A P H A S I O L O G Y

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A P H A S I O L O G Y

  1. 1. This article was downloaded by:[Universidad Michoacana de San Nicolás de Hidalgo] On: 19 September 2007 Access Details: [subscription number 780340729] Publisher: Psychology Press Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Aphasiology Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713393920 Aphasia Therapy or The importance of being earnest Anna Basso a; Alessandra Caporali a a Milan University, Italy. Online Publication Date: 01 April 2001 To cite this Article: Basso, Anna and Caporali, Alessandra (2001) 'Aphasia Therapy or The importance of being earnest', Aphasiology, 15:4, 307 - 332 To link to this article: DOI: 10.1080/02687040042000304 URL: http://dx.doi.org/10.1080/02687040042000304 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
  2. 2. APHASIOLOGY, 2001, 15 (4), 307–332 Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 Aphasia Therapy or The importance of being earnest Anna Basso and Alessandra Caporali Milan University, Italy Effectiveness of aphasia therapy, at least for some patients, is no longer under discussion but the specific effect of most of the variables influencing recovery is unknown. In this paper we address a question relative to the therapeutic regimen. Three pairs of patients with similar age, educational level, sex, aetiology, lesion site, and type and severity of aphasia are compared. Except for one of the control patients who was 2 months post-onset, all patients were at least 6 months post-onset (range: 6–22 months) and had already been rehabilitated when they entered the study. The three experimental subjects underwent a very long and intensive therapeutic programme (2/3 hours per day, 7 days per week, for many months), with the help of the family and volunteers. The control patients were rehabilitated daily (1 hour, 5 days a week) for similar periods of time. It is argued that the intensive treatment achieved higher test scores and more prolonged recovery and that the experimental patients made better use of their recovered language in daily life. INTRODUCTION It is now generally agreed that aphasia therapy can be effective, namely that an aphasic patient will have better chances of recovery if he or she is rehabilitated. Experimental evidence comes from group studies (Basso, Capitani, & Vignolo, 1979; Basso, Faglioni, & Vignolo, 1975; Gloning, Trappl, Heiss, & Quatember, 1976; Hagen, 1973; Mazzoni et al, 1995; Poeck, Huber, & Willmes, 1989) and single case studies (Byng, 1988; De Partz, 1986; Jones, 1986). The beneficial effect of therapy is also confirmed by results of meta- analyses (Robey, 1994, 1998). In his 1998 study, Robey reviewed 55 reports on the effectiveness of aphasia therapy and studied whether there is a difference between treated and untreated patients. The reanalysis of the data showed a distinction between treated and untreated patients, which exceeded the criterion value for a medium-sized effect. However, the question is far from being settled because we still need to know which patients (or, perhaps better, which impairments) can be profitably rehabilitated and how. In a few single case studies both the impairment and the intervention have been described in a sufficiently detailed way so as to be reproducible (Byng, 1988; De Partz, 1986; Jones, 1986; Miceli, Amitrano, Capasso, & Caramazza, 1996). However, we do not know whether other variables (such as the associated disorders or the therapeutic regimen) have an effect on recovery and therefore we cannot be sure whether another patient showing Address correspondenc e to: Anna Basso, Neurological Clinic, Via F. Sforza 35, 20122 Milan, Italy. Email: abasso@micronet.it # 2001 Psychology Press Ltd http://www.tandf.co.uk/journals/pp/02687038.html DOI:10.1080/02687040042000304
  3. 3. 308 BASSO AND CAPORALI the same functional impairment (but different in other respects) would benefit from the Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 same intervention. A theory of rehabilitation should comprise various aspects, the most important being the intervention strategies themselves. Other important aspects are the characteristics of the patient (such as age and education), the functional damage (impaired word comprehension, impaired lexical reading, and so on), and the therapeutic regimen. In this paper we shall address a question relative to the therapeutic regimen. In the literature there are some descriptions of patients who have benefited from very brief periods of therapeutic interventions (see, for instance, Byng, 1988; Marshall, Pound, White-Thompson, & Pring, 1990; Penn, 1993). In the majority of cases these are chronic patients who can be used as their own controls. After having received what is generally called traditional therapy and having reached a plateau, they are offered a new method