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1.  Multimodal Alexia: Neuropsychological Mechanisms and Implications for Treatment 
Neuropsychologia  2011;49(13):3551-3562.
Letter-by-letter (LBL) reading is the phenomenon whereby individuals with acquired alexia decode words by sequential identification of component letters. In cases where letter recognition or letter naming is impaired, however, a LBL reading approach is obviated, resulting in a nearly complete inability to read, or global alexia. In some such cases, a treatment strategy wherein letter tracing is used to provide tactile and/or kinesthetic input has resulted in improved letter identification. In this study, a kinesthetic treatment approach was implemented with an individual who presented with severe alexia in the context of relatively preserved recognition of orally spelled words, and mildly impaired oral/written spelling. Eight weeks of kinesthetic treatment resulted in improved letter identification accuracy and oral reading of trained words; however, the participant remained unable to successfully decode untrained words. Further testing revealed that, in addition to the visual-verbal disconnection that resulted in impaired word reading and letter naming, her limited ability to derive benefit from the kinesthetic strategy was attributable to a disconnection that prevented access to letter names from kinesthetic input. We propose that this kinesthetic-verbal disconnection resulted from damage to the left parietal lobe and underlying white matter, a neuroanatomical feature that is not typically observed in patients with global alexia or classic LBL reading. This unfortunate combination of visual-verbal and kinesthetic-verbal disconnections demonstrated in this individual resulted in a persistent multimodal alexia syndrome that was resistant to behavioral treatment. To our knowledge, this is the first case in which the nature of this form of multimodal alexia has been fully characterized, and our findings provide guidance regarding the requisite cognitive skills and lesion profiles that are likely to be associated with a positive response to tactile/kinesthetic treatment.
doi:10.1016/j.neuropsychologia.2011.09.007
PMCID: PMC3221964  PMID: 21952194
acquired alexia; letter-by-letter reading; pure alexia; global alexia; alexia with agraphia; kinesthetic treatment
2.  Letter-recognition and reading speed in peripheral vision benefit from perceptual learning 
Vision research  2004;44(7):695-709.
Visual-span profiles are plots of letter-recognition accuracy as a function of letter position left or right of the midline. Previously, we have shown that contraction of these profiles in peripheral vision can account for slow reading speed in peripheral vision. In this study, we asked two questions: (1) can we modify visual-span profiles through training on letter-recognition, and if so, (2) are these changes accompanied by changes in reading speed? Eighteen normally sighted observers were randomly assigned to one of three groups: training at 10° in the upper visual field, training at 10° in the lower visual field and a no-training control group. We compared observers’ characteristics of reading (maximum reading speed and critical print size) and visual-span profiles (peak amplitude and bits of information transmitted) before and after training, and at trained and untrained retinal locations (10° upper and lower visual fields). Reading speeds were measured for six print sizes at each retinal location, using the rapid serial visual presentation paradigm. Visual-span profiles were measured using a trigram letter-recognition task, for a letter size equivalent to 1.4 × the critical print size for reading. Training consisted of the repeated measurement of 20 visual-span profiles (over four consecutive days) in either the upper or lower visual field. We also tracked the changes in performance in a sub-group of observers for up to three months following training. We found that the visual-span profiles can be expanded (bits of information transmitted increased by 6 bits) through training with a letter-recognition task, and that there is an accompanying increase (41%) in the maximum reading speed. These improvements transferred, to a large extent, from the trained to an untrained retinal location, and were retained, to a large extent, for at least three months following training. Our results are consistent with the view that the visual span is a bottleneck on reading speed, but a bottleneck that can be increased with practice.
doi:10.1016/j.visres.2003.09.028
PMCID: PMC2729075  PMID: 14751554
Reading; Letter-recognition; Peripheral vision; Perceptual learning; Low vision; Visual rehabilitation
3.  Dependence of Reading Speed on Letter Spacing in Central Vision Loss 
Purpose
Crowding, the difficulty in recognizing a letter in close proximity with other letters, has been suggested as an explanation for slow reading in people with central vision loss. The goals of this study were (1) to examine whether increased letter spacing in words, which presumably reduces crowding among letters, would benefit reading for people with central vision loss; and (2) to relate our finding to the current account of faulty feature integration of crowding.
Methods
Fourteen observers with central vision loss read aloud single sentences, one word at a time, using rapid serial visual presentation (RSVP). Reading speeds were calculated based on the RSVP exposure durations yielding 80% accuracy. Letters were rendered in Courier, a fixed-width font. Observers were tested at 1.4× the critical print size (CPS), three were also tested at 0.8× CPS. Reading speed was measured for five center-to-center letter spacings (range: 0.5–2× the standard spacing). The preferred retinal locus (PRL) for fixation was determined for nine of the observers, from which we calculated the horizontal dimension of the integration field for crowding.
