Aphasia, Alexia and Oral Reading

Aphasia, Alexia, and Oral Reading
Leora Reiff Cherney
Alexia is an acquired disturbance in reading. Alexias that occur after left hemisphere damage typically result from linguistic
deficits and may occur as isolated symptoms or as part of an aphasia syndrome. This article presents an overview of the
classification of the alexias, including both the traditional neuroanatomical perspective and the more recent psycholinguistic approach. Then, assessment procedures are reviewed, followed by a summary of treatment approaches for alexia. Finally, two case studies illustrate how oral reading of connected language (sentences and paragraphs rather than single words) has been used as a technique for treating alexia in patients with aphasia. Key words: alexia, aphasia,
assessment, classification, reading, treatment
lexia, an acquired disturbance in reading,
is a common consequence of brain damage. Both left and right hemisphere
pathology may result in loss or impairment of the
ability to comprehend written or printed language. Disturbances of reading that occur after
right-brain damage are typically related to problems in visual processing such as spatial discrimination and unilateral visual neglect; these alexias
have been referred to as neglect dyslexia or spatial or
hemispatial alexia.1–7 Reading disturbances that
occur after left-hemisphere damage typically result
from linguistic deficits and may occur as isolated
symptoms or as part of an aphasia syndrome.8
This article focuses on the alexias that result
from left-hemisphere damage. First, an overview
of the classification of the alexias is provided,
including both the traditional neuroanatomical
perspective and the more recent psycholinguistic
approach. Then, assessment procedures are
reviewed, followed by a summary of various treatment approaches for alexia. Finally, two case studies illustrate how oral reading of connected language (sentences and paragraphs rather than
single words) has been used as a technique for
treating alexia in patients with aphasia.
Classification of the Alexias
Traditionally, classification of the alexias has
been based primarily on neuroanatomic distinctions. More than a century ago, Dejerine described
two distinct alexia syndromes—alexia with
agraphia and alexia without agraphia.9,10 Alexia
with agraphia occurred after left-hemisphere parietal damage; alexia without agraphia resulted from
occipital damage together with damage to the
splenium of the corpus callosum. Since then, several case reports have supported the clinical and
neuropathological patterns of these two alexias.
More recently, a third major alexia syndrome has
been proposed, based on an anterior lesion in the
left hemisphere; this has been called frontal alexia.8 Each of the alexias are described further in the
following discussion. However, it should be noted
that although the symptoms of each of these alexias are relatively clear-cut, associated clinical findings vary considerably depending on the extent of
the lesions and involvement of other areas of the
Alexia without agraphia (occipital alexia)
Alexia without agraphia is easily recognized
because it is characterized by a disturbance of
reading contrasted with relatively preserved writLeora Reiff Cherney, PhD, CCC-SLP, BC-NCD, is Associate
Professor, Physical Medicine and Rehabilitation,
Northwestern University Feinberg School of Medicine,
Chicago, Illinois, is Clinical Research Scientist,
Rehabilitation Institute of Chicago, and is Associate Professor,
Communication Sciences and Disorders, Northwestern
University, Evanston, Illinois.
Top Stroke Rehabil 2004;11(1):22–36
© 2004 Thomas Land Publishers, Inc.
Aphasia, Alexia, & Oral Reading
ing skills. Patients typically cannot read what they
have just finished writing. The difficulty with letter and word recognition is specific to the visual
modality, and patients can spell out aloud and recognize words spelled to them by the examiner.
Therefore, alexia without agraphia is also called
pure alexia, pure word blindness, or agnosic alexia.
Letter naming, although initially slow, improves
with practice, and the patients often learn to read
the individual letters of the word aloud and then
decipher the words from their oral spelling.
Alexia with agraphia (parietal-temporal alexia)
As its name implies, alexia with agraphia is characterized by impairments of both reading and
writing, with the writing impairment usually
equal in severity to the alexia. Patients display difficulty in comprehending written material that is
read silently as well as in reading out loud.
Reading of letters and words is impaired, and this
difficulty extends to comprehension of numbers
and musical notations.8 The problem with letter
identification is not restricted to the visual modality; patients also have problems recognizing words
when they are spelled aloud. Parietal-temporal
alexia is often associated with a fluent paraphasic
Frontal alexia
In patients with frontal alexia, reading comprehension is typically limited to a few single words,
usually content words. Reading comprehension of
function words such as prepositions and pronouns is impaired. In contrast to their ability to
recognize some words, patients are unable to read
the individual letters of the word. Spelling words
out loud and comprehension of words that are
spelled aloud is also poor. A severe agraphia
accompanies the alexia, with writing characterized
by poorly formed letters, omission of letters, and
agrammatic sentences. Frontal alexia is typically
associated with a nonfluent aphasia.
