Intensity of aphasia therapy, impact on recovery

Computer- and Smart-Tablet-Based Self-Administered Treatments in Chronic Post-Stroke Aphasia: A Systematic Review

BACKGROUND

In current clinical practice, resources remain limited and are insufficient to address the needs of people with chronic post-stroke aphasia. To improve access to speech therapy, self-administered therapies using computers or smart tablets are increasingly recommended. In addition to enabling more intensive and prolonged treatment, computer- and smart-tablet-delivered therapies can be highly enjoyable and motivating for patients.

AIMS

This systematic review aimed to identify computer- and smart-tablet-based self-administered treatments and analyze the proposed interventions in terms of treatment targets, effectiveness (considering specificity, generalization, transfer, and maintenance), and clinician involvement (during and/or prior self-administered therapies).

METHODS

Terms encompassing three main concepts (rehabilitation, self-administration, and aphasia) were used to search three electronic databases (Scopus, PubMed, and PsycINFO). Two reviewers independently screened titles and abstracts against eligibility criteria. Data extraction of included studies was completed by three reviewers.

RESULTS

Thirty-nine studies were included in this study. In terms of treatment targets, anomia is the most treated symptom in published studies (n = 24), but the existence of promising studies for other disorders means that the targets can be broadened. Therapies are effective for trained items, and gains are maintained. There is some evidence of transfer effects for treatments targeting the sentence level. Most studies offer training sessions, previous self-administered therapy, and/or observation and monitoring sessions during therapy; more rarely, self-administered therapy is supplemented with face-to-face therapy.

CONCLUSIONS

This systematic review is the first to focus specifically on self-administered technology-based therapies. It provides important evidence-based information for clinical practice in self-administered therapies via computer or smart tablet.

Comparative Effectiveness of In-Person and Virtual Picture-Naming Treatment for Poststroke Anomia

PURPOSE

In light of COVID-19, telepractice for speech therapy has been increasingly adopted. Telepractice promotes accessibility to therapy services for those in rural environments, lowers the frequency of missed appointments, and reduces the costs of rehabilitation. The efficacy of telepractice has been scarcely explored in the aphasia literature. Preliminary research has demonstrated comparable results of telepractice and in-person therapy for people with aphasia, but the current scope of research is insufficient to guide clinical practice. The present study examined whether the virtual administration of a picture-naming therapy paradigm was as effective as in-person administration.

METHOD

The treatment effects of two similar clinical trials, one completed in-person (n = 13) and one completed virtually (n = 13), are compared. Participants were adults with chronic (> 6 months) poststroke aphasia. Both clinical trials administered Cued Picture-Naming Therapy 4 days a week for 2 weeks (eight treatment sessions). Treatment outcomes were analyzed using Tau-U effect sizes and Mann-Whitney U tests.

RESULTS

Weighted Tau-U averages showed an advantage of telepractice over in-person treatment in the acquisition effects of trained words, with participants demonstrating a very large effect (0.84, p < .01) following telepractice and a large effect (0.75, p < .01) following in-person treatment. Both telepractice and in-person rehabilitation demonstrated significant treatment effects and were not significantly different from each other per Mann-Whitney U independent-samples t tests.

CONCLUSIONS

The present study demonstrated that telepractice of a picture-naming paradigm is as effective as in-person treatment administration. This justifies the use of telepractice to overcome accessibility and cost barriers to speech therapy administration and justifies taking patient preference into account. Future research should explore the efficacy of telepractice for treatments that promote greater generalizability to functional communication.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27641031.

Self-Improved Language Production in Nonfluent Aphasia Through Automated Recursive Self-Feedback

BACKGROUND

Persons with nonfluent aphasia (PWNA) use feedback from external agents (e.g., speech-language pathologists) and self-feedback to improve their language production. The extent to which PWNA can improve their language production using their self-feedback alone is underexplored. In a proof-of-concept study, we developed an automated recursive self-feedback procedure to demonstrate the extent to which two PWNA who used self-feedback alone improved their production of sentences from trained and untrained scripts. In the current study, we use the Rehabilitation Response Specification System as a framework to replicate our initial findings.

METHOD

We tested the effects of two treatments: script production with recursive self-feedback and script production with external feedback in four persons with chronic nonfluent aphasia. We compared the effects of treatment by measuring percent script produced, speaking rate, and speech initiation latency of trained and untrained scripts. The participants received the treatments remotely through mini tablets using two versions of a mobile app we developed. All the participants received each treatment intensively for 14 sessions across 2-3 weeks. We estimated clinical improvements of production of sentences from trained and untrained scripts through nonoverlap of all pairs analysis of performance pretreatment and posttreatment.

RESULTS

Both treatments improved PWNA's language production. Recursive self-feedback improved speaking rate and speech initiation latency, which generalized to untrained scripts in all participants. External feedback treatment did not generalize to improvement in speaking rate in two participants.

CONCLUSIONS

Our findings confirm our initial evidence that PWNA can self-improve their sentence production from scripts through recursive self-feedback. This novel procedure enables PWNA to autonomously enhance their language production over time. Given the evidence and the mechanics of the procedure, we propose that its utility is not constrained by linguistic idiosyncrasies across cultures. Consequently, it has the potential to bypass linguistic barriers to aphasia care.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27007060.

Targeting Phonology or Semantics to Improve Reading Aloud Response Times and Accuracy: A Case Series Investigation of Stroke Survivors With Aphasia

PURPOSE

Acquired reading deficits, or alexia, affect a significant proportion of individuals with aphasia. We sought to improve treatment for alexia by targeting specific cognitive information-processing components critical to reading (i.e., phonology or semantics).

METHOD

To target either phonological or semantic processing, we administered two anomia treatments, phonomotor treatment (PMT) and semantic feature analysis, modified to include a focus on reading throughout the therapy. Chronic left-hemisphere stroke survivors (N = 5) completed one or two 60-hr treatment rounds. Based on predictions from a computational reading model, three participants received the treatment recommended for their specific reading challenges (e.g., PMT for phonological deficits), while two participants had the nonrecommended treatment first, followed by the recommended model-matched treatment. Changes in reading aloud accuracy and response times (RTs) from before to after treatment were examined as a function of matching treatment to the deficit profile, type of treatment, therapy round, and word characteristics.

RESULTS

Participants' reading aloud accuracy improved after treatment relative to baseline with higher accuracy for high-frequency words and shorter words. After the first treatment round, participants' accuracy and RT improved, irrespective of whether treatment was matched to the deficit profile. Furthermore, participants who completed the second treatment round continued achieving accuracy gains. Following treatment, participants demonstrated enhanced reading efficiency and generalized improvements on the selected sections of the Woodcock Reading Mastery Test.

CONCLUSIONS

While larger studies are needed to test for the effects of matching treatment type to the deficit profile, we conclude that treatments targeting specific information-processing components can effectively improve reading. Doubling the treatment dose offers small but significant gains.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26517319.

'But I have a cat, I have to talk to her now': a qualitative study on reasons for not participating in guideline-based aphasia therapy from the perspective of patients in German-speaking countries

OBJECTIVES

Clinical guidelines recommend high-frequency speech therapy for people with aphasia. Little is known about the experiences of people with aphasia with high-frequency speech therapy, why they do not receive it, what they expect from it and their general wishes and requirements for therapy. The aim of this qualitative study was to investigate the reasons for refusing high-frequency speech therapy and therapy preferences of patients with aphasia.

DESIGN

An interview study with people with aphasia.

SETTING

Interviewees were recruited via snowball sampling in different settings of healthcare system (eg, speech and language practices, self-help groups, clinics of neurorehabilitation).

PARTICIPANTS

Twenty-one people with aphasia and one relative participated in semi-structured interviews.

RESULTS

We identified five categories of not using high-frequency speech therapy: patient-related factors, health system-related factors, disease-related factors, social-economic factors and organisational factors. Most reasons for non-utilisation are within the domain of the healthcare system and are partly attributable to personnel shortages in care provision and knowledge deficits among healthcare practitioners. Patient therapy preferences notably pertain to the enhancement of speech therapy services, encompassing sessions both inclusive and exclusive of family members as well as the facilitation of information dissemination.

CONCLUSIONS

As expected, there were indications of a lack of staff, poor care in rural areas and the influence of being affected by aphasia for a longer period on utilisation behaviour. These factors in the healthcare system and organisational factors are not unknown to those with practical experience, and some of them must and could be changed quickly. This would require a change from the established face-to-face setting in presence to sufficient digital therapy adjuvants. The results of patient-related factors could be a further reason to reflect on speech therapy and its settings and to view and treat people with aphasia in a more holistic, less language-focused way.

