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Aphasia Therapy or The importance of being earnestAnna Basso a; Alessandra Caporali aa Milan University, Italy.

Online Publication Date: 01 April 2001To cite this Article: Basso, Anna and Caporali, Alessandra (2001) 'Aphasia Therapyor The importance of being earnest', Aphasiology, 15:4, 307 - 332To link to this article: DOI: 10.1080/02687040042000304URL: http://dx.doi.org/10.1080/02687040042000304

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7

Aphasia Therapyor

The importance of being earnest

Anna Basso and Alessandra CaporaliMilan University, Italy

Effectiveness of aphasia therapy, at least for some patients, is no longer under discussion butthe specific effect of most of the variables influencing recovery is unknown. In this paper weaddress a question relative to the therapeutic regimen. Three pairs of patients with similarage, educational level, sex, aetiology, lesion site, and type and severity of aphasia arecompared. Except for one of the control patients who was 2 months post-onset, all patientswere at least 6 months post-onset (range: 6–22 months) and had already been rehabilitatedwhen they entered the study. The three experimental subjects underwent a very long andintensive therapeutic programme (2/3 hours per day, 7 days per week, for many months),with the help of the family and volunteers. The control patients were rehabilitated daily (1hour, 5 days a week) for similar periods of time. It is argued that the intensive treatmentachieved higher test scores and more prolonged recovery and that the experimental patientsmade better use of their recovered language in daily life.

INTRODUCTION

It is now generally agreed that aphasia therapy can be effective, namely that an aphasicpatient will have better chances of recovery if he or she is rehabilitated. Experimentalevidence comes from group studies (Basso, Capitani, & Vignolo, 1979; Basso, Faglioni,& Vignolo, 1975; Gloning, Trappl, Heiss, & Quatember, 1976; Hagen, 1973; Mazzoni etal, 1995; Poeck, Huber, & Willmes, 1989) and single case studies (Byng, 1988; De Partz,1986; Jones, 1986). The beneficial effect of therapy is also confirmed by results of meta-analyses (Robey, 1994, 1998). In his 1998 study, Robey reviewed 55 reports on theeffectiveness of aphasia therapy and studied whether there is a difference between treatedand untreated patients. The reanalysis of the data showed a distinction between treatedand untreated patients, which exceeded the criterion value for a medium-sized effect.However, the question is far from being settled because we still need to know whichpatients (or, perhaps better, which impairments) can be profitably rehabilitated and how.In a few single case studies both the impairment and the intervention have been describedin a sufficiently detailed way so as to be reproducible (Byng, 1988; De Partz, 1986;Jones, 1986; Miceli, Amitrano, Capasso, & Caramazza, 1996). However, we do not knowwhether other variables (such as the associated disorders or the therapeutic regimen) havean effect on recovery and therefore we cannot be sure whether another patient showing

# 2001 Psychology Press Ltdhttp://www.tandf.co.uk/journals/pp/02687038.html DOI:10.1080/02687040042000304

Address correspondenc e to: Anna Basso, Neurological Clinic, Via F. Sforza 35, 20122 Milan, Italy. Email:[email protected]

APHASIOLOGY, 2001, 15 (4), 307–332

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7 the same functional impairment (but different in other respects) would benefit from thesame intervention.

A theory of rehabilitation should comprise various aspects, the most important beingthe intervention strategies themselves. Other important aspects are the characteristics ofthe patient (such as age and education), the functional damage (impaired wordcomprehension, impaired lexical reading, and so on), and the therapeutic regimen.

In this paper we shall address a question relative to the therapeutic regimen. In theliterature there are some descriptions of patients who have benefited from very briefperiods of therapeutic interventions (see, for instance, Byng, 1988; Marshall, Pound,White-Thompson, & Pring, 1990; Penn, 1993). In the majority of cases these are chronicpatients who can be used as their own controls. After having received what is generallycalled traditional therapy and having reached a plateau, they are offered a new methodand show recovery of the treated impairment. TC (Penn, 1993), for instance, was amultilingual aphasic patient 9 months post-onset who ‘‘had a mild aphasia with relativelyintact receptive abilities, fluent output, and marked word-finding difficulty’’ (p. 36) whena discourse-based therapy programme was implemented. The programme was carried outin nine sessions after which ‘‘improvement in the target areas was noted in all languagesdespite the fact that therapy was conducted only in English; the specific targetedbehaviors (. . .) were assessed as being markedly more appropriate across the testedlanguages’’ (Penn, 1993, p. 40). BRB (Byng, 1988), a frequently cited case, was 6 yearspost-onset (during which time he had been rehabilitated) when he received a specificprogramme for mapping thematic roles onto grammatical relations. Therapy consisted oftwo sessions a week apart and intervening homework. BRB showed marked improvementin his comprehension of locative sentences (which had been the object of therapy) and ofsimple reversible sentences, as well as in sentence production, which had not beenrehabilitated.

Unfortunately this has never been our experience. We have seen patients recover withtherapy, but following intensive treatment. Over the years we have been augmenting whatwe considered the minimum duration and intensity of aphasia rehabilitation necessary forrecovery to show up in daily life, also in view of the fact that there is some experimentalevidence that to be effective rehabilitation must be intensive and protracted (see Basso,1992 for a review).

The regimen we now offer to our patients generally consists of 1-hour daily sessions,supported by intensive homework (2–3 hours per day) and protracted for many monthswith control examinations every 3 months. The rationale for discontinuing the therapy isno recovery between two successive control examinations.

This regimen in not easy to implement. We must first persuade the patient and his orher family that this is necessary and then help them to find a way to implement thenecessary homework. With the help of the family, we try to identify a relative, a friend, ora volunteer who can do it. We must also identify the objectives of the rehabilitationprogramme that can be pursued by a lay person and the exercises that can be carried outby the patient alone.

The focus of this paper is the regimen of aphasia therapy. The paper does not raise theissue of the content of therapy nor does it discuss our approach, which is described insome detail elsewhere (Basso, 1977, 1999). Briefly, we can say that in our aphasia unitwe adopt two rather different approaches. In those cases in which we can arrive at aprecise functional diagnosis with reference to a cognitive neuropsychological model ofnormal processing, we endeavour to target the identified impairment/s and implementwhat could be broadly defined as a cognitive neuropsychological approach. For severely

308 BASSO AND CAPORALI

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7 damaged patients with an across-the-board impairment, less analytic approaches targetingthe disability itself can prove efficacious. By way of example, if a patient has anunderstanding disorder that can be explained by, say, damage to the input lexicon, itappears obvious to target the damaged lexicon. If, however, comprehension is severelyimpaired and the patient fails all tasks, a cognitive diagnosis is still possible but it is notreally helpful in dictating what to do. We prefer to rehabilitate comprehension as a globalbehaviour in more ecological settings such as a conversation. The principal function oflanguage is to permit communication among human beings and the main goal ofrehabilitation is to enable the patient to communicate through language. To communicatethe patient must be able to understand what his or her interlocutor is saying and to expresswhat he or she wants to say. In this sort of therapy, the therapist engages the patient in aconversation which must be as similar as possible to a natural conversation the patientmay want to sustain in his or her daily life. Right from the beginning of the treatment thepatient’s participation must be similar to normal conversational behaviour. For eachpatient we also identify specific goals (reduction of apraxia of speech, prevention ofagrammatism, recovery of word-finding abilities, reading aloud, and so on) with the aimof setting the stage for a successive and more specific intervention. If we want to labelour intervention strategies, it can perhaps be suggested that for severe aphasic patientsour intervention can be considered loosely akin to the so-called stimulation approach (seeHoward & Hatfield, 1987, for a review).

In this paper we attempt to demonstrate that an intensive therapeutic regimen cancause such a degree of recovery as to show up in the patient’s daily living. We are notinvestigating the outcome of therapy for a well-defined task such as, for instance, namingof 50 action pictures or reading of nonwords. We compare three pairs of patients matchedas far as possible for the variables known to influence recovery. They have all been re-educated for long periods of time, the main difference being the intensity of therehabilitation: the three control patients were seen by the speech therapist for 1 hour 5days per week, the three experimental patients were seen for 5 hours per week and werealso helped at home 2–3 hours per day.

PAIR 1: PATIENTS FC AND AM

Patient FC

FC was a 37-year-old right-handed mechanic with 13 years of education who suffered aCVA in June 1997; his previous medical history was uneventful. He was admittedunconscious to hospital where a CT-scan showed ischaemic damage to the left frontal-temporal-parietal area surrounded by oedema. Neurological assessment immediatelypost-stroke indicated global aphasia and right hemiplegia. The patient recovered clearconsciousness in the following days and underwent motor rehabilitation. A MRIperformed in April 1999 showed a large temporal-parietal lesion with extensiveinvolvement of the white matter and the subcortical structures.

