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Token Test Scores of Three Matched Patient Groups: Left Brain-Damaged with Aphasia; Right Brain-Damaged without Aphasia; Non-Brain-Damaged
TOKEN TEST SCORES OF THREE MATCHED PATIENT GROUPS: LEFT BRAIN-DAMAGED WITH APHASIA; RIGHT BRAIN-DAMAGED WITHOUT APHASIA; NON-BRAIN-DAMAGED Linda Peck Swisher and Martha Taylor Sarno (Institute of Rehabilitation Medicine, New York University Medical Center)
Determining a patient's ability to understand speech is one of the most difficult tasks a clinician faces in the evaluation of patients with aphasia. In 1962 De Renzi and Vignolo contributed to this important area of study by introducing the Token Test, developed to reveal mild receptive disorders. The three major studies of Token Test (TT) scores have used either Italian or German speaking Ss. The results indicate that the TT detects receptive difficulties which are not obvious during routine clinical testing (De Renzi and Vignolo, 1962; Boller and Vignolo, 1966), and that poor performance is specifically associated with a lesion in the left hemisphere (Boller and Vignolo, 1966). In addition, it appears that the responses are minimally contaminated by general intellectual impairment (De Renzi and Vignolo, 1962; Boller and Vignolo, 1966), that age does not affect scores in normal Ss over 15 years of age (Orgass and Poeck, 1966), and that there is a high correlation between the clinical evaluation of the severity of aphasia and the TT scores (Orgass and Poeck, 1966). The present study was conducted primarily to determine whether the findings concerning TT scores for German and Italian speaking subjects apply to English speaking subjects.
1 The work reported here was supported in part by the Social and Rehabilitation Service, Department of Health, Education and Welfare, under the designation of New York University as a Rehabilitation Research and Training Center. Parts of this paper were presented to the American Speech and Hearing Association, Denver, Colorado, November 16, 1968.
Token Test
265
MATERIALS AND METHODS
The TT was administered as described by Boller and Vignola (1966) with the S seated at a table on which the tokens were displayed. Plastic tokens of two shapes (circle and rectangle), two sizes (large and small) and five colors were used. The large circles were approximately the size of a poker chip. An example from each of the five parts of the TT follows: Part I - Touch the red circle. (10 commands; large rectangles and large circles only). Part II - Touch the small yellow circle. (10 commands; large and small rectangles and circles). Part III - Touch the yellow circle and the red rectangle. (10 commands; large rectangles and large circles only). Part IV - Touch the small yellow circle and the large green rectangle. (10 commands; large and small rectangles and circles). Part V - Put the red circle on the green rectangle. (22 commands; large rectangles and large circles only). As indicated above, specific tokens are used for each part. For this study, the tokens were displayed in the same random arrangement during each part of the test for every S. In the first four · parts the commands are expressed in simple syntactic structure - verb and object. In Part V structures are more complex, and prepositions, conjuctions and articles are an essential part of each command. Before beginning the test, the examiner ruled out the presence of visual agnosia by asking the S to match the tokens for the two forms and five colors. Then the examiner said "I am going to ask you to do something. I can only ask you once. Please listen carefully." The commands were then given. After every response tokens which had been removed were returned to the original token display. That is, the same tokens were available for choice at the beginning and end of each part. For the present study the responses were scored in terms of total commands correct. The maximum score was 62. That is, each command was worth one point. The Functional Communication Profile (FCP) was used as a measure of severity of language impairment (Taylor, 1965). The FCP quantifies how much language a patient actually uses. Commu-
266
L. Peck Swisher and M. Taylor Sarno
nication skills are rated in each of 48 common language behaviors, after conversational interaction with the patient. The sum of these reflects a person's overall communication effectiveness. That is, how well he functions with his residual skills. For example, an Overall score of less than 25 % indicates that a patient is severely impaired and an Overall score of 100% reflects no impairment.
SUBJECTS
In all, 129 5s were tested who met the criteria for inclusion in this study. They were hospitalized, right-handed, native English speakers, 70 years of age or under and had either no cerebral damage or damage apparently restricted to one hemisphere. Also their hearing threshold levels for the speech frequencies (500, 1000 and 2000 Hz) were 45-dB ISO or better. 5s were assigned to one of three groups: non-brain-damaged; left brain-damaged with aphasia; and right brain-damaged without aphasia.
