A multinational comparison of aphasia management practices

A systematic review of Intensive Comprehensive Aphasia Programmes - who takes part, what is measured, what are the outcomes?

PURPOSE

This study synthesizes participant and outcome data from peer-reviewed Intensive Comprehensive Aphasia Programme (ICAP) studies.

METHODS

A systematic review was conducted following PRISMA guidelines. Study eligibility criteria were specified in relation to population, intervention, comparison, outcome, and design considerations. Data were extracted according to six research questions. Narrative synthesis was used.

RESULTS

Twenty-one studies were included covering 13 ICAPs (N = 485, aged 18-86 years, between 11 and 335 months post-stroke). Twenty-seven participant selection criteria were identified. Fifty-six outcome measures spanning the WHO-ICF were used, with the majority assessing the body function domain. Only eight studies employed an experimental design with data appropriate for analysis and synthesis. Risk of bias was noted across this sub-group. Participants improved in word-finding, communication, activity/participation, and communication-related quality of life, and maintained their gains; however, except for word finding, evidence of effect came from isolated studies. Factors influencing outcomes were rarely considered. Some drop-outs, missed sessions, and fatigue were noted. Some studies reported IPD alongside group analyses.

CONCLUSIONS

ICAP selection criteria need justification and should contribute to the understanding of candidacy for this treatment model. Rationalisation of ICAP treatment content and outcome measurement is required, spanning all WHO-ICF domains. Employment of the core outcome set for aphasia would enable data synthesis and facilitate comparisons between the ICAP and other therapy models.

Using a combined working memory - Semantic feature analysis approach to treat anomia in aphasia: A Pilot Study

INTRODUCTION

The purpose of the study was to pilot a working memory (WM) - and modified Semantic Feature Analysis (SFA) approach to treat word finding deficits in a group of people with aphasia (PwA). Two research questions were posed: 1. Will the group of PwA be able to complete the WM tasks used in the approach? 2. Will the approach improve naming performance in PwA?

METHOD

Three individuals with mild - moderate aphasia participated in this singlesubject multiple baseline treatment design. Pre-treatment assessments of language, and pre- to post-treatment assessments of WM abilities were carried out. The treatment protocol incorporated WM and linguistic tasks in order to improve naming accuracy across two treatment lists. Probes were carried out prior to treatment on each list, and at one-month following completion of treatment. Two outcome measures were obtained: Percent accuracy in completing the WM steps, and treatment effect sizes (Beeson & Robey, 2006). Additionally, modified t-tests (Crawford & Garthwaite, 2012; Crawford & Howell, 1998), were calculated in which post-treatment WM measures were compared against neurotypical control groups to detect any improvements in WM functions.

RESULTS

All three participants completed the WM steps with a high degree of accuracy. A range of small to large ESs were obtained for all three participants across the two treated lists, while no meaningful ESs were obtained for the control (untreated) list. All three participants demonstrated improved scores across most of the WM measures with significant improvements noted on certain WM assessments.

CONCLUSIONS

The findings revealed that the WM - SFA approach can be used successfully in individuals with mild - moderate aphasia. The proposed approach holds promise as feasible intervention designed to remediate anomia in PwA.

Intensive and comprehensive aphasia therapy-a survey of the definitions, practices and views of speech and language therapists in the United Kingdom

BACKGROUND

Research evidence suggests aphasia therapy must be delivered at high intensity to effect change. Comprehensive therapy, addressing all domains of the International Classification of Functioning, Disability and Health, is also called for by people with aphasia and their families. However, aphasia therapy is rarely intense or comprehensive. Intensive Comprehensive Aphasia Programmes (ICAPs) were designed to address this challenge, but such programmes are not widely implemented.

AIMS

This study surveyed the views of UK-based speech and language therapists (SLTs) regarding intensive and comprehensive aphasia therapy. It explored definitions of intensive and comprehensive therapy, patterns of provision, views about candidacy and barriers/facilitators. It also investigated awareness of ICAPs and perceived potential of this service model. Differences across UK regions and workplace settings were explored.

METHODS & PROCEDURES

An e-survey ran for 5 months. Quantitative data were analysed using descriptive and inferential statistics. Qualitative free text comments were analysed using content analysis.

OUTCOMES & RESULTS

Two hundred twenty-seven respondents engaged in the e-survey. Definitions of intensive aphasia therapy did not reach UK clinical guideline/research-level thresholds for most of the sample. Those providing more therapy provided definitions with higher standards of intensity. Mean therapy delivered was 128 min/week. Geographical location and workplace setting influenced the amount of therapy delivered. The most frequently delivered therapy approaches were functional language therapy and impairment-based therapy. Cognitive disability and fatigue were concerns for therapy candidacy. Barriers included lack of resources and low levels of optimism that issues could be solved. 50% of respondents were aware of ICAPs and 15 had been involved in ICAP provision. Only 16.5% felt their service could be reconfigured to deliver an ICAP.

CONCLUSIONS & IMPLICATIONS

This e-survey evidences a mismatch between an SLT's concept of intensity and that espoused by clinical guidelines/research. Geographical variations in intensity are concerning. Although a wide range of therapy approaches are offered, certain aphasia therapies are delivered more frequently. Awareness of ICAPs was relatively high, but few respondents had experience of this model or felt it could be executed in their context. Further initiatives are needed if services are to move from a low-dose or non-comprehensive model of delivery. Such initiatives might include but not be confined to wider uptake of ICAPs. Pragmatic research might also explore which treatments are efficacious with a low-dose model of delivery, given that this model is dominant in the United Kingdom. These clinical and research implications are raised in the discussion.

WHAT THIS PAPER ADDS

What is already known on this subject There is a gap between the high intensity of aphasia treatment provided in research versus mainstream clinical settings. A lower standard of 45 min/day set by UK clinical guidelines is also not achieved. Although speech and language therapists (SLTs) provide a wide range of therapies, they typically focus on impairment-based approaches. What this study adds This is the first survey of UK SLTs asking about their concept of intensity in aphasia therapy and what types of aphasia therapy they provide. It explores geographical and workplace variations and barriers and facilitators to aphasia therapy provision. It investigates Intensive Comprehensive Aphasia Programmes (ICAPs) in a UK context. What are the clinical implications of this work? There are barriers to the provision of intensive and comprehensive therapy in the United Kingdom and reservations about the feasibility of ICAPs in a mainstream UK context. However, there are also facilitators to aphasia therapy provision and evidence that a small proportion of UK SLTs are providing intensive/comprehensive aphasia therapy). Dissemination of good practice is necessary and suggestions for increasing intensity of service provision are listed in the discussion.

Predicting Outcomes of Language Rehabilitation: Prognostic Factors for Immediate and Long-Term Outcomes After Aphasia Therapy

BACKGROUND

Aphasia therapy is an effective approach to improve language function in chronic aphasia. However, it remains unclear what prognostic factors facilitate therapy response at the individual level. Here, we utilized data from the POLAR (Predicting Outcomes of Language Rehabilitation in Aphasia) trial to (a) determine therapy-induced change in confrontation naming and long-term maintenance of naming gains and (b) examine the extent to which aphasia severity, age, education, time postonset, and cognitive reserve predict naming gains at 1 week, 1 month, and 6 months posttherapy.

