Left hemisphere plasticity and aphasia recovery

A recent study by our group revealed a strong relationship between functional brain changes in the left hemisphere and anomia treatment outcome in chronic stroke patients (N=26) with aphasia (Fridriksson, 2010). The current research represents a continuation of this work in which we have refined our methods and added data from four more patients (for a total sample size of 30) to assess where in the left hemisphere treatment-related brain changes occur. Unlike Fridriksson (2010) which only focused on changes in correct naming as a marker of treatment outcome, the current study examined the relationship between changes in left hemisphere activity and changes in correct naming, semantic paraphasias, and phonemic paraphasias following treatment. We also expanded on the work by Fridriksson by examining whether neurophysiological measures taken at baseline (defined henceforth as the time-point before the start of anomia treatment) predict treatment outcome. Our analyses revealed that changes in activation in perilesional areas predicted treatment-related increases in correct naming in individuals with chronic aphasia. This relationship was most easily observed in the left frontal lobe. A decrease in the number of semantic and phonemic paraphasias was predicted by an activation change in the temporal lobe involving cortical areas that were shown to be active during picture naming in 14 normal subjects. In contrast, a far less certain relationship was found between baseline neurophysiological measures and anomia treatment outcome. Our findings suggest that improved naming associated with behavioral anomia treatment in aphasia is associated with modulation of the left frontal lobe whereas a reduction in naming errors is mediated by left posterior regions that classically are thought to be involved in language processing.

Aphasia--the hidden disability

Aphasia is an acquired language disorder due to brain damage and which may include difficulty in producing or comprehending spoken or written language. Stroke is the commonest cause and each year 50,000 new patients develop aphasia. People with aphasia differ in their speech output and in their fluency. Some people communicate reasonably well, while others have very limited powers of expression. This review will describe the neurology of speech and aphasia, and will focus on the role of the speech and language therapist in dealing with people with aphasia.

CLINICAL RELEVANCE

Dentists and their staff should be aware that after a stroke some people are unable to talk or have limited powers of expression. Comprehension might be impaired and people with aphasia may be unable to grasp some common language, such as appointment letters and patient information.

[Music and brain (II): evidence of musical training in the brain]

Music is a very powerful multimodal stimulus that transmits visual, auditory and motor information to our brain, which in turn has a specific network for processing it, consisting in the frontotemporoparietal regions. This activation can be very beneficial in the treatment of several syndromes and diseases, either by rehabilitating or by stimulating altered neuronal connections. We also review the peculiarities of the musician's brain and we look at how the brain adapts according to the needs that must be met in order to improve musical performance.

[Efficacy observation of Thoroughfare Vessel theory in acupuncture for post-stroke dysphasia]

OBJECTIVE

To compare the difference in the efficacy on post-stoke dysphagia between the point selection according to Thoroughfare Vessel theory and conventional point selection in treatment.

METHODS

Seventy-eight patients were randomly divided into an observation group (n = 42) and a control group (n = 36). In observation group, acupuncture was applied to the acupoints selected according to Thoroughfare Vessel theory such as Dazhu (BL 11), Shangjuxu (ST 37), Xiajuxu (ST 39), Neiguan (PC 6) and Gongsun (SP 4) Mainly. In control group, acupuncture was applied to the conventional acupoints such as Fengchi (GB 20), Lianquan (CV 23), Tiantu (CV 22), Neiguan (PC 6) and Zusanli (ST 36), etc. Acupuncture was given once per day in either group, 12 treatments made one session and 4 sessions of treatment were required. The water swallow test was adopted to assess the swallowing function in two groups.

RESULTS

The effective rate was 100.0% (42/42) in observation group and was 77.8% (28/36) in control group. The efficacy in observation group was superior to control group (P < 0.05). The curative time was (28.65 +/- 10.42) days in observation group and was (38.74 +/- 21.30) days in control group. The time was shorter apparently in observation group as compared with control group (P < 0.05).

