This presentation will address issues associated with reading and writing impairments resulting from acquired neurological injuries (ABI). Key information will target the identification and classification of reading and writing deficits, the functional impact of these disorders, and evidence-based practices used to facilitate recovery. Case examples will provide illustrations of the development and application of multi-component intervention programs.

Speakers: Dr. Hux, Tim Benak, Steve Kerschke

Video Transcription


Tim Benak – 00:00

Good morning, everyone. Thank you for joining us this morning. We quickly gonna jump into a pretty quick this morning and we we typically have quite a few pleasantries in the meeting. But there’s a lot of content that we want to make sure you get, get get all of it this morning.

So I’ve actually got Steve Kerschke here with me. If you want to switch this slide there, Steve.

If you’ve attended our January webinar, you would have heard of him briefly talked about telerehab, and just with the global landscape of healthcare right now, we thought it was timely for him to come in and just just briefly chat about what you’re seeing. So if you want to talk to that.

QLI Telerehab

Steve Kerschke – 00:40

Yeah, definitely. An interesting time for everyone, I’m sure. Interesting time for us from a telerehab perspective.

You know, we were talking within our team, and even you and I were talking when we first started, you know, this morning, Tim, I think, you know, if you’d have asked me three weeks ago, what the perspective of telerehab in general was, you know, I would have said that it was for early adopters. And those are the types of individuals that are utilizing telerehab.

And what we also know is that, oftentimes crisis is one of the biggest catalysts for change. And unfortunately, this crisis has created a bit more urgency on the telerehab side of things.

So what we wanted to do today is just let you know that we’re here to help. Many of you guys are familiar with our services.

But at the same time, we are ramping up. And we want to do our part in making sure that folks have access to care. And that we can take care of the injured workers that maybe are not in our system yet.

Or for our case managers on the line, if there’s anything we can do to help manage their caseload, and take care of the individuals that they serve, whether it be in a short term basis, or potentially a long term basis.

So as you can see, here, here’s just a few areas, we’ve had some carriers reach out to us and trying to establish some coverage for their folks.

Delivering Treatment in a Convenient, Healthy, and Safe Environment

You know, first and foremost, we can do it remotely and virtually so are the individuals that we’re serving, don’t have to access the community.

One thing I will say, though, because of the closings of restaurants and and job sites and things like that, even our teams having having to get pretty creative with our therapy.

But it’s a it’s a really great challenge. And we have some really great ideas. So there’s more to come on that actually. So you’ll probably see an E blast on Friday, with some free services that we’re going to be offering.

Carrying Out and Supporting Established Treatment Plans

As far as the second one. You know, if you have someone with an established provider already, we don’t want to necessarily upset that situation.

But if there’s an instance where they can’t access that provider, we’re happy to simply carry it out, as carry out the treatment plan has is make adjustments as needed. But literally just be a bridge between now and maybe when they can re access that provider.

If you’ve had some if you have some new individuals coming onto your caseload, certainly this is a nice option.

Providing Support to Increase Caregiver Effectiveness

And then, you know, I think now more than ever, caregivers are going to potentially feel some of this burden. And so if there’s anything that we can do to help the caregiver navigate this and provide them some direction, in, you know, taking care of their loved ones and friends and that sort of thing. So these are just a few ideas.

I’m not going to be able to be able to take any questions, but my contact information is here, I’ll be available all day via phone, that’s my cell phone, so please call my cell phone. And that is my email. So we can definitely take emails.

Tim Benak – 03:50

So make sure send those over to Steve. And also if you if you happen to miss this information or not, you can send it on to the QLI webinars if that’s that’s the one that you have saved. And Taylor and I can direct that all to Steve.

Steve Kerschke – 04:05

A little out of the ordinary. We don’t usually hijack people’s presentations. So sorry, Karen. She’s a first time presenter, so she doesn’t know how we roll yet.

I also changed the title slide on her and she didn’t know that.

But with that, I will go ahead and introduce introduce Dr. Karen Hux.

Karen’s been with QLI For how long? You’ve been with us a couple years now a couple years. You know, Karen has been a longtime friend of QLI and, you know, started her career actually in the academic system. And, you know, consulted with QLI for for many years, and, again, has helped a lot of our residents along the way.

Fortunately, we were able to take her from the academic system and she’s now a teammate of ours and a huge resource when it comes to research. When it comes to even treatment. She’s been known to have into some therapy sessions. She’s a speech therapist by trade. So a really valuable team member.

And one of the big reasons we added to added her to our team is because of that research research component, she’s really knowledgeable. And it allows us to really, again, do our part in contributing to some outcomes and data when it comes to the effectiveness of our program as well as how to treat individuals with brain injury.

So today, she’s going to talk to you about reading and writing following acquired brain injury. And welcome to your first webinar.

So I’ll turn it over to you. I know we have a lot of content today. And thanks again, everyone, for letting us hijack this presentation for a few minutes.

Reading and Writing Following Acquired Brain Injury

Dr. Hux – 05:44

Okay, thank you. Thank you. thank everybody for coming. Okay, so today we’re going to talk about reading and writing challenges.

I purposefully left this broad to begin with, so we’re going to talk about a few different kinds of acquired brain injury. And my hope is that we’ll go through some treatment approaches and compensatory strategies that people can use.

And then probably most importantly, the way that you can combine some of these treatments together to build a program for one specific person.

