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Richardson JD, Hubbard HI, Dalton SG, Davidson S, Maple T, Smith TB, Chen M, Hiltner R, Jones T, Mayer AR, Myers O, Nelson C, Pirio-Richardson S, Robertson-Benta C, Sponheim S, Upston J, Worth L, Davenport N, Quinn DK. Standardizing Attention Process Training-III for a Multisite Clinical Trial of Neuromodulation. Mil Med 2024; 189:568-578. [PMID: 39160811 DOI: 10.1093/milmed/usae188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/19/2024] [Accepted: 04/02/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION The Control Network Neuromodulation to Enhance Cognitive Training in Complex Traumatic Brain Injury (CONNECT-TBI) study is an ongoing randomized, double-blinded, sham-controlled multisite clinical trial to determine the enhancing effects of noninvasive neuromodulation when paired with cognitive training in military participants (Veterans and active duty) with mild TBI. Attention Process Training-III (APT-III) was selected for its strong evidence base, manualized procedures, and computerized program. However, many aspects of APT-III that make it ideal for personalization make it less ideal for reliable implementation across participants, clinicians/technicians, and sites. The purpose of this feature article is to highlight APT-III procedures that require additional standardization for reliable administration across participants and sites. MATERIALS AND METHODS Ten studies using APT-III were reviewed for methodology of APT-III administration. The manual was also scrutinized; aspects of administration that involved clinical decision-making, subjectivity, flexibility, and/or that were identified by the APT-III developers as areas in need of "empirical evaluation" were flagged by clinicians. Literature and manual review findings were presented to the team for discussion and solution-finding. The authors created and refined a standardized process that would allow participants to move through APT-III training, including task movement algorithms and new materials drafts. Refining of algorithms and drafts continued until there was a consensus from team members. RESULTS Many gray areas were identified, but we will limit our reporting to focus on (1) dosage, (2) adaptation, (3) metacognitive strategy instruction, and (4) goal attainment scaling. We present APT-III manual details, literature review findings, and CONNECT-TBI decisions and materials for each of these areas of focus. CONCLUSIONS We have highlighted some of the major gray areas of APT-III administration so that fellow researchers can understand the need to take similar steps in clinical trials using APT-III. We provide examples of our standardization process and resultant rules and materials. Our algorithm, based on prior studies using the APT-III and our own iterative adjustments, allows for adjustment of the difficulty and speed of the training tasks (but within certain parameters) in order to achieve the best balance between individualization and consistency across participants and sites. We provide an example of a workflow and reporting process for future studies.
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Affiliation(s)
- Jessica D Richardson
- Speech and Hearing Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Honey I Hubbard
- Speech and Hearing Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Sarah Grace Dalton
- Speech Pathology and Audiology, Marquette University, Milwaukee, WI 53233, USA
| | - Sloan Davidson
- Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN 55455, USA
| | - Tiana Maple
- Raymond G. Murphy VA Medical Center, Albuquerque, NM 87108, USA
| | - Tyler B Smith
- Speech and Hearing Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Mo Chen
- Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN 55455, USA
- Neuroscience Research Program, Gillette Children's Specialty Healthcare, St. Paul, MN 55101, USA
| | - Rebecca Hiltner
- Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN 55455, USA
| | - Thomas Jones
- Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | | | - Orrin Myers
- Family and Community Medicine, University of New Mexico, Albuquerque, NM 87131, USA
| | | | | | | | - Scott Sponheim
- Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN 55455, USA
| | - Joel Upston
- Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Lindsay Worth
- Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | | | - Davin K Quinn
- Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
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Modarres Zadeh A, Mehri A, Murray LL, Nejati V, Khatoonabadi AR. The effects of adding attention training to naming treatment for individuals with aphasia. APPLIED NEUROPSYCHOLOGY. ADULT 2024:1-15. [PMID: 38359428 DOI: 10.1080/23279095.2024.2315555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
AIM Given the ever-increasing evidence for the co-occurrence of attention impairments and language disorders in chronic aphasia, this study aimed to compare the effects of two naming treatment programs, one with and one without attention training components, on the naming performance of participants with aphasia. MATERIALS AND METHODS This was a single-subject crossover study in which six people with chronic aphasia and different degrees of naming and attention impairments participated. Two treatment programs were implemented for each participant, with the sequence of the treatments with crossover design. Each program consisted of 12 treatment sessions plus pre- and post-treatment assessment sessions (15 weeks for each participant). The visual analysis and WEighted STatistics methods were employed for data analysis. RESULTS Based on visual analysis, both treatments improved in comparison to the baseline phase. Statistical analysis revealed that the number of participants with significant naming improvement following combined program (5 participants) was larger than the number of participants showing improvement following completion of the single, program. CONCLUSION Although integrating attention training into a conventional treatment for anomia can increase the effect of treatment on naming ability, more studies are required to clarify the role of attention in remediating naming impairments in aphasia.
