Telerehabilitation of Anomia in Primary Progressive Aphasia

Rehabilitation Services for Young-Onset Dementia: Examples from High- and Low-Middle-Income Countries

The WHO Dementia Global Action Plan states that rehabilitation services for dementia are required to promote health, reduce disability, and maintain quality of life for those living with dementia. Current services, however, are scarce, particularly for people with young-onset dementia (YOD). This article, written by an international group of multidisciplinary dementia specialists, offers a three-part overview to promote the development of rehabilitation services for YOD. Firstly, we provide a synthesis of knowledge on current evidence-based rehabilitative therapies for early-onset Alzheimer's disease (EOAD), behavioural variant frontotemporal dementia (bvFTD), primary progressive aphasia (PPA), and posterior cortical atrophy (PCA). Secondly, we discuss the characteristics of rehabilitation services for YOD, providing examples across three continents for how these services can be embedded in existing settings and the different roles of the rehabilitation multidisciplinary team. Lastly, we conclude by highlighting the potential of telehealth in making rehabilitation services more accessible for people with YOD. Overall, with this paper, we aim to encourage clinical leads to begin introducing at least some rehabilitation into their services, leveraging existing resources and finding support in the collective expertise of the broader multidisciplinary dementia professional community.

TelePriming sentence production in aphasia

Background

The application of videoconferencing to the assessment and treatment of aphasia has been rapidly increasing; however, there is a need to develop treatments targeting sentence production in persons with aphasia (PWA) that can be delivered through videoconferencing. Structural priming has received recent attention as a potential training method for PWA. We investigated the feasibility and efficacy of a collaborative structural priming task delivered via the internet, TelePriming, in facilitating sentence production in PWA and healthy adults.

Method

In Study 1, young adults (YA), older adults (OA), and PWA participated in a collaborative dialogue-like priming task through videoconferencing, taking turns with an interlocutor (experimenter) to describe transitive action pictures with the goal of finding matching pictures. We measured whether participants produced more passive sentences to describe their picture after hearing their interlocutor produce passive compared to active sentences (primes). In Study 2, we compared the data from the OA and PWA of Study 1 (TelePriming) to different groups of OA and PWA, who completed the same priming task in person.

Results

All three groups showed robust priming effects in Study 1, producing more passive sentences to describe target pictures after hearing the experimenter produce passive versus active sentences. In Study 2, when controlling for demographic information (age, education) and aphasia severity, TelePriming resulted in larger priming effects for OA and PWA, compared to the in-person priming task. Survey results revealed that both OA and PWA experienced increased comfort and satisfaction with using technology following the task.

Conclusion

Interactive message-structure alignment processes remain largely intact in PWA, and the positive effects of structural priming in a collaborative communicative task are not diminished by remote delivery. The findings demonstrate the feasibility and validity of TelePriming in OA and PWA, laying experimental groundwork for future use of TelePriming in the assessment and treatment of clinical populations with limited access to face-to-face sessions.

Behavioral Treatment for Speech and Language in Primary Progressive Aphasia and Primary Progressive Apraxia of Speech: A Systematic Review

Primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS) are neurodegenerative syndromes characterized by progressive decline in language or speech. There is a growing number of studies investigating speech-language interventions for PPA/PPAOS. An updated systematic evaluation of the treatment evidence is warranted to inform best clinical practice and guide future treatment research. We systematically reviewed the evidence for behavioral treatment for speech and language in this population. Reviewed articles were published in peer-reviewed journals through 31 May 2021. We evaluated level of evidence, reporting quality, and risk of bias using a modified version of the American Speech-Language Hearing Association (ASHA) Levels of Evidence, an appraisal point system, additional reporting quality and internal/external validity items, and, as appropriate, the Single Case Experimental Design Scale or the Physiotherapy Evidence Database - PsycBITE Rating Scale for Randomized and Non-Randomized Controlled Trials. Results were synthesized using quantitative summaries and narrative review. A total of 103 studies reported treatment outcomes for 626 individuals with PPA; no studies used the diagnostic label PPAOS. Most studies evaluated interventions for word retrieval. The highest-quality evidence was provided by 45 experimental and quasi-experimental studies (16 controlled group studies, 29 single-subject designs). All (k = 45/45) reported improvement on a primary outcome measure; most reported generalization (k = 34/43), maintenance (k = 34/39), or social validity (k = 17/19) of treatment for at least one participant. The available evidence supports speech-language intervention for persons with PPA; however, treatment for PPAOS awaits systematic investigation. Implications and limitations of the evidence and the review are discussed.

A Multimodal Approach for Clinical Diagnosis and Treatment of Primary Progressive Aphasia (MAINSTREAM): A Study Protocol

Primary Progressive Aphasia (PPA) is a syndrome due to different neurodegenerative disorders selectively disrupting language functions. PPA specialist care is underdeveloped. There are very few specialists (neurologists, psychiatrists, neuropsychologists, and speech therapists) and few hospital- or community-based services dedicated to the diagnosis and continuing care of people with PPA. Currently, healthcare systems struggle to provide adequate coverage of care that is too often fragmented, uncoordinated, and unresponsive to the needs of people with PPA and their families. Recently, attention has been gained by non-invasive brain stimulation techniques that allow a personalized treatment approach, such as transcranial Direct Current Stimulation (tDCS). The MAINSTREAM trial looks forward to introducing and evaluating therapeutic innovations such as tDCS coupled with language therapy in rehabilitation settings. A Multimodal Approach for Clinical Diagnosis and Treatment of Primary Progressive Aphasia, MAINSTREAM (ID: 3430931) was registered in the clinicaltrials.gov database (identifier: NCT05730023) on 15 February 2023.

