Six individuals with probable Alzheimer’s disease (AD) participated in a phase 1 study employing a repeated measures, parallel baseline design testing the hypothesis that error-free experience during word production practice combined with an acetyl cholinesterase inhibitor would improve confrontation naming ability. While acetyl cholinesterase inhibitors are safe and delay cognition decline associated with AD, improvement over baseline cognition is less evident; clinically significant cognitive deficits persist and progress. Both animal and clinical research strongly implicate acetylcholine in learning, a form of neuroplasticity. In clinical practice, however, people with AD are given cholinergic medications without concomitant systematic/targeted retraining. In this study six participants with probable AD and taking donepezil participated in targeted word production practice using an errorless learning strategy. Results showed that combining behavioral enrichment training and an acetyl cholinesterase inhibitor resulted in significant improvements in verbal confrontation naming of trained items for three of six participants. Differences in baseline dementia severity, living conditions, and medications may have influenced the training response. Detection of substantial treatment effects in 50% of subjects suggests further language treatment studies in AD in combination with an acetyl cholinesterase inhibitor are warranted and provide useful information on inclusion/exclusion criteria for use in subsequent studies. (JINS, 2009, 15, 311–322.)

Humans learn skilled acts in order to effectively interact with their environment. A loss of the ability to perform skilled acts is termed apraxia. Apraxia has been thought to be of theoretical interest, but the ecological implications of apraxia are controversial and have not been fully studied. We examined ten patients with unilateral left hemisphere cerebral infarctions (eight of whom were apraxic) and compared their mealtime eating behavior to a group of neurologically normal, age-matched controls. The stroke patients were less efficient in completing the meal. They made more action errors and were less organized in the sequencing of mealtime activities. Because the patients made more errors while using tools than when performing nontool actions, their deficit could not be accounted for by an elemental motor deficit. A positive relationship was found between mealtime action errors and the severity of apraxia. These findings suggest that limb apraxia may adversely influence activities of daily living. (JINS, 1995, I, 62–66.)

Twenty-three chronic nonfluent aphasia patients with moderate or severe word-finding impairments and 11 with profound word-finding impairments received two novel picture-naming treatments. The intention treatment initiated picture-naming trials with a complex left-hand movement and was designed to enhance right frontal participation during word retrieval. The attention treatment required patients to view visual stimuli for picture-naming trials in their left hemispace and was designed to enhance right posterior perisylvian participation during word retrieval. Because the intention treatment addressed action mechanisms and nonfluent aphasia reflects difficulty initiating or maintaining action (i.e., language output), it was hypothesized that intention component of the treatment would enhance re-acquisition of picture naming more than the attention component. Patients with moderate and severe word-finding impairment showed gains with both treatments but greater incremental improvement from one treatment phase to the next with the intention than the attention treatment. Thus, the hypothesis that intention component would be a more active constituent than the attention component was confirmed for these patients. Patients with profound word-finding impairment showed some improvement with both treatments but no differential effects for the intention treatment. Almost all patients who showed treatment gains on either treatment also demonstrated generalization from trained to untrained items. (JINS, 2007, 13, 582–594.)

Links between verbs and gesture knowledge suggest that verb retrieval may be particularly amenable to gesture+verbal training (GVT) in aphasia compared to noun retrieval. This study examines effects of GVT for noun and verb retrieval in nine individuals with aphasia subsequent to left hemisphere stroke. Participants presented an array of noun and verb retrieval deficits, including impairments of semantic and/or phonologic processing. In a single-participant experimental design, we investigated effects of GVT for noun and verb retrieval in two counterbalanced treatment phases. Effects were evaluated in spoken naming and gesture production to pictured objects and actions. Spoken naming improvements associated with large effect sizes were noted for trained nouns (5/9) and verbs (5/9); no improvements were evident for untrained words. Gesture production improved for trained nouns (8/9) and verbs (6/9), and for untrained nouns (2/9) and verbs (2/9). No significant differences were evident between nouns and verbs in spoken naming or gesture production. Improvements were evident across individuals with varied sources of word retrieval impairments. GVT has the potential to improve communication by increasing spoken word retrieval of trained nouns and verbs and by promoting use of gesture as a means to communicate when word retrieval fails. (JINS, 2006, 12, 867–882.)

Stroke is the leading health care problem requiring rehabilitation services today (CDC, 2001; Lee et al., 1996) with the worldwide incidence estimated to be between 300 and 500 per 100,000 people (Sudlow & Warlow, 1997). In most recent years, the rates of mortality are decreasing, resulting in a significant increase in the number of survivors living with the disabilities/handicaps associated with stroke (Thorvaldsen et al., 1997). Not only is stroke a common health problem, but the cognitive disorders that result are common as well (Mayo, 1993; Paolucci et al., 1996).This article is based in part on a Presidential Address by the first author to the Annual meeting of the International Neuropsychological Society in Honolulu, Hawaii in February, 2002.

