significance, whether the gains were seen on RCBA-2 or DCT and when the gains were seen, differed between participants. Participant CC showed some improvement immediately post-therapy but this was not maintained at follow-up. For AC, EG and DB, gains continued to increase at followup on at least one of the assessment measures. Following therapy, CC required more time to read the assessment stimuli and answer the questions whereas the other participants showed a reduction in the time taken. All of the participants reported some positive change in their reading either post-therapy or at follow-up. Again, there was a significant amount of individual variation, with participants reporting changes in their feelings about reading, changes in their reading choices or frequency of reading or changes in their reading ability. Discussion This section will consider issues arising from these studies within the context of the wider literature with an aim of informing future research investigating the assessment of, and therapy for, reading comprehension difficulties in people with aphasia. Issues Related to Assessment of Reading Comprehension Reading comprehension is a complex skill and Mayer and Murray (2002) propose that: “a multi-factorial model of reading, which integrates single-word models from cognitive neuropsychology with central linguistic text-level processes (e.g. integration of world knowledge, abstract language processing) and cognitive factors (e.g. motivation, attention and working memory), is necessary to describe the nature of acquired disability in reading and subsequently to treat high-level reading deficits”. (pp 741) Snow (2002) provides a framework for investigating reading comprehension, identifying important factors such as reader characteristics (including cognitive and linguistic capabilities, knowledge and experience), text characteristics and the reading activity (the
purpose of, processes involved in and consequences associated with reading e.g. enjoyment, knowledge, application). Snow describes the inter-related nature of the three aspects; for example, the specific cognitive and linguistic capacities and knowledge base required for reading comprehension will vary depending on the text being read, whether it is being read for gist or detailed study and can change as reading continues. Snow also acknowledges that reading takes place within a wider sociocultural context. This is a useful framework within which to view reading comprehension, but does not provide a cognitive model which would allow us to determine the potential impact of the impaired linguistic and/or cognitive processing that may be present in aphasia. Within functional reading, there is also a complex interaction between lexical, sentential, textual and cognitive processes. During assessment, a person’s difficulties at one level may be identified but the impact of these on text comprehension is hard to determine. For example, all of the participants in the current studies scored below the normal mean in written sentence comprehension, indicating possible difficulties with syntactic comprehension. However, it is not clear if these difficulties contribute to their difficulties at paragraph level or if paragraphs provide a context that compensates for these difficulties. If this could be determined, it may influence intervention, with the choice of therapy approach dependent on the potential functional outcome. Assessment of reading comprehension in people with aphasia is a complex process, often drawing on a diverse range of assessments (see Cherney, 2004; Morris, Webster, Whitworth, & Howard, 2009 for discussion of assessments). Currently, published aphasia assessments for reading provide limited direction regarding intervention as they identify what is difficult but not why and do not illuminate the relationship between identified ‘deficits’ and everyday reading abilities. Assessment design should also be considered. Clinical assessments often reflect a compromise between sensitivity, reliability and feasibility. In people with aphasia, reading may be slow and the complexity of reading comprehension and its interaction with other cognitive processes may mean performance is variable and vulnerable to fatigue. It is therefore extremely important to ensure tests are reliable, over
time and between testers. The RCBA-2 and the GORT both provide information on testretest and inter-rater reliability; the DCT provides this for the listening but not silent reading version. Normal variability across time may mean it is more difficult to demonstrate gains as a consequence of therapy. Very few studies do multiple baselines of comprehension pre-therapy. This may reflect the constraints of the study, the time required for testing or issues related to repeating formal tests on a regular basis. The likelihood of participants learning the correct responses with repeated testing is reduced by the use of matched paragraphs, as in the DCT. When assessed, stable performance is reported for some participants (e.g. participants SV and TD, Beeson & Insalaco, 1998). Repeated baselines a week apart were carried out in study 1 and performance showed some variability in accuracy (on DCT, AC scored 26/40 and 21/40). The potential impact of the variability, even if not statistically significant, needs to be considered as it is of a similar magnitude to the numerical