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Oral Reading for Language in Aphasia: Impact

of 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: Lcherney@ric.org).

42

Treatment of Chronic Aphasia: International Perspectives;


Guest Editor, Chris Code, Ph.D.
Semin Speech Lang 2010;31:4251. 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.

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ABSTRACT

esearch has shown that individuals with


aphasia benefit from a variety of different treatments, even months and years beyond the time
of onset.13 Recently, 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.2,4,5 Yet, such treatment is not
always available. In fact, patients may be eligible for only a limited number of treatment
sessions following their acute hospitalization,
and the costs of communication treatment
delivered to patients with chronic aphasia (beyond 12 months after onset) are often not
reimbursable. There is a need to identify treatments that are appropriate, efficacious even
when provided at low intensity, and easily
administered to individuals with chronic
aphasia.
The purpose of this article is to present the
results of a study in which an aphasia treatment, Oral Reading for Language in Aphasia
(ORLA), was provided at low intensity to
participants with chronic nonfluent aphasia.
With ORLA, the person with aphasia systematically and repeatedly reads sentences and
paragraphs aloud, first in unison with the
clinician, and then independently.6,7 Lowintensity treatment was defined as 1 hour of
treatment, one to three times a weeka treatment schedule that is typical of aphasia outpatient therapy in the United States.
Based on neuropsychological models of
reading, ORLA was initially developed to improve reading comprehension in individuals
with aphasia by providing practice in the phonological and semantic reading routes.6,7 However, preliminary studies with a small number
of subjects have shown that improvements may
occur in other modalities aside from reading
comprehension. Improvements in oral expression, auditory comprehension, and written expression have been seen in both fluent and
nonfluent aphasia.610
Several explanations for the cross-modal
generalization have been suggested, and these
may be related to specific features of the ORLA
technique. For example, ORLA incorporates
repetitive multimodality stimulation and practice to elicit a response. Participants see a
written sentence and, at the same time, hear

it and attempt to say it. Their verbal responses


are not overtly corrected but are followed by
additional multimodality stimulation.11,12
With repeated practice in auditory comprehension and oral expression, improvements in
these modalities would typically be expected.
Others suggest that the interactive processing
during oral reading also serves to strengthen
partial or degraded lexical information, so that
the benefit is not only at the level of the
orthographic input lexicon, but extends to
language processing by other modalities as
well, including written expression.13
Additionally, ORLA has been shown to
be an efficacious approach for treating apraxia
of speech in two patients with Brocas aphasia.8 The technique may be efficacious because
it incorporates three elementsrhythm, pacing, and linguistic templatesthat contribute
to establishing an underlying oscillatory
rhythm, melody, and rate for speech production.14 The patients paced pointing to each
word of the sentence, together with the linguistic template and natural rhythms and intonation provided by the clinician, may help
facilitate the patients temporal flow and articulatory rate of speech.
By focusing on connected discourse,
ORLA allows practice on a variety of grammatical structures rather than just one specific
grammatical form. It has four levels of difficulty
based on length and reading level:
 Level 1: Simple 3- 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, at a third
grade reading level
 Level 3: 15 to 30 words, divided into two
to three sentences, at a sixth grade reading level
 Level 4: 50 to 100 words comprising a
four- to six-sentence simple paragraph, 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. Details
of the ORLA procedure are described in the
Appendix.

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ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY

SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31, NUMBER 1

2010

Appendix: Oral Reading for Language in Aphasia (ORLA)


1. The speech-language pathologist reads aloud to the patient, pointing to each word as he or she reads
along. The length of the material may vary from 3 to 100 words, depending on the auditory
comprehension skills of the patient.
2. The speech-language pathologist reads aloud to the patient again, pointing to each word as he or she
reads along and encouraging the patient to also point to each word.
3. The speech-language pathologist reads the paragraph aloud together with the patient, while continuing
to point to each word as he or she reads along. The patient also points to each word. The clinician
adjusts the rate and volume of the oral reading according to the specific patient (e.g., reading a little
ahead of the patient so he or she is able to hear the initial phonemes of the words; decreasing volume
as the patient requires fewer cues).
4. For each line or sentence of the paragraph, the speech-language pathologist states a word that the
patient must then identify. Words may be content words (e.g., nouns, verbs) or function words
(e.g., pronouns, prepositions, conjunctions).
5. For each line or sentence of the paragraph, the speech-language pathologist points to a word for the
patient to read aloud. Both content and function words are selected.
6. The patient reads the whole sentence aloud again in unison with the speech-language pathologist.

