LINGUIST List 14.2170

Sun Aug 17 2003

Review: Cog Sci/Neuroling: Papathanasiou & De Bleser

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  1. Liang Chen, The Sciences of Aphasia: From Therapy to Theory

Message 1: The Sciences of Aphasia: From Therapy to Theory

Date: Sat, 16 Aug 2003 14:30:01 +0000
From: Liang Chen <chenlouisiana.edu>
Subject: The Sciences of Aphasia: From Therapy to Theory

Papathanasiou, Ilias and Ria De Bleser, ed. (2003) The Sciences of
Aphasia: From Therapy to Theory, Elsevier Science Ltd.

Announced at http://linguistlist.org/issues/14/14-774.html


Liang Chen, University of Louisiana at Lafayette.

SYNOPSIS

This book grew out of the first European Research Conference on
Aphasia (Euroconference 2000: The Sciences of Aphasia: From Therapy to
Theory). It consists of 18 chapters in addition to a preface by John
C. Marshall. Each chapter is an independent article by different
authors, and provides state-of-the-art review on controversial
research and clinical issues in aphasia and aphasia therapy. The
editors arranged these articles according to 4 major sections. It will
be an invaluable resource for clinicians, students and researchers
involved in aphasia and aphasic therapy including doctors,
psychologists, linguists and speech and language therapists.

Chapter 1, 'Prospects in the Study of Aphasia: The Nature of the
Symptom and Its Relevance for Future Research' by Jason Brown, stands
on its own. It attempts to formulate a scientific theory of the
symptom by focusing on the growth process of morphogenesis in the
fetal brain that 'mediates the translation from the genetic code to
brain structure' (p. 5). Two mechanisms, namely, parcellation and
heterochrony are involved in morphogenesis. Parcellation essentially
involves initial proliferation cells and their connections with later
loss of cells and cell connectivity due to competitive interactions to
achieve synaptic specificity. Heterochrony is the rate or timing of
parcellation. It refers to the idea that 'in brain development or
evolution, different organ systems can develop at different rates, and
that this difference in the timing of development can lead to shifts
in evolutionary outcomes, including adaptations, errors, and severe
aberrations' (p. 8). The author advances the concept of the error 'as
a link between specification and timing, or the pattern of process and
its rate' (p. 11), and argues that 'The recapitulation is for the
process, not the actualized elements it deposits' (p. 11). Symptoms
are predicted to undergo a coherent rather than piecemeal transition.

Section 1: THE NEUROSCIENCES OF APHASIA

Chapter 2. The Neurology of Recovery From Stroke, by Nick Ward and
Martin Brown. The authors recommend the admission of the patient to a
stroke unit to enhance early recovery during the acute stage. After
the acute stage, rehabilitation input from specialist therapists
(e.g., physiotherapy) is recommended. In assessing any form of
rehabilitative strategy, including treatment of aphasia, it is
important to look beyond improvements in activities of daily
living. This idea echoes the functional, pragmatic, communicative,
quality-of-life orientation in aphasia assessment, therapy, and
outcome research.

Chapter 3. Evidence from Basic Neuroscience and Human Studies of
Pharmacologic Therapy, by Delaina Walker-Batson. The author first
reviews theories of neuroplasticity thought to underlie behavioral
recovery. The author then reviews a number of animal studies of
recovery which suggest 'that the type of input may effect neural
reorganization and that the timing of retraining or rehabilitation may
be very important' (p. 37). They also suggest that 'treatment
approaches can be either adaptive or maladaptive' (p. 37). The author
then reports some data from humans on pharmacologic therapy in the
treatment of hemiplegia and aphasia. The data suggest that 'low-dose
amphetamine accelerates the rate and in some patients the extent of
aphasia recovery when entered in the subacute but not the chronic
recovery period independent of initial language severity, age or
lesion size' (p. 41).

