Speech and language therapy for aphasia following stroke

Speech-Language Pathologists' Practice Patterns When Designing Home Practice Programs for Persons With Aphasia: A Survey

Purpose We aimed to describe the current practices of speech-language pathologists regarding the creation and implementation of home practice programs for persons with poststroke aphasia. Method Survey participants were American Speech-Language-Hearing Association-certified speech-language pathologists, had 30% of their caseload include persons with aphasia, and had recently created at least two home programs for persons with aphasia. Respondents completed a web-based survey on home program creation, training, technology, and methods for tracking adherence with closed and open-ended questions. Results We analyzed 80 complete surveys. Most of the participants (n = 56) created home programs for greater than 75% of their caseload. Common interventions in home programs addressed functional practice and spoken expression. Participants describe instructional techniques including building skill practice in daily routines and guided practice. Applications of technology and formal mechanisms to monitor adherence were less frequently reported. Various factors were identified as facilitators and barriers to home program creation with environmental support from others and client factors (i.e., motivation, impairments) most evident. Conclusions This study provides insight into speech-language pathologists' home program creation and implementation. Results can be used to consider mechanisms to improve use of and adherence to home programs to further support recovery. Supplemental Material https://doi.org/10.23641/asha.16840204.

Resting-State Functional Connectivity following Phonological Component Analysis: The Combined Action of Phonology and Visual Orthographic Cues

Anomia is the most frequent and pervasive symptom for people with aphasia (PWA). Phonological component analysis (PCA) is a therapy incorporating phonological cues to treat anomia. Investigations of neural correlates supporting improvements following PCA remain scarce. Resting-state functional connectivity (rsFC) as a marker of therapy-induced neuroplasticity has been reported by our team. The present study explores the efficacy of PCA in French and associated therapy-induced neuroplasticity using whole-brain rsFC analysis. Ten PWA participated in a pre-/post-PCA fMRI study with cognitive linguistic assessments. PCA was delivered in French following the standard procedure. PCA led to significant improvement with trained and untrained items. PCA also led to changes in rsFC between distributed ROIs in the semantic network, visual network, and sub-cortical areas. Changes in rsFC can be interpreted within the frame of the visual and phonological nature of PCA. Behavioral and rsFC data changes associated with PCA in French highlight its efficacy and point to the importance of phonological and orthographic cues to consolidate the word-retrieval strategy, contributing to generalization to untrained words.

Scoping review: Health needs of the family caregivers of elderly stroke survivors

This scoping review mapped out the relevant literature, identified gaps and made suggestions on the subject of the health needs of family caregivers (FC) of elderly stroke survivors (ESS). The authors utilised the PRISMA-ScR checklist to guide the scoping review. The databases PubMed, Elsevier and BioMed Central were searched for academic articles published in the English Language between the years 2010 and 2020 that met a pre-set criteria of content on the health needs of FC of ESS. The process of selection of sources of evidence based on screening and eligibility of evidence reduced the initially identified 13,303 sources of evidence in the searched databases to five sources of evidence. The content of these five sources of evidence was mapped out on a charting table where data was summarised and synthesised first individually and then collectively by the authors. Repetitive and irrelevant data were removed collectively by the authors from the charting table. The gaps identified were a paucity of research on the subject of health needs of FC of ESS, lack of longitudinal and mixed-methods research on the health needs of FC of ESS, sparse use of social sciences perspectives and theories, research that addresses specific physical and mental health concerns beyond general descriptions and gaps in information, social networks, interventions, health policy and systems. Future research directions were suggested and a limitation of this scoping review are addressed in the discussion.

New Treatment Strategy Using Repetitive Transcranial Magnetic Stimulation for Post-Stroke Aphasia

Repetitive transcranial magnetic stimulation (rTMS) for post-stroke aphasia (PSA) has been suggested to promote improvement of language function when used in combination with rehabilitation. However, many challenges remain. In some reports examined by category of language function, only naming has good evidence of improvement, and the improvement effect on other language modalities is low. Therefore, it is necessary to establish methods that contribute to the improvement of language functions other than naming. Therapeutic methods for PSA based on the mechanism of rTMS are mainly inhibitory stimulation methods for language homologous areas. However, the mechanisms of these methods are controversial when inferred from the process of recovery of language function. Low-frequency rTMS applied to the right hemisphere has been shown to be effective in the chronic phase of PSA, but recent studies of the recovery process of language function indicate that this method is unclear. Therefore, it has been suggested that evaluating brain activity using neuroimaging contributes to confirming the effect of rTMS on PSA and the elucidation of the mechanism of functional improvement. In addition, neuroimaging-based stimulation methods (imaging-based rTMS) may lead to further improvements in language function. Few studies have examined neuroimaging and imaging-based rTMS in PSA, and further research is required. In addition, the stimulation site and stimulation parameters of rTMS are likely to depend on the time from onset to intervention. However, there are no reports of studies in patients between 90 and 180 days after onset. Therefore, research during this period is required. New stimulation methods, such as multiple target methods and the latest neuroimaging methods, may contribute to the establishment of new knowledge and new treatment methods in this field.

Core Outcome Set Use in Poststroke Aphasia Treatment Research: Examining Barriers and Facilitators to Implementation Using the Theoretical Domains Framework

Purpose A core outcome set (COS; an agreed minimum set of outcomes) was developed to address the heterogeneous measurement of outcomes in poststroke aphasia treatment research. Successful implementation of a COS requires change in individual and collective research behavior. We used the Theoretical Domains Framework (TDF) to understand the factors influencing researchers' use and nonuse of the Research Outcome Measurement in Aphasia (ROMA) COS. Method Aphasia trialists and highly published treatment researchers were identified from the Cochrane review of speech and language therapy for aphasia following stroke and through database searches. Participants completed a theory-informed online survey that explored factors influencing COS use. Data were analyzed using descriptive statistics and qualitative content analysis. Results Sixty-four aphasia researchers from 13 countries participated. Most participants (81%) were aware of the ROMA COS, and participants identified more facilitators than barriers to its use. The TDF domain with the highest agreement (i.e., facilitator) was "knowledge" (84% agree/strongly agree). Participants had knowledge of the measures included in the ROMA COS, their associated benefits, and the existing recommendations. The TDF domains with the least agreement (i.e., barriers) were "reinforcement" (34% agree/strongly agree); "social influences" (41% agree/strongly agree); "memory, attention, and decision processes" (45% agree/strongly agree); and "behavioral regulation" (49% agree/strongly agree). Hence, participants identified a lack of external incentives, collegial encouragement, and monitoring systems as barriers to using the ROMA COS. The suitability and availability of individual measurement instruments, as well as burden associated with collecting the COS, were also identified as reasons for nonuse. Conclusions Overall, participants were aware of the benefits of using the ROMA COS and believed that its implementation would improve research quality; however, incentives for routine implementation were reported to be lacking. Findings will guide future revisions of the ROMA COS and the development of theoretically informed implementation strategies. Supplemental Material https://doi.org/10.23641/asha.16528524.

Long-Term Stability of Short-Term Intensive Language-Action Therapy in Chronic Aphasia: A 1-2 year Follow-Up Study

Background. Intensive aphasia therapy can improve language functions in chronic aphasia over a short therapy interval of 2-4 weeks. For one intensive method, intensive language-action therapy, beneficial effects are well documented by a range of randomized controlled trials. However, it is unclear to date whether therapy-related improvements are maintained over years. Objective. The current study aimed at investigating long-term stability of ILAT treatment effects over circa 1-2 years (8-30 months). Methods. 38 patients with chronic aphasia participated in ILAT and were re-assessed at a follow-up assessment 8-30 months after treatment, which had been delivered 6-12.5 hours per week for 2-4 weeks. Results. A standardized clinical aphasia battery, the Aachen Aphasia Test, revealed significant improvements with ILAT that were maintained for up to 2.5 years. Improvements were relatively better preserved in comparatively young patients (<60 years). Measures of communicative efficacy confirmed improvements during intensive therapy but showed inconsistent long-term stability effects. Conclusions. The present data indicate that gains resulting from intensive speech-language therapy with ILAT are maintained up to 2.5 years after the end of treatment. We discuss this novel finding in light of a possible move from sparse to intensive therapy regimes in clinical practice.

Computerised speech and language therapy or attention control added to usual care for people with long-term post-stroke aphasia: the Big CACTUS three-arm RCT

BACKGROUND

People with aphasia may improve their communication with speech and language therapy many months/years after stroke. However, NHS speech and language therapy reduces in availability over time post stroke.

OBJECTIVE

This trial evaluated the clinical effectiveness and cost-effectiveness of self-managed computerised speech and language therapy to provide additional therapy.

DESIGN

A pragmatic, superiority, single-blind, parallel-group, individually randomised (stratified block randomisation, stratified by word-finding severity and site) adjunct trial.

SETTING

Twenty-one UK NHS speech and language therapy departments.

PARTICIPANTS

People with post-stroke aphasia (diagnosed by a speech and language therapist) with long-standing (> 4 months) word-finding difficulties.