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. Specifically,
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, 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. Eligibility criteria included the following: a single left-hemisphere stroke as
determined by history and physician report;
nonfluent aphasia (but not global aphasia);
premorbidly right-handed; at least a 12th grade
education; visual acuity no worse than 20/100
corrected in the better eye; auditory acuity no
worse than 30 dB HL at 500, 1000, and
2000 Hz, aided in the better ear. All partic-

ipants provided written, informed consent


under the approval of the Northwestern University Institutional Review Board.
Twenty-five individuals (16 men, 9
women) with chronic nonfluent aphasia (more
than 12 months post-onset) met the inclusion
and exclusion criteria. Severity of the aphasia, as
determined by the Aphasia Quotient (AQ) of
the Western Aphasia Battery (WAB), ranged
from 9.7 to 81.5 (mean, 53.74; standard deviation [SD], 25.34) for the entire group. When
subjects were divided into three groups based on
severity, AQ range for the 6 severe subjects was
9.7 to 21.1 (mean, 13.73; SD, 3.97); AQ range
for the 9 subjects in the moderate group was
49.4 to 60.7 (mean, 54.74; SD, 3.53); and AQ
range for the 10 subjects with mild to moderate
aphasia was 66 to 81.5 (mean, 76.84; SD, 5.56).
It was not necessarily intended that groups
should be equivalent on key variables such as
age and chronicity; rather, 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. Additional demographic details
can be found in Table 1.

Study Design
A delayed treatment design was used,
which allowed all subjects to receive treatment
following a period of no treatment. Subjects

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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)
66.33 (11.79)
Range
50.2180.36
Months post-onset
Mean (SD)
31.98 (24.13)
Range
12.3671.97
Age at Baseline testing (years)
Mean (SD)
69.00 (10.28)
Range
56.2281.65
WAB AQ
Baseline
13.73 (3.97)
Pretreatment
15.73 (4.78)
Post-treatment
18.48 (5.06)
WAB reading
Baseline
29.00 (13.94)
Pretreatment
26.83 (14.29)
Post-treatment
33.83 (14.03)
WAB writing
Baseline
8.17 (6.14)
Pretreatment
7.42 (6.61)
Post-treatment
7.33 (6.06)
RCBA4 subtests
Baseline
6.17 (4.75)
Pretreatment
6.50 (4.0)
Post-treatment
7.50 (6.16)
Discourse wds/min
Picture description
Baseline
9.58 (7.50)
Pretreatment
7.90 (9.47)
Post-treatment
12.19 (22.69)
Discourse CIUs/min
Picture description
Baseline
0.00 (0.00)
Pretreatment
0.00 (0.00)
Post-treatment
0.00 (0.00)
Discourse wds/min
Narrative
Baseline
5.37 (4.39)
Pretreatment
10.12 (11.17)
Post-treatment
11.89 (18.78)
Discourse CIUs/min
Narrative
Baseline
0.00 (0.00)
Pretreatment
0.11 (0.27)
Post-treatment
0.19 (0.46)

Moderate Aphasia
(AQ 4565)

Mild-to-Moderate
Aphasia (AQ 6685)

9
5:4

10
9:1

51.62 (17.59)
25.2078.60

50.59 (9.10)
33.9564.03

71.83 (83.86)
12.16253.21

47.34 (43.38)
12.16138.56

57.61 (13.46)
39.0679.64

54.54 (10.74)
35.1871.95

54.74 (3.53)
54.91 (6.75)
57.34 (5.93)

76.84 (5.56)
77.63 (6.36)
79.75 (4.71)

61.56 (17.11)
65.89 (15.49)
58.44 (15.93)

85.90 (9.61)
88.40 (9.41)
87.80 (9.34)

38.50 (16.65)
41.22 (17.65)
39.78 (20.22)