Although these traditional neuroanatomically
based distinctions have provided us with a better
understanding of the alexias, they do not fully
explain the degree of variability seen in patients
with alexia and do not permit subtypes of alexias
to be distinguished. Interest has therefore shifted
from the anatomical correlates of acquired reading
disorders to the neurolinguistic and cognitive
mechanisms underlying them. In this approach,
various theoretical models of reading have been
proposed to account for the performance of normal readers and to identify the components of the
normal reading system that are disturbed in the
alexia syndromes.
Figure 1 shows a model of normal reading
comprehension that was developed by analyzing
the errors made by alexic patients while they read
single words out loud.11–14 After the perceptual
analysis and identification of letters, there are
three distinct ways in which a phonological code
(pronunciation of the word) is attained from the
written word:
1. In the direct lexical-semantic route, the written
word is matched to a corresponding word
form in the visual word store or orthographic
lexicon and is recognized. Meaning is then
retrieved by activation of the semantic representation of the word by the semantic processor. Finally, if the word is to be read out loud,
its pronunciation is activated by the phonological processor. This route accounts for “wholeword” reading of familiar real words.
2. In the indirect route, the written word is transformed into the spoken word via grapheme-tophoneme correspondence rules in the lettersound converter. This nonlexical or sublexical
route accounts for oral reading of novel words
that have no meaning or stored pronunciation or
for regular words that can be pronounced correctly by sounding out the constituent letters.
3. In the lexical-nonsemantic route, the written
word is matched to a visual word form in the
orthographic lexicon and is recognized. Then
its pronunciation is retrieved by the phonological processor. The word is read aloud, but
without comprehension because the semantic
processor is bypassed.
It should be noted that Figure 1 represents only
the major routes of the normal reading process.
More complex models with other components
have been postulated. For example, a phonologic
buffer or short-term memory is thought to main-
Visual Word
Figure 1. Model of the normal reading process (after Marshall & Newcombe13 and Morton & Patterson14).
tain individual phonemes during speech output
and is active during oral reading regardless of the
reading route that is used. As further investigations of oral reading in alexic patients continue,
the model and its component processes will be
more specifically defined.
The direct and indirect routes are both available
to the normal reader. The direct route enables
patients to read real words, particularly high frequency words that are in their reading vocabulary
and visual word store. The indirect route is used
for reading low frequency, unfamiliar words; these
are sounded out using grapheme-to-phoneme correspondence rules.
In the proficient reader, the indirect route is
used only when the reader is confronted with an
unfamiliar word for which neither a phonological
code nor a meaning code is activated quickly.
Grapheme-phoneme decoding is usually achieved
rapidly and automatically, so that most attention
can be focused on comprehension of meaning. In
contrast, the nonproficient reader has fewer words
in the visual word store and must utilize the indirect route more frequently. Therefore attention is
given primarily to the grapheme-to-phoneme conversion process, a complex process that is thought
to involve three stages: graphemic parsing (segmentation of the written graphemes into individual units), grapheme-to-phoneme conversion
(translation of the grapheme segments into corresponding sounds), and blending (assembling of
the individual sounds into a whole word). As a
result, the ability to comprehend meaning is compromised.15
Within the psycholinguistic approach, four different alexic syndromes have been described, each
Aphasia, Alexia, & Oral Reading
of which may occur in association with an aphasia. They have been labeled phonological, deep, surface, and semantic alexia and occur because of differential breakdowns in the normal reading
process.16–24 Figures 2–5 illustrate these reading
disorders as they relate to the model of reading
described previously.
In phonological alexia (Figure 2), the graphemeto-phoneme correspondence rules of language are
no longer available, so reading is accomplished by
the direct route. Often the reading disturbance is
not readily apparent. The patient can read aloud
real words, particularly high frequency words;
these words have an orthographic address and are
in the individual’s reading vocabulary and visual
word store. However, there is difficulty with nonwords (e.g., bome), or with low frequency words.
The patient is not able to sound out the letters to
get the word, because the letter sound converter is
not functioning. Typically, there are visual errors,
such as mild for slid, in which the target word is
read as another word that has similar letters in it.
Patients with phonological alexia often complain of
difficulty reading high level material such as books
and newspapers.
Deep alexia (Figure 3) is characterized by both
an unavailability of the grapheme-to-phoneme
correspondence rules and a disturbance of the lexical-semantic operations. Like phonological alexia,
patients are unable to read nonwords with visual
errors evident. In addition, patients with deep
alexia make many semantic errors such as producing synonyms, antonyms, or subordinates for
a target word. Reading is limited to a vocabulary
of known words and is restricted by imageability
and part of speech. Concrete nouns are read better than abstract nouns, and nouns are generally
read better than verbs or adjectives. Patients with
deep alexia also exhibit difficulty with function
words. Deep alexia is often present in Broca’s
In semantic alexia (Figure 4), the semantic
processor is not available. Thus, patients are able
to read aloud fluently, but without meaning. They
do not comprehend what they are reading aloud.