When discharged from the hospital in August, FC was admitted to a rehabilitationclinic where he started language rehabilitation, 5 days a week, until November when hewent home. He continued language rehabilitation in the same clinic on an outpatient basisfour times per week during the first months, which reduced to three and then two times aweek. He had been dismissed from rehabilitation when first seen at the Aphasia Unit ofMilan University in February 1999, 20 months post-stroke, after being told that no furtherrecovery was possible.

APHASIA THERAPY 309

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7 The language examination (Ciurli, Marangolo, & Basso, 1996) at this timedemonstrated that it was not possible to classify FC’s language impairments into anyof the classical syndromes, and a diagnosis of mixed nonfluent aphasia (Goodglass &Kaplan, 1983) was considered appropriate. He also showed verbal apraxia and acalculia(on a written calculation test he scored 15/101; cut-off score: 74/101; Basso & Capitani,1979). He had no oral apraxia (20/20; cut-off score: 17/20; De Renzi, Pieczuro, &Vignolo, 1966) or ideomotor apraxia (67/72; cut-off score: 53/72; De Renzi, Motti, &Nichelli, 1980). His speech was impoverished and scanty; few isolated words (generallynouns) were produced with long pauses. Naming of object pictures was 60% correct,naming of action pictures was 30% correct. FC did not try to express himself usinggestures or any other nonverbal means; he rarely looked at the interlocutor and appearedto be concentrating on trying to find the words to make himself understood. When hisattention was caught, comprehension was sufficient for simple questions but severelyimpaired on the Token Test (13/36; cut-off score: 29/36; De Renzi & Faglioni, 1978).Reading comprehension was at the same level as auditory comprehension. Reading aloudand repetition were possible for single words but not for sentences; writing wasimpossible except for copying which was generally correct. He scored 34/36 on theRaven’s Coloured Progressive Matrices (Figure 1). The Appendix reports his descriptionof the picture of a drawing room where a woman is knitting, a man is reading anewspaper, a girl is watching television, a boy is playing with blocks and a cat with a ballof wool.

FC had come to see us because he did not want to give up therapy. Mainly inconsideration of his young age, we thought this worthwhile notwithstanding twoimportant negative factors: the time elapsed since onset and the fact that the patient hadalready been re-educated for 18 months. We discussed with FC and his wife the fact thatin our opinion his only chance of recovery depended on very hard and lasting work hewould have to do by himself, with a friend or a relative under our supervision, anddirectly with us. Even in this case chances of recovery were rather poor because theperiod of spontaneous recovery had finished long ago and he had already been re-educated for a long period of time, although lately rehabilitation had been reduced. FCand his wife agreed to do all they could. Because his wife worked and was away all day,she could dedicate only an hour per day, in the evening, to her husband, with more time atweekends. They found a young woman to work at home with him two more hours per dayand he received treatment at the Aphasia Unit for an hour daily. Initially his homeworkconsisted of sentence repetition and written action naming, tasks that a lay person caneasily handle. FC’s wife and assistant were shown how to work with the patient and theyregularly came to the clinic for supervision. Repetition was chosen because it could helpFC overcome his verbal apraxia (which was not very severe), give him confidence in hiscapacity to produce sentences, and hopefully help prevent the production of agrammaticsentences (Beyn & Shokhor-Trotskaya , 1966). Written naming was considered importantbecause of FC’s markedly reduced vocabulary, and actions instead of nouns were chosenbecause he was inclined to use only nouns in speech and we thought that facilitatingretrieval of verbs could be helpful in preventing or reducing agrammatism.

The therapist reserved for herself that which we thought was more difficult todelegate. During the evaluation it had become clear that FC had severe difficulties inhaving a conversation; he was eager to speak (frequently without succeeding in makingthe interlocutor understand what he was talking about) but would not pay attention towhat was said to him. This made it very difficult to help him express himself by askingadequate questions. It was then decided that the therapist would involve the patient in a


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conversation, rapidly changing the subject of the conversation and getting the patientaccustomed to answering in any possible way.

A control evaluation 3 months later did not disclose much change, except for oralaction naming which was now 80% correct. We were not discouraged because we had notexpected much improvement in 3 months and therapy was continued.

At home he was required to read aloud (which he could do by himself) and to declineverbs he had first retrieved in the infinitive form. With the therapist he now started to read

TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences.

February 1999 (Ciurli et al. 1996)

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N V S N V S N S N S N S N S N S

Oral Production Written Production OralComprehen.

WrittenComprehen.

Repetition Readingaloud

Writing todictation

TT = 13/36 Rv = 34/36

October 1999 (Ciurli et al. 1996)

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WrittenComprehen.


Writing todictation

TT = 13/36 Rv = 36/36

April 2000 (Ciurli et al. 1996)

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WrittenComprehen.


Writing todictation

TT = 16/36 Rv = 50/60

Figure 1. Percentage correct responses by FC at three subsequent evaluations: February, 1999, October, 1999;April, 2000.

APHASIA THERAPY 311

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7 a short paragraph, imagine a scene that represented what he had read and, when he couldclearly see the scene in his mind’s eye, describe it. This was thought to help him speakbecause the content of the message was already clear in his mind; at the same time thetherapist did not know in advance what he was going to say and therefore it had acommunicative value.

A second control examination in October 1999 (Ciurli et al., 1996) disclosed ageneralised although mild improvement in all language tasks. He was given a score of 5/10 for his description of a picture (see Appendix) and he could write some words todictation and in a confrontation naming task. However, he still scored 13/36 on the TokenTest (Figure 1).

Rehabilitation continued without any important change and a final controlexamination was carried on in April 2000, after 14 months of intensive languagetherapy (Ciurli et al., 1996). Improvement was now evident in all tasks and his speechoutput was more abundant and more informative. Confrontation naming of nouns was85% correct and of actions 70% correct, and he could write to confrontation 70% ofnouns and 60% of actions. It was now possible for him to read and repeat short sentences.Only his score on the Token Test was not much changed (16/36) (Figure 1). Hiscomprehension in a conversation, however, was quick and correct. His production wasmore abundant and informative although still agrammatic with some correct sentences,and he did not wait to be asked something but frequently introduced new topics. Theappendix reports his retelling of a typical day.

Patient AM

AM was a 37-year-old right-handed bookbinder with 8 years of formal education whosuffered a CVA in July 1988. On admission to the hospital the neurological examinationshowed mild right hemiparesis and expressive aphasia. A CT scan performed in October1988 disclosed a large left temporal-parietal lesion with deep extension to the basalganglia. AM started daily language rehabilitation in September, which was still going onin June 1989, 11 months post-onset, when he was first examined at the Aphasia Unit.

The language examination (Basso & Vignolo, 1974) disclosed a mixed nonfluentaphasia with severely reduced speech and verbal apraxia. His description of how to shaveis reported in the Appendix. Repetition and reading aloud were only mildly impaired forwords and nonwords but he could not repeat or read sentences. Writing was moreseverely impaired than oral speech; he could sign and copy and he correctly wrote onlyone of 20 words. Comprehension was adequate for oral and written words and sentences;on the Token Test he scored 15/36. He had no oral (17/20) or ideomotor (69/72) apraxiaand scored 30/36 on the Raven’s Coloured Progressive Matrices. In the writtencalculation test he scored 12/101 (Figure 2).

Rehabilitation in our unit was started, an hour daily, with the immediate objectives ofreducing AM’s verbal apraxia by having him repeat short sentences. It was also thoughtthat this could prevent or reduce agrammatism. In order to augment his speech output andhis vocabulary he was engaged in conversations above various subjects and asked todescribe pictures.

A control examination 6 months later, in December 1989 (Basso & Vignolo, 1974),showed some recovery of speech production, which was now agrammatic but slightlymore fluent (see Appendix), and in writing of single words. His comprehension asevaluated by the Token Test was much better (22/36). He scored 30/36 on the Raven’sColoured Progressive Matrices and 8/101 in the written calculation test (Figure 2). Daily


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rehabilitation was continued. Since AM’s speech production was still very slow, reduced,and agrammatic, the main objective of therapy was to have the patient speak morefluently with more verbs. Oral and written confrontation naming and retrieval of actionswere added, in the hope that a richer vocabulary would induce AM to speak more. Thelanguage examination had shown that comprehension was superior to his speechproduction. It was therefore not thought to be a problem and was not specificallyretrained. In June 1990, after a year of daily rehabilitation, a very mild across-the-board

TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences; n.t. = not tested.

June 1989 (Basso & Vignolo, 1974)

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N V(n.t.)

S N V(n.t.)

S N S N S N S N S N S


WrittenComprehen.


Writing todictation

December 1989 (Basso & Vignolo, 1974)

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N V(n.t.)

S N V(n.t.)



WrittenComprehen.


Writing todictation


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N V(n.t.)

S N V(n.t.)



WrittenComprehen.


Writing todictation

TT = 15/36 Rv = 30/36

TT = 22/36 Rv = 30/36

TT =18/36 Rv = 33/36

Figure 2. Percentage correct responses by AM at three subsequent evaluations: June, 1989; December, 1989;June, 1990.

