Intensity of Aphasia Therapy: Evidence and Efficacy

Experiences of People with Aphasia Receiving Enhanced Community-Based Speech-Language Pathology Provided by Speech-Language Pathology Students

INTRODUCTION

Treatment intensity for people with aphasia (PWA) is a significant factor in enhancing recovery. Personal factors such as fatigue, physical endurance, and motivation as well as clinician availability have been described as barriers to increased intensity. The use of student therapists has been shown to assist with addressing service gaps.

METHODS

The aim of the study was to explore the experiences of PWA who received enhanced community-based treatment delivered by speech-language pathology (SLP) students. Enhanced community-based treatment was defined as three or more treatment sessions per week targeting communication. Semi-structured interviews were conducted with 10 PWA living in New Zealand. Interview data were analysed with reflexive thematic analysis.

RESULTS

Two themes and six sub-themes were developed. Theme 1 related to intensity and included more treatment is better than less (sub-theme 1), there's a "right time" for more intensive treatment (sub-theme 2), the hard work is worth the effort (sub-theme 3). Theme 2 related to working with SLP students; it didn't feel like they were students (sub-theme 4), we just got on so well (sub-theme 5), and they listened to what I wanted (sub-theme 6).

CONCLUSIONS

The findings confirm that PWA value access to more intensive treatment and desire involvement in decisions about flexible treatment schedules. PWA have positive experiences when treatment is provided by SLP students. Implications for clinical practice and future research directions are discussed.

A systematic review of Intensive Comprehensive Aphasia Programmes - who takes part, what is measured, what are the outcomes?

PURPOSE

This study synthesizes participant and outcome data from peer-reviewed Intensive Comprehensive Aphasia Programme (ICAP) studies.

METHODS

A systematic review was conducted following PRISMA guidelines. Study eligibility criteria were specified in relation to population, intervention, comparison, outcome, and design considerations. Data were extracted according to six research questions. Narrative synthesis was used.

RESULTS

Twenty-one studies were included covering 13 ICAPs (N = 485, aged 18-86 years, between 11 and 335 months post-stroke). Twenty-seven participant selection criteria were identified. Fifty-six outcome measures spanning the WHO-ICF were used, with the majority assessing the body function domain. Only eight studies employed an experimental design with data appropriate for analysis and synthesis. Risk of bias was noted across this sub-group. Participants improved in word-finding, communication, activity/participation, and communication-related quality of life, and maintained their gains; however, except for word finding, evidence of effect came from isolated studies. Factors influencing outcomes were rarely considered. Some drop-outs, missed sessions, and fatigue were noted. Some studies reported IPD alongside group analyses.

CONCLUSIONS

ICAP selection criteria need justification and should contribute to the understanding of candidacy for this treatment model. Rationalisation of ICAP treatment content and outcome measurement is required, spanning all WHO-ICF domains. Employment of the core outcome set for aphasia would enable data synthesis and facilitate comparisons between the ICAP and other therapy models.

Intensive and comprehensive aphasia therapy-a survey of the definitions, practices and views of speech and language therapists in the United Kingdom

BACKGROUND

Research evidence suggests aphasia therapy must be delivered at high intensity to effect change. Comprehensive therapy, addressing all domains of the International Classification of Functioning, Disability and Health, is also called for by people with aphasia and their families. However, aphasia therapy is rarely intense or comprehensive. Intensive Comprehensive Aphasia Programmes (ICAPs) were designed to address this challenge, but such programmes are not widely implemented.

AIMS

This study surveyed the views of UK-based speech and language therapists (SLTs) regarding intensive and comprehensive aphasia therapy. It explored definitions of intensive and comprehensive therapy, patterns of provision, views about candidacy and barriers/facilitators. It also investigated awareness of ICAPs and perceived potential of this service model. Differences across UK regions and workplace settings were explored.

METHODS & PROCEDURES

An e-survey ran for 5 months. Quantitative data were analysed using descriptive and inferential statistics. Qualitative free text comments were analysed using content analysis.

OUTCOMES & RESULTS

Two hundred twenty-seven respondents engaged in the e-survey. Definitions of intensive aphasia therapy did not reach UK clinical guideline/research-level thresholds for most of the sample. Those providing more therapy provided definitions with higher standards of intensity. Mean therapy delivered was 128 min/week. Geographical location and workplace setting influenced the amount of therapy delivered. The most frequently delivered therapy approaches were functional language therapy and impairment-based therapy. Cognitive disability and fatigue were concerns for therapy candidacy. Barriers included lack of resources and low levels of optimism that issues could be solved. 50% of respondents were aware of ICAPs and 15 had been involved in ICAP provision. Only 16.5% felt their service could be reconfigured to deliver an ICAP.

CONCLUSIONS & IMPLICATIONS

This e-survey evidences a mismatch between an SLT's concept of intensity and that espoused by clinical guidelines/research. Geographical variations in intensity are concerning. Although a wide range of therapy approaches are offered, certain aphasia therapies are delivered more frequently. Awareness of ICAPs was relatively high, but few respondents had experience of this model or felt it could be executed in their context. Further initiatives are needed if services are to move from a low-dose or non-comprehensive model of delivery. Such initiatives might include but not be confined to wider uptake of ICAPs. Pragmatic research might also explore which treatments are efficacious with a low-dose model of delivery, given that this model is dominant in the United Kingdom. These clinical and research implications are raised in the discussion.

