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Aphasiology
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Aiding chronic written
language expression
difficulties: A case study
Linda Armstrong & Alison Macdonald
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To cite this article: Linda Armstrong & Alison Macdonald (2000) Aiding chronic
written language expression difficulties: A case study, Aphasiology, 14:1,
93-108, DOI: 10.1080/026870300401612
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aphasiology, 2000, vol. 14, no. 1, 93±108
Case Study
Aiding chronic written language
expression di¬culties: A case study
LINDA ARMSTRONG
and ALISON MACDONALD
Department of Speech and Language Sciences, Queen Margaret University
College, Clerwood Terrace, Edinburgh EH12 8TS, UK
(
)
Received 26 November 1998; accepted 12 March 1999
Abstract
This paper describes some progress made in helping a young aphasic man
(MD) to overcome what had appeared to be intractable written language
expression di¬culties, which continued to be signi®cant for him. Traditional
therapy methods based on cognitive neuropsychological assessment had failed
to help MD to generalize improvement in his spelling particularly, but not
exclusively, of longer and irregular words. Both a splint which allowed him to
use his dominant hand for writing directly onto a computer screen and a simple
word-processing programme with synthesized auditory feedback and lexical
and grammatical prediction (Write:OutLoud‡ and Co:Writer‡ ) enabled him
to produce more normal written output (increased quantity and more normal
quality). The discussion also focuses on how eåectiveness of language therapy
can be measured in this man with chronic aphasia.
Introduction
We present in this paper a young man with chronic aphasia, MD, who experienced
(unusually in the current climate of health care) long-term speech and language
therapy and re-referral at 9 years post-onset. His ability to bene®t at that late stage
from two very diåerent `aids’ to writing, one physical and one linguistic, merits
discussion.
Two clinical fora in
are pertinent to this case and indeed the subject
Aphasiology
of one from 1995 which examined `left and right hand productions in aphasic
agraphic hemiplegics’ motivated one aspect of the interventions described below.
The second, more recent forum in 1998 considered `discharge dilemmas in chronic
aphasia’ and presents two alternative models of aphasia therapy, one medically- and
the other socially-based. Issues raised in that forum are recognized in the present
discussion.
Some brief comments follow before MD and his most recent therapy are
discussed. These relate to the idea that some aphasic people can write better with
their dominant hand than their non-dominant hand, to the use of computers in
aphasia therapy and ®nally to the use of single cases in e¬cacy research.
!
* Please address correspondence to Alison MacDonald, e-mail: a.macdonald sls.qmced.ac.uk
}
’
Aphasiology ISSN 0268±7038 print ISSN 1464±5041 online
}}
2000 Psychology Press Ltd
http: www.psypress.co.uk

94
.
.
L Armstrong and A MacDonald
`
’
Prosthesis for the dominant hand promotes better written output
There has been interest for at least 15 years in the diåerence in written output
produced by people with severe or global aphasia when using their dominant but
hemiplegic arm or their non-dominant hand (Brown . 1983, Leischner 1983).
et al
Lorch (1995) reviews the relevant literature in detail and examines theoretical
explanations for the side diåerence, none of which adequately explain the
phenomenon. This study will augment already-published case studies and answers
Sasanuma’s (1995) call for more detailed studies of people with mild or moderate
aphasic agraphia. However it again reports on a case who was able to bene®t from
using his dominant hand rather than on someone who was not.
Computers in aphasia therapy
Following early enthusiasm in the 1980s and despite the excellent work being
undertaken by the Aphasia Computer Team at Frenchay Hospital, Bristol, and by
others, computer technology has so far failed to live up to therapeutic hopes for the
general population of people with aphasia and examples of eåective computer-
based treatment have been sparse in the literature. The development of much more
sophisticated software and the continuing reduction in the cost of hardware and
software may again hold promise for the aphasia clinic. In particular the availability
of auditory feedback, lexical and grammatical prediction, spell-checkers and
Internet access should encourage aphasiologists to re-examine the potential of
computer technology for their clients. For example, Bluestone (1998) described a
case whose life developed from social isolation in a residential home setting to
relative independence with the help of the Internet.