CONCLUSION

The Thoroughfare Vessel theory in acupuncture treatment for post-stroke dysphasia achieves a superior efficacy as compared with the conventional acupoint selection, and this theory may quickly determine the point prescription in treatment.

[Music therapy for dementia and higher cognitive dysfunction: a review]

Music is known to affect the human mind and body. Music therapy utilizes the effects of music for medical purposes. The history of music therapy is quite long, but only limited evidence supports its usefulness in the treatment of higher cognitive dysfunction. As for dementia, some studies conclude that music therapy is effective for preventing cognitive deterioration and the occurrence of behavioral and psychological symptoms of dementia (BPSD). In patients receiving music therapy for the treatment of higher cognitive dysfunction, aphasia was reported as the most common symptom. Many studies have been conducted to determine whether singing can improve aphasic symptoms: singing familiar and/or unfamiliar songs did not show any positive effect on aphasia. Melodic intonation therapy (MIT) is a method that utilizes melody and rhythm to improve speech output. MIT is a method that is known to have positive effects on aphasic patients. Some studies of music therapy for patients with unilateral spatial neglect; apraxia; hemiparesis; and walking disturbances, including parkinsonian gait, are available in the literature. Studies showed that the symptoms of unilateral spatial neglect and hemiparesis significantly improved when musical instruments were played for several months as a part of the music therapy. Here, I describe my study in which mental singing showed a positive effect on parkinsonian gait. Music is interesting, and every patient can go through training without any pain. Future studies need to be conducted to establish evidence of the positive effects of music therapy on neurological and neuropsychological symptoms.

Cathodal transcranial direct current stimulation of the right Wernicke's area improves comprehension in subacute stroke patients

Previous studies have shown the appearance of right-sided language-related brain activity in right-handed patients after a stroke. Non-invasive brain stimulation such as transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) have been shown to modulate excitability in the brain. Moreover, rTMS and tDCS have been found to improve naming in non-fluent post-stroke aphasic patients. Here, we investigated the effect of tDCS on the comprehension of aphasic patients with subacute stroke. We hypothesized that tDCS applied to the left superior temporal gyrus (Wernicke's area) or the right Wernicke's area might be associated with recovery of comprehension ability in aphasic patients with subacute stroke. Participants included right-handed subacute stroke patients with global aphasia due to ischemic infarct of the left M1 or M2 middle cerebral artery. Patients were randomly divided into three groups: patients who received anodal tDCS applied to the left superior temporal gyrus, patients who received cathodal tDCS applied to the right superior temporal gyrus, and patients who received sham tDCS. All patients received conventional speech and language therapy during each period of tDCS application. The Korean-Western Aphasia Battery (K-WAB) was used to assess all patients before and after tDCS sessions. After intervention, all patients had significant improvements in aphasia quotients, spontaneous speech, and auditory verbal comprehension. However, auditory verbal comprehension improved significantly more in patients treated with a cathode, as compared to patients in the other groups. These results are consistent with the role of Wernicke's area in language comprehension and the therapeutic effect that cathodal tDCS has on aphasia patients with subacute stroke, suggesting that tDCS may be an adjuvant treatment approach for aphasia rehabilitation therapy in patients in an early stage of stroke.

Recovery from post-stroke aphasia: lessons from brain imaging and implications for rehabilitation and biological treatments

Aphasia, a condition defined as the partial or complete loss of language function after brain damage, is one of the most devastating cognitive deficits produced by stroke lesions. Over the past decades, there have been great advances in the diagnosis and treatment of post-stroke language and communication deficits. In particular, the advent of functional brain imaging and other brain mapping methods has advanced our understanding of how the intact and lesioned brain takes over the activity of irretrievably damaged networks in aphasic patients. This review examines the contribution of these ancillary methods to elucidate the neural changes that take place to promote improvement of language function in early, late, and very late stages of recovery. Also, functional neuroimaging is helpful to identify brain areas involved in language recovery as well as to characterize the plastic reorganization of neural networks produced by scientifically-based language therapies and biological treatments (drugs, transcranial magnetic stimulation).

