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

Progressive lesion necrosis is related to increasing aphasia severity in chronic stroke

BACKGROUND

Volumetric investigations of cortical damage resulting from stroke indicate that lesion size and shape continue to change even in the chronic stage of recovery. However, the potential clinical relevance of continued lesion growth has yet to be examined. In the present study, we investigated the prevalence of lesion expansion and the relationship between expansion and changes in aphasia severity in a large sample of individuals in the chronic stage of aphasia recovery.

METHODS

Retrospective structural MRI scans from 104 S survivors with at least 2 observations (k = 301 observations; mean time between scans = 31 months) were included. Lesion demarcation was performed using an automated lesion segmentation software and lesion volumes at each timepoint were subsequently calculated. A linear mixed effects model was conducted to investigate the effect of days between scan on lesion expansion. Finally, we investigated the association between lesion expansion and changes on the Western Aphasia Battery (WAB) in a group of participants assessed and scanned at 2 timepoints (N = 54) using a GLM.

RESULTS

Most participants (81 %) showed evidence of lesion expansion. The mixed effects model revealed lesion volumes significantly increase, on average, by 0.02 cc each day (7.3 cc per year) following a scan (p < 0.0001). Change on language performance was significantly associated with change in lesion volume (p = 0.025) and age at stroke (p = 0.031). The results suggest that with every 10 cc increase in lesion size, language performance decreases by 0.9 points, and for every 10-year increase in age at stroke, language performance decreases by 1.9 points.

CONCLUSIONS

The present study confirms and extends prior reports that lesion expansion occurs well into the chronic stage of stroke. For the first time, we present evidence that expansion is predictive of longitudinal changes in language performance in individuals with aphasia. Future research should focus on the potential mechanisms that may lead to necrosis in areas surrounding the chronic stroke lesion.

Systematic Review and Meta-analysis of Language Symptoms due to Cerebellar Injury

To date, cerebellar contribution to language is well established via clinical and neuroimaging studies. However, the particular functional role of the cerebellum in language remains to be clarified. In this study, we present the first systematic review of the diverse language symptoms in spoken language after cerebellar lesion that were reported in case studies for the last 30 years (18 clinical cases from 13 papers), and meta-analysis using cluster analysis with bootstrap and symptom co-occurrence analysis. Seven clusters of patients with similar language symptoms after cerebellar lesions were found. Co-occurrence analysis revealed pairs of symptoms that tend to be comorbid. Our results imply that the "linguistic cerebellum" has a multiform contribution to language function. The most possible mechanism of such contribution is the cerebellar reciprocal connectivity with supratentorial brain regions, where the cerebellar level of the language network has a general modulation function and the supratentorial level is more functionally specified. Based on cerebellar connectivity with supratentorial components of the language network, the "linguistic cerebellum" might be further functionally segregated.

An electrophysiological and behavioral investigation of feedback-based learning in aphasia

Introduction

Feedback is a fundamental aspect of aphasia treatments. However, learning from feedback is a cognitively demanding process. At the most basic level, individuals must detect feedback and extract outcome-related information (i.e., feedback processing). Neuroanatomical and neuropsychological differences associated with post-stroke aphasia may influence feedback processing and potentially how people with aphasia (PWA) respond to feedback-based treatments. To better understand how post-stroke aphasia affects feedback-based learning, the current study leverages event-related potentials (ERPs) to (1) characterize the relationship between feedback processing and learning, (2) identify cognitive skills that are associated with feedback processing, and (3) identify behavioural correlates of feedback-based learning in PWA.

Methods

Seventeen PWA completed a feedback-based novel word learning task. Feedback processing was measured using the feedback-related negativity (FRN), an ERP hypothesized to reflect the detection and evaluation of outcomes communicated via feedback. Individuals also completed neuropsychological assessments of language (phonological processing, verbal short-term memory) and executive functioning.

Results

PWA elicited an FRN that was sensitive to feedback valence. The magnitude of the FRN was not associated with novel word learning but was strongly correlated with performance on another feedback-based task, the Berg Card Sort. Cognitive variables (information updating, selective attention) but not language variables were associated with novel word learning.

Discussion & Conclusion

For PWA, feedback processing may be associated with learning in some but not all feedback-based contexts. These findings may inform future research in determining which variables moderate the relationship between feedback processing and learning with the long-term goal of identifying how feedback can be modified to support successful learning during aphasia rehabilitation.

Recursive Self-feedback Improved Speech Fluency in Two Patients with Chronic Nonfluent Aphasia

Background

Previous studies have demonstrated that people with nonfluent aphasia (PWNA) improve their language production after repeating personalized scripts, modeled by speech-language pathologists (SLPs). If PWNA could improve by using their own self-feedback, relying less on external feedback, barriers to aphasia treatment, such as a dearth of clinicians and mobility issues, can be overcome. Here we examine whether PWNA improve their language production through an automated procedure that exposes them to playbacks of their own speech, which are updated recursively, without any feedback from SLPs.

Method

We tested if recursive self-feedback could improve speech fluency in two persons with chronic nonfluent aphasia. We compared two treatments: script production with recursive self-feedback (a new technique) and a non-self-feedback training. We administered the treatments remotely to the participants through their smartphones using two versions of a mobile app we developed. Each participant engaged in each treatment for about three weeks. We estimated clinical improvements of script production through a quantitative trend analysis and nonoverlap of all pairs.

Results

Recursive self-feedback improved speaking rate and speech initiation latency of trained and untrained scripts in both participants. The control (non-self-feedback) training was also effective, but it induced a somewhat weaker improvement in speaking rate, and improved speech initiation latency in only one participant.

Conclusion

Our findings provide preliminary evidence that PWNA can improve their speaking rate and speech initiation latency during production of scripts via fully automated recursive self-feedback. The beneficial effects of recursive self-feedback training suggest that speech unison and repeated exposures to written scripts may be optional ingredients of script-based treatments for aphasia.

