=Paper=
{{Paper
|id=Vol-3888/paper10
|storemode=property
|title=An Embodied Approach to Treating Aphasia: __ Missing ___ Prepositions and Bringing Them In
|pdfUrl=https://ceur-ws.org/Vol-3888/Paper_10.pdf
|volume=Vol-3888
|authors=Daniela Diesner
|dblpUrl=https://dblp.org/rec/conf/isd2/Diesner24
}}
==An Embodied Approach to Treating Aphasia: __ Missing ___ Prepositions and Bringing Them In
==
https://ceur-ws.org/Vol-3888/Paper_10.pdf
An Embodied Approach to Treating Aphasia: __ Missing ___
Prepositions and Bringing Them In
Daniela Diesner1
1 University of Vienna, Universitätsstraße 7, 1010 Vienna, Austria
Abstract
Persons affected by Broca’s aphasia are known to face challenges in dealing with prepositions with
treatment outcomes that render current therapy approaches ineffective. For the present study, an
interdisciplinary analytical literature review was conducted in combination with an exploratory
clinical pilot study that put image schema theory into practice. Results showed improvement in most
tasks of the key assessment areas, including sustained effects. Raising doubts regarding underlying
causes of prepositional deficits, the findings of this embodied method may have an impact on current
therapy approaches.
Keywords
aphasia, embodiment, multimodality, container schema, inside-out framework, second language
learning
1. Introduction
The wide variety of potential deficits following a stroke render designing effective therapies for
non-fluent aphasia a highly complex matter. Unsurprisingly, current therapy approaches are
reported to lack efficacy [1]. Prepositions in particular pose a challenge to individuals with
Broca’s aphasia and foreign language learners alike, and difficulties with prepositions may linger
tenaciously [2, 3]. While developmental language learning is claimed to be embodied, embedded
and active [4, 5], this embodied and dynamic aspect appears to be neither accounted for in
Broca’s aphasia therapy nor in second language learning. In the context of aphasia, partly this
may be due to a lack of informative interaction between theoretical research, current therapies
and research on therapy efficacy. A potential factor for unsatisfactory treatment outcomes may
be a misconception of the nature of the deficit that underlies the loss of prepositional use in
Broca’s aphasia.
The primary purpose of this paper is to suggest an interdisciplinary alternative approach
which shows potential in enabling persons affected by Broca’s aphasia to (re-)grasp the meaning
of locative and directional prepositions. The approach is grounded in embodied theories and
illustrates how image schema, or more accurately, embodied schema theory [6, 7] can be
employed in therapy settings. The starting point of the study is the container schema, with a
focus on the senses of the preposition in in verb-particle constructions such as phrasal verbs. It
is an embodied schema that is ubiquitous in everyday life and acquired early in developmental
language learning. This paper has three main objectives: (1) to explore ways of synthesising
theories in different disciplines and fields to suggest a practical therapy approach for individuals
with Broca’s aphasia that may also be utilised in second language learning, (2) to demonstrate
how this may be applied by reporting promising findings of an exploratory clinical case study
conducted by the author, and finally, (3) to outline potential factors that may in part explain the
underlying mechanisms.
The Eighth Image Schema Day (ISD8), 25–28 November 2024, Bozen-Bolzano, Italy
a09205640@unet.univie.ac.at (D. Diesner)
© 2024 Copyright for this paper by its authors. Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0).
CEUR Workshop Proceedings (CEUR-WS.org)
CEUR
ceur-ws.org
Workshop ISSN 1613-0073
Proceedings
It ought to be emphasised that this account of applied linguistics in a clinical context is merely
a small overview of a considerably bigger research area. Thus, this paper aims at initiating
interest and research on a wider basis. Due to the current scope, it will not be able to cover the
complexity in its entirety.
2. Aphasia: __ missing ___ prepositions
Aphasia is an acquired severe language disorder that mainly occurs as the consequence of a
cerebrovascular accident. After an acute phase that lasts approximately six months, a chronic
phase sets in. While aphasia affects communicative abilities, intelligence remains intact. The
symptoms can be misinterpreted in social interactions and are associated with poor quality of
life.
Types of aphasia are classified according to speech fluency, speech comprehension and the
ability to repeat words or phrases. In what follows, I will restrict myself to a non-fluent type, viz.