Transcranial Direct Current Stimulation Paired With Verb Network Strengthening Treatment Improves Verb Naming in Primary Progressive Aphasia: A Case Series

PURPOSE

There are few evidence-based treatments for language deficits in primary progressive aphasia (PPA). PPA treatments are often adopted from the poststroke aphasia literature. The poststroke aphasia literature has shown promising results using Verb Network Strengthening Treatment (VNeST), a behavioral therapy that focuses on improving naming by producing verbs and their arguments in phrases and sentences. Emerging research in poststroke aphasia and PPA has shown promising results pairing behavioral language therapy with transcranial direct current stimulation (tDCS).

METHOD

This study used a double-blind, within-subjects, sham-controlled crossover design to study the effect of anodal tDCS applied to left inferior frontal gyrus (IFG) plus VNeST versus VNeST plus sham stimulation in two individuals with nonfluent variant PPA and one individual with logopenic variant PPA. Participants received two phases of treatment, each with 15 1-hr sessions of VNeST. One phase paired VNeST with tDCS stimulation, and one with sham. For each phase, language testing was conducted at baseline, and at 1 week and 8 weeks posttreatment conclusion. For each participant, treatment efficacy was evaluated for each treatment phase by comparing the mean change in accuracy between baseline and the follow-up time points for naming trained verbs (primary outcome measure), untrained verbs, and nouns on the Object and Action Naming Battery. Mean change from baseline was also directly compared between tDCS and sham phases at each time point.

RESULTS

Results revealed a different pattern of outcomes for each of the participants. A tDCS advantage was not found for trained verbs for any participant. Two participants with nonfluent variant PPA had a tDCS advantage for generalization to naming of untrained verbs, which was apparent at 1 week and 8 weeks posttreatment. One participant with nonfluent variant also showed evidence of generalization to sentence production in the tDCS phase.

CONCLUSION

VNeST plus anodal tDCS stimulation of left IFG shows promising results for improving naming in PPA.

Modified script training for nonfluent/agrammatic primary progressive aphasia with significant hearing loss: A single-case experimental design

Speech-language pathology caseloads often include individuals with hearing loss and a coexisting neurogenic communication disorder. However, specific treatment techniques and modifications designed to accommodate this population are understudied. Using a single-case experimental design, the current study investigated the utility of modified Video Implemented Script Training for Aphasia (VISTA) for an individual with nonfluent/agrammatic variant primary progressive aphasia and severe-to-profound, bilateral hearing loss. We analyzed the impact of this intervention, which incorporates orthographic input and rehearsal, on script production accuracy, speech intelligibility, grammatical complexity, mean length of utterance, and speech rate. Treatment resulted in comparable positive outcomes relative to a previous study evaluating script training in nonfluent/agrammatic primary progressive aphasia patients with functional hearing. Follow-up data obtained at three months, six months, and one year post-treatment confirmed maintenance of treatment effects for trained scripts. To our knowledge, this is the first study to investigate a modified speech-language intervention tailored to the needs of an individual with PPA and hearing loss, with findings confirming that simple treatment modifications may serve to broaden the range of treatment options available to those with concomitant sensory and communication impairments.

Noninvasive brain stimulation to augment language therapy for primary progressive aphasia

Primary progressive aphasia (PPA) is a debilitating disorder characterized by the gradual loss of language functioning resulting from neurodegenerative diseases including frontotemporal lobar degeneration or Alzheimer's disease pathology. There is a dearth of research investigating language therapy in PPA. Unlike individuals with poststroke aphasia, language skills are expected to decline over time, so the goal of treatment is often to preserve existing language functioning. There has been an increasing interest in using non-invasive brain stimulation including transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) to augment traditional behavioral therapy in PPA. Research is promising and suggests neuromodulation can lead to generalization and maintenance of treatment effects for a longer period compared to behavioral therapy alone. Emerging research is also beginning to identify predictors of treatment response. Yet there is still much to learn regarding how neuromodulation factors (e.g., type of stimulation, stimulation intensity), participant factors (e.g., demographics, extent and location of atrophy), and treatment factors (e.g., type of language therapy, and dosage) will interact to predict treatment response. We are moving toward a promising future where individuals with PPA will benefit from individualized therapy protocols pairing traditional language therapy with neuromodulation.

Behavioral interventions for primary progressive aphasia

Primary progressive aphasia (PPA) is a neurodegenerative syndrome characterized by a gradual loss of communication ability. Due to the centrality of communication deficits, speech-language pathologists play a prominent role in the provision of care for individuals with PPA. In this chapter, we outline a person-centered approach to the management of PPA that aims to preserve independence for as long as possible while anticipating future decline in communication and other domains. A growing evidence base supports the utility of speech-language treatment approaches in PPA, including restitutive, compensatory, and communication partner-focused techniques. Restitutive interventions aim to rebuild lost communication skills, such as naming or fluent speech production. Compensatory approaches include training with high- and low-tech augmentative and alternative communication systems that provide complementary means of communication beyond speech. Communication partner interventions focus on education and strategy training in order to equip conversation partners as skilled communication facilitators. Throughout intervention, clinicians should aim to provide treatment that impacts functional communication and promotes social engagement. Given the documented benefits of speech-language intervention in PPA, we are optimistic that such treatment will become the standard of care and that additional research will continue to improve the quality and accessibility of behavioral interventions.