Relationships of the arcuate fasciculus and nigrostriatal tract with language ability in intracerebral hemorrhage using a diffusion tensor imaging

We investigated the relationships of the arcuate fasciculus (AF) and the nigrostriatal tract (NST) with the language ability in patients with putaminal hemorrhage (PH) in the dominant hemisphere, using diffusion tensor tractography (DTT). Twenty-seven consecutive right-handed patients with PH and 27 age- and sex-matched normal control subjects were recruited. The aphasia quotient (AQ) score was used to evaluate the language ability at the early stage (within six weeks after onset). The fractional anisotropy (FA) value and tract volume (TV) of the ipsilesional AF and the ipsilesional NST were measured. The FA values and TVs of the ipsilesional AF and the ipsilesional NST of the patient group were lower than those of the control group (p < 0.05). The AQ score showed no significant correlation with the FA values of the ipsilesional AF and the ipsilesional NST (p > 0.05). By contrast, the AQ score showed a strong positive correlation with the TV of the ipsilesional AF (r = 0.868, p < 0.05). In addition, the AQ score revealed a moderate positive correlation with the TV of the ipsilesional NST (r = 0.577, p < 0.05). The states of the ipsilesional AF and the ipsilesional NST were closely related to the language ability at the early stages in patients with PH in the dominant hemisphere. Furthermore, the ipsilesional AF was more closely related to the language ability than the ipsilesional NST.

Predicting Outcomes of Language Rehabilitation: Prognostic Factors for Immediate and Long-Term Outcomes After Aphasia Therapy

BACKGROUND

Aphasia therapy is an effective approach to improve language function in chronic aphasia. However, it remains unclear what prognostic factors facilitate therapy response at the individual level. Here, we utilized data from the POLAR (Predicting Outcomes of Language Rehabilitation in Aphasia) trial to (a) determine therapy-induced change in confrontation naming and long-term maintenance of naming gains and (b) examine the extent to which aphasia severity, age, education, time postonset, and cognitive reserve predict naming gains at 1 week, 1 month, and 6 months posttherapy.

METHOD

A total of 107 participants with chronic (≥ 12 months poststroke) aphasia underwent extensive case history, cognitive-linguistic testing, and a neuroimaging workup prior to receiving 6 weeks of impairment-based language therapy. Therapy-induced change in naming performance (measured as raw change on the 175-item Philadelphia Naming Test [PNT]) was assessed 1 week after therapy and at follow-up time points 1 month and 6 months after therapy completion. Change in naming performance over time was evaluated using paired t tests, and linear mixed-effects models were constructed to examine the association between prognostic factors and therapy outcomes.

RESULTS

Naming performance was improved by 5.9 PNT items (Cohen's d = 0.56, p < .001) 1 week after therapy and by 6.4 (d = 0.66, p < .001) and 7.5 (d = 0.65, p < .001) PNT items at 1 month and 6 months after therapy completion, respectively. Aphasia severity emerged as the strongest predictor of naming improvement recovery across time points; mild (ß = 5.85-9.02) and moderate (ß = 9.65-11.54) impairment predicted better recovery than severe (ß = 1.31-3.37) and very severe (ß = 0.20-0.32) aphasia. Age was an emergent prognostic factor for recovery 1 month (ß = -0.14) and 6 months (ß = -0.20) after therapy, and time postonset (ß = -0.05) was associated with retention of naming gains at 6 months posttherapy.

CONCLUSIONS

These results suggest that therapy-induced naming improvement is predictable based on several easily measurable prognostic factors. Broadly speaking, these results suggest that prognostication procedures in aphasia therapy can be improved and indicate that personalization of therapy is a realistic goal in the near future.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22141829.

A Comparative Investigation of Automatic Speech Recognition Platforms for Aphasia Assessment Batteries

The rehabilitation of aphasics is fundamentally based on the assessment of speech impairment. Developing methods for assessing speech impairment automatically is important due to the growing number of stroke cases each year. Traditionally, aphasia is assessed manually using one of the well-known assessment batteries, such as the Western Aphasia Battery (WAB), the Chinese Rehabilitation Research Center Aphasia Examination (CRRCAE), and the Boston Diagnostic Aphasia Examination (BDAE). In aphasia testing, a speech-language pathologist (SLP) administers multiple subtests to assess people with aphasia (PWA). The traditional assessment is a resource-intensive process that requires the presence of an SLP. Thus, automating the assessment of aphasia is essential. This paper evaluated and compared custom machine learning (ML) speech recognition algorithms against off-the-shelf platforms using healthy and aphasic speech datasets on the naming and repetition subtests of the aphasia battery. Convolutional neural networks (CNN) and linear discriminant analysis (LDA) are the customized ML algorithms, while Microsoft Azure and Google speech recognition are off-the-shelf platforms. The results of this study demonstrated that CNN-based speech recognition algorithms outperform LDA and off-the-shelf platforms. The ResNet-50 architecture of CNN yielded an accuracy of 99.64 ± 0.26% on the healthy dataset. Even though Microsoft Azure was not trained on the same healthy dataset, it still generated comparable results to the LDA and superior results to Google's speech recognition platform.

Rehabilitation of Post-Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is rare and only accounts for 0.5% of all reported stroke cases. CVT includes severe headaches with neurological deficits, but the vague presentation of symptoms necessitates efficient clinical examination and imaging for a proper diagnosis. Here, we present a case of this rare type of stroke. Our patient exhibited continuous headaches, further complicated by other neurological deficits. We documented this case to aid in the diagnosis and rehabilitation management of CVT. We aim to demonstrate to physicians the importance of early rehabilitation in such stroke cases and improve the outcome for patients.

Updates in mechanical thrombectomy

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

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.

Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis

BACKGROUND

Stroke rehabilitation interventions are routinely personalized to address individuals' needs, goals, and challenges based on evidence from aggregated randomized controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias.

AIM

We explored associations between speech and language therapy (SLT) interventions frequency (days/week), intensity (h/week), and dosage (total SLT-hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking prespecified subgroup network meta-analyses of the RELEASE database.

METHODS

MEDLINE, EMBASE, and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ⩾ 10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardized. A one-stage, random effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomized by age (⩽/> 65 years), aphasia severity (mild-moderate/ moderate-severe based on language outcomes' median value), chronicity (⩽/> 3 months), and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (> 50%), results were reported for completeness.

RESULTS

959 IPD (25 RCTs) were analyzed. For working-age participants, greatest language gains from baseline occurred alongside moderate to high-intensity SLT (functional communication 3-to-4 h/week; overall-language and comprehension > 9 h/week); older participants' greatest gains occurred alongside low-intensity SLT (⩽ 2 h/week) except for auditory comprehension (> 9 h/week). For both age-groups, SLT-frequency and dosage associated with best language gains were similar. Participants ⩽ 3 months post-onset demonstrated greatest overall-language gains for SLT at low intensity/moderate dosage (⩽ 2 SLT-h/week; 20-to-50 h); for those > 3 months, post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3-4 SLT-h/week; ⩾ 50 hours). For moderate-severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ⩾ 4 SLT-days/week; mild-moderate participants' greatest functional communication gains were associated with similar frequency (⩾ 4 SLT-days/week) and greatest overall-language gains with higher frequency SLT (⩾ 6 days/weekly). Males' greatest gains were associated with SLT of moderate (functional communication; 3-to-4 h/weekly) or high intensity (overall-language and auditory comprehension; (> 9 h/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (< 2 SLT-h/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-h in total; auditory comprehension gains were generally observed when SLT > 9 h over ⩾ 4 days/week.