Non-brain-damaged subjects The control 5s were hospitalized because of spinal cord lesions or other orthopedic disabilities. It was our impression that all of them were of average intelligence.
Brain-damaged subjects The brain-damaged 5s met two additional criteria: history of a cerebrovascular accident and the presence of a paralysis or weakness contralateral to the side of brain damage. Also, only LBD subjects who were diagnosed aphasic, and RBD subjects who were diagnosed nonaphasic were included. 5s with evidence of dysarthria or verbal apraxia were excluded because these disorders affect scores on the FCP but not on the TT, and the results of both tests were to be correlated. Also, no patient presented evidence of a limb apraxia. The side of brain damage was determined by neurological symptoms, and the EEG and neuro-radiological data provided in the medical chart. Four 5s in each of the brain-damaged groups had known visual field defects, but these defects did not interfere with test performance. Subjects who needed glasses wore them during the test.
Token Test
267
The LBD subjects were referred by a doctor because of obvious 'or suspected communication deficits. The non-brain-damaged and the RBD subjects were referred for evaluation at our request and came preselected by their physicians as cooperative and generally oriented. Three matched groups were chosen from the total group of 129 5s. The matched groups contained only 58 who had been equated with one 5 in each of the other groups for age and educational level. Thus, one trio of matched 5s would have ages within five years of each other and the same educational level - elementary (6 to 8 years), high school (9 to 12 years) or college (over 12 years). It was possible to match 22 5s across groups. Table I presents data relative to the age, sex and educational level for the three matched groups. The sex of the 5 was not TABLE I
Age, Sex and Education of Matched Groups
Controls
Right brain-damaged nonaphasics
Left brain-damagec aphasics
Males Females
11 11
16 6
11 11
Mean age
56,0
57.7
57.9
3
3
3
15
15
15
4
4
4
Education: Elementary (6 to 8 years) High school (9 to 12 years) College (over 12 years)
considered in the matching procedure. The mean age and ranges for the three groups agreed within two years. Most of the 5s had a high school education. Although duration since onset of the stroke was not considered for matching individual 5s, the two brain-damaged groups were comparable as a whole in this respect. Most 5s were tested three to six months after onset of symptoms. As mentioned before, the FCP was used as the measure of
268
L. Peck Swisher and M. Taylor Sarno
language proficiency for the LBD subjects. The Overall scores of the 22 Ss ranged from 12% to 96%. There was also a wide range in Understanding and Speaking subscores. That is, the most severe aphasic used almost no oral or gestural communication whereas the mildest aphasic appeared almost normal in functional communication abilities. The most severe aphasics could not respond appropriately to simple questions such as "How are you?" and "Have you had breakfast?" whereas the least impaired only had difficulty understanding complex sentences.
RESULTS
The relationship between Token Test scores and: Age. The presence of a correlation between TT scores and age was investigated. All Ss were divided into three groups: RBD nonaphasic, LBD aphasic, and hospitalized control. To offset the effects of educational level, these groups were subdivided into elementary, high school, and college educated. There were not enough elementary educated RBD subjects to form a group; thus eight, rather than nine, groups resulted. No relationship was demonstrated between age (17 to 70 years) and TT scores by the Kendall Rank Correlation Coefficients (Siegel, 1956). Education. The relationship between education and TT scores could not be determined because of the small number of elementary and university educated Ss. The only effect apparent to the examiners was that the word "rectangle" was sometimes