69.60 (15.99)
69.35 (17.08)
75.05 (18.66)

17.44 (8.60)
17.78 (10.72)
20.22 (10.84)

32.10 (4.12)
31.60 (33)
32.00 (6.63)

34.15 (21.36)
32.93 (21.36)
33.31 (17.48)

44.85 (19.90)
44.70 (20.89)
55.65 (18.51)

10.96 (10.10)
11.55 (8.99)
12.17 (9.13)

26.49 (16.52)
26.11 (13.81)
31.93 (13.49)

39.44 (19.07)
31.89 (23.27)
35.75 (16.91)

45.82 (17.74)
47.76 (23.64)
55.90 (20.96)

10.90 (9.84)
10.39 (10.32)
15.18 (12.88)

24.54 (12.67)
28.73 (15.37)
31.28 (14.52)

AQ, Aphasia Quotient; SD, standard deviation; WAB, Western Aphasia Battery; RCBA, Reading Comprehension
Battery for Aphasia; CIUs, correct information units; wds, words.

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Table 1 Demographic Information and Test Scores (Mean and SD) for Subjects with Severe,
Moderate, and Mild to Moderate Chronic Aphasia

SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31, NUMBER 1

outcomes were measured at three separate time


periods: (1) at entry into the study (baseline),
(2) after the no-treatment period of 7 to 12
weeks and before the start of the intervention
(pretreatment), (3) at the end of the intervention (post-treatment). The speech-language
pathologist who conducted the assessments
was independent of the clinician who provided
the ORLA treatment.
At each evaluation, subjects were assessed
using the WAB,15 four subtests of the Reading
Comprehension Battery for Aphasia (RCBA2),16 and several discourse measures. The
RCBA-2 subtests included paragraph-level
reading (paragraph-picture, paragraph-factual,
paragraph-inferential) as well as functional
reading. Discourse tasks included descriptions
of two composite pictures and two narratives
based on a series of picture sequences.17 The
elicited discourse samples were analyzed for
rate of speech (words per minute) and informational content (correct information units
[CIUs] per minute). 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.

Intervention
Subjects participated in 24 1-hour sessions of
ORLA treatment, scheduled two to three times
a week; therefore, the planned treatment period
varied from 8 to 12 weeks. Subjects did not
receive any other individual or group treatment
while they were participating in this study.
Treatment was as follows: (1) Subjects listened
to a sentence twice, while simultaneously looking at it written on an index card or computer
screen; the second time, they also pointed to
each word of the sentence. (2) Subjects attempted to read the sentence aloud together
with the therapist; this was repeated twice.
(3) For each sentence, subjects were asked to
identify two or three randomly selected single
words and read each word aloud. (4) Finally,
the subject read the entire stimulus aloud again
in unison with the therapist. Stimuli were
sentences of varied vocabulary items and grammatical structures, presented with natural
speech prosody. During an hour of treatment,

2010

subjects typically practiced 30 different stimuli


of a specific length (3- to 5-word sentences,
8- to 12-word sentences, 15- to 30-word brief
paragraphs) predetermined by their language
level. Over 24 sessions, 90 stimuli at each
length were available for practice.

Data Analysis
Because we were interested in how ORLA
impacts individuals with aphasia of different
severity levels, subjects were divided into three
severity levels based on their score on the WAB
AQ. Means and SDs of each test score were
calculated at each assessment period for each of
the three severity levels. Because of the relatively small number of subjects within each
severity level, effect size measures were computed. Effect size measures the magnitude of a
treatment effect and, unlike significance testing, is independent of sample size.18 Cohens d
and the effect-size correlation rYl were calculated using the original means and SDs of the
two dependent groups.19 A positive effect size
represents improvement, and a negative effect
size represents a worsening of symptoms.
The effect sizes were benchmarked against
Cohens (1988) definition of effect size as:
small, d 0.2; medium, d 0.5; and large,
d 0.8.18

RESULTS
Intervention Period
Subjects were scheduled to receive 24 1-hour
sessions of ORLA, two to three times a week.
All subjects received the same number of sessions. However, unexpected issues such as
transportation difficulties or unplanned outof-town trips sometimes arose. Therefore the
treatment periods varied, with some patients
attending only once per week, and one subject
attending as many as four times a week. The
mean length of the treatment period was 12.62
weeks (range of 6 to 22 weeks).

