Evaluating the Benefits of Aphasia Intervention Delivered in Virtual Reality: Results of a Quasi-Randomised Study

Embracing virtual reality in rehabilitation of post-stroke aphasia

About one-third of stroke survivors experience aphasia, i.e., language dysfunction caused by brain damage. Aphasia affects not only a person's ability to communicate, but it often leads to the inability to return to work, loss of close relationships, diminished quality of life, negative self-perception, and depression. Yet persons with aphasia are globally underserved due to limited access to resources, which limits their chance for recovery. Immersive virtual reality (VR) has the potential to solve this problem and deliver efficient, personalized treatments to millions of people worldwide who need access to rehabilitation services or more flexibility in treatment delivery. To reduce the global burden of stroke experts recommend taking bold, pragmatic actions across all four pillars of stroke quadrangle-surveillance, prevention, acute care, and rehabilitation. Embracing immersive VR-based rehabilitation of poststroke aphasia would be one step in that direction.

Collaborative co-design and evaluation of an immersive virtual reality application prototype for communication rehabilitation (DISCOVR prototype)

PURPOSE

Virtual reality (VR) lends itself to communication rehabilitation by creating safe, replicable, and authentic simulated environments in which users learn and practice communication skills. The aim of this research was to obtain the views of health professionals and technology specialists on the design characteristics and usability of a prototype VR application for communication rehabilitation.

MATERIALS AND METHODS

Nine professionals from different health and technology disciplines participated in an online focus group or individual online interview to evaluate the application and use of the VR prototype. Data sources were analysed using a content thematic analysis.

RESULTS

Four main themes relating to VR design and implementation in rehabilitation were identified: (i) designing rehabilitation-focused virtual worlds; (ii) understanding and using VR hardware; (iii) making room for VR in rehabilitation and training; and (iv) implementing VR will not replace the health professional's role.

DISCUSSION

Health professionals and technology specialists engaged in co-design while evaluating the VR prototype. They identified software features requiring careful consideration to ensure improved usability, client safety, and success in communication rehabilitation outcomes. Continuing inclusive co-design, engaging health professionals, clients with communication disability, and their families will be essential to creating useable VR applications and integrating these successfully into rehabilitation. Implications for rehabilitationHealth and technology professionals, along with clients, are integral to the co-design of new VR technology applications.Design of VR applications needs to consider the client's communication, physical, cognitive, sensory, psychosocial, and emotional needs for greater usability of these programs.Realism and authenticity of interactions, characters, and environments are considered important factors to allow users to be fully immersed in virtual simulations to enhance rehabilitation.

Virtual Reality for the Rehabilitation of Acquired Cognitive Disorders: A Narrative Review

This review article explores the use of Virtual Reality (VR) technology in cognitive rehabilitation for individuals with neurological conditions, such as stroke, traumatic brain injury, and neurodegenerative diseases. The introduction highlights the challenges posed by cognitive impairments and the limitations of traditional rehabilitation methods. VR is presented as a transformative tool that immerses individuals in interactive environments, offering promising opportunities for enhancing cognitive functions and improving quality of life. This article covers the foundational principles of VR, its applications across different clinical conditions and cognitive domains, and evaluates empirical evidence supporting its efficacy. It also discusses the advantages, limitations, challenges, and ethical considerations in the use of VR for cognitive rehabilitation. This review concludes by exploring future developments, including advancements in VR technology, the integration of Augmented Reality (AR) and artificial intelligence (AI), and the importance of standardized assessment tools for the objective evaluation of rehabilitation outcomes.

The use of virtual reality in the rehabilitation of aphasia: a systematic review

PURPOSE

This systematic review explored how virtual reality (VR) has been used to rehabilitate aphasia.

MATERIALS AND METHODS

Empirical studies were included where VR was used to target language, well-being, or quality of life in adults with acquired language impairment. Degenerative communication disabilities were excluded. Seven health databases were searched in October 2021. Risk of Bias was assessed using published checklists and completeness of intervention reporting evaluated. Narrative synthesis described forms of VR, rationales given, outcome measures, communication functions targeted, characteristics of interventions, and outcomes achieved within the framework of impairment, activity, and participation.

RESULTS

Fourteen studies, involving 229 participants, met the criteria. The studies employed four forms of VR with various rationales given. Interventions used published and novel protocols. Primary outcomes targeted language impairment (12/14), activity (1/14), and well-being (1/14) and achieved positive outcomes in impairment and activity. All studies were exploratory. Risk of bias was high. Findings are discussed in the context of gains achieved by VR in other health contexts and the multi-user gaming literature.

CONCLUSIONS

Uses of VR in aphasia rehabilitation described in the literature are limited. Most applications target the remediation of language impairments. Opportunities to address activity, participation, and wider aspects of well-being are rare.IMPLICATIONS FOR REHABILITATIONResearch documenting the use of virtual reality (VR) to rehabilitate aphasia is limited and exploratory, so does not yet offer clear guidance for clinicians.Many of the identified studies have used known published protocols (e.g., naming therapy or scripts therapy) delivered through the novel VR format and focus on language impairment outcomes.VR offers clinicians a unique opportunity to address communication activity and participation through the use of multi-user virtual worlds, but this has only been explored by only two research teams.

Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study

BACKGROUND

Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders.

OBJECTIVE

This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders.

METHODS

Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes.

RESULTS

The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology.

CONCLUSIONS

Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities.

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.

Investigating the Impact of Visual Input on Voice Production in Virtual Reality

OBJECTIVE

This study explored the independent effects of visual input on voice production using virtual reality. Specifically, its effects on acoustic voice parameters and vocal status ratings, with the hypothesis that larger (a virtual lecture hall and theater compared to an office) and more full virtual rooms (75% of the capacity compared to 45%) would result in changes to the voice parameters and vocal status ratings.