and show recovery of the treated impairment. TC (Penn, 1993), for instance, was a multilingual aphasic patient 9 months post-onset who ‘‘had a mild aphasia with relatively intact receptive abilities, fluent output, and marked word-finding difficulty’’ (p. 36) when a discourse-based therapy programme was implemented. The programme was carried out in nine sessions after which ‘‘improvement in the target areas was noted in all languages despite the fact that therapy was conducted only in English; the specific targeted behaviors (. . .) were assessed as being markedly more appropriate across the tested languages’’ (Penn, 1993, p. 40). BRB (Byng, 1988), a frequently cited case, was 6 years post-onset (during which time he had been rehabilitated) when he received a specific programme for mapping thematic roles onto grammatical relations. Therapy consisted of two sessions a week apart and intervening homework. BRB showed marked improvement in his comprehension of locative sentences (which had been the object of therapy) and of simple reversible sentences, as well as in sentence production, which had not been rehabilitated. Unfortunately this has never been our experience. We have seen patients recover with therapy, but following intensive treatment. Over the years we have been augmenting what we considered the minimum duration and intensity of aphasia rehabilitation necessary for recovery to show up in daily life, also in view of the fact that there is some experimental evidence that to be effective rehabilitation must be intensive and protracted (see Basso, 1992 for a review). The regimen we now offer to our patients generally consists of 1-hour daily sessions, supported by intensive homework (2–3 hours per day) and protracted for many months with control examinations every 3 months. The rationale for discontinuing the therapy is no recovery between two successive control examinations. This regimen in not easy to implement. We must first persuade the patient and his or her family that this is necessary and then help them to find a way to implement the necessary homework. With the help of the family, we try to identify a relative, a friend, or a volunteer who can do it. We must also identify the objectives of the rehabilitation programme that can be pursued by a lay person and the exercises that can be carried out by the patient alone. The focus of this paper is the regimen of aphasia therapy. The paper does not raise the issue of the content of therapy nor does it discuss our approach, which is described in some detail elsewhere (Basso, 1977, 1999). Briefly, we can say that in our aphasia unit we adopt two rather different approaches. In those cases in which we can arrive at a precise functional diagnosis with reference to a cognitive neuropsychologica l model of normal processing, we endeavour to target the identified impairment/s and implement what could be broadly defined as a cognitive neuropsychologica l approach. For severely
  4. 4. APHASIA THERAPY 309 damaged patients with an across-the-board impairment, less analytic approaches targeting Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 the disability itself can prove efficacious. By way of example, if a patient has an understanding disorder that can be explained by, say, damage to the input lexicon, it appears obvious to target the damaged lexicon. If, however, comprehension is severely impaired and the patient fails all tasks, a cognitive diagnosis is still possible but it is not really helpful in dictating what to do. We prefer to rehabilitate comprehension as a global behaviour in more ecological settings such as a conversation. The principal function of language is to permit communication among human beings and the main goal of rehabilitation is to enable the patient to communicate through language. To communicate the patient must be able to understand what his or her interlocutor is saying and to express what he or she wants to say. In this sort of therapy, the therapist engages the patient in a conversation which must be as similar as possible to a natural conversation the patient may want to sustain in his or her daily life. Right from the beginning of the treatment the patient’s participation must be similar to normal conversational behaviour. For each patient we also identify specific goals (reduction of apraxia of speech, prevention of agrammatism, recovery of word-finding abilities, reading aloud, and so on) with the aim of setting the stage for a successive and more specific intervention. If we want to label our intervention strategies, it can perhaps be suggested that for severe aphasic patients our intervention can be considered loosely akin to the so-called stimulation approach (see Howard & Hatfield, 1987, for a review). In this paper we attempt to demonstrate that an intensive therapeutic regimen can cause such a degree of recovery as to show up in the