METHOD

A total of 107 participants with chronic (≥ 12 months poststroke) aphasia underwent extensive case history, cognitive-linguistic testing, and a neuroimaging workup prior to receiving 6 weeks of impairment-based language therapy. Therapy-induced change in naming performance (measured as raw change on the 175-item Philadelphia Naming Test [PNT]) was assessed 1 week after therapy and at follow-up time points 1 month and 6 months after therapy completion. Change in naming performance over time was evaluated using paired t tests, and linear mixed-effects models were constructed to examine the association between prognostic factors and therapy outcomes.

RESULTS

Naming performance was improved by 5.9 PNT items (Cohen's d = 0.56, p < .001) 1 week after therapy and by 6.4 (d = 0.66, p < .001) and 7.5 (d = 0.65, p < .001) PNT items at 1 month and 6 months after therapy completion, respectively. Aphasia severity emerged as the strongest predictor of naming improvement recovery across time points; mild (ß = 5.85-9.02) and moderate (ß = 9.65-11.54) impairment predicted better recovery than severe (ß = 1.31-3.37) and very severe (ß = 0.20-0.32) aphasia. Age was an emergent prognostic factor for recovery 1 month (ß = -0.14) and 6 months (ß = -0.20) after therapy, and time postonset (ß = -0.05) was associated with retention of naming gains at 6 months posttherapy.

CONCLUSIONS

These results suggest that therapy-induced naming improvement is predictable based on several easily measurable prognostic factors. Broadly speaking, these results suggest that prognostication procedures in aphasia therapy can be improved and indicate that personalization of therapy is a realistic goal in the near future.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22141829.

People with aphasia share their views on self-management and the role of technology to support self-management of aphasia

PURPOSE

Self-management can lead to increased self-efficacy and improved quality of life for individuals with chronic conditions; however, there is little research exploring how self-management approaches can be used for chronic communication disorders, such as aphasia. Modifications to self-management approaches would be required to accommodate for aphasia; therefore, the input of people with aphasia (PwA) should be sought. The aims of the present study were: (1) To investigate and document the experiences and perspectives of PwA regarding self-management; (2) To explore how technology can be used to support aphasia self-management.

MATERIALS AND METHODS

In-depth, semi-structured interviews were conducted with 26 PwA living in Australia. Qualitative content analysis was used to analyse interview data.

RESULTS

Analysis resulted in six themes: (1) In self-management, PwA take control of life with aphasia and assume responsibility for engaging in opportunities to improve overall communication; (2) Community aphasia groups are important enablers of self-management because they facilitate peer support; (3) Communication partners (CPs) provide multifaceted support in aphasia self-management; (4) SLPs provide integrated support and coordination in aphasia self-management; (5) Technology supports PwA to self-manage speech therapy and communication in daily life; (6) Psychological and physical health issues and societal factors may impact aphasia self-management abilities.

CONCLUSION

From the perspective of PwA, aphasia self-management involves enhancing skills enabling communication and life participation. PwA are central to aphasia self-management, with support provided by CPs, peers, and SLPs. Technology has a range of applications in aphasia self-management. PwA identified potential personal and contextual barriers that may impact self-management.IMPLICATIONS FOR REHABILITATIONFor people with aphasia, engaging in conversation and social interaction are primary means of managing/improving communicative life participation; therefore, this should be a key focus of aphasia self-management programs.Aphasia self-management approaches should maximise the use of available support and provide tailored information, education, and training in the area of self-management to key stakeholders (people with aphasia, communication partners, and speech-language pathologists).People with aphasia should be supported to use technology for aphasia self-management, encompassing communication specific and daily life use.People with aphasia should be heavily involved in the development of structured aphasia self-management approaches.

Characteristics and impacts of community aphasia group facilitation: a systematic scoping review

PURPOSE

Community aphasia groups (CAGs) can provide a range of benefits to people with aphasia and support long-term psychosocial wellbeing. However, the dominant speech-pathologist-led service delivery model is inherently limited in scope. Peer-led groups hold potential as a sustainable and empowering extension of this traditional model. The implementation of peer-led models likely requires targeted training and support, however little is known about the characteristics and impacts of CAG facilitation. This study reviews the literature on CAGs and their facilitation.

MATERIALS AND METHODS

We conducted a scoping review on this topic.

RESULTS

One hundred and seventy-seven texts were included, reporting on a heterogeneous range of activities. Most texts reported on speech-pathologist-led groups, however, a range of alternative models were also represented. While no studies directly compared the impacts of different facilitation models, some comparative benefits could be drawn from the literature. Facilitation was perceived as complex and challenging, and significant gaps were identified in the training of facilitators. Ten qualitative studies investigated characteristics and impacts of facilitator behaviours, providing a useful foundation for future development of training and evaluation tools.

CONCLUSIONS

Further investigation into alternative facilitation models and facilitator training needs will likely support the proliferation of high-quality CAGs.Implications for RehabilitationCommunity aphasia groups (CAGs) play an important role in supporting identity and wellbeing for individuals with chronic aphasia.The traditional speech-pathology led model of group service delivery is limited in scope; the addition of peer- and volunteer-led CAGs may facilitate access to groups and meet a range of different needs for individuals with aphasia.CAG facilitation is a complex and challenging task, likely requiring specialised training, however, this has not been widely available to facilitators.The development of specialised facilitator training will likely support the proliferation of sustainable and high-quality CAGs.

Communication partner perspectives of aphasia self-management and the role of technology: an in-depth qualitative exploration

PURPOSE

"Self-management" empowers individuals to take responsibility for their healthcare through skill-building, personal growth, and self-efficacy related to chronic health condition management. Self-management approaches may benefit people with aphasia (PwA); however, PwA are often excluded from stroke self-management research and there is no published research reporting on aphasia-specific self-management programs. Communication partners (CPs) are involved in the rehabilitation and day-to-day lives of PwA, thus giving them unique insights and knowledge of PwA needs. The present study aimed to investigate CP experiences and perspectives regarding aphasia self-management and to explore CP perceptions of the use of technology in aphasia self-management.

METHODS

In-depth, semi-structured interviews with 14 CPs living in Australia. Interview data was analysed using qualitative content analysis.

RESULTS

Analysis revealed six core themes: (1) aphasia self-management is embedded into everyday life, (2) CPs provide comprehensive self-management support, (3) speech-language pathologists (SLPs) provide tools and support to enable PwA to self-manage, (4) aphasia self-management can be enhanced by technological supports, (5) potential positive outcomes of aphasia self-management, and (6) factors influencing successful aphasia self-management.

CONCLUSIONS

Aphasia self-management programs should focus on individual needs, functional communication in daily life, and social interaction. PwA and CPs are central to these programs, assisted by SLPs. Technology should be explored to augment aphasia self-management.Implications for RehabilitationCommunication partners suggest that people with aphasia are already engaging in aspects of self-management and that more formal aphasia-specific self-management approaches may be beneficial.Dedicated aphasia self-management programs should be situated in daily life with a focus on functional communication, life participation, confidence, and independence.Communication partners, speech-language pathologists, and technology are key support sources for aphasia self-management.Further input should be sought from communication partners in the development of aphasia self-management programs.