gains seen post-therapy. The time taken was similar across the two baselines (29 and 27 minutes respectively). The nature of the assessment tasks also needs to be considered. All of the assessments used in the current study and which are reported in the current therapy literature involve off-line processing. Participants are asked to read a single word, phrase or sentence and point to a picture that represents the meaning or read a paragraph and answer questions about it; this off-line processing may result in the use of information and the development of strategies that are not part of usual reading comprehension. For example, Tompkins and colleagues (2004) discuss that questions used to test comprehension of inferred meaning may facilitate understanding of a particular inference even if it was not understood on-line. However, off-line investigations also mean there is additional processing required for people to demonstrate their understanding, for example they must understand the question as well as the passage. The memory demands of the RCBA-2 and DCT also differ; within the RCBA-2, the passage remains in view and the person is able to refer back to the text whereas in the DCT, the passage is removed. The continued presence of the
passage in the RCBA-2 also offers the potential to go back and re-read, possibly also increasing the time taken. Choice of therapy It is important to consider which therapy is likely to be suitable for an individual. As previously highlighted, current reading assessments for aphasia provide limited direction regarding treatment; they give limited insight into the nature of the underlying difficulty or what strategies are likely to be beneficial. Kim and Russo (2010) discuss candidacy for MOR, emphasising the importance of considering reading profile, overall language profile and the presence of any cognitive deficits. These factors are important considerations when selecting any therapy, although the profile of candidacy is likely to differ between therapies; the therapies described here clearly differ in what therapy entails and thus the language and other cognitive abilities that are pre-requisites. Overall, therapies that require the learning of and use of strategies may be more demanding cognitively and therapies using constrained summarisation to consolidate reading comprehension will not be suitable for people with extensive production difficulties. An individual’s reading preferences, e.g. oral versus silent reading, and self developed reading strategies may also need to be considered. The current study provides limited evidence regarding the effectiveness of each of the therapies. Whilst significant changes in reading were not frequently seen, this may be a consequence of the lack of sensitivity of the assessments (see discussion below) rather than the treatment being ineffective per se. It is also important to consider aspects related to amount, duration and possibly scheduling or intensity of therapy. These studies all provided relatively minimal therapy input with low intensity and short duration. It is feasible that for more robust gains to be seen, that therapy needed to increase in total amount, in duration, or that scheduling or intensity of intervention are important factors. Certainly in study 4, which replicates ORLA therapy, the intensity and duration of therapy was less than the only
study of ORLA (Cherney, 2004) which robustly demonstrates gains in reading comprehension. The interventions described within each study are multi-faceted, sharing some components but differing in their focus. Understanding the similarities and differences and considering performance during therapy may be important in determining the mechanism(s) underpinning potential improvement and developing future therapies. All of the therapies involved repeated reading in a positive and encouraging environment. ARCS, PICS and ORLA had a particular focus on reading processes via attentive reading, repeated re-reading or reading aloud. ARCS, PICS and 3 strategy therapy checked understanding either via the production of summaries or answering questions. PICS and 3 strategy therapy focused on the development of strategies, identifying important information in the text and for, 3 strategy therapy, advance organisers alongside the text. The effect of therapy may reflect one or more of these components. With ORLA, any gains in comprehension were due to repeated reading but it is not clear whether EG needed to read aloud or if the same gains would have been seen with silent reading. Following ARCS, AC showed an increase in the recall and comprehension of main ideas. This would suggest therapy had resulted in a focus on key information, possibly facilitated by the attentive reading. She could have used the strategy in DCT although the reduction in time taken would suggest she is not using repeated reading of chunks. In PICS, CC found it difficult to produce the summaries suggesting this did not result in the change. Repeated reading, with attention on key propositions, may have resulted in the improved reading ability but the gains were not sufficient to be maintained over time. For both AC and CC, the increases in confidence and willingness to attempt reading may have been a consequence of simply attempting to read in a supportive environment. They were encouraged to read functional passages in a way which allowed them to demonstrate their retained reading ability and understanding, breaking down the text into smaller chunks and promoting re-reading. This revealing of competence may have resulted in increased confidence. Within the therapy, DB showed he was able to identify advance organisers and