WHAT THIS PAPER ADDS

What is already known on this subject There is a gap between the high intensity of aphasia treatment provided in research versus mainstream clinical settings. A lower standard of 45 min/day set by UK clinical guidelines is also not achieved. Although speech and language therapists (SLTs) provide a wide range of therapies, they typically focus on impairment-based approaches. What this study adds This is the first survey of UK SLTs asking about their concept of intensity in aphasia therapy and what types of aphasia therapy they provide. It explores geographical and workplace variations and barriers and facilitators to aphasia therapy provision. It investigates Intensive Comprehensive Aphasia Programmes (ICAPs) in a UK context. What are the clinical implications of this work? There are barriers to the provision of intensive and comprehensive therapy in the United Kingdom and reservations about the feasibility of ICAPs in a mainstream UK context. However, there are also facilitators to aphasia therapy provision and evidence that a small proportion of UK SLTs are providing intensive/comprehensive aphasia therapy). Dissemination of good practice is necessary and suggestions for increasing intensity of service provision are listed in the discussion.

Unraveling the Thread of Aphasia Rehabilitation: A Translational Cognitive Perspective

Translational neuroscience is a multidisciplinary field that aims to bridge the gap between basic science and clinical practice. Regarding aphasia rehabilitation, there are still several unresolved issues related to the neural mechanisms that optimize language treatment. Although there are studies providing indications toward a translational approach to the remediation of acquired language disorders, the incorporation of fundamental neuroplasticity principles into this field is still in progress. From that aspect, in this narrative review, we discuss some key neuroplasticity principles, which have been elucidated through animal studies and which could eventually be applied in the context of aphasia treatment. This translational approach could be further strengthened by the implementation of intervention strategies that incorporate the idea that language is supported by domain-general mechanisms, which highlights the impact of non-linguistic factors in post-stroke language recovery. Here, we highlight that translational research in aphasia has the potential to advance our knowledge of brain-language relationships. We further argue that advances in this field could lead to improvement in the remediation of acquired language disturbances by remodeling the rationale of aphasia-therapy approaches. Arguably, the complex anatomy and phenomenology of aphasia dictate the need for a multidisciplinary approach with one of its main pillars being translational research.

Transcranial Direct-Current Stimulation in Subacute Aphasia: A Randomized Controlled Trial

BACKGROUND

Transcranial direct-current stimulation (tDCS) is a promising adjunct to therapy for chronic aphasia.

METHODS

This single-center, randomized, double-blind, sham-controlled efficacy trial tested the hypothesis that anodal tDCS augments language therapy in subacute aphasia. Secondarily, we compared the effect of tDCS on discourse measures and quality of life and compared the effects on naming to previous findings in chronic stroke. Right-handed English speakers with aphasia <3 months after left hemisphere ischemic stroke were included, unless they had prior neurological or psychiatric disease or injury or were taking certain medications (34 excluded; final sample, 58). Participants were randomized 1:1, controlling for age, aphasia type, and severity, to receive 20 minutes of tDCS (1 mA) or sham-tDCS in addition to fifteen 45-minute sessions of naming treatment (plus standard care). The primary outcome variable was change in naming accuracy of untrained pictures pretreatment to 1-week posttreatment.

RESULTS

Baseline characteristics were similar between the tDCS (N=30) and sham (N=28) groups: patients were 65 years old, 53% male, and 2 months from stroke onset on average. In intent-to-treat analysis, the adjusted mean change from baseline to 1-week posttreatment in picture naming was 22.3 (95% CI, 13.5-31.2) for tDCS and 18.5 (9.6-27.4) for sham and was not significantly different. Content and efficiency of picture description improved more with tDCS than sham. Groups did not differ in quality of life improvement. No patients were withdrawn due to adverse events.

CONCLUSIONS

tDCS did not improve recovery of picture naming but did improve recovery of discourse. Discourse skills are critical to participation. Future research should examine tDCS in a larger sample with richer functional outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02674490.

Automatic Assessment of Aphasic Speech Sensed by Audio Sensors for Classification into Aphasia Severity Levels to Recommend Speech Therapies

Aphasia is a type of speech disorder that can cause speech defects in a person. Identifying the severity level of the aphasia patient is critical for the rehabilitation process. In this research, we identify ten aphasia severity levels motivated by specific speech therapies based on the presence or absence of identified characteristics in aphasic speech in order to give more specific treatment to the patient. In the aphasia severity level classification process, we experiment on different speech feature extraction techniques, lengths of input audio samples, and machine learning classifiers toward classification performance. Aphasic speech is required to be sensed by an audio sensor and then recorded and divided into audio frames and passed through an audio feature extractor before feeding into the machine learning classifier. According to the results, the mel frequency cepstral coefficient (MFCC) is the most suitable audio feature extraction method for the aphasic speech level classification process, as it outperformed the classification performance of all mel-spectrogram, chroma, and zero crossing rates by a large margin. Furthermore, the classification performance is higher when 20 s audio samples are used compared with 10 s chunks, even though the performance gap is narrow. Finally, the deep neural network approach resulted in the best classification performance, which was slightly better than both K-nearest neighbor (KNN) and random forest classifiers, and it was significantly better than decision tree algorithms. Therefore, the study shows that aphasia level classification can be completed with accuracy, precision, recall, and F1-score values of 0.99 using MFCC for 20 s audio samples using the deep neural network approach in order to recommend corresponding speech therapy for the identified level. A web application was developed for English-speaking aphasia patients to self-diagnose the severity level and engage in speech therapies.

