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  BOOK REVIEWS Why Should We Care About “Fluent Aphasia?” The Importance of StudyingConnected Speech in Aphasiology DOI: 10.1017 0 S1355617707210239 Fluent Aphasia , by Susan Edwards. 2006. New York: Cambridge University Press. 230 pp.,$75.00 (HB). Reviewed by  Carlo Semenza, M.D. ,  Department of Psychology, University of Trieste, Italy. The 21st-century aphasiologist may be surprised to find anew book with such a title as  FluentAphasia .Three decadesof cognitive neuropsychology advances would seem suffi-cient to relegate a fuzzy concept like “fluent aphasia” as arelic of the past, or, at best, restrict it to the realm of short-hand descriptions meant to facilitate daily communicationamong clinicians. Even among those accustomed to strictcollaboration, a concept like “fluent aphasia” may causemisunderstanding.Ipersonallylearnedaboutaphasiadirectlyfrom the Boston school. Yet, when I speak with my Italiancolleagues from Milan, whom I have known for most of myprofessional life, and with whom I have written quite a fewpapers on aphasia, I am often unsure about what they meanwhen they label an aphasic patient as “fluent.” I still remem-ber Harold Goodglass telling me, in almost the same wordsSusan Edwards quotes from him, how “fluency is best ratedin terms of the  longest occasional uninterrupted strings  of words that are produced.” My own understanding of histeaching included the concept that the presence of phoneticproblems and 0 or abnormal articulation effort was not soessential in drawing the fluency-non fluency distinction:according to his rule of thumb, fluent aphasia should bediagnosed when a patient can produce at least  five con-nected words . This rule derived from observations made inGoodglass, Quadfasel, and Timberlake’s (1964) study onphrase length and type of aphasia, whereby it was shownthat aphasics can be dichotomized on the basis of the num-ber of words that they can typically utter as an uninter-rupted string. Edwards reports that other people entertaindifferent beliefs about what is fluent aphasia. Surely sev-eral, heterogeneous criteria such as phrase length, verbalagility,melodicline,amountofarticulationeffort,andgram-matical form are differently weighted by different aphasi-ologists as they consider their diagnosis.This said, for what is a diagnosis of fluent aphasia ulti-mately meant? To this simple question I could not find anexplicit answer anywhere in this book. In other words, weare never told exactly for what reason, beyond wanting toindicate with a general term all conditions resembling theclassiccategoriesofWernicke,conduction,anomicandtrans-cortical sensory aphasia (and not global, Broca’s or trans-cortical motor), an aphasiologist should take some pain insetting more or less rigid criteria for isolating fluent aphasiaas a concept. This is not exclusively Edwards’s fault, sincenowhere else can I find an answer to this question. Yet,numerous aphasiologists intuitively, it seems, find the con-cept useful. In my own experience, I always found Goodg-lass’s rule helpful in telling me something about the lesionand the prognosis: if, no matter how bad the articulation is,an acute patient can produce, within a reasonably long con-versation or piece of narrative, five grammatically con-nected words, then the bulk of the lesion is not likely to bein Broca’s area but would be somehow more posterior. Inthe presence of articulation problems, I would regard thiscondition more likely to evolve in a positive way. But Icannot now easily locate these notions in Goodglass’s writ-ings, and they may not have come from him but from mydoubtable memory. This is just an example of how, basedmore upon intuition and oral transmission rather than uponsecure empirical and theoretical grounds, the notion of flu-ent aphasia may serve, rather idiosyncratically, differentpurposes for individual aphasiologists. Then why, with thisdegree of variability and arbitrariness, should one care about“fluent aphasia” at all?Susan Edwards takes a theoretically oriented clinician’sapproach, and in so doing, manages to convince the readerthat, indeed, the notion of fluent aphasia is currently usefuland may have a future. I think she succeeds in her intentinsofar she shows how much there is to be gained in study-ing aphasics’connected speech. She starts, in fact, with theprovoking statement that “fluent aphasia is . . . commonlyseen in clinics but (about it) . . . little is written (p. 1).” Oneunderstands to what extent she is right as soon as she makesclear that she considers drawing on connected speech data  Journal of the International Neuropsychological Society  (2007),  13 , 