Exploring How People with Expressive Aphasia Interact with and Perceive a Social Robot

People with aphasia need high-intensive language training to significantly improve their language skills, however practical barriers arise. Socially assistive robots have been proposed as a possibility to provide additional language training. However, it is yet unknown how people with aphasia perceive interacting with a social robot, and which factors influence this interaction. The aim of this study was to gain insight in how people with mild to moderate chronic expressive aphasia perceived interacting with the social robot NAO, and to explore what needs and requisites emerged. A total of 11 participants took part in a single online semi-structured interaction, which was analysed using observational analysis, thematic analysis, and post-interaction questionnaire. The findings show that participants overall felt positive towards using the social robot NAO. Moreover, they perceived NAO as enjoyable, useful, and to a lesser extent easy to use. This exploratory study provides a tentative direction for the intention of people with mild to moderate chronic expressive aphasia to use social robots. Design implications and directions for future research are proposed.

Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

Background

Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients’ quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies.

Methods

Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes.

Results

4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures.

Conclusions

Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Are single-word picture naming assessments a valid measure of word retrieval in connected speech?

Purpose: Picture naming assessments are one of the most common methods of examining word retrieval in aphasia. However, currently, it is unclear whether these assessments are able to accurately predict word retrieval in "real-life" communication. This paper aims to explore the evidence in the current literature regarding the relationship between picture naming and word retrieval in connected speech in people with aphasia.Method: Literature was reviewed that examined the correlation between picture naming and word retrieval in connected speech. The literature search was limited to articles that were English language, participants with aphasia, and that were not therapy studies.Result: The existing studies showed mixed findings. However, comparison of study outcomes was complicated by inconsistency in the research methods used, including in word retrieval measures and connected speech elicitation.Conclusion: While there is some evidence of a relationship between picture naming and word retrieval in connected speech, correlation outcomes were mixed with possible influences from participant characteristics, assessment method and speech sample type. We therefore suggest that clinical decision-making would benefit from supplementing picture naming tests with an analysis of word retrieval in connected speech. Further research is required with a focus on natural conversation and the development of standard testing procedures for connected speech.

Using experience-based codesign to coproduce aphasia rehabilitation services: study protocol

INTRODUCTION

Aphasia is an impairment of language that occurs in 30%-40% of stroke survivors. This often chronic condition results in poor outcomes for the individual with aphasia and their family. Long-term aphasia management is limited, with few people receiving sufficient services by 6-12 months postonset. We present a protocol for the development of coproduced aphasia service elements. We will use experience-based codesign (EBCD), an approach that enables service users and providers to collaboratively develop services and care pathways. Drawing on the experiences of people with aphasia, their families and clinicians we will establish priorities for the development of new services and later work together to codesign them.

METHODS AND ANALYSIS

This research will be coproduced with people with aphasia (n=30-60), their families (n=30-60) and speech pathologists (n=30-60) in Queensland, Australia, using EBCD. A consumer advisory committee will provide oversight and advice throughout the research. In phase 1, we will use semistructured interviews and the nominal group technique to explore experiences and unmet needs in aphasia rehabilitation. Data will be analysed using thematic analysis and the resulting themes will be prioritised in multistakeholder focus groups. Outcomes of phase 1 will inform future research (phase 2) to codesign services. Financial costs and participant experiences of EBCD will be measured.

ETHICS AND DISSEMINATION

Human Research Ethics Committee approval for phase 1 has been obtained (HREC/2020/QRBW/61368). Results will be reported in peer-reviewed journal articles, presented at relevant conferences and, following EBCD suggested best practice, fed back to participants and community members at a celebratory event at completion of the project. The inclusion of service users in all stages of research will facilitate an integrated approach to knowledge translation. A summary of research findings will be made available to participating sites.

Is There a Research-Practice Dosage Gap in Aphasia Rehabilitation?

Purpose Aphasia intervention research aims to improve communication and quality of life outcomes for people with aphasia. However, few studies have evaluated the translation and implementation of evidence-based aphasia interventions to clinical practice. Treatment dosage may be difficult to translate to clinical settings, and a mismatch between dosage in research and clinical practice threatens to attenuate intervention effectiveness. The purpose of this study is to quantify a potential research-practice dosage gap in outpatient aphasia rehabilitation. Method This study utilized a two-part approach. First, we estimated clinical treatment dosage in an episode of care (i.e., treatment provided from outpatient assessment to discharge) via utilization in a regional provider in the United States. Second, we undertook a scoping review of aphasia interventions published from 2009 to 2019 to estimate the typical dosage used in the current aphasia literature. Results Outpatient clinical episodes of care included a median of 10 treatment sessions and a mean of 14.8 sessions (interquartile range: 5-20 sessions). Sessions occurred 1-2 times a week over 4-14 weeks. The median total hours of treatment was 7.5 hr (interquartile range: 3.75-15 hr). In contrast, published interventions administered a greater treatment dosage, consisting of a median of 20 hr of treatment (interquartile range: 12-30 hr) over the course of 15 sessions (interquartile range: 10-24 sessions) approximately 3 times per week. Conclusions Results demonstrate a meaningful research-practice dosage gap, particularly in total treatment hours and weekly treatment intensity. This gap highlights the potential for attenuation of effectiveness from research to outpatient settings. Future translational research should consider clinical dosage constraints and take steps to facilitate intervention implementation, particularly with regard to dosage. Conversely, health care advocacy and continued development of alternative delivery methods are necessary for the successful implementation of treatments with dosage that is incompatible with current clinical contexts. Pragmatic, implementation-focused trials are recommended to evaluate and optimize treatment effectiveness in outpatient clinical settings. Supplemental Material https://doi.org/10.23641/asha.15161568.

Intensive Comprehensive Aphasia Programmes: a systematic scoping review and analysis using the TIDieR checklist for reporting interventions

PURPOSE

Aphasia is an acquired language disorder that typically occurs as a result of a stroke. People with aphasia experience communication difficulties and risk secondary impacts, for example, affecting social and work life and mental health. Intensive Comprehensive Aphasia Programmes (ICAPs) aims to address the multiple consequences of aphasia using intensive intervention and a wide range of therapy approaches. Although basic parameters of ICAP intervention have been defined, a fuller characterisation is needed. This systematic scoping review aimed to determine what constitutes an ICAP.

METHODS

Peer-reviewed and Grey databases were searched for articles on ICAPs using Joanna Brigg's Institute methodology. Data was extracted following the Template for Intervention Description and Replication (TIDieR) checklist for reporting interventions and synthesised using a narrative synthesis.

RESULTS AND CONCLUSIONS

17 ICAPs were reported in 20 peer-reviewed literature sources (9 ICAPs supplemented by Grey literature sources). There were high degrees of variation in dose, professionals involved, and no qualitative data from participants. Of note, ICAP intervention was highly tailored to individual participants on the same ICAP, and intervention content varied between ICAPs. ICAPs appear to be rationalised as intensive impairment-based programmes with other components added for comprehensiveness. Stronger rationale and a logic model are required to justify the core components of ICAPs. The input of stakeholders into designing future ICAP interventions is recommended.IMPLICATIONS FOR REHABILITATIONThe ICAP model is in its infancy when it comes to mainstream clinical application as only the intensity component of the ICAP has clear theoretical underpinning as reported in the peer-reviewed literature.There have been clinical uptakes of the ICAP model which is likely to continue and is valid in the context of an under-researched area of aphasia therapy and on a background of a less than perfect relationship between evidence base and practice.Aspects of the ICAP model are valid for clinicians to implement, for example, intensive evidence-based aphasia therapy in combination with therapy which addresses some of the broader implications of aphasia, for example, social isolation.Clinicians can use the ICAP model to review their existing service provision and explore whether their service provides aphasia therapy that addresses the multiple aspects of aphasia (i.e., ensuring the focus is not only on impairment-based therapy).

