MANAGEMENT OF PALILALIA WITH

A PACING BOARD

Nancy A. Helm
Veterans Administration Hospital, Boston

Palilalia is a speaking disorder that has been likened to the festinating gait of
Parkinsonian patients. This report describes a pacing device developed as a means
of controlling the severely palilalic output of one patient. The device is modeled
after Luria's suggestion that a treatment program for such patients can be developed
successfully by transferring automatic motor acts to a conscious, reactive level.

Palilalia is a speech disorder in which a word, phrase, or sentence may be re-

peated several times with increasing rapidity, and decreasing distinctness, so
that the latter part of a phrase may become almost inaudible (Critchley, 1927).
Palilalia most often occurs in association with postencephalitic Parkinson's
syndrome and pseudobulbar palsy (Brain, 1961). It is seen frequently in
Alzheimer's Disease, and multiple infarct dementia, and it has also been de-
scribed in two cases of idiopathic cerebral calcinosis (Boller, Albert, Denes,
1975).
Palilalia has been compared to the festinating gait of patients with Parkin-
sonism (Critchley, 1927; Espir and Rose, 1970; Boller, Albert, and Denes,
1975). These patients may have difficulty initiating walking, but once under-
way, they progress more and more rapidly with loss of control. Luria (1967)
observed that such patients have no difficulty climbing stairs, or walking across
lines painted at frequent intervals on the floor, and attributes this phenomenon
to the substitution of reactive movements for automatic movements. He sug-
gested that motor acts can be transferred to a cortical level by substituting a
series of individual, conscious impulses for a patterned response cycle, and
that this approach could be used in developing a treatment program.
This report describes the practical application of Luria's theory to the
development of a simple device for managing severe palilalia in one patient.

CASE REPORT

J. B. was a 54-year-old male referred to the Neurology Service of the Boston

Veterans Administration Hospital with a slowly progressing Parkinsonian

350

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 HELM: Pacing Board 351

syndrome. For many years he was considered demented and confined to a

mental hospital. Upon admission, the patient had stooped posture, and diffi-
culty with initiation of standing and walking. His speech was so palilalic as to
make his noncommunicative. For example, when asked his name, he might
say, m y n a m e , m y n a m e , m y n a m e . . . twenty or more times. Each repetition
was more rapid and inarticulate than the previous. Because the palilalia
blocked the transmission of information, severly hampering J. B.'s communi-
cative ability, he was referred to the speech-language pathology department
for evaluation.
During informal examination it was noted that J. B. was not palilalic
when asked to perform categorical naming tasks, which allowed him to speak
a syllable at a time. For example, when asked to list the names of animals he
replied bea~, c o w , h o r s e , with no palilalia. Furthermore, careful examination
of language skills using the Boston Diagnostic Aphasia Examination (Good-
glass and Kaplan, 1972) demonstrated intact auditory comprehension, verbal
word finding, reading comprehension and writing. Administration of the
W e c h s l e r A d u l t I n t e l l i g e n c e Scale (Wechsler, 1954) demonstrated a full scale
IQ of 90 with a verbal IQ of 97 and performance IQ of 82.
Because J. B. was neither severely demented nor aphasic, it was thought that
if he could be induced to speak slowly, syllable by syllable, he would be able
to communicate effectively. Merely suggesting this to him had no effect. A trial
of metronomic pacing also proved ineffective. Hand tapping was successful
only as long as the clinician tapped his hand, otherwise his tapping mirrored
his speech, becoming more and more rapid and indistinct. It was felt that a
device that helped J. B. to consciously control his own motor behavior might
produce results similar to those achieved with assisted hand tapping. For that
reason, a tactile pacing apparatus was conceived. It consisted of a wooden

5/16" 2-1/4"

I/8" 5/16" frl I J I/2"

LJ --]J--~ U-- q_r u U- 1 1/2' I

~" -13-3/4" ~T

2•--I/4"
l

PACING BOARD
Figure I. Illustration of pacing board with dimensions.