CONCLUSIONS

We observed a treatment response in most subgroups' overall-language, auditory comprehension, and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild-moderate, and male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate-severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical, and cost effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia severity, and chronicity should be evaluated in future clinical RCTs.

Auditory Comprehension Interventions for People With Aphasia: A Scoping Review

PURPOSE

This scoping review examined studies reporting restorative treatments designed to improve auditory comprehension in people with aphasia.

METHOD

We searched eight databases using keywords aphasia, auditory comprehension, treatment, intervention, and rehabilitation, for studies published between 1970 and 2020. Searches returned 170 records, and after applying exclusionary criteria, 28 articles remained. For each article, two authors independently extracted data on study design parameters, participant characteristics, treatment protocol, and treatment outcomes, including generalization.

RESULTS

Studies were categorized by treatment focus: direct auditory (n = 7), mixed auditory (n = 13), or indirect (n = 8). Study designs were group (n = 12), single-subject experimental design (n = 11), or case study (n = 5). Fifteen studies had a control condition and/or a control group. Thirteen studies included two to 10 participants. Aphasia severity and auditory comprehension severity were infrequently reported, and most participants were greater than 1-year poststroke. Treatment targets and tasks varied. Sessions ranged from 8 to 240 min, once or more per week, for eight to 60 total sessions over 2-20 weeks. Impairment-based outcome measures were typically used. Improvement and generalization were regularly reported; however, authors frequently did not report statistical significance.

CONCLUSIONS

A variety of treatments have addressed auditory comprehension deficits in people with aphasia, with many reporting improvements in auditory comprehension for some people. However, the variability in treatment tasks and delivery and outcome measurements preclude confidently offering specific clinical recommendations for implementing auditory comprehension treatments. Gaps identified by the current study may guide the development and exploration of transparent, repeatable, patient-centered treatments.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21291345.

Better long-term speech outcomes in stroke survivors who received early clinical speech and language therapy: What's driving recovery?

Establishing whether speech and language therapy after stroke has beneficial effects on speaking ability is challenging because of the need to control for multiple non-therapy factors known to influence recovery. We investigated how speaking ability at three time points post-stroke differed in patients who received varying amounts of clinical therapy in the first month post-stroke. In contrast to prior studies, we factored out variance from: initial severity of speaking impairment, amount of later therapy, and left and right hemisphere lesion size and site. We found that speaking ability at one month post-stroke was significantly better in patients who received early therapy (n = 79), versus those who did not (n = 64), and the number of hours of early therapy was positively related to recovery at one year post-stroke. We offer two non-mutually exclusive interpretations of these data: (1) patients may benefit from the early provision of self-management strategies; (2) therapy is more likely to be provided to patients who have a better chance of recovery (e.g., poor physical and/or mental health may impact suitability for therapy and chance of recovery). Both interpretations have implications for future studies aiming to predict individual patients' speech outcomes after stroke, and their response to therapy.

Predictors of Therapy Response in Chronic Aphasia: Building a Foundation for Personalized Aphasia Therapy

Chronic aphasia, a devastating impairment of language, affects up to a third of stroke survivors. Speech and language therapy has consistently been shown to improve language function in prior clinical trials, but few clinicially applicable predictors of individual therapy response have been identified to date. Consequently, clinicians struggle substantially with prognostication in the clinical management of aphasia. A rising prevalence of aphasia, in particular in younger populations, has emphasized the increasing demand for a personalized approach to aphasia therapy, that is, therapy aimed at maximizing language recovery of each individual with reference to evidence-based clinical recommendations. In this narrative review, we discuss the current state of the literature with respect to commonly studied predictors of therapy response in aphasia. In particular, we focus our discussion on biographical, neuropsychological, and neurobiological predictors, and emphasize limitations of the literature, summarize consistent findings, and consider how the research field can better support the development of personalized aphasia therapy. In conclusion, a review of the literature indicates that future research efforts should aim to recruit larger samples of people with aphasia, including by establishing multisite aphasia research centers.

Implementation Science Research in Communication Sciences and Disorders: A Scoping Review

PURPOSE

The purpose of this study was to complete a scoping review of implementation science (IS) research in communication sciences and disorders (CSD) over time and to determine characteristics of IS research in CSD.

METHOD

A scoping review was conducted of PubMed and Education Resources Information Center for sources published in English that (a) included CSD practitioners, (b) addressed IS research, and (c) identified a specific evidence-based practice. Resulting sources were systematically examined for study aim, patient populations, implementation framework utilized, setting of the study, implementation strategy examined, and implementation outcome measured.

RESULTS

The majority of the 82 studies that underwent a full-text review (80.5%) were published in 2014 or later. One fourth of the studies were concept papers, and another one fourth focused on context assessment (25.6% of studies, each), 11% focused on designing implementation strategies, and 36.6% focused on testing implementation strategies. The patient population most frequently represented aphasia (21.3%), and most studies (34.4%) were conducted in inpatient medical settings. Nearly half (42.6%) of the nonconcept studies lacked an IS framework. Among implementation strategies identified, approximately one third of studies focused on education and/or training plus another strategy and one fourth focused on education and/or training alone. Implementation outcomes measured typically represented early stages of implementation.

CONCLUSIONS

This scoping review of IS research in CSD described the landscape of IS studies in CSD. IS is intersecting with CSD at a rapid rate, especially since 2014. Future IS research in CSD should adopt an implementation framework a priori and consider the broad range of implementation strategies and outcomes to support the uptake of research into typical practice settings.

Using an Implementation Framework to Survey Outcome Measurement and Treatment Practices in Aphasia

PURPOSE

Best practices in the field of aphasia rehabilitation increasingly acknowledge a whole-person approach that values interventions aimed at reducing impairments, while also recognizing the impact of aphasia on participation and quality of life. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to examine whether current clinical practices along levels of service provision reflect this whole-person, multifaceted approach.

METHOD

Speech-language pathologists (SLPs) in the United States who provide intervention to people with aphasia across the continuum of care completed this cross-sectional online survey. Current outcome measurement and treatment practices were evaluated within the Living With Aphasia: Framework for Outcome Measurement via multiple-choice and open-text response questions. Data were analyzed descriptively and using ordinal logistic regression models to compare clinical practices along levels of service provision.