Measuring and inducing brain plasticity in chronic aphasia

Brain plasticity associated with anomia recovery in aphasia is poorly understood. Here, I review four recent studies from my lab that focused on brain modulation associated with long-term anomia outcome, its behavioral treatment, and the use of transcranial brain stimulation to enhance anomia treatment success in individuals with chronic aphasia caused by left hemisphere stroke. In a study that included 15 participants with aphasia who were compared to a group of 10 normal control subjects, we found that improved naming ability was associated with increased left hemisphere activity. A separate study (N = 26) revealed similar results in that improved anomia treatment outcome was associated with increased left hemisphere recruitment. Taken together, these two studies suggest that improved naming in chronic aphasia relies on the damaged left hemisphere. Based on these findings, we conducted two studies to appreciate the effect of using low current transcranial electrical stimulation as an adjuvant to behavioral anomia treatment. Both studies yielded positive findings in that anomia treatment outcome was improved when it was coupled with real brain stimulation as compared with a placebo (sham) condition. Overall, these four studies support the notion that the intact cortex in the lesioned left hemisphere supports anomia recovery in aphasia.

LEARNING OUTCOMES

Readers will (a) be able to appreciate the possible influence of animal research upon the understanding of brain plasticity induced by aphasia treatment, (b) understand where functional changes associated with anomia treatment occur in the brain, (c) understand the basic principles of transcranial direct current stimulation, and (d) understand how brain stimulation coupled with aphasia treatment may potentially improve treatment outcome.

Supervised home training of dialogue skills in chronic aphasia: a randomized parallel group study

PURPOSE

The aim of this study was to prove the efficacy of supervised self-training for individuals with aphasia. Linguistic and communicative performance in structured dialogues represented the main study parameters.

METHOD

In a cross-over design for randomized matched pairs, 18 individuals with chronic aphasia were examined during 12 weeks of supervised home training. Intensive language training, assisted by an electronic learning device (B.A.Bar), was compared with nonlinguistic training. Language performance, communicative abilities, and cognitive abilities were controlled before and after each intervention and at follow-up. The language training was designed to facilitate dialogue skills as required in everyday life.

RESULTS

Robust and specific improvements in the participants' linguistic and communicative abilities were obtained using B.A.Bar dialogue training but not with nonlinguistic training. The transfer to general linguistic and communicative performance remained limited when the whole group was considered. For 30%-50% of the participants, individual analysis revealed significant improvements in spontaneous language and general communicative skills. Furthermore, individual participants demonstrated significant improvements regarding standardized aphasia assessment and proxy rating of communicative effectiveness.

CONCLUSION

Supervised home training works. This study has proven that it is an effective tool for bolstering linguistic and communicative skills of individuals with aphasia.

Computer-based script training for aphasia: emerging themes from post-treatment interviews

This study presents results of post-treatment interviews following computer-based script training for persons with chronic aphasia. Each of the 23 participants received 9 weeks of AphasiaScripts training. Post-treatment interviews were conducted with the person with aphasia and/or a significant other person. The 23 interviews yielded 584 coded comments that were categorized into ten themes. Five of the themes related to the communication behaviors of the participant, whereas the other five related to the computer program and study procedures. Examples of each theme are presented. The themes provide qualitative evidence of change and generalization, supporting the use of this computer-based script training program.

Treatment of semantic verb classes in aphasia: acquisition and generalization effects

Verb retrieval difficulties are common in aphasia; however, few successful treatments have been documented (e.g. Conroy, P., Sage, K., & Lambon Ralph, M. A. (2006) . Towards theory-driven therapies for aphasic verb impairments: A review of current theory and practice. Aphasiology, 20, 1159-1185). This study investigated the efficacy of a novel verb retrieval treatment in two individuals with aphasia who experience verb retrieval difficulty. It involved training verb classes with large (e.g. cut verbs) and limited (e.g. contact verbs) sets of semantic features. Based on action representation theories, semantically based training of cut verbs was predicted to generalize to retrieval of untrained cut and contact verbs. One participant improved on trained verbs whereas the other participant did not. Neither participant demonstrated within nor across-class generalization to untrained verbs. However, both participants significantly improved in verb naming as measured by An Object and Action Naming Battery, and their predominant error pattern changed from noun to verb substitutions. Therefore, both participants improved in overall verb retrieval strategies despite limited success with verbs trained in this treatment. Implications for the design of future treatments are discussed.

