The case for single-case studies in treatment research-comments on Howard, Best and Nickels "Optimising the design of intervention studies: critiques and ways forward"

An exploration of anomia rehabilitation in drug-resistant temporal lobe epilepsy

Around 40% of patients who undergo a left temporal lobe epilepsy (LTLE) surgery suffer from anomia (word-finding difficulties), a condition that negatively impacts quality of life. Despite these observations, language rehabilitation is still understudied in LTLE. We assessed the effect of a four-week rehabilitation on four drug-resistant LTLE patients after their surgery. The anomia rehabilitation was based on cognitive descriptions of word finding deficits in LTLE. Its primary ingredients were psycholinguistic tasks and a psychoeducation approach to help patients cope with daily communication issues. We repeatedly assessed naming skills for trained and untrained words, before and during the therapy using an A-B design with follow-up and replication. Subjective anomia complaint and standardized language assessments were also collected. We demonstrated the effectiveness of the rehabilitation program for trained words despite the persistence of seizures. Furthermore, encouraging results were observed for untrained items. Variable changes in anomia complaint were observed. One patient who conducted the protocol as self-rehabilitation responded similarly to the others, despite the different manner of intervention. These results open promising avenues for helping epileptic patients suffering from anomia. For example, this post-operative program could easily be adapted to be conducted preoperatively.

Focusing on the locus of the breakdown for treatment of anomia: a pilot study

The primary goal of this study was to evaluate the treatment effects of semantic feature analysis (SFA) and phonological components analysis (PCA) on word retrieval processing in persons with aphasia (PWAs). After identifying the locus of the breakdown in lexical retrieval processing, 15 monolingual native Persian speakers with aphasia were divided into two groups. After three naming trials, participants with dominant semantic deficits received SFA, and participants with primary phonological deficits were provided with PCA three times a week for eight weeks. Both approaches improved participants' naming and performance on language tests, including spontaneous speech, repetition, comprehension, and semantic processing. However, the correct naming of treated and untreated items was higher in mild-to-moderate participants, with mostly circumlocution and semantic paraphasias in the SFA group. The same holds for mild-to-moderate participants with mostly phonemic paraphasia who received PCA therapy. Moreover, the results showed that participants' baseline naming performance and semantic abilities could be associated with the treatment outcomes. Although limited by a lack of a control group, this study provided evidence supporting the possible benefits of focusing on the locus of the breakdown for treating anomia through SFA and PCA approaches, specifically in participants with mild to moderate aphasia. However, for those with severe aphasia, the treatment choice may not be as straightforward because several variables are likely to contribute to this population's word-finding difficulties. Replication with larger, well-stratified samples, use of a within-subjects alternating treatment design and consideration of treatments' long-term effects are required to better ascertain the effects of focusing on the locus of breakdown for treatment of anomia.

Early within therapy naming probes as a clinically-feasible predictor of anomia treatment response

This study investigated the relationship between early within-therapy probe naming performance and anomia therapy outcomes in individuals with aphasia. Thirty-four adults with chronic, post-stroke aphasia participated in the Aphasia Language Impairment and Functioning Therapy (Aphasia LIFT) programme, comprised of 48 h of comprehensive aphasia therapy. Sets of 30 treated and 30 untreated items identified at baseline were probed during impairment therapy which targeted word retrieval using a combined semantic feature analysis and phonological component analysis approach. Multiple regression models were computed to determine the relationship between baseline language and demographic variables, early within-therapy probe naming performance (measured after 3 h of impairment therapy) and anomia treatment outcomes. Early within-therapy probe naming performance emerged as the strongest predictor of anomia therapy gains at post-therapy and at 1-month follow-up. These findings have important clinical implications, as they suggest that an individual's performance after a brief period of anomia therapy may predict response to intervention. As such, early within-therapy probe naming may provide a quick and accessible tool for clinicians to identify potential response to anomia treatment.

The effects of adding attention training to naming treatment for individuals with aphasia

AIM

Given the ever-increasing evidence for the co-occurrence of attention impairments and language disorders in chronic aphasia, this study aimed to compare the effects of two naming treatment programs, one with and one without attention training components, on the naming performance of participants with aphasia.

MATERIALS AND METHODS

This was a single-subject crossover study in which six people with chronic aphasia and different degrees of naming and attention impairments participated. Two treatment programs were implemented for each participant, with the sequence of the treatments with crossover design. Each program consisted of 12 treatment sessions plus pre- and post-treatment assessment sessions (15 weeks for each participant). The visual analysis and WEighted STatistics methods were employed for data analysis.

RESULTS

Based on visual analysis, both treatments improved in comparison to the baseline phase. Statistical analysis revealed that the number of participants with significant naming improvement following combined program (5 participants) was larger than the number of participants showing improvement following completion of the single, program.

CONCLUSION

Although integrating attention training into a conventional treatment for anomia can increase the effect of treatment on naming ability, more studies are required to clarify the role of attention in remediating naming impairments in aphasia.

Reproducibility in Small-N Treatment Research: A Tutorial Using Examples From Aphasiology

PURPOSE

Small-N studies are the dominant study design supporting evidence-based interventions in communication science and disorders, including treatments for aphasia and related disorders. However, there is little guidance for conducting reproducible analyses or selecting appropriate effect sizes in small-N studies, which has implications for scientific review, rigor, and replication. This tutorial aims to (a) demonstrate how to conduct reproducible analyses using effect sizes common to research in aphasia and related disorders and (b) provide a conceptual discussion to improve the reader's understanding of these effect sizes.

METHOD

We provide a tutorial on reproducible analyses of small-N designs in the statistical programming language R using published data from Wambaugh et al. (2017). In addition, we discuss the strengths, weaknesses, reporting requirements, and impact of experimental design decisions on effect sizes common to this body of research.

RESULTS

Reproducible code demonstrates implementation and comparison of within-case standardized mean difference, proportion of maximal gain, tau-U, and frequentist and Bayesian mixed-effects models. Data, code, and an interactive web application are available as a resource for researchers, clinicians, and students.

CONCLUSIONS

Pursuing reproducible research is key to promoting transparency in small-N treatment research. Researchers and clinicians must understand the properties of common effect size measures to make informed decisions in order to select ideal effect size measures and act as informed consumers of small-N studies. Together, a commitment to reproducibility and a keen understanding of effect sizes can improve the scientific rigor and synthesis of the evidence supporting clinical services in aphasiology and in communication sciences and disorders more broadly. Supplemental Material and Open Science Form: https://doi.org/10.23641/asha.21699476.

A randomized crossover single-case series comparing blocked versus random treatment for anomia

The motor learning literature has demonstrated that blocked practice facilitates better acquisition of motor skills, whereas random practice facilitates retention and transfer. The verbal learning and memory literature offers similar evidence. The purpose of this study was to investigate effects of blocked versus random practice in treatment for anomia. The study used a single site, randomized crossover design, with two replicated experimental phases (two blocked and two random) for each of 10 individuals with anomia. Each phase consisted of a cued picture-naming treatment. Individual treatment and maintenance effects, as well as weighted averages and group effects, were calculated using Tau-U based on the proportion of correctly named probes. Nine of 10 participants demonstrated treatment effects during each of the four phases. Acquisition was comparable for blocked and random practice. Maintenance effects were observed following seven blocked phases of treatment and 12 random phases of treatment across participants. For four of 10 participants the random schedule resulted in better maintenance of trained items. Although further research is needed, the present data suggest that for word retrieval treatment with multiple repetitions of the same items, a random presentation may benefit maintenance of treatment gains.