Chapter 4. Neuroanatomical Substrates of Recovery of Function in
Aphasia: Techniques and Evidence from Neurophysiology, by Ilias
Papathanasiou. The author first discusses various theories of
functional neuroanatomical recovery mechanisms and their
limitations. Then current neurophysiological techniques used to study
brain structure and brain function are described. For example, the
neuroimaging methods used to study brain structure include CT
(transmission tomography), MRI (magnetic resonance imaging), PET
(positron emission tomography) and SPECT (single photon emission
tomography). Techniques available to study brain function include (a)
using PET or fMRI to image brain during a 'task' by looking at the
blood flow, (b) using EEG (electoencephalography) and MEG
(magnetoencephalography) to record electrical or magnetic activity of
the brain during performance of a task, and (c) using TMS
(transcranial magnetic stimulation) to stimulate brain neurons and
examine the effects on behavior. Finally, the author reviews a number
of animal studies, brain imaging studies, and TMS studies which
'provide empirical evidence for functional neuroanatomical mechanisms
involved in the recovery of function' (p. 55). The author recommends
the use of available neurophysiological techniques in future therapy
studies in order to provide better service delivery.

Chapter 5. Subcortical Aphasia: Evidence from Stereotactic Surgical
Lesions, by Bruce E. Murdoch, Brooke-Mai Whelan, Deborah G. Theodoros,
and Peter Silburn. The authors examined the pre- and post-surgical
language abilities of two subjects, one of whom underwent pallidotomy,
and the other thalmotomy. Results support the hypothesized role for
subcortical structure (i.e., globus pallidus and the dominant
thalamus) in linguistic processes. They also lend support to the
hypothesis of a cortico-striato-pallido- thalamo-cortical loop
subserving language function. However, the authors point out
immediately that more data for larger sample of subjects need to be
collected to substantiate these results.

Section 2: COGNITIVE AND PSYCHOLINGUISTIC APPROACH TO APHASIA THERAPY

Chapter 6. Cognitive Neuropsychological Approaches to Aphasia Therapy:
An Overview, by Ria De Bleser and J�rgen Cholewa. They first describe
the three approaches to aphasia therapy, namely, communicative,
linguistic, and cognitive approaches. Shift of paradigm from group
studies to single case studies in aphasia therapy has brought about
the shift of paradigm from linguistic or communicative disabilities to
impaired cognitive language functions in efficacy study of aphasia
therapy. In order to be able to predict and generalize, any cognitive
approach need to meet several requirements of therapy design. Among
them are: (a) clearly defined and evaluable dependent variable, (b)
consistent therapy method throughout the intervention, and (c)
multiple baselines design. As examples of cognitive therapy research,
the authors review several studies on deficits in segmental written
language processing. [>> see p. 102-106).]These studies raise the
question of 'why certain therapeutic procedures but not others lead to
the desired results with certain patients, or why some patients but
not others benefit from a particular intervention procedure' (p. 106).
To answer such questions, 'several authors (e.g., Hillis and
Caramazza, 1994; Schwartz and Whyte, 1992; Wilson and Patterson, 1990)
advocate that new models on cognitive learning mechanisms must be
developed in addition to the existing cognitive models of language'
(p. 107).

In Chapter 7. Lurian Approach to Aphasia Therapy: A Review, Zsolt
Cs�falvay reviews Luria's approach to clinical aphasiology which
characterized by a 'logical link between diagnosis of aphasia and its
treatment' (p. 111). The review is based on Luria (1963, 1973). As
Caplan (1987: 132) points out, 'Luria provided the first reasonably
detailed model of language processing related to aphasia and to the
brain'. For Luria, aphasia therapy must consider patients'
personality and must always be directed toward the whole person
instead of his/her isolated abilities. Luria and his colleagues
proposed five methodlogical principles of clinical therapy. They are
(a) identification of the primary problem, (b) inclusion of intact
systems of analyzators, (c) transfer of the function to hierarchically
higher or lower level of realization, (d) inclusion of intact
cognitive processes, and (e) including control and feedback into
therapy.