patient’s daily living. We are not investigating the outcome of therapy for a well-defined task such as, for instance, naming of 50 action pictures or reading of nonwords. We compare three pairs of patients matched as far as possible for the variables known to influence recovery. They have all been re- educated for long periods of time, the main difference being the intensity of the rehabilitation: the three control patients were seen by the speech therapist for 1 hour 5 days per week, the three experimental patients were seen for 5 hours per week and were also helped at home 2–3 hours per day. PAIR 1: PATIENTS FC AND AM Patient FC FC was a 37-year-old right-handed mechanic with 13 years of education who suffered a CVA in June 1997; his previous medical history was uneventful. He was admitted unconscious to hospital where a CT-scan showed ischaemic damage to the left frontal- temporal-parietal area surrounde d by oedema. Neurological assessment immediately post-stroke indicated global aphasia and right hemiplegia. The patient recovered clear consciousness in the following days and underwent motor rehabilitation. A MRI performed in April 1999 showed a large temporal-parietal lesion with extensive involvement of the white matter and the subcortical structures. When discharged from the hospital in August, FC was admitted to a rehabilitation clinic where he started language rehabilitation, 5 days a week, until November when he went home. He continued language rehabilitation in the same clinic on an outpatient basis four times per week during the first months, which reduced to three and then two times a week. He had been dismissed from rehabilitation when first seen at the Aphasia Unit of Milan University in February 1999, 20 months post-stroke, after being told that no further recovery was possible.
  5. 5. 310 BASSO AND CAPORALI The language examination (Ciurli, Marangolo, & Basso, 1996) at this time Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 demonstrated that it was not possible to classify FC’s language impairments into any of the classical syndromes, and a diagnosis of mixed nonfluent aphasia (Goodglass & Kaplan, 1983) was considered appropriate. He also showed verbal apraxia and acalculia (on a written calculation test he scored 15/101; cut-off score: 74/101; Basso & Capitani, 1979). He had no oral apraxia (20/20; cut-off score: 17/20; De Renzi, Pieczuro, & Vignolo, 1966) or ideomotor apraxia (67/72; cut-off score: 53/72; De Renzi, Motti, & Nichelli, 1980). His speech was impoverished and scanty; few isolated words (generally nouns) were produced with long pauses. Naming of object pictures was 60% correct, naming of action pictures was 30% correct. FC did not try to express himself using gestures or any other nonverbal means; he rarely looked at the interlocutor and appeared to be concentrating on trying to find the words to make himself understood. When his attention was caught, comprehension was sufficient for simple questions but severely impaired on the Token Test (13/36; cut-off score: 29/36; De Renzi & Faglioni, 1978). Reading comprehension was at the same level as auditory comprehension. Reading aloud and repetition were possible for single words but not for sentences; writing was impossible except for copying which was generally correct. He scored 34/36 on the Raven’s Coloured Progressive Matrices (Figure 1). The Appendix reports his description of the picture of a drawing room where a woman is knitting, a man is reading a newspaper, a girl is watching television, a boy is playing with blocks and a cat with a ball of wool. FC had come to see us because he did not want to give up therapy. Mainly in consideration of his young age, we thought this worthwhile notwithstanding two important negative factors: the time elapsed since onset and the fact that the patient had already been re-educated for 18 months. We discussed with FC and his wife the fact that in our opinion his only chance of recovery depended on very hard and lasting work he would have to do by himself, with a friend or a relative under our supervision, and directly with us. Even in this case chances of recovery were rather poor because the period of spontaneous recovery had finished long ago and he had already been re- educated for a long period of time, although lately rehabilitation had been reduced. FC and his wife agreed to do all they could. Because his wife worked and was away all day, she could dedicate only an hour per day, in the evening, to her husband, with more time at weekends. They found a young woman to work at home with him two more hours per day and he received treatment at the Aphasia Unit for an hour daily. Initially his homework consisted of sentence repetition and written action naming, tasks that a lay person can easily handle. FC’s wife and assistant were shown how to work with the patient and they regularly came to the clinic for