Constraint and multimodal approaches to therapy for chronic aphasia: A systematic review and meta-analysis

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.

Remapping and Reconnecting the Language Network after Stroke

Here, we review the literature on neurotypical individuals and individuals with post-stroke aphasia showing that right-hemisphere regions homologous to language network and other regions, like the right cerebellum, are activated in language tasks and support language even in healthy people. We propose that language recovery in post-stroke aphasia occurs largely by potentiating the right hemisphere network homologous to the language network and other networks that previously supported language to a lesser degree and by modulating connection strength between nodes of the right-hemisphere language network and undamaged nodes of the left-hemisphere language network. Based on this premise (supported by evidence we review), we propose that interventions should be aimed at potentiating the right-hemisphere language network through Hebbian learning or by augmenting connections between network nodes through neuroplasticity, such as non-invasive brain stimulation and perhaps modulation of neurotransmitters involved in neuroplasticity. We review aphasia treatment studies that have taken this approach. We conclude that further aphasia rehabilitation with this aim is justified.

The effects of symbolic gestural training on enhancing recovery of spoken naming in people with aphasia: A systematic review and meta-analysis

PURPOSE

This study aimed to evaluate the effects of symbolic gestural training on enhancing recovery of spoken naming in people with aphasia (PWA) using a systematic review and meta-analysis.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, article search was conducted from four databases: Web of Science Core Collection, Medline, PsycINFO, and EBSCO. A total of 45 participants from four studies investigating the symbolic gestural training effects on PWA and outcome measures of spoken naming were included.

RESULT

The meta-analysis showed a medium overall effect of symbolic gestural training on enhancing recovery of spoken naming in PWA. Subgroup analysis also revealed that the training effect was more remarkable in the gesture + verbal training paradigm than in the gesture-only training paradigm. However, the differences in the training effects between short and long duration, and training supplied with and without feedback, were nonsignificant.

CONCLUSION

This study illustrates the current state of the literature on symbolic gestural training in PWA, and serves as a reference for clinicians, patients, and health policy-makers regarding the application of symbolic gestural training in clinical or rehabilitation programs.

Effectiveness of Constraint-Induced Language Therapy for Aphasia: Evidence From Systematic Reviews and Meta-Analyses

PURPOSE

Constraint-induced language therapy (CILT) is an aphasia treatment that incorporates neuroplasticity principles of forced verbal use and high-intensity training to facilitate language recovery in individuals with stroke-induced aphasia (Pulvermüller et al., 2001). The burgeoning CILT literature has led to systematic reviews (SRs) that summarize treatment results. In this project, we appraised the quality and examined findings reported in several SRs to draw conclusions about the effectiveness of CILT.

METHOD

We searched multiple databases for SRs that summarized CILT research for poststroke aphasia. We identified six SRs, among which three summarized findings qualitatively and three included meta-analysis (MA) to quantify results. We rated each SR for methodologic quality using the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2; Shea et al., 2017) and extracted findings across the six SRs.

RESULTS

Two reviewers reliably applied the AMSTAR 2 to the six SRs. Although the six SRs generally were conducted with satisfactory rigor, each was lacking two or more critical domains. Descriptive summaries in SRs reported positive effects of CILT for language and communication measures. However, the three MAs showed that effects of CILT often did not surpass those of comparison treatments for naming, comprehension, and repetition measures. MA findings were positive in a review that included all research designs and evaluated treatment effects for trained naming items. Generalized CILT effects for standardized language measures were limited in two other MAs.

CONCLUSIONS

CILT led to improvements in a variety of language and communication measures. When compared with intensive multimodality treatments, CILT effects were similar, suggesting that training intensity may be the potent factor in CILT outcomes. Future SRs should be implemented with increased rigor across quality rating scale domains to increase confidence in conclusions.

Repetitive transcranial magnetic stimulation (rTMS) combined with multi-modality aphasia therapy for chronic post-stroke non-fluent aphasia: A pilot randomized sham-controlled trial

Repetitive transcranial magnetic stimulation (rTMS) shows promise in improving speech production in post-stroke aphasia. Limited evidence suggests pairing rTMS with speech therapy may result in greater improvements. Twenty stroke survivors (>6 months post-stroke) were randomized to receive either sham rTMS plus multi-modality aphasia therapy (M-MAT) or rTMS plus M-MAT. For the first time, we demonstrate that rTMS combined with M-MAT is feasible, with zero adverse events and minimal attrition. Both groups improved significantly over time on all speech and language outcomes. However, improvements did not differ between rTMS or sham. We found that rTMS and sham groups differed in lesion location, which may explain speech and language outcomes as well as unique patterns of BOLD signal change within each group. We offer practical considerations for future studies and conclude that while combination therapy of rTMS plus M-MAT in chronic post-stroke aphasia is safe and feasible, personalized intervention may be necessary.

