A meta-analysis of clinical outcomes in the treatment of aphasia

Individual variability in the anatomical distribution of nodes participating in rich club structural networks

With recent advances in computational analyses of structural neuroimaging, it is possible to comprehensively map neural connectivity, i.e., the brain connectome. The architectural organization of the connectome is believed to play an important role in several biological processes. Central to the conformation of the connectome are connectivity hubs, which are likely to be organized in accordance with the rich club phenomenon, as evidenced by graph theory analyses of neural architecture. It is yet unclear whether rich club connectivity hubs are consistently organized in the same anatomical framework across healthy adults. We constructed the brain connectome from 43 healthy adults, based on T1-weighted and diffusion tensor MRI data. Probabilistic fiber tractography was used to evaluate connectivity between each possible pair of cortical anatomical regions of interest. Connectivity hubs were identified in accordance with the rich club phenomenon applied to binarized matrices, and the variability in frequency of hub participation was assessed node-wise across all subjects. The anatomical location of nodes participating in rich club networks was fairly consistent across subjects. The most common locations for rich club nodes were identified in integrative areas, such as the cingulate and pericingulate regions, medial aspect of the occipital areas and precuneus; or else, they were found in important and specialized brain regions (such as the oribitofrontal cortex, caudate, fusiform gyrus, and hippocampus). Marked anatomical consistency exists across healthy brains in terms of nodal participation and location of rich club networks. The consistency of connections between integrative areas and specialized brain regions highlights a fundamental connectivity pattern shared among healthy brains. We propose that approaching brain connectivity with this framework of anatomical consistencies may have clinical implications for early detection of individual variability.

Cross-linguistic generalization in the treatment of two sequential Spanish-English bilingual children with speech sound disorders

PURPOSE

The effect of bilingual service delivery on treatment of speech sound disorders (SSDs) in bilingual children is largely unknown. Bilingual children with SSDs are typically provided intervention in only one language, although research suggests dual-language instruction for language disorders is best practice for bilinguals. This study examined cross-linguistic generalization of bilingual intervention in treatment of two 5-year-old sequential bilingual boys with SSDs (one with Childhood Apraxia of Speech), hypothesizing that selecting and treating targets in both languages would result in significant overall change in their English and Spanish speech systems.

METHOD

A multiple baseline across behaviours design was used to measure treatment effectiveness for two targets per child. Children received treatment 2-3 times per week for 8 weeks and in Spanish for at least 2 of every 3 days. Ongoing treatment performance was measured in probes in both languages; overall speech skills were compared pre- and post-treatment.

RESULT

Both children's speech improved in both languages with similar magnitude; there was improvement in some non-treated errors.

CONCLUSION

Treating both languages had an overall positive effect on these bilingual children's speech. Future bilingual intervention research should explore alternating treatments designs, efficiency of monolingual vs bilingual treatment, different language and bilingual backgrounds, and between-group comparisons.

Rehabilitation of poststroke cognition

Given the increasing rates of stroke and our aging population, it is critical that we continue to foster innovation in stroke rehabilitation. Although there is evidence supporting cognitive rehabilitation in stroke, the set of cognitive domains effectively addressed to date represents only a small subset of the problems experienced by stroke survivors. Further, a gap remains between investigational treatments and our evolving theories of brain function. These limitations present opportunities for improving the functional impact of stroke rehabilitation. The authors use a case example to encourage the reader to consider the evidence base for cognitive rehabilitation in stroke, focusing on four domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. Ultimately, they attempt to draw neuroscience and practice closer together by using translational reasoning to suggest possible new avenues for treating these disorders.

Transcranial brain stimulation (TMS and tDCS) for post-stroke aphasia rehabilitation: Controversies

Transcranial brain stimulation (TS) techniques have been investigated for use in the rehabilitation of post-stroke aphasia. According to previous reports, functional recovery by the left hemisphere improves recovery from aphasia, when compared with right hemisphere participation. TS has been applied to stimulate the activity of the left hemisphere or to inhibit homotopic areas in the right hemisphere. Various factors can interfere with the brain's response to TS, including the size and location of the lesion, the time elapsed since the causal event, and individual differences in the hemispheric language dominance pattern. The following questions are discussed in the present article:

[a] Is inhibition of the right hemisphere truly beneficial?;

[b] Is the transference of the language network to the left hemisphere truly desirable in all patients?;

[c] Is the use of TS during the post-stroke subacute phase truly appropriate? Different patterns of neuroplasticity must occur in post-stroke aphasia.

Feasibility and cost analysis of implementing high intensity aphasia clinics within a sub-acute setting

The current study explored the clinical feasibility and costs of embedding three different intensive service delivery models for aphasia treatment (computer, group therapy, and therapy with a speech pathology therapy assistant) within three sub-acute facilities. The study employed a two cohort comparison design, with the first cohort (n = 22) receiving the standard service of treatment currently offered. This treatment was delivered by a speech-language pathologist and involved on average 3 hours of treatment/week over 8 weeks. Participants in the second cohort (n = 31) received one of the three intensive treatment models providing up to 9 hours of therapy/week for 11 weeks. Organizational data was collected throughout treatment, with participant, caregiver, and clinician satisfaction with the intensive models also being measured. Participants completed the spoken language production sub-tests and the Disability Questionnaire of the Comprehensive Aphasia Test (CAT) pre- and post-treatment. All intensive models yielded high participant attendance, satisfaction, and significant improvements to the CAT sub-tests. The pro-rata cost of providing treatment per hour per client for the computer and group therapy models was found to be ˜ 30% cheaper compared to the standard service. The outcomes support the potential feasibility of embedding the different models into sub-acute facilities to enhance client access to intensive treatment for aphasia.

