Sunday, July 15, 2007

Gestures and Words: Facilitating Recovery in Aphasia

cite as:
Raymer, A. (2007, June 19). Gestures and words: Facilitating recovery in aphasia. The ASHA Leader, 12(8), 8-11.

by Anastasia Raymer

One of my patients with aphasia, a gentleman who had a serious brain hemorrhage more than 10 years ago, recently presented with me to a class of physical therapy students. Because of his profound aphasia, he struggled for words to describe the event that caused his aphasia, an automobile accident that led to a left hemisphere hemorrhage. By pantomiming a driving motion with his arms, he eventually got the idea across. One of the students asked why he gestured: Was it to communicate the idea through pantomime? Was it to help him get words out? He astutely responded that it was both.

Like many individuals with aphasia, this gentleman often resorts to gestures when he is unable to retrieve specific words. Sometimes using a gesture seems to increase the likelihood that he can say the word. As in the gesturing we all do to embellish a message or as we pause to think of words, it is a natural step in communication. Luria (1970) wrote about this phenomenon decades ago, calling the process intersystemic reorganization—using one part of the brain to facilitate increased activity in another part of the brain. Recent research efforts in our lab and others in America and abroad represent renewed interest in the use of gesture to facilitate language recovery in aphasia.

Limb Apraxia

Individuals with severe aphasia often attempt gesturing to communicate. Using gestures is not without complications, however. The brain’s left hemisphere, which controls the ability to retrieve words and construct grammatical sentences, also is the dominant hemisphere for controlling the performance of learned, skilled limb movements. Daily activities in the home and at work, such as writing, cooking, self-care, and manual labor, depend upon stored memories, including the sequences of muscle packages necessary for skilled limb movements. Damage to the left hemisphere can lead to limb apraxia—impairment in the ability to use skilled limb movements.

The typical clinical test that evaluates limb praxis abilities has a patient perform pantomimes to verbal command, including use of transitive tool use gestures (e.g., show me how to use a hammer to pound a nail into the wall), or intransitive symbolic gestures (e.g., show me how you salute). Gesture performance to verbal command is often compared to gesture production for viewed tools or gesture imitation. In general, pantomime to verbal command for transitive gestures tends to be more difficult and, thus, makes detecting limb apraxia more sensitive as compared to other gesture tasks.

Just as the pattern of aphasia varies depending upon what regions of the left hemisphere are disturbed, so too can limb apraxia take different forms. Two types of limb apraxia, described extensively (e.g., Heilman, Watson, & Rothi, 2006), include conceptual apraxia and ideomotor apraxia. Conceptual apraxia represents impairment in conceptual knowledge about tools, the objects they act upon, and the actions required to use them. Patients with conceptual apraxia have difficulty determining the appropriate tool or action needed to complete a given task. In pantomime testing, they may make conceptual errors (e.g., hammering when asked to demonstrate how to use a screwdriver), using no tool (e.g., using their hand to smooth their hair when asked to demonstrate how to use a comb), or providing no response at all.

Ideomotor apraxia, in contrast, represents an impairment related to praxis production knowledge. Although patients with ideomotor apraxia know the tools and actions required, they have difficulty accurately performing the actions. When pantomiming, they make errors in which they move the wrong combination of joints (e.g., fixate at the shoulder rather than the elbow when demonstrating use of a screwdriver, leading to a circular motion rather than a rotating motion), orient their hands in the wrong direction (e.g., use an iron with the palm of the hand oriented perpendicular to the table), or configure their hand poorly (e.g., saluting with the hand in a fist, rather than fingers extended), including use of a body part as tool (e.g., forming the hand in the shape of a tool such as scissors or comb).

Some pantomimes can be unrecognizable, making it difficult to determine whether a patient has conceptual apraxia or severe ideomotor apraxia. The presence of conceptual apraxia and moderate-to-severe ideomotor apraxia can impede the ability of patients with aphasia to use gestures to communicate, as their gestures often are not meaningful or cannot be interpreted readily.

Limb apraxia can cause other problems as well, at times posing a safety risk. The same people who produce unrecognizable gestures may have great difficulty using tools and utensils during daily activities. In a study several years ago, we found that individuals with limb apraxia often have difficulty with routine tasks such as eating (Foundas et al., 1995). Some people had such difficulty using utensils that they gave up and ate their food by shoveling it with a slice of bread or by hand. Others used the wrong objects and implements, such as stirring tea with a knife or sprinkling salt into their tea. When testing one patient in his home for another apraxia study, I observed him struggle to plug in a video recorder and to unlock a deadbolt. Thus individuals with limb apraxia should be closely supervised when using implements, as some apraxic mistakes could place them at risk for injury.

