Gestural impairment and gestural ability in aphasia: A review

BRAIN

AND

LANGUAGE

14, 333-348

(1981)

Gestural Impairment and Gestural Ability in Aphasia: A Review LAURA N. PETERSON AND HOWARD S. KIRSHNER Vanderbilt

University

School

of Medicine Medical

and Nashville Center

Veterans

Administration

Studies of gestural ability in aphasic subjects have found impairment of gestural expression and comprehension, with a close relationship between severity of aphasia and degree of gestural impairment. A few investigators have correlated gestural ability with specific language functions or subcategories of aphasia. Reading appears to correlate better with gestural recognition than does auditory comprehension. Despite the general findings of gestural impairment in aphasia, successes have been reported with gestural training including artificial language techniques, pantomime, Amerind, and American Sign Language. Future studies of gestural therapy in aphasia should examine specific language deficits in order to identify those aphasic individuals who can benefit from gestural training.

INTRODUCTION Numerous studies have examined the gestural abilities of aphasic patients. Most studies have found that gesture, like verbal language, is impaired in aphasia, but the cause and nature of this gestural impairment has been controversial. Gestural impairments have been viewed as cognitive, linguistic, or apraxic disorders. Systematic tests of gestural ability have been designed to assess aphasics’ success in the gestural modality (Goodglass & Kaplan, 1963; Porch, 1973; Pickett, 1974; Duffy, Duffy, & Pearson, 1975; Kobler & Schlanger, 1975; Kadish, 1978: Duffy, Watt, & Duffy, 1979; Skelly, 1979; Cicone, 1979). Despite the general finding of gestural impairment in aphasia, recent applications of pantomime, Amerind gestural code, and American Sign Language have revealed that many aphasics can benefit from training in the gestural modality (e.g. Bonvillian & Friedman, 1978; Schlanger & Freiman, 1979; Skelly, 1979; Heilman, Rothi, Campanella, & Wolfson, 1979; Kirshner & Webb, 1981). Skelly (1979) and others have described This research was supported by NINCDS Teacher Investigator Development Award 1 K07 NS 00 429-02 to Dr. Kirshner. The authors thank Ms. Beth Gehrke for assistance in preparation of the manuscript. Address reprint requests to: Howard S. Kirshner, Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN 37232. 333 0093-934X/81/060333-16$02.00/0 Copyri&t 0 1981 by Academic Press. Inc. All rights of reproduction in any form reserved.

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general prognostic indicators of ability to learn gestures. A few investigators have found that selective language performance traits in subcategories of aphasia or specific modalities of language function, such as reading versus auditory comprehension (e.g., Varney, 1978; Seron, 1979), may predict ability to learn gestures. Even severe, global aphasics, however (Glass, Gazzaniga, & Premack, 1973; Gardner, Zurif, Berry, Kz Baker, 1976; Helm & Benson, 1978), have been able to learn simple forms of gestural communication. This paper will review studies of gestural ability in adult aphasia and clarify differences in approaches and findings with respect to differing theoretical perspectives. We hope to provide a rational basis for future applications of gestural training in aphasia therapy. CLASSIFICATION

OF GESTURAL

BEHAVIORS

The prediction of overall gestural ability is complicated by the abundance of types of gestural behaviors. Interpretation of many studies of gestural ability in aphasia is difficult because of the variety of classification schemes of gestural assessment. Critchley (1970) defined “pantomime” as propositional gesture, and “gesticulation” as automatic, emotional gestural expression. Pantomime thus replaces speech, while gesticulation accompanies speech. Although this dichotomy does not always distinguish gestural behaviors (Goldstein, 1948), several studies have separated gesture from pantomime on the basis of the presence or absence of speech during gestural performance (e.g., Goodglass & Kaplan, 1963; Pickett, 1974; Duffy et al., 1975; Schlanger & Schlanger, 1970; Vamey, 1978; Seron, van der Kaa, Remitz, & van der Linden, 1979). Goodglass and Kaplan (1963) further subdivided gestural performance into “natural” versus “conventional” or stylized descriptions of actions. They divided pantomimic performance into “simple” or single movements, versus “complex” or sequential movements. Pickett (1974) differentiated “gesticulation” and “gesture” in regard to the random and sequential quality of the former and the meaningful intent and singular quality of the latter. Kadish (1978) defined both gesture and pantomime as communication by a series of sequential manual movements in the absence of speech. “Receptive gesture” is the visuoperceptive translation of movements into a symbolic system; “expressive gesture” is the encoding of information by sequential motor movements superimposed upon manual postures. Complementary to these classification schemes are recent analyses of the conceptual relationship between a gesture and its intended meaning. Hecaen (1967) applied the use of Pierce’s (1932) categorization of gestures into “symbolic,” “iconic,” and “indicative” types. “Symbolic” ges-