Treatment of Underlying Forms: A Bayesian Meta-Analysis of the Effects of Treatment and Person-Related Variables on Treatment Response

Purpose This meta-analysis synthesizes published studies using "treatment of underlying forms" (TUF) for sentence-level deficits in people with aphasia (PWA). The study aims were to examine group-level evidence for TUF efficacy, to characterize the effects of treatment-related variables (sentence structural family and complexity; treatment dose) in relation to the Complexity Account of Treatment Efficacy (CATE) hypothesis, and to examine the effects of person-level variables (aphasia severity, sentence comprehension impairment, and time postonset of aphasia) on TUF response. Method Data from 13 single-subject, multiple-baseline TUF studies, including 46 PWA, were analyzed. Bayesian generalized linear mixed-effects interrupted time series models were used to assess the effect of treatment-related variables on probe accuracy during baseline and treatment. The moderating influence of person-level variables on TUF response was also investigated. Results The results provide group-level evidence for TUF efficacy demonstrating increased probe accuracy during treatment compared with baseline phases. Greater amounts of TUF were associated with larger increases in accuracy, with greater gains for treated than untreated sentences. The findings revealed generalization effects for sentences that were of the same family but less complex than treated sentences. Aphasia severity may moderate TUF response, with people with milder aphasia demonstrating greater gains compared with people with more severe aphasia. Sentence comprehension performance did not moderate TUF response. Greater time postonset of aphasia was associated with smaller improvements for treated sentences but not for untreated sentences. Conclusions Our results provide generalizable group-level evidence of TUF efficacy. Treatment and generalization responses were consistent with the CATE hypothesis. Model results also identified person-level moderators of TUF (aphasia severity, time postonset of aphasia) and preliminary estimates of the effects of varying amounts of TUF for treated and untreated sentences. Taken together, these findings add to the TUF evidence and may guide future TUF treatment-candidate selection. Supplemental Material https://doi.org/10.23641/asha.16828630.

Demystifying the complexity of aphasia treatment: Application of the Rehabilitation Treatment Specification System (RTSS)

A considerable body of research supports the use of behavioral communication treatment as the standard of care for aphasia. In spite of robust progress in clinical aphasiology, many questions regarding optimal care remain unanswered. One of the major challenges to progress in the field is the lack of a common framework to adequately describe individual treatments, which, if available, would allow comparisons across studies as well as improved communication among researchers, clinicians, and other stakeholders. Here, we describe how aphasia treatment approaches can be systematically characterized using the Rehabilitation Treatment Specification System (RTSS). At the core of the RTSS is a tripartite structure that focuses on targets (the behavior that is expected to change as a result of treatment), ingredients (what a clinician does to affect change in the target), and mechanism(s) of action (why a given treatment works by linking the ingredients to the target). Three separate papers in the current issue specifically describe how the RTSS can be used to describe different kinds of aphasia treatment approaches: functional approaches, cognitive-linguistic approaches, and biological approaches. It is our hope that the application of the RTSS in clinical aphasiology will improve communication in published studies, grant proposals, and in the clinical care of persons with aphasia.

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.

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.

Developments in the application of Intensive Comprehensive Aphasia Programs: an international survey of practice

PURPOSE

Intensive Comprehensive Aphasia Programs (ICAPs) were first described in 2013 with an international survey documenting 12 unique programs. ICAPs involve high dose intervention delivered in both group and individual settings, targeting communication across impairment, functioning, participation, and contextual domains. In this study, we aimed to investigate international growth in ICAPs.

MATERIALS AND METHODS

We developed a 43-item questionnaire expanding on the original 2013 version to investigate program modifications, activities, protocolised therapies, software and apps, and family involvement. The survey was disseminated to aphasia clinicians and researchers internationally (November 2019-February 2020).

RESULTS

Thirty-nine unique respondents completed the survey from nine countries. Twenty-one met the criteria for an ICAP or modified ICAP (mICAP): 14 ICAPs; 7 mICAPs, and 13 of these were new programs. ICAPs differed from mICAPs with greater emphasis on group sessions, use of technology, total communication, advocacy, and art activities. A large range of protocolised therapies were used across programs. An increased focus on mood and psychosocial well-being was observed compared to the 2013 survey.

CONCLUSIONS

The number and comprehensiveness of ICAPs has grown since 2013 with development of modified versions. Future research should focus on comparative efficacy of ICAPs/mICAPs and other forms of aphasia interventions and factors underpinning growth and sustainability.Implications for RehabilitationClinicians who coordinate or are considering commencing an ICAP in future can use these results to consider the design of their program.Coordinators should carefully consider the components of their ICAPs and advise consumers whether they meet the definition of an ICAP or a mICAP.With the increasing number of ICAPs across the globe, clinicians commencing an ICAP may wish to contact existing ICAPs within their country for advice.Program sustainability may be challenging and these results provide an indication of some of the key challenges coordinators may face.

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.

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.

Intensive and non-intensive treatment of lexical anomia are equally efficient in post-stroke aphasia

Although the treatment for lexical anomia in individuals with aphasia (IWA) was shown effective, little is known about the optimal treatment intensity required. The aim of this study was to verify whether intensive and non-intensive treatments led to different outcomes when parameters of intensity are rigorously controlled. Six IWA with post-stroke lexical anomia received phonological treatment at two distinct frequencies: intensive (four times a week) and non-intensive (once a week). Results showed that both treatments were equally effective. This finding is especially relevant in contexts in which speech-language therapy delivery services are limited.

Effect of speech therapy intervention program for non-fluent aphasic patients after stroke

PURPOSE

the objective of this paper is to verify the effect of speech therapy intervention program in patients with non-fluent aphasia due to stroke in language tasks related to verbal fluency in semantic and phonological categories.