Results
All observers showed increased reading speed with letter spacing for small spacings, until an optimal spacing, beyond which reading speed either showed a plateau, or dropped as letter spacing further increased. The optimal spacing averaged 0.95±0.06× [±95%CI] the standard spacing for 1.4× CPS (similar for 0.8× CPS), which was not different from the standard. When converted to angular size, the measured values of the optimal letter spacing for reading show a good relationship with the calculated horizontal dimension of the integration field.
Conclusions
Increased letter spacing beyond the standard size, which presumably reduces crowding among letters in text, does not improve reading speed for people with central vision loss. The optimal letter spacing for reading can be predicted based on the PRL.
doi:10.1097/OPX.0b013e318264c9dd
PMCID: PMC3429790  PMID: 22842309
reading; crowding; central vision loss; low vision; age-related macular degeneration
4.  Accurate Reading with Sequential Presentation of Single Letters 
Rapid, accurate reading is possible when isolated, single words from a sentence are sequentially presented at a fixed spatial location. We investigated if reading of words and sentences is possible when single letters are rapidly presented at the fovea under user-controlled or automatically controlled rates. When tested with complete sentences, trained participants achieved reading rates of over 60 wpm and accuracies of over 90% with the single letter reading (SLR) method and naive participants achieved average reading rates over 30 wpm with greater than 90% accuracy. Accuracy declined as individual letters were presented for shorter periods of time, even when the overall reading rate was maintained by increasing the duration of spaces between words. Words in the lexicon that occur more frequently were identified with higher accuracy and more quickly, demonstrating that trained participants have lexical access. In combination, our data strongly suggest that comprehension is possible and that SLR is a practicable form of reading under conditions in which normal scanning of text is not possible, or for scenarios with limited spatial and temporal resolution such as patients with low vision or prostheses.
doi:10.3389/fnins.2012.00158
PMCID: PMC3483628  PMID: 23115548
visual prosthesis; bionic vision; low vision; reading; RSVP; phosphene; word recognition
5.  Reading Speed, Comprehension and Eye Movements While Reading Japanese Novels: Evidence from Untrained Readers and Cases of Speed-Reading Trainees 
PLoS ONE  2012;7(5):e36091.
Background
A growing body of evidence suggests that meditative training enhances perception and cognition. In Japan, the Park-Sasaki method of speed-reading involves organized visual training while forming both a relaxed and concentrated state of mind, as in meditation. The present study examined relationships between reading speed, sentence comprehension, and eye movements while reading short Japanese novels. In addition to normal untrained readers, three middle-level trainees and one high-level expert on this method were included for the two case studies.
Methodology/Principal Findings
In Study 1, three of 17 participants were middle-level trainees on the speed-reading method. Immediately after reading each story once on a computer monitor, participants answered true or false questions regarding the content of the novel. Eye movements while reading were recorded using an eye-tracking system. Results revealed higher reading speed and lower comprehension scores in the trainees than in the untrained participants. Furthermore, eye-tracking data by untrained participants revealed multiple correlations between reading speed, accuracy and eye-movement measures, with faster readers showing shorter fixation durations and larger saccades in X than slower readers. In Study 2, participants included a high-level expert and 14 untrained students. The expert showed higher reading speed and statistically comparable, although numerically lower, comprehension scores compared with the untrained participants. During test sessions this expert moved her eyes along a nearly straight horizontal line as a first pass, without moving her eyes over the whole sentence display as did the untrained students.
Conclusions/Significance
In addition to revealing correlations between speed, comprehension and eye movements in reading Japanese contemporary novels by untrained readers, we describe cases of speed-reading trainees regarding relationships between these variables. The trainees overall tended to show poor performance influenced by the speed-accuracy trade-off, although this trade-off may be reduced in the case of at least one high-level expert.
doi:10.1371/journal.pone.0036091
PMCID: PMC3348914  PMID: 22590519
6.  Improving word reading speed: individual differences interact with a training focus on successes or failures 
Reading and Writing  2011;25(9):2061-2089.
The effect of two training procedures on the development of reading speed in poor readers is examined. One training concentrates on the words the children read correctly (successes), the other on the words they read incorrectly (failures). Children were either informed or not informed about the training focus. A randomized controlled trial was conducted with 79 poor readers. They repeatedly read regularly spelled Dutch consonant–vowel–consonant words, some children their successes, others their failures. The training used a computerized flashcards format. The exposure duration of the words was varied to maintain an accuracy rate at a constant level. Reading speed improved and transferred to untrained, orthographically more complex words. These transfer effects were characterized by an Aptitude-Treatment Interaction. Poor readers with a low initial reading level improved most in the training focused on successes. For poor readers with a high initial reading level, however, it appeared to be more profitable to practice with their failures. Informing students about the focus of the training positively affected training: The exposure duration needed for children informed about the focus of the training decreased more than for children who were not informed. This study suggests that neither of the two interventions is superior to the other in general. Rather, the improvement of general reading speed in a transparent orthography is closely related to both the children’s initial reading level and the type of words they practice with: common and familiar words when training their successes and uncommon and less familiar words with training their failures.
doi:10.1007/s11145-011-9342-7
PMCID: PMC3443357  PMID: 23002327
Training; Intervention; Orthography; Poor readers; Reading speed
7.  Learning to Identify Crowded Letters: Does It Improve Reading Speed? 
Vision research  2007;47(25):3150-3159.
