A New Approach to the Treatment of Severe Dysphasia: A Case Study CAROL
L. DAVIES and
PAMELA GRUNWELL
School of Speech Therapy, City of Birminghani Polytechnic.
Summary This paper describes the application of linguistic principles in the treatment of a case of long-standing severe dysphasia who had previously failed to make any progress with expressive speech ability despite intensive therapy. It could thus be considered that the patient was acting as his own "control" (Sefer 1973). This seems to be an interesting case in that, as the linguistic analysis indicates, while there seems to have been some delayed spontaneous recovery in vocabulary and morphology, sentence structure always followed the patterns taught. Introduction The effectiveness of therapy with dysphasic patients has been and still is controversial. The majority decision in the current literature (Wepman; Sarno et a1 1970) seems to be that treatment does not influence recovery. There have been occasional exceptions to this point of view (Sefer 1973). It is generally agreed that the more severe the dysphasia the less chance there is of subtantial improvement as the severity is directly related to the extent of brain damage. In the patient to be described, facts about extent of damage are unfortunately unknown, but one may presume from the severe dysphasia present, that damage was quite extensive at least in the systems involving speech and language. The patient (Mr M) did, however, have exceptionally high motivation. Although a high motivational level is very important in the remediation of any functional or pathological speech and language disorder it obviously cannot be the main factor in recovery, particularly from bilateral brain damage, since a grossly impaired neurological system cannot regenerate or have enough intact pathways to provide the necessary alternative routes (Schuell et a1 1964 CH. 14). By this case study we hope to demonstrate not only the value of aphasia therapy but also the significance of the treatment procedures ; indeed therapy only became successful when new therapeutic techniques were employed. Medical and Social History Previous to his illness Mr M held an executive managerial position in the car industry and was very active in the scout movement. He was married with one son. In 1963 he had a nephrectomy for renal artery sclerosis with hypertension, cured by resection of the ischaemic kidney. He was admitted to hospital in November 1969 with thrombosis of the right leg. During his inpatient stay there was sudden weakness of the right hand and accompanying dysphasia which recovered very quickly. He was left with a dysarthria and right hemiplegia, and a diagnosis of paradoxical emboli was made. He was discharged from hospital at the end of November 1969, but was readmitted two weeks later after a 142
A NEW APPROACH TO THE TREATMENT OF SEVERE DYSPHASIA
143
domicillary visit by the consultant. There had been further weakness of the right side and loss of speech, and a diagnosis of a second CVA was made. There was obvious right facial palsy, right hemiplegia and right homonymous hemianopia. A left carotid angiogram revealed complete obstruction of middle carotid with displacement of mid-line structures to the right. A space occupying lesion in the left hemisphere was suggested but not confirmed. There was no evidence of tumor to explain the deep vein thrombosis. He had further swelling of the right hand and deep vein thrombosis was again queried. A diagnosis of left basal atalectasis with pleurisy and pulmonary embolism was made. He remained dysphasic and hemiplegic but with no subsequent episodes he was discharged home in December 1969. Over the next year he was receiving intensive speech therapy but there was very slow improvement in speech. By November 1971 there was some recovery of movement of the right arm and he was walking confidently with a stick.
Summary of previous Speech and Language Assessments December 1969 - August 1970. Moderate to severe auditory comprehension problem and dyspraxia. September 1970 - April 1971. There is no record of any improvement in comprehension for this period, but he began to use what speech he had spontaneously in conversation. He was able to use “yes, no, thank you, good morning” and more single words if the initial sound was supplied. April 1971 Schuell Assessment Report Auditory: Few errors on single word comprehension, but an evident discrimination problem recognising individual letters. Severe reduction of auditory memory where accurate comprehension was required, but understood the gist of sentences reasonably well due to redundancy of language. Chance correct responses at paragraph level. Visual and Reading: There were no perceptual problems and reading was intact at single word level, with a few errors matching spoken to written words. He was able to read orally a few simple words but expressive speech was severely disturbed by a sensori-motor loss. There was 50 % comprehension of sentences, but complete failure at paragraph level. Speech and Language: Evidence of dyspraxia on repetition of monosyllables, and serial speech was slightly disturbed. Able to complete sentences and answer simple questions fairly well, and name half the pictures, but could perform no other tasks in this section. Visuomotor and Writing: No perceptual problem. Used non-preferred left hand for writing. Only able to write 50% of letters from dictation and two words. No evidence of spontaneous writing. Summary: Moderate to severe dysphasia with sensori-motor involvement. (See Schuell profile). In June 1971 he was referred to the therapist co-author (C.L.D.) in the speech therapy department of a large hospital. The first Schuell Assessment was available and we considered that after two years’ intensive traditional speech therapy there was little chance of any further significant improvement. However, we were so impressed by Mr M’s strong personality and sheer determination that it was agreed that a trial period of twice weekly treatment be undertaken.