Reading and Writing Today

Reading and writing today is increasingly important. We rely on written communication much more than we used to we text people, we use Facebook, we use all sorts of social connections that are done through the written mode.

So you’ve got to be able to read those emails, those posts, and you need to be able to write them as well. So there’s a lot of greater emphasis on written communication than there used to be. And there’s actually less information on less emphasis on oral communication, although obviously, that’s still necessary for meeting immediate needs and transferring information.

Now, there is a ton of terminology that goes along with reading and writing stuff, and most of it is not important.

Hence the slide.

These were all of the different kinds of alexia and agraphia and those are the two words I am going to use.

  • Alexia is an acquired reading problem.
  • Agraphia is an acquired writing problem.

They’re very similar to the terms dyslexia for developmental problem, or dysgraphia, for developmental writing problem.

But all of these other types of alexia and agraphia, you really don’t need to worry about it. It’s just different ways of categorizing the problems. So we’re just going to stick with alexia and agraphia.

Alexia and Agraphia Associated with Neurological Disorders

Okay, and the types of neurological disorders that I want to talk about today are right hemisphere strokes, left hemisphere strokes and traumatic brain injuries.

And each of these types of brain damage, have unique problems associated with them when you think about reading and writing.

Right Hemisphere Strokes

For people with strokes to the right hemisphere of the brain, usually these, these this brain damage affects the way a person processes visual information.

So you get a lot of visual scanning problems, there are a lot of attention problems. And there are some abstract reasoning problems. So kind of putting the whole picture together is problematic for a person with a right hemisphere stroke.

That’s the group that I’m going to speak the least about today.

Left Hemisphere Strokes

Left hemisphere strokes. The most common communication problem resulting from that is aphasia. And aphasia has reading and writing problems incorporated into it.

So the term aphasia automatically means that there are going to be problems with reading and writing.

Because aphasia itself is a broad based communication problem, any type of symbolic processing is going to be problematic for a person who has aphasia.

There are two terms that specifically go along with left hemisphere strokes. One is alexia with agraphia, and the other is alexia without agraphia.

  • Alexia with agraphia simply means that the person has both a reading problem and a writing problem.
  • Alexia without agraphia means that the person has problems reading, but they’re actually capable of writing.

So you put a piece of paper down in front of them, they can write a message on that paper and it will be written accurately or relatively accurately.

You can also if the person’s fluent at keyboard and you can stick a keyboard keyboard in front of them and they will type a message that is relatively good.

But take that message away from them for a couple hours and then put in front of them again and they won’t be able to read it.

So they have a reading problem, even though they’re still able to read So that’s what that term means. It’s a little bit counterintuitive, but it’s it’s out there.

Again, though, almost all of these people with alexia with agraphia or alexia without agraphia, they’re going to have aphasia with it, to some degree at least. And so we’re just going to lump those together for today.

Traumatic Brain Injuries

And then finally, traumatic brain injuries, the most common communication disorder, there is a cognitive communication deficit.

This is a problem where the individual has some problems with cognitive issues that support or the cognitive processes that support communication, things like attention, or organization or memory.

So the effect is, is indirect on reading and writing, because of those cognitive processes that are going to support your ability to read and write. Some people with traumatic brain injury also have aphasia, so I included that as another possibility.

Right Hemisphere Dysfunction

Dr. Hux – 11:00

Okay, right hemisphere dysfunction, I said, we’re not going to spend a whole lot of time on this. But just to give you a flavor of what these visual processing problems are like.

This was a person who was shown this drawing and was asked to copy this drawing, and what you see is that they copied only one side of the drawing.

This is very typical of people with right hemisphere dysfunction, they have a left neglect or a left hemi inattention, left inattention. And so they only pay attention to things on the right side of the page.

Hence, the drawing is only of the tree and a bit of the house.

Same idea here, this was a freehand drawing of a clock. They were asked to draw a clock set to 7:15.

And you can see all of the numbers are only appearing on the right hand side of the clock, the left hand side of it doesn’t exist.

Well, if you translate this to writing, what you’ll see is that the person only writes on the right hand side of the page, they often write on an upward slant, there may be some repetition of the writing strokes, especially with like M’s or N’s, where you just kind of getting a pattern of repeating the same motion over and over again. Some people will write off the page entirely, so they won’t even attend to the edge of the paper.

So it’s very much an organization on the on the paper and a visual processing problem.

Same thing with reading.

Now this was the grandfather passage. A person with right hemisphere dysfunction might have read this passage, but only attending to the words that appear on the right hand side of the page.

So the underlined parts, they might read my grandfather, well, he still thinks as swiftly as in an old black frock coat, a long beard, things who observe him a pronounced when he speaks his quivers a bit, twice each and with vest upon a small organ, which of course, makes no sense whatsoever.

But that fact that it doesn’t make sense often doesn’t bother the person with right hemisphere dysfunction, they are just reading the words, and not really processing that information. So they don’t pay attention to the fact that it doesn’t make sense.

Again, though, largely a vision problem, they’ve got to attend to the left side.

That’s all I’m going to say about right hemisphere dysfunction. Somehow, we’re going to go on to aphasia.


And here on these next few slides, you’ll see some speech bubbles. These are actually what people with aphasia or with the other disorders, types of communication disorders say about their reading and writing ability.

