The feasibility of improving discourse in people with aphasia through AAC: Clinical and functional MRI correlates

Executive functioning and nonverbal cognitive factors associated with response to technology-assisted language intervention

OBJECTIVE

To explore potential differences in the relationship between executive function (EF) skills and language development when integrating augmentative and alternative communication technology into speech-language therapy for deaf/hard of hearing (DHH) children.

METHOD

Randomized trial data were analysed to investigate this relationship among children who participated in a Technology-Assisted Language Intervention (TALI) compared to treatment as usual (TAU). Language samples were assessed for pre-post-intervention changes, including mean length of utterance in morphemes (MLU), mean turn length (MTL), and number of different words spoken (NDW). EF skills were measured with standardized parent-report assessment.

RESULTS

Thirty-seven DHH children were included (TALI n = 19 and TAU n = 18). Results of regression models indicated that higher EF skills were significantly (p < 0.05) associated with improvements in MLU, MTL, and NDW among children who received TAU. No significant associations between EF skills and any of the measures (MLU, MTL, NDW) were seen in children who received TALI.

CONCLUSION

These results suggest that TALI may offer language learning support, particularly for DHH children with EF difficulties. Future research should investigate the direct relationship between EF measurements and language outcomes in TALI recipients. Establishing baseline EF measurements in DHH children could inform personalized strategies within language interventions and therapy.

Augmentative and alternative communication for individuals with post-stroke aphasia: perspectives of South African speech-language pathologists

This qualitative study aimed to describe speech-language pathologists' (SLPs') perspectives on augmentative and alternative communication (AAC) use for people with post-stroke aphasia focusing on: (a) current AAC practice, (b) factors that influence the use of AAC, and (c) the success and relevance of AAC interventions. Semi-structured interviews took place with ten South African SLPs with experience in aphasia intervention. The transcribed interviews were thematically analyzed using a six-phase process of inductive and deductive analysis within a phenomenological framework. All the participants use AAC with their clients, employing a variety of approaches that reflect their diverse settings, experiences, and perspectives on AAC. AAC use is complex, and SLPs make conscious choices considering multiple factors. Barriers to use were often associated with limited resources in the low- and middle-income country (LMIC) context, but most participants retained a positive view of AAC, actively working to circumvent barriers to use. Participants consistently emphasized the vital role of partners in communication interactions, linked to the importance of defining AAC broadly. It is necessary to advance the integration of AAC into rehabilitation plans to improve communication and social participation outcomes for people with post-stroke aphasia, especially in LMICs such as South Africa.

Functional Magnetic Resonance Imaging Activation During Unscripted Discourse in People With Poststroke Aphasia

PURPOSE

The purpose of this project was to determine the feasibility of employing a functional magnetic resonance imaging (fMRI) task that captured activation associated with overt, unscripted (or free) discourse of people with aphasia (PWA), using a continuous scan paradigm.

METHOD

Seven participants (six females, ages 48-70 years) with chronic poststroke aphasia underwent two fMRI scanning sessions that included a discourse fMRI paradigm that consisted of five 1-min picture description tasks, using personally relevant photographs, interspersed with two 30-s control periods where participants looked at a fixation cross. Audio during the continuous fMRI scan was collected and marked with speaking times and coded for correct information units. Activation maps from the fMRI data were generated for the contrast between speaking and control conditions. In order to show the effects of the multi-echo data analysis, we compared it to a single-echo analysis by using only the middle echo (echo time of 30 ms).

RESULTS

Through the implementation of the free discourse fMRI task, we were able to elicit activation that included bilateral regions in the planum polare, central opercular cortex, precentral gyrus, superior temporal gyrus, middle temporal gyrus, superior temporal gyrus, Crus I of the cerebellum, as well as bilateral occipital regions.

CONCLUSIONS

We describe a new tool for assessing discourse recovery in PWA. By demonstrating the feasibility of a natural language paradigm in patients with chronic, poststroke aphasia, we open a new area for future research.

Perceived Factors That Facilitate or Prevent the Use of Speech-Generating Devices in Bilingual Individuals With Aphasia

PURPOSE

The aim of this study was to explore practicing speech-language pathologists' (SLPs') perceptions of factors that could facilitate or prevent the use of speech-generating devices (SGDs) in bilingual individuals with aphasia. Specifically, this exploratory study sought to identify the facilitators and barriers to SGD use in individuals with culturally and linguistically diverse backgrounds.

