Journal of Speech and Hearing Disorders, HELM-ESTABROOKSEl' AL.

, Volume 47, 385-389, November 1982

VISUAL ACTION THERAPY FOR GLOBAL APHASIA

NANCY HELM-ESTABROOKS PATRICIA M. FITZPATRICK BARBARABARRESI

Neurologtj Service Boston Veterans Administration Medical Center and Boston Universit!l School qf Medicine

Eight globally aphasic patients who had not responded to traditional treatment received Visual Action Therapy (VAT), a
nonvocal approach which ultimately trains patients to produce symbolic gestures for visually absent stimuli. Statistical analyses
of pre and post VAT scores earned on the Porch Index of Communicative Abilit~ (PICA) showed highly significant improve-
ment on those subtests which measure pantomimic and auditory comprehension skills. The theoretical and practical implica-
tions of these findings are discussed.

By definition, globally aphasic patients are severely
impaired in all language modalities. These individuals
neither produce understandable speech or writing nor
comprehend spoken or written language. Unfortunately,
attempts to rehabilitate global patients through these
modalities generally have proven futile (Marks, Taylor,
& Rusk, 1957; Sarno, Silverman, & Sands, 1970; Schuell,
Jenkins, & J i m e n e z - P a b o n , 1964). Davis, Artes, and
Hoops (1979), suggest that pantomimic training rather
than linguistic i n t e r v e n t i o n may e n h a n c e the com-
municative effectiveness of severely impaired patients
by circumventing the linguistic deficits,
There are several theoretical rationales to support the
training of gestural output systems of global patients: (a)
Gestural communication may be used independently of
vocal communication. (b) H a n d gestures for manual
communication require less refined motor control than
the articulatory movements required for speech com-
munication. (c) Limb movements, unlike facial move-
ments, have more predominately unilateral control. The
left arm and hand are innervated by right hemisphere
p y r a m i d a l p a t h w a y s w h i c h are p r e s u m a b l y uneom-
promised in right hemiplegic global patients having ex-
clusively left hemisphere lesions. (d) The hand arm, un-
like the bucco/facial apparatus necessary for speech, is
visible to the initiator and can be visually monitored.
Despite the theoretical advantages of using gesture
with global patients, there are certain obstacles which
may interfere with their learning a gestural system. Pa-
tients with global aphasia usually have severe limb ap-
raxia of the n o n h e m i p l e g i c left arm as part of their
symptom complex. This limb apraxia may prevent pa-
tients from using representational gestures as a natural
means of communication. In a 1977 pilot study Helm,
Kaplan, and Vercruysse (Note 2) found that global pa-
tients with severe limb apraxia produced no spontaneous
representational gestures during a confrontation naming
task and no deliberate representational gestures during a
task which d e m a n d e d gestural representation of the
same pictured items. Even when trained with practice
items, the patients only tapped on or traced the pictures.
By the very nature of the language problem, these global
patients were unable to name, so that neither verbal nor
gestural labels were produced for the stimuli. The re-
sults imply that rehabilitation must first confront and
overcome the limb apraxia if global patients are to learn
a gestural system.
Another obstacle to teaching global patients any task is
that severe auditory and reading comprehension disturb-
ances may preclude the use of verbal or written instruc-
tions. There is evidence that this problem can be cir-
cumvented in one of two ways. First, global patients can
use nonorthographie visual stimuli as a symbol system as
well as for c o m p r e h e n s i o n of commands. (Gardner,
Zurif, Berry, & Baker, 1976; Glass, Gazzaniga, & Pre-
mack, 1973). Second, right hemiplegic patients respond
better to pantomimed instructions than to verbal instruc-
tions for the same tasks (Fordyee & Jones, 1966).
In this paper we will describe Visual Action Therapy,
a new approach to facilitating gestural communication.
This treatment procedure is based on the theoretical
constructs and empirical evidence presented above. We
also shall report and discuss the responses of eight
global patients to Visual Action Therapy.
METHOD
Treatment Program
Visual Aetion Therapy (VAT) is a nonverbal treatment
program which ultimately enables globally aphasic pa-
tients to produce symbolic gestures for visually absent
pictured object stimuli. The object is accomplished via a
hierarchically struetured, three level program which
utilizes: (a) eight uni-manual objects each of which can
be represented with a distinct gesture; (b) large, realis-
tic, colored drawings of each object outlined in black and
reproduced on 5 x 8 index cards; (e) small drawings of
each object on 1% × 3 cards and (d) eight drawings on 3
x 5 cards which depict a figure appropriately manipulat-
ing each object (see Figure 1). None of the VAT objects

