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Pragmatic performance and functional communication in adults with aphasia.


This study used linear regression Linear regression

A statistical technique for fitting a straight line to a set of data points.
 to define the relationship between pragmatic performance and functional communication by 27 individuals with aphasia aphasia (əfā`zhə), language disturbance caused by a lesion of the brain, making an individual partially or totally impaired in his ability to speak, write, or comprehend the meaning of spoken or written words. , including 14 with fluent aphasia Noun 1. fluent aphasia - aphasia characterized by fluent but meaningless speech and severe impairment of the ability understand spoken or written words
impressive aphasia, receptive aphasia, sensory aphasia, Wernicke's aphasia
 and 13 with non-fluent aphasia. Pragmatic performance was measured with the Pragmatic Protocol. Functional communication was measured using the ASHA Functional Assessment of Communication Skills (ASHA FACS FACS Fellow of the American College of Surgeons.

Fellow of the American College of Surgeons


fluorescence-activated cell sorter.
). Results provide support for the relationship between these variables and for their underlying link to linguistic competence. Nonetheless, standard language assessment (Western Aphasia Battery The Western Aphasia Battery or WAB is an instrument for assessing the language function of adults, able to discern the presence, degree, and type of aphasia. Another such test is the Boston Diagnostic Aphasia Examination. ) appears insufficient for describing overall communicative com·mu·ni·ca·tive  
1. Inclined to communicate readily; talkative.

2. Of or relating to communication.

 competencies and for explaining differences between some participants' functional communication abilities. Implications for assessment and treatment of communicative effectiveness are discussed.

Keywords: Aphasia Pragmatics pragmatics

In linguistics and philosophy, the study of the use of natural language in communication; more generally, the study of the relations between languages and their users.
 Functional Communication.


With any type of disorder, different assessment measures can be, and have been, constructed to assess different aspects of behavior. For example, numerous assessments for aphasia currently exist. Some assessments, such as the Western Aphasia Battery (WAB WAB Windows Address Book (file extension for Microsoft Outlook and Exchange)
WAB Western Academy of Beijing
WAB Westinghouse Air Brake Technologies Corp.
) (Kertesz, 1982) or the Boston Diagnostic Aphasia Examination The Boston Diagnostic Aphasia Examination or BDAE is a test used to evaluate adults suspected of having aphasia, and is currently in its third edition. It was created by Harold Goodglass and Edith Kaplan.  (Goodglass & Kaplan, 1983) purport To convey, imply, or profess; to have an appearance or effect.

The purport of an instrument generally refers to its facial appearance or import, as distinguished from the tenor of an instrument, which means an exact copy or duplicate.

PURPORT, pleading.
 to assess type and severity of aphasia. Other assessment tools focus on different aspects of communication. The Pragmatic Protocol (Prutting & Kirchner, 1983), for example, examines communication from an entirely different perspective.

Pragmatics is the study of the relationship between language behavior and the contexts in which language is used (Prutting & Kirchner, 1983). It involves the acquisition and use of conversational knowledge and the semantic See semantics. See also Symantec.  rules necessary to communicate intent. In addition, pragmatics involves the interactional aspects of communication, including sensitivity to social contexts (Chapey, 1992). Specific pragmatic aspects investigated in adults with aphasia include communication acts (Gurland, Chwat, & Wollner, 1982; Wambaugh, Thompson Thompson, city, Canada
Thompson, city (1991 pop. 14,977), central Man., Canada, on the Burntwood River. A mining town, it developed after large nickel deposits were discovered in the area in 1956.
, Doyle, & Camarata, 1991), speech acts (Doyle, Thompson, Oleyar, Wambaugh, & Jackson Jackson.

1 City (1990 pop. 37,446), seat of Jackson co., S Mich., on the Grand River; inc. 1857. It is an industrial and commercial center in a farm region.
, 1994; Prinz, 1980; Wilcox & Davis, 1977), discourse analysis Discourse analysis (DA), or discourse studies, is a general term for a number of approaches to analyzing written, spoken or signed language use.

The objects of discourse analysis—discourse, writing, , conversation, communicative event, etc.
 (Armstrong, 1987, 1991; Bottenberg & Lemme The Lemme is a 35 km torrent, a right tributary of the Orba, which flows through the Province of Alessandria in northern Italy.

Its source is near Monte Calvo; from there it passes through the communes of Fraconalto, Voltaggio, Carrosio, Gavi, San Cristoforo, Francavilla
, 1991; Guilford & O'Connor, 1982; Mentis & Prutting, 1987) and use of nonverbal communication nonverbal communication 'Body language', see there  (Behrmann & Penn, 1984; Cicone, Wapner, Foldi, Zurif, & Gardner, 1979; Glosser gloss 1  
1. A surface shininess or luster.

2. A superficially or deceptively attractive appearance.

v. glossed, gloss·ing, gloss·es
, Weiner, & Kaplan, 1986; May, David, & Thomas (language) Thomas - A language compatible with the language Dylan(TM). Thomas is NOT Dylan(TM).

The first public release of a translator to Scheme by Matt Birkholz, Jim Miller, and Ron Weiss, written at Digital Equipment Corporation's Cambridge Research Laboratory runs
, 1988). Researchers have investigated pragmatic performance in individuals with aphasia (Avent & Wertz, 1996; Holland, 1982; Prutting & Kirchner, 1987; Wilcox & Davis, 1977), and data suggest that individuals with aphasia maintain a high level of pragmatic appropriateness despite their linguistic impairments (Avent & Wertz, 1996; Prutting & Kirchner, 1987).

Another area of assessment for aphasia has been referred to as "functional communication." Functional communication is defined as "the ability to receive or convey a message, regardless of the mode, to communicate effectively and independently in a given [natural] environment" (p.2)(ASHA, 1990). While profiling specific pragmatic strengths and weaknesses may assist in identifying the nature and processes involved in "communication," a functional communication assessment should help to outline the consequences of the communication deficit in an individuals' daily interactions. For example, when assessing pragmatic ability with an instrument such as the Pragmatic Protocol (Prutting & Kirchner, 1987), speech act usage, turn-taking ability, and lexical lex·i·cal  
1. Of or relating to the vocabulary, words, or morphemes of a language.

