"White coat effect" induced by therapist's presence during speech therapy for stroke rehabilitation: a single case study

"I Assumed It Would Be Somebody Who Had a Stroke That Was Doing This": Views of Stroke Survivors, Caregivers, and Health Professionals on Tailoring a Relaxation and Mindfulness Intervention

Stroke survivors and informal caregivers experience high levels of stress and anxiety, linked to heightened risk of secondary stroke in survivors. Relaxation and mindfulness could reduce stress and anxiety; being most effective when tailored to the target populations. Aims of the PPI include to: (1) consult on possible alterations to an existing relaxation and mindfulness intervention, delivered via YouTube/DVD and (2) discuss relevance and preference of prompts and cues designed to facilitate the daily practice of the intervention. Eleven UK PPI contributors were consulted during 2020: four stroke survivors (F = 2, M = 2), three caregivers (F = 1, M = 2), and four HCPs (F = 4) (range = 23-63 years). Contributors watched the existing intervention and provided feedback via online discussions. Transcripts were analysed using thematic analysis. Five themes were identified, highlighting several necessary alterations to the intervention: "Who represents the stroke population?"; "The paradox of age"; "Specifically selected language"; "Visual presentation of the intervention"; and the "Audio qualities". Contributors ranked the prompts and cues in order of preference with setting alarms and email alerts as the most popular. The PPI consultations resulted in several alterations enabling a revised version of the intervention. Including a PPI consultation at an early stage of the research improves the relevance and appropriateness of the research. The revised intervention is more representative of the stroke population thus more likely to be practised by survivors and caregivers, which will enhance the extent of effectiveness, reducing the risk of a secondary stroke.

Language as a Threat: Multimodal Evaluation and Interventions for Overwhelming Linguistic Anxiety in Severe Aphasia

Linguistic anxiety (LA) is an abnormal stress response induced by situations that require the use of verbal behavior, and it is accentuated during language testing in persons with aphasia (PWA). The presence of LA in PWA may jeopardize the interpretation of cognitive evaluations, leading to biased conclusions about the severity of the language alteration and the effectiveness of the treatments. In the present study, we report the case of a woman (Mrs. A) with severe chronic mixed transcortical aphasia due to left frontal and parietal hemorrhages that partially spared the perisylvian area. Mrs. A was treated with the dopamine agonist Rotigotine alone and combined with Intensive Language-Action Therapy (ILAT). Complementary evaluations included autonomic reactivity during the performance of different language tasks, resting state functional magnetic resonance imaging (rs-fMRI) and [18F]-fluorodeoxyglucose positron emission tomography (18F-FDG-PET). We found that formal language testing in a clinical setting triggered a dramatic increase of automatic echolalia, perseverations and frustration, making the task completion difficult. The treatment improved aphasia, but gains were more robust when evaluation was performed by Mrs. A's husband at home than by clinicians. Autonomic evaluation under Rotigotine revealed higher reactivity during tasks tapping an impaired function in comparison with a task evaluating a preserved function (verbal repetition). Baseline 18F-FDG-PET analysis showed decreased metabolic activity in left limbic-paralimbic areas, whereas rs-fMRI revealed compensatory activity in the right hemisphere. We also analyzed the different factors (e.g., premorbid personality traits, task difficulty) that may have contributed to LA in Mrs. A during language testing. Our findings emphasize the usefulness of implicating adequately trained laypersons in the evaluation and treatment of PWA showing LA. Further studies using multidimensional evaluations are needed to disentangle the interplay between anxiety and abnormal language as well as the neural mechanisms underpinning LA in PWA.

Cardiovascular Responses Associated with the Moving Beans Task: Influence of Psychological Characteristics

BACKGROUND AND OBJECTIVE

High blood pressure (BP) after stroke is associated with a poor outcome. However, exercise training or speech therapy for patients with stroke can raise the BP. The aim of this study was to examine cardiovascular responses during the moving beans task (MBT) used in occupational therapy and to study the influence of psychological characteristics on cardiovascular responses during this task in healthy subjects.

MATERIALS AND METHODS

In 34 healthy volunteers, the BP and the heart rate (HR) were continuously measured during the baseline period, the 5-minute MBT, and the 1-minute cold pressor test (CPT). All subjects completed self-reported questionnaires, including the Center for Epidemiologic Studies Depression Scale (CES-D), the State Trait Anxiety Inventory Y-2, and the Japanese version of the 20-item Toronto Alexithymia Scale (TAS-20).

RESULTS

The systolic blood pressure (SBP), the diastolic blood pressure (DBP), and the mean blood pressure (MBP) significantly increased during the MBT and the CPT compared with the baseline values. SBP, DBP, and MBP responses during the MBT significantly correlated with the TAS-20 scores. Moreover, DBP response during the MBT correlated with the CES-D scores.

CONCLUSIONS

The MBT significantly raised BP without increasing the HR. BP responses during this task were influenced by the psychological characteristics of depression and alexithymia.

Methodology for astronaut reconditioning research

Space medicine offers some unique challenges, especially in terms of research methodology. A specific challenge for astronaut reconditioning involves identification of what aspects of terrestrial research methodology hold and which require modification. This paper reviews this area and presents appropriate solutions where possible. It is concluded that spaceflight rehabilitation research should remain question/problem driven and is broadly similar to the terrestrial equivalent on small populations, such as rare diseases and various sports. Astronauts and Medical Operations personnel should be involved at all levels to ensure feasibility of research protocols. There is room for creative and hybrid methodology but careful systematic observation is likely to be more achievable and fruitful than complex trial based comparisons. Multi-space agency collaboration will be critical to pool data from small groups of astronauts with the accepted use of standardised outcome measures across all agencies. Systematic reviews will be an essential component. Most limitations relate to the inherent small sample size available for human spaceflight research. Early adoption of a co-operative model for spaceflight rehabilitation research is therefore advised.

White-coat effect induced by therapist's presence during speech therapy: study of post-stroke aphasic Japanese patients

OBJECTIVE

To delineate the clinical characteristics of post-stroke aphasic patients exhibiting the white-coat effect when a therapist is present during therapy session, 18 Japanese inpatients were studied.

DESIGN

On the basis of blood pressure assessments during two speech therapy sessions, one directed by a speech therapist and the other self-directed, patients were divided into two groups: one including the seven who exhibited the white-coat effect and the other including the 11 patients who did not. The white-coat effect was diagnosed when a pressor response was greater during a therapist-directed session than during a self-directed session. The parametric Student's t test and nonparametric Fisher's exact test were applied to clinical, laboratory, and language parameters for these two groups.

RESULTS

The groups did not differ significantly in terms of clinical or laboratory parameters. Compared with the noneffect group, the white-coat-effect group more frequently had quotients of >or=40.0 for aphasia, comprehension, and expression on the Western Aphasia Battery. The type of aphasia did not influence the prevalence of the white-coat effect.

CONCLUSIONS

The white-coat effect induced by the speech therapist's presence is more common among patients with mild aphasia, without regard to the type of aphasia. Blood pressure monitoring during speech therapy should help therapists treat patients safely.