Increasing frequency of therapy by software-based treatment of naming ability in people with aphasia: a preliminary study

This study aimed to explore the effect of new software targeting naming deficits in Turkish-speaking people with aphasia. The study included seven Turkish people with aphasia. These participants took the Aphasia Language Assessment Test (ADD), Turkish Picture-Naming Test (T-RAT), and Technology Familiarity Assessment, and the words for therapy were determined. The selection of categories and words for inclusion in the application was based on the frequency and typicality features. The 12-week speech-language treatment sessions were divided into two sections. During the first six weeks, a speech-language pathologist (SLP) used the software to train people. After the first part, the SLP applied the T-RAT. Participants utilized the software at home in the second part. All participants took the ADD, T-RAT, and Software Evaluation Questionnaire following the second part. Participants' naming abilities improved in all tests. Both therapy sessions with the SLP and those in which participants used the program independently demonstrated this improvement. Participants also reported high levels of treatment satisfaction. Cueing hierarchy approaches used in the software helped to improve naming skills in people with aphasia (PWA), independent of type, stage, or severity of aphasia. The findings of this study indicate that both sessions directed by an SLP and independent use of the software by participants can positively impact the therapy process with the developed software.

Success rates of intensive aphasia therapy: real-world data from 448 patients between 2003 and 2020

BACKGROUND

Aphasia is a devastating consequence after stroke, affecting millions of patients each year. Studies have shown that intensive speech and language therapy (SLT) is effective in the chronic phase of aphasia. Leveraging a large single-center cohort of persons with aphasia (PWA) including patients also in the subacute phase, we assessed treatment effects of intensive aphasia therapy in a real-world setting.

METHODS

Data were collected at the Aachen aphasia ward in Germany between 2003 and 2020. Immediate treatment responses across different language domains were assessed with the Aachen Aphasia Test (AAT) using single-case psychometrics, conducted before and after 6-7 weeks of intensive SLT (10 h per week, median (IQR) dosage = 68 (61-76)). We adjusted for spontaneous recovery in subacute patients. Differential treatment effects between subgroups of chronicity and predictors of therapy response were investigated.

RESULTS

A total of 448 PWA were included (29% female, median (IQR) age = 54 (46-62) years, median (IQR) time post-onset = 11 (6-20) months) with 12% in the early subacute, 15% in the late subacute and 74% in the chronic phase of aphasia. The immediate responder rate was 59%. Significant improvements in all AAT subtests und subscales were observed hinting at broad effectiveness across language domains. The degree of therapy-induced improvement did not differ between the chronicity groups. Time post-onset, dosage of therapy and aphasia severity at the beginning of treatment were predictors of immediate treatment response.

DISCUSSION

Intensive therapy protocols for aphasia after stroke are yielding substantial responder rates in a routine clinical setting including a wide range of patients.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

Characteristics of drawing deficits in people with aphasia: Differences between symbolic and realistic drawn objects

BACKGROUND

Pictures drawn by people with aphasia (PWA) are often more challenging to understand than those drawn by healthy people. There are two types of objects: those that tend to be drawn symbolically (symbolically drawn objects-SOs) and those that are likely to be drawn realistically (realistically drawn objects-ROs).

AIMS

To compare the identification rate and number of misunderstanding types between SOs and ROs drawn by PWA and healthy controls (HCs). To reveal trends in the misunderstandings of drawings by PWA, and to identify the language or cognitive abilities related to the identification rate of pictures drawn by PWA.

METHODS & PROCEDURES

We designed a drawing task involving SOs and ROs. A total of 18 PWA and 30 HCs completed the task, and respondents identified the drawings. The identification rate and number of misunderstandings were analysed with two-way analysis of variance (ANOVA) including group (PWA and HCs) and object type (SOs and ROs). The misunderstandings were divided into four categories varying in semantic and morphological similarity; these ratios were examined with a chi-square test. The relationships of language and cognitive abilities with the identification rate were investigated with multiple regression analyses.

OUTCOMES & RESULTS

There was a significant effect of the interaction between group and object type on the identification rate (F(1.1387) = 3.90, Mean Squared Error (MSE) = 4139.67, p = 0.04): the identification rates for ROs were lower in the PWA than in the HCs. For the number of misunderstanding types, an interaction was observed between group and object type (F(1.56) = 8.26, MSE = 26.93, p < 0.01): the number of misunderstanding types for ROs in the PWA was greater than that in the HCs. The misunderstanding patterns differed between ROs and SOs (χ2(3) = 694.30, p < 0.001, V = 0.37). ROs were semantically related, whereas SOs were morphologically related. The identification rates of ROs and SOs were correlated only with Kanji writing scores (ROs: β = 3.66, p = 0.01; SOs: β = 6.57, p < 0.01).

CONCLUSIONS & IMPLICATIONS

In drawings by the PWA, SOs had a higher identification rate, while ROs had a lower identification rate and a greater variety of misunderstandings. SOs may increase drawing motivation. Interventions to improve the identifiability of SOs and ROs should reflect each character. Identification rates were correlated only with Kanji writing scores. The PWA, whose native language was Japanese and had preserved Kanji writing abilities, and their communication abilities may be increased through drawing.

WHAT THIS PAPER ADDS

What is already known on the subject PWA often have impaired drawing abilities and draw pictures that third parties misinterpret. Some objects tend to be drawn symbolically, and some are drawn realistically. However, it is not clear whether there is a difference between these types of drawings depicted by PWA in identifiability and the tendency to be misunderstood by ordinary people. In addition, the relationships between language or cognitive abilities and the identification rate of drawn pictures are not clear. What this paper adds to the existing knowledge The identification rate differed between SOs and ROs. In drawings by PWA, SOs had a higher identification rate, while ROs had a lower identification rate and the greatest variety of misunderstandings. Approximately half of the misunderstandings were related to the target object. SOs tended to be confused with morphologically related objects, while ROs tended to be confused with semantically related objects. Identification rates were correlated only with Kanji writing scores. What are the potential or actual clinical implications of this work? To motivate PWA's drawing, it is suitable to begin with SOs. Examining drawing ability from the perspective of SOs and ROs increases the chance of identifying drawing ability. PWA whose native language is Japanese and have preserved Kanji writing abilities may be able to increase their communication abilities through drawing.

Transcranial Direct Current Stimulation to Ameliorate Post-Stroke Cognitive Impairment

Post-stroke cognitive impairment is a common and disabling condition with few effective therapeutic options. After stroke, neural reorganization and other neuroplastic processes occur in response to ischemic injury, which can result in clinical improvement through spontaneous recovery. Neuromodulation through transcranial direct current stimulation (tDCS) is a promising intervention to augment underlying neuroplasticity in order to improve cognitive function. This form of neuromodulation leverages mechanisms of neuroplasticity post-stroke to optimize neural reorganization and improve function. In this review, we summarize the current state of cognitive neurorehabilitation post-stroke, the practical features of tDCS, its uses in stroke-related cognitive impairment across cognitive domains, and special considerations for the use of tDCS in the post-stroke patient population.

Non-pharmacological interventions for improving language and communication in people with primary progressive aphasia

BACKGROUND

Primary progressive aphasia (PPA) accounts for approximately 43% of frontotemporal dementias and is mainly characterised by a progressive impairment of speech and communication abilities. Three clinical variants have been identified: (a) non-fluent/agrammatic, (b) semantic, and (c) logopenic/phonological PPA variants. There is currently no curative treatment for PPA, and the disease progresses inexorably over time, with devastating effects on speech and communication ability, functional status, and quality of life. Several non-pharmacological interventions that may improve symptoms (e.g. different forms of language training and non-invasive brain stimulation) have been investigated in people with PPA.

OBJECTIVES

To assess the effects of non-pharmacological interventions for people with PPA on word retrieval (our primary outcome), global language functions, cognition, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's trial register, MEDLINE (Ovid SP), Embase (Ovid SP), four other databases and two other trial registers. The latest searches were run on 26 January 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effects of non-pharmacological interventions in people with PPA.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

There were insufficient data available to conduct the network meta-analyses that we had originally planned (due to trial data being insufficiently reported or not reported at all, as well as the heterogeneous content of the included interventions). Therefore, we provide a descriptive summary of the included studies and results. We included 10 studies, with a total of 132 participants, evaluating non-pharmacological interventions. These were: transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) as stand-alone treatments (used by two and one studies, respectively); tDCS combined with semantic and phonological word-retrieval training (five studies); tDCS combined with semantic word-retrieval training (one study); and tDCS combined with phonological word-retrieval training (one study). Results for our primary outcome of word retrieval were mixed. For the two studies that investigated the effects of tDCS as stand-alone treatment compared to placebo ("sham") tDCS, we rated the results as having very low-certainty evidence. One study found a significant beneficial effect on word retrieval after active tDCS; one study did not report any significant effects in favour of the active tDCS group. Five studies investigated tDCS administered to the dorsolateral prefrontal cortex, inferior frontal cortex, left frontotemporal region, or the temporoparietal cortex, combined with semantic and phonological word-retrieval training. The most consistent finding was enhancement of word-retrieval ability for trained items immediately after the intervention, when behavioural training was combined with active tDCS compared to behavioural training plus sham tDCS. We found mixed effects for untrained items and maintenance of treatment effects during follow-up assessments. We rated the certainty of the evidence as very low in all studies. One study investigated tDCS combined with semantic word-retrieval training. Training was provided across 15 sessions with a frequency of three to five sessions per week, depending on the personal preferences of the participants. tDCS targeted the left frontotemporal region. The study included three participants: two received 1 mA stimulation and one received 2 mA stimulation. The study showed mixed results. We rated it as very low-certainty evidence. One study investigated tDCS combined with phonological word-retrieval training. Training was again provided across 15 sessions over a period of three weeks. tDCS targeted the left inferior frontal gyrus. This study showed a significantly more pronounced improvement for trained and untrained words in favour of the group that had received active tDCS, but we rated the certainty of the evidence as very low. One study compared active rTMS applied to an individually determined target site to active rTMS applied to a control site (vertex) for effects on participants' word retrieval. This study demonstrated better word retrieval for active rTMS administered to individually determined target brain regions than in the control intervention, but we rated the results as having a very low certainty of evidence. Four studies assessed overall language ability, three studies assessed cognition, five studies assessed potential adverse effects of brain stimulation, and one study investigated quality of life.