Factors predicting long-term recovery from post-stroke aphasia

BACKGROUND

It remains widely accepted that spontaneous recovery from aphasia is largely limited to the first related factors. This has direct implications for acute and chronic interventions for aphasia. few months following stroke. A few recent studies challenge this view, revealing that some individuals' language abilities improve even during the chronic stage.

AIMS

To identify prognostic indicators of long-term aphasia recovery.

METHODS & PROCEDURES

Eighteen people with aphasia initially evaluated in the chronic stage were retested at least one year later. The Western Aphasia Battery-Revised (WAB-R) Aphasia Quotient (AQ) was used to quantify changes in language impairment. Prognostic factors included those related to the patient (demographic, psychosocial), stroke (lesion volume and location), and treatment (medical, rehabilitative).

OUTCOMES & RESULTS

Twelve participants improved and 6 remained stable or declined. Linear regression analysis revealed that lesion volume predicted long-term language gains, with smaller lesions yielding greater improvements. Individuals who did not improve were more likely to have lesions encompassing critical frontal and temporoparietal cortical regions and interconnecting white matter pathways. Exploratory regression analysis of psychosocial and treatment-related factors revealed a positive relationship between improvement and satisfaction with life participation, and a negative relationship between improvement and perceived impairment severity. Critically, psychosocial and treatment-related factors significantly improved model fit over lesion volume, suggesting that these factors add predictive value to determining long-term aphasia prognosis.

CONCLUSIONS

Long-term aphasia recovery is multidetermined by a combination of stroke-, psychosocial-, and treatment-related factors. This has direct implications for acute and chronic interventions for aphasia.

'I hated being ghosted' - The relevance of social participation for living well with post-stroke aphasia: Qualitative interviews with working aged adults

Background

In the context of increasing incidence of stroke in working aged adults, there is a specific need to explore the views of working aged adults with post‐stroke aphasia, whose communication difficulties may result in restricted social participation, loss of employment and changed relationship and parenting roles. This study aimed to explore the perspectives of working aged adults with post‐stroke aphasia in relation to social participation and living well with aphasia (LWA).

Design and participants

We conducted qualitative interviews with 14 people with post‐stroke aphasia (PWA). Data were analysed following principles of reflexive, thematic analysis.

Patient or Public Contribution: A Public and Patient Involvement aphasia advisory group inputted into the study design and interpretation of data.

Results

Social participation spanned 5 themes: Relationships and roles; Social support; Peer network, Aphasia awareness; and Employment and training. Meaningful, interesting social participation for LWA is individually defined. Working aged PWA may require flexible support with parenting, accessing a diverse social network and finding opportunities for meaningful social connection, training and employment.

Conclusions

The findings extend knowledge of social participation in the context of LWA for working aged adults by elucidating the individually defined nature of meaningful participation and how PWA may need flexible support with parenting, accessing a diverse social network and training and employment. For aphasia research, policy and services to be relevant, it is crucial that working aged PWA are meaningfully involved in setting the aphasia agenda.

Treatment of post-stroke aphasia: A narrative review for stroke neurologists

This review is intended to help physicians guide patients to optimal management of post-stroke aphasia. We review literature on post-stroke aphasia treatment, focusing on: (1) when and for whom language therapy is most effective, (2) the variety of approaches that can be effective for different individuals, and (3) the extent to which behavioral therapy might be augmented by non-invasive brain stimulation and/or medications.

Current Approaches to the Treatment of Post-Stroke Aphasia

Aphasia, impairment of language after stroke or other neurological insult, is a common and often devastating condition that affects nearly every social activity and interaction. Behavioral speech and language therapy is the mainstay of treatment, although other interventions have been introduced to augment the effects of the behavioral therapy. In this narrative review, we discuss advances in aphasia therapy in the last 5 years and focus primarily on properly powered, randomized, controlled trials of both behavioral therapies and interventions to augment therapy for post-stroke aphasia. These trials include evaluation of behavioral therapies and computer-delivered language therapies. We also discuss outcome prediction trials as well as interventional trials that have employed noninvasive brain stimulation, or medications to augment language therapy. Supported by evidence from Phase III trials and large meta-analyses, it is now generally accepted that aphasia therapy can improve language processing for many patients. Not all patients respond similarly to aphasia therapy with the most severe patients being the least likely responders. Nevertheless, it is imperative that all patients, regardless of severity, receive aphasia management focused on direct therapy of language deficits, counseling, or both. Emerging evidence from Phase II trials suggests transcranial brain stimulation is a promising method to boost aphasia therapy outcomes.

Self-managed, computerised word finding therapy as an add-on to usual care for chronic aphasia post-stroke: An economic evaluation

OBJECTIVE

To examine the cost-effectiveness of self-managed computerised word finding therapy as an add-on to usual care for people with aphasia post-stroke.

DESIGN

Cost-effectiveness modelling over a life-time period, taking a UK National Health Service (NHS) and personal social service perspective.

SETTING

Based on the Big CACTUS randomised controlled trial, conducted in 21 UK NHS speech and language therapy departments.

PARTICIPANTS

Big CACTUS included 278 people with long-standing aphasia post-stroke.

INTERVENTIONS

Computerised word finding therapy plus usual care; usual care alone; usual care plus attention control.

MAIN MEASURES

Incremental cost-effectiveness ratios (ICER) were calculated, comparing the cost per quality adjusted life year (QALY) gained for each intervention. Credible intervals (CrI) for costs and QALYs, and probabilities of cost-effectiveness, were obtained using probabilistic sensitivity analysis. Subgroup and scenario analyses investigated cost-effectiveness in different subsets of the population, and the sensitivity of results to key model inputs.

RESULTS

Adding computerised word finding therapy to usual care had an ICER of £42,686 per QALY gained compared with usual care alone (incremental QALY gain: 0.02 per patient (95% CrI: -0.05 to 0.10); incremental costs: £732.73 per patient (95% CrI: £674.23 to £798.05)). ICERs for subgroups with mild or moderate word finding difficulties were £22,371 and £21,262 per QALY gained respectively.

CONCLUSION

Computerised word finding therapy represents a low cost add-on to usual care, but QALY gains and estimates of cost-effectiveness are uncertain. Computerised therapy is more likely to be cost-effective for people with mild or moderate, as opposed to severe, word finding difficulties.

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.

The relevance of stroke care for living well with post-stroke aphasia: a qualitative interview study with working-aged adults

PURPOSE

This study aimed to explore the perspectives of working-aged adults with post-stroke aphasia (PWA) towards what has or would help them in living well with aphasia (LWA). This paper reports the findings in relation to stroke care and its relevance for LWA.

MATERIALS AND METHODS

This qualitative study was designed with input from a Public and Patient Involvement advisory group. We conducted in-depth, semi-structured interviews with 14 PWA. Data were analysed following principles of reflexive thematic analysis.

RESULTS

Support services and LWA spanned five themes: Inpatient care; Support in the community; Speech therapy; Mental health; and Aphasia education and training. Per the findings, all aspects of stroke care were affected and challenged by aphasia. Access to services and information was variable. PWA of working-age, their families and children need access to person-centred stroke care and information responsive to their changing needs at all stages of recovery. Healthcare workers must be equipped with aphasia competency.