Integrated training for aphasia: an application of part-whole learning to treat lexical retrieval, sentence production, and discourse-level communications in three cases of nonfluent aphasia

PURPOSE

The purpose of this study was to evaluate integrated training for aphasia (ITA), a multicomponent language-production treatment based on part-whole learning that systematically trains lexical retrieval, sentence production, and discourse-level communications. Specific research objectives were to evaluate acquisition of target structures, statistical parameters associated with learning variables, treatment generalization, and the efficacy of individual treatment components.

METHOD

ITA was administered to 3 individuals with nonfluent aphasia following a multiple-baseline, across-behaviors design. Effect size and correlational coefficients were computed to assess acquisition, generalization, and maintenance of target structures. Standardized tests and a treatment efficacy questionnaire were also completed.

RESULTS

A significant treatment effect was found in 2 of the 3 participants. In addition, as is seen in normal skill acquisition, practice time and error rate were significantly correlated. All participants demonstrated evidence of generalization on standardized language measures. Only 1 participant improved, however, on the communication measures. Results of the treatment component analysis revealed significant differences in the perceived efficacy of individual therapy tasks.

CONCLUSIONS

Findings add to the evidence supporting multicomponent aphasia treatments, provide preliminary support for ITA and the application of a part-whole learning approach, and suggest that specific treatment components may contribute differentially to outcomes and generalization effects.

Description of an intensive residential aphasia treatment program: rationale, clinical processes, and outcomes

PURPOSE

The purpose of this article is to describe the rationale, clinical processes, and outcomes of an intensive comprehensive aphasia program (ICAP).

METHOD

Seventy-three community-dwelling adults with aphasia completed a residentially based ICAP. Participants received 5 hr of daily 1:1 evidence-based cognitive-linguistically oriented aphasia therapy, supplemented with weekly socially oriented and therapeutic group activities over a 23-day treatment course. Standardized measures of aphasia severity and communicative functioning were obtained at baseline, program entry, program exit, and follow-up. Results were analyzed using a Bayesian latent growth curve model with 2 factors representing (a) the initial level and (b) change over time, respectively, for each outcome measure.

RESULTS

Model parameter estimates showed reliable improvement on all outcome measures between the initial and final assessments. Improvement during the treatment interval was greater than change observed across the baseline interval, and gains were maintained at follow-up on all measures.

CONCLUSIONS

The rationale, clinical processes, and outcomes of a residentially based ICAP have been described. ICAPs differ with respect to treatments delivered, dosing parameters, and outcomes measured. Specifying the defining components of complex interventions, establishing their feasibility, and describing their outcomes are necessary to guide the development of controlled clinical trials.

Relation between aphasia and arcuate fasciculus in chronic stroke patients

Background

The role of the arcuate fasciculus (AF) in the dominant hemisphere in stroke patients with aphasia has not been clearly elucidated. We investigated the relation between language function and diffusion tensor tractography (DTT) findings for the left AF in chronic stroke patients with aphasia.

Method

Twenty five consecutive right-handed stroke patients with aphasia following lesions in the left hemisphere were recruited for this study. The aphasia quotient (AQ) of Korean-Western Aphasia Battery was used for assessment of language function. We measured values of fractional anisotropy (FA), apparent diffusion coefficient (ADC), voxel number of the left AF. We classified patients into three groups: type A - the left AF was not reconstructed, type B - the left AF was discontinued between Wernicke’s and Broca’s areas, and type C – the left AF was preserved around the stroke lesion.

Results

Moderate positive correlation was observed between AQ and voxel number of the left AF (r = 0.471, p < 0.05). However, no correlation was observed between AQ and FA (r = 0.275, p > 0.05) and ADC values (r = -0.286, p > 0.05). Significant differences in AQ scores were observed between the three types (p < 0.05); the AQ score of type C was higher than those of type A and B, and that of type B was also higher than that of type A (p < 0.05).

Conclusion

According to our findings, the remaining volume of the left AF, irrespective of directionality and diffusivity, showed moderate positive correlation with language function in chronic stroke patients with aphasia. Discontinuation or non-construction of the left AF was also an important factor for language function.

A comparison of aphasia therapy outcomes before and after a Very Early Rehabilitation programme following stroke

BACKGROUND

Very early aphasia rehabilitation studies have shown mixed results. Differences in therapy intensity and therapy type contribute significantly to the equivocal results.

AIMS

To compare a standardized, prescribed very early aphasia therapy regimen with a historical usual care control group at therapy completion (4-5 weeks post-stroke) and again at follow-up (6 months).

METHODS & PROCEDURES

This study compared two cohorts from successive studies conducted in four Australian acute/sub-acute hospitals. The studies had near identical recruitment, blinded assessment and data-collection protocols. The Very Early Rehabilitation (VER) cohort (N = 20) had mild-severe aphasia and received up to 20 1-h sessions of impairment-based aphasia therapy, up to 5 weeks. The control cohort (n = 27) also had mild-severe aphasia and received usual care (UC) therapy for up to 4 weeks post-stroke. The primary outcome measure was the Aphasia Quotient (AQ) and a measure of communicative efficiency (DA) at therapy completion. Outcomes were measured at baseline, therapy completion and 6 months post-stroke and were compared using Generalised Estimating Equations (GEE) models.