METHODS

Voice production from 30 vocally healthy participants was recorded in six virtual reality conditions. After each condition, the participants provided vocal status ratings. The voice recordings were processed to calculate mean and standard deviation of sound pressure level and fundamental frequency, mean pitch strength, time dose, and cepstral peak prominence smoothed. The effects of the virtual reality conditions on these voice acoustic parameters and the vocal status ratings were analyzed.

RESULTS

The full virtual reality rooms resulted in significantly higher vocal fatigue and vocal discomfort ratings. The larger virtual reality rooms were significantly related to increases in mean and the standard deviation of sound pressure level, mean pitch strength, and cepstral peak prominence smoothed.

CONCLUSIONS

This study demonstrated that visual size and visual fullness input during speech tasks have distinct effects on voice production and self-reported vocal status. Visual size is related to voice acoustic outcomes, while visual fullness is related to self-reported outcomes.

Telehealth Assessments and Interventions for Individuals With Poststroke Aphasia: A Scoping Review

PURPOSE

There are increasing demands for aphasia assessment and intervention services to be delivered remotely. The purpose of this scoping review was to address what is known about the delivery of assessments and interventions using telehealth for people with poststroke aphasia. Specifically, the review sought to (a) identify which telehealth assessment protocols have been used, (b) identify which telehealth intervention protocols have been used, and (c) describe evidence on the effectiveness and feasibility of telehealth for people with poststroke aphasia.

METHOD

A scoping review of the literature published in English since 2013 was conducted by searching MEDLINE, Embase, PsycINFO, CINAHL, and Scopus databases to identify relevant studies. A total of 869 articles were identified. Two reviewers screened records independently, finding 25 articles eligible for inclusion. Data extraction was conducted once and validated by the second reviewer.

RESULTS

Two of the included studies examined telehealth assessment protocols, whereas the remaining studies focused on the delivery of telehealth interventions. The results of the included studies illustrated both effectiveness and feasibility regarding telehealth for people with poststroke aphasia. However, a lack of procedural variation among the studies was found.

CONCLUSIONS

Overall, this scoping review yielded continued support for the use of telehealth practices as an alternate mode of delivering both assessment and intervention services to people with poststroke aphasia. However, further research is needed to investigate the range of aphasia assessment and intervention protocols that can be offered via telehealth, such as assessments or interventions that use patient-reported measures or address extralinguistic cognitive abilities.

Speech-Language Pathologists' Views of Using Virtual Reality for Managing Cognitive-Communication Disorders Following Traumatic Brain Injury

PURPOSE

Using virtual reality (VR) to support rehabilitation is an emerging area of research that may offer people with communication disorders a stable and safe communication environment to practice their communication skills. There are currently no VR applications that have been designed to assess or treat cognitive-communication disorders (CCDs) following traumatic brain injury (TBI). Therefore, this study aimed to explore the views of speech-language pathologists (SLPs) who work with people who have a TBI to generate ideas and considerations for using VR in rehabilitation for CCDs. VR researchers were included to provide expert advice about VR technology.

METHOD

A total of 14 SLPs and three VR specialists participated in an online interview or focus group. Semistructured discussions explored participants' perspectives related to potential ideas for VR use and any perceived barriers and facilitators to VR implementation for managing CCDs following TBI. Data were video- and audio-recorded, transcribed, and analyzed qualitatively using thematic analysis.

RESULTS

Three main themes were generated from thematic analysis: VR is a tool that could enhance clinical practice, the need to consider and navigate potential red flags, and solutions to pave the way forward. Suggestions to overcome perceived barriers to VR use were also provided.

DISCUSSION

Participants expressed interest in using VR for rehabilitation of CCDs following TBI. However, potential barriers and risks to use should be considered prior to implementation. The findings offer guidance to support future research and development of VR in this field.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21669647.

The Excess Costs of Hospitalization for Acute Stroke in People With Communication Impairment: A Stroke123 Data Linkage Substudy

OBJECTIVE

To describe the costs of hospital care for acute stroke for patients with aphasia or dysarthria.

DESIGN

Observational study from the Stroke123 project.

SETTING

Data from patients admitted with stroke (2009-2013) from 22 hospitals in Queensland participating in the Australian Stroke Clinical Registry (AuSCR) were linked to administrative datasets.

PARTICIPANTS

Communication impairments were identified using International Classification of Diseases, 10th Revision, Australian Modification codes. Overall, 1043 of 4195 (25%) patients were identified with aphasia (49% were women; median age 78 years; 83% with ischemic stroke), and 1005 (24%) with dysarthria (42% were women; median age 76 years; 85% with ischemic stroke).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Linked patient-level, hospital clinical costing related to the stroke, were adjusted to 2013/2014 Australian dollars (AU$, US$ conversion x 0.691) using recommended national price indices and multivariable regression analysis with clustering by hospital performed.

RESULTS

Compared with patients without aphasia, the median hospital costs/patient were greater for those with aphasia for medical (aphasia AU$2273 vs AU$1727, P<.001), nursing (aphasia AU$3829 vs AU$2748, P<.001) and allied health services (aphasia AU$1138 vs AU$720, P<.001). Similarly, costs were greater for patients with dysarthria compared with those without dysarthria. Adjusted median total costs were AU$2882 greater for patients with aphasia compared with patients without aphasia (95% confidence interval, AU$1880-3884), and AU$843 greater for patients with dysarthria compared with those without dysarthria (95% confidence interval, AU$-301 to 1987).

CONCLUSIONS

People with communication impairment after stroke incur greater hospital costs, in particular for medical, allied health, and nursing resources.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Delivering group support for people with aphasia in a virtual world: experiences of service providers

PURPOSE

This study explored the acceptability to service providers of delivering a novel group support intervention for people with aphasia (PWA) in a virtual world.

MATERIALS AND METHODS

The service providers were six group coordinators and 10 volunteers. Fourteen of the service providers participated in a semi-structured qualitative interview and 15 took part in a consensus group discussion. Qualitative interviews were analysed using framework analysis. For consensus group discussions, nominal group rankings were analysed and semantically similar responses were identified.