144
BRITISH JOURNAL OF DISORDERS OF COMMUNICATION
Language Rehabilitation Programme It is generally considered uneconomic to continue regular therapy with a severely dysphasic patient so long after onset and especially when previous treatment has met with almost complete failure (but compare Schuell et a1 1964 CH. 12). In the case of Mr M the decision to continue and indeed intensify treatment was made on the basis of three factors: (1) The very high motivation of the patient even after so long a period of failure. Mr M could never have enough therapy and his comment on his own progress during the successful programme was always “Slow” ; though when he learnt comparatives we did manage to persuade him to say, very occasionally, “ . . .but better”; and then, of course, he always wanted it “Faster” (2) The presence of a linguistic observer (co-author P.G.) in the clinic inspired the development of the structured treatment programme. If any success was to be achieved, it seemed that a new approach to the problem was required. (3) The existence of precedent in the experimental treatment procedures of Gordon (1969) ;here the mechanical equipment of the language laboratory (the “hardware”) was used; we decided to adapt the “software” of language teaching, the use of substitution drills for learning sentence structures. Mr M seemed to need personal contact during therapy sessions although later a tape recorder was used for reinforcement. Long term aims were to increase verbal output and improve performance on written tasks. The following structured treatment programme was formulated : substitution drills beginning with subject-verb-object sentences. Each structure was presented in the following modes : written texts; copying sentences, repeating with clinician, reading alone, then finally producing sentences orally from visual (picture) stimulus alone. Initially the supplementary technique of rearranging sentences word order was extremely difficult but there was great improvement fairly quickly. “Functors” were produced relatively easily and automatically, therapy was concentrated on the use of content words in complete sentences. After a period of four months treatment in this manner, there was obvious improvement in the availability and limited productivity of spontaneous language, so we decided to continue the successful techniques. November 1971 2nd Schuell Assessment: (See Profile) Comparison with first assessment. Auditory: No change from previous assessment. Visual and Reading: There was a significant improvement on sentence and paragraph comprehension. Speech and Language: There was slight improvement in answering simple questions and completing sentences, but still unable to formulate sentences for the test. Visuomotor and Writing: Now attempting to produce sentences but still incorrect on test items. The plan of therapy was then to proceed as follows: to increase verb vocabulary, incorporate various verb tense forms, adjectives, pronouns, comparatives, prepositions and question words in appropriate sentence structures, in that order. The basic sentence pattern was provided in each case and the “fillers” for the “content slots” changed appropriately. As can be imagined therapy sessions with such rigourously administered treatment were hard work for both patient and therapist. Even now there was no
145
A NEW APPROACH TO THE TREATMENT OF SEVERE DYSPHASIA
Errors 100%
75 %
50 %
25 %
0%
A KEY
B
C
D
E
-April 1971 - - - - November 1971 . . . . June1973
A Auditory disturbances B Visual and reading disturbances C Speech and language disturbances D Visuomotor and writing disturbances E Arithmetic disturbances
really spontaneous production of language. Strict adherence to the learned pattern was necessary, any deviation produced chaos ! Our choice of structures was determined by a rather informal criterion of difficulty in relation to sentence length, concept encoded and previous therapeutic experience. We also took into account the potential usefulness to the patient. All sentence structures were simple sentences; we did not get as far as teaching conjunctions though the patient did learn to conjoin adjectives and nouns with “and”. June 1973 3rd Schuell Assessment (See Profile) Auditory: Considerable improvement in length of auditory memory; sentences almost totally correct, and 50% of paragraph was understood. Visual and Reading: Approximately same as previous test. Speech and Language: Much improved, prompt and accurate answers up to formulating sentences, which were reasonably attempted but could not be given credit on the test. Viscuomotor and Writing: Approximately same as previous test. Summary: Significant improvement on Speech and Language section. This last assessment was carried out imediately prior to admission to hospital for major surgery, and unfortunately the patient died soon thereafter. E
146
BRITISH JOURNAL OF DISORDERS OF COMMUNICATION
Communicative Achievements
During therapy sessions Mr M’s newly re-acquired language skills enabled him to discuss current events in free conversation and with reference to newspaper articles. In an aphasic group he was able to participate fully in the activities in spite of having the lowest verbal ability and extremely poor gestural communication. As to written language abilities he kept a substantial diary in which he recorded his own activities and current events. He continued to play bridge and chess and to meet his former business colleagues socially. We do not wish to suggest that Mr M s speech in these situations approximated his premorbid level, but it was communicatively adequate and his thoughts were generally expressed in sentences;whereas previous to the treatment programme the average length of his utterances was a single haltingly articulated word. Continuous Linguistic Assessment During the course of the structured treatment programme we found it necessary to review continuously Mr M’s language abilities and progress and in consequence our plans and aims. As Mr M began