OUTCOMES & RESULTS

After controlling for initial aphasia and stroke disability, the GEE models demonstrated that at the primary end-point participants receiving VER achieved 18% greater recovery on the AQ and 1.5% higher DA scores than those in the control cohort. At 6 months, the VER participants maintained a 16% advantage in recovery on the AQ and 0.6% more on DA scores over the control cohort participants.

CONCLUSIONS & IMPLICATIONS

A prescribed, impairment-based aphasia therapy regimen, provided daily in very early post-stroke recovery, resulted in significantly greater communication gains in people with mild-severe aphasia at completion of therapy and at 6 months, when compared with a historical control cohort. Further research is required to demonstrate large-scale and long-term efficacy.

The Efficacy and Timing of Melodic Intonation Therapy in Subacute Aphasia

Background. Little is known about the efficacy of language production treatment in subacute severe nonfluent aphasia. Although Melodic Intonation Therapy (MIT) is a language production treatment for this disorder, until now MIT effect studies have focused on chronic aphasia. Purpose. This study examines whether language production treatment with MIT is effective in subacute severe nonfluent aphasia. Methods. A multicenter, randomized controlled trial was conducted in a waiting-list control design: patients were randomly allocated to the experimental group (MIT) or the control group (control intervention followed by delayed MIT). In both groups, therapy started at 2 to 3 months poststroke and was given intensively (5 h/wk) during 6 weeks. In a second therapy period, the control group received 6 weeks of intensive MIT. The experimental group resumed their regular treatment. Assessment was done at baseline (T1), after the first intervention period (T2), and after the second intervention period (T3). Efficacy was evaluated at T2. The impact of delaying MIT on therapy outcome was also examined. Results. A total of 27 participants were included: n = 16 in the experimental group and n = 11 in the control group. A significant effect in favor of MIT on language repetition was observed for trained items, with mixed results for untrained items. After MIT there was a significant improvement in verbal communication but not after the control intervention. Finally, delaying MIT was related to less improvement in the repetition of trained material. Conclusions. In these patients with subacute severe nonfluent aphasia, language production treatment with MIT was effective. Earlier treatment may lead to greater improvement.

Drug treatment of poststroke aphasia

Impairment of language function (aphasia) is one of the most common neurological symptoms after stroke. Approximately one in every three patients who have an acute stroke will suffer from aphasia. The estimated incidence and prevalence of stroke in Western Europe is 140 and 800 per 100,000 of the population. Aphasia often results in significant disability and handicap. It is a major obstacle for patients to live independently in the community. When recovery from aphasia occurs, it is usually incomplete and patients are rarely able to return to full employment and other social activities. Currently, the main treatment for aphasia is conventional speech and language therapy. However, the effectiveness of this intervention has not been conclusively demonstrated and empirical observations suggest that spontaneous biological recovery may explain most of the improvement in language function that occurs in aphasics. The generally poor prognosis of the severe forms of poststroke language impairment (Broca, Wernicke and global aphasia), coupled with the limited effectiveness of conventional speech and language therapy has stimulated the search for other treatments that may be used in conjunction with speech and language therapy, including the use of various drugs. Dopamine agonists, piracetam (Nootropil), amphetamines, and more recently donepezil (Aricept), have been used in the treatment of aphasia in both the acute and chronic phase. The justification for the use of drugs in the treatment of aphasia is based on two types of evidence. Some drugs, such as dextroamphetamine (Dexedrine), improve attention span and enhance learning and memory. Learning is an essential mechanism for the acquisition of new motor and cognitive skills, and hence, for recovery from aphasia. Second, laboratory and clinical data suggest that drug treatment may partially restore the metabolic function in the ischemic zone that surrounds the brain lesion and also has a neuroprotective effect following acute brain damage. An example of this is the nootropic agent piracetam. Extensive animal studies have demonstrated the beneficial effects of this and other drugs on neural plasticity, but data on humans are still sparse. This review provides a critical analysis of the current evidence of the effectiveness of these drugs in the treatment of acute and chronic aphasia.

Effects of dual transcranial direct current stimulation for aphasia in chronic stroke patients

OBJECTIVE

To investigate any additional effect of dual transcranial direct current stimulation (tDCS) compared with single tDCS in chronic stroke patients with aphasia.

METHODS

Eleven chronic stroke patients (aged 52.6±13.4 years, nine men) with aphasia were enrolled. Single anodal tDCS was applied over the left inferior frontal gyrus (IFG) and a cathodal electrode was placed over the left buccinator muscle. Dual tDCS was applied as follows: 1) anodal tDCS over the left IFG and cathodal tDCS over the left buccinator muscle and 2) cathodal tDCS over the right IFG and anodal tDCS over the right buccinator muscle. Each tDCS was delivered for 30 minutes at a 2-mA intensity. Speech therapy was provided during the last 15 minutes of the tDCS. Before and after the stimulation, the Korean-Boston Naming Test and a verbal fluency test were performed.

RESULTS

The dual tDCS produced a significant improvement in the response time for the Korean-Boston Naming Test compared with the baseline assessment, with a significant interaction between the time and type of interventions. Both single and dual tDCS produced a significant improvement in the number of correct responses after stimulation with no significant interaction. No significant changes in the verbal fluency test were observed after single or dual tDCS.

CONCLUSION

The results conveyed that dual tDCS using anodal tDCS over the left IFG and cathodal tDCS over the right IFG may be more effective than a single anodal tDCS over the left IFG.

