Outline What is letter-by-letter (LBL) reading? How do you assess for LBL reading? Treatment approaches for LBL reading Acquired Alexia: Understanding the Nature and Treatment of Letter-by-Letter Reading Multiple Oral Rereading (MOR) Case examples Discussion of treatment candidacy Esther Kim, Ph.D., CCC-SLP1 Kindle Rising, M.S., CCC-SLP1 Steven Rapcsak, M.D.2 Pélagie Beeson, Ph.D., CCC-SLP1,2 1Department of Speech, Language and Hearing Sciences of Neurology University of Arizona 2Department Alexia Profiles What is Alexia? Global Alexia Severely Alexia is an acquired impairment of reading There can be different alexia profiles in individuals with stroke Understanding the nature of the reading impairment informs our treatment impaired reading; Often associated with severely impaired spoken language (global aphasia) Deep Alexia Phonological Alexia hallmark lexicality is semantic errors in reading single words effect (reads words > nonwords) with left MCA stroke associated Surface Alexia regularity effect (reads regular words > irregular words) with left PCA stroke Associated A Cognitive Model of Written Language “apple” apple Acoustic Analysis Visual Analysis Pure Alexia apple A Cognitive Model of Reading Visual Analysis Semantics Phonology Orthography Phonology Speech Motor Programs Graphic Motor Programs Speech Motor Programs “apple” after Beeson & Hillis, 2001 Semantics apple “apple” after Beeson & Hillis, 2001 Orthography Impaired access to orthographic lexicon Pure Alexia apple Alexia without Agraphia Letter-by-Letter (LBL) Reading Visual Analysis Semantics Letter naming a-p-p-l-e Phonologic Lexicon Orthographic Lexicon Phonemes Graphemes Pure Alexia Letter-byLetter Reading “a-p-p-l-e …apple” Visual input cannot access spelling knowledge Sometimes pure alexia is not so pure... Sequential letter identification (aloud/subvocal) Word length effect Slow rate for text reading No other effects of word type in reading Preserved recognition of oral spelling Speech Motor Programs Characteristic Features Other clinical features: May have right homonymous hemianopia Spoken language profile consistent with anomic aphasia Lesion associated with LBL Reading May see surface errors in reading Regularity effect (regular words > irregular words) Phonologically plausible errors May be letter identification errors Often accompanied by surface agraphia profile Assessment of LBL Reading Reading Single word level Word length effects Text level Recognition of oral spelling Visual orthography Letter Visual identification lexical decision tasks PCA stroke: Left inferior temporo-occipital lesion R L Single Word Reading Arizona Battery for Reading and Spelling regular, 40 irregular words (balanced for length, frequency, imageability), 20 pronounceable nonwords 40 Regular Words broom mile spring branch hunch fact slate Irregular Words yacht circuit doubt choir sword island debt Nonwords flig hoach snite glope boak cheed merber Word Length Effects Text Reading 40 words at 4, 5, 6 and 7 letters (balanced for regularity, frequency) presented via computer calculate reaction time measures of reading rate (words per minute) and error rate (per 100 words) comprehension questions (5 m/c questions) 2 matched forms (Form A and Form B) Word Length List RT 6000 RT (msec) Additional passages 100 words each, 2 levels of difficulty and Keys” ~ easier passage “Petra” ~ more challenging passage 5000 Word length effect Gray Oral Reading Test-3 (Wiederholt & Bryant, 1992) 4 letters 4000 “Locks 5 letters 3000 6 letters 2000 7 letters 1000 0 Ctrl PCA Visual Orthography Letter Identification PALPA 22 Psycholinguistic Assessment of Language Processing in Aphasia (Kay, Lesser & Coltheart, 1992) Visual Lexical Decision PALPA 24 – Words/Illegal Nonwords 25 – Imageability/Frequency PALPA 27 – Spelling/Sound Regularity Orthographic Choice Task PALPA Treatment Approaches for LBL Reading Word-level approaches Rapid presentation treatment (Rothi & Moss, 1992) treatment (Lott & Friedman, 1999) Tactile-kinesthetic Text-level approaches Multiple Oral Rereading (MOR; Moyer, 