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

Fidelity to the Consensus Auditory-Perceptual Analysis of Voice (CAPE-V): A Pilot Study

OBJECTIVES

Auditory-perceptual measurements of voice are among the most common diagnostic tools used during a voice evaluation and are considered a gold standard for documenting voice disorders. The goal of this pilot study was to examine the fidelity of clinicians in the administration of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and its published protocol. This investigation aimed to determine how the CAPE-V is being used by clinicians and researchers and the extent to which users deviate from the published procedure.

STUDY DESIGN

Survey METHODS: Data were collected by surveying a group (N = l7) of speech-language pathologists who regularly evaluate and treat patients with voice disorders. Survey results revealed that few of the sampled speech-language pathologists follow exactly the standardized instructions for administering the CAPE-V. Considerable variability in CAPE-V administration, including tasks and stimuli examined, was found across respondents.

CONCLUSIONS

This exploratory project may be used to develop a larger national survey study investigating fidelity to the CAPE-V and to motivate recommendations for possible revisions to the instrument and its protocol for administration.

Mechanisms of brain activation following naming therapy in aphasia: A systematic review on task-based fMRI studies

The pattern of brain neuroplasticity after naming therapies in patients with aphasia can be evaluated using task-based fMRI. This article aims to review studies investigating brain reorganization after semantic and phonological-based anomia therapy that used picture-naming fMRI tasks. We searched for those articles that compared the activation of brain areas before and after aphasia therapies in the PubMed and the EMBASE databases from 1993 up to April 2020. All studies (single-cases or group designs) on anomia treatment in individuals with acquired aphasia were reviewed. Data were synthesized descriptively through tables to allow the facilitated comparison of the studies. A total of 14 studies were selected and reviewed. The results of the reviewed studies demonstrated that the naming improvement is associated with changes in the activation of cortical and subcortical brain areas. This review highlights the need for a more systematic investigation of the association between decreased and increased activation of brain areas related to anomia therapy. Also, more detailed information about factors influencing brain reorganization is required to elucidate the neural mechanisms of anomia therapy. Overall, regarding the theoretical and clinical aspects, the number of studies that used intensive protocol is growing, and based on the positive potential of these treatments, they could be suitable for the rehabilitation of people with aphasia.

Treatment-induced neuroplasticity after anomia therapy in post-stroke aphasia: A systematic review of neuroimaging studies

We systematically reviewed the literature on neural changes following anomia treatment post-stroke. We conducted electronic searches of CINAHL, Cochrane Trials, Embase, Ovid MEDLINE, MEDLINE-in-Process and PsycINFO databases; two independent raters assessed all abstracts and full texts. Accepted studies reported original data on adults with post-stroke aphasia, who received behavioural treatment for anomia, and magnetic resonance brain imaging (MRI) pre- and post-treatment. Search results yielded 2481 citations; 33 studies were accepted. Most studies employed functional MRI and the quality of reporting neuroimaging methodology was variable, particularly for pre-processing steps and statistical analyses. The most methodologically robust data were synthesized, focusing on pre- versus post-treatment contrasts. Studies more commonly reported increases (versus decreases) in activation following naming therapy, primarily in the left supramarginal gyrus, and left/bilateral precunei. Our findings highlight the methodological heterogeneity across MRI studies, and the paucity of robust evidence demonstrating direct links between brain and behaviour in anomia rehabilitation.

Supporting Post-Stroke Language and Cognition with Pharmacotherapy: Tools for Each Phase of Care

PURPOSE OF REVIEW

There is enormous enthusiasm for the possibility of pharmacotherapies to treat language deficits that can arise after stroke. Speech language therapy remains the most frequently utilized and most strongly evidenced treatment, but the numerous barriers to patients receiving the therapy necessary to recover have motivated the creation of a relatively modest, yet highly cited, body of evidence to support the use of pharmacotherapy to treat post-stroke aphasia directly or to augment traditional post-stroke aphasia treatment. In this review, we survey the use of pharmacotherapy to preserve and support language and cognition in the context of stroke across phases of care, discuss key ongoing clinical trials, and identify targets that may become emerging interventions in the future.