INTERVENTIONS

The groups were (1) usual care; (2) daily self-managed computerised word-finding therapy tailored by speech and language therapists and supported by volunteers/speech and language therapy assistants for 6 months plus usual care (computerised speech and language therapy); and (3) activity/attention control (completion of puzzles and receipt of telephone calls from a researcher for 6 months) plus usual care.

MAIN OUTCOME MEASURES

Co-primary outcomes - change in ability to find treated words of personal relevance in a bespoke naming test (impairment) and change in functional communication in conversation rated on the activity scale of the Therapy Outcome Measures (activity) 6 months after randomisation. A key secondary outcome was participant-rated perception of communication and quality of life using the Communication Outcomes After Stroke questionnaire at 6 months. Outcomes were assessed by speech and language therapists using standardised procedures. Cost-effectiveness was estimated using treatment costs and an accessible EuroQol-5 Dimensions, five-level version, measuring quality-adjusted life-years.

RESULTS

A total of 818 patients were assessed for eligibility and 278 participants were randomised between October 2014 and August 2016. A total of 240 participants (86 usual care, 83 computerised speech and language therapy, 71 attention control) contributed to modified intention-to-treat analysis at 6 months. The mean improvements in word-finding were 1.1% (standard deviation 11.2%) for usual care, 16.4% (standard deviation 15.3%) for computerised speech and language therapy and 2.4% (standard deviation 8.8%) for attention control. Computerised speech and language therapy improved word-finding 16.2% more than usual care did (95% confidence interval 12.7% to 19.6%; p < 0.0001) and 14.4% more than attention control did (95% confidence interval 10.8% to 18.1%). Most of this effect was maintained at 12 months (n = 219); the mean differences in change in word-finding score were 12.7% (95% confidence interval 8.7% to 16.7%) higher in the computerised speech and language therapy group (n = 74) than in the usual-care group (n = 84) and 9.3% (95% confidence interval 4.8% to 13.7%) higher in the computerised speech and language therapy group than in the attention control group (n = 61). Computerised speech and language therapy did not show significant improvements on the Therapy Outcome Measures or Communication Outcomes After Stroke scale compared with usual care or attention control. Primary cost-effectiveness analysis estimated an incremental cost per participant of £732.73 (95% credible interval £674.23 to £798.05). The incremental quality-adjusted life-year gain was 0.017 for computerised speech and language therapy compared with usual care, but its direction was uncertain (95% credible interval -0.05 to 0.10), resulting in an incremental cost-effectiveness ratio of £42,686 per quality-adjusted life-year gained. For mild and moderate word-finding difficulty subgroups, incremental cost-effectiveness ratios were £22,371 and £28,898 per quality-adjusted life-year gained, respectively, for computerised speech and language therapy compared with usual care.

LIMITATIONS

This trial excluded non-English-language speakers, the accessible EuroQol-5 Dimensions, five-level version, was not validated and the measurement of attention control fidelity was limited.

CONCLUSIONS

Computerised speech and language therapy enabled additional self-managed speech and language therapy, contributing to significant improvement in finding personally relevant words (as specifically targeted by computerised speech and language therapy) long term post stroke. Gains did not lead to improvements in conversation or quality of life. Cost-effectiveness is uncertain owing to uncertainty around the quality-adjusted life-year gain, but computerised speech and language therapy may be more cost-effective for participants with mild and moderate word-finding difficulties. Exploring ways of helping people with aphasia to use new words in functional communication contexts is a priority.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68798818.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 19. See the NIHR Journals Library website for further project information. The Tavistock Trust for Aphasia provided additional support to enable people in the control groups to experience the intervention after the trial had ended.

NUVA: A Naming Utterance Verifier for Aphasia Treatment

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NUVA automatically assesses online word naming attempts in aphasia therapy.

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Significantly more accurate and faster than leading commercial speech recognition.

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Accuracies between 83.6% and 93.6% validate use in clinical research.

Anomia (word-finding difficulties) is the hallmark of aphasia, an acquired language disorder most commonly caused by stroke. Assessment of speech performance using picture naming tasks is a key method for both diagnosis and monitoring of responses to treatment interventions by people with aphasia (PWA). Currently, this assessment is conducted manually by speech and language therapists (SLT). Surprisingly, despite advancements in automatic speech recognition (ASR) and artificial intelligence with technologies like deep learning, research on developing automated systems for this task has been scarce. Here we present NUVA, an utterance verification system incorporating a deep learning element that classifies 'correct' versus' incorrect' naming attempts from aphasic stroke patients. When tested on eight native British-English speaking PWA the system's performance accuracy ranged between 83.6% to 93.6%, with a 10-fold cross-validation mean of 89.5%. This performance was not only significantly better than a baseline created for this study using one of the leading commercially available ASRs (Google speech-to-text service) but also comparable in some instances with two independent SLT ratings for the same dataset.

Cost-effectiveness of speech and language therapy plus scalp acupuncture versus speech and language therapy alone for community-based patients with Broca's aphasia after stroke: a post hoc analysis of data from a randomised controlled trial

OBJECTIVE

This study aimed to assess the cost-effectiveness of combined scalp acupuncture therapy with speech and language therapy for patients with Broca's aphasia after stroke.

DESIGN

A within-trial cost-effectiveness analysis.

SETTINGS

Community health centres.

SUBJECTS

A total of 203 participants with Broca's aphasia after stroke who had been randomly assigned to receive scalp acupuncture with speech and language therapy (intervention) or speech and language therapy alone (control).

INTERVENTION

Both groups underwent speech and language therapy (30 min per day, 5 days a week, for 4 weeks), while the intervention group simultaneously received scalp acupuncture.

PRIMARY OUTCOMES

All outcomes were collected at baseline, and after the 4-week intervention and 12-week follow-up. Cost-effectiveness measures included the Chinese Rehabilitation Research Center Standard Aphasia Examination (CRRCAE) and Boston Diagnostic Aphasia Examination (BDAE). Cost-utility was evaluated using quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratios were expressed, and sensitivity analysis was conducted.

RESULTS

The total cost to deliver the intervention was €4001.72, whereas it was €4323.57 for the control group. The incremental cost-effectiveness ratios showed that the intervention was cost-effective (€495.1 per BDAE grade gained; €1.8 per CRRCAE score gained; €4597.1 per QALYs gained) relative to the control over the 12 weeks. The intervention had a 56.4% probability of being cost-effective at the ¥50 696 (€6905.87) Gross Domestic Product (GDP) per capita threshold. Sensitivity analyses confirmed the robustness of the results.

CONCLUSIONS

Compared with speech and language therapy alone, the addition of scalp acupuncture was cost-effective in Chinese communities. As the costs of acupuncture services in China are likely to differ from other countries, these results should be carefully interpreted and remain to be confirmed in other populations.

TRIAL REGISTRATION NUMBER

ChiCTR-TRC-13003703.

The economic burden of stroke: a systematic review of cost of illness studies

Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.

Melodic Intonation Therapy for Post-stroke Non-fluent Aphasia: Systematic Review and Meta-Analysis

Introduction: Melodic intonation therapy (MIT) is one of the most studied speech and language therapy (SLT) approaches for patients with non-fluent aphasia, although the methodological quality of the studies has been rated as low in previous reviews. The aim of this study is to update current evidence on the possible efficacy of MIT for the treatment of non-fluent post-stroke aphasia.

Methods: A systematic review and meta-analysis. We selected randomized clinical trials (RCT) that included adult patients over 18 years of age with non-fluent post-stroke aphasia, whose intervention was MIT vs. no therapy or other therapy. We excluded non-RCT studies, mixed populations including patients with aphasia of non-stroke etiology, studies with no availability of post-stroke aphasia-specific data, and incomplete studies. Three sections of communicative ability were analyzed as outcomes: functional communication, expressive language (naming and repetition), and comprehension.

Results: We identified a total of four eligible RCTs involving 94 patients. Despite the heterogeneity in the psychometric tests employed among the trials, a significant effect of MIT on functional communication (evaluated by the Communication Activity Log) was found (SMD 1.47; 95% CI 0.39–2.56). In addition, a positive effect of MIT on expressive language (repetition) was found (SMD 0.45; 95% CI 0.01–0.90). No significant effects on comprehension measurements were found, despite a lack of significant statistical heterogeneity.

Conclusion: This systematic review and meta-analysis shows a significant effect of MIT on improving functional communication and on repetition tasks. Future larger RCT specifically addressing those outcomes should provide the definite evidence on the efficacy of MIT on post-stroke aphasia recovery.

Systematic Review Registration:PROSPERO-URL https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020144604.