Language intervention in bilingual children with developmental language disorder: A systematic review

BACKGROUND

Although there is a growing body of literature on cognitive and language processing in bilingual children with developmental language disorder (DLD), there is a major gap in the evidence for language intervention. Critically, speech-language therapists are often required to make clinical decisions for language intervention on specific domains, such as phonology, vocabulary, morphosyntax and literacy.

AIMS

To examine evidence for language intervention and cross-language transfer effects in bilingual children with DLD. Specifically, the study aimed to review intervention evidence targeting non-linguistic cognitive skills and six areas of language: phonology, vocabulary, morphosyntax, pragmatics, narrative skills and literacy.

METHODS & PROCEDURES

We carried out searches in five electronic databases: CINAHL, Scopus, Psychinfo, Proquest and Sciencedirect. Data from selected papers were extracted and organized into the three following categories: study information, participant information and intervention information. Critical appraisal for selected papers was conducted using a quality assessment tool (QAT).

OUTCOMES & RESULTS

We included 14 papers in the review. The majority indicated evidence for vocabulary intervention. There was limited evidence for intervention targeting phonology or morphosyntax. Cross-language generalization effects were evident for vocabulary, but in some instances also reported for morphosyntax and literacy.

CONCLUSIONS & IMPLICATIONS

The present review indicates that there is a significant gap in the literature regarding language intervention for several key language areas such as morphosyntax, narrative skills and literacy. There are only limited data for the effects of cross-language generalization indicating that more research is needed in this area specifically for skills beyond vocabulary.

WHAT THIS PAPER ADDS

What is already known on the subject Previous studies have examined the effects of bi- and monolingual intervention in bilingual children with DLD. Although the results indicated superior effects for bilingual compared with monolingual intervention, language intervention evidence in specific language domains (e.g., vocabulary, literacy) has not been investigated. What this paper adds to existing knowledge This study will add intervention evidence specific to language domains such as phonology, vocabulary, morphosyntax, pragmatics, narrative skills and literacy. Additionally, we have synthesized intervention evidence on non-linguistic cognition given that these skills are often impaired in bilingual children with DLD. The review has also demonstrated evidence for the effects of cross-language transfer beyond vocabulary skills, especially when the intervention was provided in the home language. What are the potential or actual clinical implications of this work? Although there was a lack of intervention evidence in language domains such as pragmatics, the results indicated some evidence for intervention targeting vocabulary. However, positive effects of cross-language generalization were not constrained to vocabulary but were also reported for intervention targeting mean length of utterance and literacy in the home language. This result indicates an interactive nature of the two languages, as well as provides further evidence for supporting home language(s) in intervention. Finally, intervention targeting non-linguistic cognition may yield additional cross-domain generalization to language skills specifically for bilingual children with DLD.

Neural evidence for a separation of semantic and phonological control processes

There remain major doubts about the nature and domain specificity of inhibitory control processes, both within and between cognitive domains. This study examined inhibitory processes within the language domain, by contrasting semantic versus phonological inhibitory control. In an fMRI experiment, elderly participants performed phonological and semantic inhibitory control tasks involving resistance to highly or weakly interfering stimuli. In the semantic domain, inhibitory control effects, contrasting high vs. low interference control levels, were observed at univariate and multivariate levels in all fronto-parieto-temporal region-of-interests. In the phonological domain, inhibitory control effects were observed only at multivariate levels, and were restricted to the pars triangularis of the bilateral inferior frontal gyrus and to the left middle temporal gyrus. Critically, no reliable multivariate cross-domain prediction of neural patterns associated with inhibitory control was observed. This study supports a functional dissociation of the neural substrates associated with inhibitory control for phonological vs. semantic domains.

French Phonological Component Analysis and aphasia recovery: A bilingual perspective on behavioral and structural data

Studies show bilingualism entails an advantage in cognitive control tasks. There is evidence of a bilingual advantage in the context of aphasia, resulting in better cognitive outcomes and recovery in bilingual persons with aphasia compared to monolingual peers. This bilingual advantage also results in structural changes in the right hemisphere gray matter. Very few studies have examined the so-called bilingual advantage by reference to specific anomia therapy efficacy. This study aims to compare the effect of French-Phonological Component Analysis (Fr-PCA) in monolinguals and bilingual persons with aphasia, both at the linguistic and cognitive control level, and to examine the structural impact of left hemisphere lesion location and right hemisphere structural data. Eight participants with chronic aphasia received Fr-PCA for a total of 15 h over 5 weeks. The results showed improved accuracy for treated words and generalization to untreated items and discourse in both groups, and improved Flanker task performance for some participants. Bilingual participants improved more than monolinguals for picture-naming tasks and narrative discourse. Damage to the left postcentral gyrus and the middle frontal gyrus was associated with less therapy-induced improvement. Additionally, left hemisphere damage to the inferior parietal gyrus and postcentral gyrus was associated with reduced cognitive control pre-therapy. Undamaged right hemisphere cortical thicknesses were significantly different between groups; the inferior frontal gyrus and the middle frontal gyrus were greater for the bilingual participants and correlated with cognitive control skills. These results suggest a bilingual advantage in anomia recovery following Fr-PCA, potentially resulting from enhanced cognitive control abilities that could be supported by right hemisphere neural reserve.

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.

The Effectiveness of Transcranial Magnetic Stimulation (TMS) Paradigms as Treatment Options for Recovery of Language Deficits in Chronic Poststroke Aphasia

Background

In an effort to boost aphasia recovery, modern rehabilitation, in addition to speech and language therapy (SALT), is increasingly incorporating noninvasive methods of brain stimulation. The present study is aimed at investigating the effectiveness of two paradigms of neuronavigated repetitive transcranial magnetic stimulation (rTMS): (i) 1 Hz rTMS and (ii) continuous theta burst stimulation (cTBS) each as a standalone treatment for chronic aphasia poststroke.

Methods

A single subject experimental design (SSED) trial was carried out in which six people with aphasia (PWA) were recruited, following a single left hemispheric stroke more than six months prior to the study. Three individuals were treated with 1 Hz rTMS, and the remaining three were treated with cTBS. In all cases, TMS was applied over the right pars triangularis (pTr). Language assessment, with standardized and functional measures, and cognitive evaluations were carried out at four time points: twice prior to treatment (baseline), one day immediately posttreatment, and at follow-up two months after treatment was terminated. Quality of life (QoL) was also assessed at baseline and two months posttreatment. In addition, one of the participants with severe global aphasia was followed up again one and two years posttherapy.

Results

For all participants, both rTMS paradigms (1 Hz rTMS and cTBS) generated trends towards improvement in several language skills (i.e., verbal receptive language, expressive language, and naming and reading) one day after treatment and/or two months after therapy. Rated QoL remained stable in three individuals, but for the other three, the communication scores of the QoL were reduced, while two of them also showed a decline in the psychological scores. The participant that was treated with cTBS and followed for up to two years showed that the significant improvement she had initially exhibited in comprehension and reading skills two months after TMS (1^st follow-up) was sustained for at least up to two years.

Conclusion

From the current findings, it is suggested that inhibitory TMS over the right pTr has the potential to drive neuroplastic changes as a standalone treatment that facilitates language recovery in poststroke aphasia.