CONCLUSIONS

The results highlight a need for equitable, transparent, responsive access to services, information and stroke liaison support. The findings extend knowledge of the importance of stroke care for supporting working-aged adults and their families to live well in the context of aphasia.Implications for rehabilitationThere is a need for equitable, transparent access to a responsive integrated pathway of stroke care to support living well with aphasia.People with aphasia post-stroke and their families need access to person-centred stroke care and information responsive to their changing needs at all stages of recovery.This includes flexible access to mental healthcare and speech and language therapy.In order to access relevant care, people with post-stroke aphasia need access to information and stroke liaison support.Training to improve aphasia competency is imperative for healthcare workers.

Supporting people with post-stroke aphasia to live well: A cross-sectional survey of Speech & Language Therapists in Ireland

Living well with post-stroke aphasia is supported by responsive, collaborative heath and related services, aphasia information and training for people with aphasia (PWA) and their social networks, and opportunities to contribute and participate autonomously in their communities. Several international surveys indicate shortcomings in the provision of long-term support and, in Ireland, while there is a lack of data around service provision for PWA, there is evidence that post-acute stroke services are fragmented and under-resourced. The aim of this study was to survey Speech & Language Therapists (SLTs), due to their unique role in aphasia management, to understand what SLT and related support services and aphasia information and training are currently available to support living well with aphasia in Ireland. We developed and piloted a self-administered, web-based cross-sectional survey with questions informed by a systematic review and qualitative evidence synthesis around living well with aphasia, and with input from a Public and Patient Involvement aphasia advisory group. Data from 95 SLTs working with PWA were analysed using descriptive statistics. Although SLT was generally available for PWA, the results highlight access barriers and evidence-practice gaps in terms of the amount, intensity and timing of SLT to be maximally effective and there was a lack of PWA input into service design and evaluation. Access to other relevant supports such as mental health services was inconsistent and there was a lack of community support for families. There were shortcomings in access to aphasia information/training for PWA, families, friends and other healthcare professionals. There is a need for a coordinated and standardised approach to supporting PWA across Ireland. This study addresses an evidence gap around the provision of stroke services for PWA and is part of a larger project aiming to produce recommendations for improving person-centred support to facilitate living well with aphasia.

Transcranial Direct Current Stimulation vs Sham Stimulation to Treat Aphasia After Stroke: A Randomized Clinical Trial

Importance

Aphasia is a debilitating language disorder for which behavioral speech therapy is the most efficient treatment, but therapy outcomes are variable and full recovery is not always achieved. It remains unclear if adjunctive brain stimulation (anodal transcranial direct current stimulation [A-tDCS]) applied during aphasia therapy can improve outcomes.

Objective

To examine the futility of studying A-tDCS as an adjunctive intervention during speech therapy to improve speech production (naming) for individuals with long-term poststroke aphasia.

Design, Setting, and Participants

Double-blinded, prospective randomized clinical trial using a futility design to test adjunctive A-tDCS during speech therapy. The setting was an outpatient clinic. Enrollment of individuals began in August 2012 and was completed in March 2017, and the duration of follow-up was 6 months. Analyses began in April 2017. The study recruited from a volunteer sample, and 89 patients were screened. Patients with long-term (>6 months) aphasia due to 1 previous left hemisphere stroke were enrolled. In comparing A-tDCS and sham tDCS, patients were matched based on site (University of South Carolina or Medical University of South Carolina), baseline age, type of aphasia, and aphasia severity.

Interventions

Outpatient speech therapy for 3 weeks (15 sessions, 45 minutes each) combined with either A-tDCS vs sham tDCS applied to preserved left temporal lobe regions.

Main Outcomes and Measures

The primary outcome was the ability to name common objects, assessed twice before and after therapy.

Results

A total of 74 patients were enrolled. Participants had a mean (SD) age of 60 (10) years, had 15 (2) years of education, and were 44 (40) months from stroke onset. There were 52 men (70%) and 62 non-Hispanic white individuals (84%). Most were retired or not employed (59 [80%]). Broca aphasia was the most common aphasia type (39 [52.7%]). The adjusted mean (SE) change from pretreatment baseline in correct naming was 13.9 (2.4) words (95% CI, 9.0-18.7) for A-tDCS and 8.2 (2.2) words (95% CI, 3.8-12.6) for sham tDCS, with mean (SE) A-tDCS difference of 5.7 (3.3) words (95% CI, -0.9 to 12.3), indicating a relative 70% increase in correct naming for A-tDCS relative to sham. The futility hypothesis P value was .90, indicating failure to reject the null hypothesis and, therefore, providing no evidence that further study of A-tDCS is futile. No serious adverse events were associated with A-tDCS.

Conclusions and Relevance

Our findings provide motivation to proceed with another trial to study the effect of A-tDCS on the outcome of aphasia treatment in individuals poststroke. Anodal tDCS during speech therapy is feasible and potentially transformative for aphasia treatment and should be further studied.

Trial Registration

ClinicalTrials.gov Identifier: NCT01686373.

The Factor Structure of the Boston Diagnostic Aphasia Examination, Third Edition

OBJECTIVE

The Boston Diagnostic Aphasia Examination (BDAE) is one of the most commonly used aphasia batteries. The newest edition has undergone significant revisions since its original publication in 1972, but existing evidence for its validity is lacking. We examined the construct validity of BDAE-3 and identified the factor structure of this battery.

METHOD

A total of 355 people with aphasia of various types and severity completed neuropsychological evaluations to assess their patterns of language impairment. A principal component analysis with varimax rotation was conducted to examine the components of BDAE-3 subtests.

RESULTS

Five components accounting for over 70% of the BDAE-3 total variance were found. The five language factors identified were auditory comprehension/ideomotor praxis, naming and reading, articulation-repetition, grammatical comprehension, and phonological processing.

CONCLUSIONS

Our results show that the BDAE-3 demonstrates good construct validity, and certain language functions remain primary, distinct language domains (i.e., receptive vs. expressive language) across severities of aphasia. Overall, our findings inform clinical practice by outlining the inherent structure of language abilities in people with aphasia. Clinicians can utilize the findings to select core BDAE-3 tests that are most representative of their respective functions, thereby reducing the total testing time while preserving diagnostic sensitivity. (JINS, 2019, 25, 772-776).

The development and feasibility of an online aphasia group intervention and networking program - TeleGAIN

PURPOSE

Aphasia group therapy offers many benefits, however people with aphasia report difficulty accessing groups and speech-language pathologists are faced with many challenges in providing aphasia group therapy. Telerehabilitation may offer an alternative service delivery option. An online aphasia group therapy program - Telerehabilitation Group Aphasia Intervention and Networking (TeleGAIN) - has been developed according to the guidelines of the Medical Research Council (MRC) framework for complex interventions. The purpose of this paper is to describe the development of TeleGAIN and the results of a pilot trial to determine feasibility and acceptability.

METHOD

The development of TeleGAIN was informed through literature reviews in relevant topic areas, consideration of expert opinion and application of the social cognitive theory. TeleGAIN was then modelled through a feasibility pilot trial with four people with aphasia.

RESULT

TeleGAIN appeared to be feasible and acceptable to participants and able to be implemented as planned. Participant satisfaction with treatment was high and results suggested some potential for improvements in language functioning and communication-related quality of life.

CONCLUSION

TeleGAIN appeared to be feasible and acceptable, however the study highlighted issues related to technology, clinical implementation and participant-specific factors that should be addressed prior to a larger trial.

What speech and language therapy do community dwelling stroke survivors with aphasia receive in the UK?