The predictive software used to aid MD’s spelling and written expression is
another example of how computer technology has advanced and how commercially
available programmes can now be functional aids rather than merely presenting a
limited range of traditional drill-and-practice exercises in another modality. A
positive feature of such technology is its `normality’ when compared to a range of
augmentative and alternative communication devices for people with aphasia
which are under development (e.g. Rostron
. 1996, Waller
. 1998). King and
et al
et al
Hux (1995) provide an example of language gains. They describe a single case
whose spelling error rate decreased when using a talking word processing
programme (Write:OutLoud‡ , which MD also used in combination with a
predictive programme, Co:Writer‡ ).
E¬cacy of therapy and single cases
The eåectiveness of speech and language therapy for people with aphasia continues
to be a very live topic and its measurement has to some extent transferred from
group studies to single case studies. Enderby and Emerson (1995, p. 33) review the
literature in aphasia therapy eåectiveness but state that `what constitutes a positive
outcome has yet to be de®ned’. One of their concluding statements is also very
pertinent to the present discussion of MD:
All workers in the ®eld are faced with the question as to what constitutes good recovery, and
whilst there are many standardized tests of language function, these may not inform us regarding
the e¬ciency, eåectiveness, naturalness of a person’s communication and his or her ability to
cope with life. (Enderby and Emerson 1995, p. 28)

95
Aiding chronic written language expression di¬culties
As will be seen, on one standardized language measure, MD’s language could be
described as recovered. This test result fails to account however for MD’s
continuing di¬culties in regaining full communicative functioning. We recognize
that single cases `will [only] provide evidence for the e¬cacy ofa speci®c treatment
with a speci®c aphasic patient’ (Wertz 1995, p. 329) but hope that this report of late
intervention will show change that Wertz calls of `clinical signi®cance’ (Wertz
1995, p. 334).
Aims of the present study
We sought to discover whether MD’s written language expression could be
improved under two separate conditions: (1) using his dominant but hemiplegic
arm and hand; and (2) with the aid of a word-processing programme which
provided auditory feedback and word and grammatical prediction. In addition, we
discuss MD’s mainly non-aphasic problems which seem to be contributing to his
unemployability and the problem of how to measure any eåectiveness of therapy
in his case so late post-onset.
Case information
Relevant medical history
In 1982 MD (date of birth: 15 March 1963) had a subarachnoid haemorrhage with
no de®cit. At that time total cerebral angiography revealed a left parietal arterio-
venous malformation (AVM), ®lling predominantly from the middle cerebral and
vertebral arteries. It was considered unsuitable for radiotherapy embolization. He
collapsed on 4 December 1986. The CT scan showed a `massive left hemisphere
clot with an old thrombosed AVM’. The intracerebral haematoma was surgically
removed and he was ventilated and tracheostomized. In January 1987 a ventriculo-
peritoneal shunt was inserted. MD was left with aphasia, right hemiplegia more
marked in his arm than leg, right VII weakness, right hemianopia and drug-
controlled epilepsy.
A sketch of language recovery and previous therapy
Western Aphasia Battery (WAB)(Kertsez 1982) results over an 8-year period
document MD’s language recovery (see ®gure 1). There was early noteworthy
improvement in all modalities, with the subsections of spontaneous speech,
repetition and naming reaching near ceiling within two years of his neurosurgery.
Auditory verbal comprehension was slower to recover±it was not until 7 years
post-onset of aphasia that MD scored almost 90% in that subsection. Reading and
writing scores (although not always recorded) did not exceed 83%, with the
writing subtests accounting for the depleted score. His aphasia quotient (AQ) was
over 90 by mid-1990 and was within what the test’s author considers the normal
range (93.81 ) by the end of 1993.