For a person with aphasia, as I said earlier, it’s a very broad communication problem. So they’re going to have problems, decoding the words, the individual words, and they’re going to have a problem understanding what it is that those words mean, or put those words into sentences what those sentences mean.

When we start looking specifically at reading and writing, then we tend to look at different kinds of words to try to figure out exactly what’s going on with the person’s ability to decode words.

Regular vs. Irregular Words

So you might hear people talk about regular versus irregular words.

A regular word is one that is written the same way that it sounds it’s spelled the same way that it sounds so a word like mint, where the pronunciation of each of those letter sounds is is accurate for the word that you’re trying to say.

Compare that with a word like knock. Well, if you pronounced knock as it’s written, you would get Canuck.

Or my second example, stunt versus circuit. Stunt is regular circuit might be pronounced curcuit by a person who was just trying to base the pronunciation on the way it’s written, the way it’s spelled.

So we have some people who will be able to read regular words, but not irregular words.

Real Words vs. Nonwords

Next is a comparison of real words versus nonwords. Now, you don’t have to read nonwords, this is completely non functional. Nonwords don’t exist.

So this is only for assessment purposes, it’s to figure out what the person can do.

So flag versus flig. Flig is is not a word, but you should be able to pronounce it based on the way that it’s spelled. And a person with aphasia might not be able to pronounce that word, even though they could read the word flag.

And that’s because they have the semantic information for flag. But flig, since it’s not a word doesn’t have any semantic information. So we sometimes look at real words versus nonwords.

High vs Low Frequency Real Words

And then high frequency versus low frequency words, you can think of this as common versus uncommon words.

So word like flower is a high frequency word, we use it a lot in our language, versus scorpion, which I haven’t used, I don’t think in the past year.

So how common the word is, is something sometimes the distinguishing factor.

Error Type – Phonologically plausible vs. Implausible

In terms of writing, a person may have similar issues that they might write a word like knock, and actually write it down on a piece of paper in a couple different ways.

They might write it correctly, which would be great.

They might write it in the way that it sounds, which would end up nok, and that would be considered phonologically plausible. It’s the way the word sounds.

But then some other people, if you ask them to write that word, they’d come up with something that did not resemble knock, or the way knock sounds at all. And that’s called phonologically implausible.

Cognitive-Communication Deficit

Okay, switching to cognitive communication deficits. These are people, usually with traumatic brain injury.


And in terms of reading, their decoding is usually intact. So they can read the words, they don’t have this problem of, they can read some words, but not other words, they can read all of them.

Their problem is with comprehension. They can’t put that information together to make sense of it to integrate it with other information that they already have to figure out what’s important and what’s not important.

So it’s very much a higher level reading problem, a comprehension based problem for individuals with cognitive communication deficits.


And in terms of writing, a person with a cognitive communication deficit is likely to have problems thinking of enough information to write.

They may have trouble thinking of ideas that they want to write about.

They might have spelling problems.

They might have word choice problems, where they pick a word that’s it’s close, but it’s not really the right word.

They may have trouble organizing the information in a way that makes sense to another person, so they don’t get things in the right sequence, or it doesn’t really pull the information together.

Sometimes you’ll have punctuation problems and grammar problems. Usually this is issues of just omitting all punctuation sometimes, sometimes it’s it’s problems of matching the subject and the verb correctly together.

A very common problem is that productivity is quite slow. So it takes them a long time to come up with enough information to write and to get it down on paper.

And they may need multiple attempts to correct errors. If they see an error. It’s not something they can just easily correct with one shot the way we typically do. I’ll show you some examples of that in a minute.

So here, this was a person with a with a cognitive communication deficit following traumatic brain injury. And he was writing a story.

So he started out fairly on he’s typing this and I’m going to show you exactly how he typed the next sentence. And see watch hear how many attempts it takes for him to correct what he has written.

So as he goes along, he makes some errors and doesn’t catch it right away. So that word was supposed to be “kept” earlier and then kept going off warning.

And you see how many times he has to go back to try to correct the same thing. Now you jump back to correct the kept and same issue multiple attempts to correct one word.

Okay, I’m gonna stop that there because you get the idea. Now imagine how frustrating that is that not only are you trying to be creative here on right, but your attempts to correct something a simple word that Oh yeah, I see that and I typed it wrong and I just hit the wrong key.

But it takes 3, 4, 5, 6 attempts to correct one word, so you can easily see how productivity is is impacted and how frustrating this becomes for the individual.

Clinical Practice

Emphasis on Speaking Rather Than Reading and Writing

Now, in clinical practice, as speech language pathologists, we have for years put an emphasis on speaking rather than reading and writing.

And to a certain extent, this has been appropriate because the first way that we usually communicate our needs is through speech, we say something to somebody else.

But with the increased emphasis in our society on reading and writing, now we really need to pay attention to these other modalities. Reading and writing really have become just as important as speaking. And, especially if this is a younger person who’s going to go back to a school situation or a work situation, or even just be socially connected with friends, reading and writing are critical.

Assessments Are Inadequate

Our assessments are very inadequate. We have assessments for children that look at reading and writing. But we don’t have good assessments for adults, the ones that we do have are based typically on reading single words or writing single words rather than writing sentences or texts.

And we also need to realize that there’s huge variability among adults, and how competent we are in reading and writing. Especially writing. There are big, big differences.