Effect of verb network strengthening treatment in moderate-to-severe aphasia

PURPOSE

This Phase II treatment study examined the effect of Verb Network Strengthening Treatment (VNeST) on individuals with moderate-to-severe aphasia. Research questions addressed (a) pre- to posttreatment changes and pretreatment to treatment phase changes on probe sentences containing trained verbs (e.g., "The carpenter is measuring the stairs") and semantically related untrained verbs (e.g., "The nurse is weighing the baby"); (b) lexical retrieval changes in single-word naming, sentence, and discourse measures; (c) functional communication by way of proxy and participant report; and (d) error evolution.

METHOD

A multiple-baseline approach across participants was used. Effect sizes were calculated for pre- and posttreatment and maintenance probe responses. A C statistic was used to determine changes from the baseline to treatment phases.

RESULTS

One participant exhibited improvement on all generalization measures, whereas the other participant exhibited more limited generalization. Both participants showed improvement on the functional communication measure.

CONCLUSIONS

As predicted, the participants did not show the same extent of improvement that was observed in participants with more moderate aphasia (Edmonds, Nadeu, & Kiran, 2009). Nonetheless, the findings suggest that VNeST may be appropriate for persons with moderate-to-severe aphasia, especially with a small adaptation to the treatment protocol that will be retained for future iterations of VNeST.

Negotiation of identity in group therapy for aphasia: the Aphasia Café

BACKGROUND

There has been increasing interest in ensuring that aphasia intervention includes attention to the negotiation of a robust identity after the life-altering changes that often accompany the onset of aphasia. But how does one go about simultaneously improving communication and positive identity development within aphasia therapy? Socially oriented group therapy for aphasia has been touted as one means of addressing both psychosocial and communicative goals in aphasia.

AIMS

This article describes the results of a sociolinguistic analysis of group therapy for aphasia in which positive personal and group identity are skilfully negotiated.

METHODS & PROCEDURES

Sociolinguistic microanalysis of discourse in a group therapy session was undertaken. The session, described as group conversation therapy, included eight adults with aphasia, a speech-language pathologist and an assistant. The session was videotaped and transcribed, and the data were analysed to identify 'indices of identity' within the discourse. This included discourse that exposed members' roles, values or beliefs about themselves or others. The data were further analysed to identify 'patterns' of discourse associated with identity. The result is a detailed description of identity-enhancing discourse within group therapy for aphasia.

OUTCOMES & RESULTS

The findings included several categories associated with the negotiation of identity in therapy including: (1) discourse demonstrating that group members were 'being heard', (2) that the competence of group members was assumed, (3) that 'solidarity' existed in the group, (4) that saving face and promoting positive personal identity was important, and (5) that markers of group identity were made visible via discourse that referenced both member inclusion as well as non-member exclusion.

CONCLUSIONS & IMPLICATIONS

The results suggest that it is possible to create identity-enhancing interactions as part of therapy for aphasia; the analysis demonstrates the potential role of the group leader/clinician in managing identity negotiation in aphasia therapy.

Rethinking aphasia therapy: a neuroscience perspective

This article explores how consideration of acquired speech and language disorders from the perspective of neuroscience permits new insights into the content and design of therapy for people with aphasia. Key proposals are that aspects of current therapies often neglect the sensory-motor components of speech and language processing, and the interconnectivity of sensory-perceptual and motor systems. Furthermore, current therapy regimes are often administered at too low an intensity to stimulate neural reorganization. Neuroscientific perspectives on learning are explored and in particular the issues of associationist learning, learned misuse, mirror neurone systems, and procedural and errorless learning. The value of use of computer programs in administering high intensity therapy is outlined and it is proposed that aphasia therapies can be enhanced if clinicians adopt an explicit neuroscientific rationale for intervention.

