A case of pure alexia and how it can inform our approach to therapy

What do we know about therapy techniques for pure alexia? The short answer is…not much. Why? Because pure alexia is a rare disorder that occurs in a heterogeneous population. As a result, research efforts are often limited to case reports and single-subject designs. What we do know is that clinicians often take one of two approaches: either “bottom-up” (i.e., letter-based treatment) or “top-down” (i.e., phrase or word-based treatment). If you’re stuck trying to decide which approach to take with your patient, then consider this: Ramsberger et al. found that both bottom-up and top-down approaches resulted in large treatment effects for trained and untrained stimuli for their participant. This adds to a previous case by Sage et al. with similar findings. So, the good news is that both approaches may be effective for your patient…now you don’t have to lose sleep over whether or not you selected the right one! Phew. But if you’re still not sure…the authors suggest conducting your own single-participant study. And it’s not as cumbersome as you might think!

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Ramsberger et al. suggest that conducting your own single-participant design is feasible and can help to inform the long-term treatment of individuals with pure alexia. As informed SLPs, this is definitely worth a shot!


Ramsberger, G., Messamer, P., Robinaugh, G., Ervin, M., Knauss Spees, H., Tran, NV. (2019). Top-down and Bottom-up Treatment Approaches Compared in a Single Case of Pure Alexia. Aphasiology. doi:10.1080/02687038.2019.1637813

Two considerations for the FAVRES with bilingual patients

Is the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) an appropriate test of executive function (EF) for bilingual patients with mild traumatic brain injury (mTBI)? Maybe, but use with caution. Ratiu & Azuma compared “bilingual” participants with and without a history of mTBI on the FAVRES, self reports of EF, and a nonlinguistic measure of EF/ inhibition (the flanker test). The participants were all college students, ranging in language background from fully bilingual non-native English speakers to native English speakers with “at least basic proficiency in Spanish.”

What did they find?

The participants with mTBI performed significantly worse than the controls on the accuracy, rationale, and reasoning portions of the FAVRES. And the scores on the FAVRES were mostly consistent with the results of the flanker test and self-reported symptoms (worse symptoms, worse FAVRES score).

Sounds promising. Why the caution? 

  • 20% of the non-brain injured bilingual controls also fell at or below the FAVRES cutoff for brain injury. Not good. Especially because these are all college students, who are presumably functioning at a pretty high level. Therefore, expect that the FAVRES may make your bilingual patients look worse than they really are.

  • The mTBI group in this study may not have the same kind of bilingual background as your bilingual patients with mTBI. Unlike the bilingual control group, the participants with mTBI were mainly native English speakers with lower Spanish proficiency. Bilingualism and being a non-native speaker of the test language could potentially have two separate effects on EF and test performance. Statistically, the history of brain injury—not the language profile—predicted lower test scores on the FAVRES. But, we don’t know quite how the results might be different with a larger, more diverse bilingual mTBI group.


Despite its limitations, this study provides enough evidence to support using the FAVRES as one tool to assess EF strengths and weaknesses in your bilingual patients with mTBI. Just remember to think twice before comparing their scores with the monolingual norms—particularly if your patients are non-native English speakers.


Ratiu, I., & Azuma, T. (2019). Assessment of executive function in bilingual adults with history of mild traumatic brain injury. Brain Impairment. doi:10.1017/BrImp.2019.17