Oral Reading for Language in Aphasia: Impactof Aphasia Severity on Cross-Modal Outcomes in Chronic Nonfluent Aphasia Leora R. Cherney, Ph.D., CCC-SLP1,2 This study examined the efficacy of a treatment, Oral Reading for Language in Aphasia (ORLA), for individuals with chronic nonfluent aphasia of varying severity levels. With ORLA, the person with aphasia systematically and repeatedly reads sentences aloud, first in unison with the clinician and then independently. Following a period of no treatment, 25 individuals with chronic nonfluent aphasia received 24 sessions of ORLA, 1 to 3 times per week. A small, but significant mean change in the Western Aphasia Battery (WAB) Aphasia Quotient (AQ) was obtained from pre- to post-treatment. When subjects were divided by severity, medium effect sizes were obtained for all severity levels from pre- to post-treatment for the WAB AQ. Medium effect sizes were obtained for the severe aphasia group on the WAB reading subtests only, for the moderate aphasia group on the discourse measures only, and for the mild to moderate aphasia group on both the discourse and WAB writing subtests. Although more intensive therapy is preferred, individuals with chronic nonfluent aphasia may improve their language skills with low-intensity ORLA treatment, and differences in modality-specific outcomes may be anticipated based on the severity of the aphasia. KEYWORDS: Aphasia, rehabilitation, language therapy, reading Learning Outcomes: As a result of this activity, the reader will be able to (1) describe the procedures of ORLA (Oral Reading for Language in Aphasia), and (2) discuss potential outcomes of ORLA based on the severity of the aphasia. 1 Director, Center for Aphasia Research and Treatment, Rehabilitation Institute of Chicago, and 2Professor, Physical Medicine and Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago, Illinois. Address for correspondence and reprint requests: Leora R. Cherney, Ph.D., CCC-SLP, Rehabilitation Institute of Chicago, 345 East Superior Street, Chicago, IL 60611 (e-mail:
[email protected]). 42 Treatment of Chronic Aphasia: International Perspectives; Guest Editor, Chris Code, Ph.D. Semin Speech Lang 2010;31:42–51. Copyright # 2010 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662. DOI: http://dx.doi.org/10.1055/s-0029-1244952. ISSN 0734-0478. Downloaded by: Dot. Lib Information. Copyrighted material. ABSTRACT For example. Lib Information.to 5-word sentences at a first-grade reading level Level 2: 8 to 12 words that may be single sentences or two short sentences.8 The technique may be efficacious because it incorporates three elements—rhythm.to six-sentence simple paragraph. Copyrighted material. including written expression.2. improvements in these modalities would typically be expected. and rate for speech production. the person with aphasia systematically and repeatedly reads sentences and paragraphs aloud.11.7 Lowintensity treatment was defined as 1 hour of treatment. first in unison with the clinician. Their verbal responses are not overtly corrected but are followed by additional multimodality stimulation. auditory comprehension. at a third grade reading level Level 3: 15 to 30 words.4. Oral Reading for Language in Aphasia (ORLA). may help facilitate the patient’s temporal flow and articulatory rate of speech. also at a sixth grade reading level Although the graded nature of ORLA makes it appropriate for individuals with a broad range of aphasia severities. little data are available on the differential effects of ORLA based on severity of aphasia. ORLA was initially developed to improve reading comprehension in individuals with aphasia by providing practice in the phonological and semantic reading routes.12 With repeated practice in auditory comprehension and oral expression. one to three times a week—a treatment schedule that is typical of aphasia outpatient therapy in the United States. With ORLA. pacing.1–3 Recently.14 The patient’s paced pointing to each word of the sentence. divided into two to three sentences. and linguistic templates—that contribute to establishing an underlying oscillatory rhythm. and written expression have been seen in both fluent and nonfluent aphasia.7 However. even months and years beyond the time of onset. but extends to language processing by other modalities as well. The purpose of this article is to present the results of a study in which an aphasia treatment. 