supervision. Repetition was chosen because it could help FC overcome his verbal apraxia (which was not very severe), give him confidence in his capacity to produce sentences, and hopefully help prevent the production of agrammatic sentences (Beyn & Shokhor-Trotskaya , 1966). Written naming was considered important because of FC’s markedly reduced vocabulary, and actions instead of nouns were chosen because he was inclined to use only nouns in speech and we thought that facilitating retrieval of verbs could be helpful in preventing or reducing agrammatism. The therapist reserved for herself that which we thought was more difficult to delegate. During the evaluation it had become clear that FC had severe difficulties in having a conversation; he was eager to speak (frequently without succeeding in making the interlocutor understand what he was talking about) but would not pay attention to what was said to him. This made it very difficult to help him express himself by asking adequate questions. It was then decided that the therapist would involve the patient in a
  6. 6. APHASIA THERAPY 311 Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 February 1999 (Ciurli et al. 1996) TT = 13/36 Rv = 34/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation October 1999 (Ciurli et al. 1996) TT = 13/36 Rv = 36/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation April 2000 (Ciurli et al. 1996) TT = 16/36 Rv = 50/60 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences. Figure 1. Percentage correct responses by FC at three subsequent evaluations: February, 1999, October, 1999; April, 2000. conversation, rapidly changing the subject of the conversation and getting the patient accustomed to answering in any possible way. A control evaluation 3 months later did not disclose much change, except for oral action naming which was now 80% correct. We were not discouraged because we had not expected much improvement in 3 months and therapy was continued. At home he was required to read aloud (which he could do by himself) and to decline verbs he had first retrieved in the infinitive form. With the therapist he now started to read
  7. 7. 312 BASSO AND CAPORALI a short paragraph, imagine a scene that represented what he had read and, when he could Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 clearly see the scene in his mind’s eye, describe it. This was thought to help him speak because the content of the message was already clear in his mind; at the same time the therapist did not know in advance what he was going to say and therefore it had a communicative value. A second control examination in October 1999 (Ciurli et al., 1996) disclosed a generalised although mild improvement in all language tasks. He was given a score of 5/ 10 for his description of a picture (see Appendix) and he could write some words to dictation and in a confrontation naming task. However, he still scored 13/36 on the Token Test (Figure 1). Rehabilitation continued without any important change and a final control examination was carried on in April 2000, after 14 months of intensive language therapy (Ciurli et al., 1996). Improvement was now evident in all tasks and his speech output was more abundant and more informative. Confrontation naming of nouns was 85% correct and of actions 70% correct, and he could write to confrontation 70% of nouns and 60% of actions. It was now possible for him to read and repeat short sentences. Only his score on the Token Test was not much changed (16/36) (Figure 1). His comprehension in a conversation, however, was quick and correct. His production was more abundant and informative although still agrammatic with some correct sentences, and he did not wait to be asked something but frequently introduced new topics. The appendix reports his retelling of a typical day. Patient AM AM was a 37-year-old right-handed bookbinder with 8 years of formal education who suffered a CVA in July 1988. On admission to the hospital the neurological examination showed mild right hemiparesis and expressive aphasia. A CT scan performed in October 1988 disclosed a large left temporal-parietal lesion with deep extension to the basal ganglia. AM started daily language rehabilitation in September, which was still going on in June 1989, 11 months post-onset, when he was first examined at the Aphasia Unit. The language examination (Basso & Vignolo, 1974) disclosed a mixed nonfluent aphasia with severely reduced speech and verbal apraxia. His description of how to shave is reported in the Appendix. Repetition and reading aloud were only mildly impaired for words and nonwords but he could not repeat or read sentences. Writing was more severely impaired than oral speech; he could sign and copy and he correctly wrote only one of 20 words. Comprehension was adequate for oral and written words and sentences; on the Token Test he scored 15/36. He had no