Semantic Variant Primary Progressive Aphasia: Practical Recommendations for Treatment from 20 Years of Behavioural Research

People with semantic variant primary progressive aphasia (svPPA) present with a characteristic progressive breakdown of semantic knowledge. There are currently no pharmacological interventions to cure or slow svPPA, but promising behavioural approaches are increasingly reported. This article offers an overview of the last two decades of research into interventions to support language in people with svPPA including recommendations for clinical practice and future research based on the best available evidence. We offer a lay summary in English, Spanish and French for education and dissemination purposes. This paper discusses the implications of right- versus left-predominant atrophy in svPPA, which naming therapies offer the best outcomes and how to capitalise on preserved long-term memory systems. Current knowledge regarding the maintenance and generalisation of language therapy gains is described in detail along with the development of compensatory approaches and educational and support group programmes. It is concluded that there is evidence to support an integrative framework of treatment and care as best practice for svPPA. Such an approach should combine rehabilitation interventions addressing the language impairment, compensatory approaches to support activities of daily living and provision of education and support within the context of dementia.

Cognitive Intervention Strategies Directed to Speech and Language Deficits in Primary Progressive Aphasia: Practice-Based Evidence from 18 Cases

BACKGROUND

Practice-based evidence can inform and support clinical decision making. Case-report series about the implementation of programs in real-world clinical settings may contribute to verifying the effectiveness of interventions for treating PPA in specific contexts, as well as illustrating challenges that need to be overcome.

OBJECTIVE

To describe and provide practice-based evidence on the effectiveness of four cognitive rehabilitation programs designed for individuals with PPA and directed to speech and language impairments, which were implemented in a specialized outpatient clinic.

METHODS

Multiple single-case study. Eighteen individuals with different subtypes of PPA were each assigned to one out of four training programs based on comprehensive speech and language assessments. The treatments targeted naming deficits, sentence production, speech apraxia, and phonological deficits. Pre- and post-treatment assessments were undertaken to compare trained and untrained items. Gains were generalized to a different task in the first two types of intervention (naming and sentence production). A follow-up assessment was conducted 1-8 months after treatment among 7 participants.

RESULTS

All individuals presented better performance in the trained items at the post-test for each rehabilitation program accomplished, demonstrating that learning of the trained strategies was achieved during the active phase of treatment. For 13 individuals, statistical significance was reached; while for five, the results were maintained. Results about untrained items, generalization to other tasks, and follow-up assessments are presented.

CONCLUSIONS

The positive results found in our sample bring some practice-based evidence for the benefits of speech and language treatment strategies for clinical management of individuals with PPA.

Embedding Aphasia-Modified Cognitive Behavioral Therapy in Script Training for Primary Progressive Aphasia: A Single-Case Pilot Study

Purpose This study sought to determine the initial feasibility and benefit of a novel intervention that combines speech-language treatment with counseling treatment for an individual with the nonfluent/agrammatic variant of primary progressive aphasia (PPA). Method Using a single-case experimental design, we evaluated the utility of modified script training paired with aphasia-modified cognitive behavioral therapy. The study employed a multiple baseline design across scripts for the primary linguistic outcome measure and a mixed methods approach for analyzing counseling outcomes. Psychosocial and communicative functioning scales were administered in conjunction with a phenomenological analysis of semi-structured interviews. Results The participant completed all study phases and participated in all treatment components. She met the criterion of 90% correct, intelligible scripted words on all trained scripts through 12 months post-treatment. Treatment outcomes were comparable to a comparison cohort that received script training without counseling (Henry et al., 2018). At post-treatment, the participant demonstrated stability or improvement on all measures of psychosocial and communicative functioning, with stability documented on seven out of 11 scales at follow-ups through 12 months post-treatment. A phenomenological analysis revealed pervasive themes of loss and resilience at both time points, and emerging themes of positive self-perception, sense of agency, and emotional attunement following treatment. Conclusions Results indicate that script training with aphasia-modified cognitive behavioral therapy is a feasible treatment for an individual with the nonfluent/agrammatic variant of PPA, with immediate and lasting benefits to speech-language production and psychosocial functioning. These findings are the first to support the integration of personal adjustment counseling techniques within a speech-language treatment paradigm for PPA. Supplemental Material https://doi.org/10.23641/asha.14925330.

Novel Advances to Post-Stroke Aphasia Pharmacology and Rehabilitation

Aphasia is one of the most common clinical features of functional impairment after a stroke. Approximately 21–40% of stroke patients sustain permanent aphasia, which progressively worsens one’s quality of life and rehabilitation outcomes. Post-stroke aphasia treatment strategies include speech language therapies, cognitive neurorehabilitation, telerehabilitation, computer-based management, experimental pharmacotherapy, and physical medicine. This review focuses on current evidence of the effectiveness of impairment-based aphasia therapies and communication-based therapies (as well as the timing and optimal treatment intensities for these interventions). Moreover, we present specific interventions, such as constraint-induced aphasia therapy (CIAT) and melodic intonation therapy (MIT). Accumulated data suggest that using transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) is safe and can be used to modulate cortical excitability. Therefore, we review clinical studies that present TMS and tDCS as (possible) promising therapies in speech and language recovery, stimulating neuroplasticity. Several drugs have been used in aphasia pharmacotherapy, but evidence from clinical studies suggest that only nootropic agents, donepezil and memantine, may improve the prognosis of aphasia. This article is an overview on the current state of knowledge related to post-stroke aphasia pharmacology, rehabilitation, and future trends.

Language training for oral and written naming impairment in primary progressive aphasia: a review

BACKGROUND

Primary progressive aphasia (PPA) is a neurodegenerative disorder characterized by a gradual, insidious and progressive loss of language abilities, with naming difficulties being an early and persistent impairment common to all three variants. In the absence of effective pharmacological treatments and given the progressive nature of the disorder, in the past few decades, many studies have investigated the effectiveness of language training to minimize the functional impact of word-finding difficulties in daily life.

