Efficacy of early cognitive-linguistic treatment for aphasia due to stroke: A randomised controlled trial (Rotterdam Aphasia Therapy Study-3)

Validation of a Cantonese Version of the Amsterdam-Nijmegen Everyday Language Test (CANELT): A functional approach

BACKGROUND

The current study aimed to validate the Cantonese version of the Amsterdam-Nijmegen Everyday Language Test (CANELT), a functional communication assessment tool for Cantonese speakers with aphasia. A quantitative scoring method was adopted to examine the pragmatics and informativeness of the production of people with aphasia (PWA).

METHOD

CANELT was translated from its English version with cultural adaptations. The performance on the 20-item CANELT collected from 56 PWA and 100 neurologically healthy Cantonese-speaking controls aged 30 to 79 years was orthographically transcribed. Scoring was based on the completeness of the main concepts produced in the preamble and subsequent elaborations, defined as Opening (O) and New Information (NI). Measures examining the validity and reliability were conducted.

RESULTS

An age effect was found in neurologically healthy controls, and therefore z scores were used for subsequent comparisons between neurologically healthy controls and PWA. The test showed strong evidence for known-group validity in both O [χ2 (2) = 95.2, p < .001] and NI [χ2 (2) = 100.4, p < .001]. A moderate to strong correlation was found between CANELT and standardized aphasia assessment tools, suggesting satisfactory concurrent validity. Reliability measures were excellent in terms of internal consistency (Cronbach's α of .95 for both 'O' and 'NI'), test-retest reliability (ICC = .96; p < .001), intra-rater reliability (ICC = 1.00; p < .001), and inter-rater reliability for O (ICC = .99; p < .001) and NI (ICC = .99; p < .001). Sensitivity and specificity for O are 97% and 76.8%, respectively, while for NI, a sensitivity of 95% and specificity of 91.1% were obtained.

CONCLUSIONS

Measures on validity and reliability yielded promising results, suggesting CANELT as a useful and reliable functional communication assessment for PWA. Its application in managing PWA and potential areas for development are discussed.

Aphasia associated with non-traumatic subarachnoid haemorrhage: a systematic review

PURPOSE

Individuals with non-traumatic subarachnoid haemorrhage (SAH) are often excluded from studies of stroke populations due to differing pathophysiology and treatment pathways. Thus, aphasia presentation in the non-traumatic SAH population is potentially under-represented within existing research evidence.

MATERIALS AND METHODS

Five databases were systematically searched with terms related to "aphasia" and "subarachnoid haemorrhage." Studies were included if aphasia was attributed to non-traumatic SAH or its associated complications, and where at least one language assessment measure used determined the presence or absence of aphasia. Study quality was evaluated using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Following deduplication, 2726 articles were identified for title and abstract screening. Full text screening for 162 articles occurred, with 18 articles selected for inclusion. Aphasia incidence ranged from 5 to 24%, and was influenced by assessment measure, timing of assessment, subgroup studied, and classifications of aphasia. Many studies excluded participants with poorer clinical outcome, intracerebral complications, or severe aphasia. Few studies used comprehensive language assessment measures to examine across language domains.

CONCLUSIONS

Aphasia presentation is highly heterogenous following non-traumatic SAH. Future research using comprehensive language assessments at multiple time points post onset is required to better understand aphasia presentation and management needs for this population.

Insights gained over 60 years on factors shaping post-stroke aphasia recovery: A commentary on Vignolo (1964)

Aphasia is an acquired language disorder resulting from brain injury, including strokes which is the most common etiology, neurodegenerative diseases, tumors, traumatic brain injury, and resective surgery. Aphasia affects a significant portion of stroke survivors, with approximately one third experiencing its debilitating effects in the long term. Despite its challenges, there is growing evidence that recovery from aphasia is possible, even in the chronic phase of stroke. Sixty years ago, Vignolo (1964) outlined the primary challenges confronted by researchers in this field. These challenges encompassed the absence of an objective evaluation of language difficulties, the scarcity of evidence regarding spontaneous aphasia recovery, and the presence of numerous variables that could potentially influence the process of aphasia recovery. In this paper, we discuss the remarkable progress that has been made in the assessment of language and communication in aphasia as well as in understanding the factors influencing post-stroke aphasia recovery.