oral (17/20) or ideomotor (69/72) apraxia and scored 30/36 on the Raven’s Coloured Progressive Matrices. In the written calculation test he scored 12/101 (Figure 2). Rehabilitation in our unit was started, an hour daily, with the immediate objectives of reducing AM’s verbal apraxia by having him repeat short sentences. It was also thought that this could prevent or reduce agrammatism. In order to augment his speech output and his vocabulary he was engaged in conversations above various subjects and asked to describe pictures. A control examination 6 months later, in December 1989 (Basso & Vignolo, 1974), showed some recovery of speech production, which was now agrammatic but slightly more fluent (see Appendix), and in writing of single words. His comprehension as evaluated by the Token Test was much better (22/36). He scored 30/36 on the Raven’s Coloured Progressive Matrices and 8/101 in the written calculation test (Figure 2). Daily
  8. 8. APHASIA THERAPY 313 Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 June 1989 (Basso & Vignolo, 1974) TT = 15/36 Rv = 30/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S (n.t.) (n.t.) Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation December 1989 (Basso & Vignolo, 1974) TT = 22/36 Rv = 30/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S (n.t.) (n.t.) Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation June 1990 (Basso & Vignolo, 1974) TT =18/36 Rv = 33/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S (n.t.) (n.t.) Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences; n.t. = not tested. Figure 2. Percentage correct responses by AM at three subsequen t evaluations: June, 1989; December, 1989; June, 1990. rehabilitation was continued. Since AM’s speech production was still very slow, reduced, and agrammatic, the main objective of therapy was to have the patient speak more fluently with more verbs. Oral and written confrontation naming and retrieval of actions were added, in the hope that a richer vocabulary would induce AM to speak more. The language examination had shown that comprehension was superior to his speech production. It was therefore not thought to be a problem and was not specifically retrained. In June 1990, after a year of daily rehabilitation, a very mild across-the-board
  9. 9. 314 BASSO AND CAPORALI recovery was detectable (Basso & Vignolo, 1974), except for the Token Test score which Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 was only 18. Confrontation naming was now 90% correct and written confrontation naming 40%; reading aloud of sentences was 70% and repetition and writing to dictation of sentences, although still severely impaired, were better than at first examination (Figure 2). This degree of recovery, however, was apparently not sufficient to bring about a change in his spontaneous production and did not show up in his daily life. Communication was still very difficult (see Appendix) and AM did not try to speak with members of his family or other people. Recovery showed up only in the rehabilitation setting. The patient was young and highly motivated, and we did not understand why he did not use his speech outside the rehabilitation setting. Moreover, his speech therapist was firmly convinced that she could obtain more from him. Rehabilitation was continued for a year, 5 days a week with the only interruption the summer break, but without any further recovery. Between June 1990 and July 1991 he was tested on three further occasions but no amelioration was noted (in all testing sessions, for instance, the Token Test score was 18). Figures 1 and 2 report percentage of correct responses by the two patients in the language tasks. The two patients were examined with two different language examinations (Basso & Vignolo, 1974; Ciurli et al., 1996). The two tests have been devised for severe aphasic patients and all tasks are easily performed by normal subjects with a ceiling effect. The stimuli used differ in the two batteries but the tasks are the same and can easily be compared. The main difference between the two tests lies in the sentence production task (see later). Comparison FC and AM were two men of similar age though their educational level was different (13 vs 8 years). They presented with very similar language disorder 20 and 11 months post- onset when they started rehabilitation at the Aphasia Unit of Milan University. Both had mild right hemiplegia without visual field defects. Comparison of their CT lesions showed that they were similar although the cortical area involved in FC’s lesion was slightly larger as was AM’s extension to the deep structures. Both had previously been treated for aphasia with similar regimens. From their clinical reports it would appear that initially they both had global aphasia which recovered to a point that it could be reclassified as mixed nonfluent aphasia; in other words, comprehension