MAIN BODY

We review language treatments most commonly used in clinical practice among patients with different variants of PPA, with a focus on the enhancement of spoken and written naming abilities. Generalization of gains to the ability to name untrained stimuli or to other language abilities and the maintenance of these results over time are also discussed. Forty-eight studies were included in this literature review, identifying four main types of language treatment: a) lexical retrieval treatment, b) phonological and/or orthographic treatment, c) semantic treatment, and d) a multimodality approach treatment. Overall, language training is able to induce immediate improvements of naming abilities in all variants of PPA. Moreover, despite the large variability among results, generalization and long-term effects can be recorded after the training. The reviewed studies also suggest that one factor that determines the choice of a particular approach is the compromised components of the lexical/semantic processing system.

CONCLUSION

The majority of studies have demonstrated improvements of naming abilities following language treatments. Given the progressive nature of PPA, it is essential to apply language treatment in the early stages of the disease.

Conducting a Virtual Study With Special Considerations for Working With Persons With Aphasia

Purpose The use of technology (e.g., telehealth) in clinical settings has rapidly increased, and its use in research settings continues to grow. The aim of this report is to present one potential solution to a clinical issue that of virtual and remote assessment for the purposes of spoken language research in persons with aphasia (PWA). To do so, we report detailed methods for conducting a multitimepoint (test-retest) virtual paradigm, assessing lifestyle, physiological, cognitive, and linguistic factors in persons with and without aphasia. Method Procedures for virtual assessment are detailed in a sample of adults with no brain damage (N = 24) and PWA (N = 25) on a test-retest paradigm (data collection approximately 10 ± 3 days apart). This report provides practical information about pre-assessment (e.g., recruitment, scheduling), assessment (e.g., aphasia-friendly consent presentation, investigator fidelity), and postassessment (e.g., data storage, quality check) procedures for human behavior research using a virtual platform. Results Preliminary study data are provided, indicating high retention rates, high rates of data acquisition, and feasibility. Common technological troubles and solutions are discussed, and solutions are offered. The results suggest that our pre-assessment, assessment, and postassessment procedures contributed to the success of our study. Conclusions We provide a practical methodology for conducting a multitimepoint study, with considerations for PWA, adding to the body of research on telehealth in clinical populations. Future studies should continue to evaluate telemethodology, which may be core for diversifying studies, improving study retention, and enrolling larger sample sizes. Supplemental Material https://doi.org/10.23641/asha.14608101.

A Scoping Review of Cognitive Training in Neurodegenerative Diseases via Computerized and Virtual Reality Tools: What We Know So Far

Most prevalent neurodegenerative diseases such as Alzheimer's disease, frontotemporal dementia, Parkinson's disease and multiple sclerosis are heterogeneous in their clinical profiles and underlying pathophysiology, although they typically share the presence of cognitive impairment that worsens significantly during the course of the disease. Viable pharmacological options for cognitive symptoms in these clinical conditions are currently lacking. In recent years, several studies have started to apply Computerized Cognitive Training (CCT) and Virtual Reality (VR) tools to try and contrast patients' cognitive decay over time. However, no in-depth literature review of the contribution of these promising therapeutic options across main neurodegenerative diseases has been conducted yet. The present paper reports the state-of-the-art of CCT and VR studies targeting cognitive impairment in most common neurodegenerative conditions. Our twofold aim is to point out the scientific evidence available so far and to support health professionals to consider these promising therapeutic tools when planning rehabilitative interventions, especially when the access to regular and frequent hospital consultations is not easy to be provided.

Treating lexical retrieval using letter fluency and tDCS in primary progressive aphasia: a single-case study

Background

In early stages, individuals with Primary Progressive Aphasia (PPA) report language symptoms while scoring within norm in formal language tests. Early intervention is important due to the progressive nature of the disease.

Method

We report a single case study of an individual with logopenic variant PPA (lvPPA). We tested whether letter fluency, used as a therapy task, can improve lexical retrieval when combined with tDCS to either the left inferior-frontal gyrus (IFG) or the left inferior parietal lobe (IPL), administered in two separate therapy phases separated by a wash-out period of three months.

Outcomes and results

We observed increases in number of words retrieved during a letter fluency task in trained and untrained letters, when letter fluency therapy (LeFT) was administered with anodal tDCS. When LeFT was combined with left IFG stimulation, words produced in a letter fluency task were lower frequency and higher age of acquisition after treatment, compared to before treatment and there was also an increase in accuracy and response times in an untrained picture-naming task.

Conclusions

The results indicate that letter fluency therapy combined anodal tDCS is effective in improving lexical retrieval, particularly when left IFG stimulation was used. Effects generalize beyond the trained task, albeit slowing down of responses in picture naming. This task may provide a useful clinical intervention strategy for patients with mild anomia, who are not challenged enough by traditional naming therapies.

Plasticity of sentence processing networks: evidence from a patient with agrammatic variant of primary progressive aphasia (PPA)

This study reports the results of a longitudinal study examining the effects of treatment for sentence processing deficits for a 70-year-old gentleman (DK) with the agrammatic variant of Primary Progressive Aphasia (PPA). On entry into the study, he presented with a 2-year history of impaired verb and sentence processing and concomitant neural atrophy in primarily subcortical regions. Spanning an 18-month period, treatment focused on improving comprehension and production of syntactically complex, passive and object cleft, structures, consecutively. Results, derived from extensive behavioral and neurocognitive testing, showed not only improved ability to comprehend and produce both trained and untrained, less complex, linguistically related structures in offline tasks, but also improved online sentence processing strategies as revealed by partially normalized eye movements in online comprehension (i.e., emergence of thematic prediction and thematic integration) and production (i.e., use of incremental processing) tasks. Changes in neural activation from pre- to post-treatment of both structures also were found, with upregulation of tissue in both the left and right hemispheres, overlapping with regions recruited by neurotypical adults performing the same task. These findings indicate that Treatment of Underlying Forms (TUF) is effective for treatment of patients with the agrammatic variant of PPA (as it is for those with stroke-induced agrammatism), and show that unaffected neural tissue in patients with PPA is malleable and may be recruited to support language, providing evidence of experience-based plasticity in neurodegenerative disease.