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

BACKGROUND

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

AIMS

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

METHODS & PROCEDURES

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

OUTCOMES & RESULTS

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

CONCLUSIONS & IMPLICATIONS

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

WHAT THIS PAPER ADDS

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

Therapies and Challenges in the Post-Stroke Aphasia Rehabilitation Arena: Current and Future Prospects

Aphasia is a serious consequence of stroke that results in a breakdown in communication. The course of aphasia recovery differs between afflicted individuals, and responsiveness to treatment cannot be predicted. Aphasiologists continue to investigate numerous behavioral treatment protocols that have shifted their focus to complimentary rehabilitation strategies. The aim of this study is threefold. First, to summarize the different categories of aphasia interventions post-stroke, considering their respective protocols, and present available evidence on the effectiveness of those protocols. Second, to document the challenges regarding the prediction of aphasia treatment response post-stroke in individual patients. Third, to report the challenges faced by researchers in recruiting people with aphasia (PWA) for treatment studies, and provide recommendations on how to increase participant recruitment and retention. This study provides up-to-date information on (i) effective therapies and aphasia recovery processes, and (ii) research recruitment hurdles together with potential strategies for overcoming them.

The usability of an AAC pain description system for patients with acquired expressive communication disorders

Augmentative and alternative communication (AAC) has been used by patients with acquired expressive communication disorders as an alternative to natural speech. The use of symbols to express pain, which is intangible, is challenging because designing a series of comprehensible symbols to represent personal experiences such as pain is not straightforward. This study describes (a) the development of symbols to express pain that were derived from Chinese pain-related similes and metaphors for an AAC mobile application developed specifically for this study known as PainDiary and (b) an assessment of the appropriateness of the app compared to conventional methods of collecting pain information. The symbols depicted headache pain and discomfort, which is prevalent among neurosurgical patients. The participants were 31 patients diagnosed with acquired expressive communication disorders who were receiving treatment in a neurosurgery general ward of Chang Gung Memorial Hospital in Taiwan and 14 nurses who worked on the ward. Pain information was collected by nurses using conventional methods and the PainDiary app. Assessment data, including the accuracy and efficiency of and user satisfaction with PainDiary, are compared. The results show that use of the app was effective in reporting pain and that patients required less time to report a pain event. The results further indicate that the PainDiary app was better received by younger individuals than by their older counterparts.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

SUPPLEMENTAL MATERIAL

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

Development and Implementation of a New Model of Care for Patients With Stroke, Acute Hospital Rehabilitation Intensive SErvices: Leveraging a Multidisciplinary Rehabilitation Team

ABSTRACT

The optimal timing and intensity of early rehabilitation remain uncertain. The literature has stated that too early high-intensity mobility within 24 hours can result in poor outcomes as compared with the 24- to 48-hour poststroke (Stroke 2012;43:2389-94. Stroke 2004;35:1005-9). However, few studies have shown that mobilizing patients a few times per day can have positive results (Stroke 2004;35:1005-9. Cerebrovasc Dis 2010;29:352-60). In addition to mobility impairments, many patients after stroke have dysphagia, aphasia, and cognitive-linguistic deficits. To date, there is limited literature on early rehabilitation in these areas. Here, we describe a program of enhanced rehabilitation in the acute care hospital. In this enhanced model of care, our team delivers up to six sessions of therapy per day focused on the patient's deficits. A patient can receive up to two sessions of each discipline daily to include physical therapy, occupational therapy, and speech language pathology. The model emphasizes team collaboration between therapy disciplines, physiatry, nursing, and neurology accomplished through a daily therapy schedule, rehabilitation huddle, and direct communication before and after therapy sessions. With this model, we aim to enhance coordination of care resulting in improved patient satisfaction and, ultimately, recovery.

Update on the Efficacy of Cognitive Rehabilitation After Moderate to Severe Traumatic Brain Injury: A Scoping Review

OBJECTIVES

To identify, categorize, and analyze the methodological issues of cognitive rehabilitation of patients with moderate to severe traumatic brain injury and its efficacy.

DATA SOURCES

Pubmed and PsycINFO were searched for studies published between 2015 and 2021 using keywords for cognitive intervention and traumatic brain injury.

STUDY SELECTION

Two independent reviewers selected articles concerning cognitive rehabilitation for adults with traumatic brain injury. Of 458 studies, 97 full-text articles were assessed and 46 met the inclusion criteria.

DATA EXTRACTION

Data were analyzed by 1 reviewer according to criteria concerning the methodological quality of studies.