METHODS

Patients with aphasia due to stroke were selected to take part in this study. Two groups were formed: diagnosed patients with Broca/transcortical motor aphasia (GA), and a control group (healthy individuals). GA took a fluency verbal task (FAS, other complementary categories: phonological /p/ /l/ and semantic: "fruits" and "names"). These patients were all engaged in a language intervention program developed by the authors of this study. GA received speech therapy sessions (ten sessions lasting for an hour once a week), following a specific language program. After the sessions, the patients were re-evaluated.

RESULTS

GA had statistical significant improvement in the verbal fluency task after the speech therapy program (p-value < 0,001).

CONCLUSION

The speech language therapy program we proposed was efficient enough to show improvement in the results for GA in the verbal fluency task.

Treatment dose in post-stroke aphasia: A systematic scoping review

Little is known about how the amount of treatment a person with aphasia receives impacts aphasia recovery following stroke, yet this information is vital to ensure effective treatments are delivered efficiently. Furthermore, there is no standard dose terminology in the stroke rehabilitation or aphasia literature. This scoping review aims to systematically map the evidence regarding dose in treatments for post-stroke aphasia and to explore how treatment dose is conceptualized, measured and reported in the literature. A comprehensive search was undertaken in June 2019. One hundred and twelve intervention studies were reviewed. Treatment dose (amount of treatment) has been conceptualized as both a measure of time and a count of discrete therapeutic elements. Doses ranged from one to 100 hours, while some studies reported session doses of up to 420 therapeutic inputs per session. Studies employ a wide variety of treatment schedules (i.e., session dose, session frequency, and intervention duration) and the interaction of dose parameters may impact the dose-response relationship. High dose interventions delivered over short periods may improve treatment efficiency while maintaining efficacy. Person- and treatment-level factors that mediate tolerance of high dose interventions require further investigation. Systematic exploration of dose-response relationships in post-stroke aphasia treatment is required.

Comparing higher and lower weekly treatment intensity for chronic aphasia: A systematic review and meta-analysis

Optimizing intensity for aphasia treatment is a high priority research issue for people with aphasia, their families and clinicians, and could result in healthcare cost savings. An important aspect of intensity is the frequency of intervention, or how regularly treatment should be provided each week. While principles of neuroplasticity endorse massed practice, cognitive psychology has established superiority of distributed practice within normal learning. Neither concept has been conclusively tested in aphasia. There have been many literature reviews of intensity in aphasia intervention, but most have not investigated treatment intensity whilst also ensuring that therapy dose and treatment type are identical between study groups. Some have also combined studies across acute, subacute and chronic aphasia. We searched systematically for studies directly comparing higher and lower weekly treatment frequency in chronic aphasia. Eight studies were retrieved and rated for methodological quality. Meta-analysis was completed for group and single case experimental designs. Results showed that there are few studies investigating treatment frequency in chronic aphasia and their quality is low-moderate. Meta-analyses were inconclusive due to limited data, but there was no indication of either schedule being superior. Further research directly comparing treatment schedules is needed.

Elizabeth Usher Memorial Lecture: Lost in Translation? Challenges and future prospects for a neurobiological approach to aphasia rehabilitation

While there has been considerable progress in conducting trials of aphasia therapy, there is no consistent evidence for long-term benefits of aphasia treatment, suggesting the need to reconsider current approaches. There are also no accurate methods for determining the amount, type and timing of aphasia therapy that should be provided for an individual. At the same time, there has been increasing interest in applying various principles of neuroplasticity to aphasia treatment and using measures of brain structure and function to predict recovery. This article will consider the potential of neuroplasticity principles and neurobiological predictors to improve our current approach to aphasia rehabilitation and optimise outcomes. Reviewing these principles highlights some of the challenges of translating animal model-based principles and emphases the need to also consider relevant theories of human learning. While considerable progress has been made in considering neurobiological principles and using measures of brain structure and function to predict recovery, there is significant work required to achieve the full potential of this neurobiological approach to aphasia management.

Developing, Implementing, and Improving Assessment and Treatment Fidelity in Clinical Aphasia Research

Purpose The purpose of this study was to describe the development and implementation of a fidelity program for an ongoing, multifacility, aphasia intervention study and to explain how initial fidelity measures are being used to improve study integrity. Method A Clinical Core team developed and incorporated a fidelity plan in this study. The aims of the Clinical Core team were to (a) supervise data collection and data management at each clinical site, (b) optimize and monitor assessment fidelity, and (c) optimize and monitor treatment fidelity. Preliminary data are being used to guide ongoing efforts to preserve and improve the fidelity of this intervention study. Results Preliminary results show that specific recruitment strategies help to improve appropriate referrals and that accommodations to participants and their families help to maintain excellent retention. A streamlined and centralized training program assures the reliability of assessors and raters for the study's assessment and treatment protocols. Ongoing monitoring of both assessment and treatment tasks helps to maintain study integrity. Less-than-optimal interrater reliability data for the raters of some of the discourse measures guided the Clinical Core team to address the training and coding inconsistencies in a timely manner. Conclusions The creation of a Clinical Core team is instrumental in developing and implementing a fidelity plan for improved assessment and treatment fidelity. Intentional planning and assignment of study staff to implement and monitor ongoing fidelity measures assures that clinical data are reliable and valid. Ongoing review of the plan shows areas of strengths and weaknesses for continuing adjustments and improvement of study fidelity.