43 Downloaded by: Dot. ORLA allows practice on a variety of grammatical structures rather than just one specific grammatical form. and easily administered to individuals with chronic aphasia. Participants see a written sentence and.5 Yet. at a sixth grade reading level Level 4: 50 to 100 words comprising a four. melody. together with the linguistic template and natural rhythms and intonation provided by the clinician. hear it and attempt to say it.R esearch has shown that individuals with aphasia benefit from a variety of different treatments. By focusing on connected discourse. Others suggest that the interactive processing during oral reading also serves to strengthen partial or degraded lexical information. Improvements in oral expression.13 Additionally. Details of the ORLA procedure are described in the Appendix. at the same time. preliminary studies with a small number of subjects have shown that improvements may occur in other modalities aside from reading comprehension. ORLA incorporates repetitive multimodality stimulation and practice to elicit a response. Based on neuropsychological models of reading. There is a need to identify treatments that are appropriate. efficacious even when provided at low intensity. It has four levels of difficulty based on length and reading level: Level 1: Simple 3. was provided at low intensity to participants with chronic nonfluent aphasia.6. ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY . In fact.6. so that the benefit is not only at the level of the orthographic input lexicon. emphasis has been put on the need for intensive aphasia treatment to make the long-term neuroplastic changes associated with recovery and rehabilitation following a stroke. and these may be related to specific features of the ORLA technique.6–10 Several explanations for the cross-modal generalization have been suggested. and the costs of communication treatment delivered to patients with chronic aphasia (beyond 12 months after onset) are often not reimbursable. patients may be eligible for only a limited number of treatment sessions following their acute hospitalization. such treatment is not always available. and then independently. ORLA has been shown to be an efficacious approach for treating apraxia of speech in two patients with Broca’s aphasia. Words may be content words (e. AQ range for the 6 severe subjects was 9. The speech-language pathologist reads aloud to the patient again.g. AQ range for the 9 subjects in the moderate group was 49. premorbidly right-handed. Twenty-five individuals (16 men.7 (mean. Study Design A delayed treatment design was used. and AQ range for the 10 subjects with mild to moderate aphasia was 66 to 81. All partic- ipants provided written. Specifically. 2. we ask the following questions for chronic nonfluent aphasia: Does low-intensity ORLA treatment result in language changes? Are these changes greater than what occurs without any treatment? If so. 13. prepositions.5 (mean. 76. The purpose of this study was to examine the efficacy of low-intensity ORLA for individuals with chronic nonfluent aphasia and how severity of aphasia may impact changes in the various language modalities. reading a little ahead of the patient so he or she is able to hear the initial phonemes of the words. auditory acuity no worse than 30 dB HL at 500. Copyrighted material. Eligibility criteria included the following: a single left-hemisphere stroke as determined by history and physician report. standard deviation [SD].. pointing to each word as he or she reads along. aided in the better ear.SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31. SD. The length of the material may vary from 3 to 100 words. pointing to each word as he or she reads along and encouraging the patient to also point to each word. which allowed all subjects to receive treatment following a period of no treatment. 4. The clinician adjusts the rate and volume of the oral reading according to the specific patient (e. decreasing volume as the patient requires fewer cues). 44 . The speech-language pathologist reads the paragraph aloud together with the patient. 54. The speech-language pathologist reads aloud to the patient. The patient also points to each word. SD. the speech-language pathologist points to a word for the patient to read aloud. visual acuity no worse than 20/100 corrected in the better eye. 9 women) with chronic nonfluent aphasia (more than 12 months post-onset) met the inclusion and exclusion criteria. 3. Additional demographic details can be found in Table 1. SD.4 to 60. the speech-language pathologist states a word that the patient must then identify. 5.7 to 21. rather.. pronouns. conjunctions). NUMBER 1 2010 Appendix: Oral Reading for Language in Aphasia (ORLA) 1. consecutive eligible subjects were recruited into the study and the determination of groups was based on the way in which the aphasia severities naturally clustered together.74. 1000. 