Training verb argument structure production in agrammatic aphasia: behavioral and neural recovery patterns

INTRODUCTION

Neuroimaging and lesion studies indicate a left hemisphere network for verb and verb argument structure processing, involving both frontal and temporoparietal brain regions. Although their verb comprehension is generally unimpaired, it is well known that individuals with agrammatic aphasia often present with verb production deficits, characterized by an argument structure complexity hierarchy, indicating faulty access to argument structure representations for production and integration into syntactic contexts. Recovery of verb processing in agrammatism, however, has received little attention and no studies have examined the neural mechanisms associated with improved verb and argument structure processing. In the present study we trained agrammatic individuals on verbs with complex argument structure in sentence contexts and examined generalization to verbs with less complex argument structure. The neural substrates of improved verb production were examined using functional magnetic resonance imaging (fMRI).

METHODS

Eight individuals with chronic agrammatic aphasia participated in the study (four experimental and four control participants). Production of three-argument verbs in active sentences was trained using a sentence generation task emphasizing the verb's argument structure and the thematic roles of sentential noun phrases. Before and after training, production of trained and untrained verbs was tested in naming and sentence production and fMRI scans were obtained, using an action naming task.

RESULTS

Significant pre- to post-training improvement in trained and untrained (one- and two-argument) verbs was found for treated, but not control, participants, with between-group differences found for verb naming, production of verbs in sentences, and production of argument structure. fMRI activation derived from post-treatment compared to pre-treatment scans revealed upregulation in cortical regions implicated for verb and argument structure processing in healthy controls.

CONCLUSIONS

Training verb deficits emphasizing argument structure and thematic role mapping is effective for improving verb and sentence production and results in recruitment of neural networks engaged for verb and argument structure processing in healthy individuals.

Using computers to enable self-management of aphasia therapy exercises for word finding: the patient and carer perspective

BACKGROUND

Speech and language therapy (SLT) for aphasia can be difficult to access in the later stages of stroke recovery, despite evidence of continued improvement with sufficient therapeutic intensity. Computerized aphasia therapy has been reported to be useful for independent language practice, providing new opportunities for continued rehabilitation. The success of this option depends on its acceptability to patients and carers.

AIMS

To investigate factors that affect the acceptability of independent home computerized aphasia therapy practice.

METHODS & PROCEDURES

An acceptability study of computerized therapy was carried out alongside a pilot randomized controlled trial of computer aphasia therapy versus usual care for people more than 6 months post-stroke. Following language assessment and computer exercise prescription by a speech and language therapist, participants practised three times a week for 5 months at home with monthly volunteer support. Semi-structured interviews were conducted with 14 participants who received the intervention and ten carers (n = 24). Questions from a topic guide were presented and answered using picture, gesture and written support. Interviews were audio recorded, transcribed verbatim and analysed thematically. Three research SLTs identified and cross-checked themes and subthemes emerging from the data.

OUTCOMES & RESULTS

The key themes that emerged were benefits and disadvantages of computerized aphasia therapy, need for help and support, and comparisons with face-to-face therapy. The independence, flexibility and repetition afforded by the computer was viewed as beneficial and the personalized exercises motivated participants to practise. Participants and carers perceived improvements in word-finding and confidence-talking. Computer practice could cause fatigue and interference with other commitments. Support from carers or volunteers for motivation and technical assistance was seen as important. Although some participants preferred face-to-face therapy, using a computer for independent language practice was perceived to be an acceptable alternative.

CONCLUSIONS & IMPLICATIONS

Independent computerized aphasia therapy is acceptable to stroke survivors. Acceptability can be maximized by tailoring exercises to personal interests of the individual, ensuring access to support and giving consideration to fatigue and life style when recommending practice schedules.

A randomized, rater-blinded, parallel trial of intensive speech therapy in sub-acute post-stroke aphasia: the SP-I-R-IT study

BACKGROUND

There is conflicting evidence regarding the benefits of intensive speech and language therapy (SLT), particularly because intensity is often confounded with total SLT provided.

AIMS

A two-centre, randomized, rater-blinded, parallel study was conducted to compare the efficacy of 100 h of SLT in a regular (RT) versus intensive (IT) treatment in sub-acute post-stroke aphasia.

METHODS & PROCEDURES

Consecutive patients with aphasia, within 3 months of a left hemisphere ischemic stroke, were randomized to IT (2 h per day × 5 days per week, 10 weeks) or RT (2 h per week × 50 weeks). Evaluations took place at 10, 50 and 62 weeks. Primary outcome was the frequency of responders, defined by 15% increase of Aphasia Quotient (AQ) from the baseline to 50 weeks. Secondary outcomes were changes from the baseline in AQ and functional communication profile (FCP) at 50 and 62 weeks and improvement stability between 50 and 62 weeks.

OUTCOMES & RESULTS

Thirty patients were randomized and 18 completed the study. No significant differences were found between groups in primary or secondary outcomes, although IT patients (N = 9) obtained higher scores in language measures between 10 and 62 weeks in per protocol analysis. The number of non-completions was identical between groups.

CONCLUSIONS & IMPLICATIONS

This study suggests that, in the sub-acute period following stroke and controlling for the number of hours of SLT provided, there is a trend for a greater improvement in language and functional communication measures with IT compared with RT. The lack of statistical significance in results was probably due to the small sample size.