Crowding, the difficulty in identifying a letter embedded in other letters, has been suggested as an explanation for slow reading in peripheral vision. In this study, we asked whether crowding in peripheral vision can be reduced through training on identifying crowded letters, and if so, whether these changes will lead to improved peripheral reading speed. We measured the spatial extent of crowding, and reading speeds for a range of print sizes at 10° inferior visual field before and after training. Following training, averaged letter identification performance improved by 88% at the trained (the closest) letter separation. The improvement transferred to other untrained separations such that the spatial extent of crowding decreased by 38%. However, averaged maximum reading speed improved by a mere 7.2%. These findings demonstrated that crowding in peripheral vision could be reduced through training. Unfortunately, the reduction in the crowding effect did not lead to improved peripheral reading speed.
doi:10.1016/j.visres.2007.08.017
PMCID: PMC2134936  PMID: 17928026
crowding; perceptual learning; training; reading
8.  Repetition priming in oral text reading: a therapeutic strategy for phonologic text alexia 
Aphasiology  2009;23(6):659-675.
Background
Phonologic text alexia (PhTA) is a reading disorder in which reading of pseudowords is impaired, but reading of real words is impaired only when reading text. Oral reading accuracy remains well preserved when words are presented individually, but when presented in text the part-of-speech effect that is often seen in phonologic alexia (PhA) emerges.
Aims
To determine whether repetition priming could strengthen and/or maintain the activation of words during text reading.
Methods & Procedures
We trained NYR, a patient with PhTA, to use a strategy, Sentence Building, designed to improve accuracy of reading words in text. The strategy required NYR to first read the initial word, and then build up the sentence by adding on sequential words, in a step-wise manner, utilizing the benefits of repetition priming to enhance accuracy.
Outcomes & Results
When using the strategy, NYR displayed improved accuracy not only for sentences she practiced using the strategy, but unpracticed sentences as well. Additionally, NYR performed better on a test of comprehension when using the strategy, as compared to without the strategy.
Conclusions
In light of research linking repetition priming to increased neural processing efficiency, our results suggest that use of this compensatory strategy improves reading accuracy and comprehension by temporarily boosting phonologic activation levels.
doi:10.1080/02687030801969539
PMCID: PMC2906786  PMID: 20664804
phonologic text alexia; repetition priming; aphasia; alexia; rehabilitation
9.  The Effect of Letter-stroke Boldness on Reading Speed in Central and Peripheral Vision 
Vision research  2013;84:33-42.
People with central vision loss often prefer boldface print over normal print for reading. However, little is known about how reading speed is influenced by the letter-stroke boldness of font. In this study, we examined the reliance of reading speed on stroke boldness, and determined whether this reliance differs between the normal central and peripheral vision. Reading speed was measured using the rapid serial visual presentation paradigm, where observers with normal vision read aloud short single sentences presented on a computer monitor, one word at a time. Text was rendered in Courier at six levels of boldness, defined as the stroke-width normalized to that of the standard Courier font: 0.27, 0.72, 1, 1.48, 1.89 and 3.04× the standard. Testings were conducted at the fovea and 10° in the inferior visual field. Print sizes used were 0.8× and 1.4× the critical print size (smallest print size that can be read at the maximum reading speed). At the fovea, reading speed was invariant for the middle four levels of boldness, but dropped by 23.3% for the least and the most bold text. At 10° eccentricity, reading speed was virtually the same for all boldness <1, but showed a poorer tolerance to bolder text, dropping by 21.5% for 1.89x boldness and 51% for the most bold (3.04x) text. These results could not be accounted for by the changes in print size or the RMS contrast of text associated with changes in stroke boldness. Our results suggest that contrary to the popular belief, reading speed does not benefit from bold text in the normal fovea and periphery. Excessive increase in stroke boldness may even impair reading speed, especially in the periphery.
doi:10.1016/j.visres.2013.03.005
PMCID: PMC3642228  PMID: 23523572
Reading; stroke boldness; peripheral vision
10.  Subretinal electronic chips allow blind patients to read letters and combine them to words 
A light-sensitive, externally powered microchip was surgically implanted subretinally near the macular region of volunteers blind from hereditary retinal dystrophy. The implant contains an array of 1500 active microphotodiodes (‘chip’), each with its own amplifier and local stimulation electrode. At the implant's tip, another array of 16 wire-connected electrodes allows light-independent direct stimulation and testing of the neuron–electrode interface. Visual scenes are projected naturally through the eye's lens onto the chip under the transparent retina. The chip generates a corresponding pattern of 38 × 40 pixels, each releasing light-intensity-dependent electric stimulation pulses. Subsequently, three previously blind persons could locate bright objects on a dark table, two of whom could discern grating patterns. One of these patients was able to correctly describe and name objects like a fork or knife on a table, geometric patterns, different kinds of fruit and discern shades of grey with only 15 per cent contrast. Without a training period, the regained visual functions enabled him to localize and approach persons in a room freely and to read large letters as complete words after several years of blindness. These results demonstrate for the first time that subretinal micro-electrode arrays with 1500 photodiodes can create detailed meaningful visual perception in previously blind individuals.