had partially recovered in both patients. Both presented with severely reduced speech and mild verbal apraxia; agrammatism became evident in both patients when their speech production became slightly more abundant. To recapitulate, except for the educational level, FC and AM had similar demographic characteristics, aetiology, aphasia profiles, and previous therapy regimen when we met them. Rehabilitation was then started with similar objectives: to reduce their verbal apraxia, to augment speech output, and to prevent agrammatism. In neither case was comprehension specifically rehabilitated: AM initially showed an important recovery of comprehension and it was thought that conversation could be a sufficient stimulation for FC’s comprehension. The therapy programmes were not much different and were carried out by the same therapist. The only important difference was the amount of time spent in therapy: 1 hour 5 days a week for AM, and no less than 2–3 hours 7 days per week for FC. After a year, at testing AM’s comprehension, albeit still severely impaired,
  10. 10. APHASIA THERAPY 315 had recovered slightly more than FC’s, and FC produced much more and was more Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 communicative than AM. Direct comparison of their production poses a problem because FC was asked to describe a picture and AM to explain how to shave, and procedural language can be more difficult than description of a picture for aphasic patients. However, FC’s production clearly shows a continuous recovery and AM’s production does not change much (see Appendix). The difference between the two patients was clearly evident in ecological situations. AM was reported never to start talking or participate in a conversation even with his family members. FC talks more with more people and although his comprehension is severely impaired on testing, he rarely has problems comprehending what is said to him. A second year of therapy did not result in any further recovery in AM; FC is still being rehabilitated and there is no indication that a plateau has been reached. PAIR 2: PATIENTS DT AND SB Patient DT At the beginning of March 1996 DT, a 35-year-old right-handed man with a degree in architecture, suffered a subarachnoid haemorrhage caused by an existing arterio-venous malformation. He was immediately admitted to the local hospital, where the neurological examination showed intense rigor without focal neurological signs. An angiography demonstrated a large aneurysm at the origin of the left communicating posterior artery. Five days later DT was operated on and three days after the intervention he became drowsy and showed a mild right hemiparesis and aphasia. Successive CT-scans showed a progressive enlargement of the ventricles. Two weeks after the first intervention, he was again operated on and a ventricular peritoneal shunt was positioned with progressive recovery of consciousness. At the end of April he was discharged from hospital. The neurological examination showed global aphasia without hemiparesis or hemianopia. In September 1996 a CT scan showed a frontal hypodense lesion. He started aphasia rehabilitation while in hospital, and it was still going on when he was first seen at the Aphasia Unit at Milan University in September 1996, six months post-onset. Language examination (Basso & Vignolo, 1974) disclosed global aphasia with severe acalculia (12/101); oral (17/20) and ideomotor (71/72) apraxia were not present. His spontaneous speech was scanty, apparently without verbal apraxia but totally incomprehensible; he uttered short sequences of phonemes and sometimes such words as ‘‘is, a, so’’ (see Appendix). Oral and written comprehension of words was possible (75% and 85%) but it was severely impaired for short commands (30 and 40% respectively). He scored 2/36 on the Token Test. Repetition, reading aloud, and writing to dictation were all nil but he could copy some words. His score on the Raven’s Coloured Progressive Matrices was 24/36 (Figure 3). At that time it was not possible to involve the patient in a decision about rehabilitation because he appeared not to realise how severe his deficit was and it was very difficult to make him understand what was said to him, even when he himself was the subject of the conversation. However, the family was very supportive and an aunt had plenty of time to dedicate to the patient. As for DT, he had a rather passive attitude but was always willing to do what he was asked. We therefore thought that we could rely on the family and planned a therapeutic intervention that did not require DT to work alone. He lived rather far from Milan but we decided, together with his family, that for the present time it was better to come to Milan every morning and work at home in the afternoon, as we were not convinced that a lay person could manage all the tasks we considered necessary.
