Applying the Rehabilitation Treatment Specification System (RTSS) to Functional Communication Treatment Approaches for Aphasia

Self-Improved Language Production in Nonfluent Aphasia Through Automated Recursive Self-Feedback

BACKGROUND

Persons with nonfluent aphasia (PWNA) use feedback from external agents (e.g., speech-language pathologists) and self-feedback to improve their language production. The extent to which PWNA can improve their language production using their self-feedback alone is underexplored. In a proof-of-concept study, we developed an automated recursive self-feedback procedure to demonstrate the extent to which two PWNA who used self-feedback alone improved their production of sentences from trained and untrained scripts. In the current study, we use the Rehabilitation Response Specification System as a framework to replicate our initial findings.

METHOD

We tested the effects of two treatments: script production with recursive self-feedback and script production with external feedback in four persons with chronic nonfluent aphasia. We compared the effects of treatment by measuring percent script produced, speaking rate, and speech initiation latency of trained and untrained scripts. The participants received the treatments remotely through mini tablets using two versions of a mobile app we developed. All the participants received each treatment intensively for 14 sessions across 2-3 weeks. We estimated clinical improvements of production of sentences from trained and untrained scripts through nonoverlap of all pairs analysis of performance pretreatment and posttreatment.

RESULTS

Both treatments improved PWNA's language production. Recursive self-feedback improved speaking rate and speech initiation latency, which generalized to untrained scripts in all participants. External feedback treatment did not generalize to improvement in speaking rate in two participants.

CONCLUSIONS

Our findings confirm our initial evidence that PWNA can self-improve their sentence production from scripts through recursive self-feedback. This novel procedure enables PWNA to autonomously enhance their language production over time. Given the evidence and the mechanics of the procedure, we propose that its utility is not constrained by linguistic idiosyncrasies across cultures. Consequently, it has the potential to bypass linguistic barriers to aphasia care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27007060.

A Meta-Analysis of Anomia Treatment in Bilingual Aphasia: Within- and Cross-Language Generalization and Predictors of the Treatment Outcomes

PURPOSE

The present meta-analysis investigated the efficacy of anomia treatment in bilingual and multilingual persons with aphasia (BPWAs) by assessing the magnitudes of six anomia treatment outcomes. Three of the treatment outcomes pertained to the "trained language": improvement of trained words (treatment effect [TE]), within-language generalization of semantically related untrained words (WLG-Related), and within-language generalization of unrelated words (WLG-Unrelated). Three treatment outcomes were for the "untrained language": improvement of translations of the trained words (cross-language generalization of trained words [CLG-Tx]), cross-language generalization of semantically related untrained words (CLG-Related), and cross-language generalization of unrelated untrained words (CLG-Unrelated). This study also examined participant- and treatment-related predictors of these treatment outcomes.

METHOD

This study is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42023418147. Nine electronic databases were searched to identify word retrieval treatment studies of poststroke BPWAs of at least 6 months postonset. Pre- and posttreatment single-word naming scores were extracted for each eligible participant and used to calculate effect sizes (within-case Cohen's d) of the six treatment outcomes. Random-effects meta-analyses were conducted to assess weighted mean effect sizes of the treatment outcomes across studies. Multiple linear regression analyses were used to examine the effects of participant-related variables (pretreatment single-word naming and comprehension representing poststroke lexical processing abilities) and treatment-related variables (type, language, and duration). The methodological quality of eligible studies and the risk of bias in this meta-analysis were assessed.

RESULTS

A total of 17 published studies with 39 BPWAs were included in the meta-analysis. The methodological quality of the included studies ranged from fair (n = 4) to good (n = 13). Anomia treatment produced a medium effect size for TE (M = 8.36) and marginally small effect sizes for WLG-Related (M = 1.63), WLG-Unrelated (M = 0.68), and CLG-Tx (M = 1.56). Effect sizes were nonsignificant for CLG-Related and CLG-Unrelated. TE was significantly larger than the other five types of treatment outcomes. TE and WLG-Related effect sizes were larger for BPWAs with milder comprehension or naming impairments and for treatments of longer duration. WLG-Unrelated was larger when BPWAs received phonological treatment than semantic and mixed treatments. The overall risk of bias in the meta-analysis was low with a potential risk of bias present in the study identification process.