This is the type of alexia that accompanies a
dementia or some of the fluent aphasias such as
transcortical sensory aphasia.
Figure 2. Phonological alexia.
Figure 3. Deep alexia.
Figure 4. Semantic alexia.
Figure 5. Surface alexia.
In surface alexia (Figure 5), the direct route of
reading aloud is not available, so the patient relies
on the indirect route. However, the grapheme-tophoneme rules are applied inadequately. Although
the patient can read nonwords and regular words
with unambiguous orthographies, he or she has
difficulty with irregular words that cannot be
sounded out. The patient tends to make phonological (i.e., the error word sounds similar to the
target word) and visual errors. Comprehension is
tied to success at pronunciation; if a word is mispronounced as another real word, meaning will be
assigned in accordance with the incorrect pronunciation.
Reading problems that are associated with aphasia may conform to the distinct alexia syndromes
described previously, but a predictable relationship between aphasia type and alexia syndrome
has not been identified.25 In many cases, alexia
associated with aphasia reflects multiple levels of
impairment and has been called a mixed alexia or
aphasic alexia.26,27 In other cases, like the nonproficient reader described previously, patients with
aphasia may have difficulty, in varying degrees,
with the grapheme-to-phoneme conversion system.28 The aphasic patient may have lost the ability to rapidly decode the phonological and visual
information of the word, which interferes with the
ability to read for meaning. This would explain
why many aphasic patients who successfully read
at the word and sentence level continue to show
delays and comprehension problems when reading texts.
In contrast to patients with aphasia, patients
with pure alexia do not have direct visual access to
the normal reading system. Several plausible
hypotheses have been suggested to explain why
the written word is not recognized overtly. Some
investigators have suggested that visual perception
of letters is adequate, but the word form that is
needed to match the string of perceived letters is
not available.29 Others have suggested that the
word-form system is intact, but input from the letter recognition system is limited to a single letter
at a time, so that the problem is primarily a deficit
in the speed of letter identification.30 In either
case, the patient with pure alexia cannot activate
either the direct lexical-semantic or indirect sub-
Aphasia, Alexia, & Oral Reading
lexical reading routes when the input is visual.
Assessment of Reading
Although a brief screening is usually sufficient
for identifying the presence of an acquired alexia,
detailed assessment is necessary to delineate the
precise areas of breakdown so that an effective
treatment program can be developed. A thorough
evaluation includes assessment of reading comprehension to determine the level at which breakdown occurs, an analysis of single word oral reading, and consideration of associated areas of
strengths and deficits including visual skills, writing, naming, and spelling.
that correspond to a written sentence. One subtest
assesses specifically morphosyntactic reading and
another subtest assesses short paragraph comprehension. Longer paragraph comprehension is
evaluated with factual and inferential questions.
Functional reading of labels and signs is also
included. This second edition of the RCBA also
includes a lexical decision task in which patients
choose a real word from a triad of one real word
and two pseudowords.
Several tests of reading comprehension provide
grade levels and age equivalencies and may be
appropriate for individuals with acquired alexia.
Such tests include the Gates-MacGinitie Reading
Tests,35 the Woodcock Reading Mastery Tests,36
and the Nelson-Denny Reading Test.37
Reading comprehension and level of
Oral reading
Reading comprehension tasks provide information about the ability to access semantic meaning
from print. All general tests of aphasia have a variety of subtests that assess reading comprehension.
These subtests are typically hierarchically organized, beginning with recognition of letters, matching letters written in different forms (e.g., uppercase, lower case, script), and letter naming.
Testing then progresses to the single word level
(e.g., recognizing highly familiar words such as
name, name of town, country; matching single
words to pictures), the sentence level (e.g., following written commands ), and finally to more complex paragraphs (e.g., answering questions about a
paragraph that has just been read). However, reading subtests on aphasia batteries such as the
Western Aphasia Battery31 and the Boston
Diagnostic Aphasia Examination32 may have too
few items on some tasks and may be insufficient to
detect milder problems.33
A specific test of reading comprehension that
has been developed for individuals with aphasia is
the Reading Comprehension Battery for Aphasia
(2nd ed.) (RCBA-2).34 The test includes single
word comprehension tasks in which a single picture must be matched to one of three words that
are orthographically, phonologically, or semantically similar. Sentence comprehension is assessed
by having the patient select one of three pictures
Oral reading of single words provides insight
into the specific patterns of reading breakdown
consistent with the neuropsychological models
and the integrity of the semantic versus phonologic reading routes. A variety of word lists have been
developed. Typically, these word lists include pronounceable nonwords, regular words, and irregular words. They also include words of different
lengths, different frequencies, different degrees of
imageability/concreteness, and different grammatical class (function words vs. content words).
Accuracy of oral reading is compared across stimulus types (e.g., word vs. nonword), and careful
analysis of errors (semantic, phonologic, visual,
morphosyntactic) permits a determination of the
type of alexia.