APHASIA THERAPY 313

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7 recovery was detectable (Basso & Vignolo, 1974), except for the Token Test score whichwas only 18. Confrontation naming was now 90% correct and written confrontationnaming 40%; reading aloud of sentences was 70% and repetition and writing to dictationof sentences, although still severely impaired, were better than at first examination(Figure 2). This degree of recovery, however, was apparently not sufficient to bring abouta change in his spontaneous production and did not show up in his daily life.Communication was still very difficult (see Appendix) and AM did not try to speak withmembers of his family or other people. Recovery showed up only in the rehabilitationsetting.

The patient was young and highly motivated, and we did not understand why he didnot use his speech outside the rehabilitation setting. Moreover, his speech therapist wasfirmly convinced that she could obtain more from him. Rehabilitation was continued for ayear, 5 days a week with the only interruption the summer break, but without any furtherrecovery. Between June 1990 and July 1991 he was tested on three further occasions butno amelioration was noted (in all testing sessions, for instance, the Token Test score was18).

Figures 1 and 2 report percentage of correct responses by the two patients in thelanguage tasks. The two patients were examined with two different languageexaminations (Basso & Vignolo, 1974; Ciurli et al., 1996). The two tests have beendevised for severe aphasic patients and all tasks are easily performed by normal subjectswith a ceiling effect. The stimuli used differ in the two batteries but the tasks are the sameand can easily be compared. The main difference between the two tests lies in thesentence production task (see later).

Comparison

FC and AM were two men of similar age though their educational level was different (13vs 8 years). They presented with very similar language disorder 20 and 11 months post-onset when they started rehabilitation at the Aphasia Unit of Milan University. Both hadmild right hemiplegia without visual field defects. Comparison of their CT lesionsshowed that they were similar although the cortical area involved in FC’s lesion wasslightly larger as was AM’s extension to the deep structures.

Both had previously been treated for aphasia with similar regimens. From their clinicalreports it would appear that initially they both had global aphasia which recovered to apoint that it could be reclassified as mixed nonfluent aphasia; in other words,comprehension had partially recovered in both patients. Both presented with severelyreduced speech and mild verbal apraxia; agrammatism became evident in both patientswhen their speech production became slightly more abundant.

To recapitulate, except for the educational level, FC and AM had similar demographiccharacteristics, aetiology, aphasia profiles, and previous therapy regimen when we metthem.

Rehabilitation was then started with similar objectives: to reduce their verbal apraxia,to augment speech output, and to prevent agrammatism. In neither case wascomprehension specifically rehabilitated: AM initially showed an important recoveryof comprehension and it was thought that conversation could be a sufficient stimulationfor FC’s comprehension. The therapy programmes were not much different and werecarried out by the same therapist. The only important difference was the amount of timespent in therapy: 1 hour 5 days a week for AM, and no less than 2–3 hours 7 days perweek for FC. After a year, at testing AM’s comprehension, albeit still severely impaired,


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7 had recovered slightly more than FC’s, and FC produced much more and was morecommunicative than AM. Direct comparison of their production poses a problem becauseFC was asked to describe a picture and AM to explain how to shave, and procedurallanguage can be more difficult than description of a picture for aphasic patients.However, FC’s production clearly shows a continuous recovery and AM’s productiondoes not change much (see Appendix). The difference between the two patients wasclearly evident in ecological situations. AM was reported never to start talking orparticipate in a conversation even with his family members. FC talks more with morepeople and although his comprehension is severely impaired on testing, he rarely hasproblems comprehending what is said to him.

A second year of therapy did not result in any further recovery in AM; FC is still beingrehabilitated and there is no indication that a plateau has been reached.

PAIR 2: PATIENTS DT AND SB

Patient DT

At the beginning of March 1996 DT, a 35-year-old right-handed man with a degree inarchitecture, suffered a subarachnoid haemorrhage caused by an existing arterio-venousmalformation. He was immediately admitted to the local hospital, where the neurologicalexamination showed intense rigor without focal neurological signs. An angiographydemonstrated a large aneurysm at the origin of the left communicating posterior artery.Five days later DT was operated on and three days after the intervention he becamedrowsy and showed a mild right hemiparesis and aphasia. Successive CT-scans showed aprogressive enlargement of the ventricles. Two weeks after the first intervention, he wasagain operated on and a ventricular peritoneal shunt was positioned with progressiverecovery of consciousness. At the end of April he was discharged from hospital. Theneurological examination showed global aphasia without hemiparesis or hemianopia. InSeptember 1996 a CT scan showed a frontal hypodense lesion. He started aphasiarehabilitation while in hospital, and it was still going on when he was first seen at theAphasia Unit at Milan University in September 1996, six months post-onset.

Language examination (Basso & Vignolo, 1974) disclosed global aphasia with severeacalculia (12/101); oral (17/20) and ideomotor (71/72) apraxia were not present. Hisspontaneous speech was scanty, apparently without verbal apraxia but totallyincomprehensible; he uttered short sequences of phonemes and sometimes such wordsas ‘‘is, a, so’’ (see Appendix). Oral and written comprehension of words was possible(75% and 85%) but it was severely impaired for short commands (30 and 40%respectively). He scored 2/36 on the Token Test. Repetition, reading aloud, and writing todictation were all nil but he could copy some words. His score on the Raven’s ColouredProgressive Matrices was 24/36 (Figure 3).

At that time it was not possible to involve the patient in a decision about rehabilitationbecause he appeared not to realise how severe his deficit was and it was very difficult tomake him understand what was said to him, even when he himself was the subject of theconversation. However, the family was very supportive and an aunt had plenty of time todedicate to the patient. As for DT, he had a rather passive attitude but was always willingto do what he was asked. We therefore thought that we could rely on the family andplanned a therapeutic intervention that did not require DT to work alone. He lived ratherfar from Milan but we decided, together with his family, that for the present time it wasbetter to come to Milan every morning and work at home in the afternoon, as we were notconvinced that a lay person could manage all the tasks we considered necessary.

APHASIA THERAPY 315

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Because almost everything the patient tried to do resulted in a failure, it wasdecided that the family should start with what can appear a very easy task: DT hadto repeat syllables or short words, whichever was more successful. In fact this provedto be very difficult for DT and required a lot of skill and patience on the part ofhis aunt. After he succeeded in repeating a few words and syllables, reading andwriting of syllables was introduced; mostly, however, these were accomplished byrepetition and copying.

TT = Token Test; RV = Raven’s Matrices; N = nouns; V = verbs; S = sentences;n.t. = not tested.

September 1996 (Basso & Vignolo, 1974)

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N V(n.t.)

S N V(n.t.)



WrittenComprehen.


Writing todictation

June 1997 (Miceli et al., 1991)

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N V S N V S N S N S N S N S N S(n.t.)


WrittenComprehen.


Writing todictation

January 2000 (Miceli et al., 1991)

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WrittenComprehen.


Writing todictation

TT =2/36 Rv =24/36

TT = 11/36 Rv = 29/36

TT = 19/36 (written = 31/36)Rv = 36/36

Figure 3. Percentage correct responses by DT at three subsequent evaluations: September, 1996; June, 1997;January, 2000.


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7 The therapist took on the difficult task of having DT say some content words that weretotally absent from his speech. She could not rely on such classical facilitation as repetitionor reading because DT could do neither. As for phonemic cueing it was sometimes, albeitrarely, successful but its effectiveness was very short-lived. We gave up the idea ofobtaining a target content word in a convergent task, such as confrontation naming, and wetried to elicit them in more divergent and open tasks, accepting any content word DT wouldproduce. For instance, we said a word and asked DT to say the first word that came into hismind or to complete a sentence with any word he could think of. Any content word DT saidwas repeated by the therapist and then included in a sentence, hoping that this would helpDT become conscious of what he had said, if by chance he had produced the wordautomatically without really being aware of its meaning.

Comprehension exercises of words and sentences such as pointing to pictures were notused. We decided that continuous verbal interactions with the therapist and his auntwould provide sufficient stimulation and we argued that this would be a more dynamicand ecological exercise.

A re-evaluation 3 months later showed slight improvement in repetition and readingaloud that were now possible for some words and nonwords. Moreover, DT was nowmore conscious of his difficulties and he was more motivated in his rehabilitation. Thisallowed us to increase his homework. As he could now write some words he was alsoasked to do written naming at home, especially action naming, with the help of his aunt.

Six months after starting rehabilitation he was again reassessed (Miceli, Laudanna, &Burani, 1991). His speech output was severely reduced and anomic; he sometimesomitted verbs and prepositions. Notwithstanding frequent omissions and phonemicparaphasias, when speaking he could make himself understood, being very good at usinggestures, mime and drawings. He could name about 60% of object pictures and 30% ofaction pictures. Comprehension was adequate in conversation but still severely impairedon the Token Test (13/36). Repetition and reading aloud were still very severelyimpaired.