Individualized response to semantic versus phonological aphasia therapies in stroke

Attempts to personalize aphasia treatment to the extent where it is possible to reliably predict individual response to a particular treatment have yielded inconclusive results. The current study aimed to (i) compare the effects of phonologically versus semantically focussed naming treatment and (ii) examine biographical and neuropsychological baseline factors predictive of response to each treatment. One hundred and four individuals with chronic post-stroke aphasia underwent 3 weeks of phonologically focussed treatment and 3 weeks of semantically focussed treatment in an unblinded cross-over design. A linear mixed-effects model was used to compare the effects of treatment type on proportional change in correct naming across groups. Correlational analysis and stepwise regression models were used to examine biographical and neuropsychological predictors of response to phonological and semantic treatment across all participants. Last, chi-square tests were used to explore the association between treatment response and phonological and semantic deficit profiles. Semantically focussed treatment was found to be more effective at the group-level, independently of treatment order (P = 0.041). Overall, milder speech and language impairment predicted good response to semantic treatment (r range: 0.256-0.373) across neuropsychological tasks. The Western Aphasia Battery-Revised Spontaneous Speech score emerged as the strongest predictor of semantic treatment response (R ² = 0.188). Severity of stroke symptoms emerged as the strongest predictor of phonological treatment response (R ² = 0.103). Participants who showed a good response to semantic treatment were more likely to present with fluent speech compared to poor responders (P = 0.005), whereas participants who showed a good response to phonological treatment were more likely to present with apraxia of speech (P = 0.020). These results suggest that semantic treatment may be more beneficial to the improvement of naming performance in aphasia than phonological treatment, at the group-level. In terms of personalized predictors, participants with relatively mild impairments and fluent speech responded better to semantic treatment, while phonological treatment benefitted participants with more severe impairments and apraxia of speech.

Novel Advances to Post-Stroke Aphasia Pharmacology and Rehabilitation

Aphasia is one of the most common clinical features of functional impairment after a stroke. Approximately 21–40% of stroke patients sustain permanent aphasia, which progressively worsens one’s quality of life and rehabilitation outcomes. Post-stroke aphasia treatment strategies include speech language therapies, cognitive neurorehabilitation, telerehabilitation, computer-based management, experimental pharmacotherapy, and physical medicine. This review focuses on current evidence of the effectiveness of impairment-based aphasia therapies and communication-based therapies (as well as the timing and optimal treatment intensities for these interventions). Moreover, we present specific interventions, such as constraint-induced aphasia therapy (CIAT) and melodic intonation therapy (MIT). Accumulated data suggest that using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) is safe and can be used to modulate cortical excitability. Therefore, we review clinical studies that present TMS and tDCS as (possible) promising therapies in speech and language recovery, stimulating neuroplasticity. Several drugs have been used in aphasia pharmacotherapy, but evidence from clinical studies suggest that only nootropic agents, donepezil and memantine, may improve the prognosis of aphasia. This article is an overview on the current state of knowledge related to post-stroke aphasia pharmacology, rehabilitation, and future trends.

Factors predicting long-term recovery from post-stroke aphasia

BACKGROUND

It remains widely accepted that spontaneous recovery from aphasia is largely limited to the first related factors. This has direct implications for acute and chronic interventions for aphasia. few months following stroke. A few recent studies challenge this view, revealing that some individuals' language abilities improve even during the chronic stage.

AIMS

To identify prognostic indicators of long-term aphasia recovery.

METHODS & PROCEDURES

Eighteen people with aphasia initially evaluated in the chronic stage were retested at least one year later. The Western Aphasia Battery-Revised (WAB-R) Aphasia Quotient (AQ) was used to quantify changes in language impairment. Prognostic factors included those related to the patient (demographic, psychosocial), stroke (lesion volume and location), and treatment (medical, rehabilitative).

OUTCOMES & RESULTS

Twelve participants improved and 6 remained stable or declined. Linear regression analysis revealed that lesion volume predicted long-term language gains, with smaller lesions yielding greater improvements. Individuals who did not improve were more likely to have lesions encompassing critical frontal and temporoparietal cortical regions and interconnecting white matter pathways. Exploratory regression analysis of psychosocial and treatment-related factors revealed a positive relationship between improvement and satisfaction with life participation, and a negative relationship between improvement and perceived impairment severity. Critically, psychosocial and treatment-related factors significantly improved model fit over lesion volume, suggesting that these factors add predictive value to determining long-term aphasia prognosis.

CONCLUSIONS

Long-term aphasia recovery is multidetermined by a combination of stroke-, psychosocial-, and treatment-related factors. This has direct implications for acute and chronic interventions for aphasia.

A systematic review of maintenance following intensive therapy programs in chronic post-stroke aphasia: importance of individual response analysis

PURPOSE

Recent evidence supports the benefit of intensive aphasia intervention programs for people with chronic aphasia, yet it is unclear if all participants can expect positive outcomes and for how long therapeutic gains last.

METHODS

We systematically searched for studies investigating intensive interventions in chronic aphasia. To explore individual response rates and maintenance of therapeutic gains we carried out meta-synthesis by calculating and analysing the Standard Error of Measurement and Minimal Detectable Change metrics of six common outcome measures.

RESULTS

Forty-four studies comprising 24 experimental (13 group, 11 single-subject) and 20 non-experimental studies met our inclusion criteria (n = 670). Whereas most group studies reported statistically significant post-therapy improvement and maintenance, analysis of individual participant data (IPD, n = 393) from these studies revealed that only about a third of participants were classified as "immediate responders," of which more than a third had lost their initial immediate gains at follow-up. This pattern did not change when IPD from single-subject studies (n = 49) was added to the analysis. Thus, only 22% of all IPD receiving an intensive intervention improved significantly and maintained their therapy gains.

CONCLUSIONS

Intensive aphasia therapy is effective when measured at the group-level, but many individuals do not respond significantly to the intervention, and even fewer individuals preserve their initial gains. Group study results do not allow prediction of an individual's response to the intervention. Future research should elucidate which factors mediate positive treatment response and maintenance for an individual.Implications for rehabilitationOnly a small proportion (about one fifth in this review) of intensive aphasia treatment program participants respond and maintain their therapy gains, a fact that is obscured by traditional p-value group analysis.A simple clinical decision-making method is presented for evaluating individual therapy gains and their maintenance.For some immediate treatment responders (about one third in this review), gains from intensive therapy programs are unlikely to be maintained in the long-term without additional, ongoing practice.Clinicians should consider the possibility of individual clients losing some of their therapy gains and take proactive steps to support long-term maintenance.

Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association

The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.

Implementation and Effects of an Information Technology-Based Intervention to Support Speech and Language Therapy Among Stroke Patients With Aphasia: Protocol for a Virtual Randomized Controlled Trial

Background

Mobile app–based therapies are increasingly being employed by speech-language pathologists in the rehabilitation of people with aphasia as adjuncts or substitutes for traditional in-person therapy approaches. These apps can increase the intensity of treatment and have resulted in meaningful outcomes across several domains.

Objective

VoiceAdapt is a mobile therapy app designed with user and stakeholder feedback within a user-centered design framework. VoiceAdapt uses two evidence-based lexical retrieval treatments to help people with aphasia in improving their naming abilities through interactions with the app. The purpose of the randomized controlled trial (RCT) proposed here is to examine the feasibility and clinical efficacy of training with VoiceAdapt on the language and communication outcomes of people with aphasia.

Methods

A multicenter RCT is being conducted at two locations within Canada. A total of 80 people with aphasia will be recruited to participate in a two-arm, waitlist-controlled, crossover group RCT. After baseline assessment, participants will be randomized into an intervention group or a waitlist control group. The intervention group participants will engage in 5 weeks of training with the app, followed by posttreatment and follow-up assessments after an additional 5 weeks. Those in the waitlist control group will have no training for 5 weeks; this is followed by pretreatment assessment, training for 5 weeks, and posttreatment assessment. All trial procedures are being conducted remotely given the COVID-19 pandemic.

Results

Recruitment of participants started in September 2020, and the study is expected to be completed by March 2022. Publication of results is expected within 6 months of study completion.

Conclusions

The results of the RCT will provide information on evidence-based practice using technology-based solutions to treat aphasia. If positive results are obtained from this RCT, the VoiceAdapt app can be recommended as an efficacious means of improving lexical retrieval and communicative functioning in people with aphasia in an easily accessible and a cost-effective manner. Moreover, the implementation of this RCT through remote assessment and delivery can provide information to therapists on telerehabilitation practices and monitoring of app-based home therapy programs.

Trial Registration

ClinicalTrials.gov NCT04108364; https://clinicaltrials.gov/ct2/show/NCT04108364

International Registered Report Identifier (IRRID)

DERR1-10.2196/30621

Telerehabilitation for people with aphasia: A systematic review and meta-analysis

OBJECTIVES

To evaluate effectiveness or non-inferiority of telerehabilitation for people with aphasia when compared to conventional face-to-face speech and language therapy.

MATERIALS AND METHODS

Five electronic databases (PUBMED, EMBASE, WEB OF SCIENCE, SCOPUS and the Cochrane Library) were searched. We extrapolated data from the included studies and evaluated the methodological quality using the Revised Cochrane risk-of-bias tool for Randomized Trials (RoB 2) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). A meta-analysis compared effects of intervention, and it was conducted using the Review Manager 5.3 software. GRADE profile to assess overall quality of evidence was carried out.

RESULTS

Out of a total of 1157 records, five studies met the inclusion criteria and were eligible for meta-analysis with a total of 132 participants with post-stroke aphasia.

DISCUSSION

Results revealed that telerehabilitation and face-to-face speech and language treatment are comparable with respect to the gains achieved in auditory comprehension (SMD = -0.02; 95% CI -0.39, 0.35), naming accuracy (SMD = -0.09; 95% CI -0.44, 0.25), Aphasia Quotient (MD = -2.18; 95% CI -16.00, 11.64), generalization (SMD = 0.77; 95% IC -0.95, 2.49) and functional communication skills (SMD = -0.08; 95% IC -0.54, 0.38).