Chapter 8. Therapy for Lexical Disorders, by Anna Basso. Assuming
that therapy for lexical disorder should take both the form and the
origin of the error into consideration, the author sketches a
dual-route model of the structure of the lexical system which has been
used as a reference point in analyzing the patients' functional
damage. Several distinctions are made in such a model: meaning/form
distinction of a lexical item; input/output lexicon distinction;
orthographic/phonological information distinction; and
lexical/sublexical processes distinction. A review of several studies
on cognitive rehabilitation of naming disorders shows that (a) no
treatment has been reported for rehabilitation of comprehension, (b)
no really new technique for naming disorders has been reported, and
(c) cognitive approaches are limited to treating patients in clinical
setting, but may not improve the patients' everyday life. Therefore,
the author suggests that we need consider data about learning in
normal subjects in constructing a theory of aphasia therapy, as long
as we don't know more about how recovery from aphasia occurs.

Chpater 9. Verbal Retrieval Problems at the Word and Sentence Level:
Localization of the Functional Impairments and Clinical Implications,
by Roelien Bastiaanse. Following Levelt's (1989) model for speech
production, this paper argues that the impairments in verb retrieval
in Broca's and anomic aphasia arise at different levels (lemma
vs. lexeme level respectively). For Broca's aphasia, verb retrieval
deficits arise at thematic (argument-structure), morphological, and
syntactic levels, but usually not at the lexical-semantic level. In
contrast, lexical-semantic factors do affect verb retrieval ability of
anomic aphasics. The author also reports two recent studies to
address the question of whether lemma selection itself or the
processing of lemma information (i.e., grammatical encoding) is
impaired in Broca's aphasics. It is found that grammatically more
complex constructions (e.g., those with verb movement) are more
difficult for patients with Broca's aphasia, suggesting the locus of
impairment in Broca's aphasia is in the grammatical encoder. The
clinical implication of this approach to verb retrieval deficits is
the necessity to identify the level of breakdown and then focus on the
training of verb production as an essential part of language therapy,
because 'verbs are not only central in the sentence construction
process, but also contain much semantic information' (p. 146).

In Chapter 10, Luise Springer describes 'Reduced Syntax Therapy
(REST): A Compensatory Approach to Agrammatism'. Assuming the
adaptation theory (i.e., aphasic symptoms can reflect either the
underlying deficit or the attempt to compensate this deficit), the
REST approach focuses on reduced sentence structures, 'deliberately
encouraging rather than preventing the production of a telegraphic
style' (p. 152). There are five levels in the REST-approach to
treatment of agrammatism, namely, (1) 2-word utterances: VP with
direct objects, (2) 2+1-word utterances: VP with prepositional phrase,
(3) 3-word utterances: VP plus subject, (4) 3-4-word utterances: VP
plus S-Adverb, and (5) 3-4 word utterances: VP plus indirect
object. Each level is exemplified for both German and English. From
Level 1 to Level 5, there is the systematic expansion of sentence
fragments and syntactic frames, and the verb is always the
focus. Springer also reports the findings of a study using REST
approach to treat a group of 11 right-handed patients with chronic
agrammatism. After a total of 30 full hour treatments each, eight
patients showed significantly more constituents per utterance, more
non-finite verbs in their spontaneous language. Moreover, follow-up
data in four patients show that REST approach, in contrast to earlier
approaches focusing on the relearning of grammatically correct
sentences, has led to stable transfer into spontaneous speech. As a
conclusion to the paper, Springer suggests the potential of
integrating REST into computer- mediated-communication, and thus
providing patients with impairments of sentence production
possibilities for remote communication.

Section 3: FUNCTIONAL, PRAGMATIC AND PSYCHOLOGICAL APPROACHES TO
APHASIA THERAPY

Chapter 11. Functional and Pragmatic Directions in Aphasia Therapy, by
Leonard L. LaPointe. Since 1970s, aphasiology has undergone a shift of
focus from formal aspects of language (e.g., phonology, morphology,
syntax and semantics) to functional, pragmatic, and communicative
aspects of language use. Models of aphasia incorporate more and more
social elements and interaction needs of communicators (e.g., the life
participation approaches in US, UK, and Australia). These models pay
special attention to the subjective quality of life of aphasic people
(Simmons-Mackie & Damico, 2001). People start to accept the notion
that 'aphasia in most cases is a chronic condition' (p. 164), and
group treatment become popular again. LaPointe asserts that the
functional, pragmatic, and life participation approaches are effective
in facilitating successful life with aphasia, and he suggests that
clinical aphasiology need 'adapt to the changing landscape of aphasia
intervention' (p. 170), and aphasia researchers and practioners need
to 'find out a lot more within the realm of aphasia sociology to
better guide our services' (p. 168).