not familiar to Ss with limited schooling. For example, one elementary educated RBD subject who consistently failed to identify rectangles in Part I, learned to do so by Part II. FCP scores. The Spearman Rank Correlation Coefficient was used to investigate the relationship between scores obtained by the LBD aphasic subjects on the FCP and the TT. Because past education was considered in the scoring of the FCP but not in scoring the TT, to minimize the effects of educational level only the 15 high school educated LBD aphasics in the main group were used. A high correlation « .01) was present between the Understanding and Speaking subscores on the FCP for the LBD aphasic
Token Test
269
subjects. Because of this correlation, it was not surprising that the TT scores correlated highly « .01) with both of these FCP subscores as well as with the total FCP scores. Thus, all three measures of language impairment (FCP-Speaking; FCP-Understanding; and TT) appeared related. Token Test scores Total scores. Of a possible 62 points the mean total test score for the control group was 57 with a range of 48 to 62. The mean for the RBD nonaphasic group was 53 with a range of 35 to 61, and for the LBD aphasic group the mean was 23 with a range of o to 58. Eighteen Ss in the RBD group and two in the LBD group scored above 48. Thus, the total score would have discriminated 91 % of the LBD subjects and 18% of the RBD subjects from the control group. One of the two LBD aphasics whose scores were within the normal range could be discriminated from normal because he did not attempt to pedorm parts of three of the commands in Part V. The responses of the other LBD aphasics did not appear unusual in any way. It is interesting that a speech pathologist unaware of the TT scores commented that this 5 behaved more like a RBD nonaphasic than a LBD aphasic. Scores by parts. Table II summarizes the mean correct responses for each part of the TT for the matched groups. In general, the three groups of Ss had increasing difficulty with progressive parts. TABLE II
Mean Correct Responses for Matched Groups
Part Part Part Part Part
I
II III IV V
Controls
Right brain-damaged nOflaphasics
Left brain-damaged aphasics
9.9 9.9 9.6 9.6 7.6*
9.6 9.6 9.1 7.8 7.3*
5.7 5.6 3.6 3.3 2.6*
* Scores adjusted to comply with Parts I-IV.
L. Peck Swisher and M. Taylor Sarno
270
It is also obvious that the LBD aphasic subjects had the greatest difficulty on all parts; and that the scores for control and RBD nonaphasic subjects on Parts I, II and III did not differ markedly. In Figure 1, it is obvious that the five parts of the TT did not contribute equally to discriminating among groups. This figure presents the percent of patients in the three matched groups who scored all commands correct for a given part. For example, in Part I, 85% of the control group responded correctly to all 10 commands. With one exception, the number of 5s in each group who had all items correct decreased progressively from Part I to Part V. The exception occurred because a few control 5s made more errors in Part I than in Part II. This was probably due to a practice effect. Thus, within each group Parts I and II were the easiest and gave 4 100
He
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L.ID
He
RBO
He
L8D
Reo
LBO
He
IU~D
LID
"'0
He
LID
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PERCENT OF
10
1""11ENT5
&0
WITH ALL "[S,"ONSEt CORItfCT
00 40 >0
'0 10
- - o t -___
H7t-t-+--IIt-l~H-_II_I~_H-_I
__¥7J_+_1I__I__
~_.__r_
10 20 PERCENT OF PATIENTS
WITHOUT ALL USPONSES CORRECT
'0 40
00 .0 70 .0 .0 100
RESULTS OF STATISTICAL ANALYSES ( p VALUES. WILCOXON hlATCHED PAIRS SIGNED RANKS TEST I 2 3 4 I
TOTAL TOKEN TEST
RIGHT BRA'N" DAMAGED VS. LEFT IIRAIN~DAMAG£O
(,01
~.Ol
(.01
(.01
(.01
(.01
LEFT alllAIN- DAt.4AGED VS. HOSPITALIZED CONTROL.
<.01
(.01
COl
(,01
(.CI
cal
,"01
CO2
co,
"'GHT 8ft"'N- DAMAGED
VI. HOSPITAL.IZED CONTROL
N.S.
N.S.
H.S.
Fig. 1 - Percent of patients in three matched groups (age and education) with all responses correct for each part of the Token Test.
