Treatment and generalization of complex sentence production in agrammatism

Towards efficient, ecological assessment of interaction: A scoping review of co-constructed communication

BACKGROUND

The complexity of communication presents challenges for clinical assessment, outcome measurement and intervention for people with acquired brain injury. For the purposes of assessment or treatment, this complexity is usually managed by isolating specific linguistic functions or speech acts from the interactional context. Separating linguistic functions from their interactional context can lead to discourse being viewed as a static entity comprised of discrete features, rather than as a dynamic process of co-constructing meaning. The ecological validity of discourse assessments which rely on the deconstruction of linguistic functions is unclear. Previous studies have reported assessment tasks that preserve some of the dialogic features of communication, but as yet, these tasks have not been identified as a distinct genre of assessment. We suggest the term 'co-constructed communication' to describe tasks which are specifically designed to capture the dynamic, jointly produced nature of communication within a replicable assessment task.

AIMS

To identify and summarize how co-constructed communication has been assessed with individuals with non-progressive acquired communication disability regarding task design, measures and psychometric robustness.

METHODS

A scoping review methodology was used to identity relevant studies. Systematic database searches were conducted on studies published before July 2021. Studies in the yield were assessed against eligibility criteria, with 37 studies identified as eligible for inclusion.

MAIN CONTRIBUTION

This is the first time that co-constructed communication has been defined as a genre of discourse assessment for stroke and traumatic brain injury populations. Co-constructed communication has been assessed for 144 individuals with aphasia and 111 with cognitive-communication disability. Five categories of co-constructed communication tasks were identified, ranging in complexity. Variability exists in how these assessment tasks are labelled and measured. Assessment measures require further psychometric profiling, specifically regarding test-retest reliability and validity.

CONCLUSIONS

Co-constructed communication is a discourse genre which offers researchers and clinicians a replicable method to assess language and communication in an experimentally rigorous way, within an ecologically valid context, bridging the gap between experimental and ecological assessment approaches.

WHAT THIS PAPER ADDS

What is already known on this subject Standardized assessments of language skills and monologue offer reliable, replicable ways to measure language. However, isolating language from an interactional context fundamentally changes the behaviour under study. This raises questions about the ecological validity of the measures we routinely use to determine diagnoses, guide treatment planning and measure the success of treatment. What this study adds to the existing knowledge This review highlights studies that conceptualize, and often quantify, interaction by combining experimental rigour and aspects of everyday dialogue. This is the first time this genre of discourse assessment has been identified. We propose the term 'co-constructed communication' to describe this genre and provide an operational definition for the term. What are the practical and clinical implications of this study? Co-constructed communication assessment tasks require refinement, particularly regarding aspects of psychometric robustness. In the future, these tasks offer pragmatic, meaningful ways to capture the effect and impact of aphasia and cognitive-communication disability within interaction.

A scoping review of transcription-less practices for analysis of aphasic discourse and implications for future research

BACKGROUND

It is important to capture a comprehensive language profile from speakers with aphasia. One way to do this is to evaluate spoken discourse, which is language beyond a single simple clause used for a specific purpose. While the historical trend in aphasiology has been to capture performance during isolated language tasks, such as confrontation naming, there is a demonstrated need and benefit to collecting language information from tasks that resemble everyday communication. As a result, there has been an increase in discourse analysis research over time. However, despite clinicians' and researchers' desire to analyse spoken discourse, they are faced with critical barriers that inhibit implementation.

AIMS

To use scoping review methodology to identify transcription-less tools developed to analyse discourse from individuals with aphasia. The review addressed the following question: 'What transcription-less tools and analysis procedures are available to assess discourse in people with aphasia?' and included several sub-questions to further characterise the type of discourse and tool being used, participants on whom the tool was used to rate discourse abilities, tool users (raters), and psychometric properties.

METHODS

The scoping review was conducted between the months of October 2022 and January 2023, concluding 30 January 2023, on PubMed/NCBI, Academic Search Complete and Linguistics and Language Behavior Abstracts. Major inclusion parameters included peer-reviewed papers written in English; that the tool was used to analyse discourse elicited by individuals with acquired aphasia; and that the tool was not a part of a standardised battery or assessment. Perceptual discourse analysis was defined as any analysis which primarily relied on listener impressions and did not numerically quantify specific language behaviours. 'Transcription-less' analysis was defined as any discourse analysis which did not require a written record of the discourse sample in order to be completed. A total of 396 abstracts were screened and 39 full articles were reviewed, yielding 21 papers that were included in the review.

MAIN CONTRIBUTION

An overview of the state of transcription-less tools for aphasic discourse analysis is provided, and next steps are identified to facilitate increased implementation of discourse analysis in clinical and research settings.

CONCLUSION

Transcription-less tools have many benefits for analysing multiple levels (e.g., linguistic, propositional, macrostructural, pragmatic) of discourse, but require more research to establish sound psychometric properties and to explore the implementation of these tools in clinical settings.

WHAT THIS PAPER ADDS

What is already known on this subject Individuals with aphasia prioritise treatment outcomes at the discourse level such as being able to engage in conversations with friends and family about important topics and participating in social and leisure activities. However, discourse is rarely used as a treatment outcome measure in clinical practice due to multiple barriers. When speech-language pathologists do assess discourse, they often make perceptual judgements without transcribing the discourse sample. Transcription-less analysis procedures may improve clinical implementation of discourse assessment, which would better match treatment outcome measurement to clients' desired outcomes. However, little is known about the current state of transcription-less discourse analysis, blocking progress. What this paper adds to existing knowledge This study provides an overview of currently available transcription-less discourse analysis procedures that are not part of published standardised aphasia assessments. Transcription-less measures are available to evaluate discourse at all levels (i.e., lexical, propositional, macro-structural/planning, and pragmatic) and most measures include items that assess discourse abilities across multiple levels. Additionally, there are transcription-less measures available for both structured (e.g., picture scene description) and spontaneous (e.g., conversation) discourse tasks. However, current transcription-less procedures are lacking psychometric data including information about validity and reliability. What are the potential or actual clinical implications of this work? Transcription-less analysis methods may provide an avenue for increased implementation of discourse measurement into clinical practice. Further research is needed to determine the clinical utility of transcription-less discourse analysis to better monitor clients' desired treatment outcomes.

A Developmental Approach to Assessing and Treating Agrammatic Aphasia

PURPOSE

There is mounting evidence that the agrammatism that defines Broca's aphasia can be explained in processing terms. However, the extant approach simply describes agrammatism as disparate deficits in a static, mature system. This tutorial aims to motivate and outline a developmental alternative. This alternative is processability theory (PT), a root-to-apex theory of language development, with its origins in the field of second language acquisition, which can connect the findings of aphasia research.

METHOD

This tutorial critically reviews research on agrammatism as a language deficit, a representational deficit, and a processing phenomenon. Given evidence from research applying PT to language disorders, this tutorial outlines PT's multidimensional architecture of language processing. Using an emergence (onset) criterion, PT predicts fixed developmental stages in word order (syntax) and inflection (morphology) and individual differences in the timing of syntax and morphology. To link PT to agrammatism, this theory's applications to diagnosis and teaching are overviewed, and a case study of five individuals with moderate agrammatism is presented.

RESULTS

Analysis showed that all individuals were positioned in the early PT stages and differed in their timing of syntax and morphology consistent with theoretical predictions.

CONCLUSIONS

Evidence from the case study suggests that, although agrammatism results from neural damage and associated language loss, the processing procedures necessary for relearning remain and can be exploited for recovery. A program of diagnosis and intervention is proposed, and future research directions are discussed.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19416488.