2. Of or relating to lexicography or a lexicon.

[lexic(on) + -al1.
 selection categories may be rated as appropriate or inappropriate. Using a functional communication measure, such as the American Speech Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) (Frattali, Thompson, Holland, Wohl, & Ferketic, 1995), rather than profiling specific deficits, the overall quality of communication in "real-life" activities can be established, as well as the amount of assistance needed during these activities. Thus, ratings are made regarding specific daily activities such as "Participates in a group conversation," "Requests information of others," and "Initiates communication with other people."

Although assumptions regarding communicative effectiveness have been based on pragmatic analyses of conversation (e.g., Wambaugh et al., 1991; Wilcox & Davis, 1977), there is little empirical research Noun 1. empirical research - an empirical search for knowledge
inquiry, research, enquiry - a search for knowledge; "their pottery deserves more research than it has received"
 suggesting how pragmatic performance actually relates to functional communication. At first glance, the literature regarding pragmatic performance and functional communication in adults with aphasia appears to indicate that these concepts are one and the same. In fact, as Irwin, Wertz, and Avent (2002) so appropriately noted, these terms are often used interchangeably INTERCHANGEABLY. Formerly when deeds of land were made, where there Were covenants to be performed on both sides, it was usual to make two deeds exactly similar to each other, and to exchange them; in the attesting clause, the words, In witness whereof the parties have hereunto  (Davis, 1993). However, as Murray Murray, river, Australia
Murray, principal river of Australia, 1,609 mi (2,589 km) long, rising in the Australian Alps, SE New South Wales, and flowing westward to form the New South Wales–Victoria boundary.
 and Chapey (2001) indicate, there are important distinctions between the two assessment approaches. Irwin, Wertz, and Avent (2002) concur CONCUR - ["CONCUR, A Language for Continuous Concurrent Processes", R.M. Salter et al, Comp Langs 5(3):163-189 (1981)]. , reporting that improvement on a pragmatic performance assessment is not significantly related to improvement on a functional communication assessment and that "these tests may measure different aspects of change in performance" (p.96). The authors report that both pragmatic performance and functional communication correlate well with language ability over time but that they do not correlate well with each other over time (i.e., pragmatics and functional communication do not correlate). Thus, these assessments seem to be measuring different underlying constructs. Although there are many overlapping variables within these components of communication, research has not fully demonstrated empirically how pragmatic performance relates to the ability of individuals with aphasia to communicate effectively and independently.

Breaking down aphasia performance into fluent fluent /flu·ent/ (floo´int) flowing effortlessly; said of speech.  versus non-fluent has not clarified these relationships. Holland (1980, 1982) reported that adults with non-fluent aphasia demonstrated a more 'normal' pattern of communication than adults with fluent aphasia. Busch, Brookshire, and Nicholas (1988) also found adults with non-fluent aphasia to be more efficient in communicating crucial information than adults with fluent aphasia. And, Behrmann and Penn (1984) reported more functional use of gestures in adults with non-fluent aphasia. These data suggest that we can at least feel comfortable stating that non-fluent aphasics are superior in terms of functional communication. On the other hand, standardization standardization

In industry, the development and application of standards that make it possible to manufacture a large volume of interchangeable parts. Standardization may focus on engineering standards, such as properties of materials, fits and tolerances, and drafting
 data for the ASHA FACS (Frattali et al., 1995), a functional communication measure, revealed that adults with fluent aphasia demonstrated a higher level of functional communication than adults with non-fluent aphasia. Some of the differences cited above would likely occur simply because different assessments of functional communication are employed. Still, concerns regarding the relationship between fluency flu·ent  
a. Able to express oneself readily and effortlessly: a fluent speaker; fluent in three languages.

 and functional communication appear valid.

Prutting and Kirchner (1987) used the Pragmatic Protocol to develop profiles of deficits for individuals with fluent and non-fluent aphasia. Deficits identified were related to the linguistic constraints CONSTRAINTS - A language for solving constraints using value inference.

["CONSTRAINTS: A Language for Expressing Almost-Hierarchical Descriptions", G.J. Sussman et al, Artif Intell 14(1):1-39 (Aug 1980)].
 characteristic of each aphasia subtype (programming) subtype - If S is a subtype of T then an expression of type S may be used anywhere that one of type T can and an implicit type conversion will be applied to convert it to type T. . The majority of inappropriate behaviors for both groups were in the categories of specificity/accuracy, fluency, pause time in turn-taking, and quantity/conciseness. Participants with non-fluent aphasia had more difficulty with pause time in turn-taking and quantity/conciseness than the participants with fluent aphasia. Avent and Wertz (1996) reported no significant differences between adults with fluent aphasia and adults with non-fluent aphasia with regard to pragmatic performance, but did observe that adults with fluent aphasia performed slightly better than adults with non-fluent aphasia. Participants with fluent aphasia, however, entered therapy with a higher level of pragmatic performance.

If pragmatic performance is indicative of an individual with aphasia's functional communication, then similar ratings would be expected on both a pragmatic performance assessment and a functional communication assessment, regardless of fluency. Research has not addressed the interaction of these two variables. If, on the whole, individuals with non-fluent aphasia are considered to be better functional communicators and individuals with fluent aphasia are better or at least equal pragmatically prag·mat·ic  
1. Dealing or concerned with facts or actual occurrences; practical.