doi:10.1098/rspb.2010.1747
PMCID: PMC3081743  PMID: 21047851
subretinal neuro-prosthetics; retinal implant; retinitis pigmentosa; blindness; artificial vision; bionic vision
11.  Word-Initial Letters Influence Fixation Durations during Fluent Reading 
The present study examined how word-initial letters influence lexical access during reading. Eye movements were monitored as participants read sentences containing target words. Three factors were independently manipulated. First, target words had either high or low constraining word-initial letter sequences (e.g., dwarf or clown, respectively). Second, targets were either high or low in frequency of occurrence (e.g., train or stain, respectively). Third, targets were embedded in either biasing or neutral contexts (i.e., targets were high or low in their predictability). This 2 (constraint) × 2 (frequency) × 2 (context) design allowed us to examine the conditions under which a word’s initial letter sequence could facilitate processing. Analyses of fixation duration data revealed significant main effects of constraint, frequency, and context. Moreover, in measures taken to reflect “early” lexical processing (i.e., first and single fixation duration), there was a significant interaction between constraint and context. The overall pattern of findings suggests lexical access is facilitated by highly constraining word-initial letters. Results are discussed in comparison to recent studies of lexical features involved in word recognition during reading.
doi:10.3389/fpsyg.2012.00085
PMCID: PMC3317262  PMID: 22485100
reading; eye movements; word-initial letter constraint; word frequency; contextual predictability
12.  Effects of Tactile–Kinesthetic Stimulation on Low Birth Weight Neonates 
Iranian Journal of Pediatrics  2013;23(3):289-294.
Objective
Low Birth Weight [LBW] (1500gr ≤ Birth Weight ≤ 2499 gr) is one of the most serious health problems in neonates. These neonates need complementary interventions (e.g. tactile-kinesthetic stimulation) to promote development. This study was conducted to determine the effect of Tactile-Kinesthetic Stimulation (TKS) on physical and behavioral development of Low Birth Weight neonates.
Methods
This was a randomized controlled trial with equal randomization (1:1 for two groups) and parallel group design. Forty LBW neonates were randomly allocated into test (n = 20) and control (n = 20) groups. TKS was provided for three 15 minute periods per day for 10 consecutive days to the test group, with the massages consisting of moderate pressure strokes in supine and prone position and kinesthetic exercises consisting of flexion and extension of limbs. All measurements were taken before and after completion of the study with the same equipment (Philips electronic weighing scale with an accuracy of ±5 grams and Brazelton Neonatal Behavioral Assessment) and by the same person.
Findings
There was a trend towards increased daily weight gain, but without statistical significance. On the Brazelton scale, the test group showed statistically significant improved scores on the ‘motor’ (P-value <0.001) and ‘regulation of state’ (P-value = 0.039) clusters after the 10 days TKS.
Conclusion
TKS has no adverse effects on physiologic parameters and gives better adaptive behavior of LBW neonates compared to those without TKS.
PMCID: PMC3684473  PMID: 23795251
Tactile Stimulation; Kinesthetic Stimulation; Low Birth Weight; Neonatal Behavioral Assessment Scale
13.  Learning to Identify Near-Acuity Letters, either with or without Flankers, Results in Improved Letter Size and Spacing Limits in Adults with Amblyopia 
PLoS ONE  2012;7(4):e35829.
Amblyopia is a developmental abnormality that results in deficits for a wide range of visual tasks, most notably, the reduced ability to see fine details, the loss in contrast sensitivity especially for small objects and the difficulty in seeing objects in clutter (crowding). The primary goal of this study was to evaluate whether crowding can be ameliorated in adults with amblyopia through perceptual learning using a flanked letter identification task that was designed to reduce crowding, and if so, whether the improvements transfer to untrained visual functions: visual acuity, contrast sensitivity and the size of visual span (the amount of information obtained in one fixation). To evaluate whether the improvements following this training task were specific to training with flankers, we also trained another group of adult observers with amblyopia using a single letter identification task that was designed to improve letter contrast sensitivity, not crowding. Following 10,000 trials of training, both groups of observers showed improvements in the respective training task. The improvements generalized to improved visual acuity, letter contrast sensitivity, size of the visual span, and reduced crowding. The magnitude of the improvement for each of these measurements was similar in the two training groups. Perceptual learning regimens aimed at reducing crowding or improving letter contrast sensitivity are both effective in improving visual acuity, contrast sensitivity for near-acuity objects and reducing the crowding effect, and could be useful as a clinical treatment for amblyopia.
doi:10.1371/journal.pone.0035829
PMCID: PMC3340394  PMID: 22558234
14.  Effect of letter spacing on visual span and reading speed 
Journal of vision  2007;7(2):2.1-210.