DT had always been very keen to resume work, which he apparently could do. He wasa fashion designer for a glamorous Italian fashion house. His drawing capacity wasunaltered and he decided to go to work at least twice a week and come to Milan the other3 days, working at home in the afternoons and the evenings. This regimen did not lastlong and he soon resumed work 5 days a week coming to Milan once every 3–4 weeks.After an initial period in which he gave up his commitment to rehabilitation becauseworking was both tiring and very involving for DT, his homework has always beenregular and intensive.

Reassessed in June 1997 (Miceli et al., 1991), 15 months post-onset and 9 months afterstarting rehabilitation, he showed an across-the-board recovery but was still impaired inall tasks. Some peaks of impairment were evident. Reading and repetition wereparticularly difficult for him; he read very slowly, recognising one letter at a time.However, if given enough time he could correctly read 70% of words and 50% of shortsentences. Repetition was made difficult, besides other reasons, by the fact that he haddifficulties identifying heard phonemes; the contrast voiced–voiceless, for instance, wasbeyond his possibilities. His Token Test score was 11/36. However, his vocabulary wasricher, his production more abundant but still agrammatic. His comprehension inconversation was fair, and his writing easier (Figure 3). The Appendix reports hisretelling of a typical day.

The same regimen was continued for the following two and a half years. Regularcontrol examinations showed slow but continued recovery. Treatment was changed

APHASIA THERAPY 317

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7 whenever a new priority appeared. Work on auditory comprehension, for instance, wasstarted when it became evident that his difficulty in phoneme identification would notprogress further without specific intervention.

A last control examination in January 2000 (Miceli et al., 1991) disclosed an importantacross-the-board recovery. Repetition and reading aloud were still impaired. His score onthe Token Test had not changed much (19/36) but he scored 31/36 in a written version ofthe test (Figure 3). Conversation was easy, DT’s comprehension was quick and correct,although he sometimes had to ask for repetition when the topic was abruptly changed. Hecould talk about any topic notwithstanding his still evident aphasic disorders (word-finding difficulty, phonemic paraphasias, and agrammatism). The Appendix reports hisretelling of a day at the seaside with his son.

Patient SB

SB was a 44-year-old right-handed Swedish engineer who had lived in Italy for nearly 30years and was perfectly bilingual. In April 1983, he suffered a left intracerebralhaemorrhage. On admission to the hospital he had alternating states of consciousnesswith global aphasia and right hemiplegia. The haemorrhage was drained 20 days laterwith partial recovery of the motor disorder, especially of the hand. A CT scan performedin September showed a small area of frontal rolandic hypodensity extending to theexternal capsule and the head of the caudate nucleus.

SB was examined at the Aphasia Unit of Milan University 2 months post-intervention,in June 1983. Language examination (Basso & Vignolo, 1974) disclosed global aphasiawith oral (8/20) and ideomotor (38/72) apraxia. His speech output was severely reducedand he generally refused to speak, trying instead to make himself understood throughgestures (see Appendix). Comprehension was moderately impaired for oral and writtenwords (70% and 60% correct) and sentences (50% correct) but his score on the TokenTest was very low (5/36). Repetition, reading aloud, and writing were nil. He scored 26/101 in the written calculation test and 34/36 in the Raven’s Coloured ProgressiveMatrices (Figure 4). With the aid of his wife, SB was also examined in Swedish with thesame language examination. Results were comparable.

Daily rehabilitation was started in Italian with the main objectives of amelioratingSB’s comprehension and augmenting his speech production. He was involved inconversations with the therapist, in naming tasks, and repetition of sentences.Comprehension was tackled by asking the patient to point to a target picture and byquestions. Five months later a control examination (Basso & Vignolo, 1974) showedhints of recovery of all language skills, although speech output was still severely reducedand moderate verbal apraxia was now evident. The Appendix reports his description ofhow to shave. The Token Test score was 11/36 and he scored 29/36 on the Raven’sColoured Progressive Matrices. The oral apraxia score was 13/20 but ideomotor apraxiawas no longer present (53/72) (Figure 4). The Swedish version of the language testdisclosed the same results.

Daily rehabilitation was continued with very small but regular improvements untilOctober 1984 when a further control examination (Basso & Vignolo, 1974) wasperformed. SB had mixed nonfluent aphasia with very reduced speech, moderate verbalapraxia and, as far as it could be evinced from his very rare tentative sentences,agrammatism (see Appendix). Oral confrontation naming was 30% correct, writtennaming was 20% correct. Repetition, reading aloud, and writing to dictation weremoderately impaired for syllables and were possible for very few words. Comprehension


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was fair for sentences and he scored 14/36 on the Token Test. Oral apraxia (16/20) andcalculation disorders (86/101) were no longer present and he scored 35/36 on the Raven’sColoured Progressive Matrices (Figure 4). Once again there was no difference betweenthe Italian and the Swedish versions of the test.

Rehabilitation was continued until February 1985 but no further improvement wasnoted and it was decided to discontinue it.



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N V(n.t.)

S N V(n.t.)



WrittenComprehen.


Writing todictation

November 1983 (Basso & Vignolo, 1974)

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N V(n.t.)

S N V(n.t.)



WrittenComprehen.


Writing todictation

October 1984 (Basso & Vignolo, 1974)

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S N V(n.t.)



WrittenComprehen.


Writing todictation

TT =11/36 Rv = 24/36

TT = 14/36 Rv = 35/36

TT =5/36 Rv = 24/36

Figure 4. Percentage correct responses by SB at three subsequent evaluations: June, 1983; November, 1983;October, 1984.

APHASIA THERAPY 319

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7 Figures 3 and 4 report the percentage of correct responses by patients DT and SB.Direct comparison of the results at the second and the third examination is not possiblebecause DT was examined with the Miceli et al. (1991) test, which is more exacting thanthe Basso and Vignolo (1974) and the Ciurli et al. (1996) tests. It has more tasks than theother two tests and it is not used with severely aphasic patients because of a floor effect.Figure 3 reports results only for the tasks that are also included in the other tests.

Comparison

DT and SB were two men with similar levels of education and slightly different ages (35vs 44) who underwent neurosurgery for rupture of an arterio-venous malformation (DT)and evacuation of a haemorrhage (SB). Their aphasia profiles were similar when theybegan rehabilitation at the Aphasia Unit. Their frontal lesions were not very large andwere quite similar but SB’s lesion had a slightly larger extension to the subcorticalstructures. SB was only 2 months post-onset and spontaneous recovery was still possible;DT, on the contrary, was 6 months post-onset, a period in which spontaneous recoveryhas generally reached a plateau. They both had global aphasia, which evolved towards amixed nonfluent aphasia with agrammatism.

Recovery was similar in the first months, albeit SB’s speech remained very sparse andDT’s gradually became more abundant. SB had mild verbal and oral apraxia, which wereabsent in DT and this can perhaps explain the difference in their production. However,SB’s speech remained sparse although the oral apraxia recovered and his verbal apraxiawas mild. Beside the amount of recovery, an important difference between SB’s andDT’s recovery lies in its duration. SB showed very small but regular recovery from themoment he started rehabilitation, 2 months post-onset, for a period of 16 months, afterwhich, although rehabilitation was continued, recovery was no longer evident. Inaddition, SB’s speech production always remained sparse and uninformative. DT startedrehabilitation 6 months post-onset and showed an uninterrupted recovery for thefollowing 3 years, reaching a very satisfactory communicative capacity.

PAIR 3: PATIENTS MG AND AP

Patient MG

MG, a 46-year-old right-handed nursery school teacher with 12 years of education,suffered the rupture of an aneurysm of the left internal carotid for which she was operatedon, in February 1996. In the following days a right hemiparesis and a global aphasiabecame apparent due to a temporal-parietal ischaemia. A CT scan in July 1997 showedthe surgical clips on the left internal carotid and a large ischaemic left frontal-temporal-parietal area of low density extending to the deep structures. She started a rehabilitationprogramme while at the hospital; after discharge in May rehabilitation was carried onthree times a week for a few months and then once a week for approximately another 6months. It was then suspended because no further recovery was expected.

She was first seen at the Aphasia Unit of Milan University in December 1997, 22months post-onset. The aphasia examination (Ciurli et al., 1996) disclosed a moderate tosevere nonfluent aphasia with agrammatism and verbal apraxia. Her spontaneous speechwas sufficiently informative, although lacking many verbs (declension of the producedverbs was faulty) and nearly all the prepositions. Score on the Token Test was very low:10/36. Oral output was difficult because of the presence of verbal apraxia andagrammatism, which showed up in any task, including repetition and reading aloud. The


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7 Appendix reports her description of the same picture described by FC and DT. Oral (20/20) and ideomotor (67/72) apraxia were not present and she scored 25 on the Raven’sColoured Matrices. Her score on the acalculia test was moderately impaired: 57/101(Figure 5).

The major obstacle to a conversation with MG was her anxious behaviour and a sort ofimpulsiveness to speak that prevented her from listening to what was being said. Sheimmediately attempted to reply whenever she was asked something, without listening tothe question but apparently catching a word and responding to it. At first we thought thatexplaining to her that she had to listen carefully to questions, and wait before answering,would lead to better understanding but this was not the case. MG verbalised the fact thatshe had to listen carefully and try to find out what was said to her, but this did not helpher to listen.