Broca’s aphasia, also referred to as expressive aphasia. For affected persons, uttering words or
generating sentences is effortful. Broca’s aphasia is characterised by elliptic speech, which may
result from the omission of function words (e.g., prepositions), word finding problems or the
inability to repeat words or phrases. The affected cortical region associated with these
symptoms is Broca’s area, concerned with language production. Wernicke‘s area, associated with
language comprehension, tends to be regarded as unaffected. Recent research raises doubt
whether this is indeed the case [8].
Where aphasia treatment is concerned, many types of therapy exist. However, neither
impairment-based nor functional communication approaches are reported as effective since a
substantial proportion of the subjects do not seem to benefit in any way [1]. Thus, new therapy
approaches are required to tackle prepositional deficits in Broca’s aphasia.
3. Putting embodied (image) schema theory into practice
A key question that arises concerning therapy approaches is how meaning emerges. Given the
premises that meaning is grounded in experience and that this is reflected in language, one may
thus ask how initially meaningless sound patterns obtain a strong association with content and
indeed acquire meaning. Furthermore, how does the ‘binding’ of meaning to linguistic units
occur? In other words, when use of prepositions is lost, how can it be (re-)acquired?
Concerning prepositional deficits in Broca’s aphasia, the quest for answers involves
identifying factors contributing to the poor therapy outcomes reported. Two potential factors
that tend not to be questioned may warrant closer inspection. Firstly, neuroscience tends to test
immobile healthy subjects [9]. Secondly, a conception that may be related to this, prepositional
deficits tend to be considered as syntactic deficit (agrammatism) [10]. This position has recently
been challenged [e.g., 2]. Developmental language learning may be considered as an effective
approach that may be referred to as a strong design. Infants internalise spatial relations and
learn words by exploring the world in a manner that is embodied, active and multimodal [11, 5],
providing a powerful model for acquiring use of prepositions. Involving many objectives, all this
was factored in and pondered in the exploration of an alternative method that is semantic,
embodied and dynamic in nature.
To test if an embodied methodology can be efficacious in acquiring use of prepositions, an
exploratory clinical case study was conducted. For this purpose, an applied linguistic approach
was developed within a cognitive semantic framework. The approach taken is grounded in image
schema, i.e. embodied schema, theory [6, 7]. The latter will be used in this context, given its status
as an alternative that is regarded as more accurate.2 Embodied schemas such as the container
schema are considered to be our first conceptual structures [11]. They are defined as dynamic
experiential patterns that become conceptualised as multimodal representations of
sensorimotor activity. The container schema was selected for two reasons, (i) its early
acquisition in developmental language learning, and (ii) the fact that in English verb-in
constructions, it builds complexes with the locomotion and the path schema as well as with the
centre-periphery schema. Mainly concerned with containment, the container schema generally
involves a more salient component that is brought into relation with a less salient one that serves
as a reference point. In other words, this generally involves one entity that is contained in
another, in a broad sense, or moves into another entity that has the potential to contain the
former.
Theoretical support from neuroscience for the embodied and dynamic approach is provided
by the inside-out framework [12, 9]. It incorporates elements found in enactive cognition and
dynamical systems theory in cognitive science. In particular, the brain is considered to be a self-
organized system with both pre-existing networks and dynamics. Initially meaningless entities
of self-generated neuronal activity carry the potential to acquire meaning by being associated
with the result of self-initiated action and its consequences. Perception is thus regarded as a
process that is grounded in action. In a nutshell, memorable experience involves associating self-
generated activity patterns with relevant events in the world [12].
3.1. Methodology
Due to the scope and the theoretical nature of this paper, the methodology mainly comprised an
analytical literature review that was conducted with a flexible survey methodology. The
exploratory pilot study reported trained a 59-year-old male English native speaker with chronic
Broca’s aphasia 20 years after stroke and comorbidities3 under unfavourable conditions. Despite
intensive long-term treatment with a syntactic approach, prepositional deficits lingered
tenaciously. As was mentioned above, the embodied schema approach applied targets locative
and directional prepositions. It focuses on the different senses of container schema complexes of
the English preposition in [13].
Premises involved in the semantic approach include that meaning that had been previously
grounded in experience had been lost or was inaccessible due to brain damage and resulting
consequences. Dynamic and multimodal experience targeting spatial relations would initiate a
‘semantic (re-)grounding’ of spatial prepositions. As a side effect, self-initiated action would
establish a feeling of self-efficacy. This would in turn increase motivation, which, like volition, is
a factor that often seems to be underestimated in treatment.