S. T. L. Chung (2002) has shown that rapid serial visual presentation (RSVP) reading speed varies with letter spacing, peaking near the standard letter spacing for text and decreasing for both smaller and larger spacings. In this study, we tested the hypothesis that the dependence of reading speed on letter spacing is mediated by the size of the visual span—the number of letters recognized with high accuracy without moving the eyes. If so, the size of the visual span and reading speed should show a similar dependence on letter spacing. We tested this prediction for RSVP reading and asked whether it generalizes to the reading of blocks of text requiring eye movements. We measured visual-span profiles and reading speeds as a function of letter spacing. Visual-span profiles, measured with trigrams (strings of three random letters), are plots of letter-recognition accuracy as a function of letter position left or right of fixation. Size of the visual span was quantified by a measure of the area under the visual-span profile. Reading performance was measured using two presentation methods: RSVP and flashcard (a short block of text on four lines). We found that the size of the visual span and the reading speeds measured by the two presentation methods showed a qualitatively similar dependence on letter spacing and that they were highly correlated. These results are consistent with the view that the size of the visual span is a primary visual factor that limits reading speed.
doi:10.1167/7.2.2
PMCID: PMC2729067  PMID: 18217817
visual span; reading speed; letter spacing; visual crowding
15.  Letters and Notes in Orthopaedic Surgery 
INTRODUCTION
Accurate written communication is essential in orthopaedic surgery. Incomplete and poorly structured letters can lead to poor knowledge of a patient's diagnosis.
MATERIALS AND METHODS
Structured and traditional letter formats were compared for speed of reading and preference by general practitioners (GPs), consultants, registrars and out-patient nursing staff. In addition, out-patient clinic letters and notes were analysed and compared for speed of reading and ease of assimilating information and content.
RESULTS
There was overwhelming preference for the structured letter format. This style of letter could be read significantly more quickly with information better assimilated and relevant data included more frequently. However, only 26% of letters generated contained a complete set of information sought by GPs and hospital staff.
CONCLUSIONS
Structured letters are better in orthopaedics because it is easier to access the contents. The structured format disciplines medical staff to address essential information. Even with a structured format the majority of letters omitted essential information. Training in letter writing is necessary. A structured letter format next to dictating machines might improve the quality of letters generated.
doi:10.1308/003588406X98612
PMCID: PMC1963690  PMID: 16786610
Communication; Orthopaedic surgery; Education
16.  Modelling normal and impaired letter recognition: Implications for understanding pure alexic reading 
Neuropsychologia  2012;50(12):2773-2788.
Letter recognition is the foundation of the human reading system. Despite this, it tends to receive little attention in computational modelling of single word reading. Here we present a model that can be trained to recognise letters in various spatial transformations. When presented with degraded stimuli the model makes letter confusion errors that correlate with human confusability data. Analyses of the internal representations of the model suggest that a small set of learned visual feature detectors support the recognition of both upper case and lower case letters in various fonts and transformations. We postulated that a damaged version of the model might be expected to act in a similar manner to patients suffering from pure alexia. Summed error score generated from the model was found to be a very good predictor of the reading times of pure alexic patients, outperforming simple word length, and accounting for 47% of the variance. These findings are consistent with a hypothesis suggesting that impaired visual processing is a key to understanding the strong word-length effects found in pure alexic patients.
Highlights
► We develop a connectionist letter recognition model which provides the link between visual input and letter recognition. ► The model can deal with the invariance problem and generalise to previously unseen letters. ► The model can extract key features for letter recognition. ► We demonstrate the model can simulate confusability effects in normal readers and predict PA patients' RTs. ► Impaired visual processing is a key to understanding the strong word-length effects found in PA patients.
doi:10.1016/j.neuropsychologia.2012.07.031
PMCID: PMC3657697  PMID: 22841988
Letter recognition; Letter confusability; Pure alexia; Computational modelling
17.  Treatment for lexical retrieval using abstract and concrete words in persons with aphasia: Effect of complexity 
Aphasiology  2009;23(7):835-853.
Background
The significance of imageability and concreteness as factors for lexical tasks in aphasic individuals is under debate. No previous treatment studies have looked specifically at training abstract words compared to concrete for improved lexical retrieval in patients with chronic aphasia.
Aim
The goal of the present study was to determine the efficacy of a treatment for lexical retrieval that is based on models of lexical processing by utilizing abstractness as a mode of complexity. It was hypothesized that training abstract words in a category will result in improvement of those words and generalization to untrained target concrete words in the same category. Training concrete words in a category, however, will result in the retrieval of trained concrete words, but not generalization to target abstract words.