We discussed whether it was possible and worthwhile for MG to start rehabilitation atour unit in Milan. She was told that chances of recovery were poor because she hadalready been rehabilitated for a long time and she was nearly 2 years post-onset.Moreover we felt that we could not rely on her working by herself. Because of herimpulsiveness, she would be unable to monitor herself. However, the municipality whereshe lived helped her by asking a voluntary worker to work with her 3–4 hours per day.Initially the two main aims of the rehabilitation programme were to have MG listen to herinterlocutor and produce more verbs in her spontaneous speech. The volunteer wasinstructed to have MG say all the verbs she could think of relative to a situation or asemantic field (at the restaurant, verbs of motion), write them down, go over them again,and add some new ones each day. In addition, given a verb, she had to say in randomorder the correct declension for a given time (now, yesterday, tomorrow) and person (I,Frank, you, and so on). We thought that these exercises could easily be supervised by alay person and could familiarise MG with using verbs. As for her impulsiveness, wethought that any exercise that would oblige MG to think before giving a response wouldget her used to being less precipitous. We chose written grammaticality judgementsbecause they seemed to present many advantages. Having to localise the grammaticalerror made her think about the structure of the sentence and we supposed that having tocorrect the error would exercise her grammatical capacity.

She initially came once every 2 weeks for a clinical evaluation of her work anddiscussion of any problems with the volunteer. Five months later, in May 1998, she wasre-evaluated (Miceli et al., 1991) but the results were not much different from theprevious evaluation, notwithstanding some small favourable changes (Figure 5). This washardly unexpected because her volunteer had proved to be incapable of controlling MG’sanxiety and impulsiveness and therefore it was MG that controlled the situation. TheAppendix reports her retelling of a typical day.

The volunteer was dismissed and a teacher who had previously worked with MG andhad offered her help worked at home with MG, who also started to come daily to Milan atthe Aphasia Unit. Our main objective was always to stop MG from giving immediate andunpondered responses. For that purpose she was, for instance, given an oral sentence thatcould be the same or slightly different from a written one, and was asked to say whetherthe two sentences were the same or not. If they were not the same, she had to find outwhere they differed. She was also given a word and asked to say how many syllablescomposed the word, say the syllables, and produce a given syllable on request. Theseexercises forced MG to reflect on the verbal input and we hoped they would reduce herhaste in answering. She was also shown a picture and asked to say what could possiblyhappen next, which required her to think about possible sequels. Her impulsiveness was

APHASIA THERAPY 321

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also evident in reading aloud which was rather fanciful because she did not pay muchattention to what was written. In reading she made such errors as ‘‘Once upon a timethere was a child ! king’’, or ‘‘Now I am old ! tired’’, or ‘‘cucire ! cucinare (to sew! to cook). She was therefore also asked to read aloud, stopping after each word.Initially only one word at a time was visible and later on she had to pace herself.

Eventually, a control evaluation in January 1999 (Miceli et al., 1991), a year after shehad started rehabilitation with us, showed an across-the-board improvement. Errors were


December 1997 (Ciurli et al. 1996)

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WrittenComprehen.


Writing todictation

TT = 10/36 Rv = 25/36

May 1998 (Miceli et al. 1991)

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WrittenComprehen.


Writing todictation

January 1999 (Miceli et al. 1991)

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WrittenComprehen.


Writing todictation

TT = 13/36 Rv = 27/36

TT = 19/36 (written = 27/36)Rv = 31/36

Figure 5. Percentage correct responses by MG at three subsequent evaluations: December, 1997; May, 1998;January, 1999.


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7 still present in the majority of tasks but were definitely less frequent. She scored 19/36 onthe Token Test but 27/36 in a written version where she was required to read the wholesentence before being shown the tokens (Figure 5). She was less precipitous and paidmore attention to her interlocutor. She could now follow a conversation and was notdisturbed by sudden topic changes. Her production was more abundant and verbs morefrequent, although sometimes produced in an incorrect form and some prepositions werestill lacking or wrong (see Appendix).

Patient AP

AP was a 48-year-old right-handed woman with 8 years of education who lived alone. InDecember 1992 after 2 days of not hearing from her (she had not answered the telephoneor the doorbell) her relatives found her lying on the floor, unable to speak or move. Shewas immediately admitted to hospital, where the neurological examination disclosedright hemiplegia, right hemianopia, and global aphasia. A CT scan showed a left frontal-temporal ischaemic area of low density extending to the subcortical structures.

A month later AP entered a rehabilitation clinic. She had global aphasia with arecurrent utterance (‘‘please, to phone’’) with total agraphia and severe comprehensionimpairments. At the end of February she was first evaluated with a standardised battery(Aachener Aphasie Test; Luzzatti et al., 1987). She was rehabilitated daily until June1993, when she was discharged and returned to Milan to ask for rehabilitation at theAphasia Unit of Milan University.

The language evaluation (Miceli et al., 1991) showed nonfluent aphasia withcomprehension slightly too impaired for a diagnosis of Broca’s aphasia. She wasmoderately to severely impaired in all tasks except delayed copying of words andnonwords and auditory comprehension of words. Her naming of nouns was better thanher naming of actions, and her written naming was slightly better than her oral naming,but it was impossible for her to read the word she had written. Her speech outputpresented mild verbal apraxia and was scanty and agrammatic. The Appendix reports herretelling of a typical day. She scored 16/36 on the Token Test and 25/36 in the Raven’sColoured Matrices. She had mild oral apraxia (11/20) but no ideomotor apraxia (58/72) oracalculia (76/101) (Figure 6).

Rehabilitation was started, 5 days a week. It was decided that her comprehension wasgood enough for a normal conversation but her production severely inadequate and thatthis should be the main objective of rehabilitation. Due to her agrammatism, emphasiswas put on production of verbs rather than nouns. As her orthographic output was betterthan her phonological output it was decided that oral reading should also be rehabilitatedto enable her to make use of her written production for facilitating oral production.

A control examination (Miceli et al., 1991) 5 months later, in November 1993, showedsome recovery in the majority of tasks with, however, no significant changes in hercommunicative behaviour (see Appendix). In particular, she was still severelyagrammatic and her sublexical reading was nil, although she could read some words inan all-or-none way, always producing first the correct article even if this was not writtenand if asked not to say it. In the Token Test her score was slightly lower than the one sheobtained in June (16 ! 12) (Figure 6).

Rehabilitation was continued for another 6 months. A control examination in May1994 (Miceli et al., 1991) again showed a small but generalised recovery, which did nothowever change the characteristics of her aphasia. AP could more or less describe apicture, always omitting verbs and preposition, or recount a typical day of hers (see

APHASIA THERAPY 323

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Appendix). When asked something unusual, however, she was incapable of producingmore than a few isolated words and she frequently could not make herself understood.Reading was now possible for short unisyllabic nonwords and for 80% of nouns (shecould not read verbs). She scored 15/36 on the Token Test (Figure 6).

Due to her relatively young age and the fact that, although very slowly, recovery wasapparent at every control evaluation, we elected to continue giving her therapy. However,no further recovery showed up at any of the following control evaluations. Sixteen


June 1993 (Miceli et al. 1991)

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Writing todictation

November 1993 (Miceli et al. 1991)

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May 1994 (Miceli et al. 1991)

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TT = 16/36 Rv = 25/36

TT = 12/36 Rv = 26/36

TT = 15/36 Rv = 25/36

Figure 6. Percentage correct responses by AP at three subsequen t evaluations: June, 1993; November, 1993;May, 1994.


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7 months later, in September 1995, rehabilitation was discontinued. Except for the TokenTest, where she now scored 20, and a very slight reduction in the number of errors inmany tasks, her language disturbances were the same. AP was agrammatic, with veryreduced speech production, word-finding difficulties, and severe alexia, more evident forsublexical reading than for lexical reading.

Figures 5 and 6 report the percentage of correct responses by patients MG and AP.Comparison of results at first examination is not straightforward because two differenttests were used and AP underwent a more exacting test. The same test was then used forboth patients at the second and the third examination.

Comparison

MG and AP were two women of similar age with slightly different educational levels (12vs 8 years). They both underwent neurosurgery and were left with right hemiparesis andglobal aphasia. MG was nearly 2 years post-onset and AP was 6 months post-onset whenthey came to the Aphasia Unit, and they had both been regularly rehabilitated in thatperiod. AP’s lesion was frontal-temporal and corresponded fairly well to the anterior partof MG’s lesion, which however extended posteriorly and involved the whole temporallobe and part of the parietal lobe. When first examined their aphasia profiles were quitesimilar, although MG’s speech was more abundant. AP’s score on the Token Test, on theother hand, was higher (16 vs 10) and her verbal apraxia was milder. Rehabilitation wasprovided by the same speech therapist. A small amount of recovery was seen in AP fromthe start, continued for approximately a year, and then reached a plateau even thoughrehabilitation was continued for another year. More importantly, recovery was apparentin the test scores only; AP did not seem to be able to take advantage of her recovery in hereveryday life.