© 1982, American Speech-Language-Hearing Association 385 0022-4677/82/4704-0385501.00/0

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 386 Journal of Speech and Hearing Disorders 47 385-389 November 1982

Visual Action Therapy is divided into three levels.

The first contains 12 steps, while Levels II and III con-
tain 6 steps each. All directions and reinforcements are
given nonverbally.
Patient responses for each item at each step are scored
one point for fully correct, one half point for self cor-
rected, and zero for incorrect. A new step is introduced
when the patient produces correct responses for every
item at the training step. Each session begins with a re-
view of the preceding step. The step-by-step procedure
is described in the Appendix.

FIGURE 1. Examples of action picture cards.
(hammer, razor, screwdriver, phone, cup, saw, black-
board eraser, pistol) are used on the Porch Index of
Communicative Ability (Porch, 1967) which served as
the dependent variable. Contextual prompts such as a
piece of wood, a slate, and a large nail and a large screw
in separate wooden blocks were used in conjunction
with the saw, eraser, hammer, and screwdriver.
Subjects
Eight globally aphasic stroke patients were treated
with VAT. All were right-handed, right hemiplegic
males who ranged in age from 37 to 70 (Y = 56.3). Each
had received some other form of language therapy before
initiation of VAT. Number of weeks post onset ranged
from 12 to 144 (Y = 46.8 weeks). Each patient had sus-
tained unilateral left hemisphere damage as confirmed
by computerized tomographical scanning. Patient infor-
mation is presented in Table 1.
Prior to experimental treatment, a diagnosis of global
aphasia was made for each patient. This diagnosis was
made on the basis of aphasia severity ratings below 1 on
the Boston Diagnostic Aphasia Examination (Goodglass
& Kaplan, 1972), an overall auditory comprehension

TABLE 1. Patient information.

Patient Age (yrs) Etiology ClinicalFindings CT Scan S/P (wks)

1 63 CVA right hemiplegia left temporal, frontal and 24
severe limb/facial apraxia subcortical
mutism--global aphasia
2 37 CVA right hemiplegia At least two lesions left 56
severe limb/facial apraxia temporal, frontal, parietal,
global aphasia occipital and subcortical
3 55 CVA right hemiplegia left cortex to ventricles 66
severe facial/limb apraxia frontal, parietal, temporal
global aphasia
4 55 CVA right hemiplegia left frontal, parietal, 12
severe facial/limb apraxia temporal
global aphasia
5 70 CVA right hemiplegia left frontal, parietal, 144
severe facial/limb apraxia temporal, subcortical
global aphasia internal capsule, and
putamen
6 59 CVA right hemiparesis left subcortical, putamen, 12
severe facial/moderate and corona radiata
limb apraxia
global aphasia
7 51 CVA right hemiparesis left frontal, temporal, 46
moderate facial/mild parietal, subcortical
limb apraxia
global aphasia
8 54 CVA right hemiplegia left frontal, parietal, 14
severe facial/limb apraxia temporal, cortical, and
global aphasia subeortical