These formal assessment scores are augmented by descriptions of MD’s language
abilities and disabilities in speech and language therapy reports. Initially diagnosis
of Broca’s aphasia with greater comprehension involvement than classic Broca’s
was made. On 3 September 1987 MD had `marked problems with writing. MD is

96
.
.
L Armstrong and A MacDonald
Figure 1. MD’s WAB results 1988±1995. SP ± spontaneous speech; CO ± auditory verbal com-
prehension; RE ± repetition; NA ± naming; RW ± reading and writing; AQ ± aphasia quotient.
now able to copy with the left non-preferred hand, but continues to exhibit a
writing dyspraxia.’ A year later, following a period of rehabilitation, he had
`slightly telegrammatic expressive language: non-¯uent and eåortful. He has
severe word ®nding di¬culties but also ®nds it di¬cult to plan and structure
sentences ¼ auditory memory is poor¼ comprehension of complex syntactic
structures is poor.’ His `propositional writing re¯ects and magni®es his problems
in spoken language. He uses a more telegrammatic style and is extremely slow. He
has di¬culty converting sounds to letters, and also often omits letters’. In reading
he was using a whole-word route and had di¬culty with grapheme-phoneme
conversion. Therapy at that time concentrated on his word ®nding and grapheme-
phoneme conversion.
By 1988 he was receiving both weekly group and individual therapy. His
language had been investigated in detail using tests based on cognitive neuro-

97
Aiding chronic written language expression di¬culties
psychological theory. It was found that he had no di¬culty with lexical decision or
reading aloud real words irrespective of syllable length or imageability, but could
not read aloud non-word letter strings (he tended to lexicalize these). He became
distressed at his inability to write down non-word letter strings but had more
success with real regular words. A problem in orthographic output lexicon was
hypothesized and individual therapy focused on grapheme-phoneme conversion,
especially of vowels. At that time self-monitoring of written output was noted to
be good. MD himself wished to focus on his writing but he tired quickly in therapy
sessions and feared that concentration for a protracted period might have induced
a ®t.
In the 1989±90 session, the spelling of irregular words was targeted in therapy.
A set of 50 irregular words was employed. MD was taught several strategies to help
him spell the targets±guessing word length, leaving blanks to return to and
incorporating irregular words into sentences. Overall, from a base-line score of
}
}
14 50, a 45% improvement was noted six months later (35 50). For words which
had been included in two periods of therapy there was a 80% improvement, in one
period of therapy a 70% improvement and for words not targeted in therapy a
27% improvement. Unfortunately these improvements did not generalize and
were not enduring, as later assessment showed, but do demonstrate some ability to
learn.
Between March 1990 and May 1991 MD participated in the `Computer-based
Microworld Reading Project ’ (Crerar
. 1996). This project provided
et al
computerized therapy for comprehension of reversible verb and preposition
sentences using a `microworld’ of three characters (ball, box and star). He did not
have a good outcome±slightly better performance on prepositions (but not on
verbs) was oåset by a much slower performance. His main problems were
described as `poor concentration and reduced internal capacity [i.e. working
memory at sentence level] ’.
Later therapy concentrated on reading comprehension and timed written word
¯uency. Assessment results from November 1992 reveal that MD was still having
di¬culty with the spelling of irregular words (e.g. `gost’ for `ghost’, `lenth’ for
`length’). Individual therapy was discontinued in early 1994 when his performance
was felt to have plateaued and when he was able to use taught strategies in therapy
sessions. At the time of discharge MD was reminded of strategies to use in his
speech, reading and writing (in outline±to be concise, to highlight important
information and to use a dictionary respectively). His group therapy continued for
another two years and involved a wide range of communicative activities,
including writing (description of composite pictures, constructing sentences from
three given words, sentence completion and form ®lling), reading comprehension
of passages, socio-interactive role play, giving instructions, verbal planning,
debates, word ®nding (suggesting verbs related to a speci®c noun, semantic links,
opposites and crosswords), grammar (use of function words and prepositions),
homophones and question words (selecting appropriate `wh’ words and con-
structing sentences with them).