The training method followed a protocol yet remained flexible for the purpose of being able
to adapt to the participant’s respective current needs. At different stages, units of language
competence assessment were administered [14, 15]. Inter alia, tasks consisted in locative
relations (auditory, comprehension), elicited spontaneous speech (picture description,
production), and synonymous constructions involving prepositions (auditory, comprehension).
The elicited spontaneous speech task was analysed, for instance, concerning number of
constructions that include prepositions (e.g., ‘in the kitchen’), number of different prepositions
used, multiple prepositions (e.g., ‘out in the garden‘) and verb-preposition constructions (e.g.,
‘stand up’).
This pilot study showcases how an approach grounded in embodied schema theory can be
applied in 16 hours of training in total. This mainly involved the participant engaging with the
body in interaction with household props, deploying different techniques. Inter alia, this
2 Embodied schemas are inherently multimodal and do not refer to 'images' as such.
3 Inter alia, this involved paresis of right extremities, apraxia of speech and formulaic speech.
included mirroring actions and expressing their content, or triggering memory via a nursery
rhyme and song that includes relevant active embodiment, when the respective sense was
addressed. Senses of English verb-in constructions involved were mainly based on entering, as
in going in, see Figure 1, and inserting, e.g., throwing in a comment, but also confining or
protecting as in locking in or buckling in, and moving towards a focal point as in handing in papers,
see Figure 2.4 This included auditory explanation and demonstration of the schema’s scope of a
respective sense and corresponding schematic depictions as exemplified in Figure 1 and Figure 2
[13].
Figure 1: Entering Figure 2: Moving towards a focal point
Applying this dynamic embodied approach proved to be very informative. To give an example,
the utterance ‘I’m sitting on the table’ instead of ‘at the table’ had repeatedly caused irritation in
everyday life. It was requested whether this could become part of the uses covered in the training
sessions despite at not being among the three focal prepositions. This was addressed by
encouraging the participant to carry out the corresponding action while speaking. This resulted
in shocked surprise and disbelief as realisation struck in terms of utterance content. In this kind
of semantic grounding, initially meaningless sound patterns seem to have acquired meaning
through concurrent self-initiated action and its consequences. Concurrently, this appears to have
become incorporated with concomitant sensorimotor experience of ‘this is what it feels like to sit
on a table’ and an understanding that this was incongruent with the message that was intended.
Comparatively fine adjustment was obtained by physically exploring the difference between ‘on
a chair’, i.e. support, as compared to ‘in an armchair’, i.e. containment.
Based on a mid-training spot check, the presumed minimum of two to three words per
utterance was considered to be unproductive. The underlying prepositional deficit appeared to
be more severe than had initially been assumed. Thus, the approach was modified to targeting
prepositions in isolation, i.e. uttering only one word per spatial arrangement or ‘scene’. This was
mainly limited to the preposition in as opposed to on, and out. The performance displayed in turn
indicated further deficits that are beyond the scope of this paper yet opened up new questions.
These will be briefly commented on in the final section.
Additionally, the embodied schema approach, along with observations and findings, was
considered from a systems neuroscience position, the inside-out framework [12], to shed new
light on relevant mechanisms.
3.2. Results
Performance improved in most tasks of the key assessment areas, i.e. involving prepositions.
Performance concerning auditory locative prepositions (24 items) displayed a sustained effect
five weeks after training completion. It can be considered as highly demanding due to its
transient nature. With focus solely on whether the correct preposition was selected (blue and
orange bar components), initial 79 per cent of correct responses prior to training increased to
92 per cent five weeks after training completion (post-training 2). This even exceeded
performance assessed the week after training completion (post-training 1) as illustrated in
4 Going in is intransitive and involves the locomotion schema, throwing something in is transitive and involves the
path schema, and, finally, handing in involves the centre-periphery schema.
Figure 3. A mid-training spot check revealed a drop in performance below the level prior to
training, as illustrated and highlighted in Figure 4.
Figure 3: Locative relations (auditory, 24 items) Figure 4: Locative relations (auditory,
24 items) incl. mid-training spot check
In one of the most taxing tasks, elicited spontaneous speech, performance in most areas
showed substantial improvement one week after training completion. Even a split verb-particle
construction could be observed (e.g., ‘take something out’). Assessment five weeks after training
completion displayed a decrease in performance in most of these areas. However, performance
at this stage still exceeded speech production results assessed prior to training.