Transcranial Magnetic Stimulation and Working Memory Training to Address Language Impairments in Aphasia: A Case Study

BACKGROUND

Traditionally, people with aphasia (PWA) are treated with impairment-based language therapy to improve receptive and expressive language skills. In addition to language deficits, PWA are often affected by some level of working memory (WM) impairments. Both language and working memory impairments combined have a negative impact on PWA's quality of life. The aim of this study was to investigate whether the application of intermittent theta-burst stimulation (iTBS) combined with computerized WM training will result in near-ransfer effects (i.e., trained WM) and far-transfer effects (i.e., untrained language tasks) and have a positive effect on the quality of life of PWA.

METHODS

The participant was a 63-year-old Greek-Cypriot male who presented with mild receptive aphasia and short-term memory difficulties. Treatment was carried out using a multiple baseline (MB) design composed of a pretherapy or baseline testing phase, a therapy phase, and a posttherapy/follow-up phase. The treatment program involved iTBS application to the left dorsolateral prefrontal cortex (DLPFC), an area responsible for WM, for 10 consecutive sessions. The participant received a 3-minute iTBS application followed by 30-minute computer-assisted WM training. Outcome measures included a WM screening test, a standardized aphasia test, a nonverbal intelligence test, story-telling speech samples, a procedural discourse task, and a questionnaire addressing quality of life. These measures were performed three times before the treatment, immediately upon completion of the treatment, and once during follow-up testing at 3 months posttreatment.

RESULTS

We found a beneficial effect of iTBS and WM training on naming, reading, WM, reasoning, narrative, communication efficiency, and quality of life (QoL). Implications for Rehabilitation. Noninvasive brain stimulation combined with computerized WM training may be used in aphasia rehabilitation to improve WM and generalize to language improvement.

Effects of Physical Exercise Interventions on Stereotyped Motor Behaviours in Children with ASD: A Meta-Analysis

Studies have reported that physical exercise reduces maladaptive stereotyped motor behaviours (SMB) in children with ASD, but these intervention studies vary in design and outcome. The present systematic review and meta-analysis included 22 studies, involving 274 children with ASD, to quantify the effect of exercise on SMB and its potential moderators. Multi-level modelling revealed a large overall effect, Hedges' g = 1.16, with significant heterogeneity across participant, treatment, and study levels. Further, a more appropriate model using between-case estimation for within-subject effects to improve comparability between single-case and group-design studies, yielded a smaller but still significant effect, g = 0.51. Lastly, higher exercise intensity, but not age, exercise duration or settings, reliably predicted treatment effectiveness. Implications for clinical practice and research are discussed.

Treatment of verbal short-term memory abilities to improve language function in aphasia: A case series treatment study

Recent approaches to interventions for aphasia have incorporated verbal short-term memory (STM) and working memory (WM) components. We investigated whether a treatment involving repetition of word sequences after a response delay would improve tolerance of increased verbal STM load in repetition and, consequently, improve performance on repetition and other language tasks. Eight individuals with aphasia participated. We used a single subject design with outcome measures on near-transfer tasks closely related to the treatment task and far-transfer tasks more distantly related to the treatment task. We minimized repeated presentation of stimuli in all phases of treatment to control for confounding effects of repeated exposure of treated items. Four participants demonstrated modest acquisition effects. On outcome measures, we observed improvements by some participants on near-transfer tasks, (repetition of concrete and abstract word strings and verbal spans) and far-transfer tasks (naming and discourse). Some participants demonstrated a significant decline in word repetition accuracy after a response delay before treatment, indicating difficulty in maintaining activation of linguistic representations. It was these participants who showed the most improvement on outcome measures. More studies are needed to determine who will respond to this treatment and what factors might influence the effectiveness of this treatment approach.

A Randomized Case Series Approach to Testing Efficacy of Interventions for Minimally Verbal Autistic Children

BACKGROUND

Randomized Controlled Trials (RCTs) are the gold standard for assessing whether an intervention is effective; however, they require large sample sizes in order to detect small effects. For rare or complex populations, we advocate a case series approach as a more realistic and useful first step for intervention evaluation. We consider the importance of randomization to such designs, and advocate for the use of Randomization Tests and Between Case Effect Sizes to provide a robust and statistically powerful evaluation of outcomes. In this tutorial, we describe the method, procedures, and analysis code necessary to conduct robust single case series, using an empirical example with minimally verbal autistic children.

METHOD

We applied a pre-registered (https://osf.io/9gvbs) randomized baseline design with between-case effect size to a case series (n = 19), to test the efficacy of a novel, parent-mediated, app-based speech production intervention (BabbleBooster) for minimally verbal autistic children. Parent-rated probe scores were used to densely sample performance accuracy over time.

RESULTS

Parents were able to reliably code their children's speech productions using BabbleBooster. A non-significant Randomization Test and small Between-Case Effect Size (d = 0.267), suggested there was no evidence that BabbleBooster improved speech production in minimally verbal autistic children, relative to baseline scores, during this brief period of intervention.

CONCLUSION

The current analyses exemplify a more robust approach to examining treatment effects in rare or complex populations, where RCT may be difficult or premature to implement. To facilitate adoption of this method by researchers and practitioners, we provide analysis code that can be adapted using open source R packages. Future studies could use this case series design to evaluate interventions aiming to improve speech and language outcomes for minimally verbal autistic children, and other heterogeneous and hard to reach populations.

Outcomes of semantic feature analysis treatment for aphasia with and without apraxia of speech

BACKGROUND

To date, studies have not explored whether a dual diagnosis of aphasia plus apraxia of speech (AOS) versus aphasia alone (APH) affects the response to language-based naming treatments.

AIMS

To compare the effects of semantic feature analysis (SFA) treatment for individuals with APH versus aphasia plus AOS, and to test if the presence of AOS impacted the effects of treatment.

METHODS AND PROCEDURES

A non-randomized experimental group study was conducted to explore the treatment, generalization and maintenance effects between the AOS and APH groups. Participants included nine individuals with aphasia and 11 with concomitant aphasia and AOS. Dependent measures included lexical accuracy, number of sound-level distortions, and lexical stress and syllable segmentation errors.

OUTCOMES AND RESULTS

Both groups showed significantly improved naming accuracy of trained items for up to 2 months post-treatment. Improvement on naming accuracy of untrained items post-treatment, both semantically related and unrelated to trained items, was lower in magnitude. That this may have been due to effects of repeated probing (which included target repetition) or regression to the mean cannot be excluded. There was a tendency for the AOS group to respond slightly better to treatment than the APH group overall, which was not correlated with aphasia severity. Also, measures of phonetic accuracy and fluency improved for both groups, with no main effect of group. Treatment effects did not generalize to formal measures of (untrained) picture naming or expression of correct information units in discourse in a story retelling task.