The Psycholinguistic Assessments of Language
Processing in Aphasia (PALPA)38 is a commercially
available test with tasks that allow in-depth assessment of single word oral reading, as well as various tasks that assess semantic processing. Other
word lists include the Johns Hopkins University
Dyslexia Battery39,40 and the Battery of Adult
Reading Functions.41 Oral reading of single words
has also been added to the revised edition of the
RCBA-2, but the stimuli are only nouns.
Oral reading of sentences and paragraphs
should also be evaluated. In addition to providing
a measure of oral reading rate, attentional or con-
textual factors that affect performance may be
identified. The Grey Oral Reading Test–4 (GORT4)42 consists of 13 increasingly difficult passages of
text. From the assessment of oral reading rate
(time to read each passage), accuracy (number of
oral reading errors), and comprehension (accuracy answering five multiple choice questions at the
end of each passage), grade levels for reading fluency and comprehension are derived as well as an
overall Oral Reading Quotient.
Associated skills
The assessment of reading is best conducted in
the context of a general language evaluation that
compares performance given a variety of input
and output modalities. In particular, spelling skills
should be assessed, including both the ability to
spell words aloud as well as the ability to recognize words spelled aloud by the examiner. Both
oral and written naming should always be
assessed to determine whether there is an associated anomia or agraphia or whether the reading
problem is a pure alexia. Assessment of visualperceptual processes, visual spatial attention, and
working memory also should be included.
Traditional approaches to the treatment of
acquired reading problems typically begin at the
level of breakdown, that is, at the grapheme,
word, phrase, sentence, or paragraph level, and
patients practice tasks that are arranged hierarchically. Some commonly used treatment tasks
include: letter matching; word–picture matching;
word–word matching in which the target may be
the category name, an antonym, or a synonym;
word–definition matching; phrase or sentence
completion; following written commands; and
answering yes/no or “wh” questions about a sentence or paragraph. Difficulty is modified by a
change in various parameters such as the degree of
similarity between the target and distractors; the
number of distractors in the field; the frequency,
grammatical class, concreteness of the words; or
the complexity of the grammatical structure.
Most commercially available workbooks for
aphasia have numerous pages of pencil and paper
exercises, and more recently a number of computer programs also have been developed that provide
practice on these types of reading activities.
However, despite their clinical widespread use,
these reading tasks and programs for aphasia have
not been carefully evaluated and there is little evidence supporting their efficacy. One randomized
clinical trial evaluated the efficacy of computerized
treatment in general by using hierarchically organized reading activities consistent with the traditional approach.43 Fifty-five patients with chronic
aphasia were randomly assigned to one of three
conditions: computer reading treatment that consisted of visual matching and reading comprehension tasks, computer stimulation such as nonverbal games and cognitive rehabilitation tasks, or no
treatment. Patients in the computer groups used
the computers 3 hours a week for 26 weeks. The
results suggested that computerized reading treatment was efficacious with improvements generalizing to noncomputer language performance. It was
also shown that these improvements resulted from
the language content of the software and not from
the stimulation provided by the computer.
In contrast to the lack of evidence supporting
the traditional approach to acquired reading disorders, a variety of treatment approaches consistent with the neuropsychological approach have
been developed for specific alexia syndromes.
These treatments are implemented only after a
detailed evaluation of the acquired alexia and target the impaired reading processes. Table 1 presents a brief summary of these studies. Taken
together, these studies provide evidence that reading can be improved in cases of relatively wellspecified alexia syndromes44–68 and in cases of
unspecified alexia associated with aphasia.43,69 The
changes affected by treatment stand in contrast to
the reports of relatively stable alexia profiles in
patients who are untreated.2,70
Several issues arise from a review of the literature on treatment of alexia, as illustrated in Table
1. Although positive results have been reported
for each type of alexia, the treatment approaches
have been evaluated on only a limited number of
patients. Furthermore, each approach has met
with varying degrees of success, and often a treat-
Aphasia, Alexia, & Oral Reading
Table 1. Treatment of acquired alexia: summary of studies
Lott et al.44
Alexia type
Pure alexia
Maher et al.45
Pure alexia
Greenwald &
Pure alexia
Behrmann &
Lott & Friedman48
Pure alexia
Rothi & Moss49
Rothi et al.73
Pure alexia
Pure alexia
Friedman & Lott50
Pure alexia
Toumainen & Laine53
Pure alexia
Pure alexia
Pure alexia
Pure alexia
Pure alexia
No. of
Treatment rationale and procedures
Tactile-kinesthetic letter identification: trained patient to trace letters onto the
palm of his hand during oral letter naming
Motor cross-cuing strategy: patient used finger to pretend to copy letters in
words and sentences
Trained letter-by-letter reading using letter naming
Speeded stimulus presentation so first and last letters of a word are
apprehended together
Three-stage approach: (1) single-letter naming using tactile-kinesthetic feedback
and feedback about speed of letter naming, (2) naming of letters in a letter
string, (3) single word reading aloud with feedback about reading speed
Encouraged reliance on residual whole-word reading by presenting words too
rapidly to allow for letter-by-letter reading. Required patient to make a semantic
category decision about each word.