Syntax Acquisition in Healthy Adults and Post-Stroke Individuals: The Intriguing Role of Grammatical Preference, Statistical Learning, and Education

Previous work has provided contrasting evidence on syntax acquisition. Syntax-internal factors, i.e., instinctive knowledge of the universals of grammar (UG) for finite-state grammar (FSG) and phrase-structure grammar (PSG) but also syntax-external factors such as language competence, working memory (WM) and demographic factors may affect syntax acquisition. This study employed an artificial grammar paradigm to identify which factors predicted syntax acquisition. Thirty-seven healthy individuals and forty-nine left-hemispheric stroke patients (fourteen with aphasia) read syllable sequences adhering to or violating FSG and PSG. They performed preference classifications followed by grammatical classifications (after training). Results showed the best classification accuracy for sequences adhering to UG, with performance predicted by syntactic competence and spatial WM. Classification of ungrammatical sequences improved after training and was predicted by verbal WM. Although accuracy on FSG was better than on PSG, generalization was fully possible only for PSG. Education was the best predictor of syntax acquisition, while aphasia and lesion volume were not predictors. This study shows a clear preference for UG, which is influenced by spatial and linguistic knowledge, but not by the presence of aphasia. Verbal WM supported the identification of rule violations. Moreover, the acquisition of FSG and PSG was related to partially different mechanisms, but both depended on education.

Complexity and feedback during script training in aphasia: A feasibility study

OBJECTIVE

To explore the impact of complexity and feedback on script training outcomes in aphasia DESIGN: Randomized balanced single-blind 2 × 2 factorial design SETTING: Freestanding urban rehabilitation hospital.

PARTICIPANTS

Adults with fluent and nonfluent aphasia (at least six months post-onset).

INTERVENTIONS

Experimental treatment was AphasiaScripts®, a computer-based script training program. Scripts were 10-turns long and developed at different complexity levels to allow for comparison of high versus low complexity. The program was modified to contrast high versus low feedback conditions during sentence practice. Participants were instructed to practice three 30-minute sessions per day, six days a week for three weeks.

MAIN MEASURES

Gains achieved from baseline in accuracy and rate of production of trained and untrained script sentences at post-treatment and at 3-, 6- and 12-weeks after the end of treatment.

RESULTS

Sixteen participants completed the intervention. On the trained script, gains were statistically significant for both accuracy and words per minute, at post-treatment and 3-, 6- and 12-week maintenance. Gains on the untrained script were smaller than on the trained script; they were statistically significant only for accuracy at post-treatment and 3-week maintenance. Complexity had an influence on accuracy at post-treatment (F(1) = 4.8391, p = 0.0501) and at maintenance (F(1) = 5.3391, p = 0.04125). Practicing scripts with high complexity increased accuracy by 11.33% at post-treatment and by 9.90% at maintenance compared to scripts with low complexity. Participants with nonfluent aphasia made greater gains than those with fluent aphasia. There was no significant effect of feedback.

CONCLUSION

This study reinforces script training as a treatment option for aphasia. Results highlight the use of more complex scripts to better promote acquisition and maintenance of script production skills. There is a need for further investigation of these variables with larger samples and with other types of aphasia treatments.

CLINICALTRIALS

gov identifier: NCT01597037.

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.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb and Sentence Deficits in Aphasia: Sentence Treatments

PURPOSE

This review article synthesizes and evaluates the evidence for sentence production treatments in aphasia, systematically charting impairment-based and functional communication outcomes. It reports (a) the level of evidence and fidelity of sentence treatments; (b) the impact of treatment on production of trained and untrained verbs and sentences, functional communication, and discourse; and (c) the potential active ingredients of treatment.

METHOD

The search included studies from January 1980 to June 2019. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to treatment methods used.

RESULTS

Thirty-three studies were accepted into the review and predominantly constituted Level 4 evidence (e.g., case control studies and case series). Thirty studies (90%) described treatment in sufficient detail to allow replication, but dosage was poorly reported, and fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were mapping (10 studies: 30%), predicate argument structure treatment (six studies: 18%), and verb network strengthening treatment (five studies: 15%). Production of trained sentences improved for 83% of participants, and improvements generalized to untrained sentences for 59% of participants. Functional communication was rarely assessed, but discourse production improved for 70% of participants.

CONCLUSIONS

The evidence for sentence treatments is predominantly generated from Level 4 studies. Treatments were effective for the majority of participants regarding trained sentence and discourse production. However, there is inconsistent use of statistical analysis to verify improvements, and diverse outcome measures are used, which makes interpretation of the evidence difficult. The quality of sentence treatment research would be improved by agreeing a core set of outcome measures and extended by ascertaining the views of participants on sentence treatments.

A Randomized Controlled Trial of the Effects of Group Conversation Treatment on Monologic Discourse in Aphasia

PURPOSE

Evidence has shown that group conversation treatment may improve communication and reduce social isolation for people with aphasia. However, little is known about the impact of conversation group treatment on measures of discourse. This project explored the impact of conversation treatment on measures of monologic discourse.

METHOD

In this randomized controlled trial, 48 participants with chronic aphasia were randomly assigned to dyadic, large group, or control conditions. Conversation group treatment was provided for 1 hr, twice per week, for 10 weeks. Discourse samples were collected and coded at pretreatment, posttreatment, and 6-week maintenance. There were three narrative tasks: (a) Comprehensive Aphasia Test (CAT) picture description, (b) Cat Rescue Picture, and (c) Cinderella retell. All narratives were coded using the percent correct information units (percent CIUs), the CAT standardized narrative analysis method, and the complete utterance (CU) method.

RESULTS

No significant changes were observed on percent CIU, which was the primary outcome measure. The treated groups demonstrated improvement on aspects of the CU method following treatment, whereas the control group did not. Significant changes were observed for other CIU measures and the CAT standardized narrative analysis in both the treated and control groups.

CONCLUSIONS

The results suggest that the CU measures were more sensitive to the effects of conversation treatment in monologic discourse compared to CIU and CAT measures. Changes were more common in absolute rather than relative values, suggesting that conversation treatment impacts the overall amount of language produced rather than efficiency of production.

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

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

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.

German Language Adaptation of the NAVS (NAVS-G) and of the NAT (NAT-G): Testing Grammar in Aphasia

Grammar provides the framework for understanding and producing language. In aphasia, an acquired language disorder, grammatical deficits are diversified and widespread. However, the few assessments for testing grammar in the German language do not consider current linguistic, psycholinguistic, and functional imaging data, which have been shown to be crucial for effective treatment. This study developed German language versions of the Northwestern Assessment of Verbs and Sentences (NAVS-G) and the Northwestern Anagram Test (NAT-G) to examine comprehension and production of verbs, controlling for the number and optionality of verb arguments, and sentences with increasing syntactic complexity. The NAVS-G and NAT-G were tested in 27 healthy participants, 15 right hemispheric stroke patients without aphasia, and 15 stroke patients with mild to residual aphasia. Participants without aphasia showed near-perfect performance, with the exception of (object) relative sentences, where accuracy was associated with educational level. In each patient with aphasia, deficits in more than one subtest were observed. The within and between population-groups logistic mixed regression analyses identified significant impairments in processing syntactic complexity at the verb and sentence levels. These findings indicate that the NAVS-G and NAT-G have potential for testing grammatical competence in (German) stroke patients.

An Efficient Bedside Measure Yields Prognostic Implications for Language Recovery in Acute Stroke Patients

BACKGROUND

It is estimated that ∼30% of stroke survivors have aphasia, a language disorder resulting from damage to left-hemisphere language networks. In acute care settings, efficient identification of aphasia is critical, but there is a paucity of efficient bedside assessments.

OBJECTIVE

To determine whether objective measures on a picture description task administered within 48 hours post stroke (a) predict language recovery, (b) estimate left-hemisphere lesion volume and location, and (c) correlate with other bedside language assessments.