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score no higher than - 1 . 2 5 standard deviation, and the
absence of naming, repetition, reading and writing skills.
Overall scores on the Porch Index o f C o m m u n i c a t i v e
Ability (PICA), ranged from 5.61 to 8.22 (~ 7.2) which
indicates marked impairment on all tasks except those
involving visual matching (PICA Manual Vol. 2, p. 72).
Treatment Schedule
Visual Action Therapy was administered in half hour
sessions at the rate of approximately five sessions per
week. Patients completed the treatment program in 4 to
14 weeks (g = 6.36) then were retested on the verbal and
gestural subtests of the PICA.
RESULTS
Pre and post VAT scores on the 10 "gestural" and
"verbal" PICA subtests were analyzed, These scores
were divided into three groups for separate analyses of
variance: Group 1 (PICA subtests II, III, VI, X) was ex-
pected to show significant post-VAT improvement;
Group II (PICA subtests V, VII) might show significant
improvement; Group III (PICA subtests I, IV, IX, XII)
was not expected to improve significantly. The rationale
for these expectations was as follows: (a) G r o u p I
gestural-pantomime seores (subtests II and III) should
improve significantly as a result of generalization from
the training program. (b) Group I auditory comprehen-
sion scores for the names of objects (subtest VI) and as-
sociated function verbs (subtest X) should improve as a
result of internal verbal monitoring during the training
program. (c) Group II reading comprehension scores for
function verbs (subtest V) and nouns (subtest VII) might
improve as a result of training in visual attention and
visual discrimination. (d) Group III verbal scores for sen-
tence production (subtest I,) naming (subtest IV), sen-
tence completion (subtest IX), and noun repetition (sub-
test XII) should not improve beeause VAT provides no
facilitation of either oral praxis or speech.
Three separate within-subject analyses of variance
(Meyers, 1966, p. 152) were performed (see Table 2).
Each analysis had two variables: subtests and replication
(pre VAT and post VAT testing). The expectations for all
groups were confirmed. The over-all pre/post treatment
effect for Group I was highly significant p = .01). Pair-
wise t-tests were conducted using the Newman-Keuls
post hoe procedure for multiple comparisons. Compari-
sons of pre and post treatment scores for all four subtests
were significant. The effect was significantly larger for
snbtests II and III than for VI and X (p = .05). While the
overall pre/post treatment effect for Group II approached
significance (p = .075), the overall pre/post treatment ef-
fect for Group III showed no trends toward signficance
(p = .15).
Finally, a Spearman rank order correlation coefficient
was used to measure the relationship between time post
onset of aphasia and response to VAT as measured by
Group I PICA subtest scores. Response to VAT was not
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HELM-ESTABROOKSET AL.: Visual Action Therapy 387
TABLE 2. Results of analyses of variance for three groups of
pre/post treatment data.
Group I (Predict Improvement)
Pica II Pica III Pica VI Pica X
pre post pre post pre post pre post
mean 6.78 10.08 8.3 11.04 9.4 10.74 10.38 11.63
SD 3.18 2.62 3.04 1.76 2.51 1.72 3.62 2.57
over-all efi~ct: F = 11.85; df 1,7; p = .01
Group II (Predict Possible Improvement)
Pica V Pica VII
pre post pre post
mean 6.09 8.16 6.65 9.18
SD 2.19 1.88 2.96 2.42
over-all effect: F = 4.36; df 1,7; p = .075
Group III (Predict No Improvement)
Pica I Pica IV Pica IX Pica XII
pre post pre post pre post pre post
mean 3.74 3.89 3.98 4.35 3.3 4.13 5.36 6.16
SD 1.65 1.42 1.08 1.23 1.52 1.37 3.01 2.82
over-all effect: F = 2.54; df 1,7; p = .15
correlated significantly with time post onset (r = -.42; p