Trained whole-word recognition as above; however, patient did not need to make
a semantic judgment about each word. Patient was only required to read aloud
each word as it was rapidly presented at a rate of 50 ms per word.
Multiple oral rereading (MOR), i.e., patient repeatedly read aloud a given text
over several days or weeks (see case study 2 for details)
Coltheart & Byng55
Surface alexia
Weekes & Coltheart56 Surface alexia
Scott & Byng57
Surface alexia
Surface alexia
Designed to facilitate reading of irregularly spelled words. Irregular words were
paired with a mnemonic picture/semantic cue (e.g., the word through was
presented with an arrow through it). Patient practiced at home with sets of cards.
Computer presentation of a sentence with a homophone deleted and six word
choices, including the correct word, its homophone, and pseudohomophone of
the correct word. Feedback provided regarding accuracy of patient selection.
Homophone training. Patient read each homophone presented, its definition, and
then wrote the word in a sentence.
Friedman & Robinson59 Surface alexia
Direct training of a set of words with ambiguous pronunciation of specific
letter clusters
Moss et al.60
Surface alexia
Increased reading rate by having patient name the semantic category of target
words presented at a speed too rapid to allow reading aloud
De Partz61
Laine & Niemi71
Mitchum & Berndt72
Deep alexia
Deep alexia
Friedman & Lott63
Deep alexia
Trained grapheme-phoneme conversion: (1) patient trained to associate each
written letter with a code word that began with that letter; (2) each letter was
associated with the first sound of the code word; (3) reading of short words and
Note: In later two studies, patients had difficulty blending the phonemes into
Auto-cue strategy, i.e., patient instructed to produce the first phoneme of a word,
think about its meaning, and then attempt to say the word
Bigraph training to access phonology from orthography: (1) a set of bigraphs (CV
and VC) were associated with their corresponding sounds; (2) patient trained to
produce a word that began with the two letters; (3) then trained to cut it short so
only the bigraph was produced; (4) practiced combining CV and VC bigraphs
into CVC words.
Direct teaching of phonics and blending using a phonics-based commercial reading
program, the Wilson Reading System, to read aloud real words. Involved multisensory presentation, and systematic hierarchical, step-by-step instruction.
Phonological awareness training using the Auditory Discrimination in Depth
program that trains motor-articulatory awareness during phoneme production
Taught rule-based sound conversion of whole-word orthography. Systematically
exposed patient to words containing the “c” and “g” rules (e.g., cent, gem)
until correct responses were given.
Paired associate learning: words that were low in semantic value were paired
with words that sounded similar but were high in semantic content, e.g.,
be/bee, me/meat. Patient read target word printed on a card. If patient’s response
was incorrect, he or she turned the card over and read/named the
homophone/near homophone.
Yampolsky & Waters64 Deep alexia
Conway et al.65
Phonological alexia
Kendall et al.66
Phonological alexia
Friedman et al.67
Phonological alexia
Table 1. (continued)
No. of
Treatment rationale and procedures
MOR, i.e., repeated reading aloud of a given text over several days or weeks
(see case study 2 for details)
Alexia type
Phonological alexia
Beeson & Insalaco25
Mayer & Murray78
Phonological alexia
Mild alexia with
decreased lexicalsemantic abilities and
associated deficits in
attention and working
Alexia due to deficits
with the phonological
output lexicon and
grapheme-to- phoneme
Cherney et al.69
Katz & Wertz43
Kiran et al.79
Used MOR and oral reading of phrase-formatted text
Used two treatment approaches: (1) text-level oral reading treatment (MOR)
modified to include five comprehension questions that assessed comprehension
of main ideas, details, and inferences; and (2) a working memory treatment
that involved judging the grammaticality of a set of sentences as well as holding
and processing the last word of each sentence in the set. The number of sentences
in each set and the length of each sentence increased progressively.
Trained grapheme-phoneme conversion for single words via oral reading of
words. If the patients could not orally read a word, then they (1) repeated the
word, (2) spelled the word out loud, (3) selected the letters of the target word
from distractor letters, (4) identified the target word letters presented randomly,
(5) read letters of target word. Finally, the patient attempted to read the word
aloud again with feedback given.