METHOD

Behavioral data were scored at acute and chronic time points. Neuroimaging data were used to determine associations between the picture description task, other language assessments, and lesion volume and location.

RESULTS

Acute content units, age, and total lesion volume predicted communication recovery; F3,18 = 3.98, P = 0.024; r = 0.40. Significant correlations were found between the picture description task and lesion volume and location. Picture description outcomes were also associated with other clinical language assessments.

DISCUSSION

This picture description task quickly predicted the language performance (communication recovery and outcome) for patients who suffered a left-hemisphere stroke. Picture description task measures correlated with damage in the left hemisphere and with other, more time-consuming and cumbersome language assessments that are typically administered acutely at bedside.

CONCLUSION

The predictive value of this picture description task and correlations with existing language assessments substantiate the clinical importance of a reliable yet rapid bedside measure for acute stroke patients that can be administered by a variety of health care professionals.

Automation of the Northwestern Narrative Language Analysis System

Purpose Analysis of spontaneous speech samples is important for determining patterns of language production in people with aphasia. To accomplish this, researchers and clinicians can use either hand coding or computer-automated methods. In a comparison of the two methods using the hand-coding NNLA (Northwestern Narrative Language Analysis) and automatic transcript analysis by CLAN (Computerized Language Analysis), Hsu and Thompson (2018) found good agreement for 32 of 51 linguistic variables. The comparison showed little difference between the two methods for coding most general (i.e., utterance length, rate of speech production), lexical, and morphological measures. However, the NNLA system coded grammatical measures (i.e., sentence and verb argument structure) that CLAN did not. Because of the importance of quantifying these aspects of language, the current study sought to implement a new, single, composite CLAN command for the full set of 51 NNLA codes and to evaluate its reliability for coding aphasic language samples. Method Eighteen manually coded NNLA transcripts from eight people with aphasia and 10 controls were converted into CHAT (Codes for the Human Analysis of Talk) files for compatibility with CLAN commands. Rules from the NNLA manual were translated into programmed rules for CLAN computation of lexical, morphological, utterance-level, sentence-level, and verb argument structure measures. Results The new C-NNLA (CLAN command to compute the full set of NNLA measures) program automatically computes 50 of the 51 NNLA measures and generates the results in a summary spreadsheet. The only measure it does not compute is the number of verb particles. Statistical tests revealed no significant difference between C-NNLA results and those generated by manual coding for 44 of the 50 measures. C-NNLA results were not comparable to manual coding for the six verb argument measures. Conclusion Clinicians and researchers can use the automatic C-NNLA to analyze important variables required for quantification of grammatical deficits in aphasia in a way that is fast, replicable, and accessible without extensive linguistic knowledge and training.

Neurocognitive Recovery of Sentence Processing in Aphasia

Purpose Reorganization of language networks in aphasia takes advantage of the facts that (a) the brain is an organ of plasticity, with neuronal changes occurring throughout the life span, including following brain damage; (b) plasticity is highly experience dependent; and (c) as with any learning system, language reorganization involves a synergistic interplay between organism-intrinsic (i.e., cognitive and brain) and organism-extrinsic (i.e., environmental) variables. A major goal for clinical treatment of aphasia is to be able to prescribe treatment and predict its outcome based on the neurocognitive deficit profiles of individual patients. This review article summarizes the results of research examining the neurocognitive effects of psycholinguistically based treatment (i.e., Treatment of Underlying Forms; Thompson & Shapiro, 2005) for sentence processing impairments in individuals with chronic agrammatic aphasia resulting from stroke and primary progressive aphasia and addresses both behavioral and brain variables related to successful treatment outcomes. The influences of lesion volume and location, perfusion (blood flow), and resting-state neural activity on language recovery are also discussed as related to recovery of agrammatism and other language impairments. Based on these and other data, principles for promoting neuroplasticity of language networks are presented. Conclusions Sentence processing treatment results in improved comprehension and production of complex syntactic structures in chronic agrammatism and generalization to less complex, linguistically related structures in chronic agrammatism. Patients also show treatment-induced shifts toward normal-like online sentence processing routines (based on eye movement data) and changes in neural recruitment patterns (based on functional neuroimaging), with posttreatment activation of regions overlapping with those within sentence processing and dorsal attention networks engaged by neurotypical adults performing the same task. These findings provide compelling evidence that treatment focused on principles of neuroplasticity promotes neurocognitive recovery in chronic agrammatic aphasia. Presentation Videohttps://doi.org/10.23641/asha.10257587.

The relationship between trained ratings and untrained listeners' judgments of global coherence in extended monologues

BACKGROUND

Global coherence rating scales have been used by a number of researchers to examine spoken discourse in populations with and without acquired neurogenic communication disorders. The 4-point global coherence (GC) scale in the current study has demonstrated reliability and convergent validity. However, we have not yet established how a global coherence rating corresponds to functional communication.

AIMS

The current study explores the clinical meaningfulness of the 4-point GC rating scale. Survey questions and ratings were developed to examine discourse quality and functional coherence as perceived by untrained listeners. Ratings by untrained listeners were compared to trained discourse ratings using the established 4-point GC scale.

METHODS

Twelve discourse samples, scored by a trained rater, were selected for the current study from a previously collected set of discourse transcripts. Transcripts were extended monologues in response to one of four possible open-ended questions that were re-recorded by the trained rater to remove any distracting features of the original recordings, such as articulatory errors. Twenty-four untrained listeners rated the discourse samples using a short questionnaire that included questions for each sample about: topic maintenance, inclusion of unnecessary information, and the listener level of interest and attention. Questions for untrained listeners were based on operational definitions of global coherence and discourse quality respectively. These untrained ratings were compared to trained ratings of global coherence. Outcome measures were compared using non-parametric tests and a Spearman Rank Order test was also used to examine relationships among variables.

OUTCOMES AND RESULTS

Untrained listeners' ratings for topic maintenance and inclusion of unnecessary information were significantly different between trained low, medium, and high global coherence ratings. Topic maintenance and inclusion of unnecessary information were also both significantly correlated with global coherence. Untrained listeners' ratings of their level of interest and attention for a sample were significantly different between trained medium-high and low-high global coherence ratings. Interest and attention ratings were also significantly correlated with ratings of global coherence.

CONCLUSIONS

Untrained raters did differentiate between levels of global coherence using ratings of topic maintenance, inclusion of unnecessary information, and their level of attention and interest. Global coherence was also significantly correlated with the untrained ratings. These findings provide preliminary external validity for the global coherence scale and support its clinical utility.

Recovery of offline and online sentence processing in aphasia: Language and domain-general network neuroplasticity

This paper examined the effects of treatment on both offline and online sentence processing and associated neuroplasticity within sentence processing and dorsal attention networks in chronic stroke-induced agrammatic aphasia. Twenty-three neurotypical adults and 19 individuals with aphasia served as participants. Aphasic individuals were randomly assigned to receive a 12-week course of linguistically-based treatment of passive sentence production and comprehension (N = 14, treatment group) or to serve as control participants (N = 5, natural history group). Both aphasic groups performed two offline tasks at baseline and three months following (at post-testing) to assess production and comprehension of trained passive structures and untrained syntactically related and unrelated structures. The aphasic participants and a healthy age-matched group also performed an online eyetracking comprehension task and a picture-verification fMRI task, which were repeated at post-testing for the aphasic groups. Results showed that individuals in the treatment, but not in the natural history, group improved on production and comprehension of both trained structures and untrained syntactically related structures. Treatment also resulted in a shift toward more normal-like eye movements and a significant increase in neural activation from baseline to post-testing. Upregulation encompassed right hemisphere regions homologs of left hemisphere regions involved in both sentence processing and domain-general functions and was positively correlated with treatment gains, as measured by offline comprehension accuracy, and with changes in processing strategies during sentence comprehension, as measured by eyetracking. These findings provide compelling evidence in favor of the contribution of both networks within the right hemisphere to the restoration of normal-like sentence processing patterns in chronic aphasia.