salient features, highlighting the potential value of the strategies. In sessions, he needed prompts to use them but there was evidence of underlining in his reading log. In post-therapy assessment, he was unable to use the strategies to support his comprehension suggesting any gains were a consequence of improved reading ability. The contribution of repeated reading and any taught strategies needs to be considered when evaluating any therapy techniques. Issues Related to Measuring Outcome There are a range of issues that need to be considered when determining whether therapy has been effective. These include what constitutes improvement, how to measure change and when to measure the impact of intervention. What constitutes improvement and how to measure it? Improvement may involve changes in reading ability, reading speed, perception of reading ability, reading behaviours or a complex interaction between these. i) Reading ability Within the current studies, the DCT was the main outcome measure used to investigate change in reading comprehension ability. Some participants showed numerical increases but gains did not reach statistical significance. The DCT is a well-designed and carefully controlled assessment but there are a limited number of stimuli overall, and more specifically, a limited number of each question type. A lack of significant change may be a reflection that therapy is not effective or that the measures used are not sensitive enough. The passages within the DCT are also longer than the passages used in therapy and are perhaps too difficult for some of the participants. In line with other studies (e.g. Cherney, 2004, 2010), sub-sections of the RCBA-2 were also used with some participants. Like the DCT, the number of items within each sub-section is limited, potentially restricting the ability to identify significant changes in performance. EG showed significant gains on the RCBA-2
but not on the DCT, with changes in paragraph comprehension; the passages in the RCBA-2 are shorter and perhaps EG’s gains were restricted to these shorter stimuli. This highlights the need for graded passages and for specific predictions about the changes that should be seen as a consequence of therapy, with measures evaluated on their sensitivity to those changes. Current published assessments may, therefore, not be the most appropriate measure of therapy outcome due to their limited sensitivity to change at a particular level of difficulty or comprehension of a particular type of information. Lacey and colleagues (Lacey et al., 2010; Lacey, Lott, Sperling, Snider, & Friedman, 2007) showed that carefully controlled generalisation passages could help to identify specific therapy effects and demonstrate how MOR therapy facilitated reading. This highlights the need for a greater understanding of the potential benefits of individual therapy techniques (and mechanism of change) so that measures can be designed which are sensitive to those changes. Generalisation probes may be more sensitive to therapy effects but designing them in a rigorous way and controlling for the factors known to influence reading ability can be very difficult within the constraints of the clinical setting. Within formal assessment, there is also limited scope to use strategies which were targeted in therapy or could be used to support everyday reading. For example in the DCT, passages are presented in isolation so advance organisers in the form of a title or picture support are not available. Post-therapy performance may, therefore, reflect any change in reading as a consequence of practising reading using a therapeutic strategy rather than the functional benefits of the strategy per se. It may be important to investigate whether strategies are being used and the impact of those strategies on performance. ii) Reading speed Within the current studies, all participants read quite slowly and for some people reported in previous literature, reduced reading speed is seen as the primary deficit. An increase in
reading speed may, therefore, be the desired treatment outcome, with people needing to achieve a minimum rate to ensure reading is functional and enjoyable. Within the current studies, reading speed was considered using a broad measure, time taken to read and answer the questions (rounded to the nearest minute). This would seem appropriate as any changes in reading speed would need to be of a significant magnitude to influence functional reading. In the studies of MOR, there is no evidence that increasing reading speed has a negative impact on comprehension i.e. participants maintain their level of understanding with the increased rate (Beeson & Insalaco, 1998; Lacey et al., 2010). Similarly, ORLA aims to increase the automaticity of decoding, resulting in improved speed of reading and the possibility of directing processing resources to comprehension. As a consequence, increased reading speed (in these oral reading approaches) would be an indication of therapy gain and should precede any gains in comprehension accuracy (Cherney et al., 1986). In study 4, EG does show a