METHOD

An online survey was distributed to SLPs through an e-mail listserv and social media of an augmentative and alternative communication company. This article focused on the results of the survey items related to (a) the presence of bilingual individuals with aphasia on an SLP's caseload, (b) training related to SGD or bilingual aphasia, and (c) barriers and facilitators to SGD use. A thematic analysis was conducted to analyze the barriers and facilitators to SGD use reported by the respondents.

RESULTS

A total of 274 SLPs who met the inclusion criteria had experience in implementing SGD for people with aphasia. Regarding relevant training, our results indicated that very few SLPs received bilingual aphasia intervention training (17.22%) or bilingual SGD training (0.56%) in graduate school. The results from our thematic analysis revealed four major themes of barriers and facilitators to SGD use, including (a) hardware and software, (b) cultural and language content, (c) SLP's cultural and linguistic competency, and (d) resources.

CONCLUSIONS

Practicing SLPs reported several barriers to SGD use in bilinguals with aphasia. Most notably, language barriers for monolingual SLPs were seen as the greatest barrier to language recovery in individuals with aphasia whose primary language is not English. Several other barriers were consistent with previous research, such as financial factors and insurance disparities. The top three most important factors that facilitate SGD use in bilinguals with aphasia, as identified by the respondents, include user-friendly symbol organization, personalized words, and ease of programming.

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

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

Attitudes Toward and Perceived Communicative Competence of Individuals with Aphasia Using Speech-Generating Devices

The purpose of this study was to investigate the effects of interface display and respondent group on listener attitudes toward and perceived communicative competence of persons with aphasia. The Attitudes Toward Nonspeaking Persons scale and the Communicative Competence Scale was used to measure listener attitudes and communicative competence, respectively. A 2 × 3 mixed factorial design was used. Interface display videos served as the within-subjects variable (i.e., grid and scene displays), and the respondent group served as the between-subjects variable. A total of 113 respondents (i.e., undergraduate lower-division students, undergraduate upper-division students, and family caregivers of individuals with aphasia) watched an individual with aphasia using a grid display in one video and a scene display in another video. The respondents completed the two scales. Significant main effects (p < .05) were found for interface display and respondent group. The use of scene displays had a more favorable impact on competence ratings than the use of grid displays. Family caregiver ratings were significantly (p < .05) more favorable than ratings from other groups. The Communicative Competence Scale was found to be a reliable measure of perceived communicative competence. Scene displays have the potential to enhance the perceived communicative competence of this population.

Psychometric and Logometric Properties of the Armenian Version of Augmentative and Alternative Communication Assessment Questionnaire: Assessing Reliability and Validity

The study describes the development of the AAC-Arm questionnaire and its initial psychometric and logometric testing for reliability and validity. Psychometric and logometric principles were used to develop an assessment questionnaire capable of evaluating the communication state domains important to patients with neurological disorders. The hypothesized domains were to include (1) auditory function, (2) speech function (3) cognitive functions (4) sensorimotor function, and (5) activities of daily living (ADL). An initial pool of 78 questions was pilot-tested for clarity in 10 patients; following factor analysis, the number of questions was reduced to 39-items. Then the questionnaire was subjected to reliability and validity testing. Factor analysis supported the 5 hypothesized domains. Test-retest reliability using Spearman's correlation demonstrated substantial agreement, ranging from 0.72 for the ADL domain to 0.92 for the auditory function domain. In testing for internal consistency, Cronbach's alphas ranged from 0.86 for-the ADL domain to 0.96 for the cognitive function domain. Correlation between domains gave evidence of construct validity. In comparing similar domains in the AAC questionnaire, a moderate correlation (range 0.33-0.83) for the ADL and sensorimotor function scales were found. The correlation was more positive between the other domains. Testing of reliability for the phraseological, syntactic and semantic competence indices showed good positive correlation between initial and retest scores. The questions in the AAC questionnaire have undergone rigorous psychometric and logometric testing, and the tool is an appropriate instrument for the assessment of neurological patients with communication deficit. The psycholinguistic assessment provides with the main weight of data for successful communication therapy.