Transcranial direct current stimulation and aphasia: the case of mr. C

PURPOSE

To illustrate the ethical challenges that arose from investigating a novel treatment procedure, transcranial direct current stimulation (tDCS), in a research participant with aphasia.

METHOD

We review the current evidence supporting the use of tDCS in aphasia research, highlighting methodological gaps in our knowledge of tDCS. Then, we examine the case of Mr. C, a person with chronic aphasia who participated in a research protocol investigating the impact of tDCS on aphasia treatment. We describe the procedures that he underwent and the resulting behavioral and neurophysiological outcomes. Finally, we share the steps that were taken to balance beneficence and nonmaleficence and to ensure Mr. C's autonomy.

RESULTS

The objective data show that while Mr. C may not have benefitted from participating in the research, neither did he experience any harm.

CONCLUSION

Researchers must consider not only the scientific integrity of their studies, but also potential ethical issues and consequences to the research participants.

Recovered vs. not-recovered from post-stroke aphasia: the contributions from the dominant and non-dominant hemispheres

PURPOSE

Several adult studies have documented the importance of the peri-stroke areas to aphasia recovery. But, studies examining the differences in patterns of cortical participation in language comprehension in patients who have (LMCA-R) or have not recovered (LMCA-NR) from left middle cerebral artery infarction have not been performed up to date.

METHODS

In this study, we compare cortical correlates of language comprehension using fMRI and semantic decision/tone decision task in 9 LMCA-R and 18 LMCA-NR patients matched at the time of stroke for age and handedness. We examine the cortical correlates of language performance by correlating intra- and extra-scanner measures of linguistic performance with fMRI activation and stroke volumes.

RESULTS

Our analyses show that LMCA-R at least 1 year after stroke show a return to typical fMRI language activation patterns and that there is a compensatory reorganization of language function in LMCA-NR patients with shifts to the right hemispheric brain regions. Further, with increasing strength of the left-hemispheric fMRI signal shift there are associated improvements in performance as tested with standardized linguistic measures. A negative correlation between the size of the stroke and performance on some of the linguistic tests is also observed.

CONCLUSIONS

This right-hemispheric shift as a mechanism of post-stroke recovery in adults appears to be an ineffective mode of language function recovery with increasing right-hemispheric shift associated with lower language performance. Thus, normalization of the post-stroke language activation patterns is needed for better language performance while shifts of the activation patterns to the non-dominant (right) hemisphere and/or large stroke size are associated with decreased linguistic abilities after stroke.

Eficácia da fonoterapia em um caso de afasia expressiva decorrente de acidente vascular encefálico

O objetivo deste estudo de caso foi relatar e analisar o caso de um paciente afásico adulto em tratamento fonoaudiológico na clínica escola do Curso de Fonoaudiologia de uma instituição federal de ensino. O sujeito estudado é um paciente do sexo masculino, com 68 anos de idade, em tratamento na clínica escola desde maio de 2009, sendo que seu processo terapêutico foi analisado até dezembro de 2010. Quanto à história clínica, o paciente sofreu acidente vascular encefálico isquêmico no hemisfério esquerdo, em janeiro de 2009, quando repentinamente apresentou um quadro de mutismo. Após serem realizadas avaliações fonoaudiológicas, concluiu-se que o mesmo apresentava como hipótese diagnóstica "Afasia de expressão, oral e escrita, decorrente de acidente vascular encefálico isquêmico." Diante disto foi elaborado o planejamento terapêutico. Desde o início do processo de terapia foi possível observar evoluções linguísticas no paciente. O fato de o sujeito ter procurado atendimento fonoaudiológico 15 dias após o acometimento pelo acidente vascular encefálico, provavelmente foi um fator fundamental para sua boa recuperação, pois há um grau de recuperação espontânea em pacientes afásicos, porém a melhora é mínima sem o tratamento adequado. Em aproximadamente um mês de terapia fonoaudiológica, o paciente expandiu consideravelmente seu vocabulário. Apesar de a área lesada ser extensa e fundamental para a linguagem, observou-se avanços bastante positivos com a terapia. Deste modo, acredita-se que a intervenção fonoaudiológica precoce contribuiu, em grande parte, para a reorganização da atividade linguística, visto que o paciente comunica-se satisfatoriamente considerando a grande extensão de sua lesão.

Role of aphasia in discharge location after stroke

OBJECTIVE

To evaluate language deficits after acute stroke and their association with post-acute care at a setting other than home. We hypothesized that deficits in language comprehension would be associated with discharge to a setting other than home after adjustment for physical/occupational therapy (PT/OT) needs.

DESIGN

Secondary analysis of prospectively collected data. Discharge location, demographic characteristics (age, sex, race), and the presence of PT/OT recommendations were abstracted from the medical record.

SETTING

Acute stroke unit at a tertiary medical center.

PARTICIPANTS

Left hemispheric stroke patients (N=152) within 24 hours of event.

INTERVENTIONS

The following tasks were administered: (a-b) oral and written naming of pictured objects, (c) oral naming with tactile input (tactile naming), (d-f) oral reading, oral spelling, and repetition of words and pseudowords, (g) written spelling to dictation, (h) spoken word-picture verification (ie, auditory comprehension), and (i) written word-picture verification (ie, written word comprehension).

MAIN OUTCOME MEASURE

Discharge to a setting other than home.

RESULTS

Of 152 cases, 88 were discharged home and 64 to another setting. Among stroke subjects discharged to a setting other than home, 63.6% had auditory comprehension deficits compared with 42.9% of those discharged home (P=.03). Deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a setting other than home after adjustment for age and PT/OT recommendations.