DATA SYNTHESIS

Results showed a large scope of 7 cognitive domains targeted by interventions, delivered mostly in individual sessions (83%) with an integrative cognitive approach (48%). Neuroimaging tools as a measure of outcome remained scarce, featuring in only 20% of studies. Forty-three studies reported significant effects of cognitive rehabilitation, among which 7 fulfilled a high methodological level of evidence.

CONCLUSIONS

Advances and shortcomings in cognitive rehabilitation have both been highlighted and led us to develop methodological key points for future studies. The choice of outcome measures, the selection of control interventions, and the use of combined rehabilitation should be investigated in further studies.

Management of communication disability in the first 90 days after stroke: a scoping review

INTRODUCTION

People with communication disability after stroke need interventions to optimise healthcare communication and rehabilitation outcomes. Current evidence syntheses do not adequately inform the management of communication disability during the first 90 days post-stroke.

PURPOSE

To explore the scope of literature for the management of communication disability in the first 90 days after stroke.

MATERIALS AND METHODS

A scoping review was conducted using a systematic keyword search of six databases. A descriptive synthesis was generated using communication-related domains related to the biopsychosocial framework of the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

A total of 129 studies met eligibility criteria. Aphasia was the most frequently addressed communication disability after stroke (76/129 studies) with a paucity of evidence investigating other acquired neurogenic communication impairments. Management predominantly focused on communication-related: body functions and structures (62 studies) (e.g., linguistic-behavioural therapies), followed by environmental factors (39 studies) (e.g., communication partner training/support); activities and participation (15 studies) (e.g., augmentative and alternative communication); and personal factors (13 studies) (e.g., assessment of depression after aphasia).

CONCLUSION

A coordinated, integrated approach to developing and testing acute and subacute interventions for all communication disabilities across all communication-related domains is required.IMPLICATIONS FOR REHABILITATIONInterdisciplinary stroke clinicians need to manage communication disabilities in the first 90 days after stroke to optimise healthcare communication and rehabilitation outcomes.There is some evidence to guide clinicians in aphasia management but less in other disabilities of speech and cognitive functioning.Most interventions to inform clinical practice address communication-related body functions and structures (e.g., linguistic and speech therapies). Clinicians need to address all domains and more evidence is needed to address environmental factors (e.g., communication support); activities and participation (e.g., person-centred goal setting); and personal factors (e.g., psychological care).

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.

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

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

Understanding Language Reorganization With Neuroimaging: How Language Adapts to Different Focal Lesions and Insights Into Clinical Applications

When the language-dominant hemisphere is damaged by a focal lesion, the brain may reorganize the language network through functional and structural changes known as adaptive plasticity. Adaptive plasticity is documented for triggers including ischemic, tumoral, and epileptic focal lesions, with effects in clinical practice. Many questions remain regarding language plasticity. Different lesions may induce different patterns of reorganization depending on pathologic features, location in the brain, and timing of onset. Neuroimaging provides insights into language plasticity due to its non-invasiveness, ability to image the whole brain, and large-scale implementation. This review provides an overview of language plasticity on MRI with insights for patient care. First, we describe the structural and functional language network as depicted by neuroimaging. Second, we explore language reorganization triggered by stroke, brain tumors, and epileptic lesions and analyze applications in clinical diagnosis and treatment planning. By comparing different focal lesions, we investigate determinants of language plasticity including lesion location and timing of onset, longitudinal evolution of reorganization, and the relationship between structural and functional changes.

Does acupuncture therapy improve language function of patients with aphasia following ischemic stroke? A systematic review and meta-analysis

BACKGROUND

Aphasia is one of the most common complications in patients with ischemic stroke. Studies have shown that acupuncture can improve the symptoms of aphasia patients. However, the effect of acupuncture on language function in patients with ischemic stroke is still controversial.

OBJECTIVE

This study aimed to critically assess the efficacy and safety of acupuncture for aphasia following ischemic stroke.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, China National Knowledge Infrastructure, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals database were searched. All randomized controlled trials (RCTs) that met the criteria were included.

RESULTS

Meta-analyses showed that mean difference in change of auditory comprehension score (MD = 7.71, 95% CI: 1.83 to 13.59, P = 0.01), spontaneous speech (MD = 2.77, 95% CI: 0.59 to 4.95, P = 0.01), repetition score (MD = 14.48, 95% CI: 11.04 to 17.91, P < 0.00001) and naming score (MD = 14.60, 95% CI: 11.33 to 17.88, P < 0.00001) measured by WAB scale were statistically significant. Subgroup analyses demonstrated that there were statistically significant mean differences in four items of WAB scale in patients with sub-acute stroke, and no statistically significant differences in patients with acute stroke.

