Aphasiology

ISSN: 0268-7038 (Print) 1464-5041 (Online) Journal homepage: http://www.tandfonline.com/loi/paph20

Cognitive approaches to writing rehabilitation in

aphasics: Evaluation of two treatment strategies

Sergio Carlomagno , Anna Colombo , Paola Casadio , Serena Emanuelli &

Carmelina Razzano

To cite this article: Sergio Carlomagno , Anna Colombo , Paola Casadio , Serena
Emanuelli & Carmelina Razzano (1991) Cognitive approaches to writing rehabilitation
in aphasics: Evaluation of two treatment strategies, Aphasiology, 5:4-5, 355-360, DOI:
10.1080/02687039108248536

To link to this article: http://dx.doi.org/10.1080/02687039108248536

Published online: 29 May 2007.

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 APHASIOLOGY, 1991, VOI.. 5, NOS. 4 & 5, 355-360

Cognitive approaches to writing

rehabilitation in aphasics: evaluation of
two treatment strategies

SERGIO CARLOMAGNO, ANNA COLOMBO,

Istituto di Scienze Neurologiche, Universiti di Napoli, Italy

P A O L A C A S A D I O , S E R E N A E M A N U E L L I and
CARMELINA RAZZANO
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Centro Ricerche Clinica Santa Lucia, Roma, Italy

Abstract
Chronic aphasic patients received each of two rehabilitation programmes that
were devised for writing disturbances according to dual route models of
writing function. The phonological treatment stimulated non-lexical phoneme
to grapheme conversion procedures whereas patients were stimulated to use
whole word form by the vlsual-semantic treatment. Overall results showed
that the effect of both treatment procedures was significant and stable over
time. However, when single case improvement was taken into account,
almost all patients were found to respond only to one treatment. These results
are consistent with a view that models of human cognitive functions are
suitable for planning therapies for neuropsychological disturbances.

Introduction
In recent years a few single case studies have attempted to demonstrate that an
examination of aphasics’ writing disturbances from the standpoint of cognitive
neuropsychology can be used to devise specific rehabilitation programmes (Hatfield
1984, Behrmann 1987, Carlomagno and Parlato 1989). In these studies single
patients’ writing disturbances were analysed in the framework of current dual route
models of writing function, see Hatfield and Patterson for a brief survey (1984).
Then, according to such an analysis, patients were trained to use
phoneme-grapheme conversion procedures or lexical (whole word form) writing
strateges. O n the whole it was stressed that the effectiveness of a treatment depends
on our knowledge of both defective and intact components of the writing system:
i.e. only selective stimulation of (partially) spared components of the writing system,
was effective for obtaining positive effects of treatment programmes.
However, previous studies o n writing rehabilitation, conducted o n small
groups of aphasic patients by using visual or phonological strategies, had failed to
demonstrate a significant effect (stable over time) of similar rehabilitation programs
(Hatfield and Weddel 1976, Seron et al. 1980).
O u r hypothesis was that fiiilure to demonstrate positive effects of writing
rehabilitation o n a group of aphasic patients was due to the individual variability
of damaged and spared components of the writing system.

Address correspondence to: S e r h ~ oCarlomagno, Istituto di Scienze Neurologiche, Via Pansini

5, 80131 Napoli, Italy.

0268-7038/91 $3.00 0 1991 Taylor 81 Francis Ltd.

 356 Sergio Carlomagno, et al.

To test such an hypothesis each of six chronic aphasic patients was gven two
treatment programmes intended to stimulate writing by using either
phoneme-grapheme conversion procedures or visual strateges. Our main
prediction was that, if we could have observed an improvement in patients’
performance after completion of treatment, single cases, or at least some of them,
would have shown selective response to one of the two.

Method
Patients
Six highly educated aphasic patients participated in the study. They had been
chosen as having stable language deficit, from mild to moderate severity and
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severe writing disturbances as assessed by written naming and writing from

dictation tasks. All of them were at least 8 months post onset of a single
left-hemisphere stroke. Furthermore, repeated assessments on realng and writing
subsets of standard aphasia test (Pizzamiglio et al. 1985) did not show significant
improvement. Two patients showed fluent oral expression with moderate word
finding difficulties and rare phonemic paraphasias, impaired repetition and oral
comprehension disturbances fiom mild to moderate severity. Another three
patients showed non-fluent oral expression, dysartric and word finding difficulties
but quite normal oral comprehension. The last patient exhibited severely reduced
oral language with marked word finding difficulties and semantic paraphasias. His
oral comprehension was moderately impaired but repetition of single words was
error free.