Outcomes
For all 25 individuals with nonfluent aphasia,
the mean change in AQ test scores (the primary

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ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY

each evaluation task completed at each assessment time (baseline, pretreatment, and posttreatment) for each aphasia severity level.
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.
None of the effect sizes were large; however,
several effect sizes indicating improvements
from pretreatment to post-treatment could be
benchmarked as medium.
Medium effect sizes were obtained for all
severity levels from pre- to post-treatment for
the primary outcome measure, the WAB AQ,

Table 2 Cohens 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- to post-treatment
WAB Reading
Baseline to pretreatment
Pre- to post-treatment
WAB Writing
Baseline to pretreatment
Pre- to post-treatment
RCBA4 subtests
Baseline to pretreatment
Pre- to post-treatment
Discourse wds/min
Picture description
Baseline to pretreatment
Pre- to post-treatment
Discourse CIUs/min
Picture description
Baseline to pretreatment
Pre- to post-treatment
Discourse wds/min
Narrative
Baseline to pretreatment
Pre- to post-treatment
Discourse CIUs/min
Narrative
Baseline to pretreatment
Pre- to post-treatment

Moderate Aphasia
(AQ 4565)
9

Mild to Moderate
Aphasia
(AQ 6685)
10

0.455
0.559

0.222
0.269

0.032
0.382

0.016
0.188

0.132
0.379

0.066
0.186

0.154
0.494

0.077
0.240

0.265
0.474

0.132
0.231

0.263
0.066

0.130
0.033

0.118
0.014

0.009
0.007

0.159
0.076

0.079
0.038

0.015
0.321

0.008
0.159

0.058
0.157

0.029
0.078

0.035
0.226

0.017
0.112

0.021
0.065

0.011
0.032

0.197
0.247

0.098
0.122

0.088
0.246

0.044
0.122

0.028
0.512

0.014
0.248

Cannot be computed

0.132
0.320

0.066
0.158

0.019
0.389

0.009
0.191

0.560
0.115

0.270
0.057

0.169
0.376

0.084
0.185

0.123
0.331

0.062
0.163

0.576
0.212

0.277
0.105

0.032
0.501

0.016
0.243

0.345
0.139

0.170
0.069

Medium effect sizes are in boldface.


AQ, Aphasia Quotient; WAB, Western Aphasia Battery; RCBA, Reading Comprehension Battery for Aphasia; CIUs,
correct information units.

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outcome measure) from pre- to post-treatment


was 2.38 (SD, 5.3) compared with a mean
change of 0.85 (3.5) in the 8- to 12-week
pretreatment interval. Although these differences were small, the change in WAB AQ from
pretreatment to post-treatment was significant
(P < 0.05), whereas the change during the notreatment period from baseline to pretreatment
was not significant. Furthermore, there was a
significant mean change of 3.24 (SD, 4.47) in
the WAB AQ from baseline to post-treatment
(P < 0.001).
Table 1 presents additional demographic
data, as well as the mean and SD obtained for

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SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31, NUMBER 1

which assesses a combination of auditory comprehension and oral expression. The greatest
effect size (d 0.559) was obtained for the
severe group. However, it is important to
note that for this group, a smaller yet medium
effect size was also obtained for the no-treatment period from baseline to pretreatment.
For the WAB reading subtests, a medium
effect size was obtained only for the severe
aphasia group. For the WAB writing subtests,
a medium effect size was obtained only for the
mild to moderate aphasia group.
Two different discourse tasks were used
with different outcomes. For the picture description task, the mild to moderate aphasia
group achieved medium effect sizes on both
rate (words per minute) and content (CIUs per
minute). The moderate aphasia group achieved
a medium effect size for rate only. In contrast,
for the narrative discourse task, the moderate
aphasia group displayed a medium effect size
for treatment changes on both rate (words per
minute) and content (CIUs per minute),
whereas the mild to moderate aphasia group
showed improvements only on rate. Once
again, the medium effect size in the no-treatment period for the severe aphasia group is
noteworthy.