to produce more expressive speech and provide written responses, the emergence of a consistent error pattern in sounds and letters indicated that the dysphasic factor was of equal importance with the dyspraxic in relation to articulatory errors. While articulatory performance continued to show many characteristics of dyspraxia, for example seemingly ‘random’ vowel errors (however these usually could be accounted for by an ‘inability to maintain proximal phonemic boundaries’ (see FRY 1958). Many consonantal errors were systematic in that they involved the substitution of a single phonemic feature eg (dAt-kllg&It-dnk ) “duck”. In many cases he seemed to “know” the word at an “abstract phonological level” in that stress pattern, number of syllables, vowels and some consonantal features were correct, errors involved the detailed specification of segments which probably occuis at a lower level of encoding eg, ( hzmsta haemstad- haensam ) “handsome”. (cf Brown and McNeill 1966; Aitchison 1972). Mr M’s articulatory errors also conformed to the characterisation of “phonemic paraphasias” given by Lecours and L‘Hermitte (1969). The direction of substitutions was indifferent and variable, thus contrary to Jakobson’s theory of “phonetic disintegration”; sound sequences generally conformed to the phonological system of English; sequencing errors also occurred eg, ( kselas ) “castle”; consonant clusters were generally simplified; writing errors followed a similar substitution pattern eg, “my’for “b”. Nevertheless, his articulatory abilities did not change during treatment; his speech remained slow and laboured. Some time after we had been working on verb tenses in the language programme, we observed examples of their use in spontaneous speech and writing which indicated some confusion in this area of grammatical morphology:N
e.
Spoken Written
: :
The bike has ( padalq -pEdaldNpzdalz) Yesterday it raining it is rained it was raining.
These examples point to some kind of systematic organisation of grammatical morphemes, an awareness of certain basic linguistic processes. The errors seem to be the result of the characteristic aphasic problems of inhibition and appropriate selection. To investigate this level of grammatical morphology further we devised a test of noun
A NEW APPROACH TO THE TREATMENT OF SEVERE DYSPHASIA
147
plurals, possessives and adjectival comparison using simple picture stimuli together with an auditory cue, requiring a spoken response. We referred to other expetiments of this kind (Goodglass and Berko (1960); Goodglass and Hunt (1958)) but considered the verbal stimuli here too long and complex. To explore this level of the grammar more comprehensively, we also used ITPA: sub test of Grammatic Closure. In all these cases, the tests were not administered as such, but used for learning purposes ie, ‘diagnostic therapy’. It is interesting to note that several of Mr M’s responses on the ITPA test, though technically incorrect, were always semantically appropriate eg, “The boy is going to eat all the biscuits. Now all the biscuits have been . . . . . . ( f m J t )”. From these investigations we discovered that Mr M produced “regular” plurals consistently and accurately, although these had never been “taught’. He made errors with ‘irregular’ plurals in the direction of overregularisation, eg, houses ( havsIz ) knives ( naIOs ). With exceptional forms “feet” and “teeth” our experiment produced a very interesting reaction. On being shown a picture of the singular item he produced ( fit) and ( ti0 ), a response probably conditioned by frequency of usage. With prompting the correct singular form was elicited, but following this the plural response on two separate occasions was (fnts) and (tuBz), suggesting once again the operation of a “rule”. The possessive morpheme was produced only twice out of ten items; Mr M did not understand his error though he did understand the concept of possession and after specific therapy was able to use “mine” and “his”. Adjectival comparatives were produced spontaneously and correctly on the “test” in the absence of prior drills; the “superlative” concept was again understood, but Mr M’s first attempt was ( 1Dggala ) “longest”. With the second adjective his response was ( bIga:) “biggest”. Also relevant here is Mr M’s attempts to convey the meaning “even faster still” ( fasta fastata). It seems that some principle of sound symbolism seems to be operating here (compare also children’s preference for longer words to indicate plurality (Anisfeld and Tucker) and the use of reduplication to indicate ‘more of same’ in some ‘exotic’ languages (Javanese, Australian Aboriginal languages). With evidence such as this one may speculate on the relevance of aphasic language to the theory of linguistic universals: especially when there appears to be several parallels with processes in child language acquisition : eg, overregularisation; inability to form possessives even though the morphological form is identical to that of the plural (cf Goodglass and Hunt). We did not investigate fully verb tense forms, because Mr M was hospitalised for major surgery in Spring 1973, but we did observe one overegularisation here too, (teIkt ) “taked”. At the syntactic level, Mr M did not produce any sentence structures other than those drilled; but these sentences were eventually supplied spontaneously, accurately and ‘creatively’ in that he used new words in the various “slots”. There were several “syntactico-semantic” areas where prolonged difficulty was encountered viz prepositions, pronouns and “mass” nouns eg, “milk, water” ie, non-quantifiable substances. These three specific problems lend support to Goldstein’s theory that the abstract functions of language are most severely affected in aphasia (Osgood and Miron 1963, Chapter 2). In general we noted a considerable spontaneous increase in active vocabulary, and bearing in mind his language post trauma he produced quite surprising new words eg “pedals; squirrel, growling”.