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Affiliation(s)
- Amin Modarres Zadeh
- Tehran University of Medical Sciences, School of Rehabilitation, Speech Therapy Department, Tehran, Iran
| | - Azar Mehri
- Tehran University of Medical Sciences, School of Rehabilitation, Speech Therapy Department, Tehran, Iran
| | - Laura L Murray
- School of Communication Sciences and Disorders, Western University, Ontario, Canada
| | - Vahid Nejati
- Faculty of Psychology and Educational Sciences, Shahid Beheshti University, Tehran, Iran
| | - Ahmad Reza Khatoonabadi
- Tehran University of Medical Sciences, School of Rehabilitation, Speech Therapy Department, Tehran, Iran
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Abstract
Although language deficits are the primary area of weakness, people with poststroke aphasia often experience challenges with nonlinguistic cognitive skills, including attention processing. The purpose of this review is to synthesize the evidence for the relationship between attention deficits and language deficits in people with poststroke aphasia. Three different types of studies are reviewed: (1) studies exploring whether people with poststroke aphasia exhibit concomitant attention and language deficits, (2) studies explicitly exploring the relationship between attention and language deficits in people with poststroke aphasia, and (3) either language or attention (or both) treatment studies exploring whether treatment gains in one domain generalize to the other. In the last section, we briefly review research evidence for the neural basis of the attention-language relationship in aphasia.
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Affiliation(s)
- Maria Varkanitsa
- Aphasia Research Laboratory, Department of Speech, Language & Hearing Sciences, Sargent College of Health and Rehabilitation, Boston, MA, USA
| | - Erin Godecke
- Edith Cowan University and Sir Charles Gairdner Hospital, Perth, Australia
| | - Swathi Kiran
- Aphasia Research Laboratory, Department of Speech, Language & Hearing Sciences, Sargent College of Health and Rehabilitation, Boston, MA, USA
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Biel M, Enclade H, Richardson A, Guerrero A, Patterson J. Motivation Theory and Practice in Aphasia Rehabilitation: A Scoping Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:2421-2443. [PMID: 36264648 DOI: 10.1044/2022_ajslp-22-00064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE In the aphasia literature, motivation has been described as potentially influencing rehabilitation outcomes, and there are reports that researchers and clinicians have acted to promote it. However, studies directly investigating the range of beliefs and practices surrounding motivation do not exist currently. The purpose of this scoping review is to develop themes related to the beliefs and practices appearing in the recent aphasia literature. METHOD Four databases (CINAHL, PsycINFO, PubMed, and Google Scholar) were searched using keywords aphasia and motivation (including derivatives such as motiv*) for articles published between 2009 and 2020. Searches returned 19,731 articles; after deleting duplicates and applying inclusionary criteria, 365 articles remained. In each article, text surrounding the term motivation was highlighted and thematic analysis was applied to these quotations. RESULTS Sixteen themes were developed through thematic analysis and placed into two groups. The first group contained five themes suggesting that researchers believed that motivation should be studied and recognized the value of motivation in person(s) with aphasia when participating in research or clinical activities. The second group contained 11 themes reporting diverse beliefs and practices in how motivation is incorporated in research and clinical activities. CONCLUSIONS Results from this scoping review suggest that aphasia researchers, clinicians, and persons with aphasia hold beliefs about motivation that can influence clinical and research decisions. In general, beliefs and decisions related to motivation appeared to be guided by intuition rather than theories of motivation. These themes are discussed within the context of three psychological needs proposed by self-determination theory: competency, autonomy, and relatedness. Applying theories of motivation to future study in aphasia rehabilitation will guide work that can provide empirical support for these beliefs.