Manual Versus Automated Narrative Analysis of Agrammatic Production Patterns: The Northwestern Narrative Language Analysis and Computerized Language Analysis

Purpose

The purpose of this study is to compare the outcomes of the manually coded Northwestern Narrative Language Analysis (NNLA) system, which was developed for characterizing agrammatic production patterns, and the automated Computerized Language Analysis (CLAN) system, which has recently been adopted to analyze speech samples of individuals with aphasia (a) for reliability purposes to ascertain whether they yield similar results and (b) to evaluate CLAN for its ability to automatically identify language variables important for detailing agrammatic production patterns.

Method

The same set of Cinderella narrative samples from 8 participants with a clinical diagnosis of agrammatic aphasia and 10 cognitively healthy control participants were transcribed and coded using NNLA and CLAN. Both coding systems were utilized to quantify and characterize speech production patterns across several microsyntactic levels: utterance, sentence, lexical, morphological, and verb argument structure levels. Agreement between the 2 coding systems was computed for variables coded by both.

Results

Comparison of the 2 systems revealed high agreement for most, but not all, lexical-level and morphological-level variables. However, NNLA elucidated utterance-level, sentence-level, and verb argument structure-level impairments, important for assessment and treatment of agrammatism, which are not automatically coded by CLAN.

Conclusions

CLAN automatically and reliably codes most lexical and morphological variables but does not automatically quantify variables important for detailing production deficits in agrammatic aphasia, although conventions for manually coding some of these variables in Codes for the Human Analysis of Transcripts are possible. Suggestions for combining automated programs and manual coding to capture these variables or revising CLAN to automate coding of these variables are discussed.

Reviewing the quality of discourse information measures in aphasia

BACKGROUND

Discourse is fundamental to everyday communication, and is an increasing focus of clinical assessment, intervention and research. Aphasia can affect the information a speaker communicates in discourse. Little is known about the psychometrics of the tools for measuring information in discourse, which means it is unclear whether these measures are of sufficient quality to be used as clinical outcome measures or diagnostic tools.

AIMS

To profile the measures used to describe information in aphasic discourse, and to assess the quality of these measures against standard psychometric criteria.

METHODS & PROCEDURES

A scoping review method was employed. Studies were identified using a systematic search of Scopus, Medline and Embase databases. Standard psychometric criteria were used to evaluate the measures' psychometric properties.

MAIN CONTRIBUTION

The current review summarizes and collates the information measures used to describe aphasic discourse, and evaluates their quality in terms of the psychometric properties of acceptability, reliability and validity. Seventy-six studies described 58 discourse information measures, with a mean of 2.28 measures used per study (SD = 1.29, range = 1-7). Measures were classified as 'functional' measures (n = 33), which focused on discourse macrostructure, and 'functional and structural' measures (n = 25), which focused on micro-linguistic and macro-structural approaches to discourse. There were no reports of the acceptability of data generated by the measures (distribution of scores, missing data). Test-retest reliability was reported for just 8/58 measures with 3/8 > 0.80. Intra-rater reliability was reported for 9/58 measures and in all cases percentage agreement was reported rather than reliability. Per cent agreement was also frequently reported for inter-rater reliability, with only 4/76 studies reporting reliability statistics for 12/58 measures; this was generally high (>.80 for 11/12 measures). The majority of measures related clearly to the discourse production model indicating content validity. A total of 36/58 measures were used to make 41 comparisons between participants with aphasia (PWA) and neurologically healthy participants (NHP), with 31/41 comparisons showing a difference between the groups. Four comparisons were made between discourse genres, with two measures showing a difference between genres, and two measures showing no difference.

CONCLUSIONS

There is currently insufficient information available to justify the use of discourse information measures as sole diagnostic or outcome measurement tools. Yet the majority of measures are rooted in relevant theory, and there is emerging evidence regarding their psychometric properties. There is significant scope for further psychometric strengthening of discourse information measurement tools.

Evaluating Treatment and Generalization Patterns of Two Theoretically Motivated Sentence Comprehension Therapies

Purpose

The current study examined treatment outcomes and generalization patterns following 2 sentence comprehension therapies: object manipulation (OM) and sentence-to-picture matching (SPM). Findings were interpreted within the framework of specific deficit and resource reduction accounts, which were extended in order to examine the nature of generalization following treatment of sentence comprehension deficits in aphasia.

Method

Forty-eight individuals with aphasia were enrolled in 1 of 8 potential treatment assignments that varied by task (OM, SPM), complexity of trained sentences (complex, simple), and syntactic movement (noun phrase, wh-movement). Comprehension of trained and untrained sentences was probed before and after treatment using stimuli that differed from the treatment stimuli.

Results

Linear mixed-model analyses demonstrated that, although both OM and SPM treatments were effective, OM resulted in greater improvement than SPM. Analyses of covariance revealed main effects of complexity in generalization; generalization from complex to simple linguistically related sentences was observed both across task and across movement.

Conclusions

Results are consistent with the complexity account of treatment efficacy, as generalization effects were consistently observed from complex to simpler structures. Furthermore, results provide support for resource reduction accounts that suggest that generalization can extend across linguistic boundaries, such as across movement type.

Do age-related word retrieval difficulties appear (or disappear) in connected speech?

We conducted a comprehensive literature review of studies of word retrieval in connected speech in healthy aging and reviewed relevant aphasia research that could shed light on the aging literature. Four main hypotheses guided the review: (1) Significant retrieval difficulties would lead to reduced output in connected speech. (2) Significant retrieval difficulties would lead to a more limited lexical variety in connected speech. (3) Significant retrieval difficulties would lead to an increase in word substitution errors and in pronoun use as well as to greater dysfluency and hesitation in connected speech. (4) Retrieval difficulties on tests of single-word production would be associated with measures of word retrieval in connected speech. Studies on aging did not confirm these four hypotheses, unlike studies on aphasia that generally did. The review suggests that future research should investigate how context facilitates word production in old age.

Linguistic analysis of discourse in aphasia: A review of the literature

This review examined previous research applications of linguistic discourse analysis to assess the language of adults with aphasia. A comprehensive literature search of seven databases identified 165 studies that applied linguistic measures to samples of discourse collected from people with aphasia. Analysis of methodological applications revealed an increase in published research using linguistic discourse analysis over the past 40 years, particularly to measure the generalisation of therapy outcomes to language in use. Narrative language samples were most frequently subject to analysis though all language genres were observed across included studies. A total of 536 different linguistic measures were applied to examine language behaviours. Growth in the research use of linguistic discourse analysis and suggestions that this growth may be reflected in clinical practice requires further investigation. Future research directions are discussed to investigate clinical use of discourse analysis and examine the differences that exist between research and clinical practice.

Contextual Constraint Treatment for coarse coding deficit in adults with right hemisphere brain damage: generalisation to narrative discourse comprehension

Coarse coding is the activation of broad semantic fields that can include multiple word meanings and a variety of features, including those peripheral to a word's core meaning. It is a partially domain-general process related to general discourse comprehension and contributes to both literal and non-literal language processing. Adults with damage to the right cerebral hemisphere (RHD) and a coarse coding deficit are particularly slow to activate features of words that are relatively distant or peripheral. This manuscript reports a pre-efficacy study of Contextual Constraint Treatment (CCT), a novel, implicit treatment designed to increase the efficiency of coarse coding with the goal of improving narrative comprehension and other language performance that relies on coarse coding. Participants were four adults with RHD. The study used a single-subject controlled experimental design across subjects and behaviours. The treatment involved pre-stimulation, using a hierarchy of strong and moderately biased contexts, to prime the intended distantly related features of critical stimulus words. Three of the four participants exhibited gains in auditory narrative discourse comprehension, the primary outcome measure. All participants exhibited generalisation to untreated items. No strong generalisation to processing non-literal language was evident. The results indicate that CCT yields both improved efficiency of the coarse coding process and generalisation to narrative comprehension.