1979) Multiple Oral Rereading (MOR) Goal: Increase reading rate and accuracy for novel text Rationale: Semantic and syntactic context of text provides top-down facilitation of whole-word recognition Expected Response to MOR Tx No Tx Treatment 80 7% rate Words per Minute 60 5% 4% 40 3% 30 2% 20 Has resulted in improved reading of practiced and new material (Beeson, 1998; Beeson & Insalaco, 1998; Beeson et 10 1% 0 0% errors 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 28 29 30 31 32 33 37 38 39 40 46 47 48 49 47 52 54 rate 6% 50 errors per 100 words errors 70 al., 2005; Tuomainen & Laine, 1991) Weeks Post Onset Beeson, Magloire, & Robey (2005). Behavioural Neurology. Multiple Oral Rereading Spelling and Grammar Reading Materials Text passages from Scientific Research Associates Reading Laboratory (SRA, 1978) Controlled for length and complexity Reading levels range from grade 1 to grade 6 Most content is interesting and appropriate for adult readers Other passages can be used Higher level reading passages or personally relevant text Choose passages of ~ 200-500 words for practice Determine reading level using Microsoft Word Flesch-Kincaid grade level Therapy Sessions Collect reading rate and accuracy data Baseline: Three sessions prior to starting treatment Probes on novel text at the beginning of each session Calculating reading rate and accuracy: Rate (words per minute) = (#words/#seconds) x 60 sec/min Accuracy (errors per 100 words) = (#errors/#words) x 100 Therapy Sessions Examining MOR Repeated oral reading of text. Clinician points out errors and provides assistance with difficult words or passages. Daily homework is key! Implemented with 4 individuals with acquired alexia due to left hemisphere damage all complained of slow, effortful reading Oral reading of practice text at least 3-5 times per day Homework log for accountability P1 P1 Treatment RT (msec) P1 Word Length List RT 1200 1000 800 600 400 200 0 4 letters 5 letters 6 letters 7 letters Ctrl P1 pre 79 y o male 18 years education Anomic aphasia WAB AQ: 95.0 BNT: 32/60 Single Word Reading Accuracy – 97% Visual Orthography Composite – 99% Approximately Grade 12-13 Text: Smithsonian Magazine articles Practice Text: A biography of Winston Churchill Novel Treatment goal was 100 words/minute on high level text Concurrent spelling treatment L Practice Text R P1 Response to MOR Tx 130 120 110 P1 Pre-Post GORT-3 P1 GORT-R Reading Rate 200 100 90 80 70 Practiced Text 60 50 1 2 3 4 5 6 7 8 9 10 Rate (wpm) Reading Rate: WPM Hour long therapy sessions 2 x week for 6 weeks Reading Passages 150 Pre 100 Post Reading Rate (wpm) 50 11 0 Session Levels 1-6 Levels 7-11 Novel Text P1 GORT-R Reading Accuracy 10 120 110 100 90 80 70 60 50 40 30 20 10 0 6 8 wpm 4 errors/100 wds 5 # errors 6 2 4 Pre 3 Post 2 1 0 1B 2B 3B 4 5 6 7 8 Session 9 10 11 12 13 Novel Text 0 Levels 1-6 Levels 7-11 Error Rate (per 100 words) P1 Pre-Post Reading Reaction Time P2 P2 Word Length List RT P1 Word Length List RT 1800 1600 1400 RT (msec) 1000 4 letters 800 6 letters 400 5 letters 6 letters 7 letters 400 200 0 5 letters 600 80 y o female 12 years education Anomic aphasia WAB AQ: 90.4 BNT: 30/60 4 letters 1200 1000 800 600 RT (msec) 1200 Ctrl P2 pre 7 letters 200 0 Ctrl P1 pre P1 post Single Word Reading Accuracy – 95% Visual Orthography Composite – 99% R L 110 100 Hour long therapy sessions 2 x week for 6 weeks Reading Passages SRA Reading Rate: WPM 90 80 70 60 50 40 30 Practiced Text 20 10 0 1 2 3 4 P2 Pre-Post GORT-3 7 8 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Rate (wpm) 60 Reading Rate (wpm) 40 20 12 13 8 7 wpm 6 errors/100 wds 5 4 3 2 Novel Text 1 0 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 P2 Text Reading Locks and Keys (2nd grade level) Petra (12th grade level) Rate (wpm) Error rate (per 100wd) Rate (wpm) Error rate (per 100wd) Pre-Tx 111 0 42 4 Post-Tx 136 0 70 1 Controls ~200 0 ~140 0 100 Post 11 9 120 Pre 10 10 140 80 9 Session 1 P2 GORT-R Reading Rate 6 Novel Text 4.5-6.0 grade level passages levels 4.5-6.0 Goal: 100 words/minute Concurrent spelling