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IN APHASIA

tures bear a codified or arbitrary relationship to their referents, while “iconic” gestures clearly express the meaning of the referent by the form of the gesture. “Indicative” gestures are often performed in the presence of the object and describe its function or use. Schuell (1975) similarly distinguished “symbol communiques,” which bear an arbitrary relationship to the object represented, from “signal communiques,” which have an ideographic or pictorial relationship to the object. Two gestural codes, American Indian Gestural Code (Amerind) and American Sign Language (ASL), have found application in aphasia therapy. Amerind is a gestural system based on American Indian Hand Talk, composed of signals which are concrete representations of the characteristics of objects, actions, or persons described by history, appearance, or use (Skelly, 1974, 1975, 1979). Amerind is not a language in the true sense, because any viewer should be able to interpret it without translation (Rao & Horner, 1979). American Sign Language is a gestural system composed of signs which bear a symbolic relationship to the object, action, or person in reference (Stokoe, 1970, 1975, 1978). ASL qualifies as a language, with dialects that are more or less accommodating to English syntax (Bornstein, 1973; Stokoe, 1978). ASL signs are usually not understandable to an unfamiliar recipient (Hoemann, 1977). Within these two systems, gestures may be subdivided similarly to some of the previous schemes. For example, in Amerind, gestures may be examined according to their movement and level of complexity (Rao & Horner, 1979). In American Sign Language, gestures may be classified further with respect to their spatial execution, or linguistic and cognitive characteristics (Madsen, 1972; Siple, 1975; Poizner, Battison, & Lane, 1979). THE NATURE

OF THE GESTURAL

DEFICIT

IN APHASIA

Studies of gestural ability in aphasia must consider how aspects of cognition, language impairment, and motor apraxic disturbance affect gestural performance in aphasics. Various investigators have emphasized each of these three aspects of gestural ability as they apply to aphasia. Proponents of the cognitive and linguistic points of view consider gestural impairment in aphasia to be reflective of an underlying deficit in symbolic expression and comprehension. The linguistic viewpoint attempts to distinguish gestural communication from cognitive and motor involvements by showing that gestural deficits are correlated with severity of aphasia, specific language abilities, or distinctive categories of aphasia. Proponents of the motor-apraxic point of view primarily regard the gestural impairment in aphasia as an apraxic phenomenon. Cognitive and Linguistic Viewpoints In the 19th and early 20th centuries, several prominent aphasiologists observed the impairment of gestures in aphasics and considered the

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deficit to reflect the overall representational or symbolic weakness of these patients (Finkelnburg, 1870; Head, 1926; Jackson, 1932; Critchley, 1939). During this period, gestural deficits were not systematically studied among clinical categories of aphasia, and comprehension of gestures was not distinguished and assessed separately from gestural expression. Critchley (1939) observed that “in very severe cases of speech loss, there may occur a limitation of the language of gesture (‘asemesia’), more marked in the propositional domain of pantomime than in the more affective symbology of gesture.” Goldstein (1948) considered gestures as part of a cognitive impairment of the “abstract attitude” in cases of mixed or global aphasia. Disturbances of gestures or pantomime could be reflected in emotional or logical expression. Goldstein noted that some aphasics have intact gestures and pantomimes, an observation relevant for the current application of gesture as a language therapy technique. With regard to intellectual functioning, Goodglass and Kaplan (1963) found a direct relationship between the loss of intellectual efficiency, as measured by the WAIS, and overall gestural ability, in a comparison of a group of mild to moderately severe aphasics to a nonaphasic control group (Table 1). These authors did not find a close correlation between severity of aphasia and gestural ability. Kadish (1978) found no apparent relationship between general intellectual ability and gestural performance in a group of six aphasic patients. Receptive gestural ability did correlate with mnestic ability. Pickett (1974) and Wertz (1978) have noted the difficulty of accurate assessment of intelligence in the aphasic population. In contrast to Goodglass and Kaplan’s (1963) findings, several studies have reported a close relationship between gestural and linguistic deficits in aphasics (Table l), suggesting a common underlying symbolic incompetence. Pickett (1974) found that gestural ability correlated closely with aphasia scores on the Porch Index of Communicative Ability (PICA). Duffy et al. (1975) reported a close correlation between pantomime recognition and verbal ability, as measured by selected tests of word discrimination, oral naming, and the PICA. Kadish (1978) found a significant relationship between speech comprehension and receptive gesture but no relationship between speech production and expressive gesture. Duffy et al. (1979) found a .79 correlation between aphasia scores on the PICA and pantomime expression deficit, and a .66 correlation between aphasia scores and pantomime recognition deficit. In comparison, the correlation between pantomime expression and limb apraxia was .24, and that between pantomime recognition and IQ was .09. Pickett (1974) noted that the very severe category of aphasic patients was excluded from the Goodglass and Kaplan (1963) study, possibly accounting for the lack of correlation between severity of aphasia and gestural ability. Several authors have examined specific features of gestures which permit an aphasic to learn them. Most studies have focused on the