A controlled study of changes in conversation following aphasia therapy for anomia

This paper investigates the relationship between change in picture naming with anomia therapy and changes in word retrieval in conversations between adults with aphasia and a regular conversational partner. We present data from two therapy projects (Hickin et al. [ 1 ] and Best et al. [ 2 ]). In each study, therapy involved cueing with the aim of improving retrieval of a set of nouns. Naming of the experimental items was assessed twice prior to therapy and again immediately afterwards. There was a significant change in word finding, as measured by picture naming, for the group and for 11 of the 13 participants. At the same time points, we collected conversations between the person with aphasia and a regular conversational partner. We analysed these using Profile of Word Errors and Retrieval in Speech (Herbert et al. [ 3 ]) and investigated a set of conversational variables predicted to change with therapy. Unsurprisingly, the conversation data is not straightforward. There is no significant change on the conversation measures for the group but some changes for individuals. We predicted change in word retrieval after therapy would relate to change in everyday conversations and tested this by correlating the change (post-therapy minus mean pre-therapy) in picture naming with the change in conversation variables. There was a significant positive relationship between the change in picture naming and change in some conversation measures including the number of nouns produced in 5 min of conversation (r = 0.50, p < 0.05, one-tailed) and the number of nouns produced per substantive turn (r = 0.55, p < 0.05, one-tailed). The findings suggest changes in word finding following therapy for aphasia can be reflected in changes in conversation. The clinical implications of the complex results are explored.

Executive functions and aphasia treatment outcomes: data from an ortho-phonological cueing therapy for anomia in Chinese

This study examined the existence of a possible relationship between anomic treatment outcomes and executive functions. An ortho-phonological cueing method was used to facilitate object naming in 12 Cantonese-speaking anomic individuals. Treatment effectiveness for each participant was quantified and correlated with the performance of executive functions and language tasks. It was found that 10 participants showed significant improvement in naming treated items. Eight of the participants were able to maintain treatment gains for at least 1 month. Phonological generalization effects were observed in two participants. Performance on the Test of Nonverbal Intelligence (TONI-3) was significantly correlated with effect sizes of treatment, treatment generalization and maintenance and the Attention Network Test (ANT) was significantly correlated with phonological generalization. The result of a simultaneous multiple regression suggested that the performance of the ANT played an important role in phonological generalization. The findings reinforce the current view about the role of executive functions in language rehabilitation. They also shed light on the effect of inhibitory control on treatment generalization.

[Meta analysis on acupuncture treatment of aphasia]

OBJECTIVE

To evaluate the therapeutic effect of acupuncture for the aphasia.

METHODS

The publications of acupuncture for the treatment of aphasia are comprehensively searched from relevant domestic medical literature databases, China National Knowledge Infrastructure and Chinese BioMedical Literature Database. Meta analysis was conducted by using the publications.

RESULTS

Twenty six trials of 338 matched the selection criteria and their data were suitable for Meta analysis. The total aphasia patients were 1749. The total odds ratio (OR) of the improvement with acupuncture plus language training and drugs compared with language training plus drug intervention was 3.66 (95% confidence interval, 2.81, 4.76), and the funnel plot was approximately symmetry. It is indicated that the curative effect of the acupuncture group is better than that of the control group (Z = 9.60, P < 0.001).

CONCLUSION

The effect of acupuncture with language training plus drugs for the treatment of aphasia is better than that of language training plus drugs only.

[Acupuncture therapy for apoplectic aphasia: a systematic review]

OBJECTIVE

To assess the therapeutic effect of acupuncture for apoplectic aphasia.