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia

BACKGROUND

While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity.

METHODS

We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs.

RESULTS

We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up.

CONCLUSIONS

CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses.

TRIAL REGISTRATION NUMBER

ACTRN 2615000618550.

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.

A systematic review of non-drug interventions to prevent and treat anxiety in people with aphasia after stroke

PURPOSE

To investigate the effectiveness of non-drug interventions for people with aphasia in the prevention and/or treatment of anxiety post-stroke as either a primary or secondary outcome.

MATERIALS AND METHODS

A systematic search of Medline, CINAHL, PsycINFO and Cochrane Library up to March 2021 was carried out. Studies of stroke populations were included if people with aphasia represented 25% or more of the enrolled participants. Quality of the evidence was assessed. A narrative synthesis of results is presented. The PROSPERO record ID for this study is 106451.

RESULTS

Ten studies were included: five randomised controlled trials (RCTs), a single case experimental design, and four pre-post studies. The quality of the RCT trials was at least adequate but none demonstrated a benefit to anxiety outcomes. Those studies that reported benefit were of lower-level evidence with respect to National Health and Medical Research Classifications. No studies were found that evaluated the prevention of anxiety after stroke for people with aphasia.

CONCLUSION

Definitive conclusions about the effectiveness of non-drug interventions for the prevention and/or treatment of anxiety in people with aphasia post-stroke cannot be made. Interventions that may show promise for those with aphasia and symptoms of anxiety include mindfulness meditation, modified cognitive behaviour therapy, unilateral nostril breathing, and the "Enhance Psychological Coping after Stroke" programme. Further high-quality research with better reporting of the inclusion of participants with aphasia and their specific sub-group results are required.Implications for RehabilitationIt is important for rehabilitation professionals to consider prevention of anxiety post-stroke as well as treatment.Mindfulness meditation, modified cognitive behavioural therapy, unilateral nostril breathing, and the and the "Enhance Psychological Coping after Stroke" programme may be of benefit to people with aphasia post-stroke.Adapting intervention protocols to be more communicatively accessible and training health professionals in supported communication may help people with aphasia engage in psychological therapies.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The management of subacute and chronic vascular aphasia: an updated review

Background

Post-stroke aphasia (PSA) is an impairment of the generation or comprehension of language due to acute cerebrovascular lesions. Subacute phase span the 7th day to 24 weeks post-onset while > 6 months is termed chronic phase. Language recovery does not arise immediately in chronic PSA, unlike the acute phase. The majority of the treatment modalities in these two PSA phases are still in the infancy stage, facing dilemmas and considered experimental requiring constant updates. Hence, we aimed to upgrade the existing literature regarding available PSA management options, advances, and drawbacks pertaining to subacute and chronic phases.

Main text

In this review, we analyzed the management options for subacute and chronic vascular aphasia. MEDLINE, through PubMed, ScienceDirect, and Google Scholar were explored for English studies by utilizing the terms “stroke aphasia” Plus “vascular aphasia”; 160,753 articles were retrieved. The latest studies, published from 2016 to July 2020, were selected. Article headings and abstracts were analyzed for relevance and filtered; eventually, 92 articles were included in this review. Various management options were extracted as follows: noninvasive brain stimulation (NIBS), technology-based therapies, speech-language therapy (SLT), pharmacotherapy, music-based therapies, and psychosocial interventions.

Conclusion

The PSA therapy evolves towards more intense SLT therapy, yet the optimal dosage of the emerging high-intensity therapies is controversial. As spinal and cerebellar NIBS, Telespeech, and E-mental health mark PSA's future, distinct pharmacological options remain a dilemma. Across the continuum of care, PSA–depression comorbidity and inadequate PSA post-discharge education to patient’s families are the significant therapeutic challenges. Future therapeutic mechanisms, optimal dose/timing, and tolerability/safety exploration are obliged.