2. Philosophy Of or relating to pragmatism.

, then an examination of the relationship between pragmatics and functional communication in relationship to language impairment Impairment

1. A reduction in a company's stated capital.

2. The total capital that is less than the par value of the company's capital stock.

1. This is usually reduced because of poorly estimated losses or gains.

 is warranted. Pragmatic performance is often a target in treatment of aphasia. The relationship between one's ability to "understand" the rules of language (pragmatics) and implement the rules of language successfully (functionally communicate) speaks directly to appropriate treatment goals. If functional communication is independent of pragmatic performance, then treating pragmatics may not be the most valuable use of treatment time and dollars. The purpose of this study was to examine the relationship between pragmatic performance and functional communication in light of severity of language impairment and fluency. In doing so, the following questions were posed: 1) Is there a relationship between pragmatic performance and functional communication?; 2) How well do measures of functional communication and pragmatic performance predict type of aphasia (fluent vs. non-fluent)?; and 3) How well do measures of functional communication and pragmatic performance predict the severity of aphasia (mild-moderate or moderate-severe)?



Twenty-seven individuals with aphasia (14 fluent and 13 non-fluent), who had suffered a single, left-hemisphere stroke participated in this study. All participants met the following inclusion criteria
For Wikipedia's inclusion criteria, see: What Wikipedia is not.

Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial.
: 1) English speaker; 2) at least two months post-onset to insure Insure can mean:
  • To provide for financial or other mitigation if something goes wrong: see insurance or .
  • Or you may be looking for ensure or inshore.
 medical stability and to allow for adjustment to the aphasia; 3) no evidence of additional neurologic neurologic /neu·ro·log·ic/ (-loj´ik) pertaining to neurology or to the nervous system.
Having to do with the nervous system.
 disorders (e.g., dementia dementia (dĭmĕn`shə) [Lat.,=being out of the mind], progressive deterioration of intellectual faculties resulting in apathy, confusion, and stupor. In the 17th cent. , Parkinson's disease Parkinson's disease or Parkinsonism, degenerative brain disorder first described by the English surgeon James Parkinson in 1817. When there is no known cause, the disease usually appears after age 40 and is referred to as Parkinson's disease. ); 4) no evidence of psychiatric psy·chi·at·ric
Of or relating to psychiatry.

psychiatric adjective Pertaining to psychiatry, mental disorders
 disorder (as reported by caregiver care·giv·er
1. An individual, such as a physician, nurse, or social worker, who assists in the identification, prevention, or treatment of an illness or disability.

); and 5)completion of an audiometric au·di·om·e·ter  
An instrument for measuring hearing activity for pure tones of normally audible frequencies. Also called sonometer.



For the purpose of this study, pragmatic performance was defined by an overall percentage of pragmatically "appropriate" parameters according to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 the Pragmatic Protocol (Prutting & Kirchner, 1987). The Pragmatic Protocol is a reliable measure and has been widely used to profile the pragmatic performance of adults with aphasia (Roberts & Wertz, 1993; Avent & Wertz, 1996). Functional communication was defined by overall quantitative and qualitative ratings from the ASHA FACS (Frattali et al., 1995). The Western Aphasia Battery (WAB) (Kertesz, 1982) was used to determine type and severity of aphasia. Descriptive information for individual participants is provided in Table 1. Descriptive data for participants classified by type of aphasia (fluent and non-fluent) are provided in Table 2; and descriptive data for participants classified by severity are provided in Table 3.

Participant Assessment

Participation involved one experimental session lasting approximately 1-11/2 hours and two additional observation sessions lasting approximately 1-11/2 hours each. The initial experimental sessions were conducted in the participants' homes and included administration of portions of the Western Aphasia Battery (Kertesz, 1982) necessary to obtain an aphasia quotient quotient - The number obtained by dividing one number (the "numerator") by another (the "denominator"). If both numbers are rational then the result will also be rational.  (AQ), a fluency classification, an audiometric screening, and an informal 15-20 minute conversation between the participant and principal investigator Noun 1. principal investigator - the scientist in charge of an experiment or research project

scientist - a person with advanced knowledge of one or more sciences
. Work history and illness were the targeted topics for conversation because they have been found to yield the most complex language (Glosser, Weiner, & Kaplan, 1988). Alternative conversational topics included recent activities, interests, recent life changes, education, and family. Open-ended requests (e.g., "Tell me about your family."), as opposed to yes-no questions Noun 1. yes-no question - a question that can be answered by yes or no
interrogation, interrogative, interrogative sentence, question - a sentence of inquiry that asks for a reply; "he asked a direct question"; "he had trouble phrasing his interrogations"
, were employed (Terrell & Ripich, 1989). The principal investigator attempted to keep the topics and the form of the conversations similar for all participants; however, the exact content of the conversation depended largely on the participant. All experimental sessions were videotaped for data analysis.

Observational sessions of the participants during everyday activities allowed the principal investigator to observe a representative sample of the individual with aphasias' communicative abilities in typical interactions. Activities observed included attending church, therapy, grocery shopping, and swimming class. The additional observation sessions were necessary to complete the ASHA FACS and were not videotaped.

Pragmatic Performance: Pragmatic aspects of language were analyzed an·a·lyze  
tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es
1. To examine methodically by separating into parts and studying their interrelations.

2. Chemistry To make a chemical analysis of.

 for each participant using the Pragmatic Protocol (Prutting & Kirchner, 1987). This protocol measures 30 pragmatic aspects of language use including verbal (e.g., speech act usage, turn-taking, topic maintenance/initiation), paralinguistic par·a·lin·guis·tic  
Of or relating to paralanguage or its study.

 (e.g., prosody prosody: see versification.

Study of the elements of language, especially metre, that contribute to rhythmic and acoustic effects in poetry.
, vocal quality/intensity), and nonverbal non·ver·bal  
1. Being other than verbal; not involving words: nonverbal communication.