CONCLUSIONS AND IMPLICATIONS

Findings indicate that individuals with aphasia plus AOS can gain equivalent benefits in word retrieval and production from the language-based SFA treatment as individuals with aphasia alone. This may be, in part, due to the tendency for SFA to incorporate principles of practice that are known to support motor learning in AOS, such as high intensity, random stimulus presentation and variable practice. Findings provide further support for high-intensity practice and use of self-generated features to facilitate maintenance of effects. What this paper adds What is already known on the subject SFA treatment is the most common intervention for word-finding difficulties for individuals with aphasia. AOS is a common concomitant disorder to aphasia. However, it is not clear whether the effects of language-based SFA treatment are mitigated by the presence of AOS, which tends to respond well to treatments focused on articulatory-kinematic aspects of speech movement. What this paper adds to the existing knowledge This study compares the effects of SFA in a group of individuals with aphasia alone and a group with similar severity of aphasia but with concomitant AOS, ranging from mild to moderate-severe. Overall, AOS did not have a negative effect on response to the treatment. What are the potential or actual clinical implications of this work? Individuals with aphasia plus AOS can be expected to benefit to a similar degree from SFA as people with aphasia alone. It is likely that the use of practice principles of high intensity, random stimulus presentation and varied practice are important components of the protocol.

The effect of an integrated reading and anxiety intervention for poor readers with anxiety

A recent systematic review has reported that poor reading is reliably associated with anxiety. However, we currently lack evidence-based intervention for children who have both poor reading and anxiety (PRAX). In this study, we tested a new PRAX intervention in 8- to 12-year-old children using a double-baseline intervention case series design. Analyses of both group and individual data revealed that 12 weeks of PRAX intervention significantly improved children's reading and spelling accuracy, and significantly reduced both anxiety disorders and symptoms. These results support PRAX intervention as a treatment for comorbid reading and anxiety problems in children and pave the way to a randomised controlled trial.

Exploring the effects of verb and noun treatment on verb phrase production in primary progressive aphasia: A series of single case experimental design studies

Evidence of generalization to connected speech following lexical retrieval treatment in Primary Progressive Aphasia (PPA) is scarce. Consequently, this study systematically investigated changes in verb phrase production following lexical retrieval treatment in a series of single case experimental design studies. Four individuals with PPA (three semantic- and one logopenic variant PPA) who had previously demonstrated that they could integrate verbs and nouns into sentence structures in a cueing paradigm, undertook a sequence of verb and noun lexical retrieval treatments using Repetition and Reading in the Presence of a Picture. Production of treated nouns- and/or verbs-in-isolation significantly improved following treatment for three of the four participants. Verb phrase production did not improve for one of these participants (logopenic PPA), perhaps due to the relatively small treatment dose. Two participants (semantic variant PPA) did, however, demonstrate across-level generalization, with improvement in treated verbs and using those verbs in (untreated) verb phrases. Their verb phrase production improved most after lexical retrieval treatment for both nouns and verbs, suggesting this combined approach may benefit across-level generalization for some individuals in clinical practice.

Computer-assisted challenge point intervention for residual speech errors

Purpose

This preliminary case series investigated the effects of biofeedback intervention for residual rhotic errors delivered within a modified challenge point framework. In the challenge point framework, practice difficulty is adaptively adjusted with the goal of enhancing generalization learning. This study more specifically evaluated the feasibility of a computer-mediated implementation of challenge point treatment for rhotic errors using a custom open-source software, the Challenge Point Program (CPP).

Method

Participants were five native English speakers, ages 7;3-15;5, who had established but not generalized correct rhotic production in previous treatment; overall treatment duration was flexible. Treatment incorporated either electropalatographic or visual-acoustic biofeedback and was structured by challenge point principles implemented using the CPP software.

Results

Participants were highly variable in the magnitude of generalization gains attained. However, the median overall effect size was 4.24, suggesting that participants' response in treatment tended to exceed the minimum value considered clinically significant.

Conclusions

These findings provide preliminary evidence that computer-mediated implementation of the challenge point framework can be effective in producing generalization in some participants.

Single-case experimental designs: Characteristics, changes, and challenges

Tactics of Scientific Research (Sidman, 1960) provides a visionary treatise on single-case designs, their scientific underpinnings, and their critical role in understanding behavior. Since the foundational base was provided, single-case designs have proliferated especially in areas of application where they have been used to evaluate interventions with an extraordinary range of clients, settings, and target foci. This article highlights core features of single-case experimental designs, how key and ancillary features of the designs have evolved, the special strengths of the designs, and challenges that have impeded their integration in many areas where their contributions are sorely needed. The article ends by placing the methodological approach in the context of other research traditions. In this way, the discussion moves from the specific designs toward foundations and philosophy of science issues in keeping with the strengths of the person and book we are honoring.

Understanding differing outcomes from semantic and phonological interventions with children with word-finding difficulties: A group and case series study

Developmental Language Disorder occurs in up to 10% of children and many of these children have difficulty retrieving words in their receptive vocabulary. Such word-finding difficulties (WFD) can impact social development and educational outcomes. This research aims to develop the evidence-base for supporting children with WFD and inform the design and analysis of intervention studies. We included 20 children (age 6 to 8) with WFD each of whom participated in two interventions one targeting semantic attributes and the other phonological attributes of target words. The interventions, employing word-webs, were carefully constructed to facilitate direct comparison of outcome which was analysed at both group and case-series level. The study used a robust crossover design with pre-intervention baseline, between-intervention wash-out and post-intervention follow-up testing. We incorporated: matching of item sets on individual performance at baseline, independent randomisation of order of intervention and items to condition, blinding of assessor, evaluation of fidelity and control items. The interventions were clinically feasible, with weekly sessions over six weeks. Intervention improved children's word-finding abilities with statistically significant change only during treatment phases of the study and not over baseline, wash-out or follow-up phases. For the group the semantic intervention resulted in a gain of almost twice as many items as the phonological intervention, a significant difference. However, children differed in their response to intervention. Importantly, case-series analysis revealed outcomes predictable on the basis of children's theoretically driven language profiles. Taking account of individual profiles in determining choice of intervention would enable more children to benefit. The study provides new evidence to inform and refine clinical practice with this population. Future studies should be designed such that results can be analysed at both group and case series levels to extend theoretical understanding and optimise use of appropriate interventions.

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.

Videoconferencing Interventions for Children with Reading and Spelling Difficulties: A Pilot Study

Background: Many children in rural and remote areas do not have access to professionals providing literacy interventions. However, delivery of services through videoconferencing would increase access and choice for end users. Introduction: This pilot study investigated the efficacy of videoconferencing literacy interventions. As videoconferencing platforms become easier and cheaper to use, this form of telehealth delivery is increasing in popularity. However, there is currently no strong evidence base to support this practice. Materials and Methods: We studied 18 children, aged 7-12 years, with poor reading and/or spelling, and whose literacy interventions were videoconferenced into their homes and/or schools. Children were tested on three reading measures: (1) reading words, (2) reading nonwords, and (3) letter-sound knowledge, twice before their interventions commenced and once after their intervention concluded. Results: Children's raw and standardized scores on 2 of 3 outcome measures increased significantly more during the intervention than in the no-intervention period before their training commenced. Discussion and Conclusions: This study demonstrates that videoconferencing is a promising delivery mode for literacy interventions, and the results justify running a larger, randomized controlled trial.