Oral reading for language in aphasia (ORLA), i.e., repeated reading aloud of
sentences in unison with the clinician (see case study 1 for details)
Computer treatment that consisted of 10 visual matching activities (e.g., matching
letters, matching numbers, matching words) and 22 reading comprehension
tasks involving words, phrases, "wh" questions, and sentences. Activities and
tasks arranged sequentially in a hierarchy of difficulty determined by the activity,
the task, and the number and type of response foils.
ment that was initially successful turned out to be
less successful with replication. For example, the
success achieved by de Partz61 on a treatment
involving grapheme-to-phoneme conversion
training for a patient with deep alexia was not
demonstrated in the subsequent studies,71,72
because the patients had particular difficulty
blending phonemes into syllables. Rothi and colleagues73 were not able to replicate the successful
outcome of the speeded whole-word training for a
patient with pure alexia that they accomplished in
an earlier study.49 Another factor that requires
consideration but is not included in Table 1 is the
number of treatment sessions provided to accomplish a positive outcome. In some studies, fewer
than 10 sessions were needed, whereas in other
studies, as many as 9 months of treatment were
administered. For further details of each study, the
reader is referred to the original articles.
Many of the treatment studies reported in Table
1 are primarily directed toward improved reading
accuracy of a corpus of single words, with little
information about the impact of these treatments
on reading performance for connected texts,
which often is the ultimate treatment goal.25
Treatment protocols that have targeted connected
text are rare. One such technique that focuses on
connected discourse has been called multiple oral
rereading (MOR).51 Unlike other methods of treatment that usually involve repeated practice on isolated words to increase speed of word identification, MOR involves repeated reading aloud of the
same text over a period of days or weeks. MOR
was initially applied to a 30-year-old alexic patient
with a transitory mild aphasia and resulted in a
substantial gain in reading speed over a relatively
short period of time.51 MOR has been used in later studies to improve letter-by-letter reading, and
results have consistently indicated improved reading rate for practiced materials as well as for new
material.25,52–54 In the following section, a case
study is presented to illustrate how MOR was used
successfully in a patient with phonological alexia.
A second case study illustrates a different oral
reading approach for acquired alexia, called oral
reading for language in aphasia (ORLA).69 With this
technique, the person with aphasia repeatedly reads
aloud sentences and short paragraphs, first in unison with the clinician and then independently. The
box titled “Oral Reading for Language in Aphasia
(ORLA)” delineates the specific steps of ORLA. The
treatment is based on a stimulation approach in
which repetitive multimodality stimulation is presented to elicit a response. Responses are not forced
Aphasia, Alexia, & Oral Reading
Oral Reading for Language
in Aphasia (ORLA)
1. The speech-language pathologist reads aloud to
the patient, pointing to each word as he or she
reads along. The length of the material may vary
from 3 to 100 words, depending on the auditory comprehension skills of the patient.
2. The speech-language pathologist reads aloud to
the patient again, pointing to each word as he
or she reads along and encouraging the patient
to also point to each word.
3. The speech-language pathologist reads the
para- graph aloud together with the patient,
while continuing to point to each word as he or
she reads along. The patient also points to each
word. The clinician adjusts the rate and volume
of the oral reading according to the specific
patient (e.g., reading a little ahead of the patient
so he or she is able to hear the initial phonemes
of the words; decreasing volume as he or she
requires fewer cues).
4. For each line or sentence of the paragraph,
the speech-language pathologist states a word
that the patient must then identify. Words
may be content words (e.g., nouns, verbs) or
function words (e.g., pronouns, prepositions,
5. For each line or sentence of the paragraph, the
speech-language pathologist points to a word
for the patient to read aloud. Both content and
function words are selected.
6. The patient reads the whole sentence aloud
again in unison with the speech-language
or corrected; rather, correct responses are modeled
while error responses are followed by further stimulation. The design of the ORLA technique is consistent with learning theory and adheres to principles
such as active participation by the learner, repetitive
practice in the over-learning of skills, use of meaningful materials, and successful experiences.
ORLA is unique for several reasons. Like MOR, it
focuses on connected discourse rather than single
words, therefore it permits the modeling of more natural intonations and speech. Furthermore, it allows
practice on a variety of grammatical structures, rather
than just one specific grammatical form. Finally, the
technique is quickly learned by patients because of
its simplicity and ease of administration.
In a study of 10 patients with different types of
reading problems, ORLA was shown to be effec-
tive for all groups of patients regardless of the
type, severity, and acuity of the associated aphasia.69 An important observation from this study
indicated that improved oral reading preceded
changes in reading comprehension. This finding
lends support to the idea that as the patients learn
to decode words more rapidly, they are able to
direct their attention to comprehension of meaning, which results in improved comprehension
scores. This study remains the largest published
study of an oral reading treatment for patients
with acquired reading problems.