So if you’ve got a literate adult, you assume that they’re going to be able to read and write, but how much they use writing in their daily life varies and the type of writing they do.

So what what standard they’re expecting for the quality of that writing differs tremendously from person to person. We don’t have any way of capturing this through assessments at this point.

Treatment Options

So let me switch to treatment options. Now, this is not rocket science. These are really pretty straightforward activities to do. The trick is to know which ones will work with which person and and to combine them together.

So for alexia for reading issues, we’re going to talk about tactile-kinesthetic input, which sounds complicated and it’s not. Re-Learning grapheme to phoneme conversion rules, which is relearning the letters and sounds that go together.

Drilling on frequently occurring words, something called multiple oral, multiple oral reading, functional reading tests and text to speech support.

For agraphia, we again have the phoneme-to-grapheme conversion rules. Anagram and copy treatment, Copy and recall treatment, and retraining written language conventions. (That’s the rules of writing.)

Semantic mapping, functional writing and speech to text support. So let me talk a little bit about each of those.

Tactile-Kinesthetic Input

Very simple. If you have little kids, this is what you do with little kids all the time.

The idea here is to get a lot of different sensory input is in about what a letters shape is. So we are tracing letters, we’re feeling them we’re using manipulable, just like you do with little kids.

With adults, I usually use either the the magnetic letters, or you can use Scrabble letters, looks a little bit more adult like than some of the kids stuff.

One individual who has a film on the internet about Alexia without agraphia and his experiences where he talked about tracing the letters on the roof of his mouth. So he would use his tongue to make the shape of a letter and the roof of your mouth is very, very sensitive. So it was really a smart way to do it.

It’s also one that nobody can see except, you know, the individual can feel it for himself, but that would help him identify the letters. And it’s the same approach of tactile-kinesthetic.

It’s getting input through a different modality than just seeing.

Re-learning Conversion Rules for Reading.

This is often done with flashcards. So you simply have a key word associated with each alphabet letters. So A for Apple. So, the idea is that you’re going to learn that letter A and associate it with the A sound or B with the B sound in boy.

So you’re learning one key word for each letter. And it’s just a matter of memorizing those key words so that then you can put them together to rebuild the phonology of a word.

You can modify that approach a little bit by putting both vowels and consonants together. Sometimes the vowel changes the sounds rather dramatically and so you want that combination of the consonant and the vowel together. But it’s the same idea. And flashcards work really well for this.

Dolch High-Frequency Words

Drilling on high frequency words. If any of you have little kids, then you may have seen these lists of words. They’re used for young children, learning how to read, and these are the words that they’re supposed to just memorize.

These are words that we don’t sound out, we simply have memorized what the form of the word is. And so these lists are available on the internet, called the dolch, high frequency words, and very, very convenient to have a list of function words.

You’ll see that there are no nouns in here. The nouns actually appear in a separate list that is usually introduced after these other lists.

But these are very commonly used words, and will account for a lot of the function words that appear in most written work.

Multiple Oral Reading

Multiple oral reading is a technique that we use with people with aphasia, or people with, with any kind of fluency problem in their reading, where they’re not as smooth in reading written text as they used to be.

So the basic goal is to enhance reading fluency. It also helps in recognizing those really common words, though.

So the idea here is that you would sit down with a person and you have a reading passage, very simple reading passage. You start with whatever level the person is at, oftentimes, that’s a preschool level, or maybe a kindergarten, first grade level, and you read the passage with the person.

So choral reading means that two of you are reading it together. So you’re supporting the person by reading it with them.

And then after the person gets used to the passage understands what the passage is about, you have them independently read that passage aloud several times over. And the goal is that you’re trying to get accuracy and a certain rate of speech, which indicates that they’re decoding it relatively quickly.

Now they’re going to memorize it. And this is okay. Because you’re what you’re trying to do is get that rapid decoding of those easy words. So it’s okay if they memorize it. In fact, that’s part of why this approach works.

Then, you usually set the send the person home with that passage to work on independently. And then they come back the next day or the next week, whenever your session is, and you make sure that that passage is still at the desired rate and with the desired accuracy, and then you introduce the next passage and go through the process again, and again, and again with new passages.

The new passages can get increasingly long and increasingly difficult. And you start to see well, okay, now you can’t just memorize the passage, you really are going to have to pay attention to reading the words.

So this is effective for some people with aphasia.

Functional Reading

Functional reading is any kind of reading that you would do in your daily activities. So, a progression, if I would doing functional reading with an individual had a pretty severe, Alexia, pretty severe reading problem, I would start with, say, a newspaper or a magazine that was of some on some topic that was of interest to them. And I would start by just looking for common features on the page.

So you may want to say, Where does the page number appear? Where does the date appear on the newspaper? Where is the name of the newspaper? Where’s a heading for a story?

So you’re not actually asking the person to read the heading or read the name of the paper. What you’re doing is you’re asking them to locate specific graphic elements on the page.

You can move from there to locating specific letters. So you can say okay, find the letter S for me. It’s somewhere in this headline, look in this headline and see if you can find the letter S for me.

Then you might move from that into looking for specific words, or highly predictable words or let’s look for the word “the” and see how many times we can find the word “the” here, you might start reading picture legends, because again, that’s going to the picture is going to give you some context, so that you already have an idea of what this legend might be about, which is going to help the person decode it. And then move on to reading headings and eventually reading sentences.