similar results, Parts III and IV were progressively more difficult, and Part V was the most difficult. The results of the statistical analyses are summarized below the figure. All parts discriminate the LBD aphasics from the other two groups. Parts I, II and III did not discriminate between the control and the RBD nonaphasic groups, whereas Parts IV and V did. The
Token Test
271
results for Part IV are especially interesting because this part appeared to be the most sensitive in discriminating between RBD nonaphasic and control subjects. When individual test results were examined, it was apparent that 5s who did poorly on one part also performed poorly on successive parts. There were only two subjects (RBD) whose scores improved more than two points on a successive part. One with an elementary level education who apparently learned the word " rectangle" during testing was referred to previously. The other scored 90 or 100% of the items correct for every part except Part IV in which he scored 60% correct. There were no exceptions in the LBD and control groups to the trend of increased errors as the test progressed. DISCUSSION
The present findings with English speaking 5s generally agree with those reported for German and Italian speaking 5s (Orgass and Poeck, 1966; Boller and Vignolo, 1966) with respect to the usefulness of the Token Test in discriminating LBD aphasics from other 5s. That is, aphasics scored the least correct on all parts of the test. The findings concerning age and educational level agree with the study of normal German speaking 5s (Orgass and Poeck, 1966). In that study and in the present study, age did not relate to TT scores, and it appeared that subjects with a high school education made fewer mistakes than those with an elementary level education. Our results differ from those ()f other studies (Orgass and Poeck, 1966; Boller and Vignolo, 1966) with regard to overall scores. Despite their higher level of education, our normal and RBD nonaphasic 5s made more errors than those previously studied. Possibly their greater number of errors occurred because English requires fewer morphological changes than either German or Italian, and therefore provides fewer cues and imposes greater dependence on understanding each lexical item. Our RBD nonaphasics increased their errors as the test progressed, whereas the group studied by Boller and Vignolo (1966) did not. The present findings are consistent with the theory that the right cerebral hemisphere participates in high level functioning (Critchley, 1962; Eisenson, 1962). Another possibility is mentioned by Archibald and Wepman (1968). They suggested that the poor responses made
272
L. Peck Swisher and M. Taylor Sarno
by RBD nonaphasic Ss on language tasks might relate to a general mental deterioration involving decreased attention. In this regard, it is interesting that our RBD nonaphasic Ss were chosen by their physicians for their ability to participate in testing whereas our LBD aphasic Ss were less selected. It is also possibile that subclinical symptoms of left brain damage were present. However, our RBD nonaphasics showed no neurological evidence of bilateral damage. Still another explanation is suggested by the visual requirements of the Token Test. In the present study an unsystematic display of tokens was used. Boller and Vignolo (1966) used a systematic array in which all tokens of a certain shape were arranged in one line. It would seem that our Ss were required to scan more of the total display to find a specific token. Thus, our results may relate to the finding that RBD subjetcs have greater difficulty than LBD subjects in tasks requiring visual scanning (Diller and Weinberg, 1969) and visual spatial skills (Weinstein, 1964; Russo and Vignolo, 1967).
SUMMARY
The Token Test was administered to English speaking left braindamaged aphasic, right brain-damaged nonaphasic and non-brain-damaged control patients who were matched across groups for age and educational level. : In general, all patients had increasing difficulty as the parts progressed. The results are consistent with the findings of previous investigators in that the left brain-damaged aphasic patients made the greatest number of errors on all parts of the test, and no relationship was demonstrated between age and Token Test scores. An unexpected finding was that Parts IV and V differentiated the right brain-damaged nonaphasics from the control patients. Acknowledgments. We are indebted to Doctors Sanders Davis, Edward W. Lowman, and Herbert J. Dietz for their assistance in providing subjects for this study.
REFERENCES Y. M., and WEPMAN, ]. M. (1968) Language disturbance and nonverbal cognitive performance in eight patients following in;ury to the right hemisphere, "Brain," 91, 117-130. BOLLER, F., and VIGNOLO, 1. A. (1966) Latent sensory aphasia in hemisphere-damaged patients: an experimental study with the Token Test, "Brain," 89, 815-830. ARCHIBALD,
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M. (1962) Speech and speech-loss in relation to the duality of the brain, in Interhemispheric Relations and Cerebral Dominance, ed. by V. B. Mountcastle, Johns Hopkins Press, Baltimore. DE RENZI, E., and VIGNOLO, L. A. (1962) The Token Test: a sensitive test to detect receptive disturbances in aphasics, "Brain," 85, 665-678. DILLER, L., and WEINBERG, J. (1969) Dimension of attention in right and left hemiplegia (in press). EISENSON, J. (1962) Language and intellectual modifications associated with right cerebral damage, "Lang. Speech," 5, 49-53. ORGASS, B., and POECK, K. (1966) Clinical validation of a new test for aphasia; an experimental study on the Token Test, "Cortex," 2, 222-243. Russo, M., and VIGNOLO, L . A. (1967) Visual figure-ground discrimination in patients with unilateral cerebral disease, "Cortex," 3, 113-127. SIEGEL, S. (1956) Nonparametric Statistics for the Behavioral Sciences, McGraw-Hill, New York. TAYLOR, M. (1965) A measurement of functional communication in aphasia, "Arch. Phys. Med. Rehab.," 46, 101-107. WEINSTEIN, S. (1964) Deficits concomitant with aphasia or lesions of either cerebral hemipshere, "Cortex," 1, 154-169. ~RITCHLEY,
Linda Peck Swisher, Ph. D.; Martha Taylor Sarno, M. A., Institute of Rehahilitation Medicine, New York University Medical Center, 400 East 34th Street, New York, N. Y. 10016.