This investigation reports the results of a pilot study concerning the application of principles of use-dependent learning developed in the motor rehabilitation literature as Constraint Induced Therapy to language rehabilitation in a group of individuals with chronic aphasia. We compared treatment that required forced use of the language modality, Constraint Induced Language Therapy, (CILT) to treatment allowing all modes of communication. Both treatments were administrated intensively in a massed practice paradigm, using the same therapeutic stimuli and tasks. Results suggest that whereas both interventions yielded positive outcomes, CILT participants showed more consistent improvement on standard aphasia measures and clinician judgments of narrative discourse. These findings suggest that CILT intervention may be a viable approach to aphasia rehabilitation. (JINS, 2006, 12, 843–852.)

Two patients (G01, J02) with chronic nonfluent aphasia and sentence production deficits received syntactic mapping treatment to improve sentence production. The patients had dramatically different outcomes in that improved syntax production generalized to nontreatment tasks for G01, but not for JO2. To learn how treatment influenced the neural substrates for syntax production, both patients underwent pre- and posttreatment functional magnetic resonance imaging (fMRI) of sentence generation. G01 showed more robust activity posttreatment than pretreatment in Broca's area; ventral temporal activity decreased slightly from pre- to posttreatment. Comparison of J02's pretreatment and posttreatment images revealed little change, although activity was more diffuse pre- than posttreatment. Findings suggest that for G01, rehabilitation led to engagement of an area (Broca's area) used minimally during the pretreatment scan, whereas for J02, rehabilitation may have led to more efficient use of areas already involved in sentence generation during the pretreatment scan. fMRI findings are discussed in the context of sentence-production outcome and generalization. (JINS, 2006, 12, 132–146.)

Patients with apraxia are more impaired when performing transitive pantomimes than intransitive gestures. This dissociation might be related to the differences in movement complexity. Alternatively, the programs for intransitive gestures might be better defined, more widely distributed, or easier to activate than are those for transitive pantomimes. The purpose of this study was to test the complexity versus representational hypotheses. Twenty right-handed normal subjects both performed and discriminated correct from incorrect transitive pantomimes and intransitive gestures. The discrimination was performed by having subjects point at illustrations of hand postures. The subjects performed better when discriminating postures than when performing gestures or pantomimes. On both the production and discrimination tests, subjects performed better with intransitive gestures than transitive pantomimes. Although the finding that even normal subjects had more difficulty performing transitive pantomimes than intransitive gestures might appear to support the complexity hypothesis, that subjects also had more difficulty discriminating transitive than intransitive postures supports the representational activation hypothesis. (JINS, 2002, 8, 958–963.)

Cognitive deficits associated with neurologic disease or damage are quite common and they are known to negatively impact the lives of patients, caregivers and society at large. Unfortunately, documented effective rehabilitation of cognitive deficits is extremely scarce. In addition the concept of cognitive rehabilitation is usually viewed with tremendous skepticism. This pessimism is manifested in so many ways: It is found in the reluctance of skeptical physicians to refer patients to rehabilitation clinicians, it is seen in the reluctance of service payers to fund clinical efforts, it gets reflected in the graduate training programs which place cognitive rehabilitation in the lower echelons of curricular priorities, it underlies the dearth of funded programs in cognitive rehabilitation research, and it even permeates professional organizations and journals where “treatment studies” represent an extreme minority of presentations and articles. The most salient explanation for this therapeutic nihilism is the implicit belief that “everyone knows it doesn't work.”

We report the results of a letter naming treatment designed to facilitate letter-by-letter reading in an aphasic patient with no reading ability. Patient M.R.'s anomia for written letters reflected two loci of impairment within visual naming: impaired letter activation from print (a deficit commonly seen in pure alexic patients who read letter by letter) and impaired access to phonology via semantics (documented in a severe multimodality anomia). Remarkably, M.R. retained an excellent ability to pronounce orally spelled words, demonstrating that abstract letter identities could be activated normally via spoken letter names, and also that lexical phonological representations were intact when accessed via spoken letter names. M.R.'s training in oral naming of written letters resulted in significant improvement in her oral naming of trained letters. Importantly, as M.R.'s letter naming improved, she became able to employ letter-by-letter reading as a compensatory strategy for oral word reading. M.R.'s success in letter naming and letter-by-letter reading suggests that other patients with a similar pattern of spared and impaired cognitive abilities may benefit from a similar treatment. Moreover, this study highlights the value of testing the pronunciation of orally spelled words in localizing the source of prelexical reading impairment and in predicting the functional outcome of treatment for impaired letter activation in reading. (JINS, 1998, 4, 595–607.)

We present a case study of a 43-year-old woman with chronic and stable pure alexia. Using a multiple baseline design we report the results of two different interventions to improve reading. First, a restitutive treatment approach using an implicit semantic access strategy was attempted. This approach was designed to exploit privileged access to lexical–semantic representations and met with little success. Treatment was then switched to a substitutive treatment strategy, which involved using the patient's finger to pretend to copy the letters in words and sentences. Reading using this motor cross-cuing strategy was 100% accurate and doubled in speed after 4 weeks of intervention. We propose that this patient's inability to benefit from the implicit semantic access treatment approach may be in part related to her inability to suppress the segmental letter identification process of word recognition. (JINS, 1998, 4, 636–647.)