CONCLUSIONS

Current anomia treatment practices for bilingual speakers are efficacious in improving trained items but produce marginally small within-language generalization and cross-language generalization to translations of the trained items. These results highlight the need to provide treatment in each language of BPWAs and/or investigate other approaches to promote cross-language generalization. Furthermore, anomia treatment outcomes are influenced by BPWAs' poststroke single-word naming and comprehension abilities as well as treatment duration and the provision of phonological treatment.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25595712.

Generalization in Aphasia Treatment: A Tutorial for Speech-Language Pathologists

PURPOSE

Generalization has been defined and instantiated in a variety of ways over the last half-century, and this lack of consistency has created challenges for speech-language pathologists to plan for, implement, and measure generalization in aphasia treatment protocols. This tutorial provides an overview of generalization with a focus on how it relates to aphasia intervention, including a synthesis of existing principles of generalization and examples of how these can be embedded in approaches to aphasia treatment in clinical and research settings.

METHOD

Three articles collectively listing 20 principles of generalization formed the foundation for this tutorial. The seminal work of Stokes and Baer (1977) focused attention on generalization in behavioral change following treatment. Two aphasia-specific resources identified principles of generalization in relation to aphasia treatment (Coppens & Patterson, 2018; Thompson, 1989). A selective literature review was conducted to identify evidence-based examples of each of these 20 principles from the extant literature.

RESULTS

Five principles of generalization were synthesized from the original list of 20. Each principle was supported by studies drawn from the aphasia treatment literature to exemplify its application.

CONCLUSIONS

Generalization is an essential aspect of meaningful aphasia intervention. Successful generalization requires the same dedication to strategic planning and outcome measurement as the direct training aspect of intervention. Although not all people with aphasia are likely to benefit equally from each of the principles reviewed herein, our synthesis provides information to consider for maximizing generalization of aphasia treatment outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24714399.

Looking at gesture: The reciprocal influence between gesture and conversation

INTRODUCTION

There is limited research in group communication treatment for people with aphasia but existing studies report benefits of gesture to support conversation. Gesture supports conversation through recipient design features and reducing linguistic demands of lexical retrieval and formulation. Additionally, gesture serves an affiliative function. However, the relationship between gesture use and gestural capacity has not been widely examined. As part of a larger study on group cohesiveness and conversation, this investigation examined the patterns of co-speech gesture within authentic conversations among persons with aphasia to discern the functions of gesture use for the participants, changes in the use of gesture over time, and the relationship between gesture use and gesture ability.

METHODS

Conversation Analysis (CA) was applied in an embedded case-study design. Three participants received an academic semester of group and individual conversation-based treatment according to Facilitating Authentic Conversation (Damico et al., 2015). Four conversations from the treatment were selected and transcribed for multi-modality communication with CA conventions applied, and then cyclically analysed for patterns of gesture.

RESULTS

Participants demonstrated gesture that served social and linguistic functions: ratifying clinicians' proxy turns, turn-allocation, turn repair, relaying novel visual information, emphasizing content, demonstrating affiliation with the prior speaker, demonstrating their assessment others' talk, and demonstrating humor. All three participants showed an increased rate of gesture per turn and increasingly used gesture to repair conversation breakdown. Increased gesture use over the course of the semester coincided with increased scores for pantomime on the Porch Index of Communicative Ability (Porch, 1981, PICA).

CONCLUSION

Individuals with aphasia demonstrated increased use of gesture for varied purposes and improved gestural processing following a semester of conversation-based treatment. This is significant because gesture is an effective support for the repair of conversation breakdown typical of persons with aphasia.

Telehealth Assessments and Interventions for Individuals With Poststroke Aphasia: A Scoping Review

PURPOSE

There are increasing demands for aphasia assessment and intervention services to be delivered remotely. The purpose of this scoping review was to address what is known about the delivery of assessments and interventions using telehealth for people with poststroke aphasia. Specifically, the review sought to (a) identify which telehealth assessment protocols have been used, (b) identify which telehealth intervention protocols have been used, and (c) describe evidence on the effectiveness and feasibility of telehealth for people with poststroke aphasia.