Discussion It has been recognised that patients with severe, long-standing aphasia can make late
148
BRITISH JOURNAL OF DISORDERS OF COMMUNICATION
“artificial” recovery with intensive training. Mr M was such a case. Furthermore, his improvement as shown on the third Schuell assessment occurred only in those areas on which therapy had been concentrated; there was little or no recovery in other areas except for a noticeable spontaneous increase in vocabulary. The expressive language being used post-therapy derived directly from the treatment programme. Before the programme Mr M was only producing a limited number of single word utterances, we, therefore, conclude that improvement was due to therapeutic intervention with the patient acting ‘as his own control’. (Sefer 1973). This successful treatment programme was based on techniques new to aphasia therapy. As has been indicated above, we do not want to suggest that these techniques would be effective with all dysphasic patients. There is evidence for successful application of similar techniques with another very severely dysphasic patient who began to receive therapy in our department two months post CVA. We consider that the structured approach is most suitable for the severely dysphasic. It might be worthwhile, however, planning treatment for the less severe dysphasic on these principles but with a modified, more flexible approach.
Acknowledgement We would l i e to express our indebtedness to the late Mr M and his wife; also to acknowledge the assistance of our student therapists, especially MissE. Tregonning LCST.
References J. (1972). British Journal of Disorders of Communication,Vol7, 38-42. AITCHISON, ANISFELDand TUCKER (1967). Child Development, Vol38,1202-17. BROWNand MCNEIL(1966). JVLVB, 15, 325-337. DAVIES and GRUNWELL (1973). British Amendments to MTDDA (City of Birmingham Polytechnic). FRY, D. B. (1958). Speech, 1, 52-61. H and BERKO,J. (1960) JSHR, 3, 257-267. GOODGLASS, GOODGLASS, H and HUNTJ. (1958), Word, 14, 197-207. GORDON,M. (1969) British Journal of Disorders of Communication, 4, 83-88. HALLIDAY, M. A. K. MCINTOSH, A & STREVENS, P (1964). The Linguistic Sciences and Language Teaching. Longman, London. R (1941). Child Language, Aphasia and Phonological Universals. Mouton, The Hague, 1968. JAKOBSON, KIRKand K ~ R(1968). K Illinois Test of Psvcholinpuistic Abilities. Rev. Ed. Univ of Illinois Press, Urbana. (1969). Cortex, 5, i93-228 LECOURS and L‘m& P. (1971). The Acquisition and Development of Language. Prentice Hall, London. MENYUK, OSGOOD and MIRON(1963). Approaches to the Study ofAphasia, Univ. of Illinois Press, Urbana. SARNO,SILVERMAN & SANDS (1970). JSHR, 13, 607-23. H. M. (1965). Aphasia, Univ. of Minnesota, Minneapolis. SCHUELL, J. J and JIMENEZ-PABON, E. (1964). Aphasia in Adults, Harper and Rowe, New SCHUELL, H. M. JENKINS, York. H. M. (1969) British Journal of Disorders of Communication,4,73-82. SEFERJ. W. and SCHUELL, SEFERJ. W. (1973) British Journal of Disorders of Communication,8,99-104. SHANKWEILER and HARRIS(1966). Cortex, 2, 77-292. TATHAM, M. A. A. (1968). English Structure Manipulation Drills. Longman, London. WEPMAN, J. From Proceedings of Conference on Language Retraining for Aphasics. Ohio State Univ.