AUTHORS' CONCLUSIONS

There is currently no high-certainty evidence to inform clinical decision-making regarding non-pharmacological treatment selection for people with PPA. Preliminary evidence suggests that the combination of active tDCS with specific language therapy may improve impaired word retrieval for specifically trained items beyond the effects of behavioural treatment alone. However, more research is needed, including high-quality RCTs with detailed descriptions of participants and methods, and consideration of outcomes such as quality of life, depressive symptoms, and overall cognitive functioning. Moreover, studies assessing optimal treatments (i.e. behavioural interventions, brain stimulation interventions, and their combinations) for individual patients and PPA subtypes are needed. We were not able to conduct the planned (network) meta-analyses due to missing data that could not be obtained from most of the authors, a general lack of RCTs in the field, and heterogeneous interventions in eligible trials. Journals should implement a mandatory data-sharing requirement to assure transparency and accessibility of data from clinical trials.

A Meta-Analysis of Anomia Treatment in Bilingual Aphasia: Within- and Cross-Language Generalization and Predictors of the Treatment Outcomes

PURPOSE

The present meta-analysis investigated the efficacy of anomia treatment in bilingual and multilingual persons with aphasia (BPWAs) by assessing the magnitudes of six anomia treatment outcomes. Three of the treatment outcomes pertained to the "trained language": improvement of trained words (treatment effect [TE]), within-language generalization of semantically related untrained words (WLG-Related), and within-language generalization of unrelated words (WLG-Unrelated). Three treatment outcomes were for the "untrained language": improvement of translations of the trained words (cross-language generalization of trained words [CLG-Tx]), cross-language generalization of semantically related untrained words (CLG-Related), and cross-language generalization of unrelated untrained words (CLG-Unrelated). This study also examined participant- and treatment-related predictors of these treatment outcomes.

METHOD

This study is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42023418147. Nine electronic databases were searched to identify word retrieval treatment studies of poststroke BPWAs of at least 6 months postonset. Pre- and posttreatment single-word naming scores were extracted for each eligible participant and used to calculate effect sizes (within-case Cohen's d) of the six treatment outcomes. Random-effects meta-analyses were conducted to assess weighted mean effect sizes of the treatment outcomes across studies. Multiple linear regression analyses were used to examine the effects of participant-related variables (pretreatment single-word naming and comprehension representing poststroke lexical processing abilities) and treatment-related variables (type, language, and duration). The methodological quality of eligible studies and the risk of bias in this meta-analysis were assessed.

RESULTS

A total of 17 published studies with 39 BPWAs were included in the meta-analysis. The methodological quality of the included studies ranged from fair (n = 4) to good (n = 13). Anomia treatment produced a medium effect size for TE (M = 8.36) and marginally small effect sizes for WLG-Related (M = 1.63), WLG-Unrelated (M = 0.68), and CLG-Tx (M = 1.56). Effect sizes were nonsignificant for CLG-Related and CLG-Unrelated. TE was significantly larger than the other five types of treatment outcomes. TE and WLG-Related effect sizes were larger for BPWAs with milder comprehension or naming impairments and for treatments of longer duration. WLG-Unrelated was larger when BPWAs received phonological treatment than semantic and mixed treatments. The overall risk of bias in the meta-analysis was low with a potential risk of bias present in the study identification process.

CONCLUSIONS

Current anomia treatment practices for bilingual speakers are efficacious in improving trained items but produce marginally small within-language generalization and cross-language generalization to translations of the trained items. These results highlight the need to provide treatment in each language of BPWAs and/or investigate other approaches to promote cross-language generalization. Furthermore, anomia treatment outcomes are influenced by BPWAs' poststroke single-word naming and comprehension abilities as well as treatment duration and the provision of phonological treatment.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25595712.

Experiences of People with Aphasia Receiving Enhanced Community-Based Speech-Language Pathology Provided by Speech-Language Pathology Students

INTRODUCTION

Treatment intensity for people with aphasia (PWA) is a significant factor in enhancing recovery. Personal factors such as fatigue, physical endurance, and motivation as well as clinician availability have been described as barriers to increased intensity. The use of student therapists has been shown to assist with addressing service gaps.

METHODS

The aim of the study was to explore the experiences of PWA who received enhanced community-based treatment delivered by speech-language pathology (SLP) students. Enhanced community-based treatment was defined as three or more treatment sessions per week targeting communication. Semi-structured interviews were conducted with 10 PWA living in New Zealand. Interview data were analysed with reflexive thematic analysis.

RESULTS

Two themes and six sub-themes were developed. Theme 1 related to intensity and included more treatment is better than less (sub-theme 1), there's a "right time" for more intensive treatment (sub-theme 2), the hard work is worth the effort (sub-theme 3). Theme 2 related to working with SLP students; it didn't feel like they were students (sub-theme 4), we just got on so well (sub-theme 5), and they listened to what I wanted (sub-theme 6).

CONCLUSIONS

The findings confirm that PWA value access to more intensive treatment and desire involvement in decisions about flexible treatment schedules. PWA have positive experiences when treatment is provided by SLP students. Implications for clinical practice and future research directions are discussed.

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

PURPOSE

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

METHOD

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

RESULT

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

CONCLUSION

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

Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation

INTRODUCTION

We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020.

DEVELOPMENT

We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research.

CONCLUSIONS

All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.

Acceptability, feasibility and preliminary efficacy of low-moderate intensity Constraint Induced Aphasia Therapy and Multi-Modality Aphasia Therapy in chronic aphasia after stroke

BACKGROUND

High-intensity Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) and Multi-Modality Aphasia Therapy (M-MAT) are effective interventions for chronic post-stroke aphasia but challenging to provide in clinical practice. Providing these interventions may be more feasible at lower intensities, but comparative evidence is lacking. We therefore explored feasibility, acceptability, and preliminary efficacy of the treatments at a lower intensity.

METHODS

A multisite, single-blinded, randomized Phase II trial was conducted within the Phase III COMPARE trial. Groups of participants with chronic aphasia from the usual care arm of the COMPARE trial were randomized to M-MAT or CIAT-Plus, delivered at the same dose as the COMPARE trial but at lower intensity (6 hours/week × 5 weeks rather than 15 hours/week × 2 weeks). Blinded assessors measured aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient), word retrieval, connected speech, multimodal communication, functional communication, and quality of life immediately post interventions and after 12 weeks. Feasibility and acceptability were explored.

RESULTS

Of 70 eligible participants, 77% consented to the trial; 78% of randomized participants completed intervention and 98% of assessment visits were conducted. Fatigue and distress ratings were low with no related withdrawals. Adverse events related to the trial (n = 4) were mild in severity. Statistically significant treatment effects were demonstrated on word retrieval and functional communication and both interventions were equally effective.

CONCLUSIONS

Low-moderateintensity CIAT-Plus and M-MAT were feasible and acceptable. Both interventions show preliminary efficacy at a low-moderate intensity. These results support a powered trial investigating these interventions at a low-moderate intensity.

More than one way to improve a CAT: Outcomes and reflections on two iterations of the Queen Square Intensive Comprehensive Aphasia Programme

Background

The field of human expert performance teaches us that high quality, high-dose guided practice is required to make large gains in cognitively driven acts. The same also seems to be true for people with acquired brain injury, yet therapy services for people with aphasia (PWA) have traditionally not been designed with this in mind. Intensive Comprehensive Aphasia Programmes (ICAPs) are one way to address the chronic under-dosing of therapy that most PWA experience.

Aims

There are several ways to deliver an ICAP; here we describe two iterations of our Queen Square ICAP. There was a 20-month COVID-induced pause between the Year 1 (Y1) and Year 2 (Y2) ICAP groups. We analyse ICAP-induced changes in both groups of PWA on a series of key outcome measures that span the International Classification of Functioning, Disability and Health, covering language impairment and function as well as mood and social participation.

Methods & Procedures

Forty-six PWA took part in Y1 and 44 in Y2. The PWA were all in the chronic stage post stroke and varied in aphasia severity from mild to severe, with the Y2 group being more impaired than Y1. Quantitative data was collected before and after the ICAP. The Y2 therapy team provided independent reflections on their experiences of delivering an ICAP.