The ORLA technique was developed to target
reading comprehension, but an interesting outcome
of the study was that the patients’ language performance improved in all modalities, not only reading.69 Beeson and Insalaco noted similar findings;
both their patients improved their aphasia quotients over the course of the oral reading treatment.25 The reasons for the occurrence of crossmodal generalization are not clear. Cherney and
colleagues have suggested that the choral reading in
their study provided repeated stimulation to the
auditory comprehension modality as well as repeated practice in oral expression.69 Therefore,
improvements in these modalities could be expected. Indeed, the ORLA treatment program was
found to be an effective approach for treating apraxia of speech in two patients with Broca’s aphasia.74
ORLA may be effective because it incorporates three
elements — rhythm, pacing, and linguistic templates — that have been identified as important to
help establish an underlying oscillatory rhythm,
melody, and rate for speech production.75 The
patient’s paced pointing to each word of the sentence, together with the linguistic template provided by the clinician, may help facilitate the patient’s
temporal flow and articulatory rate of speech.
Although oral reading appears to give the
patient practice with the grapheme-to-phoneme
conversion process, Beeson and Insalaco explain
the cross-modal generalization by suggesting that
the interactive processing during oral reading also
serves to strengthen partial or degraded lexical
information.25 Therefore, the benefit is not purely
at the level of the orthographic input lexicon but
extends to language processing by other modalities as well.
Oral Reading Treatment: Case Studies
Multiple oral rereading (MOR)
G.B., a 23-year-old male, initially presented with
a moderately severe Wernicke’s aphasia after resection for an arteriovenous malformation in
December 1998. He participated in approximately
6 months of intensive interdisciplinary rehabilitation, first as an inpatient at an acute rehabilitation
facility and then as an outpatient in a day rehabilitation program. At the time of evaluation by this
investigator at the end of May 2000, G.B. was no
longer receiving any rehabilitation. His goal was to
return to school, but he reported that his difficulty
in reading prevented him from doing this.
Testing indicated that G.B. presented with a
mild anomic aphasia and an associated phonological alexia. The alexia was characterized by difficulty reading aloud nonwords and low frequency
words. He was slow in sounding out letters to get
to words, although this was a strategy that he
attempted when presented with less familiar
words. He could read aloud real words, particularly high frequency words. Errors were typically
visual errors, in which the target word was read as
another word with similar letters in it.
G.B. completed the reading comprehension subtest of the Boston Diagnostic Aphasia Examination32
and achieved a score of 6/10. Oral reading rate of
novel text was 34.6 words per minute. A reading
comprehension test, the Gates-MacGinitie Reading
Tests, Level D,76 geared for 4th–6th graders was
attempted; however, G.B. was unable to proceed
with the test because of slow reading and subsequent complaints of fatigue during reading.
Because the patient lived geographically far from
the investigator and insurance would no longer
provide reimbursement for services, there was a
need to provide a reading program that could be
independently practiced by the patient. Therefore
MOR was selected in which a family member
chose an item from the newspaper and the patient
would practice reading it aloud for 30 min each
day for an entire week. All practice sessions were
tape recorded; at the end of the week, tapes were
sent to the investigator for review. Then a new
item was selected by a family member for practice
during the following week.
Table 2 shows the initial reading rate of each item
at the beginning of the week and the final reading
rate that was accomplished at the end of each week.
The patient was seen again in August 2000 after 6
weeks of practice, at which time the reading rate of
novel material had not yet improved. However,
G.B. was able to achieve reading rates of up to 100
words per minute at the end of a week of practicing
and reported improved reading comprehension of
the items. It was decided to continue with the MOR
program. Because G.B. was compliant with all
aspects of the treatment, he was only required to
tape record the first and last reading of the week for
submission to the investigator.
After an additional 10 weeks, G.B. was re-evaluated in December 2000. He reported that his
understanding of each new reading item had
improved; he understood more of it the first time
he read it. He also reported that he was able to
achieve a faster reading rate much sooner, after
just 2 or 3 days of practice. Reading rate of practiced text had increased to a maximum of 156
words per minute (normal oral reading rate is
approximately 150–200 words per minute).
During the assessment, reading rate of novel text
had improved to 44 words per minute. The readTable 2. Initial and final weekly reading rates
obtained by G.B. during independent MOR practice
Week no.
7 – Reevaluation
18 – Reevaluation
Initial reading rate
Final reading rate
No tape submitted
No tape submitted (Thanksgiving)
Aphasia, Alexia, & Oral Reading
ing comprehension test (Gates-MacGinitie, Level
D, 1978)76 was readministered and G.B. achieved
a grade equivalent of 5.0. It should be noted that
this is a timed test, and G.B. completed only 25
items of the total 43 items. For the items that he
did complete, comprehension was high (96%
accuracy). This test also offers a multiple-choice
vocabulary test. For the vocabulary items, G.B.
scored at a grade equivalency of 11.9. It was suggested that G.B. continue with the oral reading
program on his own, but no further follow-up was
scheduled because G.B. had moved out of state.