MG was nearly 2 years post-onset when she started rehabilitation with us and recoverydid not start immediately, but it also must be remembered that her assistant wasinadequate and had to be changed. When recovery started, it was immediately transferredto her everyday life and she became much more communicative than before.

Table 1 reports background information about the three pairs of patients and offers anoverview of the type and duration of the therapeutic regimen and of the progress ofrecovery.

DISCUSSION

We have described three pairs of very similar patients with respect to the variables knownto influence recovery. These can be grouped according to whether they refer to thebiographical characteristics of the patients (age, sex, handedness, educational level), tothe lesion’s variables (aetiology, type and size of the lesion, severity of the languagedisorder), or to therapy.

The biographical characteristics were very similar in our pairs of patients, except foreducation in pairs 1 and 3, but it has been argued that they play only a minor role inrecovery from aphasia (see Basso, 1992, for a review). As for the second group ofvariables, aetiology was the same, and the patients’ lesions, as evidenced by CT scans,although not identical, were similar. Their influence on recovery, however, is not welldefined (Basso, 1992). The site and the size of the lesion are the main cause of the typeand the severity of the initial aphasic disorder; the severity of the disorder, in turn, is themain factor influencing recovery (Gloning et al., 1976; Kertesz & McCabe, 1977; Basso

APHASIA THERAPY 325

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TA

BLE

1B

ackg

rou

nd

info

rma

tio

nfo

rth

esi

xp

atie

nts

Nam

eA

ge/S

exH

ande

ness

Edu

catio

n(y

ears

)Le

sion

site

Tpo

(mon

ths)

Aph

asia

type

Ther

apy

regi

men

Dur

atio

nof

ther

apy

(mon

ths)

Rec

over

y

FC37

/MR

13T

P,de

epst

ruct

ures

20M

ixed

NF

7D

CO

T14

Still

impr

ovin

g

AM

37/M

R8

TP,

deep

stru

ctur

es11

Mix

edN

F5

DC

T25

Plat

eaue

daf

ter

12m

inut

es

DT

35/M

R17

F6

Glo

bal

7DC

OT

!7

DO

T40

Still

impr

ovin

gSB

44/M

R17

F2

Glo

bal

5D

CT

20Pl

atea

ued

afte

r16

mon

ths

MG

46/F

R12

FT

P22

NF

(agr

am)

7D

OT

!7

DC

OT

14St

illim

prov

ing

AP

48/F

R8

FT

6N

F(a

gram

)5

DC

T15

Plat

eaue

daf

ter

11m

onth

s

Tpo

=tim

epo

st-o

nset

agra

m=

agra

mm

atis

mN

F=

nonf

luen

t5

DC

T=

1ho

ur/d

ay,

5da

y/w

eek

clin

icia

n-ad

min

iste

red

ther

apy.

7D

OT

=2–

3ho

ur/d

ay,

7da

y/w

eek

othe

r-ad

min

iste

red

ther

apy.

7D

CO

T=

3–4

hour

/day

,7

day/

wee

kcl

inic

ian-

+ot

her-

adm

inis

tere

dth

erap

y.T

P=

tem

pora

lpa

riet

alF

=fr

onta

lF

TP

=fr

onta

l-te

mpo

ral-

pari

etal

FT

=fr

onta

l-te

mpo

ral

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7 et al., 1979; Sands, Sarno, & Shankweiler, 1969; Selnes, Niccum, Knopman, & Rubens,1984).

When it was not possible to equate patients on a specific variable we chose to favourthe non-experimental subjects. Time post-onset, for instance, is always longer inexperimental patients, and we tried to choose control patients with smaller lesions thantheir experimental counterparts. In pair 3, for instance, the lesion is much larger andextends more posteriorly in the experimental patient than in the control patient. The typeof aphasia and the severity of the language disorder were quite similar except for theToken Test score of the control patient of pair 3, which was higher (16 vs 10). As forapraxia, oral apraxia was present at the first examination in two control patients (SB andAP), and it was still present in a milder form in AP at the second but not at the thirdexamination. SB also had ideomotor apraxia at the first examination but he scored withinthe normal range at the second examination. Apraxia was never present in theexperimental patients.

Regarding the therapeutic intervention, except for SB who was only 2 months post-onset, all the patients had been re-educated before being seen at our Aphasia Unit. Wecould reconstruct their therapeutic regimen but we have no data on how the rehabilitationwas carried out. When they started rehabilitation in our unit, two pairs of patients wererehabilitated by the same therapist; pair 2 patients were rehabilitated by two therapists,but this does not mean that the language interventions were dissimilar because in ourAphasia Unit regular meetings for discussion of the therapeutic interventions are held.

Finally, mention should be made of the fact that the control patients were all seenmany years ago whereas the experimental patients were seen in more recent years. Thiswas unavoidable because our therapeutic regimen has changed over time and onlyrecently have we reached the therapeutic regimen described in the present paper. It can beargued that during the course of time our therapeutic methods have changed and that wehave learned something from the amazingly rich literature on aphasia therapy and fromthe new perspective of the cognitive neuropsychological approach. This allows us toreach a more detailed functional diagnosis, to identify very specific functional damages,and to target intervention to the impaired module/s. However, in severe aphasic patientswith an across-the-board impairment, like those of this study, we prefer to begin bytackling the consequences that this impairment has on the person’s linguistic capacity,and implement a more general approach.

The therapeutic interventions carried out with the three experimental patients did notdiffer theoretically from the interventions carried out years before with the controlpatients. The main difference lies in the fact that with the experimental patients we triedto identify exercises that could be carried out by the patients themselves or with the helpof a lay person. In one case (FC) these were supported by an hour of daily therapy withthe speech therapist who kept for herself that which she thought was more difficult todelegate. In the other two cases the therapist delivered daily therapy for 9 months;otherwise the therapy was carried out by a family member or a friend, and the therapistsaw the patients twice or three times per month.

All six patients showed some recovery in test results, which was impressive in DT. Inthe remaining two experimental subjects, recovery in test results was somewhat betterthan that of their control patients, and the use they have made of their linguistic capacitiesis very different. None of the control patients has been reported to use language ineveryday exchanges. FC and MG, on the contrary, are reported to have very muchchanged, to talk to their children and partners, and to be able to communicate far morethan they used to, as can also be seen from the Appendix. DT has recovered much more

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7 than anybody else and, notwithstanding his obvious aphasic problems, his familial andworking life is apparently normal. A further obvious difference lies in the time course ofrecovery which is still going on in FC and DT (we do not have any follow-up for MG),nearly 3 and 4 years post-onset respectively. It had reached a plateau in AM, SB, and APtwo, one and a half, and one and a half years post-onset respectively.

To conclude, we do not argue that these positive results could not have been reachedwith different therapeutic interventions. What we do want to stress is that recovery didnot show up suddenly after a short period of re-education. All the experimental patientswere chronic aphasics who had been rehabilitated under less intensive regimens, and intwo cases therapy had been suspended because it was thought that further recovery wasnot possible. We believe that recovery in the experimental patients, and particularly theirbetter use of language for communication purposes, was the result of the intense workdone with each patient and that such a regimen could be successful in a number ofpatients for whom a less intensive regimen would be ineffective. The difference inrecovery cannot be attributed to the duration of therapy. The control patients receiveddaily therapist-delivered therapy for 25, 20, and 15 months respectively, and in each casetherapy continued for many months after they had reached their maximum recovery(Table 1). The experimental patients received daily therapist-delivered therapy for 14, 9,and 9 months; otherwise they worked by themselves or with the aid of a lay person.

A different explanation of the better recovery of the experimental patients is possible.Contrary to what happened with the control patients, therapy was delivered by more thanone person (therapist and care-giver) and in two different settings (hospital and home). Assuggested by a referee, this can facilitate generalisation to other situations. Withoutexcluding a possible effect of these variables, we do not believe this was the main causeof better recovery in the experimental patients. Much of the work the patients were askedto do had to be done on their own, and the care-giver was generally asked to do some veryrepetitive exercises, such as dictation and repetition, but not more ‘‘ecological’’ ones.Our interpretation of choice is that it was the recovery in the drilled tasks that permittedfurther recovery. Furthermore, we argue that the habit of processing language acquired byintensively working on some of its aspects can explain the confidence that theexperimental patients had with language and their better use of it in everyday situations.

This however remains an open question that awaits for further experimental studies.