Nosology of Primary Progressive Aphasia and the Neuropathology of Language

Primary progressive aphasia (PPA) is a dementia syndrome associated with several neuropathologic entities, including Alzheimer's disease (AD) and all major forms of frontotemporal lobar degeneration (FTLD). It is classified into subtypes defined by the nature of the language domain that is most impaired. The asymmetric neurodegeneration of the hemisphere dominant for language (usually left) is one consistent feature of all PPA variants. This feature offers unique opportunities for exploring mechanisms of selective vulnerability in neurodegenerative diseases and the neuroanatomy of language. This chapter reviews some of the current trends in PPA research as well as the challenges that remain to be addressed on the nosology, clinicopathologic correlations, and therapy of this syndrome.

Evaluating a Maintenance-Based Treatment Approach to Preventing Lexical Dropout in Progressive Anomia

Purpose Primary progressive aphasia (PPA) and the amnestic variant of Alzheimer's disease (AD) are neurodegenerative conditions characterized by a profound loss of functional communication abilities. Communicative impairment in AD and PPA is especially apparent in the domain of naming common objects and familiar faces. We evaluated the effectiveness of a language intervention targeting maintenance of an individualized core vocabulary in a longitudinal cohort of older adults experiencing either PPA or AD. Method PPA (n = 9) and AD (n = 1) patients were administered a semantically based language treatment for up to 2 years. Patients repeatedly named and generated semantic features for a personalized lexicon consisting of 100 words. We evaluated naming accuracy and off-line neuropsychological measures at four successive timepoints. Naming accuracy was assessed in patients (n = 7) who completed at least three recurrent evaluations. Off-line neuropsychological performance was assessed across timepoints in all patients. Results Patients demonstrated relative preservation of naming trained words relative to a steep decline for untrained (control) words. The greatest decrements were observed for naming people relative to objects. Conclusion These results suggest that consistent training of a finite set of words can protect a core lexicon composed of crucial target concepts (e.g., a spouse's name). We discuss potential benefits and clinical implications of maintenance-based approaches to promoting language functioning in the context of neurodegeneration.

Telepractice for Adult Speech-Language Pathology Services: A Systematic Review

Purpose

We conducted a systematic review of the literature regarding adult telepractice services (screening, assessment, and treatment) from approximately 2014 to 2019.

Method

Thirty-one relevant studies were identified from a literature search, assessed for quality, and reported.

Results

Included studies illustrated feasibility, efficacy, diagnostic accuracy, and noninferiority of various speech-language pathology services across adult populations, including chronic aphasia, Parkinson's disease, dysphagia, and primary progressive aphasia. Technical aspects of the equipment and software used to deliver services were discussed. Some general themes were noted as areas for future research.

Conclusion

Overall, results of the review continue to support the use of telepractice as an appropriate service delivery model in speech-language pathology for adults. Strong research designs, including experimental control, across multiple well-described settings are still needed to definitively determine effectiveness of telepractice services.

Assessment of individuals with aphasia: an integrative literature review

ABSTRACT Objective: to analyze which evaluations are used by occupational therapists, speech-language pathologists and physiotherapists on individuals presented with aphasia and what these evaluations address. Methods: the study conducted a national and international documental analysis of evaluations used by professionals working on the neurological rehabilitation of adults and/or elderly individuals with aphasia, published in the last ten years (January 2008/June 2018). This analysis was performed by an integrative review of databases LILACS, SciELO and PubMed, using the descriptors: Health Assessment or Testing, or Protocols, or Psychometrics, or Questionnaires and Rehabilitation, combined with the descriptors: Aphasia, Occupational Therapy, Speech-language Pathology and Physiotherapy. Results: 26 studies were included, most of which were scored as level VI of scientific evidence; the years of 2013 and 2016 presented publication peaks. The studies used 54 evaluation tools, among which 13 were recurrent in the studies, mostly analyzing aspects of communication/language. It is assumed that these data are related to the fact that speech-language pathologists provide care for individuals with aphasia; however, these individuals may present other needs beyond communication, such as those related to human occupation, requiring multiprofessional and integral health care. Among the protocols, the Stroke Impact Scale (SIS) was considered the most complete, since it addresses communication, linguistic, human occupation and psycho-affective aspects. Conclusion: this study identified the use of few instruments dedicated to individuals with aphasia related to all aspects that involve life, with predominance of protocols and evaluations that only address disabilities, highlighting the importance of assessments that address subjectivity, evaluating individuals with aphasia in all dimensions of their lives.

Cognitive and language performance predicts effects of spelling intervention and tDCS in Primary Progressive Aphasia

Predictors of treatment effects allow individual tailoring of treatment characteristics, thereby saving resources and optimizing outcomes. Electrical stimulation coupled with language intervention has shown promising results in improving language performance in individuals with Primary Progressive Aphasia (PPA). The current study aimed to identify language and cognitive variables associated with response to therapy consisting of language intervention combined with transcranial direct current stimulation (tDCS). Forty individuals with PPA received written naming/spelling intervention combined with anodal tDCS or Sham, using a between-subjects, randomized design, with intervention delivered over a period of 3 weeks. Participants were assessed using a battery of neuropsychological tests before and after each phase. We measured letter accuracy during spelling of trained and untrained words, before, immediately after, 2 weeks, and 2 months after therapy. We used step-wise regression methods to identify variables amongst the neuropsychological measures and experimental factors that were significantly associated with therapy outcomes at each time-point. For trained words, improvement was related to pre-therapy scores, in RAVLT (5 trials sum), pseudoword spelling, object naming, digit span backward, spatial span backward and years post symptom onset. Regarding generalization to untrained words, improvement in spelling was associated with pseudoword spelling, RAVLT proactive interference, RAVLT immediate recall. Generalization effects were larger under tDCS compared to Sham at the 2-month post training measurement. We conclude that, for trained words, patients who improve the most are those who retain for longer language skills such as sublexical spelling processes (phoneme-to-grapheme correspondences) and word retrieval, and other cognitive functions such as executive functions and working memory, and those who have a better learning capacity. Generalization to untrained words occurs through improvement in knowledge of phoneme-to-grapheme correspondences. Furthermore, tDCS enhances the generalizability and duration of therapy effects.