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 352 JOURNAL OF SPEECH AND HEARING DISORDERS XLIV 350-353 August 1979

board approximately 13 in. long (36.5 cm) and 2 in. wide (5 cm). Eight
colored segments separated by raised wooden dividers ran along the length
of the board. The colors were chosen arbitrarily and were meant to make
the segments more salient as a way of encouraging progression along the
board. While tapping his finger from left to right, from segment to segment,
J. 13. spoke syllable by syllable with no palilalia. In addition to use during
speech remediation training sessions, the board was carried in the patient's
pocket for use in conversations on the ward. It was noted, however, that J. 13.
usually had to be reminded by hospital personnel to use the board. Following
two weeks of training, J. B. was transferred to another facility, where he con-
tinues to use the pacing board to help him communicate with others.

DISCUSSION

A simple wooden pacing board proved to be an effective device for con-

trolling palilalia in one severely impaired patient. This is consistent with
Luria's statement that reactive movements can take the place of automatic
movements thus allowing Parkinsonian patients to overcome motor defects.
Of interest is the fact that J. 13. was unable to benefit from metronomic
pacing. Allan (1970) also reports that patients with advanced degrees of
festination were not helped by metronomic pacing. She interprets this as a
failure to grasp the significance of the electronic metronome. Although J. 13.
could comprehend the instructions to speak in time with the metronome, it
provided only visual and auditory stimulation. He apparently required the
reactive or purposeful motor control involved in manual tapping. Motor ac-
tivity alone was not sufficient, however. If J. B. was instructed to simply tap in
place on his leg or the table, the tapping became more and more rapid, and
the palilalia reappeared after a few syllables. It was also found that neither
manual nor verbal festination could be controlled by merely instructing him
to tap colored areas presented on a smooth surface. This finding supports
Critchley's (1927) notion that for palilalics it is easier to go on repeating words
than to make the effort of stopping. The raised dividers of the pacing board,
however, apparently imposed the stop-go control necessary for nonpalilalic
speech.
Allan (1970) has warned that patients with Parkinsonian speech disorders
must be treated forever because they deteriorate once treatment is terminated.
By contrast, the pacing board described here for palilalia allows the patient
to control his speech independent of the clinician after a short training period.
The question remains as to whether such a patient will always need the board
to speak fluently. Luria (1970) has postulated that mediating activity can
slowly be internalized. If this is the case, then one might expect that the
patient will eventually be able to pace his speech without the actual activity
of manually tapping the board. It would seem, however, that the patient's
general level of cognitive function or severity of disease might influence the
internalization process. Because J. 13. displayed an advanced form of post-

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 HELM. Pacing Board 353

e n c e p h a l i t i c P a r k i n s o n s s y n d r o m e , i n t e r n a l i z a t i o n of the m e d i a t i n g process
m a y n e v e r occur, necessitating the c o n t i n u e d use of the p a c i n g b o a r d . E v e n so,
the benefits o b t a i n e d t h r o u g h use of this b o a r d far o u t w e i g h the d i s a d v a n t a g e s
associated w i t h a n e x t e r n a l device in so far as its use allowed this p a t i e n t to
c o m m u n i c a t e effectively.

ACKNOWLEDGMENTS

Appreciatiou is expressed to Aubrey Lieberman, M.D. and D. Frank Benson, M.D. for the
assistance and encouragement they provided in preparing this case study. Requests for re-
prints should be sent to Nancy A. Helm, Director, Speech Pathology/Audiology, Aphasia
Unit, Neurology Service, Veterans Administration Hospital, 150 S. Huntington Avenue, Boston,
Massachusetts 02130.

REFERENCES

ALLAN, C. M., Treatment of nonfluent speech resulting from neurological disease-treatment

of dysarthria. Brit. ]. Dis. Commun., 5, 3 (1970).
BOLLER, F., ALBERT, M., DENES, F., Palilalia. Brit. 1. Dis. Commun., 10, 92-97 (1975).
BRMN, R., Speech disorders--Aphasia, Apraxia and dgnosia. Washington, D.C.: Butterworth
(1962).
CRITCHLEY, M., On Palilalia, ]. Neurol. r Psych. July, 23-52 (1927).
EsPm, M. L., RosE, F. C., The Basic Neurology ol Speech, Oxford and Edinburgh: Blackwell
Scientific Publication (1970).
GOOI)GLASS,H., KAPLAN, E., Boston Diagnostic Aphasia Examination, Philadelphia: Lea and
Febiger (1972).
LURIA, A. R., Traumatic Aphasia, The Hague: Mouton (1967).
WECHSLER, 1)., The Measurement of Adult Intelligence. New York: Williams and Williams
(1954).

Received October 11, 1978.

Accepted January 15, 1979.

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