The Role of Gesture in Communication and Cognition: Implications for Understanding and Treating Neurogenic Communication Disorders

When people talk, they gesture. Gesture is a fundamental component of language that contributes meaningful and unique information to a spoken message and reflects the speaker's underlying knowledge and experiences. Theoretical perspectives of speech and gesture propose that they share a common conceptual origin and have a tightly integrated relationship, overlapping in time, meaning, and function to enrich the communicative context. We review a robust literature from the field of psychology documenting the benefits of gesture for communication for both speakers and listeners, as well as its important cognitive functions for organizing spoken language, and facilitating problem-solving, learning, and memory. Despite this evidence, gesture has been relatively understudied in populations with neurogenic communication disorders. While few studies have examined the rehabilitative potential of gesture in these populations, others have ignored gesture entirely or even discouraged its use. We review the literature characterizing gesture production and its role in intervention for people with aphasia, as well as describe the much sparser literature on gesture in cognitive communication disorders including right hemisphere damage, traumatic brain injury, and Alzheimer's disease. The neuroanatomical and behavioral profiles of these patient populations provide a unique opportunity to test theories of the relationship of speech and gesture and advance our understanding of their neural correlates. This review highlights several gaps in the field of communication disorders which may serve as a bridge for applying the psychological literature of gesture to the study of language disorders. Such future work would benefit from considering theoretical perspectives of gesture and using more rigorous and quantitative empirical methods in its approaches. We discuss implications for leveraging gesture to explore its untapped potential in understanding and rehabilitating neurogenic communication disorders.

Constraint-induced aphasia therapy for patients with aphasia: A systematic review

Objectives

This study aimed to systematically evaluate the effects of constraint-induced aphasia therapy (CIAT) for aphasic patients reported by randomized controlled trials.

Methods

Relevant randomized controlled trials were retrieved from 11 electronic databases. A methodological quality assessment was conducted in accordance with the Cochrane Handbook, and meta-analyses were performed by using RevMan 5.2. A descriptive analysis was conducted when the included trials were not suitable for a meta-analysis.

Results

A total of 12 trials were included. A statistically significant group difference was shown from the meta-analysis in the results measured by the Western Aphasia Battery (random-effects model, MD = 1.23, 95% CI = 0.31 to 2.14, P < 0.01). However, there were no statistically significant differences shown in the results of the Boston Naming Test (fixed-effects model, MD = −1.79, 95% CI = −11.19 to 7.62, P > 0.05) and Aachen Aphasia Test (fixed-effects model, MD = −1.11, 95% CI = −4.49 to 2.27, P > 0.05). The descriptive analysis showed positive results in language performances of naming, repetition, and comprehension.

Conclusion

This systematic review indicated that CIAT was efficient for improving language performance with regard to naming, comprehension, repetition, written language, and oral language based on the current evidence. And this review provides some meaningful guides for clinical practice: expand the therapy duration to 2 or 3 h per day, focus on naming, and choose the best assessment tool. It also indicates a need for more rigorous, large-scale, and high-quality trials in the future.

What Is Meant by "Multimodal Therapy" for Aphasia?

Purpose Multimodal therapy is a frequent term in aphasia literature, but it has no agreed upon definition. Phrases such as "multimodal therapy" and "multimodal treatment" are applied to a range of aphasia interventions as if mutually understood, and yet, the interventions reported in the literature differ significantly in methodology, approach, and aims. This inconsistency can be problematic for researchers, policy makers, and clinicians accessing the literature and potentially compromises data synthesis and meta-analysis. A literature review was conducted to examine what types of aphasia treatment are labeled multimodal and determine whether any patterns are present. Method A systematic search was conducted to identify literature pertaining to aphasia that included the term multimodal therapy (and variants). Sources included literature databases, dissertation databases, textbooks, professional association websites, and Google Scholar. Results Thirty-three original articles were identified, as well as another 31 sources referring to multimodal research, all of which used a variant of the term multimodal therapy. Treatments had heterogeneous aims, underlying theories, and methods. The rationale for using more than 1 modality was not always clear, nor was the reason each therapy was considered to be multimodal when similar treatments had not used the title. Treatments were noted to differ across 2 key features. The 1st was whether the ultimate aim of intervention was to improve total communication, as in augmentative and alternative communication approaches, or to improve 1 specific modality, as when gesture is used to improve word retrieval. The 2nd was the point in the treatment that the nonspeech modalities were employed. Discussion Our review demonstrated that references to "multimodal" treatments represent very different therapies with little consistency. We propose a framework to define and categorize multimodal treatments, which is based both on our results and on current terminology in speech-language pathology. Video Abstract and Supplemental Material https://doi.org/10.23641/asha.7646717.