Gestural Facilitation of Word Retrieval

The interplay between limb apraxia and aphasia is important to consider as we promote using gestures to enhance communication and language recovery in patients with aphasia. With colleagues at Old Dominion University and the University of Florida, we have engaged in a series of studies examining gestural training to facilitate word retrieval in patients with aphasia. In the training protocol, participants learn to form an appropriate gesture corresponding to a given picture, rehearse the words spoken, and then pair the gesture and spoken word to encourage gestural facilitation of word retrieval. Our study shows that this verbal+gestural training protocol is effective for improving retrieval of both nouns and verbs in patients with varied patterns of aphasia (Raymer et al., 2006). One important issue, however, was to determine the extent to which limb apraxia affected the ability to produce gestures during word retrieval training. Even people with severe limb apraxia improved their ability to produce recognizable gestures. Furthermore, there was no relationship between severity of limb apraxia and treatment effects for word retrieval. Gestural facilitation of word retrieval was effective in individuals with mild and severe limb apraxia. We also found that the effects of verbal+gestural training were as strong as effects of a more conventional treatment method encouraging activation of semantic and phonologic information during word retrieval training.

Several people who participated in our studies did not improve word retrieval with training, whether wirh verbal+gestural or semantic-phonologic training. Most had particularly severe word retrieval impairments. An advantage of verbal+gestural training for these individuals was that many who did not increase their use of spoken words nonetheless demonstrated remarkable improvements in the use of gestures. In fact, the physician of one participant called to say how amazed she was at the improvements her patient had made since participating in our aphasia treatment research. Although the patient did not increase word retrieval abilities, he significantly improved his ability to produce meaningful, recognizable gestures. Furthermore, because all participants in our recent studies participated in videotaped conversations with a spouse or caregiver, we documented that he dramatically increased use of conversational gestures following treatment, more than any other participant in our studies. We suspected that the physician appreciated the improved communication afforded through the patient’s increased use of gestures in conversation.

Nonsymbolic Movements

Unfortunately, not all words can be expressed through gestures. Bruce Crosson and colleagues at the University of Florida (Richards et al., 2002) have implemented a different type of word retrieval treatment using non-symbolic limb movements that can be used in training for all types of words, regardless of whether the word has a characteristic pantomime. In their intentional movement training, participants perform a complex non-meaningful movement of the left limb in left space, first in the form of reaching and turning a lever in a box, and later reducing the movement to a circular motion with the left hand, all when paired with rehearsal of spoken target words. The premise of the treatment is that the complex left limb movement engages intact right frontal regions to facilitate activation of that region for word retrieval as well.

The advantage of intentional training is that the complex circular movement can be used quite naturally during conversation, without regard to the topic, whereas pantomime facilitation of word retrieval is limited to concepts that can be expressed by pantomime. Whether it is the rhythm of the intentional movement or the ability of the movement to engage other parts of the brain to improve language recovery is not clear. But these preliminary studies suggest that complex limb movements, not just pantomimes, have the potential to enhance communication attempts in individuals with aphasia and limb apraxia.

Supported Communication

Recent discussions of supported communication in patients with aphasia emphasize the use of gesture to enhance communication with conversational partners. Clinicians must bear in mind that severe limb apraxia can hinder gestural communication in some patients with aphasia. Patients may need training to address the limb apraxia directly, which several studies indicate is amenable to treatment. At times people with aphasia insist they want to speak and are unwilling to use gestures, as was one of my patients with severe aphasia. We had to work gently and diligently to help her see that not only could gestures be an effective means to communicate some ideas, but they also could promote retrieval of spoken words. Once she understood that gestures might help her recover verbal abilities, she started to incorporate them in communication attempts.

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Anastasia Raymer is a professor in the Department of Early Childhood, Speech Pathology, and Special Education at Old Dominion University in Norfolk, Va. She is chair of the ASHA/American Psychological Association Joint Committee on Interprofessional Relations with Neuropsychology, and is the past coordinator of ASHA Special Interest Division 2, Neurophysiology and Neurogenic Speech and Language Disorders. Contact her at

Sunday, July 1, 2007

Language, Writing, and the Spatial Representation of Events

Picture in your head one person throwing a ball to another. How were the two people oriented spatially? Was one on the left, and the other on the right? If so, which one was on the left, and which on the right? Chances are, the thrower was on the left, and the catcher was on the right. For some reason, that seems to be our default way of representing actions: with the actor on the right, the patient on the left, and the actions occurring from left to right(1), as in this beautifully drawn figure:


Why is that? Good question, but before we answer it, let's look at some research.