Oral reading for language in aphasia (ORLA)
V.P., a 39-year-old female, was evaluated in May
2003, more than 13 years after suffering a stroke
during emergency surgery for a chronic gastrointestinal disorder. At the time of this evaluation, she
presented with a moderate Broca’s aphasia and
achieved an Aphasia Quotient of 62.8 on the
Western Aphasia Battery.32 Additional testing
included the reading and writing subtests of the
Western Aphasia Battery and selected subtests of
the Reading Comprehension Battery for
Aphasia–2.34 Spontaneous language samples were
obtained using two composite pictures and two
picture sequences, and these were scored for
Correct Information Units.77 These assessment
results are included in Table 3.
Oral reading of word lists from the Battery of
Adult Reading Function was also completed.41 V.P.
was unable to read aloud any nonwords. She read
regular words, rule-governed words, and irregular
words with 46%, 40%, and 36% accuracy, respectively. Errors were primarily semantic and morphological. She achieved 88% on a homonym–picture
matching task, but only 38% on pseudohomonym–picture matching. Finally, she read a list
of content words with 73% accuracy and a list of
function words with 30% accuracy. These results
are consistent with the presence of a deep alexia.
The ORLA treatment was initiated, with V.P.
attending a total of 24 one-hour treatment sessions
over 7 weeks. Three groups of sentences, each with
30 sentences, were used. During the first 10 sessions, V.P. practiced Group 1 sentences that were
three to five words in length. From sessions 11–24,
Table 3. Pre- and posttreatment test scores of V.P.
WAB: Reading
WAB: Writing
RCBA-2: Functional reading
RCBA-2: Paragraph-picture
RCBA-2: Paragraph factual
RCBA-2: Paragraph inferential
% CIU – Composite picture 1
% CIU – Composite picture 2
% CIU – Sequenced picture 1
% CIU – Sequenced picture 2
Note: WAB = Western Aphasia Battery; AQ = Aphasia Quotient;
RCBA = Reading Comprehension Battery for Aphasia; CIU = Correct
Information Units.
Group 2 sentences (i.e., stimuli that were 8 to10
words in length) were trained. Group 3 sentences
were an untrained set with three- to five-word sentences. Daily oral reading probes of 10 randomly
selected sentences from each of the groups were
taken at the beginning of each treatment session.
Figure 6 displays oral reading accuracy achieved
on the probes during baseline and throughout
treatment. It can be seen that accuracy on Group 1
sentences increased from a baseline score of about
60% to 90% after 10 sessions. Performance on
Group 2 sentences varied from 58% to 68% during
the first 10 sessions when she was not treated, and
then improved to 84% during treatment. Some
improvement in the accuracy of the untreated
Group 3 sentences was evident but performance
was variable between 68% and 78%. These results
indicate that ORLA treatment is effective in
improving oral reading of trained sentences.
A reevaluation was conducted at the end of
treatment and results are shown in Table 3. It can
be seen that improvements were made in reading
comprehension, as measured by the RCBA-2 and
the reading subtests of the WAB. Cross-modal
generalization was also evident. The WAB AQ,
which measures auditory comprehension and oral
expression, improved almost 5 points; CIU analysis indicated improvements in V.P.’s ability to
describe pictures; and some improvements on the
writing subtest of the WAB were also noted.
These results indicate that, for V.P., an individual
with chronic aphasia and deep alexia, ORLA was
Percent Accuracy
Group 1
Group 2
Group 3
Figure 6. Daily oral reading probes for V. P. Arrows indicate the beginning of treatment of each group of
sentences. Sessions 1-3: baseline; Sessions 4-12: treatment – Group 1 (3- to 5-word sentences); Sessions
13-24: treatment – Group 2 (8- to 10-word sentences).
effective in improving not only oral reading of sentences but also reading comprehension. In addition, generalized improvement to other language
modalities resulted from the ORLA treatment.
This article has presented an overview of the
acquired alexias, including classification, assessment, and treatment. The alexia therapies are idiosyncratic and are frequently highly individualized
by the treating clinician to conform to a particular
patient’s unique combination of deficits and residual capabilities. As a result, few therapy approaches have been sufficiently defined and critically
evaluated with large numbers of patients. Yet, several studies have suggested that oral reading, particularly oral reading of connected text, may be an
effective treatment mode. Two examples of how
oral reading of connected text has been successfully used to treat acquired alexia have been provided. The rationale for using such an approach is
derived from the neuropsychological models of
normal reading and acquired alexias. Repeated
reading aloud, particularly when done in unison
with another individual, seems to provide practice
primarily in grapheme-phoneme decoding. In
addition, oral reading may strengthen partial or
degraded lexical information, thereby positively
impacting other language modalities. Additional
studies with larger numbers of participants,
detailed description of the specific reading problems, careful administration of the selected treatment, and frequent measurement of the patients’
response to treatment will help elucidate our
understanding of the acquired alexias.
The preparation of this manuscript was supported by grant H133G010098 from the National
Institute on Disability and Rehabilitation Research,
US Department of Education. The author gratefully acknowledges the participation of G.B. and V.P.
and extends thanks to Edna Babbitt and Jodi
Oldani for their assessment and treatment of V.P.
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