CONCLUSION

The present study suggests that acupuncture may improve the language function of patients with aphasia following ischemic stroke, especially during the sub-acute phase. However, due to insufficient sample sizes and information on the safety, more high-quality RCTs are still needed.

Demystifying the complexity of aphasia treatment: Application of the Rehabilitation Treatment Specification System (RTSS)

A considerable body of research supports the use of behavioral communication treatment as the standard of care for aphasia. In spite of robust progress in clinical aphasiology, many questions regarding optimal care remain unanswered. One of the major challenges to progress in the field is the lack of a common framework to adequately describe individual treatments, which, if available, would allow comparisons across studies as well as improved communication among researchers, clinicians, and other stakeholders. Here, we describe how aphasia treatment approaches can be systematically characterized using the Rehabilitation Treatment Specification System (RTSS). At the core of the RTSS is a tripartite structure that focuses on targets (the behavior that is expected to change as a result of treatment), ingredients (what a clinician does to affect change in the target), and mechanism(s) of action (why a given treatment works by linking the ingredients to the target). Three separate papers in the current issue specifically describe how the RTSS can be used to describe different kinds of aphasia treatment approaches: functional approaches, cognitive-linguistic approaches, and biological approaches. It is our hope that the application of the RTSS in clinical aphasiology will improve communication in published studies, grant proposals, and in the clinical care of persons with aphasia.

Effects of computer-based therapy versus therapist-mediated therapy in stroke-related aphasia: Pilot non-inferiority study

PURPOSE

The burgeoning growth of computer-based rehabilitation technologies has led to a paradigm shift in the delivery of aphasia intervention. The aim of this study was to conduct a pilot non-inferiority study comparing computer-based training for people with aphasia versus traditional therapist-mediated training on language skills, functional communication and quality of life outcomes in the hospital setting.

METHODS

Twenty-two fluent, monolingual Italian speakers with stroke-related aphasia in the acute phase of recovery were enrolled in the study. Participants were assigned randomly to computer-based or therapist-mediated aphasia treatment. Both groups received one, 50-minute session for 5 days per week over a period of 8 weeks. During the training, they were administered words and sentence comprehension, written naming, word completion, fluency, word and sentence reorganization tasks. The complexity of each task was increased progressively based on the severity of each person's language deficits.

RESULTS

Participants in both computer-based and traditional therapist-mediated aphasia intervention showed significant gains in language skills, functional communication and quality of life from pre- to post-treatment. Statistically significant within-group differences were found across all outcome measures. In contrast, no significant between-group and group x time interaction effects were found across language skills, functional communication and quality-of-life measures.

CONCLUSIONS

The overall pattern of findings suggested computer-based intervention was not inferior to traditional therapist-based intervention for enhancing functional communication deficits in stroke-related aphasia during the acute phase of recovery. A follow-up, fully-powered clinical trial is needed to confirm the reliability of these results.

A Systematic Review of Transcranial Direct Current Stimulation in Primary Progressive Aphasia: Methodological Considerations

A variety of tDCS approaches has been used to investigate the potential of tDCS to improve language outcomes, or slow down the decay of language competences caused by Primary Progressive Aphasia (PPA). The employed stimulation protocols and study designs in PPA are generally speaking similar to those deployed in post-stroke aphasic populations. These two etiologies of aphasia however differ substantially in their pathophysiology, and for both conditions the optimal stimulation paradigm still needs to be established. A systematic review was done and after applying inclusion and exclusion criteria, 15 articles were analyzed focusing on differences and similarities across studies especially focusing on PPA patient characteristics (age, PPA variant, language background), tDCS stimulation protocols (intensity, frequency, combined therapy, electrode configuration) and study design as recent reviews and group outcomes for individual studies suggest tDCS is an effective tool to improve language outcomes, while methodological approach and patient characteristics are mentioned as moderators that may influence treatment effects. We found that studies of tDCS in PPA have clinical and methodological and heterogeneity regarding patient populations, stimulation protocols and study design. While positive group results are usually found irrespective of these differences, the magnitude, duration and generalization of these outcomes differ when comparing stimulation locations, and when results are stratified according to the clinical variant of PPA. We interpret the results of included studies in light of patient characteristics and methodological decisions. Further, we highlight the role neuroimaging can play in study protocols and interpreting results and make recommendations for future work.