RESULTS

Data from 90 SLPs revealed that language and cognitive skills are assessed with equal consistency across clinical settings; however, functional communication, participation, and quality of life domains are prioritized in settings providing care to clients within the community. Psychological well-being is rarely assessed within clinical practice along most of the rehabilitation process and prioritized within the university clinic setting when clients are in the chronic stage of recovery.

CONCLUSIONS

Clinical practices related to a multifaceted approach to aphasia intervention are variable across levels of service provision. Further exploration of barriers and facilitators to multifaceted aphasia care along the domains of the CFIR is needed to provide an informed approach to implementing change.

Cognitive Training to Enhance Aphasia Therapy (Co-TrEAT): A Feasibility Study

Persons with aphasia (PWA) often have deficits in cognitive domains such as working memory (WM), which are negatively correlated with recovery, and studies have targeted WM deficits in aphasia therapy. To our knowledge, however, no study has examined the efficacy of multi-modal training which includes both WM training and targeted language therapy. This pilot project examined the feasibility and preliminary efficacy of combining WM training and naming therapy to treat post-stroke PWA. Chronic PWA were randomly assigned to either the a) Phonological Components Analysis (PCA) and WM intervention (WMI) condition (i.e., a computerized adaptive dual n-back task), or b) PCA and active control condition (WMC). Participants received face-to-face PCA therapy 3 times/week for 5 weeks, and simultaneously engaged in WM training or the active control condition five times/week, independently at home. Six PWA were enrolled, 3 in each condition. Feasibility metrics were excellent for protocol compliance, retention rate and lack of adverse events. Recruitment was less successful, with insufficient participants for group analyses. Participants in the WMI (but not the WMC) condition demonstrated a clinically significant (i.e., > 5 points) improvement on the Western Aphasia Battery- Aphasia Quotient (WAB-R AQ) and Boston Naming Test after therapy. Given the small sample size, the performance of two individuals, matched on age, education, naming accuracy pre-treatment, WAB-R AQ and WM abilities was compared. Participant WMI-3 demonstrated a notable increase in WM training performance over the course of therapy; WMC-2 was the matched control. After therapy, WMI-3's naming accuracy for the treated words improved from 30 to 90% (compared to 30–50% for WMC-2) with a 7-point WAB-R AQ increase (compared to 3 for WMC-2). Improvements were also found for WMI-3 but not for WMC-2 on ratings of communicative effectiveness, confidence and some conversation parameters in discourse. This feasibility study demonstrated excellent results for most aspects of Co-TrEAT. Recruitment rate, hampered by limited resources, must be addressed in future trials; remotely delivered aphasia therapy may be a possible solution. Although no firm conclusions can be drawn, the case studies suggest that WM training has the potential to improve language and communication outcomes when combined with aphasia therapy.

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.

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.

Applying the Transtheoretical Model to Stuttering Management Among Adolescents: Part I. Scale Development

Purpose This article is the first in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. In this article, we describe the process of developing measures to assess stage of change (SOC) by defining behaviors of stuttering management, as well as the two primary cognitive constructs that underlie one's readiness to make behavioral change: decisional balance (DB) and situational self-efficacy (SSE). This work hinges on the ability to develop an operational definition of what it means to successfully manage or do something positive about one's stuttering. Method We used an iterative process to develop the three scales. Through qualitative analysis of key informant interview and focus group transcripts with 24 adolescents who stutter and 26 clinicians specializing in stuttering, we developed stuttering-specific SOC, DB, and SSE scales. The drafted scales were cognitively tested with nine adolescents who stutter. Results Thematic analysis yielded a three-part definition of successful stuttering management that formed the basis for the SOC scale: (a) learning and using strategies to modify speech or stuttering, (b) changing negative thoughts and attitudes regarding stuttering, and (c) talking without avoiding sounds, words, or situations. Results from this analysis support a broader view of successful stuttering management; that is, it is likely that doing so requires more than just behavior change, which has long been considered the main objective of stuttering treatment. Additional analyses yielded pros and cons of managing stuttering (62 items for the DB scale) and situations in which it is difficult to manage stuttering (39 items for the SSE scale). Conclusions Qualitative analyses provided a three-part definition of "stuttering management" and a comprehensive pool of items that would allow measurement of DB and SSE that underlie readiness to manage stuttering among adolescents. In the companion article in this two-part series, we describe the next step in scale development: exploratory scale validation of the drafted SOC, DB, and SSE scales.

Top Ten Tips Palliative Care Clinicians Should Know About Strokes

Stroke is a common cause of long-term disability and death, which leaves many patients with significant and unique palliative care (PC) needs. Shared decision-making for patients with stroke poses distinct challenges due to the sudden nature of stroke, the uncertainty inherent in prognostication around recovery, and the common necessity of relying on surrogates for decision-making. Patients with stroke suffer from frequently underrecognized symptoms, which PC clinicians should feel comfortable identifying and treating. This article provides 10 tips for palliative clinicians to increase their knowledge and comfort in caring for this important population.

The effects of intensity on a phonological treatment for anomia in post-stroke aphasia

INTRODUCTION

The evidence regarding optimal treatment intensity is mixed, and differing definitions have further confounded existing findings. The primary objective of this study was to compare the efficacy of Phonological Components Analysis (PCA) treatment for anomia delivered at intense and non-intense schedules, using a well-controlled design. The number of teaching episodes and active ingredients of therapy are important considerations when defining intensity. We hypothesized that an active ingredient of PCA is the self-generation of phonological components during therapy sessions. Our secondary aim was to examine whether component generation predicted treatment outcome.

METHODS

Sixteen adults (M = 52.63 years old, SD = 11.40) with chronic post-stroke aphasia (M = 4.52 years post-onset, SD = 5.55) were randomly assigned to intensive (IT) or standard (ST) PCA treatment conditions. Cumulative treatment intensity in both conditions was equivalent: ST participants received PCA 1 hour/day, 3 days/week for 10 weeks, whereas IT participants received PCA 3 hours/day, 4 days/week for 2.5 weeks. The primary outcome was naming accuracy on a set of treated and (matched) untreated words, measured pre- and post-treatment, and at four- and eight-week follow-ups.

RESULTS

IT and ST conditions were similarly efficacious. However, secondary analyses suggest an advantage for the IT condition in naming of the treated words immediately post-treatment, but not at follow-ups. The self-generation of phonological components emerged as a significant positive predictor of naming accuracy for both the treated and untreated words. However, this relationship did not reach significance once baseline anomia severity was accounted for.