The most striking work on the relationship between language and the spatial representation of actions has been done by Chatterjee and his colleagues. They first looked at the relationship in a patient with profound agrammatism, an aphasia that makes it difficult to put grammatical sentences together. Here's an example of their agrrammatic aphasic's speech(2, p. 58):

Well, uh, essentially language abandon preposition. I telegraph... I, I... consciously, uh, continuity...I, I, uh, this subtle of prepositional phrases this simply cannot do. Under stress, under stress rapid I just flustered ... but continue to do basically.

As you can see, it's a mess. When they had this aphasic identify the agents and patients in pictures, he almost always said that the figure on the left was the agent, and the one on the right was the patient, regardless of which one was actually the agent and the patient in the figure(3).

Interesting, but this could be the product of the aphasia right? What about people with normal speech and comprehension abilities? To answer this question, Chatterjee et al.(4) conducted a series of studies with non-aphasic participants. In their first study, they had participants (all right-handed) read one of three types of sentences: an action by a patient in the direction of the patient (e.g., "John pushes Tom"), an action by an agent towards the agent and away from the patient ("John pulls Tom"), or a state requiring an agent and a patient ("John likes Tom"). Participants were then asked to draw the events on a piece of paper. In almost all cases, participants drew the agents on the left and patients on the right for each type of sentence, with drawings of the first type (action moving from agent towards the patient, as in "John pushes Tom") tending to represent the agent the furthest to the left relative to the patient.

In their second experiment, they had participants draw actions that occurred on either a horizontal (e.g., "staggering drunk") or vertical (e.g., "falling book") axis. The vertical actions were used as a control. For the horizontal actions, participants drew 8 out of 10 moving from left to right, on average. Here are a couple example drawings, from their Figure 1 (p. 398):


In their third experiment, Chatterjee et al. had participants listen to sentences, after which they were presented with figures that either represented the actions in the sentences (e.g., "Square pushes Circle," with a picture of a square-headed stick figure pushing a circle-headed stick figure). The sentences either involved actions moving from the actor to the patient (like pushing) or from the patient to the agent (like pulling). Half of the pictures presented the agent on the left and the patient on the right. The participants were told to indicate as quickly as they could (by pressing the right or left mouse buttons) whether the picture represented the action in the sentence they'd just heard. Overall, participants were faster to indicate whether the picture represented the sentence when the agent was on the left and the patient on the right.

So there's good evidence that we represent actors on the left and agents on the right, and tend to think of actions as occurring from left to right. But why? Chatterjee et al. argue that this is because our representations of actions have an inherent spatial component, and that this is due to the way our nervous system is organized. They write:

The left to right directional bias is likely to be linked to the neural encoding of events[ Both cerebral hemispheres deploy spatial attention with vectors in opposing directions[ The left hemisphere deploys spatial attention with a vector from left to right. As previously speculated, development of languagein the left hemisphere may have coopted left hemisphere spatial attentional networks opportunistically. An overlap of neural circuits mediating spatial attention, the directional representations of events and the instantiation of verbs, may provide the neural link between the spatial and propositional representation of events. (p. 401)

However, recent evidence argues against this explanation. Several studies have shown that adults who learned to write in a right-to-left writing system (as in Hebrew), as opposed to left-to-right (as in English), tend to put agents on the right and patients on the left, with actions tending to be represented as moving from right to left. In other words, the inherent spatial aspect of action representations could be a product of the writing system we use, rather than the wiring of our brain.

Aphasia and Its Therapy (Medicine)

Product Details

»Book Publisher: Oxford University Press, USA (08 January, 2003)
»ISBN: 0195135873
»Book author: Anna Basso
»Amazon Rating:

Book Description:
This is the first single-authored book to attempt to bridge the gap between aphasia research and the rehabilitation of patients with this language disorder. Studies of the deficits underlying aphasia and the practice of aphasia rehabilitation have often diverged, and the relationship between theory and practice in aphasiology is loose. The goal of this book is to help close this gap by making explicit the relationship between what is to be rehabilitated and how to rehabilitate it.L Early chapters cover the history of aphasia and its therapy from Broca’s discoveries to the 1970’s, and provide a description of the classic aphasia syndromes. The middle section describes the contribution of cognition neuropsychology and the treatment models it has inspired. It includes discussion of the relationship between the treatment approach and the functional model upon which it is based. The final chapters deal with aphasia therapy. After providing a sketch of a working theory of aphasia, Basso describes intervention procedures for disorders resulting from damage at the lexical and sentence levels as well as a more general conversation-based intervention for severe aphasics.L Anna Basso has run an aphasia rehabilitation unit for more than thirty years. In this book she draws on her considerable experience to provide researchers, clinicians, and their students and trainees with comprehensive coverage of the evolution and state of the art of aphasia research and ther

Research Project on Aphasia Training Software

Research Project on Aphasia Training Software
Published: Jun 19, 2007

A team from the Hungarian University of Veszprém has developed Aphasia training software to support patients in learning everyday words. The software can also be useful for children with severe mental disabilities, according to the research team.