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Wadams A, Suting L, Lindsey A, Mozeiko J. Metacognitive Treatment in Acquired Brain Injury and Its Applicability to Aphasia: A Systematic Review. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:813416. [PMID: 36188940 PMCID: PMC9397955 DOI: 10.3389/fresc.2022.813416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this systematic review is to identify the utility of metacognitive therapeutic intervention for persons with acquired brain injury (ABI), with a focus on persons with aphasia. Methods A search of six databases resulted in two hundred and sixty-six unique manuscripts relating to the explicit use of metacognitive treatment for people with ABI. Two independent reviewers rated abstracts for inclusion or exclusion of the study given predetermined criteria. Twenty-nine articles, five of which included people with aphasia, were selected for inclusion in this systematic review. SCED+ and PEDro+ rating scales were used to rate the methodological quality of each study. Results Methodological quality of the 29 studies that met inclusion criteria ranged from weak to high quality studies. Three -hundred and sixty-nine individuals with ABI took part in the 29 studies. Varying treatment methods were employed. Outcome measures were inconsistent. Metacognitive treatment has been applied to people with aphasia with positive results, but efficacy of the treatment cannot yet be determined. Conclusions Metacognitive therapeutic intervention tends to be effective for persons with acquired brain injury (ABI) despite variability between intervention designs and treatment outcomes across studies. Due to so few studies with participants with aphasia, we were unable to draw conclusions regarding the efficacy of metacognitive treatment for people with aphasia. Further research on the efficacy of metacognitive treatment for this population is warranted.
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Affiliation(s)
- Amanda Wadams
- Department of Speech, Language and Hearing Science, University of Connecticut, Mansfield, MA, United States
- *Correspondence: Amanda Wadams
| | - Louisa Suting
- Department of Speech, Language and Hearing Science, University of Connecticut, Mansfield, MA, United States
| | - André Lindsey
- School of Education, Speech Pathology, Nevada State College, Henderson, NV, United States
| | - Jennifer Mozeiko
- Department of Speech, Language and Hearing Science, University of Connecticut, Mansfield, MA, United States
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Cherney LR, Lee JB, Kim KYA, van Vuuren S. Web-based Oral Reading for Language in Aphasia (Web ORLA ®): A pilot randomized control trial. Clin Rehabil 2021; 35:976-987. [PMID: 33472420 DOI: 10.1177/0269215520988475] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate an intensive asynchronous computer-based treatment delivered remotely with clinician oversight to people with aphasia. DESIGN Single-blind, randomized placebo-controlled trial. SETTING Free-standing urban rehabilitation hospital. PARTICIPANTS Adults with aphasia (at least six months post-onset). INTERVENTIONS Experimental treatment was Web ORLA® (Oral Reading for Language in Aphasia) which provides repeated choral and independent reading aloud of sentences with a virtual therapist. Placebo was a commercially available computer game. Participants were instructed to practice 90 minutes/day, six days/week for six weeks. MAIN MEASURES Change in Language Quotient of the Western Aphasia Battery-Revised from pre-treatment to post-treatment and pre-treatment to six weeks following the end of treatment. RESULTS 32 participants (19 Web ORLA®, 13 Control) completed the intervention and post-treatment assessment; 27 participants (16 Web ORLA®, 11 Control) completed the follow-up assessment six weeks after treatment had ended. Web ORLA® treatment resulted in significant improvements in language performance from pre-treatment to immediately post-treatment (X = 2.96; SD = 4.32; P < 0.01; ES = 0.68) and from pre-treatment to six weeks following the end of treatment (X = 4.53; SD = 3.16; P < 0.001; ES = 1.43). There was no significant difference in the gain from pre-treatment to post-treatment for the Web ORLA® versus Control groups. However, the Web ORLA® group showed significantly greater gains at the six-week follow-up than the control group (X = 2.70; SD = 1.01; P = 0.013; ES = 1.92). CONCLUSION Results provide evidence for improved language outcomes following intensive, web-based delivery of ORLA® to individuals with chronic aphasia. Findings underscore the value of combining clinician oversight with the flexibility of asynchronous practice.