In-Home Video Telehealth for Dementia Management: Implications for Rehabilitation

PURPOSE OF REVIEW

The progressive nature of dementia requires ongoing care delivered by multidisciplinary teams, including rehabilitation professionals, that is individualized to patient and caregiver needs at various points on the disease trajectory. Video telehealth is a rapidly expanding model of care with the potential to expand dementia best practices by increasing the reach of dementia providers to flexible locations, including patients' homes. We review recent evidence for in-home video telehealth for patients with dementia and their caregivers with emphasis on implications for rehabilitation professionals.

RECENT FINDINGS

Eleven studies were identified that involved video visits into the home targeting patients with dementia and/or their family caregivers. The majority describe protocolized interventions targeting caregivers in a group format over a finite, pre-determined period. For most, the discipline of the interventionist was unclear, though two studies included rehabilitation interventions. While descriptions of utilized technology were often lacking, many reported that devices were issued to participants when needed, and that technical support was provided by study teams. Positive caregiver outcomes were noted but evidence for patient-level outcomes and cost data are mostly lacking.

SUMMARY

More research is needed to demonstrate implementation of dementia best care practices through in-home video telehealth. Though interventions delivered using in-home video telehealth appear to be effective at addressing caregivers' psychosocial concerns, the impact on patients and the implications for rehabilitation remain unclear. Larger, more systematic inquiries comparing in-home video telehealth to traditional visit formats are needed to better define best practices.

Treatment for Word Retrieval in Semantic and Logopenic Variants of Primary Progressive Aphasia: Immediate and Long-Term Outcomes

Purpose Recent studies confirm the utility of speech-language intervention in primary progressive aphasia (PPA); however, long-term outcomes, ideal dosage parameters, and relative benefits of intervention across clinical variants warrant additional investigation. The purpose of this study was to determine whether naming treatment affords significant, lasting, and generalized improvement for individuals with semantic and logopenic PPA and whether dosage manipulations significantly affect treatment outcomes. Method Eighteen individuals with PPA (9 semantic and 9 logopenic variant) underwent lexical retrieval treatment designed to leverage spared cognitive-linguistic domains and develop self-cueing strategies to promote naming. One group (n = 10) underwent once-weekly treatment sessions, and the other group (n = 8) received the same treatment with 2 sessions per week and an additional "booster" treatment phase at 3 months post-treatment. Performance on trained and untrained targets/tasks was measured immediately after treatment and at 3, 6, and 12 months post-treatment. Results Outcomes from the full cohort of individuals with PPA showed significantly improved naming of trained items immediately post-treatment and at all follow-up assessments through 1 year. Generalized improvement on untrained items was significant up to 6 months post-treatment. The positive response to treatment was comparable regardless of session frequency or inclusion of a booster phase. Outcomes were comparable across PPA subtypes, as was maintenance of gains over the post-treatment period. Conclusion This study documents positive naming treatment outcomes for a group of individuals with PPA, demonstrating strong direct treatment effects, maintenance of gains up to 1 year post-treatment, and generalization to untrained items. Lexical retrieval treatment, in conjunction with daily home practice, had a strong positive effect that did not require more than 1 clinician-directed treatment session per week. Findings confirm that strategic training designed to capitalize on spared cognitive-linguistic abilities results in significant and lasting improvement, despite ongoing disease progression, in PPA.

Retraining speech production and fluency in non-fluent/agrammatic primary progressive aphasia

The non-fluent/agrammatic variant of primary progressive aphasia (nfvPPA) presents with a gradual decline in grammar and motor speech resulting from selective degeneration of speech-language regions in the brain. There has been considerable progress in identifying treatment approaches to remediate language deficits in other primary progressive aphasia variants; however, interventions for the core deficits in nfvPPA have yet to be systematically investigated. Further, the neural mechanisms that support behavioural restitution in the context of neurodegeneration are not well understood. We examined the immediate and long-term benefits of video implemented script training for aphasia (VISTA) in 10 individuals with nfvPPA. The treatment approach involved repeated rehearsal of individualized scripts via structured treatment with a clinician as well as intensive home practice with an audiovisual model using 'speech entrainment'. We evaluated accuracy of script production as well as overall intelligibility and grammaticality for trained and untrained scripts. These measures and standardized test scores were collected at post-treatment and 3-, 6-, and 12-month follow-up visits. Treatment resulted in significant improvement in production of correct, intelligible scripted words for trained topics, a reduction in grammatical errors for trained topics, and an overall increase in intelligibility for trained as well as untrained topics at post-treatment. Follow-up testing revealed maintenance of gains for trained scripts up to 1 year post-treatment on the primary outcome measure. Performance on untrained scripts and standardized tests remained relatively stable during the follow-up period, indicating that treatment helped to stabilize speech and language despite disease progression. To identify neural predictors of responsiveness to intervention, we examined treatment effect sizes relative to grey matter volumes in regions of interest derived from a previously identified speech production network. Regions of significant atrophy within this network included bilateral inferior frontal cortices and supplementary motor area as well as left striatum. Volumes in a left middle/inferior temporal region of interest were significantly correlated with the magnitude of treatment effects. This region, which was relatively spared anatomically in nfvPPA patients, has been implicated in syntactic production as well as visuo-motor facilitation of speech. This is the first group study to document the benefits of behavioural intervention that targets both linguistic and motoric deficits in nfvPPA. Findings indicate that behavioural intervention may result in lasting and generalized improvement of communicative function in individuals with neurodegenerative disease and that the integrity of spared regions within the speech-language network may be an important predictor of treatment response.

