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.