2. Involving little use of language: a nonverbal intelligence test.
 (e.g., facial expression facial expression,
n the use of the facial muscles to communicate or to convey mood.
, eye gaze, gestural usage) parameters. Each of the pragmatic parameters was rated as "appropriate," "inappropriate," or "no opportunity to observe." Appropriate ratings were defined as behaviors that facilitated the communicative interaction. Inappropriate ratings were defined as behaviors that detracted from the communicative interaction and penalized pe·nal·ize  
tr.v. pe·nal·ized, pe·nal·iz·ing, pe·nal·iz·es
1. To subject to a penalty, especially for infringement of a law or official regulation. See Synonyms at punish.

 the individual (Prutting & Kirchner, 1987). The percentage of appropriate parameters was then computed and used to determine overall pragmatic appropriateness.

Functional Communication: Functional communication abilities were analyzed using the American Speech-Language-Hearing Association The American Speech-Language-Hearing Association (ASHA) is a professional association for speech-language pathologists, audiologists, and speech, language, and hearing scientists in the United States and internationally.  Functional Assessment of Communication Skills for Adults (ASHA FACS) (Frattali et al., 1995). The ASHA FACS, which has undergone extensive research and standardization procedures, measures an individual's ability to receive and convey messages effectively and independently, regardless of the mode of communication, in natural contexts. This assessment evaluates how a deficit (e.g., aphasia) affects one's ability to communicate in daily life activities. Forty-three behaviors are assessed across four domains: Social Communication; Communication of Basic Needs; Reading, Writing, and Number Concepts; and Daily Planning. Within each domain, specific functional behaviors are rated both quantitatively and qualitatively. The 7-point quantitative scale measures functional communication performance along a continuum Continuum (pl. -tinua or -tinuums) can refer to:
  • Continuum (theory), anything that goes through a gradual transition from one condition, to a different condition, without any abrupt changes or "discontinuities"
 of independence relating to relating to relate prepconcernant

relating to relate prepbezüglich +gen, mit Bezug auf +acc 
 levels of assistance and/or prompting needed to communicate. The 5-point qualitative scale measures a range of response dimensions (i.e., adequacy, appropriateness, promptness, and communication sharing) that characterize the individual's communication abilities for each assessment domain addressed. The ASHA FACS employs an observation format in which ratings are based on either the clinician's direct observations or observations made by others who are familiar with the individual with aphasia. The observation allows the clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher.

 to make judgments based on interactions that take place in the individual with aphasia's daily life rather than on artificial testing situations set up by the clinician.

Data Analysis

A standard multiple linear regression analysis was used to answer the research questions. Unless there is a reason to suppose that experimental variables are related in a nonlinear A system in which the output is not a uniform relationship to the input.

nonlinear - (Scientific computation) A property of a system whose output is not proportional to its input.
 fashion, it is common practice to use linear regression as a tool to determine whether the variables are statistically related. Linear regression relates a single dependent variable, such as a fluency rating, to one or more independent variables, such as pragmatic performance and functional communication ability. It is assumed that a constant difference in an independent variable is associated with a constant difference in the dependent variable. Therefore, linear regression can indicate which variables are significantly related to one another as well as the relative sizes of the effects. The .05 level of significance was used for all tests. Bonferroni corrections In statistics, the Bonferroni correction states that if an experimenter is testing n independent hypotheses on a set of data, then the statistical significance level that should be used for each hypothesis separately is 1/n  were used to control the experiment-wise error rate in correlation matrices. Normal quantile quantile

division of a total into equal subgroups; includes terciles, quartiles, quintiles, deciles, percentiles.
 quantile plots were used to verify (1) To prove the correctness of data.

(2) In data entry operations, to compare the keystrokes of a second operator with the data entered by the first operator to ensure that the data were typed in accurately. See validate.
 that the variables used in correlations and the regression regression, in psychology: see defense mechanism.

In statistics, a process for determining a line or curve that best represents the general trend of a data set.
 residuals were normally distributed.


Intra- and Inter-judge Agreement

Intra- and inter-judge agreements were determined for both the Pragmatic Protocol and the ASHA FACS. Intra-judge agreement was determined by having the principal investigator re-score the Pragmatic Protocol and the ASHA FACS for five randomly selected participants. The principal investigator viewed the videotapes of the conversation samples and completed a second Pragmatic Protocol without access to the original ratings. Percent agreement between the principal investigator's first and second ratings was 95.5%. The principal investigator completed a second ASHA FACS within two weeks of the original rating. Percent agreement between the principal investigator's first and second ratings was 95.7%.

Inter-judge agreement for the Pragmatic Protocol and the ASHA FACS was determined for 6 of the 27 participants. These 6 participants were selected randomly. The second judge was a graduate student in speech-language pathology pathology, study of the cause of disease and the modifications in cellular function and changes in cellular structure produced in any cell, organ, or part of the body by disease.  with experience working with individuals with aphasia prior to and throughout her graduate training. The second judge trained to criterion for all measures prior to the initiation of the study. She viewed the videotapes of all six samples and completed an independent Pragmatic Protocol for each. Comparisons were then made between these ratings and the original ratings made by the principal investigator. Inter-judge percent agreement for the Pragmatic Protocol was 92.1%. The second judge also observed the six participants during the three scheduled sessions in order to complete the ASHA FACS. Inter-judge percent agreement for the ASHA FACS was 92.4%.

Pragmatics and Functional Communication

The answer to the first research question, "Is there a relationship between pragmatic performance and functional communication?" is yes. The correlations calculated for the regression model were examined. The variables included were the percentage of appropriate pragmatic parameters calculated for the Pragmatic Protocol (Prutting & Kirchner, 1987) and both of the overall ratings (qualitative and quantitative) provided by the ASHA FACS (Frattali et al., 1995). Results are presented in Table 4. A Bonferroni correction was applied to the alpha level and all three correlations were significant at the .05/3=.017 level, indicating a strong relationship (r = .838 to .916) between pragmatics and functional communication, at least as they are defined by the Pragmatic Protocol and ASHA FACS.

To answer the second question, "How well do measures of functional communication and pragmatic performance predict type of aphasia (fluent vs. non-fluent)?", standard linear regression analysis was used to examine the relationship between fluency type, as measured by the fluency subscale of the WAB, the two functional communication ratings, and pragmatic performance. To control for the fact that two regressions were performed (fluency and severity), a .05/2 or .025 level of significance was used. For both models, the influence diagnostics (1) Software routines that test hardware components (memory, keyboard, disks, etc.). Diagnostics are often stored in ROM chips and activated on startup.