5.g.g.97). When subjects were divided into three groups based on severity. do modality-specific improvements vary according to the severity of the aphasia? METHODS Participants Participants with chronic aphasia (more than 12 months post-onset) who met the inclusion and exclusion criteria of the study were recruited. 25. For each line or sentence of the paragraph..34) for the entire group. The patient reads the whole sentence aloud again in unison with the speech-language pathologist. informed consent under the approval of the Northwestern University Institutional Review Board.74. Severity of the aphasia. nonfluent aphasia (but not global aphasia). 3. as determined by the Aphasia Quotient (AQ) of the Western Aphasia Battery (WAB).84. Lib Information.7 to 81. ranged from 9.56). verbs) or function words (e. while continuing to point to each word as he or she reads along.5 (mean. 3. at least a 12th grade education. It was not necessarily intended that groups should be equivalent on key variables such as age and chronicity. and 2000 Hz. 6.73. 53. depending on the auditory comprehension skills of the patient.1 (mean. Subjects’ Downloaded by: Dot. For each line or sentence of the paragraph.53). nouns. Both content and function words are selected. 00 (0.72) 20.50) Pretreatment 7.35 (17.0) Post-treatment 7.16) Discourse wds/min Picture description Baseline 9.03) WAB writing Baseline 8.39 (10.65) 39.90) 44.07) 31.79) Range 50.00) Discourse wds/min Narrative Baseline 5.75 (4.89 (23.85 (19.59) 25.61 (13.49 (16.49) 39.16–138.61) 88.89) 55.31 (17.60 (33) 32. Reading Comprehension Battery for Aphasia.10) 33.44 (8.21–80.86) 12.14) Pretreatment 7.56) 77. Lib Information.90 (20.44 (19.81) 31.18 (12.12) 31.65) 41.44 (15.08) 75. Copyrighted material.00 (13.67) 28.27) 35.34 (5. Aphasia Quotient.36–71.50 (6.70 (20.71) 61.99) 12.97 Age at Baseline testing (years) Mean (SD) 69.63 (6.51) 10.11) 65.54 (10.78 (10.80 (9.74 (3.33 (6.29) Post-treatment 33.11 (0.60) 17.56 57.06) WAB reading Baseline 29.15 (21.36) 33.50 (16.03 71.10) 11.91) 45.56 (17.63) 34.19 (0.00) Pretreatment 0.39) Pretreatment 10.46) 39.94) Pretreatment 26.84) 32.46) Moderate Aphasia (AQ ¼ 45–65) Mild-to-Moderate Aphasia (AQ 66–85) 9 5:4 10 9:1 51.37 (4. and Mild to Moderate Chronic Aphasia .89 (18.00 (0.54 (12.73 (15.00 (0.18–71. SD. Table 1 Demographic Information and Test Scores (Mean and SD) for Subjects with Severe.64 54.84) 10.96 (10.17 (4.36) 32.93 (13.05 (18. RCBA.00 (10.21 47.34 (43.17) Post-treatment 11.06–79.55 (8.65 WAB AQ Baseline 13. Western Aphasia Battery.66) 17.20–78.47) Post-treatment 12.95 54.34) 38.06) RCBA–4 subtests Baseline 6.75) Pretreatment 6.11 (13.48 (5.36) 79.42 (6. wds.00) Post-treatment 0.65 (18.53) 54.62 (17.22 (17.17 (6.40 (9.28) Range 56.97) Pretreatment 15.50 (4.95–64.22) 69.00) Pretreatment 0.75) 57.64) 55.13) Range 12.49) 58.76 (23.78) Discourse CIUs/min Narrative Baseline 0.41) 87.91 (6. WAB.ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY 45 Severe Aphasia (AQ <25) Number of subjects 6 Males:Females 2:4 Age at stroke onset (years) Mean (SD) 66.36 Months post-onset Mean (SD) 31.74) 35.12 (11.58 (7.90 (9.10 (4.84 (5.75 (16.99) 69.83 (14.59 (9.48) 44.33 (11.32) 15.61) Post-treatment 7. words.00 (0.28 (14.90 (9.93 (21.89 (15.16–253. Downloaded by: Dot.78) Post-treatment 18.93) 85.22 (10.74) 47.38) 12.17 (9.78 (20. CIUs.00 (6. standard deviation.96) 10.13) 26.22–81.82 (17.93) 76.69) Discourse CIUs/min Picture description Baseline 0.88) 24.98 (24.19 (22. Moderate.83 (83.37) 31.60 (15.52) AQ.60 50.52) 26.73 (3.27) Post-treatment 0.83 (14. correct information units.90 (9.73 (4. All subjects received the same number of sessions. d ¼ 0. unexpected issues such as transportation difficulties or unplanned outof-town trips sometimes arose. Stimuli were sentences of varied vocabulary items and grammatical structures. unlike significance testing.to 5-word sentences. At each evaluation.18 Cohen’s d and the effect-size correlation rYl were calculated using the original means and SDs of the two dependent groups. two to three times a week. The RCBA-2 subtests included paragraph-level reading (paragraph-picture. Lib Information. paragraph-inferential) as well as functional reading.to 30-word brief paragraphs) predetermined by their language level. is independent of sample size. this was repeated twice. and one subject attending as many as four times a week. 15.to 12-word sentences. scheduled two to three times a week. (2) Subjects attempted to read the sentence aloud together with the therapist.16 and several discourse measures. Intervention Subjects participated in 24 1-hour sessions of ORLA treatment.19 A positive effect size represents improvement. Means and SDs of each test score were calculated at each assessment period for each of the three severity levels. subjects were assessed using the WAB.17 The elicited discourse samples were analyzed for rate of speech (words per minute) and informational content (correct information units [CIUs] per minute). subjects were asked to identify two or three randomly selected single words and read each word aloud. medium. 