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symbolism versus iconicity of the gesture. Schuell (Jenkins, JimenezPabon, Shaw, & Sefer, 1975) pointed out that “symbol communiques” should be impaired in aphasics, whereas “signal communiques” should be preserved. Gainotti and Lemmo (1976) found that a significant number of aphasics scored pathologically on a test of comprehension of symbolic gestures when compared to nonaphasic brain-injured individuals and normals. They also found that aphasics’ ability to understand the meaning of symbolic gestures was highly related to semantic impairment in the verbal modality. Three other studies (Duffy & McEwen, 1978; Bonvillian & Friedman, 1978; DeRenzi, Fabrizia, & Nichelli, 1980), on the other hand, found that aphasics’ ability to recognize or imitate gestures did not relate closely to the degree of symbolism or iconicity of the specific gestures. Seron et al. (1979) suggested that the “plausibility” of a gesture, the relationship of the object to the movement, might be the most important determinant of performance on gestural tasks. Other investigators have correlated gestural deficits not with overall verbal performance or severity of aphasia, but with specific language functions. Varney (1978) found correlations between pantomime recognition and the visual modality of language recognition, i.e., comprehension of printed material. Deficits in pantomime recognition, while absent in some severe aphasics, were always associated with equal or greater deficits in reading. Auditory comprehension and naming ability were only weakly correlated with pantomime recognition. Seron et al. (1979) also reported a relationship between reading comprehension and pantomime recognition in their study of 27 aphasic patients, though there was no apparent relationship between the pantomime deficit and severity of aphasia. Two studies have reported the ability of aphasic patients with preserved visual language functions to communicate via the gestural system. Heilman et al. (1975) described a patient with severe global aphasia but preserved reading comprehension who was able to perform and recognize more than 100 Amerind signs. Kirshner and Webb (1981) reported a patient with muteness and word deafness resulting from bilateral temporal lobe infarcts who also retained the ability to comprehend printed material. This patient also had been able to learn more than 100 Amerind and ASL signs. Both studies suggest that sparing of the visual language modality may permit the acquisition of effective communication via the gestural system, regardless of the severity of the aphasic deficit. Cicone, Wapner, Foldi, Zurif, and Gardner (1979) observed the spontaneous gestural expression of two Wernicke’s and two Broca’s aphasics and found that the quality of the gestural output paralleled the oral language impairment in each type of aphasia. The Broca’s aphasics presented sparse, simple, single appropriate gestures, in contrast to the

1 IN APHASIA

Luria’s Neuropsychol ogical Investigation, WAIS Raven’s Progressive Matrices

BDAE

PICA

Kadish (1978)

J. Duffy, et al (1979)

Not examined

PICA Verbal Recognition Test, Naming Test

R. Duffy et al. (1975)

Pantomime Recognition Test (Duffy et al., 1975) Pantomime Expression Test (1979)

Gestural Test Battery; recognition of pantomimed object functions; expression of object functions in pantomime and gesture Pantomime Recognition Test: ability to point to picture of objects’ functions in pantomime Gestural Test Battery (adapted from Pickett, 1974)

Not examined

PICA

Pickett (1974)

Gesture-Pantomime Test (natural and conventional gestures, simple and complex pantomime)

Gestural skills

IMPAIRMENT

WAIS

Intellectual functions

Selected tests from Boston VA Hospital Test of Aphasia: Conversational Speech, Object Naming, Comprehension

Language functions

TABLE OF GESTURAL -

Goodglass & Kaplan (1963)

Study

CORRELATES

Severity of gestural impairment related strongly to severity of aphasia, especially on receptive side; no relationship between gestural deficit and intellectual impairment r = .66 PICA/PR r = .79 PICAIPE r = .09 RPMIPE r = .24 Limb apraxia/PE

Gestural impairment related strongly to verbal impairment

tasks

Gestural impairment in direct relation to intellectual efficiency; not related to severity of aphasia; no improvement on imitation trials Gestural ability related strongly to severity of aphasia; aphasics improved on imitative gestural

Results of correlation

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Wernicke’s aphasics, whose gestures tended to be clustered and unclear. These results suggested differential impairment of gesture in two subcategories of aphasia. Motor-Apraxic