Outcomes & Results

ICAP-related changes in outcome measures (impairment, function and goal attainment) were generally comparable for the Y1 and Y2 groups, with both groups' speech production abilities improving the most. Both groups made clinically and statistically significant gains on the main quality of life measure. Participation in the ICAP made a big difference to PWAs' self-confidence ratings. Their mood ratings also improved significantly, although they were not, on average, in the depressed range at baseline (directly pre-ICAP). All improvements achieved in both groups were maintained at the 3-month follow-up, highlighting the lasting effects that ICAPs can provide.

Conclusions

Evidence continues to accrue that ICAPs are an efficient way of increasing the dose of expert coaching required for people with chronic aphasia to make clinically meaningful improvements in their communicative abilities and quality of life. The main challenge remaining is convincing health-care providers to invest in them.

Mechanisms of brain activation following naming therapy in aphasia: A systematic review on task-based fMRI studies

The pattern of brain neuroplasticity after naming therapies in patients with aphasia can be evaluated using task-based fMRI. This article aims to review studies investigating brain reorganization after semantic and phonological-based anomia therapy that used picture-naming fMRI tasks. We searched for those articles that compared the activation of brain areas before and after aphasia therapies in the PubMed and the EMBASE databases from 1993 up to April 2020. All studies (single-cases or group designs) on anomia treatment in individuals with acquired aphasia were reviewed. Data were synthesized descriptively through tables to allow the facilitated comparison of the studies. A total of 14 studies were selected and reviewed. The results of the reviewed studies demonstrated that the naming improvement is associated with changes in the activation of cortical and subcortical brain areas. This review highlights the need for a more systematic investigation of the association between decreased and increased activation of brain areas related to anomia therapy. Also, more detailed information about factors influencing brain reorganization is required to elucidate the neural mechanisms of anomia therapy. Overall, regarding the theoretical and clinical aspects, the number of studies that used intensive protocol is growing, and based on the positive potential of these treatments, they could be suitable for the rehabilitation of people with aphasia.

Unraveling the Thread of Aphasia Rehabilitation: A Translational Cognitive Perspective

Translational neuroscience is a multidisciplinary field that aims to bridge the gap between basic science and clinical practice. Regarding aphasia rehabilitation, there are still several unresolved issues related to the neural mechanisms that optimize language treatment. Although there are studies providing indications toward a translational approach to the remediation of acquired language disorders, the incorporation of fundamental neuroplasticity principles into this field is still in progress. From that aspect, in this narrative review, we discuss some key neuroplasticity principles, which have been elucidated through animal studies and which could eventually be applied in the context of aphasia treatment. This translational approach could be further strengthened by the implementation of intervention strategies that incorporate the idea that language is supported by domain-general mechanisms, which highlights the impact of non-linguistic factors in post-stroke language recovery. Here, we highlight that translational research in aphasia has the potential to advance our knowledge of brain-language relationships. We further argue that advances in this field could lead to improvement in the remediation of acquired language disturbances by remodeling the rationale of aphasia-therapy approaches. Arguably, the complex anatomy and phenomenology of aphasia dictate the need for a multidisciplinary approach with one of its main pillars being translational research.

Supporting Post-Stroke Language and Cognition with Pharmacotherapy: Tools for Each Phase of Care

PURPOSE OF REVIEW

There is enormous enthusiasm for the possibility of pharmacotherapies to treat language deficits that can arise after stroke. Speech language therapy remains the most frequently utilized and most strongly evidenced treatment, but the numerous barriers to patients receiving the therapy necessary to recover have motivated the creation of a relatively modest, yet highly cited, body of evidence to support the use of pharmacotherapy to treat post-stroke aphasia directly or to augment traditional post-stroke aphasia treatment. In this review, we survey the use of pharmacotherapy to preserve and support language and cognition in the context of stroke across phases of care, discuss key ongoing clinical trials, and identify targets that may become emerging interventions in the future.

RECENT FINDINGS

Recent trials have shifted focus from short periods of drug therapy supporting therapy in the chronic phase to longer terms approaching pharmacological maintenance beginning more acutely. Recent innovations in hyperacute stroke care, such as tenecteplase, and acute initiation of neuroprotective agents and serotonin reuptake inhibitors are important areas of ongoing research that complement the ongoing search for effective adjuvants to later therapy. Currently there are no drugs approved in the United States for the treatment of aphasia. Nevertheless, pharmacological intervention may provide a benefit to all phases of stroke care.

The impact of participation in research for speech and language therapy departments and their patients: A case example of the Big CACTUS multicentre trial of self-managed computerized aphasia therapy

BACKGROUND

In order to conduct research that is meaningful to speech and language therapy services and their patients, it is often desirable to conduct the research within routine clinical services. This can require considerable time and commitment from speech and language therapists (SLTs). It is therefore important to understand the impact that such participation in research can have.

AIMS

To explore the impact of research participation in the Big CACTUS study of self-managed computerized aphasia therapy conducted in 21 UK NHS speech and language therapy departments.

METHODS & PROCEDURES

An online survey was sent to SLTs who took the lead role for the study at their NHS Trust to evaluate the impact of study participation in three domains: capacity-building, research development and health services. The questionnaire, based on the VICTOR framework for evaluating research impact, included Likert scale statements and closed and open-ended questions. The results from open-ended questions were coded and analysed using framework analysis in NVivo 12 and the data from closed questions were analysed descriptively.

OUTCOMES & RESULTS

A total of 12 SLTs returned the survey. Nine codes were identified from open-ended questions and 20 predefined from the literature. Analysis of the responses demonstrated the perceived impact including improvements in practices and access to therapy, investments in infrastructure, increased SLT profile, and impact on research culture among SLTs. The usefulness of the intervention during the COVID-19 pandemic was also highlighted.

CONCLUSIONS & IMPLICATIONS

The results suggest participation in Big CACTUS has resulted in improvements in patient care and SLT research capacity and culture in speech and language therapy departments.

WHAT THIS PAPER ADDS

What is already known on the subject Practice-based research is encouraged to assist with the clinical relevance of the research findings. Participation in research can be seen as an activity that is additional to the core business of patient care and it can be difficult to secure time to participate or conduct research in clinical settings. Impact evaluation initiatives of individual trials facilitate early identification of benefits beyond the trial. What this paper adds to existing knowledge This study describes specific examples of the impact on services, staff and patients from SLT participation and leadership in the Big CACTUS speech and language therapy trial in clinical settings. What are the potential or actual clinical implications of this study? Clinical services participating in research may benefit from improved clinical care for patients both during and after the study, an improved professional reputation, and increased research capacity and culture within the clinical settings.

Comparing the efficiency of speech and language therapy and transcranial magnetic stimulation for treating Broca's aphasia

OBJECTIVES

Aphasia is an acquired language-cognitive disorder that highly affects an individual's speech, language, and communication skills. Recovery from aphasia requires attentive treatment since it is a long and dynamic process. This study aimed to show interactive benefits of combining classical intervention strategies with new technological approaches and demonstrating their effectiveness.

MATERIALS AND METHODS

A total of 40 individuals with Broca's aphasia were included in the study. The participants were divided into Application-1 Speech and Language Therapy, Application-2 Transcranial Magnetic Stimulation, Application-3 (consecutive Transcranial Magnetic Stimulation and Speech and Language Therapy), and Application-4 (Control Group) experimental groups, with 10 participants in each group.

RESULTS

Analysis indicated that individuals in the group in which Transcranial Magnetic Stimulation and Speech and Language Therapy were applied consecutively had further increases in speech fluency, repetition, and naming scores from pre-test to post-test (p<0.01). Picture naming and quality-of-life communication scores of individuals in the group in which Speech and Language Therapy was performed increased further from pre-test to post-test (p<0.01).

CONCLUSIONS

The results of the study showed a positive effect on language skills, naming scores, and participation in social life of Turkish-speaking aphasic individuals with the Speech and Language Therapy and Transcranial Magnetic Stimulation methods. The use of Transcranial Magnetic Stimulation alone is insufficient in this context. Although Speech and Language Therapy alone is effective in naming ability, Transcranial Magnetic Stimulation in addition to Speech and Language Therapy significantly increases the gain obtained with therapies.

Transcranial Direct-Current Stimulation in Subacute Aphasia: A Randomized Controlled Trial

BACKGROUND

Transcranial direct-current stimulation (tDCS) is a promising adjunct to therapy for chronic aphasia.

METHODS

This single-center, randomized, double-blind, sham-controlled efficacy trial tested the hypothesis that anodal tDCS augments language therapy in subacute aphasia. Secondarily, we compared the effect of tDCS on discourse measures and quality of life and compared the effects on naming to previous findings in chronic stroke. Right-handed English speakers with aphasia <3 months after left hemisphere ischemic stroke were included, unless they had prior neurological or psychiatric disease or injury or were taking certain medications (34 excluded; final sample, 58). Participants were randomized 1:1, controlling for age, aphasia type, and severity, to receive 20 minutes of tDCS (1 mA) or sham-tDCS in addition to fifteen 45-minute sessions of naming treatment (plus standard care). The primary outcome variable was change in naming accuracy of untrained pictures pretreatment to 1-week posttreatment.