Abstract Semantic Associative Network Training: A Replication and Update of an Abstract Word Retrieval Therapy Program

Purpose We report on a study that replicates previous treatment studies using Abstract Semantic Associative Network Training (AbSANT), which was developed to help persons with aphasia improve their ability to retrieve abstract words, as well as thematically related concrete words. We hypothesized that previous results would be replicated; that is, when abstract words are trained using this protocol, improvement would be observed for both abstract and concrete words in the same context-category, but when concrete words are trained, no improvement for abstract words would be observed. We then frame the results of this study with the results of previous studies that used AbSANT to provide better evidence for the utility of this therapeutic technique. We also discuss proposed mechanisms of AbSANT. Method Four persons with aphasia completed one phase of concrete word training and one phase of abstract word training using the AbSANT protocol. Effect sizes were calculated for each word type for each phase. Effect sizes for this study are compared with the effect sizes from previous studies. Results As predicted, training abstract words resulted in both direct training and generalization effects, whereas training concrete words resulted in only direct training effects. The reported results are consistent across studies. Furthermore, when the data are compared across studies, there is a distinct pattern of the added benefit of training abstract words using AbSANT. Conclusion Treatment for word retrieval in aphasia is most often aimed at concrete words, despite the usefulness and pervasiveness of abstract words in everyday conversation. We show the utility of AbSANT as a means of improving not only abstract word retrieval but also concrete word retrieval and hope this evidence will help foster its application in clinical practice.

Targeting Complex Orthography in the Treatment of a Bilingual Aphasia with Acquired Dysgraphia: The Case of a Malay/English Speaker with Conduction Aphasia

Background: Disruption of spoken language in people with aphasia tends to interfere with the ability to write, which is referred to as dysgraphia. This study examined the effectiveness of the anagram and copy treatment (ACT), administered in English on a bilingual Malay/English patient with conduction aphasia (GM). ACT is the arrangement of component letters presented in scrambled order (i.e., an anagram) so that the patient could use the letters to form target words, followed by repeated copying of the word. Methods: A single-subject multiple-baseline design was used with sets of English words (both nouns and verbs) sequentially targeted for treatment. Prior to the treatment, a series of single word writing and reading baselines were conducted in two languages: English and Malay. The ACT treatment was done in English, the language reported as more dominant for reading by the patient. Probes assessing generalizations to untrained pictures were presented at 8th, 13th, and 18th sessions. Results: GM showed steady and incremental improvement in the writing of trained nouns and verbs, with generalizations to untrained English nouns and verbs. Conclusions: Single word writing treatment in a non-transparent language may improve dysgraphia among adults with bilingual aphasia through the administration of a structured and systematic treatment.

The utility of lesion classification in predicting language and treatment outcomes in chronic stroke-induced aphasia

Stroke recovery models can improve prognostication of therapy response in patients with chronic aphasia, yet quantifying the effect of lesion on recovery is challenging. This study aimed to evaluate the utility of lesion classification via gray matter (GM)-only versus combined GM plus white matter (WM) metrics and to determine structural measures associated with aphasia severity, naming skills, and treatment outcomes. Thirty-four patients with chronic aphasia due to left hemisphere infarct completed T1-weighted and DTI scans and language assessments prior to receiving a 12-week naming treatment. GM metrics included the amount of spared tissue within five cortical masks. WM integrity was indexed by spared tissue and fractional anisotropy (FA) from four homologous left and right association tracts. Clustering of GM-only and GM + WM metrics via k-medoids yielded four patient clusters that captured two lesion characteristics, size and location. Linear regression models revealed that both GM-only and GM + WM clustering predicted baseline aphasia severity and naming skills, but only GM + WM clustering predicted treatment outcomes. Spearman correlations revealed that without controlling for lesion volume, the majority of left hemisphere metrics were related to language measures. However, adjusting for lesion volume, no relationships with aphasia severity remained significant. FA from two ventral left WM tracts was related to naming and treatment success, independent of lesion size. In sum, lesion volume and GM metrics are sufficient predictors of overall aphasia severity in patients with chronic stroke, whereas diffusion metrics reflecting WM tract integrity may add predictive power to language recovery outcomes after rehabilitation.

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

Purpose Aphasia research demonstrates increasing interest in the treatment of verb retrieval deficits. This systematically conducted scoping review reports on the level and fidelity of the current evidence for verb treatments; on its effectiveness regarding the production of trained and untrained verbs, functional communication, sentences, and discourse; and on the potential active ingredients. Recommendations to guide clinical decision making and future research are made. Method The computerized database search included studies from January 1980 to September 2018. 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 the treatment methods used. Results Thirty-seven studies were accepted into the review, and all but 1 constituted a low level of evidence. Thirty-three studies (89%) described treatment in sufficient detail to allow replication, dosage was poorly reported, and the fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were phonological and semantic cueing in 25 (67.5%) and 20 (54%) studies, respectively. Retrieval of trained verbs improved for 80% of participants, and improvements generalized to untrained verbs for 15% of participants. There was not sufficient detail to evaluate the impact of treatment on sentence production, functional communication, and discourse. Conclusions The evidence for verb treatments is predominantly of a low level. There are encouraging findings in terms of treatments being replicable; however, this is tempered by poor monitoring of treatment fidelity. The quality of verb treatment research would be improved by researchers reaching consensus regarding outcome measures (including generalization to, e.g., sentences and discourse) by manualizing treatment to facilitate implementation and exploring the opinions of participants. Finally, while treatment is largely effective in improving production of trained verbs, lack of generalization to untrained items leads to the recommendation that personally relevant verbs are prioritized.

An Exploration of the Impact of Group Treatment for Aphasia on Connected Speech

OBJECTIVE

Group treatment enables people with aphasia to practise communication skills outside the typical clinician-patient dyad. While there is evidence that this treatment format can improve participation in everyday communication, there is little evidence it impacts linguistic abilities. This project aimed to investigate the effects of 'typical' group treatment on the communication skills of people with aphasia with a focus on word retrieval in discourse.

METHODS

Three people with aphasia took part in a 6-week group therapy programme. Each week focused on a different topic, and three topics also received a home programme targeting word retrieval. The six treated topics were compared with two control topics, with regard to language production in connected speech. Semistructured interviews were collected twice prior to treatment and twice following the treatment and analysed using (a) word counts; (b) the profile of word errors and retrieval in speech; (c) a measure of propositional idea density, and (d) perceptual discourse ratings.

RESULTS

Two participants showed no significant improvements; one participant showed significant improvement on discourse ratings.

CONCLUSIONS

This study provides limited support for group treatment, leading to improved communication as measured by semistructured interviews, even when supplemented with a home programme. We suggest that either group treatment, as implemented here, was not an effective approach for improving communication for our participants and/or that outcome measurement was limited by difficulty assessing changes in connected speech.

Effect Sizes in Single-Case Aphasia Studies: A Comparative, Autocorrelation-Oriented Analysis

Purpose In single-case treatment studies, researchers may compare client performance during a baseline, nontreatment phase(s) to client performance during intervention phases. Autocorrelation in the data series gathered during such studies increases the likelihood that analysts will detect or fail to detect meaningful differences between baseline and treatment phase data. We examined the impact that autocorrelation has on 4 effect size calculation methods when these methods are applied to data generated by people with aphasia during anomia treatment studies. The effect sizes we selected were Busk and Serlin's d, Young's C, nonoverlap of all pairs, and Tau-U. We hypothesized that d and C would be influenced by autocorrelation, whereas nonoverlap of all pairs and Tau-U would not. Method We extracted 173 highly autocorrelated data series from published investigations of treatments for anomia. These data series were then "cleansed" of autocorrelation through the use of an autoregressive integrated moving average (ARIMA) process. The 4 effect size calculation methods were used to derive an effect size for each published and each corresponding ARIMA-tized data series. The published and ARIMA-tized effect sizes associated with each calculation method were then compared. Results For all of the 4 effect sizes, statistically significant differences existed between the published effect sizes and the ARIMA-tized effect sizes. Conclusions All 4 of the methods were influenced by autocorrelation. Further research that develops effect size calculation methods that are not influenced by autocorrelation will help to improve the quality of single-case studies. Supplemental Material https://doi.org/10.23641/asha.8298530.