reduction in the time taken to read and answer questions immediately post-therapy but this is not initially accompanied by improved reading comprehension; gains in comprehension are only seen at follow-up. In studies 1, 2 and 3, one might predict an increase in the time taken to read and answer the questions if participants were using the strategies to aid their understanding. The use of strategies may be time consuming and the trade-off between time needed and accuracy may be an important consideration when selecting an intervention. Cocks et al. (2010) suggest that reading rate may not be a sensible intervention target or outcome measure when strategies typically reduce pace in favour of accuracy and comprehension. Within these studies, CC took longer to read post-therapy and at follow-up on the DCT but it is not clear whether this is a consequence of her using the strategy. For the other participants, the maintenance or decrease in time taken post-therapy would suggest that participants are not using the strategies within the assessment. This may be due to the constraints of the
assessment process or may suggest that unless a strategy can be used rapidly, it may not be of functional relevance or acceptable to the participant. iii) Perception of reading ability and reading behaviour Therapy may also result in changes in the person’s perception of their reading ability, their feelings about reading e.g. frustration, confidence, and in reading behaviours e.g. frequency of reading, material chosen. For some participants (e.g. GB, Cherney, 2004), a willingness to complete the reading assessment was considered to be a significant indication of improvement. It is perhaps more of a challenge to collect information about these aspects in a valid and reliable way and to identify any changes resulting from therapy. Within these studies, this information was obtained via informal interviews, supplemented by ratings scales. The use of similar scales has been reported in the literature, with some considering perceived difficulty (e.g. Lott & Friedman, 1999) and some considering confidence and any negative emotions associated with reading (Cocks et al., 2010). The ratings scales allow a measure of perceived change but the reliability of the scales needs to be determined. In the current studies, there was only one opportunity to gain this information prior to therapy and thus changes post-therapy may reflect day to day variability and the impact of recent reading experiences on their perception of difficulty, alongside any changes as a consequence of therapy. Across the studies, information was obtained via the CAT disability questionnaire, COAST and CDP. All of these measures contain limited questions about reading and it is perhaps detailed supplementary questions about specific reading material and the processes involved in reading which are necessary to identify change. The interviews provided a more in-depth opportunity to explore the persons’ perception of their reading and the extent of any change following therapy. These were structured but informal post-therapy discussions. Within these interviews, we must recognise the potential for bias; participants may have responded positively simply because of the focus and interest in reading (and not because of any perceived change). In the interviews,
some participants e.g. AC and CC reported important changes in their reading activity with an increased willingness to attempt reading and try different reading material. These changes could reflect differences in their acceptance of their reading difficulties, an increased willingness to attempt reading or a change in their reading ability. There is a need to capture these changes in a more robust way and to see whether they can shed light on the potential mechanism of therapy. iv) Relationship between aspects of reading When considering improvement, it is also essential to consider the relationship between formal assessment, everyday reading and perception of reading ability. As Morris et al. (2004) raised with the client ‘Lawrence’ we may not see improvement in all aspects. Lawrence showed improvement on specific reading tasks but improvement was not seen in a more generic measure of reading. In contrast Lawrence and his wife were positive about therapy in a post-therapy interview and there was anecdotal evidence of increased participation. Participant MM (Cocks et al., 2010) reported positive outcomes following therapy and showed an increase in reading accuracy as reading errors decreased. Despite this, in a reading confidence questionnaire, confidence decreased and negative emotions associated with reading increased. There is a complex relationship between formal assessments of language and everyday literacy practice, with Parr (1996) highlighting the limited predictive relationship between the two. Linguistic impairments may be masked by strategies used in everyday reading and difficulties occur in everyday literacy which may not be indicated by formal assessments of reading. It is, therefore, important to measure in more than one way, and to consider effectiveness in more than one sense (change on specific tasks, on more everyday tasks and on perception and impact). This layered examination of change will hopefully allow us to understand both the mechanism and impact of therapy further. When to measure improvements in reading?