RESULTS

Baseline characteristics were similar between the tDCS (N=30) and sham (N=28) groups: patients were 65 years old, 53% male, and 2 months from stroke onset on average. In intent-to-treat analysis, the adjusted mean change from baseline to 1-week posttreatment in picture naming was 22.3 (95% CI, 13.5-31.2) for tDCS and 18.5 (9.6-27.4) for sham and was not significantly different. Content and efficiency of picture description improved more with tDCS than sham. Groups did not differ in quality of life improvement. No patients were withdrawn due to adverse events.

CONCLUSIONS

tDCS did not improve recovery of picture naming but did improve recovery of discourse. Discourse skills are critical to participation. Future research should examine tDCS in a larger sample with richer functional outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02674490.

Psychometric Testing of the CEECCA Questionnaire to Assess Ability to Communicate among Individuals with Aphasia

(1) Background: The CEECCA questionnaire assesses the ability to communicate among individuals with aphasia. It was designed using the NANDA-I and NOC standardised nursing languages (SNLs), reaching high content validity index and representativeness index values. The questionnaire was pilot-tested, demonstrating its feasibility for use by nurses in any healthcare setting. This study aims to identify the psychometric properties of this instrument. (2) Methods: 47 individuals with aphasia were recruited from primary and specialist care facilities. The instrument was tested for construct validity and criterion validity, reliability, internal consistency, and responsiveness. The NANDA-I and NOC SNLs and the Boston test were used for criterion validity testing. (3) Results: five language dimensions explained 78.6% of the total variance. Convergent criterion validity tests showed concordances of up to 94% (Cohen's κ: 0.9; p < 0.001) using the Boston test, concordances of up to 81% using DCs of NANDA-I diagnoses (Cohen's κ: 0.6; p < 0.001), and concordances of up to 96% (Cohen's κ: 0.9; p < 0.001) using NOC indicators. The internal consistency (Cronbach's alpha) was 0.98. Reliability tests revealed test-retest concordances of 76-100% (p < 0.001). (4) Conclusions: the CEECCA is an easy-to-use, valid, and reliable instrument to assess the ability to communicate among individuals with aphasia.

Telerehab at Home: Mobile Tablet Technology for Patients With Poststroke Communication Deficits-A Pilot Feasibility Randomized Control Trial

PURPOSE

Poststroke communication deficits (PSCD) are common following stroke. Early and intensive speech and language therapy is recommended to maximize outcomes. We wanted to test the feasibility of providing telerehabilitation for patients with PSCD using mobile tablet-based technology to bridge the gap between acute stroke care and outpatient speech-language therapy (SLT) services.

METHOD

This was a prospective, randomized, open-label, blinded end-point design. Patients were randomized to either the treatment arm (mobile tablet) or the control arm (standard of care). The study duration was either 8 weeks or when the patient was called to start outpatient SLT services, whichever occurred first. The primary outcome was feasibility, while secondary objective was to assess patient engagement and to explore improvement in communication ability.

RESULTS

We had a 38% recruitment rate, with a 100% retention rate for the treatment arm and a 50% retention rate for the control arm. Fifty percent of patients in the treatment arm adhered to the recommended 1 hr per day, whereas none of the control arm did. Patients were engaged in using the mobile tablet and feedback on the protocol was positive.

CONCLUSIONS

SLT using telerehabilitation via mobile technology is feasible in the very early stages of acute stroke recovery. It is potentially an effective means of bridging the gap between discharge from the acute care setting to the start of outpatient SLT services. Our study supported proceeding to a clinical trial to assess efficacy of the intervention.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21844569.

Consistent long-term practice leads to consistent improvement: Benefits of self-managed therapy for language and cognitive deficits using a digital therapeutic

Background

Although speech-language therapy (SLT) is proven to be beneficial to recovery of post-stroke aphasia, delivering sufficiently high amounts of dosage remains a problem in real-world clinical practice. Self-managed SLT was introduced to solve the problem. Previous research showed in a 10-week period, increased dosage frequency could lead to better performance, however, it is uncertain if dosage still affects performance over a longer period of practice time and whether gains can be seen following practice over several months.

Objective

This study aims to evaluate data from a health app (Constant Therapy) to investigate the relationship between dosage amount and improvements following a 30-week treatment period. Two cohorts of users were analyzed. One was comprised of patients with a consistent average weekly dosage amount and the other cohort was comprised of users whose practice had higher variability.

Methods

We conducted two analyses with two cohorts of post-stroke patients who used Constant Therapy. The first cohort contains 537 "consistent" users, while the second cohort contains 2,159. The 30-week practice period was split into three consecutive 10-week practice windows to calculate average dosage amount. In each 10-week practice period, patients were grouped by their average dosage into low (0-15 min/week), medium (15-40 min/week) and moderate dosage (greater than 40 min/week) groups. Linear mixed-effects models were employed to evaluate if dosage amount was a significant factor affecting performance. Pairwise comparison was also applied to evaluate the slope difference between groups.

Results

For the consistent cohort, medium (β = .002, t _17,700 = 7.64, P < .001) and moderate (β = .003, t _9,297 = 7.94, P < .001) dosage groups showed significant improvement compared to the low dosage group. The moderate group also showed greater improvement compared to the medium group. For the variable cohort in analysis 2, the same trend was shown in the first two 10-week windows, however, in weeks 21-30, the difference was insignificant between low and medium groups (β = .001, t = 1.76, P = .078).

Conclusions

This study showed a higher dosage amount is related to greater therapy outcomes in over 6 months of digital self-managed therapy. It also showed that regardless of the exact pattern of practice, self-managed SLT leads to significant and sustained performance gains.

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

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

Comparison of the efficacy of acupuncture-related Therapies for post-stroke motor aphasia: A Bayesian network meta-analysis

Background

Motor aphasia, which can affect the communication ability of patients and even triggers severe psychological disorders, is one of the most common sequelae after stroke. Acupuncture (a typical complementary alternative therapy) is frequently combined with speech training (ST) to treat post-stroke motor aphasia (PSMA) and presents significant efficacy. However, the most effective acupuncture intervention is still unknown. This study aims to analyze the efficacy of several acupuncture approaches combined with ST for PSMA to identify the best intervention for clinical decision-making by using network meta-analysis (NMA).

Methods

Eight major databases were searched from the time of their establishment to March 2022. Clinical efficacy rate (CER) was used as the primary outcome indicator. R software (version 4.13.0) and STATA software (version 16.0) were used to analyze the data.

Results

A total of 29 randomized controlled trials (RCTs) and six treatment regimens were included in this study. In the pair-wise meta-analysis, we found that the efficacy of scalp-tongue acupuncture (STA) combined with ST [OR = 8.30; 95% Credible interval (CrI): 3.87, 17.33], tongue acupuncture (TA) combined with ST (OR = 3.95; 95% CrI: 2.27, 6.89), scalp-body acupuncture (SBA) combined with ST (OR = 3.75; 95% CrI: 2.26, 6.22), scalp acupuncture (SA) combined with ST (OR = 2.95; 95% CrI: 1.74, 5.0), and body acupuncture (BA) combined with ST (OR = 2.30; 95% CrI: 1.26, 4.19) were significantly superior to that of ST. In addition, the efficacy of STA + ST was significantly superior to that of SA +ST (OR = 2. 82; 95% CrI: 1.24, 6.38) and BA + ST (OR = 3.61; 95% CrI: 1.40, 9.29). According to the surface under the cumulative ranking curve (SUCRA), STA + ST (SUCRA = 97.9%) may be the best treatment regimen to improve the clinical outcome in patients with PSMA.

Conclusion

The NMA showed that STA combined with ST may be the best treatment to improve CER, compared with other combination treatments. However, since the overall quality and number of studies are limited, further RCTs with a large sample and multicenter are needed for further validation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=316081, identifier CRD42022316081.

Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis

BACKGROUND

Stroke rehabilitation interventions are routinely personalized to address individuals' needs, goals, and challenges based on evidence from aggregated randomized controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias.

AIM

We explored associations between speech and language therapy (SLT) interventions frequency (days/week), intensity (h/week), and dosage (total SLT-hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking prespecified subgroup network meta-analyses of the RELEASE database.

METHODS

MEDLINE, EMBASE, and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ⩾ 10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardized. A one-stage, random effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomized by age (⩽/> 65 years), aphasia severity (mild-moderate/ moderate-severe based on language outcomes' median value), chronicity (⩽/> 3 months), and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (> 50%), results were reported for completeness.