190–195.Copyright © 2007 INS. Published by Cambridge University Press. Printed in the USA. 190  the pivotal means of obtaining new and important informa-tion on aphasia. The best part of the book is indeed thatportion devoted to connected speech, and it may be truethat studies of connected speech are much less numerousfor fluent aphasia categories compared to those availablefor non-fluent categories.In the first chapter she tries to identify fluent aphasia as aself-standing concept from Wernicke’s time onward. Dueconsideration, here as well as very often throughout thewhole book, is paid to the work of Goodglass and of theBoston school. Notably, however, no mention is made of the work of Norman Geschwind, of his revival of the oldaphasiology masters, and of the anatomically based inter-pretative framework that so heavily influenced thinking atthe Boston V.A. Aphasia Research Center and elsewhere.Indeed,accordingtoGoodglass(1993,p.33),itisGeschwindwho deserves credit for introducing the terms “fluent” and“non-fluent” to designate the two major subtypes of apha-sic syndromes. Nevertheless Geschwind is mentioned,  en passant  , only later in Chapter 3, whereby his contributionto the concept of fluent aphasia is briefly acknowledged,and, oddly, Goodglass is said to have been his student(sic). Other 20th-century descriptions of fluent aphasia arereported, overwhelmingly within the Anglo-Saxon tradi-tion, whereas important contributions from the Russian, theFrench, the German, and the Italian schools do not receivemuch mention. This is the author’s choice and a compre-hensive review of available literature on fluent aphasia isclearly not within the scope of this book. Issues includingthe utility of syndromes, the syndrome-lesion site relation-ship and converging evidence brought about by studies withnormal subjects complete the chapter.The second chapter describes fluent aphasia in the con-text of the most popular psycholinguistic models, wherebythe srcin of the most distinctive errors made by fluentaphasics is located.Adescription of such errors is providedwith examples and with a long discussion of how lexicalproblems may interfere with grammatical problems in pro-ducing the characteristic pattern of fluent aphasic speech.Chapter 3 is devoted to assessment and contains a criticaldescription of most commonly used aphasia batteries. Italso contains an updated description of several diagnosticinstruments recently developed for assessing aphasia withintheoretically driven research projects. A final note warnsthe reader about several limitations of aphasia assessmentsas clinical and as research tools.The book enters its most interesting and srcinal partwith Chapter 4.Anybody wanting to study connected speechin aphasia could profitably start by reading this chapter.Ways of collecting representative samples, their strengthsandweaknesses,andproblemsinqualitativeaswellasquan-titative analysis of data are thoroughly reported.As Edwardsnotes, different perspectives yield different interpretations.Examples are provided of how recently developed, sophis-ticated coding schemes can capture interesting, revealingdetails about disorders of sentence structure when appliedto fluent aphasic production. In Chapter 5, Edwards leadsthe reader to consider current debates over the nature of production and comprehension problems in agrammatism.In doing so she manages to render palatable and balanceddescriptions of theoretical stances that have been furiouslychallengedinrecentyears.Whileagrammatismismostoften,but not necessarily, associated with non-fluent aphasia, thisdiscussion is justified in the context of this book since find-ings in fluent aphasia have been frequently used as a mean-ingful contrast.Comprehension problems in fluent aphasia, remarkablymore severe and frequent (but how different in quality?)than in non-fluent, non-global varieties, are described inChapter 6. Clinical phenomena are reported along with theirinterpretation since Wernicke’s time. The contribution of non-linguistic factors to comprehension deficits is also dis-cussed. Comprehension at the single word level and com-prehension of sentences has been found to be influenced byvarious factors like argument structure and movement thataregenerallyignoredinclinicalreports,but,Edwardsshows,have increasingly captured researchers’attention for the lasttwo decades. Chapter 7 reports a single paradigmatic caseof fluent aphasia, underlining the fact that no linguisticdimension may be considered unimpaired. Concludingremarks and some interesting afterthought constitute thebulk of the last chapter.This book may be in many ways a useful one. It is notomni-comprehensive, in that it does not