Too harts, won sole: Using dysgraphia treatment to address homophone representation

Previous spoken homophone treatment in aphasia found generalization to untreated homophones and interpreted this as evidence for shared phonological word form representations. Previous written treatment of non-homophones has attributed generalization to orthographic neighbours of treated items to feedback from graphemes to similarly spelled orthographic word forms. This feedback mechanism offers an alternative explanation for generalization found in treatment of spoken homophones. The aim of this study was to investigate the mechanism underpinning generalization (if any) from treatment of written homophones. To investigate this question a participant with acquired dysgraphia and impaired access to orthographic output representations undertook written spelling treatment. Generalization to untreated items with varying degrees of orthographic overlap was investigated. Three experimental sets included homographs (e.g., bank-bank), heterographs (e.g., sail-sale), and direct orthographic neighbours (e.g., bath-path). Treatment improved written picture naming of treated items. Generalization was limited to direct neighbours. Further investigation of generalization found that items with a greater number of close neighbours in the treated set showed greater generalization. This suggests that feedback from graphemes to orthographic word forms is the driving force of generalization. The lack of homograph generalization suggests homographs do not share a representation in the orthographic lexicon.

The Methodological Quality of Short-Term/Working Memory Treatments in Poststroke Aphasia: A Systematic Review

Purpose The aims of this systematic review are to provide a critical overview of short-term memory (STM) and working memory (WM) treatments in stroke aphasia and to systematically evaluate the internal and external validity of STM/WM treatments. Method A systematic search was conducted in February 2014 and then updated in December 2016 using 13 electronic databases. We provided descriptive characteristics of the included studies and assessed their methodological quality using the Risk of Bias in N-of-1 Trials quantitative scale ( Tate et al., 2015 ), which was completed by 2 independent raters. Results The systematic search and inclusion/exclusion procedure yielded 17 single-case or case-series studies with 37 participants for inclusion. Nine studies targeted auditory STM consisting of repetition and/or recognition tasks, whereas 8 targeted attention and WM, such as attention process training including n-back tasks with shapes and clock faces as well as mental math tasks. In terms of their methodological quality, quality scores on the Risk of Bias in N-of-1 Trials scale ranged from 4 to 17 ( M = 9.5) on a 0-30 scale, indicating a high risk of bias in the reviewed studies. Effects of treatment were most frequently assessed on STM, WM, and spoken language comprehension. Transfer effects on communication and memory in activities of daily living were tested in only 5 studies. Conclusions Methodological limitations of the reviewed studies make it difficult, at present, to draw firm conclusions about the effects of STM/WM treatments in poststroke aphasia. Further studies with more rigorous methodology and stronger experimental control are needed to determine the beneficial effects of this type of intervention. To understand the underlying mechanisms of STM/WM treatment effects and how they relate to language functioning, a careful choice of outcome measures and specific hypotheses about potential improvements on these measures are required. Future studies need to include outcome measures of memory functioning in everyday life and psychosocial functioning more generally to demonstrate the ecological validity of STM and WM treatments.

Test-retest reliability in an fMRI study of naming in dementia

fMRI has been used as an outcome measure in dementia treatment studies, with many previous studies comparing only single pre- and post-treatment fMRI scans to determine treatment-induced neural changes, while utilizing single subject experimental designs. The purpose of the current study was to evaluate fMRI test-retest reliability in dementia patients and typical older adults using noun and verb confrontation naming to evaluate the validity of using a single pre/post-treatment scan comparison. Seven individuals with dementia and 9 control participants were tested three times over two months using the same fMRI procedures. Differences in individual and group level activation patterns were observed that varied across time. Additionally, the extent of variability fluctuated across individuals, groups, and the grammatical category of target words. Our findings suggested that one time fMRI scanning may inadequately represent an individual's typical brain activation pattern, particularly an individual with dementia. Thus, multiple imaging baselines are recommended.

Modified semantic feature analysis for anomia: a single case study

Semantic feature analysis (SFA) is a treatment approach designed for patients with lexical retrieval difficulty caused by semantic deficits. During training, a structured framework (e.g. requiring the patient to name the category, function, and colour of the target items) is usually provided to facilitate the patient in thinking of the semantic features of the target items. Nevertheless, the use of a structured framework potentially limits the variety of semantic features activated for lexical retrieval. This study investigated the effectiveness of modified SFA training to address this potential limitation. An odd-man-out task was carried out in the modified SFA training with an anomic patient with impaired access to the phonological output lexicon. The task aimed to encourage a detailed comparison of semantic features among items in the same category. It is hypothesized that activations of more distinctive semantic features belonging to the target items will result in greater extent of generalizations in the lexical processing. The patient's abilities in naming semantic features at the beginning and at the end of each treatment session were compared. Besides, accuracy and error patterns in oral and written naming in the initial and post-treatment assessment were also compared. The results showed a significant increase in the number of semantic features retrieved within treatment sessions. Moreover, a significant improvement in oral picture naming was also observed subsequent to the modified SFA training. Finally, the results of the error analyses further supported that the modified SFA was effective in promoting overall lexical processing. The findings indicated that both quantity and distinctiveness of concepts activated in the semantic system are essential to effective lexical retrieval. Theoretical and clinical implications were also discussed.

Statistical analysis in Small-N Designs: using linear mixed-effects modeling for evaluating intervention effectiveness

BACKGROUND

Advances in statistical methods and computing power have led to a renewed interest in addressing the statistical analysis challenges posed by Small-N Designs (SND). Linear mixed-effects modeling (LMEM) is a multiple regression technique that is flexible and suitable for SND and can provide standardized effect sizes and measures of statistical significance.

AIMS

Our primary goals are to: 1) explain LMEM at the conceptual level, situating it in the context of treatment studies, and 2) provide practical guidance for implementing LMEM in repeated measures SND.

METHODS & PROCEDURES

We illustrate an LMEM analysis, presenting data from a longitudinal training study of five individuals with acquired dysgraphia, analyzing both binomial (accuracy) and continuous (reaction time) repeated measurements.

OUTCOMES & RESULTS

The LMEM analysis reveals that both spelling accuracy and reaction time improved and, for accuracy, improved significantly more quickly under a training schedule with distributed, compared to clustered, practice. We present guidance on obtaining and interpreting various effect sizes and measures of statistical significance from LMEM, and include a simulation study comparing two p-value methods for generalized LMEM.

CONCLUSION

We provide a strong case for the application of LMEM to the analysis of training studies as a preferable alternative to visual analysis or other statistical techniques. When applied to a treatment dataset, the evidence supports that the approach holds up under the extreme conditions of small numbers of individuals, with repeated measures training data for both continuous (reaction time) and binomially distributed (accuracy) dependent measures. The approach provides standardized measures of effect sizes that are obtained through readily available and well-supported statistical packages, and provides statistically rigorous estimates of the expected average effect size of training effects, taking into account variability across both items and individuals.