METHODS

A systematic review of the relevant randomized controlled trials (RCTs) of acupuncture for apoplectic aphasia was performed with Cochrance system assessment methods. The quality of researches was reviewed one by one, and data was extracted by two reviewers independently. Meta-analysis was conducted with the assistance of RevMan 5.0 software.

RESULTS

Eleven randomized controlled trials (RCTs) involving 756 patients were included. Meta-analysis indicated that there was statistical difference between acupuncture and language training groups on cured rate with [RR = 1.74, 95% CI (1.10, 2.74), P = 0.02] at the end of treatment. However, acupuncture combined language training group was statistically superior to language training group on cured rate with [RR = 3.01, 95% CI (1.81, 5.01), P < 0.000 1], language function score with [WMD =10.54, 95% CI (7.86, 13.21), P < 0.000 01], oral expression with [WMD = 8.86, 95% CI (7.38, 10.35), P < 0.000 01].

CONCLUSION

It is approved that acupuncture (or acupuncture combined language training) is effective for apoplectic aphasia. But the quality of inclusive literature is low. Therefore, more RCTs of high methodological quality is requested to be carried out.

Knowledge is BLISS: an investigation into the transparency of BLISS symbol strings directed by a person with aphasia

BACKGROUND

Since his stroke 15 years ago, Tony O'Donnell has worked with BLISS, a symbolic, graphical language. BLISS has been used with a variety of clinical populations, including people with severe aphasia. O'Donnell found his adapted version of BLISS was meaningful to him when spoken and written English was not. The present study is part of a larger project that investigated the validity and generality of O'Donnell's belief that his adapted system would be useful for people with severe aphasia.

AIMS

The first aim was to investigate whether people without aphasia and without training could match the adapted version of BLISS to pictures. The second aim was to conduct collaborative research involving researchers with and without aphasia and to explore their experiences.

METHODS & PROCEDURES

The performance of 55 undergraduate students was investigated on two forced-choice matching tasks: (1) matching three pictures and three BLISS strings; and (2) selecting one of two BLISS strings to match to a picture. A semi-structured interview was conducted to obtain the researchers' perceptions of the research process.

OUTCOMES & RESULTS

The participants' performance across tasks showed that individuals without aphasia can match BLISS strings without training. However, there was considerable individual variation and only some participants scored significantly above chance on both tasks. The interview revealed that although this study took longer to complete, there were many positive aspects of working collaboratively. All the researchers gained personally and professionally from their involvement. Of particular interest was the realization that the researcher with aphasia had a greater ability to plan, problem solve and develop ideas than was initially thought.

CONCLUSIONS AND IMPLICATIONS

Individuals without aphasia are able to match symbol strings to pictures without teaching. Further research is required to establish whether people with aphasia can similarly match the adapted version of BLISS to pictures. This study provides further evidence that people with aphasia can engage productively in the research process, even when experimental methodologies are employed.

Speech and language therapy for aphasia following stroke

BACKGROUND

Aphasia is an acquired language impairment following brain damage which affects some or all language modalities: expression and understanding of speech, reading and writing. Approximately one-third of people who have a stroke experience aphasia.

OBJECTIVES

To assess the effectiveness of speech and language therapy (SLT) for aphasia following stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched April 2009), MEDLINE (1966 to April 2009) and CINAHL (1982 to April 2009). In an effort to identify further published, unpublished and ongoing trials we handsearched the International Journal of Language and Communication Disorders, searched reference lists of relevant articles and contacted other researchers and authors.

SELECTION CRITERIA

Randomised controlled trials comparing SLT versus no SLT, SLT versus social support or stimulation, and one SLT intervention versus another SLT intervention. SLT refers to a formal speech and language therapy intervention that aims to improve language and communication abilities and in turn levels of communicative activity and participation. Social support and stimulation refers to an intervention which provides social support or communication stimulation but does not include targeted therapeutic interventions. Direct comparisons of different SLT interventions refers to SLT interventions that differ in terms of duration, intensity, frequency or method of intervention or in the theoretical basis for the SLT approach.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the quality of included trials. We sought missing data from study investigators if necessary.