> .05).
DISCUSSION
The prognosis for globally aphasic patients is consid-
ered poor. Lomas and Kertesz (1978) reviewed various
studies of recovery in aphasia and concluded that the
only unequivocal finding is that global patients may be
expected to have poor recovery. Schuell et al. (1964)
were so impressed with the failure of this group to re-
spond to treatment that they coined the phrase "irrevers-
ible syndrome." These authors characterize aphasia as
"impaired retrieval of a learned code," but given the
poor response of global patients it is not surprising that
other authors describe this disorder as a "massive lan-
guage loss" (Glass et al. 1973) and have questioned
whether global patients have the conceptual or cognitive
basis for regaining language skills. A successful treat-
ment approach was reported by Glass et al. who trained
global patients to use an artificial language system by ar-
ranging cutout paper symbols to express various rela-
tionships such as same/different, negation and sub-
ject-predicate-direct object. This finding led these
investigators to conclude that global patients retain a
rich conceptual system despite a massive language loss
and do not suffer cognitive impairment in direct propor-
tion to their language impairment. Further support for
functional cognitive skills was reported by Risse (Note
3). She reported that five global patients demonstrated
nearly intact conceptual performance on various Piage-
tian type developmental problem solving tasks.
Gardner, et al. (1976) reported on eight global patients
who learned a visual communication system which
 388 Journal of Speech and Hearing Disorders
utilized a series of index cards, each containing either a
simple, arbitrary (geometric) or representational (ideo-
graphic) form. The findings indicated that at least some
of the cognitive operations necessary for natural lan-
guage are intact despite global aphasia.
Visual Action Therapy, like the system of Gardner, et
al. is a nonvocal method which relies heavily on the use
of visual cues. The ultimate goal of the VAT program,
however, is to train global patients to produce repre-
sentational gestures for visually absent stimuli through
the manipulation of real objects. It, therefore, could be
considered a program for training limb praxis. Indeed,
VAT patients improved significantly in their ability to
perform pantomimes with the untrained PICA objects on
subtests II and Ill.
In addition to the e x p e c t e d i m p r o v e m e n t in pan-
tomimie ability, patients improved significantly in their
ability to respond to PICA auditory comprehension sub-
tests VI and X which require patients to seleet real ob-
jects from an array of 10 on hearing associated noun and
verb stimuli. There was a trend toward significant im-
provement in ability to read noun and verb stimuli for
subtests V and VII, while there was no such improve-
ment on subtests of verbal expression (I, IV, IX, XII).
Several hypotheses may explain w h y improvement in
auditory and reading comprehension should occur sub-
sequent to treatment with this nonverbal method. T h e y
i n c l u d e : (a) P a t i e n t s m a y e m p l o y i n t e r n a l v e r b a l
monitoring during the training program; (b) VAT may
improve general attentional skills; (c) VAT may improve
visual spatial and visual search skills; or (d) VAT may
reintegrate some of the conceptual systems necessary for
l i n g u i s t i c p e r f o r m a n c e ( H e l m & B e n s o n , N o t e 1).
Phenomena 1 and 2 also may result in improved scores
in verbal expression. That this did not occur might be
explained by the fact that the patients in this study had
severe facial apraxia which may have inhibited verbal
expression. The VAT program, a s presented, treated
limb praxis but did not train bucco/facial praxis, in order