Assessment
During the entire study period the six patients received standard aphasia testing
every 3 months. Furthermore, their writing abilities were evaluated by means of a
modified version of a standardized battery for assessing reading and writing
disturbances (Burani et al. 1984, unpublished). We shall focus on written naming
and word and non-word writing from dictation tasks which were slightly
modified in order to obtain a sufficient number of controlled stimuli.
The original written naming task of the battery consists of 40 stimuli chosen in
the Snodgrass and Vanderwart (1980) list so that the corresponding Italian names
are controlled for frequency, orthographic complexity and length, the last one
ranging from 4 to 9 letters. According to the orthographic peculiarities of written
Italian (Coltheart 1984), half of the stimuli contained only phonemes which are
written by one-to-one phoneme to grapheme correspondences, half also
contained phonemes which require a single phoneme to multigraphemic string
correspondence. To the orignal object naming list we added 40 items for testing
naming of actions. Action names were comparable for length (third person form),
orthographic complexity and frequency to object names. Patients were requested
to write the infinitive or the third person form of the verb.
The non-word and word lists of the original battery, 147 and 249 stimuli
respectively, were both reduced to 80 stimuli so that resulting lists were
comparable for length and orthographic complexity to that of written naming.
Moreover, in the case of words, care was taken in order to respect the criteria of
 Cognitive approaches to writing rehabilitation: evaluation of two treatments 357

grammatical class, frequency and concrete versus abstract dimension that informed
the oripnal battery. Each patient received the first 20-24 sessions of one writing
treatment. Then he received about 18 sessions of P.A.C.E. therapy (Davis and
Wilcox 1985). He subsequently was gven the 20-24 sessions of the other writing
rehabilitation programme. Finally another 18-20 sessions of language therapy, not
involving writing abilities, were administered. Three patients received first
visual-semantic treatment, the odd order was used for the remaining patients.
Writing abilities were initially assessed (pre-test), upon completion (post-test) of
each writing treatment and about 50 days after stopping the second writing
programme (delayed control). Obviously the pre-test of the second treatment
course was the delayed control of the first one.
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Rehabilitation procedures
Two treatment programmes were devised in order to stimulate, by means of
appropriate treatment tasks and coherent cues, only one of the two writing
routines assumed by current dual route models. Namely, written naming with
visual and semantic cues was used to stimulate writing by lexical routine and,
conversely, non-word writing from dictation with phonologcal cues was used to
improve writing by non-lexical phoneme to grapheme correspondences.
Each treatment programme was structured so that it stimulated patients
through all possible stages involved in each writing routine. For instance, in the
case of phonologcal treatment, patients were required to make a phonological
segmentation of the dictated stimulus, to match phonemes with a phonologcal
cue (word containing this phoneme in first position), to translate single phonemes
into their orthographic counterparts and, finally, to assemble graphemic segments
in the written form of the target. Each stage of such a procedure was
contemplated as a particular step in the treatment itself. Phonologcal cues were
provided by using town names or Christian names as previously described by
Hatfield and Weddel (1976).
On the other hand the visual-semantic treatment stimulated patients to use
residual knowledge on the whole word form: number of letters, relative position
of a letter in the string, presence of a relevant orthographic group, and so on.
Therefore, the training task was structured as a cross-word puzzle of increasing
&fticulty. In each step patients were gven visual and semantic information about
the target and such help was progressively faded out. Clinicians carefully
discouraged oral naming in order to avoid subsequent attempts to apply phoneme
to grapheme conversion procedures. Each treatment followed a progression rate
through appropriate levels of difficulty and avoided patients overtraining on few
stimuli by alternating practising items. Finally, to control learning transfer,
practising lists contained only items different fiom those of the assessment.
A complete description of the two treatment programmes is available in
Carlomagno et al. (1991).

Results
Mean number of correct responses out of the 240 target items ( 3 tasks X 80 items)
obtained in the five testing sessions are reported in Table la. Results were
analysed by means of ANOVA which showed on the whole group a significant
 358 Sevgio Curlomugno, et al.

Table 1. (a) Mean correct responses out of the 240 items (80 x 3 writing tasks) before (pre) and
upon completion (post) of each treatment.

Treatment 1 Treatment 2

Del.
Pre Post Pre Post Con.

-X 90 + 130.8 - 136.8 + 161.7 -

- 1684

one way ANOVA, F = 20.15, p<O.OOl

+ = p <0.05 (Neumann-Keuls test)
Del. Con. = delayed control, see text.