review, as the poten-tial customer may be led into believing, all issues con-cerned with fluent aphasia. For example, it ignores, asmentioned earlier, very significant contributions from non-Anglo-Saxon literature. Also, while phonological distur-bances are described, the account of research on segmentaland supra-segmental phonology in fluent aphasia is kept toa minimum with respect to the generous spaces allotted tolexical and grammatical aspects. This is to some extent sur-prising, since phonological disturbances may interact in nonobvious ways with the production of fluent aphasic speech.Moreover, the study of phonologically related phenomenalike, for example, hesitations has been used to draw infer-ences on the nature of lexical and grammatical disorders influent aphasia. However, this book comes forth with a verystrong message: studies of connected speech will make thefuture of aphasiology. Edwards lays down for the reader, ina relatively simple way, the theoretical ground for further,effective, studies of lexical and grammatical aspects of con-nected speech in fluent aphasia. And, in dealing with boththe productive as well as the receptive side, she providesabundant indications of ways to exploit the outcome of suchinvestigations in an interesting way.A few remarks on readability and ideal readership mustbe added as a conclusion. The vivid and occasionally col-loquial style does not in itself make this book easy to read.The intent to discuss clinical phenomena and theoreticaland research issues on the same time accounts for somedifficulty in keeping the thread of several arguments. Forthis reason I would hesitate in recommending this book tobeginners, maybe with an exception for one or two chapters  JINS, Vol. 13, No. 1  191  (notably Chapter 3). I recommend it to any expert neuro-psychologist wanting to start exploring connected speechin aphasia and to linguists and psycholinguists curious aboutwhere aphasiology is nowadays on several issues withintheir respective interests. They should, however, be awarethat there is much more recent and interesting material aboutaphasia than they can learn from this book. Finally, theexpert21st-centuryaphasiologistwillfindinEdwards’sbook plenty of hidden and less hidden inspirational tips for veryinteresting research. Reviving the concept of fluent aphasiamay not have been, indeed, a waste of time. REFERENCES Goodglass, H. (1993).  Understanding aphasia . San Diego: Aca-demic Press.Goodglass, H., Quadfasel, F., and Timberlake, W. (1964). Phraselength and the type and severity of aphasia.  Cortex  ,  1 , 133–153. Mental Retardation: Is It in the Genes? DOI: 10.1017 0 S1355617707220235  Mental Retardation and Developmental Delay: Genetic and Epigenetic Factors , by MoyraSmith. 2006. New York: Oxford University Press, 344 pp., $49.95 (HB). Reviewed by  Lynn Bennett Blackburn, Ph.D. ,  St. Louis Children’s Hospital, St. Louis, MO. Most of us have had the experience of evaluating a childwho looks just like other children, whose MRI scan is readas normal, and whose test performance results in a diagno-sis of mental retardation. Such children cause us to ponderthe question, “How can a brain look so normal, yet work soabnormally?”As the results are presented, parents ponder adifferent question. They want to know why this has hap-pened to their child. What makes the question a hard one torespond to is that we ask ourselves the same question butoften do not have an answer. The neuropsychological con-ceptualization of mental retardation starts with skill pat-terns and works backwards through neural networks lookingfor cause.  Mental Retardation and Developmental Delay:Genetic and Epigenetic Factors  begins with the inner work-ings of the cell, examining genes, gene products, and cellmetabolism as the basis for the observed disruption of learn-ing and memory.Following the provision of an historic perspective (Chap-ter 1), Dr. Smith moves into an overview of brain develop-ment and neurotransmitters (Chapter 2). The reader is takenfrom territory familiar to the neuropsychologist up to thecell wall. From this point on, the reader enters into the innerworkings of the cell systems and individual cells, through adiscussion of the impact of gene defects on cell migration,gene transcription factors and cell metabolism. As Chapter2 ends, the reader is rapidly introduced to a large number of abbreviations for gene products and proteins. Without arecent course in cell biology to serve as a context for thisinformation, the discussion that follows places high de-mands on working memory to track the referents of theseabbreviations.In the chapters that follow, Dr. Smith provides a compre-hensive review of