Clinical Outcomes Following Language-Specific Attention Treatment Versus Direct Attention Training for Aphasia: A Comparative Effectiveness Study

Purpose This study was conducted to examine the comparative effectiveness of 2 different approaches, 1 domain-specific and the other domain-general, to language and attention rehabilitation in participants with stroke-induced aphasia. The domain-specific treatment consisted of language-specific attention treatment (L-SAT), and the domain-general treatment consisted of direct attention training (DAT) using the computerized exercises included in Attention Process Training-3 (Sohlberg & Mateer, 2010). Method Four individuals with mild-moderate aphasia participated in this study. A randomized controlled cross-over single-subject design was used to assess the effectiveness of the 2 treatments administered in this study. Treatment outcomes were evaluated in terms of participants' task performance for each program, standardized language and attention measures, tests of functional abilities, and patient-reported outcomes. Results Visual comparisons demonstrated linear improvements following L-SAT and variable patterns following DAT. Omnibus effect sizes were statistically significant for 9 of the 13 L-SAT tasks. The weighted standardized effect sizes for posttreatment changes following L-SAT ranged from small to large, with the exception of 1 task. The average group gain following DAT was 5%. The Western Aphasia Battery-Revised Aphasia Quotients (Kertesz, 2007) demonstrated reliable improvements for 3 of the 4 participants following L-SAT, whereas only 1 of the participants improved reliably following DAT. The margins of improvements in functional language were substantially larger following L-SAT than DAT. Performance on the Test of Everyday Attention improved significantly for 2 participants following L-SAT and for 1 participant following DAT on selected Test of Everyday Attention (Robertson, Ward, Ridgeway, & Nimmo-Smith, 1994) subtests. Patient-reported outcomes for communication and attention following treatment favored L-SAT compared to DAT. Conclusions The results support the view that attention is allocated in ways that are particular to specific tasks rather than as a general resource that is allocated equivalently to all processing tasks. Domain-specific treatment for language deficits due to attentional impairment appears to be a suitable, if not preferable, approach for aphasia rehabilitation. Supplemental Material https://doi.org/10.23641/asha.8986427.

Two to Tango or the More the Merrier? A Randomized Controlled Trial of the Effects of Group Size in Aphasia Conversation Treatment on Standardized Tests

Purpose Group conversation treatment has the potential to improve communication and reduce social isolation for people with aphasia. This project examined how 2 conflicting hypotheses-treatment dosage and group dynamics-affect treatment outcomes. Method Forty-eight participants with chronic aphasia were randomly assigned to either a dyad, a large group, or a delayed control group. Conversation group treatment was provided for an hour, twice per week, for 10 weeks. Individual goals were developed by each participant and addressed in the context of thematically oriented conversation treatment. Standardized testing across language domains was completed pretreatment (Time 1), posttreatment (Time 2), at a 6-week maintenance point (Time 3), and at 11-month follow-up for the experimental groups. Results Treatment groups showed greater changes on standardized measures than the control group posttreatment. Dyads showed the most changes on measures of language impairment, whereas changes on the self-reported functional communication measure (Aphasia Communication Outcome Measure) and connected speech task only showed significant changes in the large group. Conclusions This randomized controlled trial on conversation treatment indicated that both treatment groups-but not the delayed control group-showed significant changes on standardized tests. Hence, conversation treatment is associated with changes in measures of language impairment and quality of life. Dyads showed the most changes on measures of language impairment, whereas changes on the functional communication measure (Aphasia Communication Outcome Measure) and discourse production only showed significant changes in the large group. Thus, group size may be associated with effects on different types of outcome measures.

Acquisition and Generalization Responses in Aphasia Naming Treatment: A Meta-Analysis of Semantic Feature Analysis Outcomes

Purpose This meta-analysis synthesizes results from published studies that used semantic feature analysis (SFA) treatment to improve naming for people with aphasia. It examines how both person- and treatment-related variables affected the likelihood of correct naming responses in individual probe sessions for both acquisition (treated) and generalization (untreated) stimuli. Method The meta-analysis compiled data from 12 studies analyzing a total of 35 participants with aphasia. It used mixed-effects models as a novel statistical tool to examine the effects of 2 sets of variables on naming performance: treatment-related variables, including treatment phase (baseline vs. treatment), dosage (number of treatment sessions), and stimulus type (treated vs. untreated, semantically related vs. unrelated items), and person-specific variables, including degree of language impairment and demographic variables (age, time poststroke). Results Results of the meta-analysis revealed that SFA intervention promoted increased naming accuracy during naming probes when comparing baseline and treatment phases. In addition, increased dosages of SFA were associated with increased naming accuracy, and treatment-related gains were larger for acquisition (treated) than generalization (untreated) stimuli, likewise for related versus unrelated generalization stimuli. Furthermore, a subset of person-specific variables was predictive of SFA-related gains: Language impairment variables were related to treatment-related changes in naming performance, but demographic variables were not. Conclusion These results provide group-level evidence for the efficacy of SFA as well as preliminary estimates of how much naming performance benefit is engendered by varying dosages of SFA. The results also provide promising and previously unobserved evidence of potential person-level predictors of SFA treatment response.

Intensive Auditory Comprehension Treatment for Severe Aphasia: A Feasibility Study

BACKGROUND

Severe auditory comprehension impairments secondary to aphasia can adversely influence rehabilitative outcomes and quality of life. Studies examining intensive rehabilitative treatments for severe single-word auditory comprehension impairments are needed.