RESULTS

959 IPD (25 RCTs) were analyzed. For working-age participants, greatest language gains from baseline occurred alongside moderate to high-intensity SLT (functional communication 3-to-4 h/week; overall-language and comprehension > 9 h/week); older participants' greatest gains occurred alongside low-intensity SLT (⩽ 2 h/week) except for auditory comprehension (> 9 h/week). For both age-groups, SLT-frequency and dosage associated with best language gains were similar. Participants ⩽ 3 months post-onset demonstrated greatest overall-language gains for SLT at low intensity/moderate dosage (⩽ 2 SLT-h/week; 20-to-50 h); for those > 3 months, post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3-4 SLT-h/week; ⩾ 50 hours). For moderate-severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ⩾ 4 SLT-days/week; mild-moderate participants' greatest functional communication gains were associated with similar frequency (⩾ 4 SLT-days/week) and greatest overall-language gains with higher frequency SLT (⩾ 6 days/weekly). Males' greatest gains were associated with SLT of moderate (functional communication; 3-to-4 h/weekly) or high intensity (overall-language and auditory comprehension; (> 9 h/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (< 2 SLT-h/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-h in total; auditory comprehension gains were generally observed when SLT > 9 h over ⩾ 4 days/week.

CONCLUSIONS

We observed a treatment response in most subgroups' overall-language, auditory comprehension, and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild-moderate, and male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate-severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical, and cost effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia severity, and chronicity should be evaluated in future clinical RCTs.

Auditory Comprehension Interventions for People With Aphasia: A Scoping Review

PURPOSE

This scoping review examined studies reporting restorative treatments designed to improve auditory comprehension in people with aphasia.

METHOD

We searched eight databases using keywords aphasia, auditory comprehension, treatment, intervention, and rehabilitation, for studies published between 1970 and 2020. Searches returned 170 records, and after applying exclusionary criteria, 28 articles remained. For each article, two authors independently extracted data on study design parameters, participant characteristics, treatment protocol, and treatment outcomes, including generalization.

RESULTS

Studies were categorized by treatment focus: direct auditory (n = 7), mixed auditory (n = 13), or indirect (n = 8). Study designs were group (n = 12), single-subject experimental design (n = 11), or case study (n = 5). Fifteen studies had a control condition and/or a control group. Thirteen studies included two to 10 participants. Aphasia severity and auditory comprehension severity were infrequently reported, and most participants were greater than 1-year poststroke. Treatment targets and tasks varied. Sessions ranged from 8 to 240 min, once or more per week, for eight to 60 total sessions over 2-20 weeks. Impairment-based outcome measures were typically used. Improvement and generalization were regularly reported; however, authors frequently did not report statistical significance.

CONCLUSIONS

A variety of treatments have addressed auditory comprehension deficits in people with aphasia, with many reporting improvements in auditory comprehension for some people. However, the variability in treatment tasks and delivery and outcome measurements preclude confidently offering specific clinical recommendations for implementing auditory comprehension treatments. Gaps identified by the current study may guide the development and exploration of transparent, repeatable, patient-centered treatments.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21291345.

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).

A systematic review of maintenance following intensive therapy programs in chronic post-stroke aphasia: importance of individual response analysis

PURPOSE

Recent evidence supports the benefit of intensive aphasia intervention programs for people with chronic aphasia, yet it is unclear if all participants can expect positive outcomes and for how long therapeutic gains last.

METHODS

We systematically searched for studies investigating intensive interventions in chronic aphasia. To explore individual response rates and maintenance of therapeutic gains we carried out meta-synthesis by calculating and analysing the Standard Error of Measurement and Minimal Detectable Change metrics of six common outcome measures.

RESULTS

Forty-four studies comprising 24 experimental (13 group, 11 single-subject) and 20 non-experimental studies met our inclusion criteria (n = 670). Whereas most group studies reported statistically significant post-therapy improvement and maintenance, analysis of individual participant data (IPD, n = 393) from these studies revealed that only about a third of participants were classified as "immediate responders," of which more than a third had lost their initial immediate gains at follow-up. This pattern did not change when IPD from single-subject studies (n = 49) was added to the analysis. Thus, only 22% of all IPD receiving an intensive intervention improved significantly and maintained their therapy gains.

CONCLUSIONS

Intensive aphasia therapy is effective when measured at the group-level, but many individuals do not respond significantly to the intervention, and even fewer individuals preserve their initial gains. Group study results do not allow prediction of an individual's response to the intervention. Future research should elucidate which factors mediate positive treatment response and maintenance for an individual.Implications for rehabilitationOnly a small proportion (about one fifth in this review) of intensive aphasia treatment program participants respond and maintain their therapy gains, a fact that is obscured by traditional p-value group analysis.A simple clinical decision-making method is presented for evaluating individual therapy gains and their maintenance.For some immediate treatment responders (about one third in this review), gains from intensive therapy programs are unlikely to be maintained in the long-term without additional, ongoing practice.Clinicians should consider the possibility of individual clients losing some of their therapy gains and take proactive steps to support long-term maintenance.

Better long-term speech outcomes in stroke survivors who received early clinical speech and language therapy: What's driving recovery?

Establishing whether speech and language therapy after stroke has beneficial effects on speaking ability is challenging because of the need to control for multiple non-therapy factors known to influence recovery. We investigated how speaking ability at three time points post-stroke differed in patients who received varying amounts of clinical therapy in the first month post-stroke. In contrast to prior studies, we factored out variance from: initial severity of speaking impairment, amount of later therapy, and left and right hemisphere lesion size and site. We found that speaking ability at one month post-stroke was significantly better in patients who received early therapy (n = 79), versus those who did not (n = 64), and the number of hours of early therapy was positively related to recovery at one year post-stroke. We offer two non-mutually exclusive interpretations of these data: (1) patients may benefit from the early provision of self-management strategies; (2) therapy is more likely to be provided to patients who have a better chance of recovery (e.g., poor physical and/or mental health may impact suitability for therapy and chance of recovery). Both interpretations have implications for future studies aiming to predict individual patients' speech outcomes after stroke, and their response to therapy.

The Use of the ICF Classification Sheet to Assess Cognitive-Behavioral Disorders and Verbal Communication in Patients after Ischemic and Hemorrhagic Stroke during Rehabilitation

Background: In patients after experiencing stroke, the cognitive-behavioral deficits and disorders of verbal communication limit the effectiveness of rehabilitation. The key is to diagnose them at an early stage of rehabilitation and to implement appropriate psychological and speech therapy. Objective: Identify differences in the frequency and effectiveness of cognitive-behavioral disorder therapy depending on the clinical type of stroke, assessed before and after rehabilitation treatment, and their presentation using the ICF (International Classification of Functioning, Disability, and Health) classification. Materials and Methods: The study was prospective and included the analysis of cognitive-behavioral and verbal communication disorders. The study consisted of 47 patients after intracerebral hemorrhage (ICH) and 47 patients after an ischemic stroke (IS) before the implementation of rehabilitation and after completing a 4-week rehabilitation. Results: In the group after ICH, psychological therapy significantly reduced the disturbances of consciousness and orientation (p < 0.001) and improved the speed of performing tasks in tests (p < 0.001). In patients after IS and ICH, memory and attention function improved significantly (p < 0.001). Moreover, in patients after ICH, language function deficits decreased significantly (p = 0.018). Mood disturbances were maintained in 17% of patients after ICH and 40% of patients after IS (p = 0.007). Speech therapy reduced speech articulation disorders and aphasia in 85% of patients after ICH (p = 0.001) and in 68% of patients after IS (p = 0.033). Conclusions: The frequency and type of cognitive-behavioral and verbal communication disorders vary depending on the history of ICH or IS. The ICF classification may be useful in assessing and analyzing cognitive-behavioral and verbal communication disorders, which may lead to the implementation of appropriate psychological and speech therapy at an early stage of rehabilitation and increase the effectiveness of the therapy.

Evaluation of rTMS in patients with poststroke aphasia: a systematic review and focused meta-analysis

PURPOSE

Aphasia-acquired loss of the ability to understand or express language-is a common and debilitating neurological consequence of stroke. Evidence suggests that transcranial magnetic stimulation (TMS) can significantly improve language outcomes in patients with aphasia. Repetitive transcranial magnetic stimulation (rTMS) has been reported to improve naming in chronic stroke patients with nonfluent aphasia since 2005.

METHODS

We conducted a systematic review and meta-analyses of TMS treatment studies in patients with aphasia. Eight electronic databases (PubMed, Medline, Embase, Scopus, ScienceDirect, Cochrane Central Register of Controlled Trials, Journals@Ovid, and clinicaltrials.gov) were searched for articles. Relevant studies were further evaluated, and studies that met inclusion criteria were reviewed. The searches were limited to human studies written in English and published between January 1960 and January 2020. In keeping with the main objective of this review, we included all studies that carried out treatment using rTMS in stroke patients with aphasia, regardless of the trial (or experimental) design of the study. Studies that implemented between-subject or randomized controlled (RCT) design, cross-over trials, and within-subject or pre-post trials were all included. Standard mean difference (SMD) for changes in picture naming accuracy was estimated.

RESULTS

The literature search yielded 423 studies. Fifty articles were further evaluated to be included. Eleven met all inclusion criteria and were chosen for review. Eleven eligible studies involving 242 stroke patients were identified in this meta-analysis. Further analyses demonstrated prominent effects for the naming subtest (SMD = 1.26, 95% CI = 0.80 to 1.71, p = 0.01), with heterogeneity (I² = 69.101%). The meta-analysis continued to show that there was a statistically significant effect of rTMS compared with sham rTMS on the severity of aphasia. None of the patients from the 11 included articles reported adverse effects from rTMS.