DISCUSSION
The purpose of this study was to examine
whether low-intensity ORLA resulted in language improvements that are greater than
changes without treatment, and if so, whether
there were differential effects related to the
severity of the aphasia. For the participants as
a group, overall small but statistically significant changes occurred during the treatment
period as measured by the WAB AQ, the
primary outcome measure. In contrast, the
small changes that occurred during the notreatment period were not significant. With
regard to clinical significance, a 5-point change
on the WAB AQ is considered to be important.20 The mean change of 2.38 obtained for
the entire group of 25 participants certainly
does not reach this target change. However,
examination of individual subject data indicated that 7 of the 25 did make a greater than
5-point change, with improvements ranging

2010

from 6.2 points to 16.3 points. Of these subjects, one was in the severe group, two were in
the moderate group, and four were in the mild
to moderate group. Interestingly, these seven
subjects were all men with ages varying between 35 and 69 years. Presently, we have
insufficient data to differentiate these good
responders from poor responders based on
personal characteristics or neuroanatomical or
neurophysiological differences. Intensity of
treatment was also not a factorthe treatment
period for 24 sessions of ORLA ranged from
6 weeks to 16 weeks, with no obvious trend for
greater improvement with more intensive
treatment. Nevertheless, the present data support the notion that for some patients with
aphasia, even low-intensity ORLA treatment
may result in large changes on the WAB AQ,
regardless of the chronicity of the aphasia.
Overall, results are consistent with those of a
meta-analysis of 55 aphasia treatment studies,
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 (0.66 versus 0.05).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. Although 1 to
3 hours of treatment per week is typical of
outpatient treatment in the United States,
research is indicating that more intense treatment results in better outcomes. For example,
a retrospective analysis was conducted of
10 studies, 5 of which had significant treatment
effect. In these 5 studies, participants were
provided an average of 8.8 hours of treatment
per week for an average of 11.2 weeks.22 The
5 of these 10 studies that did not have positive
outcomes provided only 2 hours of therapy
per week for 22.9 weeks. Furthermore, number
of treatment hours per week was significantly
correlated with improvement on the language
outcome measures.22
More recently, a systematic review of the
literature identified five studies that directly
evaluated treatment intensity in chronic aphasia.23 These included a retrospective analysis
of the pre- and post-treatment abilities of
40 participants who demonstrated greater

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48

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.24 Another study compared three pairs of participants matched in
type and severity of aphasia, as well as demographic characteristics.25 All participants improved, 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).25
Overall, the systematic review indicated that
there is modest evidence for the efficacy of
more intensive treatment of chronic aphasia.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.4
However, even low-intensity ORLA may affect the induction of neural plasticity. 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.26 For one participant, brain
activation increased in the right hemisphere
during oral reading, but decreased bilaterally
in most regions on story comprehension. For
the other participant, there was decreased
activation, particularly in the right hemisphere, during oral reading but increased activation bilaterally on story comprehension.
Although the neurophysiological pattern of
change differed in the two subjects and interpretation remains difficult, results highlight
the fact that low-intensity ORLA can affect
brain activation changes in individuals with
chronic aphasia.
Results support the differential effects of
the ORLA treatment based on severity of the
aphasia. Subjects with severe aphasia were
the only group to make noticeable change on
the WAB reading scores, where a medium
effect size was obtained for the treatment
period. Although the RCBA-2 did not reflect
changes in reading to the same extent, the
effect size of 0.2 was greater than the effect
size of 0.058 obtained in the no-treatment
period. Because ORLA was initially designed
to improve reading comprehension, the finding