OBJECTIVES

Our purpose was to examine the feasibility and influence of a high-intensity word-picture verification treatment on high-frequency, word response accuracy. Research questions: (a) Can people with severe aphasia tolerate an intensive comprehension treatment? (b) Does an intensive intervention increase auditory comprehension response accuracy of spoken high-frequency words?

METHOD

This single-case ABA design study included 2 participants with chronic, severe auditory comprehension deficits secondary to stroke. A high-frequency, word-picture verification treatment was administered 2 hr/day, 5 days/week for 4 weeks and required participants to match the spoken word of the examiner to a picture representing an object.

RESULTS

Preliminary results suggest that some people with severe chronic aphasia can tolerate an intensive auditory comprehension treatment and demonstrate improvements in high-frequency, word-level response accuracy with large effect sizes suggesting generalization to untrained stimuli.

CONCLUSIONS

An intensive auditory comprehension treatment protocol can contribute to improvements in response accuracy for some people with severe aphasia. Larger sample size studies are needed to further examine the influence of intensity on improvements in auditory comprehension.

Treatment Response to a Double Administration of Constraint-Induced Language Therapy in Chronic Aphasia

Purpose

This study investigated changes in oral-verbal expressive language associated with improvements following 2 treatment periods of constraint-induced language therapy in 4 participants with stroke-induced chronic aphasia. Generalization of treatment to untrained materials and to discourse production was also analyzed, as was the durability of the treatment effect.

Method

Participants with aphasia were assessed using standardized measures and discourse tasks at 3 to 4 time points to document behavioral changes throughout each of two 30-hr treatment periods of constraint-induced language therapy. Daily probes of trained and untrained materials were also administered.

Results

Despite participant heterogeneity, behavioral results for each person with aphasia indicated a positive response to treatment following each treatment period indicated by performance on standardized tests, trained materials, or both. Treatment effects generalized to some degree to untrained stimuli and to discourse measures and were generally maintained at follow-up testing.

Conclusions

Data support the utility of a 2nd treatment period. Results are relevant to rehabilitation in chronic aphasia, confirming that significant language gains continue well past the point of spontaneous recovery and can occur in a relatively short time period. Importantly, changes are not confined to a single treatment period, suggesting that people with aphasia may benefit from multiple doses of high-intensity treatment.

What Matters in Semantic Feature Analysis: Practice-Related Predictors of Treatment Response in Aphasia

PURPOSE

This study investigated the predictive value of practice-related variables-number of treatment trials delivered, total treatment time, average number of trials per hour, and average number of participant-generated features per trial-in response to semantic feature analysis (SFA) treatment.

METHOD

SFA was administered to 17 participants with chronic aphasia daily for 4 weeks. Individualized treatment and semantically related probe lists were generated from items that participants were unable to name consistently during baseline testing. Treatment was administered to each list sequentially in a multiple-baseline design. Naming accuracy for treated and untreated items was obtained at study entry, exit, and 1-month follow-up.

RESULTS

Item-level naming accuracy was analyzed using logistic mixed-effect regression models. The average number of features generated per trial positively predicted naming accuracy for both treated and untreated items, at exit and follow-up. In contrast, total treatment time and average trials per hour did not significantly predict treatment response. The predictive effect of number of treatment trials on naming accuracy trended toward significance at exit, although this relationship held for treated items only.

CONCLUSIONS

These results suggest that the number of patient-generated features may be more strongly associated with SFA-related naming outcomes, particularly generalization and maintenance, than other practice-related variables.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5734113.

Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting

BACKGROUND

Treatment guidelines for aphasia recommend intensive speech and language therapy for chronic (≥6 months) aphasia after stroke, but large-scale, class 1 randomised controlled trials on treatment effectiveness are scarce. We aimed to examine whether 3 weeks of intensive speech and language therapy under routine clinical conditions improved verbal communication in daily-life situations in people with chronic aphasia after stroke.

METHODS

In this multicentre, parallel group, superiority, open-label, blinded-endpoint, randomised controlled trial, patients aged 70 years or younger with aphasia after stroke lasting for 6 months or more were recruited from 19 inpatient or outpatient rehabilitation centres in Germany. An external biostatistician used a computer-generated permuted block randomisation method, stratified by treatment centre, to randomly assign participants to either 3 weeks or more of intensive speech and language therapy (≥10 h per week) or 3 weeks deferral of intensive speech and language therapy. The primary endpoint was between-group difference in the change in verbal communication effectiveness in everyday life scenarios (Amsterdam-Nijmegen Everyday Language Test A-scale) from baseline to immediately after 3 weeks of treatment or treatment deferral. All analyses were done using the modified intention-to-treat population (those who received 1 day or more of intensive treatment or treatment deferral). This study is registered with ClinicalTrials.gov, number NCT01540383.

FINDINGS

We randomly assigned 158 patients between April 1, 2012, and May 31, 2014. The modified intention-to-treat population comprised 156 patients (78 per group). Verbal communication was significantly improved from baseline to after intensive speech and language treatment (mean difference 2·61 points [SD 4·94]; 95% CI 1·49 to 3·72), but not from baseline to after treatment deferral (-0·03 points [4·04]; -0·94 to 0·88; between-group difference Cohen's d 0·58; p=0·0004). Eight patients had adverse events during therapy or treatment deferral (one car accident [in the control group], two common cold [one patient per group], three gastrointestinal or cardiac symptoms [all intervention group], two recurrent stroke [one in intervention group before initiation of treatment, and one before group assignment had occurred]); all were unrelated to study participation.