CONCLUSIONS

Although replication in a larger sample is warranted, results suggest that PCA treatment is similarly efficacious when delivered at different intensities. Other factors related to the quality of treatment (i.e., active ingredients such as cue-generation) may play an important role in determining treatment efficacy and must also be considered when comparing treatment intensities.

Intensive Comprehensive Aphasia Programmes: a systematic scoping review and analysis using the TIDieR checklist for reporting interventions

PURPOSE

Aphasia is an acquired language disorder that typically occurs as a result of a stroke. People with aphasia experience communication difficulties and risk secondary impacts, for example, affecting social and work life and mental health. Intensive Comprehensive Aphasia Programmes (ICAPs) aims to address the multiple consequences of aphasia using intensive intervention and a wide range of therapy approaches. Although basic parameters of ICAP intervention have been defined, a fuller characterisation is needed. This systematic scoping review aimed to determine what constitutes an ICAP.

METHODS

Peer-reviewed and Grey databases were searched for articles on ICAPs using Joanna Brigg's Institute methodology. Data was extracted following the Template for Intervention Description and Replication (TIDieR) checklist for reporting interventions and synthesised using a narrative synthesis.

RESULTS AND CONCLUSIONS

17 ICAPs were reported in 20 peer-reviewed literature sources (9 ICAPs supplemented by Grey literature sources). There were high degrees of variation in dose, professionals involved, and no qualitative data from participants. Of note, ICAP intervention was highly tailored to individual participants on the same ICAP, and intervention content varied between ICAPs. ICAPs appear to be rationalised as intensive impairment-based programmes with other components added for comprehensiveness. Stronger rationale and a logic model are required to justify the core components of ICAPs. The input of stakeholders into designing future ICAP interventions is recommended.IMPLICATIONS FOR REHABILITATIONThe ICAP model is in its infancy when it comes to mainstream clinical application as only the intensity component of the ICAP has clear theoretical underpinning as reported in the peer-reviewed literature.There have been clinical uptakes of the ICAP model which is likely to continue and is valid in the context of an under-researched area of aphasia therapy and on a background of a less than perfect relationship between evidence base and practice.Aspects of the ICAP model are valid for clinicians to implement, for example, intensive evidence-based aphasia therapy in combination with therapy which addresses some of the broader implications of aphasia, for example, social isolation.Clinicians can use the ICAP model to review their existing service provision and explore whether their service provides aphasia therapy that addresses the multiple aspects of aphasia (i.e., ensuring the focus is not only on impairment-based therapy).

Individualized response to semantic versus phonological aphasia therapies in stroke

Attempts to personalize aphasia treatment to the extent where it is possible to reliably predict individual response to a particular treatment have yielded inconclusive results. The current study aimed to (i) compare the effects of phonologically versus semantically focussed naming treatment and (ii) examine biographical and neuropsychological baseline factors predictive of response to each treatment. One hundred and four individuals with chronic post-stroke aphasia underwent 3 weeks of phonologically focussed treatment and 3 weeks of semantically focussed treatment in an unblinded cross-over design. A linear mixed-effects model was used to compare the effects of treatment type on proportional change in correct naming across groups. Correlational analysis and stepwise regression models were used to examine biographical and neuropsychological predictors of response to phonological and semantic treatment across all participants. Last, chi-square tests were used to explore the association between treatment response and phonological and semantic deficit profiles. Semantically focussed treatment was found to be more effective at the group-level, independently of treatment order (P = 0.041). Overall, milder speech and language impairment predicted good response to semantic treatment (r range: 0.256-0.373) across neuropsychological tasks. The Western Aphasia Battery-Revised Spontaneous Speech score emerged as the strongest predictor of semantic treatment response (R ² = 0.188). Severity of stroke symptoms emerged as the strongest predictor of phonological treatment response (R ² = 0.103). Participants who showed a good response to semantic treatment were more likely to present with fluent speech compared to poor responders (P = 0.005), whereas participants who showed a good response to phonological treatment were more likely to present with apraxia of speech (P = 0.020). These results suggest that semantic treatment may be more beneficial to the improvement of naming performance in aphasia than phonological treatment, at the group-level. In terms of personalized predictors, participants with relatively mild impairments and fluent speech responded better to semantic treatment, while phonological treatment benefitted participants with more severe impairments and apraxia of speech.

Factors predicting long-term recovery from post-stroke aphasia

BACKGROUND

It remains widely accepted that spontaneous recovery from aphasia is largely limited to the first related factors. This has direct implications for acute and chronic interventions for aphasia. few months following stroke. A few recent studies challenge this view, revealing that some individuals' language abilities improve even during the chronic stage.

AIMS

To identify prognostic indicators of long-term aphasia recovery.

METHODS & PROCEDURES

Eighteen people with aphasia initially evaluated in the chronic stage were retested at least one year later. The Western Aphasia Battery-Revised (WAB-R) Aphasia Quotient (AQ) was used to quantify changes in language impairment. Prognostic factors included those related to the patient (demographic, psychosocial), stroke (lesion volume and location), and treatment (medical, rehabilitative).

OUTCOMES & RESULTS

Twelve participants improved and 6 remained stable or declined. Linear regression analysis revealed that lesion volume predicted long-term language gains, with smaller lesions yielding greater improvements. Individuals who did not improve were more likely to have lesions encompassing critical frontal and temporoparietal cortical regions and interconnecting white matter pathways. Exploratory regression analysis of psychosocial and treatment-related factors revealed a positive relationship between improvement and satisfaction with life participation, and a negative relationship between improvement and perceived impairment severity. Critically, psychosocial and treatment-related factors significantly improved model fit over lesion volume, suggesting that these factors add predictive value to determining long-term aphasia prognosis.

CONCLUSIONS

Long-term aphasia recovery is multidetermined by a combination of stroke-, psychosocial-, and treatment-related factors. This has direct implications for acute and chronic interventions 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.

Intermittent Theta Burst Stimulation (iTBS) for Treatment of Chronic Post-Stroke Aphasia: Results of a Pilot Randomized, Double-Blind, Sham-Controlled Trial

Background

Research indicates intermittent theta burst stimulation (iTBS) is a potential treatment of post-stroke aphasia.

Material/Methods

In this double-blind, sham-controlled trial (NCT 01512264) participants were randomized to receive 3 weeks of sham (G₀), 1 week of iTBS/2 weeks of sham (G₁), 2 weeks of iTBS/1 week of sham (G₂), or 3 weeks of iTBS (G₃). FMRI localized residual language function in the left hemisphere; iTBS was applied to the maximum fMRI activation in the residual language cortex in the left frontal lobe. FMRI and aphasia testing were conducted pre-treatment, at ≤1 week after completing treatment, and at 3 months follow-up.