I’ve also listed some materials here that are appropriate for adults, news for you as an adult newspaper, but it’s a large print newspaper that’s available and many rehab facilities and hospitals have subscriptions to it.

Tween Tribune is written for teenagers basically. But again, it’s going to have common news articles. And so it’s going to be appropriate for your adult readers who, who might have reading issues.

The same with these magazines. Some of these are actually geared towards children or teenagers. But the topics are appropriate for adults. So it’s not they’re not cartoons, it’s not going to people aren’t going to feel as if you’re insulting them by asking him to read these materials.

Recipes are appropriate letters, cards that they’ve gotten, emails that have come to them would certainly be appropriate. And children’s books are appropriate, as long as the person doesn’t feel insulted by it.

So I’ve had many adults who are very happy reading Dr. Seuss, they don’t mind. It was fun when they were kids, and it’s fun now. And they just look at it as that as okay, I’m learning how to read again.

But I would never do that without first checking with the person to make sure that that’s okay with them that we use those kinds of materials.

Text-to-Speech Conversion

Now, one strategy for a person who is having problems reading, and is struggling to get sufficient reading skill back to really read functionally, is to use text to speech conversion. There are a lot of systems that will read text to you.

Many systems are available for free. You simply download them on a computer or an iPad or on your phone. They come on different systems, different platforms. You can control a lot of the features. So you can control how fast it reads to you, you can control whether it’s a male voice, a female voice, what accent that voice has.

There’s a lot of highlighting features. So you can have it word by word, you can have it highlight a whole sentence at a time or align at a time or paragraph at a time. You can pause and replay sections if you want to, as many times as you want to.

So these are really helpful and very good way to get content. Now, some mispronunciations are going to occur, because these systems are not perfect in reading, speech.

I do have a sample here of what text to speech sounds like. Probably you’re relatively familiar with this, but let me just play a real brief sample for you and what can we go.

Tim Benak – 33:09

Alright, so I’m gonna slide this over here. It may or may not work.

Dr. Hux – 33:13

We hope you can hear this.

A Taste of downtown. Walking through downtown Juneau, Georgia, all the summertime vendors, the amount of food choices may seem almost overwhelming. Having just moved to Juneau in February, I definitely wanted to get a taste of the town. Here are some unique eats and drinks to try out yourself.

Dr. Hux 33:45

Okay, so that’s an idea of what that sounds like. And it’s pretty good speech. And that’s not the best voice that you can pick. That is actually the standard voice for the PC platform. But there are there are some voices that are actually better than that.

And as I said, you can control the rate and you can go back and repeat things. So a good way for a person to read their email if they need if they can’t read it themselves, they can have it read to them.

Re-learning Conversion Rules for Writing

Okay, in terms of writing some of the techniques you can use. Re-learning those sound letter conversion rules that you do for reading, you can do the same thing for writing.

So this is very similar, you do D as in dog S as in Sam, you’re just practicing those phoneme-grapheme. So the sound written letter pair, so that the person can be accurate in saying, Oh, that’s an S. I know an S sounds like s. So I’m going to go with that sound.

That is not the way that most of us as fluent readers and writers, write words or read words. But it’s a way to get to that fluency eventually. It’s back to the learning process.

Anagram and Copy Treatment

Okay, another technique is to do what’s called the anagram and copy treatment or ACT.

You present letters I use Scrabble letters, because again, they’re a little more adult oriented.

You give the person the letters for spelling a certain word, you tell them what the word is. So maybe the word is “crazy” here, although usually you start with something like “cat” or “dog”, some simple word, a consonant vowel, consonant word is where you usually start, and you’re putting the letters down in front of them, just mixed up.

And what you want them to do is be able to orient the letter correctly, so that it’s in front of them in the correct direction, and then put the letters in the right order to, to spell that word.

Once they have the letters accurately arranged, then you have them copy that word for just practice. So they’re getting the the written practice as well as the reading practice.

Usually with this, you would have a set of words that you’re working on. Once the person has, and I would, very quickly, make sure that that set of words, is an important set of words for that person. So it may very quickly go to things like my daughter’s name, my husband’s name, something like that. So it’s not just the word “cat” or the word “crazy” as on the slide, something a little more functional for the individual.

And then once they’ve got that, where they’ve learned that set of words, then you can make it a little harder by adding in extra letters. So now we’ve got the word “crazy”, but I’m going to add the letter T, which you don’t use in that word, and make sure that they can recognize, oh, this is an extra letter, I’m not using it.

Now, I’m going to tell them that I’m adding extra letters. But their job then is to pick out the correct letters.

Copy and Recall Treatment

Copy and recall treatment is called CART. And it’s a good supplement for the anagram and copy treatment.

Here again, you’ve got a specific set of words, and you’re having the person repeatedly copy those words, as a homework assignment. And what you’re doing is you’re having the person copy at once, make sure it’s correct that first time and then copy it repeatedly.

And then as as they’re copying it, you’re hoping that you get to the point where you can cover up the word and they can write the word without needing to see the sample. And then as mastery occurs, you go on to a new set of words.

I’ve used this with those function words, it can be very appropriate for those words that tend to not sound the way they are spelled.

This is a good way to drill and practice on those words.