(2) Error messages in a programmer's source code that refer to statements or syntax that the compiler or assembler
 Cook's D and DFBETA were examined and no participants were found to have undue influence on the model. Residuals were examined and found to be normally distributed.

For fluency, the overall model was significant F(3,23)=5.212, p=.007 and explained 40.5% of the variance The discrepancy between what a party to a lawsuit alleges will be proved in pleadings and what the party actually proves at trial.

In Zoning law, an official permit to use property in a manner that departs from the way in which other property in the same locality
. However, the partial t-tests for the quantitative and qualitative measures of the ASHA FACS were not significant, indicating that they provided redundant information. This was not surprising since they were highly correlated cor·re·late  
v. cor·re·lat·ed, cor·re·lat·ing, cor·re·lates
1. To put or bring into causal, complementary, parallel, or reciprocal relation.

. Strong correlations between independent variables (i.e., Pragmatic Protocol and ASHA FACS) often indicate multicollinearity. Since the quantitative measure of the ASHA FACS was the least significant, it was dropped from the equation. The resulting model still explained a significant 39.7% of the variance in fluency F (2,24)=7.898, p=.002. Partial t-tests showed a significant result for the Pragmatic Protocol rating, t=3.49, p=.002 and a marginally useful level for the qualitative measure of the ASHA FACS, t=1.89, p=.070. Since dropping the qualitative measure resulted in a drop in variance of 9%, it was left in the model. The final regression equation Regression equation

An equation that describes the average relationship between a dependent variable and a set of explanatory variables.
 was fluency=-.276+.158(Pragmatic Protocol)1.819(qualitative) (see Table 5). Thus, the Pragmatic Protocol explained most of the variability in fluency while the ASHA FACS was found to only provide redundant information.

In order to answer the third research question, "How well do measures of functional communication and pragmatic performance predict the severity of aphasia (mild-moderate or moderatesevere)?", the same type of regression was employed--this time examining the relationship between the same independent variables and severity of impairment (as measured by the WAB). The overall model for severity of impairment (WAB AQ) was significant F(3,23)=24.56, p<.001 and explained 76% of the variance in severity. Again, the partial t-tests for the quantitative and qualitative measures failed to reach statistical significance, thus indicating that they provided redundant information. Since the quantitative measure of the ASHA FACS was the least significant, it was dropped from the equation first. In the resulting model, the qualitative measure of the ASHA FACS was still not significant so it too was dropped from the equation. The final regression equation contained only the Pragmatic Protocol and explained a significant 75% of the variance in severity, F (1,25)=73.39, p<.001. The equation itself was Severity (WAB) =-42.86+1.25(Pragmatic Protocol) (see Table 6). Thus, the Pragmatic Protocol explained most of the variability in severity while the ASHA FACS was found to only provide redundant information.


The purpose of the present study was to investigate the relationship between pragmatic performance and functional communication. To do this with any relevance, this study also had to examine how well measures of pragmatic performance and functional communication ability predict the type (fluent or non-fluent) and severity of aphasia.

Pragmatic performance, as measured by the Pragmatic Protocol (Prutting & Kirchner, 1987), was found to have a strong, positive correlation Noun 1. positive correlation - a correlation in which large values of one variable are associated with large values of the other and small with small; the correlation coefficient is between 0 and +1
direct correlation
 with functional communication, as measured by the ASHA FACS (Frattali et al., 1995). The most obvious common denominator common denominator
1. Mathematics A quantity into which all the denominators of a set of fractions may be divided without a remainder.

2. A commonly shared theme or trait.
 between pragmatic performance and functional communication, based on our results, appears to be severity of oral expressive language. In most instances, the higher the WAB aphasia quotient (i.e., severity of language impairment), the better the pragmatic performance and functional communication ratings. This is consistent with strong correlations. Other investigations have also reported that communicative performance (i.e., Pragmatic Protocol, ASHA FACS) correlates well with traditional language measures (Avent et al., 1998; Frattali et al., 1995; Irwin et al., 2002),). And while some investigations (Goldblum, 1985; Guilford & O'Connor, 1982; Penn, 1988) have demonstrated preserved pragmatic abilities with little correlation between traditional language measures and communicative performance, interpretation of pragmatic performance independent of oral-expressive language in this sample would be difficult. The number of pragmatic problems was clearly more abundant in the moderate-severe group than in the mild-moderate group. Moreover, the majority of the pragmatic problems recorded related to behaviors classified as "verbal aspects" in the Pragmatic Protocol.

Severity of impairment was found to be a stronger indicator of both pragmatic performance and functional communication than type of aphasia (fluent or non-fluent) in this study. However, severity of impairment within our sample could be a factor in that result, as well. Avent and Wertz (1996) reported that adults with fluent aphasia in their sample demonstrated a slightly higher level of pragmatic appropriateness than did adults with non-fluent aphasia. Although the differences in participants with fluent and non-fluent aphasia were minimal and no differences were observed between more specific types of aphasia, it is interesting to compare their observations to those of Holland (1980, 1982), who reported that adults with non-fluent aphasia demonstrated the most "normal" pattern of communication and were believed to be the most functionally communicative. Results from the current investigation revealed significant differences between fluent and non-fluent groups for pragmatic performance; but the fluent group, as a whole, was less severely impaired than the non-fluent group. Examining individual performance, differences were minimal in the number and type of inappropriate pragmatic behaviors displayed between the fluent and non-fluent subjects within each severity level.