Feasibility and acceptability of cognitive rehabilitation during the acute phase of schizophrenia

AIM

Although numerous studies have demonstrated promising results for the cognitive rehabilitation in subjects with schizophrenia, the efficacy of cognitive rehabilitation for everyday and social functioning is not yet sufficient. Although consideration of the contents and methods are vital, the timing for implementing cognitive rehabilitation also seems to be crucial. The aim of this study was to examine the feasibility and acceptability of cognitive rehabilitation during the acute phase of schizophrenia.

METHODS

Patients were recruited from consecutive acute admissions to the inpatient unit during a 15-month period and were evaluated to determine whether they could be enrolled in an 8-week cognitive rehabilitation program within 14 days of their hospital admission. Cognitive rehabilitation programs with a workbook style were adopted, taking the patients' conditions and burdens into consideration.

RESULTS

Eighty-three patients were newly admitted during the entry period, and 49 patients (59.0%) were eligible for inclusion. Of them, 22 patients (44.9%) agreed to participate and started the program. Sixteen patients completed the program and underwent a second assessment. Thus, 32.7% (16/49) of all the eligible patients actually completed the study. The participants were quite satisfied with the program.

CONCLUSIONS

This preliminary study yielded encouraging data demonstrating the feasibility and acceptability of cognitive remediation for patients with schizophrenia during the acute phase. The provision of cognitive rehabilitation during the acute phase of the first episode can reasonably be expected to lead to better functional outcomes.

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

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

Current Approaches to the Treatment of Post-Stroke Aphasia

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

Predictors of Poststroke Aphasia Recovery: A Systematic Review-Informed Individual Participant Data Meta-Analysis

BACKGROUND AND PURPOSE

The factors associated with recovery of language domains after stroke remain uncertain. We described recovery of overall-language-ability, auditory comprehension, naming, and functional-communication across participants' age, sex, and aphasia chronicity in a large, multilingual, international aphasia dataset.

METHODS

Individual participant data meta-analysis of systematically sourced aphasia datasets described overall-language ability using the Western Aphasia Battery Aphasia-Quotient; auditory comprehension by Aachen Aphasia Test (AAT) Token Test; naming by Boston Naming Test and functional-communication by AAT Spontaneous-Speech Communication subscale. Multivariable analyses regressed absolute score-changes from baseline across language domains onto covariates identified a priori in randomized controlled trials and all study types. Change-from-baseline scores were presented as estimates of means and 95% CIs. Heterogeneity was described using relative variance. Risk of bias was considered at dataset and meta-analysis level.

RESULTS

Assessments at baseline (median=43.6 weeks poststroke; interquartile range [4-165.1]) and first-follow-up (median=10 weeks from baseline; interquartile range [3-26]) were available for n=943 on overall-language ability, n=1056 on auditory comprehension, n=791 on naming and n=974 on functional-communication. Younger age (<55 years, +15.4 Western Aphasia Battery Aphasia-Quotient points [CI, 10.0-20.9], +6.1 correct on AAT Token Test [CI, 3.2-8.9]; +9.3 Boston Naming Test points [CI, 4.7-13.9]; +0.8 AAT Spontaneous-Speech Communication subscale points [CI, 0.5-1.0]) and enrollment <1 month post-onset (+19.1 Western Aphasia Battery Aphasia-Quotient points [CI, 13.9-24.4]; +5.3 correct on AAT Token Test [CI, 1.7-8.8]; +11.1 Boston Naming Test points [CI, 5.7-16.5]; and +1.1 AAT Spontaneous-Speech Communication subscale point [CI, 0.7-1.4]) conferred the greatest absolute change-from-baseline across each language domain. Improvements in language scores from baseline diminished with increasing age and aphasia chronicity. Data exhibited no significant statistical heterogeneity. Risk-of-bias was low to moderate-low.

CONCLUSIONS

Earlier intervention for poststroke aphasia was crucial to maximize language recovery across a range of language domains, although recovery continued to be observed to a lesser extent beyond 6 months poststroke.