Chapter 12. Conversation Analysis and Aphasia Therapy, by Ruth
Lesser. The functional and social/societal aspects of language use
have been increasingly important in aphasia assessment and therapy
since 1970s. Conversation analysis (CA) provides not only a useful
means for assessing functional communication, but also 'a structure
for directly targeting the ultimate aim of therapy in improving
quality of life' (p. 183). This paper illustrates CA through examining
repairs in conversation and correction as the interactional
business. It also deals with the implications of CA in intervention
and how CA can be applied in therapy. Issues of quantification in the
use of CA are also briefly discussed.

Chapter 13. Supported Self-Help Groups for Aphasia People: Development
and Research, by Chris Code, Chris Eales, Gill Pearl, Margaret Conan,
Kate Cowin and Julie Hickin. The authors first relate the development
of supported self-help groups for people with aphasia to the
disability movement and an interest in 'more socially relevant and
authentic rehabilitation' (p. 189). Aphasia clinicians may help the
members with both practical issues (e.g., finding a meeting place) and
professional advising. They then report the results of a study which
aimed to determine the profile of the membership of the supported
self-help groups for aphasic people in Britain. They find that most
self-help group members are chronic, relatively less severe and young
aphasics. Most groups center around densely populated urban areas,
Although self-help in aphasia is still evolving, the authors suggest
that it ' can make an effective contribution to the psychosocial
reintegration of aphasic people, encouraging autonomy and empowerment'
(p. 199).

Chapter 14, 'The Science or Sciences of Aphasia?', by Sally Byng,
Susie Parr, and Deborah Cairns, highlights the important role of
qualitative methods in aphasia research (see e.g., Damico et al.,
1999a, b) and in other scientific displines. If we consider aphasia as
social as well as a physiological or biological event (Goodwin, 1995),
we cannot study it in isolation from the social context. In this
regard, 'Qualitative methods are particularly suited to capturing the
subjective, social and changing aspects of illness and healthcares and
the complexities of sickness in context' (p. 204). The authors argue
that qualitative methodologies contribute to (a) a better and more
complete understanding of aphasia; (b) an examination of the
assumptions underlying the sciences of aphasia; and (c) opening up new
areas for intervention and legitimating current areas that are
practiced by clinicians but not explored or evaluated by researchers,
e.g., the relationship between identity, language and communication
for aphasics.

Section 4: METHODOLOGY AND EFFICACY IN APHASIA THERAPY RESEARCH

In Chapter 15, Klaus Willmes talks about 'Some Psychometric Issues in
Aphasia Therapy Research'. Topics include scales in neuropsychological
assessment and rehabilitation, psychometric single case analysis
(e.g., individual profile analysis and intra-individual profile
comparisons), and randomization tests for single-subject therapy
research. The paper is mainly concerned with various considerations in
the development of assessment methods. In order to conform to the
theme of the book, it also suggests some specific applications in
aphasia research. Due to its high technicality, however, its
applicability might be limited.

In Chapter 16, David Howard compares the characteristics of 'Single
Cases, Group Studies, and Case Series in Aphasia Therapy'. The author
first examines two examples of group studies (Pring et al., 1993;
Howard et al., 1985), which reported misleading results due to their
reliance on analysis of variance and to their false assumption of
homogeneous treatment effects. The author thus suggests the use of
statistical tests for homogeneity of treatment effects in group
studies. Then, in spite of being 'simple, cheap, and when properly
designed, very informative', single case studies are 'clearly open to
the accusation that these are selected results from selected
participants' (p. 254). Moreover, selected reports of improvement in
specific patient may be misleading because 'it might be a chance
improve (a type I statistical error), or it might be a patient who
would have improved under any circumstances' (p. 254). In fact, such
'selection bias' is evident in the published single case
studies. Finally, the author concludes that case series designs
involving a series of participants given the same treatment in the
same way can have the advantages of both single case studies and group
studies, while avoiding their drawbacks. In particular, 'supported by
proper use of homogeneity tests, it is possible to address the null
hypothesis that treatment gains are equal for all the participants'
(p. 257).