Manuscript received 8 June 2000Manuscript accepted 20 October 2000

REFERENCES

Basso, A. (1977). Il paziente afasico. Milan, Italy: Feltrinelli.Basso, A. (1992). Prognostic factors in aphasia. Aphasiology, 6, 337–348.Basso, A, (1999). La rieducazione dei pazienti afasici gravi. In A. Mazzucchi (Ed.), La riabilitazione

neuropsicologica (pp. 125–138). Milan, Italy: Masson.Basso, A., & Capitani, E. (1979). Un test standardizzato per la diagnosi di acalculia. Descrizione e valori

normativi. AP-Rivista di Applicazioni Psicologiche, 1, 551–564.Basso, A., Capitani, E., & Vignolo, L. (1979). Influence of rehabilitation of language skills in aphasic patients:

A controlled study. Archives of Neurology, 36, 190–196.Basso, A., Faglioni, P., & Vignolo, L. (1975). Etude controleÂ e de la reÂ eÂ ducation du langage dans l’aphasie:

comparaison entre aphasiques traiteÂ s et non-traiteÂ s. Revue Neurologique, 131, 607–614.Basso, A. & Vignolo, L. (1974). Esame del linguaggio. Florence, Italy: Organizzazion i Speciali.Beyn, E.S., & Shokhor-Trotskaya M.K. (1966). The preventive method of speech rehabilitation in aphasia.

Cortex, 2, 96–108.


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r 200

7 Ciurli, P., Marangolo, P., & Basso, A. (1996). Esame del linguaggio—II. Florence, Italy: OrganizzazioniSpeciali.

Byng, S. (1988). Sentence comprehension deficit: Theory and therapy. Cognitive Neuropsychology, 5, 629–676.De Partz, M-P. (1986). Re-education of a deep dyslexic patient: Rationale of the method and results. Cognitive

Neuropsychology, 3, 149–178.De Renzi, E., & Faglioni, P. (1978). Normative data and screening power of a shortened version of the Token

Test. Cortex, 14, 41–49.De Renzi, E., Motti, F., & Nichelli, P. (1980). Imitating gestures: A quantitative approach to ideomotor apraxia.

Archives of Neurology, 37, 6–10.De Renzi, E., Pieczuro, A., & Vignolo, L. (1966). Oral apraxia and aphasia. Cortex, 2, 50–73.Jones, E.V. (1986). Building the foundations for sentence production in a non-fluent aphasic. British Journal of

Disorders of Communication, 21, 63–82.Gloning, K., Trappl, R., Heiss, W.D., & Quatember, R. (1976). Prognosis and speech therapy in aphasia. In Y.

Lebrun & R. Hoops (Eds.), Recovery in aphasia (pp. 57–62). Atlantic Highlands, NJ: Humanities Press.Goodglass, H., & Kaplan, E. (1983). The assessment of aphasia and related disorders. (2nd ed.) Philadelphia:

Lea & Febiger.Hagen, C. (1973). Communication abilities in hemiplegia: effect of speech therapy. Archives of Physical

Medicine and Rehabilitation, 54, 454–563.Howard, D., & Hatfield F. (1987). Aphasia therapy. Historical and contemporary issues. Hillsdale, NJ:

Lawrence Erlbaum Associates Inc.Kertesz, A., & McCabe P. (1977). Recovery patterns and prognosis in aphasia. Cortex, 8, 56–68.Luzzatti, C., Willmes, K., Bisiacchi, P., De Bleser, R., Mazzucchi , A., Posteraro, C., Taricco, M., & Faglia, L.

(1987). L’Aachener Aphasie Test (AAT). ProprietaÁ psicometriche della versione italiana. Archivio diPsicologia, Neurologia e Psichiatria, 4, 480–519.

Marshall, J., Pound, C., White-Thompson, M., & Pring, T. (1990). The use of picture/word matching tasks toassist word retrieval in aphasic patients. Aphasiology, 4, 167–184.

Mazzoni, M., Vista, M., Geri, E., Avila, L., Bianchi, F., & Moretti, P. (1995). Comparison of language recoveryin rehabilitated and matched, non-rehabilitated aphasic patients. Aphasiology, 9, 553–563.

Miceli, G., Amitrano, A., Capasso, R., & Caramazza, A. (1996). The treatment of anomia resulting from outputlexical damage: Analysis of two cases. Brain and Language, 52, 150–174.

Miceli, G., Laudanna, A., & Burani, C. (1991). Batteria per l’analisi dei deficit afasici. Milan, Italy:Associazione per le Ricerche Neuropsicologiche .

Penn, C. (1993) Aphasia therapy in South Africa: Some pragmatic and personal perspectives. In A.L. Holland &M.M. Forbes (Eds.), Aphasia treatment: World perspectives (pp. 25–53). San Diego: Singular PublishingGroup.

Poeck, K., Huber, W., & Willmes, K. (1989). Outcome of intensive language treatment in aphasia. Journal ofSpeech and Hearing Disorders, 54, 471–479.

Robey, R.R. (1994). The efficacy of treatment for aphasic persons: A meta-analysis. Brain and Language, 47,582–608.

Robey, R.R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. Journal of Speech,Language, and Hearing Research, 41, 172–187.

Sands, E., Sarno M.T., & Shankweiler, D. (1969). Long-term assessment of language function in aphasia due tostroke. Archives of Physical Medicine and Rehabilitation, 50, 202–206.

Selnes, O.A., Niccum, N., Knopman D.S., & Rubens, A.B. (1984). Recovery of single-word comprehension—CT scan correlates. Brain and Language, 21, 72–84.

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7 APPENDIX

FC

1. Description of a picture (February, 1999):Prima di tutto la mamma e il marito ehm . . . il marito . . . legge un eh . . .un . . . legge un . . . giornale. L’altra ehm. . . la mamma invece legge ehm . . . la mamma . . . filo di lana. I ragazzzi eh . . . il . . . la tivuÁ . Lo gatto incita . . .incita . . . il gatto . . .eh . . .incita . . .[First of all the mother and the husband ehm . . . the husband . . . reads a eh . . . a . . . reads a newspaper. The otherehm . . . the mother instead reads ehm . . . the mother . . . wool thread. The children eh . . . the (masc.) the (fem.;correct) television. The cat provokes . . . provokes . . . the cat . . . eh . . . provokes]

2. Description of a picture (October 1999):. . .L’abitazione eÁ . . . l’abitazione eÁ una un locale ampio. La mamma fa il . . . la mamma fa il . . . le calze, le calze.E il papaÁ invece legge il giornale mentre guarda la televisione e . . .il lego, il lego . . . il lego. Mentre, mentre. . .mentre . . . foglie e piante, alberi. Il gatto miagola, fa le fusa . . . I libri, i libri . . . escono . . . i libri mentre la . . .i mobile, il mobile . . . il mobile . . . fiori, fiori, mobile fiori . . .candelabro e vaso, no! . . . mentre . . . il quadro, ilquadro . . .[ . . . The home is . . . the home is a large room. The mother makes the . . . the mother makes the (masc. sing.) . . .the (fem. plur.; correct) socks. And the father instead reads the newspaper while he looks the television and thebuilding blocks (3 times). While (3 times) leaves and trees, trees. The cat miaows, purrs. The books, the books. . . go out . . . the books while the (fem) the (masc.; correct) furniture . . . flowers, flowers, furniture flowers. . .candlestick and vase, no! while . . . the picture, the picture . . .]

3. Retelling of a typical day (April 2000):Alzo e . . . e . . . caffeÁ e latte. Verso la caffeÁ e latte nella tazzina. Mentre mangio faccio . . . l’areoplano leggere . . .leggere . . . Asciugo quello che eÁ rimasto e . . . il bagno, sciacquo, sciacquo . . . e lavo . . . vesto e preparo la . . .giornata. Elena eÁ una signora molto carina e umana. L’ospedale vedo un signore . . . un po’ . . . un po’ . . . dimezza etaÁ . . . La mamma eÁ diventata giovane, giovane e pimpante. Guardo la televisione e mangio . . . Prendol’autobus e vado in . . . in un . . . autobus giro . . . giro . . . Prendo l’autobus e faccio Rosselli . . . I bambini studianotutto il giorno. Mentre io e . . . Katia leggere . . . leggere . . . parole difficili e . . . Katia eÁ molta brava, eÁ unasignorina difficile, bisogna stare attenti . . . che faccia quello che io avevo detto . . .[ (I) get up . . . and . . . and . . . coffee and milk . . . I pour the coffee and milk in the cup. While I eat I make . . . theairplane . . . to read . . . to read. I dry what has been left and . . . the bathroom I rinse (3 times) and wash . . . I dressand prepare the . . . day. Elena (the therapist) is a very nice and kind lady. The hospital I see a man a little . . . alittle . . . middle-aged . . . Mommy has become very young and flashy. I look at the television and eat. I take thebus and go along Rosselli (the name of a street) . . . The children study all day. While . . . I and . . . Katia (hisassistant) to read . . . difficult words and . . . Katia is very good, she is a difficult young lady, one has to be careful. . . to do what I had said.