The verbal, non-verbal and structural bases of functional communication abilities in aphasia

The ability to communicate, functionally, after stroke or other types of acquired brain injury is crucial for the person involved and the people around them. Accordingly, assessment of functional communication is increasingly used in large-scale randomized controlled trials as the primary outcome measure. Despite the importance of functional communication abilities to everyday life and their centrality to the measured efficacy of aphasia interventions, there is little knowledge about how commonly used measures of functional communication relate to each other, whether they capture and grade the full range of patients’ remaining communication skills and how these abilities relate to the patients’ verbal and non-verbal impairments as well as the underpinning lesions. Going beyond language-only factors is essential given that non-verbal abilities can play a crucial role in an individual’s ability to communicate effectively. This study, based on a large sample of patients covering the full range and types of post-stroke aphasia, addressed these important, open questions. The investigation combined data from three established measures of functional communication with a thorough assessment of verbal and non-verbal cognition as well as structural neuroimaging. The key findings included: (i) due to floor or ceiling effects, the full range of patients’ functional communication abilities was not captured by a single assessment alone, limiting the utility of adopting individual tests as outcome measures in randomized controlled trials; (ii) phonological abilities were most strongly related to all measures of functional communication and (iii) non-verbal cognition was particularly crucial when language production was relatively impaired and other modes of communication were allowed, when patients rated their own communication abilities, and when carers rated patients’ basic communication abilities. Finally, in addition to lesion load being significantly related to all measures of functional communication, lesion analyses showed partially overlapping clusters in language regions for the functional communication tests. Moreover, mirroring the findings from the regression analyses, additional regions previously associated with non-verbal cognition emerged for the Scenario Test and for the Patient Communication Outcome after Stroke rating scale. In conclusion, our findings elucidated the cognitive and neural bases of functional communication abilities, which may inform future clinical practice regarding assessments and therapy. In particular, it is necessary to use more than one measure to capture the full range and multifaceted nature of patients’ functional communication abilities and a therapeutic focus on non-verbal cognition might have positive effects on this important aspect of activity and participation.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A randomized control trial of intensive aphasia therapy after acute stroke: The Very Early Rehabilitation for SpEech (VERSE) study

BACKGROUND

Effectiveness of early intensive aphasia rehabilitation after stroke is unknown. The Very Early Rehabilitation for SpEech trial (VERSE) aimed to determine whether intensive aphasia therapy, beginning within 14 days after stroke, improved communication recovery compared to usual care.

METHODS

Prospective, randomized, single-blinded trial conducted at 17 acute-care hospitals across Australia/New Zealand from 2014 to 2018. Participants with aphasia following acute stroke were randomized to receive usual care (direct usual care aphasia therapy), or one of two higher intensity regimens (20 sessions of either non-prescribed (usual care-plus or prescribed (VERSE) direct aphasia therapy). The primary outcome was improvement of communication on the Western Aphasia Battery-Revised Aphasia Quotient (AQ) at 12 weeks after stroke. Our pre-planned intention to treat analysis combined high intensity groups for the primary outcome.

FINDINGS

Among 13,654 acute stroke patients screened, 25% (3477) had aphasia, of whom 25% (866) were eligible and 246 randomized to usual care (n = 81; 33%), usual care-plus (n = 82; 33%) or VERSE (n = 83; 34%). At 12 weeks after stroke, the primary outcome was assessed in 217 participants (88%); 14 had died, 9 had withdrawn, and 6 were too unwell for assessment. Communication recovery was 50.3% (95% CI 45.7-54.8) in the high intensity group (n = 147) and 52.1% (95% CI 46.1-58.1) in the usual care group (n = 70; difference -1.8, 95% CI -8.7-5.0). There was no difference between groups in non-fatal or fatal adverse events (p = 0.72).

INTERPRETATION

Early, intensive aphasia therapy did not improve communication recovery within 12 weeks post stroke compared to usual care.

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.

Patterns of Recovery From Aphasia in the First 2 Weeks After Stroke

Purpose Recovery from aphasia after stroke has a decelerating trajectory, with the greatest gains taking place early and the slope of change decreasing over time. Despite its importance, little is known regarding evolution of language function in the early postonset period. The goal of this study was to characterize the dynamics and nature of recovery of language function in the acute and early subacute phases of stroke. Method Twenty-one patients with aphasia were evaluated every 2-3 days for the first 15 days after onset of acute ischemic or hemorrhagic stroke. Language function was assessed at each time point with the Quick Aphasia Battery (Wilson, Eriksson, Schneck, & Lucanie, 2018), which yields an overall summary score and a multidimensional profile of 7 different language domains. Results On a 10-point scale, overall language function improved by a mean of 1.07 points per week, confidence interval [0.46, 1.71], with 19 of 21 patients showing positive changes. The trajectory of recovery was approximately linear over this time period. There was significant variability across patients, and patients with more impaired language function at Day 2 poststroke experienced greater improvements over the subsequent 2 weeks. Patterns of recovery differed across language domains, with consistent improvements in word finding, grammatical construction, repetition, and reading, but less consistent improvements in word comprehension and sentence comprehension. Conclusion Overall language function typically improves substantially and steadily during the first 2 weeks after stroke, driven mostly by recovery of expressive language. Information on the trajectory of early recovery will increase the accuracy of prognoses and establish baseline expectations against which to evaluate the efficacy of interventions. Supplemental Material https://doi.org/10.23641/asha.7811876.