Table 1 (b) Mean number of correct responses out of the 80 items of each writing assessment
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task before (pre) and upon completion (post) of the phonological and the visual-semantic
treatment.

Pre Post

Phonological treatment

Naming 39.7 49.0

Word Writing 45.5 60.0
N-W Writing 29.0 39.3

Total 112.1 143.6

Visual semantic treatment

Naming 37.3 54.0

Word Writing 45.8 55.0
N-W Writing 28.6 34.6

Total 113.8 148.7

3 way ANOVA @/post x assessment task x type of treatment)

Pre/post F = 112.46 p <0.001

Task F = 24.81 p <0,001
Treatment NS
All interactions NS

writing improvement. Post-hoc comparisons (Neuman-Keuls) showed that

improvement was due to the two writing rehabilitation programmes whereas no
improvement could be observed through other (non-writing) aphasia therapies.
Furthermore, according to our experimental design, delayed controls provided
evidence that patients retained what they had learned.
A subsequent analysis was made by means of a three-way ANOVA (pre/post
evaluation X type of treatment X task) in order to compare the relative
effectiveness of the two programmes on the three writing tasks (see Table lb).
According to this analysis, both rehabilitation strategies were equally effective in
improving the whole group performance.
However, when looking into single patient’s results we observed that in three
out of the six patients only phonologcal treatment was effective whereas the
visual-semantic was not. For instance patient G.I. produced only 45 correct out of
 Cognitive approaches to writingrehabilitation: evaluation of two treatments 359

240 stimuli (pre-therapy score = 41) upon completion of the visual-semantic

treatment. In contrast, upon completion of the phonologcal treatment 116
correct responses were recorded (p <0.001). The reverse pattern was observed in
one patient who scored 167 correct responses after the visual-semantic treatment
(pre-therapy score = 95, p <0.001) whereas no improvement could be found after
the phonological one. For the remaining two patients we observed a strong effect
of the visual-semantic treatment but some effect of the phonologcal one was still
present.

Discussion
Our assumption was that cognitive models of neuropsychological deficit could
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provide a rationale for planning treatments for specific aphasic disturbances. As a

matter of fact the effectiveness of our two treatment programmes was supported
by a number of experimental constraints. When therapy was carried out, patients
could be considered neurologcally stable as they were at least eight months post
onset and, despite language therapy, no writing improvement could be noticed
on testing. O n the other hand, the experimental design showed that the
improvement was due to the two programmes since no improvement was
observed following other language therapies. Furthermore, patients retained what
they had learned 40-50 days after completion of treatment. Finally, a significant
learning transfer was observed since practising lists were different from those used
in the assessment sessions.
O n the whole, our results were quite different from those of Hatfield and
Weddel (1976) and Seron tTt al. (1980) whose studies did not show an effect of
writing rehabilitation procedures stable over time on unselected aphasic patients.
Contrary to their results, the positive effect of each of our programmes, when
present in a patient, was stable over time. It suggests that the two studies of
Hatfield and Weddel (1976) and Seron et al. (1980) did not take into account
the variability of patients’ compensatory behaviour: i.e. tendency to use residual
visual or phonologcal strateges. We argue that the two previous studies could
have been biased by the conflicting effects of patients’ spontaneous strategies and
the rehabilitation techniques so that training effect was reported but no retention
was found. Such an hypothesis was supported by our finding that the majority of
cases, four out of the six patients, were shown to improve by means of only one
treatment.
With reference to the last point, according to current dual route models of
writing function, we expected that only written naming and word writing could
improve by visual-semantic tretment whereas the effect of the phonologcal
could rely on better performance only on word and non-word writing.
However, such patterns failed to reach statistical significance. That was mostly
due to the fact that written naming could improve by phonological treatment.
All patients, indeed, had quite preserved oral naming (60 to 80%) and, given the
‘transparent’ structure of written Italian, improvement of phoneme to grapheme
routines could result in a better performance in written naming task by a
self-dictation strategy. However when looking into single case patterns we did
not find relevant exceptions to the predicted patterns of improvement
(Carlomagno et al. 1991). The last result was consistent with a view that each of
the two treatment techniques preferentially stimulated (partially) spared
 360 Sergio Carlomagno, et al.

components of one of the two writing routines assumed by current dual route
models.

Acknowledgements
This work has been supported by a grant &om Centro Ricerche Clinica Santa
Lucia, Roma. The authors are deeply indebted to G. Deloche (CNRS-INSERM,
Paris) for his helpfil suggestions.

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