Determining a patient's ability to understand speech is one of the most difficult tasks a clinician faces in the evaluation of patients with aphasia. In 1962 De Renzi and Vignolo contributed to this important area of study by introducing the Token Test, developed to reveal mild receptive disorders. The three major studies of Token Test (TT) scores have used either Italian or German speaking Ss. The results indicate that the TT detects receptive difficulties which are not obvious during routine clinical testing (De Renzi and Vignolo, 1962; Boller and Vignolo, 1966), and that poor performance is specifically associated with a lesion in the left hemisphere (Boller and Vignolo, 1966). In addition, it appears that the responses are minimally contaminated by general intellectual impairment (De Renzi and Vignolo, 1962; Boller and Vignolo, 1966), that age does not affect scores in normal Ss over 15 years of age (Orgass and Poeck, 1966), and that there is a high correlation between the clinical evaluation of the severity of aphasia and the TT scores (Orgass and Poeck, 1966). The present study was conducted primarily to determine whether the findings concerning TT scores for German and Italian speaking subjects apply to English speaking subjects.
1 The work reported here was supported in part by the Social and Rehabilitation Service, Department of Health, Education and Welfare, under the designation of New York University as a Rehabilitation Research and Training Center. Parts of this paper were presented to the American Speech and Hearing Association, Denver, Colorado, November 16, 1968.
Token Test
265
MATERIALS AND METHODS
The TT was administered as described by Boller and Vignola (1966) with the S seated at a table on which the tokens were displayed. Plastic tokens of two shapes (circle and rectangle), two sizes (large and small) and five colors were used. The large circles were approximately the size of a poker chip. An example from each of the five parts of the TT follows: Part I - Touch the red circle. (10 commands; large rectangles and large circles only). Part II - Touch the small yellow circle. (10 commands; large and small rectangles and circles). Part III - Touch the yellow circle and the red rectangle. (10 commands; large rectangles and large circles only). Part IV - Touch the small yellow circle and the large green rectangle. (10 commands; large and small rectangles and circles). Part V - Put the red circle on the green rectangle. (22 commands; large rectangles and large circles only). As indicated above, specific tokens are used for each part. For this study, the tokens were displayed in the same random arrangement during each part of the test for every S. In the first four · parts the commands are expressed in simple syntactic structure - verb and object. In Part V structures are more complex, and prepositions, conjuctions and articles are an essential part of each command. Before beginning the test, the examiner ruled out the presence of visual agnosia by asking the S to match the tokens for the two forms and five colors. Then the examiner said "I am going to ask you to do something. I can only ask you once. Please listen carefully." The commands were then given. After every response tokens which had been removed were returned to the original token display. That is, the same tokens were available for choice at the beginning and end of each part. For the present study the responses were scored in terms of total commands correct. The maximum score was 62. That is, each command was worth one point. The Functional Communication Profile (FCP) was used as a measure of severity of language impairment (Taylor, 1965). The FCP quantifies how much language a patient actually uses. Commu-
266
L. Peck Swisher and M. Taylor Sarno
nication skills are rated in each of 48 common language behaviors, after conversational interaction with the patient. The sum of these reflects a person's overall communication effectiveness. That is, how well he functions with his residual skills. For example, an Overall score of less than 25 % indicates that a patient is severely impaired and an Overall score of 100% reflects no impairment.
SUBJECTS
In all, 129 5s were tested who met the criteria for inclusion in this study. They were hospitalized, right-handed, native English speakers, 70 years of age or under and had either no cerebral damage or damage apparently restricted to one hemisphere. Also their hearing threshold levels for the speech frequencies (500, 1000 and 2000 Hz) were 45-dB ISO or better. 5s were assigned to one of three groups: non-brain-damaged; left brain-damaged with aphasia; and right brain-damaged without aphasia.