RECENT FINDINGS

Recent trials have shifted focus from short periods of drug therapy supporting therapy in the chronic phase to longer terms approaching pharmacological maintenance beginning more acutely. Recent innovations in hyperacute stroke care, such as tenecteplase, and acute initiation of neuroprotective agents and serotonin reuptake inhibitors are important areas of ongoing research that complement the ongoing search for effective adjuvants to later therapy. Currently there are no drugs approved in the United States for the treatment of aphasia. Nevertheless, pharmacological intervention may provide a benefit to all phases of stroke care.

Treatment-induced neural reorganization in aphasia is language-domain specific: Evidence from a large-scale fMRI study

Studies investigating the effects of language intervention on the re-organization of language networks in chronic aphasia have resulted in mixed findings, likely related to-among other factors-the language function targeted during treatment. The present study investigated the effects of the type of treatment provided on neural reorganization. Seventy individuals with chronic stroke-induced aphasia, recruited from three research laboratories and meeting criteria for agrammatism, anomia or dysgraphia were assigned to either treatment (N = 51) or control (N = 19) groups. Participants in the treatment group received 12-weeks of language intervention targeting sentence comprehension/production, naming, or spelling. At baseline and post-testing, all participants performed an fMRI story comprehension task, with blocks of auditorily-presented stories alternated with blocks of reversed speech. Participants in the treatment, but not control, group significantly improved in the treated language domain. FMRI region-of-interest (ROI) analyses, conducted within regions that were either active (or homologous to active) regions in a group of 22 healthy participants on the story comprehension task, revealed a significant increase in activation from pre-to post-treatment in right-hemisphere homologues of these regions for participants in the sentence and spelling, but not naming, treatment groups, not predicted by left-hemisphere lesion size. For the sentence (but not the spelling) treatment group, activation changes within right-hemisphere homologues of language regions were positively associated with changes in measures of verb and sentence comprehension. These findings support previous research pointing to recruitment of right hemisphere tissue as a viable route for language recovery and suggest that sentence-level treatment may promote greater neuroplasticity on naturalistic, language comprehension tasks, compared to word-level treatment.

No evidence of impediment by three common classes of prescription drugs to post-stroke aphasia recovery in a retrospective longitudinal sample

A number of pharmaceuticals have been identified as potential adjuvants to speech language therapy following stroke, but it is also important to consider which pharmaceuticals may result in a less robust recovery. Here we examine whether post-stroke language recovery was meaningfully impeded by cholinergic, GABAergic, or dopaminergic medications patients received. Eighty participants with left hemisphere stroke were examined retrospectively to see whether the use of one of these three classes of medication prior to admission for acute stroke, during their inpatient stay, or at discharge was associated with differences in recovery on three common measures of language. While prescription of any of the candidate drugs was relatively uncommon, groups were very well matched for many common factors that impact performance. When age, education, and acute lesion volume were controlled, there were no significant differences in performance among those taking cholinergic, GABAergic, or dopaminergic medications and those who were not. Those who experienced a "good recovery" of language (≥10% improvement on any one language measure over time) had similar exposure to these drugs to those with a poor recovery. This work represents a first look at these drug classes with regard to their effects on the recovery of language after stroke and should not be interpreted as resolving all potential for concern, but these results do offer modest reassurance that these common classes of pharmacotherapy, when given for short periods in this population, do not appear to have marked deleterious effects on post-stroke recovery of language.

Tone and vowel disruptions in Mandarin aphasia and apraxia of speech

In this study, we investigated the lexical tones and vowels produced by ten speakers diagnosed with aphasia and coexisting apraxia of speech (A-AOS) and ten healthy participants, to compare their tone and vowel disruptions. We first judged the productions of both A-AOS and healthy participants and classified them into three categories, i.e. those by healthy speakers and rated as correct, those by A-AOS participants and rated as correct, and those by A-AOS participants and rated as incorrect. We then compared the perceptual results for the three groups based on their respective acoustic correlates to reveal the relations among different accuracy groups. Results showed that the numbers of tone and vowel disruptions by A-AOS speakers occurred on a comparable scale. In perception, approximately equal numbers of tones and vowels produced by A-AOS participants were identified as correct; however, acoustic parameters showed that, unlike vowels, the patients' tones categorised as correct by native Mandarin listeners differed considerably from those of the healthy speakers, suggesting that for Mandarin A-AOS patients, tones were in fact more disrupted than vowels in acoustic terms. Native Mandarin listeners seemed to be more tolerant of less well-targeted tones than less-well targeted vowels. The clinical implication is that tonal and segmental practice should be incorporated for Mandarin A-AOS patients to enhance their overall motor speech control.