INTERPRETATION

3 weeks of intensive speech and language therapy significantly enhanced verbal communication in people aged 70 years or younger with chronic aphasia after stroke, providing an effective evidence-based treatment approach in this population. Future studies should examine the minimum treatment intensity required for meaningful treatment effects, and determine whether treatment effects cumulate over repeated intervention periods.

FUNDING

German Federal Ministry of Education and Research and the German Society for Aphasia Research and Treatment.

Refining an Asynchronous Telerehabilitation Platform for Speech-Language Pathology: Engaging End-Users in the Process

Asynchronous telerehabilitation in which computer-based interventions are remotely monitored and adapted offline is an emerging service delivery model in the rehabilitation of communication disorders. The asynchronous nature of this model may hold a benefit over its synchronous counterpart by eliminating scheduling issues and thus improving efficiency in a healthcare landscape of constrained resource allocation. The design of asynchronous telerehabilitation platforms should therefore ensure efficiency and flexibility. The authors have been engaged in a program of research to develop and evaluate an asynchronous telerehabilitation platform for use in speech-language pathology. eSALT is a novel asynchronous telerehabilitation platform in which clinicians design and individualize therapy tasks for transfer to a client's mobile device. An inbuilt telerehabilitation module allows for remote monitoring and updating of tasks. This paper introduces eSALT and reports outcomes from an usability study that considered the needs of two end-user groups, people with aphasia and clinicians, in the on-going refinement of eSALT. In the study participants with aphasia were paired with clinicians who used eSALT to design and customize therapy tasks. After training on the mobile device the participants engaged in therapy at home for a period of 3 weeks, while clinicians remotely monitored and updated tasks. Following the home trial, participants, and clinicians engaged in semi-structured interviews and completed surveys on the usability of eSALT and their satisfaction with the platform. Content analysis of data involving five participants and three clinicians revealed a number of usability themes including ease of use, user support, satisfaction, limitations, and potential improvements. These findings were translated into a number of refinements of the eSALT platform including the development of a client interface for use on the Apple iPad®, greater variety in feedback options to both the participant and clinician, automatic transfer of results to the clinician, and expansion of the task template list. This research highlights the importance of including end-users in the process of technology refinement, in order to ensure effective and efficient use of the technology. Future directions for research are discussed including clinical trials in which the effectiveness of and adherence to intervention protocols using asynchronous telerehabilitation are examined.

The Use of One or Three Semantic Associative Primes in Treating Anomia in Aphasia

PURPOSE

The aims of the study were to investigate the use of semantic associative relationships as primes in treating naming deficits, or anomia, in aphasia and to determine if differential treatment effects would be found if 1 or 3 primes were presented.

METHOD

Ten individuals with varying degrees of anomia participated in the study. A single-subject, A-B treatment design with a cross-over component was used. A 1-PRIME condition (use of 1 prime) was compared with a 3-PRIMES condition (use of 3 primes) for each participant.

RESULTS

Visual analyses of treatment data revealed improvements in 8 of 10 participants. Meaningful effect sizes were obtained in at least 1 of the conditions for 6 of the 10 participants. Slightly more participants demonstrated meaningful effect sizes in the 3-PRIMES condition than in the 1-PRIME condition. Correlation analyses revealed a positive correlation between the number of teaching episodes and 3-PRIMES probe performance.

CONCLUSIONS

The results support a protocol that uses semantic associative primes to increase naming accuracy in aphasia. The 3-PRIMES condition was slightly more beneficial than the 1-PRIME condition in terms of improving naming abilities in these participants, but there was no overwhelming advantage in using one or the other condition.

Intensive Language Action Therapy in Chronic Aphasia: A Randomized Clinical Trial Examining Guidance by Constraint

Purpose

Intensive language action therapy (ILAT) can be effective in overcoming learned nonuse in chronic aphasia. It is suggested that all three guiding principles (constraint, communication embedding, massed practice) are essential to ILAT's success. We examined whether one of these, guidance by constraint, is critical.

Method

Twenty-four participants with aphasia (PWAs) were assigned to ILAT or a modified version of promoting aphasic communicative effectiveness (PACE) in a randomized block, single-blind, parallel-group treatment study. Blocking was by severity (mild/moderate, moderate to severe, severe). Both groups received intensive treatment in the context of therapeutic language action games. Whereas the ILAT group was guided toward spoken responses, the PACE group could choose any response modality.

Results

All participants, whether assigned to ILAT or PACE groups, improved on the primary outcome measure, picture naming. There was a Severity × Treatment interaction, with the largest effects estimated for PWAs with mild/moderate and moderate to severe aphasia. Regardless of severity, the ILAT group outperformed the PACE group on untrained pictures, suggesting some benefit of ILAT to generalization. However, this difference was not statistically significant.

Conclusion

Although the groups differed in subtle ways, including better generalization to untrained pictures for ILAT, the study was inconclusive on the influence of guidance by constraint.

Speech and language therapy for aphasia following subacute stroke

The aim of this study was to investigate the time window, duration and intensity of optimal speech and language therapy applied to aphasic patients with subacute stroke in our hospital. The study consisted of 33 patients being hospitalized for stroke rehabilitation in our hospital with first stroke but without previous history of speech and language therapy. Sixteen sessions of impairment-based speech and language therapy were applied to the patients, 30-60 minutes per day, 2 days a week, for 8 successive weeks. Aphasia assessment in stroke patients was performed with Gülhane Aphasia Test-2 before and after treatment. Compared with before treatment, fluency of speech, listening comprehension, reading comprehension, oral motor evaluation, automatic speech, repetition and naming were improved after treatment. This suggests that 16 seesions of speech and language therapy, 30-60 minutes per day, 2 days a week, for 8 successive weeks, are effective in the treatment of aphasic patients with subacute stroke.