David Howard assumes that therapy program and the criteria for its
effectiveness should be personalized/individualized for the individual
patient, due to the qualitative heterogeneity of impairments and
therefore treatments. Treatment studies in a sense should 'establish
what treatments are effective and for whom' (p. 246). This requires
any such study to specify the treatment, the nature of the impairment,
and which of the participants benefited; and to differentiate the
sources of improvement if there is any (e.g., is the improvement due
to spontaneous recovery, or placebo effect, or to specific
treatment?).

Chapter 17, 'Efficacy of Aphasia therapy, Escher, and Sisyphus', by
Robert T. Wertz, is a review on the efficacy of aphasia therapy. Wertz
first suggests three possible ''rules'' in designing and evaluating
aphasia outcomes research, namely, precise definitions of the
terminology, the five-phase outcomes research model (Robey & Schultz,
1998), and levels or quality of evidence scales (e.g., The American
Academy of Neurology, 1994; Birch & Davis, 1997). Wertz then applies
these ''rules'' to evaluate selected literature on the efficacy of
aphasia therapy. This article highlights the confusion that exists in
the research on the efficacy of aphasia therapy. As is also pointed
out in the next chapter, some researchers see positive aphasia
treatment outcome while others conclude aphasia treatment is not
efficacious on the basis of the same literature. To avoid the
confusion, speech-language pathologists and investigators need first
differentiate terms like 'outcome', 'efficacy', 'effectiveness' and
'efficiency'. In particular, we cannot 'leap to effectiveness and
efficiency studies without having demonstrated a treatment's efficacy'
(p. 262). It is necessary to progress from efficacy to effectiveness
to efficiency by following the Five-Phase Outcomes Research
Model. Meanwhile, outcome evaluations should also follow the
appropriate quality of evidence of scales.

Chapter 18, 'Meta-Analysis in Aphasia Therapy' by Chad Nye and Renata
Whurr, focuses on systematic summary or meta- analysis of research
data in aphasia therapy. Such systematic summary should 'provide at
least two important general results: (1) a basis for estimating the
quantitative effects of treatment, and (2) a guide for future research
agenda' (p. 274). The authors first briefly survey four basic methods
of summary. They are from the least systematic to the most systematic
narrative review, significance vote counting method, cumulation of
p-values method, and meta- analysis. According to Nye and Whurr, the
first three methods suffer from subjectivity, scientific flaws, and
inefficiency. Meta-analysis, by contrast, deals with those problems in
combining findings using statistically systematic
procedures. Meta-analysis should follow the same procedure for
conducting a primary research, and must (a) define the problem, (b)
describe the method, (c) analyze the data, and (d) interpret the data.
Nye and Whurr warn us that different conclusions might be drawn from
similar sources even with meta-analysis, due to use of different study
inclusion criteria, use of different effect size formula, and outcome
criteria selected for analysis. All of them make it difficult if not
impossible to evaluate the speech and language effects in aphasia
therapy.


CRITICAL EVALUATION

The articles are concise, comprehensible, and accessible to a wide
audience. For the interested general public though, some more
technical background might be necessary to understand some of the
articles in full. Given that the book is intended to provide 'state of
the art review chapters on controversial research and clinical issues
in aphasia and aphasia therapy' (back cover), various ways of cross-
referencing suitable for exploratory as well as reference reading may
be added in later editions.

The broad range of the articles shows clearly that a simplistic
medical model is not adequate to accommodate the metamorphosis in the
neuropathologies. A much more complex systems-theory/social model may
better approximates the needs of individuals in the neuropathologies,
i.e., aphasics in this case. This book helps researchers and
clinicians to recognize the important conceptual issues, and better
understand the framework manifested in the World Health Organization's
newest tripartite classification system of impairments, activity
limitations, and participation restrictions (WHO, 2000).