Viewpoints

Gestural communication in aphasics may be impaired not only by symbolic and linguistic deficits, but also by motor-apraxia. Liepmann (1900) first defined apraxia as a dissociation between the idea of a movement and its motor execution, in the presence of intact comprehension of the requested movement and ability to perform the same motor act in other contexts. Performance of motor acts to imitation is variable in apraxic subjects (Benson & Geschwind, 1975). Geschwind (1975) has proposed that the left hemisphere is dominant not only for speech but also for learned movements. If the left hemisphere motor association areas are either destroyed or disconnected from the right hemisphere, the minor hemisphere may be unable to program learned movements of the left extremities. This “disconnection” hypothesis explains the inability of many Broca’s aphasics to carry out commands with the nonparalyzed left extremities. Kimura and Archibald (1974) proposed that the left hemisphere controls complex motor sequences, regardless of the familiarity of the movements. DeRenzi et al. (1980) found that the performance of apraxic patients on tests using objects to imitation correlates well with tests of intransitive hand postures. Both studies indicated that the ability to form gestures depends less on the type of movement requested than on the type of cue, whether imitation or verbal command, and the presence of which frequently improves the patient’s contextual information, performance. Goodglass and Kaplan (1963) studied the gestural/pantomime performance of 20 aphasics. The aphasic group not only showed impaired gestural performance but failed to improve on imitation trials of the gestural tasks. The authors interpreted this lack of improvement on imitation as evidence that the gestural abnormality in aphasia is an apraxic disturbance. Ettlinger (1969) noted that the response to commands does not separate aphasic disorders of comprehension from apraxic disorders of motor performance. Other authors have noted that even in patients with apraxia, gestures which accompany language may be preserved (Goldblum, 1972). ASSESSMENT

OF GESTURAL

ABILITY

IN APHASIA

Most tests of gestural ability evaluate gestural performance in strucwith use of pictures, manipulable tured presentations of pantomime, objects, and/or tasks of imitation (e.g., Goodglass & Kaplan, 1963; Pickett, 1974; Freiman, 1976; Duffy et al., 1979). Gestural recognition has

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usually been evaluated with pointing responses to pictures in a multiplechoice format (Koller, & Schlanger, 1975; Duffy et al., 1975; Varney, 1978; Seron et al., 1979). Recent evaluations (Skelly, 1979; Cicone et al., 1979) have attempted to describe gestural comprehension and performance in a natural communicative setting or in spontaneous conversation. Goodglass and Kaplan’s (1963) tests distinguish gesture from pantomime and determine the specific difficulty of various types of gestural movements. The required gestural tasks are generally elicited in the auditory modality and are later compared to performance by imitation. Pickett’s (1974) battery of gestural tasks is organized around the use of the 10 common items from the PICA and includes a prescreening of tactile object-naming and visual object-picture matching ability. Duffy and McEwen (1978) and Gainotti and Lemmo (1976) designed tests which avoid responses in the verbal modality and differentiate symbolic from nonsymbolic gestures. Approaching the natural test milieu, but still in a conventional format, the pantomime expression test developed by Freiman (in Schlanger and Freiman, 1979) elicits action pantomimes related to specific object functions and to “states of being,” i.e., feeling states expressed in pictures. The Schlanger-Koller Index of Pantomime Reception (Koller & Schlanger, 1975) depicts 25 situational pantomimes on videotape. The subject is required to select one of four picture choices representing each pantomimic action. Varney (1978) also paired videotape displays of pantomime with visual picture choices, depicting the use of common objects. Skelly (1979) pointed out the discrepancies between aphasics’ performance on standardized language tests, presented in the auditory modality, and that on tests of dictated commands in natural environments. Rao and Horner (1979) recommended that an evaluation of gestural ability include the assessment of modality differences and preferences of the individual aphasics, in addition to describing the type of gesture and the amount of cueing necessary. The Skelly Action Test of Auditory Reception of Language (Skelly et al., 1979) assesses appropriate behavioral responses to spoken language commands in a familiar setting, using specific objects naturally present in a clinical environment. The tester makes verbal requests in a conversational manner without accompanying gestures. If the testee does poorly in response to spoken directives, a signal version of the test is administered a few days later, and the test responses are compared. Skelly (1979) also constructed a gestural performance hierarchy which examines the level of use of Amerind signals in ongoing communication. In contrast to previous assessments which have not examined specific impairments among aphasic subcategories (e.g., Broca’s vs. Wernicke’s), Cicone et al. (1979), cited previously, designed an assessment technique for gestural skills based on videotaped interviews of two Broca’s and

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two Wernicke’s aphasics in informal conversation. In addition to testing specific subcategories of aphasics, these authors specifically described the amount, clarity, propositional type, semantic role, and pragmatic function of the spontaneous gestures. A follow-up study by Delis et al. (1979) examined the temporal occurence of the gestures in these same aphasics. THE APPLICATION

OF GESTURES, PANTOMIME, APHASIA TREATMENT

AND SIGNS TO

Holland (1977) has stressed the improvement of functional communication in aphasics brought about by nonoral strategies. Artificial language techniques involving gesture, first developed in studies of primate language, have found use in studies of aphasics. Table 2 summarizes the results of artificial language and pantomime techniques in aphasics. Glass et al. (1973) reported the successful use of an artificial language training program in global aphasics with “no syntactic or grammatical ability.” Limited but significant linguistic skills, even on an abstract level, were achieved. The Visual Communication System (VIC), developed by GardTABLE 2 RESULTS OF GESTURE AND PANTOMIME TRAINING Study

