Treatment of Writing in Aphasia

Treatment of Writing in Aphasia

When an individual has aphasia, verbal output is often no longer sufficient for communication. Because of this, other modalities of communication are often explored. "Speech" therapy for aphasic patients often does not include speech activities at all, but rather focuses on a modality with which they will experience more success, and which will facilitate their communication in functional situations. Promoting Aphasic Communicative Effectiveness (PACE) is a multi-modality approach to therapy that encourages aphasics to use any means available to express themselves. One communication modality that can be included in this therapy approach is writing.

Writing can pose some problems for aphasics, however. Often following a left hemisphere stroke, a patient is forced to write with the non-dominant left hand due to right sided weakness or paralysis. For this reason, aphasic patients are sometimes reluctant to try writing as a form of communication. A way to compensate for this is to have the patient write in block letters rather than attempting to write in cursive, as block letters are much easier to produce and decipher. Another complication that can get in the way of writing therapy is the possibility of agraphia or alexia, or a combination of the two. These disorders can sometimes be seen in addition to aphasia. Also, sometimes a patient with aphasia will make some of the same errors in writing as they make in speaking, (i.e. telegraphic speech, jargon, paraphasias) and so their writing will not be any easier to understand than their speech. Depending on where the lesion is located, spelling can also be a major stumbling block to success with a writing treatment. In some cases it may be necessary to work on sound to letter correspondences before working on writing words or sentences. If spelling problems persist, a possible solution to be explored is a keyboarding device either that accepts spelling errors, or that provides a word prediction function. Word prediction could be a great help to a person with aphasia, as the words with difficult spellings would appear as choices and the aphasic would only have to recognize it rather than having to generate it independently.

Two treatments for writing abilities are Anagram and Copy Treatment (ACT) and Copy and Recall Treatment (CART.) Each of these treatments has been used with aphasic patients and produced some success in their abilities to communicate.

ACT consists of providing the patient with the letters of the target word in the form of an anagram and allowing them to put the letters in the correct order before attempting to write the word. This allows the patient to rearrange letters in the word and independently find the correct spelling. Once they have arranged the anagram to spell the target word, they copy the word several times to practice the correct spelling. After the word has been copied, the patient is asked to write it from memory. The eventual goal is for the patient to be able to write single words to facilitate communication with conversation partners. This technique can be modified to accommodate different patients. In some cases, unnecessary letters can be added to the anagram to make the task more challenging, so that the patient has to decide not only what order to write the letters in, but which letters to include. For some more severely impaired patients, there are no extra letters in the anagram, and a cueing hierarchy can be followed to help them get through the rearranging of the anagram. The cues would consist of providing one letter at a time until the word is arranged correctly, and then gradually fading out the cues so that the patient constructs the word more independently.

CART is a variation of ACT that relies only on copying the words, rather than having to unscramble them first. CART includes daily homework assignments, and can be used either alone or in addition to ACT. A CART homework packet consists of pages to copy each of the target words, and also blank "self-test" pages that are intended to be used to write the words from memory. CART has been used in many types and severities of aphasic patients, and has been shown to be effective.

In a study by Beeson, Rising, & Volk, CART was used for seven individuals with severe aphasia. The participants in the study had not had any previous treatment specifically for their writing abilities, but had been seen for speech and language therapy previously. They were all diagnosed with a severe form of aphasia and were several years post onset of the stroke. They were each seen for one individual session per week in addition to group therapy sessions. In individual sessions, the participants worked on writing words from a list that was submitted by their families. Some of the participants experienced great success with the treatment and were able to use the treated words to facilitate their communication in real life situations. The type and severity of aphasia in the patients did not turn out to be a good indicator of their success. Rather, a high level of motivation and consistent completion of the daily homework assignments was the most common indicator of success with the program. Some of the individuals who experienced success with the program attempted to write during group sessions to facilitate communication with others in the group.

In an individual case study done by Beeson in 1999, ACT and CART were used for a man with Wernicke's aphasia, ST. The words used in the treatment were chosen by the clinician and ST's wife so that they would be functional for ST. The treatment consisted of four phases, beginning with introduction of the word lists and work with them using ACT. Once the words were mastered in anagram form, ST worked on the words in daily CART homework. ST managed to maintain his abilities and to learn new words during a phase of only CART and no individual therapy sessions. In the final phase of the treatment, ST chose words to learn how to spell out of a picture dictionary and attempted to learn them independently through CART. In his individual sessions, the clinician would ask him questions that would elicit responses of the words that he had successfully learned to write, thus making the writing of the single words both functional and conversation-like. ST was highly motivated both to do his homework and to attempt to use his writing for communication. His wife provided anecdotal evidence of ST using written words to communicate at home, and he also began to combine words to comment and tell stories. ST was eager to communicate, and ACT and CART provided him the tools he needed to do so successfully. However, ST's writing of untreated words did not improve from pre-test to post-test.

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