Behavioral interventions for poststroke aphasia

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

Better language through chemistry: Augmenting speech-language therapy with pharmacotherapy in the treatment of aphasia

Speech and language therapy is the standard treatment of aphasia. However, many individuals have barriers in seeking this measure of extensive rehabilitation treatment. Investigating ways to augment therapy is key to improving poststroke language outcomes for all patients with aphasia, and pharmacotherapies provide one such potential solution. Although no medications are currently approved for the treatment of aphasia by the United States Food and Drug Administration, numerous candidate mechanisms for pharmaceutical manipulation continue to be identified based on our evolving understanding of the neurometabolic experience of stroke recovery across molecular, cellular, and functional levels of inquiry. This chapter will review evidence for catecholaminergic, glutamatergic, cholinergic, and serotonergic drug therapies and discuss future directions for both candidate drug selection and pharmacotherapy practice in people with aphasia.

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

There are many different approaches to the rehabilitation of aphasia, a communication disorder that affects a person's understanding and expression of spoken and written language. One approach called "functional communication interventions" aims to enhance communication success as opposed to solely improve linguistic abilities. This approach encompasses many skills (e.g., gesturing) and factors (e.g., access to communication supports) that support sending and receiving messages in "real world" daily activities and environments. Functional communication treatments are highly diverse and not always well described. A framework that may provide structure to the description of functional communication interventions for aphasia is the Rehabilitation Treatment Specification System (RTSS). The RTSS was developed by an interdisciplinary research team to describe interventions across any rehabilitation discipline and in any setting or format. The RTSS uses a common language and a systematic approach to describing treatment and includes three connected elements - a single target, one or more ingredients, and a mechanism of action - that, taken together, attempt to explain how and why a treatment works. While the RTTS has been described previously within the field of speech-language pathology, it has not yet been applied to the field of aphasiology. We applied the RTSS framework to a sample of peer-reviewed studies that represent functional communication treatments, including Promoting Aphasics' Communicative Effectiveness (PACE), Modified Response Elaboration Training (M-RET), Script Training, Conversation Treatment, and Communication Partner Training. We discuss both the advantages and disadvantages of using the RTSS framework to better understand the important elements of functional communication treatment approaches for aphasia.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Effects of a Tablet-Based Home Practice Program With Telepractice on Treatment Outcomes in Chronic Aphasia

Purpose

The aim of this study was to determine if a tablet-based home practice program with weekly telepractice support could enable long-term maintenance of recent treatment gains and foster new language gains in poststroke aphasia.

Method

In a pre-post group study of home practice outcomes, 21 individuals with chronic aphasia were examined before and after a 6-month home practice phase and again at follow-up 4 months later. The main outcome measure studied was change in naming previously treated or untreated, practiced or unpracticed pictures of objects and actions. Individualized home practice programs were created in iBooks Author with semantic, phonemic, and orthographic cueing in pictures, words, and videos in order to facilitate naming of previously treated or untreated pictures.

Results

Home practice was effective for all participants with severity moderating treatment effects, such that individuals with the most severe aphasia made and maintained fewer gains. There was a negative relationship between the amount of training required for iPad proficiency and improvements on practiced and unpracticed pictures and a positive relationship between practice compliance and same improvements.

Conclusion

Unsupervised home practice with weekly video teleconferencing support is effective. This study demonstrates that even individuals with chronic severe aphasia, including those with no prior smart device or even computer experience, can attain independent proficiency to continue practicing and improving their language skills beyond therapy discharge. This could represent a low-cost therapy option for individuals without insurance coverage and/or those for whom mobility is an obstacle to obtaining traditional aphasia therapy.