disorders in which mental retardation is acore feature. Attempts are made to group disorders by thepresumed mechanism underlying the retardation. Underly-ing mechanisms range from structural defects to disordersof metabolism and are linked to current knowledge regard-ing responsible chromosomes, genes, and 0 or gene prod-ucts.The organization of this information differs dependingon the disorder under discussion. Chapter 3 reviews syn-dromes that result in major malformations of the neuraltube or cortex. The reader is introduced to the role of spe-cific genes and gene products in normal and abnormal cellmigration. This material provides a context for understand-ing what has gone wrong in the disorders that are sub-sequently described.In Chapter 4, most of the disorders discussed are associ-ated with dysmorphic features and an identified chromo-somal abnormality.The syndrome is described first in termsof presenting features followed by a description of the chro-mosomal abnormality. Unlike the disorders in Chapter 3,the mechanism by which the chromosome abnormalityresults in the presenting features of the syndrome remainsunknown for many of these disorders. This chapter pro-vides a fascinating look at familiar and rare syndromes fromanother perspective. Chapter 4 ends with a brief descriptionof Fetal Alcohol Syndrome (FAS). This appears to havebeen included to complete a comprehensive look at retar-dation syndromes associated with dysmorphic features,although it clearly deviates from the book’s basic theme.The majority of Chapters 5 and 6 focus on inborn errorsin metabolism, many of which can be treated through dietaryadjustment. If untreated, the disorders typically result inmental retardation. Disorders in Chapter 5 are primarilyassociated with failures to develop normal cognition whiledisorders in Chapter 6 involve a period of normal develop-ment followed by skill loss (i.e. neurodegenerative disor-ders).Thedietarytreatmentsthatsignificantlyaltercognitiveoutcome for many of the disorders discussed in Chapter 5are further described in Chapter 10. For some disorders inChapter 6, treatments such as bone marrow transplantationare effective in halting the degenerative process. Whereas192  Book Reviews  the majority of Chapters 5 and 6 focus on metabolic disor-ders, each chapter also contains information about otherconditions. Chapter 5 includes epilepsy syndromes accom-panied by mental retardation for which a genetic cause hasbeen identified, genetic disorders in which sensory impair-ment or movement disorder accompanies the mental retar-dation, and muscular dystrophy. The depiction of cognitiveoutcome for epilepsy and muscular dystrophy is oversim-plified, failing to capture the variability evident in clinicalpractice. In Chapter 6, there is a brief discussion of envi-ronmental toxins as a cause of retardation following a periodof normal cognitive development. As for information pro-vided on FAS, the treatment of these disorders is superficial.Chapter7beginswithcontentstronglylinkedtothebook’smain theme (e.g., non-syndromic X-linked mental retarda-tion), and progresses with discussions of disorders poten-tiallyhavingageneticbasis(autism,developmentallanguagedisorders). These discussions provide the reader with anoverview of the process of discovery (i.e., the work thatmay lead to the detailed information available for earlierdiscussed disorders).The final three chapters address the larger picture, interms of understanding genetic research, in diagnosing men-tal retardation, and in treatment of mental retardation. InChapter 8, Dr. Smith examines both the relationship of thehuman genome project to advances in identification of tar-get genes for disorders and current understanding of how agene or gene sequence may impact function. In my opinion,this chapter’s content would have been helpful to build acontext upon which readers could base their understandingof the data presented in Chapters 3 through 7. Chapter 9includes a discussion of the diagnosis of mental retardationfrom the physician’s perspective. Whereas the chart listing“Formal Tests of Development and Cognition” seems inad-equate when reviewed by a neuropsychologist, the overallthought process underlying recommendations for history,physical exam, and sequencing of diagnostic procedures isexcellent. In addition to information on treatments for somemetabolic syndromes, Chapter 10 describes new methodsbeing developed for early identification of metabolic disor-ders. This information rounds out the diagnostic processpresented in Chapter 9.Overall, this book will provide a challenging cover-to-cover read for neuropsychologists not actively involved ingenetics research or well versed in cell biology.The author’sassumptions regarding the knowledge of the reader varieswidely, from providing basic information (e.g. males havean X and Y chromosome) to the use of terms or abbrevia-tions before giving their definition. The organization of thematerial is also somewhat challenging, with a single disor-der discussed in more than one chapter, requiring a multi-chapter scan to obtain the complete picture.  