MAIN RESULTS

We included 30 trials (41 paired comparisons) in the review: 14 subcomparisons (1064 participants) compared SLT with no SLT; six subcomparisons (279 participants) compared SLT with social support and stimulation; and 21 subcomparisons (732 participants) compared two approaches to SLT. In general, the trials randomised small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures.

AUTHORS' CONCLUSIONS

This review shows some indication of the effectiveness of SLT for people with aphasia following stroke. We also observed a consistency in the direction of results which favoured intensive SLT over conventional SLT, though significantly more people withdrew from intensive SLT than conventional SLT. SLT facilitated by a therapist-trained and supervised volunteer appears to be as effective as the provision of SLT by a professional. There was insufficient evidence to draw any conclusions in relation to the effectiveness of one SLT approach over another.

Beginning to teach the end: the importance of including discharge from aphasia therapy in the curriculum

BACKGROUND

Discharging clients with long-term aphasia from therapy services constitutes a challenging dilemma for practising clinicians for a multitude of reasons. Although discharge was raised and discussed as a contentious issue in the field of aphasiology ten years ago, it remains an aspect of practice which is complex and underexplored. We are only a little more enlightened now than then on how to address this issue in relation to professional education and practice.

AIMS

This paper draws on a single case study of a man with aphasia, his wife, and treating clinician, taken from a substantial research study, to highlight awareness of how communication, choice and differing perceptions of goals of therapy influence the experience of the discharge process. The case serves as the context for addressing a gap in the university curriculum around teaching about discharge practice in the context of long-term aphasia.

METHODS & PROCEDURES

This paper describes how university and practice educators could include discharge issues in students' learning by teaching discharge in context, addressing it in formal university lessons as well as through work-based learning opportunities in clinical placements, and by scaffolding learning using graduated learning outcomes over the different stages of the students' programme.

MAIN CONTRIBUTION

This paper provides practical suggestions to guide the inclusion of discharge in teaching about communication disorders generally, and specifically in relation to long-term aphasia. Discharge needs to be appreciated within the context of the entire intervention process, with good practice modelled in both university and workplace settings. We propose that it is learned in association with stages of decision-making, duty of care, documentation, goal setting, continuous therapy evaluation, clinical reasoning, professional communication with clients, ethical behaviour, and evidence-based practice.

CONCLUSIONS & IMPLICATIONS

Bringing discharge practice from the realm of implicit knowledge to one that can be examined and discussed in an explicit manner should help reduce anxieties about discharge for new clinicians, help to clarify and improve the discharge approaches used by clinicians and lead to better discharge experiences for clients.

Chapter 52: the emergence of the age variable in 19th-century neurology: considerations of recovery patterns in acquired childhood aphasia

In the 19th century, descriptions of patients with disorders of higher cerebral functions were typically presented in a mixed series of children, adolescents, adults, and the elderly. There was no indication in the analysis or interpretation that age was thought to play a role in the signs or symptoms displayed, or in the prognosis. The role of age in the manifestation of language disorders only became explicit in the late 19th century in the elaboration of ideas regarding perinatal illnesses, developmental difficulties, and the emerging clinical category of "cerebral palsy" as evinced in the work of Bastian, Osler, Sachs and Peterson, and Freud. Their patient series studies afforded the opportunity to identify relations between age at symptom onset and patterns of language acquisition and impairment. These analyses contributed directly to the elaboration of hypotheses regarding localization of function, hemispheric specialization, and patterns of recovery. The factor of "age at symptom onset" would steadily assume even greater theoretical importance, as explanations of patterns of symptom co-occurrence, etiology, and prognosis were elaborated through the increasing appreciation of a developmental/maturational perspective.

Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia

BACKGROUND

Some patients with suspected achalasia are found on manometry to have preserved peristalsis, thereby excluding that diagnosis. This study evaluated a series of such patients with functional esophagogastric junction (EGJ) obstruction.