Language recovery following stroke

Objective: To review the research literature pertaining to post-stroke language recovery, and to discuss neurocognitive assessment in patients in the context of aphasia, time course of language recovery, factors associated with language recovery, and therapeutic techniques designed to facilitate language recovery. Method: Articles were identified through PubMed, MEDLINE, PsychINFO, and Google Scholar searches. Examples of utilized keywords include "post-stroke aphasia," "post-stroke language recovery," "post-stroke neurocognitive assessment," and "neuropsychology and aphasia." Results: Most language recovery occurs in the first few weeks following stroke, but residual recovery may occur for many years. Although initial aphasia severity is the single largest determinant of post-stroke language recovery, a number of other variables also contribute. Several techniques have been developed to aid in the recovery process including speech-language therapy and noninvasive brain stimulation, although the effectiveness of acute and subacute treatment remains unclear. Some degree of valid neurocognitive assessment is possible in patients with aphasia, and the information gained from such an evaluation can aid the rehabilitative process Conclusions: Significant recovery of language function is possible following a stroke, but prediction of level of recovery in an individual patient is difficult. Information about initial aphasia severity and the integrity of cognitive domains other than language can help guide the rehabilitation team, as well as manage expectations for recovery.

Validation of a prediction model for long-term outcome of aphasia after stroke

Background

About 30% of stroke patients suffer from aphasia. As aphasia strongly affects daily life, most patients request a prediction of outcome of their language function. Prognostic models provide predictions of outcome, but external validation is essential before models can be used in clinical practice. We aim to externally validate the prognostic model from the Sequential Prognostic Evaluation of Aphasia after stroKe (SPEAK-model) for predicting the long-term outcome of aphasia caused by stroke.

Methods

We used data from the Rotterdam Aphasia Therapy Study – 3 (RATS-3), a multicenter RCT with inclusion criteria similar to SPEAK, an observational prospective study. Baseline assessment in SPEAK was four days after stroke and in RATS-3 eight days. Outcome of the SPEAK-model was the Aphasia Severity Rating Scale (ASRS) at 1 year, dichotomized into good (ASRS-score of 4 or 5) and poor outcome (ASRS-score < 4). In RATS-3, ASRS-scores at one year were not available, but we could use six month ASRS-scores as outcome. Model performance was assessed with calibration and discrimination.

Results

We included 131 stroke patients with first-ever aphasia. At six months, 86 of 124 (68%) had a good outcome, whereas the model predicted 88%. Discrimination of the model was good with an area under the receiver operation characteristic curve of 0.87 (95%CI: 0.81–0.94), but calibration was unsatisfactory. The model overestimated the probability of good outcome (calibration-in-the-large α = − 1.98) and the effect of the predictors was weaker in the validation data than in the derivation data (calibration slope β = 0.88). We therefore recalibrated the model to predict good outcome at six months.

Conclusion

The original model, renamed SPEAK-12, has good discriminative properties, but needs further external validation. After additional external validation, the updated SPEAK-model, SPEAK-6, may be used in daily practice to discriminate between patients with good and patients with poor outcome of aphasia at six months after stroke.

Trial registration

RATS-3 was registered on January 13th 2012 in the Netherlands Trial Register: NTR3271. SPEAK was not listed in a trial registry.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1174-5) contains supplementary material, which is available to authorized users.

Aphasia Recovery: When, How and Who to Treat?

PURPOSE OF REVIEW

We now know that speech and language therapy (SALT) is effective in the rehabilitation of aphasia; however, there remains much individual variability in the response to interventions. So, what works for whom, when and how?

RECENT FINDINGS

This review evaluates the current evidence for the efficacy of predominantly impairment-focused aphasia interventions with respect to optimal dose, intensity, timing and distribution or spacing of treatment. We conclude that sufficient dose of treatment is required to enable clinical gains and that e-therapies are a promising and practical way to achieve this goal. In addition, aphasia can be associated with other cognitive deficits and may lead to secondary effects such as low mood and social isolation. In order to personalise individual treatments to optimise recovery, we need to develop a greater understanding of the interactions between these factors.