Does this mean that pragmatic performance and functional communication are synonymous (Davis, 1993) and that any differences are based entirely on severity of aphasia? No. Our results demonstrate that pragmatic performance is very predictive of severity of aphasia and type of aphasia. Functional communication, however--at least as it is defined by the ASHA FACS--did not contribute to or explain any of the variability in type or severity of aphasia. Thus, despite its strong correlation with pragmatic performance, differences must exist in what measures of functional communication actually assess. This supports the findings of Irvin, Wertz, and Avent (2002) that assessments of pragmatic performance and functional communication measure different underlying constructs. They observed more variances in the two measures over time than in initial assessments of individuals with aphasia.

While one may on the surface see that correlations exist (albeit some stronger than others) between linguistic severity, pragmatics, and functional communication, examining differences between participants on a more individual level can provide, perhaps, a more pragmatic endpoint. Traditional language testing (e.g., WAB) did not capture all of the communicative competencies observed. For the most part, participants with better linguistic skills performed better pragmatically. However, in participants with similar linguistic ability or severity of impairment (i.e., similar WAB aphasia quotient), variances in pragmatic performance appeared to correlate better with variances in functional communication. For example, Participants #1 and #24 presented with similar aphasia quotients (45.3 and 45 respectively). However, participant #1 received a rating of pragmatically appropriate behaviors that was 23 percentage points higher on the Pragmatic Protocol, and he received much higher ratings on the quantitative and qualitative portions of the ASHA FACS. His superior ability to convey intentions and attitudes may influence his communicative effectiveness and independence in the absence of superior linguistic competence. This is what Holland (1977) meant when she stated that "aphasics probably communicate better than they talk" (p. 173). Thus, evaluation with the WAB alone would provide a much worse prognosis prognosis /prog·no·sis/ (prog-no´sis) a forecast of the probable course and outcome of a disorder.prognos´tic

n. pl. prog·no·ses
 for that individual than would be provided by an assessment of pragmatic performance and functional communication.

Other participants with moderate to severe impairments also performed much better than expected based on their linguistic deficits. Although no single factor was significant for producing variability, different factors could produce changes in communicative competence Communicative competence is a linguistic term which refers to a learner's L2 ability. It not only refers to a learner's ability to apply and use grammatical rules, but also to form correct utterances, and know how to use these utterances appropriately.  for different individuals without showing statistical significance. For example, although time-post onset was not significantly correlated with pragmatic performance or functional communication, it is important to note that Participant #1 was approximately eight years and five months further post-onset than Participant #24. Thus, individuals with aphasia may continue to show improvement in pragmatic abilities and acquire strategies necessary for successful functional communication despite relatively little improvement in linguistic skills over time. This is consistent with the results of Avent et al. (1998), who also reported that even though there is a relationship between language impairment and pragmatic behavior, improvement in pragmatic performance is not necessarily related to improvement in language ability. Further research is necessary to examine the influence of time-post onset on linguistic competence, pragmatic performance, and functional communication.

The close alignment of pragmatics and functional communication in the absence of linguistic competence could also be influenced by several other factors including: a) age, b) communicative environment, and c) ability to read and write. For example, Participant #13 presented with an aphasia quotient that was clinically similar to Participant #20, but performed much worse on the Pragmatic Protocol and the ASHA FACS. Upon further examination of the data, several potential factors were identified that could enhance Participant #20's communication abilities. First, Participant #20 was 22 years younger than Participant #13. Although no significant correlations were found between age and the measures employed, age has been previously identified as a variable affecting prognosis (Davis, 1993). Secondly, Participant #13 was essentially confined con·fine  
v. con·fined, con·fin·ing, con·fines
1. To keep within bounds; restrict: Please confine your remarks to the issues at hand. See Synonyms at limit.
 to bed due to physical limitations, whereas Participant #20 was able to drive a car (with modifications) and do some light shopping on her own. Thus, Participant #20 had the opportunity to engage in a variety of communicative interactions, whereas Participant #13's communicative environment was limited to two aides that stayed with her in her home. Finally, Participant #20's reading and writing skills were far superior to Participant #13's, allowing her to use a communication notebook independently.

While functional communication and pragmatic performance correlate in many patients despite linguistic severity, there are also patients in whom none of the measures seem to align align (līn),
v to move the teeth into their proper positions to conform to the line of occlusion.
. Some researchers have stressed the importance of situational context (the physical environment, communication partners, sociolinguistic so·ci·o·lin·guis·tics  
n. (used with a sing. verb)
The study of language and linguistic behavior as influenced by social and cultural factors.

 considerations, etc.) (Ferguson, 1994; Holland, 1991; Lyon Lyon
 English Lyons

City (pop., 1999: city, 445,452; metro. area, 1,348,932), east-central France. Located at the confluence of the Rhône and Saône rivers, it was founded as the Roman military colony Lugdunum in 43 BC (see
, 1992) and it does appear to be relevant to the previous example. However, for other participants in this study (#16 and #18), good environments for promoting communication (i.e., strong family support, ongoing language therapy, opportunities for varied communicative experiences) were not sufficient to overcome severe linguistic deficits. In these participants pragmatic performance was much better than linguistic skill, but their functional communication remained severely limited; thus, the need for "evaluation in natural contexts" (Ferguson, 1994; Holland, 1982) and using measures such as the Pragmatic Protocol and the ASHA FACS to assess quality of communication, as well as traditional measures of linguistic severity.

While this investigation focused on assessment of pragmatic performance and functional communication, implications for treatment should be considered. While pragmatics appears to have a relationship to functional communication, much of the relationship is tied to linguistic competence, especially when time post-onset is relatively short. Thus, early on, evaluating patients with traditional language measures, such as the WAB or the BDAE BDAE Boston Diagnostic Aphasia Examination
BDAE Bund der Auslands-Erwerbstätigen
 may be most appropriate. Such examinations provide information on linguistic severity and, especially with the BDAE, provide information on where to initiate treatment of auditory auditory /au·di·to·ry/ (aw´di-tor?e)
1. aural or otic; pertaining to the ear.