Aphasia is an impairment of language affecting the production or comprehension of speech and the ability to read or write. The most common cause of aphasia is acquired aphasia, affecting 23–40 % of stroke survivors. The rehabilitation of aphasia is a medical, specialized treatment (speech therapy), which is the task of a psychologist.

The software package contains two programs. The first program was developed in Flash, the second in Macromedia Director. The goal of the software is to teach the most important everyday words.

The research reports states that “one result of the first tests done was that the software is a useful device not only in the education of aphasics but heavy mental deficient children too. Moreover, both the children and the teachers can use it easily. Considering the advice of the teachers helping us during the program development, the children need some motivating animation and reassurance on the right answer and increasing their interest for the oncoming items and adults do not require such motivating exercises or tasks.”

Image of a bathroom with simple assignment (click clock on the wall).

Aphasia patients that used the software and had difficulties in naming objects managed to get through levels 1-3 easily. At the 4th level, naming of the objects, especially in case of long words, required more time than at the previous ones.

The results of the research team of University of Veszprém can help other projects worldwide in development of Aphasia training and rehabilitation software.

Nonfluent aphasia in a patient with Waldenstrom’s macroglobulinemia


Waldenstrom’s macroglobulinemia (WM) is an uncommon low-grade lymphoma. Cognitive impairment due to central nervous system infiltration by lymphoplasmocytoid cells (Bing-Neel syndrome) has been rarely reported. We describe a 54-year-old man who was referred to a memory disorder clinic with a 9-month history of clinically obvious nonfluent aphasia and WM. He underwent extensive neuropsychological testing, clinical examination and structural and functional brain imaging. The diagnosis of the diffuse form of the Bing-Neel syndrome was supported by abnormal lymphoid cells found in the cerebrospinal fluid. Structural and functional brain imaging revealed impairment of brain areas due to white matter changes and subsequent functional deficits mimicking the neuropsychological syndrome encountered in progressive nonfluent aphasia. The diffuse form of Bing-Neel syndrome and neurological deficits are assumed to be the result of leptomeningeal infiltration by malignant cells and/or neoplastic vascular obstruction.

Keywords: Waldenstrom’s macroglobulinemia; Bing-Neel syndrome; Neuropsychology

Aphasia: A neurological challenge

June is National Aphasia Awareness Month. Aphasia is the total or partial inability to use or understand language. It is typically the result of stroke, brain disease or injury. These patients have no intellectual impairment and no outward sign of handicap.

There are two broad categories of aphasia:
1. Non-fluent or motor aphasia is an inability to enunciate words. Patients with this form of aphasia fully understand language and accommodate for their loss of speech by writing or drawing responses.
2. Fluent or receptive aphasia is an inability to understand words. These patients will often have difficulty finding the right word or following a command. They will sometimes make up new words to try and express their thoughts.

Injuries causing aphasia involve the dominant brain hemisphere which contains the neural pathways necessary for speech. In 95% of right-handed people and a majority of left-handed people, this is the left hemisphere.

Aphasia is a treatable condition. Speech pathologists are trained to perform detailed testing to fully analyze the extent of the impairment and implement a rehabilitation program. These programs require intense effort and patience on the part of people with aphasia. Newly designed computer software provides drills for patients as they retrain the neural pathways necessary for speech.

Recovery is often incomplete and can be frustrating for patients and those around them. Speaking slowly is essential, as is calmly waiting for a response. Aphasic patients are not deaf, yet there is often an inclination to speak loudly to someone who has a speech deficit.

Aphasia represents a fascinating neurological condition. If someone you know is recovering from aphasia, applaud their efforts and never underestimate their intellectual ability.
Anthony G. Alessi, MD, is a neurologist on The William W. Backus Hospital Medical Staff with a private practice at NeuroDiagnostics, LLC in Norwich. This column should not replace advice or instruction from your personal physician. E-mail Dr. Alessi and all of the Healthy Living columnists at

Good useful article, we live in India, my father in law has been diognised with receptive aphasia after the recent brain surgery that he had undergone. In searching the web for more info, I stumbled on this article and thought I will leave a note of appreciation. Thanks.
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