METHODS

Among 1,000 consecutive high-resolution manometry studies, 16 patients had functional EGJ obstruction characterized by impaired EGJ relaxation and intact peristalsis. Eight patients with post-fundoplication dysphagia and similarly impaired EGJ relaxation were studied as a comparator group with mechanical obstruction. Intrabolus pressure (IBP) was measured 1 cm proximal to the EGJ. Sixty-eight normal controls were used to define normal IBP. Patients' clinical features were evaluated.

RESULTS

Functional EGJ obstruction patients presented with dysphagia (96%) and/or chest pain (42%). IBP was significantly elevated in idiopathic and post-fundoplication dysphagia patients versus controls. Among the idiopathic EGJ obstruction group treated with pneumatic dilation, BoTox(TM), or Heller myotomy, only the three treated with Heller myotomy responded well. Among the post-fundoplication dysphagia patients, three of four responded well to redo operations.

CONCLUSION

Functional EGJ obstruction is characterized by pressure topography metrics demonstrating EGJ outflow obstruction of magnitude comparable to that seen with post-fundoplication dysphagia. Affected patients experience dysphagia and/or chest pain. In some cases, functional EGJ obstruction may represent an incomplete achalasia syndrome.

Improved vocabulary production after naming therapy in aphasia: can gains in picture naming generalize to connected speech?

BACKGROUND

Naming accuracy for nouns and verbs in aphasia can vary across different elicitation contexts, for example, simple picture naming, composite picture description, narratives, and conversation. For some people with aphasia, naming may be more accurate to simple pictures as opposed to naming in spontaneous, connected speech; for others, the opposite pattern may be evident. These differences have, in some instances, been related to word class (for example, noun or verb) as well as aphasia subtype. Given that the aim of picture-naming therapies is to improve word-finding in general, these differences in naming accuracy across contexts may have important implications for the potential functional benefits of picture-naming therapies.

AIMS

This study aimed to explore single-word therapy for both nouns and verbs, and to answer the following questions. (1) To what extent does an increase in naming accuracy after picture-naming therapy (for both nouns and verbs) predict accurate naming of the same items in less constrained spontaneous connected speech tasks such as composite picture description and retelling of a narrative? (2) Does the word class targeted in therapy (verb or noun) dictate whether there is 'carry-over' of the therapy item to connected speech tasks? (3) Does the speed at which the picture is named after therapy predict whether it will also be used appropriately in connected speech tasks?

METHODS & PROCEDURES

Seven participants with aphasia of varying degrees of severity and subtype took part in ten therapy sessions over five weeks. A set of potentially useful items was collected from control participant accounts of the Cookie Theft Picture Description and the Cinderella Story from the Quantitative Production Analysis. Twenty-four of these words (twelve verbs and twelve nouns) were collated for each participant, on the basis that they had failed to name them in either simple picture naming or connected speech tasks (picture-supported narrative and unsupported retelling of a narrative). These were placed in a larger cohort of verb and noun sets for therapy. Post-therapy assessments examined naming accuracy and speed of target items in single-word picture-naming and naming accuracy in connected speech contexts.

OUTCOMES & RESULTS

There was a step-wise decrement in naming accuracy over the three naming contexts following targeted therapy. Simple pictures elicited the most correct names, followed by picture-supported narratives and lastly unsupported narratives. Picture-naming accuracy significantly predicted naming in the connected speech contexts for the group as a whole. The speed of picture naming after therapy did not predict the extent to which items were named in composite picture description and narrative tasks.

CONCLUSIONS & IMPLICATIONS

The findings suggest that gains in naming accuracy obtained through picture-naming therapy may generalize to naming of the same items in more linguistically and cognitively demanding connected speech tasks. Demonstrating this generalization is methodologically challenging and the method utilized in this study may serve as one starting point for gathering a larger database in order to answer the question posed by this paper more robustly.