to explore the contribution of bucco/facial praxis to the
speech skills of global patients, another VAT program
has been developed for training patients who have com-
pleted a course of limb VAT.
ACKNOWLEDGMENTS
The authors wish to thank D. Frank Benson for his early con-
tributions to this project, Michael Alexander for his critical
comments, and Errol Baker for his assistance with the statistieal
analysis. Margaret Naeser graciously provided CT scan informa-
tion.
This study was supported with flmds from the Veterans Ad-
ministration Merit Review Grant, "Visual Gommunieation in
Global Aphasia."
REFERENCE NOTES
1. HELM, N. A., & BENSON, D. F. Visual action therapy for
global aphasia: Preliminary report. Paper presented to the
annual meeting of the Academy of Aphasia, Chicago, 1978.
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47 385-389 N o v e m b e r 1982
2. HELM, N., KAPLAN,E., & VERCRUYSSE, L. The role of ges-
ture in naming. Unpublished study, 1977.
3. RISSE, G. L. The performance of aphasic patients on devel-
opmental conceptual tasks of Piaget. Paper presented at an-
nual meeting of the International Neuropsychology Society,,
Minneapolis, 1978.
REFERENCES
DAVIS, S. A., ARTES, R., & HOOPS, R. Verbal expression and
expressive pantomime in aphasic patients. Lebrun & Hoops
(Eds.), Problems of aphasia. Lisse: Adam, Swets, & Zeit-
linger, 1979.
FORDYCE, W. E., & JONES, R. H. The efficacy of oral and pan-
tomime instructions for hemiplegic patients. Archives of
Physical Medicine and Rehabilitation, 1966, 46,676-680.
GARDNER, H., ZumF, E., BERRY, T., & BAKER,E. Visual com-
munication in aphasia. Neuropsychology, 1976, 14, 275-292.
GLASS, A. V., GAZZANIGA,M. S., & PREMACK,D. Artificial lan-
guage training in aphasia. Neuropsychology, 1973, 11, 95-103.
GOODGLASS, H., • KAPLAN, E. Boston Diagnostic Aphasia
Examination. Philadelphia: Lea & Febiger, 1972.
Lo.v~s, J., & KERTESZ,A. Patterns of spontaneous recovery in
aphasic groups: a study of adult stroke patients. Brain and
Language, 1978, 5, 388-401.
MARKS, M., TAYLOR, M., & RUSK, H. Rehabilitation of the
aphasic patient: A survey of three years experience in a re-
habilitation setting. Neurology, 1957, 7, 837-843.
MEYERS, J. L. Fundamentals of experimental design. Boston:
Allyn &Baeon, 1966.
PORCH, B. E. Porch Index of Communicative Ability. Palo Alto,
CA: Consulting Psychologists, 1967.
SAN*go,M. T., SILVERMAN,M., & SANDS,E. Speech therapy and
language recovery in severe aphasia. Journal of Speech and
Hearing Research, 1970, 13,607-623.
SCHUELL, H., JENKINS, J., & JIMENEZ-PABON, J. Aphasia in
Adults. New York: Hoeber, i964.
Received March 31, 1981
Accepted September 30, 1981
Requests for reprints should be sent to Dr. Nancy Helm Es-
tabrooks, Neurology Service, Boston Veterans Administration
Medical Center, 150 South Huntington Avenue, Boston, Mass.,
02130.
APPENDIX
PROCEDURE FOR VISUAL ACTION THERAPY
General Instructions
Visual Action Therapy is a nonvocal treatment program for
severely aphasic patients. All directions, reinforcements, and
procedural steps are nonvocal. The program follows a hierarchy
of difficulty requiring nearly 100% success for each step before
progressing to the next step. It is advisable to review previous
or easier steps at the beginning of each session. Sessions are
approximately V2hour long.
The materials used are eight objects (razor, telephone, cup,
toy pistol, saw, hammer, screwdriver, and blackboard eraser)
and their contextual prompts if indieated (block of wood, block
of wood with protruding nail, block of wood with protruding
serew, and slate), eight colored, large line drawings, and eight
colored, small llne drawings of these objects (object picture
cards), and eight drawings depieting the objects being manipu-
lated by a stick figure (action picture cards).