Background

Speech and language therapy provision for aphasia (a language disorder) post stroke has been studied over time through surveys completed by speech and language therapists. This paper revisits provision based on what was received by 278 patients in 21 UK speech and language therapy departments in 2014–2016.

Aims

To explore the speech and language therapy received by community dwelling people with post stroke aphasia in the UK.

Methods and procedures

A quantitative content analysis was conducted by two speech and language therapist researchers. Therapy goals recorded were coded into categories and subcategories. Descriptive statistics were used to identify the frequency with which goal categories were targeted, average therapy time received, length and frequency of therapy sessions, personnel involved and mode of delivery.

Outcomes and results

Forty-five percent of participants were in receipt of therapy in the three month window observed. Six goal categories were identified. Rehabilitation was the most frequent (60%) followed by enabling (17.2%), review (4.3%), assessment (3.6%), supportive (3.5%) and activity to support therapy (2.8%). The median amount of therapy received in three months was 6.3 hours at an average of one 60-minute session every two weeks. Seventy-seven percent of therapy sessions were delivered by qualified speech and language therapists and 23% by assistants. Ninety percent of sessions were one to one, face to face sessions whilst 9.5% were group sessions.

Discussion

In line with previous reports, speech and language therapy for community dwelling stroke survivors with aphasia is restricted. Rehabilitation is a large focus of therapy but the intensity and dose with which it is provided is substantially lower than that required for an effective outcome. Despite this, one to one face to face therapy is favoured. More efficient methods to support more therapeutic doses of therapy are not commonly used in routine clinical services.

An International Survey of Assessment Practices for Short-Term and Working Memory Deficits in Aphasia

PURPOSE

Recent research has highlighted the clinical relevance of understanding the nature of short-term memory (STM) and working memory (WM) deficits in persons with aphasia and the way these deficits affect linguistic processing and functional communication in activities of daily living. The psychometric properties of tests commonly used to identify STM/WM problems in individuals with aphasia, however, have been questioned. No previous study has sought to investigate assessment practices and attitudes by speech-language pathologists involved in aphasia management. Accordingly, the aims of this study were (a) to investigate both attitudes toward STM/WM assessment in individuals with aphasia, as well as the types and frequency of STM/WM tests used with individuals with aphasia, and (b) to explore factors (e.g., educational background) that may influence STM/WM assessment practices.

METHOD

Respondents recruited via professional and aphasia support organizations completed an online survey. The survey elicited information about the respondents' demographic and clinical backgrounds and STM/WM assessment clinical practices and views, including frequency and preferred use of specific STM/WM tests.

RESULTS

The majority of respondents reported regular use of STM/WM tests as part of aphasia management. Positive attitudes toward STM/WM assessments were also reported. The most popular rankings of tests were the Cognitive Linguistic Quick Test (Helm-Estabrooks, 2001), the Comprehensive Aphasia Test (Swinburn, Porter, & Howard, 2005), and the Token Test (McNeil & Prescott, 1978). Results suggested limited knowledge about measures that assess self-perceptions of functional memory abilities. Regression analyses showed that the frequency of reported STM/WM test use was similar between clinicians and dual-role researchers/clinicians, but their attitudes toward the value of STM/WM differed. U.S. and UK respondents reported similar assessment practices.

CONCLUSIONS

It is reassuring that STM/WM is taken into consideration by clinicians when providing aphasia management. Two of the most popular tests, however, have poor psychometric properties, and caution should be exercised in clinical decision making. The different value placed on STM/WM testing by clinicians and researchers/clinicians has implications for continuing professional development.

Validity, reliability and sensitivity of the NORLA-6: Naming and oral reading for language in aphasia 6-point scale

PURPOSE

Evaluation of the Naming and Oral Reading for Language in Aphasia 6-point scale (NORLA-6), a scoring system of oral reading and naming performance in aphasia.

METHOD

Data were drawn from 91 participants with non-fluent aphasia secondary to left-hemisphere stroke across four treatment studies. To assess validity, Spearman's correlations were calculated between the NORLA-6 and the Gray Oral Reading Test-Fourth Edition (GORT-4) Accuracy score, GORT-4 Rate score and the Boston Naming Test (BNT). Inter-rater and test-retest reliability were evaluated using correlations. Sensitivity to change following oral reading intervention was analysed using Wilcoxon Signed Rank tests between pre- and post-treatment NORLA-6 scores.

RESULT

NORLA-6 performance was significantly correlated (p < 0.001) with all reference tests (GORT-4 Accuracy, r_s=0.84; GORT-4 Rate, r_s= 0.61; and BNT, r_s= 0.92). Inter-rater (ICC ≥0.90) and test-retest (r > 0.92) reliability were both excellent. Sensitivity following oral reading intervention was demonstrated in both oral reading accuracy and rate (p < 0.004).

CONCLUSION

The NORLA-6 is a valid and reliable measure of oral reading and naming performance. It also demonstrates sensitivity to change in treatment-targeted behaviours. Therefore, the NORLA-6 scale may enhance outcome measurement in both clinical practice and aphasia research.

Priorities for Closing the Evidence-Practice Gaps in Poststroke Aphasia Rehabilitation: A Scoping Review

OBJECTIVE

To identify implementation priorities for poststroke aphasia management relevant to the Australian health care context.

DATA SOURCES

Using systematized searches of databases (CINAHL and MEDLINE), guideline and stroke websites, and other sources, evidence was identified and extracted for 7 implementation criteria for 13 topic areas relevant to aphasia management. These 7 priority-setting criteria were identified in the implementation literature: strength of the evidence, current evidence-practice gap, clinician preference, patient preference, modifiability, measurability, and health effect.

STUDY SELECTION

Articles were included if they were in English, related to a specific recommendation requiring implementation, and contained information pertaining to any of the 7 prioritization criteria.

DATA EXTRACTION

The scoping review methodology was chosen to address the broad nature of the topic. Evidence was extracted and placed in an evidence matrix. After this, evidence was summarized and then aphasia rehabilitation topics were prioritized using an approach developed by the research team.

DATA SYNTHESIS

Evidence from 100 documents was extracted and summarized. Four topic areas were identified as implementation priorities for aphasia: timing, amount, and intensity of therapy; goal setting; information, education, and aphasia-friendly information; and constraint-induced language therapy.

CONCLUSIONS

Closing the evidence-practice gaps in the 4 priority areas identified may deliver the greatest gains in outcomes for Australian stroke survivors with aphasia. Our approach to developing implementation priorities may be useful for identifying priorities for implementation in other health care areas.

The feasibility of delivering constraint-induced language therapy via the Internet

Objective

This study is designed to determine the feasibility of the provision of an evidenced-based aphasia therapy, constraint-induced language therapy, via telerehabilitation. It describes the computer software that was developed specifically for the delivery of constraint-induced language therapy in the online environment and presents two case studies.

Methods

Two participants with chronic aphasia were assessed before and after a two-week intensive treatment block of constraint-induced language therapy delivered via Web-based videoconferencing. The group-based, dual card request game utilized in face-to-face constraint-induced language therapy was transformed into an innovative and user-friendly Web-based game - Internet constraint-induced language therapy (iCILT). Participants accessed iCILT via the Internet from their own home every weekday for two weeks. Language and quality of life measures were administered pre- and post-therapy in order to detect treatment effects. Participant satisfaction information was also recorded.