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Affiliation(s)
- Leora R Cherney
- Think and Speak Lab, Shirley Ryan AbilityLab, Chicago, IL, USA.,Departments of Physical Medicine and Rehabilitation and Communication Sciences and Disorders, Northwestern University, Chicago, IL, USA
| | - Jaime B Lee
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, VA, USA
| | - Kwang-Youn A Kim
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sarel van Vuuren
- Institute of Cognitive Science, University of Colorado Boulder, Boulder, CO, USA
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Harvey SR, Carragher M, Dickey MW, Pierce JE, Rose ML. Treatment dose in post-stroke aphasia: A systematic scoping review. Neuropsychol Rehabil 2020; 31:1629-1660. [PMID: 32631143 DOI: 10.1080/09602011.2020.1786412] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Little is known about how the amount of treatment a person with aphasia receives impacts aphasia recovery following stroke, yet this information is vital to ensure effective treatments are delivered efficiently. Furthermore, there is no standard dose terminology in the stroke rehabilitation or aphasia literature. This scoping review aims to systematically map the evidence regarding dose in treatments for post-stroke aphasia and to explore how treatment dose is conceptualized, measured and reported in the literature. A comprehensive search was undertaken in June 2019. One hundred and twelve intervention studies were reviewed. Treatment dose (amount of treatment) has been conceptualized as both a measure of time and a count of discrete therapeutic elements. Doses ranged from one to 100 hours, while some studies reported session doses of up to 420 therapeutic inputs per session. Studies employ a wide variety of treatment schedules (i.e., session dose, session frequency, and intervention duration) and the interaction of dose parameters may impact the dose-response relationship. High dose interventions delivered over short periods may improve treatment efficiency while maintaining efficacy. Person- and treatment-level factors that mediate tolerance of high dose interventions require further investigation. Systematic exploration of dose-response relationships in post-stroke aphasia treatment is required.
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Affiliation(s)
- Sam R Harvey
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Australia.,Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Bundoora, Australia
| | - Marcella Carragher
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Australia.,Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Bundoora, Australia
| | - Michael Walsh Dickey
- Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Bundoora, Australia.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Communication Sciences and Disorders, University of Pittsburgh, Pittsburgh, PA, USA
| | - John E Pierce
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Australia.,Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Bundoora, Australia
| | - Miranda L Rose
- Discipline of Speech Pathology, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Australia.,Centre of Research Excellence in Aphasia Recovery and Rehabilitation, Bundoora, Australia
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Caute A, Woolf C, Wilson S, Stokes C, Monnelly K, Cruice M, Bacon K, Marshall J. Technology-Enhanced Reading Therapy for People With Aphasia: Findings From a Quasirandomized Waitlist Controlled Study. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2019; 62:4382-4416. [PMID: 31765277 DOI: 10.1044/2019_jslhr-l-18-0484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose This study investigated the effects of technology-enhanced reading therapy for people with reading impairments, using mainstream assistive reading technologies alongside reading strategies. Method The study used a quasirandomized waitlist controlled design. Twenty-one people with reading impairments following stroke were randomly assigned to receive 14 hr of therapy immediately or after a 6-week delay. During therapy, participants were trained to use assistive reading technology that offered a range of features to support reading comprehension. They developed skills in using the technology independently and in applying the technology to their personal reading goals. The primary outcome measure assessed reading comprehension, using Gray Oral Reading Test-Fourth Edition (GORT-4). Secondary measures were as follows: Reading Comprehension Battery for Aphasia-Second Edition, Reading Confidence and Emotions Questionnaire, Communication Activities of Daily Living-Second Edition, Visual Analog Mood Scales, and Assessment of Living With Aphasia. Matched texts were used with the GORT-4 to compare technology-assisted and unassisted reading comprehension. Mixed analyses of variance explored change between T1 and T2, when the immediate group had received therapy but the delayed group had not, thus serving as untreated controls. Pretherapy, posttherapy, and follow-up scores on the measures were also examined for all participants. Results GORT-4 results indicated that the immediately treated group improved significantly in technology-assisted reading following therapy, but not in unassisted reading. However, the data were not normally distributed, and secondary nonparametric analysis was not significant. The control group was unstable over the baseline, improving significantly in unassisted reading. The whole-group analysis showed significant gains in assisted (but not unassisted) reading after therapy that were maintained at follow-up. The Reading Confidence and Emotions Questionnaire results improved significantly following therapy, with good maintenance of change. Results on all other secondary measures were not significant. Conclusions Technology-assisted reading comprehension improved following the intervention, with treatment compensating for, rather than remediating, the reading impairment. Participants' confidence and emotions associated with reading also improved. Gains were achieved after 14 therapy sessions, using assistive technologies that are widely available and relatively affordable, meaning that this approach could be implemented in clinical practice.