Subjects

Type of training

Results Subjects achieved various levels of competence in expressing relations and making statement with symbols 3 subjects unable to master WC; 5 achieved varying degrees of success of following commands, answering questions, describing events All patients improved in auditory comprehension and other language skills, in addition to learning the pantomimes Significant improvement in pantomimic ability and facilitation of spontaneous verbalization Improvement in expression and recognition of pantomimes; generalized to untrained expressive pantomimes

Glass et al. (1973)

7 adult aphasics (global)

Artificial language training, adapted from Premack (1971)

Gardner et al. (1976)

8 adult aphasics (severe)

Helm & Benson (1978)

7 adult aphasics (global)

Schlanger et al. (1974)

4 adult aphasics (2 mild; 2 severe) 8 adult aphasics (Range of severities)

Visual Communication System (V.I.C.)use of ideographic and geographic forms to denote meaningful units Visual Action Therapy-trained gestural production in association with objects Pantomime (group training)

Schlanger & Freiman (1979)

Pantomime (taught to express actions and states of feeling)

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ner et al. (1976), also indicated that some cognitive operations are preserved even in severely impaired aphasics. Visual communication training appeared to reintegrate cognitive processes necessary for linguistic performance. Visual Action Therapy (VAT) is a modified form of VIC which allows for the training of gestures (Helm & Benson, 1978). Patients learn to recognize and produce a distinct pantomime in association with each object presented. This study also indicated that even severe aphasics may benefit from gestural language training. Pantomime Several authors have studied pantomime as a gestural alternative for aphasics (Tennenbaum & Schlanger, 1968; Schlanger & Schlanger, 1970; Schlanger et al., 1974; Schlanger, 1976; Schlanger & Freiman, 1979). Schlanger (1976) suggested that pantomime both stimulates oral-verbal language and promotes communication via a nonverbal modality. Schlanger and Freiman (1979) found significant improvement in pantomime performance after pantomimic training in eight aphasic patients. Pantomime therapy seemed to stimulate the thought processes and improve the self-concept of these patients. Dalgaard, Newhoff, and Barnes (1979) designed a program of pantomime cueing for use in aphasia therapy. The subject improved in the overall PICA score, in each of the gestural, verbal, and graphic combined scores, and in auditory and verbal subtests of the PICA. Amerind Several programs of the Amerind signals have been offered as an alternative means of communication for severe aphasics who are “nonfunctional in the oral-verbal modality” (Rae, Basili, & Horner, 1977; Rao, 1979; Skelly, 1979; Skelly, Schinsky, Smith, & Fust, 1974; Skelly, Schinsky, Smith, Donaldson, & Griffin, 1975; Boehler, 1977; Bosone, 1977; Table 3). The majority of patients showed improvement in language ability and in apraxia of speech. Rao (1977) noted that the most positive changes were in those with greatest severity of aphasia. Boehler (1977) reported that two of five patients were not able to retain the gestural signals from session to session or produce them spontaneously, although they were able to imitate them successfully. Bosone (1977) found that following group therapy, 4 of 17 patients self-initiated gestures for communication outside of the clinical setting; 4 did not learn the gestures; and 6 learned but did not transfer the use of gestures. Rao (1979) found ongoing observation of improvement in communication to be a better indicator of progress than formal linguistic skills. Skelly (1979) studied 20 aphasic patients, all of whom achieved a repertoire of signals to express their needs and wishes. Drummond (1979) evaluated the use of Amerind gestural cueing in word-retrieval therapy

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PETERSON

AND KIRSHNER TABLE

RESULTS

Study

OF AMERIND

Subjects

AND

3 ASL

Training

Heilman et al. (1979)

1 adult aphasic (global)

Amerind

Rao et al. (1979)

10 adult aphasics (severe) 7 adult aphasics (6 CVA, 1 postinfectious leukoencephal wathy) 17 adult aphasics with moderate to severe dysarthria and dyspraxia

Amerind (Group training)

Boehler (1977)

Bosone (1977)

Skelly (1979)

Bonvillian 82 Friedman (1978) Kirshner & Webb (1981)

20 adult aphasics (mild but with no usable verbalization) 1 adult aphasic with dysarthria 1 adult patient (bitemporal infarcts with word deafness)

Amerind (individual and group sessions)

SIGN

TRAINING

Results Patient learned over 100 Amerind signals and began to sequence three in code Improvement in one or more areas of language as measured by ALPS” 5 patients unable to self-initiate code; 2 patients imitated but could not retain signals or selfinitiate code

Amerind (Multimodal: Speech, gestures, drawing) Preferred modality training Amerind (taught average of 50 signals during 50 sessions)