Prior to discharge from individual therapy strenuous attempts were made to
establish some meaningful employment for MD whose sole social activity outwith
the parental home had been attendance at a day centre. These proved unsuccessful
and MD enrolled in a college of further education on a course for people with
special needs.

98
.
.
L Armstrong and A MacDonald
Dominant hand and computer-aided writing therapy
The possibility of splinting his dominant hand was ®rst investigated during his
college attendance in conjunction with staå from the local communication aids
centre, KEYCOMM. Individual sessions were then re-instated at his speech and
language therapy clinic for training in the use of his dominant hand. Before the
commencement of dominant hand and aided writing therapy and from late 1994 to
early 1995, MD had trials to familiarize him with a mouse pen. A Macintosh-based
drawing programme (KidPix) was employed with which MD initially practised
drawing lines and creating shapes. An individualized input device was made which
consisted of a perspex frame which held the mouse pen at right angles to a large
mouse pad. A standard cock-up splint was attached to the frame which MD had
strapped to his right hand. An Ergo Arm Rest with velcro supported his right
forearm to improve its mobility. Initially the mouse pen selection facility was
emulated on a single switch which MD operated with his left hand. This proved
problematic so MD soon began to operate the mouse button with his left hand.
This use of a mousepen presents a development of the usual paradigm (e.g. Whurr
and Lorch 1991) which does not involve computer technology.
-
Base line assessments
Several assessments were administered before two formal periods of intervention
began based on: (1) the use of the prosthesis; and then (2) predictive writing
programmes. Sentence level material analysed for graphemic and linguistic
(syntactic and semantic) eåects was collected as Lorch (1995) suggested. In
addition, single words written to dictation were also elicited. All three base-line
assessments were completed with MD using only his left, non-dominant hand for
writing. Five items were used from the word de®nition subtest of the Test of Word
Knowledge (TOWK) (Wiig and Secord 1991). Whilst a larger data-set would have
been advantageous, the very slow speed of MD’s output limited the number of
items used. His written word de®nition responses for the words `magician’,
`envelope’, `teacher’, `scarf’ and `bus’ are shown in ®gure 2. Some di¬culty in
written sentence construction is evident as are several spelling errors, e.g. `teathes’
for `teaches’ and `vichal’ for `vehicle’. Spelling errors account for 35% of total
words. The sample also include examples of MD’s strategies, e.g. leaving blanks to
®ll in later and scoring out.
A written picture description was elicited using the WAB picture (see ®gure 3).
This task produced a more normally expressed, if limited, written sample±20 words
and two grammatically correct sentences (11 and 9 words long) with one spelling
error (`pic-nac’ for `picnic’) (i.e. 5% of total words). One of the subtests of the
Psycholinguistic Assessments ofLanguage Processing in Aphasia (PALPA)(Kay
al
et
. 1992) was used to evaluate MD’s spelling performance on regular and exception
words (PALPA 44). Targets and MD’s attempts are shown in table 1 below with
the scores he achieved. Inspection of the errors made show a length eåect for both
regular and exception words and twice as many errors on exception words than
regular words. Types of errors include one semantic paralexia (`sleigh’ for
`sledge’), several examples where word pronunciation rather than known spelling
has driven the response (e.g. `casul’ for `castle’) and some vowel phoneme-
grapheme errors (e.g. `wetch’ for `watch’).