Delayed Stimulus-Specific Improvements in Discourse Following Anomia Treatment Using an Intentional Gesture

Purpose: In this study, the authors assessed how the addition of intentional left-hand gestures to an intensive treatment for anomia affects 2 types of discourse: picture description and responses to open-ended questions.Method: Fourteen people with aphasia completed treatment for anomia comprising 30 treatment sessions over 3 weeks.Seven subjects also incorporated intentional left-hand gestures into each treatment trial.Results: Both groups demonstrated significant changes in trained items and improved naming of untrained items but no change in Western Aphasia Battery—Aphasia Quotient(WAB–AQ; Kertesz, 1982) scores. Changes in discourse were limited to the 3-month follow-up assessment. Several discourse measures showed significant improvements in the picture description task and declines during question responses. Additionally, the gesture group produced more words at each assessment, whereas the no gesture group produced fewer words at each assessment. These patterns led to improvements in picture descriptions and minimal declines in question responses in the gesture group. In contrast, the no gesture group showed minimal improvements in picture descriptions and production declines in question responses relative to pretreatment levels.Conclusion: The intensive treatment protocol is a successful method for improving picture naming even of untrained items.Further, the authors conclude that the intentional left-hand gesture contributed significantly to the generalization of treatment to discourse.

Rehabilitation of language in expressive aphasias: a literature review

Objective

This paper reviews the methodological characteristics of studies on rehabilitation of expressive aphasia, describing the techniques of rehabilitation used.

Methods

The databases Medline, Science Direct and PubMed were searched for relevant articles (January 1999 to December 2011) using the keywords Expressive / Broca / Nonfluent Aphasia, combined with Language or Speech Rehabilitation / Therapy / Intervention.

Results

A total of 56 articles were retrieved describing rehabilitation techniques, including 22 with a focus on lexical processing, 18 on syntax stimulation, seven with the aim of developing speech and nine with multiple foci.

Conclusion

A variety of techniques and theoretical approaches are available, highlighting the heterogeneity of research in this area. This diversity can be justified by the uniqueness of patients' language deficits, making it difficult to generalize. In addition, there is a need to combine the formal measures of tests with measures of pragmatic and social skills of communication to determine the effect of rehabilitation on the patient's daily life.

Verb and sentence production and comprehension in aphasia: Northwestern Assessment of Verbs and Sentences (NAVS)

BACKGROUND

Verbs and sentences are often impaired in individuals with aphasia, and differential impairment patterns are associated with different types of aphasia. With currently available test batteries, however, it is challenging to provide a comprehensive profile of aphasic language impairments because they do not examine syntactically important properties of verbs and sentences.

AIMS

This study presents data derived from the Northwestern Assessment of Verbs and Sentences (NAVS; Thompson, 2011), a new test battery designed to examine syntactic deficits in aphasia. The NAVS includes tests for verb naming and comprehension, and production of verb argument structure in simple active sentences, with each examining the effects of the number and optionality of arguments. The NAVS also tests production and comprehension of canonical and non-canonical sentences.

METHODS & PROCEDURES

A total of 59 aphasic participants (35 agrammatic and 24 anomic) were tested using a set of action pictures. Participants produced verbs or sentences for the production subtests and identified pictures corresponding to auditorily provided verbs or sentences for the comprehension subtests.

OUTCOMES & RESULTS

The agrammatic group, compared to the anomic group, performed significantly more poorly on all subtests except verb comprehension, and for both groups comprehension was less impaired than production. On verb naming and argument structure production tests both groups exhibited difficulty with three-argument verbs, affected by the number and optionality of arguments. However, production of sentences using three-argument verbs was more impaired in the agrammatic, compared to the anomic, group. On sentence production and comprehension tests, the agrammatic group showed impairments in all types of non-canonical sentences, whereas the anomic group exhibited difficulty primarily with the most difficult, object relative, structures.

CONCLUSIONS

Results show that verb and sentence deficits seen in individuals with agrammatic aphasia are largely influenced by syntactic complexity; however, individuals with anomic aphasia appear to exhibit these impairments only for the most complex forms of verbs and sentences. The present data indicate that the NAVS is useful for characterising verb and sentence deficits in people with aphasia.

Lexical diversity for adults with and without aphasia across discourse elicitation tasks

BACKGROUND: Differences in lexical diversity (LD) across different discourse elicitation tasks have been found in neurologically intact adults (NIA) (Fergadiotis, Wright, & Capilouto, 2010) but have not been investigated systematically in people with aphasia (PWA). Measuring lexical diversity in PWA may serve as a useful clinical tool for evaluating the impact of word retrieval difficulties at the discourse level. AIMS: The study aims were (a) to explore the differences between the oral language samples of PWA and NIA in terms of LD as measured by dedicated computer software (voc-D), (b) to determine whether PWA are sensitive to discourse elicitation task in terms of LD, and (c) to identify whether differences between PWA and NIA vary in magnitude as a function of discourse task. METHOD #ENTITYSTARTX00026; PROCEDURES: Oral language samples from 25 PWA and 27 NIA were analysed. Participants completed three commonly used discourse elicitation tasks (single pictures, sequential pictures, story telling) and voc-D was used to obtain estimates of their LD. OUTCOMES #ENTITYSTARTX00026; RESULTS: A mixed 2 × 3 ANOVA revealed a significant group task interaction that was followed by an investigation of simple main effects and tetrad×comparisons. Different patterns of LD were uncovered for each group. For the NIA group results were consistent with previous findings in the literature according to which LD varies as a function of elicitation technique. However, for PWA sequential pictures and story telling elicited comparable estimates of LD. CONCLUSIONS: Results indicated that LD is one of the microlinguistic indices that are influenced by elicitation task and the presence of aphasia. These findings have important implications for modelling lexical diversity and selecting and interpreting results from different discourse elicitation tasks.

Sentactics®: Computer-Automated Treatment of Underlying Forms

BACKGROUND: Treatment of Underlying Forms (TUF) is a linguistically-based treatment for improving agrammatic sentence deficits, which enjoys a substantial database attesting to its efficacy for improving both sentence comprehension and production in agrammatic aphasia. However, TUF requires considerable linguistic background to administer and administration time can exceed the number of treatment sessions allotted in toto for reimbursement by third party payors in the United States. Thus, Sentactics®, an interactive computer system that enables delivery of TUF by a virtual clinician was developed. AIMS: This study tested the effects of Sentactics® on the acquisition and generalized production and comprehension of complex sentences. Additionally, a direct comparison of the results of computer-delivered Sentactics® and clinician-delivered TUF was undertaken. METHODS #ENTITYSTARTX00026; PROCEDURES: Twelve agrammatic aphasic speakers participated in the study, with six receiving Sentactics® and six serving as experimental controls, who received no treatment. All participants were administered pre- and post-treatment sentence comprehension and production tests and other measures to evaluate the effects of Sentactics®. Performance of the Sentactics® group also was compared to eight agrammatic patients who previously received clinician-delivered TUF treatment, identical to that delivered via Sentactics®, but with a human clinician. OUTCOMES #ENTITYSTARTX00026; RESULTS: Sentactics® significantly improved all six aphasic speakers' ability to comprehend and produce both trained and untrained, linguistically related, complex sentences as compared to six agrammatic control participants who did not receive Sentactics®. In addition, comparing the results of the Sentactics® to clinician-delivered TUF revealed no significant differences between approaches with regard to acquisition or generalization patterns. CONCLUSIONS: These data provide further support for the efficacy of TUF and demonstrate the viability of computer-delivered therapies in the field of aphasia treatment.