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Affiliation(s)
- Anna Caute
- Division of Language and Communication Science, City University of London, United Kingdom
- School of Health and Social Care, University of Essex, United Kingdom
| | - Celia Woolf
- Division of Language and Communication Science, City University of London, United Kingdom
| | - Stephanie Wilson
- Centre for Human Computer Interaction Design, City University of London, United Kingdom
| | - Carol Stokes
- Division of Language and Communication Science, City University of London, United Kingdom
- Speech and Language Therapy Department, Barts Health NHS Trust, London, United Kingdom
| | - Katie Monnelly
- Division of Language and Communication Science, City University of London, United Kingdom
| | - Madeline Cruice
- Division of Language and Communication Science, City University of London, United Kingdom
| | - Katherine Bacon
- Division of Language and Communication Science, City University of London, United Kingdom
| | - Jane Marshall
- Division of Language and Communication Science, City University of London, United Kingdom
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Peach RK, Beck KM, Gorman M, Fisher C. Clinical Outcomes Following Language-Specific Attention Treatment Versus Direct Attention Training for Aphasia: A Comparative Effectiveness Study. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2019; 62:2785-2811. [PMID: 31348732 DOI: 10.1044/2019_jslhr-l-18-0504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose This study was conducted to examine the comparative effectiveness of 2 different approaches, 1 domain-specific and the other domain-general, to language and attention rehabilitation in participants with stroke-induced aphasia. The domain-specific treatment consisted of language-specific attention treatment (L-SAT), and the domain-general treatment consisted of direct attention training (DAT) using the computerized exercises included in Attention Process Training-3 (Sohlberg & Mateer, 2010). Method Four individuals with mild-moderate aphasia participated in this study. A randomized controlled cross-over single-subject design was used to assess the effectiveness of the 2 treatments administered in this study. Treatment outcomes were evaluated in terms of participants' task performance for each program, standardized language and attention measures, tests of functional abilities, and patient-reported outcomes. Results Visual comparisons demonstrated linear improvements following L-SAT and variable patterns following DAT. Omnibus effect sizes were statistically significant for 9 of the 13 L-SAT tasks. The weighted standardized effect sizes for posttreatment changes following L-SAT ranged from small to large, with the exception of 1 task. The average group gain following DAT was 5%. The Western Aphasia Battery-Revised Aphasia Quotients (Kertesz, 2007) demonstrated reliable improvements for 3 of the 4 participants following L-SAT, whereas only 1 of the participants improved reliably following DAT. The margins of improvements in functional language were substantially larger following L-SAT than DAT. Performance on the Test of Everyday Attention improved significantly for 2 participants following L-SAT and for 1 participant following DAT on selected Test of Everyday Attention (Robertson, Ward, Ridgeway, & Nimmo-Smith, 1994) subtests. Patient-reported outcomes for communication and attention following treatment favored L-SAT compared to DAT. Conclusions The results support the view that attention is allocated in ways that are particular to specific tasks rather than as a general resource that is allocated equivalently to all processing tasks. Domain-specific treatment for language deficits due to attentional impairment appears to be a suitable, if not preferable, approach for aphasia rehabilitation. Supplemental Material https://doi.org/10.23641/asha.8986427.
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Affiliation(s)
- Richard K Peach
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, IL
| | - Katherine M Beck
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, IL
| | - Michelle Gorman
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, IL
| | - Christine Fisher
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, IL
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