99
Aiding chronic written language expression di¬culties
Table 1. Base-line PALPA 44 results
MD error Exception
Regular target
Error
cat
jam
aunt
lamb
pet
nest
bump
swim
hold
egg
ghost
knock
shoe
move
gost
nork
sho
boop
suiw
bird
tent
frog
queen
sledge
yacht
watch
castle
giraåe
squirrel
sword
soldier
heart
aeroplane
photograph
elephant
MD score
sleigh
yeight
wetch
casul
draå
squill
wind
canal
robin
tiger
potato
sister
spring
banana
holiday
caravan
MD score
[self-corrected]
slo er
squim
bananer
holaday
caraven
aroplane
tetograh
elecate
}
14 20
}
7 20
Figure 2. Base-line assessment (TOWK word de®nitions).
Figure 3. Base-line assessment (WAB picture description).
Prosthesis trials
Some pre-trial practice of single letter and short word formation across the screen
and adjustment ofthe physical environment (e.g. seat height) was completed before
12 weekly sessions of training in the use of the prosthesis were undertaken over a
period of four months with a break for holidays. The sessions focused initially on
`-dge’ words and `CCC-’ words with which MD had particular di¬culty, before he
was encouraged to write the names of pictures, words within categories and then
sentences. See ®gure 4 for an example of sentence construction in the seventh

100
.
.
L Armstrong and A MacDonald
Figure 4. Description of occupations using right hand with mouse-pen and splint.
session during which he was asked to make written descriptions of pictures
depicting occupations. Itcan be seen that although MD was able to produce legible
handwriting with his aided dominant hand, its quality remained poorly formed at
that stage. However the quality of his written production is markedly improved.
He seems to have much more ¯exibility of expression, with more use of abstract
verbs and fewer spelling errors (note especially `photographers’). Again his self-
correction ability is used in the second sentence where he adds `oo’ to indicate the
correct vowel combination in `shooting’.
-
Post prosthesis trials re assessment
Following the 12 sessions, MD undertook the ®ve items of the TOWK, PALPA
44 and a written description of the WAB picture as before but using his right hand
with the mousepen and splint. His written output after the prosthesis trial is shown
in ®gure 5. No statistical analysis of this small data-set has been attempted but his
writings can be compared descriptively.
His word de®nitions were now longer and constituted full if ungrammatical
sentences with some semantic errors (e.g. `write’ for `send’) which convey more
information but took 29 minutes to write. Now spelling errors accounted for
18.75% of total words (approximately 50% less than in the base-line assessment).
His WAB picture description was twice as long±40 words and three sentences long
(9, 15 and 15 words) with no spelling errors and with adjectives but also with a
noun-verb number agreement error. His spelling of regular words in PALPA 44
}
was slightly better (18 20) but he scored the same as before on exception words
(although one word previously incorrectly spelled was now spelled correctly and
one vice versa). Many of his errors were of letters omitted (e.g. `g ost’ for `ghost’,
in which MD recognized a letter was missing but was unable to select it) and one
was a letter addition (`yaicht’ for `yacht’). Again vowel errors were evident (e.g.
`airoplane’ for `aeroplane’). For one word which was again mis-spelled, MD now

101
Aiding chronic written language expression di¬culties
Figure 5. Post-prosthesis trials re-assessment.
had the correct number of syllables (`squinal’ for `squirrel’). He continued to have
}
}
particular di¬culty with phoneme-grapheme conversion of dz in `sledge’,
`giraåe’ and `soldier’.
Immediately after these post-prosthesis trial re-assessments and before com-
mencing the second, computerized trial, MD was asked to type the ®ve TOWK

102
.
.
L Armstrong and A MacDonald
Figure 6. Typed TOWK de®nitions.
Figure 7. Sample of writing using the programmes (session 5).
de®nitions with his left hand, which took 25 minutes (see ®gure 6). He was unable
to type a de®nition for `scarf’ (cf. ®gure 5). As in his prosthesis-aided attempt, he
used `how’ for `who’ and `performs’ was mis-spelled (`beforms’).