I would like to end this review with a serious concern for the
typographic errors. On pp. 249-250, one whole paragraph was repeated,
and the names of two subjects are 'PR and BB' in the text but 'BR and
PB' in Figure 2 on page 250. On p. 280, either 'Xc' should be changed
to 'Xpre' or the other way round. The most noticeable and most
disconcerting are the references. For example, in Chapter 18, several
major references are confusing and inconsistent. Robey (1999) should
be Robey et al. (1999); Whurr (1992) should be Whurr et
al. (1992). Moreover, we find Greener (1998, 1999) and Greener et
al. (1998) in the text, but we only find Greener et al. (2002) in the
reference list. Such confusion may also be found in other chapters
like Chapter 17. While one may think the typographic errors will not
detract the value of the book as an invaluable source of information
on present and future development of aphasia and aphasia therapy, it
is hoped that future editions avoid the noted problems.

REFERENCES:

American Academy of Neurology Therapeutics and Technology Assessment
Subcommittee. (1994). Assessment: Melodic intonation
therapy. Neurology 44: 566-568.

Birch and Davis Associates, Inc. (1997). The state-of-the- science
medical rehabilitation, Vol. 1. Fall Church, VA: Birch and Davis
Associates, Inc.

Caplan, D. (1987). Neurolinguistics and linguistic aphasiology: An
introduction. Cambridge: Cambridge University Press.

Damico, J.S., Simmons-Mackie, N.N., Oelschlaeger, M., Elman, R., and
Armstrong, E. (1999). Qualitative methods in aphasia research: Basic
issues. Aphasiology 13, 651-666.

Damico, J.S., Oelschlaeger, M., and Simmons-Mackie, N.N.
(1999). Qualitative methods in aphasia research: Conversation
analysis. Aphasiology 13, 667-680.

Howard, D., Patterson, K. E., Franklin, S., Orchard-Lisle, V. and
Morton, J. (1985). The treatment of word retrieval deficits in
aphasia: A comparison of two therapy methods. Brain 108: 817-829.

Hillis, A. E. and Caramazza, A. (1994). Theories of lexical processing
and rehabilitation of lexical deficits. In M. J. Riddoch and
G. E. Humphreys (eds.). Cognitive Neuropsychology and Cognitive
Rehabilitation. Hillsdale: Lawrence Erlbaum Associates.

Levelt, W. J. M. (1989). Speaking: From Intention to
Articulation. Cambridge: MIT Press.

Luria, A. R. (1963). The human brain and psychological processes (in
Russian). Moscow: Academic Press.

Luria, A. R. (1973). Fundamentals of neuropsychology (in
Russian). Moscow: Moscow University Press.

Pring, T., Hamilton, A., Harwood, A. and Macbride, L.
(1993). Generalization of naming after picture/word matching tasks:
Only items appearing in therapy benefit. Aphasiology 7: 383-394.

Robey, R. R. and Schultz, M. C. (1998). A model for conducting
clinical-outcome research: An adaptation of the standard protocol for
use in aphasiology. Aphasiology 12, 787-810.

Schwartz, M. F. and Whyte, J. (1992). Methodological issues in aphasia
treatment research: The big picture. US Department of Health and Human
Services, NIH Publication, 93-3424, 17-24.

Simmons-Mackie, N. and Damico, J. S. (2001). Intervention outcomes: A
clinical application of qualitative methods. Topics in Language
Disorders 21(4): 21-36.

Wilson, B. A. and Patterson, K. (1990). Rehabilitation for cognitive
impairment: Does cognitive psychology apply? Applied Cognitive
Psychology 4: 247-260.

World Health Organization (WHO) (December, 2000). ICIDH-2:
International classification of function, disability and health,
Pre-final draft. Geneva, Switzerland: WHO.

ABOUT THE REVIEWER

Liang Chen is a doctoral student of Applied Language and Speech
Sciences in the Department of Communicative Disorders at University of
Louisiana at Lafayette. His current research includes theoretical
semiotics, language disorders, language assessment, and bilingualism
and bi-literacy. Other interests include syntactic theory and Chinese
linguistics.
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