Investigating the utility of teletherapy in individuals with primary progressive aphasia

INTRODUCTION

Primary progressive aphasia (PPA) is a neurodegenerative disorder characterized by progressive deterioration of speech and language. A growing body of research supports the utility of speech and language intervention in individuals with PPA, although access to these services remains limited. One potential means of increasing treatment accessibility is the delivery of treatment via telemedicine. Evidence supports the use of teletherapy in stroke-induced aphasia, but research examining the application of teletherapy in PPA is limited. In the current study, a non-randomized group comparison design was used to evaluate the feasibility and utility of treatment delivered via teletherapy relative to treatment administered in person for individuals with PPA.

METHODS

Two treatment protocols were administered as part of a larger study investigating treatment for speech and language deficits in PPA. Participants with semantic (n=10) and logopenic (n=11) PPA received lexical retrieval treatment and individuals with nonfluent/agrammatic PPA (n=10) received video-implemented script training for aphasia designed to promote speech production and fluency. Treatment was administered via teletherapy for approximately half of the participants receiving each intervention. Treatment outcomes and performance on standardized tests were assessed at pre-treatment and post-treatment, as well as 3, 6, and 12 months post-treatment.

RESULTS

Overall, both treatment approaches resulted in significant gains for primary outcome measures. Critically, comparison of in-person and teletherapy groups revealed comparable outcomes. Generalization to untrained targets and tasks and maintenance of treatment-induced gains were also comparable for traditional vs teletherapy participants.

CONCLUSION

Overall, treatment outcomes were largely equivalent for individuals receiving treatment via teletherapy vs traditional, in-person delivery. Results support the application of teletherapy for administering restitutive interventions to individuals with mild-to-moderate PPA. Potential implications for using teletherapy in the treatment of cognitive-linguistic and motoric impairments in other disorders and suggestions for administering treatment via telemedicine are discussed.

Improvement in functional vocabulary and generalization to conversation following a self-administered treatment using a smart tablet in primary progressive aphasia

Currently, public services in speech-language pathology for primary progressive aphasia (PPA) are very limited, although several interventions have been shown to be effective. In this context, new technologies have the potential to enable people with PPA to improve their communication skills. The main aim of this study was to investigate the efficacy of a self-administered therapy using a smart tablet to improve naming of functional words and to assess generalization to an ecological conversation task. Five adults with PPA completed the protocol. Using an ABA design with multiple baselines, naming performance was compared across four equivalent lists: (1) trained with functional words; (2) trained with words from a picture database; (3) exposed but not trained; and (4) not exposed (control). Treatment was self-administered four times a week for a period of four consecutive weeks. A significant improvement for trained words was found in all five participants, and gains were maintained two months post-treatment in four of them. Moreover, in three participants, evidence of generalization was found in conversation. This study supports the efficacy of using a smart tablet to improve naming in PPA and suggests the possibility of generalization to an ecological context.

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.

Patterns of Decline in Naming and Semantic Knowledge in Primary Progressive Aphasia

BACKGROUND

Individuals with primary progressive aphasia (PPA) and their caregivers want to know what to expect so that they can plan support appropriately. The ability to predict decline in naming and semantic knowledge, and advise individuals with PPA and their caregivers regarding future planning, would be invaluable clinically.

AIMS

The aims of this study were to investigate patterns of decline in naming and semantic knowledge in each of the clinical variants of PPA (logopenic variant PPA, lvPPA; nonfluent agrammatic PPA, nfaPPA; and semantic variant PPA, svPPA) and to examine the effects of other variables on rate of decline. We hypothesized that speech-language rehabilitation, higher education, and higher baseline test scores would be associated with slower decline, and older age with faster decline.

METHODS AND PROCEDURES

A total of ninety-four participants with PPA underwent language testing, including thirty six participants with lvPPA, thirty-one participants with nfaPPA, and twenty-seven participants with svPPA. All participant groups were similar in age and education. We focused on decline on three tests: the short form of the Boston Naming Test (BNT), the Hopkins Assessment of Naming Actions (HANA), and the short form of the Pyramids and Palm Trees Test (PPTT).

OUTCOME AND RESULTS

Across language tests, the most precipitous rates of decline (loss of points per month) occurred in nfaPPA, followed by svPPA, then lvPPA. Female sex, longer symptom duration, higher baseline test score, and speech-language rehabilitation were associated with slower decline.

CONCLUSIONS

PPA variants were distinguishable by rapidity of decline, with nfaPPA having the most precipitous decline. As hypothesized, higher baseline test scores and speech-language rehabilitation were associated with slower decline. Surprisingly, age and education were not important prognostically for individuals in this study. Further study of prognostically-relevant variables in PPA is indicated in this population.