Results

27/36 participants completed the trial. We compared G₀ to each of the individual treatment group and to all iTBS treatment groups combined (G_1–3). In individual groups, participants gained (of moderate or large effect sizes; some significant at P<0.05) on the Boston Naming Test (BNT), the Semantic Fluency Test (SFT), and the Aphasia Quotient of the Western Aphasia Battery-Revised (WAB-R AQ). In G_1–3, BNT, and SFT improved immediately after treatment, while the WAB-R AQ improved at 3 months. Compared to G₀, the other groups showed greater fMRI activation in both hemispheres and non-significant increases in language lateralization to the left hemisphere. Changes in IFG connectivity were noted with iTBS, showing differences between time-points, with some of them correlating with the behavioral measures.

Conclusions

The results of this pilot trial support the hypothesis that iTBS applied to the ipsilesional hemisphere can improve aphasia and result in cortical plasticity.

Treatment of post-stroke aphasia: A narrative review for stroke neurologists

This review is intended to help physicians guide patients to optimal management of post-stroke aphasia. We review literature on post-stroke aphasia treatment, focusing on: (1) when and for whom language therapy is most effective, (2) the variety of approaches that can be effective for different individuals, and (3) the extent to which behavioral therapy might be augmented by non-invasive brain stimulation and/or medications.

Hospital staff, volunteers' and patients' perceptions of barriers and facilitators to communication following stroke in an acute and a rehabilitation private hospital ward: a qualitative description study

OBJECTIVES

To explore barriers and facilitators to patient communication in an acute and rehabilitation ward setting from the perspectives of hospital staff, volunteers and patients following stroke.

DESIGN

A qualitative descriptive study as part of a larger study which aimed to develop and test a Communication Enhanced Environment model in an acute and a rehabilitation ward.

SETTING

A metropolitan Australian private hospital.

PARTICIPANTS

Focus groups with acute and rehabilitation doctors, nurses, allied health staff and volunteers (n=51), and interviews with patients following stroke (n=7), including three with aphasia, were conducted.

RESULTS

The key themes related to barriers and facilitators to communication, contained subcategories related to hospital, staff and patient factors. Hospital-related barriers to communication were private rooms, mixed wards, the physical hospital environment, hospital policies, the power imbalance between staff and patients, and task-specific communication. Staff-related barriers to communication were staff perception of time pressures, underutilisation of available resources, staff individual factors such as personality, role perception and lack of knowledge and skills regarding communication strategies. The patient-related barrier to communication involved patients' functional and medical status. Hospital-related facilitators to communication were shared rooms/co-location of patients, visitors and volunteers. Staff-related facilitators to communication were utilisation of resources, speech pathology support, staff knowledge and utilisation of communication strategies, and individual staff factors such as personality. No patient-related facilitators to communication were reported by staff, volunteers or patients.

CONCLUSIONS

Barriers and facilitators to communication appeared to interconnect with potential to influence one another. This suggests communication access may vary between patients within the same setting. Practical changes may promote communication opportunities for patients in hospital early after stroke such as access to areas for patient co-location as well as areas for privacy, encouraging visitors, enhancing patient autonomy, and providing communication-trained health staff and volunteers.

Current Approaches to the Treatment of Post-Stroke Aphasia

Aphasia, impairment of language after stroke or other neurological insult, is a common and often devastating condition that affects nearly every social activity and interaction. Behavioral speech and language therapy is the mainstay of treatment, although other interventions have been introduced to augment the effects of the behavioral therapy. In this narrative review, we discuss advances in aphasia therapy in the last 5 years and focus primarily on properly powered, randomized, controlled trials of both behavioral therapies and interventions to augment therapy for post-stroke aphasia. These trials include evaluation of behavioral therapies and computer-delivered language therapies. We also discuss outcome prediction trials as well as interventional trials that have employed noninvasive brain stimulation, or medications to augment language therapy. Supported by evidence from Phase III trials and large meta-analyses, it is now generally accepted that aphasia therapy can improve language processing for many patients. Not all patients respond similarly to aphasia therapy with the most severe patients being the least likely responders. Nevertheless, it is imperative that all patients, regardless of severity, receive aphasia management focused on direct therapy of language deficits, counseling, or both. Emerging evidence from Phase II trials suggests transcranial brain stimulation is a promising method to boost aphasia therapy outcomes.

Predictors of Poststroke Aphasia Recovery: A Systematic Review-Informed Individual Participant Data Meta-Analysis

BACKGROUND AND PURPOSE

The factors associated with recovery of language domains after stroke remain uncertain. We described recovery of overall-language-ability, auditory comprehension, naming, and functional-communication across participants' age, sex, and aphasia chronicity in a large, multilingual, international aphasia dataset.

METHODS

Individual participant data meta-analysis of systematically sourced aphasia datasets described overall-language ability using the Western Aphasia Battery Aphasia-Quotient; auditory comprehension by Aachen Aphasia Test (AAT) Token Test; naming by Boston Naming Test and functional-communication by AAT Spontaneous-Speech Communication subscale. Multivariable analyses regressed absolute score-changes from baseline across language domains onto covariates identified a priori in randomized controlled trials and all study types. Change-from-baseline scores were presented as estimates of means and 95% CIs. Heterogeneity was described using relative variance. Risk of bias was considered at dataset and meta-analysis level.

RESULTS

Assessments at baseline (median=43.6 weeks poststroke; interquartile range [4-165.1]) and first-follow-up (median=10 weeks from baseline; interquartile range [3-26]) were available for n=943 on overall-language ability, n=1056 on auditory comprehension, n=791 on naming and n=974 on functional-communication. Younger age (<55 years, +15.4 Western Aphasia Battery Aphasia-Quotient points [CI, 10.0-20.9], +6.1 correct on AAT Token Test [CI, 3.2-8.9]; +9.3 Boston Naming Test points [CI, 4.7-13.9]; +0.8 AAT Spontaneous-Speech Communication subscale points [CI, 0.5-1.0]) and enrollment <1 month post-onset (+19.1 Western Aphasia Battery Aphasia-Quotient points [CI, 13.9-24.4]; +5.3 correct on AAT Token Test [CI, 1.7-8.8]; +11.1 Boston Naming Test points [CI, 5.7-16.5]; and +1.1 AAT Spontaneous-Speech Communication subscale point [CI, 0.7-1.4]) conferred the greatest absolute change-from-baseline across each language domain. Improvements in language scores from baseline diminished with increasing age and aphasia chronicity. Data exhibited no significant statistical heterogeneity. Risk-of-bias was low to moderate-low.