Reprint requests to Miss Pamela Crunwell M.A. Sclrool of Speech Therapy, Science and Techrzologj, (North) Center, City of Birmingham Polytechnic, Franchise St. Birtninghatn B42 2SU.
L. DAVIES and
PAMELA GRUNWELL
School of Speech Therapy, City of Birminghani Polytechnic.
Summary This paper describes the application of linguistic principles in the treatment of a case of long-standing severe dysphasia who had previously failed to make any progress with expressive speech ability despite intensive therapy. It could thus be considered that the patient was acting as his own "control" (Sefer 1973). This seems to be an interesting case in that, as the linguistic analysis indicates, while there seems to have been some delayed spontaneous recovery in vocabulary and morphology, sentence structure always followed the patterns taught. Introduction The effectiveness of therapy with dysphasic patients has been and still is controversial. The majority decision in the current literature (Wepman; Sarno et a1 1970) seems to be that treatment does not influence recovery. There have been occasional exceptions to this point of view (Sefer 1973). It is generally agreed that the more severe the dysphasia the less chance there is of subtantial improvement as the severity is directly related to the extent of brain damage. In the patient to be described, facts about extent of damage are unfortunately unknown, but one may presume from the severe dysphasia present, that damage was quite extensive at least in the systems involving speech and language. The patient (Mr M) did, however, have exceptionally high motivation. Although a high motivational level is very important in the remediation of any functional or pathological speech and language disorder it obviously cannot be the main factor in recovery, particularly from bilateral brain damage, since a grossly impaired neurological system cannot regenerate or have enough intact pathways to provide the necessary alternative routes (Schuell et a1 1964 CH. 14). By this case study we hope to demonstrate not only the value of aphasia therapy but also the significance of the treatment procedures ; indeed therapy only became successful when new therapeutic techniques were employed. Medical and Social History Previous to his illness Mr M held an executive managerial position in the car industry and was very active in the scout movement. He was married with one son. In 1963 he had a nephrectomy for renal artery sclerosis with hypertension, cured by resection of the ischaemic kidney. He was admitted to hospital in November 1969 with thrombosis of the right leg. During his inpatient stay there was sudden weakness of the right hand and accompanying dysphasia which recovered very quickly. He was left with a dysarthria and right hemiplegia, and a diagnosis of paradoxical emboli was made. He was discharged from hospital at the end of November 1969, but was readmitted two weeks later after a 142
A NEW APPROACH TO THE TREATMENT OF SEVERE DYSPHASIA
143
domicillary visit by the consultant. There had been further weakness of the right side and loss of speech, and a diagnosis of a second CVA was made. There was obvious right facial palsy, right hemiplegia and right homonymous hemianopia. A left carotid angiogram revealed complete obstruction of middle carotid with displacement of mid-line structures to the right. A space occupying lesion in the left hemisphere was suggested but not confirmed. There was no evidence of tumor to explain the deep vein thrombosis. He had further swelling of the right hand and deep vein thrombosis was again queried. A diagnosis of left basal atalectasis with pleurisy and pulmonary embolism was made. He remained dysphasic and hemiplegic but with no subsequent episodes he was discharged home in December 1969. Over the next year he was receiving intensive speech therapy but there was very slow improvement in speech. By November 1971 there was some recovery of movement of the right arm and he was walking confidently with a stick.
Summary of previous Speech and Language Assessments December 1969 - August 1970. Moderate to severe auditory comprehension problem and dyspraxia. September 1970 - April 1971. There is no record of any improvement in comprehension for this period, but he began to use what speech he had spontaneously in conversation. He was able to use “yes, no, thank you, good morning” and more single words if the initial sound was supplied. April 1971 Schuell Assessment Report Auditory: Few errors on single word comprehension, but an evident discrimination problem recognising individual letters. Severe reduction of auditory memory where accurate comprehension was required, but understood the gist of sentences reasonably well due to redundancy of language. Chance correct responses at paragraph level. Visual and Reading: There were no perceptual problems and reading was intact at single word level, with a few errors matching spoken to written words. He was able to read orally a few simple words but expressive speech was severely disturbed by a sensori-motor loss. There was 50 % comprehension of sentences, but complete failure at paragraph level. Speech and Language: Evidence of dyspraxia on repetition of monosyllables, and serial speech was slightly disturbed. Able to complete sentences and answer simple questions fairly well, and name half the pictures, but could perform no other tasks in this section. Visuomotor and Writing: No perceptual problem. Used non-preferred left hand for writing. Only able to write 50% of letters from dictation and two words. No evidence of spontaneous writing. Summary: Moderate to severe dysphasia with sensori-motor involvement. (See Schuell profile). In June 1971 he was referred to the therapist co-author (C.L.D.) in the speech therapy department of a large hospital. The first Schuell Assessment was available and we considered that after two years’ intensive traditional speech therapy there was little chance of any further significant improvement. However, we were so impressed by Mr M’s strong personality and sheer determination that it was agreed that a trial period of twice weekly treatment be undertaken.