Predictive writing
MD next had 12 sessions in which he learned how to use two linked computer
programmes. Write:OutLoud‡ is a simple word-processor programme with
spelling monitor which can provide auditory feedback through synthesized speech
at the end of a letter, word, sentence or paragraph so that the user can hear
(repeatedly if required) as well as see their output. Co:Writer‡ is an intelligent
prediction programme which can be used in conjunction with Write:OutLoud‡ or
other word processing package. It has two useful functions in lexical and
grammatical prediction as well as being a spelling-aid. Its producers suggest that it
is helpful for people with language di¬culties or physical limitations. There are
examples in the literature of the use of predictive programmes, e.g. Newell
(1992), Wood
.
et al
. (1997). By inputting the ®rst letter(s) of a word, Co:Writer‡ will
et al
predict possible targets, based on its own vocabulary, the user’s frequency and
recency of word use and British English spelling. Users can select the target from
the list by typing the associated number. It also provides a degree of grammatical
prediction, e.g. subject-verb agreement. The use of these programmes with people
who have aphasia is discussed in MacDonald and Armstrong (1998).
At ®rst MD’s knowledge of the keyboard was assessed, then the diåerent
functions of the programmes introduced. MD very quickly bene®ted from the
programmes. By the third session, in written picture descriptions his sentence
construction and content appeared normal. He was able to select his target from the
predicted words although his output was still very slow. The sample shown in
®gure 7 took approximately 20 minutes to complete and contains one mis-spelling
`bizarre’ for `bazaar’. This error exempli®es two of the problems with predictive
programmes, i.e. if the user inputs an incorrect letter then a list unrelated to the

103
Aiding chronic written language expression di¬culties
Figure 8. Post predictive writing intervention re-assessments.
target may be generated and this list may lead the user to select from the unrelated
list a word which sounds similar to the target, as in this example. More
sophisticated tools of the word-processor, such as the spell-checker, proved too
di¬cult for MD to learn.
Post predictive writing intervention assessments
The same battery of tasks was again completed by MD after the 12 computer-based
sessions. His performance is shown in ®gure 8. TOWK word de®nitions were
more complete grammatically and longer than at base-line assessment. There were
still some spelling errors evident (8% of total words±10% less than when he was
writing with his prosthesis-aided dominant hand) as well as grammatical errors and
`driver’ seems to have been de®ned rather than `bus’. His WAB picture description
was again three sentences long (39 words±5, 14 and 20 words per sentence) and
with two errors (5% of total words) which demonstrate MD’s occasional di¬culty
with attention, word recognition or selection. These ®gures are comparable to
those produced when MD was writing with his dominant hand using the prosthesis
and the content is qualitatively similar, with the inclusion of adjectives and of more
}
descriptive less frequent verbs and nouns than those used in the base-line

104
.
.
L Armstrong and A MacDonald
assessment (e.g. `¯uttering’ and `breeze’). His spelling performance on PALPA 44
shows a slight improvement for regular words (his score was almost at ceiling
when he was writing with the aid of the prosthesis) and an almost 100%
improvement in his score of exception words (100% if the plural form of `squirrel’
is accepted as correct). Although MD had not been able to relearn the spelling of
exception words (and using his dominant hand had not helped), he was often able
to recognize the correct spelling predicted by the programme provided that he was
able to input the ®rst letter(s) correctly and so did not generate an unrelated list (cf.
`draå’ for `giraåe’).
Discussion
’
?
Is MD s language normal
According to most recent WAB results, MD’s AQ lies within what Kertesz (1982)
considers to be `normal’. AQ does not include a reading and writing score, so
MD’s normal language is assessed on the oral subsections only. Based on the
written output described in this paper several di¬culties remain in spelling and in
the semantics and syntax of written expression. The WAB fails to capture MD’s
speci®c problems as its written expression assessment data-set is limited in size and
in scope.