Mental Retardation and Developmental Delay: Geneticand Epigenetic Factors  will make a good addition to thereference materials in a pediatric neuropsychology labora-tory. The book achieves the author’s goal of broadening thereader’s view of mental retardation by emphasizing the rich-ness in the variety of presentation, developmental course,and underlying pathology that results in impaired cognitivedevelopment. The book reinforces the importance of a thor-ough family history, as well as the importance of lookingcarefully for abnormalities of facial features, hair distribu-tion, and stature to uncover clues that may lead to syn-drome identification. When children come with a syndromediagnosis, the book provides the cell level picture of thecause. Whereas information may still be missing to bridgethe gap between the cell level dysfunction and the resultingcognitive profile, it does provide one more piece to con-sider in solving the puzzle of the normal MRI scan andabnormal neuropsychological test results. Progress in Sports Neuropsychology DOI: 10.1017 0 S1355617707230231 Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury . Ruben J.Echemendía (Ed.). 2006. New York: The Guilford Press, 324 pp., $45.00 (HB). Reviewed by  E. Mark Mahone, Ph.D., ABPP-CN ,  Department of Neuropsychology, Kennedy Krieger  Institute, Baltimore, MD.Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury , edited by Ruben J. Echemendía,brings together a variety of experts in the area of sportsconcussion,inanefforttointroducepsychologistsandneuro-psychologists to the rapidly developing area of sports neuro-psychology. The book is organized into five parts. Part I, Sports Neuropsychology in Context  , outlines the historicalcontext for the development of sports neuropsychology asa professional endeavor. Chapter 1 (Barth, Broshek, andFreeman), introduces the readers to a number of importantdefinitions that are used throughout the book, includingconcussion, post-concussion syndrome, second-impact syn-drome,andthesystemofgradingconcussionseverity.Impor-tantly, Barth, a pioneer in the study of sports-relatedconcussion, describes his early efforts at the University of Virginia using pre- and posttrauma assessment with theSports as a Laboratory Assessment Model (SLAM)—amethod of examining concussion in a controlled environ-  JINS, Vol. 13, No. 1  193  ment, which has become a standard for current practice.Chapter 2 (Zillmer, Schneider, Tinker, and Kamineris) pro-vides a fascinating historical account of sports-related inju-ries, dating from the 8th century B.C. (ancient Olympicgames) to the present. Their account chronicles the medicaland behavioral assessment of head trauma (beginning withHippocrates, who wrote extensively about head injury), tothe modern-day three-tiered grading system introduced byCantu (1986) and the American Academy of Neurology(1997), and provides a unique perspective on how neuro-psychologists have come to play such a critical role in sportsmedicine. Chapter 3 (Echemendía) takes on the importanttask of highlighting the potential pitfalls inherent in con-sulting with athletes, including those at the collegiate andprofessional levels. Echemendía directly confronts the dif-ferent “rules” associated with athletic consultation (e.g.,flexibility of scheduling, dealing with the media) and chal-lenges psychologists to examine their motivation for pursu-ing this type of specialty practice (i.e., the need to be around“celebrities”). The chapter even describes the down side of sports neuropsychology practice, including not being treatedwith the same level of professional respect that they areaccustomed to receiving from their clients.Part 2,  Concussion Assessment and Management  , out-lines the state of practice in concussion management. Chap-ter 4 (Webbe) addresses in greater detail the definition of concussion, including physiology and severity grading.Thisis a valuable chapter, which can potentially be a usefulteaching tool outside the area of sports neuropsychology.Webbe reviews the historical literature on potential mech-anisms of injury, including biomechanics (linear and rota-tional force) and pathophysiological theories (includingvascular, reticular, pontine cholinergic and convulsive theo-ries). He then