144
BRITISH JOURNAL OF DISORDERS OF COMMUNICATION
Language Rehabilitation Programme It is generally considered uneconomic to continue regular therapy with a severely dysphasic patient so long after onset and especially when previous treatment has met with almost complete failure (but compare Schuell et a1 1964 CH. 12). In the case of Mr M the decision to continue and indeed intensify treatment was made on the basis of three factors: (1) The very high motivation of the patient even after so long a period of failure. Mr M could never have enough therapy and his comment on his own progress during the successful programme was always “Slow” ; though when he learnt comparatives we did manage to persuade him to say, very occasionally, “ . . .but better”; and then, of course, he always wanted it “Faster” (2) The presence of a linguistic observer (co-author P.G.) in the clinic inspired the development of the structured treatment programme. If any success was to be achieved, it seemed that a new approach to the problem was required. (3) The existence of precedent in the experimental treatment procedures of Gordon (1969) ;here the mechanical equipment of the language laboratory (the “hardware”) was used; we decided to adapt the “software” of language teaching, the use of substitution drills for learning sentence structures. Mr M seemed to need personal contact during therapy sessions although later a tape recorder was used for reinforcement. Long term aims were to increase verbal output and improve performance on written tasks. The following structured treatment programme was formulated : substitution drills beginning with subject-verb-object sentences. Each structure was presented in the following modes : written texts; copying sentences, repeating with clinician, reading alone, then finally producing sentences orally from visual (picture) stimulus alone. Initially the supplementary technique of rearranging sentences word order was extremely difficult but there was great improvement fairly quickly. “Functors” were produced relatively easily and automatically, therapy was concentrated on the use of content words in complete sentences. After a period of four months treatment in this manner, there was obvious improvement in the availability and limited productivity of spontaneous language, so we decided to continue the successful techniques. November 1971 2nd Schuell Assessment: (See Profile) Comparison with first assessment. Auditory: No change from previous assessment. Visual and Reading: There was a significant improvement on sentence and paragraph comprehension. Speech and Language: There was slight improvement in answering simple questions and completing sentences, but still unable to formulate sentences for the test. Visuomotor and Writing: Now attempting to produce sentences but still incorrect on test items. The plan of therapy was then to proceed as follows: to increase verb vocabulary, incorporate various verb tense forms, adjectives, pronouns, comparatives, prepositions and question words in appropriate sentence structures, in that order. The basic sentence pattern was provided in each case and the “fillers” for the “content slots” changed appropriately. As can be imagined therapy sessions with such rigourously administered treatment were hard work for both patient and therapist. Even now there was no
145
A NEW APPROACH TO THE TREATMENT OF SEVERE DYSPHASIA
Errors 100%
75 %
50 %
25 %
0%
A KEY
B
C
D
E
-April 1971 - - - - November 1971 . . . . June1973
A Auditory disturbances B Visual and reading disturbances C Speech and language disturbances D Visuomotor and writing disturbances E Arithmetic disturbances
really spontaneous production of language. Strict adherence to the learned pattern was necessary, any deviation produced chaos ! Our choice of structures was determined by a rather informal criterion of difficulty in relation to sentence length, concept encoded and previous therapeutic experience. We also took into account the potential usefulness to the patient. All sentence structures were simple sentences; we did not get as far as teaching conjunctions though the patient did learn to conjoin adjectives and nouns with “and”. June 1973 3rd Schuell Assessment (See Profile) Auditory: Considerable improvement in length of auditory memory; sentences almost totally correct, and 50% of paragraph was understood. Visual and Reading: Approximately same as previous test. Speech and Language: Much improved, prompt and accurate answers up to formulating sentences, which were reasonably attempted but could not be given credit on the test. Viscuomotor and Writing: Approximately same as previous test. Summary: Significant improvement on Speech and Language section. This last assessment was carried out imediately prior to admission to hospital for major surgery, and unfortunately the patient died soon thereafter. E
146
BRITISH JOURNAL OF DISORDERS OF COMMUNICATION
Communicative Achievements
During therapy sessions Mr M’s newly re-acquired language skills enabled him to discuss current events in free conversation and with reference to newspaper articles. In an aphasic group he was able to participate fully in the activities in spite of having the lowest verbal ability and extremely poor gestural communication. As to written language abilities he kept a substantial diary in which he recorded his own activities and current events. He continued to play bridge and chess and to meet his former business colleagues socially. We do not wish to suggest that Mr M s speech in these situations approximated his premorbid level, but it was communicatively adequate and his thoughts were generally expressed in sentences;whereas previous to the treatment programme the average length of his utterances was a single haltingly articulated word. Continuous Linguistic Assessment During the course of the structured treatment programme we found it necessary to review continuously Mr M’s language abilities and progress and in consequence our plans and aims. As Mr M