CONCLUSIONS

Cases with deficits in auditory comprehension, reading comprehension, and oral spelling to dictation had increased odds of being discharged to settings other than home. Early evaluation of these language deficits and prompt treatment may allow patients who would otherwise be discharged to an institution to go home. Further research is needed to design and evaluate individualized treatment protocols and their effect on discharge recommendations.

Prediction of aphasia outcome using diffusion tensor tractography for arcuate fasciculus in stroke

BACKGROUND AND PURPOSE

The AF is an important neural tract in language function. We investigated aphasia outcome according to DTT findings for AF in the early stage of stroke.

MATERIALS AND METHODS

Twenty-five consecutive patients with aphasia and stroke and 12 control subjects were recruited. The AQ of K-WAB was used for the assessment of aphasia in the early stage of stroke (10-30 days) and at approximately 6 months after onset. We classified the patients into 3 groups according to the severity of left AF injury: type A, the AF was not reconstructed; type B, the AF was disrupted; and type C, the AF was preserved around the lesion.

RESULTS

When comparing AQ among AF types at early evaluation, the type C score (32.84±18.05) was significantly higher than type A (3.60±2.73) (P<.05). However, no significant difference was observed between types A and B (18.02±17.19) or between types B and C (P>.05). At late evaluation, the AQ values of types B (52.43±25.75) and C (68.08±15.76) were higher than that of type A (10.98±3.90) (P<.05). However, there was no significant difference between types B and C.

CONCLUSIONS

The aphasia outcome of the patients whose left AF could be reconstructed was better than that in patients whose left AF could not be reconstructed, irrespective of its integrity. We believe that evaluation of the left AF by using DTT in the early stage of stroke could be helpful in predicting aphasia outcome in patients with stroke.

Epidural cortical stimulation and aphasia therapy

BACKGROUND

There are several methods of delivering cortical brain stimulation to modulate cortical excitability and interest in their application as an adjuvant strategy in aphasia rehabilitation after stroke is growing. Epidural cortical stimulation, although more invasive than other methods, permits high frequency stimulation of high spatial specificity to targeted neuronal populations.

AIMS

First, we review evidence supporting the use of epidural cortical stimulation for upper limb recovery after focal cortical injury in both animal models and human stroke survivors. These data provide the empirical and theoretical platform underlying the use of epidural cortical stimulation in aphasia. Second, we summarize evidence for the application of epidural cortical stimulation in aphasia. We describe the procedures and primary outcomes of a safety and feasibility study (Cherney, Erickson & Small, 2010), and provide previously unpublished data regarding secondary behavioral outcomes from that study.

MAIN CONTRIBUTION

In a controlled study comparing epidural cortical stimulation plus language treatment (CS/LT) to language treatment alone (LT), eight stroke survivors with nonfluent aphasia received intensive language therapy for 6 weeks. Four of these participants also underwent surgical implantation of an epidural stimulation device which was activated only during therapy sessions. Behavioral data were collected before treatment, immediately after treatment, and at 6 and 12 weeks following the end of treatment. The effect size for the primary outcome measure, the Western Aphasia Battery Aphasia Quotient, was benchmarked as moderate from baseline to immediately post-treatment, and large from baseline to the 12-week follow-up. Similarly, effect sizes obtained at the 12-week follow-up for the Boston Naming Test, the Communicative Effectiveness Index, and for correct information units on a picture description task were greater than those obtained immediately post treatment. When effect sizes were compared for individual subject pairs on discourse measures of content and rate, effects were typically larger for the investigational subjects receiving CS/LT than for the control subjects receiving LT alone. These analyses support previous findings regarding therapeutic efficacy of CS/LT compared to LT i.e. epidural stimulation of ipsilesional premotor cortex may augment behavioral speech-language therapy, with the largest effects after completion of therapy.

CONCLUSIONS

Continued investigation of epidural cortical stimulation in combination with language training in post-stroke aphasia should proceed cautiously. Carefully planned studies that customize procedures to individual profiles are warranted. Information from research on non-invasive methods of CS/LT may also inform future studies of epidural cortical stimulation.

Speech therapy in primary progressive aphasia: a pilot study

BACKGROUND

Primary progressive aphasia (PPA) is a neurodegenerative disorder with no effective pharmacological treatment. Cognition-based interventions are adequate alternatives, but their benefit has not been thoroughly explored. Our aim was to study the effect of speech and language therapy (SLT) on naming ability in PPA.

METHODS

An open parallel prospective longitudinal study involving two centers was designed to compare patients with PPA submitted to SLT (1 h/week for 11 months) with patients receiving no therapy. Twenty patients were enrolled and undertook baseline language and neuropsychological assessments; among them, 10 received SLT and 10 constituted an age- and education-matched historical control group. The primary outcome measure was the change in group mean performance on the Snodgrass and Vanderwart naming test between baseline and follow-up assessments.

RESULTS

Intervention and control groups did not significantly differ on demographic and clinical variables at baseline. A mixed repeated measures ANOVA revealed a significant main effect of therapy (F(1,18) = 10.763; p = 0.005) on the performance on the Snodgrass and Vanderwart naming test.

CONCLUSION

Although limited by a non-randomized open study design with a historical control group, the present study suggests that SLT may have a benefit in PPA, and it should prompt a randomized, controlled, rater-blind clinical trial.