CONCLUSION

Although evidence is still insufficient to guide clinical decision making due to the relatively low quality of the evidence identified, the analysis of the results suggest that telerehabilitation training for aphasia seems to be as effective as the conventional face-to-face treatment.

Effectiveness of Acupuncture for Poststroke Aphasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Aphasia is one of the common complications of stroke, and it considerably influences the quality of life of patients. Acupuncture, a therapy used in traditional Chinese medicine for aphasia after stroke, has potential therapeutic effects. We aimed to investigate the therapeutic effect of acupuncture on individuals with poststroke aphasia.

METHODS

Randomized controlled trials (RCTs) on acupuncture for poststroke aphasia (either alone or combined with other therapies) were included and compared. We conducted a systematic review and meta-analysis by searching databases, such as MEDLINE, Cochrane Library, Embase, China National Knowledge Infrastructure, VIP, and Wanfang, from inception to July 15, 2019. No language restrictions were applied in this study.

RESULTS

Fourteen trials involving 936 participants had poor reporting and methodological quality. Our meta-analysis showed that compared to the speech and language therapy (SLT) group, acupuncture combined with SLT could improve the rate of Boston Diagnostic Aphasia Examination (BDAE) (OR: 0.15, 95% confidence interval [CI]: 0.04-0.25, p = 0.005), scores of Aphasia Battery of Chinese (ABC) which includes repeating ability (SMD: 1.46, 95% CI: 1.24-1.69, p < 0.00001), reading ability (SMD: 1.57, 95% CI: 1.25-1.90, p < 0.00001), writing ability (SMD: 1.52, 95% CI: 1.19-1.86, p < 0.00001), naming ability (SMD: 1.40, 95% CI: 1.04-1.76, p < 0.00001), and listening comprehension ability (SMD: 0.57, 95% CI: 0.22-0.92, p = 0.001). All RCTs were considered at high risk of biased assessment.

CONCLUSIONS

Acupuncture (either alone or combined with SLT) may be effective for poststroke aphasia. In the future, rigorous clinical trials with an accurate method design and high reporting quality are required to validate our results.

Vocal music listening enhances post-stroke language network reorganization

Listening to vocal music has been recently shown to improve language recovery in stroke survivors. The neuroplasticity mechanisms supporting this effect are, however, still unknown. Using data from a three-arm single-blind randomized controlled trial including acute stroke patients (N=38) and a 3-month follow-up, we set out to compare the neuroplasticity effects of daily listening to self-selected vocal music, instrumental music, and audiobooks on both brain activity and structural connectivity of the language network. Using deterministic tractography we show that the 3-month intervention induced an enhancement of the microstructural properties of the left frontal aslant tract (FAT) for the vocal music group as compared to the audiobook group. Importantly, this increase in the strength of the structural connectivity of the left FAT correlated with improved language skills. Analyses of stimulus-specific activation changes showed that the vocal music group exhibited increased activations in the frontal termination points of the left FAT during vocal music listening as compared to the audiobook group from acute to 3-month post-stroke stage. The increased activity correlated with the structural neuroplasticity changes in the left FAT. These results suggest that the beneficial effects of vocal music listening on post-stroke language recovery are underpinned by structural neuroplasticity changes within the language network and extend our understanding of music-based interventions in stroke rehabilitation.Significance statementPost-stroke language deficits have a devastating effect on patients and their families. Current treatments yield highly variable outcomes and the evidence for their long-term effects is limited. Patients often receive insufficient treatment that are predominantly given outside the optimal time window for brain plasticity. Post-stroke vocal music listening improves language outcome which is underpinned by neuroplasticity changes within the language network. Vocal music listening provides a complementary rehabilitation strategy which could be safely implemented in the early stages of stroke rehabilitation and seems to specifically target language symptoms and recovering language network.

Cognitive linguistic Treatment in Landau Kleffner Syndrome: Improvement in Daily Life Communication

We report a case study of cognitive linguistic treatment in a teenager with chronic severe Landau Kleffner Syndrome. The effect of speech and language therapy in LKS is rarely examined and our case is unique in that we use an effective approach in adult aphasia to treat language deficits in aphasia in LKS. The results show successful acquisition of a considerable amount of new words as well as improved communication in daily life. However, auditory verbal agnosia, the most prominent feature in LKS, persisted. Cognitive linguistic treatment seems a promising treatment to improve spoken language production in LKS, but more research is needed to optimize speech and language therapy of auditory verbal agnosia and auditory language comprehension in children with LKS

Clinical Effectiveness of the Queen Square Intensive Comprehensive Aphasia Service for Patients With Poststroke Aphasia

Supplemental Digital Content is available in the text.

Poststroke aphasia has a major impact on peoples’ quality of life. Speech and language therapy interventions work, especially in high doses, but these doses are rarely achieved outside of research studies. Intensive Comprehensive Aphasia Programs (ICAPs) are an option to deliver high doses of therapy to people with aphasia over a short period of time.

An Exploratory Study of Cerebellar Transcranial Direct Current Stimulation in Individuals With Chronic Stroke Aphasia

BACKGROUND

Aphasia is a common, debilitating consequence of stroke, and speech therapy is often inadequate to achieve a satisfactory outcome. Neuromodulation techniques have emerged as a potential augmentative treatment for improving aphasia outcomes. Most studies have targeted the cerebrum, but there are theoretical and practical reasons that stimulation over the cerebral hemispheres might not be ideal. On the other hand, the right cerebellum is functionally and anatomically linked to major language areas in the left hemisphere, making it a promising alternative target site for stimulation.

OBJECTIVE

To provide preliminary effect sizes for the ability of a short course of anodal transcranial direct current stimulation (tDCS) targeted over the right cerebellum to enhance language processing in individuals with chronic poststroke aphasia.

METHOD

Ten individuals received five sessions of open-label anodal tDCS targeting the right cerebellum. The effects of the tDCS were compared with the effects of sham tDCS on 14 controls from a previous clinical trial. In total, 24 individuals with chronic poststroke aphasia participated in the study. Behavioral testing was conducted before treatment, immediately following treatment, and at the 3-month follow-up.

RESULTS

Cerebellar tDCS did not significantly enhance language processing measured either immediately following treatment or at the 3-month follow-up. The effect sizes of tDCS over sham treatment were generally nil or small, except for the mean length of utterance on the picture description task, for which medium to large effects were observed.

CONCLUSION

These results may provide guidance for investigators who are planning larger trials of tDCS for individuals with chronic poststroke aphasia.

Functional Magnetic Resonance Imaging of Language Following Constraint-Induced Aphasia Therapy Primed with Intermittent Theta Burst Stimulation in 13 Patients with Post-Stroke Aphasia

Background

Aphasia is a debilitating consequence of stroke. This study aimed to investigate the role of functional magnetic resonance imaging (fMRI) activation changes during overt language tasks in promoting language improvements following constraint-induced aphasia therapy (CIAT) primed with intermittent theta burst stimulation (iTBS) in 13 patients with aphasia following ischemic stroke.

Material/Methods

Participants with post-stroke aphasia participated in CIAT primed with iTBS on 10 consecutive weekdays. They also underwent language testing and fMRI while performing overt language tasks at baseline (N=13), immediately post-treatment (N=13), and after 3 months (N=12). Outcome measures were compared between time points, and relationships between changes in language ability and fMRI activation were examined.

Results

We observed improvements in naming (p<0.001), aphasia symptoms (p=0.038), apraxia of speech symptoms (p=0.040), perception of everyday communicative ability (p=0.001), and the number of spoken words produced during fMRI (p=0.028). Pre- to post-treatment change in naming was negatively correlated with change in right postcentral gyrus activation related to noun-verb associations (rho=−0.554, p=0.0497). Change in aphasia symptoms from immediately after to 3 months post-treatment was negatively correlated with change in bilateral supplementary motor area activation related to verbal encoding (rho=−0.790, p=0.0022).

Conclusions

Aphasia improvements coupled with fMRI activation changes over time provide support for treatment-induced neuroplasticity with CIAT primed with iTBS. However, a larger randomized sham-controlled study is warranted to confirm our findings and further our understanding of how iTBS can potentiate beneficial effects of language therapy in post-stroke aphasia.

Treatment of post-stroke aphasia: A narrative review for stroke neurologists

This review is intended to help physicians guide patients to optimal management of post-stroke aphasia. We review literature on post-stroke aphasia treatment, focusing on: (1) when and for whom language therapy is most effective, (2) the variety of approaches that can be effective for different individuals, and (3) the extent to which behavioral therapy might be augmented by non-invasive brain stimulation and/or medications.