began to produce more expressive speech and provide written responses, the emergence of a consistent error pattern in sounds and letters indicated that the dysphasic factor was of equal importance with the dyspraxic in relation to articulatory errors. While articulatory performance continued to show many characteristics of dyspraxia, for example seemingly ‘random’ vowel errors (however these usually could be accounted for by an ‘inability to maintain proximal phonemic boundaries’ (see FRY 1958). Many consonantal errors were systematic in that they involved the substitution of a single phonemic feature eg (dAt-kllg&It-dnk ) “duck”. In many cases he seemed to “know” the word at an “abstract phonological level” in that stress pattern, number of syllables, vowels and some consonantal features were correct, errors involved the detailed specification of segments which probably occuis at a lower level of encoding eg, ( hzmsta haemstad- haensam ) “handsome”. (cf Brown and McNeill 1966; Aitchison 1972). Mr M’s articulatory errors also conformed to the characterisation of “phonemic paraphasias” given by Lecours and L‘Hermitte (1969). The direction of substitutions was indifferent and variable, thus contrary to Jakobson’s theory of “phonetic disintegration”; sound sequences generally conformed to the phonological system of English; sequencing errors also occurred eg, ( kselas ) “castle”; consonant clusters were generally simplified; writing errors followed a similar substitution pattern eg, “my’for “b”. Nevertheless, his articulatory abilities did not change during treatment; his speech remained slow and laboured. Some time after we had been working on verb tenses in the language programme, we observed examples of their use in spontaneous speech and writing which indicated some confusion in this area of grammatical morphology:N
e.
Spoken Written
: :
The bike has ( padalq -pEdaldNpzdalz) Yesterday it raining it is rained it was raining.
These examples point to some kind of systematic organisation of grammatical morphemes, an awareness of certain basic linguistic processes. The errors seem to be the result of the characteristic aphasic problems of inhibition and appropriate selection. To investigate this level of grammatical morphology further we devised a test of noun
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plurals, possessives and adjectival comparison using simple picture stimuli together with an auditory cue, requiring a spoken response. We referred to other expetiments of this kind (Goodglass and Berko (1960); Goodglass and Hunt (1958)) but considered the verbal stimuli here too long and complex. To explore this level of the grammar more comprehensively, we also used ITPA: sub test of Grammatic Closure. In all these cases, the tests were not administered as such, but used for learning purposes ie, ‘diagnostic therapy’. It is interesting to note that several of Mr M’s responses on the ITPA test, though technically incorrect, were always semantically appropriate eg, “The boy is going to eat all the biscuits. Now all the biscuits have been . . . . . . ( f m J t )”. From these investigations we discovered that Mr M produced “regular” plurals consistently and accurately, although these had never been “taught’. He made errors with ‘irregular’ plurals in the direction of overregularisation, eg, houses ( havsIz ) knives ( naIOs ). With exceptional forms “feet” and “teeth” our experiment produced a very interesting reaction. On being shown a picture of the singular item he produced ( fit) and ( ti0 ), a response probably conditioned by frequency of usage. With prompting the correct singular form was elicited, but following this the plural response on two separate occasions was (fnts) and (tuBz), suggesting once again the operation of a “rule”. The possessive morpheme was produced only twice out of ten items; Mr M did not understand his error though he did understand the concept of possession and after specific therapy was able to use “mine” and “his”. Adjectival comparatives were produced spontaneously and correctly on the “test” in the absence of prior drills; the “superlative” concept was again understood, but Mr M’s first attempt was ( 1Dggala ) “longest”. With the second adjective his response was ( bIga:) “biggest”. Also relevant here is Mr M’s attempts to convey the meaning “even faster still” ( fasta fastata). It seems that some principle of sound symbolism seems to be operating here (compare also children’s preference for longer words to indicate plurality (Anisfeld and Tucker) and the use of reduplication to indicate ‘more of same’ in some ‘exotic’ languages (Javanese, Australian Aboriginal languages). With evidence such as this one may speculate on the relevance of aphasic language to the theory of linguistic universals: especially when there appears to be several parallels with processes in child language acquisition : eg, overregularisation; inability to form possessives even though the morphological form is identical to that of the plural (cf Goodglass and Hunt). We did not investigate fully verb tense forms, because Mr M was hospitalised for major surgery in Spring 1973, but we did observe one overegularisation here too, (teIkt ) “taked”. At the syntactic level, Mr M did not produce any sentence structures other than those drilled; but these sentences were eventually supplied spontaneously, accurately and ‘creatively’ in that he used new words in the various “slots”. There were several “syntactico-semantic” areas where prolonged difficulty was encountered viz prepositions, pronouns and “mass” nouns eg, “milk, water” ie, non-quantifiable substances. These three specific problems lend support to Goldstein’s theory that the abstract functions of language are most severely affected in aphasia (Osgood and Miron 1963, Chapter 2). In general we noted a considerable spontaneous increase in active vocabulary, and bearing in mind his language post trauma he produced quite surprising new words eg “pedals; squirrel, growling”.