Methods & Procedures
A single subject experimental design across participants and behaviors was used to examine treatment and generalization. Generative naming for three categories (church, hospital, courthouse) was tested during baseline and treatment. Each treatment session was carried out in five steps: (1) category sorting, (2) feature selection, (3) yes/no feature questions, (4) word recall, and (5) free generative naming.
Results
Although participant 1 demonstrated neither significant learning nor generalization during abstract or concrete word training, participants 2, 3, and 4 showed significant learning during abstract word training and generalization to untrained concrete words. Participants 3 and 4 were also trained on concrete words which they improved on but did not show generalization to untrained abstract words.
Conclusions
The results of the present experiment support our hypothesis that training abstract words would result in greater learning and generalization to untrained concrete words. They also tentatively support the idea that generalization is facilitated by treatment focusing on more complex constructions (Kiran & Thompson, 2003; Thompson, Shapiro, Kiran, & Sobecks, 2003).
doi:10.1080/02687030802588866
PMCID: PMC2758793  PMID: 19816590
18.  Intact verbal description of letters with diminished awareness of their forms 
Visual processing and its conscious awareness can be dissociated. To examine the extent of dissociation between ability to read characters or words and to be consciously aware of their forms, reading ability and conscious awareness for characters were examined using a tachistoscope in an alexic patient. A right handed woman with 14 years of education presented with incomplete right hemianopia, alexia with kanji (ideogram) agraphia, anomia, and amnesia. Brain MRI disclosed cerebral infarction limited to the left lower bank of the calcarine fissure, lingual and parahippocampal gyri, and an old infarction in the right medial frontal lobe. Tachistoscopic examination disclosed that she could read characters aloud in the right lower hemifield when she was not clearly aware of their forms and only noted their presence vaguely. Although her performance in reading kanji was better in the left than the right field, she could read kana (phonogram) characters and Arabic numerals equally well in both fields. By contrast, she claimed that she saw only a flash of light in 61% of trials and noticed vague forms of stimuli in 36% of trials. She never recognised a form of a letter in the right lower field precisely. She performed judgment tasks better in the left than right lower hemifield where she had to judge whether two kana characters were the same or different. Although dissociation between performance of visual recognition tasks and conscious awareness of the visual experience was found in patients with blindsight or residual vision, reading (verbal identification) of characters without clear awareness of their forms has not been reported in clinical cases. Diminished awareness of forms in our patient may reflect incomplete input to the extrastriate cortex.


doi:10.1136/jnnp.68.6.782
PMCID: PMC1736980  PMID: 10811708
19.  Impact of low vision care on reading performance in children with multiple disabilities and visual impairment 
Indian Journal of Ophthalmology  2014;62(2):111-115.
Background:
Lack of evidence in literature to show low vision care enhances the reading performance in children with Multiple Disabilities and Visual Impairment (MDVI).
Aim:
To evaluate the effectiveness of Low Vision Care intervention on the reading performance of children with MDVI.
Materials and Methods:
Three subjects who were diagnosed to have cerebral palsy and visual impairment, studying in a special school were recruited for the study. All of them underwent detailed eye examination and low vision care evaluation at a tertiary eye care hospital. A single subject multiple baseline (study) design was adopted and the study period was 16 weeks. The reading performance (reading speed, reading accuracy, reading fluency) was evaluated during the baseline phase and the intervention phase. The median of all the reading parameters for each week was noted. The trend of the reading performance was graphically represented in both the phases.
Results:
Reading speed increased by 37 Word per minute, 37 Letters per minute and 5 letters per minute for the subject 1, 2 and 3 respectively after the intervention. Reading accuracy was 84%, 91% and 86.4% at the end of the baseline period and 98.7%, 98.4% and 99% at the end of 16 weeks for subject 1, 2 and 3 respectively. Average reading fluency score was 8.3, 7.1 and 5.5 in the baseline period and 10.2, 10.2 and 8.7 in the intervention period.
Conclusion:
This study shows evidence of noticeable improvement in reading performance of children with MDVI using a novel study design.
doi:10.4103/0301-4738.111207
PMCID: PMC4005221  PMID: 23619499
Low vision care; multiple disabilities and visual impairment; reading performance
20.  Letter Position Coding Across Modalities: The Case of Braille Readers 
PLoS ONE  2012;7(10):e45636.
Background
The question of how the brain encodes letter position in written words has attracted increasing attention in recent years. A number of models have recently been proposed to accommodate the fact that transposed-letter stimuli like jugde or caniso are perceptually very close to their base words.
Methodology
Here we examined how letter position coding is attained in the tactile modality via Braille reading. The idea is that Braille word recognition may provide more serial processing than the visual modality, and this may produce differences in the input coding schemes employed to encode letters in written words. To that end, we conducted a lexical decision experiment with adult Braille readers in which the pseudowords were created by transposing/replacing two letters.