Current Approaches to the Treatment of Post-Stroke Aphasia

Aphasia, impairment of language after stroke or other neurological insult, is a common and often devastating condition that affects nearly every social activity and interaction. Behavioral speech and language therapy is the mainstay of treatment, although other interventions have been introduced to augment the effects of the behavioral therapy. In this narrative review, we discuss advances in aphasia therapy in the last 5 years and focus primarily on properly powered, randomized, controlled trials of both behavioral therapies and interventions to augment therapy for post-stroke aphasia. These trials include evaluation of behavioral therapies and computer-delivered language therapies. We also discuss outcome prediction trials as well as interventional trials that have employed noninvasive brain stimulation, or medications to augment language therapy. Supported by evidence from Phase III trials and large meta-analyses, it is now generally accepted that aphasia therapy can improve language processing for many patients. Not all patients respond similarly to aphasia therapy with the most severe patients being the least likely responders. Nevertheless, it is imperative that all patients, regardless of severity, receive aphasia management focused on direct therapy of language deficits, counseling, or both. Emerging evidence from Phase II trials suggests transcranial brain stimulation is a promising method to boost aphasia therapy outcomes.

Self-managed, computerised word finding therapy as an add-on to usual care for chronic aphasia post-stroke: An economic evaluation

OBJECTIVE

To examine the cost-effectiveness of self-managed computerised word finding therapy as an add-on to usual care for people with aphasia post-stroke.

DESIGN

Cost-effectiveness modelling over a life-time period, taking a UK National Health Service (NHS) and personal social service perspective.

SETTING

Based on the Big CACTUS randomised controlled trial, conducted in 21 UK NHS speech and language therapy departments.

PARTICIPANTS

Big CACTUS included 278 people with long-standing aphasia post-stroke.

INTERVENTIONS

Computerised word finding therapy plus usual care; usual care alone; usual care plus attention control.

MAIN MEASURES

Incremental cost-effectiveness ratios (ICER) were calculated, comparing the cost per quality adjusted life year (QALY) gained for each intervention. Credible intervals (CrI) for costs and QALYs, and probabilities of cost-effectiveness, were obtained using probabilistic sensitivity analysis. Subgroup and scenario analyses investigated cost-effectiveness in different subsets of the population, and the sensitivity of results to key model inputs.

RESULTS

Adding computerised word finding therapy to usual care had an ICER of £42,686 per QALY gained compared with usual care alone (incremental QALY gain: 0.02 per patient (95% CrI: -0.05 to 0.10); incremental costs: £732.73 per patient (95% CrI: £674.23 to £798.05)). ICERs for subgroups with mild or moderate word finding difficulties were £22,371 and £21,262 per QALY gained respectively.

CONCLUSION

Computerised word finding therapy represents a low cost add-on to usual care, but QALY gains and estimates of cost-effectiveness are uncertain. Computerised therapy is more likely to be cost-effective for people with mild or moderate, as opposed to severe, word finding difficulties.

Predictors of Poststroke Aphasia Recovery: A Systematic Review-Informed Individual Participant Data Meta-Analysis

BACKGROUND AND PURPOSE

The factors associated with recovery of language domains after stroke remain uncertain. We described recovery of overall-language-ability, auditory comprehension, naming, and functional-communication across participants' age, sex, and aphasia chronicity in a large, multilingual, international aphasia dataset.

METHODS

Individual participant data meta-analysis of systematically sourced aphasia datasets described overall-language ability using the Western Aphasia Battery Aphasia-Quotient; auditory comprehension by Aachen Aphasia Test (AAT) Token Test; naming by Boston Naming Test and functional-communication by AAT Spontaneous-Speech Communication subscale. Multivariable analyses regressed absolute score-changes from baseline across language domains onto covariates identified a priori in randomized controlled trials and all study types. Change-from-baseline scores were presented as estimates of means and 95% CIs. Heterogeneity was described using relative variance. Risk of bias was considered at dataset and meta-analysis level.

RESULTS

Assessments at baseline (median=43.6 weeks poststroke; interquartile range [4-165.1]) and first-follow-up (median=10 weeks from baseline; interquartile range [3-26]) were available for n=943 on overall-language ability, n=1056 on auditory comprehension, n=791 on naming and n=974 on functional-communication. Younger age (<55 years, +15.4 Western Aphasia Battery Aphasia-Quotient points [CI, 10.0-20.9], +6.1 correct on AAT Token Test [CI, 3.2-8.9]; +9.3 Boston Naming Test points [CI, 4.7-13.9]; +0.8 AAT Spontaneous-Speech Communication subscale points [CI, 0.5-1.0]) and enrollment <1 month post-onset (+19.1 Western Aphasia Battery Aphasia-Quotient points [CI, 13.9-24.4]; +5.3 correct on AAT Token Test [CI, 1.7-8.8]; +11.1 Boston Naming Test points [CI, 5.7-16.5]; and +1.1 AAT Spontaneous-Speech Communication subscale point [CI, 0.7-1.4]) conferred the greatest absolute change-from-baseline across each language domain. Improvements in language scores from baseline diminished with increasing age and aphasia chronicity. Data exhibited no significant statistical heterogeneity. Risk-of-bias was low to moderate-low.

CONCLUSIONS

Earlier intervention for poststroke aphasia was crucial to maximize language recovery across a range of language domains, although recovery continued to be observed to a lesser extent beyond 6 months poststroke.

Statistical analysis plan for the COMPARE trial: a 3-arm randomised controlled trial comparing the effectiveness of Constraint-induced Aphasia Therapy Plus and Multi-modality Aphasia Therapy to usual care in chronic post-stroke aphasia (COMPARE)

BACKGROUND

While high-quality meta-analyses have confirmed the effectiveness of aphasia therapy after stroke, there is limited evidence for the comparative effectiveness of different aphasia interventions. Two commonly used interventions, Constraint-induced Aphasia Therapy Plus (CIAT Plus) and Multi-modality Aphasia Therapy (M-MAT), are hypothesised to rely on diverse underlying neural mechanisms for recovery and may be differentially responsive to aphasia severity. COMPARE is a prospective randomised open-blinded end-point trial designed to determine whether, in people with chronic post-stroke aphasia living in the community, CIAT Plus and M-MAT provide greater therapeutic benefit compared to usual care, are differentially effective according to aphasia severity, and are cost-effective. This paper details the statistical analysis plan for the COMPARE trial developed prior to data analysis.

METHODS

Participants (n = 216) are randomised to one of three arms, CIAT Plus, M-MAT or usual care, and undertake therapy with a study trained speech pathologist in groups of three participants stratified by aphasia severity. Therapy occurs for 3 h blocks per day for 10 days across 2 weeks. The primary clinical outcome is aphasia severity as measured by the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ) immediately post intervention. Secondary outcomes include WAB-R-AQ at 12-week follow-up, and functional communication, discourse efficiency, multimodal communication, and health-related quality of life immediately post intervention and at 12-week follow-up.

RESULTS

Linear mixed models (LMMs) will be used to analyse differences between M-MAT and UC, and CIAT-Plus and UC on each outcome measure immediately and at 12 weeks post-intervention. The LMM for WAB-R-AQ will assess the differences in efficacy between M-MAT and CIAT-Plus. All analyses will control for baseline aphasia severity (fixed effect) and for the clustering effect of treatment groups (random effect).

DISCUSSION

This trial will provide relative effectiveness data for two common interventions for people with chronic post-stroke aphasia, and highlight possible differential effects based on aphasia severity. Together with the health economic analysis data, the results will enable more informed personalised prescription for aphasia therapy after stroke.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN 12615000618550 . Registered on 15 June 2016.

Predicting language recovery in post-stroke aphasia using behavior and functional MRI

Language outcomes after speech and language therapy in post-stroke aphasia are challenging to predict. This study examines behavioral language measures and resting state fMRI (rsfMRI) as predictors of treatment outcome. Fifty-seven patients with chronic aphasia were recruited and treated for one of three aphasia impairments: anomia, agrammatism, or dysgraphia. Treatment effect was measured by performance on a treatment-specific language measure, assessed before and after three months of language therapy. Each patient also underwent an additional 27 language assessments and a rsfMRI scan at baseline. Patient scans were decomposed into 20 components by group independent component analysis, and the fractional amplitude of low-frequency fluctuations (fALFF) was calculated for each component time series. Post-treatment performance was modelled with elastic net regression, using pre-treatment performance and either behavioral language measures or fALFF imaging predictors. Analysis showed strong performance for behavioral measures in anomia (R² = 0.948, n = 28) and for fALFF predictors in agrammatism (R² = 0.876, n = 11) and dysgraphia (R² = 0.822, n = 18). Models of language outcomes after treatment trained using rsfMRI features may outperform models trained using behavioral language measures in some patient populations. This suggests that rsfMRI may have prognostic value for aphasia therapy outcomes.

Machine learning-based multimodal prediction of language outcomes in chronic aphasia

Recent studies have combined multiple neuroimaging modalities to gain further understanding of the neurobiological substrates of aphasia. Following this line of work, the current study uses machine learning approaches to predict aphasia severity and specific language measures based on a multimodal neuroimaging dataset. A total of 116 individuals with chronic left-hemisphere stroke were included in the study. Neuroimaging data included task-based functional magnetic resonance imaging (fMRI), diffusion-based fractional anisotropy (FA)-values, cerebral blood flow (CBF), and lesion-load data. The Western Aphasia Battery was used to measure aphasia severity and specific language functions. As a primary analysis, we constructed support vector regression (SVR) models predicting language measures based on (i) each neuroimaging modality separately, (ii) lesion volume alone, and (iii) a combination of all modalities. Prediction accuracy across models was subsequently statistically compared. Prediction accuracy across modalities and language measures varied substantially (predicted vs. empirical correlation range: r = .00-.67). The multimodal prediction model yielded the most accurate prediction in all cases (r = .53-.67). Statistical superiority in favor of the multimodal model was achieved in 28/30 model comparisons (p-value range: <.001-.046). Our results indicate that different neuroimaging modalities carry complementary information that can be integrated to more accurately depict how brain damage and remaining functionality of intact brain tissue translate into language function in aphasia.