2. pertaining to hearing.

 comprehension comprehension

Act of or capacity for grasping with the intellect. The term is most often used in connection with tests of reading skills and language abilities, though other abilities (e.g., mathematical reasoning) may also be examined.
 and verbal expression Noun 1. verbal expression - the communication (in speech or writing) of your beliefs or opinions; "expressions of good will"; "he helped me find verbal expression for my ideas"; "the idea was immediate but the verbalism took hours"
verbalism, expression
. Improving linguistic competence during the period of spontaneous recovery The introduction to this article provides insufficient context for those unfamiliar with the subject matter.
Please help [ improve the introduction] to meet Wikipedia's layout standards. You can discuss the issue on the talk page.
 may be most beneficial, since pragmatics and functional communication are both related to linguistic competence and may continue to emerge.

After spontaneous recovery has slowed and individuals are unable to make substantive gains in linguistic competence, improvements may still be made in treatment by targeting "functional communication," or communication in natural contexts. Gains may be more likely when training someone to specifically function within their own communicative environment, a task which may be too difficult to undertake in the constraints of acute care or rehab. But teaching strategies to establish communicative intent and to "get the point across" in the context of daily activities may move a patient's skills beyond the limitations of linguistic competency COMPETENCY, evidence. The legal fitness or ability of a witness to be heard on the trial of a cause. This term is also applied to written or other evidence which may be legally given on such trial, as, depositions, letters, account-books, and the like.
. While many "pragmatic" behaviors are tied to verbal or linguistic competence, working in the realm of the more non-verbal areas of pragmatics (i.e., eye contact, turn taking, body language) may be very functional in getting across one's message.


Though common sense may suggest that pragmatic performance and functional communication are related to each other and to linguistic competence, different assessments are designed and marketed to test each separately. This investigation examined these relationships and the results provide empirical support for the different types of assessment. Based on the current data, it appears that linguistic competence is an underlying factor influencing the relationship between pragmatic performance and functional communication. Communication includes both linguistic competence and pragmatic competence, and, in most cases, linguistic competence appears to be inseparable in·sep·a·ra·ble  
1. Impossible to separate or part: inseparable pieces of rock.

2. Very closely associated; constant: inseparable companions.
 from the ability to communicate functionally and in a pragmatically appropriate way. Despite the strong relationship among these communicative parameters, tests designed to examine severity of linguistic impairment (i.e., WAB), while valuable, provide an incomplete description of the individual with aphasia's communication ability. Observations made in natural communicative environments were important for identifying communicative strengths. This is evidenced by a number of participants whose pragmatic performance and functional communication abilities were different despite having similar WAB aphasia quotients, especially those who were further post-onset and had different opportunities for communication.

Continued research is needed to determine how specific aspects of pragmatic behavior influence specific domains of functional communication. Further investigation is also needed to determine whether tools such as the Pragmatic Protocol and the ASHA FACS are more sensitive to changes over time in communication skills than traditional standardized standardized

pertaining to data that have been submitted to standardization procedures.

standardized morbidity rate
see morbidity rate.

standardized mortality rate
see mortality rate.
 measures (e.g., WAB). Avent and Wertz (1996) reported that pragmatic performance does improve. Functional communication measures such as the ASHA FACS can do more than measure impairment and function. They can provide the clinician with a view of aphasia from the patient's perspective, a means of appreciating the person's daily struggle in adapting to a new life that has been imposed upon them. They can be used to assist in developing meaningful goals, assessing the outcomes of rehabilitation rehabilitation: see physical therapy. , and in documenting multidimensional mul·ti·di·men·sion·al  
Of, relating to, or having several dimensions.

 benefits of therapy. It is yet to be determined if individuals with aphasia can be taught to utilize preserved pragmatic performance to improve functional communication or whether time and/or environment may, alone, be the true therapists.


American Speech-Language-Hearing Association. (1990, May). Functional communication measures project. Rockville, MD: Author.

Armstrong, E. (1987). Cohesive cohesive,
n the capability to cohere or stick together to form a mass.
 harmony in aphasic a·pha·sia  
Partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain caused by injury or disease.
 discourse and its significance to listener perception of coherence coherence, constant phase difference in two or more Waves over time. Two waves are said to be in phase if their crests and troughs meet at the same place at the same time, and the waves are out of phase if the crests of one meet the troughs of another. . In R. H. Brookshire (Ed.), Clinical Aphasiology aphasiology /apha·si·ol·o·gy/ (ah-fa?ze-ol´ah-je) the scientific study of aphasia and the specific neurologic lesions producing it.

The study of aphasia.
: Conference proceedings (pp. 210-215). Minneapolis, MN: BRK BRK Break
BRK Broken (meteorological, cloud cover)
BRK Bayerisches Rotes Kreuz (Bavarian Red Cross)
BRK Berkshire Hathaway (stock symbol)
BRK Brick

Armstrong, E. M. (1991). The potential of cohesion cohesion: see adhesion and cohesion.
Cohesion (physics)

The tendency of atoms or molecules to coalesce into extended condensed states. This tendency is practically universal.
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The International Clinical Phonetics and Linguistics Association is the unofficial organisation of the field, and was formed
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linguistics - the scientific study of language
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Of or relating to the structure, organization, or functioning of society.

so·cie·tal·ly adv.

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Any of various disorders, such as stuttering or perseveration, characterized by impaired written or verbal expression.
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In 1997, the UNMC hospital merged with the nearby hospital operated by Clarkson College to become what was later renamed The Nebraska Medical Center.

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New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of
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Author contact information:

Gary H. McCullough, Ph.D.

Department of Speech-Language Pathology

University of Central Arkansas The University of Central Arkansas is a state-run institution located in the city of Conway, the seat of Faulkner County, north of Little Rock. The school is most respected for its programs in Education, Occupational Therapy, and Physical Therapy.  

