CAN YOU READ THIS? By: Joan Monahan
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For many stroke victims with dysphasia understanding those four simple words above would prove to be very difficult. We live in a world surrounded by the usual print from street and place names, to environmental notices like "Toilet", "No Exit" to directions on working items, on medicines, washing instructions, newspaper articles, letters, forms, books and texts for special study. Yet reading difficulties following a stroke tend not to be recognised and to remain hidden.

We think of the dominant stereotypes of handicap as someone in a wheel chair or with a stick. Disabilities that don't conform are often little understood by the public. One stroke victim with a reading disorder commented "It's there, but I can't figure it out", on trying to read a few single words. While another, reflecting on his initial attempts at reading after his stroke, puzzled "All those words. An article I tackled consisted of words which were in a complete jumble of letters signifying nothing".

This disability which can occur following a stroke is referred to as dyslexia. It is one symptom of a central language disturbance, brought on by a stroke or other brain damage, called dysphasia and which affects the comprehension of the spoken word, naming of objects, expressing thoughts, writing and reading. Dyslexia may be defined simply as the loss or impairment of the ability to read caused by brain damage. A crucial consideration here is that the function of reading in the definition of dyslexia refers strictly to the comprehension or understanding of written material.

The ability to read out loud is often a separate function. If stroke persons can read out loud this does not mean that they can understand what they are reading. Conversely if persons cannot read out loud this does not mean that they do not understand what they are trying to read.

So how do we know what the stroke victim can and cannot read. What stages are involved in the reading process? It is only through careful assessments that we can identify the range and severity of the reading disorder. Investigation of the reading deficit is part of the total assessment carried out by the speech therapist using a standard dysphasia battery. Specifically the test could contain a section enabling the therapist to survey reading comprehension of single words, sentences, short paragraphs and knowledge of the alphabet. Reading is a very complex skill relying on the intact function of many different processes and dysphasia, in its various forms, may serve to dissociate these processes - sparing some and damaging others. Before working with letters and words one must check the integrity of the capacity to see and discriminate the basic elements of the written system i.e. letters as letters, words as words, numbers as numbers etc.

Assuming this is intact, we begin to investigate the reading comprehension of single words and the errors that may be made at this single word level. Some stroke victims make the errors that may be made at this single word level. Some stroke victims make errors on words which look alike, e.g. selecting the word"leap" instead of "leaf" or "brown" instead of "broom". Others may make semantic type of errors e.g. choosing the word "train" for "jet", "brother" for "sister", "nozzle" for "hose" etc.

It is usually words that are in frequent use in the English vocabulary which the dysphasic person will find easier to recognise and read and which therapists will use in programmes to increase their understanding of single words. However, occasionally, longer or less common words that are specific to a person's occupation or lifestyle are more easily recognised and understood. One particular person who had been a musician found words like "music" and "saxophone" much easier to recognise and read than words like "food" or "wall".

When someone has difficulty at this level of matching one correct word to a picture or the words that are as relevant as possible. Reading of words seen readily in the environment are important to learn early on e.g. toilet signs, stop and shop signs, banks etc. Pictures in magazines can be used effectively particularly with action type words like "put", "give", "turn" etc. These words are important for following written instructions e.g. "Turn the cooker on to 180°C"; "Put the cat outside" etc. Single word vocabulary training is helped by labeling objects around the house so that the person is exposed to the word and associations between the correct word and object is strengthened.

Beyond this one word level there is evidence that the reading of names of objects or items (so-called lexical words) uses a different mechanism from the reading of small grammatical words like "is". "so that", "under" etc. Often the relationship of these small words to the other items in the sentence e.g. "put the money behind the clock" or " the dog is being chased by the cat". Some dyslexic people find these smaller words so confusing that they are unable to follow the sentence. One particular patient referring to the confusion caused by these small words said "I'm not sure what way they should go".

Once the client has a single word vocabulary of 50-100 nouns and verbs that can be easily understood we move onto phrases and sentences. This may begin by selecting pictures depicting images of noun-verb combinations, a woman cooking, a man gardening, that the person should know as separate words. A lot of different ideas and exercises exist to build up the person's understanding of short and long sentences. At a much later level tasks, such as identifying grammatical errors in sentences, can be useful as this demands very close reading and understanding.

Comprehension of written questions is one of the more difficult regarding reading tasks for dyslexic readers. Yes/No questions about personal information are often the easiest to comprehend. "Wh-questions" (when, why, where) are often difficult to read and understand. With a person who can manage sentences/questions well it may often be the more complex grammatical structures in a sentence that can cause problems for them. It may be necessary to work on these before the stroke victim can cope with paragraphs from the newspaper or articles. Here we may wish to improve on the memory of what has been read and speed of reading.

However many of the people that we see for treatment will not be able to recover to their previous level of reading skill. There are a great many people in our population who do not have occasion to read in their work or for pleasure and this impairment does not interrupt their routine. But for those people who did enjoy reading there are a few strategies which may assist. One "Talking Books" which are taped editions of books. Stroke victims may prefer to recruit a friend or volunteer who will spend some time each day or week reading with them. Reading matter of any kind, especially social letters from family members, can be taped and played back while the words can be followed by the person.

In conclusion, to understand these simple words -"Can you read this"- depends on many different processes working together. By identifying the extent of the problem and planning remediation programmes for family and volunteers we can help to make sense of that "jumble of letters".