Effect of triangular electrode schemes on Broca's cortical stimulation: conventional and HD-tDCS study

Transcranial direct current stimulation (tDCS) is a therapeutic and complementary treatment in several cognitive diseases, psychiatric disorders, and disabilities that occur due to an accident or stroke. In the current research, we aimed to boost some parts of the stimulation structure and proposed a new electrode scheme in the mentioned approach. After segmenting magnetic resonance imaging (MRI) scans and using a tissue correction routine algorithm, we attempted to create an appropriate head model and electrode placement according to electric stimulation, whereby we completed tDCS processing. The considered electrodes are divided into two general categories. All the considered electrodes consist of rectangular, circular, triangular, and empty triangular patches with specific dimensions. We investigated common electrode schemes and introduced better electrode schemes for more effective cortical stimulation. We observed that the triangular electrodes in the conventional and anodal arrangement in the triangular 4 × 1 HD-tDCS create more electric field than others. Also, we calculated the current density and attempted to substantially improve it. Therefore, we recommended the empty triangular schemes. We investigated the designed model thoroughly and observed that it increased the current density not only in the conventional but also in the HD-tDCS. Graphical abstract.

Accuracy of NIH Stroke Scale for diagnosing aphasia

OBJECTIVES

The National Institutes of Health Stroke Scale (NIHSS) has not been validated to diagnose aphasia in the stroke population. We therefore examined the diagnostic accuracy of NIHSS for detecting aphasia in acute ischemic stroke.

METHODS

Consecutive patients with acute first-ever ischemic stroke were included prospectively in Lund Stroke Register Study at Skåne University Hospital, Sweden. Exclusion criteria were: (a) non-native Swedish; (b) obtundation (c) dementia or psychiatric diagnosis. Patients were assessed with NIHSS item 9 (range 0-3, where 1-3 indicate aphasia) by a NIHSS certified research nurse in the acute phase after stroke onset (median 3 days). Within 24 h after this assessment, a speech therapist evaluated the patients' language function with the comprehensive language screening test (LAST, range 0-15 where 0-14 indicates aphasia). Data were analyzed using LAST as 'reference standard'.

RESULTS

We examined 221 patients. Among these, 23% (n = 50) had aphasia according to NIHSS (distribution of scores 0, 1, 2, 3 were n = 171, n = 29, n = 12, n = 9) compared to 26% (n = 58) with aphasia according to LAST (score ≤14; median = 11). Assuming LAST as reference standard, NIHSS gave 16 false negatives (NIHSS item 9 = 0) for aphasia (LAST scores range 8-14), and 8 false positives (NIHSS item 9 score = 1) for aphasia, yielding a sensitivity of 72% (0.59-0.83) and a specificity of 95% (0.91-0.98).

CONCLUSIONS

When using NIHSS for screening and diagnosing aphasia in adults with acute ischemic stroke, patients with severe aphasia can be detected, however, some mild aphasias might be misclassified. Given the 72% sensitivity, absence of aphasia on the NIHSS should not be used to guide stroke treatment.

Spectral Resting-State EEG (rsEEG) in Chronic Aphasia Is Reliable, Sensitive, and Correlates With Functional Behavior

We investigated spectral resting-state EEG in persons with chronic stroke-induced aphasia to determine its reliability, sensitivity, and relationship to functional behaviors. Resting-state EEG has not yet been characterized in this population and was selected given the demonstrated potential of resting-state investigations using other neuroimaging techniques to guide clinical decision-making. Controls and persons with chronic stroke-induced aphasia completed two EEG recording sessions, separated by approximately 1 month, as well as behavioral assessments of language, sensorimotor, and cognitive domains. Power in the classic frequency bands (delta, theta, alpha, and beta) was examined via spectral analysis of resting-state EEG data. Results suggest that power in the theta, alpha, and beta bands is reliable for use as a repeated measure. Significantly greater theta and lower beta power was observed in persons with aphasia (PWAs) than controls. Finally, in PWAs theta power negatively correlated with performance on a discourse informativeness measure, while alpha and beta power positively correlated with performance on the same measure. This indicates that spectral rsEEG slowing observed in PWAs in the chronic stage is pathological and suggests a possible avenue for directly altering brain activation to improve behavioral function. Taken together, these results suggest that spectral resting-state EEG holds promise for sensitive measurement of functioning and change in persons with chronic aphasia. Future studies investigating the utility of these measures as biomarkers of frank or latent aphasic deficits and treatment response in chronic stroke-induced aphasia are warranted.

Extended fMRI-Guided Anodal and Cathodal Transcranial Direct Current Stimulation Targeting Perilesional Areas in Post-Stroke Aphasia: A Pilot Randomized Clinical Trial

Transcranial direct current stimulation (tDCS) may enhance speech and language treatment (SLT) for stroke survivors with aphasia; however, to date, there is no standard protocol for the application of tDCS in post-stroke aphasia. We explored the safety and efficacy of fMRI-guided tDCS on functional language and cortical activity when delivered to the lesioned left hemisphere concurrently with SLT across an extended, six-week treatment period. Twelve persons with chronic, nonfluent aphasia following a single left-hemisphere stroke participated in the three-arm (anodal vs. cathodal vs. sham) single-blind, parallel, pilot trial. No serious adverse events occurred during 30 treatment sessions or in the following six weeks. All groups demonstrated functional language gains following intensive treatment; however, active tDCS resulted in greater gains in standardized, probe, and caregiver-reported measures of functional language than sham. Evidence declaring one polarity as superior for inducing language recovery was mixed. However, cathodal stimulation to the lesioned left hemisphere, expected to have a down-regulating effect, resulted in increased areas of cortical activation across both hemispheres, and specifically perilesionally. Generalization of these preliminary findings is limited; however, results are nevertheless compelling that tDCS combined with SLT can be safely applied across extended durations, with the potential to enhance functional language and cortical activation for persons with aphasia.

Evaluating the Long-Term Efficacy of Acupuncture Therapy for Subacute Poststroke Aphasia: Study Protocol for a Randomized, Blinded, Controlled, Multicentre Trial

Background

Poststroke aphasia (PSA) is a disabling condition that decreases the quality of life, and the duration of the disease harms the quality of life of PSA patients. Acupuncture has been widely employed for PSA. There is some evidence for the immediate treatment efficacy of acupuncture for PSA; however, long-term results after acupuncture may be poorer.

Methods

This is a multicentre, randomized, blinded, nonacupoint (NA) acupuncture controlled, multimodal neuroimaging clinical trial. A total of 48 subjects with subacute PSA will be randomly assigned to an acupoint group or an NA control group. The acupoint group will receive acupuncture with normal needling at DU20, EX-HN1, HT5, GB39, EX-HN12, EX-HN13, and CV23. The NA control group will receive acupuncture in locations not corresponding to acupuncture points as sham acupoints. Both groups will receive identical speech and language therapy thrice a week for four weeks. The primary outcome will be the change in the aphasia quotient (AQ) score measured by the Western Aphasia Battery (WAB) test during the 12th week after randomization. Participants will be blindly assessed at prerandomization (baseline) and 4 weeks, 12 weeks, and 24 weeks after randomization. The secondary outcomes include the Boston Diagnostic Aphasia Examination (BDAE) score, the Disease Prognosis Scale score for ischaemic stroke, etc. Magnetic resonance imaging (MRI) and electroencephalogram (EEG) will also be performed at 4-time intervals as secondary outcomes. All scores and image evaluations will be taken at the same point as the linguistic evaluation. The multilevel evaluation technique will be used to assess the long-term efficacy of acupuncture therapy. MRI scans and EEG will be used to assess acupuncture-related neuroplasticity changes. Discussion. The results from our trial will help to supply evidence for the long-term acupuncture effects for PSA over a long follow-up period. It will provide valuable information for future studies in the field of PSA treatment. The trial was registered at the Chinese Clinical Trial Registry on 16 March 2020 (ChiCTR2000030879).

Effect of Anodic Transcranial Direct Current Stimulation Combined With Speech Language Therapy on Nonfluent Poststroke Aphasia

OBJECTIVES

Transcranial direct current stimulation (tDCS) facilitates or inhibits spontaneous neuronal activity by low-intensity current. In this study, we evaluated the effects of tDCS and sham stimulation combined with speech language therapy (SLT) on nonfluent poststroke aphasia (PSA) patients.

MATERIALS AND METHODS

Patients with PSA were randomly divided into the anode tDCS (A-tDCS) group (n = 8) and sham tDCS (S-tDCS) group (n = 10). The anodes and cathodes were fixed over left inferior gyrus frontalis (L-IFG) and the deltoid muscle of the right shoulder. A-tDCS consisted of 2 mA for 20 min, while S-tDCS current started at 2 mA but automatically decreased to 0 mA after 30 sec. Stimulation was concurrent with 30 min of SLT. Stimulation + SLT sessions occurred five times a week for four weeks. The Western Aphasia Battery (WAB) was given before treatment to obtain the baseline score and once more after all sessions were completed, and the Aphasia Quotient (AQ) was calculated.