addresses our current understanding of thephysiology of injury in concussion including changes incerebral blood flow, ion flux (neurotoxicity), glucose hypo-metabolism, electrical changes, and mitochondrial swell-ing. The chapter concludes with a review of injury causedby physical force, with a recommendation (based on animalstudies) that an injury with peak accelerative force of 200 gshould be considered a threshold for single impact to cause“significant brain injury” in humans. In Chapter 5 (Maccio-cci) the extent and epidemiology of sports concussion isdelineated in greater detail, including the challenges asso-ciated with variable terminology used in epidemiologicalresearch. Much of the initial section of this chapter repeatsinformation presented earlier in the book. The chapter con-tains specific sections on incidence of injury in football,soccer,hockey,andacombinedsectiononbaseball,lacrosse,basketball, and wrestling; however, interestingly, there isno mention of other popular sports with high likelihoodof concussion, including skiing 0 snowboarding, boxing,gymnastics 0 cheerleading, and “extreme” sports (e.g.,skateboarding, BMX biking, motocross). Chapter 6 (Barr)addresses components of sideline assessment of concussionand specific procedures (including review of history, orien-tation, concentration and memory tests, and motor 0 gait 0 balance assessment) that are used in making return to playdecisions. The chapter makes several crucial observations.First, it is the athletic trainer and team physician who typ-ically make sideline assessments—not neuropsychologists.Secondly, sideline assessment requires great caution, espe-cially because of the non-ideal (i.e., noisy) setting for assess-ment, the incidence of pre-existing learning disorders 0 ADHD among athletes, and base rates of proficiency ontests of attention (e.g., he cites a study in which only 50%of healthy high school athletes could accurately performserial seven subtractions). Chapter 7 (Echemendía) intro-duces the reader to the complex, dynamic, decision-makingprocess regarding return-to-play.The neuropsychologist fre-quently has a significant role in the process although it isusually the team physician or athletic trainer making thefinal decision. A very useful element of this chapter is thediagram of Echemendía’s return to play model (p. 122),which includes: medical factors, neuropsychological data,concussion factors, player factors (e.g., age, personality,style of play), team factors (elite  vs . recreational), and extra-neous factors (e.g., playing surface, field condition).Sports concussion is a public health concern, and man-agement occurs at all age levels. Part 3,  Testing Programs ,outlines concussion management programs for school age,high school, college, and professional athletes. In Chap-ter 8, Brooks reports that 30 million children and adoles-cents participate in out-of-school sports programs in theUnited States each year. As such, she emphasizes generalsurveillance and preventative education. Pardini and Col-lins (Chapter 9) address the unique challenges of concus-sion management in high schools. They provide useful,“high school relevant” methods for on-field screening, andraise the important issue of estimating an athlete’s pre-injury cognitive ability using available data (level of course-work, grade point average, SAT scores). Three case studiesare provided, although it is not clear whether these areactual cases, or composites used to illustrate points in thechapter. In Chapter 10 (Schatz and Covassin), the chal-lenges of concussion management in college are described.This chapter also reviews general issues in concussion thatare described earlier in the book, but is particularly usefulfor psychologists who have never worked with athletes inthe college setting. One important point emphasized in thechapter is the variability in approach, depending on sport(e.g., football  vs . lacrosse), or depending on size and scopeof the athletic programs (e.g., Division I  vs . Division III).Part 3 concludes with the section on working with profes-sional athletes by Mark Lovell (Chapter 11). Lovell high-lights two decades of experience working with professionalfootball and hockey teams to this chapter, and addressesthe role of neuropsychology not just in working with indi-vidual players but also in developing guidelines for pre-vention. The unique challenges of working with professionalathletes are discussed, including athletes’ minimizing of symptoms, the potentially opposing priorities of coaches,and the prevalence of athletes for whom English is not aprimary language.194  Book Reviews


Apr 16, 2018
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