6 patients expressed gesture only in clinical situation; 3 selfinitiated gesture; 3 used gesture only for communication; 4 patients unsuccessful; 3 improved in spoken language skills

American Sign Language signs (9month period) Amerind and American Sign Language signs (6month period)

Subject mastered 79 signs and applied them; improved social behavior

12 achieved propositional use of code; others achieved varying degrees of use of code; 8 facilitated verbal output

Subject learned over 100 Amerind signals and ASL signs combined, began to sequence signals and signs

” ALPS = Aphasia Language Performance Scales.

with aphasics. She found that gestures were not significantly different from other types of visual and auditory cues in facilitating word retrieval. In all of these studies of Amerind training in aphasics, several themes emerged in regard to problems and predictors of benefit. The most important variable has generally been the patient’s desire to communicate. Additional predictive variables have included the degree of aphasia or of specific language deficits (Rao & Horner, 1979); the acceptance of gestural communication by family members @kelly, 1979; Rao & Hornet-, 1979); the number and frequency of communicative situations (Skelly,

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1979); the presence and degree of limb apraxia (Rao & Horner, 1979); and the reinforcement of gestural use (Skelly, 1979). Other, more specific indicators of gestural potential included attention by eye contact, imitation of manual and other movements; spontaneous attempts to express gestures, and the use of the index finger to point to desired objects (Skelly, 1979). A general problem has been the transfer of gestures learned in the clinical setting to spontaneous communication at home or work. American

Sign Language

Meckler et al. (1979) reported a case of “sign-language aphasia” in a hearing, young adult of deaf parents who suffered a stroke with global aphasia. The gestural language deficit of this patient was equivalent to the spoken language impairment and was independent of apraxia or motor weakness. Several other studies, however, have described aphasic patients who were able to learn ASL signs while unsuccessful in verbal modalities (Table 3). A 49-year-old dysarthric and aphasic male learned a large lexicon of ASL signs and showed improvement in social behavior (Bonvillian & Friedman, 1978). The authors noted that the iconicity of certain signs helped in the subject’s initial learning, but many noniconic signs were also mastered. Kirshner and Webb (1981) and Heilman et al. (1975), both previously cited, reported the use of Amerind and ASL in aphasic patients with preserved reading ability. Both studies suggested that preserved visual language ability might predict potential for gestural training. CONCLUSIONS

AND IMPLICATIONS

FOR FUTURE RESEARCH

Studies of gesture in aphasia have revealed the complexity of the process of evaluation and representation of gestural/pantomimic behavior. Any study of the “average gestural performance” of the “average aphasic” may well find below-average gestural performances, but generalizations cannot be made from these studies to all aphasics. The “average” statistic does not provide insight into the selective potential of some aphasics to learn to use gestures or pantomime as an alternative communication modality. Some investigators (Skelly, 1979; Rao & Horner, 1979) have noted general prognostic indicators of Amerind gestural learning by aphasics. It has been demonstrated that some aphasics with modality-selective language impairments have later success in gestural therapy (Heilman et al., 1979; Kirshner & Webb, 1981) or do well on tests of pantomime recognition (Varney, 1978; Seron et al., 1979). We suggest that future research on gestural potential be directed toward specific subcategories of aphasia and correlated with specific gestural types (e.g., gestures, pantomime, Amerind, or American Sign Language). Gestural comprehension should be correlated with specific deficits of visual and auditory