CONCLUSIONS

Earlier intervention for poststroke aphasia was crucial to maximize language recovery across a range of language domains, although recovery continued to be observed to a lesser extent beyond 6 months poststroke.

The relationship between health-related quality of life, perceived social support, and social network size in African Americans with aphasia: a cross-sectional study

Stroke significantly impairs health-related quality of life (HRQL). Stroke survivors with aphasia (SWA) experience lower HRQL than stroke survivors without aphasia (SSA) as a result of poorer communication and social functioning. The extent to which aphasia influences HRQL in African-Americans and the components of social functioning that are most important to HRQL warrants further exploration.There were two main objectives of this paper. The first was to survey HRQL domains of communication, physical, mental/emotional, role, and social functioning in African American SWA and SSA. The second was to examine if social support and social network predicted HRQL in SWA.A total of 39 African American adults (62.4 ± 11.10) participated in this descriptive cross-sectional case control study. Patient-reported outcome measures were used to assess HRQL, perceived social support, and social network in SWA, SSA, and normal-aging healthy controls (NAH). Data analysis included an ANOVA and moderator regression to determine if social support or social network predicted HRQL in SWA.SWA reported a significantly lower overall HRQL (p = <.000) than NAH adults. Communication HRQL was the hallmark difference found between SWA and SSA (p = <.000). Social support and social network were relatively similar among all three groups. However, social support and social network did not predict HRQL in SWA.Findings from this study suggest that social HRQL continues to be significantly lower in SWA; however, social support and social network factors do not drive differences among African-Americans. Moreover, communication HRQL remains the hallmark difference between SWA and SSA.

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.

Effects of Semantic Feature Type, Diversity, and Quantity on Semantic Feature Analysis Treatment Outcomes in Aphasia

Purpose Semantic feature analysis (SFA) is a naming treatment found to improve naming performance for both treated and semantically related untreated words in aphasia. A crucial treatment component is the requirement that patients generate semantic features of treated items. This article examined the role feature generation plays in treatment response to SFA in several ways: It attempted to replicate preliminary findings from Gravier et al. (2018), which found feature generation predicted treatment-related gains for both trained and untrained words. It examined whether feature diversity or the number of features generated in specific categories differentially affected SFA treatment outcomes. Method SFA was administered to 44 participants with chronic aphasia daily for 4 weeks. Treatment was administered to multiple lists sequentially in a multiple-baseline design. Participant-generated features were captured during treatment and coded in terms of feature category, total average number of features generated per trial, and total number of unique features generated per item. Item-level naming accuracy was analyzed using logistic mixed-effects regression models. Results Producing more participant-generated features was found to improve treatment response for trained but not untrained items in SFA, in contrast to Gravier et al. (2018). There was no effect of participant-generated feature diversity or any differential effect of feature category on SFA treatment outcomes. Conclusions Patient-generated features remain a key predictor of direct training effects and overall treatment response in SFA. Aphasia severity was also a significant predictor of treatment outcomes. Future work should focus on identifying potential nonresponders to therapy and explore treatment modifications to improve treatment outcomes for these individuals. Supplemental Material https://doi.org/10.23641/asha.12462596.

Dose effects in behavioural treatment of post-stroke aphasia: a systematic review and meta-analysis

PURPOSE

Aphasia is a debilitating chronic acquired language disorder that impacts heavily on a person's life. Behavioural treatments aim to remediate language processing skills or to enhance communication between the person with aphasia and others, and a number of different treatments are efficacious. However, it is unclear how much of a particular treatment a person needs in order to optimise recovery of language and communication skills following stroke.

MATERIALS AND METHODS

Systematic search for and meta-analysis of experimental studies that directly compared different amounts of the same behavioural aphasia treatment, following PRISMA guidelines.

RESULTS

Treatment dose research in aphasia is an emerging area. Just six studies comparing different doses of the same intervention met all criteria for inclusion. Evidence from these studies was synthesised and meta-analysed, where possible. Meta-analyses were inconclusive due to limited data; however, there are indications that suggest increased dose may confer greater improvement on language and communication measures, but with diminishing returns over time. Aphasia severity and chronicity may affect dose-response relationships.

CONCLUSIONS

There is currently insufficient evidence to determine the effect of dose on treatment response. A dedicated and coordinated research agenda is required to systematically explore dose-response relationships in post-stroke aphasia interventions.A video abstract is available in the Supplementary Material.Implications for rehabilitationThe investigation of the effect of dose on treatment outcomes in post-stroke aphasia is an emerging research area with few studies reporting comparison of different amounts of the same intervention.In the acute phase of recovery following stroke, higher doses of treatment provided over short periods may not be preferable, tolerable, or superior to lower doses of the same treatment.In the chronic phase, providing additional blocks of treatment may confer additional benefit for some people with aphasia but with diminishing returns.People with chronic aphasia can achieve and maintain significant gains in picture naming after a relatively brief period of high-dose treatment.

Mechanisms underlying anomia treatment outcomes

Treatments for anomia have demonstrated short- and long-term efficacy. However, individual outcomes can be variable, and evidence for treatment generalization is limited. We investigated whether treatment-related measures of access to- and learning of language, namely, a) responsiveness to cues, and b) during-treatment improvements in naming, are good predictors of treatment outcomes. In addition, we investigated mechanisms underlying treatment generalization. Ten adults with chronic, post-stroke aphasia received a phonological treatment for anomia three times a week for five weeks. Naming accuracy of treated and untreated words was assessed pre- and post-treatment and at four- and eight-week follow-ups. Generalization to an untrained naming task, which involved analyses of naming accuracy and speech errors, was also assessed; speech errors were analyzed according to the Interactive Activation (IA) model of word retrieval. Group analyses indicate significant improvements in naming treated compared to untreated words, at all timepoints after therapy. Additional analyses showed significant long-term improvements in naming untreated words. Initial responsiveness to cueing and early improvement emerged as significant predictors of overall pre- to post-treatment improvements in naming treated words; naming improvements made early-on in treatment were also predictive of improvements in naming of the untreated words at follow-up. Furthermore, our study is the first to demonstrate that generalization after a phonological treatment for anomia may be driven by a strengthening of lexical-phonological connections. This study provides novel insights regarding mechanisms driving anomia treatment outcomes. Understanding such mechanisms is critical to improving existing assessment practices, optimizing treatment selection and building treatment protocols that are more likely to generalize.