A final point relates to when to measure improvement. Within the current studies, participants were tested immediately post-therapy and at follow-up which typically took place four weeks later. Within the constraints of the studies, it was not possible to carry out a more long-term measure of therapy maintenance. It is interesting that performance often varied between the two testing periods; some participants e.g. AC and EG showed a trend for continued improvement at follow-up whereas CC showed gains immediately after therapy with a decline in performance at follow-up. If therapy encourages the participants to read and gives them a strategy to facilitate reading, the person should continue to read and practise independently after the intervention. In this case, the independent practice should continue to reinforce the use of the strategies and improvement should be consolidated. Maximum gains in comprehension may then be seen some time after the therapy period. When gains are not maintained at follow-up, the effectiveness of the reading therapy approach should be questioned. Conclusion Reading, whether for pleasure or for practical or employment reasons, is fundamental to everyday activity. We need to develop the evidence base to be better able to support people with aphasia maximise their ability to read the information they want to read. Despite the prevalence of reading difficulties in people with aphasia, no comprehensive assessment of reading comprehension currently exists and this has hampered the development and robust evaluation of theoretically motivated therapies. There is a need for a diagnostic assessment which investigates reading at single word, sentence and paragraph level and considers the relationship between comprehension at each level and everyday reading. Whilst some studies have shown improvements in either reading speed or reading comprehension, there have been few robust demonstrations of effective therapy and limited direction regarding what therapy is likely to be useful for any particular individual. This all needs to be done with careful consideration of literacy abilities and preferences. An improved understanding of the reading difficulties experienced by people with aphasia and the impact of therapy may in turn
increase our theoretical understanding of the complex processes involved in reading comprehension. References Anderson, J. R. (2000). Cognitive psychology and its implications. New York: W H Freeman. Beeson, P., & Insalaco, D. (1998). Acquired alexia: Lessons from successful treatment. . Journal of the International Neuropsychological Society, 4, 621-635. Bransford, J. D., & Johnson, M. K. (1973). Consideration of some problems of comprehension. . In W. G. Chase (Ed.), Visual Information Processing (pp. 383-438). Brookshire, R. H., & Nicholas, L. E. (1984). Comprehension of directly and indirectly stated main ideas and details in discourse by brain damaged and non-brain damaged listeners. Brain and Language, 21, 21-36. Brookshire, R. H., & Nicholas, L. E. (1993). Discourse Comprehension Test. Tuscon, Arizona: Communication Skill Builders. Cherney, L. R. (2004). Aphasia, alexia and oral reading. Topics in Stroke Rehabilitation, 11, 22-36. Cherney, L. R. (2010). Oral reading for language in aphasia: Impact of aphasia severity on cross-modal outcomes in chronic nonfluent aphasia. Seminars in Speech and Language, 31, 42-51. Cherney, L. R., Merbitz, C., & Grip, J. (1986). Efficacy of oral reading in aphasia treatment outcome. Rehabilitation Literature, 112-119. Cocks, N., Matthews, N., Barnett, L. P., E., Middleton, R., Gregoire-Clarke, J., & Cruice, M. (2010). Functional reading therapy for individuals with acquired reading difficulties: A preliminary investigation exploring its effectiveness. Acquiring Knowledge in Speech, Language and Hearing, 12(1), 37-41. Coelho, C. A. (2005). Direct attention training as a treatment of reading impairment in aphasia. Aphasiology, 19(3/4/5), 275-283.
Ellis, A. W. (1993). Reading, Writing and Dyslexia: A Cognitive Analysis (2nd ed.). London: Psychology Press. Friedman, R. B., & Lott, S. N. (2002). Successful blending in a phonological reading treatment for deep alexia. Aphasiology, 16(3), 355-372. Friedman, R. B., Sample, D. M., & Lott, S. N. (2002). The role of level of representation in the use of paired associate learning for rehabilitation of alexia. Neuropsychologia, 40(2), 223-234. Kim, M., & Russo, S. (2010). Multiple Oral Rereading (MOR) treatment: Who is it for? Contemporary Issues in Communication Science and Disorders, 37, 58-68. Kincaid, J. P., Fishburne, R. P., Rogers, R. L., & Chissom, B. S. (1975). Derivation of new readability formulas (Automated Readability Index, Fog and Flesch Reading Ease Formula) for navy enlisted personnel. (pp. 8-75). Chief of Naval Technical Training Naval Air Section, Memphis. Lacey, E. H., Lott, S. N., Snider, S. F., Sperling, A. J., & Friedman, R. B. (2010). Multiple Oral Rereading treatment for alexia: The parts may be greater than the whole. Neuropsychological Rehabilitation, 20(4), 601-623. Lacey, E. H., Lott, S. N., Sperling, A. J., Snider, S. F., & Friedman, R. B. (2007). Multiple oral rereading treatment for alexia: It works but why? Brain and Language, 103, 248-249. Lapointe, L. L., & Horner, J. (1998). Reading Comprehension Battery for Aphasia-2. Austin, Texas: Pro-ed. Long, A., Hesketh, A., Paszek, G., Booth, M., & Bowen, A. (2008). Development of a reliable, self-report outcome measure for pragmatic trials of communication therapy following stroke: the Communication Outcome after Stroke (COAST) scale. Clinical Rehabilitation, 22, 1083-1094. Lott, S. N., & Friedman, R. B. (1999). Can treatment for pure alexia improve letter-by-letter reading speed without sacrificing accuracy. Brain and Language, 67, 188-201. Marshall, J. (1995). The mapping hypothesis and aphasia therapy. Aphasiology, 9, 517-539.