Constraint-Induced Aphasia Therapy in the Acute Stage

Background. Constraint-induced aphasia therapy (CIAT) has proven effective in patients with subacute and chronic forms of aphasia. It has remained unclear, however, whether intensity of therapy or constraint is the relevant factor. Data about intensive speech and language therapy (SLT) are conflicting. Objective. To identify the effective component of CIAT and assess the feasibility of SLT in the acute stage after stroke. Method. A total of 60 patients with aphasia (68.2 ± 11.7 years) were enrolled 18.9 days after first-ever stroke. They were randomly distributed into 3 groups: (1) CIAT group receiving therapy for 3 hours per day (10 workdays, total 30 hours); (2) conventional communication treatment group, with same intensity without constraints; and (3) control group receiving individual therapy twice a day as well as group therapy (total 14 hours). Patients were assessed pretreatment and posttreatment using the Aachener Aphasia Test (primary end point: token test) and the Communicative Activity Log (CAL). Results. Pretreatment, there were no between-group differences. Posttreatment, all groups showed significant improvements without between-group differences. Conclusion. It was found that 14 hours of aphasia therapy administered within 2 weeks as individual therapy, focusing on individual deficits, combined with group sessions has proven to be most efficient. This approach yielded the same outcome as 30 hours of group therapy, either in the form of CIAT or group therapy without constraints. SLT in an intensive treatment schedule is feasible and was well tolerated in the acute stage after stroke.

Feature rich, but user-friendly: Speech pathologists' preferences for computer-based aphasia therapy

PURPOSE

High-intensity language therapy has been shown to provide greater outcomes for people with aphasia (PWA). Unfortunately, a number of issues including the ageing population and a lack of rurally-based clinicians prevent high-intensity interventions. Computer-based therapies are a potential solution to the issues of intensity and accessibility; however, this service delivery model is not commonly used. A possible reason behind the poor uptake is that current computer-based aphasia therapy (CBAT) programs may not meet the needs of speech-language pathologists (SLPs). This study investigated the preferences of SLPs with regard to the features desired in their ideal CBAT program.

METHOD

Phenomenological research methodology was used to explore the preferences of 10 SLPs. Data were analysed using qualitative thematic analysis.

RESULT

Desired features were grouped into five themes: therapy activities, stimuli, cues, access and progress data. A range of sub-themes were also identified.

CONCLUSION

The wide range of desirable features found in this study may reflect the extent to which current CBAT programs are considered to be useful, but perhaps do not meet the needs of users. The study's findings provide useful information for future CBAT developers to create programs with high clinician usability.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Epidural Cortical Stimulation as Adjunctive Treatment for Nonfluent Aphasia

Background. There is increasing interest in the application of cortical stimulation (CS) as an adjuvant strategy in aphasia rehabilitation. Epidural CS, although more invasive than other methods, can provide high-frequency ipsilesional stimulation with greater spatial specificity. Objective. We review methods and results of a phase 1 study of epidural CS in combination with rehabilitation therapy in aphasia and provide new objective and self-report data collected between 6 and 21 months after the end of treatment. Methods. Eight stroke survivors with nonfluent aphasia received intensive language therapy, 3 hours a day, for 6 weeks. Four participants also underwent surgical implantation of an epidural stimulation device that was activated only during therapy sessions. Behavioral data were collected before treatment, at the end of treatment, and at 6 and 12 weeks after the end of treatment. Of the 8 participants, 7 also participated in the longer-term follow-up visit. Results. Changes in objective scores from baseline were larger in investigational participants than controls at all assessments, including the longer-term follow-up visit. Satisfaction ratings and ratings of overall improvement by investigational participants and their companions were more varied than those of the controls, but all indicated that they would recommend the investigational treatment to others with aphasia. Conclusions. Improvements were generally maintained for at least 12 weeks posttreatment and possibly as long as 21 months posttreatment. Epidural CS is a potentially safe, feasible adjunctive intervention for persons with chronic nonfluent aphasia that spares the ventral premotor cortex and warrants further investigation.

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.

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.

Releasing the constraints on aphasia therapy: the positive impact of gesture and multimodality treatments

PURPOSE

There is a 40-year history of interest in the use of arm and hand gestures in treatments that target the reduction of aphasic linguistic impairment and compensatory methods of communication (Rose, 2006). Arguments for constraining aphasia treatment to the verbal modality have arisen from proponents of constraint-induced aphasia therapy (Pulvermüller et al., 2001). Confusion exists concerning the role of nonverbal treatments in treating people with aphasia. The central argument of this paper is that given the state of the empirical evidence and the strong theoretical accounts of modality interactions in human communication, gesture-based and multimodality aphasia treatments are at least as legitimate an option as constraint-based aphasia treatment.

METHOD

Theoretical accounts of modality interactions in human communication and the gesture production abilities of individuals with aphasia that are harnessed in treatments are reviewed. The negative effects on word retrieval of restricting gesture production are also reviewed, and an overview of the neurological architecture subserving language processing is provided as rationale for multimodality treatments. The evidence for constrained and unconstrained treatments is critically reviewed.

CONCLUSION

Together, these data suggest that constraint treatments and multimodality treatments are equally efficacious, and there is limited support for constraining client responses to the spoken modality.