RESULTS

Service providers described the virtual world as a safe space in which to communicate, connect, and experiment. The key barriers were technical, particularly relating to sound and connectivity issues. Service providers suggested a range of improvements to the virtual world and intervention programme. They reported that PWA benefitted from accessing a support group in a virtual world, with opportunities to connect socially and to develop their communication skills.

CONCLUSIONS

Service providers found delivery of group support intervention in a virtual world to be acceptable. The use of a bespoke virtual world to deliver group support intervention may enhance the experience and increase its accessibility, enabling more PWA to benefit from this type of intervention.Implications for rehabilitationPeople with aphasia benefit from group support intervention but may find it difficult to access face-to-face groups.Delivery of group support intervention in a virtual world is acceptable to service providers, can enhance the experience and increase accessibility of groups.Technical challenges present potential barriers when delivering group support in a virtual world, relating particularly to sound and connectivity.Potential benefits of this model of delivery, as perceived by service providers, include opportunities to connect socially and to develop communication skills plus specific and strong levels of enjoyment of the virtual context.

Reversing the Ruin: Rehabilitation, Recovery, and Restoration After Stroke

PURPOSE OF REVIEW

Stroke is a common cause of disability in aging adults. A given individual's needs after stroke vary as a function of the stroke extent and location. The purpose of this review was to discuss recent clinical investigations addressing rehabilitation of an array of overlapping functional domains.

RECENT FINDINGS

Research is ongoing in the domains of movement, cognition, attention, speech, language, swallowing, and mental health. To best assist patients' recovery, innovative research has sought to develop and evaluate behavioral approaches, identify and refine synergistic approaches that augment the response to behavioral therapy, and integrate technology where appropriate, particularly to introduce and titrate real-world complexity and improve the overall experience of therapy. Recent and ongoing trials have increasingly adopted a multidisciplinary nature - augmenting refined behavioral therapy approaches with methods for increasing their potency, such as pharmaceutical or electrical interventions. The integration of virtual reality, robotics, and other technological advancements has generated immense excitement, but has not resulted in consistent improvements over more universally accessible, lower technology therapy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Mobile-based Virtual Reality Speech Rehabilitation App for Patients With Aphasia After Stroke: Development and Pilot Usability Study

Background

Stroke has the highest disability-adjusted life-years lost in any disease, and approximately one-third of the patients get aphasia. Computers and tablets are innovative and aid in intensive treatments in speech rehabilitation for patients with aphasia. However, mechanical training limits the help to patients.

Objective

This study aims to provide a framework for an integrated virtual reality (VR) app to provide speech rehabilitation for patients with aphasia.

Methods

The content was generated through an in-depth literature review and discussion with experienced rehabilitation physicians and occupational therapists. We then conducted a 2-round Delphi study with 15 experts from hospitals and universities to rate the content using a 5-point Likert scale. The app was developed by an interdisciplinary team involving VR, medical science of rehabilitation, and therapeutic rehabilitation. Pilot usability testing of this novel app was conducted among 5 patients with aphasia, 5 healthy volunteers, 5 medical staff, and 2 VR experts.

Results

We designed 4 modules of speech rehabilitation: oral expression, auditory comprehension, cognition, and comprehensive application. Our VR-based interactive and intelligent app was developed to provide an alternative option for patients with aphasia. Pilot usability testing revealed user satisfaction with the app.

Conclusions

This study designed and tested a novel VR-based app for speech rehabilitation specifically adapted to patients with aphasia. This will guide other studies to develop a similar program or intelligent system in a clinical setting.

Behavioral interventions for poststroke aphasia

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

Post-stroke aphasia rehabilitation using computer-based Arabic software program: a randomized controlled trial

Background

Aphasia is considered an acquired communication disorder. Language intervention in aphasia enhances the patient outcomes. Recently, computer programs are developed for the treatment of aphasia. It is an effective and a low-cost therapy choice. The aim of the study was to assess the effectiveness of language therapy using a computer-based Arabic software program for rehabilitation of post-stroke Arabic-speaking aphasic patients in comparison to the conventional language therapy. We conducted a randomized controlled trial with blinded endpoint evaluation. The trial included 50 aphasic patients. They were randomized into either group I or group II to receive 48 therapy sessions using the Arabic software program (group I) or the conventional therapy (group II). The primary outcome was a measure of improvement in language abilities. It was measured using the Arabic version of the Boston Diagnostic Aphasia Examination to detect any significant improvement in the language of both groups in comparison to pre-therapy results. The post-therapy results of both groups were compared to each other to document the effectiveness of the software program.

Results

A total of 105 aphasic patients were screened and 50 subjects were randomized to the intervention groups [40 subjects were males, mean age of the patients: 57.04 years± SD 10.88 for group I and 58.80 years ± SD 11.58 for group II]. The therapy results showed a significant improvement from the baseline in both groups. There was no significant difference in the post-therapy results between group I and group II except for some items whereas group I showed more significant improvement.

Conclusions

Language therapy using a computer-based Arabic software program was as effective as the conventional therapy in the improvement of language abilities of Arabic-speaking aphasic patients.

Communication partner engagement: A relevant factor for functional outcomes in speech language therapy for aphasic dementia

OBJECTIVES

Previous reports established the feasibility of a telehealth model for delivering speech-language therapy via Internet videoconferencing, which connects individuals with primary progressive aphasia (PPA) to an expert speech and language pathologist for treatment. This study reports feasibility of the same telehealth intervention in a larger set of progressive aphasia participants and explores factors potentially influencing functional intervention outcomes.