Martinoff, J. T., Martinoff, R., & Stokke, V. (1981). Language Rehabilitation: Reading. Austin, Texas: Pro-Ed. Mayer, J. F., & Murray, L. L. (2002). Approaches to the treatment of alexia in chronic aphasia. Aphasiology, 16(7), 727-743. McKevitt, C., Fudge, N., Redfern, J., Sheldenkar, A., Crichton, S., Rudd, A. R., . . . Wolfe, C. D. A. (2011). Self-Reported Long-Term Needs After Stroke. Stroke, 42(5), 13981403. Meteyard, L., Bruce, C., Edmundson, A., & Ayre, J. (2010). Intervention for higher level reading difficulties: A case study. Paper presented at the BAS Therapy Symposium, Newcastle University. Morris, J., Howard, D., & Kennedy, S. (2004). The value of therapy: What counts? In J. Duchan & S. Byng (Eds.), Challenging Aphasia Therapies: Broadening the discourse and extending the boundaries. (pp. 134-157). Hove: Psychology Press. Morris, J., Webster, J., Whitworth, A., & Howard, D. (2009). Newcastle University Aphasia Therapy Resources: Written Comprehension University of Newcastle upon Tyne Parr, S. (1996). Everyday literacy in aphasia: radical approaches to functional assessment and therapy. Aphasiology, 10(5), 469-503. Pasternak, K. F., & LaPointe, L. L. (1982). Aphasic-nonaphasic performance on the Reading Comprehension Battery for Aphasia (RCBA). Paper presented at the American Speech-Language Hearing Association Annual Convention, Toronto, Ontario. Rogalski, Y., & Edmonds, L. A. (2008). Attentive reading and constrained summarisation (ARCS) treatment in primary progressive aphasia: A case study Aphasiology, 22(78), 763-775. Snow, C. (2002). Reading for understanding: Toward a research and development program in reading comprehension. Santa Monica: RAND. Strain, E., Patterson, K., & Seidenberg, M. S. (1995). Semantic effectsin single word naming. Journal of Experimental Psychology: Learning, Memory and Cognition, 21(5), 11401154.
Swinburn, K., & Byng, S. (2006). The Communication Disability Profile London Connect. Swinburn, K., Porter, G., & Howard, D. (2004). The Comprehensive Aphasia Test. Hove: Psychology Press. Thompson, C. K. (2001). Treatment of underlying forms: A linguistic specific approach for sentence production deficits in agrammatic aphasia. In R. Chapey (Ed.), Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders. (Fourth ed.). Baltimore: Lippincott, Williams and Wilkins. Tompkins, C. A., Fassbinder, W., Blake, M. L., Baumgaertner, A., & Jayaram, N. (2004). Inference generation during text comprehension by adults with right hemisphere brain damage: Activation failure versus multiple activation. Journal of Speech, Language, and Hearing Research, 47, 1380-1395. Whitworth, A., Webster, J., & Howard, D. (2013). A Cognitive Neuropsychological Approach to Assessment and Intervention in Aphasia: A Clinician's Guide. (2nd ed.). London Psychology. Wiederholt, J. L., & Bryant, B. R. (2001). Gray Oral Reading Test (GORT): Psychological Assessment Resources.