Neural plasticity and treatment-induced recovery of sentence processing in agrammatism

This study examined patterns of neural activation associated with treatment-induced improvement of complex sentence production (and comprehension) in six individuals with stroke-induced agrammatic aphasia, taking into account possible alterations in blood flow often associated with stroke, including delayed time-to-peak of the hemodynamic response function (HRF) and hypoperfused tissue. Aphasic participants performed an auditory verification fMRI task, processing object cleft, subject cleft, and simple active sentences, prior to and following a course of Treatment of Underlying Forms (TUF; Thompson et al., 2003), a linguistically based approach for treating aphasic sentence deficits, which targeted object relative clause constructions. The patients also were scanned in a long-trials task to examine HRFs, to account for any local deviations resulting from stroke, and perfusion images were obtained to evaluate regions of hypoperfused tissue. Region-of-interest (ROI) analyses were conducted (bilaterally), modeling participant-specific local HRFs in left hemisphere areas activated by 12 healthy age-matched volunteers performing the same task, including the middle and inferior frontal gyri, precentral gyrus, middle and superior temporal gyri, and insula, and additional regions associated with complex syntactic processing, including the posterior perisylvian and superior parietal cortices. Results showed that, despite individual variation in activation differences from pre- to post-treatment scans in the aphasic participants, main-effects analyses revealed a general shift from left superior temporal activation to more posterior temporoparietal areas, bilaterally. Time-to-peak of these responses correlated negatively with blood flow, as measured with perfusion imaging.

Principles of motor learning in treatment of motor speech disorders

PURPOSE

There has been renewed interest on the part of speech-language pathologists to understand how the motor system learns and determine whether principles of motor learning, derived from studies of nonspeech motor skills, apply to treatment of motor speech disorders. The purpose of this tutorial is to introduce principles that enhance motor learning for nonspeech motor skills and to examine the extent to which these principles apply in treatment of motor speech disorders.

METHOD

This tutorial critically reviews various principles in the context of nonspeech motor learning by reviewing selected literature from the major journals in motor learning. The potential application of these principles to speech motor learning is then discussed by reviewing relevant literature on treatment of speech disorders. Specific attention is paid to how these principles may be incorporated into treatment for motor speech disorders.

CONCLUSIONS

Evidence from nonspeech motor learning suggests that various principles may interact with each other and differentially affect diverse aspects of movements. Whereas few studies have directly examined these principles in speech motor (re)learning, available evidence suggests that these principles hold promise for treatment of motor speech disorders. Further research is necessary to determine which principles apply to speech motor (re)learning in impaired populations.

Unambiguous generalization effects after treatment of non-canonical sentence production in German agrammatism

Agrammatism is-among others, characterized by a deficit in producing grammatical structures. Of specific difficulty is the utilization of complex, non-canonical sentence structures (e.g. object-questions, passives, object-clefts). Several studies have documented positive effects when applying a specific treatment protocol in terms of increasingly correct production of target complex sentence structures with some variance in generalization patterns noted across individuals. The objective of this intervention study was to evaluate an intervention program focussing on the production of non-canonical sentences. Hypotheses about the occurrence of treatment effects were formulated on the basis of syntactic complexity, referring to the amount of syntactic phrase structures necessary to generate specific German sentence structures. A multiple single case study with seven agrammatic participants was applied, each participant receiving training in the production of object-relative-clauses and who-questions. The investigation was designed to unambiguously evaluate for each individual, structure specific and generalized learning effects with respect to the production of object-relative-clauses, who-questions and passive sentences. Results showed significant improvements for all sentences types. This outcome is considered within methodological issues of treatment studies. Theoretical and clinical implications are discussed.

The relation between syntactic and morphological recovery in agrammatic aphasia: A case study

BACKGROUND: Production of grammatical morphology is typically impaired in agrammatic aphasic individuals, as is their capacity to produce the syntactic structure responsible for licensing that morphology. Whether these two impairments are causally related has been an issue of long-standing debate. If morphological deficits are a side-effect of underlying syntactic ones, as has been claimed (Friedmann & Grodzinsky, 1997; Izvorski & Ullman, 1999), therapy which improves the syntactic deficit should remediate the morphological deficit as well. This paper reports a case study of one individual with such co-occurring impairments and describes their recovery in response to linguistically-motivated treatment targeting his syntactic deficits. METHODS #ENTITYSTARTX00026; PROCEDURES: MD is a 56 year-old male diagnosed with non-fluent Broca's aphasia subsequent to a left-hemisphere CVA, with limited capacity to produce syntactically complex utterances and grammatical morphology. He was enrolled in therapy using Treatment of Underlying Forms (TUF; Thompson & Shapiro, 2005), targeting production of sentences involving Wh-movement (object relative clauses). MD participated in twice-weekly treatment sessions for approximately two months, with daily probes assessing his production of treated and untreated sentence types. In addition, probes assessing his grammatical morphology and sentence production were administered pre- and post-treatment. OUTCOMES #ENTITYSTARTX00026; RESULTS: Pre-treatment scores in tests of grammatical morphology and sentence production indicated deficits in both domains. During treatment, MD successfully acquired production of a variety of sentence with Wh-movement, though this did not generalize to sentences involving a grammatically distinct movement operation (NP-movement). Post-treatment scores also indicated a lack of improvement in production of grammatical morphology. CONCLUSIONS: The dissociation between MD's morphological and syntactic recovery indicates that the recovery of syntactic and morphological processes in aphasia may occur independently. This result is thus surprising under approaches in which morphological and syntactic impairments are strongly and causally related in aphasia, such as the Tree-Pruning Hypothesis (Friedmann, 2001; Friedmann & Grodzinsky, 1997). Further, these results reinforce the conclusion that aphasia treatment can lead to generalization, but only to linguistic material which is in a subset relation to trained structures (Thompson, Shapiro, Kiran & Sobecks, 2003).

Mapping therapy for sentence production impairments in nonfluent aphasia

This study investigated a new treatment in which sentence production abilities were trained in a small group of individuals and nonfluent aphasia. It was based upon a mapping therapy approach which holds that sentence production and comprehension impairments are due to difficulties in mapping between the meaning form (thematic roles) and the syntactic form of sentences. We trained production of both canonical and noncanonical reversible sentences. Three patients received treatment and two served as control participants. Patients who received treatment demonstrated acquisition of all trained sentence structures. They also demonstrated across-task generalisation of treated and some untreated sentence structures on two tasks of constrained sentence production, and showed some improvements on a narrative task. One control participant improved on some of these measures and the other did not. There was no noted improvement in sentence comprehension abilities following treatment. Results are discussed with reference to the heterogeneity of underlying impairments in sentence production impairments in nonfluent patients, and the possible mechanisms by which improvement in sentence production might have been achieved in treatment.

Complexity in treatment of syntactic deficits

PURPOSE

This article addresses complexity in the context of treatment for sentence structural impairments in agrammatic aphasia, with emphasis on noncanonical sentences involving linguistic movement and their related counterparts. Extensions of the complexity effect to recovery of canonical sentences also are discussed, stressing the linguistic properties of verbs as well as grammatical morphology in building complexity hierarchies.

METHOD

A number of variables to consider in developing complexity hierarchies in the syntactic domain are addressed, and a series of studies using single-subject controlled experimental analysis are discussed.

RESULTS

Findings across studies show that training complex sentences results in improvement of simpler structures when, and only when, the underlying linguistic properties are shared by both. The opposite approach, training simple structures first and building to more complex ones, does not provide the full benefit of treatment, in that little or no generalization occurs across structures.