Long-Term maintenance of anomia treatment effects in primary progressive aphasia

This study examined the maintenance of anomia treatment effects in primary progressive aphasia (PPA). Following baseline testing, a phonological treatment and an orthographic treatment were administered over the course of six months. The treatment stimuli consisted of nouns that were consistently named correctly at baseline (Prophylaxis items) and/or nouns that were consistently named incorrectly at baseline (Remediation items). Naming accuracy was measured at baseline, and it was measured at 1 month, 8 months, and 15 months post-treatment. The change in naming accuracy from baseline to each post-treatment evaluation was calculated within each treatment condition, and within a matched untrained condition. The change in naming accuracy was then compared between the three conditions. The results of these analyses indicate that phonological and orthographic treatments are both effective in the Prophylaxis and Remediation of anomia in all three variants of PPA. For Prophylaxis items, some of the effects of each treatment can persist for as long as 15 months post-treatment. These long-term treatment effects were more robust in the orthographic treatment condition and for participants with the semantic variant of PPA.

Cognitive telerehabilitation in mild cognitive impairment, Alzheimer's disease and frontotemporal dementia: A systematic review

INTRODUCTION

Given the limited effectiveness of pharmacological treatments, non-pharmacological interventions in neurodegenerative diseases have gained increasing attention in recent years and telerehabilitation has been proposed as a cognitive rehabilitation strategy. The purpose of this systematic review is to examine the evidence for the efficacy of cognitive telerehabilitation interventions compared with face-to-face rehabilitation in patients with mild cognitive impairment, Alzheimer's disease and frontotemporal dementia.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of the Medline database was conducted. Out of 14 articles assessed for eligibility, five studies were identified, three in participants with mild cognitive impairment or Alzheimer's disease, two in patients with primary progressive aphasia.

RESULTS

The Physiotherapy Evidence Database scale was used to assess the methodological quality of four out of five studies included in this systematic review, with only one report receiving a high-quality rating. Effect-size analysis evidenced positive effects of telerehabilitation interventions, comparable with those reported for face-to-face rehabilitation.

DISCUSSION

The available evidence for the effectiveness of cognitive telerehabilitation is limited, and the quality of the evidence needs to be improved. The systematic review provides preliminary evidence suggesting that cognitive telerehabilitation for neurodegenerative disease may have comparable effects as conventional in-person cognitive rehabilitation.

Comparing the effects of clinician and caregiver-administered lexical retrieval training for progressive anomia

There is a growing body of literature indicating that lexical retrieval training can result in improved naming ability in individuals with neurodegenerative disease. Traditionally, treatment is administered by a speech-language pathologist, with little involvement of caregivers or carry-over of practice into the home. This study examined the effects of a lexical retrieval training programme that was implemented first by a clinician and, subsequently, by a trained caregiver. Two dyads, each consisting of one individual with anomia caused by neurodegenerative disease (one with mild cognitive impairment and one with logopenic primary progressive aphasia) and their caregiver, participated in the study. Results indicated medium and large effect sizes for both clinician- and caregiver-trained items, with generalisation to untrained stimuli. Participants reported improved confidence during communication as well as increased use of trained communication strategies after treatment. This study is the first to document that caregiver-administered speech and language intervention can have positive outcomes when paired with training by a clinician. Caregiver-administered treatment may be a viable means of increasing treatment dosage in the current climate of restricted reimbursement, particularly for patients with progressive conditions.

The Relationship Between Baseline Volume in Temporal Areas and Post-Treatment Naming Accuracy in Primary Progressive Aphasia

BACKGROUND

Structural imaging has not been used previously to predict the effect of treatment in primary progressive aphasia (PPA).

AIMS

This study examined relationships between baseline brain volume and the effects of phonological and orthographic treatments for anomia in PPA. It was predicted that lower baseline volume would be associated with lower post-treatment naming accuracy for treated items and smaller generalization effects.

METHODS & PROCEDURES

Twenty-one individuals with PPA participated. The treatment stimuli consisted of nouns that were consistently named correctly at baseline (Prophylaxis items) and/or nouns that were consistently named incorrectly at baseline (Remediation items). All 21 participants had Prophylaxis items, while 10 participants had Remediation items. Naming accuracy for untrained and trained items (Exemplar set 1) was measured. In addition, stimulus generalization was examined by having participants name an alternative exemplar of each untrained and trained item (Exemplar set 2). Correlational analyses focused on the relationships between naming accuracy and volume of regions previously identified as having a role in naming and semantic processing.

OUTCOMES & RESULTS

Unexpectedly, there were no significant correlations between baseline volume and post-treatment accuracy for treated items. However, baseline volume within the left temporal pole was positively correlated with post-treatment accuracy for Untrained Exemplar set 2 Prophylaxis items, while baseline volume in the left inferior temporal gyrus was positively correlated with post-treatment accuracy for Untrained Exemplar set 1 Remediation items.

CONCLUSIONS

These findings suggest that lower volume in the left temporal pole is associated with decline for Untrained items, while lower volume in the left inferior temporal gyrus is associated with a lack of improvement for Untrained items. Possible explanations for the different patterns observed across Exemplar sets are discussed.

Prophylaxis and remediation of anomia in the semantic and logopenic variants of primary progressive aphasia

This study evaluated the efficacy of phonological and orthographic treatments for anomia in the semantic and logopenic variants of primary progressive aphasia (svPPA and lvPPA, respectively). Both treatments were administered for 6 months. The treatment stimuli consisted of nouns that were consistently named correctly at baseline (prophylaxis items) and/or nouns that were consistently named incorrectly at baseline (remediation items). Oral naming accuracy was measured for trained and untrained picture exemplars, as well as matched items from an untrained condition (UC). Written naming and scene description tasks were also conducted. For all tasks, the change in naming accuracy from baseline to 1 month post-treatment was compared between the UC and each treatment condition. These comparisons indicated that both treatments were effective in the remediation and prophylaxis of anomia in both variants. Furthermore, generalisation to untrained exemplars occurred in both subtypes, whereas item generalisation occurred in lvPPA, and task generalisation was present in svPPA.