METHOD

A scoping review of the literature published in English since 2013 was conducted by searching MEDLINE, Embase, PsycINFO, CINAHL, and Scopus databases to identify relevant studies. A total of 869 articles were identified. Two reviewers screened records independently, finding 25 articles eligible for inclusion. Data extraction was conducted once and validated by the second reviewer.

RESULTS

Two of the included studies examined telehealth assessment protocols, whereas the remaining studies focused on the delivery of telehealth interventions. The results of the included studies illustrated both effectiveness and feasibility regarding telehealth for people with poststroke aphasia. However, a lack of procedural variation among the studies was found.

CONCLUSIONS

Overall, this scoping review yielded continued support for the use of telehealth practices as an alternate mode of delivering both assessment and intervention services to people with poststroke aphasia. However, further research is needed to investigate the range of aphasia assessment and intervention protocols that can be offered via telehealth, such as assessments or interventions that use patient-reported measures or address extralinguistic cognitive abilities.

Rehabilitation Treatment Specification System: Identifying Barriers, Facilitators, and Strategies for Implementation in Research, Education, and Clinical Care

OBJECTIVE

To explore rehabilitation professionals' experiences and perspectives of barriers and facilitators to implementing the Rehabilitation Treatment Specification System (RTSS) in research, education, and clinical care.

DESIGN

A cross-sectional survey with free text and binary responses was completed by rehabilitation professionals. Survey data were analyzed with a deductive approach of directed content analysis using 2 implementation science frameworks: Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC).

SETTING

Rehabilitation professionals across research, educational, and clinical settings.

PARTICIPANTS

One hundred and eleven rehabilitation professionals-including speech-language pathologists, occupational therapists, physical therapists, physicians, psychologists, researchers, and clinic directors-who explored possible uses or applications of the RTSS for clinical care, education, or research (N=111).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of reported CFIR barriers and facilitators, as well as keywords related to CFIR and ERIC constructs.

RESULTS

The barriers and facilitating strategies differed according to the end-users' intended use, that is, research, education, or clinical. Overall, the 4 most frequently encountered CFIR barriers were the RTSS's complexity, a lack of available RTSS resources, reduced access to knowledge and information about the RTSS, and limited knowledge and beliefs about the RTSS. The ERIC-CFIR matching tool identified 7 ERIC strategies to address these barriers, which include conducting educational meetings, developing and distributing educational materials, accessing new funding, capturing and sharing local knowledge, identifying and preparing champions, and promoting adaptability.

CONCLUSIONS

When attempting to use the RTSS, rehabilitation professionals commonly encountered barriers to understanding and skillfully using the framework. Theory-driven implementation strategies have been identified that have potential for addressing the RTSS's complexity and lack of educational and skill-building resources. Future work can develop the identified implementation strategies and evaluate their effects on RTSS implementation.

Errorless, Errorful, and Retrieval Practice for Naming Treatment in Aphasia: A Scoping Review of Learning Mechanisms and Treatment Ingredients

PURPOSE

Increasingly, mechanisms of learning are being considered during aphasia rehabilitation. Well-characterized learning mechanisms can inform "how" interventions should be administered to maximize the acquisition and retention of treatment gains. This systematic scoping review mapped hypothesized mechanisms of action (MoAs) and treatment ingredients in three learning-based approaches targeting naming in aphasia: errorless learning (ELess), errorful learning (EFul), and retrieval practice (RP). The rehabilitation treatment specification system was leveraged to describe available literature and identify knowledge gaps within a unified framework.

METHOD

PubMed and CINHAL were searched for studies that compared ELess, EFul, and/or RP for naming in aphasia. Independent reviewers extracted data on proposed MoAs, treatment ingredients, and outcomes.

RESULTS

Twelve studies compared ELess and EFul, six studies compared ELess and RP, and one study compared RP and EFul. Hebbian learning, gated Hebbian learning, effortful retrieval, and models of incremental learning via lexical access were proposed as MoAs. To maximize treatment outcomes within theorized MoAs, researchers manipulated study ingredients including cues, scheduling, and feedback. Outcomes in comparative effectiveness studies were examined to identify ingredients that may influence learning. Individual-level variables, such as cognitive and linguistic abilities, may affect treatment response; however, findings were inconsistent across studies.

