September 1, 2013 Features

Write On

A computer-administered treatment program allows for high-intensity practice to improve writing skills in patients with aphasia.

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Phil, 63, and his wife first contacted us about a year after his stroke. He had moderate nonfluent aphasia and communicated in single words and short, halting phrases. He occasionally used gestures. Although he understood simple day-to-day conversation around him, he struggled to express himself verbally. He also had trouble reading and writing, scrawling only single words and failing to fully comprehend sentences and paragraphs. Like many people with chronic aphasia, his health insurance would no longer cover speech-language services. But he obviously needed significant language help. He and his wife turned to us, seeking any opportunity to help him regain some of his language skills.

Write OnSpeech-language pathologists who work with people with aphasia are all too familiar with Phil's predicament. Growing evidence on neural plasticity indicates the importance of intensive therapy in rehabilitation—several studies have suggested that language improvement in aphasia requires eight or more hours of treatment per week. However, government and private insurance strictly limit the amount of treatment a person with aphasia may receive—often only a small number of treatment sessions over a limited period of time (see "In The Limelight: Guides for the Long Journey Back").

Even when treatment is covered, the focus is often on spoken language impairment rather than on reading and writing deficits. However, written communication via e-mail, text and social media is now prevalent, so impairment in reading and writing greatly limits these clients' ability to connect with others electronically, too. This limitation further hinders their efforts to re-establish social roles and participate more fully in life. For example, Phil couldn't independently complete medical forms prior to physician visits, write a note on his children's birthday cards, or write a word to orient his listener to a new topic of conversation that he wanted to initiate.

To realize these goals, these patients need ongoing, innovative services—beyond the acute stage—not just in spoken language skills, but also in reading and writing. At the Rehabilitation Institute of Chicago's Center for Aphasia Research and Treatment, we seek to address these needs through treatment administered via computer, an option that allows for high-intensity practice and that is considerably less expensive than working one-on-one with an SLP. One of our recent innovations was a Web-based version of an aphasia treatment, Oral Reading for Language in Aphasia. In a 2011 study published in Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, we found that participants who received Web-ORLA improved in oral expression, reading comprehension and writing on standardized aphasia tests, including the Western Aphasia Battery-Revised. We're now adding more writing treatment to enhance Web-ORLA's effectiveness in this realm. Let's take a look at how it works.

Intensive writing

In our pioneering Web-ORLA program, virtual therapist "PAT" (personal animated therapist) guides participants through the treatment sequence by speaking, reading aloud and instructing throughout. Developed by our collaborators at the Institute of Cognitive Science at the University of Colorado, Boulder, PAT carefully demonstrates accurate oral-motor movements. With Web-ORLA, the participant repeatedly reads sentences aloud. In ORLA + Writing, the participant not only repeatedly reads sentences aloud but also copies and writes the sentences from memory. This contrasts with traditional writing treatment for aphasia, which typically focuses on writing single words.

Both programs allow clinicians to monitor treatment sessions remotely, while participants use the software on computers at home. To monitor participants' writing responses, we elected to use a Livescribe smartpen, which writes with ink on microdot paper that preserves digital copies of the writing sample. It records the participants' handwriting and oral productions, which can be downloaded to a computer and forwarded to the clinician for analysis and treatment monitoring. Using this innovative technology, we are running a randomized controlled trial comparing Web-ORLA to ORLA + Writing.

A promising start

Phil was eligible to participate in this new research study and was randomized to receive the ORLA + Writing treatment. After a language evaluation, baseline reading and writing probes, and thorough training, we sent Phil and Janet home with the software and the smartpen. For the next six weeks, without fail, Phil independently completed three 30-minute treatment sessions per day, six days a week. And each evening, Janet downloaded his daily writing samples to share with our lab for analysis and monitoring.

Phil also completed weekly writing probes from a set of trained sentences (encountered during treatment) and a set of untrained sentences (not encountered during treatment). For both sets, he briefly saw one sentence at a time on the computer screen and wrote the sentence from memory on the microdot paper. The chart [PDF] shows the results of Phil's writing probes at baseline, before treatment and throughout the six-week intervention. Before the treatment, Phil wrote the target sentences with about 20 percent accuracy. By the end of treatment, his writing performance on the trained and untrained sentences improved considerably, to approximately 60 percent accuracy.

Although Phil is just one participant in this ongoing trial, his results are exciting. If other participants have similar outcomes, it will further support the efficacy of intensive therapy, as well as the convenience and cost-effectiveness of delivering treatment remotely. These initial results point to the promise of targeting writing in aphasia. We still don't know if improved sentence writing with a smartpen will translate into improved everyday writing or writing via keyboard, cellphone or tablet. But in the meantime, Phil and Janet can communicate with each other more easily because he now uses writing to help convey his ideas. As Janet told us in an interview, following the six-week ORLA + Writing intervention:

I think he writes better left-handed, also his communication skills ... he doesn't seem so frustrated ... it doesn't take him as long to get his point across ... his writing before, it was chicken-scratch and that was with his right hand! Now his writing has improved two-thousand percent!

Jaime B. Lee, MS, CCC-SLP, is a research speech-language pathologist at the Center for Aphasia Research and Treatment at the Rehabilitation Institute of Chicago. She is an affiliate of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders.

Leora R. Cherney, PhD, CCC-SLP, is professor of physical medicine and rehabilitation at the Northwestern University Feinberg School of Medicine and a senior research scientist at the Rehabilitation Institute of Chicago, where she directs the Center for Aphasia Research and Treatment. She is an affiliate of SIGs 2 and 18, Telepractice.

cite as: Lee, J. B.  & Cherney, L. R. (2013, September 01). Write On. The ASHA Leader.


Bhogal, S. K., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34, 987–993.

Cherney, L. R. (2012). Aphasia treatment: Intensity, dose parameters, and script training. International Journal of Speech-Language Pathology, 14, 424–31.

Cherney, L. R., Kaye, R. C., & Hitch, R.S. (2011). The best of both worlds: Combining synchronous and asynchronous telepractice in the treatment of aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 21(3), 83–93.

Cherney, L. R., Patterson, J., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282–1299.

Kleim, J. E., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, Hearing Research, 51(1), S225–S239.


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