Speech therapy in primary progressive aphasia: a pilot study

BACKGROUND

Primary progressive aphasia (PPA) is a neurodegenerative disorder with no effective pharmacological treatment. Cognition-based interventions are adequate alternatives, but their benefit has not been thoroughly explored. Our aim was to study the effect of speech and language therapy (SLT) on naming ability in PPA.

METHODS

An open parallel prospective longitudinal study involving two centers was designed to compare patients with PPA submitted to SLT (1 h/week for 11 months) with patients receiving no therapy. Twenty patients were enrolled and undertook baseline language and neuropsychological assessments; among them, 10 received SLT and 10 constituted an age- and education-matched historical control group. The primary outcome measure was the change in group mean performance on the Snodgrass and Vanderwart naming test between baseline and follow-up assessments.

RESULTS

Intervention and control groups did not significantly differ on demographic and clinical variables at baseline. A mixed repeated measures ANOVA revealed a significant main effect of therapy (F(1,18) = 10.763; p = 0.005) on the performance on the Snodgrass and Vanderwart naming test.

CONCLUSION

Although limited by a non-randomized open study design with a historical control group, the present study suggests that SLT may have a benefit in PPA, and it should prompt a randomized, controlled, rater-blind clinical trial.

Computer Therapy Compared With Usual Care for People With Long-Standing Aphasia Poststroke

Background and Purpose—

The purpose of this study was to test the feasibility of conducting a randomized controlled trial to study the effectiveness of self-managed computer treatment for people with long-standing aphasia after stroke.

Method—

In this pilot single-blinded, parallel-group, randomized controlled trial participants with aphasia were allocated to self-managed computer treatment with volunteer support or usual care (everyday language activity). The 5-month intervention period was followed by 3 months without intervention to investigate treatment maintenance.

Results—

Thirty-four participants were recruited. Seventeen participants were allocated to each group. Thirteen participants from the usual care group and 15 from the computer treatment group were followed up at 5 months. An average of 4 hours 43 minutes speech and language therapy time and 4 hours volunteer support time enabled an average of 25 hours of independent practice. The difference in percentage change in naming ability from baseline at 5 months between groups was 19.8% (95% CI, 4.4–35.2; P =0.014) in favor of the treatment group. Participants with more severe aphasia showed little benefit. Results demonstrate early indications of cost-effectiveness of self-managed computer therapy.

Conclusion—

This pilot trial indicates that self-managed computer therapy for aphasia is feasible and that it will be practical to recruit sufficient participants to conduct an appropriately powered clinical trial to investigate the effectiveness of self-managed computer therapy for people with long-standing aphasia.

Clinical Trial Registration—

www.controlled-trials.com . Unique identifier: ISRCTN91534629.

A new era in speech-language pathology practice: innovation and diversification

A new era in speech-language pathology practice is pending, and one that impels us to innovate and diversify as we move forward into the 21(st) century. The impetus for this transformation will include the increasing cost and demand for healthcare services as the population ages, changes in Australian society, rapid developments in technology, and major advances in neuroscience. New models of service delivery will need to be considered in line with evidence-based treatment protocols, the concept of a continuum of care for chronic disorders, and the need to engage clients in self-management. Innovations in technology will provide the means by which these new models of service delivery might be achieved. The exponential increase in electronic therapy resources and devices will transform the therapeutic process and provide clinicians with engaging and flexible therapy options. Clinicians will be challenged by this paradigm shift in service delivery, and their long-held perceptions of their clients' capacity to respond to these changes. Other challenges will include the preparation of future speech-language pathologists, reimbursement for services, availability of appropriate technology, and widespread connectivity. The future of the profession is an exciting one as we move forward into an era of unprecedented change.

Speech and language therapy for aphasia following stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched June 2011), MEDLINE (1966 to July 2011) and CINAHL (1982 to July 2011). In an effort to identify further published, unpublished and ongoing trials we handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles and contacted academic institutions and other researchers. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) with (1) no SLT; (2) social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); and (3) another SLT intervention (which differed in duration, intensity, frequency, intervention methodology or theoretical approach).

DATA COLLECTION AND ANALYSIS

We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators.

MAIN RESULTS

We included 39 RCTs (51 randomised comparisons) involving 2518 participants in this review. Nineteen randomised comparisons (1414 participants) compared SLT with no SLT where SLT resulted in significant benefits to patients' functional communication (standardised mean difference (SMD) 0.30, 95% CI 0.08 to 0.52, P = 0.008), receptive and expressive language. Seven randomised comparisons (432 participants) compared SLT with social support and stimulation but found no evidence of a difference in functional communication. Twenty-five randomised comparisons (910 participants) compared two approaches to SLT. There was no indication of a difference in functional communication. Generally, the trials randomised small numbers of participants across a range of characteristics (age, time since stroke and severity profiles), interventions and outcomes. Suitable statistical data were unavailable for several measures.

AUTHORS' CONCLUSIONS

Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. However, some trials were poorly reported. The potential benefits of intensive SLT over conventional SLT were confounded by a significantly higher dropout from intensive SLT. More participants also withdrew from social support than SLT interventions. There was insufficient evidence to draw any conclusion regarding the effectiveness of any one specific SLT approach over another.