Therapy-Induced Neuroplasticity in Chronic Aphasia After Phonological Component Analysis: A Matter of Intensity

Despite the growing evidence regarding the importance of intensity and dose in aphasia therapy, few well-controlled studies contrasting the effects of intensive and non-intensive treatment have been conducted to date. Phonological components analysis (PCA) treatment for anomia has been associated with improvements in some patients with chronic aphasia; however, the effect of treatment intensity has not yet been studied with PCA. Thus, the aim of the present study was to identify the effect of intensity on neural processing associated with word retrieval abilities after PCA treatment. We used functional magnetic resonance imaging to examine therapy-induced changes in activation during an overt naming task in two patients who suffered from a stroke in the left middle cerebral artery territory. P1 received intensive PCA treatment whereas P2 received the standard, non-intensive, PCA treatment. Behavioral results indicate that both standard and intensive conditions yielded improved naming performance with treated nouns, but the changes were only significant for the patient who received the intensive treatment. The improvements were found to be long lasting as both patients maintained improved naming at 2-months follow-ups. The associated neuroimaging data indicate that the two treatment conditions were associated with different neural activation changes. The patient who received the standard PCA showed significant increase in activation with treatment in the right anterior cingulate, as well as extensive areas in bilateral posterior and lateral cortices. By contrast, the patient who received intensive PCA showed more decreases in activation following the treatment. Unexpectedly, this patient showed subcortical increase in activation, specifically in the right caudate nucleus. We speculate that the recruitment of the caudate nucleus and the anterior cingulate in these patients reflects the need to suppress errors to improve naming. Thus, both short-term intensive and standard, non-intensive, PCA treatment can improve word retrieval in chronic aphasia, but neuroimaging data suggest that improved naming is associated with different neural activation patterns in the two treatment conditions.

Constraint-induced aphasia therapy in post-stroke aphasia rehabilitation: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Constraint-induced aphasia therapy (CIAT) has been widely used in post-stroke aphasia rehabilitation. An increasing number of clinical controlled trials have investigated the efficacy of the CIAT for the post-stroke aphasia.

PURPOSE

To systematically review the randomized controlled trials (RCTs) concerning the effect of the CIAT in post-stroke patients with aphasia, and to identify the useful components of CIAT in post-stroke aphasia rehabilitation.

METHODS

A computerized database search was performed through five databases (Pubmed, EMbase, Medline, ScienceDirect and Cochrane library). Cochrane handbook domains were used to evaluate the methodological quality of the included RCTs.

RESULTS

Eight RCTs qualified in the inclusion criteria. Inconsistent results were found in comparing the CIAT with conventional therapies without any component from the CIAT based on the results of three RCTs. Five RCTs showed that the CIAT performed equally well as other intensive aphasia therapies, in terms of improving language performance. One RCT showed that therapies embedded with social interaction were likely to enhance the efficacy of the CIAT.

CONCLUSION

CIAT may be useful for improving chronic post-stroke aphasia, however, limited evidence to support its superiority to other aphasia therapies. Massed practice is likely to be a useful component of CIAT, while the role of "constraint" is needed to be further explored. CIAT embedded with social interaction may gain more benefits.

Cholinergic Potentiation and Audiovisual Repetition-Imitation Therapy Improve Speech Production and Communication Deficits in a Person with Crossed Aphasia by Inducing Structural Plasticity in White Matter Tracts

Donepezil (DP), a cognitive-enhancing drug targeting the cholinergic system, combined with massed sentence repetition training augmented and speeded up recovery of speech production deficits in patients with chronic conduction aphasia and extensive left hemisphere infarctions (Berthier et al., 2014). Nevertheless, a still unsettled question is whether such improvements correlate with restorative structural changes in gray matter and white matter pathways mediating speech production. In the present study, we used pharmacological magnetic resonance imaging to study treatment-induced brain changes in gray matter and white matter tracts in a right-handed male with chronic conduction aphasia and a right subcortical lesion (crossed aphasia). A single-patient, open-label multiple-baseline design incorporating two different treatments and two post-treatment evaluations was used. The patient received an initial dose of DP (5 mg/day) which was maintained during 4 weeks and then titrated up to 10 mg/day and administered alone (without aphasia therapy) during 8 weeks (Endpoint 1). Thereafter, the drug was combined with an audiovisual repetition-imitation therapy (Look-Listen-Repeat, LLR) during 3 months (Endpoint 2). Language evaluations, diffusion weighted imaging (DWI), and voxel-based morphometry (VBM) were performed at baseline and at both endpoints in JAM and once in 21 healthy control males. Treatment with DP alone and combined with LLR therapy induced marked improvement in aphasia and communication deficits as well as in selected measures of connected speech production, and phrase repetition. The obtained gains in speech production remained well-above baseline scores even 4 months after ending combined therapy. Longitudinal DWI showed structural plasticity in the right frontal aslant tract and direct segment of the arcuate fasciculus with both interventions. VBM revealed no structural changes in other white matter tracts nor in cortical areas linked by these tracts. In conclusion, cholinergic potentiation alone and combined with a model-based aphasia therapy improved language deficits by promoting structural plastic changes in right white matter tracts.