2010 subjects typically practiced 30 different stimuli of a specific length (3. The speech-language pathologist who conducted the assessments was independent of the clinician who provided the ORLA treatment. the subject read the entire stimulus aloud again in unison with the therapist. Effect size measures the magnitude of a treatment effect and. (3) For each sentence.18 RESULTS Intervention Period Subjects were scheduled to receive 24 1-hour sessions of ORLA. During an hour of treatment. d ¼ 0. the second time. effect size measures were computed.SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31. paragraph-factual.8. they also pointed to each word of the sentence. with some patients attending only once per week.2. 90 stimuli at each length were available for practice. Outcomes For all 25 individuals with nonfluent aphasia. Data Analysis Because we were interested in how ORLA impacts individuals with aphasia of different severity levels. and large. The effect sizes were benchmarked against Cohen’s (1988) definition of effect size as: small. The mean length of the treatment period was 12. presented with natural speech prosody. the planned treatment period varied from 8 to 12 weeks. Therefore the treatment periods varied. (4) Finally. Because of the relatively small number of subjects within each severity level. Treatment was as follows: (1) Subjects listened to a sentence twice. Subjects did not receive any other individual or group treatment while they were participating in this study. d ¼ 0. 8. Discourse tasks included descriptions of two composite pictures and two narratives based on a series of picture sequences.62 weeks (range of 6 to 22 weeks). The change in scores from baseline to pretreatment compared with the change in scores from pretreatment to posttreatment provides an index of the efficacy of the ORLA treatment. NUMBER 1 outcomes were measured at three separate time periods: (1) at entry into the study (baseline). However. therefore. (3) at the end of the intervention (post-treatment). (2) after the no-treatment period of 7 to 12 weeks and before the start of the intervention (pretreatment). Over 24 sessions. 46 . subjects were divided into three severity levels based on their score on the WAB AQ. the mean change in AQ test scores (the primary Downloaded by: Dot.15 four subtests of the Reading Comprehension Battery for Aphasia (RCBA2). Copyrighted material.5. while simultaneously looking at it written on an index card or computer screen. and a negative effect size represents a ‘‘worsening’’ of symptoms. 132 0.474 0.015 0.47) in the WAB AQ from baseline to post-treatment (P < 0.016 0.019 0.084 0.008 0.559 0.455 0. Copyrighted material.032 0.247 0.058 0.345 0.494 0.001).130 0.226 0. WAB.246 0. whereas the change during the notreatment period from baseline to pretreatment was not significant. Aphasia Quotient.112 0.029 0.170 0.035 0.159 0.85 (3.5) in the 8. Table 2 shows the corresponding effect size (d) and effect-size correlation (rYl) that was calculated between baseline and pretreatment and between pretreatment and post-treatment. the WAB AQ.222 0. None of the effect sizes were large.248 Cannot be computed 0.240 0.066 0. and posttreatment) for each aphasia severity level. 5.157 0.212 0.to post-treatment WAB Writing Baseline to pretreatment Pre. as well as the mean and SD obtained for 47 .576 0. the change in WAB AQ from pretreatment to post-treatment was significant (P < 0. Reading Comprehension Battery for Aphasia. Table 2 Cohen’s d and the Effect-Size Correlation (rYl) for the No-Treatment and Treatment Periods for Each Severity Group Severe Aphasia (AQ <25) Number of subjects WAB AQ Baseline to pretreatment Pre.188 0.016 0.044 0.265 0. Western Aphasia Battery.to post-treatment RCBA–4 subtests Baseline to pretreatment Pre.069 Medium effect sizes are in boldface. there was a significant mean change of 3.079 0.139 0.062 0.512 0. several effect sizes indicating improvements from pretreatment to post-treatment could be benchmarked as medium.331 0.115 0.379 0.389 0.382 0.122 0. AQ.066 0.to 12-week pretreatment interval.077 0. pretreatment.185 0. Downloaded by: Dot. however.066 0.243 0.197 0.270 0.to post-treatment was 2.021 0.to post-treatment Discourse wds/min Narrative Baseline to pretreatment Pre. RCBA.038 0.065 0.105 0.007 0. Table 1 presents additional demographic data.163 0.014 0.186 0.3) compared with a mean change of 0.231 0.017 0. CIUs.159 0. Although these differences were small.158 0.088 0.132 0.191 0.to post-treatment 6 Moderate Aphasia (AQ ¼ 45–65) 9 Mild to Moderate Aphasia (AQ ¼ 66–85) 10 0. Furthermore.123 0.560 0. Medium effect sizes were obtained for all severity levels from pre.032 0.009 0.014 0.154 0. outcome measure) from pre.376 0.ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY each evaluation task completed at each assessment time (baseline.118 0.032 0.132 0.to post-treatment Discourse CIUs/min Narrative Baseline to pretreatment Pre.to post-treatment WAB Reading Baseline to pretreatment Pre.169 0.38 (SD.501 0.05). 4.to post-treatment Discourse CIUs/min Picture description Baseline to pretreatment Pre.033 0. Lib Information. correct information units.277 0.to post-treatment for the primary outcome measure.24 (SD.009 0.098 0.028 0.263 0.to post-treatment Discourse wds/min Picture description Baseline to pretreatment Pre.078 0.269 0.011 0.076 0.320 0.321 0.122 0.057 0. results are consistent with those of a meta-analysis of 55 aphasia treatment studies. Of these subjects. these seven subjects were all men with ages varying between 35 and 69 years. examination of individual subject data indicated that 7 of the 25 did make a greater than 5-point change.38 obtained for the entire group of 25 participants certainly does not reach this target change. a medium effect size was obtained only for the severe aphasia group. In contrast. research is indicating that more intense treatment results in better outcomes.9 weeks. with no obvious trend for greater improvement with more intensive treatment. The greatest effect size (d ¼ 0.22 More recently.and post-treatment abilities of 40 participants who demonstrated greater Downloaded by: Dot. Although 1 to 3 hours of treatment per week is typical of outpatient treatment in the United States. a medium effect size was obtained only for the mild to moderate aphasia group. and four were in the mild to moderate group. DISCUSSION The purpose of this study was to examine whether low-intensity ORLA resulted in language improvements that are greater than changes without treatment. it is important to note that for this group. overall small but statistically significant changes occurred during the treatment period as measured by the WAB AQ. Lib Information. the mild to moderate aphasia group achieved medium effect sizes on both rate (words per minute) and content (CIUs per minute).22 The 5 of these 10 studies that did not have positive outcomes provided only 2 hours of therapy per week for 22. However. whereas the mild to moderate aphasia group showed improvements only on rate.3 points.05). For the WAB writing subtests. whether there were differential effects related to the severity of the aphasia. the small changes that occurred during the notreatment period were not significant. a retrospective analysis was conducted of 10 studies. For the WAB reading subtests. the present data support the notion that for some patients with aphasia. a 5-point change on the WAB AQ is considered to be important. where treatment initiated during the chronic stage (after 1 year post-onset) showed an effect size that was notably larger than that for untreated individuals (0.559) was obtained for the severe group. Copyrighted material. Two different discourse tasks were used with different outcomes. Interestingly. participants were provided an average of 8. In these 5 studies. we have insufficient data to differentiate these good responders from poor responders based on personal characteristics or neuroanatomical or neurophysiological differences. For example. 48 . Nevertheless.23 These included a retrospective analysis of the pre. the primary outcome measure. However. Once again. In contrast. even low-intensity ORLA treatment may result in large changes on the WAB AQ. with improvements ranging 2010 from 6.2 points to 16. the medium effect size in the no-treatment period for the severe aphasia group is noteworthy. number of treatment hours per week was significantly correlated with improvement on the language outcome measures. and if so. the moderate aphasia group displayed a medium effect size for treatment changes on both rate (words per minute) and content (CIUs per minute). regardless of the chronicity of the aphasia.20 The mean change of 2. Overall. For the picture description task. one was in the severe group. a smaller yet medium effect size was also obtained for the no-treatment period from baseline to pretreatment. a systematic review of the literature identified five studies that directly evaluated treatment