CONCLUSIONS

There are some strong studies evaluating the efficacy of rTMS in stroke patients but further research is required to fully establish the usefulness of this treatment. This meta-analysis indicates a clinically positive effect of rTMS with or without speech and language therapy (SLT) for patients with aphasia following stroke in overall language function and expressive language, including naming, repetition, writing, and comprehension. Low-frequency (1 Hz) rTMS over the unaffected hemisphere is effective and compatible with the concept of interhemispheric inhibition. Moreover, the treatment of 1 Hz rTMS for patients with aphasia after stroke was safe.

Dosage Frequency Effects on Treatment Outcomes Following Self-managed Digital Therapy: Retrospective Cohort Study

BACKGROUND

Although the efficacy of high-dose speech-language therapy (SLT) for individuals with poststroke aphasia has been established in the literature, there is a gap in translating these research findings to clinical practice. Therefore, patients continue to receive suboptimal amounts of SLT, with negative consequences for their functional communication recovery. Recent research has identified self-managed digital health technology as one way to close the dosage gap by enabling high-intensity therapy unrestricted by clinician availability or other practical constraints. However, there is limited empirical evidence available to rehabilitation professionals to guide dose prescriptions for self-managed SLT despite their increasing use in the COVID-19 era and likely beyond.

OBJECTIVE

This study aims to leverage real-world mobile health data to investigate the effects of varied dosage frequency on performance outcomes for individuals with poststroke speech, language, and cognitive deficits following a 10-week period of self-managed treatment via a commercially available digital health platform.

METHODS

Anonymized data from 2249 poststroke survivors who used the Constant Therapy app between late 2016 and 2019 were analyzed. The data included therapy tasks spanning 13 different language and cognitive skill domains. For each patient, the weekly therapy dosage was calculated based on the median number of days per week of app use over the 10-week therapy period, binned into groups of 1, 2, 3, 4, or ≥5 days per week. Linear mixed-effects models were run to examine change in performance over time as a function of dosage group, with post hoc comparisons of slopes to evaluate the performance gain associated with each additional day of practice.

RESULTS

Across all skill domains, linear mixed-effects model results showed that performance improvement was significantly greater for patients who practiced 2 (β=.001; t_15,355=2.37; P=.02), 3 (β=.003; t₉₇₃₈=5.21; P<.001), 4 (β=.005; t₉₂₈₉=7.82; P<.001), or ≥5 (β=.005; t₆₃₄₃=8.14; P<.001) days per week compared with those who only practiced for 1 day per week. Post hoc comparisons confirmed an incremental dosage effect accumulating with each day of practice (ie, 1 day vs 2 days, 2 days vs 3 days, and 3 days vs 4 days), apart from 4 days versus ≥5 days of practice per week. The result of greater improvement for higher versus lower dosage frequency groups was true not only across all domains but also within a majority of individual subdomains.

CONCLUSIONS

The findings from this study demonstrated that increased dosage frequency is associated with greater therapy gains over a 10-week treatment period of self-managed digital therapy. The use of real-world data maximizes the ecological validity of study results and makes the findings more generalizable to clinical settings. This study represents an important step toward the development of optimal dose recommendations for self-managed SLT.

Feasibility of Remotely Supervised Transcranial Direct Current Stimulation (RS-tDCS) for People with Stroke-Induced and Progressive Aphasia

Background

Remotely-supervised transcranial direct current stimulation (RS-tDCS) is a telerehabilitation protocol that provides access to tDCS treatment to participants with aphasia in their homes using real-time monitoring via videoconference and overcomes barriers associated with in-person tDCS treatment of neurological disease.

Aims

Two feasibility studies for participants with aphasia are presented herein that investigate (1) RS-tDCS procedural implementation, acceptability, and demand, and (2) acceptability of ten repeated consecutive RS-tDCS sessions.

Methods & Procedures

Thirteen participants with aphasia were enrolled in Study 1: (1) seven participants with stroke-induced latent aphasia, (2) four participants with stroke-induced clinically diagnosed aphasia, and (3) two participants with logopenic variant primary progressive aphasia (lvPPA). Four supervisors (1 certified speech-language pathologist [SLP], 3 graduate SLPs-in-training) were trained to supervise RS-tDCS and also provided survey responses. All participants participated in RS-tDCS training and a virtual simulation of home delivery. Two participants with stroke-induced aphasia (1 latent aphasia, 1 clinically diagnosed aphasia) were enrolled in 10 consecutive sessions of RS-tDCS alongside computerized treatment in their home for Study 2.

Outcomes & Results

This work provides preliminary evidence for the feasibility of RS-tDCS for people with stable and progressive aphasia of varying severity and typology and includes both participant and clinician perspectives. Importantly, no major barriers to use of RS-tDCS were revealed for people with aphasia, though eHelpers were required for two participants.

Conclusions

This work confirms that remotely supervised at-home tDCS studies can be used to enable much-needed efficacy trials, with sufficient sample size, power, and dosing considerations, that will determine the clinical efficacy of tDCS as a treatment adjuvant to aphasia treatment.

Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review-Based, Individual Participant Data Network Meta-Analysis

BACKGROUND AND PURPOSE

Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia.

METHODS

Databases including MEDLINE and Embase were searched (inception to September 2015). Published, unpublished, and emerging trials including SLT and ≥10 individual participant data on aphasia, language outcomes, and time post-onset were selected. Patient-level data on stroke, language, SLT, and trial risk of bias were independently extracted. Outcome measurement scores were standardized. A statistical inferencing, one-stage, random effects, network meta-analysis approach filtered individual participant data into an optimal model examining SLT regimen for overall language, auditory comprehension, naming, and functional communication pre-post intervention gains, adjusting for a priori-defined covariates (age, sex, time poststroke, and baseline aphasia severity), reporting estimates of mean change scores (95% CI).

RESULTS

Data from 959 individual participant data (25 trials) were included. Greatest gains in overall language and comprehension were associated with >20 to 50 hours SLT dosage (18.37 [10.58-26.16] Western Aphasia Battery-Aphasia Quotient; 5.23 [1.51-8.95] Aachen Aphasia Test-Token Test). Greatest clinical overall language, functional communication, and comprehension gains were associated with 2 to 4 and 9+ SLT hours/week. Greatest clinical gains were associated with frequent SLT for overall language, functional communication (3-5+ days/week), and comprehension (4-5 days/week). Evidence of comprehension gains was absent for SLT ≤20 hours, <3 hours/week, and ≤3 days/week. Mixed receptive-expressive therapy, functionally tailored, with prescribed home practice was associated with the greatest overall gains. Relative variance was <30%. Risk of trial bias was low to moderate; low for meta-biases.

CONCLUSIONS

Greatest language recovery was associated with frequent, functionally tailored, receptive-expressive SLT, with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges, informing hypothesis-testing trials and tailoring of clinical services. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018110947.

What is Functional Communication? A Theoretical Framework for Real-World Communication Applied to Aphasia Rehabilitation

Aphasia is an impairment of language caused by acquired brain damage such as stroke or traumatic brain injury, that affects a person’s ability to communicate effectively. The aim of rehabilitation in aphasia is to improve everyday communication, improving an individual’s ability to function in their day-to-day life. For that reason, a thorough understanding of naturalistic communication and its underlying mechanisms is imperative. The field of aphasiology currently lacks an agreed, comprehensive, theoretically founded definition of communication. Instead, multiple disparate interpretations of functional communication are used. We argue that this makes it nearly impossible to validly and reliably assess a person’s communicative performance, to target this behaviour through therapy, and to measure improvements post-therapy. In this article we propose a structured, theoretical approach to defining the concept of functional communication. We argue for a view of communication as “situated language use”, borrowed from empirical psycholinguistic studies with non-brain damaged adults. This framework defines language use as: (1) interactive, (2) multimodal, and (3) contextual. Existing research on each component of the framework from non-brain damaged adults and people with aphasia is reviewed. The consequences of adopting this approach to assessment and therapy for aphasia rehabilitation are discussed. The aim of this article is to encourage a more systematic, comprehensive approach to the study and treatment of situated language use in aphasia.

Treatment dose in post-stroke aphasia: A systematic scoping review

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.