Figure 1: Comprehension accuracy on DCT
40 35 30 25 Pre-Therapy 20
Post-Therapy
15
Follow-Up
10 5 0 AC
CC
DB
EG
Table 1: Participants: Background Information Therapy
ARCS
PICS
3 strategy
ORLA
Participant
AC
CC
DB
EG
Age
75
61
72
84
Female
Female
Male
Male
Retired retail assistant
Retired teacher
Retired teacher
Retired marine
Gender Occupation
engineer Education Medical Information Time post-onset Handedness Vision Hearing
Left school at 15
University educated
University educated
University educated
Left TACS
Left MCA infarct
Left CVA
Left PACS
3 years
2 years
8 years
4 years
Right
Right
Right
Right
Glasses
Glasses for reading
Glasses
No difficulty
No difficulty
No difficulty
No difficulty
Hearing aid
Table 2: Pre-Therapy Assessment Normal
Normal
AC
CC
DB
EG
Mean
Range
Semantic memory (10)
9.8
9-10
10
10
10
10
Recognition memory (10)
9.4
8-10
10
10
10
10
Spoken single words (30)
29.2
25-30
26
24
24
25
Spoken sentences (32)
30.2
26-32
18
22
26
20
Written single words (30)
29.6
27-30
Not tested
28
28
30
Written sentences (32)
29.8
24-32
Not tested
14
22
23
Word repetition (32)
31.7
30-32
31
Not tested
26
24
Object naming (48)
45.4
42-48
35
Not tested
33
38
Picture description
52.2
33-87
25
Not tested
16
30
741
Not known
83
84
86
93
CAT Cognitive
CAT Comprehension
CAT Expression
Oral Reading Real word reading
(Strain et al. 1995) (96) CAT non-word reading (10)
9.4
6-10
Not tested
9
Not tested
0
RCBA-2 IV Functional reading (10)
Normal data not
5
Not tested2
7
7
VII Paragraph-picture (10)
available
6
4
7
9
VIII Paragraph factual (10)
7
Not tested
9
10
IX Paragraph inferential (10)
8
Not tested
7
7
Total accuracy (40)
26
30
33
Total Time taken (mins)
68
29
22
Discourse Comprehension Test Main ideas stated (10)
10
10
4
6
10
10
Main ideas implied (10)
9.8
9-10
7
6
6
9
Details stated (10)
9
7-10
4
5
5
7
Details implied (10)
8.4
7-10
6
4
8
6
Total accuracy (40)
37.2
34-40
21
21
29
32
Not known
Not known
27
15
Not
18
Total time taken (mins)
recorded
Bold indicates performance outside normal range 1
The mean has been calculated from error data in the paper. The majority of errors were on low imageability/low frequency words.
2
CC was only tested on one sub-test of the RCBA-2. She found assessment of her reading very stressful and therefore assessments were kept
to a minimum
Table 3: Comparisons of Performance Pre-Therapy, Post-Therapy and at Follow-up Pre-Therapy
Post-Therapy
Follow-Up (2-4 weeks posttherapy)
Study 1 (ARCS): Participant AC Discourse Comprehension Test Total accuracy (40)
(26) 21a
30
34
Time taken (minutes)
(29) 27
20
24
13
10
Not repeated
4
6
7
Total accuracy (40)
21
29
24
Time taken (minutes)
15
29
30
Control Task: Object Naming test (52)
18
13
14
Control Task: CAT word fluency Study 2 (PICS): Participant CC RCBA-2 Sub-test VII paragraph-picture (10) Discourse Comprehension Test
Study 3 (3 Strategy): DB
RCBA-2 Total accuracy (40)
30
33
Not re-tested
Total Time taken (mins)
29
21
Not re-tested
Total accuracy (40)
29
32
34
Control Task: CAT Object Naming
33
37
33
Total accuracy (40)
33
32
39*
Total Time taken (mins)
22
19
18
Total accuracy (40)
32
33
32
Time taken (minutes)
18
13
13
Control Task: CAT Picture Description
30
38
30
Discourse Comprehension Test
Study 4 (ORLA): Participant EG RCBA-2
Discourse Comprehension Test
* statistically significant difference between post-therapy and follow-up performance a
In study 1, two baseline measures on the DCT were carried out a week apart. Both scores are recorded. When comparing performance, the second, immediately pre-therapy measure is used to be consistent with other studies.
Table 4: Scores on CAT Disability Questionnaire for Participant AC
Area of Language
Max
AC
Disability Score Pre-
Post-
Therapy
Therapy
Talking
16
10
6
Understanding
16
5
6
Reading
16
6
4
Writing
16
16
16
Total score
64
37
32