Results

Online delivery of iCILT was technically feasible and participant satisfaction was high with a number of benefits associated with telerehabilitation identified by participants. Post-treatment performance for language functioning and communication-related quality of life was variable for each participant, however improvements in naming were noted.

Conclusions

Constraint-induced language therapy delivered via telerehabilitation may be a feasible alternative to traditional face-to-face therapy for people with chronic aphasia.

Improved language in chronic aphasia after self-delivered iPad speech therapy

Self-delivered speech therapy provides an opportunity for individualised dosage as a complement to the speech-therapy regime in the long-term rehabilitation pathway. Few apps for speech therapy have been subject to clinical trials, especially on a self-delivered platform. In a crossover design study, the Comprehensive Aphasia Test (CAT) and Cookie Theft Picture Description (CTPD) were used to measure untrained improvement in a group of chronic expressive aphasic patients after using a speech therapy app. A pilot study (n = 3) and crossover design (n = 7) comparing the therapy app with a non-language mind-game were conducted. Patients self-selected their training on the app, with a recommended use of 20 minutes per day. There was significant post-therapy improvement on the CAT and CTPD but no significant improvement after the mind-game intervention, suggesting there were language-specific effects following use of the therapy app. Improvements on the CTPD, a functional measurement of speech, suggest that a therapy app can produce practical, important changes in speech. The improvements post-therapy were not due to type of language category trained or amount of training on the app, but an inverse relationship with severity at baseline and post-therapy improvement was shown. This study suggests that self-delivered therapy via an app is beneficial for chronic expressive aphasia.

Constraint-Induced Aphasia Therapy for Treatment of Chronic Post-Stroke Aphasia: A Randomized, Blinded, Controlled Pilot Trial

Background

Few studies have documented the possibility of treatment-induced improvements in language functions 12 months or longer after stroke. The purpose of the current study was to provide a preliminary estimate of efficacy of constraint-induced aphasia therapy (CIAT) when compared to no-intervention in patients with chronic (>1 year) post-stroke aphasia in order to provide the data needed to design an appropriately powered trial.

Material/Methods

This was a randomized, controlled, single-blinded, pilot trial. We identified 32 patients with chronic post-stroke aphasia. Of these, 27 were offered participation, and 24 were randomized (CONSORT diagram): 14 to CIAT and to 10 to no-intervention. CIAT groups received up to 4 hours/day of intervention for 10 consecutive business days (40 hours of therapy). Outcomes were assessed within 1 week of intervention and at 1 and 12 weeks after intervention and included several linguistic measures and a measure of overall subjective communication abilities (mini-Communicative Abilities Log (mini-CAL)). To maintain blinding, clinicians treating patients (CIAT group) did not communicate with other team members and the testing team members were blinded to treatment group assignment.

Results

Overall, the results of this pilot trial support the results of previous observational studies that CIAT may lead to improvements in linguistic abilities. At 12 weeks, the treatment group reported better subjective communication abilities (mini-CAL) than the no-intervention group (p=0.019). Other measures trended towards better performance in the CIAT group.

Conclusions

In this randomized, controlled, and blinded pilot study, intensive language therapy (CIAT) led to an improvement in subjective language abilities. The effects demonstrated allow the design of a definitive trial of CIAT in patients with a variety of post-stroke aphasia types. In addition, our experiences have identified important considerations for designing subsequent trial(s) of CIAT or other interventions for post-stroke aphasia.

Success of Anomia Treatment in Aphasia Is Associated With Preserved Architecture of Global and Left Temporal Lobe Structural Networks

BACKGROUND AND OBJECTIVE

Targeted speech therapy can lead to substantial naming improvement in some subjects with anomia following dominant-hemisphere stroke. We investigated whether treatment-induced improvement in naming is associated with poststroke preservation of structural neural network architecture.

METHODS

Twenty-four patients with poststroke chronic aphasia underwent 30 hours of speech therapy over a 2-week period and were assessed at baseline and after therapy. Whole brain maps of neural architecture were constructed from pretreatment diffusion tensor magnetic resonance imaging to derive measures of global brain network architecture (network small-worldness) and regional network influence (nodal betweenness centrality). Their relationship with naming recovery was evaluated with multiple linear regressions.

RESULTS

Treatment-induced improvement in correct naming was associated with poststroke preservation of global network small worldness and of betweenness centrality in temporal lobe cortical regions. Together with baseline aphasia severity, these measures explained 78% of the variability in treatment response.

CONCLUSIONS

Preservation of global and left temporal structural connectivity broadly explains the variability in treatment-related naming improvement in aphasia. These findings corroborate and expand on previous classical lesion-symptom mapping studies by elucidating some of the mechanisms by which brain damage may relate to treated aphasia recovery. Favorable naming outcomes may result from the intact connections between spared cortical areas that are functionally responsive to treatment.

Verb production tasks in the measurement of communicative abilities in aphasia

BACKGROUND

The neurofunctional correlates of verbs and nouns have been the focus of many theoretically oriented studies. In clinical practice, however, more attention is typically paid to nouns, and the relative usefulness of tasks probing nouns and verbs is unclear. The routine administration of tasks that use verbs could be a relevant addition to current batteries. Evaluating performance on both noun and verb tasks may provide a more reliable account of everyday language abilities than an evaluation restricted to nouns.

AIMS

To assess the benefits of administering verb tasks in addition to noun tasks, and their relation to three functional measures of language.

METHOD AND PROCEDURE

Twenty-one subjects with poststroke language disorders completed four picture-naming tasks and a role-playing test (Communicative Abilities in Daily Living, Second Edition, CADL-2), commonly used as measure of everyday language abilities. Two questionnaires (Communicative Effectiveness Index, CETI, and Communicative Activity Log, CAL) were completed by caregivers. Picture-naming tasks were matched for psycholinguistic variables to avoid lexicosemantic and morphosyntactic confounds.

RESULTS

No significant differences emerged across picture-naming tasks. Scores on the role-playing test and the two questionnaires differed; scores between the two questionnaires did not. The four naming tasks correlated significantly with CADL-2, CETI, and CAL. The strength of the correlation with CADL-2 was significantly greater for Naming Finite Verbs than for Object Naming. Thirteen participants showed no differences in performance between tasks, 6 fared significantly worse on verb tasks than on Object Naming, 1 fared better at Naming Finite Verbs though his performance was poor overall, and 1 was significantly more impaired on verbs.

CONCLUSIONS

Performance on tasks that use verbs, and especially Naming Finite Verbs, may provide a more accurate estimate of language abilities in daily living than Object Naming alone. Administering both verb and noun tasks may be recommended in clinical practice.

Assessment practices of speech-language pathologists for cognitive communication disorders following traumatic brain injury in adults: an international survey

PRIMARY OBJECTIVE

This study's objective was to examine the current assessment practices of SLPs working with adults with acquired cognitive communication impairments following a TBI.

METHODS AND PROCEDURES

Two hundred and sixty-five SLPs from the UK, the US, Canada, Australia and New Zealand responded to the online survey stating the areas of communication frequently assessed and the assessment tools they use.

MAIN OUTCOMES AND RESULTS

SLPs reported that they routinely assessed functional communication (78.8%), whereas domains such as discourse were routinely assessed by less than half of the group (44.3%). Clinicians used aphasia and cognitive communication/high level language tools and tools assessing functional performance, discourse, pragmatic skills or informal assessments were used by less than 10% of the group. The country and setting of service delivery influenced choice of assessment tools used in clinical practice.