Level I
Step 1: Tracing
This step is designed to help the patient understand that line
drawings of objects can represent real objects.
1. Trace the patient's hand on a large piece of unlined paper.
2. Help the patient trace your hand on a second piece of un-
lined paper.
3. Help the patient trace two objeets (e.g., hammer and
screwdriver) on separate pieces of unlined paper.
4. Arrange the four line drawings in front of the patient and
hand the patient each object to place on the correct draw-
ing. Place your hand on the matching line drawing and si-
lently encourage the patient to do the same with his hand.
If the patient is unable to do this task, try coloring the pie-
hires and tracing additional objects. If the patient continues to
show confusion, this treatment program is probably inappropri-
ate and should be discontinued.
Step 2: Large Picture Matching
1. Object to Picture Matching. Arrange the eight object pic-
ture cards randomly in a straight line in front of the pa-
tient. (Hemianopic patients are taught to scan for eight
items). In random order, hand each object to the patient to
be placed on the matching picture. Do not remove each
object before presenting the next one.
2. Picture to Object Matching. Arrange the eight objects
randomly in a straight line in front of the patient. In ran-
dom order, hand each large object picture card to the pa-
tient to be placed on the matching object. Do not remove
each card before presenting the next one.
3. Picture to Object Pointing. Arrange the eight objects ran-
domly in a straight line in front of the patient. Hold up
each large object picture card and nonverbally indicate to
the patient to point with the index finger to the object that
matches the card. Do not permit the patient to pick up the
object.
4. Object to Picture Pointing. Arrange the eight large object
picture cards randomly in front of the patient. Hold up
each object and nonverbally indicate to the patient to point
with the index finger to the card that matches the object.
Do not permit the patient to pick up the card.
Step 3: Small Picture Matching
Using the small object picture cards and the eight objects, fol-
low the steps outlined in 2A, 2B, 2C, and 2D.
Step 4: Manipulating Objects
Demonstrate the function of each object using a contextual
prompt when indicated (e.g., pounding the nail with the ham-
mer), then place the object in front of the patient who must pick
it up and correctly demonstrate its function. If the patient has
persistent difficulty manipulating a particular object, remove it
from the array and select a permanent substitution (e.g., a paint
brush).
Step 5: Action Picture "'Command" Instruction
Place an object and contextual prompt if indicated and the
corresponding action picture card in front of the patient. Point
to the action picture card, pick up the object, and demonstrate
its function. Place the object in front of the patient, point to the
card, and encourage the patient to manipulate the object.
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HELM-ESTABROOKS ET AL.: Visual Action Therapy 389
Step 6: Following Action Picture "Commands"
Arrange the eight objects and contextual prompts in front of
the patient. Hold up an action picture card and encourage the
patient to find the appropriate object and demonstrate its func-
tion.,
No contextual prompts are used for the following steps:
Step 7: Pantomimed Gesture Demonstration
Place one object within the patient's visual field. Produce the
pantomimed gesture most commonly associated with the object.
Follow this procedure with all eight objects. The patient is not
required to respond.
Step 8: Recognizing Pantomimed Gestures
Place the eight objects in a line in front of the patient. Pro-
duce a representational gesture for each object and encourage
the patient to point to the object associated with the gesture.
Step 9: Pantomimed Gesture Instruction
Place one object within the patient's visual field and encour-
age him to produce a correct pantomimed gesture for the object.
Follow this procedure with all eight objects. If the patient fails
or has difficulty, provide assistance until the patient can pro-
duce tire gesture without assistance.
Step 10: Producing Pantomimed Gestures
Hold up an object and encourage the patient to produce a
pantomimed gesture for the object. Follow this procedure with
all eight objects. If the patient is unable to initiate appropriate
gestures, review Step 9.
Step 11: Pantomimed Gesture for Absent Object
Demonstration
Place two objects in front of the patient. Produce the appro-
priate pantomimed gesture for each object. Hide the two objects
under a box and bring 1 of 2 objects into the patient's view.
Produce questioning gestures while pointing to the box and
then produce the pantomimed gesture associated with the hid-
den object. Follow this procedure for four pairs of objects. The
patient is not required to respond.
Step 12: Producing Pantomimed Gestures for
Absent Objects
As in Step 11, place two objects in front of the patient, hide
the objeets under a box, and bring one of the two objects into
the patient's view. Nonvocally encourage the patient to produce
the pantomimed gesture associated with the hidden object. Re-
peat this procedure for each combination of pairs hiding each of
the eight objects at least once.
Level II
Repeat Steps 7-12 of Level I substituting the action picture
cards for the objects.
Level III
Repeat Steps 7-12 of Level I substituting the small object pic-
ture cards for the objects.