METHODS

Participants with PPA or progressive aphasia in the context of a neurodegenerative dementia syndrome and their communication partners were enrolled into an 8-session intervention, with 3 evaluations (Baseline, 2- and 6-months post-enrollment). Half of the participants were randomized into a "check-in" group and received three monthly half-hour sessions post-intervention. Mixed linear models with post hoc testing and percent change in area under the curve (AUC) were used to examine communication confidence over time, the primary patient reported outcome, as well as the influence of check-in sessions and role of communication partner engagement on communication confidence.

RESULTS

Communication confidence improved at the 2-month evaluation and showed no significant decline at the 6-month evaluation. Item-level analysis revealed gains in communication confidence across multiple communication contexts. Gains and maintenance of communication confidence were only present for the engaged communication partner group and were not bolstered by randomization to the check-in group.

DISCUSSION

Internet-based, person-centered interventions demonstrate promise as a model for delivering speech-language therapy to individuals living with PPA. Maintenance is possible for at least 6-months post-enrollment and is better for those with engaged communication partners, which supports the use of dyadic interventions.

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.

Solution Focused Brief Therapy in Post-Stroke Aphasia (SOFIA): feasibility and acceptability results of a feasibility randomised wait-list controlled trial

OBJECTIVES

The Solution Focused Brief Therapy in Post-Stroke Aphasia feasibility trial had four primary aims: to assess (1) acceptability of the intervention to people with aphasia, including severe aphasia, (2) feasibility of recruitment and retention, (3) acceptability of research procedures and outcome measures, and (4) feasibility of delivering the intervention by speech and language therapists.

DESIGN

Two-group randomised controlled feasibility trial with wait-list design, blinded outcome assessors and nested qualitative research.

SETTING

Participants identified via two community NHS Speech and Language Therapy London services and through community routes (eg, voluntary-sector stroke groups).

PARTICIPANTS

People with aphasia at least 6 months post stroke.

INTERVENTION

Solution-focused brief therapy, a psychological intervention, adapted to be linguistically accessible. Participants offered up to six sessions over 3 months, either immediately postrandomisation or after a delay of 6 months.

OUTCOME MEASURES

Primary endpoints related to feasibility and acceptability. Clinical outcomes were collected at baseline, 3 and 6 months postrandomisation, and at 9 months (wait-list group only). The candidate primary outcome measure was the Warwick-Edinburgh Mental Well-being Scale. Participants and therapists also took part in in-depth interviews.

RESULTS

Thirty-two participants were recruited, including 43.8% with severe aphasia. Acceptability endpoints: therapy was perceived as valuable and acceptable by both participants (n=30 interviews) and therapists (n=3 interviews); 93.8% of participants had ≥2 therapy sessions (90.6% had 6/6 sessions). Feasibility endpoints: recruitment target was reached within the prespecified 13-month recruitment window; 82.1% of eligible participants consented; 96.9% were followed up at 6 months; missing data <0.01%. All five prespecified feasibility progression criteria were met.

CONCLUSION

The high retention and adherence rates, alongside the qualitative data, suggest the study design was feasible and therapy approach acceptable even to people with severe aphasia. These results indicate a definitive randomised controlled trial of the intervention would be feasible.

TRIAL REGISTRATION NUMBER

NCT03245060.

Telerehabilitation for people with aphasia: A systematic review and meta-analysis

OBJECTIVES

To evaluate effectiveness or non-inferiority of telerehabilitation for people with aphasia when compared to conventional face-to-face speech and language therapy.

MATERIALS AND METHODS

Five electronic databases (PUBMED, EMBASE, WEB OF SCIENCE, SCOPUS and the Cochrane Library) were searched. We extrapolated data from the included studies and evaluated the methodological quality using the Revised Cochrane risk-of-bias tool for Randomized Trials (RoB 2) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). A meta-analysis compared effects of intervention, and it was conducted using the Review Manager 5.3 software. GRADE profile to assess overall quality of evidence was carried out.

RESULTS

Out of a total of 1157 records, five studies met the inclusion criteria and were eligible for meta-analysis with a total of 132 participants with post-stroke aphasia.

DISCUSSION

Results revealed that telerehabilitation and face-to-face speech and language treatment are comparable with respect to the gains achieved in auditory comprehension (SMD = -0.02; 95% CI -0.39, 0.35), naming accuracy (SMD = -0.09; 95% CI -0.44, 0.25), Aphasia Quotient (MD = -2.18; 95% CI -16.00, 11.64), generalization (SMD = 0.77; 95% IC -0.95, 2.49) and functional communication skills (SMD = -0.08; 95% IC -0.54, 0.38).

CONCLUSION

Although evidence is still insufficient to guide clinical decision making due to the relatively low quality of the evidence identified, the analysis of the results suggest that telerehabilitation training for aphasia seems to be as effective as the conventional face-to-face treatment.

App-based data collection, mental imagery, and naming performance in adults with aphasia

BACKGROUND AND PURPOSE

Naming impairments are often found in aphasia. Combining mHealth technology with mental imagery may offer new insights into novel approaches to naming interventions in persons with aphasia. The aims of this study are to (1) explore whether mental imagery can improve performance during a naming task in adults with aphasia; and, (2) demonstrate the use of app-based data collection for research in aphasia rehabilitation through utilization of an app designed specifically for this study.

MATERIALS AND METHODS

A single subject non-concurrent multiple baseline design across participants was utilized. Four participants with anomic and conduction aphasia were included. Each participant's percentage of naming accuracy was measured before the initiating intervention to establish a baseline level of performance.

RESULTS

Per overlap metrics, two of the participants demonstrated a strong effect in improving naming from baseline to intervention on items using the app. Two participants showed no effect in naming accuracy from the imagery intervention.

CONCLUSION

Some participants showed improvement in naming items following an imagery script, suggesting that this complementary health practice should continue to be explored. Additionally, this study demonstrates the successful use of app-based data collection.

Effects of virtual reality in post-stroke aphasia: a systematic review and meta-analysis

OBJECTIVE

To investigate whether virtual reality (VR) interventions have beneficial effects on the functional communication and language function of patients with post-stroke aphasia (PSA).