Principal Findings
We found a word-frequency effect for words. In addition, unlike parallel experiments in the visual modality, we failed to find any clear signs of transposed-letter confusability effects. This dissociation highlights the differences between modalities.
Conclusions
The present data argue against models of letter position coding that assume that transposed-letter effects (in the visual modality) occur at a relatively late, abstract locus.
doi:10.1371/journal.pone.0045636
PMCID: PMC3467024  PMID: 23071522
21.  Letters in the forest: global precedence effect disappears for letters but not for non-letters under reading-like conditions 
Normally skilled reading involves special processing strategies for letters, which are habitually funneled into an abstract letter code. On the basis of previous studies we argue that this habit leads to the preferred usage of an analytic strategy for the processing of letters, while non-letters are preferably processed via a holistic strategy. The well-known global precedence effect (GPE) seems to contradict to this assumption, since, with compound, hierarchical figures, including letter items, faster responses are observed to the global than to the local level of the figure, as well as an asymmetric interference effect from global to local level. We argue that with letters these effects depend on presentation conditions; only when they elicit the processing strategies automatized for reading, an analytic strategy for letters in contrast to non-letters is to be expected. We compared the GPE for letters and non-letters in central viewing, with the global stimulus size close to the functional visual field in whole word reading (6.5° of visual angle) and local stimuli close to the critical size for fluent reading of individual letters (0.5° of visual angle). Under these conditions, the GPE remained robust for non-letters. For letters, however, it disappeared: letters showed no overall response time advantage for the global level and symmetric congruence effects (local-to-global as well as global-to-local interference). We interpret these results as according to the view that reading is based on resident analytic visual processing strategies for letters.
doi:10.3389/fpsyg.2014.00705
PMCID: PMC4102249  PMID: 25101012
reading acquisition; global advantage effect; analytic processing; holistic processing; literacy; developmental dyslexia; congruence effect
22.  Pseudo-Synesthesia through Reading Books with Colored Letters 
PLoS ONE  2012;7(6):e39799.
Background
Synesthesia is a phenomenon where a stimulus produces consistent extraordinary subjective experiences. A relatively common type of synesthesia involves perception of color when viewing letters (e.g. the letter ‘a’ always appears as light blue). In this study, we examine whether traits typically regarded as markers of synesthesia can be acquired by simply reading in color.
Methodology/Principal Findings
Non-synesthetes were given specially prepared colored books to read. A modified Stroop task was administered before and after reading. A perceptual crowding task was administered after reading. Reading one book (>49,000 words) was sufficient to induce effects regarded as behavioral markers for synesthesia. The results of the Stroop tasks indicate that it is possible to learn letter-color associations through reading in color (F(1, 14) = 5.85, p = .030). Furthermore, Stroop effects correlated with subjective reports about experiencing letters in color (r(13) = 0.51, p = .05). The frequency of viewing letters is related to the level of association as seen by the difference in the Stroop effect size between upper- and lower-case letters (t(14) = 2.79, p = .014) and in a subgroup of participants whose Stroop effects increased as they continued to read in color. Readers did not show significant performance advantages on the crowding task compared to controls. Acknowledging the many differences between trainees and synesthetes, results suggest that it may be possible to acquire a subset of synesthetic behavioral traits in adulthood through training.
Conclusion/Significance
To our knowledge, this is the first evidence of acquiring letter-color associations through reading in color. Reading in color appears to be a promising avenue in which we may explore the differences and similarities between synesthetes and non-synesthetes. Additionally, reading in color is a plausible method for a long-term ‘synesthetic’ training program.
doi:10.1371/journal.pone.0039799
PMCID: PMC3384588  PMID: 22761905
23.  How useful are post consultation letters to patients? 
BMC Medicine  2006;4:2.
Background
As part of the NHS plan it was suggested that all patients receive copies of letters sent to their General Practitioner following outpatient consultations. The former Secretary of State for Health extended this proposal, suggesting that patients have a specific letter to themselves after a hospital consultation.
Methods
The aim of this study was to send cardiorespiratory patients attending Charing Cross Hospital, a copy of the letter sent to their G.P. plus a specific letter to themselves and to assess the usefulness and comprehensibility of each. The letters were analysed for dictation time, Flesch Reading Ease Score, Flesch-Kincaid Grade Level and word count. Eighty-four out of 105 sequential patients (80%) consented and were sent both types of letter after their attendance. Patients returned both letters circling any items they did not understand and stated a preference for the GP letter, patient letter, or both. The patients' GPs were subsequently also asked for their views on each letter.