A Pilot Randomized Controlled Trial of Intermittent Theta Burst Stimulation as Stand-Alone Treatment for Post-Stroke Aphasia: Effects on Language and Verbal Functional Magnetic Resonance Imaging (fMRI)

BACKGROUND There is an ongoing need for facilitating language recovery in chronic post-stroke aphasia. The primary aim of this study (NCT01512264) was to examine if noninvasive intermittent theta burst stimulation (iTBS) applied to the injured left-hemispheric cortex promotes language improvements and fMRI changes in post-stroke aphasia. MATERIAL AND METHODS Participants were randomized to 3 weeks of sham (Tx0) or 1-3 weeks of iTBS (Tx123). We assessed participants who completed the first 2 functional MRI (fMRI) sessions (T1, T2) where they performed 2 overt language fMRI tasks, and examined longitudinal response after 3 months (T3). Language performance and fMRI activation changes, and relationships between these changes were assessed. RESULTS From T1 to T2, both groups showed improvements on the Boston Naming Test (BNT). From T1 to T3, Tx123 improved on the Aphasia Quotient, post-scan word recognition on the verbal paired associates task (VPAT), and perceived communicative ability. Each group exhibited significant activation changes between T1 and T2 for both tasks. Only the Tx123 group exhibited fMRI activation changes between T2 to T3 on the verb-generation task and between T1 and T3 on VPAT. Delayed aphasia symptom improvement for Tx123 was associated with increased left ventral visual stream activation from T1 to T3 (rho=0.74, P=0.0058), and with decreased bilateral supplementary motor area activation related to VPAT encoding from T2 to T3 (rho=-0.80, P=0.0016). CONCLUSIONS Observed iTBS-induced language improvements and associations between delayed fMRI changes and aphasia improvements support the therapeutic and neurorehabilitative potential of iTBS in post-stroke aphasia recovery.

Augmentative and alternative communication intervention for in-patient individuals with post-stroke aphasia: study protocol of a parallel-group, pragmatic randomized controlled trial

BACKGROUND

People with post-stroke aphasia commonly receive speech-language therapy (SLT) when they are admitted to hospitals. Commonly, these patients reported communication difficulties in in-patient settings. Augmentative and alternative communication (AAC) has been reported as an effective treatment approach to improve communication effectiveness, language performance, decreasing depression, and improving quality of life for this population. However, little evidence has demonstrated the use of AAC intervention (AACT) in early recovery from people with post-stroke aphasia in in-patient rehabilitation settings for improving these patients' communication effectiveness. The pilot randomized controlled trial (RCT) will explore the effectiveness and feasibility of including AACT in regular SLT for in-patient people with post-stroke aphasia.

METHOD

This pilot RCT is a single-blind, randomized controlled trial with two parallel groups. Both groups receive a 1-h treatment session, including either both AACT and SLT or SLT only for ten consecutive days. We aim to include 22 in-patient participants with post-stroke aphasia in each group. Participants will be assessed at pre- and post-intervention and 2 weeks after intervention. The primary outcomes are the ability of communication measured by the communication of basic needs subtest in the Functional Assessment of Communication Skills for Adult (FACS) and the overall language performance measured by the Chinese Standard Aphasia Battery (ABC). The secondary outcomes include a 10-min conversation, the 10-item Hospital version of the Stroke Aphasic Depression Questionnaire (SADQH-10), the Stroke-Specific Quality of Life Scale (SS-QOL), and a patient and caregiver satisfaction questionnaire.

DISCUSSION

This pilot RCT will contribute to new scientific evidence to the field of aphasia rehabilitation in early recovery during the in-patient period. The paper describes the trial, which will explore the effect of combining AACT and SLT and SLT only, our choice of primary and secondary outcome measures, and proposed analyses. The study results will provide information for implementing AACT in the regular in-patient SLT of future RCTs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry database (ChiCTR) ChiCTR2000028870 . Registered on 5 January 2020.

AAC apps for aphasia: a pilot study on the role of intuition and learning

PURPOSE

To characterize the untrained performance of people with aphasia (PWA) in finding symbols (single words) on two symbol-based augmentative and alternative communication applications (AAC apps).

METHODS

Nine individuals with aphasia and no previous experience with AAC searched for five symbols on two grid display apps with differing representation systems and vocabulary (Proloquo2Go and Speak for Yourself) following a brief demonstration. Participants were allowed two minutes to locate each symbol on each app (Trial 1), following which the process was repeated with the same symbols (Trial 2) for both apps. Measured variables included total number of symbols found as well as average efficiency score, search time per symbol, and number of cell selections per second for successful trials. Participants were interviewed about their stated app preferences.

RESULTS

In the absence of training, participants performed significantly better using Proloquo2Go for average search time (p < .001), and rate of cell selection (p < .001). No significant differences were found across trials. Seven of the nine participants expressed a preference for Proloquo2Go.