METHODS

We searched nine electronic literature databases and two clinical registry platforms to identify randomized controlled trials (RCTs) and quasi-RCTs performed up to September 2020. Screening, quality assessment, and data collection were performed by two authors independently, using standard protocols. Data aggregation and risk of bias evaluation were conducted using Review Manager Version 5.4. The quality of evidence was evaluated with GRADEpro.

RESULTS

A total of five studies involving 121 participants met the inclusion criteria and were appraised. Four studies were included in the quantitative synthesis. VR reduced the severity of language impairment with borderline significance [SMD (95%CI) = 0.70[0.01, 1.39], P=0.05]. The meta-analysis showed no statistical difference in functional communication [SMD (95%CI) =0.41[-0.29, 1.12], P=0.25], word finding [SMD (95%CI) =0.42[-0.24, 1.08], P=0.21], and repetition [SMD (95%CI) =0.16[-0.62, 0.94], P=0.68] between VR group and the control group.

CONCLUSION

This review demonstrated a borderline positive clinical effect of VR for the severity of language impairment when compared with conventional rehabilitation therapy. Conversely, VR had no effect on functional communication, word finding, and repetition. Further research is warranted to reach more definite conclusions.

"It's really exciting to think where it could go": a mixed-method investigation of clinician acceptance, barriers and enablers of virtual reality technology in communication rehabilitation

PURPOSE

Acquired communication disorders can result in significant barriers to everyday life activities, and commonly require long-term rehabilitation. This research aimed to investigate usability, acceptance, barriers and enablers to the use of immersive virtual reality (VR) technology for communication rehabilitation from the perspective of speech-language pathologists (SLPs).

METHODS

Semi-structured interviews and surveys (system usability and motion sickness) were carried out with 15 SLPs following their participation in communication activities typical of daily life, experienced within an immersive VR kitchen environment.

RESULTS

The system usability scores were average. In addition, motion sickness symptoms were low after interaction with the VR system. The main findings from semi-structured interviews are discussed across five main themes: (i) attitude towards the use of VR in communication rehabilitation (ii) perceived usefulness of VR (iii) perceived ease of use of VR (iv) intention to use VR, and (v) clinical adoption barriers and enablers.

CONCLUSIONS

Overall, participants were positive about VR and its potential applications to communication rehabilitation. This study provides a foundation to inform the design, development, and implementation of a VR system to be used in the rehabilitation of individuals with acquired communication disorders.IMPLICATIONS FOR REHABILITATIONVirtual Reality applications could simulate social communication situations within the clinic.VR could be used as a rehabilitation tool for communication assessment and/or outcome measure.VR requires customisation to the specific communication rehabilitation needs of the client.Participants identified barriers and enablers to adoption of VR by speech-language pathologists.

Diagnosing and managing post-stroke aphasia

Introduction: Aphasia is a debilitating language disorder and even mild forms of aphasia can negatively affect functional outcomes, mood, quality of life, social participation, and the ability to return to work. Language deficits after post-stroke aphasia are heterogeneous. Areas covered: The first part of this manuscript reviews the traditional syndrome-based classification approach as well as recent advances in aphasia classification that incorporate automatic speech recognition for aphasia classification. The second part of this manuscript reviews the behavioral approaches to aphasia treatment and recent advances such as noninvasive brain stimulation techniques and pharmacotherapy options to augment the effectiveness of behavioral therapy. Expert opinion: Aphasia diagnosis has largely evolved beyond the traditional approach of classifying patients into specific syndromes and instead focuses on individualized patient profiles. In the future, there is a great need for more large scale randomized, double-blind, placebo-controlled clinical trials of behavioral treatments, noninvasive brain stimulation, and medications to boost aphasia recovery.

Adjunctive Approaches to Aphasia Rehabilitation: A Review on Efficacy and Safety

Aphasia is one of the most socially disabling post-stroke deficits. Although traditional therapies have been shown to induce adequate clinical improvement, aphasic symptoms often persist. Therefore, unconventional rehabilitation techniques which act as a substitute or as an adjunct to traditional approaches are urgently needed. The present review provides an overview of the efficacy and safety of the principal approaches which have been proposed over the last twenty years. First, we examined the effectiveness of the pharmacological approach, principally used as an adjunct to language therapy, reporting the mechanism of action of each single drug for the recovery of aphasia. Results are conflicting but promising. Secondly, we discussed the application of Virtual Reality (VR) which has been proven to be useful since it potentiates the ecological validity of the language therapy by using virtual contexts which simulate real-life everyday contexts. Finally, we focused on the use of Transcranial Direct Current Stimulation (tDCS), both discussing its applications at the cortical level and highlighting a new perspective, which considers the possibility to extend the use of tDCS over the motor regions. Although the review reveals an extraordinary variability among the different studies, substantial agreement has been reached on some general principles, such as the necessity to consider tDCS only as an adjunct to traditional language therapy.

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 randomised trial of social support group intervention for people with aphasia: A Novel application of virtual reality