RESULTS

After tDCS treatment, the AQ mean(SD) in both groups was significantly higher than before treatment (p < 0.001) and the AQ of the A-tDCS group 72.99 (21.91) was significantly higher than that of the S-tDCS group 46.18 (19.29) (t = 2.760, p < 0.05). Upon further analysis of the WAB subscores, except for comprehension, all other items were significantly higher in the A-tDCS group than in the S-tDCS group (p < 0.05).

CONCLUSION

Our results suggest that left inferior gyrus frontalis anodic transcranial direct current stimulation is an effective adjuvant to conventional speech language therapy for patients with nonfluent PSA.

Impact of COVID-19 on the Speech and Language Therapy Profession and Their Patients

Introduction: The UK's response to the COVID-19 pandemic presented multiple challenges to healthcare services including the suspension of non-urgent care. The impact on neurorehabilitation professions, including speech and language therapy (SLT), has been substantial. Objectives: To review the changes to SLT services triggered by the COVID-19 pandemic with respect to referral rates, service delivery and outcomes, as well as examining the contribution of SLTs to the neurorehabilitation of COVID-19 patients. Methods: Two surveys were distributed to Royal College of Speech and Language Therapists (RCSLT) members exploring experiences of service provision at 6 weeks and 22 weeks after the pandemic was declared in the UK. Responses to closed-ended questions, including questions regarding referral numbers were analyzed descriptively and compared at the two time-points. A database comprising routine clinical data from SLT services across the UK was used to compare information on patients receiving services prior to and during the pandemic. Data on COVID-19 patients was extracted, and findings are provided descriptively. Results: Referrals to SLT services during the acute COVID-19 period in the UK were substantially less than in the same period in 2019. A number of service changes were common including adopting more flexible approaches to provision (such as tele-therapy) and being unable to provide services to some patients. Database analysis suggests fewer patients have accessed SLT since the pandemic began, including a reduction in neurorehabilitation patients. For those who received SLT, the outcomes did not change. SLTs supported a range of needs of COVID-19 patients. Treatment outcomes for COVID-19 patients with dysphagia were positive. Discussion: The pandemic has affected neurorehabilitation and SLT services broadly: referral patterns are different, usual care has been disrupted and interventions have been modified affecting the impact on patient outcomes both positively and negatively. Some patients with COVID-19 require and benefit from SLT intervention.

A Virtual, Randomized, Control Trial of a Digital Therapeutic for Speech, Language, and Cognitive Intervention in Post-stroke Persons With Aphasia

Background: Post-stroke aphasia is a chronic condition that impacts people's daily functioning and communication for many years after a stroke. Even though these individuals require sustained rehabilitation, they face extra burdens to access care due to shortages in qualified clinicians, insurance limitations and geographic access. There is a need to research alternative means to access intervention remotely, such as in the case of this study using a digital therapeutic.

Objective: To assess the feasibility and clinical efficacy of a virtual speech, language, and cognitive digital therapeutic for individuals with post-stroke aphasia relative to standard of care.

Methods: Thirty two participants completed the study (experimental: average age 59.8 years, 7 female, 10 male, average education: 15.8 years, time post-stroke: 53 months, 15 right handed, 2 left handed; control: average age 64.2 years, 7 female, 8 male, average education: 15.3 years, time post-stroke: 36.1 months, 14 right handed, 1 left handed). Patients in the experimental group received 10 weeks of treatment using a digital therapeutic, Constant Therapy-Research (CT-R), for speech, language, and cognitive therapy, which provides evidence-based, targeted therapy with immediate feedback for users that adjusts therapy difficulty based on their performance. Patients in the control group completed standard of care (SOC) speech-language pathology workbook pages.

Results: This study provides Class II evidence that with the starting baseline WAB-AQ score, adjusted by −0.69 for every year of age, and by 0.122 for every month since stroke, participants in the CT-R group had WAB-AQ scores 6.43 higher than the workbook group at the end of treatment. Additionally, secondary outcome measures included the WAB-Language Quotient, WAB-Cognitive Quotient, Brief Test of Adult Cognition by Telephone (BTACT), and Stroke and Aphasia Quality of Life Scale 39 (SAQOL-39), with significant changes in BTACT verbal fluency subtest and the SAQOL-39 communication and energy scores for both groups.

Conclusions: Overall, this study demonstrates the feasibility of a fully virtual trial for patients with post-stroke aphasia, especially given the ongoing COVID19 pandemic, as well as a safe, tolerable, and efficacious digital therapeutic for language/cognitive rehabilitation.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT04488029.

Standardizing Assessment of Spoken Discourse in Aphasia: A Working Group With Deliverables

Purpose The heterogeneous nature of measures, methods, and analyses reported in the aphasia spoken discourse literature precludes comparison of outcomes across studies (e.g., meta-analyses) and inhibits replication. Furthermore, funding and time constraints significantly hinder collecting test-retest data on spoken discourse outcomes. This research note describes the development and structure of a working group, designed to address major gaps in the spoken discourse aphasia literature, including a lack of standardization in methodology, analysis, and reporting, as well as nominal data regarding the psychometric properties of spoken discourse outcomes. Method The initial initiatives for this working group are to (a) propose recommendations regarding standardization of spoken discourse collection, analysis, and reporting in aphasia, based on the results of an international survey and a systematic literature review and (b) create a database of test-retest spoken discourse data from individuals with and without aphasia. The survey of spoken discourse collection, analysis, and interpretation procedures was distributed to clinicians and researchers involved in aphasia assessment and rehabilitation from September to November 2019. We will publish survey results and recommend standards for collecting, analyzing, and reporting spoken discourse in aphasia. A multisite endeavor to collect test-retest spoken discourse data from individuals with and without aphasia will be initiated. This test-retest information will be contributed to a central site for transcription and analysis, and data will be subsequently openly curated. Conclusion The goal of the working group is to create recommendations for field-wide standards in methods, analysis, and reporting of spoken discourse outcomes, as has been done across other related disciplines (e.g., Consolidated Standards of Reporting Trials, Enhancing the Quality and Transparency of Health Research, Committee on Best Practice in Data Analysis and Sharing). Additionally, the creation of a database through our multisite collaboration will allow the identification of psychometrically sound outcome measures and norms that can be used by clinicians and researchers to assess spoken discourse abilities in aphasia.

Diagnosing and managing post-stroke aphasia

Introduction: Aphasia is a debilitating language disorder and even mild forms of aphasia can negatively affect functional outcomes, mood, quality of life, social participation, and the ability to return to work. Language deficits after post-stroke aphasia are heterogeneous. Areas covered: The first part of this manuscript reviews the traditional syndrome-based classification approach as well as recent advances in aphasia classification that incorporate automatic speech recognition for aphasia classification. The second part of this manuscript reviews the behavioral approaches to aphasia treatment and recent advances such as noninvasive brain stimulation techniques and pharmacotherapy options to augment the effectiveness of behavioral therapy. Expert opinion: Aphasia diagnosis has largely evolved beyond the traditional approach of classifying patients into specific syndromes and instead focuses on individualized patient profiles. In the future, there is a great need for more large scale randomized, double-blind, placebo-controlled clinical trials of behavioral treatments, noninvasive brain stimulation, and medications to boost aphasia recovery.

Adjunctive Approaches to Aphasia Rehabilitation: A Review on Efficacy and Safety

Aphasia is one of the most socially disabling post-stroke deficits. Although traditional therapies have been shown to induce adequate clinical improvement, aphasic symptoms often persist. Therefore, unconventional rehabilitation techniques which act as a substitute or as an adjunct to traditional approaches are urgently needed. The present review provides an overview of the efficacy and safety of the principal approaches which have been proposed over the last twenty years. First, we examined the effectiveness of the pharmacological approach, principally used as an adjunct to language therapy, reporting the mechanism of action of each single drug for the recovery of aphasia. Results are conflicting but promising. Secondly, we discussed the application of Virtual Reality (VR) which has been proven to be useful since it potentiates the ecological validity of the language therapy by using virtual contexts which simulate real-life everyday contexts. Finally, we focused on the use of Transcranial Direct Current Stimulation (tDCS), both discussing its applications at the cortical level and highlighting a new perspective, which considers the possibility to extend the use of tDCS over the motor regions. Although the review reveals an extraordinary variability among the different studies, substantial agreement has been reached on some general principles, such as the necessity to consider tDCS only as an adjunct to traditional language therapy.