treatment 5 0 Levels 1-6 Levels 7-9 P2 GORT-R Error Rate 4 3.5 # errors 3 2.5 Pre 2 Post 1.5 1 0.5 0 Levels 1-6 Levels 7-9 Error Rate (per 100 words) R P2 Response to MOR Tx Practice Text P2 Treatment L P3 P2 Pre-Post Reading Reaction Time P3 Word Length List RT P2 Word Length List RT RT (msec) 1600 1400 1200 4 letters 1000 5 letters 800 6 letters 600 400 RT (msec) 1800 3500 3000 2500 2000 1500 1000 500 0 76 y o male 14 years education Anomic aphasia WAB AQ: 91.4 BNT: 50/60 4 letters 5 letters 6 letters 7 letters Ctrl 7 letters P3 pre 200 0 Ctrl P2 pre P2 post Single Word Reading Accuracy – 96% Visual Orthography Composite – 95% L Practice Text 90 Hour long therapy sessions 2 x week for 6 weeks Reading Passages Reading Rate: WPM 80 L 70 60 50 40 30 20 Practiced Text 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Session Novel Text Novel text: SRA passages levels 2.5-3.0 text: Magazine passages of his choosing Practice Goal: 100 words/minute for easy text Concurrent spelling treatment 100 90 80 70 60 50 40 30 20 10 0 10 9 8 7 6 5 4 3 2 1 0 wpm errors/100 wds Novel Text 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 P3 Pre-Post GORT-3 P3 Text Reading Rate (wpm) Error rate (per 100wd) Rate (wpm) Error rate (per 100wd) 51.6 4 28.8 8 Post-Tx 92.3 3 50 8 Controls ~200 0 ~140 0 90 80 70 60 50 40 30 20 10 0 Pre Post Levels 1-6 Reading Rate (wpm) Levels 7-8 P3 GORT-R Error Rate 6 5 # errors Pre-Tx Petra (12th grade level) Rate (wpm) P3 GORT-R Reading Rate Locks and Keys (2nd grade level) 4 Pre 3 Post 2 1 0 Levels 1-6 R P3 Response to MOR Tx 100 P3 Treatment R Levels 7-8 Error Rate (per 100 words) P3 Pre-Post Reading Reaction Time P4 P4 Word Length List RT P3 Pre-Post Word Length List RT 58 y o male 14 years education Minimally aphasic WAB AQ: 98.8 BNT: 58/60 1200 3500 1000 2500 4 letters 2000 5 letters 1500 6 letters 1000 7 letters 4 letters 800 RT (msec) RT (msec) 3000 5 letters 600 6 letters 400 7 letters 200 0 Ctrl P4 500 Single Word Reading Accuracy – 92% Visual Orthography Composite – 93% 0 Ctrl P3 pre P3 post R L P4 Response to MOR Tx Practice Te xt P4 Treatment 120 Hour long therapy sessions 2 x week for 6 weeks Reading Passages SRA Reading Rate: WPM 110 100 90 80 70 Practiced Text 60 50 1 2 3 4 5 6 7 8 10 11 12 13 Session Novel Text passages 4.0-6.0 Goal: 100 words/minute Concurrent spelling treatment 100 10 90 9 80 8 70 7 60 6 50 5 40 4 30 3 20 2 10 Novel Text 0 1 P4 Pre-Post GORT-3 wpm errors/100 wds 1 0 P4 GORT-R Reading Rate 9 2 3 4 5 6 7 8 9 10 11 12 P4 Pre-Post Reading Reaction Time 120 P4 Word Length List RT Rate (wpm) 100 80 Pre 60 Post 40 1200 Reading Rate (wpm) 1000 RT (msec) 20 0 Levels 1-6 Levels 7-9 P4 GORT-R Error Rate 5 letters 600 6 letters 400 7 letters 200 6 5 # errors 4 letters 800 0 4 Pre 3 Post 2 1 0 Levels 1-6 Levels 7-9 Error Rate (per 100 words) Ctrl P4 pre P4 post Candidacy for MOR Candidacy for MOR Relatively preserved visual perception of orthography single word reading accuracy letter identification (naming) P1 100% 99% P2 95% 100% 99% P3 96% 100% 94% P4 92% 100% 91% 8 2 0 4 5 6 7 8 9 10 11 12 13 Novel Text 4.5-6.0 grade level 130 120 110 100 90 80 70 60 50 40 30 20 10 0 10 9 3000 2500 4 letters 2000 5 letters 1500 6 letters 1000 7 letters Ctrl P1 P2 P3 P2 8 7 wpm 6 errors/100 wds 5 4 3 2 1 0 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 Nove l Te xt 3500 0 P4 100 90 80 70 60 50 40 30 20 10 0 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 P3 wpm errors/100 wds 9 10 11 12 13 14 15 16 17 Nove l Te xt 100 10 90 9 80 8 70 7 60 6 50 40 5 4 30 3 20 2 10 1 0 0 1 2 3 4 5 6 7 8 9 10 11 P4 wpm errors/100 wds 12 Acknowledgment X XX X XX P1 P2 P3 X XX X X errors/100 wds 4 1B 2B 3B 500 Positive Views of Treatment wpm 6 Word Length List - RT determined by visual lexical decision tasks P1 10 1 Relatively preserved orthographic lexicon as 99% Letter ID 120 110 100 90 80 70 60 50 40 30 20 10 0 Vis Ortho Se ssion RT (msec) Novel Text Wd Read X P4 This work was supported by Grants RO1DC007646 & RO1DC008286 from the National Institute on Deafness and Other Communication Disorders