Constraint Induced Aphasia Therapy: Volunteer-led, unconstrained and less intense delivery can be effective

BACKGROUND

Constraint Induced Aphasia Therapy (CIAT) has been shown to be effective in the treatment of aphasia, but clinicians have expressed concern regarding how far CIAT is practical to implement in clinical practice.

OBJECTIVE

To determine whether CIAT delivered in a less-intense, lower dose, reduced constraint and volunteer-led format could produce positive outcomes in people with chronic aphasia.

METHODS

Two groups were run, each with two people with chronic aphasia. Treatment involved a standard CIAT card-exchange game, supplemented by a home activity. Spoken language was required for responses but alternative modalities of communication were also permitted. Each group was led by a trained volunteer, lasted 90 minutes and was delivered twice a week for four weeks.

RESULTS

Three of the four participants showed significant improvements in target word retrieval following treatment. No significant improvements were observed for untreated stimuli or language tasks. Two participants showed increases in the elaboration of their responses, and the same two showed an increase in the frequency with which they engaged in communication activities.

CONCLUSIONS

Clear gains in performance were observed for the majority of people with aphasia who participated in a less intense format, considerably lower dose and less constrained form of CIAT led by trained volunteers. This suggests that this 'clinically realistic' service delivery model for CIAT could be added to the clinical repertoire of speech pathologists.

Therapy-Induced Neuroplasticity of Language in Chronic Post Stroke Aphasia: A Mismatch Negativity Study of (A)Grammatical and Meaningful/less Mini-Constructions

Clinical language performance and neurophysiological correlates of language processing were measured before and after intensive language therapy in patients with chronic (time post stroke >1 year) post stroke aphasia (PSA). As event-related potential (ERP) measure, the mismatch negativity (MMN) was recorded in a distracted oddball paradigm to short spoken sentences. Critical 'deviant' sentence stimuli where either well-formed and meaningful, or syntactically, or lexico-semantically incorrect. After 4 weeks of speech-language therapy (SLT) delivered with high intensity (10.5 h per week), clinical language assessment with the Aachen Aphasia Test battery demonstrated significant linguistic improvements, which were accompanied by enhanced MMN responses. More specifically, MMN amplitudes to grammatically correct and meaningful mini-constructions and to 'jabberwocky' sentences containing a pseudoword significantly increased after therapy. However, no therapy-related changes in MMN responses to syntactically incorrect strings including agreement violations were observed. While MMN increases to well-formed meaningful strings can be explained both at the word and construction levels, the neuroplastic change seen for 'jabberwocky' sentences suggests an explanation in terms of constructions. The results confirm previous reports that intensive SLT leads to improvements of linguistic skills in chronic aphasia patients and now demonstrate that this clinical improvement is associated with enhanced automatic brain indexes of construction processing, although no comparable change is present for ungrammatical strings. Furthermore, the data confirm that the language-induced MMN is a useful tool to map functional language recovery in PSA.

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.

Plasticity and Reorganization in the Rehabilitation of Stroke

Abstract. This paper outlines some actual developments in the behavioral treatment and rehabilitation of stroke and other brain injuries in post-acute and chronic conditions of brain lesion. It points to a number of processes that demonstrate the enormous plasticity and reorganization capacity of the human brain following brain lesion. It also highlights a series of behavioral and neuroscientific studies that indicate that successful behavioral rehabilitation is paralleled by plastic changes of brain structures and by cortical reorganization and that the amount of such plastic changes is obviously significantly determining the overall outcome of rehabilitation.