About a third of strokes cause aphasia, or language loss, with profound consequences for the person's social participation and quality of life. These problems may be mitigated by group social support. But this intervention is not available to all individuals. This study investigated whether it is feasible to deliver group social support to people with aphasia via a multi-user, virtual reality platform. It also explored the indicative effects of intervention and the costs. Intervention aimed to promote wellbeing and communicative success. It enabled participants to form new social connections and share experiences of living with aphasia. It comprised 14 sessions delivered over 6 months and was led by community based co-ordinators and volunteers. Feasibility measures comprised: recruitment and retention rates, compliance with intervention and assessment of treatment fidelity. Effects of intervention were explored using a waitlist randomised controlled design, with outcome measures of wellbeing, communication, social connectedness and quality of life. Two intervention groups were randomised to an immediate condition and two were randomised to a delayed condition. The main analysis explored scores on the measures between two time points, between which those in the immediate condition had received intervention, but those in the delayed group had not (yet). A comprehensive approach to economic data collection ensured that all costs of treatment delivery were recorded. Feasibility findings showed that the recruitment target was met (N = 34) and 85.3% (29/34) of participants completed intervention. All groups ran the 14 sessions as planned, and participants attended a mean of 11.4 sessions (s.d. 2.8), which was 81.6% of the intended dose. Fidelity checking showed minimal drift from the manualised intervention. No significant change was observed on any of the outcome measures, although the study was not powered to detect these. Costs varied across the four groups, from £7,483 - £12,562 British Pounds Sterling ($10,972 - $18,419 US dollars), depending on travel costs, the relative contributions of volunteers and the number of hardware loans that were needed. The results suggest that a larger trial of remote group support, using virtual reality, would be merited. However the treatment content and regime, and the selection of outcome measures should be reviewed before conducting the trial. Trail registration: Study registered with ClinicalTrials.gov; Identifier: https://www.ncbi.nlm.nih.gov/NCT03115268.

Is Aphasia Treatment Beneficial for the Elderly? A Review of Recent Evidence

Purpose

We review recent literature regarding aphasia therapy in the elderly. Relevant articles from the last 5 years were identified to determine whether or not there is evidence to support that various therapeutic approaches can have a positive effect on post-stroke aphasia in the elderly.

Recent findings

There were no studies examining the effects of aphasia therapy specifically in the elderly within the timeframe searched. Therefore, we briefly summarize findings from 50 relevant studies that included large proportions of participants with post-stroke aphasia above the age of 65. A variety of behavioral and neuromodulation therapies are reported.

Summary

We found ample evidence suggesting that a variety of behavioral and neuromodulatory therapeutic approaches can benefit elderly individuals with post-stroke aphasia.

Conversational Therapy through Semi-Immersive Virtual Reality Environments for Language Recovery and Psychological Well-Being in Post Stroke Aphasia

Aphasia is a highly disabling acquired language disorder generally caused by a left-lateralized brain damage. Even if traditional therapies have been shown to induce an adequate clinical improvement, a large percentage of patients are left with some degree of language impairments. Therefore, new approaches to common speech therapies are urgently needed in order to maximize the recovery from aphasia. The recent application of virtual reality (VR) to aphasia rehabilitation has already evidenced its usefulness in promoting a more pragmatically oriented treatment than conventional therapies (CT). In the present study, thirty-six chronic persons with aphasia (PWA) were randomly assigned to two groups. The VR group underwent conversational therapy during VR everyday life setting observation, while the control group was trained in a conventional setting without VR support. All patients were extensively tested through a neuropsychological battery which included not only measures for language skills and communication efficacy but also self-esteem and quality of life questionnairies. All patients were trained through a conversational approach by a speech therapist twice a week for six months (total 48 sessions). After the treatment, no significant differences among groups were found in the different measures. However, the amount of improvement in the different areas was distributed over far more cognitive and psychological aspects in the VR group than in the control group. Indeed, the within-group comparisons showed a significant enhancement in different language tasks (i.e., oral comprehension, repetition, and written language) only in the VR group. Significant gains, after the treatment, were also found, in the VR group, in different psychological dimensions (i.e., self-esteem and emotional and mood state). Given the importance of these aspects for aphasia recovery, we believe that our results add to previous evidence which points to the ecological validity and feasibility of VR treatment for language recovery and psychosocial well-being.

[Computer-based auditory training for hearing rehabilitation of adult cochlear implant users]

BACKGROUND

Digitalization has become a part of everyday life and digital applications offer an opportunity to promote health. In Germany, hearing rehabilitation after cochlear implantation (CI) typically takes place in specialized audiology centers. However, a variety of new auditory training programs have been developed and although most are for hearing aid users, some are suitable for CI patients. The purpose of this study is to give an overview of CBAT schedules and their effectiveness.

MATERIALS AND METHODS

Currently available English and German CBAT programs for adult CI users identified in searches of Google, Google App Store, and Google Play Store were analyzed. A systematic literature search on studies dealing with CBAT in adult CI recipients from 2000 to 2019 was performed in PubMed, LIVIVO, and Google Scholar.

RESULTS

German and English CBAT for adult hearing aid and CI users are generally intended to complement face-to-face therapies. The content of the programs differs primarily in terms of complexity and quantity of tasks, graphic design, allowed time and the device used. In contrast to the nine available German programs, some of the English CBAT include advanced concepts of adaptivity and feedback. Studies on the effectiveness of CBAT have mainly been conducted for the English versions and generally analyze only individual therapeutic subfunctions. All investigations show a short-term improvement of the auditory subfunction shortly after training. Unfortunately, the quality of the studies is low and follow-up results are only available in two cases.

CONCLUSION

CBAT programs might be an effective option for auditory rehabilitation in CI patients. However, suitable German-language programs conceived as an alternative to face-to-face training and studies on longterm effects of CBAT are still lacking.

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.

Comparing Traditional and Tablet-Based Intervention for Children With Speech Sound Disorders: A Randomized Controlled Trial

Purpose This article reports on the effectiveness of a novel tablet-based approach to phonological intervention and compares it to a traditional tabletop approach, targeting children with phonologically based speech sound disorders (SSD). Method Twenty-two Portuguese children with phonologically based SSD were randomly assigned to 1 of 2 interventions, tabletop or tablet (11 children in each group), and received intervention based on the same activities, with the only difference being the delivery. All children were treated by the same speech-language pathologist over 2 blocks of 6 weekly sessions, for 12 sessions of intervention. Participants were assessed at 3 time points: baseline; pre-intervention, after a 3-month waiting period; and post-intervention. Outcome measures included percentage of consonants correct, percentage of vowels correct, and percentage of phonemes correct. A generalization of target sounds was also explored. Results Both tabletop and tablet-based interventions were effective in improving percentage of consonants correct and percentage of phonemes correct scores, with an intervention effect only evident for percentage of vowels correct in the tablet group. Change scores across both interventions were significantly greater after the intervention, compared to baseline, indicating that the change was due to the intervention. High levels of generalization (60% and above for the majority of participants) were obtained across both tabletop and tablet groups. Conclusions The software proved to be as effective as a traditional tabletop approach in treating children with phonologically based SSD. These findings provide new evidence regarding the use of digital materials in improving speech in children with SSD. Supplemental Material https://doi.org/10.23641/asha.9989816.