Telepractice Treatment for Aphasia: Association Between Clinical Outcomes and Client Satisfaction

Introduction: Health services research has demonstrated the association between patient satisfaction and treatment outcomes illustrating the importance of satisfaction in determining favorable treatment outcomes. Despite abundant evidence in the acute care setting, few researchers have explored these associations among patients receiving speech rehabilitation or therapeutic treatment particularly those receiving treatment through nontraditional delivery methods. Objective: To examine the satisfaction with a community-based telepractice approach for treating aphasia among stroke survivors who reside in rural areas and assess potential correlations between satisfaction and patient outcomes. Methods: In total, 22 adults with poststroke aphasia who resided in rural areas received comprehensive language-oriented treatment (LOT) for aphasia through community-based telepractice. Post-treatment satisfaction with the telepractice approach was assessed using the Client Satisfaction Questionnaire-8 (CSQ-8). Results: After 12 sessions of LOT, Western Aphasia Battery-revised (WAB-R) aphasia quotients (AQs) improved on average 4.64 U. Mean scores on the CSQ-8 averaged 31.0/32.0, indicating a high level of satisfaction with the telepractice approach. In addition, each 1 U of improvement in patient satisfaction was associated with a 1.75 U increase in the WAB-R AQ. Conclusions: Examination of post-treatment satisfaction indicated that satisfaction was highly predictive of effectiveness-a one-point increase in satisfaction was associated with a nearly two-point increase in WAB-R AQ. Results echo findings from acute care studies underscoring the importance of the patient experience in treatment efficacy.

The feasibility, usability and acceptability of a tablet-based aphasia therapy in the acute phase following stroke

QUESTION

Independent practice via an application with a language exercise program for aphasia, as an add-on to conventional care can be a good solution to intensify aphasia therapy. The aim of this prospective trial was to investigate the feasibility, usability and acceptability of the newly-developed aphasia exercise program in the 'Speech Therapy App (STAPP)' in the acute phase post-stroke.

METHODS

All eligible people with aphasia following stroke (<2 weeks post-stroke) admitted to the Stroke Unit of Ghent University Hospital were recruited in this prospective clinical trial between September 2018 and December 2019. After linguistic assessments and two short training sessions, participants were asked to practice independently with 'STAPP' for at least 30 min/day during hospitalization. Exercises were individually tailored and adjusted if necessary. Outcome was measured by recruitment, adherence and retention rates, usability questionnaires and a visual analogue scale for satisfaction.

RESULTS

Twenty-five (mean age 65 years (SD = 17), 14 females) of 31 eligible people with aphasia were enrolled in this trial (recruitment rate = 81 %). All participants but one (23/24) practiced with the language app until the end of hospitalization (retention rate = 96 %). Ten participants practiced at least 30 min/day (adherence rate = 42 %). Participants reported they learned to work quickly with the app (92 %; agreed/totally agreed), the app was easy to use (88 %), they could work independently (79 %), practiced their language (67 %) and wanted to continue working with the app at home (79 %). Acceptability was high (median satisfaction rate 91 %; IQR = 75-100).

CONCLUSION

The aphasia exercise program in 'STAPP' is feasible to use as an additional rehabilitation tool along with standard of care in the acute phase post-stroke. Further research is needed to assess the efficacy. CLINICAL TRIAL REGISTRATION-URL: https://clinicaltrials.gov/ct2/show/NCT03679637.

Design Considerations for Clinical Trials in Aphasia

The use of the randomised controlled trial (RCT) design to evaluate the effectiveness of new interventions in aphasia has increased in recent years in response to calls for high quality evidence of the effectiveness of interventions for this population. This view-point article highlights some of the important considerations when designing a trial for an aphasia intervention, illustrated with decisions made when designing the Big CACTUS RCT for self-managed computer-based word finding therapy in aphasia. Considerations outlined include whether an RCT is needed, readiness for conducting an RCT, choice of comparators, randomisation options, blinding/masking, selection of outcome measures, pragmatic versus explanatory approaches, and fidelity measurement.

Factors Associated With Adherence to Self-Managed Aphasia Therapy Practice on a Computer-A Mixed Methods Study Alongside a Randomized Controlled Trial

Background: Aphasia is a communication disorder often acquired after a stroke. Independent use of specialist aphasia software on a home computer is a form of asynchronous tele-rehabilitation that can provide increased opportunity for practice of rehabilitation exercises. This study aimed to explore the factors associated with adherence to self-managed aphasia computer therapy practice.

Method: A mixed methods exploration of adherence was conducted alongside the Big CACTUS randomized controlled trial [ISRCTN: 68798818]. The trial evaluated the clinical effectiveness of self-managed aphasia computer therapy. This study reports secondary analysis of data from participants randomized to the computer therapy group to investigate whether any demographic, clinical or intervention variables were associated with adherence to therapy practice. A sub-sample of the same participants took part in qualitative interviews exploring the factors perceived to influence the amount of aphasia computer therapy practice undertaken. Interviews were analyzed thematically. A convergence-coding matrix was used to triangulate the two sets of findings.

Results: Data from 85 participants randomized to the computer therapy group were included in the quantitative analyses. At a clinical level, a greater length of time post-stroke was associated with higher adherence to self-managed aphasia therapy practice on a computer. At an intervention level, length of computer therapy access and therapist time supporting the participant were associated with greater adherence to computer therapy practice. Interviews with 11 patients and 12 informal carers identified a multitude of factors perceived to influence engagement with tele-rehabilitation by people with aphasia. The factors grouped around three themes: capability to use the computer therapy, having the opportunity to practice (external influences and technological issues) and motivation (beliefs, goals and intentions vs. personality, emotions, habit and reinforcement). Triangulation demonstrated convergence for the finding that participants' practiced computer-based therapy exercises more when they received increased support from a speech and language therapist.

Conclusion: Clinicians delivering asynchronous tele-rehabilitation involving self-management of aphasia therapy practice on a computer should consider the factors found to be associated with engagement when deciding which patients may be suited to this option, as well as how they can be supported to optimize the amount of practice they engage in.

The verbal, non-verbal and structural bases of functional communication abilities in aphasia

The ability to communicate, functionally, after stroke or other types of acquired brain injury is crucial for the person involved and the people around them. Accordingly, assessment of functional communication is increasingly used in large-scale randomized controlled trials as the primary outcome measure. Despite the importance of functional communication abilities to everyday life and their centrality to the measured efficacy of aphasia interventions, there is little knowledge about how commonly used measures of functional communication relate to each other, whether they capture and grade the full range of patients’ remaining communication skills and how these abilities relate to the patients’ verbal and non-verbal impairments as well as the underpinning lesions. Going beyond language-only factors is essential given that non-verbal abilities can play a crucial role in an individual’s ability to communicate effectively. This study, based on a large sample of patients covering the full range and types of post-stroke aphasia, addressed these important, open questions. The investigation combined data from three established measures of functional communication with a thorough assessment of verbal and non-verbal cognition as well as structural neuroimaging. The key findings included: (i) due to floor or ceiling effects, the full range of patients’ functional communication abilities was not captured by a single assessment alone, limiting the utility of adopting individual tests as outcome measures in randomized controlled trials; (ii) phonological abilities were most strongly related to all measures of functional communication and (iii) non-verbal cognition was particularly crucial when language production was relatively impaired and other modes of communication were allowed, when patients rated their own communication abilities, and when carers rated patients’ basic communication abilities. Finally, in addition to lesion load being significantly related to all measures of functional communication, lesion analyses showed partially overlapping clusters in language regions for the functional communication tests. Moreover, mirroring the findings from the regression analyses, additional regions previously associated with non-verbal cognition emerged for the Scenario Test and for the Patient Communication Outcome after Stroke rating scale. In conclusion, our findings elucidated the cognitive and neural bases of functional communication abilities, which may inform future clinical practice regarding assessments and therapy. In particular, it is necessary to use more than one measure to capture the full range and multifaceted nature of patients’ functional communication abilities and a therapeutic focus on non-verbal cognition might have positive effects on this important aspect of activity and participation.

Predicting treatment outcomes for bilinguals with aphasia using computational modeling: Study protocol for the PROCoM randomised controlled trial

INTRODUCTION

Bilinguals with aphasia (BWA) present varying degrees of lexical access impairment and recovery across their two languages. Because both languages may benefit from therapy, identifying the optimal target language for treatment is a current challenge for research and clinical practice. Prior research has demonstrated that the BiLex computational model can accurately simulate lexical access in healthy bilinguals, and language impairment and treatment response in bilingual aphasia. Here, we aim to determine whether BiLex can predict treatment outcomes in BWA in the treated and the untreated language and compare these outcome predictions to determine the optimal language for rehabilitation.

METHODS AND ANALYSIS

The study involves a prospective parallel-group, double-blind, randomised controlled trial. Forty-eight Spanish-English BWA will receive 20 sessions of semantic treatment for lexical retrieval deficits in one of their languages and will complete assessments in both languages prior and after treatment. Participants will be randomly assigned to an experimental group receiving treatment in the optimal language determined by the model or a control group receiving treatment in the language opposite to the model's recommendation. Primary treatment outcomes include naming probes while secondary treatment outcomes include tests tapping additional language domains. Treatment outcomes will be compared across the two groups using 2×2 mixed effect models for repeated measures Analysis of variance (ANOVA) on metrics of treatment effects commonly employed in rehabilitation studies (ie, effect size and percentage change).

ETHICS AND DISSEMINATION

All procedures included in this protocol (protocol number 29, issue date: 19 March 2019) were approved by the Boston University Charles River Campus Institutional Review Board at Boston, Massachusetts (reference number: 4492E). The results of this study will be published in peer-reviewed scientific journals and will be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02916524.