Constrained versus unconstrained intensive language therapy in two individuals with chronic, moderate-to-severe aphasia and apraxia of speech: behavioral and fMRI outcomes

PURPOSE

This Phase I study investigated behavioral and functional MRI (fMRI) outcomes of 2 intensive treatment programs to improve naming in 2 participants with chronic moderate-to-severe aphasia with comorbid apraxia of speech (AOS). Constraint-induced aphasia therapy (CIAT; Pulvermüller et al., 2001) has demonstrated positive outcomes in some individuals with chronic aphasia. Whether constraint to the speech modality or treatment intensity is responsible for such gains is still under investigation. Moreover, it remains to be seen whether CIAT is effective in individuals with persistent severe nonfluent speech and/or AOS.

METHOD

A single-subject multiple-baseline approach was used. Both participants were treated simultaneously, first with Promoting Aphasics' Communicative Effectiveness (PACE; Davis & Wilcox, 1985) and then with CIAT. Pre-/posttreatment testing included an overt naming fMRI protocol. Treatment effect sizes were calculated for changes in probe accuracy from baseline to posttreatment phases and maintenance where available.

RESULTS

Both participants made more and faster gains in naming following CIAT. Treatment-induced changes in BOLD activation suggested that better naming was correlated with the recruitment of perilesional tissue.

CONCLUSION

Participants produced more target words accurately following CIAT than following PACE. Behavioral and fMRI results support the notion that the intense and repetitive nature of obligatory speech production in CIAT has a positive effect on word retrieval, even in participants with chronic moderate-to-severe aphasia with comorbid AOS.

First decade of research on constrained-induced treatment approaches for aphasia rehabilitation

Approaches for treating poststroke language impairments (aphasia) based on constraint-induced (CI) principles were first introduced in 2001. CI principles as previously applied to upper extremity and locomotor retraining in stroke survivors were derived from basic neuroscience. They comprise forced-use of the affected modality, a gradual rebuilding of targeted functions using a highly intensive treatment protocol, administered in a behaviorally relevant context. CI-based approaches have stimulated considerable neurorehabilitation research interest in the past decade. The original CI aphasia treatment protocol was tailored to improve functional communication in chronic aphasia (ie, 6-12mo after stroke) and more recently, it has been adapted to treat language impairments in acute stroke survivors as well. Moreover, CI therapy applied to aphasia has been used as a model to assess language network plasticity in response to treatment using functional imaging techniques. In the following article, we review the first 10 years of behavioral and functional brain imaging research on CI-based approaches for aphasia rehabilitation.

Is Aphasia Therapy Effective? Exploring the Evidence in Systematic Reviews

In December 1999, Greener, Enderby and Whurr reported the findings of their Cochrane review to assess the effects of formal speech and language therapy for people with aphasia following stroke. They concluded that aphasia therapy had not been shown to be “clearly effective or clearly ineffective within a randomised controlled trial (RCT)” (p. 1). Their conclusion led to much discussion among speech pathologists with some expressing grave concern that the outcome of the review would undermine the provision of services for people with aphasia and their carers. In this paper, evidence for the effectiveness of aphasia therapy that has been provided by published systematic reviews is critically explored. Clearly, challenges remain with respect to provision of evidence-based aphasia therapy. However, the weight of evidence accumulated over the years and synthesised in systematic reviews supports the broad conclusion that aphasia therapy is effective.

Simulated in-home teletreatment for anomia

This pilot study explored the feasibility of in-home teletreatment for patients with post-stroke anomia. Three participants over 65 years of age suffering from post-stroke anomia were treated in this pre/post-intervention case study. They received 12 speech therapy teletreatments (two sessions/week for 6 weeks) aimed at improving confrontation naming skills. Half of the failed items from a set of 120 preselected stimuli were trained during treatment (Block A-trained stimuli) while the other half served as controls (Block B-untrained stimuli). Variables measured were: 1) efficacy of treatment (performance on Block-A vs. Block B Stimuli), and 2) participants’ satisfaction with teletreatment (using a French adaptation of the Telemedicine satisfaction questionnaire). All participants showed a clinically relevant improvement on confrontation naming of trained items and less improvement for untrained items. The researchers also obtained high satisfaction scores on the questionnaire (above 57/60). This pilot study supports the feasibility of speech therapy teletreatments applied to neurological language disorders.

The Effect of Choice on Compliance Using Telerehabilitation for Direct Attention Training: A Comparison of “Push” Versus “Pull” Scheduling

Home practice, a type of asynchronous telerehabilitation, is an integral component of most rehabilitation regimens. Exercise drills conducive to home practice have been shown to be beneficial in remediating acquired impairments in attention, speech, language, and voice. A variety of interacting psychological, cognitive, and socioenvironmental factors contribute to short- and long-term exercise adherence. There has been little research evaluating the personal characteristics most likely to motivate clients to engage in their rehabilitation and follow through with prescribed activities. In this project, we were interested in using telerehabilitation to learn more about factors that might increase clients' adherence to home exercise; we used direct attention training as our experimental domain. The study used a single-subject, alternating treatment experimental design with 2 participants to compare compliance on home attention exercises under two conditions. The Attention Process Training-3 (APT-3, 2010) direct attention training program, delivered via the Televised Assistance Program (TAP) system, allowed us to compare compliance under (a) conditions when the client had no control over the start-up of the program (push) versus (b) conditions when the client had to initiate turning on the program to do the home program (pull). Results showed that home exercise adherence was higher for both participants under the nonautonomous push condition. This ran counter to our hypothesis, based on the therapy literature, that suggested patients are more likely to follow through with home assignments when practice is under their control. We discuss our findings with respect to the interaction between self-efficacy, therapy beliefs, and autonomy for patients with acquired brain injury.