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language comprehension, while gestural expression should be correlated with deficits in spoken and written langauge expression. Such studies are of obvious importance in selecting those aphasic patients who can benefit from gestural training in improving their communication skills. Analyses of this type may also shed light upon the problematic relationship of gestural impairment to symbolic and verbal dysfunction in aphasia. REFERENCES Benson, D., & Geschwind, N. 1971. The aphasias and related disturbances. In A. Baker & L. Baker (Eds.), Clinical neurology. Hagerstown, MD: Harper & Row. Vol. 1, Chap. 8. Boehler, J. 1977. (Paper presented to Amerind Conference, St. Louis.) Cited by M. Skelly, 1979; Amerind gestural code based on universal American Indian hand talk. New York: Elsevier, North-Holland. Bonvillian, J., & Friedman, R. 1978. Language development in another mode: The acquisition of signs by a brain-damaged adult. Sign Language Studies, 19, 11 l-120. Bomstein, H. 1973. A description of some current sign systems designed to represent English. American Annals of the Deaj-, 118, 454-470. Bosone, Z. 1977. (Paper presented to Amerind Conference, St. Louis.) Cited by M. Skelly, 1979. Amerind gestural code based on universal American Indian hand talk. New York: Elsevier, North-Holland. Cicone, M., Wapner, W., Foldi, N., Zurif, E., & Gardner, H. 1979. The relation between gesture and language in aphasic communication. Bruin and Lnnguage, 8, 324-349. Critchley, M. 1939. (The language of gesture.) Cited by M. Critchley, 1969. The parietal lobes. New York: Hafner. Critchley, M. 1970. Aphnsiology. London: Edward Arnold. Dalgaard, J., Newhoff, M., & Barnes, G. 1979. Show me . . . Enhancing receptive and expressive language through pantomime. Paper presented to American Speech-Language-Hearing Association Convention, Atlanta. Delis, D., Foldi, N., Hamby, S., Gardner, H., & Zurif, E. 1979. A note on the temporal relations between language and gestures. Brain and Language, 8, 350-354. DeRenzi, E., Fabrizia, M., & Nichelli, P. 1980. Imitating gestures: A quantitative approach to ideomotor apraxia. Archives of Neurology, 37, 6-10. Drummond, S. 1979. Gestural cueing techniques in dysphasic word retrieval. Paper presented American Speech-Language-Hearing Association Convention, Atlanta. Duffy, R., & McEwen, W. 1978. A study of the relationship between pantomime symbolism and pantomime recognition in aphasics. Poliu Phoniatrica, 30, 286-292. Duffy, R., Duffy, J., & Pearson, K. 1975. Pantomime recognition in aphasia. Journal of Speech and Hearing Research, 18, 115-132. Duffy, J., Watt, J., & Duffy, R. 1979. Pantomime impairment in aphasia: Path analysis of proposed causes. Paper presented to American Speech-Language-Hearing Association Convention, Atlanta. Ettlinger, G. 1969. Apraxia considered as a disorder of movements that are language dependent: Evidence from cases of brain dissection. Cortex, 5, 285-289. Finkelnburg, F. 1870. [Vortrag in der niedemheim Gessellschaft der Aerzte.] Cited by H. Hecaen & M. Albert 1978. Human neuropsychology. New York: Wiley Gainotti, G., & Lemmo, M. 1976. Comprehension of symbolic gestures in aphasia. Brain and Language, 3, 451-460. Gardner, H., Zurif, E., Berry, T., & Baker, E. 1976. Visual communication in aphasia. Neuropsychologia,

14, 275-292.

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Geschwind, N. 1975. The apraxias: Neural mechanisms of learned movements. American Scientist, 63, 188-195. Glass, A., Gazzaniga, M., & Premack, D. 1973. Artificial language training in global aphasics. Neuropsychologia, 11, 95-103. Goldblum, M. C. 1972. Cited by H. Hecaen & M. Albert (Eds.), 1978. Human neuropsychology, New York: Wiley. Goldstein, K. 1948. Language and language disturbances. New York: Grune & Stratton. Goodglass, H., & Kaplan, E. 1963. Disturbances of gesture and pantomime in aphasia. Brain,

86, 703-720.

Head, H. 1926. Aphasia

and kindred

disorders

ofspeech. New York: MacMillan

Co. Vol.

Hecaen, H. 1967. Approche semiolique des troubles de geste. Languages, 5, 67-83. Htcaen, H., & Albert, M. 1978. Human neuropsychology. New York: Wiley. Helm, H., & Benson, D. F. 1978. Visual action therapyfor global aphasia. Paper presented to Academy of Aphasia Annual Meeting, Chicago. Heilman, K., Rothi, L., Campanella, D., & Wolfson, S. 1979. Wemicke’s and global aphasia without alexia. Archives of Neurology, 36, 129-133. Hoemann, H. 1975. The transparency of meaning of sign language gestures. Sign Language Studies, 7, 151-161. Holland, A. 1977. Observing the functional communication of aphasic people. Paper presented to American Speech-Language-Hearing Association Convention, Chicago. Jackson, H. 1932. [Affections of Speech.] In J. Taylor (Ed.) 1932. Selected writings. London: Hodder & Stoughton. Vol. 2. Jenkins, J., Jimenez-Pabon, E., Shaw, R., & Sefer, J. 1975. Schuells’s aphasia in adults: Diagnosis, prognosis, and treatment, Hagerstown, MD; Harper & Row. Kadish, J. 1978. A neuropsychological approach to the study of gesture and pantomime in aphasia. South African Journal of Communication Disorders, 25, 102-l 17. Kimura, D., & Archibald, Y. 1974. Motor functions of the left hemisphere. Brain, 97, 337-350. Kirshner, H., & Webb, W. 1981. Selective involvement of the auditory-verbal modality in an acquired communication disorder: Benefit from sign language therapy. Brain and Language, 13, 161-170. Koller, J., & Schlanger, P. 1975. Iden@cation of action words and activity pantomimes by aphasics. Paper presented to American Speech-Language-Hearing Association Convention, Washington, D.C. LaPointe, L. 1978. Aphasia therapy: Some principles and strategies for treatment. In D. F. Johns (Ed.), Clinical management of neurogenic communication disorders. Boston: Little, Brown. Pp. 129-190. Liepmann, H. 1900. [The syndrome of apraxia (motor asymboly) based on a case of unilateral apraxia.] Translated by W. Bohne, K. Liepmann, & D. Rottenberg, In D. Rottenberg & F. Hochberg (Eds.), 1977. Neurological classics in modern translation, New York: Hafner. Pp. 155-183. Madsen, W. 1972. Conversational sign language. II. Washington, DC: Gallaudet College Press. Meckler, R., Mack, J., & Bennett, R. 1979. Sign language aphasia in a nondeaf mute. Neurology, 29, 1037-1040. Pickett, L. 1974. An assessment of gestural and pantomime deficit in aphasic patients. Acta

Symbolica,

5, 69-86.