Self-reported feedback in ICT-delivered aphasia rehabilitation: a literature review

PURPOSE

Information and Communication Technologies (ICT) can provide an option for the delivery of intensive aphasia rehabilitation but the users' views (i.e., People with Aphasia) must be considered to ensure satisfaction, motivation and adherence with this mode of rehabilitation. The aim of this literature review is to provide a critical overview of studies where feedback was elicited from participants about their experiences with ICT-delivered aphasia rehabilitation.

METHODS

A systematic search using six electronic databases was conducted in July 2015 and updated in May 2019. Studies of synchronous telerehabilitation and interventions targeting compensatory strategies were excluded from the review. Studies retrieved were screened for eligibility and information was extracted on the characteristics of each study, methods of data collection and study outcomes.

RESULTS

Seventeen studies met the inclusion criteria including studies with quantitative, qualitative and mixed-methods research designs. The studies employed a variety of data collection methods, examining a number of ICT-delivered aphasia rehabilitation activities and the findings investigated aspects of feasibility, usability and acceptance of this mode of rehabilitation.

CONCLUSIONS

The findings indicate ICT-delivered aphasia rehabilitation is considered an acceptable mode of rehabilitation by people with aphasia who reported generally positive feedback, though variation among personal perspectives and experience is noted. There is currently no consensus measure of self-reported feedback in ICT-delivered aphasia rehabilitation.IMPLICATIONS FOR REHABILITATIONICT-delivered aphasia rehabilitation may provide an acceptable mode of rehabilitation for people with aphasia.Exploring self-reported feedback from people with aphasia engaging in ICT-delivered aphasia rehabilitation will provide insights into their experiences of this mode of rehabilitation.This information may help to guide clinicians when collaboratively planning and monitoring ICT-delivered aphasia rehabilitation.Currently there is no consensus measure of self-reported feedback for people with aphasia engaging in ICT-delivered aphasia rehabilitation.

Toward Improving Poststroke Aphasia: A Pilot Study on the Growing Use of Telerehabilitation for the Continuity of Care

BACKGROUND

Aphasia is a quite common and very disabling symptom following stroke, negatively affecting patient's quality of life. Aim of the study is to evaluate the effectiveness of a rehabilitation training for aphasia that employ a touch-screen tablet using a virtual reality rehabilitation system (VRRS-Tablet).

MATERIAL AND METHODS

Thirty patients with aphasia due to ischemic or hemorrhagic stroke were randomized into either the control or the experimental group and assessed by means of a specific neuropsychological evaluation. The study lasted 6 months and included 2 phases. During the former, the experimental group underwent an experimental linguistic treatment performed using the VRRS-Tablet, while the control group was trained with a traditional linguistic treatment. In the latter, the control groups were delivered to territorial services, while the experimental group was provided with the VRRS-Tablet.

RESULTS

The experimental group improves in all the investigated areas, except for writing, while the control group only improves in comprehension, depression, and quality of life.

CONCLUSIONS

Our study has demonstrated the effectiveness of a home-based telerehabilitation program specific for poststroke aphasia. The use of telerehabilitation by means of VRRS-Tablet could be one of the best solutions to treat aphasic patients after their discharge, promoting continuity of care by monitoring functional outcomes, maintaining preserved abilities, reducing depression, and improving linguistic functions, besides the psychological well-being.

Fidelity protocol for the Action Success Knowledge (ASK) trial: a psychosocial intervention administered by speech and language therapists to prevent depression in people with post-stroke aphasia

INTRODUCTION

Treatment fidelity is a complex, multifaceted evaluative process which refers to whether a studied intervention was delivered as intended. Monitoring and enhancing fidelity is one recommendation of the TiDIER (Template for Intervention Description and Replication) checklist, as fidelity can inform interpretation and conclusions drawn about treatment effects. Despite the methodological and translational benefits, fidelity strategies have been used inconsistently within health behaviour intervention studies; in particular, within aphasia intervention studies, reporting of fidelity remains relatively rare. This paper describes the development of a fidelity protocol for the Action Success Knowledge (ASK) study, a current cluster randomised trial investigating an early mood intervention for people with aphasia (a language disability caused by stroke).

METHODS AND ANALYSIS

A novel fidelity protocol and tool was developed to monitor and enhance fidelity within the two arms (experimental treatment and attention control) of the ASK study. The ASK fidelity protocol was developed based on the National Institutes of Health Behaviour Change Consortium fidelity framework.

ETHICS AND DISSEMINATION

The study protocol was approved by the Darling Downs Hospital and Health Service Human Research Ethics Committee in Queensland, Australia under the National Mutual Acceptance scheme of multicentre human research projects. Specific ethics approval was obtained for those participating sites who were not under the National Mutual Agreement at the time of application. The monitoring and ongoing conduct of the research project is in line with requirements under the National Mutual Acceptance. On completion of the trial, findings from the fidelity reviews will be disseminated via publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12614000979651.