201 Donaghey Avenue

Box 4895

Conway, AR 72035-0001

Phone: (501) 852-7886

Email :

Jacki L. Ruark

Department of Speech-Language Pathology

University of Central Arkansas

201 Donaghey Avenue

Box 4895

Conway, AR 72035-0001

Phone: (501) 450-3310

Email :

Jacqueline Rainey, Dr. PH

Associate Dean

College of Health and Behavioral Sciences behavioral sciences, those sciences devoted to the study of human and animal behavior.

University of Central Arkansas

Doyne Health Science Center 104

Conway, AR 72035-0001

Phone: (501) 450-5509

Table  1 Descriptive Data for Individual

Subject     Gender      Age      Education

   1          M          76         16
   2          F          65         16
   3          M          60         16
   4          F          78         12
   5          M          46         12
   6          M          69         14
   7          F          39         13
   8          F          38         12
   9          M          76         12
   10         M          54         12
   11         F          70         15
   12         F          79         12
   13         F          79         12
   14         M          66          8
   15         F          65          6
   16         M          68         16
   17         F          83         18
   18         M          64          9
   19         F          70         12
   20         F          57         18
   21         M          77         14
   22         M          65         12
   23         F          74         13
   24         M          60          9
   25         M          70         11
   26         F          56         16
   27         M          48         12

Subject        MPO         AQ      Fluency

   1          114.0       45.3      NF
   2          202.0       73.4      NF
   3            3.0       82.4       F
   4            2.0       64.6       F
   5           59.0       68.5       F
   6            7.0       88.5       F
   7          131.0       88.9       F
   8          120.0       67.7      NF
   9            6.0       78.7       F
   10         108.0       15.3      NF
   11          91.0       57.6      NF
   12           3.0       35.6       F
   13          15.0       27.4      NF
   14           8.0       16.6       F
   15          10.0       12.4      NF
   16          60.0        7.7      NF
   17          24.0       58.9       F
   18           9.0       10.4      NF
   19           2.0       20.3      NF
   20          87.0       20.6      NF
   21           7.0       89.3       F
   22          23.0       72.9       F
   23          72.0       39.4       F
   24           7.0         45       F
   25           2.0       81.1       F
   26          26.0       61.4      NF
   27           4.0       69.0      NF

Subject       PP        CIDS       CQDS

   1        68.96       4.28       3.13
   2        93.00       6.70       4.38
   3        93.00       6.49       4.56
   4        80.00       3.98       2.50
   5        86.00       5.73       3.80
   6       100.00       6.27       4.56
   7        96.00       6.60       4.56
   8        86.00       5.78       3.98
   9        89.00       6.21       4.40
   10       55.60       4.88       4.06
   11       82.80       6.54       4.44
   12       68.90       3.37       2.38
   13       41.38       2.97       2.94
   14       41.38       2.67       1.73
   15       48.20       2.98       2.63
   16       48.27       2.70       2.56
   17       86.20       5.21       3.88
   18       51.70       2.55       2.13
   19       69.00       3.82       3.06
   20       75.70       5.92       3.44
   21      100.00       6.91       4.88
   22       86.20       5.85       4.00
   23       89.65       5.64       3.69
   24       45.00       2.90       2.40
   25       93.00       6.56       4.50
   26       79.30       5.10       3.69
   27       86.00       6.10       4.33

Age and Education are reported in years.
MPO = months post onset
AQ = aphasia quotient (based on administration
of the Western Aphasia Battery
F = fluent aphasia, NF = non-fluent aphasia
PP = pragmatic protocol
CIDS = quantitative score of ASHA FACS
QDSC = qualitative score of ASHA FACS

Table 2. Descriptive Data for participants
classified by type of aphasia

Variable             Fluent Aphasia         Non-Fluent
                     (N=14)                 Aphasia (N=13)

Age (years)
Mean                 67.5                   62.3
Standard deviation   12.7                   11.43
Range                39.0 to 83.0           38.0 to 79.0
MPO (months)
Mean                 25.4                   65.3
Standard deviation   37.4                   61.3
Range                2.5 to 131.1           2.5 to 202.0
Mean                 64.64                  37.57
Standard deviation   22.51                  25.26
Range                16.6 to 89.3           7.7 to 73.4

MPO = months post onset
WBA AQ = Aphasia quotient based on the
Western Aphasia Battery

Table 3. Descriptive Data for participants
classified by severity of impairment

Variable             Fluent Aphasia (N=14)  Non-Fluent Aphasia (N=13)
Age (years)
Mean                 62.8                   67.5
Standard deviation   14.5                   8.2
Range                38 ti 83               54 to 79
MPO (months)
Mean                 47.2                   41.3
Standard deviation   61.3                   43.8
Range                2.5 to 202             2.5 to 114
Mean                 73.5                   24.2
Standard deviation   10.8                   13.2
Range                57.6 to 89.3           7.70 to 45.3

MPO = months post onset
WBA AQ = Aphasia quotient based on the
Western Aphasia Battery

Table 4. Correlation results for Pragmatic
Protocol and ASHA FACS

                           PP        CIDS      QDSC
Pearson Correlation        1.000     .916      .838
Sig. (2-tailed)            <.001     <.001
N                          27        27        27
Pearson Correlation        0.916     1         0.948
Sig. (2-tailed)            <.001     *         <.001
N                          27        27        27
Pearson Correlation        0.838     0.948     1.000
Sig. (2-tailed)            <.001     <.001     *
N                          27        27        27

PP = Pragmatic Protocol
CIDS = Quantitative score of ASHA FACS
QDSC = Qualitative score of ASHA FACS
Correlations are significant
at the 0.017 level (2-tailed)

Table 5. Summary of multiple linear regression
analysis for variables predicting fluency.

Variables              V         SE B      [beta]

Pragmatic Protocol    0.158      0.045      1.016
QDSC                 -1.819      0.96      -0.551

[R.sup.2]= .397

QDSC = Qualitative score of ASHA FACS

Table 6. Summary of multiple linear regression
analysis for variables predicting severity

Variables                B        SE B     [beta]

Pragmatic Protocol     1.249     0.146      0.864

N = 27
[R.sup.2] = .746
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