  11. 11. 316 BASSO AND CAPORALI September 1996 (Basso & Vignolo, 1974) TT =2/36 Rv =24/36 Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S (n.t.) (n.t.) Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation June 1997 (Miceli et al., 1991) TT = 11/36 Rv = 29/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S (n.t.) Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation January 2000 (Miceli et al., 1991) TT = 19/36 (written = 31/36) Rv = 36/36 100 90 80 70 60 50 40 30 20 10 0 N V S N V S N S N S N S N S N S (n.t.) Oral Production Written Production Oral Written Repetition Reading Writing to Comprehen. Comprehen. aloud dictation TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences;n.t. = not tested. Figure 3. Percentage correct responses by DT at three subsequent evaluations: September, 1996; June, 1997; January, 2000. Because almost everything the patient tried to do resulted in a failure, it was decided that the family should start with what can appear a very easy task: DT had to repeat syllables or short words, whichever was more successful. In fact this proved to be very difficult for DT and required a lot of skill and patience on the part of his aunt. After he succeeded in repeating a few words and syllables, reading and writing of syllables was introduced; mostly, however, these were accomplished by repetition and copying.
  12. 12. APHASIA THERAPY 317 The therapist took on the difficult task of having DT say some content words that were Downloaded By: [Universidad Michoacana de San Nicolás de Hidalgo] At: 01:13 19 September 2007 totally absent from his speech. She could not rely on such classical facilitation as repetition or reading because DT could do neither. As for phonemic cueing it was sometimes, albeit rarely, successful but its effectiveness was very short-lived. We gave up the idea of obtaining a target content word in a convergent task, such as confrontation naming, and we tried to elicit them in more divergent and open tasks, accepting any content word DT would produce. For instance, we said a word and asked DT to say the first word that came into his mind or to complete a sentence with any word he could think of. Any content word DT said was repeated by the therapist and then included in a sentence, hoping that this would help DT become conscious of what he had said, if by chance he had produced the word automatically without really being aware of its meaning. Comprehension exercises of words and sentences such as pointing to pictures were not used. We decided that continuous verbal interactions with the therapist and his aunt would provide sufficient stimulation and we argued that this would be a more dynamic and ecological exercise. A re-evaluation 3 months later showed slight improvement in repetition and reading aloud that were now possible for some words and nonwords. Moreover, DT was now more conscious of his difficulties and he was more motivated in his rehabilitation. This allowed us to increase his homework. As he could now write some words he was also asked to do written naming at home, especially action naming, with the help of his aunt. Six months after starting rehabilitation he was again reassessed (Miceli, Laudanna, & Burani, 1991). His speech output was severely reduced and anomic; he sometimes omitted verbs and prepositions. Notwithstanding frequent omissions and phonemic paraphasias, when speaking he could make himself understood, being very good at using gestures, mime and drawings. He could name about 60% of object pictures and 30% of action pictures. Comprehension was adequate in conversation but still severely impaired on the Token Test (13/36). Repetition and reading aloud were still very severely impaired. DT had always been very keen to resume work, which he apparently could do. He was a fashion designer for a glamorous Italian fashion house. His drawing capacity was unaltered and he decided to go to work at least twice a week and come to Milan the other 3 days, working at home in the afternoons and the evenings. This regimen did not last long and he soon resumed work 5 days a week coming to Milan once every 3–4 weeks. After an initial period in which he gave up his commitment to rehabilitation because working was both tiring and very involving for DT, his homework has always been regular and intensive. Reassessed in June 1997 (Miceli et al., 1991), 15 months post-onset and 9 months after starting rehabilitation, he showed an across-the-board recovery but was still impaired in all tasks. Some peaks of impairment were evident. Reading and repetition were particularly difficult for him; he read very slowly, recognising one letter at a time. However, if given enough time he could correctly read 70% of words and 50% of short sentences. Repetition was made difficult, besides other reasons, by the fact that he had difficulties identifying heard phonemes; the contrast voiced–voiceless, for instance, was beyond his possibilities. His Token Test score was 11/36. However, his vocabulary was richer, his production more abundant but still agrammatic. His comprehension in conversation was fair, and his writing easier (Figure 3). The Appendix reports his retelling of a typical day. The same regimen was continued for the following two and a half years. Regular control examinations showed slow but continued recovery. Treatment was changed

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