Written Language Conventions

So these are all the rules of when do you use commas? Or what, when to use capitalization? Quotation marks? How do you organize an essay? If you’re at that point of writing essays? How do you develop your ideas?

So there’s a lot of rules here that that if you’re at if the person is at that level, and many people with cognitive communication problems from traumatic brain injury will be at this level, and this is the level that we need to be working on for them.

And there are a lot of websites that will give you lists of these rules. You don’t have to figure them out for yourself.

Semantic Mapping

Semantic mapping is a good technique for generating ideas and for building connections between words.

So I have two examples here. And these actually came from a person, a young adult with traumatic brain injury, had a cognitive communication problem. And his problem with writing was that he could not generate ideas.

So we used this and the top example for the word wheel was one that he did early on in treatment. And then a month later, he did the one for fire. And you can see the change.

The idea here, this was a this was an online tool. There are lots of these, they’re free again, so you can you don’t have to create this yourself.

But you start with a word, and then you make connections off of that word. So different categories of ideas that might go with it.

So for wheel, he thought of what wheels go on, so where you might find them. And for that he thought of cars or parts of cars and axle and tire, which are all associated with wheel.

He also thought of another category, which was what wheels are used for. And he came up with driving and spinning. And he came up with types of wheels like Ferris wheel, but that was all he was able to come up with at that point.

Several weeks later, we had practiced this and gave him the word fire. And you can see how much more complex this is and filled out his grid is about what he associates with fire.

Now, this is fine just for generating ideas, you can also use this technique for organizing your information.

So if I wanted to write an essay about fire, I might talk about what fire looks like. So I might talk about different colors, I might talk about what is required to make a fire, or where fire might occur, or what fire does, or how to put that fire out.

So all of these may be separate paragraphs in an essay that I end up writing. So you can also use this strategy for organizational purposes later on.

For him, it was just a way to get ideas about things I might want to write about, and was very effective for him.

Functional Writing

And then again, you want to do functional writing tasks. This is going to go from very simple to very complex to do lists, checklists is a good place to start. It’s one or two words. Emails, cards, or thank you notes, where maybe there’s even a script that you’re following to write those notes. Writing checks, that’s a very functional skill. Any of the social media stuff. So Facebook tweets. Journaling becomes important for some people. Writing notes. If you’re in an academic setting, or if you’re in a business setting, and you’re trying to go into a meeting and trying to write things down.

Or, obviously, papers, reports, work documentation, if you’re at that level, which many of our people get to that level.

Speech-to-Text Conversion

And then finally, the same way there was text-to-speech conversion, there’s speech-to-text conversion, where you can dictate, instead of writing by hand or writing on a keyboard typing, so you can use dictation systems.

Again, many of these are built right into Word Processing System, so you don’t have to buy anything new.

Some systems are slower than others. So with some systems, you have to take pauses, or they will make mistakes and it won’t catch everything that you have said.

So some of them are more accurate than others. And the other issue is that you do have to dictate punctuation. So that becomes an issue. You need to get used to that.

If you have a person who has a motor speech disorder, so they have some dysarthria, some slurring of the sounds or incorrect production of the sounds, then translation is going to be harder. So there are some issues you need to consider here.

But for some people without those problems, this is a very effective way to return to being able to write.

Multicomponent Intervention

Now, I want to take the last few minutes here to talk about putting all of these ideas together to make an intervention program. So what you want to do is pick the kinds of treatment that will be appropriate for an individual where are they with their reading and writing process, and combine different types of activities that will match their strengths and challenges.

So as an example, this was a case of a 15 year old boy who had a very severe traumatic brain injury from a fall. He was very gifted academically prior to his injury. But the injury caused a severe traumatic brain injury, diffuse axonal injury.

He was unresponsive completely for three weeks, in post traumatic amnesia for two months following injury. So this is severe by any way you look at it.

He came to us as a post hospital inpatient rehab facility at four months post injury, so he already had quite a bit of rehab at this point. Initially, during that hospitalization before us, in acute rehab, he had severe expressive and receptive aphasia.

He was producing nonwords, just kind of made up words, except in automatic utterances. You know, he could say, I don’t know, he could say hello, goodbye, things like that. But otherwise, he create words that weren’t really words.

He could not copy or write any letters, he could not read any words. He did have some anomic aphasia, which is basically trouble recalling specific words, and very inconsistent in single letter identification and letter to sound correspondence. So very severe reading and writing problems that were overshadowing everything else.

When he came to us, mostly his aphasia had resolved except for naming. And that’s where we get that anomic aphasia. So if you held a cup up in front of him and said, What is this, he was going to have trouble coming up with the word cup. But he was speaking in sentences, so don’t push him to retrieve a specific word and he was very functional. But he did still have that anomic aphasia.

Here was where his real problem was, word attack skills. He was in the first percentile grade equivalency of 1.8 in word reading skills, again, first percentile, 1.6 grade level. Spelling at less than the kindergarten grade level. So very, very severe alexia and agraphia.

Informally, we did some of that testing with all those different kinds of words I talked about at the very beginning, he was very poor. Reading single words, he could read about 50% of consonant vowel consonant words. So this is Cat, Dog, Tap, words like that. Irregular words, he couldn’t read it all.

Writing single words, single syllable, regular words, he did really quite well at but could not do any irregular words and no multi syllabic words.