Non-brain-damaged subjects The control 5s were hospitalized because of spinal cord lesions or other orthopedic disabilities. It was our impression that all of them were of average intelligence.
Brain-damaged subjects The brain-damaged 5s met two additional criteria: history of a cerebrovascular accident and the presence of a paralysis or weakness contralateral to the side of brain damage. Also, only LBD subjects who were diagnosed aphasic, and RBD subjects who were diagnosed nonaphasic were included. 5s with evidence of dysarthria or verbal apraxia were excluded because these disorders affect scores on the FCP but not on the TT, and the results of both tests were to be correlated. Also, no patient presented evidence of a limb apraxia. The side of brain damage was determined by neurological symptoms, and the EEG and neuro-radiological data provided in the medical chart. Four 5s in each of the brain-damaged groups had known visual field defects, but these defects did not interfere with test performance. Subjects who needed glasses wore them during the test.
Token Test
267
The LBD subjects were referred by a doctor because of obvious 'or suspected communication deficits. The non-brain-damaged and the RBD subjects were referred for evaluation at our request and came preselected by their physicians as cooperative and generally oriented. Three matched groups were chosen from the total group of 129 5s. The matched groups contained only 58 who had been equated with one 5 in each of the other groups for age and educational level. Thus, one trio of matched 5s would have ages within five years of each other and the same educational level - elementary (6 to 8 years), high school (9 to 12 years) or college (over 12 years). It was possible to match 22 5s across groups. Table I presents data relative to the age, sex and educational level for the three matched groups. The sex of the 5 was not TABLE I
Age, Sex and Education of Matched Groups
Controls
Right brain-damaged nonaphasics
Left brain-damagec aphasics
Males Females
11 11
16 6
11 11
Mean age
56,0
57.7
57.9
3
3
3
15
15
15
4
4
4
Education: Elementary (6 to 8 years) High school (9 to 12 years) College (over 12 years)
considered in the matching procedure. The mean age and ranges for the three groups agreed within two years. Most of the 5s had a high school education. Although duration since onset of the stroke was not considered for matching individual 5s, the two brain-damaged groups were comparable as a whole in this respect. Most 5s were tested three to six months after onset of symptoms. As mentioned before, the FCP was used as the measure of
268
L. Peck Swisher and M. Taylor Sarno
language proficiency for the LBD subjects. The Overall scores of the 22 Ss ranged from 12% to 96%. There was also a wide range in Understanding and Speaking subscores. That is, the most severe aphasic used almost no oral or gestural communication whereas the mildest aphasic appeared almost normal in functional communication abilities. The most severe aphasics could not respond appropriately to simple questions such as "How are you?" and "Have you had breakfast?" whereas the least impaired only had difficulty understanding complex sentences.
RESULTS
The relationship between Token Test scores and: Age. The presence of a correlation between TT scores and age was investigated. All Ss were divided into three groups: RBD nonaphasic, LBD aphasic, and hospitalized control. To offset the effects of educational level, these groups were subdivided into elementary, high school, and college educated. There were not enough elementary educated RBD subjects to form a group; thus eight, rather than nine, groups resulted. No relationship was demonstrated between age (17 to 70 years) and TT scores by the Kendall Rank Correlation Coefficients (Siegel, 1956). Education. The relationship between education and TT scores could not be determined because of the small number of elementary and university educated Ss. The only effect apparent to the examiners was that the word "rectangle" was sometimes not familiar to Ss with limited schooling. For example, one elementary educated RBD subject who consistently failed to identify rectangles in Part I, learned to do so by Part II. FCP scores. The Spearman Rank Correlation Coefficient was used to investigate the relationship between scores obtained by the LBD aphasic subjects on the FCP and the TT. Because past education was considered in the scoring of the FCP but not in scoring the TT, to minimize the effects of educational level only the 15 high school educated LBD aphasics in the main group were used. A high correlation « .01) was present between the Understanding and Speaking subscores on the FCP for the LBD aphasic
Token Test
269
subjects. Because of this correlation, it was not surprising that the TT scores correlated highly « .01) with both of these FCP subscores as well as with the total FCP scores. Thus, all three measures of language impairment (FCP-Speaking; FCP-Understanding; and TT) appeared related. Token Test scores Total scores. Of a possible 62 points the mean total test score for the control group was 57 with a range of 48 to 62. The mean for the RBD nonaphasic group was 53 with a range of 35 to 61, and for the LBD aphasic group the mean was 23 with a range of o to 58. Eighteen Ss in the RBD group and two in the LBD group scored above 48. Thus, the total score would have discriminated 91 % of the LBD subjects and 18% of the RBD subjects from the control group. One of the two LBD aphasics whose scores were within the normal range could be discriminated from normal because he did not attempt to pedorm parts of three of the commands in Part V. The responses of the other LBD aphasics did not appear unusual in any way. It is interesting that a speech pathologist unaware of the TT scores commented that this 5 behaved more like a RBD nonaphasic than a LBD aphasic. Scores by parts. Table II summarizes the mean correct responses for each part of the TT for the matched groups. In general, the three groups of Ss had increasing difficulty with progressive parts. TABLE II
Mean Correct Responses for Matched Groups
Part Part Part Part Part
I
II III IV V
Controls
Right brain-damaged nOflaphasics
Left brain-damaged aphasics
9.9 9.9 9.6 9.6 7.6*
9.6 9.6 9.1 7.8 7.3*
5.7 5.6 3.6 3.3 2.6*
* Scores adjusted to comply with Parts I-IV.