CONCLUSIONS

Participant performance and stated preferences appeared to favour the layout found in Proloquo2Go, possibly suggestive of greater intuitiveness in the absence of training. However, significant learning was not observed across two trials, suggesting the importance of training and increased exposure.Implications for RehabilitationIndividuals who are diagnosed with aphasia may have long-term communication difficulties that require alternative means of communication.There are numerous commercially available augmentative and alternative communication applications (AAC apps) which may be beneficial for this population. However, there is limited research examining their usefulness.This study with a small sample of individuals with aphasia found that in the absence of training some apps may be easier to use than others.Additionally, the study found that learning may not occur in the absence of training highlighting the importance of treatment.

Neuroplasticity in post-stroke aphasia: A systematic review and meta-analysis of functional imaging studies of reorganization of language processing

Recovery from aphasia is thought to depend on neural plasticity, that is, functional reorganization of surviving brain regions such that they take on new or expanded roles in language processing. We carried out a systematic review and meta-analysis of all articles published between 1995 and early 2020 that have described functional imaging studies of six or more individuals with post-stroke aphasia, and have reported analyses bearing on neuroplasticity of language processing. Each study was characterized and appraised in detail, with particular attention to three critically important methodological issues: task performance confounds, contrast validity, and correction for multiple comparisons. We identified 86 studies describing a total of 561 relevant analyses. We found that methodological limitations related to task performance confounds, contrast validity, and correction for multiple comparisons have been pervasive. Only a few claims about language processing in individuals with aphasia are strongly supported by the extant literature: first, left hemisphere language regions are less activated in individuals with aphasia than neurologically normal controls, and second, in cohorts with aphasia, activity in left hemisphere language regions, and possibly a temporal lobe region in the right hemisphere, is positively correlated with language function. There is modest, equivocal evidence for the claim that individuals with aphasia differentially recruit right hemisphere homotopic regions, but no compelling evidence for differential recruitment of additional left hemisphere regions or domain-general networks. There is modest evidence that left hemisphere language regions return to function over time, but no compelling longitudinal evidence for dynamic reorganization of the language network.

A scoping review of PhotoVoice for people with post-stroke aphasia

BACKGROUND

PhotoVoice is a qualitative research methodology designed to engage and empower marginalized members of a community and/or to understand community needs. PhotoVoice seems aphasia-friendly because it relies on personal photographs to convey opinions regarding prespecified topics. However, PhotoVoice is based on a procedure referred to as the SHOWeD method. Participants are asked to reflect upon their photos by discussing (1) what they See, (2) what is Happening, (3) the relation to Our life, (3) Why the issue or condition exists, and then to (4) explain what can be Done to address the issue(s) at hand. Due to the linguistic demand required to convey complex thoughts and ideas inherent in this methodology, adaptations are likely required to successfully implement with people who have aphasia.

AIMS

A scoping review was conducted to summarize the current literature regarding the use of PhotoVoice with people who have aphasia, to address two questions:(1) Are people with post-stroke aphasia included in PhotoVoice studies?(2) What, if any, modifications are required to address post-stroke aphasia and motor impairments?

MAIN CONTRIBUTION

This scoping review revealed that researchers often exclude people with aphasia from post-stroke PhotoVoice research. Three studies outlined adaptations that allowed successful implementation with people who have post-stroke aphasia.

CONCLUSIONS

Further inquiry regarding how best to adapt PhotoVoice for people with aphasia will facilitate their ability to be included in community-based research. This is an important step in ensuring that all post-stroke stakeholders are involved in projects related to social justice and policy for stroke survivors.

Revisiting the Role of Augmentative and Alternative Communication in Aphasia Rehabilitation

Purpose The purpose of this article is to revisit the role of augmentative and alternative communication (AAC) in poststroke aphasia rehabilitation. The authors' intent is to provide a viewpoint that expands the use of AAC in poststroke aphasia rehabilitation. Specifically, we seek to clarify the role of AAC in restorative and participation approaches to aphasia rehabilitation while also considering the role of AAC in a comprehensive treatment plan. The authors support their viewpoint with citations from both the historic and contemporary literature on aphasia rehabilitation. Conclusions A thought-provoking viewpoint on the role of AAC in poststroke aphasia rehabilitation is proposed. More specifically, the versatility of AAC strategies is reviewed, with an emphasis on how AAC can be used to empower people with aphasia to fully participate and engage in life activities with increased independence. Moreover, we argue that AAC can be viewed as a dual-purpose tool that can simultaneously serve to drive intersystemic reorganization resulting in some improved language performance-and perhaps restoration of language function-while offering a communication alternative during inevitable anomic events.