Discussion It has been recognised that patients with severe, long-standing aphasia can make late
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“artificial” recovery with intensive training. Mr M was such a case. Furthermore, his improvement as shown on the third Schuell assessment occurred only in those areas on which therapy had been concentrated; there was little or no recovery in other areas except for a noticeable spontaneous increase in vocabulary. The expressive language being used post-therapy derived directly from the treatment programme. Before the programme Mr M was only producing a limited number of single word utterances, we, therefore, conclude that improvement was due to therapeutic intervention with the patient acting ‘as his own control’. (Sefer 1973). This successful treatment programme was based on techniques new to aphasia therapy. As has been indicated above, we do not want to suggest that these techniques would be effective with all dysphasic patients. There is evidence for successful application of similar techniques with another very severely dysphasic patient who began to receive therapy in our department two months post CVA. We consider that the structured approach is most suitable for the severely dysphasic. It might be worthwhile, however, planning treatment for the less severe dysphasic on these principles but with a modified, more flexible approach.
Acknowledgement We would l i e to express our indebtedness to the late Mr M and his wife; also to acknowledge the assistance of our student therapists, especially MissE. Tregonning LCST.
References J. (1972). British Journal of Disorders of Communication,Vol7, 38-42. AITCHISON, ANISFELDand TUCKER (1967). Child Development, Vol38,1202-17. BROWNand MCNEIL(1966). JVLVB, 15, 325-337. DAVIES and GRUNWELL (1973). British Amendments to MTDDA (City of Birmingham Polytechnic). FRY, D. B. (1958). Speech, 1, 52-61. H and BERKO,J. (1960) JSHR, 3, 257-267. GOODGLASS, GOODGLASS, H and HUNTJ. (1958), Word, 14, 197-207. GORDON,M. (1969) British Journal of Disorders of Communication, 4, 83-88. HALLIDAY, M. A. K. MCINTOSH, A & STREVENS, P (1964). The Linguistic Sciences and Language Teaching. Longman, London. R (1941). Child Language, Aphasia and Phonological Universals. Mouton, The Hague, 1968. JAKOBSON, KIRKand K ~ R(1968). K Illinois Test of Psvcholinpuistic Abilities. Rev. Ed. Univ of Illinois Press, Urbana. (1969). Cortex, 5, i93-228 LECOURS and L‘m& P. (1971). The Acquisition and Development of Language. Prentice Hall, London. MENYUK, OSGOOD and MIRON(1963). Approaches to the Study ofAphasia, Univ. of Illinois Press, Urbana. SARNO,SILVERMAN & SANDS (1970). JSHR, 13, 607-23. H. M. (1965). Aphasia, Univ. of Minnesota, Minneapolis. SCHUELL, J. J and JIMENEZ-PABON, E. (1964). Aphasia in Adults, Harper and Rowe, New SCHUELL, H. M. JENKINS, York. H. M. (1969) British Journal of Disorders of Communication,4,73-82. SEFERJ. W. and SCHUELL, SEFERJ. W. (1973) British Journal of Disorders of Communication,8,99-104. SHANKWEILER and HARRIS(1966). Cortex, 2, 77-292. TATHAM, M. A. A. (1968). English Structure Manipulation Drills. Longman, London. WEPMAN, J. From Proceedings of Conference on Language Retraining for Aphasics. Ohio State Univ.
Reprint requests to Miss Pamela Crunwell M.A. Sclrool of Speech Therapy, Science and Techrzologj, (North) Center, City of Birmingham Polytechnic, Franchise St. Birtninghatn B42 2SU.