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 of agrammatism in oral and written production in patients with Broca's aphasia The use of implicit and explicit learning

Several approaches to the rehabilitation of agrammatism use implicit and explicit learning methods.

An exploration of aphasia therapy dosage in the first six months of stroke recovery

Aphasia research uses the length of time within rehabilitation sessions as the main measure of dosage. Few papers detail therapeutic ingredients or outline the number of times these were delivered over the treatment period. The present observational study identified therapeutic ingredients in the Very Early Rehabiltiation in SpEech (VERSE) trial and explored the dosage provided using a model of cumulative intervention intensity (CII). Therapists video recorded one therapy session per week and 53 (12%) randomly selected therapy videos were analysed. The videos were coded for number of error productions, self-corrections and type and frequency of therapist cueing. The Western Aphasia Battery Revised-Aphasia Quotient (WABR-AQ) was used for measuring patient outcome with total verbal utterances (p < 0.001) and cues used with success (p < 0.001) being independent positive predictors of WABR-AQ score at six months post stroke and hypothesized as key therapeutic ingredients. The CII was calculated by counting identified therapeutic ingredients and multiplying this by the number of sessions completed. Collectively, the key ingredients occurred on average 504 times per session and over 10,000 times per participant during the treatment period. This paper reports a novel approach for identifying key treatment ingredients and detailing the dosage delivered within an early aphasia rehabilitation trial.

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.

Follow-Up in Aphasia Caused by Acute Stroke in a Prospective, Randomized, Clinical, and Experimental Controlled Noninvasive Study With an iPad-Based App (Neolexon®): Study Protocol of the Lexi Study

Rationale: Treatment of aphasia is still challenging for clinicians and patients. So far, there is proven evidence for "face-to-face" speech therapy. However, the digital age potentially offers new and complementary strategies that may add to treatment outcome in a cost-effective way. Neolexon® is a commercial tablet-based software for treatment of aphasia, which can be applied with the help of a therapist or as self-training by the patient. Aims and hypothesis: In the Lexi study, we aim to determine whether treatment with Neolexon® is superior to standard therapy in acute post-stroke aphasia. Sample size estimates: A sample size of 180 patients, 90 for each group, will be included with an assumed dropout rate of ~20%. Methods and design: Prospective, randomized, parallel group, open-label, blinded-endpoint clinical, and experimental controlled non-invasive trial (PROBE). Adult German native speakers with acute aphasia after stroke are included. Computer-generated, blocked, and stratified randomization by aphasia severity will assign patients to one of two groups: 4 weeks of either standard logopedic speech therapy or logopedic speech therapy with the app version of Neolexon®. Both groups will be instructed in self-training: the frequency and duration of self-training will be documented. Screening for aphasia will be performed using the Language Screening Test (LAST). The severity of aphasia in general and in subitems will be assessed using the Bielefelder Aphasie Screening (BIAS) and the Aphasia Check List (ACL). Follow-up will be assessed after 3 months. Study outcomes: Based on the consensus in our study team, we considered a 10% mean difference in the change of percentile rank (PR) of BIAS to be a minimal and clinically important difference. The primary endpoint is defined as a significant difference in BIAS comparing the two groups. Differences in quality of life, Beck Depression Inventory (BDI), and modified Ranking Scale (mRS) will be evaluated as secondary outcome parameters. Discussion: This trial will determine whether speech therapy with the use of Neolexon® is superior to standard logopedic therapy. Subgroups with the greatest response to Neolexon® will be described. The trial was prospectively registered on the "EU Clinical Trials Register" (NCT04080817).

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.

Cerebral perfusion of the left reading network predicts recovery of reading in subacute to chronic stroke

Better understanding of cerebral blood flow (CBF) perfusion in stroke recovery can help inform decisions about optimal timing and targets of restorative treatments. In this study, we examined the relationship between cerebral perfusion and recovery from stroke‐induced reading deficits. Left stroke patients were tested with a noninvasive CBF measure (arterial spin labeling) <5 weeks post‐stroke, and a subset had follow up testing >3 months post‐stroke. We measured blood flow perfusion within the left and right sides of the brain, in areas surrounding the lesion, and areas belonging to the reading network. Two hypotheses were tested. The first was that recovery of reading function depends on increased perfusion around the stroke lesion. This hypothesis was not supported by our findings. The second hypothesis was that increased perfusion of intact areas within the reading circuit is tightly coupled with recovery. Our findings are consistent with this hypothesis. Specifically, higher perfusion in the left reading network measured during the subacute stroke period predicted better reading ability and phonology competence in the chronic period. In contrast, higher perfusion of the right homologous regions was associated with decreased reading accuracy and phonology competence in the subacute and chronic periods. These findings suggest that recovery of reading and language competence may rely on improved blood flow in the reading network of the language‐dominant hemisphere.

Benchmarks of Significant Change After Aphasia Rehabilitation

OBJECTIVE

To establish benchmarks of significant change for aphasia rehabilitation outcome measures (ie, Western Aphasia Battery-Aphasia Quotient [WAB-AQ], Communicative Effectiveness Index [CETI], Boston Naming Test [BNT]) and assess if those benchmarks significantly differ across subgroups (ie, time post onset, dose frequency, treatment type).

DATA SOURCES

A comprehensive literature search of 12 databases, reference lists of previous reviews, and evidence-based practice materials was conducted.

STUDY SELECTION

Randomized controlled trials, quasi-experimental studies, single-subject design, and case studies that used a standardized outcome measure to assess change were included. Titles and full-text articles were screened using a dual review process. Seventy-eight studies met criteria for inclusion.

DATA EXTRACTION

Data were extracted independently, and 25% of extractions were checked for reliability. All included studies were assigned quality indicator ratings and an evidence level.

DATA SYNTHESIS

Random-effects meta-analyses were conducted separately for each study design group (ie, within-/between-group comparisons). For within-group designs, the summary effect size after aphasia rehabilitation was 5.03 points (95% confidence interval, 3.95-6.10, P<.001) on the WAB-AQ, 10.37 points (6.08-14.66, P<.001) on the CETI, and 3.30 points (2.43-4.18, P<.001) on the BNT. For between-group designs, the summary effect size was 5.05 points (1.64-8.46, P=.004) on the WAB-AQ and 0.55 points (-1.33 to 2.43, P=.564) on the BNT, the latter of which was not significant. Subgroup analyses for the within-group designs showed no significant differences in the summary effect size as a function of dose frequency or treatment type.

CONCLUSIONS

This study established benchmarks of significant change on 3 standardized outcome measures used in aphasia rehabilitation.