Pierce, C. 1932. [Speculative grammar.] Cited by H. HCcaen & M. Albert (Eds.), Human neuropsychology. New York: Wiley. Poizner, H., Battison, R., & Lane, H. 1979. Cerebral asymmetry for American Sign Language: The effects of moving stimuli. Brain and Language, 7, 351-362. Porch, B. 1971. Porch Index of Communicative Ability. Palo Alto, CA: Consulting Psychologist Press. Vol. 2., revised ed.

348

PETERSON

AND KIRSHNER

Premack, D. 1971. Language in chimpanzee. Science, 172, 81X3-822. Rao, P. 1979. Use of Amerind gestural code by severe aphasic adults. Paper presented to American Speech-Language-Hearing Association Convention, Atlanta. Rao, P., Basili, A., Homer, J., & Koller, J. 1979. (Paper presented to Amerind Conference, St. Louis.) Cited by M. Skelly 1979. Amerind gestural code. New York: Elsevier, North-Holland. Rao, P., & Homer, J. 1979. Non-verbal strategies forfunctional communication by aphasic persons. Miniseminar presented to American Speech-Language-Hearing Association Convention, Atlanta. Rosenbeck, J. 1978. Treating apraxia of speech. In D. F. Johns (Ed.), Clinicat management of neurogenic communication disorders. Boston: Little, Brown. Pp. 191-241. Rosenbeck, J., Collins, M., & Wertz, R. 1976. Intersystemic reorganization for apraxia of speech. In R. H. Brookshire (Ed.), Clinical aphasiology: Conference proceedings. Minneapolis: B. R. K. Publishers. Pp. 255-260. Schlanger, P., & Schlanger, B. 1970. Adapting role-playing activities with aphasic patients. Journal of Speech and Hearing Disorders, 35, 229-235. Schlanger, P., DiCarrado, C., & Geffner, D. 1974. A comparison of gestural communication with aphasics; pre- and post-therapy. Paper presented to the American SpeechLanguage-Hearing Association Convention, Las Vegas. Schlanger, P. 1976. Training an adult aphasic to pantomime. Paper presented to the American Speech-Language-Hearing Association Convention, Houston. Schlanger, P., & Freiman, R. 1979. Pantomime therapy with aphasics. Aphasin, Apraxia, and Agnosia, 1, 34-39. Seron, X., van der Kaa, M., Remitz, A., & van der Linden, M. 1979. Pantomime interpretation and aphasia. Neuropsychologia, 17, 661-668. Siple, P. 1978. Visual constraints for sign language communication. Sign Language Studies, 19, 95-l 10. Skelly, M., Schinsky, L., Smith R., & Fust, R. 1974. American Indian Sign (Amerind) as a facilitator of verbalization for the oral-verbal apraxic. Journal of Speech and Hearing Disorders, 39, 445-456. Skelly, M., Schinsky, L., Smith, R., Donaldson, R., & Griffin, J. American Indian Sign: A gestural communication system for the speechless. Archives of Physical Medicine and Rehabilitation, 56, 156-160. Skelly, M. 1979. Amerind gestural code based on universal American Indian hand talk. New York: Elsevier North-Holland. Stokoe, W. 1970. The study of sign language. Washington, DC: ERIC Clearinghouse for Linguistics. Stokoe, W. 1975. The use of sign language in teaching English. American Annals of the Deaf, 120, 417-421. Stokoe, W. 1978. Sign codes and sign languages: Two orders of communication. Journal of Communication Disorders, 11, 187- 192. Tennenbaum, D., & Schlanger, C. 1969. (Gestural communication with aphasics in a dyadic situation.) Cited by P. Schlanger 13 R. Freiman 1979. Pantomime therapy with aphasics. Aphasia, Apraxia, Agnosia, 1, 34-39. Vamey, N. 1978. Linguistic correlates of pantomime recognition in aphasic patients. Journal of Neurology, Neurosurgery, and Psychiatry, 41, 564-568. Wertz, R. 1978. Neuropathologies of Speech and Language; An Introduction to Patient Management. In D. Johns (Ed.), CIinical management of neurogenic communication disorders. Boston: Little, Brown. Pp. l-101.