L. Peck Swisher and M. Taylor Sarno
270
It is also obvious that the LBD aphasic subjects had the greatest difficulty on all parts; and that the scores for control and RBD nonaphasic subjects on Parts I, II and III did not differ markedly. In Figure 1, it is obvious that the five parts of the TT did not contribute equally to discriminating among groups. This figure presents the percent of patients in the three matched groups who scored all commands correct for a given part. For example, in Part I, 85% of the control group responded correctly to all 10 commands. With one exception, the number of 5s in each group who had all items correct decreased progressively from Part I to Part V. The exception occurred because a few control 5s made more errors in Part I than in Part II. This was probably due to a practice effect. Thus, within each group Parts I and II were the easiest and gave 4 100
He
,.SO
L.ID
He
RBO
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L8D
Reo
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He
IU~D
LID
"'0
He
LID
'0 .0
PERCENT OF
10
1""11ENT5
&0
WITH ALL "[S,"ONSEt CORItfCT
00 40 >0
'0 10
- - o t -___
H7t-t-+--IIt-l~H-_II_I~_H-_I
__¥7J_+_1I__I__
~_.__r_
10 20 PERCENT OF PATIENTS
WITHOUT ALL USPONSES CORRECT
'0 40
00 .0 70 .0 .0 100
RESULTS OF STATISTICAL ANALYSES ( p VALUES. WILCOXON hlATCHED PAIRS SIGNED RANKS TEST I 2 3 4 I
TOTAL TOKEN TEST
RIGHT BRA'N" DAMAGED VS. LEFT IIRAIN~DAMAG£O
(,01
~.Ol
(.01
(.01
(.01
(.01
LEFT alllAIN- DAt.4AGED VS. HOSPITALIZED CONTROL.
<.01
(.01
COl
(,01
(.CI
cal
,"01
CO2
co,
"'GHT 8ft"'N- DAMAGED
VI. HOSPITAL.IZED CONTROL
N.S.
N.S.
H.S.
Fig. 1 - Percent of patients in three matched groups (age and education) with all responses correct for each part of the Token Test.