Results
GP letters took significantly longer to dictate than patient letters. The Flesch Reading Ease Score was significantly higher in the patient letters, indicating that the patient letters were easier to read. The GP letters were significantly longer than the patient letters and patients were significantly more likely to circle more items in the GP letters (p < 0.001). The content of letters is sometimes inaccurate. Thirty-six out of 62 patients (58%) would like to receive both letters, 13/62 (21.6%) would prefer the GP letter and 13/62 (20%) wanted only the patient letter. 45 GPs replied (62.5%), 28/45 (62.5%) wanted the GP letter, 14 GPs (31.1%) wanted both letters and 3/45 (6.7%) wanted the patient letter only. General themes concerned insufficient clinical details and the GPs preferred the structure of the letters written to them.
Conclusion
Patients appreciate copies of the letter being sent to their GP but comprehension is less good than with a shorter letter written especially to the patient. More attention needs to be paid to making letters to GPs simpler to read without losing the structure and detail liked by GPs. A compromise might be to dictate the letter in front of the patient and to provide a speciality-specific glossary to accompany each letter.
doi:10.1186/1741-7015-4-2
PMCID: PMC1360088  PMID: 16426444
24.  Training Synesthetic Letter-color Associations by Reading in Color 
Synesthesia is a rare condition in which a stimulus from one modality automatically and consistently triggers unusual sensations in the same and/or other modalities. A relatively common and well-studied type is grapheme-color synesthesia, defined as the consistent experience of color when viewing, hearing and thinking about letters, words and numbers. We describe our method for investigating to what extent synesthetic associations between letters and colors can be learned by reading in color in nonsynesthetes. Reading in color is a special method for training associations in the sense that the associations are learned implicitly while the reader reads text as he or she normally would and it does not require explicit computer-directed training methods. In this protocol, participants are given specially prepared books to read in which four high-frequency letters are paired with four high-frequency colors. Participants receive unique sets of letter-color pairs based on their pre-existing preferences for colored letters. A modified Stroop task is administered before and after reading in order to test for learned letter-color associations and changes in brain activation. In addition to objective testing, a reading experience questionnaire is administered that is designed to probe for differences in subjective experience. A subset of questions may predict how well an individual learned the associations from reading in color. Importantly, we are not claiming that this method will cause each individual to develop grapheme-color synesthesia, only that it is possible for certain individuals to form letter-color associations by reading in color and these associations are similar in some aspects to those seen in developmental grapheme-color synesthetes. The method is quite flexible and can be used to investigate different aspects and outcomes of training synesthetic associations, including learning-induced changes in brain function and structure.
doi:10.3791/50893
PMCID: PMC4126805  PMID: 24638033
Behavior; Issue 84; synesthesia; training; learning; reading; vision; memory; cognition
25.  Effect of Verb Network Strengthening Treatment (VNeST) on Lexical Retrieval of Content Words in Sentences in Persons with Aphasia 
Aphasiology  2009;23(3):402-424.
Background
Verb Network Strengthening Treatment (VNeST) is a semantic treatment that aims to improve lexical retrieval of content words in sentence context by promoting systematic retrieval of verbs (e.g., measure) and their thematic roles (i.e., agent (doer of the action, e.g., carpenter, chef)) and patient (receiver of the action, e.g., lumber, sugar)). VNeST is influenced by Loverso and colleagues (e.g., Loverso, Selinger, and Prescott, 1979), who used “verb as core” treatment to improve sentence production with encouraging results, and McRae and colleagues, who showed that verbs prime typical agents (e.g., pray-nun) and patients (arrest-criminal) (Ferretti, McRae, & Hatherell, 2001) and vice-versa (McRae, Hare, Elman, & Ferretti, 2005).
Aims
There are four specific questions in this study. Does training a set of verbs using VNeST generalize to the ability to produce 1) an agent (carpenter), trained verb (measure), and patient (stairs) in response to novel picture stimuli and 2) an agent (nurse), untrained semantically related verb (weigh), and patient (baby) in response to novel picture stimuli? 3) Are generalization effects maintained?, and 4) Does VNeST generalize to the ability to retrieve nouns and verbs not directly related to treatment items in single word naming, picture description and connected speech tasks?
Methods & Procedures
Four participants with aphasia participated. Participants received VNeST, which involves retrieval of agent-patient pairs (e.g., chef/sugar, surveyor/land) related to trained verbs (e.g., measure), two times per week. A single subject, repeated probe, multiple baseline experimental design was used. Generalization to sentence production for sentences containing trained verbs and untrained semantically related verbs was tested weekly.
Outcomes & Results
Results demonstrated generalization to lexical retrieval of content words in sentences with trained and untrained verbs across participants. Additionally, pre- to post-treatment generalization was observed on single verb and noun naming and lexical retrieval in sentences across a variety of tasks across participants. Generalization to connected speech was observed for 3 of 4 participants.
Conclusions
Though preliminary, these results indicate that VNeST may be effective in promoting generalization from single word naming to connected speech in persons with moderate aphasia. A number of clinical implications related to treatment efficiency are discussed.
doi:10.1080/02687030802291339
PMCID: PMC2744980  PMID: 19763227
aphasia; semantic therapy; verb; generalization; connected speech; thematic roles

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