Fourth European stroke science workshop

Lake Eibsee, Garmisch-Partenkirchen, 16 to 18 November, 2017: The European Stroke Organisation convened >120 stroke experts from 21 countries to discuss latest results and hot topics in clinical, translational and basic stroke research. Since its inception in 2011, the European Stroke Science Workshop has become a cornerstone of European Stroke Organisation's academic activities and a major highlight for researchers in the field. Participants include stroke researchers at all career stages and with different backgrounds, who convene for plenary lectures and discussions. The workshop was organised in seven scientific sessions focusing on the following topics: (1) acute stroke treatment and endovascular therapy; (2) small vessel disease; (3) opportunities for stroke research in the omics era; (4) vascular cognitive impairment; (5) intracerebral and subarachnoid haemorrhage; (6) alternative treatment concepts and (7) neural circuits, recovery and rehabilitation. All sessions started with a keynote lecture providing an overview on current developments, followed by focused talks on a timely topic with the most recent findings, including unpublished data. In the following, we summarise the key contents of the meeting. The program is provided in the online only Data Supplement. The workshop started with a key note lecture on how to improve the efficiency of clinical trial endpoints in stroke, which was delivered by Craig Anderson (Sydney, Australia) and set the scene for the following discussions.

Early Rehabilitation After Stroke: a Narrative Review

PURPOSE OF REVIEW

Despite current rehabilitative strategies, stroke remains a leading cause of disability in the USA. There is a window of enhanced neuroplasticity early after stroke, during which the brain's dynamic response to injury is heightened and rehabilitation might be particularly effective. This review summarizes the evidence of the existence of this plastic window, and the evidence regarding safety and efficacy of early rehabilitative strategies for several stroke domain-specific deficits.

RECENT FINDINGS

Overall, trials of rehabilitation in the first 2 weeks after stroke are scarce. In the realm of very early mobilization, one large and one small trial found potential harm from mobilizing patients within the first 24 h after stroke, and only one small trial found benefit in doing so. For the upper extremity, constraint-induced movement therapy appears to have benefit when started within 2 weeks of stroke. Evidence for non-invasive brain stimulation in the acute period remains scant and inconclusive. For aphasia, the evidence is mixed, but intensive early therapy might be of benefit for patients with severe aphasia. Mirror therapy begun early after stroke shows promise for the alleviation of neglect. Novel approaches to treating dysphagia early after stroke appear promising, but the high rate of spontaneous improvement makes their benefit difficult to gauge. The optimal time to begin rehabilitation after a stroke remains unsettled, though the evidence is mounting that for at least some deficits, initiation of rehabilitative strategies within the first 2 weeks of stroke is beneficial. Commencing intensive therapy in the first 24 h may be harmful.

The Role of the BDNF Val66Met Polymorphism in Recovery of Aphasia After Stroke

BACKGROUND

Brain-derived neurotrophic factor (BDNF) is assumed to play a role in mediating neuroplasticity after stroke. Carriers of the function-limiting Val66Met (rs6265) single nucleotide polymorphism (SNP) may have a downregulation in BDNF secretion, which may lead to a poorer prognosis after stroke compared to noncarriers in motor learning and motor function recovery. The present study investigates whether this polymorphism may also affect the recovery of poststroke aphasia (ie, language impairment).

OBJECTIVE

To study the influence of the BDNF Val66Met polymorphism on the recovery of poststroke aphasia.

METHODS

We included 53 patients with poststroke aphasia, all participating in an inpatient rehabilitation program with speech and language therapy. All patients were genotyped for the Val66Met SNP and subdivided into carriers (at least one Met allele) and noncarriers (no Met allele). Primary outcome measures included the improvement over rehabilitation time on the Amsterdam-Nijmegen Everyday Language Test (ANELT) and the Boston Naming Test (BNT).

RESULTS

The outcome measures showed a large variability in the improvement scores on both the ANELT and BNT. There was no significant difference between noncarriers and carriers in the primary outcome measures.

CONCLUSION

This study investigated the effect of the BDNF Val66Met polymorphism on clinical recovery of poststroke aphasia. In contrast to earlier studies describing a reducing effect of this polymorphism on motor function recovery after stroke, the present study does not support a reduction in language recovery for carriers compared to noncarriers with poststroke aphasia.