He was accurate by the time he got to us in identifying single letters and producing the sound that went along with that letter. And that’s because the clinicians before us had done that association of A is for apple, B is for boy, and he had all those flashcards, and it worked. So he came to us with that skill. When he got to us.

We set up a program. We met him five days a week for an hour for seven weeks, seven weeks isn’t very long, really.

We drilled on sight words, to get that immediate recognition of common words and to encourage whole word recognition rather than sounding out the words. We did multiple oral reading procedures. So I was trying to get him to shift from that sounding out of words to the fluent reading of words. We did functional reading tasks, because that was very motivating for him. And, we did CART procedures, the copy and recall task procedures, to generalize the skills from reading to writing. We would do every one of those in every session.

Now, these graphs show his improvement. But the details of this aren’t important.

What’s important, is that you see, initially, this was the reading of those very basic words. And we have 5 different lists of words, with this being the pre kindergarten list that he started at, above 90%, and quickly went to 100% on.

But as soon as you went to kindergarten, first grade, second grade words, you can see he’s quite poor.

But very quickly, he went to 100% accuracy and stayed there. Okay, so very quick improvement.

Again, a very confusing chart…What I want you to realize here is that the blue part of the chart, this is multiple oral reading. The blue lines on the chart indicate where he would first read a passage, how many words per minute. Now, this is like 25 words per minute that he was reading this first passage.

That is really slow. That is sounding out every word.

And then we would do it together during the session, and then he would take it home and practice it and practice and practice it. And the next day come in, and he was up to 80 words per minute. Now we set 80 words per minute, initially, as that’s fast enough for us. That is very, very slow, very, very slow still. But that’s the point that he was at.

And you notice here, these were first grade materials, so very simple materials. So then the next day he’d come in, we do the same thing. We’d start here, and he didn’t make the 80% criteria. So we actually did that for another day before he could get up to being fluent and reading this.

And we would go through the materials and eventually started getting harder materials. So second grade materials. And then I thought he’s getting this on one day, this is too easy. So we upped how fast he had to do and we went up to 95 words per minute as the threshold for him.

You can still see a lot of times he’d make it in one day. A lot of times it would take two days to get it fluent enough, but we were going up to fifth grade reading level. And this was over 34 sessions.

Okay, so pretty stark improvement even though the bottom line No, that initial reading is still like, yeah, we’re lucky, 50 words a minute, it’s a whole lot better than 25 words a minute. But that’s still very slow. But we were able to get it fast and it was going to come. And with the increased complexity. That was a big deal.

Spelling, again, terribly complicated chart here. What you want to see is all these lines up at the 100% level.

So we would not accept that he had mastered a spelling list. So the red line here is one list. We didn’t accept that he’d mastered it until he could do it three times in a row without making any errors.

And then we would introduce, then we would stop that list and say, okay, that one’s mastered. He had to do it at least once before we would introduce a second list.

So here was our second list, and you can see it would take several times to get up to mastering that. Now, these were those same words. So we’re talking about pre kindergarten words here…Pre kindergarten words here, kindergarten, first grade, second grade words.

Now you see this big drop down between list eight and list nine? That’s because I ran out of those easy words, and I suddenly went to vocabulary words, that were I think were fourth grade vocabulary words. So a big shift here. And that’s why these were suddenly hard.

But he’s still able to do it. And it was just a matter of relearning.

Okay, after seven weeks, we retested. So, this chart shows you the baseline testing that I showed you before where he was at, basically kindergarten, first grade level.

After seven weeks, he was at third, fourth grade level, in his reading ability. Pretty dramatic for less than two months of treatment. Informally, now he’s got the reading of single single words is good, except those irregular words, we still have a problem. Okay, it’s not, it’s not quite there yet.

And you see the same thing with the writing of the irregular words. So anything that was an irregular spelling, he was still struggling with. He is by no means cured. He still has a substantial reading and writing problem, but he’s made a lot of improvement in a very short period of time, enough that he was able to return to a regular classroom setting with help.

He did have special education, resource room treatment with a reading specialist, he was given access to assistive technology to read to him read textbooks to him, and to allow him to dictate reports.

He was tested again, nine months later. And he was at that point reading at an eighth grade level. So he got continued treatment in the school to build on what we had done, and essentially was back to a very, very good reading level.

It’s not where he was prior to injury. But he was very functional at this point. And this wasn’t to say he was stopping at that point either. So very good improvement.

So at that point, I’m going to stop. And we’ve got just a few minutes for questions.

Poll Question

Tim Benak – 53:26

Yes. So I’m going to go ahead and launch the poll that we do every time here to take control here.

Okay, so there is a poll question on the screen right now. As always, if you are looking for your certificate, please make sure you answer that. That this is our guide to who wants to receive the certificate and who wants to get the evaluation. So please answer that. That’s on right now.


And then I also have the question and answer panel open as well as the chat. So if you have any questions, send those in. We did have a few come through.

When is this treatment recommended to begin with a QLI patient?

So the first one that I’ve got here for you is when is this treatment recommended to begin with a TBI patient, and how does brain rest come into play if a patient is having post concussive symptoms?

Dr. Hux – 54:27

Okay, those are really good questions. Like I said, clinical treatment right now, when a person has a stroke or has traumatic brain injury and is in the hospital, the emphasis is still on reading and writing. And that’s, I’m sorry, is still on speaking. And that is a good emphasis, but it shouldn’t be the sole emphasis.