similar results, Parts III and IV were progressively more difficult, and Part V was the most difficult. The results of the statistical analyses are summarized below the figure. All parts discriminate the LBD aphasics from the other two groups. Parts I, II and III did not discriminate between the control and the RBD nonaphasic groups, whereas Parts IV and V did. The
Token Test
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results for Part IV are especially interesting because this part appeared to be the most sensitive in discriminating between RBD nonaphasic and control subjects. When individual test results were examined, it was apparent that 5s who did poorly on one part also performed poorly on successive parts. There were only two subjects (RBD) whose scores improved more than two points on a successive part. One with an elementary level education who apparently learned the word " rectangle" during testing was referred to previously. The other scored 90 or 100% of the items correct for every part except Part IV in which he scored 60% correct. There were no exceptions in the LBD and control groups to the trend of increased errors as the test progressed. DISCUSSION
The present findings with English speaking 5s generally agree with those reported for German and Italian speaking 5s (Orgass and Poeck, 1966; Boller and Vignolo, 1966) with respect to the usefulness of the Token Test in discriminating LBD aphasics from other 5s. That is, aphasics scored the least correct on all parts of the test. The findings concerning age and educational level agree with the study of normal German speaking 5s (Orgass and Poeck, 1966). In that study and in the present study, age did not relate to TT scores, and it appeared that subjects with a high school education made fewer mistakes than those with an elementary level education. Our results differ from those ()f other studies (Orgass and Poeck, 1966; Boller and Vignolo, 1966) with regard to overall scores. Despite their higher level of education, our normal and RBD nonaphasic 5s made more errors than those previously studied. Possibly their greater number of errors occurred because English requires fewer morphological changes than either German or Italian, and therefore provides fewer cues and imposes greater dependence on understanding each lexical item. Our RBD nonaphasics increased their errors as the test progressed, whereas the group studied by Boller and Vignolo (1966) did not. The present findings are consistent with the theory that the right cerebral hemisphere participates in high level functioning (Critchley, 1962; Eisenson, 1962). Another possibility is mentioned by Archibald and Wepman (1968). They suggested that the poor responses made
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by RBD nonaphasic Ss on language tasks might relate to a general mental deterioration involving decreased attention. In this regard, it is interesting that our RBD nonaphasic Ss were chosen by their physicians for their ability to participate in testing whereas our LBD aphasic Ss were less selected. It is also possibile that subclinical symptoms of left brain damage were present. However, our RBD nonaphasics showed no neurological evidence of bilateral damage. Still another explanation is suggested by the visual requirements of the Token Test. In the present study an unsystematic display of tokens was used. Boller and Vignolo (1966) used a systematic array in which all tokens of a certain shape were arranged in one line. It would seem that our Ss were required to scan more of the total display to find a specific token. Thus, our results may relate to the finding that RBD subjetcs have greater difficulty than LBD subjects in tasks requiring visual scanning (Diller and Weinberg, 1969) and visual spatial skills (Weinstein, 1964; Russo and Vignolo, 1967).
SUMMARY
The Token Test was administered to English speaking left braindamaged aphasic, right brain-damaged nonaphasic and non-brain-damaged control patients who were matched across groups for age and educational level. : In general, all patients had increasing difficulty as the parts progressed. The results are consistent with the findings of previous investigators in that the left brain-damaged aphasic patients made the greatest number of errors on all parts of the test, and no relationship was demonstrated between age and Token Test scores. An unexpected finding was that Parts IV and V differentiated the right brain-damaged nonaphasics from the control patients. Acknowledgments. We are indebted to Doctors Sanders Davis, Edward W. Lowman, and Herbert J. Dietz for their assistance in providing subjects for this study.
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M. (1962) Speech and speech-loss in relation to the duality of the brain, in Interhemispheric Relations and Cerebral Dominance, ed. by V. B. Mountcastle, Johns Hopkins Press, Baltimore. DE RENZI, E., and VIGNOLO, L. A. (1962) The Token Test: a sensitive test to detect receptive disturbances in aphasics, "Brain," 85, 665-678. DILLER, L., and WEINBERG, J. (1969) Dimension of attention in right and left hemiplegia (in press). EISENSON, J. (1962) Language and intellectual modifications associated with right cerebral damage, "Lang. Speech," 5, 49-53. ORGASS, B., and POECK, K. (1966) Clinical validation of a new test for aphasia; an experimental study on the Token Test, "Cortex," 2, 222-243. Russo, M., and VIGNOLO, L . A. (1967) Visual figure-ground discrimination in patients with unilateral cerebral disease, "Cortex," 3, 113-127. SIEGEL, S. (1956) Nonparametric Statistics for the Behavioral Sciences, McGraw-Hill, New York. TAYLOR, M. (1965) A measurement of functional communication in aphasia, "Arch. Phys. Med. Rehab.," 46, 101-107. WEINSTEIN, S. (1964) Deficits concomitant with aphasia or lesions of either cerebral hemipshere, "Cortex," 1, 154-169. ~RITCHLEY,
Linda Peck Swisher, Ph. D.; Martha Taylor Sarno, M. A., Institute of Rehahilitation Medicine, New York University Medical Center, 400 East 34th Street, New York, N. Y. 10016.