The Microworld reading project also highlighted some di¬culties for MD which
would not be directly elucidated by clinically-available formal assessments of
language. His processing speed was very slow and his learning capacity seemed
diminished, associated with working memory de®cit. MD requested to repeat the
project as he felt he `was just getting it’ when the requisite number of sessions was
completed the ®rst time. Some of the assessments used during his most recent
therapy were timed. Length of time taken to complete ®ve TOWK de®nitions was
regularly more than 20 minutes. However speed, accuracy and ¯exibility may work
against each other, e.g. in the Microworld project improved scores were associated
with longer times to complete tasks. Similarly the increased numbers of words
produced when MD’s writing was aided by a prosthesis or by computer
programmes were associated with increased complexity but more spelling and
grammar errors (i.e. compare WAB base-line written picture description with post-
prosthesis and post-computer sessions). This latter need not be in a causative
relationship as with longer and more complex sentences there is more opportunity
for error.
Eåect of splinting and programmes on written output
Both splinting and use of the computer programmes are methods of compensation
for physical and linguistic di¬culties, rather than methods of remediation per se.
Both resulted in some positive eåect on spelling and in improved quantity and
quality of written output than that produced at base-line assessment. In table 2
below empty cells represent correct responses at base-line, following prosthesis
trials and word-processing sessions. Both prosthesis and word-processing aid
allow MD to spell longer regular words more accurately. Use of the prosthesis has
minimal eåect on the number of exception words spelled correctly, but arguably
some of the mis-spelled exception words are closer to target than at base-line

105
Aiding chronic written language expression di¬culties
Table 2. PALPA 44 results
Target
LH
RH
WP
Regular:
cat
jam
pet
nest
bump
swim
hold
boop
suiw
bird
tent
frog
wind
canal
robin
tiger
potato
sister
spring
banana
holiday
caravan
j
s ring
squim
bananer
holaday
caraven
16
srine
carevan
18
}
Total 20
Exception
19
aunt
lamb
egg
ghost
knock
shoe
move
gost
nork
sho
g ost
nock
golt
nock
j
sho
queen
sledge
yacht
watch
castle
giraåe
squirrel
sword
soldier
heart
aeroplane
photograph
elephant
sleigh
sle
slegh
yeight
wetch
casul
draå
squill
yaicht
warct
cas le
braå
draå
squirrels
squinal
[self-corrected]
slo er
j
sol are
hearth
solner
hart
airoplane
aroplane
tetogra h
elecate
6
elethant
7
}
Total 20
13
LH ± written with left, non-dominant hand; RH ± written with prosthesis-aided dominant hand;
WP ± word-processed with the aid of Co: Wwriter‡ and Write: OutLoud‡ .
assessment (e.g. `yaicht’ rather than `yeight’ for `yacht’ and `cas le ’ rather than
`casul’ for `castle’). Because MD has sentence-level reading comprehension ability,
he was able to use that ability to improve his spelling of exception words with the
aid of the word prediction programme. Despite doubling his score, MD still
spelled incorrectly approximately 30% of the exception words with the prediction

106
.
.
L Armstrong and A MacDonald
programme but did spell the longest three words correctly. He continued in both
aided conditions to have speci®c di¬culty in phoneme-grapheme conversion of
}
}
dz .
In sentence level material, MD produced more words and made fewer spelling
errors overall when using the prosthesis and when using the word-processing
programme than at base-line. However the increased complexity of his written
output was accompanied by more grammatical and semantic errors. Although
di¬cult to quantify, both aids seemed to allow MD to express himself in a more
abstract and complex way.
MD was very positive about his use of the splint to enable him to write with his
dominant hand but found it di¬cult to express exactly what was improved. Both
use of the prosthesis and of the word-processing programmes appear overall in our
clinical trials to have improved MD’s written output. The former has disadvantage
in its `clinical ’ appearance whereas use of the computer programmes would appear
much more normal.
-
1998
Follow up November
In the longer-term MD has bought a PC and has opted to continue to employ the
word prediction programme in preference to the splint as he ®nds it more useful.