The impact of dose on naming accuracy with persons with aphasia

BACKGROUND

Although aphasia rehabilitation has been shown to be efficacious, many questions remain regarding how best to deliver treatment to maximize functional gains for persons with aphasia. Treatment delivery variables, such as intensity and dosage, are likely to influence both behavioral and structural changes during anomia treatment. While numerous protocols have concluded that treatment intensity positively impacts functional outcomes, few studies to date have examined the role that dose plays in patient outcomes for anomia treatment.

AIMS

This study sought to investigate how manipulating dose of repeated confrontation naming within sessions influences naming in persons with aphasia. Repeated practice of confrontation naming, without feedback, was hypothesized to improve trained but not untrained words, to be persistent after withdrawal, and to be sensitive to the number of trials (i.e., dose) within sessions.

METHODS AND PROCEDURES

A single-subject ABA design with replication across seven participants with aphasia was used to investigate the influence of repeated confrontation naming attempts on the acquisition and maintenance of trained pictures relative to untrained pictures. Training involved repeated attempts to name pictures, along with repeated exposure to pictures of objects (nouns) and their names, without feedback. The primary independent variable was within session dose; the dependent variable was naming accuracy.

OUTCOMES AND RESULTS

Naming accuracy improved for all participants for trained pictures across both acquisition and maintenance phases per visual inspection; such positive effects were not observed for untrained pictures. Effect size calculations indicate that three of seven participants demonstrated considerable change for trained items, while one of seven participants demonstrated meaningful change for untrained items. The high-dose condition elicited small effect sizes for one participant, and large effect sizes for two of seven participants, while the low-dose condition elicited small and medium effect sizes for two of seven participants.

CONCLUSIONS

Participants across a variety of aphasia severity levels responded positively to two doses of repeated confrontation naming practice, without feedback, across phases of this naming protocol. Results are in line with principles of neuroplasticity and demonstrate that repeated practice, without feedback, can produce significant and persistent changes in naming ability for some persons with aphasia.

Brain plasticity in aphasic patients: intra- and inter-hemispheric reorganisation of the whole linguistic network probed by N150 and N350 components

The present study examined linguistic plastic reorganization of language through Evoked Potentials in a group of 17 non-fluent aphasic patients who had suffered left perisylvian focal lesions, and showed a good linguistic recovery. Language reorganisation was probed with three linguistic tasks (Phonological, Semantic, Orthographic), the early word recognition potential (N150) and the later phonological-related component (N350). Results showed the typical left-lateralised posterior N150 in healthy controls (source: left Fusiform Gyrus), that was bilateral (Semantic) or right sided (Phonological task) in patients (sources: right Inferior/Middle Temporal and Fusiform Gyri). As regards N350, controls revealed different intra- and inter-hemispheric linguistic activation across linguistic tasks, whereas patients exhibited greater activity in left intact sites, anterior and posterior to the damaged area, in all tasks (sources: Superior Frontal Gyri). A comprehensive neurofunctional model is presented, describing how complete intra- and inter-hemispheric reorganisation of the linguistic networks occurs after aphasic damage in the strategically dominant left perisylvian linguistic centres.

Bilateral brain reorganization with memantine and constraint-induced aphasia therapy in chronic post-stroke aphasia: An ERP study

Changes in ERP (P100 and N400) and root mean square (RMS) were obtained during a silent reading task in 28 patients with chronic post-stroke aphasia in a randomized, double-blind, placebo-controlled trial of both memantine and constraint-induced aphasia therapy (CIAT). Participants received memantine/placebo alone (weeks 0-16), followed by drug treatment combined with CIAT (weeks 16-18), and then memantine/placebo alone (weeks 18-20). ERP/RMS values (week 16) decreased more in the memantine group than in the placebo group. During CIAT application (weeks 16-18), improvements in aphasia severity and ERP/RMS values were amplified by memantine and changes remained stable thereafter (weeks 18-20). Changes in ERP/RMS occurred in left and right hemispheres and correlated with gains in language performance. No changes in ERP/RMS were found in a healthy group in two separated evaluations. Our results show that aphasia recovery induced by both memantine alone and in combination with CIAT is indexed by bilateral cortical potentials.