CONCLUSION

Using complex language material as a starting point for treatment of sentence structural deficits in aphasia results in cascading generalization to simpler, linguistically related material and expands spontaneous language production in many language-disordered adults with aphasia. Clinicians are, therefore, urged to adopt this approach in clinical practice, even though it is counterintuitive and departs significantly from conventional treatment methods.

Informativeness ratings of messages created on an AAC processing prosthesis

BACKGROUND: SentenceShaper() (SSR) is a computer program that supports spoken language production in aphasia by recording and storing the fragments that the user speaks into the microphone, making them available for playback and allowing them to be combined and integrated into larger structures (i.e., sentences and narratives). A prior study that measured utterance length and grammatical complexity in story-plot narratives produced with and without the aid of SentenceShaper demonstrated an "aided effect" in some speakers with aphasia, meaning an advantage for the narratives that were produced with the support of this communication aid (Linebarger, Schwartz, Romania, Kohn, & Stephens, 2000). The present study deviated from Linebarger et al.'s methods in key respects and again showed aided effects of SentenceShaper in persons with aphasia. AIMS: Aims were (1) to demonstrate aided effects in "functional narratives" conveying hypothetical real-life situations from a first person perspective; (2) for the first time, to submit aided and spontaneous speech samples to listener judgements of informativeness; and (3) to produce preliminary evidence on topic-specific carryover from SentenceShaper, i.e., carryover from an aided production to a subsequent unaided production on the same topic. METHODS #ENTITYSTARTX00026; PROCEDURES: Five individuals with chronic aphasia created narratives on two topics, under three conditions: Unaided (U), Aided (SSR), and Post-SSR Unaided (Post-U). The 30 samples (5 participants, 2 topics, 3 conditions) were randomised and judged for informativeness by graduate students in speech-language pathology. The method for rating was Direct Magnitude Estimation (DME). OUTCOMES #ENTITYSTARTX00026; RESULTS: Repeated measures ANOVAs were performed on DME ratings for each participant on each topic. A main effect of Condition was present for four of the five participants, on one or both topics. Planned contrasts revealed that the aided effect (SSR >U) was significant in each of these cases. For two participants, there was also topic-specific carryover (Post-U >U). CONCLUSIONS: Listeners judged functional narratives generated on SentenceShaper to be more informative than comparable narratives spoken spontaneously. This extends the evidence for aided effects of SentenceShaper. There was also evidence, albeit weaker, for topic-specific carryover, suggesting that the program might be used effectively to practise for upcoming face-to-face interactions.

Treating agrammatic aphasia within a linguistic framework: Treatment of Underlying Forms

BACKGROUND: Formal linguistic properties of sentences-both lexical, i.e., argument structure, and syntactic, i.e., movement-as well as what is known about normal and disordered sentence processing and production, were considered in the development of Treatment of Underlying Forms (TUF), a linguistic approach to treatment of sentence deficits in patients with agrammatic aphasia. TUF is focused on complex, non-canonical sentence structures and operates on the premise that training underlying, abstract, properties of language will allow for effective generalisation to untrained structures that share similar linguistic properties, particularly those of lesser complexity. AIMS: In this paper we summarise a series of studies focused on examining the effects of TUF. METHODS #ENTITYSTARTX00026;PROCEDURES: In each study, sentences selected for treatment and for generalisation analysis were controlled for their lexical and syntactic properties, with some structures related and others unrelated along theoretical lines. We use single-subject experimental designs-i.e., multiple baseline designs across participants and behaviours-to chart improvement in comprehension and production of both trained and untrained structures. One structure was trained at a time, while untrained sentences were tested for generalisation. Participants included individuals with mild to moderately severe agrammatic, Broca's aphasia with characteristic deficits patterns. OUTCOMES #ENTITYSTARTX00026; RESULTS: Results of this work have shown that treatment improves the sentence types entered into treatment, that generalisation occurs to sentences which are linguistically related to those trained, and that treatment results in changes in spontaneous discourse in most patients. Further, we have found that generalisation is enhanced when the direction of treatment is from more to less complex structures, a finding that led to the Complexity Account of Treatment Efficacy (CATE, Thompson, Shapiro, Kiran, & Sobecks, 2003). Finally, results of recent work showing that treatment appears to affect processing of trained sentences in real time and that treatment gains can be mapped onto the brain using functional magnetic resonance imaging (fMRI) are discussed. CONCLUSIONS: These findings indicate that TUF is effective for treating sentence comprehension and production in patients who present with language deficit patterns like those seen in our patients. Patients receiving this treatment show strong generalisation effects to untrained language material. Given the current healthcare climate, which limits the amount of treatment that aphasic patients receive following stroke, it is important that clinicians deliver treatment that results in optimal generalisation in the least amount of time possible.

Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002

OBJECTIVE

To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled.

STUDY SELECTION

One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke.

DATA EXTRACTION

Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 as class III. Evidence within each area of intervention was synthesized and recommendations for practice standards, practice guidelines, and practice options were made.

CONCLUSIONS

There is substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.

Integrated technology for evaluation of brain function and neural plasticity

The study of neural plasticity has expanded rapidly in the past decades and has shown the remarkable ability of the developing, adult, and aging brain to be shaped by environmental inputs in health and after a lesion. Robust experimental evidence supports the hypothesis that neuronal aggregates adjacent to a lesion in the sensorimotor brain areas can take over progressively the function previously played by the damaged neurons. It definitely is accepted that such a reorganization modifies sensibly the interhemispheric differences in somatotopic organization of the sensorimotor cortices. This reorganization largely subtends clinical recovery of motor performances and sensorimotor integration after a stroke. Brain functional imaging studies show that recovery from hemiplegic strokes is associated with a marked reorganization of the activation patterns of specific brain structures. To regain hand motor control, the recovery process tends over time to bring the bilateral motor network activation toward a more normal intensity/extent, while overrecruiting simultaneously new areas, perhaps to sustain this process. Considerable intersubject variability exists in activation/hyperactivation pattern changes over time. Some patients display late-appearing dorsolateral prefrontal cortex activation, suggesting the development of "executive" strategies to compensate for the lost function. The AH in stroke often undergoes a significant "remodeling" of sensory and motor hand somatotopy outside the "normal" areas, or enlargement of the hand representation. The UH also undergoes reorganization, although to a lesser degree. Although absolute values of the investigated parameters fluctuate across subjects, secondary to individual anatomic variability, variation is minimal with regards to interhemispheric differences, due to the fact that individual morphometric characters are mirrored in the two hemispheres. Excessive interhemispheric asymmetry of the sensorimotor hand areas seems to be the parameter with highest sensitivity in describing brain reorganization after a monohemispheric lesion, and mapping motor and somatosensory cortical areas through focal TMS, fMRI, PET, EEG, and MEG is useful in studying hand representation and interhemispheric asymmetries in normal and pathologic conditions. TMS and MEG allow the detection of sensorimotor areas reshaping, as a result of either neuronal reorganization or recovery of the previously damaged neural network. These techniques have the advantage of high temporal resolution but also have limitations. TMS provides only bidimensional scalp maps, whereas MEG, even if giving three-dimensional mapping of generator sources, does so by means of inverse procedures that rely on the choice of a mathematical model of the head and the sources. These techniques do not test movement execution and sensorimotor integration as used in everyday life. fMRI and PET may provide the ideal means to integrate the findings obtained with the other two techniques. This multitechnology combined approach is at present the best way to test the presence and amount of plasticity phenomena underlying partial or total recovery of several functions, sensorimotor above all. Dynamic patterns of recovery are emerging progressively from the relevant literature. Enhanced recruitment of the affected cortex, be it spared perilesional tissue, as in the case of cortical stroke, or intact but deafferented cortex, as in subcortical strokes, seems to be the rule, a mechanism especially important in early postinsult stages. The transfer over time of preferential activation toward contralesional cortices, as observed in some cases, seems, however, to reflect a less efficient type of plastic reorganization, with some aspects of maladaptive plasticity. Reinforcing the use of the affected side can cause activation to increase again in the affected side with a corresponding enhancement of clinical function. Activation of the UH MI may represent recruitment of direct (uncrossed) corticospinal tracts and relate more to mirror movements, but it more likely reflects activity redistribution within preexisting bilateral, large-scale motor networks. Finally, activation of areas not normally engaged in the dysfunctional tasks, such as the dorsolateral prefrontal cortex or the superior parietal cortex in motor paralysis, might reflect the implication of compensatory cognitive strategies. An integrated approach with technologies able to investigate functional brain imaging is of considerable value in providing information on the excitability, extension, localization, and functional hierarchy of cortical brain areas. Deepening knowledge of the mechanisms regulating the long-term recovery (even if partial), observed for most neurologic sequelae after neural damage, might prompt newer and more efficacious therapeutic and rehabilitative strategies for neurologic diseases.