4. Concluding remarks on missing out prepositions in aphasia and future
work
Aphasia is an interesting research area since brain region damage and its consequences are
unique. The exploratory clinical pilot study showcases how sensorimotor involvement can be
utilised to mitigate prepositional deficits.
According to previous research, embodied exploration of spatial relations is also crucial to
language learning in terms of prepositions, as it has an impact on learning speed and capacity
[4, 16]. The compelling results of the exploratory case study corroborated these findings and
even showed sustained effects. There is plenty of theoretical support for these claims from
neuroscience. Furthermore, observations indicated that the underlying impairment is semantic,
i.e. meaning-based, in nature, corroborating previous research [2]. This stands in opposition to
the traditional view of prepositional ‘agrammatism’ in Broca’s aphasia as a syntactic issue [10].
Importantly, this qualitative study revealed further potential deficits and thus opened up new
questions, giving rise to more hypotheses. To give some examples, questions included issues
concerned with the duration of the interval between an uttered single word and when another
could be articulated. It was likewise targeted accordingly during training, to decrease the
intervals. Observations included both a noticeable increase in working memory capacity, during
the assessment unit prior to training as compared to the ones after training completion, and
word retrieval facilitation after training completion. Thus, the role of working memory capacity5
in (Broca’s) aphasia may have been underestimated. This may also apply to body representation,
such as concerning a topological ‘body map’ in the context of aphasia. Together, this may initiate
a rethinking in diagnostic testing strategies in the acute phase, as comorbidities can exacerbate
5 Depending on the respective definitions, this may also be argued to refer to short term memory capacity.
the condition. Consequently, this embodied semantic approach requires testing in a larger
clinical setting as it has the potential to initiate plenty of potential research with yet more
hypotheses. As was mentioned before, second language learners likewise may benefit from
adopting this approach concerning prepositions, as embodied methods have been reported to
yield promising results [3, 16]. This may be particularly effective in the early stages of second
language learning when addressing prepositions.
To recap, this study tested whether this embodied methodology is effective in targeting
prepositions and has an impact on performance. The unexpectedly compelling results after
training completion may speak for themselves. Observations made raised yet further questions
and hypotheses that are beyond the scope of this paper.
Where limitations are concerned, among the shortcomings of the setup was that this
exploratory pilot study was conducted in a non-lab setting and under unfavourable conditions.
As previously mentioned, there was an unexpected drop in performance during the mid-training
spot check that would have remained undetected without assessment at this stage. Accordingly,
the approach was modified before returning to the course initially intended. Given this
impressive positive development, it now remains unclear whether improvement was based on
an adaptation phase, as might be indicated by the spot check, or was assisted or motivated by
targeting prepositions in isolation. Further limitations concern the limited sample size.
Accordingly, not many claims can be made. The fact that only one person was tested was due to
the language barrier. As was mentioned above, the approach focused on embodied schemas in
English verb-particle constructions. Even languages as closely related as English and German do
not have identical construals of spatial relations or ‘scenes’. This relates to second language
learners and issues regarding prepositions. Thus, testing this methodology in other languages
may be expected to require respective analyses prior to testing. Despite these shortcomings,
some of which may also be argued to represent strengths, this exploratory pilot study still
yielded very promising results that may serve as a basis for future research.
Future work includes testing this methodology in a full clinical study that involves multiple
participants in a clinical setup. A longitudinal study that covers one year or more and includes
regular training sessions is suggested to monitor how performance changes over time. Further
suggestions include extending the scope in terms of testing this approach in other languages than
English as well as in second language learning.
To conclude, the body’s role in language competence may have been neglected in current
approaches. Observations of its considerable importance to acquiring use of prepositions may
spark a rethinking of both current diagnostics and therapy approaches in terms of acute and
chronic Broca’s aphasia, as well as teaching methods in second language learning. This research
agenda aims at laying the groundwork with reference to concrete recommendations for future
research on Broca’s aphasia as well as second language learning, concerning both spatial
prepositions and phrasal verbs, and their seemingly arbitrariness.
Acknowledgements
I would like to express my gratitude to the participant of the pilot study. I would also like to
extend my heartfelt thanks to Maria M. Hedblom as well as the anonymous reviewers for the
informative comments and suggestions. Thank you so much for putting in both time and effort.
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