intensity in chronic aphasia. Presently.21 It is possible that those participants who demonstrated small changes with low-intensity ORLA treatment might have made larger changes had they been able to participate in more intensive treatment. For the participants as a group. NUMBER 1 which assesses a combination of auditory comprehension and oral expression.8 hours of treatment per week for an average of 11. two were in the moderate group. With regard to clinical significance.SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31. for the narrative discourse task. 5 of which had significant treatment effect.2 weeks. The moderate aphasia group achieved a medium effect size for rate only. Furthermore.66 versus 0. Intensity of treatment was also not a factor—the treatment period for 24 sessions of ORLA ranged from 6 weeks to 16 weeks. and written expression.24 Another study compared three pairs of participants matched in type and severity of aphasia. where a medium effect size was obtained for the treatment period. The differentiation of the groups into three severities was an arbitrary but pragmatic decision determined by the subject pool. during oral reading but increased activation bilaterally on story comprehension. Results support the differential effects of the ORLA treatment based on severity of the aphasia. as well as demographic characteristics. We have previously reported on two of the subjects in the mild to moderate group who underwent functional imaging before and after the ORLA treatment. Because it 49 Downloaded by: Dot. Writing is a complex skill and therefore it is one of the last language skills that is acquired. Different results may also have been obtained if different evaluation tools to measure outcomes had been selected. no subjects with a severity on the WAB AQ of 26 to 44 were recruited.improvements in naming skills over 6 to 8 weeks after intensive (23 times per week) compared with nonintensive (less than 3 times per week) aphasia therapy. Therefore.2 was greater than the effect size of 0. and for the content of the picture description.25 Overall. Although the neurophysiological pattern of change differed in the two subjects and interpretation remains difficult. Additionally. For the other participant. we do not have any data about the performance of this severity group on ORLA. the effect size of 0. but decreased bilaterally in most regions on story comprehension. These changes in discourse are reflected in the overall change in the WAB AQ. the most noticeable changes were for rate in both tasks.25 All participants improved. The WAB was selected because it provides an overall quantitative metric of aphasia severity (the AQ). results highlight the fact that low-intensity ORLA can affect brain activation changes in individuals with chronic aphasia. particularly in the right hemisphere. the category of subjects within the WAB AQ range of 26 to 44 may have formed their own moderately severe aphasia group. Because ORLA was initially designed to improve reading comprehension. Subjects with both moderate aphasia and mild to moderate aphasia demonstrated changes in discourse with treatment. Lib Information. Although the RCBA-2 did not reflect changes in reading to the same extent. depending on the number of subjects. However.058 obtained in the no-treatment period. For the moderate group.088 for the no-treatment period. the small effect size obtained for rate on the picture description task contrasts with the effect size of 0. medium effect sizes were evident for both rate and content of the narrative discourse and for content on the picture description task. oral expression. the systematic review indicated that there is modest evidence for the efficacy of more intensive treatment of chronic aphasia. Furthermore. it explores a wide range of communicative abilities including auditory comprehension. Subjects with mild to moderate aphasia were the only group to show changes on writing. there was decreased activation. On the other hand. the cutoff points for the other severity levels may have changed. brain activation increased in the right hemisphere during oral reading. ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY . the finding of improved reading comprehension in the severe aphasia group is not surprising.23 Recent research has indicated that intensive therapy is necessary to obtain a level of improvement and brain reorganization sufficient for a patient to make functional gains. even low-intensity ORLA may affect the induction of neural plasticity. the effect sizes may also have changed.4 However. Copyrighted material. With a different distribution of subjects. Subjects with severe aphasia were the only group to make noticeable change on the WAB reading scores. reading comprehension. rather than by any theoretical basis. consistent with our clinical perceptions. We also cannot ignore the possibility that if we had recruited subjects with this range of severity. without changing the makeup of the other groups. The goal was to ensure that there were sufficient numbers of subjects in each severity group to evaluate trends. but the three in each pair who received more intensive treatment (3 to 4 hours per day for 14 to 40 months) achieved higher test scores and made better use of language in daily life than those who received less intensive treatment (1 hour per day for 6 to 22 months).26 For one participant. For the mild to moderate group. Constraint-induced therapy of chronic aphasia after stroke. anticipate improvement in specific language modalities. research speech-language pathologists. Department of Education. but there was no measure of the impact of ORLA on everyday communication participation. the person with severe aphasia may be more susceptible to the stress and anxiety of the test-taking situation. Elbert T. Nicholas M.32(7):1621–1626 3. the WAB measures language at the impairment level only. There are several limitations to the study. Naeser MA. It should also be noted that the severe aphasia group was the oldest group. the relatively few subjects within each severity level limited our analyses. Bernstein-Ellis E.27 the WAB AQ was selected to serve as the primary outcome measure. and older patients may find such situations more stressful than those who are younger. for assessing and treating the participants with aphasia. Although there is a preference for more intensive therapy. Martin PI.93(1):95– 105 Downloaded by: Dot. and document goals accordingly.28 it is not a direct measure of activity/participation. 50 . particularly for individuals with chronic aphasia. It appears that low-intensity ORLA treatment may lead to improved reading comprehension in individuals with severe chronic aphasia and improved writing skills in those with mild to moderate chronic aphasia. Improved picture naming in chronic aphasia after TMS to part of right Broca’s area: an open-protocol study. no follow-up data were collected. With the WAB AQ as the primary outcome measure. on the WAB AQ. the surroundings. based on their patients’ needs and goals. Improved discourse skills may be anticipated in those with moderate or mild to moderate aphasia. The discourse measures provided a better indication of change at the activity level.SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31. This was apparent on the WAB AQ as well as on both the rate and content measures of the narrative discourse task. Clinicians should be aware of these potential differential improvements so that. Rather than a true change in language skills. we need to investigate what the optimum dose of ORLA might be. especially with oral expression. Brain Lang 2005. Thanks are extended to Edna Babbitt and Jodi Oldani. and differences in modality-specific outcomes may be anticipated based on the severity of the aphasia. However. there was sufficient power to address questions related to treatment efficacy with the entire group of 25 subjects. Lib Information. which is an important consideration. REFERENCES 1. Neininger B. Pulvermu¨ller F. and. et al. although scores may correlate with caregiver ratings of functional communication skills. With the new knowledge emerging about the importance of treatment intensity. a randomized controlled trial with two independent groups would have provided stronger evidence for evaluating the efficacy of low-intensity ORLA. Copyrighted material. Future studies need to include a main- 2010 tenance period so that the long-term impact of ORLA can be assessed. However. It is important to address the medium effect sizes obtained during the no-treatment period. resulting in decreased performance. et al. they can determine whether ORLA will be an appropriate treatment to select. NUMBER 1 has been psychometrically characterized and found to be valid and reliable. individuals with chronic aphasia may still improve their language skills even with low-intensity treatment.42:411– 419 2. ACKNOWLEDGMENTS This study and preparation of the article were supported by Grants # H133G060055 and H133G010098 from the National Institute on Disability and Rehabilitation Research. particularly for the severe aphasia group.29 At the second test session. J Speech Hear Res 1999. U. perhaps resulting in better measures of performance. and tasks were now familiar and the situation was overall less stressful. 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