Ultra-rapid access to words in chronic aphasia: the effects of intensive language action therapy (ILAT)

Effects of intensive language action therapy (ILAT) on automatic language processing were assessed using Magnetoencephalography (MEG). Auditory magnetic mismatch negativity (MMNm) responses to words and pseudowords were recorded in twelve patients with chronic aphasia before and immediately after two weeks of ILAT. Following therapy, Patients showed significant clinical improvements of auditory comprehension as measured by the Token Test and in word retrieval and naming as measured by the Boston Naming Test. Neuromagnetic responses dissociated between meaningful words and meaningless word-like stimuli ultra-rapidly, approximately 50 ms after acoustic information first allowed for stimulus identification. Over treatment, there was a significant increase in the left-lateralisation of this early word-elicited activation, observed in perilesional fronto-temporal regions. No comparable change was seen for pseudowords. The results may reflect successful, therapy-induced, language restitution in the left hemisphere.

Changes of right-hemispheric activation after constraint-induced, intensive language action therapy in chronic aphasia: fMRI evidence from auditory semantic processing

The role of the two hemispheres in the neurorehabilitation of language is still under dispute. This study explored the changes in language-evoked brain activation over a 2-week treatment interval with intensive constraint induced aphasia therapy (CIAT), which is also called intensive language action therapy (ILAT). Functional magnetic resonance imaging (fMRI) was used to assess brain activation in perilesional left hemispheric and in homotopic right hemispheric areas during passive listening to high and low-ambiguity sentences and non-speech control stimuli in chronic non-fluent aphasia patients. All patients demonstrated significant clinical improvements of language functions after therapy. In an event-related fMRI experiment, a significant increase of BOLD signal was manifest in right inferior frontal and temporal areas. This activation increase was stronger for highly ambiguous sentences than for unambiguous ones. These results suggest that the known language improvements brought about by intensive constraint-induced language action therapy at least in part relies on circuits within the right-hemispheric homologs of left-perisylvian language areas, which are most strongly activated in the processing of semantically complex language.

Dosing of a cued picture-naming treatment for anomia

PURPOSE

Recent investigations into effects of intensity or distribution of aphasia therapy have provided moderate evidence supporting intensive therapy schedules on aphasia treatment response. The purpose of the present study was to investigate the feasibility of creating an intensive therapy session without extending the amount of daily time a person spends in treatment.

METHOD

Individuals who presented with chronic anomia poststroke (N = 8) participated in 2 weeks of a computerized, therapist-delivered, cued, picture-naming treatment. Dosing parameters for each session were 8 presentations of 50 pictures, totaling 400 teaching episodes per session.

RESULTS

Of the 8 participants, 6 achieved significant increases from baseline on trained items after 400 teaching episodes (i.e., 1 treatment hr), and the remaining 2 participants achieved significant increases from baseline after 1200 teaching episodes (i.e., 3 treatment hr). Maintenance data from 7 of the participants indicated that 6 participants maintained significant improvement from baseline on trained items.

CONCLUSIONS

Given an intensive and saturated context, anomic individuals were surprisingly quick at relearning to produce problematic words successfully. Most participants demonstrated retention of the gains 2 months after treatment ended. The high density of teaching episodes within the treatment session (i.e., the intensive treatment schedule) may have contributed to the behavioral gains.

Neuroimaging in aphasia treatment research: standards for establishing the effects of treatment

The goal of this paper is to discuss experimental design options available for establishing the effects of treatment in studies that aim to examine the neural mechanisms associated with treatment-induced language recovery in aphasia, using functional magnetic resonance imaging (fMRI). We present both group and single-subject experimental or case-series design options for doing this and address advantages and disadvantages of each. We also discuss general components of and requirements for treatment research studies, including operational definitions of variables, criteria for defining behavioral change and treatment efficacy, and reliability of measurement. Important considerations that are unique to neuroimaging-based treatment research are addressed, pertaining to the relation between the selected treatment approach and anticipated changes in language processes/functions and how such changes are hypothesized to map onto the brain.

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.