A review of virtual reality technologies in the field of communication disability: implications for practice and research

Background: Technology devices and applications including virtual reality (VR) are increasingly used in healthcare research and practice as tools to promote health and wellbeing. However, there is limited research examining the potential for VR to enable improved communication for people with communication disability.Aims: To review: (a) current research using VR in speech-language pathology; and (b) the ethical and safety considerations of VR research, to inform an agenda for future research applying VR in the field of speech-language pathology.Main contribution: This review reveals that there is an emergent body of literature applying VR to improve or develop physical, psychological and communication interventions. Use of non-immersive virtual environments to provide speech-language pathology assessment or intervention for people with communication disability has demonstrated positive outcomes, with emerging evidence of the transfer of functional communication skills from virtual to real-world environments. However, the use of VR technology and immersive virtual environments in communication disability practice and research introduces safety and ethical issues that must be carefully considered.Conclusions: Research employing VR is in its infancy in the field of speech-language pathology. Early evidence from other healthcare disciplines suggests that VR is an engaging means of delivering immersive and interactive training to build functional skills that can be generalized to the real world. While the introduction of new technology requires careful consideration of research ethics and patient safety, future VR communication research could proceed safely with adequate engagement of interdisciplinary teams and technology specialists.Implications for rehabilitationImmersive virtual reality may be used in rehabilitation to simulate natural environments to practice and develop communication skills.The sense of immersion that can be achieved using virtual reality may promote the generalization of skills learnt during clinical rehabilitation to real-world situations.Ethical and safety considerations, including cybersecurity and cybersickness, must be carefully monitored during all virtual reality research.

Accessibility and Applicability of Currently Available e-Mental Health Programs for Depression for People With Poststroke Aphasia: Scoping Review

Background

Depression affects approximately 60% of people with aphasia 1 year post stroke and is associated with disability, lower quality of life, and mortality. Web-delivered mental health (e-mental health) programs are effective, convenient, and cost-effective for the general population and thus are increasingly used in the management of depression. However, it is unknown if such services are applicable and communicatively accessible to people with poststroke aphasia.

Objective

The aim of this study was to identify freely available e-mental health programs for depression and determine their applicability and accessibility for people with poststroke aphasia.

Methods

A Web-based search was conducted to identify and review freely available e-mental health programs for depression. These programs were then evaluated in terms of their (1) general features via a general evaluation tool, (2) communicative accessibility for people with aphasia via an aphasia-specific communicative accessibility evaluation tool, and (3) empirical evidence for the general population and stroke survivors with and without aphasia. The program that met the most general evaluation criteria and aphasia-specific communicative accessibility evaluation criteria was then trialed by a small subgroup of people with poststroke aphasia.

Results

A total of 8 programs were identified. Of these, 4 had published evidence in support of their efficacy for use within the general population. However, no empirical evidence was identified that specifically supported any programs’ use for stroke survivors with or without aphasia. One evidence-based program scored at least 80% (16/19 and 16/20, respectively) on both the general and aphasia-specific communicative accessibility evaluation tools and was subject to a preliminary trial by 3 people with poststroke aphasia. During this trial, participants were either unable to independently use the program or gave it low usability scores on a post-trial satisfaction survey. On this basis, further evaluation was considered unwarranted.

Conclusions

Despite fulfilling majority of the general evaluation and aphasia-specific evaluation criteria, the highest rated program was still found to be unsuitable for people with poststroke aphasia. Thus, e-mental health programs require substantial redevelopment if they are likely to be useful to people with poststroke aphasia.

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.

From individual to global: Human rights and aphasia

This commentary marks the 70th anniversary of the Universal Declaration of Human Rights by examining Article 19 and its application to people with aphasia. This group of people still face lack of access, stigmatisation, exclusion, disadvantage and social withdrawal as well as poor public awareness of aphasia and inadequate prioritisation of support and resources. Nevertheless, a range of creative initiatives at individual, healthcare, local community, national and global levels have helped to connect and empower people with aphasia. Such initiatives include provision of accessible information in a range of media, inclusion of people with aphasia in decision-making and as research partners, awareness raising campaigns to counter attitudinal barriers, organisation of community aphasia groups, development of guidelines for best practice, national aphasia associations and international collaborations such as Aphasia United. While ongoing work and resourcing is needed to expand these efforts further, they have helped people with aphasia to be heard and to protect their sense of dignity which underlies human rights. A human rights approach can unite, politicise and refocus these efforts, and highlight the essential role of communication in fostering a better quality of life.

Virtual reality for stroke rehabilitation

BACKGROUND

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

OBJECTIVES

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

MAIN RESULTS

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

PRIMARY OUTCOME

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

SECONDARY OUTCOMES

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Experiencing EVA Park, a Multi-User Virtual World for People with Aphasia

Virtual worlds are used in wide-ranging ways by many people with long-term health conditions, but their use by people with aphasia (PWA) has been limited. In contrast, this article reports the use of EVA Park, a multi-user virtual world designed for PWA to practice conversations, focusing on people's emotional, social, and conversational experiences. An analysis of observation and interview data collected from 20 people with aphasia who participated in a 5-week therapy intervention revealed key themes related to user experience. The themes offer a rich insight into aspects of the virtual world experience for PWA that go beyond therapeutic outcomes. They are as follows: affect (positive and negative); types of conversation, miscommunication, and misunderstanding; immersion in the virtual world; social presence and initiative and flow. Overall, the study showed that participants experienced positive emotional and social outcomes. We argue that this was achieved as a consequence of EVA Park being not only accessible but also a varied and entertaining environment within which PWA experienced both the realistic and the quirky while engaging with others and having fun.

In vivo 19F-NMR study of isoflurane elimination from brain

The time course of isoflurane elimination from rabbit brain was studied in vivo with 19F-NMR spectroscopy. Two exponential decay functions with different time constants were observed and assigned to two distinct brain compartments. Isoflurane has a 26 min time constant for one compartment (similar to a value of 25 min with halothane) but 174 min in the second one, compared with 320 min for halothane. The shorter half-life for isoflurane may be due to lower solubility of this agent in brain tissue. Comparison of isoflurane 19F chemical shifts in solvents in isolated brain lipids and in whole brain tissue indicates that the anesthetic present in the brain exists in a single environment (on the NMR time scale), which is a weighted average of both hydrophilic and hydrophobic environments.