He reportsthat heuses the computer regularly at home for writingÐapproximately
four times per week. He is still slow to ®nd his way around the keyboard but feels
that he is much better at this than he used to be. He loads the programmes and
closes down entirely independently. He mainly writes letters and has been provided
with a list of address labels to facilitate addressing. When asked if he writes a diary
or stories, he said that he `doodles’ at stories but does not save them. His
independent use of the computer to write letters represents achievement of MD’s
aim for this late written expression therapy and demonstrates that he has chosen to
generalise his use of the word-processing programmes as an aid to writing, rather
than the use of his prosthesis.
?
What would be an eåective therapy outcome for MD
MD was initially discharged from individual speech and language therapy at eight
years post-onset, having had both individual and group treatment over a much
more extended period than is usually available to people with aphasia. At that time,
on formal assessment his oral language was `normal’ although his communication
skills were clearly not fully recovered and his WAB scores had remained similar for
some time (he had reached a `plateau’). He had learned communicative coping
strategies but was unable to resume employment in his previous profession and had
another 30 or more years before the age for retirement.
Further improvement in writing for MD could be measured in a variety of ways:
quicker responses; increased range of word classes in written output; increased
frequency and imageability range of words written; better spelling; fewer sessions
to learn; generalization or increased con®dence in writing. His motivation for
improving this modality remains high but he cannot be considered a priority for
therapy.
It is very pertinent to ask for MD `what lies beyond the plateau ’ (Hersh 1998)
since he appears to have been able to take some steps beyond that plateau with

107
Aiding chronic written language expression di¬culties
novel approaches to his di¬culties. Re-entry into paid employment was not a goal
for the therapy described here but this issue is discussed brie¯y below as it aåects
all people who become aphasic at MD’s age.
It is probably not only his aphasic and writing di¬culties which are preventing
MD from being able to take up paid employment, especially in his previous chosen
®eld of work where considerable interpersonal contact is required as are quick
decision-making skills, constant new learning and the ability to function well
despite long and unsocial working hours. Working memory de®cit, organisational
functioning, impaired motor skills and slowness in processing all impact on his
employability. Factors such as those described by Pound (1998, p. 224), `hidden
comprehension impairments, fatigue or day-to-day ¯uctuations in communicative
ability ’, will also aåect how able to work people with aphasia will be±as well as the
general rates of unemployment in the country.
This theme is discussed also by Parr
. (1997, p. 27) whose ®gures for people
et al
in their study show that before the onset of aphasia most were in full-time
employment but after the onset of aphasia most were not working. These authors
identify both external and internal factors which aåect the possibility of return to
work. These include `the opportunities, alternatives and support which are
available, and the decisions made and advice given by others, including doctors and
employers’, how well the person with aphasia `understandsthe nature and severity
of the aphasia and the other eåects of stroke’ as well as their work attitudes. MD
currently works part-time on a voluntary basis as a helper with a voluntary
organization.
Conclusion
Whilst age should never be considered as a major factor in discharge decisions, in
the case of MD the possibility of further review of his communicative skills in the
future rather than absolute discharge would seem fair. He has demonstrated ability
to bene®t from two diåerent approaches to his spelling and written expression
di¬culties and to be motivated to do so. Should new therapy approaches become
available which aim to increase speed of language processing without detriment to
accuracy, for example, then MD might be considered a suitable candidate.
Acknowledgments
We thank MD for allowing us to write in public about him. Much of MD’s
individual and group therapy was undertaken by speech and language therapy
students at Queen Margaret University College clinic under the supervision of Dr
Elizabeth Dean and Alison MacDonald respectively. The prosthesis project was
initiated and supported by Dr Elizabeth Dean of the Department of Speech and
Language Sciences at Queen Margaret University College in collaboration with
KEYCOMM (Lothian Communication Technology Service), Edinburgh and the
Specialist Assessment and Training Service, Stevenson College, Edinburgh.
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