Treatment of Underlying Forms: A Bayesian Meta-Analysis of the Effects of Treatment and Person-Related Variables on Treatment Response

Purpose This meta-analysis synthesizes published studies using "treatment of underlying forms" (TUF) for sentence-level deficits in people with aphasia (PWA). The study aims were to examine group-level evidence for TUF efficacy, to characterize the effects of treatment-related variables (sentence structural family and complexity; treatment dose) in relation to the Complexity Account of Treatment Efficacy (CATE) hypothesis, and to examine the effects of person-level variables (aphasia severity, sentence comprehension impairment, and time postonset of aphasia) on TUF response. Method Data from 13 single-subject, multiple-baseline TUF studies, including 46 PWA, were analyzed. Bayesian generalized linear mixed-effects interrupted time series models were used to assess the effect of treatment-related variables on probe accuracy during baseline and treatment. The moderating influence of person-level variables on TUF response was also investigated. Results The results provide group-level evidence for TUF efficacy demonstrating increased probe accuracy during treatment compared with baseline phases. Greater amounts of TUF were associated with larger increases in accuracy, with greater gains for treated than untreated sentences. The findings revealed generalization effects for sentences that were of the same family but less complex than treated sentences. Aphasia severity may moderate TUF response, with people with milder aphasia demonstrating greater gains compared with people with more severe aphasia. Sentence comprehension performance did not moderate TUF response. Greater time postonset of aphasia was associated with smaller improvements for treated sentences but not for untreated sentences. Conclusions Our results provide generalizable group-level evidence of TUF efficacy. Treatment and generalization responses were consistent with the CATE hypothesis. Model results also identified person-level moderators of TUF (aphasia severity, time postonset of aphasia) and preliminary estimates of the effects of varying amounts of TUF for treated and untreated sentences. Taken together, these findings add to the TUF evidence and may guide future TUF treatment-candidate selection. Supplemental Material https://doi.org/10.23641/asha.16828630.

Long-Term Stability of Short-Term Intensive Language-Action Therapy in Chronic Aphasia: A 1-2 year Follow-Up Study

Background. Intensive aphasia therapy can improve language functions in chronic aphasia over a short therapy interval of 2-4 weeks. For one intensive method, intensive language-action therapy, beneficial effects are well documented by a range of randomized controlled trials. However, it is unclear to date whether therapy-related improvements are maintained over years. Objective. The current study aimed at investigating long-term stability of ILAT treatment effects over circa 1-2 years (8-30 months). Methods. 38 patients with chronic aphasia participated in ILAT and were re-assessed at a follow-up assessment 8-30 months after treatment, which had been delivered 6-12.5 hours per week for 2-4 weeks. Results. A standardized clinical aphasia battery, the Aachen Aphasia Test, revealed significant improvements with ILAT that were maintained for up to 2.5 years. Improvements were relatively better preserved in comparatively young patients (<60 years). Measures of communicative efficacy confirmed improvements during intensive therapy but showed inconsistent long-term stability effects. Conclusions. The present data indicate that gains resulting from intensive speech-language therapy with ILAT are maintained up to 2.5 years after the end of treatment. We discuss this novel finding in light of a possible move from sparse to intensive therapy regimes in clinical practice.

Lesion site and therapy time predict responses to a therapy for anomia after stroke: a prognostic model development study

Stroke is a leading cause of disability, and language impairments (aphasia) after stroke are both common and particularly feared. Most stroke survivors with aphasia exhibit anomia (difficulties with naming common objects), but while many therapeutic interventions for anomia have been proposed, treatment effects are typically much larger in some patients than others. Here, we asked whether that variation might be more systematic, and even predictable, than previously thought. 18 patients, each at least 6 months after left hemisphere stroke, engaged in a computerised treatment for their anomia over a 6-week period. Using only: (a) the patients' initial accuracy when naming (to-be) trained items; (b) the hours of therapy that they devoted to the therapy; and (c) whole-brain lesion location data, derived from structural MRI; we developed Partial Least Squares regression models to predict the patients' improvements on treated items, and tested them in cross-validation. Somewhat surprisingly, the best model included only lesion location data and the hours of therapy undertaken. In cross-validation, this model significantly out-performed the null model, in which the prediction for each patient was simply the mean treatment effect of the group. This model also made promisingly accurate predictions in absolute terms: the correlation between empirical and predicted treatment response was 0.62 (95% CI 0.27, 0.95). Our results indicate that individuals' variation in response to anomia treatment are, at least somewhat, systematic and predictable, from the interaction between where and how much lesion damage they have suffered, and the time they devoted to the therapy.

Automatic boost articulation therapy in adults with dysarthria: Acceptability, usability and user interaction

BACKGROUND

Imprecise articulation has a negative impact on speech intelligibility. Therefore, treatment of articulation is clinically relevant in patients with dysarthria. In order to be effective and according to the principles of motor learning, articulation therapy needs to be intensive, well organized, with adequate feedback and requires frequent practice.

AIMS

The aims of this pilot study are (1) to evaluate the feasibility of a virtual articulation therapy (VAT) to guide patients with dysarthria through a boost articulation therapy (BArT) program; (2) to evaluate the acoustic models' performance used for automatic phonological error detection; and (3) to validate the system by end-users from their perspective.

METHODS & PROCEDURES

The VAT provides an extensive and well-structured package of exercises with visual and auditory modelling and adequate feedback on the utterances. The tool incorporates automated methods to detect phonological errors, which are specifically designed to analyse Dutch speech production. A total of 14 subjects with dysarthria evaluated the acceptability, usability and user interaction with the VAT based on two completed therapy sessions using a self-designed questionnaire.

OUTCOMES & RESULTS

In general, participants were positive about the new computer-based therapy approach. The algorithm performance for phonological error detection shows it to be accurate, which contributes to adequate feedback of utterance production. The results of the study indicate that the VAT has a user-friendly interface that can be used independently by patients with dysarthria who have sufficient cognitive, linguistic, motoric and sensory skills to benefit from speech therapy. Recommendations were given by the end-users to further optimize the program and to ensure user engagement.

CONCLUSIONS & IMPLICATIONS

The initial implementation of an automatic BArT shows it to be feasible and well accepted by end-users. The tool is an appropriate solution to increase the frequency and intensity of articulation training that supports traditional methods.

WHAT THIS PAPER ADDS

What is already known on the subject Behavioural interventions to improve articulation in patients with dysarthria demand intensive treatments, repetitive practice and feedback. However, the current treatments are mainly limited in time to the interactive sessions in the presence of speech-language pathology. Automatic systems addressing the needs of individuals with dysarthria are scarce. This study evaluates the feasibility of a VAT program and investigates its acceptability, usability and user interaction. What this paper adds to existing knowledge The computer-based speech therapy approach developed and applied in this study intends to support intensive articulation training of patients with dysarthria. The virtual speech therapy offers the possibility of an individualized and customized therapy programme, with an extensive database of exercises, visual and auditory models of the target utterances, and providing adequate feedback based on automatic acoustic analysis of speech. What are the potential or actual clinical implications of this work? The automatic BArT overcomes the limitation in time of face-to-face traditional speech therapy. It offers patients the opportunity to have access to speech therapy more intensively and frequently in their home environment.

Training flexibility in fixed expressions in non-fluent aphasia: A case series report

BACKGROUND

Many speakers with non-fluent aphasia (NFA) are able to produce some well-formed word combinations such as 'I like it' or 'I don't know', although they may not use variations such as 'He likes it' or 'I don't know that person'. This suggests that these utterances represent fixed forms.

AIMS

This case series investigation explored the impact of a novel intervention aimed at enhancing the connected speech of individuals with NFA. The intervention, motivated by usage-based principles, involved filling open slots in semi-fixed sentence frames.

METHODS & PROCEDURES

Five participants with NFA completed a 6-week intervention programme. The intervention trained participants to insert a range of different lexical items into the open slots of high-frequency phrases such as 'I like it' to enable more productive sentences (e.g., 'they like flowers'). The outcomes and acceptability were examined: The primary outcome measure focused on changes in connected narrative, and the availability of trained constructions (e.g., 'I like it') was explored through a story completion test. Two baseline measures of behaviour were taken prior to intervention, and outcomes assessed immediately after intervention and at a 6-week maintenance assessment.

OUTCOME & RESULTS

A pre-/post-treatment comparison of connected speech measures showed evidence of enhanced connected speech for two of the five participants (P2 and P5). An analysis of story completion test scores revealed positive change for two participants (P1 and P2). Findings were mixed with regard to baseline stability of outcome measures and post-intervention stability of language changes. The intervention was acceptable to all participants.

CONCLUSION & IMPLICATIONS

While this pilot study yielded promising findings with regard to the intervention's acceptability and increased connected speech for some participants, the findings were mixed across the sample of five participants. This research helps inform hypotheses and selection criteria for future studies.

WHAT THIS PAPER ADDS

What is already known on the subject Despite difficulties producing grammatically correct sentences, many speakers with aphasia are able to produce well-formed utterances, often representing familiar expressions such as 'I don't know' and 'I like it'. In usage-based Construction Grammar (CxG) theories, familiar utterances are assumed to be processed as one unit and are therefore more resilient to brain damage. CxG assumes that residual utterances such as 'I like it' map onto more abstract sentence frames (e.g., '[REFERENT] like-TENSE [THING]'). What this paper adds to existing knowledge Sentence therapy, informed by CxG principles, is novel in aphasiology, and usage-based interventions need to be evaluated with regard to their impact on language processing at the connected speech level. This case series report explores the acceptability and outcomes of a usage-based sentence therapy. We also introduce and explore the value of an automated, frequency-based analysis tool for evaluating connected speech outcomes in aphasia therapy. What are the potential or actual clinical implications of this work? The findings inform further development of usage-based aphasia interventions targeting word combinations.