Deciphering the mechanisms of phonological therapy in jargon aphasia

BACKGROUND

Severe word production difficulties remain one of the most challenging clinical symptoms to treat in individuals with jargon aphasia. Clinically, it is important to determine why some individuals with jargon aphasia improve following therapy when others do not. We report a therapy study with AM, an individual with severe neologistic jargon aphasia, and provide a subsequent comparison with previous cases, with the purpose of informing both our theoretical and clinical understanding of jargon aphasia.

AIMS

To investigate AM's locus of word production deficit and determine the effectiveness of phonological component analysis (PCA) therapy, a phonological cueing therapy, in the re-learning and generalization of naming responses for words. In addition, AM's performance in therapy, linguistic profile and ability to engage with therapy/cues were compared in a retrospective analysis with the background linguistic and therapy data of two other individuals with jargon aphasia (P9 and FF), who responded differentially to PCA. This was undertake to explore possible prognostic indicators of phonological therapy for jargon aphasia.

METHODS & PROCEDURES

A battery of linguistic and neuropsychological tests was used to identify AM's word production deficit. A single-subject multiple probe design across behaviours was employed to evaluate the effects of PCA therapy on the re-learning and generalization of naming responses. In the retrospective analysis of AM, P9 and FF, we compared differences and similarities in performance on various linguistic tasks, the ability to engage in therapy (i.e., ability to generate and use the cues), as well as to retain and maintain cues.

OUTCOMES & RESULTS

AM's locus of deficit was identified in the mapping between semantics and phonology. PCA was found to be effective in improving naming in two of the three treated word lists during the treatment phase; however, these gains were not maintained. Generalization to untreated picture names was not observed. Findings from the retrospective analysis illustrated that oral reading skills, the ability to segment phonological information from words and active engagement with provided cues are likely prerequisites for obtaining robust and long-term gains.

CONCLUSIONS & IMPLICATIONS

We demonstrated that phonological therapy could be beneficial for the remediation of naming abilities at least in the re-learning phase; however, maintenance and generalization of these gains were limited. This research helps to elucidate the considerations and evaluations necessary for the appropriateness of phonological therapy and candidacy of individuals with jargon aphasia for this treatment approach.

Interaction-focussed therapy for aphasia: Effects on communication and quality of life

PURPOSE

This study examined the effects of an interaction-focussed therapy for aphasia, which involved both people with aphasia and their familiar conversation partners. It was hypothesised the interaction-focussed therapy would lead to positive changes in targeted conversation behaviours, and improved quality of life for participants with aphasia.

METHOD

Three people with chronic aphasia and three of their familiar conversation partners completed an 8-week interaction-focussed therapy programme. A series of single case multiple-baseline ABA experiments were conducted. Outcome measures focussed on changes in targeted behaviours between pre- and post-therapy conversation samples, and changes in quality of life.

RESULT

All participant dyads improved their conversations. Familiar conversation partners demonstrated significant changes in targeted behaviours, while only one participant with aphasia achieved significant improvements. There was little evidence of a positive impact on quality of life for participants with aphasia.

CONCLUSION

Interaction-focussed therapy enhances everyday communication for people with aphasia and their conversation partners. However, the complex nature of learning in this intervention means that further, likely interdisciplinary work is required to better understand what mediates skill acquisition and therapeutic change and its psychosocial impact. This information is particularly important for optimising interaction-focussed therapy for people with aphasia.

Treatment for spoken and written word retrieval in the semantic variant of primary progressive aphasia

This study investigated whether a treatment programme for spoken word retrieval, supplemented with written naming, was beneficial for an individual with right-hemisphere dominant semantic variant of PPA (svPPA). Assessment and treatment were delivered remotely through Skype. Treatment consisted of two phases of lexical retrieval therapy (Repetition and Reading in the Presence of a Picture: RRIPP), with and without written responses (Phases 1 and 2 respectively), and a third treatment phase based on the procedures of Conceptual Enrichment (COEN) therapy. The first two phases of treatment resulted in short-lasting improvements in spoken and written word retrieval, with greater improvement in Phase 2 when written production was also required. Both treatment phases resulted in gains only for treated items, but generalised to different depictions to those treated. However, Phase 2 also resulted in significant improvement of treated items on a comprehension task. COEN treatment did not result in significant gains in word retrieval or comprehension. This study reinforces the value of a simple lexical retrieval treatment delivered remotely. It adds to the current evidence that anomia in svPPA can be responsive to treatment, but also shows that challenges remain regarding maintenance effects and the generalisation of treatment effects to connected speech.

Intervention for a lexical reading and spelling difficulty in two Greek-speaking primary age children

An intervention study was carried out with two nine-year-old Greek-speaking dyslexic children. Both children were slow in reading single words and text and had difficulty in spelling irregularly spelled words. One child was also poor in non-word reading. Intervention focused on spelling in a whole-word training using a flashcard technique that had previously been found to be effective with English-speaking children. Post-intervention assessments conducted immediately at the end of the intervention, one month later and then five months later showed a significant improvement in spelling of treated words that was sustained over time. In addition, both children showed generalisation of improvement to untrained words and an increase in scores in a standardised spelling assessment. The findings support the effectiveness of theoretically based targeted intervention for literacy difficulties.

Masked Visual Analysis: Minimizing Type I Error in Visually Guided Single-Case Design for Communication Disorders

PURPOSE

Single-case experimental designs are widely used to study interventions for communication disorders. Traditionally, single-case experiments follow a response-guided approach, where design decisions during the study are based on participants' observed patterns of behavior. However, this approach has been criticized for its high rate of Type I error. In masked visual analysis (MVA), response-guided decisions are made by a researcher who is blinded to participants' identities and treatment assignments. MVA also makes it possible to conduct a hypothesis test assessing the significance of treatment effects.

METHOD

This tutorial describes the principles of MVA, including both how experiments can be set up and how results can be used for hypothesis testing. We then report a case study showing how MVA was deployed in a multiple-baseline across-subjects study investigating treatment for residual errors affecting rhotics. Strengths and weaknesses of MVA are discussed.

CONCLUSIONS

Given their important role in the evidence base that informs clinical decision making, it is critical for single-case experimental studies to be conducted in a way that allows researchers to draw valid inferences. As a method that can increase the rigor of single-case studies while preserving the benefits of a response-guided approach, MVA warrants expanded attention from researchers in communication disorders.

Intervention research: Appraising study designs, interpreting findings and creating research in clinical practice

Speech-language pathologists (SLPs) are increasingly required to read, interpret and create evidence regarding the effectiveness of interventions. This requires a good understanding of the strengths and weaknesses of different intervention study designs. This paper aims to take readers through a range of designs commonly used in speech-language pathology, working from those with the least to most experimental control, with a particular focus on how the more robust designs avoid some of the limitations of weaker designs. It then discusses the factors other than research design which need to be considered when deciding whether or not to implement an intervention in clinical practice. The final section offers some tips and advice on carrying out research in clinical practice, with the hope that more SLPs will become actively involved in creating intervention research.

Efficacy of Visual-Acoustic Biofeedback Intervention for Residual Rhotic Errors: A Single-Subject Randomization Study

PURPOSE

This study documented the efficacy of visual-acoustic biofeedback intervention for residual rhotic errors, relative to a comparison condition involving traditional articulatory treatment. All participants received both treatments in a single-subject experimental design featuring alternating treatments with blocked randomization of sessions to treatment conditions.