AM

1. How to shave (June 1989):. . . barba . . . scu schiuma . . . e ra rasoio, basta e . . . lavo come come . . . basta . . . la sciacquo . . . schiuma, labarba . . . la rasoio e basta, non so . . . basta[ . . . beard . . . fo . . . foam . . . and ra razor, stop and . . . I wash like like . . . stop . . . I rinse . . . foam, the beard . . .the razor and stop, I don’t know . . . stop]

2. How to shave (December 1989):come, allora, la sciu la schiuma, la schiuma spalma la barba poi poi poi il rasoio, eh, non lo so, faccio la barba.Sciacquo, asciugamano, basta[as, then,, the fo foam, the foam spreads the beard then then then the razor, eh, I don’t know, I shave. I rinse,towel, stop]

3. How to shave (June 1990):mannaggia , come cavolo eÁ ? . . . ho messo la barba . . . dopo fatto la barba . . . ho sciacquato . . . la faccia . . .prendo l’asciugamano e asciuga la faccia . . . basta . . . io profumo, non c’eÁ proprio . . . e basta[damn, how is it? I put the beard . . . after shaved the beard . . . I have rinsed . . . the face . . . I take the towel anddries the face . . . stop . . . I perfume, there isn’t any . . . and stop]


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7 DT

1. Description of a picture (September 1996)A visto darenero su ulvatese dimabghera irero consersatesa [phonemic jargon]

2. Retelling of a typical day (June 1997):D. (his name) al mattino con la macchina prende ospe . . . ospetale (ospedale) Milano di laÁ non mi ricordo cosac’eÁ scritto, mi piace molto anche percheÁ non riesco sempre uguale e poi alla una da mangiare con la mamma e ilpapaÁ , quindi un caffeÁ e poi alle tre e trenta con la zia . . . leggio (legge) . . . legge e scrive abbastanza, insomma.Poi verso le qui . . . le cinque . . . a casa c’eÁ la Maura ed Edoardo, subito c’eÁ sempre Edoardo (and so on).[D. in the morning with the car takes hosp . . . hospital Milan . . . from there I don’t remember what is written, Ilike it very much also because I don’t succeed always the same and then at one to eat with mommy and daddy,then a coffee and then at . . . three thirty with my aunt . . . reads . . . reads and writes enough. Then at about fi . . .five . . . home there is Maura and Edoardo, immediately there always is Edoardo.]

3. Retelling of a day at the seaside (January 2000):Agosto vado al mare. Al mattino pevo (bevo) un caffeÁ e vado sulla riva e poi voglio nuotare. Poi voglio giocarecon il mio bambino e giochiamo giochiamo. Mangeremo e ghiochiamo, giocheremo ancora. Alla sera dormiamoe sogneremo (and so on)[August I go to the sea. In the morning I drink a coffee and I go to the shore and then I want to swim. Later Iwant to play with my child and we play we play. We will eat and we play, we will play again. In the evening wesleep and we will dream) (and so on)]

SB

1. How to shave (June 1983):[mimes shaving while saying a few syllables]

2. How to shave (November 1983):Barba . . . sapone . . . acqua (mimes shaving)[Beard . . . soap . . . water]

3. How to shave (October 1984):Prima acqua sapone . . . lametta barba . . . acqua . . . barba (mimes shaving)[First water soap . . . razor blade . . . beard . . . water . . . beard]

MG

1. Description of a picture (December 1997):La babino (bambino), no il papa’ eÁ seduto con la poltrona e guarda il gionale (giornale). La papina (bambina)seduta seduta oh Dio seduta pero’ . . . per terra per terra e cuarda (guarda) il televisione. La mamma eÁ seduta lapoltrona e lavora a maglia e vicina al gatto gioca la lana, cerca e il pambino (bambino) gioca i dadi. Poi la casala sala c’eÁ puffet (buffet) c’eÁ la, questo lo so, il vaso i fiori poi la catela (candela), questo lo so, candela. Fattomale, pero’ . . . Tende, bello giardino.[The child, no the father is sitting with an armchair and looks at the newspaper. The girl sitting sitting oh Godsitting but . . . on the floor on the floor and looks at the (masc. instead of fem.) television. The mother is sittingthe armchair and is knitting and near to the cat plays the wool, looks for and the child plays dice. Then the housethe room there is sideboard there is, this one I know, the vase the flowers then the candlestick. Done badly, but. . . curtains, beautiful garden]

2. Retelling of a typical day (May 1998):Il mi alzo presto alle 6 e mezza e vado in cucina a preparare il cafettiera. Metto il fuoco, il . . . e preparo lacolazione. Pronto, viene Paolo e Matteo e io vado subito in bagno a preparare a lavare e mi cambio i vestiti. Poimi . . . metto . . . io esco subito a prendere il treno. Io vado a Milano alla ospedale per terapia. La Elena eÁ brava,aiuta per me.[the I get up early at 6,30 and I go to the kitchen to prepare the coffee-maker. I put the fire, the . . . and preparethe breakfast. Ready, Paolo and Matteo comes and I go in the bathroom to prepare to wash and I change myclothes. Them I . . . put . . . I go out to take the train. I go to Milan to the (fem. instead of masc.) hospital fortherapy. Elena is good, she helps for me]

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7 3. Retelling of a typical day (June 1999):Oggi eÁ sereno; mi sono alzata alle 6 e ho visto il cielo, era rosso. Allora ho pensato eÁ sereno. Sono andata incucina a preparare il caffe’; io, Matteo, la mamma e Paolo. Paolo eÁ sempre ultimo. Poi ho mangiato la colazione,ho preparato i vestiti, sono andata in bagno a lavare. Poi sono uscita a prendere il treno, in macchina. In treno eraritardo, ho telefonato Milano; a Milano non c’era, era presto. Finalmente eÁ arrivato a Pavia e ho preso a Milano.Poi sono andata a comprare i biglietti il metro’ e poi sono andato ospedale velocissimo. Insomma, ero accaldata.[Today is serene; I got up at 6 and I saw the sky, it was red. So I thought: it is serene. I went to the kitchen toprepare the coffee; I, Matteo, mommy and Paolo. Paolo is always the last. Then I ate the breakfast, I preparedmy clothes, I went in the bathroom to wash. Then I went out to take the train, by car. In train was late, phonedMilan; in Milan there was not, it was early. Finally it arrived in Pavia and I took to Milan. Then I went to buy thetickets the metro and then I went hospital very quickly. In conclusion, I was overheated]

AP

1. Retelling of a typical day (June 1993):La famiglia . . . inizia cosi’ . . . alle otto e mezza. Faccio di qua e di la’ . . ., scopo e faccio . . . le pulizie . . . (Epoi?) E poi . . . il negoziante . . . e poi incarto le buste . . . poi faccio le fatture e poi . . . i pacchetti . . . i pacchett i. . . poi chiudo il cassetto e . . . (dopo?) dopo . . . a Milano . . ., io faccio . . . alla gente che cerca . . .[The family . . . it starts like this . . . at 8,30. I do here and there . . . I sweep and clean . . . (What more?) and then. . . the shopkeepe r . . . and the I wrap the envelopes . . . then I prepare the bills and then . . . the parcels . . . theparcels . . . then I close the drawer and . . . (then?) then to Milan . . . , I make . . . to the people who looks for . . .]

2. Retelling of a typical day (November 1993):Il bagno . . . la colazione . . . la logopedia . . . e poi ritorno a casa e poi . . . le mam . . . e poi . . . il caffeÁ e poi . . .apparecchio e poi . . . si! mi bevo un caffeÁ . . . Dopo faccio un film . . . e poi faccio la spesa e poi metto via le robein frigorifero.[the bathroom . . . the breakfast . . . the therapy . . . and then I go back home and then mom . . . and the . . . thecoffee and then . . . I lay the table and them . . . yes! I drink a coffee . . . Later I make a film . . . and then I do theshopping and then I put the things in the fridge]

3. Retelling of a typical day (May 1994):Colazione . . . in bagno . . . l’afasia . . . e poi torno a casa . . . pranzare . . . e poi vado a fare la spesa . . . e poi lametto via . . . e poi mi guardo la televisione e cenare . . . poi mi guardo la televisione e un po’ di sonno . . . perdormire . . . poi basta. Il negozio . . . e . . . la cartoleria. Prima di tutto piego la carta velina . . . e poi faccio dellecommissioni e poi basta. Mia mamma . . . ammalata mia mamma . . . la vertebra . . . e . . . andata all’ospedale epoi eÁ uscita . . . e poi piange . . . piange e poi non vuole rimettersi a posto. La carrozzella . . . perche’ non puo’muoversi . Io sono stanca.[Breakfast . . . in the bathroom . . . the aphasia . . . and then I go back home . . . to eat . . . and then I go shopping. . . and then I put it away . . . and then I look at the television and eat . . . and then I look at the television and a bitsleepy . . . to sleep . . . that’s all. The shop . . . and . . . the stationary shop. First of all I fold up the flimsy paper . . .and I do some shopping and stop. My mother . . . ill my mother . . . the vertebra . . . and . . . gone to the hospitaland then she has come out . . . and she cries . . . cries and it does not want to put herself right. The wheel-chair . . .because she cannot move: I am tired.]


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