The role of syntactic complexity in treatment of sentence deficits in agrammatic aphasia: the complexity account of treatment efficacy (CATE)

This experiment examined the hypothesis that training production of syntactically complex sentences results in generalization to less complex sentences that have processes in common with treated structures. Using a single subject experimental design, 4 individuals with agrammatic aphasia were trained to comprehend and produce filler-gap sentences with wh-movement, including, from least to most complex, object-extracted who-questions, object clefts, and sentences with object-relative clausal embedding. Two participants received treatment first on the least complex structure (who-questions), and 2 received treatment first on the most complex form (object-relative constructions), while untrained sentences and narrative language samples were tested for generalization. When generalization did not occur across structures, each was successively entered into treatment. Results showed no generalization across sentence types when who-questions were trained; however, as predicted, object-relative training resulted in robust generalization to both object clefts and who-questions. These findings support those derived from previous work, indicating not only that generalization occurs across structures that are linguistically related, but also that generalization is enhanced when the direction of treatment is from more complex to less complex constructions. This latter finding supports the authors' newly coined "complexity account of treatment efficacy" (CATE).

Treatment of sound errors in aphasia and apraxia of speech: Effects of phonological complexity

BACKGROUND: Recent research suggests that the complexity of treatment stimuli influences the effectiveness of treatment. However, no studies have examined the role of complexity on sound production treatment in adult individuals with sound production impairments. AIMS: This study examines effects of syllable complexity on treatment outcome in two patients with acquired sound production problems. Complexity is defined in terms of syllable structure: clusters are more complex than singletons. Using a single-subject multiple-baseline design, we address the question: Is treatment of complex syllables more effective than treatment of simple syllables? METHODS #ENTITYSTARTX00026; PROCEDURES: Two patients with aphasia and apraxia of speech were trained to produce complex or simple syllables (using modelling). Improvement was measured by percent correct on a word and nonword repetition test. OUTCOMES #ENTITYSTARTX00026; RESULTS: We found that both treatment on simple syllables and treatment on complex syllables led to improved production of simple syllables, while treatment of complex syllables also led to improvement on some complex syllables for one of the two patients. CONCLUSIONS: These results suggests that training complex items is more effective than training simple items, at least for some patients. Possible reasons for lack of stronger effects are discussed, as well as directions for future research.

Complexity in Phonological Treatment

The construct of complexity has been advanced recently as a potentially contributing variable in the efficacy of treatment for children with functional phonological disorders. Thus far, complexity has been defined in terms of linguistic and psycholinguistic structure, articulatory phonetic variables, and conventional clinical factors. The focus of this paper is on clinical complexity as it influences the selection of target sounds for treatment, with three clinical factors reviewed: consistency of the error, normative age of acquisition, and number of errors to be treated. The collective findings suggest that treatment of seemingly more complex targets results in greater phonological gains. These results are integrated with converging evidence from other populations and language and learning domains.

Syllable onsets II: three-element clusters in phonological treatment

This study extends the application of the Sonority Sequencing Principle, as reported in J. A. Gierut (1999), to acquisition of word-initial 3-element clusters by children with functional phonological delays (ages in years;months: 3;4 to 6;3). The representational structure of 3-element clusters is complex and unusual because it consists of an s-adjunct plus a branching onset, which respectively violate and conform to the Sonority Sequencing Principle. Given the representational asymmetry, it is unclear how children might learn these clusters in treatment or whether such treatment may even be effective. Results of a single-subject staggered multiple-baseline experiment demonstrated that children learned the treated 3-element cluster in treatment but showed no further generalization to similar types of (asymmetric) onsets. Treatment of 3-element clusters did, however, result in widespread generalization to untreated singletons, including affricates. Moreover, there was differential generalization to untreated 2-element clusters, with individual differences being traced to the composition of children's singleton inventories. Theoretically, the results suggest a segmental-syllabic interface that holds predictive potential for determining the effectiveness and effects of clinical treatment as based on the notion of linguistic complexity.

Social validity of changes in informativeness and efficiency of aphasic discourse following linguistic specific treatment (LST)

This study presents the results of an analysis of pragmatic aspects of language samples obtained from five agrammatic aphasic individuals prior to and following Linguistic Specific Treatment (LST). Clinically and statistically significant positive changes in informativeness and efficiency were documented in posttreatment samples. Analysis of communicative competence (i.e., naïve listeners' ratings of pre- and posttreatment audiotaped samples), was undertaken to examine the social validity of quantified changes. Mean ratings across listeners were computed to evaluate their subjective perceptions of general communicative constructs. Results indicated that objectively measured changes in pragmatic aspects were perceptible to naïve listeners, however, to varying degrees across participants and constructs.

Adaptive learning: interventions for verbal and motor deficits

Advances in basic and clinical neuroscience are uniting to form new optimism for treatment and rehabilitation of persons with a variety of neurologic disorders. Both cognitive and motor systems have shown remarkable degrees of plasticity in response to incoming stimuli. Understanding the brain (and spinal cord) capacity for change will lead to new topics for research as well as new approaches to rehabilitation. Adaptive learning has been shown to be a fundamental part of the developmental process and has been used in remediation of a variety of language difficulties. Using such principles to approach motor functions also is showing promise. Expanding these observations to encompass other areas of disease and rehabilitation is an area for further research. Interdisciplinary approaches including the fields of computer technology, imaging, and genetic analysis will provide new tools. Contribution of new concepts within adaptive learning must address such topics as the relation between motor and sensory responses, measures that accurately indicate cognitive health, the brain and spinal cord areas involved in particular learning tasks, the optimal time windows for intervention, and the importance of behavior and motivation in treatment and rehabilitation.

Response generalization in apraxia of speech treatments: taking another look

The purpose of the present paper is to present a critical review and reanalysis of response generalization effects in studies of treatment efficacy in apraxia of speech (AOS). Response generalization takes two forms: generalization of treatment effects to untrained exemplars of trained behaviors and generalization to untrained (i.e., novel) behaviors. In the past, response generalization has not been extensive and typically has been restricted to untrained exemplars of trained behaviors. Reasons for these findings are discussed with reference to recent advances in our understanding of the nature of AOS and to theories of speech motor control and teaming. The discussion focuses on the influence of the theoretical basis used to develop hypotheses and select behaviors to test predictions, the complexity of the treatment task/s, and patient characteristics. Suggestions for future directions in treatment efficacy research are offered. Learner outcomes: (1) An understanding of the nature of AOS, based on recent experimental analyses. (2) An understanding of the efficacy of current treatments for AOS in the area of response generalization. (3) An understanding of how theories of speech motor control might be applied to develop hypotheses for testing and increase effectiveness in treatment studies. (4) An understanding of how theories of speech motor control might guide selection of behaviors to test treatment effects and response generalization.