So these reading and writing treatments need to be looked at initially to see how bad the problem is, to get a feel of are we going to need to focus on this. And that should happen early.

I was just working with some people with traumatic brain injury who were several months post injury and nobody had ever asked them to write anything prior to that, and lo and behold, there were all sorts of writing problems.

Some of them were aware of those problems, and some were not. So it needs to happen relatively early, it should definitely be happening in acute rehab.

How does brain rest (cognitive rest) issue come into play if a patient is having post concussive symptoms?

Now, the cognitive rest issue…When you’ve got somebody with post concussive symptoms, then the notion is that you back off on anything that might cause eye strain, so you don’t want screen screen time and you don’t want a lot of focusing on written work.

Anytime you have a person who’s experiencing headaches, from attempts to read, they need to stop reading when those headaches happen. So as soon as the symptoms kick in, you back off.

But you don’t have to be afraid about trying it. You don’t have to be afraid about saying, well, let’s see, if we get headaches from this. If we get headaches, we’re going to stop. But if we don’t get headaches, then that’s great. We can go on.

Most likely with that person with post concussive issues. Once you get over the eye strain and the problems associated with vision and focusing on print, then you’re probably going to be into the high level, organization problems in terms of writing or the comprehension problems in terms of terms of reading, which was not the part that I focused on the most today, but is another aspect of this.

Why can’t I see the poll question?

Tim Benak – 56:43

Okay. We have a few folks saying that they can’t see the poll question. Yes. If you can’t see it, just send an email to and Taylor and I will see that you are on.

The question is, “true or false, handwashing is important to stopping the spread of a virus.” So just shoot us true or false to that. That way, we can see that you’re wanting the evaluation.

If you had a struggling reader and writer prior to the TBI, and he continues to treat afterwards, would you recommend a med psyche eval to determine if this is existing or related to the TBI to guide intervention services?

Dr. Hux – 57:25

Yes, this is another good question. You need to know what what type of reading and writing the individual was doing prior to injury, and what their goals are in terms of reading and writing.

If a person was having reading problems, prior to injury, they’re going to have reading problems after injury. You’re not going to get rid of those problems.

It’s hard to tell from even from neuropsych testing the extent of those reading problems. We can administer tests that will show basically, this was the general IQ. There are tests that will give you a measure of prior functioning. So it gives you an idea, but there isn’t there aren’t good reading and writing tests that are going to say, Well, this is what the person was able to do before injury.

So you need to talk with family, you need to talk with the individual. You need to know what kind of reading and writing they need to do to be functional in their life. And that’s the kind of reading and writing you’re going to work on. You’re not going to work on, you know, polished report writing, if that’s not what the person has to do.

Tim Benak – 58:35

Okay, Becky, I will have somebody reach out to you to answer your question.

With younger people that have reading and reading difficulties post TBI, are you beginning to work with them on all the texting shorthand that is commonly used now? Do you need to focus on traditional reading or writing first?

Dr. Hux – 58:58

That is a very interesting question. I hadn’t thought of that. I am going to say yes, you need to work on that, because that’s what socially is socially accepted for them and expected by their peers. So I think that’s going to be an important thing to work on. But I really had not thought of that before.

Tim Benak – 59:22

Great question. Whoever submitted that.

Do you have a text-to-speech system recommendation?

Back to the text-to-speech part of your presentation. Do you have any recommendations for the best systems that you’ve had experience with or that you’ve used?

Dr. Hux – 59:40

That’s hard. There are hundreds of them out there. And I am working on a project right now with some colleagues where we are looking at just that with people with aphasia, and using text-to-speech systems.

The trick is to figure out what the person wants control of. So do they want to be able to have highlighting of single words as they go along? Do they want to be able to pick which voice? Are they willing to pay for? versus do they need a free system?

You got to answer those questions first, so that you know what you can pick from. And then once you get those questions, so you know, if you know, I have somebody who only has a PC at home, then you got to have a system that’s going to work on a PC.

Or, this other person wants to do it on their phone, then we have to assist them at work on their phone. And so you’ve got to answer those questions first, that will limit your choices. And then from there, you have to experiment. But no, I can’t name a brand for you at this point. And I wouldn’t dare do it even if I could.

Tim Benak – 1:00:52

If I answer the poll question, can I sign off?

Yes, if you answered the poll question, you were okay to sign off. We will see that you are wanting to get the evaluation.

If there’s any other questions that do come through, Dr. Hux’s his contact information is currently on the screen, so feel free to email those directly to her. And if any of the ones that we didn’t get to, I think we actually got to all of them, but if anything comes through, we will also get those sent over to you as well. Okay, thank you so much.

We actually will be sending out an invite for our next webinar. It won’t be attached to the evaluation. We’re still trying to line some things up on our end for what next month’s presentation will be just to see who’s going to be maybe on campus or off campus with kind of the the global climate of what’s going on.

So be on lookout for that.

Please join us and as always check us out on our social media pages, LinkedIn, Facebook, Instagram.

We’ve got some amazing stories and then is our website. Any of the telerehab questions, direct those directly to Steve Kerschke. That’s or send them to and we’ll get those over to him.

Hope you all stay healthy out there. Have a great day. Thanks for joining us.

Categories: Brain Injury