of improved reading comprehension in the


severe aphasia group is not surprising.
Subjects with both moderate aphasia and
mild to moderate aphasia demonstrated
changes in discourse with treatment. For the
moderate group, medium effect sizes were
evident for both rate and content of the narrative discourse and for content on the picture
description task. Additionally, the small effect
size obtained for rate on the picture description
task contrasts with the effect size of 0.088 for
the no-treatment period. For the mild to moderate group, the most noticeable changes were
for rate in both tasks, and for the content of the
picture description. These changes in discourse
are reflected in the overall change in the WAB
AQ. Subjects with mild to moderate aphasia
were the only group to show changes on writing. Writing is a complex skill and therefore it
is one of the last language skills that is acquired.
The differentiation of the groups into
three severities was an arbitrary but pragmatic
decision determined by the subject pool, rather
than by any theoretical basis. The goal was to
ensure that there were sufficient numbers of
subjects in each severity group to evaluate
trends. However, no subjects with a severity
on the WAB AQ of 26 to 44 were recruited.
Therefore, we do not have any data about the
performance of this severity group on ORLA.
We also cannot ignore the possibility that if we
had recruited subjects with this range of severity, depending on the number of subjects,
the cutoff points for the other severity levels
may have changed. With a different distribution of subjects, the effect sizes may also have
changed. On the other hand, consistent with
our clinical perceptions, the category of subjects
within the WAB AQ range of 26 to 44 may
have formed their own moderately severe aphasia group, without changing the makeup of the
other groups.
Different results may also have been obtained if different evaluation tools to measure
outcomes had been selected. The WAB was
selected because it provides an overall quantitative metric of aphasia severity (the AQ).
Furthermore, it explores a wide range of
communicative abilities including auditory
comprehension, oral expression, reading comprehension, and written expression. Because it

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ORLA: IMPACT OF APHASIA SEVERITY ON OUTCOMES IN CHORNIC NONFLUENT APHASIA/CHERNEY

SEMINARS IN SPEECH AND LANGUAGE/VOLUME 31, NUMBER 1

has been psychometrically characterized and


found to be valid and reliable,27 the WAB
AQ was selected to serve as the primary outcome measure. However, the WAB measures
language at the impairment level only, and,
although scores may correlate with caregiver
ratings of functional communication skills,28 it
is not a direct measure of activity/participation.
The discourse measures provided a better indication of change at the activity level, but there
was no measure of the impact of ORLA on
everyday communication participation, which is
an important consideration, particularly for individuals with chronic aphasia.
It is important to address the medium
effect sizes obtained during the no-treatment
period, particularly for the severe aphasia
group. This was apparent on the WAB AQ
as well as on both the rate and content measures of the narrative discourse task. Rather than
a true change in language skills, the person with
severe aphasia may be more susceptible to the
stress and anxiety of the test-taking situation,
often in unfamiliar surroundings with unfamiliar clinicians, resulting in decreased performance, especially with oral expression. It should
also be noted that the severe aphasia group was
the oldest group, and older patients may find
such situations more stressful than those who
are younger.29 At the second test session, the
surroundings, personnel, and tasks were now
familiar and the situation was overall less
stressful, perhaps resulting in better measures
of performance.
There are several limitations to the study.
With the WAB AQ as the primary outcome
measure, there was sufficient power to address
questions related to treatment efficacy with the
entire group of 25 subjects. However, the
relatively few subjects within each severity level
limited our analyses. Future research needs to
have more participants across the full range of
severities, including those between 26 and
65 years old, on the WAB AQ. Although the
delayed treatment design allowed all patients to
receive the ORLA treatment, a randomized
controlled trial with two independent groups
would have provided stronger evidence for
evaluating the efficacy of low-intensity
ORLA. Finally, no follow-up data were collected. Future studies need to include a main-

2010

tenance period so that the long-term impact of


ORLA can be assessed.
With the new knowledge emerging about
the importance of treatment intensity, we need
to investigate what the optimum dose of
ORLA might be. Although there is a preference for more intensive therapy, individuals
with chronic aphasia may still improve their
language skills even with low-intensity treatment, and differences in modality-specific outcomes may be anticipated based on the severity
of the 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 discourse skills may be anticipated in
those with moderate or mild to moderate
aphasia. Clinicians should be aware of these
potential differential improvements so that,
based on their patients needs and goals, they
can determine whether ORLA will be an
appropriate treatment to select, anticipate improvement in specific language modalities, and
document goals accordingly.

ACKNOWLEDGMENTS

This study and preparation of the article were


supported by Grants # H133G060055 and
H133G010098 from the National Institute
on Disability and Rehabilitation Research,
U.S. Department of Education. Thanks are
extended to Edna Babbitt and Jodi Oldani,
research speech-language pathologists, for assessing and treating the participants with
aphasia.
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