CONCLUSIONS

Significant knowledge gaps were identified and include (a) which MoAs operate during ELess, EFul, and RP; (b) which ingredients are active and engage specific MoAs; and (c) how individual-level variables may drive treatment administration. Theory-driven research can support or refute MoAs and active ingredients enabling clinicians to modify treatments within theoretical frameworks.

Examining Dose Frameworks to Improve Aphasia Rehabilitation Research

The effect of treatment dose on recovery of post-stroke aphasia is not well understood. Inconsistent conceptualization, measurement, and reporting of the multiple dimensions of dose hinders efforts to evaluate dose-response relations in aphasia rehabilitation research. We review the state of dose conceptualization in aphasia rehabilitation and compare the applicability of 3 existing dose frameworks to aphasia rehabilitation research-the Frequency, Intensity, Time, and Type (FITT) principle, the Cumulative Intervention Intensity (CII) framework, and the Multidimensional Dose Articulation Framework (MDAF). The MDAF specifies dose in greater detail than the CII framework and the FITT principle. On this basis, we selected the MDAF to be applied to 3 diverse examples of aphasia rehabilitation research. We next critically examined applicability of the MDAF to aphasia rehabilitation research and identified the next steps needed to systematically conceptualize, measure, and report the multiple dimensions of dose, which together can progress understanding of the effect of treatment dose on outcomes for people with aphasia after stroke. Further consideration is required to enable application of this framework to aphasia interventions that focus on participation, personal, and environmental interventions and to understand how the construct of episode difficulty applies across therapeutic activities used in aphasia interventions.

Treatment of the Linguistic and Temporal Components of Lexical Activation to Improve Word Retrieval in Aphasia

Current approaches to treatments for word processing impairments in aphasia emphasize two components to target, the linguistic content, semantic or phonological representations of words, and the processing component, access to and retrieval of those representations. In this study, we explore these two components of a treatment to improve lexical activation that supports access and retrieval of word representations. Five people with aphasia participated. The treatment task was repetition of concrete word pairs after a 5-s response delay which was intended to provide practice in maintaining activation of the words for that 5-s period before reproducing them. Two of the five participants demonstrated a difficulty in maintaining activation of single words in repetition, with accuracy decreasing significantly after the 5-s interval. The treatment was applied to all participants, however, to determine if its benefit was specific to those with the activation maintenance impairment. Results confirmed that the activation maintenance treatment in the context of this repetition task led to more treatment gains for the two participants who demonstrated this specific impairment. They made gains on four of the nine measures compared to improvements on one to two measures for the other participants. A second question addressed in this study was the relative importance of the item component (linguistic content) of the treatment and the processing component, maintenance of activation. To that end, there were two conditions of treatment probes, (1) repeated content for all treatment, immediate post-treatment and 3-month maintenance probes and (2) novel content for probes in these three phases of treatment. Only one participant showed significant improvement in treatment when items were novel for all probes. We discuss the possibility that this outcome reflects a more specific deficit in the temporal processing component of lexical activation compared to the two other participants who showed better performance on probes with repeated items in treatment and post-treatment phases. Clinical implications of this study and directions of future research are discussed.

Evaluating Cognitive-Linguistic Approaches to Interventions for Aphasia Within the Rehabilitation Treatment Specification System

The Rehabilitation Treatment Specification System (RTSS) provides a framework to identify specific components of treatments developed within various rehabilitation disciplines (eg, physical, occupational, or speech-language therapy). Furthermore, this framework offers the opportunity to identify the target and active ingredients of a therapy approach as well as the mechanism of action by which it is hypothesized to effect change in abilities or functions. In this article, we apply the RTSS framework to the characterization of a sample of treatments for aphasia that are based on cognitive-linguistic models of language processing. Our discussion of these applications centers on the benefits of this classification system and additional criteria to consider when evaluating cognitive-linguistic treatments for aphasia.