CONCLUSIONS

These findings have implications for training of SLPs in a more diverse range of assessment tools for this clinical group. The findings raise questions regarding the statistical validity and reliability of assessments currently used in clinical practice. It highlights the need for further research into how SLPs can be supported in translating current evidence about the use of assessment tools into clinical practice.

Aphasia rehabilitation in Australia: Current practices, challenges and future directions

This study reports on current aphasia rehabilitation practices of speech-language pathologists in Australia. A 30-item web-based survey targeted approaches to aphasia rehabilitation, education, discharge, follow-up practices, counselling, interventions to improve communication access, community aphasia support services, and challenges to practice. One hundred and eighty-eight surveys were completed representing ~33% of the potential target population, with 58.5% urban and 41.5% rural participants across all states and territories. Respondents reported embracing a wide variety of approaches to aphasia rehabilitation; however, significant challenges in providing aphasia management in acute and residential care were identified. Low levels of knowledge and confidence were reported for both culturally and linguistically diverse clients and discourse approaches. Group and intensive services were under-utilized and clinicians reported inflexible funding models as major barriers to implementation. Few clinicians work directly in the community to improve communicative access for people with aphasia. Despite the chronic nature of aphasia, follow-up practices are limited and client re-entry to services is restricted. Counselling is a high frequency practice in aphasia rehabilitation, but clinicians report being under-prepared for the role. Respondents repeatedly cited lack of resources (time, space, materials) as a major challenge to effective service provision. Collective advocacy is required to achieve system level changes.

Speech pathology services for people with aphasia: what is the current practice in Singapore?

PURPOSE

This study reports on current provision of aphasia services by speech pathologists in Singapore.

METHOD

A 44-item web-based survey was conducted looking into areas of service delivery, assessment, cultural and linguistic adaptations, clinical approaches, education of clients, recovery, goal setting and discharge as well as scope and challenges to practice.

RESULTS

A total of 36 surveys were completed representing approximately 86% of the potential target population. The intensity of aphasia services provided was well below that recommended by the literature. Participants reported embracing approaches to aphasia rehabilitation that spanned across the ICF domains. Numerous challenges were reported in providing aphasia services. These included the lack of locally relevant resources for aphasia, lack of family support and patient motivation, manpower shortages as well as barriers such as transport and cost restricting access to services.

CONCLUSIONS

This research reveals several findings with considerable implications for practice planning and future direction in aphasia rehabilitation. There is a need for the development of locally relevant aphasia resources to enable comprehensive provision of aphasia services. In addition, further investigation is required to tackle the resource challenges faced by the profession and improve community support for people with aphasia. Implications for Rehabilitation Speech pathology services for aphasia in Singapore This article has identified the challenges of providing aphasia services in the Singapore context. Further investigation is required to address the key issues to improve aphasia services in Singapore. This includes developing locally relevant resources, looking at means like telerehabilition to tackle resource challenges, and improving community support for people with aphasia.

Computer-assisted analysis of spontaneous speech: quantification of basic parameters in aphasic and unimpaired language

Although generally accepted as an important part of aphasia assessment, detailed analysis of spontaneous speech is rarely carried out in clinical practice mostly due to time limitations. The Aachener Sprachanalyse (ASPA; Aachen Speech Analysis) is a computer-assisted method for the quantitative analysis of German spontaneous speech that allows for a detailed assessment by means of linguistic basic parameters in an acceptable amount of time. It has previously been proven sensitive for monitoring changes over time. In this study, we present data of 52 aphasic participants whose spontaneous speech was analyzed retrospectively before and after an intensive therapy program. The measured changes are evaluated with reference to normative data of 60 non-brain-damaged speakers. Results confirm good sensitivity to document changes over time. Clinical relevance of changes is assessed with reference to critical score ranges derived from the normative data. Findings provide further evidence of the clinical applicability and usefulness of ASPA.

The Impact of Varied Speaker Role and Communication Partner on the Communicative Interactions of a Person With Traumatic Brain Injury: A Single Case Study Using Systemic Functional Linguistics

This article presents preliminary findings on an investigation into the differences in communicative performance across varying speaking conditions, of an individual with a cognitive–linguistic impairment following traumatic brain injury (TBI). The article compares the communicative exchanges of an individual in a conversation with a therapist, a conversational dyad with a peer with TBI, and in a communication group task where they were interacting with other participants with TBI. The speaking conditions studied included an unstructured chat, the participant requesting information and the participant giving information. Results showed that the person with TBI responded to differences in communication partner and speaker role. He was best able to give information in the unstructured chat with the clinician and the information giving session in the group. Requesting was maximally facilitated in the information request condition with the clinician. Qualitatively, however, the most equal interactions occurred with the peer, with evidence of the person with TBI engaging in typical conversational strategies such as establishing common ground to facilitate topic development and co-constructing the discourse topics. These strategies did not occur in the clinician or group interactions, possibly due to power imbalance in the former and impaired cognitive–linguistic ability in the latter situation. Implications for clinical decision making regarding intervention strategies for patients with cognitive–communication deficits are discussed.

Rethinking aphasia therapy: a neuroscience perspective

This article explores how consideration of acquired speech and language disorders from the perspective of neuroscience permits new insights into the content and design of therapy for people with aphasia. Key proposals are that aspects of current therapies often neglect the sensory-motor components of speech and language processing, and the interconnectivity of sensory-perceptual and motor systems. Furthermore, current therapy regimes are often administered at too low an intensity to stimulate neural reorganization. Neuroscientific perspectives on learning are explored and in particular the issues of associationist learning, learned misuse, mirror neurone systems, and procedural and errorless learning. The value of use of computer programs in administering high intensity therapy is outlined and it is proposed that aphasia therapies can be enhanced if clinicians adopt an explicit neuroscientific rationale for intervention.

Delivering for aphasia

Providing a quality service for people with aphasia is a primary goal of speech-language pathologists working with neurogenic communication disorders. This paper reviews what is known about the incidence and prevalence of aphasia and what services are provided for people with aphasia. On the basis of the stroke data, the incidence of aphasia in the developed world ranges between 0.02-0.06% with prevalence ranging between 0.1-0.4%. Average hours of treatment for aphasic people in the developed world ranges between 1-5 hours per week, with a great deal of variability, although recent research suggests that intense treatment of ∼9 hours per week over a relatively short period is needed in order to be effective. It is concluded that there is a significant gap between what the research suggests is the appropriate amount of treatment and actual provision throughout the English-speaking world.

Lost in translation? Issues of content validity in interpreter-mediated aphasia assessments

In many parts of the world, speech-language pathologists (SLPs) are frequently called upon to assess aphasia in bilingual speakers, or in speakers of languages of which they have little or no knowledge. One of the strategies that SLPs employ in these situations is to involve an interpreter in the assessment process. Three authentic interpreter-mediated aphasia assessments were analysed for the present study, which aimed to determine the degree to which the content validity of the individual tests was compromised in the process of their administration through an interpreter. Findings reveal that content validity was frequently weakened either at the point of administration of the test or at the point at which responses were reported back by the interpreter to the SLP. Based on these findings, it is argued that the conduct of interpreter-mediated aphasia assessments needs to be fundamentally re-thought to take account of the limitations inherent in the interpreting process. To this end, this study presents a number of practical recommendations for the involvement of interpreters in aphasia assessments, with a view to making optimal use of existing assessment materials and enhancing the quality of diagnostic information to emerge from such clinical sessions.