METHOD

Seven child and adolescent participants received 20 half-hour sessions of individual treatment over 10 weeks. Within each week, sessions were randomly assigned to feature traditional or biofeedback intervention. Perceptual accuracy of rhotic production was assessed in a blinded, randomized fashion. Each participant's response to the combined treatment package was evaluated by using effect sizes and visual inspection. Differences in the magnitude of response to traditional versus biofeedback intervention were measured with individual randomization tests.

RESULTS

Four of 7 participants demonstrated a clinically meaningful response to the combined treatment package. Three of 7 participants showed a statistically significant difference between treatment conditions. In all 3 cases, the magnitude of within-session gains associated with biofeedback exceeded the gains associated with traditional treatment.

CONCLUSIONS

These results suggest that the inclusion of visual-acoustic biofeedback can enhance the efficacy of intervention for some individuals with residual rhotic errors. Further research is needed to understand which participants represent better or poorer candidates for biofeedback treatment.

Cross-linguistic transfer effects after phonologically based cognate therapy in a case of multilingual specific language impairment (SLI)

BACKGROUND

Clinicians globally recognize as exceptionally challenging the development of effective intervention practices for bi- or multilingual children with specific language impairment (SLI). Therapy in both or all of an impaired child's languages is rarely possible. An alternative is to develop treatment protocols that facilitate the transfer of therapy effects from a treated language to an untreated language.

AIMS

To explore whether cognates, words that share meaning and phonological features across languages, could be used to boost lexical retrieval in the context of multilingual SLI. This is dependent on exploiting the phonological information in the one, trained language as a mechanism for (phonological) language transfer to the other, untrained languages.

METHODS & PROCEDURES

The participant is an 8.5-year-old girl diagnosed with SLI who showed a severe naming deficit in her three spoken languages (Bulgarian, English and Greek). She received training on cognates (n = 20) using a picture-based naming task in English only, three times a week, over a 4-week period for 20 min each time. Phonological-based naming therapy was carried out using form-based strategies.

OUTCOMES & RESULTS

There was a significant improvement during therapy and immediately after intervention on cognate performance in English which was maintained 1 month after intervention. Cognate production in Bulgarian and Greek also improved during all stages of the intervention. Improvement in the non-treated languages was slightly more than half of the improvement recorded in English. The findings reflected some degree of cross-linguistic transfer effects.

CONCLUSIONS & IMPLICATIONS

Cross-linguistic transfer effects were evident during therapy and after therapy had finished and the effects were maintained 1 month post-treatment. Both the native language (Bulgarian) and the dominant language (Greek) benefitted equally from the treatment of cognates in English. Generalization to non-treatment words was evident, predominantly for English. The results suggest that cognates can indeed be used successfully as a WFD intervention strategy for multilingual children with SLI with lasting effects.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of Cognitive Ability on Therapy Outcomes for Anomia in Adults With Chronic Poststroke Aphasia

PURPOSE

The relationship between cognitive abilities and aphasia rehabilitation outcomes is complex and remains poorly understood. This study investigated the influence of language and cognitive abilities on anomia therapy outcomes in adults with aphasia.

METHOD

Thirty-four adults with chronic aphasia participated in Aphasia Language Impairment and Functioning Therapy. A language and cognitive assessment battery, including 3 baseline naming probes, was administered prior to therapy. Naming accuracy for 30 treated and 30 untreated items was collected at posttherapy and 1-month follow-up. Multiple regression models were computed to evaluate the relationship between language and cognitive abilities at baseline and anomia therapy outcomes.

RESULTS

Both language and cognitive variables significantly influenced anomia therapy gains. Verbal short-term memory ability significantly predicted naming gains for treated items at posttherapy (β = -.551, p = .002) and for untreated items at posttherapy (β = .456, p = .014) and 1-month follow-up (β = .455, p = .021). Furthermore, lexical-semantic processing significantly predicted naming gains for treated items at posttherapy (β = -.496, p = .004) and 1-month follow-up (β = .545, p = .012).

CONCLUSIONS

Our findings suggest that individuals' cognitive ability, specifically verbal short-term memory, affects anomia treatment success. Further research into the relationship between cognitive ability and anomia therapy outcomes may help to optimize treatment techniques.

The Effects of Sentence Repetition-Based Working Memory Treatment on Sentence Comprehension Abilities in Individuals With Aphasia

PURPOSE

This study investigated whether sentence repetition-based working-memory (SR-WM) treatment increased sentence-repetition abilities and the treatment effects generalized to sentence-comprehension abilities, WM-span tasks, and general language-assessment tasks.

METHOD

Six individuals with aphasia participated in the study. The treatment consisted of 12 sessions of approximately 1 hr per day, 3 times per week. The SR-WM treatment protocol followed components including maintenance and computation of linguistic units by facilitating a chunking strategy. We manipulated the length and syntactic structures of the sentence-repetition stimuli using a limited set of vocabulary.

RESULTS

Participants demonstrated significant increased repetition ability in treated and untreated sentences after treatment. Furthermore, they showed generalization effects on the sentence-comprehension task, WM measures, and general language tasks, but with some differential patterns, depending on task demands.

CONCLUSIONS

The SR-WM treatment approach, by manipulating syntactic structures and minimizing top-down semantic processing, elicited increased performance on sentence repetition as well as other linguistic domains. Results indicated that it is clinically and theoretically important to examine whether WM treatment serves as a potentially underlying treatment approach that facilitates the distributed network associated with language processing.

Conversation Therapy with People with Aphasia and Conversation Partners using Video Feedback: A Group and Case Series Investigation of Changes in Interaction

Conversation therapies employing video for feedback and to facilitate outcome measurement are increasingly used with people with post-stroke aphasia and their conversation partners; however the evidence base for change in everyday interaction remains limited. We investigated the effect of Better Conversations with Aphasia (BCA), an intervention that is freely available online at https://extend.ucl.ac.uk/. Eight people with chronic agrammatic aphasia, and their regular conversation partners participated in the tailored 8 week program involving significant video feedback. We explored changes in: (i) conversation facilitators (such as multi-modal turns by people with aphasia); and (ii) conversation barriers (such as use of test questions by conversation partners). The outcome of intervention was evaluated directly by measuring change in video-recorded everyday conversations. The study employed a pre-post design with multiple 5 minute samples of conversation before and after intervention, scored by trained raters blind to the point of data collection. Group level analysis showed no significant increase in conversation facilitators. There was, however, a significant reduction in the number of conversation barriers. The case series data revealed variability in conversation behaviors across occasions for the same dyad and between different dyads. Specifically, post-intervention there was a significant increase in facilitator behaviors for two dyads, a decrease for one and no significant change for five dyads. There was a significant decrease in barrier behaviors for five dyads and no significant change for three dyads. The reduction in barrier behaviors was considerable; on average change from over eight to fewer than three barrier behaviors in 5 minutes of conversation. The pre-post design has the limitation of no comparison group. However, change occurs in targeted conversational behaviors and in people with chronic aphasia and their partners. The findings suggest change can occur after eight therapy sessions and have implications for clinical practice. A reduction in barrier behaviors may be easier to obtain, although the controlled case series results demonstrate a significant increase in conversation facilitators is also possible. The rehabilitation tool is available online and video technology was central to delivering intervention and evaluating change.